High Incidence of Recurrent Patellofemoral Crepitus in Total Knee Arthroplasty Patients Following Arthroscopic Debridement.

Background: Patellofemoral crepitus is an unfavorable complication following total knee arthroplasty (TKA) with a posterior-stabilized (PS) implant. The purpose of this study was to study patellar crepitus recurrence and reoperation rates following arthroscopic debridement in patients with a PS-TKA. Methods: Our institution database was used to identify patients with a PS-TKA who underwent arthroscopic debridement for patellofemoral crepitus at our institution. Patients must have had a resurfaced patella and minimum 2 years clinical follow-up from the arthroscopic debridement to be included in the study. Recurrence of patellar crepitus, subsequent operations, and any adverse events were documented. Results: We identified 35 patients who met inclusion criteria with an average follow-up of 8.0 years (range 2.1 to 18.4 years) from their arthroscopic debridement. Nineteen patients (54.3%) had history of a nonarthroplasty knee surgery prior to their TKA. The mean time interval between TKA and arthroscopic debridement for patellar crepitus was 1.6 years (range 0.2 to 5.0 years). Overall, 16 patients (45.7%) developed recurrent crepitus (8 asymptomatic and 8 symptomatic). Six of the symptomatic patients (17.1% of the entire cohort) underwent a repeat surgery for recurrent patellofemoral crepitus. Of theses 6 patients, 3 developed recurrent crepitus but only 1 patient had a third surgical procedure. No postoperative complications were noted following any surgical procedure. The mean knee range of motion following arthroscopic debridement did not change (126.9° preoperatively vs 127.0° postoperatively). Conclusions: Patients experienced high rates of recurrent patellofemoral crepitus following arthroscopic debridement. One-sixth of the patient cohort required a second surgical intervention for recurrent crepitus.

Total Hip Revision with a Custom Acetabular Component and Femoral Allograft-Prosthetic Composite as Salvage for Failed Unstable Megaprosthesis in an Adolescent Patient: A Case Report at 19-Year Follow-up Duration.

CASE: A 13-year-old girl presented after a right proximal femur replacement after proximal femoral resection for treatment of an Ewing sarcoma. She presented after multiple episodes of recurrent instability with her hip endoprosthesis chronically dislocated. Her hip was revised to a custom, constrained metal-on-metal acetabular component with a small iliac flange. The femoral component was revised to an allograft-prosthetic composite. She has been free of malignancy recurrence, implant failure, or dislocation at 19-year follow-up duration. CONCLUSION: Dislocation of the prosthetic hip can be a challenging postoperative complication, particularly when associated with a tumor megaprosthesis in a pediatric age group. This is further compounded in the presence of deficient pelvic bone stock. Restoration of bone stock is optimal, but when impossible, custom components may be necessary to establish hip stability.

What is the Effect of Posterior Osteophytes on Flexion and Extension Gaps in Total Knee Arthroplasty? A Cadaveric Study.

BACKGROUND: Posterior compartment knee osteophytes may pose a challenge in achieving soft-tissue balance during total knee arthroplasty (TKA). Obtaining symmetry of flexion and extension gaps involves balance of both bony and soft-tissue structures. We hypothesize that space-occupying posteromedial femoral osteophytes affect soft-tissue balance. METHODS: Five cadaveric limbs were acquired. Computed tomography scans were obtained to define the osseous contours. Three-dimensionally printed, specimen-specific synthetic posterior femoral osteophytes were fabricated in 10-mm and 15-mm sizes. TKAs were implanted. Medial and lateral compartment contact forces were measured during passive knee motion using pressure-sensing technology. For each specimen, trials were completed without osteophytes and with 10-mm and 15-mm osteophytes affixed to the posteromedial femoral condyle. Contact forces were obtained at full extension, 10°, 30°, 45°, 60°, and 90° of flexion. These were recorded across each specimen in each condition for three trials. Tukey post hoc tests were used with a repeated measures ANOVA for statistical data analysis. RESULTS: The presence of posteromedial osteophytes increased asymmetric loading from full extension to 45° of flexion, with statistically significant differences observed at full extension and 30°. A reduction in lateral compartment forces was noted. The 25%-75% bounds of variability in the contact force was less than 3.5 lbs. CONCLUSIONS: Posteromedial femoral osteophytes caused an asymmetric increase in medial contact forces from full extension continuing into mid-flexion. The soft-tissue imbalance created from these osteophytes supports their removal before performing ligament releases to obtain desired soft-tissue balancing during TKA.

