Traffic Cameras-An Effective and Sustainable Method of Reducing Traffic and Airborne Particles During Arthroplasty Surgery.

BACKGROUND: Traffic in the operating room (OR) create turbulence and contaminates air by bacterial shedding. Therefore, we examined: (1) if the number and duration of door openings were associated with increased particles during arthroplasty surgery; (2) if traffic cameras installed in the operating room were an effective intervention to decrease traffic and particles during arthroplasty surgery; and (3) the effectiveness of traffic camera over time. METHODS: Fifty cases were included between November 3, 2021, and June 22, 2022, with 25 cases in each group. Two particle counters were used to count particles sized 0.5 to 10 µm. One counter was positioned within the sterile field, and another between the OR doors. Two door counters were mounted to count door openings. For the intervention, traffic cameras were mounted facing each door and took snapshots with door openings. RESULTS: The number of door openings/minute was 30% less in the Intervention group (P < .001). The Intervention group had significantly lower particles by 26 to 43% in the operative field (0.5 µm, P = .01; 0.7 µm, P = .008; 1 µm, P = .007; 2.5 µm, P = .006; 5 µm, P = .01; and 10 µm, P = .01). The particles between the OR doors were decreased by 2 to 42% in the Intervention group and the difference was significant for (0.5 µm, P = 0.03; 0.7 µm, P = .02; and 1 µm, P = .03). The decrease in door openings and particles were sustained over the study period. CONCLUSION: The use of traffic cameras was an effective and sustainable method to limit OR traffic and door openings, which resulted in a reduction in particles in the operating room.

Decision making for early surgical technology adoption into Canada's healthcare system: a scoping review of the decision-making criteria, challenges, and opportunities.

OBJECTIVES: In 2020, Canada spent 12.9 percent of its GDP on healthcare, of which 3 percent was on medical devices. Early adoption of innovative surgical devices is mostly driven by physicians and delaying adoption can deprive patients of important medical treatments. This study aimed to identify the criteria in Canada used to decide on the adoption of a surgical device and identify challenges and opportunities. METHODS: This scoping review was guided by the Joanna Briggs Institute Manual for Evidence Synthesis and PRISMA-ScR reporting guidelines. The search strategy included Canada's provinces, different surgical fields, and adoption. Embase, Medline, and provincial databases were searched. Grey literature was also searched. Data were analyzed by reporting the criteria that were used for technology adoption. Finally, a thematic analysis by subthematic categorization was conducted to arrange the criteria found. RESULTS: Overall, 155 studies were found. Seven were hospital-specific studies and 148 studies were from four provinces with publicly available Web sites for technology assessment committees (Alberta, British Columbia, Ontario, and Quebec). Seven main themes of criteria were identified: economic, hospital-specific, technology-specific, patients/public, clinical outcomes, policies and procedures, and physician specific. However, standardization and specific weighted criteria for decision making in the early adoption stage of novel technologies are lacking in Canada. CONCLUSIONS: Specific criteria for decision making in the early adoption stage of novel surgical technologies are lacking. These criteria need to be identified, standardized, and applied in order to provide innovative, and the most effective healthcare to Canadians.

Five- to 12-Year Outcomes of a Short, Tapered, Highly Porous, Proximally Coated Cementless Femoral Stem.

BACKGROUND: Short cementless stems in total hip arthroplasty have gained increasing popularity, yet on-going studies of many of these implants are lacking. The aim of this study was to evaluate the minimum 5 year clinical and radiological results of a short, highly porous, single-tapered-wedge cementless femoral implant. METHODS: A retrospective study of 281 hips in 256 patients who had a minimum 5-year follow-up and underwent primary total hip arthroplasty between 2010 and 2016 were evaluated. Clinical and radiological results, complications, and the presence of postoperative thigh pain were evaluated. RESULTS: The mean follow-up was 8 years (range, 5 to 12 years). Clinically, patients had significant improvement in the average patient-related outcome scores postoperatively (Harris hip score: pre 47 versus post 95, University of California Los Angeles activity scale: pre 4 versus post 6, Western Ontario and McMaster Universities Arthritis Index: pre 51 versus post 3, Short Form (SF)-12 physical component summary : pre 32 versus post 52, Short Form-12 mental component summary: pre 49 versus post 55 (P < .001)). Radiographic signs of ingrowth were present in all hips. There were three patients (1.1%) who developed transient thigh pain postoperatively, all of which resolved with nonoperative management. CONCLUSION: This study provides the longest follow-up of this short, highly porous, single-tapered-wedge cementless femoral stem in the literature. This short, single-wedge stem with its highly porous coating demonstrated reproducible bone ingrowth in all patients and significant functional improvement with a very low rate of transient thigh pain.

