Utility of prophylactic closed suction drainage in open reduction and internal fixation for tibial plateau fracture.

PURPOSE: The usefulness of closed suction drains (CSD) after open reduction and internal fixation (ORIF) of tibial plateau fractures is a contested topic. The purpose of this study was to examine the impact of CSD in postoperative outcomes after tibial plateau fracture. METHODS: Data were retrospectively collected from patients who underwent primary repair of closed tibial plateau fractures via an anterolateral approach between June 2021 to May 2022 at a single academic center. Fifty-six patients were included and 28 received CSDs at time of surgery. P values less than 0.05 were considered significant. RESULTS: Fifty-six patients were included. There was no significant difference in demographics, pre- and post-op hemoglobin, estimated blood loss during surgery, length of stay, postoperative MMEs and pain at 3 month follow-up, deep vein thrombosis (DVT), compartment syndrome, flexion contracture, use of incisional vac, infection rate, wound drainage, hematoma, neurologic pain, dehiscence, additional surgery, or range of motion at 3 months follow-up. We noted a significant difference in Defense and Veterans Pain Rating Scale (DVPRS) on POD1, demonstrating greater pain in those in the CSD group. CONCLUSION: Our findings suggest that the use of CSD in ORIF of tibial plateau fractures may not be of significant prophylactic benefit. CSDs in ORIF patients were associated with increased early postoperative pain and had no identifiable benefits. LEVEL OF EVIDENCE: III.

Minimal stress shielding with a Mallory-Head titanium femoral stem with proximal porous coating in total hip arthroplasty.

BACKGROUND: As longevity of cementless femoral components enters the third decade, concerns arise with long-term effects of fixation mode on femoral bone morphology. We examined the long-term consequences on femoral remodeling following total hip arthroplasty with a porous plasma-sprayed tapered titanium stem. METHODS: Clinical data and radiographs were reviewed from a single center for 97 randomly selected cases implanted with the Mallory-Head Porous femoral component during primary total hip arthroplasty. Measurements were taken from preoperative and long-term follow-up radiographs averaging 14 years postoperative. Average changes in the proximal, middle and diaphyseal zones were determined. RESULTS: On anteroposterior radiographs, the proximal cortical thickness was unchanged medially and the lateral zone increased 1.3%. Middle cortical thickness increased 4.3% medially and 1.2% laterally. Distal cortical thickness increased 9.6% medially and 1.9% laterally. Using the anteroposterior radiographs, canal fill at 100 mm did not correlate with bony changes at any level (Spearman's rank correlation coefficient of -0.18, 0.05, and 0.00; p value = 0.09, 0.67, 0.97). On lateral radiographs, the proximal cortical thickness increased 1.5% medially and 0.98% laterally. Middle cortical thickness increased 2.4% medially and 1.3% laterally. Distal cortical thickness increased 3.5% medially and 2.1% laterally. From lateral radiographs, canal fill at 100 mm correlated with bony hypertrophy at the proximal, mid-level, and distal femur (Spearman's rank correlation coefficient of 0.85, 0.33, and 0.28, respectively; p value = 0.001, 0.016, and 0.01, respectively). CONCLUSION: Stress shielding is minimized with the Mallory-Head titanium tapered femoral stem with circumferential proximal plasma-sprayed coating in well-fixed and well-functioning total hip arthroplasty. Additionally, the majority of femora demonstrated increased cortical thickness in all zones around the stem prosthesis. LEVEL OF EVIDENCE: Therapeutic Level III.

Survivorship of 2000 tapered titanium porous plasma-sprayed femoral components.

