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Background: In the COVID-19 era, there has been increasing interest in same-day discharge (SDD) after total joint arthroplasty (TJA). However, patient perception of SDD is not well reported. Purpose: We sought to understand patients' perceptions and preferences of postoperative care by surveying patients who have completed both an overnight stay (ONS) and an SDD after TJA. Methods: We emailed survey links to 67 patients who previously underwent either 2 total hip arthroplasties (THAs) or 2 total knee arthroplasties (TKAs). Results: Fifty-two patients (78%) responded to the survey. Thirty-four (65%) patients underwent staged, bilateral TKAs, and 18 (35%) patients underwent staged, bilateral THAs. Overall, 63% of patients preferred their SDD, 12% had no preference, and 25% preferred their ONS, with no difference in preference between TKA and THA groups. Those who preferred their SDD reported being more comfortable at home. Those who preferred their ONS felt their pain and concerns were better addressed. No differences were found in comfort, sleep quality, appetite, burden on family, return to function, feelings of being discharged too soon, overall experience, 30-day emergency department (ED) visits, or readmissions within 30 days between patients' SDD and ONS. There was a small statistically significant difference between patients' perception of safety between SDD and ONS. Conclusion: Our survey found that most patients reported a preference for SDD after TJA over ONS. Although there was a small difference in patient perception of safety, there were no differences in return to the ED or readmissions after SDD and ONS. [ABSTRACT FROM AUTHOR]

Background: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are no longer considered inpatient-only procedures. Qualifying for inpatient status reimbursement requires additional, unreimbursed administrative effort, and may limit care to these patients. Purpose : We sought to evaluate and compare the overall health status of patients receiving THA and TKA. Methods : We conducted a retrospective review evaluating 2207 patients undergoing primary THA and TKA from 2015 to 2018 at a single institution. Clinical parameters, surgical procedure, medical history, laboratory values, length of stay (LOS), and discharge location were recorded and compared between the 2 groups. Results : In 2202 patients, we observed differences for body mass index (THA = 29.4 ± 0.4, TKA = 32.1 ± 0.3), low-density lipoprotein cholesterol levels (THA = 105.8 ± 13.5 mg/dL; TKA = 128.6 ± 13.7 mg/dL), and blood glucose levels (THA = 98.2 ± 1.7 mg/dL; TKA = 101.4 ± 1.3 mg/dL), indicating that TKA patients were more likely than THA patients to be classified as obese, hypercholesterolemic, and hyperglycemic. We observed longer LOS in THA patients (51.25 hours, 95% CI ± 3.87 hours) than in TKA patients (36.93 hours, 95% CI ± 1.17 hours). A greater proportion of TKA patients were discharged home (81.97%, N = 1155) rather than to additional care facilities compared with THA patients (71.84%, N = 539). Conclusion : In this retrospective study, we observed that TKA patients had higher rates of comorbidities than did THA patients, but TKA patients spent less time in the hospital and were more likely to be discharged home. Future studies should evaluate reasons for poor clinical outcomes for patients undergoing total joint arthroplasty with an outpatient designation. [ABSTRACT FROM AUTHOR]

