Characterization of opioid consumption and disposal patterns after total knee arthroplasty.

AIMS: The aim of this study was to determine the general postoperative opioid consumption and rate of appropriate disposal of excess opioid prescriptions in patients undergoing primary unilateral total knee arthroplasty (TKA). PATIENTS AND METHODS: In total, 112 patients undergoing surgery with one of eight arthroplasty surgeons at a single specialty hospital were prospectively enrolled. Three patients were excluded for undergoing secondary procedures within six weeks. Daily pain levels and opioid consumption, quantity, and disposal patterns for leftover medications were collected for six weeks following surgery using a text-messaging platform. RESULTS: Overall, 103 of 109 patients (94.5%) completed the daily short message service (SMS) surveys. The mean oral morphine equivalents (OME) consumed during the six weeks post-surgery were 639.6 mg (sd 323.7; 20 to 1616) corresponding to 85.3 tablets of 5 mg oxycodone per patient. A total of 66 patients (64.1%) had stopped taking opioids within six weeks of surgery and had the mean equivalent of 18 oxycodone 5 mg tablets remaining. Only 17 patients (25.7%) appropriately disposed of leftover medications. CONCLUSION: These prospectively collected data provide a benchmark for general opioid consumption after uncomplicated primary unilateral TKA. Many patients are prescribed more opioids than they require, and leftover medication is infrequently disposed of appropriately, which increases the risk for illicit diversion. Cite this article: Bone Joint J 2019;101-B(7 Supple C):98-103.

The modern, hybrid total hip arthroplasty for primary osteoarthritis at the Hospital for Special Surgery.

We describe our technique and rationale using hybrid fixation for primary total hip arthroplasty (THA) at the Hospital for Special Surgery. Modern uncemented acetabular components have few screw holes, or no holes, polished inner surfaces, improved locking mechanisms, and maximised thickness and shell-liner conformity. Uncemented sockets can be combined with highly cross-linked polyethylene liners, which have demonstrated very low wear and osteolysis rates after ten to 15 years of implantation. The results of cement fixation with a smooth or polished surface finished stem have been excellent, virtually eliminating complications seen with cementless fixation like peri-operative femoral fractures and thigh pain. Although mid-term results of modern cementless stems are encouraging, the long-term data do not show reduced revision rates for cementless stems compared with cemented smooth stems. In this paper we review the conduct of a hybrid THA, with emphasis on pre-operative planning, surgical technique, hypotensive epidural anaesthesia, and intra-operative physiology.

Meta-analysis of cause of death following total joint replacement using different thromboprophylaxis regimens.

We performed a meta-analysis of modern total joint replacement (TJR) to determine the post-operative mortality and the cause of death using different thromboprophylactic regimens as follows: 1) no routine chemothromboprophylaxis (NRC); 2) Potent anticoagulation (PA) (unfractionated or low-molecular-weight heparin, ximelagatran, fondaparinux or rivaroxaban); 3) Potent anticoagulation combined (PAC) with regional anaesthesia and/or pneumatic compression devices (PCDs); 4) Warfarin (W); 5) Warfarin combined (WAC) with regional anaesthesia and/or PCD; and 6) Multimodal (MM) prophylaxis, including regional anaesthesia, PCDs and aspirin in low-risk patients. Cause of death was classified as autopsy proven, clinically certain or unknown. Deaths were grouped into cardiopulmonary excluding pulmonary embolism (PE), PE, bleeding-related, gastrointestinal, central nervous system, and others (miscellaneous). Meta-analysis based on fixed effects or random effects models was used for pooling incidence data. In all, 70 studies were included (99 441 patients; 373 deaths). The mortality was lowest in the MM (0.2%) and WC (0.2%) groups. The most frequent cause of death was cardiopulmonary (47.9%), followed by PE (25.4%) and bleeding (8.9%). The proportion of deaths due to PE was not significantly affected by the thromboprophylaxis regimen (PA, 35.5%; PAC, 28%; MM, 23.2%; and NRC, 16.3%). Fatal bleeding was higher in groups relying on the use of anticoagulation (W, 33.8%; PA, 9.4%; PAC, 10.8%) but the differences were not statistically significant. Our study demonstrated that the routine use of PA does not reduce the overall mortality or the proportion of deaths due to PE.

