Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 470 | Issue 1 | Jan, 2012

The New Knee Society Knee Scoring System

Giles R. Scuderi MD, Robert B. Bourne MD, FRCSC, Philip C. Noble MD, James B. Benjamin MD, Jess H. Lonner MD, W. N. Scott MD

Development of a New Knee Society Scoring System

Philip C. Noble PhD, Giles R. Scuderi MD, Adam C. Brekke BA, Alla Sikorskii PhD, James B. Benjamin MD, Jess H. Lonner MD, Priya Chadha MD, Daniel A. Daylamani BS, W. Norman Scott MD, Robert B. Bourne MD, FRCSC

The Knee Society Clinical Rating System was developed in 1989 and has been widely adopted. However, with the increased demand for TKA, there is a need for a new, validated scoring system to better characterize the expectations, satisfaction, and physical activities of the younger, more diverse population of TKA patients.

The John Insall Award: No Functional Advantage of a Mobile Bearing Posterior Stabilized TKA

Ormonde M. Mahoney MD, Tracy L. Kinsey MSPH, Theresa J. D’Errico MSHS, Jianhua Shen MS

Mobile bearing (MB) total knee design has been advocated as a means to enhance the functional characteristics and decrease the wear rates of condylar total knee arthroplasty (TKA). However, it is unclear if these designs achieve these goals.

The Chitranjan Ranawat Award: Is Neutral Mechanical Alignment Normal for All Patients?: The Concept of Constitutional Varus

Johan Bellemans MD, PhD, William Colyn MD, Hilde Vandenneucker MD, Jan Victor MD, PhD

Most knee surgeons have believed during TKA neutral mechanical alignment should be restored. A number of patients may exist, however, for whom neutral mechanical alignment is abnormal. Patients with so-called “constitutional varus” knees have had varus alignment since they reached skeletal maturity. Restoring neutral alignment in these cases may in fact be abnormal and undesirable and would likely require some degree of medial soft tissue release to achieve neutral alignment.

Mark B. Coventry Award: Synovial C-reactive Protein: A Prospective Evaluation of a Molecular Marker for Periprosthetic Knee Joint Infection

Javad Parvizi MD, FRCS, Christina Jacovides BS, Bahar Adeli BA, Kwang Am Jung MD, William J. Hozack MD

C-reactive protein (CRP) serum assays are a standard element of the diagnostic workup for periprosthetic joint infection (PJI). However, because CRP is a marker for systemic inflammation, this test is not specific to PJI.

No Long-term Difference Between Fixed and Mobile Medial Unicompartmental Arthroplasty

Sebastien Parratte MD, Vanessa Pauly MS, Jean-Manuel Aubaniac MD, Jean-Noel A. Argenson MD

Early studies in the literature reported relatively high early minor reintervention rate for the mobile-bearing unilateral knee arthroplasty (UKA) compared with short- and midterm survivorship after fixed- or mobile-bearing UKA. However, whether the long-term function and survivorship are similar is unclear.

Lateral Unicompartmental Knee Arthroplasty Relieves Pain and Improves Function in Posttraumatic Osteoarthritis

Sebastien Lustig MD, PhD, Sebastien Parratte MD, PhD, Robert A. Magnussen MD, Jean-Noel Argenson MD, Philippe Neyret MD

Posttraumatic arthritis secondary to lateral tibial plateau fracture malunion causes pain and limited function for patients. It is sometimes technically challenging to correct malalignment in these patients with advanced arthritis using osteotomies. Lateral unicompartmental knee arthroplasty (UKA) may be an option to treat such patients.

Lateral Unicompartmental Knee Arthroplasty Through a Lateral Parapatellar Approach Has High Early Survivorship

Keith R. Berend MD, Michael C. Kolczun MD, Joseph W. George MD, Adolph V. Lombardi MD

The literature suggests lateral unicompartmental knee arthroplasties are associated with low revision rates. However, there are fewer reports describing techniques for lateral unicompartmental arthroplasty and whether technique influences ROM and function compared to reports for medial unicompartmental arthroplasty.

