Adherence of Patients to Methods of Self-Reduction of Shoulder Dislocation Taught via Smartphones: A Medium-Term Follow-up Survey.

INTRODUCTION: Self-reduction of a shoulder dislocation may reduce the time from injury to reduction and to the relief of patient discomfort. The purpose of this study was to assess adherence to earlier acquired self-reduction techniques during real-time recurrent shoulder dislocation. METHODS: A telephone survey was conducted among 58 patients previously taught shoulder self-reduction via an instructional video sent to their smartphones during a visit to the emergency department (ED) for the treatment of anterior shoulder dislocation. Participants were queried on recurrent dislocations, use of self-reduction methods, success rate, the effect that instruction in self-reduction had on their willingness to participate in recreational sports activities, on the decision to avoid surgery, and on the overall level of satisfaction with self-reduction methods. RESULTS: Forty-five patients (77.6%; average age 31.4±11.7 y, 10 females) were available for follow-up at an average 60.8±11.0 mo after the index visit to the ED. Eighteen of 23 patients (78.2%) who experienced a recurrent dislocation during the follow-up period attempted self-reduction, and 12 of them successfully achieved self-reduction. Sixteen patients (35.6%) reported that the knowledge in self-reduction increased their willingness to participate in recreational sports activities, whereas 4 (8.9%) patients reported that knowledge in self-reduction affected their decision not to undergo surgical stabilization. CONCLUSIONS: Individuals who sustain recurrent shoulder dislocations should be educated on shoulder self-reduction with the aims of minimizing discomfort, obviating referral to the ED, and motivating participation in recreational activities.

Does addition of gentamicin for antibiotic prophylaxis in total knee arthroplasty reduce the rate of periprosthetic joint infection?

BACKGROUND: First-generation cephalosporins are used as antibiotic prophylaxis in total joint arthroplasty patients. However, this regimen does not address Gram-negative bacteria causing periprosthetic joint infection (PJI). Previous studies have suggested that the addition of an aminoglycoside as antibiotic prophylaxis in THA reduces surgical site infection (SSI), and less is known on its effect in TKA. This study aimed to investigate if the addition of a single-dose gentamicin, administered pre-operatively, is associated with lower rates of infection in TKA patients. PATIENTS AND METHODS: This is a retrospective study of patients who underwent primary TKA as treatment for osteoarthritis between January 2011 and April 2021, with a minimum 1-year follow-up. The mean age was 69.9 (± 9.8), the mean BMI was 29.7 (± 5.5), and most patients had American Society of Anaesthesiology (ASA) score of 2-3 (92.9%). Patients were stratified based on the peri-operative antibiotic prophylaxis they received: cefazolin with addition of gentamicin (case group) or cefazolin (control group). Our primary study endpoints were rates of PJI and SSI, which were compared between groups using the chi-square test. Statistical significance was set as p < 0.05. RESULTS: The final study population consisted of 1590 patients, 1008 (63.4%) in the control group and 582 (36.6%) patients in the case group. The total infection rate for patients that received gentamicin dropped by 34%; however, this finding did not reach statistical significance (1.3% (control) vs. 0.86% (case), p = 0.43). The same drop was seen after subdivision of infections to PJI (0.5% vs. 0.34%, 32% drop, p = 0.66) and SSI (0.8% vs. 0.52%, 35% drop, p = 0.52). CONCLUSIONS: A single dose of gentamicin administered pre-operatively to a standard antibiotic prophylaxis was not associated with a statistically significant lower rate of PJI. Although the difference in infection rate did not reach statistical significance, the current study noted a drop in the rate of infection by 1/3 in the gentamicin cohort. Further investigation to evaluate the potential benefit of adding gentamicin to a peri-operative antibiotic regimen is warranted.

Increased postoperative glycemic variability is associated with increased mortality in diabetic patients undergoing hip arthroplasty for hip fracture.