UNLABELLED: Tapered titanium porous plasma-sprayed components have performed well in primary THA. To confirm the literature at longer followup we retrospectively reviewed all 1639 patients who underwent 2000 THAs in which a specific porous femoral component was used. One hundred fourteen patients (134 hips) were lost to followup leaving a cohort of 1525 patients (1866 THAs). The component is a tapered titanium plasma spray-coated design that remained relatively unchanged since its first implantation except for circumferential proximal porous coating added in 1986 and an offset option added in 1999. Minimum followup was 24 months (average, 119 months; range, 24 to 275 months). To date there have been 39 femoral revisions for an implant survival of 98%. Using the Kaplan-Meier method, cumulative survival with any stem revision as the end point was 98.6% at 5 years, 98.4% at 10 years, 97.1% at 15 years, and 95.5% at 20 years. Using aseptic revision for failure of ingrowth as the endpoint, stem survival was 99.1%. Kaplan-Meier cumulative survival with aseptic revision for failure of ingrowth as the endpoint was 99.4% at 5 years, 99.3% at 10, 15 and 20 years. Harris hip pain and total scores improved. This titanium, porous plasma spray-coated femoral component continues to demonstrate high long-term survival with a low rate of component revision for any reason or aseptic failure of ingrowth. LEVEL OF EVIDENCE: Level IV, therapeutic study (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Tapered cementless femoral stem: difficult to place in varus but performs well in those rare cases.

This retrospective review was conducted to determine the incidence and minimum 5-year follow-up of varus placement of a tapered, proximally plasma-sprayed, titanium femoral component. Twenty-six (2.4%) of 1080 components were placed in > or = 5 degrees of varus in primary cementless total hip arthroplasty at one institution. Harris hip scores improved an average of 50 points. One stem was revised for malposition at 2.5 years, yet was well-fixed by radiographic criteria. Survival with aseptic loosening as an end-point is 100% with an overall femoral component survival of 96% at an average 10-year follow-up. A tapered, titanium component is reliably placed into appropriate position and is forgiving as to varus implant position.

Modular calcar replacement prosthesis with strengthened taper junction in total hip arthroplasty.

Whereas femoral component modularity allows the surgeon to address a variety of femoral defects in complex total hip arthroplasty (THA), breakage of modular stems is a known complication that typically occurs at the taper junction. In response, a proprietary process of taper roller-hardening that increases taper strength by a factor of 3.5 was introduced in 1999. The authors reviewed a consecutive series of patients by a single surgeon who underwent cementless revision or difficult primary THA with a taper roller-hardened modular calcar replacement prosthesis, and have the potential for a minimum of two-year follow up. In 116 patients, 123 hips were involved. Two surgeries were primary, 101 were revision/conversion, 18 were for reimplantation after treatment of infection, and two were intramedullary total femur constructs, one of which was a reimplantation after sepsis. The patients' ages at surgery averaged 71 years, and BMIs averaged 28.12 kg/m2. Nine of the patients, all with single hip involvement, were lost to contact. Twenty-one patients, three of whom had bilateral hip involvement, expired during the follow-up period with implant outcome known. Follow up in the patients who survived averaged 44 (range: 18-78) months. Six femoral components have been revised: two (1.6%) due to recurrent sepsis, three (2.4%) due to sepsis, one (0.8%) from periprosthetic fracture, and none from septic loosening or component breakage. Survivorship with aseptic loosening as the end-point was 100%. In this series, roller-hardening appears to improve the durability of the tapered junction. No roller-hardened modular calcar devices have failed due to component breakage. However, their use is not recommended in the totally deficient proximal femur, as fatigue breaks of distally fixed monoblock extensively coated stems have been reported. Caution is advised when potting or anchoring any stem in the femoral diaphysis without reconstituting proximal bone stock and support.

A lateralized tapered titanium cementless femoral component does not increase thigh or trochanteric pain.

