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Background: Periprosthetic femur fractures (PPFFs) following total hip arthroplasty (THA) have increased in the past decade as the demand for primary surgery continues to grow. Although there is now more evidence to describe the treatment of Vancouver B fractures, there is still limited knowledge regarding factors that cause surgeons to perform either an open reduction and internal fixation (ORIF) or revision THA (rTHA). The purpose of this study was to determine what type of surgeons treat Vancouver B PPFFs at 11 major academic institutions and if there are trends in treatment decision-making regarding the use of ORIF or rTHA based on surgical training or patient factors. Methods: This multicenter retrospective study evaluated patients surgically treated for Vancouver B PPFF after THA between 2014 and 2019. Patients from 11 academic centers located in the United States were included in this study. Surgical outcomes and patient demographics were evaluated based on surgeon training, surgical treatment type, and institution. Results: Presence of Vancouver B2 (odds ratio [OR]: 0.02, P < .001) or B3 (OR: 0.04, P < .001) fractures were independent risk factors for treatment with rTHA. Treatment by a trauma (OR: 12.49, P < .001) or other-specified surgeon (OR: 13.63, P < .001) were independent risk factors for ORIF repair of Vancouver B fractures. There were no differences in outcomes based on surgeon subspecialty training. Conclusions: This study showed the trends in surgeons who surgically manage Vancouver B fractures at 11 major academic institutions and highlighted that regardless of surgical training or surgical treatment type, postoperative outcomes following management of PPFF were similar.
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BACKGROUND: This study aimed to identify differences in patient characteristics, perioperative management methods, and outcomes for total hip arthroplasty (THA) for femoral neck fracture (FNF) when performed by orthopaedic surgeons who have arthroplasty versus orthopaedic trauma training. METHODS: This study was a multicenter retrospective review of 636 patients who underwent THA for FNF between 2010 and 2019. There were 373 patients who underwent THA by an arthroplasty surgeon, and 263 who underwent THA by an orthopaedic trauma surgeon. Comorbidities, management methods, and outcomes were compared between patients operated on by orthopaedic surgeons who had arthroplasty versus trauma training. RESULTS: Arthroplasty-trained surgeons had shorter operative times (102 versus 128 minutes, P < .0001) and utilized tranexamic acid more frequently than trauma-trained surgeons (48.8 versus 18.6%, P < .0001). Orthopaedic trauma surgeons more frequently utilized an anterior approach. Patients of arthroplasty-trained surgeons had lower rates of complications including pulmonary embolism (1.6 versus 6.5%, P = .0019) and myocardial infarction (1.6 versus 11.0%, P < .0001). Similarly, patients of arthroplasty-trained surgeons were discharged faster (5.3 versus 7.9 days, P < .0001) with greater ambulation capacity (92.2 versus 57.2 feet, P < .0001). Dislocation, periprosthetic joint infection, and revision were similar between both groups. When adjusted for covariates, there was no difference in 90-day, 1-year, or 2-year mortality. CONCLUSION: A THA performed for FNF by arthroplasty surgeons was associated with lower in-hospital morbidities and improved functional statuses at discharge. However, mortalities and complications after discharge were similar between both specialties when adjusted for confounding variables. Optimization of protocols may further improve outcomes for THA for FNF.
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Artroplastia de Reemplazo de Cadera , Fracturas del Cuello Femoral , Ortopedia , Cirujanos , Humanos , Artroplastia de Reemplazo de Cadera/efectos adversos , Ortopedia/educación , Becas , Fracturas del Cuello Femoral/cirugía , Estudios RetrospectivosRESUMEN
BACKGROUND: The treatment of Vancouver B periprosthetic proximal femur fractures (PPFFs) is complex due to the overlap between arthroplasty and orthopedic trauma techniques. Our purpose was to assess the effects of fracture type, treatment difference, and surgeon training on the risk of reoperation in Vancouver B PPFF. METHODS: A collaborative research consortium of 11 centers retrospectively reviewed PPFFs from 2014 to 2019 to determine the effects of variations in surgeon expertise, fracture type, and treatment on surgical reoperation. Surgeons were classified as per fellowship training, fractures using the Vancouver classification, and treatment as open reduction internal fixation (ORIF) or revision total hip arthroplasty with or without ORIF. Regression analyses were performed with reoperation as the primary outcome. RESULTS: Fracture type (Vancouver B3 versus B1: odds ratio [OR]: 5.70) was an independent risk factor for reoperation. No differences were found in reoperation rates with treatment (ORIF versus revision: OR 0.92, P = .883). Treatment by a nonarthroplasty-trained surgeon versus an arthroplasty specialist led to higher odds of reoperation in all Vancouver B fracture (OR: 2.87, P = .023); however, no significant differences were seen in the Vancouver B2 group alone (OR: 2.61, P = .139). Age was a significant risk factor for reoperation in all Vancouver B fractures (OR: 0.97, P = .004) and in the B2 fractures alone (OR: 0.96, P = .007). CONCLUSION: Our study suggests that age and fracture type affect reoperation rates. Treatment type did not affect reoperation rates and the effect of surgeon training is unclear.
