Bilateral Total Hip Arthroplasty Research Articles

Incidence of local anesthetic systemic toxicity in patients receiving bupivacaine infiltration analgesia for total joint arthroplasty under general anesthesia: a retrospective single-center study

BackgroundLocal infiltration analgesia (LIA) is a crucial component of multimodal analgesia that enhances recovery after total hip arthroplasty (THA) and knee arthroplasty (TKA). However, LIA can cause fatal local anesthetic systemic toxicity (LAST). The incidences of LIA-induced LAST in different surgeries and anesthetic agents have not been well investigated.MethodsThis observational study enrolled 1,267 adult patients who received LIA with bupivacaine for primary THA or TKA under general anesthesia at a single medical center between January 2020 and October 2021. LAST incidence was graded by severity: severe (refractory seizure or arrhythmia requiring lipid rescue), major (seizure or arrhythmia requiring prompt medication), and minor (all other) events. Patient demographics, surgical and anesthesia details, recovery profiles, and LAST incidences were recorded and analyzed.ResultsThe incidence of severe LAST events was 2.41 per 1000 in unilateral THA, 0 in TKA, and 3.16 per 1000 in the entire cohort. The odds ratio of developing major LAST events was 4.35 in patients undergoing unilateral THA compared with those undergoing unilateral TKA in a matched comparison. Patients who underwent bilateral THA had the highest risk of developing LIA-induced LAST. Additionally, patients using propofol infusion for anesthesia maintenance had a lower risk of seizures and tremors than those using sevoflurane inhalation. The odds ratio of major LAST events was 0.47 in matched comparisons.ConclusionsLIA was associated with a significantly higher risk of LAST in the THA group than in the TKA group. Propofol maintenance reduces the likelihood of seizures and tremors compared with sevoflurane inhalation. Exploring strategies to reduce the incidence of LIA-induced LAST is essential to improve perioperative patient safety.

Subsidence of the Corail stem in total hip arthroplasty: no influence of bony contact

IntroductionThis study investigated stem subsidence following primary total hip arthroplasty (THA) with a Corail stem in patients who underwent two-staged bilateral THA. The second outcome of interest was to investigate whether a specific single cortical bone contact point might reduce postoperative stem subsidence.MethodsThe present study was conducted following the STROBE guidelines. The records of patients who underwent THA between 2016 and 2023 were accessed. All patients who underwent two-staged bilateral THA were retrieved. The direct contact between the stem and the cortical bone was assessed at various points in the metaphysis and the distal portion of the stem (diaphysis) in both anteroposterior radiographs of the pelvis (medial and lateral bone contact) and a Lauenstein view of the hip (anterior and posterior bone contact). The following parameters were measured and compared to assess stem subsidence: distance from the proximal femur at the stem bone interface and the tip of the lesser trochanter (distance A); distance from the tip of the lesser trochanter and the tip of the femoral stem (distance B).ResultsIn total, 250 patients were included, 45% (149 of 250 patients) were women and 61% (153 of 250 THAs) were implanted primarily on the right side. The mean age of patients at the time of the first THA was 64.3 ± 10.0 years and the mean body mass index (BMI) was 28.0 ± 4.9 kg/m2. The mean length of the follow-up was 14.1 ± 10.8 months. The overall stem subsidence following THA was 2.8 ± 0.7 mm (P < 0.006). A direct cortical bone-implant contact did not exert a statistically significant difference in subsidence of the THA stem at the metaphysis and diaphysis (P > 0.5). Stem subsidence following THA with a collarless cementless Corail stem was approximately 2.8 mm at 14 months.ConclusionsDirect cortical bone contact of the stem at diaphysis and metaphysis seems not to influence stem subsidence following THA using the Corail stem.

Bilateral Total Hip and Right Knee Arthroplasty in a Sickle Cell Disease Patient with Multiple Joint Osteonecrosis: A Case Report and Literature Review.

