Intraoperative Proximal Tibia Periprosthetic Fractures in Primary Total Knee Arthroplasty.

Intraoperative fracture of the proximal tibia is a rare complication of total knee arthroplasty (TKA) with few studies available reporting risk factors or prognosis. A review of our prospective joint registry was performed to determine the incidence and associated risk factors of intraoperative tibia fractures during primary TKA; 14,966 TKAs of all manufacturers were performed with 9 intraoperative tibia fractures. All fractures occurred in a single TKA design. There were 8,155 TKAs of this design performed with a fracture incidence of 0.110%. All but one fracture occurred on the medial tibial plateau, and all but one occurred during preparation of the tibia with keel punching. A control group of 75 patients (80 knees) with the same TKA design were randomly selected. Baseplates size 3 or smaller were less likely to experience an intraoperative fracture (odds ratio [OR]: 0.864, 95% confidence interval [CI]: 0.785-0.951), as were knees with a polyethylene insert thickness of 13 mm or larger (OR: 0.882, 95% CI: 0.812-0.957). Fractures were treated with a variety of different methods, but every patient had at least one screw placed and most (67%) had postoperative weight-bearing restrictions. At final follow-up, there were no cases of nonunion, component subsidence, or need for reoperation. Intraoperative tibia fractures are a rare complication of this TKA design at 0.11%. Knees with baseplates of size ≤3 and polyethylene thickness ≥13 mm were less likely to experience intraoperative fracture. These findings may be related to the depth of tibial resection, requiring the use of a thicker polyethylene insert, and a change in the keel width in implants size 4 or larger. No fracture patients required reoperation.

Management and Prevention of Intraoperative Acetabular Fracture in Primary Total Hip Arthroplasty.

Intraoperative acetabular fracture (IAF) is a rare complication of primary total hip arthroplasty (THA). Known risk factors include poor bone stock, underreaming of the acetabular bed, and use of elliptic components. There is a paucity of literature on risk factors, treatment strategies, and outcomes of this potentially devastating complication. We studied the incidence of IAF in primary THA at our high-volume institution. We reviewed 21,519 primary THA cases and identified 16 patients (16 hips) with IAFs. Mean follow-up was 4 years (range, 0-10 years). Implant data were recorded, and acetabular components were identified as elliptic modular or hemispheric modular. The institution's IAF rate was 0.0007%. All IAFs were associated with uncemented acetabular components. Sixty-nine percent of the fractures were not appreciated during surgery. All posterior column fractures required operative intervention in the immediate or early (<3 months) postoperative period. Compared with anterior column fractures, posterior column fractures were associated with acetabular component instability and need for additional surgery. In this article, we also present strategies for managing and preventing IAF in primary THA. This rare fracture requires prompt recognition and often necessitates aggressive management. More study is needed to determine how to better manage IAFs.

Femoral Component Revision of Total Hip Arthroplasty.

Modern primary total hip arthroplasty (THA) is among the most successful operations in medicine. It has been a consistently effective treatment for end-stage osteoarthritis of the hip. With the increasing number of primary THA procedures being performed and the decreasing age of patients undergoing the procedure, there is an inevitable associated increase in revision burden for arthroplasty surgeons. Revision THA is most often indicated for instability, aseptic loosening, osteolysis, infection, periprosthetic fracture, component malposition, and catastrophic implant failure. Understanding the etiology of THA failure is essential for guiding clinical decision making. Femoral component revision presents a complex challenge to the arthroplasty surgeon because of modern implant design as well as bone loss in the proximal femur. Thorough patient evaluation, defect classification, and well-executed surgical reconstruction based on comprehensive preoperative planning may determine the postoperative results. Knowledge of various reconstructive options and the indications for each is necessary to achieve a successful outcome. This article highlights the most common indications for revision after THA and offers recommendations for how to approach revision of the femoral component. Specifically, the authors review preoperative assessment, common classification systems for femoral deficiency, techniques for component extraction, and modalities of femoral component fixation. [Orthopedics. 2016; 39(6):e1129-e1139.].

Antipyretic treatment of noninfectious fever in children with severe traumatic brain injury.

OBJECTIVE: The purpose of this study was to describe the treatment of noninfectious fever in children with severe traumatic brain injury (TBI). MATERIALS AND METHODS: We conducted a retrospective study to compare type of and response to antipyretic treatment strategies in children less than or equal to 17 years and Glasgow Coma Scale (GCS) score less than 9. RESULTS: The average admission GCS score was 4. Forty children (35 boys, 5 girls), age 7.8 +/- 5.2 years, had noninfectious fever. Seventy percent (28 of 40) received acetaminophen only, and 30% (12 of 40) received acetaminophen plus either ibuprofen or physical cooling. Time to next febrile episode was longer in patients receiving combination therapy than those receiving monotherapy (p = 0.03). Fever refractory to treatment dose or strategy occurred in more than 40% of the patients. CONCLUSIONS: Early combination antipyretic therapy may be needed to effectively maintain normothermia in children with severe TBI.