Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 475 | Issue 1 | Jan, 2017
Articles

The Chitranjan S. Ranawat Award

Simon W. Young FRACS, Matthew L. Walker FRACS, Ali Bayan FRACS, Toby Briant-Evans FRCS, Paul Pavlou FRCS, Bill Farrington FRCS, FRACS

Neutral mechanical alignment (MA) in total knee arthroplasty (TKA) aims to position femoral and tibial components perpendicular to the mechanical axis of the limb. In contrast, kinematic alignment (KA) attempts to match implant position to the prearthritic anatomy of the individual patient with the aim of improving functional outcome. However, comparative data between the two techniques are lacking.

The Law and Social Values: Medical Uncertainty

Wendy Z. W. Teo BA(Cantab), BM BCh (Oxon), LLM, Lawrence H. Brenner JD, B. Sonny Bal MD, JD, MBA

The John N. Insall Award: Do Intraarticular Injections Increase the Risk of Infection After TKA?

Nicholas A. Bedard MD, Andrew J. Pugely MD, Jacob M. Elkins MD, PhD, Kyle R. Duchman MD, Robert W. Westermann MD, Steve S. Liu MD, Yubo Gao PhD, John J. Callaghan MD

Infection after total knee arthroplasty (TKA) can result in disastrous consequences. Previous research regarding injections and risk of TKA infection have produced conflicting results and in general have been limited by small cohort size.

The Mark Coventry, MD, Award: Oral Antibiotics Reduce Reinfection After Two-Stage Exchange: A Multicenter, Randomized Controlled Trial

Jonathan M. Frank MD, Erdan Kayupov MSE, Mario Moric MS, John Segreti MD, Erik Hansen MD, Curtis Hartman MD, Kamil Okroj BS, Katherine Belden MD, Brian Roslund PharmD, Randi Silibovsky MD, Javad Parvizi MD, Craig J. Valle MD

Many patients develop recurrent periprosthetic joint infection after two-stage exchange arthroplasty of the hip or knee. One potential but insufficiently tested strategy to decrease the risk of persistent or recurrent infection is to administer additional antibiotics after the second-stage reimplantation.

Higher Frequency of Reoperation With a New Bicruciate-retaining Total Knee Arthroplasty

Jesse C. Christensen PT, DPT, Justin Brothers MD, Gregory J. Stoddard MPH, MBA, Mike B. Anderson MSc, Christopher E. Pelt MD, Jeremy M. Gililland MD, Christopher L. Peters MD

With as many as 25% of patients reporting residual knee symptoms after primary total knee arthroplasty (TKA), alternative implant designs and surgical techniques have been proposed to further reduce these symptoms. There is growing evidence that retention of the anterior cruciate ligament (ACL) results in more natural knee kinematics; thus, implants with more normal joint mechanics could provide improved physical function postoperatively and reduce the amount of residual symptoms. Advancements in the bicruciate-retaining (BCR) TKA implant design have been made, and based on these, we wished to compare the BCR with a more traditional cruciate-retaining (CR) implant.

Length of Endoprosthetic Reconstruction in Revision Knee Arthroplasty Is Associated With Complications and Reoperations

Jeffrey J. Barry MD, Zachary Thielen MD, David C. Sing BS, Paul H. Yi MD, Erik N. Hansen MD, Michael Ries MD

Complex revision total knee arthroplasty (TKA) often calls for endoprosthetic reconstruction to address bone loss, poor bone quality, and soft tissue insufficiency. Larger amounts of segmental bone loss in the setting of joint replacement may be associated with greater areas of devascularized tissue, which could increase the risk of complications and worsen functional results.

What Is the Frequency of Noise Generation in Modern Knee Arthroplasty and Is It Associated With Residual Symptoms?

Denis Nam MD, MSc, Toby Barrack BA, Ryan M. Nunley MD, Robert L. Barrack MD

Prior investigations have recognized the presence of patient-perceived noise generation after total knee arthroplasty (TKA). However, questions remain regarding its overall frequency after both TKA and unicompartmental knee arthroplasty (UKA) as well as with respect to its association with demographic and prosthesis-related factors and its association with patient-reported outcomes.

