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There are still some controversies regarding the clinical use of cementless UKAs. The aim of this systematic review was to determine whether cementless medial UKA leads to similar outcomes compared to cemented medial UKA. This search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews guidelines (PRISMA). The random effects model with 95% confidence interval (CI) was applied to the analysis. The I 2 statistic was used to assess study heterogeneity. Six studies were eligible for inclusion (4784 UKAs, 4776 patients): 2947 cemented UKAs (61.6%) and 1837 cementless UKAs (38.4%). The overall mean follow-up was 4.9 years. The all-cause reoperation rate was 11.3% (80 of 706) at mean 5.7-year follow-up for cemented UKA and 6.9% (57 of 824) at mean 4.1-year follow-up for the cementless. The overall revision rate was 10.2% (303 of 2947) for the cemented and 5.8% (108 of 1837) for the cementless. Aseptic loosening was the most frequent reason of revision (2.3% cemented vs 0.5% cementless). The overall rate of radiolucent lines (RLL) was 28.3% (63 of 223) in the cemented cohort and 11.1% in the cementless (26 of 234). All the studies reported improved functional outcomes. Cementless UKA provides at least equivalent if not better results compared to cemented UKA. Despite the use of cemented UKA outnumber cementless fixation, available data shows that cementless UKA had a reduced midterm revision rate, while providing similar functional outcomes., (© 2023. The Author(s), under exclusive licence to Istituto Ortopedico Rizzoli.)

Background: A number of papers have been published about the clinical performance of modern rough-blasted titanium Burch-Schneider antiprotrusio cages (BS-APCs) for the treatment of acetabular bone defects. However, no systematic review of the literature has been published to date., Methods: The US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviews were queried for publications using keywords pertinent to Burch-Schneider antiprotrusio cage, revision THA, and clinical outcomes., Results: 8 articles were found to be suitable for inclusion in the present study in which 374 cases (370 patients) had been treated with modern BS-APCs. Most acetabular bone defects were type 3 according to the Paprosky classification (type 2C: 18.1%, 3A: 51%, and 3B: 28.9%). The overall re-revision rate for the 374 acetabular reconstructions with modern BS-APCs was 11.5% (43 cases). The short-term survival rate of the modern BS-APC construct was 90.6% (339 out of 374 cases), while the mid-term survival rate was 85.6% (320 out of 374 cases), and the long-term survival rate 62% (54 out of 87 cases). The most common reasons for revision were aseptic loosening (5.6%), periprosthetic joint infection (3.8%), dislocation (2.7%), and acetabular periprosthetic fracture (1.9%)., Conclusions: There was moderate quality evidence to show that the use of modern rough blasted titanium BS-APCs in cases of acetabular bone loss has an unacceptably high failure rate (38%). Given that antiprotrusio cages do not provide any biological fixation, we would not recommend the routine use of modern BS-APCs in complex revision THA cases. By contrast, the satisfactory short- to mid-term outcome of modern BS-APCs in combination with their low cost compared to highly porous acetabular implants, make us feel that BS-APCs might still be used in selected elderly or low-demand patients without severe superomedial acetabular bone loss.

Background: There remains inconsistent data about the association of surgical approach and periprosthetic joint infection (PJI). We sought to evaluate the risk of reoperation for superficial infection and PJI after primary total hip arthroplasty (THA) in a multivariate model., Methods: We reviewed 16,500 primary THAs, collecting data on surgical approach and all reoperations within 1 year for superficial infection (n = 36) or PJI (n = 70). Considering superficial infection and PJI separately, we used Kaplan-Meier survivorship to assess survival free from reoperation and a Cox Proportional Hazards multivariate models to assess risk factors for reoperation., Results: Between direct anterior approach (DAA) (N = 3,351) and PLA (N = 13,149) cohorts, rates of superficial infection (0.4 versus 0.2%) and PJI (0.3 versus 0.5%) were low and survivorship free from reoperation for superficial infection (99.6 versus 99.8%) and PJI (99.4 versus 99.7%) were excellent at both 1 and 2 years. The risk of developing superficial infection increased with high body mass index (BMI) (hazard ratio [HR] = 1.1 per unit increase, P = .003), DAA (HR = 2.7, P = .01), and smoking status (HR = 2.9, P = .03). The risk of developing PJI increased with the high BMI (HR = 1.04, P = .03), but not surgical approach (HR = 0.68, P = .3)., Conclusion: In this study of 16,500 primary THAs, DAA was independently associated with an elevated risk of superficial infection reoperation compared to the PLA, but there was no association between surgical approach and PJI. An elevated patient BMI was the strongest risk factor for superficial infection and PJI in our cohort., Level of Evidence: III, retrospective cohort study., (Copyright © 2023. Published by Elsevier Inc.)

Introduction: The direct anterior approach (DAA) for total hip arthroplasty (THA) is considered less invasive than the posterolateral approach (PLA), possibly leading to earlier mobilization, faster recovery, and lower levels of thrombogenic markers. The purpose of the current study was to prospectively compare readiness for discharge, rehabilitation milestones, markers of thrombosis and inflammation at 6 weeks postoperatively between DAA and PLA., Methods: A total of 40 patients (20 anterior and 20 posterolateral) were prospectively enrolled. Readiness for discharge, length of stay (LOS), and related outcomes were additionally documented. Blood was drawn at baseline, wound closure, 5-h post-closure, and 24-h post-closure for assays of interleukin-6 (IL-6), PAP (plasmin anti-plasmin), a marker of fibrinolysis, and PF1.2 (Prothrombin fragment 1.2), a marker of thrombin generation., Results: Compared to the PLA group, the DAA group was ready for discharge a mean 13 h earlier (p = 0.03), while rehabilitation milestones were met a mean 10 h earlier (p = 0.04), and LOS was 13 h shorter (p = 0.02) on average. Pain scores at all study timepoints and patient satisfaction at 6 weeks were similar (p > 0.05). At 24 h postoperatively, PAP levels were 537.53 ± 94.1 µg/L vs. 464.39 ± 114.6 µg/L (p = 0.05), and Il-6 levels were 40.94 ± 26.1 pg/mL vs. 60.51 ± 33.0 pg/mL (p = 0.03), in DAA vs. PLA, respectively., Conclusions: In the immediate postoperative period, DAA patients were ready for discharge before PLA patients. DAA patients had shorter LOS, a lower inflammatory response, and higher systemic markers of fibrinolysis. However, these differences may not be clinically significant. Future studies with larger study populations are warranted to confirm the validity and significance of these findings., Level of Evidence: Level II, Therapeutic Study., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The interest in ambulatory total hip arthroplasty (THA) has increased recently due to a national focus on value-based care and improved rapid recovery protocols. Purpose: We sought to determine if surgical approach had an effect on discharge outcomes in outpatient THA. Methods: We performed a retrospective cohort study examining patients who underwent unilateral THA at a single institution using a standardized perioperative care pathway who were discharged home within 24 hours. In total, we compared 106 patients who underwent THA using the direct anterior approach (ATHA) and 90 patients who underwent THA using the posterior approach (PTHA). Univariate and multivariable analyses were used to compare time to ambulation, length of surgery, readmissions, and 90-day complications. Results: Time to ambulation in the ATHA and PTHA groups was 3.9 hours and 4.1 hours, respectively, and time to discharge was 5.9 hours and 6.0 hours, respectively. Length of surgery was shorter in the ATHA group than in the PTHA group (78 minutes vs 86 minutes, respectively). Complications occurred in 3 patients (3%) in the ATHA group vs 4 patients (4%) in PTHA group. In both groups, early ambulation (within 5 hours) predicted earlier time to discharge. Surgical approach was not associated with time to ambulation or time to discharge on multivariable analysis. Conclusion: In this retrospective study, outpatient THA was feasible in a well-selected population of patients undergoing anterior or posterior approaches. Further study is warranted., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Bradford S. Waddell, MD, and Michael P. Ast, MD, both report relationships with Surgical Care Associates, Eastern Orthopaedic Association (EOA), American Association of Hip and Knee Surgeons (AAHKS), and American Academy of Orthopaedic Surgeons (AAOS), outside the submitted work. David J. Mayman, MD, reports relationships with CyMedica Orthopedics, Evolve Ortho LLC, HS2, Imagen Technologies, InSight Medical, OrthAlign, Smith & Nephew, Stryker-Consulting, and Wishbone, outside the submitted work. Seth A. Jerabek, MD, reports relationships with Imagen and Stryker outside the submitted work. Michael M. Alexiades, MD, reports relationships with DePuy and DJO outside the submitted work. Drake G. LeBrun, MD, MPH, and Scott M. LaValva, MD, declare they have no potential conflicts of interest., (© The Author(s) 2021.)

