Failure to Optimize Before Total Knee Arthroplasty: Which Modifiable Risk Factor is the Most Dangerous?

BACKGROUND: Complications after total knee arthroplasty (TKA) are devastating for patients, and surgeons are held accountable in alternative payment models. Optimization of modifiable risk factors has become a mainstay in the preoperative period. We sought to evaluate the consequence of failure to optimize key risk factors in a modern cohort of patients who underwent TKA. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was searched to identify patients who underwent TKA in 2017-2018. Patients were considered optimized if they had a body mass index <40kg/m2, had albumin >3.5g/dL, were nonsmokers, and were nondiabetic. Patients were then grouped based on the previous 4 risk factors. Thirty-day readmission, infection, general complications, and mortality were analyzed and compared between the groups. RESULTS: Overall, 84,315 patients were included in the study. A total of 31.6% of patients were not considered optimized. Body mass index >40kg/m2, albumin <3.5, smoking, and insulin-dependent diabetes were all found to be associated with postoperative infection, readmission, mortality, and complication in general (P < .05). When compared, the nonoptimized group was found to have significantly higher risk of readmission (5 vs 3%), infection (2 vs 1%), general complications (8 vs 5%), and mortality (0.35 vs 0.1%) (all P < .001). Logistic regression showed that those with albumin less than 3.5g/dL had 3.7-fold higher odds of infection and 7.2-fold higher odds of 30-day mortality. CONCLUSION: Despite knowledge that modifiable risk factors significantly influence postoperative outcomes, surgeons continue to operate on patients who are not optimized. Among the modifiable risk factors analyzed, hypoalbuminemia appears to be the strongest risk factor for all complications evaluated. Special attention should be paid to preoperative nutritional optimization. LEVEL OF EVIDENCE: Retrospective cohort study, level IV.

Shoulder arthroplasty in patients with immunosuppression following solid organ transplantation.

BACKGROUND: The purpose was to determine the risk and outcomes of primary shoulder arthroplasties in patients with immunosuppression who had undergone solid organ transplantation. METHODS: Using a single institution's total joint registry, we reviewed 30 primary shoulder arthroplasties in 25 post-transplantation patients, including 12 total shoulder arthroplasties, 10 hemiarthroplasties, and 8 reverse shoulder arthroplasties, between 1985 and 2012. Therapy and patient variables were recorded, including immunosuppressive therapy protocols, the date of preceding solid organ transplantation, and specific medications taken in the perioperative period. We matched a cohort of control patients for age, sex, type of implant, and year of surgery at a ratio of 4:1. Two groups were compared regarding mortality risk, complications, and clinical outcomes (pain score, range of motion, and American Shoulder and Elbow Surgeons score). RESULTS: No periprosthetic infections occurred in the post-transplantation group at a mean follow-up of 39 months. However, the post-transplantation group showed an increased risk of periprosthetic fractures compared with the control group (hazard ratio, 8.18; 95% confidence interval, 1.22-70.98; P = .03). Despite the increase in fractures, the overall number of complications did not differ between the groups. Furthermore, postoperative shoulder function and outcome scores were not significantly different between patients who had a prior transplant and those who did not. CONCLUSION: Primary shoulder arthroplasty in patients with immunosuppression who underwent solid organ transplantation is a successful procedure to treat glenohumeral arthritis. In contrast, there may be an increased risk of periprosthetic fractures in patients with a history of a solid organ transplant.

Shoulder arthroplasty in patients with cerebral palsy: a matched cohort study to patients with osteoarthritis.

