Continuous Femoral Nerve Block Reduces the Need for Manipulation Following Total Knee Arthroplasty.

Peripheral nerve blocks improve both pain control and functional outcomes following total knee arthroplasty (TKA). However, few studies have examined the effects of different peripheral nerve block protocols on postoperative range of motion. The present study assessed the impact of a single-shot femoral nerve block (SFNB) versus continuous femoral nerve block (CFNB) on postoperative range of motion and the need for subsequent manipulation following TKA. Methods: We retrospective reviewed patient charts to identify patients who had undergone primary elective unilateral TKA by 2 surgeons at a high-volume orthopaedic specialty hospital over a 3-year period. A total of 1,091 patients received either SFNB or CFNB and were included in the data analysis. Identical surgical techniques, postoperative oral analgesic regimens, and rehabilitation protocols were used for all patients. Patients with <90° of flexion at 6 weeks postoperatively underwent closed manipulation under anesthesia (MUA). Results: Overall, 608 patients (55.7%) received CFNB and 483 patients (44.3%) received SFNB. Overall, 94 patients (8.6%) required postoperative manipulation for stiffness, including 36 (5.9%) in the CFNB group and 58 (12%) in the SFNB group. The 50% reduction in the need for manipulation in the CFNB group was independent of primary surgeon (p > 0.05). No significant differences were observed between the groups in terms of postoperative range of motion, either at the time of discharge or at 6 weeks postoperatively. A history of knee surgery, decreased preoperative range of motion, and decreased range of motion at the time of discharge were significantly associated with the need for further MUA (p = 0.0002, p < 0.0001, and p < 0.0001, respectively). Conclusions: Despite similar final postoperative range of motion between patients in both groups, our results suggest that CFNB may be superior to SFNB for reducing the need for postoperative manipulation after primary TKA. Furthermore, a history of ipsilateral knee surgery, decreased preoperative range of motion, and decreased range of motion at the time of discharge were identified as independent risk factors for postoperative stiffness requiring MUA after primary TKA. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Factors Influencing Survivorship in Vasculopathic Patients.

Total knee arthroplasty (TKA) in patients with peripheral vascular disease has sparsely been studied. This study examined patient and radiographic factors that could affect reoperation free survival in these patients. We retrospectively reviewed TKA procedures performed in patients with nonpalpable pulses on physical examination between January 1, 2004, and December 31, 2013. Ninety-two cases met inclusion criteria. Preoperative ankle-brachial index (ABI), date of surgery, sex, age, body mass index (BMI), tourniquet use, American Society of Anesthesiologists (ASA) score, presence of preoperative calcifications, and follow-up data were obtained. Failure was defined as reoperation. Patients were included if they experienced a failure or had at least 2 years of follow-up. Reoperation free survival was calculated by Kaplan-Meier's analysis. Odds ratios (ORs) were calculated for patient factors; hazard ratios (HRs) were calculated by Cox's regression analysis. Ninety-two TKAs were included in the study. Mean age was 68.8 years, mean BMI was 32.15, and mean ASA score was 2.44. Tourniquet was used in 78 patients. Mean preoperative ABI was 1.016. Nine patients had calcifications on X-ray prior to surgery. Reoperation free survival was 9.378 years. Patients with a preoperative ABI of below 0.7 had shorter reoperation free survival (ABI <0.7, 6.854 years; ABI >0.7, 9.535 years; p = 0.015). Patients with a preoperative ABI below 0.7 had greater odds of failure and were at higher risk for earlier failure (OR = 6.5, p = 0.027; HR = 1.678, p = 0.045). When corrected for age, sex, and BMI, the HR for patients with a preoperative ABI below 0.7 worsened (HR = 1.913, p = 0.035) compared with those with an ABI above 0.7. The remaining patient factors produced no statistically significant differences in survivorship, odds of failure, or HRs. No patient factors were associated with increased risk of mortality. These results suggest that patients who undergo TKA with an ABI below 0.7 are at increased risk for reoperation and have shorter reoperation free survival.

Revision of a dual-modular stem in patients with adverse tissue reaction.

