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Background: Urinary incontinence has been linked to worse postoperative pain, decreased physical function, and reduced quality of life in patients following total joint arthroplasty. The purpose of this study was to analyze whether incontinence is associated with increased postoperative medical and joint complications following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods: A retrospective cohort study was conducted using a national insurance database. Thirty-two thousand eight hundred eleven patients with incontinence who underwent primary THA were identified and matched 1:4 with 129,073 patients without incontinence. Ninety-one thousand nine hundred thirty-five patients with incontinence who underwent primary TKA were matched 1:4 with 367,285 patients without incontinence. Medical and joint complication rates at 90 days and 2 years, respectively, were then compared for patient cohorts using multivariable logistic regressions. Results: Patients who underwent primary THA with incontinence had statistically higher rates of dislocation, periprosthetic fracture, aseptic revisions, and overall joint complications compared to controls. Patients who underwent primary TKA with incontinence had higher rates of mechanical failure, aseptic revision, and all-cause revision compared to controls. Conclusions: This study demonstrated an association between patients with incontinence and higher rates of dislocation, periprosthetic fractures, aseptic revisions, and overall joint complications following primary THA compared to controls. Patients with incontinence experience higher rates of mechanical failure, aseptic revision, and all-cause revision following TKA compared to controls. As such, perioperative management of urinary incontinence may help mitigate the risk of postoperative complications.

Background: Orthopaedic surgeons who are fellowship-trained in adult reconstruction (AR) specialize specifically in total joint arthroplasty, including total knee arthroplasty (TKA). However, TKA procedures are not only performed by AR surgeons. The purpose of this study was to compare the patient demographics and postoperative outcomes of patients who had a TKA procedure performed by an AR surgeon vs a sports medicine (SM) surgeon. Methods: A retrospective cohort study was conducted using a national insurance database. Patients who underwent a primary elective TKA procedure by an AR surgeon (n = 56,570) and an SM surgeon (n = 72,888) were identified. Patient demographics, rates of joint complications within 2 years, and medical complications within 90 days postoperatively were compared using multivariable logistic regression. Results: Compared to the cohort of patients undergoing TKA by SM surgeons, the patient cohort of AR surgeons had a higher mean Elixhauser comorbidity index (4.2 vs 4.0, P < .001), and had significantly higher rates of several comorbidities. Within 90 days, patients of AR surgeons demonstrated significantly lower rates of acute kidney injury and transfusions. When compared to patients of SM surgeons, patients of AR surgeons demonstrated significantly lower rate of manipulation under anesthesia or lysis of adhesions within 2 years. Rates of all other joint-related complications were statistically comparable between the 2 cohorts. Conclusions: As a cohort, AR surgeons perform TKA on a higher-risk cohort of patients compared to sports medicine surgeons. Despite the higher-risk patient population, outcomes of TKA by AR surgeons appear equivalent compared to their SM colleagues.

Background: Hepatitis C virus (HCV) is associated with increased complications of risk after arthroplasty. The purpose of this study was to examine the impact of HCV and a pre-arthroplasty antiviral treatment on complications following total shoulder arthroplasty (TSA). Methods: A retrospective matched cohort study was conducted using an administrative claims database. Patients who underwent TSA were identified with Current Procedural Terminology -23472 and International Classification of Diseases procedural codes. A total of 1244 HCV patients were matched 1:3 with 3732 noninfected controls across age, sex, diabetes mellitus, tobacco use, and obesity. The HCV patients with treatment before TSA were identified by claims containing antiviral drug codes. Multivariable logistic regression was used to compare rates of 90-day medical complications and prosthesis-related complications within 2 years postoperatively for (1) HCV patients vs. controls, (2) antiviral-treated HCV patients vs. controls, and (3) antiviral-treated HCV patients vs. untreated HCV patients. Results: Patients with HCV exhibited significantly higher rates of blood transfusion (OR 2.12), acute kidney injuries (OR 1.86), inpatient readmission (OR 2.06), revision TSA (OR 1.48), dislocation (OR 1.92), mechanical complications (OR 1.39), and prosthetic joint infection (OR 1.53) compared to controls. Antiviral-treated HCV patients exhibited a significantly lower rate of myocardial infarction (OR 0.27) and comparable rates of all other complications relative to controls (all P > .05). Compared to untreated HCV patients, antiviral-treated HCV patients exhibited significantly lower rates of 90-day medical complications (OR 0.57) and prosthetic joint infection (OR 0.36). Conclusions: HCV is associated with significantly increased complication rates after TSA. Antiviral treatment before TSA may reduce the risk of postoperative complications.

