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As the number of patients receiving total joint replacements continues to rise, considerable attention has been directed towards the early detection and prevention of postoperative complications. While D-dimer has long been studied as a diagnostic tool in venous thromboembolism (VTE), this assay has recently received considerable attention in the diagnosis of periprosthetic joint infection (PJI). D-dimer values are substantially elevated in the acute postoperative period after total joint arthroplasty, with levels often exceeding the standard institutional cutoff for VTE (500 µg/L). The utility of D-dimer in detecting VTE after total joint replacement is currently limited, and more research to assess its value in the setting of contemporary prophylaxis protocols is warranted. Recent literature supports D-dimer as a good to excellent biomarker for the diagnosis of chronic PJI, especially when using serum sample technique. Providers should exercise caution when interpreting D-dimer levels in patients with inflammatory and hypercoagulability disorders, as the diagnostic value is decreased. The updated 2018 Musculoskeletal Infection Society criteria, which includes D-dimer levels > 860 µg/L as a minor criterion, may be the most accurate for diagnosing chronic PJI to date. Larger prospective trials with transparent lab testing protocols are needed to establish best assay practices and optimal cutoff values for D-dimer in the diagnosis of PJI. This review summarizes the most current literature on the value of D-dimer in total joint arthroplasty and elucidates areas for future progress.

Rapidly progressive idiopathic arthritis of the hip (RPIA) is defined by progressive joint space narrowing of > 2 mm or > 50% within 1 year. Our aims were to assess (a) the occurrence of RPIA after intra-articular steroid injection, and (b) possible risk factors for RPIA including: patient age, BMI, joint space narrowing, anesthetic and steroid selections, bone mineral density, and pain reduction after injection. A retrospective search of our imaging database identified 1471 patients who had undergone fluoroscopically guided hip injection of triamcinolone acetonide (Kenalog) and anesthetic within a 10-year period. Patient data, including hip DXA results and patient-reported pain scores, were recorded. Pre-injection and follow-up radiographs were assessed for joint space narrowing, femoral head deformity, and markers of osteoarthritis. Osteoarthritis was graded by Croft score. Associations between patient characteristics and outcome variables were analyzed. One hundred six of 1471 injected subjects (7.2%) met the criteria for RPIA. A control group of 161 subjects was randomly selected from subjects who underwent hip injections without developing RPIA. Compared to controls, patients with RPIA were older, had narrower hip joint spaces, and higher Croft scores before injection (p

Liver disease carries significant risk in total joint arthroplasty (TJA). The authors sought to investigate the complications in hepatitis C virus (HCV) and cirrhosis patients after TJA. PRISMA guidelines extracted ten studies and meta-analytic analysis was performed. Five hundred and twenty-seven patients with liver disease underwent TJA. The complication rate was 38.9%, with 8% infection at 57 months. Cirrhotic patients had higher complication and infection rates compared to HCV patients (p0.001, p0.039, respectively). Mortality in cirrhosis patients was 17.8% at 36 months. Studies suggested Child Pugh Class A patients had significantly lower complications than Class B or C. One study revealed lower MELD (Model for End-Stage Liver Disease) scores10 carry a low mortality risk of 9.8% compared with 32% mortality if MELD score 10 or above. Cirrhosis has significant infection and mortality risk in total hip and knee arthroplasty. Surgeons can risk stratify these patients by MELD score and Child Pugh Class. (Journal of Surgical Orthopaedic Advances 31(1):001-006, 2022).

PURPOSE OF REVIEW: Advances in technology, implant design, and surgical technique have lowered the dislocation rate in primary total hip arthroplasty (THA). Despite these advances, there remain a large number of instability episodes without a known etiology. Recent research suggests that the pelvic and lumbar spine interrelationship may be the explanation in prosthetic dislocations without a known cause. In this review, we describe the biomechanics, measurements, diagnoses, classification, management, and outcomes of total hip and revision total hip instability as it relates to spinopelvic alignment. RECENT FINDINGS: As a person goes from standing to sitting, lumbar lordosis decreases, and the sacrum and entire pelvis tilts posteriorly with sacrum and coccyx rotating posterior-inferiorly, resulting in increased acetabular cup anteversion to accommodate femoral flexion. A fused spine and associated fixed acetabulum can result in abnormal pelvic femoral motion, impingement, and dislocation. Classifying the spinopelvic mechanics by sacral motion based on sitting and standing lateral radiographs provides an understanding of how the acetabulum behaves in space. This information helps appropriate cup positioning, reducing the risk of femoral side impingement and subsequent dislocation. SUMMARY: Surgical techniques to consider in the spinopelvic at-risk patient are positioning considerations in acetabular cup inclination and anteversion, high offset femoral stems, high offset acetabular liners, dual mobility articulations, and removal of impinging structures. Future research is needed to define the safest order of operation in concomitant hip and spine pathology, the effects on pelvic femoral biomechanics in spine surgery, and whether preoperative and intraoperative management strategies have a long-term beneficial effect on the dislocation rate.

Introduction As the research landscape evolves, we sought to investigate the current most cited Orthopaedic Surgery articles and compare these to previously cited articles. Methods Web of Science database screened orthopaedic journal articles with comparison to previous data using multivariate regression analysis. Results Rate of citations increased 172% within the last decade. Previous rank and citations within the last decade had a greater effect on contemporary rank (p = 0.084, p = 0.002, respectively). Conclusion Trends in investigative research can shift by the next decade. Previous citation rank and citations in last decade contributed most to current rank.