Background: Clinical outcomes of cemented femoral stems revisions using the cement-in-cement technique in aseptic conditions after total hip arthroplasty have been widely described., Methods: The US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviews were queried., Results: Twelve articles were included (620 revision THA). Revision rate for complications related to the femoral side was 1.4% at mid-term follow-up (5.4 years). Periprosthetic femoral fracture rate was 1.1%, aseptic loosening of the femoral component 0.3%., Conclusions: Cement-in-cement revision technique of the femoral component is associated with a high mid-term success rates (98.6%) and is potentially less challenging than other revision techniques., (© 2021 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Aims: Traditionally, acetabular component insertion during total hip arthroplasty (THA) is visually assisted in the posterior approach and fluoroscopically assisted in the anterior approach. The present study examined the accuracy of a new surgeon during anterior (NSA) and posterior (NSP) THA using robotic arm-assisted technology compared to two experienced surgeons using traditional methods., Methods: Prospectively collected data was reviewed for 120 patients at two institutions. Data were collected on the first 30 anterior approach and the first 30 posterior approach surgeries performed by a newly graduated arthroplasty surgeon (all using robotic arm-assisted technology) and was compared to standard THA by an experienced anterior (SSA) and posterior surgeon (SSP). Acetabular component inclination, version, and leg length were calculated postoperatively and differences calculated based on postoperative film measurement., Results: Demographic data were similar between groups with the exception of BMI being lower in the NSA group (27.98 vs 25.2; p = 0.005). Operating time and total time in operating room (TTOR) was lower in the SSA (p < 0.001) and TTOR was higher in the NSP group (p = 0.014). Planned versus postoperative leg length discrepancy were similar among both anterior and posterior surgeries (p > 0.104). Planned versus postoperative abduction and anteversion were similar among the NSA and SSA (p > 0.425), whereas planned versus postoperative abduction and anteversion were lower in the NSP (p < 0.001). Outliers > 10 mm from planned leg length were present in one case of the SSP and NSP, with none in the anterior groups. There were no outliers > 10° in anterior or posterior for abduction in all surgeons. The SSP had six outliers > 10° in anteversion while the NSP had none (p = 0.004); the SSA had no outliers for anteversion while the NSA had one (p = 0.500)., Conclusion: Robotic arm-assisted technology allowed a newly trained surgeon to produce similarly accurate results and outcomes as experienced surgeons in anterior and posterior hip arthroplasty. Cite this article: Bone Jt Open  2021;2(6):365-370.

Background: The early months of the coronavirus disease 19 (COVID-19) pandemic in New York City led to a rapid transition of non-essential in-person health care, including outpatient arthroplasty visits, to a telemedicine context. Questions/Purposes: Based on our initial experiences with telemedicine in an outpatient arthroplasty setting, we sought to determine early lessons learned that may be applicable to other providers adopting or expanding telemedicine services. Methods: A cross-sectional study was performed by surveying all patients undergoing telemedicine visits with 8 arthroplasty surgeons at 1 orthopedic specialty hospital in New York City from April 8 to May 19, 2020. Descriptive statistics were used to analyze demographic data, satisfaction with the telemedicine visit, and positive and negative takeaways. Results: In all, 164 patients completed the survey. The most common reasons for the telemedicine visit were short-term (less than 6 months), postoperative appointment ( n = 88; 54%), and new patient consultation ( n = 32; 20%). A total of 84 patients (51%) noted a reduction in expenses versus standard outpatient care. Several positive themes emerged from patient feedback, including less anxiety and stress related to traveling ( n = 82; 50%), feeling more at ease in a familiar environment ( n = 54; 33%), and the ability to assess postoperative home environment ( n = 13; 8%). However, patients also expressed concerns about the difficulty addressing symptoms in the absence of an in-person examination ( n = 28; 17%), a decreased sense of interpersonal connection with the physician ( n = 20; 12%), and technical difficulties ( n = 14; 9%). Conclusions: Patients were satisfied with their telemedicine experience during the COVID-19 pandemic; however, we identified several areas amenable to improvement. Further study is warranted., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Drake G. LeBrun, MD, MPH, Christina Malfer, BA, Mallory Wilson, BA, Kaitlin M. Carroll, BA, and Victoria Wang declare that they have no conflicts of interest. David J. Mayman, MD, reports stock or stock options from Imagen, Wishbone, and Insight; stock or stock options and royalties from Orthalign; and personal fees, royalties, and research support from Smith and Nephew, outside the submitted work. Michael B. Cross, MD, reports personal fees from Depuy, Smith and Nephew, and Flexion Therapeutics; personal fees and research support from Exactech; personal fees and stock or stock options from Imagen; personal fees, research support, and stock or stock options from Intellijoint; personal fees and research support from KCI; and stock or stock options from Parvizi Surgical Innovation, outside the submitted work. Michael M. Alexiades, MD, reports personal fees and royalties from DJ Orthopedics, outside the submitted work. Seth A. Jerabek, MD, reports stock or stock options from Imagen, personal fees and research support from Stryker, outside the submitted work. Fred D. Cushner, MD, reports personal fees from Acelity and Smith and Nephew, stock or stock options from Canary Medical, personal fees and stock or stock options from Orthalign, outside the submitted work. Jonathan M. Vigdorchik, MD, reports personal fees and research support from Corin, personal fees and stock or stock options from Intellijoint, and personal fees from Medacta, Motion Insights, and Zimmer, outside the submitted work. Steven B. Haas, MD, reports personal fees from Smith and Nephew, outside the submitted work. Michael P. Ast, MD, reports personal fees from Conformis, Stryker, and Surgical Care Affiliates; personal fees, stock or stock options, and royalties from Orthalign; stock or stock options from OSSO VR; and personal fees and research support from Smith and Nephew, outside the submitted work., (© The Author(s) 2020.)

