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Opiate-based regimens have been used as a foundation of postoperative analgesia in orthopedic surgery for decades, and the vast majority of orthopedic patients in the United States receive postoperative opioid prescriptions. Both the safety and efficacy of opioid use in orthopedic patients have been questioned because of mounting evidence that postoperative opioid use can be detrimental to outcomes and patient satisfaction. The purpose of this study is to compare a new, opioid-free pain management pathway with a traditional opioid-containing, multimodal pathway in patients undergoing shoulder arthroplasty.This is a single-center randomized clinical trial in which 67 patients who underwent shoulder arthroplasty were allocated into 2 treatment arms: either a completely opioid-free, multimodal perioperative pain management pathway (OF), or a traditional opioid-containing perioperative pain management pathway (OC). Pain was measured on a numeric rating scale from 0 to 10 at 6-, 12-, 24-hour, 2-week, and 6-week time points. Deviations from the OF pathway, morphine milligram equivalents, readmissions, and opioid-related side effects were analyzed.Pain levels were significantly lower in the OF group at 12 hours, 24 hours, and 2 weeks. At 12 hours, the median pain rating was 0 compared with a median pain rating of 3 in the OC group (P = .003). At 24 hours, the OF group reported a median pain rating of 1 and the OC group reported a median pain rating of 4 (P .001). The median pain rating at the 2-week time point in the OF group was 2 compared with 4 in the OC group (P = .006). Median pain ratings were similar between the OF group and the OC group at the 6-week time point. The median pain rating in the OF group at 6 weeks was 1, compared with 1.5 in the OC group. Of the 35 patients in the OF pathway, 1 required a rescue opioid medication for left cervical radiculopathy that ultimately necessitated cervical spine fusion after recovery from right shoulder arthroplasty, and 1 was noted to have taken an opioid medication, diverted from a prior prescription, at the 2-week visit. The morphine milliequivalents received in the OF group was 20 compared with 4936.25 in the OC group. There were no readmissions in the OF pathway, and no differences between the groups with regard to constipation, falls, or delirium.A multimodal, opioid-free perioperative pain management pathway is safe and effective in patients undergoing total shoulder arthroplasty and offers superior pain relief to that of a traditional opioid-containing pain management pathway at 12 hours, 24 hours, and 2 weeks postoperatively.

Background: In response to the opioid epidemic, the use of multimodal pain management in orthopaedic surgery is increasing. Efforts to decrease opioid prescribing and opioid consumption among foot and ankle surgical patients are needed. The purpose of this study was to compare the efficacy and adverse events between 2 multimodal pain management pathways for forefoot surgical patients: standard opioid-containing (OC) and opioid-free (OF). Methods: This is a single-center noninferior randomized controlled trial of 51 patients undergoing forefoot surgery allocated to one of 2 perioperative pain management treatments: opioid-free, multimodal (OF, n=27 patients), or traditional opioid-containing (OC, n=24 patients). Patient characteristics, creatine markers, pain (numeric rating scale [NRS]), general health (Veterans Rand 12-Item Health Survey [VR-12]), and depression were measured preoperatively. Postoperatively, pain was measured at 24-hour, 2-week, and 6-week time points. Satisfaction with pain control, complications, and general health were measured at 2 and 6 weeks. Results: The OF group is statistically noninferior to the OC group and reported lower median pain scores at 24 hours (2 [IQR 0, 3] vs 6 [IQR 3.5, 7]; p90% at 6 weeks. The VR-12 scores were similar between groups across all time points. At 2 weeks, 8 patients in each group reported constipation. By 6 weeks, all but 2 OC patients reported resolution. No other adverse events of postoperative wound complications, readmissions, medication reactions, thrombosis, or persistent pain were documented. Conclusion: In forefoot surgery, the opioid-free pain management protocol was statistically noninferior to the opioid-containing protocol in reducing postoperative pain. Level of Evidence: Level II, prospective cohort study.