BACKGROUND: Patients with cerebral palsy (CP) often experience shoulder impairment via spasticity, muscle contractures, and joint instability. Currently, few studies investigate shoulder arthroplasty (SA) in patients with CP. This study reviewed the outcomes of both anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA) in patients with CP. METHODS: Over a 30-year-period, 5 patients undergoing SA (2 TSA, 3 RSA) with a diagnosis of CP were identified. The cohort included 4 male patients with a mean age of 50.4 years (range, 44-58 years). CP patients were matched 1:2 based on age, sex, body mass index, and year of surgery with a group of patients undergoing SA for osteoarthritis (OA). RESULTS: Survival from implant revision for both TSA and RSA in CP was 100% at both 2 and 5 years postoperatively. Clinical complications were only observed in 2 patients after TSA, with 1 patient requiring revision at 14 years postoperatively. Collectively, there was no difference in the rate of complications and implant survival between patients with CP vs. OA. Prior to the surgical procedure, all CP patients had severe or moderate pain, with no moderate or severe pain postoperatively. Notable postoperative increases from preoperative baselines were noted in forward elevation (57°-106°), abduction (48°-84°), and external rotation (30°-64°). RSA had significantly improved postoperative abduction compared to TSA (97° vs. 64°, P < .01). CONCLUSIONS: SA is a safe, durable procedure in patients with CP to clinically improve pain, function, and satisfaction. RSA was associated with better function and fewer complications than TSA.

Outcome of Direct Anterior Total Hip Arthroplasty Complicated by Superficial Wound Dehiscence Requiring Irrigation and Debridement.

BACKGROUND: Superficial wound dehiscence after total hip arthroplasty (THA) performed through the direct anterior approach (DAA) can be treated with superficial irrigation and debridement (I&D). The incidence and treatment of this complication has been described, but there are little data on the outcomes after a superficial I&D have not been described. The purpose of this paper was to examine the clinical outcomes of DAA THAs requiring postoperative superficial I&D. METHODS: A retrospective review of 1573 THAs performed using the DAA were identified utilizing a prospectively collected, single-institution joint registry. Of these 1573 cases, 18 THAs in 18 patients (1.1%) underwent a superficial I&D for superficial wound dehiscence. Outcomes studied included prosthetic joint infection (PJI) after superficial I&D, revisions, re-reoperations, complications, and clinical outcome scores. RESULTS: Survivorship from superficial I&D at 1, 2, and 5 years postoperatively was 98.6% at all time points. In the 18 patients who underwent superficial I&D, this was performed an average of 37 (range 12-83) days after their THA. Female gender (hazard ratio 5.5, 95% confidence interval 1.20-32.34, P = .0271) was associated with a higher risk of undergoing superficial I&D as was body mass index >30 kg/m2 (P = .0028), >35 kg/m2 (P < .0001), and >40 kg/m2 (P = .0037). At average follow-up of 2.2 (range 0.2-5.5) years, 0 patients developed PJI. Complications included femoral revision for a painful fibrously ingrown femoral component (1), pulmonary embolus (1), and death from respiratory failure (1). Postoperative Harris Hip Scores averaged score was 86.8 (range 57-99). CONCLUSIONS: Superficial wound dehiscence requiring superficial I&D after DAA THA occurs in about 1%-2% of patients with low risk of subsequent PJI.

Outcomes of shoulder arthroplasty in diabetic patients as assessed by peri-operative A1C.

