Scheduling and Vendor Consistency Improves Turnover Time Efficiency in Total Joint Arthroplasty.

BACKGROUND: Maximizing operative room (OR) efficiency is important for hospital efficiency, patient care, and positive surgeon and staff morale. Reducing turnover time (TOT) has become a popular focus to improve OR efficiency. The present study evaluated if TOT is influenced by changing case type, implant vendor, and/or laterality. METHODS: In total, 444 turnovers from January to July 2023 were retrospectively analyzed. All turnovers were same-surgeon turnovers between primary arthroplasty cases in dedicated, overlapping rooms. Single linear regression models tested the predictability of TOT based on case type, vendor, and laterality. A multivariate multiple regression and 1-way Analyses of Variance analyzed variables against each other. Independent sample t-tests evaluated TOTs when all variables were the same or different. RESULTS: Changing versus keeping the same case type increased TOT by 2.4 minutes (95% confidence interval [CI] = 0.7, 4.0; P = .004). Changing vendors increased TOT by 2.9 minutes (95% CI = 1.1, 4.7; P = .002). Laterality did not affect TOT, with a change of 0.9 minutes (95% CI = -0.6, 2.5; P = .229). Vendor (P = .030) independently predicted TOT when analyzed as a covariate with case type (P = .410). The TOT with same case type and vendor (mean 38.2 minutes; range, 22 to 62) was less than that of different case types and vendors (mean 41.4 minutes; range, 26 to 73) (P = .017). Mean TOT differed by 5.5 minutes when keeping all variables the same versus all different (P = .018). CONCLUSIONS: Maintaining a consistent case type, vendor, and laterality had a synergistic effect in reducing TOT in arthroplasty ORs with the same primary surgeon running 2 overlapping rooms. Changing vendor representatives was found to independently predict TOT increases, which is likely attributed to a disruption in workflow and collaboration of the multidisciplinary OR team. LEVEL OF EVIDENCE: Level III.

Dislocation Following Anterior and Posterior Total Hip Arthroplasty in the Setting of Spinal Deformity and Stiffness: Evolving Trends Using a High-Risk Protocol at a Single Tertiary Center.

BACKGROUND: Patients who have spinal stiffness and deformity are at the highest risk for dislocation after total hip arthroplasty (THA). Previous reports of this cohort are limited to antero-lateral and postero-lateral (PL) approaches. We investigated the dislocation rate after direct anterior (DA) and PL approach THA with a contemporary high-risk protocol to optimize stability. METHODS: We investigated patients undergoing THA who had preoperative biplanar imaging from January-December 2019. Patients were identified using radiographic criteria of spinal-stiffness (<10-degree change in sacral slope from standing to seated) and deformity (flatback deformity with >10-degree difference in pelvic incidence and lumbar lordosis). There were 367 patients identified (181 DA, 186 PL). The primary outcome was dislocation rate at 2-years postoperatively. Risk-factors for dislocation were evaluated using logistic regressions (significance level of 0.05). RESULTS: There were 6 (1.6%) dislocations in the entire cohort, with low dislocation rates for both DA (0.6%) and PL-THA (2.7%). We observed increased utilization of dual mobility with larger outer head bearings (>38 mm) with PL-THA (34.4 versus 5.0%, P < .01) and conversely increased utilization of 32-mm femoral-heads with DA-THA (39.4 versus 7.0%, P < .001). Surgical approach (PL) was not a significant risk-factor for dislocation (odds ratio: 5.03, P = .15). Patients who had a history of lumbar-fusion had 8-times higher odds for dislocation (OR: 8.20, P = .020). CONCLUSIONS: To the best of our knowledge, this is the largest series to date evaluating DA and PL-THA in the hip-spine 2B-group. Our results demonstrate lower dislocation rate than expected with either surgical approach using a high-risk protocol.

Complications and Survivorship After Aseptic Revision Total Hip Arthroplasty: Is There a Difference by Surgical Approach?

