Extended Trochanteric Osteotomy Closure Performed Before or After Canal Preparation and Stem Impaction Does Not Affect Axial Stability.

BACKGROUND: An extended trochanteric osteotomy (ETO) safely addresses femoral component removal during challenging revision total hip arthroplasty. However, no prior study has evaluated whether a difference in axial stability exists between ETO closure performed before (reconstitution) or after (scaffolding) canal preparation and stem impaction. We hypothesized that given the absence of clinical reports of outcome differences despite the wide use of both practices, no significant difference in the initial axial stability would exist between the 2 fixation techniques. METHODS: ETOs were performed and repaired using the reconstitution technique for the 6 right-sided femora and the scaffolding technique for the six left-sided femora. The 195-mm long, 3.5°-tapered splined titanium monobloc stems were impacted into 6 matched pairs of human fresh cadaveric femora. Three beaded cables were placed in a standardized fashion on each specimen, 1 for prophylaxis against osteotomy propagation during reaming/impaction and 2 to close the ETO. Stepwise axial loading was performed to 2600 N or until failure, which was defined as subsidence >5 mm or femoral/cable fracture. RESULTS: All specimens successfully resisted axial testing, with no stem in either ETO repair group subsiding >2 mm. The mean subsidence for the reconstitution group was 0.9 ± 0.4 mm, compared to 1.2 ± 0.5 mm for the scaffolding group (P = .2). CONCLUSION: In this cadaveric model with satisfactory proximal bone stock, no difference existed between the reconstitution and scaffolding ETO repair techniques, and both provide sufficient immediate axial stability in a simulated revision total hip arthroplasty setting under physiologic loads.

Monobloc Dual Mobility With a Minimum 5-Year Follow-Up: A Safe and Effective Solution in Primary Total Hip Arthroplasty.

BACKGROUND: Instability constitutes over 20% of revisions after total hip arthroplasty (THA). Dual mobility (DM) designs were introduced as a solution to this problem. However, the few publications that have reported promising results for monobloc DM constructs have been limited by sample size or length of follow-up. The purpose of this study is to evaluate mid-term outcomes (minimum 5-year follow-up) of a single-surgeon series utilizing a monobloc DM acetabular component in patients with high risk for dislocation. METHODS: This is a single-surgeon consecutive series of 207 primary THAs implanted with a monobloc DM component in patients who were considered at high risk for dislocation. Patient demographics and case-specific data were collected retrospectively. All patients had a minimum of 5-year follow-up. The Mann-Whitney U test was used to assess continuous variables, whereas categorical variables were analyzed using the chi-square test. Survival probability was calculated using the Kaplan-Meier method. RESULTS: Radiographic analysis did not reveal acetabular radiolucency in any patients, and there were no revisions for aseptic loosening. In addition, there were no dislocations. Seven of 205 patients (3.4%) were revised, 5 on the femoral side due to periprosthetic fracture and the remaining two for infection. Survivorship of the acetabular component from revision was 99%. The mean Veteran RAND (VR-12) physical score improved from 7 (standard deviation [SD]: 13.7) preoperatively to 9.5 (SD: 17.6) at the final follow-up. Similarly, the hip disability osteoarthritis score improved from 8 (SD: 17.9) preoperatively to 21.2 (SD: 37). CONCLUSION: Monobloc DM components reliably prevent dislocation after primary THA in high-risk patients. At mid-term follow-up, this DM monobloc component demonstrates excellent implant survivorship, radiographic fixation, and improved functional outcomes.

Heterotopic Ossification Negatively Influences Range of Motion After Revision Total Knee Arthroplasty.

