Primary Total Hip Arthroplasty Outcomes for Labral Tears are Comparable to Advanced Osteoarthritis.

BACKGROUND: There is a paucity of evidence on outcomes following total hip arthroplasty (THA) in patients who have symptomatic degenerative labral tears and mild to moderate osteoarthritis (OA). The purpose of this study was to determine if outcomes of primary THA in the setting of painful, symptomatic labral tear and mild to moderate arthritic changes were comparable to outcomes of primary THA performed for severe arthritic changes. Primary outcomes were patient-reported outcome (PRO) scores. Secondary outcomes included length of stay and perioperative complications. METHODS: This was a retrospective investigation of all THAs between January 2018 and July 2022. There were 111 patients who had THA due to failure of nonoperative treatment of a degenerative labral tear without advanced arthritic changes (mild to moderate OA cohort, Kellgren-Lawrence Grades 1 to 3). These patients were matched to 111 patients who underwent THA for advanced OA (AOA cohort, Kellgren-Lawrence Grade 4). PROs included the Western Ontario McMaster Universities Arthritis Index (WOMAC). The average age for the labral tear cohort was 59 years, with 50.6% women, compared to 70 years (P < 0.001), and 49.4% women (P = 0.93) in the AOA cohort. RESULTS: There were no differences in preoperative PROs, complications, or length of stay between groups. When looking at postoperative PROs between cohorts, the labral tear cohort had less improvement in WOMAC-Stiffness (24.3 versus 34.0, P = 0.005) and WOMAC-Functional limitation (26.3 versus 36.0, P = 0.005) at 12 months and greater improvement in WOMAC-Pain at 12 months (38.3 versus 34.7, P = 0.04). The Short Form 12-Physical function scores were significantly higher among the labral tear cohort compared to the AOA cohort at 12 months (48.5 versus 47.8, P < 0.001). The Short Form 12-Mental scores were significantly higher in the AOA cohort compared to the labral tear cohort at 3 months (47.1 versus 47.4, P = 0.02) and 12 months (46.7 versus 47.6, P < 0.001). In the multivariate analysis, the change in WOMAC-Pain at 12 months was significantly better for labral tear patients (odds ratio 7.5, P = 0.008, confidence interval 6.85 to 8.14). CONCLUSIONS: Our study showed that patients who have symptomatic degenerative labral tears with mild to moderate arthritic changes have comparable outcomes to patients who have AOA following primary THA. Given suboptimal outcomes with hip arthroscopy for labral tear in the setting of early arthritis, primary THA can be a reasonable treatment modality for patients failing nonoperative treatments.

2-Octyl-Cyanoacrylate Mesh Dressings for Total Joint Arthroplasty: Dressing Design Influences Risks of Wound Complications.

BACKGROUND: Recent liquid adhesive skin closure systems with a mesh patch and a 2-octyl cyanoacrylate liquid formula have shown promising results in total joint arthroplasty. Chemical accelerators are typically included to promote the rapid polymerization of 2-octyl cyanoacrylate. The goal of the study is to distinguish designs and wound complication differences between 2 similar systems. METHODS: An 18-week retrospective study was conducted from July to December 2023, including 207 total hip arthroplasty and 212 total knee arthroplasty cases from 4 attending surgeons at 1 institution that used 1 of 2 dressing designs. Both dressings had a 2-octyl cyanoacrylate liquid adhesive formula that applied topically to a polyester-based mesh overlaying the wound. Mesh A (used in 274 cases) included an accelerator, a quaternary ammonium salt, on the mesh patch, whereas Mesh B (used in 145 cases) included a similar accelerator within the adhesive applicator. RESULTS: Wound complications (3.2 versus 7.6%; X2 = 3.86; df = 1; P = .049), early periprosthetic joint infections (0 versus 2.8%; X2 = 7.63; df = 1; P = .006), and 90-day reoperations for wound complications (0.4 versus 3.4%; X2 = 6.39; df = 1; P = .011) were significantly lower in patients who received Mesh A versus B, respectively. There was no difference in superficial surgical site infections (0.7 versus 0%; X2 = 1.06; df = 1; P = .302) or allergy rates (3.3 versus 4.1%; X2 = 0.12; df = 1; P = .655) between Mesh A and B. CONCLUSIONS: We observed significantly different performance in wound complications, early postoperative periprosthetic joint infections, and 90-day reoperation between the 2 designs. Having the accelerator in the applicator rather than on the mesh patch may lead to premature polymerization before bonding appropriately with the mesh to create the desired wound closure and seal. LEVEL OF EVIDENCE: Level III.

