Three Differing Methods of Treating Intraoperative Nondisplaced Calcar Fractures Demonstrate Similar Radiographic Stem Subsidence.

BACKGROUND: Several management strategies have been described to treat intraoperative calcar fractures during total hip arthroplasty (THA), including retaining the primary implant and utilizing cerclage cables (CCs) or switching the implant to one that bypasses the fracture and achieves diaphyseal fixation. However, the radiographic and clinical outcomes of these differing strategies have never been described and compared. METHODS: We retrospectively identified 50 patients who sustained an intraoperative calcar fracture out of 9,129 primary total hip arthroplasties (0.55%) performed by one of three surgeons between 2008 and 2022. Each of the three surgeons consistently employed a distinct strategy for the management of these fractures: retention of the primary metaphyseal-engaging implant and placement of CCs; exchange to a modular, tapered-fluted stem (MTF); or exchange to a fully-coated, diaphyseal-engaging stem (FC). Stem subsidence was then evaluated on standing anteroposterior pelvis radiographs at three months and one year postoperatively. Postoperative medical and surgical complication rates were evaluated. RESULTS: A total of fifteen patients were treated with CC, 15 with MTF, and 20 with FC. At three-month follow-up, mean stem subsidence was 0.43 ± 0.08 mm, 1.47 ± 0.36 mm, and 0.68 ± 0.39 mm for CC, MTF, and FC cohorts, respectively (P = .323). At one-year, mean stem subsidence was 0.70 ± 0.08 mm, 1.74 ± 0.69 mm, and 1.88 ± 0.90 mm for the CC, MTF, and FC cohorts, respectively (P = .485). Medical complications included 2 venous thromboembolic events (4%) within 90 days of surgery. There were 6 reoperations (12%); 3 (6%) for acute periprosthetic joint infection (all within the FC cohort); 2 (4%) for postoperative periprosthetic fractures (one fracture distal to the stem in the FC cohort and one fracture at the level of the stem in the MTF cohort), and 1 (2%) closed reduction for instability (within the CC cohort). CONCLUSIONS: The three described methods of managing intraoperative nondisplaced calcar fractures demonstrated little radiographic stem subsidence; however, the risk of reoperation was much higher than expected.

The Ideal Timing of Bilateral Total Knee Arthroplasty: Simultaneous Versus Staged.

Objectives: The ideal timing for patients undergoing bilateral total knee arthroplasty (TKA) remains unknown. The purpose of this study was to compare 90-day outcomes between unilateral, simultaneous bilateral, and staged bilateral TKA. Methods: The PearlDiver database was used to retrospectively identify 231,119 patients undergoing primary TKA during 2015-2020, of which 67,956 (29.4%) were bilateral. Bilateral TKA patients were divided into cohorts of simultaneous bilateral TKA and staged bilateral TKA at 1-14 days, 15-30 days, 31-90 days, and 91-365 days. Each bilateral TKA cohort underwent one-to-one matching with unilateral TKA patients based on age, gender, year, Elixhauser Comorbidity Index (ECI), and a history of obesity, diabetes, and tobacco use. Ninety-day outcomes were compared between matched groups via univariate and multivariate analysis. In staged bilateral TKA groups, outcomes were collected beginning after the second TKA. Results: Compared to unilateral TKA, simultaneous bilateral TKA was associated with higher rates of venous thromboembolism (VTE; odds ratio [OR] 1.28, 95% confidence interval [CI] 1.07-1.54, p=0.007), acute kidney injury (AKI; OR 1.47, CI 1.17-1.84, p=0.001), blood transfusion (OR 6.81, CI 5.43-8.65, p<0.001), and any complication (OR 1.63, CI 1.49-1.78, p<0.001). Staged bilateral TKA at any time interval studied was associated with a similar or decreased risk of individual complications, emergency department visits, readmissions, reoperations, and any complication relative to unilateral TKA. Conclusion: Simultaneous bilateral TKA is associated with an increased risk of adverse events compared to unilateral TKA. However, bilateral TKA staged at a short interval appears safe in appropriately selected patients.