Relationship Between Preoperative Nutritional Status and Predicting Short-Term Complications Following Revision Total Hip Arthroplasty.

BACKGROUND: The association between malnutrition and complications following primary total joint arthroplasty is well-delineated; however, nutritional status has yet to be explored specifically in revision total hip arthroplasty (THA). Therefore, our objective was to examine if a patient's nutritional status based on body mass index, diabetic status, and serum albumin predicted complications following a revision THA. METHODS: A retrospective national database review identified 12,249 patients who underwent revision THA from 2006 to 2019. Patients were stratified based on body mass index (<18.5 = underweight, 18.5-29.9 = healthy/overweight, ≥30 = obese), diagnosis of diabetes (no diabetes, insulin-dependent diabetes mellitus (IDDM), non-insulin-dependent diabetes mellitus), and preoperative serum albumin (<3.5 = malnourished, ≥3.5 = non-malnourished). Multivariate analyses were performed using chi-square tests and multiple logistic regressions. RESULTS: In all groups including underweight (1.8%), healthy/overweight (53.7%), and obese (44.5%), those without diabetes were less likely to be malnourished (P < .001), while those with IDDM had a higher rate of malnutrition (P < .001). Underweight patients were significantly more malnourished compared to healthy/overweight or obese patients (P < .05). Malnourished patients had an increased risk of wound dehiscence/surgical site infections (P < .001), urinary tract infection (P < .001), requiring a blood transfusion (P < .001), sepsis (P < .001), and septic shock (P < .001). Malnourished patients also have worse postoperative pulmonary and renal function. CONCLUSION: Patients who are underweight or have IDDM are more likely to be malnourished. The risk of complications within 30 days of surgery following revision THA significantly increases with malnutrition. This study shows the utility of screening underweight and IDDM patients for malnutrition prior to revision THA to minimize complications.

Variability in Acetabular Component Position in Patients Undergoing Direct Anterior Approach Total Hip Arthroplasty Who Have Concomitant Spine Pathology.

BACKGROUND: Hip instability following total hip arthroplasty (THA) can be a major cause of revision surgery. Physiological patient position impacts acetabular anteversion and abduction, and influences the functional component positioning. Osteoarthritis of the spine leads to abnormal spinopelvic biomechanics and motion, but there is no consensus on the degree of component variability for THAs performed by anterior approach. Therefore, we sought to present guidelines for changes in acetabular component positioning between supine and standing positions for patients undergoing primary THA by a uniform anterior approach. METHODS: Perioperative patient radiographs of the pelvis and lumbar spine were collected. Images were used to determine acetabular component positioning and degree of coexisting spinal pathology, categorized as a Lane Grade (LG). Final analysis of variance was performed on a sample size of 643 anterior primary THAs. RESULTS: From supine to standing position, as the severity of lumbar pathology increased the change in anteversion also increased (LG:0 = -0.11° ± 4.65°, LG:1 = 2.02° ± 4.09°, LG:2-3 = 5.78° ± 5.72°, P < .001). The mean supine anteversion in patients with absent lumbar pathology was 19.72° ± 5.05° and was lower in patients with worsening lumbar pathology (LG:1 = 18.25° ± 4.81°, LG:2-3 = 16.73° ± 5.28°, P < .001). CONCLUSION: Patients undergoing primary THA by anterior approach with worsening spinal pathology have larger increases in component anteversion when transitioning from supine to standing positions. Consideration should be given to this expected variability when placing the patient's acetabular component.

Management of Refractory Pain After Total Joint Replacement.

PURPOSE OF REVIEW: Chronic pain after total joint replacement (TJA), specifically total knee replacement (TKA), is becoming more of a burden on patients, physicians, and the healthcare system as the number of joint replacements performed increases year after year. The management of this type of pain is critical, and therefore, understanding the various modalities physicians can use to help patients with refractory pain after TJA is essential. RECENT FINDINGS: The modalities by which chronic pain can be successfully managed include genicular nerve radioablation therapy (GN-RFA), neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), and peripheral subcutaneous field stimulation (PSFS). Meta-analyses and case reports have demonstrated the effectiveness of these treatment options in improving pain and functional outcomes in patients with chronic pain after TKA. The purpose of this paper is to review and synthesize the current literature investigating the different ways that refractory pain is managed after TJA, with the goal being to provide treatment recommendations for providers treating these patients.

