Incidence of and Risk Factors for Lateral Trochanteric Pain After Direct Anterior Approach Total Hip Arthroplasty.

Lateral trochanteric pain (LTP) is a common complication after total hip arthroplasty (THA). The goals of this study were to report the incidence of LTP after direct anterior approach (DAA) THA, describe the treatment course and outcomes, and examine patient-specific and implant-related potential risk factors. A retrospective review identified patients who underwent primary DAA THA with at least 1-year follow-up. Postoperative functional outcome scores and LTP occurrence were recorded. Patient demographics, surgical indications, implant characteristics, medical comorbidities, and radiographic parameters were obtained. Logistic regression analysis was used to identify risk factors. A total of 610 THA procedures were performed for 563 patients (mean follow-up, 30.9±15.2 months). The overall incidence of LTP was 11.6%. All cases of LTP were successfully treated conservatively, although these patients, compared with patients who did not have postoperative LTP, experienced significantly lower functional outcome scores (Harris Hip Score, 96.6±4.7 [range, 55-100] vs 89.9±8.5 [range, 42-100], respectively; P<.001). Logistic regression analysis identified female sex (odds ratio, 2.30; 95% CI, 1.32-4.02), diabetes mellitus (odds ratio, 2.32; 95% CI, 1.11-4.88), hypertension (odds ratio, 1.94; 95% CI, 1.15-3.28), and the use of an offset acetabular liner (odds ratio, 2.50; 95% CI, 1.06-5.91) as independent risk factors for LTP. There was no correlation between LTP and radiographic parameters. The incidence of LTP after DAA THA is similar to reported rates for other THA surgical approaches. Female sex, medical comorbidities, and the use of offset acetabular liners are likely associated, and patients should be counseled appropriately. Postoperative LTP results in worse functional outcomes, although all cases can be treated conservatively. [Orthopedics. 2022;45(2):e79-e85.].

A Unique Complication of Femoral Broach Fracture and Incarceration During Total Hip Arthroplasty.

In recent years, total hip arthroplasty via the direct anterior approach has been gaining popularity. It offers potential early advantages for less pain and quicker return of hip function; however, compared to other surgical approaches, it is associated with a more difficult femoral reconstruction. Inadequate femoral exposure during the direct anterior approach can result in suboptimal press fit, implant malalignment, and intraoperative fracture. This case report presents a unique complication of femoral broach failure and describes a simple technical solution that is feasible, cost-effective, and safe.

Negative Online Ratings of Joint Replacement Surgeons: An Analysis of 6,402 Reviews.

BACKGROUND: With the expanding accessibility of online health-care information, patients frequently report visiting physician rating websites before choosing a surgeon. As such, it is important to analyze patients' perception of arthroplasty surgeons as reflected on physician rating websites. METHODS: A total of 6402 online reviews of arthroplasty surgeons were extracted for analysis. Each review rated less than 5 on a 5-point scale was deemed a "negative" review and was subsequently assigned to an appropriate category. Reviews were stratified by practice type, years in practice, gender, and low (<3) vs high (> 3) ratings. RESULTS: A total of 6402 reviews comprising 315 physicians were included in the analysis. The average rating for all surgeons was 4.35. The average rating for physicians in private practice was 4.3, compared to 4.5 for those in an academic setting. The average rating for physicians in practice for 1-10 years was 4.46, compared to 4.03 for those with >10 years of experience (P < .001). The most common factors contributing to negative reviews were bedside manner, wait time, poor outcome, and surgeon proficiency. Surgeon-dependent factors were more commonly associated with lower rated reviews (P < .001). CONCLUSIONS: Arthroplasty surgeons typically receive high online ratings, with a mean of 4.35 on a 5-point scale. Physicians in academic practice received higher ratings than those in private practice, and physicians who have been in practice for 1-10 years received higher ratings than those with more than 10 years in practice. The most common factors contributing to negative reviews are surgeon-dependent, including bedside manner, poor outcome, and surgeon proficiency.

A Rare Case of Periprosthetic Joint Infection Caused by a Periodontal Pathogen, Slackia exigua: A Case Report.

