Are modular pedicle screws associated with a high complication rate following posterior spinal fixation?

Background: Modular pedicle screws have a separate head that can be intraoperatively assembled to the inserted shank. The aim of this study was to report associated intra- and post-operative complications and reoperation rates of posterior spinal fixations with modular pedicle screws at a single center. Methods: A retrospective, institutional chart review was performed on 285 patients who underwent posterior thoracolumbar spinal fusion with modular pedicle screw fixation between January 1, 2017, and December 31, 2019. The primary outcome was failure of the modular screw component. Other measures recorded were length of follow-up, other complications, and need for additional procedures. Results: There were 1,872 modular pedicle screws (average 6.6 per case). There were no (0.0%) screw head dissociations at the rod screw junction. There was 20.8% overall complication rate (59/285) with 25 reoperations: 6 due to non-union and rod breakage, 5 for screw loosening, 7 for adjacent segment disease, 1 for acute postoperative radiculopathy, 1 for epidural hematoma, 2 for deep surgical-site infections, and 3 for superficial surgical-site infections. Other complications included superficial wound dehiscence [8], dural tears [6], non-unions not requiring reoperation [2], lumbar radiculopathies [3], and perioperative medical complications [5]. Conclusions: This study demonstrates that modular pedicle screw fixation has reoperation rates similar to those previously reported for standard pedicle screws. There was no failure at the screw-head junction, and no increases in other complications. Modular pedicle screws present an excellent option to allow surgeons to place pedicle screws without the risk of extra complications.

Decreasing the Pedicle Screw Misplacement Rate in the Thoracic Spine With Robot-guided Navigation.

STUDY DESIGN: A retrospective chart review. OBJECTIVE: The aim of this study was to evaluate the screw accuracy of thoracic pedicle screws placed with a robot-guided navigation system. SUMMARY OF BACKGROUND DATA: Thoracic pedicles are smaller in diameter than lumbar pedicles, making pedicle screw placement difficult. Misplaced pedicle screws may present complications including decreased construct stability, and increased risks of neurological deficits and blood vessel perforation. There is a dearth of knowledge on thoracic pedicle screw accuracy placed with a robot. MATERIALS AND METHODS: A retrospective analysis of the robot-assisted placement of thoracic pedicle screws was performed. Preoperative and postoperative computed tomography (CT) scans of the implanted thoracic screws were collected to assess screw placement accuracy, pedicle breadth, and placement deviations. A CT-based Gertzbein and Robbins System was used to classify pedicle screw accuracy in 2 mm increments. A custom image overlay software was used to determine the deviations between the preoperatively planned trajectory of pedicle screws and final placement at screw entry (tail), and tip in addition to the angular deviation. RESULTS: Seventy-five thoracic pedicle screws were implanted by navigated robotic guidance in 17 patients, only 1.3% (1/75) were repositioned intraoperatively. Average patient age and body mass index were 57.5 years and 25.9 kg/m 2 , respectively, with 52.9% female patients. Surgery diagnoses were degenerative disk disease (47.1%) and adjacent segment disease (17.6%). There were zero complications, with no returns to the operating room. According to the CT-based Gertzbein and Robbins pedicle screw breach classification system, 93.3% (70/75) screws were grade A or B, 6.6% (5/75) were grade C, and 0% were grade D or E. The average deviation from the preoperative plan to actual final placement was 1.8±1.3 mm for the screw tip, 1.6±0.9 mm for the tail, and 2.1±1.5 degrees of angulation. CONCLUSIONS: The current investigation found a 93.3% accuracy of pedicle screw placement in the thoracic spine. Navigated robot assistance is a useful system for placing screws in the smaller pedicles of the thoracic spine. LEVEL OF EVIDENCE: Level III-retrospective nonexperimental study.

Does design change in total knee arthroplasty implants affect patient-reported outcomes?

