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Type C bone, as described by Dorr, exhibits both cellular and structural compromise, which presents a challenge for fixation of a total hip arthroplasty (THA). We evaluated the performance of the Omnifit HA stem, a hydroxyapatite-coated titanium alloy stem, by retrospectively reviewing the clinical and radiographic data of 15 patients with femoral Type C bone who received the stem during primary THA between 1991 and 1994. The patients were followed a minimum of 9 years (mean, 11.5 years; range, 9-14 years). The average age at surgery was 54 years and the average body mass index was 28. Eight of the patients were men. The median Harris hip score was 94.5 points. Radiographically, two independent reviewers identified all patients as Type C bone. The average canal to calcar isthmus ratio was 0.74 (range, 0.65-0.95). At most recent followup, four patients demonstrated proximal osteolysis. Using plain radiography we detected no patients with distal osteolysis or subsidence. At 9 to 14 years, the stem has performed well in a selected series of patients with poor bone quality and the outcomes compare favorably with previously reported findings using this design of stem in other bone types. These results support the decision to use a hydroxyapatite-coated stem in patients with Type C bone. [ABSTRACT FROM AUTHOR]

Background: Tenuous blood supply carries a risk of wound-healing problems and subsequent infection following total knee arthroplasty (TKA). This risk may be increased by the presence of previous incisions. Performing a sham incision procedure allows for detection of wound-healing problems prior to performing TKA. The purpose of this retrospective case series is to describe the indications for and technique of a sham incision procedure in patients with previous knee incisions who underwent TKA following this procedure and to report the clinical outcomes observed in these patients following further surgery., Methods: Patients who had prior knee incisions, had undergone a sham incision prior to TKA, and had a minimum follow-up of 2 years were identified, and their cases were retrospectively reviewed. The identified cases typically adhered to the surgeon's standard protocol, which consisted of making a midline incision adventitious to TKA, dissecting down to deep fascia, and closing the wound with suture. Incisions were then observed for at least 4 weeks to determine the viability of the skin flaps before TKA was performed via the same incision., Results: A total of 47 knees in 47 patients were included in the study cohort. TKA was performed at an average of 21.1 weeks (range, 4 to 163 weeks) following the sham incision. There were no cases of skin necrosis or periprosthetic joint infection at an average follow-up of 4.6 years (range, 2 to 12 years) after sham incision. A total of 11 patients (23.4%) required manipulation under anesthesia for stiffness., Conclusions: In our series, no patients developed skin necrosis or periprosthetic joint infection following TKA subsequent to a sham incision procedure, suggesting that healed sham incisions are safe to use for TKA and may be considered prior to TKA in cases in which local previous incisions increase the risk of wound-healing problems., Level of Evidence: Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I212 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Failure due to trunnionosis with adverse local tissue reaction (ALTR) has been reported with cobalt-chrome (CoCr) heads in total hip arthroplasty (THA); however, there are limited data on the use of these heads in the revision setting. The purpose of this study was to analyze the outcomes of patients who underwent revision THA with a retained femoral component and received a CoCr femoral head on a used trunnion., Methods: In this retrospective review, we identified all patients who underwent revision THA with a retained femoral component and received a CoCr femoral head between February 2006 and March 2014. Demographic factors, implant details, and postoperative complications, including the need for repeat revisions, were recorded. In total, 107 patients were included (mean age 67 years, 74.0% women). Of the 107 patients, 24 (22.4%) required repeat revisions., Results: Patients who required repeat revision were younger than those who did not (mean age: 62.9 versus 69, P = .03). The most common indications for repeat revision were instability (8 of 24, 33.3%), ALTR (5 of 24, 20.8%), and infection (4 of 18, 16.7%). Evidence of ALTR or metallosis was identified at the time of reoperation in 10 of the 24 patients who underwent re-revision (41.7%)., Conclusions: The placement of a new CoCr femoral head on a used trunnion during revision THA with a retained femoral component carries a significant risk of complication (22.4%) and should be avoided when possible., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Despite the most recent American Academy of Orthopaedic Surgeons clinical practice guideline making a "strong" recommendation against the use of intraoperative navigation in total knee arthroplasty (TKA), its use is increasing. We utilized the concept of the reverse fragility index (RFI) to assess the strength of neutrality of the randomized controlled trials (RCTs) comparing the long-term survivorship of computer-navigated and conventional TKA., Methods: A systematic review was performed including all RCTs through August 3, 2021, comparing the long-term outcomes of computer-navigated and conventional TKA. Randomized trials with mean follow-up of >8 years and survivorship with revision as the end point were included. The RFI quantifies the strength of a study's neutrality by calculating the minimum number of events necessary to flip the result from nonsignificant to significant. The RFI at a threshold of p < 0.05 was calculated for each study reporting nonsignificant results. The reverse fragility quotient (RFQ) was calculated by dividing the RFI by the study sample size., Results: Ten clinical trials with 2,518 patients and 38 all-cause revisions were analyzed. All 10 studies reported nonsignificant results. The median RFI at the p < 0.05 threshold was 4, meaning that a median of 4 events would be needed to change the results from nonsignificant to significant. The median RFQ was 0.029, indicating that the nonsignificance of the results was contingent on only 2.9 events per 100 participants. The median loss to follow-up was 27 patients. In all studies, the number of patients lost to follow-up was greater than the RFI., Conclusions: The equipoise in long-term survivorship between computer-navigated and conventional TKA rests on fragile studies, as their statistical nonsignificance could be reversed by changing the outcome status of only a handful of patients--a number that was always smaller than the number lost to follow-up. Routine reporting of the RFI in trials with nonsignificant findings may provide readers with a measure of confidence in the neutrality of the results., Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/H302)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Peripheral nerve blocks improve both pain control and functional outcomes following total knee arthroplasty (TKA). However, few studies have examined the effects of different peripheral nerve block protocols on postoperative range of motion. The present study assessed the impact of a single-shot femoral nerve block (SFNB) versus continuous