Surgical Treatment of Severe Heterotopic Ossification After Total Hip Arthroplasty Over the Last 25 Years: A Systematic Review of the Literature and a New Case Series.

BACKGROUND: Severe heterotopic ossification (HO) (grades III and IV) after total hip arthroplasty (THA) over the last 25 years requiring excision is very uncommon. We performed a systematic review of the literature and reported a new case series with operative treatment after primary uncemented THA. METHODS: A systematic review identified papers describing patients who had excision of HO after THA performed after 1988. Concepts of hip arthroplasty, HO, and surgical excision were searched in MEDLINE, Embase, and Scopus from database inception to November 2022. The inclusion criteria were articles that included specific patient data on the grade of HO, operative procedure, and prophylaxis. Studies were screened for inclusion by 2 independent reviewers. The extracted data included demographic data, the interval from index surgery to excision, clinical results, and complications. There was one surgeon who performed reoperation for ankylosis of primary THA in 3 men who had severe pain and hip deformity. RESULTS: Data from 7 studies were included. There were 41 patients who had grade III or IV HO who had excision, and in 5 patients, revision of a component was also performed. Perioperative prophylaxis was irradiation alone in 10 patients, irradiation and indomethacin in 10 patients, and indomethacin alone in 21 patients. At a mean follow-up time of 14.8 months, the definition of the results was not uniform, and range of motion was improved, but relief of pain was inconsistent. There was one dislocation after resection without revision, one gastrointestinal complication, and 2 recurrences. Treatment of the 3 new patients, with wide excision of periarticular bone, selective exchange of components, and perioperative irradiation prophylaxis, was successful in improving pain, motion, and deformity. CONCLUSIONS: There is insufficient good-quality data on the operative treatment of severe symptomatic HO after THA performed over the last 25 years. Prophylaxis with low-dose irradiation prevented a recurrence. Multicenter studies are needed to determine the optimum timing and prognosis for treatment.

Periarticular Injection and Peripheral Nerve Blocks With Standard Agents.

The block of sensory nerves in the ipsilateral limb or locally is an integral part of the multimodal pain management protocol after primary total knee arthroplasty. The 2022 clinical practice guidelines published by the American Association of Hip and Knee Surgeons, the American Society of Regional Anesthesia and Pain Medicine, and the American Academy of Orthopaedic Surgeons describe various strengths of recommendations concerning the use of nerve blocks and periarticular injection. There is also experimental and clinical evidence to support a technique for the surgeon to perform both the periarticular injection and an intra-articular saphenous nerve block. High-dose bupivacaine injection has been shown to be effective and safe. The value of adductor canal block is currently uncertain. Future studies are needed concerning longer-lasting local anesthetic agents and techniques.

Failure of a Femoral Revision Knee Component with Chemical Corrosion and Elevated Metal Ions: A Case Report and Literature Review.

CASE: Failure of the modular junction in revision total knee arthroplasty is a rare complication. We report a patient with late, atraumatic failure of a modern, modular revision femoral component, with preoperative elevation of serum cobalt and chromium levels. Retrieval analysis showed extensive chemical corrosion. CONCLUSION: Failure of a modern, modular femoral component may cause metal synovitis and elevated serum metal levels. Subtle radiographic changes and preoperative serum metal levels may identify this complication.

Heterotopic Ossification After Modern Total Hip Arthroplasty: Predisposing Factors, Prophylaxis, and Surgical Treatment.

Heterotopic ossification (HO) is a common radiographic finding and potentially serious complication after modern total hip arthroplasty. Although historically associated with the posterolateral approach, HO has been noted in 10% to 40% of patients having direct anterior or anterior-based muscle sparing approaches. The available data are uncertain whether robotic arm-assisted procedures are associated with this complication. Current prophylaxis for patients considered high risk of this complication includes postoperative, nonsteroidal, anti-inflammatory medication for several weeks or low-dose perioperative irradiation. The surgical treatment of symptomatic HO associated with severely restricted motion or ankylosis of the hip should be individualized but may include wide excision of bone, acetabular revision to prevent instability, and prophylaxis to prevent recurrence.