The utilization of aspirin for VTE prophylaxis following TJA has increased due to updated clinical practice guidelines. Aspirin is the only approved VTE prophylaxis medication that does not require a prescription, but adherence and tolerance remain unknown. We hypothesized decreased patient compliance utilizing full-strength 325 mg aspirin twice daily following TJA when compared to low-dose 81 mg twice daily. We also investigated the reasons why patients may elect to stop the medication earlier than 28 days. A consecutive series of patients undergoing primary total hip or knee arthroplasty utilizing 325 or 81 mg of EC aspirin twice daily for 4 weeks were surveyed to determine compliance with use and any adverse events related to the medication. Fisher's exact test was used to determine statistical significance. 404 patients were enrolled with 199 patients prescribed the 325 mg regimen. Fifty-two patients who were prescribed 325 mg missed a dose versus 51 patients who were prescribed 81 mg (p = 0.082). No significant difference in the frequency of missed doses (missing 10 doses) between the treatment regimens (p = 0.78, 0.39 and 0.83, respectively). Most commonly cited reason for stopping aspirin in both treatment groups was gastrointestinal issues (10.5% and 7%, respectively). By surveying patients on their use of aspirin we find no difference in adherence between full-strength and low-dose treatment regimens. Additionally, we have a better understanding of the reasons for noncompliance as GI upset was a relatively common complaint with both doses.

The incidence of concomitant lumbar spine and hip pathology is common in referral patients to spine clinics. Differentiating between the two pathologies is a key component to the clinical practitioner's role. At our institution, it has become routine protocol to obtain radiographs including the femoroacetabular joints on the AP and lateral views of the lumbar spine as part of the initial workup. The purpose of this study was to determine the rates of radiographic hip pathology seen on lumbar spine imaging. We report just over 25% concomitant spine and hip pathology with 25% of patients requiring further management from a hip surgeon. The studied protocol will assist in the workup of spine patients to further differentiate the intricacies of hip- and spine-related pathology.

Management of prosthetic joint infection in hip and knee arthroplasty patients is traditionally undertaken with a two-stage treatment protocol. However, this strategy carries high morbidity and cost, yet a substantial portion of patients sustain reinfection. One-stage treatment protocols have been popularized in Europe and other parts of the world but remain infrequently performed in the United States, despite equivocal efficacy with two-stage treatment based on currently available data. Herein, we describe a current one-stage treatment protocol used as part of a multicenter randomized clinical trial in the United States. Furthermore, a case example is presented of a patient with prosthetic joint infection of the hip, successfully treated with a one-stage protocol including details on revising the hip through a direct anterior approach with use of an anterior cortical window osteotomy for removal of a well-fixed femoral component. (Journal of Surgical Orthopaedic Advances 30(4):216-219, 2021).

Knee arthrodesis is an option in the setting of failed total knee arthroplasty. Dual-plate fixation is a described technique to obtain knee fusion in this scenario. Literature on the complications of knee arthrodesis with dual-plate constructs is limited. We present 3 cases who underwent dual-plate knee arthrodesis complicated by peri-implant femur fracture. Keywords: Knee arthrodesis, Knee fusion, Fracture, Failed TKA, Complication

Background All aspects of the arthroplasty pathway must be scrutinized to maximize value and eliminate unnecessary cost. Radiology providers’ contracts with hospitals often call for readings of all radiographs. This policy has little effect on patient care when intraoperative radiographs are taken and used to make real-time decisions. In order to determine the value of radiologist overreads, we asked 3 questions: what was the delay between the time an intraoperative radiograph was taken and time the report was generated, were the overreads accurate, and what is the associated cost? Methods Two hundred hip and knee radiograph reports generated over 6 months during 391 cases were reviewed. The time the report was dictated was compared to the time taken and time of surgery completion. To determine accuracy, each overread was rated as accurate or inaccurate. The cost of the overread was determined by multiplying the number of radiographs times the radiology fee less the technical fee. Results Median delay between taking the radiograph and filing the report was 45 minutes (range, 0-9778 minutes). Only 31.5% were filed before completion of the procedure. And 18.0% (36/200) were considered inaccurate despite lenient criteria. The reading fee for hip radiographs was $52.00, and for knee radiographs was $38.00, representing a total cost of $10,182 in our select series. This cost projects to $43,614 annually at our facility. Conclusion Radiology overreads of intraoperative radiographs have no effect on real-time decision-making. In the era of value-based care, payors should stop paying for overreads and reimburse providers who actually read the films intraoperatively.