Local tissue concentrations of cefazolin during total joint arthroplasty: a systematic review.

BACKGROUND: Periprosthetic joint infections (PJI) following joint arthroplasty are now the leading cause of reoperation and are associated with serious morbidity to the patient, often requiring several staged operations and a prolonged course of parenteral antibiotics. Prophylactic administration of intravenous antibiotics before skin incision is arguably the most important measure to prevent PJI; however, the dose effectiveness of cefazolin in target tissue is not well known. We aimed to identify parameters affecting local tissue concentration (LTC) of cefazolin. METHODS: We performed a literature search using the following keywords: "orthopaedics," "orthopedic," "arthroplasty" and "cefazolin." We included studies that measured LTC of cefazolin from samples obtained during either a total knee or total hip arthroplasty. RESULTS: Of the 332 records screened, we included 10 studies that described LTC of cefazolin. The included studies evaluated dosing (n = 7), procedure type (n = 3), body mass index (n = 1) and tourniquet utilization (n = 1). CONCLUSION: Few studies have measured LTC levels of antibiotics (or levels of cefazolin) to validate current recommendations for antibiotic prophylaxis in orthopedic surgery. With infection as the leading reason for early reoperation or revision surgery, the parameters affecting LTC during orthopedic procedures need to be further assessed.

Episode-of-care costs of total hip arthroplasty: day surgery versus same-day admission.

BACKGROUND: Although day surgery (DS) total hip arthroplasty (THA) has good patient satisfaction and a good safety profile, accurate episode-of-care cost (EOCC) calculations for this procedure compared to standard same-day admission (SDA) THA are not well known. We determined the EOCCs for patients who underwent THA, comparing DS and SDA pathways. METHODS: We evaluated the EOCCs for consecutive patients who underwent DS or SDA THA for osteoarthritis or osteonecrosis performed by a single surgeon at 1 academic centre from July 2018 to January 2020. Patient demographic and clinical data were recorded, as were preoperative diagnosis, type of anesthesia, type of implant used, surgical time and estimated blood loss. We determined direct and indirect costs from time of arrival at the presurgical unit to hospital discharge. We determined the EOCCs using an ABC method. RESULTS: The study included 50 patients who underwent THA (25 DS, 25 SDA). The mean length of stay in the SDA group was 45.1 (standard deviation [SD] 21.4) hours. Differences were observed between the 2 groups in mean age, mean Charlson Comorbidity Index score, surgical technique and mean surgical time (p ≤ 0.001). The mean total EOCC for SDA THA was $10 911 (SD $706.12, range $9944.07-$12 871.95), compared to $9672 (SD $546.55, range $8838.30-$11 058.07) for DS THA, a difference of 11.4%, mostly attributable to hospital resources such as laboratory tests, radiologic studies and cost of the surgical admission. CONCLUSION: Day surgery THA is cost-effective in selected patient populations. With the savings identified in this study, every 10 additional DS THA procedures would save sufficient resources to perform an additional THA operation.

The Psychological Impact of COVID-19 on Arthroplasty Surgeons.

