Complication, Survival, and Reoperation Rates Following Girdlestone Resection Arthroplasty.

Failed hip arthroplasty patients unsuitable for reimplantation may be offered Girdlestone resection arthroplasty (GRA). The purpose of this study was to detail complication and failure rates following GRA. Our results show that 66% (25/38), 34% (13/38), and 76% (29/38) of GRA patients experienced minor, major, and overall complications, respectively. Within 90 days of surgery, three patients required additional surgery and four died. Reoperation or death occurred an average of 26.3 (SD=3.5) and 55.6 (SD=76) months after surgery, respectively. Male gender and increasing comorbidity significantly predicted higher reoperation and mortality rates, P=0.01 and P=0.04, respectively. Complication and mortality rates following GRA are among the highest reported succeeding elective hip surgery for non-traumatic etiology.

Acetabular imprinting device (AID) improves acetabular component positioning: a Sawbones® study.

The purpose of this study was to define the ability of a novel acetabular positioning device with 3D preoperative planning (AID) to improve acetabular component placement in total hip arthroplasty. Four surgeons placed the acetabular component in two Sawbones® models using three different methods: standard method, 3D planning method, and the AID method. The AID significantly decreased the mean deviation of actual acetabular component inclination from the preoperative plan when compared with standard and 3D planning methods (p = 0.003). Overall, AID reduced the number of malpositioned implants to 12.5%, compared with 87.5% in the standard method and 75% in the 3D planning method without use of the AID (p = 0.005). A clinical trial is needed to compare AID to standard surgical techniques.

Comparison of mechanical and nonmechanical failure rates associated with rotating hinged total knee arthroplasty in nontumor patients.

Rotating hinge total knee arthroplasty (TKA) has had acceptable to poor results in terms of clinical outcomes and survivorship, leading to skepticism with regard to its use. A total of 271 hinged TKAs performed between 1998 and 2008 were studied to determine survivorship and factors affecting survivorship. A median survivorship of 6.9 years was found for the best-case cohort (n = 111), and 4.1 years, for the worst-case group (n = 174). Of the 111 patients, 51 (45.9%) experienced a failure that required reoperation, with more than half of these (29/51, or 56.9%) due to nonmechanical modes of failure. Comparison of the kinematic hinge implants with the distal femoral replacements showed that the Kaplan-Meier survivorship was slightly higher for the patients with distal femoral replacements, although this was not significant (P = .962). Our study suggests that the hinge TKA is well designed and provides acceptable survivorship in healthy patients who do not have nonmechanical complications.

Dedicated orthopedic operating room unit improves operating room efficiency.

We investigated the effectiveness of dedicated orthopedic operating rooms (OR) on minimizing time spent on perioperative processes to increase OR throughput in total knee and hip arthroplasty procedures. The use of a dedicated orthopedic unit that included 6 ORs with staff allocated only for those ORs was compared to the use of a traditional staffing model. After matching to simulate randomization, each group consisted of 422 procedures. The dedicated orthopedic unit improved average anesthesia controlled time by 4 minutes (P<.001), operative time by 7 minutes (P=.004) and turnover time by 8 minutes (P<.001). An overall improvement of 19 minutes per procedure using the dedicated unit was observed. Utilizing a dedicated orthopedic unit can save time without increasing adverse events.

Validity of patient-reported comorbidities before total knee and hip arthroplasty in patients older than 65 years.

Obtaining preoperative medical histories in elderly patients can be challenging, and tools have been developed to aid in history gathering. The purpose of this study is to determine the agreement between patient- and physician-reported histories before total knee or hip arthroplasty. Three hundred eighty-two patients older than 65 years completed a preoperative morbidity assessment form preoperatively. Sensitivity, specificity, κ, and agreement were calculated for each dichotomous response. Diabetes (κ = 0.77) and lung disease (κ = 0.68) had substantial agreement. Fourteen comorbidities ranged from slight to moderate agreement. Osteoarthritis and peripheral vascular disease had no agreement. These results highlight the incongruence between patient- and physician-reported comorbidities and emphasizes the need for detailed histories by health care professionals for medically complicated elderly patients preoperatively.

Intraoperative Proximal Tibia Periprosthetic Fractures in Primary Total Knee Arthroplasty.

Intraoperative fracture of the proximal tibia is a rare complication of total knee arthroplasty (TKA) with few studies available reporting risk factors or prognosis. A review of our prospective joint registry was performed to determine the incidence and associated risk factors of intraoperative tibia fractures during primary TKA; 14,966 TKAs of all manufacturers were performed with 9 intraoperative tibia fractures. All fractures occurred in a single TKA design. There were 8,155 TKAs of this design performed with a fracture incidence of 0.110%. All but one fracture occurred on the medial tibial plateau, and all but one occurred during preparation of the tibia with keel punching. A control group of 75 patients (80 knees) with the same TKA design were randomly selected. Baseplates size 3 or smaller were less likely to experience an intraoperative fracture (odds ratio [OR]: 0.864, 95% confidence interval [CI]: 0.785-0.951), as were knees with a polyethylene insert thickness of 13 mm or larger (OR: 0.882, 95% CI: 0.812-0.957). Fractures were treated with a variety of different methods, but every patient had at least one screw placed and most (67%) had postoperative weight-bearing restrictions. At final follow-up, there were no cases of nonunion, component subsidence, or need for reoperation. Intraoperative tibia fractures are a rare complication of this TKA design at 0.11%. Knees with baseplates of size ≤3 and polyethylene thickness ≥13 mm were less likely to experience intraoperative fracture. These findings may be related to the depth of tibial resection, requiring the use of a thicker polyethylene insert, and a change in the keel width in implants size 4 or larger. No fracture patients required reoperation.

