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Purpose: Antimicrobial cement spacer (ACS) placement has been a cornerstone of two-stage management of prosthetic hip and knee infection. Pharmacokinetic modelling has described peak systemic antibiotic concentrations within the first 24-48 h post-operatively, followed by rapid clearance. A few studies have, however, identified detectable tobramycin levels in patients with a post-operative decline in creatinine clearance. Our study sought to determine how frequently detectable serum tobramycin levels occurred within the first 72 h following ACS placement in all patients regardless of baseline or subsequent changes in renal function, whether these levels correlated with tobramycin spacer dosage, creatinine clearance, or potential nephrotoxicity risk factors, and whether any patients developed acute kidney injury within the 14-day post-operative period. Methods: We prospectively enrolled patients with prosthetic hip or knee infections and subsequent ACS placement from October 2017 to February 2020. Patient comorbidities (chronic kidney disease, diabetes mellitus, chronic liver disease, chronic obstructive pulmonary disease, and atrial fibrillation), Charleston Comorbidity Index score, risk factors for post-operative nephrotoxicity (perioperative hypotension and nephrotoxic agent receipt), total tobramycin dosage, post-operative days 1 and 3 serum tobramycin concentrations, and serum creatinine and creatinine clearance throughout a 14-day post-operative period were recorded. Results: A total of 20 patients were enrolled, comprising 20 spacers with a median total tobramycin dosage of 4.80 g with an interquartile range (IQR) of 4.13-7.20 g. Thirteen patients had a median detectable post-operative day 1 serum tobramycin concentration of 0.80 (IQR 0.50-1.60) mcg/mL. Five of these 13 patients had a median detectable post-operative day 3 serum tobramycin concentration of 0.80 (IQR 0.50-1.10) mcg/mL. A correlation was not found between serum tobramycin drug levels and patient comorbidities, receipt of nephrotoxic medications, or baseline and subsequent post-operative creatinine clearance up to day 14. Conclusion: The majority of patients who underwent tobramycin ACS placement had detectable serum tobramycin levels in the immediate post-operative period, but most reached undetectable levels within 72 h. There were no reliable perioperative predictors of detectable drug levels.

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BACKGROUND: The COVD-19 global pandemic has placed a large demand on personal protective equipment for healthcare workers. N-95 respirators, required to perform aerosolizing procedures, are in short supply and have increased significantly in cost. The lack of a clear end to the pandemic requires hospitals to create a long-term, cost effective solution to the N95 shortage. We initially used previously described methods to reuse and resterilize N95 masks; however, we found they did not solve the issues related to just-in-time fit-testing and cost. STUDY DESIGN: We initiated a program with the aim to reduce our dependence on N95 masks by initiating a phased program to acquire industrial style elastomeric P100 masks as a substitute for reuse and resterilization of disposable N95s. We created an allocation strategy based on availability of the masks, as well as an operational plan to fit test, educate, and disinfect the masks. RESULTS: Within 1 month, we were able to reduce the number of N95s needed by our network by 95%. We also found that the cost was, conservatively, 10 times less per month than purchasing disposable N95s, and the cost benefit increases the longer they are needed. CONCLUSIONS: Establishment of an elastomeric mask program is feasible and less expensive than programs focused on reusing and disinfecting disposable N95 masks. A well thought out elastomeric distribution and disinfection program does not pose greater operational challenges than an N95 reuse and resterilization program. In addition, elastomeric masks can be stored for future surges and should be considered an essential part of all healthcare facilities' supply of personal protective equipment. Implementation of the program has eliminated our dependence on disposable N95s to maintain normal operations during the global pandemic.

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BACKGROUND: Currently, no consensus exists for selection criteria of appropriate candidates for outpatient total hip arthroplasty (THA). This study evaluates patient characteristics associated with same-day discharge, examined surgical start time's effect on rates of same-day discharge, and compares readmission and reoperation rates between groups. METHODS: All patients who underwent a THA by one surgeon at a single quaternary care hospital between February 2016 and May 2018 were captured. All patients were given the option for same-day discharge. Patient characteristics and perioperative variables were analyzed. RESULTS: A total of 429 patients met inclusion criteria, 153 (36%) were discharged on the day of surgery. In a multivariate analysis, age (P = .000), multiple comorbidities (P = .004), and start time remained statistically significant (P = .000). Patients with start times prior to 9 AM had odds ratio of 11.56 of being discharged same day when compared to those with start times after 12 PM. Patients discharged the day of surgery were less likely to have a 90-day emergency room visit (P = .010), a readmission within 30 days (P = .001) or 90 days (P = .000), or a reoperation (0 vs 14, P = .003). CONCLUSION: Same-day discharge following THA is safe and feasible. Patient's age and number of comorbidities should be considered when developing selection criteria for same-day discharge programs. Patients selected for same-day discharge should receive earlier operating room start times.

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Persistent pain following hip arthroplasty remains a concern, especially in young, active patients. Four hundred twenty patients less than 60 years of age with a pre-symptomatic UCLA score ≥ 6 (196 total hip arthroplasty [THA]; 224 surface replacement arthroplasty [SRA]) completed a pain-drawing questionnaire investigating the location, severity, and frequency of pain around the hip. At a mean of 2.9 years of follow-up, 40% reported pain in at least one location around the hip. There was no difference in the incidence of groin pain between SRA and THA patients (32% vs. 29%, P=0.6), but THA patients had a greater incidence of anterior (25% vs. 8%, P<0.001) and lateral (20% vs. 10%, P=0.01) thigh pain. A high percentage of young, active patients experience persistent pain following hip arthroplasty.

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Pain following total hip arthroplasty (THA) and surface arthroplasty (SRA) remains a significant source of patient dissatisfaction. Two hundred twenty-four SRA and 196 THA patients completed a pain drawing questionnaire and postoperative radiographic measurements of component positioning were performed. In the SRA cohort, 11 of 21 patients (52%) with acetabular uncoverage of ≥5 mm versus 43 of 147 (29%) with acetabular uncoverage of ≤4.9 mm reported groin pain (P=.03). In the THA cohort, an increased distal-third canal fill ratio and a lower canal calcar ratio trended towards a higher incidence of thigh pain (P=.10 and .06), while a decreased mid-third canal fill ratio was associated with increased severity of thigh pain (P=.04). This study identifies associations between radiographic findings and pain following THA and SRA.

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The purpose of the present study is to retrospectively analyze clinical and radiographic outcomes in primary constrained condylar knee arthroplasty at a minimum follow-up of 7 years. Given the concern for early aseptic loosening in constrained implants, we focused on this outcome. Our cohort consists of 127 constrained condylar knees. The mean age of patients in the study was 68.3 years, with a mean follow-up of 110.7 months. The diagnosis was primary osteoarthritis in 92%. There were four periprosthetic distal femur fractures, with a rate of revision of 0.8%. No implants were revised for aseptic loosening. Kaplan-Meier survivorship analysis with removal of any component as the end point revealed that the 10-year rate of survival of the primary CCK was 97.6% (95% CI, 94%-100%).

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The use of modular femoral stems in primary total hip arthroplasty has increased considerably in recent years. These modular components offer the surgeon the ability to independently alter version, offset, and length of the femoral component of a hip arthroplasty. This increases the surgeon's ability to accurately recreate the relevant anatomy but increases the possibilities of corrosion and fracture. Multiple case reports have highlighted fractures of these modular components. We present a case of a fracture of a modular design that has had no previously reported modular neck fractures. The patient was informed that data concerning the case would be submitted, and he consented.

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