Background: Vancomycin is a prophylactic antibiotic with bactericidal activity against methicillin-resistant Staphylococcus aureus that is commonly used in total joint replacement surgery1. In total knee arthroplasty (TKA), intraosseous infusions administered following tourniquet inflation have demonstrated improved local vancomycin concentrations with decreased systemic absorption1-3. This administration method results in no adverse reactions locally, as well as equivalent or lower systemic complications compared with other vancomycin administration methods4. Intraosseous infusion of prophylactic surgical antibiotics has been shown to be more effective than intravenous administration, with the potential for reduction in surgical site infections5. Description: After the operative extremity has been prepared and draped in the usual sterile fashion, the limb is elevated and the tourniquet is inflated to 250 mm Hg. Prior to incision, an intraosseous vascular access system (Arrow EZ IO; Teleflex) is inserted with a power driver into the tibial tubercle region. The desired volume of the medication is injected into the tibia. The device is removed and then inserted into the anterior distal femur, centrally, just proximal to the patella. Following this, the desired volume of the medication is injected into the femur. The device is then removed, and the TKA proceeds according to the surgeon's standard technique. Alternatives: Alternative administration methods for vancomycin include other invasive methods and noninvasive delivery. Intravenous delivery is the most traditional form of medication delivery1,2. Additional alternatives include noninvasive placement of antibiotic powder into the wound and localized soft-tissue injections of desired medications1-3. Rationale: Opting to administer antibiotics and other medications intraosseously (rather than intravenously) has shown improved compliance with the golden-hour rule of preoperative antibiotics (especially for vancomycin)4, lower incidences of acute kidney injury or adverse systemic effects4, and improved local tissue concentrations of all medications delivered1-3. Expected Outcomes: Expected outcomes include improved local tissue concentrations with decreased systemic concentrations of vancomycin and with no reported local or systemic adverse reactions, as well as the potential for improved infection prevention1-5. Literature regarding the use of intraosseous infusion during TKA has been thorough and very well received. A prospective, randomized study by Young et al. evaluated local and systemic concentrations of vancomycin following intraosseous versus intravenous administration. The authors found that low-dose intraosseous vancomycin resulted in tissue concentrations equal to or superior to those of systemic administration, also noting that the administration route reduced the infiltration time of the vancomycin without systemic complications1. Local concentrations at the knee were found to be 5 to 9 times greater with intraosseous infusion in patients with a body mass index of >35 kg/m2 as compared with the use of intravenous administration, with no adverse reactions systemically. Local concentrations in this patient population were also found to be comparable to those observed in patients with a lower body mass index2. A recent study assessing the use of intraosseous vancomycin showed that local concentrations of vancomycin were maintained even if the procedure continued beyond the point of tourniquet deflation, with mean concentrations being 5 times higher locally at the end of the procedure in the intraosseous versus the intravenous group3. A separate study showed no adverse systemic reactions and no incidents of acute kidney injury among patients receiving intraosseous vancomycin. An additional study showed that intraosseous administration of vancomycin decreased the incidence of postoperative joint infections compared with traditional intravenous administration5. Newer studies assessing the use of intraosseous infiltration have begun to focus on the delivery of other medications, not just antibiotics. At our institution, we have examined the benefits of intraosseously administrated morphine, which has shown a significant decrease in pain and opioid consumption up to 2 weeks postoperatively. Important Tips: You may run into issues with the medication delivery due to the amount of resistance you encounter. If resistance is too great, you may first attempt to readjust the intraosseous needle depth to improve flow. If resistance is still high, you may consider downsizing to a 30-cc syringe in order to better infiltrate the medication. Note that if you downsize your syringe, you will require more time to infiltrate the desired amount of fluid. An additional way to save time is to open multiple syringes and have them prefilled with your desired medication so that they may be handed off once completed rather than needing to be refilled. A hemostat or pickup may be applied underneath the cuff of the intraosseous needle in order to help remove the needle from the bone. This step is sometimes required because the intraosseous handpieces do not have multidirectional trigger capabilities, and removing the needle can require an upward force to be applied. The use of midline locations allows the small incisions you make for intraosseous infusion to be incorporated into your larger knee incision, with no additional morbidity to the patient. Consider utilizing the medial and/or lateral femoral condyles as landmark locations for infusion if your patient is large. Alternatively, recent literature has shown nearly equivalent results with just the tibial infusion, so you may consider discontinuing the femoral intraosseous infusion if there are consistent issues with successfully initiating the medication delivery. Acronyms and Abbreviations: IO = intraosseous MRSA = methicillin-resistant Staphylococcus aureus RCT = randomized controlled trials IV = intravenous BMI = body mass index OR = operating room [ABSTRACT FROM AUTHOR]

