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Background Numerous factors influence total hip arthroplasty (THA) stability including surgical approach and soft tissue tension, patient compliance, and component position. One long-held tenet regarding component position is that cup inclination and anteversion of 40° ± 10° and 15° ± 10°, respectively, represent a “safe zone” as defined by Lewinnek that minimizes dislocation after primary THA; however, it is clear that components positioned in this zone can and do dislocate. Questions/purposes We sought to determine if these classic radiographic targets for cup inclination and anteversion accurately predicted a safe zone limiting dislocation in a contemporary THA practice. Methods From a cohort of 9784 primary THAs performed between 2003 and 2012 at one institution, we retrospectively identified 206 THAs (2%) that subsequently dislocated. Radiographic parameters including inclination, anteversion, center of rotation, and limb length discrepancy were analyzed. Mean followup was 27 months (range, 0–133 months). Results The majority (58% [120 of 206]) of dislocated THAs had a socket within the Lewinnek safe zone. Mean cup inclination was 44° ± 8° with 84% within the safe zone for inclination. Mean anteversion was 15° ± 9° with 69% within the safe zone for anteversion. Sixty-five percent of dislocated THAs that were performed through a posterior approach had an acetabular component within the combined acetabular safe zones, whereas this was true for only 33% performed through an anterolateral approach. An acetabular component performed through a posterior approach was three times as likely to be within the combined acetabular safe zones (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1–1.6) than after an anterolateral approach (OR, 0.4; 95% CI, 0.2–0.7; p < 0.0001). In contrast, acetabular components performed through a posterior approach (OR, 1.6; 95% CI, 1.2–1.9) had an increased risk of dislocation compared with those performed through an anterolateral approach (OR, 0.8; 95% CI, 0.7–0.9; p < 0.0001). Conclusions The historical target values for cup inclination and anteversion may be useful but should not be considered a safe zone given that the majority of these contemporary THAs that dislocated were within those target values. Stability is likely multifactorial; the ideal cup position for some patients may lie outside the Lewinnek safe zone and more advanced analysis is required to identify the right target in that subgroup. Level of Evidence Level III, therapeutic study.

Background Although some surgeons strongly advocate for one approach over the other, there are few data directly comparing the direct anterior approach with a miniposterior approach for total hip arthroplasty (THA). Questions/purposes Using the same advanced pain and rapid rehabilitation protocols for both groups, we compared the direct anterior and miniposterior approaches with respect to (1) return to activities of daily living at 2 days, 2 weeks, or 2 months; (2) risk of intraoperative or early postoperative complications; and (3) component position. Methods Over a 1-year period we identified all consecutive, primary direct anterior and miniposterior THAs performed by two surgeons at our institution, totaling 242 patients. Of those, 20 did not meet inclusion criteria as a result of prior trauma or surgery about the hip. A total of 222 patients, 126 direct anterior and 96 miniposterior, were retrospectively evaluated. All cases were done by one of two surgeons, one of whom performs THA exclusively through the direct anterior approach and the other who only uses the miniposterior approach. Groups did not differ demographically with mean ± SD age 64 ± 12 years, mean body mass index 30 ± 5.7 kg/m 2 , and 50% female. The same rapid rehabilitation protocols were used with no postoperative hip positioning precautions. Results No differences were seen between the two groups in mean length of stay (2.2 days; range, 1–9 days), operative or in-hospital complications, intravenous breakthrough analgesia, stairs, maximum feet walked in-hospital, or percent discharged to home (80% [177 of 222]; all p > 0.2). The direct anterior patients had longer mean operative times (114 minutes; range, 60–251 minutes) than the miniposterior patients (mean, 60 minutes; range, 41–113 minutes; p < 0.001). The direct anterior group had a higher maximum visual analog scale pain score (5.3 direct anterior; ± 2, versus 3.8 MP; ± 2; p < 0.0001). At 2 weeks, more direct anterior patients required gait aids (92% [116 of 126]) than miniposterior (68% [62 of 96]; p < 0.0001). At 8 weeks, direct anterior patients had higher mean Harris hip scores (95 versus 89) but a lower return to work and driving with no difference in their use of gait aids, narcotics, activities of daily living, or walking 0.5 mile. More wound problems occurred in the miniposterior group (p < 0.01). With the numbers available, component alignment was not different between the study groups (p > 0.05 for all comparisons). Conclusions There was no systematic advantage of direct anterior THA versus miniposterior THA. Contrary to conventional belief and somewhat surprising were the fewer minor wound problems in the direct anterior group and the higher proportion of patients free of gait aids at 2 weeks and back to driving and working at 8 weeks in the miniposterior group. Factors other than surgical approach, perhaps including attentive pain management, patient selection, surgical volume and experience, careful preoperative templating, and rapid rehabilitation protocols, may be more