Rapid Return to Braking After Anterior and Posterior Approach Total Hip Arthroplasty.

BACKGROUND: Little is known about the effect of surgical approach on return to braking after total hip arthroplasty (THA), and few studies have investigated braking after THA with modern surgical techniques and rehabilitation protocols. METHODS: In a prospective comparative design, we enrolled 65 patients who received right-sided primary THA at our institution from April 2018 through March 2020, 34 with a direct anterior approach (DAA) and 31 with a posterior approach (PA). Braking tests measuring brake reaction time (BRT) and brake pedal depression (BPD) were administered to patients preoperatively and at 1, 2, and 4 weeks postoperatively using a realistic driving simulator. BRT and BPD were compared between groups and preoperatively versus postoperatively using mixed-effects models. RESULTS: Preoperative BRT averaged 638 msec in the DAA group and 604 msec in the PA group (P = 0.31). At 1 week postoperatively, the DAA group had significantly prolonged BRT compared with preoperatively (694 msec, P = 0.02). No significant difference was observed in the PA group (633 msec, P = 0.31). Both groups had returned to baseline by 2 weeks, and both had significantly faster BRT at 4 weeks compared with preoperatively (583 msec for DAA, P = 0.01; 537 msec for PA, P < 0.001). BPD was similar between groups, and there were no significant differences between preoperative and postoperative BPD at any time point. CONCLUSIONS: With modern surgical techniques, BRT after right-sided THA returns to baseline levels approximately 2 weeks after surgery. There seems to be a quicker return to preoperative BRT observed in patients with a PA.

Results of Porous-Coated Anatomic Total Hip Arthroplasty without Cement at 25 to 30 Years: A Concise Follow-up of a Previous Report.

The purpose of this study was to update the results of a prospective series of 100 primary cementless total hip arthroplasty (THA) procedures that were performed between 1983 and 1986 with use of the Porous Coated Anatomic (PCA) system. This is one of the first prospective studies of cementless primary THA with a minimum of 25 years of follow-up. Twenty-one patients (22 hips) of the original series were alive and had clinical and radiographic follow-up at a minimum of 25 years postoperatively. Twenty-three percent (23) of all hips and 50% (11) of the hips among the living cohort had undergone revision for loosening and/or osteolysis of the acetabular component, and 7% (7) of all hips and 4.5% (1) of the hips among the living cohort were revised for loosening and/or osteolysis of the femoral component. Only 4 femoral stems were revised for isolated loosening (without osteolysis). The PCA femoral component proved to be durable at a minimum of 25 years postoperatively, while the acetabular component was less durable. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

No clinically meaningful weight changes in a young cohort following total joint arthroplasty at 3-year follow-up.

BACKGROUND: Total joint arthroplasty (TJA) is one of the most successful operations. There is little in the literature regarding weight change following TJA, particularly in a young cohort. METHODS: Retrospective analysis of 181 primary total hip arthroplasty (THA) and 185 primary total knee arthroplasty (TKA) patients was conducted. We reviewed preoperative and post-operative weights and post-operative body mass index at 3 and 6 months, 1 year, 2 and 3 years. We evaluated expected versus actual weight gain, and performed subgroup analyses of obese versus non-obese patients and active duty versus civilian patients. We used a minimal clinically meaningful weight change from baseline of ≥5%. RESULTS: One hundred and fifty-one (41.3%) patients were active duty military service members with the mean age of 53 ± 11.1 years. In TKA patients, statistically significant differences were found in mean weights at 3 months (-1.8%, P ≤ 0.0001) and 2 years (+1.9%, P = 0.0006). In THA patients, statistically significant weight gains were found at 6 months (+1.1%, P = 0.006). For obese TKA patients, significant weight changes were observed at 3 months (-2.5%, P ≤ 0.0001), and none in the obese THA group. There were no statistical or clinically meaningful weight changes in the non-obese TKA or THA groups. There was a clinically meaningful weight gain in active duty TKA patients at 3 years (5.18%, P = 0.17). CONCLUSION: Despite a theoretical ability to lose weight following TJA, patients maintain their preoperative weight following TJA. We found a clinically meaningful weight gain at 3 years post-operatively only in active duty TKA patients. Overall, however, we found no clinically significant weight changes following TJA at 3-year follow-up.

Fifty Most-Cited Articles in the Orthopaedic Treatment of the Hip.

This study sought to identify the 50 most-cited articles in the literature pertaining to the surgical treatment of the hip, which has not yet been done to the authors' knowledge. In December 2014, an all-years search of the Thompson Institute for Scientific Information Web of Science was conducted for the term ``hip.'' Articles were sorted from most to least cited. Citations per article ranged from 3176 to 372. The majority of the articles were clinical in nature (64%) and hip arthroplasty was the predominant focus (70%). Eight different journals were included. The majority of the articles were published since the 1990s. Sixty-two percent of the articles originated from U.S. institutions. Only 12% of the articles were level I or II evidence with the majority being level IV evidence (44%). This study highlights the paucity of high-quality evidence, and further well-designed studies are needed to guide the future direction of hip surgery.