Hypersensitivity reactions to zirconia (ZrO2) or similar ceramics is highly unusual. Owing to the stable oxide formed between the base metal and oxygen, ceramics are considered relatively biologically inert. We report the case of an otherwise healthy 50-year-old woman with a 5-year history of progressively worsening right hip pain who underwent a ceramic-on-polyethylene total hip replacement and subsequently developed hypersensitivity reaction. After metal allergy testing showed her to be highly reactive to zirconium, the femoral head was revised to a custom titanium implant and her symptoms resolved., (© 2020 The Authors.)

Background: A number of articles have been published reporting on the clinical outcomes of various acetabular reconstructions for the management of chronic pelvic discontinuity (PD). However, no systematic review of the literature has been published to date comparing the outcome and complications of different approaches to reconstruction., Methods: The US National Library of Medicine (PubMed/MEDLINE) and EMBASE were queried for publications from January 1980 to January 2019 using keywords pertinent to total hip arthroplasty, PD, acetabular dissociation, clinical or functional outcomes, and revision total hip arthroplasty or postoperative complications., Results: Overall, 18 articles were included in this analysis (569 cases with chronic PD). The overall survival rate of the acetabular components used for the treatment of chronic PD was 84.7% (482 of 569 cases) at mid-term follow-up, whereas the most common reasons for revision were aseptic loosening (54 of 569 hips; 9.5%), dislocations (45 of 569 hips; 7.9%), periprosthetic joint infection (30 of 569 hips; 5.3%), and periprosthetic fractures (11 of 569 hips; 1.9%). Both pelvic distraction technique (combined with highly porous shells) and custom triflanges resulted in less than 5% failure rates (96.2% and 95.8%, respectively) at final follow-up. Also, highly effective in the treatment of PD were cup-cages and highly porous shells with and/or without augments with 92% survivorship free of revision for aseptic loosening for both reconstruction methods. Inferior outcomes were reported for conventional cementless shells combined with acetabular plates (72.7%) as well as ilioischial cages and reconstruction rings (66.7% and 60.6% survivorship, respectively)., Conclusion: The current literature contains moderate quality evidence in support of the use of custom triflange implants and pelvic distraction techniques for the treatment of chronic PD, with a less than 5% all-cause revision rate and low complication rates at mean mid-term follow-up. Cup-cages and highly porous shells with or without augments could also be considered for the treatment of PD because both resulted in greater than 90% survival rates. Finally, there is still no consensus regarding the impact of different types of acetabular reconstruction methods on optimizing the healing potential of PD, and further studies are required in this area to better understand the influence of PD healing on construct survivorship and functional outcomes with each reconstruction method., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Femoral exposure for direct anterior approach (DAA) total hip arthroplasty (THA) invariably requires posterior soft tissue releases. Released posterior structures cannot be repaired. The purpose of this study is to describe the frequency and anatomic consequences of DAA THA posterior soft tissue releases and to compare the appearance of the anterior capsule between a group of patients who had capsulotomy and repair versus capsulectomy., Methods: Thirty-two DAA THA patients underwent metal artifact reduction sequence magnetic resonance imaging at discharge and 1-year follow-up. Seventeen had underwent capsulotomy and repair and 15 capsulectomy. A radiologist blinded to intraoperative data scored each metal artifact reduction sequence magnetic resonance imaging. Anterior capsular integrity, status of the piriformis and conjoint tendons, and muscle atrophy were graded. Descriptive statistics were performed to analyze results., Results: Immediately postoperatively, 75% of piriformis tendons were intact and 38% of conjoined tendons were intact. At 1 year, 97% had an intact piriformis and conjoined tendon, although many were in continuity through scar with the capsule. The posterior capsule directly contacted bone in all patients. At 1 year, none of the patients who underwent capsulotomy with repair had persistent anterior capsule defects, while 27% in the capsulectomy group had persistent defects., Conclusion: Posterior capsule and conjoined tendon releases were commonly performed during DAA THA, yet continuity with bone was frequently achieved at 1 year. In this study, capsulotomy with repair resulted in no anterior capsular defects when compared with capsulectomy. These results may support improved THA stability observed after DAA with capsular repair despite posterior soft tissue releases., Level of Evidence: Level III, prospective cohort study., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Competing Interests: Conflict of InterestMichael M. Alexiades, MD, declares board or committee membership at Weill Cornell Medicine; research support from Stryker; and personal fees as a consultant to Intellijoint, DJ Orthopaedics, Imagen, and Zimmer Biomet, outside the submitted work.

While preservation and repair of the acetabular labrum are increasingly being recognized as important goals in hip arthroscopy, controversies still exist regarding the clinical outcome of arthroscopic acetabuloplasty with chondrolabral preservation. A systematic review was conducted and implemented by two independent reviewers, who used the MEDLINE/PubMed database and the Cochrane Database of Systematic Reviews for their search. These databases were queried with the terms "arthroscopic acetabuloplasty" and "chondrolabral preservation" and "arthroscopic acetabular recession." From the 55 initial studies the reviewers finally chose and assessed five clinical studies which were eligible to their inclusion-exclusion criteria. The reviewed studies included in total 444 patients, mainly young, between 30 and 40 years old. The follow-up evaluation varied between 24 and 41 months, while all studies utilized at least a 24-month final end-point assessment. All five studies illustrated improved outcome with the use of chondrolabral preservation acetabuloplasty without labral detachment. The rate of complications was very low. The different techniques of arthroscopic acetabuloplasty combined with chondrolabral preservation illustrated encouraging results in patients suffering from pincer-type or mixed-type FAI. However, the available clinical evidence was limited and insufficient to establish any superiority of these techniques over the traditional labral detachment and sequential reattachment. In relation to the optimal treatment of FAI without isolated CAM, further research of higher quality is recommended to be conducted in order to lead to definitive conclusions.

Background: There is a concern for higher rates of wound complications and a potentially increased periprosthetic joint infection (PJI) risk after total hip arthroplasty (THA) with the direct anterior approach (DAA) compared to the posterolateral approach (PLA). Our purpose was to compare PJI risk after THA with the DAA or the PLA and to identify risk factors for PJI after primary THA., Methods: Clinical characteristics of patients treated in our institution with primary DAA or PLA THA between 1/2010 and 12/2015 were retrospectively reviewed. The respective deep PJI rates were calculated. A logistic regression model was constructed to determine a potential difference in the PJI risk between the 2 groups, and risk factors for hip PJI in all patients., Results: During the period studied, there were 1,182 DAA THAs and 18,853 PLA THAs. The PJI rate was 0.25% for the DAA group and 0.31% for the PLA group ( p = 1.0). The DAA was not associated with a significantly increased risk for PJI compared to the PLA. Compared to younger patients, older patients had lower PJI risk; patient discharge to home was also associated with lower PJI risk compared to other discharge disposition; longer length of stay was associated with higher PJI risk compared to shorter length of stay., Conclusion: The DAA is equally safe compared the PLA with respect to PJI risk. Younger age, discharge to facilities other than home and increased length of stay increase the risk for deep PJI after primary THA.

