The Effects of Body Mass Index on Pain Control With Liposomal Bupivacaine in Hip and Knee Arthroplasty.

BACKGROUND: There is evidence to suggest that liposomal bupivacaine (LB) is an effective component of a multimodal pain regimen for total joint arthroplasty (TJA). Obesity has been associated with chronic pain following TJA. This study assessed whether early postoperative pain is affected by body mass index (BMI), and whether the standard LB dose has similar effects on obese vs nonobese patients. METHODS: A retrospective analysis of 2629 primary TJA over a 12-month period was conducted, with LB used in half of this group. Patients were further classified as nonobese (BMI < 30) or obese (BMI ≥ 30). Pain scores and narcotic use were recorded. Independent-sample t-tests were used for continuous variables and chi-squared analyses for categorical variables. A multivariate regression analysis was performed. RESULTS: Significantly less narcotic was required on postoperative days (POD) 0 and 1 in patients receiving LB compared to those who did not in both obese and nonobese patient groups. On POD 2, obese and nonobese patients had an increase in narcotic requirement, which was significant in obese patients. A regression analysis found that on POD 0 and POD 1, lack of LB use, obesity, and younger age were independently associated with increased narcotic use. CONCLUSION: While narcotic requirement of obese and nonobese patients decreased on POD 0 and POD 1 with initiation of LB at our institution, all patients demonstrated increased narcotic requirement on POD 2 which was statistically and clinically significant in obese patients. Further studies are needed to determine the optimal pain regimen in the growing obese population undergoing TJA.

Tendon Disorders After Total Hip Arthroplasty: Evaluation and Management.

BACKGROUND: Most patients who undergo total hip arthroplasty are very satisfied with their outcomes. However, there is a small subset of patients who have persistent pain after surgery. The etiology of pain after total hip arthroplasty varies widely; however, tendon disorders are a major cause of debilitating pain that often go unrecognized. METHODS: We performed a literature review to identify the most common tendon pathologies after total hip arthroplasty which include iliopsoas tendinitis, greater trochanteric pain syndrome, snapping hip syndrome, and abductor tendinopathy. RESULTS: We present a simplified approach highlighting the presentation and management of patients with suspected tendinopathies after total hip arthroplasty. These tendinopathies are treatable, and management begins with nonoperative modalities; however, in cases not responsive to conservative management, operative intervention may be necessary. CONCLUSION: Tendinopathies after total hip arthroplasty sometimes go unrecognized but when treated can result in higher surgeon and patient satisfaction.

Platelet aggregation and coagulation factors in orthopedic surgery.

Hemostasis is a major concern during the perioperative period. Changes in platelet aggregation and coagulation factors may contribute to the delicate balance between thrombosis and bleeding. We sought to better understand perioperative hemostasis by investigating the changes in platelet aggregation and coagulation factors during the perioperative period. We performed a prospective cohort analysis of 70 subjects undergoing non-emergent orthopedic surgery of the knee (n = 28), hip (n = 35), or spine (n = 7) between August 2011 and November 2011. Plasma was collected preoperatively (T1), 1-h intraoperatively (T2), 1-h (T3), 24-h (T4) and 48-h (T5) postoperatively. Platelet function testing was performed using whole blood impedance aggregometry. Coagulation assays were performed for factor VII, factor VIII, von Willebrand Factor (vWF), and fibrinogen. Of the 70 patients, mean age was 64.1 ± 9.8 years, 61% were female, and 74% were Caucasian. Platelet activity decreased until 1 h postoperatively and then significantly increased above baseline at 24- and 48-h postoperatively. Compared to baseline, coagulation factors decreased intraoperatively. Factor VII activity continued to decrease, while FVIII, vWF, and fibrinogen all increased above baseline postoperatively. The results of our study indicate significant changes in platelet activity and coagulation factors during the perioperative period. Both platelet activity and markers of coagulation decrease during the intraoperative period and then some increase postoperatively. These changes may contribute to the hypercoagulabity and/or bleeding risk that occurs in the perioperative period. Future prospective studies aimed at correlating hemostatic changes with perioperative outcomes are warranted.

