Revision Total Knee Arthroplasty for Catastrophic Tibial Post Failure: Rare Complication of Total Knee Replacement.

Tibial post failure is a rare but serious complication of posterior-stabilized total knee arthroplasty that requires revision surgery. Although tibial post fracture has previously been reported, this case involves an implant with a design feature that may predispose patients to the complication. The fracture also occurred later than observed in most other reports. A 72-year-old male who had undergone a posterior stabilized total knee arthroplasty seven years prior presented with knee pain and instability after a fall from standing. Although plain radiographs were not diagnostic, history and physical exam suggested failure of the tibial polyethylene post. This was confirmed during surgery when the fractured component was identified in the suprapatellar pouch. Given absence of malrotation or malalignment of the well-fixed femoral and tibial components, a polyethylene liner exchange was performed. Postoperatively, the patient had complete resolution of pain and instability with 0-120 degrees of stable ROM, which has persisted to latest follow-up at 6 months.

The Effect of Surgical Duration on Complications and Patient Reported Outcomes in Total Hip Replacement as Evaluated Through Multi-Surgeon Pooled FORCE Registry Data from a Tertiary Care Referral Total Joint Center.

BACKGROUND: The relationship between operative times and patient outcomes in total hip arthroplasty (THA) has not been well defined. METHODS: From January 2016 to December 2019, data were prospectively collected for THA patients in the FORCE-TJR registry and hospital EMR of an academic total-joint center. RESULTS: 1,123 patients were included. Operative times ranged from 36 to 366 minutes, with a mean operative time of 111.26+/-31.37 minutes. Unadjusted GLM showed HOOS pain, ADL, and QoL scores differed across operative times, with patients who had operative times between 106 and 120 minutes having significantly lower pain, higher function, and better quality of life at 12 months, especially compared to patients with operative times < 90 minutes. Patients who had operative times between 106 and 120 minutes had significantly better VR-12 PCS and MCS at 12 months. Although statistically significant, differences were small and did not persist after controlling for within-surgeon effects, patient socio-demographics and baseline patient-reported outcomes, suggesting that patient characteristics or within-surgeon effects may play a more significant role in these patient-reported outcomes than operative time. CONCLUSION: This study showed that among THA patients, operative times were significantly associated with patient-reported outcomes at 12 months post-operatively, but is one of many surgeon and patient-related factors with effect on THA outcome.

Improvise, Adapt & Overcome: Successful Surgery-Sparing Prosthetic Hip Infection Antibiotic Suppression During COVID-19 Crisis.

CASE: A 79-year-old active male presented during the first COVID-19 pandemic surgery moratorium with late Staphylococcus lugdunensis periprosthetic total hip arthroplasty infection. Due to the unprecedented circumstances, novel treatment of IV and oral antibiotic suppression was trialed without preceding surgical intervention. At latest follow-up, the patient has two-year revision-free survival with normalization of inflammatory markers and MRI findings, and resolution of clinical symptoms. CONCLUSION: We report a novel surgery-sparing treatment for periprosthetic hip infection. Judicious caution should be used in the application of similar therapies, as host and organism characteristics likely contributed substantially to the success of this case.

Role of corrosion in taper failure and head disassociation in total hip arthroplasty of a single design.

Modular junctions have been associated with corrosion in total hip arthroplasty. In a small number of cases, disassociation of the femoral head from the stem following gross wear of the taper has been reported. The purpose of this study was to investigate the role of corrosion in the development of mechanical changes leading to disassociation. Twenty-one retrieved stems and heads of one design previously reported with head disassociation were identified in an IRB-approved database. Components were scored for corrosion and measured for material loss. Stem alloy hardness was measured. Parametric and non-parametric statistics were performed (α < 0.05). Seven of twenty-one stems demonstrated gross material loss of the stem taper and head disassociation. The maximum linear depth (MLD) of material loss on stem tapers without dissociation and all head bores was 7.63 ± 6.04 and 63.76 ± 60.83 µm, respectively. Hardness of the stem material was statistically distinct, but similar to other stem materials. Results suggest material loss via corrosion at the head bore loosens the taper lock, allowing relative motion leading to abrasive wear of the stem taper. All cases of disassociation occurred at greater than 65 months with a minimum of 50 µm of loss at on the head bore. It may be warranted to survey patients with systems reporting head disassociation; for this system, including recalled heads, risk appears to begin after 6 years in vivo. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2996-3003, 2018.

