Spinal Anesthetic Type and Independent Risk Factors for Postoperative Urinary Retention Following Total Joint Arthroplasty.

While risk factors for postoperative urinary retention (POUR) after total joint arthroplasty (TJA) have been identified, its association with type of spinal anesthetic has not yet been thoroughly investigated. Patients undergoing primary TJA between 2013-2018 were reviewed. From August 2013 to March 2016 bupivacaine was primarily given and from March 2016 through August 2018, most, although not all, received mepivacaine. Patient demographics as well as intraoperative data were recorded. One-thousand and fifty-four patients were included. POUR rates were not significantly different between groups (5.5% vs 6.1%, p = 0.675). Those who received mepivacaine had a significantly shorter length of stay (LOS) (1 vs. 2 days, p < 0.001). However, spinal anesthetic type was not significantly associated with either POUR or LOS after controlling for between-group differences. Older age (odds ratio [OR] 1.024 [95% confidence interval {CI}:1.000-1.049]; p = 0.049) and a history of benign prostatic hyperplasia or urinary incontinence/retention (OR 2.155 [95% CI:1.114-4.168]; p = 0.023) were confirmed as independent risk factors for POUR. (Journal of Surgical Orthopaedic Advances 29(4):225-229, 2020).

Clinical Characteristics and Long-term Outcomes After Septic Arthritis of the Native Glenohumeral Joint: A 20-Year Retrospective Review.

Septic arthritis of the native glenohumeral joint is rare, and there is little information available regarding the natural progression and long-term joint outcomes of this pathology. The authors performed a retrospective analysis of 97 patients with culture-positive glenohumeral septic arthritis between 1995 and 2015 at their institution with a mean clinical follow-up of 83.1 months. Patient records were reviewed to document demographic and laboratory data, clinical presentation, postoperative complications, recurrences, and subsequent shoulder arthroplasty. Common comorbidities uncovered included 20 immunocompromised patients (20.6%), intravenous drug use among 27 patients (27.8%), diabetes mellitus among 40 patients (41.2%), and 18 patients (18.5%) receiving hemodialysis. Staphylococcus aureus was the most common pathogen identified (61 patients; 62.8%), followed by streptococcal species (17 patients; 17.2%). Hematogenous spread of infection was the most common etiology of shoulder sepsis (40.2%). Seven patients (7.2%) developed shoulder sepsis of undetermined etiology in the absence of established risk factors, and 16 patients (16.4%) developed recurrent glenohumeral septic arthritis at a mean of 40 months following initial eradication of infection. Three patients (3.0%) eventually underwent same-side shoulder arthroplasty at a mean of 18 months following septic arthritis, with none experiencing a periprosthetic joint infection. Glenohumeral septic arthritis is highly unlikely in the absence of medical risk factors. Long-term recurrence after clinically successful treatment is low (16.5%), and few patients undergo elective arthroplasty following shoulder septic arthritis. However, orthopedic surgeons can expect 30% to 40% of patients to require multiple trips to the operating room to successfully treat the initial joint infection, regardless of treatment method. [Orthopedics. 2019; 42(1):e118-e123.].

Adductor Canal Block Versus Femoral Nerve Block for Pain Control After Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Trial.

BACKGROUND: Femoral nerve block (FNB) is a commonly performed technique that has been proven to provide effective regional analgesia after anterior cruciate ligament (ACL) reconstruction. The adductor canal block (ACB) uses a similar sensory block around the knee while avoiding motor blockade of the quadriceps muscles. PURPOSE/HYPOTHESIS: The purpose of our study was to compare the efficacy of FNB versus ACB for pain control after ACL reconstruction. It was hypothesized that there would be no difference in pain levels or opioid requirements between the 2 groups. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: We performed a prospective, double-blinded, randomized controlled trial. Sixty patients undergoing primary ACL reconstruction with bone-patellar tendon-bone autograft were randomized to receive either an ACB or an FNB preoperatively. The primary outcomes assessed were pain levels (visual analog scale) and narcotic requirements for 4 days after surgery. Secondary outcomes included ability to perform a straight leg raise in the recovery room and difference in thigh circumference between the operative and nonoperative leg measured at 7 days postoperatively. RESULTS: Morphine requirements were less in the ACB group in the first 4 hours postoperatively ( P = .02). Aside from this time interval, no differences were found between the 2 groups with regard to opioid requirements and pain scores at any other time. Similarly, no differences were noted in patients' ability to perform a straight leg raise in the recovery room ( P = .13) or in thigh circumference at the first postoperative visit ( P = .09). CONCLUSION: The results of our study suggest similar efficacy in perioperative pain control with the use of an ACB for ACL reconstruction when compared with FNB. The potential long-term benefit of quadriceps preservation with the ACB is worthy of future study. REGISTRATION: NCT03033589 (ClinicalTrials.gov identifier).

