Ankylosing spondylitis in patients undergoing total hip arthroplasty increases the risk of medical and implant-related complications: a case control analysis.

INTRODUCTION: Ankylosing spondylitis (AS) is an inflammatory spondyloarthropathy, often involving the spine and sacroiliac joints. Total hip arthroplasty (THA) has been shown to be effective in improving pain and function in patients with AS with hip involvement. However, extraskeletal manifestations and altered mechanics in those with AS leads to increased complications. Thus, the aims of this study were to assess the effects that AS has on medical and implant complications, falls, length of stay, and readmissions following THA. METHODS: A retrospective review of the Mariner private insurance claims database was conducted from 2010 to 2020. All cases of THA and those with AS were identified using Current Procedural Terminology, and International Classification of Disease 9th and 10th revision codes. Patients who underwent THA with a diagnosis of AS were matched to non-AS patients 1:5 based on demographic and comorbidity profiles. 90-day medical complications, falls, and readmission rates, as well as 2-year implant complications were compared between cohorts. RESULTS: A total of 6509 AS patients were matched to 32,489 control patients. The AS group had significantly higher rates of myocardial infarction, cerebrovascular accident, deep vein thrombosis, pulmonary embolism, urinary tract infection, wound complications, acute kidney injury, pneumonia, sepsis, transfusions, and falls when compared to the control group. The AS group had significantly higher rates of prosthetic joint infection, dislocation, mechanical loosening, and periprosthetic fracture (all p < 0.0001). Likewise, mean length of stay and readmissions were significantly greater in the AS group. CONCLUSIONS: Ankylosing spondylitis in patients undergoing THA is associated with significant risk of medical and implant complications, as well as fall risk, length of stay, and readmission rates. These findings may allow orthopaedic surgeons to be more attentive in identifying those patients at risk and allow for more educated patient counseling and perioperative planning.

Body Mass Index is Not an Appropriate Proxy for the Condition of Peri-Incisional Adiposity in Primary Total Joint Arthroplasty Patients.

BACKGROUND: The American Academy of Orthopaedic Surgeons (AAOS) defined the acceptable threshold for elective safe surgery as a body mass index (BMI) under 40 due to the increased risk of complications. A consequence of this recommendation has been a hard cutoff based on BMI, which restricts access to care for an increasingly large and diverse population. There is an improved understanding that excess adipose tissue confers additional risk for postoperative complications, including infection, through mechanical and physiologic mechanisms. But it is unclear if BMI is an accurate indicator of adiposity in total joint arthroplasty (TJA) patients and, thus, whether BMI is capturing clinically relevant information in obese patients. Our objective was to determine the relationship between peri-incisional adiposity (PIA) and BMI in a consecutive series of diverse primary TJA patients. METHODS: A consecutive series of patients indicated for primary TJA were preoperatively evaluated. For each patient, the following variables were collected: BMI, and measures of peri-incisional adiposity (PIA) on radiographs and ultrasounds. RESULTS: In THA patients (N = 99), Pearson's correlation coefficient (r) = 0.436, which indicates a moderate correlation between BMI and adiposity. In TKA patients (N = 271), r = 0.395 for femoral PIA (FPIA) and r = 0.249 for tibial PIA (TPIA), which indicates a weak correlation between BMI and adiposity measured on radiography. In TKA patients, r = 0.560 for FPIA and r = 0.544 for TPIA, which indicates a moderate correlation between BMI and adiposity measured on ultrasound. CONCLUSION: Quantification of obesity has become common practice in the preoperative evaluation of primary TJA patients. The intent is to determine the magnitude of adipose tissue, which is one of the main drivers of postoperative complications in obesity. The BMI is ubiquitously used as a proxy for obesity due to its simplicity of attainment and calculation. We report that BMI has a weak to moderate association with peri-incisional adiposity in this population. These findings indicate that BMI may not accurately represent the condition of peri-incisional adipose tissue and, thus, is not capturing the relevant obesity data for preoperative risk stratification in primary total joint arthroplasty patients.

Dual-mobility with modular components for primary total hip arthroplasty in bilateral bony ankylosis of the hips: A case report.

