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Background Evidence suggests some metal-on-metal (MOM) THAs have higher rates of failure and subsequent revision than other bearing surfaces. However, there are few studies demonstrating how these patients fare after revision. Questions/purposes We asked: (1) What is the short-term survivorship of revision THA in patients whose index THAs employed MOM bearings? (2) What are the causes of failure of revision THA in these patients (ie, what are the indications for repeat revision)? (3) What are the most common complications after revisions of MOM THAs? Methods We identified 37 patients (24 women, 13 men; mean age, 55 years; 37 hips) revised for aseptic failure of primary stemmed MOM THAs. Reasons for revision included pain with loose components (n = 19), adverse reaction to metal debris (n = 8), periprosthetic fracture (n = 4), impingement (n = 3), dislocation (n = 2), and pain of unknown origin (n = 1). Minimum followup was 24 months (mean, 33 months; range, 24–81 months) postrevision, but 11 were not seen in the last 2 years as our routine followup is at 2 and 5 years. Clinical histories were reviewed for reasons for failure of the MOM THAs and complications associated with revision surgery. Results Survivorship free from further revision for any cause was 95% at 24 months and 92% at latest followup (24–81 months). There were three repeat revisions, all for periprosthetic infection, and all were treated with two-stage reimplantation. No other complications were observed. Conclusions We observed a higher-than-expected rate of infection after revision of MOM THAs. The infection rate was higher in this report than in an earlier series looking at revision THAs for other indications at our institution. As revision of MOM THA becomes more common, it will be important to continue monitoring postrevision outcomes and providing treatment strategies to mitigate complications for these patients. Level of Evidence Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Background Maintaining robust perfusion is an important physiologic parameter in wound healing. The effect of different closure techniques on wound perfusion after total knee arthroplasty (TKA) has not been established previously and may have implications for wound healing. Questions/purposes We asked whether a running subcuticular, vertical mattress, or skin staple closure technique enables the most robust wound perfusion after TKA as measured by laser-assisted indocyanine green angiography (LA-ICGA) in patients without specific risk factors for wound healing complications. Methods Forty-five patients undergoing primary TKA without comorbidities known to impact wound healing and perfusion were prospectively randomized to receive superficial skin closure with one of the following techniques: (1) running subcuticular (3-0 monofilament); (2) vertical mattress (2-0 nylon); or (3) skin staples. Twenty procedures were performed by RTT, 15 by RJS, and 10 by FHS. All surgeons used an anterior skin incision over the medial third of the patella in combination with a median parapatellar arthrotomy. Perfusion was assessed with a LA-ICGA device and software system immediately after closure to quantify fluorescence. Twenty-seven points were assessed immediately after closure in the operating room in each patient (nine along the incision and nine pairs medial and lateral to the incision). Mean incision perfusion was determined from the nine points along the incision with higher values indicating greater blood flow. Mean perfusion impairment was determined by calculating the difference between the nine pairs of surrounding skin and the nine points along the incision with smaller values indicating less perfusion impairment. These parameters were compared with analysis of variance (ANOVA) and subsequent pairwise comparisons with an unadjusted analysis as well as a multivariate analysis that adjusted for age, sex, and body mass index. Patients were followed for a mean of 7 months after surgery (range, 3–12 months) for possible incision-related complications. No patents were lost to followup. Results Running subcuticular closure demonstrated the best overall perfusion. Mean incision perfusion in fluorescent units with SD was as follows: running subcuticular, 64 (16); vertical mattress, 32 (18); and staples, 19 (7) (ANOVA p < 0.001). The running subcuticular closure demonstrated the least impairment of perfusion among the closures compared. Mean perfusion impairment was as follows: running subcuticular, 21 (12); vertical mattress, 37 (24); and staples, 69 (27) (ANOVA p < 0.001). All Tukey-adjusted pairwise comparisons from both metrics likewise favored the subcuticular closure (p < 0.001) both before and after adjusting for age, sex, and body mass index. One patient in the vertical mattress cohort experienced a surgical site infection; no other wound-related complications were observed in this study. Conclusions The method of closure can influence skin and soft tissue perfusion after TKA. Running subcuticular closure enables the most physiologic robust blood flow, which may improve wound healing. However, the clinical importance of these findings remains uncertain, because patients in this study were selected because they lacked risk factors for wound healing complications. Studies with this modality in specific patient populations at higher risk for wound complications will be necessary to quantify the clinical advantage of using running subcuticular closure. Level of Evidence Level I, therapeutic study.

