The purpose of this modified Delphi study was to obtain consensus on wound closure (including best practices for each tissue layer of closure) and dressing management in total hip arthroplasty (THA), using an evidence-based approach.

The Delphi panel included 20 orthopedic surgeons from Europe and North America. Eighteen statements were identified (14 specific to THA and 4 relating to both THA and total knee arthroplasty) using a targeted literature review. Consensus was developed on the statements with up to three rounds of anonymous voting per topic. Panelists ranked their agreement with each statement on a five-point Likert scale. An a priori threshold of 75% was required for consensus.

In Round 1, 15 of 18 statements achieved consensus via a structured electronic questionnaire. In Round 2, the 3 statements that did not achieve consensus were revised during a virtual face to face meeting. An additional 2 statements were edited for clarity. In Round 3, the 5 revised statements achieved consensus via a structured electronic questionnaire. Wound closure related interventions that were recommended for use in THA included: 1) barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); 2) subcuticular sutures over skin staples (lower risk of infections and higher patient preference); 3) mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); 4) negative pressure wound therapy over other dressings (lower wound complications and reoperations and fewer dressing changes); 5) triclosan coated sutures (lower risk of surgical site infection).

Using a modified Delphi approach, a panel of 20 orthopedic surgeons achieved consensus on 18 statements pertaining to multi-layer wound closure and dressing management in THA. This study forms the basis for identifying critical evidence gaps within wound management to help reduce variability in outcomes during THA.

Introduction

The purpose of the study was to determine access to and, ability to use telemedicine technology in an adult hip and knee reconstruction patient population and we seek to understand these patients' perceived benefits, risks and preferences of telemedicine.

Introduction

Multimodal pain management strategies are now commonplace in perioperative management of total knee arthroplasty (TKA), although controversy remains regarding the role of adductor canal blocks (ACB) in this algorithm. Proposed benefits include theoretical decreased role of perioperative narcotic pain medication, improved function with physical therapy postoperatively, shorter duration of hospital stay and improved patient satisfaction. Those opposed cite increased cost and risk of complications including inadvertent motor blockade. The purpose of this study was to independently evaluate the effect of adductor canal block on short-term post-operative outcomes including (1) length of stay (LOS), (2) post-operative narcotic utilization, and (3) function with physical therapy in the era of modern TKA.

To assess clinical outcomes, metal ion levels, and periprosthetic femoral bone mineral density (BMD) in young, active patients receiving a modular dual mobility acetabulum and recently introduced titanium, proximally coated, tapered femoral stem design.

This was a prospective study of patients  65 years of age, with a BMI  35 kg/m², and UCLA activity score > 6 who received a modular cobalt chrome acetabular liner, highly cross-linked polyethylene mobile bearing, and cementless titanium femoral stem for their primary THA. Patients with a history of renal disease and metal hardware elsewhere in the body were excluded. All patients had a minimum of 2-year clinical follow-up.

Patient reported outcome measures, whole blood metal ion levels (ug/L), and periprosthetic femur BMD were measured at baseline and at 1- and 2-years postoperatively.

43 patients (30 male, 13 female; mean age 52.6 ± 6.5 years) were enrolled. Harris Hip Scores improved from 54.1 ± 20.5 to 91.2 ± 10.8 at 2 years postoperatively (p<0.001). All patients had radiographically well-fixed components, no patients have sustained an instability event, and no patients have required a return to the operating room or revision procedure.

Mean cobalt levels increased from 0.065 ± 0.03 ug/L preoperatively to 0.30 ± 0.51 at 1-year postoperatively (p=0.01), but decreased at 2 years postoperatively to 0.16 ± 0.23 (p=0.2) (Table 1). Four patients (9.3%) had a cobalt level outside the reference range (0.03 to 0.29ug/L) at 2 years postoperatively with values from 0.32 to 0.94. None were symptomatic

The mean femoral BMD ratio was maintained in Gruen zones 2 thru 7 at both 1- and 2-years postoperatively using this stem design (Table 2). At 2 years postoperatively, BMD in the medial calcar was 101.5% of the baseline value.

