Similar incidence of postoperative sciatic nerve palsy in direct anterior and posterior approach total hip arthroplasty.

BACKGROUND: Sciatic nerve palsy is a rare but devastating complication following total hip arthroplasty (THA). While the use of the direct anterior approach is increasing, limited data exist regarding sciatic nerve palsy and surgical approach. The purpose of this study was to determine the factors and outcomes associated with sciatic nerve palsy (SNP) after THA. METHODS: A retrospective analysis was performed at a single institution of 7 SNP that occurred in 4045 THA via direct anterior approach and 10 SNP in 8854 THA via posterior approach, being operated between 01 January 2017 and 12 December 2021. SNP patients were matched 1:5 to patients without SNP. Medical records were reviewed for demographics including age, gender, body mass index (BMI), comorbidities, and preoperative indication. Additional workup of SNP patients including advanced imaging and reoperation were documented. Recovery grades were assigned to all SNP patients at most recent clinical follow-up. RESULTS: 5 of the SNP were complete and 12 partial. They occurred as frequently with the direct anterior (0.17%) and posterior approach (0.11%, p = 0.5). The presence of femur cables and reoperations were associated with SNP (p = 0.04 and p = 0.002, respecitvely). Age, gender, BMI, comorbidities, and surgical indication had no effect on SNP. 4 of the 17 affected patients had almost complete recovery at latest follow-up. CONCLUSIONS: The incidence of SNP was similar in direct anterior and posterior approach. Surgeons should counsel patients regarding the risks of SNP regardless of the used approach.

Association Between Surgical Opioid Prescriptions and Opioid Initiation by Opioid-naïve Spouses.

OBJECTIVE: To determine whether surgical opioid prescriptions are associated with increased risk of opioid initiation by operative patients' spouses. SUMMARY OF BACKGROUND DATA: Adverse effects of surgical opioids on operative patients have been well described. Whether risks of surgical opioids extend to operative patients' family members is unknown. METHODS: This was a retrospective cohort study of opioid-naïve, married patients undergoing 1 of 11 common surgeries from January 1, 2011 to June 30, 2017. The adjusted association between surgical opioid prescriptions and opioid initiation by the operative patient's spouse in the 6-months after surgery was assessed. Secondary analyses assessed how this association varied with postoperative time. RESULTS: There were 318,022 patients (mean ± standard deviation age 48.8 ±9.3 years; 49.5% women). Among the 50,833 (16.0%) patients that did not fill a surgical opioid prescription, 2152 (4.2%) had spouses who filled an opioid prescription within 6-months of their surgery. In comparison, among the 267,189 (84.0%) patients who filled a surgical opioid prescription, 15,026 (5.6%) had spouses who filled opioid prescriptions within 6-months of their surgery [unadjusted P < 0.001; adjusted odds ratio (aOR) 1.37, 95% confidence interval (CI) 1.31-1.43, P < 0.001]. Associated risks were only mildly elevated in postoperative month 1 (aOR 1.11, 95% CI 1.00-1.23, P = 0.04) before increasing to a peak in postoperative month 3 (aOR 1.57,95% CI 1.391.76, P < 0.001). CONCLUSIONS: Surgical opioid prescriptions were associated with increased risk of opioid initiation by spouses of operative patients, suggesting that risks associated with surgical opioids may extend beyond the surgical patient. These findings may highlight the importance of preoperative counseling on safe opioid use, storage, and disposal for both patients and their partners.

Continuous Femoral Nerve Block Reduces the Need for Manipulation Following Total Knee Arthroplasty.

