Survivorship and Radiographic Evaluation of Metaphyseal Cones With Short Cemented Stems in Revision Total Knee Arthroplasty.

BACKGROUND: The purpose of this study is to evaluate the survivorship and radiographic outcomes of a single design of metaphyseal cone used in conjunction with short cemented stems. METHODS: A retrospective analysis was conducted of revision total knee arthroplasty (rTKA) patients (June 2015 to December 2017) using porous titanium femoral or tibial cones in conjunction with short cemented stems (50-75 mm). Minimum follow-up was 2 years. Survivorship, complications, and a modified Knee Society Radiographic score were analyzed. RESULTS: Forty-nine rTKAs were included in the study (12 femoral cones, 48 tibial cones). Varus-valgus constraint was used in 28 (57%) and a hinged bearing was used in 3 (6%) of these constructs. The majority were index rTKAs of primary components (86%), performed for aseptic loosening (51%) and reimplantation following staged treatment for infection (37%). Median follow-up was 39 months (range 25-58). Using a modified Knee Society Radiographic score, all constructs were classified as stable. Postoperatively, 4 rTKAs were complicated by recurrent infection (8%), periprosthetic fracture 2 (4%), and superficial wound infection 1 (2%). Seven rTKAs (14%) required reoperation. The majority of reoperations (4 rTKAs) were debridement and irrigation with implant retention for infection. Metaphyseal cone constructs with short cemented stems demonstrated 100% survivorship free of revision for aseptic loosening without evidence of radiographic loosening in any case. CONCLUSION: Our results demonstrate excellent outcomes with the use of metaphyseal cones with short cemented stems at mid-term follow-up. This construct avoids the use of long-stem fixation with the associated extraction difficulty, end of stem pain, and potential for malposition at the joint line. LEVEL OF EVIDENCE: IV, Case Series.

The Importance of Appropriate Incision Choice in Conversion Total Knee Arthroplasty.

When faced with the necessity of surgery in a previously operated knee, pre-operative planning and understanding of the vascular anatomy to the front of the knee is essential. Blood flow to the anterior aspect of the knee comes from medial to lateral. Therefore, in the case of multiple previous knee incisions the most lateral incision should always be chosen to avoid skin necrosis. The concept of a safe distance between incisions is inappropriate, risks extensive skin necrosis, and should be abandoned. (Journal of Surgical Orthopaedic Advances 30(4):253-255, 2021).

Can Flexed-Seated and Single-Leg Standing Radiographs Be Useful in Preoperative Evaluation of Lumbar Mobility in Total Hip Arthroplasty?

BACKGROUND: The purpose of this study is to determine whether simulated radiographs in the "flexed-seated" or "step-up" positions better demonstrate a patient's range of spinopelvic motion between standing and sitting positions than relaxed sitting and standing radiographs. METHODS: An institutional review board approved cohort of 43 patients with hip osteoarthritis whom underwent full body sitting-standing radiographs from August 2016 to December 2017 at a single institution was reviewed. Subjects underwent single-leg step-up standing and flexed-seated radiographs, and relaxed standing and sitting radiographs. Sacral slope, spinopelvic tilt (SPT), and lumbar lordosis were measured in all radiographs. Alignment parameters were compared between both sets of imaging, and the change in SPT between the imaging modalities was plotted and stratified by pre-existing lumbar pathology. RESULTS: There were significant differences between the relaxed standing and step-up radiographs and the relaxed and flexed-seated radiographs for sacral slope, SPT, and lumbar lordosis (P < .002 for all), with the exception of SPT in the relaxed and step-up standing postures (P = .110). When transitioning from the standing to sitting position, the mean changes in SPT differed significantly between both sets of radiographs. Most importantly, when plotting changes in SPT between flexed and relaxed sitting postures, patients with fusions and flatback deformity trended toward greater anterior pelvic tilting, a position of greater risk of posterior dislocation. CONCLUSION: Flexed sitting and single-leg standing imaging may emphasize the compensatory mechanisms of patients with concomitant hip and spine pathology more than relaxed imaging using our measurements. Our method may provide insight into high dislocation risk patients compared to the previously published hip measurement method. LEVEL OF EVIDENCE: III.

