Randomized Controlled Trial of Irrigation-Coupled Bipolar Electrocautery Versus Tourniquet in Total Knee Arthroplasty.

Background: Recovery from total knee arthroplasty remains arduous for some patients, prompting interest in perioperative management. While tourniquet use is not associated with longer-term outcomes, its effect on quadriceps strength in the immediate postoperative window is unknown. Methods: A single-center, double-blind, randomized controlled trial of 66 patients undergoing primary total knee arthroplasty from 2019 to 2022 was performed to compare the use of an irrigation-coupled bipolar device (ICBD) and no tourniquet (ICBD group, N = 34) to tourniquet use with no ICBD (tourniquet group, N = 32). Groups were similar with respect to age, sex, and obesity. The primary outcome was quadriceps strength at 2 weeks, measured using a handheld dynamometer and standardized to the contralateral side. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement was measured with the difference from baseline serving as a secondary outcome. Comparisons were performed using the Student's t-test. Results: Only 28 patients, 14 in each group, had primary outcome data. At 2-weeks, quadriceps strength was higher in the ICBD group compared to the tourniquet group (83% vs 70%), though not statistically significant (P = .16). There was no difference between the ICBD and tourniquet groups in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement changed at 2-weeks (13 vs 10, P = .37) or 6-weeks (16 vs 17, P = .76). Conclusions: Tourniquet use was associated with a small but not statistically significant difference in quadriceps strength at 2 weeks that may justify further study given the loss of power here. There can be limitations to conducting randomized controlled trials that are important for early-career investigators to consider and that were magnified due to COVID-related restrictions in the present study, which we discuss. Level of Evidence: Level II.

Two-Year Outcomes of Novel Dual-Mobility Implant in Primary Total Hip Arthroplasty.

Introduction: Dual-mobility (DM) implants for total hip arthroplasty (THA) have gained popularity due to their potential to reduce hip instability and dislocation events that may lead to revision surgery. These implants consist of a femoral head articulated within a polyethylene liner, which articulates within an outer acetabular shell, creating a dual-bearing surface. Our study aimed to report our observations on the survivorship of a novel DM implant for primary total hip arthroplasty at two years. Methods: We conducted a retrospective, multicenter study to assess the clinical outcomes of patients undergoing a THA with a novel DM implant (OR3O acetabular system™, Smith & Nephew, Inc., Memphis, TN) from January 2020 to September 2021. Patient demographics, surgical information, and survivorship data were collected from medical records for patients with a minimum of two years of follow-up. Primary outcomes included overall implant survivorship at two years as well as aseptic survivorship, revision rates of the DM acetabular shell, and average time to revision. Patient-reported outcomes were collected in the form of HOOS JR. Results: A total of 250 hips in 245 patients had a minimum two-year follow-up. Primary osteoarthritis (80%) was the most common indication for index THA. The average aseptic survivorship of the DM acetabular components at two years for the cohort was 98.4% and survivorship of the acetabular implants overall was 97.6%. There were a total of four (1.6%) aseptic revisions of the DM acetabular component. Reasons for aseptic acetabular revision included one case of instability, one intraprosthetic dislocation, one periprosthetic acetabular fracture, and one malpositioned acetabular cup resulting in impingement. The mean time of follow-up was 893.9 days. Eighty-seven patients had preoperative and two-year HOOS JR available. HOOS JR improved by an average of 38.5 points. Conclusion: This novel DM acetabular implant demonstrates excellent survivorship at two years follow-up with low rates of instability and intraprosthetic dislocation and no episodes of metal-on-metal corrosion. Use of the DM implant demonstrated clinically relevant improvements in patient-reported outcomes at two years.

Practice Changes Induced by a Traveling Fellowship.

