Hip – pubmed Results

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In Hospital Outcomes of Total Hip Arthroplasty in the Medicaid Population.

J Surg Orthop Adv. 2019;28(4):281-284

Authors: Schwartz BE, Shah NR, Woon C, Moretti V, Hussain AK, Parekh A, Goldberg B, Osmani F, Gonzalez MH

Abstract
Total hip arthroplasty (THA) is one of the most common orthopaedic procedures. This study's purpose was to evaluate national trends, patient demographics and hospital outcomes for Medicaid patients who underwent a primary THA. The National Hospital Discharge Survey (NHDS) database was queried for patients undergoing THA from 2001-2010. Patients were stratified into two groups based on insurance. We found from 2001-2005, Medicaid accounted for 2.38% of all THA performed, increasing insignificantly to 2.61% between 2006-2010. The Medicaid group was younger (50.3 vs. 65.6 years, p < 0.01). Length of stay was longer for the Medicaid group (4.6 vs. 4.0 days, p < 0.01). Medicaid patients were more likely to be discharged home (53.7% vs. 47.2%, p < 0.01) and less likely to be discharged to rehabilitation facilities (24.4% vs. 29.0%, p < 0.05). In conclusion, we discovered that the rate of Medicaid insurance in patients undergoing primary THA was stable through 2010, prior to the Affordable Care Act. We found Medicaid THA patients had longer length of stay, despite being a mean 15 years younger than the non-Medicaid cohort. Medicaid insurance status should be factored into risk adjustment models to avoid creating additional disincentive to treat the Medicaid population. (Journal of Surgical Orthopaedic Advances 28(4):281-284, 2019).

PMID: 31886765 [PubMed - indexed for MEDLINE]

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Incidence of Periprosthetic Femur Fractures Utilizing the Posterior Approach with a Single Wedge Tapered Stem.

J Surg Orthop Adv. 2019;28(4):277-280

Authors: Formby P, Hong CS, Ryan S, Wellman S, Bolognesi M

Abstract
We sought to determine early periprosthetic femur fracture rate and stem-related failures in primary total hip arthroplasty (THA) performed through a posterior approach with a cementless wedge stem. We reviewed 818 primary THAs in 713 patients with a single wedge tapered titanium component. We used multivariate logistic regression to determine predisposing factors to stem failure. The mean radiographic follow up was 1.6 years. Overall there were eight perioperative femur fractures (0.98%). There were two intraoperative fractures (0.24%), six postoperative fractures (0.73%) and one case of stem subsidence (0.1%). There was a 0.49% rate of operative fractures occurring within 90 days of surgery. There were five stem revisions due to loosening or fracture (0.61%). When excluding infection, the ultimate stem retention rate at latest follow up was 99.3%. Multivariate logistic regression did not find age, sex, body mass index or American Society of Anesthesiologists (ASA) score significantly associated with periprosthetic fracture. (Journal of Surgical Orthopaedic Advances 28(4):277-280, 2019).

PMID: 31886764 [PubMed - indexed for MEDLINE]

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Cost Analysis and Bundled Care of Hip and Knee Replacement.

J Surg Orthop Adv. 2019;28(4):241-249

Authors: Kee J, Mears SC, Edwards PK, Lowry Barnes C

Abstract
Financial success in a bundled payment system requires knowledge of the costs of care throughout the period of risk. Understanding the significant cost-drivers of total joint arthroplasty (TJA) is crucial in this effort. This article inspects the basics of reimbursement under Medicare's bundled care programs as well as some common investigative tools used in the literature to measure cost. Additionally, the effects of standardized enhanced recovery clinical pathways on costs are reviewed. Finally, drivers of implant costs and several proven measures for implant cost-reduction are evaluated. This review provides surgeons and hospitals successful measures to reduce the cost of TJA via enhanced recovery pathways and reduced implant pricing. (Journal of Surgical Orthopaedic Advances 28(4):241-249, 2019).

PMID: 31886758 [PubMed - indexed for MEDLINE]

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What is the importance of canal-to-diaphysis ratio on osteoporosis-related hip fractures?