Background: Although a variety of studies have assessed the outcomes of simultaneous bilateral total knee arthroplasty (BTKA) and staged BTKA, there remains no definitive conclusion regarding the superiority of one technique in terms of safety., Methods: The US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviews were queried utilizing keywords pertinent to BTKA, simultaneous and staged, and clinical or functional outcomes. In order to examine the contemporary relevant literature, studies published prior to 2009 were excluded from our search., Results: In total, 19 articles met the inclusion criteria and were included in this analysis. The overall quality of the studies included in this review was rated as moderate. Seven of the 19 studies reported no significant differences between the 2 groups in regards to baseline clinical and demographic characteristics (comorbidity index, American Society of Anesthesiologists grade, preoperative clinical subjective scores). Nearly all from these 7 studies with comparable initial characteristics documented no significant differences in the overall complication rates between the 2 groups in addition to no difference in mortality rate, cardiac complications, revision rate, thromboembolic events, and functional outcomes., Conclusion: In contemporary studies involving comparable baseline demographics (including comorbidity index, American Society of Anesthesiologists grade), there was moderate evidence to show that simultaneous BTKA is as safe as the staged BTKA., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aims: The aim of this study was to determine the general postoperative opioid consumption and rate of appropriate disposal of excess opioid prescriptions in patients undergoing primary unilateral total knee arthroplasty (TKA)., Patients and Methods: In total, 112 patients undergoing surgery with one of eight arthroplasty surgeons at a single specialty hospital were prospectively enrolled. Three patients were excluded for undergoing secondary procedures within six weeks. Daily pain levels and opioid consumption, quantity, and disposal patterns for leftover medications were collected for six weeks following surgery using a text-messaging platform., Results: Overall, 103 of 109 patients (94.5%) completed the daily short message service (SMS) surveys. The mean oral morphine equivalents (OME) consumed during the six weeks post-surgery were 639.6 mg (sd 323.7; 20 to 1616) corresponding to 85.3 tablets of 5 mg oxycodone per patient. A total of 66 patients (64.1%) had stopped taking opioids within six weeks of surgery and had the mean equivalent of 18 oxycodone 5 mg tablets remaining. Only 17 patients (25.7%) appropriately disposed of leftover medications., Conclusion: These prospectively collected data provide a benchmark for general opioid consumption after uncomplicated primary unilateral TKA. Many patients are prescribed more opioids than they require, and leftover medication is infrequently disposed of appropriately, which increases the risk for illicit diversion. Cite this article: Bone Joint J 2019;101-B(7 Supple C):98-103.

Background: Periarticular injection is a popular method to control postoperative pain after total knee replacement. An adductor canal block is a sensory block that can also help to alleviate pain after total knee replacement. We hypothesized that the combination of adductor canal block and periarticular injection would allow patients to reach discharge criteria 0.5 day faster than with periarticular injection alone., Methods: This prospective trial enrolled 56 patients to receive a periarticular injection and 55 patients to receive an adductor canal block and periarticular injection. Both groups received intraoperative neuraxial anesthesia and multiple different types of pharmaceutical analgesics. The primary outcome was time to reach discharge criteria. Secondary outcomes, collected on postoperative days 1 and 2, included numeric rating scale pain scores, the PAIN OUT questionnaire, opioid consumption, and opioid-related side effects., Results: There was no difference in time to reach discharge criteria between the groups with and without an adductor canal block. The Wilcoxon-Mann-Whitney odds ratio was 0.87 (95% confidence interval [CI], 0.55 to 1.33; p = 0.518). The median time to achieve discharge criteria (and interquartile range) was 25.8 hours (23.4 hours, 44.3 hours) in the adductor canal block and periarticular injection group compared with 26.4 hours (22.9 hours, 46.2 hours) in the periarticular injection group. Patients who received an adductor canal block and periarticular injection reported lower worst pain (difference in means, -1.4 [99% CI, -2.7 to 0]; adjusted p = 0.041) and more pain relief (difference in means, 12% [99% CI, 0% to 24%]; adjusted p = 0.048) at 24 hours after anesthesia. There was no difference in any other secondary outcome measure (e.g., opioid consumption, opioid-related side effects, numeric rating scale pain scores)., Conclusions: The time to meet the discharge criteria was not significantly different between the groups. In the adductor canal block and periarticular injection group, the patients had lower worst pain and greater pain relief at 24 hours after anesthesia. No difference was noted in any other secondary outcome measure (e.g., opioid consumption, opioid-related side effects, numeric rating scale pain scores)., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The purpose of this study was to determine if there is a difference in the number of diagnostic tests and interventions, pain and function scores, or satisfaction of patients discharged to inpatient rehabilitation facilities vs to home. From February to May 2015, 171 consecutive patients were prospectively recruited following primary total knee arthroplasty. Six weeks postoperatively, based on the patients' recollections, the number and types of diagnostic imaging tests, number of blood transfusions, and overall satisfaction whether discharged to inpatient rehabilitation facilities (n=85) or to home (n=86) were assessed. A significantly greater proportion of patients discharged to inpatient rehabilitation facilities reported undergoing at least 1 diagnostic imaging test compared with patients discharged to home (25.9% vs 8.1%; P=.013). Multivariate logistic regressions revealed that patients discharged to an inpatient rehabilitation facility were more likely to have a greater number of diagnostic tests (odds ratio, 5.01; 95% confidence interval, 1.69-14.92; P=.004) and radiographs (odds ratio, 16.10; 95% confidence interval, 1.54-169.70; P=.020) performed. There was no significant difference in readmission rates for patients discharged to home (2.3%) vs to an inpatient rehabilitation facility (0%) (P=.246). No significant differences were observed in postoperative Knee Society pain or function scores (P=.083 and P=.057, respectively) or visual analog scale satisfaction scores (P=.206). Twenty-nine (34.1%) patients were discharged under the care of the visiting nurse service after leaving the rehabilitation facility. Patients discharged to an inpatient rehabilitation facility underwent more diagnostic testing, especially radiographs, than patients discharged to home. There were no clinically relevant differences in Knee Society pain or function scores or patient satisfaction. [Orthopedics. 2018; 41(6):e841-e847.]., (Copyright 2018, SLACK Incorporated.)

