Failure Following Revision Total Hip Arthroplasty After Cobalt-Chrome Femoral Heads are Placed on a Retained Femoral Stem.

BACKGROUND: Failure due to trunnionosis with adverse local tissue reaction (ALTR) has been reported with cobalt-chrome (CoCr) heads in total hip arthroplasty (THA); however, there are limited data on the use of these heads in the revision setting. The purpose of this study was to analyze the outcomes of patients who underwent revision THA with a retained femoral component and received a CoCr femoral head on a used trunnion. METHODS: In this retrospective review, we identified all patients who underwent revision THA with a retained femoral component and received a CoCr femoral head between February 2006 and March 2014. Demographic factors, implant details, and postoperative complications, including the need for repeat revisions, were recorded. In total, 107 patients were included (mean age 67 years, 74.0% women). Of the 107 patients, 24 (22.4%) required repeat revisions. RESULTS: Patients who required repeat revision were younger than those who did not (mean age: 62.9 versus 69, P = .03). The most common indications for repeat revision were instability (8 of 24, 33.3%), ALTR (5 of 24, 20.8%), and infection (4 of 18, 16.7%). Evidence of ALTR or metallosis was identified at the time of reoperation in 10 of the 24 patients who underwent re-revision (41.7%). CONCLUSIONS: The placement of a new CoCr femoral head on a used trunnion during revision THA with a retained femoral component carries a significant risk of complication (22.4%) and should be avoided when possible.

Reducing Narcotic Usage With 0.5% Bupivacaine Periarticular Injections in Total Knee Arthroplasty.

BACKGROUND: Periarticular injections (PAIs) and adductor canal blocks (ACBs) are widely accepted pain management strategies for total knee arthroplasty (TKA); however, the optimal anesthetic concentration to provide adequate pain relief while avoiding toxicity remains controversial. The purpose of this study is to evaluate the efficacy of different anesthetic concentrations for PAI alone and in combination with ACB. METHODS: This retrospective cohort study of patients undergoing primary TKAs between January 2019 and November 2020 included 3 groups: 0.25% PAI (50 cc of 0.25% bupivacaine PAI diluted with 50 cc of saline and ketorolac), 0.5% PAI (50 cc of 0.5% bupivacaine with 50 cc of saline and ketorolac), and PAI + ACB (ultrasound-guided preoperative anesthesiologist-administered ACB and 0.25% PAI). RESULTS: In total, 368 TKAs were analyzed (123 0.25%, 132 0.5%, and 113 PAI + ACB). Total overall hospital narcotic usage in oral morphine equivalents (OME) was significantly lower for the 0.5% group (120.09 vs 165.26 and 175.75) compared to the 0.25% and PAI + ACB groups, respectively (P < .0001). Cumulative OME for the first 3 shifts was also lower for 0.5% (68.7 vs 83.7 and 76.4) compared to the 0.25% and PAI + ACB groups, respectively (P = .030). Total postoperative narcotics in OME were significantly lower for 0.5% (617.9 vs 825.2 and 1047.6) than 0.25% and PAI + ACB, respectively (P = .0003). Number of prescriptions within 6 weeks postoperatively were also significantly lower for 0.5% (1.7) than 0.25% (2.1) and PAI + ACB (2.4) (P = .0003). CONCLUSION: Patients receiving 0.5% PAI had lower narcotic usage compared to 0.25% PAI or PAI + ACB. ACB may be eliminated without compromising pain control if the dose of local anesthetic in the PAI is sufficiently high.

An Algorithm for Detection and Correction of Pelvic Tilt in Total Hip Replacement.

Successful joint replacement surgery requires precise preoperative planning and intraoperative placement of implants such that the function of the joint is optimized biomechanically and biologically. The five-step "pelvic tilt algorithm" will enhance the outcome of hip replacement surgery as a result of improved acetabular component alignment. It will solve the problem of pelvic tilt as an unknown variable during hip replacement surgery, and will allow for more consistent and accurate acetabular component placement.

An Update to a Novel Technique for Centering the Femoral Stem in Primary Total Hip Arthroplasty.