Increased femoral component lateralization has been reported to recreate femoral offset accurately, and should provide better function. Concerns exist that negative effects may occur such as increased thigh pain, trochanteric bursitis, and loosening. The current study aims to examine whether a lateralized femoral component design is associated with increase in thigh pain, trochanteric pain, or implant failure when used to recreate hip soft tissue balance and stability. The authors reviewed 98 total hip arthroplasties (THA) using the Mallory-Head Porous femoral component. Group 1 had 49 consecutive THA performed before the lateralized stem was available. Group 2 had 49 consecutive THA in which lateralization was deemed necessary, based upon preoperative templating and intraoperative soft tissue balancing. Follow up averaged 46 and 38 months, respectively. No stems failed. Group 1 had three dislocations and Group 2 had none with increased offset. Six (12%) patients in Groups 1 and 3 (6%) patients in Group 2 had trochanteric pain (p<0.05). Three (6%) patients had moderate thigh pain in Group 1 and none in Group 2. Significantly less trochanteric and thigh pain was observed in those patients in whom a lateralized stem was deemed necessary. The use of a lateralized stem improves the accuracy of hip soft tissue reconstruction and does not increase thigh pain, trochanteric pain, or loosening. Accurate soft tissue reconstruction may decrease trochanteric and thigh pain and improve function following THA.

A simple and accurate method for determining leg length in primary total hip arthroplasty.

Reconstruction of appropriate leg length is an important part of soft-tissue balance in total hip arthroplasty (THA). Leg length discrepancy (LLD) is one of the more common reasons for litigation after otherwise successful THA. The purpose of the study reported here was to analyze the accuracy of using preoperative templating and intraoperative referencing of the well leg to determine postoperative leg length in unilateral primary THA. Seven-hundred primary THAs performed at an institution by 3 surgeons were randomly selected from a computerized database. Cases with significant bilateral disease, congenital dysplasia, acute fracture, or previous surgery or without complete preoperative and postoperative radiographs were excluded. Three reviewers used a standardized method to measure preoperative and postoperative LLD. Included in the review were 410 THAs. Mean postoperative LLD was 3.9 mm lengthening (SD, 7.5 mm). In 20 THAs (4.9%), lengthening was more than 15 mm. Lengthening was more than 20 mm (maximum, 22 mm) in 4 THAs (1%). Of the 20 THAs with LLD of more than 15 mm, 14 involved hips that were longer preoperatively. Thirteen of these hips were reconstructed to within 10 mm of preoperative LLD. Only 2 patients with radiographic LLD of more than 15 mm perceived LLD. There were no differences in gender, height, weight, or body mass index. This method of preoperative templating and referencing the well leg intraoperatively is an inexpensive, reliable, and accurate method for determining leg length in primary THA and has few significant radiographic or clinical outliers.

Manipulation with prolonged epidural analgesia for treatment of TKA complicated by arthrofibrosis.

Inability to achieve adequate range of motion (ROM) after total knee arthroplasty (TKA) represents a frustrating complication for both patient and surgeon. Manipulation under anesthesia is indicated in TKA having less than 90 degrees ROM after six weeks, with no progression or regression in ROM. A modified technique has evolved for patients with chronic regional pain syndrome (CRPS) symptoms or persistent stiffness after standard manipulation. A retrospective review was conducted to determine the efficacy of the modified technique, which uses epidural anesthesia continued for postoperative analgesia, hospital stay of one to three days, continuous passive motion (CPM) for two to three days, and daily physical therapy (PT). Between 1997 and 2003, 5714 TKAs were performed in 4106 patients. Manipulation using a standard technique was performed on 334 (5.8%) knees in 273 patients. Manipulation using a modified technique was performed on 65 (1%) knees in 60 patients. Age averaged 58 years and body mass index (BMI) averaged 34.39. Follow up averaged 18.4 months. ROM improved significantly from 71 degrees to 102 degrees (p < 0.0001). Knee Society pain, function, and total clinical scores all improved significantly (all p < 0.0001). Successful results were observed in 48 (74%) knees. Four (6%) additional knees achieved a successful result after a subsequent manipulation. Nine (14%) knees required component revision for treatment of persistent arthrofibrosis, which included one full revision, five polyethylene exchanges, and three revisions of femoral component and polyethylene. Two significant complications occurred: one subdural hematoma and one death due to pulmonary embolism. Although not without complications, manipulation under epidural anesthesia represents a viable option for treatment of persistent stiffness after TKA; 80% of these difficult cases achieved successful results.