CASE: A 72-year-old woman with a history of right total hip arthroplasty and subsequent revision 18 years ago developed right hip periprosthetic joint infection with significant bone destruction caused by Slackia exigua. She underwent a dental cavity filling without prophylactic antibiotics before presentation that may have contributed to development of the infection. The patient required total hip revision and prolonged antibiotic therapy to eradicate the bacteria. CONCLUSION: This case is an example that certain high-risk patients undergoing invasive dental procedures are at risk of developing prosthetic joint infection.

Single-Stage Bilateral Total Hip Arthroplasty in an Ambulatory Surgical Center: A Report of Three Cases.

In recent years, there has been increased interest in transitioning total joint arthroplasty procedures from inpatient settings to ambulatory surgical centers to decrease costs and eliminate the need for hospital stays. In addition, simultaneous bilateral total hip arthroplasty (THA) has been found to be favorable in certain patient populations when compared with staged bilateral THA. In this study, we report the results of a series of three patients who underwent single-stage bilateral THA in a free-standing ambulatory surgical center with excellent short-term outcomes and no 90-day complications.

Comparison Between the Attune and PFC Sigma in Total Knee Arthroplasty: No Difference in Patellar Clunk and Crepitus or Anterior Knee Pain.

Patellar crepitus and clunk (PCC) is a known complication in total knee arthroplasty (TKA) and the cause of dissatisfaction. Patellofemoral articulations have reportedly been optimized in newer TKAs. This study compared the incidence of PCC between a historical and modern TKA design. A single-surgeon retrospective review of primary PFC Sigma (DePuy Synthes, Warsaw, Indiana) or Attune TKA (DePuy Synthes) was performed. A total of 114 PFC Sigma and 103 Attune implants were analyzed at a mean 3.2 years follow-up for overall PCC, painful PCC, anterior knee pain (regardless of crepitus), and PCC necessitating revision. Similar rates of overall PCC (14.6% vs 20.2%, P=.803), painful PCC (8.7% vs 6.1%, P=.605), and anterior knee pain (15.5% vs 9.7%, P=.219) were observed in the Attune and PFC Sigma groups, respectively. No clinically significant differences in range of motion, pain, or Knee Society Scores were found between groups. Subgroup analyses of mobile vs fixed bearing PFC Sigma implants demonstrated higher rates of overall PCC (32.4% vs 15.0%, P=.043), painful PCC (20.6% vs 5.0%, P=.016), anterior knee pain (17.6% vs 1.3%, P=.003), and crepitus requiring revision surgery (17.6% vs 1.3%, P=.003) for mobile bearing PFC Sigma implants. No difference was found in the rates of anterior knee pain or PCC between the PFC Sigma and Attune implants. Subgroup analysis suggests that a mobile bearing PFC Sigma implant results in higher PCC. The authors believe the true incidence of anterior knee pain and PCC is underreported in the literature because many outcome measures do not capture these complications. [Orthopedics. 2020;43(6):e508-e514.].

Synthetic Mesh Allograft Reconstruction for Extensor Mechanism Insufficiency After Knee Arthroplasty.

Extensor mechanism (EM) insufficiency after knee arthroplasty is a rare but devastating complication resulting in severe disability. To date, primary repair and allograft reconstructive options have produced suboptimal results. A synthetic mesh allograft reconstruction technique has recently been introduced with promising outcomes. A retrospective chart review was performed to identify all patients who experienced EM failure after total or unicompartmental knee arthroplasty and subsequently underwent synthetic mesh EM reconstruction using a previously described technique. Patient demographics, pre- and postoperative knee range of motion and residual extensor lag, pre- and postoperative pain and functional outcome scores, and complications were extracted during the chart review. Twelve patients met inclusion criteria: 3 with patellar tendon and 9 with quadriceps tendon defects. At mean follow-up of 27.0 months, all patients were ambulatory, with a mean residual extensor lag of 12.9° (range, 0°-30°). Mean visual analog scale pain score decreased significantly after EM reconstruction: 4.6±2.3 (range, 1-8) preoperatively vs 1.8±2.4 (range, 0-7) postoperatively (P=.01). The mean Knee Society knee score improved from 41.5±11.1 (range, 21-57) preoperatively to 79.5±13.8 (range, 54-90) postoperatively (P<.0001). The mean Knee Society function score improved from 14.6±12.3 (range, 0-40) preoperatively to 64.2±27.1 (range, 5-95) postoperatively (P<.0001). One clinical failure occurred as a result of prosthetic joint infection. Synthetic mesh EM reconstruction effectively restores knee function for a variety of EM deficiencies following knee arthroplasty. [Orthopedics. 2019; 42(4):e385-e390.].

