Impact of sugammadex and neostigmine on outcome after major orthopaedic surgery: A population-based analysis.

BACKGROUND: Residual neuromuscular blockade after surgery remains a major concern given its association with pulmonary complications. However, current clinical practices with and the comparative impact on perioperative risk of various reversal agents remain understudied. OBJECTIVE: We investigated the use of sugammadex and neostigmine in the USA, and their impact on postoperative complications by examining national data. DESIGN: This population-based retrospective study used national Premier Healthcare claims data. SETTING AND PARTICIPANTS: Patients undergoing total hip/knee arthroplasty (THA, TKA), or lumbar spine fusion surgery between 2016 and 2019 in the United States who received neuromuscular blocking agents. INTERVENTION: The effects of sugammadex and neostigmine for pharmacologically enhanced reversal were compared with each other and with controls who received no reversal agent. MAIN OUTCOMES: included pulmonary complications, cardiac complications, and a need for postoperative ventilation. Mixed-effects regression models compared the outcomes between neostigmine, sugammadex, and controls. We report odds ratios (OR) and 95% confidence intervals (CI). Bonferroni-adjusted P values of 0.008 were used to indicate significance. RESULTS: Among 361 553 patients, 74.5% received either sugammadex (20.7%) or neostigmine (53.8%). Sugammadex use increased from 4.4% in 2016 to 35.4% in 2019, whereas neostigmine use decreased from 64.5% in 2016 to 43.4% in 2019. Sugammadex versus neostigmine or controls was associated with significantly reduced odds for cardiac complications (OR 0.86, 95% CI, 0.80 to 0.92 and OR 0.83, 95% CI, 0.78 to 0.89, respectively). Both sugammadex and neostigmine versus controls were associated with reduced odds for pulmonary complications (OR 0.85, 95% CI, 0.77 to 0.94 and OR 0.91, CI 0.85 to 0.98, respectively). A similar pattern of sugammadex and neostigmine was observed for a reduction in severe pulmonary complications, including the requirement of invasive ventilation (OR 0.54, 95% CI, 0.45 to 0.64 and OR 0.53, 95% CI, 0.46 to 0.6, respectively). CONCLUSIONS: Population-based data indicate that sugammadex and neostigmine both appear highly effective in reducing the odds of severe life-threatening pulmonary complications. Sugammadex, especially, was associated with reduced odds of cardiac complications.

Interventions used to mitigate muscle fatty degeneration following the repair of massive rotator cuff tears. A systematic review of animal studies.

BACKGROUND: Muscle fatty degeneration following rotator cuff tears has been unequivocally associated with poorer functional outcomes and increased risk for retear following rotator cuff repair. Promising results have emerged from animal studies, with the implementation of various interventions for biologic inhibition of this fatty muscle degeneration. The lack of high quality randomized human evidence on this topic, increases the impact of pooled results from animal literature. The aim of the present study was to systematically review the available published literature for animal studies evaluating the ability of several interventions used to mitigate muscle fatty degeneration following the repair of massive rotator cuff tears. PATIENTS AND METHODS: A comprehensive search was conducted on Pubmed, Scopus and Google Scholar, covering the period from conception until 16th April 2022. Datasets were stratified based on the type of intervention performed. SYRCLE risk of bias instrument was implemented for quality assessment of the included studies. RESULTS: Rotator cuff repair augmentation with Adipose derived stem cells (ADSC's), Mesenchymal stem cells (MSC's) and Nandrolone was effective against fatty infiltration, but less effective against muscle atrophy. More beneficial effect was shown by the utilization of Beige adipose tissue - Fibroadipogenic progenitors (BAT-FAP) stimulation, using either Amibregon or BAT-FAPs transplantation. Both provided good results in mitigating muscle atrophy, fatty infiltration and fibrosis. DISCUSSION: ADSC's, MSC's, Nandrolone and BAT-FAP stimulation may have a role in mitigating muscle fatty degeneration following rotator cuff tears. Large scale human studies are required to further elucidate their role in the clinical setting. LEVEL OF EVIDENCE: V; systematic review of pre-clinical studies.