Intraosseous Vancomycin May Not Be Helpful in Aseptic Revision Knee Arthroplasty: A Single-Surgeon Consecutive Case Series.

BACKGROUND: Infection after aseptic revision total knee arthroplasty (TKA) has been reported from 9% to 14%. Intraosseous (IO) vancomycin infusion has decreased the risk of infection after primary TKA. The results of this additional prophylaxis were evaluated in aseptic revision TKA. METHODS: In this prospective, single-surgeon study of 20 consecutive patients having aseptic revision TKA, 500 milligrams of vancomycin in 120 mL of saline were infused into the tibia prior to incision, in addition to intravenous (IV) cefazolin. There were 18 men and 2 women who had a mean age of 67 years (range, 47-79), and mean body mass index of 34.4 (range, 25.9-51.2). The knees were aspirated in the operating room prior to IV and IO antibiotics. The outcomes were infections at 90 days requiring reoperation and complications from the infusion. RESULTS: Three of the 20 aseptic revisions had early prosthetic joint infection, 2 with gram-negative organisms and one with coagulase-negative Staphylococcus. All had debridement, liner exchange and IV antibiotic treatment, but 1 patient eventually had an above knee amputation. No patient had total body "erythema syndrome", but 1 patient had transient facial flushing. Six patients had a transient elevation of serum creatinine including 3 with an abnormal preoperative serum creatinine. CONCLUSION: In this small series of aseptic revision TKA, there was no added benefit of IO vancomycin infusion, but there were no infections with methicillin-resistant Staphylococcus aureus. Additional studies are needed before this technique should be routinely recommended.

Current Trends in Revision Hip Arthroplasty: Indications and Types of Components Revised.

BACKGROUND: The materials and techniques for both primary and revision total hip arthroplasty (THA) have changed over time. This study evaluated if the indications for revision THA, rates of components utilized (femoral or acetabulum, both, or head/liner exchange), length of stay (LOS), and payments to surgeons and facilities have also changed. METHODS: A retrospective study, utilizing the PearlDiver database, of 38,377 revision THA patients from January 2010 through December 2018 was performed. Data included the indication for revision, components revised (femoral or acetabulum, both, or head/liner exchange), LOS, and payments. Indications and components were analyzed by logistic regression (Dunnett's post hoc test). Revision totals were analyzed with a linear regression model. Analysis of variance assessed changes in LOS and payments. RESULTS: Patients' median age was 67 years (Q1-Q3: 59-74), and 58.7% were female. Revisions for dislocation decreased between 2010 and 2018 (odds ratio [OR] 0.82, 95% confidence interval [CI] 0.68-0.98). Revisions for component loosening increased (OR 1.54, 95% CI 1.25-1.91). Dislocation remained the most common indication (19.3%), followed by PJI (17.3%) and loosening (17.1%). Both-component (OR:1.45; 95% CI:1.25-1.67) and femoral component only revisions increased; acetabular component only and head/liner exchanges decreased. Acetabular (OR 0.57, 95% CI 0.47-0.70) and head/liner exchange (OR 0.29, 95% CI 0.20-0.43) revisions decreased, while both component exchange (OR 1.45, 95% CI 1.25-1.67) and femoral revisions (OR 1.17, 95% CI 0.99-1.37) increased. Average LOS (-0.68 days; P < .001) and surgeon payments decreased (-$261.8; P < .001) while facility payments increased ($4,211; P < .001). CONCLUSION: Indications for revision THA in this database study changed over time, with revision for dislocation decreasing and revision for loosening increasing over time. Both component and femoral revisions increased, and acetabular component and head/liner exchanges decreased. It is possible that these associations could be attributed to a number of details, the method of femoral fixation, surgical approach, and cementing, all of which require additional study.

Early Infection After Aseptic Revision Knee Arthroplasty: Prevalence and Predisposing Risk Factors.

