Total hip arthroplasty (THA) is performed under general anesthesia (GA) or spinal anesthesia (SA). The first objective of this study was to determine which patient factors are associated with receiving SA versus GA. The second objective was to discern the effect of anesthesia type on short-term postoperative complications and readmission. The third objective was to elucidate factors that impact the effect of anesthesia type on outcome following arthroplasty.

This retrospective cohort study included 108,905 patients (median age, 66 years; IQR 60-73 years; 56.0% females) who underwent primary THA for treatment of primary osteoarthritis in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database during the period of 2013-2018. Multivariable logistic regression analysis was performed to evaluate variables associated with anesthesia type and outcomes following arthroplasty.

Anesthesia type administered during THA was significantly associated with race. Specifically, Black and Hispanic patients were less likely to receive SA compared to White patients (White: OR 1.00; Black: OR 0.73; 95% confidence interval [CI] 0.71-0.75; Hispanic: OR 0.81; CI, 0.75-0.88), while Asian patients were more likely to receive SA (OR 1.44, CI 1.31-1.59). Spinal anesthesia was associated with increased age (OR 1.01; CI 1.00-1.01). Patients with less frailty and lower comorbidity were more likely to receive SA based on the modified frailty index ([mFI-5]=0: OR 1.00; mFI-5=1: OR 0.90, CI 0.88-0.93; mFI-5=2 or greater: OR 0.86, CI 0.83-0.90) and American Society of Anesthesiologists (ASA) class (ASA=1: OR 1.00; ASA=2: OR 0.85, CI 0.79-0.91; ASA=3: OR 0.64, CI 0.59-0.69; ASA=4-5: OR 0.47; CI 0.41-0.53). With increased BMI, patients were less likely to be treated with SA (OR 0.99; CI 0.98-0.99).

Patients treated with SA had less post-operative complications than GA (OR 0.74; CI 0.67-0.81) and a lower risk of readmission than GA (OR 0.88; CI 0.82-0.95) following THA. Race, age, BMI, and ASA class were found to affect the impact of anesthesia type on post-operative complications. Stratified analysis demonstrated that the reduced risk of complications following arthroplasty noted in patients treated with SA compared to GA was more pronounced in Black, Asian, and Hispanic patients compared to White patients. Furthermore, the positive effect of SA compared to GA was stronger in patients who had reduced age, elevated BMI, and lower ASA class.

Among patients undergoing THA for management of primary osteoarthritis, factors including race, BMI, and frailty appear to have impacted the type of anesthesia received. Patients treated with SA had a significantly lower risk of readmission to hospital and adverse events within 30 days of surgery compared to those treated with GA. Furthermore, the positive effect on outcome afforded by SA was different between patients depending on race, age, BMI, and ASA class. These findings may help to guide selection of anesthesia type in subpopulations of patients undergoing primary THA.

The purpose of this study was to compare the clinical, radiographic, and DEXA results of Epoch® Femoral Component for primary THA with other non-cemented femoral components. The Epoch and Epoch 14+ (Zimmer, Warsaw, IN) Composite Femoral Components were studied in conjunction with the VerSys® Fiber Metal Taper, Fiber Metal Mid coat and Beaded Fullcoat Femoral Components (Zimmer, Warsaw, IN). All patients were randomized into one of five component groups and followed prospectively. All patients across the five groups were matched with respect to demographics and body mass index (BMI) (Table 1). Diagnoses were evenly distributed across all study groups. There was no significant change in BMD at 5-years when compared to the baseline (6 month) DEXA measurements for all component groups except for the Beaded Fullcoat component subset which had significant decreases in BMD in proximal zones 1, 6 and 7, The Fiber Metal Taper showed similar decreases in BMD in zones 1 and 7, and the Epoch Component had a significant decrease in BMD in zone 7 only. Additionally, our DEXA findings complement and support the subjective radiographic interpretations performed for this study cohort. The results from this prospective, randomized controlled clinical trial showed that the Epoch Composite Femoral Component for primary THA can achieve results equal to standard alloy components of varying design. Based on these early results, the Epoch and Epoch 14+ Femoral Components for primary THA are justified for continuance of further prospective study.

Hemangioendothelioma is a rare vascular tumor that is infrequently recognized in bone. It can be multicentric and often painful with an indolent course. The treatments of choice include curettage, resection, radiation, systemic medications or a combination of these modalities.

O.G. 5 years old girl, presented with left ankle pain and limping, without response to non steroidal anti-inflammatory drugs for few months. Radiological investigation (MRI) showed a lytic vascular lesion in the methadiaphysis, invading the epiphysis of the distal left tibia and lateral cartilage of the ankle, with atrophy of the left lower limb. Bone scan showed high uptake in this area. Histology showed fragments of bone, infiltrated by a vascular lesion with nodular pattern, well differentiated vascular spaces and endothelial cells with few mitotic figures. Immunostains were positive for CD31 and F8. The pathology report confirmed hemangioendothelioma.

