Faculty Bibliography

AIMS:Tranexamic acid (TXA) is proven to reduce blood loss following total knee arthroplasty (TKA), but there are limited data on the impact of similar dosing regimens in revision TKA. The purpose of this multicentre randomized clinical trial was to determine the optimal regimen to maximize the blood-sparing properties of TXA in revision TKA. PATIENTS AND METHODS:-tests for equivalence. RESULTS:In total, one patient withdrew, five did not undergo surgery, 16 were screening failures, and 25 did not receive the assigned treatment, leaving 186 patients for analysis. There was no significant difference in haemoglobin reduction among treatments (2.8 g/dl for single-dose IV TXA, 2.6 g/dl for double-dose IV TXA, 2.6 g/dl for combined IV/topical TXA, 2.9 g/dl for oral TXA; p = 0.38). Similarly, calculated blood loss (p = 0.65) and transfusion rates (p = 0.95) were not significantly different between groups. Equivalence testing assuming a 1 g/dl difference in haemoglobin change as clinically relevant showed that all possible pairings were statistically equivalent. CONCLUSION:2019;101-B(Supple 7):10-16.

AIMS/OBJECTIVE:A variety of surgical approaches are used for total hip arthroplasty (THA), all with reported advantages and disadvantages. A number of common complications can occur following THA regardless of the approach used. The purpose of this study was to compare five commonly used surgical approaches with respect to the incidence of surgery-related complications. PATIENTS AND METHODS/METHODS:-tests where appropriate and proportions were compared using the chi-squared test. RESULTS:A total of 248 patients had 263 complications related to the surgery, with an incidence of 6.94%. The anterior approach had the highest incidence of complications (8.5% (113/1329)) and the posterior approach had the lowest, at 5.85% (97/1657; p = 0.006). Most complications were due to deep infection (22.8%), periprosthetic fracture (22.4%), and prolonged wound drainage (21.3%). The rate of dislocation was 0.84% (14/1657) with the posterior approach and 1.28% (17/1329) with the anterior approach (p = 0.32). CONCLUSION/CONCLUSIONS:2019;101-B:646-651.

AIMS/OBJECTIVE:With an ageing population of patients who are infected with hepatitis C virus (HCV), the demand for total knee arthroplasty (TKA) in this high-risk group continues to grow. It has previously been shown that HCV infection predisposes to poor outcomes following TKA. However, there is little information about the outcome of TKA in patients with HCV who have been treated successfully. The purpose of this study was to compare the outcomes of TKA in untreated HCV patients and those with HCV who have been successfully treated and have a serologically confirmed remission. PATIENTS AND METHODS/METHODS:A retrospective review of all patients diagnosed with HCV who underwent primary TKA between November 2011 and April 2018 was conducted. HCV patients were divided into two groups: 1) those whose HCV was cured (HCV-C); and 2) those in whom it was untreated (HCV-UT). All variables including demographics, HCV infection characteristics, surgical details, and postoperative medical and surgical outcomes were evaluated. There were 64 patients (70 TKAs) in the HCV-C group and 63 patients (71 TKAs) in the HCV-UT cohort. The mean age at the time of surgery was 63.0 years (sd 7.5; 44 to 79) in the HCV-C group and 61.7 years (sd 6.9; 47 to 88) in the HCV-UT group. RESULTS:1.4%; p < 0.01) than HCV-C patients. CONCLUSION/CONCLUSIONS:2019;101-B:667-674.