Thrombotic and bleeding complications after orthopedic surgery.

BACKGROUND: Thrombotic and bleeding complications are major concerns during orthopedic surgery. Given the frequency of orthopedic surgical procedures and the limited data in the literature, we sought to investigate the incidence and risk factors for thrombotic (myocardial necrosis and infarction) and bleeding events in patients undergoing orthopedic surgery. METHODS AND RESULTS: We performed a retrospective cohort analysis of 3,082 consecutive subjects ≥21 years of age undergoing hip, knee, or spine surgery between November 1, 2008, and December 31, 2009. Patient characteristics were ascertained using International Classification of Diseases, Ninth Revision, diagnosis coding and retrospective review of medical records, and laboratory/blood bank databases. In-hospital outcomes included myocardial necrosis (elevated troponin), major bleeding, coded myocardial infarction, and coded hemorrhage as defined by International Classification of Diseases, Ninth Revision, coding. Of the 3,082 subjects, mean age was 60.8 ± 13.3 years, and 59% were female. Myocardial necrosis, coded myocardial infarction, major bleeding, and coded hemorrhage occurred in 179 (5.8%), 20 (0.7%), 165 (5.4%), and 26 (0.8%) subjects, respectively. Increasing age (P < .001), coronary artery disease (P < .001), cancer (P = .004), and chronic kidney disease (P = .01) were independent predictors of myocardial necrosis, whereas procedure type (P < .001), cancer (P < .001), female sex (P < .001), coronary artery disease (P < .001), and chronic obstructive pulmonary disease (P = .01) were independent predictors of major bleeding. CONCLUSION: There is a delicate balance between thrombotic and bleeding events in the perioperative period after orthopedic surgery. Perioperative risk of both thrombosis and bleeding deserves careful attention in preoperative evaluation, and future prospective studies aimed at attenuating this risk are warranted.

Oblique posterior trochanteric osteotomy in revision total hip arthroplasty.

Modular polyethylene failure and attendant revision play an increasing role in hip arthroplasty. In spite of well-fixed, well-aligned components, bearing exchange has a high risk of chronic instability, which may be attributed to the resection of stabilizing soft tissue structures to gain exposure. This creates a difficult situation for the surgeon and an inexplicable one for the patient with a previously well-functioning implant. The senior author modified a technique previously described by Shaw that included an osteotomy of the posterior one third of the greater trochanter and preservation of posterior soft tissues. Thirty-five patients underwent 47 revision procedures utilizing this approach, including 16 modular component and 31 more extensive procedures. There were no dislocations or significant complications and no loss of reduction or nonunion. The approach offers excellent exposure while preserving stabilizing soft tissues.

Association Between Anemia, Bleeding, and Transfusion with Long-term Mortality Following Noncardiac Surgery.

BACKGROUND: Preoperative anemia is a well-established risk factor for short-term mortality in patients undergoing noncardiac surgery, but appropriate thresholds for transfusion remain uncertain. The objective of this study was to determine long-term outcomes associated with anemia, hemorrhage, and red blood cell transfusion in patients undergoing noncardiac surgery. METHODS: We performed a long-term follow-up study of consecutive subjects undergoing hip, knee, and spine surgery between November 1, 2008 and December 31, 2009. Clinical data were obtained from administrative and laboratory databases, and retrospective record review. Preoperative anemia was defined as baseline hemoglobin < 13 g/dL for men and < 12 g/dL for women. Hemorrhage was defined by International Classification of Diseases, Ninth Revision coding. Data on long-term survival were collected from the Social Security Death Index database. Logistic regression models were used to identify factors associated with long-term mortality. RESULTS: There were 3050 subjects who underwent orthopedic surgery. Preoperative anemia was present in 17.6% (537) of subjects, hemorrhage occurred in 33 (1%), and 766 (25%) received at least one red blood cell transfusion. Over 9015 patient-years of follow-up, 111 deaths occurred. Anemia (hazard ratio [HR] 3.91; confidence interval [CI], 2.49-6.15) and hemorrhage (HR 5.28; 95% CI, 2.20-12.67) were independently associated with long-term mortality after multivariable adjustment. Red blood cell transfusion during the surgical hospitalization was associated with long-term mortality (HR 3.96; 95% CI, 2.47-6.34), which was attenuated by severity of anemia (no anemia [HR 4.39], mild anemia [HR 2.27], and moderate/severe anemia [HR 0.81]; P for trend .0015). CONCLUSIONS: Preoperative anemia, perioperative bleeding, and red blood cell transfusion are associated with increased mortality at long-term follow-up after noncardiac surgery. Strategies to minimize anemia and bleeding should be considered for all patients, and restrictive transfusion strategies may be advisable. Further investigation into mechanisms of these adverse events is warranted.