femoral nerve block (CFNB) on postoperative range of motion and the need for subsequent manipulation following TKA., Methods: We retrospective reviewed patient charts to identify patients who had undergone primary elective unilateral TKA by 2 surgeons at a high-volume orthopaedic specialty hospital over a 3-year period. A total of 1,091 patients received either SFNB or CFNB and were included in the data analysis. Identical surgical techniques, postoperative oral analgesic regimens, and rehabilitation protocols were used for all patients. Patients with <90° of flexion at 6 weeks postoperatively underwent closed manipulation under anesthesia (MUA)., Results: Overall, 608 patients (55.7%) received CFNB and 483 patients (44.3%) received SFNB. Overall, 94 patients (8.6%) required postoperative manipulation for stiffness, including 36 (5.9%) in the CFNB group and 58 (12%) in the SFNB group. The 50% reduction in the need for manipulation in the CFNB group was independent of primary surgeon (p > 0.05). No significant differences were observed between the groups in terms of postoperative range of motion, either at the time of discharge or at 6 weeks postoperatively. A history of knee surgery, decreased preoperative range of motion, and decreased range of motion at the time of discharge were significantly associated with the need for further MUA (p = 0.0002, p < 0.0001, and p < 0.0001, respectively)., Conclusions: Despite similar final postoperative range of motion between patients in both groups, our results suggest that CFNB may be superior to SFNB for reducing the need for postoperative manipulation after primary TKA. Furthermore, a history of ipsilateral knee surgery, decreased preoperative range of motion, and decreased range of motion at the time of discharge were identified as independent risk factors for postoperative stiffness requiring MUA after primary TKA., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2022 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Background: Periarticular injections (PAIs) and adductor canal blocks (ACBs) are widely accepted pain management strategies for total knee arthroplasty (TKA); however, the optimal anesthetic concentration to provide adequate pain relief while avoiding toxicity remains controversial. The purpose of this study is to evaluate the efficacy of different anesthetic concentrations for PAI alone and in combination with ACB., Methods: This retrospective cohort study of patients undergoing primary TKAs between January 2019 and November 2020 included 3 groups: 0.25% PAI (50 cc of 0.25% bupivacaine PAI diluted with 50 cc of saline and ketorolac), 0.5% PAI (50 cc of 0.5% bupivacaine with 50 cc of saline and ketorolac), and PAI + ACB (ultrasound-guided preoperative anesthesiologist-administered ACB and 0.25% PAI)., Results: In total, 368 TKAs were analyzed (123 0.25%, 132 0.5%, and 113 PAI + ACB). Total overall hospital narcotic usage in oral morphine equivalents (OME) was significantly lower for the 0.5% group (120.09 vs 165.26 and 175.75) compared to the 0.25% and PAI + ACB groups, respectively (P < .0001). Cumulative OME for the first 3 shifts was also lower for 0.5% (68.7 vs 83.7 and 76.4) compared to the 0.25% and PAI + ACB groups, respectively (P = .030). Total postoperative narcotics in OME were significantly lower for 0.5% (617.9 vs 825.2 and 1047.6) than 0.25% and PAI + ACB, respectively (P = .0003). Number of prescriptions within 6 weeks postoperatively were also significantly lower for 0.5% (1.7) than 0.25% (2.1) and PAI + ACB (2.4) (P = .0003)., Conclusion: Patients receiving 0.5% PAI had lower narcotic usage compared to 0.25% PAI or PAI + ACB. ACB may be eliminated without compromising pain control if the dose of local anesthetic in the PAI is sufficiently high., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Intraoperative fracture of the proximal tibia is a rare complication of total knee arthroplasty (TKA) with few studies available reporting risk factors or prognosis. A review of our prospective joint registry was performed to determine the incidence and associated risk factors of intraoperative tibia fractures during primary TKA; 14,966 TKAs of all manufacturers were performed with 9 intraoperative tibia fractures. All fractures occurred in a single TKA design. There were 8,155 TKAs of this design performed with a fracture incidence of 0.110%. All but one fracture occurred on the medial tibial plateau, and all but one occurred during preparation of the tibia with keel punching. A control group of 75 patients (80 knees) with the same TKA design were randomly selected. Baseplates size 3 or smaller were less likely to experience an intraoperative fracture (odds ratio [OR]: 0.864, 95% confidence interval [CI]: 0.785-0.951), as were knees with a polyethylene insert thickness of 13 mm or larger (OR: 0.882, 95% CI: 0.812-0.957). Fractures were treated with a variety of different methods, but every patient had at least one screw placed and most (67%) had postoperative weight-bearing restrictions. At final follow-up, there were no cases of nonunion, component subsidence, or need for reoperation. Intraoperative tibia fractures are a rare complication of this TKA design at 0.11%. Knees with baseplates of size ≤3 and polyethylene thickness ≥13 mm were less likely to experience intraoperative fracture. These findings may be related to the depth of tibial resection, requiring the use of a thicker polyethylene insert, and a change in the keel width in implants size 4 or larger. No fracture patients required reoperation., Competing Interests: J.V.B. reports personal fees from Stryker, outside the submitted work., (Thieme. All rights reserved.)

There is abundant data concerning morphological dimensions of the distal femur, particularly in women, which has led to redesign of the femoral component in total knee arthroplasty (TKA). Clinical experience reveals existing asymmetry of the femoral posterior condyles, yet current implant designs have a symmetrical femoral component. The objectives of this study were to analyze the dimensions of posterior condylar bone resection from a group of patients undergoing TKA and correlate the measurements to one prosthetic system. We retrospectively reviewed single surgeon morphological data from the posterior condyles of 105 knees during TKA. The study included 54 males and 51 females. Measurement of the posterior condylar bones was performed with a standard metric metal ruler by one investigator. Known dimensions of a single type of implant design were compared with the resection data. The average difference of posterior medial and lateral condylar width was 5.7 and 5.3 mm in males and females, respectively. The average host posterolateral condylar bone was 5.4 mm less than the trial implant across five sizes in both males and females. Results suggest that the dimension of the posterior lateral condyle is much smaller than the dimension of the implant in both groups of patients. Dimension of the posterior medial is close to dimension of the implant. Overhang of the component posterolaterally can create soft tissue irritation and result in postoperative pain and decreased range of motion. Our results increase awareness of the dimensions of the native posterolateral condyle and may influence future design of femoral implants used in total knee arthroplasty., Competing Interests: J.V.B. reports personal fees from Stryker, outside the submitted work., (Thieme. All rights reserved.)