Preoperative planning is a fundamental element in total knee arthroplasty (TKA). A previous surgery that must be recognized and identified preoperatively is the Hauser procedure, a posteromedialization of the tibial tubercle for recurrent patellar instability. Here, we describe 2 case reports in patients with previous Hauser surgeries. The first TKA surgery was complicated from a standard medial peripatellar approach resulting in complete transection of the patellar tendon during standard arthrotomy. The tendon was repaired, and the arthroplasty was aborted. For the second case, correct preoperative identification of the Hauser procedure was performed. The second TKA surgery was performed using a lateral peripatellar arthrotomy with excellent exposure, resulting in a successful operation. Here, we highlight the importance of an accurate history, physical and radiographic examination, and the recommendation of an alternative TKA approach to help avoid the serious intraoperative complication of a patellar tendon laceration. Keywords: Hauser procedure, Patellar tendon disruption, Extensor mechanism disruption, Lateral parapatellar approach, Total knee arthroplasty

Periprosthetic joint infections (PJIs) are fraught with multiple complications including poor patient-reported outcomes, disability, reinfection, disarticulation, and even death. We sought to perform a systematic review asking the question: (1) What is the mortality rate of a PJI of the knee undergoing 2-stage revision for infection? (2) Has this rate improved over time? (3) How does this compare to a normal cohort of individuals?We performed a database search in MEDLINE/EMBASE, PubMed, and all relevant reference studies using the following keywords: "periprosthetic joint infection," "mortality rates," "total knee arthroplasty," and "outcomes after two stage revision." Two hundred forty-two relevant studies and citations were identified, and 14 studies were extracted and included in the review.A total of 20,719 patients underwent 2-stage revision for total knee PJI. Average age was 66 years. Mean mortality percentage reported was 14.4% (1.7%-34.0%) with average follow-up 3.8 years (0.25-9 years). One-year mortality rate was 4.33% (3.14%-5.51%) after total knee PJI with an increase of 3.13% per year mortality thereafter (r = 0.76 [0.49, 0.90], P.001). Five-year mortality was 21.64%. When comparing the national age-adjusted mortality (Actuarial Life Table) and the reported 1-year mortality risk in this meta-analysis, the risk of death after total knee PJI is significantly increased, with an odds ratio of 3.05 (95% confidence interval, 2.69-3.44; P.001).The mortality rate after 2-stage total knee revision for infection is very high. When counseling a patient regarding complications of this disease, death should be discussed.

While advanced technology, increased medical knowledge and improved surgical technique has improved patient outcomes in total joint arthroplasty, prosthetic joint infection still remains one of the leading causes of increased healthcare costs, medical resources and societal burdens in orthopaedic care.Two stage arthroplasty revision remains the gold standard for treatment of prosthetic joint infection.Proponents of single stage revision arthroplasty for infection argue that it results in lower healthcare costs while improving patient reported functional outcomes and with equivalent success rates.Here we review the history of single stage revision arthroplasty, discuss the key principles, highlight the indications and contraindications, and review the reported outcomes with a focus on future developments of single stage revision arthroplasty for hip and knee periprosthetic joint infections.

Enoxaparin is a widely used low-molecular-weight heparin for perioperative thromboembolic prophylaxis. Enoxaparin-induced skin necrosis in the setting of arthroplasty has been rarely reported in the literature with varying outcomes and management decisions. Our patient developed skin necrosis at his injection site and thrombocytopenia 10 days following left total knee arthroplasty surgery and after receiving subcutaneous Lovenox injections postoperatively. The patient was started on an alternative anticoagulation based on a high suspicion for heparin-induced thrombocytopenia and the wound was monitored without surgical debridement. Our case highlights the key clinical management decisions when facing this potentially life-threatening adverse reaction. Keywords: Lovenox, Enoxaparin, Skin necrosis, Adverse reaction, Arthroplasty

