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Editor

P Maxwell Courtney MD

Assistant Professor

Department of Orthopedic Surgery

Thomas Jefferson University

Rothman Institute

Philadelphia, Pennsylvania, USA

Orthopedics-2

Recent Advances in

The Health Sciences PublisherNew Delhi | London | Panama

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Jaypee Brothers Medical Publishers (P) Ltd

Website: www.jaypeebrothers.comWebsite: www.jaypeedigital.com© 2018, Jaypee Brothers Medical PublishersThe views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book.All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photo copying, recording or otherwise, without the prior permission in writing of the publishers.All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contra indications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to �� CD/DVD-ROM (if any) provided in the sealed envelope with this book is complimentary and free of cost. Not meant for sale.Inquiries for bulk sales may be solicited at: [email protected]

Recent Advances in Orthopedics-2

First Edition: 2018ISBN: 978-93-5270-287-9Printed at

HeadquartersJaypee Brothers Medical Publishers (P) Ltd4838/24, Ansari Road, DaryaganjNew Delhi 110 002, IndiaPhone: +91-11-43574357Fax: +91-11-43574314E-mail: [email protected]

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Dedicated toMy wife, Courtney

for her patience, love and unending support

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Contributors

Lucas A Anderson MDDepartment of Orthopedic Surgery and

Sports Medicine

Coeur d’Alene, Idaho, USA

D Greg Anderson MDProfessor

Departments of Orthopedic and

Neurological Surgery


Rothman Institute


Bradley M AndersonDepartment of Orthopedic Surgery


Rothman Institute


Blair Ashley MD


University of Pennsylvania


Philip Ashley MD

Assistant Professor


University of Alabama-Birmingham

Children’s of Alabama

Birmingham, Alabama, USA

Frank R Avilucea MD

Assistant Professor


University of Cincinnati College of Medicine

Cincinnati, Ohio, USA

Pedro Beredjiklian MD

Assistant Professor


Thomas Jefferson University Hospital

Rothman Institute


Daniel Bouton MD

Shriner’s Hospital for Children

Portland, Oregon, USA

James Carey MD MPH

Director

Penn Center for Cartilage Repair and

Osteochondritis Dissecans Treatment

Assistant Professor




Gerard Chang MD




Ryan S Charette MD




Daniel E Davis MD

Assistant Professor



Rothman Institute


Carl A Deirmengian MD

Associate Professor



Rothman Institute


Claudio Diaz-Ledezma MD

Adult Reconstruction Surgeon

Clínica Bicentenario

Santiago, Chile

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Recent advances in orthopedics-2viii

Jill A Erickson PA-C


University of Utah

Salt Lake City, Utah, USA

David Figueroa MD

Professor


Facultad de Medicina Clinica Alemana

Universidad del Desarrollo

Santiago, Chile

Francisco Figueroa MD



Santiago, Chile

Yale A Fillingham MD

Adult Reconstruction Fellow


Rothman Institute


Charles L Getz MD

Associate Professor



Rothman Institute


J Gabriel Horneff MD

Assistant Professor



Rothman Institute


Asif Ilyas MD

Associate Professor



Rothman Institute


Tetsuya Jinno MD PhD

Associate Professor

Department of Rehabilitation Medicine/

Orthopedic Surgery

Tokyo Medical and Dental University

Bunkyo, Tokyo, Japan

Gregg R Klein MD

Vice Chairman


Hackensack University Medical Center

Hartzband Center for Hip and

Knee Replacement

Paramus, New Jersey, USA

James Krieg MD

Professor



Rothman Institute


Harlan Levine MD

Hackensack University Medical Center

Hartzband Center for Hip and

Knee Replacement

Paramus, New Jersey, USA

Daniel Lim MD




Jess H Lonner MD

Associate Professor



Rothman Institute


Kevin Lutsky MD

Assistant Professor



Rothman Institute


Rafael Martínez MD

Orthopedics Department

Universidad Finis Terrae

Santiago, Chile

Jonas Matzon MD

Associate Professor



Rothman Institute


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Contributors ix

Christopher M Melnic MD

Instructor of Orthopedic Surgery

Harvard Medical School

Massachusetts General Hospital

Boston, Massachusetts, USA

Liane Miller MD




Wayne G Paprosky MD

Professor


Rush University Medical Center

Chicago, Illinois, USA

Christopher E Pelt MD

Associate Professor


University of Utah


Christopher L Peters MD

Professor


University of Utah


David A Podeszwa MD

Associate Professor


Texas Scottish Rite Hospital for Children

Dallas, Texas, USA

Ivan Radovic MD

Hip Surgeon

Clínica Bicentenario

Santiago, Chile

Andrew Tice MD


Dallas, Texas, USA

Maria Jesus Tuca MD



Santiago, Chile

John S Vorhies MD


Stanford University School of Medicine

Lucile Packard Children’s Hospital

Stanford, California, USA

Toshifumi Watanabe MD PhD

Associate Professor

Adult Reconstruction Division


Orthopedic Surgery



Kazuyoshi Yagishita MD PhD


Orthopedic Surgery



Stephan Zmugg MD


Dallas, Texas, USA

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Thank you for your interest in Recent Advances in Orthopedics-2.

This series is intended to serve as a practical source for the general

orthopedic surgeon, both in practice and still in training. Surgeons

with a subspecialty focus will also find this book of value. Our goal was

to provide the reader with a broad understanding on the “hot topics”

in each orthopedic subspecialty with a special emphasis on current

debates in the field of adult reconstruction.

Like the first volume, we have sought to provide the reader with an

informed perspective on the most important subjects in orthopedics, written by renowned

thought leaders in their specialty. This new edition highlights topics including minimally

invasive approaches to the spine, new developments in cartilage basic science, implant

selection in revision arthroplasty and surgical techniques in joint preservation. We are

both honored and excited to have contributions from internationally recognized surgeons

in South America and Asia. We hope these chapters can give the reader new insight on

challenges faced by orthopedic surgeons all over the world.

