David Brigati

Surgical hip dislocation through a direct lateral approach: A cadaveric study of vascular danger zones

OBJECTIVE There is limited information on the potential danger to the vascularity of the femoral head during surgical dislocation of the hip using the direct lateral approach. The objective of this study was to investigate the topographical anatomy of the medial femoral circumflex artery (MFCA), the primary source of blood supply to the femoral head, in relationship to the direct lateral approach. METHODS Seven unembalmed cadaver hips had dye injection into either the profunda femoris artery or the MFCA. Surgical hip dislocation was then performed through a direct lateral approach, noting the danger zones to the MFCA branches during each step of the exposure. RESULTS None of the MFCA branches were found to cross the anterior surgical field superficial to the capsule. The deep (main) branch of the MFCA pierced the inferior capsule at the level of the lesser trochanter after emerging posterior to iliopsoas tendon. Ascending branches up the medial femoral neck were identified at this level. The deep branch then coursed posteriorly terminating in a variable number of vessels ascending the posterior femoral neck. Dislocation of the femoral head did not stretch or alter the course of the deep branch of the MFCA. CONCLUSION Safe surgical hip dislocation preserving the MFCA can be performed though a direct lateral approach as long as the inferomedial portion of the anterior capsule is preserved (main branch of the MFCA pierces the capsule at this level). Extracapsular injury is possible from inadvertent dissection at the level of the lesser trochanter or aggressive retraction on the iliopsoas. The posterior capsule should be left intact and instrumentation around the posterior neck should be avoided.

Birmingham Hip Resurfacing in Patients 55 Years or Younger: Risk Factors for Poor Midterm Outcomes

BACKGROUND Birmingham hip resurfacing (BHR) is the only Food and Drug Administration-approved hip resurfacing system available in the United States and is used as an alternative to conventional total hip arthroplasty in younger patients. The purpose of this study is to report on the midterm outcomes of BHR in patients 55 years and younger, and specifically to examine the risk factors for aseptic failure, all-cause revision, and complications in this patient population. METHODS Four hundred forty-two consecutive patients with 5-year follow-up were retrospectively reviewed. Multivariate analyses were conducted to control for potential confounding factors identified by univariate analyses. RESULTS Mean follow-up was 71.68 ± 10.24 months. Among the potential risk factors, only female gender and smaller head sizes had a significant univariate relationship with aseptic revision, all-cause revision, and all-cause complications. When both risk factors were included in a multivariable logistic regression model, analyses showed both variables were closely related, with female gender a better predictor of adverse outcomes than head size (ie, small head size can be thought of as a proxy for female gender). The 5-year implant survival is 95.1% females compared to 99.0% in males. CONCLUSION Hip resurfacing with BHR has excellent survival rates in young patients with degenerative hip disease. Although this study suggests that females with small templated head sizes may not be suitable candidates for BHR, further studies are needed to better understand the underlying differences in gender.

Same-Day Bilateral Total Knee Arthroplasty Candidacy Criteria Decrease Length of Stay and Facility Discharge

Simultaneous bilateral total knee arthroplasty (SBTKA) may present a higher risk for postoperative complications than unilateral surgery. The authors retrospectively identified 561 patients who underwent SBTKA between 2013 and 2015. The cohort was stratified according to the following appropriateness of care criteria (AOCC): (1) age younger than 70 years; (2) absence of cardiac disease; (3) controlled diabetes; and (4) body mass index less than 30 kg/m2. The authors created an AOCC score, with 0 representing the most ideal candidates and 4 representing the least ideal candidates. The cohort included 140 (25%) ideal candidates with a score of 0; the cohort also included 299 (53%) non-ideal candidates with a score of 1, 105 (19%) with a score of 2, 14 (2%) with a score of 3, and 3 (1%) with a score of 4. Ideal candidates had the shortest mean length of stay at 3.6±1.2 days. Length of stay was longer for patients with an AOCC score of greater than 2 compared with those with an AOCC score of 2 or less (5.2±4.3 vs 3.8±1.6 days, P<.001). Ideal candidates were discharged to home more often than other patients (26% vs 13%, P<.001). Although there was no difference in 90-day all-cause complications between ideal and non-ideal candidates (13% vs 16%, P=.400), medical complications trended strongly (6% vs 11%, P=.086). Appropriateness of care criteria for SBTKA patients were associated with shorter length of stay, higher rates of home discharge, and a trend toward lower complication rates. Simultaneous bilateral total knee arthroplasty can offer better outcomes in a subgroup of patients appropriately selected for surgery. Physicians can use these results to counsel their patients about risks and benefits of undergoing SBTKA. [Orthopedics. 2018; 41(5):293-298.].