Careful surgical technique is a critical component of total hip arthroplasty. Femoral preparation and component positioning are vital to improving outcomes and preventing complications. Femoral preparation begins with creating an entry hole in the proximal femur. Various tools have been used for this purpose which resemble a "cookie cutter." An axial starter reamer, or awl, is then inserted through the entry hole in the proximal femur to aid in opening and centralizing the canal for sequential reaming or broaching. A novel technique was described previously which allows the awl to center itself in the canal with little risk of deviation from midline or cortical perforation. Since describing this technique in 2014, the senior surgeon has further modified the method of preparing the entry hole in the proximal femur. The surgeon now uses a 1/8" drill bit to penetrate the piriformis fossa, instead of a "cookie cutter" or osteotome. A 1/8" entry hole eliminates gaps between the bone and the implant, results in lateralization of the stem, and avoids varus malposition. We evaluated 300 primary hip arthroplasties by a single surgeon using one of the three techniques: traditional clockwise technique (Group 1), our previously published novel counterclockwise technique (Group 2), and our updated novel technique (Group 3). While the deviation from midline of Group 3 did not differ significantly from Group 2, it was significantly less than the deviation from midline of Group 1 (p=00006). This simple updated technique enables the surgeon to avoid potential malalignment during femoral preparation.

Effects of Coronal Limb Alignment and Ligament Balance on Pain and Satisfaction Following Total Knee Arthroplasty at Short-Term Follow Up.

INTRODUCTION: Few studies have evaluated the concomitant effect of both total knee arthroplasty (TKA) limb alignment and ligament laxity. Therefore, the primary aim of this study is to evaluate the impact of lower extremity alignment on the short-term outcome (one year) following TKA, including pain relief, function, and patient satisfaction. The secondary aim of the study is to evaluate the impact of ligament laxity and balance on early outcomes following TKA. MATERIALS AND METHODS: A prospective evaluation of mechanical alignment and ligament tension was performed for 110 consecutive TKAs using an identical surgical technique. Patients were evaluated with knee society score, visual analog pain score, and satisfaction one year following TKA. Linear regression analysis was then performed to determine the effect of lower extremity alignment and ligament laxity. RESULTS: There was no significant relationship between lower extremity alignment and outcome measures. A significant relationship was identified between medial collateral laxity in full extension and knee society scores for function, but not for pain. There was also a significant relationship identified between lateral knee laxity at 90 degrees of flexion and knee society score and pain at one-year follow up. CONCLUSION: Our results demonstrated no correlation between mechanical alignment restoration and pain or function. However, more interestingly, this study found patients with medial laxity in extension and lateral laxity in knee flexion, similar to normal physiologic knee laxity, to have less pain and greater function and satisfaction at one-year short-term follow up.

Influence of Soft Tissue Preservation in Total Hip Arthroplasty: A 16-Year Experience.

BACKGROUND: Surgical technique in total hip arthroplasty (THA) has been a topic of debate over the last 50 years. Evidence-based studies are needed to compare one technique to another. This study investigated the outcome of the direct superior approach in primary THA as measured by patient perception of pain and recovery over a 16-year period. MATERIALS AND METHODS: We retrospectively reviewed a series of 3,357 consecutive patients who underwent primary THA by a single surgeon using the direct superior approach between 2001 and 2017. The surgical technique was modified twice during this 16-year period. The first modification (2007) consisted of piriformis tendon preservation. The second modification (2012) consisted of iliotibial band (ITB) preservation. These two modifications of the surgical technique created three different patient groups. A telephone interview regarding patient pain and recovery after each THA was conducted with 147 patients who had staged bilateral THA procedures wherein the surgical technique was modified between the first and second (contralateral) THA. RESULTS: Results show the addition of ITB preservation to capsular repair, with or without piriformis preservation, greatly improves the patient's perception of pain and recovery, causing the majority of patients to prefer their ITB-preserving surgery over their ITB-sacrificing surgery. In addition, the dislocation rate over this 16-year period is 0.17%. CONCLUSION: The direct superior approach to the hip results in excellent stability with a dislocation rate of 0.17%. The patient's perception of pain and recovery is dramatically improved with preservation of the iliotibial band.

Total Hip Intraoperative Femur Fracture: Do the Design Enhancements of a Second-Generation Tapered-Wedge Stem Reduce the Incidence?