BACKGROUND: Dual-modular femoral components with exchangeable cobalt-chrome neck segments have had higher than expected failure rates due to corrosion and adverse local tissue reaction (ALTR). Complications, survival rates and early clinical outcomes of revision surgery for the treatment of corrosion and ALTR as a result of these implants are underreported. METHODS: We identified 44 cases of revision THA for corrosion and ALTR resulting from the same dual modular stem. All revision procedures were performed using a modular tapered fluted titanium stem, ceramic heads and highly cross-linked polyethylene. RESULTS: Complications included: dislocation, infection, reoperation, and chronic pain. Mean Harris Hip Score was 84 following revision surgery. CONCLUSIONS: Patients undergoing revision surgery for ALTR related to this prosthesis should be aware of the risk of postoperative dislocation and other complications and the potential long-term risk of some chronic pain.

High Rate of Early Revision After Custom-Made Unicondylar Knee Arthroplasty.

BACKGROUND: There has been a recent interest in custom-made partial knee arthroplasties to provide patient-specific instrumentation and better fit of the prosthesis. While unicondylar knee arthroplasties (UKAs) have demonstrated good outcomes and durable results in many studies, there is little evidence on outcomes of these custom-made implants. METHODS: We performed a retrospective review of all custom-made UKAs performed at our institution by one surgeon from 2008 to 2015. We analyzed preoperative demographics, clinical follow-up evaluations, and radiographs and performed an analysis of risk factors including age, gender, height, weight, body mass index, and tibial insert thickness. The incidence of revision surgery, radiographic failures indicating component loosening, and symptomatic clinically failed implants was calculated at an average of 54.0 months of follow-up. RESULTS: We analyzed 115 consecutive custom-made medial UKAs from a single surgeon at our institution and found 29 (25.2%) UKAs had failed at an average of 33.1 months after surgery. Reasons for failure included aseptic femoral loosening (10), aseptic tibial loosening (8), loosening of both components (4), infection (3), progression of osteoarthritis (2), pain (1), and dislodged polyethylene insert (1). We found a significant relationship between implant failure and body mass index; no other study variables were statistically significant. CONCLUSION: We found a relatively high rate of aseptic loosening and particularly femoral component loosening in the short- to intermediate-term follow-up period. While further study of larger numbers of custom-made UKA from multiple institutions may help verify these findings, we recommend careful consideration of the use of this implant.

Management and Prevention of Intraoperative Acetabular Fracture in Primary Total Hip Arthroplasty.

Intraoperative acetabular fracture (IAF) is a rare complication of primary total hip arthroplasty (THA). Known risk factors include poor bone stock, underreaming of the acetabular bed, and use of elliptic components. There is a paucity of literature on risk factors, treatment strategies, and outcomes of this potentially devastating complication. We studied the incidence of IAF in primary THA at our high-volume institution. We reviewed 21,519 primary THA cases and identified 16 patients (16 hips) with IAFs. Mean follow-up was 4 years (range, 0-10 years). Implant data were recorded, and acetabular components were identified as elliptic modular or hemispheric modular. The institution's IAF rate was 0.0007%. All IAFs were associated with uncemented acetabular components. Sixty-nine percent of the fractures were not appreciated during surgery. All posterior column fractures required operative intervention in the immediate or early (<3 months) postoperative period. Compared with anterior column fractures, posterior column fractures were associated with acetabular component instability and need for additional surgery. In this article, we also present strategies for managing and preventing IAF in primary THA. This rare fracture requires prompt recognition and often necessitates aggressive management. More study is needed to determine how to better manage IAFs.

Total Hip Intraoperative Femur Fracture: Do the Design Enhancements of a Second-Generation Tapered-Wedge Stem Reduce the Incidence?

BACKGROUND: Intraoperative femur fracture (IFF) is a well-known complication in primary uncemented total hip arthroplasty (THA). Variations in implant instrumentation design and operative technique may influence the risk of IFF. This study investigates IFF between a standard uncemented tapered-wedge femoral stem and its second-generation successor with the following design changes: size-specific medial curvature, proportional incremental stem growth, modest reduction in stem length, and distal lateral relief. METHODS: A single experienced surgeon's patient database was retrospectively queried for IFF occurring during primary uncemented THA using a standard tapered-wedge femoral stem system or a second-generation stem. All procedures were performed using soft tissue preserving anatomic capsule repair and posterior approach. The primary outcome measure was IFF. A z-test of proportions was performed to determine significant difference between the 2 stems with respect to IFF. Patient demographics, Dorr classification, and implant characteristics were also examined. RESULTS: Forty-one of 1510 patients (2.72%) who received a standard tapered-wedge femoral stem sustained an IFF, whereas 5 of 800 patients (0.63%) using the second-generation stem incurred an IFF. No other significant associations were found. CONCLUSION: A standard tapered-wedge femoral stem instrumentation system resulted in greater than 4 times higher incidence of IFF than its second-generation successor used for primary uncemented THA. Identifying risk factors for IFF is necessary to facilitate implant system improvements and thus maximize patient outcomes.