The John N. Insall Knee Society Traveling Fellowship selects four international arthroplasty or sports fellowship-trained orthopaedic surgeons to spend 1 month traveling to various Knee Society members' joint replacement and knee surgery centers in North America. The fellowship aims to foster research and education and shares ideas among fellows and Knee Society members. The role of such traveling fellowships on surgeon preferences has yet to be investigated. A 59-question survey encompassing patient selection, preoperative planning, intraoperative techniques, and postoperative protocols was completed by the four 2018 Insall Traveling Fellows before and immediately after the completion of traveling fellowship to assess anticipated practice changes (e.g., initial excitement) related to their participation in a traveling fellowship. The same survey was completed 4 years after the completion of the traveling fellowship to assess the implementation of the anticipated practice changes. Survey questions were divided into two groups based on levels of evidence in the literature. Immediately after fellowship, there was a median of 6.5 (range: 3-12) anticipated changes in consensus topics and a median of 14.5 (range: 5-17) anticipated changes in controversial topics. There was no statistical difference in the excitement to change consensus or controversial topics (p = 0.921). Four years after completing a traveling fellowship, a median of 2.5 (range: 0-3) consensus topics and 4 (range: 2-6) controversial topics were implemented. There was no statistical difference in the implementation of consensus or controversial topics (p = 0.709). There was a statistically significant decline in the implementation of changes in consensus and controversial preferences compared with the initial level of excitement (p = 0.038 and 0.031, respectively). After the John N. Insall Knee Society Traveling Fellowship, there is excitement for practice change in consensus and controversial topics related to total knee arthroplasty. However, few practice changes that had initial excitement were implemented after 4-year follow-up. Ultimately, the effects of time, practice inertia, and institutional friction overcome most of the anticipated changes induced by a traveling fellowship.

Incidence of Rapidly Progressive Osteoarthritis Following Intra-articular Hip Corticosteroid Injection: A Systematic Review and Meta-Analysis.

Background: The American Academy of Orthopedic Surgery recommends intra-articular corticosteroid injections (CSIs) for managing hip osteoarthritis (OA) based on short-term, prospective studies. Recent retrospective studies have raised concerns that CSIs may lead to rapidly progressive OA (RPOA). We sought to systematically review the literature of CSIs for hip OA to estimate the incidence of RPOA. Methods: MEDLINE, Embase, and Cochrane Library were searched to identify original research of hip OA patients receiving CSIs. Overall, 27 articles involving 5831 patients published from 1988 to 2022 were included. Study design, patient characteristics, CSI details, follow-up, and cases of RPOA were recorded. Studies were classified by their ability to detect RPOA based on follow-up. Random effects meta-analysis was used to calculate the incidence of RPOA for studies able to detect RPOA. Results: The meta-analytic estimate of RPOA incidence was 6% (95% confidence interval, 3%-9%) based on 10 articles classified as able to detect RPOA. RPOA definitions varied from progression of OA within 6 months to the presence of destructive changes. These studies were subject to bias from excluding patients with missing post-CSI radiographs. The remaining 17 articles were classified as unable to detect RPOA, including all of the studies cited in the American Academy of Orthopedic Surgery recommendation. Conclusions: The incidence of RPOA after CSIs remains unknown due to variation in definitions and follow-up. While RPOA following CSIs may be 6%, many cases are not severe, and this may reflect selection bias. Further research is needed to understand whether clinically significant RPOA is incident enough to limit CSI use.

The Use of Calcium Sulfate/Hydroxyapatite Bone Graft Substitute to Restore Acetabular Bone Loss in Revision Total Hip Arthroplasty.

Acetabular bone loss is not uncommon when performing revision total hip arthroplasty. This can create a challenge, especially on the acetabular side. In the present report, our patient presented with aseptic loosening of the acetabular component. The patient had a Paprosky IIIA acetabular defect that was reconstructed with stacked acetabular augments in addition to a highly porous acetabular cup. The remaining bone defects were addressed through the use of a calcium sulfate/hydroxyapatite bone graft substitute. We set out to describe how to reconstruct severe acetabular bone loss with a combination of acetabular augments in addition to an injectable bone graft substitute as a novel method to address a complex clinical scenario.

Nutritional Laboratory Studies Prior to Total Knee Arthroplasty: Practice Versus Publication.

