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The Management of Osteoarthritis (OA) of the Hip Evidence-Based Clinical Practice Guideline is based on a systematic review of published studies examining the treatment of OA of the hip in adults (aged 18 years and older). Based on the best current available evidence, this guideline contains eight recommendations and nine options to assist orthopaedic surgeons and all qualified physicians managing patients who have been diagnosed by a trained healthcare provider with OA of the hip and are currently undergoing treatment. It is also intended to serve as an information resource for professional healthcare practitioners and developers of practice guidelines and recommendations. In addition to providing pragmatic practice recommendations, this guideline also highlights gaps in the literature and informs areas for future research and quality measure development., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Case: A 56-year-old woman underwent a left total hip arthroplasty (THA) after developing avascular necrosis after chemotherapeutic treatment of breast cancer. She presented approximately 2 years after index THA with left groin pain and complaints of instability. Imaging revealed pseudodislocation of the ceramic femoral head with erosion through the acetabular component. Intraoperative evaluation revealed a dissociated polyethylene liner, damaged acetabular locking mechanism, metallosis, and well-fixed and aligned components. Treatment consisted of component retention, bone grafting, and dual-mobility liner cementation into the acetabular component., Conclusions: The two-year follow-up demonstrated a pain-free, well-functioning hip, bone graft incorporation, and no evidence of loosening., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B906)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Clostridioides difficile infection (CDI) may be a surrogate for poor patient health. As such, a history of CDI before THA may be used to identify patients at higher risk for postoperative CDI and complications after THA. Investigations into the associations between CDI before THA and postoperative CDI and complications are lacking., Questions/purposes: We compared the (1) frequency and potential risk factors for CDI after THA, (2) the frequency of 90-day complications after THA in patients with and without a history of CDI, and (3) the length of stay and frequency of readmissions in patients experiencing CDIs more than 6 months before THA, patients experiencing CDIs in the 6 months before THA, and patients without a history of CDI., Methods: Patients undergoing primary THA from 2010 to 2019 were identified in the PearlDiver database using ICD and Current Procedural Terminology codes (n = 714,185). This analysis included Medicare, Medicaid, and private insurance claims across the United States with the ability to perform longitudinal and costs analysis using large patient samples to improve generalizability and reduce error rates. Patients with a history of CDI before THA (n = 5196) were stratified into two groups: those with CDIs that occurred more than 6 months before THA (n = 4003, median 2.2 years [interquartile range 1.2 to 3.6]) and those experiencing CDIs within the 6 months before THA (n = 1193). These patients were compared with the remaining 708,989 patients without a history of CDI before THA. Multivariable logistic regression was used to evaluate the association of risk factors and incidence of 90-day postoperative CDI in patients with a history of CDI. Variables such as antibiotic use, proton pump inhibitor use, chemotherapy, and inflammatory bowel disease were included in the models. Chi-square and unadjusted odds ratios with 95% confidence intervals were used to compare complication frequencies. A Bonferroni correction adjusted the p value significance threshold to < 0.003., Results: Prior CDI during either timespan was associated with higher unadjusted odds for postoperative CDI (CDI > 6 months before THA: OR 8.44 [95% CI 6.95 to 10.14]; p < 0.001; CDI ≤ 6 months before THA: OR 49.92 [95% CI 42.26 to 58.54]; p < 0.001). None of the risk factors included in the regression were associated with increased odds for postoperative CDI in patients with preoperative history of CDI. Patients with a history of CDI before THA were associated with higher unadjusted odds for every 90-day complication compared with patients without a history of CDI before THA. CDI during either timespan was associated with longer lengths of stay (no CDI before THA: 3.8 days; CDI > 6 months before THA: 4.5 days; CDI ≤ 6 months before THA: 5.3 days; p < 0.001) and 90-day readmissions (CDI > 6 months before THA: OR 2.21 [95% CI 1.98 to 2.47]; p < 0.001; CDI ≤ 6 months before THA: OR 3.39 [95% CI 2.85 to 4.02]; p < 0.001)., Conclusion: Having CDI before THA was associated with higher odds of postoperative CDI compared with patients without a history of CDI. A history of CDI within the 6 months before THA was associated with the greatest odds for postoperative complications and readmissions. Providers should strongly consider delaying THA until 6 months after CDI, if possible, to provide adequate time for patient recovery and eradication of infection., Level of Evidence: Level III, therapeutic study., Competing Interests: Each author certifies that neither he, nor any member of his immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

Case: A 19-year-old woman with a history of Hoffa fat pad syndrome underwent infrapatellar fat pad synovectomy and subsequently developed extensor mechanism disruption secondary to iatrogenic patellar tendon injury. She received a modified extensor mechanism patella-patellar tendon-tibial tubercle allograft to restore extensor function with satisfactory results at 2-year follow-up. We also review alternative techniques that were considered for her extensor mechanism repair., Conclusion: The patient demonstrated satisfactory outcomes, similar to other established techniques. This modified extensor mechanism allograft reconstruction may be an effective alternative for patients experiencing acute extensor mechanism disruptions., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B337)., (Copyright © 2020 by The Journal of Bone and Joint Surgery, Incorporated.)