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Artroplastia de Reemplazo de Cadera , Fracturas del Fémur , Fracturas Periprotésicas , Fracturas Femorales Proximales , Cirujanos , Humanos , Reoperación/métodos , Estudios Retrospectivos , Fracturas Periprotésicas/etiología , Fracturas Periprotésicas/cirugía , Fijación Interna de Fracturas/métodos , Fracturas del Fémur/etiología , Fracturas del Fémur/cirugía , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Cadera/métodos , Fémur/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: Effective pain control balanced with maintaining physical function and minimizing medication side effects is essential to accelerated recovery after total knee arthroplasty (TKA). Multimodal pain management regimens combining oral medications as well as local analgesia have shown promise in facilitating these goals. Some regimens use anesthetics delivered via a local infiltration catheter while others use periarticular injections (PAIs). However, it is uncertain if an infiltration catheter provides additional pain relief or decreases opioid consumption when compared with conventional PAI alone. METHODS: Fifty patients undergoing TKA at one institution were randomized equally into 2 groups for a prospective trial. Group I received an intraarticular catheter (On-Q∗) in combination with injection of 30 ml of 0.5% bupivacaine the day after surgery before removal. Group II received no pain catheter. Both groups received a conventional intraoperative PAI and postoperative oral pain medication. Pain scores were measured with visual analog scale and opioid medication consumption in morphine milligram equivalents (mgs). RESULTS: There were no differences in pain scores or opioid consumption in the first 48-hours postoperatively (P = .05). Reported maximum pain scores were low in both groups; 3.33 in group I and 2.97 in group II. Although not statistically significant in this cohort, there was increased opioid consumption in the catheter group: 14.78 mg vs 12.76 mg. CONCLUSION: An intraarticular pain catheter in conjunction with a multimodal approach with intraoperative PAI after TKA does not improve 48-hour pain scores or opioid consumption compared with PAI alone in this randomized controlled trial. Overall pain scores were very low.
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Computer-assisted orthopedic surgery improves mechanical alignment and the accuracy of surgical cuts in the context of total knee arthroplasty (TKA). A simplified, navigation-enhanced instrumentation system was assessed to determine whether the same effects could be achieved with a less intrusive system. Two cohorts of surgeons (experienced and trainees) performed a series of TKA cuts using models with and without navigation-enhanced instrumentation. The accuracy of each system was determined via the rate of outliers, measured as any cut that deviated from the planned cut by more than 2° or 2 mm. The effect of experience level was limited, with only the outlier rate for tibial varus or valgus measurement showing a significant difference between user groups with conventional instrumentation (P=.004). The use of navigation-enhanced instrumentation significantly reduced the total outlier rate compared with conventional instrumentation from 35% to 4% for experienced users (P<.001) and from 34% to 10% for trainees (P<.001). These results suggest that navigation-enhanced instrumentation is a viable alternative to conventional instrumentation to reduce outlier rates and improve cut accuracy. This trial also showed that additional experience may not correlate with improved surgical accuracy. Outliers may not reflect individual surgical ability as much as limitations of the instrumentation or other unidentified factors. [Orthopedics. 2021;44(1):54-57.].