What are the prevalence and risk factors for repeat ipsilateral knee arthroscopy?

PURPOSE: The number of arthroscopic knee surgeries performed annually has increased over the last decade. It remains unclear what proportion of individuals undergoing knee arthroscopy is at risk for subsequent ipsilateral procedures. Better knowledge of risk factors and the incidence of reoperative ipsilateral arthroscopy are important in setting expectations and counselling patients on treatment options. The aim of this study is to determine the incidence of repeat ipsilateral knee arthroscopy, and the risk factors associated with subsequent surgery over long-term follow-up. METHODS: The New York Statewide Planning and Research Cooperative Systems outpatient database was reviewed from 2003 to 2016 to identify patients who underwent elective, primary knee arthroscopy for one of the following diagnosis-related categories of procedures: Group 1: cartilage repair and transfer; Group 2: osteochondritis dissecans (OCD) lesions; Group 3: meniscal repair, debridement, chondroplasty, and synovectomy; Group 4: multiple different procedures. Subjects were followed for 10 years to determine the odds of subsequent ipsilateral knee arthroscopy. Risk factors including the group of arthroscopic surgery, age group, gender, race, insurance type, surgeon volume, and comorbidities were analysed to identify factors predicting subsequent surgery. RESULTS: A total of 765,144 patients who underwent knee arthroscopy between 2003 and 2016, were identified. The majority (751,873) underwent meniscus-related arthroscopy. The proportion of patients undergoing subsequent ipsilateral knee arthroscopy was 2.1% at 1-year, 5.5% at 5 years, and 6.7% at 10 years of follow-up. Among patients who underwent subsequent arthroscopic surgery at 1-, 5-, and 10-year follow-up, there was a greater proportion of patients with worker's compensation insurance (p < 0.001), index operations performed by very high volume surgeons (p < 0.001), and cartilage restoration index procedures (p < 0.001), compared with those who never underwent repeat ipsilateral surgery. CONCLUSION: Understanding the incidence of subsequent knee arthroscopy after index procedure in different age groups and the patterns over 10 years of follow-up is important in counselling patients and setting future expectations. The majority of subsequent surgeries occur within the first 5 years after index surgery, and subjects tend to have higher odds of ipsilateral reoperation for up to 10 years if they have worker's compensation insurance, or if their index surgery was performed by a very high volume surgeon, or was a cartilage restoration procedure. LEVEL OF EVIDENCE: III.

Patterns and Costs of 90-Day Readmission for Surgical and Medical Complications Following Total Hip and Knee Arthroplasty.

BACKGROUND: Unplanned readmissions following elective total hip (THA) and knee (TKA) arthroplasty as a result of surgical complications likely have different quality improvement targets and cost implications than those for nonsurgical readmissions. We compared payments, timing, and location of unplanned readmissions with Center for Medicare and Medicaid Services (CMS)-defined surgical complications to readmissions without such complications. METHODS: We performed a retrospective analysis on unplanned readmissions within 90 days of discharge following elective primary THA/TKA among Medicare patients discharged between April 2013 and March 2016. We categorized unplanned readmissions into groups with and without CMS-defined complications. We compared the location, timing, and payments for unplanned readmissions between both readmission categories. RESULTS: Among THA (N = 23,231) and TKA (N = 43,655) patients with unplanned 90-day readmissions, 27.1% (n = 6307) and 16.4% (n = 7173) had CMS-defined surgical complications, respectively. These readmissions with surgical complications were most commonly at the hospital of index procedure (THA: 84%; TKA: 80%) and within 30 days postdischarge (THA: 73%; TKA: 77%). In comparison, it was significantly less likely for patients without CMS-defined surgical complications to be rehospitalized at the index hospital (THA: 63%; TKA: 63%; P < .001) or within 30 days of discharge (THA: 58%; TKA: 59%; P < .001). Generally, payments associated with 90-day readmissions were higher for THA and TKA patients with CMS-defined complications than without (P < .001 for all). CONCLUSION: Readmissions associated with surgical complications following THA and TKA are more likely to occur at the hospital of index surgery, within 30 days of discharge, and cost more than readmissions without CMS-defined surgical complications, yet they account for only 1 in 5 readmissions.

