Michael D. Hellman

Blood Management Strategies for Total Knee Arthroplasty

Perioperative blood loss during total knee arthroplasty can be significant, with magnitudes typically ranging from 300 mL to 1 L, with occasional reports of up to 2 L. The resultant anemia can lead to severe complications, such as higher rates of postoperative infection, slower physical recovery, increased length of hospital stay, and increased morbidity and mortality. Although blood transfusions are now screened to a greater extent than in the past, they still carry the inherent risks of clerical error, infection, and immunologic reactions, all of which drive the need to develop alternative blood management strategies. Thorough patient evaluation is essential to individualize care through dedicated blood management and conservation pathways in order to maximize efficacy and avoid associated complications. Interventions may be implemented preoperatively, intraoperatively, and postoperatively.

Does Resident Involvement Impact Post-Operative Complications Following Primary Total Knee Arthroplasty? An Analysis of 24,529 Cases

Little is known about the impact of resident involvement on complication rates following total knee arthroplasty (TKA). The goal of our study was to determine the impact of resident involvement on complications following primary TKA. Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2005-2012) we identified 24,529 patients who underwent primary TKA. Of these, 5960 (24.3%) had a resident involved in a primary TKA. Using a multivariate logistic regression which incorporated propensity score adjustment, no differences were seen in morbidity and mortality following those cases with resident involvement (OR: 1.15, P = 0.129). In the first large scale, comprehensive analysis of resident impact on short-term morbidity and mortality, no increase in complications was observed with resident involvement in primary TKA.

Resident Involvement Does Not Influence Complication After Total Hip Arthroplasty: An Analysis of 13,109 Cases

Our study aimed to determine the impact of resident involvement on the 30-day postoperative complication rates following primary total hip arthroplasty (THA). Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, 13,109 primary THAs were identified, of which 3462 (26.4%) had resident involvement. Neither univariate (4.45% vs 4.52%, P = 0.86) nor multivariate (OR 1.04, P = 0.75) analyses demonstrated an increased complication rate with resident involvement following THA. We did find, however, that increased operative time, comorbidities, age, obesity, prior history of stroke and/or cardiac surgery were all independent risk factors for short-term complication. Our findings suggest that resident involvement does not increase 30-day complication rates following primary THA.

Acetabular distraction: An alternative Approach to Pelvic Discontinuity in failed Total Hip Replacement

A pelvic discontinuity occurs when the superior and inferior parts of the hemi-pelvis are no longer connected, which is difficult to manage when associated with a failed total hip replacement. Chronic pelvic discontinuity is found in 0.9% to 2.1% of hip revision cases with risk factors including severe pelvic bone loss, female gender, prior pelvic radiation and rheumatoid arthritis. Common treatment options include: pelvic plating with allograft, cage reconstruction, custom triflange implants, and porous tantalum implants with modular augments. The optimal technique is dependent upon the degree of the discontinuity, the amount of available bone stock and the likelihood of achieving stable healing between the two segments. A method of treating pelvic discontinuity using porous tantalum components with a distraction technique that achieves both initial stability and subsequent long-term biological fixation is described.

Bilateral extensor mechanism disruption after total knee arthroplasty in two morbidly obese patients.

Disruption of the extensor mechanism as a result of patellar tendon or quadriceps tendon rupture is an uncommon but devastating complication after total knee arthroplasty. Treating a disrupted extensor mechanism can be challenging, particularly in patients who are morbidly obese, due to an increased risk of postoperative complications. Therefore, despite the debilitating nature of extensor mechanism disruption, many community surgeons do not feel comfortable pursuing more complex cases like revision total knee arthroplasty with extensor mechanism allograft on morbidly obese patients, and consequently many of these patients are referred to tertiary-care centers for reconstruction secondary to the complexity of this patient cohort. The authors report 2 cases of bilateral extensor mechanism disruption after total knee arthroplasty in patients who are morbidly obese. One patient experienced trauma leading to her initial rupture; however, her contralateral atraumatic disruption was subsequently diagnosed at a later date. The second patient did not experience trauma leading to either of her extensor mechanism disruptions. Despite substantial medical comorbidities and morbid obesity, revision total knee arthroplasties with extensor mechanism allografts were recommended in both cases in a staged bilateral fashion. The surgical technique is described and the unique challenges afforded by the marked obesity are detailed. The current literature on this subject is reviewed. Despite early complications related to recumbency, this report serves as an example of successful repairs of extensor mechanism disruptions in patients who are morbidly obese, suggesting that extensor mechanism allograft is viable even in patients with high risk of complications.

Arthroscopic Acetabular Microfracture With the Use of Flexible Drills: A Technique Guide.

Chondral injuries of the hip joint are often symptomatic and affect patient activity level. Several procedures are available for addressing chondral injuries, including microfracture. Microfracture is a marrow-stimulating procedure, which creates subchondral perforation in the bone, allowing pluripotent mesenchymal stem cells to migrate from the marrow into the chondral defect and form fibrocartilaginous tissue. In the knee, microfracture has been shown to relieve pain symptoms. In the hip, microfracture has been studied to a lesser extent, but published studies have shown promising clinical outcomes. The depth, joint congruity, and geometry of the hip joint make microfracture technically challenging. The most common technique uses hip-specific microfracture awls, but the trajectory of impaction is not perpendicular to the subchondral plate. Consequently, the parallel direction of impaction creates poorly defined channels. We describe an arthroscopic microfracture technique for the hip using a flexible microfracture drill. The drill and angled guides simplify access to the chondral defect. The microfracture drill creates clear osseous channels, avoiding compaction of the surrounding bone and obstruction of the channels. Furthermore, this technique allows for better control of the angle and depth of the drill holes, which enhances reproducibility and may yield improved clinical outcomes.

