The Conversion of Unicompartmental Knee Arthroplasty to Total Knee Arthroplasty with Non-CT Based Robotic Assistance: A Novel Surgical Technique and Case Series.

INTRODUCTION: Robotic-assisted devices help provide precise component positioning in conversion of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA). A few studies offer surgical techniques for CT-based robotic-assisted conversion of UKA to TKA, however no studies to date detail this procedure utilizing a non-CT based robotic assisted device. This paper introduces a novel technique employing a non-CT based robotic assisted device (ROSA® Knee System, Zimmer Biomet, Warsaw, IN) for converting UKA to TKA with a focus on its efficacy in gap balancing. CASE: We present three patients (ages 46 to 66) who were evaluated for conversion of UKA to TKA for aseptic loosening, stress fracture, and progressive osteoarthritis. Each patient underwent robotic-assisted conversion to TKA. Postoperative assessments at 6 months revealed improved pain, function, and radiographic stability. TECHNIQUE: Preoperative planning included biplanar long leg radiographs to determine the anatomic and mechanical axis of the leg. After arthrotomy with a standard medial parapatellar approach, infrared reflectors were pinned into the femur and tibia, followed by topographical mapping of the knee with the UKA in-situ. The intraoperative software was utilized to evaluate flexion and extension balancing and plan bony resections. Then, the robotic arm guided placement of the femoral and tibial guide pins and the UKA components were removed. After bony resection of the distal femur and proximal tibia, the intraoperative software was used to reassess the extension gap, and plan posterior condylar resection to have the flexion gap match the extension gap. CONCLUSION: The use of a non-CT based robotic assisted device in conversion of UKA to TKA is a novel technique and a good option for surgeons familiar with robotic-assisted arthroplasty, resulting in excellent outcomes at 6 months.

The Impact of Surgeon Volume on Unicompartmental Knee Arthroplasty Survivorship: A Michigan Arthroplasty Registry Collaborative Quality Initiative Database Analysis.

BACKGROUND: The utilization of unicompartmental knee arthroplasty (UKA) has remained low when compared to total knee arthroplasty (TKA), possibly due to higher rates of revision and reoperation. This study aimed to quantify surgeon UKA case-volumes and measure the effect of surgeon volume on early revision. We hypothesized that surgeons who have high case volumes would have lower revision rates compared to medium- and low-volume surgeons. METHODS: Primary UKAs were performed between February 2012 and November 2021, and associated revisions were identified utilizing the Michigan Arthroplasty Registry Collaborative Quality Initiative. Surgeon information, including total cases and annual UKA volume, was collected. Case volume per year was stratified as High (≥ 35 cases per year), Medium (15 to 34 cases per year), and low (< 15 cases per year). RESULTS: There were a total of 15,542 UKAs performed. Of these, 701 (4.5%) were revised, and 412 (58.8%) revisions occurred within 2 years. Of the 287 surgeons who performed an UKA in the registry, 237 (82.6%) were low-volume surgeons, 36 (12.5%) were medium-volume, and 14 (4.9%) were high-volume. High-volume surgeons were more likely to operate on older patients (P < 0.01), Medicare patients (P < 0.01), and patients who had American Society of Anesthesiologists scores of III and IV (P < 0.01). High-volume surgeons had significantly lower 5-year revision rates compared to medium and low-volume surgeons (high: 4.3% (95% confidence interval: 3.7 to 4.9), medium: 5.2% (4.4 to 6.1), low: 7.2% (6.4 to 8.0); P < 0.001). In comparison, the 5-year revision rate for TKA in Michigan was 3.0% (95% confidence interval: 2.9 to 3.1). CONCLUSIONS: When UKAs were performed by high-volume surgeons in the state of Michigan, there was better survivorship when compared to low-and medium-volume surgeons. High-volume surgeons were more likely to perform UKA on older patients, Medicare patients, and patients who had American Society of Anesthesiologists scores of III and IV. The revision rate for the high-volume surgeons still exceeded the 5-year revision rate for TKA in Michigan.

Survivorship of Primary NexGen Knee Replacement: Comparing Cementless Trabecular Metal to Other Designs of Tibial Component.