BACKGROUND: Intraoperative femur fracture (IFF) is a well-known complication in primary uncemented total hip arthroplasty (THA). Variations in implant instrumentation design and operative technique may influence the risk of IFF. This study investigates IFF between a standard uncemented tapered-wedge femoral stem and its second-generation successor with the following design changes: size-specific medial curvature, proportional incremental stem growth, modest reduction in stem length, and distal lateral relief. METHODS: A single experienced surgeon's patient database was retrospectively queried for IFF occurring during primary uncemented THA using a standard tapered-wedge femoral stem system or a second-generation stem. All procedures were performed using soft tissue preserving anatomic capsule repair and posterior approach. The primary outcome measure was IFF. A z-test of proportions was performed to determine significant difference between the 2 stems with respect to IFF. Patient demographics, Dorr classification, and implant characteristics were also examined. RESULTS: Forty-one of 1510 patients (2.72%) who received a standard tapered-wedge femoral stem sustained an IFF, whereas 5 of 800 patients (0.63%) using the second-generation stem incurred an IFF. No other significant associations were found. CONCLUSION: A standard tapered-wedge femoral stem instrumentation system resulted in greater than 4 times higher incidence of IFF than its second-generation successor used for primary uncemented THA. Identifying risk factors for IFF is necessary to facilitate implant system improvements and thus maximize patient outcomes.

Total Hip Arthroplasty Dislocation after Cardioversion: A Case Report.

New onset postoperative atrial fibrillation (AF) is the most common perioperative arrhythmia in the elderly. The incidence after total joint arthroplasty is much lower than other non-cardiac surgeries. Since postoperative atrial fibrillation can cause increased length of hospital stay, mortality, and healthcare costs, it is critical to focus on prevention and prompt management. New onset atrial fibrillation is treated with rhythm control for patients who demonstrate hemodynamic instability or refractory to rate control measures. Electrical cardioversion is an effective option for unstable patients with known complications. However, there is limited data on orthopedic problems after cardioversion. A unique case is reported presenting postoperative total hip arthroplasty (THA) dislocation after electrical cardioversion for new onset atrial fibrillation in the postanesthesia care unit (PACU).

Low dose compared to variable dose Warfarin and to Fondaparinux as prophylaxis for thromboembolism after elective hip or knee replacement surgery; a randomized, prospective study.

BACKGROUND: Deep vein thrombosis (DVT) and pulmonary emboli (PE), known together as venous thromboembolic (VTE) disease remain major complications following elective hip and knee surgery. This study compares three chemoprophylactic regimens for VTE following elective primary unilateral hip or knee replacement, one of which was designed to minimize risk of post-operative bleeding. METHODS: Patients were randomized and stratified for hip vs. knee to receive A: variable dose warfarin (first dose on the night preceding surgery with subsequent target INR 2.0-2.5), B: 2.5 mg fondaparinux daily starting 6-18 h postoperatively, or C: fixed 1.0 mg dose warfarin daily starting 7 days preoperatively. All treatments continued until bilateral leg venous ultrasound day 28 ± 2 or earlier upon a VTE event. The study examined primary endpoints including leg DVT, PE or death due to VTE and secondary endpoints including effects on D-dimer, estimated blood loss (EBL) at surgery and hemorrhagic complications. RESULTS: Three hundred fifty-five patients were randomized. None was lost to follow-up. Taking 1.0 mg warfarin for seven days preoperatively did not prolong the prothrombin time (PT). Two patients in Arm C had asymptomatic distal DVT. One major bleed occurred in Arm B and one in Arm C (ischemic colitis). Elevated d-dimer did not predict delayed VTE for one year. CONCLUSIONS: Fixed low dose warfarin started preoperatively is equivalent to two other standards of care under study (95 % CI: -0.0428, 0.0067 for both) as VTE prophylaxis for the patients having elective major joint replacement surgery. TRIAL REGISTRATION: ClinicalTrials.gov identifier # NCT00767559 FDA IND: 103,716.

Corrosion and Adverse Local Tissue Reaction in One Type of Modular Neck Stem.

