Publications by authors named "Bradford S Waddell"

21 Publications

  • Page 1 of 1

Can robotic technology mitigate the learning curve of total hip arthroplasty?

Bone Jt Open 2021 Jun;2(6):365-370

Department of Orthopaedic Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana, USA.

Aims: Traditionally, acetabular component insertion during total hip arthroplasty (THA) is visually assisted in the posterior approach and fluoroscopically assisted in the anterior approach. The present study examined the accuracy of a new surgeon during anterior (NSA) and posterior (NSP) THA using robotic arm-assisted technology compared to two experienced surgeons using traditional methods.

Methods: Prospectively collected data was reviewed for 120 patients at two institutions. Data were collected on the first 30 anterior approach and the first 30 posterior approach surgeries performed by a newly graduated arthroplasty surgeon (all using robotic arm-assisted technology) and was compared to standard THA by an experienced anterior (SSA) and posterior surgeon (SSP). Acetabular component inclination, version, and leg length were calculated postoperatively and differences calculated based on postoperative film measurement.

Results: Demographic data were similar between groups with the exception of BMI being lower in the NSA group (27.98 vs 25.2; p = 0.005). Operating time and total time in operating room (TTOR) was lower in the SSA (p < 0.001) and TTOR was higher in the NSP group (p = 0.014). Planned versus postoperative leg length discrepancy were similar among both anterior and posterior surgeries (p > 0.104). Planned versus postoperative abduction and anteversion were similar among the NSA and SSA (p > 0.425), whereas planned versus postoperative abduction and anteversion were lower in the NSP (p < 0.001). Outliers > 10 mm from planned leg length were present in one case of the SSP and NSP, with none in the anterior groups. There were no outliers > 10° in anterior or posterior for abduction in all surgeons. The SSP had six outliers > 10° in anteversion while the NSP had none (p = 0.004); the SSA had no outliers for anteversion while the NSA had one (p = 0.500).

Conclusion: Robotic arm-assisted technology allowed a newly trained surgeon to produce similarly accurate results and outcomes as experienced surgeons in anterior and posterior hip arthroplasty. Cite this article:  2021;2(6):365-370.
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http://dx.doi.org/10.1302/2633-1462.26.BJO-2021-0042.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8244790PMC
June 2021

Genicular Artery Embolization for Refractory Hemarthrosis following Total Knee Arthroplasty: Technique, Safety, Efficacy, and Patient-Reported Outcomes.

J Vasc Interv Radiol 2021 May 5. Epub 2021 May 5.

Department of Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, New York.

Purpose: To investigate the safety and efficacy of genicular artery embolization for treatment of refractory hemarthrosis following total knee arthroplasty.

Material And Methods: Patients who underwent genicular artery embolization with spherical embolics between January 2010 and March 2020 at a single institution were included if they had undergone total knee arthroplasty and subsequently experienced recurrent hemarthrosis. Technical success was defined as the significant reduction or elimination of the hyperemic blush. Clinical success was defined as the absence of clinical evidence of further hemarthrosis. Clinical follow-up was performed 7-14 days after the procedure and at 3-month intervals thereafter via a telephone interview. A total of 117 embolizations, comprising 82 initial, 28 first repeat, and 7 second repeat, were performed.

Results: An average of 2.5 arteries was treated per procedure. The superior lateral genicular artery was the most frequently embolized. The most utilized embolic size was 100-300 μm. Follow-up was available for all patients, with a median duration of 21.5 months. 65.9%, 25.6%, and 8.5% of patients underwent 1, 2, and 3 treatments, respectively. Complications occurred following 12.8% of treatments, of which the most common was transient cutaneous ischemia. Technical success was achieved in all cases. Clinical success was achieved in 56%, 79%, and 85% of patients following the first, second, and third treatment, respectively. 83% of patients reported being either satisfied or very satisfied with the overall result.

Conclusions: Targeted genicular artery embolization with spherical embolics is an effective treatment for recurrent hemarthrosis with infrequent serious complications. Repeat embolization should be considered in cases of recurrence following initial therapy.
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http://dx.doi.org/10.1016/j.jvir.2021.04.020DOI Listing
May 2021

Adverse Reaction to Zirconia in a Modern Total Hip Arthroplasty with Ceramic Head.

