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.

As the emphasis on value-based care within total joint arthroplasty increases, this procedure is becoming more prevalent in the outpatient setting. The goals of this study were to report on the authors' early experiences with same-day discharge and to identify patient characteristics that are associated with failure to discharge after total hip arthroplasty within this program. All patients who were enrolled in the same-day discharge total hip arthroplasty program at the study institution between January 2015 and July 2016 were included. Demographics, baseline characteristics, and clinical and quality outcomes were compared between patients who successfully completed this program and those who did not. Of the 163 study subjects, 143 (87.7%) were discharged successfully on the same day as surgery. Women, patients younger than 40 years, and patients older than 60 years all had an increased risk of failing the program. Body mass index of 26 kg/m² or less was associated with a 40% greater risk of failure. Patients with an American Society of Anesthesiologists score of 3 had a 3-fold risk of failure compared with patients with an American Society of Anesthesiologists score of 2 or less. The screening protocol for same-day discharge at the study institution had an 87.7% rate of successful same-day discharge. Further investigation is needed to identify patients who are at risk of failing the same-day discharge initiative. [Orthopedics. 2018; 41(1):35-42.].

Background/UNASSIGNED:Hip and knee replacements for osteoarthritis are established procedures for improving joint pain and function, yet their safety in patients with multiple sclerosis (MS) is unknown. Patients with MS face unique surgical challenges due to underlying neurologic dysfunction. Current literature on arthroplasty in MS is limited to case reports focusing on adverse events. Methods/UNASSIGNED:Of 40 identified patients who underwent hip or knee replacement, 30 had sufficient data for inclusion. We reviewed their medical records and recorded reasons for surgery, age at surgery, MS characteristics, surgical complications, and ambulatory aid status before and after surgery. We supplemented medical record review with questionnaires regarding preoperative and postoperative pain and satisfaction with surgical outcomes. Results/UNASSIGNED:Median follow-up was 26 months. Complications of surgery were reported in ten patients (33%), mostly mild and self-limited, although four patients (13%) required repeated operation. Six patients (20%) reported improvements in ambulatory aid use compared with presurgery baseline, ten (33%) worsened, and 14 (47%) were unchanged. In 20 patients who completed the questionnaire, mean ± SD joint pain scores (on 0-10 scale) decreased from 8.6 ± 2.0 preoperatively to 2.9 ± 2.4 postoperatively (P < .001). Five patients (25%) were free of joint pain at last follow-up. Conclusions/UNASSIGNED:These results suggest that pain reduction is a realistic outcome of total knee or hip arthroplasty in people with MS and that improved functional gait outcomes are possible in some patients. Prospective, multicenter, collaborative studies are needed to optimize selection and improve outcomes in people with MS considering arthroplasty.

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

Introduction/objectives: As surgeons, we have a moral obligation to address potentially preventable complications in an effort to improve total hip arthroplasty (THA) outcomes. The goal of this study is to identify and report potentially preventable causes for revision THA (rTHA). Methods: A retrospective review of 352 consecutive patients that underwent rTHA or re-revision THA from August 2015 to August 2017 was conducted. 138 of these were identified as primary to rTHA within a 5 year interval. Two adult reconstruction fellowship trained surgeons reviewed perioperative parameters and classified rTHA recipients into two categories: preventable rTHA and nonpreventable rTHA. Basic demographics, surgical characteristics for the primary THA (pTHA), and pre- and post-rTHA variables were analyzed. Results: Sixty (43.5%) rTHAs were deemed preventable. Of these rTHA recipients, 20 were male and 40 were female. Mean age at time of rTHA was 61.5 years and mean body mass index was 27.8 kg/m2. The following were identified as preventable reasons for rTHA: cup malpositioning (70%), instability (53%), intra-operative fracture (40%), history of spinal surgery/deformity (22%), aseptic loosening (20%), femoral component subsidence (15%), and other (18%). The most common bearing surface during pTHA was cobalt chrome on highly crosslinked polyethylene (40%). The most common femoral head size was 36mm (38%). Technology was used for assistance in 8.3% of pTHAs. Four patients (6.7%) underwent re-revision THA, three for instability and one for aseptic loosening. Conclusion: A high proportion (43.4%) of rTHA is potentially preventable. Furthermore, surgeons are responsible for carefully evaluating causes for rTHA and identifying new methods to address these issues

Introduction/objectives: Cemented dual mobility cups combined with outer porous cups allows for optimal bony purchase by the outer porous metal shell and a more ideal anatomic orientation by the cemented inner dual mobility cup. The purpose of this study is to report on the clinical outcomes of this novel construct. Methods: A retrospective review of a single center's revision THA cases from January 1st, 2016 to July 1st, 2017 was conducted. Patients that received this novel construct were included. Demographic data including age, gender, body mass index (BMI), American Anesthesiology Society (ASA) score, smoking history, and calculated Charlson Comorbidity Index (CCI) was collected. Surgical details including reason for revision THA, time in years from primary THA, outer shell size, dual mobility cup size, and additional fixations was collected. Outcome information on radiographic assessment for implant fixation, infections, re-operations, periprosthetic fractures, and dislocations was collected. Results: Sixteen patients met the inclusion criteria for the study of which 9 were females and 7 were males. The average age at the time of THA was 61.1 years with an average follow-up of 5.9 months. Conclusion: Our study demonstrates encouraging results with the use of this novel construct in preventing instability after THA as evidenced by the absence of any dislocation or implant loosening. Although this study is limited by the lack of long-term follow-up and sample size, our novel construct shows promising short-term results. Moreover, as the majority of dislocations occur within the first 3 months, we believe that this construct may present as a new technique to solve the challenge of recurrent dislocation and instability following revision THA

