Surgical Approach Does Not Influence Instability Risk in Revision Total Hip Arthroplasty.

BACKGROUND: Although the direct anterior (DA) approach has increased in popularity for primary total hip arthroplasty (THA), there is limited evidence regarding its use for revision THA. It is unknown whether the dislocation benefit seen in the primary setting translates to revision cases. METHODS: This retrospective review compared the dislocation rates of revision THA performed through DA versus postero-lateral (PL) approaches at a single institution (2011 to 2021). Exclusion criteria included revision for instability, ≥ 2 prior revisions, approaches other than DA or PL, and placement of dual-mobility or constrained liners. There were 182 hips in 173 patients that met the inclusion criteria. The average follow-up was 6.5 years (range, 2 to 8 years). RESULTS: There was a trend toward more both-component revisions being performed through the PL approach. There were no differences in dislocation rates between the DA revision and PL revision cohorts, which were 8.1% (5 of 72) and 7.5% (9 of 120), respectively (P = .999). Dislocation trended lower when the revision approach was discordant from the primary approach compared to cases where primary and revision had a concordant approach (4.9 versus 8.5%), but this was not statistically significant (P = .740). No significant differences were found in return to operating room, 90-day emergency department visits, or 90-day readmissions. However, the length of stay was significantly shorter in patients who had DA revisions after a primary PL procedure (P = .021). CONCLUSIONS: Dislocation rates following revision THA did not differ between the DA and PL approaches irrespective of the primary approach. Surgeons should choose their revision approach based on their experience and the specific needs of the patient.

An Increase in Same-day Discharge After Total Joint Arthroplasty During the COVID-19 Pandemic Does Not Influence Patient Outcomes: A Retrospective Cohort Analysis.

Background: The coronavirus disease 2019 (COVID-19) pandemic caused major transitions in total joint arthroplasty (TJA), notably with the increased utilization of same-day discharge (SDD) pathways. This study assessed the effect of accelerated discharge pathways following the resumption of elective cases during the COVID-19 pandemic on SDD rates, adverse events, and characteristics associated with successful SDD following total hip and total knee arthroplasty. Methods: This retrospective study split patients into cohorts: TJA prior to COVID-19 (pre-COVID, July 2019-December 2019) and TJA following the resumption of elective surgeries (post-COVID, July 2020-December 2020). Patient characteristics such as age, sex, body mass index, American Society of Anesthesiologists score, and pertinent comorbidities were analyzed, and length of stay, 30-day emergency department (ED) visit rates, readmissions, and reoperations were compared. Results: A total of 1333 patients met inclusion criteria that were divided into pre-COVID (692) and post-COVID (641) cohorts. The pre-COVID group had a median age of 69 years (interquartile range 63-76), and the post-COVID group had a median age of 68 years (interquartile range 61-75) (P = .024). SDD increased from 0.1% to 28.9% (P < .001), and length of stay decreased from 1.3 days to 0.89 days (P < .001). There was no change in 30-day ED visits, readmissions, or reoperations (P = .817, P = .470, and P = .643, respectively). There was no difference in ED visits, readmissions, or reoperations in SDD patients. The odds of SDD were associated with age (P < .001, odds ratio [OR] = 0.94), body mass index (P = .006, OR = 0.95), male sex (P < .001, OR = 1.83), and history of tobacco use (P < .001, OR = 1.87). Conclusions: At our institution, the COVID-19 pandemic accelerated the utilization of SDD pathways without increasing ED visits, readmissions, or reoperations.

Dislocation rates following total hip arthroplasty via the direct anterior approach in a consecutive, non-selective cohort.

AIMS: Use of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased in recent years due to proposed benefits, including a lower risk of dislocation and improved early functional recovery. This study investigates the dislocation rate in a non-selective, consecutive cohort undergoing THA via the DAA without any exclusion or bias in patient selection based on habitus, deformity, age, sex, or fixation method. METHODS: We retrospectively reviewed all patients undergoing THA via the DAA between 2011 and 2017 at our institution. Primary outcome was dislocation at minimum two-year follow-up. Patients were stratified by demographic details and risk factors for dislocation, and an in-depth analysis of dislocations was performed. RESULTS: A total of 2,831 hips in 2,205 patients were included. Mean age was 64.9 years (24 to 96), mean BMI was 29.2 kg/m2 (15.1 to 53.8), and 1,595 patients (56.3%) were female. There were 11 dislocations within one year (0.38%) and 13 total dislocations at terminal follow-up (0.46%). Five dislocations required revision. The dislocation rate for surgeons who had completed their learning curve was 0.15% compared to 1.14% in those who had not. The cumulative periprosthetic infection and fracture rates were 0.53% and 0.67%, respectively. CONCLUSION: In a non-selective, consecutive cohort of patients undergoing THA via the DAA, the risk of dislocation is low, even among patients with risk factors for instability. Our data further suggest that the DAA can be safely used in all hip arthroplasty patients without an increased risk of wound complications, fracture, infection, or revision. The inclusion of seven surgeons increases the generalizability of these results. Cite this article: Bone Joint J 2021;103-B(7 Supple B):38-45.