Phlegmasia cerulea dolens and external iliac vein disruption after revision total hip arthroplasty.

We present a unique case of phlegmasia cerulea dolens and compartment syndrome secondary to external iliac vein disruption after revision total hip arthroplasty. To our knowledge, this complication has not yet been described following revision total hip arthroplasty. We conclude that although vascular complications are fortunately rare after hip arthroplasty, they can have significant morbidity and mortality. Surgeons should have a thorough understanding of pelvic and hip anatomy for screw and retractor placement and know how to appropriately and expeditiously manage vascular complications should they occur.

Bundled Payments for Care Improvement in the Private Sector: A Win for Everyone.

BACKGROUND: To help slow the rising costs associated with total joint arthroplasty (TJA), the Centers for Medicare and Medicaid Services introduced the Bundled Payments for Care Improvement (BPCI) initiative. The purpose of this study is to report our 1-year experience with BPCI in our 2 arthroplasty surgeon private practice. METHODS: In this series, a historical baseline group is compared with our first year under BPCI. We reviewed the cohorts with respect to hospital length of stay (LOS), readmission rates, discharge disposition, postacute care LOS, and overall savings on a per episode basis. RESULTS: The baseline group included 582 episodes from July 2009 to June 2012. The BPCI study group included 332 episodes from July 2015 to September 2016. We witnessed a substantial learning curve over the course of our involvement in the initiative. The total reduction in cost per episode for TJA was 20.0% (P = .10). Hospital LOS decreased from 4.9 to 3.5 days (P = .02). All-cause 90-day readmission rates decreased from 14.5% to 8.2% (P = .0078). Overall, discharges to home increased from 11.6% to 49.8% (P = .005). CONCLUSION: Our small, private, 2 arthroplasty surgeon orthopedic practice has shown improvement in postoperative management for TJA patients in 1 year under the BPCI initiative, with increased discharges to home, decreased skilled nursing admissions, days in skilled nursing, and overall readmissions. Because BPCI includes fracture care arthroplasty, the model could be made more equitable if these patients were reimbursed a rate commensurate with their increased costs and risks.

The direct anterior approach for acetabular augmentation in primary total hip arthroplasty.

Addressing acetabular bone defects can be difficult and depends on the amount of bone loss. Augments, either with bone or highly porous metals, are options that still allow the use of a hemispherical cup. Almost all previous research and publication on acetabular augments have focused on revision hip arthroplasty utilizing either a modified lateral or a posterolateral surgical approach. We describe 3 cases of augmenting acetabular bone defects through a direct anterior approach for primary total hip arthroplasty. We achieved proper cup placement, alignment, and augment incorporation while reconstructing complex acetabular deficiencies. All patients had complete pain relief and a satisfactory clinical outcome with stable radiographs at follow-up. With appropriate training, acetabular augmentation can be performed safely and efficiently with excellent clinical results through this approach.

Correlation of the Caprini Score and Venous Thromboembolism Incidence Following Primary Total Joint Arthroplasty-Results of a Single-Institution Protocol.

