Magnetic resonance imaging of femoral nerve injury in the setting of anterior approach total hip arthroplasty.

PURPOSE: To illustrate MRI findings in patients with femoral neuropathy following anterior approach total hip arthroplasty (THA). METHODS: This was a retrospective review of patients who underwent MRI for femoral neuropathy following anterior approach THA between January 1, 2010, and July 1, 2022. Included patients had no preexisting neurologic condition. Clinical and diagnostic data were collected. MRIs were reviewed in consensus by 2 musculoskeletal radiologists. RESULTS: A total of 115 patient records were reviewed, 17 of which were included in the final analysis (mean age 64 years; 11 females). Study subjects presented with weakness with hip flexion and knee extension and pain and numbness in the femoral nerve distribution. In 7 subjects, the femoral nerve appeared normal. In 5 subjects, the femoral nerve was hyperintense on fluid-sensitive fat-suppressed imaging. In 4 patients, mass effect on the femoral nerve by either ill-defined soft tissue edema (n = 2), seroma (n = 1), or heterotopic ossification (n = 1) was detected. Only 1 patient had a nerve transection. Patients were imaged at a median time of 8 months (range: 1 day to 11 years) following arthroplasty placement. Clinical follow-up was available in 8 patients, of whom half had complete symptomatic resolution and half had partial improvement at a mean follow-up time of 39.3 months (SD 51.1). Of these 8, 1 underwent revision arthroplasty, 1 had removal of hardware, and another had excision of heterotopic ossification. CONCLUSION: MRI provides a means to directly evaluate the femoral nerve following anterior approach THA in both the immediate and chronic postoperative periods.

Arthritis Foundation/HSS Workshop on Hip Osteoarthritis, Part 2: Detecting Hips at Risk: Early Biomechanical and Structural Mechanisms.

Far more publications are available for osteoarthritis of the knee than of the hip. Recognizing this research gap, the Arthritis Foundation (AF), in partnership with the Hospital for Special Surgery (HSS), convened an in-person meeting of thought leaders to review the state of the science of and clinical approaches to hip osteoarthritis. This article summarizes the recommendations gleaned from 5 presentations given in the "early hip osteoarthritis" session of the 2023 Hip Osteoarthritis Clinical Studies Conference, which took place on February 17 and 18, 2023, in New York City. It also summarizes the workgroup recommendations from a small-group discussion on clinical research gaps.

Musculoskeletal Telemedicine Trends Preceding the COVID-19 Pandemic and Potential Implications of Rapid Telemedicine Expansion.

Introduction: Telemedicine was rapidly deployed at the onset of the COVID-19 pandemic. Little has been published on telemedicine in musculoskeletal care prior to the COVID-19 pandemic. This study is aimed at characterizing trends in telemedicine for musculoskeletal care preceding the COVID-19 pandemic. Methods: This retrospective study used insurance claims from the Truven MarketScan database. Musculoskeletal-specific outpatient visits from 2014 to 2018 were identified using the musculoskeletal major diagnostic category ICD-10 codes. Telemedicine visits were categorized using CPT codes and Healthcare Common Procedure Coding Systems. We described annual trends in telemedicine in the overall dataset and by diagnosis grouping. Multivariable logistic regression modeling estimated the association between patient-specific and telemedicine visit variables and telemedicine utilization. Results: There were 36,672 musculoskeletal-specific telemedicine visits identified (0.020% of all musculoskeletal visits). Overall, telemedicine utilization increased over the study period (0% in 2014 to 0.05% in 2018). Orthopedic surgeons had fewer telemedicine visits than primary care providers (OR 0.57, 95% CI 0.55-0.59). The proportion of unique patients utilizing telemedicine in 2018 was higher in the south (OR 2.28, 95% CI 2.19-2.38) and west (OR 5.58, 95% CI 5.36-5.81) compared to the northeast. Those with increased comorbidities and lower incomes and living in rural areas had lower rates of telemedicine utilization. Conclusions: From 2014 to 2018, there was an increase in telemedicine utilization for musculoskeletal visits, in part due to insurance reimbursement and telemedicine regulation. Despite this increase, the rates of telemedicine utilization are still lowest in some of the groups that could derive the most benefit from these services. Establishing this baseline is important for assessing how the roll-out of telemedicine during the pandemic impacted how/which patients and providers are utilizing telemedicine today.