important in terms of influencing early recovery after THA. Level of Evidence Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Background Tranexamic acid (TXA) reduces blood loss and transfusion after total joint arthroplasty (TJA) but concerns remain that patients with severe medical comorbidities might be at increased risk for thromboembolic complications. Questions/purposes Among patients undergoing primary TJA with severe systemic medical disease, (1) was TXA associated with increased symptomatic thromboembolic events; (2) was TXA associated with decreased blood transfusion rates; and (3) were there differences in symptomatic thromboembolism or transfusions in the subset of patients with a history of, or risk factors for; thromboembolic disease? Methods We performed a retrospective review of 1131 primary TJAs in 1002 patients with American Society of Anesthesiologists score III or IV. Of these, 402 had at least one of seven risk factors for thromboembolic events and were designated as high risk; 240 of those patients received TXA. Outcome measures included 30-day postoperative symptomatic thromboembolic events and postoperative transfusion. Results There were no differences in symptomatic thromboembolic events within 30 days of surgery between patients who received TXA and those who did not (2.5% versus 2.6%, p = 0.97). Fewer patients treated with TXA received transfusions (11% with versus 41% without; p < 0.0001). In high-risk patients, TXA was not associated with an increase in symptomatic thromboembolic events (6.7% with versus 4.3% without; p = 0.27) and was associated with a decrease in transfusion rates (17% with versus 48% without; p = 0.001). Conclusions Although TXA seemed safe and effective in this database review of patients with severe medical comorbidities, a larger prospective trial is warranted to confirm these results. Level of Evidence Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background The use of antifibrinolytic medications in hip and knee arthroplasty reduces intraoperative blood loss and decreases transfusion rates postoperatively. Tranexamic acid (TXA) specifically has not been associated with increased thromboembolic (TE) complications, but concerns remain about the risk of symptomatic TE events, particularly when less aggressive chemical prophylaxis methods such as aspirin alone are chosen. Questions/purposes We determined whether the rate of symptomatic TE events differed among patients given intraoperative TXA when three different postoperative prophylactic regimens were used after primary THA and TKA. Methods We retrospectively reviewed 2046 patients who underwent primary THA or TKA and received TXA from 2007 to 2009. The three chemical regimens included aspirin alone, warfarin (target international normalized ratio, 1.8–2.2), and dalteparin. Primary outcome measures were venous TE events, including symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE), and arterioocclusive events, including myocardial infarction and cerebrovascular accident. Patients judged to be at high risk for TE due to recent cardiac stent placement or strong personal/family history of TE disease were excluded. Results For aspirin, warfarin, and dalteparin, the rates of symptomatic DVT (0.35%, 0.15%, and 0.52%, respectively) and nonfatal PE were similar (0.17%, 0.43%, and 0.26%, respectively). There were no fatal PE. Among the three groups, we found no difference in the rates of symptomatic DVT or PE with or without stratification by ASA score. Conclusions A low complication rate was seen when using TXA as a blood conservation modality during primary THA and TKA with less aggressive thromboprophylactic regimens such as aspirin alone and dose-adjusted warfarin. Level of Evidence Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Background We observed isolated tibial component debonding from the cement in one modern primary TKA design (NexGen LPS 3° tibial tray; Zimmer, Warsaw, IN, USA). This failure mechanism is sparsely reported in the literature. Questions/Purposes We (1) assessed survivorship of this tibial tray with special emphasis on debonding; (2) described clinical and radiographic features associated with tibial failure; and (3) compared patient and radiographic features of the failures with a matched cohort. Methods A total of 1337 primary TKAs were performed with a cemented NexGen LPS 3° tibial tray over an 11-year period. Twenty-five knees (1.9%) were revised for tibial debonding. BMI and radiographic alignment in the tibial debonding group were compared with a matched control group. Implant survivorship was assessed using tibial debonding as the end point. Results Survival free of revision from tibial debonding was 100% at 1 year and 97.8% at 5 years. The tibial failures shared a typical radiographic pattern with debonding at the cement-implant interface and subsidence into varus and flexion. We found no link between limb alignment or individual component alignment and failure because 22 of the 25 failures occurred in well-aligned knees. Conclusions Our standardized followup of patients undergoing TKA at routine intervals allowed us to discover a higher rate of revision resulting from tibial debonding. We have discontinued the use of this particular tibial tray for primary TKA and surveillance for patients undergoing TKA continues to be warranted. Level of Evidence Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Although most orthopedic surgeons presume that patients with more severe degenerative osteoarthritis are better candidates for total knee arthroplasty (TKA), few data have compared outcomes based