Background
Intraoperative fluoroscopy is commonly used to both guide the osteotomy and judge correction of the acetabular fragment in periacetabular osteotomy (PAO). Prior studies that have compared ...intraoperative fluoroscopic correction with postoperative radiographic correction were small studies that did not report intra- or interreader reliability.
Questions/purposes
(1) What is the correlation between intraoperative fluoroscopic correction in PAO compared with the correction seen on postoperative radiographs? (2) What is the reliability of radiographic measures of correction in PAO?
Methods
We performed a retrospective study of 121 patients (141 hips) who underwent PAO for symptomatic hip dysplasia at a tertiary referral center. Patients were included in the study if they had preoperative radiographs, intraoperative fluoroscopy, and minimum 6-week postoperative radiographs. Of the 272 PAO procedures performed in this time period, 61 patients who underwent PAO for retroversion and five patients with a history of Perthes disease were excluded as a result of the inability for these radiographic measures to judge fragment correction in PAOs for retroversion and the difficulty in measurement in post-Perthes deformity. Of the 206 PAOs performed for symptomatic acetabular dysplasia, 65 (32%) could not be analyzed because they lacked appropriate preoperative films, leaving 141 PAOs in 121 patients for analysis. The patients lacking appropriate preoperative films had them performed at an outside facility or had plain films that have since been destroyed. The lateral center-edge angle (LCEA) and acetabular index (AI) on the fluoroscopic views and postoperative radiographs were measured by two authors. The concordance between the amount of correction on intraoperative fluoroscopy and minimum 6-week postoperative measurements was analyzed using the concordance correlation coefficient (r
c
) and a Bland–Altman analysis. Intra- and interrater reliability was calculated between measurements.
Results
The amount of intraoperative correction of LCEA as measured on fluoroscopic images demonstrated substantial agreement with postoperative radiographs (r
c
= 0.79; 95% confidence interval CI, 0.73–0.85; p < 0.001) as did the AI (r
c
= 0.77; 95% CI, 0.70–0.84; p < 0.001). The mean difference between intraoperative correction was only −0.38° (SD 3.6°) for LCEA and −0.84° (SD 3.4°) for AI. Interrater reliability for both LCEA and AI also demonstrated substantial agreement (all, r
c
= 0.70–0.90) for preoperative, operative, and postoperative imaging. Furthermore, intrarater reliability for both LCEA and AI demonstrated almost perfect agreement for all measures (all, r
c
> 0.81).
Conclusions
Intraoperative fluoroscopy is an accurate and reliable measure of correction of lateral coverage of the acetabular fragment during PAO. Further studies on measures of anterior coverage and acetabular version are needed to validate intraoperative fluoroscopic correction in these planes.
Level of Evidence
Level III, diagnostic study.
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FZAB, GEOZS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Abstract Background We sought to assess the prevalence of soft tissue changes seen on magnetic resonance imaging (MRI) after metal-on-metal (MOM) total hip arthroplasty (THA) and determine if the ...presence of pseudotumors was associated with metal ion levels, acetabular cup position, outcomes scores, and femoral head size. Methods After receiving an institutional review board exemption for secondary data analysis, we performed a cross-sectional study identifying 55 patients (55 hips) that underwent primary THA with a MOM articulation and had subsequent MRI imaging between February 2013 and February 2014 at a single academic medical center. Results Twenty-four patients (44%) had no evidence of pseudotumors, 27 (49%) had type I pseudotumors, and 4 (7%) were classified as having type II pseudotumors. The presence and severity of pseudotumors were associated with higher serum chromium levels ( P = .043). Neither acetabular inclination nor acetabular version was associated with the presence of pseudotumors, the severity of pseudotumors, or elevated serum metal ion levels (all P > .05). Increased metal ion levels were associated with lower Harris Hip Score and higher Harris Hip Score pain subscores (all P < .05). Conclusion In conclusion, pseudotumors on metal artifact reduction sequencing MRI may be present in both symptomatic and asymptomatic MOM THAs. Surgeons should therefore exercise caution in placing too much emphasis on isolated studies such as cross-sectional imaging. Instead, a structured approach to evaluation of MOM arthroplasty should be followed.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Adding value in a university-based academic health care system provides unique challenges when compared to other health care delivery models. Herein, we describe our experience in adding value to ...joint arthroplasty care at the University of Utah, where the concept of value-based health care reform has become an embraced and driving force.
To improve the value, new resources were needed for care redesign, physician leadership, and engagement in alternative payment models. The changes that occurred at our institution are described.
