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Total knee arthroplasty continues to be one of the most commonly performed surgical procedures worldwide. However, considerable controversy exists regarding the optimal implant design. Total knee implants with both posterior-stabilized and cruciate-retaining designs have excellent long-term outcomes with inadequate data demonstrating superiority of either design. Recently, the popularity of total knee designs with more conforming polyethylene liners has increased. These polyethylene inserts prevent paradoxical anterior translation of the femur, without relying on a cam and post mechanism, and promote more physiologic native knee kinematics. This review summarizes the design rationale of several commercially available implants, discusses the kinematic data of several designs, and reviews the available clinical data.

OBJECTIVE To determine individual bilateral differences (IBDs) in tibial torsion in a diverse population. METHODS Computed tomography scans of uninjured bilateral tibiae were used to determine tibial torsion and IBDs in torsion using 4 measurement methods. Age, sex, and self-identified race/ethnicity were also recorded for each subject. Mean tibial torsion and IBDs in torsion were compared in the overall cohort and when stratified by sex and race/ethnicity. Simple and multiple linear regression models were used to correlate demographic variables with tibial torsion and IBDs in torsion. RESULTS One hundred ninety-five patients were evaluated. The mean tibial torsion was 27.5 ± 8.3 degrees (range -3 to 47.5 degrees). The mean IBD in torsion was 5.3 ± 4.0 degrees (range 0-23.5 degrees, P < 0.001). 12.3% of patients had IBDs in torsion of ≥10 degrees. In the regression analysis, patients who identified as White had greater average torsion by 4.4 degrees compared with Hispanic/Latinx patients (P = 0.001), whereas age and sex were not significantly associated with absolute torsion. Demographics were not associated with significant differences in IBDs in torsion. CONCLUSIONS Tibial torsion varies considerably and individual side-to-side differences are common. Race/ethnicity was associated with differences in the magnitude of tibial torsion, but no factors were associated with bilateral differences in torsion. The results of this study may be clinically significant in the context of using the uninjured contralateral limb to help establish rotational alignment during medullary nail stabilization of diaphyseal tibia fractures. In addition, these findings should be considered in the evaluation of tibia rotational malalignment. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical debridement is critical to the treatment of open tibia fractures, although the effects of delayed debridement have not been well-established. Other factors such as Gustilo-Anderson type, prompt initiation of antibiotics, and time to definitive closure may be more predictive of infection than time to surgery. We sought to determine the effect of a prolonged delay to surgical debridement with respect to infection and reoperation rates for open tibia fractures. All open diaphyseal tibia fractures with > 12-week follow-up were evaluated. Patient demographics, Gustilo-Anderson type, and rates of deep infection and all-cause reoperation were recorded. Patients were divided into 3 groups based on time to surgery: early ( 48 h). Univariate and multivariate analyses were performed to evaluate the relationship between time to surgery, fracture type, infection, and reoperation. In total, 96 open tibia fractures with average follow-up of 59.3 weeks and infection rate of 13.5% were included. Infection rates for the early, delayed, and late groups were 13.3%, 17.2%, and 9.1%, respectively (p = 0.70). Reoperation rates for the early, delayed, and late groups were 29.8%, 31.0%, and 22.7%, respectively (p = 0.80). The groups did not vary in proportion of Gustilo-Anderson fracture types; infection rates between Gustilo-Anderson types were similar (p = 0.57). Type IIIA-C fractures required more reoperations than other fracture types (p = 0.01). Delayed surgical debridement of open tibia fractures did not result in greater rates of infection or reoperation. Gustilo-Anderson classification was more predictive of reoperation, with Type IIIA-C injuries having a significantly higher reoperation rate.

Background: Anterior and posterior pelvic tilt appears to play a role in total hip arthroplasty (THA) stability. When changing from the standing to the sitting position, the pelvis typically rotates posteriorly while the hips flex and this affects the femoro-acetabular positions. This case-control study compares changes in 3-D acetabular cup orientation during functional pelvic tilt between posterior THA dislocations vs stable THAs. Methods: Standing and sitting 3-D cup orientation was compared between fifteen posterior dislocations vs 233 prospectively followed stable THAs. 3-D cup orientation was calculated using previously validated trigonometric algorithms on biplanar radiographs. Those algorithms combine the angles in the three anatomical planes (coronal inclination, transverse version, and sagittal ante-inclination) in the standing position with the change in sagittal pelvic tilt from standing to sitting to calculate the 3-D orientation in the sitting position. Results: The standing cup orientation of the dislocated THAs was only characterized by a lower coronal inclination (P =.039). Compared with the controls, from standing to sitting, they showed less posterior pelvic tilt (P

Background Opioids are commonly prescribed for postoperative pain following total joint arthroplasty. Despite widespread use, few studies have examined the dose-dependent effect of perioperative opioid use on postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Therefore, we examined the dose-dependent relationship between opioid use and postoperative complications following primary THA and TKA. Methods We queried the Premier Healthcare Database to identify adult patients who underwent primary elective THA or TKA from 2004 to 2014, and quantified opioid consumption within the first 3 postoperative days. Opioid consumption was standardized to morphine milligram equivalents (MMEs). Patients were divided into quintiles on the basis of MME exposure: 172 MMEs. Primary outcomes included postoperative periprosthetic joint infection, pulmonary embolism, deep venous thrombosis, and pulmonary complications. Secondary outcomes included wound infection, wound dehiscence, and readmission within 30 and 90 days postoperatively. Univariate and multivariate analyses were performed to compare differences between groups and to account for confounders. Results A total of 1,525,985 patients were identified. The mean age was 65.7 ± 10.8 years, 598,320 patients (39.2%) were male, and 1,174,314 patients (77.0%) were Caucasian. On multiple logistic regression analysis, increasing MME exposure was associated with a dose-dependent increased risk of postoperative complications. Compared with patients receiving 172 MMEs was associated with greater odds of periprosthetic joint infection (adjusted odds ratio [aOR], 1.37; 95% confidence interval [CI], 1.33 to 1.42), deep venous thromboembolism (aOR, 1.34; 95% CI, 1.30 to 1.38), pulmonary embolism (aOR, 1.29; 95% CI, 1.25 to 1.34), and pulmonary complications (aOR, 1.06; 95% CI, 1.05 to 1.08). Exposure to >172 MMEs was associated with increased risk of wound infection (aOR, 1.37; 95% CI, 1.33 to 1.41), wound dehiscence (aOR, 1.24; 95% CI, 1.19 to 1.31), and readmission within 30 (aOR, 1.21; 95% CI, 1.20 to 1.22) and 90 days (aOR, 1.20; 95% CI, 1.19 to 1.21). Conclusions Increasing opioid use within the early postoperative period following THA or TKA was associated with a dose-dependent increased risk of periprosthetic joint infection and venous thromboembolic events. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

We introduce a new sign on a Merchant view present in acute patellar tendon ruptures (APTR). We aim to determine the accuracy, sensitivity, and specificity of this new radiographic sign and measure the effect of a tutorial on these measures between trainees and non-trainees.Lateral and Merchant radiographs (22 images) of knees with four conditions (patellar instability, APTR, quadriceps tendon rupture, and controls) were randomly shown to 50 trainees and non-trainees who were asked to make a diagnosis based on radiographs. A brief tutorial was administered describing the "Empty Merchant Sign" and the same 22 images were randomly shown after the tutorial. Accuracy, sensitivity, specificity, and positive predictive value were calculated between the two image types and the effect of tutorial on these measures was assessed.After the tutorial: 1. the "Empty Merchant Sign" had a higher specificity (100%) and positive predictive value (99%) compared to the lateral radiograph (81% and 64% respectively, P 0.001), 2. There was significant improvement (from 56% to 95.3%; P 0.001) in the accuracy of the Merchant view, making it as accurate as the lateral view (95.3% vs. 90.7%, respectively; P = 0.113). There was no difference in the accuracy of the Merchant view between trainees (97.2%) and non-trainees (90.5%) (P = 0.079).The "Empty Merchant Sign" is a highly sensitive and specific diagnostic sign in cases of APTR. With very little training, physicians can identify this sign to diagnose APTRs on a Merchant view.