BACKGROUND: After the COVID-19 pandemic declaration in March 2020, all the elective total joint replacement surgeries in Canada were abruptly canceled for an indefinite period of time. The principal objective of this study was to determine the prevalence of psychological morbidity experienced by arthroplasty surgeons during the peak of the first wave of the COVID-19 pandemic. Secondary objectives included characterizing influential variables affecting the surgeon's well-being and suggesting directives for improvement. METHODS: This study surveyed Canadian Arthroplasty Society (CAS) members regarding their psychological well-being using the validated General Health Questionnaire (GHQ-12), the Center for Epidemiological Studies Depression (CES-D) scale, and the Personal Wellbeing Index-Adult (PWI-A). As well, the survey included questions regarding concerns about COVID-19, precautionary measures, personal well-being, and sociodemographic characteristics. RESULTS: A total of 80 surgeons (52% of those surveyed) completed the questionnaire, representing all 10 provinces in Canada. The prevalence of emotional distress and depression were 38% and 29%, respectively. Psychological morbidity most commonly resulted from concerns of loss of income/operating time, experiences of emotional conflict, and generalized safety worries. The surgeons commonly (93%) demonstrated insight in recognizing the impact of COVID-19 on their emotional health. CONCLUSION: Canadian arthroplasty surgeons demonstrated emotional resilience and insight during COVID-19. Continual communication, as well as remuneration action plans, could improve the mental well-being of at-risk individuals.

New Implant Introduction in Total Hip Arthroplasty Using Radiostereometric Analysis: A Cautionary Note.

BACKGROUND: It has been proposed that the introduction of new hip implant technology in orthopedic surgery be conducted in a more controlled manner in order to properly ensure patient safety and the likelihood of favorable outcomes. This stepwise introduction would first require a prospective randomized study in a small cohort of patients, using radiostereometric analysis (RSA). The aim of this study is to determine if the recent literature supports the use of RSA as an early screening tool to accurately predict the long-term outcomes of cementless femoral stems. METHODS: A review of the recent published literature identified 11 studies that used RSA to predict the long-term stability of a cementless femoral component. These RSA predictive data were compared to the 10-year revision rate reported in the Australian Registry or in the published literature to determine its reliability. RESULTS: RSA data did not universally predict long-term stem fixation. In 2 of the 11 cases (18%), the RSA study incorrectly predicted the ability of the cementless stem to reliably osseointegrate. Of the 9 stems considered stable in the RSA studies, the 10 year registry and literature data confirmed that 6 implants had a low revision rate and were well performing. One stem has not performed well clinically and has been listed as having a higher than anticipated rate of revision in the registry. Two stems do not have sufficient follow-up. Of the 2 stems RSA predicted to do poorly, 1 is well performing at 10 years, and 1 has a high revision rate at 8 years. CONCLUSION: In the stepwise introduction of new hip implants, RSA should be best considered as an adjunct tool in deciding whether or not an implant should be evaluated in a larger multicenter clinical studies, rather than the sole criterion.

Redesigning operating room booking in a tertiary care academic centre during the COVID-19 pandemic.

SUMMARY: With the closure of most operating rooms (ORs) during the coronavirus disease 2019 (COVID-19) pandemic, the traditional allocation of block OR time needed to be redesigned. An important factor permitting the treatment of patients in a prioritized fashion was our pre-existing centralized OR booking (CORB) framework, which already required surgeons to categorize the priority level for each patient. The CORB, in conjunction with the multidisciplinary OR oversight committee that was formed during COVID-19 to review and triage the urgent cases, allowed for prioritization of cases among surgical services. Centralized OR booking provided opportunities that were essential in OR planning during the pandemic, including the ability to plan surgeries to maximize OR efficiency, minimize the number of admissions on any given day to the wards and the intensive care unit, flatten the number of admissions over the week and provide the flexibility to ramp up or down the number of ORs as the crisis changed.

