Surgeon's Experience and Accuracy of Preoperative Digital Templating in Primary Total Hip Arthroplasty.

Purpose: Preoperative planning has become essential in performance of total hip arthroplasty (THA). However, data regarding the effect of the planner's experience on the accuracy of digital preoperative planning is limited. The objective of this study was to assess the accuracy of digital templating in THA based on the surgeon's experience. Materials and Methods: A retrospective study was conducted. An analysis of 98 anteroposterior pelvic radiographs, which were individually templated by four surgeons (two hip surgeons and two orthopaedic residents) using TraumaCad® digital planning, was performed. A comparison of preoperatively planned sizes with implanted sizes was performed to evaluate the accuracy of predicting component size. The results of preoperative planning performed by hip surgeons and orthopaedic residents were compared for testing of the planner's experience. Results: Femoral stem was precisely predicted in 32.4% of cases, acetabular component in 40.3%, and femoral offset in 76.7%. Prediction of cup size showed greater accuracy than femoral size among all observers. No differences in any variable were observed among the four groups (acetabular cup P=0.07, femoral stem P=0.82, femoral offset P=0.06). All measurements showed good reliability (intraclass correlation coefficient [ICC] acetabular cup: 0.76, ICC femoral stem: 0.79). Conclusion: The results of this study might suggest that even though a surgeon's experience supports improved precision during the planning stage, it should not be restricted only to surgeons with a high level of experience. We consider preoperative planning an essential part of the surgery, which should be included in training for orthopaedics residents.

Routine pretransfusion testing before primary total hip or knee arthroplasty are an expensive and wasteful routine. Systematic review and meta-analysis.

BACKGROUND: The excessive routine ordering of pretransfusion tests (blood typing, screening, and cross-matching) for surgical cases incurs significant unnecessary costs and places an undue burden on transfusion services. This study aims to systematically review the literature regarding the necessity of routine pretransfusion tests before total hip arthroplasty (THA) or total knee arthroplasty (TKA) and summarize their outcomes. STUDY METHODS: A systematic review and meta-analysis were performed. The study's characteristics, the prevalence of over-ordering pretransfusion tests, transfusion rates, and potential cost savings to the healthcare system were analyzed. RESULTS: The study included 17,667 patients. Pooled results revealed a 96.3% over-ordering pretransfusion test rate (95% CI: 0.92-1.00; p < 0.001) among patients undergoing primary THA or TKA. The pooled prevalence of hospital transfusion rate was 3.6%. Notably, there were statistically significant differences in preoperative hemoglobin (Hb) levels between patients not requiring transfusion (Hb = 13.9 g/dl; 95% CI 12.59-15.20; p < 0.001) and those needing transfusion (Hb = 11.9 g/dl; 95% CI 10.69-13.01; p < 0.001) (p = 0.03). The per-patient total cost savings ranged from 28.63 to 191.27 dollars. DISCUSSION: Our study suggests that routine pre-transfusion testing for all patients undergoing primary THA or TKA may be unnecessary. We propose limiting pretransfusion test orders to patients with preoperative hemoglobin levels below 12 g/dl in unilateral primary TKA or THA. This targeted approach can result in significant cost savings for healthcare systems and transfusion services by reducing the over-ordering of pretransfusion tests in these surgical procedures.

Risk of venous thromboembolism in thromboprophylaxis between aspirin and low molecular weight heparins after total hip arthroplasty or total knee arthroplasty: Systematic review and meta-analysis. / Riesgo de tromboembolismo venoso en la tromboprofilaxis entre aspirina y heparinas de bajo peso molecular tras una artroplastia total de cadera o artroplastia total de rodilla. Revisión sistemática y metaanálisis.

