Faculty Bibliography

Acute kidney injury is a reported complication of total joint arthroplasty (TJA), with potentially severe long-term complications. Our study aimed to identify the rate of perioperative renal injury in patients without pre-existing renal dysfunction who undergo TJA. Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified a mean annual rate of perioperative renal injury of 0.172% between 2009 and 2015. Factors most strongly associated with perioperative renal injury are age of 70 years or older, current smoking, history of diabetes mellitus, history of hypertension, and American Society of Anesthesiologists class of 3 or greater. There was no significant increase in the rate of renal injury from year to year. In patients without pre-existing renal disease, perioperative rates of acute kidney injury remain low in patients undergoing TJA.

Vascular complications in revision total hip arthroplasty may occur in cases where the components of the hip implant migrate through the acetabular wall, through the iliopectineal line of the pelvis, and into the pelvic cavity. This migration may lead to substantial intrapelvic vascular compromise, drastically increasing the surgical complexity and potential risk for morbidity and mortality in these surgical cases. Here, we present a case of a 78-year-old woman with significant acetabular protrusio, which resulted in intraoperative compromise of the external iliac artery with rapid extravasation. As a result of prudent preoperative planning, interdisciplinary collaboration, and precautionary measures, significant patient morbidity and mortality was averted.

Increasingly the relationship between the hip and spine has become recognized as a risk factor for postoperative instability following total hip arthroplasty. Thorough understanding of the relationship between the spine and pelvis, spinopelvic parameters, and normal and pathologic spinopelvic motion is critical to surgical planning and prevention of instability after total hip arthroplasty. This review details spinopelvic motion and postural changes that predispose patients to instability, guides readers through a preoperative risk assessment tool and our stepwise protocol to classify spinopelvic motion and prevent instability.
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Poor outcomes associated with increased perioperative opioid use have led investigators to seek alternative pain management modalities after total joint arthroplasty. Nonpharmacological approaches, such as electroceuticals, have shown promise. The purpose of this study was to evaluate the effects of "havening," a specific form of psychosensory therapy, on postoperative pain scores and narcotic consumption. In this prospective, randomized controlled trial, the authors compared 19 patients who underwent psychosensory therapy with 22 patients who served as the control group. Visual analog scale scores were collected preoperatively, every day during the hospitalization, and at approximately 1-month follow-up. Narcotic consumption during hospitalization was converted into daily morphine milligram equivalents and compared between the cohorts. In addition, postoperative complications, emergency department visits, and readmissions were compared between the cohorts. No difference in visual analog scale pain scores was reported between cohorts on postoperative day 1 (P=.229), at discharge (P=.434), or at 1-month follow-up (P=.256). Furthermore, there was no significant variance in mean daily morphine milligram equivalents (P=.221), length of stay (P=.313), postoperative complications (P=.255), 90-day readmissions (P=.915), and emergency department visits (P=.46) between the cohorts. This study showed that psychosensory therapy was not effective in reducing pain or narcotic consumption following total joint arthroplasty. Nonetheless, future studies assessing the role of psychosensory therapeutic interventions among patients after total joint arthroplasty are warranted to better understand the clinical implications of innovative therapies aimed at alleviating pain. [Orthopedics. 2018; 41(6):e848-e853.].

