The Creation of Data-Driven Preoperative Hemoglobin A1c and Same-Day Glucose Strata to Stratify Complication Risk Following Total Hip Arthroplasty.

BACKGROUND: This study identifies data-driven strata for preoperative Hemoglobin A1c (HbA1c) and same-day glucose levels that maximize differences in the likelihood of complications following total hip arthroplasty (THA). METHODS: Patients who underwent THA from 2013 to 2022 were identified using a national database. In total, 18,728 patients were identified with a mean age of 67 years (range, 18 to 80). Stratum specific likelihood ratio (SSLR) analysis determined separate strata for HbA1c and same-day glucose levels that minimized the likelihood of 90-day complications following THA. Each stratum was propensity-score matched based on age, sex, hypertension, heart failure, chronic obstructive pulmonary disease, and obesity to the lowest respective stratum. The risk ratio (RR) with respect to the lowest matched stratum was observed. RESULTS: Our SSLR analysis identified 3 data-driven HbA1c strata (4.5 to 5.9, 6.0 to 6.9, and 7.0+) and two same-day glucose strata (60 to 189 and 190+) that predicted 90-day major complications. For HbA1c, when compared to the lowest strata (4.5 to 5.9), the risk of 90-day major complications sequentially increased as the HbA1c strata increased: 6.0 to 6.9 (RR: 1.21; P = .041), 7+ (RR: 1.82; P < .001). For same-day glucose, when compared to the matched lowest strata (60 to 189), the risk of 90-day major complications was higher for the 190+ strata (RR: 1.5; P < .001). CONCLUSIONS: Our results support the use of multiple HbA1c strata that can be incorporated into preoperative risk-stratification models. Additionally, we identified a single cut-off level of 190 as a maximum target blood glucose level perioperatively.

A Comparative Biomechanical Analysis of Various Rod Configurations Following Anterior Column Realignment and Pedicle Subtraction Osteotomy.

OBJECTIVE: The objective of this study was to compare the biomechanical differences of different rod configurations following anterior column realignment (ACR) and pedicle subtraction osteotomy (PSO) for an optimal correction technique and rod configuration that would minimize the risk of rod failure. METHODS: A validated spinopelvic (L1-pelvis) finite element model was used to simulate ACR at the L3-4 level. The ACR procedure was followed by dual-rod fixation, and for 4-rod constructs, either medial/lateral accessory rods (connected to primary rods) or satellite rods (directly connected to ACR level screws). The range of motion (ROM), maximum von Mises stress on the rods, and factor of safety (FOS) were calculated for the ACR models and compared to the existing literature of different PSO rod configurations. RESULTS: All of the 4-rod ACR constructs showed a reduction in ROM and maximum von Mises stress compared to the dual-rod ACR construct. Additionally, all of the 4-rod ACR constructs showed greater percentage reduction in ROM and maximum von Mises stress compared to the PSO 4-rod configurations. The ACR satellite rod construct had the maximum stress reduction i.e., 47.3% compared to dual-rod construct and showed the highest FOS (4.76). These findings are consistent with existing literature that supports the use of satellite rods to reduce the occurrence of rod fracture. CONCLUSION: Our findings suggest that the ACR satellite rod construct may be the most beneficial in reducing the risk of rod failure compared to all other PSO and ACR constructs.

Total Hip Arthroplasty in Patients With Sickle Cell Disease: A Comprehensive Systematic Review.

BACKGROUND: Total hip arthroplasty (THA) is a common treatment for end-stage osteonecrosis of the hip in patients with sickle cell disease (SCD). This patient population presents unique challenges in the perioperative period. This systematic review aims to investigate the existing literature on the outcomes, complications, and survivorship of primary THA in SCD patients. METHODS: A systematic search using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed of PubMed, MEDLINE, EMBASE, and Cochrane databases for clinical studies on THA in SCD patients. Studies on primary THA in SCD patients with a mean follow-up greater than 90 days were included. RESULTS: Sixteen studies containing 5193 SCD patients met criteria for inclusion. The Coleman Quality of Evidence score ranged from poor to moderate. SCD patients had a significant increase in Harris Hip Scores and Merle d'Aubigne Scores after undergoing THA. Compared to non-SCD patients, SCD patients had increased hospital length-of-stay, 30-day and 90-day readmission rates, and rates of medical complications, including pain crises, acute chest syndrome, cardiac complications, sepsis, and mortality. SCD patients also had increased rates of surgical complications, including wound complications, infection, periprosthetic fracture, and aseptic loosening. Overall, THA revision rates were higher in SCD patients relative to those with primary osteoarthritis. CONCLUSION: THA remains an effective treatment modality for osteonecrosis of the hip in SCD patients. However, these patients are at increased risk of medical and surgical complications. Surgeons should be aware of the unique challenges in this patient population when counseling and managing these patients in the perioperative period.

Preoperative hyponatremia is an independent risk factor for postoperative complications in aseptic revision hip and knee arthroplasty.