Perioperative antiplatelet therapy and cardiovascular outcomes in patients undergoing joint and spine surgery.

STUDY OBJECTIVE: Perioperative thrombotic complications after orthopedic surgery are associated with significant morbidity and mortality. The use of aspirin to reduce perioperative cardiovascular complications in certain high-risk cohorts remains controversial. Few studies have addressed aspirin use, bleeding, and cardiovascular outcomes among high-risk patients undergoing joint and spine surgery. DESIGN/SETTING/PATIENTS: We performed a retrospective comparison of adults undergoing knee, hip, or spine surgery at a tertiary care center during 2 periods between November 2008 and December 2009 (reference period) and between April 2013 and December 2013 (contemporary period). MEASUREMENTS: Patient demographics, comorbidities, management, and outcomes were ascertained using hospital datasets. MAIN RESULTS: A total of 5690 participants underwent 3075 joint and spine surgeries in the reference period and 2791 surgeries in the contemporary period. Mean age was 61±13 years, and 59% were female. In the overall population, incidence of myocardial injury (3.1% vs 5.8%, P<.0001), hemorrhage (0.2% vs 0.8%, P=.0009), and red blood cell transfusion (17.2% vs 24.8%, P<.001) were lower in the contemporary period. Among 614 participants with a preoperative diagnosis of coronary artery disease (CAD), in-hospital aspirin use was significantly higher in the contemporary period (66% vs 30.7%, P<.0001); numerically, fewer participants developed myocardial injury (13.5% vs 19.3%, P=.05), had hemorrhage (0.3% vs 2.1%, P=.0009), and had red blood cell transfusion (37.2% vs 44.2%, P<.001) in the contemporary vs reference period. CONCLUSIONS: In a large tertiary care center, the incidence of perioperative bleeding and cardiovascular events decreased over time. In participants with CAD, perioperative aspirin use increased and appears to be safe.

Relation of perioperative elevation of troponin to long-term mortality after orthopedic surgery.

Myocardial necrosis in the perioperative period of noncardiac surgery is associated with short-term mortality, but long-term outcomes have not been characterized. We investigated the association between perioperative troponin elevation and long-term mortality in a retrospective study of consecutive subjects who underwent hip, knee, and spine surgery. Perioperative myocardial necrosis and International Classification of Disease, Ninth Revision-coded myocardial infarction (MI) were recorded. Long-term survival was assessed using the Social Security Death Index database. Logistic regression models were used to identify independent predictors of long-term mortality. A total of 3,050 subjects underwent surgery. Mean age was 60.8 years, and 59% were women. Postoperative troponin was measured in 1,055 subjects (34.6%). Myocardial necrosis occurred in 179 cases (5.9%), and MI was coded in 20 (0.7%). Over 9,015 patient-years of follow-up, 111 deaths (3.6%) occurred. Long-term mortality was 16.8% in subjects with myocardial necrosis and 5.8% with a troponin in the normal range. Perioperative troponin elevation (hazard ratio 2.33, 95% confidence interval 1.33 to 4.10) and coded postoperative MI (adjusted hazard ratio 3.51, 95% confidence interval 1.44 to 8.53) were significantly associated with long-term mortality after multivariable adjustment. After excluding patients with coronary artery disease and renal dysfunction, myocardial necrosis remained associated with long-term mortality. In conclusion, postoperative myocardial necrosis is common after orthopedic surgery. Myocardial necrosis is independently associated with long-term mortality at 3 years and may be used to identify patients at higher risk for events who may benefit from aggressive management of cardiovascular risk factors.