Skilled Nursing Facility Partnerships May Decrease 90-Day Costs in a Total Joint Arthroplasty Episode Under the Bundled Payments for Care Improvement Initiative.

BACKGROUND: The Bundled Payments for Care Improvement initiative was developed to reduce costs associated with total joint arthroplasty through a single payment for all patient care from index admission through a 90-day post-discharge period, including care at skilled nursing facilities (SNFs). The aim of this study is to investigate whether forming partnerships between hospitals and SNFs could lower the post-discharge costs. We hypothesize that institutionally aligned SNFs have lower post-discharge costs than non-aligned SNFs. METHODS: A cohort of 615 elective, primary total hip and knee arthroplasty subjects discharged to an SNF under the Bundled Payments for Care Improvement from 2014 to 2016 were included in our analysis. Patients were grouped into one of the 3 categories of SNF alignment: group 1: non-partners; group 2: agreement-based partners; group 3: institution-owned partners. Demographics, comorbidities, length of stay (LOS) at SNF, and associated costs during the 90-day post-operative period were compared between the 3 groups. RESULTS: Mean index hospital LOS was statistically shortest in group 3 (mean 2.7 days vs 3.5 for groups 1 and 2, P = .001). SNF LOS was also shortest in group 3 (mean 11 days vs 19 and 21 days in groups 2 and 1 respectively, P < .001). Total SNF costs and total 90-day costs were both significantly lower in group 3 compared with groups 1 and 2 (P < .001 for all), even after controlling for medical comorbidities. CONCLUSION: Institution-owned partner SNFs demonstrated the shortest patient LOS, and the lowest SNF and total 90-day costs, without increased risk of readmissions, compared with other SNFs.

Athletic performance and career longevity following anterior cruciate ligament reconstruction in the National Basketball Association.

PURPOSE: To identify the impact of anterior cruciate ligament (ACL) reconstruction on performance and career longevity for National Basketball Association (NBA) players. METHODS: Seventy-nine players (80 knees) with acute ACL tears in the NBA between the 1984-2014 seasons, and 112 age, height, weight, and performance-matched controls were identified. Pre- and post-injury performance outcomes including seasons played, games played, games started, minutes per game, points per game, field goals, 3-point shots, rebounds, assists, steals, blocks, turnovers, personal fouls, usage percentage and player efficiency ratings were compared between cases and controls using independent samples t tests and Fisher's exact tests. RESULTS: Sixty-eight of seventy-nine players (86.1 %) returned to play in the NBA following ACL reconstruction. Mean length of post-operative play was 1.84 years shorter than matched controls (P = 0.001). There was a significantly higher rate of attrition from professional basketball for players with a history of ACL reconstruction (P = 0.014). In the first full season following surgery, players started in 15.5 fewer games (P = 0.001), they played in 17.3 fewer games (P < 0.001), and had combined player efficiency ratings 2.35 points lower (P = 0.001) when compared to matched controls. Over the length of their careers, players competed in 22.2 fewer games per season (P = 0.009). CONCLUSIONS: There is a high rate of return to sport in the NBA following ACL reconstruction, although playing time, games played, player efficiency ratings and career lengths are significantly impacted in the post-operative period. These data should be used to manage patients' expectations regarding their abilities to return to elite levels of athletic performance.

Cementless vs Cemented Tibial Fixation in Primary Total Knee Arthroplasty.