Complications and Survivorship After Aseptic Revision Total Hip Arthroplasty: Is There a Difference by Surgical Approach?

BACKGROUND: Revision total hip arthroplasty (rTHA) has traditionally been performed through the posterolateral approach (PA). Anterior approaches (AA) for rTHA are increasingly being utilized. The purpose of this study was to compare complications and survivorship from re-revision and reoperation after aseptic rTHA performed using an AA versus a PA. METHODS: We retrospectively reviewed patients who underwent aseptic rTHA either through an AA (direct anterior approach [DAA], anterior-based muscle sparing [ABMS]) or PA from January 2017 to December 2021. There were 116 patients who underwent AA-rTHA (DAA 50, ABMS 66) or PA-rTHA (n = 105). Patient demographics, complications, and postoperative outcomes were collected. RESULTS: The most common indication in both groups was aseptic loosening (n = 26, 22.4% AA, n = 28, 26.7% PA). Acetabular revision alone was most common in the AA group (n = 33, 28.4%), while both components were most commonly revised in the PA groups (n = 47, 44.8%). In all the AA-rTHA group, the index total hip arthroplasty was performed through a PA in 51% of patients, while the PA-rTHA group had the index procedure performed via AA in 4.8%. There was no statistically significant difference in re-revision rate between the DAA, ABMS, or PA groups (9.55 versus 5.3% versus 11.4%, respectively, P = .11). The most common overall reason for re-revision was persistent instability, with no difference in incidence of postoperative hip dislocation (n = 4, 6.8% DAA, n = 3, 5.3%, n = 10, 9.5% PA; P = .31). CONCLUSIONS: This study demonstrates no difference in complication or re-revision survivorship after aseptic rTHA performed through a DAA, ABMS approach, or PA, nor between anterior or posterior-based approaches. LEVEL OF EVIDENCE: Level III.

Aseptic Revision Total Hip Arthroplasty Through an Anterior Approach: Survivorship and Risk Factors for Re-Revision.

BACKGROUND: The utilization of anterior-based approaches for total hip arthroplasty (THA) is increasing. Literature on the outcomes of revision THA (rTHA) through an anterior approach, however, is sparse. This study reports the survivorship and risk factors for re-revision in patients undergoing aseptic rTHA through an anterior approach. METHODS: This was a single-institution, retrospective cohort analysis of patients who underwent aseptic rTHA through an anterior approach (direct anterior, anterior-based muscle sparing) from January 2017 to December 2021, regardless of the original surgical approach. Exclusion criteria were age <18 years, conversion THA, and septic revisions. Patient demographics, complications, and postoperative outcomes were collected. Kaplan-Meier curves were used to measure survivorship while Cox regression analyses were used to identify risk factors for re-revision of THA. RESULTS: We identified 251 total anterior rTHAs, of which 155 were aseptic anterior revisions. There were 111 patients (111 rTHAs; 63 anterior-based muscle sparing and 48 direct anterior) who met criteria and had a mean follow-up of 4.2 years (range, 2.1 to 6.9). There were a total of 54 (49%) anterior-based index approaches and 57 (51%) posterior index approaches. The most common indications for rTHA were femoral loosening (n = 25, 22.5%), followed by instability (n = 16, 14.4%) and wear or osteolysis (n = 16, 14.4%). At 2 years, the survivorship from reoperation and re-revision was 89% (95% confidence interval: 84 to 95) and 91% (95% confidence interval: 86 to 96), respectively. Reoperation occurred in 14 patients (12.6%) at a mean time of 7.8 months (range, 0.5 to 28.6). Re-revision occurred in 12 patients (10.8%) at a mean time of 7.3 months (range, 0.5 to 28.6). Instability was the most common reason for re-revision (4.5%). Neither index approach type, revision approach type, nor any patient-specific risk factors were identified as predictors of re-revision or reoperation in multivariable regression analysis. CONCLUSIONS: This study demonstrates an acceptable rate of re-revision when aseptic rTHA is performed through an anterior approach, with the most common reason for aseptic re-revision being instability.