Ten-Year Follow-Up of High-Flexion Versus Conventional Total Knee Arthroplasty: A Matched-Control Study.

BACKGROUND: High-flexion total knee arthroplasty (HF-TKA) prostheses were designed with hopes of improving knee function. Studies have suggested increased failure with HF-TKAs. The purpose is to compare clinical results of HF-TKA versus conventional TKA (C-TKA) from the same implant system with long-term follow-up. METHODS: This review of prostheses implanted between 2004 and 2007 matched 145 of 179 possible HF-TKAs with 145 of 1347 possible C-TKAs. Mean follow-up was 121.5 ± 20.3 months. We were unable to match 12 HF-TKAs. HF-TKAs with less than 8-year follow-up were excluded. The primary outcome was failure requiring revision. Secondary outcomes included range of motion (ROM), Knee Society Scores (KSS), and radiolucent lines. RESULTS: In the matched cohort, there were 15 HF-TKA reoperations, 8 of which involved component revisions. There were 12 reoperations in the C-TKA cohort but no component revisions (P = .001). The analysis of the unmatched cohorts revealed a higher revision rate for HF-TKAs (P = .039) (HF-TKA: 10/179 vs C-TKA: 27/1347). At final follow-up, HF-TKAs exhibited more prosthesis radiolucent lines without evidence of loosening. Particularly, HF-TKAs demonstrated more femoral zone IV radiolucencies (38.7%) at final follow-up compared with C-TKAs (13.8%) (P < .001). There were no differences found between cohorts in ROM or KSS. CONCLUSION: This study found an increased incidence of failure requiring revision with the HF-TKA in the matched and unmatched analyses. Higher incidences of radiolucent lines were found with HF-TKA. With no observed differences in ROM or KSS and a higher rate of failure with HF-TKA, there appears to be no advantage for use of the HF-TKA.

Usefulness of Perioperative Laboratory Tests in Total Hip and Knee Arthroplasty: Are They Necessary for All Patients?

BACKGROUND: Laboratory studies are routinely obtained preoperatively and postoperatively for total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study evaluates the necessity of routine, perioperative laboratory tests and identifies risk factors for laboratory-associated interventions. METHODS: This retrospective review evaluated 967 consecutive patients scheduled for primary, unilateral TKAs (n = 593) or THAs (n = 374) over an 18-month period at a single institution. Preoperative prothrombin time (PT) and International Normalized Ratio (INR), complete blood count (CBC), complete metabolic panel (CMP), and postoperative CBC and basic metabolic panel (BMP) were recorded along with any laboratory-associated intervention. Patient demographics and comorbidities identified risk factors for abnormal or actionable laboratory studies. RESULTS: Preoperatively, the actionable rates for PT/INR, CMP, and CBC were 0.3%, 1.4%, and 0.5%, respectively. Vascular, renal, and immunologic diseases were risk factors for an actionable CBC. Risk factors for an actionable CMP include cardiac arrhythmia and diabetes. There were no risk factors for an actionable PT/INR. Postoperatively, only 1.5% of BMPs and 1.5% of CBCs were actionable. Congestive heart failure, renal disease vascular disease, or history of cancer (P = .030) were risk factors for an actionable CBC. There were no risk factors for an actionable BMP. Patients with an abnormal preoperative lab were 2.4 times more likely to have an actionable postoperative lab. Patients with an actionable preoperative lab were 11.3 times more likely to have an actionable postoperative lab. CONCLUSION: Routine preoperative and postoperative labs may not be necessary on all patients undergoing a TKA or THA. Comorbid risk factors and abnormal or actionable preoperative CMPs and CBCs can help determine the usefulness of postoperative laboratory assessments.

Does the use of intraoperative fluoroscopy improve postoperative radiographic component positioning and implant size in total hip arthroplasty utilizing a direct anterior approach?