BACKGROUND: Increased glycemic variability (GV) during hospitalization has been associated with increased rates of surgical site and periprosthetic joint infections (PJI) following elective total joint arthroplasty. Uncertainty exists surrounding GV as a predictor for complications in urgent arthroplasty cases following hip fractures. In this study, we evaluated the association between GV and postoperative complications in diabetic patients undergoing total hip arthroplasty (THA) and hemiarthroplasty (HA) for hip fractures. METHODS: We analyzed data on 2421 consecutive patients who underwent THA or HA at our institution from 2011 to 2020. Patients with a known diagnosis of diabetes mellitus who had a minimum of three postoperative glucose values taken within the first week after surgery were included. GV was assessed using a coefficient of variation. Outcomes included short- and long-term mortality, reoperations, prosthetic joint infection (PJI) requiring revision and readmissions for any cause. RESULTS: The final cohort consisted of 482 patients (294 females, 188 males). Higher GV was associated with an increased 90-day mortality (p = 0.017). GV was not associated with 30-day mortality (p = 0.45), readmissions of any cause at 30 or 90 days (p = 0.99, p = 0.91, respectively), reoperation of any cause (p = 0.91) or PJI requiring revision surgery (p = 0.42). CONCLUSIONS: Higher GV in the postoperative period is associated with increased rates of mortality in diabetic patients following THA and HA for hip fractures. Efforts should be made to monitor and control glucose variability in the postoperative period.

Comparison of canal fill and radiolucent line formation between two fully coated, hydroxyapatite tapered stems: a 2-year follow-up after total hip arthroplasty.

INTRODUCTION: Comparison between fully hydroxyapatite (HA)-coated stems with differing geometry are lacking in the total hip arthroplasty (THA) literature. This study aimed to compare femoral canal fill, radiolucency formation, and 2-year implant survivorship between two commonly used, HA-coated stems. METHODS: All primary THAs performed with two fully HA-coated stems (Polar stem, Smith&Nephew, Memphis, TN and Corail stem, DePuy-Synthes, Warsaw, IN) with a minimum 2-year radiographic follow-up were identified. Radiographic measures of proximal femoral morphology based on the Dorr classification and femoral canal fill were analyzed. Radiolucent lines were identified by Gruen zone. Perioperative characteristics and 2-year survivorship were compared between stem types. RESULTS: A total of 233 patients were identified with 132 (56.7%) receiving the Polar stem (P) and 101 (43.3%) receiving the Corail stem (C). No differences were observed with respect to proximal femoral morphology. Femoral stem canal fill at the middle third of the stem was greater for P stem patients than for C stem patients (P stem; 0.80 ± 0.08 vs. C stem; 0.77 ± 0.08, p = 0.002), while femoral stem canal fill at the distal third of the stem and presence of subsidence were comparable between groups. A total of six and nine radiolucencies were observed in P stem and C stem patients, respectively. Revision rate at 2-year (P stem; 1.5% vs C stem; 0.0%, p = 0.51) and latest follow-up (P stem; 1.5% vs C stem; 1.0%, p = 0.72) did not differ between groups. CONCLUSION: Greater canal fill at the middle third of the stem was observed for the P stem compared to the C stem, however, both stems demonstrated robust and comparable freedom from revision at 2-year and latest follow-up, with low incidences of radiolucent line formation. Mid-term clinical and radiographic outcomes for these commonly used, fully HA-coated stems remain equally promising in THA despite variations in canal fill.

Hip Arthroplasty With the Use of a Reconstruction Cage and Porous Metal Augment to Treat Massive Acetabular Bone Loss: A Midterm Follow-Up.

BACKGROUND: Acetabular reconstruction in the context of massive acetabular bone loss is challenging. In rare scenarios where the extent of bone loss precludes shell placement (cup-cage), reconstruction at our center consisted of a cage combined with highly porous metal augments. This study evaluates survivorship, complications, and functional outcomes using this technique. METHODS: Patients with minimum 2-year follow-up were included. Baseline characteristics were collected. Preintervention and postintervention ambulatory scores were collected. Kaplan-Meier (KM) survival analysis for cage failure requiring revision surgery was conducted. Binomial regression analysis was performed to assess for correlation of aseptic cage failure with baseline characteristics. Preintervention and postintervention ambulatory aid requirements were compared. RESULTS: A total of 41 patients were identified. Mean follow-up was 6.4 years (range 2.8-11.0). Four (9.8%) aseptic cage revisions were identified. Aseptic KM survival analysis was 87.4% (95% confidence interval 75.3-99.6) at 10 years. Aseptic KM survival was 45.0% versus 92.8% at 9 years (P = .14) for patients with vs without pelvic discontinuity. KM survival for all-cause failure was 61.6% (95% confidence interval 44.0-79.2) at 10 years. Binomial regression did not demonstrate correlation of cage failure with baseline characteristics. Wilcoxon signed-rank test demonstrated a significant reduction in ambulatory aide requirement after surgery (mean rank 11.47 vs 9.00, Z = -2.95, P = .003). CONCLUSION: In scenarios of massive acetabular bone loss where a cup-cage is not a viable option, good survivorship free from aseptic cage failure can be expected at mid-term follow-up using an antiprotrusio cage combined with porous metal augments. Success requires extensive experience in revision surgery.