Combined fractures of the femoral head and acetabulum due to ballistic injuries are rare injuries, especially in the elderly. We present a case of a 70-year-old female who sustained a gunshot wound to the left hip, resulting in a comminuted femoral head fracture and posterior wall acetabular fracture. She was treated with open reduction and internal fixation of the acetabulum, as well as bipolar hemiarthroplasty for treatment of her femoral head fracture. At her 18-month follow-up visit, the patient was doing well and had no complaints.

Background: The purpose of this study was to compare the biomechanical strength of femurs before an iatrogenic periprosthetic fracture vs after an initial fracture with supporting cerclage fixation during cementless total hip arthroplasty. Material and methods: Nineteen composite femurs and 5 matched pairs of cadaveric femurs were implanted with a single-wedge or dual-wedge tapered femoral stem and tested for ultimate load to failure producing a periprosthetic fracture. Following initial fracture, each femur was cerclaged with Vitallium cables and retested for ultimate load to failure. The mean force eliciting iatrogenic fracture before cabling and that after cabling were compared with a two-sided paired Student’s t-test. Results: All composite femurs developed periprosthetic fractures with an average length extension from the calcar of 75.17 mm. For the 19 composite femurs, the mean ultimate load to failure before cabling and that after cabling were not significantly different (2422.95 N vs 2505.14 N, P = .678). For the 10 cadaveric femurs, the mean ultimate load to failure for the initial fracture vs that after cabling was statistically comparable (5828.62 N vs 7002.63 N, P = .126). Subanalysis of the 5 cadaveric femurs with a double-wedge stem revealed a significantly higher mean load to failure following cabling (5007.38 N vs 7811.17 N, P = .011). Conclusion: Biomechanical strength was similar for femurs that sustained an initial iatrogenic periprosthetic fracture and the same femurs cabled with cerclage wires after being fractured. These data may assist in operative decision-making for treating iatrogenic fractures during total hip arthroplasty.

Background: After failed nonoperative treatment, unicompartmental osteoarthritis can be treated surgically by either unicompartmental knee arthroplasty (UKA) or high tibial osteotomy (HTO). The purpose of this retrospective study is to analyze utilization and demographic trends of UKA and HTO relative to total knee arthroplasty (TKA) over the past decade. Methods: A retrospective review was conducted using the PearlDiver database. Patients that received a UKA or HTO were identified. Trend analyses of surgical procedure utilization were performed with the Mann-Kendall trend test. Demographic data and the rates of various comorbidities were also queried. Results: A total of 103,465 UKAs, 2183 HTOs, and 1,413,425 TKAs, between 2010 and 2021 quarter 1, were analyzed. Trend analyses revealed that relative to TKA utilization, UKA utilization significantly increased (P < .001) while HTO utilization significantly decreased (P < .001). The compound annual growth rate of UKA utilization relative to TKA was +5.16% from 2010 to 2017 but was −10.61% from 2018 to 2021, while that of HTO relative to TKA was −9.69% from 2010 to 2021. Demographic analyses demonstrated the UKA cohort (63.1) was significantly older than the HTO cohort (46.5) (P < .001). Additionally, there were significantly more female patients who underwent UKA than HTO (P < .001). Conclusions: The present study demonstrated that relative to TKA, UKA utilization increased from 2010 to 2017, with a subsequent decrease afterward, whereas HTO utilization decreased since 2010. Demographic differences exist between the 2 operations, with HTOs more commonly performed in younger male patients, and UKAs in older female patients. Level of Evidence: Level III.