Arthroplast Today 2020 Sep 19;6(3):612-616.e1. Epub 2020 Jun 19.

Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA.

Hypersensitivity reactions to zirconia (ZrO2) or similar ceramics is highly unusual. Owing to the stable oxide formed between the base metal and oxygen, ceramics are considered relatively biologically inert. We report the case of an otherwise healthy 50-year-old woman with a 5-year history of progressively worsening right hip pain who underwent a ceramic-on-polyethylene total hip replacement and subsequently developed hypersensitivity reaction. After metal allergy testing showed her to be highly reactive to zirconium, the femoral head was revised to a custom titanium implant and her symptoms resolved.
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http://dx.doi.org/10.1016/j.artd.2020.03.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7502561PMC
September 2020

Prospective Evaluation of a Noninvasive Hemoglobin Measurement System in Total Joint Arthroplasty.

J Surg Orthop Adv 2020 ;29(2):94-98

Hospital for Special Surgery, New York, New York.

We sought to prospectively determine the efficacy of a noninvasive hemoglobin measurement system compared to a traditional blood draw in patients undergoing total joint arthroplasty. One hundred consecutive patients had their hemoglobin level measured by blood draw and the noninvasive device, simultaneously. Results were analyzed for the entire group and further stratified based on race and perfusion index measured by the device. The financial implications and patient satisfaction were compared. Hemoglobin measurements in the entire group and the two sub-groups were similar between the noninvasive device and the traditional blood draw. The noninvasive system was preferred by 100% of patients. Additionally, cost savings per patient using the noninvasive system was $16.50. This correlated to an 86% savings per case over the standard blood draw. The noninvasive hemoglobin monitoring system offers comparable measurements to a standard blood draw, while improving patient satisfaction and lowering costs. (Journal of Surgical Orthopaedic Advances 29(2):94-98, 2020).
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November 2020

Insulin-Dependent Diabetic Patients are at Increased Risk of Postoperative Hyperglycemia When Undergoing Total Joint Arthroplasty.

J Arthroplasty 2020 09 30;35(9):2375-2379. Epub 2020 Apr 30.

Hospital for Special Surgery, Ault Reconstruction and Joint Replacement, New York, NY.

Background: Diabetic patients are at an increased risk of prosthetic joint infection (PJI) after total joint arthroplasty (TJA). The relationship between insulin-dependence and PJI has not been investigated. We aimed at evaluating whether insulin-dependent diabetes mellitus (IDDM) patients were more susceptible to postoperative hyperglycemia and PJI than their non-insulin-dependent diabetes mellitus (NIDDM) counterparts.

Methods: A retrospective review was conducted of diabetic patients undergoing TJA (hip or knee) from January 2011 to December 2016. Preoperative hemoglobin A1c (A1c) and postoperative glucose measurements were observed. Patients were stratified as IDDM or NIDDM. The A1c values that predicted hyperglycemia >200 mg/dL for each group were calculated. Primary end point was postoperative hyperglycemia >200 mg/dL and secondary end point was PJI.

Results: There were 773 patients meeting inclusion criteria. The IDDM cohort had a higher preoperative A1c (6.97% vs 6.28%, P < .0001) and postoperative glucose (235.2 vs 163.5, P < .0001). IDDM patients were more likely to have postoperative hyperglycemia (63.84% vs 20.83%, P < .0001; odds ratio, 5.2; 95% confidence interval, 3.66-7.4). Overall, an A1c of >7.45% predicted postoperative hyperglycemia >200 mg/mL (odds ratio, 6.94; 95% confidence interval, 4.32-11.45). When separating our 2 cohorts, an A1c of >6.59% in IDDM, and >6.60% in NIDDM, was associated with an increased risk of postoperative hyperglycemia (P < .0001). PJI was similar between the 2 cohorts (2.52% vs 2.38%, P = .9034).

Conclusion: IDDM patients undergoing TJA are 5.2 times more likely to have postoperative hyperglycemia >200 mg/dL than their NIDDM counterparts, although increased risk of PJI was not found in this study. Despite the higher A1c and postoperative hyperglycemia in IDDM patients, there was found to be no clinical difference between A1c cutoff values for postoperative hyperglycemia between IDDM and NIDDM patients.
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http://dx.doi.org/10.1016/j.arth.2020.04.082DOI Listing
September 2020

Anesthesia and Analgesia Practices in Total Joint Arthroplasty: A Survey of the American Association of Hip and Knee Surgeons Membership.