Eklem Hastalik Cerrahisi. 2019 Dec;30(3):296-300

Authors: Bozkurt HH, Tokgöz MA, Yapar A, Atik OŞ

Abstract
OBJECTIVES: This study aims to investigate whether the ratio of the canal-to-diaphysis in femoral subtrochanteric region is helpful in determining risk before hip fracture.
PATIENTS AND METHODS: The study group consisted of 116 patients with osteoporotic hip fractures (26 males, 90 females; mean age 77.8 years; range, 61 to 89 years) and the control group consisted of 56 subjects (11 males, 45 females; mean age 75.3 years; range, 60 to 83 years). The canal-to-diaphysis ratio of patients in the study group was measured on plain radiographs. The results of the affected side and intact side were compared. To ensure the interobserver reliability of the measurements and to minimize technical errors, the assessments were performed twice (two weeks apart) by two different orthopedic surgeons.
RESULTS: The canal-to-diaphysis ratio was significantly increased in patients with hip fracture compared with the intact side of same patient (p<0.001) and control subjects (p<0.001). According to the results of the receiver operating characteristic analysis, canal-to-diaphysis ratio had a diagnostic value in predicting hip fracture in osteoporosis patients, and the limit value was approximately 0.53 (sensitivity: 81%, specificity: 86%). An index of 0.53 represents a risk of intertrochanteric hip fracture of 89%.
CONCLUSION: This method can be easily applied by all physicians as X-ray device is readily accessible with low cost. The risk of hip fracture should be determined, osteoporosis should be evaluated, and treatment should be started in patients with high risk to take the necessary precautions before the fracture develops.

PMID: 31650928 [PubMed - indexed for MEDLINE]

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Acetabular Lateral View: Effective Fluoroscopic Imaging to Evaluate Screw Penetration Intraoperatively.

Med Sci Monit. 2019 Aug 10;25:5953-5960

Authors: Lin Z, Guo J, Dong W, Zhao K, Hou Z, Zhang Y

Abstract
BACKGROUND Screw penetration into the hip joint is a severe complication during acetabular fracture surgery. The standard fluoroscopic views of the pelvis cannot provide adequate safety during screw insertion. The aim of this research was to determine and evaluate the accuracy of the acetabular lateral view for screw placement. MATERIAL AND METHODS Twenty screws were randomly chosen and intentionally penetrated into the articular surface (1-2 mm), and the remaining 20 screws were extra-articular ones positioned in close proximity to the articular surface. Three surgeons, each evaluating 40 screws, provided a total of 120 rated observations for each screw position. We compared the traditional view or combined with lateral acetabular view with the criterion standard based on unaided visual assessment. A blinded and independent review of each pelvic intraoperative fluoroscopy was made by 3 independent observers. Specificity, sensitivity, positive predictive value, negative predictive value, correct interpretation, intra-class correlation coefficients (ICC), and Youden index were calculated. RESULTS There were significant differences in sensitivity, NPV, correct interpretation, and Youden index between the 2 groups (P<0.05). The ICC was 0.531 when the antero-posterior, iliac, and obturator oblique views were used. The ICC was remarkably increased when using a combination of the ''lateral'' view and the standard views for screw perforation of the joint. CONCLUSIONS Use of the lateral view of the acetabulum can be a complementary method to identify malpositioned screws, and it helps increase the accuracy rate of inserting screws in the treatment of posterior wall fracture.

PMID: 31399554 [PubMed - indexed for MEDLINE]

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A Comprehensive Review of Analgesia and Pain Modalities in Hip Fracture Pathogenesis.