BACKGROUND: Revision total hip arthroplasty (rTHA) has traditionally been performed through the posterolateral approach (PA). Anterior approaches (AA) for rTHA are increasingly being utilized. The purpose of this study was to compare complications and survivorship from re-revision and reoperation after aseptic rTHA performed using an AA versus a PA. METHODS: We retrospectively reviewed patients who underwent aseptic rTHA either through an AA (direct anterior approach [DAA], anterior-based muscle sparing [ABMS]) or PA from January 2017 to December 2021. There were 116 patients who underwent AA-rTHA (DAA 50, ABMS 66) or PA-rTHA (n = 105). Patient demographics, complications, and postoperative outcomes were collected. RESULTS: The most common indication in both groups was aseptic loosening (n = 26, 22.4% AA, n = 28, 26.7% PA). Acetabular revision alone was most common in the AA group (n = 33, 28.4%), while both components were most commonly revised in the PA groups (n = 47, 44.8%). In all the AA-rTHA group, the index total hip arthroplasty was performed through a PA in 51% of patients, while the PA-rTHA group had the index procedure performed via AA in 4.8%. There was no statistically significant difference in re-revision rate between the DAA, ABMS, or PA groups (9.55 versus 5.3% versus 11.4%, respectively, P = .11). The most common overall reason for re-revision was persistent instability, with no difference in incidence of postoperative hip dislocation (n = 4, 6.8% DAA, n = 3, 5.3%, n = 10, 9.5% PA; P = .31). CONCLUSIONS: This study demonstrates no difference in complication or re-revision survivorship after aseptic rTHA performed through a DAA, ABMS approach, or PA, nor between anterior or posterior-based approaches. LEVEL OF EVIDENCE: Level III.

Aseptic Revision Total Hip Arthroplasty Through an Anterior Approach: Survivorship and Risk Factors for Re-Revision.

BACKGROUND: The utilization of anterior-based approaches for total hip arthroplasty (THA) is increasing. Literature on the outcomes of revision THA (rTHA) through an anterior approach, however, is sparse. This study reports the survivorship and risk factors for re-revision in patients undergoing aseptic rTHA through an anterior approach. METHODS: This was a single-institution, retrospective cohort analysis of patients who underwent aseptic rTHA through an anterior approach (direct anterior, anterior-based muscle sparing) from January 2017 to December 2021, regardless of the original surgical approach. Exclusion criteria were age <18 years, conversion THA, and septic revisions. Patient demographics, complications, and postoperative outcomes were collected. Kaplan-Meier curves were used to measure survivorship while Cox regression analyses were used to identify risk factors for re-revision of THA. RESULTS: We identified 251 total anterior rTHAs, of which 155 were aseptic anterior revisions. There were 111 patients (111 rTHAs; 63 anterior-based muscle sparing and 48 direct anterior) who met criteria and had a mean follow-up of 4.2 years (range, 2.1 to 6.9). There were a total of 54 (49%) anterior-based index approaches and 57 (51%) posterior index approaches. The most common indications for rTHA were femoral loosening (n = 25, 22.5%), followed by instability (n = 16, 14.4%) and wear or osteolysis (n = 16, 14.4%). At 2 years, the survivorship from reoperation and re-revision was 89% (95% confidence interval: 84 to 95) and 91% (95% confidence interval: 86 to 96), respectively. Reoperation occurred in 14 patients (12.6%) at a mean time of 7.8 months (range, 0.5 to 28.6). Re-revision occurred in 12 patients (10.8%) at a mean time of 7.3 months (range, 0.5 to 28.6). Instability was the most common reason for re-revision (4.5%). Neither index approach type, revision approach type, nor any patient-specific risk factors were identified as predictors of re-revision or reoperation in multivariable regression analysis. CONCLUSIONS: This study demonstrates an acceptable rate of re-revision when aseptic rTHA is performed through an anterior approach, with the most common reason for aseptic re-revision being instability.

Robotic Total Knee Arthroplasty is Associated with Earlier Return of Postoperative Range of Motion.

INTRODUCTION: Postoperative range of motion (ROM) is an important measure for the functional outcome and overall success after total knee arthroplasty (TKA). While robotic knee systems have been shown to reduce pain and improve early function, the return of postoperative ROM specifically has not been adequately studied. The purpose of this study was to compare postoperative ROM in robotic and conventional TKA. We hypothesized that robotic TKA leads to an improvement in postoperative ROM. MATERIALS AND METHODS: A retrospective cohort study of 674 primary TKAs by a single surgeon between January 2018 and February 2023 was completed. Patients that did not have both a two-week follow up and eight-week follow up were excluded. Revision/conversion TKAs were excluded. The population was divided into two cohorts based on technique utilized: robotic versus conventional. Preoperative extension/flexion data, postoperative extension/flexion data at two-week and eight-week follow ups, and manipulation under anesthesia data were collected. ROM was defined as flexion minus extension. Chi-square tests were used to examine for differences between categorical variables and t-tests for continuous variables. RESULTS: A total of 307 robotic and 265 conventional knees were included. There were no differences in demographics, mean follow up, or preoperative ROM between groups. The robotic group had significantly more flexion (99.20° vs. 96.98°; p=0.034) and ROM (97.81° vs. 95.56°; p=0.047) at the two-week follow up. The loss in ROM at the two-week follow up from preoperative ROM was significantly less for the robotic group (-11.21° vs. -14.16°; p=0.031). There were no significant differences in extension at either follow up, in flexion at the eight-week follow up, or in ROM at the eight-week follow up. CONCLUSION: Robotic TKA leads to an improvement in postoperative flexion and ROM when compared to preoperative ROM at two-week follow up. These findings could partially explain the quicker recovery associated with robotic TKA.

