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 2 | Feb, 2012

The John Charnley Award: An Accurate and Sensitive Method to Separate, Display, and Characterize Wear Debris: Part 1: Polyethylene Particles

Fabrizio Billi PhD, Paul Benya PhD, Aaron Kavanaugh BS, John Adams MD, PhD, Edward Ebramzadeh PhD, Harry McKellop PhD

Numerous studies indicate highly crosslinked polyethylenes reduce the wear debris volume generated by hip arthroplasty acetabular liners. This, in turns, requires new methods to isolate and characterize them.

The John Charnley Award: An Accurate and Extremely Sensitive Method to Separate, Display, and Characterize Wear Debris Part 2: Metal and Ceramic Particles

Fabrizio Billi PhD, Paul Benya PhD, Aaron Kavanaugh BS, John Adams MD, PhD, Harry McKellop PhD, Edward Ebramzadeh PhD

Metal-on-metal and ceramic-on-ceramic bearings were introduced as alternatives to conventional polyethylene in hip arthroplasties to reduce wear. Characterization of wear particles has been particularly challenging due to the low amount and small size of wear particles. Current methods of analysis of such particles have shortcomings, including particle loss, clumping, and inaccurate morphologic and chemical characterization.

The Frank Stinchfield Award: Dislocation in Revision THA: Do Large Heads (36 and 40 mm) Result in Reduced Dislocation Rates in a Randomized Clinical Trial?

Donald S. Garbuz MD, MHSc, Bassam A. Masri MD, Clive P. Duncan MD, MSc, Nelson V. Greidanus MD, MPH, Eric R. Bohm MD, MSc, Martin J. Petrak MSc, PEng, Craig J. Della Valle MD, Allan E. Gross MD

Dislocation after revision THA is a common complication. Large heads have the potential to decrease dislocation rate, but it is unclear whether they do so in revision THA.

The Otto Aufranc Award: Demineralized Bone Matrix Around Porous Implants Promotes Rapid Gap Healing and Bone Ingrowth

Letitia Lim MD, J. Dennis Bobyn PhD, Kristian M. Bobyn BA, Louis-Philippe Lefebvre MEng, Michael Tanzer MD

Noncemented revision arthroplasty is often complicated by the presence of bone implant gaps that reduce initial stability and biologic fixation. Demineralized bone matrix has osteoinductive properties and therefore the potential to enhance gap healing and porous implant fixation.

Second-generation Modular Acetabular Components Provide Fixation at 10 to 16 Years

Paul F. Lachiewicz MD, Elizabeth S. Soileau BSN

First-generation modular titanium fiber-metal-coated acetabular components had high rates of wear, pelvic osteolysis, and liner dissociation. Second-generation components were designed to reduce the incidence of these problems but it is unclear whether the changes achieved these goals.

Ceramic Bearings for Total Hip Arthroplasty Have High Survivorship at 10 Years

James A. D’Antonio MD, William N. Capello MD, Marybeth Naughton BS

Ceramic bearings were introduced to reduce wear and increase long-term survivorship of total hip arthroplasty. In a previous study comparing ceramic with metal-on-polyethylene at 5 to 8 years, we found higher survivorship and no osteolysis for the ceramic bearings.

Causes of Failure of Ceramic-on-Ceramic and Metal-on-Metal Hip Arthroplasties

Manny Porat MD, Javad Parvizi MD, FRCS, Peter F. Sharkey MD, Keith R. Berend MD, Adolph V. Lombardi MD, FACS, Robert L. Barrack MD

Few large series of hard bearing surfaces have reported on reasons for early failure. A number of unique mechanisms of failure, including fracture, squeaking, and adverse tissue reactions, have been reported with these hard bearing surfaces. However, the incidence varies among the published studies.

Low Incidence of Groin Pain and Early Failure with Large Metal Articulation Total Hip Arthroplasty

John B. Meding MD, Lindsey K. Meding, E. Michael Keating MD, Michael E. Berend MD

Large-diameter metal-on-metal articulations reportedly improve stability and wear in THAs. However, some reports suggest some patients have unexplained hip and early failures with these implants. Thus, the potential benefits may be offset by these concerns. However, the incidence of these problems is not clearly established.

Tantalum Augments for Paprosky IIIA Defects Remain Stable at Midterm Followup

Daniel J. Gaizo MD, Vamsi Kancherla MD, Scott M. Sporer MD, Wayne G. Paprosky MD

Initial reports with short-term followup of porous tantalum acetabular components and augments for Paprosky IIIA acetabular defects demonstrate high hip scores, low rates of aseptic loosening, and low rates of complications. However, longer-term followup with a larger cohort is needed to determine the durability of these reconstructions.

