Total Hip Arthroplasty in Patients With Avascular Necrosis After Hematopoietic Stem Cell Transplantation.

The immunosuppressive regimens required for hematopoietic stem cell transplantation predispose recipients to complications, including avascular necrosis. Cancer-related comorbidities, immunosuppression, and poor bone quality theoretically increase the risk for perioperative medical complications, infection, and implant-related complications in total joint arthroplasty. This study reviewed 20 primary total hip arthroplasties for avascular necrosis in 14 patients. Outcomes were assessed at routine clinical visits and Harris hip scores were calculated. Follow-up radiographs were evaluated for component malposition, loosening, polyethylene wear, and osteolysis. Average follow-up was 44.5 months for all patients. Postoperative clinical follow-up revealed good to excellent outcomes, with significant improvement in functional outcome scores. There were no periprosthetic infections or revisions for aseptic loosening. There was 1 dislocation on postoperative day 40, which was treated successfully with a closed reduction. Two patients with a prior history of venous thromboembolism developed a pulmonary embolus on postoperative day 13 and 77, respectively. Four patients died several months to years after arthroplasty of complications unrelated to the surgical procedure. Total hip arthroplasty can both be safely performed and greatly improve quality of life in recipients of hematopoietic stem cell transplantation who develop avascular necrosis. However, prolonged venous thromboembolism prophylaxis should be carefully considered in this high-risk patient population. [Orthopedics. 2018; 41(2):e257-e261.].

Same Day Total Hip Arthroplasty Performed at an Ambulatory Surgical Center: 90-Day Complication Rate on 549 Patients.

BACKGROUND: There is an increasing interest in outpatient total hip arthroplasty (THA), as there are perceived benefits to the patient, insurer, and overall healthcare system. However, the safety of outpatient total joint arthroplasty has not been studied. METHODS: Five hundred forty-nine patients who underwent mini-posterior THA at a freestanding independent ambulatory surgical center (ASC) were reviewed. All patients were discharged to home on the day of surgery. RESULTS: The average age of the patients was 54.4 years (range 27-73). The average American Society of Anesthesiologists score was 1.6 (range 1-3). Of the 549 patients, 3 (0.5%) admitted from the surgery center to our local hospital. One patient was admitted for pain control after failing to disclose his long-term high-dose narcotic dependence, one patient was admitted for an acetabular component migration identified on postoperative x-ray, and one patient was admitted for hypotension, bradycardia, and an acute polyarthralgia exacerbation. An additional patient was seen 2 days after surgery in a local emergency department for oversedation secondary to narcotics and later discharged to home. CONCLUSION: Outpatient THA at an ASC is safe and effective when performed on the appropriately indicated patient. There were 4 visits to the hospital within 2 days of surgery. Only 1 was related to medical events, 2 were pain control and/or medication-related and the final was technique-related. Known orthopedic complications including infection, dislocation, and deep vein thrombosis appear consistent with the literature for a series of this size. Same day discharge THA in an ASC is safe and reproducible.

Fracture of the proximal tibia after revision total knee arthroplasty with an extensor mechanism allograft.

Extensor mechanism reconstruction with an extensor mechanism allograft (EMA) remains one of the most reliable methods for treating the extensor mechanism deficient total knee arthroplasty. We report 3 patients who were treated with an EMA who sustained a proximal tibial shaft fracture. In all 3 cases, a short tibial component was present that ended close to the level of the distal extent of the bone block. When performing an EMA, it is important to recognize that the tibial bone block creates a stress riser and revision to a long-stemmed tibial component should be strongly considered to bypass this point to minimize the risk of fracture.

Clinical results of a modular neck hip system: hitting the "bull's-eye" more accurately.