As the lesion invaded the growth plate of the distal tibia, surgical or radiation therapy at this age could cause a permanent damage. We therefore successfully treated the child with Interferon α–2β 0.5 million IU three times a week for 18 months. She was pain free after the first few months of therapy with full recovery of daily function and activity. Radiological evaluation showed improvement on X-ray and MRI, and shrinkage of the lesion to the epiphysis area only.

Unfortunately, 3 years later the pain and limping reappeared. MRI showed a lytic lesion in the diamethaphysis of the left tibia. Re-biopsy supported the diagnosis of recurrent hemangioendothelioma. She was retreated with Interferon α–2β using the same protocol with considerable improvement of the pain and limping.

We present here a non invasive option for therapy with Interferon α–2β for bony lesion of hemangioendothelioma that enable us to spare the growth plate in a growing prepubertal child.

Health utilities indicate the value of a given health state. They are essential components of decision analyses, and economic evaluations. In the area of total shoulder arthroplasty (TSA) we were unable to find literature estimating changes in utilities or the effect of method of obtaining utilities. The purpose of this pilot study was to describe the trajectory of utility scores before and after TSA using three approaches: the EQ-5D and the Health Utilities Index (HUI2 and HUI3) self-report format.

Twenty-four patients undergoing TSA at two teaching hospitals (Boston and Toronto) were assessed twice preoperatively, as well as at four and twelve weeks follow-up by self report mailed survey. At each survey all three utility estimates were obtained. Demographic and functional status was also gathered. The EQ-5D is a five item questionnaire which scores into a profile to which utility weights obtained from the developers were applied. The HUI self-report is a fifteen item scale obtaining a score on eight domains. A multiplicative formula is used to assign utility weights to these responses. Descriptive analysis of the sample, baseline characteristics and change in utility were completed. Intra-class correlation coefficients were used to calculate test-retest reliability between the two preoperative visits. Standardised response means (SRM) (mean change/SD of change) and relative efficiency (RE=ratio of SRM2) were calculated. Individual trajectories of change were graphed and examined for trends.

Twenty-four patients participated with average age of sixty-seven years, 58% were female and experienced large improvements in disability and pain (mean change DASH = 18.9/100, SPADI Pain = 30.3/100). Utility scores had low to moderate correlations with each other (0.26–0.68). Mean baseline scores were low (EQ5D=0.44, HUI2=0.68, HUI3 = 0.50). The average change in utility is shown in the following table along with effect size estimations and test-retest reliability.

Patients experience clinically important and statistically significant changes in their utility values even in the early stages of recovery after TSA (three months). The HUI3 and EQ-5D were most responsive to changes experienced in this sample.

Hospital and surgeon volume is inversely associated with perioperative mortality, dislocation and infection rates following total hip replacement (THR). This study evaluated the relationship between hospital/surgeon volume on early failures requiring revision in a sample of 6826 Medicare beneficiaries in 1995–1996. The primary outcome for the analysis was the time between the primary THR and the first revision. After adjustment for sociodemographic/clinical variables, patients of low volume surgeons in centers with a caseload less than one hundred THR/year were twice as likely to be revised compared with patients in high volume centers by high volume surgeons.

The purpose of this study was to determine whether hospital/surgeon volume is associated with early failures requiring revision.

Patients of low volume surgeons have considerably higher rates of early failure, especially within the first year following surgery.

This study highlights the importance of including surgeon volume among factors that influence referrals for elective THR.

We analyzed claims data of 6826 Medicare beneficiaries, who underwent elective primary THR in 1995–1996 in OH, PA and CO. Hospitals were stratified into, low (< 12 THR/year), medium (12–100 THR/year) and high (> 100 THR/year) volume groups. Low volume surgeons performed fewer than twelve primary THR/ yr. Associations between rates of revisions/surgeon volume were determined by risk ratios after adjusting for hospital volume, patient age, poverty status, gender and comorbidities. We examined whether the effect of surgeon volume on revision rates differed across yearly time intervals. Of patients who had primary THR in 1995–96, two hundred and seventy-one (4%) had at least one revision by the end of 1999, one hundred and twenty-six (46%) of those occurring within the first year after the surgery. Cumulative rates of revision ranged from 2.3% for primary THR in high volume centers performed by high volume surgeons to 5.9% for patients who had primary THR performed by low volume surgeons in low volume centers. Further analysis revealed that the effect of surgeon volume was striking in the first year after the surgery (RR: 2.34; 95%CI: 1.47– 3.78) and was not evident in the subsequent years (RR: 1.08; 95%CI: 0.73–1.58).