Factors Affecting Modular Acetabular Ceramic Liner Insertion: A Biomechanical Analysis

James P. McAuley MD, Douglas A. Dennis MD, Justin Grostefon, William G. Hamilton MD

Ceramic liner fracture is a concern in THA. However, it is unclear what factors influence the risk of facture. To study these factors under controlled conditions, we created a laboratory model to avoid fractures in vitro.

High Incidence of Migration with Poor Initial Fixation of the Accolade® Stem

Craig A. White MD, Sasha Carsen MD, Kevin Rasuli BSc, Robert J. Feibel MD, FRCSC, Paul R. Kim MD, FRCSC, Paul E. Beaulé MD, FRCSC

Numerous cementless femoral stem design variations are in clinical use. Because initial implant instability and micromotion are associated with aseptic loosening of the femoral component, migration analysis provides an early assessment of implant survivorship.

Bony Impingement Limits Design-related Increases in Hip Range of Motion

Adam Bunn BS, Clifford W. Colwell MD, Darryl D. D’Lima MD, PhD

Factors affecting risk for impingement and dislocation can be related to the patient, implant design, or surgeon. While these have been studied independently, the impact of each factor relative to the others is not known.

Pelvic Discontinuity Treated With Custom Triflange Component: A Reliable Option

Michael J. Taunton MD, Thomas K. Fehring MD, Paul Edwards MD, Thomas Bernasek MD, Ginger E. Holt MD, Michael J. Christie MD

Pelvic discontinuity is an increasingly common complication of THA. Treatments of this complex situation are varied, including cup-cage constructs, acetabular allografts with plating, pelvic distraction technique, and custom triflange acetabular components. It is unclear whether any of these offer substantial advantages.

Surgical Technique: A Cup-in-Cup Technique to Restore Offset in Severe Protrusio Acetabular Defects

Thomas J. Blumenfeld MD, William L. Bargar MD

Severe medial and/or superior defects encountered in revision THA are currently managed with jumbo (≥ 66 mm) acetabular components and modular augments, with reconstruction cages, or with the cup-cage technique. Preoperative planning can indicate when these techniques may not restore vertical and horizontal offset. Failure to restore offset can lead to impingement, leg length inequality, abductor weakness, and dislocation.

Stable Fixation of Short-stem Femoral Implants in Patients 70 Years and Older

Ronak M. Patel MD, Matthew C. Smith MD, Chase C. Woodward BA, S. David Stulberg MD

Limitations of conventional uncemented femoral stems persist, including proximal-distal mismatch, nonideal load transfer, loss of bone, and difficulties with minimally invasive surgery. Metaphyseal-engaging short-stem implants have been designed to address these issues in THA. While these devices have been studied in younger patients, it is unclear whether they offer advantages in older patients.

A Short Tapered Stem Reduces Intraoperative Complications in Primary Total Hip Arthroplasty

Ryan G. Molli DO, Adolph V. Lombardi MD, FACS, Keith R. Berend MD, Joanne B. Adams BFA, Michael A. Sneller BS

While short-stem design is not a new concept, interest has surged with increasing utilization of less invasive techniques. Short stems are easier to insert through small incisions. Reliable long-term results including functional improvement, pain relief, and implant survival have been reported with standard tapered stems, but will a short taper perform as well?

The Effect of Poly Sterilization on Wear, Osteolysis and Survivorship of a Press-fit Cup at 10-Year Followup

Charles A. Engh MD, Cara C. Powers MD, Henry Ho MS, Sarah E. Beykirch-Padgett BS, Robert H. Hopper PhD, C. Anderson Engh MD

During the mid-1990s when our institution was using a press-fit porous-coated cup without supplemental initial fixation for primary THA, the manufacturer transitioned from gamma irradiation to gas plasma for the terminal sterilization of their polyethylene liners.

A More Reliable Method to Assess Acetabular Component Position

John V. Tiberi MD, Nicholas Pulos MD, Michael Kertzner BS, Thomas P. Schmlazried MD

Acetabular component position is associated with joint function and bearing wear. Current techniques for determining acetabular component version on standard radiographs lack reliability. Other, more consistent techniques are time-consuming and require additional equipment or software.

Increased Anteversion of Press-fit Femoral Stems Compared With Anatomic Femur

Roger H. Emerson MD

With contemporary canal-filling press-fit stems, there is no adjustability of stem position in the canal and therefore the canal anatomy determines stem version. Stem version will affect head/neck impingement, polyethylene wear from edge loading, and hip stability, but despite this, the postoperative version of a canal-filling press-fit stem is unclear.

Is an Algorithmic Approach to the Treatment of Recurrent Dislocation After THA Effective?

Ehsan Saadat MD, Glenn Diekmann MD, Steven Takemoto PhD, Michael D. Ries MD

The indications for surgical techniques for treatment of recurrent hip dislocation after THA differ, and their rates of achievement of stability may not be similar.