The Use of Intravenous Tranexamic Acid in Patients Undergoing Total Hip or Knee Arthroplasty: A Retrospective Analysis at a Single Military Institution.

OBJECTIVE: To describe a single institution's experience after initiation of a protocol in which all primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients were administered intravenous tranexamic acid (TXA) intraoperatively to decrease perioperative blood loss. METHODS: A retrospective review of medical records at a single institution from February 2012 to April 2014. The TXA treatment group was compared to a control group. We reviewed intraoperative blood loss, preoperative hemoglobin (Hb) levels, postoperative day 0 to 2 Hb levels, transfusion rates, postoperative venous thromboembolism, and other complication rates. RESULTS: 259 patients underwent either TKA (165) or THA (94). 121 received perioperative intravenous TXA and 138 did not. There was a statistically decreased rate of allogeneic blood transfusion (0 vs. 10, p = 0.003) as well as a higher postoperative day 2 Hb level (10.8 ± 1.1 vs. 10.2 ± 2.6 g/dL, p = 0.02) in the treatment group. There was no statistical difference in any variable measured in the THA group, though there was a trend toward higher postoperative Hb levels at all-time points measured. CONCLUSION: Intravenous TXA is a safe and effective drug to decrease perioperative blood loss and allogeneic transfusion in THA and TKA. There was no increased risk of venous thromboembolism or other complications in our review.

An Analysis of Research from Faculty at U.S. Adult Reconstruction Fellowships.

We reviewed all articles published in three major orthopaedic journals from January 2010 to December 2014. Any article focusing on adult reconstruction of the hip or knee was reviewed for first and last authorship, institution, and level of evidence. Three institutions had authored work from arthroplasty faculty that fell within the top five most published institutions in all three journals, while one institution ranked first in all three journals. 43 of 67 (64.2%) reconstruction fellowships had at least one publication included in this study. The majority of the adult reconstruction literature published by faculty at U.S. reconstruction fellowships stems from a few academic centers with the ten most prolific institutions accounting for 65.9% of all U.S. fellowship publications.

Treatment of open proximal femoral fractures sustained in combat.

BACKGROUND: Open proximal femoral fractures are rare injuries that often result from wartime high-energy causes. Limited data exist regarding the treatment and complications of these injuries. METHODS: We retrospectively reviewed the records of combat casualties treated at two institutions between March 2003 and March 2008. The casualty patient databases, medical records, radiographs, and laboratory data were reviewed to determine time to union, complication rates, and patient outcomes. RESULTS: Forty-one patients (thirty-nine men and two women) with a mean age of 25.7 years were identified as receiving treatment for open proximal femoral fractures. The mechanisms of injury for these forty-one patients were blast (twenty-nine patients [71%]), gunshot wound (eight patients [20%]), motor vehicle crash (three patients [7%]), and helicopter crash (one patient [2%]). There were thirty Type-IIIA, six Type-IIIB, and five Type-IIIC open fractures. The predominant method of definitive fixation was a cephalomedullary or reconstruction nail in thirty-four patients (83%). Thirty-nine patients had at least two years of follow-up data available for assessment of complications and radiographic union. The mean time to union was 5.1 months (range, 2.8 to 16.0 months). Complications requiring reoperation occurred in twenty-two (56%) of thirty-nine patients. Wound infection (twelve patients [31%]) and symptomatic heterotopic ossification (ten patients [26%]) were the most common complications. CONCLUSIONS: Cephalomedullary nail fixation of open Type-III wartime subtrochanteric and pertrochanteric femoral fractures can be reliably used to effect fracture union in a timely manner. The most frequent complications of treatment are wound infection and symptomatic heterotopic ossification.

Microbiology and injury characteristics in severe open tibia fractures from combat.

BACKGROUND: Type III open tibia fractures are common combat injuries. The purpose of the study was to evaluate the effect of injury characteristics and surveillance cultures on outcomes in combat-related severe open tibia fractures. METHODS: We conducted a retrospective study of all combat-related open Gustilo and Anderson (G/A) type III diaphyseal tibia fractures treated at our centers between March 2003 and September 2007. RESULTS: One hundred ninety-two Operation Iraqi Freedom/Operation Enduring Freedom military personnel with 213 type III open tibial shaft fractures were identified. Fifty-seven extremities (27%) developed a deep infection and 47 extremities (22%) ultimately underwent amputation at an average follow-up of 24 months. Orthopedic Trauma Association type C fractures took significantly longer to achieve osseous union (p = 0.02). G/A type III B and III C fractures were more likely to undergo an amputation and took longer to achieve fracture union. Deep infection and osteomyelitis were significantly associated with amputation, revision operation, and prolonged time to union. Surveillance cultures were positive in 64% of extremities and 93% of these cultures isolated gram-negative species. In contrast, infecting organisms were predominantly gram-positive. CONCLUSIONS: Type III open tibia fractures from combat unite in 80.3% of cases at an average of 9.2 months. We recorded a 27% deep infection rate and a 22% amputation rate. The G/A type is associated with development of deep infection, need for amputation, and time to union. Positive surveillance cultures are associated with development of deep infection, osteomyelitis, and ultimate need for amputation. Surveillance cultures were not predictive of the infecting organism if a deep infection subsequently develops.