Is there a difference in mobility and inpatient physical therapy need after primary total hip and knee arthroplasty? A decade-by-decade analysis from 60 to 99 years.

INTRODUCTION: Extended inpatient rehabilitation (PT) after total hip (THA) and knee arthroplasty (TKA) has a significant impact on total care costs. As patients age, extended PT might be required following THA and TKA. This study examined the relationship between patient age, functional mobility, inpatient PT need, and discharge disposition in THA and TKA patients. MATERIALS AND METHODS: This retrospective study included patients aged 60 + undergoing primary THA or TKA between 2018 and 2020 at an orthopedic hospital. Comparing by age-decade, 7374 (3600 THA, 3774 TKA) sexagenarians, 5350 (2367 THA, 2983 TKA) septuagenarians, 1356 (652 THA, 704 TKA) octogenarians, and 78 (52 THA, 26 TKA) nonagenarians were analyzed. We compared the number of PT sessions needed for discharge clearance and the postoperative functional mobility using the Activity Measure for Post-Acute Care (AM-PAC) tool. Statistical analyses included ANOVA with post-hoc Tukey's HSD for continuous data and Chi-squared test for categorical variables. RESULTS: The number of PT sessions required for discharge clearance increased with age after THA (3.3 ± 1.9 sessions vs 3.8 ± 2.1 vs 5.0 ± 2.7 vs 6.2 ± 3.0; p < 0.01) and TKA (4.0 ± 2.1 vs 4.7 ± 3.1 vs 5.2 ± 2.8 vs 5.0 ± 1.6; p < 0.01). The functional mobility improvement as measured by AM-PAC was significantly lower for nonagenarians after THA (4.9 ± 2.8 vs 5.1 ± 2.8 vs 4.6 ± 3.3 vs 3.3 ± 3.9; p < 0.01) and TKA (5.0 ± 2.9 vs 4.7 ± 3.2 vs 3.9 ± 3.4 vs 3.2 ± 2.6; p < 0.01). CONCLUSION: Patients in their eighth and ninth decade had less improvement in functional mobility during in-hospital rehabilitation and utilized more PT services. However, clinical results in the elderly are still satisfying and the data may be helpful for resource utilization planning and risk-adjustment in value-based payment models.

Blood management in direct anterior versus posterior primary total hip arthroplasty using tranexamic acid: a matched cohort study.

INTRODUCTION: Proponents of the direct anterior approach (DAA) for THA claim patients recover faster compared to primary THA through the posterior approach (PA). Blood loss and transfusion have substantially declined with the use of tranexamic acid (TXA). However, it is still controversial if hemoglobin drops and transfusion rates are affected by the surgical approach when TXA is routinely used. MATERIALS AND METHODS: 2418 patients undergoing DAA THA were matched 1:1 with patients undergoing PA THA according to preoperative hemoglobin (± 1 g/dl), age (± 5 years), sex, BMI (± 5 kg/m2) and year of surgery (± 2 years). All patients received perioperative TXA. None of the patients donated autologous blood. Hemoglobin levels, drain placement and output, blood transfusion rates and volume as well as length of stay were recorded. RESULTS: A closed suction drain was used in 121 (5.0%) DAA and in 135 (5.6%) PA THAs (p = 0.369). Mean drain output was higher in the DAA compared to the PA group (134 ml (0-520 ml) versus 92.3 ml (0-600 ml), p = 0.004). There was no difference in hemoglobin drop [2.6 g/dl versus 2.6 g/dl (p = 0.143)] and transfusion rate [n = 31 (1.3%) versus n = 29 (1.2%), p = 0.793)] between DAA and PA THA. Mean transfusion amounts were 421.8 ml (250-1120.8 ml) in the DAA and 353.9 ml (250-560 ml) in the PA group (p = 0.801). The length of stay was shorter in the DAA group with a mean 1.6 days versus 2.1 days in the PA group (p ≤ 0.001). CONCLUSION: In this large matched cohort study, there was no difference in the perioperative hemoglobin drop, the transfusion rate and the transfusion amount between DAA and PA THA.