Sickle cell disease is an autosomal recessive genetic disorder with the underlying pathology, resulting in sickling of the red blood cells in deoxygenated conditions. Osteonecrosis is a common orthopaedic manifestation of sickle cell disease, and total joint arthroplasty is the preferred option in managing patients with advanced disease. This article describes bilateral total hip arthroplasty and right total knee arthroplasty (TKA) in a 41-year-old woman, a known haemoglobin SS (HBSS) patient who presented to the outpatient clinic of National Orthopaedic Hospital, Igbobi, Lagos, with recurrent bilateral hip and right knee pain of 10-year duration, with associated stiffness, valgus deformity in the knee and severe limitation of function. She had sequential bilateral total hip replacement and right TKA. She had significant improvement in function in the follow-up period. The effectiveness of total hip and knee arthroplasties in HBSS patients with osteonecrosis is well demonstrated in this article.

Differences in Time to Return to Work Between Patients Undergoing Staged Versus Simultaneous Bilateral Total Hip Arthroplasty

BackgroundPatients who undergo total hip arthroplasty (THA) oftentimes have severe osteoarthritis in both hips and may consider staged or simultaneous bilateral THA (bTHA). The goal of this study was to compare the total workdays missed following staged and simultaneous bTHA performed via either postero-lateral (PA) or direct anterior approach (DAA). MethodsPatients who were (1) employed, (2) underwent a staged (within 12 months) or simultaneous bTHA at our institution between February 1, 2016, and December 31, 2021, (3) completed a return-to-work questionnaire, and (4) had the same surgical approach for both THAs were included. The primary outcome of interest was the total days of work missed. ResultsWe identified 78 employed patients who had undergone staged bTHA (62 PA, 16 DAA) and 76 patients (44 PA, 32 DAA) who underwent simultaneous bTHA, and had completed the return-to-work questionnaire. Simultaneous bTHA patients missed an average of 25.6 days of work (SD: 14.3 days) compared to staged bTHA patients, who missed an average of 36.9 days of work (SD: 23.4) when combining days missed from both operations (P < 0.001). In multivariate mixed regression analysis adjusted for sex, age, body mass index, American Society of Anesthesiologists status, type of work, and surgical approach, the staged bTHA group missed a mean of 8.2 more days of work (SD: 3.3) compared to the simultaneous bTHA group (95% confidence interval: 1.8 to 14.7, P = 0.013). ConclusionsEmployed patients who underwent simultaneous bTHA missed an average of 8.2 fewer days of work compared to those who were treated with staged bTHA. These findings may help surgeons counsel their employed patients who have bilateral hip osteoarthritis and are considering surgical treatment. Level of EvidenceIV, retrospective cohort study.

How Do Changes in Femoral Anteversion Impact Femoral Rotation and Anterior Offset After Total Hip Arthroplasty?

BackgroundThe impact of femoral anteversion changes on femoral rotation and anterior offset following total hip arthroplasty (THA) has not been well studied. This study therefore investigated the relationship among femoral anteversion, anterior offset, and femoral rotation before and after THA. MethodsThere were 995 patients who had staged primary bilateral THAs who received a preoperative supine computerized axial tomography (CT) scan, following a standardized protocol, for surgical planning prior to each THA. The following measurements were performed for the first operative hip preoperatively and postoperatively on the first and second CT scans, respectively: femoral anatomic anteversion, defined as the angle between the native femoral neck or stem neck axis and the posterior condylar axis; femoral rotation, defined as the angle of the posterior condylar axis relative to the coronal plane of the CT; and femoral anterior offset, defined as the shortest distance between the femoral head center and a femoral plane containing the epicondyles and the piriformis fossa. The mean time between imagings was 11 months (range, 2 to 44). Associations are described using linear regression (β = slope) and Pearson correlation (r) coefficients. A t distribution was used for testing correlation. ResultsFemoral anteversion correlated with femoral anterior offset preoperatively (β = 0.565, r = 0.914, P < 0.001) and postoperatively (β = 0.671, r = 0.958, P < 0.001), and with femoral rotation preoperatively (β = 0.623, r = 0.575, P < 0.001) and postoperatively (β = 0.459, r = 0.517, P < 0.001). Increasing anteversion from preoperatively to postoperatively increased anterior offset (β = 0.621, r = 0.908, P < 0.001) and femoral internal rotation (IR) (β = 0.241, r = 0.273, P < 0.001). Patients who had >20° increase in anteversion (mean increase 26°, range 20 to 40.5°, n = 71) had a mean increase in femoral IR of 9.6 ± 9.8°. ConclusionsIncreasing femoral anteversion increases anterior offset and IR of the femur, with approximately a 1° increase in IR for every 4° increase in anteversion on average. Surgeons should appreciate the implications of changing anteversion during THA planning.