Unicompartmental Versus Total Knee Arthroplasty Database Analysis: Is There a Winner?

Matthew C. Lyons MBBS, FRACS, Steven J. MacDonald MD, FRCSC, Lyndsay E. Somerville MSc, Douglas D. Naudie MD, FRCSC, Richard W. McCalden MD, FRCSC

TKA and unicompartmental knee arthroplasty (UKA) are both utilized to treat unicompartmental knee arthrosis. While some surgeons assume UKA provides better function than TKA, this assumption is based on greater final outcome scores rather than on change in scores and many patients with UKA have higher preoperative scores.

Does a Modified Gap-balancing Technique Result in Medial-pivot Knee Kinematics in Cruciate-retaining Total Knee Arthroplasty?: A Pilot Study

Wolfgang Fitz MD, Sonal Sodha, William Reichmann, Tom Minas MD, MS

Normal knee kinematics is characterized by posterior femorotibial rollback with tibial internal rotation and medial-pivot rotation in flexion. Cruciate-retaining TKAs (CR-TKAs) do not reproduce normal knee kinematics.

Improved Accuracy of Alignment With Patient-specific Positioning Guides Compared With Manual Instrumentation in TKA

Vincent Y. Ng MD, Jeffrey H. DeClaire MD, Keith R. Berend MD, Bethany C. Gulick RT (R), Adolph V. Lombardi MD

Coronal malalignment occurs frequently in TKA and may affect implant durability and knee function. Designed to improve alignment accuracy and precision, the patient-specific positioning guide is predicated on restoration of the overall mechanical axis and is a multifaceted new tool in achieving traditional goals of TKA.

All-polyethylene and Metal-backed Tibial Components Are Equivalent With BMI of Less Than 37.5

Jared Toman MD, Richard Iorio MD, William L. Healy MD

Modular, metal-backed tibial (MBT) components are associated with locking mechanism dysfunction, breakage, backside wear, and osteolysis, which compromise survivorship. All-polyethylene tibial (APT) components eliminate problems associated with MBTs, but, historically, APT utilization has generally been limited to older, less active patients. However, it is unclear whether APT utilization can be expanded to a nonselected patient population.

All-Polyethylene Tibial Components in Obese Patients Are Associated With Low Failure at Midterm Followup

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

In the United States, the obese population has increased markedly over the last four decades, and this trend continues. High patient weight places additional stress on TKA components, which may lead to increased polyethylene wear, osteolysis, radiolucencies, and clinical failure. Metal-backed tibial components and all-polyethylene tibial components in the general population have comparable osteolysis and failure, but it is unclear whether these components yield similar osteolysis and failure in obese patients.

Perioperative Closure-related Complication Rates and Cost Analysis of Barbed Suture for Closure in TKA

Jeremy M. Gililland MD, Lucas A. Anderson MD, Grant Sun BS, Jill A. Erickson PA-C, Christopher L. Peters MD

The use of barbed suture for surgical closure has been associated with lower operative times, equivalent wound complication rate, and comparable cosmesis scores in the plastic surgery literature. Similar studies would help determine whether this technology is associated with low complication rates and reduced operating times for orthopaedic closures.

Patient-related Risk Factors for Postoperative Mortality and Periprosthetic Joint Infection in Medicare Patients Undergoing TKA

Kevin J. Bozic MD, MBA, Edmund Lau MS, Steven Kurtz PhD, Kevin Ong PhD, Daniel J. Berry MD

The impact of specific baseline comorbid conditions on the relative risk of postoperative mortality and periprosthetic joint infection (PJI) in elderly patients undergoing TKA has not been well defined.