Two-stage Treatment for Hip and Knee Periprosthetic Infections.

Two-stage exchange remains the standard of care for treatment of chronic periprosthetic infections in the United States. The strategy involves three steps; a resection arthroplasty with a thorough debridement and placement of a temporary spacer, an extended period of targeted antibiotics, and finally, a second definitive reconstruction procedure. The lengthy period of time between surgeries, where patients have diminished mobility, a long period of IV antibiotics and its considerable side effects, and the need for two large operations and hospitalizations places physiologic and emotional demands on patients and their families. A two-stage exchange has considerable morbidity and mortality, with significant attrition between stages. Nonetheless, it remains the gold standard for treatment of chronic periprosthetic infections, with good historic success rates. In this review, we outline its historical origins, surgical technique, outcomes and current research shaping two-stage exchanges. (Journal of Surgical Orthopaedic Advances 30(4):220-225, 2021).

A retrospective analysis of the use of intravenous dexamethasone for postoperative nausea and vomiting in total joint replacement.

BACKGROUND: Multimodal perioperative pain-management protocols have contributed to the success of elective total joint replacement in orthopedic surgery. General or neuraxial anesthesia for arthroplasty is accompanied by complications such as pruritis, nausea, and vomiting. Dexamethasone has been demonstrated to be a safe perioperative antiemetic. This study evaluates the benefit of low-dose intravenous dexamethasone used in the perioperative period to prevent postoperative nausea and vomiting. METHODS: Two scheduled doses of 8 mg of dexamethasone 12 hours apart after total hip arthroplasty or total knee arthroplasty were given to a dexamethasone group (n = 492) and were retrospectively compared with a no-dexamethasone group (n = 364) based on the use of antiemetics in the postoperative period. Frequency of antiemetic use in both groups was compared using a zero-inflated fixed-model Poisson distribution. Additional analysis included need for opioid analgesic, administration of diphenhydramine, and postoperative infection rates at 30 and 90 days. RESULTS: The dexamethasone group was found to have a significant reduction in need for the rescue antiemetic ondansetron (P = .00194). There was an associated reduction in length of stay for the treatment group (mean 1.83 days) relative to the control group (mean 2.17 days) (P < .001). There was no significant difference in postoperative infection rates at 30 or 90 days after arthroplasty. CONCLUSIONS: Dexamethasone is a safe adjunct to perioperative protocol that may reduce nausea, thus improving patient satisfaction. There is an associated reduction in length of stay that may reduce cost of hospitalization.

Evaluating and managing acetabular dysplasia in adolescents and young adults.

Hip dysplasia is a developmental deformity in which abnormal acetabular or proximal femoral growth causes structural instability of the hip joint due to inadequate bony coverage of the acetabulum over the femoral head. Skeletally mature adolescents or young adults with underlying acetabular dysplasia may present with activity-related groin or lateral hip pain and a limp. This article reviews the current understanding of the disease and better treatment options for correcting acetabular dysplasia in symptomatic adolescents and young adults before secondary osteoarthritis develops.

Previous failed hip arthroscopy negatively impacts early patient-reported outcomes of the periacetabular osteotomy: an ANCHOR Matched Cohort Study.