Background For patients with symptomatic bilateral knee arthritis, it is unknown whether the risk of developing stiffness requiring manipulation under anesthesia postoperatively is higher or lower for those undergoing simultaneous bilateral total knee arthroplasty (TKA) compared with those having staged bilateral TKA. Therefore, we undertook this study to evaluate the risk of requiring manipulation under anesthesia in staged versus simultaneous bilateral TKA as well as patients undergoing unilateral TKA. Methods We utilized the California Patient Discharge Database, which is linked with the California Emergency Department, Ambulatory Surgery, and master death file databases. Using a literature-based estimate of the number of patients who failed to undergo the second stage of a staged bilateral TKA, replacement cases were randomly selected from patients who had unilateral TKA and were matched on 8 clinical characteristics of the patients who had staged bilateral TKA. Hierarchical multivariate logistic regression was performed to determine the risk-adjusted odds of manipulation in patients undergoing unilateral TKA, staged bilateral TKA, and simultaneous bilateral TKA using yearly hospital TKA volume as a random effect. Adjustment was made to allow fair comparison of the outcome at 90 and 180 days of follow-up after staged compared with simultaneous bilateral TKA. Results During the time period from 2005 through 2013, the cumulative incidence of manipulation within 90 days was 2.14% for unilateral TKA (4,398 events per 205,744 patients), 2.11% for staged bilateral TKA (724 events per 34,352 patients), and 1.62% for simultaneous bilateral TKA (195 events per 12,013 patients). At 180 days of complete follow-up, the cumulative incidence of manipulation was 3.07% after unilateral TKA (6,313 events per 205,649 patients), 2.89% after staged bilateral TKAs (957 events per 33,169 patients), and 2.29% after simultaneous bilateral TKA (267 events per 11,653 patients). With multivariate analyses used to adjust for relevant risk factors, the 90-day odds ratio (OR) of undergoing manipulation after simultaneous bilateral TKA was significantly lower than that for unilateral TKA (OR = 0.70; 95% confidence interval [CI], 0.57 to 0.86) and staged bilateral TKA (OR = 0.71; 95% CI, 0.57 to 0.90). Similarly, at 180 days, the odds of undergoing manipulation were significantly lower after simultaneous bilateral TKA than after both unilateral TKA (OR = 0.71; 95% CI, 0.59 to 0.84) and staged bilateral TKA (OR = 0.76; 95% CI, 0.63 to 0.93). The frequency of manipulation was significantly associated with younger age, fewer comorbidities, black race, and the absence of obesity. Conclusions Although the ORs were small (close to 1), simultaneous bilateral TKA had a significantly decreased rate of stiffness requiring manipulation under anesthesia at 90 days and 180 days after knee replacement compared with that after staged bilateral TKA and unilateral TKA. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The increasing demand for total hip arthroplasty (THA) in relatively young, high-demand patients has led to the use of hard-on-hard bearing surfaces. Adverse local tissue reaction/pseudotumor and elevated serum metal ion levels are commonly reported complications encountered in metal-on-metal THA, while audible articulation and rim fracture are reported in ceramic-on-ceramic THA. For this reason, ceramic-on-metal THA was implemented as an ideal hard-on-hard bearing combination. In this report, we describe a case of bilateral simultaneous ceramic-on-metal THA in a 69-year-old woman who presented 7 years postoperatively with unilateral hip pain associated with underlying pseudotumor and elevated serum cobalt and chromium ion levels. Pre-revision workup, intraoperative findings, and postoperative evaluation are included and suggest acetabular malposition as a potential source for complication. Keywords: Total hip arthroplasty, Adverse local tissue reaction, Pseudotumor, Hard-on-hard, Ceramic-on-metal

Background The sacro-femoral-pubic (SFP) parameter, calculated using the SFP angle measured on a frontal pelvis radiograph, has previously been shown to have a strong correlation with sagittal pelvic tilt (PT) measured on a lateral x-ray. The purpose of this study is to assess the validity, interobserver reliability and intraobserver reproducibility of the SFP parameter in predicting the sagittal PT. Methods This is a retrospective study of 100 patients with frontal and lateral radiographs of the pelvis. Two observers independently measured the SFP angle on frontal x-ray (midpoint of S1 end plate to centroid of acetabula to upper midpoint of the pubic symphysis) and PT on lateral x-ray (midpoint of sacral plate to the centroid of acetabula to vertical plane). The SFP parameter was defined using the equation: SFP parameter = 75 − SFP angle. The interobserver reliability and intraobserver reproducibility were calculated using interclass correlation coefficient (ICC). Validity of the SFP parameter was calculated using Pearson correlation coefficient. Results The intraobserver reproducibility of the SFP parameter was excellent (ICC >0.90) for both observers. The interobserver reliability of all measurements was substantial for the SFP parameter (ICC >0.80) and PT (ICC >0.70). The concurrent validity of the SFP parameter was substantial ( r = 0.70). Conclusion Calculating PT from a frontal radiograph using the equation for the SFP parameter is a valid, reliable, and reproducible formula that may be used to predict sagittal PT.

Total knee arthroplasty (TKA) may decrease coronary heart disease (CHD) risk in patients with advanced osteoarthritis by reducing pain and allowing for a more active lifestyle. We examined cardiovascular fitness, CHD risk factors, and quality of life in patients for 1 year after TKA compared with matched controls who did not undergo surgery. A total of 14 patients, 7 surgery patients and 7 matched controls, were tested for measurements of body composition, knee range of motion, resting blood pressure, strength testing, a maximal exercise test, quality-of-life questionnaires (Medical Outcomes Study Short Form-36 and Knee Osteoarthritis Outcome Score [KOOS]), and activity monitoring, fasting blood glucose, and lipids at 0, 3, 6, and 12 months after surgery or baseline testing. Comparison between the two groups was analyzed. Twelve months after surgery, patients with TKA had significantly (p

