Assessing Pelvic Tilt in Patients Undergoing Total Hip Arthroplasty Using Sensor Technology.

BACKGROUND: The purpose of our study was to assess the accuracy of a commercially available wearable sensor in replicating pelvic tilt movement in both the sitting and standing position in patients before total hip arthroplasty. METHODS: This prospective study evaluated patients undergoing a primary unilateral total hip arthroplasty by a single surgeon. Patients were excluded if they had a body mass index (BMI) greater than 40 kg/m2. Two sensors were adhered directly to patients' skin at S2 and T12. The S2 angle was recorded on the sensor at maximum flexion and extension angles and compared with pelvic tilt measurements on both sitting and standing radiographs. The primary outcomes recorded were patients' pelvic tilts measured using radiographs (PT-RAD) and sensors (PT-SEN), with Pearson correlation coefficients and intraclass correlation coefficients (ICCs) calculated. RESULTS: Sixty-one patients (35 males and 26 females) with an average age of 61.5 ± 8.5 years and BMI of 26.9 ± 4.1 kg/m2 were analyzed. The mean prestanding PT-RAD and PT-SEN were 1.5 ± 8.3 and 1.0 ± 8.1, respectively, with an ICC of 0.98 (95% confidence interval, 0.96-0.99). The mean presitting PT-RAD and PT-SEN were -21.9 ± 12.5 and -20.9 ± 11.7, respectively, with an ICC of 0.97 (95% confidence interval, 0.95-0.98). The multiple R2 was 0.95 for the prestanding and presitting comparisons. The R2 for all comparisons between PT-RAD and PT-SEN was >0.85, regardless of BMI or sex. CONCLUSIONS: Although the use of wearable technology may have limitations, based on our results, a wearable sensor is accurate in replicating pelvic tilt movement.

Head-to-Head Comparison of Kinematic Alignment Versus Mechanical Alignment for Total Knee Arthroplasty.

BACKGROUND: Seeing as there are many alignment strategies for total knee arthroplasty (TKA), we need to determine differences between them in a rigorous scientific way. Therefore, we sought to compare perioperative and postoperative functional outcomes in patients undergoing TKA for varus osteoarthritis with a mechanical alignment target vs a kinematic alignment target, both executed with the same implant and same technological guidance. METHODS: One hundred consecutive patients who underwent TKA using a mechanical alignment technique were 1:1 matched to 100 patients who underwent TKA using a kinematic alignment (KA) technique, using the same implant and robotic technology. Patient-reported outcomes were measured postoperatively at 1 and 2 years. Power analysis revealed 94 patients to detect a significant difference. RESULTS: Mean Visual Analog Scale scores were higher in the mechanical alignment group during the first 6 weeks (P = .04), but statistically similar at 1 year. Six-week Veterans RAND 12 Item Health Survey mental and physical components were statistically similar (P = .1). Patients did not differ in 6-week or 1-year knee range of motion (P > .43). Knee Injury and Osteoarthritis Outcome Score Joint Replacement was significantly better in the KA group at 6 weeks, 1 year, and 2 years (P = .09). Forgotten Joint Score at 1 and 2 years postoperatively were significantly higher in the KA group (P < .001). CONCLUSION: Patients undergoing TKA with KA experienced less pain in 6 weeks after surgery, and higher Forgotten Joint Scores at 1 and 2 years postoperatively. Alternative TKA alignment and balancing strategies should be considered to increase patient satisfaction.

The journey to preventing dislocation after total hip arthroplasty : how did we get here?

Dislocation following total hip arthroplasty (THA) is a well-known and potentially devastating complication. Clinicians have used many strategies in attempts to prevent dislocation since the introduction of THA. While the importance of postoperative care cannot be ignored, particular emphasis has been placed on preoperative planning in the prevention of dislocation. The strategies have progressed from more traditional approaches, including modular implants, the size of the femoral head, and augmentation of the offset, to newer concepts, including patient-specific component positioning combined with computer navigation, robotics, and the use of dual-mobility implants. As clinicians continue to pursue improved outcomes and reduced complications, these concepts will lay the foundation for future innovation in THA and ultimately improved outcomes. Cite this article: Bone Joint J 2022;104-B(1):8-11.

Preoperative spinopelvic hypermobility resolves following total hip arthroplasty.