Introduction/objectives: An understanding of patient characteristics associated with persistent-chronic opioid use after total joint arthroplasty (TJA) will allow surgeons to better manage these patients. Our study aims to identify risk factors among preoperative chronic opioid users who continue to chronically use narcotics after total hip arthroplasty (THA). Methods: A retrospective analysis was performed on 256 THA recipients using the state's mandated opioid monitoring program to identify preoperative chronic opioid users. Chronic users were stratified into two cohorts based on their use 6 months after surgery: 1) persistent-chronic, and 2) previous chronic users. Patient demographics and relevant histories were abstracted and comparatively assessed between the cohorts. In addition, an analysis was performed to calculate which preoperative opioid dose was most predictive of chronic use. Results: Within the study population, 54 patients were identified as preoperative chronic opioid users. Of these, 13 (24.1%) were identified as persistent-chronic users 6 months following surgery. Specific characteristics associated with a higher likelihood of persistent-chronic opioid use included: male gender, ASA score >2, and Medicare as a payer type. A 33 mg/day morphine-equivalent dose consumption prior to surgery was most predictive for persistent chronic opioid use. Conclusion: Our study demonstrates that patients who are male, have an ASA >2, and use Medicare are at greater risk for persistent chronic opioid use. Thus, given the poor outcomes associated with chronic opioid use, these findings may help guide surgeons' clinical decision-making process when encountering patients with a history of opioid use

Introduction/objectives: Routine use of DM may not be a cost-effective measure, but an increasing number of THA candidates have coexisting spinal disorders, substantially increasing their risk for instability. This study seeks to expand our understanding of the cost-effectiveness of dual mobility components as an alternative to standard articulations in this high-risk dislocation population. Methods: A state-transition Markov model with expectedvalue decision analysis was used to evaluate the costeffectiveness of DM cups for high-risk patients who would be at high risk for dislocation within one year of their index THA. Direct and indirect costs of dislocation, incremental DM cost ($1000), quality-adjusted life years (QALY) values and dislocation probabilities were derived from published data. Results: Spine fusion patients were modelled to have a 15% probability of dislocation following primary THA based on published clinical ranges. A hypothetical reduction of 5% in probability of dislocation was deemed clinically plausible with the addition of a DM implant. Under these model parameters, sensitivity analysis was used to identify scenarios for which DM would be cost effective. For example, if the probability of dislocation is 15% with traditional bearings, then the use of DM is cost-effective if it reduces the dislocation risk to 10% and costs less than $640 (Figure 1). However, at its current average selling price ($1000), it would only be cost-effective if it reduces the probability of dislocation from 15% to 7% in this population. Conclusion: Dislocation is a significant complication and spine fusion patients have been shown to be at high risk. Our results indicate that under specific conditions DM cups are cost-effective for this high risk spine fusion population

Introduction/objectives: Diagnosis and treatment of patients with coexisting hip and spine pathologies can be challenging. Patients with sagittal spinopelvic deformity utilize pelvic tilt (PT) and their lower extremities in order to compensate for malalignment. In patients with lower extremity osteoarthritis (OA), these compensatory mechanisms can be compromised, leading to further disability. Methods: Patients > 18 years with SSD [SVA > 50mm, PT > 25degree, or TK > 60degree] were included for analysis. Spinopelvic, lower extremity, and cervical alignment were assessed on standing full-body stereoradiographs. Hip OA severity was graded by Kellgren-Lawrence scale (0-4). Propensity score matching was used to control for age and T1 pelvic angle (TPA). Patients were categorized as limited OA (LOA: grade 0-2) and severe OA (SOA: grade 3-4). Results: A total of 997 patients (LOA=929, SOA=68) were identified meeting inclusion criteria. After PSM, 136 patients (SOA: n=68, LOA n=68) were included in the study. SOA had less PT (17.8degree+/-12.6degree vs 22.6degree+/-8.4degree, p=0.011), TK (42.5degree+/-21.2degree vs 52.3degree+/-20.2degree, p=0.007), higher SVA (71.6 mm+/-47.1 vs 40.7 mm+/-43.9, p<0.001) and T1Spi (+2.3degree+/-6.4degree vs -2.6degree+/-5.5degree, p<0.001) than LOA. SOA also had a lower SFA (194.3degree+/-12.4degree vs 202.4degree+/-9.5degree, p<0.001) and AA (5.9degree+/-3.5degree vs 7.2degree+/-3.6degree, p=0.043), increased P.Shift (49.7mm+/-39.5 vs 19.7mm+/-28.4; p<0.001) and increased GSA (7.7degree+/-4.5degree vs 5.0degree+/-4.0degree, p< 0.001) compared to LOA. There was no difference in PI, PI-LL mismatch, LL, KA or cervical alignment (p >0.05). Conclusion: Patients with coexisting spinal malalignment and severe hip OA compensate by pelvic shift and thoracic hypokyphosis rather than pelvic tilt, likely as a result of limited hip extension