Effect of Vitamin D Deficiency on Periprosthetic Joint Infection and Complications After Primary Total Joint Arthroplasty.

BACKGROUND: Vitamin D deficiency is a global problem, and 13 to 75% of patients undergoing total joint arthroplasty (TJA) have vitamin D deficiency. Several studies have shown that low preoperative vitamin D levels may increase the risk of postoperative complications, including periprosthetic joint infection (PJI), in patients undergoing primary TJA. Most of the studies are underpowered. This study aimed to investigate the relationship between vitamin D deficiency and surgical and medical complications after primary TJA, with a specific focus on PJI. METHODS: Prospectively collected institutional multicenter arthroplasty databases were reviewed to identify patients who underwent primary total knee and hip arthroplasty. The study group was defined as patients whose vitamin D level is < 30 ng/dL and who received a single oral dose of 7.5 mg (300,000 IU) D3 within two weeks before index surgery (n = 488; mean age 63 years). Patients in the control group were those whose preoperative vitamin D levels were unknown and who did not receive vitamin D supplementation (n = 592, mean age 66). The groups were compared regarding 90-day medical and surgical complications, including PJI, mortality, and readmission rates. RESULTS: The total number of complications (8.6 and 4.3%; respectively; P = .005), superficial wound infection (2.5 and 0.2%, respectively; P < .001), and postoperative cellulitis (2.2 and 0% respectively; P < .001) were statistically significantly higher in the patient group who did not receive vitamin D supplementation. However, 90-day mortality (P = .524), PJI (P = .23), and readmission rate (P = .683) were similar between the groups. CONCLUSIONS: This study demonstrated that preoperative optimization of vitamin D levels may be beneficial in reducing postoperative complications, including superficial wound infection and postoperative cellulitis. Administering an oral 300,000 U single-dose vitamin D regimen to correct vitamin D deficiency can positively impact outcomes following primary TJA.

Unseen Threefold Mortality After the First Ten Days in Hemodialysis Patients Following Joint Arthroplasty: A Nationwide Retrospective Cohort Study of 1,287 Arthroplasty Patients on Hemodialysis.

BACKGROUND: The study addresses the growing number of hemodialysis (HD) patients undergoing joint arthroplasty, who are at higher risk of complications and mortality. Previous research has often overlooked deaths after discharge. This study aimed to examine early outcomes in a large nationwide cohort of patients who underwent arthroplasty for elective and fracture-related reasons. METHODS: Between 2016 and 2022, a study was conducted using the e-Nabiz database of the Türkiye Ministry of Health, focusing on patients aged 18 years and above who underwent elective or fracture-related arthroplasty. This study included 1,287 patients reliant on dialysis who underwent total hip arthroplasty, total knee arthroplasty, or hemiarthroplasty (HA), with 7.7% of them receiving dialysis for the first time. Propensity score matching was used to create an equally sized group of non-dialysis-dependent patients, ensuring demographic balance in terms of age, sex, a comorbidity index, and surgery type. The primary objective was to compare mortality rates 10, 30, and 90 days after arthroplasty. RESULTS: The first-time dialysis patients who underwent HA had significantly higher 30- and 90-day mortality rates compared to the chronic dialysis group (P = .040 and P < .001, respectively). Also, the HD patients consistently exhibited higher 90-day mortality rates across all surgery types. With total knee arthroplasty, HD patients had a mortality rate of 8.7%, in stark contrast to 0% among non-HD patients (P < .001). Similarly, with total hip arthroplasty, HD patients had a 12% mortality rate, while non-HD patients had a markedly lower rate of 2.7% (P = .008). In the case of HA, HD patients had a significantly elevated 90-day mortality rate of 31.9%, in contrast to 17.1% among non-HD patients (P < .001). CONCLUSIONS: Joint arthroplasty has higher rates of mortality and complications among HD patients. Surgical decisions must be based on patients' overall health, necessitating collaboration among specialists. These patients should be closely monitored.

Comparison of Iliac and Femoral Autograft Practices in Pemberton Pelvic Osteotomy.

