Short-term Functional Outcomes and Complications of Custom Patellofemoral Arthroplasty.

Background: Patellofemoral arthroplasty (PFA) is a treatment option for isolated patellofemoral arthritis. Custom PFA is an innovative procedure utilizing patient-specific instrumentation. The purpose of this study is to evaluate short-term functional outcomes and complications of the custom PFA in treatment of isolated patellofemoral arthritis. Methods: A retrospective study was conducted to analyze patients who received a PFA operation from a single surgeon. Inclusion criteria were surgical patients from 2012 to 2018 who underwent PFA using a custom prosthesis implant. Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) and Lower Extremity Functional Scale (LEFS) were collected before and after surgery. Results: A total of 79 patients (94 knees) participated in the study; 55 (69.6%) were women. The median age was 57 at the time of index arthroplasty; 15 patients (30 knees) were bilateral. Follow-up rate was 94%. Median follow-up duration was 3.6 years (2-8.9). Overall prefunctional and postfunctional scores differed significantly for both KOOS, JR and LEFS. Postoperative scores increased for KOOS, JR by 27.5 points, and for LEFS, they increased 26.0 points; P < .001 for both. Complications included 6 reoperations (6.7%) related to PFA: 4 conversions (4.4%) to total knee arthroplasty at a median of 2.5 (1.5-3) years after the index procedure, one vastus medialis oblique advancement (1.1%) secondary to patellar maltracking, and one manipulation under anesthesia (1.1%). Conclusions: Custom PFA in patients with isolated patellofemoral arthritis showed good short-term functional outcomes and low revision rates with very few complications.

Short-Term Radiographic Evaluation of a Tri-Tapered Femoral Stem in Direct Anterior Total Hip Arthroplasty.

INTRODUCTION: Direct anterior approach (DAA) total hip arthroplasty (THA) has become increasingly popular, largely due to utilization of a true internervous and intermuscular plane. However, recent literature has demonstrated an increased rate of femoral implant subsidence with this approach. Hence, different femoral implants, such as the tri-tapered femoral stem, have been developed to facilitate proper component insertion and positioning to prevent this femoral subsidence. The purpose of this study was to evaluate the subsidence rate of a tri-tapered femoral stem implanted utilizing a DAA, and to determine if the proximal femoral bone quality affects the rate of subsidence. METHODS: A retrospective analysis of 155 consecutive primary THAs performed by a single surgeon was conducted. Age, gender, primary diagnosis, and radiographic measurements of each subject were recorded. Radiological evaluations, such as bone quality, femoral canal fill, and implant subsidence, were measured on standardized anteroposterior (AP) and frog-leg lateral radiographs of the hip at 6-week and 6-month postoperative follow-up evaluations. RESULTS: The average subsidence of femoral stems was 1.18 ± 0.8 mm. There was no statistical difference in the amount of subsidence based on diagnosis or proximal femora quality. The tri-tapered stem design consistently filled the proximal canal with an average of 91.9 ± 4.9% fill. Subsidence was not significantly associated with age, canal flare index (CFI), or experience of the surgeon. CONCLUSION: THA utilizing the DAA with a tri-tapered femoral stem can achieve consistent and reliable fit regardless of proximal femoral bone quality.

Urine Screening for Opioid and Illicit Drugs in the Total Joint Arthroplasty Population.

INTRODUCTION: Recent studies have shown an increase in post-operative orthopaedic complications associated with pre-operative opioid use. It is, therefore, important to know if patients use opioids before scheduled surgery. The purpose of this study was to determine if urine drug screening (UDS) is an effective screening tool for detecting opioid and illicit drug use prior to joint arthroplasty (JA) procedures. METHODS: This retrospective chart review was performed with IRB approval on 166 out of 172 consecutive patients in a community-based practice. All the patients had a pre-operative UDS prior to primary or revision JA by a fellowship trained orthopaedic surgeon between March 2016 and April 2017. Patient demographics documented opioid and illicit drug use, co-morbid diagnosis, and UDS results were collected from clinical charts. Statistical analysis was conducted using Pearson Chi-square, Fisher's exact, McNemar test, and t-tests with IBM SPSS Statistics, ver. 23. Significant differences were p < 0.05. RESULTS: Sixty-four of 166 patients (38.6%) tested positive for opioids. Among them, 55.0% (35/64) had no history of prescription opioid use. Significant differences were observed when comparing the test results of the UDS with the patient reported history of prescribed opioids (p = 0.001). CONCLUSION: With a significant number of patients testing positive for opioids without evidence of a previous prescription, UDS may be beneficial for initial risk assessment for patients undergoing JA procedures.

Postresurfacing periprosthetic femoral neck fractures: nonoperative treatment.