It is our sincerest hope that this edition of Recent Advances in Orthopedics-2 will serve as

a compendium of the newest advances in orthopedic surgery. We hope that you will find

this to be a unique, practical source for the latest information as you care for your patients.

P Maxwell Courtney MD

Preface

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Acknowledgments

I would like to express my sincere appreciation to the talented contributors to Recent Advances in Orthopedics-2, without whom this wonderful work would not be possible. I

would also like to thank, the editors of the first volume of this book, who helped build the

foundation for a successful series.

I especially appreciate the constant support and encouragement of Mr Jitendar P Vij

(Group Chairman) and Mr Ankit Vij (Group President), Jaypee Brothers Medical Publishers

(P) Ltd, New Delhi, India in publishing this textbook and also their associates particularly

Ms Chetna Malhotra Vohra (Associate Director—Content Strategy) and Ms Angima Shree

(Senior Development Editor) who have been prompt, efficient and most helpful.

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Chapter 1 What’s new in spinal surgery? 1

Bradley M Anderson, D Greg Anderson

Chapter 2 What’s new in hip joint preservation surgery? 8

Lucas A Anderson, Frank R Avilucea, Christopher E Pelt,

Jill A Erickson, Christopher L Peters

Chapter 3 What’s new in total hip arthroplasty? 37

Harlan Levine, Gregg R Klein

Chapter 4 What’s new in knee arthroplasty? 49

Yale A Fillingham, Carl A Deirmengian, Jess H Lonner

Chapter 5 What’s new in revision arthroplasty? 63

Christopher M Melnic, Ryan S Charette, Wayne G Paprosky

Chapter 6 What’s new in sports medicine? 81

Daniel Lim, James Carey

Chapter 7 What’s new in shoulder and elbow surgery? 89

Charles L Getz, Daniel E Davis, J Gabriel Horneff

Chapter 8 What’s new in orthopedic trauma? 96

Gerard Chang, James Krieg

Chapter 9 What’s new in hand surgery? 113

Kevin Lutsky, Asif Ilyas, Jonas Matzon, Pedro Beredjiklian

Chapter 10 What’s new in orthopedics: Asian perspective—hip? 130

Tetsuya Jinno, Toshifumi Watanabe, Kazuyoshi Yagishita

Chapter 11 What’s new in orthopedics: Asian perspective—knee? 143

Toshifumi Watanabe, Kazuyoshi Yagishita, Tetsuya Jinno

Chapter 12 What’s new in knee arthroplasty: South American

perspective? 150

David Figueroa, Rafael Martínez, Maria Jesus Tuca,

Francisco Figueroa

Chapter 13 What’s new in hip arthroplasty: South American

perspective? 162

Claudio Diaz-Ledezma, Ivan Radovic

Contents

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Recent advances in orthopedics-2xvi

Chapter 14 What’s new in basic orthopedic science? 169

Blair Ashley, Liane Miller

Chapter 15 What’s new in pediatric orthopedics? 191

Philip Ashley, Daniel Bouton, Andrew Tice, John S Vorhies,

Stephan Zmugg, David A Podeszwa

Index 201

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Harlan Levine, Gregg R Klein

What’s new in total hip arthroplasty?

Chapter 3

INTRODUCTIONThis installment of “What is new in total hip arthroplasty?” reviews several topics relevant to

the total hip arthroplasty surgeon including the use of tapered stems in the revision setting,

consensus statements regarding the perioperative use of antirheumatic medications, and

the use of antibiotics prior to dental work for total hip arthroplasty (THA) patients and the

utility of hip precautions following posterolateral THA and outpatient THA.

TAPERED STEMS IN REVISION TOTAL HIP ARTHROPLASTY It has been projected that by 2020 the need for revision total hip arthroplasty will increase a

factor of 2.1 Reliable instruments systems and implants that can be used to manage a wide

range of bone defects encountered at the time of revision that are easy to use and predictable

in outcome will continue to be important tools in the orthopedic surgeon’s armamentarium.

Titanium tapered, splined stems, originally popularized by Wagner in the 1980s2 have

tremendous utility, particularly in the setting of proximal bone loss and poor bone quality,

and are now commonly used in revision total hip arthroplasty.3-5

The original stem design was a monolithic, tapered splined stem made of titanium with

a grit blasted surface texture. Early concerns with the use of this stem design involved stem

subsidence resulting from suboptimal femoral preparation and undersizing of the implant,

as well as instability resulting from inadequate neck length and femoral offset restoration.6

To overcome these shortcomings of earlier generation monolithic stems, modular implants

were developed that allow for the independent placement of the stem and proximal body

and give the surgeon the ability to independently control anteversion, length, and offset.

However, concerns with the use of modular stems exist including fatigue failure and

corrosion at the body/stem interface.7,8 Several recent articles extolling the benefits of both

monolithic as well as modular tapered revision implants have been published.

Hellman et al. recently reported on a single surgeon, minimum 2 year (range 24–89

month, mean 41.8 month) revision experience using a monolithic splined tapered grit

blasted titanium stem (Wagner SL, Zimmer-Biomet, Warsaw Indiana) in revision total hip

arthroplasty.9 The authors believe that there is a place in revision total hip arthroplasty for

a monolithic stem as it provides economic benefits compared to modular stems, simplicity

in inventory management, and eliminates the risk of corrosion and fatigue failure of the

body/stem junction versus a modular stem. The authors followed 67 patients (68 cases) for a

minimum of 2 years. Femoral defect classification was Paprosky grade IIIa or greater in 85%

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What’s new in total hip arthroplasty?38

of the cases. At 4-year follow-up, the Kaplan-Meier estimated survivorship was 95.5% for

aseptic femoral revision. In this series, fixation by bone ingrowth was observed in 94.1% of

patients. One patient developed stable fibrous fixation and three patients required revision

for failure of osseointegration. Mean stem subsidence in this series was 2.03 ± 3.64 mm, and

two patients had greater than 1 cm of stem subsidence both of whom required revision. The

authors advocate accurate preoperative templating, considering the use of intraoperative

X-rays to assess canal fill, and protected weight-bearing for 6 weeks postoperatively to

minimize the risk of stem subsidence. The average limb length discrepancy following revision

was 1.43 ± 11.9 mm and 86.4% of patients had limb lengths within 1 cm of the contralateral

side. The authors stress that most patients in this series with large limb length discrepancy

postoperatively had severe limb length discrepancy preoperatively as well. They report

a dislocation rate of 7.4%. They note that this dislocation rate is lower than the European

experience which ranges from 2.5% to 21%; the authors attribute the lower rate of dislocation

to a design modification in North America giving the stem a neck shaft angle of the 135°

versus the European model which has a neck shaft angle of 145°. The authors report that this

improvement in implant offset as well as the use of large femoral heads (85.3% had a head

size of 36 mm or greater in this series), and appropriate femoral canal preparation to limit

stem subsidence are the factors responsible for the improvement in dislocation rate.

