Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Symposium: 2013 Knee Society Proceedings 34 articles


In Vivo Determination of Cam-Post Engagement in Fixed and Mobile-bearing TKA

Sumesh M. Zingde MS, Filip Leszko PhD, Adrija Sharma PhD, Mohamed R. Mahfouz PhD, Richard D. Komistek PhD, Douglas A. Dennis MD

Kinematics vary, sometimes in important ways, among the different types of total knee arthroplasty (TKA) designs, yet differences between the in vivo mechanisms of cam-post engagement in rotating-platform posterior-stabilized (PS) TKA, bicruciate-stabilized TKA, and fixed-bearing PS TKA designs remain largely uncharacterized.

High Level of Residual Symptoms in Young Patients After Total Knee Arthroplasty

Javad Parvizi MD, FRCS, Ryan M. Nunley MD, Keith R. Berend MD, Adolph V. Lombardi MD, Erin L. Ruh MS, John C. Clohisy MD, William G. Hamilton MD, Craig J. Della Valle MD, Robert L. Barrack MD

TKA is among the fastest growing interventions in medicine, with procedure incidence increasing the most in younger patients. Global knee scores have a ceiling effect and do not capture the presence of difficulty or dissatisfaction with specific activities important to patients.

Does Adding Antibiotics to Cement Reduce the Need for Early Revision in Total Knee Arthroplasty?

Eric Bohm MD, MSc, FRCSC, Naisu Zhu MD, DrPH, Jing Gu MD, Nicole Guia MHSc, Cassandra Linton MSc, Tammy Anderson MSc, David Paton MSc, Michael Dunbar MD, FRCSC, PhD

There is considerable debate about whether antibiotic-loaded bone cement should be used for fixation of TKAs. While antibiotics offer the theoretical benefit of lowering early revision due to infection, they may weaken the cement and thus increase the likelihood of aseptic loosening, perhaps resulting in a higher revision rate.

Perioperative Morbidity and Mortality of Same-day Bilateral TKAs: Incidence and Risk Factors

Lazaros Poultsides MD, Stavros Memtsoudis MD, Alejandro Gonzalez Della Valle MD, Ivan De Martino MD, Huong T. Do MA, Michael Alexiades MD, Thomas Sculco MD

Controversy persists regarding the safety of same-day bilateral TKAs, and indications for same-day versus staged bilateral surgery need to be clarified.

The John Insall Award: A Minimum 10-year Outcome Study of Autologous Chondrocyte Implantation

Tom Minas MD, MS, Arvind Keudell MD, Tim Bryant RN, Andreas H. Gomoll MD

Autologous chondrocyte implantation (ACI) has demonstrated good and excellent results in over 75% of patients up to 10 years after surgery. Reports of longer-term outcomes, however, remain limited.

Are Cementless Stems More Durable Than Cemented Stems in Two-stage Revisions of Infected Total Knee Arthroplasties?

Paul K. Edwards MD, Thomas K. Fehring MD, William G. Hamilton MD, Brett Perricelli MD, Walter B. Beaver MD, Susan M. Odum PhD

The routine use of stems in revision TKA improves survival rates by enhancing the stability of the prosthesis. The ideal method of stem fixation (cemented or uncemented) in two-stage reimplantation remains controversial.

Preliminary Results Suggest Tranexamic Acid is Safe and Effective in Arthroplasty Patients with Severe Comorbidities

Daniel R. Whiting MD, Blake P. Gillette MD, Christopher Duncan MD, Hugh Smith MD, PhD, Mark W. Pagnano MD, Rafael J. Sierra MD

Tranexamic acid (TXA) reduces blood loss and transfusion after total joint arthroplasty (TJA) but concerns remain that patients with severe medical comorbidities might be at increased risk for thromboembolic complications.

Knee Moments After Unicompartmental Knee Arthroplasty During Stair Ascent

Yang-Chieh Fu PhD, Kathy J. Simpson PhD, Cathleen Brown PhD, Tracy L. Kinsey MSPH, Ormonde M. Mahoney MD

For unicompartmental knee arthroplasty (UKA), abnormal loading on the tibiofemoral joint could exacerbate knee osteoarthritis or implant wear. Joint moments are an indirect measure of such loading. However, little is known about knee moments of patients with UKA, tempering enthusiasm for its use.