Background: Patellar resurfacing is routinely performed during total knee arthroplasty to reduce pain associated with patellofemoral osteoarthritis. With 3-dimensional ingrowth materials readily available, the present study aimed to evaluate if cemented polyethylene (CP) patellar buttons conferred higher ultimate load to failure than press-fit metal-backed (PF) buttons in axial compression. Material and methods: Ten matched cadaveric and 20 composite patellae were resurfaced and implanted with either a PF or CP button. Biomechanical testing using an MTS machine was performed to measure the force required to generate a periprosthetic patella fracture. Mean load to failure and load to failure per 1-mm patellar thickness were compared with a paired and independent samples Students’ t-test for the cadaveric and composite patellae, respectively. Results: The average load to failure for the matched cadaveric patellae with PF implants was significantly lower than that for patellae with CP buttons (4082.05 N vs 5898.37 N, P = .045). The average load to failure for composite patella with PF implants was significantly higher than that for composite patellae with CP implants (6004.09 N vs 4551.40 N, P = .001). The mean load to failure per 1-mm patellar thickness was also significantly higher for composite patellae with PF implants (263.80 N/mm vs 200.37 N/mm, P = .001). Conclusion: Cadaveric patellae with cemented implants had a significantly higher ultimate load to failure in axial compression than press-fit patella. However, this result was reversed in the composite model. Exploration of biological and composite model properties could provide further insight into patellar implant selection during total knee arthroplasty.

Background: As the aging population expands, proximal humerus fractures have become more prevalent. This study aimed to evaluate acute management of proximal humerus fractures in women and men older than the age of 50 years to determine how gender and age have affected definitive treatment selection over the last decade. Methods: Patient records were retrospectively reviewed from a commercially available database, PearlDiver, to identify treatments for proximal humerus fractures between 2010 and 2019. Data were separated by age into two cohorts, patients aged 50-64 years and those aged 65 years and older before stratification by gender. Within each cohort, groups were matched with respect to age, region, and Elixhauser comorbidity index. Logistic regression analyses were performed to determine which gender was associated with a higher risk of undergoing operative treatment, which gender was associated with a higher risk of receiving arthroplasty, and which of the individual surgical operations were more likely given the patient’s gender and age. Results: In the 50- to 64-year-old cohort, men were less likely to be treated operatively than women (odds ratio [OR]: 0.90). However, men in this cohort had a 31% higher likelihood of receiving an arthroplasty procedure than women when given operative treatment. Specifically, men aged 50 to 64 years were more likely to receive hemiarthroplasty (OR: 1.48) and intramedullary nailing (OR: 1.19) and were less likely to have open reduction internal fixation (ORIF) (OR: 0.71). In the 65 years and older cohort, there was no relationship between gender and the likelihood of operative treatment for a proximal humerus fracture. Men older than 65 years had a 29% lower likelihood of receiving an arthroplasty type procedure than women older than 65 years. In addition, men older than 65 years were more likely to receive ORIF (OR: 1.14) and intramedullary nailing (OR: 1.43) and less likely to receive hemiarthroplasty (OR: 0.86) and reverse total shoulder arthroplasty (OR: 0.66) than similarly aged women. Conclusion: Both age and gender have an association with the definitive treatment patients received for proximal humerus fractures over the last decade. Women younger than 65 years of age were more likely to undergo operative treatment, although once older than 65 years, there was no influence of gender on operative treatment. Men younger than 65 years were more likely to receive arthroplasty and women, more likely to undergo ORIF; however, as patients reached the age of 65 years and older, this finding was reversed such that women were more likely to receive arthroplasty and men, ORIF. Further exploration into these differences could improve decision-making between surgeons and patients.

Background: Anterior cruciate ligament (ACL) tears are common injuries. Ipsilateral bone patellar tendon bone (BPTB) autograft has been frequently used for ACL reconstructions. A large percentage of patients who sustain ACL ruptures develop early osteoarthritis and require total knee arthroplasty (TKA). When patients with previous BPTB autograft for an ACL tear undergo TKA, there may be an increased risk of fracture after patellar resurfacing. Methods: There were 20 artificial Sawbones and 10 cadaveric patellae resurfaced. To simulate the presence of a previous BPTB autograft, a bone plug was removed from the anterior surface of the patellae and was resurfaced with a cemented patellar button. Biomechanical testing was performed to determine the compressive load to fracture of patellae with and without previous BPTB autograft. Results: The average maximum load to failure for the artificial Sawbones patellae without a previous BPTB autograft was 4551.40 N ± 753.12 compared with 2855.39 N ± 531.46 with a previous BPTB autograft (P < .001). The average maximum load to failure for the cadaveric patellae without a previous BPTB autograft was 7256.37 N ± 1473.97 compared with 5232.22 N ± 475.04 with a previous BPTB autograft (P = .021). Conclusions: The results demonstrate a significantly lower maximum load to failure of a resurfaced patella in the presence of a previous BPTB autograft. This can be used to aid in the decision of whether to resurface the patellae in these patients and to educate patients that the presence of a previous BPTB autograft may be an increased risk factor for patella fracture after TKA.

