Direct anterior approach total hip arthroplasty with an orthopedic traction table.

OBJECTIVE: Direct anterior approach total hip arthroplasty (DAA THA) has gained significant popularity in the last decade as it is a muscle-sparing procedure. Modern techniques for DAA THA utilize both a standard operating table and an orthopedic traction table. As the use of an orthopedic traction table shows technical ease and predictability, this article will focus on the use of the orthopedic table or table extension to facilitate DAA THA. INDICATIONS: Primary or secondary arthritis requiring THA; revision surgery-both acetabular and femoral. CONTRAINDICATIONS: Posterior wall hardware requiring removal; posterior mass (tumor) to be removed at surgery: large, overhanging pannus; need for gluteal tendon reconstruction; anterior skin envelope not conducive to DAA. SURGICAL TECHNIQUE: The incision is made over the tensor fascia latae. Capsulotomy is performed exposing the hip joint. After osteotomy of the femoral neck, traction is placed on the leg utilizing the orthopedic table and the head is removed. The acetabular cup is inserted. Traction, flexion, and internal reduction are used simultaneously while directing the femoral head into the acetabulum. RESULTS: In a meta-analysis, operative time (100 vs. 71 min), blood loss (531 vs. 382 ml), and intraoperative fracture rate (1.7 vs. 1.3%) were increased in the traction table cohort. All other complications and outcome measurements were the same. Traction-table related complications such as pudendal nerve palsy and ankle fractures were not found. An assessment of the senior author's initial 855 DAA THAs (2008-2014) showed a mean operative time of 65 min with a mean blood loss of 238 ml. Operative times decreased to average 56 min. Intraoperative fracture rate was 0.8%. Infection rate was 2.1%. Finally, 1.5% femoral implants did not osseointegrate and required revision after an average of 3.0 years.

Logistical and Economic Advantages of Sterile-Packed, Single-Use Instruments for Total Knee Arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) is well established as a clinically successful and cost-effective procedure. The transition of the US healthcare system from a fee-for-service model to a value-based care model requires careful examination of patient care to ensure both quality and efficiency. Sterile-packed, single-use instruments have been introduced as a tool to help streamline the operating room (OR) logistics while reducing sterilization requirements. The aim of this study was to examine the potential logistic and economic benefits of single-use instruments compared to traditional, reusable instruments for TKA. METHODS: Four variables related to TKA costs and logistics were modeled in this study: OR turnover time tray sterilization, tray management time, and 90-day infection rates. Model input data for traditional instruments and single-use instruments were based on peer-reviewed literature. A total of 200 sites and 500 cases per site were simulated using the Monte-Carlo-Technique. RESULTS: The median total cost savings with single-use instruments was $994 per case. The largest driver for cost savings was tray sterilization. Sites with higher staff wages and sterilization costs had a larger probability of realizing greater cost savings with adoption of single-use instruments. In cases using single-use instruments, up to 51% of operating days could have accommodated an additional procedure due to the time savings in OR turnover. CONCLUSION: This cost modeling study observed significant potential for logistical and economic improvements in TKA with single-use vs reusable instruments. Although few studies have been conducted to measure the impact of single-use instruments in practice, the results of these simulations motivate further investigation.

Surface cementation of stemmed tibial components in primary total knee arthroplasty: minimum 5-year follow-up.

Cement remains the "gold standard" for fixation in total knee arthroplasty. Between 1991 and 1998, 128 consecutive knees in 109 patients underwent primary cemented total knee arthroplasty using a surface cementation technique. The average follow-up was 95 (range, 63-155) months. Preoperative range of motion (ROM) averaged 5 degrees to 111 degrees which improved to 1 degrees to 116 degrees postoperatively. Modified Hospital for special surgery score (HSS) scores improved from 61 (range, 47-76) to 97 (range, 81-100) and the corresponding Knee Society Scores from 122 (range, 94-152) to 195 (range, 162-200). No osteolytic lesions were found; however, 3 tibias had radiolucent lines which were asymptomatic, nonprogressive, and not associated with implant failure. The average depth of penetration of cement was 2.7 mm. One knee (1%) required revision surgery for femoral loosening, and 1 required revision of the polyethylene liner. The present cementation technique provides excellent durable results at midterm follow-up.

Ten-year experience using an articulating antibiotic cement hip spacer for the treatment of chronically infected total hip.

Infection is a devastating complication after total-hip arthroplasty. Between June 1991 and December 2001, 42 patients were treated at our center for chronically infected total-hip arthroplasty using a 2-stage articulating antibiotic hip spacer technique. Of the 27 patients available for review, 26 (94%) remain clinically free of infection at an average 76 months (range, 28-148 months) postoperatively. Twenty-two (81%) patients had a positive identification of the infecting organism. All patients received a minimum of 6 weeks of intravenous antibiotics and the Harris Hip Scores improved from 53 (range, 36-68) to 92 (range, 81-99) postoperatively. Advantages of this technique include improved patient function, maintenance of bone stock and soft tissue tension, thus simplifying reimplantation.