Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 469 | Issue 1 | Jan, 2011

The John Insall Award: Control-matched Evaluation of Painful Patellar Crepitus After Total Knee Arthroplasty

Douglas A. Dennis MD, Raymond H. Kim MD, Derek R. Johnson MD, Bryan D. Springer MD, Thomas K. Fehring MD, Adrija Sharma PhD

Patellar crepitus (PC) is reported in up to 14% of subjects implanted with cruciate-substituting total knee arthroplasty (TKA). Numerous etiologies of PC have been proposed.

The Chitranjan Ranawat Award: Fate of Two-stage Reimplantation After Failed Irrigation and Débridement for Periprosthetic Knee Infection

J. Christopher Sherrell MD, Thomas K. Fehring MD, Susan Odum MEd, Erik Hansen MD, Benjamin Zmistowski BS, Anne Dennos BS, Niraj Kalore MD

Irrigation and débridement is an attractive low morbidity solution for acute periprosthetic knee infection. However, the failure rate in the literature is high, averaging 68% (range, 61%–82%). Patients who fail subsequently undergo two-stage reimplantation after a prolonged period of illness. This leads to higher surgical risk and further delays in rehabilitation and may contribute to failure of subsequent revision surgery.

Methicillin-resistant Staphylococcus aureus in TKA Treated With Revision and Direct Intraarticular Antibiotic Infusion

Leo A. Whiteside MD, Michael Peppers PharmD, Tariq A. Nayfeh MD, PhD, Marcel E. Roy PhD

Resistant organisms are difficult to eradicate in infected total knee arthroplasty. While most surgeons use antibiotic-impregnated cement in these revisions, the delivery of the drug in adequate doses is limited in penetration and duration. Direct infusion is an alternate technique.

The Mark Coventry Award: Diagnosis of Early Postoperative TKA Infection Using Synovial Fluid Analysis

Hany Bedair MD, Nicholas Ting BA, Christina Jacovides BA, Arjun Saxena MD, Mario Moric MS, Javad Parvizi MD, Craig J. Della Valle MD

Synovial fluid white blood cell count is useful for diagnosing periprosthetic infections but the utility of this test in the early postoperative period remains unknown as hemarthrosis and postoperative inflammation may render standard cutoff values inaccurate.

Wear and Lysis is the Problem in Modular TKA in the Young OA Patient at 10 Years

Andrew N. Odland BS, John J. Callaghan MD, Steve S. Liu MD, Christopher W. Wells BA

Most long-term followup studies of younger patients who underwent TKA include a relatively high percentage of rheumatoid patients, whose function and implant durability may differ from those with osteoarthritis (OA).

Do “Premium” Joint Implants Add Value?: Analysis of High Cost Joint Implants in a Community Registry

Terence J. Gioe MD, Amit Sharma MD, Penny Tatman MPH, Susan Mehle BS

Numerous joint implant options of varying cost are available to the surgeon, but it is unclear whether more costly implants add value in terms of function or longevity.

Knee Arthroplasty With a Medially Conforming Ball-and-Socket Tibiofemoral Articulation Provides Better Function

Fahad Hossain MRCS, Shelain Patel MRCS, Shin-Jae Rhee MRCS, Fares Sami Haddad FRCS (Tr & Orth)

A knee design with a ball-and-socket articulation of the medial compartment has a femoral rollback profile similar to the native knee. Compared to a conventional, posterior-stabilized knee design, it provides AP stability throughout the entire ROM. However, it is unclear whether this design difference translates to clinical and functional improvement.

Management of Intraoperative Medial Collateral Ligament Injury During TKA

Gwo-Chin Lee MD, Paul A. Lotke MD

Intraoperative injuries to the medial collateral ligament are often unrecognized and failure to appropriately manage ligament loss may result in knee instability and loosening.

Technical Challenges of Total Knee Arthroplasty in Skeletal Dysplasia

Raymond H. Kim MD, Giles R. Scuderi MD, Douglas A. Dennis MD, Steven W. Nakano BA

Total knee arthroplasty (TKA) in patients with skeletal dysplasias is particularly challenging as a result of the anatomic variances and substantial bony deformities. Little has been written regarding technical considerations that should be made when performing TKA in skeletal dysplasia.

Popliteus Tendon Resection During Total Knee Arthroplasty: An Observational Report

Thomas J. Kesman MD, MBA, Kenton R. Kaufman PhD, Robert T. Trousdale MD

The contribution provided by the popliteus tendon in patients undergoing TKA is poorly defined. Some authors believe the popliteus tendon is essential to a well-functioning arthroplasty, while others do not believe it provides a critical function.