Adjacent vertebral body osteolysis with bone morphogenetic protein use in transforaminal lumbar interbody fusion.

BACKGROUND CONTEXT: Recent studies have demonstrated cases of adjacent vertebral body osteolysis when assessing the effect of bone morphogenetic protein (BMP) on fusion rates. However, no study to date has evaluated the course of osteolysis at different periods. PURPOSE: To determine the incidence and resolution of osteolysis associated with BMP used in transforaminal lumbar interbody fusions (TLIF). STUDY DESIGN: Retrospective review. PATIENT SAMPLE: All TLIF cases using BMP performed at one institution with routine postoperative computed tomography (CT) scans at defined intervals. OUTCOME MEASURES: Area of osteolysis and fusion as determined by CT scan. METHODS: We performed a retrospective analysis of all patients at our facility who underwent TLIF with BMP. Included were all patients who had obtained a CT scan within 48 hours of surgery, 3 to 6 months postoperatively, and 1 to 2 years postoperatively. Areas of osteolysis were defined as lucency within the vertebral body communicating with the interbody spacer that was not present on the immediately postoperative CT scan. Areas of osteolysis were measured in all three planes and the volume used for comparison of the 3 to 6 months CT scans with the greater than 1 year CT scan. RESULTS: Twenty-three patients who underwent TLIF with BMP had obtained CT scans at all time periods required for evaluation. Seventy-eight vertebral bodies/end plates were assessed for osteolysis (39 levels). The incidence of osteolysis 3 to 6 months postoperatively in the adjacent vertebral bodies was 54% compared with 41% at 1 to 2 years. The mean volume of osteolysis was at 0.216 cm(3) at 1 to 2 years compared with 0.306 cm(3) at 3 to 6 months (p=.082). The area/rate of osteolysis did not appear to significantly affect the rate of fusion or final outcome with an overall union rate of 83%. CONCLUSIONS: The rate of osteolysis decreased at 1 year compared with 3 to 6 months, but only 24% of the vertebral bodies with evidence of osteolysis at 3 to 6 months completely resolved by 1 year.

Biomechanical analysis of occipitocervical stability afforded by three fixation techniques.

BACKGROUND CONTEXT: Occipital condyle screws appear to be a novel technique that demands biomechanical consideration. It has the potential to achieve fixation anterior to the axis of rotation while offering a point of fixation in line with the C1/C2 screws. PURPOSE: To compare the segmental stability and range of motion (ROM) of standard occipitocervical (OC) screw/rod and plate constructs versus a new technique that incorporates occipital condyle fixation. STUDY DESIGN: Human cadaveric biomechanical analysis. METHODS: After intact analysis, 10 fresh-frozen human cadaveric OC spine specimens were instrumented bilaterally with C1 lateral mass screws and C2 pedicle screws. Additional occipital instrumentation was tested in random order under the following conditions: standard occipitocervical plate/rod system (Vertex Max; Medtronic, Inc., Minneapolis, MN, USA); occipital condyle screws alone; and occipital condyle screws with the addition of an eyelet screw placed into the occiput bilaterally. After nondestructive ROM testing, specimens were evaluated under computed tomography (CT) and underwent destructive forward flexion failure comparing Group 1 to Group 3. RESULTS: There was no significant difference in OC (Occiput-C1) axial rotation and flexion/extension ROM between the standard occipitocervical plate/rod system (Group 1) and the occipital condyle screws with one eyelet screw bilaterally (Group 3). Furthermore, the occipital condyle screws alone (Group 2) did allow significantly more flexion/extension compared with Group 1. Interestingly, the two groups with occipital condyle screws (Groups 2 and 3) had significantly less lateral bending compared with Group 1. During CT analysis, the mean occipital condyle width was 10.8 mm (range, 9.1-12.7 mm), and the mean condylar length was 24.3 mm (range, 20.2-28.5). On destructive testing, there was no significant difference in forward flexion failure between Groups 1 and 3. CONCLUSIONS: With instrumentation across the mobile OC junction, our results indicate that similar stability can be achieved with occipital condyle screws/eyelet screws compared with the standard occipitocervical plate/rod system.