The impact of multimodal analgesia in coronary artery bypass graft surgery-a population-based analysis.

OBJECTIVE: Multimodal pain management aims to concurrently target several pain pathways for improved treatment efficacy and recovery. We investigated associations between multimodal analgesia use and postoperative complications, length of hospital stay (LOS), and opioid consumption among patients undergoing coronary artery bypass graft surgery. METHODS: This retrospective cohort study included 349,940 adult patients undergoing elective coronary artery bypass graft surgery (January 2006 to December 2019), from the national Premier Healthcare claims dataset. The study intervention was multimodal analgesia, defined as opioid use with the addition of nonopioid analgesic modalities. These included, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, paracetamol/acetaminophen, neuraxial anesthesia, steroids, gabapentin/pregabalin, and ketamine. Analgesic management was stratified into 4 categories: opioids only and multimodal analgesia with the addition of 1, 2 or ≥3 nonopioid analgesic modalities. Mixed-effects regression models measured associations between multimodal analgesia and postoperative complications, LOS, and opioid consumption measured in milligram oral morphine equivalents. RESULTS: Multimodal analgesia was associated with a beneficial dose response pattern. With increasing nonopioid analgesic modalities added to opioid analgesia, a stepwise decrease in complication risk was consistently observed, eg, with the addition of 1, 2, or ≥3 nonopioid modalities the odds for any complication decreased by 8% (odds ratio [OR], 0.92; confidence interval [CI], 0.90-0.94), 17% (OR, 0.83; CI, 0.81-0.86), and 22% (OR, 0.78; CI 0.69-0.79), respectively. This stepwise pattern was consistent in respiratory, cardiac, and renal complications individually. Similarly, LOS decreased stepwise with added analgesic modalities. CONCLUSIONS: These nationally representative data indicate that enhanced pain management by multiple pain pathways is associated with significant reductions in postoperative complications and shortened patient recovery.

Clinical Outcomes of Total Hip Arthroplasty in Patients with Prior Periacetabular Osteotomy.

BACKGROUND: Periacetabular osteotomy (PAO) has been used as a treatment modality for development dysplasia of the hip (DDH). Many patients will progress to total hip arthroplasty (THA) following PAO. There is a discrepancy in the literature regarding outcomes of THA after PAO. METHODS: A retrospective study was performed. Ten pa- tients (12 hips) with prior PAO who progressed to THA with at least 1-year follow-up after THA were identified. A control group of patients matched for age, sex, and body mass index (BMI) who underwent primary THA with minimum of 1-year follow-up were included. Demographic and radiographic parameters as well as clinical outcomes using the modified Harris Hip Score (mHHS) were collected. RESULTS: The mean age at the time of THA was 36.2 ± 9.7 years for the PAO and 37.8 ± 9.1 years for the control cohorts. There was no difference in the demographics be- tween the groups. At mean follow-up time of 22.8 ± 10.7 months for the PAO group and 25 ± 13.8 months for the control group, there was no significant difference in mHHS following THA. There was significant improvement in mHHS from preoperative to postoperative levels (p < 0.01). CONCLUSION: Total hip arthroplasty is an effective means to restore quality of life and function in patients who develop osteoarthritis following PAO, with equivalent outcomes to those undergoing primary THA.

Improving Safety of Bilateral Knee Arthroplasty: Impact of Selection Criteria on Perioperative Outcome.

