Life Lost Too Soon: Navy Corpsman from Ohio Killed in Afghanistan Attack August 26, 2021

Navy Corpsman Maxton “Max” W. Soviak, HM3 (22 years old) of Berlin Heights, Ohio, was one of the 13 U.S. service members killed while supporting non-combatant evacuation operation in Kabul, Afghanistan. Max was advanced to the rank of Hospital Corpsman Third Class “as a result of his brave actions in support of fellow service members,” according to a Navy statement. He was also posthumously awarded the Purple Heart and Fleet Marine Force Corpsman warfare badge.

A Literature-Based Resource for the Development of Outpatient Arthroplasty Patient Selection Criteria

Total joint arthroplasty (TJA) is moving towards the outpatient setting. Teams must develop patient selection criteria to ensure appropriate candidates are treated at the optimal site of care. Protocols and recommendations have been developed to aid care teams in developing patient selection criteria, but these come from multiple disparate sources. We review the available literature on patient selection criteria and optimization in the outpatient TJA population, and synthesize this information into a workable format for care design. We hope to provide a resource to stakeholders that can be tailored to their unique outpatient facility. Keywords: Total joint arthroplasty, outpatient, same day discharge, selection criteria, patient optimization.

Intrapelvic Pseudotumor Causing Neuropathy and Vascular Obstruction After Revision Total Hip Arthroplasty: A Case Report

Background: There is a growing body of recent literature regarding the occurrence of pseudotumors associated with modular junctions and various bearing surfaces after total hip arthroplasty (THA). Revision surgery is often technically challenging and high complication rates have been reported. The optimal management of these patients and outcomes after operative treatment remain poorly understood. Methods: We report the case of a 77-year-old male with progressive unilateral lower extremity swelling, pain, and neuropathy 9 years after revision THA for polyethylene liner wear. Imaging and biopsy confirmed a massive intrapelvic pseudotumor exerting compressive effects. Radiographs demonstrated extensive femoral and pelvic osteolysis without evidence of component loosening. Debulking of the intrapelvic portion of the pseudotumor was performed via the lateral window of the ilioinguinal approach with component retention. Results: Debulking of the intrapelvic mass resulted in resolution of symptoms. One year postoperatively the patient reported pain free ambulation using a walker and no recurrence of symptoms. Radiographs demonstrated stable THA components in comparison with preoperative films. Discussion and Conclusion: This case demonstrates a rare finding of intrapelvic pseudotumor causing neurovascular compression after revision THA. Clinicians should be aware of intrapelvic pseudotumor as a possible cause of limb swelling and neuropathy, and that debulking of the mass is a potential treatment option in the setting of well-fixed implants.

Addressing a Complex Proximal Femoral Deformity With Custom Cutting Guides Using 3D-Computer Design Software: A Case Report and 2-year Follow-Up

We report a case of a 23-year-old female with a history of congenital proximal femoral deformity and malunion of a prior proximal femoral corrective osteotomy, who presented seeking treatment for debilitating end-stage arthritis of her hip. Consideration for total hip arthroplasty (THA) for this patient was complicated by her young age and the complexity of her proximal femoral deformity. A 3-dimensional bone model of the patient’s femur was created using digital reconstructive software based on preoperative CT-imaging and used to plan our corrective osteotomy and arthroplasty component specifications. Using the detailed characterization of the femoral morphology, custom cutting guides were designed to fit uniquely into the correct position and ensure a high degree of accuracy with our osteotomy cuts. This unique case highlights the use of 3D-modeling software and printing technology for detailed surgical planning and precise execution in patients with complex deformities or otherwise abnormal anatomy.

Metal-on-Metal Total Hip Arthroplasty: Current Recommendations and Lessons Learned

Metal-on-metal (MoM) hip arthroplasty was re-popularized in the 1990s to resolve osteolysis and wear associated with metal-on-polyethylene products. Despite early success, registries began reporting high failure rates due to adverse reactions to metal debris (ARMD), manifesting as pseudotumors, hip effusions and osteolysis. Evaluation includes clinical exam, advanced imaging, and blood metal ions and infectious markers. This review provides physicians with an evidence-based update on the 1) clinical workup and management of patients with existing MoM implants, 2) risk and prognostic factors associated with suboptimal results and 3) the precipitating events and lessons learned applicable to future orthopedic prosthesis.

