The use of dual-mobility bearings in patients at high risk of dislocation.

AIMS: Instability continues to be a troublesome complication after total hip arthroplasty (THA). Patient-related risk factors associated with a higher dislocation risk include the preoperative diagnosis, an age of 75 years or older, high body mass index (BMI), a history of alcohol abuse, and neurodegenerative diseases. The goal of this study was to assess the dislocation rate, radiographic outcomes, and complications of patients stratified as high-risk for dislocation who received a dual mobility (DM) bearing in a primary THA at a minimum follow-up of two years. MATERIALS AND METHODS: We performed a retrospective review of a consecutive series of DM THA performed between 2010 and 2014 at our institution (Hospital for Special Surgery, New York, New York) by a single, high-volume orthopaedic surgeon employing a single prosthesis design (Anatomic Dual Mobility (ADM) Stryker, Mahwah, New Jersey). Patient medical records and radiographs were reviewed to confirm the type of implant used, to identify any preoperative risk factors for dislocation, and any complications. Radiographic analysis was performed to assess for signs of osteolysis or remodelling of the acetabulum. RESULTS: There were 151 patients who met the classification of high-risk according to the inclusion criteria and received DM THA during the study period. Mean age was 82 years old (73 to 95) and 114 patients (77.5%) were female. Mean follow-up was 3.6 years (1.9 to 6.1), with five patients lost to follow-up and one patient who died (for a reason unrelated to the index procedure). One patient (0.66%) sustained an intraprosthetic dislocation; there were no other dislocations. CONCLUSION: At mid-term follow-up, the use of a DM bearing for primary THA in patients at high risk of dislocation provided a stable reconstruction option with excellent radiographic results. Longer follow-up is needed to confirm the durability of these reconstructions.

Dislocation following total hip arthroplasty using dual mobility acetabular components: a systematic review.

AIMS: The aim of this systematic review was to report the rate of dislocation following the use of dual mobility (DM) acetabular components in primary and revision total hip arthroplasty (THA). MATERIALS AND METHODS: A systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was performed. A comprehensive search of Pubmed/Medline, Cochrane Library and Embase (Scopus) was conducted for English articles between January 1974 and March 2016 using various combinations of the keywords "dual mobility", "dual-mobility", "tripolar", "double-mobility", "double mobility", "hip", "cup", "socket". The following data were extracted by two investigators independently: demographics, whether the operation was a primary or revision THA, length of follow-up, the design of the components, diameter of the femoral head, and type of fixation of the acetabular component. RESULTS: In all, 59 articles met our inclusion criteria. These included a total of 17 908 THAs which were divided into two groups: studies dealing with DM components in primary THA and those dealing with these components in revision THA. The mean rate of dislocation was 0.9% in the primary THA group, and 3.0% in the revision THA group. The mean rate of intraprosthetic dislocation was 0.7% in primary and 1.3% in revision THAs. CONCLUSION: Based on the current data, the use of DM acetabular components are effective in minimising the risk of instability after both primary and revision THA. This benefit must be balanced against continuing concerns about the additional modularity, and the new mode of failure of intraprosthetic dislocation. Longer term studies are needed to assess the function of these newer materials compared with previous generations. Cite this article: Bone Joint J 2017;99-B(1 Supple A):18-24.

Simultaneous-bilateral TKA: double trouble - opposes.

In this paper, we will consider the current role of simultaneous-bilateral TKA. Based on available evidence, it is our opinion that bilateral one stage TKR is a safe and efficacious treatment for patients with severe bilateral arthritic knee disease but should be reserved for selected patients without significant medical comorbidities.

Elevated high-sensitivity C-reactive protein levels are associated with local inflammatory findings in patients with osteoarthritis.

