Andrew N. Fleischman

Periprosthetic fractures around the femoral stem: overcoming challenges and avoiding pitfalls.

Management of periprosthetic fractures around the femoral stem after total hip arthroplasty (THA) represents a significant challenge and optimal treatment remains controversial. The most common treatment paradigm involves treating fractures around a well-fixed stem with osteosynthesis, whereas fractures around a loose stem require revision arthroplasty and those with poor bone require augmentation with bone graft. Paradoxically, the literature reports a higher rate of failure for osteosynthesis around prostheses considered to be well-fixed. Such a high rate of poor outcomes may result not only from difficult fracture fixation and compromised biologic healing, but also from unrecognized peri-implant pathology. Therefore, proper preoperative and intraoperative evaluation is key, and a subset of patients may benefit from alternative management. We review the appropriate methods for evaluation and treatment of Vancouver type B fractures with particular emphasis on avoiding missteps that can lead to failure.

Formal Physical Therapy After Total Hip Arthroplasty Is Not Required: A Randomized Controlled Trial.

Background: The value of formal physical therapy after total hip arthroplasty is unknown. With substantial changes that have occurred in surgical and anesthesia techniques, self-directed therapy may be efficacious in restoring function to patients undergoing total hip arthroplasty. Methods: We conducted a single-center, randomized trial of 120 patients undergoing primary, unilateral total hip arthroplasty who were eligible for direct home discharge. The experimental group followed a self-directed home exercise program for 10 weeks. The control group received the standard protocol for physical therapy that included in-home visits with a physical therapist for the first 2 weeks followed by formal outpatient physical therapy for 8 weeks. Functional outcomes were measured using validated instruments including the Harris hip score (HHS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form-36 Health Survey (SF-36) preoperatively, at 1 month postoperatively, and at 6 to 12 months postoperatively. Results: Of 120 randomized patients, 108 were included in the final analysis. Ten patients (19%) were randomized to unsupervised home exercise and 20 patients (37%) were randomized to formal outpatient therapy crossed over between groups. There was no significant difference in any of the measured functional outcomes between patients receiving formal therapy (n = 54) and those participating in unsupervised home exercise (n = 54) at any time point (HHS, p = 0.82; WOMAC, p = 0.80; and SF-36 physical health, p = 0.90). Conclusions: This randomized trial suggests that unsupervised home exercise is both safe and efficacious for a majority of patients undergoing total hip arthroplasty, and formal physical therapy may not be required. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

L5/S1 Fusion Rates in Degenerative Spine Surgery: A Systematic Review Comparing ALIF, TLIF, and Axial Interbody Arthrodesis.

Study Design:Systematic review. Objective:To determine the fusion rate of an anterior lumbar interbody fusion (ALIF), transforaminal lumbar interbody fusion (TLIF), and axial arthrodesis at the lumbosacral junction in adult patients undergoing surgery for 1- and 2-level degenerative spine conditions. Summary of Background Data:An L5/S1 interbody fusion is a commonly performed procedure for pathology such as spondylolisthesis with stenosis; however, it is unclear if 1 technique leads to superior fusion rates. Materials and Methods:A systematic search of MEDLINE was conducted for literature published between January 1, 1992 and August 17, 2014. All peer-reviewed articles related to the fusion rate of L5/S1 for an ALIF, TLIF, or axial interbody fusion were included. Results:In total, 42 articles and 1507 patients were included in this systematic review. A difference in overall fusion rates was identified, with a rate of 99.2% (range, 96.4%–99.8%) for a TLIF, 97.2% (range, 91.0%–99.2%) for an ALIF, and 90.5% (range, 79.0%–97.0%) for an axial interbody fusion (P=0.005). In a paired analysis directly comparing fusion techniques, only the difference between a TLIF and an axial interbody fusion was significant. However, when only cases in which bilateral pedicle screws supported the interbody fusion, no statistical difference (P>0.05) between the 3 techniques was identified. Conclusions:The current literature available to guide the treatment of L5/S1 pathology is poor, but the available data suggest that a high fusion rate can be expected with the use of an ALIF, TLIF, or axial interbody fusion. Any technique-dependent benefit in fusion rate can be eliminated with common surgical modifications such as the use of bilateral pedicle screws.