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Artroplastia de Reemplazo de Rodilla/instrumentación , Cirugía Asistida por Computador , Sistemas de Navegación Quirúrgica , Herida Quirúrgica , Artroplastia de Reemplazo de Rodilla/normas , Competencia Clínica , Humanos , TibiaRESUMEN
BACKGROUND: Prosthetic joint infection (PJI) is a morbid complication following total joint arthroplasty (TJA). PJI diagnosis and treatment has changed over time, and patient co-management with a high-volume musculoskeletal infectious disease (MSK ID) specialist has been implemented at our institution in the last decade. METHODS: We retrospectively evaluated all consecutive TJA patients treated for PJI between 1995 and 2018 by a single high-volume revision TJA surgeon. Microbial identities, antibiotic resistance, prior PJI, and MSK ID consultation were investigated. RESULTS: In total, 261 PJI patients (median age 66 years, interquartile range 57-75) were treated. One-year and 5-year reinfection rates were 15.8% (95% confidence interval [CI] 11.6-20.7) and 22.1% (95% CI 17.0-27.7), respectively. Microbial identities and antibiotic resistances did not change significantly over time. Despite seeing more prior PJI patients (53.3% vs 37.6%, P = .012), MSK ID-managed patients had similar infection rates as non-MSK ID-managed patients (hazard ratio [HR] 1.02, 95% CI 0.6-1.75, P = .93). Prior PJI was associated with higher reinfection risk (HR 2.39, 95% CI 1.39-4.12, P = .002) overall and in patients without MSK ID consultation, specifically (HR 2.78, 95% CI 1.37-5.65, P = .005). This risk was somewhat lower and did not reach significance in prior PJI patients with MSK ID consultation (HR 1.97, 95% CI 0.87-4.48, P = .106). CONCLUSION: We noted minimal differences in microbial/antibiotic resistances for PJI over 20 years in a single institution, suggesting current standards of PJI treatment remain encouragingly valid in most cases. MSK ID involvement was not associated with lower reinfection risk overall; however, in patients with prior PJI, the risk of reinfection appeared to be somewhat lower with MSK ID involvement. LEVEL OF EVIDENCE: Level IV-Case Series.
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Artritis Infecciosa , Artroplastia de Reemplazo de Cadera , Infecciones Relacionadas con Prótesis , Cirujanos , Anciano , Artroplastia de Reemplazo de Cadera/efectos adversos , Humanos , Infecciones Relacionadas con Prótesis/epidemiología , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/cirugía , Reoperación , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Burnout and depression among healthcare professionals and trainees remain alarmingly common. In 2009, 56% of orthopaedic surgery residents reported burnout. Alcohol and illicit drug use are potential exacerbating factors of burnout and depression; however, these have been scarcely studied in residency populations. QUESTIONS/PURPOSES: (1) What proportion of orthopaedic residents report symptoms of burnout and depression? (2) What factors are independently associated with an orthopaedic resident reporting emotional exhaustion, depersonalization, low personal accomplishment, and depression? (3) What proportion of orthopaedic residents report hazardous alcohol or drug use? (4) What factors are independently associated with an orthopaedic resident reporting hazardous alcohol or drug use? METHODS: We asked 164 orthopaedic surgery programs to have their residents participate in a 34-question internet-based, anonymous survey, 28% of which (46 of 164) agreed. The survey was distributed to all 1147 residents from these programs, and 58% (661 of 1147) of these completed the survey. The respondents were evenly distributed among training years. Eighty-three percent (551 of 661) were men, 15% (101 of 661) were women, and 1% (nine of 661) preferred not to provide their gender. The survey asked about demographics, educational debt, sleep and work habits, perceived peer or program support, and substance use, and validated instruments were used to assess burnout (abbreviated Maslach Burnout Inventory), depression (Patient Health Questionnaire-2), and hazardous alcohol use (Alcohol Use Disorder Identification Test-Consumption). The main outcome measures included overall burnout, emotional exhaustion, depersonalization, low personal accomplishment, depression, and hazardous alcohol and drug use. Using the variables gathered in the survey, we performed an exploratory analysis to identify significant associations for each of the outcomes, followed by a multivariable analysis. RESULTS: Burnout was reported by 52% (342 of 661) of residents. Thirteen percent of residents (83 of 656) had positive screening results for depression. Factors independently associated with high emotional exhaustion scores included early training year (odds ratio 1.15; 95% confidence interval, 1.01-1.32; p = 0.03) unmanageable work volume (OR 3.13; 95% CI, 1.45-6.67; p < 0.01), inability to attend health maintenance appointments (OR 3.23; 95% CI, 1.69-6.25; p < 0.01), lack of exercise (OR 1.69; 95% CI, 1.08-2.70; p = 0.02), and lack of program support (OR 3.33; 95% CI, 2.00-5.56; p < 0.01). Factors independently associated with