Surgical management of the rheumatoid elbow.

Many patients with rheumatoid arthritis demonstrate elbow involvement that may limit upper extremity function, usually within 5 years of disease onset. Initial management consists of nonsurgical measures that address synovitis and capsular inflammation in an effort to diminish pain and maintain elbow range of motion. Disease progression may result in articular damage and ligamentous compromise, causing increased symptoms, elbow instability, and functional debilitation. For patients unresponsive to nonsurgical management, open or arthroscopic synovectomy may provide relief of symptoms. For those with more advanced disease, elbow arthroplasty is a reasonable alternative. Advancements in prosthetic technology and surgical techniques allow elbow arthroplasty to be reliably performed in patients with severe rheumatoid arthritis of the elbow.

Different surgical options for monocompartmental osteoarthritis of the knee: high tibial osteotomy versus unicompartmental knee arthroplasty versus total knee arthroplasty: indications, techniques, results, and controversies.

The decision of what procedure to perform for the treatment of monocompartmental osteoarthritis of the knee when nonsurgical treatment methods fail remains controversial. Recent advances using osteotomy, unicompartmental knee replacement, and total knee replacement have been reported. For example, there are new concepts for performing high tibial osteotomies rather than the traditional Coventry method. Many techniques now involve osteotomies below the tibial tubercle. Unicompartmental knee replacement can be done using a standard approach, but less invasive approaches exist, along with minimally invasive approaches for total knee replacement, rather than the standard large incision, that promote decreased soft-tissue destruction.

The spectrum of prosthesis design for primary total knee arthroplasty.

Many types of prostheses are currently used for total knee arthroplasty. Controversy exists, however, regarding which prostheses are the most appropriate for use by individual surgeons and specific patient groups. Six types of prostheses are currently being used in the United States for primary total knee arthroplasty: posterior cruciate ligament-retaining prostheses; posterior cruciate ligament-substituting prostheses; prostheses with ceramic components; mobile-bearing prostheses; nonmodular, compression-molded polyethylene prostheses; and medial-pivot prostheses. The historical and current result of using these different types of prostheses are discussed, and the indications, contraindications, and recommendations for each type are delineated.

Recurrent hemarthrosis in a hemophilic patient after revision total knee arthroplasty.

Recurrent hemarthrosis following a revision total knee arthroplasty is a rare complication. The likelihood of encountering bleeding complications in patients with hemophilia C following major surgery is unpredictable. Although the use of postoperative chemotherapeutic agents to prevent deep venous thrombosis (DVT) is considered the standard of care for most patients, its use in the hemophiliac population is unknown. This case describes a woman with Hemophilia C who presented with recurrent hemarthrosis 9 days after her revision total knee arthroplasty. Initial treatment efforts were directed towards treating the patient's underlying coagulopathy. Repeated transfusions of fresh frozen plasma and desmopressin were given in an attempt to achieve hemostasis. However the hemarthrosis did not resolve and 36 days postoperatively, a pseudoaneurysm of the left superior geniculate artery was found by angiography and percutaneously embolized. This article presents the first case, to our knowledge, of recurrent hemarthrosis in a hemophiliac patient after revision total knee arthroplasty. It further highlights the importance of considering all possible causes of postoperative bleeding to make a timely diagnosis in the face of a confounding clinical picture.

Extra-articular deformities and the role of hip resurfacing - a proposed classification system.

There has been an increasing demand for hip resurfacing as an alternative to total hip arthroplasty. A number of reports have been published recently detailing the technique and role of resurfacing in a variety of extra-articular deformities, dysplastic conditions, and settings of retained intramedullary hardware and other impediments. The following report proposes a classification system that recognizes intramedullary and extramedullary deformities. With the long-term expectation for resurfacing, these complex situations may require categorization to segregate risk factors in order to allow for better planning and prognostication.

Anatomic diameter femoral heads in total hip arthroplasty: a preliminary report.

