Effectiveness of Constrained Liner Use During Harrington Hip Reconstruction in Oncology Patient.

BACKGROUND: Patients with destructive acetabular lesions are at high risk for morbidity. Harrington described reinforcing acetabular diseased bone with methylmethacrylate, supplemented by metal fixation, to allow total hip reconstruction. However, all published studies using this technique report dislocations. We believe that initial use of constrained liners would help alleviate dislocation risk, without increasing component loosening or polyethylene wear. METHODS: Sixty-eight patients who underwent Harrington hip arthroplasties for metastatic cancer from August 2005 to March 2015 were identified. All patients had a constrained acetabular liner implanted during their index procedure. Electronic medical records and radiographs were reviewed. A literature review of studies with similar technique was used as a historical control. RESULTS: Forty-seven patients (69.2%) died 22.7 ± 22.7 months after surgery, at age 62.4 ± 17.2 years. At an average clinical follow-up of 9.9 ± 14.2 months (range 2-50 months), we found no incidents of dislocation. No patients had component failure requiring revision or evidence of loosening on x-ray. Thirteen papers, comprising 185 patients, demonstrated 39 patients (21.1%) with dislocations and 13 patients (7.0%) requiring revision surgery for aseptic loosening. CONCLUSION: Modified Harrington technique has demonstrated relative durability when reconstructing metastatic acetabular disease, although dislocation occurs in approximately 20% of patients. This study demonstrates that initial use of a constrained liner can alleviate postoperative dislocations without increasing risk of perioperative complications. Even modest reduction in complications during the limited lifespan of oncologic patients can have dramatic positive effects on quality of life.

Operative Intervention of Supracondylar Humerus Fractures More Complicated in July: Analysis of the July Effect.

BACKGROUND: The "July Effect" involves the influx of new interns and residents early in the academic year (July and August), which may have greater potential for poorer patient outcomes. Current orthopaedic literature does not demonstrate the validity of this concept in arthroplasty, spine, hand, and arthroscopy. No study has investigated the possibility of this effect on common pediatric orthopaedic procedures, such as closed reduction and percutaneous pin fixation of supracondylar humerus fractures. METHODS: A retrospective review of all type II or III supracondylar humerus fractures that underwent primary closed reduction and percutaneous pin fixation (CPT code 24538) at a single pediatric level 1 trauma center from July 2009 to June 2013. Patients were grouped according to time in the academic year: early (July and August) and late (May and June). Demographic data included length of follow-up, age at surgery, sex, side of injury, and Wilkin's modified Gartland classification. Outcomes included length of operation, number of pins used, length of stay, complications, and the need for repeat surgery. RESULTS: There were 245 patients, 101 in the early and 144 in the late group. There was no increase in surgical time [33.32±24.74 (early) vs. 28.63±10.06 (late) min, P=0.07) or complication rates [7.0% (early) vs. 2.1% (late), P=0.06) between the early and the late groups. Cases performed with junior residents demonstrated longer operative (31.72±17.07 vs. 28.96±18.71 min, P=0.02) and fluoroscopy (48.63±30.96 vs. 34.12±27.38 s, P=0.01) times. CONCLUSIONS: The academic orthopaedic surgeon must ensure the education of residents, while providing the highest level of safety to patients. Our study shows that education of young residents early in the academic year results in no increase in operative times, radiation exposure, or complications. LEVEL OF EVIDENCE: Level III.

Liposomal Bupivacaine Injection Technique in Total Knee Arthroplasty.

Liposomal bupivacaine has gained popularity for pain control after total knee arthroplasty (TKA), yet its true efficacy remains unproven. We compared the efficacy of two different periarticular injection (PAI) techniques for liposomal bupivacaine with a conventional PAI control group. This retrospective cohort study compared consecutive patients undergoing TKA with a manufacturer-recommended, optimized injection technique for liposomal bupivacaine, a traditional injection technique for liposomal bupivacaine, and a conventional PAI of ropivacaine, morphine, and epinephrine. The optimized technique utilized a smaller gauge needle and more injection sites. Self-reported pain scores, rescue opioids, and side effects were compared. There were 41 patients in the liposomal bupivacaine optimized injection group, 60 in the liposomal bupivacaine traditional injection group, and 184 in the conventional PAI control group. PAI liposomal bupivacaine delivered via manufacturer-recommended technique offered no benefit over PAI ropivacaine, morphine, and epinephrine. Mean pain scores and the proportions reporting no or mild pain, time to first opioid, and amount of opioids consumed were not better with PAI liposomal bupivacaine compared with PAI ropivacaine, morphine, and epinephrine. The use of the manufacturer-recommended technique for PAI of liposomal bupivacaine does not offer benefit over a conventional, less expensive PAI during TKA.