BACKGROUND: The ideal fixation for modern tibial components in total knee arthroplasty (TKA) remains controversial with uncertainty on whether cementless implants can yield equivalent outcomes to cemented fixation in early follow-up. METHODS: A series of 70 consecutive cases with reverse hybrid cementless fixation were matched to 70 cemented cases from 2008 to 2015 based on implant design and patient demographics. RESULTS: Cementless TKA demonstrated greater aseptic loosening (7 vs 0, P = .013) and revision surgery (10 vs 0, P = .001) than cemented fixation within 5 years of follow-up, but with no clinically significant differences in outcome scores. CONCLUSION: It remains unclear whether early aseptic loosening in cementless TKA can be reduced with enhanced adjunct fixation and what proportion of early failure justifies the potential lifelong fixation through biologic ingrowth of cementless tibial components.

Patterns of Ninety-Day Readmissions Following Total Joint Replacement in a Bundled Payment Initiative.

BACKGROUND: Alternative payment models aim to improve quality and decrease costs associated with total joint replacement. Postoperative readmissions within 90 days are of interest to clinicians and administrators as there is no additional reimbursement beyond the episode bundled payment target price. The aim of this study is to improve the understanding of the patterns of readmission which would better guide perioperative patient management affecting readmissions. We hypothesize that readmissions have different timing, location, and patient health profile patterns based on whether the readmission is related to a medical or surgical diagnosis. METHODS: A retrospective cohort of 80 readmissions out of 1412 total joint replacement patients reimbursed through a bundled payment plan was analyzed. Patients were grouped by readmission diagnosis (surgical or medical) and the main variables analyzed were time to readmission, location of readmission, and baseline Perioperative Orthopaedic Surgical Home and American Society of Anesthesiologists scores capturing pre-existing state of health. Nonparametric tests and multivariable regressions were used to test associations. RESULTS: Surgical readmissions occurred earlier than medical readmissions (mean 18 vs 33 days, P = .011), and were more likely to occur at the hospital where the surgery was performed (P = .035). Perioperative Orthopaedic Surgical Home and American Society of Anesthesiologists scores did not predict medical vs surgical readmissions (P = .466 and .879) after adjusting for confounding variables. CONCLUSION: Readmissions appear to follow different patterns depending on whether they are surgical or medical. Surgical readmissions occur earlier than medical readmissions, and more often at the hospital where the surgery was performed. The results of this study suggest that these 2 types of readmissions have different patterns with different implications toward perioperative care and follow-up after total joint replacement.

Are Harris hip scores and gait mechanics related before and after THA?

BACKGROUND: Discordance between subjective and objective functional measures hinders the development of new ways to improve THA outcomes. QUESTIONS/PURPOSES: We asked if (1) any kinematic or kinetic gait variables are correlated with preoperative Harris hip scores (HHS), (2) any kinematic or kinetic gait variables are correlated with postoperative HHS, and (3) pre- to postoperative changes in any kinematic or kinetic gait variables are associated with the change in HHS? METHODS: For this retrospective study, an institutional review board-approved data repository that included all individuals who participated in motion analysis research studies was used to identify subjects evaluated before (n=161) and at least 6 months after primary unilateral THA (n=156). Selected kinematic (sagittal plane dynamic hip ROM and kinetic (peak external moments about the hip in the sagittal, frontal, and transverse planes) gait variables were collected at subjects' self-selected normal walking speeds. We used first-order partial correlations to identify relationships between HHS and gait variables, controlling for the influence of speed. RESULTS: Preoperative HHS correlated with hip ROM (R|speed=0.260; p<0.001) and the peak extension moment (R|speed=0.164; p=0.038), postoperative HHS correlated with the peak internal rotation moment (R|speed=0.178; p=0.034), and change in HHS correlated with change in hip ROM (R|speed=0.288; p=0.001) and peak external rotation moment (R|speed=0.291; p=0.002). Similar associations were seen when the HHS pain and function were analyzed separately. CONCLUSIONS: This study identified relationships between a common clinical outcome measure and specific, modifiable gait adaptations that can persist after THA-ROM and transverse plane gait moments. Addressing these aspects of gait dysfunction through focused rehabilitation could be a new strategy for improving clinical outcomes. Prospective studies are needed to evaluate this concept. LEVEL OF EVIDENCE: Level III, diagnostic study. See the Instructions for Authors for a complete description of levels of evidence.

