Hemiarthroplasty for Femoral Neck Fractures: Does Surgeon Subspecialty Affect Perioperative Outcomes?

OBJECTIVES: To determine if surgeon subspecialty training affects perioperative outcomes for displaced femoral neck fractures treated with hemiarthroplasty. DESIGN: Retrospective comparative study. SETTING: One health system with 2 hospitals (Level I and Level III trauma centers). PATIENT AND PARTICIPANTS: Patients who were treated with hemiarthroplasty for displaced femoral neck fractures between October 2012 and September 2017. OUTCOME MEASURES: Leg length discrepancy, femoral offset, estimated blood loss (EBL), incidence of blood transfusion, time to surgery, operative time, and length of stay. Data were analyzed based on the treating surgeon's subspecialty training [arthroplasty (A), trauma (T), other (O)]. Hierarchical regression was used to compare the groups and control for confounding variables. RESULTS: A total of 292 patients who received hemiarthroplasty for displaced femoral neck fractures were included (A = 158; T = 73; O = 61). Surgeon subspecialty had a statistically significant effect on operative time, with arthroplasty surgeons completing the procedure 9.6 minutes faster than trauma surgeons and 17.7 minutes faster than other surgeons (P < 0.01; ΔR = 0.03). Surgeon subspecialty did not significantly affect other outcomes, including leg length discrepancy (P = 0.26), femoral offset (P = 0.37), EBL (P = 0.10), incidence of transfusion (P = 0.67), time to surgery (P = 0.10), or length of stay (P = 0.67). CONCLUSIONS: This study demonstrates that arthroplasty-trained surgeons perform hemiarthroplasty slightly faster than other subspecialists, but subspecialty training does not affect other perioperative outcomes, including leg length discrepancy, femoral offset, EBL, transfusion rate, time to surgery, or length of stay. This suggests that hemiarthroplasty can be adequately performed by various subspecialists, and deferring treatment to an arthroplasty surgeon might not have a clinically significant benefit in the perioperative period. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Use of tranexamic acid results in decreased blood loss and decreased transfusions in patients undergoing staged bilateral total knee arthroplasty.

BACKGROUND: Tranexamic acid (TXA) is an antifibrinolytic that reduces blood loss and transfusion rates in total joint arthroplasty. Blood loss and allogenic transfusion rates have not been well studied in patients receiving TXA and undergoing bilateral staged total knee arthroplasty (TKA). The purpose was to evaluate the effect of TXA on blood loss, hemoglobin (Hb) changes, and transfusion in patients undergoing staged bilateral TKA. STUDY DESIGN AND METHODS: The authors compared 51 patients undergoing staged bilateral TKA who received TXA (2 g; subjects) with 70 who did not (controls). There were no significant differences between the groups in terms of demographics or preoperative Hb. For each TKA, 1 g of TXA was administered intravenously 15 minutes before incision and 1 g was administered intravenously at tourniquet release. Blood loss, Hb levels, and transfusions were recorded. Statistical analyses were performed using computer software. Significance was set at 0.05. RESULTS: Subjects had a significantly lower (p < 0.001) mean (±SD) blood loss (373.8 ± 264.6 mL vs. 871.6 ± 457.7 mL), significantly higher (p < 0.005) Hb levels on Postoperative Days 1 and 2, and a significantly lower (p < 0.001) mean (±SD) number of transfused allogenic blood units (0.60 ± 0.84 units vs. 1.53 ± 1.30 units). CONCLUSIONS: TXA reduces blood loss, improves postoperative Hb, and decreases the allogenic blood transfusion requirements for patients undergoing bilateral staged TKA. TXA is an option for patients choosing bilateral staged TKA to decrease the risks associated with blood transfusion or when autologous blood is not available.

Efficacy of multimodal perioperative analgesia protocol with periarticular medication injection in total knee arthroplasty: a randomized, double-blinded study.

Pain control is necessary for successful rehabilitation and outcome after total knee arthroplasty. Our goal was to compare the clinical efficacy of periarticular injections consisting of a long-acting local anesthetic (ropivacaine) and epinephrine with and without combinations of an α2-adrenergic agonist (clonidine) and/or a nonsteroidal anti-inflammatory agent (ketorolac). In a double-blinded controlled study, we randomized 160 patients undergoing total knee arthroplasty to receive 1 of 4 intraoperative periarticular injections: Group A, ropivacaine, epinephrine, ketorolac, and clonidine; Group B, ropivacaine, epinephrine, and ketorolac; Group C, ropivacaine, epinephrine, and clonidine; Group D (control), ropivacaine and epinephrine. Compared with Group D, Group A and B patients had significantly lower postoperative visual analog pain scores and nurse pain assessment and Group C patients had a significantly greater reduction in physical therapist pain assessment. We found no differences in other parameters analyzed.

Medial UKA: favorable mid-term results in middle-aged patients.