BACKGROUND: The stability of total hip replacements has been directly related to the diameter of the femoral head in several studies; however, durability has necessitated the use of femoral heads with a relatively small diameter. Recent developments in metal-on-metal technology have allowed for the use of femoral head bearings that are anatomic in diameter. In this case series, we report on the early results of patients who were at greater risk for dislocation because of anatomic deficiencies or increased range-of-motion activities and underwent hip arthroplasty with implants that had articulating surfaces approaching anatomic dimensions. METHODS: Thirty-four patients underwent forty total hip arthroplasties with use of a modular metal-on-metal articulation with an anatomic diameter femoral head and a press-fit stem. Thirty patients were active, and four patients were profoundly disabled and had bone or soft-tissue deficiencies that would increase the risk for dislocation. Dislocation precautions were maintained for six weeks, and patients were allowed extreme ranges of motion at three months. RESULTS: There were no dislocations. Active patients continued in extreme range-of-motion activities. Disabled patients improved but were limited by their comorbidities. CONCLUSIONS: Anatomic diameter femoral heads offer distinct theoretical advantages in total hip arthroplasty. These short-term results are encouraging, and further study of this new technology in a larger series with a longer follow-up period is warranted.

Management of periprosthetic femur fractures with a first generation locking plate.

Periprosthetic femoral fractures associated with well-fixed total hip or total knee prostheses present a challenging management problem as these injuries typically occur in osteoporotic bone. Conventional management entails extensive periosteal stripping to allow for plate fixation. We reviewed a consecutive series of patients who sustained fractures associated with a well fixed total knee prosthesis, a total hip prosthesis, or both. Twenty four patients with a mean age of 69.4 years were included. All patients underwent fixation via percutaneous insertion techniques with a first generation locking plate and screws (LISS--Less Invasive Skeletal Stabilization, Synthes, Paoli, PA). Three patients sustained fractures distal to a well-fixed total hip prosthesis, eighteen fractures occurred above a well-fixed total knee femoral component, and three were interprosthetic. The mean length of time from the index procedure to fracture was 76 months, range (2-172 months). Blood loss was minimal in each case, with a mean operative time of 90 min (range 60-120 min). Twenty one of twenty four went on to unite at a mean 6.2 months (range 3-19 months). Three patients underwent further surgery. One failure of fixation was encountered. Percutaneous fixation is technically demanding as it requires stable fixation without direct visualisation of the fracture site or the entire fixation device. Our results suggest percutaneous fixation with the LISS plate is an effective although technically demanding method of treatment. Complication rates were comparable to existing reports of this treatment method, and appear to be improved over traditional methods of fixation.

Protein isoprenylation regulates secretion of matrix metalloproteinase 1 from rheumatoid synovial fibroblasts: effects of statins and farnesyl and geranylgeranyl transferase inhibitors.

OBJECTIVE: To determine whether protein prenylation (farnesyl/geranylgeranylation) regulates matrix metalloproteinase (MMP) secretion from rheumatoid arthritis (RA) synovial fibroblasts (RASFs), and whether MMP-1 secretion can be regulated by statins or prenyltransferase inhibitors via effects mediated by ERK, JNK, and NF-kappaB. METHODS: RASFs obtained from patients during elective knee replacement surgery were assessed by immunoblotting and/or enzyme-linked immunosorbent assay for secretion of MMP-1 and MMP-13 in the presence of tumor necrosis factor alpha (TNFalpha), interleukin-1beta (IL-1beta), statins, the farnesyl transferase (FT) inhibitor FTI-276 and geranylgeranyl transferase inhibitor GGTI-298, and prenyl substrates (farnesyl pyrophosphate [FPP] and geranylgeranyl pyrophosphate [GGPP]). Activities of JNK and ERK were determined by phosphoimmunoblotting, and NF-kappaB activation was determined by nuclear translocation of the p65 component. RESULTS: FTI-276, but not statins, inhibited RASF secretion of MMP-1, but not MMP-13, following induction with TNFalpha (P = 0.0007) or IL-1beta (P = 0.006). Loading RASFs with FPP to promote farnesylation enhanced MMP-1 secretion. FTI-276 inhibited activation of JNK (P < 0.05) and NF-kappaB (P = 0.02), but not ERK. In contrast, GGTI-298 enhanced, while GGPP inhibited, MMP-1 secretion. FTI-276 and GGTI-298 together had no effect on MMP-1 secretion. Stimulation of RASFs with TNFalpha or IL-1beta led to increased expression and activity of FT. CONCLUSION: Protein farnesylation is required for expression and secretion of MMP-1 from RASFs, via effects on JNK and NF-kappaB. The ability of cytokines to stimulate the expression and activity of FT suggests that FT may be increased in the rheumatoid joint. In contrast, geranylgeranylation down-regulates MMP-1 expression. Statins simultaneously inhibit farnesylation and geranylgeranylation, and in consequence do not inhibit MMP-1 secretion. The ability of FTI-276 to inhibit MMP-1 secretion suggests a potential therapeutic strategy in RA.

