Faculty Bibliography

The purpose of this study was to determine if there is a difference in the number of diagnostic tests and interventions, pain and function scores, or satisfaction of patients discharged to inpatient rehabilitation facilities vs to home. From February to May 2015, 171 consecutive patients were prospectively recruited following primary total knee arthroplasty. Six weeks postoperatively, based on the patients' recollections, the number and types of diagnostic imaging tests, number of blood transfusions, and overall satisfaction whether discharged to inpatient rehabilitation facilities (n=85) or to home (n=86) were assessed. A significantly greater proportion of patients discharged to inpatient rehabilitation facilities reported undergoing at least 1 diagnostic imaging test compared with patients discharged to home (25.9% vs 8.1%; P=.013). Multivariate logistic regressions revealed that patients discharged to an inpatient rehabilitation facility were more likely to have a greater number of diagnostic tests (odds ratio, 5.01; 95% confidence interval, 1.69-14.92; P=.004) and radiographs (odds ratio, 16.10; 95% confidence interval, 1.54-169.70; P=.020) performed. There was no significant difference in readmission rates for patients discharged to home (2.3%) vs to an inpatient rehabilitation facility (0%) (P=.246). No significant differences were observed in postoperative Knee Society pain or function scores (P=.083 and P=.057, respectively) or visual analog scale satisfaction scores (P=.206). Twenty-nine (34.1%) patients were discharged under the care of the visiting nurse service after leaving the rehabilitation facility. Patients discharged to an inpatient rehabilitation facility underwent more diagnostic testing, especially radiographs, than patients discharged to home. There were no clinically relevant differences in Knee Society pain or function scores or patient satisfaction. [Orthopedics. 201x; xx(x):xx-xx.].

Heterotopic ossification (HO) is prevalent after total hip arthroplasty (THA). Oral nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 (COX-2) inhibitors have reduced the incidence of HO; however, to the authors' knowledge, no studies have reported the incidence and severity of HO with a pain protocol highlighted by celecoxib in the pre- and postoperative period with a posterolateral approach. Between October 2014 and October 2015, a retrospective study was conducted of 687 consecutive primary THAs with minimum 1-year follow-up performed between January 2009 and December 2013. All patients underwent a posterolateral THA with a multimodal pain protocol consisting of preoperative celecoxib; local steroid infiltration intraoperatively; postoperative celecoxib, dexamethasone, and ketorolac; and aspirin or warfarin thromboprophylaxis. For all patients, pre- and postoperative radiographs were examined and classified for HO using the Brooker classification. Interobserver reliability was calculated for both incidence of HO and Brooker classification. Overall, HO was present around 98 (14.3%) THAs. The incidence of Brooker I, II, and III HO was 38 (5.5%), 47 (6.8%), and 12 (1.7%), respectively. No patients required surgical excision or had radiographic evidence of Brooker IV HO. Multivariate logistic regression identified male sex and hypertrophic osteoarthritis as significant risk factors. The use of aspirin for thromboprophylaxis significantly reduced the incidence of HO. This study found the overall incidence of HO when using celecoxib during a posterior THA to be 14.3%, which is similar to what others have reported with the direct lateral approach and with other COX-2 inhibitors for a posterior approach. Risk factors include male sex and preoperative hypertrophic osteoarthritis. [Orthopedics. 2018; 41(1):e92-e97.].

Despite advances in thromboprophylaxis, the relationship between preexisting deep venous thromboses (DVTs) and postoperative thromboembolic complications is not fully established. The aim of this study was to assess the utility of selective and nonselective preoperative lower extremity venous Doppler screening protocols as tools in reducing the incidence of thromboembolic events (DVT/pulmonary embolism [PE]) after total joint arthroplasty. In the 2-year period from August 2013 to August 2015, a total of 455 consecutive elective primary total joint arthroplasties were identified from the authors' database. During the first year, a selective preoperative Doppler ultrasound screening protocol (only patients with a history of DVT/PE) was used for 182 patients, 31 of whom had preoperative ultrasound scans. The following year, a nonselective screening protocol was used for 273 consecutive patients, all of whom had preoperative Doppler ultrasound scans. All patients were followed for a minimum of 3 months postoperatively for postoperative Doppler ultrasound scans, emergency department visits, and readmissions related to DVT/PE. Preoperatively, there was no difference between the selective and nonselective cohorts regarding preoperative DVTs (3 and 1, respectively; P=.307); all patients were known to have prior DVT. Postoperative thromboembolic events were found in 4 (2.6%) of the patients in the selective cohort and 2 (0.7%) of the patients in the nonselective cohort (P=.196). Use of a nonselective preoperative Doppler ultrasound screening protocol did not improve the identification of preoperative DVTs or reduce postoperative thromboembolic complications. [Orthopedics. 201x; xx(x):xx-xx.].