Treatment Outcomes of Fungal Periprosthetic Joint Infection.

BACKGROUND: Periprosthetic joint infection (PJI) continues to challenge surgeons and patients. The burden of fungal organisms may represent approximately 1% of all PJI. Additionally, fungal PJI is difficult to treat. Most available case series are small and report poor success rates. Fungi are opportunistic pathogens and patients who have fungal PJI are believed to be immunocompromised. Additionally, fungal biofilms are more complex than those formed by other pathogens and confer additional drug resistance. Due to these factors, treatment failure is common. METHODS: A retrospective review of our institutional registry was performed to identify patients treated for fungal PJI. There were 49 patients identified with 8 excluded for not having follow-up, which left 22 knees and 19 hips for analyses. Demographics, clinical characteristics, and surgical details were collected. The primary outcome was failure defined as reoperation for infection following the index surgery for fungal PJI within 1 year of the index surgery. RESULTS: Failure occurred in 10 of 19 knees and 11 of the 22 hips. A higher proportion of patients who have extremity grade C failed treatment, and every patient who failed was host grade 2 or 3. The average number of prior surgeries and time from resection to reimplantation were similar between groups. CONCLUSION: To our knowledge, this represents the largest cohort of fungal PJIs reported in the literature to date. This data supports other literature in that failure rates were high. More study is needed to further understand this entity and improve care for these patients.

No Benefit to Sensor-guided Balancing Compared With Freehand Balancing in TKA: A Randomized Controlled Trial.

BACKGROUND: Soft tissue balancing in TKA has traditionally relied on surgeons' subjective tactile feedback. Although sensor-guided balancing devices have been proposed to provide more objective feedback, it is unclear whether their use improves patient outcomes. QUESTIONS/PURPOSES: We conducted a randomized controlled trial (RCT) comparing freehand balancing with the use of a sensor-guided balancing device and evaluated (1) knee ROM, (2) patient-reported outcome measures (PROMs) (SF-12, WOMAC, and Knee Society Functional Scores [KSFS]), and (3) various surgical and hospital parameters (such as operative time, length of stay [LOS], and surgical complications) at a minimum of 2 years of follow-up. METHODS: A total of 152 patients scheduled for primary TKA were recruited and provided informed consent to participate in this this study. Of these, 22 patients were excluded preoperatively, intraoperatively, or postoperatively due to patient request, surgery cancellation, anatomical exclusion criteria determined during surgery, technical issues with the sensor device, or loss to follow-up. After the minimum 2-year follow-up was accounted for, there were 63 sensor-guided and 67 freehand patients, for a total of 130 patients undergoing primary TKA for osteoarthritis. The procedures were performed by one of three fellowship-trained arthroplasty surgeons (RPS, HJC, JAG) and were randomized to either soft tissue balancing via a freehand technique or with a sensor-guided balancing device at one institution from December 2017 to December 2018. There was no difference in the mean age (72 ± 8 years versus 70 ± 9 years, mean difference 2; p = 0.11), BMI (30 ± 6 kg/m 2 versus 29 ± 6 kg/m 2 , mean difference 1; p = 0.83), gender (79% women versus 70% women; p = 0.22), and American Society of Anesthesiology score (2 ± 1 versus 2 ± 1, mean difference 0; p = 0.92) between the sensor-guided and freehand groups, respectively. For both groups, soft tissue balancing was performed after all bony cuts were completed and trial components inserted, with the primary difference in technique being the ability to quantify the intercompartmental balance using the trial tibial insert embedded with a wireless sensor in the sensor-guided cohort. Implant manufacturers were not standardized. Primary outcomes were knee ROM and PROMs at 3 months, 1 year, and 2 years. Secondary outcomes included pain level evaluated by the VAS, opioid consumption, inpatient physical therapy performance, LOS, discharge disposition, surgical complications, and reoperations. RESULTS: There was no difference in the mean knee ROM at 3 months, 1 year, and 2 years postoperatively between the sensor-guided cohort (113° ± 11°, 119° ± 13°, and 116° ± 12°, respectively) and the freehand cohort (116° ± 13° [p = 0.36], 117° ± 13° [p = 0.41], and 117° ± 12° [p = 0.87], respectively). There was no difference in SF-12 physical, SF-12 mental, WOMAC pain, WOMAC stiffness, WOMAC function, and KSFS scores between the cohorts at 3 months, 1 year, and 2 years postoperatively. The mean operative time in the sensor-guided cohort was longer than that in the freehand cohort (107 ± 0.02 versus 84 ± 0.04 minutes, mean difference = 23 minutes; p = 0.008), but there were no differences in LOS, physical therapy performance, VAS pain scores, opioid consumption, discharge disposition, surgical complications, or percentages of patients in each group who underwent reoperation. CONCLUSION: This RCT demonstrated that at 2 years postoperatively, the use of a sensor-balancing device for soft tissue balancing in TKA did not confer any additional benefit in terms of knee ROM, PROMs, and clinical outcomes. Given the significantly increased operative time and costs associated with the use of a sensor-balancing device, we recommend against its routine use in clinical practice by experienced surgeons. LEVEL OF EVIDENCE: Level I, therapeutic study.