No Benefit to Sensor-guided Balancing Compared With Freehand Balancing in TKA: A Randomized Controlled Trial.

BACKGROUND: Soft tissue balancing in TKA has traditionally relied on surgeons' subjective tactile feedback. Although sensor-guided balancing devices have been proposed to provide more objective feedback, it is unclear whether their use improves patient outcomes. QUESTIONS/PURPOSES: We conducted a randomized controlled trial (RCT) comparing freehand balancing with the use of a sensor-guided balancing device and evaluated (1) knee ROM, (2) patient-reported outcome measures (PROMs) (SF-12, WOMAC, and Knee Society Functional Scores [KSFS]), and (3) various surgical and hospital parameters (such as operative time, length of stay [LOS], and surgical complications) at a minimum of 2 years of follow-up. METHODS: A total of 152 patients scheduled for primary TKA were recruited and provided informed consent to participate in this this study. Of these, 22 patients were excluded preoperatively, intraoperatively, or postoperatively due to patient request, surgery cancellation, anatomical exclusion criteria determined during surgery, technical issues with the sensor device, or loss to follow-up. After the minimum 2-year follow-up was accounted for, there were 63 sensor-guided and 67 freehand patients, for a total of 130 patients undergoing primary TKA for osteoarthritis. The procedures were performed by one of three fellowship-trained arthroplasty surgeons (RPS, HJC, JAG) and were randomized to either soft tissue balancing via a freehand technique or with a sensor-guided balancing device at one institution from December 2017 to December 2018. There was no difference in the mean age (72 ± 8 years versus 70 ± 9 years, mean difference 2; p = 0.11), BMI (30 ± 6 kg/m 2 versus 29 ± 6 kg/m 2 , mean difference 1; p = 0.83), gender (79% women versus 70% women; p = 0.22), and American Society of Anesthesiology score (2 ± 1 versus 2 ± 1, mean difference 0; p = 0.92) between the sensor-guided and freehand groups, respectively. For both groups, soft tissue balancing was performed after all bony cuts were completed and trial components inserted, with the primary difference in technique being the ability to quantify the intercompartmental balance using the trial tibial insert embedded with a wireless sensor in the sensor-guided cohort. Implant manufacturers were not standardized. Primary outcomes were knee ROM and PROMs at 3 months, 1 year, and 2 years. Secondary outcomes included pain level evaluated by the VAS, opioid consumption, inpatient physical therapy performance, LOS, discharge disposition, surgical complications, and reoperations. RESULTS: There was no difference in the mean knee ROM at 3 months, 1 year, and 2 years postoperatively between the sensor-guided cohort (113° ± 11°, 119° ± 13°, and 116° ± 12°, respectively) and the freehand cohort (116° ± 13° [p = 0.36], 117° ± 13° [p = 0.41], and 117° ± 12° [p = 0.87], respectively). There was no difference in SF-12 physical, SF-12 mental, WOMAC pain, WOMAC stiffness, WOMAC function, and KSFS scores between the cohorts at 3 months, 1 year, and 2 years postoperatively. The mean operative time in the sensor-guided cohort was longer than that in the freehand cohort (107 ± 0.02 versus 84 ± 0.04 minutes, mean difference = 23 minutes; p = 0.008), but there were no differences in LOS, physical therapy performance, VAS pain scores, opioid consumption, discharge disposition, surgical complications, or percentages of patients in each group who underwent reoperation. CONCLUSION: This RCT demonstrated that at 2 years postoperatively, the use of a sensor-balancing device for soft tissue balancing in TKA did not confer any additional benefit in terms of knee ROM, PROMs, and clinical outcomes. Given the significantly increased operative time and costs associated with the use of a sensor-balancing device, we recommend against its routine use in clinical practice by experienced surgeons. LEVEL OF EVIDENCE: Level I, therapeutic study.