J Arthroplasty 2019 Dec 8;34(12):2872-2877.e2. Epub 2019 Jul 8.

Adult Reconstruction Division, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL.

Background: The purpose of this study is to survey the current analgesia and anesthesia practices used by total joint arthroplasty surgeon members of the American Association of Hip and Knee Surgeons (AAHKS).

Methods: A survey of 28 questions was created and approved by the AAHKS Research Committee. The survey was distributed to all 2208 board-certified adult reconstruction surgeon members of AAHKS in November 2018.

Results: There were 622 responses (28.2%) to the survey. A majority of respondents (93.2%, n = 576) use preemptive analgesia prior to total joint arthroplasty. Most respondents use a spinal for total knee arthroplasty (TKA) (74.4%) and total hip arthroplasty (THA) (72.6%). A peripheral nerve block is routinely used by 68.7% of respondents in primary TKA. Periarticular injection or local infiltration anesthesia is routinely used by 80.3% of respondents for both TKA and THA patients. The average number of opioid pills prescribed postoperatively after TKA is 49 pills (range 0-200) and after THA is 44 pills (range 0-200). Most surgeons (58%) expect that this prescription should last for 2 weeks. A majority of respondents (74.0%) use multimodal analgesics in addition to opioids.

Conclusion: There is no consensus regarding the optimal multimodal anesthetic and analgesic regimen for total joint arthroplasty among surveyed board-certified arthroplasty surgeon members of AAHKS. Understanding current practice patterns in anesthesia, analgesia, and opioid prescribing may serve as a platform for future work aimed at establishing best clinical practices of maximizing effective postoperative pain control and minimizing the risks associated with prescribing opioids.
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http://dx.doi.org/10.1016/j.arth.2019.06.055DOI Listing
December 2019

Web-based patient portal access in an orthopedic adult reconstruction patient population.

Arthroplast Today 2019 Mar 22;5(1):83-87. Epub 2019 Feb 22.

Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA.

Background: We surveyed patients in an adult reconstruction practice as to their use of the Web-based portal provided by our electronic health record, seeking to reveal patterns of use and helpfulness.

Methods: A total of 150 completed surveys were received. The survey queried demographics, the number of clinic visits, Internet access, portal activation, portal use frequency, and portal information questions and how patients answered them. Helpfulness was rated from 1 (not helpful) to 5 (very helpful). Statistical analysis included bivariate analysis and logistic regression, with odds ratio (OR) and 95% confidence interval (CI) reported.

Results: The mean age was 67.6 years. Most were females (n = 97, 65.1%). Most (68.7%) patients used the portal. Younger age (OR, 0.94; CI, 0.90-0.99) and access to Internet (OR, 31.8; CI, 8.5-119.4) predicted portal use ( < .005), whereas gender and number of clinic visits did not ( > .373). Of all, 47.5% of patients were unclear about online chart information. Older age indicated being unclear of portal information (68.5 vs 66,  = .0002). Of those who clarified doubts regarding information (n = 67), 23 used the Internet (34.3%), 32 (47.7%) called the physician, and 12 (17.9%) asked a friend and/or family member. Most (90.3%) patients felt the portal was helpful in gathering health information.

Conclusions: Age and Internet access affected portal usage; ability to understand chart information decreased with age. Most patients used the Internet or a family member to clarify doubts regarding portal information. The use of portal data resulted in 32 extra communications to the physician.
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http://dx.doi.org/10.1016/j.artd.2019.01.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6470345PMC
March 2019

Have large femoral heads reduced prosthetic impingement in total hip arthroplasty?

Hip Int 2019 Jan 7;29(1):83-88. Epub 2018 May 7.

1 Adult Reconstruction and Joint Replacement Division, Hospital for Special Surgery, New York, NY, USA.

Background:: Prosthetic impingement is implicated in dislocation after total hip arthroplasty (THA). While use of larger diameter femoral heads reduces the incidence of dislocation, the effect of larger heads upon impingement rate is unknown. We assessed retrieved THA components for evidence of impingement to determine if large femoral heads reduced the rate of impingement in primary THA and what factors might influence impingement.

