Bloodless Total Hip Arthroplasty in Jehovah's Witness Patients: Contemporary Strategies and Outcomes.

BACKGROUND: Reported blood transfusion rates in total hip arthroplasty (THA) range between 3 and 22%. Jehovah's Witnesses (JW) do not accept blood transfusions and make conscience decisions to accept blood derivatives. This study reports on strategies and outcomes for bloodless THA. METHODS: All JW patients undergoing primary THA at our institution between 2011 and 2022 were included in this study (94 of 110 THA). The indications for THA were osteoarthritis (92%), femoral neck fracture (6%), rheumatoid arthritis (1%), and failed open reduction and internal fixation (1%). Strategies used to optimize outcomes included erythropoietin, tranexamic acid, cell savers, intrailiac artery tourniquets, and minimizing phlebotomy. RESULTS: The mean estimated blood loss was 201.2 ± 122.2 mL. Preoperative hemoglobin (Hgb) levels were 13.4 ± 1.4 g/dL, which decreased to 11.0 ± 1.3 g/dL on postoperative day 1 (POD1, P < 0.001), 10.3 ± 1.5 g/dL on POD2 (P = 0.001), and 9.8 ± 1.1 g/dL on POD3 (P = 0.171). The use of tranexamic acid significantly decreased Hgb drop on POD1 (P = 0.04). Subgroup analysis showed that preoperatively anemic patients (closed circuit, Hgb < 12 g/dL) had significantly less Hgb drop postoperatively (P = 0.003). No patients met the recommended transfusion threshold (Hgb < 7 g/dL). There were two 90-day readmissions due to falls. There was zero 90-day mortality. CONCLUSIONS: A THA can be safely performed on JW patients. Preoperatively anemic patients had a decreased Hgb drop postoperatively. JW patients make a conscious decision to accept blood derivatives, which may be present in medications including erythropoietin. We recommend maintaining an Hgb above 11 g/dL prior to surgery, as a Hgb drop of 3.1 g/dL can be expected. These findings highlight the efficacy of a multimodal approach to optimizing bloodless primary THAs.

The Watson Extraction System for removal of well-fixed femoral stems: A retrospective review of 10 cases.

Background: Revision of well-fixed cementless femoral stems is a challenging and time-consuming aspect of revision hip arthroplasty. The Watson Extraction System (WES) is a novel, size-specific 3-D fabricated instrument that mimics the outer geometry of the implanted femoral stem. The device acts to cut circumferentially around the stem as it is impacted into place, effectively disrupting the bone-implant interface. Methods: This is a retrospective review assessing the experience of 3 fellowship-trained adult reconstruction surgeons who used the WES to extract 10 well-fixed femoral stems during rTHA between 11/7/2020 and 11/7/2022. Outcomes and measures included: ability to remove the stem without a femoral osteotomy, femoral stem extraction time, incidence of femoral fracture, stem type used for reconstruction, blood loss, total surgical time, post-operative complications. Results: No femoral osteotomies were required. The mean time for stem extraction was 7 min (range, 2-13), and there were 2 (20%) intra-operative femoral fractures. The stem type utilized for reconstruction included: 4 (40%) modular, tapered style stems, 3 (30%) antibiotic spacers, 2 (20%) primary style stems, and 1 (10%) ream and broach proximally porous stem. The mean blood loss was 425 ml (range, 200-800), total surgical time was 160 min (range, 107-232), and duration of follow-up was 7 months (range, 2-22 months). Conclusion: The WES may mitigate the need for femoral osteotomy, reduce femoral stem extraction and overall intraoperative time, and decrease blood loss in rTHA. Further, reduced bone loss with use of this device may permit final reconstruction with a primary style stem.

What factors can reduce the need for repeated revision for humeral loosening in revision total elbow arthroplasty?

