Dual-mobility (DM) articulations are increasingly utilized to prevent or manage hip instability after total hip arthroplasty (THA). DM cups offer enhanced stability due to the dual articulation resulting in larger jump distance and... more
Dual-mobility (DM) articulations are increasingly utilized to prevent or manage hip instability after total hip arthroplasty (THA). DM cups offer enhanced stability due to the dual articulation resulting in larger jump distance and greater range of motion before impingement. Improvement in design features and biomaterials has contributed to increased interest in dual-mobility articulations due to lower risk of complications compared to their historic rates. The incidence of implant-specific complications like intra-prosthetic dislocation (IPD) and wear has reduced with newer-generation implants. DM THAs are used in primary THA in patients with high risk for dislocation, e.g. neuromuscular disorder, femoral neck fracture, spinopelvic deformity, etc. They offer an attractive alternative option to constrained liner for treatment of hip instability in revision THA. The medium- to short-term results with DM THA have been encouraging in primary and revision THA. However, there are concerns of fretting, corrosion and long-term survivorship with DM THA. Hence, longer-term studies and surveillance are required for the safe use of DM THA in clinical practice.
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Cementless fixation in total knee arthroplasty (TKA) offers the potential for biologically active osseointegration and the potential for life-long fixation. With early cementless TKA designs, several design issues were identified related... more
Cementless fixation in total knee arthroplasty (TKA) offers the potential for biologically active osseointegration and the potential for life-long fixation. With early cementless TKA designs, several design issues were identified related to early failure, particularly with the tibial and patellar components. However, in the recent two decades, with improvements upon the early designs, particularly in porous metal technology as well as improved early biomechanical stability, interest was re-established in cementless TKA. The surgical technique for cementless TKA is more exacting than cemented technique, with an important emphasis on indications, accurate resections, and component alignment. Modern cementless TKA designs have demonstrated excellent early- and mid-term survivorship equivalent to cemented TKA. More long-term studies are needed to study this comparison. While implant cost maybe higher with cementless designs, there is emerging evidence that there may be an overall cost s...
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Dual-mobility (DM) articulations are increasingly utilized to prevent or manage hip instability after total hip arthroplasty (THA). DM cups offer enhanced stability due to the dual articulation resulting in larger jump distance and... more
Dual-mobility (DM) articulations are increasingly utilized to prevent or manage hip instability after total hip arthroplasty (THA). DM cups offer enhanced stability due to the dual articulation resulting in larger jump distance and greater range of motion before impingement. Improvement in design features and biomaterials has contributed to increased interest in dual-mobility articulations due to lower risk of complications compared to their historic rates. The incidence of implant-specific complications like intra-prosthetic dislocation (IPD) and wear has reduced with newer-generation implants. DM THAs are used in primary THA in patients with high risk for dislocation, e.g. neuromuscular disorder, femoral neck fracture, spinopelvic deformity, etc. They offer an attractive alternative option to constrained liner for treatment of hip instability in revision THA. The medium- to short-term results with DM THA have been encouraging in primary and revision THA. However, there are concerns of fretting, corrosion and long-term survivorship with DM THA. Hence, longer-term studies and surveillance are required for the safe use of DM THA in clinical practice.
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The rotating hinge prosthesis was originally used and designed as a primary total knee arthroplasty implant, but was hampered due to poor outcomes and catastrophic failures. Newer rotating hinge implants can be utilized in complex... more
The rotating hinge prosthesis was originally used and designed as a primary total knee arthroplasty implant, but was hampered due to poor outcomes and catastrophic failures. Newer rotating hinge implants can be utilized in complex revision total knee arthroplasties when appropriately indicated, but their outcome data is very difficult to interpret due to the strict and varied indications for use and subsequently small number of procedures performed. The goal of this review is to evaluate the current evidence on large cohort, rotating hinge knee prostheses used in the revision setting, in order to provide a clearer understanding of the indications, outcomes and complications. The PubMed database was utilized to search the available literature regarding "hinged knee," or "rotating hinge" devices. Exclusion criteria included papers focusing on primary arthroplasty, revision for oncologic issues, one-stage revision for infection or studies with less than fifty cases....
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Metal hypersensitivity (MHS) is a rare complication of total joint arthroplasty that has been linked to prosthetic device failure when other potential causes have been ruled out. The purpose of this review was to conduct an analysis of... more
Metal hypersensitivity (MHS) is a rare complication of total joint arthroplasty that has been linked to prosthetic device failure when other potential causes have been ruled out. The purpose of this review was to conduct an analysis of existing literature in order to get a better understanding of the pathophysiology, presentation, diagnosis, and management of MHS. It has been described as a type IV hypersensitivity reaction to the metals comprising prosthetic implants, often nickel and cobalt-chromium. Patients suffering from this condition have reported periprosthetic joint pain and swelling as well as cutaneous, eczematous dermatitis. There is no standard for diagnosis MHS, but tests such as patch testing and lymphocyte transformation testing have demonstrated utility, among others. Treatment options that have demonstrated success include administration of steroids and revision surgery, in which the existing metal implant is replaced with one of less allergenic materials. Moreover...
