BACKGROUND:Periprosthetic femur fractures are a known complication after hip hemiarthroplasty (HA) in geriatric patients. The relationship between femoral stem design and fracture risk remains unclear. This study aimed to assess (1) the association between stem geometry and fixation on periprosthetic femur fracture risk and (2) the effect of a femoral stem collar. METHODS:The American Joint Replacement Registry data were analyzed for HA cases in patients aged 70+ years from 2012 to 2021. We identified 56,828 primary HAs for the diagnosis of femoral neck fracture. Patient demographics and revision surgery for periprosthetic femur fracture in the form of open reduction with internal fixation or revision arthroplasty were documented. Stems were categorized into tapered wedge or fit and fill, and cemented stems were categorized into composite beam or taper slip. Cox models and Benjamini-Hochberg adjustments were used for statistical analysis. RESULTS:Cemented composite beam stems accounted for 38% of implants, followed by fit-and-fill stems at 32%, tapered wedge stems at 29%, and cemented taper slip stems at 1%. A collar was present in all cemented composite beam stems, 23% of tapered wedge stems, and 20% of fit-and-fill stems. After applying inverse probability weighting adjustment, cemented composite beam stems showed a markedly lower periprosthetic femur fracture risk over other stems. Compared with cemented composite beam stems, collarless tapered wedge demonstrated a markedly higher hazard ratio (HR) (3.63; P < 0.001), as did both collarless (HR, 3.4; P < 0.001) and collared fit-and-fill stems (HR, 3.45; P < 0.001). The presence of a collar reduced periprosthetic femur fracture risk across all designs, with the most pronounced reduction seen in tapered wedge stems (0.90% versus 0.41%). CONCLUSION:For HA in patients aged 70 years and older, cemented composite beam stems with a collar were associated with the lowest risk of periprosthetic femur fractures in the American Joint Replacement Registry database. However, these findings reflect implant utilization patterns up to 2021 and may not fully account for the recent rise in triple taper collared stem use. Surgeons should consider these implants when selecting fixation strategies for HA. LEVEL OF EVIDENCE:Level III.

OBJECTIVES:To compare the periprosthetic fracture rates of three stem designs: cemented, press-fit fit-and-fill, and tapered wedge for hemiarthroplasty in geriatric patients with femoral neck fractures. METHODS:Design: Retrospective review. SETTING:Two institutions, including one level I trauma center. PATIENT SELECTION CRITERIA:Patients aged 70 years or older with a displaced femoral neck fracture (OTA/AO 31B) treated with press-fit or cemented hemiarthroplasty were included. Patients treated with total hip arthroplasty, conversion procedures, concomitant acetabular fracture, and pathologic fractures were excluded. OUTCOME MEASURES AND COMPARISONS:Rates of intraoperative and postoperative periprosthetic femur fracture (PFF), 30-day and 1-year mortality, operative time, length of stay, and rate of reoperation were compared between stem subtypes. RESULTS:A total of 758 consecutive patients (404 tapered wedge, 227 fit-and-fill, and 127 cemented) were included. The mean follow-up was 10.1±14.1, 13.0±16.6, 6.8±10.9 months, for tapered wedge, fit-and-fill, and cemented stems, respectively. Tapered wedge stems had an average age of 83.6 years (range 70-100) with 29.2% male; fit-and-fill stems had an average age of 84.3 years (70-102) with 34.8% male; and cemented stems had an average age of 84.1 years (range 70-100) with 26.0% male. 56 (41 intraoperative and 15 postoperative) PFFs were identified. The rate of PFF between tapered wedge (9.4%), fit-and-fill (4.8%), and cemented stems (5.5%) differed significantly (P = 0.01). Fit-and-fill implants had a lower rate of PFF than tapered wedge implants (P = 0.04) and were equivalent to cemented fixation (P = 0.78). Among intraoperative PFFs, tapered wedge stems had a significantly higher calcar fracture rate than fit-and-fill (P = 0.03) and cemented (P = 0.02) stems. Use of fit-and-fill stems did not result in a higher rate of intraoperative calcar fracture than cemented stems (P = 0.85). Postoperative PFF reoperation rates did not reach statistical significance between fit-and-fill (1.8%), tapered wedge (1.7%), and cemented (0.8%) stems (P = 0.39). Fit-and-fill stems had significantly less operative time than cemented stems (93.6 ± 30.0 vs 108.7 ± 41.0 minutes, respectively; P <0.001). No differences in 30-day (4.5%, 4.9%, 5.5%; P = 0.88) or 1-year mortality (17.1%, 17.0%, 22.4%; P = 0.37) were observed between tapered wedge, fit-and-fill, and cemented stems, respectively. CONCLUSIONS:When treating displaced femoral neck fractures, tapered wedge stems may result in a higher rate of PFF. As an alternative, fit-and-fill stems may lower PFF rates without the risk of bone cement implant syndrome and longer operative times. LEVEL OF EVIDENCE:Therapeutic Level III.

