Adverse local tissue reaction (ALTR) is a frequently described, although uncommon, complication of metal-on-metal total hip arthroplasty. Here in we report on 2 patients with unique metal-inlay polyethylene liners who suffered from ALTR that required revision arthroplasty. In 2 of 3 cases the femoral trunnion was noted to have minimal corrosion and the stem was salvaged with a titanium adapter. In one case there was catastrophic femoral stem failure and an extended trochanteric osteotomy was required to remove the unique lateral flare stem. The surgeon must pay special attention when scrutinizing radiographs to identify a metal inlay polyethylene liner and when performing revision arthroplasty to prevent greater trochanter fracture in a patient who likely already has compromised abductor function due to ALTR.

Study Objective. Neuraxial and regional anesthesia have become commonly utilized for patients undergoing total hip arthroplasty to aid in postoperative analgesia, facilitating early ambulation and better functional recovery. This study investigated the efficacy of a lumbar erector spinae plane block (ESPB) on reducing postoperative opioid consumption in total hip arthroplasty performed under spinal anesthesia. Design. Prospective, randomized, controlled trial. Patients. Sixty-three adult patients with an American Society of Anesthesiologists Status I–III who are undergoing elective primary total hip arthroplasty. Interventions. Patients were randomized to the control group (no block) or the ESPB group (preoperative ultrasound-guided lumbar ESPB). Intraoperatively, all patients received spinal anesthesia with moderate sedation. Postoperatively, patients received a standardized multimodal analgesia protocol. Measurements. The primary outcome was cumulative opioid consumption at 24 hours postoperatively. Secondary outcomes included cumulative opioid consumption at 8 hours and through 48 hours postoperatively and pain scores at 24 and 48 hours post surgery. Main Results. Thirty-one patients were randomized to the control group (spinal alone) and 32 patients to the ESPB group. The median opioid requirement in the first 8 hours after surgery was higher in the control group (28 mg of oral morphine equivalents (OME) versus 5 mg of OME in the ESPB group) (p=0.013). There was no statistically significant difference in opioid consumption between the groups at 24 hours (p=0.153) or 48 hours (p=0.357) postoperatively. There was no statistically significant difference in pain scores between the two groups through 24 hours (p=0.143) or 48 hours (p=0.617) after surgery. Conclusion. Lumbar ESPB reduces opioid utilization during the first 8 hours postoperatively after total hip arthroplasty but not thereafter. Evaluating the use of either adding a local anesthetic adjunct to the ESPB or using longer-acting local anesthetic warrants further investigation.

INTRODUCTION The United States is experiencing an opioid epidemic, and orthopedists prescribe a large proportion of these drugs. Patients often become dependent on painkillers and face barriers to treatment. Given that many joint arthroplasty patients are enrolled in Medicare, we aimed to examine the ease of orthopedic patients with various insurance types to access addiction and pain specialists. METHODS Using three web-based directories, we identified addiction specialists within a 5-mile radius of our hospital. We contacted these practices and inquired as to whether they treated addiction, types of insurance they accepted, and appointment availability. RESULTS We identified 190 addiction and pain management specialists and were able to reach 134/190 (70.5%). Nine (6.7%) of the 134 reachable physicians accepted Medicare or Medicaid, which is nine (4.7%) of the 190 physicians initially located. The average wait time to an appointment was 4.2 days, and a significant difference in wait time existed across insurance types (p = 0.0284). DISCUSSION Orthopedic patients face many barriers to receiving treatment for painkiller addiction. Wait time to see an addiction specialist also varied based on insurance type. Online directories may not be useful for certain patient populations to identify physicians. Orthopedic surgeons should partner with addiction and pain specialists to help alleviate the barriers that patients face.

➤ Operating-room (OR) heating, ventilation, and air-conditioning (HVAC) systems play an important role in the reduction of airborne bacterial colony-forming units. ➤ Laminar flow ventilation systems reduce OR bacterial counts, but their ability to lower surgical site infection (SSI) rates in joint replacement procedures is controversial. ➤ Airborne bacteria in the OR during surgery are primarily produced by the OR staff and circulate in the air on shed skin particles (squames). ➤ Airflow patterns in the OR are complex and may be affected by the layout and operational characteristics of the HVAC system, door-opening events, heat generated by surgical equipment, forced-air warmers, and the movement of equipment and personnel. ➤ Forced-air warmers generate excess heat and convection currents within the OR but have not conclusively been shown to increase SSI rates. They are considered safe for use by the Association of periOperative Registered Nurses and remain the gold standard for maintaining perioperative patient normothermia.