OBJECTIVE: C-reactive protein (CRP) has been associated with disease progression in patients with osteoarthritis (OA), but the reasons for this remain unclear. We hypothesized that higher CRP would be related to local inflammatory findings in the joints of patients with OA. METHODS: Plasma and synovial membrane specimens from 54 OA patients undergoing total hip or knee arthroplasty or arthroscopy were obtained. Synovial fluid was obtained from 25 of these patients. Hematoxylin and eosin stained synovial membrane sections were scored for degree of inflammatory cell infiltration. Plasma high-sensitivity CRP (hsCRP) levels, and serum and synovial fluid interleukin (IL)-6 and IL-1beta levels were measured by enzyme-linked immunosorbent assay. RESULTS: Fifty-seven percent of patients with idiopathic OA had inflammatory infiltrates within the synovial membrane. The mean hsCRP level in patients with inflammatory infiltrates was significantly higher than those without inflammation (4.7 +/- 5.0 mg/L vs 1.7 +/- 3.6 mg/L, P = 0.003). There were significant correlations between hsCRP levels and synovial fluid IL-6 (r = 0.64, P = 0.0006), degree of synovial inflammatory infiltration (r = 0.43, P = 0.002), and body mass index (r = 0.31, P = 0.02). Multivariate analysis indicated that only degree of inflammatory infiltrate was significantly associated with hsCRP level (P = 0.026). CONCLUSION: These results suggest that systemic hsCRP levels reflect synovial inflammation in OA patients, perhaps by means of synovial IL-6 production. Future studies are needed to clarify how these infiltrates and their products may contribute to disease pathogenesis.

Postoperative ileus in the lower extremity arthroplasty patient.

Postoperative ileus is a recognized complication of lower extremity surgery. In a review of 21,589 patients who underwent either total hip or total knee arthroplasty between 1988 and 1997, 0.32% developed postoperative ileus. The ileus lasted >3 days in 46% of patients. The purpose of this study was to investigate the risk factors associated with ileus during 3 days after total joint arthroplasty. The average age of the patients with prolonged ileus was 69.1 years, and 70% were male. The development of a prolonged ileus was associated significantly with younger age (P<.005) and male gender (P<.02). In total knee arthroplasty, more cases of postoperative ileus were seen in bilateral surgery. Patients who are younger, male, and undergoing bilateral total knee arthroplasty are at an increased risk of having a more prolonged postoperative ileus and should be monitored closely.

Nonpharmacologic thromboembolic prophylaxis in total knee arthroplasty.

Deep venous thrombosis is the most common complication in patients having elective total knee replacement. Pneumatic compression devices play an important role in the prophylaxis of deep venous thrombosis and effectively decrease the risk of distal deep venous thrombosis. The combination therapy with pharmacologic agents has the benefit of decreasing the rate of proximal deep venous thrombosis and therefore is recommended. In the absence of clinical data, recent in vivo flow studies suggest that calf or combined foot and calf compression are superior to foot compression alone. Epidural anesthesia in comparison with general anesthesia decreases the incidence of thromboembolic disease after total knee arthroplasty. Although hypotensive anesthesia and intraoperative heparin have been proven to substantially lower the incidence of deep venous thrombosis after total hip arthroplasty, the current literature does not support its application during the implantation of a total knee replacement. Pneumatic compression devices are an important part of deep venous thrombosis prophylaxis especially in the early postoperative period considering that pharmacologic anticoagulation is contraindicated in the first 12 hours after spinal anesthesia and in the presence of an epidural line.

Total condylar knee arthroplasty: a long-term followup.

Between July 1977 and December 1983, 80 patients underwent 120 arthroplasties using a total condylar knee prostheses. Forty-one patients (68 knees) died and 13 patients were lost to followup. Twenty-six patients with 34 total condylar replacements were available for clinical followup. During the followup, 10 knees in nine patients (8.3%) from the overall 80 patients (120 knees) underwent revision; three (four knees) for aseptic loosening, one for periprosthetic fracture, three for infection, and two patients underwent revision for pain. Three revisions (three patients) occurred in the group of 26 patients available for followup. The average age of this group of patients at followup was 78 years (range, 53-94 years). There were 10 men and 16 women. Considering the high mean age of the patients in the series and patients' overall health status, the clinical results were extremely good. Kaplan-Meier analysis showed a survivorship of 91% at 23 years followup, considering revision as an end point. Although there have been several changes in total knee replacement designs, materials, and implantation techniques, the long-term outcome of the original total condylar knee prosthesis is excellent.