BACKGROUND: The incidence of heterotopic ossification (HO) after total knee arthroplasty (TKA) varies and is of unclear clinical significance. This study aimed to identify the incidence of HO in patients undergoing revision TKA for either stiffness or aseptic loosening/instability and determine if the presence of HO is associated with inferior absolute range of motion (ROM) and ROM gains. METHODS: Eighty-seven patients were prospectively enrolled and separated into 2 cohorts to evaluate ROM after revision TKA (2017-2019). Group 1 (N = 40) patients were revised for stiffness, while group 2 (N = 47) patients were revised for either aseptic loosening or instability. Goniometer-measured ROM values were obtained preoperatively and at 6 weeks, 6 months, and 1 year postoperatively. Statistical analysis included a Fisher's exact test to assess for an association between preoperative HO and final ROM at 1 year after revision TKA. RESULTS: HO was identified on preoperative radiographs in 17 patients (20%). There was a significantly higher rate of preoperative HO in patients revised for stiffness compared to patients revised for instability or loosening (30% vs 11%; P = .03). Five cases of HO qualitatively identified as most clinically severe were associated with lower ROM at each time point compared to the remainder of HO cases in this study cohort (P < .02). CONCLUSION: The presence of HO is greater in patients undergoing revision TKA for stiffness. Additionally, HO severity appears to have a major effect on preoperative and postoperative ROM trajectory. This information should help guide patient expectations and highlight the need for a comprehensive, standardized classification system for HO.

Irrigation and Debridement With Implant Retention: Does Chronicity of Symptoms Matter?

BACKGROUND: Periprosthetic joint infection (PJI) remains a rare, yet devastating complication of total joint arthroplasty (TJA). Chronic infection is generally considered a contraindication to debridement, antibiotics, and implant retention (DAIR); however, outcomes stratified by chronicity have not been well documented. METHODS: A retrospective review of all DAIR cases performed at a single institution from 2008 to 2015 was performed. Chronicity of PJI was categorized as acute postoperative, chronic, or acute hematogenous. Failure after DAIR, defined as re-revision for infection recurrence with the same organism, was evaluated between the 3 chronicity groups at 90 days as well as at a minimum 2-year follow-up. RESULTS: Overall, 248 patients undergoing DAIR for total hip arthroplasty or total knee arthroplasty PJI were included. Categorization of PJI was acute (acute postoperative) in 59 cases (24%), chronic in 54 (22%), and acute hematogenous in 135 (54%). DAIR survivorship was 47% (range 0.3-10 years). Overall, there were 118 (47.6%) treatment failures after DAIR with a minimum of 2-year follow-up. There was no difference in failure rate between total hip or total knee arthroplasty patients (P = .07). Patients infected with Staphylococcus conferred a higher risk of failure for all DAIR procedures regardless of chronicity category. CONCLUSION: Identification of microbial species prior to undertaking DAIR may be more clinically relevant than stratification according to chronicity category when considering treatment options.

How Does Contact Length Impact Titanium Tapered Splined Stem Stability: A Biomechanical Matched Pair Cadaveric Study.

BACKGROUND: Titanium tapered stems (TTS) achieve fixation in the femoral diaphysis and are commonly used in revision total hip arthroplasty. The initial stability of a TTS is critical, but the minimum contact length needed and impact of implant-specific taper angles on axial stability are unknown. This biomechanical study was performed to better guide operative decision-making by addressing these clinical questions. METHODS: Two TTS with varying conical taper angles (2° spline taper vs 3.5° spline taper) were implanted in 9 right and left matched fresh human femora. The proximal femur was removed, and the remaining femoral diaphysis was prepared to allow for either a 2 cm (n = 6), 3 cm (n = 6), or 4 cm (n = 6) cortical contact length with each implanted stem. Stepwise axial load was then applied to a maximum of 2600N or until the femur fractured. Failure was defined as either subsidence >5 mm or femur fracture. RESULTS: All 6 femora with 2 cm of stem-cortical contact length failed axial testing, a significantly higher failure rate (P < .02) than the 4 out of 6 femora and all 6 femora that passed testing at 3 cm and 4 cm, respectively, which were not statistically different from each other (P = .12). Taper angle did not influence success rates, as each matched pair either succeeded or failed at the tested contact length. CONCLUSION: 4 cm of cortical contact length with a TTS demonstrates reliable initial axial stability, while 2 cm is insufficient regardless of taper angle. For 3 cm of cortical contact, successful initial fixation can be achieved in most cases with both taper angle designs.

