Surgeons Who Perform Total Hip Arthroplasty Are at Risk for Noise-Induced Hearing Loss, Especially When Using Automated Broaching.

BACKGROUND: Noise-induced hearing loss (NIHL) is a serious concern for orthopedic surgeons. The National Institute for Occupational Safety and Health (NIOSH) sets the safe exposure limit at 85 dB for 8 hours, yet operating rooms often surpass this limit. This study investigated if using an automated broaching system exposes orthopedic surgeons to dangerous decibel (dB) levels. MATERIALS AND METHODS: A prospective study analyzed 138 intraoperative sound recordings from 92 total hip arthroplasty (THA) surgeries and 46 baseline measurements at an academic-affiliated private practice, using the NIOSH Sound Level Meter (SLM) application and a microphone. The surgeries were categorized into manual and automated broaching. Key metrics measured included maximal dB level (MDL), peak sound pressure (LCpeak), average continuous sound (LAeq), and average weighted sound in an 8-hour period (TWA), along with dose representations, to identify hazardous noise levels. RESULTS: Of the 92 THA sound recordings, 50 used manual broaching and 42 employed automated broaching. Automated broaching exhibited higher noise levels, with an average MDL of 109.92 dBA, a LAeq of 86.09 dBA, a TWA of 76.48 dBA, and a projected noise dose of 137.74%. In contrast, manual broaching exhibited an average MDL of 105.87 dBA, a LAeq of 83.06 dBA, a TWA of 72.82 dBA, and a projected noise dose of 82.02%. CONCLUSION: This study highlights the auditory risks from automated broach and manual THA surgeries that orthopedic surgeons experience. Manufacturers should focus on reducing instrument noise when designing surgical tools and orthopedic surgeons and operating room staff should take measures to protect themselves from NIHL during surgery. [Orthopedics. 202x;4x(x):xx-xx.].

Medial Calcar Density Measured via Opportunistic Computed Tomography Is Well Represented by the Dorr C Classification.

Introduction The canal-to-calcar isthmus (CC) ratio has been previously correlated with proximal femur osteology, but its relationship with bone density is not well established. Our purpose was to assess the relationship between femoral bone density, measured on opportunistic quantitative CT in Hounsfield units (HU), and CC ratio. Methods A total of 148 THA patients were included. The CC ratio was measured on anteroposterior hip radiographs. Using perioperative CT scans, a 1 cm diameter area was identified on a single mid-coronal slice in the medial calcar just proximal to the intertrochanteric ridge. The mean HU was calculated in this region to represent calcar bone density. Results Twenty-four percent (n = 35) of patients were classified as Dorr A (average CC ratio 0.47 [0.45; 0.48]), 67% (n = 96) as Dorr B (0.62 [0.55; 0.68]), and 11% (n = 17) as Dorr C (0.78 [0.77; 0.80]). There was a significant difference between Dorr A and Dorr C femurs (769 (144) vs. 588 (154) HU) as well as between B and C femurs (718 (166) vs. 588 (154) HU). The CC ratio was correlated with calcar bone density on CT (-0.370). Conclusion CC ratio is correlated with bone density determined by HU measurements on an opportunistic quantitative computed tomography scan, and bone density HU values were able to accurately differentiate bone density in Dorr A and B from Dorr C femurs. These findings suggest that the CC ratio is a reliable measurement to predict bone density in Dorr C femurs. Therefore, arthroplasty surgeons can confidently use the Dorr classification for patients with Dorr C femurs when preoperatively planning for THA.

Older Age, Male Sex, and Early Start Time Lengthen the Recovery Room Stay Following Total Joint Arthroplasty in an Ambulatory Surgical Center.