Debridement and Implant Retention for Acute Periprosthetic Knee Infection.

Periprosthetic joint infection (PJI) is a devastating complication of total joint arthroplasty. We reviewed the current data on DAIR procedures and two-stage exchange for periprosthetic knee infection. This case study illustrates successful treatment of an acute PJI using a debridement and implant retention (DAIR) technique with adjuvant intraosseous (IO) vancomycin. (Journal of Surgical Orthopaedic Advances 30(4):249-252, 2021).

Tibial cement mantle thickness is not affected by tourniquetless total knee arthroplasty when performed with tranexamic acid.

PURPOSE: Evidence exists that tourniquet use leads to increased cement penetration in total knee arthroplasty (TKA) due to decreased blood and fat in the bone during cementation. The use of tranexamic acid (TXA) has led to decreased blood loss and transfusion rates. The purpose of this study was to determine if the use of a tourniquet while utilising modern TXA protocols affects the tibial cement mantle penetration. METHODS: 140 patients who underwent primary TKA with and without a tourniquet (70 in each group) were retrospectively reviewed. All patients received a standard TXA protocol. The primary outcome measure was cumulative depth of cement mantle penetration of the tibial plateau on post-operative radiographs. Secondary outcome measures included post-operative change in haemoglobin and hematocrit levels, blood loss, and transfusion rates. RESULTS: There was no significant difference in age, sex, or pre-operative haemoglobin or hematocrit levels between groups. Tourniquet use resulted in significantly lower blood loss (100.0 mL versus 154.7 mL, p < 0.001), and significantly reduced drop in haemoglobin (1.8 g/dL vs 2.5 g/dL, p < 0.001) and hematocrit (5.7% vs 7.4%, p = 0.04) levels. However, depth of tibial cement mantle penetration did not differ between the tourniquet group (15.3 mm) and non-tourniquet group (15.0 mm, p value n.s.). No patient in either group required a blood transfusion. CONCLUSIONS: Tourniquet use in primary TKA results in decreased blood loss and less change in pre-operative vs post-operative haemoglobin and hematocrit levels. However, with the use of TXA, not using a tourniquet resulted in similar cement mantle penetration around the tibial component as with a tourniquet.

Risk Factors for Periprosthetic Femur Fracture and Influence of Femoral Fixation Using the Mini-Anterolateral Approach in Primary Total Hip Arthroplasty.