Complications after patello-femoral versus total knee replacement in the treatment of isolated patello-femoral osteoarthritis. A meta-analysis.

PURPOSE: Both patellofemoral arthroplasty (PFA) and total knee arthroplasty (TKA) are successful in treating isolated patellofemoral osteoarthritis, but the complication rates after PFA are concerning. We performed a meta-analysis to compare the incidence of complications, re-operations, and revision following PFA and TKA for patellofemoral osteoarthritis. METHODS: We systematically identified publications with patients who underwent PFA or TKA for patellofemoral osteoarthritis with minimum 1.5 year follow-up. Demographics, implant (TKA, first [1G] or second-generation [2G] PFA), complications, and cause of re-operations were extracted. Random-effects meta-analysis was used to pool incidence data, which was compared between groups using logistic regression to adjust for length of follow-up. RESULTS: Twenty-eight observational studies and no randomized trials were included in this meta-analysis, which limits its generalizability. There was a higher likelihood of any re-operation (odds ratio 8.06) and revision (OR 8.11) in PFA compared to TKA. Re-operation (OR 4.33) and revision (OR 4.93) were more likely in 1G-PFA than 2G-PFA. When comparing 2G-PFA to TKA, there was no significant difference in re-operation, revision, pain, or mechanical complications. CONCLUSIONS: Patients who undergo PFA rather than TKA are more likely to experience complications and require re-operation or revision, but subgroup analysis suggests a relation to implant design. There is no significant difference in re-operation, revision, pain, or mechanical complications between 2G-PFA and TKA. LEVEL OF EVIDENCE: Systematic review of Level III therapeutic studies, Level III.

[Cemented stems in hip arthroplasty: history and evolution]. / Vástagos cementados en la artroplastía de cadera: historia y evolución.

Despite the favorable results in cemented femoral fixation, there is a growing tendency to use uncemented stems. Due to the successful results of cementless acetabular fixation, the most versatile and easy implantation technique, to the misinformation about the "cement disease" and the poor performance of cemented stems with a rough surface. However, the advantages of cemented femoral fixation are numerous: it can be implemented successfully in femurs of diverse morphology and quality of bone, the surgeon can position the implant with the desired femoral anteversion, without it being determined by th natural femoral anteversion, very low incidence of intraoperative and postoperative fractures, allows the addition of antibiotics in patients with a history or predisposition to infection and minimal risk of postoperative leg pain during walking.

La planificación preoperatoria del reemplazo protésico en las fracturas de cadera del anciano / Preoperative planning of prosthetic replacement in hip fractures in the elderly

Existen numerosas publicaciones sobre la planificación preoperatoria en los reemplazos de cadera electivos con resultados satisfactorios. Sin embargo, ninguna de ellas se ha enfocado para el tratamiento de las fracturas de cadera. La planificación aumenta su importancia en estos pacientes debido a que la reconstrucción de la biomecánica de la cadera se ve dificultada por la ausencia de un fémur intacto.En este trabajo se describe un método de planificación preoperatoria basado en la reproducción de la biomecánica de la cadera contralateral no fracturada, siempre y cuando ésta sea anatómicamente normal. El plan registra medidas radiológicas que se reproducen durante la cirugía para lograr una reconstrucción de la biomecánica normal de la cadera fracturada (AU)

There are numerous reports on successful results for total hip replacement being achieved through preoperative planning. However, none of these reports have been focused on the treatment of hip fractures. Preoperative planning has increased importance in this group of patients as the correct biomechanical reconstruction of the hip is made more difficult by the absence of an intact femur.This report describes a method for preoperative planning based on the reproduction of the biomechanics of the intact contralateral hip, if and when it is anatomically normal. The plan is based on radiological measurements that are reproduced during surgery to achieve normal biomechanical reconstruction for the fractured hip (AU)

Bilateral total hip arthroplasty in siblings with Stickler Syndrome.