Introduction: Door openings and increased foot traffic in operating rooms (ORs) during total joint arthroplasty are thought to increase the risk of surgical site infection. Methods: Digital manometers were used to collect pressure data during off-hours at the thresholds of both the outer door (ie, the door to the common OR hallway) and the inner substerile door, which opens to the substerile hallway, of six empty ORs used for total joint arthroplasty. Airflow patterns were visualized with smoke studies to determine whether outside air entered the ORs during single or multiple door openings. Data were analyzed using the Student t-test and one-way analysis of variance. Results: Positive pressure was not defeated during any door-opening event. The average time for recovery of the initial pressurization in the OR regardless of the door used was between 14 and 15 seconds (P = 0.462). No differences in the degree of room depressurization were noted between entry of personnel through the outer door, passing of a surgical tray through the outer door, and entry of personnel through the inner door (P = 0.312). Smoke studies confirmed that no contaminated outside air entered the OR with single door opening. Outside air entered the OR if two doors were open simultaneously. Conclusion: Single door opening does not defeat OR positive pressure, but simultaneous opening of two doors allows contaminated air to flow into the OR. OR traffic should continue to be limited during surgical procedures. OR personnel should be educated about the danger to the sterile field that can result from simultaneous door openings and should be discouraged from such activity.

BACKGROUND:Interest in outpatient/same-day discharge (SDD) total hip arthroplasty (THA) has been increasing over the last several years. There is considerable debate in the literature regarding the complication and readmission rates of these patients. To evaluate and validate the safety and efficacy of our institutional SDD THA care pathway, we compared the outcomes of patients undergoing SDD THA with patients who had a similar comorbidity profile and underwent inpatient THA. METHODS:A retrospective review was conducted on 164 patients who underwent SDD THA from January 2015 to September 2016. The Risk of Readmission Tool, a validated risk stratification instrument, was applied to all inpatient THAs performed from June 2014 to December 2016. A cutoff Risk of Readmission Tool score < 3 was used to produce a cohort of 1858 inpatient THA patients, all of whom had a similar risk profile to patients who underwent SDD THA. Medicare patients were excluded from the inpatient THA cohort, which left a final inpatient sample of 1315 patients. Each cohort was evaluated for demographic variables, length of stay, 30-/90-day readmissions, and discharge disposition. RESULTS:The SDD THA cohort had significantly lower body mass index (26.9 vs 28.2 kg/m2; P = .002), had fewer minorities (89.6% vs 66.3% Caucasians; P < .001), was exclusively commercial insurance (100% vs 36.3%), had a shorter length of stay (0.37 vs 2.3 days, P < .001), and was exclusively discharged home (100% vs 92.6%). There was no statistically significant difference in 30-day readmission rates between either cohort (SDD 0.6% vs inpatient 1.6%; P = .325). However, the SDD cohort had a significantly lower rate of 90-day readmissions than the inpatient cohort (0.6% vs 3.6%; P = .014). CONCLUSION:The use of an institutional SDD THA care pathway can produce results with equivalent or better short-term outcomes than that of traditional inpatient THA.

➤ The etiology of clinically relevant trunnion corrosion remains to be fully understood, but appears to be multifactorial with synergy among implant-based, surgeon-based, and patient-based factors. ➤ Trunnion corrosion causing an adverse local tissue reaction (ALTR) typically manifests as delayed onset of groin, buttock, or thigh pain after primary total hip arthroplasty. ➤ Trunnionosis is probably underreported since it often causes osteolysis and loosening, and the awareness of the problem, although increasing, is not universal. ➤ Measurement of serum cobalt and chromium ions and advanced cross-sectional imaging, including metal artifact reduction sequence magnetic resonance imaging, can aid in diagnosis. ➤ Revision for trunnion corrosion-induced ALTR can often be accomplished with a head and liner exchange, with retention of the acetabular and femoral components. ➤ The surgeon should be aware of implant recalls and be cognizant of ongoing litigation against implant manufacturers. ➤ The surgeon should strive to preoperatively identify the angle and type of taper in the well-fixed stem and request that the proper implants are available for the revision total hip arthroplasty.

CASE:A 52-year-old man who previously had undergone total hip arthroplasty with use of an Epoch (Zimmer) extensively porous-coated femoral stem presented with hip pain after a high-energy motor-vehicle accident. Radiographs demonstrated delamination at the polyaryletheretherketone-cobalt-chromium (PEEK-CoCr) core interface, which led to loosening. At revision, the implant demonstrated gross evidence of debonding at the PEEK-CoCr interface.CONCLUSION:We demonstrate clinical and tribologic evidence of a rare failure mode involving the PEEK-metal interface in a composite femoral stem, which surgeons should be aware of when evaluating patients with this type of implant.