Background: Total joint arthroplasty (TJA) performed in the ambulatory surgical center (ASC) has been shown to be safe and cost-effective for an expanding cohort of patients. As criteria for TJA in the ASC become less restrictive, data guiding the efficient use of ASC resources are crucial. Purpose: We sought to identify factors associated with length of stay in the recovery room after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed in the ASC. Methods: We conducted a retrospective review of 411 patients who underwent primary THA or TKA at our institution's ASC between November 2020 and March 2022. We collected patient demographics, perioperative factors, success of same-day discharge (SDD), and length of time in the recovery room. Results: Of 411 patients, 100% had successful SDD. The average length of time spent in recovery was 207 minutes (SD: 73.9 minutes). Predictors of longer time in recovery were increased age, male sex, and operative start time before 9:59 am. Body mass index, preoperative opioid use, Charlson Comorbidity Index, type of surgery (THA vs TKA), urinary retention risk, and type of anesthesia (spinal vs general) were not significant predictors of length of time in the recovery room. Conclusion: In this retrospective study, factors associated with increased length of time in the recovery room included older age, male sex, and operative start time before 9:59 am. Such factors may guide surgeons in determining the optimal order of cases for each day at the ASC, but further prospective studies should seek to confirm these observations.

Social Risk Determinants for Successful Same Calendar Day Discharge in Total Joint Arthroplasty.

Background: While many studies have examined the impact of comorbidities on the success of same calendar day discharge (SCDD) in total joint arthroplasty (TJA), literature surrounding the impact of social determinants is lacking. Purpose: We sought to investigate the relationship between various social determinants and success of SCDD after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods: We conducted a retrospective review of 1160 THA and 1813 TKA performed at a single academic institution between November 2020 and August 2022. Social factors including substance use, occupation, marital status, income, and participation in physical exercise were included. In addition, aspects of discharge planning were reviewed such as living situation and transportation details. Results: Overall, 952 (32%) patients had successful SCDD, whereas 2021 (68%) patients were discharged on postoperative day 1 (POD1) or greater. Successful SCDD patients were more likely to have health care (4.8% vs 2.5%) and active (5.4% vs 4.6%) rather than sedentary occupations, be married (79.6% vs 67.4%), have access to transportation (95.6% vs 92.9%), live in a higher median income area ($64,044 [16,183] vs $61,572 [14,594]), and exercise weekly (62.6% vs 23.9%). Interestingly, the successful patients had more stories in their homes (1.62 [0.56] vs 1.43 [0.53]), more stairs to enter their homes (5.19 [5.22] vs 4.60 [5.24]), lived farther from the hospital (43.3 [138.0] vs 32.0 [75.9] miles), and a higher prevalence of alcohol use (60.7% vs 44.7%) and tobacco use (19.3% vs 17.3%). Conclusion: These findings may help arthroplasty surgeons to better understand the social factors that contribute to successful SCDD in TJA patients, ultimately aiding in patient selection and preoperative counseling.

Use of Botulinum Toxin A to Manage Hamstring-Induced Flexion Contracture Following Total Knee Arthroplasty: A Case Series.

Introduction Flexion contractures following total knee arthroplasty (TKA) greatly affect patient function and satisfaction. Botulinum toxin A (BTX) has been described in the literature as a means of addressing post-operative flexion contractures due to hamstring muscle rigidity. Methods We retrospectively report a case series of eight patients with range of motion (ROM) who developed a flexion contracture status post-TKA and were managed with the use of physical therapy, diagnostic hamstring lidocaine injections, and therapeutic hamstring BTX injections. Results All patients had an improvement in extension ROM following diagnostic lidocaine hamstring injections and were therefore considered candidates for therapeutic hamstring BTX injections. Prior to therapeutic hamstring BTX injections, patients had an average flexion contracture of 19° (range: 15°-22°). All patients had an improvement in extension ROM two to four weeks following the therapeutic hamstring BTX injection, with an average improvement in ROM of 7° (range: 2°-19°). At the final follow-up, all patients continued to sustain an improvement in extension ROM with an average deficit of 9° (range: 0°-17°). Conclusion Our case series highlights the use of diagnostic hamstring lidocaine injections to confirm hamstring rigidity as an etiology for flexion contracture following TKA. In addition, we showed a persistent improvement in flexion contracture for all patients after hamstring BTX injections. Therefore, when the appropriate patient is selected, BTX may provide an additional treatment option for a flexion contracture following TKA.

