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Background: In an effort to combat the opioid epidemic, state legislation was passed to limit postoperative narcotic prescribing. The purpose of this study was to assess if the legislation had an impact on patients’ perception of pain management after total hip arthroplasty (THA) and total knee arthroplasty (TKA). We hypothesized that patients would not perceive their pain management experience to be impacted. Methods: A prospective survey study was performed on all consenting patients undergoing primary THA or TKA at a large academic center from July 2019 to February 2020. Patients taking opioids preoperatively were excluded. Surveys given preoperatively and at 2 weeks postoperatively assessed patients' concerns surrounding postoperative pain control and their perception of the impact of a newly implemented legislation. Descriptive analysis and Spearman’s rho correlation coefficients were performed. Results: Ninety-three patients met inclusion criteria and consented. Seventy-nine (29 THA and 50 TKA) completed both surveys. Preoperatively, 9.2% of patients were concerned that the legislation would impact their pain management, despite 43.0% having pain concerns. Postoperatively, 87.0% of patients felt that the legislation had no or mild effect on pain control. Although 36.7% of patients reported moderate to severe postoperative pain, 15.2% of patients reported being dissatisfied with pain control. There was no statistical correlation between preoperative pain concern and feelings that the legislation impacted pain. Conclusions: After primary THA and TKA, our data suggest that patients’ perception of their pain management was not impacted by the legislation. Prescribers should be reassured that the decreased allowable opioids does not hinder the patients’ perception of their pain management experience.

Background The purpose of this study was to investigate if there is an association between musculoskeletal health literacy with outcome and satisfaction after total knee arthroplasty (TKA). Methods A cross-sectional study was performed at our tertiary center to include patients between one and six years postoperatively after primary TKA. Patients were provided a survey including basic demographics, validated musculoskeletal health literacy scale (Literacy in Musculoskeletal Problems), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and TKA satisfaction (whether they would choose to undergo the same operation again). Patients were categorized as either low or normal health literacy based on number of questions (cutoff 6 out of 9) answered correctly on the Literacy in Musculoskeletal Problems. Statistical analysis included multivariate regression with significance at P Results Four hundred fifty-three individuals fully completed the survey of eligible participants. Two hundred ninety-six individuals (65.3%) had normal health literacy, and one hundred fifty-seven individuals (34.7%) had low health literacy. Average WOMAC (/96) was 18.0 ± 19.7 in the low and 12.1 ± 15.4 in the normal health literacy groups. Patients with low health literacy had significantly higher WOMAC (worse function) than those with normal health literacy (P = .001). Patients with normal musculoskeletal health literacy were significantly more likely to undergo the same operation again (P = .01, odds ratio 2.163). Conclusion This study shows that patients with low musculoskeletal health literacy have worse outcome scores and are less likely to be satisfied with their TKA. By identifying these patients preoperatively, emphasis can be placed on enhancing procedure expectations and understanding to improve outcome measures and overall satisfaction.

Introduction: The optimal treatment of patients with a displaced intracapsular femoral neck fracture remains controversial. We utilised a national database of Medicare patients to determine if there was any difference in complications and reoperation rate of patients undergoing total hip arthroplasty (THA) or hemiarthroplasty (HA) for femoral neck fractures. Methods: This study utilised the PearlDiver Patient Records Database, a national for-fee database of Medicare patient procedure and diagnosis records from 2005 to 2012. Outcome procedures and diagnoses including revision, dislocation, infection, and cardiovascular events that occurred during the study time period were also identified over the entire study period as well as 90 days and 2 years. Results: We identified 275,439 patients with femoral neck fractures who underwent HA and 26,017 patients who underwent THA, respectively. Patients undergoing HA had significantly lower rates ( p < 0.0001) of revision 2.48% versus 3.85% (OR = 0.633; 95% CI, 0.592–0.678), dislocation 1.76% versus 3.39% (0.512; 0.476–0.551), infection 3.44% versus 4.87% (0.694; 0.657–0.737). There was no statistical significant difference in 2-year cardiac morbidity ( p = 0.252). However, when controlling for age, patients 65–69 years showed no significant difference in infection or revision over the study period or at 2 years. Conclusions: In this study, patients who underwent THA for femoral neck fractures had a higher rate of dislocations, infections and increased rates of repeat surgery than those who underwent HA but this difference was not significant in patients 65–69 years. Hemiarthroplasty may result in fewer complications in older Medicare patients although this difference may not be present in younger Medicare patients.