INTRODUCTION: The aim of this study was to evaluate the efficacy of aspirin versus low molecular weight heparins (LMWH) for the prophylaxis of venous thromboembolism (VTE), deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing total knee arthroplasty (TKA) and/or total hip arthroplasty (THA). MATERIALS AND METHODS: Systematic review and meta-analysis. Sixteen studies were selected. The risk of VTE, DVT and PE were analyzed. Mortality, risk of bleeding and surgical wound complications was also analyzed. RESULTS: 248,461 patients were included. 176,406 patients with thromboprophylaxis with LMWH and 72,055 patients with aspirin thromboprophylaxis. There were no significant differences in the risk of VTE (OR = 0.93; 95% CI: 0.69-1.26; P = .64), DVT (OR = 0.72; 95% CI: 0.43-1.20; P = .21) or PE (OR = 1.13; 95% CI: 0.86-1.49; P = .38) between both groups. No significant differences were found in mortality (P = .30), bleeding (P = .22), or complications in the surgical wound (P = .85) between both groups. These same findings were found in the sub-analysis of only randomized clinical trials (P>.05). CONCLUSIONS: No increased risk of PE, DVT, or VTE was found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis. There was also no greater mortality, greater bleeding, or greater complications in the surgical wound found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis.

Autonomy with responsibility ¿Is informed consent just a signature on a paper? Evaluation in patients who underwent spine's surgery.

PURPOSE: To evaluate the information that patients undergoing spine surgery truly receive and assimilate when they sign their informed consent documents. METHODS: This was a retrospective study on patients who underwent spine arthrodesis or spine discectomy. Patients were given a full explanation of the surgical technique to be employed and its potential risks before they were included on the surgical waiting list. Before surgery, they were asked to sign an informed consent form. The studied variables included whether patients read the informed consent form, whether they recalled the surgical technique used or the spinal segment operated, whether they were aware of the surgical risks involved, and if they had looked for information about their procedure elsewhere. Answers were analyzed by age and educational level. RESULTS: Of a total of 458 total patients, only 51.9% answered all the questions. Sixty-three percent of patients said they had read the informed consent document before surgery. Although 91.6% of patients were aware of the spine segment operated, only 73.5% remembered the surgical technique employed. A total of 63.9% of patients could recall the vertebral levels operated. 39.1% were not aware of the surgical risks involved, and only 16.0% of patients admitted having looked for additional information. A statistically significant correlation was found between the search for additional information and young age (p < 0.001) on the one hand, and high educational level on the other (p = 0.023). CONCLUSION: Even though obtaining informed consent is an important procedure before spinal surgery, almost 40% of the patients in this study underwent surgery without reading the informed consent document or being aware of the risks posed by the procedure.

Hypoalbuminemia increases the risk of failure following one-stage septic revision for periprosthetic joint infection.

PURPOSE: Malnutrition is a potentially modifiable risk factor of periprosthetic joint infection (PJI). The purpose of this study was to analyze the role of nutritional status as a risk factor for failure after one- stage revision hip or knee arthroplasty for PJI. METHODS: Retrospective, single-center, case-control study. Patients with PJI according to the 2018 International Consensus Meeting criteria were evaluated. Minimum follow-up was 4 years. Total lymphocyte count (TLC), albumin values, hemoglobin, C-reactive protein, white blood cell (WBC) count and glucose levels were analyzed. An analysis was also made of the index of malnutrition. Malnutrition was defined as serum albumin < 3.5 g/dL and TLC < 1500/mm3. Septic failure was defined as the presence of local or systemic symptoms of infection and the need of further surgery as a result of persistent PJI. RESULTS: No significant differences were found between increased failure rates after a one-stage revision hip or knee arthroplasty for PJI and TLC, hemoglobin level, WBC count, glucose levels, or malnutrition. Albumin and C-reactive protein values were found to have a positive and significant relationship with failure (p < 0.05). Multivariate logistic regression identified only hypoalbuminemia (serum albumin < 3.5 g/dL) (OR 5.64, 95% CI 1.26-25.18, p = 0.023) as a significant independent risk factor for failure. The receiver operating characteristic (ROC) curve for the model yielded an area under the curve of 0.67. CONCLUSION: TLC, hemoglobin; WBC count; glucose levels; and malnutrition, understood as the combination of albumin and TLC, were not found to be statically significant risk factors for failure after single-stage revision for PJI. However, albumin < 3.5 g/dL, alone was a statically significant risk factor for failure after single-stage revision for PJI. As hypoalbuminemia seems to influence the failure rate, it is advisable to measure albumin levels in preoperative workups.