Intraoperative cell salvage reduces postoperative allogeneic blood transfusion and shortens off-bed time in simultaneous bilateral total hip arthroplasty: a single-center retrospective study

BackgroundSimultaneous bilateral total hip arthroplasty (SI-THA) results in more blood loss and a greater need for postoperative allogeneic blood transfusion (ABT). Previous studies have reported that multimodal patient blood management (PBM) strategies were associated with a smaller effect of intraoperative cell salvage (ICS) in unilateral total hip arthroplasty. However, there are few studies on the role of ICS in SI-THA. This study aims to explore the effect of ICS with multimodal PBM strategies on SI-THA and to identify risk factors associated with ABT.MethodsThis retrospective matched cohort study included 72 patients in the ICS group and 72 patients in the control group who were matched according to age, sex, and year of hospitalization. Demographic data, hematological indicators, blood loss, and ABT were compared between the two groups. Logistic regression analysis was performed to identify independent risk factors for postoperative ABT. Postoperative outcomes were also recorded.ResultsIn the cohort of 144 patients, 27 patients (37.5%) in the ICS group while 45 patients (62.5%) in the control group received postoperative ABT after SI-THA. Compared with the control group, the ICS group showed significant differences in terms of blood loss, postoperative hemoglobin and hematocrit. The transfused volume of allogeneic red blood cells per ABT patient was also lower in the ICS group. Multivariate logistic regression analysis indicated that sex, the utilization of ICS, and preoperative hematocrit level were identified as independent factors associated with postoperative ABT. The utilization of ICS significantly shortened off-bed time and length of hospital stay, but had no effect on early pain and functional outcomes.ConclusionThe utilization of ICS can significantly affect postoperative ABT in SI-THA patients with multimodal PBM strategies. Sex, the utilization of ICS and preoperative hematocrit level were identified as independent factors associated with postoperative ABT. The utilization of ICS promoted weight-bearing functional exercises, but had no effect on early outcomes.

Simultaneous Bilateral Total Hip Arthroplasty With Either the Direct Anterior or Posterior Approaches: A Propensity Score Match Study

BackgroundBilateral hip osteoarthritis is evident in approximately 20% of patients who present to the clinic for evaluation of hip pain, and for those undergoing total hip arthroplasty (THA), 22% will end up needing a contralateral THA. The risk and benefits of simultaneous bilateral total hip arthroplasty (SBTHA) versus staged bilateral THA procedures have been well studied, demonstrating equivalent safety profiles comparable to unilateral and SBTHA. However, the influence of the surgical approach on SBTHA on postoperative outcomes remains unclear. We sought to compare perioperative outcomes and complication rates between the direct anterior approach (DAA) and posterior approach (PA) in patients undergoing SBTHA. MethodsWe performed a 1:1 propensity score match based on age, sex, and body mass index. A total of 252 patients were available after matching, 126 patients in the DAA group and 126 in the PA group. Perioperative outcomes as well as surgical complications at the latest follow-up were retrospectively collected for each group. The mean follow-up was 36.7 months (range, 12.5 to 74.4). ResultsA SBTHA with DAA had significantly shorter surgical time (P < 0.001), anesthesia time (P < 0.001), and length of stay (P < 0.001), compared to the PA. A greater percentage of patients in the DAA group (91%) were discharged home compared to the PA group (57%) (P < 0.001). There were no differences in in-hospital complications (P = 0.617), 90-day complications (P = 0.605), or reoperation rates (P = 0.309) between surgical approaches. ConclusionsA SBTHA, either through the DAA or PA, can be safely performed with low complication rates. The DAA in the setting of SBTHA provides shorter surgical times, a shorter length of stay, and a greater percentage of patients discharged home.

