Mortality After Revision Total Hip Arthroplasty.

BACKGROUND: In counseling patients about the complications of revision total hip arthroplasty (revTHA), it is imperative that mortality be considered. The actual mortality rate by indication of revision is ill-defined. The purpose of this study is to determine the mortality rate after revTHA. METHODS: An institutional database identified 596 patients who had undergone revTHA between 2012 and 2018. Medical records, national, state, and local death indexes were queried for mortality status and indication for revTHA. For survivors, the last clinical visit date was used for censoring in the mortality analysis. Mortality rates were calculated for all clinical patients and then by specific indication for revision. RESULTS: The overall 2-year mortality rate following revTHA was 19.5 deaths per 1000 or 1 in 51 patients. Patients presenting with a periprosthetic fracture had a significantly higher 2-year mortality rate of 74.5 deaths per 1000 or 1 in 13 patients (P < .001), while an indication of dislocation or instability had a slightly higher 2-year mortality rate of 50.3 per 1000 (1 in 20) but this difference was not significant (P = .531). Other indications such as mechanical loosening or infection did not have a significantly different mortality rate. CONCLUSION: The overall 2-year mortality rate following revTHA was 19.5 deaths per 1000 which was largely attributed to patients with a periprosthetic fracture (74.5 per 1000) with other indications not significantly impacting mortality. Mortality rates and specific rates by indication for revision should be considered when counseling patients prior to revTHA.

Treatment of Periprosthetic Nonunions of the Lower Extremity.

Multiple studies have reported nonunion rates of 3% to 17% following peri-prosthetic fractures. Determining management strategies based on the available literature is difficult because existing studies are small and involve heterogeneous treatments and multiple surgeons. The purpose of this study was to describe a consecutive series of patients who presented to the authors' clinic with a periprosthetic nonunion of the lower extremity and to report the methods used to achieve limb salvage and the associated complications. Patients were included if they were indicated for surgery for a nonunion of a periprosthetic fracture of the lower extremity that had previously undergone either closed or open intervention. A total of 26 patients were included in this study. Average follow-up was 58 months. Average age was 69 years, and 77% of the patients were female. Twenty-three patients had periprosthetic nonunions of the femur, with 6 being associated with total hip arthroplasty, 15 with total knee arthroplasty, and 2 with both a total hip arthroplasty and a total knee arthroplasty. Three patients had a periprosthetic nonunion of the tibia associated with a total knee arthroplasty. Limb salvage was successful in 25 of 26 cases. This was achieved by either healing of the nonunion using exuberant fixation with prosthesis revision when necessary (n=20) or resection of the nonunion with placement of a tumor prosthesis (n=5). Four of the 26 patients (15%) incurred at least 1 complication during treatment. Exuberant fixation of the nonunion (with prosthesis revision when necessary) or nonunion resection with placement of a tumor prosthesis was successful in 96% of cases. [Orthopedics. 2020;43(4):209-214.].

Increased Orthopedic Specialization Lowers Costs and Improves Outcomes in Total Joint Arthroplasty.

BACKGROUND: Total joint arthroplasty (TJA) volumes have risen in the past decade, resulting in increased national spending. Prior studies indicate that TJA performed at higher-volume hospitals result in better patient outcomes at lower costs. The purpose of this study is to determine whether increased orthopedic specialization has similar effects. METHODS: Centers for Medicare and Medicaid Services Inpatient Charge Data queries identified 2677 hospitals that performed TJA in 2015. Hospitals were assigned an orthopedic specialization ratio (OSR), defined as the ratio of musculoskeletal discharges to total discharges. Average covered charges (ACC), average total payments, and average Medicare payments (AMP) of TJA were extracted. TJA-specific, risk-adjusted complication and readmission scores were obtained from the Centers for Medicare and Medicaid Services Hospital Compare database. Comparisons between orthopedic specialty hospitals and nonspecialty hospitals performing TJA were made with Student t-tests. Regression models analyzed the relationship between OSR, volume and cost, payments, readmission rate score, and complication rate score. RESULTS: Orthopedic specialty hospitals had lower ACC, average total payments, AMP, readmission, and complication scores than nonspecialty hospitals (all P < .001). Regression models showed that as the OSR increased from 0 to 1.0, ACC decreased by $19,242.83 and AMP decreased by $2310.75 (P < .001). Readmission score decreased by 0.349 and complication score decreased by 0.346 (P < .001) when controlling for volume as the OSR increased from 0 to 1. CONCLUSION: Hospitals with increased OSR appear to perform TJA for Medicare patients at a lower cost with lower complication and readmission risk. It may be beneficial to consider the OSR when determining the ideal settings for TJA.