Does Revision of an Acetabular Shell With Insertion of an Uncemented Constrained Liner Confer Benefit Over Cementing Into a Well-Ingrown Shell?

BACKGROUND: During revision total hip arthroplasty (THA), a constrained acetabular liner (CAL) may be inserted to enhance hip stability. It is unclear, however, whether cementation of a CAL into a retained cup offers an advantage compared to revision of the acetabular cup and insertion of an uncemented CAL. The purpose of our study was to compare outcomes and survivorship between the 2 methods. METHODS: We identified a total of 177 patients who underwent revision THA with a specific CAL at our center between July 2004 and May 2019 (114 cup revisions and insertion of an uncemented CAL, 63 cementations of a CAL into a retained cup). Kaplan-Meier (KM) survival analysis was performed for implant survival free from aseptic failure of the CAL for both cohorts. RESULTS: The average follow-up time was 7.2 and 7.02 years for the cemented and uncemented cohort, respectively (P = .55). Five patients (7.93%) in the cemented CAL group experienced failure of the CAL, whereas 10 patients (8.77%) in the uncemented CAL cohort experienced failure (P = .21). Kaplan-Meier (KM) survival analysis demonstrated comparable survivorship at 10 years (P = .055). CONCLUSION: The results of our study suggest comparable survivorship between cementing a CAL into a retained cup and inserting an uncemented CAL in a revised acetabular cup. As a result of these findings along with the benefits associated with cementing a CAL, we encourage surgeons to readily consider this option in the management of recurrent instability.

Overutilization of Radiographs for Pulled Elbow Among Orthopedic Surgeons Compared With Pediatricians.

METHODS: Electronic medical records of the largest health provider in Israel, which provides health services to more than 50% of the population, were reviewed for pulled elbow cases between 2005 and 2020. Patients aged 4.5 months to 7 years were included. Demographic information, the discipline of the treating physician, and acquisition of elbow radiographs were gathered. RESULTS: A total of 4357 patients, 62.8% girls, were included. The average body mass index was 16.1 (SD, 1.2). Most patients were from communities in the upper half of the socioeconomic status clusters 6 to 10 (64.63%). Most patients were attended by a pediatrician (51.5%), followed by an orthopedic surgeon (19.9%). Radiographs were acquired for 570 children (13.1%). Most radiographs (36.5%) were requested by orthopedic surgeons and for children in the boundary age groups. The patient's socioeconomic status was associated with access to physicians of different subspecialties, and lower income families had a higher tendency to be treated by nonspecialized physician ( P < 0.001). CONCLUSIONS: Orthopedic surgeons use elbow radiographs much more than pediatricians; effort should aim at reducing the imaging rate for this population.

Would giving priority in surgery timing to the oldest patients result in lower mortality?

PURPOSE: Early hip fracture surgery in elderly patients is recognized as a positive prognostic factor. When applied as an intervention, it does not always reduce overall patient mortality. A plausible explanation for this is that not all patients equally benefit from early surgery. The purpose of the study is to investigate the effect of early surgery on mortality in patients ages 80 and older. METHODS: This is a retrospective cohort of 3463 patients with hip fractures, operated upon within seven days of admission in a tertiary medical center between 2010 and 2018. Patients were divided into five groups: ages 80-84, 85-89, 90-94, 95-99, and 100 or above. Baseline characteristics were compared between groups. Mortality at one year post-operatively as a function of surgery delay was visualized for each group, using restricted spline curve analysis. RESULTS: Patients with increasing age were operated on earlier, had increased co-morbidities with a higher ASA score and experienced higher mortality. Spline curve analysis in younger patients, ages 80 to 94, demonstrated an inflection point at 48 hours after admission, prior to which mortality was rising rapidly and after which it continued rising slowly. In the two oldest age cohorts, there was no increased mortality with an increasing surgical delay. CONCLUSIONS: In patients ages 80-94 surgery on day one may be preferable to surgery on day two. In patients ages 95 and older, surgery time did not influence mortality. Pursuit of better patient outcomes may include prioritizing early surgery in younger patients.

Expandable Proximal Femoral Nail versus Gamma Proximal Femoral Nail for the treatment of hip reverse oblique fractures.

