Studying the indications for revision total hip arthroplasty (THA) may enable surgeons to change their practice during the initial procedure, thereby reducing the need for revision surgery. The aim of this study was to identify and describe the potentially avoidable indications for revision THA within five years of the initial procedure. A retrospective review of 117 patients (73 women, 44 men; mean age 61.5 years (27 to 88)) who met the inclusion criteria was conducted. Three adult reconstruction surgeons independently reviewed the radiographs and medical records, and they classified the revision THAs into two categories: potentially avoidable and unavoidable. Baseline demographics, perioperative details, and quality outcomes up to the last follow-up were recorded.Aims
Patients and Methods
A variety of surgical approaches are used for total hip arthroplasty (THA), all with reported advantages and disadvantages. A number of common complications can occur following THA regardless of the approach used. The purpose of this study was to compare five commonly used surgical approaches with respect to the incidence of surgery-related complications. The electronic medical records of all patients who underwent primary elective THA at a single large-volume arthroplasty centre, between 2011 and 2016, with at least two years of follow-up, were reviewed. After exclusion, 3574 consecutive patients were included in the study. There were 1571 men (44.0%) and 2003 women (56.0%). Their mean age and body mass index (BMI) was 63.0 years (Aims
Patients and Methods
Revision total knee arthroplasty (rTKA) accounts for approximately 5% to 10% of all TKAs. Although the complexity of these procedures is well recognized, few investigators have evaluated the cost and value-added with the implementation of a dedicated revision arthroplasty service. The aim of the present study is to compare and contrast surgeon productivity in several differing models of activity. All patients that underwent primary or revision TKA from January 2016 to June 2018 were included as the primary source of data. All rTKA patients were categorized by the number of components revised (e.g. liner exchange, two or more components). Three models were used to assess the potential surgical productivity of a dedicated rTKA service : 1) work relative value unit (RVU) Aims
Materials and Methods
We studied the impact of direct anterior (DA) A total of 6086 consecutive patients undergoing primary total hip arthroplasty (THA) at a single institution between 2013 and 2016 were retrospectively evaluated. Data obtained from electronic patient medical records included age, sex, body mass index (BMI), medical comorbidities, surgical approach, and presence of deep PJI. There were 3053 male patients (50.1%) and 3033 female patients (49.9%). The mean age and BMI of the entire cohort was 62.7 years (18 to 102, Aims
Patients and Methods
Computer-assisted hip navigation offers the potential for more accurate placement of hip components, which is important in avoiding dislocation, impingement, and edge-loading. The purpose of this study was to determine if the use of computer-assisted hip navigation reduced the rate of dislocation in patients undergoing revision THA. We retrospectively reviewed 72 patients who underwent computer-navigated revision THA [Fig. 1] between January 2015 and December 2016. Demographic variables, indication for revision, type of procedure, and postoperative complications were collected for all patients. Clinical follow-up was performed at 3 months, 1 year, and 2 years. Dislocations were defined as any episode that required closed or open reduction or a revision arthroplasty. Data are presented as percentages and was analyzed using appropriate comparative statistical tests (z-tests and independent samples t- tests).Introduction
Methods and Materials
A comprehensive understanding of pelvic orientation prior to total hip arthroplasty is necessary to allow proper cup positioning and mitigate the risks of complications associated with component malpositioning. Measurements using anteroposterior (AP) radiographs have been described as effective means of accurately predicting pelvic orientation. The purpose of our study was to describe the inter- and intra-observer reliability and predictive accuracy of predicting pelvic tilt using AP radiographs. Five fellowship-trained orthopaedic surgeons independently analyzed pelvic tilt, within 10 degrees, for 50 different AP pelvis radiographs. All surgeons were blinded to patient information, diagnosis, and correct measurements prior to analysis. Responses were then compared to correct measurements using sitting-standing AP and lateral stereoradiographs.Introduction
Methods
Narcotic administration within the inpatient setting is highly variable any may benefit from the implementation of standardized multi-modal pain management protocols. Total joint arthroplasty (TJA) candidates have historically received high doses of opioids within the perioperative period for the management of surgical pain. Healthcare systems have responded by improving opioid prescribing documentation and implementing narcotic-sparing pain protocols into TJA integrate care pathways (ICP). Despite these efforts, there are few technological platforms designed to curtail excessive inpatient narcotic administration. Here we present an early iteration of an inpatient narcotic administration reporting tool which normalizes patient narcotic consumption as an average daily morphine milligram equivalence (MME) per surgical encounter (MME/day/encounter) among total hip arthroplasty (THA) recipients. This information may help orthopaedic surgeons visualize their individual granular inpatient narcotic prescribing habits individually and compared to other surgeons, while taking into consideration patient and procedure specific variables.Summary