Hemiarthroplasty (HA) has been the traditional gold standard for managing displaced femoral neck fractures (DFNFs) in elderly patients, offering satisfactory functional outcomes with lower technical demands. However, total hip arthroplasty (THA) has emerged as an alternative because of its superior long-term function, despite concerns regarding higher early dislocation rates. This review evaluates the comparative outcomes of HA and THA in patients aged 70 years or older to guide optimal treatment selection. A systematic review of PubMed, Embase, and MEDLINE was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies comparing HA and THA in patients aged 70 years or older with DFNFs were included. Data extraction focused on functional outcomes, dislocation rates, revision rates, operative time, blood loss, length of stay, infection, and mortality. Risk of bias was assessed using the Cochrane RoB-2 tool and Methodological Index for Non-Randomized Studies criteria. Five studies (2 RCTs and 3 retrospective cohorts) comprising 661 patients (346 HA and 315 THA) met the inclusion criteria. Functional outcomes, primarily assessed by the Harris Hip Score, favored THA at long-term follow-up, although one study found no difference at 12 years. Dislocation occurred exclusively in THA patients (0-9.1%), with higher rates associated with the posterior approach. Revision rates varied, with one randomized controlled trials reporting a higher reoperation rate for HA, whereas another found no significant difference. THA was associated with longer operative times (14-28 minutes) and greater blood loss (170 mL higher on average). Length of stay findings were inconsistent. Infection rates were low (0-3.6%), and mortality rates showed no significant difference, although long-term follow-up revealed high overall mortality (23.3%-76.6%). Although THA provides superior function in elderly patients with DFNFs, it carries increased early complications, particularly dislocation risk. Patient selection should be individualized, considering frailty, mobility, and surgical risk. Additional high-quality RCTs are needed to clarify the optimal treatment strategy for functionally active elderly patients.

IntroductionArthrofibrosis is a debilitating postoperative complication, and a major cause of patient dissatisfaction following total knee arthroplasty (TKA). There is no consensus regarding the optimal treatment for stiffness after TKA. For cases not amenable to manipulation under anesthesia (MUA), one component or full revision are both suitable options. In a value-based healthcare era, maximizing cost-effectiveness with optimized clinical outcomes for patients remains the ultimate goal. As such, we compared (1) Knee Injury and Osteoarthritis Outcome Scores for Joint Replacement (KOOS, JR), (2) ranges of motion (ROM), as well as (3) complication rates, including MUA and lysis of adhesions (LOA), between polyethylene exchange and full component revision for TKA arthrofibrosis.MethodsPatients were queried from an institutional database who underwent revision TKA for arthrofibrosis between January 1, 2015, and April 31, 2021. There were 33 patients who underwent full revision and 16 patients who underwent polyethylene exchange. Demographics and baseline characteristics between the cohorts were analyzed. Postoperative outcomes included MUA, LOA, and re-revision rates as well as KOOS, JR, and extension and flexion ROM at a mean follow-up of 3.8 years. Baseline comorbidities, including age, body mass index, alcohol use, tobacco use, and diabetes, were comparable between the full revision and polyethylene exchange revision cohorts (P > 0.05). The one and full component revisions had similar preoperative KOOS, JR (43 versus 42, P = 0.85) and flexion (81 versus 82 degrees, P = 0.80) versus extension (11 versus 11 degrees, P = 0.87) ROM.ResultsThe full component revision had higher KOOS, JR (65 versus 55, P = 0.04) and flexion (102 versus 92 degrees, P = 0.02), but similar extension (3 versus 3 degrees, P = 0.80) ROM at final follow-up compared to the polyethylene exchange revision, respectively. MUA (18.2 versus 18.8%, P = 0.96) and LOA (2.0 versus 0.0%, P = 0.32) rates were similar between full component and polyethylene exchange revisions. There was one re-revision (3.0%) for the cohort of patients who initially underwent full revision. There were four full re-revisions (25.0%) and two polyethylene exchange re-revisions (12.5%) performed in the cohort of patients who initially underwent a polyethylene exchange revision.ConclusionThe full component revision for stiffness after TKA showed favorable KOOS, JR, ROM, and outcomes in comparison to the polyethylene exchange revision. While the optimal treatment for stiffness after TKA is without consensus, this study supports the use of the full component revision when applied to the institutional population at hand. It is imperative that homogeneity exists in preoperative definitions, preoperative baseline patient demographics, ROM and function levels, outcome measures, preoperative indications, as the inclusion of clinical data that assesses complete exchange, single exchange, and tibial insert exchange.