Traditional studies of hip kinematics have not identified which anatomic structures limit the range of motion (ROM) when the hip is placed in different maneuvers. In this study, we attempted to answer two questions: (a) During which maneuvers is the motion of the hip limited by bony impingement between the femur and pelvis? (b) When is hip ROM determined by the constraint of soft tissues and to what extent? ROM of eight cadaveric hips was measured in 17 maneuvers using a motion capture system. The maneuvers were recreated in silico using 3D CT models of each specimen to detect the occurrence of bony impingement. If bony impingement was not detected, the variable component of 3D hip motion was increased until a collision was detected. The difference between the virtual ROM at the point of bony impingement and the initial ROM measured experimentally was termed as the soft‐tissue restriction. The results showed that bony impingement was present in normal hips during maneuvers consisting of high abduction with flexion, and high flexion combined with adduction and internal rotation. At impingement‐free maneuvers, the degree of soft tissue restriction varies remarkably, ranging from 4.9° ± 3.8° (internal rotation) at 90° of flexion to 80.0° ± 12.5° (internal rotation) at maximum extension. The findings shed light on the relative contributions of osseous and soft tissues to the motion of the hip in different maneuvers and allow for a better understanding of physical exams of different purposes in diagnosing bone‐ or soft tissue‐related diseases. [ABSTRACT FROM AUTHOR]

Background: Hip abductor tendon tears are a well-recognized entity that results in progressive lateral hip pain, weakness, and limping. These can occur in patients with native hips or in patients following total hip arthroplasty. However, treatment of these 2 distinct groups does not differ. We describe a new repair technique utilizing a longitudinal bone trough in the greater trochanter. We compare our results (focusing on gluteus medius tendon avulsions) and traditional repair with suture anchors or transosseous bone tunnels. Additionally, we propose a classification system that attempts to describe the different types of tears to guide treatment, as the current classification system is not helpful in defining pathology or guiding treatment. Our proposed classification will help to better describe tear types anatomically and thereby guide appropriate surgical interventions based on these types. Description: Abductor tears were classified, according to our system, as Type I when there was no gluteus medius avulsion from bone (with subtype A indicating a partial tear of the gluteus minimus or gluteus medius; B, a complete tear of the gluteus minimus; and C, a longitudinal tear of the gluteus medius) or Type II when there was a gluteus medius avulsion (with subtypeAindicating an avulsion of <50% of the insertion into the greater trochanter, and B, an avulsion of ≥50% of the insertion). Repair into a bone trough involves (1) freeing up and mobilizing the tendon from overlying fascia, (2) placing 2 evenly spaced Krackow stitches in the tendon, (3) creating a bone trough using a burr in the midline of the greater trochanter, (4) creating bone tunnels out the lateral wall of the trough to pass sutures, and (5) passing sutures through the bone tunnels to allow inset of the tendon into the trough, and later tying the sutures over the lateral osseous bridge. Alternatives: Alternative treatment options include nonoperative and operative management. Nonoperative treatment choices include physical therapy, nonsteroidal anti-inflammatory drugs, and activity modification with assistive walking devices. Surgical alternatives include endoscopic or open direct soft-tissue repair, suture anchor repair, bone tunnel repair, graft jacket reconstruction, or gluteus maximus muscle transfer. Rationale: Because of discouraging outcomes experienced by us and others, a new technique (a greater trochanter longitudinal bone trough) was developed to improve surgical results. This technique, utilizing an abductor tendon repair into a bone trough, improved our surgical outcomes for abductor tendon avulsions. We found that outcomes after surgical treatment of abductor tendon tears without avulsion are superior to those after repairs of abductor tendon avulsions, which is an important distinction compared with previous literature on abductor tendon repairs. [ABSTRACT FROM AUTHOR]