Prophylactic Celecoxib Administration Is Associated With Decreased Incidence and Severity of Heterotopic Ossification After Hip Resurfacing by Direct Lateral Approach in Male Patients

Heterotopic ossification is a potential complication that may have a particularly higher association with hip resurfacing. The 2 current mainstays for heterotopic ossification treatment and prophylaxis are administration of nonsteroidal anti-inflammatory drugs and radiotherapy. Recent studies have determined that celecoxib is effective in heterotopic ossification prophylaxis after total hip arthroplasty. However, considering the reportedly higher incidence and severity of heterotopic ossification in these patients, relatively few studies have evaluated its role in hip resurfacing. Therefore, the authors assessed the incidence, severity, and risk factors of heterotopic ossification in patients who had hip resurfacing and did or did not receive celecoxib. Of the 198 patients, 83 received celecoxib and 115 did not. Radiographs were examined to grade heterotopic ossification using the Brooker classification system. The rate of heterotopic ossification differed between patients who did and patients who did not receive celecoxib prophylaxis (25% vs 65%, P<.001). Celecoxib was an independent predictor of decreased heterotopic ossification (odds ratio, 0.16; 95% confidence interval, 0.08-0.35). Celecoxib administration is associated with decreased incidence and severity of heterotopic ossification after hip resurfacing performed using the direct lateral approach in male patients. [Orthopedics. 2018; 41(6):e807-e812.].

Emergency Department Visits Within Thirty Days of Discharge After Primary Total Hip Arthroplasty: A Hidden Quality Measure

BACKGROUND Thirty-day hospital readmissions following total hip arthroplasty (THA) have received increasing scrutiny by policy makers and hospitals. Emergency department (ED) visits may not necessarily result in an inpatient readmission but can be a measure of performance and can incur costs to the health system. The purpose of this study is to describe the following: (1) the frequency and subsequent disposition; (2) patient characteristics; (3) reasons; and (4) potential risk factors for ED visits that did not result in a readmission within 30 days of discharge after THA. METHODS All primary THAs performed at a large healthcare system between 2013 and 2015 were identified. Patients who received unplanned hospital services for complications within 30 days following surgery were identified and analyzed. A multiple regression analysis was utilized to identify risk factors predisposing for returning to the ED without readmission. RESULTS From a total of 6270 primary THAs, 440 patients (7%) had an unplanned return to the hospital within 30 days. Of those, 227 (3.6%) patients presented to the ED and were not readmitted. Higher percentage of African Americans was noted among patients who returned to the ED versus those who did not (20.2% vs 9.8%, P < .01). The most common medical diagnoses were nonspecific medical symptoms (24.8%) followed by minor gastrointestinal problems (10.5%). The most common surgery-related diagnoses were pain and swelling (35%), followed by wound complications (12%) and hip dislocations (7.3%). Nearly 50% of wound complications and 40% of hip dislocations were managed and discharged from the ED without a readmission. Both African Americans (odds ratio 2.28, 95% confidence interval 1.55-3.36) and home discharge (odds ratio 1.90, 95% confidence interval 1.28-2.82) were independent risk factors for return to the ED without readmission. CONCLUSION ED visits that do not result in hospital readmissions, many of which may be due to serious complications, are more frequent than inpatient readmission. This is extremely relevant to policy makers and quality metrics, especially as comprehensive and bundled payment initiatives become more prevalent.

Validation of a Novel Surgical Data Capturing System Following Total Hip Arthroplasty

BACKGROUND The OrthoMiDaS (Orthopedic Minimal Data Set) Episode of Care (OME) database was developed in an effort to advance orthopedic outcome measurements on a national scale. This study was designed to evaluate if the OME data capture system would increase the quality of data collected in the context of primary and revision total hip arthroplasty (THA) compared to conventional operative notes. METHODS This study includes data from the first 100 primary THAs and 100 revision THAs performed by 15 surgeons at a single institution from January through April 2016. Surgeons prospectively entered procedural details into OME following surgery. The OME database and operative notes were compared to evaluate completion rates and agreement. Completion rates were compared using McNemars test (with continuity correction), while agreement was analyzed using Cohens kappa (κ) and concordance correlation coefficient. RESULTS The OME database had significantly higher completion rates for 41% (39/96) of the variables. Proportion of data points that matched between the operative notes and OME data revealed that 54% (52/96) had a proportion agreement >0.90, and 79% (76/96) had a proportion agreement >0.80. In regard to measured agreement, 25% (24/96) of variables had almost perfect agreement, 29% (28/96) had substantial agreement, and 14% (13/96) had moderate agreement. Only 4% (4/96) had fair agreement, 8% (8/96) had slight agreement, and 6% (6/96) had poor agreement. CONCLUSION The OME data capture system is an efficient tool to document procedural details following THA. The system is user-friendly, comprehensive, and accurate. It has the potential to be a valuable tool for future orthopedic research.