No Difference in Early Analgesia Between Liposomal Bupivacaine Injection and Intrathecal Morphine After TKA

John W. Barrington MD, Roger H. Emerson MD, Scott T. Lovald PhD, Adolph V. Lombardi MD, Keith R. Berend MD

Opioid analgesics have been a standard modality for postoperative pain management after total knee arthroplasty (TKA) but are also associated with increased risk of nausea, pruritus, vomiting, respiratory depression, prolonged ileus, and cognitive dysfunction. There is still a need for a method of anesthesia that can deliver effective long-term postoperative pain relief without incurring the high cost and health burden of opioids and nerve blocks.

Pain Control and Functional Milestones in Total Knee Arthroplasty: Liposomal Bupivacaine versus Femoral Nerve Block

Stephen Yu MD, Alessandra Szulc MA, Sharon Walton MD, Joseph Bosco MD, Richard Iorio MD

Although pain management after total knee arthroplasty (TKA) affects rehabilitation, length of stay, and functional outcomes, pain management for patients undergoing TKA has yet to be standardized. Femoral nerve blocks (FNBs) are commonly used as an adjunct; however, these can result in transient quadriceps weakness and have been associated with in-hospital falls. Periarticular infiltration of liposomal bupivacaine has been recently introduced as a long-acting analgesic that can be administered without affecting motor function.

No Difference Between Trabecular Metal Cones and Femoral Head Allografts in Revision TKA: Minimum 5-year Followup

Nemandra A. Sandiford MSc, FRCS(Tr&Orth), Peter Misur FRACS, Donald S. Garbuz MD, MHSc, FRCS(C), Nelson V. Greidanus MSc, FRCS (C), Bassam A. Masri MD, FRCS(C)

Encouraging clinical results have been reported with the use of femoral head structural allografts and, more recently, trabecular metal cones for the management of large structural defects of the femur and tibia during revision total knee arthroplasty (TKA). However, to our knowledge, there are no published studies comparing these two techniques.

Crosslink Density Is Reduced and Oxidation Is Increased in Retrieved Highly Crosslinked Polyethylene TKA Tibial Inserts

Tong Liu MD, Christina I. Esposito PhD, Jayme C. Burket PhD, Timothy M. Wright PhD

The wear resistance of highly crosslinked polyethylene depends on crosslink density, which may decrease with in vivo loading, leading to more wear and increased oxidation. The relationship among large and complex in vivo mechanical stresses, breakdown of the polyethylene crosslinks, and oxidative degradation is not fully understood in total knee arthroplasty (TKA). We wished to determine whether crosslink density is reduced at the articular surfaces of retrieved tibial inserts in contact areas exposed to in vivo mechanical stress.

Do Stemmed Tibial Components in Total Knee Arthroplasty Improve Outcomes in Patients With Obesity?

Sébastien Parratte MD, Matthieu Ollivier MD, Alexandre Lunebourg MD, Nicolas Verdier MD, Jean Noel Argenson MD, PhD

Recent clinical studies have reported that patients with higher body mass index (BMI) are more likely to experience premature failure of total knee arthroplasty (TKA), lower knee scores, and perhaps more pain in the prosthetic joint. However, it is not known whether certain implant design features such as tibial stems might be associated with differences in the frequency of tibial pain in patients with higher BMIs.

Can Preoperative Patient-reported Outcome Measures Be Used to Predict Meaningful Improvement in Function After TKA?

Jonathan L. Berliner MD, Dane J. Brodke BA, Vanessa Chan MPH, Nelson F. SooHoo MD, Kevin J. Bozic MD, MBA

Despite the overall effectiveness of total knee arthroplasty (TKA), a subset of patients do not experience expected improvements in pain, physical function, and quality of life as documented by patient-reported outcome measures (PROMs), which assess a patient’s physical and emotional health and pain. It is therefore important to develop preoperative tools capable of identifying patients unlikely to improve by a clinically important margin after surgery.