INTRODUCTION AND IMPORTANCE: Primary total hip arthroplasty (THA) is a procedure performed in the United States for a variety of indications, with operation rates slated to increase over 275 % by 2040 when compared to 2014 (Thilak et al., 2015). Dual-mobility (DM) implants have gained popularity in the United States since gaining approval in the early 2010s (Heckmann et al., 2020). It has been well reported that DM implants decrease the risk of dislocation after primary and revision THA (Vielpeau et al., 2011; Donovan et al., 2022; Heifner et al., 2023; Foissey et al., 2023; Schmidt et al., 2020; Neri et al., 2019). CASE PRESENTATION: We present the case of a 33-year-old male with a suspected ankylosing spondylitis (AS) diagnosis and bilateral bony ankylosis of the hips who underwent staged THA with modular dual-mobility (MDM) implants. At one year post-operatively, the patient is walking without the use of an assistive device and reports a VAS pain score of 0 at rest and 2 with activity and HHS of 90. CLINICAL DISCUSSION: Implant selection is important in this patient population due to the increased risk of dislocation. Contemporary reports reveal MDM implants have demonstrated a substantial reduction in dislocation risk compared to fixed-bearing implants in patients with a high risk of dislocation. We opted to place the acetabular component inside the safe zone to improve stability and use the dual-mobility prosthesis to achieve our desired range of motion. CONCLUSION: The improved stability of DM implants allows for a greater range of acetabular positions in patients who have a highly unpredictable functional outcome at the time of surgery. Our preliminary results contribute to the growing list of indications for MDM total hip arthroplasty.

Planovalgus Foot Deformity in Patients Undergoing Total Hip Arthroplasty Is Associated With Increased Risk of Falls, Implant-Related Complications, and Revisions: A Case-Control Analysis.

BACKGROUND: Pes planus occurs due to the loss of the longitudinal arch of the foot, resulting in altered gait mechanics. This may lead to increased complications following total hip arthroplasty (THA). Thus, the aim of this study was to assess the effects that pes planus has on rates of falls, implant complications, fall-related injuries, and times to revision among THA patients. METHODS: A retrospective review of a private insurance claims database was conducted from 2010 to 2021. Patients who had a diagnosis of congenital or acquired pes planus and cases of THA were identified. Patients undergoing THA with a diagnosis of pes planus were matched to control patients 1:5 based on age, sex, and comorbidity profiles. Logistic regression was utilized to assess for differences in complication rates. RESULTS: A total of 3,622 pes planus patients were matched to 18,094 control patients. The pes planus group had significantly higher rates of falls than the control group (6.93 versus 2.97%, OR [odds ratio]: 2.43; CI [confidence interval]: 2.09 to 2.84; P < .001). Pes planus patients also had significantly greater odds of dislocation (OR: 1.89; CI: 1.58 to 2.27; P < .001), mechanical loosening (OR: 2.43; CI: 2.09 to 2.84; P = .019), and periprosthetic fracture (OR: 2.43; CI: 2.09 to 2.84; P < .001). The pes planus group had significantly greater rates of proximal humerus fractures (P = .008), but no difference was seen in distal radius fractures (P = .102). The time to revision was significantly shorter in the pes planus group (190 versus 554 days, P < .001). CONCLUSIONS: Pes planus in patients undergoing THA is associated with increased risk of complications and faster time to revision. These findings may allow orthopaedic surgeons to identify those patients at risk and allow for more educated patient counseling and operative planning.

Leg length discrepancy before total knee arthroplasty is associated with increased complications and earlier time to revision.