Stickler Syndrome is an infrequent autosomal dominant connective tissue disorder. The most prevalent mutation affects type II collagen gene and results in abnormalities in cartilage, vitreous and nucleus pulposus. Orthopaedic manifestations include joint hyper- mobility and pain with early development of secondary osteoarthritis. The condition has a predilection for the femoral head and patients usually present in their third to fourth decade with secondary hip arthritis. We report on two siblings with Stickler Syndrome who presented with hip osteoarthritis in their third decade of life and underwent staged bilateral total hip arthroplasties (THA). The patients experienced pain relief and improved quality of life after surgery.

High failure rate of a modern, proximally roughened, cemented stem for total hip arthroplasty.

The role of surface finish on the survivorship of cemented femoral stems continues to be debated. A total of 34 proximally roughened cemented stems were implanted in 33 consecutive patients undergoing total hip arthroplasty by a single surgeon. An alarmingly high failure rate was observed, prompting a retrospective chart review, analysis of radiographs, and evaluation of retrieved stems and pathological specimens. Nineteen patients were available with more than two years follow-up. Of these 19 patients, nine stems had failed (47%) due to severe osteolysis and stem loosening. Failures were significantly more common in the male gender (p<0.005), and young (p=0.05), tall (p<0.002), and heavy patients (p<0.004). All failed revised hips showed severe metallosis, with both gross and microscopic evidence of metallic shedding from the stems. Our findings suggest that this proximally roughened stem is susceptible to early failure. Failure is characterized by stem debonding, subsidence within the cement mantle, shedding of metallic and cement particles due to fretting, and rapidly progressive osteolysis. These findings have been observed with other rough surface finish cemented stems.

A new technique to improve cup inclination accuracy in primary total hip arthroplasty.

Accurate inclination and anteversion of the acetabular component is paramount to achieve a stable total hip arthroplasty, prevent prosthetic dislocation and minimize long- term wear. We present and evaluate a simple new technique to improve consistency in cup inclination during primary total hip arthroplasty, based on information available from the preoperative plan. The technique consists of assessing the distance and relationship between the inferomedial border of the acetabular cup and the inferomedial margin of the teardrop, with the use of a measuring probe. This simple surgical gesture improved consistency in cup inclination during total hip arthroplasty.;

Total hip replacement in identical twins with Scheie Mucopolysaccharidosis.

Investigation performed at the Hospital for Special Surgery, New York, USA Scheie Syndrome is an autosomal recessive metabolic storage disease with distinct skeletal findings known as "dysostosis multiplex". This paper reports on identical twins with Scheie Syndrome who required total hip arthroplasty for early osteoarthritis of the hip. The surgical approach and exposure was particularly demanding due to the stiffness imposed by the soft tissues arising from infiltration of glycosaminoglycans. The small femoral head and acetabulum limited the diameter of the acetabular component and subsequently the prosthetic head diameter that could be safely utilized without compromising the thickness of the polyethylene liner. Twenty-two millimeter heads with a standard polyethylene insert were therefore utilized in the two arthroplasties performed in 1998 in the first twin, and a 28 mm head with a highly cross linked polyethylene liner, in the arthroplasty performed on the second twin in 2003. This is a relevant issue considering that these patients required an arthroplasty at a young age. Hip arthroplasty relieved pain, improved ambulation and provided a better range of motion in our two patients. There were no peri-operative complications. Long-term survivorship of total hip replacement in this population is not yet known. (Hip International 2005; 15: 55-8).

Age affects the perception of limb length discrepancy in patients with and without a total hip arthroplasty.

