Faculty Bibliography

As the demand for total hip arthroplasty (THA) continues to increase, the burden of revision THA is also expected to increase. Although the quality of polyethylene has improved markedly, osteolysis continues to be a risk for older designs and younger, active patients. Although progressive but typically asymptomatic in early stages, osteolysis can result in component failure and complicate revision surgery. Serial radiographs are paramount for monitoring progression. Although select cases may be treated with observation, surgery should be considered based on age, activity level, and projected life span. Well-fixed, noncemented modular acetabular components may be treated with curettage and bone grafting, as well as having to bear liner exchange with retention of the acetabular shell. However, in the setting of osteolysis, it is controversial whether bone grafting and component retention is superior to cup revision. This review explores the pathophysiology of osteolysis after THA and provides a comprehensive analysis of the evaluation and treatment of patients with osteolysis.

Interprosthetic femur fractures are a rare but serious complication following total hip and knee arthroplasty. Classification systems have focused not only on diagnosis but also on treatment algorithm. Critical to the evaluation of patients with these fractures are an assessment of fracture location, bone quality, and the presence of stemmed implants. The gold standard for fracture fixation is locked plating with bicortical and unicortical screws, supplemented with wires or cables as needed. For patients with compromised bone stock or insufficient bony area for fixation, allograft augmentation with struts or interprosthetic sleeves may be used. For fractures with severe bone loss, conversion to a megaprosthesis or total femur replacement may be warranted.

There currently exists an array of operative strategies to manage Lisfranc injuries. Modular fixation systems present surgeons with a choice between fully threaded solid cortical (FSC) and partially threaded cannulated cancellous (PCC) bone screws when using a transarticular screw approach. It is currently unknown how screw design influences fixation strength in Lisfranc reconstructions. The purpose of this study was to evaluate the biomechanical differences of FSC and PCC screws using a cadaveric model of a simulated Lisfranc injury and controlled benchtop experiments. Ten matched pairs of cadaveric feet received an acute Lisfranc injury and were repaired with FSC or PCC screws. Diastasis was measured between the medial and intermediate cuneiforms and the first and second metatarsals during simulations of partial weight bearing. Three-point bending and axial pull-out tests were performed to characterize screw mechanics that could not be measured within the cadaveric model. Screw design did not affect cuneiform or metatarsal diastasis. Neither screw loosening nor deformation was observed following cadaveric testing. Bending tests indicated FSC screws had higher ultimate strength, but there was no significant difference in yield load. Partially threaded cannulated cancellous bone screws exhibited superior axial pull-out strength. Fully threaded solid cortical and PCC screws provide equal amounts of fixation strength during partial weight bearing and similar resistance to deformation under bending loads. Partially threaded cannulated cancellous screws may simplify the operative procedure and minimize nonoptimal screw placement. If a clinician so desires, PCC screws may be used in lieu of FSC screws without sacrificing fixation strength. [Orthopedics. 2018; 41(2):e222-e227.].

Avascular necrosis (AVN) of the capitate is a rare clinical entity for which a variety of treatment options have been described, ranging from immobilization to microvascular bone transfer. Outcomes following medial femoral condyle corticocancellous free flap reconstruction have not been reported for this specific pathology. We present the case of a 16-year-old girl with posttraumatic capitate AVN who was treated with curettage and medial femoral condyle corticocancellous vascularized bone grafting. At 18 months after surgery, the patient remains pain-free and had resumed all activities including lifeguarding by 6 months after surgery. This microsurgical technique, described previously for AVN of the scaphoid and lunate, may be applied in a similar fashion for the capitate with promising clinical results.

BACKGROUND:Multimodal pain protocols have reduced opioid requirements and decreased complications after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, these protocols are not universally effective. The purposes of this study are to determine the risk factors associated with increased opioid requirements and the impact of preoperative narcotic use on the length of stay and inhospital complications after THA or TKA. METHODS:We prospectively evaluated a consecutive series of 802 patients undergoing elective primary THA and TKA over a 9-month period. All patients were managed using a multimodal pain protocol. Data on medical comorbidities and history of preoperative narcotic use were collected and correlated with deviations from the protocol. RESULTS:Of the 802 patients, 266 (33%) required intravenous narcotic rescue. Patients aged <75 years (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.10-3.12; P = .019) and with preoperative narcotic use (OR, 2.74; 95% CI, 2.01-3.75; P < .001) were more likely to require rescue. Multivariate logistic regression analysis demonstrated that preoperative narcotic use (OR, 2.74; 95% CI, 2.01-3.75; P < .001) was the largest independent predictor of increased postoperative opioid requirements. These patients developed more inhospital complications (OR, 1.92; 95% CI, 1.34-2.76; P < .001). This was associated with an increased length of stay (OR, 1.59; 95% CI, 1.06-2.37; P = .025) and a 2.5-times risk of requiring oral narcotics at 3 months postoperatively (OR, 2.48; 95% CI, 1.61-3.82; P < .001). CONCLUSION:Despite the effectiveness of multimodal postoperative pain protocols, younger patients with preoperative history of narcotic use require additional opioids and are at a higher risk for complications and a greater length of stay.