Introduction
In major orthopaedic departments, typically several total knee systems are used. Each system requires several sets of instruments, each set with many trays of complicated and expensive parts. The logistics and costs of maintainance are considerable. Our overall goal is to investigate the feasibility of autoclavable single-use 3D printed instruments made from a polymeric material, used for any type of total knee design. The procedure will be standardized and adjustments easy to implement. Each set will be packaged individually, and used for a single case. There are many aspects to this study; in this part, the aims are to identify suitable materials for autoclavability and strength, and then to compare the accuracy of a novel design of 3D printed tibial cutting guide with a current metallic guide. Test samples were designed to simulate shapes in current instruments, such as mating pegs and holes, threaded screws, and slotted blocks. Each set was produced in biocompatible materials, ABS-M30i, VeroClear (MED610), Ultem1010, and Nylon 12. Each part was laser scanned, and then imaged virtually using a reverse engineering software (GeoMagic). Manual measurements of key dimensions were also made using calipers. The parts were autoclaved using a standardized protocol, 30 minutes at 250° F. All parts were re-scanned and measured to determine any changes in dimensions. To test for strength and abrasion resistance, the slotted blocks were pinned to sawbones model tibias, and an oscillating saw used to cut through the slot. A compact 3D printed tibial cutting guide was then designed which fitted to the proximal tibia and allowed varus-valgus, tibial slope and height adjustments. A small laser attached to the guide projected to a target at the ankle. Tests were made on 20 sawbones, and compared with 20 with a standard metal cutting guide. Digitization was used to measure the angles of the cuts.Introduction
Methods
Complications can be defined as preventable, potentially preventable, or non-preventable. While often discussed, there are virtually no data whether or not the most common causes of revision total hip arthroplasty (THA) are preventable or not. The goal of this study was to identify and report preventable causes of revision THA within 5 years of the index THA. We conducted a retrospective review of 128 consecutive revision THAs between August 2015 and August 2017, with 62% being referred from another institution. Mean time to revision THA from the index arthroplasty was 10 months. Mean age at revision THA was 61 years, with 67% being female. Three fellowship-trained adult reconstruction surgeons reviewed the radiographs and operative notes and classified the revision THAs into two categories: preventable vs. non-preventable. Reviewers were instructed to be extremely lenient with the benefit of the doubt given to the operative surgeon. Inter-observer reliability was assessed by Cohen's kappa analysis.Introduction
Methods
There has been a renewed interest in the surgical approach used for total hip arthroplasty (THA). Risk factors for periprosthetic joint infection (PJI) have been well studied over the past decade, yet PJI remains one of the most devastating complications following THA. We studied the impact of direct anterior (DA) versus non-direct anterior (NA) surgical approaches on PJI, and examined the impact of new perioperative protocols on PJI rates following all surgical approaches at a single institution. 6086 continuous patients undergoing primary THA at a single institution from 2013–2016 were retrospectively evaluated. Data obtained from electronic patient medical records included age, sex, body mass index (BMI), medical comorbidities, surgical approach, and presence of deep PJI. Deep PJI was defined according to National Healthcare Safety Network's (NHSN) criteria for joint space infection following prosthetic hip replacement. Infection rates were calculated yearly for the DA and NA approach groups. Covariates were assessed and used in multivariate analysis to calculate adjusted odds ratios for risk of development of PJI with DA compared to NA approaches. In order to determine the effect of adopting a set of infection prevention protocols and patient optimization on PJI, we calculated odds ratios for PJI comparing patients undergoing THA for two distinct time periods: 2013–2014 and 2015–2016. These periods corresponded to before and after we implemented a set of perioperative infection protocols.Introduction
Methods
The routine use of dual-mobility (DM) acetabular components in total hip arthroplasty (THA) may not be cost-effective, but an increasing number of patients undergoing THA have a coexisting spinal disorder, which increases the risk of postoperative instability, and these patients may benefit from DM articulations. This study seeks to examine the cost-effectiveness of DM components as an alternative to standard articulations in these patients. A decision analysis model was used to evaluate the cost-effectiveness of using DM components in patients who would be at high risk for dislocation within one year of THA. Direct and indirect costs of dislocation, incremental costs of using DM components, quality-adjusted life-year (QALY) values, and the probabilities of dislocation were derived from published data. The incremental cost-effectiveness ratio (ICER) was established with a willingness-to-pay threshold of $100 000/QALY. Sensitivity analysis was used to examine the impact of variation.Aims
