Early Postoperative Femur Fracture After Uncemented Collarless Primary Total Hip Arthroplasty: Characterization and Results of Treatment.

Thirty Vancouver type B periprosthetic fractures occurred within 90 days of total hip arthroplasty were identified using two institutional databases. Twenty-eight of these fractures were of a stereotyped fracture pattern consisting of a displaced fracture of the femoral neck including the lesser trochanter and a variable amount of the proximal medial femoral cortex creating a roughly triangular fragment. Time from operation until fracture was 2-88 days (mean 28). Mechanism of injury was fall from standing height in 12, no defined trauma in 11, stumble without fall in 5, and twisting motion in 2. Fracture treatment consisted of femoral revision in 24, fracture fixation in two, and nonoperative in four. Of the 24 treated with revision, 21 had healed fractures and stable revision stems.

Tourniquet use during cementation only during total knee arthroplasty: a randomized trial.

BACKGROUND: Total knee arthroplasty with the use of a tourniquet during the entire operation has not been shown to improve the performance of the operation and may increase the risk of complications. QUESTIONS/PURPOSES: We asked whether the limited use of a tourniquet for cementation only would affect (1) surgical time; (2) postoperative pain and motion of the knee; (3) blood loss; or (4) complications such as risk of nerve injuries, quadriceps dysfunction, and drainage compared with use of a tourniquet throughout the procedure. METHODS: Seventy-one patients (79 knees) were randomized to either use of a tourniquet from the incision through cementation of the implants and deflated for closure (operative tourniquet group) or tourniquet use only during cementation (cementation tourniquet group). The initial study population was a minimum of 30 knees in each group as suggested for randomized studies by American Society for Testing and Materials standards; termination of the study was determined by power analysis performed after 40 knees in each group showed any statistical solution to our questions would require a minimum of 260 more cases. Patients were excluded who were considered in previous randomized studies as high risk for complications, which might be attributed to the tourniquet. RESULTS: There were no differences in terms of surgical time, pain scores, pain medicine requirements, range of motion, hemoglobin change, or total blood loss. One major complication (compartmental syndrome) occurred in a patient with tourniquet inflation until closure. No other complications were attributed to the use of a tourniquet. CONCLUSIONS: With the numbers available, our results suggest that there are no important clinical differences between patients who had a tourniquet inflated throughout the procedure compared with those who had it inflated only during cementation. Tourniquet inflation for cementation only provides the benefit of bloodless bone for fixation and may eliminate the risks associated with prolonged tourniquet use.

Primary hip arthroplasty with 28-mm Metasul articulation.

This follow-up study reports on 69 patients at mean 13 years with total hip arthroplasty using 28-mm Metasul (Zimmer, Winterthur, Switzerland) metal-on-metal articulation. These results are not transferable to large-diameter head metal-on-metal articulations. Four new revisions, 3 for disassociation of the liner and 1 for mechanical loosening of the acetabulum, occurred since the previous report of mean 7.3 years. The prevalent cause of late revision is disassociation, which suggests a high frictional torque or impingement in these articulation surfaces. No revision was done for osteolysis. Overall, of the original 127 hips, 116 (91%) were known to have maintained their original components.

Failure of the Durom Metasul acetabular component.

UNLABELLED: Large-diameter metal-on-metal articulations reportedly provide better stability and range of motion than smaller diameter bearings. We therefore asked whether a large-diameter (44- to 50-mm) metal-on-metal articulation (Durom) would eliminate dislocation and provide similar functional scores and clinical and radiographic failure rates as those with 28-mm articulation. We prospectively followed 181 patients (207 hips) who had a large-diameter articulation implanted between May 2006 and November 2007. We compared these patients with a historical control of 54 patients who had a small-diameter (28-mm Metasul) articulation. All patients had a Harris hip score and a self-assessment of outcome and radiographic followup. The minimum followup was 1 year (mean, 1.6 years; range, 1-2 years). During the followup period, we performed revisions on 29 patients (30 hips [15%]) with 21 of 29 (72%) having radiographic criteria of loosening. Thirteen retrieved cups and acetabular tissue were examined histologically. Twenty-eight of 151 unrevised patients had radiographic impending failure; 12 without revision had clinical failure. Eight patients (nine hips) had both clinical failure and impending radiographic failure. Cup inclination was 41.3 degrees +/- 5.4 degrees and anteversion was 20.2 degrees +/- 7 degrees. The revision rate and quality of clinical results were unacceptable as compared with our historical controls. We do not recommend use of the Durom implant. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Outpatient total hip arthroplasty.