Simultaneous Bilateral Total Hip Arthroplasty With Contemporary Blood Management is Associated With a Low Risk of Allogeneic Blood Transfusion.

BACKGROUND: There is a paucity of data on blood loss and the risk of allogeneic blood transfusion after simultaneous bilateral total hip arthroplasty (SBTHA) with contemporary blood management including neuraxial anesthesia, routine tranexamic acid use, and a restrictive transfusion protocol. As such, we sought to determine the in-hospital outcomes of SBTHA, specifically analyzing blood loss and the rate and risk factors for transfusion. METHODS: We identified 191 patients who underwent SBTHA at a single institution from 2016 to 2019. No drains were utilized and no patients donated blood preoperatively. Mean age was 59 years with 96 females (50.3%). The surgical approach was posterior in 138 (72.3%) and direct anterior in 53 (27.7%) patients. We analyzed blood loss, the rate of allogeneic blood transfusions, and in-hospital thromboembolic complications. We analyzed risk factors for transfusion with a logistic regression analysis. RESULTS: Twenty-two patients (11.5%) underwent allogeneic blood transfusion. All transfused patients were female. Univariate analysis revealed female gender as a transfusion risk factor since it had statistically significant higher proportion in the transfusion group than the nontransfusion group (100% vs 43.5%, respectively, P < .001). We did not identify any other singular significant risk factors for transfusion in a multivariable regression analysis. However, females with a preoperative Hb <12 had an elevated risk of transfusion at 37.5% (15/40 patients). CONCLUSION: With contemporary perioperative blood management protocols, there is a relatively low (11.5%) risk of a blood transfusion after SBTHA. Females with a lower preoperative Hb (<12 g/dL) had the highest risk of transfusion at 37.5%.

Survivorship and Risk Factors for Re-Revision after Aseptic Revision Total Hip Arthroplasty in Patients Aged ≤55 Years.

BACKGROUND: There is a relative paucity of literature on the outcomes after revision total hip arthroplasty (rTHA) in young patients. This study reports the survivorship and risk factors for re-revision in patients aged ≤55 years. METHODS: We identified 354 patients undergoing aseptic nononcologic rTHA at mean follow-up of 5 years after revision, with mean age of 48 years, body mass index of 28 kg/m2, and 64% female. Thirty-five (10%) patients underwent at least 1 previous rTHA. The main indications for rTHA included wear/osteolysis (21%), adverse local tissue reaction (21%), recurrent instability (20%), acetabular loosening (16%), and femoral loosening (7%); and included acetabular component-only rTHA in 149 patients (42%), femoral component-only rTHA in 46 patients (13%), both component rTHA in 44 patients (12%), and head/liner exchanges in patients 115 (33%). The Kaplan-Meier method was used to measure survivorship free from re-revision THA, and multivariate regression was used to identify risk factors for re-revision THA. RESULTS: Sixty-two patients (18%) underwent re-revision THA at the mean time of 2.5 years, most commonly for instability (37%), aseptic loosening (27%), and prosthetic joint infection (15%). The rTHA survivorship from all-cause re-revision and reoperation was 83% and 79% at 5 years, respectively. Multivariate analysis demonstrated that patients undergoing femoral component only (hazard ratio 4.8, P = .014) and head/liner exchange rTHA (hazard ratio 2.5, P = .022) as risk factors for re-revision THA. CONCLUSION: About 1 in 5 patients aged ≤55 years undergoing rTHA required re-revision THA at 5 years, most commonly for instability. The highest risk group included patients undergoing head/liner exchanges and isolated femoral component revisions.

Registration of Bony Landmarks and Soft Tissue Laxity during Robotic Total Knee Arthroplasty is Highly Reproducible.