Preoperative ferritin and hemoglobin levels are lower in patients with a history of COVID-19 but blood loss and transfusion requirements are not increased.

INTRODUCTION: A history of COVID-19 (Coronavirus Disease 2019), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may have an impact on hemoglobin and ferritin levels predisposing patients to increased blood transfusion requirements following total joint arthroplasty (TJA). The current study compares ferritin levels, hemoglobin levels, and transfusion rates between SARS-CoV-2 IgG positive and SARS-CoV-2 IgG negative TJA patients. MATERIALS AND METHODS: Preoperative ferritin levels, pre- and postoperative hemoglobin levels, postoperative change in hemoglobin, and transfusion rates of 385 consecutive SARS-CoV-2 IgG positive patients undergoing TJA were compared to those of 5156 consecutive SARS-CoV-2 IgG negative patients undergoing TJA. RESULTS: Preoperative hemoglobin levels were significantly lower in SARS-CoV-2 IgG positive patients [13.3 g/dL (range 8.9-17.7 g/dL)] compared to 13.5 g/dl (7.3-18.3 g/dL; p value 0.03). Ferritin levels were significantly lower in SARS-CoV-2 IgG positive patients (mean of 106.1 ng/ml (2.1-871.3.3 ng/ml) vs. 123.7 ng/ml (1.4-1985 ng/ml) (p value 0.02)). Hemoglobin on postoperative day (POD) one, after four-six weeks, and transfusion rates did not differ between the two groups. CONCLUSION: Although preoperative hemoglobin and ferritin levels are lower in SARS-CoV2 IgG positive patients, there was no difference in hemoglobin on POD one, recovery of hemoglobin levels at four-six weeks postoperatively, and transfusion rates after surgery. Routine ferritin testing prior to TJA is not recommended in SARS-CoV-2 IgG positive patients.

Femoral Component Undersizing and Alignment are Risk Factors for Early Periprosthetic Femur Fracture.

BACKGROUND: Known risk factors for early periprosthetic femur fracture (PFF) following total hip arthroplasty (THA) include poor bone quality and the use of cementless implants. The association between femoral component size and alignment and the risk of early PFF is not well described. We evaluated radiographic parameters of femoral component sizing and alignment as risk factors for early PFF. METHODS: From 16,065 primary cementless THAs, we identified 66 cases (0.41%) of early PFFs (<90 days from index THA) at a single institution between 2016 and 2020. Sixty early PFFs were (1:2) matched to 120 controls based on the femoral component model, offset, surgical approach, age, body mass index (BMI), and gender. Radiographic assessment of preoperative bone morphology and postoperative femoral component orientation included stem alignment, metaphyseal fill, and implant congruence with medial cortical bone. A multivariable logistic regression was built to identify radiographic risk factors associated with early PFF. RESULTS: Markers of preoperative bone quality including canal calcar ratio (P = .003), canal flare index (P < .001), anteroposterior canal bone ratio (CBR) (P < .001), and lateral CBR (P < .001) were statistically associated with PFF. Distance between the medial cortical bone and implant was greater in cases of PFF (2.5 mm vs 1.4 mm) (P < .001). A multivariate analysis demonstrated that a larger lateral metaphyseal CBR (Odds Ratio [OR] 5), valgus implant alignment (OR 5), and medial implant-bone incongruity (OR 2) increased the risk of early PFF. CONCLUSION: A larger lateral metaphyseal CBR, valgus component alignment, and implant incongruity with medial cortical bone posed the greatest radiographic risk for early PFF following cementless THA.

Predicting Total Knee Arthroplasty Outpatient Discharge: Surgeons versus Insurance Companies.

