3D-Printed Metaphyseal Cones in Revision Total Knee Arthroplasties: Excellent Survivorship of 740 Cones at 5 Years.

BACKGROUND: Porous metaphyseal cones are frequently utilized during revision total knee arthroplasty (TKA) procedures. The purpose of the present study was to evaluate 3D-printed metaphyseal cones used for revision TKA, with specific emphasis on implant survivorship, radiographic appearance, and clinical outcomes after short-term follow-up. METHODS: We identified 740 cones (498 tibial, 242 femoral) that had been inserted during 533 revision TKA procedures that had been performed at a single tertiary care academic institution. Aseptic loosening (n = 199), periprosthetic joint infection (PJI) (n = 183), and instability (n = 84) were the most common reasons for the index revision. Type-2B or 3 bone loss was present in 67% of the knees. The mean age was 66 years, the mean body mass index was 34 kg/m 2 , and 55% of the patients were female. Serial radiographs were reviewed. The mean duration of follow-up was 4 years. RESULTS: The 5-year cumulative incidence of cone revision for aseptic loosening was 1% (95% confidence interval [CI], 0% to 3%). The 5-year cumulative incidence of any cone revision or removal was 6% (95% CI, 4% to 9%). In total, 37 cones (19 femoral, 18 tibial) were revised, with PJI (n = 23; 14 recurrent), periprosthetic femoral fracture (n = 3), arthrofibrosis (n = 3), and aseptic loosening of the femoral component and femoral cone (n = 3) as the most common reasons for cone revision. The 5-year cumulative incidence of any TKA re-revision was 14% (95% CI, 11% to 18%). There were a total of 67 re-revisions, with PJI (n = 38), persistent drainage (n = 6), and extensor mechanism disruption (n = 3) being the most common reasons. Radiographically, 2 unrevised femoral cones and 1 unrevised tibial cone appeared to be possibly loose; all 3 cones were in knees with distal femoral replacements or hinged constructs. CONCLUSIONS: This large series showed that 3D-printed titanium metaphyseal cones were very durable at short-term follow-up, with a 5-year cumulative incidence of cone revision for aseptic loosening of 1%. PJI was the most common reason for cone revision and any revision. LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Modular fluted tapered stems in two-stage reimplantation of previously infected total hip arthroplasties.

Aims: Uncemented implants are now commonly used at reimplantation of a two-stage revision total hip arthoplasty (THA) following periprosthetic joint infection (PJI). However, there is a paucity of data on the performance of the most commonly used uncemented femoral implants - modular fluted tapered (MFT) femoral components - in this setting. This study evaluated implant survival, radiological results, and clinical outcomes in a large cohort of reimplantation THAs using MFT components. Methods: We identified 236 reimplantation THAs from a single tertiary care academic institution from September 2000 to September 2020. Two designs of MFT femoral components were used as part of an established two-stage exchange protocol for the treatment of PJI. Mean age at reimplantation was 65 years (SD 11), mean BMI was 32 kg/m2 (SD 7), and 46% (n = 109) were female. Mean follow-up was seven years (SD 4). A competing risk model accounting for death was used. Results: The 15-year cumulative incidence of any revision was 24%. There were 48 revisions, with the most common reasons being dislocation (n = 25) and infection (n = 16). The 15-year cumulative incidence of any reoperation was 28%. Only 13 revisions involved the fluted tapered component (FTC), for a 15-year cumulative incidence of any FTC revision of 8%. Only two FTCs were revised for aseptic loosening, resulting in a 15-year cumulative incidence of FTC revision for aseptic loosening of 1%. Stem subsidence ≥ 5 mm occurred in 2% of unrevised cases. All stems were radiologically stable at most recent follow-up. Mean Harris Hip Score was 69 (SD 20) at most recent follow-up. Conclusion: This series demonstrated that MFT components were durable and reliable in the setting of two-stage reimplantation THA for infection. While the incidence of aseptic loosening was very low, the incidence of any revision was 24% at 15 years, primarily due to dislocation and recurrent PJI.

Marlex Mesh Reconstruction of the Extensor Mechanism: A Concise 5-Year Follow-up of 2 Previous Reports.

LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Contemporary outcomes of primary total hip arthroplasty in patients with inflammatory arthritis.

