Repair of horizontal meniscus tears: a systematic review.

PURPOSE: Despite the well-documented advantages of meniscal repair over meniscectomy, horizontal cleavage tears (HCTs) are often not repaired. Reported reasons include difficulty performing the repair, potential suture failure due to mechanical stresses, and poor healing rates. In addition, many surgeons have the perception that debriding the tear until the superior and inferior laminae are stable results in a good clinical outcome. Furthermore, many of the tears occur in patients who are older than the generally accepted indicated age for repair and may also have a degenerative component, making them potentially less likely to benefit from repair. This review was performed to evaluate the published outcomes of HCT repairs and test the hypothesis that surgically repaired HCTs have an unacceptably low rate of success. METHODS: A systematic search of the PubMed and Embase databases was performed in December 2013 to identify studies in which meniscal HCTs were repaired. Inclusion criteria for the analysis were English language, reference to a patient with an HCT repaired by any method, and a report of at least 1 postoperative outcome. For the purposes of this review, a failed outcome was defined as the need for reoperation. RESULTS: More than 16,000 abstracts were returned in the search. From these abstracts, we identified 210 articles for further review, of which 9 met the inclusion criteria. A total of 98 repairs of horizontal tears were evaluated in these studies. By use of reoperation as the criterion for treatment failure, 77 of the repairs were successful, for an overall success rate of 77.8%. CONCLUSIONS: The literature does not support the hypothesis that surgically repaired HCTs have an unacceptably low rate of success. Rather, our results show that existing studies of repaired HCTs show a comparable success rate to repairs of other types of meniscal tears. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Effects of fondaparinux on wound drainage after total hip and knee arthroplasty.

BACKGROUND: The purpose of this investigation was to determine the effects of fondaparinux on postoperative wound drainage, length of hospital stay (LOS) and rate of surgical site infection in total joint patients. METHODS: 117 patients undergoing total joint arthroplasty treated with fondaparinux for venous thromboembolism (VTE) prophylaxis were prospectively studied. RESULTS: The average time to a dry wound was 3.4 days, with an average LOS of 3.77 days. Perioperative complications included 2 cases each of superficial cellulitis, deep vein thrombosis, and pulmonary embolism; there were no cases of deep infection. Multi-variate analysis showed increased patient BMI increased LOS (p = 0.0169). CONCLUSION: Fondaparinux is an effective drug for VTE prophylaxis in total joint arthroplasty with wound drainage and LOS comparable to historical controls of enoxaparin, warfarin, and rivaroxaban.

Periprosthetic supracondylar femur fracture treated with spanning external fixation.

Periprosthetic supracondylar fractures of the femur after total knee arthroplasty represent a devastating complication for the patient and a technical challenge for the surgeon. Treatment is often complicated by advanced patient age, retained cement, and accompanying osteoporosis. We present the case of a 54-year-old woman with a comminuted fracture of the distal femur just above a total knee prosthesis. She had a complex past medical history, including extensive coronary artery disease, morbid obesity, chronic osteoporosis, anemia, diabetes, and rheumatoid arthritis. She was a Jehovah's Witness and thus refused all blood products. Given her medical history, religious preferences, and fracture comminution, a spanning external fixator was used. She completed fracture union with an excellent clinical and radiographic result at 2 years.

Effect of day of the week of primary total hip arthroplasty on length of stay at a university-based teaching medical center.

Length of hospital stay (LHS) after primary total hip arthroplasty (THA) constitutes a critical outcome measure, as prolonged LHS implies increased resource expenditure. Investigations have highlighted factors that affect LHS after THA. These factors include advanced age, medical comorbidities, obesity, intraoperative time, anesthesia technique, surgical site infection, and incision length. We retrospectively analyzed the effect of day of the week of primary THA on LHS. We reviewed the surgery and patient factors of 273 consecutive patients who underwent THA at our institution, a tertiary-care teaching hospital. There was a 15% increase in LHS for patients who underwent THA on Thursday versus Monday when controlling for other covariates that can affect LHS. Other statistically significant variables associated with increased LHS included American Society of Anesthesiologists grade, transfusion requirements, and postoperative complications. The day of the week of THA may be an independent variable affecting LHS. Institutions with reduced weekend resources may want to perform THA earlier in the week to try to reduce LHS.

The financial impact of the loss of county indigent patient funding on a single orthopedic trauma surgery service.

BACKGROUND: We examined the financial ramifications on the orthopedic trauma service after loss of payment to our institution for care of indigent patients. Our institution is the only Level I trauma center located within the county. Before mid-2009, county insurance-eligible patients treated at our institution had their health care paid for by the county. After mid-2009, the county no longer reimbursed our institution for care provided. METHODS: A retrospective review was performed on 653 county patients treated by the four orthopedic trauma surgeons during a 4-year period including the 2 years before the loss of county payments as well as the 2-year period following the loss of payment. Data collected included demographics, admitting service, injuries treated, length of stay, surgeon billing, and reimbursement. We also classified the urgency of care that was rendered into one of three categories as follows: emergent, urgent, or elective. RESULTS: There was a higher frequency of emergent and urgent procedures and a lower frequency of elective cases performed in the noncontracted period versus the contracted period. During the contracted period, we billed and collected $1,161,036. After the loss of reimbursement from the county, we billed $870,590 and were paid $0. County reimbursements made up 33.5% of the total professional fees billed. There was a 20% net drop in total billing during the noncontracted period, of which the money not reimbursed by the county accounted for 31%. CONCLUSION: Despite the lack of county payment, our institution continues to provide care to the indigent population. This lack of payment may have significant long-term economic ramifications for the orthopedic trauma surgeons and for our institution. The financial burden preferentially falls on the "safety net" Level I trauma centers and the physicians who take care of patients with urgent and emergent injuries. This burden may be unsustainable in the future. LEVEL OF EVIDENCE: Economic and value-based evaluation, level V.

Relationship between deep vein thrombosis and pulmonary embolism following THA and TKA.

Patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) are at risk for venous thromboembolisms, including deep vein thrombosis and pulmonary embolism. Most deep vein thromboses are asymptomatic, but they can lead to long-term morbidity to the same extent as symptomatic events. The risk of complications of venous thromboembolisms depends on the location of thrombi; potential long-term complications include recurrent venous thromboembolism, postthrombotic syndrome, and chronic thromboembolic pulmonary hypertension. Risk of recurrence persists for several years after the initial event. Approximately 20% of recurrent events are pulmonary embolisms, and approximately half of those are fatal. The causal relationship between deep vein thrombosis and pulmonary embolism remains controversial. Some consider them distinct clinical entities, while others have found asymptomatic distal deep vein thrombosis to be associated with elevated risk of developing pulmonary embolism. Unique coagulation factors may be associated with orthopedic surgery patients that differentiate them from patients undergoing other types of surgery. Symptomatic and asymptomatic deep vein thrombosis can lead to the development of recurrent venous thromboembolism, pulmonary embolism, postthrombotic syndrome, and chronic thromboembolic pulmonary hypertension, all of which are associated with reduced quality of life and increased health care expenditures. Thromboprophylaxis is therefore important in patients undergoing THA or TKA. However, traditional anticoagulants are not ideal, particularly for long-term use. Orthopedic surgeons should be aware of the causes and potential sequelae of venous thromboembolism and of the new thromboprophylactic agents that can help prevent it.