BACKGROUND: The direct anterior approach (DAA) for total hip arthroplasty (THA) has gained recent popularity, with 1 purported benefit being access to intraoperative fluoroscopy. However, there are limited data demonstrating improved component position with the use of intraoperative fluoroscopy. The aim of this study is to compare radiographic implant positioning on 2 consecutive cohorts of patients undergoing DAA THA performed by 1 surgeon either utilizing intraoperative fluoroscopy or not. We hypothesized that there would be no relevant radiographic differences between the cohorts. METHODS: Forty-two consecutive patients underwent DAA THA utilizing fluoroscopy (IFC), and 42 consecutive patients then underwent DAA THA without fluoroscopy (NFC). Using preoperative pelvis radiographs and 6-week postoperative pelvis radiographs, acetabular anteversion, inclination, femoral offset, and templated component sizes vs final intraoperatively selected sizes were recorded and compared between cohorts. RESULTS: Acetabular inclination was 45.0° for IFC and 45.6° for NFC (P = .629). Femoral offset difference preoperatively and postoperatively was 0.8 mm for IFC and 1.3 mm for NFC (P = .734). Number of hips within the so-called safe zone was 32 for IFC and 33 for NFC (P = .794). These all demonstrated no significant difference between the cohorts. However, acetabular anteversion was 13.7° for IFC and 11.2° for NFC (P = .02). CONCLUSIONS: In this limited series, the routine use of intraoperative fluoroscopy did not improve implant positioning or sizing. This may be surgeon-specific or due to the result of the use of acetabular landmarks to guide placement of the components without fluoroscopy.

Management of Bone Defects in Revision Total Knee Arthroplasty with Use of a Stepped, Porous-Coated Metaphyseal Sleeve.

BACKGROUND: Revision total knee arthroplasty is a costly operation associated with many challenges including bone loss in the distal end of the femur and proximal end of the tibia1,2. Reconstruction of bone defects remains a difficult problem that may require more extensive reconstruction techniques to restore mechanical stability and ensure long-term fixation. Use of porous-coated metaphyseal sleeves is a modern technique to address bone deficiency in revision total knee arthroplasty3,4. Midterm reports have shown excellent survivorship and osseointegration5-7. DESCRIPTION: The use of a porous-coated metaphyseal sleeve begins with intramedullary canal reaming to determine the diameter of the diaphyseal-engaging stem. Bone loss is assessed followed by broaching of the tibial and/or femoral metaphyses. Broaching continues until axial and rotational stability are achieved. The sleeve typically occupies most, if not all, of the proximal tibial and distal femoral cavitary osseous defects often encountered during revision total knee arthroplasty. However, a sleeve does not address all distal and posterior femoral condylar bone loss, for which augments are often required. ALTERNATIVES: Previously described methods to address various bone deficiencies include use of morselized or structural bone-grafting, reinforcing screws within cement, metal augments, and metaphyseal cone fixation8-17. RATIONALE: Structural allografts or metal augments remain a suitable option for uncontained metaphyseal defects. Metaphyseal structural allografts may undergo stress-shielding, resorption, and late fracture. Metaphyseal sleeves offer long-term biologic fixation to host bone while creating a stable platform to receive a cemented femoral and/or tibial component7. This hybrid combination may provide mechanically protective properties to decrease the loads at the cement-bone interfaces and enhance loads to metaphyseal bone to ensure long-term implant fixation in the setting of substantial bone deficiencies18-20.

Does the Method of Sterile Glove-Opening Influence Back Table Contamination? A Fluorescent Particle Study.

