A Smartwatch Paired With A Mobile Application Provides Postoperative Self-Directed Rehabilitation Without Compromising Total Knee Arthroplasty Outcomes: A Randomized Controlled Trial.

BACKGROUND: Self-directed rehabilitation (SDR) after total knee arthroplasty (TKA) has not been traditionally recommended. The purpose of this study was to determine if there was an impact on postoperative outcomes with the use of an SDR program after primary TKA. METHODS: In this prospective, randomized, multicenter, controlled trial, we paired a smartwatch with a mobile application, providing an SDR program after TKA. Three groups were examined in this level I study: (1) control group (formal physical therapy [PT]), (2) high exercise compliance group, and (3) low exercise compliance group. Patient-reported outcome measures (PROMs) of knee injury and osteoarthritis outcome scores, joint replacement (KOOS, JR), and EuroQol five-dimension five-level (EQ-5D-5L) along with range of motion (ROM) and manipulation rates were evaluated. RESULTS: Three hundred thirty-seven patients were enrolled in two groups with 184 in the control group and 153 in the study groups (90 in the high-compliance group and 63 in the low-compliance group). The KOOS, JR score was statistically lower in the low-compliance group in net change from preoperative scores at 3 months (P = .046) and 6 months (P = .032) than that in the control group; difference was noted at 6 months for the high-compliance group, P = .036. However, these did not meet the threshold of 8.02 units for KOOS JR minimal clinically important difference. No differences were seen in PROMs at other time intervals and in manipulation rates or ROM. CONCLUSION: Postoperative outcomes including manipulation under anesthesia, ROM, and PROMs were not different when a smartwatch paired with a self-directed PT mobile application was compared with traditional formal PT. Surgeons can consider this an appropriate alternative to traditional PT programs after TKA.

Prospective, Randomized, Surgeon-Blinded Comparison of Standard Magnification Assumption vs Magnification Marker Usage for Preoperative Templating in Total Hip Arthroplasty.

BACKGROUND: We undertook this prospective, randomized, surgeon-blinded study to compare the accuracy of using of a magnification marker on preoperative radiographs for templating vs using a standard 21% magnification. METHODS: One hundred consecutive total hip arthroplasties were randomized to preoperative templating using a 25-mm magnification marker (50 patients) or a standard 21% magnification (50 patients). Intraoperative data were collected regarding the actual and predicted size of the femoral and acetabular components. RESULTS: The 2 groups were found to be comparable with respect to body mass index (28.9 vs 27.9, P = .26) and gender (P = .69). In the magnification marker group, we predicted the femoral size within 1 size in 80% of the cases and the acetabular component in 94%. In the group of a standard 21% magnification, we predicted the femoral size within 1 size in 90% of the cases and the acetabular component in 96%. These proportions did not statistically differ (femur: χ2P = .16, odds ratio = 2.3, 95% confidence interval = 0.7-7.1; acetabulum: χ2P = .65, odds ratio = 1.5, 95% confidence interval = 0.3-9.6). CONCLUSION: We did not detect a statistically significant difference in accuracy by using one method over the other when comparing the accuracy of component size selection. As the use of the magnification marker adds to the time and expense of preoperative radiographic acquisition, we feel using a standard 21% magnification is an equally accurate technique.

Super Obesity Is an Independent Risk Factor for Complications After Primary Total Hip Arthroplasty.