depersonalization included early training year (OR 1.27; 95% CI, 1.12-1.41; p < 0.01), inability to attend health maintenance appointments (OR 2.70; 95% CI, 1.67-4.35; p < 0.01), and lack of co-resident support (OR 2.52; 95% CI, 1.52-4.18; p < 0.01). Low personal accomplishment was associated with a lack of co-resident support (OR 2.85; 95% CI, 1.54-5.28; p < 0.01) and lack of program support (OR 2.33; 95% CI, 1.32-4.00; p < 0.01). Factors associated with depression included exceeding duty hour restrictions (OR 2.50; 95% CI, 1.43-4.35; p < 0.01) and lack of program support (OR 3.85; 95% CI, 2.08-7.14; p < 0.01). Sixty-one percent of residents (403 of 656) met the criteria for hazardous alcohol use. Seven percent of residents (48 of 656) reported using recreational drugs in the previous year. Factors independently associated with hazardous alcohol use included being a man (OR 100; 95% CI, 35-289; p < 0.01), being Asian (OR 0.31; 95% CI, 0.17-0.56; p < 0.01), single or divorced marital status (OR 2.33; 95% CI, 1.47-3.68; p < 0.01), and more sleep per night (OR 1.92; 95% CI, 1.21-3.06; p < 0.01). Finally, single or divorced marital status was associated with drug use in the past year (OR 2.30; 95% CI, 1.26-4.18; p < 0.01). CONCLUSIONS: The lack of wellness among orthopaedic surgery residents is troubling, especially because most of the associated risk factors are potentially modifiable. Programs should capitalize on the modifiable elements to combat burnout and improve overall wellbeing. Programs should also educate residents on burnout, focus on work volume, protect access to health maintenance, nurture those in the early years of training, and remain acutely aware of the risk of substance abuse. Orthopaedic surgery trainees should strive to encourage peer support, cultivate personal responsibility, and advocate for themselves or peers when faced with challenges. At a minimum, programs and educational leaders should foster an environment in which admitting symptoms of burnout is not seen as a weakness or failure. LEVEL OF EVIDENCE: Level II, prognostic study.
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Agotamiento Profesional/epidemiología , Depresión/epidemiología , Internado y Residencia/estadística & datos numéricos , Procedimientos Ortopédicos/educación , Trastornos Relacionados con Sustancias/epidemiología , Adulto , Agotamiento Profesional/psicología , Depresión/psicología , Femenino , Encuestas Epidemiológicas , Humanos , Satisfacción en el Trabajo , Masculino , Procedimientos Ortopédicos/psicología , Prevalencia , Factores de Riesgo , Trastornos Relacionados con Sustancias/psicologíaRESUMEN
BACKGROUND: Knee arthrodesis (KA) and above-knee amputation (AKA) have been used for salvage of failed total knee arthroplasty (TKA) after periprosthetic joint infection (PJI). However, few studies have assessed the outcomes of KA after TKA PJI, as it remains an uncommon procedure. We investigated rates of AKA, control of infection, and ambulatory status after KA for TKA PJI treatment. METHODS: This was a retrospective and single-surgeon series of 51 failed TKAs due to PJI treated with two-stage KA between 2000 and 2016 with a minimum of 2-year follow-up. Patient demographics, comorbidities, surgical history, radiographic data, and outcomes of KA treatment were recorded. RESULTS: Infection was successfully controlled in 48 of 51 patients (94.1%); of these, 24 knees (50.0%) required no reoperation subsequent to the index KA, whereas the remaining 24 (50.0%) patients required a median of 1 additional operation. Nonunion, malunion, or delayed union was noted in 10 patients (19.6%). Of the 48 patients who were successfully treated with KA, 41 patients (85.4%) remained ambulatory after KA and 9 of these patients (18.8%) did not require assistive devices. Three of 51 patients (5.9%) progressed to AKA after KA. CONCLUSION: Patients undergoing KA for TKA PJI had high rates of infection control and preservation of ambulatory status, with low rates of progression to AKA in our study. LEVEL OF EVIDENCE: Level IV-case series.
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Artroplastia de Reemplazo de Rodilla , Prótesis de la Rodilla , Infecciones Relacionadas con Prótesis , Artrodesis , Artroplastia de Reemplazo de Rodilla/efectos adversos , Humanos , Prótesis de la Rodilla/efectos adversos , Infecciones Relacionadas con Prótesis/epidemiología , Infecciones Relacionadas con Prótesis/cirugía , Reoperación , Estudios RetrospectivosRESUMEN
A 61-year-old woman with a right total knee arthroplasty presented with 1 week of atraumatic right knee swelling, pain, and fevers 2 weeks following a routine screening colonoscopy. Aspiration was concerning for prosthetic joint infection and she underwent definitive treatment with irrigation and debridement with polyethylene exchange followed by a 6-week course of oral metronidazole. Cultures speciated as Bacteroides fragilis with the presumed source being the colonoscopy causing transient bacteremia and subsequent seeding of the right knee. This case highlights the need for consideration of guidelines regarding prophylactic antibiotics to prevent prosthetic joint infection after endoscopic procedures.