Introduction:Robotic assisted total knee arthroplasty has become an increasingly popular technique over the past several years. Manual total knee arthroplasty can be associated with acute blood loss anemia. Instrumentation of the femoral canal with the alignment guide may in part contribute to this blood loss. Because the femoral canal is not entered during robotic assisted total knee arthroplasty, the blood loss may be lower compared to that seen in manual total knee arthroplasty. The purpose of this study was to determine if acute blood loss is greater in manually instrumented total knee arthroplasty versus robotic assisted total knee arthroplasty. Materials and methods:This retrospective cohort study was performed in a large tertiary academic hospital network by two fellowship trained surgeons. Patients underwent either robotic assisted or manually instrumented total knee arthroplasty and were assessed for postoperative acute blood loss anemia, defined as hemoglobin <13 g/dL for males or <12 g/dL for females plus a 2 g/dL drop from preoperative levels, as well as postoperative drop in hemoglobin. Results:A total of 75 patients were included in each study arm. There was no significant difference (p > 0.05) in postoperative hemoglobin in robotic assisted (2.1 g/dL) compared to manually instrumented total knee arthroplasty (2.1 g/dL). There was no significant difference in the incidence of postoperative acute blood loss anemia between robotic assisted (45 %) and manually instrumented total knee arthroplasty (39 %). Higher BMI and increased age were protective against postoperative drop in hemoglobin. These protective effects were not significant when controlling for confounding variables. Surgical time was significantly longer for robotic assisted (99 min) versus manually instrumented total knee arthroplasty (86 min) (p < 0.001). Conclusions:There is no significant difference in acute blood loss when comparing patients undergoing robotic assisted and manually instrumented total knee arthroplasty.

IntroductionThe use of ChatGPT (Generative Pretrained Transformer), which is a natural language artificial intelligence model, has gained unparalleled attention with the accumulation of over 100 million users within months of launching. As such, we aimed to compare: 1) orthopaedic surgeons’ evaluation of the appropriateness of the answers to the most frequently asked patient questions after total hip arthroplasty (THA); and 2) patients’ evaluation of ChatGPT and arthroplasty-trained nurses responses to answer their postoperative questions.MethodsWe prospectively created 60 questions to address the most commonly asked patient questions following THA. We obtained answers from arthroplasty-trained nurses and from the ChatGPT-3.5 version for each of the questions. Surgeons graded each set of responses based on clinical judgment as 1) “appropriate,” 2) “inappropriate” if the response contained inappropriate information, or 3) “unreliable” if the responses provided inconsistent content. Each patient was given a randomly selected question from the 60 aforementioned questions, with responses provided by ChatGPT and arthroplasty-trained nurses, using a Research Electronic Data Capture (REDCap) survey hosted at our local hospital.ResultsThe three fellowship-trained surgeons graded 56 out of 60 (93.3%) responses for the arthroplasty-trained nurses and 57 out of 60 (95.0%) for ChatGPT to be “appropriate.” There were 175 out of 252 (69.4%) patients who were more comfortable following the ChatGPT responses and 77 out of 252 (30.6%) who preferred arthroplasty-trained nurses’ responses. However, 199 out of 252 patients (79.0%) responded that they were “uncertain” in regards to trusting AI to answer their postoperative questions.ConclusionChatGPT provided appropriate answers from a physician perspective. Patients were also more comfortable with the ChatGPT responses than those from arthroplasty-trained nurses. Inevitably, its successful implementation is dependent on its ability to provide credible information that is consistent with the goals of the physician and patient alike.

