Intraprosthetic Dislocation of a Modular Dual-Mobility Total Hip Arthroplasty With Posterior Migration of the Polyethylene Liner.

Dual-mobility (DM) implants have been used in total hip arthroplasty since 1974. Modular DM implants have seen an increase in use in primary and revision total hip arthroplasties given the theoretical decreased dislocation rate. DM constructs have 2 articulation sites, one between the acetabular shell and a polyethylene liner, as well as one between the liner and the femoral head component. However, dislocations with modular DM implant dislocations can still occur. These dislocations occur via an extraprosthetic or intraprosthetic mechanism. Intraprosthetic dislocation is a phenomenon in which the smaller femoral head dissociates from the polyethylene liner. We present a case of intraprosthetic dislocation in an 81-year-old female with migration of the polyethylene liner into her gluteal muscles after 2 attempted closed reductions.

Closed Reduction of a Dislocated Constrained Total Hip Arthroplasty With 2-year Follow-up: A Case Report.

In the setting of chronic instability following total hip arthroplasty, implantation of a constrained acetabular liner may be warranted. We report on a patient who sustained a posterior prosthetic hip dislocation out of the constrained acetabular liner component (Stryker Trident [Kalamazoo, MI]), which had been previously replaced 2 months prior, and underwent a successful closed reduction in the emergency department. At 2-year follow-up, the patient's prosthetic hip has remained stable with no reported issues. To our knowledge, this is the first reported closed reduction of a revised constrained total hip arthroplasty with this implant system, size, and length of follow-up.

Prevalence and risk factors for secondary hyperparathyroidism (SHPT) in patients undergoing bariatric surgery.

INTRODUCTION: Secondary hyperparathyroidism (SHPT) after bariatric surgery has significant adverse implications for bone metabolism, increasing the risk for osteoporosis and fracture. Our aim was to characterize prevalence and identify risk factors for SHPT in bariatric surgery patients. METHODS: We performed a single-institution, retrospective chart review of patients who underwent bariatric surgery from June 2017 through December 2021. Demographic and clinical data were collected, including serum parathyroid hormone, calcium, and vitamin D3 at enrollment and 3, 6, and 12-months postoperatively. Chi-square or Fisher's exact tests were used to analyze categorical data and Mann-Whitney U test for continuous data. Multivariable analysis using binomial logistic regression assessed risk factors for SHPT. P-values ≤ 0.05 were considered significant. RESULTS: 350 patients were analyzed. SHPT prevalence at any time point was 72.9%. 65.8% had SHPT at enrollment; 45.9% resolved with intensive vitamin supplementation; and 19.7% had recurrent SHPT. New-onset SHPT occurred in 8.6%. Persistent SHPT was present in 42.4% at 1-year. Baseline SHPT correlated with black race and T2DM. SHPT at any time point correlated with T2DM and higher baseline BMI. 1-year SHPT correlated with RYGB, depression, and longer time in program. SHPT was not correlated with %TBWL at any time point. In patients with SHPT, vitamin D3 deficiency prevalence was significantly higher at baseline (77.0%) compared to all post-bariatric time points (16.7%, 17.3%, and 23.1%; P < 0.0001). CONCLUSIONS: SHPT is highly prevalent in patients with obesity seeking weight loss surgery. 42% had persistent SHPT at 1-year despite appropriate vitamin supplementation. Current vitamin D3 and calcium supplementation protocols may not effectively prevent SHPT in many post-bariatric patients. Low prevalence of concomitant vitamin D3 deficiency with SHPT after bariatric surgery suggests that there may be alternative mechanisms in this population. Further studies are needed to develop effective treatment strategies to mitigate the adverse effects of bariatric surgery on bone metabolism.

Total hip arthroplasty complications in patients with chronic kidney disease: A comparison study.