Background: Bilateral total knee arthroplasty (BTKA) procedures are associated with an increased risk of complications when compared with unilateral approaches. In 2006, in an attempt to reduce this risk, our institution implemented selection criteria that specified younger and healthier patients as candidates for BTKA. Questions/Purpose: We sought to investigate the effect of these selection criteria on perioperative outcomes. Methods: In a retrospective cohort study, we used institutional data to identify patients who underwent BTKA between 1998 and 2014. Patients were divided into 2 groups: those who underwent surgery before the 2006 introduction of our selection criteria (1998-2006) and those who underwent surgery after (2007-2014). Groups were compared in terms of demographics, comorbidity burden, and incidence of perioperative complications. Regression analysis was performed, calculating incidence rate ratios to evaluate changes in complication rates. Results: Before the selection criteria were implemented in 2006, patients who underwent BTKA were older and had a higher comorbidity burden. The rate of major complications per 1000 hospital days decreased from 31.5 in 1998 to 7.9 in 2014. A reduction in cardiac complications was the most significant contributor to this decrease in major complications. Conclusion: After stringent criteria for BTKA candidates were implemented at our institution, selection of younger patients with lower comorbidity burden was accompanied by a reduction in the incidence of operative complications. This suggests that introducing such criteria can be associated with a reduction in adverse perioperative outcomes.

Tramadol prescribed at discharge is associated with lower odds of chronic opioid use after elective total joint arthroplasty.

INTRODUCTION: We aimed to study the association between tramadol prescribed at discharge (after elective total hip and knee arthroplasty (THA/TKA) surgery) and chronic opioid use postoperatively. METHODS: This retrospective cohort study queried the Truven MarketScan database and identified patients who underwent an elective THA/TKA surgery between 2016 and 2018 and were prescribed opioids at discharge (n=81 049). Multivariable analysis was conducted to study the association between tramadol prescription at discharge and chronic opioid use, with additional analysis adjusting for the amount of opioids prescribed in oral morphine equivalents. Chronic opioid use was defined as filling ≥10 opioid prescriptions or prescriptions for ≥120 pills within the period from 90 days to 1 year after surgery. RESULTS: Overall, tramadol was prescribed at discharge in 11.0% of all THA/TKA cases. Of those, 26.9% and 73.1% received tramadol only or tramadol with another opioid, respectively. Chronic opioid use was observed in 5.4% of cases. After adjustment for relevant covariates, prescription of tramadol combined with another opioid at discharge was associated with lower odds of chronic opioid use comparing to prescription of other opioids (OR 0.69 CI 0.61 to 0.78). DISCUSSION: Among patients undergoing elective THA/TKA surgery and discharged with a prescription of opioids, we found that prescription of tramadol combined with another opioid was associated with lower odds of chronic opioid use. This finding must be considered in the context of the tramadol's pharmacology, as well-described genetic differences in metabolism that can make it ineffective in many patients, while for patients with ultrarapid metabolism can cause drug-drug interactions and adverse events, including feelings of high and seizures.

The Perioperative Use of Benzodiazepines for Major Orthopedic Surgery in the United States.

BACKGROUND: Despite numerous indications for perioperative benzodiazepine use, associated risks may be exacerbated in elderly and comorbid patients. In the absence of national utilization data, we aimed to describe utilization patterns using national claims data from total hip/knee arthroplasty patients (THA/TKA), an increasingly older and vulnerable surgical population. METHODS: We included data on 1,863,996 TKAs and 985,471 THAs (Premier Healthcare claims data, 2006-2019). Benzodiazepine utilization (stratified by long- and short-acting agents) was assessed by patient- and health care characteristics, and analgesic regimens. Given the large sample size, standardized differences instead of P values were utilized to signify meaningful differences between groups (defined by value >0.1). RESULTS: Among 1,863,996 TKA and 985,471 THA patients, the utilization rate of benzodiazepines was 80.5% and 76.1%, respectively. In TKA, 72.6% received short-acting benzodiazepines, while 7.9% received long-acting benzodiazepines, utilization rates 68.4% and 7.7% in THA, respectively. Benzodiazepine use was particularly more frequent among younger patients (median age [interquartile range {IQR}]: 66 [60-73]/64 [57-71] among short/long-acting compared to 69 [61-76] among nonusers), White patients (80.6%/85.4% short/long-acting versus 75.7% among nonusers), commercial insurance (36.5%/34.0% short/long-acting versus 29.1% among nonusers), patients receiving neuraxial anesthesia (56.9%/56.5% short/long-acting versus 51.5% among nonusers), small- and medium-sized (≤500 beds) hospitals (68.5% in nonusers, and 74% and 76.7% in short- and long-acting benzodiazepines), and those in the Midwest (24.6%/25.4% short/long-acting versus 16% among nonusers) in TKA; all standardized differences ≥0.1. Similar patterns were observed in THA except for race and comorbidity burden. Notably, among patients with benzodiazepine use, in-hospital postoperative opioid administration (measured in oral morphine equivalents [OMEs]) was substantially higher. This was even more pronounced in patients who received long-acting agents (median OME with no benzodiazepines utilization 192 [IQR, 83-345] vs 256 [IQR, 153-431] with short-acting, and 329 [IQR, 195-540] with long-acting benzodiazepine administration). Benzodiazepine use was also more frequent in patients receiving multimodal analgesia (concurrently 2 or more analgesic modes) and regional anesthesia. Trend analysis showed a persistent high utilization rate of benzodiazepines over the last 14 years. CONCLUSIONS: Based on a representative sample, 4 of 5 patients undergoing major orthopedic surgery in the United States receive benzodiazepines perioperatively, despite concerns for delirium and delayed postoperative neurocognitive recovery. Notably, benzodiazepine utilization was coupled with substantially increased opioid use, which may project implications for perioperative pain management.