As health care reimbursement evolves, physicians will continue to be evaluated based on the quality of care that they provide. One measure of quality is based on patient satisfaction as reported through the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS). Although previous studies have explored expectations and their role in patient satisfaction, no studies have investigated the role of patient expectations for interventions in surgical specialty clinics. Patients (N=126) were given 2 surveys, a pre-visit and a post-visit questionnaire, with options based on the CAHPS survey. Patients were asked to select common orthopedic services that they expected to receive from their appointments, rate their physicians on Likert scales, and report the services that were actually provided. Patients who left with unmet expectations for interventions (45%) rated their physicians lower than patients who had all of their expectations met (9.0±1.4 vs 9.5± 0.8; P P Orthopedics . 2020;43(5):e378–e382.]

The SPOT GRADE (SG), a Surface Bleeding Severity Scale, is a unique visual method for assessing bleeding severity based on quantitative determinations of blood flow. This study assessed the reliability of the SG scale in a clinical setting and collected initial data on the safety and efficacy of HEMOBLAST Bellows (HB), a hemostatic agent, in abdominal and orthopedic operations. Twenty-seven patients were enrolled across 3 centers and received the investigational device. Bleeding severity and hemostasis were independently assessed by 2 surgical investigators at baseline and at 3, 6, and 10 minutes after application of HB and compared for agreement. The mean paired κ statistic for assignment of SG scores was .7754. The mean paired κ statistics for determining eligibility for participation in the trial based on bleeding severity and the mean paired κ statistics determining the presence of hemostasis were .9301 and .9301, respectively. The proportion of patients achieving hemostasis within 3, 6, and 10 minutes of HB application were 50.0%, 79.2%, and 91.7%, respectively. There were no unanticipated adverse device effects and one possible serious adverse device effect, as determined by the Independent Data Monitoring Committee (IDMC). The reliability of the SG scale was validated in a clinical setting. Initial data on the safety and efficacy of HB in abdominal and orthopedic operations were collected, and there were no concerns raised by the investigators or the IDMC.

Background Postoperative urinary retention (POUR) in total joint arthroplasty (TJA) is common. However, risk factors for POUR and its consequences, specifically on postoperative renal function, have not been well defined. Methods We performed a review of prospectively collected data on consecutive adult patients undergoing primary total joint arthroplasty from August 2014 to December 2015. Catheters were placed preoperatively and removed on the first or second postoperative day. The exclusion criterion was traumatic catheter insertion or the presence of fracture or neoplasm. Univariate and multiple logistic regression identified associations with POUR and its invasive therapies. Subgroup analysis of renal function by incidence of preoperative bladder outlet obstruction (BOO) and POUR was performed with nonparametric testing. Results A total of 591 operations met inclusion criteria. The incidence of POUR was 6.4% and was directly related to a positive history of BOO (odds ratio [OR]: 4.15) and increased the duration of urinary catheterization (OR: 1.04). These factors, in addition to preoperative incontinence (OR: 8.36, 28.69) and lengthier hospitalizations (OR: 1.37, 1.30), were significantly associated with intermittent straight catheterization and reinsertion of an indwelling catheter to treat POUR. Serum creatinine increased with combined preoperative BOO and POUR (+0.22 mg/dL) but was preserved in others (+0.02-0.04 mg/dL) (P Conclusions Preoperative BOO and longer catheterization increased the risk of POUR and were associated with the use of invasive modalities to treat POUR. POUR was associated with a longer hospitalization and impaired renal function in those with preoperative BOO; therefore, renal function should be monitored closely and nephrotoxic medications used cautiously when using urinary catheters in this patient population. Level of Evidence Retrospective Analysis, Level IV.

Background: The SPOT GRADE (SG), a surface bleeding severity scale (SBSS), is a unique visual method for assessing bleeding severity based on quantitative determinations of blood flow. This study assessed the reliability of the SG scale in a clinical setting and collected initial data on the safety and efficacy of HEMOBLAST Bellows (HB), a hemostatic agent, in abdominal and orthopedic operations.Methods: Twenty-seven (27) subjects were enrolled across three (3) centers and received the investigational device. Bleeding severity and hemostasis were independently assessed by two (2) surgical investigators at baseline and at 3, 6, and 10 minutes after application of HB and compared for agreement.Results: The mean paired Kappa statistic for assignment of SG scores was 0.7754. The mean paired Kappa statistics for determining eligibility for participation in the trial based on bleeding severity and the mean paired Kappa statistics determining the presence of hemostasis were 0.9301 and 0.9301, respectively. The proportion of subjects achieving hemostasis within 3, 6, and 10 minutes of HB application were 50.0%, 79.2%, and 91.7%, respectively. There were no unanticipated adverse device effects (UADEs) and one possible serious adverse device effect (SADE), as determined by the Independent Data Monitoring Committee (IDMC).Conclusions: The reliability of the SG scale was validated in a clinical setting. Initial data on the safety and efficacy of HB in abdominal and orthopedic operations were collected and there were no concerns raised by the Investigators or the IDMC.