Patients and Methods
Despite adoption of robust clinical pathways, narcotic administration within the inpatient setting is highly variable and may benefit from the implementation of standardized multi-modal pain management protocols. Total knee arthroplasty (TKA) candidates have historically received high doses of opioids within the perioperative period for the management of surgical pain. Healthcare systems have responded by improving opioid prescribing documentation and implementing narcotic-sparing pain protocols into TKA integrated care pathways (ICP). Despite these efforts, there are few technological platforms specifically designed to measure the narcotic burden immediately postoperatively. Here we present an early iteration of an inpatient narcotic administration-reporting tool, which normalizes patient narcotic consumption as an average daily morphine-milligram-equivalence (MME) per surgical encounter (MME/day/encounter) among total knee arthroplasty (TKA) recipients. This information may help orthopaedic surgeons visualize their individual granular inpatient narcotic prescribing habits individually and compared to other surgeons, while taking into consideration patient and procedure specific variables in order to optimize use and curtail unnecessary narcotic prescriptions.Summary
Introduction
Interferon (IFN) based treatments for chronic hepatitis C (HCV) have been the standard of care until 2014 when direct antiviral agents (DAA) were introduced. Patients with HCV have had extremely high complication rates after total hip arthroplasty (THA). It is unknown whether HCV is a modifiable risk factor for these complications prior to THA. The purpose of this study was 1) to compare perioperative complication rates between untreated and treated HCV in THA and 2) to compare these rates between patients treated with two different therapies (IFN vs. DAA). A multicenter retrospective database query was used to identify patients diagnosed with chronic hepatitis C virus who underwent total hip arthroplasty from 2006–2016. All patients (n=105) identified were included and were divided into two groups: untreated HCV (n=63) and treated (n=42); the treated group were further subdivided into those receiving IFN based therapies (n=16) or DAA therapies (n=26). Comparisons between the treated and untreated groups were made with respect to demographic data, comorbidities, preoperative viral load, MELD score, and all surgical (≤1 yr) and medical (≤90d) complications; a sub-group analysis of the treated patients was also performed. Separate independent t-tests were conducted for dependent variables that were normally distributed, and Mann-Whitney U tests were conducted for variables which were not normally distributed. Categorical variables were compared through the chi-square test of independence. The level of statistical significance was set at p<0.05.Introduction
Methods
Tranexamic acid (TXA) is proven to reduce blood loss following total knee arthroplasty (TKA), but there are limited data on the impact of similar dosing regimens in revision TKA that is associated with greater blood loss. The purpose of this multi-center randomized trial was to determine the optimal regimen to maximize the blood-sparing properties of TXA in revision TKA. 233 Septic and aseptic revision TKA from six-centers were randomized to either receive 1g pre-incision intravenous (IV) TXA, 1g pre- and post-incision IV TXA, 1g pre-incision IV and 1g intra-operative topical TXA, or three doses of 1950mg oral TXA given 2 hours pre-operatively, 6 hours post-operatively, and the morning of postoperative day 1. Randomization was performed based on type of revision to ensure equivalent distribution among groups. The primary outcome was reduction in hemoglobin. Power analysis determined 40 patients per group were necessary to identify a 1g/dL difference with an alpha of 0.05 and beta of 0.80. Per-protocol analysis involved regression analysis and two one-sided t-tests for equivalence.Introduction
Methods
Lumbar fusion is known to reduce the variation in pelvic tilt
between standing and sitting. A flexible lumbo-pelvic unit increases
the stability of total hip arthroplasty (THA) when seated by increasing
anterior clearance and acetabular anteversion, thereby preventing
impingement of the prosthesis. Lumbar fusion may eliminate this protective
pelvic movement. The effect of lumbar fusion on the stability of
total hip arthroplasty has not previously been investigated. The Medicare database was searched for patients who had undergone
THA and spinal fusion between 2005 and 2012. PearlDiver software
was used to query the database by the International Classification
of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedural
code for primary THA and lumbar spinal fusion. Patients who had
undergone both lumbar fusion and THA were then divided into three
groups: 1 to 2 levels, 3 to 7 levels and 8+ levels of fusion. The
rate of dislocation in each group was established using ICD-9-CM codes.