Tourniquet Use During Cementation Only During Total Knee Arthroplasty: A Randomized Trial

Rupesh Tarwala MD, Lawrence D. Dorr MD, Paul K. Gilbert MD, Zhinian Wan MD, William T. Long MD

Total knee arthroplasty with the use of a tourniquet during the entire operation has not been shown to improve the performance of the operation and may increase the risk of complications.

Inter- and Intraobserver Reliability of Two-dimensional CT Scan for Total Knee Arthroplasty Component Malrotation

Beau Konigsberg MD, Ryan Hess MD, Curtis Hartman MD, Lynette Smith MS, Kevin L. Garvin MD

Rotational malalignment of total knee arthroplasty (TKA) has been correlated with patellofemoral maltracking, knee instability, and stiffness. CT is the most accurate method to assess rotational alignment of prosthetic components after TKA, but inter- and intraobserver reliability of CT scans for this use has not been well documented.

Abnormal Axial Rotations in TKA Contribute to Reduced Weightbearing Flexion

Bradley Meccia BS, Richard D. Komistek PhD, Mohamed Mahfouz PhD, Douglas Dennis MD

Previous in vivo fluoroscopy studies have documented that axial rotation for patients having a TKA was significantly less than those having a normal knee. In fact, many subjects having a TKA experience a reverse axial rotation pattern where the femur internally rotates with increasing flexion. However, no previous studies have been conducted to determine if this reverse axial rotation pattern affects TKA performance.

Surgical Technique: Muscle Transfer Restores Extensor Function After Failed Patella-Patellar Tendon Allograft

Leo A. Whiteside MD

Extensor mechanism allograft provides an effective remedy for severe quadriceps deficiency caused by loss of the patella, patellar tendon, and quadriceps tendon in TKA. Late failure is common, however, and major quadriceps deficiency occurs after removal of the allograft material.

Do Patients Return to Work After Total Knee Arthroplasty?

Adolph V. Lombardi MD, Ryan M. Nunley MD, Keith R. Berend MD, Erin L. Ruh MS, John C. Clohisy MD, William G. Hamilton MD, Craig J. Della Valle MD, Javad Parvizi MD, Robert L. Barrack MD

Although there is extensive literature supporting a high success rate, there are limited data on return to work after total knee arthroplasty (TKA).

Total Knee Arthroplasty in Patients With Juvenile Idiopathic Arthritis

Thomas J. Heyse MD, Michael D. Ries MD, Johan Bellemans MD, Stuart B. Goodman MD, Richard D. Scott MD, Timothy M. Wright PhD, Jospeh D. Lipman MSc, Ran Schwarzkopf MD, Mark P. Figgie MD

Total knee arthroplasty (TKA) for juvenile idiopathic arthritis is rare but is nonetheless indicated for many patients with this disease. Few reports exist on the results of TKA in patients with juvenile idiopathic arthritis.

The Effect of Geometric Variations in Posterior-stabilized Knee Designs on Motion Characteristics Measured in a Knee Loading Machine

Peter S. Walker PhD, Michael T. Lowry BS, Anoop Kumar MS

In different posterior-stabilized (PS) total knees, there are considerable variations in condylar surface radii and cam-post geometry. To what extent these variations affect kinematics is not known. Furthermore, there are no clearly defined ideal kinematics for a total knee.

Oxidized Zirconium versus Cobalt-Chromium in TKA: Profilometry of Retrieved Femoral Components

Thomas J. Heyse MD, Marcella E. Elpers BS, Danyal H. Nawabi MD, Timothy M. Wright PhD, Steven B. Haas MD

Oxidized zirconium (OxZr) was introduced as an alternative bearing for femoral components in total knee arthroplasty (TKA) in an attempt to reduce wear compared with conventional cobalt-chromium (CoCr) alloys.

Correction of Varus Deformity During TKA With Reduction Osteotomy

Arun B. Mullaji FRCS Ed, MCh Orth, MS Orth, Gautam M. Shetty MS Orth

Reduction osteotomy (removing the posteromedial tibial bony flare) is one step to aid in achieving deformity correction in varus arthritic knees during TKA. However, the amount of deformity correction achieved with reduction osteotomy during TKA is unclear.