BACKGROUND: The mini-anterolateral (AL) approach for total hip arthroplasty (THA) has gained popularity. In contrast to other approaches, risk factors for periprosthetic femur fractures have not been well established for the AL approach. METHODS: Six hundred eighty-four primary THAs performed using the AL approach were retrospectively reviewed for risk factors associated with perioperative periprosthetic femur fractures within 3 months of surgery. Risk factors evaluated were gender, age, body mass index, laterality, and Dorr ratio of the proximal femur. Cemented stems and collared uncemented stems were compared to uncemented tapered-wedge and meta-diaphyseal stems. A Student's t-test was used for continuous variables, and a chi-squared test was used for categorical variables. RESULTS: Of 684 primary THAs performed, 57 (8.3%) resulted in fracture. Twenty-eight (4.1%) occurred intraoperatively and 29 (4.2%) occurred postoperatively within 90 days. All intraoperative fractures were fixed at the time of surgery and healed uneventfully. Of the postoperative fractures, 15 (2.2%) were amenable to nonoperative management and healed. Fourteen (2.0%) required revision arthroplasty. There was a significantly lower rate of fracture in patients receiving cemented or collared stems (0%, n = 101) than in those receiving tapered-wedge or meta-diaphyseal fitting stems (9.8%, n = 583; P = .0009). Odds of fracture increased with female gender (P = .0063) and increasing Dorr ratio (P = .0003). Analysis showed a trend toward increased risk with older age, but did not achieve statistical significance. Body mass index and laterality showed no statistically significant effect. CONCLUSION: Performing primary THA via the AL approach, 2.0% of patients had a postoperative fracture requiring revision within the first 3 months. With cemented and collared stems, the fracture rate was significantly lower. Surgeons should consider using cemented or collared stems in high-risk patients.

The Impact of Running, Monofilament Barbed Suture for Subcutaneous Tissue Closure on Infection Rates in Total Hip Arthroplasty: A Retrospective Cohort Analysis.

BACKGROUND: Recently, running, monofilament barbed suture has become more popular as an efficient and economical alternative to traditional braided interrupted suture for wound closure following total joint arthroplasty. Its overall association with wound complications following surgery remains unknown at this time. Several studies have investigated its use in total knee arthroplasty (TKA), but there is limited literature surrounding use in total hip arthroplasty (THA). In this retrospective cohort study, our primary objective was to determine whether the use of monofilament barbed suture in THA was associated with reduced rates of postoperative infection when compared to traditional braided suture. METHODS: Patients who underwent primary unilateral THA between November 2011 and December 2017 by a single senior surgeon with closure using either monofilament barbed suture (162 patients) or braided interrupted suture (429 patients) were retrospectively reviewed for postoperative wound complications during the first 90 days after surgery. Demographics, comorbidities, and perioperative data were also included to assess for risk factors for infection. RESULTS: There was no difference between braided and barbed suture in overall rates of major complication, including periprosthetic joint infection (PJI) (0.47% vs 0.62%, P = .82) or revisions (1.86% vs 1.23%, P = .60). The overall rate of minor, superficial wound complications was also similar between both groups (6.1% vs 3.1%, P = .15). However, when superficial complications were categorized by type (dehiscence vs infection), the use of barbed suture was associated with a decreased rate of superficial wound infection (0% vs 5.4%, P = .003) and an increased rate of wound dehiscence (3.1% vs 0.7%, P = .04). CONCLUSION: The use of monofilament barbed suture for superficial skin closure in THA leads to similar overall rates of both major and minor wound complications when compared to traditional interrupted braided suture. However, while barbed suture was associated with fewer superficial infections, there was an increased incidence of wound dehiscence. Overall, barbed suture demonstrated a cumulatively equivalent rate of superficial wound complications compared to braided suture. Based on this investigation, barbed suture appears safe to use in THA and may represent an efficient and effective alternative to braided suture for wound closure. LEVEL OF EVIDENCE: Level IV; retrospective cohort study.

Hemiarthroplasty Conversion: A Comparison to Primary and Revision Total Hip Arthroplasty.