Aims: Contemporary outcomes of primary total hip arthroplasties (THAs) with highly cross-linked polyethylene (HXLPE) liners in patients with inflammatory arthritis have not been well studied. This study examined the implant survivorship, complications, radiological results, and clinical outcomes of THA in patients with inflammatory arthritis. Methods: We identified 418 hips (350 patients) with a primary diagnosis of inflammatory arthritis who underwent primary THA with HXLPE liners from January 2000 to December 2017. Of these hips, 68% had rheumatoid arthritis (n = 286), 13% ankylosing spondylitis (n = 53), 7% juvenile rheumatoid arthritis (n = 29), 6% psoriatic arthritis (n = 24), 5% systemic lupus erythematosus (n = 23), and 1% scleroderma (n = 3). Mean age was 58 years (SD 14.8), 66.3% were female (n = 277), and mean BMI was 29 kg/m2 (SD 7). Uncemented femoral components were used in 77% of cases (n = 320). Uncemented acetabular components were used in all patients. Competing risk analysis was used accounting for death. Mean follow-up was 4.5 years (2 to 18). Results: The ten-year cumulative incidence of any revision was 3%, and was highest in psoriatic arthritis patients (16%). The most common indications for the 15 revisions were dislocations (n = 8) and periprosthetic joint infections (PJI; n = 4, all on disease-modifying antirheumatic drugs (DMARDs)). The ten-year cumulative incidence of reoperation was 6.1%, with the most common indications being wound infections (six cases, four on DMARDs) and postoperative periprosthetic femur fractures (two cases, both uncemented femoral components). The ten-year cumulative incidence of complications not requiring reoperation was 13.1%, with the most common being intraoperative periprosthetic femur fracture (15 cases, 14 uncemented femoral components; p = 0.13). Radiological evidence of early femoral component subsidence was observed in six cases (all uncemented). Only one femoral component ultimately developed aseptic loosening. Harris Hip Scores substantially improved (p < 0.001). Conclusion: Contemporary primary THAs with HXLPE in patients with inflammatory arthritis had excellent survivorship and good functional outcomes regardless of fixation method. Dislocation, PJI, and periprosthetic fracture were the most common complications in this cohort with inflammatory arthritis.

Comparative Survival of Contemporary Cementless Acetabular Components Following Revision Total Hip Arthroplasty.

BACKGROUND: The advent of highly porous ingrowth surfaces and highly crosslinked polyethylene has been expected to improve implant survivorship in revision total hip arthroplasty. Therefore, we sought to evaluate the survival of several contemporary acetabular designs following revision total hip arthroplasty. METHODS: Acetabular revisions performed from 2000 to 2019 were identified from our institutional total joint registry. We studied 3,348 revision hips, implanted with 1 of 7 cementless acetabular designs. These were paired with highly crosslinked polyethylene or dual-mobility liners. A historical series of 258 Harris-Galante-1 components, paired with conventional polyethylene, was used as reference. Survivorship analyses were performed. For the 2,976 hips with minimum 2-year follow-up, the median follow-up was 8 years (range, 2 to 35 years). RESULTS: Contemporary components with adequate follow-up had survivorship free of acetabular rerevision of ≥95% at 10-year follow-up. Relative to Harris-Galante-1 components, 10-year survivorship free of all-cause acetabular cup rerevision was significantly higher in Zimmer Trabecular Metarevision (hazard ratio (HR) 0.3, 95% confidence interval (CI) 0.2-0.45), Zimmer Trabecular MetaModular (HR 0.34, 95% CI 0.13-0.89), Zimmer Trilogy (HR 0.4, 95% CI 0.24-0.69), DePuy Pinnacle Porocoat (HR 0.24, 95% CI 0.11-0.51), and Stryker Tritanium revision (HR 0.46, 95% CI 0.24-0.91) shells. Among contemporary components, there were only 23 rerevisions for acetabular aseptic loosening and no rerevisions for polyethylene wear. CONCLUSION: Contemporary acetabular ingrowth and bearing surfaces were associated with no rerevisions for wear and aseptic loosening was uncommon, particularly with highly porous designs. Therefore, it appears that contemporary revision acetabular components have dramatically improved upon historical results at available follow-up.

Lymphedema Is a Significant Risk Factor for Failure After Primary Total Hip Arthroplasty.