Curr Pain Headache Rep. 2019 Aug 06;23(10):72

Authors: Dizdarevic A, Farah F, Ding J, Shah S, Bryan A, Kahn M, Kaye AD, Gritsenko K

Abstract
PURPOSE OF REVIEW: Hip fracture is common in the elderly population, painful and costly. The present investigation was undertaken to review epidemiology, socio-economic and medical implications, relevant anatomy, and anesthetic and pain modalities of hip fracture.
RECENT FINDINGS: A literature search of PubMed, Ovid Medline, and Cochrane databases was conducted in December 2018 to identify relevant published clinical trials, review articles, and meta-analyses studies related to anesthetic and pain modalities of hip fracture. The acute pain management in these situations is often challenging. Common issues associated with morbidity and mortality include patients' physiological decrease in function, medical comorbidities, and cognitive impairment, which all can confound and complicate pain assessment and treatment. Perioperative multidisciplinary and multimodal approaches require medical, surgical, and anesthesiology teams employing adequate preoperative optimization. Reduction in pain and disability utilizing opioid and non-opioid therapies, regional anesthesia, patient-tailored anesthetic approach, and delirium prevention strategies seems to ensure best outcomes.

PMID: 31388846 [PubMed - indexed for MEDLINE]

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Osteonecrosis of the femoral head with subchondral collapse.

Cleve Clin J Med. 2019 Aug;86(8):511-512

Authors: Piuzzi NS, Anis HK, Muschler GF

PMID: 31385795 [PubMed - indexed for MEDLINE]

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Comparison of Proximal Femoral Nail Antirotation and Dynamic Hip Screw Internal Fixation on Serum Markers in Elderly Patients with Intertrochanteric Fractures.

J Coll Physicians Surg Pak. 2019 Jul;29(7):644-648

Authors: Wang B, Liu Q, Liu Y, Jiang R

Abstract
OBJECTIVE: To compare effect of proximal femoral nail antirotation (PFNA) and dynamic hip screw (DHS) internal fixation on serum inflammatory mediators (CRP, IL-1, IL-6 and TNF-α), myocardial injury markers (cTnT, CK-MB), and Myo-heart failure marker (BNP) in elderly patients with intertrochanteric fractures.
STUDY DESIGN: Experimental study.
PLACE AND DURATION OF STUDY: Department of Orthopedics, The Second Affiliated Hospital of Xuzhou Medical University, China, from January 2016 to February 2018.
METHODOLOGY: A total of 114 patients with intertrochanteric fractures were randomly divided into Group A and Group B, with 57 cases in each group. Group A was treated with PFNA and Group B with DHS internal fixation. Serum CRP, IL-1, IL-6, TNF-α, cTnT, CK-MB, Myo, BNP and surgical indication were compared.
RESULTS: Operation time and weight-bearing time in Group A were shorter than Group B (both p<0.001). Intraoperative blood loss and postoperative drainage volume in Group A were lower than Group B (both p<0.001). On the 7ᵗʰ day after surgery, serum CRP, IL-1, IL-6, TNF-α, cTnT, CK-MB, Myo and BNP in Group A were lower than Group B (all p<0.001).
CONCLUSION: Compared with DHS, PFNA effectively reduced serum inflammatory mediators with less damage to cardiac function and myocardium in elderly patients with intertrochanteric fractures.

PMID: 31253216 [PubMed - indexed for MEDLINE]

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[Bilateral hip fracture in a patient with Down syndrome].

An Sist Sanit Navar. 2019 Aug 23;42(2):231-234

Authors: Díaz de Rada P, Machado V, Villas C, Alfonso M

Abstract
There are few published data available about simultaneous bilateral hip fractures. We present the case of a 56-year-old man with Down syndrome and Alzheimer-like dementia with simultaneous bilateral hip fracture. A bilateral partial hip cemented arthroplasty was performed on this patient. The aim was to avoid the partial burden that could be caused by ostheosynthesis, due to the patient's lack of cooperation arising from his mental deterioration and his problems realizing everyday activities. He was able to walk unaided with complete autonomy until his death fourth years later. In our experience, one stage surgery for bilateral hip prosthesis is safe and provides good results in patients with severe mental impairment.

PMID: 31081501 [PubMed - indexed for MEDLINE]

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Mild or Borderline Hip Dysplasia: Are We Characterizing Hips With a Lateral Center-Edge Angle Between 18° and 25° Appropriately?