Background The functional anatomy of the osteoarthritic hip joint in the sagittal plane has not been defined. The purpose of this study was to define the functional anatomy of the hip using clinical and radiographic analyses. Methods 320 hips had preoperative standing and sitting lateral spine-pelvis-hip X-rays. Radiographic pelvic measurements were pelvic incidence (PI) and sacral slope (SS), and hip measurements were anteinclination (AI) and pelvic femoral angle (PFA). Pelvic tilt (PT) was calculated as PI-SS. A triangle model was created from the clinical data that illustrates the functional motion of the hip during postural changes from standing to sitting. Results Pelvic motion was coordinated with hip motion, even with spinopelvic imbalance and stiffness. Pelvic motion (ΔSS) varied for all 5 types of imbalance, but pelvic motion (ΔSS) and acetabular motion (ΔAI) changed with a 1:1 ratio and inversely with femoral motion (ΔPFA) with a 1:1 ratio. The triangle model showed similar results with ΔSS, ΔPT, and ΔAI changing in a 1:1:1 ratio, and femur motion inversely changing with a 1:1 ratio. Conclusion The functional anatomy of the hip joint can be visually illustrated using a triangle model. Pelvic angles SS, PT, and AI change in unison, whereas femoral motion (ΔPFA) changes inversely with pelvic motion (ΔSS) in a 1:1 ratio. This coordinated mobility explains the limitations of the Lewinnek safe zone, which include only the acetabulum.

Background Outcomes of knee arthroscopy (KA) after total knee arthroplasty (TKA) have been limited to small case series with short-term follow-up. The purpose of this study is to report the outcomes of patients who undergo a KA after a TKA using a large longitudinal database. Methods The PearlDiver Medicare database was queried for patients who underwent a KA procedure after a TKA on the ipsilateral extremity. A randomly selected control group was created by matching controls to cases in a 3:1 ratio based on age, gender, year of procedure, and Elixhauser Comorbidity Index. Revision for infection and all-cause revision were used as end points. Results A total of192 TKA patients who underwent a subsequent KA (TKA + KA group) were compared to 571 TKA patients who did not have a subsequent KA (TKA − KA group). The incidence of revision for infection was 6.3% in the TKA + KA group compared to 2.2% in the TKA − KA group (odds ratio, 2.87; P = .009). The incidence of all-cause revision was 18.8% in the TKA + KA group compared to 5.1% in the TKA − KA group (odds ratio, 4.34; P Conclusion KA after TKA was associated with increased infection-related and all-cause revision. The association between KA and subsequent infection requires further investigation.

Background The minimal clinically important difference (MCID) is used when interpreting the importance of outcome data. However, a consensus regarding the MCID for commonly used patient-reported outcomes in shoulder surgery has not been established. The purpose of this systematic review was to evaluate the available literature on shoulder MCID to improve clinical interpretation of shoulder outcome data. Methods A systematic review of the literature was conducted to identify studies reporting anchor-based MCID values for the patient-reported outcomes recommended by the American Shoulder and Elbow Surgeons (ASES): Veterans Rand 12 score, ASES score, Single Assessment Numeric Evaluation (SANE) score, Western Ontario Rotator Cuff (WORC) score, Western Ontario Osteoarthritis Score (WOOS), Western Ontario Shoulder Instability Index (WOSI), Pennsylvania Shoulder Score, and Oxford Shoulder Score (OSS). Results A total of 14 articles reporting anchor-based MCID values were included in the final analysis. No studies reporting the Western Ontario Osteoarthritis Score (WOOS) were identified. The ASES score (6 studies), OSS (4 studies), and WORC score (2 studies) were the only instruments investigated in more than 1 study. The average reported MCID values for the ASES, OSS, and WORC scores were 15.5 (15% total difference), 275.7 (13% total difference), and 6 (13% total difference), respectively. The vast majority of studies failed to report information necessary to validate the credibility of these MCID values. Discussion and conclusion The current utility of the MCID for patient-report shoulder outcome instruments is limited by poor study methodology, inadequate reporting, and a lack of data. Further research is needed to more clearly define the MCID values for commonly used patient-reported outcomes in shoulder surgery.

Aims In patients with a “dry” aspiration during the investigation of prosthetic joint infection (PJI), saline lavage is commonly used to obtain a sample for analysis. The aim of this study was to investigate prospectively the impact of saline lavage on synovial fluid analysis in revision arthroplasty. Methods Patients undergoing revision hip (THA) or knee arthroplasty (TKA) for any septic or aseptic indication were enrolled. Intraoperatively, prior to arthrotomy, the maximum amount of fluid possible was aspirated to simulate a dry tap (pre-lavage) followed by the injection with 20 ml of normal saline and re-aspiration (post-lavage). Pre- and post-lavage synovial white blood cell (WBC) count, percent polymorphonuclear cells (%PMN), and cultures were compared. Results A total of 78 patients had data available for analysis; 17 underwent revision THA and 61 underwent revision TKA. A total of 16 patients met modified Musculoskeletal Infection Society (MSIS) criteria for PJI. Pre- and post-lavage %PMNs were similar in septic patients (87% vs 85%) and aseptic patients (35% vs 39%). Pre- and post-lavage synovial fluid WBC count were far more disparate in septic (53,553 vs 8,275 WBCs) and aseptic (1,103 vs 268 WBCs) cohorts. At a cutoff of 80% PMN, the post-lavage aspirate had a sensitivity of 75% and specificity of 95%. At a cutoff of 3,000 WBCs, the post-lavage aspirate had a sensitivity of 63% and specificity of 98%. As the post-lavage synovial WBC count increased, the difference between pre- and post-lavage %PMN decreased (mean difference of 5% PMN in WBC < 3,000 vs mean difference 2% PMN in WBC > 3,000, p = 0.013). Of ten positive pre-lavage fluid cultures, only six remained positive post-lavage. Conclusion While saline lavage aspiration significantly lowered the synovial WBC count, the %PMN remained similar, particularly at WBC counts of > 3,000. These findings suggest that in patients with a dry-tap, the %PMN of a saline lavage aspiration has reasonable sensitivity (75%) for the detection of PJI. Cite this article: Bone Joint J 2020;102-B(6 Supple A):138–144.

Background While reimbursement models for physicians continue to evolve, limited data exist regarding recent trends in physician reimbursement for hip and knee arthroplasty. The purpose of this study is to evaluate monetary trends in Medicare reimbursement rates from 2000 to 2019 for the most common hip and knee arthroplasty procedures. Methods The American Academy of Orthopedic Surgeons coding reference was queried to determine the Current Procedural Terminology codes most frequently used in hip and knee adult reconstruction. Next, the Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services was queried for each Current Procedural Terminology code, and physician fee data were extracted. All monetary data were adjusted for inflation using the consumer price index and expressed in 2019 US dollars. The average annual and the total percent change in reimbursement were calculated based on these adjusted trends for all procedures. Results After adjusting for inflation, the average physician reimbursement decreased by 31.9% for all hip arthroplasty procedures and by 33.3% for all knee arthroplasty procedures from 2000 to 2019. During this period, primary total hip arthroplasty physician fees decreased by 37.1% and primary total knee arthroplasty fees decreased by 40.6%. From 2000 to 2019, the inflation-adjusted reimbursement rate for all procedures decreased by an average of 1.7% per year. Conclusion Throughout the study period, physician reimbursement decreased for all knee and hip arthroplasty procedures. Increased awareness and consideration of these trends will be important for policy-makers, hospitals, and surgeons to assure equitable access to quality hip and knee arthroplasty care in the United States.