High reoperation and mortality rate after distal femoral replacement for periprosthetic knee fracture in the elderly.

PURPOSE: To analyze the outcomes of elderly patients with periprosthetic fractures around the knee operated on with a distal femur replacement (DFR). METHODS: We performed a retrospective case series study of eleven elderly patients who underwent DFR due to a periprosthetic fracture. Mean follow-up was 30.1 months (SD 28.1). Demographic, clinical and radiological data were reviewed. A descriptive analysis and a study of survival were conducted. Then, a comparative analysis between the patients who needed reoperation and did not need reoperation, and the patients who died and the patients who were alive during the follow-up was performed. RESULTS: Mean age was 77.1 years (SD 13.9). Reoperation rate was 36%, being infection the most common complication (27%). The risk of reoperation increased with a longer time between fracture and surgery. The 36.4% of patients died during the follow-up. Older age, need of blood transfusion and need of early reoperation were related to a higher risk of mortality. CONCLUSION: DFR could be a valuable option for knee periprosthetic fractures in elderly patients. However, surgeons should be aware of the high reoperation and mortality rate.

Pectoralis-major-pedicled bone window for revision of a shoulder arthroplasty.

PURPOSE: The aim of this study is to review our experience with the pectoralis-major-pedicled bone window for the revision of shoulder arthroplasty. METHODS: This study used the retrospective case series of six patients who underwent a pectoralis-major-pedicled bone window for revision of shoulder arthroplasty, with a minimum follow-up of 2 years. Demographic, clinical, and radiological data were analyzed. RESULTS: The mean age of the included patients was 72.6 years old (standard deviation (SD) 4.7), and 83.3% were women (5/1). The mean follow-up was 36.6 months (range 25-48 months). Five patients had a shoulder hemiarthroplasty and one patient a reverse shoulder arthroplasty. The indications for revision were pain in five patients and recurrent dislocation in one patient. No intraoperative complications were found. One patient developed a wound infection that required debridement and a two-stage revision. Despite complications, 2 years after surgery, the range of motions and functional scores were improved from preoperative levels. The difference between preoperative and postoperative VAS pain scores was 7.1 points (p < 0.001). The difference between preoperative and postoperative CSS and ASES questionnaires were 32 and 31.6 points, respectively (p < 0.001). At the final follow-up, all radiographs showed bone union of the osteotomy, good fixation of all components, without evidence of prosthetic loosening or migration. CONCLUSIONS: Revision of a shoulder arthroplasty using a pectoralis-major-pedicled bone window can be an effective treatment that can yield pain relief; however, improvements in motion and function were difficult to achieve.

Clinical practice guidelines: The good, the bad, and the ugly.

Clinical practices guidelines (CPGs) play a fundamental role in improving healthcare and patients' outcomes by helping clinicians make the best evidence-based decisions for their patients in a time-efficient manner. By following the available methods and criteria to create trustworthy CPGs, panel members can develop high-quality guidelines. However, despite the improvements over the years, CPGs are still subjected to biases and limitations, with conflicts of interest being the ugliest problem GCPs must face. In this review, we discuss the main characteristics of clinical practice guidelines, their pros and cons, and the future challenges they need to overcome.

Outcomes of cervical arthroplasty versus anterior cervical arthrodesis: a systematic review and meta-analysis of randomized clinical trials with a minimum follow-up of 7-year.