BACKGROUND: Insurance companies are increasingly making unilateral determinations of admission status for primary total knee arthroplasty (TKA). These determinations may differ from those based on surgeon-derived criteria for outpatient knee replacement. The goal of this study is to determine if insurance company determinations of outpatient status are as reliable as surgeon-derived criteria in predicting outpatient discharge after TKA. METHODS: We retrospectively reviewed 709 patients who were preoperatively authorized for outpatient TKA. Patients were stratified into 2 groups: "outpatient per surgeon" (appropriate for outpatient surgery per institutional protocols) or "outpatient per insurance" (appropriate for inpatient surgery per institutional protocols but denied inpatient status by insurance). The primary endpoint of this study was the conversion rate of outpatient to inpatient stay. Univariate logistic regression was performed to compare the odds of conversion to inpatient stay between outpatient per surgeon and outpatient per insurance procedures and other covariates. RESULTS: The cohort included 434 outpatient per insurance (61.2%) and 275 outpatient per surgeon (38.8%) patients. Surgeons accurately predicted outpatients' discharge 92.0% of the time, while insurance companies did so 81.3% of time (P < .001). Outpatient per insurance procedures (odds ratio [OR] 2.20, P = .003) and body mass index >35 kg/m2 (OR 1.82, P = .026) had higher odds of being converted to inpatient. Males had higher odds (OR 1.52, P < .001) of being discharged as outpatient. CONCLUSION: Determining inpatient versus outpatient status is a complex decision involving both clinical and social factors. Surgeons accurately predicted outpatient discharge 92% of the time. Moreover, outpatient per insurance procedures were twice as likely to be converted to inpatient status. Therefore, insurance companies should leave deciding admission status up to both the patient and surgeon.

Incidence and risk factors for development of persistent postsurgical pain following total knee arthroplasty: A retrospective cohort study.

Persistent postsurgical pain (PPP) is defined as the discomfort that lasts >3 months postoperatively. The primary aim of this retrospective study was to estimate the risk of developing moderate-to-severe PPP after primary total knee arthroplasty (TKA). The secondary goal was to explore potential predictors of this outcome.Data were collected via hospital arthroplasty registry and chart review. The risk of moderate-to-severe PPP, defined as ≥4 on the numerical rating scale (NRS) at minimum of 3 months post-surgery, was calculated. Multivariable logistic regression was used to estimate the association of patient demographics, diagnoses, length of hospital stay, and preoperative NRS with the odds of developing PPP. Exploratory, simple logistic regression was used to estimate the association of perioperative factors with the odds of developing PPP on a subset of patients (n = 72).The risk of PPP after TKA was 31.3% (95% confidence interval [CI]: 27.5-35.0) (n = 578). Every 2-point increase in baseline NRS was associated with 1.66 (95% CI: 1.37-2.03) times the odds of developing PPP (P < .001). African-Americans (vs whites) had 1.82 (95% CI: 1.03-3.22) times the odds of developing PPP (P = .040). Exploratory analysis suggested that the adductor canal saphenous nerve (vs femoral nerve) blocks were associated with 2.87 (95% CI: 1.00-8.26) times the odds of developing PPP (P = .049).This study estimated a high risk (31.3%) of moderate-to-severe PPP after primary TKA. This study suggested that higher preoperative pain scores might be associated with greater odds of developing PPP. Moreover, this study suggested the possibility that racial differences and types of peripheral nerve blocks might be associated with greater odds of developing moderate-to-severe PPP after TKA surgery. However, the evidence obtained from our exploratory analysis of limited data certainly requires further exploration in large-scale studies.

The impact of obesity on resource utilization among patients undergoing total joint arthroplasty.