BACKGROUND: There is no consensus in regard to grafts used after pelvic osteotomy in developmental dysplasia of the hip in the literature. The aim of this study was to compare iliac and femoral autografts used after Pemberton pelvic osteotomy (PPO). METHODS: In this prospective, randomized study, 60 hips with dysplasia of the hip were included. All patients underwent open reduction, PPO, and femoral shortening osteotomy. Iliac autograft (group I; n=30 hips; mean age, 39.07; range, 18 to 72 mo) and femoral autograft (group II; n=30 hips; mean age, 42.53; range, 19 to 70 mo) were used to fill the iliac osteotomy. The height and width of the iliac and femoral autografts were measured intraoperatively. Anteroposterior pelvic radiographs were obtained on the 45th day, and in the 2nd, 3rd, 6th, and 12th months postoperatively. Acetabular index angle, height of the graft, loss of graft position, graft resorption, operative time, blood loss, and union time were compared between the groups. RESULTS: There was a significant difference in each group in terms of loss of graft height between the intraoperative measurement and the postoperative measurement at the 6th week and 3rd month. The intraoperative width of the grafts was significantly greater, loss of graft height was significantly less, and the amount of bleeding was significantly lower in group II (P<0.001 for all 3). However, time to union was significantly shorter in group I (P<0.001). There was no significant difference between the groups in terms of acetabular index angle at the last controls. There were loss of graft position in 2 cases and graft resorption in 1 case for group I, but no such cases occurred for group II. CONCLUSIONS: Graft height and position loss, donor site morbidity, and graft resorption were less in the femoral autografts group compared with the iliac autografts group in the treatment PPO with femoral shortening osteotomy. LEVEL OF EVIDENCE: Level II.

The Natural Course of Serum D-Dimer, C-Reactive Protein, and Erythrocyte Sedimentation Rate Levels After Uneventful Primary Total Joint Arthroplasty.

BACKGROUND: This study aimed to assess the baseline levels of D-dimer, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) and monitor the natural course of these serum markers after uneventful primary total joint arthroplasty. METHODS: This prospective study enrolled 81 patients undergoing primary total knee arthroplasty or total hip arthroplasty. The level of serum D-dimer, CRP, and ESR was measured preoperatively and on postoperative days 1, 3, 5, 15, and 45. Mean peak values, peak times, and distribution were compared between D-Dimer, CRP, and ESR. RESULTS: The mean preoperative serum D-dimer, CRP, and ESR level was 412 ± 260 (range 200-980) ng/mL, 2.93 ± 2.1 (range 1-18) mg/L, and 22.88 ± 17.5 (range 3-102) mm/h, respectively. The highest mean peak for D-dimer, CRP, and ESR was at postoperative day 1, 3, and 5, respectively. CONCLUSION: D-dimer levels reached peak levels on postoperative day 1 and then declined rapidly to a plateau level by postoperative day 3. A second, albeit small, peak in the level of D-dimer occurred on postoperative day 15. The level of CRP and ESR remained elevated for much longer with CRP returning to baseline on postoperative day 45 and the level of ESR had not returned back to normal on postoperative day 45.

Low-Dose Aspirin Is Adequate for Venous Thromboembolism Prevention Following Total Joint Arthroplasty: A Systematic Review.