The prognostic value of pain catastrophizing in health-related quality of life judgments after Total knee arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) is a highly effective procedure that yields reductions in pain and disability associated with end stage osteoarthritis (OA) of the knee. Quality of life instruments are frequently used to gauge the outcomes of total knee arthroplasty (TKA). However, research suggests that post-TKA reductions in symptom severity may not be the sole predictors of quality of life post-TKA. The primary objective of the present study was to examine the prognostic value of catastrophic thinking in health-related quality of life (HRQoL) judgments in patients with severe OA after TKA. METHODS: In this study we used a prospective cohort design to examine the value of pain catastrophizing in predicting HRQoL 1 year after TKA. Participants with advanced OA of the knee who were scheduled for TKA were recruited at one of three hospitals in Canada. The study sample consisted of 116 individuals (71 women, 45 men) who completed study questionnaires at their pre-surgical evaluation and 1 year after surgery. Hierarchical regression analysis was used to assess the unique contribution of pre-surgical pain catastrophizing to the prediction of post-surgical HRQoL judgments. RESULTS: The results of the hierarchical regression equation revealed that the overall model was significant, F (9,106) = 8.3, p < 001, and accounted for 36.4% of the variance in the prediction of post-surgical physical component score of HRQoL. Pain catastrophizing was entered in the last step of the equation and contributed significant unique variance (ß = -.35, p < .001) to the prediction of post-surgical physical component score of HRQoL above and beyond the variance accounted for by demographic variables, co-morbid health conditions, baseline HRQoL, and post-surgical reductions in pain, joint stiffness and physical disability. CONCLUSIONS: The current findings highlight the importance of pre-surgical catastrophic cognitions in influencing HRQoL judgments after TKA. The findings suggest that psychosocial interventions designed to reduce pain catastrophizing before TKA might contribute to better quality of life outcomes following surgery.

Changing Patient Expectations Decreases Length of Stay in an Enhanced Recovery Program for THA.

BACKGROUND: The implementation of care pathways in hip arthroplasty programs has been shown to result in a decreased length of stay (LOS), but often multiple elements of a care pathway are implemented at the same time. As a result, it is difficult to understand the impact each of the individual modifications has made to the patient's prepathway care. In particular, it is unknown what the role of patient expectations pertaining to anticipated LOS alone is on the LOS after primary THA. QUESTIONS/PURPOSES: (1) Does changing the patient's expectations regarding his or her anticipated LOS, without intentionally changing the rest of the care pathway, result in a change in the patient's LOS after primary THA? (2) Is the resultant LOS associated with the patient's age, gender, or day of the week the surgery was performed? METHODS: We retrospectively compared the LOS in 100 consecutive patients undergoing THA immediately after the implementation of a 4-day care pathway (4-day Group) with 100 consecutive patients, 3 months later, who were also in the same pathway but were told by their surgeon preoperatively and in the hospital to expect a LOS of 2 days (2-day Group). Aside from reeducation by the surgeon, there was no difference in the surgery or intentional changes to the intraoperative or postoperative management of the two groups. Only the patient and the surgeon were made aware of the accelerated discharge plan. We compared the LOS between the two groups and the number of patients who met their discharge goal. As well, the ability to meet the discharge goal for each group was further determined based on age, gender, and day of the week the surgery was performed. RESULTS: Overall, patients in the 2-day Group had a shorter LOS than those in the 4-day Group (2.9 ± 0.88 days versus 3.9 ± 1.71 days; mean difference 1 day; 95% confidence interval [CI], 0.60-1.36; p = 0.001). In the 2-day Group, the LOS was 2 days in 32% compared with 8% in the 4-day Group (odds ratio, 4.0; 95% CI, 1.76-9.11; p < 0.001). Men in the 4-day Group had a shorter LOS than women (3.4 ± 1.22 days versus 4.2 ± 1.89 days; mean difference 0.8 days; 95% CI, 0.17-1.78; p = 0.019), but there was no difference in LOS by gender in the 2-day Group (2.8 ± 0.81 days versus 3.1 ± 0.93 days; mean difference 0.3 days; 95% CI, -0.14 to 0.61; p = 0.219). For all patients > 40 years and < 90 years of age, a greater percentage of patients in the 2-day Group went home by postoperative day 2 than those in the 4-day Group (32% compared with 7%; odds ratio, 4.6; p < 0.001). In both groups, there was no difference in the LOS if the surgery was on Friday compared with an earlier day of the week (4-day Group: 3.4 ± 0.67 days versus 4.0 ± 1.80 days; p = 0.477 and 2-day Group: 2.8 ± 0.62 days versus 3.0 ± 0.93 days; p = 0.547). CONCLUSIONS: We found that a surgeon who sets a clear expectation in terms of LOS could achieve a reduction in this parameter. Although it is impossible to be certain in the context of a retrospective study whether other caregivers adjusted the pathway in response to the surgeon's preferences, and we suspect this probably did occur, this still points to an opportunity on the topic of expectations setting that future studies should explore. This study highlights the influence patient education and expectations has on the effectiveness of care pathways in THA as well as the importance of continuous reinforcement of discharge planning both preoperatively and in the hospital. LEVEL OF EVIDENCE: Level III, therapeutic study.