Human adipose-derived mesenchymal stem cells (ASCs) transduced with a lentiviral vector system to express bone morphogenetic protein 2 (LV-BMP-2) have been shown to reliably heal bone defects in animal models. However, the influence of donor characteristics such as age, sex, race, and medical co-morbidities on ASC yield, growth and bone regenerative capacity, while critical to the successful clinical translation of stem cell-based therapies, are not well understood. Human ASCs isolated from the infrapatellar fat pads in 122 ASC donors were evaluated for cell growth characteristics; 44 underwent additional analyses to evaluate in vitro osteogenic potential, with and without LV-BMP-2 transduction. We found that while female donors demonstrated significantly higher cell yield and ASC growth rates, age, race, and the presence of co-morbid conditions were not associated with differences in proliferation. Donor demographics or the presence of comorbidities were not associated with differences in in vitro osteogenic potential or stem cell differentiation, except that transduced ASCs from healthy donors produced more BMP-2 at day 2. Overall, donor age, sex, race, and the presence of co-morbid conditions had a limited influence on cell yield, proliferation, self-renewal capacity, and osteogenic potential for non-transduced and transduced (LV-BMP-2) ASCs. These results suggest that ASCs are a promising resource for both autologous and allogeneic cell-based gene therapy applications.

Prior studies evaluating perioperative risk associated with smoking following total joint arthroplasty (TJA) have assessed smoking as a categorical variable. The purpose of this study was to analyze smoking as a risk factor for complications following TJA by assessing pack-year data as a continuous variable. The National Surgical Quality Improvement Program (NSQIP) database was used to identify primary total hip (THA) and total knee arthroplasty (TKA) patients. Propensity scoring was used to match smokers with nonsmokers based on age and sex. Pack-year data were treated as a continuous variable using a smoothing cubic spline analysis to assess risk of wound complications, thrombotic events, 30-day readmission, and total complications. A total of 1044 smokers who underwent a primary TJA were matched to 1044 controls from 143,641 nonsmokers. Smoothing spline analysis did not identify a relationship between increasing pack-years and wound complications, thrombotic events, or total complications. However, the 30-day readmission rate was increased regardless of the pack-year exposure (odds ratio, 2.30; 95% CI, 1.45–3.65; P P Orthopedics . 2021;44(5):e639–e644.]

Background Cutibacterium (formerly Propionibacterium) acnes persists in the dermis despite standard skin antiseptic agents, prompting some surgeons to use topical antimicrobials such as benzoyl peroxide and clindamycin prior to shoulder arthroplasty surgery. However, the efficacy of these topical agents has not been established. Methods The upper backs of 12 volunteers were randomized into 4 treatment quadrants: topical benzoyl peroxide, topical clindamycin, combination topical benzoyl peroxide and clindamycin, and a negative control. The corresponding topical agents were applied to each site twice daily for 3 days. A 3-mm dermal punch biopsy specimen was obtained from each site and cultured for 14 days to assess for C acnes growth. Positive cultures were assessed for the hemolytic phenotype. The McNemar test was used to compare the proportion of positive cultures in each group. Results C acnes grew in 4 of 12 control sites (33.3%), 1 of 12 benzoyl peroxide sites (8.3%), 2 of 12 clindamycin sites (16.7%), and 2 of 12 combination benzoyl peroxide–clindamycin sites (16.7%). The C acnes hemolytic phenotype was present in 2 of 12 control specimens (16.7%) compared with 0 (0.0%) in the benzoyl peroxide group, 2 of 12 (16.7%) in the clindamycin group, and 2 of 12 (16.7%) in the combination benzoyl peroxide–clindamycin group. There were no statistically significant differences between treatment arms. Conclusion The topical application of benzoyl peroxide and clindamycin did not eradicate C acnes in all subjects. The clinical implications of these findings are yet to be determined.

INTRODUCTION Intramedullary devices are being used more frequently to treat intertrochanteric (IT) femur fractures but without clear benefit in several clinical trials. This study determines differences in complication rates in patients with IT fractures treated with intramedullary versus extramedullary devices. METHODS Using the National Surgical Quality Improvement Program database, patients aged ≥55 years with an isolated IT fracture and an American Society of Anesthesiologists score of

Background: Computer navigation and robotic assistance technologies are used to improve the accuracy of component positioning in total knee arthroplasty (TKA), with the goal of improving function and optimizing implant longevity. The purpose of this study was to analyze trends in the use of technology-assisted TKA, identify factors associated with the use of these technologies, and describe potential drivers of cost. Methods: The Nationwide Inpatient Sample database was used to identify patients who underwent TKA using conventional instrumentation, computer navigation, and robot-assisted techniques between 2005 and 2014. Variables analyzed include patient demographics, hospital and payer types, and hospital charges. Descriptive statistics were used to describe trends. Univariate and multivariate analyses were performed to identify differences between conventional and technology-assisted groups. Results: Our analysis identified 6,060,901 patients who underwent TKA from 2005 to 2014, of which 273,922 (4.5%) used computer navigation and 24,084 (0.4%) used robotic assistance. The proportion of technology-assisted TKAs steadily increased over the study period, from 1.2% in 2005 to 7.0% in 2014. Computer navigation increased in use from 1.2% in 2005 to 6.3% in 2014. Computer navigation was more likely to be used in the Western United States, whereas robot-assisted TKAs were more likely to be performed in the Northeast. Increased hospital charges were associated with the use of technology assistance ($53,740.1 vs $47,639.2). Conclusions: The use of computer navigation and robot-assisted TKA steadily increased over the study period, accounting for 7.0% of TKAs performed in the United States in 2014. Marked regional differences in the use of these technologies were identified. The use of these technologies was associated with increased hospital charges. Keywords: Computer navigation, Technology assistance, Total knee arthroplasty, Trends, TKA

Purpose To understand the effect of obesity on operative times and 30-day readmission rates after arthroscopic anterior cruciate ligament reconstruction (ACLR). Methods The American College of Surgeons National Surgical Quality Improvement Program database was queried using Current Procedural Terminology billing codes to identify all patients aged 18 years and older who underwent ACLR between 2007 and 2014. The Student t test was used for continuous variables, and the χ-square or Fisher exact test was used for categorical variables. Multivariate analysis was conducted to identify factors associated with 30-day readmission. Results We identified 9,000 patients who underwent ACLR. In the readmission analysis, the total readmission rate was 0.70%. After multivariate analysis, a body mass index (BMI) of 40 or greater was associated with a significantly increased risk of 30-day readmission (odds ratio, 3.06; 95% confidence interval, 1.09-8.57). An operative time of less than 80 minutes was associated with a decreased risk of readmission (odds ratio, 0.40, 95% confidence interval, 0.18-0.92). In the operative-time analysis, the mean operative time was 100.7 minutes. Older age was predictive of decreasing operative time, with the operative time being 32.75 minutes shorter in patients aged 65 years or older than in those younger than 25 years. After multivariate analysis, class II obesity (BMI of 35-39.9) predicted an increase of 7.11 minutes and class III obesity (BMI ≥ 40) predicted an increase of 8.70 minutes compared with normal weight (BMI of 18.5-24.9). Conclusions Obesity is associated with longer operative times and increased 30-day readmissions after ACLR, with patients with a BMI of 40 or greater having over 3 times the risk of readmission compared with patients with a normal weight. Male sex, black race, and younger age are all also associated with increased operative times. Level of Evidence Level III, observational, retrospective cohort study.