The amount of lengthening or shortening that can be detected by patients before and after total hip arthroplasty has not been yet quantified. We studied the ability to detect limb length inequality in 194 patients with and without a total hip arthroplasty, match-paired for age and sex. None of the participants had clinical signs of lumbosacral pathology, spinal deformity, or fixed pelvic obliquity; and all had equal functional and actual limb length. The participants walked with shoes, with and without the addition of fixed insoles, to simulate 2.5, 5, 10 and 15 millimeters of shortening and lengthening of the tested limb. Lengthening and shortening were similarly detected. Younger individuals detected the differences better than older ones (p=0.001), and there was a significant correlation between the decade of life and the ability to detect a limb length discrepancy (r=-0.22; p=0.002). This study demonstrates that perception of limb length is affected by the age, with older individuals having less awareness of changes in limb length than younger ones. (Hip International 2004; 14: 249-53).

Revision of the femoral prosthesis with impaction allografting and a Charnley stem. A 2- to 12-year follow-up.

Impacted morcellised bone allograft and a Charnley stem was used to revise 59 loose femoral components in 57 consecutive patients. Femoral bone loss was rated as Endo-Klinik grade 2 in nine patients, grade 3 in 41, and grade 4 in nine. The immediate postoperative radiographs and those taken at the most recent follow-up were compared for radiolucencies, subsidence and incorporation of the graft. One patient was lost to follow-up and two were not available for radiological analysis. The mean clinical follow-up in 58 procedures was 56.7 months (24 to 144) and the mean radiological review of 56 reconstructions was 54.4 months (24 to 144). An intraoperative femoral fracture occurred in one patient (1.7%) and was successfully treated by strut grafting and cerclage wiring. Extrusion of cement through perforations or incomplete hoop fractures was detected in the postoperative radiographs of ten procedures (17%); none of these patients sustained a complete fracture. Three patients had dislocations (5%) and two (3.5%) developed painful subsidence of the stem which required a further revision. The latest follow-up radiographs in 56 reconstructions showed a well fixed stem and radiological healing of the graft in 52 (93%), and definite loosening in four (7%). Of these four, two were revised again and two were asymptomatic after a follow-up of 120 months each. The mean subsidence in the 52 successful revisions was 0.38 mm (0 to 4). Impaction allografting with a Charnley stem restored bone stock and provided adequate fixation of the stem in 93% of the hips. There was a low rate of rerevision (3.5%) and a low incidence of intraoperative and postoperative complications.

Psoas abscess associated with infected total hip arthroplasty.

A 65-year-old man with a left uncemented total hip arthroplasty performed 11 years previously was admitted with a history of progressive low back pain, left hip pain, and sepsis that had begun 6 months earlier. On physical examination, a gross, fluctuant mass was palpated in the left thigh. A computed tomography (CT) scan revealed a 6.5 x 3 cm left retrofascial psoas abscess communicating with the hip joint. The patient underwent irrigation and débridement of the hip with removal of the components. The psoas abscess was drained through the iliopsoas bursa. A residual psoas abscess was drained percutaneously under CT guidance. Cultures isolated Escherichia coli, and the patient responded to 6 months of ciprofloxacin therapy. After 1 year, the patient had no evidence of infection. Pathways of infection spread, diagnosis, and treatment of a patient with this rare association are discussed with a review of the literature.

Inflatable pillows as axillary support devices during surgery performed in the lateral decubitus position under epidural anesthesia.

UNLABELLED: The lateral decubitus position can cause dependent shoulder discomfort or result in traction on the brachial plexus. We measured pressure beneath the dependent shoulder and lateral angulation of the cervical spine in patients positioned in the lateral decubitus position for total hip replacement under epidural anesthesia. Inflatable pillows (Shoulder-Float) beneath the chest wall and head reduced pressure beneath the dependent shoulder from 66 to 12 mm Hg (P < 0.001) and lateral angulation of the cervical spine from 14 degrees to 4 degrees (P < 0.001). In a randomized crossover study of a further 15 patients, the use of inflatable pillows resulted in significantly less pressure beneath the dependent shoulder and chest wall than either a gel-pad or a 1000-mL lactated Ringer's bag. Inflatable pillows placed beneath the chest wall and head in the lateral decubitus position provided lower pressure beneath the dependent shoulder than other support devices and facilitated alignment of the cervical spine. IMPLICATIONS: When patients lie on their side, this results in pressure beneath the shoulder and tilting of the head and neck to one side. These problems were effectively corrected with an inflatable pillow (Shoulder-Float).

