William T. Long

Early pain relief and function after posterior minimally invasive and conventional total hip arthroplasty. A prospective, randomized, blinded study.

BACKGROUND Few prospective randomized studies have demonstrated benefits of minimally invasive total hip arthroplasty when compared with conventional total hip arthroplasty. We hypothesized that patients treated with a posterior mini-incision would have better results than those treated with a posterior long incision with regard to the achievement of established goals for pain relief and functional recovery permitting hospital discharge by the second postoperative day. METHODS Sixty of 231 eligible patients were randomized (with thirty in each group) to have a total hip arthroplasty performed through either a posterior mini-incision (10 +/- 2 cm) or a traditional long incision (20 +/- 2 cm). After completion of the total hip arthroplasty, the mini-incision group underwent extension of the skin incision to 20 cm. Patients were evaluated on the basis of self-determined pain scores, requirements for pain medicine, need for assistive gait devices, and time until discharge. Gait analysis provided objective functional assessment. RESULTS The average hospital stay was 63.2 +/- 13.3 hours in the mini-incision group and 73.6 +/- 23.5 hours in the long-incision group (p = 0.04). More patients with a mini-incision were discharged by the second postoperative day (p = 0.003) and more were using just a single assistive device at the time of discharge (p = 0.005). As scored on a verbal analog scale of 0 to 10 points, patients with a mini-incision had less pain on each postoperative day and the pain score remained significantly lower at the time of discharge (mean, 2.2 +/- 1.0 points compared with 3.1 +/- 0.9 points in the long-incision group; p = 0.002). After hospital discharge, there were no clinical differences in pain or function between the two groups of patients. CONCLUSIONS Compared with conventional total hip arthroplasty performed through a posterior incision, posterior minimally invasive total hip arthroplasty resulted in better early pain control, earlier discharge to home, and less use of assistive devices. Subsequent evaluations at six weeks and three months showed equivalency between the clinical results in the two groups. LEVEL OF EVIDENCE Therapeutic Level I.

Functional recovery of noncemented total hip arthroplasty

Eighteen patients with unilateral hip disease had noncemented total hip arthroplasty. Clinical follow-up data were complete to five years postsurgery. Gait analysis was done preoperatively, at three and six months, and at one and two years. Force plate data showed continued weakness of the operated hip in all patients at two years post-surgery. Preoperative dynamic electromyograms (EMGs) were abnormal in eight patients and showed two patterns. Stance loss seen in three patients was characterized by absence of activity of the gluteus medius and upper and lower gluteus maximus muscles. In five patients, continuous activity occurred in the tensor fascia lata, rectus femoris, and adductor longus muscles during the entire gait cycle. Postoperatively, all abnormal EMGs returned to normal. Four patients with a normal preoperative EMG developed abnormal EMG patterns postoperatively, demonstrating either a prolonged stance or stance loss pattern. AH four of these hips have been revised. Although gait characteristics return to normal by two years post-surgery, weakness of the hip persists. This weakness jeopardizes the implant fixation interface. This study supports the prohibition of activities that cause high impact loading of total hip arthroplasties and suggests that a prolonged exercise program be employed postoperatively.

Multimodal Thromboprophylaxis for Total Hip and Knee Arthroplasty Based on Risk Assessment