Is Cemented or Cementless Femoral Stem Fixation More Durable in Patients Older Than 75 Years of Age? A Comparison of the Best-performing Stems.

BACKGROUND: There is ongoing debate concerning the best method of femoral fixation in older patients receiving primary THA. Clinical studies have shown high survivorship for cemented and cementless femoral stems. Arthroplasty registry studies, however, have universally shown that cementless stems are associated with a higher rate of revision in this patient population. It is unclear if the difference in revision rate is a reflection of the range of implants being used for these procedures rather than the mode of fixation. QUESTIONS/PURPOSES: (1) Is the risk of revision higher in patients older than 75 years of age who receive one of the three cementless stems with the highest overall survivorship in the registry than in those of that age who received one of the three best-performing cemented stems? If so, is there a difference in risk of early revision versus late revision, defined as revision within 1 month after index surgery? (2) Are there any diagnoses (such as osteoarthritis [OA] or femoral neck hip fracture) in which the three best-performing cementless stems had better survivorship than one of the three best-performing cementless stems? (3) Do these findings change when evaluated by patient sex? METHODS: The Australian Orthopaedic Association National Joint Replacement Registry data were used to identify the best three cemented and the best three cementless femoral stems. The criteria for selection were the lowest 10-year revision rate and use in > 1000 procedures in this age group of patients regardless of primary diagnosis. The outcome measure was time to first revision using Kaplan-Meier estimates of survivorship. Comparisons were made for THAs done for any reason and then specifically for OA and femoral neck fracture separately. RESULTS: Overall, the cumulative percent revision in the first 3 months postoperatively was lower among those treated with one of the three best-performing cemented stems than those treated with one of the three best-performing cementless stems (hazard ratio [HR] for best three cementless versus best three cemented = 3.47 [95% confidence interval {CI}, 1.60-7.53], p = 0.001). Early revision was 9.14 times more common in the best three cementless stems than in the best three cemented stems (95% CI, 5.54-15.06, p = 0.001). Likewise, among patients with OA and femoral neck fracture, the cumulative percent revision was consistently higher at 1 month postoperatively among those treated with one of the three best-performing cementless stems than those treated with one of the three best-performing cementless stems (OA: HR for best three cementless versus best three cemented = 8.82 [95% CI, 5.08-15.31], p < 0.001; hip fracture: HR for best 3 cementless versus best three cemented = 27.78 [95% CI, 1.39-143.3], p < 0.001). Overall, the cumulative percent revision was lower in the three best cemented stem group than the three best cementless stem group for both males and females at 1 month postoperatively (male: HR = 0.42 [95% CI, 0.20-0.92], p = 0.030; female: HR = 0.06 [95% CI, 0.03-0.10], p < 0.001) and for females at 3 months postoperatively (HR = 0.15 [95% CI, 0.06-0.33], p < 0.001), after which there was no difference. CONCLUSIONS: Cementless femoral stem fixation in patients 75 years or older is associated with a higher early rate of revision, even when only the best-performing prostheses used in patients in this age group were compared. Based on this review of registry data, it would seem important to ensure the proper training of contemporary cementing techniques for the next generation of arthroplasty surgeons so they are able to use this option when required. However, the absence of a difference in the two groups undergoing THA after 3 months suggests that there can be a role for cementless implants in selected cases, depending on the surgeon's expertise and the quality and shape of the proximal femoral bone. LEVEL OF EVIDENCE: Level III, therapeutic study.

Washing the Femoral Canal Results in More Predictable Seating of a Short, Tapered Femoral Stem.