Overnight or Short Stay Joint Replacements in the Public and Private settings: An Australian Experience.

Introduction: In today’s post COVID 19 world, many healthcare systems have been pushed past the brink of economic sustainability. With Total Hip (THR) and Knee Replacements (TKR) being a few of the biggest ticket items, the need to adopt methods that improve quality of care & reduce unnecessary costs, is imperative. In this context, we report our experience with a Short Stay / Overnight joint replacement model using an ERAS (Enhanced Recovery After Surgery) Protocol which promotes rapid post-operative recovery and a decreased LOS without an increase in complications or readmission rates. Method: Retrospective collection of clinical & demographic data was undertaken for 114 consecutive patients undergoing primary THR or TKR by a single surgeon between 1 January 2018 and 19 March 2020 at 2 hospitals (1 public, 1 private). The data was analyzed for LOS, complications & readmission rates within 90 days after surgery. Results: In THR (n=93) and TKR (n=21), mean LOS was1.54 nights (range 0 - 4). 8 patients were discharged to a rehabilitation facility, the remaining 106 were discharged home. 2 patients were readmitted within 90 days of surgery - one with a periprosthetic fracture and the other for an unrelated respiratory illness. Conclusion: The implementation of a Short Stay model and associated ERAS protocols in both the public and private hospital settings reduced LOS without a concomitant increase in postoperative complications or readmission rates.

Range of Motion Comparison Following Total Knee Arthroplasty with and without Patella Resurfacing

Background: Despite significant evaluation, no consensus has been reach for best clinical practice for resurfacing the patella during total knee arthroplasty. Further complicating the ability to reach a conclusion is the inclusion of several different implant types used in previous research. Questions/Purpose: The purpose of this study was to compare post-TKA outcomes between two cruciate retaining implants with or without patella resurfacing. Methods: This retrospective review included 289 patients (380 knees) with a minimum six-month follow-up. All patients received a CR implant, with either a symmetric or an asymmetric tibial baseplate. Post-TKA knee flexion was categorized as <120° and ≥120° and knee extension classified as 0° or >0° and required knee manipulations were noted. Descriptive, nonparametric statistics were performed and a multivariate logistic regression was performed to determine risk of poor range of motion and manipulations. Results: Age was significantly lower in the resurfaced group (p=0.001) and the resurfaced group had longer tourniquet time (p=0.003). The symmetric-resurfaced group had ≥120° of flexion and full extension in 72% and 98.7% of patients, respectively. Compared to symmetric-resurfaced, all other groups had a significantly greater risk of not reaching 120° of knee flexion (p<0.05). There were no significant differences in the risk of requiring a MUA between groups (p>0.06). Conclusions: The effect of resurfacing the patella on post-TKA outcomes may be influenced by tibial implant design. Compared to all other combinations, a symmetric tibial baseplate and resurfaced patella resulted in the highest percentage of patients reaching ≥120°, with a low incidence of manipulations.

Early Term Radiographic Follow-Up of the Trident Tritanium Acetabular Component

INTRODUCTION: The purpose of this study was to evaluate the two year clinical and radiographic outcomes of patients undergoing a primary total hip arthroplasty (THA) using the Trident Tritanium primary Cup. METHODS: 197 patients who underwent a direct anterior THA using a Tritanium acetabular component between 2011 and 2015 were retrospectively reviewed by two surgeons from a single institution. The investigators, along with an independent physician, separately reviewed radiographs blinded to clinical data looking for radiolucent lines adjacent to the acetabular cup using the Charnley-DeLee zones. Clinical results were measured using acetabular revision surgery as an end point for failure. According to the American Academy of Orthopaedic Surgeons Levels of Evidence, this study was consistent with a Level III Therapeutic study. RESULTS: 101 (48.73%) subjects did not exhibit any radiolucent lines around the acetabular component. 53 (26.90%) subjects displayed radiolucency in only one zone. 27 (13.71%) subjects displayed radiolucency in two zones, and 16 (8.12%) displayed radiolucency in all three zones. Radiolucency was most prevalent in zone 1 at 2 years with 83 (42.13%) subjects displaying radiolucency. There were five (2.54%) acetabular failures within two years of the index surgery. Of those 5 subjects, 3 displayed radiolucency in 1 zone, 2 displayed radiolucency in >1 zone, and 2 displayed radiolucencies >1 mm. CONCLUSION: In our study, the Tritanium Cup demonstrated a 2.54% failure rate for aseptic loosening at 2 year follow-up. In addition, 48.73% of patients displayed a radiolucent line in at least one Charnley-DeLee zone. We also observed a progression of radiolucencies between the 6 month radiographs and the 2 year radiographs.