AIMS:Revision total knee arthroplasty (rTKA) accounts for approximately 5% to 10% of all TKAs. Although the complexity of these procedures is well recognized, few investigators have evaluated the cost and value-added with the implementation of a dedicated revision arthroplasty service. The aim of the present study is to compare and contrast surgeon productivity in several differing models of activity. MATERIALS AND METHODS:rTKA with a single OT; and 3) primary TKA with two OTs versus rTKA with a single OT. RESULTS:In total, 4570 procedures were performed: 4128 primary TKAs, 51 TKA liner exchanges, and 391 full rTKAs. Surgical time was significantly different between the primary TKA, liner exchange, and rTKA cohorts (100.6, 97.1, and 141.7 minutes, respectively; p < 0.001). Primary TKA yielded a mean of 7.1% more RVU/min per procedure than rTKA. Our one-OT model demonstrated that primary TKA (n = 4) had a 1.9% RVU/day advantage over rTKA (n = 3). If two OTs are used for primary TKA (n = 6), the outcome strongly favours primary TKA by an added 34.6% RVUs/day. CONCLUSION:Our results suggest that a dedicated rTKA service would lead to lower surgeon remuneration based on the current RVU paradigm. Revision arthroplasty specialists may need additional or alternative incentives to promote the development of a dedicated revision service. Through such an approach, healthcare organizations could enhance the quality of care provided, but surgeon productivity measures would need to be adjusted to reflect the burden of these cases. Cite this article: Bone Joint J 2019;101-B:675-681.

AIMS/OBJECTIVE:non-anterior (NA) surgical approaches on prosthetic joint infection (PJI), and examined the impact of new perioperative protocols on PJI rates following all surgical approaches at a single institution. PATIENTS AND METHODS/METHODS:(13.3 to 57.6, sd 6.1), respectively. Infection rates were calculated yearly for the DA and NA approach groups. Covariates were assessed and used in multivariate analysis to calculate adjusted odds ratios (ORs) for risk of development of PJI with DA compared with NA approaches. In order to determine the effect of adopting a set of infection prevention protocols on PJI, we calculated ORs for PJI comparing patients undergoing THA for two distinct time periods: 2013 to 2014 and 2015 to 2016. These periods corresponded to before and after we implemented a set of perioperative infection protocols. RESULTS:There were 1985 patients in the DA group and 4101 patients in the NA group. The overall rate of PJI at our institution during the study period was 0.82% (50/6086) and decreased from 0.96% (12/1245) in 2013 to 0.53% (10/1870) in 2016. There were 24 deep PJIs in the DA group (1.22%) and 26 deep PJIs in the NA group (0.63%; p = 0.023). After multivariate analysis, the DA approach was 2.2 times more likely to result in PJI than the NA approach (OR 2.2 (95% confidence interval 1.1 to 3.9); p = 0.006) for the overall study period. CONCLUSION/CONCLUSIONS:2019;101-B(6 Supple B):2-8.

AIMS/OBJECTIVE:Studying the indications for revision total hip arthroplasty (THA) may enable surgeons to change their practice during the initial procedure, thereby reducing the need for revision surgery. The aim of this study was to identify and describe the potentially avoidable indications for revision THA within five years of the initial procedure. PATIENTS AND METHODS/METHODS:A retrospective review of 117 patients (73 women, 44 men; mean age 61.5 years (27 to 88)) who met the inclusion criteria was conducted. Three adult reconstruction surgeons independently reviewed the radiographs and medical records, and they classified the revision THAs into two categories: potentially avoidable and unavoidable. Baseline demographics, perioperative details, and quality outcomes up to the last follow-up were recorded. RESULTS:A total of 60 revision THAs (51.3%) were deemed potentially avoidable and 57 (48.7%) were deemed unavoidable. The following were identified as avoidable factors: suboptimal positioning of the acetabular component (29; 48%), intraoperative fracture or a fracture missed on an intraoperative radiograph (20; 33%), early (less than two weeks) aseptic loosening (seven; 11.7%), and symptomatic leg length discrepancy of > 1 cm (four; 6.7%). CONCLUSION/CONCLUSIONS:2019;101-B(6 Supple B):97-103.