BACKGROUND: Reverse oblique intertrochanteric fractures are classified by the AO/OTA as 31A3 and account for 2-23% of all trochanteric fractures. The Gamma 3-Proximal Femoral Nail (GPFN) and the Expendable Proximal Femoral Nail (EPFN) are among the various devises used to treat this fracture. The aim of this study was to compare outcomes and complication rates in patients with AO/OTA 31A1-3 fractures, treated by either a GPFN or an EPFN. PATIENTS AND METHODS: A total of 67 patients (40 in the GPFN group and 27 in the EPFN group, average age 78.8 years) were treated in our institution between July 2008 and February 2016. Data on postoperative radiological variables, including peg location and tip-apex distance (TAD), as well as orthopedic complications, such as union rate, surgical wound infection and cut-outs rates were also recorded, along with the incidence of non-orthopedic complications and more surgical data. Functional results were evaluated and quantified using the Modified Harris Hip Score (MHHS) and by the Short Form 12 Mental Health Composite questionnaire (SF-12 MHC) in order to assess the quality of life. RESULTS: The total prevalence of postoperative orthopedic complications including postoperative infection showed a significant difference with a p-value of 0.016 in favor of the EPFN group. Nonetheless, the frequency of revision did not differ between the two groups, being 0.134. The main orthopedic complication in both groups was head cut-out of the GPFN lag screw and the EPFN expendable peg, which was 20% and 7.4%, respectively, and required a revision surgery using a long nail or total hip replacement (THR). However, the average TAD did not significantly differ between groups which might be due to a relatively low cohort to reach a significant difference. Nonunion rate of 5% occurred solely in the GPFN group, with similar results of intraoperative open reduction between both groups. The EPFN group achieved better scores in both questionnaires (p = 0.027 and p = 0.046, respectively). Both the MHHS and SF-12 MCS values significantly differed between groups, with the EPFN group achieving better scores than the GPFN group in both questionnaires (p = 0.027 and p < 0.05, respectively). CONCLUSIONS: According to this study, the EPFN yields better results in comparison with the GPFN, with relatively less complications rate, for the treatment of unstable reverse oblique pertrochanteric fracture. In light of this results, we conclude that the EPFN might be as good as GPFN for the treatment of reverse oblique intertrochanteric fractures. LEVEL OF EVIDENCE: Level III retrospective study. The local institutional review board of the Tel Aviv Medical Center approved this study and all the surgeries were done exclusively in this institution.

The Effect of Femoral Head Size, Neck Length, and Offset on Dislocation Rates of Constrained Acetabular Liners.

BACKGROUND: Constrained acetabular liners (CALs) are used in both primary and revision total hip arthroplasty in cases where stability and abductor deficiency are of concern. The efficacy of CALs has been shown to be design dependent. There is clear evidence that the use of small head sizes and shorter offset in unconstrained total hip arthroplasty is associated with higher rates of dislocation. To our knowledge, no such study has assessed the effect of femoral head size, neck length, and offset for CALs. METHODS: We performed a retrospective study assessing the outcomes of CALs with minimum 2-year follow-up. A Kaplan-Meier survivorship analysis was conducted for all patients and for patients revised for instability. A binomial regression analysis was performed to assess for variables significantly associated with CAL failure. RESULTS: A total of 285 CALs in 281 patients were identified with a mean follow-up of 5.7 years. Ten-year Kaplan-Meier survival analyses were as follows: all indication 91.9% vs instability 85.5% (P = .15). Increasing neck length was associated with lower rates of failure (odds ratio, 0.81; P = .042). Femoral head size, offset, and abductor reconstruction were not significantly associated with CAL failure. CONCLUSION: Larger head size has not been demonstrated to lead to lower failure in CALs. Increasing neck length was associated with lower failure rate. Surgeons should be cautious when attempting to ream to larger acetabular shell sizes for the purpose of using larger heads with CALs. Increasing neck length may instead be targeted intraoperatively.

Good clinical and radiological outcomes of the varus-valgus constrained mobile-bearing implant in revision total knee arthroplasty.