Tapered titanium porous plasma-sprayed femoral component in patients aged 40 years and younger.

Total hip arthroplasty (THA) in patients aged 40 years and younger requires decades of increased activity demands. Between 1987 and 2000, 249 primary THAs in patients 40 years of age or younger were performed with the Mallory-Head component. The average age at THA was 34.7 years (range, 20-40 years). Follow-up averaged 91 months with 125 hips having minimum 5-year follow-up and 51 THAs having a minimum of 10 years. Four stems failed the 98.2% overall survivorship. Two stems were revised for loosening for a 99.2% (95% confidence interval, 96.4%-99.8%) survivorship with aseptic loosening as the end-point at 18 years. In young patients, this tapered titanium, proximally porous plasma-sprayed femoral component provides outstanding long-term fixation and function with significant pain relief into the second decade. Overall stem survivorship is 98.2% at up to 18 years.

Intramedullary total femoral replacement for salvage of the compromised femur associated with hip and knee arthroplasty.

Severely compromised femora because of prosthetic loosening, osteolysis, or periprosthetic fracture around total hip and knee arthroplasties are increasing. Two approaches that create an intramedullary total femoral (IMTF) replacement are reported. Twenty-three IMTF replacements in 22 patients were performed at 2 institutions. Seven revision total knee arthroplasties with a stemmed component were linked to a well-fixed hip stem with a custom intramedullary sleeve. Sixteen IMTF replacements involved revision of both hip and knee arthroplasties which were connected via an intercalary segment with morse taper junctions. Follow-up averaged 36 months. Complications included 2 dislocations, 2 deep infections, and 2 knee revisions for tibial loosening. Advantages over conventional total femoral replacement or ORIF include less dissection, maintenance of soft tissue attachments, and immediate component stability to allow for early mobilization.

Hydroxyapatite-coated titanium porous plasma spray tapered stem: experience at 15 to 18 years.

Advocates of hydroxyapatite in primary total hip arthroplasty report enhanced fixation and early improvements in pain and function. Others report no difference in long-term outcomes with hydroxyapatite application to an already proven fixation surface. We previously reported more rapid clinical improvement with a proximally porous, plasma-sprayed titanium, tapered geometry stem. We now report the long-term followup data on 191 consecutive total hip arthroplasties in which a standard (130 hips) or the hydroxyapatite-coated stem (61 hips) was implanted. At average 12.7 years followup, one stem (noncoated) was revised for aseptic loosening. The Harris hip total and pain scores were similar. Survivorship of the femoral component with aseptic loosening as the endpoint was 99.2% for noncoated stems and 100% for hydroxyapatite stems. The long-term survivorship of plasma-sprayed titanium tapered stems was excellent regardless of hydroxyapatite application, with neither benefit nor detriment observed.

Metal-on-metal total hip arthroplasty with large heads may prevent early dislocation.

UNLABELLED: Postoperative dislocation is one of the major causes of morbidity and failure of total hip arthroplasty. We reviewed 327 patients (377 hips) retrospectively with varying diagnoses and indications but all of whom received large-diameter metal-on-metal prostheses. Two surgical approaches were used: the anterolateral abductor splitting (342 procedures) and a mini-incision posterior approach (35 procedures). Average age at time of surgery was 55.9 years and average followup was 4.0 months. There were 346 (91.8%) primary procedures, 15 (4.0%) conversion procedures, and 16 (4.2%) revisions or reimplantations. The most common preoperative diagnoses included osteoarthritis (250 hips; 66.3%) and avascular necrosis (46 hips; 12.2%). There were 62 (16.4%) patients with high-risk diagnoses for dislocation. The status in terms of postoperative dislocation was known for all patients. During the short followup period, there were no dislocations. Use of large-diameter femoral heads and metal-on-metal articulations decreases the risk of dislocations, making their use a viable choice for primary and revision procedures. LEVEL OF EVIDENCE: Therapeutic study, Level IV-1 (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Isolated liner exchange using the anterolateral approach is associated with a low risk of dislocation.

