Robot-Assisted Patellofemoral Arthroplasty.

Background: Patellofemoral arthroplasty is indicated in patients with isolated patellofemoral arthritis in whom nonoperative treatment has failed2. The goal of the presently described procedure is to provide relief from patellofemoral arthritis pain while maintaining native knee kinematics2. Description: Patient radiographs are carefully reviewed for isolated patellofemoral arthritis in order to determine the appropriateness of robotic-assisted patellofemoral arthroplasty. Magnetic resonance imaging can be performed preoperatively to help confirm isolated patellofemoral arthritis. We perform this procedure with use of the MAKO Surgical Robot (Stryker). Preoperative computed tomography is performed to plan the bone resection, the size of the implant, and the positioning of the device. The steps of the procedure include (1) medial parapatellar arthrotomy, (2) intraoperative inspection to confirm isolated patellofemoral arthritis, (3) patellar resurfacing, (4) placement of optical arrays and trochlear registration, (5) trochlear resection, (6) trialing of implants, (7) removal of the optical array, (8) impaction of final implants, (9) confirmation of appropriate patellar tracking, and (10) closure. Alternatives: Alternatives to patellofemoral arthroplasty include standard nonoperative treatment, bicompartmental arthroplasty, total knee arthroplasty, tibial tubercle osteotomy, partial lateral facetectomy, and arthroscopy2. Rationale: Patellofemoral arthroplasty is indicated in patients with isolated patellofemoral arthritis in whom nonoperative treatment has failed2. Patellofemoral arthroplasty may be superior to total knee arthroplasty because it helps treat pain that affects patient quality of life and activities of daily living while also preserving greater tibiofemoral bone stock2. We recommend against performing patellofemoral arthroplasty in patients with arthritis of the tibiofemoral joints2. Expected Outcomes: In properly selected patients, outcomes include improvement in patient pain and function1. One study found that robotic-assisted patellofemoral arthroplasty may result in improved patellar tracking compared with non-robotic-assisted patellofemoral arthroplasty1; however, functional outcomes were found to be similar between procedures, and data for all non-robotic-assisted controls were retrospectively captured1. Important Tips: Confirm isolated patellofemoral arthritis on radiographs and/or magnetic resonance imaging.Review the preoperative plan for appropriate positioning of the trochlear implant.○ Confirm coverage of the trochlear groove.○ Avoid medial overhang.○ Avoid lateral overhang.○ Avoid anterior femoral notching.○ Avoid impingement of the trochlear component into the notch.○ Avoid excessive prominence of the trochlear component on the anterior femoral cortex.○ General principles are to place the trochlear component in 0° to 6° of flexion and 0° to 2° of external rotation.Robotic-assisted trochlear resurfacing is accurate and efficient. Acronyms and Abbreviations: CT = computed tomography.

Medical advisability of softball youth pitching recommendations on the internet.

OBJECTIVE: Developing softball pitchers are prone to injury due to the repetitive throwing motion. Many children and parents use the internet as a source of medical advice, but this information may not always be aligned with medical guidelines. The purpose of this study was to assess the medical advisability of injury prevention guidelines for developing softball pitchers on websites using Google as the primary search engine. METHODS: The first 100 websites populated from a Google search using the term softball youth pitching recommendations were evaluated. Each website was categorized as discussing baseball, softball, or both, and as athletic, commercial, or educational. For every website, 16 recommendations described by the American Orthopaedic Society for Sports Medicine (AOSSM) Stop Sports Injuries softball injury prevention guidelines (Table 1) were scored as in agreement (+1), different guideline mentioned (0.5), no mention (0), or discordant (-1).[Table: see text]. RESULTS: Of the 98 qualifying websites, 57 advised only about softball, while 19 advised about both baseball and softball. Fifty websites had no mention of any recommendation outlined by AOSSM. Websites that were mostly in agreement with AOSSM were educational websites (mean score = 3.9, p = 0.02), websites discussing only softball (mean score = 2.0, p = 0.02), and the first 50 websites (mean score = 2.2, p = 0.04). The most common discordant guideline was differing opinions in pitch count (13 websites). CONCLUSION: The most common category in disagreement with AOSSM was different pitch count guidelines, highlighting a need for websites to provide more consistent information using high-quality resources. Educational websites, websites discussing only softball, and the first 50 websites had the highest scores, indicating that these types of websites are most likely to have the highest amount of medically advisable information. We recommend users conduct targeted Google searches on reliable websites for information on pitching softball recommendations to maximize the validity of Google search results.

Subscapularis Management With Biologic Augmentation in Anatomic Total Shoulder Arthroplasty.