PURPOSE: The purpose of this study is to compare the early results of patient-reported outcomes between two generations of a total knee system. METHODS: Between June 2018 and April 2020, 121 first-generation, cemented TKAs (89 patients) and 123 s-generation, cemented TKAs (98 patients) were performed by a single surgeon. Demographic and surgical data were collected from all patients. Starting at the 6-month follow-up, patient-reported outcome measures Knee Injury and Osteoarthritis Outcome Score, Joint Reconstruction (KOOS-JR) and Knee Society (KS) clinical and radiographic scores were prospectively recorded. This study represents a retrospective review of these prospectively collected data. RESULTS: There were no statistically significant differences between the two groups in terms of demographic variables such as age, body mass index, gender and race. KOOS-JR and Knee Society (KS) scores improved significantly (p < 0.001) from their preoperative values in both device generations. There were no differences, pre-operatively, between the two groups in terms of KOOS-JR, KS functional, KS objective, patient satisfaction, and expectation scores; however, there were statistically significant (p < 0.001) lower values of KOOS-JR and KS functional scores for first versus second generation at 6 months (81 vs. 89 and 69 vs. 74, respectively). CONCLUSION: While significant improvement in KS objective, subjective, and patient satisfaction scores were noted with both knee systems, KOOS-JR and KS function scores were significantly higher at the early (6-month) follow-up in the second-generation group. Patients responded acutely to the design change as evidenced by significantly improved patient-reported outcome scores for the second generation.

Robotic-assisted spine surgery allows for increased pedicle screw sizes while still improving safety as indicated by elevated triggered electromyographic thresholds.

The present study used triggered electromyographic (EMG) testing as a tool to determine the safety of pedicle screw placement. In this Institutional Review Board exempt review, data from 151 consecutive patients (100 robotic; 51 non-robotic) who had undergone instrumented spinal fusion surgery of the thoracic, lumbar, or sacral regions were analyzed. The sizes of implanted pedicle screws and EMG threshold data were compared between screws that were placed immediately before and after adoption of the robotic technique. The robotic group had significantly larger screws inserted that were wider (7 ± 0.7 vs 6.5 ± 0.3 mm; p < 0.001) and longer (47.8 ± 6.4 vs 45.7 ± 4.3 mm; p < 0.001). The robotic group also had significantly higher stimulation thresholds (34.0 ± 11.9 vs 30.2 ± 9.8 mA; p = 0.002) of the inserted screws. The robotic group stayed in the hospital postoperatively for fewer days (2.3 ± 1.2 vs 2.9 ± 2 days; p = 0.04), but had longer surgery times (174 ± 37.8 vs 146 ± 41.5 min; p < 0.001). This study demonstrated that the use of navigated, robot-assisted surgery allowed for placement of larger pedicle screws without compromising safety, as determined by pedicle screw stimulation thresholds. Future studies should investigate whether these effects become even stronger in a later cohort after surgeons have more experience with the robotic technique. It should also be evaluated whether the larger screw sizes allowed by the robotic technology actually translate into improved long-term clinical outcomes.

A Retrospective Analysis of Pedicle Screw Placement Accuracy Using the ExcelsiusGPS Robotic Guidance System: Case Series.

BACKGROUND: Robotic guidance has become widespread in spine surgery. Although the intent is improved screw placement, further system-specific data are required to substantiate this intention for pedicle screws in spinal stabilization constructs. OBJECTIVE: To determine the accuracy of pedicle screws placed with the aid of a robot in a cohort of patients immediately after the adoption of the robot-assisted surgery technique. METHODS: A retrospective, Institutional Review Board-approved study was performed on the first 100 patients at a single facility, who had undergone spinal surgeries with the use of robotic techniques. Pedicle screw accuracy was graded using the Gertzbein-Robbins Scale based on pedicle wall breach, with grade A representing 0 mm breach and successive grades increasing breach thresholds by 2 mm increments. Preoperative and postoperative computed tomography scans were also used to assess offsets between the objective plan and true screw placements. RESULTS: A total of 326 screws were analyzed among 72 patients with sufficient imaging data. Ages ranged from 21 to 84 years. The total accuracy rate based on the Gertzbein-Robbins Scale was 97.5%, and the rate for each grade is as follows: A, 82%; B, 15.5%; C, 1.5%; D, 1%; and E, 0. The average tip offset was 1.9 mm, the average tail offset was 2.0 mm, and the average angular offset was 2.6°. CONCLUSION: Robotic-assisted surgery allowed for accurate implantation of pedicle screws on immediate adoption of this technique. There were no complications attributable to the robotic technique, and no hardware revisions were required.