Abnormal spinopelvic motion from spine pathology is associated with inferior outcomes after total hip arthroplasty, including inferior patient-reported outcomes, increased rates of instability, and higher revision rates. Identifying these high-risk patients preoperatively is important to conduct the appropriate workup and formulate a surgical plan. Standing and sitting lateral spinopelvic radiographs are able to identify and quantify abnormal spinopelvic motion. Depending on the type of spinopelvic deformity, some patients may require increased anteversion, increased offset, and large diameter heads or dual mobility articulations to prevent dislocation. This review article will provide the reader with practical information that can be applied to patients regarding the terminology, pathophysiology, evaluation, and management of total hip arthroplasty patients with spinopelvic pathology.

STUDY DESIGN This is a retrospective cohort study of consecutive patients undergoing lumbar spinal fusion (LSF) within the PearlDiver Humana research database from 2010 to 2018. OBJECTIVE The aim of this study was to determine if timing of total hip arthroplasty (THA) affects LSF outcomes. SUMMARY OF BACKGROUND DATA In patients with both spine and hip pathology, outcomes of THA have been shown to be affected by the timing of THA relative to LSF. However, few studies have assessed postoperative outcomes following LSF in this clinical scenario. MATERIALS AND METHODS A national database was queried for patients undergoing lumbar fusion and divided into 4 groups: (1) those who underwent LSF without THA (No THA); (2) those who underwent THA at least 2 years before LSF (>2 Prior THA); (3) those who underwent THA in the 2 years before LSF (0-2 Prior THA); and (4) those who underwent THA after LSF (THA After). We assessed lumbar-specific outcomes, including pseudarthrosis, revision, mechanical failure, and adjacent segment disease (ASD); as well as systemic complications. Controlling for age, sex, and Charlson comorbidity index, complication rates between all groups were assessed using univariate and multivariate logistic regression analysis. Post hoc comparisons were performed using the Fisher exact test with Bonferroni correction to account for multiple pairwise comparisons, resulting in an adjusted threshold for statistical significance of P

Background Limb length discrepancy (LLD) after total hip arthroplasty may affect clinical outcomes and patient satisfaction. Preoperative LLD estimates on anteroposterior pelvic radiographs fail to account for anatomical limb variation distal to the femoral reference points. The objective of this study is to determine how variations in lower limb skeletal lengths contribute to true LLD. Methods Full-length standing anteroposterior radiographs were used to measure bilateral leg length, femoral length, and tibial length. Leg length was evaluated using 2 different proximal reference points: the center of the femoral head (COH) and the lesser trochanter (LT). Mean side-to-side discrepancy (MD) and percentage asymmetry (%AS) for each measurement were evaluated in the overall cohort and when stratified by patient demographic variables. Results One hundred patients were included with an average age of 62.9 ± 11.2 years. Average femoral length was 434.0 ± 39.8 mm (MD 4.3 ± 3.5 mm) and tibial length was 379.9 ± 34.6 mm (MD 5.9 ± 12.7 mm). Average COH-talus was 817.5 ± 73.2 mm (MD 6.4 ± 5.1 mm). Average LT-talus was 760.5 ± 77.6 mm (MD 5.8 ± 5.1 mm). Absolute asymmetry >10 mm was detected in 16% of patients for COH-talus and 15% for LT-talus, while %AS >1.5% was detected in 13% of patients for COH-talus and 18% for LT-talus. Female gender was associated with increased femoral length %AS (P = .037). Conclusion Approximately 1 in 6 patients have an LLD of >10 mm when measured from either the LT or COH. Surgeons using either of these common femoral reference points to estimate LLD on pelvic radiographs should consider these findings when planning for hip reconstruction. Level of Evidence Level III.

Active patients with displaced femoral neck fractures are often treated with total hip arthroplasty (THA). However, optimal femoral fixation in these patients is controversial. The purpose of this study was to compare early complication and readmission rates in patients with hip fracture treated with THA receiving cemented vs cementless femoral fixation.The National Readmissions Database was queried to identify patients undergoing primary THA for femoral neck fracture from 2016 to 2017. Postoperative complications and unplanned readmissions at 30, 90, and 180 days were compared between patients treated with cemented and cementless THA. Univariate and multivariate analyses were performed to compare differences between groups and account for confounding variables.Of 17,491 patients identified, 4427 (25.3%) received cemented femoral fixation and 13,064 (74.7%) cementless. The cemented group was significantly older (77.2 vs 71.1, P.001), had more comorbidities (Charlson comorbidity index: 4.44 vs 3.92, P.001), and had a greater proportion of women (70.5% vs 65.2%, P.001) compared with the cementless group. On multivariate analysis, cemented fixation was associated with reduced rates of periprosthetic fracture (odds ratio: 0.052, 95% confidence interval: 0.003-0.247, P = .004) at 30 days but similar readmission rates at 30, 90, and 180 days (odds ratio range: 1.012-1.114, P.05) postoperatively compared with cementless fixation. Cemented fixation was associated with greater odds of medical complications at 180 days postoperatively (odds ratio:: 1.393, 95% confidence interval: 1.042-1.862, P = .025).Cemented femoral fixation was associated with a lower short-term incidence of periprosthetic fractures, higher incidence of medical complications, and equivalent unplanned readmission rates within 180 days postoperatively compared with cementless fixation in patients undergoing THA for femoral neck fracture.Level III.

To determine individual bilateral differences (IBDs) in tibial torsion in a diverse population.Computed tomography scans of uninjured bilateral tibiae were used to determine tibial torsion and IBDs in torsion using 4 measurement methods. Age, sex, and self-identified race/ethnicity were also recorded for each subject. Mean tibial torsion and IBDs in torsion were compared in the overall cohort and when stratified by sex and race/ethnicity. Simple and multiple linear regression models were used to correlate demographic variables with tibial torsion and IBDs in torsion.One hundred ninety-five patients were evaluated. The mean tibial torsion was 27.5 ± 8.3 degrees (range -3 to 47.5 degrees). The mean IBD in torsion was 5.3 ± 4.0 degrees (range 0-23.5 degrees, P0.001). 12.3% of patients had IBDs in torsion of ≥10 degrees. In the regression analysis, patients who identified as White had greater average torsion by 4.4 degrees compared with Hispanic/Latinx patients (P = 0.001), whereas age and sex were not significantly associated with absolute torsion. Demographics were not associated with significant differences in IBDs in torsion.Tibial torsion varies considerably and individual side-to-side differences are common. Race/ethnicity was associated with differences in the magnitude of tibial torsion, but no factors were associated with bilateral differences in torsion. The results of this study may be clinically significant in the context of using the uninjured contralateral limb to help establish rotational alignment during medullary nail stabilization of diaphyseal tibia fractures. In addition, these findings should be considered in the evaluation of tibia rotational malalignment.Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Case A 73-year-old woman was diagnosed with a nondisplaced incomplete atypical bisphosphonate-related subtrochanteric femur fracture and ipsilateral hip osteoarthritis. She was treated with a total hip arthroplasty using a monoblock revision stem and a strut allograft to provide adjunctive mechanical and biological support. At the final follow-up, the patient had no pain, the stem was well fixed, and the allograft strut had incorporated; however, a persistent fracture line was noted. Conclusion When an atypical femur fracture coexists with hip osteoarthritis, total hip arthroplasty may be a reasonable treatment option to address the fracture and concomitant hip osteoarthritis with a single surgical intervention. However, consideration should be given to using a stem with distal fixation and augmenting the construct with a strut allograft.