Introduction Outpatient total joint arthroplasty (TJA) is gaining popularity in the United States. With a shift towards value-based healthcare and bundled payment models, the importance of safe discharge after TJA is pertinent in reducing readmissions and subsequent cost of care. However, many acute issues or complications may not occur until after discharge which can result in emergency department visits and readmission. Our study aims to characterize the effect of remote monitoring devices on acute postoperative recovery in TJA discharged within 24 h. We hypothesized there would be a decreased readmission rate in the remote home monitoring cohort. Methods This prospective cohort compared 50 outpatient TJAs (primary total hip and total knee replacements) defined as discharged within 24 h with a remote home monitoring device to 50 outpatient TJAs who did not receive remote monitoring. Demographics, hospital length of stay, American Society of Anesthesiology scores, and Charlson Comorbidity Index were compared with no significant difference observed between cohorts (p > 0.05). Patients’ vital signs were transmitted to a virtual response center for up to 48 h after discharge. An on-call medical team reviewed the transmissions and if prompted, would contact the patient to troubleshoot and triage. Primary outcome was 30-day hospital readmissions rates, while 30-day ED visits and patient satisfaction scores for the remote home monitoring were measured as secondary outcomes. Results Within the remote monitoring cohort there was a 20 % incidence (10 patients) of abnormal vitals captured and 2 patients visited the ED, however there were no readmissions attributed to this group. Readmission rates and ED visits in the control non-monitored group were significantly higher at 12 % (p = 0.03), secondary to syncope, uncontrolled postoperative pain, cellulitis, hip dislocations, and postoperative fever. Of the patients who received remote monitoring, 14 % had trouble connecting the device to their smartphone, 44 % felt home monitoring helped in their care while recovering at home, 52 % made them feel safer, and 70 % would recommend this program. Conclusions Remote home monitoring with a virtual response team after outpatient TJA is a feasible way to mitigate readmissions in the acute postoperative period and increase patient satisfaction. Efforts to minimize costs should not be implemented at the expense of patients’ health outcomes with a goal to find an appropriate balance between both agendas. Level of evidence Therapeutic Level III.

Introduction In the face of an ongoing opioid epidemic and an aging population, the utilization of a successful multimodal pain regimen in patients undergoing total knee arthroplasty (TKA) is vital. This study looks to explore the effect of different types of anesthesia in addition to a multimodal pain regimen on post-operative outcomes after undergoing TKA. Materials and methods From January 2016 to December 2022, 783 charts of patients undergoing an elective TKA were reviewed. Patients undergoing primary, isolated, and unilateral TKA procedures were included. Patients were grouped into three study arms: 1) general anesthesia (GA); 2) general anesthesia with a local anesthetic adductor canal block (GA + ACB); 3) spinal anesthesia with local anesthetic adductor canal block (SA + ACB). Patients who received other anesthesia types or received ACB utilizing liposomal bupivacaine were excluded. Results Of the 420 included patients, 63 patients received GA, 148 GA + ACB, and 209 SA + ACB. Patients in the SA + ACB group had a shorter LOS compared to both the GA + ACB and GA groups (p < 0.01. The SA + ACB group had the lowest daily average OME requirement (p < 0.01). Finally, patients in the SA + ACB group had the lowest average total cost of $11,683.91 (p < 0.01). Discussion Spinal anesthesia with adductor canal block is effective in decreasing opioid usage and improving postoperative outcomes after TKA. Surgeons and anesthesiologists should look to utilize this anesthetic option along with a multimodal regimen when deciding how to best manage postoperative pain after TKA procedures. Level of evidence Level III.