Large Femoral Heads With Small Acetabular Components: An Examination of 10-Year Polyethylene Wear.

Highly cross-linked polyethylene (HXLPE) has improved polyethylene (PE) wear rates while decreasing osteolysis and aseptic loosening. However, concerns exist regarding the risk of mechanical failure with thin HXLPE liners in total hip arthroplasty (THA). Our purpose was to evaluate long-term outcomes and PE wear rates in primary THAs pairing large femoral heads with small acetabular components and thin HXLPE liners. We retrospectively reviewed 29 patients who underwent 33 primary THAs using large femoral heads (32 or 36 mm) with small acetabular components (48 or 50 mm) and thin HXLPE liners (3.9 or 5.9 mm) at minimum 10-year follow-up. PE liner wear was measured using a validated radiographic technique. Mean age was 66 years, 97% of the patients were women, and mean body mass index was 26.3 kg/m2. Thirty hips (90.9%) had ceramic femoral heads, and 13 hips (39%) had 36-mm femoral heads with 3.9-mm HXLPE liners. All cases used a neutral PE design. Mean linear wear rate and volumetric wear rate were 0.04 mm/year and 39.6 mm3/year, respectively, at mean 10.9-year follow-up. There were no instances of liner fracture, liner dissociation, or revision. Mean Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR) was 92.1. In the largest long-term study of primary THAs using large femoral heads with small acetabular components and thin HXLPE liners, we found low linear and volumetric wear rates and no cases of liner mechanical failures. Thin HXLPE liners are a safe and viable option for THA surgeons. [Orthopedics. 2024;47(2):118-122.].

Primary Cementless Femoral Stems in Conversion Hip Arthroplasty After Failed Fixation of Intertrochanteric Fractures.

Salvage conversion hip arthroplasty is a viable solution to restore function and reduce pain after failed intertrochanteric hip fracture fixation. Our primary objective was to assess early outcomes achieved with primary cementless metaphyseal-engaging femoral stems for conversion hip arthroplasty compared with revision diaphyseal-engaging stems. This was a retrospective review of 70 patients with failed intertrochanteric hip fractures subsequently managed with conversion total hip arthroplasty or hemiarthroplasty. Thirty-five patients who underwent conversion using a primary cementless stem were compared with 35 patients who underwent conversion using a revision stem. The groups were similar regarding sex, body mass index, American Society of Anesthesiologists classification, preoperative diagnosis, and implants removed. Clinical and radiographic outcomes and complications were compared over a mean follow-up of 6 years. The primary stem cohort had a shorter mean hospital stay (3.03 vs 4.34 days, P=.028). There were no significant differences between the primary and revision cohorts regarding mean time to conversion (2.26 vs 1.75 years, P=.671), operative time (127 vs 131 minutes, P=.611), incidence of discharge to home (54.3% vs 37.1%, P=.23), postoperative complications (5.71% vs 5.71%, P=1.0), reoperations (5.71% vs 11.4%, P=.669), leg length discrepancy (5.33 vs 7.38 mm, P=.210), subsidence (20.0% vs 23.3%, P=.981), and Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement (78.6 vs 81.9, P=.723). We report comparable outcomes of conversion hip arthroplasty with the use of primary cementless and revision stems. Current primary cementless femoral stems may be considered for conversion hip arthroplasty for failed intertrochanteric fracture fixation. [Orthopedics. 2024;47(1):e6-e12.].

Success of Same-Day Discharge Total Hip and Knee Arthroplasty: Does Location Matter?