Peripheral nerve blocks improve both pain control and functional outcomes following total knee arthroplasty (TKA). However, few studies have examined the effects of different peripheral nerve block protocols on postoperative range of motion. The present study assessed the impact of a single-shot femoral nerve block (SFNB) versus continuous femoral nerve block (CFNB) on postoperative range of motion and the need for subsequent manipulation following TKA. Methods: We retrospective reviewed patient charts to identify patients who had undergone primary elective unilateral TKA by 2 surgeons at a high-volume orthopaedic specialty hospital over a 3-year period. A total of 1,091 patients received either SFNB or CFNB and were included in the data analysis. Identical surgical techniques, postoperative oral analgesic regimens, and rehabilitation protocols were used for all patients. Patients with <90° of flexion at 6 weeks postoperatively underwent closed manipulation under anesthesia (MUA). Results: Overall, 608 patients (55.7%) received CFNB and 483 patients (44.3%) received SFNB. Overall, 94 patients (8.6%) required postoperative manipulation for stiffness, including 36 (5.9%) in the CFNB group and 58 (12%) in the SFNB group. The 50% reduction in the need for manipulation in the CFNB group was independent of primary surgeon (p > 0.05). No significant differences were observed between the groups in terms of postoperative range of motion, either at the time of discharge or at 6 weeks postoperatively. A history of knee surgery, decreased preoperative range of motion, and decreased range of motion at the time of discharge were significantly associated with the need for further MUA (p = 0.0002, p < 0.0001, and p < 0.0001, respectively). Conclusions: Despite similar final postoperative range of motion between patients in both groups, our results suggest that CFNB may be superior to SFNB for reducing the need for postoperative manipulation after primary TKA. Furthermore, a history of ipsilateral knee surgery, decreased preoperative range of motion, and decreased range of motion at the time of discharge were identified as independent risk factors for postoperative stiffness requiring MUA after primary TKA. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Amyloidosis of the Femoral Neck: An Unusual Cause of Pathologic Fracture.

The deposition of amyloid within human tissue can be detrimental to the proper functioning of multiple organ systems. While the infiltration of the amyloid protein within the musculoskeletal soft tissues can lead to compressive neuropathies, tendon irritation or rupture, and joint stiffness, pathologic fracture as a result of amyloid deposition in bone is a rare manifestation of amyloidosis. We present a case of pathologic fracture of the femoral neck from amyloid deposition in a 59-year-old male on chronic hemodialysis who was found to have lytic lesions in his proximal femur. At the time of hemiarthroplasty, histopathologic analysis of a femoral head sample revealed apple-green birefringence of the deposits under polarized light, consistent with amyloid deposition. Clinicians should have a high index of suspicion for the atypical presentation of amyloidosis in a patient on chronic hemodialysis with lytic bone lesions.

Comparing the Risk of Osteonecrosis of the Femoral Head Following Intra-Articular Corticosteroid and Hyaluronic Acid Injections.

BACKGROUND: Although intra-articular corticosteroid injections (CSIs) are a cornerstone in the nonoperative management of hip pathology, recent reports have raised concerns that they may cause osteonecrosis of the femoral head (ONFH). However, these studies might have been limited by nonrepresentative patient samples. Therefore, the purpose of this study was to assess the incidence of ONFH after CSI and compare it with the incidence in a similar patient population that received a non-CSI injection. METHODS: This was a retrospective propensity-matched cohort study of patients in the MarketScan database who underwent an intra-articular hip injection from 2007 to 2017. Patients receiving hip CSIs were matched 4:1 with patients receiving hip hyaluronic acid injections (HAIs) based on age, sex, geographic region, comorbidities, type of hip pathology, injection year, and baseline and follow-up time using propensity scores. The patients' first injections were identified, and the time to development of ONFH was analyzed using Kaplan-Meier curves and Cox proportional-hazards models. Patients with a history of osteonecrosis or those who received both types of injections were excluded. RESULTS: A total of 3,710 patients undergoing intra-articular hip injection were included (2,968 CSIs and 742 HAIs; mean [standard deviation] age, 53.1 [9.2] years; 55.4% men). All baseline factors were successfully matched between the groups (all p > 0.57). The estimated cumulative incidence (95% confidence interval [CI]) of ONFH for CSI and HAI patients was 2.4% (1.8% to 3.1%) versus 2.1% (1.1% to 3.5%) at 1 year and 2.9% (2.2% to 3.7%) versus 3.0% (1.7% to 4.8%) at 2 years (hazard ratio, 1.05; 95% CI, 0.59 to 1.84; p = 0.88). The results held across a range of sensitivity analyses. CONCLUSIONS: The incidence of ONFH after intra-articular hip injection was similar between patients who received CSIs and those who received HAIs. Although this study could not determine whether intra-articular injections themselves (regardless of the drug that was used) lead to ONFH, the results suggest that ONFH after CSI often may be due, in part, to the natural course of the underlying disease. Future randomized controlled trials are needed to definitively answer this question; in the interim, clinicians may be reassured that they may continue judicious use of CSIs as clinically indicated. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Total Joint Arthroplasty in Homeless Patients at an Urban Safety Net Hospital.