Stiffness following total knee arthroplasty (TKA) is a common complication that can result in unsatisfactory outcomes. Manipulation under anesthesia (MUA) has been widely employed to treat this problem. It is uncertain whether an association exists between range of motion (ROM) at discharge and need for MUA following primary TKA.A retrospective review of an institutional joint registry identified cases of primary TKA performed by three surgeons at a single institution over a 22-month period. A logistic regression model was used to examine the association between ROM at discharge and subsequent MUA controlling for confounding variables related to patient demographics and perioperative details. Of the 1,546 cases identified, 113 (7.3%) cases underwent subsequent MUA. As discharge ROM increased, manipulation rates decreased. Patients with discharge flexion <65 degrees were more likely to undergo MUA than those with flexion >90 degrees (odds ratio [OR] = 17.57, 95% confidence interval [CI] [7.97, 38.73], p  < 0.0001). The largest differential in odds of MUA was observed between the <65 degrees at discharge group (OR = 17.57) and the 65 ≤ 75 degrees at discharge group (OR = 7.89). At discharge ROM of 80 ≤ 90 degrees of flexion, patients had more than a twofold increase in odds of MUA relative to those in the >90 degrees group (OR = 2.22, 95% CI [1.20, 4.10], p  = 0.011). The results of this study suggest that there is an association between lower ROM at discharge and greater risk of MUA post primary TKA. Counseling patients in regard to discharge ROM and associated risk of MUA may optimize gains in ROM during recovery., Competing Interests: J. V. B. reports receiving of royalties from Stryker, Springer Verlag, and Sectra., (Thieme. All rights reserved.)

Total knee arthroplasty (TKA) in patients with peripheral vascular disease has sparsely been studied. This study examined patient and radiographic factors that could affect reoperation free survival in these patients. We retrospectively reviewed TKA procedures performed in patients with nonpalpable pulses on physical examination between January 1, 2004, and December 31, 2013. Ninety-two cases met inclusion criteria. Preoperative ankle-brachial index (ABI), date of surgery, sex, age, body mass index (BMI), tourniquet use, American Society of Anesthesiologists (ASA) score, presence of preoperative calcifications, and follow-up data were obtained. Failure was defined as reoperation. Patients were included if they experienced a failure or had at least 2 years of follow-up. Reoperation free survival was calculated by Kaplan-Meier's analysis. Odds ratios (ORs) were calculated for patient factors; hazard ratios (HRs) were calculated by Cox's regression analysis. Ninety-two TKAs were included in the study. Mean age was 68.8 years, mean BMI was 32.15, and mean ASA score was 2.44. Tourniquet was used in 78 patients. Mean preoperative ABI was 1.016. Nine patients had calcifications on X-ray prior to surgery. Reoperation free survival was 9.378 years. Patients with a preoperative ABI of below 0.7 had shorter reoperation free survival (ABI <0.7, 6.854 years; ABI >0.7, 9.535 years; p  = 0.015). Patients with a preoperative ABI below 0.7 had greater odds of failure and were at higher risk for earlier failure (OR = 6.5, p  = 0.027; HR = 1.678, p  = 0.045). When corrected for age, sex, and BMI, the HR for patients with a preoperative ABI below 0.7 worsened (HR = 1.913, p  = 0.035) compared with those with an ABI above 0.7. The remaining patient factors produced no statistically significant differences in survivorship, odds of failure, or HRs. No patient factors were associated with increased risk of mortality. These results suggest that patients who undergo TKA with an ABI below 0.7 are at increased risk for reoperation and have shorter reoperation free survival., Competing Interests: None declared., (Thieme. All rights reserved.)

Ileus following total knee arthroplasty is a clinically and financially significant postoperative complication that has not been extensively described in the orthopaedic joint literature. Ileus has been found to occur in 0.7 to 4.0% of patients after total joint arthroplasty. In a 17-year period (2001 fiscal year through 2017 fiscal year) at one institution, we found an incidence of 0.500% (190/38,007) following knee arthroplasty. In addition, the incidence of ileus following total knee arthroplasty (TKA) has drastically declined over this 17-year period, from 1.593% (13/816) in 2001 to 0.120% (4/3,332) in 2017. This decrease may be attributed to a reduction in narcotic use postoperatively, earlier ambulation following surgery, and reduction in length of hospital stay. Though postoperative ileus is not yet a preventable complication, recognition of risk factors may permit earlier intervention to ameliorate some of the morbidity associated with this condition., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Dual-modular femoral components with exchangeable cobalt-chrome neck segments have had higher than expected failure rates due to corrosion and adverse local tissue reaction (ALTR). Complications, survival rates and early clinical outcomes of revision surgery for the treatment of corrosion and ALTR as a result of these implants are underreported., Methods: We identified 44 cases of revision THA for corrosion and ALTR resulting from the same dual modular stem. All revision procedures were performed using a modular tapered fluted titanium stem, ceramic heads and highly cross-linked polyethylene., Results: Complications included: dislocation, infection, reoperation, and chronic pain. Mean Harris Hip Score was 84 following revision surgery., Conclusions: Patients undergoing revision surgery for ALTR related to this prosthesis should be aware of the risk of postoperative dislocation and other complications and the potential long-term risk of some chronic pain.