The Effect of Bladder Catheterization on Ambulation and Venous Thromboembolism Following Total Knee Arthroplasty: An Institutional Analysis.

BACKGROUND: Although intermittent catheters are immediately removed, indwelling catheterization may lead to decreased ambulation and participation in physical therapy, critical components to post-total knee arthroplasty (TKA) management. Therefore, this study aimed to compare the effect of catheterization treatments on (1) postoperative ambulation distances, (2) deep vein thromboses (DVTs), and (3) pulmonary emboli (PEs) following TKA. METHODS: A total of 9123 prospectively collected primary TKA patients were assessed based on postoperative catheter status. Patient demographics, Charlson Comorbidity Indices, body mass indices, DVT prophylaxes, first ambulation distances, DVTs, and PEs were collected at approximately mean 12 months of follow-up. Univariate and multivariate analyses were performed with independent t-tests and multiple linear regression models in order to compare catheterization techniques. RESULTS: There were 1193 patients who had urinary retention and treated with either indwelling only (62%, n = 734), both indwelling and intermittent catheterizations (13%, n = 160), or intermittent only (25%, n = 299). Multivariate analyses found that indwelling catheter-only use had an 11% decrease in ambulation distance (P < .001). Additionally, the indwelling catheterization-only group was found to be at increased risk of DVTs (odds ratio 2.605, P < .001), even after controlling for DVT prophylaxes (odds ratio 2.807, P < .001). CONCLUSION: This study showed that the use of an indwelling catheter for treatment of urinary retention significantly decreased TKA patient ambulation distance and subsequently increased the risk for DVTs. This information is important as we would recommend the treatment with intermittent catheterization rather than indwelling catheters to decrease the risk of immobilization and postoperative DVTs.

Does Intermittent Catheterization Compared to Indwelling Catheterization Decrease the Risk of Periprosthetic Joint Infection Following Total Knee Arthroplasty?

BACKGROUND: Catheterization for the prophylaxis against or treatment for urinary retention commonly occurs after total knee arthroplasty (TKA). Recent studies have questioned the use of the indwelling catheterization, especially in its potential role as a nidus for infection. We are still unsure of its downstream effects on periprosthetic joint infections (PJIs). Therefore, this study aimed to compare the risks of postoperative PJI following intermittent vs indwelling catheterization after TKA. METHODS: Between 2017 and 2019, 15 hospitals in a large health system collected data on patients undergoing TKA. Patient treatments with indwelling catheter only, intermittent straight catheter only, and both indwelling and intermittent straight catheterizations were recorded. Patient demographics, comorbidities, body mass indices, and PJIs were collected from time of surgery to time of data collection at mean 14 months of follow-up. Univariate and multivariate analyses were performed with independent t-tests and multiple linear regression models to compare catheterization treatment types. RESULTS: A total of 9123 TKAs were performed, with patients receiving indwelling catheter only (62%, n = 734), intermittent straight catheter only (25%, n = 299), or both indwelling and intermittent catheterizations (13%, n = 160). Univariate analyses showed that PJIs occurred in 1.1% of no-catheter patients and 2.3% of patients treated with bladder catheterization (P = .002). Using multivariate analyses, indwelling catheter use (odds ratio [OR] 2.647, P < .001), diabetes (OR 1.837, P = .005), and peripheral vascular disease (OR 2.372, P = .046) were found to have a statistically significant increased risk for PJIs. The use of intermittent straight catheterization (OR 1.249, P = .668) or both indwelling and intermittent (OR 1.171, P = .828) did not increase the risk for PJIs. CONCLUSION: Urinary bladder catheterization is commonly required for prophylaxis against or treatment for urinary retention following TKA. The use of a urinary catheter can provide a potential nidus for infection in these patients. This study found that indwelling catheterization, but not intermittent catheterization, was associated with an increased risk for PJI. Surgeons should therefore limit the duration of catheterization in an effort to decrease the risk for PJI.