Surgical treatment of hip dysplasia by arthroscopic procedures remains controversial. The aim of this study was to compare outcomes of periacetabular osteotomy (PAO) after failed hip arthroscopy to a matched-control group without previous arthroscopy. Fifty-two patients who underwent PAO after failed hip arthroscopy were matched to two subjects without arthroscopy based on age, sex, BMI and radiographic severity. Pre- and post-operative patient self-reported outcomes and radiographic parameters were compared at minimum 1-year follow-up. Prior to PAO the failed hip arthroscopy group exhibited lower modified Harris hip scores (mHHS; 57 versus 62; P = 0.04), WOMAC (59.9 versus 66.3; P = 0.08), UCLA activity (5 versus 7; P = 0.001) and SF12 physical scores (34 versus 40; P = 0.001) compared with the non-arthroscopy group. At minimum 1-year follow-up, the failed hip arthroscopy group had lower mHHS (78 versus 87; P = 0.003); worse WOMAC (84.1 versus 90.8; P = 0.02) and SF-12 physical component (46 versus 50; P = 0.02) with similar UCLA (7 versus 8; P = 0.21) compared with the non-arthroscopy group. No differences were detected regarding radiographic parameters or in patient-reported outcomes from preoperative to follow up. PAO achieved the desired radiographic correction and significant improvement in pain and function after a failed previous hip arthroscopy, however, the patient-reported outcomes were inferior to those of PAO without previous failed arthroscopy.

Acetabular Component Position and the Risk of Dislocation Following Primary and Revision Total Hip Arthroplasty: A Matched Cohort Analysis.

BACKGROUND: Recently, the importance of acetabular component positioning in the Lewinnek "safe zone" in preventing prosthetic dislocation following total hip arthroplasty (THA) has been questioned. The purpose of this study was to determine the proportion of acetabular components within the Lewinnek safe zone between primary and revision THAs that have sustained a dislocation vs matched controls without a dislocation event. METHODS: This was a retrospective, institutional review board-approved investigation of THAs performed at our institution or referred to our institution between 1997 and 2013. Ninety-six primary THAs and 60 revision THAs that sustained a dislocation were included and matched 1:1 based on age, gender, and body mass index with nondislocated controls. Acetabular component inclination and anteversion were performed using Martell Hip Analysis Suite and compared between the 2 cohorts for both primary and revision THAs. RESULTS: The proportion of acetabular components within the safe zone for both inclination and anteversion was 23 of 96 (24%) in primary THA dislocators vs 48 of 96 (50%, P < .001) in controls. The proportion of acetabular components within the safe zone for both inclination and anteversion was 28 of 60 (47%) in revision THA dislocators vs 40 of 60 (66%, P = .03) in controls. CONCLUSION: Patients sustaining a dislocation following a primary or revision THA had acetabular components less frequently positioned within the safe zone compared to control patients. This study suggests acetabular component positioning remains an important variable in decreasing the risk of dislocation following primary and revision THA.

Contemporary Concepts in the Young Adult Hip Patient: Periacetabular Osteotomy for Hip Dysplasia.

The Bernese periacetabular osteotomy, as originally described by Dr. Reinhold Ganz, is an effective treatment for symptomatic acetabular dysplasia in the pre-arthritic young adult hip. This technique has experienced several recent modifications in an attempt to optimize the clinical outcomes of these patients. We will review the clinical presentation of acetabular dysplasia, indications for surgery, contemporary refinements in technique and clinical results following periacetabular osteotomy. In well-selected patients, this reconstructive osteotomy should be considered safe and effective in alleviating pain and improving hip function.

Complete Wear-Through of a Polyethylene Liner and Metal-Backed Acetabular Cup Resulting in a Unique Form of Catastrophic Total Hip Arthroplasty Failure: A Case Report.

CASE: We describe a case of total hip arthroplasty failure where a cobalt-chrome femoral head completely wore through the polyethylene liner and the titanium acetabular cup. The patient subsequently underwent revision total hip arthroplasty with acetabular revision and femoral head exchange. CONCLUSION: This case illustrates the natural history of catastrophic failure in a metal-on-polyethylene total hip arthroplasty design. If recognized earlier, this patient may have been a candidate for isolated liner and head exchange. Additionally, this case represents a unique complication in using mixed metals in total hip arthroplasty, where the harder cobalt-chrome femoral head wore completely through the much softer titanium component.

Improving outcomes for posterolateral knee injuries.

Until recently, the posterolateral corner of the knee was noted both for its complex anatomy and diagnostic challenges. To improve the understanding of the posterolateral knee, we completed a comprehensive and stepwise research program with a focus on five primary areas: (1) surgical approach and relevant anatomy; (2) diagnosis; (3) clinically relevant biomechanics; (4) natural history; and (5) surgical treatment. Based on this comprehensive research program, the diagnosis and outcomes following treatment of posterolateral knee injuries have been significantly improved comparing the preoperative state to the state of the knee at a minimum 2 year follow-up in the cases series presented here. © 2014 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 32:485-491, 2014.