BACKGROUND: This study aimed to determine the re-revision rate in a cohort of patients who underwent revision total elbow arthroplasty (rTEA) for humeral loosening (HL) and identify factors contributing to re-revision. We hypothesized that proportional increases in the stem and flange lengths would stabilize the bone-implant interface significantly more than a disproportional increase in stem or flange length alone. Additionally, we hypothesized that the indication for the index arthroplasty would impact the need for repeated revision for HL. The secondary objective was to describe the functional outcomes, complications, and presence of radiographic loosening after rTEA. METHODS: We retrospectively reviewed 181 rTEAs performed from 2000-2021. We included 40 rTEAs for HL performed on 40 elbows that either required a subsequent revision for HL (10 rTEAs) or had a minimum of 2 years of clinical or radiographic follow-up. One hundred thirty-one cases were excluded. Patients were grouped based on stem and flange length to determine the re-revision rate. Patients were divided based on re-revision status into the single-revision group and the re-revision group. The stem-to-flange length (S/F) ratio was calculated for each surgical procedure. The mean length of clinical and radiographic follow-up was 71 months (range, 18-221 months and 3-221 months, respectively). RESULTS: Rheumatoid arthritis was statistically significant in predicting re-revision total elbow arthroplasty for HL (P = .024). The overall re-revision rate for HL was 25% at an average of 4.2 years (range, 1-19 years) from the revision procedure. There was a significant increase in stem and flange lengths from the index procedure to revision, on average by 70 ± 47 mm (P < .001) and 28 ± 39 mm (P < .001), respectively. In the cases of re-revision (n = 10), 4 patients underwent an excisional procedure; in the remaining 6 cases, the size of the re-revision implant increased on average by 37 ± 40 mm for the stem and 73 ± 70 mm for the flange (P = .075 and P = .046, respectively). Furthermore, the average flange in these 6 cases was 7 times shorter than the average stem (S/F ratio, 6.7 ± 2.2). This ratio was significantly different from that in cases that were not re-revised (P = .03; S/F ratio, 4.2 ± 2). Mean range of moion was 16° (range, 0°-90°; standard deviation, 20°) extension to 119° (range, 0°-160°; standard deviation, 39°) flexion at final follow-up. Complications included ulnar neuropathy (38%), radial neuropathy (10%), infection (14%), ulnar loosening (14%), and fracture (14%). None of the elbows were considered radiographically loose at final follow-up. CONCLUSION: We show that a primary diagnosis of rheumatoid arthritis and a humeral stem with a relatively short flange relative to the stem length significantly contribute to re-revision of total elbow arthroplasty. The use of an implant where the flange can be extended beyond one-fourth of the stem length may increase implant longevity.

Impact of State Opioid Regulation on Postoperative Opioid Prescribing Patterns for Total Knee Arthroplasty: A Retrospective Analysis.

BACKGROUND: Limited studies have assessed the impact of state regulations on opioid prescribing patterns for patients undergoing total knee arthroplasty (TKA). This study evaluates how Florida House Bill 21 (FL-HB21) affected postoperative opioid prescribing for patients after TKA. METHODS: Institutional review board approval was obtained to retrospectively review all patients who underwent TKA during 3 months of 2017 (pre-law) and 2018 (post-law) by five arthroplasty surgeons in Florida. Prescribed opioid quantity in morphine milligram equivalents (MME), quantity of refills, and number of prescribers were recorded for each patient's 90-day postsurgical episode. The differences between pre-law and post-law prescription data and short-term postoperative pain levels were compared. RESULTS: The average total MME was notably reduced by over 30% for all time periods for the post-law group. The average MME per patient decreased by 169 MME at the time of discharge, by 245 MME during subsequent postoperative visits, and by 414 MME for the 90-day postsurgical episode ( P < 0.001 for all). The quantity of refills was unchanged (1.6 vs. 1.6, P = 0.885). The total number of prescribers per patient for the 90-day postsurgical episode was unchanged (1.31 vs. 1.24 prescribers/patient, P = 0.16). Postoperative pain levels were similar at discharge (3.6 pre-law vs. 3.3 post-law, P = 0.272). DISCUSSION: Restrictive opioid legislation was associated with notably reduced postoperative opioid (MME) prescribed per patient after TKA at the time of discharge and for the entire 90-day postsurgical episode. There was no increase in the number of prescribers or refills required by patients. LEVEL OF EVIDENCE: Level III retrospective cohort.

Minimally Invasive Anterior Cruciate Ligament With Quadriceps Tendon Graft: A Proximal-to-Distal Harvest Technique.

Recent systematic reviews have shown anterior cruciate ligament reconstruction using quadriceps tendon (QT) grafts to have superior clinical outcomes compared with traditional bone-patella tendon-bone and hamstring tendons grafts. Using minimally invasive techniques to harvest the QT graft can reduce postoperative pain and intraoperative surgical time. This technique is usually performed with a distal-to-proximal approach but often has issues of inadvertently harvesting a graft short of the desired length or causing a hematoma. As an alternative, we introduce a minimally invasive approach with a proximal-to-distal harvest technique that results in better visualization of tissue planes, more consistent graft sizes, lower risk of inadvertent arthrotomy, and reduced risk of hematoma. The minimally invasive QT graft harvest with a proximal-to-distal approach can offer unique advantages over the current standard distal-to-proximal approach.