Dual mobility (DM) bearings are an attractive treatment option to obtain hip stability during challenging primary and revision total hip arthroplasty (THA) cases. The purpose of this study was to analyze data submitted to the American Joint Replacement Registry (AJRR) to characterize utilization trends of DM bearings in the USA.All primary and revision THA procedures reported to AJRR from 2012 to 2018 were analyzed. Patients of all ages were included and subdivided into DM and traditional bearing surface cohorts. Patient demographics, geographical region, hospital size, and teaching affiliation were assessed. Associations were determined by chi-squared analysis and logistic regression was performed to assess outcome variables.A total of 406,900 primary and 34,745 revision THAs were identified, of which 35,455 (8.7%) and 8,031 (23.1%) received DM implants respectively. For primary THA, DM usage increased from 6.7% in 2012 to 12.0% in 2018. Among revision THA, DM use increased from 19.5% in 2012 to 30.6% in 2018. Patients50 years of age had the highest rates of DM implantation in every year examined. For each year of increase in age, there was a 0.4% decrease in the rate of DM utilization (odds ratio (OR) 0.996 (95% confidence interval (CI) 0.995 to 0.997); p0.001). Females were more likely to receive a DM implant compared to males (OR 1.077 (95% CI 1.054 to 1.100); p0.001). Major teaching institutions and smaller hospitals were associated with higher rates of utilization. DM articulations were used more commonly for dysplasia compared with osteoarthritis (OR 2.448 (95% CI 2.032 to 2.949); p0.001) during primary THA and for instability (OR 3.130 (95% CI 2.751 to 3.562) vs poly-wear; p0.001) in the revision setting.DM articulations showed a marked increase in utilization during the period examined. Younger patient age, female sex, and hospital characteristics such as teaching status, smaller size, and geographical location were associated with increased utilization. DM articulations were used more frequently for primary THA in patients with dysplasia and for revision THA in patients being treated for instability. Cite this article

Background:Ulnar collateral ligament (UCL) reconstruction is frequently performed on Major League Baseball (MLB) pitchers. Previous studies have investigated the effects of UCL reconstruction on fastball and curveball velocity, but no study to date has evaluated its effect on fastball accuracy or curveball movement among MLB pitchers.Purpose/Hypothesis:The primary purpose of this study was to determine the effects of UCL reconstruction on fastball accuracy, fastball velocity, and curveball movement in MLB pitchers. Our hypothesis was that MLB pitchers who underwent UCL reconstruction would return to their presurgery fastball velocity, fastball accuracy, and curveball movement. The secondary purpose of this study was to determine which factors, if any, were predictive of poor performance after UCL reconstruction.Study Design:Case-control study; Level of evidence, 3.Methods:MLB pitchers who underwent UCL reconstruction surgery between 2011 and 2012 were identified. Performance data including fastball velocity, fastball accuracy, and curveball movement were evaluated 1 year preoperatively and up to 3 years of play postoperatively. A repeated-measures analysis of variance with a Tukey-Kramer post hoc test was used to determine statistically significant changes in performance over time. Characteristic factors and presurgery performance statistics were compared between poor performers (>20% decrease in fastball accuracy) and non—poor performers.Results:We identified 56 pitchers with a total of 230,995 individual pitches for this study. After exclusion for lack of return to play (n = 14) and revision surgery (n = 3), 39 pitchers were included in the final analysis. The mean presurgery fastball pitch-to-target distance was 32.9 cm. There was a statistically significant decrease in fastball accuracy after reconstruction, which was present up to 3 years postoperatively ( P = .007). The mean presurgery fastball velocity of 91.82 mph did not significantly change after surgery ( P = .194). The mean presurgery curveball movement of 34.49 cm vertically and 5.89 cm horizontally also did not change significantly ( P = .937 and .161, respectively).Conclusion:Fastball accuracy among MLB pitchers significantly decreased after UCL reconstruction for up to 3 years postoperatively. There were no statistically significant differences in characteristic factors or presurgery performance statistics between poor and non--poor performers.

» The optimal regimen for wound irrigation in the setting of an open fracture has been a subject of debate. Basic science evidence as well as results from a recent prospective clinical trial have shed new light on this controversial topic. » While normal saline solution appears to be the optimal irrigation agent, the optimal timing and volume often are determined by the surgeon. Future clinical trials are needed to determine the optimal timing for debridement and irrigation, as well as the ideal volume of irrigant. » Irrigation pressure and the use of pulsatile lavage do not appear to have an effect on outcomes.

Background The goal of computer navigation in total knee arthroplasty (TKA) is to improve the accuracy of alignment. However, the relationship between this technology and implant longevity has not been established. The purpose of this study was to analyze survivorship of computer-navigated TKAs compared with traditionally instrumented TKAs. Methods The PearlDiver Medicare database was used to identify patients who underwent a primary TKA using conventional instrumentation versus computer navigation between 2005 and 2014. Conventional and computer-navigated cohorts were matched by age, sex, year of procedure, comorbidities, and geographic region. Kaplan-Meier curves were generated to estimate survivorship with aseptic mechanical complications, periprosthetic joint infection, and all-cause revision as end points. Results During the study period, 75,709 patients who underwent a computer-navigated TKA were identified and matched to a cohort of 75,676 conventional TKA patients from a cohort of 1,607,803 conventional TKA patients. No difference existed in survival between conventional instrumentation (94.7%) and navigated TKAs (95.1%, P = 0.06) at 5 years. A modest decrease was found in revisions secondary to mechanical complications associated with navigation (96.1%) compared with conventional instrumentation (95.7%, P = 0.02) at 5 years. No differences in revision rates because of periprosthetic joint infection were observed (97.9% versus 97.9% event-free survival, P = 0.30). In a subgroup of Medicare patients younger than 65 years of age, use of computer navigation was associated with a decrease in all-cause revision (91.4% versus 89.6% event free survival, P = 0.01) and revision secondary to mechanical complications (89.6% versus 87.8% event-free survival, P = 0.01) at 5 years. Discussion Among Medicare patients, no notable difference existed in TKA survival associated with the use of computer navigation at the 5-year follow-up. Use of computer navigation was associated with a slight decrease in revisions secondary to mechanical failure. Although improved survivorship was associated with patients younger than 65 years of age who had a navigated TKA, generalizability of these findings is limited given the unique characteristics of this Medicare subpopulation.

Accurate and precise component positioning in total hip arthroplasty is a ubiquitous goal amongst hip surgeons and an important topic of research. Early studies defined a “safe zone” for placement of the acetabular cup, and divergence from the defined safe zone was shown to predispose patients to dislocation [1]. However, ideas regarding the position of the acetabular cup have continued to evolve beyond the initial description by Lewinnek in 1978 [1]. Murray et al. [2], in 1993, defined anatomic, operative, and radiographic parameters for inclination and anteversion. DiGioa et al. expanded upon this work by describing functional cup position, rather than just anatomical inclination and anteversion, as being the angles of the acetabulum that correlated to the axis of the body, using lateral radiographic measurements of the spine, pelvis, and hip [3]. This expanded definition was the first to consider spinal parameters as part of a functional spine–pelvis–hip relationship. Lazennec et al. [4], in France, used a new imaging modality (EOS, Biospace Med, Paris, France) to clearly demonstrate the interrelationship of spinal mobility to acetabular position during postural change of sitting to standing (Fig. 12.1). This research increased our understanding that spine–pelvis–hip motion is synchronized for the purpose of allowing the normal hip to move freely through its arc of motion without the greater trochanter impinging on the pelvis, or the lesser trochanter on the ischium. As hip surgeons learned more about the anatomy of this spine–pelvis–hip relationship, research shifted to studying the effect of this relationship on outcomes following total hip arthroplasty. The cumulative effect of that work has been to redefine the safe zone for acetabular component positioning (functional safe zone) and the influence of sagittal hip motion by taking into account spinopelvic motion. This chapter will focus on the evolving definition of an acetabular safe zone in the context of the spine–pelvis–hip construct, as well as how to personalize and optimize component positioning based on patient-specific spinopelvic parameters.