MATCHING THE OTHER SIDE: RADIOLOGICAL VARIABILITY IN STAGED, BILATERAL TOTAL HIP ARTHROPLASTY

The purpose of this study was to assess the variability in implant position between sides in patients who underwent staged, bilateral THA and whether variation from one side to the other affected patient-reported outcomes.A retrospective review was conducted on 207 patients who underwent staged, bilateral THA by the same surgeon from 2017–2022. Leg length, acetabular height, cup version, and coronal and sagittal stem angles were assessed radiographically and compared to the contralateral THA. Surgical approach and technology utilization were further assessed for their impact on variability. Linear regression was used to model the relationship between side-to-side variability and patient-reported outcome measures (PROMS).Between sides, mean radiographic leg length varied by 4.6mm (0.0–21.2), acetabular height varied by 3.3mm (0.0–13.7), anteversion varied by 8.2° (0.0 to 28.7), coronal stem alignment varied by 1.1° (0.0 to 6.9), and sagittal angulation varied by 2.3° (0.0 to 10.5). The anterior approach resulted in more variability in stem angle position in both the coronal (1.3° vs. 1.0°, p=0.036) and sagittal planes (2.8° vs. 2.0° p=0.012) compared to the posterior approach. The posterior approach generally led to more anteversion than the anterior approach. Use of robotics or navigation for acetabular positioning did not increase side-to-side variability in cup-related position or leg length. Despite considerable side-to-side variability, Hip dysfunction and osteoarthritis outcome scores (HOOS JR) were not affected by higher levels of position inconsistency.Staged, bilateral THA results in considerable variability in component position between sides. The anterior approach leads to more side-to-side variability in sagittal stem angle and cup anteversion than the posterior approach. Navigation and robotics do not improve the consistency of component position in bilateral THA. Variation in implant position was not associated with differences in PROMs, suggesting that despite variability, patients can tolerate these differences between sides.

Does Discharge Disposition or Length of Stay for Patients Undergoing Staged Bilateral Total Joint Arthroplasty Change Between First and Second Procedures?

Introduction This study investigates whether ambulatory surgery rates, discharge disposition, or hospital length of stay (LOS) differ between the first and second surgeries for staged bilateral total joint arthroplasty (TJA). We hypothesize that patients have higher rates of ambulatory surgery and shorter LOS for the second surgery. Methods Data were retrospectively collected from staged bilateral total knee (TKA) or total hip arthroplasty (THA) patients within a 12-month period. Ambulatory surgery rates, discharge to home, and LOS after first (LOS_1) vs. second surgery (LOS_2) were compared. Multivariable regression analysis was performed to identify predictors of shorter LOS. Results Rates of ambulatory surgery were significantly higher after second surgery for TKA (28.7% vs. 20.2%, p&lt;0.001) but not for THA (24.8% vs. 23.0%, p=0.405). Likelihood of discharge to home was not significantly different between first and second surgeries for TKA (p=0.225) or THA (p=0.248). LOS_2 was significantly shorter than LOS_1 for TKA (1.4 vs 1.6 days, p=0.005) but not for THA (1.4 vs 1.4 days, p=0.723). Undergoing TKA (OR=1.846, 95% CI=[1.142, 2.984]), former smoking (OR=1.686, 95% CI=[1.068, 2.660]), and younger age (OR=0.968, 95% CI=[0.939, 0.997]) were associated with LOS_2&lt;LOS_1. Conclusions Our results show higher rates of ambulatory surgery and shorter LOS after second surgery vs. first for staged bilateral TKA but not THA. Factors associated with LOS_2&lt;LOS_1 include undergoing TKA, former smoking, and younger age.

Best timing of bilateral total hip arthroplasty – an analysis of revision and mortality rates from the German Arthroplasty Registry (EPRD)