Modular neck stems allow for optimization of joint biomechanics by restoring anteversion, offset, and limb length. A potential disadvantage is the generation of metal ions from fretting and crevice corrosion. We identified 118 total hip arthroplasty implanted with one type of dual-modular femoral component. Thirty-six required revision due to adverse local tissue reaction. Multivariate analysis isolated females and low offset necks as risk factors for failure. Kaplan-Meir analysis revealed small stem sizes failed at a higher rate during early follow-up period. Although the cobalt/chrome levels were higher in the failed group, these tests had low diagnostic accuracy for ALTR, while MRI scan was more sensitive. We conclude that the complications related to the use of dual modular stems of this design outweigh the potential benefits.

Gross trunnion failure after primary total hip arthroplasty.

Unfavorable outcomes from trunnion fretting and corrosion damage have been reported in the literature, gross failures of tapers in primary total hip arthroplasties have been less frequently reported. We report on 5 patients, who presented with gross trunnion failures of modular metal-on-polyethylene or ceramic-on-polyethylene bearings from 5 implant manufacturers, all necessitating revision surgery. None of these patients had an antecedent history of trauma, and the majority presented with pain or instability. No common factor was identified that may be predictive of these type of failures. Since there were 5 different stem designs, this suggests that it may be a rare generic phenomenon occurring with multiple designs. Currently, further investigations are necessary, including retrieval analysis, to identify risk factors that may predispose to such failures.

A low-cost digital templating system for total hip arthroplasty.

Acetate templating for total hip arthroplasty (THA) is cumbersome and inaccurate. High cost hampers mainstream use of digital templating despite ease of use and accuracy. The aim of this study was to validate a low-cost digital THA templating system. Low-cost digital templating software was created using C# programming language. On the basis of power calculations, three surgeons templated 20 consecutive anteroposterior pelvis X-rays using this software against an industry standard. Intraclass correlation coefficient for both systems was approximately .90 for component size and femoral neck cut position. Bland-Altman plots demonstrated that both systems predicted actual implant size with similar accuracy. Interrater reliability was not significantly different between the two systems. This low-cost digital THA templating system is up to 12-fold lower in cost than currently available software with similar accuracy.

Femoral head dislodgement complicating use of a dual mobility prosthesis for recurrent instability.

The dual mobility cup is an unconstrained tripolar configuration newly introduced to the United States in February 2011. The dual mobility construct allows for a larger femoral head to improve motion and minimize the risk of dislocation. We present a case of a patient who received the dual mobility cup for the treatment of recurrent dislocation following total hip arthroplasty. Early in the patient's postoperative course, the implant failed at the articulation between the larger outer polyethylene head and inner smaller metal femoral head following an attempt at closed reduction. This implant specific complication has not been reported in the North American literature.

Adverse tissue reactions in modular exchangeable neck implants: a report of two cases.

Dual-modular femoral stems with exchangeable necks theoretically allow optimization of hip joint biomechanics via selective restoration of femoral anteversion, offset, and limb length. A potential disadvantage is the possible generation of metal ions and debris by fretting and crevice corrosion at the additional stem-neck interface. We present 2 cases of early-onset adverse inflammatory tissue reactions as a result of accelerated corrosion at the stem-neck interface of a dual-modular implant, requiring subsequent revision of well-fixed components.

Skin avulsion injuries with use of adhesive surgical drapes.

Iodophor-impregnated adhesive drapes are commonly used to reduce the incidence of surgical site infections (SSI).While proper and discretionary use of drapes can provide significant benefit, there are potential risks. We present two cases of degloving injuries sustained from use of these drapes during total knee arthroplasty. The patients, deemed high risk for potential skin avulsion injuries, received standard wound care and close follow-up which resulted in healing of the lesions at 6-week follow-up.

Prophylactic antipropagation stitch in total knee arthroplasty performed via medial parapatellar approach: a simple and cost-effective technique for reducing quadriceps injury.

This article describes a novel, simple, and effective technique for limiting extensor mechanism damage during total knee arthroplasty (TKA) performed via the medial parapatellar (MPP) approach. Immediately on making the quadriceps tendon split in the MPP approach, a figure-of-eight stitch is placed at the apex of the split. The prophylactic stitch technique has been used by one surgeon in 1000 consecutive TKAs over the past 5 years. This technique has eliminated proximal extension of the quadriceps tendon split into the muscle belly and may help to decrease postoperative pain, increase postoperative quadriceps strength, and improve patient satisfaction and outcomes.

