A new single-incision, soft tissue sparing approach to total hip arthroplasty: a case report.

Over the past decade, the development of modified instrumentation and navigation assistance (permitting in-situ bone excision) have stimulated advances in minimally invasive total hip arthroplasty techniques. These techniques have been developed with an objective to reduce perioperative morbidity, hospitalization expenses, and total rehabilitation time. Furthermore, a concomitant increase in the promotion of these techniques by both industry and orthopaedic surgeons themselves has fueled patient demand. However, the most common minimally invasive techniques used require two incisions and either prevent or limit the surgeon's ability to directly visualize the bony structures of the hip. In this chapter, the authors present a case study that describes a single-incision, soft-tissue sparing, minimally invasive technique for total hip arthroplasty.

Efficacy of antibiotic-impregnated cement in total hip replacement.

BACKGROUND AND PURPOSE: Antibiotic-impregnated cement is used as a spacer or during re-implantation surgery for the treatment of infected total hip arthroplasties. The routine use of antibiotic-impregnated cement during primary or uninfected revision total hip arthroplasty remains controversial. With this meta-analysis of the published literature, we intended to assess efficacy and safety in the use of antibiotic-impregnated cement for uninfected arthroplasty. METHODS: Following a detailed literature search, only studies reporting on the outcome of total hip replacement performed with antibiotic cement were included. Strict inclusion criteria were used and studies lacking sufficient sample size or critical data were excluded. 19 studies reporting on 36,033 hip replacements in 35,659 patients met the initial inclusion criteria. The main aim of the meta-analysis was to determine the rate of deep infection with and without the use of antibiotic cement, and to assess the revision rate and the ultimate survivorship of arthroplasty using antibiotic cement. RESULTS: The rate of deep infection following primary total hip arthroplasty, at 1.2%, was significantly lower when antibiotic cement was used than when cement without antibiotics was used (2.3%). Similarly, the rate of deep infection following revision total hip arthroplasty when a standard combination of cement and antibiotic--or a custom-made combination of cement and antibiotic, depending on the results of culture--was used, was almost half of the rate of deep infection when no antibiotics were present in the cement. Overall, the survivorship was 98% (101 failures in 5,178 hips) for primary arthroplasty and 88% (100 failures in 855 hips) for revision arthroplasty. There were no reported adverse events or complications associated with the use of antibiotic-impregnated cement. INTERPRETATION: The use of antibiotic-impregnated cement lowered the infection rate by approximately 50% in primary hip arthroplasty. For revisions of previously infected hips, combinations or culture-dependent antibiotics lowered infection rates by approximately 40%.

Clinical experience using a minimally invasive surgical approach for total knee arthroplasty: early results of a prospective randomized study compared to a standard approach.

There has been recent attention concerning minimally invasive techniques for knee arthroplasty. It is not clear whether these complicated techniques can be reproduced across multiple centers and for all surgeons. This prospective, randomized, multicenter study was carried out to assess safety and efficacy of a minimally invasive total knee arthroplasty. The study consisted of 80 knees. There were no differences in blood loss, operative time for completion of surgery, infection, and ultimate wound healing. There were 4 knees with delayed wound healing in the minimally invasive surgical technique group versus 1 in the standard group, which did not affect outcome. Early clinical and radiographic results were also indistinguishable. At 12 weeks follow-up, there was no difference in mean Knee Society objective and functional scores. In summary, in this study, minimal incision total knee arthroplasty demonstrated no improvement over a standard approach.

Gait analysis of patients with resurfacing hip arthroplasty compared with hip osteoarthritis and standard total hip arthroplasty.

Patients with standard total hip arthroplasties may have reduced hip abduction and extension moments when compared with normal nonosteoarthritic hips. In comparison, patients after resurfacing total hip arthroplasty appear to have a near-normal gait. The authors evaluated temporal-spatial parameters, hip kinematics, and kinetics in hip resurfacing patients compared with patients with unilateral osteoarthritic hips and unilateral standard total hip arthroplasties. Patients with resurfacing walked faster (average 1.26 m/s) and were comparable with normals. There were no significant differences in hip abductor and extensor moments of patients with resurfacing compared with patients in the standard hip arthroplasty group. This study showed more normal hip kinematics and functionality in resurfacing hip arthroplasty, which may be due to the large femoral head.