Total Hip Arthroplasty With Subtrochanteric Osteotomy for Developmental Hip Dysplasia: A Long-term Follow-up Study.

Background: Total hip arthroplasty (THA) for developmental hip dysplasia (DDH) often requires a subtrochanteric shortening derotational osteotomy (SDO) to limit leg lengthening, mitigate risk of peripheral nerve palsy, and reduce excessive femoral anteversion. Few studies exist detailing long-term clinical outcomes and survivorship. The aim of this study is to analyze the long-term outcomes and survivorship of an SDO-THA cohort. Methods: We retrospectively reviewed all patients who underwent cementless THA with femoral osteotomy due to Crowe I-IV DDH between 1991 and 2001. Primary outcome measures included revision surgery for any reason and functional outcome measures using modified Harris Hip scores. Secondary outcome measures included mode of implant failure and radiographic assessment for osteotomy union, polyethylene wear, osteolysis, and implant loosening. Results: Our review resulted in 24 SDO-THA cases in 20 patients with a mean follow-up of 19 years (range, 8-27 years). Overall survivorship was 67%. All 8 failures were treated with acetabular revision at a mean time to revision of 11 years (range, 1-25 years). Of the failures, there were 5 cases due to polyethylene wear (62.5%), 2 cases due to acetabular loosening (25%), and 1 case due to recurrent instability (12.5%). The mean postoperative modified Harris Hip score was 76 (range, 52-91) with long-term improvement of 43 points maintained (P < .001). Conclusions: THA with SDO can produce durable long-term outcomes for the patient with DDH. It is important to consider some common reasons for revision, namely polyethylene wear and osteolysis, acetabular loosening, and recurrent acetabular dislocations.

Efficacy and Durability of Opioid Restrictive State Legislation Two Years After Implementation for Total Knee Arthroplasty.

BACKGROUND: To curtail the U.S. opioid crisis, many states have instituted regulations that mandate time and/or dosage limits for opioid prescriptions. This study evaluates the impact of one such law, Florida House Bill 21, on postoperative opioid prescribing patterns for patients undergoing total knee arthroplasty (TKA) and the durability of the law's impact over time. METHODS: All patients who underwent TKA at a single institution during the same three-month period in 2017 (pre-law), 2018 (post-law), and 2020 (2 years post-law) were identified. Outcomes and measures included: prescribed morphine milligram equivalents (MME) at discharge and for the 90-day surgical episode, refill quantity with associated MME, and quantity of opioid prescribers. Patients with established chronic pain or those who underwent contralateral TKA during the 90-day window were excluded. Data was compared using a one-way analysis of variance. Significance was set at alpha <0.05. RESULTS: The average MME of filled opioid prescriptions per patient during the 90-day post-surgical episode decreased from 1310 MME in 2017 to 891 MME in 2018 (P < .001). The average MME in 2020 was 814 MME, which was significantly lower than the average in 2017 (P < .001), and statistically stable compared to the average in 2018 (P = .215). CONCLUSION: Restrictive opioid state policy implementation was associated with reduced overall MME prescription to patients undergoing TKA at discharge and for the 90-day surgical episode. There was no increase in the number of opioid refills or opioid prescribers. Durable change and continued improvement were observed 2 years after implementation of law.

Morphologic analysis of the sublime tubercle: considerations in the approach to ulnar collateral ligament reconstruction.

Background: Given the increased incidence of ulnar collateral ligament (UCL) injuries and the projected increase in reconstruction procedures, a robust understanding of the morphologic location of the sublime tubercle is paramount to anatomic reconstruction. There is limited research evaluating the morphology of the sublime tubercle of the proximal ulna in an anterior-to-posterior plane. Methods: Twenty-five computed tomography (CT) scans of intact proximal elbow joints for patients were selected using a de-identified database. Cases with history of fracture or surgical intervention to the elbow joint were excluded. These CT scans were then imported into the Mimics Innovation Suite 24.0 software to analyze the sublime tubercle angle from the midpoint of the trochlear notch. All left elbow angle and clock-face values were converted to right elbow values for analysis. Results: The average sublime tubercle angle from the midpoint of the trochlear notch was 282.53 degrees. The angle was converted to a clock face descriptor which located the sublime tubercle at 9.42. Our findings demonstrate that, in the non-throwing population, the morphology of the sublime tubercle can be expected to have a consistent medial location between 9 and 10 o'clock or 2 and 3 o'clock on the contralateral elbow. Conclusions: In relation to the proximal ulnar landmarks, the sublime tubercle, in the non-throwing population, has a consistent relative location.