AIMS: Spinopelvic mobility plays an important role in functional acetabular component position following total hip arthroplasty (THA). The primary aim of this study was to determine if spinopelvic hypermobility persists or resolves following THA. Our second aim was to identify patient demographic or radiological factors associated with hypermobility and resolution of hypermobility after THA. METHODS: This study investigated patients with preoperative posterior hypermobility, defined as a change in sacral slope (SS) from standing to sitting (ΔSSstand-sit) ≥ 30°. Radiological spinopelvic parameters, including SS, pelvic incidence (PI), lumbar lordosis (LL), PI-LL mismatch, anterior pelvic plane tilt (APPt), and spinopelvic tilt (SPT), were measured on preoperative imaging, and at six weeks and a minimum of one year postoperatively. The severity of bilateral hip osteoarthritis (OA) was graded using Kellgren-Lawrence criteria. RESULTS: A total of 136 patients were identified as having preoperative spinopelvic hypermobility. At one year after THA, 95% (129/136) of patients were no longer categorized as hypermobile on standing and sitting radiographs (ΔSSstand-sit < 30°). Mean ΔSSstand-sit decreased from 36.4° (SD 5.1°) at baseline to 21.4° (SD 6.6°) at one year (p < 0.001). Mean SSseated increased from baseline (11.4° (SD 8.8°)) to one year after THA by 11.5° (SD 7.4°) (p < 0.001), which correlates to an 8.5° (SD 5.5°) mean decrease in seated functional cup anteversion. Contralateral hip OA was the only radiological predictor of hypermobility persisting at one year after surgery. The overall reoperation rate was 1.5%. CONCLUSION: Spinopelvic hypermobility was found to resolve in the majority (95%) of patients one year after THA. The increase in SSseated was clinically significant, suggesting that current target recommendations for the hypermobile patient (decreased anteversion and inclination) should be revisited. Cite this article: Bone Joint J 2021;103-B(12):1766-1773.

2021 Otto Aufranc Award: A simple Hip-Spine Classification for total hip arthroplasty : validation and a large multicentre series.

AIMS: Patients with spinal pathology who undergo total hip arthroplasty (THA) have an increased risk of dislocation and revision. The aim of this study was to determine if the use of the Hip-Spine Classification system in these patients would result in a decreased rate of postoperative dislocation in patients with spinal pathology. METHODS: This prospective, multicentre study evaluated 3,777 consecutive patients undergoing THA by three surgeons, between January 2014 and December 2019. They were categorized using The Hip-Spine Classification system: group 1 with normal spinal alignment; group 2 with a flatback deformity, group 2A with normal spinal mobility, and group 2B with a stiff spine. Flatback deformity was defined by a pelvic incidence minus lumbar lordosis of > 10°, and spinal stiffness was defined by < 10° change in sacral slope from standing to seated. Each category determined a patient-specific component positioning. Survivorship free of dislocation was recorded and spinopelvic measurements were compared for reliability using intraclass correlation coefficient. RESULTS: A total of 2,081 patients met the inclusion criteria. There were 987 group 1A, 232 group 1B, 715 group 2A, and 147 group 2B patients. A total of 70 patients had a lumbar fusion, most had L4-5 (16; 23%) or L4-S1 (12; 17%) fusions; 51 patients (73%) had one or two levels fused, and 19 (27%) had > three levels fused. Dual mobility (DM) components were used in 166 patients (8%), including all of those in group 2B and with > three level fusions. Survivorship free of dislocation at five years was 99.2% with a 0.8% dislocation rate. The correlation coefficient was 0.83 (95% confidence interval 0.89 to 0.91). CONCLUSION: This is the largest series in the literature evaluating the relationship between hip-spine pathology and dislocation after THA, and guiding appropriate treatment. The Hip-Spine Classification system allows surgeons to make appropriate evaluations preoperatively, and it guides the use of DM components in patients with spinopelvic pathology in order to reduce the risk of dislocation in these high-risk patients. Cite this article: Bone Joint J 2021;103-B(7 Supple B):17-24.

Mental Health in Patients Undergoing Orthopaedic Surgery: Diagnosis, Management, and Outcomes.

¼: Mental health and psychosocial factors play a critical role in clinical outcomes in orthopaedic surgery. ¼: The biopsychosocial model of disease defines health as a product of physiology, psychology, and social factors and, traditionally, has not been as emphasized in the care of musculoskeletal disease. ¼: Improvement in postoperative outcomes and patient satisfaction is incumbent upon the screening, recognition, assessment, and possible referral of patients with high-risk psychosocial factors both before and after the surgical procedure.

An Overview of Telehealth in Total Joint Arthroplasty.