INTRODUCTION: Leg length discrepancy (LLD) following total knee arthroplasty (TKA) is a common complaint, leading to decreased patient satisfaction. However, the effect of LLD diagnosis prior to TKA on outcomes and complications is not well defined. Thus, this study aimed to assess the effects that LLD has on rates of falls and implant complications, length of stay and readmissions, and implant survivorship following TKA. METHODS: A retrospective review of a private insurance claims database was conducted from 2010 to 2021. All cases of TKA and those with a diagnosis of leg length discrepancy were identified. Patients undergoing TKA with a diagnosis of LLD were matched to control patients 1:5 based on demographic and comorbidity profiles. Two-year fall rates and implant complications, lengths of stay, 90-day readmissions, and time to revision were compared between cohorts. RESULTS: A total of 1,378 LLD patients were matched to 6,889 control patients. The LLD group had significantly higher rates of falls, dislocation, mechanical loosening, periprosthetic fracture, and fibrosis when compared to the control group (all P < 0.01). Additionally, mean length of stay was significantly greater in the LLD group (4.9 days vs. 3.0 days, P < 0.001). There was no significant difference in 90-day readmission rates between groups (P = 0.178). Time to revision was significantly shorter in the LLD group (392 days vs. 928 days, P < 0.001). CONCLUSIONS: Leg length discrepancy in patients undergoing TKA was associated with significantly increased fall risk, rates of implant complications, length of stay, and faster time to revision. The findings of this study may allow orthopedic surgeons to identify those patients at risk and allow for more educated patient counseling and operative planning. LEVEL OF EVIDENCE: III, retrospective case-control study.

Immediate Postoperative Zolpidem Use Increases Risk of Falls and Implant Complication Rates Following Total Hip Arthroplasty: A Retrospective Case-Control Analysis.

BACKGROUND: Zolpidem is the most widely used hypnotic in the United States and has known side effects. However, the morbidity of zolpidem use following total hip arthroplasty (THA) is not well-defined. Thus, the aim of this study was to assess the effects that zolpidem use has on medical and implant complications, falls, lengths of stay, and medical utilizations following THA. METHODS: A retrospective query of a nationwide insurance claims database was conducted from 2010 to 2020. All cases of THA and hypnotic use were identified using procedural and national drug codes. Patients who were prescribed zolpidem within 90 days of surgery were matched to hypnotic naive patients 1:5 based on demographic and comorbidity profiles. The 90-day medical complications, falls, fragility fractures, costs, and readmission rates, as well as 2-year implant complications were compared between cohorts. A total of 50,328 zolpidem patients were matched to 251,286 hypnotic naive patients. RESULTS: The zolpidem group had significantly higher rates of medical complications, falls, and fragility fractures when compared to the hypnotic-naive group. The zolpidem group had significantly higher rates of dislocation, mechanical loosening, and periprosthetic fracture. Likewise, healthcare utilization was significantly greater in the zolpidem group. CONCLUSION: Zolpidem use following THA is associated with significant risk of medical and implant complications, as well as fall risks, increased costs, lengths of stay, and readmissions. The findings of this study may affect discussions between orthopaedic surgeons and their patients on the benefits of sleep quality in their recovery versus the incurred risks of zolpidem use. LEVEL OF EVIDENCE: III, retrospective case-control study.

Local adiposity may be a more reliable predictor for infection than body mass index following total knee arthroplasty: a systematic review.

PURPOSE: Improved understanding of the factors that predispose TKA patients to infection has considerable economic and medical impact. BMI is commonly used as a proxy for obesity to determine the risk of postoperative infection. However, this metric appears to be fraught with inconsistency in this application. BMI is a simple calculation which provides general insight into body habitus. But it fails to account for anatomic distribution of adipose tissue and the proportion of the mass that is skeletal muscle. Our objective was to review the literature to determine if local adiposity was more predictive than BMI for infection following TKA. METHODS: A database search was performed for the following PICO (Population, Intervention, Comparison, and Outcome) characteristics: local measurements of adiposity (defined as soft tissue thickness or fat thickness or soft tissue envelope at the knee) in patients over 18 years of age treated with total knee arthroplasty used to determine the relationship between local adiposity and the risk of infection (defined as prosthetic joint infection or wound complication or surgical site infection). Quality was assessed using the GRADE framework and bias was assessed using ROBINS-I . RESULTS: Six articles (N=7081) met the inclusion criteria. Four of the six articles determined that adiposity was more associated with or was a better predictor for infection risk than BMI. One of the six articles concluded that increased adiposity was protective for short term infection and that BMI was not associated with the outcome of interest. One of the six articles determined that BMI was more strongly associated with PJI risk than soft tissue thickness. CONCLUSION: The use of adiposity as a proxy for obesity in preoperative evaluation of TKA patients is an emerging concept. Although limited by heterogeneity, the current literature suggests that local adiposity may be a more reliable predictor for infection than BMI following primary TKA. LEVEL OF EVIDENCE: IV systematic review.