Sandiford et al. also recently reported their institution’s experience with the same

monolithic, tapered, splined, titanium, grit blasted femoral stem (Wagner SL, Zimmer-

Biomet, Warsaw Indiana) as reported above.10 Citing concerns regarding stress shielding on

femoral bone stock with the use of nonmodular, cylindrical stems as well as apprehension

resulting from failures at the body/stem interface with tapered splined stems, the authors

advocate the use of nonmodular, tapered stems for all but the most complex revision cases

were a modular stem or proximal femoral replacement may be more appropriate. They report

on 104 cases performed over a 20 month period with a median follow-up of 32 months (24–

46 months). Femoral defects were classified as follows: Paprosky type I—10 hips, Paprosky

II—26 hips, Paprosky IIIA—52 hips, Paprosky IIIB—9 hips, and Paprosky IV—2 hips. In this

series, the mean Oxford Hip Scores improved from 39 ± 15 preoperatively to 87 ± 19 (p <

0.001) at latest follow-up. Similarly, WOMAC scores improved from 44 ± 15 to 87 ± 20 (p

< 0.001). Six patients exhibited stem subsidence of between 10 mm and 15 mm while the

remaining 98 patients had a mean subsidence of 2 mm (0–9 mm). There was one revision for

septic loosening. The authors advocate that this monoblock stem is a reasonable option to

treat Paprosky II and III femoral defects while avoiding potential complications at a modular

interface. They also indicate that the stem may be used for selected type IV defects.

There are many reports in the literature regarding the use of modular, tapered, splined

stems showing favorable results in the setting of femoral bone loss,11,12 periprosthetic

fracture13,14 and infection (Figures 3.1A and B).15 However, many of these studies are limited

by short-term follow-up and small patient numbers. Abdel et al. reviewed their institution’s

experience of 519 aseptic hip revisions using a modular, tapered, splined stem. Follow-up

ranged from 2 years to 14 years with a mean of 4.5 years. Harris hip scores improved from

51 points preoperatively to 76 points postoperatively. In this series, there were 16 femoral

failures requiring full femoral revisions (removal of both the body and tapered stem)

performed for the following reasons: aseptic loosening—6, infection—4, instability—3,

periprosthetic fracture—2, implant fracture—1. There were 12 other operations to address

instability where the tapered stem was retained and the proximal modular body was revised.

Ten-year survivorship was 98% with revision of the tapered, splined component for aseptic

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Consensus statements

loosening as the endpoint, was 96% with revision of the tapered splined component for any

reason as the endpoint, and was 90% for any reoperation on the hip. The authors did not note

any difference in revision rates between different modular systems. Additionally, bone loss

had no appreciable effect on risk of revision. Twelve-stems were noted to have subsidence

of greater than 5 mm on radiographic evaluation. Eleven of these had no further subsidence

after 1 year and showed no radiographic evidence for loosening. One implant continued

to subside but was not revised secondary to medical comorbidities. The authors could not

demonstrate a relationship between increased BMI, stem diameter, or stem length as risk

factors for subsidence. Importantly, the authors did not find a significant increased risk for

stem subsidence when comparing degrees of bone loss. The authors note this finding is

advantage over fully coated, cylindrical stems. In this series 68 intraoperative fractures (13%)

and 20 hip dislocations were noted.

Few studies have looked at potential differences in utility and outcomes comparing

monolithic versus modular tapered splined stems. Huang et al. retrospectively compared

160 revision hips with a modular stem to 129 hips revised with a nonmodular stem.16 No

differences with respect to postoperative Harris Hip Scores, patient satisfaction, 8 year

survival rates, rates of dislocation, infection or periprosthetic fractures were noted between

the two groups. The modular group had significantly more fractures (16.9%) compared to

the nonmodular group (7%) (p = 0.011). The nonmodular group had significantly more stem

subsidence at 1.93 mm compared to the modular group at 0.95 mm (p = 0.001).

CONSENSUS STATEMENTSTwo consensus statements have recently been released that are particularly germane to

the practicing total hip arthroplasty surgeon. The first is a collaborative guideline from

the American College of Rheumatology and the American Association of Hip and Knee

39

Figures 3.1A and B A tapered, flu-ted, monoblock titanium stem (A) and a modular tapered stem (B) used in revision hip arthroplasty.

A B

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Surgeons regarding the perioperative management of antirheumatic medication for patients

undergoing elective total joint arthroplasty. The second is an appropriate use criteria (AUC)

guideline from the American Academy of Orthopaedic Surgeons and the American Dental

Association regarding the use of antibiotics in patients that have total joint implants who are

undergoing dental procedures.

ANTIRHEUMATIC MEDICATIONThe American College of Rheumatology and the American Association of Hip and Knee

Surgeons together have released guidelines regarding the usage and stoppage of antirheumatic

medications in the perioperative period for patients undergoing elective total hip and total

knee arthroplasty.17,18 The concern is to minimize the effect these medications can have on

the immune system while mitigating the risk of a rheumatic flare-up. The panel consisted

of orthopedic surgeons, rheumatologists, methodologists and patients who, through a

consensus process, made their evaluations and recommendations. Rheumatic conditions

considered in this consensus statement include rheumatoid arthritis, spondyloarthritis,

juvenile idiopathic arthritis, and systemic lupus erythematous. Patients with these diseases

show tremendous improvement in pain and function after elective total joint arthroplasty,

however, these patients are also inherently susceptible to increased risk of complications

including infection.19-21 Many patients with rheumatologic disorders are now being treated

with biologic agents, disease modifying antirheumatic drugs, and glucocorticoids all of

which may influence the immune system to further increase susceptibility to infection.