CASE A 29-year-old man sustained a near-complete laceration to the left pectoralis major muscle belly. The muscle and epimysium were repaired using the Kragh technique-a combination of running interlocked and Mason-Allen stitches. At the 6-year follow-up, the patient had an excellent outcome as measured by clinical scores (Short Form Survey-36, Disabilities of the Arm, Shoulder, and Hand, and American Shoulder and Elbow Surgeons Score), bench press, cosmesis, and magnetic resonance imaging. CONCLUSIONS Acute traumatic open pectoralis muscle belly tears may be successfully repaired in select patients using the Kragh technique with excellent postoperative function and cosmesis.

Over the next decade, orthopedic surgeons will encounter an increasing number of periprosthetic fractures of the femur after hip arthroplasty. This rise is directly related to the increasing numbers of primary and revision hip arthroplasties being performed and the aging of the population. The Vancouver classification is the most widely used classification system for periprosthetic fractures of the femur occurring after hip arthroplasty. This classification considers the location of the fracture in relation to the femoral stem, the stability of the femoral stem, and the availability of femoral bone stock for revision. Most Vancouver AG and AL fractures can be treated nonsurgically, the exceptions being fractures associated with osteolysis and clamshell fractures of the lesser trochanter. B and C type fractures usually require operative intervention. Both Vancouver B1 and C types can be treated with fracture fixation alone, as the femoral implant is stable. Vancouver types B2 and B3 require femoral revision as the implant is loose. Distinguishing between types B1 and B2 can be difficult from radiographs alone and may require computed tomography and intraoperative testing.

» The incidence of displaced femoral neck fractures among elderly patients is increasing as the population ages. » Historically, the preferred treatment for displaced femoral neck fractures in elderly patients has been hemiarthroplasty with use of cemented fixation of the implant. However, there is evidence that this technique may be associated with fat embolization and subsequent cardiopulmonary arrest in the early postoperative period. Cementing techniques are also associated with increased operative time when compared with cementless techniques. » There is increasing evidence that, among elderly patients, the use of uncemented hemiarthroplasty has equivalent functional outcomes and overall mortality rates when compared with the use of hemiarthroplasty with cemented fixation. The main complication associated with uncemented hemiarthroplasty is intraoperative periprosthetic fracture.

Compared with other proximal femoral fractures, subtrochanteric fractures are at a higher risk for nonunion because of the high deforming forces in this region, the associated increased risk of malreduction, and the risk of poor bone healing secondary to bisphosphonate use frequently associated with these fractures. Further understanding of nonunion of subtrochanteric fractures is of increasing importance given the rise in incidence of subtrochanteric hip fractures. Surgeons should be aware of risk factors for nonunion and techniques for prevention as well as surgical management and complications associated with surgical implantation devices. Surgeons should also consider using adjuncts including bone-grafting and biologic agents.

Background: Many orthopedic surgeons decline to perform total knee arthroplasty on patients for whom the use of blood components are not an option due to the perceived risk ofacute blood loss-related anemia and subsequent mortality. While tourniquets were previously believed to reduce blood loss during total knee arthroplasty, recent studies suggest similar volumes of blood loss and increased risk of other complications when performed with using a tourniquet. Antifibrinolytics are a safe alternative to tourniquets in reducing blood loss in total knee arthroplasty. Materials and Methods: The current study analyzed the use ofanttfibrinolytics in Jehovah's Witness patients for total knee arthroplasty performed without a tourniquet. Hemoglobin values were measured on 64 patients preoperatively, 1 hour postoperative, and 72 hours postoperatively. Relative change in hemoglobin was analyzed by the t-test. Results: The average drop in hemoglobin from preoperatively to postoperatively was 1.61 g/dl (p < 0.001). At a mean follow-up of 20 months (range: 1 to 73 months) there was one incidence ofa deep vein thrombosis, one deep infection requiring a two-stage revision, and three patients requiring manipulation for stiffitess. There were no pulmonary embolisms (PEs) and a 0% mortality rate. Conclusions: Total knee arthroplasty in Jehovah's Witness patients can be done safely and efficiently using anttfibrinolytic therapy without a tourniquet.