INTRODUCTION: The purpose of this study is to investigate the relationship between preoperative hyponatremia and postoperative complications in aseptic revision hip and knee arthroplasty. METHODS: Aseptic revision arthroplasties from 2007 to 2016 were collected using a large, United States database. Patients were stratified into eunatremic and hyponatremic cohorts. Rates of complications were collected and analyzed. RESULTS: 25,517 surgeries were evaluated. Preoperative hyponatremia was independently associated with organ/space infections (OR= 2.316; p<0.001), postoperative blood transfusions (OR= 1.467; p<0.001), pneumonia (OR= 2.05; p =0.002), sepsis (OR= 2.533; p<0.001), extended length-of-stay (OR= 2.221; p<0.001), minor complications (OR= 1.549; p<0.001), wound complications (OR= 1.505; p=0.001), pulmonary complications (OR= 1.72; p=0.007), and sepsis complications (OR= 2.305; p<0.001). CONCLUSION: Hyponatremia is an independent risk factor for several postoperative complications in aseptic revision hip and knee arthroplasty.

Chronic preoperative corticosteroid use is not associated with surgical site infection following revision total knee arthroplasty.

INTRODUCTION: The objective of this study was to determine whether chronic preoperative corticosteroid use is associated with increased infectious complications following revision total knee arthroplasty (rTKA). METHODS: A retrospective cohort analysis was conducted using patients from a large national database. Patients were divided into two cohorts based upon chronic steroid usage preoperatively. Infectious complications in the 30-day postoperative period were recorded, and univariate and multivariate analyses were performed. RESULTS: A total of 10,973 patients were included in this study. No significant difference was observed in surgical site infection rates between patients with and without preoperative steroid use. In multivariate analysis, preoperative steroid use was independently associated with an increased likelihood of septic shock (OR 6.17; p = 0.015) and prolonged length-of-stay (OR 1.57; p = 0.038). CONCLUSION: Chronic preoperative steroid is not a significant risk factor for surgical site infection following rTKA, but it is independently associated with increased risk of septic shock and prolonged hospital length of stay.

Improving healthcare value through clinical community and supply chain collaboration.

BACKGROUND: We hypothesized that integrating supply chain with clinical communities would allow for clinician-led supply cost reduction and improved value in an academic health system. METHODS: Three clinical communities (spine, joint, blood management) and one clinical community-like physician led team of surgeon stakeholders partnered with the supply chain team on specific supply cost initiatives. The teams reviewed their specific utilization and cost data, and the physicians led consensus-building conversations over a series of team meetings to agree to standard supply utilization. RESULTS: The spine and joint clinical communities each agreed upon a vendor capping model that led to cost savings of $3 million dollars and $1.5 million dollars respectively. The blood management decreased blood product utilization and achieved $1.2 million dollars savings. $5.6 million dollars in savings was achieved by a clinical community-like group of surgeon stakeholders through standardization of sutures and endomechanicals. CONCLUSIONS: Physician led clinical teams empowered to lead change achieved substantial supply chain cost savings in an academic health system. The model of combining clinical communities with supply chain offers hope for an effective, practical, and scalable approach to improving value and engaging physicians in other academic health systems. IMPLICATIONS: This clinician led model could benefit both private and academic health systems engaging in value optimization efforts. LEVEL OF EVIDENCE: N/A.

Acetabular Placement Accuracy With the Direct Anterior Approach Freehand Technique.

BACKGROUND: Acetabular cup placement in total hip arthroplasty (THA) has been recognized as an important factor in operative success, and accurate cup placement has been the impetus for novel medical technologies. METHODS: This article examines the cup placement in 955 THAs using a freehand Direct Anterior Approach on a standard operating table. Acetabular anteversion and inclination were determined using the circle theorem. Measurements were divided into safe zone placement determined by Callanan et al as 5°-25° for anteversion and 30°-45° for inclination, as well as by Lewinnek et al as 5°-25° for anteversion and 30°-50° for inclination. Dislocation rate was determined and correlated to safe zone placement. RESULTS: Although technology has advanced for cup placement, this investigation shows that a freehand technique demonstrates 0.31% dislocation after THA with an accuracy of 85% for the Lewinnek safe zone and 61% for Callanan, potentially because of the sparing of the posterior hip capsule. CONCLUSION: The direct anterior approach to the hip on a regular operating table is safe and reliable. Our results demonstrate improvement in cup positioning compared with other freehand techniques. Surgeon awareness and control of the position of the pelvis within space optimizes acetabular component accuracy and precision without the need for special equipment, such as intraoperative fluoroscopy.

Direct anterior total hip arthroplasty.

The direct anterior approach to hip arthroplasty has become a popular technique. This technique, which was described almost 70 years ago, allows the surgeon to approach the hip through an internervous and intermuscular plane. Preliminary studies show that direct anterior hip arthroplasty may allow patients to recover faster with a lower dislocation rate. It is helpful to understand the history, scientific basis, and surgical technique of direct anterior hip arthroplasty.

Comparison of minimally invasive direct anterior versus posterior total hip arthroplasty based on inflammation and muscle damage markers.