PURPOSE: Although diabetes mellitus (DM) has an adverse effect on complication rates in orthopaedic surgery, neither the effect of DM nor the association between haemoglobin A1C (HbA1C) and outcomes after shoulder arthroplasty (SA) has been studied. METHODS: A retrospective review of 406 SAs (70 HAs, 188 total shoulder arthroplasties [TSAs], 148 reverse total shoulder arthroplasties [RSAs]) with HbA1Cs within 90 days of surgery was conducted. The average age was 70 years (range 27-97) and 55% were female. The average peri-operative HbA1C was 6.4% (range 4.7-9.8%), with 104 (26%) having a HbA1C of 7.0% or greater. Kaplan-Meier curves were constructed to determine complication, re-operation, and revision rates at two, five and ten years post-operatively. RESULTS: At mean follow-up of four years, 58 (16.5%) SAs were associated with post-operative complications including six (1.5%) infections. Kaplan-Meier two and five year survivorship free of any complication was 87.3 and 82.6% and of infection was 95.8 and 90.9%, respectively. Thirty-two (7.9%) SAs required reoperation with 26 (6.4%) of these being revisions. Survivorship at two and five years post-operatively was 97.1 and 92.7% for re-operation and 98.6 and 98.2% for revision, respectively. No increased risk of complications, re-operation, revision, or infection was seen with increased HbA1C analyzed as a continuous variable (hazard ratio = 0.97-1.11, 95% CI = 0.28-3.94, p = 0.5882-0.9445) or as a dichotomous variable with a cutoff of 7.0% (hazard ratio = 1.02-1.47, 95% CI = 0.20-7.48, p = 0.3253-0.9544). CONCLUSIONS: A collaborative and comprehensive approach to the pre-operative medical evaluation of patients with DM is critical, as is future investigation into alternative methods associated with outcomes after shoulder arthroplasty in patients with DM. LEVEL OF EVIDENCE: Level IV.

What Risks are Associated with Primary THA in Recipients of Hematopoietic Stem Cell Transplantation?

INTRODUCTION: As patients who receive hematopoietic stem cell transplantation are at increased risk of avascular necrosis (AVN) and subsequent degenerative arthritis, THA may be considered in some of these patients, particularly as overall patient survival improves for patients undergoing stem-cell transplants. Patients receiving hematopoietic stem cell transplantation theoretically are at increased risk of experiencing complications, infection, and poorer implant survivorship owing to the high prevalence of comorbid conditions, immunosuppressive therapy regimens including corticosteroids, and often low circulating hematopoietic cell lines; however, there is a paucity of studies elucidating these risks. QUESTIONS/PURPOSES: We asked: (1) What is the overall mortality of patients with hematopoietic stem cell transplantation who have undergone THA? (2) What is the complication rate for these patients? (3) What are the revision and reoperation rates and implant survivorship for these patients? PATIENTS AND METHODS: Between 1999 and 2013, we performed 42 THAs in 36 patients who underwent stem-cell transplants. Other than those who died, all were available for followup at a minimum of 2 years; of the patients whose procedures were done more than 10 years ago and who are not known to have died, two (5%) had not been seen in the last 5 years and so are considered lost to followup. All patients underwent thorough evaluation by the transplant team before arthroplasty; general contraindications included active medical comorbidities or evidence of unstable end-organ damage, active rejection, and critically low circulating hematopoietic cell lines. Underlying primary diseases leading to hematopoietic stem cell transplantation included lymphoma (14/42; 33%), plasma cell disorders (10/42; 24%), leukemia (9/42; 21%), and amyloidosis (3/42; 7%). Complications, reoperations, revisions, and implant and patient survivorship, were recorded from chart review and data from the institutional total joint registry. Mean followup was 5 years (range, 2-15 years). RESULTS: Patient survivorship free of mortality was 91% (95% CI, 81%-100%) and 82% (95% CI, 68%-96%) at 2 and 5 years, respectively. Complications occurred in four of 42 THAs (10%); these complications included an intraoperative fracture and a venous thromboembolism. Revisions occurred in two of 42 (5%) THAs; there were no reoperations. Implant survivorship free of component revision for any reason or implant removal accounting for death as a competing risk was 93% (95% CI, 83%-100%) at 5 years. CONCLUSION: With appropriate medical evaluation and comanagement by transplant specialists, carefully selected patients with hematopoietic stem cell transplants may undergo elective primary THA, although complications do occur in this relatively fragile patient population. Although implant survivorship was modest at 93% at 5 years, there was not a high risk of revision for infection. Improved outcomes for these patients may be expected as their medical management advances and additional comparative studies may clarify other important patient factors. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Use of a shorter humeral stem in revision reverse shoulder arthroplasty.

