Total Hip and Knee Arthroplasty Surgery in the Morbidly Obese Patient: A Critical Analysis Review.

¼: Obesity, defined as body mass index (BMI) ≥30, is a serious public health concern associated with an increased incidence of stroke, diabetes, mental illness, and cardiovascular disease resulting in numerous preventable deaths yearly. ¼: From 1999 through 2018, the age-adjusted prevalence of morbid obesity (BMI ≥40) in US adults aged 20 years and older has risen steadily from 4.7% to 9.2%, with other estimates showing that most of the patients undergoing hip and knee replacement by 2029 will be obese (BMI ≥30) or morbidly obese (BMI ≥40). ¼: In patients undergoing total joint arthroplasty (TJA), morbid obesity (BMI ≥40) is associated with an increased risk of perioperative complications, including prosthetic joint infection and mechanical failure necessitating aseptic revision. ¼: The current literature on the role that bariatric weight loss surgery before TJA has on improving surgical outcomes is split and referral to a bariatric surgeon should be a shared-decision between patient and surgeon on a case-by-case basis. ¼: Despite the increased risk profile of TJA in the morbidly obese cohort, these patients consistently show improvement in pain and physical function postoperatively that should be considered when deciding for or against surgery.

Perioperative management of leg-length discrepancy in total hip arthroplasty: a review.

Leg-length discrepancy (LLD) presents a significant management challenge to orthopedic surgeons and remains a leading cause of patient dissatisfaction and litigation after total hip arthroplasty (THA). Over or under-lengthening of the operative extremity has been shown to have inferior outcomes, such as dislocation, exacerbation of back pain and sciatica, and general dissatisfaction postoperatively. The management of LLD in the setting of THA is multifactorial, and must be taken into consideration in the pre-operative, intra-operative, and post-operative settings. In our review, we aim to summarize the best available practices and techniques for minimizing LLD through each of these phases of care. Pre-operatively, we provide an overview of the appropriate radiographic studies to be obtained and their interpretation, as well as considerations to be made when templating. Intra-operatively, we discuss several techniques for the assessment of limb length in real time, and post-operatively, we discuss both operative and non-operative management of LLD. By providing a summary of the best available practices and strategies for mitigating the impact of a perceived LLD in the setting of THA, we hope to maximize the potential for an excellent surgical and clinical outcome.

Conversion total hip arthroplasty following extracapsular hip fracture fixation with a cephalomedullary device: a comprehensive review.

With the annual incidence of hip fractures and hip fracture fixation rising, the need for conversion total hip arthroplasty has also risen. About half of the 280,000 hip fractures that occur annually in the United States are extracapsular. Commonly extracapsular hip fractures are treated with either cephalomedullary nails (CMNs) or sliding hip screws (SHS). More recently, there has been a shift toward increased CMN use due to increased training with this fixation method as well as perioperative and biomechanical benefits. Given this shift, orthopedic surgeons need to understand the factors that lead to CMN failure. Failed CMN treatment leaves both patients and surgeons with few management options including revision fixation with or without osteotomy, conversion total hip arthroplasty, and conversion hemiarthroplasty. Surgeons must consider the patient and injury characteristics before deciding the best treatment plan. Conversion total hip arthroplasty is indicated in younger patients without femoral head and/or acetabular articular injury, degenerative joint disease, or avascular necrosis. Conversion total arthroplasty is a technically demanding and resource-intensive surgery associated with lower success rates and outcomes than primary total hip arthroplasty. Orthopedic surgeons should have thorough understanding of preoperative workup needed prior to surgery, implant selection associated with best outcomes, most common surgical approaches used, intraoperative considerations, and complications associated with conversion total hip arthroplasty. A comprehensive understanding of these concepts gives patients the best chance of having a successful outcome.

Team Approach: Management of Geriatric Acetabular Fractures.