INTRODUCTION: Homelessness is a key social determinant of health, and the patient population has grown to over 580,000. Total joint arthroplasty (TJA) is an effective treatment of symptomatic end-stage osteoarthritis of the hip and knee and has been shown to improve health-related quality of life in the general population. However, the literature on the outcomes of TJA among homeless patients is limited. METHODS: We retrospectively reviewed 442 patients who underwent primary, unilateral TJA between June 1, 2016, and August 31, 2017, at an urban, tertiary, academic safety net hospital. Based on self-reported living status, we classified 28 homeless patients and 414 control nonhomeless patients. Fisher exact tests, Student t-tests, and multivariate logistic regression were used to compare the demographics, preoperative conditions, and surgical outcomes between the two groups. RESULTS: The homeless group were younger, more often male, and smokers; had alcohol use disorder; and used illicit drugs. After controlling for age, sex, and preoperative medical and social conditions, homeless patients were 15.83 times more likely to have an emergency department visit (adjusted odds ratio, 15.83; 95% confidence interval, 5.05 to 49.59; P < 0.0001) within 90 days but had similar rates of readmission (P = 0.25), revision surgery (P = 0.38), and prosthetic joint infection (P = 0.25) when compared with nonhomeless patients. DISCUSSION: Although homeless patients did not have higher rates of readmission or revision surgery, homelessness still presents unique challenges for the TJA patients and providers. With careful preoperative optimization and collaborative support, however, the benefits of TJA may outweigh the risk of poor outcomes for these patients.

Image-Guided Intra-articular Hip Injections and Risk of Infection After Hip Arthroscopy.

BACKGROUND: Although intra-articular injections are important in the management of patients who may later undergo hip arthroscopy, conflicting data are available regarding the safety of such injections when administered within 3 months of surgery. Furthermore, despite the increasing use of image-guided intra-articular hip injections, it is unknown whether the type of imaging modality used is associated with infection after hip arthroscopy. PURPOSE: To assess the risk of infection associated with image-guided intra-articular injections before hip arthroscopy and, secondarily, compare that risk between ultrasound (US) and fluoroscopic (FL) guidance. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This was a retrospective cohort study of patients in a large national insurance database who underwent hip arthroscopy between 2007 and 2017. Patients were required to have continuous enrollment from at least 1 year before to 6 months after hip arthroscopy. Patient age, sex, geographic region, medical history, surgical details, and hip injections were collected. Patients who underwent injection ≤3 months preoperatively and >3 to ≤12 months preoperatively were compared with patients who did not undergo preoperative injection. Bivariate analyses and multivariable logistic regressions were used to assess the association between ipsilateral preoperative hip injection and surgical site infection within 6 months of surgery. RESULTS: We identified 17,987 patients (36.3% female; mean ± SD age, 37.6 ± 14.0 years) undergoing hip arthroscopy, 2276 (12.7%) of whom had an image-guided hip injection in the year preceding surgery (53.0% FL). Patients who underwent intra-articular injection ≤3 months preoperatively had similar infection rates to patients who did not undergo preoperative injection in the year before surgery for both the FL (0.46% vs 0.46%; P≥ .995) and the US cohorts (0.50% vs 0.46%; P = .76). Results persisted in adjusted analysis (FL ≤3 months: OR, 1.04; 95% CI, 0.32-3.37; P = .94; US ≤3 months: OR, 1.19; 95% CI, 0.36-3.90; P = .78). Similar results were seen for patients undergoing injections >3 to ≤12 months preoperatively. CONCLUSION: Postoperative infection was rare in patients undergoing intra-articular hip injection ≤3 months before hip arthroscopy and was no more common than in patients not undergoing preoperative injection. Moreover, no differences were seen in infection risk between US and FL guidance. Although intra-articular hip injections should always be administered with careful consideration, these results do not suggest that these injections are uniformly contraindicated in the 3 months preceding hip arthroscopy.