BACKGROUND: Recent emphasis has been placed on nutritional status assessment prior to total knee arthroplasty (TKA), including multiple American Academy of Orthopaedic Surgeons publications recommending specific laboratory studies; however, the frequency with which surgeons obtain these laboratory studies remains unclear. We sought to assess the incidence of ordering nutritional laboratory studies in the 90 days prior to TKA, utilizing data from a large administrative claims database. METHODS: With use of the PearlDiver database, we identified 557,670 patients undergoing primary TKA from 2011 to 2020 with a metabolic panel or blood cell count claim within 90 days prior to TKA. We then determined the incidence of prealbumin, transferrin, vitamin D, and zinc laboratory tests claimed 90 days prior to TKA. Associations between claims and the year of surgery, patient demographics, and clinical characteristics were assessed by comparing proportions and chi-square testing. RESULTS: Nutritional laboratory studies were infrequently claimed within 90 days prior to TKA, with studies for prealbumin being performed in 2.2% of patients; transferrin, 1.9%; vitamin D, 10.2%; and zinc, 0.2%. From 2011 to 2020, there was a moderate but steady increase in the proportion of patients with claims for prealbumin (change from 0.8% in 2011 to 3.4% in 2020; p < 0.001), transferrin (0.8% to 2.7%; p < 0.001), and vitamin D (7.6% to 9.4%; p < 0.001) laboratory tests but there was less of a change for zinc (0.1% to 0.2%; p < 0.001). There were weak-to-absent associations of age, gender, obesity, diabetes, and anemia with laboratory claims. CONCLUSIONS: Despite multiple publications and recommendations, nutritional laboratory studies are infrequently ordered prior to TKA. Although there has been a slight increase in the use of nutritional laboratory studies over the past decade, patient factors such as gender and obesity were not associated with this increase. Understanding current practice patterns may help target future areas for improvement. LEVEL OF EVIDENCE: Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

The Practice Patterns of American Association of Hip and Knee Surgeons for the Management of Chronic Periprosthetic Joint Infection After Total Knee Arthroplasty.

BACKGROUND: The management of periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) has considerable variation. In order to better capture current preferences for the management of PJI, this study sought to poll the current members of American Association of Hip and Knee Surgeons (AAHKS) first to characterize the distribution of practice patterns. METHODS: There were 32 questions in an online survey distributed to members of AAHKS. The questions were multiple choice regarding the management of PJI for TKA. There were 844 out of 2,752 members who completed the survey (response rate of 31%). RESULTS: Most of the members were in private practice (50%) compared to 28% being in an academic setting. On average, members were performing between 6 to 20 PJI cases per year. Two-stage exchange arthroplasty was performed in over 75% of the cases with either a cruciate retaining (CR) or posterior stabilized (PS) primary femoral component used in over 50% of the cases and 62% using an all-polyethylene tibial implant. Most of the members were using vancomycin and tobramycin. Typically, 2 to 3 grams of antibiotics were added per bag of cement regardless of the cement type. When indicated, amphotericin was the most often-used antifungal. Post-operative management had major variability with range of motion, brace use, and weight-bearing restrictions. CONCLUSION: There was variability in the responses from the members of AAHKS, but there was a preference toward performing a two-stage exchange arthroplasty with an articulating spacer using a metal femoral component and an all-polyethylene liner.

Penalty for Switching Implants? Assessing the Learning Curve With a Collarless, Tapered Wedge Cementless Femoral Component.

Background: Surgeon learning curve associated with a tapered wedge femoral implant as measured by early femoral component subsidence and 90-day risk of reoperation was evaluated. Methods: The first 451 patients undergoing primary, cementless total hip arthroplasty by a single, fellowship-trained arthroplasty surgeon with a tapered wedge stem design were retrospectively reviewed. Early radiographic femoral component subsidence during the first 6 weeks postoperatively and 90-day reoperations was recorded. Results: When stratified by approach, there was no association between date of surgery and femoral component subsidence in the posterior approach (P-value for linear trend over time = 0.44). In the direct anterior approach, there was a significant association between date of surgery and early femoral component subsidence (P-value for linear trend over time = 0.01). For both approaches, there was an increase in implanted stem size relative to templated stem size over time (P < .01 and P = .03, respectively). There was no association between the date of surgery and risk of 90-day reoperation (P = .45). Conclusions: In a single surgeon's initial use of a tapered cementless wedge stem, early femoral component subsidence was not impacted by the surgeon's learning curve when the posterior approach was utilized. Although subsidence was associated with date of surgery in the direct anterior cohort, this was not associated with increased risk of 90-day reoperation. Should a surgeon adopt a new tapered-wedge stem, these findings suggest that the stem is forgiving both in relation to subsidence and 90-day reoperation risk when appropriate surgical technique is utilized.

Additional Distal Femoral Resection Minimally Improves Terminal Knee Extension: A Systematic Review and Meta-Regression Challenging the Dogma.