¼: Geriatric acetabular fractures are defined as fractures sustained by patients who are ≥60 years old. With the rapidly aging American populace and its increasingly active lifestyle, the prevalence of these injuries will continue to increase. ¼: An interdisciplinary approach is necessary to ensure successful outcomes. This begins in the emergency department with hemodynamic stabilization, diagnosis of the fracture, identification of comorbidities and concomitant injuries, as well as early consultation with the orthopaedic surgery service. This multifaceted approach is continued when patients are admitted, and trauma surgery, geriatrics, and cardiology teams are consulted. These teams are responsible for the optimization of complex medical conditions and risk stratification prior to operative intervention. ¼: Treatment varies depending on a patient's preinjury functional status, the characteristics of the fracture, and the patient's ability to withstand surgery. Nonoperative management is recommended for patients with minimally displaced fractures who cannot tolerate the physiologic stress of surgery. Percutaneous fixation is a treatment option most suited for patients with minimally displaced fractures who are at risk for displacing the fracture or are having difficulty mobilizing because of pain. Open reduction and internal fixation is recommended for patients with displaced acetabular fractures who are medically fit for surgery and have a displaced fracture pattern that would do poorly without operative intervention. Fixation in combination with arthroplasty can be done acutely or in delayed fashion. Acute fixation combined with arthroplasty benefits patients who have poorer bone quality and fracture characteristics that make healing unlikely. Delayed arthroplasty is recommended for patients who have had failure of nonoperative management, have a fracture pattern that is not favorable to primary total hip arthroplasty, or have developed posttraumatic arthritis.

Perioperative Management of Hepatitis C in Patients Undergoing Total Joint Arthroplasty.

¼: A small yet growing subset of total joint arthroplasty (TJA) candidates are diagnosed with the hepatitis C virus (HCV), which is a known risk factor for periprosthetic joint infections. Given the poor outcomes associated with TJA infection, we recommend that candidates with HCV receive treatment prior to elective TJA. ¼: Interferon and ribavirin have historically been the standard treatment regimen for the management of HCV; however, adverse events and an inconsistent viral response have limited the efficacy of these therapies. The advent of direct-acting antivirals has resolved many of the issues associated with interferon and ribavirin regimens. ¼: Despite the success of direct-acting antivirals, there are still barriers to seeking treatment for TJA candidates with HCV. Many patients are faced with financial burdens, as insurance coverage of direct-acting antiviral therapies is inconsistent and varies by the patient's state of residence and specific treatment regimen. ¼: TJA candidates with HCV present health-care providers with a unique set of challenges, often encompassing economic, psychosocial, and complex medical concerns. Multidisciplinary care teams can be beneficial when caring for and optimizing this patient cohort. ¼: Management of HCV prior to elective TJA is associated with higher up-front costs but ultimately reduces long-term patient morbidity as well as associated direct and indirect health-care expenditures.

Patient Positioning for Proximal Femur Fracture Fixation: a Review of Best Practices.

PURPOSE OF REVIEW: Proximal femur fractures are common traumatic injuries treated by orthopedic surgeons. Preparation and positioning for surgical intervention are critical in the proper management of proximal femur fractures. The purpose of this study was to review the current evidence on the various positioning options for patients and to highlight the principles and emerging techniques to help orthopedic surgeons treat this common injury. RECENT FINDINGS: Strategic patient positioning is key to the reduction and fixation of proximal femur fractures without complications. The use of intramedullary devices for the fixation of proximal femur fractures has led to an increased use of the modern fracture table. The fracture table should be used when surgeons are facile with its use to avoid significant complications. Recent best available evidence has suggested increased risk of malrotation associated with the use of the fracture table. The use of the radiolucent table offers the most flexibility, but limits surgeons as multiple assistants are needed to maintain reduction during fixation. Positioning for proximal femur fractures is an important technique for general and trauma orthopedic surgeons. Surgeons need to be aware of the various techniques for positioning of proximal femur fractures due to the diversity of injury patterns and patient characteristics. Each positioning technique has it benefits and potential complications that every orthopaedic surgeon should be familiar with while treating these injuries.