While femoral intramedullary alignment has been found to be the most accurate and reproducible method for proper femoral component orientation in total knee arthroplasty, certain situations preclude the use of intramedullary alignment, such as ipsilateral long-stem total hip arthroplasty, femoral shaft deformity (congenital or post-traumatic), capacious femoral canal, and retained hardware. These cases require alternative alignment guides, that is, extramedullary alignment. The purpose of this study was to determine the accuracy of intramedullary alignment in reproducing the femoral anatomic axis. Using 35 adult cadaveric femora without obvious clinical deformity, and 7 with proximal prosthetic devices blocking the passage of an intramedullary guide, the accuracy of the guide rod was assessed both anatomically and radiographically. In the seven femora with proximal femoral devices, the guide rod could not be completely seated, resulting in a greater degree of flexion of the guide rod compared with the mechanical axis of the femur, and a greater degree of varus compared with the anatomical axis, as compared with 35 femora without obvious deformity. In cases where seating of the intramedullary guide rod is either incomplete or impossible, extramedullary femoral guides allow more accurate determination of the distal femoral cut by referencing directly from the mechanical axis, that is, the center of the femoral head. We present case studies as examples of indications for use of an extramedullary femoral guide. In addition, we demonstrate two different techniques for extramedullary femoral alignment using fluoroscopic guidance in cases incompatible with intramedullary alignment., Competing Interests: Dr. Carangelo reports personal fees from Smith and Nephew, outside the submitted work. Dr. James Bono reports personal fees from Stryker, personal fees from Springer, personal fees from Sectra, outside the submitted work. Dr. Olcott, Dr. Jamison, Dr. Tigges, Dr. Talmo, and Olivia Bono have nothing to disclose., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Total knee arthroplasty (TKA) is one of the most highly successful orthopaedic procedures performed in North America. It is also one of the most common procedures performed, and its incidence continues to increase. Despite this, it is the opinion of many that patients of advanced age groups are not ideal candidates to undergo such procedures secondary to the concern over higher complication rates and poorer functional outcomes. This review article attempts to analyze the current body of literature concerning TKA outcomes and to evaluate some of the issues that are more specific to this population when they undergo TKA. It is our hypothesis that the literature does not support this popular misconception, and that older patients who do not have significant medical comorbidities are good candidates to undergo primary TKA. However, certain cohorts of this population are not ideal candidates to undergo this procedure. Also, certain joint reconstructive procedures, such as simultaneous and staged bilateral TKA, are higher risk procedures in this patient cohort., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Careful surgical technique is a critical component of total hip arthroplasty. Femoral preparation and component positioning are vital to improving outcomes and preventing complications. Femoral preparation begins with creating an entry hole in the proximal femur. Various tools have been used for this purpose which resemble a "cookie cutter." An axial starter reamer, or awl, is then inserted through the entry hole in the proximal femur to aid in opening and centralizing the canal for sequential reaming or broaching. A novel technique was described previously which allows the awl to center itself in the canal with little risk of deviation from midline or cortical perforation. Since describing this technique in 2014, the senior surgeon has further modified the method of preparing the entry hole in the proximal femur. The surgeon now uses a 1/8" drill bit to penetrate the piriformis fossa, instead of a "cookie cutter" or osteotome. A 1/8" entry hole eliminates gaps between the bone and the implant, results in lateralization of the stem, and avoids varus malposition. We evaluated 300 primary hip arthroplasties by a single surgeon using one of the three techniques: traditional clockwise technique (Group 1), our previously published novel counterclockwise technique (Group 2), and our updated novel technique (Group 3). While the deviation from midline of Group 3 did not differ significantly from Group 2, it was significantly less than the deviation from midline of Group 1 (p=00006). This simple updated technique enables the surgeon to avoid potential malalignment during femoral preparation.

During cruciate retaining (CR) total knee arthroplasty (TKA), the posterior cruciate ligament (PCL) may avulse at its insertion. The incidence of PCL avulsion fracture has not been previously studied. The aim of this study is to report on the incidence and clinical significance of intraoperative PCL avulsion during primary CR TKA and to identify potential risk factors. Our institutional joint registry was retrospectively reviewed for PCL avulsion occurring during CR TKA implanted between April 2008 and April 2016. Patient demographics, preoperative range of motion (ROM), complications, and revision rate were examined. A control group of 132 patients was used for comparison to identify potential risk factors. Forty-four of 2,457 patients (1.7%) suffered a PCL avulsion fracture during primary CR TKA. No intraoperative repair was performed and no postoperative weight bearing or ROM restrictions were implemented. There was no significant difference in BMI ( p  = 0.258), mean preoperative ROM ( p  = 0.763), or femoral and tibial component sizes ( p  = 0.3069, p  = 0.1306) between groups. Logistic regression found female gender ( p  = 0.0254) to be the only statistically significant risk factor for PCL avulsion. The incidence of intraoperative PCL avulsion fracture during CR TKA is low (1.7%) and does not appear to affect postoperative ROM, subjective stability, or incidence of revision. Female gender was identified as the only patient factor that increased the risk of PCL avulsion fracture., Competing Interests: Dr. James Bono reports personal fees from Stryker, personal fees from Springer, personal fees from Sectra, outside the submitted work. Marie Anderson, Olivia Bono, Dr. Kim and Dr. Talmo report no conflict of interest., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Stiffness after total knee arthroplasty (TKA) is often treated with manipulation under anesthesia (MUA) to improve range of motion (ROM). However, many authors recommend against MUA beyond 3 months after TKA. This study investigates the timing of MUA for stiffness after TKA, focusing on MUA performed at >12 weeks., Methods: In total, 142 MUAs were retrospectively reviewed. "Early" MUAs were at <12 weeks after TKA; "Late" MUAs were >12 weeks. MUAs were further subdivided into 4 groups: 83 "Group I" cases at <12 weeks, 34 "Group II" between 12 and 26 weeks, 12 "Group III" between 26 and 52 weeks, and 13 "Group IV" at >52 weeks. Gains in ROM were compared between groups., Results: Gains in flexion and overall ROM were statistically equivalent in Early vs Late MUA when controlling for pre-MUA ROM. ROM gains between the early Group I and the later Groups II-IV were also statistically comparable. Overall ROM gain in Group I was 24.1°, 17.9° in Group II, 20.8° in Group III, and 11.1° in Group IV. There were no significant complications., Conclusions: Early and late MUA resulted in statistically equivalent gains in ROM, regardless of timing after TKA. All groups showed an average improvement in ROM of ≥11°. MUA performed beyond 3 months, and even beyond 1 year, appears to be safe and may improve ROM and allow select patients to avoid revision surgery., (© 2019 Published by Elsevier Inc. on behalf of The American Association of Hip and Knee Surgeons.)

