RESUMEN
BACKGROUND: Treatment of adverse local tissue reaction (ALTR) is challenging owing to high complications and poor outcomes after a revision surgery. As dislocation is the most common cause of reoperation, it is often necessary to use advanced articulations such as dual mobility. This study aims to evaluate the outcome and complication rates after revision surgery with dual mobility constructs, compared to constrained and conventional articulations in the setting of significant abductor deficiency due to ALTR. METHODS: Out of a total of 338 revision total hip arthroplasties for ALTR, 234 patients with a significant tissue necrosis and abductor muscle insufficiency (grade 3) were evaluated. The complication rates after revisions were compared between 42 hips with dual mobility implants, 24 hips with constrained liners, 104 hips with large diameter heads (36-40 mm), and 64 hips with small diameter heads (≤32 mm). RESULTS: After an average of 4 years of follow-up (2.8-8.6), the dual mobility articulation had no dislocation, compared to 4.1% and 15.5% for constrained liner and conventional articulations, respectively (P < .001). Utilization of dual mobility and constrained liner cup also did not increase the risk of nondislocation complications, including periprosthetic joint infection and periprosthetic fracture (P = .18 and .52). CONCLUSIONS: This study demonstrates significantly lower dislocation rates for dual mobility when compared to conventional articulations and comparable to constrained liners in cases of severe abductor deficiency due to ALTR, suggesting that dual mobility implants are viable surgical treatment alternatives to constrained liners to minimize dislocation during revision total hip arthroplasty in the setting of significant abductor deficiency due to ALTR.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Luxación de la Cadera , Prótesis de Cadera , Artroplastia de Reemplazo de Cadera/efectos adversos , Luxación de la Cadera/epidemiología , Luxación de la Cadera/etiología , Luxación de la Cadera/cirugía , Prótesis de Cadera/efectos adversos , Humanos , Diseño de Prótesis , Falla de Prótesis , Reoperación , Estudios RetrospectivosRESUMEN
Adverse local tissue reaction (ALTR) associated with mechanically assisted crevice corrosion of metal-on-polyethylene (MoP) head-neck modular total hip arthroplasty (THA), similarly observed in the metal-on-metal bearing, is a growing concern in MoP THA patients. Given the complex pathogenesis as well as variable clinical presentation, the diagnosis can be challenging. This article focuses on providing surgeons with an evidence-based update on (1) implant, surgical, and patient risk factors associated with ALTRs; (2) clinical systematic evaluation; and (3) surgical management options for ALTRs in MoP THA patients based on the currently available evidence.
Asunto(s)
Artroplastia de Reemplazo de Cadera/efectos adversos , Metales/efectos adversos , Polietileno/efectos adversos , Diseño de Prótesis/efectos adversos , Falla de Prótesis/efectos adversos , Corrosión , Medicina Basada en la Evidencia , Humanos , Reoperación , Factores de RiesgoRESUMEN
Posterior condylar referencing, a common method for determining femoral axial orientation during total knee arthroplasty (TKA), relies upon an assumed consistent relationship between the posterior condylar line (PCL) and the transepicondylar axis (TEA) of 3 degrees rotation. A total of 3,010 computed tomography (CT) scans and three-dimension (3D)-reconstructions for presurgical creation of patient-matched TKA instrumentation were analyzed. Demographic data and five anthropometric measurements (hip-knee angle [HKA], distal femoral angle [DFA], proximal tibial angle [PTA], tibial slope [TS], and PCL-TEA relationship) were recorded for each scan. A logistic regression model was fit to assess interaction between the PCL-TEA relationship and demographic and radiological variables. The mean (standard deviation [SD]) PCL-TEA was +2.9 degrees (0.8 degree). The range varied between +0.5 and +16.5 degrees. In 2,758 knees (91.6%), the PCL-TEA was within 3 ± 1 degrees, whereas 252 knees (8.4%) fell outside this range. There were no significant demographic or anthropometric differences between those knees with PCL-TEA relationship between 3 ± 1 degrees and those falling outside that range. The posterior condyles of diseased knees undergoing TKA can be reliably used to indirectly reference the TEA of the distal femur with an error of only 1 degree in 92% of patients.
Asunto(s)
Puntos Anatómicos de Referencia , Articulación de la Rodilla/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Anciano , Artroplastia de Reemplazo de Rodilla , Femenino , Humanos , Imagenología Tridimensional , MasculinoRESUMEN
BACKGROUND: Opioid use is a public health crisis in the United States and an area of increased focus in orthopaedic surgery. The aim of this study is to investigate whether preoperative opioid use had any effect on patient-reported outcome measures (PROMs) before and after total hip arthroplasty (THA). METHODS: A total of 389 patients with THA with both preoperative and postoperative PROMs were reviewed: (1) 76 patients with preoperative opioid use (24%) and (2) 237 patients without preoperative opioid use (76%). Patient demographics and clinical information including opioid use, length of stay, and implant information. RESULTS: Preoperative opioid users were more likely to stay in the hospital longer (P = 0.004) and be discharged to a rehabilitation facility (P = 0.038). Postoperatively, the Physical Function Short Form 10a (P = 0.021) and Patient-Reported Outcomes Measurement Information System Global-10 (P < 0.001 physical, P = 0.001, mental) were significantly lower in the preoperative opioid users. Within groups, both nonusers and preoperative opioid users saw improvements after THA in Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form (P < 0.001), Short Form 10a (P < 0.001), and Patient-Reported Outcomes Measurement Information System Global-10 (P < 0.001, physical and P = 0.008, mental). DISCUSSION: Although all patients reported improvements after THA regardless of preoperative opioid use, preoperative opioid users undergoing THA had significantly lower patient-reported outcome scores, longer hospital stays, and a more likely discharge to rehabilitation.