Open Reduction of a Fracture-Dislocation of the Shoulder in an 11-Month-Old Child: A Case Report.

CASE: An 11-month-old boy was brought to the emergency department because he was refusing to use his right arm. X-rays demonstrated an anteroinferior Salter-Harris I fracture-dislocation of the proximal humeral epiphysis. Closed reduction with sedation was unsuccessful, so open reduction under general anesthesia was pursued. At 2 years, the patient has made a full recovery. CONCLUSION: Pediatric shoulder fracture-dislocations are rare. Clinicians must have a high index of suspicion for nonaccidental trauma when evaluating such injuries. When this injury is encountered in patients younger than 1 year, open reduction of the proximal humeral epiphysis can be a successful treatment option.

Oral health implications in total hip and knee arthroplasty patients: A review.

Over the past two decades, oral health has emerged as a health care priority. Historically, patients greater than 65 years of age, the economically disadvantaged, members of racial or ethnic minority groups, or the disabled or home bound have experienced significant barriers to routine dental care. The connection between oral health care and periprosthetic joint infections (PJI) continues to be of importance to the orthopedic surgeon, as such infections are significantly morbid and costly. This review aims to introduce the importance of oral health as a small but crucial portion of an arthroplasty patient's overall perioperative management.

Outcomes of a Total Joint Arthroplasty Enhanced Recovery Program in a Community Hospital Setting.

BACKGROUND: Same-day discharge (SDD) total joint arthroplasty (TJA) is increasingly popular, yet there remain concerns regarding patient safety, complication rates, and unforeseen overnight admission (failure to launch; FTL). The aim of this study is to retrospectively examine the outcomes of a large consecutive SDD-TJA series in the community hospital setting. METHODS: We retrospectively reviewed 1200 consecutive SDD-TJA candidates between March 2017 and December 2019 by 5 surgeons at a community hospital. Patient demographics, perioperative data including anesthesia type, and 30-day complications were evaluated, including FTL, infection, intraoperative fracture, postoperative periprosthetic fracture or dislocation, return to operating room, and unplanned postoperative care. RESULTS: We included 1200 SDD patients (582/618 total hip arthroplasty/total knee arthroplasty, mean age 62.1 years, 595 females, 605 males). Spinal anesthesia was more common than general anesthesia (1087 vs 113 patients). There were 85 FTLs (7.1%), of this cohort 58.8% were female, with a mean age of 62.4 years. General anesthesia increased the risk of FTL (odds ratio 2.93). Complications resulting in FTL included block-induced neuropraxia (32.1%), orthostatic hypotension (26.1%), urinary retention (19.0%), and nausea (13.1%). Sixteen patients were readmitted within 30 days (1.3%). Six patients returned to the operating room for periprosthetic fracture (4), wound dehiscence (1), and superficial surgical site infection (1). CONCLUSION: SDD-TJA can be safely performed at community hospitals, but general anesthesia should be avoided to decrease risk of FTL. Inpatient programs may allow young surgeons to gain experience with SDD-TJA while retaining overnight admission as a safety net for their patients. LEVEL OF EVIDENCE: Level III (Prognostic).

Team Approach: Developmental Dysplasia of the Hip.

Developmental dysplasia of the hip (DDH) encompasses a wide spectrum of hip disorders, including neonatal instability, acetabular dysplasia, hip subluxation, and frank dislocation of the hip. It is a common disorder, with a reported incidence of between 0.1% and >10% of live births. Coordinated, interdisciplinary care is important to achieving successful outcomes. This starts with accurate assessment of risk factors in the prenatal period, thorough clinical examination by the primary care provider at all well-child visits, and early referral to a pediatric orthopaedic surgeon for prompt diagnosis and treatment. Early diagnosis and prompt treatment is critical for an excellent outcome. Ongoing, open communication between clinicians is essential for the effective coordination of care. Treatment options vary depending on the age of presentation. A Pavlik harness (dynamic hip abduction orthosis) is used for children up to 6 months of age. A more rigid abduction orthosis may be used if treatment with a Pavlik harness is unsuccessful, with a closed reduction and spica cast being the next step if needed for children up to 18 months of age. Finally, open reduction with possible concomitant femoral and/or pelvic osteotomies is the surgical option in an older child, when necessary. In general, the later the child is diagnosed with and treated for DDH, the greater the risk of a nonoptimal outcome. Depending on the severity of the condition, children with DDH may need to be followed closely until skeletal maturity so as not to miss the diagnosis of asymptomatic residual hip dysplasia, which can predispose patients to early hip arthritis.