Dual-taper modular hip implant: Investigation of 3-dimensional surface scans for component contact, shape, and fit.

BACKGROUND: The etiology of wear particle generation and subsequent corrosion in modular total hip arthroplasty implants likely begins with mechanical fretting. The purpose of this study was to determine geometric features of the male and female taper surfaces that drive stability within the neck-stem junction. METHODS: Eighteen modular hip components received 3-dimensional surface scans to examine the neck-stem taper junction using an optical scanner. The normal distance between the surfaces of the neck taper as seated in the stem slot was measured and produced a color map of the contact proximity. Contour plots identified surface shape variation and contact. Angle measurements and neck seated depth were analyzed by regression. RESULTS: The typical features observed were (1) a vertical line of contact at one end of the transition from the flat surface to the radius surface; (2) a vertical line of contact in the radius surface just past the centerline; (3) a concavity along the flat surface between the neck and stem components; and (4) one of the neck flat surfaces was closer to its mating surface on the stem. The seated depth of the neck was dependent on the taper angles in the flat section of the neck (R2 = 0.5000, P = .0332). CONCLUSIONS: The shape of the neck and stem tapers deviate from ideal design dimensions, contributing to relative motions between the neck and stem. While these processes are not proven to directly cause implant failure, they may place the implants at higher risk for failure.

The stability of dual-taper modular hip implants: a biomechanical analysis examining the effect of impact location on component stability.

BACKGROUND: The purpose of this study was to investigate the stability of dual-taper modular implants following impaction forces delivered at varying locations as measured by the distraction forces required to disassemble the components. METHODS: Distraction of the head-neck and neck-stem (NS) tapers of dual-taper modular implants with 0°, 8°, and 15° neck angles were measured utilizing a custom-made distraction fixture attached to a servohydraulic materials test machine. Distraction was measured after hand pressing the components as well as following a simulated firm hammer blow impaction. Impacts to the 0°, 8°, 15° necks were directed axially in line with the neck, 10° anterior, and 10° proximal to the axis of the neck, respectively. RESULTS: Impaction increased the range of NS component distraction forces when compared to hand pressed components (1125-1743 N vs 248-302 N, respectively). Off-axis impacts resulted in significantly reduced mean (±95% confidence interval) distraction forces (8° neck, 1125 ± 117 N; 15° neck, 1212 ± 73 N), which were up to 35% lower than the mean distraction force for axial impacts to the 0° neck (1743 ± 138 N). CONCLUSIONS: Direction of impaction influences stability of the modular interface. The greatest stability was achieved with impaction directed in line with the longitudinal axis of the taper junction. Off-axis impaction of the 8° and 15° neck led to significantly reduced stability at the NS. Improving stability of dual-taper modular hip prostheses with appropriately directed impaction may help to minimize micromotion, component settling, fretting corrosion, and subsequent failure.

Liposomal bupivacaine versus interscalene nerve block for pain control after shoulder arthroplasty: a prospective randomized trial.

HYPOTHESIS: Our hypothesis was that in patients undergoing shoulder arthroplasty, a prospective randomized trial would find no significant differences in average daily pain scores of those treated with interscalene nerve block (INB) vs. local liposomal bupivacaine (LB). METHODS: Sixty patients undergoing primary shoulder arthroplasty were assessed for eligibility. Study arms included either intraoperative local infiltration of LB (20 mL bupivacaine/20 mL saline) or preoperative INB, with a primary outcome of postoperative average daily visual analog scale scores for 4 days. Secondary outcomes assessed included opioid consumption, length of stay, and complications. Randomization was by a computerized algorithm. Only the observer was blinded to the intervention. RESULTS: Three patients were excluded, all before randomization. A total of 57 patients were analyzed. Outcomes showed a significant increase in pain in the LB group between 0 and 8 hours postoperatively (mean [standard deviation] 5.3 [2.2] vs. 2.5 [3.0]; P = .001). A significant increase in intravenous morphine equivalents was found in the INB group at 13 to 16 hours (mean [standard deviation] 1.2 [0.9] vs. 0.6 [0.7]; P = .01). No significant differences were found in any variable after postoperative day 0 between the 2 groups. CONCLUSION: An increase in early postoperative pain on the day of surgery was found with LB, whereas the INB group required more narcotics at the end of the day. After the day of surgery, there were no significant differences found in any variables. These findings suggest that LB provides similar overall pain relief as INB, with no increase in complications or length of stay and a decrease in narcotic requirements on the day of surgery.

Patient Perceptions of Reimbursement for Arthroscopic Meniscectomy and Anterior Cruciate Ligament Reconstruction.