BACKGROUND: The purpose of this study was to examine the outcomes of revision reverse arthroplasty using short bone-preserving humeral components in revising a long-stemmed component. METHODS: During a 7-year period, 39 patients who underwent revision reverse shoulder arthroplasty using the long to short humeral component technique were included. The mean age was 72 years. Prior implants used in the primary setting included anatomic (n = 26), hemiarthroplasty (n = 11), and reverse (n = 2). RESULTS: At a follow-up of 3 years (2-5), 5 shoulders (13%) required revision surgery, including 1 for a periprosthetic humerus fracture and 4 for glenoid component loosening. The survival free of revision for any reason and revision for humeral disease was 84% and 94%, respectively. One patient experienced a nondisplaced greater tuberosity fracture at 18 months postoperatively that healed without operative intervention. There were no dislocations or infections. Overall, patients experienced excellent overall improvements in their pain levels and shoulder motion (P < .001), with a postoperative 91% satisfaction rate as well as postoperative American Shoulder and Elbow Surgeons score of 68 and Simple Shoulder Test score of 6.7. At most recent radiographic follow-up, 1 (5%) patient had grade 3 humeral lucency. CONCLUSIONS: Preserving bone stock through conversion to a shorter reverse humeral stem in the revision setting is a reasonable option with good short- to intermediate-term results and low rates of humeral complications. Using the shorter stem components provides adequate stability and high rates of humeral component ingrowth.

Revision Total Hip and Knee Arthroplasties After Solid Organ Transplant.

BACKGROUND: As solid organ transplant (SOT) patients' survival improves, the number undergoing total hip (THA) and total knee arthroplasty (TKA) is increasing. Accordingly, the number of revision procedures in this higher-risk group is also increasing. The goals of this study were to identify the most common failure mechanisms, associated complications, clinical outcomes, and patient survivorship of SOT patients after revision THA or TKA. METHODS: A retrospective review identified 39 revision procedures (30 revision THAs and 9 revision TKAs) completed in 37 SOT patients between 2000 and 2013. The mean age at revision surgery was 62 years with a mean follow-up of 6 years. RESULTS: The most common failure mode for revision THA was aseptic loosening (10/30, 33%), followed by periprosthetic joint infection (PJI; 7/30, 23%). The most common failure mode for revision TKA was PJI (5/9, 56%). There were 6 re-revision THAs for PJI (3/30; 10%) and instability (3/30; 10%). There were 2 reoperations after revision TKA, both for acute PJI (2/9; 22%). Final Harris Hip Scores significantly (P = .03) improved as did Knee Society Scores (P = .01). Estimated survivorship free from mortality at 5 and 10 years was 71% and 60% after revision THA and 65% and 21% after revision TKA, respectively. CONCLUSION: Revision THA and TKA after solid organ transplantation carry considerable risk for re-revision, particularly for PJI. Although SOT recipients demonstrate improved clinical function after revision procedures, patient survivorship at mid- to long-term follow-up is low.

Primary Total Knee Arthroplasty After Solid Organ Transplant: Survivorship and Complications.

BACKGROUND: Clinical outcomes remain largely unknown beyond perioperative and short-term follow-up of solid organ transplant (SOT) patients undergoing total knee arthroplasty (TKA). METHODS: Patient mortality, implant survivorship, and complications of 96 TKAs (76 patients) after SOT were retrospectively reviewed through an internal joint registry. Mean age at index arthroplasty was 66 years, and mean follow-up was 4 years. RESULTS: Overall mortality rates at 1 year, 2 years, and 5 years from TKA were 2.6%, 7.9%, and 13.2%, respectively, and combined SOT patient survivorship was 92% at 2 years and 82% at 5 years. Implant survivorship free of any component revision or implant removal was 98% at 2 years and 93% at 5 years. There was a high rate of perioperative complications (12.5%), including periprosthetic fractures (5.2%) and deep periprosthetic infection (3.2%). CONCLUSION: TKA does not appear to have any effect on SOT patient survivorship following the procedure. However, SOT patients may have a higher risk of perioperative complications and a lower implant survivorship than the general population of TKA patients at midterm follow-up.