Bias Does Not Exist in Treating Knee Periprosthetic Joint Infection Among Patients With Substance Use Disorder.

Debridement, antibiotics with implant retention (DAIR), and 2-stage revision are standard surgical interventions for treating knee periprosthetic joint infection (PJI). Patients with substance use disorder (SUD), especially addictive drug use disorder (DUD), have been shown to receive inferior medical care in many specialties compared with nonusers. The authors identified patients with a diagnosis of PJI after knee arthroplasty who received either DAIR or 2-stage revision with the Nationwide Inpatient Sample (NIS) database from 2010 to 2014. Patients were stratified into 2 groups, patients with DUD and nonusers, based on Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, criteria. Descriptive analysis was conducted to show the national trend for knee PJI treatment among the 2 patient groups. Multivariate logistic regression was used to compare the prevalence of DAIR and 2-stage revision between these 2 groups, adjusted for likely confounders, including age, sex, income, race, and comorbidities. Among the 11,331 patients with knee infection, 139 (1.23%) had DUD. Compared with nonusers, patients with DUD were significantly younger (P<.001), had more chronic conditions (P<.001), and were predominantly in lower income quartiles (P=.046). The 2 groups did not differ in sex and race (P=.072 and P=.091, respectively). The authors found that 30.22% of patients with DUD and 36.36% of nonusers received DAIR. The difference in these proportions was not statistically significant (P=.135). The results did not change after adjustment for confounding factors (P=.509). The findings suggested that bias does not exist among orthopedic surgeons who choose DAIR or 2-stage revision for knee PJI among patients with DUD. [Orthopedics. 2021;44(3):e385-e389.].

Out-of-Network Facility Charges for Patients Undergoing Outpatient Total Joint Arthroplasty.

BACKGROUND: The utilization of outpatient (OP) total joint arthroplasty (TJA) is increasing. Although many arthroplasty surgeons and hospitals have longstanding agreements with insurance companies, it may take time for ambulatory surgery centers (ASCs) to establish in-network agreements. The purposes of this study are to investigate trends in out-of-network facility charges for OP-TJA, as well as compare rates of out-of-network facilities between ASC and hospital outpatient department (HOPD) OP-TJA. METHODS: This is a retrospective study of the MarketScan commercial claims database of OP-TJAs (same-day discharge) performed at ASCs or HOPDs from 2007 to 2017. Detailed demographic, geographic, operative, insurance, temporal, and financial details were collected. Out-of-network facility utilization was trended over time. Adjusted regressions compared the prevalence of out-of-network facilities between ASCs and HOPDs. RESULTS: There were 13,031 OP-TJA patients (58.8% total knee arthroplasty). Utilization of out-of-network facilities significantly decreased over time, from 27.8% of surgeries in 2007 to 9.5% in 2017 (Ptrend < .001); however, this was non-linear with a significant increase in 2013-2015 corresponding to rising use of out-of-network ASCs. Patients treated at ASCs were significantly more likely to be out-of-network than those treated at HOPDs (odds ratio 4.88, 95% confidence interval 4.28-5.57, P < .001; odds ratio 7.70, 95% confidence interval 6.42-9.25, P < .001 among the 11,870 patients with in-network surgeons). About 10.4% of patients with in-network surgeons were treated at out-of-network facilities. CONCLUSION: Although the utilization of out-of-network facilities has decreased, over 10% of patients with in-network surgeons face out-of-network facility charges, which may often come as a surprise. Efforts are warranted to reduce the out-of-network facility burden for OP-TJA patients, including accelerating insurance contracting and reviewing patients' coverage statuses.

