Ajit J. Deshmukh

Does Fluoroscopy With Anterior Hip Arthoplasty Decrease Acetabular Cup Variability Compared With a Nonguided Posterior Approach

BackgroundThe direct anterior approach for THA offers some advantages, but is associated with a significant learning curve. Some of the technical difficulties can be addressed by the use of intraoperative fluoroscopy which may improve the accuracy of acetabular component placement.Questions/purposesThe purposes of this study were to determine if (1) there is decreased variability of acetabular cup inclination and anteversion with the direct anterior approach using fluoroscopic guidance as compared with the posterior approach THA without radiographic guidance; (2) if there is a learning curve associated with achieving accuracy with the direct anterior approach THA. We also wanted (3) to assess the frequency of complications including dislocation with the anterior approach, which initially had a learning curve, and the posterior approach.MethodsThis retrospective, comparative study of 825 THAs (372 posterior THAs without fluoroscopic guidance and 453 direct anterior THAs, performed by one surgeon, focused on a radiographic analysis to determine cup inclination and anteversion on standardized pelvic radiographs using specialized software. The first 100 direct anterior THAs performed while transitioning from the posterior approach to the direct anterior approach were included in the learning curve group. During this learning curve period, the direct anterior approach was used for all patients except those with conversion of previously fixed intertrochanteric or femoral neck fractures to THAs, gluteus medius tears, and obese patients with an immobile abdominal pannus (100 of 127 THAs). Variability of the acetabular component was compared among the posterior group, learning curve group, and direct anterior group.ResultsVariances for cup inclination and anteversion were significantly lower in the direct anterior group (19 and 16 respectively, p < 0.01) as compared with the posterior group (50 and 79 respectively).Target inclination and anteversion were achieved better in the direct anterior group (98% and 97% respectively) as compared with the posterior group (86% and 77% respectively) (p < 0.01, OR for inclination = 9.1, 95% CI, 3.5 to 23.4; OR for anteversion = 8, 95% CI, 4 to 16). In the learning curve group, target anteversion achieved (91% of cases) was marginally lower than that of the direct anterior group (p = 0.03; OR = 2.9, 95% CI, 1.1 to 7.3) and target inclination (95%) was similar (p = 0.13). There was one posterior dislocation in the posterior group, two anterior dislocations in the learning curve group, and none in the direct anterior group.ConclusionsUse of fluoroscopy with the patient in the supine position during direct anterior THA enables intraoperative assessment of cup orientation resulting in decreased variability of acetabular cup anteversion. However, there is a learning curve associated with achieving this accuracy. We could not discern whether this difference was the result of the approach or the use of fluoroscopy in the direct anterior group.Level of EvidenceLevel III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Similar improvement in gait parameters following direct anterior & posterior approach total hip arthroplasty.

We compared gait parameters prior to, at 6 months and 1 year following total hip arthroplasty (THA) performed via direct anterior approach (DAA) and posterior approach (PA) by a single surgeon in 22 patients. A gait analysis system involving reflective markers, infrared cameras and a multicomponent force plate was utilized. Postoperatively, the study cohort demonstrated improvement in flexion/extension range of motion (ROM) (P = 0.001), peak flexion (P = 0.005) and extension (P = 0.002) moments with no differences between groups. Internal/external ROM improved significantly in the DAA group (P = 0.04) with no change in the PA group. THA performed via DAA and PA offers similar improvement in gait parameters with the exception of internal/external ROM which might be related to the release and repair of external rotators during PA THA.

Management of Failed Trochanteric Fracture Fixation With Cementless Modular Hip Arthroplasty Using a Distally Fixing Stem

Failure of internal fixation of intertrochanteric fractures is associated with delayed union or malunion resulting in persistent pain and diminished function. We evaluated 15 elderly patients treated with a tapered, fluted, modular, distally fixing cementless stem. At an average follow-up of 2.86 years, mean Harris hip score improved from 35.90 preoperatively to 83.01 (P < .01). Fourteen stems had stable bony on growth, and one stem was loose. Distal fixation with a tapered, fluted, modular cementless stem allows stable fixation with good functional outcome in a reproducible fashion in this challenging cohort of patients.