Effect of surgeon experience on femoral component size selection during total knee arthroplasty.

Femoral component size selection during total knee arthroplasty should not vary from surgeon to surgeon for patients with the same bone size. This study explored if systematic variations in femoral component size selection exist. Thirteen surgeons' choices of femoral component size (Duracon, n = 1388; Triathlon, n = 740) were analyzed using a generalized linear model with femoral component size as the dependent variable and surgeon identification, years in practice, and adult reconstruction fellowship training as the independent variables. The model adjusted for differences in bone size. It was found that more experienced surgeons implant larger femoral components. New instruments and training protocols may be necessary to adjust for surgeon experience.

The Reverse Fragility Index: Interpreting the Current Literature on Long-Term Survivorship of Computer-Navigated Versus Conventional TKA: A Systematic Review and Cross-Sectional Study of Randomized Controlled Trials.

BACKGROUND: Despite the most recent American Academy of Orthopaedic Surgeons clinical practice guideline making a "strong" recommendation against the use of intraoperative navigation in total knee arthroplasty (TKA), its use is increasing. We utilized the concept of the reverse fragility index (RFI) to assess the strength of neutrality of the randomized controlled trials (RCTs) comparing the long-term survivorship of computer-navigated and conventional TKA. METHODS: A systematic review was performed including all RCTs through August 3, 2021, comparing the long-term outcomes of computer-navigated and conventional TKA. Randomized trials with mean follow-up of >8 years and survivorship with revision as the end point were included. The RFI quantifies the strength of a study's neutrality by calculating the minimum number of events necessary to flip the result from nonsignificant to significant. The RFI at a threshold of p < 0.05 was calculated for each study reporting nonsignificant results. The reverse fragility quotient (RFQ) was calculated by dividing the RFI by the study sample size. RESULTS: Ten clinical trials with 2,518 patients and 38 all-cause revisions were analyzed. All 10 studies reported nonsignificant results. The median RFI at the p < 0.05 threshold was 4, meaning that a median of 4 events would be needed to change the results from nonsignificant to significant. The median RFQ was 0.029, indicating that the nonsignificance of the results was contingent on only 2.9 events per 100 participants. The median loss to follow-up was 27 patients. In all studies, the number of patients lost to follow-up was greater than the RFI. CONCLUSIONS: The equipoise in long-term survivorship between computer-navigated and conventional TKA rests on fragile studies, as their statistical nonsignificance could be reversed by changing the outcome status of only a handful of patients--a number that was always smaller than the number lost to follow-up. Routine reporting of the RFI in trials with nonsignificant findings may provide readers with a measure of confidence in the neutrality of the results. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Allograft closure of lateral release after revision total knee arthroplasty.

Lateral patellar retinacular release (lateral release) is a common technique for resolving patellar tracking issues during total knee arthroplasty. Complications such as hemarthrosis, wound healing complications, patellar fracture, reflex sympathetic dystrophy, and medial subluxation of the patella have been described. This is a case presentation of a 69-year-old woman who developed severe prepatellar bursitis from a sinus tract resulting from a lateral release after total knee arthroplasty. After failing nonoperative modalities, she was treated with an allograft dermal tissue graft (AlloDerm; LifeCell Corp, Branchburg, NJ) over the defect, which has resulted in resolution of symptoms at 2-year follow-up.

Complications of femoral nerve blockade in total knee arthroplasty and strategies to reduce patient risk.

Femoral nerve catheters are widely used for analgesia in total knee arthroplasty. Although evidence suggests that catheters improve pain control and may facilitate short-term rehabilitation, few reports exist regarding their complications. This case series explores the experience of femoral nerve catheter use at high-volume orthopedic specialty hospitals. Serious complications including compartment syndrome, periprosthetic fracture, and vascular injury are reported. The authors support femoral nerve catheter use with appropriate precautions taken to reduce risk of patient falls, vascular injury, and wrong-site surgery.