Factors Affecting the Accuracy of Pedicle Screw Placement in Robot-Assisted Surgery: A Multicenter Study.

STUDY DESIGN: Retrospective multicenter. OBJECTIVE: The aim was to investigate the factors involved in, and their relative contributions to, the overall accuracy of robot-assisted pedicle screw placement. SUMMARY OF BACKGROUND DATA: Robot-assisted surgery has reportedly resulted in greater accuracy for placement of pedicle screws than conventional methods. There are many potential factors affecting the accuracy of pedicle screws placed with a robot. No study has investigated these factors in a robust way. MATERIALS AND METHODS: Radiographic and clinical data of three centers were pooled. Preoperative and postoperative computerized tomographies were obtained by all three centers to assess the accuracy of the placed screws. The primary outcome measured was accuracy of pedicle screws placed with the robot. The authors performed a multivariate regression analysis to determine the significant patient-related and screw-related variables and their relative contribution to the overall accuracy. In addition, an ordinal regression analysis was conducted to investigate the effects of different variables on accuracy of robot-placed screws graded by Gertzbein-Robbins grading system (GRS). RESULTS: The total contribution of all studied variables to overall accuracy variation as measured by offsets between the placed and planned screws was only 18%. Obesity, long constructs, female gender, surgeon, and vertebral levels were among the factors that had small contributions to the different screw offsets. For GRS grades, significant variables were gender (Log odds: 0.62, 95% CI: 0.38-0.85), age (Log odds: 0.02, 95% CI: 0.01-0.03), length of constructs (Log odds: 0.07, 95% CI: 0.02-0.11), screw diameter (Log odds: 0.55, 95% CI: 0.39-0.71), and length of the screws (Log odds: 0.03, 95% CI: 0.01-0.05). However, these variables too, regardless of their significant association with the accuracy of placed screws, had little contribution to overall variability of accuracy itself (only about 7%). CONCLUSION: The accuracy of screws placed with robotic assistance, as graded by GRS or measured offsets between planned and placed screw trajectories, is minimally affected by different patient-related or screw-related variables due to the robustness of the robotic navigation system used in this study. LEVEL OF EVIDENCE: Level III.

Cost and determinants of acute kidney injury after elective primary total joint arthroplasty.

BACKGROUND: Acute kidney injury (AKI) is a serious complication after major surgery, which may lead to increased morbidity and mortality. The aim of this study was to identify cost and determinants of AKI after total joint arthroplasty. METHODS: A retrospective case-controlled study was conducted with 1719 primary elective total hip or knee replacements performed from January 2004 through September 2015 at an urban teaching hospital. Patients who developed AKI were matched in a 1:3 ratio with those in a control group who did not develop AKI based on age, sex, race, operated joint, and comorbidities including hypertension and diabetes. Increased postoperative serum creatinine was considered indicative of AKI. RESULTS: Fifty-four patients (3.1%) had AKI that was significantly associated with increased length of hospital stay (8.07 days) compared with that of the control group (4.50 days, P < .0001) and incurred significantly higher hospital charges ($224,533) than those of the control group ($142,753, P < .0001). We identified high body mass index, undergoing bilateral surgery in one session, high estimated blood loss, and longer duration of surgery as significant risk factors for AKI in univariate analysis. Elevated preoperative creatinine, large postoperative drop in hemoglobin, and high American Society of Anesthesiologists physical status scores were significant independent predictors of AKI in multivariate analysis. CONCLUSIONS: Health-care providers and patients should work together to manage risk factors and to lower the risk of morbidity and mortality, longer in-hospital stay, and high associated costs of AKI.

Cost Determinants in the 90-Day Management of Isolated Ankle Fractures at a Large Urban Academic Hospital.