Background: It has been noted in the literature that there are increased complication rates following total hip arthroplasty (THA) in patients with chronic kidney disease (CKD) or end stage renal disease (ESRD). However, there is little data directly comparing outcomes in patients undergoing THA for osteoarthritis (OA) versus ESRD or CKD with OA. The objective of this study is to illustrate the risk of developing postoperative complications after THA in the CKD and ESRD populations by stage of disease when compared to a control group (OA) and thus better equip orthopaedic providers in the care of these patients. Methods: The National Inpatient Sample (NIS) was utilized to identify patients undergoing elective THA from 2006 to 2015 with OA, ESRD, and CKD. The prevalence of preoperative comorbidities and the incidence of numerous postoperative complications broken into categories were examined. Results: Between 2006 and 2015 the NIS database reported 4,350,961 patients diagnosed with OA, 8355 diagnosed with ESRD, and 104,313 diagnosed with CKD undergoing THA. The incidence of wound hematoma (2.5% vs. 0.8%; p < .0001), wound infection (0.7% vs. 0.4%; p = .0319), cardiac (1.3% vs. 0.6%; p = .0067), urinary (3.9% vs. 2.0%; p < .0001), and pulmonary complications (2.2% vs. 0.5%; p < .0001) occurred more frequently in patients with OA and ESRD when compared to only OA patients. For patients with OA and CKD, stages 3-5 saw at least half of the complication categories occur at significantly higher rates than OA patients. Conclusion: This study shows that patients with ESRD and CKD have increased rates of complications after THA. This study's specific breakdown by stage and complication can benefit orthopaedic surgeons and practitioners in realistic pre and postoperative planning and provides data that could benefit decision making on bundled reimbursement for this specific patient population, as providers could better account for the postoperative complications noted above and their associated costs.

A Multidisciplinary Approach to the Nonambulatory Bariatric Patient With Bilateral Knee Osteoarthritis.

Obesity and lower-extremity arthritis are challenging problems to address as they are often mutually exacerbating. Due to the known perioperative risk of morbid obesity, the modality and timing of weight loss prior to arthroplasty is debated. We present a case of a 55-year-old nonambulatory female patient with an initial body mass index of 80.3 kg/m2. This individual underwent a staged bariatric and joint replacement surgical pathway employing personnel of differing treatment disciplines. Our patient successfully lost a substantial amount of weight and has been able to ambulate, exercise, and engage in new, strenuous physical activities. In the care of the nonambulatory bariatric patient, employing a multidisciplinary treatment plan can produce successful results.

Relationships Between Body Mass Index, Allogeneic Transfusion, and Surgical Site Infection After Knee and Hip Arthroplasty Surgery.

BACKGROUND: Increased body mass index (BMI) is considered as an important factor that affects the need for total knee and hip arthroplasty (TKA/THA) and the rate of perioperative complications. Previous investigations have not fully established the relationship of BMI and perioperative transfusion with surgical site infection (SSI) or the relationship of BMI and perioperative transfusion after TKA or THA. METHODS: The National Surgical Quality Improvement Program database was used to perform a retrospective cohort study involving 333,223 TKA and 41,157 THA cases between 2011 and 2018. Multivariable regression assessed the associations of BMI (5 standard categories) and transfusion with SSI. Odds ratio (OR) of SSI was calculated relative to a normal BMI (18.5-24.9 kg/m 2 ) after adjustment of potential confounding factors. RESULTS: Perioperative transfusion decreased significantly over time for both TKA and THA; however, SSI rates remained steady at just under 1% for TKA and 3% for THA. In TKA, a higher OR for SSI was associated only with a BMI of 40+ (OR, 1.86; 95% confidence interval [CI], 1.60-2.18) compared to a referent BMI. In THA, increased ORs of SSI were seen for all BMI levels above normal and were highest for a BMI 40+ (OR, 3.08; 95% CI, 2.47-3.83). In TKA, ORs of transfusion decreased with increasing BMI and were lowest for a BMI 40+ (OR, 0.51; 95% CI, 0.47-0.54). In THA, ORs of transfusion began to increase slightly in overweight patients, reaching an OR of 1.36 (95% CI, 1.21-1.54) for a BMI 40+. CONCLUSIONS: SSI incidence remained unchanged despite continuous reductions in blood transfusion in TKA and THA patients over 8 years. In TKA, ORs for SSI increased, but ORs for transfusion decreased with increasing BMI above normal. Conversely, in THA, ORs for SSI and transfusion both increased for a BMI 40+, but only OR for transfusion increased in underweight patients. These findings suggest the importance of controlling obesity in reducing SSI following TKA and THA.