Background: The direct anterior approach (DAA) offers the potential for less soft tissue insult, improved early recovery, and reduced dislocation rates. However, complications are associated with the DAA, particularly during the learning curve. We compare the DAA learning curve experience with the posterior approach regarding in-hospital complications and revision rate., Methods: We evaluated systemic and local in-hospital complications associated with primary unilateral cementless THAs from January 1, 2010 to December 31, 2012 in 4249 patients through a posterior approach and 289 patients through a DAA. All procedures were performed consecutively by high-volume surgeons who use a single approach in a nonselective manner. The DAA was performed by surgeon transitioning from the posterior approach, thus incorporating the learning curve. Demographics were comparable. Revision procedures were captured through a minimum 4-year follow-up. Analyses compared complication and revision rates., Results: The DAA group demonstrated shorter length of stay, procedure time, lower blood transfusion rate, and increased discharge to home rate. Local and major systemic in-hospital complications were rare and comparable between groups. The minor systemic complication rate was significantly greater for the posterior group (10.9% posterior vs 6.2% DAA, P < .05). Revision rate was significantly greater for the posterior group (2.7% posterior vs 0.7% DAA, P < .032). The incidence of revision for dislocation was 1.5% for the posterior approach vs 0.4% for the DAA., Conclusion: There was an increased rate of in-hospital minor systemic complications and overall revision, predominantly due to instability, after THA by the posterior approach, in comparison with the DAA., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: As length of stay decreases for total joint arthroplasty, much of the patient preparation and teaching previously done in the hospital must be performed before surgery. However, the most effective form of preparation is unknown. This randomized trial evaluated the effect of a one-time, one-on-one preoperative physical therapy education session coupled with a web-based microsite (preopPTEd) on patients' readiness to discharge from physical therapy (PT), length of hospital stay, and patient-reported functional outcomes after total joint arthroplasty., Questions/purposes: Was this one-on-one preoperative PT education session coupled with a web- based microsite associated with (1) earlier achievement of readiness to discharge from PT; (2) a reduced hospital length of stay; and (3) improved WOMAC scores 4 to 6 weeks after surgery?, Methods: Between February and June 2015, 126 typical arthroplasty patients underwent unilateral TKA or THA. As per our institution's current guidelines, all patients attended a preoperative group education class taught by a multidisciplinary team comprising a nurse educator, social worker, and physical therapist. Patients were then randomized into two groups. One group (control; n = 63) received no further education after the group education class, whereas the intervention group (experimental; n = 63) received preopPTEd. The preopPTEd consisted of a one-time, one-on-one session with a physical therapist to learn and practice postoperative precautions, exercises, bed mobility, and ambulation with and negotiation of stairs. After this session, all patients in the preopPTEd group were given access to a lateralized, joint-specific microsite that provided detailed information regarding exercises, transfers, ambulation, and activities of daily living through videos, pictures, and text. Outcome measures assessed included readiness to discharge from PT, which was calculated by adding the number of postoperative inpatient PT visits patients had to meet PT milestones. Hospital length of stay (LOS) was assessed for hospital discharge criteria and 6-week WOMAC scores were gathered by study personnel. At our institution, to meet PT milestones for hospital discharge criteria, patients have to be able to (1) independently transfer in and out of bed, a chair, and a toilet seat; (2) independently ambulate approximately 150 feet; (3) independently negotiate stairs; and (4) be independent with a home exercise program and activities of daily living. Complete followup was available on 100% of control group patients and 100% patients in the intervention group for all three outcome measures (control and intervention of 63, respectively)., Results: The preopPTEd group had fewer postoperative inpatient PT visits (mean, 3.3; 95% confidence interval [CI], 3.0-3.6 versus 4.4; 95% CI, 4.1-4.7; p < 0.001) and achieved readiness to discharge from PT faster (mean, 1.6 days; 95% CI, 1.2-1.9 days versus 2.7 days; 95% CI, 2.4-3.0; p < 0.001) than the control group. There was no difference in hospital LOS between the preopPTEd group and the control group (2.4 days; 95% CI, 2.1-2.6; p = 0.082 versus 2.6 days; 95% CI, 2.4-2.8; p = 0.082). There were no clinically relevant differences in 6-week WOMAC scores between the two groups., Conclusions: Although this protocol resulted in improved readiness to discharge from PT, there was no effect on LOS or WOMAC scores at 6 weeks. Preoperative PT was successful in improving one of the contributors to LOS and by itself is insufficient to make a difference in LOS. This study highlights the need for improvement in other aspects of care to improve LOS., Level of Evidence: Level II, therapeutic study.

Purpose: The indications, incidence, outcomes, and survivorship of stems in primary total knee arthroplasty (TKA) are lacking in the contemporary literature. Our hypothesis is stems in primary TKA would result in worse outcomes and survivorship., Methods: All primary TKAs between 2007 and 2011 with 2-year follow-up were identified. Revision TKA or UKA conversion was excluded. Demographic information (age, sex, race, BMI, primary diagnosis, and Charlson-Deyo comorbidity index), outcome measures including KOOS and WOMAC, and any revisions were identified from the registry. A 2:1 matched cohort of non-stemmed/stemmed primary TKA patients was created to compare revision rates and outcomes at baseline and 2 years post-TKA. Subgroup analyses of long versus short stems, 1 versus 2 stems, and cemented versus hybrid stem fixation were completed. Two-sample t tests and Chi-square tests were used to compare conventional and stemmed TKA groups., Results: The registry review included 13,507 conventional TKA and 318 stemmed TKA resulting in an incidence of 2.3 % in primary TKA. The mean follow-up was approximately 49 months in both groups. No difference was found in revision rates between stemmed TKA (2.5 %) and conventional TKA (2.2 %). Patients with post-traumatic arthritis had an odds ratio of 10.5 (95 % CI 1.2-15.3) of receiving stems. Stem length did not affect revision rates. Patients with two stems had worse KOOS and WOMAC scores at baseline which equalized to single-stem patients at 2 years., Conclusions: The use of stems may provide a survival benefit in complex primary TKA over the short term and no adverse effect on patient outcomes or satisfaction., Level of Evidence: III.

Background: Management strategies for bilateral hip degenerative disease include same-day or staged bilateral total hip arthroplasty (THA), but information on outcomes remains sparse. We sought to describe in-hospital complications and blood transfusion rates after same-day and staged bilateral THAs at different time intervals and to assess risk factors for these events., Methods: We retrospectively reviewed administrative data for 3785 patients treated with same-day bilateral (n = 1946; group A) and staged bilateral THA within (1) 0-3 months apart (n = 328; group B); (2) 3-6 months apart (n = 703; group C); and (3) 6-12 months apart (n = 808; group D), between 1999 and 2014. We recorded demographics, the Charlson-Deyo comorbidity index and in-hospital local and systemic (minor and major) complications. Complication and blood transfusion rates among groups were compared. A logistic regression model was developed to identify risk factors for major complications., Results: Local complications were rare. Minor complications were less frequent in group A (P < .001). Major complications were more frequent in group D (P = .012). Group A had higher overall (P < .001) and allogeneic blood transfusion rates (P < .001) compared with the staged groups. Staged procedures within 6-12 months apart vs same-day bilateral THA, older age, Charlson-Deyo index ≥2 vs 0, and earlier vs recent admission year were associated with higher adjusted odds for major complications., Conclusion: Same-day bilateral THA in a high-volume joint replacement center may be a safe option for younger and healthier patients, given the relatively low incidence of adverse events reported in this study., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Duloxetine is effective for chronic musculoskeletal and neuropathic pain, but there are insufficient data to recommend the use of antidepressants for postoperative pain. The authors hypothesized that administration of duloxetine for 15 days would reduce pain with ambulation at 2 weeks after total knee arthroplasty., Methods: In this triple-blinded, randomized, placebo-controlled trial, patients received either duloxetine or placebo for 15 days, starting from the day of surgery. Patients also received a comprehensive multimodal analgesic regimen including neuraxial anesthesia, epidural analgesia, an adductor canal block, meloxicam, and oxycodone/acetaminophen as needed. The primary outcome was the pain score (0 to 10 numeric rating scale) with ambulation on postoperative day 14., Results: One hundred six patients were randomized and analyzed. On day 14, duloxetine had no effect on pain with ambulation; mean pain was 3.8 (SD, 2.3) for placebo versus 3.5 (SD, 2.1) for duloxetine (difference in means [95% CI], 0.4 [-0.5 to 1.2]; P = 0.386). Symptoms potentially attributable to duloxetine discontinuation at study drug completion (nausea, anxiety) occurred among nine patients (duloxetine) and five patients (placebo); this was not statistically significant (P = 0.247). Statistically significant secondary outcomes included opioid consumption (difference in mean milligram oral morphine equivalents [95% CI], 8.7 [3.3 to 14.1], P = 0.002 by generalized estimating equation) over the postoperative period and nausea on day 1 (P = 0.040). There was no difference in other side effects or in anxiety and depression scores., Conclusions: When included as a part of a multimodal analgesic regimen for knee arthroplasty, duloxetine does not reduce subacute pain with ambulation.