OBJECTIVES: To determine the independent risk factors associated with increasing costs and unplanned hospital readmissions in the 90-day episode of care (EOC) for isolated operative ankle fractures at our institution. DESIGN: Retrospective cohort study. SETTING: Level I Trauma Center. PATIENTS: Two hundred ninety-nine patients undergoing open reduction internal fixation for the treatment of an acute, isolated ankle fracture between 2010 and 2015. INTERVENTION: None. MAIN OUTCOME MEASURES: Independent risk factors for increasing 90-day EOC costs and unplanned hospital readmission rates. RESULTS: Orthopaedic (64.9%) and podiatry (35.1%) patients were included. The mean index admission cost was $14,048.65 ± $5,797.48. Outpatient cases were significantly cheaper compared to inpatient cases ($10,164.22 ± $3,899.61 vs. $15,942.55 ± $5,630.85, respectively, P < 0.001). Unplanned readmission rates were 5.4% (16/299) and 6.7% (20/299) at 30 and 90 days, respectively, and were often (13/20, 65.0%) due to surgical site infections. Independent risk factors for unplanned hospital readmissions included treatment by the podiatry service (P = 0.024) and an American Society of Anesthesiologists score of ≥3 (P = 0.017). Risk factors for increasing total postdischarge costs included treatment by the podiatry service (P = 0.011) and male gender (P = 0.046). CONCLUSIONS: Isolated operative ankle fractures are a prime target for EOC cost containment strategy protocols. Our institutional cost analysis study suggests that independent financial clinical risk factors in this treatment cohort includes podiatry as the treating surgical service and patients with an American Society of Anesthesiologists score ≥3, with the former also independently increasing total postdischarge costs in the 90-day EOC. Outpatient procedures were associated with about a one-third reduction in total costs compared to the inpatient subgroup.

Ten-Year Trends and Independent Risk Factors for Unplanned Readmission Following Elective Total Joint Arthroplasty at a Large Urban Academic Hospital.

BACKGROUND: Total joint arthroplasty procedures continue to provide consistent, long-term success and high patient satisfaction scores. However, early unplanned readmission to the hospital imparts significant financial risks to individual institutions as we shift away from the traditional fee-for-service payment model. METHODS: Using a combination of our hospital's administrative database and retrospective chart reviews, we report the 30-day and 90-day readmission rates and all causes of readmission following all unilateral, primary elective total hip and knee arthroplasty procedures at a large, urban, academic hospital from 2004 to 2013. RESULTS: In total, 1165 primary total hip (511) and knee (654) arthroplasty procedures were identified, and the 30-day and 90-day unplanned readmission rates were 4.6% and 7.3%, respectively. A multivariate regression model controlled for a variety of potential clinical and surgical confounders. Increasing body mass index levels, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each independently correlated with risk of both 30-day and 90-day unplanned readmission to our institution. Additionally, use of general anesthesia during the procedure independently correlated with risk of readmission at 30 days only, while congestive heart failure independently correlated with risk of 90-day unplanned readmission. Readmissions related directly to the surgical site accounted for 47% of the cases, and collectively totaled more than any single medical or clinical complication leading to unplanned readmission within the 90-day period. CONCLUSION: Increasing body mass index values, general anesthesia, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each were independent risk factors for early unplanned readmission.

Surgical Risks and Costs of Care are Greater in Patients Who Are Super Obese and Undergoing THA.