INTRODUCTION: There is growing interest and enthusiasm for robotic total knee arthroplasty (TKA). Many robotic systems require registration of bony landmarks as well as a dynamic soft tissue evaluation to plan femoral and tibial resections. Variability in this user-driven registration can introduce error and undermine the purported precision and accuracy offered by robotics. The purpose of this study was to evaluate inter- and intrarater reliability in robotic registration with a new robotic system (ROSA®; Zimmer-Biomet, Warsaw, IN). METHODS: Two unpaired cadaveric knee specimens were exposed, and optical arrays were placed into the femur and tibia. Three separate evaluators conducted repeated trials of anatomic registration and assessment of soft tissue laxity, as well as coronal alignment, sagittal alignment, femoral size, and maximum opening in the medial and lateral compartments in both flexion and extension. Repeated trials were conducted using these specimens with and without preoperative imaging for landmarking (image-based and image-free workflows). An Intraclass Correlation Coefficient (ICC) was calculated for each observer and across observers to determine intra-and interrater reliability, respectively, in robotic registration. RESULTS: There was good to excellent reliability for all conditions, and all correlation coefficients were >0.767. On average, ICCs for intrarater reliability were excellent for Doctor 1 (0.952), Doctor 2 (0.975), and Doctor 3 (0.925). On average, the ICCs for interrater reliability were excellent for both the "Registration + Gap Assessment" condition (0.961) and the "Gap Assessment" condition (0.994). CONCLUSION: Our results show a high repeatability of registration of anatomic landmarks and gap assessment among observers using this robotic system for both image-based and image-free software.

Reduction in hospital length of stay and increased utilization of telemedicine during the "return-to-normal" period of the COVID-19 pandemic does not adversely influence early clinical outcomes in patients undergoing total hip replacement: a case-control study.

BACKGROUND AND PURPOSE: Elective total hip replacement (THR) was halted in our institution during the COVID-19 surge in March 2020. Afterwards, elective THR volume increased with emphasis on fast-track protocols, early discharge, and post-discharge virtual care. We compare early outcomes during this "return-to-normal period" with those of a matched pre-pandemic cohort. PATIENTS AND METHODS: We identified 757 patients undergoing THR from June to August 2020, who were matched 1:1 with a control cohort from June to August 2019. Length of stay (LOS) for the study cohort was lower than the control cohort (31 vs. 45 hours; p < 0.001). The time to first postoperative physical therapy (PT) was shorter in the study cohort (370 vs. 425 minutes; p < 0.001). More patients were discharged home in the study cohort (99% vs. 94%; p < 0.001). Study patients utilized telehealth office and rehabilitation services 14 times more frequently (39% vs. 2.8%; p < 0.001). Outcomes included post-discharge 90-day unscheduled office visits, emergency room (ER) visits, complications, readmissions, and PROMs (HOOS JR, and VR-12 mental/physical). Mann-Whitney U and chi-square tests were used for group comparisons. RESULTS: Rates of 90-day unscheduled outpatient visits (5.0% vs. 7.3%), ER visits (5.0% vs. 4.8%), hospital readmissions (4.0% vs. 2.8%), complications (0.04% vs. 0.03%), and 3-month PROMs were similar between cohorts. There was no 90-day mortality. INTERPRETATION: A reduction in LOS and increased telehealth use for office and rehabilitation visits did not adversely influence 90-day clinical outcomes and PROMs. Our findings lend further support for the utilization of fast-track arthroplasty with augmentation of postoperative care delivery using telemedicine.

Operative Duration and Short-Term Postoperative Complications after Unicompartmental Knee Arthroplasty.

BACKGROUND: Prolonged operative duration is an independent risk factor for postoperative complications in many orthopedic procedures ranging from shoulder arthroscopy to total hip and knee arthroplasties. It has not been well studied in unicompartmental knee arthroplasty (UKA). The purpose of this study is to assess the effect of operative duration on complications after UKA. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program registry, we identified all primary unilateral UKAs from 2005 to 18. Patients were divided into three cohorts based on the operative duration: < 90 minutes, between 90 and 120 minutes, and >120 minutes. Baseline patient and operative demographics (age, gender, etc.) and thirty-day complications were compared using bivariate analysis. Multivariate analysis was used to assess the independent effect of operative duration on postoperative outcomes after adjusting for differences in baseline characteristics. RESULTS: We identified 11,806 patients who underwent primary UKA from 2005 to 18. There was no difference in the "any complication" rate between cohorts. However, operative duration >120 minutes was associated with a significantly higher likelihood of reoperation (odds ratio [OR] 2.02, 95% confidence interval [CI]: 1.15-3.57, P = .015), non-home discharge (OR: 2.14, CI: 1.65-2.77, P < .001), surgical site infection (OR: 1.76, CI: 1.03-3.01, P = .038), and blood transfusions (OR: 3.23, CI: 1.44-7.22, P = .004) when compared with operative duration <90 minutes. There was no difference in mortality rates. CONCLUSION: Increased operative duration greater than 2 hours in primary UKA is associated with an increased risk of non-home discharge, surgical site infection, reoperation, and blood transfusion.

Tibial cement mantle thickness is not affected by tourniquetless total knee arthroplasty when performed with tranexamic acid.