Objective: Outcomes of total hip arthroplasty (THA) in patients with psoriasis have been poorly studied. This study was undertaken to assess whether patients with psoriatic arthritis (PsA) or those with cutaneous psoriasis (PsC) without evidence of inflammatory joint disease are at an increased risk for worse outcomes after THA as compared to patients with osteoarthritis (OA)., Methods: Among subjects in a prospective THA registry, PsA and PsC cases were identified by International Classification of Diseases, Ninth Revision codes, and all cases were matched with patients with OA as controls. Analyses were performed to identify predictors of poor postoperative pain or function., Results: Of the 289 potential cases of PsA or PsC, 63 with PsA and 153 with PsC were validated. Self-report data were available postoperatively from 75% of PsA patients, 69% of PsC patients, and 94% of OA controls. In total, 51% of PsA patients and 56% of PsC patients were male, compared to 45% of OA controls (P = 0.04). Body mass index was higher in those with PsA or PsC (P = 0.002 versus controls). There were no differences in race or education between the 3 groups. PsA patients and PsC patients had more comorbidities than OA controls. PsA patients were more likely than PsC patients and OA controls to be current or previous smokers. Moreover, 54% of PsA patients were being treated with biologics or nonbiologic disease-modifying antirheumatic drugs, compared to 8% of PsC patients. There were no significant differences in pre- or postoperative Western Ontario and McMaster Universities OA Index scores for pain or function between the 3 groups. Short-Form 36 mental component summary scores were significantly better in the OA controls, both pre- and postoperatively (P = 0.006 and P < 0.001, respectively, versus PsA or PsC). EuroQol 5-domain health-related quality of life scores were significantly worse postoperatively for those with PsA or PsC (P < 0.0001 versus OA controls). In regression analyses, neither PsA nor PsC were risk factors for worse THA outcomes. Satisfaction with the outcomes of THA was similarly high among all 3 groups (P = 0.54)., Conclusion: Neither PsA nor PsC are risk factors for poor outcomes after THA. This is important information to convey to patients with either PsA or PsC who are contemplating surgical intervention with THA., (© 2016, American College of Rheumatology.)

Conflicting evidence has created substantial controversy regarding the use of continuous passive motion (CPM) in the in-patient setting post total knee arthroplasty (TKA). A total of 109 patients were randomly assigned to two groups, CPM or no CPM, applied after TKA. All patients received the same physical therapy protocol (3 sessions per day), with the only exception being the CPM. Both groups had a knee flexion of 115° at 6 weeks and 120° at 3 months, with no significant differences (P=0.69 and P=0.41, respectively). Length of stay was significantly less for the group who did not receive CPM. The use of CPM had no clinically relevant benefits with respect to AROM, clinical outcomes or discharge disposition and was associated with a cost of $235.50 per TKA., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: Historically, arthroplasty in systemic lupus erythematosus (SLE) patients has been less successful than for patients with osteoarthritis (OA). It is not known if SLE remains an independent risk factor for poor arthroplasty outcomes or if other factors, such as avascular necrosis (AVN), continue to play a role., Methods: A case-control study using data from a single-institution arthroplasty registry compared SLE total hip arthroplasty (THA) and total knee arthroplasty (TKA) with OA controls matched by age, gender and presence of AVN. Baseline, two-year administrative and self-report data, and diagnosis leading to arthroplasty were evaluated., Results: A total of 54 primary SLE THA and 45 primary SLE TKA were identified from May 2007 through June 2011. AVN was present in 32% of SLE THA and no TKA. SLE THA had worse preoperative WOMAC pain (42.5 vs. 52.7; p = 0.01) and function (38.8 vs. 48.0; p = 0.05) compared with OA. However, at two years there was no difference in WOMAC pain (91.1 vs. 92.1; p = 0.77) or WOMAC function (86.4 vs. 90.8; p = 0.28). SLE TKA were similar to OA in both preoperative pain (42.6 vs. 48.4; p = 0.14) and function (42.1 vs. 46.8; p = 0.30) and two-year pain (85.7 vs. 88.6; p = 0.50) and function (83.7 vs. 85.1; p = 0.23). Compared to OA, SLE THA and TKA patients had more renal failure (14% vs. 1%; p = 0.007) and hypertension (52% vs. 29%; p = 0.009). In a multivariate linear regression, SLE was not predictive of either poor pain or poor function., Conclusions: While SLE patients have more comorbidities than OA, and SLE THA have worse preoperative pain and function compared with OA controls, SLE was not an independent risk factor for poor short-term pain or function after either hip or knee arthroplasty., (© The Author(s) 2015.)

Background: Pregabalin may reduce postoperative pain and opioid use. Higher doses may be more effective, but may cause sedation and confusion. This prospective, randomized, blinded, placebo-controlled study tested the hypothesis that pregabalin reduces pain at 2 weeks after total knee arthroplasty, but increases drowsiness and confusion., Methods: Patients (30 per group) received capsules containing pregabalin (0, 50, 100, or 150 mg); two capsules before surgery, one capsule twice a day until postoperative day (POD) 14, one on POD15, and one on POD16. Multimodal analgesia included femoral nerve block, epidural analgesia, oxycodone-paracetamol, and meloxicam. The primary outcome was pain with flexion (POD14)., Results: Pregabalin did not reduce pain at rest, with ambulation, or with flexion at 2 weeks (P=0.69, 0.23, and 0.90, respectively). Pregabalin increased POD1 drowsiness (34.5, 37.9, 55.2, and 58.6% in the 0, 50, 100, and 150 mg arms, respectively; P=0.030), but did not increase confusion (0, 3.5, 0, and 3.5%, respectively; P=0.75). Pregabalin had no effect on acute or chronic pain, opioid consumption, or analgesic side-effects. Pregabalin reduced POD14 patient satisfaction [1-10 scale, median (first quartile, third quartile): 9 (8, 10), 8 (7, 10), 8 (5, 9), and 8 (6, 9.3), respectively; P=0.023). Protocol compliance was 63% by POD14 (50.0, 70.0, 76.7, and 56.7% compliance, respectively), with no effect of dose on compliance. Per-protocol analysis of compliant patients showed no effect of pregabalin on pain scores., Conclusions: Pregabalin had no beneficial effects, but increased sedation and decreased patient satisfaction. This study does not support routine perioperative pregabalin for total knee arthroplasty patients., Clinical Trial Registration: ClinicalTrials.gov: http://www.clinicaltrials.gov/ct2/show/study/NCT01333956., (© The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objective: Total hip replacement (THR) outcomes have been worse for patients with rheumatoid arthritis (RA) compared with those who have osteoarthritis (OA). Whether this remains true in contemporary patients with RA with a high use of disease-modifying and biologic therapy is unknown. The purpose of our study is to assess pain, function, and quality of life 2 years after primary THR, comparing patients with RA and patients with OA., Methods: Baseline and 2-year data were compared between validated patients with RA and patients with OA who were enrolled in a single-center THR registry between May 1, 2007, and February 25, 2011., Results: There were 5666 eligible primary THR identified, of which 193 were for RA. RA THR had worse baseline Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain (44.8 vs 53.2, p < 0.001) and function (38.7 vs 49.9, p < 0.001) compared with OA. These differences remained after surgery: pain (88.4 vs 94.0, p < 0.001) and function (82.9 vs 91.8, p < 0.001). Patients with RA were as likely to have a significant improvement as patients with OA (Δ WOMAC > 10) in pain (94% vs 96%, p = 0.35) and function (95% vs 94%, p = 0.69), but were 4 times as likely to have worse function (WOMAC ≤ 60; 19% vs 4%, p < 0.001) and pain (12% vs 3%, p < 0.001). In multivariate logistic regression controlling for multiple potential confounders, RA increased the odds of poor postoperative function (OR 4.32, 95% CI 1.57-11.9), and in patients without a previous primary THR, worse postoperative pain (OR 3.17, 95% CI 1.06-9.53)., Conclusion: Contemporary patients with RA have significant improvements in pain and function after THR, but higher proportions have worse 2-year pain and function. In addition, RA is an independent predictor of 2-year pain and poor function after THR, despite high use of disease-modifying therapy.