Local Intra-wound Administration of Powdered Antibiotics in Orthopaedic Surgery

Surgical site infection (SSI) is one of the most common complications after orthopaedic surgery, leading to significant morbidity and its associated costs. Surgical guidelines strongly recommend the use of systemic antibiotic prophylaxis to reduce the risk for developing SSI. Locally administered powdered antibiotics have the potential to provide remarkably high intra-wound concentrations without risk for systemic toxicity. However, a paucity of high quality evidence in the orthopaedic literature has prevented widespread adoption of this technique. The majority of clinical studies on local intra-wound antibiotics have evaluated the use of topical powdered vancomycin in spinal surgery, though only a single prospective study currently exists. This review will discuss all the available evidence describing the effectiveness, pharmacokinetics, and potential adverse effects with the use of topical powdered antibiotics in orthopedic surgery.

Management of Hangman's Fractures: A Systematic Review.

Background: Traumatic spondylolisthesis of the axis, is a common cervical spine fracture; however, to date there is limited data available to guide the treatment of these injuries. The purpose of this review is to provide an evidence-based analysis of the literature and clinical outcomes associated with the surgical and nonsurgical management of hangmans fractures. Methods: A systematic literature search was conducted using PubMed (MEDLINE) and Scopus (EMBASE, MEDLINE, COMPENDEX) for all articles describing the treatment of hangmans fractures in 2 or more patients. Risk of nonunion, mortality, complications, and treatment failure (defined as the need for surgery in the nonsurgically managed patients and the need for revision surgery for any reason in the surgically managed patients) was compared for operative and nonoperative treatment methods using a generalized linear mixed model and odds ratio analysis. Results: Overall, 25 studies met the inclusion criteria and were included in our quantitative analysis. Bony union was the principal outcome measure used to assess successful treatment. All studies included documented fracture union and were included in statistical analyses. The overall union rate for 131 fractures treated nonsurgically was 94.14% [95% confidence interval (CI), 76.15–98.78]. The overall union rate for 417 fractures treated surgically was 99.35% (95% CI, 96.81–99.87). Chance of nonunion was lower in those patients treated surgically (odds ratio, 0.12; 95% CI, 0.02–0.71). There was not a significant difference in mortality between patients treated surgically (0.16%; 95% CI, 0.01%–2.89%) and nonsurgically (1.04%; 95% CI, 0.08%–11.4%) (odds ratio, 0.15; 95% CI, 0.01–2.11). Treatment failure was less likely in the surgical treatment group (0.12%; 95% CI, 0.01%–2.45%) than the nonsurgical treatment group (0.71%; 95% CI, 0.28%–15.75%) (odds ratio 0.07; 95% CI, 0.01–0.56). Conclusion: Hangmans fractures are common injuries, and surgical treatment leads to an increase in the rate of osteosynthesis/fusion without significantly increasing the rate of complication. Both an anterior and a posterior approach result in a high rate of fusion, and neither approach seems to be superior.

Electrochemical Substrate and Assay for Esterolytic Activity of Human White Blood Cells