Background: Leg pain associated with walking is sometimes incorrectly attributed to hip osteoarthritis (OA) or lumbar spinal stenosis (LSS)., Purpose: This study compared physicians' values of signs and symptoms for diagnosing and differentiating hip OA and LSS to their clinical utility., Study Design/setting: Musculoskeletal physicians were surveyed with online questionnaires. Patients were recruited from hip and spine specialty practices., Patient Sample: Seventy-seven hip OA and 79 LSS patients., Outcome Measures: Signs and symptoms of hip OA and LSS., Methods: Fifty-one of 66 invited musculoskeletal physicians completed online surveys about the values of 83 signs and symptoms for diagnosing hip OA and LSS. Of these, the most valued 32 symptoms and 13 physical examination items were applied to patients with symptomatic hip OA or LSS. Positive likelihood ratios (+LR) were calculated for each items' ability to differentiate hip OA from LSS, with a +LR>2 set as indicating usefulness for favoring either diagnosis. Positive LRs were compared with surveyed physicians' values for each test., Results: All symptoms were reported by some patients with each diagnosis. Only 11 of 32 physician-valued symptoms were useful for discriminating hip OA from LSS. Eight symptoms favored hip OA over LSS: groin pain (+LR=4.9); knee pain (+LR=2.2); pain that decreased with continued walking (+LR=3.9); pain that occurs immediately with walking (+LR=2.4); pain that occurs immediately with standing (+LR=2.1); pain getting in/out of a car (+LR=3.3); pain with dressing the symptomatic leg (+LR=3.1); and difficulty reaching the foot of the symptomatic leg while dressing (+LR=2.3). Three symptoms favored LSS over hip OA: pain below the knee (+LR=2.3); leg tingling and/or numbness (+LR=2.7); and some pain in both legs (+LR=2.5). Notable symptoms that did not discriminate hip OA from LSS included: pain is less while pushing a shopping cart (+LR=1.0); back pain (+LR=1.1); weakness and/or heaviness of leg (+LR=1.1); buttocks pain (+LR=1.2); poor balance or unsteadiness (+LR=1.2); pain that increased with weight-bearing on the painful leg (+LR=1.3), and step to gait on stairs (+LR=1.7). Consistent with physicians' expectations, 7 of 13 physical examination items strongly favored hip OA over LSS: limited weight-bearing on painful leg when standing (+LR=10); observed limp (+LR=9); and painful and restricted range-of-motion with any of five hip maneuvers (+LR range 21-99). Four of five tested neurological deficits (+LR range 3-8) favored the diagnosis of LSS over hip OA., Conclusions: There is substantial crossover of symptoms between hip OA and LSS, with some physician-valued symptoms useful for differentiating these disorders whereas others were not. Physicians recognize the value of the examination of gait, the hip, and lower extremity neurological function for differentiating hip OA from LSS. These tests should be routinely performed on all patients for which either diagnosis is considered. Awareness of these findings might reduce diagnostic errors., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Successful joint replacement surgery requires precise preoperative planning and intraoperative placement of implants such that the function of the joint is optimized biomechanically and biologically. The five-step "pelvic tilt algorithm" will enhance the outcome of hip replacement surgery as a result of improved acetabular component alignment. It will solve the problem of pelvic tilt as an unknown variable during hip replacement surgery, and will allow for more consistent and accurate acetabular component placement.

Background: Surgical technique in total hip arthroplasty (THA) has been a topic of debate over the last 50 years. Evidence-based studies are needed to compare one technique to another. This study investigated the outcome of the direct superior approach in primary THA as measured by patient perception of pain and recovery over a 16-year period., Materials and Methods: We retrospectively reviewed a series of 3,357 consecutive patients who underwent primary THA by a single surgeon using the direct superior approach between 2001 and 2017. The surgical technique was modified twice during this 16-year period. The first modification (2007) consisted of piriformis tendon preservation. The second modification (2012) consisted of iliotibial band (ITB) preservation. These two modifications of the surgical technique created three different patient groups. A telephone interview regarding patient pain and recovery after each THA was conducted with 147 patients who had staged bilateral THA procedures wherein the surgical technique was modified between the first and second (contralateral) THA., Results: Results show the addition of ITB preservation to capsular repair, with or without piriformis preservation, greatly improves the patient's perception of pain and recovery, causing the majority of patients to prefer their ITB-preserving surgery over their ITB-sacrificing surgery. In addition, the dislocation rate over this 16-year period is 0.17%., Conclusion: The direct superior approach to the hip results in excellent stability with a dislocation rate of 0.17%. The patient's perception of pain and recovery is dramatically improved with preservation of the iliotibial band.

Introduction: Few studies have evaluated the concomitant effect of both total knee arthroplasty (TKA) limb alignment and ligament laxity. Therefore, the primary aim of this study is to evaluate the impact of lower extremity alignment on the short-term outcome (one year) following TKA, including pain relief, function, and patient satisfaction. The secondary aim of the study is to evaluate the impact of ligament laxity and balance on early outcomes following TKA., Materials and Methods: A prospective evaluation of mechanical alignment and ligament tension was performed for 110 consecutive TKAs using an identical surgical technique. Patients were evaluated with knee society score, visual analog pain score, and satisfaction one year following TKA. Linear regression analysis was then performed to determine the effect of lower extremity alignment and ligament laxity., Results: There was no significant relationship between lower extremity alignment and outcome measures. A significant relationship was identified between medial collateral laxity in full extension and knee society scores for function, but not for pain. There was also a significant relationship identified between lateral knee laxity at 90 degrees of flexion and knee society score and pain at one-year follow up., Conclusion: Our results demonstrated no correlation between mechanical alignment restoration and pain or function. However, more interestingly, this study found patients with medial laxity in extension and lateral laxity in knee flexion, similar to normal physiologic knee laxity, to have less pain and greater function and satisfaction at one-year short-term follow up.