BACKGROUND: Surgical site infections (SSI) may result from inadvertent intraoperative contamination events. This study investigated the method of opening surgical gloves onto the operative field (OF) and potential contamination rates. METHODS: Twenty surgical glove packets were coated with a commercially available fluorescent particle powder. Two methods of glove openings (10 surgical glove packets in each cohort) were investigated: direct drop (DD) onto the OF vs opening and direct hand-off (DH) to a sterile intermediary (SI). Ultraviolet black light was used to quantify fluorescent particles for dispensed glove packets and the OF in both cohorts. The gloves of the SI were inspected in the DH cohort. A previously used contamination scale for fluorescent particle model contamination was employed: 0: no detectable fluorescent particle specks, 1: 1-5 specks, 2: 5-10 specks, 3: 11-100 specks, 4: >100 specks. RESULTS: The DD cohort had a median OF contamination of 4 (range, 3-4) vs 3 for the DH trials (range, 1-3; P = .001). Likewise, the median glove contamination was higher in the DD cohort, 3 (range, 2-4) vs 1 for DH (range, 0-3; P = .007). Minimal contamination was found on the hands of the SI. Total fluorescent contamination rates, including the gloves of SI in the DH cohort, revealed greater overall contamination in DD (median, 3.5; range, 2-4) vs DH cohort (median, 1; range, 0-3); (P < .001). CONCLUSION: Using a fluorescent particle model, there is a greater burden of potential contamination from dispensed glove packets and OF with DD vs DH. The DH method did not show significant fluorescent particle contamination on the SI gloves. These data support the use of the opening of gloves via DH over the DD method in total joint arthroplasty to decrease the risk of potential contamination.

Total Knee Arthroplasty Kinematics.

Knee kinematics is an analysis of motion pattern that is utilized to assess a comparative, biomechanical performance of healthy nonimplanted knees, injured nonimplanted knees, and various prosthetic knee designs. Unfortunately, a consensus between implanted knee kinematics and outcomes has not been reached. One might hypothesize that the kinematic variances between the nonimplanted and implanted knee might play a role in patient dissatisfaction following TKA. There is a wide range of TKA designs available today. With such variety, it is important for surgeons and engineers to understand the various geometries and kinematic profiles of available prostheses. The purpose of this review is to provide readers with the pertinent information related to TKA kinematics.

Cannabis Use Does Not Affect Outcomes After Total Knee Arthroplasty.

BACKGROUND: The self-reported use of cannabis has increased since its recent legalization in several states. The primary purpose of this study is to report total knee arthroplasty (TKA) outcomes in patients using cannabis. METHODS: Seventy-one patients who underwent a primary unilateral TKA with minimum 1-year follow-up, who self-reported cannabis use, were retrospectively reviewed. The study period was from January 2014 to February 2018 at a single institution. Patients with a history of opioid consumption, alcohol abuse, tobacco, or illicit drug use were excluded. A matched control was conducted based on age, body mass index, gender, smoking status, and insurance type (surrogate of socioeconomic status) in patients with a unilateral TKA who did not report cannabis use. Outcome measures included Knee Society Scores (KSS), range of motion, Veterans RAND-12 mental and physical component scores. No preoperative differences were noted with these measures. Postoperative complications were recorded and reported. RESULTS: No difference in length of stay was noted between the users (46.9 hours ± 15.7) and nonusers (49.3 hours ± 20.4) (P = .464). In-hospital total morphine equivalents did not differ between the 2 groups (user = 137 ± 104 mg, nonuser = 146 ± 117 mg, P = .634). Postoperative range of motion did not differ between users (128.4° ± 10.4°) and nonusers (126.9° ± 7.5°) (P = .346). No mean differences in follow-up KSS (user = 180.1 ± 24.9, nonuser = 172.0 ± 33.9, P = .106) or total change (user = 61.7 ± 32.8, nonuser = 62.7 ± 30.7, P = .852) in KSS were noted. Likewise, no significant mean differences in Veterans RAND-12 (mental component scores: user = 54.8 ± 9.3, nonuser = 55.9 ± 8.79, P = .472; physical component scores: user = 48.3 ± 9.9, nonuser = 45.8 ± 10.1, P = .145) scores were demonstrated. There were no differences in readmissions (user = 5, nonuser = 4, P = .730) or reoperations (user = 5, nonuser = 2, P = .238). CONCLUSION: Cannabis use does not appear to influence (adverse or beneficial) short-term outcomes in patients undergoing a primary TKA. Further studies are warranted to determine the efficacy and safety of cannabis as a constituent of multimodal pain management following TKA before endorsements can be made by orthopedic surgeons.

What Is the Value of Component Loosening Assessment of a Preoperatively Obtained Bone Scan Prior to Revision Total Knee Arthroplasty?