Fibular collateral ligament anatomical reconstructions: a prospective outcomes study.

BACKGROUND: After the development and biomechanical validation of an anatomical fibular collateral ligament reconstruction using a semitendinosus graft, this technique has subsequently been applied clinically. HYPOTHESIS: An anatomical reconstruction of a grade III fibular collateral ligament tear using a semitendinosus graft restores the knee to near-normal lateral compartment stability and results in improved patient outcomes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A prospective study of 20 patients with an average age of 24 years (range, 16-45 years) who had an anatomical reconstruction of the fibular collateral ligament using a semitendinosus graft was performed. All patients were preoperatively and postoperatively evaluated with the modified Cincinnati and International Knee Documentation Committee (IKDC) subjective scoring systems, with the IKDC objective subscores for lateral and posterolateral knee stability and with varus stress radiographs. The patients were followed for an average of 2 years. RESULTS: Sixteen patients were available for follow-up. Six of the patients had an isolated fibular collateral ligament reconstruction. The average preoperative modified Cincinnati score was 28.2, and the average IKDC subjective score was 34.7. Postoperatively, there was a significant improvement of both the modified Cincinnati score (to 88.5) and the IKDC subjective outcome score (to 88.1). The Cincinnati component symptom and functional subscores were also evaluated. The average preoperative symptom subscore was 9.1 and the functional subscore was 19.1. Postoperatively, there was a significant improvement in both scores; symptom subscores improved to 43.0 and functional subscores improved to 45.5. Preoperative varus stress radiographs demonstrated an average differential of 3.9 mm (range, 2.5-6.2 mm) of lateral compartment gapping between the injured and noninjured knee. At an average of 2 years postoperatively, varus stress radiographs demonstrated an average side-to-side lateral compartment gap differential of -0.4 mm. CONCLUSION: An anatomical fibular collateral ligament reconstruction using a semitendinosus graft results in improved patient outcomes and near-normal lateral compartment stability in patients with grade III injuries of the fibular collateral ligament.

Intra-articular lateral femoral condyle fracture following an ACL revision reconstruction.

Lateral femoral condyle fractures following an ACL reconstruction are rare. To our knowledge, this is the first case report of a lateral femoral condyle fracture following a revision ACL reconstruction. The patient's fracture was intra-articular, had a significant amount of soft tissue damage, and was further complicated by a large defect involving the bone tunnel from the ACL revision reconstruction. The patient was treated with an open reduction and internal fixation and recovered well.

An in vitro analysis of an anatomical medial knee reconstruction.

BACKGROUND: An anatomical medial knee reconstruction has not been described in the literature. HYPOTHESIS: Knee stability and ligamentous load distribution would be restored to the native state with an anatomical medial knee reconstruction. STUDY DESIGN: Controlled laboratory study. METHODS: Ten nonpaired cadaveric knees were tested in the intact, superficial medial collateral ligament and posterior oblique ligament-sectioned, and anatomically reconstructed states. Each knee was tested at 0 degrees , 20 degrees , 30 degrees , 60 degrees , and 90 degrees of knee flexion with a 10-N.m valgus load, 5-N.m external and internal rotation torques, and 88-N anterior and posterior drawer loads. A 6 degrees of freedom electromagnetic motion tracking system measured angulation and displacement changes of the tibia with respect to the femur. Buckle transducers measured the loads on the intact and reconstructed proximal and distal divisions of the superficial medial collateral ligament and the posterior oblique ligament. RESULTS: A significant increase was found in valgus angulation and external rotation after sectioning the medial knee structures at all tested knee flexion angles. This was restored after an anatomical medial knee reconstruction. The authors also found a significant increase in internal rotation at 0 degrees , 20 degrees , 30 degrees , and 60 degrees of knee flexion after sectioning the medial knee structures, which was restored after the reconstruction. A significant increase in anterior translation was observed after sectioning the medial knee structures at 20 degrees , 30 degrees , 60 degrees , and 90 degrees of knee flexion. This increase in anterior translation was restored following the reconstruction at 20 degrees and 30 degrees of knee flexion, but was not restored at 60 degrees and 90 degrees . A small, but significant, increase in posterior translation was found after sectioning the medial knee structures at 0 degrees and 30 degrees of knee flexion, but this was not restored after the reconstruction. Overall, there were no clinically important differences in observed load on the ligaments when comparing the intact with the reconstructed states for valgus, external and internal rotation, and anterior and posterior drawer loads. Conclusion An anatomical medial knee reconstruction restores near-normal stability to a knee with a complete superficial medial collateral ligament and posterior oblique ligament injury, while avoiding overconstraint of the reconstructed ligament grafts. CLINICAL SIGNIFICANCE: This anatomical medial knee reconstruction technique provides native stability and ligament load distribution in patients with chronic or severe acute medial knee injuries.