Unusual Case of a Trunnion Fracture Following a Revision Hip Arthroplasty Surgery: A Brief Review of the Literature and Discussion About Causes of Failure.

Trunnion fracture is an incredibly rare complication of total hip arthroplasty. Of the few reported cases, all involve implants with faulty designs, a small neck taper, or an extended neck length or offset. Most also report corrosion and an adverse soft-tissue reaction. We present a review of the literature and report on the first case, to our knowledge, of trunnion fracture in a well-fixed, cemented cobalt-chromium femoral component with a standard neck length and offset with no evidence of corrosion. This failure was likely related to scratching of the metal during previous procedures which led to crack propagation and catastrophic failure. The patient was treated with revision hip arthroplasty to an uncemented, distal-fit femoral component and insertion of new bearing surfaces.

Complication Rates in Total Knee Arthroplasty Performed for Osteoarthritis and Post-Traumatic Arthritis: A Comparison Study.

BACKGROUND: The number of total knee arthroplasty (TKA) procedures performed in the United States has been increasing. Increased complication rates have been demonstrated in patients with post-traumatic arthritis (PTA) undergoing TKA. However, there remains limited data directly comparing outcomes of TKA performed for osteoarthritis (OA) and PTA. METHODS: The National Inpatient Sample was utilized to identify patients undergoing elective TKA between 2006 and 2015 for OA and PTA. The prevalence of preoperative comorbidities and the incidence of postoperative complications including superficial wound infection, deep joint infection, acute deep venous thrombosis, and pulmonary embolus were analyzed. RESULTS: Between 2006 and 2015, the National Inpatient Sample database accounted for 1,301,394 patients diagnosed with either PTA (14,206) or OA (1,287,188) undergoing TKA. The incidence of superficial wound infection, deep joint infection, and acute deep venous thrombosis was found to occur at a higher rate in patients with a diagnosis of PTA compared to OA. The incidence of pulmonary embolus was not found to be statistically different between the 2 groups. Patients with PTA had a higher prevalence of drug and alcohol abuse, psychosis, and liver disease, whereas patients with OA had a higher prevalence of obesity, diabetes, heart disease, and lung disease. CONCLUSION: This study demonstrates an increased risk of complications in patients undergoing TKA for PTA compared to OA. Surgeons can use this information to help aid in counseling patients preoperatively. Furthermore, these data provide objective evidence that could have implications with regards to establishing bundled payment reimbursement in this patient population.

Management of femoroacetabular impingement syndrome: current insights.

Since the description of femoroacetabular impingement (FAI) by Ganz in 2003, our understanding of the pathophysiology, management options, and outcomes has evolved and literature continues to be generated on this condition at a rapid rate. FAI has been identified as a primary source of hip pain as well as a generator of secondary osteoarthritis. Improvements in the radiographic detection of cam and pincer morphologies as well as a better understanding of the structural impact of these morphologies have led to improved preoperative planning. Advancements in hip arthroscopy techniques have also led to a higher rate of arthroscopic management of this condition over the initially described open surgical dislocation technique. While arthroscopic management of this condition has become the most common form of surgical management for FAI, inadequate bony resection has been shown to be a frequent source of revision surgery. Therefore, roles for open surgical dislocation and combined mini-open approaches remain, particularly in cases where concern for the inability to fully access the morphology arthroscopically exists.