Am J Sports Med. 2019 01;47(1):112-122

Authors: McClincy MP, Wylie JD, Yen YM, Novais EN

Abstract
BACKGROUND: Controversy surrounds the classification and treatment of hips with a lateral center-edge angle (LCEA) between 18° and 25°. It remains undetermined as to whether periacetabular osteotomy (PAO) or arthroscopic surgery is best used to treat this patient population.
HYPOTHESIS: Patients with hip pain and mild or borderline acetabular dysplasia defined by an LCEA between 18° and 25° have different features of acetabular and femoral morphology, as determined by other relevant radiographic measures assessing the anterior and posterior acetabular walls, anterior coverage of the femoral head by the acetabulum, and femoral head and neck junction sphericity.
STUDY DESIGN: Cross-sectional study; Level of evidence, 3.
METHODS: A retrospective review of patients who had an LCEA between 18° and 25° undergoing hip preservation between January 2010 and December 2015 with either PAO or hip arthroscopic surgery was performed. Anteroposterior, Dunn lateral, and false profile radiographs were used to measure the LCEA, Tönnis angle, anterior center-edge angle (ACEA), anterior wall index (AWI) and posterior wall index (PWI), femoral epiphyseal acetabular roof (FEAR) index and posterior to anterior wall index, and alpha angle and femoral neck-shaft angle. An agglomerative hierarchical clustering analysis was then performed on the continuous radiographic variables to identify different subtypes of hip pathomorphology among the study cohort. There were sex-specific trends in hip morphology. Therefore, we proceeded to perform separate cluster analyses for each sex. Multivariate logistic regression was used to identify radiographic parameters for distinguishing between female patients who underwent hip arthroscopic surgery versus PAO.
RESULTS: Ninety-eight patients with hip pain and an LCEA between 18° and 25° underwent surgery in the study period, 77 (78%) were female, and 81 (82%) had complete radiographs for cluster analyses. The mean age was 22.6 years. Hip arthroscopic surgery was performed in 40 (41%) patients, and PAO was performed in 58 (59%) patients. The ACEA (45%), FEAR index (34%), and AWI (30%) were the most commonly abnormal radiographic parameters among all patients. In female patients, the ACEA (55%), FEAR index (42%), and AWI (34%) were the most commonly abnormal radiographic parameters. In male patients, the PWI (48%) was the most common radiographic abnormality. For female patients, 3 clusters representing different patterns of hip morphology were identified: acetabular deficiency with cam morphology, lateral acetabular deficiency, and anterolateral acetabular deficiency. For male patients, 3 clusters were also identified: posterolateral acetabular deficiency with global cam morphology, posterolateral acetabular deficiency with focal cam morphology, and lateral acetabular deficiency without cam morphology. The ACEA (odds ratio [OR], 47.7 [95% CI, 9.6-237.6]; P < .001) and AWI (OR, 3.9 [95% CI, 1.0-15.0]; P = .049) were identified as independent factors predicting which procedure was performed in female patients.
CONCLUSION: A comprehensive evaluation of radiographic parameters in patients with an LCEA between 18° and 25° identified sex-specific trends in hip morphology and showed a large proportion of dysplastic features among these patients. An isolated assessment of the LCEA is an oversimplistic approach that may jeopardize appropriate classification and may provide insufficient data to guide the treatment of hips with additional features of dysplasia and instability.

PMID: 30781992 [PubMed - indexed for MEDLINE]

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Is Hip Arthroscopy Effective in Patients With Combined Excessive Femoral Anteversion and Borderline Dysplasia? A Match-Controlled Study.