Factors Influencing Survivorship in Vasculopathic Patients.

Total knee arthroplasty (TKA) in patients with peripheral vascular disease has sparsely been studied. This study examined patient and radiographic factors that could affect reoperation free survival in these patients. We retrospectively reviewed TKA procedures performed in patients with nonpalpable pulses on physical examination between January 1, 2004, and December 31, 2013. Ninety-two cases met inclusion criteria. Preoperative ankle-brachial index (ABI), date of surgery, sex, age, body mass index (BMI), tourniquet use, American Society of Anesthesiologists (ASA) score, presence of preoperative calcifications, and follow-up data were obtained. Failure was defined as reoperation. Patients were included if they experienced a failure or had at least 2 years of follow-up. Reoperation free survival was calculated by Kaplan-Meier's analysis. Odds ratios (ORs) were calculated for patient factors; hazard ratios (HRs) were calculated by Cox's regression analysis. Ninety-two TKAs were included in the study. Mean age was 68.8 years, mean BMI was 32.15, and mean ASA score was 2.44. Tourniquet was used in 78 patients. Mean preoperative ABI was 1.016. Nine patients had calcifications on X-ray prior to surgery. Reoperation free survival was 9.378 years. Patients with a preoperative ABI of below 0.7 had shorter reoperation free survival (ABI <0.7, 6.854 years; ABI >0.7, 9.535 years; p = 0.015). Patients with a preoperative ABI below 0.7 had greater odds of failure and were at higher risk for earlier failure (OR = 6.5, p = 0.027; HR = 1.678, p = 0.045). When corrected for age, sex, and BMI, the HR for patients with a preoperative ABI below 0.7 worsened (HR = 1.913, p = 0.035) compared with those with an ABI above 0.7. The remaining patient factors produced no statistically significant differences in survivorship, odds of failure, or HRs. No patient factors were associated with increased risk of mortality. These results suggest that patients who undergo TKA with an ABI below 0.7 are at increased risk for reoperation and have shorter reoperation free survival.

Validation of a New Web-Based System for Point-of-Care Implant Documentation in Total Knee Arthroplasty.

Implant documentation in total knee arthroplasty (TKA) must be both accurate and comprehensive. A new system enables surgeons to complete a secure, web-based operative report for each surgery. This study evaluated implant documentation using this system and hypothesized that it would be as reliable as the current standard. This was a retrospective study of all primary and revision TKA performed at a single academic institution from January 1, 2015 to March 31, 2015, by eight adult reconstruction surgeons who used the web-based system. Electronic medical records and implant logbooks were chosen as a composite standard reference for implant documentation. Cohen's kappa statistic and Pearson's correlation coefficients were used to determine agreement between the system and the standard reference. Mean kappa value for entire system was 0.916 ± 0.152 (p = 0.015) indicating "almost perfect" agreement (as per Landis and Koch's method) with standard reference. Pearson's correlation coefficient was 0.926 ± 0.147 (p = 0.021) further corroborating this excellent agreement. There was "substantial" or "fair" agreement for items pertaining to cement and augments. Overall, sensitivity was 0.98 (95% confidence interval: 0.71-0.98) and specificity 0.93 (95% confidence interval: 0.53-0.98) indicating that the system was very effective at documenting whether or not an implant was placed. The system exhibited significantly greater sensitivity than specificity (p = 0.027). This study demonstrated excellent performance of this novel system in point-of-care TKA implant documentation. Further research is needed to validate its use in arthroplasty of other joints and its potential for documentation of biomedical device implantation in other fields such as cardiothoracic surgery and gastroenterology.

Patient Factors Associated with Failure of Flap Coverage Used during Revision Total Knee Arthroplasty.

Revision total knee arthroplasty (rTKA) is a challenging problem in the setting of soft tissue defects. The purpose of this study was to evaluate patients who underwent rTKA requiring flap coverage and determine patient factors that predisposed them to failure. Forty-three consecutive patients (mean follow-up, 46.5 months) who underwent rTKA requiring flap coverage were retrospectively reviewed between January 1, 2000 and December 31, 2010. Sixteen of 43 patients experienced failure requiring either flap revision (n = 2) or above the knee amputation (n = 14). Patients with heart failure (p = 0.008), cancer (p = 0.049), or infection with Klebsiella pneumoniae (p = 0.002) had greater rates of failure. Smoking (p = 0.287), diabetes (p = 0.631), and flap type (p = 0.634, p = 0.801) were not associated with increased failure. Mean survival was 46.4 months. Survival of patients with a history of cancer (34.3 months) was less (p = 0.033) than those without (49.2 months). Flap coverage in rTKA is a viable limb salvage option for patients with soft tissue defects; however, failure rates are much higher than in patients not requiring flap coverage.