BACKGROUND: Arthroplasty is the standard of care for elderly patients with displaced femoral neck fractures, with viable options including hemiarthroplasty (HA) and total hip arthroplasty (THA). With time, HA may need to be converted to THA, but it is unclear whether this is more similar to primary or revision THA. We compare complication and revision rates between these groups within 90 days and 2 years postoperatively. METHODS: We retrospectively reviewed 3 cohorts of patients treated at our institution: primary, conversion, and revision THA. Outcomes studied included intraoperative data, postoperative complications, and revision rates. We analyzed the groups using both parametric (analysis of variance test) and nonparametric (chi-squared test) statistics. RESULTS: Operative time between primary THA (108.0 minutes), conversion HA (147.9 minutes), and revision THA (160.1 minutes) cohorts differed significantly (P = .011). Estimated blood loss was also different between primary THA (386 mL), conversion HA (587 mL), and revision THA cohorts (529 mL) (P = .011). At 2 years, major complication rates between primary THA (6.2%), conversion HA (11.7%), and revision THA (26.7%) cohorts also differed significantly (P = .003), as was the revision rate in the primary THA (4.6%), conversion HA (10.0%), and revision THA (18.3%) cohorts (P = .043). CONCLUSION: This is the first study to compare short-term and midterm complications between primary, conversion, and revision THA. We observed conversion HA had similar operative time and estimated blood loss to revision THA, which was significantly higher than primary THA. However, we found that conversion HA more closely resembled primary THA with respect to perioperative complications rates.

Trends in Length of Stay and 30-Day Complications After Total Knee Arthroplasty: An Analysis From 2006 to 2016.

BACKGROUND: Hospital length of stay (LOS) is a quality metric and target of recent efforts in the last decade to decrease healthcare costs and postoperative nosocomial complications after total knee arthroplasty (TKA). However, decreasing LOS has raised concerns of possible increased complication and readmission rates. We present a decade-long analysis in trends of LOS and 30-day complication and unplanned readmissions following TKA. METHODS: The National Surgical Quality Improvement Program registry was utilized to identify patients undergoing elective primary TKA between 2006 and 2016. Three cohorts of patients were created based on year of surgery (2006-2009 [N = 7111], 2010-2013 [N = 71,943], and 2014-2016 [N = 142,710]). Patient demographics, perioperative variables, LOS, 30-day postoperative complications, and readmission rates were analyzed between the 3 cohorts using bivariate and multivariate analyses. RESULTS: LOS decreased significantly over time when the 2006-2009 cohort (3.7 days) was compared to the 2010-2013 cohort (3.3 days, P < .001) and 2014-2016 cohort (3.0 days, P < .001). Similarly, there was a decrease in the rate of total 30-day complications in the 2006-2009 cohort (5.37%) compared to 2010-2013 (3.86%) and 2014-2016 (3.13%, P < .001), with significantly lower rates of deep vein thrombosis, sepsis, and urinary tract infection in the latter cohorts. Decreasing rates of 30-day readmission were also observed in the 2010-2013 cohort (3.63%) compared to 2013-2016 cohort (3.23%, P < .001). CONCLUSION: In the last decade, there has been a trend toward decreasing LOS after TKA. Despite concerns about early discharge, data from a national registry demonstrated a simultaneous decrease in total 30-day complication and readmission rates. LEVEL OF EVIDENCE: III, Retrospective cohort study.

How are Oral Antibiotics Being Used in Total Joint Arthroplasty? A Review of the Literature.

While the role and benefit of perioperative intravenous (IV) antibiotics in patients undergoing total joint arthroplasty (TJA) is well-established, oral antibiotic use in TJA remains a controversial topic with wide variations in practice patterns. With this review, we aimed to better educate the orthopedic surgeon on when and how oral antibiotics may be used most effectively in TJA patients, and to identify gaps in the literature that could be clarified with targeted research. Extended oral antibiotic prophylaxis (EOAP) use in high-risk primary, aseptic revision, and exchange TJA for infection may be useful in decreasing periprosthetic joint infection (PJI) rates. When prescribing oral antibiotics either as EOAP or for draining wounds, patient factors, type of surgery, and type of infectious organisms should be considered in order to optimally prevent and treat PJI. It is important to maintain antibiotic stewardship by administering the proper duration, dose, and type of antibiotics and by consulting infectious disease when necessary.

Optimizing Total Hip and Knee Arthroplasty Among an Underserved Population: Lessons Learned From a Quality-Improvement Initiative.