Patients younger than 65 years were studied to determine what percentage of patients would enroll in a study of outpatient total hip arthroplasty, its safety, and benefits of the program. Of 192 eligible patients, 69 (36%) enrolled, and 53 (77%) of these went home the same day of surgery. Of 53, 44 maintained a diary for the first 3, weeks and 52 completed a satisfaction questionnaire at 6 weeks. Patients were followed for 6 months for occurrence of complications. There were no medical readmissions. Of 52 patients who completed a 6 week questionnaire, 50 (96%) were satisfied with the decision to have outpatient total hip arthroplasty. There were no objective physical benefits identified. This study reports the distribution of acceptance and completion of same day discharge for patients with total hip arthroplasty in a metropolitan population. It confirms safety in selected patients.

Impingement as a mechanism of dissociation of a metasul metal-on-metal liner.

This case report is of a patient with disassociation of the acetabular cup liner caused by impingement. The cup inclination (39 degrees) and anteversion (24 degrees) were good as measured by computer navigation. Impingement occurred because the head-neck ratio was 2.0, and the hip length and offset were short by one head length. Successful revision without intraoperative impingement was accomplished with one size head larger (32 mm; head-neck ratio, 2.3) and one size longer to correct hip length and offset.

Multimodal analgesia without parenteral narcotics for total knee arthroplasty.

Use of parenteral narcotics after total knee arthroplasty is considered by most orthopedic surgeons to be the standard of care. This study tested the hypothesis that a multimodal oral pain medication protocol could control pain and minimize complications of parenteral narcotics. Postoperative oral analgesia was augmented with either continuous epidural infusion or continuous femoral infusion using ropivacaine only. Seventy patients had total knee arthroplasty with a protocol that included preemptive oral analgesics, epidural anesthesia, pericapsular analgesic injection, and postoperative analgesia without parenteral opioids. The average daily pain score was less than 4 out of 10, nausea occurred in 15 patients (21%), emesis in 1 patient (1.4%), and there were no severe complications. This study proved the hypothesis that pain after total knee arthroplasty could be effectively managed without routine use of parenteral opioids.

Functional recovery of muscles after minimally invasive total hip arthroplasty.

Whether mini-incision total hip arthroplasty is associated with accelerated postoperative recovery is a subject of considerable controversy. A study was conducted to compare objective outcomes using gait analysis as a measure for recovery of function in patients treated with three different minimally invasive surgical approaches and the traditional posterior approach. Sixty-nine patients underwent instrumented gait analysis at self-selected and fast velocities preoperatively and at 6 weeks and 3 months postoperatively. Four surgical groups were studied-30 treated with posterior mini-incisions, 11 anterolateral, 10 anterior Judet, and 18 traditional posterior long incisions. Overall, gait velocity increased slightly at 6 weeks and significantly at 3 months. However, there were no significant differences between groups for velocity, cadence, stride length, single-limb support time, or double-limb support time at 6 weeks or 3 months postoperatively. These data indicate that patients undergoing total hip arthroplasty with any of these surgical approaches recover muscle function, as measured by gait analysis, to preoperative levels within 6 weeks postoperatively. No advantage was shown with the use of any of the three different small-incision approaches. This finding suggests that the amount of muscle, or the particular muscle cut, does not have a significant effect on the recovery of postoperative gait function.

Metal-on-metal hip arthroplasty does equally well in osteonecrosis and osteoarthritis.

Many previous reports suggest total hip arthroplasty performs suboptimally in young patients with osteonecrosis. We retrospectively compared the performance of metal-on-metal articulation in a select group of 107 patients with 112 hips (98 uncemented and 14 cemented stems) 60 years of age or younger with either osteonecrosis (27 patients, 30 hips) or primary osteoarthritis (80 patients, 82 hips). We evaluated all patients with patient-generated Harris hip score forms and serial radiographs. Five mechanical complications were caused by impingement, two with pain, two dislocations, and one liner dissociation. At a minimum followup of 2.2 years (mean, 5.5 years; range, 2.2-11.7 years), we observed no osteolysis or aseptic loosening in the osteonecrosis group, whereas one osteoarthritic hip had cup revision for loosening (none showed evidence of osteolysis). None of the stems were loose. Patients with osteonecrosis or primary osteoarthritis were similar in clinical and radiographic performance. The patients with metal-on-metal hip arthroplasty for osteonecrosis had no revisions for aseptic loosening, but did have one liner change in a cup for painful impingement.