Platelet-rich Plasma Does Not Reduce Blood Loss or Pain or Improve Range of Motion After TKA

Timothy M. DiIorio MD, Justin D. Burkholder BS, Robert P. Good MD, Javad Parvizi MD, Peter F. Sharkey MD

Numerous reports suggest the application of platelet-rich plasma (PRP) during TKA may decrease postoperative bleeding. Because excessive bleeding can increase postoperative pain and inflammation, use of PRP also reportedly decreases the need for narcotics and increases speed of recovery after TKA. Because previous investigations of PRP and TKA reflect a weak level of medical evidence, we sought to confirm these findings.

Pain Relief and Functional Improvement Remain 20 Years After Knee Arthroplasty

John B. Meding MD, Lindsey K. Meding, Merrill A. Ritter MD, E. Michael Keating MD

TKA provides demonstrable pain relief and improved health-related quality of life. Yet, a decline in physical function may occur over the long term despite the absence of implant-related problems.

Can a High-flexion Total Knee Arthroplasty Relieve Pain and Restore Function Without Premature Failure?

Ryan D. Bauman MD, Derek R. Johnson MD, Travis J. Menge MD, Raymond H. Kim MD, Douglas A. Dennis MD

High-flexion TKA prostheses are designed to improve flexion and clinical outcomes. Increased knee flexion can increase implant loads and fixation stresses, creating concerns of premature failure. Whether these goals can be achieved without premature failures is unclear.

Can Surgeons Predict What Makes a Good TKA?: Intraoperative Surgeon Impression of TKA Quality Does Not Correlate With Knee Society Scores

Gwo-Chin Lee MD, Paul A. Lotke MD

Surgeons generally agree on what they want to achieve when performing TKA. However, we do not know which technical quality goals are correct, important, or irrelevant to achieve adequate function or durability.

Decreased Length of Stay After TKA Is Not Associated With Increased Readmission Rates in a National Medicare Sample

John S. Vorhies BA, Yun Wang PhD, James H. Herndon MD, MBA, William J. Maloney MD, James I. Huddleston MD

There is a trend toward decreasing length of hospital stay (LOS) after TKA although it is unclear whether this trend is detrimental to the overall postoperative course. Such information is important for future decisions related to cost containment.

Three-dimensional Morphology of the Knee Reveals Ethnic Differences

Mohamed Mahfouz PhD, Emam ElHak Abdel Fatah Bsc, Lyndsay Smith Bowers MSc, Giles Scuderi MD

Studies have demonstrated sex differences in femoral shape and quadriceps angle raising a question of whether implant design should be sex-specific. Much of this research has addressed shape differences within the Caucasian population and little is known about differences among ethnic groups.

How Does TKA Kinematics Vary With Transverse Plane Alignment Changes in a Contemporary Implant?

William M. Mihalko MD, PhD, Devin J. Conner BS, Rodney Benner MD, John L. Williams PhD

Assessment of patient function after TKA often focuses on implant alignment and daily activity capabilities, but the functional results and kinematics of the TKA are not easily predicted by some of these parameters during surgery.

Polyethylene Quality Affects Revision Knee Liner Exchange Survivorship

C. Anderson Engh MD, Nancy L. Parks MS, Gerard A. Engh MD

Options to treat patients with wear or osteolysis include full revision, partial (tibial or femoral) revision, and isolated polyethylene exchange. It is unclear whether one choice is superior to the other. Polyethylene quality reportedly influences the survivorship of primary TKA, but similar reports are not described for revision TKA.

Can Tantalum Cones Provide Fixation in Complex Revision Knee Arthroplasty?

Paul F. Lachiewicz MD, Michael P. Bolognesi MD, Robert A. Henderson MSc, Elizabeth S. Soileau BSN, Thomas Parker Vail MD

The best method for managing large bone defects during revision knee arthroplasty is unknown. Metaphyseal fixation using porous tantalum cones has been proposed for severe bone loss. Whether this approach achieves osseointegration with low complication rates is unclear.

