Impingement is a cause of poor outcomes of prosthetic hip arthroplasty; it can lead to instability, accelerated wear, and unexplained pain. Impingement is influenced by prosthetic design, component position, biomechanical factors, and patient variables. Evidence linking impingement to dislocation and accelerated wear comes from implant retrieval studies. Operative principles that maximize an impingement-free range of motion include correct combined acetabular and femoral anteversion and an optimal head-neck ratio. Operative techniques for preventing impingement include medialization of the cup to avoid component impingement and restoration of hip offset and length to avoid osseous impingement.

Therapeutic Level I.

Improvements in pain management techniques in the last decade have had a major impact on the practice of total hip and knee arthroplasty (THA and TKA). Although there are a number of treatment options for postoperative pain, a gold standard has not been established. However, there appears to be a shift towards multimodal approaches using regional anesthesia to minimize narcotic consumption and to avoid narcotic-related side effects. Over the last 10 years, we have used intravenous patient-controlled analgesia (PCA), femoral nerve block (FNB), and continuous epidural infusions for 24 and 48 hours with and without FNB. Unfortunately, all of these techniques had shortcomings, not the least of which was suboptimal pain control and unwanted side effects. Our practice has currently evolved to using a multimodal protocol that emphasizes local periarticular injections while minimizing the use of parenteral narcotics. Multimodal protocols after THA and TKA have been a substantial advance; they provide better pain control and patient satisfaction, lower overall narcotic consumption, reduce hospital stay, and improve function while minimizing complications. Although no pain protocol is ideal, it is clear that patients should have optimum pain control after TKA and THA for enhanced satisfaction and function. Level of Evidence: Level V, expert opinion. See the Guidelines for Authors for a complete description of levels of evidence.

No abstract

A multimodal thromboembolic prophylactic regimen is consistent with protecting patients while limiting adverse clinical outcomes secondary to thromboembolic, vascular, and bleeding complications.

Nerve injury is a relatively rare, yet potentially devastating complication of total hip arthroplasty (THA). Incidence of this ranges from 0.6 to 3.7%, and is highest in patients with developmental hip dysplasia and previous hip surgery. Apart from patient and surgeon dissatisfaction, this complication can have medico-legal consequences. Therefore, the purpose of this study was to review the risk factors, etiology, diagnostic options, management strategies, prognosis, and prevention measures of nerve injuries associated with THA. We specifically evaluated the: 1) sciatic nerve; 2) femoral nerve; 3) obturator nerve; 4) superior gluteal nerve; and 5) the lateral femoral cutaneous nerve.

Infection with hepatitis C is an infrequent but increasingly common comorbidity among patients undergoing total joint arthroplasty. Given these findings, orthopaedic surgeons should be aware of the increased risks of total joint arthroplasty in patients with hepatitis C and should discuss these risks with potential surgical candidates during a shared decision-making process.

Although metastatic disease of the foot is rare, it should be considered in the diagnosis of a painful foot, especially if suspicious radiographic changes are present in an older patient. The common primary sites are the genito-urinary, lungs, breast, and the colo-rectum. Treatment is usually palliative to reduce pain and maintain function.