BACKGROUND: Patients with morbid obesity, defined as a BMI greater than 40 kg/m2, and super obesity, defined as a BMI greater than 50 kg/m2, increasingly present for total hip replacement. There is disagreement in the literature whether these individuals have greater surgical risks and costs for the episode of care, and the magnitude of those risks and costs. There also is no established threshold for obesity as defined by BMI in identifying increased complications, risks, and costs of care. Until recently, analysis of higher BMI data was limited to small cohorts from hospital-based data banks, based on BMI or height and weight only, often as part of a multivariate analysis. On October 1, 2010 the Centers for Medicare & Medicaid Services added a fifth digit to the BMI data, V85.xx, in the Medicare data bank, which allowed data mining of cases of patients with higher BMI. To our knowledge, our study is the first large retrospective Medicare data mining study, which allows us to examine BMI levels greater than 40 and 50 kg/m2 to delineate risks, complications, and costs for these patients. QUESTIONS/PURPOSES: We sought to quantify (1) the surgical risk, and (2) the costs associated with complications after THA in patients who were morbidly obesity (BMI ≥ 40 kg/m2) or super obese (BMI ≥ 50 kg/m2). METHODS: This is a retrospective study of patients, using Medicare hospital claims data, who underwent THA. The ICD-9 Clinical Modification (CM) diagnosis code V85.4x was used to identify patients with morbid obesity and with super obesity from October 1, 2010 through December 31, 2014. Patients without any BMI-related diagnosis codes were used as the control group. Twelve complications occurring during the 90 days after THA were analyzed using multivariate Cox models adjusting for patient demographic, comorbidities, and institutional factors. In addition, hospital charges and payments were compared from primary surgery through the subsequent 90 days. RESULTS: Patients with morbid obesity had increased postoperative complications including prosthetic joint infection (hazard ratio [HR], 3.71; 95% CI, 3.2-4.31; p < 0.001), revision (HR, 1.91; 95% CI, 1.69-2.16; p < 0.001), and wound dehiscence (HR, 3.91; 95% CI, 3.14-4.86; p < 0.001). In addition, patients with morbid obesity had increased risk of deep vein thrombosis (HR, 1.43; 95% CI, 1.14-1.79; p < 0.002), pulmonary embolism (HR, 1.57; 95% CI, 1.25-1.99; p < 0.001), implant failure (HR, 1.48; 95% CI, 1.3-1.68; p < 0.001), acute renal failure (HR, 1.68; 95% CI, 1.56-1.80; p < 0.001), and all-cause readmission (HR, 1.48; 95% CI, 1.40-1.56; p < 0.001). However, death (HR, 0.94 95% CI, 0.73-1.19 p < 0.592), acute myocardial infarction (HR, 0.94; 95% CI, 0.74-1.2 p < 0.631), and dislocation (HR 1.07; 95% CI, 0.85-1.34; p < 0.585) were not different between patients in the control and morbidly obese groups. Super obese patients had an increased risk of infection (HR, 6.48; 95% CI, 4.54-9.25; p < 0.001), wound dehiscence (HR, 9.81; 95% CI, 6.31-15.24; p < 0.001), and readmission (HR, 2.16; 95% CI, 1.84-2.54; p < 0.001) compared with patients with normal BMI. Controlling for patient and institutional factors, each THA had mean total hospital charges of USD 88,419 among patients who were super obese compared with USD 73,827 for the control group, a difference of USD 14,591. Medicare payment for the patients who were super obese also was higher, but only by USD 3631. CONCLUSIONS: Patients who are super obese are at increased risk for serious complications compared with patients with morbid obesity, whose risks are elevated relative to patients whose BMI is less than 40 kg/m2. Costs of care for patients who were super obese, likewise, were increased. We present BMI outcomes to allow an objective basis for patient counseling, risk stratification, maintaining access to orthopaedic surgical care, and maintaining hospital operating margins. LEVEL OF EVIDENCE: Level III, therapeutic study.

Risk and Cost of 90-Day Complications in Morbidly and Superobese Patients After Total Knee Arthroplasty.

BACKGROUND: This study investigated the risk and cost of postoperative complications associated with morbid and super obesity after total knee arthroplasty (TKA). METHODS: A retrospective cohort study was conducted of patients who underwent TKA using Medicare hospital claims data. The International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code V85.4x was used to identify morbidly obese patients (body mass index [BMI] ≥40 kg/m(2)) and superobese patients (BMI ≥50 kg/m(2)) in 2011-2013. Patients without any BMI-related diagnosis codes were used as controls. Twelve complications occurred in the 90-day period after TKA were analyzed using multivariate Cox models, adjusting for patient demographic, morbidity, and institutional factors. In addition, hospital charges and payments were compared from primary surgery through subsequent 90 days. RESULTS: Morbidly obese patients showed a significantly elevated risk in most complications examined, with a 2-fold or higher risk in dislocation and wound dehiscence. In addition, death, periprosthetic joint infection, acute renal failure, and knee revision had significant hazard ratios between 1.5 and 2.0. However, risk of deep vein thrombosis and acute myocardial infarction did not increase for the morbidly obese patients. Superobese patients had significant increase in risk of infection, wound dehiscence, acute renal failures, revisions, death, and readmission compared with patients with BMI 40-49 kg/m(2). Significant dose-response trend was found between the level of BMI and risk for death, dislocation, implant failure, infection, readmission, revision, wound dehiscence, and acute renal failure. Controlling for patient and institutional factors, each TKA had an average total hospital charges of $75,884 among superobese patients, compared to $65,118 for the control group, a difference of $10,767. Medicare payment for the superobese patients was also higher, but only by $2703. CONCLUSION: Morbidly obese patients pose a significantly higher risk profile than normal-weight patients in a broad range of complications after TKA. Superobese patients add another layer of risk compared with less obese patients and are considerably more expensive to treat by health care systems. Technical difficulties and the high demand on resources present a severe challenge for providing treatment for such patients.