Effective bactericidal activity of tobramycin and vancomycin eluted from acrylic bone cement.

We studied the bioactivity of vancomycin and tobramycin eluted from methylmethacrylate bone cement. Aliquots of the drainage were obtained at 1, 6, 12 and 24 hours following total hip prosthetic implantation with vancomycin-tobramycin-loaded cement in 3 patients. The samples were analyzed with fluorescence polarization immunoassay and bioassay, using group B streptococcus for vancomycin and Escherichia coli for tobramycin. These bacteria were selected due to the effectiveness of vancomycin and poor effectiveness of tobramycin against group B streptococcus and conversely with E. coli. The immunodetection of vancomycin averaged 14 (1 hour), 9 (6 hours), 10 (12 hours) and 11 microg/mL (24 hours). The bioassay averaged 47, 36, 79 and 41 microg/mL (p = 0.03). The immunodetection of tobramycin averaged 43, 21, 18 and 14 microg/mL; and bioassay 30, 15, 15 and 12 microg/mL (p = 0.1). Both antibiotics eluted with a highly effective bactericidal activity. Our findings indicate that the presence of tobramycin has a synergistic-like effect on the bactericidal activity of vancomycin, which has not been previously reported. We recommend a combination of vancomycin and tobramycin with cement for the treatment of orthopedic infections caused by gram-positive organisms.

Pigmented villonodular synovitis of the hip: 2- to 23-year followup study.

Pigmented villonodular synovitis affecting the hip is rare. Seven new patients are presented and 117 cases from the literature are reviewed. Among the new patients, two refused treatment; in one patient, severe bone loss was observed after a radiographic followup of 21 years; the second patient showed no radiographic changes 2 years after diagnosis. One patient underwent a synovectomy and had a recurrence 9 years later, requiring a total hip replacement. The remaining four patients underwent synovectomy and primary total hip replacement with no recurrences detected after an average followup of 13 years (range, 2-23 years). Among 117 cases published, 62 patients (53%) did not have enough information for analysis. A metaanalysis using the remaining 55 patients was done. In nine patients (16%; nine of 55) the diagnosis was made with a preoperative biopsy. Treatment consisted of synovectomy in 26 patients (47%; 26 of 55), arthroplasty in 24 (43%; 24 of 55), arthrodesis in two (4%; two of 55), and hindquarter amputation in a patient misdiagnosed as having synovial sarcoma (2%; one of 55). Two patients (4%; two of 55) were not treated. Ten patients had a recurrence (19%; 10 of 53); nine in the synovectomy group (35 %; nine of 26) and one in the joint replacement group (4%; one of 24). Synovectomy is recommended for patients with preserved articular cartilage and total hip replacement is recommended for patients with secondary osteoarthritis. Removal of all macroscopic tumors including careful curetting of the osteolytic lesions should be done as they may constitute a source of recurrence.

Dislodgment of polyethylene liners in first and second-generation Harris-Galante acetabular components. A report of eighteen cases.