BACKGROUND: Although patient factors have been associated with prosthetic joint infection (PJI) after primary total knee arthroplasty, there are insufficient data on the relationship of patient and technical factors with early PJI after aseptic revision. METHODS: This is a retrospective study of 157 aseptic revisions performed by 2 surgeons at 1 academic center. A negative intraoperative culture during revision surgery was required for inclusion. Mean follow-up time was 3.8 years (standard deviation 2.8). PJI was defined by positive aspiration or draining wound, and an additional operation within 1 year of aseptic revision. Patient demographics, medical comorbidities, and technical factors were reviewed. Data points were evaluated with univariate and adjusted multivariate regression analyses. RESULTS: The prevalence of PJI after aseptic revision was 9% (14/157). The most common organism was Staphylococcus aureus. Initial treatment included debridement and liner exchange (11) and antibiotic spacer (3). Two patients ultimately had an above-knee amputation. Univariate analysis showed a significant difference in preoperative anemia (P < .01), transfusion (P < .01), and diabetes (P = .05) between cohorts. There was no association among the length of surgery, use of a metaphyseal cone, or the number of components revised and PJI. Adjusted logistic regression demonstrated that preoperative anemia (P < .01) was a significant risk factor for PJI. CONCLUSION: The prevalence of early PJI was similar to other studies in the literature. Anemia was an independent predictor of PJI, while technical factors did not have an association. Medical optimization of patients should be considered prior to revision surgery.

Corrigendum to 'Prosthetic Joint Infection After Dental Work: Is the Correct Prophylaxis Being Prescribed? A Systematic Review' [Arthroplasty Today 7 (2021) 69-75].

[This corrects the article DOI: 10.1016/j.artd.2020.11.007.].

Is there a problem with modular dual mobility acetabular components in revision total hip arthroplasty at mid-term follow-up?

AIMS: Modular dual mobility (MDM) acetabular components are often used with the aim of reducing the risk of dislocation in revision total hip arthroplasty (THA). There is, however, little information in the literature about its use in this context. The aim of this study, therefore, was to evaluate the outcomes in a cohort of patients in whom MDM components were used at revision THA, with a mean follow-up of more than five years. METHODS: Using the database of a single academic centre, 126 revision THAs in 117 patients using a single design of an MDM acetabular component were retrospectively reviewed. A total of 94 revision THAs in 88 patients with a mean follow-up of 5.5 years were included in the study. Survivorship was analyzed with the endpoints of dislocation, reoperation for dislocation, acetabular revision for aseptic loosening, and acetabular revision for any reason. The secondary endpoints were surgical complications and the radiological outcome. RESULTS: The overall rate of dislocation was 11%, with a six-year survival of 91%. Reoperation for dislocation was performed in seven patients (7%), with a six-year survival of 94%. The dislocations were early (at a mean of 33 days) in six patients, and late (at a mean of 4.3 years) in four patients. There were three intraprosthetic dissociations. An outer head diameter of ≥ 48 mm was associated with a lower risk of dislocation (p = 0.013). Lumbrosacral fusion was associated with increased dislocation (p = 0.004). Four revision THAs (4%) were further revised for aseptic acetabular loosening, and severe bone loss (Paprosky III) at the time of the initial revision was significantly associated with further revision for aseptic acetabular loosening (p = 0.008). Fourteen acetabular components (15%) were re-revised for infection, and a pre-revision diagnosis of reimplantation after periprosthetic joint infection (PJI) was associated with subsequent PJI (p < 0.001). Two THAs had visible metallic changes on the backside of the cobalt chromium liner. CONCLUSION: When using this MDM component in revision THA, at a mean follow-up of 5.5 years, there was a higher rate of dislocation (11%) than previously reported. The size of the outer bearing was related to the risk of dislocation. There was a low rate of aseptic acetabular loosening. Longer follow-up of this MDM component and evaluation of other designs are warranted. Cite this article: Bone Joint J 2021;103-B(7 Supple B):66-72.

Unexpected high rate of revision of a modern cemented fixed bearing modular posterior-stabilized knee arthroplasty.