Total hip arthroplasty through the direct anterior approach in morbidly obese patients.

AIMS: There is evidence that morbidly obese patients have more intra- and postoperative complications and poorer outcomes when undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA). The aim of this study was to determine the efficacy of DAA for THA, and compare the complications and outcomes of morbidly obese patients with nonobese patients. METHODS: Morbidly obese patients (n = 86), with BMI ≥ 40 kg/m2 who underwent DAA THA at our institution between September 2010 and December 2017, were matched to 172 patients with BMI < 30 kg/m2. Data regarding demographics, set-up and operating time, blood loss, radiological assessment, Harris Hip Score (HHS), International Hip Outcome Tool (12-items), reoperation rate, and complications at two years postoperatively were retrospectively analyzed. RESULTS: No significant differences in blood loss, intra- and postoperative complications, or implant position were observed between the two groups. Superficial wound infection rate was higher in the obese group (8.1%) compared to the nonobese group (1.2%) (p = 0.007) and relative risk of reoperation was 2.59 (95% confidence interval 0.68 to 9.91). One periprosthetic joint infection was reported in the obese group. Set-up time in the operating table and mean operating time were higher in morbidly obese patients. Functional outcomes and patient-related outcome measurements were superior in the obese group (mean increase of HHS was 52.19 (SD 5.95) vs 45.1 (SD 4.42); p < 0.001), and mean increase of International Hip Outcome Tool (12-items) was 56.8 (SD 8.88) versus 55.2 (SD 5.85); p = 0.041). CONCLUSION: Our results suggest that THA in morbidly obese patients can be safely and effectively performed via the DAA by experienced surgeons. Cite this article: Bone Jt Open 2022;3(1):4-11.

Association of perioperative midazolam use and complications: a population-based analysis.

