Complications and Survivorship After Aseptic Revision Total Hip Arthroplasty: Is There a Difference by Surgical Approach?

BACKGROUND: Revision total hip arthroplasty (rTHA) has traditionally been performed through the posterolateral approach (PA). Anterior approaches (AA) for rTHA are increasingly being utilized. The purpose of this study was to compare complications and survivorship from re-revision and reoperation after aseptic rTHA performed using an AA versus a PA. METHODS: We retrospectively reviewed patients who underwent aseptic rTHA either through an AA (direct anterior approach [DAA], anterior-based muscle sparing [ABMS]) or PA from January 2017 to December 2021. There were 116 patients who underwent AA-rTHA (DAA 50, ABMS 66) or PA-rTHA (n = 105). Patient demographics, complications, and postoperative outcomes were collected. RESULTS: The most common indication in both groups was aseptic loosening (n = 26, 22.4% AA, n = 28, 26.7% PA). Acetabular revision alone was most common in the AA group (n = 33, 28.4%), while both components were most commonly revised in the PA groups (n = 47, 44.8%). In all the AA-rTHA group, the index total hip arthroplasty was performed through a PA in 51% of patients, while the PA-rTHA group had the index procedure performed via AA in 4.8%. There was no statistically significant difference in re-revision rate between the DAA, ABMS, or PA groups (9.55 versus 5.3% versus 11.4%, respectively, P = .11). The most common overall reason for re-revision was persistent instability, with no difference in incidence of postoperative hip dislocation (n = 4, 6.8% DAA, n = 3, 5.3%, n = 10, 9.5% PA; P = .31). CONCLUSIONS: This study demonstrates no difference in complication or re-revision survivorship after aseptic rTHA performed through a DAA, ABMS approach, or PA, nor between anterior or posterior-based approaches. LEVEL OF EVIDENCE: Level III.

Specific Preoperative Factors Increase Manipulations under Anesthesia Following Primary TKA.

Arthrofibrosis following primary total knee arthroplasty (TKA) can result in pain and limit postoperative range of motion (ROM), jeopardizing clinical outcomes and patient satisfaction. This study aims to identify preoperative risk factors associated with necessitating a manipulation under anesthesia (MUA) following primary TKA.We retrospectively reviewed 950 cases of consecutive primary TKAs performed at one institution by three arthroplasty surgeons between May 2017 and May 2019. Recorded preoperative variables included smoking status, race, preoperative ROM, presence of effusion or positive anterior drawer, and medical comorbidities. Demographic characteristics were compared with Student's t-tests or chi-square tests as appropriate. For each preoperative factor, we obtained an odds ratio (OR) for MUA risk using multivariate logistic regression.Twenty (2.3%) patients underwent MUA following their index primary TKA surgery. History of ipsilateral knee surgery (OR: 2.727, p = 0.047) and diagnosed hypertension (OR: 4.764, p = 0.016) were identified as risk factors associated with significantly increased risk of MUA. The greater the preoperative ROM, the higher likelihood needed of MUA (OR: 1.031, p = 0.034).Patients who had diagnosed hypertension or a history of prior ipsilateral knee surgery were associated with increased risk of necessitating an MUA following primary TKA. Additionally, a greater total arc of motion preoperatively increased the odds of needing MUA.Level III of evidence was present.

Early hip fracture surgery is safe for patients on direct oral anticoagulants.

Objectives: To determine how preoperative direct oral anticoagulant (DOAC) use affects rates of blood transfusion, clinically important blood loss, and 30-day mortality in patients with hip fracture undergoing surgery within 48 hours of presentation to the emergency department. Design: Retrospective cohort study. Setting: Academic trauma center. Patients: A total of 535 patients with hip fracture who underwent open cephalomedullary nail fixation or arthroplasty either taking a direct oral anticoagulant or no form of chemical anticoagulant/antiplatelet agent before presentation (control). Main Outcome Measures: Demographics, time to surgery, type of surgery, blood transfusion requirement, clinically important blood loss, and 30-day mortality. Results: Forty-one patients (7.7%) were taking DOACs. DOAC patients were older (81.7 vs. 77 years, P = 0.02) and had higher BMI (26.9 vs. 24.2 kg/m2, P = 0.01). Time from admission to surgery was similar between DOAC users (20.1 hours) and the control (18.7 hours, P > 0.4). There was no difference in receipt of blood transfusion (P = 0.4), major bleeding diagnosis (P = 0.2), acute blood loss anemia diagnosis (P = 0.5), and 30-day mortality (P = 1) between the DOAC and control group. This was true when stratifying by type of surgery as well. Conclusions: Our results suggest that early surgery may be safe in patients with hip fracture taking DOACs despite theoretical risk of increased bleeding. Because early surgery has previously been associated with decreased morbidity and mortality, we suggest that hip fracture surgery should not be delayed because a patient is taking direct oral anticoagulants. Level of Evidence: Prognostic Level III.

