An articulating or nonarticulating antibiotic hip spacer can be placed following the first stage implant removal of a periprosthetic hip joint infection. Antibiotic spacers help fill in the dead ...space created at the time of resection and provide a high local concentration of antibiotics. Theoretical advantages of a static spacer include a higher elution of antibiotics because of the increased surface area, the ability to protect deficient bone in the proximal femur/acetabulum, and the ability to immobilize the periarticular soft tissues. Advantages of an articulating spacer include improved ambulation and easier motion for the patient, maintenance of soft tissue tension, and an easier surgical reconstruction at the time of the second stage. Additionally, an articulating antibiotic spacer may minimize the risk of dislocation following the second stage reconstruction. The choice of articulating or nonarticulating is currently one of surgeon preference yet it is advised that surgeons consider an articulating spacer for all patients except those with severe femoral/acetabular bone loss or deficient abductors.
Corrosion at the modular head-neck junction of the femoral component in total hip arthroplasty has been identified as a potential concern, although symptomatic adverse local tissue reactions ...secondary to corrosion have rarely been described.
We retrospectively reviewed the records of ten patients with a metal-on-polyethylene total hip prosthesis, from three different manufacturers, who underwent revision surgery for corrosion at the modular head-neck junction.
All patients presented with pain or swelling around the hip, and two patients presented with recurrent instability. Serum cobalt levels were elevated prior to the revision arthroplasty and were typically more elevated than were serum chromium levels. Surgical findings included large soft-tissue masses and surrounding tissue damage with visible corrosion at the femoral head-neck junction; the two patients who presented with instability had severe damage to the hip abductor musculature. Pathology specimens consistently demonstrated areas of tissue necrosis. The patients were treated with debridement and a femoral head and liner exchange, with use of a ceramic femoral head with a titanium sleeve in eight cases. The mean Harris hip score improved from 58.1 points preoperatively to 89.7 points at a mean of 13.0 months after the revision surgery (p=0.01). Repeat serum cobalt levels, measured in six patients at a mean of 8.0 months following revision, decreased to a mean of 1.61 ng/mL, and chromium levels were similar to prerevision levels. One patient with moderate hip abductor muscle necrosis developed recurrent instability after revision and required a second revision arthroplasty.
Adverse local tissue reactions can occur in patients with a metal-on-polyethylene bearing secondary to corrosion at the modular femoral head-neck taper, and their presentation is similar to the adverse local tissue reactions seen in patients with a metal-on-metal bearing. Elevated serum metal levels, particularly a differential elevation of serum cobalt levels with respect to chromium levels, can be helpful in establishing this diagnosis.
Abstract This study evaluated the efficacy of a dilute Betadine (Purdue Pharma, Stamford, Conn) lavage in preventing early deep postoperative infection after total hip (THA) and knee (TKA) ...arthroplasty. A protocol of dilute Betadine lavage (0.35%) for 3 minutes was introduced to the practice of the senior author in June 2008. A total of 1862 consecutive cases (630 THA and 1232 TKA) performed before this were compared with 688 consecutive cases (274 THA and 414 TKA) after for the occurrence of periprosthetic infections within the first 90 days postoperatively. Eighteen early postoperative infections were identified before the use of dilute Betadine lavage, and 1 since (0.97% and 0.15%, respectively; P = .04). There were no significant demographic differences between the 2 groups. Betadine lavage before wound closure may be an inexpensive, effective means of reducing acute postoperative infection after total joint arthroplasty.
Abstract We reviewed 27 patients who underwent revision for an adverse local tissue reaction (ALTR) secondary to corrosion at the head-neck junction with MoP bearings. Serum cobalt and chromium ...levels were elevated in all cases, with a mean cobalt of 11.2 ppb and chromium of 2.2 ppb. Patients underwent modular bearing exchange, including a ceramic head with a titanium sleeve in 23 of 27 cases with only one recurrence of ALTR in one of the four patients not treated with a ceramic head. The diagnosis of ALTR secondary to corrosion is associated with cobalt levels of >1 ppb with cobalt levels elevated above chromium. Retention of a well-fixed stem and modular exchange to a ceramic head leads to resolution of symptoms and decreases in metal levels.
Abstract Introduction Deep infection following elective total joint arthroplasty remains a devastating complication. Preoperative nasal swab screening for Staphylococcus aureus colonization and ...subsequent treatment of colonized patients is one proposed method to identify at-risk patients and decrease surgical site infections (SSI). The purpose of this study was to determine if a preoperative Staphylococcus screening and treatment program would decrease the incidence of SSI in elective joint replacement patients. Methods Since January 2009, 9690 patients having an elective joint replacement were screened prior to surgery for Methicillin resistant Staphylococcus aureus (MRSA) and Methicillin sensitive Staphylococcus aureus (MSSA) with nares swabs. All patients with positive nare colonization for MSSA and MRSA were treated with mupirocin and chlorhexidine gluconate (CHG) showers for 5 days prior to surgery. MRSA patients received Vancomycin preoperatively and were placed in contact isolation. All elective arthroplasty patients used CHG antiseptic cloths the evening prior and the day of surgery. Perioperative infection rates were compared from one year prior to implementation to five years post-implementation of this screening protocol. Results SSI rates have decreased from 1.11% (pre-screening) to 0.34% (nasal screening) (p<0.05) following initiation of the process. Staphylococcus was identified in 66.7% of the SSI infections prior to nasal screening and in 33.3% of the SSI after routine screening (p>0.05). Conclusion The addition of MRSA/MSSA nares screening along with a perioperative decolonization protocol have resulted in a decreased SSI rate by 69 %.