Background Previous studies have noted the progression of arthritis due to increased forces in articular structures adjacent to a fused joint. It is unknown whether spinal fusion generates increased forces at the hip joint causing progression to arthritis leading to total hip arthroplasty (THA). We sought to determine (1) is there a relationship between spinal fusion and THA, (2) what are risk factors for subsequent THA, and (3) is there a time interval from spinal fusion to THA? Methods A large patient discharge dataset was utilized to evaluate all patients who underwent spinal fusion and subsequent THA in California from 2004 through 2013. Patients were categorized by age, sex, hospital type, hospital volume, and number of spinal levels fused. Multivariate analysis was performed to investigate the relationship between spinal fusion and THA. Hazard ratios were calculated for risk factors for THA after spinal fusion. Patients were excluded for previous spinal fusion or hip arthroplasty, inflammatory arthropathy, cancer, and an age of ≤40 years, a surrogate for adolescent and neuromuscular scoliosis. Results A total of 101,206 patients underwent spinal fusion; 2,803 (2.77%) subsequently underwent THA. In a bivariate analysis comparing 1 to 2 levels versus >2 levels fused, males had a 17% increased relative risk of undergoing subsequent THA (relative risk [RR] = 1.17; 95% confidence interval [CI] = 1.16 to 1.17) and female patients had a 35% increased relative risk (RR = 1.35; 95% CI = 1.34 to 1.35) when the fusion involved >2 levels. For females, the relative risk increased by 119% when >7 levels were fused compared with 1 to 7 levels (RR = 2.19; 95% CI = 2.16 to 2.21). Using multivariate random-effects analysis, significant risk factors for THA after spinal fusion included female sex (hazard ratio [HR] = 1.21; 95% CI = 1.13 to 1.31; p 7 levels (HR = 1.52; 95% CI = 1.03 to 2.24; p = 0.035). Conclusions Patients with longer spinal fusion constructs, especially female patients, had a significantly increased risk of undergoing subsequent THA. Patients should be educated regarding the potential for the progression to hip arthritis after spinal fusion and the possibility of future THA. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

IntroductionSince the advent of antifibrinolytics, blood transfusions and their associated complications in total joint arthroplasty have decreased. Few studies have compared different antifibrinolytic types with respect to blood loss and transfusion rates. We sought to compare the blood loss and transfusion rates between epsilon-aminocaproic acid (EACA), tranexamic acid (TXA), and control.MethodsA total of 564 patients underwent primary total hip or total knee arthroplasty at our institution. Patients were divided into 3 groups: 183 EACA, 204 TXA, and 177 control. Patient demographics, hemoglobin, transfusion rates, and blood loss were collected.ResultsPatient preoperative variables were similar. The control group had a mean estimated blood loss (EBL) of 1.48 L, with 51 units of packed red blood cells (pRBCs) given and 14.7% of patients receiving a blood transfusion. The EACA group had an EBL of 1.33 L, with 20 pRBCs given and 10.9% of patients receiving a transfusion. The TXA group had an EBL of 1.05 L, with 3 pRBCs transfused in 0.98% of patients. Compared with the control group, blood loss (P = 0.0014; P < 0.0001), number of pRBCs given (P = 0.007; P < 0.0001), and number of patients transfused (P = 0.012; P < 0.0001) were significantly lower in the EACA and TXA groups, respectively. TXA had significantly lower blood loss (P < 0.0001), lower number of tranfusions (P = 0.005), and less patients transfused (P = 0.003) compared with EACA.ConclusionOur study reports lower blood loss, transfusion rates, and number of patients needing transfusion with both EACA and TXA in the setting of total joint arthroplasty. When comparing between EACA and TXA, TXA had lower blood loss, transfusion rates, and number of patients requiring transfusion.

Studies describe progression of adjacent joint arthritis after hip fusion but not vise versa. We investigated the relationship after spinopelvic fusion and total hip arthroplasty. 383 patients undergoing spinopelvic were investigated. Perioperative demographics were recorded. A matched 2:1 cohort was used to detect risk factors for THA progression. 10 patients (2.6%) underwent THA after spinopelvic fusion. Average time from surgery to THA was 24.4 months. After spinopelvic fusion, patients progressed to THA 24.4 months on average. Due to small numbers, we couldn't find differences between the two groups regarding comorbidities nor risk factors for THA. Further studies are needed.

Objective: Arthroplasty is the common treatment for intracapsular femoral neck fractures in the elderly. Recent studies have shown that there may be more overall complications related to uncemented hemiarthroplasty compared to cemented, including more subsidence, intraoperative fractures, and postoperative fractures. Uncemented femoral components rely on a press fit, and the risk of these complications would be expected to increase in patients with unrecognized distal extension of femoral neck fractures. The purpose of this study is to determine the frequency of fracture extension of displaced femoral neck fractures in the elderly population. Methods: The electronic medical record database at our institution was retrospectively reviewed to search for consecutive reports from 2005 to 2015 of patients 65 years or older that sustained an intracapsular femoral neck fracture who had computed tomography (CT) examinations of the injury. Exclusion criteria were CTs that were not fine cut (

Background: The incidence of adverse events with noncardiac procedures (NCP) after the use of drug eluting stents (DES) is not well studied. We sought to determine the incidence and temporal trends of adverse events in patients undergoing NCP after coronary DES. Methods: We performed a retrospective review of patients receiving DES during percutaneous coronary intervention (PCI) in the Lexington VAMC between January 1, 2004 and December 31, 2010 to determine the circumstances and the results of their NCP. Results: We identified 1,092 patients who underwent at least one PCI with DES who were followed for at least 3 years. Of those, 452 patients (41%) had a NCP at a median of 534 days after PCI with 1,081 procedures (894 low-, 160 Intermediate-, and 27 high-risk) performed. Clinically relevant NCP-related complications were defined as significant bleeding or stent thrombosis and occurred in 13 individuals (nine perioperative bleeding and four probable/possible stent thrombosis including two mortalities). Five adverse events occurred within the first year at a rate of 0.014 event/patient-year. During the remainder of follow-up (up to 9 years), eight events were documented at a rate of 0.0004 event/patient-years. During the first year of follow-up, there was no significant increase in risk of recurrent myocardial infarction (MI) or target vessel revascularization (TVR) in patients undergoing NCP but higher risk of all-cause mortality in those who did not undergo NCP. However, in patients who underwent NCP, there was a statistically significant increase in myocardial infarction (MI), target vessel revascularization (TVR), and rehospitalization for cardiac reasons compared with those without NCP during long term follow-up (median of 5.6 years). Conclusion: NCP after DES requiring management of DAT are relatively common among veterans following PCI using DES. The risk of bleeding and stent thrombosis is concentrated in the first year but remains very low. © 2015 Wiley Periodicals, Inc.