AIMS: To establish our early clinical results of a new total knee arthroplasty (TKA) tibial component introduced in 2013 and compare it to other designs in use at our hospital during the same period. METHODS: This is a retrospective study of 166 (154 patients) consecutive cemented, fixed bearing, posterior-stabilized (PS) TKAs (ATTUNE) at one hospital performed by five surgeons. These were compared with a reference cohort of 511 knees (470 patients) of other designs (seven manufacturers) performed at the same hospital by the same surgeons. There were no significant differences in age, sex, BMI, or follow-up times between the two cohorts. The primary outcome was revision performed or pending. RESULTS: In total, 19 (11.5%) ATTUNE study TKAs have been revised at a mean 30.3 months (SD 15), and loosening of the tibial component was seen in 17 of these (90%). Revision is pending in 12 (7%) knees. There was no difference between the 31 knees revised or with revision pending and the remaining 135 study knees in terms of patient characteristics, type of bone cement (p = 0.988), or individual surgeon (p = 0.550). In the reference cohort, there were significantly fewer knees revised (n = 13, 2.6%) and with revision pending (n = 8, 1.5%) (both p < 0.001), and only two had loosening of the tibial component as the reason for revision. CONCLUSION: This new TKA design had an unexpectedly high early rate of revision compared with our reference cohort of TKAs. Debonding of the tibial component was the most common reason for failure. Additional longer-term follow-up studies of this specific component and techniques for implantation are warranted. The version of the ATTUNE tibial component implanted in this study has undergone modifications by the manufacturer. Cite this article: Bone Joint J 2021;103-B(6 Supple A):137-144.

Prosthetic Joint Infection After Dental Work: Is the Correct Prophylaxis Being Prescribed? A Systematic Review.

BACKGROUND: Prosthetic joint infection (PJI) of total hip (THA) or total knee arthroplasty (TKA) after dental procedures is uncommon, and antibiotic prophylaxis remains controversial. For high-risk patients, the American Academy of Orthopedic Surgeons recommends amoxicillin prophylaxis. However, no systematic review of the literature of PJIs associated with dental procedures explores if amoxicillin is suitable for the reported organisms. METHODS: A librarian-assisted search of the major databases (PubMed, Medline, Embase, Scopus) identified 954 articles. Only case reports, case series, and reviews with patient level data were included. After exclusions, 79 articles were fully reviewed. RESULTS: Forty-four PJIs after dental procedures were identified, 22 in primary THA, 20 in primary TKA, one in revision THA, and one in a hip resurfacing procedure. Antibiotic prophylaxis was documented for 5 patients. The dental procedure was invasive in 35 (79.5%). Comorbidities were present in 17 patients (38.7%). The organisms reported were Streptococcus spp. in 44%, other aerobic gram-positives in 27%, anaerobic gram-positives in 18%, and gram-negative organisms in 11%. An estimated 46% of organisms may be resistant to amoxicillin. The outcomes of treatment were reported for 35 patients (79.5%). Twenty-seven patients (61.4%) had no clinical signs of PJI at the final follow-up visit. CONCLUSIONS: Lower extremity PJI associated with dental procedures is often caused by organisms unlikely to be prevented with amoxicillin. Additional studies are warranted to determine the choice and efficacy of antibiotic prophylaxis to prevent dental-associated PJI in the highest risk patients. Insufficient data exist to recommend the optimal treatment for patients with PJI in THA and TKA associated with dental procedures.

HTX-011 Reduced Pain and Opioid Use After Primary Total Knee Arthroplasty: Results of a Randomized Phase 2b Trial.

BACKGROUND: HTX-011 is an extended-release, dual-acting local anesthetic consisting of bupivacaine and low-dose meloxicam in a novel polymer that is administered by needle-free application during surgery. The active ingredients are released from the polymer by controlled diffusion over 72 hours. METHODS: This phase 2b, double-blind, placebo-controlled and active-controlled trial enrolled patients undergoing primary unilateral total knee arthroplasty under general anesthesia. Two hundred thirty-two patients were randomized into 4 groups: HTX-011 400 mg bupivacaine/12 mg meloxicam, applied without a needle into the surgical site, the same dose of HTX-011 with a separate 50 mg ropivacaine injection into the posterior capsule, bupivacaine hydrochloride (HCl) 125 mg injection, and saline placebo injection. Only opioids were permitted for postoperative pain rescue. Primary and key secondary endpoints were mean area under the curve of pain intensity scores over 48 hours and 72 hours, respectively, for HTX-011 groups vs placebo. RESULTS: Both HTX-011 groups had significantly reduced mean pain intensity vs placebo through 48 and 72 hours (both P < .001). Ropivacaine added a small initial benefit in the first 12 hours. Both HTX-011 groups also had decreased mean pain intensity vs bupivacaine HCl alone through 48 and 72 hours (P < .05). The HTX-011 groups had significantly earlier discharge readiness along with lower opioid consumption through 72 hours. HTX-011 alone or with ropivacaine was well-tolerated with a safety profile similar to controls. CONCLUSION: Needle-free application of HTX-011 400 mg bupivacaine/12 mg meloxicam provided superior pain reduction through 72 hours after total knee arthroplasty compared with placebo and bupivacaine HCl alone.