Asunto(s)
Analgésicos Opioides/efectos adversos , Artroplastia de Reemplazo de Cadera , Medición de Resultados Informados por el Paciente , Cuidados Preoperatorios , Anciano , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estados UnidosRESUMEN
OBJECTIVES: Septic arthritis results in rapid joint destruction if not properly diagnosed and treated. A work up for septic arthritis includes a peripheral white blood cell count, inflammatory markers, and a joint aspiration. In the general population, the interpretation of these labs has been well-defined by prior studies. To this point, no study has determined how immunosuppressive states affect this work up. METHODS: Patients with immunosuppressive conditions who received a joint aspiration for a painful joint were retrospectively identified. Laboratory results from their work up were gathered and analyzed. RESULTS: 216 patients were included in the study, 21 of whom were diagnosed with septic arthritis. The average aspiration WBC count was 74,190 with 88% PMNs. 81% had a positive gram stain. DISCUSSION: Laboratory values for immunosuppressed patients with septic arthritis were similar to those associated with septic arthritis in historical general population controls.
Asunto(s)
Artritis Infecciosa/diagnóstico , Artritis Infecciosa/inmunología , Huésped Inmunocomprometido , Artritis Infecciosa/sangre , Sedimentación Sanguínea , Proteína C-Reactiva/metabolismo , Diagnóstico Precoz , Humanos , Recuento de Leucocitos , Estudios Retrospectivos , Sensibilidad y Especificidad , Líquido Sinovial/metabolismo , Líquido Sinovial/microbiologíaRESUMEN
BACKGROUND: The demand for conversion of prior hip surgery to total hip arthroplasty (conversion THA) is likely to increase as a function of increasing US hip fracture burden in addition to its application in managing other conditions. Thus, outcome analysis is warranted to better inform value-based reimbursement schemes in the era of bundled payments. METHODS: Via Current Procedural Terminology codes, the National Surgical Quality Improvement Project data files were queried for all patients who underwent primary THA and conversion of previous hip surgery to THA from 2005 to 2014. To better understand the isolated effect of procedure type on adverse outcomes, primary and conversion cohorts were then propensity-score matched via logistic regression modeling. Comparisons of the study's primary outcomes were drawn between matched cohorts. Statistical significance was defined by a P-value less than or equal to .05. RESULTS: Relative to the primary THA group, the conversion THA group had statistically greater rates of Center Medicare and Medicaid Services (CMS) complications (7.5% vs 4.5%), non-home bound discharge (19.6% vs 14.7%), and longer length of hospital stay. Conversion THA was associated with increased likelihood of CMS complications (odds ratio 1.68, confidence interval 1.39-2.02) and non-home bound discharge (odds ratio 1.41, confidence interval 1.25-1.58). No statistically significant differences in mortality and readmission were detected. CONCLUSION: The elevated risk for CMS-reported complications, increased length of hospital stay, and non-home bound discharge seen in our study of conversion THA indicates that it is dissimilar to elective primary THA and likely warrants consideration for modified treatment within the Comprehensive Care for Joint Replacement structure in a manner similar to THA for fracture.