PURPOSE: The presence of obesity poses a challenge for clinical and administrative staff in the peri-operative setting. Evidence indicates that obesity may increase peri-operative complications. However, data on resource utilization in patients undergoing total knee and hip arthroplasty remain rare. Using national data, we sought to determine whether increasing levels of patient obesity is associated with greater resource utilization. We hypothesized that patient care in individuals with a body mass index (BMI) greater than 40 is associated with longer operative and anaesthetic times, longer hospital stays, and greater readmission rates. METHODS: We utilized national data from the National Surgical Quality Improvement Project and identified patients who underwent primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). Patients were divided into three groups according to their BMI (18.5 BMI < 30, 40 BMI < 45, and 45 BMI). The groups were compared regarding associated operating room utilization, length of stay, and readmission rates. RESULTS: Our study showed that TKA and THA patients with higher BMI required significantly longer operation-related times and had higher total length of hospital stay. Higher BMI patients also carried higher odds of readmissions within 30 days in both TKA and THA groups. CONCLUSION: We conclude that BMI status needs to be considered for both medical and economic reasons by health care institutions and payers, in order to make prudent decisions in a world where health care expenses are rising rapidly alongside the increasing obesity epidemic, and resources are becoming increasingly scarce.

Postoperative Myocardial Injury and Inflammation Is Not Blunted by a Trial of Atorvastatin in Orthopedic Surgery Patients.

BACKGROUND: Orthopedic patients are at risk for adverse postoperative cardiovascular outcomes. QUESTIONS/PURPOSES: This pilot randomized controlled trial (RCT) of atorvastatin vs. placebo in orthopedic surgery patients was performed in order to assess: (1) the prevalence of perioperative myocardial injury; (2) the effect of atorvastatin on perioperative inflammation; and (3) the feasibility of performing a large RCT of statin therapy in orthopedic patients. METHODS: Hip fracture (hip Fx) and total hip and knee replacement (THR and TKR) patients were randomized 1:1 to atorvastatin 40 mg daily vs. placebo, starting preoperatively and continuing until postoperative day (POD) 45. High-sensitivity cardiac troponin I (hs-cTnI), high-sensitivity C-reactive protein (hs-CRP), and interleukin-6 (IL-6) were measured preoperatively and on POD 2. Patients were monitored for adverse events until POD 90. RESULTS: Five hundred fifty-six patients were screened, 22 were recruited (4 hip Fx, 11 THR, 7 TKR), and 2 withdrew. Most (80%) had detectable hs-cTnI (> 1.1 pg/mL) preoperatively. Twenty percent had a perioperative rise in hs-cTnI (≥ 10 pg/mL), which was not blunted by atorvastatin. Hs-CRP rose in 19/20 patients, and IL-6 rose in all patients. However, atorvastatin did not blunt the rise in these inflammatory biomarkers. On POD 2, IL-6 and hs-cTnI levels correlated (ρ = 0.59, p = 0.02). Recruitment was limited by the high prevalence of statin use in the screened population and a high prevalence of exclusions among hip fracture patients. CONCLUSION: Perioperative myocardial injury and inflammation are common in orthopedic patients and do not appear to be reduced in those randomized to atorvastatin. TRIAL REGISTRATION: NCT02197065.

Subsartorial adductor canal vs femoral nerve block for analgesia after total knee replacement.

PURPOSE: Providing effective analgesia for total knee arthroplasty (TKA) patients remains challenging. Femoral nerve block (FNB) offers targeted pain control; however, its effect on motor function, related fall risk and impact on rehabilitation has been the source of controversy. Adductor canal block (ACB) potentially spares motor fibres of the femoral nerve, but the comparative effect of the two approaches has not yet been well defined due to considerable variability in pain perception. Our study compares both single-shot FNB and ACB, side to side, in the same patients undergoing bilateral TKA. METHODS: Sixty patients scheduled for bilateral TKA were randomised to receive ultrasound-guided FNB on one leg and ACB on the other, in addition to combined spinal epidural anaesthesia. The primary outcome was comparative postoperative pain in either extremity at six to eight, 24 and 48 hours postoperatively. Secondary comparative outcomes included motor strength (manually and via dynamometer), physical therapy milestones and patient satisfaction. RESULTS: While pain levels were lowest at six to eight hours postoperatively and increased thereafter (P < 0.001), no significant differences were seen between extremities at any time point with regard to pain in the quantitative comparison using visual analogue scale (VAS) scores (P = 0.4154), motor strength (P = 0.7548), physical therapy milestones or patient satisfaction. However, in the qualitative comparison, a significant proportion of patients reported the leg receiving ACB to be more painful than that receiving FNB at 24 h [50.9 % (n = 30) vs 25.42 % (n = 15), P = 0.0168)]. CONCLUSIONS: Although we could not confirm a benefit in motor function between ACB and FNB, given the equivalent analgesic potency combined with its potentially lower overall impact if neuropraxia should occur, ACB may represent an attractive alternative to FNB.