INTRODUCTION: The benzodiazepine midazolam is the main sedative used in the perioperative setting, resulting in anxiolysis and a reduction in anesthetic dose requirements. However, benzodiazepine use is also associated with potentially serious side effects including respiratory complications, and postoperative delirium (POD). A paucity of population level data exists on current perioperative midazolam use in adult orthopedic surgery and its effects on complications. Using a large national dataset, we aimed to determine perioperative midazolam utilization patterns and to analyze its effect on postoperative outcomes. METHODS: Patients who underwent total knee and hip arthroplasty (TKA/THA) were identified from Premier database (2006-2019). Primary exposure of interest was midazolam use on the day of surgery. Multivariable logistic regression models were run to determine if midazolam was associated with postoperative cardiac and pulmonary complications, delirium, and in-hospital falls. RESULTS: Among 2,848,897 patients, more than 75% received midazolam perioperatively. This was associated with increased adjusted odds for in-hospital falls in TKA/THA (OR 1.1, 95% CI 1.07 to 1.14)/(OR 1.1, 95% CI 1.06 to 1.16), while a decrease in the adjusted odds for cardiac complications in TKA/THA (OR 0.94, 95% CI 0.91 to 0.97)/(OR 0.93, 95% CI 0.89 to 0.97), and pulmonary complications (OR 0.92, 95% CI 0.87 to 0.96) (all p<0.001) was seen. Most notably, the concurrent use of midazolam and gabapentinoids significantly increased the adjusted odds for postoperative complications, including pulmonary complications (OR 1.22, 95% CI 1.18 to 1.27)/(OR 1.29, 95% CI 1.22 to 1.37), naloxone utilization (OR 1.56, 95% CI 1.51 to 1.60)/(OR 1.49, 95% CI 1.42 to 1.56), and POD (OR 1.45, 95% CI 1.38 to 1.52)/(OR 1.32, 95% CI 1.23 to 1.34) in THA/TKA. CONCLUSION: Perioperative midazolam use was associated with an increase in postoperative patient falls, and a decrease in cardiac complications. Notably, the combined use of midazolam and gabapentinoids was associated with a substantial increase in the odds for respiratory failure and delirium. Given the high prevalence of benzodiazepines perioperatively, the risk benefit profile should be more clearly established to inform perioperative decision making.

Low-Dose Perioperative Corticosteroids Can Be Administered Without Additional Morbidity in Patients Undergoing Bilateral Total Knee Replacement: A Retrospective Follow-up Study of a Randomized Controlled Trial.

Background: Short-term benefits of perioperative corticosteroid injections (CSIs) for bilateral total knee replacement (BTKR) include suppressed inflammation, improved knee motion, and reduced pain. Very little is known about the long-term benefits, complications, and safety of corticosteroids administered in the perioperative period. Purpose: We sought to compare 3-year follow-up outcomes of BTKR patients who received perioperative CSI with those who received placebo. We hypothesized that there would be no statistically significant differences in functional outcomes or adverse events based on whether or not CSIs were administered in the perioperative period. Methods: We conducted a retrospective review of chart and registry data of BTKR patients from a prior randomized controlled trial to compare outcomes in patients who received hydrocortisone vs placebo injections after BTKR (ClinicalTrials.gov: NCT01399268 and NCT01815918). Outcomes were compared at 6 and 12 weeks and at 1, 2, and 3 years. The Knee Injury and Osteoarthritis Outcome Scores (KOOS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were used to evaluate clinical outcomes. Cochran-Mantel-Haenszel tests were used to compare the risk of complications between treatments after adjustment for trial. When possible, summary relative risk estimates were calculated using the Mantel-Haenszel method. Results: No BTKR patients in the treatment group developed an infection. The risk of complications did not increase in patients who received CSI compared with those who received placebo. Patients in the CSI group experienced greater reductions in pain and stiffness, though these results were not statistically significant. There were no statistically significant differences in the KOOS-Symptoms, KOOS-Activities of Daily Living, KOOS-Sports, KOOS-Quality of Life, or WOMAC Function scores. Conclusions: Low-dose corticosteroids can be administered in selected patients who undergo BTKR without increasing the risk of adverse events. At 3-year follow-up, administration of low-dose corticosteroids did not result in superior clinical outcomes scores when compared with placebo.

Early failure of an uncemented femoral stem, as compared to two other stems with similar design, following primary total hip arthroplasty performed with direct anterior approach.