BACKGROUND: Bone scintigraphy (BS) is frequently ordered to investigate cause of failure following total knee arthroplasty (TKA). Its correlation of component loosening with intraoperative findings (IFs) at the time of revision TKA (rTKA) has not been well studied. This study investigated correlations between the preoperatively obtained radiologist report (RR) of BS, preoperatively documented surgeon prediction (SP) of component loosening, and operative reports documenting IFs. METHODS: Our institutional database was retrospectively reviewed for all rTKA done after BS and revealed 96 eligible cases. The RR and SP cohorts were subdivided into all potential combinations of component loosening and were then compared with each other as well as IF. In addition to calculating the percentage correct of RR and SP compared with IF, the levels of agreement between RR and SP were compared using the kappa statistic. RESULTS: Of the 96 cases, the RR correctly correlated with IF in 35 cases (37%), whereas the SP was correct in 66 cases (69%), indicating the preoperative interpretation of the surgeon regarding component loosening at rTKA was correct more frequently (P < .001). The kappa statistic between RR and IF was only 0.23 (95% confidence interval [CI] = 0.15-0.32), indicating minimal agreement. The kappa statistic between SP and IF was 0.57 (95% = CI 0.46-0.68), indicating weak agreement. Furthermore, the kappa statistic between RR and SP was 0.36 (95% CI = 0.27-0.45), also indicating minimal agreement. CONCLUSIONS: In rTKA, there is weak agreement regarding component loosening between a radiologist's opinion of a preoperatively obtained bone scan and the surgeon's preoperative interpretation of clinical and radiographic data. While neither reliably accurately predicts what is found at the time of rTKA, the surgeon's preoperative interpretation is more closely correlated with actual IFs of component loosening.

Fracture of the insert cone of a polyethylene liner in a failed posterior-stabilized, rotating-platform total knee arthroplasty.

Failures unique to posterior cruciate-substituting total knee prostheses rarely include polyethylene post fractures but have been described. We report a case involving a fracture of the distal insert cone of a rotating-platform (RP) polyethylene liner in a primary total knee arthroplasty. This case highlights a 67-year-old male presenting with new-onset knee pain and recurrent effusions with osteolysis 11 years following placement of a posterior-stabilized, RP total knee arthroplasty. At the time of revision surgery, the polyethylene insert cone was found to be fractured just below the junction between cone and the body of the insert. Liner exchange, synovectomy, and osteolytic-defect curettage and cement packing were performed. One year following revision surgery, the patient is without pain and has returned to function without limitations. Clinicians must be aware of this possible failure with RP prostheses in the setting of pain with a stable knee, recurrent aseptic effusions, and osteolysis.

Are reinfusion drains safe to use with periarticular liposomal bupivacaine? An analysis of systemic bupivacaine toxicity.

BACKGROUND: Intraoperative periarticular injection (PAI) with local anesthetic is an important component of multimodal pain control in total joint arthroplasty (TJA). A potential risk of this practice is serum anesthetic toxicity resulting from the autotransfusion of blood collected from a reinfusion drain. The purpose of this study is to evaluate the levels of bupivacaine in blood collected in an autotransfusion system after use of a PAI in TJA. METHODS: In this prospective study, each TJA patient had an identical PAI consisting of 20 cc of liposomal bupivacaine, 30 cc of 0.25% bupivacaine with epinephrine, and 10 cc of normal saline. An autologous reinfusion drain was utilized in all patients. At 2 and 5 hours postoperatively, blood was collected from the autotransfusion canister and sent to the laboratory to quantify bupivacaine levels. The sums of these levels were compared to the lowest reported serum bupivacaine dose associated with toxicity (1.1 mg/kg). RESULTS: Eleven unilateral TJA patients were enrolled (6 total knee arthroplasties, 5 total hip arthroplasties). The average 2-hour serum bupivacaine level was 2.9 µg (range 0.8-5.6) while the average 5-hour serum bupivacaine level was 4.5 µg (range 0.4-10.0). The average sum of the 2-hour and 5-hour serum bupivacaine level was 5.6 µg (range 0.8-13.6). Each of the 11 patient samples were well below their minimum serum bupivacaine dose toxicity. CONCLUSIONS: Use of a reinfusion drain after PAI with liposomal bupivacaine in TJA appears safe, as bupivacaine levels in the autotransfused blood remains well below the reported minimum serum toxic dose. LEVEL OF EVIDENCE: IV.