Outcomes of shoulder arthroplasty in haematopoietic stem cell transplant patients.

BACKGROUND: With the growing population of patients undergoing haematopoietic stem cell transplants (HSCTs), the demand for shoulder arthroplasty (SA) in this population can be expected to increase. No studies in the literature have examined the outcomes of SA in HSCT patients. PATIENTS AND METHODS: A retrospective review of 11 SAs in 10 patients with previous HSCT was performed. We characterized the clinical outcomes, survivorship, and peri-operative complication rates in patients who underwent SA after receiving a HSCT. We also performed a subanalysis based on implant and transplant type. RESULTS: Seven of ten patients died with average two and five year post-operative patient survival rates of 70% +/- 14% and 47% +/- 17%, respectively. At average follow up of 4.2 years of the seven patients with two year followup, pain and range of motion improved with SA (p = 0.0625-0.2500). At final follow-up, five of seven shoulders were rated as satisfactory or excellent with modified Neer ratings. Two and five year survival rates free of re-operation were 100% +/- 0% and 67% +/- 27%, respectively. There were no other complications. No differences in outcomes were seen based on implant or transplant type besides RSA being associated with greater mortality risk (p = 0.0424, hazard ratio = 10.6). CONCLUSIONS: Patients with previous HSCT who undergo SA can expect to have good pain relief, range of motion improvement, subjective satisfaction, and low peri-operative complication rate with appropriate choice of implant. However, surgeons must inform patients about realistic post-operative outcomes given the high post-operative mortality rate. LEVEL OF EVIDENCE: Level IV, Prognosis.

Shoulder arthroplasty for locked anterior shoulder dislocation: a role for the reversed design.

INTRODUCTION: Locked anterior shoulder dislocation (LASD) is an uncommon condition associated with bone, articular cartilage, and soft tissue damage. In selected cases, shoulder arthroplasty (SA) may be the best treatment. The purpose of this study was to assess outcomes of SA for LASD. MATERIALS AND METHODS: Between 1976 and 2013, 19 SAs [three hemiarthroplasties (HA), seven total shoulder arthroplasties (TSA), and nine reverse shoulder arthroplasties (RSA), mean age 62 years] were performed for LASD. Shoulders were followed for at least two years (range, 2-30 years, mean 7.1). Clinical and radiographic outcomes were studied. RESULTS/DISCUSSION: Three SAs required re-operation, two TSAs for early redislocation and one HA for late, painful glenoid arthrosis. Four additional shoulders (two TSA, two HA) were unstable at most recent follow-up. Pain improved from 4.7 to 2.2 (p < 0.0001) out of 5, elevation from 51 to 94 degrees (p = 0.004), and external rotation from 1 to 34 degrees (p = 0.01). There were two excellent, seven satisfactory, and ten unsatisfactory modified Neer ratings. Compared to TSA/HA, RSA experienced fewer re-operations (0 vs. 3, hazard ratio, 2.03*10^-9, p = 0.0844) and instability (0 vs. 6, p = 0.0108). Similar post-operative pain (p = 0.2192), range of motion (p = 0.2432-0.5299), strength (p = 0.2099), satisfaction (p = 0.6563), outcomes scores (p = 0.0683-0.0933), and complication rate (p = 0.3698) were seen with RSA vs. TSA/HA. CONCLUSIONS: RSA for the treatment of chronic LASD provides greater pain relief, and improvement in range of motion (ROM) compared to TSA/HA. Anatomic SA is associated with a high rate of instability not seen with RSA. Therefore, anatomic SA (TSA/HA) is likely not indicated in these difficult circumstances. LEVEL OF EVIDENCE: IV.

Outcomes of primary reverse shoulder arthroplasty in patients with morbid obesity.