Accuracy of Diagnostic Injection in Differentiating Source of Atypical Hip Pain

It is not uncommon to encounter patients with atypical hip or lower extremity pain, ill-defined clinicoradiological features, and concomitant hip and lumbar spine arthritis. The purpose of this study is to present our experience using the response resulting from a combined anesthetic-steroid hip injection for treatment selection in these patients. A retrospective analysis of 204 consecutive diagnostic hip injections was undertaken. Patient charts were scrutinized for outcomes of injection and treatment. Our findings suggest that the relief of symptoms following injection of local anesthetic and steroid into the hip joint has a sensitivity of 91.5%, specificity and positive predictive value of 100%, and negative predictive value of 84.6% for response to total hip arthroplasty. We thereby believe that this is a reliable test with low morbidity and can predict the potential benefit of total hip arthroplasty in this diagnostically challenging group of patients.

Patterns of Osseointegration and Remodeling in Femoral Revision With Bone Loss Using Modular, Tapered, Fluted, Titanium Stems

Radiographic signs of osseointegration with the use of fluted, tapered, modular, titanium stems in revision hip arthroplasty with bone loss have not been previously categorized. Serial radiographs of 64 consecutive hips with mean follow-up of 6.2 years were retrospectively reviewed. Bone loss was classified as per Paprosky classification, osseointegration was assessed according to a modified system of Engh et al, and Harris Hip Score was used to document pain and function. Seventy-four percent of the hips had type 3 or 4 bone loss. All stems were radiographically osseointegrated. Early minor subsidence was seen in 6.2% of the hips; definite bony regeneration, 73% of the hips; and stress shielding, 26% of the hips. These osseointegration patterns were different from those described for extensively porous-coated cobalt-chromium stems and had a bearing on the evaluation of fixation of these stems.

Reducing Blood Loss in Bilateral Total Knee Arthroplasty with Patient-Specific Instrumentation

Patient-specific instrumentation (PSI) in total knee arthroplasty (TKA) has been introduced to obtain consistent alignment, prevent instrumentation of the medullary canal and improve operating room efficiency. This article compares simultaneous bilateral TKA performed with and without the use of PSI in terms of surgical time; blood loss and transfusion requirements; length-of-stay, early thromboembolic events and complication rates. There was a trend to reduced total blood loss (as measured by drop in hemoglobin values) and lower transfusion rate after surgery. Further research in the form of high quality randomized trials and cost-benefit analyses may help in further consolidation of these findings.

Reproducible fixation with a tapered, fluted, modular, titanium stem in revision hip arthroplasty at 8–15 years follow-up

The use of tapered, fluted, modular, distally fixing stems has increased in femoral revision surgery. The goal of this retrospective study was to assess mid-term to long-term outcomes of this implant. Seventy-one hips in 70 patients with a mean age of 69 years were followed for an average of 10 years. Preoperative HHS averaged 50 and improved to 87 postoperatively. Seventy-nine percent hips had Paprosky type 3A or more bone-loss. All stems osseointegrated distally (100%). Two hips subsided >5mm but achieved secondary stability. Sixty-eight percent hips had evidence of bony reconstitution and 21% demonstrated diaphyseal stress-shielding. One stem fractured near its modular junction and was revised with a mechanical failure rate of 1.4%. Distal fixation and clinical improvement were reproducibly achieved with this stem design.

Thromboembolic complications in arthroscopic surgery.

Venous thromboembolism (VTE) is a relatively rare complication of arthroscopic surgery but has the potential to cause significant morbidity and even mortality. VTE has been reported after shoulder and knee arthroscopy prompting controversial guidelines to be proposed. More limited studies are available regarding hip and ankle arthroscopy and 1 case of deep venous thrombosis in the contralateral leg status after hip arthroscopy exists. No reports have been published regarding VTE after elbow or wrist arthroscopy to these authors’ knowledge. In this article, a systematic review of the literature was conducted to analyze the incidence, treatment, and prevention of thromboembolic complications in arthroscopy.