BACKGROUND:Short-stem (SS) hip prostheses for total hip arthroplasty (THA) have gained popularity as surgeons strive to reproduce physiological stress distributions at the proximal femur. Additionally, as THA indications continue to target younger populations, preservation of femoral bone stock for potential revision surgeries is particularly appealing. However, little is known regarding the short-term complications of each variety of short stem during the learning curve period. The purpose of this study is to evaluate the short-term complications among the THA recipients with the use of a novel SS hip prosthesis. METHODS:A retrospective chart review was performed of all patients undergoing primary THA utilizing an Echo Bi-Metric Microplasty hip stem. Patient demographics, surgical factors, complications and quality outcomes were collected utilizing our institution's data warehouse and verified by chart review. RESULTS:In total, 182 SSs were implanted in 168 patients undergoing primary THA. Of these, 5 (2.9%) patients sustained a periprosthetic fracture. Two fractures occurred during the index hospital admission, and 3 occurred in the post-discharge period. Subset analysis demonstrated that 4 (80%) fractures had occurred during the initial learning curve period, within the first 30 surgical cases with a SS. CONCLUSION/CONCLUSIONS:Short-stem hip prostheses are a safe alternative for THA. The results of the present study demonstrate a fracture incidence of 2.9% among patients. However, surgeons should remain cautious when utilizing new implant system and expect a learning curve. In this study, 80% of periprosthetic fractures following SS THA occurred within the first 30 cases for experienced arthroplasty-trained surgeons.

BACKGROUND:As the clinical and financial environments of total joint arthroplasty (TJA) have evolved over the last several decades so has the role of the surgeon in providing this care to patients. Our objective was to examine current practices and influential factors among fellowship-trained arthroplasty surgeons. METHODS:An electronic survey was sent to all surgeons who had completed one of the three high-volume adult reconstruction fellowships from the years 2007-2016. The survey consisted of 34 questions regarding current practice characteristics, case volumes for primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA), use of advanced technologies, choice of surgical approach and implant design, factors influencing their choices, and their involvement in implant selection and contract negotiations. RESULTS:Questionnaires were sent to 53 surgeons; 52 were completed. Sixty percent of respondents performed at least 100 TKAs and 84% performed at least 50 THAs annually. Ninety-four percent use a single company's implant for more than 90% of primary TKA and THA. Fellowship or residency experience was the most significant influence on TKA and THA implant selection for 62% and 45% of surgeons, respectively, while contracts of their current institution were the primary influence for 17% and 12%, respectively. Fifty-five percent of surgeons used some advanced technology of which 16% said this influenced their implant choice. Eighty-six percent perform the majority of cases at centers performing at least 200 TJAs per year, and 39% participate in implant contract negotiations. CONCLUSION/CONCLUSIONS:Despite changes in the economic environment of TJA, this study demonstrates that experience with a specific implant during training, particularly fellowship, is the most influential factor for implant selection among fellowship-trained arthroplasty surgeons.

BACKGROUND:Patients with developmental dysplasia of the hip (DDH) require special surgical considerations for total hip arthroplasty (THA). Despite the difficulties posed by the population's anatomical abnormalities, few large evaluations of postoperative outcomes exist. This study seeks to characterize outcomes following primary THA among patients diagnosed with DDH. METHODS:A retrospective review was conducted at a tertiary care center on all THA patients between June 2011 and March 2018. Inclusion criteria for this study included any patient diagnosed with DDH undergoing primary THA. Baseline information, operative reports, and postoperative outcomes were pulled from the medical record. RESULTS:. Most patients were female (82%). The majority of hips (89%, n = 344) were Crowe type 1, followed by 2 (6.9%, n = 26), 3 (2.6%, n = 10), and 4 (1.3%, n = 5). Most hips were Hartofilakidis Class A (83%, n = 320), followed by Class B (15%, n = 59), then C (1.6%, n = 6). Mean follow-up was 24.8 months. Revision THA was required in 19 (4.9%) cases, with the most common indications being infection (2.1%) and periprosthetic fracture (1.0%). Readmission rates were 1.8% (7 hips) and 2.9% (11 hips) at 30-day and 90-day, respectively. The 30-day and 90-day ED visit rates were 1.3% (5 hips) and 2.1% (8 hips), respectively. No complications were seen following 344 (87%) THAs. CONCLUSION/CONCLUSIONS:Despite their surgical complexity, DDH patients on average have notably low rates of revision and dislocation. Longer follow-up is needed to better assess outcomes after THA in this complex patient population.