Aditya V. Maheshwari

Outcomes of Cementless Primary THA for Osteonecrosis in HIV-Infected Patients

BACKGROUND Symptomatic osteonecrosis of the joint is a frequent debilitating complication in patients who have been infected with the human immunodeficiency virus (HIV). In earlier reports, outcomes of primary total joint arthroplasty in such patients have been poor due to early failures, high infection rates, and increased complication rates. We report on the clinical and radiographic outcomes of primary total hip arthroplasty (THA) in nonhemophilic, HIV-infected patients as compared with the outcomes in a cohort of osteonecrosis patients who did not have this disease. METHODS Thirty-four HIV-infected patients (forty-four hips) who underwent primary THA for the treatment of osteonecrosis during the period of 2001 through 2008 were compared with a control cohort of seventy patients (seventy-eight hips) who also underwent THA for the treatment of osteonecrosis but did not have HIV or other high-risk factors for revision. The patients in the HIV study group (eleven women and twenty-three men) had a mean age of forty-eight years (range, thirty-four to eighty years) and were followed for a mean of seven years (range, four to eleven years). Evaluated outcomes included implant survivorship, Harris hip score, infection rate, activity score, postoperative Short-Form 36 (SF-36) health survey score, and radiographic outcome. RESULTS Kaplan-Meier survival analysis demonstrated no significant difference in aseptic implant survivorship between the HIV and comparison cohorts at the five-year (100% vs. 98%, respectively) and ten-year (95% vs. 96.5%, respectively) follow-up times. In addition, at the time of final follow-up, the mean postoperative Harris hip scores (85 points in the HIV group vs. 87 points in the comparison group), activity scores (5.7 points in the HIV group vs. 6.1 points in the comparison group), and SF-36 physical (43 points in the HIV group versus 46 points in the comparison group) and mental component summary scores (54 points in the HIV group versus 57 points in the comparison group) were statistically similar between the two cohorts. There were two late infections in the HIV cohort as compared with none in the comparison cohort. CONCLUSIONS Our results demonstrated excellent implant survivorship, clinical and radiographic outcomes, and minimal complications at the time of midterm follow-up in the HIV-infected patient group. We believe that the outcomes associated with primary THA are improving in this patient population as a result of better medical management; however, late infections are potential complications.

Barbed sutures in total knee arthroplasty: are these safe, efficacious, and cost-effective?

The use of barbed sutures has become increasingly popular; however, their efficacy and safety continues to be debated. We review the records of 333 primary total knee arthroplasties (TKAs) to determine the difference in wound closure and total operative time between patients closed with a barbed versus standard sutures. We also evaluated complication rates and cost differences between the two groups. Overall, we saw no significant difference in either wound closure time (31 vs. 30 minutes) or total operative time (115 vs. 114 minutes). No significant differences were observed in the complication rate. Material costs were lower overall in the barbed suture group (

The Impact of Hepatitis C on Short-Term Outcomes of Total Joint Arthroplasty.

66.78 vs. 82.59). Further studies will be required to determine the role of barbed sutures in TKA.

Does HIV Infection Increase the Risk of Short-Term Adverse Outcomes Following Total Knee Arthroplasty?