BACKGROUND: Lymphedema is a chronic disease characterized by fluid buildup and swelling that can lead to skin and soft-tissue fibrosis and recurring soft-tissue infections. Literature with regard to the increased risk of complications following a surgical procedure in patients with lymphedema is emerging, but the impact of lymphedema in the setting of primary total hip arthroplasty (THA) remains unknown. The purpose of this study was to review outcomes following primary THA performed in patients with lymphedema compared with a matched cohort without lymphedema. METHODS: Using our institutional total joint registry and medical records, we identified 83 patients (57 were female and 26 were male) who underwent THA with ipsilateral lymphedema. For comparison, these patients were matched 1:6 (based on sex, age, date of the surgical procedure, and body mass index [BMI]) to a group of 498 patients without lymphedema who underwent primary THA for osteoarthritis. Subsequently, postoperative complications and implant survivorship were evaluated for each group. The mean follow-up for each group was 6 years. Survivorship was compared between cohorts using Kaplan-Meier methodology and included both survivorship free of infection and survivorship free of reoperation or revision. Univariate Cox regression analysis was utilized to assess the association between patient factors for the time to event outcomes noted above. RESULTS: In patients with a history of lymphedema, there was an increased risk of complications (hazard ratio [HR], 1.97; p < 0.01), including reoperation for any cause (HR, 3.16; p < 0.01) and postoperative infection (HR, 4.48; p < 0.01). The 5-year infection-free survival rate was 90.3% for patients with lymphedema compared with 97.7% for patients without lymphedema (p < 0.01). CONCLUSIONS: Patients with lymphedema are at increased risk for complications, including reoperation and infection, following primary THA. These data emphasize the importance of appropriate preoperative counseling in this population and should encourage efforts to identify methods to improve outcomes, including further investigation of the effects of preoperative optimization of lymphedema prior to THA and methods for improved perioperative management. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Free Flap Coverage for Complex Primary and Revision Total Knee Arthroplasty.

BACKGROUND: Free flap coverage in the setting of a total knee arthroplasty is rare. The purpose of the current study was to evaluate the outcome of patients who underwent a free flap to assist with soft-tissue coverage following a complex total knee arthroplasty. METHODS: The authors used their institutional total joint registry to retrospectively review patients undergoing a free soft-tissue flap in the setting of complex primary and revision total knee arthroplasty. Among 29,069 primary and 6433 revision total knee arthroplasties from 1994 to 2017, eight (0.02 percent) required a free flap for wound coverage. This included three primary total knee arthroplasties (0.01 percent) for posttraumatic arthritis and five revision total knee arthroplasties (0.07 percent) in the setting of infection. Median follow-up was 4 years. RESULTS: Free flaps included vertical rectus abdominis (n = 3), anterior lateral thigh (n = 2), latissimus (n = 2), and transverse rectus abdominis (n = 1). There were no total flap losses; however, one patient required additional skin grafting. Reoperation occurred in six patients, of which four were revisions of the total knee arthroplasty for infection (n = 2) and tibial component loosening (n = 2). One patient ultimately underwent transfemoral amputation for persistent infection. Following reconstruction, there was improvement in the median Knee Society Score (49 versus 82; p = 0.03) and total range of motion between preoperative and postoperative assessments (70 degrees versus 85 degrees; p = 0.14). CONCLUSION: Free flap coverage in the setting of total knee arthroplasty was associated with a high rate of reoperation; however, the limb was able to be preserved in the majority of patients, with a reasonable functional outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Outcomes of operatively treated interprosthetic femoral fractures.

AIMS: The prevalence of ipsilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA) is rising in concert with life expectancy, putting more patients at risk for interprosthetic femur fractures (IPFFs). Our study aimed to assess treatment methodologies, implant survivorship, and IPFF clinical outcomes. METHODS: A total of 76 patients treated for an IPFF from February 1985 to April 2018 were reviewed. Prior to fracture, at the hip/knee sites respectively, 46 femora had primary/primary, 21 had revision/primary, three had primary/revision, and six had revision/revision components. Mean age and BMI were 74 years (33 to 99) and 30 kg/m2 (21 to 46), respectively. Mean follow-up after fracture treatment was seven years (2 to 24). RESULTS: Overall, 59 fractures were classified as Vancouver C (Unified Classification System (UCS) D), 17 were Vancouver B (UCS B). In total, 57 patients (75%) were treated with open reduction and internal fixation (ORIF); three developed nonunion, three developed periprosthetic joint infection, and two developed aseptic loosening. In all, 18 patients (24%) underwent revision arthroplasty including 13 revision THAs, four distal femoral arthroplasties (DFAs), and one revision TKA: of these, one patient developed aseptic loosening and two developed nonunion. Survivorship free from any reoperation was 82% (95% confidence interval (CI) 66.9% to 90.6%) and 77% (95% CI 49.4% to 90.7%) in the ORIF and revision groups at two years, respectively. ORIF patients who went on to union tended to have stemmed knee components and greater mean interprosthetic distance (IPD = 189 mm (SD 73.6) vs 163 mm (SD 36.7); p = 0.546) than nonunited fractures. Patients who went on to nonunion in the revision arthroplasty group had higher medullary diameter: cortical width ratio (2.5 (SD 1.7) vs 1.3 (SD 0.3); p = 0.008) and lower IPD (36 mm (SD 30.6) vs 214 mm (SD 32.1); p < 0.001). At latest follow-up, 95% of patients (n = 72) were ambulatory. CONCLUSION: Interprosthetic femur fractures are technically and biologically challenging cases. Individualized approaches to internal fixation versus revision arthroplasty led to an 81% (95% CI 68.3% to 88.6%) survivorship free from reoperation at two years with 95% of patients ambulatory. Continued improvements in management are warranted. Cite this article: Bone Joint J 2021;103-B(7 Supple B):122-128.

