Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 467 | Issue 6 | Jun, 2009

Factors Influencing Early Rehabilitation After THA: A Systematic Review

Vivek Sharma MD, Patrick M. Morgan MD, Edward Y. Cheng MD A wide variation exists in rehabilitation after total hip arthroplasty (THA) in part due to a paucity of evidence-based literature. We asked whether a minimally invasive surgical approach, a multimodal approach to pain control with revised anesthesia protocols, hip restrictions, or preoperative physiotherapy achieved a faster rehabilitation and improved immediate short-term outcome. We conducted a systematic review of 16 level I and II studies after a strategy-based search of English literature on OVID Medline, PubMed, CINAHL, Cochrane, and EMBASE databases. We defined the endpoint of assessment as independent ambulation and ability to perform activities of daily living. Literature supports the use of a multimodal pain control to improve patient compliance in accelerated rehabilitation. Multimodal pain control with revised anesthesia protocols and accelerated rehabilitation speeds recovery after minimally invasive THA compared to the standard approach THA, but a smaller incision length or minimally invasive approach does not demonstrably improve the short-term outcome. Available studies justify no hip restrictions following an anterolateral approach but none have examined the question for a posterior approach. Preoperative physiotherapy may facilitate faster postoperative functional recovery but multicenter and well-designed prospective randomized studies with outcome measures are necessary to confirm its efficacy.,[object Object]

THA with a Minimally Invasive Technique, Multi-modal Anesthesia, and Home Rehabilitation: Factors Associated with Early Discharge?

Dana Christopher Mears MD, PhD, Simon C. Mears MD, PhD, Jacques E. Chelly MD, PhD, MBA, Feng Dai PhD, Katie L. Vulakovich Multimodal anesthetic and pain regimens with minimally invasive surgical approaches and rapid rehabilitation protocols are thought to decrease length of stay after hip replacement. We asked whether a program including these three elements could achieve 23-hour discharge in a group of 665 patients and whether the length of hospital stay was influenced by patient age, gender, body mass index, change in hemoglobin or estimated blood loss, duration of surgery (≤ 90 or > 90 minutes), or American Society of Anesthesiologists physical status classification. Of the 665 patients, 259 (38.9%) were discharged home with indwelling peripheral nerve catheters. Hospital discharge in less than 24 hours was achieved in 295 (44.4%) of the 665 patients. After discharge, 73.5% of patients required no home or outpatient nursing care or physical therapy. Eighteen (2.7%) dislocations, eight (1.2%) femoral fractures requiring surgery, and thirteen (2.0%) revision procedures occurred within 90 days. Female gender, increasing age, increasing estimated blood loss, and American Association of Anesthesiologists classification 3 or 4 increased length of stay. Additional study is needed to confirm these factors and develop prospective prediction rules to allow for an outpatient approach to joint arthroplasty.,[object Object]

Multimodal Pain Management after Total Hip and Knee Arthroplasty at the Ranawat Orthopaedic Center

Aditya V. Maheshwari MD, Yossef C. Blum MD, Laghvendu Shekhar MD, Amar S. Ranawat MD, Chitranjan S. Ranawat MD 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.,[object Object]

Newer Anesthesia and Rehabilitation Protocols Enable Outpatient Hip Replacement in Selected Patients

Richard A. Berger MD, Sheila A. Sanders RN, Elizabeth S. Thill RN, Scott M. Sporer MD, Craig Della Valle MD Advancements in the surgical approach, anesthetic technique, and the initiation of rapid rehabilitation protocols have decreased the duration of hospitalization and subsequent length of recovery following elective total hip arthroplasty. We assessed the feasibility and safety of outpatient total hip arthroplasty in 150 consectutive patients. A comprehensive perioperative anesthesia and rehabilitation protocol including preoperative teaching, regional anesthesia, and preemptive oral analgesia and antiemetic therapy was implemented around a minimally invasive surgical technique. A rapid rehabilitation pathway was started immediately after surgery and patients had the option of being discharged to home the day of surgery if standard discharge criteria were met. All 150 patients were discharged to home the day of surgery, at which time 131 patients were able to walk without assistive devices. Thirty-eight patients required some additional intervention outside the pathway to resolve nausea, hypotension, or sedation prior to discharge. There were no readmissions for pain, nausea, or hypotension yet there was one readmission for fracture and nine emergency room evaluations in the three month perioperative period. This anesthetic and rehabilitation protocol allowed outpatient total hip arthroplasty to be routinely performed in these consectutive patients undergoing primary total hip arthroplasty. With current reimbursement approaches the modest savings to the hospital in length of stay may be outweighed by the additional costs of personnel, thereby making this outpatient system more expensive to implement.,[object Object]

Early Discharge and Recovery with Three Minimally Invasive Total Hip Arthroplasty Approaches: A Preliminary Study