Restoration of the Distal Femur Impacts Patellar Height in Revision TKA

Saurabh Khakharia MD, Giles R. Scuderi MD

Restoring patellar height is important in revision TKA for normal knee function and kinematics. Alteration in patellar height after revision TKA is associated with inferior extensor mechanism function.

Revision Surgery for Patellofemoral Problems: Should We Always Resurface?

Todd C. Johnson MD, Penny J. Tatman MPH, Susan Mehle BS, Terence J. Gioe MD

Routine patellar resurfacing performed at the time of knee arthroplasty is controversial, with some evidence of utility in both TKA (tricompartmental) and bicompartmental knee arthroplasty. However, whether one approach results in better implant survival remains unclear.

Minimizing Dynamic Knee Spacer Complications in Infected Revision Arthroplasty

Aaron J. Johnson MD, Siraj A. Sayeed MD, Qais Naziri MD, Harpal S. Khanuja MD, Michael A. Mont MD

Deep infections are devastating complications of TKA often treated with component explantation, intravenous antibiotics, and antibiotic-impregnated cement spacers. Historically, the spacers have been static, which may limit patients’ ROM and ability to walk. Several recent reports describe dynamic spacers, which may allow for improved ROM and make later reimplantation easier. However, because of several dynamic spacer problems noted at our institution, we wanted to assess their associated failures, reinfection rates, and functionality.

Is There a Preferred Articulating Spacer Technique for Infected Knee Arthroplasty?: A Preliminary Study

Niraj V. Kalore MD, Aditya Maheshwari MD, Amit Sharma MD, Edward Cheng MD, Terence J. Gioe MD

Periprosthetic infection in TKA is a devastating and challenging problem for both patients and surgeons. Two-stage exchange arthroplasty with an interval antibiotic spacer reportedly has the highest infection control rate. Studies comparing static spacers with articulating spacers have reported varying ROM after reimplant, which could be due to differences in articulating spacer technique.

Reinfected Revised TKA Resolves With an Aggressive Protocol and Antibiotic Infusion

Leo A. Whiteside MD, Tariq A. Nayfeh MD, PhD, Renee LaZear RN, Marcel E. Roy PhD

Revision of failed two-stage revision TKA for infection is challenging, and amputation often is the only alternative.

Preoperative Patient Education Reduces In-hospital Falls After Total Knee Arthroplasty

Henry D. Clarke MD, Vickie L. Timm BSN, Brynn R. Goldberg MSN, Steven J. Hattrup MD

Inpatient hospital falls after orthopaedic surgery represent a major problem, with rates of about one to three falls per 1000 patient days. These falls result in substantial morbidity for the patient and liability for the institution.

Does Open Reduction of the Developmental Dislocated Hip Increase the Risk of Osteonecrosis?

Renata Pospischill MD, Julia Weninger MD, Rudolf Ganger MD, PhD, Johannes Altenhuber MD, Franz Grill MD

Osteonecrosis (ON) of the femoral head is one of the main complications associated with treatment of developmental dysplasia of the hips (DDH). The reported rates of ON vary widely between 6% and 48%, suggesting varying factors in these studies influence the rate. Several studies suggest open reduction combined with femoral shortening provides protection against ON. However, it is unclear whether confounders such as failed Pavlik harness treatment, preliminary traction, closed versus open reduction, and redislocation influence the rate of ON.

Hip Arthroscopy Improves Symptoms Associated with FAI in Selected Adolescent Athletes

Peter D. Fabricant MD, Benton E. Heyworth MD, Bryan T. Kelly MD

Femoroacetabular impingement (FAI) is increasingly diagnosed in young and middle-aged patients. Although arthroscopic procedures are becoming frequently used in the treatment of FAI, there are little data regarding rates of complications or the ability of hip arthroscopy to improve hip function specifically in the adolescent athlete population. Because arthroscopic treatment is being used in the treatment of FAI, it is vital to know what, if any, improvements in hip function can be expected and the potential complications.