The Cumulative Effect of Substance Abuse Disorders and Depression on Postoperative Complications After Primary Total Knee Arthroplasty.

BACKGROUND: Substance abuse disorder (SUD), alcohol abuse disorder (AUD), and depression have been identified as independent risk factors for complications after total knee arthroplasty (TKA). However, these mental health disorders are highly co-associated, and their cumulative effect on postoperative complications have not been investigated. Therefore, this study aimed to determine if patients who have more than one mental health disorder (SUD, AUD, or depression) were at an increased risk for postoperative complications following TKA. METHODS: A total of 11,403 TKA patients were identified from a prospectively collected institutional database between January 1, 2017 and April 1, 2019. Patients who had depression, SUD, and AUD were separated into 7 mental health subgroups including each of these diagnoses alone and their combined permeations. Patient demographics, body mass indices, medical comorbidities, and 15 postoperative complications were collected. Univariate analyses were performed using independent Student's t-tests. Multivariate analyses were then performed to identify odds ratios (ORs) for mental health disorders subgroups associated with complications. RESULTS: We found a total of 2073 (18%) patients diagnosed with either SUD (4%), AUD (0.6%), or depression (12%). Univariate analyses showed that depression was associated with mechanical failures (P < .001). SUD was associated with periprosthetic joint infection (PJI) (P < .001), wound complications (P = .022), and aseptic loosening (P = .007). AUD was associated with PJI (P < .001) and deep vein thromboses (P = .003). Multivariate analyses found that AUD (OR: 19.419, P < .001) and SUD (OR:3.693, P = .010) were independent risk factors for PJI. Compared with SUD alone, patients with depression plus SUD were found to have a 4-fold (OR: 13.639, P < .001) and 2-fold (OR:4.401, P = .021) increased risk for PJI and cellulitis, respectively. CONCLUSIONS: Patients who had depression, SUD, or AUD were at increased risk for postoperative complications following primary TKA. When patients have more than one mental health diagnosis, their risk for complications was amplified. The results of this study can help identify those patients who are at greater risk of postoperative complications to enable improved preoperative optimization and patient education.

The Effect of Bladder Catheterization Technique on Postoperative Urinary Tract Infections After Primary Total Hip Arthroplasty.

BACKGROUND: Urinary bladder catheters are potential sources of infection after total hip arthroplasty (THA). Therefore, the goal of this study was to determine if intermittent catheterization provides a decreased risk of postoperative urinary tract infections (UTIs) compared with indwelling catheterization in THA patients. METHODS: Patients undergoing THA at 15 hospitals within a large health system were prospectively collected between 2017 and 2019 and then stratified based on catheterization technique: no-catheter; indwelling catheter-only; intermittent catheter-only; and both intermittent and indwelling catheter. Patient demographics, medical comorbidities, anesthesia types, and postoperative UTIs were assessed. Independent Student t-tests were used to perform univariate analyses for the catheterization groups. Multiple linear regression models were used to compare the different groups while controlling for confounding variables. RESULTS: There were a total of 7306 THA patients recorded with 5513 (75%) no-catheter, 1181 (16%) indwelling catheter-only, 285 (3.9%) intermittent catheter-only, and 327 (4.5%) indwelling and intermittent catheterization patients. A total of 580 patients experienced postoperative UTI. Urinary bladder catheterization increased the risk of postoperative UTIs (P < .001) in univariate analyses. Multiple linear regression models showed that indwelling catheter-only (OR: 2.178, P < .001), intermittent catheterization (OR: 1.975, P = .003), and both indwelling and intermittent (OR: 2.372, P = .002) were more likely to experience UTIs compared with no catheters. CONCLUSION: This study found that patients treated with indwelling catheterization, with or without preceding intermittent catheterization, were significantly more likely to experience UTIs. Therefore, in an effort to decrease the risk of UTIs, THA patients experiencing postoperative urinary retention should be treated with intermittent catheterization.