Background: Proximal humerus fractures are the third most common fracture in older adults. Because of the aging population, the incidence of these fractures and their impact will continue to grow. With advancement in treatment options for proximal humeral fractures, the aim of this study was to evaluate the trends in acute management of proximal humerus fractures to determine how definitive treatment has changed over the past decade in patients older than 65 years. Methods: Using a commercially available database, patient records were queried from 2010 to 2019 for the incidence of proximal humerus fractures. For each individual year, data were queried to identify the incidence of closed reduction percutaneous pinning (CRPP), hemiarthroplasty (HA), intramedullary nailing (IMN), open reduction internal fixation (ORIF), total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RSA), or nonoperative treatment for acute proximal humeral fractures. A Cochran-Armitage trend test was used to determine significant changes in the trends of proximal humerus fracture management. Logistic regression analyses were performed to generate odds ratios (OR) with associated 95% confidence intervals comparing each individual procedure performed in 2019 to 2010. Results: A total of 160,836 patients at least 65 years of age and older were diagnosed with a proximal humerus fracture. Of this total, 28,503 (17.72%) patients received operative treatment and 132,333 (82.28%) received nonoperative treatment. From 2010 to 2019, operative treatment trends of proximal humerus fractures changed such that CRPP decreased by 60.0%, HA decreased by 81.4%, IMN decreased by 81.9%, ORIF decreased by 25.7%, TSA decreased by 80.5%, and RSA increased by 1841.4% (all P

Background: It was estimated that up to 30,000 primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures would be cancelled each week during the moratorium on elective surgeries in the United States. The purpose of this study was to analyze the impact of the COVID-19 pandemic on elective total joint arthroplasty utilization in the United States. Methods: A retrospective study was conducted using the PearlDiver database. Patients who underwent primary elective THAs and TKAs were identified and filtered by state and month from January through September of both 2019 and 2020. The volume of these procedures immediately following the moratorium on elective surgeries was compared to that of the same months the previous year. Results: For THA, overall, there was a 27.39% reduction in volume from 2019 to 2020 in March and an 88.94% reduction in April. For TKA, overall, there was a 31.28% reduction in volume in March and a 96.61% reduction in April. When the states were separated into 2 cohorts by the 2020 presidential election vote, there was a significantly larger decrease in THA and TKA volume observed in the 25 states and Washington DC that voted democrat than that in the 25 states that voted republican in both March (P < .05) and April (P < .05). Both THA (118.29%) and TKA (101.02%) volume returned to prepandemic levels by June. Conclusions: Overall, this study demonstrated that elective total joint arthroplasty utilization did reduce as anticipated following the CMS moratorium on elective surgeries but quickly returned to prepandemic levels by June. Level of Evidence: Level III.

Background: It is unclear if hepatitis C (HCV) negatively impacts outcomes of revision total knee arthroplasty (rTKA). The purpose of this study was to compare complication rates after rTKA for patients with HCV vs matched controls. Methods: A retrospective cohort study was conducted using the PearlDiver database (PearlDiver Inc., Colorado Springs, CO). Patients with HCV who underwent rTKA (n = 1448) were matched 1:4 with controls (n = 5792) on age, sex, and several comorbidities. Rates of medical complications within 90 days and prothesis-related complications within 2 years postoperatively were compared with logistic regression for (1) patients with vs without HCV and (2) HCV patients who underwent aseptic vs septic rTKA. Results: Relative to controls, patients with HCV exhibited significantly higher rates of medical complications (27.7% vs 20.9%; odds ratio [OR] 1.47), periprosthetic fractures (2.3% vs 1.1%; OR 2.20), all-cause repeat rTKA (11.7% vs 9.4%; OR 1.29), and repeat rTKA for prosthetic joint infection (PJI) (6.7% vs 3.6%; OR 1.92). Within the HCV cohort, HCV patients with initial septic rTKA exhibited significantly higher rates of medical complications (41.7% vs 22.7%; OR 2.39), all-cause subsequent rTKA (15.9% vs 10.2%; OR 1.67), and repeat rTKA for PJI (15.9% vs 3.4%; OR 5.39). Conversely, HCV patients with initial aseptic rTKA exhibited significantly higher rates of aseptic loosening (2.6% vs 7.4%; OR 0.33). Conclusions: Patients with HCV exhibited significantly higher rates of medical and prosthesis-related complications after rTKA than controls. Among patients with HCV, initial septic rTKA was associated with significantly higher rates of medical complications, repeat rTKA, and PJI.