INTRODUCTION: An increased risk of early femoral component loosening has been reported using the direct anterior approach (DAA) compared with other common surgical approaches. However, long-term data are scarce. The purpose of this study is: (1) to determine the incidence of early femoral loosening in a high volume, single surgeon's practice utilising the DAA approach; and (2) to examine the effect of stem design and type of coating on aseptic loosening in the early and mid-term postoperative period. METHODS: A retrospective review of 1650 consecutive patients (1800 hips) who underwent total hip arthroplasty (THA) using the DAA between August 2011 and December 2017 was conducted at our institution. 3 types of uncemented femoral stems (Quadra-S, Avenir, TwinSys), with similar design, but different coating, were implanted. Patients were evaluated clinically and radiologically at 4 weeks, 3 months, 1 year, and annually thereafter. RESULTS: After a mean follow-up of 46.4 months, the total incidence of revision for aseptic loosening was 0.44% (n = 8). All loose stems were Quadra-S, failing to achieve osseointegration, for an overall incidence of 0.96% (p = 0.002). None of the other stems were loose. Radiolucent lines around the proximal stem portion were visible in 75 Quadra-S stems (4.1%) on radiographs taken at 1 year postoperatively and continued to deteriorate at the latest follow-up. CONCLUSIONS: In this specific cohort of patients, the increased rate of femoral stem aseptic loosening was implant-related and was attributed only to a specific type of femoral stem (Quadra-S). No relation to other factors was proven suggesting that the surface characteristics of this femoral stem and the lack of bioactive coating are responsible for the observed early femoral failures. These findings should be confirmed by additional registry work and larger population sample sizes are needed to evaluate the prosthesis performance after implantation through the DAA.

Anterior femoral notching ≥ 3 mm is associated with increased risk for supracondylar periprosthetic femoral fracture after total knee arthroplasty: a systematic review and meta-analysis.

PURPOSE: Anterior femoral notching (AFN) may be associated with a higher risk for supracondylar periprosthetic fracture (sPPF) after total knee arthroplasty (TKA), although studies have yielded inconclusive results. We aimed to systematically investigate and meta-analyze the best available evidence regarding the association between AFN and the risk of sPPF after TKA. METHODS: A comprehensive search of PubMed, Scopus, Mendeley, Google Scholar and Cochrane databases was performed, from conception to February 29, 2020. Data were expressed as odds ratio (OR) with 95% confidence intervals (CI). I2-index was employed for heterogeneity. Newcastle-Ottawa scale was implemented for quality assessment of the included studies. RESULTS: Nine studies fulfilled the eligibility criteria, including a total of 3264 patients subjected to TKA. Among them, there were 150 patients who sustained a sPPF. Overall, patients exposed to AFN (AFN group) demonstrated an increased risk for sPPF compared to those not exposed (control group) (OR 3.91, 95% CI 1.22-12.58, p = 0.02; I2 68.52%). Subgroup analysis based on AFN depth with a cut-off value of 3 mm further clarified this association. Patients with AFN ≥ 3mm were at higher risk for sPPF compared to patients with AFN < 3 mm and control group (OR 4.85, 95% CI 2.08-11.33, p = 0.00; I2 0.0%). On the contrary, fracture risk was not significant for patients with AFN < 3 mm compared to the control group (OR 5.0, 95% CI 0.44-56.82, p = 0.19; I2 42.99%). CONCLUSION: Patients, exposed to AFN ≥ 3 mm in depth, are at higher risk for sustaining a sPPF.

Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature.

BACKGROUND: Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery. METHODS: A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations. RESULTS: Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92). CONCLUSIONS: Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes. RECOMMENDATION: PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.

Do trabecular metal and cancellous titanium implants reduce the risk of late haematogenous infection? An experimental study in rabbits.