With the increase in technological advances over the years, telehealth services in orthopedic surgery have gained in popularity, yet adoption among surgeons has been slow. With the onset of the COVID-19 pandemic, however, orthopedic surgery practices nationwide have accelerated adaptation to telemedicine. Telehealth can be effectively applied to total joint arthroplasty, with the ability to perform preoperative consultations, postoperative follow-up, and telerehabilitation in a virtual, remote manner with similar outcomes to in-person visits. New technologies that have emerged, such as virtual goniometers, wearable sensors, and app-based patient questionnaires, have improved clinicians' ability to conduct telehealth visits. Benefits of using telehealth include high patient satisfaction, cost-savings, increased access to care, and more efficiency. Notably, some challenges still exist, including widespread accessibility and adaptation of new technologies, inability to conduct an in-person orthopedic physical examination, and regulatory barriers, such as insurance reimbursement, increased medicolegal risk, and privacy and confidentiality concerns. Despite these hurdles, telehealth is here to stay and can be successfully incorporated in any total joint arthroplasty practice with the appropriate adjustments.

Applying the Hip-Spine Relationship: What X-Rays and Measurements Are Important?

Understanding spinopelvic motion and the dynamic relationship of the hip, spine, and pelvis is essential in decreasing the risk of instability after total hip arthroplasty. The hip-spine relationship is complex, and a detailed analysis of each patient's spinopelvic mobility is warranted to help guide safe acetabular component positioning. Through the use of a standing anteroposterior pelvis X-ray, lateral spinopelvic radiographs in the standing and seated position, and advanced functional imaging, key spinopelvic parameters can be obtained. A systematic preoperative workup can help to identify hip-spine pathology that predisposes patients to instability, and can help in planning and establishing a patient-specific "safe zone." Based on the presence of concomitant hip-spine pathology, patients must be evaluated thoroughly with preoperative imaging to plan for the optimal target acetabular cup position. This paper guides readers through important parameters and imaging associated to spinopelvic motion as it relates to total hip arthroplasty stability.

Does femoral morphology and stem alignment influence outcomes of cementless total hip arthroplasty with proximally coated double-tapered titanium stems?

INTRODUCTION: Stem subsidence and thigh pain can cause significant patient dissatisfaction after cementless THA. The purpose of this study was to examine the effect of proximal-femoral morphology and stem alignment on clinical outcomes using a double-tapered, cementless titanium femoral component. METHODS: We retrospectively reviewed 281 consecutive, primary THAs from 2012 to 2014 with a mean follow-up of 4 years. Preoperative radiographs were used to assess femoral neck shaft angle (FNS), canal flare index (CFI), Dorr classification, and greater trochanter (GT) overhang. Postoperative radiographs were used to determine stem alignment and 6-week follow-up radiographs were used to determine subsidence. Clinical outcomes included thigh pain, leg-length discrepancy (LLD), patient-reported outcome measures (PROMs) and revision surgeries. RESULTS: 271 stems (96%) did not subside (<4 mm) and 10 (4%) showed evidence of subsidence (>4 mm). Subsidence was significantly associated with subsequent revision surgery (p < 0.01). 278 stems (99%) were in neutral alignment and 3 in varus (1%). Alignment did not significantly influence subsidence, thigh pain, LLD, revisions, or PROMs. Femoral morphology measures (FNS, CFI, Dorr classification, and GT overhang) were not significantly associated with stem alignment, subsidence, LLD, or revisions. CFI was significantly associated with intraoperative calcar fractures (p = 0.02). GT overhang was associated with thigh pain (p = 0.03) and FNS was inversely associated with postoperative HOOS scores. CONCLUSIONS: Subsidence and proximal-femoral morphology are potential sources of postoperative morbidity in certain cementless THA patients. In accordance with prior studies, CFI was identified as a potential risk factor for intraoperative calcar fractures. More research into preoperative femoral morphologies, such as GT overhang and FNS, is warranted as these may contribute to unsatisfactory results related to cementless THA.

High Offset Stems Are Protective of Dislocation in High-Risk Total Hip Arthroplasty.