BACKGROUND: Same calendar day discharge (SCDD) following total joint arthroplasty is desirable for patients and surgeons alike. The aim of this study was to compare the success rate of SCDD in an ambulatory surgical center (ASC) versus hospital setting. METHODS: A retrospective analysis was performed on 510 patients who underwent primary hip and knee total joint arthroplasty over a 2-year period. The final cohort was divided into 2 groups based on location of surgery: ASC (N = 255) or hospital (N = 255). Groups were matched for age, sex, body mass index, American Society of Anesthesiologists score, and Charleston Comorbidity Index. Successes of SCDD, reasons for failure of SCDD, length of stay (LOS), and 90-day readmission and complication rates were recorded. RESULTS: All SCDD failures were from the hospital setting (36 [65.6%] total knee arthroplasty [TKA] and 19 [34.5%] total hip arthroplasty [THA]). There were no failures from the ASC. The main causes of failed SCDD in both THA and TKA included failed physical therapy and urinary retention. Regarding THA, the ASC group had a significantly shorter total LOS (6.8 [4.4 to 11.6] versus 12.8 [4.7 to 58.0] hours, P < .001). Similarly, TKA patients had a shorter LOS in the ASC (6.9 [4.6 to 12.9] versus 16.9 [6.1 to 57.0], P < .001). Total 90-day readmission rates were higher in the ASC group (2.75% versus 0%), where all but 1 patient underwent TKA. Similarly, complication rates were higher in the ASC group (8.2% versus 2.75%), where all but 1 patient underwent TKA. CONCLUSION: TJA performed in the ASC, compared to the hospital setting, allowed for reduced LOS and improved success of SCDD.

Does Automated Impaction Improve Femoral Component Sizing and Alignment in Total Hip Arthroplasty?

BACKGROUND: While automated impaction can provide a more standardized process for femoral canal preparation, little is known regarding its effect on femoral component sizing and position. The purpose of our study was to directly compare femoral component canal fill ratio (CFR) and coronal alignment between primary total hip arthroplasty (THA) procedures performed with automated impaction versus manual mallet impaction. METHODS: A retrospective analysis was performed on 184 patients who underwent primary THA by a single arthroplasty surgeon between 2017 and 2021 with a modern cementless femoral component using either the direct anterior or posterolateral approach. The final cohort was divided into 2 groups based on impaction technique during broaching: automated (N = 122) or manual (N = 62). A propensity score match was used to match for age, body mass index, sex, high versus standard offset stem, and preoperative femoral bone quality. Radiographic review was performed to measure intramedullary prosthetic CFR and coronal alignment. RESULTS: The automated cohort trended toward the use of a larger stem (5.67 versus 4.82, P = .006) and had a larger CFR at all 4 levels within the proximal femur (P = .004). The automated cohort had a more valgus and reliable coronal alignment (-0.57 (SD 1.50) versus -0.03 (SD 2.17) degrees, P = .03) and significantly shorter operative time (mean 78 versus 90 minutes, P < .001). There were no intraoperative or postoperative periprosthetic fractures in either cohort. CONCLUSION: Automated impaction in primary THA is a safe technique for femoral preparation, which resulted in improved stem coronal alignment, optimized canal fill within the proximal femur, and reduced operative times.

A Video Teaching Tool Is Effective for Training Residents in Hip Arthroplasty Templating.