Background The purpose of this study is to investigate outcomes of patients denied total hip (THA) or knee arthroplasty (TKA) due to morbid obesity. Methods We performed an observational study of patients denied arthroplasty due to morbid obesity. A survey including the Harris Hip Score or pain and function components of the original Knee Society Score (KSS) was conducted with minimum 2-year follow-up. Statistical analysis was performed with parametric testing with significance at P Results In total, 125 (4.4%) of 2819 patients were denied THA or TKA due to morbid obesity. Twenty-four (19.2%) met target weight and underwent arthroplasty at our institution. Of the remaining 101 (80.8%) patients, 33 (32.7%) agreed to participate in the survey. None received THA and 6 received TKA elsewhere above target body mass index. Harris Hip Score was significantly higher in the successful weight loss cohort at our institution (70.5 ± 13.4 vs 34.6 ± 13.1). KSS Pain (maximum score of 50) and Function (maximum score of 100) were significantly higher in the successful weight loss cohort at our institution (32.9 ± 16.5; 51.1 ± 19.5) compared to the denied nonoperative cohort (7.2 ± 11.5; 33.0 ± 23.1); however, only KSS Pain was higher when compared to the TKA elsewhere cohort (14.2 ± 18.0; 29.2 ± 38.7). KSS Pain and Function were similar for both denial cohorts regardless of undergoing arthroplasty. Conclusion Nearly 80% of patients denied never met target weight for arthroplasty. Those who met target weight prior to arthroplasty often reported better outcomes. Outcomes were similar when target weight was not met regardless of undergoing arthroplasty.

BACKGROUND Financial burden for patients, providers, and payers can reduce access to physical therapy (PT) after total knee arthroplasty (TKA). The purpose of the present study was to examine the effect of a virtual PT program on health-care costs and clinical outcomes as compared with traditional care after TKA. METHODS At least 10 days before unilateral TKA, patients from 4 clinical sites were enrolled and randomized 1:1 to the virtual PT program (involving an avatar [digitally simulated] coach, in-home 3-dimensional biometrics, and telerehabilitation with remote clinician oversight by a physical therapist) or to traditional PT care in the home or outpatient clinic. The primary outcome was total health-care costs for the 12-week post-hospital period. Secondary (noninferiority) outcomes included 6 and 12-week Knee injury and Osteoarthritis Outcome Score (KOOS); 6-week knee extension, knee flexion, and gait speed; and 12-week safety measures (patient-reported falls, pain, and hospital readmissions). All outcomes were analyzed on a modified intent-to-treat basis. RESULTS Of 306 patients (mean age, 65 years; 62.5% women) who were randomized from November 2016 to November 2017, 290 had TKA and 287 (including 143 in the virtual PT group and 144 in the usual care group) completed the trial. Virtual PT had lower costs at 12 weeks after discharge than usual care (median, $1,050 compared with $2,805; p < 0.001). Mean costs were $2,745 lower for virtual PT patients. Virtual PT patients had fewer rehospitalizations than the usual care group (12 compared with 30; p = 0.007). Virtual PT was noninferior to usual PT in terms of the KOOS at 6 weeks (difference, 0.77; 90% confidence interval [CI], -1.68 to 3.23) and 12 weeks (difference, -2.33; 90% CI, -4.98 to 0.31). Virtual PT was also noninferior to usual care at 6 weeks in terms of knee extension, knee flexion, and gait speed and at 12 weeks in terms of pain and hospital readmissions. Falls were reported by 19.4% of virtual PT patients and 14.6% of usual care patients (difference, 4.83%; 90% CI, -2.60 to 12.25). CONCLUSIONS Relative to traditional home or clinic PT, virtual PT with telerehabilitation for skilled clinical oversight significantly lowered 3-month health-care costs after TKA while providing similar effectiveness. These findings have important implications for patients, health systems, and payers. Virtual PT with clinical oversight should be considered for patients managed with TKA. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background Local infiltration analgesia (LIA) with liposomal bupivacaine (LB) in patients undergoing total knee arthroplasty (TKA) has yielded mixed results. The PILLAR study, which was designed to minimize limitations associated with previous studies, compared the effects of LIA with or without LB on pain scores, opioid consumption, including proportion of opioid-free patients, time to first opioid rescue, and safety after primary unilateral TKA. Methods Patients (N = 140) were randomized to LIA with LB 266 mg/20 mL (admixed with bupivacaine HCl 0.5%, 20 mL) or LIA with bupivacaine HCl 0.5%, 20 mL. Standardized infiltration techniques and a standardized multimodal pain management protocol were used. The coprimary efficacy endpoints were area under the curve (AUC) of visual analog scale pain intensity scores 12-48 hours (AUC12-48) postsurgery and total opioid consumption 0-48 hours postsurgery. Results Mean AUC12-48 of visual analog scale pain intensity score was 180.8 with LB and 209.3 without LB (least squares [LS] mean treatment difference −26.88, P = .0381). LS mean total opioid consumption 0-48 hours postsurgery was 18.7 mg with and 84.9 mg without LB (LS ratio 0.220, P = .0048). Significant differences in favor of LB were observed for the percentage of opioid-free patients (P Conclusion This study provides data on LIA with LB administered using optimal techniques specific to TKA. In this setting, LIA with LB significantly improved postsurgical pain, opioid consumption, and time to first opioid rescue, with more opioid-free patients and no unexpected safety concerns.