Background Given the rising incidence of revision total joint arthroplasty (RJR), bundled payments will likely be applied to RJR in the near future. This study aimed to compare postdischarge adverse events by discharge destination, identify risk factors for discharge placement, and stratify RJR patients based on these risk factors to identify the most appropriate discharge destination. Methods Patients that underwent revision total hip or knee arthroplasty from 2011 to 2013 were identified in the American College of Surgeon's National Surgical Quality Improvement Program database. Analysis of risk factors was assessed using preoperative and intraoperative variables. Results A total of 9973 RJR patients from 2011 to 2013 were included for analysis. The most common discharge destination included home (66%), skilled nursing facility (SNF; 23%), and inpatient rehabilitation facility (IRF; 11%). Bivariate analysis revealed higher rate of postdischarge 30-day severe adverse events (6.1% vs 4.1%, P < .001) and unplanned readmissions (9.3% vs 6.1%, P < .001) in nonhome vs home patients. In multivariate analysis, SNF and IRF patients were 1.30 and 1.51 times more likely to suffer an unplanned 30-day readmission relative to home patients (P ≤ .01), respectively. After stratifying patients by number of significant risk factors and discharge destination, IRF patients consistently had significantly higher rates of unplanned 30-day readmission than home patients (P ≤ .05). Conclusion RJR patients who are discharged to SNF or IRF have significantly increased risk for unplanned readmissions as compared with patients discharged home. Across risk levels, home discharge destination (when feasible) is the optimal strategy compared with IRF, although the distinction between SNF and home is less clear.

The management of the patient with a recalled, modular neck-body total hip arthroplasty can be complex, as it involves a combination of clinical, technical, and medicolegal challenges. Management begins with a thorough history and physical exam, radiographic evaluation, infection workup, and serum metal ion levels. Three-dimensional imaging is obtained based on patient symptomatology and metal ion levels and is used to evaluate for the presence of an adverse local tissue response as well as the integrity of the existing soft tissue envelope. The decision to perform revision surgery is based on a combination of patient symptomatology, laboratory values, and imaging findings. Revision surgery involves the entire armamentarium of femoral revision techniques, and the acetabulum may need to be revised at the surgeon’s discretion. The femoral implant can often be removed without disrupting the femoral bone envelope; however, the surgeon should have a low threshold to perform an extended trochanteric osteotomy.

Total knee arthroplasty is associated with substantial postoperative pain that may impair mobility, reduce the ability to participate in rehabilitation, lead to chronic pain, and reduce patient satisfaction. Traditional general anesthesia with postoperative epidural and patient-controlled opioid analgesia is associated with an undesirable adverse-effect profile, including postoperative nausea and vomiting, hypotension, urinary retention, respiratory depression, delirium, and an increased infection rate. Multimodal anesthesia--incorporating elements of preemptive analgesia, neuraxial perioperative anesthesia, peripheral nerve blockade, periarticular injections, and multimodal oral opioid and nonopioid medications during the perioperative and postoperative periods--can provide superior pain control while minimizing opioid-related adverse effects, improving patient satisfaction, and reducing the risk of postoperative complications.

Tourniquets are often used in total knee arthroplasty (TKA) to improve visualization of structures, shorten operative time, reduce intraoperative bleeding, and improve cementing technique. Despite these advantages, controversy remains regarding the safety of tourniquet use. Tourniquets have been associated with nerve palsies, vascular injury, and muscle damage. Some have hypothesized they may also cause deep vein thrombosis. Last, increased incidence of postoperative wound complications has been reported with use of tourniquets. We conducted a retrospective cohort study to determine whether tourniquet use in TKA in patients with preexisting radiographic evidence of vascular disease increases the risk for wound complications or venous thromboembolism (VTE). Patients (N = 373) were placed in 2 groups: One had no preoperative radiographic evidence of knee arterial calcification (n = 285), and the other had arterial calcifications (n = 88). Overall, arterial calcification did not increase the risk for wound complication or VTE (P > .05). Furthermore, location of arterial calcification did not affect risk for wound complication or VTE. There were no arterial injuries. Diabetes, hypertension, prior VTE, coronary artery disease, and male sex were linked to higher wound complication rates (P < .05). Patients who have preoperative radiographic evidence of arterial calcification can safely undergo tourniquet-assisted TKA.

The most common pathogens in surgical site infections after total hip and knee arthroplasty are methicillin-sensitive Staphylococcus aureus (MSSA), methicillin-resistant S. aureus (MRSA), and coagulase-negative staphylococci. Patients colonized with MSSA or MRSA have an increased risk for a staphylococcal infection at the site of a total hip or knee arthroplasty. Most colonized individuals who develop a staphylococcal infection at the site of a total hip or total knee arthroplasty have molecularly identical S. aureus isolates in their nares and wounds. Screening and nasal decolonization of S. aureus can potentially reduce the rates of staphylococcal surgical site infection after total hip and total knee arthroplasty.

Molecular imaging permits non-invasive visualization and measurement of molecular and cell biology in living subjects, thereby complementing conventional anatomical imaging. Herein, we review the emerging application of molecular imaging for the study of musculoskeletal biology. Utilizing mainly bioluminescence and fluorescence techniques, molecular imaging has enabled in-vivo studies of (i) the activity of osteoblasts, osteoclasts, and hormones, (ii) the mechanisms of pathological cartilage and bone destruction, (iii) skeletal gene and cell therapy with and without biomaterial support, and (iv) the cellular processes in osteolysis and osteomyelitis. In these applications, musculoskeletal molecular imaging demonstrated feasibility for research in a myriad of musculoskeletal conditions ranging from bone fracture and arthritis to skeletal cancer. Importantly, these advances herald great potential for innovative clinical imaging in orthopedics, rheumatology, and oncology.