on the extent of radiographic osteoarthritis. The authors tested the hypothesis that patients with minimal radiographic osteoarthritis would have worse outcomes compared with a matched cohort with severe osteoarthritis. The authors identified 29 patients (31 knees) with minimal degenerative changes who underwent TKA between 2000 and 2004. The authors identified a matched cohort with severe osteoarthritis. Mean follow-up was 5 years (range, 2–10 years). Preoperative knee scores were 63 and 59 in patients with minimal osteoarthritis and severe osteoarthritis, respectively. Postoperative knee scores were 89 and 93, respectively. Preoperative function scores were 57 and 56 in patients with minimal osteoarthritis and severe osteoarthritis, respectively. Postoperative function scores increased to 79 and 72, respectively. Of 31 patients in the minimal osteoarthritis group, 26 (84%) had mild or no pain at the time of last follow-up, whereas 5 (16%) had moderate or severe pain. In the group with severe osteoarthritis, 25 of 31 patients (81%) had mild or no pain at the time of last follow-up, whereas 6 (19%) had moderate or severe pain. In the group with minimal osteoarthritis, 6 of 31 knees (19%) had a complication. Only 1 of 31 knees (3.1%) in the matched cohort had a complication. Fewer than 1% of patients undergoing TKA at the authors’ institution had minimal preoperative radiographic osteoarthritis. These patients had a higher risk of complications, but similar pain relief, function, and overall satisfaction compared with a matched group with severe arthritis. [Although most orthopedic surgeons presume that patients with more severe degenerative osteoarthritis are better candidates for total knee arthroplasty (TKA), few data have compared outcomes based on the extent of radiographic osteoarthritis. The authors tested the hypothesis that patients with minimal radiographic osteoarthritis would have worse outcomes compared with a matched cohort with severe osteoarthritis. The authors identified 29 patients (31 knees) with minimal degenerative changes who underwent TKA between 2000 and 2004. The authors identified a matched cohort with severe osteoarthritis. Mean follow-up was 5 years (range, 2–10 years). Preoperative knee scores were 63 and 59 in patients with minimal osteoarthritis and severe osteoarthritis, respectively. Postoperative knee scores were 89 and 93, respectively. Preoperative function scores were 57 and 56 in patients with minimal osteoarthritis and severe osteoarthritis, respectively. Postoperative function scores increased to 79 and 72, respectively. Of 31 patients in the minimal osteoarthritis group, 26 (84%) had mild or no pain at the time of last follow-up, whereas 5 (16%) had moderate or severe pain. In the group with severe osteoarthritis, 25 of 31 patients (81%) had mild or no pain at the time of last follow-up, whereas 6 (19%) had moderate or severe pain. In the group with minimal osteoarthritis, 6 of 31 knees (19%) had a complication. Only 1 of 31 knees (3.1%) in the matched cohort had a complication. Fewer than 1% of patients undergoing TKA at the authors’ institution had minimal preoperative radiographic osteoarthritis. These patients had a higher risk of complications, but similar pain relief, function, and overall satisfaction compared with a matched group with severe arthritis. [ Orthopedics. 2015; 38(8):e681–e684.]

Background Serum markers of inflammation and muscle damage have shown clinical utility in some areas of medicine, but their value in determining the invasiveness or in predicting the early functional outcomes after total hip arthroplasty (THA) has not been demonstrated. Questions/purposes (1) Do serum markers of inflammation/muscle damage predict pain or early functional outcomes after contemporary THA performed through a direct anterior or miniposterior approach? (2) Do early functional outcomes as measured by in-hospital outcomes and clinical milestones differ between a contemporary direct anterior and miniposterior approach for THA? Methods Between August 31, 2013, and September 1, 2014, all patients presenting as candidates for THA at our institution who had not already had preoperative blood draws (161) were recruited for this study. Forty-two patients failed these exclusion criteria, eight patients declined enrollment, and 11 were consented but did not complete the required preoperative blood tests. Recruitment stopped when 50 patients had been enrolled in both the direct anterior group and the miniposterior group (2n = 100) based on a priori power analysis. One high-volume surgeon performed all of the direct anterior approaches and three high-volume surgeons performed the miniposterior approaches. Groups did not differ with the numbers available in mean age (63 years; SD 10; range, 35–86 years), sex (52% female), or mean body mass index (mean 31 kg/m 2 ; SD 7 kg/m 2 ; range, 20–73 kg/m 2 ). Serum markers measured including hemoglobin, hematocrit, myoglobin, creatine kinase (CK), C-reactive protein, interleukin-6, and tumor necrosis factor-α were collected at the preoperative clinic visit and on postoperative days 1 and 2 and compared with operative details, in-hospital complications, therapy progress, pain scores, and functional results from a milestone diary. Functional results evaluated included time to discontinue all narcotics and gait aids, independence with activities of daily living, return to driving a motor vehicle, and return to work. Results Serum markers after contemporary THA were not correlated with early functional outcomes either in-hospital or postdischarge. Specifically, no serum