This paper aims to determine if preoperative characteristics have a significant impact on functional outcome as measured by the WOMAC at 2-years following total knee replacement (TKR) surgery. Patients were recruited as part of a prospective study of outcomes of primary TKR for osteoarthritis in centres in the US (4 centres), UK (6 centres) and Australia (2 centres). Research assistants recruited eligible patients and collected clinical history and physical examination data preoperatively, 3, 12 and 24-months post surgery. The WOMAC, SF-36, patients satisfaction and demographic data were obtained by self-administered questionnaires. All scores were transformed to 0–100 scale (100 best).

We recruited 860 eligible patients and have complete 12-month WOMAC data on 736 patients (86%) and 2-year data on 701 patients (78%). Mean age was 70 years (SD 10), 59% were female, 50% were from the UK, 30% from the US and 20% from Australia. Mean preoperative clinical measures were: knee flexion 107° (SD18), SF36 Mental Health 72 (SD19), body mass index 29 (SD 6) and WOMAC Function 45 (SD 19). 46% of patients reported more than 2 comorbid conditions.

There was no significant difference between mean WOMAC Function scores at 12-months (73, SD 21) and 2-years (74, SD21). In a linear regression model (model R- square= 25), the preoperative predictors of worse WOMAC Function at 2-years, in order of decreasing importance, were: low WOMAC Function (p< 0.0001), higher number of comorbid conditions (p=0.0002), UK patients (p=0.0002), low SF36 Mental Health (p=0.01) and restricted preoperative knee flexion (p=0.02). Patients who come to surgery with poor function, restricted knee flexion, low mental health and other comorbid conditions are more likely to have worse functional outcomes 2-years following surgery. After adjusting for these predictors, the UK patients had significant lower WOMAC Function scores than the US and Australia.

Purpose: Congenital insensitivity to Pain (CIP) is a rare peripheral neuropathy which may affect various sensory pathways and often affects the autonomic nervous system. Musculoskeletal manifestations include infections, fractures, growth disturbances, avascular necrosis, Charcot arthropathy, joint dislocations and heterotopic ossification. The purpose of the study was to review the orthopaedic problems in patients with Congenital Insensitivity to Pain and make treatment recommendations.

Methods: Thirteen patients from eight families were examined and all charts and radiographs were reviewed. A quantitative sweat test was performed in five patients and an intradermal histamine test in ten.

DNA was prepared in all patients and examined for specific mutations.

Results: Three clinical presentations were found:

Type A – Five patients presented with multiple infections requiring many surgical procedures ranging from local debridement to below knee amputation.

Type B – Three patients presented with fractures and growth disturbances of the lower limbs as well as avascular necrosis of the talus or femoral condyle. Two patients underwent corrective osteotomies due to deformities. Type C – Five patients presented with Charcot arthropathies, joint dislocations, fractures and infections. Four of them were mentally retarded.

Patients underwent multiple surgical procedure to control infections.

Attempts surgical stabilization of joints were unsuccessful.

Mutations were found in four patients.

Conclusions

Patient education, shoe ware and periods of non weight bearing are important in prevention and early treatment of decubitus ulcers.

A histochemical analysis was made of 103 muscle biopsies taken from 62 patients with idiopathic club feet. Any reduction in the diameter of the muscle fibres associated with wasting of the calf muscle was recorded. Histochemical abnormalities existing in these biopsies were revealed by comparison with normal biopsies obtained from the normal legs of 13 children with unilateral deformities. No significant difference was found between the diameter of the muscle fibres taken from normal and affected legs aged under six months. This indicates that wasting of the calf muscle is due to a reduction in the number of fibres rather than their size. The muscle structure was normal excluding denervation and reinnervation. The soleus muscle in patients aged under six months contained 61 per cent Type 1 fibres in the affected legs, compared to 44.3 per cent in normal legs. Similar values were found in the normal and abnormal tibialis posterior muscles, long flexors of the toe and peroneal muscles. The change in composition of the soleus muscle and the reduction in the number of fibres may be caused by a defective neural influence on the development of the limb in club foot.

Calvaria from six-day-old infant mice were grown on a grid culture in a chemically defined medium under varying oxygen tensions. Quantitative isotope studies demonstrated a linear association between bone resorption and oxygen tension in the physiological range. This result was supported by histological, histochemical and vital staining experiments. The clinical finding of osteoporosis in areas of hyperaemia could therefore be attributed to a rise in oxygen tension causing increased bone resorption.