Age and Obesity Are Risk Factors for Adverse Events After Total Hip Arthroplasty

James I. Huddleston MD, Yun Wang PhD, Carlos Uquillas BS, James H. Herndon MD, MBA, William J. Maloney MD

Defining the epidemiology of adverse events after THA will aid in the development of strategies to enhance perioperative care.

Overdiagnosis of Pulmonary Embolism: Evaluation of a Hypoxia Algorithm Designed to Avoid This Catastrophic Problem

Brian S. Winters MD, Mark Solarz MD, Christina L. Jacovides BS, James J. Purtill MD, Richard H. Rothman MD, PhD, Javad Parvizi MD, FRCS

We observed a substantial increase in the incidence of pulmonary embolism (PE) after total joint arthroplasty (TJA) when multidetector computerized tomography (MDCT) replaced ventilation-perfusion (V/Q) scans as the diagnostic modality of choice. We questioned whether this resulted from the detection of clinically unimportant PE with the more sensitive MDCT and in 2007 instituted a hypoxia protocol to enhance the detection of PE.

Surgical Technique: Transfer of the Anterior Portion of the Gluteus Maximus Muscle for Abductor Deficiency of the Hip

Leo A. Whiteside MD

Loss of the abductor portions of the gluteus medius and gluteus minimus muscles due to THA causes severe limp and often instability.

Surgical Technique: A Simple Soft-tissue-only Repair of the Capsule and External Rotators in Posterior-approach THA

James A. Browne MD, Mark W. Pagnano MD

Posterior soft tissue repair after posterior THA reportedly decreases the risk of dislocation. Previously described techniques often require drill holes through the greater trochanter, do not include both the short external rotators and the capsule, or require a complex series of multiple sutures. We therefore describe a technique to address these issues.

Does Previous Reconstructive Surgery Influence Functional Improvement and Deformity Correction After Periacetabular Osteotomy?

Gregory G. Polkowski MD, Eduardo N. Novais MD, Young-Jo Kim MD, Michael B. Millis MD, Perry L. Schoenecker MD, John C. Clohisy MD

The Bernese periacetabular osteotomy (PAO) is commonly used to surgically treat residual acetabular dysplasia. However, the degree to which function and radiographic deformity are corrected in patients with more severe deformities that have undergone previous reconstructive pelvic or femoral osteotomies is unclear.

Which Factors Influence Preservation of the Osteonecrotic Femoral Head?

Jay R. Lieberman MD, Stephen M. Engstrom BS, R. Michael Meneghini MD, Nelson Fong SooHoo MD

Although surgeons use many procedures to preserve the femoral head in patients with hip osteonecrosis, there is no consensus regarding the best procedure.

Incidence of Contralateral THA After Index THA for Osteoarthritis

Siraj A. Sayeed MD, Aaron J. Johnson MD, David E. Jaffe MD, Michael A. Mont MD

Currently more than 200,000 THAs are performed annually in the United States. In patients with bilateral disease, the chance of subsequent contralateral THA reportedly ranges from 16% to 85%. Factors influencing contralateral THA are not completely understood.

Surface Replacement of the Hip Can Result in Decreased Acetabular Bone Stock

Michael Tanzer MD, FRCSC, Dylan Tanzer DEC, Karen Smith CRA

The recent interest in hip resurfacing arthroplasty is motivated by its potential advantages over THA. One advantage of hip resurfacing arthroplasty is that it conserves bone on the femoral side; however, it is unclear whether it does so on the acetabular side.

Does International Normalized Ratio Level Predict Pulmonary Embolism?

Patricia Hansen BS, Benjamin Zmistowski BS, Camilo Restrepo MD, Javad Parvizi MD, FRCS, Richard H. Rothman MD, PhD

Preventing pulmonary embolism is a priority after major musculoskeletal surgery. The literature contains discrepant data regarding the influence of anticoagulation on the incidence of pulmonary embolism after joint arthroplasty. The American College of Chest Physicians guidelines recommend administration of oral anticoagulants (warfarin), aiming for an international normalized ratio (INR) level between 2 and 3. However, recent studies show aggressive anticoagulation (INR > 2) can lead to hematoma formation and increased risk of subsequent infection.

Predictors of Participation in Sports After Hip and Knee Arthroplasty

Daniel H. Williams MBBCh, MSc, Nelson V. Greidanus MD, MPH, Bassam A. Masri MD, Clive P. Duncan MD, MSc, Donald S. Garbuz MD, MHSc

While the primary objective of joint arthroplasty is to improve patient quality of life, pain, and function, younger active patients often demand a return to higher function that includes sporting activity. Knowledge of rates and predictors of return to sports will help inform expectations in patients anticipating return to sports after joint arthroplasty.

