Intussusception Allograft Prosthetic Composites in Total Hip Arthroplasty: A Salvage Operation for Extensive Femoral Bone Loss.

BACKGROUND: Allograft prosthetic composites (APCs) have been used to perform revision total hip arthroplasty (THA) for massive femoral bone loss or deformity. Intussusception, or "telescoping", APC techniques have been proposed to enhance the contact area of this interface and provide superior mechanical fixation over conventional methods. The purpose of this study is to present to our knowledge, the largest series of telescoping APC THAs, along with surgical technique details and midterm (average 5-10 years) clinical results. METHODS: Between 1994 and 2015, 46 revision THAs performed with proximal femoral telescoping APCs were retrospectively reviewed at a single institution. Overall survival, reoperation-free survival, and construct survival rates were calculated via Kaplan-Meier methods. In addition, radiographic analyses were performed to evaluate for component loosening, union at the APC-host interface, and resorption of the allograft. RESULTS: At 10 years, the overall patient survival was 58%, reoperation-free survival was 76%, and construct survival was 95%. Reoperation was performed in 20% (n = 9) and only 2 constructs required resection. Radiographic analyses performed at latest follow-up revealed no instances of radiographic femoral stem loosening, an 86% union rate at the APC-host site, 23% with signs of some allograft resorption, and a 54% trochanteric union. The mean postoperative Harris hip score was 71 points (range, 46-100). CONCLUSION: Telescoping APCs are technically demanding, but provide reliable mechanical fixation for the reconstructing of large proximal femoral bone deficits in revision THA with excellent construct survivorship, acceptable reoperation rates, and good clinical outcomes. LEVEL OF EVIDENCE: IV.

Lessons Learned From the Comprehensive Care for Joint Replacement Model at an Academic Tertiary Center: The Good, the Bad, and the Ugly.

BACKGROUND: Our institution participated in the Comprehensive Care for Joint Replacement (CJR) model from 2016 to 2020. Here we review lessons learned from a total joint arthroplasty (TJA) care redesign at a tertiary academic center amid changing: (1) CJR rules; (2) inpatient only rules; and (3) outpatient trends. METHODS: Quality, financial, and patient demographic data from the years prior to and during participation in CJR were obtained from institutional and Medicare reconciled CJR performance data. RESULTS: Despite an increase in true outpatients and new challenges that arose from changing inpatient-only rules, there was significant improvement in quality metrics: decreased length of stay (3.48-1.52 days, P < .001), increased home discharge rate (70.2-85.5%, P < .001), decreased readmission rate (17.7%-5.1%, P < .001), decreased complication rate (6.5%-2.0%, P < .001), and the Centers for Medicare and Medicaid Services (CMS) Composite Quality Score increased from 4.4 to 17.6. Over the five year period, CMS saved an estimated $8.3 million on 1,486 CJR cases, $7.5 million on 1,351 non-CJR cases, and $600,000 from the voluntary classification of 371 short-stay inpatients as outpatient-a total savings of $16.4 million. Despite major physician time and effort leading to marked improvements in efficiency, quality, and large cost savings for CMS, CJR participation resulted in a net penalty of $304,456 to our institution, leading to zero physician gainsharing opportunities. CONCLUSION: The benefits of CJR were tempered by malalignment of incentives among payer, hospital, and physician as well as a lack of transparency. Future payment models should be refined based on the successes and challenges of CJR.

A hybrid implementation-effectiveness randomized trial of CYP2D6-guided postoperative pain management.

PURPOSE: Cytochrome P450 2D6 (CYP2D6) genotype-guided opioid prescribing is limited. The purpose of this type 2 hybrid implementation-effectiveness trial was to evaluate the feasibility of clinically implementing CYP2D6-guided postsurgical pain management and determine that such an approach did not worsen pain control. METHODS: Adults undergoing total joint arthroplasty were randomized 2:1 to genotype-guided or usual pain management. For participants in the genotype-guided arm with a CYP2D6 poor (PM), intermediate (IM), or ultrarapid (UM) metabolizer phenotype, recommendations were to avoid hydrocodone, tramadol, codeine, and oxycodone. The primary endpoints were feasibility metrics and opioid use; pain intensity was a secondary endpoint. Effectiveness outcomes were collected 2 weeks postsurgery. RESULTS: Of 282 patients approached, 260 (92%) agreed to participate. In the genotype-guided arm, 20% had a high-risk (IM/PM/UM) phenotype, of whom 72% received an alternative opioid versus 0% of usual care participants (p < 0.001). In an exploratory analysis, there was less opioid consumption (200 [104-280] vs. 230 [133-350] morphine milligram equivalents; p = 0.047) and similar pain intensity (2.6 ± 0.8 vs. 2.5 ± 0.7; p = 0.638) in the genotype-guided vs. usual care arm, respectively. CONCLUSION: Implementing CYP2D6 to guide postoperative pain management is feasible and may lead to lower opioid use without compromising pain control.

Hip arthroscopy for lateral cam morphology: how important are the vessels?

The purpose of this narrative review is to identify the anatomy and relevant blood supply to the femoral head as it pertains to hip arthroscopy and lateral cam morphology. The primary blood supply to the femoral head is the lateral ascending superior retinacular vessels, which are terminal branches of the medial femoral circumflex artery. These vessels penetrate the femoral head at the posterolateral head-neck junction. Surgeons performing posterolateral femoral osteoplasty must respect this vasculature to avoid iatrogenic avascular necrosis (AVN). Avoidance of excessive traction, avoidance of distal posterolateral capsulotomy and avoidance of disruption of the superior retinacular vessels should keep the risk for AVN low. Hip extension, internal rotation and distraction are useful in hip arthroscopy to better visualize lateral/posterolateral cam morphology to facilitate an accurate comprehensive cam correction and avoid vascular disruption.

Rate and risk factors for blood transfusion in patients undergoing periacetabular osteotomy.

Periacetabular osteotomy has become the procedure of choice in many centers for the treatment of symptomatic hip dysplasia in young patients without severe secondary hip arthritis. Reorientation pelvic osteotomy has the potential for large blood loss and the need for blood transfusion. Between 1996 and 2003, 108 periacetabular osteotomies (107 patients) were performed by one of the authors. There were 84 females and 23 males with an average age of 30 years at the time of surgery. The overall allograft transfusion rate was 20% (21/108). Ninety-four percent (101/108) of the patients received transfusions including autologous blood, intraoperative cell saver, and postoperative allograft transfusion. The average transfusion amount (cell saver and allograft) was 2.14 units per patient. The risk for transfusion between males and females was not significantly different. The data from this study suggest that the vast majority of patients undergoing periacetabular osteotomy will require some form of transfusion, with 20% requiring allograft blood. The need for allograft blood will be minimal if the preoperative hemoglobin is greater than 12 g/dL.