Socio-demographic factors impact time to discharge following total knee arthroplasty.

AIM: To determine social, logistical and demographic factors that influence time to discharge in a short stay pathway (SSP) by following total knee arthroplasty (TKA). METHODS: The study included primary TKA's performed in a high-volume arthroplasty center from January 2016 through December 2016. Potential variables associated with increased hospital length of stay (LOS) were obtained from patient medical records. These included age, gender, race, zip code, body mass index (BMI), number of pre-operative medications used, number of narcotic medications used, number of patient reported allergies (PRA), simultaneous bilateral surgery, tobacco use, marital status, living arrangements, distance traveled for surgery, employment history, surgical day of the week, procedure end time and whether the surgery was performed during a major holiday week. Multivariate step-wise regression determined the impact of social, logistical and demographic factors on LOS. RESULTS: Eight hundred and six consecutive primary SSP TKA's were included in this study. Patients were discharged at a median of 49 h (post-operative day two). The following factors increased LOS: Simultaneous bilateral TKA [46.1 h longer (P < 0.001)], female gender [4.3 h longer (P = 0.012)], age [3.5 h longer per ten-year increase in age (P < 0.001)], patient-reported allergies [1.1 h longer per allergy reported (P = 0.005)], later procedure end-times [0.8 h longer per hour increase in end-time (P = 0.004)] and Black or African American patients [6.1 h longer (P = 0.047)]. Decreased LOS was found in married patients [4.8 h shorter (P = 0.011)] and TKA's performed during holiday weeks [9.4 h shorter (P = 0.011)]. Non-significant factors included: BMI, median income, patient's living arrangement, smoking status, number of medications taken, use of pre-operative pain medications, distance traveled to hospital, and the day of surgery. CONCLUSION: The cost of TKA is dependent upon LOS, which is affected by multiple factors. The clinical care team should acknowledge socio-demographic factors to optimize LOS.

Precise Measurement of the Outer Diameters of Antibiotic-Laden Cement Nails Produced by Various Sized Thoracostomy Catheter Molds.

OBJECTIVES: At our institution, custom-made antibiotic-laden cement nails (ACNs) fabricated during surgery using a thoracostomy catheter as a mold are commonly used to treat long-bone infection. As the outer diameter of the nails produced has not previously been described, we designed a study to measure the outer diameter of ACNs fashioned using commercially available and commonly utilized thoracostomy catheters of various sizes. METHODS: Six thoracostomy catheters from 2 different manufactures (Argyle PVC Thoracic Catheters; Covidien Ltd and Atrium PVC Thoracic Catheters; Atrium Medical Corporation), ranging from 20 French to 40 French, were utilized in this study. Each catheter was filled with antibiotic-laden cement, and the most proximal segment (largest outer diameter) and most distal segment (smallest outer diameter) were detached for study. Once the cement was cured, the thoracostomy catheters were cut away and the segments were measured using a calibrated digital caliper (Mitutoyo Corp, Aurora, IL). Because the ACNs produced using the technique taper from proximal to distal according to the shape of the thoracostomy catheter design, data were recorded as a maximum and minimum outer diameter for each ACN produced by each of the 6 thoracostomy catheter sizes studied. All measurements were in millimeters and were rounded to the nearest one-tenth of a millimeter. RESULTS: The ACNs produced using the various sized thoracostomy catheters had segments with outer diameters ranging from 4.2 mm to 11.2 mm. Both brands of catheters produced nails with similar distal diameters. Specifically, the mean distal diameter measurements were 4.2 mm for a 20 French catheter, 5.5 mm for a 24 French catheter, 6.6 mm for a 28 French catheter, 7.7 mm for a 32 French catheter, 8.4 mm for a 36 French catheter, and 9.9 mm for a 40 French catheter. The Argyle brand catheters produced nails with proximal diameters that increased with the catheter's size, from 7.1 mm for a 20 French catheter to 11.2 mm for a 40 French catheter. The Atrium brand catheters produced nails with a much tighter range of proximal diameters ranging from 9.4 mm to 11.1 mm. CONCLUSIONS: Thoracostomy catheters are commonly utilized to produce ACNs. The results of our study confirm that the fabricated nails taper in diameter from proximal to distal. Knowledge of the specific dimensions of the ACN produced by each size thoracostomy catheter will aid the orthopaedic surgeon in selecting the right size based on the diameter of the medullary canal being treated.