BACKGROUND With recent advances in the treatment of infection with hepatitis C increasing lifespan and quality of life, the need for total joint arthroplasty in this patient population is expected to grow. Presently, there are limited and conflicting data on the perioperative outcomes of lower-extremity total joint arthroplasty among patients with hepatitis C. The purpose of our study was to assess the association between hepatitis C and perioperative outcomes of lower-extremity total joint arthroplasty. METHODS The Nationwide Inpatient Sample database was used to identify patients who underwent a total hip or knee arthroplasty in the United States from 1998 to 2010. Controls were matched in a three-to-one ratio to patients with hepatitis-C infection according to surgical procedure, age, race, sex, Deyo comorbidity score, and year of surgical procedure. Outcomes included perioperative complications (any, medical, surgical) and mean length of stay. RESULTS There were 1,700,400 total joint arthroplasties performed and recorded in the database during the study period, among which 8044 patients (0.47%) had a documented hepatitis-C infection. The frequency of hepatitis-C infection increased from 1.9 per 1000 total joint arthroplasties in 1998 to 5.9 per 1000 total joint arthroplasties in 2010 (slope = 0.47; r(2) = 0.93). Compared with matched controls, patients with hepatitis C had a 30% increased risk of any complication (95% confidence interval, 17% to 44%; p < 0.001), a 15% increased risk of a medical complication (95% confidence interval, 2% to 30%; p = 0.025), a 78% increased risk of a surgical complication (95% confidence interval, 49% to 112%; p < 0.001), and a mean length of stay that was 14% longer (95% confidence interval, 12% to 15%; p < 0.001). CONCLUSIONS Infection with hepatitis C is an infrequent but increasingly common comorbidity among patients undergoing total joint arthroplasty. Given these findings, orthopaedic surgeons should be aware of the increased risks of total joint arthroplasty in patients with hepatitis C and should discuss these risks with potential surgical candidates during a shared decision-making process.

Modes of failure of custom expandable repiphysis prostheses: a report of three cases.

Using the Nationwide Inpatient Sample, we assess the: (1) demographic trends; (2) complications; and (3) length of hospital stay among total knee arthroplasty (TKA) patients with and without human immunodeficiency virus (HIV). The study population consisted of 2772 patients with HIV and 5,672,314 controls. Patients with HIV were more likely to be younger, male, and nonwhite. Patients with HIV were at an increased risk for perioperative wound infections (OR=2.78; P=0.024), although they were not at an increased risk for overall complications (OR=1.21; P=0.321). Mean length of stay was 17% longer for patients with HIV (P<0.001). Given these findings, orthopedic surgeons should have a low threshold to work up a patient with HIV for a wound infection following TKA.

Fracture of the Outer Metallic Head of the Bipolar Hip Prosthesis: An Unusual Bearing Surface Failure

Limb preservation surgery for patients with sarcomas of the extremity is recognized as a valid, safe, and effective means of treating local disease1. However, one of the major dilemmas in lower limb preservation in skeletally immature children is the ability to maintain leg-length equality as the child ages and grows. Many prosthetic designs that allow expansion of the internal prosthesis and consequent limb-lengthening, either noninvasively or through a minor surgical procedure, have evolved2,3. One of the latest of the noninvasive expandable implants is the Repiphysis expandable limb salvage system (Wright Medical Technology, Arlington, Tennessee), originally called the Phenix prosthesis (Phenix Medical, Paris, France)4,5. Although used in Europe since the early 1990s, the first Phenix prosthesis was implanted in the United States in 1998, and in 2002, the device became approved by the Food and Drug Administration. While this system offers many advantages over earlier expandable limb salvage implants, we observed three failures among sixteen Repiphysis prostheses implanted (in fourteen patients) between 2003 and 2010 by the senior author (R.M.H.). The patients and their parents were informed that the data concerning these cases would be submitted for publication, and they consented. Case 1. An eight-year-old girl was diagnosed as having stage-IIB osteosarcoma, according to the Musculoskeletal Tumor Society (MSTS) system developed by Enneking et al.6, in the distal end of the left femur. A wide local resection was done at another institution with limb reconstruction with use of a Lewis Expandable Adjustable Prosthesis (LEAP, Wright Medical Technology) with an expansion capacity of 2.5 cm. Two years later, she presented to us with a fixed knee flexion deformity of 80° and an inability to bear weight on that leg because of the deformity and limb-length discrepancy. Following serial casting to …

Extensile posterior approach to the ankle with detachment of the achilles tendon for oncologic indications.

Fracture of the bearing surface is an infrequent cause of failure of a hip arthroplasty. Although well documented with ceramic heads, fracture of the metallic head is much rarer. We report a case of a fracture of the outer metallic head of a modular cemented bipolar hemiarthroplasty 2 years after the index procedure. Over time, the outer head lost its intended motion and assumed a vertical position. We hypothesized that this position caused asymmetrical loading with stress concentration at the poles, compounded by repeated impingement between the skirted inner cobalt-chromium (Cr-Co) head and the outer stainless steel head of this particular prosthesis. These were supported by the finite element studies. In addition, scanning electron microscopy and energy dispersive x-ray studies showed metallurgical defects that seemed to have initiated and/or accelerated the fracture. Although rare, this mode of failure calls for increased awareness, periodic follow-up, and quality control.