Multimodal thromboprophylaxis for total hip and knee arthroplasty based on risk assessment.

BACKGROUND: Orthopaedic surgeons are increasingly challenged to find a prophylaxis regimen that protects patients from thromboembolism while minimizing adverse clinical outcomes such as bleeding. We used a multimodal approach in which the treatment regimen is selected according to patient risk factors. METHODS: We retrospectively reviewed the records on 1179 consecutive total joint arthroplasties in 970 patients who had undergone primary and revision total hip and total knee replacement. Preoperatively, patients were assigned to one of two deep venous thrombosis prophylactic regimens on the basis of an assessment of their risk factors. Eight hundred and fifty-six patients (1046 operations) were considered to be low risk and were managed with aspirin, dipyridamole, or clopidogrel bisulfate as well as intermittent pneumatic calf compression devices. One hundred and fourteen patients (133 operations) were considered to be high risk and were managed with low-molecular-weight heparin or warfarin and intermittent calf compression. All patients were mobilized from bed within twenty-four hours after surgery, and all underwent Doppler ultrasonography within the twenty-four hours before hospital discharge. All of the patients were followed for six months postoperatively. The prevalence of asymptomatic and symptomatic distal and proximal deep venous thrombosis, symptomatic and fatal pulmonary emboli, overall mortality, and bleeding complications was determined. Thrombotic events were expressed as a percentage of 1179 operations because some patients had two or more operations. RESULTS: Overall, there were no fatal pulmonary emboli, three symptomatic pulmonary emboli (prevalence, 0.25%), and five clinically symptomatic deep venous thrombi (0.4%). Sixty-one asymptomatic deep venous thrombi (5.2%) were found with use of routine postoperative Doppler ultrasound scans. There were three deaths (prevalence, 0.25%) that were unrelated to thromboembolism, and there were two nonfatal gastrointestinal bleeding events (prevalence, 0.17%). Wound hematomas occurred in association with five (0.4%) of the 1179 operations. Three nonfatal pulmonary emboli (prevalence, 0.3%) were detected in association with the 1046 procedures in the low-risk group, and none were detected in association with the 133 operations in the high-risk group (p = 0.767). Clinically symptomatic deep venous thrombosis was detected in association with four (0.38%) of the 1046 operations in the low-risk group and one (0.75%) of the 133 operations in the high-risk group (p = 0.93). Asymptomatic distal deep venous thrombosis was detected in association with thirty-seven (3.5%) of the 1046 procedures in the low-risk group and four (3.0%) of the 133 operations in the high-risk group. Asymptomatic proximal thrombosis was detected in association with fourteen (1.3%) of the 1046 procedures in the low-risk group and six (4.5%) of the 133 procedures in the high-risk group (p = 0.03). Wound hematomas occurred only in patients being managed with warfarin or low-modular-weight heparin (p = 0.0001). CONCLUSIONS: A multimodal thromboembolic prophylactic regimen is consistent with protecting patients while limiting adverse clinical outcomes secondary to thromboembolic, vascular, and bleeding complications.

Precision and bias of imageless computer navigation and surgeon estimates for acetabular component position.

Computer navigation has the potential to permit accurate placement of components. We first hypothesized acetabular inclination and anteversion using navigation would be within 5 degrees of postoperative computed tomography scans, then secondly, computer precision would be better than that of surgeons. In the first phase, we obtained postoperative CT scans in 30 hips to ascertain the computer navigation values for inclination and anteversion of the cup. In the second phase, in 99 patients with 101 hips, we determined the surgeon's precision by comparing surgeons' blind estimates for trial cup position with computer navigation values. The navigation precision for inclination was 4.4 degrees with a bias of 0.03 degrees and for anteversion was 4.1 degrees with a bias of 0.73 degrees. The experienced surgeons' precision was 11.5 degrees for inclination and 12.3 degrees for anteversion, whereas the less experienced surgeons' precision was 13.1 degrees for inclination and 13.9 degrees for anteversion. The data supported the first hypothesis as computer navigation had a bias for inclination and anteversion of less than 1 degrees with precision less than 5 degrees. The precision of computer navigation was better than that of surgeons. This imageless computer navigation system allows more accurate acetabular component placement.

