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.

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.

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.

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.

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.

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.

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.

The relationship of lateral release and tourniquet deflation in total knee arthroplasty.

A total of 242 knees in 198 patients undergoing total knee arthroplasty were reviewed to evaluate the effect of tourniquet deflation on lateral release rates, possible variables associated with the need for lateral release, and adequacy of intraoperative evaluation on final radiographs. The need for lateral release was determined using the "no-thumbs" and "full contact" rules and visual evaluation. Lateral release was performed after tourniquet deflation. A total of 171 (71%) knees needed a lateral release before tourniquet deflation. After tourniquet deflation, only 53 (22%) required lateral release, representing a 69% reduction. Obesity was the only other significant factor in lateral release requirement. Based on the observations of this study, it is recommended that the need for lateral release be evaluated after tourniquet deflation. A 69% reduction in lateral release supports the hypothesis that tourniquet pressure has an effect on patellar tracking. Lateral release appears to be effective in restoring normal patellar tilt, and obesity increases its need.

Surgical Technique in Total Hip Arthroplasty Utilizing the Anterolateral Approach.

The surgical approach is an important element in the quality of total hip replacement. Adequate surgical exposure based upon thorough fundamental knowledge of anatomy facilitates surgery and ensure optimum results in total hip replacement. Several surgical exposure techniques are utilized and have been described in the literature; all stress the importance of visualization of the acetabulum and the proximal femur in affording an atraumatic, expedient entry into the hip joint. Additionally, surgical exposure should be versatile, allowing for development to easily accommodate revision scenarios.

Rapid recovery protocol for peri-operative care of total hip and total knee arthroplasty patients.

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are among the most successful procedures performed in terms of quality-of-life years gained. The long-term goals of arthroplasty, to relieve pain, increase function, provide stability, and obtain durability, are accomplished in the vast majority of cases. The short-term goals, however, have become the target of aggressive peri-operative programs that aim to speed recovery, reduce morbidity and complications, and create a program of efficiency while maintaining the highest level of patient care. The concept of rapid recovery is built upon the burgeoning interest in less-invasive and small-incision surgeries for (THA and TKA). However, the incision size does not appear to be the most critical aspect of the program. This article outlines the specific elements of the rapid-recovery program for lower-extremity arthroplasty patients, including pre-operative patient education, peri-operative nutrition, vitamin and herbal medication supplementation, preemptive analgesia, and post-operative rehabilitation. A holistic peri-operative, rapid-recovery program has lead to a significantly decreased hospital length of stay and significantly lower hospital readmission rates in patients who undergo primary THAs and TKAs. Combining these results with minimally invasive techniques and instrumentation should make recovery even faster.

Pop-top tibial component: elimination of back-side wear with potential modularity.

Survivorship analysis has demonstrated the excellent long-term clinical success of total knee arthroplasty (TKA). Despite multiple attempts to enhance fixation with cementless technology, cemented TKA continues to be the "gold standard." The rate of loosening has diminished as the accuracy of implantation has been improved through sophisticated instrumentation and enhanced experience. Current technology with respect to computer-assisted surgery serves only to improve the accuracy of implantation, leaving materials as the weakest link in the long-term survivorship of TKA. Failure secondary to polyethylene wear has ranked as one of the most frequent causes for revision. Many issues have been identified as contributory to polyethylene wear and include the quality of the polyethylene, manufacturing process, nature of the tibial-femoral or patellofemoral articulation, area of contact, sterilization process, and issues pertaining to modularity and so-called backside wear. Long-term clinical studies have documented the success of direct compression-molded monoblock tibial components. However, the benefits of modularity are widely recognized and include the ability to fine tune soft-tissue balance after implantation of metallic devices. In an effort to combine the long-term success of direct compression molded monoblock tibial components with the occasional need for modularity, a convertible tibial component has been introduced. This device is manufactured as a direct compression-molded monoblock tibial component. The surgeon has the ability at the time of the surgical intervention, or any subsequent intervention, to convert the tibial component into a modular device. Therefore, this device addresses, in the majority of cases, the concerns that arise from backside wear.

Stem modularity: rarely necessary in primary total hip arthroplasty.

A retrospective review of two consecutive series of cementless primary THA performed simultaneously from November 1987 to February 1994 within a single orthopedic practice by three surgeons was conducted. A series using non-modular Mallory-Head Porous (Biomet Inc, Warsaw, Ind) femoral components was compared to a series using modular Sivash Range of Motion (DePuy, Warsaw, Ind) femoral components to evaluate whether modularity of the femoral stem body is necessary in cementless primary THA. Clinically and radiographically, both components performed at comparable levels with equally satisfactory results. Both series demonstrated effective femoral fixation as evidenced by excellent Engh fixation scores. However, this study has shown the importance of circumferential proximal porous-coating to form an effective seal, preventing the propagation of particulate debris. Modular systems were associated with a higher degree of technical difficulty, operative time, and blood loss.

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.

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.