PURPOSE: Knee instability is one of the most common indications for having to undergo revision total knee arthroplasty (RTKA) and can be prevented with adequate implant selection and good surgical technique. Varus-valgus constrained implants (VVC) are indicated for cases of RTKA with absent ligament function in order to provide the necessary stability. While mobile-bearing articulations are thought to decrease the risk of aseptic loosening in comparison to their fixed-bearing counterparts, there is limited data on their outcomes. The purpose of our study is to present the clinical and radiological outcomes for patients undergoing an RTKA procedure with the mobile-bearing VVC implant. METHODS: Between January 2008 to January 2018, 93 patients underwent RTKA with the use of varus-valgus mobile-bearing (VVCMB) prosthesis. The main indications for RTKA were instability 38.7% (n = 36), aseptic loosening 31.2% (n = 29), infection in 26.9% (n = 25), and other 3.3%. The mean follow-up time was 56 months. Clinical outcomes were assessed by knee society scores, range of motion, and rate of re-operation. RESULTS: The mean knee society score increased significantly from 65.52 pre-operatively to 89.65 post-operatively (p < 0.001). The five year cumulative incidence of re-operation in our study was 7.53% (n = 7). Our study reported no cases of aseptic loosening or mobile-bearing spin-out. The number of flexion contractures decreased from n = 23 (24.7%) pre-operatively to n = 11 (11.8%) post-operatively (p < 0.05). CONCLUSION: The VVC mobile-bearing prosthesis demonstrated good clinical outcomes and mid-term survivorship in patients undergoing RTKA. Additional follow-up is required in the long term.

Digital templating in total hip arthroplasty using contralateral healthy hip results in decreased accuracy.

The accuracy of pre-operative digital templating for total hip arthroplasty (THA) using the diseased versus unaffected contralateral joint remains unclear. As such, we devised a study to compare templating precision between the operated hip joint versus the healthy side for patients with osteoarthritis (OA). The study hypothesis was that preoperative templating accuracy of THA on the ipsilateral diseased hip joint would be higher compared to the contralateral healthy hip in patients with OA. We retrospectively reviewed 100 patients who underwent THA for unilateral OA at our center from January 2018 to January 2020. Retrospective preoperative digital templating was performed separately on both the operated hip joint and the healthy contralateral hip joint by a single surgeon who was blinded by the in-situ components sizes. Accuracy of each group was compared to the implanted components. Assessment of the 100 included cases demonstrated superior acetabular component size prediction when templating was performed using the diseased hip compared to the healthy contralateral side (68.0% versus 51.0%, p<0.001). No differences between the cohorts were found regarding templating accuracy of femoral stem sizes (72.0% and 69.0%, p=0.375) or neck offset (73.0% and 69.0%, p=0.289). Templating acetabular cup size using the ipsilateral diseased hip is more accurate than using the contralateral healthy hip in patients with unilateral OA.

The Effect of Polyethylene Liner Thickness on Patient Outcomes and Failure After Primary Total Knee Arthroplasty.

BACKGROUND: The effect of using thicker liners in primary total knee arthroplasty (TKA) on functional outcomes and aseptic failure rates remains largely unknown. As such, we devised a multicenter study to assess both the clinical outcomes and survivorship of thick vs thin liners after primary TKA. METHODS: A search of our institutional databases was performed for patients having undergone bilateral (simultaneous or staged) primary TKA with similar preoperative and surgical characteristics between both sides. Two cohorts were created: thick liners and thin liners. Outcomes collected were as follows: change in Knee Society Score (ΔKSS), change in range of motion, and aseptic revision. Ad hoc power analysis was performed for ΔKSS (⍺ = 0.05; power = 80%). Differences between cohorts were assessed. RESULTS: About 195 TKAs were identified for each cohort. ΔKSS and change in range of motion in the thin vs thick cohorts were similar: 51.4 vs 51.6 (P = .86) and 11.1° vs 10.0° (P = .66), respectively. No difference in aseptic revision rates were observed between thin and thick cohorts: all cause (4.1%, 3.1%; P = .59), aseptic loosening (0.5%, 0.5%; P = 1.0), instability (0.5%, 0.5%; P = 1.0), all-cause revision for stiffness (3.1%, 2.1%; P = .52), manipulation under anesthesia (2.1%, 2.1%; P = 1.0), and liner exchange (0.5%, 0%; P = .32). CONCLUSION: The results of this study suggest that both rates of revision surgery and clinical outcomes are similar for TKAs performed with thick and thin liners. Preoperative factors are likely to play an important role in liner thickness selection, and emphasis should be placed on ensuring sound surgical technique.

Total hip arthroplasty in patients with fibrous dysplasia: a modern update.