Background: Under-represented minorities and those with noncommercial insurance have higher medical comorbidities and complications following elective total joint arthroplasty (TJA). In an effort to bridge this gap, our center implemented a preoperative optimization protocol for TJA in a Medicaid Clinic (Clinic). The purpose of this study is to assess the effectiveness of that protocol and highlight challenges associated with caring for this patient population. Methods: This retrospective analysis included 117 patients undergoing TJA between January 2015 and January 2020. In 2015, the protocol was implemented as a mandatory practice prior to TJA. A contemporary control cohort from the private office was also analyzed. Patient demographics, American Society of Anesthesiologists score, and postoperative complications were collected. Results: Within the clinic group, 52.5% (62) patients identified as Hispanic with 46.6% (55) Spanish-speaking as primary language, compared to 9.3% (11) and 8.5% (10) in the office group (P = .0001), respectively. Clinic group patients were significantly more likely to experience a complication compared to office patients (20 vs 7, respectively). There was no difference in complication or reoperation rate between clinic patients who underwent the optimization protocol and those who did not. Conclusions: The findings from this study highlight the demographic and comorbidities profile of an underserved population, and report on results of a quality improvement initiative among that population, which failed to improve postoperative outcomes. These results underscore the need for further study in this population to improve outcomes and health equity.

Laceration of the Sciatic Nerve After Closed Reduction of a Dislocated Total Hip Arthroplasty.

Sciatic nerve injury after closed reduction of a dislocated total hip arthroplasty (THA) is an exceedingly rare but tremendously devastating complication. Closed reduction is the standard of care and is typically associated with a low complication rate. There have only been seven sciatic nerve injuries after closed reduction of a dislocated THA reported in the literature, and none were secondary to nerve laceration. We report a case of sciatic nerve laceration after attempted closed reduction of a dislocated THA. This resulted in complete loss of sensory and motor sciatic nerve function. This case highlights the importance of a detailed neurologic examination before and after closed reduction of a dislocated total hip, the importance of using careful reduction maneuvers, and transitioning to open reduction when necessary.

Iatrogenic thrombosis of the deep inferior epigastric artery during diagnostic angiography-a rare complicating factor during rectus free flap harvest.

We describe a 28-year-old man who sustained an open IIIB left ankle fracture dislocation with heel pad avulsion. The patient underwent formal angiography of the left lower extremity, followed by free tissue transfer of a rectus abdominis flap several days later. Intraoperatively, a thrombus was identified in the deep inferior epigastric artery above the femoral artery access site requiring thrombectomy. Histologic analysis estimated the thrombus age at 12 to 72 hours, raising concern that the thrombus was induced during angiogram instrumentation. Donor and recipient site-specific risks of arterial instrumentation (including invasive diagnostics) should be considered when planning free tissue transfer.

Lower Dosing of Bupivacaine Spinal Anesthesia Is Not Associated With Improved Perioperative Outcomes After Total Joint Arthroplasty.

BACKGROUND: The choice of anesthesia plays a significant role in the success of total joint arthroplasty (TJA). Isobaric bupivacaine spinal anesthesia is often used. However, dosing of bupivacaine has not been extensively studied and is usually at the discretion of the treating anesthesiologist and surgeon. The goal of this study was to determine what, if any, effect the dose of bupivacaine spinal anesthesia had on perioperative outcomes in TJA. METHODS: A total of 761 TJAs performed with bupivacaine spinal anesthesia by arthroplasty surgeons were retrospectively reviewed. Perioperative outcomes evaluated were operation duration, estimated blood loss, length of stay (LOS) in the postanesthesia care unit, hospital LOS, discharge disposition, episodes of intraoperative hypotension, postoperative nausea and vomiting, and missed physical therapy sessions because of postoperative symptoms of hypotension. A Student's t-test was used for continuous variables, and a chi-squared test was used for categorical variables. RESULTS: Of the 761 patients, 499 (65.6%) received 15 mg isobaric bupivacaine while 262 (34.4%) received <15 mg (range = 7.5-14.5 mg, median = 12.5 mg). With the numbers available in this cohort, lower doses of bupivacaine were not associated with any significant differences between groups for any of the studied perioperative outcomes, including proportion of patients discharged home or LOS. CONCLUSION: Dosage of bupivacaine spinal anesthetic did not affect perioperative outcomes. Bupivacaine may not have a dose-related response curve in this regard, and if seeking to perform same-day or outpatient TJA, other agents may need to be considered, rather than smaller doses of bupivacaine.