Background: Comprehensive systematic reviews of results from homogenous or heterogeneous clinical trials, meta-analyses are used to summarize and to interpret studies. Proponents believe that their use can increase study power and improve precision results. Critics emphasize that heterogeneity between studies and bias of individual studies compromise the value of results. The methodology of meta-analyses has improved over time, utilizing statistical analysis to reduce bias and examining heterogeneity. With an increasing trend of meta-analyses in orthopaedic literature, this study aimed to investigate quality and clinical utility of meta-analyses for total knee arthroplasty and total hip arthroplasty.Methods: A systematic review of total knee arthroplasty and total hip arthroplasty meta-analyses in 3 major orthopaedic journals from January 2000 to August 2017 was performed. Three authors independently reviewed eligible meta-analyses. A quality assessment was conducted using the Oxman-Guyatt Index. Reporting quality was assessed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Two high-volume, fellowship-trained, attending surgeons specializing in total hip arthroplasty and total knee arthroplasty independently, in a blinded fashion, reviewed 24 of the highest-scored meta-analyses.Results: There were 114 studies meeting eligibility criteria, 25 published from 2000 to 2009 and 89 published from 2010 to 2017, a 3.6-fold increase. The mean Oxman-Guyatt Index score was 3.89 points, with 12 high-quality studies, 87 moderate-quality studies, and 15 low-quality studies. The mean PRISMA score for all meta-analyses was 22.2 points, with 79% classified as low to moderate. Only 23 studies listed the Level of Evidence, and 8 were Level-I studies and 9 were Level-II studies. Studies with >15 randomized controlled trials were associated with higher PRISMA and Oxman-Guyatt Index scores. In 12 articles, we were unable to decipher the types of studies included. Only 39.4% of studies showed the risk of bias. Of the 24 studies identified as high quality per the PRISMA statement, 71% were determined to be either clinically unimportant or inconclusive.Conclusions: The number of total hip arthroplasty and total knee arthroplasty meta-analyses has markedly increased over the past decades. The majority of published meta-analyses from 3 major orthopaedic journals were not performed in accordance with established PRISMA guidelines.Clinical Relevance: Many published meta-analyses are low to moderate quality, and clinicians should cautiously draw conclusions from poorly executed meta-analyses. [ABSTRACT FROM AUTHOR]

The article focuses on various studies related to the advancement in hip arthroplasty. It highlights studies examining the clinical and radiographic results of the use of short cementless femoral stems. Studies investigating the complications following total hip arthroplasty are reported. Findings in an analysis of high-volume hospitals and complication rates in hip and knee arthroplasty are also explained.

Case: We present here 2 cases of postoperative stress fractures in the setting of a short-stem implant. Both patients had well-aligned implants with good bone quality and presented with delayed onset and atraumatic thigh pain. They were diagnosed with periprosthetic fractures around stable implants. Conclusions: We now reserve the use of these stems for patients who have femoral morphology and are unable to accept standard stems. Patients who complain of new-onset thigh pain in the setting of short-stem total hip arthroplasty should have a femoral stress fracture included in the differential diagnosis and be worked up appropriately. [ABSTRACT FROM AUTHOR]

The article explores the trends in the surgical techniques and materials used by surgeons in conducting total hip replacement among patients. Topics include the concept of short-term to intermediate-term survivorship different among patients with common total hip arthroplasty, the popularity on the use for polyethylene infused with vitamin E and intraoperative care among patients. It also notes on the important aspects of improving patient's quality of life.

Background: While innovation drives advancement, it is not immune to failure. Previously, we reported a corrosion-related revision rate of 28% (23 of 81 total hip arthroplasties) among patients who received the Rejuvenate modular-neck stem implant with short-term follow-up. Because we observed a dramatic interval failure rate after our initial report, we undertook this study.Methods: We prospectively followed a cohort of patients who had undergone implantation of the Rejuvenate modular-neck stem, as previously reported. At a minimum of 3 years of follow-up (range, 3.0 to 5.5 years), 73 hips in 63 patients (90% of the original group) were available for analysis. The mean serum cobalt and chromium ion levels were obtained preoperatively and postoperatively. Elevated serum cobalt ion levels (>4 μg/L), pain, or abnormal magnetic resonance imaging (MRI) findings were indications for revision surgery. Patient factors and serum metal ion levels were correlated to revision surgery. Additionally, post-revision serum cobalt and chromium ion level trends were assessed.Results: An 86% clinical failure rate (63 of the 73 hips) was observed at a mean follow-up of 4.2 ± 0.6 years (range, 3.0 to 5.5 years); 57 (78%) of the hips underwent revision at a mean of 3.2 ± 1.0 years (range, 1.0 to 5.5 years), and 6 (8%) of the hips were scheduled for revision. Patients who underwent revision surgery were younger and had greater serum metal ion levels and greater pain compared with patients who did not undergo revision. An elevated serum cobalt ion level was the most important independent factor associated with revision surgery. Cobalt ion levels decreased sharply after revision; however, some patients demonstrated persistent elevation with more gradual decline.Conclusions: Emphasizing the reporting of positive results may leave orthopaedic surgeons reticent to publicize negative results; however, the high failure rate of this implant design within 5 years prompted this report. We believe that patients and orthopaedic surgeons should be made aware of this implant's clinical problems and patients should be followed closely. Expedient revision is necessary when failure is identified, to minimize potentially severe tissue damage and metal toxicity.Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The article discusses developments into the techniques and processes of hip arthoplasty. Overview of the higher rate of patients who experience complications and risks after undergoing spinal anesthesia for the procedure such as cardiac arrest, stroke and blood transfusion is provided. The effort of the American Association of Hip and Knee Surgeons (AAHKS) to create a risk stratification algorithm for the management of patients undergoing the procedure is offered.