BACKGROUND: Recent studies have reported higher postoperative complication rates in obese and morbidly obese patients undergoing total hip arthroplasty (THA). Less data are available regarding super-obese (body mass index [BMI] >50 kg/m2) patients. This study aims to quantify the risk of complications after THA in super-obese patients on a national scale and to put these risks in context by comparing them to patients of other BMI classes as well as those undergoing revision THA. METHODS: Utilizing a national insurance database, complication rates after THA in super-obese patients (n = 3244) were compared to nonobese, obese, and morbidly obese patients undergoing primary THA and all patients undergoing revision THA. A logistic regression analysis controlling for demographic and comorbidity variables was utilized to determine the independent effect of super obesity on complication rates after THA. RESULTS: Super-obese patients had significantly higher rates of most complications than nonobese, obese, morbidly obese, and revision THA patients, including venous thromboembolism, infection, blood transfusion, medical complications, dislocation, readmission, and revision THA. CONCLUSION: Super-obese patients (BMI >50 kg/m2) have higher rates of postoperative complications after THA than nonobese, obese, morbidly obese, and revision THA patients. Super obesity is an independent risk factor for increased rates of most postoperative complications including the need for early revision THA.

Acetabular Abduction and Dislocations in Direct Anterior vs Posterior Total Hip Arthroplasty: A Retrospective, Matched Cohort Study.

BACKGROUND: There is purported improvement in component positioning and hip stability with the use of direct anterior approach (DAA) total hip arthroplasty (THA). We sought to determine if there is a difference in acetabular component position or dislocation frequency between DAA and posterior THA. METHODS: One arthroplasty fellowship-trained surgeon introduced DAA THA into his practice. From the initiation of DAA in 4/2012-8/2015, this comparative series resulted in 66 DAA THAs. A matched cohort (age, gender, body mass index [BMI], and comorbidities) was then created for posterior THA, 66 hips. DAA THA used fluoroscopy with anterior capsular excision; posterior group used no image guidance and had capsular repair. Posterior group BMI was 27.8 and DAA group BMI was 27.6 (P = .36). Minimum 3-month follow-up occurred in both groups. RESULTS: Average acetabular abduction angle in the posterior group was 41.9° (range, 32°-60°; standard deviation [sdev], 6.24) and DAA group 43.8° (range, 30°-62°; sdev 6.9), P = .12. The percentage of outliers (outside Lewinnek safe zone, 30°-50°) was 9.1% (6 of 66) in posterior group and 13.6% (9 of 66) in DAA group. There were 2 anterior dislocations in the DAA THA group and 1 anterior dislocation in the posterior THA group, resulting in P = .56. The DAA dislocation frequency in this group was overall higher at 3.0% (2 of 66) compared with the matched posterior (1.5%, 1 of 66) and unmatched posterior larger series (.8%, 3 of 360). CONCLUSION: We demonstrated no observable difference in hip stability or acetabular abduction. This study provides realistic outcomes for surgeons implementing DAA THA into their practice.

Inaccuracies in the Use of Magnification Markers in Digital Hip Radiographs.

BACKGROUND: With the ubiquity of digital radiographs, the use of digital templating for arthroplasty has become commonplace. Although improved accuracy with digital radiographs and magnification markers is assumed, it has not been shown. QUESTIONS/PURPOSES: We wanted to (1) evaluate the accuracy of magnification markers in estimating the magnification of the true hip and (2) determine if the use of magnification markers improves on older techniques of assuming a magnification of 20% for all patients. METHODS: Between April 2013 and September 2013 we collected 100 AP pelvis radiographs of patients who had a THA prosthesis in situ and a magnification marker placed per the manufacturer's instructions. Radiographs seen during our standard radiographic review process, which met our inclusion criteria (AP pelvic view that included a well-positioned and observed magnification marker, and a prior total hip replacement with a known femoral head size), were included in the analysis. We then used OrthoView(TM) software program to calculate magnification of the radiograph using the magnification marker (measured magnification) and the femoral head of known size (true magnification). RESULTS: The mean true magnification using the femoral head was 21% (SD, 2%). The mean magnification using the marker was 15% (SD, 5%). The 95% CI for the mean difference between the two measurements was 6% to 7% (p < 0.001). The use of a magnification marker to estimate magnification at the level of the hip using standard radiographic techniques was shown in this study to routinely underestimate the magnification of the radiograph using an arthroplasty femoral head of known diameter as the reference. If we assume a magnification of 20%, this more closely approximated the true magnification routinely. With this assumption, we were within 2% magnification in 64 of the 100 hips and off by 4% or more in only four hips. In contrast, using the magnification marker we were within 2% of true magnification in only 20 hips and were off by 4% or more in 59 hips. CONCLUSION: We found the use of a magnification marker with digital radiographs for preoperative templating to be generally inaccurate, with a mean error of 6% and range from -5% to 15%. Additionally, these data suggest that the use of a magnification marker while taking preoperative radiographs of the hip may be unnecessary, as simply setting the software to assume a 20% magnification actually was more accurate. LEVEL OF EVIDENCE: Level III, diagnostic study.