Morbid obesity is a known risk factor for complications and failure following primary total knee arthroplasty. Complications following revision total knee arthroplasty (rTKA) in the morbidly obese (BMI > 40) have not been well described. A retrospective cohort study was designed to investigate the early complications of rTKA in morbidly obese patients. Revision TKA procedures were performed between January 2009 and December 2012 at a single institution. Comparisons were made between patients with a normal BMI (18.5–25) and patients with morbid obesity (BMI > 40). Thirty-three of 141 morbidly obese patients (23.4%) had a complication compared to 10 of 96 patients with a BMI 18.5–25 (10.4%) (p = 0.011). Morbidly obese patients were younger (69.3 vs. 61.4 years, p

AimsDebridement, antibiotics, and implant retention (DAIR) remains one option for the treatment of acute periprosthetic joint infection (PJI) despite imperfect success rates. Intraosseous (IO) administration of vancomycin results in significantly increased local bone and tissue concentrations compared to systemic antibiotics alone. The purpose of this study was to evaluate if the addition of a single dose of IO regional antibiotics to our protocol at the time of DAIR would improve outcomes.MethodsA retrospective case series of 35 PJI TKA patients, with a median age of 67 years (interquartile range (IQR) 61 to 75), who underwent DAIR combined with IO vancomycin (500 mg), was performed with minimum 12 months' follow-up. A total of 26 patients with primary implants were treated for acute perioperative or acute haematogenous infections. Additionally, nine patients were treated for chronic infections with components that were considered unresectable. Primary outcome was defined by no reoperations for infection, nor clinical signs or symptoms of PJI.ResultsMean follow-up for acute infection was 16.5 months (12.1 to 24.2) and 15.8 months (12 to 24.8) for chronic infections with unresectable components. Overall non-recurrence rates for acute infection was 92.3% (24/26) but only 44.4% (4/9) for chronic infections with unresectable components. The majority of patients remained on suppressive oral antibiotics. Musculoskeletal Infection Society (MSIS) host grade was a significant indicator of failure (p < 0.001).ConclusionThe addition of IO vancomycin at the time of DAIR was shown to be safe with improved results compared to current literature using standard DAIR without IO antibiotic administration. Use of this technique in chronic infections should be applied with caution. While these results are encouraging, this technique requires longer follow-up before widespread adoption. Cite this article: Bone Joint J 2021;103-B(6 Supple A):185–190.

The COVID-19 global pandemic has upended nearly every medical discipline, dramatically impacted patient care and has had far-reaching effects on surgeon education. In many areas of the country, elective orthopedic surgery has completely stopped to ensure that resources are available for the critically ill and to minimize the spread of disease. COVID-19 is forcing many around the world to re-evaluate existing processes and organizations and adapt to carry out business, of which medicine and education are not immune. Most national and international orthopedic conferences, training programs, and workshops have been postponed or canceled, and we are now critically evaluating the delivery of education to our colleagues as well as residents and fellows. This article describes the evolution of orthopedic education and significant paradigm shifts necessary to continue to teach ourselves and the future leaders of our noble profession.

Background Patient optimization is becoming increasingly important before arthroplasty to ensure outcomes. It has been suggested that depression is a modifiable risk factor that should be corrected preoperatively. It remains to be determined whether psychological intervention before surgery will improve outcomes. We theorized that the use of preoperative depression scales to predict postoperative outcomes may be influenced by the pain and functional disability of arthritis. To determine whether depression is a modifiable risk factor that should be corrected preoperatively we asked the following questions: (1) What is the prevalence of depression in arthroplasty patients preoperatively? (2) Do depressive symptoms improve after surgery? (3) Is preoperative depression associated with outcome? Methods Patients scheduled for surgery completed a patient health questionnaire (PHQ-9) to assess the presence and severity of depression pre-operatively and one year post-operatively. Results Sixty-five of the 282 patients had a PHQ-9 score >10 indicating moderate depression and 57 (88%) improved to P = .0012). Ten patients had a PHQ-9 score >20 indicating severe depression and 9 (90%) improved to P = .10). Of the 65 patients who had a PHQ-9 score >10 preoperatively, the median postoperative Hip Disability and Osteoarthritis Outcome Score (N = 40) was 92.3, while the median postoperative Knee Injury and Osteoarthritis Outcome Score (N = 25) was 84.6. The median postoperative Hip Disability and Osteoarthritis Outcome Score and Knee Injury and Osteoarthritis Outcome Score in nondepressed patients were 96.2 and 84.6, respectively ( P = .9041). Conclusion By diminishing pain and improving function through arthroplasty, depression symptoms improve significantly. Patients with depressive symptoms preoperatively had similar postoperative outcome scores compared to non-depressed patients. Patients should not be denied surgical intervention through optimization programs that include a depression scale threshold. Level of Evidence III.