The Validity of Administrative BMI Data in Total Joint Arthroplasty.

Identifying BMI via administrative data is a useful way to evaluate outcomes in total joint arthroplasty (TJA) for varying degrees of obesity. The purpose of this study was to evaluate the concordance between BMI coding in administrative claims data and actual clinical BMI measurements in the medical record for patients undergoing TJA. Clinical BMI value was shown to be a significant determinant of whether ICD-9 codes were used to report the patient's obesity status (P<0.01). Although a higher clinical BMI strongly increased the likelihood of having either of the ICD-9 diagnosis codes used to identify obesity status, only the accuracy of the V85 code increased with increasing levels of BMI.

Distal tibia fractures: locked or non-locked plating? A systematic review of outcomes.

BACKGROUND AND PURPOSE: Although plating is considered to be the treatment of choice in distal tibia fractures, controversies abound regarding the type of plating for optimal fixation. We conducted a systematic review to evaluate and compare the outcomes of locked plating and non-locked plating in treatment of distal tibia fractures. PATIENTS AND METHODS: A systematic review was conducted using PubMed to identify articles on the outcomes of plating in distal tibia fractures that were published up to June 2012. We included English language articles involving a minimum of 10 adult cases with acute fractures treated using single-plate, minimally invasive techniques. Study-level binomial regression on the pooled data was conducted to determine the effect of locking status on different outcomes, adjusted for age, sex, and other independent variables. RESULTS: 27 studies met the inclusion criteria and were included in the final analysis of 764 cases (499 locking, 265 non-locking). Based on descriptive analysis only, delayed union was reported in 6% of cases with locked plating and in 4% of cases with non-locked plating. Non-union was reported in 2% of cases with locked plating and 3% of cases with non-locked plating. Comparing locked and non-locked plating, the odds ratio (OR) for reoperation was 0.13 (95% CI: 0.03-0.57) and for malalignment it was 0.10 (95% CI: 0.02-0.42). Both values were statistically significant. INTERPRETATION: This study showed that locked plating reduces the odds of reoperation and malalignment after treatment for acute distal tibia fracture. Future studies should accurately assess causality and the clinical and economic impact of these findings.

Placing femoral intramedullary nails in severely bowed femurs.

The authors describe a novel technique of anterograde femoral intramedullary nail fixation for hip fracture using the starting guide pin as a blocking screw. This cost-effective technique uses fluoroscopic radiography to ensure the guidewire is within the posterior aspect of the femur on a lateral view, thereby minimizing the risk of anterior cortical femoral fractures.

The relationship between knee arthroscopy and arthroplasty in patients under 65 years of age.

A private payer database was used to examine the incidence and rates of knee arthroscopy in patients less than 65 years of age and the subsequent risk of knee arthroplasty. Time to event analysis was performed using the Kaplan-Meier method; also, Cox regression analysis was used to evaluate the relative risk of subsequent knee arthroplasty for arthroscopic patients. Overall, 247,034 knee arthroscopies, done for injury or arthropathy, were identified between 2004 and 2009. Within 1-year of arthroscopy, 2.2% of arthropathy patients and 0.9% of injury patients underwent a knee arthroplasty. These increased to 5.2% and 2.4% at 5-years, respectively. The risk of arthroplasty following arthroscopy increased significantly with age. Further study is warranted to examine the benefit of arthroscopy in younger patients with OA.