AIM: This study evaluated the late resistance to haematogenous contamination by microbial pathogens of implants and bone-implant interface and the development of late clinical infection when cementless components with different surface or structural properties are implanted. MATERIAL AND METHODS: 50 adult male New Zealand white rabbits were divided into 5 groups of 10 animals each. In Group A smooth titanium, in Group B grit blasted titanium, in Group C HA-coated titanium, in Group D trabecular metal and in group E cancellous titanium rods were implanted in the right proximal tibia. Four weeks later, 1 ml of inoculum of a standardised CA-MRSA strain (3 × 108 cfu/ml) was injected through a femoral artery catheter (groups B, C, D, E) while in group A, 1 ml of sterile saline was injected in a similar way (control group). Subjects were killed 8 weeks after the initial procedure and 3 samples of each tibial specimen were subjected to conventional cultures and PCR studies. RESULTS: The number of the specimens (conventional cultures and PCR studies) contaminated by the standardized pathogen was as follows: Group A: 0/10, Group B: 7/10, Group C: 6/10, Group D; 5/10 and Group E: 5/10. Comparing the number of colony form units isolated from the implant samples, Group B (GB titanium) showed statistically significantly higher values (Mann-Whitney test) compared to Group C (p = 0.044), Group D (p = 0.040) and Group E (p = 0.038). Local active infection was observed in 6 animals: 3 in Group B; 1 in Group C, 1 in Group D, and 1 in Group E. CONCLUSIONS: Modern cementless implants (trabecular metal and cancellous titanium) showed a lower risk of implant contamination and late clinical haematogenous infection.

Risk of chronic opioid use after simultaneous versus staged bilateral knee arthroplasty.

BACKGROUND: Several studies have identified excess risk associated with undergoing simultaneous (compared with unilateral or staged) bilateral total knee arthroplasty (BTKA). However, few have addressed subsequent chronic opioid use. Given the substantial morbidity and mortality associated with prolonged opioid use, we evaluated the incidence of postoperative chronic opioid use following simultaneous versus staged BTKA, based on the different timing strategies of staged procedures. METHODS: In this retrospective cohort study, patients who underwent BTKA procedures (2012-2016; Truven Health MarketScan; n=14 407) were classified as having undergone simultaneous or staged BTKA (<3 months, 3-6 months or 6-12 months apart). Outcomes were postoperative chronic opioid use and oral morphine equivalents prescribed on discharge. Multivariable regression models measured associations between type/timing of BTKA and outcomes. ORs and 95% CIs were reported. RESULTS: Unadjusted frequency of chronic opioid use did not differ between groups, (Simultaneous: 11.3%, staged <3 months: 10.7%, staged 3-6 months: 11.7%, staged >6 months: 10.2%; p=0.247). In an adjusted model, there was no significant difference in the odds of becoming chronic opioid users between staged and simultaneous BTKA (staged <3 months OR 1.03, 95% CI 0.88 to 1.21/staged 3-6 months OR 0.94, 95% CI 0.79 to 1.12/staged >6 months OR 0.96, 95% CI 0.82 to 1.13; p=0.755). Patients undergoing staged BTKAs <6 months apart (compared with simultaneous) were prescribed slightly greater oral morphine equivalents on hospital discharge (staged <3 months 6% increase, 95% CI 3% to 10%; staged 3-6 months 4%, 95% CI 1% to 8%; p=0.002). CONCLUSION: Although patients undergoing staged BTKA <6 months apart were prescribed greater quantities of opioids on discharge, there was no significant difference in the odds of postoperative chronic opioid use compared with simultaneous BTKA. The timing of BTKA procedures does not appear to influence the likelihood of postoperative chronic opioid dependence.

Gluteus maximus tendon transfer for chronic abductor insufficiency: the Geneva technique.

INTRODUCTION: The treatment options of chronic abductor insufficiency in the setting of muscle degeneration, are limited and technically demanding. We present the outcomes of a salvage technique for unreconstructable, chronic abductor tears performed by a single surgeon. METHODS: We retrospectively evaluated 38 patients who were surgically managed for chronic abductor insufficiency. Patients without hip implants and patients following primary or revision total hip arthroplasty (THA) were involved. All patients had a Trendelenburg gait, impaired muscle strength of abduction (⩽M4) and fatty degeneration of muscles (Goutallier ⩾3). They underwent transfer of a flap of the anterior third of gluteus maximus to the greater trochanter that was sutured under the slightly mobilised vastus lateralis. The level of pain, functional scores, muscle strength and Trendelenburg gait were re-evaluated at 12 postoperative months. RESULTS: The mean age of patients was 70.2 years. 10 patients received the tendon transfer on a native hip, 6 following primary THA and 22 after revision THA. The mean pain level (3.2 vs. 7, p < 0.001) and Harris Hip Score (80.2 vs. 41.6, p < 0.001) and the median abductor strength (4 vs. 3, p < 0.001) was significantly improved compared to the preoperative scores. 26 patients demonstrated negative and 12 positive Trendelenburg sign at 12 postoperative months. No serious complications were reported. CONCLUSIONS: This salvage technique improved the strength of abduction and functional results and reduced the level of pain in 80% of patients with chronic abductor tears. The short-term outcomes of the procedure were favourable; however, further evaluation is needed.