BACKGROUND: It is critical that a femoral rasp be effective in preparing the proximal femur to accept the size and the geometry of the femoral implant at the time of total hip arthroplasty. Short, tapered femoral stems may be at greater risk because they require the preparation of a short femoral region without any reaming. We undertook a study to determine the effect on implant seating in femora that were prepared by rasping alone with those that were rasped and the canal was washed with saline at the time of cementless THA with a short, tapered femoral implant. METHODS: We retrospectively analyzed the preoperative, intraoperative, and radiographic data on 170 consecutive patients undergoing a primary THA using a short, taper, uncemented metaphyseal-filling stem. The femur was prepared using a rasp-only technique. In the initial 99 patients, the canal was rasped, but not washed (group 1). In the subsequent 71 patients, the canal was rasped and before implant insertion the canal was washed with 100 cc of normal saline to remove all loose cancellous bone (group 2). Intraoperatively, the distance between the calcar cut and the rasp and subsequently, the calcar cut and the implant was measured. We defined a difference of more than 2 mm between the seating of the rasp and the final implant as a clinically significant mismatch. RESULTS: Overall, a clinically significant mismatch occurred in 50% (49/99) of cases in group 1 and 15% (11/71) in group 2. Multivariate logistic regression analysis corrected for preoperative, intraoperative, and radiographic measurements showed that washing significantly decreased the mismatch between the rasp and the implant (odds ratio, 5.32; confidence interval, 2.10-13.73; P < .001). CONCLUSION: Although the present rasp design is sufficient to create the geometric space for this short, metaphyseal stem, it does not adequately remove the bone debris to ensure reproducible seating of the implant. Washing the femoral metaphysis with saline to remove bone debris, after rasping and before inserting the final implant, significantly decreased the mismatch between seating of the final rasp and the implant in this cementless short, metaphyseal-filling, taper design stem. Level of Evidence III.

The effect of late radiotherapy on the progression of heterotopic ossification following total hip arthroplasty.

INTRODUCTION: Heterotopic ossification (HO) is a known complication after total hip arthroplasty (THA). Radiotherapy is an effective prophylactic treatment for high-risk patients. However, there is no treatment for patients who did not receive prophylactic treatment and subsequently develop HO postoperatively. This study was to determine whether late radiotherapy treatment can prevent the progression of HO following THA. METHODS: A chart review was performed to identify patients who developed HO following THA and were treated with late radiotherapy. All these patients received radiotherapy after their 6- or 12-week postoperative follow-up. Patients were evaluated radiographically pre- and 2 years post-radiotherapy using ImageJ software to measure the difference in the area of HO that formed. RESULTS: Nine patients with a mean age of 64.5 years were identified. All patients developed HO within 6- or 12-week postsurgery and received later radiotherapy. Eight of the nine hips (89%) treated with late radiotherapy demonstrated no further progression in the amount of bone formed. Overall, there was an increase in the mean total area of HO by 19 mm2 (2%), (p = 0.12). CONCLUSION: Late, low-dose radiotherapy is effective in preventing the progression of HO in patients who unexpectedly develop significant HO following THA.

Implant-delivered Alendronate Causes a Dose-dependent Response on Net Bone Formation Around Porous Titanium Implants in Canines.