Background: The Rejuvenate modular-neck stem implant (Stryker Orthopaedics, Mahwah, New Jersey) was recently recalled due to corrosion at the femoral neck-stem junction. The purpose of this study was to investigate the rate of corrosion-related failure and survivorship of this implant and analyze the correlation of implant and patient factors with serum metal ion levels and revisions. Methods: From June 2009 to July 2012, 123 Rejuvenate total hip arthroplasty stems (ninety-seven modular and twentysix non-modular) were implanted in 104 patients by a single surgeon. Serum cobalt (Co) and chromium (Cr) levels (micrograms per liter [mg/L]) were measured postoperatively for all patients. Patients with persistent hip pain or elevated metal ion levels underwent magnetic resonance imaging for assessment of osteolysis or adverse local tissue reactions. Correlation of implant factors (stem size, head size, head length, and femoral head-neck offset) and patient factors (age, sex, and body mass index) with serum metal ion levels and revisions were analyzed with use of logistic regression models. Results: The mean duration of follow-up (and standard deviation) was 2.7 ± 0.6 years. The mean Co and Cr levels were 5.4 ± 5.7 mg/L (range, 0.2 to 31 mg/L) and 2.1 ± 1.5 mg/L (range, 0.1 to 4.3 mg/L), respectively. The differences in Co and Cr levels between the two groups (modular and non-modular) were significant: 48% of the total hip arthroplasties in the modular group resulted in elevated metal ion levels (Co >4.0 mg/L and Cr >2.0 mg/L; p < 0.05). The metal ion levels in the non-modular group were normal. In the modular group, higher metal ion levels were significantly correlated with younger age and a higher femoral head-neck offset (p = 0.04). Pain and high Co serum levels were significant predictors of revision surgery (p = 0.006). The rate of revision at the time of this study was 28% in the modular group, with the majority of the revisions performed in the second year after surgery; the Kaplan-Meier survivorship was 40% at four years. Conclusions: The short-term high rate of corrosion-related revision with Rejuvenate modular-neck stems is striking. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Increasingly, acetabular retroversion is recognized in patients undergoing hip arthroplasty. Although prosthetic component positioning is not determined solely by native acetabular anatomy, acetabular retroversion presents a dilemma for component positioning if the surgeon implants the device in the anatomic position. Questions/purposes: We asked (1) whether there is a difference in ROM between surface replacement arthroplasty (SRA) and THA in the retroverted acetabulum, and (2) does increased femoral anteversion improve ROM in the retroverted acetabulum? Methods: Using a motion analysis tracking system, we determined the ROM of eight cadaveric hips and then created virtual CT-reconstructed bone models of each specimen. ROM was determined with THA and SRA systems virtually implanted with (1) the acetabular component placed in 45° abduction and matching the acetabular anteversion (average 23° ± 4°); (2) virtually retroverting the bony acetabulum 10°; and (3) after anteverting the THA femoral stem 10°. Results: SRA resulted in ROM deficiencies in four of six maneuvers, averaging 25% to 29% in the normal and retroverted acetabular positions. THA restored ROM in all six positions in the normal acetabulum and in four of the six retroverted acetabula. The two deficient positions averaged 5% deficiency. THA with increased femoral stem anteversion restored ROM in five positions and showed only a 2% deficiency in the sixth position. Compared with the intact hip, ROM deficits were seen after SRA in the normal and retroverted acetabular positions and to a lesser extent for THA which can be improved with increased femoral stem anteversion. Conclusion: Poor ROM may result after SRA if acetabular retroversion is present. [ABSTRACT FROM AUTHOR]

