Faculty Bibliography

BACKGROUND: A Perioperative Surgical Home (PSH) care model applies a standardized multidisciplinary approach to patient care using evidence-based medicine to modify and improve protocols. Analysis of patient outcome measures, such as postoperative nausea and vomiting (PONV), allows for refinement of existing protocols to improve patient care. We aim to compare the incidence of PONV in patients who underwent primary total joint arthroplasty before and after modification of our PSH pain protocol. METHODS: All total joint replacement PSH (TJR-PSH) patients who underwent primary THA (n=149) or TKA (n=212) in the study period were included. The modified protocol added a single dose of intravenous (IV) ketorolac given in the operating room and oxycodone immediate release orally instead of IV Hydromorphone in the Post Anesthesia Care Unit (PACU). The outcomes were (1) incidence of PONV and (2) average pain score in the PACU. We also examined the effect of primary anesthetic (spinal vs. GA) on these outcomes. The groups were compared using chi-square tests of proportions. RESULTS: The incidence of post-operative nausea in the PACU decreased significantly with the modified protocol (27.4% vs. 38.1%, p=0.0442). There was no difference in PONV based on choice of anesthetic or procedure. Average PACU pain scores did not differ significantly between the two protocols. CONCLUSION: Simple modifications to TJR-PSH multimodal pain management protocol, with decrease in IV narcotic use, resulted in a lower incidence of postoperative nausea, without compromising average PACU pain scores. This report demonstrates the need for continuous monitoring of PSH pathways and implementation of revisions as needed.

The purpose of this paper is to review the clinical indications for acetabular reconstruction in patients with underlying peri-prosthetic segmental and cavitary defects, evaluate steps in pre-operative planning, and present the American Academy of Orthopaedic Surgeons (AAOS) and Paprosky classification systems to categorize acetabular defects. We also present a review of the current surgical techniques to reconstruct the acetabular socket which includes a cementless acetabular component with morselized bone, structural allograft, jumbo and oblong cups, reinforcement rings, bone cages, custom triflange acetabular constructs, and trabecular metal components.

Posterior cruciate ligament (PCL) release may be required to balance the flexion gap in PCL retaining TKA. This study examines the incidence and functional consequences of PCL release in both fixed and mobile bearing TKA. A consecutive series of 1388 TKAs with 1014 fixed bearing, and 374 mobile bearing implants were reviewed for prevalence of partial PCL release, restoration of potential flexion and objective knee stability at minimum one-year follow-up. Patients receiving mobile bearing inserts were more likely to need partial PCL release (42% versus 17.5%). The occurrence of partial PCL release did not have a significant impact on knee range of motion and subjective knee stability. The need for a partial PCL release appears to be greater in mobile than in fixed bearing. Knees that required a release in both groups demonstrated no difference in restoration of flexion compared with unreleased knees and no adverse effects on flexion stability.

PURPOSE: To create standard T2 map profiles from the entire femoral cartilage of healthy volunteers in order to assess regional variations using an angular and layer-dependent approach. MATERIALS AND METHODS: Twenty healthy knees were evaluated using 3T sagittal images of a T2 mapping sequence. Manual segmentation of the entire femoral cartilage was performed slice-by-slice by two raters using MatLab. Inter- and intrarater reliabilities were calculated using intraclass correlation coefficient (ICC) and Bland-Altman analysis. T2 values were analyzed with respect to specific locations (medial condyle, trochlea, and lateral condyle), angles to B0 , and layers of cartilage (whole, deep, and superficial). RESULTS: Inter- and intrarater reliability obtained from the entire femoral cartilage was excellent (ICC = 0.84, 0.86, respectively). The ICCs around the trochlea were lower than those of the medial and lateral condyle. Both the inter- and intrarater Bland-Altman plots indicated larger differences in pixel count are seen as the size of the angular segment becomes larger. T2 values were significantly higher in the superficial layer compared to the deep layer at each femoral compartment (P < 0.001). A magic angle effect was clearly observed, especially within the whole and deep layer over the medial and lateral femoral condyles, except for the superficial layer at the medial condyle. CONCLUSION: The normal T2 map profiles of the entire femoral cartilage showed variations in ICCs by location and in T2 values by angles and layers. These profiles can be useful for diagnosis of early cartilage degeneration in a specific angle and layer of each condyle and trochlea. J. MAGN. RESON. IMAGING 2015.