Modular Versus Nonmodular Femoral Necks for Primary Total Hip Arthroplasty.

In total hip arthroplasty (THA), proximal femoral neck stem modularity (PFNSM) has theoretical advantages over nonmodular stems, including the ability to more closely reconstruct anatomy and improve stability. However, risks of metallosis and breakage at the junction must be considered. In this study, we compared the head centers of a modular neck system with that of its nonmodular counterpart. Of 463 primary THAs with a modular stem, 261 (56%) had a head center equivalent to that of its nonmodular counterpart, and an additional 132 (29%) had a head center within 4 mm in length and 2 mm of offset. Thus, only 70 stems (15%) had a head center that was more than 4 mm in length and more than 2 mm in offset different from the nonmodular stem. Only 12 stems had a verted neck. These findings suggest that, in a majority of primary THAs, use of a modular stem results in head center positions also achievable with a nonmodular stem. Given the risks of modularity, PFNSM should be used with caution. We recommend PFNSM in cases that cannot be reconstructed with the nonmodular option.

Failure of total hip arthroplasty secondary to infection caused by Brucella abortus and the risk of transmission to operative staff.

Infection of total knee or hip arthroplasty by Brucella species is a rare complication. We describe the case of a failed hip replacement secondary to infection by Brucella abortus, as well as presentation, treatment course, and 2-year follow-up. In addition, we review the literature for features of periprosthetic Brucella species infections, and we describe the common exposures, clinical presentations, preoperative evaluation, and treatments used in the reported cases. Furthermore, we discuss the risk of transmission to operating room personnel and the appropriate preventative measures to avoid transmission.

Primary Total Knee Arthroplasty in Super-obese Patients: Dramatically Higher Postoperative Complication Rates Even Compared to Revision Surgery.

This study utilized a national database to evaluate 90 day postoperative complication rates after total knee arthroplasty (TKA) in super obese (BMI > 50 kg/m(2)) patients (n = 7666) compared to non-obese patients (n = 1,212,793), obese patients (n = 291,914), morbidly obese patients (n = 169,308) and revision TKA patients (n = 28,812). Super obese patients had significantly higher rates of local and systemic complications compared to all other BMI groups as well as those undergoing revision TKA with higher rates of venous thromboembolism (VTE), infection, and medical complications. Super obesity is associated with dramatically increased rates of postoperative complications after TKA compared to non-obese, obese, and morbidly obese patients as well as those undergoing revision TKA.

Lessons learned from managing a prospective, private practice joint replacement registry: a 25-year experience.