The Political Action Committee (PAC) of the American Association of Orthopaedic Surgeons, also known as the OrthoPAC, is one of the most powerful and well-respected healthcare PACs in Washington, DC. Since its inception in 1999, the OrthoPAC has advocated at the federal level for orthopaedic patients and orthopaedic surgery as a profession. This manuscript will familiarize the reader with PACs, the history and structure of the OrthoPAC, important accomplishments of the OrthoPAC, current legislative positions, and leadership/organization. We also review the various ways that orthopaedic surgeons can engage in advocacy for musculoskeletal care.

Background: Dislocation remains the leading cause of revision THA. One approach to decreasing prosthetic dislocation risk has been the use of larger femoral head component sizes. The upper limit of head size in metal-on-polyethylene hip arthroplasty has historically been limited because of concerns about increased wear on thin polyethylene components. It is not known to what degree this concern should apply to more wear-resistant polyethylene components., Questions/purposes: We therefore determined (1) in vitro wear rates of polyethylene liners of varying thicknesses, (2) whether there were differences in the microscopic wear characteristics as a function of polyethylene thickness, and (3) whether thin polyethylene components resulted in early catastrophic failures., Methods: We used a hip wear simulator to compare the wear performance of 12 highly crosslinked polyethylene acetabular inserts. The internal diameter of all components was 36 mm, and there were three samples tested of each thickness (1.9, 3.9, 5.9, or 7.9 mm). Testing was conducted for 2.4 million cycles. Gravimetric mass loss was converted to volumetric loss, which was subsequently converted to theoretical linear penetration rates., Results: Wear rates decreased with increasing polyethylene thickness. Mean ± SD wear rates for the 1.9-, 3.9-, 5.9-, and 7.9-mm groups were 5.0 ± 0.5, 3.2 ± 0.3, 2.5 ± 1.1, and 2.2 ± 1.3 mm(3)/million cycles, respectively (p < 0.016). Calculated penetration rates were 0.015, 0.012, 0.011, and 0.010 mm/million cycles, respectively (p < 0.016). There were no catastrophic failures in any group., Conclusions: Thinner polyethylene components demonstrated higher wear rates, although even the highest wear rate observed in the thinnest polyethylene specimen was lower than that commonly reported for noncrosslinked polyethylene components. While encouraging, these findings should be validated in vivo before clinical recommendations can be made.

Unlabelled: Treating patients who have arthrofibrotic or stiff knees after total knee arthroplasty can be difficult. Treatment with arthroscopic débridement, arthrolysis of adhesions with polyethylene spacer exchange, or complete revision arthroplasty often has led to less than optimal range of motion and functional outcomes. We used a combination of surgical arthrolysis and an intensive postoperative rehabilitation protocol, including functional bracing, to treat this condition. We then retrospectively reviewed 18 knees in 17 patients who had stiff knees after total knee arthroplasty with no other detectable clinical or radiographic abnormalities, at a mean followup of 30 months. Seventeen knees (94%) had gains in knee range of motion with a mean increased range of motion of 31 degrees. Although 16 of 17 patients had clinical improvement and were satisfied with the procedure, only (2/3) of the patients (12 of 18 patients) had excellent or good Knee Society objective scores. This combined surgical and rehabilitation method can lead to an increased range of motion. All patients improved clinically, but good functional results were less predictable. The authors think treatment of these difficult knees should be aimed at soft tissue operative releases supplemented by an intensive rehabilitation protocol., Level of Evidence: Therapeutic study, level IV (prospective study). See Guidelines for Authors for a complete description of levels of evidence.

The management options for complex soft tissue defects about the knee are varied. Limb threatening conditions such as exposure of joint prosthesis or bone requires stable coverage to avoid amputation. A study was conducted to review the authors' management protocol and experience with complex defects about the knee. A retrospective analysis from 1986 to 1996 of 35 patients with complex defects about the knee was performed. Treatment options were based on the nature, size, location, and depth of the wound. A specific management protocol was applied for each patient. Treatments included local wound care, debridement and skin graft, fasciocutaneous flap, pedicled muscle flap, and free muscle transfer. Postoperatively, patients were evaluated using Knee Society objective and functional scores and other instruments to measure outcome. Successful salvage of the lower extremity was obtained in 34 (97%) patients. Salvage of the total knee prosthesis was obtained in 24 of 29 (83%) patients. Secondary plastic surgery procedures were necessary in eight (23%) patients. Secondary orthopaedic procedures were necessary in five (15%) patients. No patient required an amputation.