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Aims The aims of this study were to characterize antibiotic choices for perioperative total knee arthroplasty (TKA) and total hip arthroplasty (THA) prophylaxis, assess antibiotic allergy testing efficacy, and determine rates of prosthetic joint infection (PJI) based on perioperative antibiotic regimen. Patients and Methods We evaluated all patients undergoing primary TKA or THA at a single academic institution between January 2004 and May 2017, yielding 29 695 arthroplasties (22 705 patients), with 3411 arthroplasties in 2576 patients (11.5%) having undergone preoperative allergy testing. A series of institutional databases were combined to identify allergy consultation outcomes, perioperative antibiotic regimen, and infection-free survivorship until final follow-up. Results Among 2576 allergy-tested patients, 2493 patients (97%) were cleared to use cephalosporins. For the entire cohort, 28 174 arthroplasties (94.9%) received cefazolin and 1521 (5.1%) received non-cefazolin antibiotics. Infection-free survivorship was significantly higher among arthroplasties receiving cefazolin compared with non-cefazolin antibiotics, with 0.06% higher survival free of infection at one month, 0.56% at two months, 0.61% at one year, and 1.19% at ten years (p < 0.001). Overall, the risk of PJI was 32% lower in patients treated with cefazolin after adjusting for the American Society of Anesthesiologists (ASA) classification, joint arthroplasty (TKA or THA), and body mass index (BMI; p < 0.001). The number needed to treat with cefazolin to prevent one PJI was 164 patients at one year and 84 patients at ten years. Therefore, potentially 6098 PJIs could be prevented by one year and 11 905 by ten years in a cohort of 1 000 000 primary TKA and THA patients. Conclusion PJI rates are significantly higher when non-cefazolin antibiotics are used for perioperative TKA and THA prophylaxis, highlighting the positive impact of preoperative antibiotic allergy testing to increase cefazolin usage. Given the low rate of true penicillin allergy positivity, and the readily modifiable risk factor that antibiotic choice provides, we recommend perioperative testing and clearance for all patients presenting with penicillin and cephalosporin allergies. Cite this article: Bone Joint J 2019;101-B(6 Supple B):9–15.

Background: Periacetabular osteotomy (PAO) is the most common treatment for symptomatic acetabular dysplasia, or developmental dysplasia of the hip (DDH), in skeletally mature patients. The purpose of this multicenter cohort study was to delineate the long-term radiographic natural history of the dysplastic hip following PAO. Methods: We evaluated all patients undergoing PAO from 1996 to 2012 at 3 academic institutions in the United States. Inclusion criteria were PAO for DDH with a minimum 5-year radiographic follow-up. Exclusion criteria were PAO for isolated acetabular retroversion, neurogenic dysplasia, Legg-Calvé-Perthes disease, and prior hip surgery including osteotomies and arthroscopy. There were 288 patients, 83% of whom were women; the mean age and body mass index (BMI) were 29 years and 25 kg/m 2 , respectively. The mean clinical and radiographic follow-up was 9.2 years (range, 5.0 to 21.1 years). Every preoperative and postoperative hip radiograph was assessed to determine the degree of osteoarthritis according to the Tönnis classification. Survivorship was analyzed by multistate modeling, enabling assessment of progression through the Tönnis grades rather than just individual transitions as with Kaplan-Meier techniques. Results: At the time of final follow-up, 144 patients (50%) had progressed at least 1 Tönnis grade, with 42 patients (14.6%) undergoing total hip arthroplasty. The mean number of years spent in each Tönnis grade following PAO was 19 for Tönnis grade 1, 8 for Tönnis grade 2, and 4 for Tönnis grade 3. The probability of progression to total hip arthroplasty increased significantly on the basis of a higher initial Tönnis grade (p < 0.001). The most marked difference occurred between Tönnis grade 0 or 1 and Tönnis grade 2; for Tönnis grade 1, the probability of progression to total hip arthroplasty at 5 and 10 years was 2% and 11%, respectively, compared with 23% and 53%, respectively, for Tönnis grade 2. Conclusions: PAO effectively alters the natural history of DDH. Precise radiographic progression based on the Tönnis grade can now be used to ascribe prognosis for the native hip. Importantly, this investigation demonstrates a stark increase in progression to total hip arthroplasty within 10 years of PAO for patients with preoperative Tönnis grade-2 osteoarthritis compared with those with Tönnis grade-0 or 1 osteoarthritis. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

» Patients with neuromuscular spasticity about the hip with concomitant painful hip arthritis can be effectively treated with total hip arthroplasty, with excellent clinical outcomes and durable implant survivorship. » Certain subsets of patients in this population are at increased risk of dislocation, component loosening, and heterotopic ossification and are also prone to postoperative medical complications. » Strategies that may mitigate the risk of dislocation include using large femoral heads or dual-mobility articulations with cautious use of constrained liners, careful repairing of soft-tissue structures at the conclusion of the surgical procedure, and performing concomitant adductor and flexor tenotomies. In addition, the other common complications can be reduced by coordinating perioperative care with neurological and medical specialists and administering perioperative heterotopic ossification prophylaxis, most commonly in the form of nonsteroidal anti-inflammatory medications, if tolerated.