Patients' expectations of knee surgery.

BACKGROUND: Patients' expectations of medical care are linked to their requests for treatment and to their assessments of outcome and satisfaction. Our goals were to measure patients" preoperative expectations of knee surgery and to develop and test patient-derived knee expectations surveys. METHODS: An initial sample of 377 patients (mean age, 54.6 18.2 years; 52% women) was enrolled in the survey-development phase. One hundred and sixty-one (43%) of these patients subsequently underwent total knee arthroplasty; seventy-five (20%), cruciate ligament repair; eighty-five (23%), meniscal surgery; and fifty-six (15%), surgery for another knee condition. Preoperatively, these patients were asked open-ended questions about their expectations of knee surgery. Their responses were grouped with use of qualitative research techniques to generate categories of expectations. Categories were transformed into specific questions and were formatted into two draft surveys, one for patients undergoing total knee arthroplasty and one for patients undergoing other surgical procedures on the knee. A second sample of 163 patients (mean age, 55.1 17.5 years; 49% women) was enrolled in the survey-testing phase, and they completed the draft surveys on two separate occasions to establish test-retest reliability. Items were selected for the final surveys if they were cited by 5% of the patients, if they represented important functional changes resulting from surgery, or if they represented potentially unrealistic expectations. All selected items fulfilled reliability criteria, defined as a kappa (or weighted kappa) value of 0.4, or were deemed to be clinically relevant by a panel of orthopaedic surgeons. RESULTS: From the survey-development phase, a total of fifty-two categories of expectations were discerned; they included both anticipated items such as pain relief and improvement in walking ability and unanticipated items such as improving psychological well-being. Expectations varied by diagnosis and patient characteristics, including functional status. Two final surveys were generated: the seventeen-item Hospital for Special Surgery Knee Replacement Expectations Survey and the twenty-item Hospital for Special Surgery Knee Surgery Expectations Survey. Each required less than five minutes to complete. CONCLUSIONS: Patients have multiple expectations of knee surgery in the areas of symptom relief and improvement of physical and psychosocial function, and these expectations vary according to the diagnosis. We developed two valid and reliable surveys that can be used preoperatively to direct patient education and shared decision-making and to provide a framework for setting reasonable goals. Reexamining patients' responses postoperatively could provide a way to assess fulfillment of expectations, which is a crucial patient-derived measure of outcome and satisfaction.

The effect of preoperative donation of autologous blood on deep-vein thrombosis after total hip arthroplasty.

We have assessed the effect of the donation of autologous blood and the preoperative level of haemoglobin on the prevalence of postoperative thromboembolism in 2043 patients who had a total hip arthroplasty. The level of haemoglobin was determined seven to ten days before surgery and all patients had venography of the operated leg on the fifth postoperative day. The number of patients who had donated autologous blood (1037) was similar to that who had not (1006). A significant decrease in the incidence of deep-vein thrombosis (DVT) was noted in those who had donated blood preoperatively (9.0%) compared with those who had not (13.5%) (p = 0.003). For all patients, the lower the preoperative level of haemoglobin the less likely it was that a postoperative DVT would develop. Of those who had donated blood, 0.3% developed a postoperative pulmonary embolism compared with 0.7% in those who had not, but this difference was not statistically significant. No significant difference was found in the requirements for transfusion between the two groups.

Failure of bipolar hemiarthroplasty: a retrospective review of 31 consecutive bipolar prostheses converted to total hip arthroplasty.