BackgroundThe burden of osteoarthritis (OA) in multiple joints is high and for patients with bilateral OA of the hip there is no clear recommendation about the indication for simultaneous (one-stage) bilateral total hip arthroplasty (THA) versus two-staged procedures. The purpose of this study was therefore to compare revision and mortality rates after different strategies of surgical timing in bilateral hip OA from the German Arthroplasty Registry (EPRD).MethodsSince 2012 22,500 patients with bilateral THA (including 767 patients with one-staged bilateral surgery and 11,796 patients with another separate procedures within one year after first THA) are documented in the registry. The patients who underwent simultaneous bilateral THA were matched with a cohort of 767 patients who underwent the second THA between 1 and 90 days postoperatively (short interval) and another cohort of 4,602 patients with THA between 91 and 365 days postoperatively (intermediate interval). Revision for all reasons and mortality rates were recorded. Cox regression was performed to evaluate the influence of different patient characteristics.ResultsThe cumulative 5-year revision rate for patients with simultaneous bilateral THA was 1.8% (95% CI 0.9–2.6), for patients with two-staged THA 2.3% (95% CI 1.0-3.6) in the short interval and 2.5% (95% CI 2.1–2.9) in the intermediate interval, respectively. In all three groups, patients who underwent THA in a high-volume center (≥ 500 THA per year) had a significant lower risk for revision (HR 0.687; 95% CI 0.501–0.942) compared to surgeries in a low-volume center (< 250 THA per year). There was no significant difference regarding cumulative mortality rates in the three cohorts. Higher age (HR 1.060; 95% CI 1.042–1.078) and severe comorbidities as reflected in the Elixhauser Score (HR 1.046; 95% CI 1.014–1.079) were associated with higher mortality rates after simultaneous THA.ConclusionSimultaneous bilateral THA seems to be a safe procedure for younger patients with limited comorbidities who have bilateral end-stage hip OA, especially if performed in high-volume centers.Level of evidenceIII.

Evaluation of the Effectiveness of Canadian Cardiovascular Society Guidelines in Minimizing Cardiac Events After Total Hip Arthroplasty

BackgroundThe aim of the study was to analyze the Canadian Cardiovascular Society (CCS) guidelines for routine postoperative troponin testing after elective total hip arthroplasty (THA) to reduce the mortality rate resulting from myocardial injury. The purpose of this study was to assess the prognostic relevance of implementing these guidelines to minimize cardiac events in patients undergoing elective THA. MethodsPatients who underwent THA surgery in 2020 were included in the study. The inclusion criteria were elective THA patients aged ≥45 years, while emergency, revision, and simultaneous bilateral THA surgeries were excluded. The patients were categorized into 4 groups based on the CCS guidelines. ResultsThe study included 669 patients who had an average age of 67 years. There were 43 patients (6.4%), who experienced a rise in troponin levels ≥30 ng/L and developed myocardial injury after noncardiac surgery. Among these patients, 8 developed cardiac complications, and one experienced a serious cardiac event that resulted in death. Notably, there was a significant increase in the length of hospital stay for patients who received the postoperative screening protocol. ConclusionsThe implementation of the CCS guidelines for routine postoperative troponin testing in elective THA surgery did not significantly decrease the rate of cardiac events or mortality.

Successful treatment of a challenging periprosthetic femoral fracture on a premenopausal patient with a long history of immunosuppression

While immunosuppression provides relief and care in patients with rheumatic arthritis, the prolonged usage of steroids has been known to cause various and serious complications. While in older patients it is common to find those with a long history of immunosuppression, younger patients also suffer from its prolonged complications. We present a 38 year old heavily immunocompromised female patient with excellent compliance on which we operated on multiple occasions and have treated from 2019 to 2022. The patient was originally diagnosed with rheumatoid arthritis at age 7, and has been receiving high dose immunosuppressive medication. The patient received bilateral total hip arthroplasty during 2009 and 2013, and a Total Knee Arthroplasty (TKE) in 2011. Over the course of her postoperative recovery, she suffered from multiple cases of periprosthetic fractures. In October 2019, the patient again presented with spontaneous pain in her right thigh. She was then diagnosed with a Vancouver C type periprosthetic fracture on the right femur, and was referred and admitted to our level one Trauma Center in Szeged, Hungary. After multiple trials, the patient received a Locking Compression Plate (LCP) type Proximal Femoral Hook Plate (PFHP) with cable fixation, attachments and a bone allograft to reinforce stability and neutralize stress on the fractured area. Multiple and repetitive challenges can be expected in treating bony fractures of weight bearing lower limbs for heavily immunocompromised patients. The patient, despite her young age, had the osteological biology of a elderly patient, requiring us to take into consideration not only surgical components but biological components as well. With a multidisciplinary approach from osteological, biological, and surgical fields, successful results may be acquired even in these challenging cases.

Simultaneous vs staged bilateral hip arthroplasty: monocentric analysis of satisfaction rate and complications.