Use of a modular dual mobility prosthesis and cementless, tapered femoral stem has shown encouraging results in young, active patients undergoing primary THA. Elevation in mean cobalt levels and the presence of four patients outside the reference range at 2 years postoperatively demonstrates the necessity of continued surveillance in this cohort.

For any figures or tables, please contact authors directly: barrackr@wustl.edu

Surface replacement arthroplasty (SRA) has been proposed as a viable option for the treatment of osteoarthritis in young, active patients. Positive results of the Birmingham Hip Resurfacing (BHR) in select patient groups have been described in international series and registry data. We report 5–10 year U.S. follow-up for the BHR at our high volume institution.

314 patients (361 hips) between 2006–2011 underwent BHR at our institution and agreed to participate in research. Demographic features, modified Harris Hip Score, UCLA Activity Score, and satisfaction were recorded for patients with minimum 5-year follow-up (90%). Radiographs were evaluated for implant position and “at risk” signs. Complications, reoperations, and revisions were investigated.

Mean modified Harris Hip and UCLA scores significantly improved postoperatively to scores of 89.96 and 7.90 (p < 0.001), respectively. Kaplan-Meier estimated survival for all-cause revision was 96.7% [95% CI 94.7 – 98.7%] at 5 years and 91.5% [95% CI 85.3 – 97.6%] at 10 years. Estimated survival for aseptic revision in males less than 60 years old with a primary diagnosis of osteoarthritis was 99.5% [95% CI 98.7 – 100%] at 5 years and 98.8% [95% CI 97.0 – 100%] at 10 years. 14 patients required revision, including 5 revisions for adverse local tissue reaction.

Our study demonstrated excellent survivorship and clinical outcomes at 5–10 year follow up for the BHR. These results mirror other series and registry data published outside of the United States. Continued long-term follow-up and additional studies are necessary to validate the long-term safety and outcomes of the BHR, especially in young active arthroplasty patients.

As healthcare spending continues to outpace economic growth, legislators and healthcare economists have explored many processes aimed at improving efficiency and reducing waste within a bundled care environment. Gainsharing or the general concept that organizations and their employees can work together to continually improve outcomes at reduced expenditures in exchange for a portion of the savings has been shown to be effective within the healthcare system. Although gainsharing principles may be applicable to healthcare organizations and their physician partners, specific parameters should be followed when implementing these arrangements. This talk will discuss gainsharing strategies aimed at properly aligning healthcare organizations and physicians, which, if followed, will ensure the successful implementation of gainsharing initiatives.

Wound closure is not often an area that is discussed by orthopaedic surgeons. We commonly attend meetings and talks related to different types of implants and surgical technique but in reality the wound and how we close it maybe one of the most important aspects of a surgical procedure. The avoidance of wound complications such as unplanned clinic visits, readmissions, reoperations and deep infections are very important as we move into a world of bundled payments and public reporting of complications. Not to mention the poor results for the patients when wound complications occur. Often there is little thought about how wound closure and surgical dressings could affect surgical site healing. We all have a common belief that blisters, drainage and surgical site infections are rare. In the literature it has been shown that the method of wound closure can influence skin and soft tissue perfusion. Which closure techniques can achieve physiologic blood flow, which may improve wound healing? This talk will cover topics related to reducing the dead space, avoidance of hematoma formation and what the literature says regarding different types of wound closure materials.