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The burden of psychosocial problems, including substance abuse, is high among trauma patients. Use of illicit substances is often noted during urine toxicology screening on admission and can delay surgery because of concerns for an interaction with anesthesia. Methamphetamine theoretically has potential to increase perioperative anesthetic risks. However, the authors are unaware of any studies documenting increased rates of cardiovascular complications in the perioperative period among orthopedic trauma patients. This study sought to determine the rate of cardiovascular complications in these patients. The authors reviewed the medical records of all patients between 2013 and 2018 who underwent orthopedic trauma surgery at two level I trauma centers in the setting of a methamphetamine-positive urine toxicology screening prior to surgery. Information on demographics, injury, type of surgical intervention, and incidence of perioperative cardiovascular and overall medical complications prior to discharge was recorded. Ninety-four patients were included in the study (mean age, 44 years; range, 16-78 years). Twenty-six (28%) patients had multiple injuries. Thirteen (14%) patients had debridement and/or provisional stabilization of an open or unstable fracture, 18 (19%) had treatment for an infection, and 63 (67%) had definitive fracture surgery. The overall rates of perioperative cardiovascular complications and perioperative medical complications were 2.1% and 3.2%, respectively. This study provides both a baseline understanding of the complication rate for methamphetamine-positive orthopedic trauma patients during general anesthesia and justification for larger multicenter studies to further investigate this topic. [Orthopedics. 2019; 42(4):192-196.].
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Trastornos Relacionados con Anfetaminas/complicaciones , Complicaciones Intraoperatorias/epidemiología , Metanfetamina , Traumatismo Múltiple/cirugía , Procedimientos Ortopédicos/efectos adversos , Complicaciones Posoperatorias/epidemiología , Adolescente , Adulto , Anciano , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Traumatismo Múltiple/complicaciones , Periodo Perioperatorio , Centros Traumatológicos , Adulto JovenRESUMEN
BACKGROUND: Suboptimal implant rotation has consequences with respect to knee kinematics and clinical outcomes. We evaluated the functional outcomes of revision total knee arthroplasty (TKA) for poor axial implant rotation. METHODS: We retrospectively reviewed 42 TKAs undergoing aseptic revision for poor axial implant rotation. We assessed improvements in Knee Society Score (KSS) and final range of motion (ROM). Subgroup analyses were performed for preoperative instability and stiffness, as well as the number of components revised and level of implant constraint used. RESULTS: Revision for poor axial rotation in isolation improved KSS from 52 ± 22 to 84 ± 25 (P < .001), and flexion increased from 105 ± 21° to 115 ± 13° (P = .001). Revision in the setting of instability significantly improved the KSS (P < .001) but did not affect ROM (P = .172). Revision in the setting of stiffness significantly improved both KSS (P < .001) and ROM (P = .002). There was no statistically significant difference between the postoperative KSS (P = .889) and final knee flexion (P = .629) with single- or both-component revision TKA for isolated poor axial rotation or between the postoperative KSS (P = .956) and final knee flexion (P = .541) with or without the use of higher constraint during revision TKA for isolated poor axial rotation. CONCLUSION: Revision TKA for poor axial alignment improves clinical outcomes scores and functional ROM.
