Lee E. Rubin

Transcutaneous, Distal Femoral, Intramedullary Attachment for Above-the-Knee Prostheses: An Endo-Exo Device

Patients with an above-the-knee amputation often experience poor socket fit, which may become more problematic with minor weight changes, sweating, and skin problems. In 1999, the first author began using a transcutaneous, press-fit distal femoral intramedullary device with the distal, external portion serving as a hard point for attachment of an above-the-knee prosthesis (Fig. 1). The implant is placed in a retrograde fashion as a first stage, and approximately six to eight weeks later this is followed by stomatization, in which the distal aspect of the implant is exposed and an extension is added for fixation of the above-the-knee prosthesis. Thirty-seven patients underwent the procedure between 1999 and December 2009. The indications for surgery were persistent difficulties with the socket of an above-the-knee prosthesis after an above-the-knee amputation; the amputations had typically followed trauma but in some cases were for surgical treatment of a malignant tumor. Fig. 1 The Endo-Exo-Femurprosthesis is a transcutaneous, press-fit distal femoral intramedullary device with the distal, external aspect serving as a hard point for attachment of an above-the-knee prosthesis. ### Source of Funding There was no external funding source for this investigation. Branemark in Sweden is credited with the idea of a percutaneous, osteointegrated prosthesis, which has been successful in dental implantation. In 1997, Branemark performed the first procedure with a transcutaneous femoral intramedullary prosthesis, which was a 12-cm screw-type device for a patient who had undergone an above-the-knee amputation1. In 1999, ESKA Implants (Lubeck, Germany) produced the Endo-Exo-Femurprosthesis, which was first implanted into the femoral canal of a young man who had lost a leg in a motorcycle accident. Since then, the device has undergone design improvements, and by late 2009 it had been implanted in thirty-seven patients in Lubeck, Germany. The device is a modular, noncemented device that fits within the medullary canal of the femur and …

Cost Benefit Analysis of Topical Tranexamic Acid in Primary Total Hip and Knee Arthroplasty

The purpose of this study was to provide a cost-benefit analysis of topical tranexamic acid (TXA) in primary total hip and knee arthroplasty patients. A retrospective cohort of 591 consecutive patients, 311 experimental and 280 control, revealed a transfusion rate reduction from 17.5% to 5.5%, increased postoperative hemoglobin, and decreased delta hemoglobin without an increase in adverse events (all P < 0.001). This led to saving

Isolated acetabular liner exchange.

83.73 per patient based on transfusion costs alone after accounting for the cost of TXA. Hospital disposition to home compared to subacute nursing facility was also significantly increased by 9.3% (P < 0.02). We conclude that topical TXA reduces transfusion rate, increases home disposition, and reduces cost in primary hip and knee arthroplasty.

Total Hip and Knee Arthroplasty in Patients Older Than Age 80 Years.

During the past two decades, most total hip arthroplasties were performed with metal or ceramic heads on conventional polyethylene, an articulation associated with wear and limited life expectancy. Wear is associated with acetabular osteolysis. Isolated liner exchange has become a common surgical intervention when the acetabular component remains well-fixed. The purpose of isolated liner exchange is to prevent loosening of the components secondary to osteolysis and catastrophic mechanical failure caused by bearing wear-through. Treatment options for polyethylene wear include observation (in the asymptomatic hip), liner exchange, and more extensive revision procedures. Patients frequently present with asymptomatic but substantial polyethylene wear with or without associated osteolysis, the treatment of which is controversial. Other areas of debate include complete acetabular component removal to allow bone grafting and placement of an improved bearing surface, reuse of modular mechanisms, cementation into well-fixed shells, and whether to use periacetabular bone grafting.

Assessment and Treatment of Malnutrition in Orthopaedic Surgery

A rapidly aging population is currently reshaping the demographic profile of the United States. Among older patients, the cohort aged >80 years is not only living longer but also is electing to undergo more total hip and knee arthroplasties. To improve perioperative safety, orthopaedic surgeons should understand the risks and clinical outcomes of arthroplasty in patients of advanced age. Although morbidity and mortality rates are higher for patients aged >80 years than for younger patients undergoing total hip and knee arthroplasties and revision surgeries, functional outcomes, pain relief, and patient satisfaction are consistent between groups. In addition, geriatric co-management before total hip and total knee arthroplasty has reduced the rate of minor complications and the length of hospital stays in elderly patients. Surgeons should inform older patients and their families of the increased risks of morbidity and mortality before these procedures are undertaken.