BACKGROUND: Bony fixation of cementless orthopaedic implants is not always achieved, particularly in challenging scenarios such as revision surgery, trauma, and tumor reconstruction. An adjunct therapy for improving porous implant fixation could improve the reliability and durability of these reconstructive procedures. QUESTIONS/PURPOSES: In this study, we asked whether there is a positive and dose-dependent effect of the local release of the bisphosphonate alendronate from (1) alendronate/hydroxyapatite (HA) porous-coated titanium implants compared with bare metal porous controls; and (2) alendronate/HA on porous-coated titanium implants compared with HA-coated porous controls with respect to extent of bone ingrowth, bone apposition, and periimplant bone formation in a canine model? METHODS: Three-dimensional printed porous-coated cylindrical implants coated with three different doses (0.02, 0.06, and 0.18 mg/cm(2)) of alendronate were inserted bilaterally in the intramedullary canal of the proximal femora of 15 adult mongrel dogs (age range, 3-9 years; mean, 5 years) weighing between 36 kg and 60 kg (mean, 43 kg). In each dog, an implant coated with HA and one of three different doses of alendronate was inserted on one side while the contralateral femur had a bare metal porous control implant and an identical control implant with a coating of HA. The dose effect of locally released alendronate on the extent of bone ingrowth, bone apposition, and periimplant bone was assessed by backscattered electron microscopy of three pairs of cross-sections taken from each implant at 12 weeks after surgery. A linear mixed model was used to perform the statistical analyses to account for the correlation in the data resulting from the multiple measures performed on each dog. RESULTS: Compared with paired bare metal controls, periimplant bone increased by 92% (p = 0.007), and 114% (p < 0.001) in the femora with the alendronate implants with a dose of 0.06 mg/cm(2), or 0.18 mg/cm(2), respectively. At a dose of 0.02 mg/cm(2), there was no difference (46% change; p = 0.184, with the numbers available). The comparison of the alendronate-dosed implants with their HA-coated controls showed that the intermediate dose of 0.06 mg/cm(2) alendronate had the greatest effect on net bone formation. Bone apposition was enhanced with the 0.06-mg/cm(2) alendronate femoral implants (82%; p = 0.008), although there was no change in bone ingrowth (37% change; p = 0.902, with the numbers available). When compared with the HA-coated control implants, the greatest effect of the alendronate-dosed implants was the increased amount of periimplant bone at the intermediate dose of 0.06-mg/cm(2) (108%, p = 0.009). There was no effect of the low (0.02-mg/cm(2)) and high (0.18-mg/cm(2)) alendronate-dosed implants (4%, and 6%, respectively; p = 0.321, p = 0.502). Overall, all three alendronate-dosed implants revealed little to no effect on bone ingrowth compared with the HA-coated control implants. CONCLUSIONS: The local release of alendronate from a three-dimensional printed porous-coated implant from the three doses studied showed an overall improvement in bone apposition and periimplant bone at the intermediate dose compared with bare metal or with HA-coated controls, although the effect was more pronounced compared with bare metal. Long-term studies to show the effects of localized alendronate delivery and mechanical fixation would be the next step for future studies. CLINICAL RELEVANCE: Local release of alendronate from a three-dimensional printed porous-coated implant may improve the reliability of cementless fixation of currently available porous-coated bare metal implants.

Adult Reconstructive Surgery: A High-Risk Profession for Work-Related Injuries.

BACKGROUND: Adult reconstructive surgery is an orthopedic subspecialty characterized by surgical tasks that are physical, repetitive, and require some degree of stamina from the surgeon. This can result strain and/or injury of the surgeon's musculoskeletal system. This study investigates the prevalence of work-related injuries among arthroplasty surgeons. METHODS: A modified version of the physical discomfort survey was sent to surgeon members of the Hip Society, the International Hip Society, and the Canadian Orthopedic Arthroplasty via email. One hundred and eighty-three surgeons completed the survey. RESULTS: Overall, 66.1% of the arthroplasty surgeons reported that they had experienced a work-related injury. The most common injuries that occurred were low back pain (28%), lateral epicondylitis of the elbow (14%), shoulder tendonitis (14%), lumbar disc herniation (13%), and wrist arthritis (12%). Overall, 27% of surgeons took time off from work because of the injury. As the number of disorders diagnosed increased, there was a significant increase in the incidence of requiring time off work because of the disorder (P < .001) and also exacerbation of a previously diagnosed disorder (P < .01). Factors that significantly increased the risk of the surgeon requiring time off because of the disorder were age >55 years, practicing for more than >20 years, and performing >100 total hip arthroplasty procedures per year (P < .05). In addition, 31% of the orthopedic surgeons surveyed required surgery for their injury. CONCLUSION: Although most studies concentrate on the importance of patient safety and thus the quality of the health care system, the surgeon's safety is also considered an integral part of this system's quality. This study highlights a high prevalence of musculoskeletal work-related injuries among arthroplasty surgeons and indicates the need for the identification of preventive measures directed toward improving the operative surgical environment and work ergonomics for the surgeons.