The shift from long length of stays after total joint arthroplasty (TJA) to rapid recovery total joint arthroplasty has been made possible by significant advances in process improvement. Patient selection and preoperative optimization remain critical for rapid recovery TJA. Intraoperative measures such as the administration of preoperative antibiotics, multimodal analgesia and anesthesia, tranexamic acid, and betadine lavage have all reduced complications and optimized functional outcomes. These changes in TJA are the result of research that has allowed clinicians to make incremental improvements in post-operative recovery following joint arthroplasty. This chapter will discuss how evidence has led to process improvements following joint replacement surgery by expanding on the aforementioned topics.

Intra-articular drug delivery has a number of advantages over systemic administration; however, for the past 20 years, intra-articular treatment options for the management of knee osteoarthritis (OA) have been limited to analgesics, glucocorticoids, hyaluronic acid (HA) and a small number of unproven alternative therapies. Although HA and glucocorticoids can provide clinically meaningful benefits to an appreciable number of patients, emerging evidence indicates that the apparent effectiveness of these treatments is largely a result of other factors, including the placebo effect. Biologic drugs that target inflammatory processes are used to manage rheumatoid arthritis, but have not translated well into use in OA. A lack of high-level evidence and methodological limitations hinder our understanding of so-called ‘stem’ cell therapies and, although the off-label administration of intra-articular cell therapies (such as platelet-rich plasma and bone marrow aspirate concentrate) is common, high-quality clinical data are needed before these treatments can be recommended. A number of promising intra-articular treatments are currently in clinical development in the United States, including small-molecule and biologic therapies, devices and gene therapies. Although the prospect of new, non-surgical treatments for OA is exciting, the benefits of new treatments must be carefully weighed against their costs and potential risks. Intra-articular therapies for knee osteoarthritis (OA) are causing excitement among clinicians and patients, but care should be taken when choosing which therapy to use. In this Review, Vangsness and colleagues critically appraise current and future intra-articular therapies for knee OA.

AIM To explore the current evidence surrounding the administration of prophylactic antibiotics for arthroscopic knee surgery. METHODS Databases were searched from inception through May of 2018 for studies examining prophylactic antibiotic use and efficacy in knee arthroscopy. Studies with patient data were further assessed for types of arthroscopic procedures performed, number of patients in the study, use of antibiotics, and outcomes with the intention of performing a pooled analysis. Data pertaining to “deep tissue infection” or “septic arthritis” were included in our analysis. Reported data on superficial infection were not included in our data analysis. For the pooled analysis, a relative risk ratio was calculated and χ2 tests were used to assess for statistical significance between rates of infection amongst the various patient groups. Post hoc power analyses were performed to compute the statistical power obtained from our sample sizes. Number needed to treat analyses were performed for statistically significant differences by dividing 1 by the difference between the infection rates of the antibiotic and no antibiotic groups. An alpha value of 0.05 was used for our analysis. Study heterogeneity was assessed by Cochrane’s Q test as well as calculation of the I2 value. RESULTS A total of 49682 patients who underwent knee arthroscopy for a diverse set of procedures across 19 studies met inclusion critera for pooled analysis. For those not undergoing graft procedures, there were 27 cases of post-operative septic arthritis in 34487 patients (0.08%) who received prophylactic antibiotics and 16 cases in 10911 (0.15%) who received none [risk ratio (RR) = 0.53, 95% confidence interval (CI): 0.29-0.99, P = 0.05]. A sub-group analysis in which bony procedures were excluded was performed which found no significant difference in infection rates between patients that received prophylactic antibiotics and patients that did not (P > 0.05). All anterior cruciate ligament reconstruction studies used prophylactic antibiotics, but two studies investigating the effect of soaking the graft in vancomycin in addition to standard intravenous (IV) prophylaxis were combined for analysis. There were 19 cases in 1095 patients (1.74%) who received IV antibioitics alone and no infections in 2034 patients who received IV antibiotics and had a vancomycin soaked graft (RR = 0.01, 95%CI: 0.001-0.229, P < 0.01). CONCLUSION Prophylactic antibiotics are effective in preventing septic arthritis following simple knee arthroscopy. In procedures involving graft implantation, graft soaking reduces the rate of infection.

Intra-articular tongue-type fractures may develop skin breakdown and often require urgent surgical reduction and fixation. Recognition of the imaging findings, accurate interpretation, and timely communication may prevent devastating clinical outcomes including soft tissue coverage procedures and amputation. This article reviews the anatomy of the calcaneus, as well as the clinical presentation and imaging findings of intra-articular tongue-type fractures. Imaging interpretation and clinical management of these fractures are discussed.

Purpose To investigate the efficacy of various skin preparations at eradicating Propionibacterium acnes in the dermal layer of the skin. Methods Twelve healthy volunteers consented to participate in this study. Each subject's upper back was prepped using 4 different techniques: an isopropyl alcohol control, chlorhexidine gluconate paint, chlorhexidine gluconate plus a mechanical scrub, and a high-concentration chlorhexidine gluconate plus a mechanical scrub. A 3-mm dermal punch biopsy specimen was obtained at each preparation site. The 4 punch biopsy specimens were cultured for 14 days to assess for P. acnes growth. A Fisher's exact test was used to compare the proportion of positive cultures in each group and across biopsy sites. A Skillings-Mack test was used to compare the degree of culture positivity between the treatment arms. Results There were no reported complications in any of our subjects. P. acnes grew in 7 of the 12 control sites, 5 of the 12 chlorhexidine gluconate sites, 6 of the 12 chlorhexidine plus mechanical scrub sites, and 6 of the 12 high-concentration chlorhexidine gluconate plus mechanical scrub sites. There were no statistically significant differences between any of the treatment arms ( P = .820). Conclusions P. acnes persisted despite a variety of clinically relevant skin antisepsis preparations and techniques. Level of Evidence Level II, prospective comparative study.

The greater tuberosity is an important anatomic structure and its integrity is important for shoulder abduction and external rotation. Isolated fractures of the greater tuberosity are often subtle and may not be detected on initial radiographs. Clinically, these patients display symptoms which mimic a full thickness rotator cuff tear. It is important to differentiate these two entities, as their treatment is different (typically nonsurgical management for minimally displaced fractures versus rotator cuff repair for acute full thickness rotator cuff tears). When greater tuberosity fractures are significantly displaced and allowed to heal without anatomic reduction, they can lead to impingement. This article will review greater tuberosity anatomy and function, as well as the clinical presentation and multimodality imaging findings of greater tuberosity fractures. Imaging optimization, pitfalls, and clinical management of these fractures will also be discussed.

Venous thromboembolism (VTE) prophylaxis is recommended for all patients undergoing total hip arthroplasty or total knee arthroplasty. The selection of an appropriate prophylaxis regimen represents a balance between efficacy and safety. To help orthopaedic surgeons select an appropriate VTE prophylaxis regimen for their patients, the American Academy of Orthopaedic Surgeons and the American College of Chest Physicians have developed guidelines. These guidelines do not recommend an optimal regimen, however. Rather, an individualized prophylaxis regimen that balances efficacy and safety is recommended for each patient, based on various risk factors. Because of a paucity of data and a lack of adequately powered head-to-head trials, implementing these guidelines can be challenging for the orthopaedic surgeon. Knowledge of the prophylaxis options and the VTE risk factors is paramount for developing an effective VTE prophylaxis algorithm for the surgeon's practice.