BACKGROUND: Patients undergoing total joint arthroplasty (TJA) are at risk of developing venous thromboembolism (VTE) without adequate prophylaxis. Since the American Academy of Orthopedic Surgeons issued guidelines in 2007 recommending aspirin 325 mg bis in die for 6 weeks, aspirin has been favored as the main VTE prophylaxis. However, the appropriate dose and duration of aspirin are not well-studied. This systematic review aims to identify any differences between high and low dose as well as duration for aspirin thromboprophylaxis after TJA as outlined by previous studies. METHODS: A search was performed using Ovid MEDLINE, EMBASE, and PubMed, including articles up to July 2016. Studies were included if they contained at least 1 cohort that underwent TJA with aspirin as the sole chemoprophylaxis and reported either (1) symptomatic VTE or (2) secondary outcomes such as major bleeding or 90-day mortality. RESULTS: Forty-five papers were included. There were no significant differences in symptomatic pulmonary embolism, symptomatic deep vein thrombosis, 90-day mortality, or major bleeding between patients receiving low-dose or high-dose aspirin. Patients treated with aspirin for <4 weeks had a higher risk of major bleeding (1.59%) vs patients treated for 4 weeks (0.15%), which may be attributed to premature cessation or differential reporting. Patients treated with aspirin for <4 weeks had a statistically higher 90-day mortality (1.95%) vs patients treated for 4 weeks (0.07%). There was no significant difference between incidence of pulmonary embolism or deep vein thrombosis and the durations of aspirin treatment. CONCLUSION: This review suggests that low-dose aspirin is not inferior to high-dose aspirin for VTE thromboprophylaxis in TJA patients. Additionally, patients treated with aspirin for less than 4 weeks may have a higher risk of major bleeding and 90-day mortality compared to patients treated for a longer duration.

Bilateral Femoroacetabular Impingement: What is the Fate of the Asymptomatic Hip?

BACKGROUND: Bilateral symptomatic femoroacetabular impingement (FAI) is common. However, the fate of asymptomatic hip in patients with the radiographic diagnosis of bilateral FAI and unilateral symptoms remains unknown. QUESTIONS/PURPOSES: (1) What is the likelihood of the asymptomatic hip becoming painful in patients with unilateral symptoms but with radiographic evidence of bilateral femoroacetabular impingement? (2) What radiological and clinical factors are associated with the development of symptoms in an asymptomatic hip diagnosed with FAI? METHODS: A longitudinally maintained institutional FAI database was queried to collect relevant data for this retrospective study. To answer our research questions, we created a cohort of patients with bilateral radiographic signs of FAI but only unilateral symptoms at the time of initial presentation. Between 2004 and 2016, a senior surgeon (JP) at one institution treated 652 patients for hip pain determined to be from FAI, a diagnosis we made based on clinical symptoms, physical exam, and diagnostic imaging. We excluded 95 patients (15%) because of inadequate data or other diagnoses, which left 557 patients. Of those, 170 patients (31%) had bilateral radiological diagnosis of FAI, and 88 (52%) of them had bilateral hip symptoms, and so were excluded. Of the remaining 82 patients, eight (10%) underwent bilateral FAI surgery under the same anesthetic despite having only unilateral symptoms, leaving 74 for analysis in this study. Patients were followed with annual clinic visits, or contacted by phone and electronically. We defined onset of symptoms using a modified Harris Hip Score (mHHS) or the University of California at Los Angeles (UCLA) activity scale, and used a logistic regression model to identify factors associated with the development of symptoms. RESULTS: Of the 74 patients with bilateral FAI and an asymptomatic hip at initial presentation, 60 (81%) became symptomatic at a mean 2 years (range, 0.3-11 years) followup. Of these 60 patients, 43 (72%) eventually underwent subsequent surgical intervention. After controlling for potential confounding variables such as sex, age, BMI, history of trauma we identified that reduced neck-shaft angle (r = -0.243, p = 0.009), increased lateral center-edge angle (r = 0.123, p = 0.049), increased alpha angle (r = 0.069, p = 0.025), and younger age (r = -0.071, p = 0.046) were associated with the development of symptoms in the contralateral hip. With the numbers available, none of the other examined variables such as sex, BMI, history of trauma, psychiatric condition, employment, Tönnis grade, Tönnis angle, crossover sign, type of impingement, and joint congruency were found to be associated with symptom progression. CONCLUSIONS: Bilateral FAI may be observed about one-third of patients. Most patients with unilateral symptomatic FAI and radiographic diagnosis of bilateral FAI in this cohort became symptomatic relatively quickly and most of them underwent subsequent surgical intervention in the contralateral hip. Reduced neck-shaft angle, increased lateral center-edge angle, increased alpha angle, and younger age were associated with symptom development in the contralateral hip. Hip preservation surgeons may use the finding of this study to counsel patients who present with bilateral FAI but only unilateral symptoms about the natural history of their condition. LEVEL OF EVIDENCE: Level III, therapeutic study.

