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Background: The current healthcare market coupled with expedited recovery and improvements in analgesia have led to the development of total hip arthroplasty being performed as an outpatient procedure in selected patients., Questions/purposes: The purpose of this study is to compare outcomes and cost-effectiveness of traditional inpatient THA with outpatient hip replacement at the same facility., Patients and Methods: This observational, case-control study was conducted from 2008 to 2011. One hundred nineteen patients underwent outpatient THA through a direct anterior approach. These cases were all performed by a single surgeon. Outpatient cases were then compared to inpatient hospital controls performed by the same surgeon at the inpatient hospital facility., Results: Complications, length of stay, demographic data, and overall costs were compared between groups. There was no difference in complications or estimated blood loss between groups. Most notably, the average overall cost in the outpatient setting was significantly lower than inpatient, $24,529 versus $31,327 (p = 0.0001)., Conclusions: This study demonstrates that appropriately selected patients can undergo THA in an outpatient setting with no increase in complications and at a substantial savings to the healthcare system.

Background: Adequate rotation of the femoral component in total knee arthroplasty is mandatory for prevention of numerous adverse sequelae. Therefore, we investigate whether there is the distal femoral deformity in knees with tibia vara. The purpose of this study was to evaluate the reliability of the transepicondylar axis as a rotational landmark in knees with tibia vara., Methods: We retrospectively reviewed and selected 101 osteoarthritic knees with proximal tibia vara and 150 osteoarthritic knees without tibia vara for inclusion in this study. The transepicondylar axis (TEA), anteroposterior (AP) axis and posterior condylar (PC) line were measured using the axial image from magnetic resonance imaging axial images. We compared the external rotation angle of the TEA relative to the PC line between groups in order to investigate the presence of distal femoral anatomical adaptation in the tibia vara group., Results: The TEA in the tibia vara group had 6.1º of external rotation relative to the PC line, which was not significantly different from the 6.0º of external rotation in the non-tibia vara group. The line perpendicular to the AP axis in the tibia vara group had 6.1º of external rotation relative to the PC line, which was not significantly different from the 5.4º of external rotation in the non-tibia vara group. Distal femoral geometry was unaffected by the tibia vara deformity., Conclusions: The use of transepicondylar axes in determining femoral rotation may produce flexion asymmetry in knees with tibia vara., Level of Evidence: Level III., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Background: Nerve injury during acetabular and pelvic fracture fixation can have devastating consequences for trauma patients already in a compromised situation., Questions/purposes: This study aims to evaluate the efficacy of multimodality intraoperative neurophysiologic monitoring during acetabular and pelvic fracture fixation in identifying emerging iatrogenic nerve injury., Methods: Sixty patients were retrospectively identified after surgical fixation following acetabular or pelvic fracture. Neuromonitoring during surgery was performed using three different modalities, transcranial electric motor evoked potential (tceMEP), somatosensory evoked potential (SSEP), and electromyographic (EMG) monitoring. Each modality was evaluated for sensitivity and specificity of detecting an intraoperative nerve injury., Results: tceMEP monitoring was found to be 100% sensitive and 86% specific at detecting an impending nerve injury. The sensitivity and specificity of SSEP were 75% and 94%, while EMG sensitivity was unacceptably low at 20% although specificity was 93%., Conclusions: Multimodality neuromonitoring of transcranial electric motor and peroneal nerve somatosensory evoked potentials with or without spontaneous EMG monitoring is a safe and effective method for detecting impending nerve injury during acetabular and pelvic surgery.

Background: Hip fracture is a common yet serious injury sustained by the elderly patient and represents one of the major healthcare challenges today. The aim of this study was to better define the unique characteristics of treating nonagenarian peritrochanteric hip fractures and their subsequent complications during hospital stay., Methods: Seven hundred twenty-two patients underwent surgery for isolated fracture around the femoral neck. These patients were divided into one of three age groups: A, <50 years; B, 51-89 years; and C, >90 years. We performed a retrospective chart review to compare these groups in terms of patient characteristics, comorbidities, postoperative complications, fracture type, type of surgery performed, and mortality rate., Results: There was no difference in time to surgery between groups. Comorbidities were similar in groups B and C but were higher than group A. Nonagenarians received a significantly greater percentage of hemiarthroplasties compared with those aged 51 years to 89 years. Cardiac complications were significantly higher in group C. In patients with sustained cardiac complications, the odds ratio for mortality was 15.88., Conclusions: Our results suggest that groups B and C were not significantly different pre- or intraoperatively. Nevertheless, there is an increase in cardiac complications and mortality in nonagenarians postoperatively. Nonagenarians should undergo similar treatment in the operating room compared with less elderly patients with the caveat that older patients, especially those with cardiac disease, may be more at risk for complication. The surgeon must evaluate the elderly patient with a hip fracture on a case-by-case basis, while ignoring chronological age., Level of Evidence: III, prognostic study.

The purported benefits of minimally invasive total hip arthroplasty (THA) compared with conventional approaches has stirred controversy in the orthopaedic community. Some studies performed by the pioneers of the minimally invasive techniques showed improvement in immediate patient outcomes. Less blood loss, shorter hospital stays, lessened immediate postoperative pain, and faster return to normal activities are potential benefits of any type of minimally invasive surgery. Most studies of minimally invasive THA have involved changes in the intraoperative and postoperative protocols that could independently affect patient outcome. Appropriate prospective studies that compare conventional and minimally invasive THA and the effects of different rehabilitation protocols on patient outcome are needed. The results of different approaches for minimally invasive THA also require study. A review of reported short-term outcomes and complications of small-incision THA performed using several modifications of existing surgical approaches and the possible effect on postoperative pain provide needed information on this controversial topic.