Methods:: Liners from 97 primary THAs retrieved at revision arthroplasty were scored for evidence of impingement, defined as wear or deformation on the rim of the component. Component inclination and version were measured from anteroposterior and cross-table lateral radiographs.

Results:: Independent of revision diagnosis, 77% of liners demonstrated evidence of impingement. Impingement was less prevalent and less severe as head size increased. Severe impingement was observed in 50% of the liners with 28-mm heads, 15% of liners with 32-mm heads, and 21% of liners with 36-mm heads. Regardless of head size, 76% of liners revised for instability demonstrated impingement. Decreased head-neck ratio, use of an elevated liner, increased length of implantation, and increased version were associated with increased severity of impingement.

Discussion:: We showed that larger head sizes are associated with decreased incidence of impingement on retrieved acetabular liners when compared to smaller head sizes. Larger heads have reduced but not eliminated impingement, which remains a potential source of instability.
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http://dx.doi.org/10.1177/1120700018761153DOI Listing
January 2019

Preoperative Glycemic Control Predicts Perioperative Serum Glucose Levels in Patients Undergoing Total Joint Arthroplasty.

J Arthroplasty 2018 07 26;33(7S):S76-S80. Epub 2018 Feb 26.

Department of Orthopedic Surgery, Ochsner Medical Center, New Orleans, Louisiana.

Background: Diabetic patients undergoing total joint arthroplasty (TJA) with postoperative hyperglycemia >200 mg/dL have increased the risk of prosthetic joint infection (PJI). We investigated the correlation between preoperative hemoglobin A1c (A1c) and postoperative hyperglycemia in diabetic patients undergoing TJA.

Methods: A retrospective review of 773 diabetic patients undergoing TJA was conducted. A Youden's J computational analysis determined the A1c where postoperative glucose levels >200 mg/dL were statistically more likely. Patients were then stratified into 3 groups: A1c <7%, A1c 7.0-8.0%, and A1c >8.0%. Outcomes included the highest postoperative in-hospital serum glucose level and PJI.

Results: We determined an A1c >7.45% resulted in a greater chance of postoperative hyperglycemia >200 mg/dL. Average postoperative serum glucose increased with A1c (A1c < 7 = 167 mg/dL, A1c 7.0-8.0 = 240 mg/dL, and A1c > 8 = 276 mg/dL, P < .0001). PJI did not statistically increase with A1c (2.25%, 1.99%, and 4.55%, respectively, P = .4319).

Conclusion: Preoperative hemoglobin A1c levels correlate with postoperative glucose levels. We recommend using an A1c cutoff of 7.45% for patients undergoing TJA and suggest that caution should be exercised in patients with elevated A1c levels undergoing TJA.
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http://dx.doi.org/10.1016/j.arth.2018.02.071DOI Listing
July 2018

Response to letter to the editor on "Early intraprosthetic dislocation in dual-mobility implants: a systematic review".

Arthroplast Today 2018 Mar 13;4(1):133-134. Epub 2017 Dec 13.

Complex Joint Reconstruction Center, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA.

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http://dx.doi.org/10.1016/j.artd.2017.11.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5859558PMC
March 2018

Smartphone-Based Goniometry Accuracy in Clinical Scenarios.

J Surg Orthop Adv 2017 WINTER;26(4):223-226

Department of Orthopaedic Surgery, Boston University, Boston, Massachusetts.

This study compared two popular iPhone-based goniometer applications to the gold standard universal goniometer for the measurement of the hip and knee joints in scenarios mimicking the normal pace of an orthopaedic clinical practice.Three physicians measured hip and knee joint angles 35 times with one of three goniometers: universal 12-inch goniometer, DrGoniometer (iPhone-5 based), and SimpleGoniometer (iPhone-5 based). Data wwere analyzed using Pearson correlation coefficient calculations. Average knee angles measured with the universal goniometer, DrGoniometer, and SimpleGoniometer measured 83.46°, 85.23°, and 80.39°, respectively. The smartphone-based goniometers had moderate agreement with the universal goniometer in the knee (r > .322). Average hip angles measured with the universal goniometer, DrGoniometer, and SimpleGoniometer measured 62.34°, 60.87°, and 59.34°, respectively. The smartphone-based goniometers had moderate agreement with the universal goniometer in the hip (r > .168). Smartphone-based goniometers gave accurate, with weak to moderate correlation, measurements for the knee and hip. (Journal of Surgical Orthopaedic Advances 26(4):223-226, 2017).
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May 2018

Early intraprosthetic dislocation in dual-mobility implants: a systematic review.