BACKGROUND: Dislodgment of the polyethylene liner is an increasingly common complication following total hip arthroplasty. The purposes of this study are to present the results in a series of patients with this complication and to analyze the mode of failure. METHODS: Between November 1995 and January 2001, eighteen patients who had had a total hip arthroplasty presented with dislodgment of the polyethylene liner from a Harris-Galante metal acetabular shell. The medical records, radiographs, operative notes, and retrieved components were reviewed. In addition, scanning electron microscopy was used to study the fractured surfaces in a shell that had four broken tines. RESULTS: The components had been in situ for an average of seven years (range, three to eleven years). Seventeen components were second generation, and one was first generation. Symptoms developed spontaneously in sixteen patients, during sexual intercourse in one, and following a fall on the hip in one. Radiographs showed eccentric positioning of the head in all of the hips and broken tines in six. All of the shells were well fixed. Treatment consisted of revision of the shell in four patients, exchange of the liner in four, cementation of a new liner into the shell in seven, and cementation of an all-polyethylene cup in three. The liners had severe damage of the rim. Scanning-electron microscopy of the fractured surfaces of four tines revealed a fatigue pattern. CONCLUSIONS: We believe that, as the liner wears and becomes loose because of an inadequate locking mechanism, progressive micromotion occurs and the load increases on the polyethylene rim until it deforms and/or fractures. Subsequently, nothing prevents the liner from rotating out of the shell. As this mechanism of failure appears to include fatigue failure of the locking tines and wear of the liner, this complication is likely to increase as the components age in situ.

The safety and efficacy of intraoperative heparin in total hip arthroplasty.

A single dose of unfractionated heparin (15 U/kg), administered intravenously before surgery on the femur suppresses thrombogenesis during total hip replacement. Nine hundred eighty-nine patients (1021 hips) who received one dose of intraoperative heparin with hypotensive epidural anesthesia were followed up prospectively for 3 months. Asymptomatic deep vein thrombosis assessed by ultrasound in the first 198 consecutive patients showed an incidence of 7.1% (14 of 198). The incidence of clinical deep vein thrombosis in the subsequent 791 patients was 0.88% (seven of 791). Symptomatic pulmonary embolism occurred in 0.5% (five of 989). No patients died and there was one major bleeding episode. Based on this favorable experience, intraoperative heparin appears safe and efficacious as thromboembolic prophylaxis.

Warfarin-associated intracapsular hemorrhage causing an acutely painful total hip arthroplasty: a rare complication of prolonged anticoagulant therapy.

Hemorrhage is the most prevalent adverse effect of oral anticoagulant therapy. The incidence of bleeding complications is related to the duration and range of therapy. A patient on long-term warfarin anticoagulation developed a spontaneous intracapsular bleed into a total hip arthroplasty that had been implanted 11 years before. Joint aspiration allowed early recognition with immediate resolution of symptoms. Diagnosis and treatment of this rare complication are discussed with a review of the literature.

Identificación inmunohistoquímica de los fenómenos degenerativos en la hernia de disco lumbar: expresión de ácida hialurónico, metaloproteasas 1 y 3, factor de crecimiento fibroblástico básico y CD34 / Immunohistochemical detection of degenerative phenomea in lumbar disc herniations

Los objetivos de este trabajo son identificar los niveles de expresión y distribución de las metaloproteasas (MMP) 1 y 3, observar su efecto sobre el ácido hialurónico (AH), estudiar la respuesta inflamatoria, analizar los procesos de angiogénesis en el disco detectando la proteína CD34 y el factor de crecimiento fibroblástico básico (FCF-b) y relacionar los hallazgos con parámetros clínicos y epidemiológicos de los enfermos. Se analizaron discos intervertebrales obtenidos en 34 discectomías por hernia de disco y de 10 discos control con técnica histológica de rutina y técnicas inmunohistoquímicas contra MMP-1 y MMP-3, AH, CD34 y FCF-b. Se observó aumento significativo del porcentaje de degeneración, vascularización, detección de AH, MMP-1, MMP-3, CD34 y FCF-b en los discos extruidos y secuestros, lo que sugiere una relación entre las etapas más avanzadas de herniación y las más intensas de degeneración. Los enfermos con antecedentes de tabaquismo presentaron hernias con mayores niveles de expresión de FCF-b, o que sugiere una asociación entre el hábito de fumar y la intensidad de la respuesta tisular. Se discuten los hallazgos observados con una revisión de la literatura sobre el tema. La degeneración discal estaría producida por fenómenos biológicos que representan una falla en la capacidad de reparación del tejido conectivo especializado