The Center-Center Technique for the Direct Anterior Approach in Total Hip Arthroplasty: Precise Femoral Canal Preparation to Optimize Implant Fit and Fill.

BACKGROUND: The use of the direct anterior approach has been criticized as a significant risk factor for subsidence, perioperative fracture, and thigh pain. Therefore, the purpose of our study was to evaluate the outcome of using the center-center technique via the direct anterior approach. MATERIALS AND METHODS: Consecutive elective primary total hip arthroplasties performed using the center-center technique were retrospectively reviewed from May 2015 to February 2017. All cases were performed by a single surgeon at a high-volume, large academic center. The technique focuses on central alignment of the implant on both anteroposterior and lateral radiographs. Standardized objective radiographic measurements were taken at the first two-week follow-up visit to determine the fit and fill at the proximal and distal anatomic segments. Subsidence was measured by comparing the implant position at final follow up to the initial two-week postoperative visit. Other complications: intra- or postoperative fracture, infection, revision, and patient-reported thigh pain were further assessed. Functional postoperative outcomes were assessed using the Harris Hip Score (HHS). RESULTS: A total of 138 patients with a mean age of 65 years and average follow up of 2.8 years were assessed. The mean postoperative HHS was 90 points (59-100). Mean implant subsidence was 1mm. A total of 90% (124) of implants had acceptable radiographic fit and fill in both proximal and distal segments. A majority 74% (102) of implants subsided less than 1mm, and 91% (126) subsided less than 2mm. One implant had radiographic subsidence of 9mm, which was treated with a shoe lift. There were no intraoperative fractures. One postoperative lateral cortex fracture three weeks after surgery due to mechanical fall was treated conservatively. No patients required revision arthroplasty for any reason or reported postoperative thigh pain. CONCLUSION: The center-center technique can be used to consistently aid in proper femoral stem placement in both coronal and sagittal planes. Optimal fit and fill can be achieved safely using this technique.

Orthopaedic Surgeons Have a High Prevalence of Burnout, Depression, and Suicide: Review of Factors Which Contribute or Reduce Further Harm.

Orthopaedic surgeons have the highest prevalence of death by suicide among all surgical subspecialties, comprising 28.2% of surgeon suicides from 2003 to 2017. There is a continuum of burnout, depression, and other mental health illnesses likely contributing to these numbers in our profession. Stigmatization in terms of medical licensing and professional development are currently barriers to seeking mental health treatment. Education on the risk and treatment of burnout, depression, and suicidal ideations should begin early in a surgeon's career. This review documents the issue of physician burnout and depression and makes recommendations regarding necessary changes to counteract mental illness in orthopaedic surgeons.

Does Structured Postgraduate Training Affect the Learning Curve in Direct Anterior Total Hip Arthroplasty? A Single Surgeon's First 200 Cases.

BACKGROUND: The direct anterior approach (DAA) used for primary total hip arthroplasty has been shown to improve early postoperative outcomes, but prior studies have identified a marked learning curve for surgeons transitioning to this approach. However, these studies do not capture surgeons with postgraduate fellowship training in DAA. Therefore, the purpose of this study was to evaluate the learning curve by comparing perioperative outcomes for the first 100 to latter 100 cases and first 50 to final 50 cases. METHODS: The first 200 consecutive primary total hip arthroplasties performed by a single surgeon were prospectively followed up for up to 2 years postoperatively. Data on demographic and perioperative factors, 90-day readmissions, and short- and long-term complications were collected. Radiographic outcomes included acetabular cup anteversion and abduction measurements. Logistic regressions were used to calculate odds ratios and confidence intervals for surgical time greater than 2 hours. RESULTS: The first 100 and second 100 cases had significant differences in operative times (118.1 vs 110.4 minutes, P = .009), acetabular abduction (38.3 vs 35.5 degrees, P = .001) and anteversion (13.5 vs 15.1 degrees, P = .009), and incidence of neuropraxia (41 vs 9%, P < .001). Estimated blood loss, transfusions, discharge disposition, length of stay, readmission, and other complications had no statistical significance between the first and second 100 cases. The first 50 cases had higher odds of surgical time greater than 2 hours (odds ratio = 5.2, 95% confidence interval = 1.84-14.75, P = .002) than the final 50 cases. CONCLUSIONS: When compared with the existing literature, incorporation of DAA into fellowship training can lead to reduction in fractures and reoperation rates.