Fretting and Corrosion at the Backside of Modular Cobalt Chromium Acetabular Inserts: A Retrieval Analysis.

BACKGROUND: Adverse local tissue reaction formation has been suggested to occur with the Modular Dual Mobility (MDM) acetabular design. Few reports in the literature have evaluated fretting and corrosion damage between the acetabular shell and modular metal inserts in this modular system. We evaluated a series of 18 retrieved cobalt chromium MDM inserts for evidence of fretting and corrosion. METHODS: We assessed the backsides of 18 MDM components for evidence of fretting and corrosion in polar and taper regions based on previously established methods. We collected and assessed 30 similarly designed modular inserts retrieved from metal-on-metal (MoM) total hip arthroplasties as a control. RESULTS: No specific pattern of fretting or corrosion was identified on the MDM inserts. Both fretting and corrosion were significantly greater in the MoM cohort than the MDM cohort, driven by higher fretting and corrosion scores in the engaged taper region of the MoM inserts. CONCLUSION: MoM components demonstrated more fretting and corrosion than MDM designs, specifically at the taper region, likely driven by differences in the taper engagement mechanism and geometry among the insert designs. The lack of significant fretting and corrosion observed in the MDM inserts are inconsistent with recent claims that this interface may produce clinically significant metallosis and adverse local tissue reactions.

Significant Functional Improvement at 2 Years After Isolated Patellofemoral Arthroplasty With an Onlay Trochlear Implant, But Low Mental Health Scores Predispose to Dissatisfaction.

INTRODUCTION: We reviewed the clinical and radiographic outcomes of a consecutive series of patients who underwent patellofemoral arthroplasty (PFA) using a modern onlay-style trochlear design and all-polyethylene patellar component. An additional goal of the study was to elucidate, for the first time, the extent to which patients were satisfied with their implant and whether expectations were met after undergoing PFA. METHODS AND MATERIALS: We identified a consecutive series of 70 knees (53 patients) treated with primary isolated PFA between October 2007 and May 2012. For our clinical outcomes analysis, we included patients with a minimum follow-up of 2 years and available preoperative original Knee Society scores. RESULTS: At an average 4.9 years of follow-up, the mean range of motion and Knee Society Knee and Function scores improved significantly, and less than 4% of patients required revision arthroplasty. There was no radiographic evidence of component loosening or wear. Despite these improvements, new Knee Society scores indicated that fewer than two-thirds of patients were satisfied or had their expectations met. Dissatisfied patients and those whose expectations were not met had significantly lower Mental Health scores according to the Short Form-36 following PFA. CONCLUSIONS: Despite the clinical and radiographic success of this implant, patient satisfaction remained low, which may be partially explained by poor mental health.

Does the ulnar nerve enlarge after surgical transposition?

OBJECTIVES: The purpose of this study was to test the hypothesis that symptomatic transposed ulnar nerves have a larger average cross-sectional area (CSA) than symptomatic in situ ulnar nerves. METHODS: We conducted a retrospective review of the charts and sonograms of 68 patients who had failed ulnar nerve transposition compared to 48 patients with cubital tunnel syndrome who had not undergone surgical management. In addition, postoperative sonograms were compared with preoperative studies when available. Failure was defined as persistence or recurrence of symptoms of ulnar neuropathy postoperatively. The cross-sectional area of the nerve, subjective echogenicity, and residual sites of compression were recorded. Groups were subsequently compared by t tests. RESULTS: The failed ulnar nerve transposition group showed a mean cross-sectional area ± SD of 17.26 ± 9.93 mm(2), whereas the control group showed a mean cross-sectional area of 13.45 ± 7.33 mm(2). This difference was statistically significant (P= .018). Nontransposed nerves were more likely to have identifiable sites of compression (P< .05). There was a trend toward postoperative enlargement in the 6 patients with available preoperative imaging (P = .17). No difference in subjective echogenicity was found in this analysis. CONCLUSIONS: Patients with failed ulnar nerve transposition show a significantly enlarged cross-sectional area when compared to symptomatic nerves in situ. Although a specific etiology for this difference cannot be determined, the data suggest that the reference ranges for the cross-sectional area of the ulnar nerve may need to be revised for those who have undergone surgery.