Screening for deep venous thrombosis (DVT) following total joint replacement (TJR) has been recommended as an adjunct to DVT prophylaxis. This study evaluates a structured protocol utilizing impedance plethysmography (IPG) as the primary screening modality. Over a 12-month period all patients undergoing TJR of the lower extremities had an IPG 3 to 5 days after surgery. Patients received primary DVT prophylaxis with warfarin. Minimal follow up of 6 weeks was obtained on all patients. Three-hundred three TJRs were performed. The IPG appeared normal in 220 of 303 patients (73%), obviating further testing. During follow-up, two patients had thromboembolic disease (TED). Of the 83 seemingly abnormal IPGs, 81 were false positive compared to venous ultrasound, with significantly more after knee surgery (p < 0.001). There was one confirmed DVT in the abnormal IPG group and one patient died 2 weeks after discharge with an autopsy-proven pulmonary embolism. There was a low overall rate of TED (1.3%); three fourths of patients with TED presented 2–4 weeks after discharge. These results indicate that it is clinically safe to discharge patients who have had a normal-appearing postoperative IPG. However, the large number of false-positive results reduces the utility of the test, particularly after knee replacement. While IPG is safe and cheaper than venous ultrasound, prophylaxis extended beyond the of hospitalization may obviate the need for screening. [ABSTRACT FROM AUTHOR]

Screening for deep venous thrombosis (DVT) following total joint replacement (TJR) has been recommended as an adjunct to DVT prophylaxis. This study evaluates a structured protocol utilizing impedance plethysmography (IPG) as the primary screening modality. Over a 12-month period all patients undergoing TJR of the lower extremities had an IPG 3 to 5 days after surgery. Patients received primary DVT prophylaxis with warfarin. Minimal follow up of 6 weeks was obtained on all patients.Three-hundred three TJRs were performed. The IPG appeared normal in 220 of 303 patients (73%), obviating further testing. During follow-up, two patients had thromboembolic disease (TED). Of the 83 seemingly abnormal IPGs, 81 were false positive compared to venous ultrasound, with significantly more after knee surgery (p < 0.001). There was one confirmed DVT in the abnormal IPG group and one patient died 2 weeks after discharge with an autopsy-proven pulmonary embolism. There was a low overall rate of TED (1.3%); three fourths of patients with TED presented 2-4 weeks after discharge.These results indicate that it is clinically safe to discharge patients who have had a normal-appearing postoperative IPG. However, the large number of false-positive results reduces the utility of the test, particularly after knee replacement. While IPG is safe and cheaper than venous ultrasound, prophylaxis extended beyond the of hospitalization may obviate the need for screening. [ABSTRACT FROM PUBLISHER]

The author comments on the study "The Effect of Obesity on Direct Medical Costs in Total Knee Arthroplasty," by Hilal Maradit Kremers. Topics include the longer hospital stays and increased costs in total knee arthroplasty, the increase in complication rates specifically wound infection, and work-related disability.

The author comments on the article "Adverse Local Tissue Reaction Associated With a Modular Hip Hemiarthroplasty" which was published in the previous issue. The author mentions the application of modular junctions to modify leg length, large femoral heads to decrease dislocation and introduction of new taper designs and head sizes. Futher is noted the urge to maximize modular junctions, impaction techniques to improve junction integrity and clinical surveillance to provide best care.

A letter to the editor is presented in response to the article "Asymptomatic Pseudotumors in Patients with Taper Corrosion of a Dual-Taper Modular Femoral Stem: MARS-MRI and Metal Ion Study" by Young-Min Kwon.