Our objective was to determine the association between muscle cross-sectional area and attenuation, as measured on routine CT scans, and mortality in older patients with hip fracture.A retrospective 10-year study of patients with hip fracture was conducted with the following inclusion criteria: age 65 years or older, first-time hip fracture treated with surgery, and CT of the chest, abdomen, or pelvis. This yielded 274 patients (70.4% women; mean [± SD] age, 81.3 ± 8.3 years). On each CT scan, two readers independently measured the size (cross-sectional area, indexed for patient height) and attenuation of the paravertebral muscle at T12 and the psoas muscle at L4. We then determined the association between overall mortality and the muscle size and muscle attenuation, while adjusting for demographic variables (age, sex, ethnicity, and body mass index), American Society of Anesthesiologists (ASA) classification, and Charlson comorbidity index (CCI).The overall mortality rate increased from 28.3% at 1 year to 79.5% at 5 years. Mortality was associated with decreased thoracic muscle size (odds ratio [OR], 0.66; 95% CI, 0.49-0.87). This association persisted after adjusting for demographic variables (OR, 0.69; 95% CI, 0.50-0.95), the ASA classification (OR, 0.70; CI, 0.51-0.97), and the CCI (OR, 0.72; 95% CI, 0.52-1.00). Similarly, decreased survival was associated with decreased thoracic muscle attenuation after adjusting for all of these combinations of covariates (OR, 0.67-0.72; 95% CI, 0.49-0.99). Decreased lumbar muscle size and attenuation trended with decreased survival but did not reach statistical significance.In older adults with hip fractures, CT findings of decreased thoracic paravertebral muscle size and attenuation are associated with decreased overall survival.

This report describes the arthroscopic management of a case of incarcerating pincer-type femoroacetabular impingement. The hip joint had a marked restriction of range of motion and secondary pain as a result of osteophytes wrapping around the femoral head down the femoral neck. The patient was treated with staged bilateral hip arthroscopy. The procedures were initially performed through the peripheral compartment to remove the incarcerating acetabular rim, followed by arthroscopy of the central compartment with acetabuloplasty and femoral head osteochondroplasty. The patient's treatment has led to an excellent clinical and radiographic result at 24 months' follow-up despite an unrelated pelvic fracture sustained in the postoperative period. This technique emphasizes the capabilities of hip arthroscopy in advanced cases of femoroacetabular impingement as an alternative to arthroplasty for patients with healthy articular cartilage.

Anterior femoral notching during total knee arthroplasty is a potential risk factor for periprosthetic supracondylar femur fracture. We conducted a study to determine if the design of the femoral implant changes the risk for periprosthetic supracondylar femur fractures after anterior cortical notching. An anterior cortical defect was created in 12 femoral polyurethane models. Six femora were instrumented with cruciate-retaining implants and 6 with posterior-stabilized implants. Each femur was loaded in external rotation along the anatomical axis. Notch depth and distance from anterior cortical notch to implant were recorded before loading, and fracture pattern was recorded after failure. There were no statistically significant differences in notch depth, distance from notch to implant, torsional stiffness, torque at failure, final torque, or fracture pattern between cruciate-retaining and posterior-stabilized femoral component designs. Periprosthetic fracture after anterior femoral notching is independent of the bone removed from the intercondylar notch. After notching, there likely is no significant difference in femoral strength in torsion between cruciate-retaining and posterior-stabilized designs.

As the annual number of total knee arthroplasties has continued to increase, a concomitant increase in the number of bilateral total knee arthroplasties has occurred. Approximately 6% of primary total knee arthroplasties performed each year in the United States are performed on both knees as a single procedure with the patient under anesthesia (simultaneous bilateral total knee arthroplasty). This rate represents an almost twofold increase compared with the rate in the 1990s, when approximately 3.7% of all total knee arthroplasty operations were performed as a simultaneous bilateral total knee arthroplasty1. Because the fastest increase in total knee arthroplasty is occurring among younger people, a continued increase in the performance of simultaneous bilateral total knee arthroplasty is possible2. The identification of patients of all ages with symptomatic bilateral knee arthritis who are appropriate candidates for simultaneous bilateral total knee arthroplasty can be difficult. A major deficiency of the current orthopaedic literature is the absence of any adequately powered, prospective, controlled clinical trials that have directly compared simultaneous bilateral total knee arthroplasty with two total …