BackgroundTwo-stage reimplantation arthroplasty is a commonly used approach for treating chronic periprosthetic joint infections. A prereimplantation threshold value of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to determine infection eradication and the proper timing

Background One-stage protocols for the management of periprosthetic infection take an extended period of time requiring two separate preps and sets of instruments to ensure optimal sterility. While intraoperative service time is one part of the reimbursement algorithm, reimbursement has lagged behind for single-stage treatment with respect to the time and resources necessary to perform these complex treatment regimens. If one-stage results are shown to be acceptable, but not reimbursed appropriately, surgeons will be discouraged from managing periprosthetic joint infection (PJI) in a one-stage fashion. Methods The reimbursement and operative time for 50 PJI procedures were compared with 250 primary total hips and 250 primary total knees by the same 4 surgeons. Results The average reimbursement for a one-stage knee procedure was $2,597.08, with an average intraoperative service time of 259 minutes ($601.60/h). The average reimbursement for a primary total knee was $2,435.00, with an average intraoperative service time of 100 minutes ($1,461/h). The average reimbursement for a one-stage hip procedure was $2,826.17, with an average intraoperative service time of 311 minutes ($545.24/h). The average reimbursement for a primary total hip was $2,754.71 with an average intraoperative service time of 104 minutes ($1,589.26/h). Conclusion One-stage procedures for PJI are reimbursed at approximately 1/3 the hourly rate of a primary procedure, which may discourage surgeons from selecting this treatment alternative even if recent studies confirm efficacy. Payers should be encouraged to reimburse physicians commensurate with the intraoperative service time needed to perform a one-stage procedure as adoption will decrease morbidity and save the healthcare system financially.

We implemented a risk assessment tool (RAT) used by clinical navigators to quantify pre-operative mobility, home safety, social/cognitive barriers, and patient health history. We sought to determine if this RAT is associated with the need for post-acute care (PAC) services defined as inpatient rehabilitation and skilled nursing facility, home health, and none (home) following total joint arthroplasty.The study sample comprised of a total of 1438 primary TJA patients included in a bundled payment model. The RAT score, which ranges from 0 to 100, with higher scores representing healthier, more independent patents, was the key independent variable and post-acute service was the primary outcome variable.The median RAT score was 83 (interquartile range 78-87.5) for no PAC discharges compared to 74 (interquartile range 67-81) for inpatient PAC discharges (P.0001). After adjusting for the effects of length of hospital stay, surgery type, and patient gender, there was 6× increased odds of inpatient PAC for higher risk patients compared to low risk patients. A RAT score of 74 predicts discharges without PAC 87% of the time.The RAT that is based on psychosocial, cognitive, environmental factors, and health status was significantly associated with the need for PAC services. The next step is to build and validate a real time, risk adjustment model to assist physicians and patients with planning post-discharge resources.