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Artroplastia de Reemplazo de Rodilla/efectos adversos , Artroplastia de Reemplazo de Rodilla/estadística & datos numéricos , Medición de Resultados Informados por el Paciente , Rango del Movimiento Articular , Reoperación/estadística & datos numéricos , Adulto , Anciano , Fenómenos Biomecánicos , Femenino , Humanos , Articulación de la Rodilla/cirugía , Prótesis de la Rodilla , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Prótesis e Implantes , Reoperación/métodos , Estudios Retrospectivos , Rotación , Resultado del TratamientoRESUMEN
BACKGROUND: Approximately 75% of the US population over 65 years has prediabetes or diabetes. Despite current evidence for the efficacy of carbohydrate restriction in managing blood glucose, this practice has not been implemented as part of routine perioperative blood sugar management. We hypothesize that a carbohydrate reduced hospital diet (CRD) of 135 g/d may improve blood sugar levels following total knee arthroplasty (TKA) compared to a non-carbohydrate reduced hospital diet (NCRD). METHODS: We randomized non-insulin-dependent prediabetic and diabetic patients undergoing TKA to either an NCRD or a CRD. Sixty-four patients were enrolled in the study and 2 were excluded, leading to 62 patients in the final analysis. The NCRD group included 14 females (47%) and 16 males (53%), with mean age of 68.5 years (±6.3 years). The CRD group included 16 females (50%) and 16 males (50%), with mean age of 68.0 years (±8.0 years). For hemoglobin A1C, the NCRD group had mean 5.8% (±0.6%) and the CRD group had mean 5.7% (±0.8%). For body mass index, the NCRD group had mean 29.3 kg/m2 (±6.3 kg/m2) and the CRD group 32.7 kg/m2 (±5.0 kg/m2). The primary outcome measure was mean blood glucose. RESULTS: Mean blood sugar values during hospital stay were significantly lower in the CRD group with 121.5 mg/dL (±17.1 mg/dL) compared to the NCRD group 141.2 mg/dL (±31.3 mg/dL, P = .0031). CONCLUSION: Blood sugar levels after surgery can be significantly reduced with a CRD. Further research is necessary to study the effect of reduced blood sugar levels on complications and infection rates following TKA surgery. LEVEL OF EVIDENCE: I.
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Artroplastia de Reemplazo de Rodilla/métodos , Glucemia/análisis , Dieta , Carbohidratos de la Dieta/administración & dosificación , Hemoglobina Glucada/análisis , Tiempo de Internación , Anciano , Índice de Masa Corporal , Dexametasona/administración & dosificación , Diabetes Mellitus Tipo 2/sangre , Diabetes Mellitus Tipo 2/complicaciones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estado Prediabético/sangre , Estado Prediabético/complicaciones , Infecciones Relacionadas con Prótesis/sangre , Proyectos de Investigación , Resultado del TratamientoRESUMEN
BACKGROUND: A well-reduced femoral neck fracture is more likely to heal than a poorly reduced one, and increasing the quality of the surgical exposure makes it easier to achieve anatomic fracture reduction. Two open approaches are in common use for femoral neck fractures, the modified Smith-Petersen and Watson-Jones; however, to our knowledge, the quality of exposure of the femoral neck exposure provided by each approach has not been investigated. QUESTIONS/PURPOSES: (1) What is the respective area of exposed femoral neck afforded by the Watson-Jones and modified Smith-Petersen approaches? (2) Is there a difference in the ability to visualize and/or palpate important anatomic landmarks provided by the Watson-Jones and modified Smith-Petersen approaches? METHODS: Ten fresh-frozen human pelvi underwent both modified Smith-Petersen (utilizing the caudal extent of the standard Smith-Petersen interval distal to the anterosuperior iliac spine and parallel to the palpable interval between the tensor fascia lata and the sartorius) and Watson-Jones approaches. Dissections were performed by three fellowship-trained orthopaedic traumatologists with extensive experience in both approaches. Exposure (in cm) was quantified with calibrated digital photographs and specialized software. Modified Smith-Petersen approaches were analyzed before and after rectus femoris tenotomy. The ability to visualize and palpate seven clinically relevant anatomic structures (the labrum, femoral head, subcapital femoral neck, basicervical femoral neck, greater trochanter, lesser trochanter, and medial femoral neck) was also recorded. The quantified area of the exposed proximal femur was utilized to compare which approach afforded the largest field of view of the femoral neck and articular surface for assessment of femoral neck fracture and associated femoral head injury. The ability to visualize and palpate surrounding structures was assessed so that we could better understand which