Background Structural hip deformities including developmental dysplasia of the hip (DDH) and femoroacetabular impingement (FAI) are thought to predispose patients to degenerative joint changes. However, the natural history of these malformations is not clearly delineated. Questions/purposes (1) Among patients undergoing unilateral THA who have a contralateral hip without any radiographic evidence of hip disease, what is the natural history and progression of osteoarthritis in the native hip based on morphological characteristics? (2) Among patients undergoing unilateral THA who have a contralateral hip without any radiographic evidence of hip disease, what are the radiographic parameters that predict differential rates of degenerative change? Methods We identified every patient 55 years of age or younger at our institution who received unilateral primary THA from 1980 to 1989 (n = 722 patients). Preoperative radiographs were reviewed on the contralateral hip and only hips with Tönnis Grade 0 degenerative change that had minimum 10-year radiographic followup were included. A total of 172 patients met all eligibility criteria with the following structural diagnoses: 48 DDH, 74 FAI, and 40 normal morphology, and an additional 6% (10 of the 172 patients) met all eligibility criteria but were lost to followup before the 10-year minimum. Mean age at the time of study inclusion was 47 years (range, 18–55 years), and 56% (91 of 162) of the patients in this study were female. Mean followup was 20 years (range, 10–35 years). Radiographic metrics, in conjunction with the review of two experienced arthroplasty surgeons, determined the structural hip diagnosis as DDH, FAI, or normal morphology. Every available followup AP radiograph was reviewed to determine progression from Tönnis Grade 0 to 3 until the time of last followup or operative intervention with THA. Survivorship was analyzed by Kaplan-Meier methodology, hazard ratios, and multistate modeling. Thirty-five patients eventually underwent THA: 16 (33%) DDH, 13 (18%) FAI, and six (15%) normal morphology. Results Degenerative change was most rapid in patients with DDH followed by FAI and normal morphology. Among patients who recently developed Tönnis 1 degenerative change, the probability of undergoing THA in 10 years based on hip morphology was approximately one in three for DDH and one in five for both FAI and normal morphology hips, whereas the approximate probability at 20 years was two in three for DDH and one in two for both FAI and normal morphology hips. The likelihood of radiographic degeneration was increased in patients with the following findings: femoral head lateralization > 8 mm, femoral head extrusion index > 0.20, acetabular depth-to-width index < 0.30, lateral center-edge angle < 25°, and Tönnis angle > 8°. Conclusions Degenerative change occurred earliest in patients with DDH, whereas the natural history of patients with FAI was quite similar to structurally normal hips. However, patients with cam deformities and concomitant acetabular dysplasia developed osteoarthritis more rapidly. Although the results of this study cannot be directly correlated to highly active patients with FAI, these findings suggest that correction of FAI to a normal morphology may only minimally impact the natural history, especially if intervention takes place beyond Tönnis 0. Analysis of radiographic parameters showed that incremental changes toward dysplastic morphology increase the risk of degenerative change. Level of Evidence Level III, prognostic study.

Bernese (Ganz) periacetabular osteotomy is associated with significant blood loss and the need for perioperative transfusion. Tranexamic acid decreases blood loss and minimizes transfusion rates in total joint arthroplasty. However, no reports have described its use in patients undergoing Bernese periacetabular osteotomy. This study reports the use of intravenous tranexamic acid in these patients. The study included 137 patients (150 hips) who underwent isolated periacetabular osteotomy at a single institution between 2003 and 2014. Of these, 68 patients (75 hips) received intravenous tranexamic acid 1 g at the time of incision and 1 g at the time of closure. A group of 69 patients (75 hips) served as control subjects who underwent periacetabular osteotomy without administration of intravenous tranexamic acid. Thromboembolic disease was defined as deep venous thrombosis or pulmonary embolism occurring within 6 weeks of surgery. Outcomes measured included transfusion requirements, pre- and postoperative hemoglobin values, operative times, and thromboembolic disease rates. Aspirin was used as the thromboembolic prophylactic regimen in 95% of patients. The rate of allogeneic transfusion was 0 in the tranexamic acid group compared with 21% in the control group (Bernese (Ganz) periacetabular osteotomy is associated with significant blood loss and the need for perioperative transfusion. Tranexamic acid decreases blood loss and minimizes transfusion rates in total joint arthroplasty. However, no reports have described its use in patients undergoing Bernese periacetabular osteotomy. This study reports the use of intravenous tranexamic acid in these patients. The study included 137 patients (150 hips) who underwent isolated periacetabular osteotomy at a single institution between 2003 and 2014. Of these, 68 patients (75 hips) received intravenous tranexamic acid 1 g at the time of incision and 1 g at the time of closure. A group of 69 patients (75 hips) served as control subjects who underwent periacetabular osteotomy without administration of intravenous tranexamic acid. Thromboembolic disease was defined as deep venous thrombosis or pulmonary embolism occurring within 6 weeks of surgery. Outcomes measured included transfusion requirements, pre- and postoperative hemoglobin values, operative times, and thromboembolic disease rates. Aspirin was used as the thromboembolic prophylactic regimen in 95% of patients. The rate of allogeneic transfusion was 0 in the tranexamic acid group compared with 21% in the control group ( P =.0001). No significant difference was found in the autologous cell salvage requirement (.96 vs 1.01; P =.43) or the thromboembolic disease rate between the tranexamic acid group and the control group (2.67% vs 1.33%; P =.31). The use of intravenous tranexamic acid led to a decreased transfusion requirement with no increased risk of thromboembolic disease in this contemporary cohort of patients undergoing periacetabular osteotomy. [ Orthopedics. 2016; 39(1):44–48.]