New onset postoperative atrial fibrillation (AF) is the most common perioperative arrhythmia in the elderly. The incidence after total joint arthroplasty is much lower than other non-cardiac surgeries. Since postoperative atrial fibrillation can cause increased length of hospital stay, mortality, and healthcare costs, it is critical to focus on prevention and prompt management. New onset atrial fibrillation is treated with rhythm control for patients who demonstrate hemodynamic instability or refractory to rate control measures. Electrical cardioversion is an effective option for unstable patients with known complications. However, there is limited data on orthopedic problems after cardioversion. A unique case is reported presenting postoperative total hip arthroplasty (THA) dislocation after electrical cardioversion for new onset atrial fibrillation in the postanesthesia care unit (PACU).

Background: Intraoperative femur fracture (IFF) is a well-known complication in primary uncemented total hip arthroplasty (THA). Variations in implant instrumentation design and operative technique may influence the risk of IFF. This study investigates IFF between a standard uncemented tapered-wedge femoral stem and its second-generation successor with the following design changes: size-specific medial curvature, proportional incremental stem growth, modest reduction in stem length, and distal lateral relief., Methods: A single experienced surgeon's patient database was retrospectively queried for IFF occurring during primary uncemented THA using a standard tapered-wedge femoral stem system or a second-generation stem. All procedures were performed using soft tissue preserving anatomic capsule repair and posterior approach. The primary outcome measure was IFF. A z-test of proportions was performed to determine significant difference between the 2 stems with respect to IFF. Patient demographics, Dorr classification, and implant characteristics were also examined., Results: Forty-one of 1510 patients (2.72%) who received a standard tapered-wedge femoral stem sustained an IFF, whereas 5 of 800 patients (0.63%) using the second-generation stem incurred an IFF. No other significant associations were found., Conclusion: A standard tapered-wedge femoral stem instrumentation system resulted in greater than 4 times higher incidence of IFF than its second-generation successor used for primary uncemented THA. Identifying risk factors for IFF is necessary to facilitate implant system improvements and thus maximize patient outcomes., (Copyright © 2017. Published by Elsevier Inc.)

Intraoperative acetabular fracture (IAF) is a rare complication of primary total hip arthroplasty (THA). Known risk factors include poor bone stock, underreaming of the acetabular bed, and use of elliptic components. There is a paucity of literature on risk factors, treatment strategies, and outcomes of this potentially devastating complication. We studied the incidence of IAF in primary THA at our high-volume institution. We reviewed 21,519 primary THA cases and identified 16 patients (16 hips) with IAFs. Mean follow-up was 4 years (range, 0-10 years). Implant data were recorded, and acetabular components were identified as elliptic modular or hemispheric modular. The institution's IAF rate was 0.0007%. All IAFs were associated with uncemented acetabular components. Sixty-nine percent of the fractures were not appreciated during surgery. All posterior column fractures required operative intervention in the immediate or early (<3 months) postoperative period. Compared with anterior column fractures, posterior column fractures were associated with acetabular component instability and need for additional surgery. In this article, we also present strategies for managing and preventing IAF in primary THA. This rare fracture requires prompt recognition and often necessitates aggressive management. More study is needed to determine how to better manage IAFs., Competing Interests: Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.

Background: Deep vein thrombosis (DVT) and pulmonary emboli (PE), known together as venous thromboembolic (VTE) disease remain major complications following elective hip and knee surgery. This study compares three chemoprophylactic regimens for VTE following elective primary unilateral hip or knee replacement, one of which was designed to minimize risk of post-operative bleeding., Methods: Patients were randomized and stratified for hip vs. knee to receive A: variable dose warfarin (first dose on the night preceding surgery with subsequent target INR 2.0-2.5), B: 2.5 mg fondaparinux daily starting 6-18 h postoperatively, or C: fixed 1.0 mg dose warfarin daily starting 7 days preoperatively. All treatments continued until bilateral leg venous ultrasound day 28 ± 2 or earlier upon a VTE event. The study examined primary endpoints including leg DVT, PE or death due to VTE and secondary endpoints including effects on D-dimer, estimated blood loss (EBL) at surgery and hemorrhagic complications., Results: Three hundred fifty-five patients were randomized. None was lost to follow-up. Taking 1.0 mg warfarin for seven days preoperatively did not prolong the prothrombin time (PT). Two patients in Arm C had asymptomatic distal DVT. One major bleed occurred in Arm B and one in Arm C (ischemic colitis). Elevated d-dimer did not predict delayed VTE for one year., Conclusions: Fixed low dose warfarin started preoperatively is equivalent to two other standards of care under study (95 % CI: -0.0428, 0.0067 for both) as VTE prophylaxis for the patients having elective major joint replacement surgery., Trial Registration: ClinicalTrials.gov identifier # NCT00767559 FDA IND: 103,716.

Modular neck stems allow for optimization of joint biomechanics by restoring anteversion, offset, and limb length. A potential disadvantage is the generation of metal ions from fretting and crevice corrosion. We identified 118 total hip arthroplasty implanted with one type of dual-modular femoral component. Thirty-six required revision due to adverse local tissue reaction. Multivariate analysis isolated females and low offset necks as risk factors for failure. Kaplan-Meir analysis revealed small stem sizes failed at a higher rate during early follow-up period. Although the cobalt/chrome levels were higher in the failed group, these tests had low diagnostic accuracy for ALTR, while MRI scan was more sensitive. We conclude that the complications related to the use of dual modular stems of this design outweigh the potential benefits., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Unfavorable outcomes from trunnion fretting and corrosion damage have been reported in the literature, gross failures of tapers in primary total hip arthroplasties have been less frequently reported. We report on 5 patients, who presented with gross trunnion failures of modular metal-on-polyethylene or ceramic-on-polyethylene bearings from 5 implant manufacturers, all necessitating revision surgery. None of these patients had an antecedent history of trauma, and the majority presented with pain or instability. No common factor was identified that may be predictive of these type of failures. Since there were 5 different stem designs, this suggests that it may be a rare generic phenomenon occurring with multiple designs. Currently, further investigations are necessary, including retrieval analysis, to identify risk factors that may predispose to such failures., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Acetate templating for total hip arthroplasty (THA) is cumbersome and inaccurate. High cost hampers mainstream use of digital templating despite ease of use and accuracy. The aim of this study was to validate a low-cost digital THA templating system. Low-cost digital templating software was created using C# programming language. On the basis of power calculations, three surgeons templated 20 consecutive anteroposterior pelvis X-rays using this software against an industry standard. Intraclass correlation coefficient for both systems was approximately .90 for component size and femoral neck cut position. Bland-Altman plots demonstrated that both systems predicted actual implant size with similar accuracy. Interrater reliability was not significantly different between the two systems. This low-cost digital THA templating system is up to 12-fold lower in cost than currently available software with similar accuracy.