Background: Additional distal femoral resection is a common technique to address a flexion contracture during primary total knee arthroplasty (TKA) but can lead to midflexion instability and patella baja. Prior reports regarding the magnitude of knee extension obtained with additional femoral resection have varied. This study sought to systematically review research describing the effect of femoral resection on knee extension and to perform meta-regression to estimate this relationship. Methods: A systematic review was conducted using MEDLINE, PubMed, and Cochrane databases by combining the terms ("flexion contracture" OR "flexion deformity") AND ("knee arthroplasty" OR "knee replacement") to identify 481 abstracts. In total, 7 articles reporting change in knee extension after additional femoral resection or augmentation across 184 knees were included. The mean value for knee extension, its standard deviation, and the number of knees tested were recorded for each level. Meta-regression was performed using weighted mixed-effects linear regression. Results: Meta-regression estimated that each 1mm resected from the joint line produced a 2.5° gain of extension (95% confidence interval, 1.7 to 3.2). Sensitivity analyses excluding outlying observations estimated each 1mm resected from the joint line produced a 2.0° gain of extension (95% confidence interval, 1.9 to 2.2). Conclusions: Each millimeter of additional femoral resection is likely to produce only a 2° improvement in knee extension. Thus, an additional resection of 2 mm is likely to improve knee extension by less than 5°. Alternative techniques, including posterior capsular release and posterior osteophyte resection, should be considered in correcting a flexion contracture during TKA.

Hemoglobinopathy is Associated With Total Hip Arthroplasty Indication Even Beyond Sickle Cell Anemia.

Background: The extent to which hemoglobinopathies other than sickle anemia (HbSS) are associated with hip osteonecrosis is unknown. Sickle cell trait (HbS), hemoglobin SC (HbSC), and sickle/ß-thalassemia (HbSßTh) may also predispose to osteonecrosis of the femoral head (ONFH). We sought to compare the distributions of indications for a total hip arthroplasty (THA) in patients with and without specific hemoglobinopathies. Methods: PearlDiver, an administrative claims database, was used to identify 384,401 patients aged 18 years or older undergoing a THA not for fracture from 2010 to 2020, with patients grouped by diagnosis code (HbSS N = 210, HbSC N = 196, HbSßTh N = 129, HbS N = 356). ß-Thalassemia minor (N = 142) acted as a negative control, and patients without hemoglobinopathy as a comparison group (N = 383,368). The proportion of patients with ONFH was compared to patients without it by hemoglobinopathy groups using chi-squared tests before and after matching on age, sex, Elixhauser Comorbidity Index, and tobacco use. Results: The proportion of patients with ONFH as the indication for THA was higher among those with HbSS (59%, P < .001), HbSC (80%, P < .001), HbSßTh (77%, P < .001), and HbS (19%, P < .001) but not with ß-thalassemia minor (9%, P = .6) than the proportion of patients without hemoglobinopathy (8%). After matching, the proportion of patients with ONFH remained higher among those with HbSS (59% vs 21%, P < .001), HbSC (80% vs 34%, P < .001), HbSßTh (77% vs 26%, P < .001), and HbS (19% vs 12%, P < .001). Conclusions: Hemoglobinopathies beyond sickle cell anemia were strongly associated with having osteonecrosis as the indication for THA. Further research is needed to confirm whether this modifies THA outcomes.

Association of Osteoarthritis and Functional Limitations With Cognitive Impairment Among Older Adults in the United States.

Objective: Given overlapping pathophysiology, this study sought to assess the association between osteoarthritis (OA), functional impairment, and cognitive impairment in the aging population. Methods: The National Health and Nutrition Examination Survey was used to identify participants >60 years of age. We analyzed multivariable associations of grouped participants that underwent cognitive function testing using linear and logistic regression, adjusting for sex, age, race, and ethnicity. Results: Of 2776 identified participants representing a population of 50,242,917, 40% did not report OA or functional limitations; 21% had OA but not functional limitations; 15% did not have OA but had functional limitations; 17% had OA and related functional limitations; and 7% had OA and non-arthritic functional limitations. OA was not independently associated with cognitive impairment. Contrarily, functional limitations were associated with cognitive impairment regardless of OA diagnosis. Discussion: Cognitive impairment is not associated with OA, but rather functional limitations, potentially guiding future intervention.

Self-Reported Health of Severely Obese US Adults With Osteoarthritis.