There is great debate around how to treat patients with periprosthetic joint infections and there are different techniques utilised throughout the world with large regional differences. In the situation where implants are well fixed there is a potential advantage to retain ingrown implants in which removal would result in severe bone damage. However, there are multiple variables on both the patient side and the surgeon side which can influence the likelihood of success with this approach. In some patients, staged revision of large and well-fixed components will result in bone damage and compromised function, but the two-stage techniques may have great success at long term infection free survivorship. The literature suggests that selective implant retention and joint débridement may be an alternative for those patients who have complex well-fixed components, are not immunocompromised, have not developed sinus formation, and who have less virulent organisms on aspiration. Implant retention techniques should be approached with caution when patients have chronic illness such as diabetes or rheumatoid disease, use immunosuppressive medications, have a negative aspirate for microorganisms, or show any signs of loosening on radiographs or during intra-operative assessment. Like many aspects of patient care, proper patient selection and meticulous surgical techniques are important components to increasing success in these difficult clinical scenarios. This talk will focus on the data currently available in the literature to help participants gain a better understanding of how to individualise treatments for patients with periprosthetic infections.

Introduction

With the introduction of new technology in orthopaedics, surgeons must balance anticipated benefits in patient outcomes with challenges or complications associated with surgical learning curve for the technology. The purpose of this study was to determine whether the surgeon learning curve with a new multi-radius primary TKA system (primary TKA implant and instruments) designed for surgical team ease would impact clinical outcomes, surgical time and complications.

With the introduction of new technology in orthopaedics, surgeons must balance anticipated benefits in patient outcomes with challenges or complications associated with surgical learning curve for the technology. The purpose of this study was to determine whether surgeon learning curve with a new multi-radius primary TKA system and instruments designed to improve surgical team ease would impact clinical outcomes, surgical time, and complications.

From November 2012 to July 2015, 2369 primary TKAs were prospectively enrolled in two multicentre studies across 50 sites in 14 countries with a new knee system (NEW-TKA) evenly balanced across four configurations: cruciate retaining or posterior stabilised with either fixed bearing or rotating platform (CRFB, CRRP, PSFB, PSRP). 2128 knees had a<1 year visit and 1189 had a minimum 1 year visit. These knees were compared to a reference dataset of 843 primary TKAs from three manufacturers in the same four configurations with currently available products (CA-TKA). Demographics for NEW-TKA and CA-TKA were similar and typical for primary TKA. Operative times, clinical outcomes and a series of five patient reported outcomes were compared for NEW-TKA vs. CA-TKA. The first 10 New-TKA subjects for each surgeon were defined as learning curve cases (N=520) and were compared to all later subjects (N=1849). Patient reported outcome measure and clinical outcome analyses were covariate adjusted for patient demographics, pre-op assessment and days post-op.

Mean (SD) surgical time for NEW-TKA learning curve cases was 79.1 (24.3) minutes, which reduced thereafter to 73.6 (24.3) (p=0.002). Beyond 10 cases, there was a continued reduction in NEW-TKA surgical time (R-Squared = 0.031). After 10 cases, surgical time was on par with the mean (SD) 71.9 (21.6) for CA-TKA (p=0.078). PROM outcomes of the first 10 learning curve cases for NEW-TKA were not statistically different from later cases at less than 1 year or later when adjusted for relevant covariates including configuration, patient demographics, pre-op functional status, and time post-op (p-values > 0.01). PROM outcomes for NEW-TKA vs. CA-TKA under the same covariate adjustments showed a trend favoring KOOS ADL, Symptoms, and Sport and Recreation subscores at minimum 1 year (p-values < 0.01). The incidence of intraoperative operative site complications was 1.3% for the NEW-TKA learning curve cases which was similar to the 0.6% rate for historical CA-TKA (p=0.231) and the intraoperative complication rate for the NEW-TKA later cases was consistent with learning curve cases (p=0.158).

The introduction of new implants into the market place needs to have adequate data to support that they are safe and effective. Except for a minor increase in surgical time during the first 10 patients, this study found that surgeon learning curve with this new primary TKA system does not adversely affect patient short term outcomes and complication rates.

PURPOSE:

Unicompartmental knee arthroplasty (UKA) is becoming more commonly performed and is more technically challenging than total knee replacement. Retention of the anterior and posterior cruciate ligaments requires more accurate re-creation of the patient's normal anatomic posterior slope with UKA. Purpose of this study was to accurately determine the posterior tibial slope in patients having medial or lateral UKA performed.