BACKGROUND: In 1984, we developed a private practice joint replacement registry (JRR) to prospectively follow patients undergoing THA and TKA to assess clinical and radiographic outcomes, complications, and implant survival. Little has been reported in the literature regarding management of this type of database, and it is unclear whether and how the information can be useful for addressing longer-term questions. QUESTIONS/PURPOSES: We answered the following questions: (1) What is the rate of followup for THA and TKA in our JRR? (2) What factors affect followup? (3) How successful is this JRR model in capturing data and what areas of improvement are identified? And (4) what costs are associated with maintaining this JRR? METHODS: We collected clinical data on all 12,047 patients having primary THA and TKA since 1984. Clinical and radiographic data were collected at routine followup intervals and entered into a prospective database. We searched this database to assess the rate of successful followup and data collection and to compare the effect of patient variables on followup. Costs related to database management were evaluated. RESULTS: Followup was poor at every time interval after surgery, with a tendency for worsening over time. Patients with a complication and those younger than 70 years tended to followup with greater frequency. There were difficulties with data capture and substantial expenses related to managing the database. CONCLUSIONS: Our findings highlight the difficulties in managing a JRR. Followup is poor and data collection is often incomplete. Newer technologies that allow easier tracking of patients and facilitate data capture may streamline this process and control costs.

Total hip arthroplasty after failed internal fixation of proximal femoral fractures.

Between February 1987 and October 2008, we performed 102 total hip arthroplasties (THAs) after failed internal fixation of a prior hip fracture. There were 39 intertrochanteric fractures and 63 femoral neck fractures. Etiology of failure included 35 cases of osteonecrosis, 32 cases of arthritis, 25 cases of early failure of fixation, and 10 cases of nonunion. There were 12 patients who had early surgical complications related to the procedure (11.8%, 12/102). These included 5 patients who had dislocations (4.9%), 4 periprosthetic fractures (3.9%), 2 hematomas (2.0%), and 1 infection (1%). Of these 102 THAs, 50 were available for at least 2 years of follow-up (mean, 3.2 years). At a minimum 2-year follow-up, THA after failed internal fixation of hip fracture in these patients was clinically successful with an elevated risk of periprosthetic fracture and dislocation.

Cost comparison of cementless versus cemented hemiarthroplasty for displaced femoral neck fractures.

Hip hemiarthroplasties are frequently performed for displaced femoral neck fractures. The purpose of this study was to identify the costs associated with cementless and cemented hemiarthroplasties, compare operative times, and identify complications. The hypothesis was that cementless hemiarthroplasties cost less than cemented hemiarthroplasties, require less operative time, and have fewer perioperative complications. A retrospective review was conducted of 2 surgeons' patients admitted for displaced femoral neck fractures between 2006 and 2010. Group 1 included 45 patients who underwent monopolar hemiarthroplasties with cementless femoral components via a standard posterior approach by a single surgeon. Group 2 included 49 patients who underwent monopolar hemiarthroplasties with cemented femoral components via a modified lateral approach by a single surgeon. Surgical and anesthesia times and the cost of implants and accessories were recorded. The cost for cementless components was $3275.60 (femoral stem, $2800; monopolar head, $400; sleeve, $75.60), whereas the cost of cemented components was $3694.47 (femoral stem, $1800; monopolar head, $400; sleeve, $75.60, 3 Simplex with tobramycin cement packets, $1221; cement mixer/irrigator with tip/centralizer and plug/pressurizer, $197.87), a cost savings of 12.7% ($418.87). Operative time was significantly reduced in group 1 vs group 2 (mean, 32.9 vs 56.1 minutes, respectively; P<.01). Anesthesia time was also significantly reduced in group 1 (mean, 82.3 vs 102.9 minutes, respectively; P<.01). The difference in mean anesthetic times demonstrates an overall cost savings of 18.6%, or $1161.30. No difference in complications was noted between the groups perioperatively. Regional cost variances, vendor-hospital contracts, and surgeons' operative times are factors that may influence cost savings. This study demonstrates significantly lower operative and anesthetic times and observable cost savings with cementless femoral implants.

Mobile-bearing total knee arthroplasty: a meta-analysis.