Early pain relief and function after posterior minimally invasive and conventional total hip arthroplasty. A prospective, randomized, blinded study.

BACKGROUND: Few prospective randomized studies have demonstrated benefits of minimally invasive total hip arthroplasty when compared with conventional total hip arthroplasty. We hypothesized that patients treated with a posterior mini-incision would have better results than those treated with a posterior long incision with regard to the achievement of established goals for pain relief and functional recovery permitting hospital discharge by the second postoperative day. METHODS: Sixty of 231 eligible patients were randomized (with thirty in each group) to have a total hip arthroplasty performed through either a posterior mini-incision (10 +/- 2 cm) or a traditional long incision (20 +/- 2 cm). After completion of the total hip arthroplasty, the mini-incision group underwent extension of the skin incision to 20 cm. Patients were evaluated on the basis of self-determined pain scores, requirements for pain medicine, need for assistive gait devices, and time until discharge. Gait analysis provided objective functional assessment. RESULTS: The average hospital stay was 63.2 +/- 13.3 hours in the mini-incision group and 73.6 +/- 23.5 hours in the long-incision group (p = 0.04). More patients with a mini-incision were discharged by the second postoperative day (p = 0.003) and more were using just a single assistive device at the time of discharge (p = 0.005). As scored on a verbal analog scale of 0 to 10 points, patients with a mini-incision had less pain on each postoperative day and the pain score remained significantly lower at the time of discharge (mean, 2.2 +/- 1.0 points compared with 3.1 +/- 0.9 points in the long-incision group; p = 0.002). After hospital discharge, there were no clinical differences in pain or function between the two groups of patients. CONCLUSIONS: Compared with conventional total hip arthroplasty performed through a posterior incision, posterior minimally invasive total hip arthroplasty resulted in better early pain control, earlier discharge to home, and less use of assistive devices. Subsequent evaluations at six weeks and three months showed equivalency between the clinical results in the two groups. LEVEL OF EVIDENCE: Therapeutic Level I.

Psychologic reasons for patients preferring minimally invasive total hip arthroplasty.

Success of an orthopaedic operation depends on patients achieving their primary goal(s) and having satisfaction with the outcome. The enthusiasm of patients for minimally invasive total hip arthroplasty seems related to satisfaction with the operation. We hypothesized patients' attitude toward a small incision would increase their confidence and satisfaction with the operation but the importance of the incision would dissipate after patients realized their goals of pain relief and functional recovery. One hundred sixty-five patients responded to a 14-question patient-perception questionnaire preoperatively and 6 weeks postoperatively and a followup survey at 6 months to 1 year postoperatively. One hundred nine patients had small incisions (mean, 9.6 cm) and 56 had long incisions (mean, 17.9 cm). Preoperatively patients expected small-incision surgery would positively influence their primary goals and satisfaction; at 6 weeks postoperative they believed more strongly that this was true. By 6 months to 1 year, the importance of the incision diminished because 100% of patients met their primary goals. Forty percent of patients with a long incision were not satisfied and the reasons given were related to the process of reincorporating their injured hip into their whole-body image. We confirmed our first hypothesis that a small incision influences a patient's satisfaction postoperatively; we could not confirm our second hypothesis that incision length did not matter after attaining primary goals.

Periprosthetic femoral fractures associated with contralateral hip disease.

Femoral osteolysis associated with contralateral hip degenerative changes is a risk factor for ipsilateral periprosthetic femoral fracture. We report 5 comminuted proximal shaft fractures around loose femoral implants occurring in patients with both symptomatic femoral lysis and a painful hip on the other side. Our evolving strategy involves timely revision surgery once this pattern is recognized. Once fracture has occurred, emergent revision requires extensive medical evaluation, availability of long-stem revision implants, and appropriate instrumentation and allografts for fracture fixation.