Comparison of Total Knee Arthroplasty With Highly Congruent Anterior-stabilized Bearings versus a Cruciate-retaining Design

Christopher L. Peters MD, Patrick Mulkey MD, Jill Erickson PA-C, Michael B. Anderson MS, ATC, Christopher E. Pelt MD

The use of a highly conforming, anterior-stabilized bearing has been associated with clinical success in a limited number of studies.

Maximizing Tibial Coverage Is Detrimental to Proper Rotational Alignment

Stacey Martin MD, Alex Saurez BS, Sabir Ismaily BS, Kashif Ashfaq MD, Philip Noble PhD, Stephen J. Incavo MD

Traditionally, the placement of the tibial component in total knee arthroplasty (TKA) has focused on maximizing coverage of the tibial surface. However, the degree to which maximal coverage affects correct rotational placement of symmetric and asymmetric tibial components has not been well defined and might represent an implant design issue worthy of further inquiry.

Risk Factors for Early Revision After Primary TKA in Medicare Patients

Kevin J. Bozic MD, MBA, Edmund Lau MS, Kevin Ong PhD, Vanessa Chan MPH, Steven Kurtz PhD, Thomas P. Vail MD, Harry E. Rubash MD, Daniel J. Berry MD

Patient, surgeon, health system, and device factors are all known to influence outcomes in total knee arthroplasty (TKA). However, patient-related factors associated with an increased risk of early failure are not well understood, particularly in elderly patients.

Total Knee Arthroplasty After High Tibial Osteotomy: No Differences Between Medial and Lateral Osteotomy Approaches

Stephen Preston MDCM, James Howard MD, FRCSC, Douglas Naudie MD, FRCSC, Lyndsay Somerville PhD, James McAuley MD, FRCSC

High tibial osteotomy (HTO) has long been accepted as an effective treatment for unicompartmental osteoarthritis of the knee in young, active adults. For varus knees, the two most commonly performed valgus-producing HTOs are the lateral closing wedge and the medial opening wedge. Regardless of technique, some HTOs fail and are converted to TKA. To our knowledge, no studies have directly compared TKAs done after lateral closing-wedge osteotomies to those done after medial opening-wedge osteotomies.

The Mark Coventry Award: Higher Tissue Concentrations of Vancomycin With Low-dose Intraosseous Regional Versus Systemic Prophylaxis in TKA

Simon W. Young FRACS, Mei Zhang PhD, Joshua T. Freeman FRCPA, John Mutu-Grigg FRACS, Paul Pavlou FRCS, Grant A. Moore BSc (Hons)

In response to increasing antibiotic resistance, vancomycin has been proposed as an alternative prophylactic agent in TKA. However, vancomycin requires a prolonged administration time, risks promoting further antibiotic resistance, and can cause systemic toxicity. Intraosseous regional administration (IORA) is known to achieve markedly higher antibiotic concentrations than systemic administration and may allow the use of a lower vancomycin dose.

Intraarticular Fibrinogen Does Not Reduce Blood Loss in TKA: A Randomized Clinical Trial

Thomas Jan Heyse MD, Steven B. Haas MD, Denise Drinkwater BA, Stephen Lyman PhD, Han Jo Kim MD, Barbara A. Kahn BS, Mark P. Figgie MD

Bleeding remains an ongoing concern after total knee arthroplasty (TKA). Intraarticular application of human fibrinogen with a topical thrombin has been described to stop diffuse bleeding in knee arthroplasty.

Bundled Payments in Total Joint Arthroplasty: Targeting Opportunities for Quality Improvement and Cost Reduction

Kevin J. Bozic MD, MBA, Lorrayne Ward MBA, MPP, Thomas P. Vail MD, Mervyn Maze MB, ChB

Understanding the type and magnitude of services that patients receive postdischarge and the financial impact of readmissions is crucial to assessing the feasibility of accepting bundled payments.

What Are the Rates and Causes of Hospital Readmission After Total Knee Arthroplasty?

William W. Schairer BA, Thomas P. Vail MD, Kevin J. Bozic MD, MBA

Total knee arthroplasty (TKA) and related interventions such as revision TKA and the treatment of infected TKAs are commonly performed procedures. Hospital readmission rates are used to measure hospital performance, but risk factors (both medical and surgical) for readmission after TKA, revision TKA, and treatment for the infected TKA have not been well characterized.