Background: The impact of prior fragility fractures and osteoporosis treatment before total hip arthroplasty (THA) on postoperative complications is unclear. The purpose of this study was to characterize the effect of prior fragility fractures and preoperative osteoporosis treatment on short-term complications and secondary fragility fractures after THA. Methods: A propensity score–matched retrospective cohort study was conducted using a commercially available database to (1) characterize the impact of prior fragility fractures on rates of short-term complications after THA and (2) evaluate if osteoporosis treatment before arthroplasty reduces risk of postoperative complications. Rates of periprosthetic fracture, revision THA, and fragility fractures were compared via multivariable logistic regression. Results: After 1:1 propensity score matching, 2188 patients were assigned to each cohort. Patients with a fragility fracture in the 3 years preceding THA were more likely to sustain a periprosthetic fracture (1 year: 1.7% vs 1.0%, odds ratio [OR] 1.89; 2 years: 2.1% vs 1.1%, OR 1.82), fragility fracture (1 year: 4.7% vs 1.1%, OR 3.59; 2 years: 6.7% vs 1.7%, OR 3.21), and revision THA (1 year: 2.7% vs 1.7%, OR 1.65; 2 years: 3.1% vs 1.9%, OR 1.58). Among patients with a prior fragility fracture, only 13.8% received osteoporosis pharmacotherapy before THA. Rates of all complications were statistically comparable postoperatively for patients with and without pre-THA osteoporosis treatment. Conclusions: Fragility fractures within 3 years before THA are associated with significantly increased risk of periprosthetic fracture, all-cause revision, and secondary fragility fractures postoperatively. Preoperative osteoporosis treatment may not decrease risk of postoperative complications.

Background: While many studies have demonstrated increased complication risk after total joint arthroplasty in patients with inflammatory bowel disease, it is unclear if celiac disease is associated with similarly increased risk. The purpose of this study was to analyze if celiac disease is associated with increased postoperative complications following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods: A retrospective cohort study was conducted using the PearlDiver database. Patients with celiac disease who underwent THA (n = 1701) and TKA (n = 3515) were matched 1:3 with controls (THA, n = 5103; TKA, n = 10,545) on age, sex, year of arthroplasty, diabetes mellitus, tobacco use, and obesity. Rates of medical complications within 90 days and joint complications including revision arthroplasty, prosthetic joint infection, periprosthetic fracture, and aseptic loosening within 2 years postoperatively were queried. Complication rates were compared for patients with celiac disease vs controls with multivariable logistic regression. Results: After primary THA, patients with celiac disease exhibited significantly higher rates of acute myocardial infarction within 90 days (2.7% vs 1.9%; odds ratio 1.45; 95% confidence interval 1.01-2.07) and periprosthetic fractures at 2 years postoperatively (1.1% vs 0.5%; odds ratio 2.09; 95% confidence interval 1.14-3.79) than controls. Following primary TKA, patients with celiac disease exhibited higher but statistically comparable complication rates than controls (all P > .05). Conclusions: Celiac disease was associated with significantly higher rates of acute myocardial infarction and periprosthetic fracture after primary THA. Complication rates after primary TKA were similar between the cohorts. Level of Evidence: Level III.