Knee or Spine Surgery First? A Survey of Treatment Order for Patients With Concurrent Degenerative Knee and Lumbar Spinal Disorders.

BACKGROUND: Total knee arthroplasty (TKA) and lumbar spine surgery have been reported to affect the outcomes of each other. There is insufficient evidence to guide the choice of treatment order for patients with both disorders that are equally symptomatic. METHODS: Five clinical scenarios of concurrent, advanced, degenerative knee and lumbar spinal disorders were designed to survey surgeons' choices of treatment order and rationale. The spinal disorder was consistently degenerative lumbar spinal stenosis, but the knee conditions varied to include (1) osteoarthritis (OA) with varus deformity, (2) OA with valgus deformity, (3) rheumatoid arthritis with a severe flexion contracture, (4) OA without deformity, and (5) bilateral OA with windswept deformities. The survey was distributed to selected clinical members of the Knee Society and Scoliosis Research Society in North America. The surgeons' choices were compared among the 5 scenarios, and their comments were analyzed using text-mining. RESULTS: Responses were received from 42 of 74 (57%) knee arthroplasty surgeons and 55 of 100 (55%) spine surgeons. The percentages of knee arthroplasty surgeons recommending "TKA first" differed significantly among scenarios: 29%, 79%, 55%, 7%, and 81% for scenarios 1 through 5, respectively (P < .001). A similar pattern was noted for the spine surgeons. CONCLUSION: For patients with concurrent degenerative knee and lumbar spinal disorders, the severity and type of knee deformity influenced the preference of treatment order in both specialties. Severe valgus deformity and windswept deformities of the knee would drive the decision toward "TKA first."

Surgeon-Performed High-Dose Bupivacaine Periarticular Injection With Intra-Articular Saphenous Nerve Block Is Not Inferior to Adductor Canal Block in Total Knee Arthroplasty.

BACKGROUND: Periarticular injection or anesthesiologist-performed adductor canal block are commonly used for pain management after total knee arthroplasty. A surgeon-performed, intra-articular saphenous nerve block has been recently described. There is insufficient data comparing the efficacy and safety of these methods. METHODS: This is a retrospective two-surgeon cohort study comparing short-term perioperative outcomes after primary total knee arthroplasty, in 50 consecutive patients with surgeon-performed high-dose periarticular injection and intra-articular saphenous nerve block (60 mL 0.5% bupivacaine, 30 mL saline, 30mg ketorolac) and 50 consecutive patients with anesthesiologist-performed adductor canal catheter (0.25% bupivacaine 6 mL/h infusion pump placed postoperatively with ultrasound guidance). Chart review assessed pain scores through POD #1, opioid use, length of stay, and short-term complications, including local anesthetic systemic toxicity. Statistical analysis was performed with two-tailed Student's T-test. RESULTS: The high-dose periarticular injection cohort had significantly lower pain scores in the postanesthesia care unit (mean difference 1.4, P = .035), on arrival to the inpatient ward (mean difference 1.7, P = .013), and required less IV narcotics on the day of surgery (mean difference 6.5 MME, P = .0004). There was no significant difference in pain scores on POD #1, total opioid use, day of discharge, or short-term complications. There were no adverse events related to the high dose of bupivacaine. CONCLUSION: Compared with postoperative adductor canal block catheter, an intraoperative high-dose periarticular block demonstrated lower pain scores and less IV narcotic use on the day of surgery. No difference was noted in pain scores on POD #1, time to discharge, or complications. There were no cardiovascular complications (local anesthetic systemic toxicity) despite the high dose of bupivacaine injected. LEVEL OF EVIDENCE: III.