A Randomized, Controlled, Prospective Study Evaluating the Effect of Patellar Eversion on Functional Outcomes in Primary Total Knee Arthroplasty

BACKGROUND Patellar mobilization technique during total knee arthroplasty has been debated, with some suggesting that lateral retraction, rather than eversion, of the patella may be beneficial. We hypothesized that patients with knees surgically exposed using patellar lateral retraction would have comparable outcomes with patients with knees surgically exposed using patellar eversion. METHODS After an a priori power analysis, 120 patients with degenerative arthrosis were prospectively enrolled and were randomized to one of two patellar exposure techniques during the primary total knee arthroplasty: lateral retraction or eversion. The primary outcome measure was one-year, dynamometer-measured quadriceps strength. The secondary outcome measures evaluated during hospital stay included the ability to straight-leg raise, visual analog scale in pain, walking distance, and length of stay. The secondary outcome measures that were evaluated preoperatively and through a one-year follow-up included the Short Form-36 Physical Component Summary and Mental Component Summary scores, range of motion, quadriceps strength, and radiographic rate of patella baja and tilt. RESULTS A mixed-model analysis of variance showed no significant differences between the two groups in the one-year outcome measures. At one year postoperatively, quadriceps strength was not different between groups (p = 0.77), and the range of motion significantly improved (p < 0.01) from preoperative values by a mean value (and standard deviation) of 6° ± 17°, with no significant difference (p = 0.60) between groups. The Short Form-36 Physical Component Summary score and Mental Component Summary score significantly improved (p < 0.01) for both study groups from preoperatively to one year postoperatively with no significantly different effects between groups (time × group, p = 0.85 for the Physical Component Summary score and p = 0.71 for the Mental Component Summary score), and the scores were not different at one year after surgery. There were no significant differences between groups in the change in frequency of the radiographic patella baja (p = 0.99) or the radiographic patellar tilt (p = 0.77) from before surgery to one year after surgery. CONCLUSIONS Lateral retraction of the patella did not lead to superior postoperative results compared with eversion of the patella during total knee arthroplasty as evaluated using our primary outcome measure of one-year, dynamometer-measured quadriceps strength or our secondary outcome measures. LEVEL OF-EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Does Tourniquet Time in Primary Total Knee Arthroplasty Influence Clinical Recovery

There are limited data on the influence of a reduced tourniquet time strategy on the clinical outcome of primary total knee arthroplasty (TKA). The aim of our study was to prospectively compare clinical recovery in two groups of patients undergoing TKA based on differences in tourniquet strategy at the same institution. Group A (40 patients) consisted of TKAs performed by a surgeon using tourniquet from incision to arthrotomy closure, and group B (40 patients) consisted of TKAs performed by another surgeon using tourniquet only during cementation. The surgical technique, implants, perioperative management, and patient demographics were similar between groups. Average tourniquet time was significantly higher in group A (71.7 minutes) as compared with group B (36.8 minutes). The maximum hemoglobin (Hb)/hematocrit (Hct) drop was statistically higher in group B (Hb drop = 3.5 ± 0.9 g/dL; Hct drop = 11 ± 3) as compared with group A (Hb drop = 2.9 ± 0.9 g/dL; Hct drop = 9 ± 2; Hb drop p = 0.01; Hct drop p = 0.002). There were no significant differences in visual analogue scale pain scores, narcotic consumption, ability to straight leg raise during hospital stay, range of motion (ROM) at discharge, as well as isometric quadriceps strength, ROM, Short Form 36 scores, Knee Society scores at 6 weeks, 3 months, and 1 year follow-up with a similar multimodal pain management protocol. Radiographic analysis revealed no differences in cement penetration around the tibial component in any zone. Four patients developed pulmonary embolism (three in group A, one in group B) and five patients underwent manipulation under anesthesia for stiffness (four in group A, one in group B). Thus, the use of a tourniquet only during cementing in TKA increases the hemoglobin drop and does not significantly influence pain or clinical recovery with available numbers, but was associated with a lower incidence of early complications. It is a learned surgical skill which significantly reduces tourniquet time and achieves a similar quality of cementing.