The impact of cementless trabecular metal (TM) implants on implant survivorship are not well delineated. This study compares primary total knee arthroplasty (TKA) revision rates of cemented knee replacements with two cementless knee replacement designs-cementless TM and a non-TM cementless design. Data from a national registry queried TKA procedures performed for osteoarthritis from 1999 to 2020. The risk of revision of Zimmer NexGen TKA using cementless TM, cementless non-TM, and cemented non-TM were compared. Analyses included Kaplan-Meier estimates of survivorship and Cox hazard ratios (HR), stratified by age and gender. Cementless TM components had higher risks of revision compared with cementless non-TM implants (HR = 1.49; p ≤ 0.001). Cementless TM implants showed higher risks of revision compared with cemented non-TM prostheses for the first 2 years (HR = 1.75, p < 0.001). Non-TM prostheses posed equal risk of revision for cementless and cemented fixations (HR = 0.95, p = 0.522). Patients aged 55 to 64 years and 65 to 74 years had a higher risk of revision for cementless TM compared with cementless non-TM (HR = 1.40, p = 0.033 and HR = 1.79, p < 0.001, respectively) and cemented non-TM implants (HR = 1.51, p < 0.001 and HR = 1.54, p < 0.001, respectively). The study shows there is an increased risk of revision with TM cementless implants for patients aged 55 to 74 years. These results do not support the use of TM tibial implants for patients of this age group for primary TKA.

Higher Annual Total Hip Arthroplasty Volume Decreases the Risk of Intraoperative Periprosthetic Femur Fractures.

BACKGROUND: Periprosthetic femur fracture (PFF) is a complication of total hip arthroplasty (THA). These occur intraoperatively or postoperatively, and documented risk factors of PFFs include women, age greater than 65 years, cementless stems, and inflammatory arthropathies. The aim of this retrospective cohort study was to assess the relationship of years of surgical experience and surgeon annual THA volume on intraoperative and postoperative PFFs. METHODS: Data were collected from a database query, and PFFs were identified as either intraoperative or postoperative. Intraoperative and postoperative PFFs were both compared to a control group of non-PFF patients. Years of surgical experience at the time of surgery and annual THA volume for the primary surgeon were calculated for all cases. Logistic regression analyses were used to calculate odds ratios for each of the surgeon variables when adjusted for patient demographics. RESULTS: Thirty-seven intraoperative and 108 postoperative PFFs were identified and compared to 7,629 controls. From regression analyses, high-volume surgeons (≥50 THA/year) had lower odds of intraoperative PFF (adjusted odds ratio (aOR) = 0.40, P = .020) but not postoperative PFF (aOR = 1.02, P = .921). Surgeon experience (≥15 years since board certification at the time of surgery), was not significantly related to either PFF outcomes. For patient factors, age ≥65 years (aOR = 2.30, P < .001) and women (aOR = 2.69, P < .001) were both significant predictors of postoperative PFFs only. CONCLUSION: Surgeons who performed 50 or more THAs per year had significantly fewer intraoperative PFFs than surgeons who did less than 50 THAs per year. Surgeon experience was not significantly related to PFFs.

The AAHKS Clinical Research Award: Oral Dexamethasone Following Total Knee Arthroplasty: A Double-Blind, Randomized Controlled Trial.

BACKGROUND: Intravenous dexamethasone has been shown to reduce pain in total joint arthroplasty. This double-blind, randomized, placebo-controlled trial investigated the postoperative effects and safety of oral dexamethasone as a potential augment to multimodal pain management in outpatient knee arthroplasty. METHODS: The authors prospectively randomized 109 consecutive patients undergoing primary total knee arthroplasty. Patients assigned to Group A (57 patients) received 4 mg of dexamethasone by mouth twice per day starting postoperative day (POD) 1 for 4 days and those assigned to Group B received placebo capsules. All healthcare professionals and patients were blinded to group allocation. The primary outcome was defined as postoperative pain scores. Secondary outcomes included 90-day postoperative complications, nausea and vomiting, daily opioid usage, assistance for ambulation, difficulty sleeping, and early patient reported outcomes. Demographics were similar between groups. RESULTS: The patients who received dexamethasone had a statistically significant decrease in VAS scores when averaging POD 1 to 4 (P = .01). The average VAS scores among individual days were significantly lower with dexamethasone on POD 2, 3, and 4. While taking dexamethasone, morning and mid-day VAS scores were significantly lower. There was no difference between the groups with opioid use, nausea or vomiting, 90-day complications, ability to walk with/without assistance, difficulty sleeping, and early patient reported outcomes. CONCLUSION: This double-blind, randomized, placebo-controlled trial demonstrated that oral dexamethasone following primary total knee arthroplasty can reduce postoperative pain. This may be a beneficial option in ambulatory surgery where intravenous limitations exist, but larger series are needed to further evaluate the safety profile in this population.