Surgical treatment of osteonecrosis of the hip.

Various surgical procedures are used in patients with osteonecrosis of the hip. Patients with precollapse of the femoral head are generally treated with head-preserving procedures (core decompression, various bone grafting techniques, and osteotomies), whereas those with collapse of the femoral head and/or arthritis may require arthroplasty. The arthroplasty options available include limited femoral resurfacing arthroplasty, metal-on-metal resurfacing arthroplasty, or total hip replacement. The indications, techniques, and early outcomes of some of these procedures for treatment of osteonecrosis of the hip merit discussion.

Hip resurfacing arthroplasty.

Hip resurfacing arthroplasty is a type of hip replacement that involves capping the femoral head and preserving bone of the proximal femur. Metal-on-metal surface replacements have been manufactured since the early 1990s. Recent studies indicate excellent clinical results with low failure rates at 1- to 5-year follow-up. Although these early results are encouraging, resurfacing devices must be used with caution because less is known about their long-term safety and efficacy. The best candidates for resurfacing are patients younger than age 60 years with good bone stock. The surgical approach is similar to that for standard total hip replacements, but with slightly more dissection because the femoral head must be preserved and displaced to visualize the acetabulum. To reduce complications, resurfacing arthroplasty should be performed by surgeons who have received training specifically in this technique.

Sports activity after total hip and knee arthroplasty : specific recommendations concerning tennis.

Lower extremity total joint arthroplasties are among the most successful operations in orthopaedics. Presently, it appears that some patients wish to not only have general functions restored, but also desire the opportunity to return or continue on a high level of activity. This review summarises the literature concerning athletic activity, and tennis in particular, in relation to lower extremity total joint arthroplasties. Orthopaedic surgeons frequently recommend participation in low-impact sports such as swimming, walking, bicycling, bowling and golf. The patient's return to these recreational activities appears to be without problems. In contrast, there has been a general consensus from surgeons to avoid high-impact sports such as tennis and jogging after total joint arthroplasty, but there have been numerous studies that reported functional results being compatible with these activity levels. Conflicts emerge with some studies that describe lower survival rates for hip and knee arthroplasty in patients participating in high-impact sports. Most of these studies report that participation in sporting activities following total joint arthroplasty refers to increased polyethylene wear and debris, which could eventually result in implant failure. With recent advances in implant technology and surgical technique, the survival rates for modern prosthetic designs and patients with these high demands are promising. Various studies assessing the association between clinical outcome and participation in tennis did not demonstrate a harmful effect on implant survival rates. Although the majority of these studies do not reflect a true representation of the average patient undergoing total joint arthroplasty, more surgeons are confronted with the patients' desire to continue with sports activity. To optimise results, patients who demand higher levels of activity must be carefully selected, and must have the motivation and drive to optimise their results. In general, all patients should be encouraged to remain physically active to improve general health, maintain good bone quality, and improve implant fixation. There is still a need for prospective, randomised controlled studies concerning high activity and its impact on total joint arthroplasty.

Resurfacing hip arthroplasty: comparison of a minimally invasive versus standard approach.

UNLABELLED: Metal-on-metal total hip resurfacing recently has gained popularity as a femoral-bone-preserving procedure. There has been a concomitant upsurge in demand by patients and the surgical community for the use of minimally invasive techniques for hip arthroplasty procedures. The fundamental questions are whether these techniques can lead to better short-term outcomes without leading to increased operative times, blood loss, transfusion requirements, length of stay, and clinical and/or radiographic complications. We compared a group of 25 patients (25 hips) in whom resurfacing with a minimally invasive approach was done, with a cohort of 25 patients (25 hips) who had resurfacing using a standard procedure. Patients were followed up for a mean of 19 months (range, 17-22 months). The minimally invasive group had less intraoperative blood loss (566 mL in the minimally invasive group versus 683 mL), and better 3-month Harris hip scores (78 versus 70 points). At latest followup, there were no differences in clinical (mean Harris hip scores 95 and 93 points, respectively) or radiographic outcomes. This minimally invasive approach may be a reasonable option for joint resurfacing. LEVEL OF EVIDENCE: Prognostic study, Level II (retrospective comparison study). See the Guidelines for Authors for a complete description of levels of evidence.