Learning curve for the anterior approach total hip arthroplasty.

The anterior approach to total hip arthroplasty has the advantages of using intermuscular and internervous planes, but it is technically demanding. We evaluated the learning curve for this approach with regard to operative parameters and immediate outcomes. From November 2005 through May 2007, 73 patients underwent 81 consecutive primary anterior-approach total hip arthroplasties. We grouped the hips into three consecutive groups of 20 and one of 21, and surgical and fluoroscopy times, estimated blood loss, intraoperative and postoperative complications, patient comorbidities, component position, and leg-length discrepancy were compared (statistical significance, p < 0.05). Comparing Groups 1 and 4, there were only two significant differences: operative time, 124 to 98 minutes, respectively, and estimated blood loss, 596 to 347 mL, respectively. Proficiency improved after Group 2 (40 cases) and was more marked after Group 3 (60 cases), with no major complications. Surgeons considering this approach should expect a substantial learning period.

Lateral femoral cutaneous nerve impairment after direct anterior approach for total hip arthroplasty.

The anterior supine approach for total hip arthroplasty (THA) offers the advantage of operating through a true intravascular and intranervous plane, but it places the lateral femoral cutaneous nerve at risk. The purpose of this study was to identify the incidence of and impairment relating to injury of the lateral femoral cutaneous nerve. We performed a retrospective chart review of 81 hips undergoing anterior supine THA from November 2005 through May 2007 to determine operative time, estimated blood loss, fluoroscopic time, type of anesthesia used, intraoperative complications, and postoperative systemic and wound complications. Postoperative radiographs were evaluated for leg-length discrepancy, acetabular inclination and anteversion, and femoral stem position. Patients were reassessed at 6 weeks, 3 months, 6 months, 1 year, and 2 years. At each visit, patients were questioned about numbness or paresthesias in the distribution of the lateral femoral cutaneous nerve; if present, the patient outlined the area with a marking pen. This area was photographed, and data were collected. No hip had frank numbness; 12 hips (14.8%) had paresthesias. For those 12, symptoms resolved in 4 by 6 months, in 6 by 1 year, and in 10 (83.3%) by 2 years; 2 remained unresolved. No significant difference was found between patients with and without paresthesias or between patients with resolved or unresolved paresthesias. Impaired sensation did not appear to affect functional outcome or Harris Hip Score. Incision position, dissection plane, retractor placement, tension and soft tissue handling, and surgeon experience may affect incidence of injury to the lateral femoral cutaneous nerve.

Bisphosphonates and osteonecrosis: potential treatment or serious complication?

They are commonly used to treat osteoporosis and other diseases that involve osteoclast-mediated bone resorption, including Paget's disease and multiple myeloma. Their use in treating osteonecrosis of the femoral head has been studied and theoretically holds promise. There are complications associated with these medications, however, including the development of osteonecrosis in the jaw.

Hip resurfacing through an anterolateral approach. Surgical description and early review.

BACKGROUND: Recently, metal-on-metal hip resurfacing has enjoyed a resurgence as an alternative to hip arthroplasty in properly selected patients. The purpose of the present study was to report the early results of hip resurfacing through an anterolateral approach and to describe the technique with modifications that have been made as experience with the procedure has increased. METHODS: A total of fifty-seven hip resurfacing procedures in fifty-three patients were performed by a single surgeon with use of the Cormet Hip Resurfacing system through an anterolateral approach. The results were assessed on the basis of Harris hip scores, a radiographic analysis, and an analysis of failures. RESULTS: After a mean duration of follow-up of thirty-eight months, the mean Harris hip score was 99 points. Fifty-five hips were in patients with normal function scores, and two were in patients who reported mild dysfunction. Fifty hips had no pain, five had slight pain, one had mild pain, and one had moderate pain. Three hips had a failure of resurfacing and required revision. Two failures were secondary to femoral neck fractures, and one was the result of debonding of the surface coating of the acetabular component. CONCLUSIONS: The early results associated with a new generation of hip resurfacing devices are promising. The anterolateral approach affords the surgeon excellent exposure with the advantage of increased hip stability and potentially improved vascular supply of the femoral head as compared with the posterior approach.