Handheld Navigation Improves Accuracy in Direct Anterior Total Hip Replacement.

Background: This study sought to determine the accuracy in placing the acetabular component, estimation of leg length, offset, radiation time and dose, and operative time using a handheld navigation device compared to conventional anterior total hip arthroplasty (THA). It also examined the learning curve of the handheld navigation device. Methods: Data were prospectively collected for a consecutive series of 159 THAs; 99 THAs with handheld navigation and 60 conventional THAs. Thresholds of <5°, ≥5° to <10°, and ≥10° for acetabular inclination and version and thresholds of <5 mm, ≥5 mm to <10 mm, and ≥10 mm for leg-length and combined offset discrepancy were used to assess accuracy. Fluoroscopy time and exposure, operative time, and complications were compared. Learning curve was determined using operative time. Statistical analysis was performed for the different accuracy thresholds with P values set a <0.05 for significance. Results: The handheld navigation device demonstrated a mean accuracy of 3.2° and 1.8° for version and inclination, respectively. The handheld navigation group had significantly fewer outliers in version (P < .001), inclination (P < .001), leg-length discrepancy (P < .001), and offset discrepancy (P < .001). Fluoroscopic dose and time (P < .001) were lower in the handheld navigation cohort. The learning curve for handheld navigation was 31-35 cases. The mean operative time after the learning curve was similar to that in the conventional fluoroscopy group (P = .113). Conclusions: Handheld navigation technology provided more accurate results while mitigating radiation exposure to the surgeon and patient. There were fewer outliers in the handheld navigation group. After the learning curve, all metrics improved in accuracy, and operative time was similar to that of the conventional technique.

Prospective Evaluation of a Noninvasive Hemoglobin Measurement System in Total Joint Arthroplasty.

We sought to prospectively determine the efficacy of a noninvasive hemoglobin measurement system compared to a traditional blood draw in patients undergoing total joint arthroplasty. One hundred consecutive patients had their hemoglobin level measured by blood draw and the noninvasive device, simultaneously. Results were analyzed for the entire group and further stratified based on race and perfusion index measured by the device. The financial implications and patient satisfaction were compared. Hemoglobin measurements in the entire group and the two sub-groups were similar between the noninvasive device and the traditional blood draw. The noninvasive system was preferred by 100% of patients. Additionally, cost savings per patient using the noninvasive system was $16.50. This correlated to an 86% savings per case over the standard blood draw. The noninvasive hemoglobin monitoring system offers comparable measurements to a standard blood draw, while improving patient satisfaction and lowering costs. (Journal of Surgical Orthopaedic Advances 29(2):94-98, 2020).

Web-based patient portal access in an orthopedic adult reconstruction patient population.

BACKGROUND: We surveyed patients in an adult reconstruction practice as to their use of the Web-based portal provided by our electronic health record, seeking to reveal patterns of use and helpfulness. METHODS: A total of 150 completed surveys were received. The survey queried demographics, the number of clinic visits, Internet access, portal activation, portal use frequency, and portal information questions and how patients answered them. Helpfulness was rated from 1 (not helpful) to 5 (very helpful). Statistical analysis included bivariate analysis and logistic regression, with odds ratio (OR) and 95% confidence interval (CI) reported. RESULTS: The mean age was 67.6 years. Most were females (n = 97, 65.1%). Most (68.7%) patients used the portal. Younger age (OR, 0.94; CI, 0.90-0.99) and access to Internet (OR, 31.8; CI, 8.5-119.4) predicted portal use (P < .005), whereas gender and number of clinic visits did not (P > .373). Of all, 47.5% of patients were unclear about online chart information. Older age indicated being unclear of portal information (68.5 vs 66, P = .0002). Of those who clarified doubts regarding information (n = 67), 23 used the Internet (34.3%), 32 (47.7%) called the physician, and 12 (17.9%) asked a friend and/or family member. Most (90.3%) patients felt the portal was helpful in gathering health information. CONCLUSIONS: Age and Internet access affected portal usage; ability to understand chart information decreased with age. Most patients used the Internet or a family member to clarify doubts regarding portal information. The use of portal data resulted in 32 extra communications to the physician.