Subscapularis insufficiency continues to be a source of morbidity after anatomic total shoulder arthroplasty (TSA). Biologic augmentation following rotator cuff repair has shown promising results. Here we show the technique for performing subscapularis repair after anatomic TSA using a "peel-tenotomy" and bone marrow aspirate concentrate (BMAC). A standard deltopectoral approach is performed. The peel-tenotomy is performed by leaving 0 to 10 mm of subscapularis attached to the lesser tuberosity and peeling off the remainder of the tendon. A trocar is used to aspirate bone marrow from the humeral head, which is then processed. Prior to placing the humeral stem, drill holes are placed at the bicipital groove and lesser tuberosity. Sutures are placed through each drill hole. After impacting the humeral stem, suture is passed through the subscapularis to perform a secure double row repair. Prior to tying the sutures, BMAC is applied along the margins of the subscapularis repair. After securing the sutures, additional BMAC can be applied to the subscapularis repair. It is hypothesized that this technique could provide a more robust subscapularis repair and decrease the rate of subscapularis insufficiency after TSA without any known risk or morbidity to the patient, although further research is needed to show this.

Failure Following Revision Total Hip Arthroplasty After Cobalt-Chrome Femoral Heads are Placed on a Retained Femoral Stem.

BACKGROUND: Failure due to trunnionosis with adverse local tissue reaction (ALTR) has been reported with cobalt-chrome (CoCr) heads in total hip arthroplasty (THA); however, there are limited data on the use of these heads in the revision setting. The purpose of this study was to analyze the outcomes of patients who underwent revision THA with a retained femoral component and received a CoCr femoral head on a used trunnion. METHODS: In this retrospective review, we identified all patients who underwent revision THA with a retained femoral component and received a CoCr femoral head between February 2006 and March 2014. Demographic factors, implant details, and postoperative complications, including the need for repeat revisions, were recorded. In total, 107 patients were included (mean age 67 years, 74.0% women). Of the 107 patients, 24 (22.4%) required repeat revisions. RESULTS: Patients who required repeat revision were younger than those who did not (mean age: 62.9 versus 69, P = .03). The most common indications for repeat revision were instability (8 of 24, 33.3%), ALTR (5 of 24, 20.8%), and infection (4 of 18, 16.7%). Evidence of ALTR or metallosis was identified at the time of reoperation in 10 of the 24 patients who underwent re-revision (41.7%). CONCLUSIONS: The placement of a new CoCr femoral head on a used trunnion during revision THA with a retained femoral component carries a significant risk of complication (22.4%) and should be avoided when possible.

Increased arthroplasty surgeon energy consumption when performing primary total hip arthroplasty compared to total knee arthroplasty.

Introduction: Previously published studies have hypothesized that total hip arthroplasty (THA) requires the surgeon to expend more energy that total knee arthroplasty (TKA). However, techniques for performing these procedures have evolved. Therefore, we sought to compare if primary THA had increased energy expenditure compared to primary TKA. Methods: We prospectively recorded the heart rate, respiratory rate, minute ventilation, cadence, and energy expenditure of a single fellowship-trained arthroplasty surgeon while performing primary THA and TKA on 372 patients. Patient demographics and operative records were reviewed to evaluate differences in the physical demands of each surgical case. Age (64.3 versus 65.9 years, p = 0.1) and gender (54.8% versus 51.0% female, p = 0.5) were similar between THA and TKA, but TKAs had a higher body mass index (31.1 versus 28.7 kg/m2, p < 0.001). Chi-square and independent-samples t-tests were used to compare cohorts. Significance was set at p < 0.05. Results: THA tended to have 1.1 times longer operative time than TKA (102.2 versus 88.9 min, p < 0.001). THA had a statistically higher heart rate compared to TKA, although this is unlikely to be clinically significant (82.5 versus 80.7 beats/minute, p < 0.001). Respiratory Rate was 1.1 times higher (15.9 versus 14.9 respirations/minute, p < 0.001) and minute ventilation was 1.2 times higher (19.6 versus 16.9 L/min, p < 0.001) when performing THA. Cadence was 1.5 times higher when performing TKA (4.2 versus 2.8 steps/minute, p < 0.001). THA had a 1.2 times higher energy expenditure/patient (378.8 versus 312.0 Calories/patient, p < 0.001) and a 1.1 times higher energy expenditure/minute (3.7 versus 3.5 Calories/minute, p = 0.01) compared to TKA. Discussion: THA is associated with longer operative time and increased energy expenditure per compared to TKA. Despite THA and TKA procedures becoming more efficient, arthroplasty surgery continues to have heavy physical burden on the surgeon. Further research is needed to understand ways to decrease surgeon energy expenditure and promote career longevity.

Similar incidence of postoperative sciatic nerve palsy in direct anterior and posterior approach total hip arthroplasty.