Radiographic Cone Zone Classification of Metaphyseal Cone Fixation in Revision Total Knee Arthroplasty.

Background: No objective radiographic scoring system exists to classify metaphyseal cone stability. Our purpose was to create a novel, systematic method to radiographically evaluate metaphyseal cone fixation based on radiographic findings suggestive of cone stability. Methods: A retrospective analysis was conducted of revision total knee arthroplasty patients (6/2015-12/2017) using porous titanium femoral or tibial metaphyseal cones in conjunction with short cemented stems (50 mm-75 mm). Minimum follow-up was 2 years. Survivorship free of aseptic loosening and reoperation, as well as radiographic evaluation using a novel cone zone scoring system were analyzed. Results: Forty-nine revision total knee arthroplasties were included in the study (12 femoral, 48 tibial cones), the majority, performed for aseptic loosening (25/49, 51%). Median follow-up was 39 months (range 25-58). Using the radiographic cone zone scoring method, >90% of all femoral cones were classified as likely stable or stable with strong, statistically significant intraclass correlations between all 3 reviewers. Similarly, >97% of all tibial cones were classified as likely stable or stable, with moderate, statistically significant intraclass correlations between all 3 reviewers. Only 1 femoral and 1 tibial cone were considered at risk of loosening. The study sample demonstrated 100% survivorship free of revision for aseptic loosening without evidence of radiographic loosening in any case. Conclusions: Using a novel systematic cone zone scoring and classification method, the overwhelming majority of femoral and tibial cones were classified as likely stable or stable, with no identified cases of aseptic loosening or related revision. Further studies are needed to validate this objective classification method.

Factors influencing the outcome of autologous chondrocyte implantation: a systematic review.

Autologous chondrocyte implantation (ACI) is an effective method of treatment of chondral defects of the knee. ACI outcomes are influenced by patient-, knee-, and lesion-specific factors. We compiled subject-level data from current studies on ACI and quantitatively analyzed this data set for associations between patient-, knee-, and lesion-specific factors and the outcome of ACI surgery. A systematic review of studies investigating ACI treatment outcomes in the knee was performed. Only studies that published subject-level data were included. Data on patient and lesion characteristics, as well as clinical outcome scores, were collected. Thirteen studies (305 defects) were included in this review. These studies showed that ACI treatment improves clinical outcomes in different patient populations. However, subject-specific variables such as patient age, gender, body mass index, duration of preoperative symptoms, as well as defect size and location were not associated with International Knee Documentation Committee score or visual analog scale score changes (p > 0.05 for all). Covariate analysis showed that patient age was related to symptom duration prior to surgery (p = 0.009). ACI surgery has been shown to improve outcomes in patients with chondral lesions of the knee. Despite evidence in the literature showing that multiple patient-, knee-, and lesion-specific factors may influence treatment outcomes, our review shows that these factors, solely, do not affect outcomes. However, together, they may synergistically affect outcomes.

Cementless Primary Total Knee Arthroplasty Will this be the Future?

Cementless fixation in total knee arthroplasty (TKA) offers the potential for biologically active osseointegration and the potential for life-long fixation. With early cementless TKA designs, several design issues were identified related to early failure, particularly with the tibial and patellar components. However, in the recent two decades, with improvements upon the early designs, particularly in porous metal technology as well as improved early biomechanical stability, interest was re-established in cementless TKA. The surgical technique for cementless TKA is more exacting than cemented technique, with an important emphasis on indications, accurate resections, and component alignment. Modern cementless TKA designs have demonstrated excellent early- and mid-term survivorship equivalent to cemented TKA. More long-term studies are needed to study this comparison. While implant cost maybe higher with cementless designs, there is emerging evidence that there may be an overall cost saving with the use of cementless components given the shorter operative time and the savings in the cost of supplies associated with the use of cement. As the population undergoing TKA is becoming younger and more active, interest in the use of cementless implants will likely increase.

Posterior Malleolar Fixation Reduces the Incidence of Trans-Syndesmotic Fixation in Rotational Ankle Fracture Repair.