The Use of Dual Mobility Implants in Patients Who Are at High Risk for Dislocation After Primary Total Hip Arthroplasty.

Dislocation after total hip arthroplasty (THA) is the leading cause of revision surgery. Dual mobility (DM) implants have been utilized over the past 40 years as a means of addressing and preventing this morbid and expensive complication. Recently, there has been renewed investigation into the role that DM implants may play in reducing instability in high-risk patients. Hemiarthroplasty or traditional THA remain the mainstays of treatment for older patients with displaced femoral neck fractures. Longer-term higher-quality studies are necessary to investigate whether DM THA outcomes may be superior to traditional THA in the physiologically young patient with high physical demands and a longer-than-average life expectancy. The use of DM implants in preventing dislocation in patients with fixed spinopelvic alignment, neuromuscular disorders, and failed fixation of previously sustained proximal femoral fractures has shown success in studies with low levels of evidence. More robust prospective data are necessary before more widespread adoption of DM arthroplasty is recommended in these clinical scenarios. Knowledge of the pertinent literature with regard to the use of DM implants in patients who are at high risk for instability will allow orthopaedic surgeons to make informed decisions as to whether or not their patients may benefit from primary THA utilizing DM implants.

Combined Acetabulum Fracture and Hip Dislocation in an 18-Year-Old Female at 35-Week Gestation: A Case Report and Review of the Literature.

Caring for an injured, pregnant patient can be a management challenge. We report the case of an 18-year-old female who sustained a left acetabulum fracture with a concurrent hip dislocation at 35 weeks' gestation following a motor vehicle accident. Through an interdisciplinary, team-based approach, the patient was guided through obstetric delivery and orthopedic surgical fracture fixation without complication. By being familiar with the unique challenges in management posed by pregnant patients, orthopedic surgeons can be better equipped to minimize morbidity and mortality in this patient population while maximizing clinical outcomes.

Perioperative Management of Orthopaedic Patients with Hematologic Disorders: A Critical Analysis Review.

Perioperative management of orthopaedic patients with a hematologic disorder is a complex endeavor that requires a multidisciplinary team-based approach. A team composed of an experienced orthopaedic surgeon, an anesthesiologist, and a hematologist is necessary to achieve optimal outcomes. Patients with hemophilia and other complex hematologic disorders should be managed at, or in consultation with a hematologist at, a comprehensive hemophilia center. Bleeding disorders and inherited thrombophilia present unique challenges for the perioperative management of orthopaedic surgery. Comprehensive preoperative planning and familiarity with treatment guidelines can help to minimize these risks. Knowledge of the disease processes outlined in this article will provide orthopaedic surgeons with the requisite background knowledge that is needed to initiate safe and effective treatment strategies involving this high-risk patient population.

Conversion Total Hip Arthroplasty Following Failed Hip Fracture Fixation in a Patient with Factor XI Deficiency: A Case Report.