Pectoralis major ruptures in professional American football players.

BACKGROUND: Pectoralis major injuries are an infrequent shoulder injury that can result in pain, weakness, and deformity. These injuries may occur during the course of an athletic competition, including football. The purpose of this study was to determine the incidence of pectoralis major ruptures in professional football players and time lost from the sport following injury. We hypothesized that ruptures most frequently occur during bench-press strength training. METHODS: The National Football League Injury Surveillance System was reviewed for all pectoralis major injuries in all players from 2000 to 2010. Details regarding injury setting, player demographics, method of treatment, and time lost were recorded. RESULTS: A total of 10 injuries-complete ruptures-were identified during this period. Five of the 10 were sustained in defensive players, generally while tackling. Nine occurred during game situations, and 1 occurred during practice. Specific data pertinent to the practice injury was not available. No rupture occurred during weight lifting. Eight ruptures were treated operatively, and 2 cases did not report the method of definitive treatment. The average days lost was 111 days (range, 42-189). The incidence was 0.004 pectoralis major ruptures during the 11-year study period. CONCLUSIONS: Pectoralis major injuries are uncommon while playing football. In the National Football League, these injuries primarily occur not during practice or while bench pressing but rather during games. When pectoralis major ruptures do occur, they are successfully treated operatively. Surgery may allow for return to full sports participation. LEVEL OF EVIDENCE: IV, case series.

Early Femoral Insufficiency Fractures After Primary Total Knee Arthroplasty.

Background: Periprosthetic femur fracture following total knee arthroplasty (TKA) is a devastating complication. Although trauma-related periprosthetic femur fractures have been well studied, early atraumatic insufficiency periprosthetic fractures (IPFs) are gaining attention. We present the largest IPF series to date to better understand and prevent this complication. Methods: A retrospective study of all patients who underwent a revision surgery for periprosthetic fracture within 6 months of primary TKA between 2007 and 2020 was performed. Patient demographics, preoperative radiographs, implant details, and fracture radiographs were reviewed. Alignment measurements and fracture characteristics were assessed. Results: Sixteen patients met criteria (rate 0.05%), and 11 had posterior-stabilized TKAs. The mean age was 79 years, mean body mass index was 31 kg/m2, and 94% (15/16) were female. Seven (47%) patients had a confirmed history of osteoporosis. IPF occurred on average 4 weeks (range, 4 days-13 weeks) after the index TKA. Overall, 12 of 16 (73%) had preoperative valgus deformities, and 11 patients (10 valgus, 1 varus) had preoperative deformities >10 degrees. A characteristic radiographic appearance of femoral condylar impaction and collapse was noted in 12 of 16 cases (75%); 11 of these 12 fractures (92%) involved the unloaded compartment based on preoperative varus/valgus deformity. Conclusions: Patients who developed IPFs were most commonly elderly, obese women with osteoporosis and severe preoperative valgus deformities. The apparent mechanism of failure was overloading of previously unloaded osteopenic femoral condyle. In high-risk patients, the use of a cruciate-retaining femoral component or a femoral stem for a posterior-stabilized femur may be considered to help avoid this catastrophic complication.

Predictors of intensive care unit admission after total joint arthroplasty.