Asunto(s)
Artroplastia de Reemplazo de Cadera/efectos adversos , Procedimientos Quirúrgicos Electivos/efectos adversos , Fracturas de Cadera/cirugía , Anciano , Femenino , Humanos , Tiempo de Internación , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Evaluación de Resultado en la Atención de Salud , Complicaciones Posoperatorias/etiología , Periodo Posoperatorio , Puntaje de Propensión , Mejoramiento de la Calidad , Factores de Riesgo , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: Hip fracture is an increasingly common expanded indication for total hip arthroplasty (THA) and warrants outcome analysis so as to best inform risk assessment models, public reporting of outcome, and value-based reimbursement schemes. METHODS: The National Surgical Quality Improvement Program data file from 2011 to 2014 was used to identify all patients undergoing THA via current procedural terminology code 27130. Propensity score matching in a 1:5 fashion was used to compare 2 cohorts: THA for osteoarthritis and THA for fracture. Primary outcomes included Centers for Medicare and Medicaid Services (CMS) reportable complications, unplanned readmission, postsurgical length of stay, and discharge destination. χ2 tests for categorical variables and Student t test for continuous variables were used to compare the 2 cohorts and adjusted linear regression analysis used to determine the association between hip fracture and THA outcomes of interest. RESULTS: A total of 58,302 patients underwent elective THA for osteoarthritis and 1580 patients underwent THA for hip fracture. Rates of CMS-reported complications (4.0% vs 10.7%; P < .001), non-homebound discharge (39.8% vs 64.7%; P < .001), readmission (4.7% vs 8.0%; P < .001), and mean days of postsurgical hospital stay (3.2 vs 4.4; P < .001) were greater in the hip fracture cohort. THA for hip fracture was significantly associated with increased risk of CMS-reportable complications (odds ratio [OR], 2.67; 95% confidence interval [CI], 2.17-3.28), non-homebound discharge (OR, 1.73; 95% CI, 1.39-2.15), and readmission (OR, 2.78; 95% CI, 2.46-3.12). CONCLUSION: Our findings support recent advocacy for the exclusion of THA for fracture from THA bundled pricing methodology and public reporting of outcomes.
Asunto(s)
Artroplastia de Reemplazo de Cadera/efectos adversos , Fracturas Óseas/cirugía , Osteoartritis de la Cadera/cirugía , Complicaciones Posoperatorias/etiología , Periodo Posoperatorio , Anciano , Distinciones y Premios , Centers for Medicare and Medicaid Services, U.S. , Estudios de Cohortes , Procedimientos Quirúrgicos Electivos/efectos adversos , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Alta del Paciente , Readmisión del Paciente , Puntaje de Propensión , Mejoramiento de la Calidad , Sistema de Registros , Factores de Riesgo , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: The arthroplasty population increasingly presents with comorbid conditions linked to elevated risk of postsurgical complications. Current quality improvement initiatives require providers to more accurately assess and manage risk presurgically. In this investigation, we assess the effect of metabolic syndrome (MetS), as well as the effect of body mass index (BMI) within MetS, on the risk of complication following hip and knee arthroplasty. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program database for total hip or knee arthroplasty cases. Thirty-day rates of Centers for Medicare and Medicaid Services (CMS)-reportable complications, wound complications, and readmissions were compared between patients with and without a diagnosis of MetS using multivariate logistic regression. Arthroplasty cases with a diagnosis of MetS were further stratified according to World Health Organization BMI class, and the role of BMI within the context of MetS was assessed. RESULTS: Of the 107,117 included patients, 11,030 (10.3%) had MetS. MetS was significantly associated with CMS complications (odds ratio [OR] = 1.415; 95% confidence interval [CI], 1.306-1.533; P < .001), wound complications (OR = 1.749; 95% CI, 1.482-2.064; P < .001), and readmission (OR = 1.451; 95% CI, 1.314-1.602; P < .001). When MetS was assessed by individual BMI class, the MetS + BMI >40 group was associated with significantly higher risk of CMS complications, wound complications, and readmission compared to the lower MetS BMI groups. CONCLUSION: MetS is an independent risk factor for CMS-reportable complications, wound complications, and readmission following total joint arthroplasty. The risk attributable to MetS exists irrespective of obesity class and increases as BMI increases.
Asunto(s)
Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Síndrome Metabólico/complicaciones , Complicaciones Posoperatorias/epidemiología , Anciano , Índice de Masa Corporal , Estudios de Cohortes , Comorbilidad , Bases de Datos Factuales , Femenino , Humanos , Modelos Logísticos , Masculino , Síndrome Metabólico/diagnóstico , Persona de Mediana Edad , Análisis Multivariante , Obesidad/complicaciones , Oportunidad Relativa , Readmisión del Paciente , Periodo Posoperatorio , Mejoramiento de la Calidad , Factores de Riesgo , Sociedades Médicas , Estados UnidosRESUMEN
Modern total knee arthroplasty is effective at treating the pain and disability associated with osteoarthritis. The number of total knee replacements done in the USA continues to increase. Despite the great care taken during all of these procedures, some patients remain dissatisfied with their outcome. While this dissatisfaction is likely multifactorial, malalignment of the prosthetic components is a major cause of postoperative complications. A neutral mechanical axis plus or minus 3° is felt to have a positive impact on the survivorship of the prosthesis. Conventional instrumentation has been shown to have a significant number of total knee replacements that lie well outside a neutral coronal alignment. With that in mind, significant effort has been placed into the development of technology to improve the overall alignment of the prosthesis. In order to reduce the number of outliers, several companies have developed cost-effective systems to aid the surgeon in achieving a more predictably aligned prosthesis in all three planes. We will review the literature that is available regarding several of these tools to examine if navigation or custom guides improve outcomes in total knee arthroplasty. Our review supports that while both navigation and custom implants guides seem to be a cost effective way to achieve a predictable mechanical alignment of a total knee prosthesis therefore reducing the number of outliers, the cost may be increased operative times with no perceived difference in patient satisfaction with navigation custom guides.