Real-time data and knowledgeable personnel working behind the scenes, while physicians provide clinical care, help move clinical pathway redesigns. Engaged physicians are essential to the successful implementation of value creation and care pathway redesign that can lead to improvements in value. An investment of money and resources toward added infrastructure and personnel is often needed to realize large-scale improvements. Alignment of providers, payers, and hospital administration, including by means of gainsharing programs, can lead to improvements.
Although significant care pathway redesign efforts may realize substantial initial cost savings, savings may be asymptotic in nature, which calls into question the likely sustainability of programs that incentivize or penalize payments based on historical targets.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
We sought to determine the 10-year survivorship and reasons for revision for a fixed-bearing unicompartmental knee arthroplasty (UKA) design. In addition, we report on patient-reported outcomes and ...satisfaction and compare results of medial vs lateral compartment UKA and cemented vs cementless UKA with the same design.
We performed a retrospective cohort study on a single-surgeon case series using a single fixed-bearing UKA design in 158 consecutive patients who underwent 177 UKA procedures between July 2000 and December 2010. Cases missing follow-up within the last year, clinically or via telephone, were excluded (n = 17, 10%). A cumulative incidence competing risk model was used to evaluate the cumulative incidence of failure.
Cumulative incidence of revision at a mean follow-up of 10 years was 13%. The majority of revisions (43%, 10/23) were for aseptic tibial component loosening, followed by progression of osteoarthritis (5/23, 22%). All Patient Reported Outcomes Measurement Information System measures demonstrated mean T-scores within one standard deviation from the US population norm. The mean Knee Injury and Osteoarthritis Outcome Score for Joint Replacement was 96.9 (range, 40-100). The mean pain score was 3.8 (range, 0-8). Eighty-six percent of patients were satisfied with the UKA.
At 10-year follow-up, the most common causes for revision were aseptic tibial loosening and adjacent compartment knee arthroplasty, and similar results were found for medial vs lateral compartment and for cemented vs cementless UKA. Surgeons should consider these findings for future UKA designs, and this represents the first study reporting on survivorship and outcomes of this specific UKA design.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract Background The primary purpose of our study was to determine the prevalence of Cam deformity in patients with symptomatic acetabular dysplasia (SAD) who underwent periacetabular osteotomy ...(PAO). Methods We retrospectively reviewed 164 SAD PAO patients from two institutions. Preoperative AP and frog-lateral radiographs were analyzed for LCEA, retroversion, alpha angles, and anterior femoral head-neck offset. Hips were classified as dysplastic (LCEA<20°, group A, n=142) and borderline dysplastic (LCEA 20°- 25°, group B, n=22). There were 128 females and 36 males with an average age of 29 years (range 13-56). Results The overall prevalence of Cam deformity was 10% (17/164) in SAD patients. There was no difference in the prevalence of Cam deformity between the groups (p>0.99). Conclusion Prevalence of Cam deformities in our series of SAD patients having undergone PAO is less than prior reports. Careful radiographic measurement should be performed to avoid over-treating these hips with unnecessary osteochondroplasty procedures.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
We describe 3 cases of DePuy Pinnacle polyethylene dissociations, their presentations, and treatment. A 34-year-old female with arthritis secondary to dysplasia, a 51-year-old male with avascular ...necrosis of the femoral head, and a 57-year-old female with osteoarthritis were treated with total hip arthroplasty. Acute nontraumatic polyethylene liner dissociations occurred at 31, 42, and 2 months postoperatively. They were treated with component retention and modular femoral head and liner revision. The 51-year-old male subsequently developed a prosthetic joint infection requiring explant of his components. Although dissociation of polyethylene liners from the DePuy Pinnacle acetabular components is an uncommon complication, this problem may increase in prevalence with longer term follow-up, and vigilance is recommended.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract Background An early physical therapy (PT) care pathway was implemented to provide same-day ambulation after total joint arthroplasty by changing PT staffing hours. Methods After receiving an ...exemption from our institutional review board, we performed a secondary data analysis on a cohort of patients that underwent primary TJA of the hip or knee 6 months before and 12 months after implementation of the change. Data on same-day ambulation rates, length of stay (LOS), and in-hospital costs were reviewed. Results Early evaluation and mobilization of patients by PT improved on postoperative day (POD) 0 from 64% to 85% after the change ( P ≤ .001). The median LOS before the change was 3.27 days compared to 3.23 days after the change ( P = .014). Patients with higher American Society of Anesthesiologists scores were less likely to ambulate on POD 0 ( P = .038) and had longer hospital stays ( P < .001). Early mobilization in the entire cohort was associated with a greater cost savings ( P < .001). Conclusions A relatively simple change to staffing hours, using resources currently available to us, and little additional financial or institutional investment resulted in a significant improvement in the number of patients ambulating on POD 0, with a modest reduction in both LOS and inpatient costs.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Despite two-stage revision remaining the gold standard in treating periprosthetic infection of total knee arthroplasty (TKA), there remains uncertainty regarding the actual success rate and the risk ...factors for failure. We retrospectively reviewed 58 knees with mean follow-up of 38 months who underwent two-stage revision TKAs from 1998 to 2012 by a single surgeon. Failure was defined as persistent infection or reoperation after two-stage revision TKA surgery. Failure occurred in 36%. The overall mortality was 22%. The mean time to reinfection was 26 months. Polymicrobial infection was associated with a higher risk of failure (RR 3.31, P < 0.001 ). Knees requiring soft tissue coverage were also at a greater risk of failure (RR 2.67, P = 0.001 ), as were knees that underwent four or more additional surgeries after the primary TKA and prior to stage-one explantation (RR 2.25, P = 0.020 ). Thus, opportunities exist for improvement in management of infected TKA.