The purpose of this study was to compare the acetabular component alignment in patients undergoing primary total hip arthroplasty (THA) via 3 surgical techniques: direct anterior using intraoperative fluoroscopy, posterolateral using an external alignment guide (posterolateral conventional), and posterolateral using computer navigation (posterolateral navigated). Two surgeons performed the direct, anterior THAs; 2 surgeons performed the posterolateral-conventional THAs; and 1 surgeon performed the posterolateral-navigated THAs. The most recent 110 THAs performed using each approach were reviewed, and Einsel-Bild-Roentgen analysis software was used to measure the acetabular component abduction and anteversion. One-way analysis of variance showed the anterior cohort to have a more horizontal alignment of the acetabular component (P,.001); 90.9% of the acetabular components in the posterolateral- navigated cohort were within 40°610° and 15°610° for both acetabular abduction and anteversion, respectively, vs 70% in the posterolateral-conventional (P,.001), and 68.2% in the anterior cohort (P,.001). The anterior technique using intraoperative fluoroscopy does not improve acetabular positioning compared with the conventional, posterolateral technique.

Objective: The patterns and risks of perioperative use of anti-tumor necrosis factor (anti-TNF) medication in patients with rheumatoid arthritis (RA) are not well studied. We examined the patterns of perioperative anti-TNF use and risk of postoperative adverse events (AE) in patients undergoing total knee replacement (TKR)., Method: Retrospective cohort study with followup. RA cases within a TKR registry were identified by ICD-9 code (714.0) or self-report. Mailed questionnaires queried anti-TNF use and duration of RA. AE were determined by chart review and patient self-report, and included surgical site infection, pulmonary embolus, deep venous thrombosis, pneumonia, and any infection or re-operation within 6 months., Results: There were 268 TKR cases with RA. The stop time for anti-TNF preoperatively correlated with dosing schedule; restart time was after wound healing. There were 7 surgical site infections (3%), one (0.4%) of which was a deep joint infection in bilateral TKA requiring explant. The anti-TNF group had 3.26% (3/92) local site infection versus 2.10% (3/143) in the group without anti-TNF and this difference was not statistically significant (Fisher exact test, p = 0.68). The one deep joint infection was in the anti-TNF group. Six-month AE rate was 7.61% in the anti-TNF group versus 6.99% in the group without anti-TNF (Fisher exact test, p = 1.0)., Conclusion: There was a low risk of infection and perioperative adverse events in patients with RA receiving anti-TNF therapy who were undergoing TKR. This raises the question whether it is necessary to stop anti-TNF for a long period prior to surgery. Given the possible risks associated with stopping anti-TNF, including worsening of disease, further study is needed to determine optimal perioperative use of anti-TNF among patients with RA undergoing TKR.

Leg-length inequality after total hip arthroplasty (THA) is a source of patient morbidity and concern, potentially contributing to nerve palsies, low back pain, and abnormal gait mechanics. The purpose of this study was to compare the degrees of leg-length inequality in patients undergoing primary THA via 3 surgical approaches: anterior, conventional posterior, and posterior-navigated (ie, using computer navigation).The authors reviewed the most recent 90 patients who underwent primary unilateral THA performed by a senior surgeon using an anterior, conventional posterior, or posterior-navigated approach. Measurements of leg-length inequality of the operative extremity were performed using interischial and interteardrop reference lines. One-way analysis of variance demonstrated no statistical difference in postoperative absolute leg-length inequality using interischial (P=.11) and interteardrop (P=.90) reference lines between the 3 approaches. In addition, no significant difference existed in the number of outliers in each cohort when measured relative to the interteardrop reference line. When a leg-length inequality more than 5 mm was considered an outlier, 31.1%, 20.0%, and 23.3% of patients in the anterior, conventional posterior, and posterior-navigated groups, respectively, were outliers (P values range, .12 to .71). Mean±SD absolute-leg-length inequality relative to the interteardrop reference line in the anterior, conventional posterior, and posterior-navigated groups were 3.8±3.9, 3.9±3.0, and 3.9±2.7 mm, respectively. The anterior and posterior-navigated approaches demonstrated no superiority over the conventional posterior approach; all methods provided reliable leg-length equalization., (Copyright 2013, SLACK Incorporated.)

This study evaluated concordance between self-reports and surgeon assessments of short-term complications. A total of 3976 primary total hip arthroplasty patients consented for an institutional registry (5/2007-12/2008); 3186 (80.1%) completed a 6-month survey; 137 (4.4%) reported deep venous thrombosis, pulmonary embolism, major bleeding, fracture, or dislocation. Patients reporting complications were called. Positive predictive values and 95% confidence intervals (95% CI) for patient self-report were measured, using surgeon assessment for comparison: pulmonary embolism, 88.9% (95% CI, 78.4%-99.4%); dislocation, 81.1% (95% CI, 75.9%-86.5%); fracture, 73.7% (95% CI, 63.8%-83.5%); deep venous thrombosis, 69.7% (95% CI, 61.9%-77.5%); major bleeding, 32.0% (95% CI, 19.4%-44.5%); any bleeding, 88.0% (95% CI, 75.3%-99.9%). Of 97 confirmed complications, 64.95% presented to outside institutions. Registry data on self-reported complications may overcome limitations of traditional methods, but data should be interpreted cautiously. Concordance was high for PE and dislocation but low for major bleeding., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: Expectations of higher activity levels associated with hip resurfacing arthroplasty (HRA) may be driving better outcomes in this group compared to total hip arthroplasty (THA). Previous studies evaluated patient expectations before consulting with the surgeon, although these expectations were likely unrealistic and would change after the consultation. We compared HRA and THA patient expectations after consultation with the surgeon., Methods: In a prospective registry setting, patients awaiting HRA were matched to THA patients by age, sex, and a preoperative Lower Extremity Activity Scale score (range 1-18, with 18 indicating levels of highest activity). Patients completed preoperatively a validated 18-item expectations survey. Mean overall expectation scores were first compared. Exploratory factor analysis (EFA) was then performed to determine if the grouping of individual expectations items represented meaningfully different underlying factors in the 2 groups., Results: We matched 123 pairs. The mean ± SD expectation scores were similar (85.2 ± 15.5 for HRA and 87.3 ± 13.9 for THA; P = 0.249). The EFA showed that HRA and THA patients shared the common expectations of pain relief and improvement in daily activities (9 items) and eliminating pain medications, the need for a cane, and improving sexual activity (3 items). THA patients perceived the remaining 6 items as an overall third expectation of participation in higher-level activities. However, HRA patients perceived a fourth expectation of normal range of motion (2 items) independent of the other higher-level activities (4 items)., Conclusion: Even after consulting with a surgeon, patients' expectations differed between HRA and THA patients regarding higher-level activities. More counseling for patients seeking hip arthroplasty is therefore needed., (Copyright © 2011 by the American College of Rheumatology.)