R. Michael Meneghini MD, Shelly A. Smits RN Purported advantages of THA performed with minimally invasive surgical approaches include less muscle damage and faster recovery. The purpose of this preliminary investigation was to determine if differences existed between minimally invasive approaches in hospital discharge and early functional recovery in THA patients with a rapid rehabilitation protocol. Twenty-four consecutive patients were randomized to one of three minimally invasive surgical approaches (two-incision, mini-posterior, and mini-anterolateral) and enrolled in an aggressive postoperative rehabilitation program. Hospital discharge, early functional milestone recovery, and validated outcome measures (SF-36, WOMAC, Harris hip score, lower extremity activity scale) were collected. All patients met hospital discharge criteria no later than the first postoperative day. There was no difference in hospital discharge, functional milestone recovery, or validated outcome measures during the first year after surgery with the numbers available. There were no complications directly related to early hospital discharge or the aggressive rehabilitation protocol. While the data suggest earlier hospital discharge and rapid rehabilitation protocols may be implemented successfully we found no difference between the three minimally invasive approaches in early hospital discharge or early functional recovery utilizing a rapid rehabilitation protocol.,[object Object]

Comparison of Outpatient versus Inpatient Total Knee Arthroplasty

Frank R. Kolisek MD, Mike S. McGrath MD, Nenette M. Jessup MPH, Eric A. Monesmith MD, Michael A. Mont MD New protocols have been designed for outpatient total knee arthroplasty procedures, but concerns exist about the potential for increased complication rates. We compared the results of two selected matched cohorts of 64 patients who underwent total knee arthroplasty during the same time period. One cohort of patients, who had no severe medical conditions, lived within one hour of the office, and had help at home, followed an accelerated pathway in which they were discharged within 23 hours of surgery, and the other cohort followed a standard inpatient protocol, with a mean hospital stay of 2.3 days (range, 2–4 days). There were no perioperative complications in either cohort, and none of the patients who followed the outpatient protocol returned to the hospital for any reason. At a mean followup of 24 months (range, 12–41 months), the mean Knee Society knee scores of the outpatient and inpatient cohorts were 96 points (range, 67–100 points) and 95 points (range, 78–100 points), respectively. The mean Knee Society function scores were 89 points (range, 50–100 points) and 90 points (range, 60–100 points), respectively. We believe outpatient total knee arthroplasty may be a safe procedure in certain selected patients, with similar outcomes to a traditional protocol.,[object Object]

The Feasibility and Perioperative Complications of Outpatient Knee Arthroplasty

Richard A. Berger MD, Sharat K. Kusuma MD, Sheila A. Sanders RN, Elizabeth S. Thill RN, Scott M. Sporer MD The duration of hospitalization and subsequent length of recovery after elective knee arthroplasty have decreased. We hypothesized same-day discharge following either a unicompartmental (UKA) or total knee arthroplasty (TKA) in an unselected group of patients would not result in a higher perioperative complication rate than standard-length hospitalization when following a comprehensive perioperative clinical pathway, including preoperative teaching, regional anesthesia, preemptive oral analgesia, preemptive antiemetics, and a rapid rehabilitation protocol. We prospectively followed 111 of all 121 patients who had primary knee arthroplasty completed by noon and who agreed to be followed prospectively; 25 had UKA and 86 TKA. Of the 111 patients, 104 (94%, 24 with UKA and 80 with TKA) met discharge criteria and were discharged directly to home the day of surgery. Nausea requiring additional treatment before discharge was the most common reason for a delay in discharge. There were four (3.6%) readmissions (all with TKA) and one emergency room visit without readmission (in a patient with a TKA) within the first week after surgery, while there were four subsequent readmissions (3.6%) and one additional emergency room visit without readmission within three months of surgery, all among patients undergoing TKA. There were no deaths, cardiac events, or pulmonary complications during this study. Outpatient knee arthroplasty surgery is feasible in a large percentage of patients yet early readmissions may be decreased with a prolonged hospitalization.,[object Object]

Is Recovery Faster for Mobile-bearing Unicompartmental than Total Knee Arthroplasty?

Adolph V. Lombardi MD, Keith R. Berend MD, Christopher A. Walter DO, Jorge Aziz-Jacobo MD, Nicholas A. Cheney DO How does unicompartmental compare with total knee arthroplasty in durability, incidence of complications and manipulations, recovery, postoperative function, and return to sport and work? We matched 103 patients (115 knees) treated with a mobile-bearing unicompartmental device through July 2005 to a selected group of 103 patients (115 knees) treated with cruciate retaining total knee arthroplasty for bilaterality, age, gender and body mass index. Patients who underwent a unicompartmental surgery had better range of motion at discharge and shorter hospital stay than those who had a total knee arthroplasty (77° versus 67° and 1.4 versus 2.2 days). At 6 weeks, Knee Society functional scores and range of motion were higher for unicompartmental than total knees (63 versus 55 and 115° versus 110°). Patient-perceived Oxford scores were similar between groups (unicompartmental 5.4 versus total 4.1). Average times to return to work and sport were similar for both groups. Minimally invasive unicompartmental knee arthroplasty demonstrated better early ROM, shorter hospital stays, and improved functional scores. No advantage was seen in terms of return to work, return to sport, or Oxford scores. The data suggest minimally invasive unicompartmental arthroplasty using a rapid recovery protocol allows patients a faster return to a more functional level than total knee arthroplasty.,[object Object]