Synchronous Periprosthetic Joint Infections: High Mortality, Reinfection, and Reoperation.

BACKGROUND: Synchronous periprosthetic joint infections (PJIs) are a catastrophic complication with potentially high mortality. We aimed to report mortality, risk of reinfection, revision, reoperation, and implant survivorship after synchronous PJIs. METHODS: We identified 34 patients treated for PJI in more than one joint within a single 90-day period from 1990 to 2018. PJIs involved bilateral knee arthroplasty (27), bilateral hip arthroplasty (4), 1 knee arthroplasty and 1 elbow arthroplasty (1), 1 knee arthroplasty and 1 shoulder arthroplasty (1), and bilateral hip and knee arthroplasty (1). Irrigation and debridement with component retention was performed in 23 patients, implant resection in 10 patients, and a combination of irrigation and debridement with component retention and implant resection in 1 patient. A competing risk model was used to analyze implant survivorship, and Kaplan-Meier survival was used for patient mortality. Mean follow-up was 6 years. RESULTS: Mortality was high at 18% at 30 days and 27% at 1 year. The 1-year cumulative incidence of any reinfection was 13% and 27% at 5 years. The 1-year cumulative incidence of any revision or implant removal was 6% and 20% at 5 years. The 1-year cumulative incidence of unplanned reoperation was 25% and 35% at 5 years. Rheumatoid arthritis was associated with increased risk of mortality (HR 7, P < .01), as was liver disease (HR 4, P = .02). CONCLUSION: In the largest series to date, patients with synchronous PJIs had a high 30-day mortality rate of 18%, and one-fourth underwent unplanned reoperation within the first year.

Outcomes of Vancouver C Periprosthetic Femur Fractures.

BACKGROUND: Periprosthetic femur fractures (PFFs) that occur distal to a total hip arthroplasty, Vancouver C fractures, are challenging to treat. We aimed to report patient mortality, reoperations, and complications following Vancouver C PFFs in a contemporary cohort all treated with a laterally based locking plate. METHODS: We retrospectively identified 42 consecutive Vancouver C PFFs between 2004 and 2018. There was a high prevalence of comorbidities, including 9 patients with neurologic conditions, 9 with a history of cancer, 8 diabetics, and 8 using chronic anticoagulation. Mean time from total hip arthroplasty to PFF was 6 years (range 1 month to 25 years). All fractures were treated with a laterally based locking plate. Fixation bypassed the femoral component in 98% of cases and extended as proximal as the lesser trochanter in 18%. Kaplan-Meier survival was used for patient mortality, and a competing risk model was used to analyze survivorship free of reoperation and nonunion. Mean follow-up was 2 years. RESULTS: Patient mortality was 5% at 90 days and 31% at 2 years. Cumulative incidence of reoperation was 13% at 2 years. There were 5 reoperations including revision osteosynthesis for nonunion and/or hardware failure (2), debridement and hardware removal for infection (2), and removal of hardware and total knee arthroplasty for post-traumatic arthritis (1). Cumulative incidence of nonunion was 10% at 2 years. CONCLUSION: Patients who sustained a Vancouver C PFFs had a high mortality rate (31%) at 2 years. Moreover, 13% of patients required a reoperation within 2 years, most commonly for infection or nonunion.

Biconvex Patellar Components: 96% Durability at 10 Years in 262 Revision Total Knee Arthroplasties.