Opioid Use Following Inpatient Versus Outpatient Total Joint Arthroplasty.

BACKGROUND: Although the risks of continued opioid use following inpatient total joint arthroplasty (TJA) have been well-studied, these risks in the outpatient setting are not well known. The purpose of the present study was to characterize opioid use following outpatient compared with inpatient TJA. METHODS: In this retrospective cohort study, opioid-naïve patients who underwent inpatient or outpatient (no overnight stay) primary, elective TJA from 2007 to 2017 were identified within a large national commercial-claims insurance database. For inclusion in the study, patients had to have been continuously enrolled in the database for ≥12 months prior to and ≥6 months after the TJA procedure. Multivariable analyses controlling for demographics, geography, procedure, year, and comorbidities were utilized to determine the association between surgical setting and risk of persistent opioid use, defined as the patient still filling new opioid prescriptions >90 days postoperatively. RESULTS: We identified a total of 92,506 opioid-naïve TJA patients, of whom 57,183 (61.8%) underwent total knee arthroplasty (TKA). Overall, 7,342 patients (7.9%) underwent an outpatient TJA procedure, including 4,194 outpatient TKAs. Outpatient TJA was associated with reduced surgical opioid prescribing (78.9% compared with 87.6% for inpatient procedures; p < 0.001). Among the 80,393 patients (86.9%) who received surgical opioids, the total amount of opioids prescribed (in morphine milligram equivalents) was similar between inpatient (median, 750; interquartile range, 450 to 1,200) and outpatient procedures (median, 750; interquartile range, 450 to 1,140; p = 0.47); however, inpatient TJA patients were significantly more likely to still be taking opioids after 90 days postoperatively (11.4% compared with 9.0% for outpatient procedures; p < 0.001). These results persisted in adjusted analysis (adjusted odds ratio, 1.13; 95% confidence interval, 1.03 to 1.24; p = 0.01). CONCLUSIONS: Outpatient TJA patients who received opioid prescriptions were prescribed a similar amount of opioids as those undergoing inpatient TJA procedures, but were significantly less likely to become persistent opioid users, even when controlling for patient factors. Outpatient TJA, as compared with inpatient TJA, does not appear to be a risk factor for new opioid dependence, and these findings support the continued transition to the outpatient-TJA model for lower-risk patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Postoperative assessment of vascularity of the femoral head after surgical hip dislocation.

Treatment for femoroacetabular impingement includes surgical hip dislocation and recontouring the femoral head-neck junction. However, a potential complication of this procedure is avascular necrosis. The purpose of this study was to assess radiographically the vascularity of the femoral head after surgical hip dislocation. Ten patients underwent surgical hip dislocation and recontouring of the femoral head-neck junction for femoroacetabular impingement. Postoperatively, all 10 patients underwent magnetic resonance imaging of the hip. Magnetic resonance imaging revealed no evidence of osteonecrosis in all patients. This study provides clear radiographic evidence that surgical hip dislocation may be performed without causing avascular necrosis of the femoral head.

Evidence-based analysis of removal of orthopaedic implants in the pediatric population.

BACKGROUND: Requested project of the Pediatric Orthopaedic Society of North America Evidenced-Based Medicine Committee. METHODS: The English literature was systematically reviewed for scientific evidence supporting or disputing the common practice of elective removal of implants in children. RESULTS: Several case series reported implant removal, but none contained a control group with retained implants. No articles reported long-term outcomes of retained implants in large numbers. Several small series describe complications associated with retained implants without evidence of causation. The existing literature was not amenable to a meta-analysis. By compiling data from the literature, it is possible to calculate a complication rate of 10% for implant removal surgery. The complication rate for removal of implants placed for slipped capital femoral epiphysis is 34%. Articles regarding postmarket implant surveillance and basic science were also reviewed. CONCLUSIONS: There is no evidence in the current literature to support or refute the practice of routine implant removal in children.