approach afforded the ability to assess structures that are relevant to femoral neck fracture reduction and fixation. RESULTS: After controlling for age, body mass index, height, and sex, we found the modified Smith-Petersen approach provided a mean of 2.36 cm (95% confidence interval [CI], 0.45-4.28 cm; p = 0.015) additional exposure without rectus femoris tenotomy (p = 0.015) and 3.33 cm (95% CI, 1.42-5.24 cm; p = 0.001) additional exposure with a tenotomy compared with the Watson-Jones approach. The labrum, femoral head, subcapital femoral neck, basicervical femoral neck, and greater trochanter were reliably visible and palpable in both approaches. The lesser trochanter was palpable in all of the modified Smith-Petersen and none of the Watson-Jones approaches (p < 0.001). All modified Smith-Petersen approaches (10 of 10) provided visualization and palpation of the medial femoral neck, whereas visualization of the medial femoral neck was only possible in one of 10 Watson-Jones approaches (p < 0.001) and palpation was possible in eight of 10 Watson-Jones versus all 10 modified Smith-Petersen approaches (p = 0.470). CONCLUSIONS: In the hands of surgeons experienced with both surgical approaches to the femoral neck, the modified Smith-Petersen approach, with or without rectus femoris tenotomy, provides superior exposure of the femoral neck and articular surface as well as visualization and palpation of clinically relevant proximal femoral anatomic landmarks compared with the Watson-Jones approach. CLINICAL RELEVANCE: Open reduction and internal fixation of a femoral neck fracture is typically performed in a young patient (< 60 years old) with the objective of obtaining anatomic reduction that would not be possible by closed manipulation, thus enhancing healing potential. In the hands of surgeons experienced in both approaches, the modified Smith-Petersen approach offers improved direct access for reduction and fixation. Higher quality reductions and fixation are expected to translate to improved healing potential and outcomes. Although our experimental results are promising, further clinical studies are needed to verify if this larger exposure area imparts increased quality of reduction, healing, and improved outcomes compared with other approaches. The learning curve for the exposure is unclear, but the approach has broad applications and is frequently used in other subspecialties such as for direct anterior THA and pediatric septic hip drainage. Surgeons treating femoral neck fractures with open reduction and fixation should familiarize themselves with the modified Smith-Petersen approach.
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Puntos Anatómicos de Referencia/cirugía , Fracturas del Cuello Femoral/cirugía , Fémur/anatomía & histología , Fijación Interna de Fracturas/métodos , Adulto , Anciano , Cadáver , Femenino , Fémur/cirugía , Humanos , Masculino , Persona de Mediana EdadRESUMEN
There is no standardization of proprietary radiology viewing software platform functions allowing recorded digital radiographic imaging studies on compact discs (CDs) to be viewed in a standardized manner at subsequent institutions. Primary concerns include the following: (1) a large number of image viewing software platforms with a wide variety of features making familiarity with use difficult, (2) an inordinate amount of time required to load imaging data, (3) imaging data may not upload or be viewed with the care center's picture archiving and communication system, (4) navigation through imaging studies is inconsistent and tedious, and (5) image viewing requires additional software downloads. Additionally, images generated from "outside CDs" are frequently of low quality and resolution, eliminating the ability to render a reliable diagnosis. The authors sought to determine the frequency and extent of these functional problems by analyzing a sample of 50 consecutive radiology CDs containing imaging studies referred to a university orthopedic oncology practice. Eighteen different viewing software platforms were encountered. Only 24 (48%) of the CDs met all optimal system criteria. Mean time required to load the studies was 3.4 seconds using the picture archiving and communication system and 37.9 seconds using the proprietary viewing software (P<.001). Fifteen (30%) of the CDs did not upload to the institution's picture archiving and communication system, and 18 (36%) required additional downloads and/or license agreements. Four CDs did not contain Digital Imaging and Communications in Medicine images. Physicians using radiology studies on CDs encounter numerous difficulties in evaluating patients' imaging data because of the plethora of viewing software platforms. These difficulties add time and cost and compromise patient care. [Orthopedics. 2018; 41(1):e136-e141.].
