Current technology does not offer a single best reconstruction option for children. Previous studies and the present series have indicated that physical and emotional functioning in patients treated with an expandable endoprosthesis are good but that complication rates remain high. Amputation and rotationplasty are alternative treatments if patients and their families are amenable to these procedures. The literature supports no single superior treatment among these three options with regard to physical or emotional health.

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common and successful orthopedic procedures, and as their frequency continues to increase substantially, the focus on limiting perioperative complications heightens. Intraoperative normothermia is recommended to minimize additional complications, but limited evidence exists regarding the effect of hypothermia on orthopedic patients. The purpose of this retrospective study was to determine the incidence of perioperative hypothermia in the setting of TKA and THA, and to evaluate its impact on complications and outcomes. The clinical records of 2580 consecutive patients who underwent TKA or THA at a single institution between January 1, 2011, and December 31, 2013 were reviewed. After excluding patients with complex or revision procedures, a total of 2397 patients comprised the study population. Patient demographic data, surgery-specific data, postoperative complications, length of hospital stay, and 30-day readmission were recorded. Patients with a mean intraoperative temperature less than 36°C were identified as hypothermic. Statistical analysis evaluated associations with hypothermia and the effect on complications and outcomes. The incidence of mean intraoperative hypothermia was 37%, 43.9%, and 32.6% for arthroplasty, THA, and TKA, respectively. General anesthesia was significantly associated with hypothermia (P<.001). Women and THA patients were at higher risk for hypothermia. In the arthroplasty and THA cohorts, longer operating room time and re-warmer use were associated with hypothermia (P=.010). Overall, hypothermia was associated with increased estimated blood loss, but no increase in associated transfusion was demonstrated (P=.006). Hypothermia was not associated with postoperative complications. [Orthopedics. 2017; 40(1):56-63.].

* There are multiple available agents and modalities for controlling pain perioperatively during total joint arthroplasty to improve the patient experience, and their unique mechanisms and applications should be considered for use preoperatively, intraoperatively, and postoperatively, keeping in mind that each has differing efficacy and side-effect profiles.* Preoperative pain control or preemptive analgesia using anti-inflammatory drugs and opioid analgesics appears to be effective in reducing postoperative pain, although the recommended timing and type of agents are unclear.* With regard to intraoperative anesthetic choice and pain control, spinal anesthesia appears to have fewer systemic risks than general anesthesia, and periarticular injections of local anesthetic agents, regardless of technique, and with or without the addition of sympathetic modulators, opioids, nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids, have been shown to improve pain scores postoperatively and to overall carry a low risk profile.* When considering postoperative pain control, there are several modalities including cryotherapy, peripheral nerve blockade, and parenteral and enteral medication options including acetaminophen, cyclooxygenase inhibitors, neuromodulators, tramadol, ketamine, and opioid patches, but there is no clearly preferred medication regimen and individual patient risk profiles must be considered when choosing appropriate pain management agents.* Multimodal pain management can decrease opioid usage, improve pain scores, increase patient satisfaction, and enhance early recovery. The ideal preoperative, intraoperative, and postoperative pain medication regimen remains unclear, and an individualized approach to perioperative pain management is recommended. Despite this, good results are demonstrated with the existing variations in pain management protocols in the literature.* Treatment of severe postoperative pain in a multimodal fashion carries the risk for serious side effects, including respiratory depression, mental status changes influencing safe gait mechanics, hypotension, renal and hepatic dysfunction, hematologic variations, gastrointestinal considerations including gastric ulcers, constipation or ileus, nausea or vomiting, infection at injection sites, and peripheral nerve injury with peripheral blockade.

Hip fractures are common orthopedic injuries and are associated with significant morbidity/mortality. Intraoperative normothermia is recommended by national guidelines to minimize additional morbidity/mortality, but limited evidence exists regarding hypothermia's effect on orthopedic patients. The purpose of this study was to determine the incidence of intraoperative hypothermia in patients with operatively treated hip fractures and evaluate its effect on complications and outcomes. Retrospective chart review was performed on clinical records from 1541 consecutive patients who sustained a hip fracture and underwent operative fixation at the authors' institution between January 2005 and October 2013. A total of 1525 patients were included for analysis, excluding those with injuries requiring additional surgical intervention. Patient demographic data, surgery-specific data, postoperative complications, length of stay, and 30-day readmission were recorded. Patients with a mean intraoperative temperature less than 36°C were identified as hypothermic. Statistical analysis with univariate and multivariate logistic regression modeling evaluated associations with hypothermia and effect on complications/outcomes. The incidence of intraoperative hypothermia in operatively treated hip fractures was 17.0%. Hypothermia was associated with an increase in the rate of deep surgical-site infection (odds ratio, 3.30; 95% confidence interval, 1.19-9.14; P=.022). Lower body mass index and increasing age demonstrated increased association with hypothermia (P=.004 and P=.005, respectively). To the authors' knowledge, this is the first and largest study analyzing the effect of intraoperative hypothermia in orthopedic patients. In patients with hip fractures, the study's findings confirm evidence found in other surgical specialties that hypothermia may be associated with an increased risk of deep surgical-site infection and that lower body mass index and increasing age are risk factors for intraoperative hypothermia. [Orthopedics. 2016; 39(6):e1170-e1177.].

Although total knee arthroplasty is a successful and well-established surgical intervention, there is renewed interest in evaluating its theoretical underpinning and surgical techniques in order to identify areas for potential improvement in patient outcomes.» The practice of using mechanical limb alignment for total knee arthroplasty arose from the design of the modern condylar knee prosthesis, with the goal of equally distributing stresses across the articulating surfaces of the prosthesis. Disclosure: No external funds were received in support of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/ JBJSREV/A441).

Background Limb preservation surgery for extremity sarcomas offers the promise of improved function and cosmesis over amputation. Application of limb salvage surgery for pediatric patients with expandable metallic endoprostheses is gaining acceptance. The few studies reporting these devices have focused on functional outcomes; one has addressed quality of life. Questions/purposes We asked the following questions: (1) how happy are these patients; (2) how do these patients perceive their bodies; (3) do these children have difficulty with social interactions; and (4) how satisfied are patients and their parents with their outcomes?

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