BACKGROUND:There is a lack of comparative data on osseointegration (BIC) of acetabular cup surfaces in hip arthroplasty in both normal bone mineral density and in conditions of osteoporosis. AIM/OBJECTIVE:To compare osseointegration of acetabular implants with various types of surfaces in an animal model with normal and osteoporotic bone tissue. MATERIAL AND METHODS/METHODS:The study was performed on 60 rats. To simulate osteoporosis ovariectomy was performed in 30 animals. Thirty healthy rats served as controls. In standardized defects of the distal metadiaphysis of the femur we implanted: porous tantalum Trabecular Metal (A), Trabecular Titanium (B), Titanium with Gription coating (C), Stiktite (D), and Tritanum (E). Bone apposition (osseointegration) was defined as all areas of direct "bone-to-implant contact" (BIC). RESULTS:No qualitative morphological differences in the evaluation of BIC around different implant types was seen in normal rats and rats with osteoporosis. Connective tissue areas around implants were larger in rats with osteoporosis. Morphometric studies showed that the highest BIC were seen in implants A and B, both in healthy animals ([72.00 ± 3.48]% and [67.46 ± 1.69]%) and ones with osteoporosis ([59.19 ± 2.10]% and [53.36 ± 2.57]%). BIC was (60.10 ± 2.05)%, (60.26 ± 2.36)%, and (61.78 ± 2.27)% around implants C, D and E in healthy rats, respectively. BIC in osteoporosis was (45.39 ± 2.37)%, (47.81 ± 2.41)% and (42.10 ± 1.44)%, respectively. CONCLUSION/CONCLUSIONS:Our study showed that the evaluated implants have good BIC features. Furthermore, based on histomorthometry and histology, Porous tantalum Trabecular Metal (A) and Trabecular Titanium (B) implants exhibit higher BIC with bone tissue.

Hemiarthroplasty is a common procedure for treatment of displaced femoral neck fractures in low-demand patients. As hip fracture incidence continues to increase, the need for revision hemiarthroplasty is also expected to increase. Multiple etiologies can result in a failed hemiarthroplasty, including persistent pain, infection, instability, leg-length discrepancy, and trauma. Preoperative clinical, radiographic, and laboratory assessments are critical in determining the etiology of the painful hemiarthroplasty. The standard of care for surgical management of failed hemiarthroplasty is conversion to a total hip arthroplasty. However, establishing the etiology preoperatively is essential to planning before treating the failed hemiarthroplasty.

One-stage and two-stage revision strategies are the two main options for treating established chronic peri-prosthetic joint infection (PJI) of the hip; however, there is uncertainty regarding which is the best treatment option. We aimed to compare the risk of re-infection between the two revision strategies using pooled individual participant data (IPD). Observational cohort studies with PJI of the hip treated exclusively by one- or two-stage revision and reporting re-infection outcomes were retrieved by searching MEDLINE, EMBASE, Web of Science, The Cochrane Library, and the WHO International Clinical Trials Registry Platform; as well as email contact with investigators. We analysed IPD of 1856 participants with PJI of the hip from 44 cohorts across four continents. The primary outcome was re-infection (recurrence of infection by the same organism(s) and/or re-infection with a new organism(s)). Hazard ratios (HRs) for re-infection were calculated using Cox proportional frailty hazards models. After a median follow-up of 3.7 years, 222 re-infections were recorded. Re-infection rates per 1000 person-years of follow-up were 16.8 (95% CI 13.6-20.7) and 32.3 (95% CI 27.3-38.3) for one-stage and two-stage strategies respectively. The age- and sex-adjusted HR of re-infection for two-stage revision was 1.70 (0.58-5.00) when compared with one-stage revision. The association remained consistently absent after further adjustment for potential confounders. The HRs did not vary importantly in clinically relevant subgroups. Analysis of pooled individual patient data suggest that a one-stage revision strategy may be as effective as a two-stage revision strategy in treating PJI of the hip.