Background: The outcomes and complication rates of patients with isolated greater tuberosity fractures are not well documented. The present study aimed to evaluate the reoperation rates, types of reoperations, and complications for patients undergoing open reduction internal fixation and those undergoing initial nonoperative treatment of isolated greater tuberosity fractures. Methods: An administrative claims database was queried from 2010 to 2018 for adult patients treated with open reduction internal fixation or initial nonoperative treatment within 6 weeks of sustaining a closed isolated greater tuberosity fracture. Reoperation rates, types of reoperations, local/surgical complications, and systemic complications for two cohorts were collected, and statistical analysis was performed using R statistical software for patients initially treated operatively and nonoperatively. Complication rates were compared using multivariate logistic regression, while demographic data were compared using chi-square analysis. Results: Of the 8509 patients who were documented to have sustained a closed isolated greater tuberosity fracture, 333 patients underwent operative treatment and 8176 patients received initial nonoperative treatment within the first 6 weeks of diagnosis. The operative cohort had a reoperation rate of 2.7% at 90 days, 5.7% at 6 months, and 7.8% at 1 year, with the majority of reoperations being rotator cuff repair (40.6%). Within the initial nonoperative cohort, 7.3% had an operation within a year, with the majority of operations being open reduction internal fixation (41.3%). The subsequent reoperation rate for those patients was 3.5% at 2 years with the majority of reoperations being rotator cuff repair (32.4%). In the operative cohort, the 90-day infection rate was 3.0%. Nonunion was demonstrated in the operative cohort at a rate of 1.8% at 6 months and 2.7% at 1 year. Conclusion: When surgical care was provided to patients sustaining isolated greater tuberosity fractures in the first 6 weeks, there was a 7.8% rate of reoperation within the first year. Patients initially treated nonoperatively had a future operation rate of 7.3% within the first year and a 3.5% reoperation rate within the second year. The most common reoperation regardless of initial treatment was rotator cuff repair. With an elevated rate of subsequent operations, education is paramount to provide patients with expectations for the sequelae of this injury especially when presenting with concomitant injuries.

Total knee arthroplasty is a common procedure performed to improve pain and dysfunction attributed to arthritis, yet postoperative patient dissatisfaction rates remain relatively high. Patient satisfaction and outcomes have been linked to successful joint gap balancing in the coronal and sagittal planes intraoperatively. In previously described balancing techniques, the fulcrum used for alignment changes is customarily centered on the intramedullary axis generating symmetric changes in medial and lateral gaps. We propose a novel technique in the literature that, with the use of robotic-arm assisted technology or similar systems, allows manipulation of the fulcrum center of rotation during pre-resection planning and intraoperative gap establishment before bony cuts to asymmetrically influence medial and lateral, flexion and extension gaps to aid in balancing during total knee arthroplasty.

Background: Aseptic loosening of the acetabular component remains one of the leading causes of early failure of total hip arthroplasty. Poor apposition of bone onto the implant surface can be due to inaccurate reaming and osteonecrosis of the acetabular bone due to the heat generated while reaming. Methods: New and used acetabular reamers were tested on an MTS system using a clinically relevant force of 87.6 N. A thermal profile and depth achieved by the reamers were analyzed and compared between the 2 cohorts. Heat generated and force required for the community used reamers to achieve the same depth as the new reamers were subsequently analyzed. Results: The new reamers achieved a depth 3.4 mm deeper than the community reamers (P < .001). The new reamers generated 4.1°C less heat than the community reamers (P = .007) under the same force and time. When programmed to ream to the average depth of the new reamers, the community reamers generated 16.8°C more heat (P = .002) and required forces 95-318% greater than the 87.6 N force used by the new reamers. Conclusions: Community use of reamers will cause variations in depth of penetration and increased temperatures at a clinically generated force vs new reamers. When community reamers were forced to the same depths the new reamers achieved, a significantly greater amount of heat was generated, and an increased amount of time was needed, both of which are known risk factors for osteonecrosis.