Implementation of a Total Hip Arthroplasty Care Pathway at a High-Volume Health System: Effect on Length of Stay, Discharge Disposition, and 90-Day Complications

BACKGROUND Standardized care pathways are evidence-based algorithms for optimizing an episode of care. Despite the theoretical promise of care pathways, there is an inconsistent literature demonstrating improvements in patient care. The authors hypothesized that implementing a care pathway, across 11 hospitals, would decrease hospital length of stay (LOS), decrease postoperative complications at 90 days, and increase discharges to home. METHODS A multidisciplinary team developed an evidence-based care pathway for total hip arthroplasty (THA) perioperative care. All patients receiving THA in 2013 (pre-protocol, historical control), 2014 (transition), and 2015 (full protocol implementation) were included in the analysis. Multivariable regression assessed the relationship of the care pathway to 90-day postoperative complications, LOS, and discharge disposition. Cost savings were estimated using previously published postarthroplasty episode and per diem hospital costs. RESULTS A total of 6090 primary THAs were conducted during the study period. After adjusting for the covariates, the full protocol implementation was associated with a decrease in LOS (mean ratio, 0.747; 95% confidence interval [CI; 0.727, 0.767]) and an increase in discharges to home (odds ratio, 2.079; 95% CI [1.762, 2.456]). The full protocol implementation was not associated with a change in 90-day complications (odds ratio, 1.023; 95% CI [0.841, 1.245]). Payer-perspective-calculated theoretical cost savings, including both index admission and postdischarge costs, were

Low-Dose Aspirin Is Safe and Effective for Venous Thromboembolism Prophylaxis Following Total Knee Arthroplasty

2533 per patient. CONCLUSION The THA care pathway implementation was successful in reducing LOS and increasing discharges to home. The care pathway was not associated with a change in 90-day complications; further targeted interventions in this area are needed. Despite care standardization efforts, high-volume hospitals and surgeons had higher performance. Extrapolation of theoretical cost savings indicates that widespread THA care pathway adoption could lead to national healthcare savings of

Determining the Threshold for HbA1c as a Predictor for Adverse Outcomes After Total Joint Arthroplasty: A Multicenter, Retrospective Study

1.2 billion annually.

Total hip arthroplasty in patients 55 years or younger: Risk factors for poor midterm outcomes

BACKGROUND Aspirin is an effective prophylaxis for venous thromboembolism (VTE) after total knee arthroplasty (TKA). The optimal prophylactic aspirin dose has not been established. The study aims to compare 2 aspirin regimens with regard to the incidence of (1) symptomatic deep venous thrombosis (DVT), (2) pulmonary embolism (PE), (3) bleeding, and (4) mortality within 90 days after TKA. METHODS We retrospectively identified 5666 patients who received aspirin twice daily for 4 to 6 weeks after TKA. A total of 1327 patients received 81-mg BID and 4339 patients received 325-mg BID aspirin. Postoperative complications collected were VTEs (DVT and PE), bleeding (gastrointestinal or wound bleeding), and mortality. RESULTS The incidence of VTE was 1.5% in the 325-mg group and 0.7% in the 81-mg group (P = .02). Symptomatic DVT was 1.4% in the 325-mg aspirin compared with 0.3% for the 81-mg aspirin (P = .0009). Regression model showed no correlation between aspirin dose and VTE incidence (odds ratio [OR] = 1.03; 95% confidence interval [95% CI], 0.45-2.36; P = .94) or DVT (OR = 0.50; 95% CI, 0.16-1.55; P = .20). The incidence of PE was 0.2% in the high-aspirin group compared with 0.4% in the low-aspirin group (P = .13). Bleeding was 0.2% in the 325-mg aspirin group and 0.2% in the 81-mg aspirin group (P = .62), and 90-day mortality was similar (0.1%) between the groups (P = .56). CONCLUSION Low-dose aspirin was not inferior to high-dose aspirin for the prevention of VTE after TKA. Low-dose aspirin can be considered a safe and effective agent in the prevention of VTE after TKA.