Background: Flexor zone II is defined as the region spanning the proximal aspect of the A1 pulley to the insertion of the flexor digitorum superficialis (FDS) tendon. Descriptions of the FDS insertion are inconsistent in the literature, but zones of injury are frequently determined with reference to superficial landmarks. The purpose of this study was to describe the footprint of the FDS insertion and define its relationship to the proximal interphalangeal (PIP) skin crease. Methods: The FDS insertion on the index, middle, ring, and small fingers was dissected in 6 matched pairs of fresh-frozen cadaveric hands. A Kirschner wire was used to mark the level of the PIP skin crease on bone before measurements of the FDS footprint and its position relative to the PIP skin crease were made using digital calipers. Results: The radial and ulnar FDS slips inserted a mean distance of 3.22 mm from the distal aspect of the PIP skin crease and varied by digit. The mean distal extent of the FDS insertion was 8.29 mm. The mean length of the insertion of each FDS slip was 5.15 mm and the mean width was 1.9 mm. Conclusions: The radial and ulnar FDS slips insert on average 3.22 mm distal to the PIP skin crease and vary by digit. Knowledge of the FDS insertion is clinically relevant when differentiating between flexor zone I and zone II injuries, planning surgical approaches to the finger, and in guiding patient expectations for surgery given the variability in outcome based on zone of injury.

Background Treatment of scaphoid proximal pole (SPP) nonunion with a vascularized osteochondral graft from the medial femoral trochlea (MFT) has been described, with positive outcomes thus far. However, our understanding of the congruency between the articular surfaces of these structures is incomplete. Objective Our purpose was to evaluate the congruency of the MFT and SPP using a quantitative anatomical approach. Methods The distal femur and ipsilateral scaphoid were dissected from 12 cadavers and scanned with computerized tomography. Three-dimensional models were created and articular surfaces were digitally “dissected.” The radius of curvature (RoC) of the radioulnar (RU) and proximodistal (PD) axes of the SPP and MFT, respectively, as well as the orthogonal axes (SPP, anteroposterior [AP]; MFT, mediolateral [ML]) were calculated. The RoC values were compared using the Wilcoxon signed-rank test. Results The RoC values for the SPP and MFT were not significantly different in the RU–PD plane (p = 0.064). However, RoC values for the SPP and MFT were significantly different in the AP-ML plane (p = 0.001). Conclusions For most individuals, the RU curvature of the SPP was similar to the PD curvature of the MFT. For nearly all individuals, the AP curvature of the SPP and the ML curvature of the MFT shared less congruence. Clinical Relevance Articular surface congruity may not be a critical factor associated with improvements in wrist function following this procedure.

Patients with adult acquired flatfoot have progressive worsening of bony alignment with many being unable to perform a heel rise. Following reconstruction, pathologic skeletal alignment is corrected and the ability to perform a heel rise is often restored. The purpose of this study was to evaluate the relationship between forefoot liftoff forces and skeletal alignment in a cadaveric flatfoot model by assessing the effect of sequential lengthening of the lateral column using an Evans-type calcaneal osteotomy. Bony alignment was measured in 8 cadaveric specimens with the use of a 3-dimensional digitizing system. Transection of the spring ligament, pie-crusting of the plantar fascia, and cyclic axial loading of the foot was performed to create an anatomic and functional flatfoot model. An Evans-type calcaneal osteotomy using 6, 8, 10, and 12 mm wedges was performed. Specimens were mounted to a custom jig that applies tensile loads to the Achilles, peroneus brevis, peroneus longus, and tibialis posterior tendons. Creation of a flatfoot reduced the lateral talo-first metatarsal angle (Meary's angle) by 13° (23.6° ± 2.8° vs 10.6° ± 3.8°, p < .05) and forefoot force by 7% (199.3 N ± 7.3 N vs 185.4 N ± 9 N, p < .05). Sequential lengthening of the lateral column restored skeletal alignment and force transfer to the forefoot (12 mm wedge: Meary's angle 22.7° ± 3.9°, liftoff force 206.8 N ± 7.5 N). The cadaveric flatfoot model demonstrated decreased forefoot forces that were restored with an Evans-type calcaneal osteotomy wedge. This highlights the importance of restoring skeletal alignment when correcting advanced adult acquired flatfoot.

Irrigation and debridement (I&D) is the gold standard for treatment of pediatric septic arthritis of the hip. If the index surgery fails, subsequent surgery may be required to eradicate the infection, resulting in substantial increases in morbidity, healthcare costs, and psychosocial burden. The purpose of this study was to identify the incidence of failed I&D for pediatric septic arthritis of the hip, defined by the need for at least one subsequent surgical intervention, and potential risk factors for failed initial I&D. The Kids' Inpatient Database was used to extract data for pediatric patients diagnosed with septic arthritis of the hip from 1997 to 2012. Factors such as patient demographics, preoperative comorbidities, inpatient variables, and hospitals variables were assessed for associations with successful versus failed I&Ds. During the period examined, 3341 (94.3%) children were successfully treated with a single I&D, whereas 203 (5.7%) children required at least one additional surgery during the same hospitalization. Univariate analysis found anemia, coagulopathy, and electrolyte disorders to be associated with repeat surgery. Patients who required multiple surgeries had significantly longer lengths of stay (11.3 vs. 6.9 days), higher likelihood of being discharged with home health (39 vs. 25%), and higher total overall inpatient costs ($58 400 vs. $31 900). On the basis of the results of this study, the nationwide incidence of patients requiring multiple I&Ds was 5.7%. Patient preoperative comorbidities such as coagulopathy, and hospital characteristics such as government ownership and teaching status were significantly associated with failed initial I&D for septic arthritis of the hip. We believe this data can be useful in guiding future research efforts and providing clearer anticipatory guidance to patients and guardians. Level of evidence: Level III: Retrospective comparative study.

Topical intrawound vancomycin has been used extensively in spine surgery to decrease surgical site infections. However, the efficacy of intrawound vancomycin in total hip (THA) and total knee arthroplasty (TKA) to prevent periprosthetic joint infection (PJI) has not been established.The PubMed and MEDLINE databases were searched to identify studies utilizing intrawound vancomycin in primary and revision THA and TKA. Data for postoperative infection were pooled using random effect models with results reported as odds ratios (ORs) and 95% confidence intervals. Studies were weighted by the inverse variance of their effect estimates.Of the 91 studies identified, 6 low-quality retrospective studies (level III) were pooled for further analysis. A total of 3298 patients were assessed, 1801 of which were treated with intrawound vancomycin. Overall, patients who received vancomycin had a decreased rate of PJI (OR 0.2530, P.0001). When analyzed separately, TKA patients and THA patients who received intrawound vancomycin had lower rates of PJI (OR 0.3467, P = .0005 and OR 0.3672, P = .0072, respectively). Pooled primary TKA and THA patients receiving vancomycin saw the rate of PJI decrease (OR 0.4435, P = .0046). Pooled revision TKA and THA patients saw a similar decrease in infection rates (OR 0.2818, P = .0013). No apparent publication bias was observed; however, the results from this analysis are limited by the low quality of evidence and inherent potential for bias.Intrawound vancomycin may reduce the risk of PJI in primary and revision TKA and THA. However, only low-quality evidence exists, highlighting the need for randomized controlled trials before broad adoption of this practice can be recommended given the potential implications of widespread use of vancomycin in hip and knee arthroplasty.

Instability is a common reason for revision surgery after total hip arthroplasty (THA). Recent studies suggest that revisions performed in the early postoperative period are associated with higher complication rates. The purpose of this study is to assess the effect of timing of revision for instability on subsequent complication rates.The Medicare Part A claims database was queried from 2010 to 2017 to identify revision THAs for instability. Patients were divided based on time between index and revision surgeries:1, 1-2, 2-3, 3-6, 6-9, 9-12, and12 months. Complication rates were compared between groups using multivariate analyses to adjust for demographics and comorbidities.Of 445,499 THAs identified, 9298 (2.1%) underwent revision for instability. Revision THA within 3 months had the highest rate of periprosthetic joint infection (PJI): 14.7% at1 month, 12.7% at 1-2 months, and 10.6% at 2-3 months vs 6.9% at12 months (P.001). Adjusting for confounding factors, PJI risk remained elevated at earlier periods:1 month (adjusted odds ratio [aOR]: 1.84, 95% confidence interval [CI]: 1.51-2.23, P.001), 1-2 months (aOR: 1.45, 95% CI: 1.16-1.82, P = .001), 2-3 months (aOR: 1.35, 95% CI: 1.02-1.78, P = .036). However, revisions performed within 9 months of index surgery had lower rates of subsequent instability than revisions performed12 months (aOR: 0.67-0.85, P.050), which may be due to lower rates of acetabular revision and higher rates of head-liner exchange in this later group.When dislocation occurs in the early postoperative period, delaying revision surgery beyond 3 months from the index procedure may be warranted to reduce risk of PJI.