Patients who underwent THA without spinal fusion were used as a
control group. Statistical significant difference between groups
was tested using the chi-squared test, and significance set at p
<
0.05.Aims
Patients and Methods
Revision Total Knee Arthroplasty (TKA) is becoming increasingly prevalent as the number of TKA procedures grow in a younger, higher-demand population. Factors associated with patients requiring multiple revision TKAs are not yet well understood. The purpose of this study is to investigate the epidemiology of re-revision TKA, and identify risk factors that are associated with failure of re-revision TKA. A retrospective analysis was performed on 358 patients who underwent revision TKA at a single institution between 1/2012 and 12/2013. Patients who underwent revision knee arthroplasty two or more times were included. Patients were excluded if their indication for the first revision was periprosthetic joint infection (PJI). Patient demographics, surgical indications, revision details, and available follow-up information were collected. Re-revision failure was defined as the need for any additional operative intervention. A logistic regression analysis was performed to assess for significant predictors of re-revision failure.Introduction
Methods
Total knee arthroplasty (TKA) surgical techniques attempt to achieve equal flexion and extension gaps to produce a well-balanced knee, but unexplainable unhappy patients persist. Mid-flexion instability is one proposed cause of unhappy patients. There are multiple techniques to achieve equal flexion and extension gaps, but their effects in mid-flexion are largely unknown. The purpose of the study is to determine the effects that changing femur implant size and/or adjusting the femur and tibia proximal -distal and femur anterior-posterior implant positions have on cruciate retaining (CR) TKA mid-flexion ligament balance when equal flexion and extension gaps are maintained.Background
Purpose of study
Acetabular cup malpositioning has been implicated in instability and wear-related complications after total hip arthroplasty. Although computer navigation and robotic assistance have been shown to improve the precision of implant placement, most surgeons use mechanical and visual guides to place acetabular components. Authors have shown that, when using a bean bag positioner, mechanical guides are misleading as they are unable to account for the variability in pelvic orientation during positioning and surgery. However, more rigid patient positioning devices may allow for more accurate free hand cup placement. To our knowledge, no study has assessed the ability of rigid devices to afford surgeons with ideal pelvic positioning throughout surgery. The purpose of this study is to utilize robotic-arm assisted computer navigation to assess the reliability of pelvic position in total hip arthroplasty performed on patients positioned with rigid positioning devices. 100 hips (94 patients) prospectively underwent total hip Makoplasty in the lateral decubitus position from the posterior approach; 77 stabilized by universal lateral positioner, and 23 by peg board. After dislocation but prior to reaming, one fellowship trained arthroplasty surgeon manually placed the robotic arm parallel to both the longitudinal axis of the patient and the horizontal surface of the operating table, which, if the pelvis were oriented perfectly, would represent 0 degrees of anteversion and 0 degrees of inclination. The CT-templated computer software then generated true values of this perceived zero degrees of anteversion and inclination based on the position of the robot arm registered to a preoperative pelvic CT. Therefore, variations in pelvic positioning are represented by these robotic navigation generated values. To assure the accuracy of robotic measurements, cup anteversion and inclination at times of impaction were recorded and compared to those calculated via the trigonometric ellipse method of Lewinnek on standardized 3 months postoperative X-rays.INTRODUCTION
METHODS
The epidemiology of re-revision total hip arthroplasty (THA) is not well understood. The purpose of this study is to investigate the epidemiology of re-revision THA, and identify risk factors that are associated with failure of re-revision THA. A retrospective analysis was performed on 288 patients who underwent revision THA at a single institution between 1/2012 and 12/2013. Patients who underwent revision hip arthroplasty two or more times were included. Patients were excluded if their indication for their first revision was due to periprosthetic joint infection (PJI). Patient demographics, surgical indications, revision details, and available follow-up information were collected through the electronic medical record. Re-revision failure was defined as the need for any additional return to the operating room, regardless of indication. A logistic regression analysis was performed to assess for significant predictors of re-revision failure.Introduction
Methods
Total knee arthroplasty (TKA) surgical techniques attempt to achieve equal flexion and extension gaps to produce a well-balanced knee. Anterior knee pain, which is not addressed by flexion-extension balancing, is one of the more common complaints for TKA patients. The variation in patellofemoral balance resulting from the techniques to achieve equal flexion and extension gaps has not been widely studied. The purpose of the study is to determine the effects on cruciate retaining (CR) TKA patellofemoral balance when equal flexion and extension gaps are maintained while changing femur implant size and/or adjusting the femur and tibia implant proximal -distal and femur anterior-posterior positions.Background
Purpose of study