The ester 4-((tosyl-l-alanyl)oxy)phenyl tosyl-l-alaninate (TAPTA) was synthesized and tested as a substrate for leukocyte esterase (LE), an enzyme produced by leukocytes (white blood cells). In the presence of LE, TAPTA released a redox-active fragment whose oxidation at an electrode provided a direct numerical measure of LE activity. The assays showed that LE recognized TAPTA as its substrate with the Michaelis constant Km and Imax equal to 0.24 mM and 0.13 mA cm-1, respectively. The esterolytic activity of leukocyte suspensions was determined by using the internally calibrated electrochemical continuous enzyme assay (ICECEA). One activity unit (U) of LE catalyzed the hydrolysis of 1.0 μmol of TAPTA per minute in a pH 7.40 phosphate buffer saline solution containing 10% dimethyl sulfoxide (DMSO) at 21 °C. The measured units were directly proportional to the number of leukocytes in the range of 0.028-4.2 U L-1 (9-690 μg L-1 LE protein). One white blood cell displayed the average esterolytic activity of 0.86 and 1.4 nU when the ultrasonic and chemical cytolysis were used, respectively. The ICECEA is an electrochemical alternative to optical assays for the determination of LE activity as an inflammatory biomarker and proxy for the presence of leukocytes.

Treatment of Axis Body Fractures: A Systematic Review

Study Design: Evidence-based systematic review. Objectives: To define the optimal treatment of fractures involving the C2 body, including those with concomitant injuries, based upon a systematic review of the literature. Summary of Background Data: Axis body fractures have customarily been treated nonoperatively, but there are some injuries that may require operative intervention. High-quality literature is sparse and there are few class I or class II studies to guide treatment decisions. Materials and Methods: A literature search was conducted using PubMed (MEDLINE), Cochrane Central Register of Controlled Trials, and Scopus (EMBASE, MEDLINE, COMPENDEX). The quality of literature was rated according to a grading tool developed by the Center for Evidence-based Medicine. Operative and nonoperative treatment of axis body fractures were compared using fracture bony union as the primary outcome measure. As risk factors for nonunion were not consistently reported, cases were analyzed individually. Results: The literature search identified 62 studies, of which 10 were case reports which were excluded from the analysis. A total of 920 patients from 52 studies were included. The overall bony union rate for all axis body fractures was 91%. Although the majority of fractures were treated nonoperatively, there has been an increasing trend toward operative intervention for Benzel type III (transverse) axis body fractures. Nearly 76% of axis body fractures were classified as type III fractures, of which 88% united successfully. Nearly all Benzel type I and type II axis body fractures were successfully treated nonoperatively. The risk factors for nonunion included: a higher degree of subluxation, fracture displacement, comminution, concurrent injuries, delay in treatment, and older age. Conclusions: High rates for fracture union are reported in the literature for axis body fractures with nonoperative treatment. High-quality prospective studies are required to develop consensus as to which C2 body fractures require operative fixation.

Stepping Toward Objective Outcomes: A Prospective Analysis of Step Count After Total Joint Arthroplasty

BACKGROUND Functional recovery monitoring after total hip arthroplasty (THA) and total knee arthroplasty (TKA) is often limited to surgeon-based assessment and patient self-reporting rather than objective measures. However, traditional outcomes may not reliably gauge return of function. The goal of this study was to evaluate and compare an objective measure of postoperative recovery, daily step-count, with patient self-reported outcomes. METHODS Prospectively, 589 patients used a mobile step-tracking application to record daily steps. Steps were recorded for 4 weeks before surgery and 12 weeks, thereafter. Patient-reported lower extremity functional scale (LEFS) scores were recorded at 1, 6, and 12 weeks, postoperatively. LEFS scores were correlated to weekly median daily steps using the Spearman rank correlation coefficient. RESULTS Preoperative median daily steps were 2682 and 1988 for patients undergoing THA and TKA, respectively. Steps for weeks 1, 6, and 12 were 214, 3,170, and 3884 after THA and 153, 1772, and 2311 after TKA, respectively. Step-count demonstrated a weakly positive correlation with LEFS scores. For week 1, the correlation was 0.27 and 0.29 for THA and TKA patients, respectively. For week 6, the correlation was 0.18 and 0.29 for THA and TKA patients, respectively. CONCLUSION Physical function improved over the first 12 weeks as measured by both steps and patient-reported assessments. Postoperative steps weakly correlated with LEFS scores, suggesting patient-reported outcomes may provide only part of the story. Incorporating objective measures may be a valuable addition to the surgeons armamentarium for monitoring patient recovery.