Total joint arthroplasty (TJA) is a relatively safe orthopedic procedure. However, complications do occur, and some may necessitate admission to the intensive care unit (ICU). Our purpose was to determine risk factors associated with admittance to ICU after TJA. We evaluated 22,343 primary and revision total hip and knee arthroplasties from 1999 to 2008. One hundred thirty patients were admitted to the ICU. Cases were matched 1:2 for date of surgery, surgeon, and type of surgery. The causes for admission to ICU were recorded. Independent risk factors for ICU admission were smoking, cemented arthroplasty, general anesthesia, allogenic transfusion, higher C-reactive protein, lower hemoglobin level, higher body mass index, and older age. Proper identification and management of these "at-risk" patients may decrease the incidence of ICU admittance after TJA.

Do Antibiotic-Loaded Calcium Sulfate Beads Improve Outcomes After Debridement, Antibiotics, and Implant Retention? A Matched Cohort Study.

BACKGROUND: Dissolvable antibiotic-loaded calcium sulfate beads are used as an intraoperative adjunct during debridement with antibiotics and implant retention (DAIR) for periprosthetic joint infections (PJI) to reduce the historically higher failure rates than one- or two-stage exchange. This study evaluated clinical outcomes after DAIRs performed with and without these antibiotic beads. The primary outcome was post-DAIR failure secondary to recurrent PJI at 2 years. The secondary outcome was early failure secondary to recurrent PJI within 90 days. MATERIAL AND METHODS: DAIRs performed for acute or acute hematogenous PJI at a single institution were retrospectively identified between 2013 and 2018. All DAIRs with adjunctive antibiotic beads (cases) were then exactly matched to a cohort of DAIRs without beads (controls) based on Charlson Comorbidity Index. The McNemar's test and Wilcoxon signed-rank test were used to evaluate differences in outcomes and patient characteristics. RESULTS: Twenty DAIR cases (with antibiotic beads) were matched with 20 DAIR controls. There was no difference in age, sex, body mass index, joint, erythrocyte sedimentation rate, C-reactive protein, microbiology profile, antibiotic-resistance profile, or intraoperative lavage adjuncts between groups. There were no statistically significant differences between cases and controls for either overall infection-related failure at 2 years (P = .21) or early infection-related failure at 90 days (P = 1.00). CONCLUSION: Adjunctive dissolvable antibiotic-loaded calcium sulfate beads did not reduce the incidence of recurrent PJIs at 2 years or 90 days postoperatively after DAIR. Given the added cost of these antibiotic dissolvable beads without clinical benefits, we cannot recommend their use as an adjunct treatment during DAIRs.

Rotating Hinge Revision Total Knee Arthroplasty for Severe Arthrofibrosis.