The treatment of knee osteoarthritis and the preparation for total knee arthroplasty require repetitive imaging to guide preoperative planning and operative technique. Full-length standing anteroposterior images are the gold standard in assessing the alignment of the limb via the measurement of the mechanical axis of the knee. The anatomical axis can be obtained from a more limited image of the knee, and as such is less expensive and exposes the patient to less ionizing radiation. The objective of this cross-sectional prospective study was to examine the extent to which the anatomical axis measured on a fixed-flexed posteroanterior (Rosenberg view) radiograph correlates with the mechanical axis. The data of 209 total knee arthroplasty radiographs were analyzed to compare the preoperative correlation between the mechanical and anatomical axis. The anatomical axis correlated with the mechanical axis when it was measured from both the standing full-length anteroposterior radiograph and from a fixed-flexed posteroanterior radiograph. Using an angle of offset found from linear regression, these correlations become closer. Body mass index and Kellgren-Lawrence grade were not found to have a significant effect. It is the conclusion of this study that the anatomical axis, as measured from a limited knee radiography, may serve as a plausible estimate of the mechanical axis when done with a neutral angle of offset, and that offset angle depends on gender and the imaging technique used to determine the anatomical axis. [Orthopedics. 2015; 38(12):e1115-e1120.].

Achondroplasia (ACH) is the most common form of hereditary dwarfism and presents with multiple musculoskeletal anomalies but is not normally associated with premature hip arthritis. Developmental dysplasia of the hip (DDH) is a spectrum of disease resulting in shallow acetabular depth and a propensity for chronic femoral subluxation or dislocation; it is among the most common causes of premature arthritis. This case report describes the diagnosis of symptomatic DDH in a patient with ACH and highlights difficulties of primary total hip arthroplasty (THA) as a treatment option. Intraoperative radiographic imaging is advised to ensure proper prosthesis placement. Femoral osteotomy may aid visualization, reduction, and avoidance of soft tissue injury. Concomitant ACH and DDH is a challenging problem that can be successfully treated with modified THA.

Total hip arthroplasty (THA) is an increasingly common procedure among elderly individuals. Although conversion THA is currently bundled in a diagnosis related group (DRG) with primary THA, there is a lack of literature supporting this classification and it has yet to be identified whether conversion THA better resembles primary or revision THA. This editorial analyzed the intraoperative and postoperative factors and functional outcomes following conversion THA, primary THA, and revision THA to understand whether the characteristics of conversion THA resemble one procedure or the other, or are possibly somewhere in between. The analysis revealed that conversion THA requires more resources both intraoperatively and postoperatively than primary THA. Furthermore, patients undergoing conversion THA present with poorer functional outcomes in the long run. Patients undergoing conversion THA better resemble revision THA patients than primary THA patients. As such, patients undergoing conversion THA should not be likened to patients undergoing primary THA when determining risk stratification and reimbursement rates. Conversion THA procedures should be planned accordingly with proper anticipation of the greater needs both in the operating room, and for in-patient and follow-up care. We suggest that conversion THA be reclassified in the same DRG with revision THA as opposed to primary THA as a step towards better allocation of healthcare resources for conversion hip arthroplasties.

The decision point with inter-hospital arthroplasty patient transfers and its financial implications have not been well studied. Factors outside of complexity of medical and surgical care are believed to drive the transfer of orthopaedic patients to tertiary care centers. We compared our institutional cost and resource utilization between transfer and elective patients in need of arthroplasty care. We hypothesized that transfer patients will incur a higher direct cost and resource utilization compared to elective patients, and that socioeconomic factors will play a role in the decision of transfer. After analysis of key metrics, transfer patients at our institution did not have any significant differences in insurance types. However, they did incur a longer length of stay (p<0.0001) and incurred greater direct costs (p<0.0001) to the hospital. After analysis of key parameters, transfer patients were more complex and costly to care for compared to our in-system patients.

Local infiltration anesthesia (LIA) with anesthetics, steroids, NSAIDS, and epinephrine has been shown to be effective in reducing total knee arthroplasty (TKA) postoperative pain. This systematic review explores the functional outcomes of randomized control trials that have compared the use of LIA with and without steroids during TKA. Five studies with 412 patients met the inclusion criteria, 228 received local infiltration anesthesia with steroids (LIAS) and 184 received local infiltration anesthesia without steroids (LIAWS). The use of LIAS in management of postoperative TKA pain has been shown to decrease the length of hospital stay, time required to achieve straight leg raise, and pro-inflammatory signals in patients. Although there is no overwhelming data to suggest LIAS improves postoperative TKA pain, current literature does support its effectiveness in producing other favorable surgical outcomes.

The clinical outcome of total knee arthroplasty (TKA) remains suboptimal in some patients. One of the factors that might hinder improved functionality may be postoperative limb length discrepancy due to increase in limb length of the operative limb. The objective of this cross-sectional prospective study was to examine the extent to which limb length change occurs after TKA and to compare the change in limb length to the degree of valgus or varus joint position preoperatively. The role of body mass index and Kellgren-Lawrence grade in limb length change was also assessed. The data of 137 TKAs were analyzed and separated into categories to compare change in limb length pre- versus postoperatively. In all, 59.1% of patients experienced an increase in limb length with an average increase of 0.438 cm, but overall, there was no statistically significant difference in limb length pre- versus postoperatively (P value 0.598). Similar trends were seen within all other groups. It is the conclusion of this study that limb lengthening after TKA does not frequently occur to a statistically significant extent, regardless of preoperative joint state.