The purpose of this guideline is to provide recommendations for the optimal perioperative

management of antirheumatic medications to lessen the risk of infection. At the time that

this committee was formulating these guidelines, no randomized controlled studies had

been performed examining the withholding and subsequent restarting of these medications.

The relevant outcomes that the committee considered for these recommendations were the

potential increased risk of infection caused by the continued use of these medications versus

the risk of disease exacerbation, if these medications were stopped. These guidelines are only

to be used for the perioperative management of adult patients undergoing total hip or total

knee arthroplasty with an underlying diagnosis of rheumatoid arthritis, spondyloarthritis,

juvenile idiopathic arthritis, or systemic lupus erythematosus. Please see Table 3.1 for the

committee’s recommendations.

DENTAL PROPHYLAXISMuch confusion remains regarding appropriate use of antibiotics for patients who

have total hip and total knee arthroplasties and are undergoing dental procedures.

The American Academy of Orthopedic Surgeons and the American Dental Association

Council on Scientific Affairs developed an Appropriate Use Criteria (AUC) “to identify the

appropriateness of the use of prophylactic antibiotics in the management of patients who

have had orthopedic implants, undergoing dental procedures.”22-24 Recommendations

of the committee were formulated from the best available evidence in the literature

combined with the clinical recommendations of experts in the medical, surgical, and

dental specialties. Several assumptions were made by the committee to create their

recommendations. Assumptions regarding the planned dental procedures include the

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Dental prophylaxis

Contd...

41

DMARDs: Continue these medications through surgery Dosing Interval Continue/Withhold

Methotrexate Weekly Continue

Sulfasalazine Once or twice daily Continue

Hydroxychloroquine Once or twice daily Continue

Leflunomide (Arava) Daily Continue

Doxycycline Daily Continue

BIOLOGIC AGENTS: STOP these medications prior to surgery and at the end of the dosing cycle. RESUME medications at minimum 14 days after surgery in the absence of wound healing problems, surgical site infection, or systemic infection. Dosing Interval

Schedule Surgery (relative to last biologic agent dose administered) during

Adalimumab (Humira) Weekly or every 2 weeks Week 2 or 3

Etanercept (Enbrel) Weekly or twice weekly Week 2

Golimumab (Simponi) Every 4 weeks (SQ) or

every 8 weeks (IV)

Week 5

Week 9

Infliximab (Remicade) Every 4, 6, or 8 weeks Week 5, 7, or 9

Abatacept (Orencia) Monthly (IV) or

weekly (SQ)

Week 5

Week 2

Certolizumab (Cimzia) Every 2 or 4 weeks Week 3 or 5

Rituximab (Rituxan) 2 doses 2 weeks apart every

4–6 months

Month 7

Tocilizumab (Actemra) Every week (SQ) or

every 4 weeks IV)

Week 2

Week 5

Anakinra (Kineret) Daily Day 2

Secukinumab (Cosentyx) Every 4 weeks Week 5

Ustekinumab (Stelara) Every 12 weeks Week 13

Belimumab (Benlysta) Every 4 weeks Week 5

Tofacitinib (Xeljanz): STOP this

medication 7 days prior to surgery.

Daily or twice daily 7 days after last dose

SEVERE SLE-SPECIFIC MEDICATIONS: CONTINUE these medications in the perioperative period. Dosing Interval Continue/Withhold

Mycophenolate mofetil Twice daily Continue

Azathioprine Daily or twice daily Continue

Cyclosporine Twice daily Continue

Tacrolimus Twice daily (N and PO) Continue

Table 3.1: Medications included in the 2017 American College of Rheumatology/ American Association of Hip and Knee Surgeons Guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. Dosing intervals were obtained from prescribing information provided online by pharmaceutical companies.

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following statements: (1) The chance of oral bacteremia being related to joint infections

is extremely low, with no evidence for association, (2) oral bacteremia frequently occurs

secondary to activities of daily living, such as tooth brushing and eating, and (3) virtually

all dental office procedures have the potential to create bacteremia. Assumptions

regarding the definition of the severely immunocompromised state include: (1) patients

with stage III AIDS, (2) cancer patients undergoing immunosuppressive therapy

with febrile (>39°C) neutropenia (ANC < 2,000) or severe neutropenia (ANC < 500),

(3) rheumatoid arthritis with the use of biologic agents including tumor necrosis factor alpha

or prednisone > 10 mg per day, (4 ) solid organ transplant on immunosuppressants, (5)

inherited diseases of immunodeficiency, and (6) active bone marrow transplant recipient.

Starting with these assumptions, the committee evaluated and made recommendations on

64 different clinical situations as to whether or not antibiotic prophylaxis prior to dental

procedure was appropriate for the patient with a total hip or knee arthroplasty. Indication

profiles for specific patient scenarios include whether or not the planned dental procedure

involves the manipulation of the gingival or periapical tissues or the perforation of the oral

mucosa; whether or not a patient is severely immunocompromised; the presence of diabetes

and extent of glycemic control; the history of periprosthetic or deep prosthetic joint infection

requiring surgery; and the timing since joint replacement surgery of less than or greater than

1 year. The AUC is available online at http://www.orthoguidelines.org/auc as an interactive

webtool that makes recommendations regarding the appropriateness of antibiotic usage

in different clinical scenarios. In most clinical situations, antibiotic prophylaxis is not

deemed appropriate. In clinical scenarios where antibiotic prophylaxis is considered to

be appropriate, the AUC guidelines make further recommendations regarding antibiotic

selection. Clindamycin is no longer recommended for dental prophylaxis. Recommended

antibiotics include 2 g of amoxicillin for patients without penicillin allergies, or either 2 g of

cephalexin or 500 mg of either azithromycin or clarithromycin for patients with a penicillin

allergy. The authors of the AUC emphasize that there is only a 5% cross-reactivity with first-

generation cephalosporins and only 1% cross reactivity for three generation cephalosporins

for patients with a penicillin allergy, and recommend that cephalosporins be used unless

there is a history of anaphylaxis from a penicillin exposure. They recommend referral to an

allergist, if there is any concern regarding antibiotic administration.