Limited data exist regarding the long-term results of labral debridement and the effect of coexisting pathology on outcomes. Our hypothesis was that untreated coexisting hip pathologies such as femoroacetabular impingement and arthritis significantly affect the outcomes of arthroscopic labral debridement. Between 1996 and 2003, fifty consecutive patients who underwent hip arthroscopy and labral debridement with a mean follow-up of 8.4 years were included in our study. Patients' preoperative Harris Hip Scores and coexisting pathologies such as femoroacetabular impingement, dysplasia, or arthritis were recorded as variables. Postoperative Harris Hip Score and satisfaction at final follow-up were recorded as outcomes. Good or excellent results were achieved in 62% of cases (58% in patients with untreated femoroacetabular impingement and 19% in patients with arthritis). Failures included 2 cases that were converted to total hip replacement (4.5 and 5.2 years after index procedure) due to advancement of arthritis and 1 case of repeat arthroscopy for cam decompression. Patients with no coexisting pathology had significantly higher satisfaction and Harris Hip Scores. Almost all of the patients with low postoperative Harris Hip Scores had arthritic changes. Arthritis had a significant correlation with low postoperative Harris Hip Scores and satisfaction. Coexisting pathology, especially arthritis and untreated femoroacetabular impingement, can result in inferior outcomes. Arthroscopic labral debridement of symptomatic tears in selected patients with no coexisting pathology can result in favorable long-term results. Arthritis is the strongest independent predictor of poor outcomes., (Copyright 2011, SLACK Incorporated.)

Background: Standard mean imputation for missing values in the Western Ontario and Mc Master (WOMAC) Osteoarthritis Index limits the use of collected data and may lead to bias. Probability model-based imputation methods overcome such limitations but were never before applied to the WOMAC. In this study, we compare imputation results for the Expectation Maximization method (EM) and the mean imputation method for WOMAC in a cohort of total hip replacement patients., Methods: WOMAC data on a consecutive cohort of 2,062 patients scheduled for surgery were analyzed. Rates of missing values in each of the WOMAC items from this large cohort were used to create missing patterns in the subset of patients with complete data. EM and the WOMAC's method of imputation are then applied to fill the missing values. Summary score statistics for both methods are then described through box-plot and contrasted with the complete case (CC) analysis and the true score (TS). This process is repeated using a smaller sample size of 200 randomly drawn patients with higher missing rate (5 times the rates of missing values observed in the 2,062 patients capped at 45%)., Results: Rate of missing values per item ranged from 2.9% to 14.5% and 1,339 patients had complete data. Probability model-based EM imputed a score for all subjects while WOMAC's imputation method did not. Mean subscale scores were very similar for both imputation methods and were similar to the true score; however, the EM method results were more consistent with the TS after simulation. This difference became more pronounced as the number of items in a subscale increased and the sample size decreased., Conclusions: The EM method provides a better alternative to the WOMAC imputation method. The EM method is more accurate and imputes data to create a complete data set. These features are very valuable for patient-reported outcomes research in which resources are limited and the WOMAC score is used in a multivariate analysis.

A polyethylene-free, metal-on-metal acetabular system (M2a-taper [Biomet, Inc., Warsaw, IN]) was designed in an effort to improve total hip arthroplasty (THA) longevity. Minimum 2-year follow-up results involving 72 polyethylene liner THAs and 78 metal liner THAs from a multicenter, randomized, controlled, investigational device exemption study are reported. Mean Harris hip scores of 95.54 (polyethylene liner group) and 95.23 (metal liner group) were reported at mean follow-up intervals of 3.29 and 3.23 years. Radiographic evaluation revealed no evidence of early failure. No acetabular components have been revised or are pending revision. No statistically significant differences in the data were calculated between liner types except for the immediate postoperative (P=.0415) and minimum 2-year follow-up (P=.0341) angles of inclination. The M2a-taper metal-on-metal articulation may represent a viable alternative for THA in younger, higher demand patients.

Rheumatoid arthritis often affects multiple joints simultaneously with pain, deformity and loss of function. The indications for surgical treatment are presented along with guidelines for determining the surgical priorities along with guidelines for determining the surgical priorities when multiple joints require surgery.

Consideration of the individual, his or her needs, and what he or she hopes to gain through surgery is of primary importance in determining a surgical plan for the rheumatoid patient. Nevertheless, procedures undertaken to save life or prevent neurologic demise must, of course, take precedence. Alleviation of pain and correction of disabling deformity take next priority. Many other considerations go into the formulation of the list of surgical priorities. A full understanding of these considerations and a well-integrated team approach to the rheumatoid patient provide the best chance for optimal outcome following surgery.

Sixty-seven feet in forty-five patients who had rheumatoid arthritis were followed for an average of six years (range, four to ten years) after an operation on the forefoot that included resection of the metatarsophalangeal heads or joints and the insertion of a double-stemmed silicone-rubber implant in the first metatarsophalangeal joint. There were forty-two women and three men, and the average age at the time of the operation was fifty-six years (range, thirty-six to seventy-nine years). The mean duration of known rheumatoid arthritis was fifteen years (range, three to thirty-seven years). Resection of the metatarsophalangeal heads or joints was performed through a plantar approach in forty-one feet and a dorsal approach in twenty-six feet. A double-stemmed silicone-rubber implant was placed in the first metatarsophalangeal joint in all feet. Each patient was evaluated clinically and radiographically with use of a foot-scoring system that was developed for this study. The results were assessed for relief of pain, ability to walk (including the use of shoes), presence of calluses or deformity, and radiographic findings. The average preoperative foot score was 47 points; the score had improved to an average of 81 points at the latest follow-up examination. A good or excellent result was obtained in fifty-eight feet (87 per cent). Complications were infrequent. In three feet, there was delayed healing of the wound; three implants were removed because of dislocation and infection; and four feet had revision to correct deformities of the lesser toes.

Seventy-five uncemented porous-coated total hip prostheses were implanted in 64 patients. The results were reviewed after a mean follow-up period of 47 months (range, 40-64 months). The mean preoperative rating was fair, and the mean postoperative rating was excellent. There were six dislocations. Ten patients had mild thigh pain at one year; by two years, the pain had resolved in six patients. Neither moderate nor severe limp nor significant loosening of beads was observed. Only one patient had progressive radiolucent lines. The high rate of dislocation may be related to a compromise of acetabular position to obtain bony fixation in acetabula early in the series. The clinical results were encouraging.

Iliac crest and corresponding second vertebral body specimens were obtained from 20 cadavers. Of these, ten underwent histopathologic evaluation and histomorphometry in a blind fashion followed by statistical evaluation of the results. In this study, the authors found the iliac crest biopsy specimens to be highly correlated and predictive of osteoid and resorptive parameters in the spine and less so for trabecular bone volume. Whereas the transileal bone biopsy is a useful tool in diagnosing and typing metabolic bone disease, its predictive value of bone volume at other sites in the skeleton requires further evaluation.