Faculty Bibliography

Background/UNASSIGNED:Failed internal fixation of intertrochanteric (IT) hip fractures presents a significant challenge in the elderly, osteoporotic population. Conversion total hip arthroplasty (cTHA) and hemiarthroplasty (cHA) are both accepted salvage operations for failed IT fracture fixation, though limited clinical data exist regarding the optimal treatment between these procedures. Methods/UNASSIGNED:A systematic review of 3 databases (PubMed, Cochrane, and Embase) was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria were English-language studies that compared clinical or functional outcomes after failed fixation of IT fractures with total hip arthroplasty and hemiarthroplasty in adult subjects (>18 years of age). Data regarding research design, surgical technique, and clinical or functional outcomes were obtained and analyzed from eligible studies using a Mantel-Haenszel random-effects analysis model. Results/UNASSIGNED:< .001) in the cTHA group (47.5 ± 4.9) than that in the cHA (38.9 ± 7.2) group at minimum 14-month follow-up. Conclusions/UNASSIGNED:Despite potential advantages of cTHA or cHA for failed IT fractures, there were no differences in complications between either of the salvage procedures. Our analysis found a slight advantage in functional outcomes (Harris Hip Score) for cTHA at a minimum 14-month follow-up. Our study suggests that cTHA and cHA are both effective salvage procedures. Additional prospective studies are warranted to further delineate outcomes after salvage arthroplasty performed for failed IT fracture fixation.

Introduction/objectives: Nonmodular and modular femoral stems have been associated with complications following revision total hip arthroplasty (rTHA). This study aims to report outcomes of modular and nonmodular femoral components in rTHA. Methods: From January 1st, 2013 to September 30th, 2017, all rTHAs using modular or nonmodular femoral stems were identified. Demographic data including age, gender, American Anesthesiology Society (ASA) score. Surgical details including operative time, length of implant, and implant cost were collected. Clinical outcomes including length of stay (LOS), dislocation, infection, fracture, femoral implant re-revision, reoperation, and mortality were also collected. Simple linear regression analysis and sub-analysis using multivariable logistic regression were performed. Results: Of 247 rTHA cases identified, 136 (55.1%) cases utilized modular stems while 111 (44.9%) cases utilized nonmodular components. The average follow-up was 15.5 months (range 0.5-59 months). Nonmodular stems had a significantly lower cost when compared to modular implants (54.3% of modular cost; p<0.001). There were no differences appreciated in cohort demographics including age (p=0.831), gender (p=0.459), and ASA (p=0.053). In addition, there were no differences observed in the surgical details or clinical outcomes assessed, including operative time (p=0.386), LOS (p=0.638), and rates of re-revision of the femoral implant (p=0.327), re-operation (p=0.410), and post-op complications including, infection (p=0.322), dislocation (p=0.687), fracture (p=0.528), and mortality (p=0.446). Conclusion: The use of distal fixation, tapered-fluted, titanium nonmodular components may offer a more costeffective approach to rTHA compared to their modular counterparts

Obesity is an epidemic in the health care system. Obesity poses several challenges and raises unique issues for the arthroplasty surgeon. Obese patients are at higher risk for infection and dislocation. Additionally, obese patients have poorer implant survivorship and functional scores postoperatively. Obesity is a modifiable risk factor and weight loss preoperatively should be strongly considered. Obese patients must be counseled so that they have realistic expectations after total joint arthroplasty.

Although bariatric surgery is a proven means of weight loss and treatment of obesity-related comorbidities in morbidly obese patients, it is not yet clear how it affects outcomes after total joint arthroplasty in this high-risk patient population. This article explores the effects of obesity and bariatric surgery on osteoarthritis and total joint arthroplasty, and also discusses the financial and ethical implications of use of bariatric surgery for risk reduction before total joint arthroplasty.