Increased Accuracy in Templating for Total Knee Arthroplasty Using 3D Models Generated from Radiographs.

Templating prior to total hip arthroplasty is a widely adopted practice that aims to improve operative efficiency and reduce clinical outliers. Predicting implant size before total knee arthroplasty (TKA), although less common, could increase operating room efficiency by reducing necessary equipment needed for the procedure. This study compared templating accuracy in TKA using two-dimensional (2D) digital radiographs to a novel imaging technology that generates a three-dimensional (3D) model from these 2D radiographs. Two hundred and two robotic-assisted primary TKA surgical cases using Persona Knee System (Zimmer Biomet, Warsaw, IN) were retrospectively analyzed. For all cases, 3D templating was completed preoperatively using a novel radiographic image acquisition protocol. Using the same radiographs, the knee was templated using a 2D digital templating program. All surgeons were blinded to the final implant sizes, and all templating was done independently. The accuracy of predictions within ± 1 from the final implant size was determined for the femoral and tibial components. The accuracy (within 1 size) of tibial size predictions was comparable between attending surgeons and residents (87 vs. 82%, p = 0.08), but attending surgeons more accurately predicted the femoral size (77 vs. 60%, p < 0.05). The 2D to 3D imaging technology more accurately predicted both tibial and femoral sizes compared with the attending surgeons (99.5 vs. 87%, p < 0.05; 84% vs. 77%, p < 0.05). However, the imaging technology, attending surgeons, and residents were all more likely to overestimate femur size (p < 0.05). Moreover, the 3D imaging technology predicted the exact tibial component size in 93.1% of cases, which was significantly greater compared with residents (40%, p < 0.01) and attending surgeons (53%, p < 0.01). The 2D to 3D imaging technology more accurately predicted tibial and femoral component sizes compared with 2D digital templating done by surgeons. All templating predictions were more accurate for the tibial implant size than for the femoral size. The increased accuracy of implant size predictions from this 3D templating technology has the potential to improve intraoperative efficiency and minimize costs and surgical time.

Effects of Preoperative Carbohydrate-rich Drinks on Immediate Postoperative Outcomes in Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: This study investigates the effects of preoperative carbohydrate-rich drinks on postoperative outcomes after primary total knee arthroplasty. METHODS: We prospectively randomized 153 consecutive patients undergoing primary total knee arthroplasty at one institution. Patients were assigned to one of three groups: group A (50 patients) received a carbohydrate-rich drink; group B (51 patients) received a placebo drink; and group C (52 patients) did not receive a drink (control). All healthcare personnel and patients were blinded to group allocation. Controlling for demographics, we analyzed the rate of postoperative nausea and vomiting, length of stay, opiate consumption, pain scores, serum glucose, adverse events, and intraoperative and postoperative fluid intake. RESULTS: Demographics and comorbidities were similar among the groups. There were no significant differences in surgical interventions or experience. Surgical fluid intake and total blood loss were similar among the three groups (P = 0.47, P = 0.23). Furthermore, acute postoperative outcomes (ie, pain, episodes of nausea, and length of stay) were similar across all three groups. There were no significant differences in adverse events between the three groups (P = 0.13). There was a significant difference in one-time postoperative bolus between the three groups (P = 0.02), but after multivariate analysis, it did not demonstrate significance. None of the intervention group were readmitted, whereas 5.9% and 11.5% were readmitted in the placebo and control groups, respectively (P = 0.047). The chance of 90-day readmission was reduced in group A compared with group C (odds ratio, 0.08; 95% confidence interval, 0.01 to 0.72; P = 0.02). There were no differences in other postoperative outcome measurements. CONCLUSION: This randomized controlled trial demonstrated that preoperative carbohydrate loading does not improve immediate postoperative outcomes, such as nausea and vomiting; however, it demonstrated that consuming fluid preoperatively proved no increased risk of adverse outcomes and there was a trend toward decrease of one-time boluses postoperatively. CLINICAL TRIALS REGISTRY: NCT03380754.

Multiple Venous Thromboembolism Pharmacologic Agents Are Associated with an Increased Risk for Early Postoperative Complications following a Total Joint Arthroplasty.