Arthroplast Today 2017 Sep 5;3(3):197-202. Epub 2017 Feb 5.

Department of Orthopaedic Surgery, Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA.

Background: Dual mobility implants are subject to a specific implant-related complication, intraprosthetic dislocation (IPD), in which the polyethylene liner dissociates from the femoral head. For older generation designs, IPD was attributable to late polyethylene wear and subsequent failure of the head capture mechanism. However, early IPDs have been reportedly affecting contemporary designs.

Methods: A systematic review of the literature according to the preferred reporting items for systematic reviews and meta-analyses guidelines was performed. A comprehensive search of PubMed, MEDLINE, Embase, and Google Scholar was conducted for English articles between January 1974 and August 2016 using various combinations of the keywords "intraprosthetic dislocation," "dual mobility," "dual-mobility," "tripolar," "double mobility," "double-mobility," "hip," "cup," "socket," and "dislocation."

Results: In all, 16 articles met our inclusion criteria. Fourteen were case reports and 2 were retrospective case series. These included a total of 19 total hip arthroplasties, which were divided into 2 groups: studies dealing with early IPD after attempted closed reduction and those dealing with early IPD with no history of previous attempted closed reduction. Early IPD was reported in 15 patients after a mean follow-up of 3.2 months (2.9 SD) in the first group and in 4 patients after a mean follow-up of 15.1 months (9.9 SD) in the second group.

Conclusions: Based on the current data, most cases have been preceded by an attempted closed reduction in the setting of outer, large articulation dislocation, perhaps indicating an iatrogenic etiology for early IPD. Recognition of this possible failure mode is essential to its prevention and treatment.
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http://dx.doi.org/10.1016/j.artd.2016.12.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5585769PMC
September 2017

Technology in Arthroplasty: Are We Improving Value?

Curr Rev Musculoskelet Med 2017 Sep;10(3):378-387

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA.

Purpose Of Review: Total joint arthroplasty is regarded as a highly successful procedure. Patient outcomes and implant longevity, however, are related to proper alignment and position of the prostehses. In an attempt to reduce outliers and improve accuracy and precision of component position, navigation and robotics have been introduced. These technologies, however, come at a price. The goals of this review are to evaluate these technologies in total joint arthroplasty and determine if they add value.

Recent Findings: Recent studies have demonstrated that navigation and robotics in total joint arthroplasty can decrease outliers while improving accuracy in component positioning. While some studies have demonstrated improved patient reported outcomes, not all studies have shown this to be true. Most studies cite increased cost of equipment and longer operating room times as the major downsides of the technologies at present. Long-term studies are just becoming available and are promising, as some studies have shown decreased revision rates when navigation is used. Finally, there are relatively few studies evaluating the direct cost and value of these technologies. Navigation and robotics have been shown to improve component position in total joint arthroplasty, which can improve patient outcomes and implant longevity. These technologies offer a promising future for total joint arthroplasty.
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http://dx.doi.org/10.1007/s12178-017-9415-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5577416PMC
September 2017

Does Spanning a Lateral Lumbar Interbody Cage Across the Vertebral Ring Apophysis Increase Loads Required for Failure and Mitigate Endplate Violation.

Spine (Phila Pa 1976) 2017 Oct;42(20):E1158-E1164

Spine and Scoliosis Specialists, Tampa, FL.

Study Design: Randomized Biomechanical Cadaveric Study-Level II.

Objective: We aimed to elucidate that placing lateral lumbar interbody cages that span the stronger ring apophysis will require increasing loads for failure, decreasing rates of subsidence, regardless of bone density or endplate integrity.

Summary Of Background Data: There are several reports regarding the rates and grades of cage subsidence when utilizing the lateral lumbar interbody fusion technique. However, there is limited data on how spanning the lateral cage across the ring apophysis can prevent it.

