For over a decade, bisphosphonate administration has evolved and become the cornerstone of the prevention and treatment of fragility fractures. Millions of post-menopausal women have relied on, and continue to depend on, the long-acting, bone density-maintaining pharmaceutical drug to prevent low-energy fractures. In return, we have seen the number of fragility fractures decrease, along with associated costs and emotional benefits. However, with any drug, there are often concerns with side effects and complications, and this unique drug class is seeing one such complication in atypical subtrochanteric femoral fracture, counterproductive to that which it was designed to prevent. This has created concern over long-term bisphosphonate administration and its potential link to these atypical fractures. There is controversial evidence surrounding such a definitive link, and no protocol for managing these fractures.

This review offers the latest information regarding this rare but increasingly controversial adverse effect and its potential connection to one of the most successful forms of treatment that is available for the management of fragility fractures.

Introduction: Ranked as the second most common cause of long-term disability amongst American adults, osteoarthritis (OA) affects well over 60 million Americans per year. OA is one of the major contributors to health care-related economic cost in the US, which is generally considered unacceptably high when compared other Western industrialized nations.

Methods: Three hundred and thirty-five patients undergoing primary unilateral or bilateral total hip arthroplasty (THA), metal-on-metal hip resurfacing (MOMHR), total knee arthroplasty (TKA), or unicondylar knee arthroplasty (UKA) were offered voluntary participation in an one-on-one preoperative education session with a pre-operative educator. Length of stay (LOS) and in-patient costs was collected for patients who received individual pre-operative education. This was then compared to patients who chose not to participate in the education sessions using linear regression models.

Results: Patients who chose to participate enjoyed a significantly shorter LOS than those who did not receive education, controlling for age, sex, type of procedure, and number of co-morbid conditions (3.1 ± 1.1 vs. 4.5 ± 4.7; p< 0.01). THA patients participating in the preoperative education program exhibited a calculated cost savings of $861 per case over non-educated patients (p=0.06), while TKA patients participating in the program exhibited a statistically significant savings of $1,144 per case (p=0.02). This translated into a cost savings of $84,351 for 93 THA patients and $93,493 for 74 TKA patients at our institution, accounting for the cost of the patient educator. Of higher significant impact on cost savings was the number of co-morbid conditions for both THA (p=0.01) and TKA (p=0.01) patients. If applied in the national setting, national cost savings projections for a mean 0.84 day reduction in LOS for educated THA patients estimated a savings of nearly $800 million; a mean 0.56 day reduction for preoperatively educated TKA translated into a projected savings of $1.1 billion on the national scale.

Conclusion: Preoperative education in the setting of hip and knee arthroplasty is an important cost-savings tool for hospitals, Medicare and third party payers in this era of rising health care costs.

Introduction: Unicondylar knee arthroplasty (UKA) has seen a resurgence in the past decade. Perpetuation of this trend can only be supported through prospective demonstration of efficacy with validated outcomes measures.

Materials & Methods: Thirty-three consecutive cemented medial Miller-Galante UKA’s (Zimmer, Warsaw, IN) were performed in 32 patients (7 males/25 females; mean age of 67 ± 9 years). Average weight, height, and body mass index (BMI) of the patient population was 189 ± 31 lbs (Range, 145–293), 65 ± 4 in (range, 60–75), and 33 ± 5 BMI (range, 25–43), respectively. Average polyethylene thickness (as labelled) for this cohort was 8.3mm (range, 8–12mm). Outcomes were prospectively assessed via the SF-12, WOMAC, and Knee Society Score (KSS). No patients were lost to follow-up. Kaplan-Meier survivorship and Student’s t-test were performed using GraphPad Prism 4 software (GraphPad Software Inc., San Diego, CA).

Results: Minimum follow-up was 39 months with a mean follow up period of 49 (range, 39–59) months. One knee was converted at 6 months at another institution to a TKA. Kaplan-Meier survivorship analysis reported 97% survivorship at 59 months (95% CI). Of the 32 knees remaining, mean preoperative KSS and WOMAC pain scores improved significantly from 52 ± 7 (range, 37–67) to 89 ± 9 (range, 67–100) (p< 0.0001) and from 40 ± 22 (range, 0–80) to 93 ± 14 (range, 35–100) (p< 0.0001), respectively. Additionally, average SF-12 Physical Component scores significantly increased from 30 ± 7 (range, 18–51) at baseline to 49 ± 10 (range, 28–59) at time of follow-up (p< 0.0001). Overall stiffness and physical function assessed via the WOMAC index also exhibited statistically significant improvement, bettering from mean baseline scores of 54 ± 24 (range, 0–100) and 52 ± 19 (range, 25–87) to 84 ± 19 (range, 50–100, p< 0.0001) and 88 ± 15 (range, 44–100, p< 0.0001), respectively. No significant cement/bone interface radiolucencies were found upon thorough radiographic review at 3 years post UKA.

Discussion & Conclusion: The significant improvements observed in knee function & stiffness, and decreases in pain at a mean of 4 years after medial UKA are encouraging. Coinciding results from the physical component of the SF-12 assessment indicate reassurance of physical improvements regarding patient lifestyle. 97% survivorship in the short term would be discouraging if not for the specific circumstances of the sole conversion to TKA. This specific patient went against the advice of the operative surgeon and solicited services at an outside institution in conversion to a TKA despite markedly improved function (Pre-op/3 month post-op WOMAC and KSS of 30/75 and 60/91). Clinical and radiographic follow-up will continue in order to assess the long-term efficacy of medial UKA with the Miller-Galante prosthesis using strict patient selection criteria.