NOT-SEVERE SLE: DISCONTINUE these medications 1 week prior to surgery Dosing Interval Continue/Withhold

Mycophenolate mofetil Twice daily Withhold

Azathioprine Daily or twice daily Withhold

Cyclosporine Twice daily Withhold

Tacrolimus Twice daily (N and PO) Withhold

(DMARDs: Disease-modifying antirheumatic drugs; SQ: Subcutaneous; IV: Intravenous; SLE: Systemic lupus

erythematosus; PO: Oral).

Source: Goodman SM, Springer B, Guyatt G, et al. 2017 American College of Rheumatology/American Association of

Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients with

Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. Arthritis Rheumatol. 2017;69(8):

1538-51.

Contd...

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Are hip precautions necessary when utilizing a posterior lateral approach to the hip?

ARE HIP PRECAUTIONS NECESSARY WHEN UTILIZING A POSTERIOR LATERAL APPROACH TO THE HIP?Hip precautions immediately following total hip arthroplasty have long been a tradition in

orthopedic surgery to minimize the risk of a postoperative dislocation which can corrupt

a patient’s confidence in their hip replacement, cause them to lose faith in their surgeon,

and can lead to further hospitalizations and revision surgery which adds economic burden

to these procedures. The contention has been that, in the postoperative period, patients

need to be protected while their tissues heal and their strength returns to minimize risk of

dislocation. However, hip precautions can be restrictive, influence patient satisfaction, and

slow down or impede recovery.25-27 In the anterolateral approach, it is been shown that hip

precautions can be removed without increasing rates of instability.28,29

The posterolateral approach remains a widely used approach to the hip as it is easy to

use, provides excellent visualization of both the acetabular and femoral anatomy, is reliable

for both primary and revision arthroplasty, is extensile, and has a low complication rate

as compared to other approaches. However, concerns for increased rate of dislocation

compared to other approaches has been a concern.30 Soft tissue repair of the posterior capsule

and short external rotators, however, have dramatically reduced the rates of dislocation to

approximately 0.5%.31-35 Some authors have shown that 4 weeks of precautions does not

increase the rate of dislocation compared to 6 weeks.36 Several recent studies (retrospective,

meta-analysis, and prospective) have examined whether or not standard hip precautions are

necessary at all following posterolateral THA.

In a prospective, comparative, safety study, Kornuijt et al.37 looked at two groups of patients

undergoing total hip arthroplasty. No differences between the two groups were noted with

respect to patient demographics or risk factors for dislocation. There were 109 patients in the

more restricted group and 108 patients in the less restricted group. For 6 weeks, the more

restricted group was managed with traditional hip precautions and the less restricted group

was managed with a modified restriction protocol. Both groups were instructed to avoid

cross legged sitting and to bend forward with the operative leg moving backwards. The less

restrictive group was given no sleeping restrictions, utilized an abduction pillow only until

they were first mobilized, used a standard pillow at home only for comfort, were instructed

to avoid the combined position of full hip flexion with internal rotation and adduction, were

allowed to drive when they were able to walk without crutches, were allowed to use a normal

toilet seat and normal chair and were instructed to use crutches only as needed. All surgeries

were performed by five experienced total hip arthroplasty surgeons using a posterior lateral

approach with posterior capsule and short external rotator soft tissue repair. Patients in the

less restricted group were given a choice of a short acting spinal or general anesthetic and

were mobilized within 4 hours of surgery whereas the patients in the more restrictive group

were offered a long acting spinal or general anesthetic and were mobilized greater than 4

hours after surgery. Femoral head sizes range from 28 mm to 36 mm. In the 3 month follow-

up period, there were no dislocations in the less restricted group and there was one anterior

dislocation in the more restrictive group. No significant difference was noted for the risk for

dislocation between the two groups (p = 0.32). The authors note that this was a safety study

undertaken to make sure that no harm would come to either study group. They called for

larger studies to be performed to reach further statistical significance. In their discussion,

the authors note that hip precautions were originally derived in the earliest stages of total

hip arthroplasty before soft tissue repair was standard and when patients were not mobilized

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for many days following surgery. They note that most early dislocations occur secondary to

either a fall or an unexpected twisting motion, and that neither of these mechanisms would

be avoided with a more restricted protocol.

Gromov et al. performed a retrospective, noninferiority study to investigate the rate of

dislocation within 90 days of posterolateral THA in unselected patients with and without

postoperative mobilization precautions. All patients underwent posterolateral THA with soft

tissue repair. 946 patients who underwent THA with postoperative mobilization restriction

were compared to 1,329 patients who underwent THA with unrestricted mobilization.

Postoperative mobilization restrictions included avoidance of hip adduction across the

midline, hip flexion greater than 90°, and internal rotation. Patients were instructed to only

use a pillow between the legs well in bed lying on the nonoperative side. Patients were

instructed to use elevated chairs and toilet seats. Precautions were followed for 3 months

postoperatively. Patients in the unrestricted group received the same physical therapy

but were mobilized without restrictions and allowed free range of motion. There were 32

dislocations in the restricted group (3.4%) and 37 (2.8%) in the unrestricted group. The

authors found that there was no increased risk for early dislocation in the group treated with

unrestricted postoperative mobilization. The results of the study also found a trend toward

a lower 30 day and 90 day risk of dislocation as well as a trend for a lower risk of recurrent

dislocation in the unrestricted mobilization group although statistical significance was not

achieved. The authors found that almost half of all dislocations in each group were the result

of either a fall or a twisting motion, neither of which would be avoided with mobilization

restrictions, and conclude that it is safe to use minimal precautions in the postoperative

period following posterolateral THA.