The Centers for Medicare and Medicaid Services beginning in 2013 introduced the Bundled Payments for Care Improvement (BPCI) initiative to test innovative payment and service delivery models. Early implementers of the BPCI program have shown decreased hospital length of stays, discharges to inpatient facilities, and readmission rates with overall cost savings. Removal of total knee arthroplasty from the Medicare inpatient-only list may potentially cause substantial changes in patients included in BPCI bundles in 2018.The 2017 Centers for Medicare and Medicaid Services data were used to compare total expenditures of diagnosis-related groups 469 and 470. Medicare patients who underwent total knee arthroplasty between January 2017 and December 2017 were defined as group one (n = 1024) and expenditures were compared to group two patients (n = 631) that included only those patients staying greater than 24 hours. Postacute events within the 90-day episode including admission to an inpatient rehabilitation facility/skilled nursing facility (SNF), home health (HH), and readmissions were analyzed. Expenditures were converted to 2018 dollars using Consumer Price Index. Statistical analysis of expenditures was performed with Wilcoxon Tests.Median expenditures were $15,587 (interquartile range [IQR] $13,915-$17,684) for group 1 and $16,706 (IQR $15,333-$19,247) for group 2 (P.001). Median postacute care spend was $3817 (IQR $2431-$5057) for group 1 and $4195 (IQR $3049-$6064) for group 2 patients (P.001). Compared with group 1 patients, group 2 patients had a higher rate of SNF admissions (21% vs 13%), inpatient rehabilitation facility admissions (0.16% vs 0.1%), HH (72% vs 69%), and readmissions (5% vs 4%).Implications of the removal of total knee arthroplasty from the inpatient-only list could potentially remove up to 40% of patients from the BPCI program leading to substantially less savings on average $1100 per patient. Remaining bundle patients are also more likely to require HH and SNF after discharge.

Opioids are frequently used to treat pain after total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of opioids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management.The MEDLINE, EMBASE, and Cochrane Central Register of controlled trials were searched for studies published before November 2018 on opioids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of opioids.Preoperative opioid use leads to increased opioid consumption and complications after TJA along with a higher risk of chronic opioid use and inferior patient-reported outcomes. Scheduled opioids administered preemptively, intraoperatively, or postoperatively reduce the need for additional opioids for breakthrough pain. Prescribing fewer opioid pills after discharge is associated with equivalent functional outcomes and decreased opioid consumption. Tramadol reduces postoperative opioid consumption but increases the risk of postoperative nausea, vomiting, dry mouth, and dizziness.Moderate evidence supports the use of opioids in TJA to reduce postoperative pain and opioid consumption. Opioids should be used cautiously as they may increase the risk of complications, such as respiratory depression and sedation, especially if combined with other central nervous system depressants or used in the elderly.

Instability is a major cause of early revision of total knee arthroplasty (TKA), of which flexion instability is a major subset. We analyzed radiologically evident corrections, patient reported outcome and complications associated with revision TKA for flexion instability in a retrospective cohort of 37 patients with minimum one year follow up. Following revision surgery, there was a significant increase in mean posterior condylar offset ratio and a significant decrease in tibial slope while the level of joint line was not significantly altered. Patient reported version of knee society score showed significant improvement with surgery and 26 of 37 patient reported perceptible improvement on a 7-point Likert scale. Level of Evidence: Level IV, Case series. See the Guidelines for Authors for a complete description of levels of evidence.

As early implementors of the Centers for Medicare and Medicaid Services (CMS) Bundled Payments for Care Improvement (BPCI) initiative, our private practice sought to compare our readmission rates, post-acute care utilization, and length of stay for the first year under BPCI compared to baseline data.We used CMS data to compare total expenditures of all diagnosis-related groups (DRGs). Medicare patients who underwent orthopedic surgery between 2009 and 2012 were defined as non-BPCI (n = 8415) and were compared to Medicare BPCI patients (n = 4757) who had surgery in 2015. Ninety-day post-acute events including inpatient rehabilitation facility or subacute nursing facility admission, home health (HH), and readmissions were analyzed.The median expenditure for non-BPCI patients was $22,193 compared to $19,476 for BPCI patients (P.001). Median post-acute care spend was $6861 for non-BPCI and $5360 for BPCI patients (P.001). Compared to non-BPCI patients, BPCI patients had a lower rate of subacute nursing facility admissions (non-BPCI 43% vs 37% BPCI; P.001), inpatient rehabilitation facility admissions (non-BPCI 3% vs 4% BPCI; P = .005), HH (non-BPCI 79% vs 73% BPCI; P.001), and readmissions (non-BPCI 12% vs 10% BPCI; P = .02). Changes in length of stay for post-acute care were only significant for HH with BPCI patients using a median 12 days and non-BPCI using 24 days.The objective of BPCI was to improve healthcare value. Through substantial efforts both financially and utilization of human resources to contain costs with clinical practice guidelines, patient navigators, and a BPCI management team, the expenditures for CMS were significantly lower for BPCI patients.