Bipolar hemiarthroplasty has been widely used for the treatment of femoral neck fractures in elderly patients. Outcome studies show excellent results with near preoperative ambulation and lasting, painless hip function. However, what has only recently been considered is that, in some cases, failure of bipolar hemiarthroplasty may be due to wear of the thin, ultra-high-molecular weight polyethylene (UHMWPE) insert between the inner and outer bearings of the prosthesis with subsequent generation of particulate debris, periprosthetic osteolysis, and stem loos ening. We reviewed 31 consecutive bipolar hemiarthroplasties converted to total hip arthroplasties by a single surgeon between 1986 and 1994. The average time to failure was 38 months. Fifty-six percent of the cases showed radiographic evidence of osteolysis around the stem. Radiographic migration of the bipolar head of more than 1 mm into the pelvis, suggestive of cartilage wear, occurred in 67% of the cases. Among the patients with radiographic osteolysis and a loose stem at the time of revision, 92% showed a characteristic histiocytic and giant cell reaction to polyethylene particles in tissue obtained during surgery. The UHMWPE liners from the retrieved outer shells showed an average wear rate of 0.7 mm per year. Recent studies comparing bipolar to unipolar hemiarthroplasty show little difference between the two with regard to morbidity, mortality, or functional outcome. In light of our findings, it might be prudent to reconsider the design and indications for bipolar hemiarthroplasty.

Dislodgment of polyethylene liners in first and second-generation Harris-Galante acetabular components. A report of eighteen cases.

BACKGROUND: Dislodgment of the polyethylene liner is an increasingly common complication following total hip arthroplasty. The purposes of this study are to present the results in a series of patients with this complication and to analyze the mode of failure. METHODS: Between November 1995 and January 2001, eighteen patients who had had a total hip arthroplasty presented with dislodgment of the polyethylene liner from a Harris-Galante metal acetabular shell. The medical records, radiographs, operative notes, and retrieved components were reviewed. In addition, scanning electron microscopy was used to study the fractured surfaces in a shell that had four broken tines. RESULTS: The components had been in situ for an average of seven years (range, three to eleven years). Seventeen components were second generation, and one was first generation. Symptoms developed spontaneously in sixteen patients, during sexual intercourse in one, and following a fall on the hip in one. Radiographs showed eccentric positioning of the head in all of the hips and broken tines in six. All of the shells were well fixed. Treatment consisted of revision of the shell in four patients, exchange of the liner in four, cementation of a new liner into the shell in seven, and cementation of an all-polyethylene cup in three. The liners had severe damage of the rim. Scanning-electron microscopy of the fractured surfaces of four tines revealed a fatigue pattern. CONCLUSIONS: We believe that, as the liner wears and becomes loose because of an inadequate locking mechanism, progressive micromotion occurs and the load increases on the polyethylene rim until it deforms and/or fractures. Subsequently, nothing prevents the liner from rotating out of the shell. As this mechanism of failure appears to include fatigue failure of the locking tines and wear of the liner, this complication is likely to increase as the components age in situ.

Septic sacroiliitis with hematogenous spread to a total knee arthroplasty.

Septic sacroiliitis is an uncommon infection that comprises <2% of all nontuberculous septic arthritis and osteomyelitis. This case report describes a patient with rheumatoid arthritis who developed septic sacroiliitis that metastasized to her total knee arthroplasty.

[Prevention of thrombosis in hip prosthesis implantation]. / Thromboseprophylaxe in der Hüftendoprothetik.

Deep venous thrombosis is one of the most common perioperative complications after total hip arthroplasty. Systemic anticoagulation has been the gold standard for prophylaxis of postoperative deep venous thrombosis. There is no doubt that early mobilization and the use of pneumatic compression devices decrease the overall deep venous thrombosis rate. Single postoperative prophylaxis may decrease the overall deep venous thrombosis rate to 15-20% and the proximal deep venous thrombosis rate to approximately 7%. However,the activation of thrombogenesis is mainly an intraoperative event. The position of the extremity during the implantation of the femoral component leads to obstruction of the venous outflow. At the same time, the coagulation cascade is activated and markers of thrombogenesis in the blood are increased. By combining intraoperative (hypotensive epidural anesthesia and intraoperative heparin) and postoperative (pneumatic compression devices and aspirin) prophylaxis of deep venous thrombosis, the total deep venous thrombosis rate is reduced to less than 10% and the proximal deep venous thrombosis rate is reduced to 2%. Patients with increased risk for deep venous thrombosis should receive Coumadin or low-molecular weight heparin. In addition, hypotensive epidural anesthesia reduces the intraoperative blood loss and the need for postoperative blood transfusion.