BACKGROUND: Spinal stiffness has been shown to increase risk of dislocation due to impingement and instability. Increasing anteversion of the acetabular component has been suggested to prevent dislocation, but little has been discussed in terms of femoral or global offset restoration. The purpose of this study is to quantify dislocation rates after primary THA using standard versus high-offset femoral components and to determine how differences in offset affect impingement-free range of motion in a stiff spine cohort using a novel impingement model. METHODS: A total of 12,365 patients undergoing THA from 2016 to 2018 were retrospectively reviewed to determine dislocation rates and utilization of standard- versus high-offset stems. For 50 consecutive patients with spinal stiffness, a CT-based computer software impingement modeling system assessed bony or prosthetic impingement during simulated range of motion. The model was run 5 times for each patient with varying offsets. Range of motion was simulated in each scenario to determine the degree at which impingement occurred. RESULTS: There were 51 dislocations for a 0.41% dislocation rate. Total utilization of high-offset stems in the entire cohort was 49%. Of those patients who sustained a dislocation, 49 (96%) utilized a standard-offset stem. The impingement modeling demonstrated 5 degrees of added range of motion until impingement for every 1 mm offset increase. CONCLUSION: In the impingement model, high-offset stems facilitated greater ROM before bony impingement and resulted in lower dislocation rates. In the setting of high-risk THA due to spinal stiffness, surgeons should consider the use of high-offset stems and pay attention to offset restoration.

Synthetic Biphasic Scaffolds versus Microfracture for Articular Cartilage Defects of the Knee: A Retrospective Comparative Study.

OBJECTIVE: The purpose of this study was to compare the results of a biphasic synthetic scaffold (TruFit, Smith & Nephew) to microfracture for the treatment of knee cartilage defects and identify patient- and lesion-specific factors that influence outcomes. DESIGN: Prospectively collected data from 132 patients (mean age, 41.8 years; 69% male) with isolated chondral or osteochondral femoral defects treated with biphasic synthetic scaffolds (n = 66) or microfracture (n = 66) were reviewed. Clinical outcomes were evaluated longitudinally over 5 years with the Short Form-36 (SF-36), Activities of Daily Living of the Knee Outcome Survey (KOS-ADL), International Knee Documentation Committee (IKDC), and Marx Activity Scale. Cartilage-sensitive magnetic resonance imaging (MRI) was performed to evaluate osseous integration and cartilage fill in a subgroup of patients. Multivariate regression analysis was used to identify predictors of clinical outcomes within the scaffold group. RESULTS: Both groups demonstrated clinically significant improvements in knee clinical scores over 5 years (P < 0.01). There were no significant differences in KOS-ADL and IKDC scores between groups up to 5 years postoperatively. Marx activity level scores in the microfracture group declined over time, while significant improvements in activity level scores were observed in the scaffold group over 5 years (P < 0.01). Good-quality tissue fill and cartilage isointensity were more often observed in the scaffold group compared with the microfracture group, particularly with longer time intervals. Increasing age, high body mass index, prior microfracture, and traumatic etiology were predictors for inferior outcomes in the scaffold group. CONCLUSIONS: Activity level and MRI appearance following treatment of cartilage lesions with the biphasic synthetic scaffold were superior to microfracture over time in this nonrandomized, retrospective comparison.

Lewinnek Safe Zone References are Frequently Misquoted.

BACKGROUND: Optimal acetabular component orientation in total hip arthroplasty (THA) is a necessity in achieving a stable implant. Although there has been considerable debate in the literature concerning the safe zone, to date, there has not been any review to determine if these references are consistent with the definition applied by Lewinnek et al. in 1978. Therefore, this article aims to examine the available literature in the PubMed database to determine how often a correct reference to the safe zone as defined by Lewinnek was applied to discussions regarding THA. METHODS: A search for literature in the PubMed database was performed for articles from 1978 to 2019. Search criteria included terms 'Lewinnek,' 'safe zone,' and 'total hip arthroplasty.' Exclusions included abstract-only articles, non-English articles, articles unrelated to THA, and those lacking full content. RESULTS: A review of literature yielded 147 articles for inclusion. Overall, only 11% (17) cited the Lewinnek article correctly. Forty-five percent (66) of articles referenced measurements in the supine position, 18% (26) referenced other positions, and 37% (55) did not specify. Nineteen percent (28) reported measurements of the acetabular cup orthogonal to the anterior pelvic plane, while 73% (108) did not, and 7% (11) did not specify. Twenty-three percent (34) measured from computed tomography scans instead of other methods. CONCLUSIONS: In the discussion of the safe zone regarding THA, only 11% of articles listed are consistent with the definition established by Lewinnek. This warrants further investigation into a consistent application of the term and its implications for THA implant stability and dislocation rates.

Correction to: At the US Epicenter of the COVID-19 Pandemic, an Orthopedic Residency Program Reorganizes.