The purpose of this study was to determine the effect that concurrent venous thromboembolism (VTE) medications had on early outcomes following primary total joint arthroplasty (TJA). 2653 total knee and hip arthroplasties were reviewed at a tertiary medical center. The study performed a multivariable comparison of outcomes in patients on 2 or more VTE medications, as well as a logistic regression on outcomes following each addition of a VTE medication postoperatively (number of VTE medications was 1-4). Controlling for gender, age, body mass index, and preoperative American Society of Anesthesiologists score throughout the analysis, patients who received 2 or more VTE prophylaxis medications had increased LOS (p < 0.001), transfusions (p < 0.001), emergency department visits (p=0.001), readmissions (p < 0.001), 90dPOE (p < 0.001), and PE (p < 0.001). Every additional postoperative VTE medication incrementally increased the risk for longer LOS (p < 0.001), transfusions (p < 0.001), 90dPOE (p < 0.001), deep vein thrombosis (p=0.049), PE (p < 0.001), emergency department visits (p=0.005), and readmission (p=0.010). Patients on multiple VTE medications following TJA demonstrate significantly poorer outcomes. The current study's findings caution the use of multiple VTE medications whenever possible immediately following a TJA.

Improved accuracy and reproducibility of a novel CT-free robotic surgical assistant for medial unicompartmental knee arthroplasty compared to conventional instrumentation: a cadaveric study.

PURPOSE: Alignment errors in medial unicompartmental knee arthroplasty (UKA) predispose to premature implant loosening and polyethylene wear. The purpose of this study was to determine whether a novel CT-free robotic surgical assistant improves the accuracy and reproducibility of bone resections in UKA compared to conventional manual instrumentation. METHODS: Sixty matched cadaveric limbs received medial UKA with either the ROSA® Partial Knee System or conventional instrumentation. Fifteen board-certified orthopaedic surgeons with no prior experience with this robotic application performed the procedures with the same implant system. Bone resection angles in the coronal, sagittal and transverse planes were determined using optical navigation while resection depth was obtained using calliper measurements. Group comparison was performed using Student's t test (mean absolute error), F test (variance) and Fisher's exact test (% within a value), with significance at p < 0.05. RESULTS: Compared to conventional instrumentation, the accuracy of bone resections with CT-free robotic assistance was significantly improved for all bone resection parameters (p < 0.05), other than distal femoral resection depth, which did not differ significantly. Moreover, the variance was significantly lower (i.e. fewer chances of outliers) for five of seven parameters in the robotic group (p < 0.05). All values in the robotic group had a higher percentage of cases within 2° and 3° of the intraoperative plan. No re-cuts of the proximal tibia were required in the robotic group compared with 40% of cases in the conventional group. CONCLUSION: The ROSA® Partial Knee System was significantly more accurate, with fewer outliers, compared to conventional instrumentation. The data reported in our current study are comparable to other semiautonomous robotic devices and support the use of this robotic technology for medial UKA. LEVEL OF EVIDENCE: Cadaveric study, Level V.

Return to Play and Performance in Golfers After Total Knee Arthroplasty: Does Component Type Matter?

BACKGROUND: Golf is a popular sport among patients undergoing total knee arthroplasty (TKA). The golf swing requires significant knee rotation, which may lead to changes in golfing ability postoperatively. The type of implant used may alter the swing mechanics or place different stresses on the knee. The purpose of this study was to evaluate golf performance and subjective stability after TKA and compare outcomes between cruciate-retaining (CR) and posterior-stabilized (PS) implants. HYPOTHESIS: Patients with CR implants will experience better stability during the golf swing compared to patients with PS implants. STUDY DESIGN: Retrospective cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: Patients who underwent primary TKA were identified from the medical record and sent an electronic questionnaire focusing on return to play (RTP), performance, pain, and stability during the golf swing. Knee injury and Osteoarthritis Outcome Scores (KOOS) were collected before and at multiple time points after surgery. Patients were surveyed postoperatively and asked to evaluate overall performance, pain, and stability before and after surgery. Outcomes were compared based on implant type. RESULTS: Most patients (81.5%) were able to return to golf at an average of 5.3 ± 3.1 months from surgery. The average postoperative KOOS was 74.6 ± 12.5 in patients able to RTP compared with 64.4 ± 9.5 in those who were not (P < 0.05). Knee pain during golf significantly improved from 6.4 ± 2.1 to 1.8 ± 2.2 (P < 0.01). There were no significant differences in pain, performance, or stability between the CR and PS patients. CONCLUSION: Most patients can successfully return to golfing after TKA. Knee replacement offers patients reliable pain relief during the golf swing and fewer physical limitations during golf, with no detriment to performance. There is no difference in performance or subjective knee stability based on component type. CLINICAL RELEVANCE: Understanding associated outcomes of different TKA knee systems allows for unbiased and confident recommendations of either component to golfers receiving total knee replacement.