Methods: Eight fresh-frozen human spines (L1-L5) were utilized. Each vertebra was placed with their endplates horizontal in an MTS actuator. A total of 40 specimens were randomized into Groups:Load displacement data was collected at 5 Hz until failure.

Results: Longer cages spanning the ring apophysis provided more strength in compression with less subsidence relative to shorter cages, regardless of endplate integrity.Longer cages, spanning the ring apophysis, resting on intact endplates (G2) had a significant (P < 0.05) increase in strength and less subsidence when compared with the smaller cage group resting on intact endplates (G1) (P = 0.003).Longer cages spanning the ring apophysis of intact endplates (G2) showed a significant (P < 0.05) increase in strength and resistance to subsidence when compared with similar length cages resting on decorticated endplates (G4) (P = 0.028).

Conclusion: Spanning the ring apophysis increased the load to failure by 40% with intact endplates and by 30% with decorticated endplates in this osteoporotic cadaveric model. Larger cages that span the endplate ring apophysis could improve the compressive strength and decrease subsidence at the operative level despite endplate violation or osteoporosis.

Level Of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000002158DOI Listing
October 2017

Favorable Early Results of Impaction Bone Grafting With Reinforcement Mesh for the Treatment of Paprosky 3B Acetabular Defects.

J Arthroplasty 2017 03 5;32(3):919-923. Epub 2016 Oct 5.

Adult Reconstruction and Joint Replacement Division, Hospital for Special Surgery, New York, New York.

Background: We present the early institutional experience with the use of impaction bone grafting, mesh augmentation, and cement fixation of an all-polyethylene cup for the treatment of Paprosky 3B acetabular defects during revision total hip arthroplasty.

Methods: Between 2005 and 2014, 21 patients (9 men, 12 women) with Paprosky 3B acetabular defects who underwent revision total hip arthroplasty using this technique were reviewed clinically and radiographically. Average age and body mass index were 72.4 (range, 48-91) years and 24.5 (range, 18.9-31) kg/m, respectively. All patients underwent revision for aseptic loosening. Surgical technique included the use of a peripheral mesh to contain the defect, followed by impaction of morselized fresh-frozen bone graft and cement fixation of a polyethylene cup.

Results: Complications occurred in 6 patients (29%) including limp (2), sciatic nerve palsy that resolved (1), limb length discrepancy (1), and greater trochanteric fracture (1). After an average follow-up of 47 months (range, 13-128 months), the average Hospital for Special Surgery hip score was 35.5 (range, 20-40). Radiographic assessment revealed cephalad cup migration of 2.29 mm (range, 0-20 mm) and medial migration of 1.57 mm (range, 0-6 mm). One patient has radiographic loosening and no symptoms 120 months postoperatively. No patient returned to the operating room for a related reason or is scheduled to undergo acetabular re-revision surgery.

Conclusion: Impaction bone grafting is a reliable technique for the treatment of Paprosky 3B acetabular defects. It restores bone stock like no other available for addressing these defects. Longer follow-up is required to assess potential deterioration of fixation.
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http://dx.doi.org/10.1016/j.arth.2016.09.037DOI Listing
March 2017

Total Hip Arthroplasty Dislocations Are More Complex Than They Appear: A Case Report of Intraprosthetic Dislocation of an Anatomic Dual-Mobility Implant After Closed Reduction.

Ochsner J 2016 ;16(2):185-90

Department of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY.

Background: Total hip arthroplasty is a successful operation for the treatment of hip pain. One of the common complications of hip arthroplasty is dislocation. While reduction of standard prosthetic dislocations is highly successful, new prostheses add the potential for new complications.

Case Report: We present the case of a patient who experienced intraprosthetic dislocation of an anatomic dual-mobility total hip prosthesis after a closed hip reduction and include the prereduction and postreduction radiographic findings.

Conclusion: Emergency department physicians should be aware of intraprosthetic dislocation. This complication can be easily missed because the metal/ceramic femoral head appears to be reduced in the acetabulum.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4896666PMC
June 2016

A Detailed Review of Hip Reduction Maneuvers: A Focus on Physician Safety and Introduction of the Waddell Technique.