Background In the setting of acetabular deficiency during total hip arthroplasty (THA), the medial protrusio technique (MPT) allows for increased component coverage while avoiding excessive component abduction or elevation of the hip center. The technique involves controlled reaming through the medial acetabular wall while maintaining the continuity of the anterior and posterior columns. The purpose of this study is to analyze the results of the largest reported series to date of primary and revision THAs using the MPT. Methods A retrospective review of THAs performed by a single surgeon from July 2004 to July 2010 identified 102 patients who underwent THA necessitating the use of the MPT (primary 86 and revision 16), with at least 2 years follow-up. Results This study reports the largest series to date of primary and revision THAs using the MPT for acetabular deficiency. Postoperatively, mean Harris hip score was 86 (range 31-96). There was no correlation with degree of medialization and change in Harris hip score (P = .12). At mean follow-up of 41.1 months (range 24-92 months), there were no intrapelvic structure injuries and no acetabular components required revision. The MPT provided a safe and effective method for addressing acetabular deficiency and avoiding component malposition. Conclusion The MPT provided a safe and effective method for addressing acetabular deficiency in this large series of patients. The technique was successful at improving component coverage while maintaining an anatomic hip center and avoiding excessive component abduction. Fixation remained durable with no cases of loosening at final follow-up.

Clinic wait time is considered an important predictor of patient satisfaction. The goal of this study was to determine whether patient satisfaction among orthopedic patients is associated with clinic wait time and time with the provider. The authors prospectively enrolled 182 patients at their outpatient orthopedic clinic. Clinic wait time was defined as the time between patient check-in and being seen by the surgeon. Time spent with the provider was defined as the total time the patient spent in the examination room with the surgeon. The Consumer Assessment of Healthcare Providers and Systems survey was used to measure patient satisfaction. Factors associated with increased patient satisfaction included patient age and increased time with the surgeon ( P =.024 and P =.037, respectively), but not clinic wait time ( P =.625). Perceived wait time was subject to a high level of error, and most patients did not accurately report whether they had been waiting longer than 15 minutes to see a provider until they had waited at least 60 minutes ( P =.007). If the results of the current study are generalizable, time with the surgeon is associated with patient satisfaction in orthopedic clinics, but wait time is not. Further, the study findings showed that patients in this setting did not have an accurate perception of actual wait time, with many patients underestimating the time they waited to see a provider. Thus, a potential strategy for improving patient satisfaction is to spend more time with each patient, even at the expense of increased wait time. [ Orthopedics. 2017; 40(1):43–48.]

To evaluate the efficacy and safety of embolization of hyperemic synovial tissue for the treatment of knee pain secondary to osteoarthritis (OA).Twenty patients with radiographic knee OA and moderate-to-severe pain refractory to conservative therapy were enrolled in a prospective, 2-site pilot study. Genicular artery embolization (GAE) was performed with 75- or 100-μm spherical particles. Patients were assessed with magnetic resonance imaging at baseline and at 1 month and with the Visual Analogue Scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at baseline and at 1, 3, and 6 months. Adverse events were recorded at all timepoints.Embolization of at least 1 genicular artery was achieved in 20/20 (100%) patients. Mean VAS improved from 76 mm ± 14 at baseline to 29 mm ± 27 at 6-month follow-up (P.01). Mean WOMAC score improved from 61 ± 12 at baseline to 29 ± 27 at 6-month follow-up (P.01). Self-limiting skin discoloration occurred in 13/20 (65%) patients. Two of 20 (10%) patients developed plantar sensory paresthesia that resolved within 14 days.GAE to treat knee pain secondary to OA can be performed safely and demonstrates potential efficacy. Further randomized comparative studies are needed to determine true treatment effect versus placebo effect.

A 75-year-old woman who suffered a left femoral neck fracture underwent a left total hip arthroplasty using a Stryker Trident (Kalamazoo, MI) hemispherical acetabular shell and Modular Dual Mobility (MDM) metal liner. Post-operative radiographs demonstrated canted seating of the liner. The patient was taken immediately back to the operating room where the acetabular liner appeared well seated superiorly but was in a canted position inferiorly. Removal and replacement was performed and post-operative radiographs demonstrated complete seating. Subsequent follow up at 6 months demonstrated good clinical function with no adverse radiographic findings. Canted seating is a potential complication of the MDM metal liner. Providers should be aware of potential incomplete seating inferiorly despite the superior portion of the liner being well seated.