Fragility Index as a Measure of Randomized Clinical Trial Quality in Adult Reconstruction: A Systematic Review.

BACKGROUND: The Fragility Index (FI) and Reverse Fragility Index are powerful tools to supplement the P value in evaluation of randomized clinical trial (RCT) outcomes. These metrics are defined as the number of patients needed to change the significance level of an outcome. The purpose of this study was to calculate these metrics for published RCTs in total joint arthroplasty (TJA). METHODS: We performed a systematic review of RCTs in TJA over the last decade. For each study, we calculated the FI (for statistically significant outcomes) or Reverse Fragility Index (for nonstatistically significant outcomes) for all dichotomous, categorical outcomes. We also used the Pearson correlation coefficient to evaluate publication-level variables. RESULTS: We included 104 studies with 473 outcomes; 92 were significant, and 381 were nonstatistically significant. The median FI was 6 overall and 4 and 7 for significant and nonsignificant outcomes, respectively. There was a positive correlation between FI and sample size (R = 0.14, P = .002) and between FI and P values (R = 0.197, P = .000012). CONCLUSIONS: This study is the largest evaluation of FI in orthopedics literature to date. We found a median FI that was comparable to or higher than FIs calculated in other orthopedic subspecialties. Although the mean and median FIs were greater than the 2 recommended by the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines to demonstrate strong evidence, a large percentage of studies have an FI < 2. This suggests that the TJA literature is on par or slightly better than other subspecialties, but improvements must be made. LEVEL OF EVIDENCE: Level I; Systematic Review.

Outcomes and survivorship after conversion of failed hip hemiarthroplasty to total hip arthroplasty.

BACKGROUND: Arthroplasty is the treatment of choice for elderly patients with displaced femoral neck fractures. When compared to total hip arthroplasty (THA), higher revision rates have been reported for hemiarthroplasty (HA). Conversion of failed HA to THA can be complex, especially in the elderly population at risk for revision surgery complications. We report a single institution's experience with conversion of failed HA to THA at mid-term follow-up. METHODS: We identified patients converted from failed HA to THA from 2006 to 2016. Clinical data including indication for index and conversion surgery, maintenance or revision of femoral component during conversion, operative time, estimated blood loss, postoperative complications, and need for revision surgery were collected. Descriptive statistics were analysed in SPSS. RESULTS: The cohort included 21 men and 39 women (mean age of 74.5 years). The mean follow-up after conversion HA to THA was 2.8 years. During conversion surgery, the femoral component was revised in 75.0% and retained in 25.0% of cases. After conversion HA to THA, the rate of major complications and re-revision at 2 years was 11.7% and 10.0%, respectively. Femoral revision versus retention did not affect complication rates (11.1% vs. 6.7%; p = 0.31) or re-revision rates (8.9% vs. 13.3%; p = 1.0). CONCLUSIONS: In this high-risk population, mid-term follow-up demonstrated tolerable complication and re-revision rates, the majority of which were for instability. We observed high rates of femoral component revision during conversion THA, although this did not increase the likelihood of postoperative complications or need for future surgery.

Concurrent Surgical Management of Advanced Osteoarthritis of the Knee and Proximal Tibiofibular Joint With Compressive Peroneal Neuropathy: 3-Year Follow-Up On a Complex Case.

The proximal tibiofibular joint (PTFJ) is susceptible to osteoarthritis (OA), making it a rare but potential source of lateral knee pain. Because PTFJ OA is a rare presentation of knee pain, no first-line treatment has been established and it can be missed in evaluation before total knee arthroplasty. We report an unusual case of a 59-year-old man who presented with advanced OA of both the knee and PTFJ, along with a progressive peroneal nerve palsy due to a large compressive ganglion cyst from the PTFJ. He was treated with concurrent total knee arthroplasty, peroneal nerve decompression, and resection of the fibular head and ganglion cyst, resulting in full recovery from his arthritic pain and resolution of his peroneal neuropathy. He remains free of symptoms without instability 3 years from the index surgery.