Time for an Update? A Look at Current Guidelines for Venous Thromboembolism Prophylaxis After Hip and Knee Arthroplasty and Hip Fracture.

Venous thromboembolism is a well-established complication of total hip and knee arthroplasty and hip fracture surgery. Clinical practice guidelines have been proposed to help clinicians provide prophylaxis against this risk. However, most guidelines reference data that are becoming outdated because of new advances in perioperative protocols. Recent data would suggest that aspirin may be appropriate for most patients after total hip and knee replacement and a more potent chemoprophylaxis for higher risk patients. Low-molecular-weight heparin remains the recommended choice after hip fracture surgery, although there is a paucity of recent literature in this patient population. There are randomized trials currently underway in the arthroplasty population that may guide clinicians in the appropriate choice of chemoprophylaxis. These studies should inform updates to the current clinical practice guidelines.

Comparison of Area Deprivation Index, Socioeconomic Parameters, and Preoperative Demographics With Postoperative Emergency Department Visits After Total Knee Arthroplasty.

BACKGROUND: This study aims to determine if socioeconomic (SE) parameters, primarily area deprivation index (ADI), relate to postoperative emergency department (ED) visits after total knee arthroplasty (TKA). METHODS: We retrospectively reviewed 2655 patients who underwent TKA in a health system of 4 hospitals. The primary outcome was an ED visit within 90 days, which was divided into those with and without readmission. SE parameters including ADI as well as preoperative demographics were analyzed. Univariable and multiple logistic regressions were performed determining risk of 90-day postoperative ED visits, as well as once in the ED, risks for readmission. RESULTS: 436 patients (16.4%) presented to the ED within 90 days. ADI was not a risk factor. The multiple logistic regression demonstrated men, Medicare or Medicaid, and preoperative ED visits were consistently risk factors for a postoperative ED visit with and without readmission. Preoperative anticoagulation was only a risk factor for ED visits with readmission. Among patients who visited the ED, if the patient was Caucasian, a lower BMI, or higher American Society of Anesthesiologists score, they were likely to be readmitted. CONCLUSION: The study demonstrated that the percentage of early ED returns after TKA was high and that ADI was not a predictor for 90-day postoperative ED visit. The only SE factor that may contribute to this phenomenon was insurance type. Once in the ED, race, preoperative ED visits, preoperative anticoagulation, BMI, gender, and preoperative American Society of Anesthesiologists score contributed to a risk of readmission. The study supports hospitals' mission to provide equal access health care.

Radiographic Predictors of Screw Cutout for Intertrochanteric Fractures Treated With Cephalomedullary Nails.

The objective of this study was to determine the predictive value of tip-apex distance (TAD) and Parker's ratio for screw cutout after treatment of intertrochanteric hip fractures with a long cephalomedullary nail. A total of 97 patients with AO/OTA 31-A1-A3 intertrochanteric fractures and a minimum follow-up of 8 weeks were included. Increased Parker's ratio on the anteroposterior radiograph (OR = 1.386, p < .003) and lateral radiograph (OR = 1.138, p < .028) was significantly associated with screw cutout. In a multivariable regression analysis, only the Parker's anteroposterior ratio was significantly associated with risk of screw cutout (OR = 1.393, p = .004), but TAD (OR = 0.977, p = .764) and Parker's lateral ratio (OR 1.032, p = .710) were not independent predictors of cutout. The study concluded that Parker's anteroposterior ratio is the most helpful measurement in predicting screw cutout. (Journal of Surgical Orthopaedic Advances 28(2):115-120, 2019).

Indwelling Urinary Catheter for Total Joint Arthroplasty Using Epidural Anesthesia.