In middle-aged patients with knee arthritis, surgical treatment options include arthroscopic procedures, osteotomies, and unicompartmental and total knee arthroplasty. Unicompartmental knee osteoarthrosis is particularly challenging and controversial in such patients. From December 2001 through October 2005, we treated 32 consecutive middle-aged patients (46 to 59 years old) with 40 medial unicompartmental knee arthroplasties. Three patients were lost to follow-up, leaving 29 for our study. There were two reoperations: one for loosening at 3 years, and one for disease progression at 5 years. Implant survival was modeled using Kaplan-Meier survival function with observations censored if lost to follow-up. At the 6-year survivorship in this group, the overall implant survival rate was 94.1% (95% CI, 78.3-98.5). Knee Society scores had improved significantly (p < 0.001). There were no other instances of osteolysis or radiographic failure. We concluded that, at mid-term follow-up, unicompartmental knee arthroplasty provided satisfactory results for this challenging population.

Modern proximally tapered uncemented stems can be safely used in Dorr type C femoral bone.

Cementless femoral fixation has become widely accepted in modern total hip arthroplasty. Treating patients who have a stovepipe-shaped femur (Dorr type C) with cementless implants has traditionally been challenging. We treated 53 consecutive patients (60 hips) who had type C bone with identical tapered, proximally coated implants and postoperative weight bearing as tolerated. At 6 weeks, all 60 hips had radiographically documented bony integration, and at 1 year, there was no evidence of fracture, subsidence, thigh pain, stress shielding, loose stems, or risk of failure. Of those patients, 40 (43 hips) had midterm follow-up (average, 6 years; range, 4-9 years); the findings were the same. We conclude that modern proximally tapered stems can be used with early weight bearing in patients with type C bone.

All-polyethylene tibial components in obese patients are associated with low failure at midterm followup.

BACKGROUND: In the United States, the obese population has increased markedly over the last four decades, and this trend continues. High patient weight places additional stress on TKA components, which may lead to increased polyethylene wear, osteolysis, radiolucencies, and clinical failure. Metal-backed tibial components and all-polyethylene tibial components in the general population have comparable osteolysis and failure, but it is unclear whether these components yield similar osteolysis and failure in obese patients. QUESTIONS/PURPOSES: We therefore determined the (1) function, (2) occurrence of osteolysis, and (3) complications in a cohort of obese patients receiving all-polyethylene tibial components. PATIENTS AND METHODS: Between September 17, 1996, and December 19, 2002, we implanted all-polyethylene tibial components in 90 obese patients (125 knees); 24 patients (33 knees) died and 13 patients (17 knees) were lost to followup, leaving 53 patients (59%) with 75 knees. All surgeries were cruciate-retaining, tricompartmental TKAs. We evaluated patients with Knee Society Scores and serial radiographs. Minimum followup was 7 years (mean, 10.4 years; range, 7-14 years). RESULTS: At latest followup, mean Knee Society Score was 92 points. There were five tibial radiolucencies, all less than 1 mm and characterized as nonprogressive. We observed minimal, nonprogressive osteolysis in one knee. One patient required reoperation after a traumatic event. There were no implant-related failures and no implants at risk of failure. CONCLUSIONS: At an average 10-year followup, all-polyethylene tibial components were functioning well in this obese group. These findings confirm the effectiveness of all-polyethylene tibial components in obese patients.

When can I drive?: brake response times after contemporary total knee arthroplasty.

BACKGROUND: After right total knee arthroplasty (TKA), patients are usually eager to return to driving. Previous studies suggest 6 weeks postsurgery is a safe time. However, recent advances in surgical technique, pain management, and rehabilitation have theoretically improved recovery after TKA. QUESTIONS/PURPOSES: We therefore determined if (1) the timeframe for return to driving, as determined by attainment of preoperative braking levels, would be shorter after contemporary right TKA than that reported previously for a traditional TKA; and (2) gender or age influence recovery of baseline response time. METHODS: Brake response times for all 29 patients undergoing right-sided TKA between January 17, 2008, and January 29, 2009, were scheduled to be measured by a trained occupational therapist before surgery and at 4, 6, and 8 weeks after surgery. For each patient, testing was discontinued once the preoperative level was achieved. RESULTS: All patients returned to baseline braking levels by 4 weeks after surgery. Gender and age did not influence recovery times. CONCLUSIONS: If other requirements for driving are met, surgeons may consider allowing patients treated with contemporary right TKAs to drive 4 weeks after surgery.

Role of navigation in total hip arthroplasty.

Current uses of computed tomography-based and imageless navigation systems for total hip arthroplasty include proper placement of the acetabular component, measurement of limb-length changes, enablement of minimally invasive surgery, and proper placement of components for hip resurfacing procedures. This article provides an overview of the rationale for computer-assisted surgery in total hip arthroplasty and hip resurfacing. The experience of the senior author (M.L.S.) with computer-assisted surgery for hip arthroplasty has demonstrated improved position of the acetabular component as compared with the position attainable with use of mechanical instruments, maintenance of appropriate position of the acetabular component during minimally invasive surgery, and appropriate positioning of the femoral and acetabular components during the learning curve for hip resurfacing procedures.