PURPOSE: Evidence exists that tourniquet use leads to increased cement penetration in total knee arthroplasty (TKA) due to decreased blood and fat in the bone during cementation. The use of tranexamic acid (TXA) has led to decreased blood loss and transfusion rates. The purpose of this study was to determine if the use of a tourniquet while utilising modern TXA protocols affects the tibial cement mantle penetration. METHODS: 140 patients who underwent primary TKA with and without a tourniquet (70 in each group) were retrospectively reviewed. All patients received a standard TXA protocol. The primary outcome measure was cumulative depth of cement mantle penetration of the tibial plateau on post-operative radiographs. Secondary outcome measures included post-operative change in haemoglobin and hematocrit levels, blood loss, and transfusion rates. RESULTS: There was no significant difference in age, sex, or pre-operative haemoglobin or hematocrit levels between groups. Tourniquet use resulted in significantly lower blood loss (100.0 mL versus 154.7 mL, p < 0.001), and significantly reduced drop in haemoglobin (1.8 g/dL vs 2.5 g/dL, p < 0.001) and hematocrit (5.7% vs 7.4%, p = 0.04) levels. However, depth of tibial cement mantle penetration did not differ between the tourniquet group (15.3 mm) and non-tourniquet group (15.0 mm, p value n.s.). No patient in either group required a blood transfusion. CONCLUSIONS: Tourniquet use in primary TKA results in decreased blood loss and less change in pre-operative vs post-operative haemoglobin and hematocrit levels. However, with the use of TXA, not using a tourniquet resulted in similar cement mantle penetration around the tibial component as with a tourniquet.

Risk Factors for Periprosthetic Femur Fracture and Influence of Femoral Fixation Using the Mini-Anterolateral Approach in Primary Total Hip Arthroplasty.

BACKGROUND: The mini-anterolateral (AL) approach for total hip arthroplasty (THA) has gained popularity. In contrast to other approaches, risk factors for periprosthetic femur fractures have not been well established for the AL approach. METHODS: Six hundred eighty-four primary THAs performed using the AL approach were retrospectively reviewed for risk factors associated with perioperative periprosthetic femur fractures within 3 months of surgery. Risk factors evaluated were gender, age, body mass index, laterality, and Dorr ratio of the proximal femur. Cemented stems and collared uncemented stems were compared to uncemented tapered-wedge and meta-diaphyseal stems. A Student's t-test was used for continuous variables, and a chi-squared test was used for categorical variables. RESULTS: Of 684 primary THAs performed, 57 (8.3%) resulted in fracture. Twenty-eight (4.1%) occurred intraoperatively and 29 (4.2%) occurred postoperatively within 90 days. All intraoperative fractures were fixed at the time of surgery and healed uneventfully. Of the postoperative fractures, 15 (2.2%) were amenable to nonoperative management and healed. Fourteen (2.0%) required revision arthroplasty. There was a significantly lower rate of fracture in patients receiving cemented or collared stems (0%, n = 101) than in those receiving tapered-wedge or meta-diaphyseal fitting stems (9.8%, n = 583; P = .0009). Odds of fracture increased with female gender (P = .0063) and increasing Dorr ratio (P = .0003). Analysis showed a trend toward increased risk with older age, but did not achieve statistical significance. Body mass index and laterality showed no statistically significant effect. CONCLUSION: Performing primary THA via the AL approach, 2.0% of patients had a postoperative fracture requiring revision within the first 3 months. With cemented and collared stems, the fracture rate was significantly lower. Surgeons should consider using cemented or collared stems in high-risk patients.

Isolated fibular stress fractures: Radiographic parameters.

BACKGROUND: Fibular stress fractures are uncommon injuries with an incompletely understood pathogenesis and predisposing characteristics. This study investigated the demographic and radiographic risk factors for fibular stress fractures. METHODS: A retrospective chart review from 2010 to 2018 revealed thirteen patients with isolated fibular stress fractures. Demographics, history of fracture, fracture location, bone quality, and heel alignment were collected. RESULTS: The cohort consisted of six men and seven women with a mean age of 41.8 years. The average BMI was 28.5kg/m2. Three patients used tobacco. 69.2% of fractures were in the distal third, 23.1% proximal third, and 7.7% middle third. No patients had evidence of osteopenia. Distal fibula stress fractures were more common in women (66.7%) and associated with hindfoot valgus. CONCLUSION: Distal third fibula stress fractures were most common and associated with hindfoot valgus. This could be due to a greater amount of axial force through fibula in this alignment. LEVEL OF EVIDENCE: Level IV, Retrospective Case Series.