Local Soft-Tissue Thickness vs. Body Mass Index as Predictors of Complications After Total Knee or Hip Arthroplasty: A Literature Review.

¼ Body mass index (BMI) is a nonspecific measure of general fat composition that demonstrates little conclusive or definitive association with surgical site complications after total knee and total hip arthroplasty.¼ Quantifying soft-tissue thickness (STT) around the joint of interest has shown positive correlations with complications and is arguably a better predictor than BMI.¼ In this literature review, 14 articles (7 discussing hips and 7 discussing knees) discussing the association of STT, BMI, and surgical site complications after total hip and knee arthroplasty were scrutinized and summarized to present relevant information necessary to compare STT with BMI.¼ Five of the 7 studies involving hips and 4 of the 7 studies involving knees show a positive relationship between STT and outcomes including complications and infection, with some claiming STT as a stronger predictor of surgery site problems than BMI.¼ Since many variables, such as STT measurement technique, surgical outcomes, sample sizes, and surgical approach, varied between the studies, definitive inferences are difficult to make and future studies of bigger sample size and higher power should focus on the described measurement techniques.

The Performance of Primary Dual-Mobility Total Hip Arthroplasty in Patients Aged 55 Years and Younger: A Systematic Review.

Background: Dual-mobility (DM) total hip arthroplasty (THA) combines the stabilization advantage provided by large head articulation with the low friction advantage provided by small head articulation. There is momentum for DM to be used in a wider selection of patients, with some advocating for DM to be the routine primary total hip construct. Further investigation is needed to determine whether the use of DM in younger adults is validated by aggregate data. Our objective was to review the literature for the clinical performance of DM THA in patients aged 55 years and younger. Methods: A systematic review of the literature was performed according to the guidelines of Preferred Reporting in Systematic Reviews and Meta-Analyses. Inclusion in the review required clinical outcome reporting for DM primary THA in ambulatory patients aged 55 years or younger. The risk of bias was appraised using the Cochrane risk of bias in nonrandomized studies of interventions and the quality of the evidence was appraised using the Grading of Recommendations Assessment, Development and Evaluation framework. Results: Across a sample of 1048 cases, the frequency weighted term of follow-up was 87.7 months. The pooled rate of revision was 9.5%. The Harris Hip Score significantly improved from 49.1 preoperatively to 93 postoperatively. The Postel-Merle d'Aubigné score significantly improved from 10.5 preoperatively to 17.1 postoperatively. Conclusions: The literature demonstrates satisfactory short-term outcomes with a mitigated risk of dislocation for DM used as primary THA in patients aged 55 years and younger. The current findings suggest that third-generation designs provide reduced rates of intraprosthetic dislocation and improved survivorship.

Resident Impact on Primary Total Knee Arthroplasty: A Consecutive Series Under a Single Surgeon.

Background: The literature has displayed conflicting evidence on resident involvement in surgical procedures. The goal of this study was to assess the impact of resident involvement on primary total knee arthroplasty (TKA) under a single fellowship-trained adult reconstruction surgeon. Methods: Two hundred sequential patients were retrospectively reviewed by a single surgeon: the first cohort represented the final 100 TKAs performed by the surgeon without resident involvement (NRI), serving as the control group, and the second cohort represented the initial 100 TKAs performed by the same surgeon with resident involvement (RI), serving as the experimental group. Perioperative variables such as number of people in operating room (OR), surgical time, and tourniquet time, and postoperative variables such as infection, minor complications, medial distal femoral angle, medial proximal tibia angle, and total angulation were assessed. Results: The rate of infection was significantly lower in the RI group (0%) compared to the NRI group (1%) (P = .043). The number of staff in the OR (P < .001), the tourniquet time (P < .001), and OR time (P < .001) were significantly higher in the RI group compared to the NRI group. There was no difference in coronal plane radiographic measurements: medial distal femoral angle (P = .10), medial proximal tibia angle (P = .19), or total angulation (P = .27). Conclusions: Resident involvement in primary TKA neither demonstrated any significant difference in coronal plane radiographic alignment of the prosthesis nor an increased risk of infection despite increased operative time, tourniquet time, and number of people in OR. Level of evidence: Level 3 - Therapeutic retrospective cohort study.