As the number of total hip arthroplasties performed in the United States increases, and as more young patients undergo this procedure, it can be expected that the number of revision hip arthroplasties will also increase. Most acetabular revisions can be performed with a hemispherical shell. Results with these components show a rate of survivorship free of aseptic loosening of 97% (range, 94% to 100%) in 729 revision surgeries1-9 at a mean follow-up time of 9.8 years (range, six to 21.3 years). Use of a hemispherical shell requires the creation of a supportive, concave hemisphere of bone. While in the majority of acetabular revisions this goal is attainable, at times the nature of the acetabular osseous defect makes this goal unobtainable. This can be understood as the inability to ream a large enough hemisphere, with the goal of reaching the apex of the superior aspect of the deformity, without in the process removing supportive anterior and posterior host bone. In this setting, an oblong osseous deficiency is left over (defined as the superior to inferior length of the overall defect being greater than the anterior to posterior width of the remaining …

Objective To evaluate the recent epidemiology of hip fractures in the US. Methods We identified hip fracture cases from the 2008 Nationwide Emergency Department Sample, which contains more than 28 million emergency department (ED) records. Results In 2008, approximately 341,000 (95% confidence interval 323,000-358,000) patients visited EDs with hip fractures. Of those, 90% were age >60 years. Between ages 60-85 years, the risk of fracture doubled for every 5- to 6-year increase in age. However, the hip fracture risk increased slowly after age 85 years. The overall trochanteric-to-cervical fracture ratio was nearly 2:1. The risk of trochanteric fracture increased faster with age compared with the risk of cervical fracture. At age 85 years, the rates of trochanteric and cervical fractures (per 100,000) were 1,300 and 700, respectively, among women and 800 and 500, respectively, among men. Conclusion The slowed growth of hip fracture risk after age 85 years suggests that the eldest old group may have a distinct hip fracture risk. Our study showed that trochanteric fractures were twice as common as cervical fractures. Because trochanteric fractures are more closely related to severe and generalized bone loss than cervical fractures, we hypothesize that the high incidence rate of trochanteric fractures in the US suggests that osteoporosis is a health problem that is linked to hip fracture. In addition to improved safety measures to reduce falls, rigorous preventive treatments of osteoporosis may be needed.

Background: It is unclear whether simultaneous-bilateral total knee arthroplasty is as safe as staged-bilateral arthroplasty is. We are aware of no randomized trials comparing the safety of these surgical strategies. The purpose of this study was to retrospectively compare these two strategies, with use of an intention-to-treat approach for the staged-bilateral arthroplasty cohort. Methods: We used linked hospital discharge data to compare the safety of simultaneous-bilateral and staged-bilateral knee arthroplasty procedures performed in California between 1997 and 2007. Estimates were generated to take into account patients who had planned to undergo staged-bilateral arthroplasty but never underwent the second procedure because of death, a major complication, or elective withdrawal. Hierarchical logistic regression modeling was used to adjust the comparisons for patient and hospital characteristics. The principal outcomes of interest were death, a major complication involving the cardiovascular system, and a periprosthetic knee infection or mechanical malfunction requiring revision surgery. Results: Records were available for 11,445 simultaneous-bilateral arthroplasty procedures and 23,715 staged-bilateral procedures. On the basis of an intermediate estimate of the number of complications that occurred after the first procedure in a staged-bilateral arthroplasty, patients who underwent simultaneous-bilateral arthroplasty had a significantly higher adjusted odds ratio (OR) of myocardial infarction (OR = 1.6, 95% confidence interval [CI] = 1.2 to 2.2) and of pulmonary embolism (OR = 1.4, 95% CI = 1.1 to 1.8), similar odds of death (OR = 1.3, 95% CI = 0.9 to 1.9) and of ischemic stroke (OR = 1.0, 95% CI = 0.6 to 1.6), and significantly lower odds of major joint infection (OR = 0.6, 95% CI = 0.5 to 0.7) and of major mechanical malfunction (OR = 0.7, 95% CI = 0.6 to 0.9) compared with patients who planned to undergo staged-bilateral arthroplasty. The unadjusted thirty-day incidence of death or a coronary event was 3.2 events per thousand patients higher after simultaneous-bilateral arthroplasty than after staged-bilateral arthroplasty, but the one-year incidence of major joint infection or major mechanical malfunction was 10.5 events per thousand lower after simultaneous-bilateral arthroplasty. Conclusions: Simultaneous-bilateral total knee arthroplasty was associated with a clinically important reduction in the incidence of periprosthetic joint infection and malfunction within one year after arthroplasty, but it was associated with a moderately higher risk of an adverse cardiovascular outcome within thirty days. If patients who are at higher risk for cardiovascular complications can be identified, simultaneous-bilateral knee arthroplasty may be the preferred surgical strategy for the remaining lower-risk patients. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

To find a safer surgical option, a number of studies have compared postoperative complications after bilateral total knee arthroplasty vs staged total knee arthroplasty (STKA) by contrasting postoperative complications collected retrospectively. However, we believe that a comparison based on retrospective studies could be biased. The purpose of this study was to demonstrate the misclassification bias associated with a retrospective study in comparing operative outcomes. Our analysis indicates that any conclusions based simply on retrospective analysis of subjects who successfully completed STKA is biased because it includes only cases that recovered after the first operation, rather than all of the patients who had planned STKA. In the absence of a prospective study to date, published studies should be interpreted with caution.