An extensive database search was completed to perform a meta-analysis of outcomes of mobile-bearing total knee arthroplasty. Nineteen manuscripts encompassing 3506 total knee arthroplasty met criteria for analysis (average follow-up, 8.6 years). Data were subdivided based on design type and included rotating platform, meniscal bearing, and anterior-posterior glide-rotation subgroups. Fifteen-year survivorship of rotating platform designs (96.4%) was greater than meniscal bearing implants (86.5%). Mean component loosening (0.33%) and bearing instability (<1%) for all subgroups were uncommon. Implants placed prior to 1995 exhibited higher rates of bearing complications (1.6% vs 0.1%). Excellent results were obtained with mobile-bearing TKA over 2 decades. Loosening and bearing instability were uncommon. Bearing complications lessened after 1995, possibly secondary to improved surgical technique.

Common errors in the execution of preoperative templating for primary total hip arthroplasty.

We reviewed 75 primary total hip arthroplasty preoperative and postoperative radiographs and recorded limb length discrepancy, change in femoral offset, acetabular position, neck cut, and femoral component positioning. Interobturator line, as a technique to measure preoperative limb length discrepancy, had the least amount of variance when compared with interteardrop and intertuberosity lines (Levene test, P = .0527). The most common error in execution of preoperative templating was excessive limb lengthening (mean, 3.52 mm), primarily due to inferior acetabular cup positioning (Pearson correlation coefficient, P = .036). Incomplete medialization of the acetabular component contributed the most to offset discrepancy. The most common errors in the execution of preoperative templating resulted in excessive limb lengthening and increased offset. Identifying these errors can lead to more accurate templating techniques and improved intraoperative execution.

Single-leg-stance (flamingo) radiographs to assess pelvic instability: how much motion is normal?

BACKGROUND: Chronic pelvic instability is a relatively uncommon cause of pelvic and low-back pain. Patients present with feelings of instability and mechanical symptoms. Static radiographs are often inadequate to detect abnormal relative motion between the hemipelves consistent with chronic pelvic instability; dynamic views of the pelvis are required. We assessed the amount of physiologic motion present at the pubic symphysis in normal adult men and nulliparous and multiparous women with alternating-single-leg-stance radiographs. METHODS: Forty-five asymptomatic adult volunteers (fifteen in each group) were evaluated with a standing anteroposterior pelvic radiograph as well as with anteroposterior pelvic radiographs made with the subjects assuming both right and left single-leg stance. The subjects completed a questionnaire to determine their eligibility for participation in the study, and an examination was performed to exclude certain physical anomalies that might alter the radiographic findings. RESULTS: The mean total translation (and standard deviation) at the pubic symphysis, as measured by three blinded observers, was 1.4 +/- 1.0, 1.6 +/- 0.8, and 3.1 +/- 1.5 mm for the men, nulliparous women, and multiparous women, respectively. With the numbers available, we found no significant difference between the translation in the men and that in the nulliparous women (p = 0.63). The multiparous women had significantly more translation than did either the nulliparous women (p = 0.002) or the men (p = 0.0005). There was a significant positive association between the number of pregnancies and the total translation (p < 0.0001). CONCLUSIONS: The use of anteroposterior pelvic radiographs made with the subject alternating between right and left single-leg stance demonstrated, with high interobserver reliability, that multiparous women had a significantly different physiologic range of pubic translation as compared with men and nulliparous women. The ranges of physiologic motion at the pubic symphysis measured on the single-leg-stance radiographs in this study can be used to identify pathologic amounts of motion at this site. CLINICAL RELEVANCE: This investigation suggests that up to 5 mm of physiologic motion can occur at the pubic symphysis in asymptomatic individuals, as demonstrated by alternating-single-leg-stance radiographs.

Comparison of locked volar plating versus pinning and external fixation in the treatment of unstable intraarticular distal radius fractures.