BACKGROUND: Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis, is a serious complication after total joint arthroplasty (TJA). Risk assessment models are increasingly used to provide patient-specific risk stratification. A recently implemented protocol mandates calculation of a Caprini Score for all surgical patients at our institution. We investigated the accuracy of the Caprini Score in predicting VTE events following TJA. METHODS: A retrospective review of patients undergoing primary total hip (THA) and total knee arthroplasty (TKA) over a 1-year time period was performed. The 90-day postoperative incidence of emergency department evaluations, hospital readmissions, medical complications, need for revision surgery, and symptomatic VTE was recorded. "Preoperative" Caprini Scores routinely recorded per protocol and calculated during review ("Calculated") were compared and assessed for relationship with VTE events. A "VTEstimator" Score was calculated for each patient. RESULTS: Three hundred seventy-six arthroplasties (151 TKA and 225 THA) meeting inclusion criteria were identified. Ten patients (2.5%) had symptomatic VTE postoperatively, with 3 pulmonary embolism (0.8%) and 7 deep vein thrombosis (1.8%). Eight VTE (5.3%) occurred following TKA and 2 (0.9%) occurred following THA. For each surgical characteristic evaluated, no significant difference was observed between mean Preoperative or Calculated Caprini Scores for patients with and without VTE (P > .05). Additionally, the distribution of VTEstimator Scores for patients with and without VTE was not significantly different (P = .93). CONCLUSION: The Caprini risk assessment model does not appear to provide clinically useful risk stratification for TJA patients. Alternative risk stratification protocols may provide assistance in balancing safety and efficacy of thromboprophylaxis.

Spontaneous Fractures of a Modern Modular Uncemented Femoral Stem.

BACKGROUND: Femoral stem fracture following total hip arthroplasty is an uncommon event that requires immediate revision surgery. QUESTIONS/PURPOSES: We report on four patients who experienced stem fractures of one design and a review of the US Food and Drug Administration adverse event reports on this design. METHODS: Fracture surfaces of four EMPERION™ (Smith & Nephew, Memphis, TN) femoral stems were analyzed under optical and scanning electron microscopy. A search of the FDA's Manufacturer and User Facility Device Experience (MAUDE) that reports on all EMPERION™ adverse events was completed. RESULTS: Fracture surfaces exhibited characteristics consistent with a fatigue fracture mechanism. Sixteen MAUDE reports claimed stem fracture or breakage of EMPERION™ stems. CONCLUSION: The four cases of EMPERION™ stem fractures were likely driven by small stem diameter, high offset, and high patient weight. Modular stem-sleeve femoral systems are susceptible to fatigue failure under high stress and should only be used in appropriate patients, whom are not considered obese.

Total Joint Arthroplasty in a Stand-alone Ambulatory Surgical Center: Short-term Outcomes.

For decades, the average hospital stay following total joint arthroplasty (TJA) has been getting shorter. The historical standard was several weeks of hospitalization, yet improvements in perioperative care have reduced the average length of stay to a few days. Medicare recognizes a 3-day inpatient stay as the standard of care following hip or knee replacement. Yet continued advances in minimally invasive surgical techniques, short-acting general anesthetics, long-acting local anesthetics, and blood loss management have further improved the safety and recovery for TJA procedures. Thus, further reductions in postoperative hospitalization have been implemented around the country, with surgeons reporting successful same-day protocols, as defined by hospitalization discharge on the day of surgery. Although these studies have presented results of same-day TJA in the hospital setting, this study is the first to report on the perioperative adverse events and early outcomes of 51 consecutive TJA procedures performed in a stand-alone ambulatory surgical center (ASC). The ASC offers an ideal setting to perform such procedures in the properly selected patient population, obviating any form of postoperative hospitalization. Although 16 (31.4%) of 51 patients reported minor adverse events in the postanesthesia care unit, specifically nausea and/or pain, early intervention permitted 50 (98.0%) of 51 patients to be discharged home, on average 176 minutes after surgery, with 1 patient discharged to a rehabilitation facility as arranged prior to surgery. There were no major adverse events in the 90-day perioperative period, and although 1 (2.0%) patient was hospitalized for persistent incisional drainage, none required admission for pain. This study examines the strict eligibility criteria and perioperative analgesia protocols that permit successful outpatient TJA. [Orthopedics. 2016; 39(4):223-228.].