Corrosion and Adverse Local Tissue Reaction in One Type of Modular Neck Stem.

Modular neck stems allow for optimization of joint biomechanics by restoring anteversion, offset, and limb length. A potential disadvantage is the generation of metal ions from fretting and crevice corrosion. We identified 118 total hip arthroplasty implanted with one type of dual-modular femoral component. Thirty-six required revision due to adverse local tissue reaction. Multivariate analysis isolated females and low offset necks as risk factors for failure. Kaplan-Meir analysis revealed small stem sizes failed at a higher rate during early follow-up period. Although the cobalt/chrome levels were higher in the failed group, these tests had low diagnostic accuracy for ALTR, while MRI scan was more sensitive. We conclude that the complications related to the use of dual modular stems of this design outweigh the potential benefits.

A multidisciplinary total hip arthroplasty protocol with accelerated postoperative rehabilitation: does the patient benefit?

Since its debut over 10 years ago, minimally invasive total hip arthroplasty (THA) has often been associated with accelerated postoperative rehabilitation when compared with THA performed with a traditional surgical approach. The objective of this study was to investigate the effect of accelerated postoperative rehabilitation and early mobilization on length of stay and hospital readmissions in patients undergoing THA at one institution. We retrospectively reviewed a consecutive series of 590 patients who underwent THA between January 31, 2011 and April 30, 2011. Six arthroplasty surgeons using varying surgical techniques participated. One hundred ninety patients received accelerated rehabilitation and were mobilized on the day of surgery. The remaining 400 patients were mobilized on postoperative day one (POD1). Length of stay for the accelerated rehabilitation group was 2.06 days and 3.38 days for the standard group. One patient was readmitted to the hospital within 30 days (.52%) in the accelerated group compared to 19 re-hospitalizations (4.72%) in the POD1 group. Ninety-six percent of the accelerated group were discharged home versus 62% in POD1 group. Our results support the use of an accelerated rehabilitation protocol at one institution following total hip replacement surgery.

Femoral head dislodgement complicating use of a dual mobility prosthesis for recurrent instability.

The dual mobility cup is an unconstrained tripolar configuration newly introduced to the United States in February 2011. The dual mobility construct allows for a larger femoral head to improve motion and minimize the risk of dislocation. We present a case of a patient who received the dual mobility cup for the treatment of recurrent dislocation following total hip arthroplasty. Early in the patient's postoperative course, the implant failed at the articulation between the larger outer polyethylene head and inner smaller metal femoral head following an attempt at closed reduction. This implant specific complication has not been reported in the North American literature.

Pharmacologic pain management before and after total joint replacement of the hip and knee.

There are many effective treatment measures for OA of the hip or knee, with varying degrees of effectiveness. Nonoperative measures include patient education, physical therapy, activity modification, weight loss, and medications. Pharmacologic strategies include acetaminophen, NSAIDs, injections of cortisone or viscosupplementation, and, less commonly, tramadol or other pain relievers. In patients who may be candidates for TJR, narcotic medications should be avoided to preserve their benefits for the postoperative period. Over the past 20 years, multimodal pain management has been beneficial to the patient undergoing TJR surgery. Studies have shown this form of pain management decreases postoperative opioid consumption and the related adverse effects. Research is warranted in the areas of postoperative pain scores and patient satisfaction as institutional multimodal protocols continue to evolve.

TKA after clamshell osteotomy for femoral diaphyseal malunion.