Acetabular Labral Tears Are Common in Asymptomatic Contralateral Hips With Femoroacetabular Impingement.

BACKGROUND: The number of patients undergoing hip arthroscopy for labral tears has increased, but labral tears are sometimes seen in asymptomatic patients with femoroacetabular impingement (FAI). The frequency of this finding, however, has not been well characterized nor is the proportion of patients with previously asymptomatic labral tears who may later become symptomatic. QUESTIONS/PURPOSES: The purpose of this study was to determine (1) the prevalence of labral tears and other intraarticular pathology in the asymptomatic contralateral hip of patients undergoing surgery for symptomatic FAI; (2) the likelihood that the asymptomatic hip had become symptomatic at latest followup; and (3) any association between MRI findings and age, sex, and body mass index (BMI) in both symptomatic and asymptomatic sides. METHODS: This study included patients who were diagnosed with unilateral symptomatic FAI between 2013 and 2015 and who had an available MRI of both hips. The study included 100 patients (47 females, 53 males) with a mean age of 33 years (range, 17-57 years). Patients with a symptomatic contralateral hip (n = 56) or an unsuitable MRI for review based on both reviewers' consensus (n = 344) were excluded. The MRI of both hips was independently evaluated by two orthopaedic surgeons and interobserver reliability tested. The interobserver reliability for the two surgeons' MRI ratings was almost perfect (κ ≥ 0.85). The presence of a labral tear, an acetabular chondral lesion, subchondral acetabular cysts, and fibrocystic changes in the femoral head-neck junction was documented for both hips. At latest followup, asymptomatic hips were investigated for any symptomatic labral tears or surgical procedures resulting from FAI. RESULTS: A labral tear was recorded in 97 (97%) and 96 (96%) of symptomatic hips, respectively, for each surgeon's evaluation. A labral tear was also detected in 41 (41%) and 43 (43%) of asymptomatic hips. In addition, an acetabular chondral lesion was detected in 32 (32%) and 35 (35%) of the symptomatic hips and 15 (15%) and 17 (17%) of the asymptomatic hips. At latest followup, nine of the patients were diagnosed with symptomatic labral tears in the contralateral asymptomatic hip and were treated. None of the radiologic parameters examined demonstrated an association with patient age, sex, or BMI in either symptomatic or asymptomatic hips. CONCLUSIONS: Labral tears and acetabular chondral lesions are common in the asymptomatic contralateral hip of patients undergoing surgery for FAI. The incidence of a symptomatic labral tear in these asymptomatic hips was 9% during 2 years of followup. We suggest that the decision to perform chondral or labral surgery in patients with FAI should be made with caution considering the relatively high prevalence of labral tears in asymptomatic hips and the low chance of development of symptoms. LEVEL OF EVIDENCE: Level IV, case-series study.

Fluid retention after shoulder arthroscopy: gravity flow vs. automated pump-a prospective randomized study.

BACKGROUND: Soft tissue fluid retention due to irrigation is relatively common after shoulder arthroscopy. The objective of this study was to compare fluid retention of 2 irrigation systems of shoulder arthroscopy: gravity flow irrigation and automated pump. METHODS: Patients undergoing shoulder arthroscopy were enrolled prospectively and randomized into 2 groups using gravity flow system (GFS) or automated pump system (APS) for irrigation. Net weight gain was the primary outcome measurement to determine periarticular fluid retention. Change in deltoid diameter and postoperative pain were also compared. RESULTS: Forty-two patients were included in the study. There were no statistically significant differences between the GFS and APS groups regarding demographics, surgical procedures, duration of surgery, or the amount of irrigation fluid used. The APS group had greater weight gain per hour (1.46 ± 0.36 kg/h vs. 1.1 ± 0.38 kg/h) than the GFS group. A strong correlation was found between the amount of fluid used and the weight gain in both the GFS and APS groups. But a strong correlation between duration of surgery and weight gain was found in the APS group only. The APS group also had a greater mean deltoid diameter increase (3.33 ± 1.56 cm vs. 2.1 ± 1.44 cm) and a higher postoperative first-hour visual analog pain scale score (5.81 ± 2 vs. 3.62 ± 1.6). CONCLUSION: APS causes more fluid retention than GFS in shoulder arthroscopy when used for equal duration in similar procedures. Use of APS, prolongation of surgery, and increased amounts of irrigation fluid increase weight gain as a result of fluid retention.