INTRODUCTION: Factor XI (FXI) deficiency is a hematologic condition that is rarely encountered by the arthroplasty surgeon. Effective risk assessment and perioperative management are paramount in minimizing the risk of intra- and post-operative bleeding in this patient population. An interdisciplinary approach is crucial in minimizing complications and achieving successful outcomes. We present the case of a patient that successfully underwent conversion total hip arthroplasty (THA) following failed internal fixation of a proximal femur fracture. CASE REPORT: A 71-year-old man with a history of FXI deficiency presented with significant right-sided hip pain secondary to post-traumatic arthritis from a previously treated right proximal femur fracture. The patient underwent removal of the cephalomedullary nail and conversion to a THA. Before the procedure, a comprehensive perioperative plan was enacted to manage the patient's FXI deficiency. The patient underwent several infusions of aminocaproic acid and tranexamic acid (TXA) in an effort to prevent intra- and post-operative bleeding. The surgery was completed with excellent hemostasis and no post-operative complications. CONCLUSION: Patients with FXI deficiency can successfully undergo conversion THA surgery; however, an individualized hematologic plan must be enacted to minimize complications and maximize surgical outcomes and patient satisfaction. This case demonstrates that the antifibrinolytic agents, aminocaproic acid and TXA, can be successfully used for hematologic prophylaxis in the perioperative period for this population of patients.

The etiology, evaluation, and management of plantar fibromatosis.

Plantar fibromatosis (Ledderhose disease) is a rare, benign, hyperproliferative fibrous tissue disorder resulting in the formation of nodules along the plantar fascia. This condition can be locally aggressive, and often results in pain, functional disability, and decreased quality of life. Diagnosis is primarily clinical, but MRI and ultrasound are useful confirmatory adjuncts. Given the benign nature of this condition, treatment has historically involved symptomatic management. A multitude of conservative treatment strategies supported by varying levels of evidence have been described mostly in small-scale trials. These therapies include steroid injections, verapamil, radiation therapy, extracorporeal shock wave therapy, tamoxifen, and collagenase. When conservative measures fail, surgical removal of fibromas and adjacent plantar fascia is often done, although recurrence is common. This review aims to provide a broad overview of the clinical features of this disease as well as the current treatment strategies being employed in the management of this condition.

Vitamin D therapy in individuals with prehypertension or hypertension: the DAYLIGHT trial.

BACKGROUND: A large body of epidemiological and experimental evidence suggests that vitamin D deficiency may promote hypertension. This raises the possibility that vitamin D supplementation could be a simple intervention to reduce blood pressure, but data from prospective, randomized trials are limited. METHODS AND RESULTS: A double-blind, randomized, controlled trial was conducted at 4 sites in the United States. We enrolled 534 individuals 18 to 50 years of age with low vitamin D status (25-hydroxyvitamin D levels ≤25 ng/mL) and systolic blood pressure of 120 to 159 mm Hg. Participants were randomized to high-dose (4000 IU/d) versus low-dose (400 IU/d) oral vitamin D3 for 6 months. The primary end point was change in mean 24-hour systolic blood pressure. Secondary end points included change in ambulatory diastolic blood pressure and clinic systolic and diastolic blood pressures. The median age was 38 years, and 62% of participants were men. Forty-six percent of participants were white, and 48% were black. The median 25-hydroxyvitamin D level at baseline was 15.3 ng/mL. Four-hundred fifty-five participants (85%) had at least 1 follow-up blood pressure measurement; 383 participants (72%) completed the full 6-month study. At the end of the study, there was no significant difference in the primary end point (change in mean 24-hour systolic blood pressure, -0.8 versus -1.6 mm Hg in the high-dose and low-dose arms; P=0.71) or in any of the secondary end points. Furthermore, there was no evidence of association between change in 25-hydroxyvitamin D and change in 24-hour systolic blood pressure at 6 months (Spearman correlation coefficient, -0.05, P=0.34). Results were consistent across prespecified subgroups. CONCLUSIONS: Vitamin D supplementation did not reduce blood pressure in individuals with prehypertension or stage I hypertension and vitamin D deficiency. Our findings suggest that the association between vitamin D status and elevated blood pressure noted in observational studies is not causal. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01240512.

Inter-electrode tissue resistance is not affected by tissue oedema when electrically stimulating the lower limb of sepsis patients.