SHORT syndrome is an extremely rare congenital condition due to a chromosomal mutation of the PIK3R1 gene found at 5q13.1. SHORT is a mnemonic representing six manifestations of the syndrome: (S) short stature, (H) hyperextensibility of joints and/or inguinal hernia, (O) ocular depression, (R) Rieger anomaly, and (T) teething delay. Other key aspects of this syndrome not found in the mnemonic include lipodystrophy, triangular face with dimpled chin (progeroid facies, commonly referred to as facial gestalt), hearing loss, vision loss, insulin resistance, and intrauterine growth restriction (IUGR). 3q duplication syndrome is rare syndrome that occurs due to a gain of function mutation found at 3q25.31-33 that presents with a wide array of manifestations including internal organ defects, genitourinary malformations, hand and foot deformities, and mental disability. We present a case of a 2 year and 3 month old male with SHORT syndrome and concurrent 3q duplication syndrome. The patient presented at birth with many of the common manifestations of SHORT syndrome such as bossing of frontal bone of skull, triangular shaped face, lipodystrophy, micrognathia, sunken eyes, and thin, wrinkled skin (progeroid appearance). Additionally, he presented with findings associated with 3q duplication syndrome such as cleft palate and cryptorchidism. Although there is no specific treatment for these conditions, pediatricians should focus on referring patients to various specialists in order to treat each individual manifestation.

BackgroundKnee osteoarthritis (OA) is a prevalent and debilitating condition for which a wide range of non-surgical treatment options are available. Although there is plethora of literature investigating their safety and efficacy, for many treatment modalities, a consensus has not yet been reached concerning efficacy. Therefore, it is essential for practitioners to understand the risks and benefits of the available treatments for the successful management of knee OA. This study explored the efficacy of non-surgical treatment options for knee OA including: (I) non-steroidal anti-inflammatory drugs (NSAIDs); (II) weight loss; (III) intra-articular injections; (IV) physical therapy; and (V) bracing.MethodsA comprehensive literature review of studies between 1995 and 2018 was conducted using the electronic databases PubMed and EBSCO Host. Searches were performed using the following terms: total knee arthroplasty (TKA); cyclooxygenase-2 inhibitors; bracing; physical therapy; weight loss; knee; treatment; therapeutics; OA; intra-articular injection; hyaluronic acid; corticosteroid; and alternatives. The initial search yielded 7,882 reports from which 545 relevant studies were identified. After full-text analysis, 43 studies were included for this analysis.ResultsNSAIDs are most effective when used continuously and may be used in conjunction with other forms of treatment for knee OA as they have been shown to provide some pain relief as well as functional improvements. Weight loss is a safe and effective way to improve knee pain, function, and stiffness without adverse effects. However, it can be very challenging for obese patients with knee OA due to their limited mobility and lack of adherence to a low-calorie diet. Intra-articular injections have had mixed results, with findings from recent studies indicating long-term outcomes to be equivocal. Physical therapy leads to significant improvements in pain and function. Decreased compliance with physical therapy is thought to be due to high copayments, pain with activities, lacks of transportation, and high time commitments. Brace modalities have demonstrated significant pain and functional improvements and prolongations of the time to TKA. Additionally, they limit the need for other treatment modalities which are associated with greater risks.ConclusionsNSAIDs, weight loss, intraarticular injections, and physical therapy have all been shown to be effective non-surgical treatment options for knee OA. However, these options have some limitations, and are best when used in conjunction. Bracing for knee OA is a noninvasive, non-pharmacologic option which can significantly reduce pain and improve function with minimal adverse effects. Therefore, a combination of knee braces along with other non-operative modalities should be one mainstay of treatment in conjunction with other treatment modalities to reduce pain, improve function, stiffness, and mobility in knee OA.

➤ Modular fluted titanium stems have become the implant of choice for most femoral component revisions as they have a lower risk of subsidence, thigh pain, femoral fracture, and stress shielding compared with previously used extensively coated cobalt-chromium stems. ➤ Modularity of the femoral component allows for optimal and independent fit and fill of the proximal and distal femoral segments, permitting immediate axial and rotational stability in shorter diaphyseal segments (<4 cm of scratch fit), thus reducing the risk of subsidence. Modularity also allows for independent adjustment of version of the proximal body relative to the distal stem, thus improving joint stability. The ability to make small adjustments in vertical and lateral offset further reduces the potential for instability and leg-length discrepancy, and the use of a titanium implant minimizes the risk of stress shielding compared with cobalt-chromium stems. ➤ In several retrospective case series, excellent mid-term to long-term outcomes and low complication rates have been observed with the use of modular fluted titanium stems in femoral revisions. ➤ The major disadvantages to the routine use of modular fluted titanium stems are the potential for taper junction failure (corrosion or fracture) and the increased cost of these stems compared with nonmodular stems.

Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA; Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA; Department of Physical Therapy, Sinai Hospital, Rubin Institute for Advanced Orthopaedics, Baltimore, MD, USA Contributions: (I) Conception and design: All authors; (II) Administrative support: All authors; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Correspondence to: Michael A. Mont, MD. System Chief of Joint Reconstruction, Vice President, Strategic Initiatives, Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA. Email: mmont@northwell.edu; rhondamont@aol.com.

This is a case report on Giant Cell Tumor (GCT) in the proximal phalanx of the fourth finger of the left hand. The patient is a 58-year-old woman who presented to the orthopedic clinic with two years history of pain in her finger without any previous trauma. The patient was clinically evaluated as an outpatient along with radiographic imaging followed by Computed Tomography (CT) and bone scan, but she did not follow up for two years. Subsequent orthopedic evaluation included a noncontrast hand Magnetic Resonance Imaging (MRI) and CT of the chest which detected multiple lung nodules. The patient then underwent ray amputation of the finger. Histopathological examination confirmed as GCT. The patient was closely followed after the surgical operation since GCT of the hand is known to recur. Postoperatively, the patient was followed for 14 months without evidence of recurrence.

INTRODUCTION:Due to the rising concern regarding excessive opioid use, several alternative pain control options have been developed for total knee arthroplasty (TKA). Therefore, the purpose of this article was to review non-narcotic treatments to manage pain after TKA. Specifically, we evaluated: 1) acetaminophen; 2) cyclooxygenase-2 (cox-2) inhibitors; 3) gabapentinoids; 4) dexmedetomidine, 5) nerve blocks; 6) local analgesic infiltration; 7) transcutaneous electrical nerve stimulation (TENS); and 8) perioperative bracing.MATERIALS AND METHODS:A literature search was conducted using the PubMed and EBSCO host electronic databases. All available studies between 1998 and 2018 were evaluated. Searches were performed using the following terms: total knee arthroplasty (title), acetaminophen (title), cyclooxygenase-2 inhibitors (title), gabapentinoids (title), nerve blocks (title), local analgesic infiltration (title), transcutaneous electrical nerve stimulation (title), knee (title), postoperative outcome (title), opioids (title), analgesics (title), alternative (title), heroin (title), chronic pain (title), opioid overdose (title), and cost (title). After full-text analysis of 273 reports that satisfied the search criteria, 58 studies were included in this review.RESULTS:There is conflicting evidence on acetaminophen and gabapentinoids, with some studies reporting opioid use reduction with their use; whereas, others found no difference. Cox-2 inhibitors can potentially reduce opioid requirements and improve pain scores following TKA; however, they are associated with several side effects. Dexmedetomidine has been associated with reduced postoperative opioid consumption, but it has limited applications as it is associated with several major side effects. Neuraxial anesthesia can potentially help control postoperative pain; however, there is a limited effective window and identifying the specific nerve can be challenging. Local infiltrating analgesia have been found to help relieve pain in the early postoperative period. Multiple studies have identified substantial reductions in pain with knee braces. The non-invasive and non-pharmacologic nature of this treatment option makes it very safe and effective for the generalized TKA population.CONCLUSION:The optimal solution for postoperative TKA pain management has yet to be determined. Although several options exist, many of them have been associated with adverse effects limiting their generalizability. Knee braces, however, have been identified as one potentially successful option. Importantly, knee braces are safe for the majority of patients and should be widely recommended for patient use.

Case: We present the case of a 26-year-old man who sustained a right transverse-posterior wall acetabular fracture while performing a cutting movement playing basketball. Conclusions: Acetabular fracture after a relatively low-energy injury in a healthy young adult male is an extremely unusual event. The cutting movement to the right likely forcefully placed the right hip in flexion, adduction, and internal rotation directing the femoral head into the posterior wall. The patient had excellent clinical and radiographic results after acetabular open reduction and internal fixation.