In this article, we present 2-year clinical results of a modular neck tapered hip stem, based on 634 patients from a 2-center study. Nearly half of the patients in this series required use of a head center location offered by the modular neck stem but not available in a nonmodular stem with an identical body. The modular neck enabled femoral-first preparation, which facilitates establishing the desired total version of the reconstruction. No fractures of a stem or modular neck occurred, and there were no dissociations of the head-neck junction. There were no complications or revisions related to the femoral implant. Optimal leg length, femoral offset, and total version are goals in hip arthroplasty. Neck modularity improves the ability to re-create the head center to achieve these goals and to hit the "bull's-eye" in total hip arthroplasty.

Gull-wing osteotomy for the treatment of the deficient patella in revision total knee arthroplasty.

Reconstruction of the deficient patella remains a challenge in revision total knee arthroplasty. Twelve consecutive patients who had a knee revision in which a nonresurfacable patella was treated with a gull-wing patellar osteotomy were followed using a computerized database. Radiographs revealed successful healing of the osteotomy in all patients with central tracking of the patella in the trochlear groove. There was a significant improvement in the range of motion and Knee Society scores. There were no patellar fractures or significant patellar malalignment in this series. This technique has shown promising results for the treatment of the nonresurfacable patella during revision total knee arthroplasty, and we conclude that it is a viable method of patellar salvage reserved for the most advanced cases of patellar bone stock compromise.

Removal of a well-fixed trabecular metal monoblock tibial component.

The use of porous tantalum (Trabecular Metal; Zimmer, Inc, Warsaw, Ind) in hip and knee reconstruction has become increasingly popular over the past few years. Widespread clinical use of porous tantalum tibial components for primary total knee arthroplasty has been tempered in part by the perceived difficulty in removing this implant after bone ingrowth has occurred. We present an easy, reproducible, and inexpensive technique for removal of a well-fixed Trabecular Metal Monoblock Tibial Component (Zimmer), which has been used in 4 revision knees. This technique does not require the use of any specialized equipment and results in the production of minimal metallic debris.

Posterolateral minimal incision for total hip replacement: technique and early results.

There presently exists in the arthroplasty community a new and heightened level of interest in minimally invasive techniques for total joint replacement. Several investigators have published their personal experience with differing techniques, all concluding that there are multiple advantages to this concept for total hip arthroplasty. The author's perception is that the advantages of minimally invasive posterolateral approach total hip arthroplasty are multiple. They include more rapid rehabilitation and more prompt return to activities of daily living. There has been a clear impression that patients experience less postoperative pain and improved satisfaction. A concomitant decrease in hospital stay has been noted. Patients undergoing the procedure today have an average length of hospital stay of 48 hours, which represents a 30% decrease in hospital stay over the last year. Other advantages include improved cosmesis and potentially reduced blood loss without increasing complication rates. Surgeons performing this procedure require familiarity with the local anatomy, because the technique is certainly more demanding than is traditional arthroplasty. It is perhaps a technique best applied by surgeons performing more than 50 total hip arthroplasties a year. The two keys to successful application of the technique are adequate surgical training and use of specialized instrumentation. It is a difficult procedure to teach, because only one person is able to access a good view of the anatomy at any one time. With respect to component positioning, there may be a tendency to vertical cup placement early in one's experience. This is avoided by proper location of the skin incision and by use of a dog legged acetabular component inserter that facilitates proper positioning of the component despite the prominence of the distal angle of the skin incision. A tendency to eccentric reaming of the acetabulum may be noted if the proximal femur is not adequately retracted anteriorly. One must beware of the potential for inadvertent levering of the acetabular reamers on the posterior aspect of there tracted femur if the operative surgeon is not performing the reaming of the acetabulum. Particularly in patients who are larger there may be a tendency toward an excessively posterior starting point in the femoral canal when broaching the femoral component. This is best avoided by careful attention at this portion of the procedure to any pressure being applied to the broach handle by the proximal corner of the skin incision. The skin incision must be lengthened at this point if the problem presents. Finally, there remains a risk for proximal skin abrasion, particularly when one is beginning to decrease, the incision length in posterolateral approach to total hip arthroplasty. The evolution of proximal femoral elevators and skin protectors has decreased this risk to an extremely low level.