Accuracy of Measuring Tape and Vertebral-level Methods to Determine Shoulder Internal Rotation

Seung-Hwan Han MD, Kyung-Soo Oh MD, Kyeong-Jin Han MD, Joon Jo MD, Doo-Hyung Lee MD

Goniometers can be used to assess shoulder ROM with reasonable accuracy, but not internal rotation. Vertebral level, as determined by the hand-behind-the-back method, is used frequently but its reproducibility is questionable. We therefore devised a new measuring tape-based method for determining vertebral level.

Nonoperative versus Operative Treatment for Thoracolumbar Burst Fractures Without Neurologic Deficit: A Meta-analysis

Sonali R. Gnanenthiran MBBS, Sam Adie BSc(Med), MBBS, MSpMed MPH, Ian A. Harris MBBS, MMed(Clin Epid), PhD, FRACS(Orth)

Decision-making regarding nonoperative versus operative treatment of patients with thoracolumbar burst fractures in the absence of neurologic deficits is controversial. Lack of evidence-based practice may result in patients being treated inappropriately and being exposed to unnecessary adverse consequences.

Does Ipsilateral Knee Pain Improve after Hip Arthroplasty?

Wenbao Wang MD, Jeffrey A. Geller MD, Jonathan D. Nyce BS, Jung Keun Choi MD, William Macaulay MD

Intraarticular hip disease is commonly acknowledged as a cause of ipsilateral knee pain. However, this is based primarily on observational rather than high-quality evidence-based studies, and it is unclear whether ipsilateral knee pain improves when hip disease has been treated.

A New High-flexion Knee Scoring System to Eliminate the Ceiling Effect

Sang-Eun Na MD, Chul-Won Ha MD, Choong-Hee Lee MD

Various scoring systems document improvement after TKA, but most are associated with a ceiling effect that may fail to distinguish between patients having different levels of knee function after TKA. We therefore developed a new scoring system for patients with higher levels of flexion to eliminate ceiling effects observed with current systems.

Surgical Technique: Porous Tantalum Reconstruction for Destructive Nonprimary Periacetabular Tumors

Fazel A. Khan MD, Peter S. Rose MD, Michiro Yanagisawa MD, David G. Lewallen MD, Franklin H. Sim MD

Large bone loss and frequently irradiated existing bone make reconstructing metastatic and other nonprimary periacetabular tumors challenging. Although existing methods are initially successful, they may fail with time. Given the low failure rates of porous tantalum acetabular implants in other conditions with large bone loss or irradiated bone, we developed a technique to use these implants in these neoplastic cases where others might fail.

Similar Outcomes for Nail versus Plate Fixation of Three-part Proximal Humeral Fractures

Gerhard Konrad MD, Laurent Audigé PhD, Simon Lambert MD, Ralph Hertel MD, Norbert P. Südkamp MD

There is a lack of consensus regarding optimal surgical management of displaced and unstable three-part proximal humeral fractures.

Antimicrobial Gauze as a Dressing Reduces Pin Site Infection: A Randomized Controlled Trial

C. K. Lee MBBS (U Malaya), Y. P. Chua MS Ortho (U Malaya), A. Saw FRCS (Edin)

Pin site infection is a common problem in external fixation. Plain gauze wetted with normal saline is commonly used for a pin site dressing owing to the simplicity and low cost. Evidence to support adding an antimicrobial agent in the dressing material is lacking.

Is Bilateral Lower Limb Lengthening Appropriate for Achondroplasia?: Midterm Analysis of the Complications and Quality of Life

Seung-Ju Kim MD, Gracia Cielo Balce MD, Mandar Vikas Agashe MD, Sang-Heon Song MD, Hae-Ryong Song MD, PhD

Use of the Ilizarov technique for limb lengthening in patients with achondroplasia is controversial, with a high risk of complications balancing cosmetic gains. Although several articles have described the complications of this procedure and satisfaction of patients after surgery, it remains unclear whether lengthening improves the quality of life (QOL) of these patients.

Case Report: Floating-clavicle from the 17th Century: The Oldest Case?

Josep Liria MD, Susana Carrascal MS, Mariano Fernández-Fairén PhD, Assumpció Malgosa PhD, Albert Isidro PhD

Dislocation of both ends of the clavicle is a rare traumatic lesion and the mechanism of the lesion is usually related to major trauma. The first case was described in 1831.

Complications In Brief: Anterior Cruciate Ligament Reconstruction

Fotios Paul Tjoumakaris MD, Amy L. Herz-Brown MD, Andrea Legath-Bowers MD, Brian J. Sennett MD, Joseph Bernstein MD When performing reconstruction of the ACL, the major complications that can arise include missed concomitant injuries, tunnel malposition, patellar fracture, knee stiffness, and infection. We review the complications that can occur as a result of errors made before, during, and after surgery.
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