Percutaneous column fixation and total hip arthroplasty for the treatment of acute acetabular fracture in the elderly.

We used our database of primary total hip arthroplasties to identify those patients who had acetabular fractures fixed with percutaneous screws under the same anesthesia as for the arthroplasty procedure. There were 19 patients with the average follow-up of 22 months. Fourteen patients sustained the fracture secondary to a low-energy trauma, while the remaining patients were involved in a high-energy trauma accident. The mean survival time was calculated to be 2.5 ± 0.6 years for the low-energy group and 4 ± 1.4 years for the high-energy group. We believe that this unique treatment of acetabular fractures has a role in carefully selected patients and provides the necessary reduction and immediate stability of the fracture needed to ensure adequate fit for the acetabular cup in the subsequent THA.

Performance outcomes after repair of complete achilles tendon ruptures in national basketball association players.

BACKGROUND: A complete rupture of the Achilles tendon is a devastating injury. Variables affecting return to competition and performance changes for National Basketball Association (NBA) players are not readily evident. HYPOTHESIS: Players in the NBA who ruptured their Achilles tendons and who underwent surgical repair would have more experience in the league, and the performance of those who were able to return to competition would be decreased when compared with their performance before injury and with their control-matched peers. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data for 18 basketball players with Achilles tendon repair over a 23-year period (1988-2011) were obtained from injury reports, press releases, and player profiles. Variables included age, body mass index (BMI), player position, and number of years playing in the league. Individual season statistics were obtained, and the NBA player efficiency rating (PER) was calculated for 2 seasons before and after injury. Controls were matched by playing position, number of seasons played, and performance statistics. Univariate and multivariate analyses were performed to assess the effect of each factor. RESULTS: At the time of injury, the average age was 29.7 years, average BMI was 25.6, and average playing experience was 7.6 years. Seven players never returned to play an NBA game, whereas 11 players returned to play 1 season, with 8 of those players returning for ≥2 seasons. Players who returned missed an average of 55.9 games. The PER was reduced by 4.57 (P = .003) in the first season and by 4.38 (P = .010) in the second season. When compared with controls, players demonstrated a significant decline in the PER the first season (P = .038) and second season (P = .081) after their return. CONCLUSION: The NBA players who returned to play after repair of complete Achilles tendon ruptures showed a significant decrease in playing time and performance. Thirty-nine percent of players never returned to play.

Acetabular components in total hip arthroplasty: is there evidence that cementless fixation is better?

BACKGROUND: The use of cementless acetabular components in total hip arthroplasty has gained popularity over the past decade. Most total hip arthroplasties being performed in North America currently use cementless acetabular components. The objective of this systematic review and meta-analysis was to compare the survivorship and revision rate of cemented and cementless acetabular components utilized in total hip arthroplasty. METHODS: A primary literature search in PubMed identified 3488 articles, of which 3407 did not meet the inclusion criteria and were excluded. Only English-language articles on either the survivorship or revision rate of primary total hip arthroplasty at a minimum of ten years of follow-up were included. The present study analyzed forty-five articles reporting the long-term outcome of cementless acetabular components, twenty-nine reporting the outcome of cemented acetabular components, and seven comparing cemented and cementless acetabular components. Meta-analysis (with a random-effects model) was performed on the data from the seven comparative studies, and study-level logistic regression analysis (with a quasibinomial model) was performed on the pooled data on the eighty-one included articles to determine a consensus. The studies were weighted according to the number of total hip arthroplasties performed. RESULTS: The meta-analysis did not reveal any effect of the type of acetabular component fixation on either survivorship or revision rate. The regression analysis revealed the estimated odds ratio for survivorship of a cemented acetabular component to be 1.60 (95% confidence interval, 1.32 to 2.40; p = 0.002) when adjustments for factors including age, sex, and mean duration of follow-up were made. CONCLUSIONS: The preference for cementless acetabular components on the basis of improved survivorship is not supported by the published evidence. Although concerns regarding aseptic loosening of cemented acetabular components may have led North American surgeons toward the nearly exclusive use of cementless acetabular components, the available literature suggests that the fixation of cemented acetabular components is more reliable than that of cementless components beyond the first postoperative decade.