Matthew S. Hepinstall

Revision Arthroplasty for the Management of Stiffness After Primary TKA

BACKGROUND The aim of this study was to evaluate the results of revision surgery for the treatment of stiffness after total knee arthroplasty (TKA). METHODS An IRB-approved retrospective review was performed to identify patients who were revised due to stiffness after a primary TKA. Patients were included when at least one major component had to be revised due to stiffness after primary TKA with a minimum follow-up of 2 years. Patients with history of previous infection and those treated with isolated polyethylene exchange were excluded. RESULTS The study group involved 42 knees. Mean follow-up was 47 months (24-109 months). Mean flexion contracture improved from 9.7° (0°-35°) preoperatively to 2.3° (0°-20°) postoperatively (P < .00). Mean flexion improved from 81.5° (10°-125°) preoperatively to 94.3° (15°-140°) postoperatively (P .02). Mean range of motion improved from 72.0° preoperatively (10°-100°) to 92° (15°-140°) postoperatively (P < .00). Mean Knee Society knee scores improved from 43.9 points (15-67) preoperatively to 72.0 points (50-93) at latest follow-up and mean Knee Society Function scores improved from 48.7 (35-80) preoperatively to 70.1 points (30-90) postoperatively. Pain improved in 73% of the patients. CONCLUSION Revision surgery appears to be a reasonable option for patients presenting with pain and stiffness after TKA. However, the benefits may be modest as the outcomes still do not approach those achieved with primary TKA.

Robotic Total Hip Arthroplasty

Modern total hip replacement is typically effective and durable, but early failures do occur. Component position influences functional outcome, durability, and risk of complications. Surgical robotics provides the detail-oriented surgeon with a robust tool to optimize the accuracy and precision of total hip arthroplasty, with the potential to minimize risk of mechanical failure. This article describes efficient workflows for using surgical robotics to optimize surgical precision without increasing surgical complexity.

Indirect Decompression of the Carpal Tunnel During Basal Joint Arthroplasty of the Thumb

PURPOSE In patients having basal joint arthroplasty, rates of concomitant carpal tunnel syndrome may exceed 43%. Excision of the trapezium during basal joint arthroplasty partially releases the transverse carpal ligament. The objective of this study was to determine whether indirect release of the remaining fibers of the ligament at its insertion on the scaphoid tubercle through the same incision would adequately decompress the carpal canal. This would avoid the morbidity of a second incision. METHODS We retrospectively reviewed 10 consecutive patients treated over a 2-year period who had concurrent ligament reconstruction, tendon interposition basal joint arthroplasty of the thumb with complete trapezial resection, and indirect carpal tunnel release through a single incision. Self-reported postoperative pain relief was documented. Preoperative and postoperative evaluations of light touch sensibility, Tinels sign, Phalens test, median nerve compression test, and Weinstein Enhanced Sensory Test monofilament testing were analyzed. All patients had preoperative electrodiagnostic testing. RESULTS At mean 12 month follow-up (range, 5-35 months), numbness and paresthesias resolved in all cases: 9 patients had good or excellent pain relief and 1 reported fair pain relief despite transient postoperative reflex sympathetic dystrophy. Tinels, Phalens, and median nerve compression tests were each positive in 9 patients preoperatively and 0 patients postoperatively. Diminished light touch sensibility was present in 7 preoperatively and 1 postoperatively. WEST monofilament thresholds improved postoperatively in 8 patients. These improvements were statistically significant. One patient had postoperative nerve conduction studies performed to evaluate an ulnar nerve lesion at the elbow; the preoperative median nerve abnormalities had normalized. CONCLUSIONS Carpal tunnel syndrome can be successfully managed with indirect release of the transverse carpal ligament during basal joint arthroplasty, thus avoiding a second incision, reducing operating time, and potentially reducing the possibility of perineural adhesions, recurrent motor branch injury, palmar cutaneous nerve damage, weakness, stiffness, and pillar pain. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Closed incision negative pressure therapy decreases complications after periprosthetic fracture surgery around the hip and knee