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FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
Epizootic bovine abortion (EBA) is an arthropod-borne bacterial disease that causes significant economic loss for cattle producers in the western United States. The etiologic agent,
, is an ...intracellular pathogen that has yet to be cultivated in vitro, thereby requiring novel methodologies for vaccine development. A vaccine candidate, using live
-infected cells (
-LIC) harvested from mouse spleens, was tested in beef cattle. Over the course of two safety studies and four efficacy trials, safety risks were evaluated, and dosage and potencies refined. No incidence of anaphylaxis, recognized health issues or significant impact upon conception rates were noted. Vaccination did result in subclinical skin reactions. Early fetal losses were noted in two trials and were significant when the vaccine was administered within 21 days prior to conception. Administration of the EBA agent (EBAA) vaccine as a single dose, at a potency of 500
-LIC, 56 days prior to breeding, provided 100% protection with no early fetal losses. Seroconversion occurred in all animals following EBAA vaccination and corresponded well with protection of the fetus from epizootic bovine abortion.
Background
Continuous femoral nerve block has been shown to decrease opioid use, improve postoperative pain scores, and decrease length of stay. However, several studies have raised the concern that ...continuous femoral nerve block may delay patient ambulation and increase the risk of falls during the postoperative period.
Questions/purposes
This study sought to determine whether continuous femoral nerve block with a single-shot sciatic block prevented early ambulation after total knee arthroplasty (TKA) and whether the technique was associated with adverse effects.
Methods
Between January 2011 and January 2013, 77 consecutive patients undergoing primary TKAs at an orthopaedic specialty hospital received a continuous femoral nerve block for perioperative analgesia. The femoral block was placed preoperatively with an initial bolus and 76 (99%) patients received a single-shot sciatic nerve block performed at the same time. Fifty-eight percent (n = 45) received an initial bolus of 0.125% bupivacaine and 42% (n = 32) received 0.25% bupivacaine. All 77 patients received 0.125% bupivacaine infusion postoperatively with the continuous femoral nerve block. All patients were provided a knee immobilizer that was worn while they were out of bed and was used until 24 hours after removal of the block. All patients also used a front-wheeled walker to assist with ambulation. All 77 patients had complete records for assessing the end points of interest in this retrospective case series, including distance ambulated each day and whether in-hospital complications could be attributed to the patients’ nerve blocks.
Results
Thirty-five patients (45%) ambulated for a mean distance of 19 ± 22 feet on the day of surgery. On postoperative Days 1 and 2, all 77 patients successfully ambulated a mean of 160 ± 112 and 205 ± 123 feet, respectively. Forty-eight patients (62%) had documentation of ascending/descending stairs during their hospital stay. No patient fell during the postoperative period, required return to the operating room, or readmission within 90 days of surgery. One patient experienced a transient foot drop related to the sciatic nerve block, which resolved by postoperative Day 1.
Conclusions
Continuous femoral nerve block with dilute bupivacaine (0.125%) can be successfully used after TKA without preventing early ambulation. By taking active steps to prevent in-hospital falls, including the use of a knee immobilizer for ambulation while the block is in effect, patients can benefit from the analgesia provided by the block and still ambulate early after TKA.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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FZAB, GEOZS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
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