Interest in bilateral total hip arthroplasty (THA) has been increasing over the past decade. This study aims to compare postoperative local and systemic complications, hospital readmissions, and satisfaction assessment in patients undergoing simultaneous versus staged bilateral THA. A retrospective observational study was conducted among patients who underwent simultaneous or staged bilateral THA between 2017 and 2020. Data on perioperative parameters, local and systemic complications, and 30-day hospital readmissions were collected. Patient satisfaction was assessed using Forgotten Joint Score (FJS). The comparison of continuous variables with normal distribution of variance was performed by ANOVA; for variables with abnormal distribution, the nonparametric test Mann-Whitney U was adopted. The distribution of dichotomous variables was analyzed by chi-square test, and statistical significance was calculated by Fisher exact test. The study included 199 patients, of whom 156 underwent staged and 43 simultaneous bilateral THA. A total of 44 patients developed complications (21 systemics, 12 locals, and 20 postoperative anemia). There were no significant differences regarding local (simultaneous 5% vs. staged 6%; p = 0.999) or systemic complications (simultaneous 14% vs. staged 10%; p = 0.408). Only the incidence of postoperative anemia was significantly higher in simultaneous group compared with staged group (p = 0.003).There were no significant differences in FJS between the two groups (p = 0.258). No differences in local or systemic complications nor readmission rates were observed following simultaneous or staged bilateral THA. Simultaneous bilateral THA is non-inferior to staged implants in terms of safety and patient satisfaction.

Simultaneous Versus Staged Bilateral Total Hip Arthroplasty: A Matched Cohort Analysis of Revenue and Contribution Margin

BackgroundThough previous studies have demonstrated improved cost benefits associated with simultaneous versus staged bilateral total hip arthroplasty (simBTHA and staBTHA), further investigation is needed regarding the revenues and contribution margins (CMs) of these procedures. In this study, we compared revenue, CM, and surgical outcomes between simBTHA and staBTHA. MethodsAll patients who underwent simBTHA (both procedures completed the same day) and staBTHA (procedures completed on different days within one year) between 2011 and 2021 at a single high-volume orthopedic specialty hospital were identified. Of the 1,517 identified patients (n = 139 simBTHA, n = 1,378 staBTHA), 232 were included in a 1:1 propensity match based on baseline demographics (116 per cohort). Revenue, costs, CM, and surgical outcomes were compared between cohorts. ResultsCompared to staBTHA, simBTHA procedures had significantly lower total costs (P < .001), direct costs (P < .001), and patient revenue. There was no significant difference in CM between groups (P = .361). Additionally, there were no significant differences in length of stay (P = .173), operative time (P = .438), 90-day readmissions (P = .701), 90-day revisions (P = .313), or all-cause revisions (P = .701) between cohorts. ConclusionsThough simBTHA procedures have lower revenues than staBTHA, they also have lower costs, resulting in similar CM between procedures. As both procedures have similar postoperative complication rates, further research is required to evaluate specifically which patients may benefit from simBTHA versus staBTHA regarding clinical and patient-reported outcomes. Level of EvidenceIII.

The Impact of Preoperative Medical Evaluation in an Orthopaedic Perioperative Medical Clinic on Total Joint Arthroplasty Outcomes: An Observational Study.