BACKGROUND: Severe obesity is associated with complications following arthroplasty, leading surgeons to increasingly counsel patients regarding weight loss. For patients seeking arthroplasty, learning that severe obesity may be a relative contraindication to surgery can create a challenging clinical interaction. We sought to describe the self-reported health of United States (US) adults who had severe obesity and osteoarthritis (OA) to better understand patient perspectives. METHODS: The National Health and Nutrition Examination Survey, a nationally representative sample of the US population, was used to identify adult participants who had a body mass index (BMI) over 35 and an OA diagnosis. In total, 889 participants representing a US population of 9,604,722 were included. Self-reported health was dichotomized as poor to fair versus good to excellent. Analyses were weighted to produce national estimates. Associations between obesity severity and patient characteristics with self-reported health were assessed. RESULTS: Of US adults with a BMI over 35 and OA diagnosis, 64% rated their health as good or better. For adults who had a BMI over 45, 55% still reported their health as good or better. The strongest predictors of self-reported health were measures of physical functioning. Only 37% of participants who had much difficulty walking a quarter mile rated their health as good or better compared to 86% without difficulty (P < .001). CONCLUSION: Approximately two-thirds of patients who have severe obesity and OA do not perceive their health as compromised and consider decreased physical function as the primary driver of decreased health. This suggests that counseling about the association between obesity and overall health may improve shared decision making and that patient satisfaction metrics may be difficult to interpret in these clinical situations.

Clinical Outcomes Following Distal Femur Replacement for Periprosthetic Distal Femur Fractures: A Systematic Review and Meta-Analysis.

BACKGROUND: Management of periprosthetic distal femur fractures (PDFFs) is often complicated by poor bone quality and limited bone stock making fixation attempts challenging and prone to failure. Distal femoral replacement (DFR) is being used to treat such injuries although outcome data are mostly from small case series. We sought to systematically review the literature on DFR for PDFF to summarize their outcomes. METHODS: PubMed, MEDLINE (EBSCO), and Cochrane Central Database were searched to identify reports of PDFFs treated with DFR. Articles reporting on 5 or more knees were systematically reviewed for clinical function, complications, and mortality. Random effects meta-analysis was used to create summary estimates and publication bias also assessed. RESULTS: Of 287 identified and screened articles, 15 were included, 14 retrospective, reporting on 352 knees. Following DFR, 87% (95% confidence interval [CI] 71-95) of patients were able to ambulate. The mean postoperative Knee Society Score was 80 (95% CI 77-84). The risk of periprosthetic joint infection was 4.3% (95% CI 2.2-8.2). One-year postoperative mortality rate was 10% (95% CI 6-18). There was some evidence of publication bias with a trend toward smaller studies reporting lower infection risk and mortality. CONCLUSION: DFR for PDFFs is associated with high functional outcomes and a relatively modest risk of infection. The periprosthetic joint infection and 1-year mortality rates reported here should be considered lower bounds estimates due to publication bias and loss to follow-up. Further investigation of long-term outcomes following DFR for PDFFs is warranted though short-term functional outcomes are promising.

Preoperative Psychosocial Factors and Short-term Pain and Functional Recovery After Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

CONTEXT: Low mental health scores, depression, and anxiety are associated with worse pain and functional outcomes after hip arthroscopy for patients with femoroacetabular impingement syndrome (FAIS). Preoperative screening of psychosocial factors such as self-efficacy, kinesiophobia, and pain catastrophizing may further aid in identifying patients at risk for poorer outcomes. OBJECTIVE: To compare preoperative function and psychosocial factors between patients with and those without elevated postoperative pain 3 months after hip arthroscopy for FAIS. DESIGN: Prospective cohort study. SETTING: University health center. PATIENTS OR OTHER PARTICIPANTS: Fifty-one individuals with FAIS (41 women, 10 men; age = 37.6 ± 12.3 years, body mass index = 27.1 ± 4.1 kg/m2). MAIN OUTCOME MEASURE(S): Preoperatively, participants completed the Pain Self-Efficacy Questionnaire (PSEQ), Tampa Scale for Kinesiophobia (TSK), Pain Catastrophizing Scale (PCS), 12-Item International Hip Outcome Tool (iHOT-12), and a 10-point visual analog scale (VAS) for hip pain at rest and during activity. Three months postoperatively, they completed the PSEQ, TSK, PCS, iHOT-12, and VAS. Preoperative scores were compared between those with (VAS ≥ 3) and those without (VAS < 3) elevated postoperative pain using Mann-Whitney U tests, and odds ratios were calculated to determine the odds of having elevated postoperative pain and lower postoperative function. RESULTS: Participants with elevated postoperative pain at rest and during activity had worse preoperative psychosocial health (P ≤ .04). Those with elevated postoperative pain at rest had worse preoperative function (P < .001). The odds of having elevated postoperative pain at rest were 45 times and 4.5 times higher for those with low self-efficacy and high pain catastrophizing, respectively (P values ≤ .03). The odds of having elevated postoperative pain during activity were 7.1, 6.2, and 3.5 times higher for those with low self-efficacy, high kinesiophobia, and high pain catastrophizing, respectively (P values ≤ .04). The odds of having lower postoperative iHOT-12 scores were 7.5 and 14.0 times higher for those with high kinesiophobia and pain catastrophizing, respectively (P values ≤ .03). CONCLUSIONS: Poor preoperative psychosocial health increased the odds of elevated pain and worse function 3 months after hip arthroscopy for FAIS. This is a first step in identifying the psychosocial factors that may contribute to poorer long-term hip arthroscopy outcomes.