ICU patients typically are given large amounts of fluid and often develop oedema. The purpose of this study was to evaluate whether the oedema would change inter-electrode resistance and, thus, require a different approach to using non-invasive electrical stimulation of nerves to assess muscle force. Inter-electrode tissue resistance in the lower leg was measured by applying a 300 µs constant current pulse and measuring the current through and voltage across the stimulating electrodes. The protocol was administered to nine ICU patients with oedema, eight surgical patients without oedema and eight healthy controls. No significant difference in inter-electrode resistance was found between the three groups. For all groups, resistance decreased as stimulation current increased. In conclusion, inter-electrode resistance in ICU patients with severe oedema is the same as the resistance in regular surgical patients and healthy controls. This means that non-invasive nerve stimulation devices do not need to be designed to accommodate different resistances when used with oedema patients; however, surface stimulation does require higher current levels with oedema patients because of the increased distance between the skin surface and the targeted nerve or muscle.

Two Mutations in ß-Tubulin 2 Gene Associated with Thiophanate-Methyl Resistance in Colletotrichum cereale Isolates from Creeping Bentgrass in Mississippi and Alabama.

Turfgrass anthracnose, caused by Colletotrichum cereale (≡C. graminicola), has become a common disease of creeping bentgrass putting greens during the summer in Mississippi and Alabama over the last 15 years. Thiophanate-methyl is a single-site mode-of-action fungicide applied to control C. cereale. In vitro bioassays were performed to evaluate the sensitivity of 103 isolates to thiophanate-methyl concentrations ranging from 0.039 to 10 µg/ml. Eighty-three isolates were collected from creeping bentgrass in Mississippi and Alabama that had been exposed to thiophanate-methyl. An additional 20 isolates were included from nonexposed turfgrasses. Radial colony growth in amended media was relative to nonamended media for all in vitro bioassays. With thiophanate-methyl at 10 µg/ml, relative growth of exposed isolates ranged from 77.5 to 130.7% with a mean of 99.3% compared with nonexposed, baseline isolates that ranged from 0.0 to 48.7% with a mean of 20.4%. A representative sample of thiophanate-methyl-exposed and nonexposed isolates was used to determine the mechanism of resistance by comparing amino acid sequences of the ß-tubulin 2 protein. All of the thiophanate-methyl-exposed isolates that were sequenced had a point mutation resulting in substitutions from glutamic acid to alanine at position 198 or from phenylalanine to tyrosine at position 200 of the ß-tubulin 2 protein. These amino acid substitutions in C. cereale isolates from Mississippi and Alabama appear to confer resistance to thiophanate-methyl and differ from those reported previously for this pathogen.

Occurrence and Molecular Identification of Azoxystrobin-Resistant Colletotrichum cereale Isolates from Golf Course Putting Greens in the Southern United States.

Turfgrass anthracnose, caused by Colletotrichum cereale (≡C. graminicola), has become a common disease of creeping bentgrass and annual bluegrass putting greens throughout the southern United States. Strobilurin (QoI) fungicides such as azoxystrobin are single-site mode-of-action fungicides applied to control C. cereale. In vitro bioassays with azoxystrobin at 0.031 and 8 µg/ml incorporated into agar were performed to evaluate the sensitivity of 175 isolates collected from symptomatic turfgrasses in Alabama, Mississippi, North Carolina, Tennessee, and Virginia. Three sensitivity levels were identified among C. cereale isolates. Resistant, intermediately resistant, and sensitive isolates were characterized by percent relative growth based on the controls with means of 81, 23, and 4%, respectively, on media containing azoxystrobin at 8 µg/ml. The molecular mechanism of resistance was determined by comparing amino acid sequences of the cytochrome b protein. Compared with sensitive isolates, C. cereale isolates exhibiting QoI resistance had a G143A substitution, whereas isolates expressing intermediate resistance had a F129L substitution. C. cereale isolates displaying azoxystrobin resistance in vitro were not controlled by QoI fungicides in a field evaluation. The dominance of QoI-resistant C. cereale isolates identified in this study indicates a shift to resistant populations on highly managed golf course putting greens.