Work hour restrictions imposed on orthopedic surgery residents since the early 2000s have reduced educational opportunities at the workplace and encouraged alternative strategies for teaching outside the clinical setting. Preoperative templating is essential for safe and effective total hip arthroplasty (THA) and is accurate in predicting final implants. We sought to determine the effectiveness of a video tool for teaching orthopedic residents basic THA templating skills. We developed a video-based teaching tool with instructions on proper THA templating techniques. Ten cases were selected for testing, after excluding patients with severe hip deformities and poor-quality radiographs and only retaining those with concordance between templating by the senior authors and implanted components. The study subjects included three postgraduate year 1 (PGY-1), three PGY-2, and three PGY-5 residents, and three adult reconstruction fellows (PGY-6). Templating skills were assessed before and after watching the instructional video. The evaluation included the size and positioning of femoral and acetabular components, as well as the restoration of leg length. Each templating session was repeated twice. Variance was measured to evaluate consistency in measurements. A linear mixed model and F-test were used for statistical analyses. The number of years in training significantly affected performance prior to exposure to the instructional video. Post-exposure, there was a significant improvement in the accuracy of sizing and positioning of acetabular and femoral components for PGY-1, PGY-2, and PGY-5 residents. The results achieved were comparable to PGY-6 examiners, who did not gain substantial performance benefits from the instructional video. Limb length restoration was less affected by experience or exposure to the video. Component positioning and sizing, as well as leg length discrepancy (LLD), showed a significant decrease in variance after the intervention in all study groups. Video learning is reliable in teaching invaluable skills to orthopedic surgery residents without encroaching on work hours. We conceived a concise video to train orthopedic residents to perform THA templating with proper technique and demonstrated its efficiency and reproducibility.

A Role for Outpatient Total Joint Arthroplasty During the COVID-19 Pandemic.

Outpatient total joint arthroplasty (TJA) gained favor during the COVID-19 pandemic. Our objective was to critically evaluate the safety and short-term outcomes of outpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA) throughout the pandemic compared with pre-pandemic given their increased use. This was a retrospective review of 941 patients who underwent elective, outpatient TKA and THA at a single institution. Patients were divided into two cohorts: pre-pandemic (N=611) and pandemic (N=330). Data points included demographics, comorbidities, failure of same calendar day discharge (SCDD), and 90-day readmissions and re-operations. The pandemic cohort was older (61.0 vs 59.0 years; P=.001) and had a higher Charlson Comorbidity Index (2 vs 1; P=.004). There were no differences between the pandemic and pre-pandemic cohorts regarding SCDD failures (23.3% vs 21.9%; P=.623) and reoperations (4.2% vs 6.2%; P=.205). The pandemic cohort had a lower readmission rate (4.8% vs 8.2%; P=.056). Overall, patients who had failure of SCDD more commonly underwent TKA than THA (63.5% vs 36.5%; P<.001), were older (63.0 vs 58.5 years; P<.001), had a higher body mass index (30.8 vs 29.9 kg/m2; P=.006) and Charlson Comorbidity Index (2 vs 1; P<.001), had an American Society of Anesthesiologists class greater than 2 (51.2% vs 31.6%; P<.001), received physical therapy later postoperatively (4.15 vs 3.12 hours; P<.001), and had a history significant for myocardial infarction (P=.025), chronic kidney disease (P=.004), or diabetes (P=.003). This study supports broadening indications for outpatient TJA because we found a shift toward older patients with more comorbidities successfully undergoing the procedure. [Orthopedics. 2023;46(5):303-309.].

Incidental findings on CT scans for robot-assisted total joint arthroplasty.

INTRODUCTION: This study documented the incidence of incidental findings from preoperative computerized-tomography (CT) scans obtained for robotic-arm-assisted total joint arthroplasty (TJA) and its effect on patient management. METHODS: A retrospective review was conducted for patients who underwent robotic-arm assisted primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) from 2016 to 2020. All patients obtained preoperative CT scans which were formally read by fellowship-trained musculoskeletal radiologists. CT's were flagged with incidental findings and those requiring physician follow-up were identified as significant. RESULTS: A total of 1519 patients (mean age, 66 years ±9; 849 females) were evaluated. Seventy-three (4.81%) patients had incidental CT scan findings, and 25 (1.65%) patients had significant incidental findings. Four patients required additional imaging and two patients required intervention. CONCLUSION: This study found a 4.81% incidence of incidental findings from preoperative CT scans for robotic-arm-assisted THA and TKA. Of these findings, less than 2% required physician follow-up and less than 1% required intervention. With the increasing popularity of robotic-arm assisted total joint arthroplasty, it is important to consider the necessity of detection and management of associated incidental findings from preoperative CT scans.