The purpose of this study was to see if subvastus approach would decrease incidence of postoperative contracture and pain following TKA compared to standard parapatellar approach. Retrospective review of 546 patients in Group A undergoing TKA using parapatellar approach were compared to 255 patients in Group B undergoing subvastus approach. No statistically significant differences regarding OR time, blood loss, BMI, or LOS. Total of 23 (4%) manipulations under anesthesia for contracture in Group A compared to 6 (2%) in Group B (p0.05). Postoperative pain scores at 6 weeks was greater in Group A, p0.05. We feel that a subvastus approach minimizes trauma to the extensor mechanism, and therefore decreases the incidence of postoperative pain following TKA.

Utilization of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased in the last decade with fluoroscopy often used to confirm implant position, leg length, and offset. Radiation exposure thresholds around 800 mGy are published for the risk of cataracts. We hypothesized that surgeon eye exposure during fluoro-assisted DAA total hip arthroplasty would be well below these published thresholds.Three experienced orthopedic surgeons performed 30 consecutive fluoro-assisted DAA THAs. During each procedure, the surgeon wore a helmet-mounted dosimeter. After 30 consecutive cases, the dosimeters were analyzed. A chart review was then completed to obtain fluoroscopic data saved for each individual case including fluoroscopic time, total radiation dose, and radiation tech experience.Fluoroscopic data were available for 89 of 90 cases (98.8%). Surgeon 1 had an average fluoroscopic time of 18.51 seconds, radiation dose of 2.396 mGy, and tech experience of 13.06 years. Surgeon 2 had an average fluoroscopic time of 15.63 seconds, radiation dose of 2.139 mGy, and tech experience of 23.69 years. Surgeon 3 had an average fluoroscopic time of 11.06 seconds, radiation dose of 1.462 mGy, and tech experience of 16.03 years. The dosimeter results were 8, 5, and1 mrem, respectively, for each surgeon. The mean total radiation dose per case for all surgeons was 2.00 mGy (±1.31), and there was no correlation between radiation dose and radiologic tech experience (0.089, P.05) or radiation dose and patients' body mass index (0.260, P = .014).Each surgeon would need to perform300,000 DAA THAs to exceed the 800-mGy cataract threshold dose. The decision to wear protective glasses should be at the surgeon's discretion; however, the findings in this study show a very low radiation dose to the surgeon's eye regardless of radiologic tech experience or patient's body mass index.

This study sought to quantify the total patient radiation exposure during fluoro-assisted direct anterior approach (DAA) total hip arthroplasty (THA). We hypothesized that the patient radiation exposure would fall within acceptable published limits for a 1-time patient exposure.After institutional review board approval, we performed a retrospective chart review of consecutive unilateral primary DAA THAs at 2 institutions (N = 157) between 2012 and 2014 by a single fellowship-trained arthroplasty surgeon assisted by residents and fellows. Incomplete dose reporting information was the sole exclusion criterion. Patient electronic medical records were queried regarding exposure time (seconds), radiation emittance (mGy), and peak kilovoltage (kVp). Descriptive statistics were calculated. Pearson correlation coefficients were used to determine the correlation between variables.Mean radiation dose for patient exposure measured 2.97 ± 1.63 mGy (range: 0.29-9.83). Positive but weak linear relationship with radiation dose and body mass index (BMI; r = 0.34; P.0002). Average exposure time per procedure was 23.74 s (range: 11.3-61.7). Average kVp per procedure was 75.38 (range: 65-86). Average BMI was 28.32 (range: 16.6-39.8). There was a significantly strong correlation between kVp and BMI (r = 0.75; P.0001).Total patient radiation exposure was nearly identical with previously published values for a screening mammogram (3 mGy) and 4 times less than that of a standard chest computed tomography (13 mGy). Although it is difficult to ascertain the exact patient-absorbed radiation, our data suggest that a 1-time exposure during DAA THA is likely negligible and provides the surgeon with additional data for counseling patients preoperatively.