BACKGROUND: Sciatic nerve palsy is a rare but devastating complication following total hip arthroplasty (THA). While the use of the direct anterior approach is increasing, limited data exist regarding sciatic nerve palsy and surgical approach. The purpose of this study was to determine the factors and outcomes associated with sciatic nerve palsy (SNP) after THA. METHODS: A retrospective analysis was performed at a single institution of 7 SNP that occurred in 4045 THA via direct anterior approach and 10 SNP in 8854 THA via posterior approach, being operated between 01 January 2017 and 12 December 2021. SNP patients were matched 1:5 to patients without SNP. Medical records were reviewed for demographics including age, gender, body mass index (BMI), comorbidities, and preoperative indication. Additional workup of SNP patients including advanced imaging and reoperation were documented. Recovery grades were assigned to all SNP patients at most recent clinical follow-up. RESULTS: 5 of the SNP were complete and 12 partial. They occurred as frequently with the direct anterior (0.17%) and posterior approach (0.11%, p = 0.5). The presence of femur cables and reoperations were associated with SNP (p = 0.04 and p = 0.002, respecitvely). Age, gender, BMI, comorbidities, and surgical indication had no effect on SNP. 4 of the 17 affected patients had almost complete recovery at latest follow-up. CONCLUSIONS: The incidence of SNP was similar in direct anterior and posterior approach. Surgeons should counsel patients regarding the risks of SNP regardless of the used approach.

Antibiotic Prophylaxis Prior to Dental Procedures After Total Hip and Knee Arthroplasty Does Not Decrease the Risk of Periprosthetic Joint Infection.

BACKGROUND: Periprosthetic joint infection (PJI) is a devastating complication after total hip and total knee arthroplasty (THA/TKA). While some guidelines no longer recommend routine use of prophylactic antibiotics for dental procedures, many surgeons continue to prescribe antibiotics for their THA/TKA patients. In a setting of increasing antibiotic resistance, it is important to reduce unnecessary antibiotic use. This study aims to evaluate antibiotics prior to dental procedures and the association between dental procedures and PJI. METHODS: We conducted a retrospective cohort study of patients who underwent THA/TKA between January 1, 2019 and December 31, 2020. The primary outcome was late-presenting PJI, occurring > 90 days after surgery. Patients were designated in the antibiotic group (2,000 mg of amoxicillin) or non-antibiotic group based on their surgeon's prophylaxis protocol. Dental-associated PJIs were considered if the patient had evidence of poor dentition or a recent dental procedure prior to the onset of PJI symptoms. RESULTS: There were 2,871 (26.4%) patients in the no antibiotics group and 8,023 (73.6%) patients in the antibiotics group. We found 27 (0.3%) late-presenting PJIs and 4 dental-associated PJIs. In the univariate and multivariable analyses, body mass index ≥-30 and revision surgery were the only variables that increased the odds of late-presenting PJI. All 4 dental-associated PJIs occurred in patients prescribed antibiotics. CONCLUSIONS: We found a low rate of late-presenting PJI. Routine antibiotics prior to dental procedures were not shown to affect the risk of late-presenting PJI. These findings suggest that routine antibiotic prophylaxis before dental procedures is not necessary after THA/TKA.

Modular Knee Arthrodesis as Definitive Treatment for Periprosthetic Infection, Bone Loss, and Failure of the Extensor Mechanism After Total Knee Arthroplasty.

Background: Periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) can result in bone and soft-tissue loss, leg length discrepancies, and dysfunctional extensor mechanisms. While above-knee amputation (AKA) is an established salvage treatment, modular knee arthrodesis (MKA) is a viable option that provides rigid stability and maintains leg length even in patients with severe bone and soft-tissue loss. We sought to report the outcomes of patients with an MKA as the definitive treatment. Methods: We retrospectively reviewed 8 patients implanted with an MKA at 2 institutions between 2016 and 2022. The mean age was 69.63 years, and 50.0% of patients were women. All patients were indicated for conversion to an MKA as the definitive treatment in the setting of treated chronic PJI after TKA, severe bone loss, and failure of the extensor mechanism not amenable to repair. Medical records and radiographs were reviewed. Results: No patients required incision and drainage or exchange of their MKA for PJI at mean 2-year follow-up. One patient required 2 revisions for mechanical failure of his implant at 5.0 and 6.4 years postoperatively. Conclusions: MKA is a viable permanent alternative to AKA for patients with treated chronic PJI and dysfunctional extensor mechanism after TKA. The procedure restores leg lengths in the setting of severe bone and soft-tissue loss, therefore allowing patients to ambulate independently. Still, surgeons should be aware of the potential for mechanical failure requiring revision.