The clinical performance of metal-on-metal as an articulation surface in total hip replacement.

The metal-on-metal articulations in total hip arthroplasty (THA) were widely used between 1960 and 1975. The McKee-Farrar and other first-generation prostheses failed at a high rate because impingement caused early component loosening. The problem of early component loosening was corrected by improved component design and better manufacturing quality. Second-generation metal-on-metal total hip replacements have experienced short and medium-term success as assessed by Harris Hip Scores and patient self-assessment. The combined annual linear wear of the metal-on-metal femoral head and acetabular insert is less than 10 mm and osteolysis has only rarely been observed in association with well-fixed metal-on-metal total hip replacements. Hypersensitivity is not a common cause of loosening with second-generation hip replacements and remains to be proven as a definitive diagnosis in unusual cases of unexplained pain. More than 40 years of use has demonstrated no increase in the incidence of renal failure or cancer in patients with metal-on-metal total hip replacements. The scientific evidence of the results using the metal-on-metal articulations would recommend its continued use in any patient who does not have compromised renal function.

Metal-on-metal: articulations for the new millennium.

Implants with metal-on-metal articulations (Metasul, Sulzer Medica, Winterthur, Switzerland [now Zimmer, Warsaw, IN]) have been used in nearly 300,000 total hip replacements. In three different clinical studies, clinical success has been demonstrated using this implant as measured by Harris hip scores, patient self-assessment, and assessment of mechanical complications. Of a study group of 924 patients who received this implant, the only reported complications were mechanical, incldding two cup loosenings (0.2%) and 36 dislocations (4.0%). In a randomized study, clinical resultsfor the group that received implants with metal-on-metal articulation were comparable to those of the ceramic-on-polyethylene (control) group. Reports assessing retrieved implants with metal-on-metal articulation demonstrate low annual linear wear rates and no consequences of elevated cobalt ion levels at follow-up from 4 years to 26 years. In light of these data, the continued ise of metal-on-metal articulations is recommended for any patient who does not have compromised renal function.

The argument for the use of Metasul as an articulation surface in total hip replacement.

Metasul metal-on-metal articulations have been used for 15 years in approximately 300,000 total hip replacements. We have used Metasul articulations in three clinical studies and have shown clinical success as measured by Harris hip scores and patient self-assessment; we also have had the usual mechanical complications. The only complications have been mechanical, including two cup loosenings and 24 dislocations in a total of 582 patients (619 hips; 3.8%) who had Metasul articulations and were included in these studies. In the randomized study, the group who had Metasul articulations had no clinical results or complications different from the control ceramic-on-polyethylene group. Authors of retrieval results in the literature report low annual linear wear rates and no consequences of elevated Co ion levels. Currently, the scientific evidence of the results of using the Metasul articulation would recommend its continued use in any patient who does not have compromised renal function.

An American experience with metal-on-metal total hip arthroplasties: a 7-year follow-up study.

This study reviews the clinical performance of 161 hip arthroplasties (154 patients) with the Metasul metal-on-metal articulation and an uncemented modular acetabular component. Between 1995 and 2002 clinical evaluation and radiographic follow-up of patients included Harris hip scores, patient self-assessment, and radiographs. Twelve operative site complications (7.5%) included 6 revision operations, (3.7%) and 3 other complications (1.9%) not needing reoperation. Six revision operations (3.7%) included 1 femoral revision for aseptic loosening (0.06%) and 5 acetabular revisions (3.1%). One cup revision was for recurrent dislocation, 1 for disassociation of the acetabular insert from the cup, 1 for infection, and 2 for unexplained pain. Histologic evidence did not support the diagnosis of metal hypersensitivity in either case of unexplained pain, and 1 had relief following spine surgery. A focal radiolucency, identified as calcar resorption, was observed in 9 patients.

Sarcoidosis.

A 48-year-old woman with an 8-year history of intermittently pruritic papules on the lower extremities suddenly developed pruritus and generalized spread of the lesions over a 1-month period. The lesions appeared as smooth, flat-topped, violaceous, round papules on all extremities, trunk, and back. A biopsy specimen showed sarcoidosis. Cutaneous sarcoidosis has many morphologic presentations and often mimics other dermatologic diseases. Despite widespread cutaneous involvement, she has no systemic involvement. Treatment options are reviewed.