Complex primary and revision total knee arthroplasty , Complex primary and revision total knee arthroplasty , کتابخانه دیجیتال جندی شاپور اهواز

Instability after total knee arthroplasty is second only to infection as a cause for revision within the first 5 years. As the numbers of knee arthroplasties performed in the United States grow at a steady rate, this clinical problem will likely increase accordingly. In managing these patients, it is critical to identify a clear etiology before proceeding with revision surgery. A thorough history and careful physical exam are both crucial to proper management. Recurrent bloody effusions should elevate suspicion for ligamentous instability as well as lateral patella tilt often signifying femoral or tibial component malrotation. Preoperative planning is also essential to ensure that all necessary implants are available; however as a general rule, the least constraint possible to allow for a stable knee arthroplasty should be utilized. While the best solution to this problem is prevention, these cases of instability do provide insight into potentially avoidable mistakes at the time of primary surgery. There are however unavoidable circumstances that can lead to this problem, and it is important to be familiar with current techniques and available equipment necessary to manage such cases. The goal of revision knee surgery in any of these cases is to restore a mechanically stable, balanced, functional knee. If the specific etiology can be identified prior to surgery, operative efforts will likely be more successful with reproducible outcomes.

Radiofrequency devices are often used during arthroscopic surgery, most commonly of the shoulder and knee, and increasingly in hip arthroscopy. The most commonly described complication is elevation of joint temperature, leading to capsular shrinkage, chondrolysis, and nerve damage. A less commonly reported complication is that of dermal burns from the heated irrigation fluid. There are several case reports describing dermal burns after shoulder arthroscopy; however, to the authors’ knowledge, there are none describing the complication in hip arthroscopy that is often performed by surgeons doing limited if any shoulder arthroscopy. The authors report this case to raise awareness that the use of radiofrequency devices can also lead to extra-articular complications because of the effect of elevated irrigant fluid temperatures on the patient’s skin. Sufficiently high temperatures were generated inside the joint, causing a superficial second-degree burn from the outflow irrigant. In the course of instrument switching from sucker/shaver to radiofrequency wand, the outflow valve was inadvertently left open with no attached suction while the radiofrequency wand was in use. Most second-degree burns like the one reported require only conservative therapy with cool compresses to decrease the temperature of the wound. The authors did recommend bacitracin ointment to prevent superficial wound infection, however unlikely with no disruption of the skin. The authors continue to use radio-frequency devices in hip arthroscopy, but are vigilant to maintain dedicated suction at the outflow tubing throughout the procedure. Surgeons should take strict precautions to avoid this preventable complication and follow all manufacturer instructions on the use of such devices.

This study describes the variance within a representative population of total knee arthroplasty (TKA) patients to provide guidance in improving coronal alignment. The authors retrospectively reviewed 250 preoperative full-length standing radiographs in a consecutive series of TKAs performed by one surgeon. The distal femoral resection was templated on each radiograph to establish a femoral mechanical anatomical (FMA) angle to guide resection. Mean FMA angle was 5.35°, with a wide variation in FMA angle ranging from 1° to 10°. Slightly more than half (56%) of patients had either a 5° or 6° FMA angle, which is concerning for surgeons using a fixed resection angle. Ninety percent of patients measured within the 5°±2° window. Similarly, 90.7% of patients measured within the 6°±2° window. However, nearly 10% of patients (9.75%) had measurements greater than 7° or less than 3°. This study reports a wide variance in the angle of resection required to establish proper femoral mechanical alignment in TKA. Surgeons should be cognizant of the numerous variables that play a role in TKA and influence overall coronal alignment. Many of these variables can be fully assessed by evaluating full-length standing leg radiographs preoperatively. With experience, templating long-leg films can be reproducible and informative in preparing for each surgical procedure. Routine reliance on a single fixed resection angle could result in malalignment in 10% of patients.