Cemented vs Cementless Total Knee Arthroplasty in Morbidly Obese Patients.

BACKGROUND: Primary total knee arthroplasty (TKA) in morbidly obese patients has been associated with greater postoperative complications. Cementless TKA has the potential for biologic fixation which may provide more durable long-term stability. METHODS: This was a multicenter review of 298 TKAs in 292 morbidly obese patients (body mass index, >40) undergoing TKA, with 154 TKAs (149 patients) in the cemented and 144 TKAs (143 patients) in the cementless group. RESULTS: There were significantly more revisions in the cemented group (n = 20) than in the cementless group (n = 1; 13.0% vs 0.7%). There was a significantly higher incidence of aseptic loosening in the cemented cohort vs the cementless cohort (9 vs 0 TKAs). All revisions in the cementless cohort were due to infection (0.7%). CONCLUSION: Cementless fixation may be an alternative in the morbidly obese patient undergoing primary TKA.

Tranexamic Acid Decreases Incidence of Blood Transfusion in Simultaneous Bilateral Total Knee Arthroplasty.

Blood management for simultaneous bilateral total knee arthroplasty (TKA) patients is more challenging than in unilateral arthroplasty. We examined if administration of tranexamic acid (TXA) to patients undergoing simultaneous bilateral TKA would reduce blood loss and decrease allogeneic blood transfusion requirements. A retrospective review of 103 patients, 57 in the control and 46 in the TXA group, was performed. There was higher postoperative day 1 hemoglobin in patients receiving TXA (2.95±1.33 versus 4.33±1.19, P<0.0001). There was also a decrease in the transfusion incidence with administration of TXA (17.4% versus 57.9%, P<0.0001). In conclusion, we have shown that TXA is an effective tool in reducing the transfusion rates by almost 70% in simultaneous bilateral total knee arthroplasty.

Intrinsic Healing of the Anterior Cruciate Ligament in an Adolescent.

The anterior cruciate ligament (ACL) is an important ligamentous stabilizer of the knee. The natural primary healing potential of the ACL has been shown to be extremely poor. We report the case of a 12-year-old boy who was involved in a motor vehicle collision and sustained a grade IIIB open tibial fracture, distal fibula fracture, medial and lateral meniscus tears, avulsion fracture of the femoral metaphysis, and anterior and posterior cruciate ligament tears. Because of delayed union of his tibia fracture, treatment of the ligamentous injuries was postponed to 16 months after initial injury. However, magnetic resonance imaging at that time showed complete healing. At 20 months, the patient returned to competitive hockey. Based on this case, we believe there is some natural primary healing potential within the ACL.

Functional outcomes of simultaneous bilateral versus unilateral total knee arthroplasty.

Many patients in need of total knee arthroplasty (TKA) have bilateral symptoms and require surgery to both extremities. Performance of a bilateral procedure under a single anesthetic provides a reduced hospitalization time, an isolated anesthesia risk, a single rehabilitation, and substantial cost savings. While most current research examines postoperative complication rates, the primary purpose of TKA is the alleviation of pain and improved quality of life. The purpose of this study was to assess pain and functional outcomes associated with simultaneous bilateral TKA. The authors believe that patients with advanced destructive arthritis to numerous joints cannot achieve complete restoration of their functional status until comprehensive treatment of their disease process occurs. A retrospective review of 697 TKAs in 511 consecutive patients with bilateral knee arthritis was performed. Patients underwent either simultaneous bilateral TKA (n=186), performed sequentially under the same anesthetic, or unilateral TKA (n=325). The same intra- and postoperative protocols were followed in each group. There was no statistically significant difference in postoperative pain, represented by Knee Society Score (P=.161). However, there was a significantly higher postoperative functional outcomes-including increased total range of motion (P=.001), flexion (P=.003), and function score (P<.001)-associated with bilateral TKA. Simultaneous bilateral TKA is an effective treatment option and may be worth possible added risk in appropriate patients because it produces a better functional outcome.