When Can I Drive?: Brake Response Times After Contemporary Total Knee Arthroplasty

David F. Dalury MD, Kimberly K. Tucker MD, Todd C. Kelley MD

After right total knee arthroplasty (TKA), patients are usually eager to return to driving. Previous studies suggest 6 weeks postsurgery is a safe time. However, recent advances in surgical technique, pain management, and rehabilitation have theoretically improved recovery after TKA.

Hospital Economics of Primary Total Knee Arthroplasty at a Teaching Hospital

William L. Healy MD, Adam J. Rana MD, Richard Iorio MD

The hospital cost of total knee arthroplasty (TKA) in the United States is a major growing expense for the Centers for Medicare & Medicaid Services (CMS). Many hospitals are unable to deliver TKA with profitable or breakeven economics under the current Diagnosis-Related Group (DRG) hospital reimbursement system.

In Vivo Normal Knee Kinematics: Is Ethnicity or Gender an Influencing Factor?

Filip Leszko MSc, Kristen R. Hovinga MS, Amy L. Lerner PhD, Richard D. Komistek PhD, Mohamed R. Mahfouz PhD

In vivo studies have suggested Caucasians achieve lower average knee flexion than non-Western populations. Some previous studies have also suggested gender may influence condylar AP translation and axial rotation, while others report an absence of such an influence.

In Vitro Quantification of Wear in Tibial Inserts Using Microcomputed Tomography

Matthew G. Teeter BSc, Douglas D. R. Naudie MD, FRCSC, David D. McErlain MSc, Jan-M. Brandt Dipl-Ing, PhD, Xunhua Yuan PhD, Steven J. MacDonald MD, FRCSC, David W. Holdsworth PhD

Wear of polyethylene tibial inserts can decrease the longevity of total knee arthroplasty. Wear is currently assessed using laboratory methods that may not permit backside wear measurements or do not quantify surface deviation.

Continuous Infusion of UHMWPE Particles Induces Increased Bone Macrophages and Osteolysis

Pei-Gen Ren DVM, PhD, Afraaz Irani BS, Zhinong Huang MD, PhD, Ting Ma MD, MSc, Sandip Biswal MD, Stuart B. Goodman MD, PhD

Aseptic loosening and periprosthetic osteolysis resulting from wear debris are major complications of total joint arthroplasty. Monocyte/macrophages are the key cells related to osteolysis at the bone-implant interface of joint arthroplasties. Whether the monocyte/macrophages found at the implant interface in the presence of polyethylene particles are locally or systemically derived is unknown.

Wear Damage in Mobile-bearing TKA is as Severe as That in Fixed-bearing TKA

Natalie H. Kelly BS, Rose H. Fu BS, Timothy M. Wright PhD, Douglas E. Padgett MD

Mobile-bearing TKAs reportedly have no clinical superiority over fixed-bearing TKAs, but a potential benefit is improved polyethylene wear behavior.

Hematologic Genetic Testing in High-risk Patients Before Knee Arthroplasty: A Pilot Study

Hany Bedair MD, Martin Berli MD, Sefer Gezer MD, Joshua J. Jacobs MD, Craig J. Della Valle MD

Patients with a personal or familial history of thromboembolism are considered at higher risk for thromboembolic disease after knee arthroplasty. While it remains unclear why some patients develop deep vein thrombosis (DVT) or pulmonary embolism (PE) despite similar operative procedures and the same prophylactic regimen, we presume one explanation would be genetic predisposition.

Incidence and Reasons for Nonrevision Reoperation After Total Knee Arthroplasty

Benjamin Zmistowski BS, Camilo Restrepo MD, Lauren K. Kahl BS, Javad Parvizi MD, FRCS, Peter F. Sharkey MD

A dramatic increase in the demand for TKA is expected. The current burden of revision TKA is well known but the incidence and etiology of nonrevision reoperations after primary TKA is not.

The Peel in Total Knee Revision: Exposure in the Difficult Knee

Carlos Lavernia MD, Juan Salvador Contreras MD, Jose Carlos Alcerro MD

The femoral peel to expose a difficult knee was first described by Windsor and Insall in the mid-1980s. This surgical exposure consists of a complete soft tissue subperiosteal peel of the femur. It includes the detachment of the origin of the medial and lateral collateral ligaments.

Liner Exchange and Bone Grafting: Rare Option to Treat Wear & Lysis of Stable TKAs

John J. Callaghan MD, Eric R. Reynolds, Nicholas T. Ting BA, Devon D. Goetz MD, John C. Clohisy MD, William J. Maloney MD

Liner exchange and bone grafting are commonly performed for wear and osteolysis around well-fixed modular acetabular components that otherwise would require structural allografting and revision THA. However, liner exchange in the face of substantial lysis around TKA has been performed rarely with reports of failure rates of up to 25% at 3 year followup.