Psychological Healthcare Burden Lessens After Hip Arthroscopy for Those With Comorbid Depression or Anxiety.

PURPOSE: In this study, we investigated whether patients undergoing arthroscopic treatment of femoral acetabular impingement syndrome (FAIS) seek health care for treatment of comorbid depression and anxiety in the year following hip arthroscopy. METHODS: Using the Truven Health Marketscan database, FAIS patients who underwent hip arthroscopy between January 2009 and December 2016 were identified. Claims related to depression or anxiety filed during the year before surgery were required for inclusion. Using claims for pharmaceutical and psychological therapy treatments for mental health disorders, four groups of patients were analyzed on the basis of preoperative anxiety/depression treatment: medication only, therapy only, medication + therapy, and no treatment. Number of opioid pain prescriptions within 180 days prior to surgery and >90 days after hip arthroscopy were also compared. RESULTS: Depression and anxiety claims were identified in 5,208/14,830 (35.1%) patients. Preoperative treatment for depression and anxiety included medication only (n = 648, 12.4%), therapy only (n = 899, 17.3%), medication + therapy (n = 252, 4.8%), and no treatment (n = 3,409, 65.5%). Of the 900 patients who filled an anxiety/depression-related prescription prior to surgery, 422 (46.9%) patients did not fill a similar prescription in the postoperative year. Of the 1,151 patients receiving anxiety/depression-related therapy prior to surgery, 549 (47.7%) did not receive therapy in the postoperative year. Preoperative opioid prescriptions were filled for 393 patients (60.6%) in medication-only group, 275 (30.6%) in therapy-only group, 156 (61.9%) in medication + therapy group, and 1,059 (31.1%) in the group receiving no treatment. Opioid prescriptions >90 days postoperatively were filled for 330 (50.9%), 225 (25.0%), 120 (47.6%), and 861 (25.3%) patients, respectively. CONCLUSION: Hip arthroscopy for FAIS is associated with a decreased postoperative use of health care resources for the treatment of depression and anxiety. Clinicians should also be aware of the potential interplay between preoperative psychotropic medication use and prolonged opioid use when counseling patients. LEVEL OF EVIDENCE: IV, therapeutic case series.

Novel Cemented Technique for Trochanteric Fixation and Reconstruction of the Abductor Mechanism in Proximal and Total Femoral Arthroplasty: An Observational Study.

BACKGROUND: Little evidence exists regarding the clinical outcomes of cemented trochanteric fixation for abductor mechanism reconstruction in proximal or total femoral replacements. Clinical outcomes were assessed for a novel cemented technique for trochanteric fixation in femoral megaprostheses. METHODS: A descriptive series of 13 patients who underwent proximal or total femoral arthroplasty from 2016 to 2019 were reviewed. Radiographic trochanteric displacement >1 cm defined construct failure. A Kaplan-Meier survival analysis was performed to determine survival rates for these cemented constructs. Demographic information was obtained to better characterize the patient population in whom this technique was used. RESULTS: Eleven patients were included (age = 63.6 years; 45.4% females; body mass index = 31.7). Mean time to final radiographic follow-up was 73.8 weeks. Three of 11 (27.2%) patients had construct failure. Overall, survival at 1 year was 81.8%. At 2 years, survival of cemented constructs was 65.5%. More construct failures occurred in patients who sustained a postoperative dislocation than in those who did not (P = .05). CONCLUSIONS: This novel cemented trochanteric fixation technique for reconstruction of the abductor mechanism in femoral megaprostheses had 81.8% survival at 1 year postoperatively. While longitudinal comparative studies with larger samples are needed, the cemented technique may provide a viable alternative to traditional cementless methods of trochanteric fixation. Increased construct failure rates after postoperative dislocation highlight the importance of robust abductor reconstruction in these implants.

