Non-traumatic osteonecrosis of the femoral head is a potentially devastating condition, the prevalence of which is increasing. Many joint-preserving forms of treatment, both medical and surgical, ...have been developed in an attempt to slow or reverse its progression, as it usually affects young patients. However, it is important to evaluate the best evidence that is available for the many forms of treatment considering the variation in the demographics of the patients, the methodology and the outcomes in the studies that have been published, so that it can be used effectively. The purpose of this review, therefore, was to provide an up-to-date, evidence-based guide to the management, both non-operative and operative, of non-traumatic osteonecrosis of the femoral head. Cite this article:
2017;99-B:1267-79.
Although previous studies have evaluated the effect of obesity on the outcomes of total knee arthroplasty (TKA), most considered obesity as a binary variable. It is important to compare different ...weight categories and consider body mass index (BMI) as a continuous variable to understand the effects of obesity across the entire range of BMI. Therefore, the objective of this study is to analyze the effect of BMI on 30-day readmissions and complications after TKA, considering BMI as both a categorical and a continuous variable.
The National Surgical Quality Improvement Project database was queried from 2011 to 2015 to identify 150,934 primary TKAs. Thirty-day rates of readmissions, reoperations, and medical/surgical complications were compared between different weight categories (overweight: BMI >25 and ≤30 kg/m2; obese: BMI >30 and ≤40 kg/m2; morbidly obese: BMI >40 kg/m2) and the normal weight category (BMI >18.5 and ≤25 kg/m2) using multivariate regression models. Spline regression models were created to study BMI as a continuous variable.
Obese patients were at increased risk of pulmonary embolism (PE) (P < .001), while morbidly obese patients were at increased risk of readmission (P < .001), reoperation (P < .001), superficial infection (P < .001), periprosthetic joint infection (P < .001), wound dehiscence (P < .001), PE (P < .001), urinary tract infection (P = .003), reintubation (P = .004), and renal insufficiency (P < .001). Transfusion was lower in overweight (P < .001), obese (P < .001), and morbidly obese (P < .001) patients. BMI had a nonlinear relationship with readmission (P < .001), reoperation (P < .001), periprosthetic joint infection (P = .041), PE (P < .001), renal insufficiency (P = .046), and transfusion (P < .001).
Obesity increased the risk of readmission and various complications after TKA, with the risk being dependent on the severity of obesity. Relationships between BMI and complications showed considerable variations with some outcomes like readmission and reoperation showing a U-shaped relationship. Based on our findings, a potential BMI goal in weight management for obese patients could be established around 29-30 kg/m2, in order to decrease the risk of most TKA postoperative complications.
This study compared multiple sclerosis (MS) patients who underwent primary total hip arthroplasty (THA) with a matched cohort. Specifically, we evaluated: 1) implant survivorship; 2) functional ...outcomes (modified Harris Hip Scores (mHHS), Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS JR), and modified Multiple Sclerosis Impact Scale (mMSIS) scores (with the MS cohort also evaluated based on the disease phenotype)); 3) physical therapy duration and return to function; 4) radiographic outcomes; and 5) complications.
We reviewed our institution's database to identify MS patients who underwent THA between January 2008 and June 2016. A total of 34 MS patients (41 hips) were matched in a 1:2 ratio to a cohort of THA patients who did not have MS, based on age, body mass index (BMI), and Charlson/Deyo score. Patient records were reviewed for complications, and their functional outcomes and radiographs were reviewed at their most recent follow-up.
Compared with the matched cohort, MS patients had lower all-cause implant survivorship at eight years (91.5% (95% confidence interval (CI) 82.7 to 100) vs 98.7% (95% CI 96.2 to 100)) (p = 0.033), lower mHHS scores (66 vs 80, p < 0.001), and HOOS JR scores (79 vs 88, p = 0.009). Multiple sclerosis patients also required more physiotherapy (five weeks vs three weeks, p = 0.002) and took longer to return to baseline (seven weeks vs five weeks, p = 0.010) than the matched cohort. Furthermore, MS patients had more complications than the non-MS patients (six vs zero, p < 0.001). The worse outcomes of the MS group can potentially be explained by predisposition of these patients to mechanical complications and progression of their disease during the period of this study, as demonstrated by worsening of the mMSIS scores (2.9 vs 3.4; p = 0.008).