Direct Anterior Approach Total Hip Arthroplasty Using a Morphometrically Optimized Femoral Stem, a Conventional Operating Table, Without Fluoroscopy.

BACKGROUND: Our experience with direct anterior approach total hip arthroplasty (THA) suggests that it can be performed successfully with a morphometrically optimized metaphyseal-diaphyseal engaging femoral stem (NOT a short stem), a regular operating room table (NOT a special custom table), and WITHOUT intraoperative fluoroscopy. We report our minimum 2-year results. METHODS: A retrospective review of a single-surgeon series of primary direct anterior approach THAs was performed. All procedures were performed on a regular table, without fluoroscopy, using a cementless tapered femoral stem. Clinical, functional, and radiographic outcomes were evaluated at a minimum of 2 years. RESULTS: In total, 1017 primary THAs were performed. The preoperative Harris Hip Score was 40.7 ± 5.1 and improved to 95.3 ± 4.2 at minimum 2-year follow-up. There were 3 dislocations (0.3%) and 15 revisions (1.5%): 7 for infection (0.7%), 4 for periprosthetic fractures (0.4%), 2 for instability (0.2%), 1 for loosening (0.1%), and 1 for pain (0.1%). Five patients (0.5%) required blood transfusion. One patient developed deep vein thrombosis and pulmonary embolism. No intraoperative fractures, perforation, or THA-related mortality occurred. Neutral stem alignment was confirmed in 98.3%. Mean cup inclination was 38.8° ± 5.1° and anteversion was 16.2° ± 3.5°. The mean leg-length discrepancy was corrected from 1.2 ± 0.2 cm preoperatively to 0.2 ± 0.1 cm postoperatively. CONCLUSION: Using a morphometrically optimized metaphyseal-diaphyseal engaging tapered femoral stem instead of a short stem reduces component malposition and minimizes risk of loosening. Combining the use of this implant design and the technique and elements described in our cohort demonstrated to have excellent results at 2 years. The patients will need continued follow-up to demonstrate further durability of this device and technique compared to others performing direct anterior THA.

Percutaneous Plantar Fascia Release With Needle: Anatomic Evaluation with Cadaveric Specimens.

Percutaneous plantar fascia release with needle is a novel procedure for the treatment of plantar fasciitis. The objective of this cadaveric study is to perform an anatomic evaluation of the percutaneous plantar fascia release method using a conventional hypodermic needle. In this study, we used 14 fresh-frozen cadaveric trans-tibial amputation specimens. Percutaneous plantar fasciotomy with a conventional hypodermic needle was performed. After a proper dissection, the width of the plantar fascia, the thickness of the medial border, and the width of the cut segment were measured and recorded. Any muscle damage on the flexor digitorum brevis and damaged area depth were recorded. Any damage on the lateral plantar nerve and the first branch of the lateral plantar nerve, also known as Baxter's nerve, and their distance to fasciotomy were also recorded. Mean width (± standard deviation) of the plantar fascia was measured as 20.34 ± 4.25 mm. The mean thickness of the medial border of the plantar fascia was 3.04 ± 0.54 mm. Partial fasciotomy was performed in all cadavers with 49.47% ± 7.25% relative width of the plantar fascia. No lateral plantar nerve, or its first branch Baxter's nerve, was damaged, and the mean distance from the deepest point of the fasciotomy up to the Baxter's nerve was 8.62 ± 2.62 mm. This cadaveric study demonstrated that partial plantar fasciotomy can be achieved via percutaneous plantar fascia release with a conventional hypodermic needle without any nerve damage.