BACKGROUND: The objective of this study was to evaluate if not placing an indwelling urinary catheter leads to a higher potential for adverse genitourinary (GU) issues after total joint arthroplasty (TJA) under epidural anesthesia. METHODS: Three hundred thirty-five consecutive patients who underwent primary TJA using epidural anesthesia were retrospectively reviewed. The initial 103 patients received a preoperative urinary catheter, which was maintained until the morning of postoperative day 1. The subsequent 232 patients did not receive a preoperative urinary catheter. Demographics, medical complications, GU complications, and length of stay were compared between groups. RESULTS: Compared between catheter and noncatheter groups, there were no differences in demographics including age, gender, or laterality of surgery. There was a difference in type of surgery (total knee arthroplasty vs total hip arthroplasty) (P = .008). There was no difference in American Society of Anesthesiologists score, but with a difference in body mass index (P = .01). There were no differences in GU complications among patients with benign prostatic hyperplasia or prostate cancer. However, among patients with a history of prostate disorders (benign prostatic hyperplasia or prostate cancer), urinary tract infection rate was higher in catheter group (P = .023). Postoperative GU complications were associated with increased median age in years and increased average length of stay in days. CONCLUSION: Patients undergoing TJA under epidural anesthesia demonstrate no increased risk of postoperative urological complications without the placement of preoperative indwelling urinary catheter. The routine use of preoperative catheters can be reconsidered for this mode of anesthesia. LEVEL OF EVIDENCE: Level II, retrospective comparative study.

Emergency Department Visit Within One Year Prior to Elective Total Joint Arthroplasty Is Predictive of Postoperative Return to Emergency Department Within 90 Days.

BACKGROUND: The Comprehensive Care for Joint Replacement Model, developed by Centers for Medicare and Medicaid Services, aims to improve the quality of joint replacement. Metrics including emergency room visit rates after primary total knee and total hip arthroplasty (TKA and THA) are of particular interest. The purpose of this study is to determine if preoperative emergency department (ED) visits are predictive of postoperative ED visits among patients undergoing elective THA or TKA. METHODS: In a retrospective analysis of 6996 patients who underwent elective primary arthroplasty (2453 hips, 4543 knees), we identified all patients who had an ED visit from up to 1 year prior to their surgical date to 90 days after. We assessed if preoperative visit frequency or temporality is predictive of a return to the ED visit within 90 days. RESULTS: TKA and THA patients with a single preoperative ED visit had an odds ratio of 1.9 and 2.0, respectively, of returning to the emergency room postoperatively (P < .001). Increasing preoperative visit frequency correlated with increasing odds ratios (1.9-16.7, P < .001). The proximity of the most recent preoperative visit prior to surgery had a positive trend toward a larger effect, but did not clearly demonstrate a dose-dependent effect. CONCLUSION: Presentation to the ED is common prior to total joint arthroplasty and is predictive of a postoperative visit within 90 days. Increasing preoperative visit frequency further increases a patient's risk of a postoperative visit within 90 days.

Short Versus Long Cephalomedullary Nails for Pertrochanteric Hip Fracture.

This study compared patients who underwent treatment with short or long cephalomedullary nails with integrated cephalocervical screws and linear compression. Patients with AO/OTA 31-A2 or A3 pertrochanteric fractures treated with either short (n=72) or long (n=97) InterTAN (Smith & Nephew, Memphis, Tennessee) cephalomedullary nails were reviewed. Information on perioperative measures (estimated blood loss, surgical time, and fluoroscopy time) and postoperative orthopedic complications (infection, implant failure, screw cutout, and periprosthetic femur fracture) was included. Estimated blood loss (short nail, 161 mL; long nail, 208 mL; P=.002) and surgical time (short nail, 64 minutes; long nail, 83 minutes; P=.001) were lower in the short nail group. There were no differences in fluoroscopy time (short nail, 90 seconds; long nail, 142 seconds; P=.071) or rates of infection (short nail, 1.4%; long nail, 3.1%; P=.637) or overall orthopedic complications (short nail, 11.1%; long nail, 9.3%; P=.798) between the 2 groups. The long nail group had a trend toward more screw cutouts (long nail, 5.2%; short nail, 0.0%; P=.134) but fewer periprosthetic femur fractures (short nail, 8.3%; long nail, 0.0%; P=.013). This study found a similar overall rate of orthopedic complications between short and long nails with integrated cephalocervical screws and linear compression. These results confirm the suspected advantages of short nails, including faster surgery and less blood loss; however, the rate of periprosthetic femur fracture remains high, despite changes to implant design. [Orthopedics. 2017; 40(2):83-88.].