Functional Outcome of Femoral versus Obturator Nerve Block after Total Knee Arthroplasty

Stephane G. Bergeron MD, Kenneth J. Kardash MD, Olga L. Huk MD, MSc, David J. Zukor MD, John Antoniou MD, PhD Patients undergoing total knee arthroplasty often experience substantial postoperative pain, which may delay functional recovery and hospital discharge. We recently reported the short-term analgesic efficacy of a single-injection femoral nerve block after spinal anesthesia in total knee arthroplasty. We have now followed 30 patients a minimum of 1 year to determine the functional outcome and pain relief after femoral and obturator nerve block after total knee arthroplasty. Patients undergoing primary unilateral total knee arthroplasty were randomized to one of three treatment groups: (1) femoral nerve block; (2) obturator nerve block; or (3) placebo (sham block). At 6 weeks and 1 year, all three groups had similar total Hospital for Special Surgery knee scores and similar subscores such as range of motion, daily function, and resting and dynamic pain. The data support the usefulness of a peripheral nerve blockade in the context of a multimodal analgesic regimen and a tailored rehabilitation program to individual patients and institutions.,[object Object]

Perioperative Dexamethasone Does Not Affect Functional Outcome in Total Hip Arthroplasty

Stephane G. Bergeron MD, Kenneth J. Kardash MD, Olga L. Huk MD, MSc, David J. Zukor MD, John Antoniou MD, PhD Current trends in orthopaedic surgery have explored different forms of adjuvant treatments to minimize postoperative pain and the risk of nausea and vomiting. A small single preoperative dose of dexamethasone, as part of a comprehensive multimodal analgesic regimen in low-risk patients undergoing total hip arthroplasty (THA), provides antiemetic and opioid-sparing effects but the longer-term effects on pain, complications, or function are not known. We therefore asked whether such a routine would affect longer-term pain, complications, or function. Fifty patients undergoing elective primary THA using spinal anesthesia were initially randomized to receive either dexamethasone (40 mg intravenous) or saline placebo. The patients, anesthesiologists, nurses, and research coordinators were blinded to the study arms. The functional outcome was measured using the Harris hip score. Outcomes were assessed 6 weeks and 1 year postoperatively. We observed no difference in resting pain between the two groups at either time period. Both groups had similar functional outcome scores for the total Harris hip score and individual scoring items at each followup interval. There were no wound complications, deep infections, or osteonecrosis in the contralateral hip at 1-year followup. We recommend the addition of a small single preoperative dose of dexamethasone to a comprehensive multimodal analgesic regimen in low-risk patients given its immediate antiemetic and opioid-sparing effects, and absence of subsequent effects.,[object Object]

Pilates Training for Use in Rehabilitation after Total Hip and Knee Arthroplasty: A Preliminary Report

Brett Levine MS, MD, Beth Kaplanek RN, William L. Jaffe MD Recently, a strong emphasis has been placed on establishing rehabilitation protocols after primary total hip and knee arthroplasty in an attempt to shorten, improve, and standardize the postoperative period of recovery. Less invasive surgical techniques, patient demands, and the pressure of insurance regulations have forced postoperative rehabilitation to be placed on an expedited scale. With these concerns in mind, we introduce a pre- and postarthroplasty program involving the Pilates method. Modified exercises have been developed to account for the postoperative precautions and needs of total hip and knee arthroplasty patients. A patient-driven interest in the use of Pilates for postoperative rehabilitation has led to the development of our programs following total hip or knee arthroplasty. In reviewing our early observations of a small series of patients, it appears this technique can be utilized without early complications; however, further studies are necessary to confirm its utility and safety.,[object Object]

Gait and Stair Function in Total and Resurfacing Hip Arthroplasty: A Pilot Study

M. Wade Shrader MD, Manoshi Bhowmik-Stoker MS, Marc C. Jacofsky MA, David J. Jacofsky MD Standard total hip arthroplasty (THA) is the established surgical treatment for patients older than 65 years with progressive osteoarthritis but survivorship curves wane in patients younger than 50. Resurfacing hip arthroplasty (RHA) is an alternative for younger, active patients reportedly providing superior range of motion. Quantitative investigation of functional recovery following arthroplasty may elucidate limitations that aid in device selection. Although limited long-term kinematic data are available, the early rate of recovery and gait compensations are not well described. This information may aid in refining rehabilitation protocols based on limitations specific to the implant. We presumed hip motion and forces for subjects receiving RHA are more similar to age-matched controls during physically demanding tasks, such as stair negotiation, at early time points than those for THA. In a pilot study, we quantified walking and stair negotiation preoperatively and 3 months postoperatively for seven patients with RHA (mean age, 49 years), seven patients with standard THA (mean age, 52 years), and seven age-matched control subjects (mean age, 56 years). Although both treatment groups demonstrated trends toward functional recovery, the RHA group had greater improvements in hip extension and abduction moment indicating typical loading of the hip. Further investigation is needed to determine if differences persist long term or are clinically meaningful.