A preoperative medical evaluation (PME) in total joint arthroplasty (TJA) is routine despite considerable variation and uncertainty regarding its benefits. The orthopaedic department in our academic health system established a perioperative medical clinic (PMC) to standardize perioperative management and to study the effect of this intervention on total hip arthroplasty (THA) and total knee arthroplasty (TKA) outcomes. This observational study compared the impact of a PME within 30 days prior to surgery at the PMC (Periop30) versus elsewhere ("Usual Care") on postoperative length of stay (LOS), extended LOS (i.e., a stay of >3 days), and Patient-Reported Outcomes Measurement Information System-10 (PROMIS-10) Global Physical Health (GPH) score improvement in TJA. We stratified adult patients (≥18 years of age) who underwent primary TJA between January 2015 and December 2020 into Periop30 or Usual Care. We utilized univariate tests (a chi-square test for categorical variables and a t test for continuous variables) to assess for differences in patient characteristics. For both TKA and THA, LOS was assessed with use of multivariable negative binomial regression models; extended LOS, with use of binary logistic regression; and PROMIS-10 GPH score, with use of mixed-effects models with random intercept and slope. Interaction terms between the focal predictor (Periop30, yes or no) and year of surgery were included in all models. Periop30 comprised 82.3% of TKAs (1,911 of 2,322 ) and 73.8% of THAs (1,876 of 2,541). For THA, the Periop30 group tended to be male (p = 0.005) and had a higher body mass index (p = 0.001) than the Usual Care group. The Periop30 group had a higher rate of staged bilateral THA (10.6% versus 7.5%; p = 0.028) and a lower rate of simultaneous bilateral TKA (5.1% versus 12.2%; p < 0.001) than the Usual Care group. Periop30 was associated with a lower mean LOS for both TKA (43.46 versus 54.15 hours; p < 0.001) and THA (41.07 versus 57.94 hours; p < 0.001). The rate of extended LOS was lower in the Periop30 group than in the Usual Care group for both TKA (15% versus 26.5%; p < 0.001) and THA (13.3% versus 27.4%; p < 0.001). There was no significant difference in GPH score improvement between Periop30 and Usual Care for either TKA or THA. Periop30 decreased mean LOS and the rate of extended LOS for TJA without an adverse effect on PROMIS-10 GPH scores. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Subsequent total joint arthroplasty: Are we learning from the first stage?

With the increasing incidence of total joint arthroplasty (TJA), there is a desire to reduce peri-operative complications and resource utilization. As degenerative conditions progress in multiple joints, many patients undergo multiple procedures. To determine if both physicians and patients learn from the patient's initial arthroplasty, resulting in improved outcomes following the second procedure. The institutional database was retrospectively queried for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients with only unilateral THA or TKA, and patients undergoing same-day bilateral TJA, were excluded. Patient demographics, comorbidities, and implant sizes were collected at the time of each procedure and patients were stratified by first vs second surgery. Outcome metrics evaluated included operative time, length of stay (LOS), disposition, 90-d readmissions and emergency department (ED) visits. A total of 642 patients, including 364 undergoing staged bilateral TKA and 278 undergoing bilateral THA, were analyzed. There was no significant difference in demographics or comorbidities between the first and second procedure, which were separated by a mean of 285 d. For THA and TKA, LOS was significantly less for the second surgery, with 66% of patients having a shorter hospitalization (P < 0.001). THA patients had significantly decreased operative time only when the same sized implant was utilized (P = 0.025). The vast majority (93.3%) of patients were discharged to the same type of location following their second surgery. However, when a change in disposition was present from the first surgery, patients were significantly more likely to be discharged to home after the second procedure (P = 0.033). There was no difference between procedures for post-operative readmissions (P = 0.438) or ED visits (P = 0.915). After gaining valuable experience recovering from the initial surgery, a patient's perioperative outcomes are improved for their second TJA. This may be the result of increased confidence and decreased anxiety, and it supports the theory that enhanced patient education pre-operatively may improve outcomes. For the surgical team, the second procedure of a staged THA is more efficient, although this finding did not hold for TKA.

High femoral offset as a risk factor for aseptic femoral component loosening in cementless primary total hip arthroplasty

PurposeLateralized stems in primary cementless total hip arthroplasty (THA) showed to be associated with aseptic femoral loosening. However, femoral head length also affects femoral offset but was not considered so far. This study analyzed the impact of high femoral offset (hFO) combinations, formed by lateralized stems or large femoral head lengths, on aseptic femoral component loosening.MethodsRetrospective cohort study was performed including all patients that underwent primary cementless THA at our institution between July 2004 and December 2016. Patients were screened for aseptic femoral component loosening and grouped in aseptic loosening (AL) and non-aseptic loosening (nAL) group. Medical records were screened; implant details were noted and classified in hFO and standard femoral offset (sFO) combinations. Supposed risk factors for aseptic loosening were analyzed.ResultsTwo thousand four hundred fifty-nine THA could be included, containing 14 THA (0.6%) with aseptic femoral component loosening. The AL group contained 11 hFO combinations (78.6%), whereas in the nAL group, 1315 hFO combinations (53.8%) were used. Subgroup analysis showed significant difference between two groups for hFO combinations (p = 0.014), age (p = 0.002), NSAR (p = 0.001), and bilateral THA on same day (p = 0.001). The multiple logistic regression analysis showed that hFO combination was the only variable for increased probability of aseptic loosening (OR, 3.7; p = 0.04).ConclusionHigh femoral offset combinations, formed by lateralized stems or large femoral head lengths in our collective of standard straight stems implanted by an anterior approach, show a 3.7-fold increased probability for aseptic femoral component loosening. Adjustment of the postoperative protocol may be considered in these cases to ensure proper stem ingrowth.