BACKGROUND:All-epiphyseal anterior cruciate ligament (ACL) reconstruction is a well-described technique for skeletally immature patients. The purpose of this study was to elucidate the early complication rate and identify associated risk factors for rerupture after this procedure in children. METHODS:We retrospectively reviewed patients who underwent all-epiphyseal ACL reconstructions performed at a large, tertiary care children's hospital between January 2007 and April 2013. Relevant postoperative data including the development of leg-length discrepancy, angular deformity, rerupture, infection, knee range of motion, arthrofibrosis, and other complications were recorded. Independent variables analyzed for association with rerupture included age, body mass index, graft type, graft size, and associated injuries addressed at surgery. RESULTS:A total of 103 patients (average 12.1 y old; range, 6.3 to 15.7) were analyzed. The mean follow-up was 21 months. The overall complication rate was 16.5% (17/103), including 11 reruptures (10.7%), 1 case (<1.0%) of clinical leg-length discrepancy of <1 cm, and 2 cases (1.9%) of arthrofibrosis requiring manipulation under anesthesia. Two patients (1.9%) sustained contralateral ACL ruptures and 3 (2.9%) sustained subsequent ipsilateral meniscus tears during the study period. There were no associations found between age, sex, graft type, graft thickness, body mass index, or associated injuries addressed during surgery and rerupture rate. Knee flexion continued to improve by 20 degrees on an average between the 6 weeks and 6 months postoperative visits (P<0.001; paired samples Student's t test). CONCLUSIONS:When taken in the context of known risk of future injury in an ACL-deficient knee, all-epiphyseal ACL reconstruction in children is safe. The rate of growth disturbance in this study is similar to previous reports in this patient demographic. The rerupture rate in this cohort is slightly higher compared with ACL reconstruction in older patients. LEVEL OF EVIDENCE/METHODS:Level IV-retrospective case series.

BACKGROUND:Improved pain management and early mobilization protocols have increased interest in the feasibility of short stay (<24 hours) or outpatient total hip (THA) and total knee (TKA) arthroplasty. However, concerns exist regarding patient safety and readmissions. The purposes of this study were to determine the incidence of in-hospital complications following THA/TKA, to create a model to identify comorbidities associated with the risk of developing major complications >24 hours postoperatively, and to validate this model against another consecutive series of patients. METHODS:We prospectively evaluated a consecutive series of 802 patients who underwent elective primary THA and TKA over a 9-month period. The mean age was 62.3 years. Demographic, surgical, and postoperative readmission data were entered into an arthroplasty database. RESULTS:Of the 802 patients, 382 experienced a complication postoperatively. Of these, 152 (19%) required active management. Multiple logistic regression analysis identified cirrhosis (odds ratio [OR], 5.89; 95% confidence interval [CI], 1.05-33.07; P = .044), congestive heart failure (OR, 3.12; 95% CI, 1.50-6.44; P = .002), and chronic kidney disease (OR, 3.85; 95% CI, 2.21-6.71; P < .001) as risk factors for late complications. One comorbidity was associated with a 77% probability of developing a major postoperative complication. This model was validated against an independent dataset of 1012 patients. CONCLUSION:With improved pain management and mobilization protocols, there is increasing interest in short stay and outpatient THA and TKA. Patients with cirrhosis, congestive heart failure, or chronic kidney disease should be excluded from early discharge total joint arthroplasty protocols.

Distal radius fractures are common in elderly patients, and the incidence continues to increase as the population ages. The goal of treatment is to provide a painless extremity with good function. In surgical decision making, special attention should be given to the patient's bone quality and functional activity level. Most of these fractures can be treated nonsurgically, and careful closed reduction should aim for maintenance of anatomic alignment with a focus on protecting fragile soft tissues. Locked plating is typically used for fracture management when surgical fixation is appropriate. Surgical treatment improves alignment, but improvement in radiographic parameters may not lead to better clinical outcomes. Treatment principles, strategies, and clinical outcomes vary for these injuries, with elderly patients warranting special consideration.

The optimal treatment of open fractures continues to be an area of debate in the orthopedic literature. Recent research has challenged the dictum that open fractures should be debrided within 6 hours of injury. However, the expedient administration of intravenous antibiotics remains of paramount importance in infection prevention. Multiple factors, including fracture severity, thoroughness of debridement, time to initial treatment, and antibiotic administration, among other variables, contribute to the incidence of infection and complicate identifying an optimal time to debridement.

INTRODUCTION/BACKGROUND:Healthcare providers are increasingly searching for ways to provide cost-efficient, high-quality care. Previous studies on evaluating cost used estimated cost-to-charge ratios, which are inherently inaccurate. The purpose of this study was to quantify actual direct cost savings from performing pediatric orthopaedic sports day surgery at an ambulatory surgery center (ASC) compared with a university-based children's hospital (UH). METHODS:Custom-scripted accounting software was queried for line-item costs for a period of 3 fiscal years (fiscal year 2012 to fiscal year 2014) for eight day surgery procedures at both a UH and a hospital-owned ASC. Hospital-experienced direct costs were compared while controlling for surgeon, concomitant procedures, age, sex, and body mass index. RESULTS:One thousand twenty-one procedures were analyzed. Using multiple linear regression analysis, direct cost savings at the ASC ranged from 17% to 43% for seven of eight procedures. Eighty percent of the cost savings was attributed to time (mean, 64 minutes/case; P < 0.001) and 20% was attributed to supply utilization (P < 0.001). Of the time savings in the operating room, 73% (mean, 47 minutes; P < 0.001) was attributed to the surgical factors whereas 27% (17 minutes; P < 0.001) was attributed to anesthesia factors. CONCLUSIONS:Performing day surgery at an ASC, compared with a UH, saves 17% to 43% from the hospital's perspective, which was largely driven by surgical and anesthesia-related time expenditures in the operating room. LEVEL OF EVIDENCE/METHODS:Level II.