Managing Superficial Distal Medial Collateral Ligament Insufficiency in Primary Total Knee Arthroplasty Using Bone Staples

Superficial medial collateral ligament (MCL) injury is an occasional intraoperative complication during total knee arthroplasty (TKA) that can lead to failure. Although previous studies have recommended complex repair or conversion to a constrained implant, the authors evaluated results of superficial distal MCL reapproximation using bone staples. Records of 31 patients who underwent staple reapproximation for superficial MCL avulsion from the tibial attachment during primary TKA from 2005 to 2015 were reviewed. They were compared with 685 patients who underwent uncomplicated TKA (primary control) and 18 who underwent revision TKA for instability (secondary control). Subjective knee instability was assessed with a patient questionnaire, and other end points included revision for instability or stiffness and manipulations under anesthesia. The authors prospectively collected Knee injury and Osteoarthritis Outcome Score (KOOS) and visual analog scale satisfaction scores. The mean follow-up was 2.6 years. No patients treated with staple repair required revision for instability, whereas two patients were revised in the primary control. Subjective instability was reported in 19.2% of staple repair patients compared with 24.2 and 46.2% of patients in the primary and secondary controls. The mean KOOS for the staple group was 71.7 points, 77.3 for the primary control, and 49.3 for the secondary. KOOSs for the staple group were 5.6 points lower than the primary control, but 22.4 points higher than the secondary. Staple reapproximation is a simple and effective method for repairing the superficial distal MCL in primary TKA. The rate of instability and functional outcomes was comparable to uncomplicated primary TKA.

Venous thromboembolic prophylaxis after simultaneous bilateral total knee arthroplasty

Aims The aims of this study were to compare the efficacy of two agents, aspirin and warfarin, for the prevention of venous thromboembolism (VTE) after simultaneous bilateral total knee arthroplasty (SBTKA), and to elucidate the risk of VTE conferred by this procedure compared with unilateral TKA (UTKA). Patients and Methods A retrospective, multi‐institutional study was conducted on 18 951 patients, 3685 who underwent SBTKA and 15 266 who underwent UTKA, using aspirin or warfarin as VTE prophylaxis. Each patient was assigned an individualised baseline VTE risk score based on a system using the Nationwide Inpatient Sample. Symptomatic VTE, including pulmonary embolism (PE) and deep vein thrombosis (DVT), were identified in the first 90 days postoperatively. Statistical analyses were performed with logistic regression accounting for baseline VTE risk. Results The adjusted incidence of PE following SBTKA was 1.0% (95% confidence interval (CI) 0.86 to 1.2) with aspirin and 2.2% (95% CI 2.0 to 2.4) with warfarin. Similarly, the adjusted incidence of VTE following SBTKA was 1.6% (95% CI 1.1 to 2.3) with aspirin and 2.5% (95% CI 1.9 to 3.3) with warfarin. The risk of PE and VTE were reduced by 66% (odds ratio (OR) 0.44, 95% CI 0.25 to 0.78) and 38% (OR 0.62, 95% CI 0.38 to 1.0), respectively, using aspirin. In addition, the risk of PE was 204% higher for patients undergoing SBTKA relative to those undergoing UTKA. For each ten‐point increase in baseline VTE risk, the risk of PE increased by 25.5% for patients undergoing SBTKA compared with 10.5% for those undergoing UTKA. Patients with a history of myocardial infarction or peripheral vascular disease had the greatest increase in risk from undergoing SBTKA instead of UTKA. Conclusion Aspirin is more effective than warfarin for the prevention of VTE following SBTKA, and serves as the more appropriate agent for VTE prophylaxis for patients in all risk categories. Furthermore, patients undergoing SBTKA are at a substantially increased risk of VTE, even more so for those with significant underlying risk factors. Patients should be informed about the risks associated with undergoing SBTKA.