BACKGROUND: A number of surgical approaches are utilized in total hip arthroplasty. It has been hypothesized that the anterior approach results in less muscle damage than the posterior approach. We prospectively analyzed biochemical markers of muscle damage and inflammation in patients treated with minimally invasive total hip arthroplasty with an anterior or posterior approach to provide objective evidence of the local soft-tissue injury at the time of arthroplasty. METHODS: Twenty-nine patients treated with minimally invasive total hip arthroplasty through a direct anterior approach and twenty-eight patients treated with the same procedure through a posterior approach were prospectively analyzed. Perioperative and radiographic data were collected to ensure cohorts with similar characteristics. Serum creatine kinase (CK), C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-1 beta (IL-1ß), and tumor necrosis factor-alpha (TNF-a) levels were measured preoperatively, in the post-anesthesia-care unit (except for the CRP level), and on postoperative days 1 and 2. The Student t test and Fisher exact test were used to make comparisons between the two groups. Independent predictors of elevation in levels of markers of inflammation and muscle damage were determined with use of multivariate logistic regression analysis. RESULTS: The levels of the markers of inflammation were slightly decreased in the direct-anterior-approach group as compared with those in the posterior-approach group. The rise in the CK level in the posterior-approach group was 5.5 times higher than that in the anterior-approach group in the post-anesthesia-care unit (mean difference, 150.3 units/L [95% CI, 70.4 to 230.2]; p < 0.05) and nearly twice as high cumulatively (mean difference, 305.0 units/L [95% CI, -46.7 to 656.8]; p < 0.05). CONCLUSIONS: We believe that the anterior total hip arthroplasty approach used in this study caused significantly less muscle damage than did the posterior surgical approach, as indicated by serum CK levels. The clinical importance of the rise in the CK level needs to be delineated by additional clinical studies. The overall physiologic burden, as demonstrated by measurement of inflammation marker levels, appears to be similar between the anterior and posterior approaches. Objective measurement of muscle damage and inflammation markers provides an unbiased way of determining the immediate effects of surgical intervention in patients treated with total hip arthroplasty.

Midterm results of a porous tantalum monoblock tibia component clinical and radiographic results of 108 knees.

The use of Trabecular Metal (TM), a biomaterial manufactured from elemental tantalum metal, has recently increased in orthopedics. One hundred eight consecutive TM monoblock tibias were implanted in 95 patients and followed for a minimum of 2 years. The average follow-up was 4.5 years. The average age was 65 years. The Knee Society score of 36 improved to 89. One hundred five of the knees were rated good/excellent, and 3 knees were rated poor. Two patellar revisions were performed for loose components and one for patellar misalignment. One patella fracture required open reduction and internal fixation. One femur was revised. There were no tibia revisions. There were no progressive radiographic lucencies. Midterm clinical and radiographic results of 108 consecutive TM tibia components have a high rate of success.

Direct Anterior Total Hip Arthroplasty.

INTRODUCTION: In theory, the direct anterior approach offers the only path to performing minimally invasive total hip arthroplasty in an intermuscular, internervous plane. STEP 1 POSITION AND DRAPE PATIENT: Careful positioning is necessary to complete this procedure on a standard operating room table. STEP 2 SUPERFICIAL EXPOSURE: Incise the fascia overlying the tensor fasciae latae and lift up the anterior edge, avoiding the perforating vessels. STEP 3 DEEP EXPOSURE: The hip is flexed 30° during the deep dissection. STEP 4 PREPARE ACETABULUM AND IMPLANT ACETABULAR COMPONENT: Ream the acetabulum in 10° to 15° of anteversion with an abduction angle of 40° to 45°. STEP 5 PREPARE FEMUR AND IMPLANT FEMORAL COMPONENT: Use offset broaches to access the femur and prevent perforation through the greater trochanter. STEP 6 TRIAL AND CLOSE: Specifically check for impingement of bone on the implant with the hip flexed 90°. RESULTS: This approach has been used successfully for total hip arthroplasty for decades. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Evaluation of a porous tantalum uncemented acetabular cup in revision total hip arthroplasty: clinical and radiological results of 60 hips.

Long-term survival of the acetabular component in revision total hip arthroplasty (THA) is determined by initial implant stability and bone ingrowth. Highly porous Trabecular Metal (TM, Zimmer, Inc, Warsaw, Ind) facilitates ingrowth and may be an ideal material for revision THA. The outcome and survivorship of a TM, nonmodular, uncemented acetabular cup were assessed in 60 consecutive patients undergoing revision THA (mean follow-up, 42 months; range, 14-68 months). Most (55/60) acetabular cups were implanted without screw fixation. Mean Harris Hips Scores improved from 74.8 preoperatively to 94.4 at last follow-up. Serial radiographs demonstrated excellent bone apposition and bone graft incorporation. Complications were limited to 7 cases of dislocation and 1 revision for aseptic loosening. The TM acetabular cup appears suitable for use in revision THA and warrants further study.