Implant Design Influences Tibial Post Wear Damage in Posterior-stabilized Knees

Mark M. Dolan MD, Natalie H. Kelly BS, Joseph T. Nguyen MPH, Timothy M. Wright PhD, Steven B. Haas MD

The tibial post in posterior-stabilized total knees is a potential source of polyethylene wear debris, but the relationship between the shape and location of the tibial post in relation to the tibiofemoral bearing surfaces and the subsequent wear damage patterns remains unknown.

Perioperative Complications of Simultaneous versus Staged Unicompartmental Knee Arthroplasty

Keith R. Berend MD, Michael J. Morris MD, Michael D. Skeels DO, Adolph V. Lombardi MD, FACS, Joanne B. Adams BFA

The complication risk of staged versus simultaneous total knee arthroplasty continues to be debated in the literature. Previous reports suggest unicompartmental knee arthroplasty provides a more rapid functional recovery than total knee arthroplasty. However, little data exist on whether simultaneous unicompartmental knee arthroplasty can be performed without increasing the perioperative risk compared with staged unicompartmental knee arthroplasty.

A Second Decade Lifetable Survival Analysis of the Oxford Unicompartmental Knee Arthroplasty

Andrew J. Price DPhil FRCS(Orth), Ulf Svard MD

The role of unicompartmental arthroplasty in managing osteoarthritis of the knee remains controversial. The Oxford medial unicompartmental arthroplasty employs a fully congruent mobile bearing intended to reduce wear and increase the lifespan of the implant. Long-term second decade results are required to establish if the design aim can be met.

Do Ion Levels In Hip Resurfacing Differ From Metal-on-metal THA at Midterm?

A. Moroni MD, L. Savarino BSc, M. Hoque PhD, M. Cadossi MD, N. Baldini MD

Metal-on-metal Birmingham hip resurfacing (MOM-BHR) is an alternative to metal-on-metal total hip arthroplasty (MOM-THA), especially for young and/or active patients. However, wear resulting in increased serum ion levels is a concern.

Reliability and Agreement of Measures Used in Radiographic Evaluation of the Adult Hip

Nicholas H. Mast MD, Franco Impellizzeri PhD, Stephan Keller MD, Michael Leunig MD

Several mechanical derangements reportedly contribute to the development of noninflammatory arthritis of the hip. Diagnosis of these derangements involves the use of specific radiographic measures (eg, alpha angle, lateral center edge angle, cross-over sign). The reliability of some of these measures is not known, whereas others have not been confirmed.

Minimally Invasive versus Classic Procedures in Total Hip Arthroplasty: A Double-blind Randomized Controlled Trial

Jon H. M. Goosen MD, PhD, Boudewijn J. Kollen PhD, René M. Castelein MD, PhD, Bart M. Kuipers MD, Cees C. Verheyen MD, PhD

For total hip arthroplasty (THA), minimally invasive surgery (MIS) uses a smaller incision and less muscle dissection than the classic approach (CLASS), and may lead to faster rehabilitation.

What Works Best, a Cemented or Cementless Primary Total Hip Arthroplasty?: Minimum 17-year Followup of a Randomized Controlled Trial

Kristoff Corten MD, Robert B. Bourne MD, FRCS(C), Kory D. Charron Dipl.MET, Keegan Au MD, FRCS(C), Cecil H. Rorabeck MD, FRCS(C)

Total hip arthroplasty (THA) has been associated with high survival rates, but debate remains concerning the best fixation mode of THA.

Does Acetabular Retroversion Affect Range of Motion after Total Hip Arthroplasty?

Stephen J. Incavo MD, Jonathan E. Gold BS, Jesse James F. Exaltacion MD, Matthew T. Thompson MS, Philip C. Noble PhD

Increasingly, acetabular retroversion is recognized in patients undergoing hip arthroplasty. Although prosthetic component positioning is not determined solely by native acetabular anatomy, acetabular retroversion presents a dilemma for component positioning if the surgeon implants the device in the anatomic position.

The Salto Total Ankle Arthroplasty: Survivorship and Analysis of Failures at 7 to 11 years

Michel Bonnin MD, Fabrice Gaudot MD, Jean-Raphael Laurent MD, Scott Ellis MD, Jean-Alain Colombier MD, Thierry Judet MD

Despite the appearance of new-generation, mobile-bearing, cementless prostheses, total ankle arthroplasty remains controversial. Among the criteria guiding the choice between arthrodesis and arthroplasty, the long-term survival and postoperative function are of critical importance. The mobile-bearing Salto prosthesis has been used in Europe since 1997, but only 2 to 5 years of followup data have been reported.