Evaluation of a Custom Device for the Treatment of Flexion Contractures after Total Knee Arthroplasty

Mike S. McGrath MD, Michael A. Mont MD, Junaed A. Siddiqui, Erin Baker PT, Anil Bhave PT Knee flexion contractures can severely impair function after total knee arthroplasties. We evaluated the use of a custom-molded knee device to treat 47 patients who had knee flexion contractures (mean, 22°; range, 10°–40°) after primary or revision total knee arthroplasties and who had failed conventional therapeutic methods. The device was used for 30 to 45 minutes per session two to three times per day in conjunction with standard physical therapy modalities two to three times per week. Twenty-seven of 29 patients who underwent primary total knee arthroplasty and 13 of 18 patients who underwent revisions achieved full extension after a mean treatment time of 9 weeks (range, 6–16 weeks). Full knee extension was maintained at a minimum followup of 18 months (mean, 24 months; range, 18–36 months). The mean Knee Society knee and functional scores improved from 50 points and 34 points to 91 points and 89 points, respectively. This protocol had comparable rates of improvement in knee extension with less treatment time when compared with other nonoperative treatments reported in the literature. The custom knee device may be a useful adjunct to a physical therapy regimen for knee flexion contractures after total knee arthroplasty.,[object Object]

Reversing Muscle and Mobility Deficits 1 to 4 Years after TKA: A Pilot Study

Paul C. LaStayo PhD, PT, Whitney Meier DPT, OCS, Robin L. Marcus PhD, PT, OCS, Ryan Mizner PhD, MPT, Lee Dibble PhD, PT, ATC, Christopher Peters MD Muscle and mobility deficits can persist for years after a total knee arthroplasty (TKA). The purposes of this study were (1) to determine if 12 weeks of rehabilitation with resistance exercise induces increases in muscle size, strength, and mobility in individuals 1 to 4 years after a TKA; and (2) to compare the muscle and mobility outcomes of a traditional resistance exercise rehabilitation program with a rehabilitation program focused on eccentric resistance exercise. Seventeen individuals (13 women, four men; mean age, 68 years; age range, 55–80 years) with either a unilateral or bilateral TKA (total of 24 knees) were included in this matched and randomized repeated-measures rehabilitation pilot trial. Increases in quadriceps muscle volume and knee extension strength followed 12 weeks of eccentric exercise. Improvements were also noted in four mobility tests. Similar improvements were noted in the traditional group in two mobility tests. An increase in muscle size and strength and an improvement in levels of mobility can occur after 12 weeks of resistance exercise in older individuals 1 to 4 years after TKA. When the exercise mode focuses on eccentric resistance, the muscle growth response is greater as is the improvement in important mobility tasks.,[object Object]

Femoral Osteolysis Around the Unrevised Stem During Isolated Acetabular Revision

Byung-Woo Min MD, Kwang-Soon Song MD, Chul-Hyun Cho MD, Ki-Cheor Bae MD, Kyung-Jae Lee MD Many surgeons treat progressive femoral osteolysis in association with a well-fixed stem with bone grafting but in uncontained proximal defects the graft could get into the joint, raising a question regarding whether the osteolysis can be treated by simple débridement without bone grafting. We investigated whether the curetted proximal osteolysis around an unrevised femoral component progressed in size and whether this lesion would have a deleterious effect on fixation of the femoral component in patients with isolated acetabular revision. We prospectively followed 21 patients (24 hips) who underwent acetabular revision and curetting of femoral osteolysis. The minimum followup was 3 years (mean, 4.3 years; range, 3–7.4 years). By the latest followup, no hips had major progression of the osteolytic defect through the followup period and none had any new osteolytic lesions. All hips were judged stable and to have well-fixed acetabular cups and femoral stems. Provided a femoral component is bone ingrown with osseointegration sufficient to provide long-term stability, the osteolytic defect is in the proximal aspect of the femur, and the defect is uncontained, simple curettage may preserve femoral implant stability and may prevent progression of osteolysis to another Gruen zone for at least 3 to 7 years.,[object Object]

Genetic Polymorphisms in Venous Thrombosis and Pulmonary Embolism After Total Hip Arthroplasty: A Pilot Study

Juergen Ringwald MD, Annika Berger MD, Werner Adler PhD, Cornelia Kraus PhD, Rocco P. Pitto MD Deep venous thrombosis (DVT) after major orthopaedic surgery is a substantial concern. We asked whether the single or combined presence of thrombophilic genetic polymorphisms might further increase the already high risk for venous thrombosis and pulmonary embolism (PE) after THA. We therefore compared the prevalence of factor V Leiden, prothrombin G20210A, methylenetetrahydrofolate reductase (MTHFR) C677T and A1298C, and plasminogen activator inhibitor 4G/5G polymorphisms between 50 patients with symptomatic DVT within 3 weeks after elective THA and an asymptomatic control group of 85 patients. We found no major difference for the presence of a single mutation between the groups. Factor V Leiden and homozygous MTHFR C667T mutations were of borderline significance with odds ratios (95% confidence intervals) of 3.73 (0.89–15.63) and 2.93 (0.92–9.29), respectively. Patients with homozygous or combined heterozygous status of MTHFR C677T and A1298C mutation had a higher frequency of DVT after elective THA (odds ratio, 2.86; 95% confidence interval, 1.32–6.35) than those with wild-type. The presence of a single mutation may not further increase the already high risk for symptomatic DVT after THA, whereas combinations of mutations of distinct polymorphisms might be important. However, prospective studies with a larger number of patients are needed before we would recommend preoperative screening.,[object Object]