Am J Sports Med. 2019 01;47(1):123-130

Authors: Chaharbakhshi EO, Hartigan DE, Perets I, Domb BG

Abstract
BACKGROUND: Appropriate patient selection is critical when hip arthroscopy is considered in the setting of borderline dysplasia (BD). It is presumable that excessive femoral anteversion (EFA) and BD may contraindicate arthroscopy.
HYPOTHESIS: Patients with combined EFA and BD (EFABD) demonstrate significantly inferior short-term outcomes after arthroscopic labral preservation and capsular closure when compared with a similar control group with normal lateral coverage and femoral anteversion.
STUDY DESIGN: Cohort study; Level of evidence, 3.
METHODS: Data were prospectively collected and retrospectively reviewed on patients undergoing hip arthroscopy between April 2010 and November 2014. The EFABD group's inclusion criteria were BD (lateral center-edge angle, 18°-25°), labral tear, capsular closure, and femoral version ≥20°, as well as preoperative modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale. Exclusion criteria were workers' compensation, preoperative Tönnis grade >1, microfracture, abductor pathology, or previous ipsilateral hip surgery or conditions. Patients in the EFABD group were matched 1:2 to a similar control group with normal coverage and femoral anteversion by age at surgery ± 6 years, sex, body mass index ± 5, acetabular Outerbridge grade (0, 1 vs 2, 3, 4), and iliopsoas fractional lengthening.
RESULTS: Sixteen EFABD cases were eligible for inclusion, and 100% follow-up was obtained at ≥2 years postoperatively. Twelve EFABD cases were matched to 24 control cases. Mean femoral version was 22.4° in the EFABD group and 10.2° in the control group ( P = .01). Mean lateral center-edge angle was 22.1° in the EFABD group and 31.5° in the control group ( P < .0001). Acetabuloplasty was performed significantly more frequently in the control group ( P = .0006). No other significant differences were found regarding demographics, findings, procedures, or preoperative scores. At latest follow-up, the EFABD group demonstrated significantly lower mean modified Harris Hip Score (76.1 vs 85.9; P = .005), Nonarthritic Hip Score (74.8 vs 88.5; P < .0001), Hip Outcome Score-Sports Specific Subscale (58.3 vs 78.4; P = .02), and patient satisfaction (7.1 vs 8.3; P = .005). There were 4 secondary surgical procedures (33.3%) in the EFABD group and 1 (4.2%) in the control group ( P = .03). One patient in each group required arthroplasty.
CONCLUSION: Patients treated with arthroscopic labral preservation and capsular closure in the setting of EFABD demonstrated significant improvements from presurgery to latest follow-up. However, their results are significantly inferior when compared with a matched-controlled group. Consideration of periacetabular osteotomy or femoral osteotomy may be warranted in the setting of EFABD to achieve optimal benefit.

PMID: 30781991 [PubMed - indexed for MEDLINE]

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Bone ongrowth of a cementless silver oxide-containing hydroxyapatite-coated antibacterial acetabular socket.

J Orthop Sci. 2019 Jul;24(4):658-662

Authors: Kawano S, Sonohata M, Eto S, Kitajima M, Mawatari M

Abstract
BACKGROUND: The silver oxide-containing hydroxyapatite-coated socket (KYOCERA, Osaka, Japan) is a cementless antibacterial implant that has both the osteoconductivity of the HA and the antibacterial activity of silver. The silver oxide-containing hydroxyapatite coating was shown to have good osteoconductivity and new bone formation in vitro and in vivo. However, the histological bone ongrowth of this implant has not been proven in a clinical study.
METHODS: We analyzed bone ongrowth using two silver oxide-containing hydroxyapatite-coated sockets that were removed in revision total hip arthroplasty for recurrent dislocation. A histomorphometric analysis was performed using a scanning electron microscope (SEM) connected to a CCD camera and an elemental analysis was performed by energy-dispersive elemental spectrometry (EDS).
RESULT: A white structure thought to be osseous tissue was attached to the retrieved socket surface macroscopically, and histological bone ongrowth of the silver oxide-containing hydroxyapatite coating of the socket was confirmed by SEM. In addition, the presence of silver in the silver oxide-containing hydroxyapatite coating was confirmed in an elemental analysis by EDS.
CONCLUSION: Histologically, the silver oxide-containing hydroxyapatite-coated socket presented bone ongrowth in this clinical study.

PMID: 30718042 [PubMed - indexed for MEDLINE]

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Effects of bupivacaine or levobupivacaine on cerebral oxygenation during spinal anesthesia in elderly patients undergoing orthopedic surgery for hip fracture: a randomized controlled trial.