Multimodal pain protocols have been proposed to achieve improved long-acting postoperative analgesia. Controlling postoperative pain after joint arthroplasty is especially important as it relates to ...patient satisfaction and outcomes. The purpose of this study was to compare the postoperative pain, time to ambulation, and overall narcotic usage between patients who received either a femoral nerve block with a periarticular bupivacaine injection or a periarticular bupivacaine and extended-release liposomal bupivacaine injection after primary total knee arthroplasty.
A total of 597 consecutive primary total knee arthroplasties performed between September 1, 2012 and August 31, 2014 received preoperative celecoxib, oxycodone, and transdermal scopolamine. Intraoperatively, patients either received a single-dose bupivacaine femoral nerve block along with 30-mL 0.25% bupivacaine periarticular injection (group A) or a 60-mL periarticular injection alone (20-mL liposomal bupivacaine, 30-mL 0.25% bupivacaine, and 10-mL saline; group B). The postoperative pain scores, narcotic usage, and time to ambulation were retrospectively collected from the electronic medical record. These outcomes were compared between treatment groups.
There were 325 patients in group A compared with 272 in group B during the time frame. There was no difference among age, gender, race, and body mass index between the groups. Group B demonstrated a decreased need for breakthrough pain medication (16.9% vs 36.3% P < .001), decreased pain 12 hours postoperatively (3.2 vs 3.6 P < .003), and an earlier time to ambulation (29.5 hours vs 32.2 hours, P < .017). There was no difference in hospital length of stay (2.8 vs 2.6 days, P = .123). On controlling for demographic factors, patients in group B were able to ambulate 2.3 hours earlier than those in group A (coefficient = −2.3, P = .049).
Liposomal bupivacaine resulted in a decrease need for breakthrough pain medication, improved pain scores at 12 hours, and an earlier time to ambulation compared to a combined femoral nerve block and periarticular bupivacaine injection.
Abstract Background The purpose of this study was to evaluate the performance of dual mobility articulations in patients at high risk for dislocation following revision THA. Methods We reviewed the ...results of 36 consecutive revision THAs performed on patients considered high risk for instability. Indications for inclusion included abductor insufficiency, recurrent instability, failure of constrained liner, or inadequate intra-operative stability when trialing. Results At a minimum of two years, there were four (11.1%) repeat revisions including both dual mobility liners that were cemented into an acetabular shell and two for deep infection treated with a two-stage exchange. There was one dislocation that was successfully closed reduced but no revisions for recurrent instability. The mean HHS improved from 45 to 90 points (p<0.001). Conclusion Dual mobility articulations are associated with a low rate of failure with no revisions for instability in this challenging group of patients.
The duration of hospitalization and subsequent length of recovery after elective knee arthroplasty have decreased. We hypothesized same-day discharge following either a unicompartmental (UKA) or ...total knee arthroplasty (TKA) in an unselected group of patients would not result in a higher perioperative complication rate than standard-length hospitalization when following a comprehensive perioperative clinical pathway, including preoperative teaching, regional anesthesia, preemptive oral analgesia, preemptive antiemetics, and a rapid rehabilitation protocol. We prospectively followed 111 of all 121 patients who had primary knee arthroplasty completed by noon and who agreed to be followed prospectively; 25 had UKA and 86 TKA. Of the 111 patients, 104 (94%, 24 with UKA and 80 with TKA) met discharge criteria and were discharged directly to home the day of surgery. Nausea requiring additional treatment before discharge was the most common reason for a delay in discharge. There were four (3.6%) readmissions (all with TKA) and one emergency room visit without readmission (in a patient with a TKA) within the first week after surgery, while there were four subsequent readmissions (3.6%) and one additional emergency room visit without readmission within three months of surgery, all among patients undergoing TKA. There were no deaths, cardiac events, or pulmonary complications during this study. Outpatient knee arthroplasty surgery is feasible in a large percentage of patients yet early readmissions may be decreased with a prolonged hospitalization.
Level of Evidence:
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Background
Initial reports with short-term followup of porous tantalum acetabular components and augments for Paprosky IIIA acetabular defects demonstrate high hip scores, low rates of aseptic ...loosening, and low rates of complications. However, longer-term followup with a larger cohort is needed to determine the durability of these reconstructions.
Questions/purposes
We therefore determined the functional scores, rates of aseptic loosening, and complications in patients with Paprosky IIIA acetabular defects treated with porous tantalum acetabular components and augments.
Methods
We retrospectively reviewed 37 acetabular revisions in 36 patients (one patient with bilateral revisions) treated with a porous tantalum acetabular component and augment. All patients had defects classified as Type IIIa using the system of Paprosky et al. Harris hip scores were obtained and radiographic examination was performed before surgery and through most recent followup. The minimum followup was 26 months (mean, 60 months; range, 26–106 months).
Results
One patient developed aseptic loosening of the acetabular reconstruction requiring revision; seven other patients required further surgery for periprosthetic femoral fracture (two), acute infection (three), and recurrent dislocation (two). Thirty-five of 37 hips had no or occasional pain at final followup. Mean Harris hip scores improved from 33.0 preoperatively (range, 12.6–58.7) to 81.5 postoperatively (range, 27.0–99.8).
Conclusions
Although the complication rate requiring further surgery was considerable, most patients with these reconstructions had pain relief and reasonable function with low rates of loosening at midterm followup.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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