BACKGROUND: Inaccuracy of ankle syndesmotic repair via reduction and trans-syndesmotic fixation can occur during ankle fracture repair. The goal of this study was to determine whether reduction and fixation of the posterior malleolar fracture (PM) fragment in rotational ankle fractures reduces the need for independent syndesmotic screw fixation. METHODS: A retrospective study was conducted using a consecutive series of patients treated operatively for a rotationally unstable ankle fracture with a PM fragment between 2011-2017. All ankle fractures underwent open reduction and internal fixation and divided into two groups: PM fixed or not fixed. An intraoperative stress evaluation of the ankle following bony fixation was performed in all cases to evaluate syndesmotic instability. Patient and fracture characteristics, and intraoperative instability and trans-syndesmotic fixation were compared between both groups. RESULTS: Eighty-five unstable ankle fractures that had a PM fragment were identified. Forty-three fractures underwent PM fixation and 42 did not. There were no differences between the PM fixation groups with regard to age, gender, body mass index or fracture pattern (p>0.183 for all). On average, PM fragments in the fixed group were larger than those not fixed (p<0.001). There were significantly lower odds of needing syndesmotic fixation if the PM fragment was reduced and fixed (p<0.001). Only 2 out of 43 ankles with a fixed PM fragment underwent syndesmotic fixation compared with 34 out of 42 non-fixed PM fragments. CONCLUSION: Posterior malleolar fixation imparts syndesmotic stability and may obviate the need for trans-syndesmotic fixation for restoring dynamic ankle mortise congruence.Level of Evidence: III.

Aseptic Loosening of Porous Metaphyseal Sleeves and Tantalum Cones in Revision Total Knee Arthroplasty: A Systematic Review.

Bone loss often complicates revision total knee arthroplasty (TKA). Management of metaphyseal defects varies, with no clearly superior technique. Two commonly utilized options for metaphyseal defect management include porous-coated metaphyseal sleeves and tantalum cones. A systematic review was conducted according to the international Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We combined search terms "Total knee arthroplasty" AND/OR "Sleeve," "Cone" as either keywords or medical subject heading (MeSH) terms in multiple databases according to PRISMA recommendations. All retrieved articles were reviewed and assessed using defined inclusion and exclusion criteria. A total of 27 studies (12 sleeves and 15 cones) of revision TKAs were included. In the 12 studies on sleeve implantation in revision TKAs, 1,617 sleeves were implanted in 1,133 revision TKAs in 1,025 patients. The overall rate of reoperation was 110/1,133 (9.7%) and the total rate of aseptic loosening per sleeve was 13/1,617 (0.8%). In the 15 studies on tantalum cone implantation in revision TKAs, 701 cones were implanted into 620 revision TKAs in 612 patients. The overall rate of reoperation was 116/620 (18.7%), and the overall rate of aseptic loosening per cone was 12/701 (1.7%). Rates of aseptic loosening of the two implants were found to be similar, while the rate of reoperation was nearly double in revision TKAs utilizing tantalum cones. Variability in the selected studies and the likely multifactorial nature of failure do not allow for any definitive conclusions to be made. This review elucidates the necessity for additional literature examining revision TKA implants.

Total Hip Arthroplasty for Femoral Neck Fracture in the Setting of Challenging Extraction of an Intramedullary Femoral Nail: A Case Report.

INTRODUCTION: Performing total hip arthroplasty (THA) for femoral neck fracture in the setting of a pre-existing intramedullary nail can be technically challenging, particularly if nail extraction is not feasible. CASE REPORT: A 76-year-old male presented with a with a displaced femoral neck fracture in the setting of a previously placed antegrade intramedullary nail with a healed femoral shaft fracture. After failed nail extraction, a novel technique was used to remove the proximal portion of the nail to allow for hybrid THA with implantation of a cemented femoral stem. CONCLUSION: This is the first reported surgical technique of using a cortical window technique for partial intramedullary nail resection and cemented stem implantation in the setting of challenging intramedullary femoral nail extraction.