Predictable healing of femoral neck fractures treated with intraoperative compression and length-stable implants.

OBJECTIVES: A healed, yet shortened, femoral neck has historically been deemed a success in fracture treatment. This, however, comes at the price of diminished physical function and quality of life. We analyzed the outcomes of our treatment algorithm, which attempts to minimize postoperative shortening of femoral neck fractures and determined which preoperative factors were associated with femoral neck shortening and failure of surgical fixation. LEVEL OF EVIDENCE: This is level IV retrospective study. MATERIALS: Fifty-four patients underwent open reduction and internal fixation for acute femoral neck fracture with nonsliding constructs. The collapse of the femoral neck in the horizontal (X), vertical (Y), and along the resultant along the (Z) vector (X+Y=Z) was measured on anteroposterior radiographs corrected for leg rotation. The migration of the superior-most screw tip in all axes was measured. Age, gender, Garden grade, and Pauwel's angle were analyzed for their association with shortening or failure of surgical fixation. RESULTS: The average age of the patients was 78.1 years. There were 23 Garden I, 2 Garden II, 14 Garden III, and 15 Garden IV fractures. Fifty-one (94%) healed successfully without complications. The minimum follow-up was 9 months (average, 17.6 months; range, 9-30 months). Surgical fixation failed in two patients, and one patient developed avascular necrosis. The average displacement of the femoral head and the screw tip was 1.23, 0.86, 1.98 mm and 0.7 mm, 0.9 mm, and 1.7 mm in the X, Y, and Z (resultant) vectors, respectively. DISCUSSION: With careful consideration to reduction, we fixed femoral neck fractures with nonsliding constructs, resulting in a high union rate with very minimal shortening of the femoral neck.

Outcomes of length-stable fixation of femoral neck fractures.

INTRODUCTION: The most common implants for treating unstable femoral neck fractures are sliding constructs, which allow postoperative collapse. Successful healing, typically, is a malunion with a shortened femoral neck. Functional sequelae resulting from altered femoral neck biomechanics have been increasingly reported. Re-operation rate due to nonunion, avascular necrosis, hardware cut-out and prominence is high with this treatment modality. We evaluated the outcomes of patients with femoral neck fractures treated with stable calcar pivot reduction, intraoperative compression across the fracture, and stabilization with length-stable implants. MATERIALS AND METHODS: Fifty-four patients with femoral neck fractures underwent open reduction and internal fixation. Average follow up duration was 23.6 months (range: 15-36 months). There were 23 Garden I, 2 Garden II, 14 Garden III and 15 Garden IV fractures. Reduction was achieved through a modified Smith-Petersen approach. Fractures were compressed initially, and subsequently stabilized with a length-stable device. Post-operative radiographs were assessed for change in fracture alignment. Variation in the femoral neck offset and abductor lever arm measurements was performed using the contralateral hip as control. Functional outcome was assessed using SF-36, Harris Hip Score (HHS) and a gait analysis device. The average patient age was 78 years. Fifty-one (94%) healed without complications. Surgical fixation failed in two patients and one patient developed avascular necrosis. The average femoral neck shortening was 1.7 mm. RESULTS: The average difference in femoral neck offset and the abductor lever arm measurement at the latest follow up was 3.5 and 1.5 mm respectively. The average score on physical, mental components of SF-36 and HHS was 42 and 47 and 87 respectively. By 6 months, patients on average recovered 94% of the single limb stance time, 98% of cadence, 90% of cycle duration, 96% in stride length compared to the uninjured side. CONCLUSION: Reduction with a stable calcar pivot, intraoperative compression and length-stable fixation can achieve high union rates with minimal femoral neck shortening and improved functional outcomes. LEVEL OF EVIDENCE: IV, retrospective with historical controls.