BACKGROUND:In recent time, metal ion debris and adverse local tissue reaction have reemerged as an area of clinical concern with the use of large femoral heads after total hip arthroplasty (THA). METHODS:Between June 2014 and January 2015, 60 patients with a noncemented THA using a titanium (titanium, molybdenum, zirconium, and iron alloy) femoral stem and a V40 trunnion were identified with a minimum 5-year follow-up. All THAs had a 32- or 36-mm metal (n = 30) or ceramic (n = 30) femoral head coupled with highly cross-linked polyethylene. Cobalt, chromium, and nickel ions were measured. RESULTS:Patients with metal heads had detectable cobalt and chromium levels. Cobalt levels were detectable in 17 (56.7%) patients with a mean of 2.0 μg/L (range: <1.0-10.8 μg/L). Chromium levels were detectable in 5 (16.7%) patients with a mean of 0.3 μg/L (range: <1.0-2.2 μg/L). All patients with a ceramic head had nondetectable cobalt and chromium levels. Cobalt and chromium levels were significantly higher with metal heads compared to ceramic heads (P < .01). Cobalt levels were significantly higher with 36-mm metal heads compared with 32-mm heads (P < .01). Seven patients with metal femoral heads had mild hip symptoms, 4 of whom had positive findings of early adverse local tissue reaction on magnetic resonance imaging. All ceramic THA was asymptomatic. CONCLUSION:The incidence and magnitude of cobalt and chromium levels is higher in metal heads compared to ceramic heads with this implant system (P < .01). Thirty-six millimeter metal femoral heads result in larger levels of cobalt compared with 32-mm metal heads.

BACKGROUND:While innovation drives advancement, it is not immune to failure. Previously, we reported a corrosion-related revision rate of 28% (23 of 81 total hip arthroplasties) among patients who received the Rejuvenate modular-neck stem implant with short-term follow-up. Because we observed a dramatic interval failure rate after our initial report, we undertook this study. METHODS:We prospectively followed a cohort of patients who had undergone implantation of the Rejuvenate modular-neck stem, as previously reported. At a minimum of 3 years of follow-up (range, 3.0 to 5.5 years), 73 hips in 63 patients (90% of the original group) were available for analysis. The mean serum cobalt and chromium ion levels were obtained preoperatively and postoperatively. Elevated serum cobalt ion levels (>4 μg/L), pain, or abnormal magnetic resonance imaging (MRI) findings were indications for revision surgery. Patient factors and serum metal ion levels were correlated to revision surgery. Additionally, post-revision serum cobalt and chromium ion level trends were assessed. RESULTS:An 86% clinical failure rate (63 of the 73 hips) was observed at a mean follow-up of 4.2 ± 0.6 years (range, 3.0 to 5.5 years); 57 (78%) of the hips underwent revision at a mean of 3.2 ± 1.0 years (range, 1.0 to 5.5 years), and 6 (8%) of the hips were scheduled for revision. Patients who underwent revision surgery were younger and had greater serum metal ion levels and greater pain compared with patients who did not undergo revision. An elevated serum cobalt ion level was the most important independent factor associated with revision surgery. Cobalt ion levels decreased sharply after revision; however, some patients demonstrated persistent elevation with more gradual decline. CONCLUSIONS:Emphasizing the reporting of positive results may leave orthopaedic surgeons reticent to publicize negative results; however, the high failure rate of this implant design within 5 years prompted this report. We believe that patients and orthopaedic surgeons should be made aware of this implant's clinical problems and patients should be followed closely. Expedient revision is necessary when failure is identified, to minimize potentially severe tissue damage and metal toxicity. LEVEL OF EVIDENCE/METHODS:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Although total knee arthroplasty is a successful and cost-effective procedure, patient dissatisfaction remains as high as 50%. Postoperative residual knee pain after total knee arthroplasty, with or without crepitation, is a major factor that contributes to patient dissatisfaction. The most common location for residual pain after total knee arthroplasty is anteriorly. Because residual pain has been associated with an un-resurfaced patella, this review includes only registry data and total knee arthroplasty with patella replacement. Some suggest that the pathogenesis of residual knee pain may be related to mechanical stimuli that activate free nerve endings around the patellofemoral joint. Various etiologies have been implicated in residual pain, including (1) low-grade infection, (2) midflexion instability, and (3) component malalignment with patellar maltracking. Less common causes include (4) crepitation and patellar clunk syndrome; (5) patellofemoral symptoms, including overstuffing and avascular necrosis of the patella; (6) early aseptic loosening; (7) hypersensitivity to metal or cement; (8) complex regional pain syndrome; and (9) pseudoaneurysm. Because all of these conditions can lead to residual pain, identifying the etiology can be a difficult diagnostic challenge. Often, patients with persistent pain and normal findings on radiographs and laboratory workup may benefit from a diagnostic injection or further imaging. However, up to 10% to 15% of patients with residual pain may have unexplained pain. This literature review summarizes the findings on the causes of residual pain and presents a diagnostic algorithm to facilitate an accurate diagnosis for residual pain after total knee arthroplasty. [Orthopedics.].