van der Weegen et al.38 performed a meta-analysis to determine the utility of postoperative

hip precautions in patients undergoing THA. Six articles were used and 1,122 procedures

were identified and included for analysis. There were 528 patients in the restricted group

and 594 in the unrestricted group. Both the standard posterior and anterolateral approaches

were used in these studies. In the restricted group there were eight dislocations (1.5%) and

six dislocations (1%) in the unrestricted group. Isolating procedures performed with mini-

posterior approaches there was a dislocation rate of 2.1% in the restricted group versus 1.8%

in the unrestricted group. The authors noted that patients in the unrestricted group were

generally more satisfied with their recovery, and returned to activities including independent

walking and driving faster then those patients in the restricted group. Based on the pooled

evidence in their study, the authors conclude that a postoperative protocol that uses either

less or no hip precautions does not lead to an increase in postoperative dislocations, and may

actually improve dislocations rates. Additionally, such protocols can lead to better and more

rapid return to activities of daily living, earlier return to work, shorter hospital admissions,

and greater patient overall satisfaction with their THA.

The posterior approach has been compared to other approaches including the

anterior approach. One promoted benefit of the anterior approach is the lack of need for

traditional hip precautions; surgeons, the lay press, and the general public have toted this

as an advantage for patients in the recovery period. The studies mentioned above serve as a

reference for surgeons who prefer the posterior approach who wish to consider reevaluating

their perioperative protocols. Additionally, several studies have failed to show benefit of the

anterior approach compared to posterior THA. Reininga et al.39 in a randomized controlled

study comparing computer-navigated direct anterior THA to conventional posterolateral

THA, found no difference in the return of gait metrics including walking speed, stride

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Outpatient total joint arthroplasty

length, cadence or frontal plane angular movements at 6 weeks, 3 months, and 6 months

postoperatively. In a single institutional experience comparing 126 direct anterior hips to 96

miniposterior hips, Poehling-Monaghan et al. found better return to work and faster return

to driving with the mini-posterior approach.40 The authors conclude that there is no inherent

advantage of direct anterior THA versus mini-posterior THA and state that factors other than

surgical approach (rapid rehabilitation protocols, patient selection, surgical volume, etc.)

may be more important for early recovery following THA. Meneghini found a higher rate of

femoral failure in direct anterior hips compared to posterior THA and are concerned that a

higher rate of complications may be associated with this approach.41

OUTPATIENT TOTAL JOINT ARTHROPLASTYTotal hip and knee arthroplasty has demonstrated excellent short- and long-term clinical

results. There has been an historic trend toward shorter length of stays and more recently

outpatient total joint arthroplasty has gained increasing popularity and success.

There is no consensus regarding the definition of outpatient total joint arthroplasties.

Many procedures designated as outpatient may not truly have a length of stay of zero nights. In

fact, some patients may be “observed” in the hospital for a day or two but still be classified as

having undergone an outpatient procedure. Bovonratwet et al. reviewed the National Surgical

Quality Improvement Program. National Surgical Quality Improvement Program (NSQIP)

database from 2004 to 2015 evaluates the effect of definitional differences on outcomes.

72,651 THAs were reviewed. 529 of these were identified as outpatient but only 61 (12%) had a

LOS of zero. Similarly, 117,454 TKAs were reviewed and 890 (11%) of these had a length of stay

of zero days. After controlling for confounding factors the authors found that the inpatient

groups had an increased risk for adverse events or readmission.42

Klein et al.43 reviewed 549 consecutive mini-posterior THA performed at a free standing

independent ambulatory surgical center. The average age was 54 (27–73) years old, with 68%

males and an average BMI of 29 (18–45). 546/549 (99.5%) of patients were discharged to home

the same day and there were no overnight stays or transfers to a rehab or skilled nursing

facility (SNF). Three patients required a hospital admission; one patient for pain control

after failing to disclose his long-term narcotic dependence, one for acetabular component

position change identified on postoperative X-ray and one for postoperative hypotension,

bradycardia, and polyarthralgia exacerbation.

There has been emphasis in the recent literature regarding patient selection and suitability

for outpatient joint replacement. Sher et al.44 reviewed NSQIP data on 120,847 patients and

found that 7,474 of these primary total joint arthroplasties were discharged within 24 hours.

The authors found that these patients were more likely to be less than 50 years of age, male,

and ASA class 1 or 2. In addition, these patients were less likely to be obese or taking steroids

and less likely to have comorbidities. Adverse events were more likely to be associated with

age over 80 years, ASA class 3 or 4, smoking and having bleeding causing disorders.

Courtney et al.45 retrospectively reviewed 1,012 patients undergoing total joint arthroplasty

to identify risk factors associated with postoperative complications. Seventy (6.9%)

complications requiring physician intervention were required. Independent multivariate

risk factors for developing a complication greater than 24 hours from the index surgery

included: chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD),

congestive heart failure (CHF), and cirrhosis.

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Courtney and Boniello46 queried the American College of Surgeons NSQIP database

from 2011 to 2014 and identified 169,406 total joint replacements. 1,220 (0.7%) of these were

outpatient procedures. They identified a complication rate of 8% in the outpatient group

and 16% in the inpatient group. Risk factors for complications or readmissions included:

age greater than 70, malnutrition, cardiac history, smoking history, and diabetes mellitus.

Outpatient surgery did not increase the risk for readmission and was a negative independent

risk factor for complications.

Rozell et al.46 prospectively evaluated a series of 802 patients who had a primary

joint arthroplasty. There were 382 postoperative complications and 152 required active

management for the complications. Multiple logistic regression analysis identified cirrhosis,

CHF, and chronic kidney disease as risk factors for a late complication.