[This corrects the article DOI: 10.1007/s11420-020-09765-5.].

Does Prosthetic or Bony Impingement Occur More Often in Total Hip Arthroplasty: A Dynamic Preoperative Analysis.

BACKGROUND: Impingement is a leading cause for instability resulting in revision total hip arthroplasty (THA). Impingement can be prosthetic, bony, or soft tissue. The purpose of this study is to investigate, using a virtual simulation, whether bony or prosthetic impingement presents first in well-positioned THAs. METHODS: Twenty-three patients requiring THA were planned for a ceramic-on-poly cementless construct using dynamic planning software. Cups were orientated at 45° inclination and 25° anteversion when standing. Femoral components and neck lengths were positioned to reproduce native anteversion and match contralateral leg length and offset. The type and location of impingement was then recorded with recreation of anterior and posterior impingement during standard and extreme ranges of motion (ROM). RESULTS: In standard ROM, flexion produced both prosthetic and bony impingement and extension resulted in prosthetic impingement in models with lipped liners. In extreme ROM, anterior impingement was 78% bony in 32-mm articulations, and 88% bony in 36-mm articulations. Posterior impingement was 65% prosthetic in 32-mm articulations, and 55% prosthetic in 36-mm articulations. Dual mobility cups showed the greatest risk of posterior prosthetic impingement in hyperextension (74%). CONCLUSION: In standard ROM, both bony and prosthetic impingement occurred in flexion, while prosthetic impingement occurred in extension in models with lipped liners. In hyperextension, prosthetic impingement was more common than bony impingement, and was exclusively the cause of impingement when a lip was used. In flexion, impingement was primarily bony with the use of a 36-mm head. The risk of posterior prosthetic impingement was greatest with dual mobility cups. LEVEL OF EVIDENCE: 3.

The Hip-Spine Relationship Simplified.

Much attention has recently been focused on the relationship between the hip and spine and its contribution to postoperative instability following total hip arthroplasty. However, the terminology can be confusing. Through an understanding of spinopelvic parameters, spinopelvic motion, and the interplay between the spine and pelvis, the surgeon can plan for and decrease the risk of instability after total hip arthroplasty. This review details spinopelvic parameters that predispose to instability and guides readers in understanding spinopelvic motion as it relates to THA instability.

Abductor Deficiency-Induced Recurrent Instability After Total Hip Arthroplasty.

¼ Operative intervention for deficient hip abductor muscles may require muscle transfer or the use of synthetic materials, possibly with biologic augmentation, to help stabilize the hip joint and prevent further dislocation following total hip arthroplasty (THA). ¼ Direct repair of the abductor mechanism onto the greater trochanter can be used in patients who present with instability <15 months following primary THA. ¼ Augmentation of soft tissue with acellular dermal allografts can be considered for patients with abductor avulsion that requires posterior capsular reconstruction. ¼ The Achilles tendon + calcaneal bone allograft is indicated for patients who have undergone multiple prior revision surgeries, who have experienced failure of nonoperative management, and have tissue inadequacy in the posterior wall of the hip joint. ¼ The gluteus maximus tendon transfer is indicated in patients with chronic abductor tears, limited or loss of function in the gluteus medius and minimus, and a fully functioning gluteus maximus. ¼ Vastus lateralis transfer may benefit patients with a history of multiple revision procedures, large separation between the gluteus medius tendon and the proximal part of the femur, and the ability to observe the postoperative protocol of splinting for 6 weeks. ¼ The latissimus dorsi tendon transfer should be reserved as a reconstructive procedure for patients with acute abductor insufficiency, such as those who have undergone extensive tumor resection. ¼ Synthetic mesh can be used to enable capsular reconstruction and prosthesis stabilization in patients undergoing salvage procedures for tumors of the hip and associated soft tissues. ¼ Synthetic ligament prostheses can be used in patients with recurrent posterior dislocations in the setting of normal components. ¼ The fascia lata plasty is indicated for patients with recurrent posterior instability without an identifiable cause. ¼ Although the quality of literature is limited, surgical interventions utilizing techniques of soft-tissue augmentation have shown promising outcomes with regard to pain relief, limping, ambulation, and the reduction of instability following THA.

Improved HCAHPS Scores with a Same Day Discharge Program for Total Hip Arthroplasty.