Characteristics and natural history of transient postoperative pseudosubluxation after total hip arthroplasty.

A series of 13 total hip arthroplasties (THAs) in which immediate postoperative radiographs revealed axial subluxation were reviewed, and the timing, incidence, and subsequent natural history of this phenomenon were determined. Each patient had received perioperative epidural anesthesia and was placed in an abduction splint before transfer to the postoperative care unit. All initial radiographs were taken while the patient was still under the effect of the epidural anesthetic agent (average, 54 minutes; range, 37-80 minutes) postoperatively. In each case, radiographs taken after anesthetic recovery and without limb manipulation revealed reduced components. The balance of the postoperative care and rehabilitation was uncomplicated; patients were followed at least 36 months postoperatively, and in only 1 patient did a subsequent hip dislocation occur. Over a 6-month period, the postoperative films of all THAs were studied, and postoperative subluxation was identified in about 3% of the cases. Postoperative subluxation is likely to be noted when the radiograph is obtained within 1 hour of transfer to the postoperative care unit. It does not appear to have a dramatic effect on the rate of postoperative dislocation, however. This radiographic finding probably is due to the continued effects of regional anesthesia, and reduction occurs as muscle tone returns. If transient subluxation is identified, no change in postoperative care is necessary.

The safety and efficacy of intraoperative heparin in total hip arthroplasty.

A single dose of unfractionated heparin (15 U/kg), administered intravenously before surgery on the femur suppresses thrombogenesis during total hip replacement. Nine hundred eighty-nine patients (1021 hips) who received one dose of intraoperative heparin with hypotensive epidural anesthesia were followed up prospectively for 3 months. Asymptomatic deep vein thrombosis assessed by ultrasound in the first 198 consecutive patients showed an incidence of 7.1% (14 of 198). The incidence of clinical deep vein thrombosis in the subsequent 791 patients was 0.88% (seven of 791). Symptomatic pulmonary embolism occurred in 0.5% (five of 989). No patients died and there was one major bleeding episode. Based on this favorable experience, intraoperative heparin appears safe and efficacious as thromboembolic prophylaxis.

Rotating hinge total knee arthroplasty in severly affected knees.

A consecutive series of 24 knees in 21 patients who received a Finn rotating hinge for primary (nine knees) or revision (15 knees) total knee arthroplasty between August 1993 and January 1997 was reviewed. The average followup was 33 months (range, 21-62 months) for all patients in the study. Seventeen patients (20 knees) were followed up for more than 2 years. Twenty-four knees (21 patients) were categorized according to Knee Society scoring criteria: 37.5% (nine knees) were Category A, 25% (six knees) were Category B, and 37.5% (nine knees) were Category C. Using the Knee Society knee and function scores, clinical and radiographic results were assessed and outcome analysis was determined. The average Knee Society knee score improved from 44 points (range, 5-64 points) before surgery to 83 points (range, 45-95 points) after surgery; the average functional score according to the Knee Society system improved from 10 points (range, 0-35 points) before surgery to 45 points (range, 0-100 points) after surgery. Pain and function markedly improved after surgery. For treatment of the most severely affected knees with compromised bone and ligamentous instability, the Finn total knee replacement appears to be an acceptable option. As a rotating hinge design, the prosthesis at early followup provides excellent pain relief, restoration of walking capacity, and stabilization, without evidence of early mechanical failure.

The knee joint in rheumatoid arthritis.

Rheumatoid arthritis may present in the knee within a wide spectrum of manifestations. Disease progression, treatment protocols, surgical treatments and the possible complications of these treatments differ distinctly from those of osteoarthritis.