Early Catastrophic Failure of Trochanteric Fixation with the Dall-Miles Cable Grip System

Malnutrition in orthopaedic patients, a condition that is overlooked and understudied, has substantial effects on outcomes1-6. Underweight and malnourished elderly patients are at risk of experiencing reduced well-being and autonomy as well as increased mortality as compared with their counterparts of normal weight7. Malnutrition may be simply defined as an imbalance of energy, protein, and nutrients leading to functional and compositional adverse effects on the body8,9. By this definition, as much as 15% of ambulatory and 65% of hospitalized patients are malnourished10. Without adequate nutrition, orthopaedic patients are more susceptible to infections, slower healing rates, and sarcopenia (reduced lean body mass and muscle function)8. Stratifying malnutrition on the basis of etiology (e.g., “starvation-related,” “chronic disease-related,” and “acute injury or illness-related”) facilitates the formation of a more clinically relevant definition11. In starvation, the primary problem is reduced intake, possibly due to socioeconomic factors or secondary to anorexia6. With chronic disease and acute injury, increases in resting energy expenditure and protein requirements due to the inflammatory response contribute to malnourishment7. The new etiology-based approach to the diagnosis of malnutrition …

Paralytic ileus in the orthopaedic patient.

Multi-filament orthopaedic cerclage cables have been used in clinical practice for several decades, and are commonly utilized to provide greater trochanteric fixation following an osteotomy or fracture. We present the first known report of patients who experienced early catastrophic failure following use of the Dall-Miles Cable Grip System (DMCGS). A root cause analysis determined that the jaws of one crimper had an increased distance at closure, resulting in inadequate ultimate fixation strength. It was discovered that operating room staff had not been trained to perform regular calibration checks and the required calibration tool was not included in any of the institutions DMCGS sets. Surgeons should be aware that these surgical instruments require regular maintenance and should be gauge tested prior to every use.

Revision Total Knee Arthroplasty in Octogenarians: An Analysis of 957 Cases

Paralytic ileus is marked by the cessation of bowel motility. This condition is a major clinical concern that may lead to severe patient morbidity in orthopaedic surgery and trauma patients. Ileus most commonly occurs following spinal surgery, traumatic injury, or lower extremity joint reconstruction, but it may also occur following minor orthopaedic procedures. Possible consequences of ileus include abdominal pain, malnutrition, prolonged hospital stay, hospital readmission, bowel perforation, and death. Therapies used in the treatment of ileus include minimization of opioids, early patient mobilization, pharmacologic intervention, and multidisciplinary care. Orthopaedic surgeons should be aware of the clinical signs and symptoms of paralytic ileus and should understand treatment principles of this relatively common adverse event.

Hip Resection Arthroplasty

BACKGROUND The number of octogenarians undergoing revision total knee arthroplasty (TKA) is increasing. However, there has been a lack of studies investigating the perioperative course and safety of revision TKA performed in this potentially vulnerable population in a large patient population. The purpose of this study is to compare complications following revision TKA between octogenarians and 2 younger patient populations (<70 and 70-79 year olds). METHODS Patients who underwent revision TKA were identified in the 2005-2015 National Surgical Quality Improvement Program database and stratified into 3 age groups: <70, 70-79, and ≥80 years. Baseline preoperative and intraoperative characteristics were compared between the 3 groups. Propensity score matched comparisons were then performed for 30-day perioperative complications, length of hospital stay, and readmissions. RESULTS This study included 6523 (<70 years), 2509 (70-79 years), and 957 octogenarian patients who underwent revision TKA. After propensity matching, statistical analysis revealed only higher rates of blood transfusion and slightly longer length of stay in octogenarians compared to <70 year olds. Similarly, octogenarians had only higher rates of blood transfusion and slightly longer length of stay compared to 70-79 year olds. Notably, there were no differences in mortality or readmission between octogenarians compared to younger populations. CONCLUSION These data suggest that revision TKA can safely be considered for octogenarians with the observation of higher rates of blood transfusion and slightly longer length of stay compared to younger populations. Octogenarian patients need not be discouraged from revision TKA solely based on their advanced age.

Total Joint Arthroplasty in Patients with Human Immunodeficiency Virus

Hip resection arthroplasty is an operative technique that can be a valuable tool for the treatment of complex hip disease. The relative rarity of the procedure makes prospective study of outcomes somewhat difficult. The purpose of this review was to gather, summarize, and analyze the entirety of cases and series published on the topic to date. Prior to the introduction of antibiotics in the 1940s, the treatment of extrapulmonary tuberculosis consisted of either isolation of the patient in a sanitarium or crude attempts at surgical debridement. Untreated infection led to pain, septic …