Outcome of Hip Resurfacing Arthroplasty in Patients with Developmental Hip Dysplasia

Florian D. Naal MD, Matthias Schmied MD, Urs Munzinger MD, Michael Leunig MD, Otmar Hersche MD Patients with osteoarthritis secondary to developmental dysplasia of the hip (DDH) typically are young and active, which might affect functional ratings or failure rates after resurfacing arthroplasty. We therefore evaluated 24 patients (32 hips; mean age, 44.2 years) after hip resurfacing performed for osteoarthritis secondary to DDH. We used the Harris hip score (HHS), the University of California, Los Angeles (UCLA) activity scale, and a sports and activity questionnaire. A radiographic analysis also was performed. We followed patients a minimum of 28 months (mean, 43 months; range 28–60 months). The HHS improved from a mean of 54.7 to 97.3 and UCLA activity levels increased from a mean of 5.3 to 8.6. All patients returned to sports activity at a mean of 11 weeks after surface replacement. There were no major differences in preoperative and postoperative participation in the most common sports and activities. Two of the 32 replacements (6%) failed. We detected femoral radiolucencies in 10 of the remaining 30 hips. Despite satisfactory outcomes in clinical scores, return to sports, and hip biomechanics, the failure rate of 6% was disappointing. Additional followup is important to assess if failure rates increase in these young, active patients.,[object Object]

One-stage Hip Arthroplasty and Bone Grafting for Bilateral Femoral Head Osteonecrosis

Lih-Yuann Shih MD, Yon-Cheong Wong MD, Hsin-Nung Shih MD One-stage hip arthroplasty and contralateral core decompression with bone grafting were performed for 30 patients with bilateral femoral head osteonecrosis between April 2002 and June 2005. The treatment course, clinical and radiographic outcomes, and medical costs were compared with another 30 age-, gender-, etiology-, and disease extent-matched patients undergoing two-stage treatment during the same period. The two groups had similar clinical data and few complications. Total hospital stay and associated costs were reduced for patients who had one-stage treatment. These patients also returned to work faster (6.0 versus 10.8 months). At an average followup of 46 months, progression to greater than 2 mm of collapse of the salvaged femoral head was observed in seven patients (23%) who had one-stage treatment and 14 patients (47%) who had two-stage treatment. Conversion to hip arthroplasty was performed in five patients (17%) in the one-stage group and 12 patients (40%) in the two-stage group. A special group of patients with bilateral osteonecrosis of the femoral head seemed to benefit from one-stage hip arthroplasty and contralateral core decompression with bone grafting and had better survival of the salvaged femoral head. One-stage hip arthroplasty and core decompression with bone grafting proved to be a cost-effective method that did not increase perioperative morbidity.,[object Object]

Transtrochanteric Rotational Osteotomy for Nontraumatic Osteonecrosis of the Femoral Head in Young Adults

Sandeep Biswal MS, Sunit Hazra MS, Ho Hyun Yun MD, Chang Yong Hur MD, PhD, Won Yong Shon MD, PhD Transtrochanteric rotational osteotomy (TRO) is a controversial procedure with reported inconsistent results. We reviewed 50 patients (60 hips) who underwent this procedure for extensive osteonecrosis of the femoral head, focusing on varization to determine its effectiveness as a head-preserving procedure in young adults. The mean age of the patients was 28 years (range, 18–46 years). Using the Ficat-Arlet classification, 40 hips had Stage II and 20 hips had Stage III involvement. According to the classification system of Shimizu et al., the extent of the lesions were Grade C in 54 hips and Grade B in six hips; the location of the lesions were Grade c in 56 hips and Grade b in four hips. Minimum followup was 18 months (mean, 84 months; range, 18–156 months). The mean preoperative Harris hip score was 44.7 points (range, 32–62 points) which improved to an average postoperative score of 80.1 points (range, 44–100 points) at the latest followup. Forty-four hips showed no radiographic evidence of progression of collapse. Ten hips showed progressive collapse, seven hips showed progressive varus deformity, three hips had stress fractures of the femoral neck, and one hip had infection. We believe TRO with varization is worth attempting for extensive osteonecrosis of the femoral head in young adults, although failures and complications are not uncommon.,[object Object]

In Vitro Testing of Femoral Impaction Grafting With Porous Titanium Particles: A Pilot Study

René Aquarius MSc, Luc Walschot MD, Pieter Buma PhD, Berend Willem Schreurs MD, PhD, Nico Verdonschot PhD The disadvantages of allografts to restore femoral bone defects during revision hip surgery have led to the search for alternative materials. We investigated the feasibility of using porous titanium particles and posed the following questions: (1) Is it possible to create a high-quality femoral graft of porous titanium particles in terms of graft thickness, cement thickness, and cement penetration? (2) Does this titanium particle graft layer provide initial stability when a femoral cemented stem is implanted in it? (3) What sizes of particles are released from the porous titanium particles during impaction and subsequent cyclic loading of the reconstruction? We simulated cemented revision reconstructions with titanium particles in seven composite femurs loaded for 300,000 cycles and measured stem subsidence. Particle release from the titanium particle grafts was analyzed during impaction and loading. Impacted titanium particles formed a highly interlocked graft layer. We observed limited cement penetration into the titanium particle graft. A total mean subsidence of 1.04 mm was observed after 300,000 cycles. Most particles released during impaction were in the phagocytable range (< 10 μm). There was no detectable particle release during loading. Based on the data, we believe titanium particles are a promising alternative for allografts. However, animal testing is warranted to investigate the biologic effect of small-particle release.