Silicone has been used in numerous health care roles, from catheters to finger joint arthroplasties, with proven success. Its use as an interpositional membrane for the prevention of adhesions has been attempted in various anatomic sites with unpredictable results. We present a case report of a patient with recurrent arthrofibrosis requiring multiple operative procedures including manipulations under anesthesia, arthroscopies, and unicompartmental and eventual total knee replacement. After developing stiffness after total knee arthroplasty, the patient received placement of a silicone interpositional membrane with the goal of minimizing scar formation. Arthrofibrosis recurred, and only eventual removal of the membrane and correction of the underlying overstuffed patellofemoral compartment has allowed for maintained functional improvement in motion after 3 years.

We present 2 cases of cam/pincer combined femoroacetabular impingement treated arthroscopically with labral debridement, acetabuloplasty, and femoral head recontouring. In both cases there was essentially no evidence of osteoarthritis of the hip. However, in both cases raised exostoses were evident on the anterolateral femoral neck in the region that commonly comes into contact with the acetabular rim. On the basis of 3-dimensional dynamic reconstructions, we surmise that these exostoses are a direct result of linear contact between the femoral neck and acetabular rim. We recommend that the presence of these exostoses be carefully noted by the arthroscopic hip surgeon and that they be a geographic marker of the zone of contact between the head-neck junction and the acetabular rim and a guide for the area of head osteochondroplasty in combination with appropriate treatment of the acetabular rim.

Periprosthetic fractures involving a total knee arthroplasty pose a challenging treatment problem with a prevalence of up to 2.5% in the literature (Instr Course Lect 2001;50:379-389). The supracondylar region of the femur is commonly involved, often with minimal available bone in contact with the components. The clinical challenges are particularly more complex in the case of a combined distal femoral and proximal tibial periprosthetic fracture. This injury is considered a "floating prosthesis" injury because of the complete separation of the prosthesis from the remaining skeleton. In this report, a floating prosthesis injury, in combination with a femoral shaft fracture, is treated with 2 locking plates using a minimally invasive technique, with limited blood loss, immediate pain relief after surgery, and successful healing of all fractures with minimal deformity.

Periprosthetic supracondylar fractures of the femur after total knee arthroplasty represent a devastating complication for the patient and a technical challenge for the surgeon. Treatment is often complicated by advanced patient age, retained cement, and accompanying osteoporosis. We present the case of a 54-year-old woman with a comminuted fracture of the distal femur just above a total knee prosthesis. She had a complex past medical history, including extensive coronary artery disease, morbid obesity, chronic osteoporosis, anemia, diabetes, and rheumatoid arthritis. She was a Jehovah's Witness and thus refused all blood products. Given her medical history, religious preferences, and fracture comminution, a spanning external fixator was used. She completed fracture union with an excellent clinical and radiographic result at 2 years.

Cam morphology in femoroacetabular impingement has been implicated in the development of osteoarthritis. The alpha angle and femoral head/neck offset are widely used to determine femoral head asphericity. To our knowledge, no study has evaluated the alpha angle circumferentially using three-dimensional imaging in a population of healthy individuals of adolescent age.We sought to (1) determine normal values for the alpha angle in adolescents, (2) define the location along the neck with the highest alpha angle, and (3) determine normal femoral head and neck radii and femoral head/neck offset.Fifty CT scans from a database of scans obtained for reasons not related to hip pain were studied. The average age of the subjects was 15 years (range, 14-16 years). Alpha angle and femoral head/neck offset were measured circumferentially.The alpha angle averaged 40.66 ± 4.46 mm for males and 37.77 ± 5.65 mm for females. The alpha angle generally was highest between the 11:40 and 12:40 o'clock and between the 6:00 and 7:40 o'clock positions. The femoral head radius was 24.53 ± 1.74 mm for males and 21.94 ± 1.13 mm for females, and the femoral neck radius was 16.14 ± 2.32 mm for males and 13.82 ± 2.38 mm for females. The mean femoral head/neck offset was 8.39 ± 1.97 mm for males and 8.13 ± 2.27 mm for females.In this healthy population of 14- to 16-year-old subjects, the highest alpha angle was at the superior and inferior aspects of the heads rather than at the anterosuperior aspect. This information will provide benchmark values for distinction between normal and abnormal morphologic features of the femoral head.

The objective of this study was to describe the trend in utilization of primary joint arthroplasties in Germany. Between 2004 and 2008, the number of total knee arthroplasties (TKAs) increased faster than that of total hip arthroplasties (THAs). In 2008, 159000 primary THAs and 146000 primary TKAs were performed. This represented a 15% increase in THAs and a 33% increase in TKAs compared to 2004. The annual increase in number of surgeries was 4500 for THAs and 9,000 for TKAs. Although older adults remained the main recipients of joint arthroplasties, incidence rate increased faster in non-elderly(18–64 years) compared with elderly (≥65 years) in both THAs and TKAs. Obesity, more strongly associated with TKAs than with THAs, could be a contributor to the recent steeper growth in TKAs in Germany.