BMC Anesthesiol. 2019 01 31;19(1):17

Authors: Vives R, Fernandez-Galinski D, Gordo F, Izquierdo A, Oliva JC, Colilles C, Pontes C

Abstract
BACKGROUND: Bupivacaine and levobupivacaine have similar pharmacokinetic and pharmacodynamic characteristics, and are used regularly in spinal anesthesia. Whether potential differences in their hemodynamic and anesthetic profiles could determine a differential risk of complications in elderly subjects, is controversial. The main objective was to compare the effects of intrathecally administered levobupivacaine (LB) versus bupivacaine (B), on regional cerebral O2 saturation during spinal anesthesia, cognitive status and neurological complications in elderly patients undergoing surgery for hip fracture.
METHODS: This was a randomized, controlled, single blind study. 58 patients aged 70 or older undergoing surgery for hip fracture with spinal anesthesia were allocated with a 1:1 ratio to receive LB or B, combined with fentanyl 15 μg, by intrathecal route. The primary outcome was the proportion of intraoperative time with regional cerebral desaturation (≥20% reduction in regional cerebral oxygen saturation from baseline), monitored by near -infrared spectroscopy. Secondary endpoints included hemodynamic parameters, level of sensory and motor block, changes in Short Portable Mental Status Questionnaire (SPMSQ), and neurological complications.
RESULTS: The mean percentage of intraoperative time with desaturation in the B group was 6.1% (SD: 17.5) and 4.7% (SD: 11.9) in the left and right hemisphere respectively; in the LB group the mean was 4.8% (SD: 11.4) in the left hemisphere and 2.4% (SD: 8.3) in the right one. No statistically significant differences were found between treatment groups. The level of sensory block at the start of surgery was lower for LB than for B (Th10 vs Th8, p:0.047) and motor block at 15 min was lower for LB (2.5 vs 3, p:0.009). No differences in postoperative SPMSQ were observed. Neurological complications such as confusional state, agitation or disorientation were reported in 50% of patients in the B group and 21.4% of patients in the LB group, p = 0.05.
CONCLUSIONS: No statistically significant differences in regional cerebral oxygen saturation or hemodynamic parameters were observed between both treatment groups. Bupivacaine and levobupivacaine differed in sensory and motor block achieved. While no differences were observed in cognitive impairment measured by the SPMSQ between treatment groups neurological complications reported by the physician were more frequent with bupivacaine.
TRIAL REGISTRATION: European Union Clinical Trials Register ( EudraCT 2013-000846 -20 ) (April 9th, 2013). ClinicalTrials.gov ( NCT01960543 ) (September 23rd, 2013).

PMID: 30704463 [PubMed - indexed for MEDLINE]

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Component positioning and ceramic damage in cementless ceramic-on-ceramic total hip arthroplasty.

J Orthop Sci. 2019 Jul;24(4):643-651

Authors: Castagnini F, Valente G, Crimi G, Taddei F, Bordini B, Stea S, Toni A

Abstract
BACKGROUND: In ceramic-on-ceramic (CoC) total hip arthroplasty (THA), component positioning demonstrated to influence the bearing damage: however the connection between angles and clinical outcomes at long-term follow-ups is currently lacking. Aims of this study were: the computer tomography (CT) assessment of component positioning in CoC THAs; the correlation analysis between positioning and ceramic damage; the identification of safe zones.
METHODS: 91 consecutive post-operative CT scans including two types of CoC implants, with a mean follow-up of 12 ± 4.4 years, were evaluated. III generation (74.2%) and IV generation (25.8%) CoC surfaces were included. The angle measurements (cup abduction, anteversion, cup tilt, stem antetorsion, sacral slope) were automated using a CT-based software. The combined anteversion was assessed as well as the cup-neck position at -15°, 0°, 45° and 90° of flexion. Ceramic damage was diagnosed using synovial fluid analyses and radiological criteria.
RESULTS: 63.7% of THAs was inside the cup abduction target 30°-45° and 68.1% was inside the cup anteversion target 5°-25°. 19 patients (20.9%) showed signs of ceramic damage. High cup abduction and high cup-neck 45° minimum angle (which stood for high abduction and extreme combined version) significantly correlated with ceramic damage. No demographical features apart III generation ceramic bearings influenced the results. No safe zones could be detected.
CONCLUSIONS: In CoC THA, no safe zones can be described. However it is important to avoid cup inclination over 45° and a combination of steep cup and extreme combined version.