Cementless Femoral Prostheses Cost More to Implant than Cemented Femoral Prostheses

Aasis Unnanuntana MD, Apostolos Dimitroulias MD, Michael P. Bolognesi MD, Katherine L. Hwang MS, Stuart B. Goodman MD, PhD, Randall E. Marcus MD Prosthetic cost contributes greatly to the overall expense of THA. A key question, therefore, in the selection of implant technique is whether any price difference exists between a cementless and a cemented femoral prosthesis. We evaluated the price difference between the most commonly used cemented and cementless femoral stems at three high-volume academic medical centers. Each hospital’s costs for prostheses from the manufacturers were recorded. The average cost of implanting a cementless femoral prosthesis was $296 more than the average cost of implanting a cemented femoral stem, even with the additional expense of two batches of bone cement and the accessories commonly used to achieve a third-generation cementing technique. The price difference was less variable if the cost of the prostheses from only the primary implant supplier for each institution was considered. As the number of THAs performed per year continues to escalate, implantation of a cemented femoral component remains an attractive method of fixation from an economic standpoint.,[object Object]

Incidence of Ceramic Liner Malseating in Trident® Acetabular Shell

Anna N. Miller MD, Edwin P. Su MD, Mathias P. G. Bostrom MD, Bryan J. Nestor MD, Douglas E. Padgett MD The low wear rates associated with ceramic hip articulations have made them a popular bearing for younger patients. Although few complications have been observed, one report revealed several instances of incomplete seating of the ceramic liner in the metallic shell. We performed a cohort study of consecutive THAs using a ceramic-ceramic bearing. Radiographic analysis showed 50 (7.2%) of the group of 694 hips had evidence of incomplete seating of the liner in the metallic shell. Although we observed no adverse effects at 6 to 12 weeks, we encourage surgeons to carefully assess liner placement in the metal shell at the time of surgery to avoid this unintended consequence and to assess placement at the time of followup so patients can be properly followed when incomplete seating is identified.,[object Object]

Inhibition of Matrix Metalloproteinases Enhances In Vitro Repair of the Meniscus

Amy L. McNulty PhD, J. Brice Weinberg MD, Farshid Guilak PhD Damage or injury of the meniscus is associated with onset and progression of knee osteoarthritis (OA). The intrinsic repair capacity of the meniscus is inhibited by inflammatory cytokines, such as interleukin-1 (IL-1). Using an in vitro meniscal repair model system, we examined the hypothesis that inhibition of matrix metalloproteinases (MMPs) in the presence of IL-1 will enhance repair of meniscal lesions. Integrative repair of the meniscus was examined between two concentric explants cultured with IL-1 and various MMP inhibitors for 14 days. Throughout the culture period, we assessed total specific MMP activity in the media. At harvest, biomechanical testing to assess the strength of repair and histologic staining were performed. IL-1 decreased the shear strength of repair, as compared with control explants. In the presence of IL-1, the broad-spectrum MMP inhibitor GM 6001 decreased the MMP activity in the media, increased the shear strength of repair, and enhanced tissue repair in the interface. However, individual MMP inhibitors did not alter the shear strength of repair in either the presence or absence of IL-1. These findings suggest IL-1 may inhibit meniscal repair through upregulation of MMPs, but inhibition of multiple MMPs may be necessary to promote integrative meniscal repair.

Trends in Bilateral Total Knee Arthroplasties: 153,259 Discharges between 1990 and 2004

Stavros G. Memtsoudis MD, PhD, Melanie C. Besculides DrPH, MPH, Shane Reid BA, Licia K. Gaber-Baylis BA, Alejandro González Della Valle MD Information regarding national trends in bilateral TKAs is needed for a rational allocation of resources, policy making, and research. Therefore, we analyzed data from the National Hospital Discharge Survey to elucidate temporal changes in the demographics, comorbidity profiles, hospital stay, and in-hospital complications of patients undergoing bilateral TKAs in the United States. We created three 5-year periods: 1990–1994, 1995–1999, 2000–2004. Procedure, healthcare system, and patient-related variables were analyzed for an estimated 153,259 discharges. Use of bilateral TKAs more than doubled for the entire civilian population and almost tripled among the female population, with the steepest increase seen during the last two study periods. A decline of nearly 50% in the use of bilateral TKAs in patients 85 years and older was seen between the second and third study periods. The prevalence of coronary artery disease and pulmonary disease increased from the first to the second study periods but decreased from the second to the third. The changes in the variables studied may reflect a recently acquired reluctance to perform bilateral TKAs in elderly patients with cardiopulmonary comorbidities. Additional studies are necessary to identify other causal relationships and define the impact of these changes on various aspects of the healthcare system.,[object Object]