INTRODUCTION Periprosthetic fractures (PPFXs) are becoming increasingly common following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients sustaining PPFXs face considerable perioperative morbidity, with relatively increased rates of surgical site infection. We sought to evaluate the efficacy of closed-incision negative-pressure wound therapy (ciNPT) in decreasing perioperative wound complications following lower extremity periprosthetic fracture surgery. METHODS We performed a retrospective review of 69 consecutive patients who underwent surgery to address lower extremity periprosthetic fractures around hip or knee implants performed over a 6.5-year period. The population was divided into two groups based on the surgical dressing used at the conclusion of the procedure: (1) a sterile, antimicrobial hydrofiber dressing, or (2) ciNPT. There were no baseline demographic differences between the two groups. Rates of wound complications, surgical site infection, and reoperation related to the surgical site were compared between groups. Continuous variables were analyzed using a students t-test, and categorical variables using either chi-square or fishers exact test. RESULTS Patients treated with ciNPT developed fewer wound complications (4% vs. 35%; p=0.002), fewer deep infections (0% vs. 25%; p=0.004), and underwent fewer reoperations related to the surgical site (4% vs. 25%; p=0.021) compared to patients treated with standard of care. CONCLUSIONS Our findings suggest that ciNPT may reduce wound complications, SSIs, and reoperations in patients undergoing lower extremity periprosthetic fracture surgery. This is the first study to investigate ciNPT as a treatment for periprosthetic fracture surgery, and has the potential to change the postoperative management of these patients.

Pin Site Complications Associated With Computer-Assisted Navigation in Hip and Knee Arthroplasty

BACKGROUND There has been a great increase in the use of navigation technology in joint arthroplasty. In most types of navigation-assisted surgery, several temporary navigation pins are placed in the patient. Goals of this study are (1) to identify complications and (2) risk factors associated with placement of these pins. METHODS This is a retrospective cohort study of all navigation-assisted hip and knee arthroplasty performed a single institution over a 3-year period. Records were reviewed and outcome measures were tabulated in a database. Complications included in the database were pin site infection, deep prosthetic joint infection, neurologic injury, vascular injury, and fracture through a pin site. RESULTS A total of 3136 pin sites in 839 patients were included in the study. Five pin site complications were reported with a complication rate of 0.16% per pin site and 0.60% per patient. The complications-per-procedure were slightly higher for unicondylar knee arthroplasty (0.64%) compared with patellofemoral arthroplasty (0%) and total hip arthroplasty (0.46%), but not statistically significant. There were three infections, one neuropraxia, and one suture abscess. No periprosthetic fractures through a pin site were reported. All complications were resolved with nonoperative treatment. The infections required oral antibiotics, and were associated with transcortical drilling in two cases and juxtacortical drilling in the third. CONCLUSION Pins required for navigation-assisted arthroplasty have a low complication rate. Transcortical or juxtacortical drilling may be a risk factor for pin site infection; future studies should be directed at quantifying this effect.

Management of Vancouver Type-B2 and B3 Periprosthetic Femoral Fractures: Restoring Femoral Length via Preoperative Planning and Surgical Execution Using a Cementless, Tapered, Fluted Stem

Introduction Periprosthetic femoral fractures, which are likely to increase as the population ages and total hip arthroplasty becomes more prevalent1, can be effectively managed by restoring femoral length via preoperative planning and surgical execution using a cementless, tapered, fluted stem. Indications & Contraindications Step 1 Preoperative Plan Template the contralateral, uninjured side. Step 2 Template the Fractured Side Identify the ideal COR on the injured side and template the femoral stem. Step 3 Establish Depth of Reaming Use stem templates to establish a reference point on the reamer for use intraoperatively, and identify the distance from that point to an identifiable distal landmark. Results We report on 14 (12 Vancouver type-B2 and 2 Vancouver type-B3) periprosthetic femoral fractures treated with the described method15. Pitfalls & Challenges