Study design Patellar tendon reflexes were elicited among patients who had had a unilateral total knee replacement, those planned for unilateral total knee replacement, and a cohort of controlled patients. Patellar tendon reflex (PTR) response was measured with surface electromyography. Objective The aim of this study was to determine if total knee arthroplasty significantly alters the PTR. Summary of background data As part of the clinical evaluation of the spine, extremity reflexes are provoked. Reflex variation between right and left extremities can be a pathological finding in disease of the spine. It has been noted that in patients who have undergone total knee arthroplasty (TKA), the PTR is diminished on the operative side compared with the contralateral nonoperative side. PTR is part of the clinical exam when evaluating a patient for lumbar radiculopathy. Methods The right and left patellar tendon reflex intensities were measured by quadriceps surface electromyography in 3 groups of patients. Group 1 consisted of 21 patients with unilateral TKA who were at least 6 months postoperative. Group 2 consisted of 18 patients with unilateral severe knee arthritis indicated for TKA. Group 3, serving as the control group, included 20 patients with no evidence of knee arthritis in either knee. The average reflex response for each group was recorded and comparisons were then made between each group. Results Patients who have undergone unilateral TKA have a PTR on average of 55.1% of their contralateral uninvolved side. This is statistically significant when compared with reflexes in patients who are planned for unilateral total knee arthroplasty, 96.03% (P = 0.001) and when compared with patients without evidence for knee arthritis, 102.2% (P Conclusion The results of this case control study show that TKAs do significantly diminish PTRs when compared with a contralateral uninvolved knee in the same patient. Level of evidence 3.

Background Enhanced postoperative care pathways have shifted total knee arthroplasty (TKA) to outpatient and short-stay settings, placing greater emphasis on predischarge outcomes. In this study, we report prespecified secondary and tertiary end points of the PILLAR study within 24 hours after TKA in patients receiving local infiltration analgesia (LIA) with or without liposomal bupivacaine (LB). Methods Patients with knee osteoarthritis were randomized 1:1 to receive LIA with LB 266 mg/20 mL admixed with bupivacaine HCl 0.5% 20 mL (n = 70) or bupivacaine HCl alone (n = 69). End points (0-24 hours postsurgery) were proportion of opioid-free patients, opioid consumption, areas under the curve of visual analog scale pain intensity scores, patient satisfaction, discharge readiness, and ambulation. Safety was also assessed. Results Patients receiving LIA with LB were 16% less likely to require opioid rescue within 24 hours postsurgery (17.1% vs 1.4%; relative risk, 0.085; 95% confidence interval, 0.011-0.633). LIA with LB was associated with a 91% reduction in opioid consumption (P = .0009) and 19% reduction in pain intensity (P = .0142). Significantly more patients receiving LB were discharge ready (42.9% vs 27.5%; P = .0449) and satisfied with pain treatment (84.6% vs 69.2%; P = .0306). A numerically lower but not significantly different proportion achieved steady gait/no dizziness with LIA with LB (42.9% vs 52.2%). Adverse event incidence was similar between groups. Conclusion LIA with LB 266 mg plus bupivacaine HCl significantly reduced opioid requirements and pain intensity and significantly improved discharge readiness and satisfaction 0-24 hours after TKA compared with bupivacaine HCl alone. These findings support the use of LIA with LB for TKA when early discharge is the goal.

Background: The Patient Reported Outcomes Measurement Information System (PROMIS) Computerized Adaptive Test (CAT) physical function rapidly assesses self-reported function capability. The Timed Up and Go (TUG) test is often used in clinical practice, but administration may be impeded by space and patient limitations. PROMIS CAT can potentially address these limitations, but we lack evidence if TUG and health indicators are predictors of PROMIS CAT. This study assessed whether TUG, body mass index (BMI), numeric pain rating scale (NPRS), and smoking status were predictors of PROMIS CAT in total knee arthroplasty (TKA) candidates. Methods: Sixty-five TKA candidates completed the PROMIS CAT physical function test using an iPad application. TUG, NPRS, BMI, and smoking status were obtained at the clinic visit or from medical records. Univariate and multiple regression analyses identified the strongest predictors of PROMIS CAT. Results: TUG was the best predictor of PROMIS CAT physical function based on simple regression (r = −0.43, 95% CI = −0.62 to −0.20) or multiple regression (βˆ = −0.45, 95% CI = −0.73 to −0.17) analyses. BMI and NPRS did not incrementally help predict the PROMIS score beyond TUG. Smoking status did not contribute to the prediction of the PROMIS CAT score. Conclusions: The findings suggest that the PROMIS CAT physical function is not a surrogate for the TUG performance-based measure in candidates for TKA. However, TUG was the best predictor of PROMIS physical function compared with BMI, NPRS, and smoking status. Clinicians should consider both patient-reported and performance-based measures when evaluating function for TKA outcomes. Keywords: Prediction, Osteoarthritis, Outcomes, Self-report, Performance-based