PURPOSE: Compare the outcomes of randomized clinical trials of cervical disc arthroplasty (CDA) versus anterior cervical discectomy with fusion (ACDF), with a minimum follow-up of 7 years. METHODS: Nine randomized clinical trials were selected. The clinical, radiological, and surgical outcomes were analyzed, including functional and pain scores, range of motion, adjacent segment degeneration, adverse events, and need for reoperation. RESULTS: 2664 patients were included in the study. Pooled results indicated that the CDA group had a significantly higher overall success rate (p < 0.001), a higher improvement in the neck disability index (NDI) (p = 0.002), less VAS arm pain (p = 0.01), and better health questionnaire SF-36 physical component (p = 0.01) than ACDF group. Likewise, the pooled results indicated a significantly higher motion rate (p < 0.001), less adjacent syndrome (p < 0.05), and a lower percentage of reoperation (p < 0.001) in the CDA group. There were no significant differences between the CDA and ACDF groups in the neck pain scale (p = 0.11), the health questionnaire SF-36 mental component (p = 0.10), and in adverse events (p = 0.42). CONCLUSION: In long-term follow-up, CDA showed a better overall success rate, better improvement in NDI, less VAS arm pain, better health questionnaire SF-36 physical component, a higher motion rate, less adjacent syndrome, and less reoperation rate than ACDF. No significant differences were found in the neck pain scale, SF-36 mental component, and in adverse events.

Total calcaneal allograft reconstruction of an Ewing's sarcoma in a child: Outcome and review of the literature.

BACKGROUND: Ewing's sarcoma rarely presents in bones of the feet. Surgical management usually includes amputation. Limb sparing surgery is anecdotal. CASE: We report the case of a 13-year-old boy with an Ewing sarcoma in his calcaneus who had a calcaneal reconstruction with total calcaneus allograft after induction chemotherapy. CONCLUSIONS: At 42 months of follow-up our patient remains disease free and functionally intact. A review of the exceptional limb salvage procedure options for malignant calcaneus tumor was performed.

Is routine blood typing and screening necessary for degenerative cervical spine surgery patients in specialty surgical hospitals?

BACKGROUND: Blood loss warranting transfusion is a relatively rare requirement for degenerative cervical spine surgery. Despite this rarity, pretransfusion testing (blood typing, screening, and cross-matching) has become routine in most parts of the world. We sought to determine if such routine testing is necessary for patients who undergo degenerative cervical spine surgery patients in specialty surgical hospitals by (1) measuring the current rate of intraoperative transfusions in degenerative cervical spine surgery and (2) identifying risk factors for transfusions. STUDY METHODS: Retrospective review was performed on patients who underwent degenerative cervical spine surgery in two institutions. Demographic and baseline clinical and laboratory data were collected and analyzed to identify predictors of transfusion. Bivariate and multivariate logistic regression analysis was performed to identify perioperative transfusion risk factors. RESULTS: Overall transfusion rate was 1.9% (7/372), with no emergent transfusions. Decreases between preoperative and postoperative hemoglobin and hematocrit were 1.4 (SD 1.1) g/dL and 7.2 (SD 4.1) %, respectively. Multivariate logistic regression identified preoperative Hgb lower than 12 gr/dl (OR 27.62; 95% CI 4.31-176.96; p < 0.001) as significant independent transfusion risk factor. The receiver operating characteristic (ROC) curve for the model showed a very good discriminatory power with an area under the curve of 0.91. DISCUSSION: Our study suggests that pretransfusion testing for all patients undergoing degenerative cervical spine surgery is unnecessary. We recommend that only patients with preoperative Hgb lower than 12 gr/dl would routinely need pretransfusion testing.

Is routine blood typing and screening necessary before primary total hip or knee arthroplasty in the 21st century?

BACKGROUND: Blood loss warranting transfusion is a relatively rare complication of major-joint arthroplasty procedures like total knee arthroplasty (TKA) and total hip arthroplasty (THA). Despite this rarity, pre-transfusion testing (blood typing, screening, and cross-matching) has become routine. We sought to determine if such routine testing is necessary for patients who undergo a primary TKA or THA by (1) measuring the current rate of intraoperative transfusions in primary TKA and THA patients, (2) identifying risk factors for transfusions, and (3) calculating the costs of such blood typing and screening. STUDY METHODS: We retrospectively examined the records of 992 patients who underwent primary TKA, THA, or unicompartmental knee arthroplasty (UKA) to identify patients requiring intra-operative or in-hospital postoperative transfusions. Demographic and baseline clinical and laboratory data also were collected and analyzed to identify predictors of transfusion. Cost analysis was performed. RESULTS: The rate of intraoperative transfusion was 1.7% (17/992 patients), with rates of 2.1%, 1.6%, and 0% for TKA, THA, and UKA respectively. The in-hospital transfusion rate was 10.3%, with corresponding postoperative transfusion rates of 9.1%, 12.9%, and 2%. The only baseline variable significantly linked to transfusions on multivariable analysis was preoperative hemoglobin level, with preoperative Hgb <12 g/dl predictive of transfusions in both TKA (p = .02) and THA (p = .024) patients. DISCUSSION: Our study suggests that pre-transfusion testing for all patients undergoing primary UKA, TKA or THA is unnecessary. We recommend reserving routine pre-transfusion testing for patients with preoperative hemoglobin levels below 12 g/dl.