Orthop Rev (Pavia) 2016 Mar 21;8(1):6253. Epub 2016 Mar 21.

Department of Orthopedics, Ochsner Clinic Foundation, New Orleans, LA, USA; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA, USA.

Dislocation of the hip is a well-described event that occurs in conjunction with high-energy trauma or postoperatively after total hip arthroplasty. Bigelow first described closed treatment of a dislocated hip in 1870, and in the last decade many reduction techniques have been proposed. In this article, we review all described techniques for the reduction of hip dislocation while focusing on physician safety. Furthermore, we introduce a modified technique for the reduction of posterior hip dislocation that allows the physician to adhere to the back safety principles set for by the Occupational Safety and Health Administration.
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http://dx.doi.org/10.4081/or.2016.6253DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4821229PMC
March 2016

Financial Analysis of Treating Periprosthetic Joint Infections at a Tertiary Referral Center.

J Arthroplasty 2016 05 10;31(5):952-6. Epub 2015 Nov 10.

Department of Orthopedics, Ochsner Clinic Foundation, New Orleans, Louisiana.

Background: Periprosthetic joint infection (PJI) is a significant challenge to the orthopedic surgeon, patient, hospital, and insurance provider. Our study compares the financial information of self-originating and referral 2-stage revision hip and knee surgeries at our tertiary referral center for hip or knee PJI over the last 4 years.

Methods: We performed an in-house retrospective financial review of all patients who underwent 2-stage revision hip or knee arthroplasty for infection between January 2008 and August 2013, comparing self-originating and referral cases.

Results: We found an increasing number of referrals over the study period. There was an increased cost of treating hips over knees. All scenarios generated a positive net income; however, referral hip PJIs offered lower reimbursement and net income per case (although not statistically significant), whereas knee PJIs offered higher reimbursement and net income per case (although not statistically significant).

Conclusion: With referral centers treating increased numbers of infected joints performed elsewhere, we show continued financial incentive in accepting referrals, although with less financial gain than when treating one's own hip PJI and an increased financial gain when treating referral knee PJIs.
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http://dx.doi.org/10.1016/j.arth.2015.10.043DOI Listing
May 2016

Comparison of Ocular Radiation Exposure Utilizing Three Types of Leaded Glasses.

Spine (Phila Pa 1976) 2016 Feb;41(4):E231-6

*Hospital for Special Surgery, New York City, NY†LSU Medical School New Orleans, New Orleans, LA‡Ochsner Medical Center, New Orleans, LA§Spine, Scoliosis and Deformity Institute, Florida Orthopedic Institute, Tampa, FL.

Study Design: Anthropomorphic phantoms were used to measure radiation exposure to the surgeon phantom's eye. Groups analyzed were: Group 1-no glasses (None); Group 2-leaded lenses without lead sides (WOLS); Group 3-leaded lenses with lead sides (WLS); and Group 4-sport wraparound leaded glasses (Sport). Glasses were 0.75 mm lead equivalent.

Objective: To evaluate the efficacy of three types of leaded eyeglasses at reducing radiation exposure to the lens during typical views of minimally invasive spine surgery.

Summary Of Background Data: Minimally invasive spine surgery relies upon fluoroscopic x-ray. Ocular radiation exposure is associated with cataract formation. Leaded glasses can reduce ocular radiation exposure.

Methods: Fifteen individual 20-second exposures with the fluoroscopic C-arm in the anteroposterior (AP) and lateral positions, with phantom head positioned at 0, 45, and 90 degrees to the fluoroscope were performed. Radiation was measured using a solid-state dosimeter. Student t test was used to calculate significance.

Results: All glasses (WOLS, WLS, and Sport) had significant reductions in ocular radiation versus no glasses, at all individual head positions (P ≤ 1.31 × 10). Sport had significantly lower ocular radiation dose than WLS at all head positions except at 90 degrees AP (P = 0.001). WOLS had significantly lower ocular radiation dose than Sport in three out of six cases including phantom head at 0 degrees AP (P = 0.0003), 90 degrees AP (P = 4.46 × 10), and 90 degrees lateral (P = 7.38 × 10). WOLS had significantly lower radiation dosage at all head positions than WLS except at 45 degrees AP (P = 0.303). All glasses resulted in a significant reduction in total radiation dose from all head positions over no glasses (P ≤ 8.37 × 10).