Careful surgical technique is a critical component of total hip arthroplasty. Femoral preparation and component positioning are vital to improving outcomes and preventing complications. Using the starting awl when preparing the femur aids in opening and centralizing the canal for sequential reaming or broaching. Although traditional techniques can lead to a deviation from midline, a novel technique allows the awl to center itself in the canal with little risk for cortical perforation. We evaluated 200 patients whose surgeries were performed by a single surgeon using the traditional technique (group 1) or a novel technique (group 2) and found a statistically significant difference in mean deviation from midline. In group 2, the mean deviation was 0.34°; in group 1, the mean deviation was 0.85°. Our novel technique provides a safe, easily reproducible approach to using the starter awl in femoral preparation.

Modular femoral heads have been used successfully for many years in total hip arthroplasty. Few complications have been reported for the modular Morse taper connection between the femoral head and trunnion of the stem in metal-on-polyethylene bearings. Although there has always been some concern over the potential for fretting, corrosion, and generation of particulate debris at the modular junction, this was not considered a significant clinical problem. More recently, concern has increased because fretting and corrosive debris have resulted in rare cases of pain, adverse local tissue reaction, pseudotumor, and osteolysis. Larger femoral heads, which have gained popularity in total hip arthroplasty, are suspected to increase the potential for local and systemic complications of fretting, corrosion, and generation of metal ions because of greater torque at the modular junction. A less common complication is dissociation of the modular femoral heads. Morse taper dissociation has been reported in the literature, mainly in association with a traumatic event, such as closed reduction of a dislocation or fatigue fracture of the femoral neck of a prosthesis. This report describes 3 cases of spontaneous dissociation of the modular prosthetic femoral head from the trunnion of the same tapered titanium stem because of fretting and wear of the Morse taper in a metal-on-polyethylene bearing. Continued clinical and scientific research on Morse taper junctions is warranted to identify and prioritize implant and surgical factors that lead to this and other types of trunnion failure to minimize complications associated with Morse taper junctions as hip implants and surgical techniques continue to evolve., (Copyright 2014, SLACK Incorporated.)

Since its debut over 10 years ago, minimally invasive total hip arthroplasty (THA) has often been associated with accelerated postoperative rehabilitation when compared with THA performed with a traditional surgical approach. The objective of this study was to investigate the effect of accelerated postoperative rehabilitation and early mobilization on length of stay and hospital readmissions in patients undergoing THA at one institution. We retrospectively reviewed a consecutive series of 590 patients who underwent THA between January 31, 2011 and April 30, 2011. Six arthroplasty surgeons using varying surgical techniques participated. One hundred ninety patients received accelerated rehabilitation and were mobilized on the day of surgery. The remaining 400 patients were mobilized on postoperative day one (POD1). Length of stay for the accelerated rehabilitation group was 2.06 days and 3.38 days for the standard group. One patient was readmitted to the hospital within 30 days (.52%) in the accelerated group compared to 19 re-hospitalizations (4.72%) in the POD1 group. Ninety-six percent of the accelerated group were discharged home versus 62% in POD1 group. Our results support the use of an accelerated rehabilitation protocol at one institution following total hip replacement surgery.

Iodophor-impregnated adhesive drapes are commonly used to reduce the incidence of surgical site infections (SSI).While proper and discretionary use of drapes can provide significant benefit, there are potential risks. We present two cases of degloving injuries sustained from use of these drapes during total knee arthroplasty. The patients, deemed high risk for potential skin avulsion injuries, received standard wound care and close follow-up which resulted in healing of the lesions at 6-week follow-up., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

This article describes a novel, simple, and effective technique for limiting extensor mechanism damage during total knee arthroplasty (TKA) performed via the medial parapatellar (MPP) approach. Immediately on making the quadriceps tendon split in the MPP approach, a figure-of-eight stitch is placed at the apex of the split. The prophylactic stitch technique has been used by one surgeon in 1000 consecutive TKAs over the past 5 years. This technique has eliminated proximal extension of the quadriceps tendon split into the muscle belly and may help to decrease postoperative pain, increase postoperative quadriceps strength, and improve patient satisfaction and outcomes.

Hip arthroplasty after open reduction and internal fixation of the proximal femur presents a challenge to reconstructive surgeons. Bony defects, fracture malunion, and non-union increase the risk of complications, including intraoperative fracture, unrecognized perforation, and trochanteric non-union. The authors describe a novel surgical technique using conversion hemiarthroplasty and valgus osteotomy for failed open reduction and internal fixation of intertrochanteric hip fractures. The described surgical technique resulted in trochanteric advancement and preservation of the bone stock in the intertrochanteric region. This technique was successful in eliminating pain and restoring ambulation and abductor function and resulted in stable ingrowth and healing in these patients., (Copyright 2013, SLACK Incorporated.)

Femoral component size selection during total knee arthroplasty should not vary from surgeon to surgeon for patients with the same bone size. This study explored if systematic variations in femoral component size selection exist. Thirteen surgeons' choices of femoral component size (Duracon, n = 1388; Triathlon, n = 740) were analyzed using a generalized linear model with femoral component size as the dependent variable and surgeon identification, years in practice, and adult reconstruction fellowship training as the independent variables. The model adjusted for differences in bone size. It was found that more experienced surgeons implant larger femoral components. New instruments and training protocols may be necessary to adjust for surgeon experience.