PMID: 30612885 [PubMed - indexed for MEDLINE]

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Bone infarction of the hip after hand allotransplantation: A case report.

Microsurgery. 2019 May;39(4):349-353

Authors: Kuo YR, Chen CC, Wang JW, Chang JK, Huang YC, Pan CC, Lin YC, Wu RW, Lee CH

Abstract
Vascularized composite allotransplantation represents as an emerging field in reconstructive surgery. However, some complications can be associated with the procedure. The authors describe a case of bone infarctions of the bilateral hip joints following the first hand allotransplantation in Taiwan. A 45-year-old man who experienced a traumatic amputation of the distal third of his forearm received a hand transplantation from a brain-dead donor. Immunosuppression included antithymocyte globulins, and bolus methylprednisolone (Solu-Medrol) was used for the induction. The maintenance therapy protocol included systemic tacrolimus, mycophenolate mofetil, and prednisone. The patient discontinued the systemic steroid 15 months after surgery. Two episodes of acute rejections were observed at 105 and 810 days after surgery. These signs disappeared after pulse therapy with Solu-Medrol, titration with tacrolimus, and topical immunosuppressive creams (tacrolimus and clobetasol). However, the patient felt pain in both hips after long periods of standing 30 months after the transplantation. A pelvic radiograph and magnetic resonance imaging revealed avascular necrosis (AVN) in both hip joints. Because of the progressive worsening of the pain, the patient underwent a decompression surgery on the left hip involving a fibula bone graft. The patient underwent a right hip hemi-arthroplasty with a bipolar prosthesis 3 months later. The patient remained in good health without major complications. These findings indicate that systemic steroids and tacrolimus might be the major predisposing factors for the induction of AVN after hand allotransplantation.

PMID: 30481394 [PubMed - indexed for MEDLINE]

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Identifying high-cost episodes in lower extremity joint replacement.

Health Serv Res. 2019 02;54(1):117-127

Authors: Philpot LM, Swanson KM, Inselman J, Schoellkopf WJ, Naessens JM, Borah BJ, Peterson S, Gladders B, Shah ND, Ebbert JO

Abstract
OBJECTIVES: To evaluate the ability of claims-based risk adjustment and incremental components of clinical data to identify 90-day episode costs among lower extremity joint replacement (LEJR) patients according to the Centers for Medicare & Medicaid Services (CMS) Comprehensive Care for Joint Replacement (CJR) program provisions.
DATA SOURCES: Medicare fee-for-service (FFS) data for qualifying CJR episodes in the United States, and FFS data linked with clinical data from CJR-qualifying LEJR episodes performed at High Value Healthcare Collaborative (HVHC) and Mayo Clinic in 2013. HVHC and Mayo Clinic populations are subsets of the total FFS population to assess the additive value of additional pieces of clinical data in correctly assigning patients to cost groups.
STUDY DESIGN: Multivariable logistic models identified high-cost episodes.
DATA COLLECTION/EXTRACTION METHODS: Clinical data from participating health care systems merged with Medicare FFS data.
PRINCIPAL FINDINGS: Our three populations consisted of 363 621 patients in the CMS population, 4881 in the HVHC population, and 918 in the Mayo population. When modeling per CJR specifications, we observed low to moderate model performance (CMS C-Stat = 0.714; HVHC C-Stat = 0.628; Mayo C-Stat = 0.587). Adding CMS-HCC categories improved identification of patients in the top 20% of episode costs (CMS C-Stat = 0.758, HVHC C-Stat = 0.692, Mayo C-Stat = 0.677). Clinical variables, particularly functional status in the population for which this was available (Mayo C-Stat = 0.783), improved ability to identify patients within cost groups.
CONCLUSIONS: Policy makers could use these findings to improve payment adjustments for bundled LEJR procedures and in consideration of new data elements for reimbursement.

PMID: 30394529 [PubMed - indexed for MEDLINE]

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