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.].

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.

Hip arthroplasty after intramedullary hip screw fixation: a perioperative evaluation.

OBJECTIVES: Although literature exists regarding surgery after hip screw/side plate devices, we are unaware of any reports of hip arthroplasty after intramedullary devices. DESIGN: This is a retrospectively reviewed case series. SETTING: Tertiary care medical center. PATIENTS/PARTICIPANTS: A consecutive unselected series. INTERVENTION: Hip arthroplasty surgery after failed hip fracture fixation surgery using an intramedullary nail device. MAIN OUTCOME MEASUREMENTS: Twenty cases of conversion surgery after intramedullary fixation for hip fractures were retrospectively reviewed. RESULTS: The indications for hip arthroplasty were nonunion with failed fixation in 15, avascular necrosis with secondary hip arthritis in three, and progression of hip arthritis in four. Average operative time and blood loss were 166 minutes and 621 mL, respectively. Of note, nine of 20 patients ultimately developed a nonunion of the greater trochanter after hip arthroplasty. In only one of these cases of nonunion was the greater trochanter refractured intraoperatively and this as part of a trochanteric osteotomy. CONCLUSION: Patients undergoing hip arthroplasty after failed hip fracture fixation using an intramedullary nail device are at high risk for greater trochanteric fracture and nonunion. The average operative time and blood loss for these procedures were greater than reported for primary but less than for revision arthroplasty. We now consider treating these cases with a trochanteric plate with or without a trochanteric slide osteotomy to minimize fracture of the remaining, damaged trochanteric bone. LEVEL OF EVIDENCE: Therapeutic Level IV. See page 128 for a complete description of levels of evidence.

Ilizarov distraction before revision hip arthroplasty after resection arthroplasty with profound limb shortening.

We report the results of Ilizarov gradual distraction to regain 6.7 cm of leg length in a severely contracted hip 11 months after a resection arthroplasty. Restoration of leg length allowed revision hip arthroplasty. At 24 months after the revision arthroplasty, the patient is ambulating independently and pain free. The use of Ilizarov gradual distraction restored leg length and facilitated postoperative function.

Femoral neck nonunion treatment.

Femoral neck fracture nonunion is a challenging complication for the orthopaedic surgeon. The etiology of nonunion can be complicated and multifactorial. The diagnosis usually is established clearly with clinical and radiographic examinations. There are no clear guidelines for treatment, although multiple factors must be taken into account. Treatment options include refixation, solitary bone grafting, osteotomy (with and without bone grafting), and prosthetic arthroplasty. The relative indications, shortcomings, contraindications, and results of these different forms of treatment are discussed.