BACKGROUND: The optimal strategy to address osseous deficiencies of the patella during revision total knee arthroplasty (TKA) remains controversial. One possible solution is a cemented biconvex patellar component used such that the non-articular convexity both improves fixation and makes up for bone loss. The aim of this study was to determine the outcomes of the use of biconvex patellar components in a large series of revision TKAs. METHODS: From 1996 to 2014, 262 revision TKAs were performed at a single institution using a biconvex patellar component. Implant survivorship, clinical and radiographic results, and complications were assessed. The mean patient age at the TKA revision was 69 years, and 53% of the patients were female. The mean follow-up was 7 years. RESULTS: The 10-year survivorship free of revision of the biconvex patellar component due to aseptic loosening was 96%. The 10-year survivorship free of any revision of the biconvex patellar component was 87%. The 10-year survivorship free of any rerevision and free of any reoperation was 75% and 70%, respectively. The mean Knee Society Score (KSS) improved from 45.4 before the index revision to 67.7 after it. The mean residual composite thickness seen on the most recent radiographs was 18.1 mm. In addition to the complications leading to revision, the most common complications were periprosthetic patellar fracture (6%), of which 3 required revision; superficial wound infection (6%) requiring antibiotic therapy only or irrigation and debridement; and arthrofibrosis (3%). CONCLUSIONS: In this cohort of 262 revision TKAs, biconvex patellar components used to treat marked patellar bone loss demonstrated excellent durability with a 10-year survivorship free of patellar rerevision due to aseptic loosening of 96%. The biconvex patellar components were reliable as evidenced by substantial improvements in clinical outcomes scores and a low risk of complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Total Femur Antibiotic Spacers: Effective Salvage for Complex Periprosthetic Joint Infections.

BACKGROUND: A simultaneous periprosthetic joint infection (PJI) of an ipsilateral hip and knee arthroplasty is a challenging complication of lower extremity reconstructive surgery. We evaluated the use of total femur antibiotic-impregnated polymethylmethacrylate (PMMA) bone cement spacers in the staged treatment of such limb-threatening PJIs. METHODS: Thirteen patients were treated with a total femur antibiotic spacer. The mean age at the time of spacer placement was 65 years. Nine patients had polymicrobial PJIs. All spacers incorporated vancomycin (3.0 g/40 g PMMA) and gentamicin (3.6 g/40 g PMMA), while 8 also included amphotericin (150 mg/40 g PMMA). Eleven spacers were biarticular. Twelve spacers were implanted through one longitudinal incision, while 8 of 12 reimplantations occurred through 2 smaller, separate hip and knee incisions. Mean follow-up after reimplantation was 3 years. RESULTS: Twelve (92%) patients underwent reimplantation of a total femur prosthesis at a mean of 26 weeks. One patient died of medical complications 41 days after spacer placement. At latest follow-up, 3 patients had experienced PJI recurrence managed with irrigation and debridement. One required acetabular component revision for instability. All 12 reimplanted patients retained the total femur prosthesis with no amputations. Eleven (91%) were ambulatory, and 7 (58%) remained on suppressive antibiotics. CONCLUSION: Total femur antibiotic spacers are a viable, but technically demanding, limb-salvage option for complex PJIs involving the ipsilateral hip and knee. In the largest series to date, there were no amputations and 75% of reimplanted patients remained infection-free. Radical debridement, antimicrobial diversity, prolonged spacer retention, and limiting recurrent soft tissue violation are potential tenets of success. LEVEL OF EVIDENCE: IV.

Low-Dose vs Regular-Dose Aspirin for Venous Thromboembolism Prophylaxis in Primary Total Joint Arthroplasty.