Stiffness following total knee arthroplasty is a challenging complication for both the patient and surgeon, with an incidence that ranges from 1% to 13%1. There are several correctable mechanical causes for stiffness including malposition, malalignment, overstuffing, aseptic loosening, patella baja, and heterotopic ossification2. Idiopathic stiffness is often termed arthrofibrosis and is more difficult to treat1. Once patients have exhausted nonoperative options, including physical therapy and manipulation under anesthesia, revision surgery may be considered. Rotating hinge revision total knee arthroplasty has been shown to be an effective surgical treatment for severe arthrofibrosis. Description: First, remove all soft-tissue and osseous sources of stiffness and adequately expose the knee, then remove all previous components. Create a stable and balanced extension gap, and, conversely, a relatively loose flexion gap, which allows for a substantial increase in range of motion. Then, in order to prevent instability in flexion, a rotating hinge prosthesis is utilized, which allows for appropriate kinematic motion despite gap imbalance. Additional steps to regain flexion include medial and lateral distal femoral partial condylectomies, as well as patellar component revision. Alternatives: The first line of treatment for stiffness following total knee arthroplasty is nonoperative and is mainly focused on physical therapy3. Manipulation under anesthesia can also be performed within the first 12 weeks postoperatively3. Surgical treatments can include arthroscopic debridement as well as open debridement with possible polyethylene liner exchange. If there is a mechanical cause for stiffness, then this should also be addressed surgically. For cases of arthrofibrosis without a clear mechanical etiology or for cases in which the above treatment has failed, complete revision of the femoral and tibial components should be considered3. An alternative option to the technique proposed here is to utilize a varus-valgus constrained implant. Rationale: Revision with a hinged implant allows for a more aggressive approach to regaining motion, as compared with all other surgical alternatives. By revising all components, the surgeon is able to remove all sources of stiffness and reconstruct the knee until as much range of motion as possible is achieved. Unfortunately, even with balanced extension and flexion gaps, refractory stiffness is common. A solution for this residual stiffness is to unbalance the gaps and create a loose flexion gap. By doing so, the surgeon is advised to switch to a hinged implant to create a kinematically balanced knee. Any other revision implant, such as a varus-valgus constrained implant, would risk flexion instability. Expected Outcomes: Several studies have examined the use of revision total knee arthroplasty with a hinged implant for arthrofibrosis and have showed substantial improvements in knee range of motion. Bingham et al. showed that the rotating hinge group had a 20° improvement in range of motion (p = 0.048)1. Hermans et al. found a 35.8° flexion gain in the hinge group compared with a 14.2° flexion gain in the varus-valgus constrained group (p = 0.0002)4. van Rensch et al. found a median gain of 45° of range of motion5. Patients should be aware that this procedure involving the use of a hinged implant has similar risks to other revision total knee arthroplasty procedures; specifically, there is a risk of recurrent arthrofibrosis as well as mechanical complications1,5. Important Tips: Achieve adequate exposure with a quadriceps snip.Perform a thorough synovectomy and debridement.Create a balanced extension gap with a relatively loose flexion gap.Distalize the joint line by resecting additional proximal tibia in cases of patella baja.Beware of refractory stiffness as a result of a scarred extensor mechanism.Consider revising the patellar component.Consider performing a partial condylectomy at the medial and lateral distal aspects of the femur. Acronyms and Abbreviations: TKA = total knee arthroplastyAP = anteroposteriorCT = computed tomographyMRI = magnetic resonance imagingRHK = rotating hinge kneeNSAIDs = nonsteroidal anti-inflammatory drugs.

Relatively Low Rate of Heterotopic Ossification Following Primary Total Knee Arthroplasty: A Systematic Review and Meta-analysis.

BACKGROUND: Heterotopic ossification (HO) is abnormal growth of ectopic bone and negatively affects the outcomes after total knee arthroplasty (TKA). This systematic review and meta-analysis were performed to characterize the prevalence and severity of HO after primary TKA. METHODS: A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Patient demographics, publication year, and HO prevalence after a primary TKA were recorded. A meta-analysis was performed to determine the overall prevalence of HO formation, and a subanalysis compared the studies published in different timeframes to determine whether a temporal effect exists for HO prevalence. RESULTS: Two thousand nine hundred eighty-eight patients underwent primary TKA across the included studies. Fourteen percent of patients (9% to 20%; I2: 93.68%) developed HO postoperatively during a mean follow-up of 40.1 months (11 to 108 months). HO rates seemed to decrease in studies published in more recent years, with a pooled HO prevalence of 5% (0% to 13%; I2: 92.26%) among studies published in the past 15 years compared with 18% (12% to 25%; I2: 92.49%) among studies published before then. CONCLUSION: Although studies reported a relatively low overall rate of HO after a primary TKA, the absence of a single, standardized classification system precludes the comparisons of HO severity between studies. Overall, HO prevalence seems to have decreased over time, likely reflecting the changes in perioperative medication protocols.

Adaptive Immune Response Associated with a Zirconium-Containing, Cemented, Total Knee Arthroplasty: A Case Report.

CASE: A 69-year-old woman underwent revision total knee arthroplasty for patellar component aseptic loosening. The periprosthetic tissue demonstrated histologic features of an adaptive immune response (aseptic lymphocyte-dominant vasculitis-associated lesion [ALVAL]). No particles of corrosion debris were identified. The inflammation seemed to be associated with zirconium oxide (ZrO2) particles added as a bone cement radio-opacifier. CONCLUSION: The factors responsible for the adaptive immune response cannot be determined with certainty; however, this is the first reported case of ALVAL associated with ZrO2-containing bone cement. Previous reports describing ALVAL around failed total knee prostheses have not included observations about the type of contrast material added to cement.