ABSTRACTIntroductionNeuropathy after total knee arthroplasty (TKA) can cause significant morbidity but is inconsistently reported.MethodsWe reviewed the clinical, electrodiagnostic and perioperative features of all patients who underwent primary TKA at our institution and developed a new neuropathy within 8 weeks postoperatively.ResultsFifty‐four cases were identified (incidence 0.37% [95% confidence interval, 0.28–0.49]) affecting the following nerve(s): peroneal (37), sciatic (11), ulnar (2), tibial (2), sural (1), and lumbosacral plexus (1). In all cases with follow‐up data, motor recovery typically occurred within 1 year and was complete or near‐complete.ConclusionsPost‐TKA neuropathy is uncommon, typically does not require intervention and usually resolves within 1 year. Post‐TKA neuropathy most often affects the nerves surgically at risk. Anesthesia type does not correlate with post‐TKA neuropathy. An inflammatory etiology for post‐TKA neuropathy is rare but should be considered in specific cases. Muscle Nerve 59:679–682, 2019

Background: Previous studies on periacetabular osteotomy (PAO) reported complication and reoperation rates of 5.9% and 10%, respectively. Hip arthroscopy is increasingly utilized as an adjunct procedure to PAO to precisely treat associated intra-articular pathology. The addition of this procedure has the potential of further increasing complication rates. Purpose: To determine the rates of complication and reoperation of combined hip arthroscopy and PAO for the treatment of acetabular deformities and associated intra-articular lesions. Study Design: Case series; Level of evidence, 4. Methods: Using a prospective database, the authors retrospectively reviewed 248 hips (240 patients) that underwent combined hip arthroscopy and PAO between 2007 and 2016. Data were collected at scheduled follow-up visits at approximately 1 month, 3 to 4 months, and 1 and 2 years after surgery. Mean follow-up from surgery was 3 years (range, 1-8 years). A total of 220 PAOs were done for symptomatic acetabular dysplasia, 18 for symptomatic acetabular retroversion, and 10 for combined acetabular dysplasia and acetabular retroversion. Central compartment arthroscopy was performed for treatment of intra-articular chondrolabral pathology in all cases. Select cases underwent femoral head-neck junction osteochondroplasty either arthroscopically before the PAO or through an open approach after it. Complications were graded according to the modified Dindo-Clavien complication scheme, which was validated for hip preservation procedures. Reoperations (excluding hardware removal) were recorded. Results: Grade III complications occurred among 7 patients (3%) while there were no grade IV complications. Grade III complications included deep infection (n = 3), wound dehiscence (n = 1), hematoma requiring exploration (n = 1), symptomatic heterotopic ossification requiring excision (n = 1), and deep venous thrombosis (n = 1). There were 13 reoperations (5%), and 3 were repeat hip arthroscopy. Univariate Cox hazard models were used to estimate the relative risk factors for complication and reoperation. Increased age (per decade) showed over twice the increased likelihood for complications (hazard ratio, 2.5; 95% CI, 1.67-3.74). Also, preoperative diagnosis of acetabular retroversion, not acetabular dysplasia, showed >3 times the increased risk of reoperation (hazard ratio, 3.05; 95% CI, 1.41-6.61). Conclusion: The rate of complications reported is comparable (3%) with previously published complication rates of PAO without hip arthroscopy. In this cohort, increasing age and diagnosis of acetabular retroversion were associated with higher complication and reoperation rates.

Diagnosis of persistent infection at the time of reimplantation for staged revision of infected arthroplasties is challenging. Implant sonication culture for the diagnosis of prosthetic joint infection (PJI) has improved sensitivity compared to standard periprosthetic tissue culture.