BACKGROUND: Consensus on whether low-dose (81 mg) or regular-dose (325 mg) aspirin (ASA) is more effective for venous thromboembolism (VTE) chemoprophylaxis in primary total joint arthroplasties (TJAs) is not reached. The goal of this study is to evaluate the efficacy of low-dose and regular-dose ASA for VTE chemoprophylaxis in primary total hip arthroplasties and total knee arthroplasties. METHODS: We retrospectively identified 3512 primary TJAs (2344 total hip arthroplasties and 1168 total knee arthroplasties) with ASA used as VTE chemoprophylaxis between 2000 and 2019. Patients received ASA twice daily for 4-6 weeks after surgery with 961 (27%) receiving low-dose ASA and 2551 (73%) receiving regular-dose ASA. The primary endpoint was 90-day incidence of symptomatic VTEs. Secondary outcomes were gastrointestinal (GI) bleeding events and mortality. The mean age at index TJA was 66 years, 54% were female, and mean body mass index was 31 kg/m2. The mean Charlson Comorbidity Index was 3.5. Mean follow-up was 3 years. RESULTS: There was no difference in 90-day incidence of symptomatic VTEs between low-dose and regular-dose ASA (0% vs 0.1%, respectively; P = .79). There were no GI bleeding events in either group. There was no difference in 90-day mortality between low-dose and regular-dose ASA (0.3% vs 0.1%, respectively; P = .24). CONCLUSION: In 3512 primary TJA patients treated with ASA, we found a cumulative incidence of VTE <1% at 90 days. Although this study is underpowered, it appears that twice daily low-dose ASA was equally effective to twice daily regular-dose ASA for VTE chemoprophylaxis, with no difference in risk of GI bleeds or mortality. LEVEL OF EVIDENCE: III, retrospective cohort study.

Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies Project-Phase II Outcomes.

BACKGROUND: Our institution previously initiated a perioperative surgical home initiative to improve quality and efficiency across the hospital arc of care of primary total knee arthroplasty and total hip arthroplasty patients. Phase II of this project aimed to (1) expand the perioperative surgical home to include revision total hip arthroplasties and total knee arthroplasties, hip preservation procedures, and reconstructions after oncologic resections; (2) expand the project to include the preoperative phase; and (3) further refine the perioperative surgical home goals accomplished in phase I. METHODS: Phase II of the Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies project ran from July 2018 to July 2019. The evaluated arc of care spanned from the preoperative surgical consult visit through 90 days postoperative in the expanded population described above. RESULTS: Mean length of stay decreased from 2.2 days to 2.0 days (P < .001), 90-day readmission decreased from 3.0% to 1.6% (P < .001), and Press-Ganey scores increased from 77.1 to 79.2 (97th percentile). Mean and maximum pain scores and opioid consumption remained unchanged (lowest P = .31). Annual surgical volume increased by 10%. Composite changes in surgical volume and cost reductions equaled $5 million. CONCLUSION: Application of previously successful health systems engineering tools and methods in phase I of Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies enabled additional evolution of an orthopedic perioperative surgical home to encompass more diverse and complex patient populations while increasing system-wide quality, safety, and financial outcomes. Improved process and outcomes metrics reflected increased efficiency across the episode of care without untoward effects. LEVEL OF EVIDENCE: III Therapeutic.

Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies Project: Phase I Outcomes.

BACKGROUND: This study aimed to improve institutional value-based patient care processes, provider collaboration, and continuous process improvement mechanisms for primary total hip arthroplasties and total knee arthroplasties through establishment of a perioperative orthopedic surgical home. METHODS: On June 1, 2017, an institutionally sponsored initiative commenced known as the orthopedic surgery and anesthesiology surgical improvement strategy project. A multidisciplinary team consisting of orthopedic surgeons, anesthesiologists, advanced practice providers, nurses, pharmacists, physical therapists, social workers, and hospital administration met regularly to identify areas for improvement in the preoperative, intraoperative, and post-anesthesia care unit, and postoperative phases of care. RESULTS: Mean hospital length of stay decreased from 2.7 to 2.2 days (P < .001), incidence of discharge to a skilled nursing facility decreased from 24% to 17% (P = .008), and the number of patients receiving physical therapy on the day of surgery increased from 10% to 100% (P < .001). Press-Ganey scores increased from 74.9 to 75.8 (94th percentile), while mean and maximum pain scores, opioid consumption, and hospital readmission rates remained unchanged (lowest P = .29). Annual total hip arthroplasty and total knee arthroplasty surgical volume increased by 11.4%. Decreased hospital length of stay and increased surgical volume yielded a combined annual savings of $2.5 million across the 9 involved orthopedic surgeons. CONCLUSION: Through application of perioperative surgical home tools and concepts, key advances included phase of care integration, enhanced data management, decreased length of stay, coordinated perioperative management, increased surgical volume without personnel additions, and more efficient communication and patient care flow across preoperative, intraoperative, and postoperative phases. LEVEL OF EVIDENCE: III Therapeutic.

Total Hip Arthroplasty in Patients With Osteopetrosis.