Proper component positioning is essential for successful total knee arthroplasty (TKA). Femoral component positioning presents a technical challenge when significant femoral deformity is present. Most commonly, an intramedullary guide is used to make an accurate distal femoral cut. However, in the presence of a significant femoral deformity, this is not a viable option.The use of clamshell osteotomy to restore anatomic alignment in patients with complex femoral diaphyseal deformity is described in the literature. This article describes a case of a patient who underwent staged TKA after clamshell osteotomy and retrograde femoral nailing to correct femoral diaphyseal malunion. The retrograde intramedullary nail was retained and used as an intramedullary guide, allowing for TKA in a routine manner. Using an intramedullary nail as an alignment guide may be more accurate than using extramedullary alignment and may avoid the increased surgical time and potential pin-site stress risers of navigation. It is a simple, effective way to treat complicated diaphyseal femoral deformities in the face of posttraumatic knee arthritis. Further study of this technique with longer follow-up and multiple surgeons is necessary to validate this treatment algorithm.

Complications of femoral nerve blockade in total knee arthroplasty and strategies to reduce patient risk.

Femoral nerve catheters are widely used for analgesia in total knee arthroplasty. Although evidence suggests that catheters improve pain control and may facilitate short-term rehabilitation, few reports exist regarding their complications. This case series explores the experience of femoral nerve catheter use at high-volume orthopedic specialty hospitals. Serious complications including compartment syndrome, periprosthetic fracture, and vascular injury are reported. The authors support femoral nerve catheter use with appropriate precautions taken to reduce risk of patient falls, vascular injury, and wrong-site surgery.

Effect of preoperative exercise on postoperative mobility in obese total joint replacement patients.

There has been a significant increase in obesity in the United States over the past 20 years. Reports in the literature identify the association of obesity-related osteoarthritis and the likelihood of future total hip arthroplasty (THA) and total knee arthroplasty (TKA) in this patient population. However, little is known about the effect of preoperative exercise on immediate postoperative mobility and discharge disposition in obese total joint replacement patients. The purpose of this study was to examine the effect of preoperative exercise in the obese total joint replacement patient on early postoperative mobility and discharge disposition. We retrospectively reviewed a consecutive series of patients with a body mass index (BMI) ≥30 kg/m(2) who underwent primary total joint replacement surgery from June 2005 through October 2005 at 1 institution. Two hundred seven patients met the inclusion criteria. Sixty-five patients performed self-reported preoperative exercise, defined as physical activity deemed above and beyond that of activities of daily living. Fewer exercise patients, 6.8%, required the assistance of ≥2 caregivers for mobility on postoperative day 1 vs 17.4% for nonexercisers. Fifty-four percent of patients participating in preoperative exercise were discharged home vs 46% who did not participate in exercise. A preoperative exercise program can improve postoperative functional mobility and increase the likelihood of discharge home in total joint replacement patients with a BMI of ≥30 kg/m(2).

Total joint replacement in the elderly patient.

Osteoarthritis of the hip and knee is extremely common in the growing elderly population. Total joint replacement (TJR) of the hip and knee are extremely effective procedures, resulting in decreased pain and improved function and quality of life in patients of all age groups including the elderly. The prevalence and use of TJR is increasing at a significant rate, therefore increased awareness of perioperative issues following TJR among health care providers is of paramount importance. Although elderly patients may be slightly more susceptible to perioperative complications, long-term success rates remain high, and careful perioperative monitoring and preventative measures have resulted in high rates of patient safety and few adverse outcomes in the elderly.

Use of a hydroxyapatite-coated stem in patients with Dorr Type C femoral bone.

Type C bone, as described by Dorr, exhibits both cellular and structural compromise, which presents a challenge for fixation of a total hip arthroplasty (THA). We evaluated the performance of the Omnifit HA stem, a hydroxyapatite-coated titanium alloy stem, by retrospectively reviewing the clinical and radiographic data of 15 patients with femoral Type C bone who received the stem during primary THA between 1991 and 1994. The patients were followed a minimum of 9 years (mean, 11.5 years; range, 9-14 years). The average age at surgery was 54 years and the average body mass index was 28. Eight of the patients were men. The median Harris hip score was 94.5 points. Radiographically, two independent reviewers identified all patients as Type C bone. The average canal to calcar isthmus ratio was 0.74 (range, 0.65-0.95). At most recent followup, four patients demonstrated proximal osteolysis. Using plain radiography we detected no patients with distal osteolysis or subsidence. At 9 to 14 years, the stem has performed well in a selected series of patients with poor bone quality and the outcomes compare favorably with previously reported findings using this design of stem in other bone types. These results support the decision to use a hydroxyapatite-coated stem in patients with Type C bone.