Historically, patient perceptions of surgeon reimbursement have been exaggerated compared with actual reimbursement. There is limited information about patient perceptions of physician reimbursement for arthroscopic meniscectomy and anterior cruciate ligament (ACL) reconstruction. This study evaluated patient perceptions of physician reimbursement for these procedures and compared perceptions of health care reform between urban and suburban clinics. Surveys were given to 231 consecutive patients, and patients were asked how much they believed a surgeon should be reimbursed for arthroscopic meniscectomy and ACL reconstruction as well as their perception of actual Medicare reimbursement to physicians. Patients were then informed of the actual reimbursement rates and asked additional questions about health care reform. Survey responses were compared in an urban setting vs a suburban setting. On average, patients reported that surgeons should receive $8096 for meniscectomy and $11,794 for ACL reconstruction. Patients estimated that Medicare paid physicians $5442 for meniscectomy and $6667 for ACL reconstruction. In addition, 65% of patients believed that reimbursement for meniscectomy was too low, and 57% of patients believed that reimbursement for ACL reconstruction was too low. Fewer than 2% of patients believed that surgeon salaries should be cut, and 75% believed that orthopedic surgeons should be paid more for subspecialty training. No differences were found in patients' perceptions of reimbursement or health care reform between urban and suburban settings. Patients perceived that the values of meniscectomy and ACL reconstruction were substantially higher than current Medicare reimbursement values and that surgeon salaries should not be cut. [Orthopedics. 2016; 39(5):e904-e910.].

The Effect of Impact Location on Force Transmission to the Modular Junctions of Dual-Taper Modular Hip Implants.

BACKGROUND: The purpose of this study was to investigate the effect that off-axis impaction has on stability of dual-taper modular implants as measured by forces delivered to and transmitted through the head-neck and neck-stem tapers, respectively. METHODS: One hundred forty-four impact tests were performed using 6 different directions: one on-axis and five 10° off-axes. Four different simulations were performed measuring the head-neck only and 3 different neck angulations: 0°, 8°, and 15°. A drop tower impactor delivered both on- and off-axis impaction from a constant height. Load cells positioned in the drop mass and at the head-neck (HN) or neck-stem (NS) junction measured the impact and joint forces, respectively. RESULTS: Impact force of the hammer on the head ranged from 3800-4500 N. Greatest impact force delivered to the head was typically with axial impact. However, greatest force transmission to the neck-stem junction was not necessarily with axial impacts. There was limited variability in the force measured at the NS junction for all impaction directions seen in the 8° neck, whereas the 15° neck had greater forces transmitted to the NS junction with off-axes impactions directed in the proximal and posterior-proximal directions. CONCLUSION: The location of the impact significantly influences the force transmitted to the head-neck and neck-stem junctions in dual-taper modular hip implants. Although axial impacts proved superior to off-axis impacts for the straight 0° neck, greater force transmission with off-axis impacts for the angled necks suggests that off-axis impacts may potentially compromise the stability of dual-taper components.

Pitching performance and longevity after revision ulnar collateral ligament reconstruction in Major League Baseball pitchers.

BACKGROUND: Medial ulnar collateral ligament (UCL) reconstruction is a common procedure performed on professional pitchers in Major League Baseball (MLB). Although a great deal is known about primary reconstruction, much less is known about revision reconstruction. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate statistical performance, return to play, and career longevity in MLB pitchers after revision UCL surgery, with the hypothesis that pitching performance and career longevity will decline after revision surgery. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 33 MLB pitchers who underwent revision UCL reconstruction surgery (UCL-R group) were identified and compared with 33 age- and position-matched controls (CTL group). Return to play, total years played, and statistical performance were evaluated and compared with controls. RESULTS: After revision surgery, 65.5% of UCL-R pitchers returned to the MLB level. On average, the UCL-R pitchers played 0.8 years less in the majors (P<.01) than did the control pitchers. The UCL-R pitchers who returned to the MLB level had a similar earned run average (UCL-R: 4.88, CTL: 4.76, P=.82) and walks/hits per innings pitched (UCL-R: 1.58, CTL: 1.44, P=.22) compared with the control pitchers. There were significant declines, however, in terms of innings pitched (UCL-R: 36.95, CTL: 75.00, P<.01), walks per 9 innings (UCL-R: 4.75, CTL: 3.49, P<.01), and wins (UCL-R: 1.88, CTL: 4.10, P<.01) as well as nonsignificant declines in wins above replacement (UCL-R: 0.25, CTL: 0.62, P=.06) and runs above replacement (UCL-R: 3.26, CTL: 6.91, P=.07). CONCLUSION: MLB pitchers who undergo UCL-R have a low rate of return to MLB play and have shortened careers after return. Pitchers who returned to the MLB level maintained performance in several statistics such as earned run average and walks/hits per innings pitched; however, pitchers returned with a significantly decreased workload.