Can Original Knee Society Scores Be Used to Estimate New 2011 Knee Society Scores?

Susan M. Odum PhD, Thomas K. Fehring MD

The Knee Society Score (KSS) instrument is one of the most commonly reported primary outcome measures for total knee arthroplasty (TKA). Originally developed in 1989, the KSS was expanded and updated in 2011; however, the original KSS does not directly translate into the 2011 KSS. To date, no conversion algorithm has been developed, hindering the ability of researchers to adopt the 2011 KSS while maintaining their historical/longitudinal original KSS data.

What Differences in Morphologic Features of the Knee Exist Among Patients of Various Races? A Systematic Review

T. K. Kim MD, PhD, Mark Phillips BSc, Mohit Bhandari MD, PhD, John Watson, Rajesh Malhotra MS, FRCS

Most TKA prostheses are designed based on the anatomy of white patients. Individual studies have identified key anthropometric differences between the knees of the white population and other major ethnic groups, yet there is limited understanding of what these findings may indicate if analyzed collectively.

Nonmodular Tapered Fluted Titanium Stems Osseointegrate Reliably at Short Term in Revision THAs

Nemandra A. Sandiford MBBS, MSc, FRCS(Tr&Orth), Donald S. Garbuz MD, MHSc, FRCS(C), Bassam A. Masri MD, FRCS(C), Clive P. Duncan MB, MSc, FRCS(C)

The ideal femoral component for revision THA is undecided. Cylindrical nonmodular stems have been associated with stress shielding, whereas junctional fractures have been reported with tapered fluted modular titanium stems. We have used a tapered fluted nonmodular titanium femoral component (Wagner Self-locking [SL] femoral stem) to mitigate this risk. This component has been used extensively in Europe by its designer surgeons, but to our knowledge, it has not been studied in North America. Added to this, the design of the component has changed since early reports.

Navigation is Equal to Estimation by Eye and Palpation in Preventing Psoas Impingement in THA

Markus Weber MD, Michael Woerner MD, Benedikt Messmer Cand Med, Joachim Grifka MD, Tobias Renkawitz MD

Iliopsoas tendon impingement is one possible reason for persistent groin pain and diminished functional outcome after THA. So far, estimation by eye and palpation is the standard procedure to intraoperatively assess the distance of the cup to the anterior rim. However, novel technologies such as imageless navigation enable intraoperative measurements of the cup in relation to the psoas tendon and bony landmarks.

What is the Diagnostic Accuracy of Aspirations Performed on Hips With Antibiotic Cement Spacers?

Jared M. Newman MD, Jaiben George MBBS, Alison K. Klika MS, Stephen F. Hatem MD, Wael K. Barsoum MD, W. Trevor North MD, Carlos A. Higuera MD

Periprosthetic joint infection is a serious complication after THA and commonly is treated with a two-stage revision. Antibiotic-eluting cement spacers are placed for local delivery of antibiotics. Aspirations may be performed before the second-stage reimplantation for identification of persistent infection. However, limited data exist regarding the diagnostic parameters of synovial fluid aspiration with or without saline lavage from a hip with an antibiotic-loaded cement spacer.

Is It Appropriate to Treat Sarcoma Metastases With Intramedullary Nailing?

Bryan S. Moon MD, Dwayne J. Dunbar MS, Patrick P. Lin MD, Robert L. Satcher MD, Justin E. Bird MD, Valerae O. Lewis MD

Patients with primary bone and soft tissue sarcoma are at risk for skeletal metastases. Although uncommon, these metastases can result in impending or pathologic fractures. Intramedullary nailing traditionally has been an accepted form of palliative treatment for patients with metastatic carcinoma, but we could find no studies that report specifically on intramedullary nailing of metastatic sarcoma lesions.