Differences in Reported Outcomes in Industry-Funded vs Nonfunded Studies Assessing Thromboprophylaxis After Total Joint Arthroplasty.

BACKGROUND: There are numerous studies discussing thromboprophylaxis after total joint arthroplasty (TJA), with varying conclusions. Patient inclusion criteria may be different for each study, which may lead to selection bias and misrepresentation of data. This study aimed to investigate if industry funding impacted patient demographics and overall reported outcomes of studies analyzing venous thromboembolism (VTE) prevention after TJA. METHODS: Electronic searches were completed using Ovid, PubMed, and Embase databases. Studies were included if (1) they are published in the English language between 2000 and 2016; (2) they included patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA); and (3) they evaluated prevention and control of postoperative VTE with at least one of the following thromboprophylactic agents: aspirin, enoxaparin, dalteparin, dabigatran, apixaban, rivaroxaban, dabigatran, ximelagatran, fondaparinux, or coumadin. Data were extracted and analyzed via mixed-effect logistic regression. RESULTS: Fifty-seven studies were included; 29 were industry funded, and 28, nonfunded. There were no significant differences between patient's age, body mass index, or revision exclusions between funded and nonfunded studies. Funded studies reported less pulmonary embolisms, fewer events of major bleeding, and significantly less 90-day mortality compared with nonfunded studies. CONCLUSION: Industry-funded studies reported less pulmonary embolisms, major bleeding, and mortality compared with nonfunded studies. Detailed demographic data were missing from the literature, and we were unable to demonstrate the cause of different reported outcomes between industry-funded and nonfunded studies. Further investigations should be aimed toward understanding how funded studies report less adverse outcomes in analyzing VTE after TJA.

Vancomycin Prophylaxis for Total Joint Arthroplasty: Incorrectly Dosed and Has a Higher Rate of Periprosthetic Infection Than Cefazolin.

BACKGROUND: In total joint arthroplasty (TJA), vancomycin is used as perioperative antibiotic prophylaxis in patients with penicillin allergy or in patients colonized with methicillin-resistant Staphylococcus aureus (MRSA). Although vancomycin dosing should be weight-based (15 mg/kg), not all surgeons are aware of this; a fixed 1-g dose is instead frequently administered. QUESTIONS/PURPOSES: (1) Is there a difference in the risk of periprosthetic joint infection (PJI) in patients receiving vancomycin or cefazolin prophylaxis after primary TJA? (2) What proportion of patients is adequately dosed with vancomycin? (3) Compared with actual fixed dosing, does weight-based dosing result in a greater proportion of patients staying above the recommended 15-mg/L level at the beginning and end of surgery? (4) Are patients overdosed with vancomycin at greater risk of developing nephrotoxicity and acute kidney injury? METHODS: A single-institution, retrospective study was performed on 1828 patients undergoing primary TJAs who received vancomycin prophylaxis between 2008 and 2014. During the same period, 5810 patients underwent primary TJA and received cefazolin monotherapy. A chart review was performed to obtain patient characteristics, antibiotic dose and timing of administration, and microbiology data. Adequate vancomycin dosing was defined as 15 mg/kg and within the 125-mg range. Vancomycin levels were calculated at the beginning and end of surgery using pharmacokinetic equations. Levels of 15 mg/L were considered adequate. Logistic regression, chi square tests, and analysis of variance were performed. RESULTS: Among primary TJAs, patients receiving vancomycin had a higher rate of PJI (32 of 1828 [2%]) compared with patients receiving cefazolin prophylaxis (62 of 5810 [1%]; adjusted odds ratio, 1.587 [1.004-2.508]; p = 0.048). Ten percent of PJIs in the vancomycin underdosed group (two of 20) was caused by MRSA, and no patients with adequate dosing or overdosing of vancomycin developed PJI with MRSA. Of all procedures in which vancomycin monotherapy was used, 28% (518 of 1828) was adequately dosed according to weight-based dosage recommendations. Furthermore, 94% (1726 of 1828) of patients received a fixed 1-g dose of vancomycin, of whom 64% (1105 of 1726) were underdosed. All patients had vancomycin infusion initiated within 2 hours before incision. A weight-based protocol would have resulted in fewer patients having unacceptably low vancomycin levels (< 15 mg/L) compared with those with actual fixed dosing, both for the beginning of surgery at the time of incision (zero of 1828 [0%] versus 471 of 1828 [26%]; odds ratio, 0.001 [0.000-0.013]; p < 0.001) and at the end of surgery (33 of 1828 [2%] versus 746 of 1828 [41%]; odds ratio, 0.027 [0.019-0.038]; p < 0.001). Between the vancomycin dosage groups, there were no differences in the rate of nephrotoxicity (underdosed: 12 of 1130 [1%], adequately dosed: five of 518 [1%], overdosed: four of 180 [2%], p = 0.363) and acute kidney injury (underdosed: 28 of 1130 [2%], adequately dosed: 10 of 518 [2%], overdosed: six of 180 [3%], p = 0.561). CONCLUSIONS: The majority of patients given vancomycin prophylaxis are underdosed according to the weight-based dosage recommendations, and MRSA did not occur in patients who were adequately dosed with vancomycin. Surgeons should thus ensure that their patients are adequately dosed with vancomycin using the recommendation of 15 mg/kg and that the dose of vancomycin is administered in a timely fashion. Furthermore, and based on the findings of this study, we have moved toward limiting the utilization of vancomycin prophylaxis for patients undergoing elective arthroplasty at our institution. LEVEL OF EVIDENCE: Level III, therapeutic study.