Short-term outcomes following mini-open repair of chronic gluteus medius tendon tears using a double-row technique.

Gluteal tendon tears represent a common but underreported cause of lateral hip pain and dysfunction. In case of conservative management failure, a surgical procedure must be performed to relieve patient symptoms. Current operative treatments, either open or endoscopic, have been however associated with different drawbacks which led to the introduction of the mini-open technique. The aim of this study was to evaluate and report the short-term outcomes of patients operated through the aforementioned surgical technique for gluteus medius (GM) chronic tears. We retrospectively analysed the records of 14 consecutive patients operated at the La Tour hospital by mini-open repair using a double-row technique for full-thickness GM chronic tears. Intra- and post-operative complications were recorded. The pre- and post-operative pain on visual analogue scale (pVAS), modified Harris Hip score (mHHS), abduction strength and gait dysfunction were assessed for all patients. Pre- and post-operative values were compared to evaluate whether improvements were statistically significant and clinically relevant. The study cohort comprised 13 women (93%) and 1 man (3%) aged 62.4 ± 18.0 at index surgery. No intra- or post-operative complications were noted. Compared to pre-operative values, patients reported a significant improvement in mHHS (59.1 ± 7.1 vs 92.7 ± 4.6) and pVAS (7.4 ± 1.0 vs 1.3 ± 1.3) at last follow-up. Patients exhibited a perfect improvement in muscle strength (3.6 ± 0.5 vs 5.0 ± 0.0), and the proportion of patients with a positive Trendelenburg sign decreased from 71% to 0%. Mini-open repair of chronic GM tendon tears using a double-row technique demonstrated excellent clinical and functional outcomes at short follow-up. Level of Evidence: IV.

Quality of the femoral cement mantle in total hip arthroplasty using the direct anterior hip approach.

BACKGROUND: Limited literature exists concerning the femoral cement mantle quality that can be achieved through an anterior approach in total hip arthroplasty (THA). We radiologically evaluated the quality and thickness of the femoral cement mantle in patients undergoing THA utilizing the direct anterior approach (DAA). METHODS: Immediate postoperative anteroposterior and lateral radiographs of 116 consecutive patients who underwent hybrid or fully cemented THA using the DAA and cemented Quadra-C stem (Medacta, International, SA, Switzerland) were assessed by 2 arthroplasty surgeons blinded to the study. Surgical indications were hip osteoarthritis or subcapital hip fracture. The cement mantle and stem alignment were evaluated using the Barrack classification and Khalily methods, respectively. After calibration of radiographs, the thinnest part of the cement mantle per Gruen zone was recorded. Parameters were compared between obese and nonobese patients. RESULTS: Agreement between raters was substantial for the cement quality in anteroposterior (k = 0.707, P ≤ .001) and moderate for lateral radiographs (k = 0.574, P ≤ 001). The cement mantle was graded A in 39.25%, B in 53.0%, and C in 7.75% of anteroposterior radiographs and similarly for lateral radiographs (40.1% A, 51.75% B, 9.5% C). 93% of stems had neutral alignment. The mean thinnest cement mantle (P = .237) and incidence of inadequate cement mantle (<2 mm) per zone (P = .431) were comparable between Gruen zones. The cement mantle quality (P = .174) and inadequacy (P > .05) and stem alignment (P = .652) were comparable between obese and nonobese patients. CONCLUSIONS: DAA enables correct implantation and effective cementation of straight femoral stems. A high-quality cement mantle can be achieved using DAA even in obese patients.