Operating room traffic has been implicated in several studies to contribute to the risk of surgical site infections and periprosthetic joint infections. The purpose of this study was to evaluate the effect of a door alarm on operating room traffic during total joint arthroplasty. This prospective cohort study evaluated 100 consecutive primary total hip and knee arthroplasty surgeries performed by a single surgeon. An inconspicuous electronic door counter was placed on the substerile operating room door. Door openings and time left ajar were recorded. After 50 cases, an audible alarm was placed on the substerile operating room door that sounded continuously when the door was ajar. Door-opening data were then recorded for an additional 50 cases. There was a significant difference in the overall mean door openings per minute ( P P Orthopedics. 2017; 40(6):e1081–e1085.]

We hypothesized that systemic ceftriaxone and high concentration local antibiotics might eradicate peri-implant sepsis. Experiment 1: Eighty-four implants inoculated with biofilm-forming Staphylococcus aureus were treated in vitro with gentamicin, vancomycin, gentamicin + rifampin, or vancomycin + rifampin for 2, 4, or 8 days. Experiment 2: Forty-five implants were wired in vivo to rat femurs and inoculated with 1 × 106 CFU S. aureus. After 48 h, rats were treated once daily for 5 days with systemic ceftriaxone, local tobramycin or ceftriaxone, and tobramycin. Experiment 3: Forty implants with established S. aureus biofilms were wired in vivo to rat femurs. After 48 h, rats were treated with systemic ceftriaxone alone or in combination with local gentamicin, gentamicin and rifampin, or vancomycin. Experiment 1: 100% of implants treated in vitro with gentamicin were sterile after 48 h. The other treatments did not become sterile until 4 days. Experiment 2: No implant was culture negative. The combination of systemic ceftriaxone and local tobramycin was significantly better than others (p

This multicenter study evaluated survivorship, functional outcomes, complications, and radiographic outcomes for patients who underwent total hip arthroplasty using a newly developed highly porous 3-dimensional titanium implant. Excellent aseptic (99.6%) and all-cause (98%) survivorship and functional outcomes were found at 3-year follow-up. This highly porous acetabular shell holds promise in total hip arthroplasty. [ Orthopedics. 2018; 41(1):e154–e157.]

BackgroundPeripheral nerve stimulation has been used for decades to treat chronic pain but has not been used for postoperative analgesia due to multiple limitations, beginning with invasive electrode placement. With the development of small-diameter/gauge leads enabling percutaneous insertion, ultrasound guidance for accurate introduction, and stimulators small enough to be adhered to the skin, neurostimulation may now be provided in a similar manner to continuous peripheral nerve blocks. Here, we report on the use of ultrasound-guided percutaneous peripheral nerve stimulation to treat postoperative pain.Materials and methodsSubjects within 60days of a total knee arthroplasty with pain insufficiently treated with oral analgesics had a 0.2-mm-diameter electrical lead (pre-loaded into a 20 gauge needle) introduced percutaneously using ultrasound guidance with the tip located approximately 0.5-1.0cm from the femoral nerve (a second lead was inserted approximately 1.0-3.0cm from the sciatic nerve for posterior knee pain). An external stimulator delivered current. Endpoints were assessed before and after lead insertion and the leads subsequently removed. Due to the small sample size for this pilot/feasibility study, no statistics were applied to the data.ResultsLeads were inserted in subjects (n = 5) 8-58days postoperatively. Percutaneous peripheral nerve stimulation decreased pain an average of 93% at rest (from a mean of 5.0 to 0.2 on a 0-10 numeric rating scale), with 4 of 5 subjects experiencing complete resolution of pain. During passive and active knee motion pain decreased an average of 27 and 30%, respectively. Neither maximum passive nor active knee range-of-motion was consistently affected.ConclusionsUltrasound-guided percutaneous peripheral nerve stimulation may be a practical modality for the treatment of postoperative pain following orthopedic surgical procedures, and further investigation appears warranted.

Background context Methylprednisolone (MP) infusion after acute spinal cord injury (SCI) remains controversial despite large randomized studies, including the National Acute Spinal Cord Injury Studies (NASCIS). Purpose To determine the effect of NASCIS protocol MP infusion on the expression of ciliary neurotrophic factor (CNTF), a neuroprotective cytokine, in a rat model after SCI. Study design Animal laboratory study. Methods Thirty rats were randomized into an MP infusion group (intravenous [IV]-MP) versus normal saline (NS) control group (IV-NS) after a standardized SCI. Ciliary neurotrophic factor expression was measured by reverse transcription-polymerase chain reaction at 6, 12, 24, 48, and 72 hours post-SCI. Results Mean CNTF expression was diminished in the MP group at 12 (p=.006) and 24 (p=.008) hours postinjury compared with the control group. Expression of CNTF was not significantly different between the groups at 6, 48, and 72 hours post-SCI. Conclusions Standardized MP infusion post-SCI reduces CNTF activation in a rat SCI model. Further study is needed to determine if this effect is seen in human SCIs.