Background: Several studies have examined the effect of insurance on the management of various orthopedic conditions. The purpose of our study was to assess the effect of insurance and other demographic factors on the operative management of tibiotalar osteoarthritis. Methods: The National Inpatient Sample (NIS) database was used to identify patients who underwent a total ankle arthroplasty (TAA) or tibiotalar arthrodesis (TTA) for tibiotalar osteoarthritis. Insurance status was identified for each patient, and the proportions of each insurance type were computed for each operative modality. A multivariate analysis was performed to account for confounding variables to isolate the effect of insurance type on operative treatment. Results: From 2007 to 2012, a total of 10 010 patients (35.6%) were identified who underwent a total ankle replacement (TAR) procedure and 18 094 patients (64.4%%) who underwent TTA for tibiotalar osteoarthritis. Patients receiving a TAR were older (65.8 vs 64.2, P < .001), more likely to be female (54% vs 51%, P < .001), and had fewer comorbidities (4.2 vs 4.5, P < .001) than patients who underwent a TTA. After controlling for baseline differences, patients with Medicare (odds ratio [OR] 3.00, P < .001), and private insurance (OR 3.19, P < .001) were approximately 3 times more likely to undergo TAR than patients with Medicaid. Conclusions: Patients with tibiotalar osteoarthritis were more likely to receive a TAR procedure if they had Medicare or private insurance compared with patients who had Medicaid. Further research should be done to better understand the drivers of this phenomenon if equitable care is to be achieved. Level of Evidence: Level II, prognostic study.

Background:Acute complete Achilles tendon ruptures are commonly missed injuries. We propose the Realtime Achilles Ultrasound Thompson (RAUT) test, a Thompson test under ultrasound visualization, to aid in the diagnosis of these injuries. We hypothesized that RAUT testing would provide improved diagnostic characteristics compared with static ultrasound.Methods:Twenty-two consecutive patients with operatively confirmed acute Achilles tendon ruptures were prospectively evaluated with RAUT testing and static ultrasonography. RAUT video recordings and static ultrasound images from both ruptured and uninjured sides were randomized and graded by a group of novice reviewers and a group of expert attendings. From these observations, sensitivity, specificity, positive predictive value, and negative predictive value for RAUT and static ultrasound were calculated. In addition, κ interobserver coefficients were computed. Forty-seven novice reviewers and 11 foot and ankle attendings made a total of 4136 and 528 observations, respectively.Results:For static ultrasound, sensitivity and specificity were 76.8% and 74.8% for the novice reviewers and 79.6% and 86.4% for the attendings, respectively. For RAUT testing, sensitivity and specificity were 87.2% and 81.1% for the novice group and 86.4% and 91.7% for the attending group, respectively. The κ coefficient was 0.62 and 0.27 for novice and attending RAUT reviewers, indicating substantial and fair agreement, respectively, but only 0.46 and 0.12 for static ultrasonography, representing moderate and slight agreement, respectively.Conclusion:RAUT testing was a sensitive and specific test, providing a cost-effective adjunct to the clinical examination when diagnosing acute Achilles tendon ruptures. This test can be used by surgeons with minimal training in ultrasonography.Level of Evidence:Level II, diagnostic study.

Introduction This study investigated nonsurgical management of type V acromioclavicular (AC) injuries to determine functional outcomes and to attempt to identify factors associated with positive results. Methods In a retrospective chart review, patients with radiographic and clinical evidence of type V AC injuries per the Rockwood classification were included in the study. Patients treated nonsurgically for ≥6 months were considered eligible for analysis. Functional outcomes were assessed using Disabilities of the Arm, Shoulder, and Hand (DASH) and American Shoulder and Elbow Surgeons (ASES) scores. Results Twenty-two patients with a mean age of 42.2 ± 12.8 years were included in the study. The average coracoclavicular distance at the time of presentation was 26.3 mm (+199%). Mean DASH and ASES scores were 27.8 ± 17.7 and 62.8 ± 17.1, respectively, at an average of 34 months from the time of injury. Patients with normal DASH (≤10) and ASES (>92) scores were younger than those with abnormal scores. At final assessment, 77% of the patients were currently working, with nine patients performing manual labor. Conclusion Following nonsurgical management of type V AC injuries, most patients are able to return to work but have limited functional outcome scores. A small subset of patients with type V AC injuries can achieve normal functional outcomes with nonsurgical management. Level of evidence Level IV, Case Series.

Background: Dog bite injuries to the upper extremity can result in traumatic neurovascular and musculotendinous damage. Currently, there are no clear guidelines dictating which patients may benefit from early operative exploration. The purpose of this study was to identify clinical variables that were predictive of abnormal intraoperative findings in patients who sustained an upper extremity dog bite injury. Methods: All patients who presented to a level I trauma center between 2007 and 2015 with an upper extremity dog bite injury who underwent subsequent surgical exploration were retrospectively screened for inclusion in our study. Patients with inadequate documentation or preexisting neurovascular or motor deficits were excluded. Abnormalities on physical exam and injuries encountered during surgical exploration were recorded for each patient. Contingency tables were constructed comparing normal and abnormal nerve, tendon, and vascular physical exam findings with intact or disrupted neurovascular and musculotendinous structures identified during surgical exploration. Results: Between 2007 and 2014, 117 patients sustained a dog bite injury to the upper extremity, of which 39 underwent subsequent surgical exploration and were included in our analysis. Sixty-nine percent of patients with neuropraxia on exam had intraoperative nerve damage. Seventy-seven percent of patients with an abnormal tendon exam had intraoperative musculotendinous damage. One hundred percent of patients with an abnormal vascular physical exam had intraoperative arterial injury. Conclusions: To date, there are no clear guidelines on what clinical criteria indicate the need for operative exploration and possible repair of neurovascular structures in upper extremity dog bite injuries. In our study, nerve, tendon, and vascular abnormalities noted on physical exam were strongly predictive of discovering neurovascular and musculotendinous damage during surgical exploration.

The use of reverse total shoulder arthroplasty (RTSA) has significantly increased in recent years. However, there is large variance in reported complication rates and sparse data on implant survival. This study used a statewide patient database to investigate complication rates and implant survival for RTSA.All patients undergoing RTSA or total shoulder arthroplasty (TSA) from 2011 to 2013 were identified within a statewide database. The complication and revision rates at 30 days, 90 days, 1 year, and 2 years postoperatively were determined. Potential risk factors for complications were analyzed with logistic regression, and Kaplan-Meier survival curves were used to compare implant failure.During the 3-year period, 10,844 procedures (6,658 TSA; 4,186 RTSA) were found within the database. The all-cause complication rate at 90 days and 2 years postoperatively was significantly higher for RTSA (P .001). RTSA patients had a significantly increased risk of infection (P .05) and dislocation (P .001) in the early and midterm postoperative course. Workers' compensation, male sex, preoperative anemia, and those aged younger than 65 years had a significantly higher risk for complications (P .001). Although RTSA initially had a higher rate of implant failure than TSA during the early postoperative period, this rate equalized at approximately the 1-year mark.RTSA patients had significantly higher complication rates compared with TSA patients, with identifiable risk factors for all-cause complications postoperatively and equivalent accepted implant failure at 2 years.Level III; Cross Sectional Design; Large Database Analysis.