Local infiltration analgesia does not have benefits in fast-track hip arthroplasty programmes: a double-blind, randomised, placebo-controlled, clinical trial.

BACKGROUND: Multimodal analgesia regimes including local infiltration analgesia (LIA) have been successfully applied in fast-track hip arthroplasty programmes. LIA's contribution to the analgesic effect in hip arthroplasty has been questioned. Our study sought to determine the analgesic efficacy of LIA in THA surgery in a fast-track programme. METHODS: Patients diagnosed with hip osteoarthritis scheduled for arthroplasty were randomised to receive LIA (120 ml ropivacaine 0.2% plus epinephrine 0.5 µ/ml) or saline as a part of a multimodal analgesia regime. The surgical team, the nursing staff, and patients were all blinded regarding patient allocation throughout the study. The primary outcome was pain assessed as a continuous variable using the visual analogue scale (VAS) at 4, 8, 24 and 48 hours postoperatively. Secondary outcomes included the amount of analgesic rescue consumption, complications and length of hospital stay. RESULTS: A total of 63 patients were interviewed and agreed to participate in the study. No statistically significant differences were found between groups for pain measurements at 4, 8, 12, 24 and 48 hours after surgery. There were also no differences in rescue medication consumption, complications, or length of stay. CONCLUSIONS: Our results suggest LIA (ropivacaine plus epinephrine, single shot) has no effect in pain management and has not shown benefits for early ambulation in primary THA surgery. Further research is needed to establish the optimal multimodal analgesia regime for THA fast-track programmes. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov (NCT03513276).

Can we trust combined anteversion and Lewinnek safe zone to avoid hip prosthesis dislocation?

INTRODUCTION: Dislocation is one of the most common complications after primary total hip arthroplasty (THA). Combined anteversion (CA) is currently considered one of the most important measures of stability for THA. Thus, the aim of this study is to determine the association between a correct CA after THA and hip prosthesis dislocation, and to analyze the reliability of the Lewinnek safe zone parameters. MATERIAL AND METHODS: This is a non-interventional retrospective study, carried out at a tertiary hospital in Spain. 2489 primary THA in 2147 patients between January 2008 and December 2014 were identified. Clinical, biological and radiographic data, including cup inclination and cup and femoral anteversion, were analyzed of all patients who developed a hip prosthesis dislocation. RESULTS: Thirty-four patients met the eligibility criteria to be analyzed. In 73.5% (25/34) of cases, acetabular anteversion (AV) was correct, with a mean AV of 15.1° ± 9.4°. Femoral anteversion (FA) was considered correct only in 38.2% (13/34) of the dislocated THA, with a mean FA of 8.4° ± 17.2°. Sixteen of these 34 patients (47.0%) presented a correct CA, with a mean CA of 24.2° ± 21.0°. Nineteen hips (55.8%) were within the Lewinnek safe zone. Moreover, eleven patients (32.3%) developed a dislocation even though components were within the Lewinnek safe zone and presented a correct CA. CONCLUSION: Our findings suggest that even when the THA components are positioned within a correct CA and in the Lewinnek safe zone, hip prosthesis dislocations can occur in a not inconsiderable percentage of the cases. Thus, further radiological and clinical analysis should be done to identify potential reasons for hip prosthesis dislocation.