Background: Fibrous dysplasia (FD) results from an abnormality in lamellar bone formation and most frequently involves the proximal femur. This can lead to the development of osteoarthritis requiring total hip arthroplasty (THA). Such cases are challenging, and there is a lack of information guiding best management. As such, we devised a study assessing the outcomes and complications in patients with FD undergoing THA with modern implant technology, and we outlined our preferred surgical technique. Methods: A search of our institutional arthroplasty database was performed to identify patients who underwent THA for FD between January 2001 and July 2018 at Mount Sinai Hospital in Toronto, Canada. Data regarding implants used and the use of allograft material or metal augments or both were obtained. Complications and revision requirements were noted. Radiographic and clinical leg length discrepancies were assessed. Results: A total of 10 hips in 9 patients who underwent THA for FD were identified. Mean follow-up time was 6.0 years (range 0.5 to 10.3 yr). The majority of patients underwent THA using uncemented femoral and acetabular components with large femoral heads on highly cross-linked polyethylene liners. Most cases (80% of hips) required allograft to the proximal femur. A single complication requiring revision was noted. In 90% of hip surgeries, the patient required transfusion of packed red blood cells. Mean radiographic and clinical leg length discrepancies were 0.9 cm (range -2.4 to 2.4 cm) and 0.9 cm (range -4 to 0 cm), respectively. Conclusion: Contrary to previous reports, low complication and revision rates were observed with cementless components and routine use of allograft material. The challenging nature of such cases warrants use of an experienced arthroplasty treatment team.

Contexte: La dysplasie fibreuse (DF) découle d'une anomalie de la formation de l'os lamellaire et affecte le plus souvent le fémur proximal. Elle peut aussi aboutir à l'arthrose qui nécessitera une arthroplastie totale de la hanche (ATH). Or, ces cas sont complexes car on manque d'information sur la meilleure façon de les traiter. Nous avons donc conçu une étude afin d'évaluer l'issue et les complications chez les patients atteints de DF qui subissent une ATH au moyen de techniques d'implants modernes, et nous indiquons la technique chirurgicale que nous privilégions. Méthodes: Nous avons interrogé la base de données de notre établissement sur les arthroplasties pour recenser les patients ayant subi une ATH en raison de la DF entre janvier 2001 et juillet 2018 à l'Hôpital du Mont-Sinaï de Toronto, au Canada. Nous avons obtenu les données sur les implants utilisés et le recours à du matériel de comblement à base d'allogreffes ou de métal ou les deux. Nous avons consigné les complications et les cas où une révision a été nécessaire. Nous avons évalué les inégalités de longueur des membres inférieurs aux plans clinique et radiographique. Résultats: En tout, 10 hanches chez 9 patients ont fait l'objet d'une ATH en raison de la DF. Le suivi moyen a duré 6,0 ans (de 0,5 à 10,3 ans). La majorité des patients ont subi une ATH avec des prothèses à composants fémoraux et acétabulaires non cimentés dotées de têtes fémorales volumineuses, sur des revêtements de polyéthylène hautement réticulé. La plupart des cas (80 % des hanches) ont nécessité une allogreffe au fémur proximal. Une seule complication nécessitant une révision a été notée. Dans 90 % des chirurgies de la hanche, les patients ont eu besoin de transfusions de culots globulaires. Les inégalités cliniques et radiographiques moyennes de la longueur des membres inférieurs ont été de 0,9 cm (entre ­2,4 et 2,4 cm) et de 0,9 cm (de ­4 à 0 cm), respectivement. Conclusion: Contrairement à de précédents rapports, les taux de complications et de révisions observés ont été faibles avec les composants non cimentés et l'utilisation de routine d'allogreffes. La nature complexe de ces cas justifie que l'on fasse appel à une équipe chevronnée pour l'arthroplastie.

Effects of surgeon experience and patient characteristics on accuracy of digital pre-operative planning in total hip arthroplasty.

BACKGROUND: The effect of surgeon experience on accuracy of digital pre-operative planning for total hip arthroplasty (THA) remains unclear. The aims of our study were to compare pre-operative planning accuracy between fellow-trained orthopaedic surgeons and residents and to explore whether surgery indication effects the prediction accuracy. METHODS: We prospectively reviewed 101 patients who underwent pre-operative digital templating for THA in our center from January 2019 to January 2020 with King Mark device. Extracted data included baseline characteristics and indication for primary arthroplasty. Pre-operative digital templating was performed separately by both a fellow-trained surgeon and a resident. Accuracy of each group was compared with the implanted components. RESULTS: The overall adequate pre-operative planning of the acetabular cup (exact or +/-1 size match) by the fellow-trained group was higher compared with the resident's group (77.2 and 64.3% respectively, p = 0.037), whereas the overall adequate pre-operative planning of the femoral stem (exact or +/-1 size match) was higher in the resident's group compared with the fellow-trained group (83.2 and 61.4% respectively, p < =0.001). The fellow-trained group showed better pre-operative planning of complex cases (developmental dysplasia of the hip and avascular necrosis of femoral head) than the resident's group. CONCLUSIONS: The experience of the planner does not significantly affect the accuracy of correctly predicting component sizes. However, in complex cases, fellow-trained surgeons should assist residents in digital pre-operative templating for THA.

