Evolving Patient Perception of Limb Length Discrepancy Following Total Hip Arthroplasty.

BACKGROUND: Limb length discrepancy (LLD) is a known complication of total hip arthroplasty (THA), leading to decreased patient function and satisfaction. It remains unknown how a patient's perception of LLD evolves over time. The aim of this study is to evaluate the relationship between measured and perceived LLD, and to assess whether perceived LLD resolved with time in most patients. METHODS: This study retrospectively reviewed radiographs of 140 consecutive patients undergoing primary THA by a single surgeon via a direct anterior approach, calculating postoperative change in limb length (ΔL). Patient perceptions of LLD were recorded at standard postoperative visit intervals. A P-value of .05 was used to determine statistical significance. RESULTS: Of 130 patients (mean ΔL = +7.9 mm), 22 patients endorsed perceived postoperative LLD and the remainder were asymptomatic (mean ΔL +11.1 mm vs +7.3 mm, P = .03). Seventeen patients reported mild symptoms and 5 reported severe symptoms (mean ΔL +10.2 mm vs +13.8 mm, P = .4). After 1 year, 45% (10) patients reported complete resolution of perceived LLD (mean follow-up 364 days), 18% (4) reported notable improvement, and 36% (8) reported no improvement. Four excluded patients endorsed perceived LLD (2 mild, 2 severe), which resolved after contralateral THA. CONCLUSION: This study noted a correlation between increasing postoperative ΔL and perceived LLD. A majority of patients (63%) experienced either improvement or full resolution of symptoms during the follow-up period. This data may have a role in reassuring the orthopedic surgeon and the patient regarding the natural course of postoperative LLD. Further investigation is needed to help identify risk factors for persistent LLD. LEVEL OF EVIDENCE: Level III (Prognostic).

Safe Zones for Anterior Acetabular Retractor Placement in Direct Anterior Total Hip Arthroplasty: A Cadaveric Study.

INTRODUCTION: There is paucity of literature evaluating anterior acetabular retractor proximity to the femoral nerve and external iliac vessels during total hip arthroplasty through the direct anterior approach. In this cadaveric study, we evaluated three retractor locations to identify optimal positioning of anterior retractors. METHODS: A direct anterior approach was performed in 22 hips of 15 cadavers. Anterior acetabular retractors were placed over the anterior acetabular wall in-line with the femoral neck (12-o'clock or middle position). The anterior neurovascular structures were identified through the ilioinguinal approach. Retractors were reinserted at 10-o'clock (right hip; superior) and 2-o'clock (right hip; inferior) locations marked using K-wires. Horizontal and vertical distances from retractor tip positions to neurovascular structures were measured with a digital caliper. RESULTS: Retractor tips moved significantly from lateral to the femoral nerve when placed in the superior position (mean, 2.8 mm) to medial to the femoral nerve in the middle (mean, -2.3 mm) and inferior (mean, -4.8 mm) locations. Retractor tips moved significantly medial toward the external iliac artery when retractors were moved from superior (mean, 15.3 mm) to inferior (mean, 6.6 mm) positions placing the retractor tip closer to the vessels. CONCLUSION: As retractor placements moved inferior, retractor tips moved medial to neurovascular structures. Inferior retractor positioning placed the femoral nerve and external iliac artery at the risk of injury during the initial retractor placement or adjustment. Retractors should be placed in a relative safe zone superior to the 12-o'clock position to avoid damage to neurovascular structures. LEVEL OF EVIDENCE: IV.

MRI for the evaluation of knee pain: comparison of ordering practices of primary care physicians and orthopaedic surgeons.

BACKGROUND: Knee pain is one of the most common reasons for outpatient visits in the U.S. The great majority of such cases can be effectively evaluated through physical examination and judicious use of radiography. Despite this, an increasing number of magnetic resonance images (MRIs) of the knee are being ordered for patients with incomplete work-ups or for inappropriate indications. We hypothesized that MRIs ordered by orthopaedic providers were more likely to result in changes in diagnoses and/or plans for care than those ordered by non-orthopaedic providers. METHODS: We reviewed the charts of all consecutive new patients seen at our orthopaedic outpatient office between January 1, 2010, and December 31, 2011, with International Classification of Diseases, Ninth Revision (ICD-9) codes for meniscal or unspecific sprains and strains of the knee. A total of 1592 patients met our inclusion criteria and were divided into two groups: those initially evaluated and referred by their primary care physician (PCP) (n = 747) and those initially evaluated by one of our staff orthopaedic surgeons (n = 845). RESULTS: MRI-ordering rates were nearly identical between orthopaedic surgeons and PCPs (25.0% versus 24.8%; p = 0.945). MRIs ordered by orthopaedic surgeons, however, resulted in significantly more arthroscopic interventions than those ordered by PCPs (41.2% versus 31.4%; p = 0.042). Orthopaedic surgeons ordered MRIs for patients who were more likely to benefit from arthroscopic intervention, including patients who were younger (mean age, 45.1 years versus 56.5 years for those with PCP-ordered MRIs; p < 0.001), patients with acute symptoms (39.3% versus 22.2%; p < 0.001), and patients with a history of trauma (49.3% versus 36.2%; p = 0.019). Finally, orthopaedic surgeons were less likely than PCPs to order MRIs for patients with substantial osteoarthritis who subsequently underwent total knee arthroplasty (4.3% versus 9.2%; p = 0.048). CONCLUSIONS: MRI utilization by orthopaedic surgeons results in more appropriate interventions for patients with symptoms and findings most amenable to surgical intervention.

Dedicated orthopaedic operating rooms: beneficial to patients and providers alike.

OBJECTIVE: Dedicated orthopaedic operating rooms (DOORs) are increasingly popular solutions to reducing after-hours procedures, physician fatigue, and elective schedule disruptions. Although the benefits to surgeons are well understood, there are comparatively few studies that explore the effects of DOORs on patient care. We compared treatments and outcomes for all consecutive patients with femoral neck fractures, 4 years before and 4 years after implementation of a DOOR-based schedule. DESIGN: Retrospective case-control study. SETTING: Level 1 academic trauma center. PATIENTS: A total of 111 consecutive trauma patients undergoing surgical management of isolated OTA group 31-B femoral neck fractures. INTERVENTION: Based on individual patient factors and fracture characteristics, patients were managed with either hemiarthroplasty or open reduction internal fixation (ORIF). MAIN OUTCOME MEASURES: Surgical timing, intervention type, perioperative complications, and postoperative length of stay. RESULTS: Retrospective analysis revealed a significant decrease in after-hour surgery (4 PM-7:30 AM) for all femoral neck fractures (66.7%-19.3%; P < 0.001). No significant differences were found between the rates of arthroplasty versus those of open reduction internal fixation. Patients undergoing surgical treatment for femoral neck fractures after DOOR suffered significantly fewer morbidities, including significantly decreased rates of postoperative intensive care unit admissions, stroke, infections, and myocardial infarction or congestive heart failure exacerbations. We also observed a significant decrease in postoperative mortality (5.6% pre-DOOR vs. 0% post-DOOR; P = 0.04). Patients undergoing hemiarthroplasty experienced a significant shorter hospitalization (14.5 days pre-DOOR vs. 9.9 days post-DOOR; P = 0.04). CONCLUSIONS: In our experience, a weekday DOOR is closely associated with improvements in both patient safety and outcomes. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.