Optimizing Mechanical Alignment With Modular Stems in Revision TKA.

BACKGROUND: Although mechanical alignment is critical for optimal function and long-term implant durability, the role of modular stems in achieving ideal alignment is unclear. METHODS: We identified 319 revision total knee arthroplasty from 2003-2013, for which stem length, stem diameter, and stem fixation method were recorded prospectively. Three-dimensional canal-filling ratio, the product of canal-filling ratio at the stem tip in both the anteroposterior and lateral planes, and alignment were measured radiographically. RESULTS: Ideal alignment of the femur was considered to be 95° in the anteroposterior (AP) plane and from 1° of extension to 4° of flexion in the lateral plane, and ideal tibial alignment was considered to be 90° in the AP plane. Even after accounting for difference in stem size and canal-fill, ideal AP alignment was more reliably achieved with press-fit stems. CONCLUSION: Furthermore, increased engagement of the diaphysis and its anatomical axis with canal-filling stems facilitates accurate alignment.

Effect of Stem Size and Fixation Method on Mechanical Failure After Revision Total Knee Arthroplasty.

BACKGROUND: Although the need for stemmed components is well accepted to improve mechanical survival in revision total knee arthroplasty (TKA), the ideal fixation method and stem design remain controversial. METHODS: We performed a retrospective review of 223 patients who underwent revision TKA in whom stemmed components had not been used previously and with a mean follow-up of 61.6 months, including 108 components with fully cemented stems and 316 components with "hybrid" press-fit stems. RESULTS: Based on a time to event model, risk for mechanical failure was equivalent for both cemented and hybrid stems (relative risk, 0.991; P = .98). Young age was the single greatest risk factor for mechanical failure (P = .006). Although there was a trend toward increased failure with cemented stems in patients aged <65 years, there was no significant difference in risk after accounting for covariates (relative risk, 1.4; P = .50). Intramedullary canal fill, not stem length or diameter, was the strongest predictor of failure with hybrid stems, and risk was reduced by 41.2% for each additional 10% canal fill. CONCLUSION: In conclusion, both cemented and hybrid modular stems are viable options in revision TKA. Surgeons should attempt to maximize canal filling of hybrid stems to obtain a solid press-fit. In addition, further studies are needed to evaluate the long-term survival of cemented stem fixation in young patients.

Minimally Invasive Plate Osteosynthesis in Open Pediatric Tibial Fractures.