Patellofemoral Arthroplasty: Short-Term Complications and Risk Factors.

There is a paucity of literature regarding the short-term readmission, reoperation, and complication rates of patellofemoral arthroplasty (PFA). The purpose of this study is to determine the incidence and risk factors of 30-day postoperative complications in patients undergoing PFA. A retrospective cohort study of subjects who underwent PFA from 2010 to 2015 was performed using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Perioperative outcomes and 30-day postoperative complications were ascertained, and patient demographics and comorbidities were analyzed using linear and binomial logistic regression analyses to determine risk factors for postoperative complications. Among the 1,069 patients identified in the NSQIP database, there was a 30-day readmission rate of 4.3% and a 30-day reoperation rate of 1.5%. The leading complications identified were bleeding requiring transfusion (11.7%), urinary tract infection (0.8%), and deep vein thrombosis (DVT) (0.8%). Younger age was a risk factor for superficial wound infection (p = 0.012). Older age was a significant risk factor for longer hospital stays, readmission, bleeding requiring transfusion, urinary tract infection, and pneumonia (p < 0.05 for all). Male sex was a risk factor for longer operation time and DVT (p = 0.001 and p = 0.017, respectively), while female sex was associated with greater incidence of bleeding requiring transfusion (p = 0.049). Elevated body mass index (BMI) was a risk factor for longer hospital stays, greater total operation time, and bleeding requiring transfusion (p < 0.001, p < 0.001, and p = 0.001, respectively). Nonwhite race was a significant risk factor for readmission (p = 0.008). This represents the largest study on early readmissions and the associated risk factors after PFA. PFA 30-day readmission and reoperation rates were <5%. Older age and elevated BMI were both identified as risk factors for adverse perioperative outcomes, including longer operation times, longer hospital stays, and bleeding requiring transfusion.

Patterns and Implications of Early Syndesmotic Screw Failure in Rotational Ankle Fractures.

BACKGROUND: The purpose of this study was to identify characteristic patterns of syndesmotic screw (SS) failure, and any effects on clinical outcome. METHODS: A retrospective study was performed using a consecutive series of patients treated with open reduction and internal fixation with trans-syndesmotic screws for unstable ankle fractures with syndesmotic injury between 2015 and 2017. Patient demographics, fracture characteristics and classification, rates and patterns of trans-syndesmotic screw breakage, and backout were analyzed. Functional outcome was assessed using passive range of motion (ROM) and Maryland Foot Score (MFS). RESULTS: A total of 113 patients (67%) had intact screws and 56 patients (33%) demonstrated either screw breakage or backout. Patients with SS failure were younger (P = .002) and predominantly male (P = .045). Fracture classification and energy level of injury were not associated with screw failure. Nine screws (11%) demonstrated backout (2 also broke) and 56 other screws broke. There was no association between the number of screws or cortices of purchase and screw failure. There was a trend toward a higher proportion of screw removal (20%) in this failed SS group compared with the intact SS group (12%) (P = .25), but with similar ankle ROM and MFS (P > .07). CONCLUSION: Syndesmotic screw breakage was common in younger, male patients. Despite similarities in ankle range of motion and clinical outcome scores to patients with intact screws, there was a trend towards more frequent screw removal. This information can be used to counsel patients pre- and postoperatively regarding the potential for screw failure and subsequent implant removal. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

The prevalence of elevated-rim polyethylene liner use in primary total hip arthroplasty in the New York State metropolitan area.

In existing radiographic studies on primary total hip arthroplasty (THA) examining the spino-pelvic effect on THA instability, there is no control of the type of polyethylene liner used, which may be a significant confounder of the results. We sought to determine the prevalence of the use of elevated liners in primary THA using regional implant company sales data. A total of 12,528 liners were analyzed, demonstrating that the overall regional percentage use of lipped liner use is high and varies inversely with larger head sizes. This prevalence data suggests that it is important to consider the use of lipped liners as a confounding variable that should not be overlooked in radiographic studies analyzing cup position and THA instability.