Complications of recombinant human BMP-2 for treating complex tibial plateau fractures: a preliminary report.

UNLABELLED: Bone morphogenic proteins (BMPs) are potent osteoinductive agents. Their use in fracture surgery is still being studied and the clinical indications are evolving. Heterotopic bone after BMP use in spine surgery is a known complication. While some literature describes the ability of BMP to enhance fracture healing, few articles describe complications of BMP. In tibial plateau fractures, after elevating the cartilage en mass, a subchondral void may be created in these fractures. Structural support provided by bone void-filling agents can be augmented with osteoinduction achieved by BMP. We asked whether heterotopic bone formation would occur more frequently with BMP-2 when used in tibial plateau fractures and whether BMP-2 enhanced the ability to maintain surgically restored subchondral bone integrity. Heterotopic bone developed more frequently in patients receiving BMP (10 of 17) than in patients not receiving BMP (one of 23). Four patients receiving BMP and no patients not receiving BMP underwent removal of heterotopic bone. Maintenance of subchondral bone integrity was similar without and with the use of BMP. BMP is a potent osteoinductive agent; however, when used for an off-label indication in periarticular situations, complications such as heterotopic bone are common and increase reoperation rates. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Osteochondral lesions of talus associated with ankle fractures.

BACKGROUND: Residual ankle pain and stiffness is not uncommon after ankle fractures. Proposed etiologies include ligamentous instability, joint arthrosis and osteochondral injuries. We studied the incidence of osteochondral lesions of the talus (OCLT) with various ankle fracture patterns and assessed their impact on functional outcome. MATERIALS AND METHODS: Preoperative MRI of 153 patients with ankle fractures who underwent operative fixation was studied. Ligamentous structures around the ankle and OCLT were assessed by MRI. The OCLT was graded as follows: 0, normal; 1, hyperintense but morphologically intact cartilage; 2, fibrillations or fissures not extending into the bone; 3, cartilage flap or bone exposed; 4, loose undisplaced fragment; 5, displaced fragments. Functional outcome was assessed using Foot and Ankle Outcome Scoring (FAOS) at a minimum of 6 months. Outcome between the OCLT and non OCLT group with similar fracture pattern was compared using Fischer's exact test. RESULTS: There were 26 (17%) associated OCLT; four grade I, five grade II, one grade III, eight grade IV, and eight grade V lesions. Three were associated with supination adduction, 21 with supination external rotation injuries and two with pronation external rotation injuries. In the OCLT and the non OCLT group, the average symptom score, pain score, activities of daily living score, sports/recreation score and quality of life score was 80, 72, 79, 45, 50 and 73, 73, 79, 60, 45, respectively. There was no statistically significant difference between the two groups (p > 0.1). CONCLUSION: Osteochondral lesions were frequently associated with ankle fractures; however they had no significant impact on the functional outcome when associated with ankle fractures.

Direct visualization for syndesmotic stabilization of ankle fractures.

BACKGROUND: Ankle fractures with syndesmotic injury treated via standard trans-syndesmotic fixation have a high percentage of syndesmotic malreduction.(10) We established a protocol involving both direct syndesmosis visualization and meticulous tibial incisura reconstruction via the posterior malleolus fracture fragment, when present, via the attached, intact PITFL, then compared this with historic controls to assess improvement after this type of syndesmosis reconstruction. MATERIALS AND METHODS: One hundred forty-nine consecutive direct visualization patients were treated prospectively with either open posterior malleolus reduction and fixation, regardless of fragment size ("PM'': 38 patients), or, with no posterior malleolar fracture, open fixation with locked syndesmotic screws ("S'': 97 patients); fracture-dislocations combined both fixation types ("C'': 16 patients). The syndesmosis was opened and debrided in all. All patients had preoperative MRI and postoperative CT. Distances between the fibula and anterior and posterior incisura facets were measured on axial CT. An incongruent joint was defined as an A-P difference greater than 2 mm. Our historic controls were 25 patients previously fixed via indirect, fluoroscopic reduction and syndesmotic screws. RESULTS: In the direct visualization group, 24 ankles (16%) had incongruity, compared with 13 controls (52%). The average difference between anterior and posterior colliculi measurements between PM and C was significant (p = 0.017). CONCLUSION: Malreductions were significantly decreased in the direct visualization group. However, our reduction sometimes remains imprecise, even with direct visualization and attention to detail. Also, posterior malleolar reconstruction was more accurate than syndesmotic screw fixation in our study.

