Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 472 | Issue 1 | Jan, 2014

What Are the Levels of Evidence on Which We Base Decisions for Surgical Management of Lower Extremity Bone Tumors?

Nathan Evaniew MD, James Nuttall MBBChBAO, Forough Farrokhyar MPhil, PhD, Mohit Bhandari MD, PhD, Michelle Ghert MD

Benign and malignant lower extremity primary bone tumors are among the least common conditions treated by orthopaedic surgeons. The literature supporting their surgical management has historically been in the form of observational studies rather than prospective controlled studies. Observational studies are prone to confounding bias, sampling bias, and recall bias.

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

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

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

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

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

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

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

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

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

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

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

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

Unicondylar Arthroplasty in Knees With Deficient Anterior Cruciate Ligaments

Gerard A. Engh MD, Deborah J. Ammeen BS

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

Knee Moments After Unicompartmental Knee Arthroplasty During Stair Ascent

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

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

Impact of Socioeconomic Factors on Outcome of Total Knee Arthroplasty

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

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

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

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

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

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

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

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

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

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

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

Maximizing Tibial Coverage Is Detrimental to Proper Rotational Alignment

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

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

Correction of Varus Deformity During TKA With Reduction Osteotomy

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

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

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

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

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

Do Patients Return to Work After Total Knee Arthroplasty?

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

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

Total Knee Arthroplasty in Patients With Juvenile Idiopathic Arthritis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Leo A. Whiteside MD

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

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

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

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

Risk Factors for Early Revision After Primary TKA in Medicare Patients

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

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

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

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

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

Abnormal Axial Rotations in TKA Contribute to Reduced Weightbearing Flexion

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What Role Do Plain Radiographs Have in Assessing the Skeletally Immature Acromioclavicular Joint?

Seung Yeol Lee MD, Soon-Sun Kwon PhD, Chin Youb Chung MD, Kyoung Min Lee MD, Moon Seok Park MD

Because of incomplete ossification of the coracoid process and acromion, acromioclavicular joint configuration in the skeletally immature patient differs from that of adults. Although comparison to radiographic standards for this joint is critical in the evaluation of acromioclavicular joint injuries, these standards are not well defined for children or adolescents.

A Patient-derived Constant-Murley Score is Comparable to a Clinician-derived Score

Ofer Levy MD, Omar Haddo BSc, Samir Massoud MCChB, Hannan Mullett MB, BCh, Ehud Atoun MD

Although there are many advantages to patient-based assessment for musculoskeletal conditions, one common problem is that many of these assessments are perceived to be subjective. To overcome this limitation for patient-based shoulder evaluation, we developed a modified Constant-Murley score that allows patients to complete subjective and objective sections of the score.

Loss of Cement-bone Interlock in Retrieved Tibial Components from Total Knee Arthroplasties

Mark A. Miller MS, Jacklyn R. Goodheart BS, Timothy H. Izant MD, Clare M. Rimnac PhD, Richard J. Cleary PhD, Kenneth A. Mann PhD

Aseptic loosening continues to be a short- and long-term complication for patients with cemented TKAs. Most studies to this point have evaluated tibial component fixation via radiographic changes at the implant-bone interface and quantification of component migration; direct assessment of morphologic features of the interface from functioning TKAs may provide new information regarding how TKAs function and are fixed to bone.

Causes, Risk Factors, and Trends in Failures After TKA in Korea Over the Past 5 Years: A Multicenter Study

In Jun Koh MD, Woo-Shin Cho MD, Nam Yong Choi MD, Tae Kyun Kim MD

Failure after total knee arthroplasty (TKA) may be related to emerging technologies, surgical techniques, and changing patient demographics. Over the past decade, TKA use in Korea has increased substantially, and demographic trends have diverged from those of Western countries, but failure mechanisms in Korea have not been well studied.

Comparison of Robotic-assisted and Conventional Acetabular Cup Placement in THA: A Matched-pair Controlled Study

Benjamin G. Domb MD, Youssef F. El Bitar MD, Adam Y. Sadik BS, Christine E. Stake MA, Itamar B. Botser MD

Improper acetabular component orientation in THA has been associated with increased dislocation rates, component impingement, bearing surface wear, and a greater likelihood of revision. Therefore, any reasonable steps to improve acetabular component orientation should be considered and explored.

Surgical Hip Dislocation for Treatment of Femoroacetabular Impingement: Factors Predicting 5-year Survivorship

Simon D. Steppacher MD, Carmen Huemmer MD, MSC, Joseph M. Schwab MD, Moritz Tannast MD, Klaus A. Siebenrock MD

Patients with femoroacetabular impingement (FAI) often develop pain, impaired function, and progression of osteoarthritis (OA); this is commonly treated using surgical hip dislocation, femoral neck and acetabular rim osteoplasty, and labral reattachment. However, results with these approaches, in particular risk factors for OA progression and conversion to THA, have varied.

Infection After Surgical Resection for Pelvic Bone Tumors: An Analysis of 270 Patients From One Institution

Andrea Angelini MD, Gabriele Drago MD, Giulia Trovarelli MD, Teresa Calabrò MD, Pietro Ruggieri MD, PhD

Surgical treatment of pelvic tumors with or without acetabular involvement is challenging. Primary goals of surgery include local control and maintenance of good quality of life, but the procedures are marked by significant perioperative morbidity and complications.

Randomized Trial of Hemiarthroplasty versus Internal Fixation for Femoral Neck Fractures: No Differences at 6 Years

Ragnhild Øydna Støen MD, Cathrine M. Lofthus MD, PhD, Lars Nordsletten MD, PhD, Jan Erik Madsen MD, PhD, Frede Frihagen MD, PhD

Hemiarthroplasty has been shown superior to internal fixation for displaced femoral neck fractures (FNF) in the first 2 years. However, there are unanswered questions about the performance of hemiarthroplasty over the longer term compared with internal fixation.

Does Research Participation Make a Difference in Residency Training?

Jonathan B. Macknin MD, Amy Brown MS, Randall E. Marcus MD

The American Board of Orthopaedic Surgery requirements state that an orthopaedic residency must offer at least 5 years of clinical education and some exposure to research. To expose residents to basic research, some programs, including ours, have a research track that allows for 1 year of basic science research. The degree to which research productivity during residency—which may be something that can perhaps be influenced by interventions like research tracks during residency—affects residency graduates’ future research contributions is unknown.

Erratum to: Collaborative Partnerships and the Future of Global Orthopaedics

Saam Morshed MD, PhD, MPH, David W. Shearer MD, MPH, R. Richard Coughlin MD, MSc
Back to top