MR imaging features of radial tunnel syndrome: initial experience.

PURPOSE: To retrospectively assess magnetic resonance (MR) imaging features of radial tunnel syndrome. MATERIALS AND METHODS: Institutional review board approval was obtained, and informed consent was waived for the retrospective HIPAA-compliant study. MR images of 10 asymptomatic volunteers (six men, four women; mean age, 30 years) and 25 patients (11 men, 14 women; mean age, 49 years) clinically suspected of having radial tunnel syndrome were reviewed for morphologic and signal intensity alterations of the posterior interosseous nerve and adjacent soft-tissue structures. MR images of the asymptomatic volunteers were reviewed to establish the normal appearance of the radial tunnel. MR images of the symptomatic patients were evaluated for the following: signal intensity alteration and morphologic alteration of the posterior interosseous nerve; the presence of mass effect on the posterior interosseous nerve such as the presence of bursae, a thickened leading edge of the extensor carpi radialis brevis, or prominent radial recurrent vessels; signal intensity alteration within the depicted forearm musculature such as edema or atrophy; and signal intensity changes at the origin of the common extensor and common flexor tendons, which would suggest a diagnosis of epicondylitis. RESULTS: All images of volunteers demonstrated normal morphology and signal intensity within the posterior interosseous nerve and adjacent soft tissues. Two volunteers had borderline thickening of the leading edge of the extensor carpi radialis brevis. Thirteen patients (52%) had denervation edema or atrophy within muscles (supinator and extensors) innervated by the posterior interosseous nerve. One patient had isolated pronator teres edema. Seven (28%) patients had the following mass effects along the posterior interosseous nerve: thickened leading edge of the extensor carpi radialis brevis (n = 4), prominent radial recurrent vessels (n = 1), schwannoma (n = 1), or bicipitoradial bursa (n = 1). The rest of the patients had either normal MR imaging findings (n = 4) or lateral epicondylitis (n = 2). CONCLUSION: Muscle denervation edema or atrophy along the distribution of the posterior interosseous nerve is the most common MR finding in radial tunnel syndrome.

Cementless porous-coated sockets without holes implanted with pure press-fit technique.

We evaluated the use of a pure press-fit technique in 220 porous-coated acetabular components without screw holes at mean follow-up of 6.1 years (4-7.5 years). The socket had a 14 degrees enhanced gradient at the periphery and was underreamed by 1 to 2 mm depending on bone quality. The Harris Hip average score was 44.3 (26-70) preoperatively and 93.1 (66-100) at final follow-up. There were no postoperative gaps in any zone. Nonprogressive radiolucent lines were detected in 4 hips. There was no movement or migration of the acetabular component on the follow-up x-rays. Pelvic osteolysis was not observed. Whereas 5 cups (2.3%) had revisions, none was revised for aseptic loosening. The press-fit technique provides stability in appropriate cases avoiding the theoretical complications related to screws or screw holes.

Postoperative management after total hip and knee arthroplasty.

Despite major advances in the field of total joint arthroplasty, a standardized postoperative management protocol currently does not exist following total hip arthroplasty (THA) and total knee arthroplasty (TKA). A survey was mailed to the active members of the American Association of Hip and Knee Surgeons to investigate issues such as postoperative rehabilitation and activity restriction. The information derived from this survey provides the total joint surgeon with a compilation and consensus of responses that can serve as the foundation for a standardized postoperative protocol for THA and TKA surgery.