Goyal et al.47 received the Otto Aufranc Award for a multicentered randomized study of

220 patients who were randomized to outpatient or inpatient direct anterior THA. Inclusion

criteria included age less than 75, BMI less than 40, the ability to ambulate without a walker,

and the absence of chronic opioid usage. One hundred twelve patients were randomized

to outpatient and 108 patients to inpatient surgery. Eighty-five (76%) of the outpatient

group were discharged on the day of surgery as planned and the remaining patients were

discharged after one night except for one patient that was discharged after two nights. In the

inpatient group 18 (17%) patients met discharge criteria and were discharged on the day of

surgery, 81 (75%) were discharged as planned on postoperative day one, and nine patients

(8%) stayed two or more nights. There were no differences in reoperations, readmissions,

emergency department visits, or acute office visits between the two groups. On the day of

surgery, the visual analog scale for pain was the same between the groups. It was higher on

postoperative day one for the patients who were discharged home.

While outpatient total joint arthroplasty is being performed with greater frequency

the general public and potential patients are generally not aware of this surgical option.

Meneghini and Ziemba-Davis48 surveyed 110 consecutive patients scheduled for primary

TJA in an academic suburban hospital regarding their perceptions of outpatient joint

replacement. Only three patients expected same-day discharge and 17 expected a one night

stay in the hospital. Over half (54%) expected to stay in the hospital two or more nights. Only

54.5% of patients were aware that outpatient TJA is an option.

Nelson et al.49 has reported on the “safety” of outpatient total hip arthroplasty. They

retrospectively reviewed prospectively collected NSQIP data regarding length of stay. Out

of 63,844 THA patients 420 (0.665) underwent outpatient surgery and had a length of stay

of zero days. The patients who were considered outpatients tended to be male, younger,

and had fewer comorbidities. Eighteen different adverse events were evaluated. Of these

18 different adverse events the only difference between the two groups was the need for

perioperative blood transfusions, which was less in the outpatient group (3.69% vs 9.06%,

p < 0.001).

REFERENCES1. Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United

States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780-5.

2. Wagner H. Revision prosthesis for the hip joint in severe bone loss. Orthopade. 1987;16:295-300.

3. Cross MB, Paprosky WG. Managing femoral bone loss in revision total hip replacement: fluted tapered

modular stems. Bone Joint J. 2013;95-B:95-7.

4. Sporer SM, Paprosky WG. Femoral fixation in the face of considerable bone loss: the use of modular stems.

Clin Orthop Relat Res. 2004;429:227-31.

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rs

References

5. Sheth NP, Melnic CM, Rozell JC, et al. Management of severe femoral bone loss in revision total hip

arthroplasty. Orthop Clin North Am. 2015;46:329-42.

6. Berry DJ. Femoral revision: distal fixation with fluted, tapered grit-blasted stems. J Arthroplasty. 2002;17:

142-6.

7. Lakstein D, Eliaz N, Levi O, et al. Fracture of cementless femoral stems at the mid-stem junction in modular

revision hip arthroplasty systems. J Bone Joint Surg Am. 2011;93:57.

8. Konan S, Garbuz DS, Masri BA, et al. Modular tapered titanium stems in revision arthroplasty of the hip: the

risk and causes of stem fracture. Bone Joint J. 2016;98-B(1)(Suppl A):50-3.

9. Hellman MD, Kearns SM, Bohl DD, et al. Revision total hip arthroplasty with a monoblock splined tapered

grit-blasted titanium stem. J Arthroplasty. 2017. [Epub ahead of print]

10. Sandiford NA, Garbuz DS, Masri BA, et al. Nonmodular tapered fluted titanium stems osseointegrate reliably

at short term in revision THAs. Clin Orthop Relat Res. 2017;475:186-92.

11. Fink B, Urbansky K, Schuster P. Mid term results with the curved modular tapered, fluted titanium Revitan

stem in revision hip replacement. Bone Joint J. 2014;96-B(7):889-95.

12. Amanatullah DF, Howard JL, Siman H, et al. Revision total hip arthroplasty in patients with extensive

proximal femoral bone loss using a fluted tapered modular femoral component. Bone Joint J. 2015;97-

B(3):312-7.

13. Abdel MP, Lewallen DG, Berry DJ. Periprosthetic femur fractures treated with modular fluted, tapered stems.

Clin Orthop Relat Res. 2014;472(2):599-603.

14. Munro JT, Garbuz DS, Masri BA, et al. Tapered fluted titanium stems in the management of Vancouver B2

and B3 periprosthetic femoral fractures. Clin Orthop Relat Res. 2014;472(2):590-8.

15. Houdek MT, Perry KI, Wyles CC, et al. Use of a modular tapered fluted femoral component in revision

total hip arthroplasty following resection of a previously infected total hip: minimum 5-year follow-up. J

Arthroplasty. 2015;30(3):435-8.

16. Huang Y, Zhou Y, Shao H, et al. What is the difference between modular and nonmodular tapered fluted

titanium stems in revision total hip arthroplasty. J Arthroplasty. 2017;32(10):3108-13.

17. Goodman SM, Springer B, Guyatt G, et al. 2017 American College of Rheumatology/American Association

of Hip and Knee Surgeons Guideline for the perioperative management of antirheumatic medication in

patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. J Arthroplasty.

2017. pii: S0883-5403(17)30401-1. [Epub ahead of print]

18. Goodman SM, Springer B, Guyatt G, et al. 2017 American College of Rheumatology/American Association

of Hip and Knee Surgeons Guideline for the perioperative management of antirheumatic medication

in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. Arthritis

Rheumatol. 2017;69(8):1538-51.

19. Singh JA, Inacio MC, Namba RS, et al. Rheumatoid arthritis is associated with higher ninety-day hospital

readmission rates compared to osteoarthritis after hip or knee arthroplasty: a cohort study. Arthritis Care

Res. 2015;67:718-24.

20. Ravi B, Croxford R, Hollands S, et al. Increased risk of complications following total joint arthroplasty in

patients with rheumatoid arthritis. Arthritis Rheumatol. 2014;66:254-63.

21. Roberts JE, Mandl LA, Su EP, et al. Patients with systemic lupus erythematosus have increased risk of short-

term adverse events after total hip arthroplasty. J Rheumatol. 2016;43:1498-1502.