Postoperative range of motion following anterior cruciate ligament reconstruction using autograft hamstrings: a prospective, randomized clinical trial of early versus delayed reconstructions.

BACKGROUND: There is a common belief that surgical reconstruction of an acutely torn anterior cruciate ligament (ACL) should be delayed for at least 3 weeks because of the increased incidence of postoperative motion loss (arthrofibrosis) and suboptimal clinical results. HYPOTHESIS: There is no difference in postoperative range of motion or stability after ACL reconstructions performed either acutely or delayed. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients with an acute ACL tear were prospectively randomized to either early (within 21 days) or delayed (beyond 6 weeks) reconstruction using autograft hamstring tendon. Previous knee surgery on the index extremity and a multiligamentous injury were exclusionary criteria. Surgical technique and postoperative rehabilitation were identical for all patients. Postoperative assessments included range of motion and KT-1000 arthrometer measurements compared with the contralateral knee. Standardized outcome measures were used including single assessment numeric evaluation (SANE), Lysholm, and Tegner Activity Score. RESULTS: Seventy consecutive patients were enrolled, and 1 patient was dropped after a postoperative infection. Sixty-nine patients (34 acute, 35 delayed) with an average age of 27 years composed the study cohort. The mean time from injury to surgery was 9 days (range, 2-17 days) for patients in the early group and 85 days (range, 42-192) for those in the delayed group. The average follow-up from surgery was 366 days (range, 185-869). Articular cartilage and meniscal injuries were comparable between the 2 groups. There were no significant differences between the 2 treatment groups in degrees of extension or flexion lost relative to the nonoperative side, operative time, KT-1000 arthrometer differences, or subjective knee evaluations. CONCLUSION: Excellent clinical results can be achieved after ACL reconstructions performed soon after injury using autograft hamstrings. Although the authors do not advocate that all reconstructions should be performed acutely, they found that early ACL reconstructions do not result in loss of motion or suboptimal clinical results as long as a rehabilitation protocol emphasizing extension and early range of motion is employed.

The relationship between tears of the peroneus brevis tendon and the distal extent of its muscle belly: an MRI study.

BACKGROUND: Anomalous distal insertion of the peroneus brevis muscle belly has been implicated as a possible etiology of tears of the peroneus brevis tendon. The purpose of this study was to assess whether patients with operatively confirmed tears of the peroneus brevis tendons have a more distally located musculotendinous junction. METHODS: A retrospective review was done to identify all patients in whom direct inspection of the peroneal tendons was done between 1999 and 2004. The operative reports were evaluated, and all in whom a peroneal tendon tear was confirmed were included in the study group, Group I (29 patients). Group II represented an operative control group and consisted of all patients who had operative inspection of the peroneal tendons but did not have a tear (30 patients). Group III represented a radiographic control group and consisted of patients who had MRI of the ankle for reasons unrelated to lateral ankle symptoms (30 patients). For each patient, the vertical distance from the musculotendinous junction of the peroneus brevis tendon to the tip of the fibula was measured on sagittal MRI. The role of gender also was examined. The average distance between the musculotendinous junction of the peroneus brevis tendon to the distal fibula was calculated solely for men and women in all three groups. Statistical comparison of the groups was performed using the Mann-Whitney test. Interobserver reliability was determined by calculating Cronbach's Alpha coefficient. RESULTS: The average distance from the musculotendinous junction to the tip of the fibula was 33.1 cm, 41.2 cm, and 46.3 cm in Groups I, II, and III, respectively. The average distance in Group I was statistically significantly lower than the average distance in both Groups II and III (p < 0.05). Interestingly, the difference in the distance between Groups II and III also was statistically significant (p < 0.05). The average distances in both men and women were statistically significantly different (p < 0.05) among the three groups. CONCLUSION: It has been hypothesized that tears of the peroneus brevis tendon result from distal insertion of the peroneus brevis muscle belly. This study provides radiographic support for this hypothesis.