Intraoperative Periprosthetic Femur Fracture: A Biomechanical Analysis of Cerclage Fixation.

Intraoperative periprosthetic femur fracture is a known complication of total hip arthroplasty (THA) and a variety of cerclage systems are available to manage these fractures. The purpose of this study was to examine the in situ biomechanical response of cerclage systems for fixation of periprosthetic femur fractures that occur during cementless THA. We compared cobalt chrome (CoCr) cables, synthetic cables, monofilament wires and hose clamps under axial compressive and torsional loading. Metallic constructs with a positive locking system performed the best, supporting the highest loads with minimal implant subsidence (both axial and angular) after loading. Overall, the CoCr cable and hose clamp had the highest construct stiffness and least reduction in stiffness with increased loading. They were not demonstrably different from each other.

Rivaroxaban Versus Enoxaparin for Venous Thromboembolism Prophylaxis after Hip and Knee Arthroplasty.

The oral Factor Xa inhibitor rivaroxaban (Xarelto) has been the pharmacologic agent used for venous thromboembolism (VTE) prophylaxis after primary hip and knee arthroplasty (THA/TKA) at our institution since February 2012. The purpose of our study was to compare rates of VTE and major bleeding between rivaroxaban and our previous protocol of enoxaparin after THA/TKA. A retrospective cohort study was performed including 2406 consecutive patients at our institution between 1/1/11 and 9/30/13. Patients who did not have unilateral primary THA/TKA or who received other anticoagulants were excluded. Of the 1762 patients included, 1113 patients (63.2%) received enoxaparin and 649 patients (36.8%) received rivaroxaban. This study found no demonstrable differences between these two anticoagulants in rates of VTE, infection, reoperation, transfusion, or major bleeding. Therapeutic, Retrospective comparative study, Level III.

Predictors and complications of blood transfusion in total hip and knee arthroplasty.

Perioperative patient optimization can minimize the need for blood transfusions in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of this study was to determine predictors and complications of transfusions. This retrospective review analyzed 1795 patients who underwent primary THA and TKA at our institution between January 2011 and December 2012. Of the 1573 patients ultimately included the rates of transfusion were 9.27% in TKA and 26.6% in THA. Significant predictors for transfusion include: preoperative hemoglobin, age, female gender, body mass index, creatinine, TKA, operating room time, operative blood loss, and intra-operative fluids. The DVT rate was comparable, but deep surgical site infection rate among transfused patients was 2.4% compared to 0.5% in non-transfused patients (P = 0.0065).

Evaluating the use and utility of noninvasive angiography in diagnosing traumatic blunt cerebrovascular injury.

BACKGROUND: Digital subtraction angiography (DSA) is the gold standard for radiographic diagnosis of blunt cerebrovascular injury (BCVI), but use of computed tomography angiography (CTA) and magnetic resonance angiography (MRA) has increased dramatically in BCVI screening. This study explores the utility, effectiveness, and cost of noninvasive CTA and MRA screening for BCVI. METHODS: Medical records of 2,025 consecutive adults evaluated for acute blunt neck trauma and BCVI were reviewed retrospectively. The incidence of BCVI, level(s) of cervical injury, involvement of foramina transversaria and internal carotid canals, presence of bony dislocation or subluxation, and subsequent treatment received were assessed. Asymptomatic patients were analyzed based on fracture and injury patterns. The cost effectiveness of CTA compared with DSA and the effects of CTA sensitivity and screening yield were determined. RESULTS: Of reviewed patients, 196 received CTA or MRA. Thirty-eight patients (19.4%) were diagnosed with BCVI. Screening yield in patients symptomatic at presentation was 48.8%. Large-vessel internal carotid, vertebral, anterior spinal, and basilar artery occlusion were associated with a positive screen, as were concurrent stroke and spinal cord injury (p < 0.01). Of patients with injuries found with noninvasive imaging, 50.0% of BCVI involved C1-3 fracture, 34.2% involved subluxation, and 65.8% involved foramina transversaria. In both symptomatic and asymptomatic patients, CTA screening was more cost effective than DSA. CONCLUSION: Noninvasive imaging is a safe, accurate, and cost-effective tool for BCVI screening. Symptomatic presentation was the best predictor of BCVI. Significant cost savings were realized using CTA rather than DSA, with similar effectiveness and patient outcomes. LEVEL OF EVIDENCE: Diagnostic study, level III; economic analysis, level IV.