Failure of initial treatment for juvenile osteochondritis dissecans (OCD) may require further surgical intervention, including microfracture, autograft chondrocyte implantation, osteochondral autografting, and fresh osteochondral allografting. Although allografts and autografts will restore function in most adults, it is unclear whether fresh osteochondral allograft transplantations similarly restore function in skeletally immature patients who failed conventional treatment.Therefore, we determined function in (1) daily activity; (2) sports participation; and (3) healing (by imaging) in children with juvenile OCD who failed conventional therapy and underwent fresh osteochondral allograft transplantation.We retrospectively reviewed 11 children with OCD of the knee treated with a fresh stored osteochondral allograft between 2004 and 2009 (six males and five females). The average age of the children at the time of their allograft surgery was 15.2 years (range, 13-20 years). The clinical assessments included physical examination, radiography, MRI, and a modified Merle D'Aubigné-Postel score. The size of the allograft was an average of 5.11 cm(2). The minimum followup was 12 months (average, 24 months; range, 12-41 months).All patients had returned to activities of daily living without difficulties at 6 months and returned to full sports activities between 9 and 12 months after surgery. The modified Merle D'Aubigné-Postel score improved from an average of 12.7 preoperatively to 16.3 at 24 months postoperatively. Followup radiographs at 2 years showed full graft incorporation and no demarcation between the host and graft bone.Our observations suggested fresh osteochondral allografts restored short-term function in patients with juvenile OCD who failed standard treatments.Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Osteoporotic fractures pose a significant health concern for postmenopausal women. Bisphosphonate therapy has been shown to decrease the risk of these fractures. The bisphosphonate alendronate was approved by the US Food and Drug Administration for use in the United States in 1995, but questions have recently arisen concerning low-energy subtrochanteric femur fractures sustained by chronic users. Although no definitive association or causality between bisphosphonates and these fractures has been established, numerous cautionary reports exist concerning the duration of use and safety of alendronate in osteoporotic patients. This article reports 3 occurrences of bisphosphonate-associated atypical femur fractures as an etiology of periprosthetic hip pain in the total hip arthroplasty (THA) patient. These fractures are particularly concerning because these patients are often not advised to protect their weight bearing simply due to a painful THA and may sustain a catastrophic failure if not followed closely. Several theories have been suggested concerning the pathophysiology of atypical low-energy subtrochanteric fractures following bisphosphonate use. Each patient described in this article carried a diagnosis of rheumatoid arthritis and underwent chronic medical therapy; each patient experienced a delay in the diagnosis and onset of therapy due to low suspicion for bisphosphonate-associated fracture. This problem may become more common in the clinical setting; therefore, one must be vigilant and aware of this etiology of periprosthetic hip pain.

This study compares the relative risk of revision and associated risk factors after total or unicompartmental knee arthroplasty (TKA or UKA) in the Medicare population. A total of 61 767 TKA and 2848 UKA patients were identified. Reviewed data included type of treatment, gender, age, race, Charlson Index for comorbidity, length of stay, Medicare buy-in for socioeconomic status, region, and year. Unicompartmental knee arthroplasty patients were at increased risk for revision at 2 and 5 years. Those patients undergoing UKA were significantly more likely to require revision in the first 5 years as compared with those undergoing TKA. Risk factors contributing to TKA revision included younger male patients with higher comorbidities and lower socioeconomic status. About UKA, lower revision rates tend to favor those surgeons with higher volume.

Background In measuring plantar pressures during gait, earlier methods have used a platform system that does not take into account the interactions feet have with orthotics and shoe wearing. The purpose of the study was to provide normal insole plantar pressure parameter data during stance phase using the Pedar pressure insole system. Methods Twenty-nine normal children, age 6 to 16 years, were recruited and walked along the 25 m walkway at self-selected speeds. Patients were divided into 2 separate groups for statistical analysis--juniors ( 13 y old). The pressure map was divided into 8 regions (masks) determined by anatomic landmarks and a total of 7 pressure parameters were analyzed of each mask. Results We did not detect significant differences in foot pressures between juniors and teenagers when regarding sex, or left and right feet for 7 parameters measured. Conclusions This normative data will provide a basis with which to more accurately assess pediatric pathologic foot deformities and to distinguish dynamic foot deformities from anatomic foot deformities. THE LEVEL OF EVIDENCE: Level II.

Background Failure of initial treatment for juvenile osteochondritis dissecans (OCD) may require further surgical intervention, including microfracture, autograft chondrocyte implantation, osteochondral autografting, and fresh osteochondral allografting. Although allografts and autografts will restore function in most adults, it is unclear whether fresh osteochondral allograft transplantations similarly restore function in skeletally immature patients who failed conventional treatment.