A randomized controlled trial comparing carbazochrome sodium sulfonate and tranexamic acid in reducing blood loss and inflammatory response after simultaneous bilateral total hip arthroplasty.

A drug known as carbazochrome sodium sulfonate (CSS) can reduce blood loss. But, it is not known how it can prevent the development of hemostatic and inflammatory conditions in patients who undergo bilateral simultaneous total hip arthroplasty (SBTHA). This study will analyze the safety and effectiveness of combining this drug with SBTHA. The study was conducted on 100 patients who underwent SBTHA with simultaneous total hip replacement. They were split into two groups: group B received TXA with CSS, group A received TXA with no CSS. The main observation of the study was the total blood loss, which is the most common indication of blood loss. Other secondary indicators of the study included hidden blood loss, postoperative blood transfusion rate, level of inflammatory reactants, hip function, pain score, venous thromboembolism (VTE) and the incidence of adverse events. Group B had significantly lower TBL and HBL compared to Group A. Group B showed significant improvement in inflammatory biomarker levels, blood transfusion rate when compared to Group A (p < .05). No thromboembolic complications occurred in either group. There were no significant differences between the two groups in terms of postoperative swelling rate, intraoperative blood loss, visual analog scale pain score, platelet count, discharge motion and average length of stay. As a hemostatic agent, CSS combined with TXA can reduce postoperative blood loss in patients undergoing SBTHA, and is more effective than TXA alone in terms of blood loss and inflammation, and does not increase the incidence of thromboembolic complications.

To Stage or Not to Stage? Comparison of Patient-Reported Outcomes, Complications, and Discharge Disposition After Staged and Simultaneous Bilateral Posterior Total Hip Arthroplasty

BackgroundPatients who have bilateral hip arthritis can be treated with bilateral total hip arthroplasty (bTHA) in either a staged or simultaneous fashion. The goal of this study was to determine whether staged and simultaneous posterior bTHA patients differ in regard to (1) patient-reported outcome measures, (2) 90-day complication rates, and (3) discharge dispositions and cumulative lengths of stay. MethodsPatients who (1) underwent simultaneous bTHA or staged bTHA (within 12 months) using the posterior approach, and (2) completed preoperative and 1-year postoperative Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement surveys were included in the study. A total of 266 patients (87 simultaneous bTHA and 179 staged bTHA) were included. Chart review was performed to collect patient-level variables, postoperative complications, discharge dispositions, and lengths of stay. ResultsStaged bTHA patients had higher Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement, Lower Extremity Activity Scale, and Veterans RAND 12-Item Health Survey physical component scores compared to simultaneous bTHA patients at 6 weeks after surgery (P = .019, .006, and .008, respectively), but these differences did not meet the minimal clinically important difference threshold for any questionnaire. Simultaneous bTHA was associated with higher rate of periprosthetic fractures (P = .034) and discharge to a location other than home (P < .001). ConclusionsThere were statistically significant, but likely not clinically meaningful differences in patient-reported outcomes for staged and simultaneous bTHA patients at 6 weeks after surgery. Surgeons should be aware of the higher periprosthetic fracture risk and greater likelihood of discharge to a rehabilitation facility associated with simultaneous bTHA. Further research should aim to understand which patients may benefit most from simultaneous bTHA.

Delta hemoglobin cutoffs do not predict readmission in patients undergoing primary simultaneous bilateral total hip or knee arthroplasty: A retrospective cohort study

Delta hemoglobin cutoffs do not predict readmission in patients undergoing primary simultaneous bilateral total hip or knee arthroplasty: A retrospective cohort study