Early Failure of Primary Total Hip Arthroplasty: Is Surgical Approach a Risk Factor?

BACKGROUND: In an era of innovation in surgical approaches for total hip arthroplasty (THA), there is concern for increasing trends of early failure. The purpose of this study is to evaluate the incidence of early failure of primary THA stratified by surgical approach. METHODS: A retrospective review was performed on consecutive primary THAs completed from 2007 to 2014 at a high-volume center. THAs were stratified by surgical approach. Only the direct anterior (DAA) and posterior approaches (PA) were included. The primary outcome measure was early revision (<5 years). Descriptive statistics were performed using SAS software. RESULTS: In total, 6894 primary THAs performed between 2007 and 2014 were included. Across 2431 DAA THAs and 4463 PA THAs, there were 103 revisions overall. There was no difference in the overall revision rate for DAA THAs (1.69%) compared to PA THAs (1.39%) (P = .33). The DAA had a higher rate of early revisions for femoral component loosening compared to the PA (P = .0003). About 35.7% of DAA THAs were revised for femoral loosening compared to 8% for the PA (P = .0003). Early failure by femoral loosening occurred more often via the DAA in Dorr A bone (P = .03). The PA had a higher incidence of revision for instability (P = .04). There was no difference in modes of failure with regards to time to failure, acetabular loosening, early periprosthetic fracture, or infection. CONCLUSION: The DAA had a higher incidence of femoral loosening while PA had a higher mode of failure due to instability. Overall revision rates were not statistically different between approaches.

Reoperation Rates Following Open-Door Cervical Laminoplasty.

BACKGROUND: Laminoplasty is a safe and effective procedure for multilevel degenerative cervical stenosis causing myelopathy, that allows for motion preservation. The purpose of this study was to determine the reoperation rate and associated risk factors after cervical laminoplasty. METHODS: We present a retrospective consecutive series of patients who underwent a laminoplasty procedure between January 1, 2005, and October 31, 2012, and had a minimum 2-year follow-up. Demographic data were collected and operative records were reviewed to determine the cervical levels involved in the laminoplasty procedure, any concomitant procedures, and estimated blood loss. Clinical records were reviewed and telephone interviews were conducted on those patients with less than 2-year in-person follow-up. Patients requiring reoperations and the reason for the reoperations were determined, as well as the incidence of postoperative C5 palsy. RESULTS: A total of 222 of 266 patients (83%) with a minimum 2-year follow-up had an average follow-up of 4.97 years. Overall, 26 patients underwent 30 reoperations (13.5%). A total of 15 patients underwent 16 reoperations (7.2%) in the acute postoperative period for infection requiring at least 1 irrigation and debridement, hardware-related issues, or posterior cervical wound issues. A total of 13 patients had 14 reoperations (6.3%) outside of the acute postoperative period for the development of a new radiculopathy, recurrent myelopathy, neurologic symptoms with a kyphotic deformity, or a posttraumatic focal kyphotic deformity. Patients who had a concomitant laminectomy demonstrated a significantly (P = .03) higher reoperation rate than those who did not. There were no other statistically significant associations. The C5 palsy rate was 8.1% (18 of 222). CONCLUSIONS: Although the preserved motion following laminoplasty may allow for the development of new neurologic symptoms, the reoperation rate continues to compare favorably with laminectomy and fusion and remains a reasonable option for the surgical management of multilevel cervical stenosis causing myelopathy. LEVEL OF EVIDENCE: 4.

Pain and Opioid Use After Total Shoulder Arthroplasty With Injectable Liposomal Bupivacaine Versus Interscalene Block.