To evaluate the recent epidemiology of hip fractures in the US.We identified hip fracture cases from the 2008 Nationwide Emergency Department Sample, which contains more than 28 million emergency department (ED) records.In 2008, approximately 341,000 (95% confidence interval 323,000-358,000) patients visited EDs with hip fractures. Of those, 90% were age60 years. Between ages 60-85 years, the risk of fracture doubled for every 5- to 6-year increase in age. However, the hip fracture risk increased slowly after age 85 years. The overall trochanteric-to-cervical fracture ratio was nearly 2:1. The risk of trochanteric fracture increased faster with age compared with the risk of cervical fracture. At age 85 years, the rates of trochanteric and cervical fractures (per 100,000) were 1,300 and 700, respectively, among women and 800 and 500, respectively, among men.The slowed growth of hip fracture risk after age 85 years suggests that the eldest old group may have a distinct hip fracture risk. Our study showed that trochanteric fractures were twice as common as cervical fractures. Because trochanteric fractures are more closely related to severe and generalized bone loss than cervical fractures, we hypothesize that the high incidence rate of trochanteric fractures in the US suggests that osteoporosis is a health problem that is linked to hip fracture. In addition to improved safety measures to reduce falls, rigorous preventive treatments of osteoporosis may be needed.

Background: This study was proposed to investigate the changes in the utilization of knee arthroscopy in an ambulatory setting over the past decade in the United States as well as its implications. Methods: The National Survey of Ambulatory Surgery, last carried out in 1996, was conducted again in 2006 by the Centers for Disease Control and Prevention. We analyzed the cases with procedure coding indicative of knee arthroscopy or anterior cruciate ligament reconstruction. To produce estimates for all arthroscopic procedures on the knee in an ambulatory setting in the United States for each year, we performed a design-based statistical analysis. Results: The number of arthroscopic procedures on the knee increased 49% between 1996 and 2006. While the number of arthroscopic procedures for knee injury had dramatically increased, arthroscopic procedures for knee osteoarthritis had decreased. In 1996, knee arthroscopies performed in freestanding ambulatory surgery centers comprised only 15% of all orthopaedic procedures, but the proportion increased to 51% in 2006. There was a large increase in knee arthroscopy among middle-aged patients regardless of sex. In 2006, >99% of arthroscopic procedures on the knee were in an outpatient setting. Approximately 984,607 arthroscopic procedures on the knee (95% confidence interval, 895,999 to 1,073,215) were performed in an outpatient setting in 2006. Among those, 127,446 procedures (95% confidence interval, 95,124 to 159,768) were for anterior cruciate ligament reconstruction. Nearly 500,000 arthroscopic procedures were performed for medial or lateral meniscal tears. Conclusions: This study revealed that the knee arthroscopy rate in the United States was more than twofold higher than in England or Ontario, Canada, in 2006. Our study found that nearly half of the knee arthroscopic procedures were performed for meniscal tears. Meniscal damage, detected by magnetic resonance imaging, is commonly assumed to be the source of pain and symptoms. Further study is imperative to better define the symptoms, physical findings, and radiographic findings that are predictive of successful arthroscopic treatment. Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

A 39-year-old man presented with weakness and a nonmobile mass in the buttock of 5 months’ duration. Hip flexion was limited to 70°. Strength was diminished for both ankle/foot plantar and dorsiflexion. Sensation was decreased on the plantar and dorsal foot. A pedunculated osseous mass measuring 6×4 cm on the posterior femoral neck was seen on plain radiographs and magnetic resonance imaging. Electromyography showed moderate sciatic neuropathy of the peroneal and tibial branches. The patient underwent excision of the tumor through a posterior approach. Due to the risk of weakening the neck, two 7.3-mm cannulated screws were passed percutaneously into the head with fluoroscopic guidance. The final pathological report indicated the tumor was an osteochondroma. At 22-month follow-up, he had full resolution of the neurologic findings. Postoperatively, the patient reported improvement in numbness and tingling in the leg but continued to have moderate buttock pain. Left hip flexion increased to 115° at last follow-up. The importance of protecting the medial femoral circumflex artery during approaches to the hip is paramount. In this case, the tumor arose from the central aspect of the quadratus femoris, with the superior muscle protecting the medial femoral circumflex artery from harm. Although osteochondromas are a rare cause of mass effect, they should be considered in the differential diagnosis of sciatic nerve compression in this anatomical location.

The local delivery of antibiotics in the treatment of osteomyelitis has been used safely and effectively for decades. Multiple methods of drug delivery have been developed for the purposes of both infection treatment and prophylaxis. The mainstay of treatment in this application over the past 20 years has been non-biodegradable polymethylmethacrylate, which has the advantages of excellent elution characteristics and structural support properties. Biodegradable materials such as calcium sulfate and bone graft substitutes have been used more recently for this purpose. Other biodegradable implants, including synthetic polymers, are not yet approved for use but have demonstrated potential in laboratory investigations. Antibiotic-impregnated metal, a recent development, holds great promise in the treatment and prophylaxis of osteomyelitis in the years to come.

This study is a retrospective evaluation of the intermediate-term results of 26 consecutive revision total hip arthroplasties performed with a modular titanium, uncemented femoral component. The average patient age at the time of revision total hip arthroplasty was 72 years, and there were an equal number of males and females. The mean follow-up was 5.7 years (ranging from 4 to 11 years). No re-revision was necessary during this follow-up time. The mean Harris hip score improved significantly (preoperative and postoperative score was 50.7 and 89.6, respectively; P < .001). Postoperatively, Short Form 36 functional scores averaged 67.7 across 9 functional parameters. Our observed low revision rate and favorable patient-reported outcome scores support the continuous use of modular titanium, uncemented femoral components in revision total hip arthroplasty.