The Impact of Running, Monofilament Barbed Suture for Subcutaneous Tissue Closure on Infection Rates in Total Hip Arthroplasty: A Retrospective Cohort Analysis.

BACKGROUND: Recently, running, monofilament barbed suture has become more popular as an efficient and economical alternative to traditional braided interrupted suture for wound closure following total joint arthroplasty. Its overall association with wound complications following surgery remains unknown at this time. Several studies have investigated its use in total knee arthroplasty (TKA), but there is limited literature surrounding use in total hip arthroplasty (THA). In this retrospective cohort study, our primary objective was to determine whether the use of monofilament barbed suture in THA was associated with reduced rates of postoperative infection when compared to traditional braided suture. METHODS: Patients who underwent primary unilateral THA between November 2011 and December 2017 by a single senior surgeon with closure using either monofilament barbed suture (162 patients) or braided interrupted suture (429 patients) were retrospectively reviewed for postoperative wound complications during the first 90 days after surgery. Demographics, comorbidities, and perioperative data were also included to assess for risk factors for infection. RESULTS: There was no difference between braided and barbed suture in overall rates of major complication, including periprosthetic joint infection (PJI) (0.47% vs 0.62%, P = .82) or revisions (1.86% vs 1.23%, P = .60). The overall rate of minor, superficial wound complications was also similar between both groups (6.1% vs 3.1%, P = .15). However, when superficial complications were categorized by type (dehiscence vs infection), the use of barbed suture was associated with a decreased rate of superficial wound infection (0% vs 5.4%, P = .003) and an increased rate of wound dehiscence (3.1% vs 0.7%, P = .04). CONCLUSION: The use of monofilament barbed suture for superficial skin closure in THA leads to similar overall rates of both major and minor wound complications when compared to traditional interrupted braided suture. However, while barbed suture was associated with fewer superficial infections, there was an increased incidence of wound dehiscence. Overall, barbed suture demonstrated a cumulatively equivalent rate of superficial wound complications compared to braided suture. Based on this investigation, barbed suture appears safe to use in THA and may represent an efficient and effective alternative to braided suture for wound closure. LEVEL OF EVIDENCE: Level IV; retrospective cohort study.

Same-Day Physical Therapy Following Total Knee Arthroplasty Leads to Improved Inpatient Physical Therapy Performance and Decreased Inpatient Opioid Consumption.

BACKGROUND: Early ambulation with physical therapy (PT) following total knee arthroplasty (TKA) has demonstrated benefits in the literature. However, the impact of early PT on rehabilitation performance and opioid consumption has not been elucidated. We evaluate the effect of same-day PT on inhospital functional outcomes and opioid consumption. METHODS: We retrospectively identified 2 cohorts of primary TKA patients from July 2016 to December 2017: PT0 (n = 295) received PT on the day of surgery, and PT1 (n = 392) received PT on postoperative day (POD) 1. Outcomes studied included number of feet walked on POD0-3, visual analog scale pain scores, morphine equivalents (ME) consumed, length of stay, and discharge disposition. Analysis was conducted using the Student t-test and Fisher exact test. RESULTS: In comparison to the PT1 group, the PT0 group walked significantly more steps on POD1 (347.6 vs 167.4 ft, P < .0001), POD2 (342.1 vs 203.5 ft, P < .0001), and POD3 (190.3 vs 128.9 ft, P = .00028). There was no difference between the 2 groups for visual analog scale. The PT0 group also consumed significantly fewer total ME when compared to the PT1 group (149.0 vs 200.3 mg, P = .0002). The PT0 group had a significantly shorter length of stay when compared to the PT1 group (2.7 vs 3.2 days, P = .00075). More patients were discharged home in the PT0 group (81.7% vs 54.8%, P < .0001). CONCLUSION: We observed that initiation of PT on POD0 led to better PT performance, reduced ME during hospitalization, and more patients discharged home. LEVEL OF EVIDENCE: III, Retrospective cohort study.

Hemiarthroplasty Conversion: A Comparison to Primary and Revision Total Hip Arthroplasty.