The Direct Anterior Approach for 1-Stage Bilateral Total Hip Arthroplasty: Early Outcome Analysis of a Single-Surgeon Case Series.

BACKGROUND: One-stage bilateral total hip arthroplasty (B-THA) is rarely performed despite a 20% incidence of bilateral degenerative hip disease requiring surgical intervention. METHODS: We retrospectively evaluated functional outcomes in 22 consecutive patients undergoing B-THA with a matched cohort undergoing unilateral THA by the same surgeon using the direct anterior approach. RESULTS: Although there was a significant difference in blood loss (P < .01) and surgical time (P < .001), there was no difference in length of hospital stay (P = .09), number of discharges to a rehabilitation facility (P = .22), or postoperative Harris Hip scores (P = .75). CONCLUSIONS: Advances in blood loss and pain management protocols in association with the direct anterior approach should renew interest in the efficacy of 1-stage B-THA.

Acute multiple flexor tendon injury and carpal tunnel syndrome after open distal radius fracture.

Although the rupture of extensor tendons after distal radius fractures is well described, acute flexor tendon ruptures are much less common. We report a case of acute rupture of the flexor pollicis longus and flexor carpi radialis tendons with acute carpal tunnel syndrome after a Gustilo-Anderson type II open distal radius fracture. We reviewed the literature to identify risk factors for tendon rupture and the development of carpal tunnel syndrome.

Primary knee arthrodesis for severe crystalline arthropathy.

Gout is a common form of inflammatory arthritis involving deposition of monosodium urate crystals within a diarthroidal joint. In this article, we report the case of a 54-year-old man who had severe, uncontrolled gout and presented with a 10-year history of knee pain. On consideration of all patient factors, including age, desired functional level, significant bone loss, periarticular soft-tissue masses, significant ligamentous instability, and difficult access to health care, knee arthrodesis was the surgery of choice. A knee fusion for gouty arthritis allowed the patient to have a stable, pain-free knee.

Four common types of bursitis: diagnosis and management.

Bursitis is a common cause of musculoskeletal pain and often prompts orthopaedic consultation. Bursitis must be distinguished from arthritis, fracture, tendinitis, and nerve pathology. Common types of bursitis include prepatellar, olecranon, trochanteric, and retrocalcaneal. Most patients respond to nonsurgical management, including ice, activity modification, and nonsteroidal anti-inflammatory drugs. In cases of septic bursitis, oral antibiotics may be administered. Local corticosteroid injection may be used in the management of prepatellar and olecranon bursitis; however, steroid injection into the retrocalcaneal bursa may adversely affect the biomechanical properties of the Achilles tendon. Surgical intervention may be required for recalcitrant bursitis, such as refractory trochanteric bursitis.

Correction of metatarsus primus varus associated with hallux valgus deformity using the arthrex mini tightrope: a report of 44 cases.

Metatarsus primus varus must be addressed during correction of moderate to severe hallux valgus deformity. As an alternative to proximal osteotomy or first tarsometatarsal fusion for hallux valgus correction, this study presents a series of patients treated using the Arthrex Mini TightRope. A total of 36 patients (44 operations) with hallux valgus and metatarsus primus varus underwent correction using the Arthrex Mini TightRope. Assessment included measurement of radiographic parameters, the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot outcomes score, and the SF-12. The average hallux valgus angle improved from 32.2° to 15.2° (P < .0001). The average first intermetatarsal angle improved from 14.6° to 8.2° (P < .0001). The average distal metatarsal articular angle improved from 17.0° to 9.6° (P < .0001). The average AOFAS midfoot outcomes scores improved from 45.44 to 84.72 (P < .0001). Postoperative SF-12 physical and mental scores averaged 52.99 and 56.63. Only one patient had recurrence of deformity. Correcting metatarsus primus varus in association with hallux valgus deformity using the Arthrex Mini TightRope should be considered a treatment option. This technique is less invasive and seems capable of maintaining correction while allowing for early weight bearing and avoiding the need for a proximal first metatarsal osteotomy or Lapidus procedure.