Minimum Five-Year Outcomes with Porous Tantalum Acetabular Cup and Augment Construct in Complex Revision Total Hip Arthroplasty.

BACKGROUND: The use of a trabecular metal revision shell with metal augmentation to fill segmental or irregular defects during complex revision hip arthroplasty has been shown to provide good short-term results in prior published series. Longer-term results of the several cup-augment constructs used clinically are not known. The objective of this study was to report, with minimum 5-year radiographic and clinical follow-up, the outcome of these various constructs in revision total hip arthroplasty. METHODS: Eighty-four patients (85 hips) underwent revision total hip arthroplasty with use of porous tantalum augments between 2000 and 2007 at a single institution and were retrospectively reviewed. Fifty-seven of the patients (58 hips) had clinical and radiographic follow-up at a minimum of 5 years. At the time of revision, the majority of the hips had acetabular defects classified as Paprosky Type 3A (28 of 58, 48%) or Type 3B (22 of 58, 38%). Eleven (19%) of the hips also had preoperative pelvic discontinuity. All hips were assessed clinically at a minimum of 5 years with use of the Mayo hip score. Postoperative radiographs were reviewed for implant stability, the presence and location of radiolucent lines and healing of the discontinuity if present. RESULTS: In 2 (3%) of the 58 hips, the constructs failed because of aseptic loosening of the acetabular component and re-revision was indicated. Six (10%) of the 58 hips demonstrated a radiolucent line between the trabecular metal shell and bone in DeLee and Charnley zone 3. In 1 hip that underwent re-revision and in 5 of the 6 hips with a zone-3 radiolucency, a pelvic discontinuity was present at the time of the index revision. The mean preoperative Mayo hip score was 35.7, which improved to 61.9 at 3 months and was 61.7 at the minimum 5-year follow-up. CONCLUSIONS: With failure defined as aseptic loosening requiring repeat revision surgery, this cohort demonstrated 97% survivorship and maintained satisfactory hip function at the minimum 5 years after the index revision surgery. Six of the 11 hips with preoperative pelvic discontinuity either failed or developed a radiolucency in zone 3 and are considered at risk for future revision. Pelvic discontinuity should prompt consideration of the addition of adjunctive fixation or the use of alternative techniques. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Modifiable Risk Factors in Total Joint Arthroplasty: A Pilot Study.

UNLABELLED: Strong evidence exists to suggest that morbid obesity, smoking, and poorly controlled diabetes mellitus are associated with poorer outcomes after total joint arthroplasty. To our knowledge, no study has reported the effect of the implementation of a risk reduction strategy. Risk factors, based on published data, were defined as Body Mass Index (BMI)>40, Hemoglobin A1c (HbA1c) >8.0, and use of any tobacco product. A retrospective pilot review was done of a 3-month period using this protocol in the practice of a single fellowship-trained academic arthroplasty surgeon (DRJ). Outcomes were evaluated in the subsequent 3-month period. Overall 19/29 (65.5%) patients identified to be "at risk" and offered support for modification followed up under the care of their index surgeon. 11/19 (57.9%) improved their risk factors and 8/19 (42.1%) ultimately met the specific goals set for surgery with 4 (21%) ultimately undergoing their replacement procedure during the 6-month study period. These initial results suggest that a significant proportion of our patients were willing and able to modify their risk before surgery. LEVEL OF EVIDENCE: Level III retrospective study. [Full article available at http://rimed.org/rimedicaljournal-2016-05.asp, free with no login].

Total joint arthroplasty in patients with chronic infectious liver disease.

The opportunity for total joint arthroplasty (TJA) in patients with chronic infectious liver disease is rapidly expanding. This is the product of both superior survival of chronic hepatitis patients, evolving implant technologies, and improvement of techniques in TJA. Unfortunately, treating this group of patients is not without significant challenges that can stem from both intrahepatic and extrahepatic clinical manifestations. Moreover, many subclinical changes occur in this cohort that can alter hemostasis, wound healing, and infection risk even in the asymptomatic patient. In this review, we discuss the various clinical presentations of chronic infectious liver disease and summarize the relevant literature involving total joint arthroplasty for this population. Hopefully, through appropriate patient selection and perioperative optimization, treating surgeons should see continued improvement in outcomes for patients with chronic infectious liver disease.