Effect of Prior Salter or Chiari Osteotomy on THA with Developmental Hip Dysplasia

Kenji Tokunaga MD, Nadim Aslam MD, FRCSC, Rad Zdero PhD, Emil H. Schemitsch MD, FRCSC, James P. Waddell MD, FRCSC

Controversy exists regarding the outcome of THA after prior pelvic osteotomy.

Comparison of PACS and Hard-copy 51-inch Radiographs for Measuring Leg Length and Deformity

Saurabh Khakharia MD, Daniel Bigman PA-C, Austin T. Fragomen MD, Helene Pavlov MD, S. Robert Rozbruch MD

The picture archiving and communication system (PACS) eventually will replace the use of standard hard-copy radiographs. It is unknown whether measurements of limb length discrepancy (LLD) and deformity on PACS compare in accuracy and reproducibility with those from hard-copy radiographs.

Extraarticular Knee Resection for Sarcomas with Preservation of the Extensor Mechanism: Surgical Technique and Review of Cases

Pawel Zwolak MD, Stefanie P. Kühnel MD, Bruno Fuchs MD, PhD

Sarcomas in or contaminating the knee are rare but extremely challenging to treat. Complete resection of the joint is necessary, and often the entire extensor mechanism is removed as well. Reconstruction of the knee is challenging, and the resulting function may be compromised.

Adductor Myocutaneous Flap Coverage for Hip and Pelvic Disarticulations of Sarcomas with Buttock Contamination

Michael L. Marfori MD, Edward H. M. Wang MD, MSc

Hip disarticulation and hemipelvectomy are alternatives to limb-salvage procedures for patients with extensive tumors of the upper thigh and buttocks. In cases when neither the conventional posterior gluteus maximus flap nor the anterior quadriceps flap can be used because of the location of the tumor, a medial adductor myocutaneous flap may be an alternative.

Insufficient Bone Regenerate after Intramedullary Femoral Lengthening: Risk Factors and Classification System

Mohamed Kenawey MSc, MRCS, Christian Krettek MD, FRACS, FRCSEd, Emmanouil Liodakis MD, Rupert Meller MD, Stefan Hankemeier MD

Control of distraction rate with an intramedullary skeletal kinetic distractor (ISKD) may be problematic and a high distraction rate may result in insufficient bone regenerate.

Acinetobacter baumannii is not Associated with Osteomyelitis in a Rat Model: A Pilot Study

Stefan Collinet-Adler MD, Carlos A. Castro MD, Charles Gerald T. Ledonio MD, Joan E. Bechtold PhD, Dean T. Tsukayama MD

Multidrug resistant Acinetobacter baumannii (MDR AB) with and without Staphylococcus aureus (SA) is a commonly isolated organism in infected segmental bone defects in combat-related trauma in Iraq and Afghanistan. Although MDR AB in visceral infections is a therapeutic challenge, control of infection appears more common for combat-related osteomyelitis.

Curettage and Graft Alleviates Athletic-Limiting Pain in Benign Lytic Bone Lesions

Vincent M. Moretti MD, Rachel L. Slotcavage MD, Eileen A. Crawford MD, Richard D. Lackman MD, Christian M. Ogilvie MD

Solitary bone cysts (SBC), nonossifying fibromas (NOF), and fibrous dysplasia (FD) create benign intramedullary lytic bone lesions. They are typically asymptomatic and treated conservatively. We present a series of lesions that caused performance-limiting pain in young athletes, a symptom phenomenon and possible treatment indication that has been poorly described in the literature.

Case Report: Bifid Iliopsoas Tendon Causing Refractory Internal Snapping Hip

Beatrice Shu MD, Marc R. Safran MD

Treatment of painful internal snapping hip (coxa saltans) via arthroscopic lengthening or release of the iliopsoas tendon is becoming preferred over open techniques because of the benefits of minimal dissection, the ability to address concomitant intraarticular disorders, and a low complication rate. Persistent snapping after release is uncommon, especially when performed arthroscopically. Reported causes include incomplete release, intraarticular disorders, and incorrect diagnosis. Anatomic variants are not discussed in the orthopaedic literature.

Case Report: Quantitative MRI of Tibial Tubercle Transfer During Active Quadriceps Contraction

Kyle Duchman BA, Chloe Mellecker BS, Ahmad Y. El-Hattab BS, John P. Albright MD

The evaluation of distal transfer procedures relies primarily on qualitative clinical findings. Although quantitative MRI measurements provide an objective supplement to qualitative clinical findings, an association between qualitative clinical findings and quantitative patellofemoral indices has yet to be established.

Orthopaedic Case of the Month: Medial Knee Pain in a 69-year-old Man

Rej S. Bhumbra MBBS, PhD, FRCS (Tr & Orth), Monica Khanna FRCR, Brendan C. Dickson MSc, MD, FRCPC, Peter C. Ferguson MD, MSc, FRCSC
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