MS patients had lower implant survivorship, lower functional outcome scores, and increased complication rates; in addition, MS patients took longer to return to their baseline functional level after THA. Cite this article: Bone Joint J 2018;100-B:875-81.
Post-operative pain management in elderly total knee arthroplasty (TKA) patients has traditionally included opioids, epidurals, and femoral nerve blocks. Although these modalities are effective, they ...are often associated with adverse side effects, which may have a greater impact on this population. Alternative modalities, such as adductor canal blocks (ACB) and multimodal periarticular analgesia (MPA) have demonstrated great efficacy with a low side effect profile. However, it is unknown if one modality is advantageous over the other in the elderly. Therefore, the purpose of this study is to assess 1) post-operative opioid use, 2) length of stay, 3) pain levels, and 4) discharge status in TKA patients aged 75 years or older who have received either ACB or MPA.
A single-hospital, single-surgeon database was reviewed for patients aged 75 years or older who had a TKA with either ACB or MPA between January 2015 and April 2016. This yielded 90 patients with a mean age of 83 years (range, 75 to 90 years) comprised of 31 men and 59 women. Forty-three patients received ACB, whereas 47 patients received MPA. Electronic medical records were reviewed to obtain demographic and endpoint data. Pain was quantified using the visual analog scale (VAS). Continuous variables were compared using the student's t-test and analysis of variance, while categorical variables were compared using chi-square analysis.
No significant difference was observed in opioid consumption between the two groups at post-operative day 0 (p= 0.832) 1 (p= 0.293), or 3 (p= 0.779). While patients in the ACB group had significantly less opioid consumption on post-operative day 2 (p= 0.005), there was no significant difference between groups in total opioid consumption (p= 0.735). There was no significant difference between groups in lengths of stay (2.8 days vs. 3.0 days, p= 0.627) or VAS scores (3.03 vs. 2.96, p= 0.922). The proportion of patients discharged to home did not yield a significant difference as well (55% vs. 45%; p= 0.331).
Elderly patients may have their post-operative pain well controlled if they receive either ACB or MPA during total knee arthroplasty. Our study demonstrates no significant difference in total opioid consumption, lengths of stay, pain levels, and discharge status between groups. Future studies should utilize larger cohorts and include assessments of post-operative functional recovery.
In this review, we (1) evaluated the effect of adult spine deformity (ASD) and its surgical correction on patients who had a total hip arthroplasty (THA); (2) evaluated the outcomes of THA in ...patients who have had previous spinal fusion; and (3) we presented an algorithm on how to surgically address patients who simultaneously require THA and ASD correction.
A comprehensive literature search was conducted. Our final analysis included 14 studies. Overall, there were 3 studies that reported on the impact of ASD on THA outcomes, 6 studies reported on the effect of ASD correction on THA outcomes, and 5 studies reported on the effect of spinal fusion on THA outcomes.
Patients with concurrent ASD and THA are at increased risk of THA dislocations and revisions with studies reporting a compiled 2.9% dislocation rate in 1167 patients. Patients who underwent ASD correction demonstrated a post-operative reduction of acetabular anteversion (mean reduction range 4.96°-11.2°, P < .001) and tilt (mean −7° ± 10°, P < .001). In THA patients with concurrent lumbosacral fusion, dislocation rates ranged between 3% at 1 year and 7.5% at 2 years compared to 0.4%-2.1% dislocation rates in matching cohorts (P < .001).
Spine balance can alter THA outcomes, but the exact mechanism is yet to be elucidated. We aimed at bridging the gap between hip and spine surgeons with an up-to-date analysis of the best available evidence and presented an algorithm for approaching patients who may simultaneously need ASD correction and THA.
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