Does the zone of injury in combat-related Type III open tibia fractures preclude the use of local soft tissue coverage?

OBJECTIVES: Does the large zone of injury in high-energy, combat-related open tibia fractures limit the effectiveness of rotational flap coverage? DESIGN: Retrospective consecutive series. SETTING: This study was conducted at Brooke Army Medical Center, Walter Reed Army Medical Center, and National Naval Medical Center between March 2003 and September 2007. PATIENTS/PARTICIPANTS: We identified 67 extremities requiring a coverage procedure out of 213 consecutive combat-related Type III open diaphyseal tibia fractures. INTERVENTION: The 67 Type III B tibia fractures were treated with rotational or free flap coverage. MAIN OUTCOME MEASURES: Flap failure, reoperation, infection, amputation, time to union, and visual pain scale. RESULTS: There were no differences between the free and rotational flap cohorts with respect to demographic information, injury characteristics, or treatment before coverage. The reoperation and amputation rates were significantly lower for the rotational coverage group (30% and 9%) compared with the free flap group (64% and 36%; P = 0.05 and P = 0.03, respectively). The coverage failure rate was also lower for the rotational flap cohort (7% versus 27%, P = 0.08). The average time to fracture union for the free flap group was 9.5 months (range, 5-15.8 months) and 10.5 months (range, 3-41 months) for the rotational flap group (P = 0.99). CONCLUSIONS: There was a significantly lower amputation and reoperation rate for patients treated with rotational coverage. Contrary to our hypothesis and previous reports, the zone of injury in combat-related open tibia fractures does not preclude the use of local rotational coverage when practicable.

Orthopaedic war injuries: recent developments in treatment and research.

Musculoskeletal injury is the most common type of injury among survivors of combat trauma, and combat-related trauma is challenging for an orthopaedic surgeon to treat. Methods of treatment are evolving, but significant gaps remain as knowledge of civilian trauma is extrapolated to combat trauma.

Contralateral structural femoral autograft use in treatment of an open periarticular knee fracture to perform knee arthrodesis.

Combat-related blast injuries often cause devastating extremity trauma. We report a case of a 21-year-old male service member who sustained massive bilateral lower extremity trauma secondary to a blast injury. His orthopaedic injuries included a near traumatic disarticulation of the right knee and a left open type IIIB periarticular knee fracture with traumatic patellectomy, loss of the extensor mechanism, and segmental loss of the distal 11 cm of his femur. Definitive treatment of his injuries included a contralateral structural cortical femoral autograft which was implanted into the left knee segmental defect to facilitate knee fusion with an intramedullary knee fusion nail and a right transfemoral amputation. Radiographic evidence of solid fusion was obtained 8 months postoperatively. Currently, the patient is a community ambulator with the aid of his right lower extremity prosthetic limb and cane.

Treatment of open periarticular shoulder fractures sustained in combat-related injuries.

Open periarticular shoulder fractures present a tremendous challenge for orthopedic surgeons. These injuries, albeit rare, are typically caused by high-energy mechanisms and are associated with insult to multiple organ systems resulting in high morbidity and mortality. Although the civilian trauma literature includes several articles on outcomes of closed periarticular shoulder fractures, only 1 peer-reviewed article has focused on this specific open injury pattern. No standard management technique has been adopted for these injuries, and treatment patterns have anecdotally evolved from war to war. In this article, we review evacuation of patients, management of combat-related open periarticular shoulder injuries, and the pertinent literature; we supplement this review with a description of the recent experience of Drs. HMF and WCD. All cases of combat-related open fractures treated at our institution between March 2003 and January 2007 were reviewed. We identified 44 patients with open periarticular shoulder fractures (33 IIIA, 1 IIIB, 10 IIIC). Inpatient and outpatient medical records, x-rays, laboratory culture data, and photographic documentation records were reviewed. Mean follow-up was 34 months (range, 12-49 months). Rates of associated neurologic and vascular injury were 41% (18/44 patients), and 23% (10/44 patients), respectively. Other associated significant injuries occurred in 38/44 patients (86%). Internal fixation was used as definitive treatment in 26/44 patients (59%). Radiographic union occurred by a mean of 4.5 months (range, 3-9 months) after surgery. Postoperative deep infection/osteomyelitis occurred in 5/35 patients (14%) with more than 1-year follow-up data available. The overall amputation rate was 9%. Open combat-related periarticular shoulder fractures are complicated injuries, often associated with several traumatic comorbidities that together present difficult challenges to treatment. Meticulous surgical débridement is essential in managing these severely comminuted and contaminated open fractures. In cases in which internal fixation is used, careful timing and patient selection are required to minimize risk for osteomyelitis. Data collection is being continued in this patient cohort to allow for eventual reporting of functional outcomes.