To identify whether new ipsilateral weakness after hip surgery may be due to an inflammatory as opposed to a mechanical process. Seven patients (8 hip surgeries) seen between July 1, 2008, and June 30, 2011, developed unexplained ipsilateral leg weakness and pain within 1 month of hip surgery, mimicking mechanical etiologies. Cutaneous sensory nerve biopsy distant from the site of surgery was performed on all the patients. Patient medical records were reviewed for the clinical, electrophysiologic, radiologic, and pathologic features of the new neuropathy. Results of all the nerve biopsies were abnormal, showing axonal damage (7 patients), inflammation (7 patients), signs of ischemic injury (7 patients), and nerve microvasculitis (6 patients). Six patients were treated with intravenous methylprednisolone. At median follow-up of 6 months, 6 patients showed improvement in function and pain. In this case series, we demonstrate that inflammatory neuropathy is an important etiologic consideration in some patients with ipsilateral weakness and pain after hip surgery. In these patients, the inflammatory mechanism was ischemic injury due to microvasculitis. Identification of these patients through clinical suspicion and subsequent nerve biopsy may lead to improved outcomes with prompt initiation of immunotherapy.

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 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 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.

We designed and implemented an in vitro bench test to simulate and identify potential biomechanical causes for hip squeaking with alumina ceramic-on-ceramic bearing surfaces. All bearings were third-generation alumina ceramic with a 32-mm head coupled with a 56-mm acetabular component with a 32-mm ceramic insert. Conditions for testing were normal gait, high load, stripe wear, stripe wear in extreme load, metal transfer, edge wear with extreme load, and microfracture. Each condition was tested two times in dry conditions and two times in a lubricated condition with 25% bovine serum. Squeaking was reproduced in all dry conditions. It occurred quickly with high load, stripe wear, or metal transfer. Once squeaking occurred, it did not stop. Squeaking disappeared for all conditions when a small amount of lubricant was introduced. In lubricated conditions, squeaking was only reproduced for the material transfer condition. Our observations suggest squeaking is a problem of ceramic-ceramic lubrication and that this noise occurs when the film fluid between two surfaces is disrupted. Material (metal) transfer was the only condition that led to squeaking in a lubricated situation.

Background Labral refixation rather than resection provides better pain relief and function after femoroacetabular impingement (FAI) surgery. When the labrum is absent, degenerated, or is irreparable, reconstruction may provide a favorable biomechanical environment for the hip. However, it is unclear whether labral reconstruction relieves pain and restores function. Question/Purposes In patients undergoing FAI surgery with concomitant labral reconstruction, (1) Do they note subjective improvement in pain at latest followup? (2) What is their postoperative activity level? (3) What are the complications, reoperation rates, and reasons for failure? Methods We retrospectively reviewed all 19 patients who underwent labral reconstruction in 20 hips at the time of surgical hip dislocation between August 2007 and February 2011. We assessed improvement in pain and function, complications, and subsequent surgery through a chart review and questionnaire. The minimum followup was 12 months (average, 26.4 months; range, 12–56 months). Results Three hips in three patients were converted to THA within 36 months of their surgical hip dislocation for continued preoperative pain. Of the 17 hips not undergoing THA, 15 reported subjective improvement in preoperative pain and function. The average UCLA score was 8.5 (range, 5–10). We observed no complications associated with the labral reconstruction itself. Conclusion The majority of patients with reconstructed acetabular labra reported improvement in their hip pain and function after surgery. The causes of persistent symptoms and conversion to THA remain uncertain. The data and conclusions of this study are limited secondary to lack of objective outcome measures. Level of Evidence Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.