Efficacy of an aiming device for the placement of distal interlocking screws in trochanteric fixation nailing.

INTRODUCTION: Locked intramedullary nailing continues to be the surgical treatment of choice for most long bone fractures. Performing distal interlocks can be a technical challenge. Free hand (FH) technique remains to be most popular. Radiation exposure, particularly to the surgeon still remains a concern with this technique. METHOD: A prospective randomized analysis of 20 patients undergoing operative fixation with long trochanteric fixation nailing for intertrochanteric or subtrochanteric fractures was performed. The groups were randomized into (1) aiming arm group (AA) and (2) FH group by computer generated randomization technique. Two distal interlocking screws were placed in every case. Various parameters were analyzed including total operating time, distal interlocking time, total fluoroscopy time, distal fluoroscopy time and nail dimensions. The variables in two groups were compared to each other using Fischer's exact test. RESULT: The mean distal interlock time was 7.1 +/- 2.4 and 12.1 +/- 3.2 min for AA and FH techniques respectively. There was a 41.3% decrease in the distal interlock time with the device, which was statistically significant (P < 0.001). The distal interlock fluoroscopy time was 9.2 +/- 4.9 and 28.9 +/- 16.4 s with AA technique and the FH technique respectively. This 68.2% reduction in time taken for distal fluoroscopy was statistically significant (P < 0.001). However, the reduction in the total fluoroscopy time was statistically not significant. CONCLUSION: The AA is very efficient and user friendly and also reduces the radiation exposure.

Anterior knee pain following the lateral parapatellar approach for tibial nailing.

BACKGROUND: Anterior knee pain after intramedullary nailing of tibial shaft fractures is a common clinical problem, with various etiologies. We have used a lateral parapatellar approach with atraumatic elevation of the infrapatellar fat pad to expose the starting point. Our hypothesis was that this approach leads to a low incidence of knee pain. METHODS: We conducted a retrospective study of 78 patients suffering from tibia fractures treated by a single surgeon. Fifty patients were available for the study. All fractures were fixed with a reamed intramedullary nail using the modified lateral approach. Complaints of knee pain and range of motion as well as keeling ability were examined in the clinic visit and recorded in the patients' charts. Lysholm knee scores were collected following the last follow-up visit. Average follow-up was 13 months (range 6-26 months). RESULTS: Nine patients (19%) had subjective anterior knee pain when directly questioned. Eighty-two percentage of patients had no difficulty kneeling and this was significantly correlated with lack of knee pain. Good or excellent knee scores were reported by 92% of patients. Average knee flexion was 130 degrees . There was a negative correlation between the presence of open fracture and outcome. No correlation was found between knee pain and nail insertion depth or coronal alignment. CONCLUSION: The modified lateral parapatellar approach with careful dissection of the fat pad may significantly reduce anterior knee pain after intramedullary nailing of the tibial shaft.

The effect of operative time on in-hospital length of stay in revision total knee arthroplasty.