BACKGROUND Orthopaedic surgeons are increasingly challenged to find a prophylaxis regimen that protects patients from thromboembolism while minimizing adverse clinical outcomes such as bleeding. We used a multimodal approach in which the treatment regimen is selected according to patient risk factors. METHODS We retrospectively reviewed the records on 1179 consecutive total joint arthroplasties in 970 patients who had undergone primary and revision total hip and total knee replacement. Preoperatively, patients were assigned to one of two deep venous thrombosis prophylactic regimens on the basis of an assessment of their risk factors. Eight hundred and fifty-six patients (1046 operations) were considered to be low risk and were managed with aspirin, dipyridamole, or clopidogrel bisulfate as well as intermittent pneumatic calf compression devices. One hundred and fourteen patients (133 operations) were considered to be high risk and were managed with low-molecular-weight heparin or warfarin and intermittent calf compression. All patients were mobilized from bed within twenty-four hours after surgery, and all underwent Doppler ultrasonography within the twenty-four hours before hospital discharge. All of the patients were followed for six months postoperatively. The prevalence of asymptomatic and symptomatic distal and proximal deep venous thrombosis, symptomatic and fatal pulmonary emboli, overall mortality, and bleeding complications was determined. Thrombotic events were expressed as a percentage of 1179 operations because some patients had two or more operations. RESULTS Overall, there were no fatal pulmonary emboli, three symptomatic pulmonary emboli (prevalence, 0.25%), and five clinically symptomatic deep venous thrombi (0.4%). Sixty-one asymptomatic deep venous thrombi (5.2%) were found with use of routine postoperative Doppler ultrasound scans. There were three deaths (prevalence, 0.25%) that were unrelated to thromboembolism, and there were two nonfatal gastrointestinal bleeding events (prevalence, 0.17%). Wound hematomas occurred in association with five (0.4%) of the 1179 operations. Three nonfatal pulmonary emboli (prevalence, 0.3%) were detected in association with the 1046 procedures in the low-risk group, and none were detected in association with the 133 operations in the high-risk group (p = 0.767). Clinically symptomatic deep venous thrombosis was detected in association with four (0.38%) of the 1046 operations in the low-risk group and one (0.75%) of the 133 operations in the high-risk group (p = 0.93). Asymptomatic distal deep venous thrombosis was detected in association with thirty-seven (3.5%) of the 1046 procedures in the low-risk group and four (3.0%) of the 133 operations in the high-risk group. Asymptomatic proximal thrombosis was detected in association with fourteen (1.3%) of the 1046 procedures in the low-risk group and six (4.5%) of the 133 procedures in the high-risk group (p = 0.03). Wound hematomas occurred only in patients being managed with warfarin or low-modular-weight heparin (p = 0.0001). CONCLUSIONS A multimodal thromboembolic prophylactic regimen is consistent with protecting patients while limiting adverse clinical outcomes secondary to thromboembolic, vascular, and bleeding complications.

Outpatient Total Hip Arthroplasty

Patients younger than 65 years were studied to determine what percentage of patients would enroll in a study of outpatient total hip arthroplasty, its safety, and benefits of the program. Of 192 eligible patients, 69 (36%) enrolled, and 53 (77%) of these went home the same day of surgery. Of 53, 44 maintained a diary for the first 3, weeks and 52 completed a satisfaction questionnaire at 6 weeks. Patients were followed for 6 months for occurrence of complications. There were no medical readmissions. Of 52 patients who completed a 6 week questionnaire, 50 (96%) were satisfied with the decision to have outpatient total hip arthroplasty. There were no objective physical benefits identified. This study reports the distribution of acceptance and completion of same day discharge for patients with total hip arthroplasty in a metropolitan population. It confirms safety in selected patients.

Multimodal Analgesia Without Parenteral Narcotics for Total Knee Arthroplasty

Use of parenteral narcotics after total knee arthroplasty is considered by most orthopedic surgeons to be the standard of care. This study tested the hypothesis that a multimodal oral pain medication protocol could control pain and minimize complications of parenteral narcotics. Postoperative oral analgesia was augmented with either continuous epidural infusion or continuous femoral infusion using ropivacaine only. Seventy patients had total knee arthroplasty with a protocol that included preemptive oral analgesics, epidural anesthesia, pericapsular analgesic injection, and postoperative analgesia without parenteral opioids. The average daily pain score was less than 4 out of 10, nausea occurred in 15 patients (21%), emesis in 1 patient (1.4%), and there were no severe complications. This study proved the hypothesis that pain after total knee arthroplasty could be effectively managed without routine use of parenteral opioids.

The argument for the use of Metasul as an articulation surface in total hip replacement.

Metasul metal-on-metal articulations have been used for 15 years in approximately 300,000 total hip replacements. We have used Metasul articulations in three clinical studies and have shown clinical success as measured by Harris hip scores and patient self-assessment; we also have had the usual mechanical complications. The only complications have been mechanical, including two cup loosenings and 24 dislocations in a total of 582 patients (619 hips; 3.8%) who had Metasul articulations and were included in these studies. In the randomized study, the group who had Metasul articulations had no clinical results or complications different from the control ceramic-on-polyethylene group. Authors of retrieval results in the literature report low annual linear wear rates and no consequences of elevated Co ion levels. Currently, the scientific evidence of the results of using the Metasul articulation would recommend its continued use in any patient who does not have compromised renal function.