UNLABELLED: Authors of reports on the outcome of isolated liner exchange for osteolysis and wear have reported high dislocation rates. Twenty-six patients (27 hips) with a minimum of 2 years of followup had isolated liner exchange for wear and osteolysis done using the abductor splitting anterolateral approach. The mean followup was 41 months. The average age at time of surgery was 51 years. Preoperative Harris hip scores averaged 70, and increased to 82 at the most recent followup. We observed improvements in pain and functional scores. The average operating time was 82 minutes, and the average blood loss was 255 mL. Only three (12%) patients required transfusion. No components were rerevised for aseptic loosening, and one patient (one hip) had a dislocation (3.7%). Isolated liner exchange for osteolysis and wear done using the anterolateral approach has a lower risk of dislocation than previously reported and provides substantial improvements in pain, function, and Harris hip score. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Early failure of minimally invasive unicompartmental knee arthroplasty is associated with obesity.

UNLABELLED: There has been increasing use of and expanding indications for unicompartmental knee arthroplasty using minimally invasive techniques. We sought to define contraindications by examining failures. We retrospectively reviewed the early results of a consecutive series of minimally invasive medial unicompartmental knee arthroplasty using two implant designs. Seventy-nine consecutive unicompartmental knee arthroplasty cases (48 instrumented and 31 noninstrumented) with minimum 2-year followup were reviewed. Patients with radiographic involvement with or without pain referable to the lateral compartment or to the patellofemoral joint were not considered candidates. Failure was defined as revision or pending revision. The average followup was 40.2 months. There were 16 failures (six tibial loosening, three plateau fracture, four persistent medial pain, one progressive arthritis, and two sepsis). Age, gender, disease severity and implant design did not predict failure. Body mass index greater than 32 did predict failure and was associated with a reduction in survivorship by log-rank and Wilcoxon analyses. These results show reliable success if obesity is considered a contraindication and technical errors resulting in fracture are eliminated. Better defining the ideal candidate for unicompartmental knee arthroplasty, with obesity remaining a contraindication, will make this a more predictable and reliable procedure. LEVEL OF EVIDENCE: Prognostic study, Level IV-2 (case series). See the Guidelines for Authors for a complete description of levels of evidence.

The long-term outcome of 755 consecutive constrained acetabular components in total hip arthroplasty examining the successes and failures.

Constrained acetabular components can treat or prevent instability after total hip arthroplasty (THA). We examine long-term results of 755 consecutive constrained THA in 720 patients (1986-1993; 62 primary, 59 conversion, 565 revision, 60 reimplantation, and 9 total femur). Eighty-three patients (88 THAs) were lost before 10-year follow-up, leaving 639 patients (667 THAs) available for study. Dislocation occurred in 117 hips (17.5%), in 37 (28.9%) of 128 constrained for recurrent dislocation, and 46 (28.2%) of 163 with dislocation history. Other reoperations were for aseptic loosening (51, 7.6% acetabular; 28, 4.2% stem; 16, 2.4% combined), infection (40, 6.0%), periprosthetic fracture (19, 2.8%), stem breakage (2, 0.3%), cup malposition (1, 0.1%), dissociated insert (1, 0.1%), dissociated femoral head (1, 0.1%), and impingement of 1 broken (0.1%) and 4 (0.6%) dissociated constraining rings. Although constrained acetabular components prevented recurrent dislocation in 71.1%, they should be used cautiously, with a 42.1% long-term failure rate observed in this series. Dislocation was common despite constraint with previous history as a significant risk.

Acute hip arthroplasty for the treatment of intertrochanteric fractures in the elderly.