BACKGROUND: Obesity is a risk factor for worse outcomes in anatomic shoulder arthroplasty. The purpose of this investigation was to determine outcomes of primary reverse shoulder arthroplasty (RSA) in patients with morbid obesity. METHODS: We reviewed all primary RSAs performed on morbidly obese (body mass index [BMI] ≥40 kg/m(2)) patients from 2005 to 2012 at our institution with at least 2 years of follow-up. The study included 41 patients (57% female), the mean BMI was 44 kg/m(2), and the mean age was 67.7 years. RESULTS: The only intraoperative complication was an inferior glenoid fracture that remained stable after glenosphere implantation. At a mean follow-up of 3.2 years (range 2-7.36 years), 2 patients (5%) required revision surgery for infection (n = 1) and humeral loosening (n = 1). Survival was 98% at 2 years and 92% at 5 years. Additional postoperative complications included ulnar neuropathy (n = 1) and heterotopic ossification (n = 2). Pain relief was excellent, with 93% reporting moderate or severe pain preoperatively compared with 2% postoperatively (P < .001). Shoulder abduction improved from 49° to 142° and external rotation from 17° to 50° (P < .001). The average American Shoulder and Elbow Surgeons score was 71.1. At the most recent follow-up, no patients had glenoid lucency, 1 (2%) had humeral lucency, and 2 (5%) had inferior scapular notching. Laborers had higher risk for revision surgery (P = .01), and females had worse functional outcomes and shoulder motion (P < .02). CONCLUSIONS: RSA is a successful procedure in morbidly obese patients (BMI ≥40 kg/m(2)). At intermediate follow-up, there is good implant survival with a reasonable complication rate and excellent pain relief.

Survivorship After Primary Total Hip Arthroplasty in Solid-Organ Transplant Patients.

BACKGROUND: Although a growing number of primary total hip arthroplasties (THAs) are being performed on solid-organ transplant (SOT) recipients, long-term patient and implant survivorships have not been well studied in contemporary transplant and arthroplasty practices. METHODS: A total of 136 THAs (105 patients) with prior SOT were retrospectively reviewed from 2000 to 2013 at mean clinical follow-up of 5 years. The mean age was 59 years, with 39% being females. The most common SOT was renal (56%), followed by liver (24%). RESULTS: Patient mortality was 3.8% and 13.3% at 2 and 5 years, respectively. There were 9 revisions (6.6%), including 5 (4%) for deep periprosthetic infection. Implant survivorship free of any revision was 95% and 94% at 2 and 5 years, respectively. Transplant type or surgical indication did not significantly impact patient or implant survivorship. CONCLUSION: Compared with the general population, SOT patients undergoing THA have slightly higher mortality rates at 5 years. Implant survivorship free of revision was slightly lower than the general population, primarily due to an increased risk of periprosthetic joint infection.

Failure to Medically Optimize Before Total Hip Arthroplasty: Which Modifiable Risk Factor Is the Most Dangerous?

BACKGROUND: There is mounting evidence that smoking, abnormal body mass index (BMI), uncontrolled diabetes, and poor nutritional status are associated with complications after total hip arthroplasty (THA). The goal of the present study was to evaluate the consequences of failure to medically optimize Medicare-eligible patients with respect to these key modifiable health targets by assessing complications in the early postoperative period after THA. METHODS: The National Surgical Quality Improvement Program database was queried for all primary THAs performed in 2018. Data were collected on preoperative serum albumin, BMI, diabetes, and tobacco use as well as postoperative infections, readmissions, complications, and mortality. We identified 47,924 THA patients with a median BMI of 29 kg/m2 and age of 72 years, and 60% of whom were female. RESULTS: We found that preoperative albumin <3.5 g/dL, BMI ≥40 kg/m2, tobacco use, and diabetes were all individually associated with increased risk of postoperative complications. Serum albumin <3.5 g/dL was the greatest overall risk factor for infection (odds ratio [OR]: 3.1, 95% confidence interval [CI]: 2.3-4.4, P < .0001), readmission (OR: 2.2, 95% CI: 1.9-2.5, P < .0001), any complication (OR: 4.2, 95% CI: 3.8-4.6, P < .0001), and mortality (OR: 7.5, 95% CI: 5.3-10.6, P < .0001). CONCLUSIONS: Low albumin, elevated BMI, tobacco use, and diabetes are associated with increased risk of postoperative infection, readmission, any complication, and mortality after primary THA. Low albumin poses the greatest risk of these. Preoperative optimization should be obtained in all patients before elective surgery, and the final decision for surgery should be individually made between a surgeon and patient. LEVEL OF EVIDENCE: IV.

