Primary total hip arthroplasty: Staying out of trouble intraoperatively

Total hip Arthroplasty is one of the most successful and commonly performed procedures in Orthopaedic Surgery. Meticulous preoperative planning allows to surgeon anticipate potential problems to reduce postoperative complications and optimize patient outcomes. Currently, the posterior approach is the most common approach utilized in the United States. In order to prevent errors in stem version, especially with cementless fixation, the entry point should be posterior, and the initial entry point should be aligned in the correct anteversion as this will determine the ultimate version of the stem. Preoperative evaluation should asses for true and apparent lengths. For successful osseointegration of cementless components, bone ingrowth occurs when there is less than 40 μm of motion between the implant and bone. Certain socket conformations such as elliptical versus hemispherical are more prone to generate fractures at the time of impaction

Delayed dislocation following metal-on-polyethylene hip replacement due to “silent” trunnion corrosion

AimsWe present a case series of ten metal-on-polyethylene total hip arthroplasties (MoP THAs) with delayed dislocation associated with unrecognised adverse local tissue reaction due to corrosion at the trunnion and pseudotumour formation.MethodsThe diagnosis was not suspected in nine of the ten patients (six female/four male; mean age 66 years), despite treatment in a specialist unit (mean time from index surgery to revision was 58 months, 36 to 84). It was identified at revision surgery and subsequently confirmed by histological examination of resected tissue. Pre-operative assessment and culture results ruled out infection. A variety of treatment strategies were used, including resection of the pseudotumour and efforts to avoid recurrent dislocation.ResultsThe rate of complications was high and included three deep infections, two patients with recurrent dislocation, and one recurrent pseudotumour.ConclusionThis series (mean follow-up of 76 months following index procedure and 19 months following revision THA) demonstrates that pseudotumour is an infrequent but important contributor to delayed instability following MoP THA. It is easy to overlook in the differential diagnosis, especially if the alignment of the components is less than optimal, leading to an assumption that malalignment is the cause of the dislocation. The instability is likely to be multifactorial and the revision surgery is complex. Take home message: Due to the high complication rate associated with revision in this cohort, the diagnosis should be borne in mind when counselling patients regarding the risks of revision surgery. Cite this article: Bone Joint J 2016;98-B:187–93.</jats:sec

Local Excision Without Radiation for High-Grade Soft-Tissue Sarcoma of the Extremity and Superficial Trunk

Purpose. Limb-sparing surgery combined with radiation treatment has become the accepted treatment for patients with high-grade soft-tissue sarcoma. Adjuvant radiation was not routinely used at this institution for patients with clear margins after surgery.This retrospective review analyses the outcome of this group of patients

Optimization of surgical tourniquet usage to improve patient outcomes: Translational cross-disciplinary implications of a surgical practice survey

Tourniquet use is common practice in many millions of orthopaedic procedures annually. Recent reviews of risks and benefits of surgical tourniquet use have primarily involved meta-analyses, many of which have forgone a comprehensive risk-benefit analysis to simply question whether “tourniquet or no tourniquet” use produces improved patient outcomes, often leading to limited, inconclusive, or conflicting results. To investigate further, a pilot survey was undertaken to determine current practices, opinions, and understandings among orthopaedic surgeons in Canada regarding use of surgical tourniquets in total knee arthroplasties (TKAs). Results of the pilot survey showed a wide range of understanding and practice associated with tourniquet use in TKAs, especially regarding tourniquet pressures and tourniquet times, two key factors known from basic research and clinical studies to impact the safety and efficacy of tourniquet use. The wide variation of use indicated by the survey results reveals important implications for surgeons, researchers, educators, and biomedical engineers, to better understand the association between key tourniquet parameters and outcomes assessed in research, which may be factors leading to their often limited, inconclusive, and conflicting results. Lastly, we provide an overview of the overly simplified assessments of tourniquet use in meta-analyses, whose conclusions may not provide an understanding of how or whether key tourniquet parameters might be optimized to retain the benefits of tourniquet use while mitigating the associated real or perceived risks

Refurbishment of public housing villas in the United Arab Emirates (UAE): energy and economic impact

© 2016, Springer Science+Business Media Dordrecht. This study aims at assessing the technical and economic benefits of refurbishing existing public housing villas in the UAE. Four representative federal public housing villas built between 1980s and 2010s were modeled and analyzed. The Integrated Environmental Solutions-Virtual Environment (IES-VE) energy modeling software was used to estimate the energy consumption and savings due to different refurbishment configurations applied to the villas. The refurbishment technical configurations were based on the UAE’s Estidama green buildings sustainability assessment system. The refurbishment configurations include upgrading three elements: the wall and roof insulation as well as replacing the glazing. The annual electricity savings results indicated that the most cost-efficient refurbishment strategy is upgrading of wall insulation (savings up to 20.8 %) followed by upgrading the roof’s insulation (savings up to 11.6 %) and lastly replacing the glazing (savings up to 3.2 %). When all three elements were refurbished simultaneously, savings up to 36.7 % were achieved (villa model 670). The savings translated to CO2 emission reduction of 22.6 t/year. The simple and discounted payback periods for the different configurations tested ranged between 8 and 28 and 10 and 50 years, respectively

Prognostic model to predict postoperative acute kidney injury in patients undergoing major gastrointestinal surgery based on a national prospective observational cohort study.