Postoperative pain control is a significant concern after total shoulder arthroplasty. Injectable periarticular liposomal bupivacaine, which has been found to decrease opioid use after orthopedic procedures, has been proposed as a viable alternative to regional anesthesia. This study compared the efficacy of liposomal bupivacaine vs interscalene block among patients undergoing total shoulder arthroplasty. A retrospective review was conducted of 79 patients who underwent anatomic total shoulder arthroplasty performed by a single surgeon between January 2013 and April 2015. Patient demographics, in-hospital Numeric Pain Rating Scale (NPRS) score obtained at 12-hour intervals, length of stay, and total in-hospital morphine equivalents in both the bupivacaine (n=25) and block (n=44) groups were recorded. Differences in length of stay, morphine equivalents, and age were assessed with Wilcoxon tests. Sex differences were assessed with the chi-square test. Repeated measures analysis with least square means was used to assess longitudinal changes in NPRS scores. No significant differences were found between groups for sex (P=.89), age (P=.81), American Society of Anesthesiologists classification (P=.50), preoperative opioid use (P=.41), length of stay (P=.32), or morphine equivalents (P=.71). The average NPRS score in the first 12 hours was 3.01 for the bupivacaine group and 4.41 for the interscalene block group (P=.25). By 48 hours postoperatively, average NPRS scores were similar (P=.93) for the 2 groups, 4.90 for the bupivacaine group and 4.19 for the interscalene block group. The findings for this cohort of patients undergoing anatomic total shoulder arthroplasty showed no significant difference for pain scores, postoperative narcotic use, or length of stay with injectable liposomal bupivacaine vs interscalene block. [Orthopedics. 2017; 40(5):e806-e811.].

Limited Added Value of the Posterolateral Approach.

BACKGROUND: Posterolateral tibial plateau fractures (AO/OTA 41-B or 41-C) represent a minority of proximal tibia fractures. Numerous surgical approaches have been described, each with unique variations and limitations. The purpose of this study is to quantitatively and qualitatively compare the surface area and structures exposed by four surgical approaches to the posterolateral proximal tibia. METHODS: Four published surgical approaches-direct posterolateral (DPL), transfibular (TF), posteromedial (PM), and anterolateral (AL)-were performed on 10 fresh-frozen cadavers. Once each exposure was obtained, a ruler was placed in the surgical field and calibrated digital images obtained. Overall, 10 bony and soft tissue landmarks were identified and the surgeon's ability to see or touch each landmark was recorded sequentially for each exposure. RESULTS: An average of 3.9 ± 2.7 cm(2) of posterolateral proximal tibial cortex was exposed by the DPL approach with significantly more surface area exposed by the TF, PM, and AL approaches (p < 0.01). The AL and PM approaches revealed a significantly larger area of tibial metaphysis and, when used together, consistently exposed posterior metaphyseal and intra-articular structures. CONCLUSION: A combination of the AL and PM approaches allows comparable surgical exposure to the proximal tibial when compared with two posterolateral approaches. These approaches can be employed together for reduction and fixation of injuries to the posterolateral tibial plateau and allow direct evaluation of the articular surface. Dedicated posterolateral approaches should be reserved for certain clinical situations, including proximal tibiofibular joint fracture or dislocation.

Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection.

OBJECTIVE: To examine the association between antibiotic timing and deep infection of type III open tibia fractures. DESIGN: Retrospective prognostic study. SETTING: Level 1 Trauma Center. PATIENTS: The study population included 137 patients after exclusions for missing data (13), nonreconstructible limbs (9), and/or absence of 90-day outcome data (3). INTERVENTION: An observational study of antibiotic timing. MAIN OUTCOME MEASUREMENT: Deep infection within 90 days. RESULTS: Age, smoking, diabetes, injury severity score, type IIIA versus 3B/C injury, and time to surgical debridement were not associated with infection on univariate analysis. Greater than 5 days to wound coverage (P < 0.001) and greater than 66 minutes to antibiotics (P < 0.01) were univariate predictors of infection. Multivariate analysis found wound coverage beyond 5 days [odds ratio, 7.39; 95% confidence interval (CI), 2.33-23.45; P < 0.001] and antibiotics beyond 66 minutes (odds ratio, 3.78; 95% CI, 1.16-12.31; P = 0.03) independently predicted infection. Immediate antibiotics and early coverage limited the infection rate (1 of 36, 2.8%) relative to delay in either factor (6 of 59, 10.2%) or delay in both factors (17 of 42, 40.5%). CONCLUSIONS: Time from injury to antibiotics and to wound coverage independently predict infection of type III open tibia fractures. Both should be achieved as early as possible, with coverage being dependent on the condition of the wound. Given the relatively short therapeutic window for antibiotic prophylaxis (within an hour of injury), prehospital antibiotics may substantially improve outcomes for severe open fractures. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.