Incidence and risk factors for hardware removal following periacetabular osteotomy and its association with clinical outcomes.

BACKGROUND: Periacetabular osteotomy (PAO) can be used for joint preservation in symptomatic developmental dysplasia of the hip (DDH) and femoroacetabular impingement (FAI). 1 of the most common procedures following PAO is hardware removal. The aims of this study were to determine the rate of hardware removal and patient characteristics associated with this outcome following PAO. METHODS: Data from a prospectively-collected registry was retrospectively reviewed at one institution managing DDH or FAI patients with PAO from July 2008-December 2015. Patients who completed preoperative and postoperative patient reported outcome (PRO) questionnaires with minimum 1-year follow-up were evaluated, resulting in 221 patients followed for a mean of 2.8 years (range 1.0-7.7 years). There were 80% women, mean age was 25 years and mean body mass index (BMI) was 25 kg/m2. Fully-threaded 4.5-mm screws were used for internal fixation. RESULTS: Hardware removal occurred in 30 patients (13.6%) at a mean of 1.0 years after PAO. Patients undergoing hardware removal were younger (mean age 20.4 vs. 26.3 years), thinner (mean BMI 22.2 vs. 25.1), had less severe dysplasia (DDH patients only: mean lateral centre-edge angle 21.0 vs. 16.2, mean Tönnis angle 12.9 vs. 16.8), and were more likely to have PAO for FAI (33% vs. 11%) compared to patients with retained hardware. At final follow-up, multivariable analysis demonstrated a trend toward inferior patient reported outcomes in the hardware removal group. CONCLUSIONS: This study defines the incidence and characteristics of patients undergoing hardware removal after PAO and demonstrates similar outcomes to patients who do not require hardware removal.

Reasons for Failure of Primary Total Hip Arthroplasty Performed Through a Direct Anterior Approach.

The direct anterior approach (DAA) for total hip arthroplasty (THA) is a technique popular among some arthroplasty surgeons. There is currently a paucity of data regarding reasons for failure of THA using the DAA. The authors conducted a retrospective review of prospectively collected data on 56 patients who underwent revision THA at their institution after failing primary THA that was performed through a DAA either at their institution (n=8) or elsewhere (n=48) from January 1, 2010, to June 1, 2017. Patients were grouped by modes of failure and compared using patient characteristics, surgical factors, and radiographic outcomes. Total hip arthroplasties performed through the DAA failed due to infection in 21 (38%) patients, aseptic/mechanical loosening in 14 (25%) patients, intraoperative fracture in 6 (11%) patients, postoperative fracture in 6 (11%) patients, tendinitis or pain of unknown etiology in 3 (5%) patients, metallosis in 3 (5%) patients, instability/dislocation in 2 (4%) patients, and leg length discrepancy in 1 (2%) patient. Patients who underwent revision due to unrecognized intraoperative fracture had a lower body mass index (BMI) and weight than patients who had failure due to postoperative fracture, aseptic loosening, or infection. The 4 most common modes of failure included infection, aseptic loosening, unrecognized intraoperative fracture, and postoperative fracture. Together, these made up 84% of failed DAA THAs. Patients with a lower BMI are more likely to have failure due to intraoperative fractures. Patients with a higher BMI are more likely to have failure due to postoperative fracture, aseptic loosening, or infection. [Orthopedics. 2020;43(4);239-244.].