Are Recently Trained Tumor Fellows Performing Less Tumor Surgery? An Analysis of 10 Years of the ABOS Part II Database

Kyle R. Duchman MD, Benjamin J. Miller MD, MS

The majority of orthopaedic trainees pursue additional subspecialty training at the conclusion of residency. Although national trends indicate that fellowship-trained surgeons are more frequently performing cases in their defined subspecialties, this may not be the case for recently trained tumor fellows. Prior work has established that low tumor case volume is a significant stressor for recently trained tumor fellows. Given the relative rarity of musculoskeletal tumors, it is important for prospective trainees to have clear expectations for the proportion of specialty-specific procedures early during their careers. In addition, knowledge of anticipated specialty case volume is important to optimize fellowship training and to provide guidance for meeting the public health requirements for orthopaedic oncology.

Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis

Amin Mohamadi MD, MPH, Jimmy J. Chan MD, Femke M. A. P. Claessen MD, David Ring MD, PhD, Neal C. Chen MD

The ability of injection of corticosteroids into the subacromial space to relieve pain ascribed to rotator cuff tendinosis is debated. The number of patients who have an injection before one gets relief beyond what a placebo provides is uncertain.

Variations in the Innervation of the Long Head of the Triceps Brachii: A Cadaveric Investigation

Alexandra J. Erhardt DO, Bennett Futterman MD

Some leading anatomy texts state that all three heads of the triceps brachii are innervated by the radial nerve. The posterior cord of the brachial plexus bifurcates to terminate as the radial and axillary nerves. Studies have noted the presence of axillary innervation to the long head of the triceps brachii muscle, patterns different from the classic exclusive radial nerve supply. An understanding of these variations may assist the clinician in the assessment of shoulder weakness and in preoperative and operative planning of radial and axillary neuropathies.

Can Surgeons Adequately Capture Adverse Events Using the Spinal Adverse Events Severity System (SAVES) and OrthoSAVES?

Brian P. Chen MD (Candidate), Katie Garland BSc, Darren M. Roffey PhD, Stephane Poitras PhD, Geoffrey Dervin MD, Peter Lapner MD, Philippe Phan MD, Eugene K. Wai MD, Stephen P. Kingwell MD, Paul E. Beaulé MD

Physicians have consistently shown poor adverse-event reporting practices in the literature and yet they have the clinical acumen to properly stratify and appraise these events. The Spine Adverse Events Severity System (SAVES) and Orthopaedic Surgical Adverse Events Severity System (OrthoSAVES) are standardized assessment tools designed to record adverse events in orthopaedic patients. These tools provide a list of prespecified adverse events for users to choose from—an aid that may improve adverse-event reporting by physicians.

A Resident-led Initiative Improves Screening and Treatment for Vitamin D Deficiency in Patients with Hip Fractures

Drew A. Lansdown MD, Amanda Whitaker MD, Rosanna Wustrack MD, Aenor Sawyer MD, Erik N. Hansen MD

Acute hip fractures carry a high risk of morbidity and are associated with low vitamin D levels. Improvements in screening and treating low vitamin D levels may lead to lower fall rates and a lower likelihood of additional fragility fractures. However, patients with low vitamin D levels often remain unassessed and untreated, even after they experience these fractures.

Do Patients Taking Warfarin Experience Delays to Theatre, Longer Hospital Stay, and Poorer Survival After Hip Fracture?

John E. Lawrence MA, MB, BChir, MRCS, Daniel M. Fountain BSc, Duncan J. Cundall-Curry MBBS, MRCS Dip Clin Ed, Andrew D. Carrothers MBChB, FRCS (Tr&Orth)

Patients sustaining a fractured neck of the femur are typically of advanced age with multiple comorbidities. As a consequence, the proportion of these patients receiving warfarin therapy is approximately 10%. There are currently few studies investigating outcomes in this subset of patients.

Erratum to: Can Wear Explain the Histological Variation Around Metal-on-metal Total Hips?

Edward Ebramzadeh PhD, Patricia Campbell PhD, Timothy L. Tan MD, Scott D. Nelson MD, Sophia N. Sangiorgio PhD
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