The appropriate use of patellofemoral arthroplasty: an analysis of reported indications, contraindications, and failures.

UNLABELLED: Patellofemoral arthroplasty is going through a recent resurgence in interest with various new designs being introduced for general orthopaedic use. With this renewed enthusiasm for the procedure, it is important to understand the various indications and contraindications for using patellofemoral arthroplasty devices with the expectation that proper patient selection will improve outcome. Our purpose was to analyze the appropriate usage of these prostheses based on published historical results. A literature search was done to review the indications, contraindications, and factors contributing to the failure of these devices. We analyzed 12 studies reporting results of patellofemoral arthroplasty between 1979 and 2005. Commonly cited contraindications for using these devices have been tibiofemoral arthritis, uncorrected patellofemoral or tibiofemoral malalignment, and inflammatory arthritis. The highest failure rates were in patients with progression of osteoarthritis in other compartments or persistence of congenital or surgically uncorrected malalignment. In analyzing the reasons for failures in these reports together with issues already known to affect total knee arthroplasty surgery, we suggest an expanded list of outcome-altering factors to consider when choosing to do a patellofemoral arthroplasty. Finally, based on these observations and our own experience, suggestions on the best approach to the patient with patellofemoral arthritis are made to avoid less than optimal results if patellofemoral arthroplasty is considered. LEVEL OF EVIDENCE: Prognostic Study, Level II-3 (systematic review of Level-II studies. See the Guidelines for Authors for a complete description of levels of evidence.

Use of constrained acetabular liners in total hip arthroplasty.

The use of constrained acetabular liners is indicated when soft-tissue tensioning techniques such as femoral neck lengthening, component repositioning, and use of lateralized acetabular liner are ineffective. It is most commonly used as a salvage procedure in revision situations. However, a locking acetabular insert may be used for primary THAs in patients with joint or soft-tissue laxity, neuromuscular disease, or intraoperative instability. In addition to the described commercially available liners, several manufacturers will provide customized components on request.

Reductions in blood loss with use of a bipolar sealer for hemostasis in primary total knee arthroplasty.

Fifty primary total knee arthroplasties were performed in a prospective, randomized study comparing the use of a bipolar sealer device versus conventional electrocautery as the method of hemostasis. Both cohorts were evaluated for intraoperative blood loss, transfusion rate, postoperative drainage, hemoglobin levels, and Knee Society scores. A significant reduction in postoperative and total blood loss was found (p = 0.05 and p = 0.02, respectively), as well as an absence of tissue charring and smoke production in the bipolar sealer group. No difference in knee scores was found between both cohorts. These results suggest that use of this bipolar sealing device is at least as effective as standard cautery devices and can reduce blood loss, tissue damage, and smoke production in total knee arthroplasties without affecting the results.

Core decompression of the femoral head for osteonecrosis using percutaneous multiple small-diameter drilling.

Osteonecrosis is a disease with a wide ranging etiology and poorly understood pathogenesis seen commonly in young patients. Core decompression has historically been used in patients with small-sized or medium-sized precollapse lesions in an attempt to forestall disease progression. Typically, an 8-10 mm wide cannula trephine is used to do this procedure. The authors report on a new technique using multiple small drillings with a 3-mm Steinman pin to effectuate the core decompression. In this report, there were 32 of 45 hips (71%; 35 patients) with a successful clinical result at a mean followup of 2 years (range, 20-39 months). Twenty four of 30 Stage I hips (80%; 23 patients) had successful outcomes compared with 8 of 15 Stage II hips (57%; 12 patients) with no surgical complications occurring with this technique. This procedure is technically straightforward and led to minimal morbidity with no surgical complications. It may be effective in delaying the need for total hip arthroplasty in young patients with early (precollapse) stages of femoral head osteonecrosis.