BACKGROUND: Revision total knee arthroplasty (TKA) is associated with increased rates of infections, readmissions, longer operative times, and lengths-of-stay (LOS) compared to primary TKA. Additionally, increasing operative times and prolonged postoperative LOS are independent risk factors for these postoperative complications in lower extremity total joint arthroplasty (TJA). This has led to an increased effort to reduce these risk factors in order to improve patient outcomes and reduce cost. However, the relationship between operative time and LOS has not been well assessed in revision arthroplasty. Therefore, the purpose of this study was to: (I) identify predictors of longer operative times; (II) identify predictors of longer LOS; and (III) evaluate the effects of operative time, treated as both a categorical variable and a continuous variable, on LOS after revision TKA. METHODS: The NSQIP database was queried for all revision TKA cases (CPT code 27487) between 2008 and 2016 which yielded 10,604 cases. Mean operative times were compared between patient demographics including age groups, sex, and body mass indexes (BMIs). To determine predictors of LOS, mean LOS were also compared between patient demographics in the same groups. To assess the correlation of operative time on LOS, the mean LOS for 30-minute operative time intervals were compared. Univariate analysis was performed with one-way analysis of variance (ANOVA) and t-tests. A multivariate analysis with a multiple linear regression model was performed to evaluate the association of LOS with operative times after adjusting for patient age, sex, and BMI. RESULTS: The mean LOS for revision TKA was 4 (±3) days. Further analysis showed that young age is associated with increased LOS (P<0.01). An analysis of operative times showed positive correlations with young age, BMI greater than 30 and male sex (P<0.05). The mean LOS of revision TKA patients was found to increase with increasing operative time in 30-minute intervals (P<0.001). Multivariate analysis showed that longer operative times had significant associations with longer LOS even after adjusting for patient factors (ß=0.102, SE =0.001, P<0.001). These results also showed that out of all of the study covariates, operative times had the greatest effect on LOS after revision TKA. CONCLUSIONS: Revision TKA is a complex procedure, often requiring increased operative times compared to primary TKA. This study provides unique insight by correlating operative times to LOS in over 10,000 revision TKAs from a nationwide database. Our results demonstrate that out of all the study covariates (age, sex, and BMI), operative times had the greatest effect on LOS. The results from this study indicate that less time spent in the operating room can lead to shorter LOS for revision TKA patients. This relationship further underscores the need for improved preoperative planning and intra-operative efficiency in an effort to decrease LOS and improve patient outcomes.

High association of posterior malleolus fractures with spiral distal tibial fractures.

UNLABELLED: Associations between fracture patterns are important and can ensure proper diagnosis and guide treatment. Occult posterior malleolus fractures associated with distal spiral tibia fractures often are underrecognized and the morbidity of a missed posterior malleolus injury can be substantial. We determined the association between the two injuries and evaluated the ability of a new protocol to improve management of these associated fractures. Of 62 consecutive patients with fractures of the distal third of the tibia, we retrospectively evaluated the first 39 patients and prospectively used a diagnostic protocol including computed tomography of the ankle in the subsequent 23 patients. The minimum followup was 3 months (mean, 25 months; range, 3-68 months). Twenty-four patients (39%) had fractures of the posterior malleolus. Before initiation of the protocol, intraarticular fractures were recognized in 33% (with one delayed diagnosis and one missed diagnosis), and after institution of the protocol, the detection rate was 48% with no known missed injuries and complete followup; however, with the limited power the detection rates were similar without and with the protocol. A spiral distal tibial shaft fracture with a proximal fibula fracture should alert the surgeon to investigate an occult ankle injury, particularly of the posterior malleolus. A protocol including computed tomography of the ankle may detect more injuries in a larger study. LEVEL OF EVIDENCE: Level II, prognostic study.

Anatomy of the greater trochanteric 'bald spot': a potential portal for abductor sparing femoral nailing?

Soft tissue injury occurs when using a piriformis portal for femoral nailing. Standard trochanteric portals also can injure the gluteus medius and external rotator tendons, which may be a source of hip pain after nailing. On the lateral facet of the greater trochanter, a "bald spot" may exist that is devoid of tendon insertion. This may be a potential portal for intramedullary nail insertion. We defined the dimensions and location of this region. Cadaveric specimens were dissected to expose the tendon insertions on the greater trochanter. A computer navigation system was used with a stylus and bone morphing to determine the tendon insertions and bald spot anatomy. The greater trochanteric bald spot is covered by the subgluteus medius bursa and has no tendon insertions. Its center lies 11 mm distal to the tip of the greater trochanter and 5 mm anterior to the midline. The shape is ellipsoid with a diameter of 21 mm. This region is large enough to accommodate the size of most nailing system reamers without tendon footprint infringement. Use of this modified entry site may reduce soft tissue injury with nailing procedures and minimize subsequent hip pain.