INTRODUCTION: We retrospectively compared the outcomes of open reduction and internal fixation (ORIF) with volar locking plate versus standard external fixation and percutaneous pinning in treating similar unstable distal radius fractures with a minimum 2-year follow-up. METHODS: The ORIF group included 41 patients with an average follow-up of 29 months. The external fixation group comprised 14 patients with an average follow-up of 33 months. Average age at presentation was 45 years in the external fixation group and 48 years in the ORIF group. The male/female ratios were 16:25 among the ORIF group and 6:8 in the external fixation group. The two groups were compared for clinical and functional outcomes measured by the disabilities of the arm, shoulder, and hand (DASH) score. Pain scores were similar. Radiographic measurements were also evaluated between groups. RESULTS: Final ranges of motion and grip strengths were similar between the two groups. The mean DASH score of the locked volar plate group was 9 compared to 23 for the external fixation group. Radiographically, volar tilt and radial length were significantly better in the patients treated with ORIF. The ORIF group required less therapy visits. No complications occurred in the locked volar plate group whereas two patients had pin tract infections and one had prolonged finger stiffness in the external fixation group. CONCLUSION: Locked volar plating compares favorably to external fixation and pinning for amenable fracture patterns. Whereas grip and range-of-motion data were similar, DASH scores, frequency of rehabilitation, and some radiographic parameters were superior in patients treated with ORIF.

Metal-on-metal total hip arthroplasty.

Although metal-on-metal total hip arthroplasty (MOM THA) has been used for over 3 decades, substantial improvements in manufacturing and design have led to improved durability with modern implants. Reported advantages of the use of MOM THA include very low wear and subsequent osteolysis, increased range of motion to impingement secondary to the availability of larger diameter femoral heads, and the potential to monitor implant performance by serial assessment of metal ion levels. Clinical results of both first-generation and second-generation MOM THA have revealed good survivorship and a low incidence of osteolysis. Although the advantages of low wear and increased range of motion have made MOM THA an attractive bearing surface option, more widespread use of MOM bearing surfaces has been tempered with concern for increased metal ion levels and hypersensitivity reactions.

Comprehensive morphologic evaluation of the hip in patients with symptomatic labral tear.

A torn acetabular labrum is a well-documented source of hip pain, but the mechanism of injury is debated because the relationship between the bone morphology and labral tears is poorly understood. We compared hips with and without labral abnormalities to determine the relative incidence of morphologic abnormalities. The study group consisted of patients with a labral tear confirmed by arthroscopy or arthrotomy at the time of open débridement or periacetabular osteotomy. We compared the affected hip with the contralateral, unaffected hip to ascertain signs of hip dysplasia and impingement. We observed differences in the center edge angle, acetabular depth to width index, acetabular index of elevation, femoral head extrusion, lateral and superior subluxation, Sharp's angle, peak to edge distance, and acetabular retroversion. Similar differences occurred in the subgroup analyses. Symptomatic labral tears correlated with abnormal hip morphology as reflected by radiographic measurements of dysplasia and impingement. This relationship occurred in patients with hip dysplasia and patients without obvious femoral head uncovering. Our findings suggest abnormal hip morphology may be a risk factor for labral tears.

Stacking of a dermal regeneration template for reconstruction of a soft-tissue defect after tumor excision from the palm of the hand: a case report.

Excision of tumors from the hand often leaves tissue defects with exposed tendons or neurovascular structures that require coverage. Various types of free and pedicled grafts have been described for use in these situations. We present a patient who had a tumor excision in the hand followed by wound coverage with a stacked dermal regeneration template. A 50-year-old man presented with a mass over the palm of the hand. He had an incisional biopsy procedure, the results of which suggested malignancy. He then had wide excision with planned temporary skin coverage with a dermal regeneration template. The dermal template incorporated nicely. With adequate skin coverage the palmar defect still was substantial in terms of depth. This was raised with layering or stacking of the template followed by a split-thickness skin graft. Excellent wound healing and coverage of the defect ultimately were achieved. Additionally the patient went on to obtain full range of motion. Stacking of a dermal regeneration template coupled with split-thickness skin grafting was used to fill a soft-tissue defect over the median and nerve and flexor tendons after wide tumor excision.