Anatomy and biomechanics of the posterolateral aspect of the canine knee.

The purpose of this study was to describe the anatomy and characterize the biomechanics of the posterolateral aspect of the canine knee. Ten adult canine knees were each used for anatomy and biomechanical testing. Distances and motion limits were measured using a 6 degree-of-freedom electromagnetic tracking system. Canine knee dissection reproducibly identified structures present in the human posterolateral knee. The course and attachment sites of the fibular collateral ligament, popliteofibular ligament, and popliteus tendon were similar to human anatomy. Sequential sectioning of the fibular collateral ligament, popliteofibular ligament, and popliteus tendon all significantly increased varus translation at full extension, 60 degrees , and 90 degrees of knee flexion. Sectioning of the fibular collateral ligament significantly increased external rotation at flexion angles near full extension, while popliteus tendon sectioning also significantly increased external rotation at 90 degrees of knee flexion. Based on the fact that the anatomy of the fibular collateral ligament, popliteus tendon, popliteofibular ligament, and the biomechanical properties of the canine posterolateral knee are similar to the human knee, we believe the canine knee is a suitable model to study the natural history of posterolateral knee injuries. The canine model will also prove valuable in the validation of reconstruction techniques and studying the potential development of medial compartment osteoarthritis following posterolateral knee injuries.

Biomechanical analysis of an isolated fibular (lateral) collateral ligament reconstruction using an autogenous semitendinosus graft.

BACKGROUND: The fibular collateral ligament is the primary stabilizer to varus instability of the knee. Untreated fibular collateral ligament injuries can lead to residual knee instability and can increase the risk of concurrent cruciate ligament reconstruction graft failures. Anatomic reconstructions of the fibular collateral ligament have not been biomechanically validated. PURPOSE: To describe an anatomic fibular collateral ligament reconstruction using an autogenous semitendinosus graft and to test the hypothesis that using this reconstruction technique to treat an isolated fibular collateral ligament injury will restore the knee to near normal stability. STUDY DESIGN: Controlled laboratory study. METHODS: Ten nonpaired, fresh-frozen cadaveric knees were biomechanically subjected to a 10 N.m varus moment and 5 N.m external and internal rotation torques at 0 degrees, 15 degrees, 30 degrees, 60 degrees, and 90 degrees of knee flexion. Testing was performed with an intact and sectioned fibular collateral ligament, and also after an anatomic reconstruction of the fibular collateral ligament with an autogenous semitendinosus graft. Motion changes were assessed with a 6 degree of freedom electromagnetic motion analysis system. RESULTS: After sectioning, we found significant increases in varus rotation at 0 degrees, 15 degrees, 30 degrees, 60 degrees, and 90 degrees, external rotation at 60 degrees and 90 degrees, and internal rotation at 0 degrees, 15 degrees, 30 degrees, 60 degrees, and 90 degrees of knee flexion. After reconstruction, there were significant decreases in motion in varus rotation at 0 degrees, 15 degrees, 30 degrees, 60 degrees, and 90 degrees, external rotation at 60 degrees and 90 degrees, and internal rotation at 0 degrees, 15 degrees, and 30 degrees of knee flexion. In addition, we observed a full recovery of knee stability in varus rotation at 0 degrees, 60 degrees, and 90 degrees, external rotation at 60 degrees and 90 degrees, and internal rotation at 0 degrees and 30 degrees of knee flexion. CONCLUSION: An anatomic fibular collateral ligament reconstruction restores varus, external, and internal rotation to near normal stability in a knee with an isolated fibular collateral ligament injury. CLINICAL SIGNIFICANCE: An anatomic reconstruction of the fibular collateral ligament with an autogenous semitendinosus graft is a viable option to treat nonrepairable acute or chronic fibular collateral ligament tears in patients with varus instability.