Femoral neck fractures after total hip resurfacing procedures occur infrequently but require immediate orthopedic intervention. Historically, they have been treated by conversion to traditional total hip arthroplasty. However, to the authors' knowledge, no treatment algorithm has ever been described. The authors have directly treated or consulted on 13 cases of periprosthetic femoral neck fractures after metal-on-metal hip resurfacing arthroplasties that were successfully treated nonoperatively: all fractures healed with protected weight bearing, producing excellent clinical results. Two cases are described in detail, and the authors propose a classification system that can assist the orthopedist in choosing the treatment regimen. Type I fractures are nondisplaced and should be initially treated nonoperatively with a course of protected weight bearing. If successful, the overall success of the resurfacing should not be compromised. Partially displaced, or type II, fractures may heal with nonoperative management. However, if the components have shifted, it may affect the long-term durability of the arthroplasty and eventually result in premature conversion to a traditional total hip replacement. Depending on the position of the components, it may also have an effect on the ion generation potential of the metal-on-metal articulation. This treatment pathway can be undertaken only with a full and detailed explanation of all of the possible complications and outcomes with the patient. Completely displaced, or type III, fractures require immediate conversion to total hip arthroplasty.

Lateral femoral cutaneous nerve impairment after direct anterior approach for total hip arthroplasty.

The anterior supine approach for total hip arthroplasty (THA) offers the advantage of operating through a true intravascular and intranervous plane, but it places the lateral femoral cutaneous nerve at risk. The purpose of this study was to identify the incidence of and impairment relating to injury of the lateral femoral cutaneous nerve. We performed a retrospective chart review of 81 hips undergoing anterior supine THA from November 2005 through May 2007 to determine operative time, estimated blood loss, fluoroscopic time, type of anesthesia used, intraoperative complications, and postoperative systemic and wound complications. Postoperative radiographs were evaluated for leg-length discrepancy, acetabular inclination and anteversion, and femoral stem position. Patients were reassessed at 6 weeks, 3 months, 6 months, 1 year, and 2 years. At each visit, patients were questioned about numbness or paresthesias in the distribution of the lateral femoral cutaneous nerve; if present, the patient outlined the area with a marking pen. This area was photographed, and data were collected. No hip had frank numbness; 12 hips (14.8%) had paresthesias. For those 12, symptoms resolved in 4 by 6 months, in 6 by 1 year, and in 10 (83.3%) by 2 years; 2 remained unresolved. No significant difference was found between patients with and without paresthesias or between patients with resolved or unresolved paresthesias. Impaired sensation did not appear to affect functional outcome or Harris Hip Score. Incision position, dissection plane, retractor placement, tension and soft tissue handling, and surgeon experience may affect incidence of injury to the lateral femoral cutaneous nerve.

Hip resurfacing through an anterolateral approach. Surgical description and early review.

BACKGROUND: Recently, metal-on-metal hip resurfacing has enjoyed a resurgence as an alternative to hip arthroplasty in properly selected patients. The purpose of the present study was to report the early results of hip resurfacing through an anterolateral approach and to describe the technique with modifications that have been made as experience with the procedure has increased. METHODS: A total of fifty-seven hip resurfacing procedures in fifty-three patients were performed by a single surgeon with use of the Cormet Hip Resurfacing system through an anterolateral approach. The results were assessed on the basis of Harris hip scores, a radiographic analysis, and an analysis of failures. RESULTS: After a mean duration of follow-up of thirty-eight months, the mean Harris hip score was 99 points. Fifty-five hips were in patients with normal function scores, and two were in patients who reported mild dysfunction. Fifty hips had no pain, five had slight pain, one had mild pain, and one had moderate pain. Three hips had a failure of resurfacing and required revision. Two failures were secondary to femoral neck fractures, and one was the result of debonding of the surface coating of the acetabular component. CONCLUSIONS: The early results associated with a new generation of hip resurfacing devices are promising. The anterolateral approach affords the surgeon excellent exposure with the advantage of increased hip stability and potentially improved vascular supply of the femoral head as compared with the posterior approach.

Effect of hospitalist consultation on treatment of osteoporosis in hip fracture patients.

The objective of this study was to determine if hospitalist consultation during admission for hip fracture results in improved treatment for osteoporosis. This was a retrospective chart review, carried out in a university-based academic hospital. Administrative discharge data was used to identify patients discharged between 1 September 1999 and 1 September 2001, discharged with the diagnosis of hip fracture. Eighty-two patient charts were reviewed after exclusion for traumatic and pathologic fractures. Treatment for osteoporosis consisted of medications recommended by the National Osteoporosis Foundation (NOF), including calcium (+/-vitamin D), estrogen, raloxifene, calcitonin, alendronate and risedronate. Osteoporosis treatment improvement was defined as the addition of a medication for osteoporosis that strengthened treatment. Twenty-nine percent of patients in our study received treatment for osteoporosis at the time of discharge from the hospitalization for hip fracture. While 20% received calcium, only 7% received a bisphosphonate. Twelve percent received improvement in osteoporosis treatment from admission to discharge. Those that received hospitalist consultation did not have a significant improvement in osteoporosis treatment (P=0.314), but had significantly more co-morbid illnesses and were significantly older than those receiving no consultation (P<0.05). Identification of osteoporosis as a medical problem was significantly associated with osteoporosis treatment (P<0.05). Potential barriers to hospitalist consultation's effect on osteoporosis treatment included patient age and co-morbidities. Further research is needed to identify and overcome barriers to effective osteoporosis treatment in patients with fractures.