The survivorship of total hip arthroplasty in younger patients is dependent on the wear characteristics of the bearing surfaces. Long-term results with conventional polyethylene in young patients show a high failure rate. This study assessed the long-term results of a first-generation annealed highly cross-linked polyethylene (HCLPE) in uncemented total hip arthroplasty in young, active patients. Between 1999 and 2003, 112 total hip arthroplasty procedures performed in 91 patients with an average University of California Los Angeles activity score of 8 and mean age of 53 years (range, 24-65 years) were included from a prospective database. In all patients, a 28-mm metal femoral head on annealed HCLPE (Crossfire; Stryker, Mahwah, New Jersey) was used. At minimum 10-year follow-up (11.5+/-0.94 years), Kaplan-Meier survivorship was 97% for all failures (1 periprosthetic infection and 1 late dislocation) and 100% for mechanical failure (no revisions for osteolysis or loosening). This study showed low revision rates for wear-related failure and superior survivorship in young, active patients. Oxidation causing failure of the locking mechanism has not been a problem with Crossfire for up to 10 years. [Orthopedics.].

This study assessed the efficacy of highly porous cups in revision total hip arthroplasty for Paprosky types II and III acetabular bone loss. The authors identified 33 acetabular revisions in 29 patients from a prospective database (66% type III, 7 with pelvic dissociation). Initial stability was achieved with interference fit between the anterior inferior iliac spine, pubis, and ischium with cups that were 2 to 4 mm larger than the reamed acetabulum and augmented with multiple screw fixations without allograft or wedges. At mean follow-up of 6 years (range, 2.7-7.7 years) after revision surgery, no dislocation, infection, or reoperation was noted. Mean satisfaction score was 6+/-3.2. Mean anteversion and abduction angles were 43 degrees +/-4.6 degrees and 21.5 degrees +/-4.4 degrees , respectively. Complications included limp in 13% of patients, wound issues in 10%, and heterotopic ossification in 17%. Osteointegration was seen in all cups, without any migration. Mean overall osteointegration, based on the average percentage of the 3 zones in both views, was 55%+/-21% (range, 25%-95%). The most osteointegration was seen in zone I (superior) and zone VI (posterior), and the least osseointegration was seen in zone II (medial) and zone IV (anterior). This method can provide reproducible results in acetabular revision arthroplasty. [Orthopedics.].

BACKGROUND: The presence of hand osteoarthritis (OA) increases the risk for developing OA in other major joints. Although genetic predisposition has been implicated in its causation, its exact role has yet to be established. The association of hand OA with symptomatic and asymptomatic major joints has not been previously studied. METHODS: Hundred consecutive patients had a hand photo taken for visual documentation of the hand joints. Radiographs of hand and all major symptomatic joints were analyzed and classified using the Kellgren-Lawrence scale by 2 independent observers including an orthopedic radiologist. RESULTS: Severe hand OA was present in 91% of the patients. Radiographic analysis showed that the hip was involved in 88% of the patients, of whom 85.2% (75) were symptomatic and 14.7% (13) were asymptomatic. Hip arthroplasty was required by 62.5% (55) of symptomatic hip patients. Knee involvement was present in 37% of the patients; all were symptomatic and 81.1% (30) of these required knee arthroplasty. Bilateral surgery was performed in 33% (28) and "2 joint (hip and knee)" surgery was performed in 6% (5). Spine involvement was present in 72% of the patients. There was a significant correlation between hand radiographic findings of OA and hip (r = 0.68; P = .03), knee (r = 0.58; P = .042), and spine (r = .39; P = .05) involvement. CONCLUSION: There was a significant correlation between severe hand OA and hip, knee, and spine involvement. Severity of Hand OA can have a predictive value on multiple joint involvement and risk of surgical intervention. This study emphasizes the need to investigate the genetic predisposition in causation of OA.