Revision total knee arthroplasty for patellar dislocation in patients with malrotated TKA components.

PURPOSE: Patellar dislocation is a serious complication leading to patient morbidity following total knee arthroplasty (TKA). The cause can be multifactorial. Extensor mechanism imbalance may be present and result from technical errors such as malrotation of the implants. We sought to understand the reasons for post-arthroplasty patellar dislocation and the clinical outcomes of patients in whom it occurs. METHODS: This is a retrospective cohort study assessing the outcomes of revision surgery for patellar dislocation in patients with component malrotation in both primary and revision TKAs. Patient demographics, dislocation etiology, presurgical deformity, intraoperation component position, complications, reoperation, and Knee Society Scores (KSS) were collected. RESULTS: Twenty patients (21 knees) were identified. The average time from primary arthroplasty to onset of dislocation was 33.6 months (SD 44.4), and the average time from dislocation to revision was 3.38 months (SD 2.81). Seventeen knees (80.9%) had internal rotation of the tibial component and seven knees (33.3%) had combined internal rotation of both the femoral and tibial components. Fifteen knees (71.4%) were treated with a condylar constrained implant at the time of revision, and five knees were converted to a hinged prosthesis. The average follow-up time was 56 months. During this time, one patient (4.54%) had a recurrent dislocation episode, requiring further surgery. At final follow up, the mean KSS was 86.2. CONCLUSION: Revision TKA following patellar dislocation for patients with malrotated components was associated with high success rates. After revision surgery, patients had a low recurrence of patellar dislocation, low complication rates, and excellent functional outcomes.

Is continuation of anti-platelet treatment safe for elective total hip arthroplasty patients?

INTRODUCTION: Acetylsalicylic acid (aspirin) is a commonly prescribed medication, especially in the age group of individuals who undergo elective total hip arthroplasty (THA). Preoperative discontinuation of aspirin is believed to reduce intraoperative bleeding and other complications, but it may increase the risk of perioperative cardiovascular events. In this study we have sought to evaluate the safety of continuous aspirin treatment in patients undergoing elective THA. MATERIALS AND METHODS: This is a retrospective analysis of a consecutive cohort who underwent elective THA in a tertiary medical center between 2011 and 2018. The cohort was divided into two groups-one that received continuous preoperative aspirin treatment and one that did not. Blood loss, peri- and postoperative complications, readmissions, and short- and long-term mortality were compared between groups. RESULTS: Out of 757 consecutive patients (293 males, 464 females) who underwent elective primary THA, 552 were in the "non-aspirin" group and 205 were in the "aspirin" group and were not treated preoperative with other medication affecting hemostasis. Perioperative continuation of aspirin treatment did not significantly increase perioperative bleeding, as indicated by changes in hemoglobin levels (P = 0.72). There were no significant differences in short- and long-term mortality (P = 0.47 and P = 0.4, respectively) or other perioperative complications, such as readmission (P = 0.78), deep or superficial infection (P = 1 and P = 0.47, respectively), and cardiovascular events (none in both groups). CONCLUSION: Peri-operative continuation of aspirin treatment in patients undergoing elective primary THA did not increase perioperative complications or mortality compared to the non-aspirin-treated patients. The protective effects of aspirin from postoperative thrombotic and cardiovascular events are well documented. The current findings dispute the need to preoperatively withhold aspirin treatment in patients undergoing elective primary THA.

Impact of Hip Antibiotic Spacer Dislocation on Final Implant Position and Outcomes.