New Cementless Total Hip Arthroplasty. A Multicentre Prospective Minimum 2 Year Follow-up Clinical Outcomes Study.

Background: Cementless implants were introduced approximately three decades ago in order to address aseptic loosening of cemented hip prostheses with the aim of early mobilisation, better functional result and bone stock preservation. The primary objective of this study is to introduce a new cementless HA coated implant and report its minimum 2 year follow up results. Material & method: This is a prospective, multi-centre, consecutive series, clinical outcomes study with 75 patients. Inclusion criteria for the study were age 21- 85 years, BMI <40, osteoarthritis of the hip. Patients were operated using a standard posterolateral approach. The Paragon stem and the Global cup were implanted in a cementless method. Patients were reviewed at 6 weeks, 6 months and two years postoperative. At each visit AQoL 6D, VAS Pain, Oxford Hip Score were recorded. Post-operative X-Rays were reviewed at immediate post-operative, 6 months and two years. Results: Mean duration of surgery was 63.1 min with range of 40-120 min. AQoL over time changed from pre-op mean 50.51, at 6 weeks and at 2 years mean 35.06. Oxford hip score had upward trend from pre-op to post-op 6wks assessments and a plateau in following assessments. VAS pain trajectories, showing a clear downward trend from pre-op to post-op 6wks and a plateau in the following postoperative assessments. Discussion & conclusion: The combination of Paragon stem and Global cup incorporates proven features of successful implants. The unique feature of lateral tension grooves and progressive neck dimension with dual offset options. This combination has shown promising early results with early follow up of a minimum of 2 years, with a 100% survivorship of the stem and 98.7% survivorship overall for any reason and is a good cementless option in THA.

Low Transfusion Rate Attainable in Anterior Approach Total Hip Arthroplasty Utilizing a Modern Protocol

Background: Transfusion is a known risk of total hip arthroplasty (THA). It has been associated with a multitude of medical complications and increased cost. Prior studies report transfusion rates associated with THA, with wide variation, but most cannot differentiate the surgical approach utilized. The anterior approach (AA) for THA has been associated with increased operative time, complications, and blood loss, but little data exists regarding the actual transfusion rate associated with the approach. Methods: We performed a retrospective review of 390 consecutive, elective, primary unilateral AA THA procedures. Patient demographic, clinical and perioperative data was analyzed. A modern perioperative pathway, including a simple protocol to limit blood loss, is defined. Results: The group consisted of a typical inpatient arthroplasty population, with wide ranges of age, body mass index (BMI), and health status. The average age was 64.05 years (+ 10.67, range 27-94). BMI averaged 29.76 kg/m2 (+ 5.98, range 16-47). The majority of patients were American Society of Anesthesiologists (ASA) class 2 (45.6%) or 3 (50.3%), with 10 patients ASA 4 (2.6%). Average preoperative hemoglobin was 13.48 g/dL (+ 1.47, range 9.1-18.2). Operative time averaged 91.22 minutes (+ 14.2). 83.3% of patients received a spinal anesthetic. Most patients were discharged on postoperative day one (93.1%) to home (99%). Estimated blood loss averaged 264mL (+ 95.19, range 100-1000). No patient required perioperative transfusion or readmission for symptomatic anemia within 30 days postoperative. Conclusion: A modern protocol we utilize and define is capable of limiting blood loss and transfusion risk in anterior approach total hip arthroplasty.