Age at the Time of Surgery Is Not Predictive of Early Patient-Reported Outcomes After Periacetabular Osteotomy.

BACKGROUND: The clinical success of periacetabular osteotomy (PAO) for the treatment of symptomatic acetabular dysplasia is well-documented. Conflicting evidence exists regarding the correlation of age with clinical outcomes. Hip disability and Osteoarthritis Outcome Score - global (HOOSglobal) is a recently validated patient-reported outcome measure following PAO. The purpose of this study is to asses HOOSglobal and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores at early follow-up based on age at the time of PAO. METHODS: A prospective multicenter cohort of 391 patients undergoing PAO with minimum 2-year follow-up (average 4.71 years) were identified. Patients were categorized into 4 age groups: <20 years (N = 131), 20-29 (N = 102), 30-39 (N = 65), and ≥40 (N = 34). A 4 × 2 repeated measures analysis of variance (Age Group × Time) was used to compare preoperative and postoperative HOOSglobal and WOMAC scores between age groups. A multiple linear regression was used to identify predictors of postoperative HOOSglobal scores. RESULTS: HOOSglobal and WOMAC scores increased across all age groups; however, a statistically greater increase in preoperative to postoperative HOOSglobal and WOMAC scores was found in those ≥40 years compared to those <20 (P< .002), 20-29 (P = .01), and 30-39 years (P = .02). Higher preoperative HOOSglobal scores were predictive of greater postoperative HOOSglobal scores (P < .001) but age (P = .65), gender (P = .80), body mass index (P = .50), and Tönnis Classification (P = .07) were not independent predictors of 1-year outcomes. CONCLUSION: The absence of differences in early postoperative patient-reported outcomes across multiple age ranges emphasizes that PAO in the setting of symptomatic acetabular dysplasia can be successful regardless of patient age alone. Therefore, age alone might not be an appropriate selection criterion when evaluating surgical candidates for PAO. LEVEL OF EVIDENCE: II.

Making Sense of Hip Preservation Procedural Coding-Getting Paid for Your Work!

Hip preservation and peri-trochanteric procedures are becoming more commonplace for the arthroplasty surgeon. Understanding the reimbursement for these procedures remains a challenge for those looking to expand this portion of their practice. In order to financially maximize the surgeon's efforts, we present recommendations for hip preservation procedural coding.

Is Cooled Radiofrequency Genicular Nerve Block and Ablation a Viable Option for the Treatment of Knee Osteoarthritis?

BACKGROUND: The purpose of this study was to determine demographic and psychosocial factors that influence the effectiveness of cooled radiofrequency genicular nerve ablation (C-RFA) and block in patients with chronic knee pain secondary to osteoarthritis (OA). METHODS: A retrospective review was completed including patients with knee OA who underwent genicular nerve ablation or block or both. Patient information collected included opioid use, psychological comorbidities, smoking history, body mass index, and medical comorbidities. Success was defined using the Osteoarthritis Research Society International criterion of greater than or equal to 50% reported pain relief from the procedure. Patients without a diagnosis of knee OA and patients with ipsilateral total knee arthroplasty were excluded. Patient factors were compared between (1) those that did or did not respond to the initial block and (2) those that did or did not respond to C-RFA. RESULTS: Of the 176 subjects that underwent genicular nerve block, 31.8% failed to respond to the procedure. Subjects that failed the initial block were significantly more likely to have psychological comorbidities, smoking history, and diabetes. Of the subjects that proceeded to genicular nerve ablation, 53.7% reported less than 50% pain relief, and 46.3% reported pain relief greater than or equal to 50% at the first follow-up visit. While the presence of psychological comorbidities, smoking, and diabetes were associated with first-stage block failures, these patient factors were not associated with second-stage ablation failures. CONCLUSIONS: C-RFA may be an effective adjunct therapy as part of a multimodal pain regimen; however, individual patient characteristics must be considered.