Effect of intra-articular injection of tranexamic acid on postoperative hemoglobin in total hip arthroplasty.

Postoperative anemia is a significant risk factor in total hip arthroplasty, leading to increased length of hospital stay and delayed mobility and rehabilitation, and is poorly tolerated by patients with peripheral vascular and cardiovascular disease. Intravenous tranexamic acid, an antifibrinolytic drug, has been shown to reduce postoperative anemia in total joint replacement. Intra-articular administration eliminates the risk of systemic effects, the most concerning of which is thrombosis. Although this method of administering tranexamic acid has been studied in total knee replacement, currently no literature has been published on its efficacy in primary total hip replacement. The purpose of this study was to examine postoperative hemoglobin decrease and the transfusion rate following intra-articular tranexamic acid administration in primary total hip arthroplasty. The authors conducted a retrospective review of 181 consecutive total hip replacements, 91 of which received tranexamic acid. No statistical significance was found between these groups in any of the demographic variables. Postoperative hemoglobin decrease in the control group was 4.4±1.0 g/dL compared with a decrease of 3.6±1.1 g/dL in the tranexamic group, demonstrating an 18% reduction in blood loss (P<.001). No significant difference was found between the number of patients transfused (P=.777) or the number of units used (P=.993). No clotting events were seen in either group. Overall, the study demonstrates that intra-articular tranexamic acid in primary total hip arthroplasty is associated with a significant improvement in postoperative hemoglobin decrease without systemic hypercoagulability.

Liposomal bupivacaine versus traditional periarticular injection for pain control after total knee arthroplasty.

The purpose of this study was to compare a novel liposomal bupivacaine to traditional peri-articular injection (PAI) in a multi-modal pain protocol for total knee arthroplasty (TKA). A retrospective cohort study compared 85 consecutive patients undergoing TKA with a traditional PAI of ropivacaine, epinephrine and morphine to 65 patients with a liposomal bupivacaine PAI. After the initial 24h, inpatient self-reported pain scores were higher in the liposomal bupivacaine group compared to the traditional PAI group (P = 0.04) and a smaller percentage (16.9%) of patients in the liposomal bupivacaine group rated their pain as "mild" compared to the traditional group (47.6%). Liposomal bupivacaine PAI provided inferior pain control compared to the less expensive traditional PAI in a multi-modal pain control program in patients undergoing TKA.

Is there a functional benefit to obtaining high flexion after total knee arthroplasty?

Clinical evidence is lacking to support the functional benefit of high flexion after total knee arthroplasty (TKA). A retrospective review of 511 TKAs in 370 patients was performed. The mean follow-up was 3.7 years (range, 2-8 years). Regression analysis determined the effect of obtaining high flexion (>125 degrees ) on Knee Society, stair, function, and pain scores. Of 511 TKAs, 340 (66.5%) obtained range of motion greater than 115 degrees , and 63 (12.3%) TKAs obtained high flexion greater than 125 degrees . There was no difference between the patients who obtained flexion greater than 115 degrees and those who obtained high flexion greater than 125 degrees in Knee Society scores (P = .34) and function scores (P = .57). Patients with greater than 125 degrees of flexion are 1.56 times more likely to demonstrate optimal stair function (P = .02). Obtaining flexion greater than 125 degrees after TKA does not offer a benefit in overall knee function. However, obtaining a high degree of flexion appears to optimize stair climbing.

The effect of retropatellar fat pad excision on patellar tendon contracture and functional outcomes after total knee arthroplasty.

Excision of the fat pad is common in total knee arthroplasty to enhance surgical exposure. However, the effect of this has not been clearly established. A retrospective review of 1055 primary total knee arthroplasties was preformed in 720 patients from 1997 to 1998. Regression analysis was performed to determine the effect of excising the fat pad on patellar tendon contracture, range of motion, Knee Society Score, function, and pain scores. Fat pad excision had no significant effect on patellar tendon contracture (P = .4599), range of motion (P = .7361), Knee Society Score (P = .7247), or function scores (P = .6786). Patients whose fat pad had been removed were nearly twice as likely to experience postoperative pain (P = .0005).