Conclusion: We demonstrate a significant reduction in ocular radiation exposure with all three types of leaded glasses. Lead glasses, WOLS and Sport, were the most effective at reducing ocular radiation.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000001204DOI Listing
February 2016

Topical Tranexamic Acid Use in Knee Periprosthetic Joint Infection Is Safe and Effective.

J Knee Surg 2016 Jul 26;29(5):423-9. Epub 2015 Sep 26.

Department of Orthopaedics, Ochsner Medical Center, New Orleans, Louisiana.

Tranexamic acid (TXA) has been shown to decrease hemoglobin loss and reduce the need for transfusions in primary hip and knee arthroplasty. Our study evaluated the safety and efficacy of topical TXA in revision TKA for periprosthetic joint infection (PJI). We performed a retrospective review of patients who underwent removal of hardware with antibiotic spacer placement (stage 1) and/or revision TKA (stage 2) for PJI at our institution between September 2007 and July 2013. During that time, 49 patients underwent stage-1 procedures (20 knees with TXA, 29 without TXA) and 47 patients underwent stage-2 revisions (28 with TXA, 19 without TXA). We evaluated hemoglobin loss, need for transfusion, reinfection rate, length of stay (LOS), complications, and mortality with and without the use of TXA in these patients. All data sets were analyzed with a two-sample t-test. Average follow-up was 3.15 years (range, 1-7 years). TXA use led to a significantly lower percentage drop in the postoperative lowest hemoglobin compared with the preoperative hemoglobin in stage-1 surgeries (19.8 vs. 30.05%, p = 0.0004) and stage-2 revisions (24.5 vs 32.01%, p = 0.01). In both groups, TXA use was associated with a significant reduction in transfusion rates (stage-1, 25 vs 51.7%, p = 0.04; stage-2, 25 vs. 52.6%, p = 0.05). There was a nonstatistical decreased LOS in both groups in which TXA was used (stage 1, 5.15 vs. 6.72 days, p = 0.055; stage 2, 5.21 vs. 6.84 days, p = 0.09). There was no difference in the reinfection rate (4 vs. 4, p = 0.56) or mortality rate between groups (0 vs. 2 non-TXA group). A single upper extremity deep vein thrombosis occurred in a stage-1 patient who received TXA, and no pulmonary embolism occurred. We show that topical TXA is safe and effective for use in both stages of revision TKA for PJI. Previous studies have shown TXA to aggravate a staphylococcal infection in mice; however, topical TXA doesn't appear to negatively effect on the treatment of PJI in our patients and did not increase the reinfection, complication, or mortality rate.
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http://dx.doi.org/10.1055/s-0035-1564599DOI Listing
July 2016

Comparison of Efficacy and Tolerability of Hylan G-F 20 in Patients with and without Effusions at the Time of Initial Injection.

J Knee Surg 2015 Jun 7;28(3):213-22. Epub 2014 May 7.

Department of Orthopedics, Orthopedic Specialists of Louisiana, Shreveport, Louisiana.

An effusion at the onset of viscosupplementation has been thought to diminish the efficacy and increase adverse event rates. This study compares efficacy of hylan G-F 20 in patients with and without an effusion. Patients with knee osteoarthritis (OA) received three weekly injections of hylan G-F 20. A total of 50 patients with an effusion requiring aspiration were compared with 50 matched patients without an effusion. Outcome measurements included Western Ontario and McMaster's Universities Osteoarthritis index (WOMAC) and visual analog scale (VAS). Patients were followed for 26 weeks. Both effusion and control group VAS was significantly lowered at all time points. WOMAC scores improved (p < 0.025) at all visits in the effusion group except for WOMAC A-1 week 14. Control WOMAC scores also significantly improved at all visits (p < 0.027), except for full WOMAC and WOMAC A-1 at week 1. Neither group experienced an adverse event. Presence of an effusion at onset of viscosupplementation requiring aspiration does not negatively impact efficacy of hylan G-F 20 or increase adverse event rates.
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http://dx.doi.org/10.1055/s-0034-1376328DOI Listing
June 2015
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