Fractures of a single design of highly cross-linked polyethylene acetabular liners: an analysis of voluntary reports to the United States Food and Drug Administration.

Polyethylene liner fracture is a risk associated with the use of highly cross-linked UHMWPE. We performed a review of the voluntary reports of fractured liners to the US Food and Drug Administration to determine if any risk factors could be identified. There have been 74 reports of fractured Trilogy, Longevity liners to the US Food and Drug Administration since 1999. Most cases utilized small acetabular shells (≤54 mm) combined with large diameter heads (≥36 mm). Liners less than 7 mm thick at the weight bearing or 4.8 mm thick at the rim should be used with caution. At revision surgery, malpositioned shells should be revised and the use of a thin liner should be avoided.

Obese patients undergoing total knee arthroplasty have distinct preoperative characteristics: an institutional study of 4718 patients.

Obesity affects a disproportionate proportion of total knee arthroplasty (TKA) patients. Our study explores pre-operative characteristics between obese and non-obese patients undergoing TKA surgery. A cohort of 4718 osteoarthritic patients, undergoing primary TKA, was studied. Patients were stratified according to BMI classes. Each class was compared in terms of age, race, gender, level of education, insurance status, pre-operative WOMAC, SF-36, and Elixhauser comorbidities. There was a positive relationship between BMI and female gender, non-white race, Medicaid, private insurance, and self-pay. A negative relationship was observed between BMI and age, Medicare, WOMAC and SF-36. Obese TKA candidates differ from their non-obese counterparts in a number of demographic, socioeconomic, and clinical characteristics.

Treatment of large acetabular defects: a surgical technique utilizing impaction grafting into a metallic mesh.

BACKGROUND: Revision total hip arthroplasty in cases with severe acetabular bone loss is challenging. In the presence of combined cavitary and segmental defects without superior acetabular coverage, reconstructions with a structural acetabular allograft protected by a cage or a custom-made triflange cage have been the treatment of choice. The current paper describes an impaction grafting into a mesh for uncontained defects in revision total hip arthroplasty. DESCRIPTION OF TECHNIQUE: After restoring containment with a mesh fixed with small fragment screws, defects were restored using impaction grafting combined with a cemented all-polyethylene cup. PATIENTS AND METHODS: Fourteen consecutive acetabular impaction graftings were performed by two surgeons. All patients had a type 3B defect according to the Paprosky classification. RESULTS: No re-revisions or radiographic failure was detected in the early follow-up period. CONCLUSION: Impaction grafting into a mesh is an interesting treatment option to restore bone in combined cavitary and segmental defects.

Long term safety, efficacy, and patient acceptability of hyaluronic acid injection in patients with painful osteoarthritis of the knee.

The increasing prevalence of painful knee osteoarthritis has created an additional demand for pharmacologic management to prevent or delay surgical management. Viscosupplementation, via intraarticular injection of hyaluronic acid (HA), aims to restore the favorable milieu present in the nonarthritic joint. The safety profile of intraarticular HA injections for painful knee osteoarthritis is well established, with the most common adverse effect being a self-limited reaction at the injection site. Although acceptance of the early literature has been limited by publication bias and poor study quality, more recent and rigorous meta-analysis suggests that intraarticular HA injection is superior to placebo injection for pain relief and matches, if not surpasses, the effect size of other nonoperative treatments, such as nonsteroidal anti-inflammatory medication. Intraarticular HA injection is effective in providing temporary pain relief in patients with painful knee osteoarthritis. Future investigations should focus on optimizing the composition and administration of HA agents to provide prolonged relief of painful osteoarthritis in the knee and other joints.