Down Syndrome Increases the Risk of Short-Term Complications After Total Hip Arthroplasty.

Background: We describe an extensile posterior approach to the ankle with detachment of the Achilles tendon for resection of extensive tumors involving the posterior ankle. To the best of our knowledge, this approach and its results have not been reported for oncologic indications. Methods: The surgical technique involved detachment of the Achilles tendon, tumor resection and reconstruction of the Achilles tendon with anchor sutures, and was used in six patients. The diagnosis was pigmented villonodular synovitis (5) and chondroblastoma (1). Results: At a mean of 6 (range, 2 to 10) years followup, all patients were free from tumor. All patients could walk an unlimited amount without any support. There were no problems with Achilles incompetence. The mean Musculoskeletal Tumor Society score was 97 ± 4.2% (range, 90 to 100) and the mean Achilles Tendon Total Rupture Score was 95 ± 5.7 (range, 87 to 100). One patient with screwed suture anchors had backing out of two anchors along with deep infection, requiring surgical debridement and anchor removal. One other patient had a post-traumatic small wound dehiscence which responded to local wound care. Conclusion: Excellent exposure, tumor control and patient function were achieved by this approach in a select group of patients. The surgical technique described in this report offers another alternative for an extensile posterior approach to the ankle and/or subtalar joints. Level of Evidence: IV, Retrospective Case Series

Total Joint Arthroplasty in Nonagenarians: What Are the Risks?

BACKGROUND Down syndrome is the most common chromosomal abnormality and is associated with degenerative hip disease. Because of the recent increase in life expectancy for patients with this syndrome, orthopaedic surgeons are likely to see an increasing number of these patients who are candidates for total hip arthroplasty (THA). METHODS Using Nationwide Inpatient Sample (NIS) data from 1998 to 2010, we compared the short-term adverse outcomes of THA among 241 patients with Down syndrome and a matched 723-patient cohort. Specifically, we assessed: (1) incidence of THA; (2) perioperative medical and surgical complications during the primary hospitalization; (3) length of stay; and (4) hospital charges. RESULTS The annual mean number of patients with Down syndrome undergoing THA was 19. Compared to matched controls, Down syndrome patients had an increased risk of perioperative (OR, 4.33; P<.001), medical (OR, 4.59; P<.001) and surgical (OR, 3.51; P<.001) complications during the primary hospitalization. Down syndrome patients had significantly higher incidence rates of pneumonia (P=.001), urinary tract infection (P<.001), and wound hemorrhage (P=.027). The mean lengths of stay for Down syndrome patients were 26% longer (P<.001), but there were no differences in hospital charges (P=.599). CONCLUSION During the initial evaluation and pre-operative consultation for a patient with Down syndrome who is a candidate for THA, orthopaedic surgeons should educate the patient, family and their clinical decision makers about the increased risk of medical complications (pneumonia and urinary tract infections), surgical complications (wound hemorrhage), and lengths of stay compared to the general population.

Giant Cell Tumor of the Pes Anserine Bursa (Extra-Articular Pigmented Villonodular Bursitis): A Case Report and Review of the Literature

With recent increases in life expectancy in the United States, the number of nonagenarians (age 90-99 years) presenting for lower extremity joint arthroplasty (TJA) will likely rise. Utilizing the National Surgical Quality Improvement Program database, we compared 30-day outcomes of TJA between nonagenarians and controls (age <90 years). Nonagenarians had lower mean BMI, no difference in mean number of comorbidities, and shorter mean operation time. Compared to controls, nonagenarians had longer mean length-of-stay, higher readmission rate, and higher risk of postoperative adverse events. Given these findings, orthopaedic surgeons should be aware of the increased risks of TJA in nonagenarians, and should discuss these risks with potential surgical candidates during a shared decision-making process.