Low-Virulence Organisms and Periprosthetic Joint Infection-Biofilm Considerations of These Organisms.

PURPOSE OF REVIEW: The purpose of this manuscript is to provide a critical review of peer-reviewed literature over the last 5 years related to low virulent organisms associated with periprosthetic joint infection (PJI). We evaluated the most common organisms, the diagnostic challenges, and the novel tools available in the perioperative workup of PJI as well as the current understanding of how biofilm potentiates the indolent clinical presentation and explore a possible shift in the surgical management of these patients. RECENT FINDINGS: Biofilm actively prevents macrophage phagocytosis by suppressing proinflammatory activity through the recruitment of myeloid-derived suppressor cells. Given the appropriate host and organism conditions, increased utilization of one-stage exchange arthroplasty in the surgical treatment of these low virulent infections may be on the rise. Biomarkers and molecular techniques offer encouraging results to diagnose low virulent organisms and future research focused on the disruption of biofilm may ultimately give rise to improved treatment strategies.

Institutional review board approval: why it matters.

The modern institutional review boards originated in the 1970s. They exist to protect human subjects participating in research from potential harm. The Belmont Report provided the ethical principles (respect for persons, beneficence, and justice) that should be observed while conducting research on human subjects. Compliance with the ethical principles of the Belmont Report is a first step in successful submissions to an institutional review board. Regulations regarding conflict of interest represent an attempt to ensure that research is not biased by financial or other interest and to maintain public trust.

Proximal femoral replacement in patients with non-neoplastic conditions.

BACKGROUND: Numerous factors may give rise to the loss of femoral bone stock that can be encountered in revision hip arthroplasty. Proximal femoral replacement is an option for the treatment of severe proximal femoral bone loss. In this study, we sought to determine the outcome of reconstructive surgery with the use of a modular proximal femoral replacement (a so-called megaprosthesis) in patients with proximal femoral bone loss due to non-neoplastic conditions. METHODS: A review of computerized databases from two institutions identified forty-eight patients with a mean age of 73.8 years who had undergone the placement of a modular megaprosthesis with or without bone-grafting. The indication for proximal femoral replacement was a periprosthetic fracture in twenty patients, reimplantation because of a deep infection in thirteen, a failed arthroplasty in thirteen, nonunion of an intertrochanteric fracture in one, and radiation-induced osteonecrosis with a subtrochanteric fracture in one. Three patients died before the minimum two-year follow-up interval had elapsed, and two additional patients were lost to follow-up. The mean duration of follow-up for the remaining study group of forty-three patients was 36.5 months. RESULTS: At the time of follow-up, there was a significant improvement in function as measured with the Harris hip score (p < 0.05). The proximal femoral replacement achieved an excellent or good functional outcome in twenty-two of the forty-three hips. The functional outcome was found to be fair in ten hips and poor in the remaining eleven. Ten patients required a reoperation or revision because of at least one complication. With revision used as the end point, the survivorship of the implant was 87% at one year and 73% at five years. CONCLUSIONS: Patients with severely compromised bone stock in whom the use of a conventional prosthesis is precluded because of an inability to achieve adequate fixation may be candidates for proximal femoral replacement. Our short-term results suggest that this is a viable salvage procedure for these patients.

Developments in spinal and epidural anesthesia and nerve blocks for total joint arthroplasty: what is new and exciting in pain management.

The decision to use regional or general anesthesia for patients undergoing total joint arthroplasty continues to be controversial. Recent reviews of the literature support the growing trend for the use of regional anesthesia with a multifaceted approach, spanning nuances in block placement as well as pharmacologic agents and delivery systems. Innovative developments offer appealing options and encouraging results for the management of pain after major orthopaedic procedures. The ultimate decision, although varied, requires careful preoperative planning and protocols to ensure adequate pain control and patient satisfaction.