BACKGROUND: Total hip arthroplasty is increasingly being performed as a same day procedure. Additionally, greater emphasis is being placed on patient satisfaction surveys such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)® Survey. This study aims to assess if patients who undergo THA through a same day discharge program respond with higher HCAHPS scores. METHODS: Patients undergoing THA through our same day surgery (SDD) program at our institution from January 1, 2015, to September 2016 and completed HCAHPS surveys were compared to a cohort of patients who underwent THA as a standard inpatient and completed the HCAHPS survey during the same period. Electronic medical records were reviewed to obtain demographic data and improvement in validated patient reported outcomes measures. RESULTS: Patientsin our SDD program were significantly more likely to rate the hospital as "top box" on eight of 11 HCAHPS domains. The remaining three domains that did not reach statistical significance all showed a trend toward increased likelihood of rating the hospital in the "top box" level. For willingness to recommend, 91% of SDD patients vs. 77% of non-SDD patients (p = 0.045) rated our hospital as "top box." We had no significant difference between the groups in change from pre- to postoperative EQ-5D score or Hip Disability and Osteoarthritis Outcomes Score (HOOS). CONCLUSION: A same day surgery program can significantly improve patient satisfaction with THA as measured by the HCAHPS survey.

Computer-assisted Navigation in Hip Resurfacing Arthroplasty: A Case Study utilizing the ReCap Femoral Resurfacing System.

INTRODUCTION: The ReCap Femoral Resurfacing System has been associated with increased cases of revision surgery when compared to other hip resurfacing systems. However, computer-assisted navigation may have the potential to reduce the risk of post-operative complications by providing more accurate intraoperative measurements for acetabular component positioning. CASE REPORT: The present case describes an active 46-year-old male presenting with severe osteoarthritis of the right hip who elected to undergo a ReCap resurfacing arthroplasty with navigation. Results demonstrated accurate acetabular component position and leg length measurements to within <1° and 1mm of standard radiographic measurements. CONCLUSION: These findings are the first to describe the use of navigation with the ReCap system and provide encouraging results for further clinical evaluation.

Does Medial-Row Fixation Technique Affect the Retear Rate and Functional Outcomes After Double-Row Transosseous-Equivalent Rotator Cuff Repair?

BACKGROUND: Double-row transosseous-equivalent (TOE) rotator cuff repair techniques have been widely accepted because of their superior biomechanical properties when compared with arthroscopic single-row repair. Concerns regarding repair overtensioning with medial-row knot tying have led to increased interest in knotless repair techniques; however, there is a paucity of clinical data to guide the choice of technique. HYPOTHESIS: Arthroscopic TOE repair techniques using knotless medial-row fixation will demonstrate lower retear rates and greater improvements in the Constant score relative to conventional knot-tying TOE techniques. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review of 3 databases (PubMed, Cochrane, and Embase) was performed using PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Inclusion criteria were English-language studies that examined repair integrity or Constant scores after arthroscopic rotator cuff repair with TOE techniques. Two investigators independently screened results for relevant articles. Data regarding the study design, surgical technique, retear rate, and Constant shoulder score were extracted from eligible studies. A quality assessment of all articles was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: The systematic review identified a total of 32 studies (level of evidence, 1-4) that met inclusion and exclusion criteria. Of the 32 studies, 5 reported on knotless TOE techniques, 25 reported on knot-tying TOE techniques, and 2 reported on both. In the knotless group, retear rates ranged from 6% to 36%, and Constant scores ranged from 38-65 (preoperative) to 73-83 (postoperative). In the knot-tying group, retear rates ranged from 0% to 48%, and Constant scores ranged from 42-64 (preoperative) to 55-96 (postoperative). CONCLUSION: Despite several theoretical advantages of knotless TOE repair, both knotless and knot-tying techniques reported considerable improvement in functional outcomes after rotator cuff repair. Although tendon failure rates showed a downward trend in knotless studies, additional prospective studies are warranted to better understand the role of medial-row fixation on tendon repair integrity and postoperative clinical outcomes.

Control Strategies for Infection Prevention in Total Joint Arthroplasty.

Despite the development of newer preventative measures, the rate of infection continues to be approximately 1% for patients undergoing total joint arthroplasty (TJA). The extent of the infection can range from a mild superficial infection to a more serious periprosthetic joint infection (PJI). PJIs not only play a significant role in the clinical well-being of the TJA patient population, but also have substantial economic implications on the health care system. Several approaches are currently being used to mitigate the risk of PJI after TJA. The variety of prophylactic measures to prevent infection after TJA must be thoroughly discussed and evaluated.