BACKGROUND: Osteopetrosis is an inherited bone disease associated with high risk of osteoarthritis and fracture non-union, which can lead to total hip arthroplasty (THA). Bone quality and morphology are altered in these patients, and there are limited data on results of THA in these patients. The goals of this study were to describe implant survivorship, clinical outcomes, radiographic results, and complications in patients with osteopetrosis undergoing primary THA. METHODS: We identified 7 patients (9 hips) with osteopetrosis who underwent primary THA between 1970 and 2017 utilizing our total joint registry. The mean age at index THA was 48 years and included two males and five females. The mean follow-up was 8 years. RESULTS: The 10-year survivorship free from any revision or implant removal was 89%, with 1 revision and 1 resection arthroplasty secondary to periprosthetic femoral fractures. The 10-year survivorship free from any reoperation was 42%, with 4 additional reoperations (2 ORIFs for periprosthetic femoral fractures, 1 sciatic nerve palsy lysis of adhesions, 1 hematoma evacuation). Harris hip scores significantly increased at 5 years (P = .04). Five hips had an intraoperative acetabular fracture, and 1 had an intraoperative femur fracture. All postoperative femoral fractures occurred in patients with intramedullary diameter less than 5 mm at a level 10 cm distal to the lesser trochanter. CONCLUSION: Primary THA in patients with osteopetrosis is associated with good 10-year implant survivorship (89%), but a very high reoperation (58%) and periprosthetic femoral fracture rate (44%). Femoral fractures appear associated with smaller intramedullary diameters.

Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty: Contemporary Outcomes of 612 Hips.

BACKGROUND: Extended trochanteric osteotomies (ETOs) provide wide femoral and acetabular exposure, give direct access to the femoral medullary canal, and facilitate implant removal and new implant placement during selected revision total hip arthroplasties (THAs). Previous studies are limited by modest patient numbers and limited length of follow-up. The goals of the current study were to assess the union rate, complications, and outcomes of contemporary ETOs performed during revision THAs. METHODS: From 2003 to 2013, 612 ETOs were performed during revision THAs at 1 institution using 2 techniques: Paprosky (laterally based osteotomy; n = 367) and Wagner (anteriorly based osteotomy; n = 245). The indications for the revision procedures were aseptic loosening (65%), periprosthetic joint infection (18%), periprosthetic fracture (6%), femoral implant fracture (5%), and other (6%). The mean patient age was 69 years, and 57% of the patients were male. The mean number of previous THAs was 1.6. The median duration of follow-up was 5 years (range, 2 to 13 years). RESULTS: The mean Harris hip scores increased from 57 preoperatively to 77 at the latest follow-up (p < 0.001). Radiographic and clinical union was achieved in 98% of the patients at a mean of 6 months (range, 1 to 24 months). The mean migration of the proximal trochanteric osteotomy fragment prior to union was 3 mm (range, 0 to 29 mm). ETO fragment migration of >1 cm occurred in 7% (37) of the 501 hips that had radiographic analysis. Nine hips (2%) had nonunion of the ETO. Intraoperative fracture of the ETO diaphyseal fragment occurred in 22 hips (4%), postoperative fracture of the ETO diaphyseal fragment occurred in 3 hips (0.5%), and postoperative fracture of the greater trochanter occurred in 41 hips (7%). Survivorship at 10 years free of revision for aseptic femoral loosening, free of femoral or acetabular component removal or revision for any reason, and free of reoperation for any reason was 97%, 91%, and 82%, respectively. CONCLUSIONS: This large series of ETOs shows that the union rate is high and clinically important trochanteric migration is infrequent. The most common complications are fracture of the osteotomy fragment intraoperatively or postoperatively. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

More Predictable Return of Motor Function with Mepivacaine Versus Bupivacaine Spinal Anesthetic in Total Hip and Total Knee Arthroplasty: A Double-Blinded, Randomized Clinical Trial.