Background: Acute illness, existing co-morbidities and surgical stress response can all contribute to postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. The aim of this study was prospectively to develop a pragmatic prognostic model to stratify patients according to risk of developing AKI after major gastrointestinal surgery. Methods: This prospective multicentre cohort study included consecutive adults undergoing elective or emergency gastrointestinal resection, liver resection or stoma reversal in 2-week blocks over a continuous 3-month period. The primary outcome was the rate of AKI within 7 days of surgery. Bootstrap stability was used to select clinically plausible risk factors into the model. Internal model validation was carried out by bootstrap validation. Results: A total of 4544 patients were included across 173 centres in the UK and Ireland. The overall rate of AKI was 14·2 per cent (646 of 4544) and the 30-day mortality rate was 1·8 per cent (84 of 4544). Stage 1 AKI was significantly associated with 30-day mortality (unadjusted odds ratio 7·61, 95 per cent c.i. 4·49 to 12·90; P < 0·001), with increasing odds of death with each AKI stage. Six variables were selected for inclusion in the prognostic model: age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Internal validation demonstrated good model discrimination (c-statistic 0·65). Discussion: Following major gastrointestinal surgery, AKI occurred in one in seven patients. This preoperative prognostic model identified patients at high risk of postoperative AKI. Validation in an independent data set is required to ensure generalizability

One- and two-stage surgical revision of peri-prosthetic joint infection of the hip: a pooled individual participant data analysis of 44 cohort studies.

One-stage and two-stage revision strategies are the two main options for treating established chronic peri-prosthetic joint infection (PJI) of the hip; however, there is uncertainty regarding which is the best treatment option. We aimed to compare the risk of re-infection between the two revision strategies using pooled individual participant data (IPD). Observational cohort studies with PJI of the hip treated exclusively by one- or two-stage revision and reporting re-infection outcomes were retrieved by searching MEDLINE, EMBASE, Web of Science, The Cochrane Library, and the WHO International Clinical Trials Registry Platform; as well as email contact with investigators. We analysed IPD of 1856 participants with PJI of the hip from 44 cohorts across four continents. The primary outcome was re-infection (recurrence of infection by the same organism(s) and/or re-infection with a new organism(s)). Hazard ratios (HRs) for re-infection were calculated using Cox proportional frailty hazards models. After a median follow-up of 3.7 years, 222 re-infections were recorded. Re-infection rates per 1000 person-years of follow-up were 16.8 (95% CI 13.6-20.7) and 32.3 (95% CI 27.3-38.3) for one-stage and two-stage strategies respectively. The age- and sex-adjusted HR of re-infection for two-stage revision was 1.70 (0.58-5.00) when compared with one-stage revision. The association remained consistently absent after further adjustment for potential confounders. The HRs did not vary importantly in clinically relevant subgroups. Analysis of pooled individual patient data suggest that a one-stage revision strategy may be as effective as a two-stage revision strategy in treating PJI of the hip

Establishing a hospital based fracture liaison service to prevent secondary insufficiency fractures

In the aging population worldwide, osteoporosis is a relatively common condition and a major cause of long-term morbidity. Initial fragility fractures can lead to subsequent fractures. After a vertebral fracture, the risk of any another fracture increases 200% and that of a subsequent hip fracture increases 300%. For starting a hospital based Fracture Liaison Service (FLS) program, the nucleus is based on a physician champion, a FLS coordinator, and a nurse manager. A Fracture Liaison Service (FLS) is a multidisciplinary system approach to reducing subsequent fracture risk in patients with a recent fragility fracture due to compromised bone health by identifying them at or close to the time when they are treated at the hospital for fracture and providing them with easy access to osteoporosis care. It has been shown that when compared to other models such as referral letters to primary care physicians or endocrinologists, the FLS model results in a higher rate of diagnosis and treatment with less attrition in the posffracture phase. Insufficiency fracture care requires more than surgery to stabilize a fractured bone. The FLS program provides an opportunity to treat osteoporosis from a public health perspective rather than leaving this to the whims of individual physicians. This is achieved by providing a seamless integration of care by health care providers, nursing staff and administration. The FLS can be adapted to any model of care including academic health systems. FLS provides a holistic approach to identify patients as well as to provide evidence-based interventions to prevent subsequent fractures. The long term goal is that internationally FLS will result in in decreased fracture-related morbidity, mortality and overall health care expenditure

Adverse Local Tissue Reaction Associated With a Modular Hip Hemiarthroplasty

BACKGROUND: The local and systemic effects of wear debris and corrosion products remain a concern in arthroplasty and reaction to corrosion or wear products from modular junctions has been reported in primary and revision total joint arthroplasties. These effects have not been reported previously for unipolar hemiarthroplasties where there is no prosthetic bearing surface to contribute to the phenomenon. This may have implications for clinical surveillance and implant design. CASE DESCRIPTION: We report the case of a 72-year-old man who had symptomatic pseudotumor formation, confirmed by pathologic examination of the excised pseudotumor, with a large-head modular hip hemiarthroplasty. Metallosis and corrosion of the modular head/neck taper junction were noted at the time of revision surgery. LITERATURE REVIEW: To our knowledge, this is the first report of pseudotumor formation where the corrosion or wear products arose from the modular junction of the implant with no bearing couple present to contribute wear debris that may influence the formation of the pseudotumor. PURPOSES AND CLINICAL RELEVANCE: Adverse tissue reactions to wear debris generated at prosthetic articulating surfaces and corrosion and wear products from nonarticulating prosthetic junctions have been reported. The problem has been reported to be higher in metal-on-metal bearing couples and in large-diameter hip arthroplasties. Mixed-alloy junctions appear to be more susceptible to corrosion. We believe that corrosion should be considered a possible diagnostic entity when investigating persistent symptoms after hemiarthroplasty and may be avoided with the use of monoblock components