Metal hypersensitivity (MHS) is a rare complication of total joint arthroplasty that has been linked to prosthetic device failure when other potential causes have been ruled out. The purpose of this review was to conduct an analysis of existing literature in order to get a better understanding of the pathophysiology, presentation, diagnosis, and management of MHS. It has been described as a type IV hypersensitivity reaction to the metals comprising prosthetic implants, often nickel and cobalt-chromium. Patients suffering from this condition have reported periprosthetic joint pain and swelling as well as cutaneous, eczematous dermatitis. There is no standard for diagnosis MHS, but tests such as patch testing and lymphocyte transformation testing have demonstrated utility, among others. Treatment options that have demonstrated success include administration of steroids and revision surgery, in which the existing metal implant is replaced with one of less allergenic materials. Moreover, the definitive resolution of symptoms has most commonly required revision surgery with the use of different implants. However, more studies are needed in order to understand the complexity of this subject.

Introduction/UNASSIGNED:The rotating hinge prosthesis was originally used and designed as a primary total knee arthroplasty implant, but was hampered due to poor outcomes and catastrophic failures. Newer rotating hinge implants can be utilized in complex revision total knee arthroplasties when appropriately indicated, but their outcome data is very difficult to interpret due to the strict and varied indications for use and subsequently small number of procedures performed. The goal of this review is to evaluate the current evidence on large cohort, rotating hinge knee prostheses used in the revision setting, in order to provide a clearer understanding of the indications, outcomes and complications. Methods/UNASSIGNED:The PubMed database was utilized to search the available literature regarding "hinged knee," or "rotating hinge" devices. Exclusion criteria included papers focusing on primary arthroplasty, revision for oncologic issues, one-stage revision for infection or studies with less than fifty cases. Results/UNASSIGNED:Review of 115 abstracts after initial search, led to ten studies in the literature that met our inclusion and exclusion criteria. The data shows that rotating hinge knee implants have good survivorship ranging from 51% to 92.5% at 10 years post-operatively. Complication rates range from 9.2% to 63% with infection and aseptic loosening as the most common complications. Conclusion/UNASSIGNED:Rotating hinge knee prostheses are most commonly indicated for infection, aseptic loosening, instability and bone loss in the literature. They have good outcome scores and survivorship, but continue to have high complication and revision rates. The implant is a good option when utilized appropriately for patients that are not candidates for less constrained devices.

Paget's disease of the bone is a chronic osteopathy that leads to structural weakness, hypervascularity, and bone deformities. Rapid bone turnover in patients with Paget's disease may affect outcomes following total hip arthroplasty (THA). Most literature on THA in the setting of Paget's disease is limited to isolated case reports or case series documenting a single institution experience. By completing a comprehensive analysis of the available cases, this study aims to investigate the outcomes and complications of THA in patients with Paget's disease.

PURPOSE: The use of unlinked constrained condylar components (CCK) has been extended to primary total knee arthroplasty (TKA); however, there is limited literature on its outcomes. The purpose of this retrospective cohort study was to assess clinical outcomes of one particular design of primary, non-stemmed, unlinked constrained TKA and to compare them with a control group of PS-TKA utilizing the same implant design. METHODS: The clinical and radiographic outcomes of 486-cemented, non-stemmed, primary TKA's performed by two surgeons at one institution using similar surgical algorithm, technique and prosthetic design were retrospectively reviewed. Primary TKA components were used in all knees; the only difference between groups was the type of polyethylene inserts used (CCK vs PS). Pre-operative deformity, knee society scores (KSS), range-of-motion (ROM), radiographic data and revision rates were compared. RESULTS: Both groups had comparable demographics, pre-operative coronal plane alignment, ROM and KSS. At a mean follow-up of 3.5 years, no difference was found in ROM, KSS, radiographic outcomes and revision rates. CONCLUSIONS: Cemented, primary, non-stemmed CCK-TKA offered comparable clinico-radiographic results to PS-TKA at short-term follow-up. Use of a semi-constrained insert without additional stems did not predispose to failure due to aseptic loosening with this implant design. Moreover, the rate of revision due to instability was lowered. LEVEL OF EVIDENCE: Retrospective cohort study, Level III.