Obese Diabetic Patients are at Substantial Risk for Deep Infection after Primary TKA

Michelle M. Dowsey RN, BApplSc, Peter F. M. Choong MBBS, MD, FRACS, FAOrthA We conducted a prospective study of 1214 consecutive primary TKAs to compare the deep prosthetic infection rate between obese and nonobese patients during the first 12 months after surgery. We also sought to determine whether patient or surgical variables such as comorbidities, age, gender, blood transfusion, use of surgical drains, and antibiotic-impregnated cement were predictors of subsequent prosthetic infection after primary TKA. The overall prosthetic infection rate was 1.5% (n = 18). The odds for a deep prosthetic infection were greater in patients with morbid obesity (odds ratio [OR], 8.96; 95% confidence interval, 1.59–50.63) and diabetes (OR, 6.87; 95% confidence interval, 2.42–19.56). Men were more likely to have a prosthetic infection develop than women (OR, 5.93; 95% confidence interval, 1.95–18.04) and the prosthetic infection rate was lower (OR, 0.24; 95% confidence interval, 0.06–0.95) in patients when a surgical drain was used. There were no prosthetic infections in patients with diabetes who were not obese. This compares with 11 prosthetic infections in patients who were obese and diabetic and four prosthetic infections in patients who were obese but not diabetic. Morbid obesity and obesity combined with diabetes are risk factors for periprosthetic infection after TKA.,[object Object]

Postoperative Lateral Ligamentous Laxity Diminishes with Time After TKA in the Varus Knee

Hitoshi Sekiya MD, Kenzo Takatoku MD, Hisashi Takada MD, Hideyuki Sasanuma MD, Naoya Sugimoto MD For successful TKA, good soft tissue balance is one of the most important factors; however, it is unknown whether the coronal balance immediately after surgery is maintained with time. We hypothesized, if neutral mechanical alignment was achieved at the time of TKA, some degree of lateral ligamentous laxity could be accepted and the laxity would diminish with time. To confirm this hypothesis, we posed two scientific questions: (1) Does the coronal ligament balance measured immediately after TKA change with time? (2) Does the degree of preoperative varus alignment correlate with the lateral or medial ligamentous laxity observed after TKA? We measured coronal lateral or medial ligamentous laxity in 71 knees with varus deformities immediately after surgery and at 3, 6, and 12 months thereafter. The mean mechanical axis was 15.9° varus preoperatively and 0.4° varus postoperatively. The mean medial ligamentous laxity was relatively constant postoperatively from immediately after surgery to 12 months. However, the mean lateral ligamentous laxity was as much as 8.6° immediately after surgery and decreased to 5.1° at 3 months. The lateral ligamentous laxity immediately after surgery correlated with the preoperative varus mechanical axis. Our data show residual lateral ligamentous laxity observed in preoperative varus deformity may be corrected spontaneously after TKA.

Genu Valgum in Legg-Calvé-Perthes Disease Treated with Femoral Varus Osteotomy

Yann Glard MD, Marcos V. Katchburian MBBS, MSBOT, FRCS (Tr & Orth), Michel Jacquemier MD, Jean-Marc Guillaume MD, Gérard Bollini MD Femoral varus osteotomy is one of the most common treatments for patients with symptomatic Legg-Calvé-Perthes disease with more severe deformities. We hypothesized knee valgus alignment at maturity in patients with Legg-Calvé-Perthes disease is an effect of the disease and not an effect of femoral varus osteotomy. We retrospectively compared matched groups of 28 patients with and without femoral varus osteotomy. The two groups were similar with respect to age at onset and classification of Herring et al. The distribution of valgus alignment among patients who had surgery and patients who did not have surgery was assessed at maturity and was similar between the operative and nonoperative groups. The data suggest valgus malalignment (genu valgum) is not a side effect of femoral varus osteotomy in patients with Legg-Calvé-Perthes disease, but rather an effect of the disease.,[object Object]

Early Experience with Biodegradable Implants in Pediatric Patients

Andreas F. Mavrogenis MD, Anastasios D. Kanellopoulos MD, George N. Nomikos MD, Panayiotis J. Papagelopoulos MD, DSc, Panayotis N. Soucacos MD, FACS We retrospectively studied nine children and adolescents with congenital malformations, large reconstruction after tumor excision, fractures and osteotomies of the upper extremity, and hand trauma with bone and soft tissue defects treated by internal synthesis using a biocopolymer of L- and DL-stereoisomers of lactic acid polymers and trimethylenecarbonate. A total of 52 biodegradable implants were placed in bone. At a minimum followup of 7 months (mean, 17 months; range, 7–22 months), wound healing was uncomplicated; local or systemic inflammatory tissue reactions, foreign body reactions, and infections were not observed. Bone healing was complete. Six biodegradable screws broke during insertion because of inadequate drilling and tapping, and three biodegradable screws had to be replaced because of damage to the screw head during assembly with the screwdriver. Biodegradable copolymers of poly-L-lactic-poly-DL-lactic acid and trimethylenecarbonate can be used safely and effectively for reconstruction and fixation of bone in children and adolescents.,[object Object]