Targeted Use of Vancomycin as Perioperative Prophylaxis Reduces Periprosthetic Joint Infection in Revision TKA

Catherine Liu MD, Anthony Kakis DPM, CIC, Amy Nichols RN, MBA, CIC, Michael D. Ries MD, Thomas P. Vail MD, Kevin J. Bozic MD, MBA

The role of vancomycin in surgical antimicrobial prophylaxis and high-risk patients who are most likely to benefit remains unclear.

The Chitranjan Ranawat Award: Should Prophylactic Antibiotics Be Withheld Before Revision Surgery to Obtain Appropriate Cultures?

Matthew W. Tetreault BA, Nathan G. Wetters MD, Vinay Aggarwal BS, Michael Mont MD, Javad Parvizi MD, FRCS, Craig J. Della Valle MD

Preoperative antibiotics are known to be critical for decreasing the risk of periprosthetic joint infection (PJI) in primary THA and TKA. However, antibiotics often are withheld before revision surgery, as there is concern that even a single dose of prophylactic antibiotics may affect intraoperative cultures.

Impact of Socioeconomic Factors on Outcome of Total Knee Arthroplasty

Robert L. Barrack MD, Erin L. Ruh MS, Jiajing Chen MPH, Adolph V. Lombardi MD, Keith R. Berend MD, Javad Parvizi MD, FRCS, Craig J. Della Valle MD, William G. Hamilton MD, Ryan M. Nunley MD

Few data exist regarding the impact of socioeconomic factors on results of current TKA in young patients. Predictors of TKA outcomes have focused primarily on surgical technique, implant details, and individual patient clinical factors. The relative importance of these factors compared to patient socioeconomic status is not known.

Patient-specific Guides Do Not Improve Accuracy in Total Knee Arthroplasty: A Prospective Randomized Controlled Trial

Jan Victor MD, PhD, Jan Dujardin MD, Hilde Vandenneucker MD, Nele Arnout MD, Johan Bellemans MD, PhD

Recently, patient-specific guides (PSGs) have been introduced, claiming a significant improvement in accuracy and reproducibility of component positioning in TKA. Despite intensive marketing by the manufacturers, this claim has not yet been confirmed in a controlled prospective trial.

Unicondylar Arthroplasty in Knees With Deficient Anterior Cruciate Ligaments

Gerard A. Engh MD, Deborah J. Ammeen BS

Historically, a functional ACL has been a prerequisite for patients undergoing unicondylar knee arthroplasty (UKA). However, this premise has not been rigorously tested.

Stratification of Standardized TKA Complications and Adverse Events: A Brief Communication

Richard Iorio MD, Craig J. Della Valle MD, William L. Healy MD, Keith R. Berend MD, Fred D. Cushner MD, David F. Dalury MD, Jess H. Lonner MD

The Total Knee Arthroplasty (TKA) Complications Workgroup of the Knee Society developed a standardized list and definitions of complications associated with TKA. Twenty-two complications and adverse events believed important for reporting outcomes of TKA were identified. The Editorial Board of , the Executive Board of the Knee Society, and the members of the Knee Society TKA Complications Workgroup came to the conclusion that reporting of a list of TKA adverse events and complications would be more valuable if they were stratified using a validated classification system.

Plain Radiographs Underestimate the Asymmetry of the Posterior Condylar Offset of the Knee Compared With MRI

Pramod B. Voleti MD, Jason W. Stephenson MD, Paul A. Lotke MD, Gwo-Chin Lee MD

Restoration of posterior condylar offset (PCO) during total knee arthroplasty is essential to maximize range of motion, prevent impingement, and minimize flexion instability. Previously, PCO was determined with lateral radiographs, which could not distinguish the asymmetries between the femoral condyles. MRI can independently measure both medial and lateral PCO.

Constitutional Varus Does Not Affect Joint Line Orientation in the Coronal Plane

Jan M. K. Victor MD, PhD, David Bassens MD, Johan Bellemans MD, PhD, Sarper Gürsu MD, Aad A. M. Dhollander MD, PhD, Peter C. M. Verdonk MD, PhD

In a previous study, we described the distribution of coronal alignment in a normal asymptomatic population and recognized the occurrence of constitutional varus in one of four individuals. It is important to further investigate the influence of this condition on the joint line orientation and how the latter is affected by the onset and progression of arthritis.