BACKGROUND: Spinal anesthesia provides several benefits for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), but historically comes at the cost of slow and unpredictable return of lower-extremity motor function related to the use of long-acting local anesthetics. In this prospective, double-blinded, randomized clinical trial we sought to determine if an alternative local anesthetic, mepivacaine, would allow more consistent return of motor function compared with low-dose bupivacaine spinal anesthesia during primary THA and TKA. METHODS: This trial was conducted at a single academic institution. Prior to trial initiation an internal pilot study determined that 154 patients were required to achieve 80% power. Patients were randomized in a 1:1 fashion with use of advanced computerized stratification based on procedure, age group, sex, and body mass index. Following the surgical procedure, motor function was assessed every 15 minutes in the nonoperative lower extremity according to the Bromage scale and discontinued once Bromage 0 was achieved (spontaneous movement at hip, knee, and ankle). RESULTS: Return of lower-extremity function was more predictable in patients who received mepivacaine than in those who received low-dose bupivacaine. Among patients who received mepivacaine, 1% achieved motor function return beyond 5 hours compared with 11% of patients who received bupivacaine (p = 0.013). The mean time to return of lower-extremity motor function was 26 minutes quicker in patients who received mepivacaine (185 minutes; 95% confidence interval, 174 to 196 minutes) compared with low-dose bupivacaine (210 minutes; 95% confidence interval, 193 to 228 minutes) (p = 0.016). There were no significant differences in safety outcomes including pain scores, time to participation in physical therapy, incidence of orthostatic hypotension, urinary retention, or transient neurologic symptoms in patients receiving mepivacaine compared with low-dose bupivacaine. CONCLUSIONS: In patients undergoing primary THA and TKA, spinal anesthesia with mepivacaine allowed more consistent return of lower-extremity motor function compared with low-dose bupivacaine, without a concomitant increase in complications potentially associated with spinal anesthetics. This is particularly of value in an era of short-stay and outpatient surgical procedures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Hip Arthroplasty Following Subtotal Sacrectomy for Chordoma.

BACKGROUND/AIM: Chordomas often affect the sacrum with a high predilection for local-regional recurrence. Patients typically retain their ability to ambulate, and the development of metastatic disease in the periacetabular region can have significant morbidity and pain with ambulation. The purpose of the study was to describe the outcome of patients undergoing a hip arthroplasty following resection of a sacral chordoma. PATIENTS AND METHODS: From 1990 to 2015, 84 patients underwent sacrectomy for chordoma, while four of these (5%) patients underwent hip arthroplasty. The most common level of nerve root sacrifice was S2-5 (n=2). The mean time between sacrectomy and hip arthroplasty was 7 years. Indications for arthroplasty included metastatic disease (n=3) and coxarthrosis (n=1). RESULTS: Postoperatively two patients ambulated with a gait aid, and no patient had a Trendelenburg gait. The mean Harris Hip Score significantly improved from 49 to 80 postoperatively (p=0.02). CONCLUSION: The results of this study indicate that hip arthroplasty is a durable treatment option for patients with metastatic disease or coxarthrosis following subtotal sacrectomy for chordoma.

Comparison of Porous Tantalum Acetabular Implants and Harrington Reconstruction for Metastatic Disease of the Acetabulum.

BACKGROUND: The periacetabular region is a common location for metastatic disease. Although large lytic acetabular defects are commonly treated with a hip arthroplasty with a cemented component according to a Harrington-style reconstruction, the use of highly porous uncemented tantalum acetabular components has been described. Currently, there are no direct comparisons of these reconstructive techniques. The purpose of this study was to compare the outcomes of the Harrington technique and tantalum acetabular component reconstruction for periacetabular metastases. METHODS: From 2 tertiary sarcoma centers, we retrospectively reviewed 115 patients (70 female and 45 male) with an acetabular metastatic defect who had been treated between 2002 and 2015 with a total hip arthroplasty using either the cemented Harrington technique (78 patients) or a tantalum acetabular reconstruction (37 patients). The mean patient age was 61 years, and the most common Eastern Cooperative Oncology Group status was 3 (39 patients). The mean follow-up for surviving patients was 4 years. RESULTS: An additional surgical procedure was performed in 24 patients (21%). Harrington-style reconstructions were more likely to require a reoperation compared with tantalum reconstructions (hazard ratio [HR], 4.59; p = 0.003). The acetabular component was revised in 13 patients (11%); 5 patients (4%) underwent revisions that were due to loosening of the acetabular component. The 10-year cumulative incidence of revision of the acetabular component for loosening was 9.6% in the Harrington group and 0% in the tantalum group (p = 0.09). The mean Harris hip score significantly improved following reconstruction (31 to 67 points; p < 0.001), with no significant difference (p = 0.29) between groups. CONCLUSIONS: In patients with periacetabular metastatic disease treated with total hip arthroplasty, an acetabular reconstruction strategy utilizing highly porous tantalum acetabular components and augments successfully provided patients with a more durable construct with fewer complications compared with the cemented Harrington-style technique. LEVELS OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.