Morbidly Obese Patients Undergoing Unicompartmental Knee Arthroplasty Compared to Total Knee Arthroplasty: A Retrospective Case-Controlled Analysis.

BACKGROUND: In this study, we assess the effects that morbid obesity (body mass index (BMI) ≥ 40) has on: (1) Ninety-day medical complications and readmission rates; (2) costs of care and lengths of stay (LOS); and (3) 2-year implant complications in patients undergoing unicompartmental knee arthroplasty (UKA) versus total knee arthroplasty (TKA). METHODS: A retrospective query of TKA and UKA patients were identified using a national database. Morbidly obese UKA patients were matched 1:5 to morbidly obese TKA patients by demographic and comorbidity profiles. Subgroup analyses were conducted using the same process between morbidly obese UKA patients and BMI <40 TKA patients, as well as to BMI <40 UKA patients. RESULTS: Morbidly obese patients who underwent UKA had significantly fewer medical complications, readmissions, and periprosthetic joint infections than TKA patients; however, UKA patients had greater odds of mechanical loosening (ML). The TKA patients had significantly longer LOS (3.0 versus 2.4 days, P < .001), as well as significantly greater costs of care than UKA patients ($12,869 versus $7,105). Morbidly obese UKA patients had similar rates of medical complications, and significantly lower readmissions, decreased LOS, and decreased costs when compared to TKA patients who had a BMI <40. CONCLUSION: In patients who have morbid obesity, complications were decreased in UKA compared to TKA. Moreover, morbidly obese UKA patients had lower medical utilizations and similar complication rates when compared to TKA patients with the recommended cutoff of BMI <40. However, UKA patients had greater rates of ML than TKA patients. A UKA may be an acceptable treatment option for unicompartmental osteoarthritis in morbidly obese patients.

Recurrence of symptoms may indicate the presence of a Morel-Lavallée lesion of the knee: A case report and literature review.

Case: An 81 year old male with four failed aspirations presented with recurrent knee swelling following irrigation and debridement, which suggested the presence of a Morel-Lavallée lesion (MLL). This diagnosis was intraoperatively confirmed by separation of the tissue layers forming a space with accumulated fluid. Treatment consisted of doxycycline sclerodesis and tight closure of the tissue layers. The patient had a satisfactory outcome at 4 months. Conclusion: Resolution of Morel-Lavallée lesions requires prompt recognition and appropriate treatment. In the presence of a different diagnosis, recurrence of symptoms following treatment may indicate an MLL. Surgical treatment with doxycycline sclerodesis resulted in resolution of symptoms.

A Systematic Review of Nontuberculous Mycobacterium Infection Following Anterior Cruciate Ligament Reconstruction.

Although infection following anterior cruciate ligament (ACL) reconstruction is rare, these cases have potentially catastrophic ramifications. Nontuberculous mycobacteria (NTM) are ubiquitous, located in the water supply and soil. Our objective was to review the literature to characterize NTM infection following ACL reconstruction. Methods: A database search was performed for arthroscopic ACL reconstructions that resulted in a postoperative diagnosis of NTM infection. Results: The literature search returned 6 case reports that met the inclusion criteria. The initial postoperative presentation occurred after 3 to 52 weeks, which is consistent with reports of postoperative NTM infection. Conclusions: The common indolent course of NTM infection hinders prompt diagnosis and treatment. Organism susceptibility testing is crucial for effective treatment and limiting unnecessary antibiotic exposure. Clinical Relevance: The duration of medical treatment for NTM infection is 4 to 6 months, depending on the severity of disease and species. Based on the aggregate literature, we recommend removal of local implants if the infection is localized and without articular involvement. However, in cases of articular involvement, all fixation and graft material should be removed.

The use of local adiposity as a proxy for obesity in primary total hip arthroplasty: A systematic review.

