Hargovind DeWal

Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty.

BACKGROUND Prolonged wound drainage following total hip or total knee arthroplasty has been associated with an increased risk of postoperative morbidity. The purpose of this study was to determine the pharmacologic, surgical, and patient-specific factors that are associated with prolonged wound drainage and the relationship of this complication to the length of hospital stay and the rate of wound infections. METHODS We conducted a retrospective observational study of 1211 primary total hip arthroplasties and 1226 primary total knee arthroplasties. Prospectively collected data included body mass index, intraoperative blood loss, surgical time, type of prophylaxis against deep venous thrombosis, and length of hospital stay. The association of these factors with the duration of postoperative wound drainage was analyzed. An acute infection developed after fifteen primary total hip arthroplasties and ten primary total knee arthroplasties. The patients with an acute postoperative infection were compared with their uninfected counterparts, and an odds ratio was determined to estimate the risk of prolonged wound drainage resulting in a wound infection. RESULTS Morbid obesity was strongly associated with prolonged wound drainage in the total hip arthroplasty group (p = 0.001) but not in the total knee arthroplasty group (p = 0.590). An increased volume of drain output was an independent risk factor for prolonged wound drainage in both groups. Patients who received low-molecular-weight heparin for prophylaxis against deep venous thrombosis had a longer time until the postoperative wound was dry than did those treated with aspirin and mechanical foot compression or those who received Coumadin (warfarin); this difference was significant on the fifth postoperative day (p = 0.003) but not by the eighth postoperative day. Prolonged wound drainage resulted in a significantly longer hospital stay in both groups (p < 0.001). Each day of prolonged wound drainage increased the risk of wound infection by 42% following a total hip arthroplasty and by 29% following a total knee arthroplasty. CONCLUSIONS Morbid obesity, the use of low-molecular-weight heparin, and a higher drain output were associated with a prolonged time until the postoperative wound was dry following a primary total hip arthroplasty, whereas a higher drain output was the only risk factor associated with prolonged drainage following a primary total knee arthroplasty. Prolonged drainage was associated with a higher rate of infection following a primary total hip arthroplasty, whereas obesity was the only identified independent risk factor for postoperative infection following a primary total knee arthroplasty.

Periprosthetic Femoral Fractures Above Total Knee Replacements

Abstract Periprosthetic femoral fractures above total knee replacements can be managed by a variety of methods, including casting, open reduction and internal fixation, external fixation, or revision arthroplasty. Because no single method has emerged as the optimal choice for all such fractures, it is important to understand which options are appropriate for each fracture pattern. Early classification systems focused on displacement as a major indication for either surgical or nonsurgical management. However, recent techniques and current implants have made surgical management preferable for most periprosthetic fractures. Classification based on fracture location can help guide such treatment. Generally, intramedullary nails are best for proximal fractures, fixed‐angle devices for fractures originating at the component, and revision arthroplasty for very distal fractures or those with implant loosening.

Thermal energy in arthroscopic surgery of the wrist.

Thermal energy in arthroscopic surgery needs further follow-up evaluation to clarify the potential benefits, specifically with respect to thermal shrinkage. Although the initial findings are promising, the long-term results need to be compared with other accepted standards of management. Preliminary findings seem to show that the addition of these surgical instruments and expanding operative techniques have definite roles in arthroscopic wrist surgery, as demonstrated through meticulous synovectomies and precise tissue debridement, along with the possible thermal shrinkage potential.

The effect of an attachable lateral support plate on the stability of intertrochanteric fracture fixation with a sliding hip screw.

BACKGROUND Use of a sliding hip screw (SHS) alone for some unstable intertrochanteric femur fractures can allow excessive medial shaft displacement during impaction. This study evaluated the effect of an attachable lateral support plate on these fractures after loading. METHODS Unstable, three-part intertrochanteric fractures were created in 10 matched pairs of embalmed femurs that were instrumented with 135-degree SHSs with or without an attachable lateral support plate. Under physiologic loading, inferior and lateral head displacements and lag screw sliding distances were measured. RESULTS After 10,000 cycles at 750 N, all measurements for femurs with the lateral support plate were significantly less than for the femurs with the SHS alone: mean lateral difference was 1.7 mm (34%) (p < 0.05), mean inferior difference was 3.0 mm (38%) (p < 0.05), and mean lag screw sliding difference was 4.5 mm (58%) (p < 0.05). CONCLUSION The addition of an attachable lateral support plate to an SHS significantly decreased displacement of the femoral head after cyclic loading.