BACKGROUND:The advent of highly cross-linked polyethylene (HCLPE) has significantly improved total hip arthroplasty survivorship. HCLPE has been shown to improve wear properties in midterm outcomes when compared to traditional polyethylene liners; however, there is a paucity of studies evaluating long-term outcomes. In addition, there is concern that wear rates may accelerate as the implant ages. Thus, the aims of this study are to report on the longest-to-date follow-up of a specific first-generation HCLPE liner and to determine whether there is a change in the annual wear rate over time. METHODS:Forty hips in 38 patients which were previously reported on in a midterm study were included in this long-term follow-up study. Patients in this cohort all received total hip arthroplasty between March 1999 and August 2004 using the Crossfire HCLPE liner. Annual wear rates (mm/y) were calculated for this cohort. Patients were contacted and asked about complications or revision procedures they may have had since the index procedure. RESULTS:Clinical follow-up averaged 12.9 years with a range of 7-18 years. The average follow-up duration was 12.5 years with a range of 10-17 years. Linear wear was found to be 0.056 ± 0.036 mm/y. Osteolysis was not observed in any of the patients with greater than 10-year radiographic follow-up. Furthermore, only 1 patient required revision surgery following a mechanical fall. CONCLUSION/CONCLUSIONS:Our study demonstrates the long-term wear rates associated with HCLPE liners continue to match rates published in midterm studies. Previously, we have reported that this cohort had an average annual wear rate of 0.05 mm/y over 10 years. This most recent report demonstrates a similar wear rate with up to 18-year follow-up.

AIMS/OBJECTIVE:The routine use of dual-mobility (DM) acetabular components in total hip arthroplasty (THA) may not be cost-effective, but an increasing number of patients undergoing THA have a coexisting spinal disorder, which increases the risk of postoperative instability, and these patients may benefit from DM articulations. This study seeks to examine the cost-effectiveness of DM components as an alternative to standard articulations in these patients. PATIENTS AND METHODS/METHODS:A decision analysis model was used to evaluate the cost-effectiveness of using DM components in patients who would be at high risk for dislocation within one year of THA. Direct and indirect costs of dislocation, incremental costs of using DM components, quality-adjusted life-year (QALY) values, and the probabilities of dislocation were derived from published data. The incremental cost-effectiveness ratio (ICER) was established with a willingness-to-pay threshold of $100 000/QALY. Sensitivity analysis was used to examine the impact of variation. RESULTS:In the base case, patients with a spinal deformity were modelled to have an 8% probability of dislocation following primary THA based on published clinical ranges. Sensitivity analysis revealed that, at its current average price ($1000), DM is cost-effective if it reduces the probability of dislocation to 0.9%. The threshold cost at which DM ceased being cost-effective was $1180, while the ICER associated with a DM THA was $71 000 per QALY. CONCLUSION/CONCLUSIONS:These results indicate that under specific clinical and economic thresholds, DM components are a cost-effective form of treatment for patients with spinal deformity who are at high risk of dislocation after THA. Cite this article: Bone Joint J 2018;100-B:1297-1302.

Introduction/objectives: The current study aims to add to the paucity of prior studies that have used a state's opioid registry to report detailed perioperative opioid use patterns and the effects of preoperative chronic opioid use among a consecutive cohort of total hip arthroplasty (THA) patients. Methods: A retrospective analysis on 256 consecutive patients who underwent a THA at our institution between February 2016 and June 2016 was performed. Two cohorts were involved in the study: THA patients who were deemed preoperative chronic opioid users and those who were not. Data on patients' opioid use histories 3 months prior to surgery and 6 months following surgery were collected using the state's prescription monitoring program. Variables that were compared between the two groups included baseline characteristics, as well as quality metrics. Results: Of the 256 patients, 54 (21.1%) patients were identified as chronic opioid users. The chronic users had a significantly higher prevalence of private insurance while the non-chronic users had a higher prevalence of worker's compensation insurance (p<0.001). Discharge disposition, value-based purchasing (VBP) costs, length of stay (LOS), emergency room visits, and postoperative office visits were similar between the two cohorts. Readmission rates, 30-day (p=0.031), 90-day (p=0.043), and 6-month (p=0.046), were significantly higher in the chronic opioid users cohort. Conclusion: The current study demonstrates that a substantial proportion of preoperative chronic opioid users continue to consume large amounts of opioids up to 6-months following THA surgery. Furthermore, preoperative chronic use is significantly associated with poorer quality outcomes, specifically with respect to readmission rates