marker was predictive of the time to discontinue gait aids or narcotics, return to driving, climb stairs, or independence in activities of daily living (all p > 0.08). The patients receiving the direct anterior approach did have lesser elevations of CK levels than the patients undergoing the miniposterior approach (436 ± 312 [direct anterior {DA}] versus 1071 ± 459 [miniposterior {MP}], difference in means: −635; 95% confidence interval [CI], −809 to −462; p < 0.001), myoglobin levels (168 ± 114 [DA] versus 378 ± 151 [MP], difference in means: −210, 95% CI, −269 to −151; p < 0.001), C-reactive protein (79 ± 57 [DA] versus 124 ± 58 [MP], difference in means: −46, 95% CI, −71 to −21; p < 0.001), and interleukin-6 (45 ± 34 [DA] versus 80 ± 53 [MP], difference in means: −35, 95% CI, −54 to −16; p < 0.001), but not in other serum markers. In the hospital, patients undergoing the direct anterior approach ambulated 35 steps farther with physical therapy (178 feet DA versus 142 feet MP, p < 0.01, difference in means: 35, 95% CI, 9–62; p = 0.009) and had visual analog scale pain scores 1.1 less (4.8 DA versus 5.9 MP, difference in means: −1.1, 95% CI, 2.0 to −0.2; p = 0.02) than patients undergoing the miniposterior approach. There were no differences between approaches in other in-hospital outcomes or in posthospital clinical milestones. Conclusions Serum markers including CK, myoglobin, C-reactive protein, interleukin-6, and tumor necrosis factor-α did not predict early pain/function after contemporary THA approaches. Although lesser elevations in myoglobin, CK, C-reactive protein, and interleukin-6 were found after direct anterior THA, that difference was not clinically meaningful. Further reporting of serum biomarkers as a measure of physiological burden after orthopaedic surgical procedures should be viewed as suspect until clear linear or threshold values are established. Level of Evidence Level III, diagnostic study.

Background Posterior soft tissue repair after posterior THA reportedly decreases the risk of dislocation. Previously described techniques often require drill holes through the greater trochanter, do not include both the short external rotators and the capsule, or require a complex series of multiple sutures. We therefore describe a technique to address these issues. Description of Technique The posterior soft tissues were repaired with a single nonabsorbable suture passed through the external rotators and posterior capsule and then through the capsule and posterior border of minimus in a figure-of-eight pattern. This repair remains pliable and obliterates the dead space. Methods We retrospectively reviewed 165 patients who underwent 178 primary THAs through a mini-posterior THA and also underwent soft tissue repair using our technique. We determined the rate of dislocation and complications associated with this technique. The minimum clinical followup was 1 year (mean, 23 months; range, 12–37 months). Results This repair was associated with a low risk of dislocation at 1 year (one of 178 hips, 0.56%) and no apparent complications related to the technique. Conclusions This soft tissue to soft tissue repair technique after posterior-approach THA is technically straightforward and reliable with a low associated dislocation rate. Level of Evidence Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Background Although highly porous metals have demonstrated excellent bone ingrowth properties and so are an intriguing option for fixation in total knee arthroplasty (TKA), some surgeons are skeptical about the durability of uncemented tibial fixation and the potential for soft tissues to adhere to these porous metals and perhaps cause knee stiffness or pain. Questions/purposes The purpose of this study was to compare, in the context of a randomized clinical trial, a highly porous metal tibia compared with a traditional modular cemented tibia in terms of survivorship, Knee Society scores, range of motion (ROM), and complications. Methods From 2003 to 2006, 397 patients (age 67.8 ± 8.7 years; 54% female) were randomized to three groups: (1) traditional modular cemented tibia; (2) cemented highly porous metal tibia; and (3) uncemented highly porous metal tibia. The same posterior-stabilized femoral component and patella component were cemented in every case. Stratified randomization was done for surgeon, patient’s age, sex, and body mass index. Survivorship at 5 years was compared between the groups, as were Knee Society scores, ROM, and complications. Radiographic assessment included alignment, radiolucency, and implant migration/loosening. Patients were followed until death, revision, or for a minimum of 2 years (mean, 5 years; range, 2–9 years). Four patients were lost to followup before 2 years. Results Highly porous metal tibias (both uncemented and cemented) were no different from traditional cemented modular tibial modular components in terms of survivorship at 5 years using a intention-to-treat analysis (96.8% [ 1 ]; 97.6% [ 2 ]; 96.7% [ 3 ]; p = 0.59). A per-protocol analysis revealed that no highly porous metal tibia was revised for aseptic loosening. Highly porous metal tibias performed comparably to traditional cemented modular tibias in terms of Knee Society scores, ROM, and the frequency of complications. Conclusions At 5 years this randomized clinical trial demonstrated that highly porous metal tibias provided comparably durable fixation and reliable pain relief and restoration of function when compared with a traditional cemented modular tibia in TKA. Level of Evidence Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.