Risk Factors for Blood Loss During Sacral Tumor Resection

Xiaodong Tang MD, Wei Guo MD, PhD, Rongli Yang MD, Shun Tang MD, Tao Ji MD [object Object],[object Object]

Risk Assessment Based on FDG-PET Imaging in Patients with Synovial Sarcoma

Jennifer W. Lisle MD, Janet F. Eary MD, Janet O’Sullivan MSc, Ernest U. Conrad MD [object Object],[object Object]

Distal Radius Fractures in Older Patients: Is Anatomic Reduction Necessary?

Andrew J. Synn BA, Eric C. Makhni BS, Melvin C. Makhni BS, Tamara D. Rozental MD, Charles S. Day MD, MBA The relationship between radiographic and functional outcomes in older patients with distal radius fractures is controversial. We explored this relationship by assessing the influence of radiographic displacement and fracture comminution on the functional outcomes of these fractures. We also asked whether operative intervention and demographic factors (age, gender, duration of followup) influenced outcome. We examined 53 patients older than 55 years with distal radius fractures with various functional assessments: range of motion (ROM) and strength measurements, three subjective surveys (Disabilities of the Arm, Shoulder, and Hand; Patient-rated Wrist Evaluation; Modernized Activity Subjective Survey of 2007), a Gartland and Werley score, and an objective, standardized hand performance test (Jebsen-Taylor). We measured angulation, articular gap/stepoff, and radial shortening on final radiographs and fracture comminution of preoperative radiographs. We observed no effect of radiographic displacement on subjective or objective outcome assessments, including standardized hand performance timed testing. Surgically treated fractures were less likely to display residual dorsal angulation and radial shortening, but surgical intervention did not independently predict functional outcome. Fracture comminution, patient gender, and months of followup similarly had no effect on outcome. We found no relationship between anatomic reduction as evidenced by radiographic outcomes and subjective or objective functional outcomes in this older patient cohort.,[object Object]

Ligament Tension in the ACL-deficient Knee: Assessment of Medial and Lateral Gaps

David Mayman MD, Christopher Plaskos PhD, Daniel Kendoff MD, G. Wernecke MS, Andrew D. Pearle MD, Richard Laskin MD Obtaining symmetric and balanced gaps under equilateral loads is a common goal in posterior cruciate ligament (PCL)-retaining and -sacrificing TKAs. Owing to limitations in existing surgical tensors, however, tensing knee ligaments with standardized and symmetric loads has been possible only with the patella subluxated or everted. We therefore determined the influences of (1) patellar eversion versus complete reduction, (2) PCL resection, and (3) load magnitude on gap symmetry and balance in the anterior cruciate ligament (ACL)-deficient knee. We used a novel computer-controlled tensioner to measure gaps in 10 cadavers with an applied force of 50 N, 75 N, and 100 N per side. Gap data were acquired at 0º, 30º, 60º, 90º, and 120º flexion with the patella reduced and everted and with the PCL intact and resected. Everting the patella tightened the medial and lateral flexion gaps between 90º and 120º by 0.7 mm to 2.7 mm. PCL resection increased gaps from 30° to 120° by 1 mm to 3 mm. Increasing the force from 50 N to 100 N increased the mean gap by 0.5 mm. Everting the patella and resecting the PCL influenced gap balance and symmetry. Surgeons should be aware of how these conditions affect gaps during assessment and balancing.

Case Report: Capnocytophaga canimorsus A Novel Pathogen for Joint Arthroplasty

A. Noelle Larson MD, Raymund R. Razonable MD, Arlen D. Hanssen MD We report the case of a 59-year-old man with Waldenstrom’s macroglobulinemia and active alcohol use who presented with bilateral knee pain 5 years after a bilateral staged TKA. Cultures of synovial fluid and periprosthetic tissue specimens from both knees yielded, after prolonged anaerobic incubation, a catalase- and oxidase-positive gram-negative bacillus, which was identified as Capnocytophaga canimorsus by 16S ribosomal RNA PCR analysis. C canimorsus, an organism that is commonly found in dog and cat saliva, is a rare cause of various infections in immunocompromised and healthy individuals. However, a review of the medical literature indicates C canimorsus has not been reported previously to cause infection after joint arthroplasty. The patient was immunocompromised by cytotoxic chemotherapy, corticosteroids, and alcohol use. The patient was managed successfully with bilateral two-stage exchange and 6 weeks of intravenous ertapenem therapy. Because of its fastidious and slow-growing characteristics, C canimorsus may be an unrecognized cause of culture-negative joint arthroplasty infections, especially in cases when dog and cat exposure is evident in the clinical history.

Reply to Letter to Editor: Femoral Component Positioning in Hip Resurfacing with and Without Navigation

Pascal-André Vendittoli MD, MSc, FRCS(C), Muthu Ganapathi MSc, FRCS(Orth), Martin Lavigne MD, MSc, FRCS(C)
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