Objectives: The Bernese periacetabular osteotomy (PAO) is becoming a widely utilized procedure. Patients are younger, highly active, and may desire to return to sport activity. Counseling and managing expectations in these patients is challenging as there is limited information regarding activity level after PAO. The purpose of this study was to analyze physical activity levels after PAO in a large, prospective multicenter cohort. Methods: Assessment of prospectively collected data from a multicenter group included 456 hips treated by PAO for hip dysplasia. After exclusions, 359 hips (80 male, 279 female) remained with a mean age of 25.9 years and mean BMI of 25. Demographics, radiographic measures, and clinical outcomes were evaluated preoperatively, at 1 year follow-up, and at minimum 2 years postoperatively (mean 44.9 months). Activity level was assessed with the University of California-Los Angeles (UCLA) activity score, patients were stratified into low, moderate, and high activity groups based on preoperative function. Descriptive statistics and linear regressions were performed for the primary outcome of change in UCLA. Results: UCLA scores were improved on average 0.6 points at final follow up (p = 0.001). When stratified, the low activity and moderate activity groups had significant improvement in UCLA scores (p<.0001 and p=0007) while the high activity group saw a decrease in UCLA scores (p<.0001). mHHS, HOOS Pain, and HOOS Sports and Recreation scores were significantly improved across all activity levels. Univariable linear regression analysis identified prior ipsilateral surgery, arthroscopy at time of PAO, and preoperative ACEA to be predictors of the change in UCLA score (p<0.05). With the multivariable model, the effect of prior ispilateral surgery was maintained (p = 0.002). Conclusion: The data suggests that improvements in activity level and function can be expected following PAO surgery, with greater gains experienced by patients with lower preoperative level of activity. [Figure: see text][Figure: see text]

Background: Redislocation of the native hip is rare. An anterior fulcrum between the proximal part of the femur and the pelvis must be present for a posterior dislocation to occur. The purpose of this study is to describe the cases of 9 patients with posterior redislocation or recurrent subluxation of the native hip that was treated with hip preservation surgery. Methods: We retrospectively identified the cases of 9 patients, from 2 institutions, who had undergone hip preservation surgery for the management of posterior redislocation or recurrent subluxation of the native hip after a dislocation. The mean number of dislocations prior to surgery was 3.2 (range, 1 to 7). Pelvic radiographs were used to classify the acetabular morphology, sufficiency of acetabular containment, and structural anatomy of the proximal part of the femur. Radiographic identification of impinging structures was used to guide surgical treatment, which involved either femoral correction alone or the combination of femoral correction and an anteverting periacetabular osteotomy. Results: At a mean follow-up of 73.8 months (range, 10 to 192 months), there had been no subsequent episodes of dislocation or subluxation in any of the hips treated with correction of the anatomic pivot point. An algorithmic approach is presented. Conclusions: In patients who have episodes of redislocation or recurrent subluxation of the native hip, the identification of anatomic abnormalities that create a fulcrum between the proximal part of the femur and the pelvis is critical for making appropriate treatment decisions. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Background: Tranexamic acid (TXA) reduces bleeding and the need for transfusion after total knee arthroplasty. Most literature has focused on intravenous (IV) administration of TXA, with less data available on the efficacy of topically administered TXA. This multicenter randomized clinical trial specifically assessed the efficacy of topical TXA compared with IV TXA as measured by calculated blood loss, drain output, and transfusion rates. Complications, including venous thromboembolism (VTE), were reported. Methods: A total of 640 patients who underwent primary unilateral total knee arthroplasty for osteoarthritis at 2 large academic centers were randomized to receive 1 g of IV TXA prior to tourniquet inflation and 1 g at closure, or 3 g of TXA diluted in 45 mL of normal saline solution (total volume of 75 mL) and topically applied after cementation. Age, sex, body mass index, American Society of Anesthesiologists (ASA) score, and preoperative hemoglobin level were similar between the groups. Univariate, multiple linear regression, and multiple logistic regression analyses were performed. Results: Patients who received topical TXA had significantly greater calculated blood loss compared with those who received IV TXA (mean of 324 compared with 271 mL; p = 0.005). Drain output was significantly higher in the topical TXA group compared with the IV TXA group (mean of 560 compared with 456 mL; p < 0.0001). The rate of transfusion was low in the topical and IV groups, with no significant difference on univariate analysis (1.6% compared with 0.6%, respectively; p = 0.45); however, on multiple logistic regression analysis, patients who received topical TXA were 2.2-fold more likely to receive a transfusion (p < 0.0001). The topical and IV TXA groups did not differ significantly with respect to the rate of thrombotic events (0.6% compared with 1.6%, respectively; p = 0.45). Conclusions: In this large, randomized clinical trial involving patients undergoing total knee arthroplasty, both IV and topical TXA were associated with a low rate of transfusion. While IV TXA was associated with less calculated blood loss, lower drain output, and fewer transfusions, the small differences between the groups may not be clinically important. Given the low prevalence of thrombotic complications, the relative safety of one formulation of TXA over the other cannot be definitely established. Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.