Incidence of Deep Vein Thrombosis and Pulmonary Embolism after Achilles Tendon Rupture

Arush Patel MD, Brent Ogawa MD, Timothy Charlton MD, David Thordarson MD

The use of venous thromboembolism prophylaxis after an Achilles rupture is controversial. The rates of reported deep vein thrombosis (DVT) range from 6.3% to 34%. There is no agreement regarding prophylactic therapy after an Achilles tendon rupture.

Navigation-assisted Surgery for Bone and Soft Tissue Tumors With Bony Extension

Makoto Ieguchi MD, Manabu Hoshi MD, PhD, Jun Takada MD, Noriaki Hidaka MD, PhD, Hiroaki Nakamura MD, PhD

The navigation system was introduced to orthopaedic surgery in the 1990s. More recently, CT-based navigation systems have been used more commonly in spine and joint replacement surgery because of their precision.

Incidence of Patients with Lower Extremity Injuries Presenting to US Emergency Departments by Anatomic Region, Disease Category, and Age

Kaj Lambers BSc, Daan Ootes MD, David Ring MD, PhD

The incidence of patients with lower extremity injuries presenting to emergency departments in the United States with respect to specific anatomic regions and disease categories is unknown. Such information might be used for injury prevention, resource allocation, and training priorities.

The Effect of Long-term Alendronate Treatment on Cortical Thickness of the Proximal Femur

Aasis Unnanuntana MD, Kashif Ashfaq MD, Quang V. Ton MD, John P. Kleimeyer BA, Joseph M. Lane MD

One of the radiographic hallmarks in patients with atypical femoral insufficiency fractures after prolonged bisphosphonate treatment is generalized cortical hypertrophy. Whether cortical thickening in the proximal femur is caused by long-term alendronate therapy, however, remains unknown.

2011 Marshall Urist Young Investigator Award: When to Release Patients to High-impact Activities after Hip Resurfacing

Katherine M. Bedigrew MD, Erin L. Ruh MS, Qin Zhang MD, MPE, John C. Clohisy MD, Robert L. Barrack MD, Ryan M. Nunley MD

Surface replacement arthroplasties are commonly performed in young, active patients who desire return to high-impact activities including heavy manual labor and recreational sports. Femoral neck fracture is an arthroplasty-related complication unique to surface replacement arthroplasty. However, it is unclear regarding whether patients are at lower risk for fracture after a certain postoperative time.

Case Report: Bilateral Proximal Epiphyseal Clavicular Stress-related Lesions in a Male Gymnast

James T. Carson MPH, Teri M. McCambridge MD, John A. Carrino MD, MPH, Edward G. McFarland MD

Stress lesions of the upper extremity are relatively uncommon, and physeal stress lesions of the clavicle are rare. We present a case of bilateral physeal stress-related lesions of the proximal clavicular growth plate near the sternoclavicular joint in an adolescent male gymnast.

Erratum to: Femoral Head Size Does Not Affect Ion Values in Metal-on-Metal Total Hips

Mitchell Bernstein MD, Alan Walsh MD, Alain Petit PhD, David J. Zukor MD, Olga L. Huk MD, MSc, John Antoniou MD, PhD

Emerging Ideas: The Effect of Hypercholesterolemia on Tendons

Joseph A. Abboud MD, David P. Beason MS, Louis J. Soslowsky PhD

High levels of total cholesterol, triglycerides, and low-density lipoprotein are toxic to the vascular endothelium and thus have long been associated with atherosclerosis. Several clinical studies have suggested that elevated cholesterol also has a negative effect on tendon structure and function. Data from our preliminary studies show that the patellar tendons of hypercholesterolemic knockout mice exhibit reduced baseline elastic modulus and strength postinjury compared with controls.

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