Primary Hip Arthroplasty With 28-mm Metasul Articulation

This follow-up study reports on 69 patients at mean 13 years with total hip arthroplasty using 28-mm Metasul (Zimmer, Winterthur, Switzerland) metal-on-metal articulation. These results are not transferable to large-diameter head metal-on-metal articulations. Four new revisions, 3 for disassociation of the liner and 1 for mechanical loosening of the acetabulum, occurred since the previous report of mean 7.3 years. The prevalent cause of late revision is disassociation, which suggests a high frictional torque or impingement in these articulation surfaces. No revision was done for osteolysis. Overall, of the original 127 hips, 116 (91%) were known to have maintained their original components.

Tourniquet Use During Cementation Only During Total Knee Arthroplasty: A Randomized Trial

BackgroundTotal knee arthroplasty with the use of a tourniquet during the entire operation has not been shown to improve the performance of the operation and may increase the risk of complications.Questions/purposesWe asked whether the limited use of a tourniquet for cementation only would affect (1) surgical time; (2) postoperative pain and motion of the knee; (3) blood loss; or (4) complications such as risk of nerve injuries, quadriceps dysfunction, and drainage compared with use of a tourniquet throughout the procedure.MethodsSeventy-one patients (79 knees) were randomized to either use of a tourniquet from the incision through cementation of the implants and deflated for closure (operative tourniquet group) or tourniquet use only during cementation (cementation tourniquet group). The initial study population was a minimum of 30 knees in each group as suggested for randomized studies by American Society for Testing and Materials standards; termination of the study was determined by power analysis performed after 40 knees in each group showed any statistical solution to our questions would require a minimum of 260 more cases. Patients were excluded who were considered in previous randomized studies as high risk for complications, which might be attributed to the tourniquet.ResultsThere were no differences in terms of surgical time, pain scores, pain medicine requirements, range of motion, hemoglobin change, or total blood loss. One major complication (compartmental syndrome) occurred in a patient with tourniquet inflation until closure. No other complications were attributed to the use of a tourniquet.ConclusionsWith the numbers available, our results suggest that there are no important clinical differences between patients who had a tourniquet inflated throughout the procedure compared with those who had it inflated only during cementation. Tourniquet inflation for cementation only provides the benefit of bloodless bone for fixation and may eliminate the risks associated with prolonged tourniquet use.Level of EvidenceLevel I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Impingement as a Mechanism of Dissociation of a Metasul Metal-on-Metal Liner

This case report is of a patient with disassociation of the acetabular cup liner caused by impingement. The cup inclination (39 degrees) and anteversion (24 degrees) were good as measured by computer navigation. Impingement occurred because the head-neck ratio was 2.0, and the hip length and offset were short by one head length. Successful revision without intraoperative impingement was accomplished with one size head larger (32 mm; head-neck ratio, 2.3) and one size longer to correct hip length and offset.

Grading system for gunshot injuries to the femoral diaphysis in civilians.

One hundred patients had surgical treatment for a gunshot injury to the femur at the authors’ hospital. Each injury was classified (Grade 1–3) based on clinical and radiographic signs of deep soft tissue necrosis. All patients were followed up for a minimum of 6 months (average, 18 months; range, 6 months–72 months). Grade 1 injuries are defined by small entry and exit wounds (< 2 cm) and the absence of high-energy characteristics on plain radiographs. Grade 2 gunshot injuries have small wounds (< 5 cm) and radiographic evidence of a high-energy injury. Grade 3 gunshot injuries are diagnosed by physical examination whenever necrotic muscle is present at the fracture site. Radiographs show extensive superficial and deep soft tissue disruption and segmental bone destruction. Seventy-nine patients with Grade 1 fractures had intramedullary nailing without wound exploration; all fractures united without infection. Seven patients with Grade 2 injuries had wound exploration; a necrotic cavity was discovered in five patients and three (43%) patients had deep infection develop. Fourteen patients with Grade 3 injuries had one or more debridements followed by skeletal stabilization, and seven patients (50%) had deep infection develop. Important decisions regarding wound debridement and fracture stabilization are determined by examination of the wound and radiographs, and not by determining muzzle velocity.