Primary Total Hip Arthroplasty in Patients 20 Years Old and Younger.

BACKGROUND: Historically, total hip arthroplasty (THA) performed in patients ≤20 years old has been associated with poor survivorship because of bearing-surface wear with conventional polyethylene, acetabular loosening with cemented sockets, and liner fracture in ceramic-on-ceramic (CoC) THA. For this population, there is a paucity of data regarding outcomes of THAs performed with use of modern implants and bearing surfaces. The purpose of the present study was to examine the mid- to long-term outcomes of modern THA in patients ≤20 years old. METHODS: Utilizing a single-institution, prospectively collected total joint registry, we retrospectively identified 91 primary THAs performed in 78 patients ≤20 years old from 1998 to 2016. The average patient age was 17 years (range, 11 to 20 years), and the average body mass index was 26 kg/m (range, 16 to 49 kg/m). Forty-eight THAs (53%) were performed in male patients, and 47 (52%) were performed on the right hip. Bearing surfaces included CoC (53 THAs, 58%), metal-on-highly cross-linked polyethylene (MoP; 28 THAs, 31%), and ceramic-on-highly cross-linked polyethylene (CoP; 10 THAs, 11%). Outcome measures included reoperations, revisions, complications, clinical outcome scores, and bearing-surface wear. RESULTS: At an average follow-up of 8 years (range, 2 to 18 years), the average modified Harris hip score was 92 (range, 54 to 100), and 95% of patients reported feeling "much better" following the surgical procedure. Survivorship at 2, 5, and 10 years postoperatively was 96.7%, 96.7%, and 95.0% for reoperation; 98.9%, 98.9%, and 97.2% for revision; and 91.2%, 91.2%, and 89.5% for complications, respectively. The most common complications were instability (3 THAs, 3%), aseptic acetabular loosening (2 THAs, 2%), and postoperative foot drop (2 THAs, 2%). Linear articular wear averaged 0.019 mm/yr. There were no correlations between age, sex, body mass index, bearing surface, femoral head size, use of cement, or operative time and survivorship from complications, reoperations, or revisions. There were no differences in linear wear among CoC, CoP, and MoP bearing surfaces. CONCLUSIONS: In patients ≤20 years old, THAs performed with use of modern implants exhibit excellent clinical outcome scores and survivorship at mid- to long-term follow-up. CoC, CoP, and MoP bearing surfaces have similar survivorship, clinical outcomes, and bearing-surface wear in this population. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Geniculate Artery Injury During Primary Total Knee Arthroplasty.

Major arterial injury associated with total knee arthroplasty (TKA) is a rare and potentially devastating complication. However, the rate of injury to smaller periarticular vessels and the clinical significance of such an injury have not been well investigated. The purpose of this study is to describe the rate and outcomes of geniculate artery (GA) injury, the time at which injury occurs, and any associations with tourniquet use. From November 2015 to February 2016, 3 surgeons at a single institution performed 100 consecutive primary TKAs and documented the presence or absence and the timing of GA injury. The data were then retrospectively reviewed. All TKAs had no prior surgery on the operative extremity. Other variables collected included tourniquet use, tranexamic acid (TXA) administration, intraoperative blood loss, postoperative drain output, and blood transfusion. The overall rate of GA injury was 38%, with lateral inferior and middle GA injury in 31% and 15% of TKAs, respectively. Most of the injuries were visualized during bone cuts or meniscectomy. The rate of overall or isolated GA injury was not significantly different (P > .05) with either use of intravenous (84 patients) or topical (14 patients) TXA administration. Comparing selective tourniquet use (only during cementation) vs routine use showed no differences in GA injury rate (P = .37), blood loss (P = .07), or drain output (P = .46). There is a relatively high rate of GA injury, with injury to the lateral GA occurring more often than the middle GA. Routine or selective tourniquet use does not affect the rate of injury.