Asunto(s)
Computadores , Radiografía/métodos , Sistemas de Información Radiológica , Programas Informáticos , Acceso a la Información , Discos Compactos , Gráficos por Computador , Humanos , Estudios Prospectivos , Radiología/normas , Interfaz Usuario-ComputadorRESUMEN
BACKGROUND: Two-stage exchange arthroplasty is a standard approach for treating total knee arthroplasty periprosthetic joint infection in the United States, but whether this should be performed with a static antibiotic spacer or an articulating one that allows range of motion before reimplantation remains controversial. It is unclear if the advantages of articulating spacers (easier surgical exposure during reimplantation and improved postoperative flexion) outweigh the disadvantages of increased cost and complexity in the setting of similar rates of infection eradication. QUESTIONS/PURPOSES: The purposes of this study were (1) to determine the ultimate range of motion; and (2) to determine the proportion of patients who remained free of infection at a minimum 2 years after treatment with static antibiotic spacers as part of a two-stage revision TKA for the treatment of periprosthetic joint infection. METHODS: Between 1999 and 2011, we treated 121 patients with chronically infected TKAs, of whom three had medical comorbidities precluding a two-stage exchange, four had died before 2-year followup for reasons other than the surgical intervention, and seven were lost to followup. The remaining 107 patients (109 knees; 53 men and 54 women) were treated using a two-stage approach with static spacers and are evaluated here at a mean of 3.7 years (range, 2.0-9.8 years); no patients were treated with articulating spacers during this study period. Twenty-five percent (27 of 109) of the organisms isolated the first-stage procedure were resistant to methicillin and/or vancomycin. Median age at the time of reimplantation was 67 years (range, 42-89 years). Range of motion was measured by an independent physical therapist with a standard goniometer. Knee Society knee and function scores were calculated before the first stage and at the 2-year mark. Because many of these patients were treated before consensus definitions of infection were established, we made the diagnosis of infection (and established that a patient was believed to be free of infection) using the approaches prevalent at that time, which generally included presence of a sinus tract communicating directly with the implant, two positive tissue cultures, or a combination of cultures, fluid analysis, and serology. RESULTS: Postoperatively, 67 knees had full extension and no patients had a flexion contracture > 10°. Median flexion was 100° (range, 60°-139°). Thirty-nine knees had postoperative flexion > 120°. Ninety-four percent of patients were clinically free of infection at last followup. CONCLUSIONS: Our two-stage exchange protocol with static spacers yielded comparable flexion and infection eradication when compared with other recent studies that have used articulating spacers. The large proportion of resistant organisms is alarming. Future multicenter studies should compare static with articulating spacers and should evaluate both cost and efficacy, because our study suggests that adequate range of motion can be achieved without the added cost of the articulating spacer. LEVEL OF EVIDENCE: Level IV, therapeutic study.
Asunto(s)
Antibacterianos/administración & dosificación , Artroplastia de Reemplazo de Rodilla/efectos adversos , Artroplastia de Reemplazo de Rodilla/instrumentación , Articulación de la Rodilla/cirugía , Prótesis de la Rodilla/efectos adversos , Infecciones Relacionadas con Prótesis/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Artrometría Articular , Fenómenos Biomecánicos , Materiales Biocompatibles Revestidos , Comorbilidad , Evaluación de la Discapacidad , Femenino , Humanos , Articulación de la Rodilla/microbiología , Articulación de la Rodilla/fisiopatología , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/microbiología , Rango del Movimiento Articular , Recuperación de la Función , Recurrencia , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
Although the International Consensus Meeting on Periprosthetic Joint Infection's definition of periprosthetic joint infection (PJI) does not include nuclear imaging as part of the diagnostic criteria, many contemporary nuclear imaging studies are reporting exceptional results in PJI diagnosis. We conducted a systematic review of studies published from 2004 to 2012 reporting the accuracy of nuclear imaging for diagnosis of PJI, utilizing a specially designed tool (QUADAS-2) for critical appraisal and investigation of bias. Our results revealed high risk of bias as well as high levels of concern regarding the clinical applicability of these tests in a majority of the studies. On the basis of our findings, we recommend that the use of nuclear imaging for diagnosis of PJI be limited to a few select cases.
Asunto(s)
Medicina Nuclear/métodos , Infecciones Relacionadas con Prótesis/diagnóstico por imagen , Infecciones Relacionadas con Prótesis/diagnóstico , Sesgo , Humanos , Prótesis Articulares/efectos adversos , Imagen Multimodal , Valor Predictivo de las Pruebas , Radiofármacos , Estándares de Referencia , Proyectos de Investigación , Sensibilidad y Especificidad , Tomografía Computarizada de Emisión de Fotón ÚnicoRESUMEN
In comparison to primary total knee arthroplasty, surgical time was 1.8 times greater for all knee revisions and 2.4 times greater for complex knee revisions. Knee revisions had an 8.5% higher rate of 90-day repeat procedures. In comparison to primary total hip arthroplasty, surgical time was 1.8 greater for all hip revisions and 2.6 fold greater for complex hip revisions. Hip revisions had a 3.4% higher rate of 90-day repeat procedures. Practices based on revisions or complex revisions alone would see a 32% and 50% decrease in reimbursement respectively compared to the ones based on primary arthroplasty. The projected future increase in primary arthroplasties and the relative incentive to perform primary arthroplasty may soon put patient access to physicians willing to perform revision arthroplasty at risk.