Intermediate-Term Results of 142 Single-Design, Rotating-Hinge Implants: Frequent Complications May Not Preclude Salvage of Severely Affected Knees.

Rotating-hinge knee prostheses have low survivorship and high complications except in primary arthroplasties in elderly patients. We retrospectively reviewed 142 single third-generation design, rotating hinge prostheses (11 primary procedures and 131 revisions) at 57 months follow up. Implant survival was 73%. Successful two-stage reimplantation for prosthetic infection was 78.4% but new infection rate was 22%. The tibial component was durable while the femoral component was problematic. We observed only one patellar maltracking and no polyethylene wear. A third generation rotating-hinge arthroplasty reconstruction was reliable in complex problems. Outcomes in primary situations were excellent. Complications were the rule rather than the exception in revisions. With timely intervention, attention to soft tissue coverage, and realistic expectations, complications were contained and functional benefits were appreciable.

Arthroscopic technique for treatment of combined pathology associated with femoroacetabular impingement syndrome using traction sutures and a minimal capsulotomy.

The use of hip arthroscopy is gaining popularity for diagnostic and therapeutic purposes. With our increasing understanding of hip biomechanics and pathophysiology, our techniques for treatment are evolving as well. The main aim is to preserve the joint and prolong the degenerative process associated with femoroacetabular impingement (FAI). In general, combined pathology is encountered when a diagnosis of FAI is established. In our experience, we have seen large number of patients with a combination of cam and pincer lesions with or without associated labral tears. It is optimal to address all symptomatic pathology with one surgical intervention. The described technique shows the feasibility of dealing with the hip FAI pathology by using traction sutures on the capsule through a 2-portal technique.

Limb-length discrepancy after total hip arthroplasty: novel treatment and proposed algorithm for care.

Limb-length discrepancy after total hip arthroplasty (THA) leads to patient dissatisfaction and can be a cause of orthopedic surgery malpractice cases. Nonsurgical and surgical techniques exist to correct limb-length discrepancies. Two limb-lengthening methods were used to correct greater than 2-cm limb-length discrepancies after THA: lengthening over a femoral nail with an external fixator and lengthening with an intramedullary kinetic skeletal distractor. These techniques achieved equal length in less than 4 weeks, with both resulting in a healed distraction gap within 4 months. No patient had loss of proximal or distal joint motion, and mean Harris Hip Score was 90 points at final follow-up. No surgical complications were reported with the intramedullary skeletal kinetic distractor. Limb lengthening using an intramedullary skeletal kinetic distractor is a viable treatment option resulting in reliable lengthening, healing of the distraction gap, and progression to full weight bearing.

Low-dose irradiation and constrained revision for severe, idiopathic, arthrofibrosis following total knee arthroplasty.

Treatment options for arthrofibrosis following total knee arthroplasty include manipulation under anesthesia, open or arthroscopic arthrolysis, and revision surgery to correct identifiable problems. We propose preoperative low-dose irradiation and Constrained Condylar or Rotating-hinge revision for severe, idiopathic arthrofibrosis. Irradiation may decrease fibro-osseous proliferation while constrained implants allow femoral shortening and release of contracted collateral ligaments. Fourteen patients underwent fifteen procedures for a mean overall motion of 46° and flexion contracture of 30°. One patient had worsening range of motion while thirteen patients had 57° mean gain in range of motion (range 5°-90°). Flexion contractures decreased by a mean of 28°. There were no significant complications at a mean follow up of 34 months (range 24 to 74 months).

Management of severe deformity using a combination of internal and external fixation.

This review addresses severe foot and ankle deformities and describes techniques for internal and external fixation. A combination of internal and external fixation techniques is often necessary in severe foot and ankle deformities secondary to leg length discrepancies. This article includes a thorough literature review as well as an extensive description of these techniques.