OBJECTIVES: The aim of this study is to investigate the effectiveness and reliability of limited-contact locking plates in minimally invasive percutaneous osteosynthesis (MIPO) of the lateral tibia. DESIGN: A retrospective study. PATIENTS AND METHODS: The retrospective study included 14 patients who were operatively treated with an MIPO technique due to open tibial fractures between 2006 and 2012. The patients were 11 males and 3 females with a mean age of 13.2 (range, 9 to 16) years. The patients were followed up for a mean period of 2.4 (range, 1 to 5) years. The mechanism of the injuries included a motor vehicle accident (n=11), a shotgun injury (n=2), and a fall from height (n=1). According to the Gustilo-Anderson classification, 10 patients had type I (72%), 2 had type II (14%), and 2 had type III (14%) open fractures. RESULTS: The mean time to radiologic union was 18 (range, 11 to 32) weeks. No infection was detected that would require implant removal. No complications such as early epiphyseal closure, angulation, or limb-length inequality were observed. CONCLUSIONS: Limited-contact locking plates in MIPO of the lateral tibia is an effective alternative method in the treatment of open pediatric tibial fractures. LEVEL OF EVIDENCE: Level IV-therapeutic.

The effect of tourniquet and knee position during wound closure after total knee arthroplasty on early recovery of range of motion: a prospective, randomized study.

INTRODUCTION: There is no consensus on the position of the knee joint while performing wound closure after total knee arthroplasty (TKA). Further, there are no studies focusing on the association between early functional outcomes and different wound closure strategies. Therefore, we investigated the effects of tourniquet and knee position during wound closure on early recovery of range of motion (ROM) after primary TKA. To our knowledge, this is the first study to evaluate the influence of both tourniquet and knee position during wound closure in primary TKA. METHODS: One hundred-twenty eligible patients were consecutively enrolled in this study and randomly divided into four groups according to wound closure strategy. Wound closure was either performed with the knee in flexion at 90° or in full extension, with the combination of an inflated or deflated tourniquet. Visual analogue score (VAS), knee ROM, ROM recovery, knee society score (KSS), and wound complications were evaluated in the early postoperative period. RESULTS: After the first postoperative week, ROM recovery in the group with knee in extension and inflated tourniquet was significantly lesser than the two groups with deflated tourniquets. Between the first and fourth postoperative weeks, ROM recovery in the group with knee inflection and deflated tourniquet was significantly higher than the two groups with knee in extension. After the first postoperative week, the visual analog score (VAS) for pain in the group with knee inflection and deflated tourniquet was significantly lesser than the two groups with inflated tourniquets. The differences in the outcomes between the four groups were not significant after the fourth postoperative week. The incidence of wound complications and KSS were not significantly different between the four groups. CONCLUSION: Following TKA, wound closure with the knee in flexion and after deflating the tourniquet significantly decreased postoperative pain and promoted the recovery of ROM in the early postoperative period.

Management of infectious fractures with "Non-Contact Plate" (NCP) method.

The aim of this study was to evaluate the outcomes of internal fixation with Non-Contact Plating (NCP) after deep infection caused by previous surgeries of the tibia or femur fractures. The study included 15 patients (4 female and 11 male). The mean age patients was 36.6 years (range, 21-64 years). There were 6 femur and 9 tibia fractures. The mean follow-up period was 25.7 months (range, 15-45 months). The study comprised 11 open and 4 closed fractures. External fixator was used in 3, plate in 4, and intramedullary nail in 8 patients for index surgery. Deep infection was diagnosed via clinical findings, laboratory parameters, and microbiological evaulation. Deep infection was diagnosed within a mean period of 5.5 weeks (range, 2-10 weeks). The infecting organism was methicillin-resistant staphylococcus aureus (MRSA) in 5, methicillin-sensitive staphylococcus aureus (MSSA) in 6, pseudomonas auroginosa in 2, and enterobacteriacea in 2 patients. Union achieved in all patients. Mean time to union was 17 (range, 11-38) weeks. Delayed union was observed in 3 patients who required additional surgeries. Of these one patient developed osteomyelitis. The NCP is an effective alternative method in the treatment of deep infection encountered after internal or external fixation for the tibia, or femur fractures.