The diagnosis and treatment of nontraumatic osteonecrosis of the femoral head.

Osteonecrosis of the femoral head is a potentially debilitating disease that frequently affects young patients in the third through fifth decades of life. If untreated, this disease will result in total destruction of the hip joint; therefore, early diagnosis and intervention are essential to optimize outcome. Although the etiology of osteonecrosis of the femoral head is poorly understood, awareness of well-established risk factors and associated disorders can assist in early detection and possible prevention of hip joint destruction. All patients with symptomatic hip disease should undergo standard radiographic evaluation; however, MRI remains the most sensitive diagnostic modality. Depending on the stage of the disease, options for treatment range from minimally invasive procedures such as core decompression to total joint arthroplasty.

Use of cancellous bone chips and demineralized bone matrix in the treatment of acetabular osteolysis: preliminary 2-year follow-up.

Twenty patients (20 hips) who had cementless acetabular revision arthroplasty and were treated with cancellous bone chips mixed with demineralized bone matrix to fill the cavitary defects were studied. At 2-years' follow-up, the grafts were fully incorporated in 18 patients. In addition, the mean Harris Hip Score increased to 89 points from a mean preoperative score of 29 points for the surviving hips. These preliminary findings suggest that the prepackaged demineralized bone matrix and cancellous chips can provide acceptable radiographic and clinical results as an adjunct in the treatment of contained osteolytic acetabular defects.

Minimally invasive total knee arthroplasty.

Currently, minimally invasive total knee arthroplasty is defined as an incision length of < 14 cm. However, the length of the incision is not the primary influence on potential postoperative benefits to the patient and should not be the only characteristic of the minimally invasive approach for knee arthroplasty. Some other factors that should also be included in this definition are: 1. The amount of soft-tissue dissection (including muscle, ligament, and capsular damage). 2. Patellar retraction or eversion. 3. Tibiofemoral dislocation. Minimally invasive surgery should not be considered to be a cosmetic procedure but rather one that addresses patients' concerns with regard to postoperative pain and slow rehabilitation. Standard total knee arthroplasties provide pain relief, but returning to activities of daily living remains a challenge for some individuals, who may take several weeks to recover. Several studies have demonstrated long-term success (at more than ten years) of standard total knee arthroplasties. However, many patients remain unsatisfied with the results of the surgery. In a study of functional limitations of patients with a Knee Society score of > or = 90 points after total knee arthroplasty, only 35% of patients stated that they had no limitations. This finding was highlighted in a study by Dickstein et al., in which one-third of the elderly patients who underwent knee replacement were unhappy with the outcome at six and twelve months postoperatively. Although many surgeons utilize objective functional scoring systems to evaluate outcome, it is likely that the criteria for a successful result of total knee arthroplasty differ between the patient and the surgeon. This was evident in a report by Bullens et al., who concluded that surgeons are more satisfied with the results of total knee arthroplasty than are their patients. Trousdale et al. showed that, in addition to concerns about long-term functional outcome, patients' major concerns were postoperative pain and the time required for recovery. Patients undergoing total knee arthroplasty have specific functional goals, such as climbing stairs, squatting, kneeling, and returning to some level of low-impact sports after surgery. Our clinical investigations demonstrated that the minimally invasive surgical approach reduces hospital stays, decreases postoperative pain, and decreases rehabilitation needs as well as enables patients to return to normal function more quickly. It is important for surgeons to take an evolutionary, rather than a revolutionary, approach when performing minimally invasive total knee arthroplasty. The surgeon should downsize incisions progressively to prevent severe damage to the quadriceps mechanism. Extensive open exposure, prolonged patellar eversion, and dislocation of the tibiofemoral joint should evolve into a vastus medialis muscle split with patellar subluxation, retraction but not dislocation of the patella, and avoidance of gross dislocation of the tibiofemoral joint. Developing the techniques of minimally invasive total knee arthroplasty may be difficult and time-consuming, but patient benefits and satisfaction should outweigh the extra effort required. These changes require well-designed clinical studies to further document their effectiveness.