BACKGROUND: Dislocation of dynamic antibiotic hip spacers during the treatment of periprosthetic joint infection is a well-described complication. Unfortunately, the repercussions of such events after reimplantation of the definitive prosthesis remain largely unknown. As such, we devised a study comparing the perioperative and postoperative outcomes of patients having undergone reimplantation with and without spacer dislocation. METHODS: A search of our institutional database was performed. Two retrospective cohorts were created: dislocated and nondislocated hip spacers. The radiographic and clinical outcomes for each cohort were collected. RESULTS: The two retrospective cohorts contained 24 patients for the dislocated group and 66 for the nondislocated group. Continuous variables noted to be significantly different between the dislocated and nondislocated groups were as follows: clinical leg-length discrepancy (1.35 cm vs 0.41 cm, P = .027), acetabular center of rotation (1.34 cm vs 0.60 cm, P = .011), total packed red blood cell transfusions (4.05 vs 2.37, P = .019), operative time (177.4 min vs 147.3 min, P = .002), and hospital length of stay (7.79 days vs 5.89 days, P = .018). Categorical variables noted to be significantly different were requirement for complex acetabular reconstruction (58.3% vs 13.7%, P < .001), requirement of constrained liners (62.5% vs 37.3%, P = .040), and dislocation after second stage (20.8% vs 6.1%, P = .039). CONCLUSION: Dislocation of dynamic hip spacers leads to inferior clinical results and perioperative outcomes after reimplantation of the definitive prosthesis. Additionally, complex acetabular reconstruction is often required. As such, every effort should be made to prevent hip spacer dislocation.

Preemptive Analgesia in Hip Arthroscopy: A Randomized Controlled Trial of Preemptive Periacetabular or Intra-articular Bupivacaine in Addition to Postoperative Intra-articular Bupivacaine.

PURPOSE: To evaluate and compare the efficacy of intra-articular and periacetabular blocks for postoperative pain control after hip arthroscopy. METHODS: Forty-two consecutive patients scheduled for hip arthroscopy were randomized into 2 postoperative pain control groups. One group received preemptive intra-articular 20 mL of bupivacaine 0.5% injection, and the second group received preemptive periacetabular 20 mL of bupivacaine 0.5% injection. Before closure all patients received an additional dose of 20 mL of bupivacaine 0.5% intra-articularly. Data were compared with respect to postoperative pain with visual analog scale (VAS) and analgesic consumption, documented in a pain diary for 2 weeks after surgery. RESULTS: Twenty-one patients were treated with intra-articular injection, and 21 patients with peri-acetabular injection. There were no significant differences with regards to patient demographics or surgical procedures. VAS scores recorded during the first 30 minutes postoperatively and 18 hours after surgery were significantly lower in the periacetabular group compared with in the intra-articular group (0.667 ± 1.49 vs 2.11 ± 2.29; P < .045 and 2.62 ± 2.2 vs 4.79 ± 2.6; P < .009). There were no differences between the groups with regard to analgesic consumption. CONCLUSIONS: Periacetabular injection of bupivacaine 0.5% was superior to intra-articular injection in pain reduction after hip arthroscopy at 30 minutes and 18 hours postoperatively. However, total analgesic consumption over the first 2 postoperative weeks and VAS pain measurements were not significantly affected. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

The medial border of the tibial tuberosity as an auxiliary tool for tibial component rotational alignment during total knee arthroplasty (TKA).

PURPOSE: The objective of this study was to quantify the amount of ensuing internal rotation of the tibial component when positioned along the medial border of the tibial tubercle, thus establishing a reproducible intraoperative reference for tibial component rotational alignment during total knee arthroplasty (TKA). METHODS: The angle formed from the tibial geometric centre to the intersection of both lines from the middle of the tibial tuberosity and its medial border was measured in 50 patients. The geometric centre was determined on an axial CT slice at 10 mm below the lateral tibial plateau and transposed to a slice at the level of the most prominent part of the tibial tuberosity. Similar measurements were taken in 25 patients after TKA, in order to simulate the intraoperative appearance of the tibia after making its proximal resection. RESULTS: This angle was found to be similar (n.s.) in normal and post-TKA tibiae [median 20.4° (range 15°-24°) vs. 20.7° (range 16°-25°), respectively]. In 89.3 % of the patients, the angle ranged from 17° to 24°. No statistical difference (p n.s.) was found between women and men in both normal [median -20.7° (range 16°-25°) vs. 19.9° (range 15°-24°)] and post-TKA tibiae [median 21.4° (range 19°-24°) vs. 20° (range 16°-25°)]. CONCLUSION: This study found that in 90 % of the patients, the medial border of the tibial tuberosity is internally rotated 17°-24° in relation to the line connecting the middle of the tuberosity to the tibial geometric centre. Since this anatomical landmark may be more easily identifiable intraoperatively than the commonly used "medial 1/3", it can provide a better quantitative reference point and help surgeons achieve a more accurate tibial implant rotational position. LEVEL OF EVIDENCE: Cohort and case control studies, Level III.