The dual mobility cup is an unconstrained tripolar configuration newly introduced to the United States in February 2011. The dual mobility construct allows for a larger femoral head to improve motion and minimize the risk of dislocation. We present a case of a patient who received the dual mobility cup for the treatment of recurrent dislocation following total hip arthroplasty. Early in the patient's postoperative course, the implant failed at the articulation between the larger outer polyethylene head and inner smaller metal femoral head following an attempt at closed reduction. This implant specific complication has not been reported in the North American literature., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Dual-modular femoral stems with exchangeable necks theoretically allow optimization of hip joint biomechanics via selective restoration of femoral anteversion, offset, and limb length. A potential disadvantage is the possible generation of metal ions and debris by fretting and crevice corrosion at the additional stem-neck interface. We present 2 cases of early-onset adverse inflammatory tissue reactions as a result of accelerated corrosion at the stem-neck interface of a dual-modular implant, requiring subsequent revision of well-fixed components., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Published reports on patients with skeletal fluorosis undergoing total knee arthroplasty are rare. Skeletal fluorosis is a chronic condition that occurs secondary to the ingestion of food and water that contain high levels of fluoride. Although fluorosis may be described as osteosclerotic and marble-like in appearance, features may also include characteristics of osteomalacia and osteoporosis. This article describes the case of a 67-year-old man with skeletal fluorosis who underwent total knee arthroplasty complicated by fracture. An intramedullary guide was used for the proximal tibia and distal femoral bone cuts intraoperatively. Following the completion of the femoral bone cuts, it was noted that the drill used to open the femoral canal had breached the medial femoral cortex. Multiple fractures were seen in both femoral condyles. A revision femoral stem was chosen to complete the total knee arthroplasty but, after further manipulation of the femur, it appeared that the fracture had displaced. A LISS plate (Synthes, West Chester, Pennsylvania) was used to ensure fracture reduction and implant stability. The remainder of the procedure was completed without complication. One year postoperatively, functional knee range of motion was limited to 70° of flexion. Radiographs showed signs of healing and satisfactory implant position. This case highlights the importance of the preoperative examination and the need to fully appreciate the bone quality of patients prior to undertaking an orthopedic procedure. Variation from the use of intramedullary guides should be considered in patients with questionable bone quality undergoing total knee arthroplasty., (Copyright 2012, SLACK Incorporated.)

There are many effective treatment measures for OA of the hip or knee, with varying degrees of effectiveness. Nonoperative measures include patient education, physical therapy, activity modification, weight loss, and medications. Pharmacologic strategies include acetaminophen, NSAIDs, injections of cortisone or viscosupplementation, and, less commonly, tramadol or other pain relievers. In patients who may be candidates for TJR, narcotic medications should be avoided to preserve their benefits for the postoperative period. Over the past 20 years, multimodal pain management has been beneficial to the patient undergoing TJR surgery. Studies have shown this form of pain management decreases postoperative opioid consumption and the related adverse effects. Research is warranted in the areas of postoperative pain scores and patient satisfaction as institutional multimodal protocols continue to evolve.

Total joint arthroplasty is a safe and highly effective treatment for moderate to severe osteoarthritic symptoms and other causes of joint derangement in the elderly population. Significant improvements in pain, function, and quality of life are nearly universal, with a low rate of complications and adverse outcomes. Because of its success and cost-effectiveness, the rate of utilization of TJR is increasing, and all health care providers must be familiar with the potential complications and perioperative management of these patients. Elderly patients may be at a higher risk for postoperative medical complications; however, the majority of these complications are minor and many are avoidable with appropriate preoperative screening and careful postoperative management. As with all patients undergoing TJR, patients should be prophylactically treated for infection and thromboembolism and carefully followed for the development of these potential complications as well as fracture, hip dislocation, and neurovascular dysfunction. Postoperative delirium may be minimized and prophylactically treated in appropriate elderly patients to maximize recovery and promote safety.

Proper component positioning is essential for successful total knee arthroplasty (TKA). Femoral component positioning presents a technical challenge when significant femoral deformity is present. Most commonly, an intramedullary guide is used to make an accurate distal femoral cut. However, in the presence of a significant femoral deformity, this is not a viable option.The use of clamshell osteotomy to restore anatomic alignment in patients with complex femoral diaphyseal deformity is described in the literature. This article describes a case of a patient who underwent staged TKA after clamshell osteotomy and retrograde femoral nailing to correct femoral diaphyseal malunion. The retrograde intramedullary nail was retained and used as an intramedullary guide, allowing for TKA in a routine manner. Using an intramedullary nail as an alignment guide may be more accurate than using extramedullary alignment and may avoid the increased surgical time and potential pin-site stress risers of navigation. It is a simple, effective way to treat complicated diaphyseal femoral deformities in the face of posttraumatic knee arthritis. Further study of this technique with longer follow-up and multiple surgeons is necessary to validate this treatment algorithm., (Copyright 2012, SLACK Incorporated.)

Femoral nerve catheters are widely used for analgesia in total knee arthroplasty. Although evidence suggests that catheters improve pain control and may facilitate short-term rehabilitation, few reports exist regarding their complications. This case series explores the experience of femoral nerve catheter use at high-volume orthopedic specialty hospitals. Serious complications including compartment syndrome, periprosthetic fracture, and vascular injury are reported. The authors support femoral nerve catheter use with appropriate precautions taken to reduce risk of patient falls, vascular injury, and wrong-site surgery., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Digital radiography is becoming the standard of care for many hospitals and clinics worldwide. The introduction of this new standard has led to the development of arthroplasty templating software. We sought to compare our results using the standard acetate method with the new software method. Our digital preoperative plan was accurate to within 1 size in 78% of the acetabular components and 90% of the femoral components. The manually templated plan was accurate to within 1 size in 67% of the acetabular components and 82% of the femoral components. There did not appear to be any correlation between body mass index and inaccuracies in the preoperative template. Digital templating is an accurate tool to preoperatively plan total hip arthroplasty. The accuracy demonstrated in this study should be achieved easily with any digital templating software. The benefit comes from the ability to scale the templates to the actual x-ray magnification. We expect that this improved accuracy over traditional acetate templating will enhance our ability to restore normal hip biomechanics.