Introduction: Preoperative optimization of obese patients is a critical component of risk stratification in primary total hip arthroplasty (THA). Body mass index is ubiquitously utilized as a proxy for obesity due to its ease of attainment and simplistic interpretation. The use of adiposity as a proxy for obesity is an emerging concept. Local adiposity provides insight into the magnitude of peri-incisional tissue and has demonstrated an association with postoperative complications. Our objective was to review the literature to determine if local adiposity is a reliable predictor for complications following primary total hip arthroplasty. Methods: In keeping with the PRISMA guidelines, a database search of PubMed was conducted for articles which reported on the relationship between quantified measures of adiposity at the hip and rates of complication following primary THA. Methodological quality was assessed using GRADE and risk of bias using ROBINS-I. Results: A total of six articles (N = 2931) met the inclusion criteria. Local adiposity at the hip was measured on anteroposterior radiograph in four articles and was measured intraoperatively in two. Across four of the six articles, adiposity was significantly associated with postoperative complications including prosthesis failure and infection. Conclusion: The use of BMI as a predictor for postoperative complication has been fraught with inconsistency. There is momentum for adiposity to be used as a proxy for obesity in preoperative THA risk stratification. The current findings demonstrated that local adiposity may be a reliable predictor for complications following primary THA.

Avascular Necrosis as a Sequela of COVID-19: A Case Series.

Avascular necrosis (AVN) is a degenerative bone condition characterized by cellular death and bone collapse from compromised subchondral blood circulation. AVN begins with vascular interruption, hypertension, intravascular occlusion, or extravascular compression which reduces bone circulation. Although corticosteroids are frequently used to treat acute COVID-19 infections, patients are prone to its side effects, particularly AVN. Furthermore, COVID-19 produces coagulopathies, specifically hypercoagulability, that may contribute to venous thrombosis, which may serve as the impetus of AVN. While the literature discussing COVID-19, AVN, and corticosteroid use is not conclusive, patients being treated with corticosteroids for COVID-19 are at an increased risk for AVN possibly due to the combination of COVID-19 infection and corticosteroid use, or the use of high-dose steroids alone. The purpose of this case series is to elucidate AVN as a long-term sequalae of COVID-19, describe our management of COVID-19 and steroid-induced AVN, and discuss the current literature regarding AVN and COVID-19. Three patients hospitalized for COVID-19 infections were treated with corticosteroids and subsequently developed AVN. All patients, but one, had multiple sites of infarction and were treated with core decompression in the hip where there was no collapse of the subchondral bone. One of these patients had multiple infarcts in bilateral femoral heads, femoral shafts, and knees. This patient had a history of end-stage renal disease, and, therefore, total knee replacement was postponed until medical clearance. Core decompression was performed on the femoral head that showed no collapse to delay osteoarthritis of the hip. Multiple articles in the current literature support the idea that the combination of COVID-19 and corticosteroid use increases the risk of AVN and reduces the onset of COVID-19-related respiratory symptoms. The patient cases discussed in this case series suggest a possible association between COVID-19, corticosteroid use, and AVN.

A Custom Device to Couple Proximal and Distal Femoral Stems: A Case Report and Literature Review.

Complex periprosthetic fractures may occur with existing ipsilateral hip and knee implants. These cases are challenging with few options. We report on a custom coupler used to connect a hinged distal femoral replacement to an existing revision hip stem. This option was preferred to a total replacement of the femur. The custom coupler maintained the anatomic attachments of the proximal femur, preserved abductor strength during ambulation, and mitigated the morbidity which may arise from a total femur replacement. At 15 months postoperatively, the patient reported no pain, did not demonstrate an antalgic gait pattern, and had satisfactory range of motion at the hip and knee. The literature displays clinical and biomechanical efficacy for coupling devices although complications and device failure are quite variable.

Nephrotoxicity Related to Antibiotic-Loaded Spacers in a 2-Stage Revision for Periprosthetic Joint Infection.

Antibiotic-loaded bone cement (ALBC) spacers are the mainstay in 2-stage revision, but antibiotics (vancomycin plus aminoglycosides) may undergo systemic absorption, resulting in acute kidney injury (AKI). Data on spacer antibiotics are heterogeneous. Our objective was to review risk factors for AKI and dosage of antibiotics. Significant AKI risk factors were antibiotic concentration greater than 3 or 3.6 g per cement batch, comorbidities, chronic kidney disease, and hypovolemia. Despite similar spacer antibiotic dosing, there was remarkable variability in serum concentrations. To err on the side of caution, it appears that antibiotic dose below 3 g per cement batch might be relatively safe until more evidence surfaces. Consideration of risk factors for AKI calls for appropriate antibiotic use in 2-stage revision. [Orthopedics. 2023;46(3):e136-e142.].