BACKGROUND: Arthroplasty is the standard of care for elderly patients with displaced femoral neck fractures, with viable options including hemiarthroplasty (HA) and total hip arthroplasty (THA). With time, HA may need to be converted to THA, but it is unclear whether this is more similar to primary or revision THA. We compare complication and revision rates between these groups within 90 days and 2 years postoperatively. METHODS: We retrospectively reviewed 3 cohorts of patients treated at our institution: primary, conversion, and revision THA. Outcomes studied included intraoperative data, postoperative complications, and revision rates. We analyzed the groups using both parametric (analysis of variance test) and nonparametric (chi-squared test) statistics. RESULTS: Operative time between primary THA (108.0 minutes), conversion HA (147.9 minutes), and revision THA (160.1 minutes) cohorts differed significantly (P = .011). Estimated blood loss was also different between primary THA (386 mL), conversion HA (587 mL), and revision THA cohorts (529 mL) (P = .011). At 2 years, major complication rates between primary THA (6.2%), conversion HA (11.7%), and revision THA (26.7%) cohorts also differed significantly (P = .003), as was the revision rate in the primary THA (4.6%), conversion HA (10.0%), and revision THA (18.3%) cohorts (P = .043). CONCLUSION: This is the first study to compare short-term and midterm complications between primary, conversion, and revision THA. We observed conversion HA had similar operative time and estimated blood loss to revision THA, which was significantly higher than primary THA. However, we found that conversion HA more closely resembled primary THA with respect to perioperative complications rates.

The Learning Curve by Operative Time for Soft Tissue Balancing in Total Knee Arthroplasty Using Electronic Sensor Technology.

BACKGROUND: Electronic sensor devices can provide an objective assessment of soft tissue balancing in total knee arthroplasty (TKA) which may potentially decrease postoperative pain. We aim to quantify the learning curve for operative time (OT) for this technology. METHODS: Consecutive TKA cases balanced with an electronic sensor balancing device by one senior surgeon from 2013 to 2017 were included in this study. The OT (in minutes) was analyzed using the cumulative sum analysis to evaluate the learning curve for this technology. Further analysis was done by splitting the 287 patients into 7 cohorts, 41 patients each. RESULTS: Two hundred eighty-seven patients balanced with sensor technology were available for analysis. The cumulative sum OT learning curve estimated that this technology's learning curve was 41 cases. This curve consisted of 2 phases: phase 1 which includes the first 41 cases and phase 2 which includes the remaining 246 patients. The mean OT for the first and last sensor-assisted cohorts was 120.4 and 108.9 minutes (P = .021). The mean OT for the first sensor-assisted cohort and the control cohort was 120.4 versus 109 minutes (P = .023). The mean OT for the last sensor-assisted cohort and the control cohort was 108.9 versus 109 minutes (P = .94). CONCLUSION: Our findings suggest that it takes approximately 41 cases of sensor-assisted TKA cases to achieve OTs identical to manually balanced TKA cases. This is a relatively shallow learning curve for the sensor technology, and allows arthroplasty surgeons to objectively achieve soft tissue balancing without adding OT to the surgery.

Early Morbidity but Not Mortality Increases With Surgery Delayed Greater Than 24 Hours in Patients With a Periprosthetic Fracture of the Hip.

BACKGROUND: Studies have identified a possible morbidity and mortality benefit with expedited time to surgery after a native hip fracture. This association after hip periprosthetic fractures (PPF) has been less clearly delineated. The purpose of this study is to assess the effect of time to surgery on rates of 30-day complications. METHODS: The National Surgical Quality Improvement Program registry was used to identify all patients who underwent surgical intervention for hip PPF between 2005 and 2016. Patients were stratified into 2 cohorts based on time from hospital admission to surgery, either ≤24 hours (expedited) or >24 hours (non-expedited). Thirty-day outcome variables were assessed using bivariate and multivariate analyses. RESULTS: We identified 857 patients undergoing surgical intervention for hip PPF, of whom 402 (46.9%) underwent expedited surgery and 455 (53.1%) underwent non-expedited surgery. Patients with non-expedited surgery had an average time to surgery of 2.4 days (range, 1-14 days). Multivariate analysis adjusting for differences in baseline patient characteristics revealed that patients with a non-expedited procedure had higher rates of overall complications (odds ratio [OR] = 1.72; P = .014), respiratory complications (OR = 4.15; P = .0029), urinary tract infections (OR = 2.77; P = .020), nonhome discharge (OR = 2.22; P < .001), and blood transfusions (OR = 1.86; P < .001). There was no statistical difference in mortality (P = .093). Patients with non-expedited surgery also had longer total and postoperative (+2.7 days; P < .001) length of stay. CONCLUSION: This study did not identify any statistical difference in mortality but found an association with increased postoperative complications and non-expedited surgery for PPF. Additional prospective studies may be warranted to identify the causative factors behind this association.