Epidemiology and risk factors for perioperative mortality after total hip and knee arthroplasty.

The perioperative mortality of total knee and hip arthroplasties (TKA, THA) remains a major concern among health care providers and their patients. The increase in utilization of TKA and THA makes it imperative to be aware of factors that are associated with this unfortunate event. Therefore we analyzed the Nationwide Inpatient Sample data from 1998 to 2008 and compared admissions with perioperative mortality to those that survived their hospitalization. An estimated total of 4,438,213 TKA and 2,182,121 THA procedures were performed in the United States between 1998 and 2008. The average mortality rate for TKA was 0.13% and 0.18% for THA, or 0.34 and 0.44 events per 1,000 inpatient days, respectively. Independent risk factors for in-hospital mortality were advanced age, male gender, ethnic minority background, emergency admission as well as a number of comorbidities and complications. Furthermore, we demonstrated that the timing of death occurred earlier after TKA when compared to THA, with 50% of fatalities occurring by day 4 versus day 6 of the hospitalization, respectively. This study provides nationally representative information on risk factors for and timing of perioperative mortality after TKA and THA. Our data can be used to assess the risk for perioperative mortality and to develop targeted intervention to decrease such risk.

Perioperative inflammatory response in total knee arthroplasty patients: impact of limb preconditioning.

BACKGROUND AND OBJECTIVES: Ischemic preconditioning of tissue that is to undergo procedure-induced underperfusion has been used in a number of surgical settings to reduce the subsequent inflammatory response and its sequelae. The objective of this prospective, randomized study was to evaluate the effect of ischemic preconditioning on the systemic inflammatory response, degree of lung catabolism, and postoperative-pain associated with total knee arthroplasty (TKA). MATERIALS: Thirty-four patients undergoing unilateral TKA under tourniquet ischemia were enrolled with half (n = 17) being randomized to an episode of limb preconditioning before induction of ischemia for surgery. Markers of inflammation (interleukin 6 [IL-6], C-reactive protein,tumor necrosis factor >, and leukocyte count) and elastin catabolism(desmosine) were measured at baseline and various points postoperatively.Pain scores and length of stay were recorded. RESULTS: A significant increase in the levels of IL-6, C-reactive protein,tumor necrosis factor >, and white blood cell count was observed after surgery in both groups. Despite trends toward decrease in the IL-6 level in the preconditioning group, no significant difference between groups was observed for all markers at any given time point. Urine desmosine-creatinine-ratios did not differ between groups, and no significant-changes from baseline were seen postoperatively. However, median pain scores and length of hospital stay were lower in the treatment group. CONCLUSIONS: Preconditioning of the lower extremity in the setting of TKA under regional anesthesia may have limited value in reducing the systemic inflammatory response and level of lung injury. However, preconditioning may be associated with beneficial effects such as reduction in postoperative pain levels, and thus, further investigations are warranted.

The 2007 ABJS Nicolas Andry Award: three decades of clinical, basic, and applied research on thromboembolic disease after THA: rationale and clinical results of a multimodal prophylaxis protocol.

Total hip arthroplasty is an operation with a high risk for venous thromboembolism. Three decades of research conducted at the Hospital for Special Surgery identified the exact timing of the thrombogenic stimulus during surgery, defined the role of magnetic resonance venography, and established the role of certain genetic and acquired predispositions. Based on these studies, we implemented a multimodal prophylaxis consisting of a series of safe preventive measures applied before, during, and immediately after surgery to reduce the risk of venous thromboembolism. If these safe preventive measures are strictly observed, postoperative pharmacologic prophylaxis does not need to be aggressive in the patient without predisposing factors who mobilizes promptly, thus diminishing the risk of bleeding associated with the use of anticoagulants and the overall cost of care. Our clinical experience with more than 5000 total hip arthroplasties performed during the last decade and closely followed prospectively for a minimum of 3 months clearly shows this multimodal prophylaxis is safe and effective resulting in a very low prevalence of thromboembolism.