Background Serum erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are important tests in the initial diagnosis of periprosthetic joint infection. Many surgeons also use these tests to determine if infection has resolved between stages of a 2-stage procedure, but little data exist regarding this practice. Methods A retrospective review of our institutional total joint databases was conducted to determine sensitivity, specificity, and predictive values of elevated ESR and/or CRP to diagnose persistent infection between stages. Results Among 16 knees and 5 hips, sensitivity was 50% for CRP, 75% for ESR, and 100% when combined. The negative predictive value of persistent infection was 100% when neither test was elevated. Conclusions Results of this study support the use of CRP and ESR as indicators of the resolution of periprosthetic joint infection between stages of 2-stage revision.

To avoid inadvertent vertical positioning of the acetabular component during total hip arthroplasty (THA), the authors routinely “cheat” component abduction an additional 10° horizontal (goal=30°). This likely increases the incidence of components placed into abduction of less than 30°, the clinical consequences of which are not well studied. The purpose of this study was to determine the clinical and radiographic outcomes in patients undergoing THA with acetabular components positioned in less than 30° of abduction as compared with those with components positioned between 30° and 50°. A retrospective review was performed of consecutive patients undergoing primary THA with horizontally cheated acetabular component position performed by a single surgeon. Patients were grouped into cohorts with either component abduction less than 30° or between 30° and 50°. Demographic data, operative data, and complications were recorded. Harris Hip Scores (HHS) and radiographic analysis were obtained from preoperative and most recent clinic visits. Between September 2004 and September 2010, 320 consecutive THA procedures were performed. A total of 149 hips had component abduction less than 30° (mean, 25.8°; range, 15.7°–29.4°). No components had greater than 50° of abduction. At an average 37-month follow-up, no significant difference in HHS was found between the 2 cohorts ( P =.137). The horizontal cohort had no dislocations, component loosening, or osteolysis. By cheating the acetabular component more horizontal, an excessively vertical position was avoided. Component abduction less than 30° yielded equivalent clinical outcomes to component abduction between 30° and 50°. [ Orthopedics. 2016; 39(6):e1092–e1096.]

Periprosthetic joint infection is one of the most common causes of failure after total hip arthroplasty. After strict sterile technique, the use of appropriate perioperative antibiotics administered before the skin incision is the most effective method to prevent infection. We have also found that a 3-minute dilute (0.35%) betadine lavage before closure has been helpful in decreasing the risk of periprosthetic joint infection. When treating the chronically infected total hip arthroplasty, debridement should be avoided, and a 2-stage exchange protocol remains the gold standard in North America.

Intra-articular block compared with conscious sedation for closed reduction of ankle fracture-dislocations: a prospective randomized trial. White BJ, Walsh M, Egol KA, Tejwani NC. J Bone Joint Surg Am. 2008;90:731–734.

We hypothesized that systemic ceftriaxone and high concentration local antibiotics might eradicate peri-implant sepsis. Experiment 1: Eighty-four implants inoculated with biofilm-forming Staphylococcus aureus were treated in vitro with gentamicin, vancomycin, gentamicin + rifampin, or vancomycin + rifampin for 2, 4, or 8 days. Experiment 2: Forty-five implants were wired in vivo to rat femurs and inoculated with 1 × 10(6) CFU S. aureus. After 48 h, rats were treated once daily for 5 days with systemic ceftriaxone, local tobramycin or ceftriaxone, and tobramycin. Experiment 3: Forty implants with established S. aureus biofilms were wired in vivo to rat femurs. After 48 h, rats were treated with systemic ceftriaxone alone or in combination with local gentamicin, gentamicin and rifampin, or vancomycin. Experiment 1: 100% of implants treated in vitro with gentamicin were sterile after 48 h. The other treatments did not become sterile until 4 days. Experiment 2: No implant was culture negative. The combination of systemic ceftriaxone and local tobramycin was significantly better than others (p 0.008). Experiment 3: Systemic ceftriaxone alone was ineffective. All implants treated with systemic ceftriaxone and local gentamicin were sterile (p 0.001), the other groups were less effective.

Patients with advanced degenerative joint disease of the hip or knee often experience chronic pain that can be effectively treated with joint replacement surgery. Joint replacement surgery remains beneficial even if patients have concurrent extrinsic pain or they are taking narcotics long term, although these groups are at higher risk for persistent pain and for dissatisfaction with their surgical results.