Thirty-Day Complications of Conventional and Computer-Assisted Total Knee and Total Hip Arthroplasty: Analysis of 103,855 Patients in the American College of Surgeons National Surgical Quality Improvement Program Database.

BACKGROUND: Computer-assisted surgery (CAS) has gained popularity in orthopedics for both total knee arthroplasty (TKA) and total hip arthroplasty (THA) in the past decades. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent a primary, unilateral THA and TKA from 2011 to 2013. Multivariate analysis was conducted to compare the postoperative complications in patients whose surgery involved the use of CAS with those by conventional techniques. RESULTS: We identified 103,855 patients who had THA and TKA in the database between 2011 and 2013. There were higher overall adverse events (odds ratio [OR], 1.40; CI, 1.22-1.59), minor events (OR, 1.38; CI, 1.21-1.58), and requirements for blood transfusion (OR, 1.44; CI, 1.25-1.67) in the conventional group when compared with CAS for TKA. However, rate of reoperation was higher in the CAS group for TKA (OR, 1.60; CI, 1.15-2.25). The results also showed higher overall adverse events (OR, 2.61; CI, 2.09-3.26), minor events (OR, 2.82; CI, 2.24-3.42), and requirements for blood transfusion (OR, 3.41; CI, 2.62-4.44) in the conventional group when compared to CAS for THA. Nevertheless, superficial wound infections (OR, 0.46; CI, 0.26-0.81) were shown to be higher in the CAS group undergoing THA. CONCLUSION: The use of CAS in THA and TKA reduced the number of minor adverse events in the first 30 days postoperatively. However, CAS was associated with an increased number of reoperations and superficial infections. The clinical benefits and disadvantages of CAS should be considered when determining the potential benefit-cost ratio of this technology.

Favorable Results of a Short, Tapered, Highly Porous, Proximally Coated Cementless Femoral Stem at a Minimum 4-Year Follow-Up.

BACKGROUND: Shorter femoral stems have been increasingly used in total hip arthroplasty. However, there are few clinical studies evaluating the outcomes of these stems and comparing them to their regular-sized counterparts. METHODS: Our study provides radiologic and functional outcomes at 5-year mean follow-up of 131 cementless Tri-Lock Bone Preservation Stems, a short tapered stem with a proximal porous coating. RESULTS: Stem-related complications were low with one revision for stem aseptic loosening. Kaplan-Meier analysis estimated 99.2% stem survival rate at 5 years, comparable to conventional length Tri-Lock stems (99.8% at 8.9 years). CONCLUSION: This study demonstrates that the Tri-Lock Bone Preservation Stem can provide successful outcomes at 5-year follow-up. Further studies are required to determine the long-term outcome of these implants in patients with poor bone stock.

Acute revision hip arthroplasty: a previously unrecognized risk factor for heterotopic ossification.

BACKGROUND: The aim of this retrospective review was to determine the incidence and severity of heterotrophic ossification (HO) following acute revision total hip arthroplasty (THA), and whether this represents a significant risk factor for HO that should be treated prophylactically. MATERIALS AND METHODS: A total of seven patients (three men and four women) with a mean age of 55 years (39-70 years) who underwent a reoperation of their THA for any reason that required a hip arthrotomy within 3 weeks of their primary or revision THA were included, with a mean follow-up of 8.8 years (2-12 years). All patients were evaluated radiographically for any evidence of HO and clinically using the Harris Hip Score. RESULTS: All seven hips (100 %) developed HO, with 71 % being severe (Brooker III and IV HO). One hip (14 %) developed Brooker IV HO, four hips (57 %) developed Brooker III HO, and two hips (29 %) developed Brooker II HO. The patient's range of motion varied, but was very limited in three patients. Three patients (42.8 %) were not satisfied with their surgery; one patient had Brooker IV HO, and two patients had Brooker III HO. CONCLUSION: Acute reoperation after primary or revision THA is a significant risk factor for the development of extensive HO, which requires prophylactic treatment.