Arthroplasty for intertrochanteric fractures in elderly patients may allow early weightbearing and avoid fixation failure. Clinical results are reviewed in a consecutive group of acute arthroplasties (5 hemiarthroplasties and 29 total hip arthroplasties) performed via the anterolateral approach for intertrochanteric fractures. Age averaged 80.2 years. Follow-up averaged 35 months for living patients. Twenty-six patients died during follow-up. Time to death averaged 3.5 years. Five hips, all total hip arthroplasties, required subsequent surgeries: four for dislocation and one revised for sepsis. Acute intertrochanteric fractures are associated with high early mortality. In this series, a 15% complication rate and high mortality rate at 12 years was associated with acute arthroplasty. Dislocation is higher than in primary total hip arthroplasty utilizing the same surgical approach. The results do not support routine use of arthroplasty in treatment of intertrochanteric hip fractures in the elderly.

Soft tissue and intra-articular injection of bupivacaine, epinephrine, and morphine has a beneficial effect after total knee arthroplasty.

The purpose of this study was to determine if an intraoperative intraarticular and soft-tissue injection of local anaesthetic, epinephrine, and morphine has a beneficial effect for total knee arthroplasty. A control group of 138 patients (181 knees) received no intraoperative injection. The study group of 171 patients (197 knees) received intraoperative injection of 0.25% bupivacaine with epinephrine and morphine with 2/3 injected into the soft tissues and 1/3 injected into the joint. Patients having bilateral simultaneous procedures received a divided dose. The pain treatment protocol otherwise was identical. Pain, sedation, rescue narcotic usage, narcotic reversal and blood loss were examined. Pain levels during the immediate postoperative period, blood loss, and bleeding indices were reduced with injection. Considerably more control patients required rescue doses of narcotics. Preemptive analgesia with soft tissue and intra-articular injection of long-acting local anesthetic with epinephrine and morphine provides better pain control in the immediate postoperative period, decreases blood loss, and decreases the need for rescue narcotics and reversal agents. This simple, inexpensive method provides an effective adjunct to a multimodal approach in improving the postoperative course of primary total knee arthroplasty.

Total femoral arthroplasty for salvage of end-stage prosthetic disease.

The complications and outcomes in patients who had total femoral arthroplasty for salvage of a severely compromised femur were studied. The clinical scenarios included numerous revision total hip or knee arthroplasties, failed periprosthetic fractures, or recurrent infection treated with multiple radical debridement surgeries. Fifty-nine patients (average age, 73.7 years) were identified. At an average 4.8 years followup, adequate pain relief was achieved and Harris hip pain scores averaged 33.8 of 44 points, and knee pain scores averaged 42.8 of 50 points. Good function was achieved with 98% of patients able to ambulate and 43% using no assistive device or a cane only. There were 18 complications or subsequent surgeries. Infection and dislocation occurred in eight patients and seven patients, respectively. Total femoral arthroplasty for salvage of a severely compromised femur provides acceptable results even in the most difficult of cases.

Cerclage wires or cables for the management of intraoperative fracture associated with a cementless, tapered femoral prosthesis: results at 2 to 16 years.

Initial stability is critical for fixation and survival of cementless total hip arthroplasty. Occasionally, a split of the calcar occurs intraoperatively. A review of 1,320 primary total hip arthroplasties with 2-year follow-up, performed between August 1985 and February 2001 using the Mallory-Head Porous tapered femoral component, revealed 58 hips in 55 patients with an intraoperative calcar fracture managed with single or multiple cerclage wires or cables and immediate full weight bearing. At 7.5 years average follow-up (range, 2-16 years), there were no revisions of the femoral component, radiographic failures, or patients with severe thigh pain, for a stem survival rate of 100%. Average Harris hip score improvement was 33.8 points. Fracture of the proximal femur occurs in approximately 4% of primary THAs using the Mallory-Head Porous femoral component. When managed intraoperatively with cerclage wire or cable, the mid- to long-term results appear unaffected with 100% femoral component survival at up to 16 years.