Delegates: Joseph A. Abboud, MD, Mark Altena, MD, Thomas L. Bradbury, MD, Jason H. Calhoun, MD, FACS, Douglas A. Dennis, MD, Daniel J. Del Gaizo, MD, Lluis Font-Vizcarra, MD, Kaisa Huotari, MD, Stephen L. Kates, MD, Kyung-Hoi Koo, PhD, Tad M. Mabry, MD, Calin Stefan Moucha, MD, Julio Cesar Palacio, MD, Trisha Nicole Peel, MBBS, Rudolf W. Poolman, MD, PhD, William J. Robb III, MD, Ralph Salvagno, MD, Thorsten Seyler, MD, Gabor Skaliczki, MD, Edward M. Vasarhelyi, MD, William Charles Watters III, MD

Patients with advanced degenerative joint disease of the hip or knee often experience chronic pain that can be effectively treated with joint replacement surgery. Joint replacement surgery remains beneficial even if patients have concurrent extrinsic pain or they are taking narcotics long term, although these groups are at higher risk for persistent pain and for dissatisfaction with their surgical results.

Powered trephines used over a femoral component to disrupt the bone component interface can yield acceptable clinical and radiographic outcomes while minimizing direct mechanical injury and indirect thermal necrosis. Thirty-six patients required trephining for fractured stems (16), infection (8), malposition (7), modular junction failure (4), and acetabular exposure (1). Harris Hip Scores (HHS), radiographic healing, and complications were assessed at a follow-up of 50.01 mo. Mean HHS increased from 46.61 preoperatively to 87.78 postoperatively (p

Instability is one of the most common causes of failure of total knee arthroplasty (TKA). The presentation can vary from pain to frank dislocation with the etiologies just as varied. Instability after TKA can be classified by where the instability occurs in the knee’s arc of motion as well as the chronicity of the problem. Acute instability is related to intraoperative injuries or excessive release of important coronal stabilizers such as the medial collateral ligament in extension or the posterolateral corner in flexion. Chronic instability in extension is often related to varus/valgus malalignment. Chronic instability in flexion can be related to an undersized femoral component, excessive tibial slope, or excessive elevation of the joint line affecting the isometry of the collateral ligaments in midflexion. Recurvatum instability is a rare complication that often coincides with extensor mechanism dysfunction or neuromuscular disorders. When addressing instability after TKA, it is critical to determine the root cause of the problem as well as evaluate for other causes of pain such as infection or aseptic loosening. When revision surgery is warranted, it should follow the basic principles of restoring a neutral mechanical alignment, setting the appropriate component rotation, balancing the flexion and extension spaces, and restoring the height of the native joint line.

The value of preoperative templating for primary total knee arthroplasty (TKA) has recently been questioned. In our clinical practice, preoperative templating is valuable for sizing components and achieving optimal coronal alignment. We preoperatively templated the size of femoral and tibial components, the distal femoral valgus cut, and the proximal tibial cut for 200 primary TKAs. Preoperative templating predicted the exact size of 165 (82.5%) femoral and 159 (79.5%) tibial components, with 194 (97%) femoral and 185 (92.5%) tibial components templated to within one size used. Postoperative tibiofemoral alignment was within +/- 3 degrees of the goal alignment in 189 (94.5%) knees. Postoperative femoral and tibial component coronal alignment was within +/- 3 degrees of the goal coronal alignment in 190 (95%) and 199 (99.5%) knees, respectively. The accuracy of component sizing in this study is greater than previously reported. The prevalence of alignment outliers in this study is less than previously reported for conventional techniques.

Background: First metatarsophalangeal joint (MTP) fusions are performed as salvage procedures for a variety of conditions ranging from osteoarthritis, rheumatoid arthritis, hallux valgus, and failed first MTP arthroplasty. A number of bone preparation techniques have been described to fuse the first MTP joint, with varying degrees of success. The aim of this study was to characterize and compare the average shortening of the first ray with a conical reamer fusion technique versus flat bone cut technique. Materials and Methods: Six paired cadaver feet were divided into two groups with one foot from each pair in each group. Preoperative first ray lengths were measured radiographically. Each group then underwent arthrodesis of first MTP joint with one of two different bone cut techniques: flat cuts or conical reaming. The postoperative lengths of the first rays were measured and the data analyzed using a two-tailed Student's t-tests. Results: The average shortening that occurred in both groups after the procedure was 7.1 mm for the flat cut group (Group I) and 5.7 mm for the machined conical reaming group (Group II). Comparing both groups, there was no statistically significant difference in the shortening between the groups. Conclusion: Both flat bone cut and conically reamed techniques caused shortening of the first ray after first MTP fusion. However, there was no statistically significant difference in the postprocedure lengths of the first ray between the two groups. Clinical Relevance: Neither technique is more likely to lead to transfer metatarsalgia since the shortening was similar.