Background: Iatrogenic intraoperative fractures are preventable complications in total knee arthroplasty. As press-fit fixation becomes more popular, further investigation into risk factors is needed. Some authors have suggested that smaller femurs may be at higher risk in posterior-stabilized constructs owing to industry designs trending toward larger, constant box sizes that increase the amount of bone resection relative to bone stock. Methods: Finite element analysis (FEA) was used to investigate the effect of insertion of posterior-stabilized femoral components on stress distributions in small femurs and whether common bony preparation techniques could further affect risk for intraoperative fracture. The FEA results were validated with mechanical testing by loading to failure with varying resection depths of the distal femur and varying lateralization of the box cut. Results: With a standard distal resection depth and neutral box position, a decrease in femur size led to an increase in maximal von Mises stresses by 43.6% medially and 44.3% laterally. Box lateralization and increased distal resection depth had minimal changes on the maximal stresses (3.3% medially and −0.4% laterally) on average-sized femurs while having a much larger effect on the stress distribution in small femurs (118.3% medially and 6.7% laterally). Conclusions: A subset of intraoperative femur fractures is potentially preventable. Small femur sizes, especially ones that would require increased distal resection or change in implant positioning, may benefit from an alternative design without the need for a cam/post mechanism.

Background:. Fragility fractures are often sentinel events in documenting new cases of osteoporosis. Numerous analyses have demonstrated low rates of adequate osteoporosis evaluation and treatment following primary fragility fractures. The purpose of this study was to quantify the incidence of primary fragility fractures in America and the rates of osteoporosis screening and management before and after fracture. Methods:. A retrospective review of the PearlDiver database was conducted using the International Classification of Diseases, Ninth Revision (ICD-9) and ICD, Tenth Revision (ICD-10) and Current Procedural Terminology codes. Patients who were 60 to 80 years of age and had primary fragility fractures of the hip, wrist, spine, pelvis, humerus, and other unspecified locations were included. The rates of dual x-ray absorptiometry (DXA) screening and osteoporosis pharmacotherapy were assessed for 2 years before and 2 years after the primary fracture. Results:. In this study, 48,668 patients with a primary fragility fracture were identified. Within this cohort, 25.8% (12,573 of 48,668) had received osteoporosis screening or treatment in the prior 2 years. In the 36,095 patients with no management before the fracture, 19% (6,799 patients) were diagnosed with osteoporosis and 18.4% (6,653 patients) received a DXA scan and/or filed claims for pharmacotherapy in the following 2 years. Patients with an osteoporosis diagnosis were more likely to receive both types of management (odds ratio [OR], 11.55 [95% confidence (CI), 10.31 to 12.95]), and male patients were less likely to receive both types of management (OR, 0.23 [95% CI, 0.17 to 0.27]). Secondary fragility fractures within the next 2 years were diagnosed in 8.4% (3,038 of 36,095) of patients at a mean of 221 days following the primary fracture. Conclusions:. The rates of appropriate osteoporosis evaluation, diagnosis, and management following primary fragility fractures remain unacceptably low. Less than one-third of patients with primary fragility fractures had been evaluated or treated for osteoporosis in the 2 years prior to fracture. Furthermore, among patients without pre-fracture management,

Phocomelia is a rare congenital birth defect marked by hypoplastic or markedly absent limbs. Developmental dysplasia of the hip (DDH) is a congenital disorder with a failure of the native acetabulum to provide complete coverage over the femoral head. The secondary osteoarthritis that develops from DDH is technically challenging for orthopedic surgeons because of distorted anatomy. The present case describes the diagnosis of Crowe 3 DDH in a phocomelia patient with hyperflexion requirements who successfully underwent staged bilateral total hip arthroplasty via a direct anterior approach. It highlights the utility of preoperative computerized tomography and intraoperative computer navigation to assist in implant placement. Recognizing difficult arthroplasty cases in advance is imperative as these cases may require great expertise and more extensive surgical planning.

During total knee arthroplasty, balancing is necessary for long-term stability and longevity of implants as improper balancing leads to abnormal surface strain. A routine practice among surgeons is to add more posterior slope to the proximal tibia to provide an increase in the flexion gap to balance the knee throughout the entire range of motion, particularly when doing cruciate-retaining knees. The aim of this technique guide is to provide a simple estimate of the posterior slope added or subtracted when cutting the proximal tibia using a standard extramedullary guide. It can also be applied to predict the amount of coronal change instituted using a standard extramedullary drop guide. Using a few basic calculations with a sine equation, a surgeon can accurately predict the amount of change in the slope applied when cutting the proximal tibia. This can be done to control the degree of slope added to the anterior-posterior direction and can be used to predict coronal alignment changes as well. This technique can be applied to any length extramedullary guide and applied across all companies to provide surgeons with an exact degree change in the tibial slope and coronal alignment with simple calculations.