Surgical Dislocation of the Hip through Lateral Approach for the Treatment of Synovial Chondromatosis.

Introduction: Synovial chondromatosis is a condition where the cells lining a joint form benign cartilaginous tumors. This benign cartilage metaplasia results in the formation of multiple intra-articular loose bodies within a joint. Case Report: This case is a 59-year-old female that presented with constant, severe left hip pain that was localized to the groin and began 2 years ago. There were severe limitation of hip flexion, extension, pain on internal rotation, and a half inch left leg shortening. Radiographs demonstrated multiple round opacities surrounding the left femoral neck. MRI showed numerous, small rounded intra-articular loose bodies, measuring about 5-6 mm each within the left hip joint. Surgical Technique: A lateral approach toward the hip was used to perform an osteotomy at the portion of the greater trochanter. The hip capsule was identified and an S-shaped incision was then made through the capsule. Repetitive hip dislocations allowed for improved visualization making further removal of the difficult fragments much easier. The capsule was closed and the osteotomy was reattached. Range of motion was found to be significantly improved compared to preoperatively. No further fixation was necessary and the patient's subcutaneous tissue was closed in normal fashion. Conclusion: The technique used in our case involves a lateral approach with a trochanteric flip osteotomy to preserve the medial femoral circumflex artery and external rotators. This is similar to the approach described by Ganz in 2001 who used a posterior approach. Following the approach, the hip is then dislocated and exposed anteriorly with full visualization of the joint with a gap of about 11 cm between the femoral head and acetabulum. Surgical dislocation allows for the removal of difficult chondromas and osteophytes around the femoral head-and-neck junction. Multiple studies support the idea of surgical dislocation as an exceptional treatment method for SC.

Utilizing a Prefabricated Antibiotic-Impregnated Articular Spacer Combined With an Intramedullary Device for Significant Femoral Bone Loss in Periprosthetic Hip Infection.

Periprosthetic joint infection can be a devastating complication following total hip arthroplasty, which often requires a lengthy treatment course that is fraught with complications. There are various types of antibiotic-impregnated spacers that can be used to treat periprosthetic hip infections, with articulating spacers being utilized frequently with the goal of preserving patient range of motion and functionality. Many of these articulating spacers have pre-set sizes and stem options, which accommodate the majority of patients. However, when significant femoral bone loss is evident at the time of revision surgery, many articulating spacer options are not sufficient to provide stability, and custom modifications of available spacer constructs may be needed to fill the bony void. The goal of this article is to report a surgical technique that can be used in the salvage of failed antibiotic-impregnated spacers where severe femoral bone loss is present.

The Treatment of Heterotopic Ossification With a Dual Mobility Total Hip Replacement System: A Case Report.

Heterotopic ossification (HO) is the formation of bone within extraskeletal soft tissue. The development of mature lamellar bone within soft tissues can be acquired in cases like trauma. Clinical manifestations of HO primarily include pain at the site of the extraskeletal ossification and limited range of motion or function when it involves a joint. This case report presents a 56-year-old man with severe HO. His past medical history included a traumatic hip dislocation in 1996. He denied any other past medical, family, or surgical history. This patient had severely limited range of motion and difficulty performing activities of daily living like going up and down the stairs and getting up from a seated position. After failing conservative therapy with non-steroidal anti-inflammatory drugs (NSAIDs) and physical therapy, a non-cemented dual mobility hip replacement system was used to treat this patient. A non-cemented dual mobility hip replacement system was chosen because the patient had significant bone loss and was relatively young. The dual mobility system significantly reduces the risk of dislocation and is a good option for younger patients who require more stability in their hips. The patient progressed well with a full range of motion and no pain. There was no evidence of HO recurrence. Treatment of HO with a total hip replacement, let alone a dual mobility system, is not prevalent throughout the literature. Furthermore, cemented total hip arthroplasty has been associated with increased recurrence of HO, which is why we elected to use a non-cemented technique. Osteoplasty is typically the mainstay of treatment for HO. The purpose of this case report is to introduce an incident of HO treated with a non-cemented dual mobility system and emphasize its use in young, middle-aged, or active patients who have bone loss and require increased stability.