22. Quinn RH, Murray JN, Pezold R, et al. The American Academy of Orthopaedic Surgeons appropriate use

criteria for the management of patients with orthopaedic implants undergoing dental procedures. J Bone

Joint Surg Am. 2017;25(7):e142-e143.

23. The American Academy of Orthopaedic Surgeons/The American Association of Orthopaedic Surgeons.

Available from http://www.aaos.org/auc. [Accessed Oct., 2017]

24. The American Academy of Orthopaedic Surgeons. Available from http://www.orthoguidelines.org/auc.

[Accessed Oct., 2017]

25. Mikkelsen LR, Petersen MK, Søballe K, et al. Does reduced movement restrictions and use of assistive

devices affect rehabilitation outcome after total hip replacement? A non-randomized, controlled study. Eur

J Phys Rehabil Med. 2014;50:383-93.

26. Ververeli PA, Lebby EB, Tyler C, et al. Evaluation of reducing postoperative hip precautions in total hip

replacement: a randomized prospective study. Orthopedics. 2009;32:889.

27. Peak EL, Parvizi J, Ciminiello M, et al. The role of patient restrictions in reducing the prevalence of early

dislocation following total hip arthroplasty. A randomized, prospective study. J Bone Joint Surg Am.

2005;87(2):247-53.

47

Jayp

ee B

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rs


28. Restrepo C, Mortazavi SM, Brothers J, et al. Hip dislocation: are hip precautions necessary in anterior

approaches? Clin Orthop Relat Res. 2011;469(2):417-22.

29. Peak EL, Parvizi J, Ciminiello M, et al. The role of patient restrictions in reducing the prevalence of early

dislocation following total hip arthroplasty. A randomized, prospective study. J Bone Joint Surg Am.

2005;87(2):247-53.

30. Kwon MS, Kuskowski M, Mulhall KJ, et al. Does surgical approach affect total hip arthroplasty dislocation

rates? Clin Orthop Relat Res. 2006;447:34-8.

31. Pellicci PM, Bostrom M, Poss R. Posterior approach to total hip replacement using enhanced posterior soft

tissue repair. Clin Orthop Relat Res. 1998;(355):224-8.

32. Tsai SJ, Wang CT, Jiang CC. The effect of posterior capsule repair upon post-operative hip dislocation

following primary total hip arthroplasty. BMC Musculoskelet Disord. 2008;9:29.

33. White RE Jr, Forness TJ, Allman JK, et al. Effect of posterior capsular repair on early dislocation in primary

total hip replacement. Clin Orthop Relat Res. 2001;(393):163-7.

34. Suh KT, Park BG, Choi YJ. A posterior approach to primary total hip arthroplasty with soft tissue repair. Clin

Orthop Relat Res. 2004;(418):162-7.

35. Osmani O, Malkani A. Posterior capsular repair following total hip arthroplasty: a modified technique.

Orthopedics. 2004;27(6):553-5.

36. Schmidt-Braekling T, Waldstein W, Akalin E, et al. Minimal invasive posterior total hip arthroplasty: are

6 weeks of hip precautions really necessary? Arch Orthop Trauma Surg. 2015;135(2):271-4.

37. Kornuijt A, Das D, Sijbesma T, et al. The rate of dislocation is not increased when minimal precautions are

used after total hip arthroplasty using the posterolateral approach: a prospective, comparative safety study.

Bone Joint J. 2016;98-B(5):589-94.

38. van der Weegen W, Kornuijt A, Das D. Do lifestyle restrictions and precautions prevent dislocation after total

hip arthroplasty? A systematic review and meta-analysis of the literature. Clin Rehabil. 2016;30(4):329-39.

39. Reininga IH, Stevens M, Wagenmakers R, et al. Comparison of gait in patients following a computer-

navigated minimally invasive anterior approach and a conventional posterolateral approach for total hip

arthroplasty: a randomized controlled trial. J Orthop Res. 2013;31(2):288-94.

40. Poehling-Monaghan KL, Kamath AF, Taunton MJ, et al. Direct anterior versus miniposterior THA with

the same advanced perioperative protocols: surprising early clinical results. Clin Orthop Relat Res.

2015;473(2):623-31.

41. Meneghini RM, Elston AS, Chen AF, et al. Direct anterior approach: risk factor for early femoral failure of

cementless total hip arthroplasty: A multicenter study. J Bone Joint Surg Am. 2017;99(2):99-105.

42. Bovonratwet P, Webb ML, Ondeck NT, et al. Definitional differences of ‘outpatient’ versus ‘inpatient’ THA and

TKA can affect study outcomes. Clin Orthop Relat Res. 2017. [Epub ahead of print]

43. Klein GR, Posner JM, Levine HB, et al. Same day total hip arthroplasty performed at an ambulatory surgical

center: 90-day complication rate on 549 patients. J Arthroplasty. 2017;32(4):1103-6.

44. Sher A, Keswani A, Yao DH, et al. Predictors of same-day discharge in primary total joint arthroplasty patients

and risk factors for post-discharge complications. J Arthroplasty. 2017;32(9S):S150-S156.e1.

45. Courtney PM, Boniello AJ, Berger RA. Complications following outpatient total joint arthroplasty: an

analysis of a national database. J Arthroplasty. 2017;32(5):1426-30.

46. Rozell JC, Courtney PM, Dattilo JR, et al. Late complications following elective primary total hip and knee

arthroplasty: who, when, and how? J Arthroplasty. 2017;32(3):719-23.

47. Goyal N, Chen AF, Padgett SE, et al. Otto Aufranc Award: A multicenter, randomized study of outpatient

versus inpatient total hip arthroplasty. Clin Orthop Relat Res. 2017;475(2):364-72.

48. Meneghini RM, Ziemba-Davis M. Patient perceptions regarding outpatient hip and knee arthroplasties.

J Arthroplasty. 2017;32(9):2701-5.

49. Nelson SJ, Webb ML, Lukasiewicz AM, et al. Is outpatient total hip arthroplasty safe? J Arthroplasty.

2017;32(5):1439-42.

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