Effect of Anterior Acetabular Rim Recession on Radiographic Parameters: An In Vivo Study

PURPOSE The purpose of this study was to validate additional radiographic parameters that detect changes within the acetabular cavity during acetabular rim trimming for pincer-type femoroacetabular impingement in an in vivo setting. METHODS Patients who met the inclusion criteria and underwent arthroscopic acetabular rim trimming had their preoperative and postoperative anteroposterior radiographs measured. Intraoperatively, these patients had their labrums detached, acetabular walls trimmed by roughly 3 to 5 mm, and then labrums reattached. Radiographic measurements were subsequently obtained by use of the anterior rim angle (ARA), anterior wall angle (AWA), and anterior margin ratio (AMR). RESULTS Statistically significant changes were seen in the postoperative ARA, AWA, and AMR. Mean pre- and post-trimming changes were 83.8° and 87.9°, respectively, for the ARA; 38.8° and 35.8°, respectively, for the AWA; and 0.57 and 0.53, respectively, for the AMR. There were no postoperative complications. No patients had any instability events. CONCLUSIONS This study shows that significant changes in anterior acetabular anatomy can be evaluated radiographically in the in vivo setting for treatment of pincer-type femoroacetabular impingement. We saw a significant, consistent decrease in both the AWA and AMR and increase in the ARA. This research serves to guide surgeons with preoperative and intraoperative templating while providing the groundwork to investigate these radiographic parameters in an asymptomatic patient population. CLINICAL RELEVANCE These novel radiographic measurements can be used by hip arthroscopists to better characterize their surgical role in altering acetabular morphology. In addition, these measurements will be able to better describe acetabular anatomy.

Does Neuraxial Anesthesia Decrease Transfusion Rates Following Total Hip Arthroplasty

Perioperative transfusions increase complications and cost following THA. Current series evaluating neuraxial anesthesia and blood loss following THA are small and utilize heterogeneous populations. Using the NSQIP database we compared transfusion rates following THA with neuraxial and general anesthesia. Between 2005 and 2012, 28,857 THAs (11,317 neuraxial anesthesia) were identified. Univariate analysis showed lower rates of transfusion, pneumonia, unplanned intubation, prolonged intubation, stroke, all complications, and medical complications in the neuraxial group. Operative time and length of stay were shorter with neuraxial anesthesia as well. After adjusting for patient comorbidities, a multivariate regression model showed fewer transfusions with neuraxial anesthesia. The multivariate regression model showed additional independent risk factors for transfusion including gender, operative time, elevated INR, and a history of hypertension, metastatic cancer, and renal failure.

Suture anchor repair of quadriceps tendon rupture

Knee extensor mechanism rupture is an uncommon, but significant, injury. The inability to actively extend the knee precludes normal gait. Quadriceps tendon injuries usually result from a simple fall in middle-aged men.1 Although low-energy fall mechanism of injury is most common, spontaneous rupture tends to occur in a subset of medical conditions (Table).2,3 Patients with quadriceps tendon ruptures are typically older (>40 years) than those who sustain patellar tendon injuries (<40 years).4 Optimal treatment mandates early evaluation, diagnosis, and surgical treatment,5 as operative treatment of chronic ruptures and nonsurgical treatment have inferior outcomes.2,6 Operative management of quadriceps tendon rupture has traditionally used either longitudinal (superior to inferior) trans-patellar drill holes (for tendinous avulsions) or simple suture repair with or without reinforcement (for intratendinous midsubstance ruptures).2 The complication and re-rupture rates after surgical repair have been approximately 14% and 2%, respectively.2 However, recent literature has demonstrated a previously unreported complication of displaced patellar stress fracture in patients undergoing extensor mechanism reconstruction using trans-patellar drill holes.7 In addition, normal anatomic studies of the quadriceps-patella tendo-osseous junction illustrate a more superficial junction (anterior 50%) with a footprint on the superior and anterior surface.8 Recently, surgeons have used a novel “pulley technique” with suture anchors to anatomically re-create the anatomic footprint for other tendinous avulsion repairs, including proximal hamstrings.9,10 Therefore, given the drill hole stress-riser effect and reproduction of normal anatomy, the authors recommend a suture anchor-based pulley technique repair that best replicates the normal anatomic footprint and may potentially avoid the risk of patellar fracture.

Operative treatment of FAI: open hip preservation surgery

Femoroacetabular Impingement (FAI) is characterized by abnormal contact of the hip joint. Many etiologies cause this painful condition, which leads to early osteoarthritis. While hip arthroscopy has become the most prevalent way to surgically correct a hip, some presentations of FAI require open surgical hip preservation techniques to fully address the pathology at hand. Certain head neck deformities may require open surgical hip dislocation utilizing a trochanteric slide osteotomy. A retroverted acetabulum may require an open periacetabular osteotomy to gain anteversion and eliminate impingement in the hip joint. Acetabular protrusio may require surgical hip dislocation with rim trimming and a possible valgus intertrochanter osteotomy. The sequelae of Legg-Calvé-Perthes disease causes complex abnormalities about the hip joint, which may require open surgery to address both the intra-articular pathology and the extra-articular pathology. Osteotomies of the proximal femur and acetabulum may all be necessary to restore a hip back to normal morphology. Chronic slipped capital femoral epiphysis (SCFE) may also require open surgical hip dislocations and complex intertrochanter osteotomies to recreate normal morphology.