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➢ As of 2015, members of the “baby boomer generation” comprise 75 million people in the growing United States population. Many of these individuals will be facing the need for total hip or knee replacement. Currently, the age of onset of... more
➢ As of 2015, members of the “baby boomer generation” comprise 75 million people in the growing United States population. Many of these individuals will be facing the need for total hip or knee replacement. Currently, the age of onset of osteoarthritis continues to decrease and the need for total joint replacements continues to increase.➢ In current practice, nearly all patients undergoing joint replacement receive similar preoperative, intraoperative, and postoperative management strategies. However, wide variability in outcomes and satisfaction with total joint replacement still remain. The key to understanding the cause for such varied outcomes may lie in our understanding of the genetic basis of degenerative joint disease.➢ The future of “orthogenomic” research should be centered on clinical application focusing on early preoperative identification of at-risk patients. The goal is to establish twenty-first-century patient-specific strategies for optimizing results and expectatio...
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Introduction: Non-hinged constrained condylar components (CCK) may be used for primary TKA in presence of severe deformity, fixed contractures and ligamentous laxity. Several authors have recommended use of stem extensions to accompany... more
Introduction: Non-hinged constrained condylar components (CCK) may be used for primary TKA in presence of severe deformity, fixed contractures and ligamentous laxity. Several authors have recommended use of stem extensions to accompany CCK type of components. However, use of stem extensions in primary TKA, not only invades the medullary canal, but may also be associated with increased surgical time, implant cost, and thigh or leg pain. The purpose of this study was to assess the short-term outcomes of primary CCK knees without stem extensions and to compare this to a control group of standard posterior stabilized (PS) knees, otherwise using the same implant design. Materials and Methods: We retrospectively reviewed the clinical and radiographic data on 503 consecutive TKA9s performed by 2 arthroplasty surgeons at the same institution between 2008–2010. Surgical technique, implant type, bone-cement and cementation technique was similar. The only difference between groups was the use of CCK polyethylene insert in one group and a PS insert in the other. Knee society scores (KSS) were used to determine pain, function and ROM. Radiographic evaluation was done using the knee society9s criteria to determine implant fixation. Failure was defined as revision for any reason. Statistical analyses were performed using SPSS software. Results: There were 250 primary CCK (2–3 degrees of varus-valgus and rotational constraint) and 253 PS knees (7–8 degrees of varus-valgus and rotational constraint) with a mean follow-up of 3.1 years in the study cohort. Both groups had similar patient demographics, preoperative tibio-femoral alignment and KSS. Postoperative component alignment, tibio-femoral alignment, poly thickness, ROM, KSS, prevalence of radiolucent lines and revision rates were similar. No difference was found specifically for aseptic loosening between groups. Discussion: Use of stem extensions may not be needed despite use of CCK in primary cemented TKA.
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Flexion instability in posterior-stabilized total knee arthroplasty is a relatively uncommon but distinct problem that is often underdiagnosed and may require surgical management. This retrospective study evaluated the authors’ management... more
Flexion instability in posterior-stabilized total knee arthroplasty is a relatively uncommon but distinct problem that is often underdiagnosed and may require surgical management. This retrospective study evaluated the authors’ management strategy and assessed the results of revision surgery. The authors identified 19 knees that underwent revision for isolated flexion instability after primary posterior-stabilized total knee arthroplasty. All patients had typical symptoms and signs of flexion instability, which include diffuse pain, especially when negotiating stairs, a sense of instability without giving way, recurrent joint effusions, and diffuse periarticular tenderness. Knee Society scores were used to assess pain and function. Complete revision was performed in 11 knees, femoral revision with a thicker insert was performed in 1 knee, and isolated tibial polyethylene insert exchange was performed in 7 knees. Postoperatively, all patients reported improvement in instability sympt...
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Research Interests: Medicine, Activities of Daily Living, Prospective studies, Humans, Female, and 15 moreMale, Orthopedics, Clinical Sciences, Aged, Middle Aged, Questionnaires, Analysis of Variance, Chi Square Distribution, Pain Measurement, Biomechanical Phenomena, Postoperative Complications, Recovery of Function, Disability Evaluation, Functional independence measure, and Hip Joint
Research Interests: Biomedical Engineering, Medicine, Muscle strength, Prospective studies, Humans, and 15 moreFemale, Male, Arthroplasty, Length of Stay, Clinical Sciences, Postoperative pain, Aged, Middle Aged, Radiography, Analysis of Variance, Randomized Controlled Trial, Pain Measurement, Patella, Joint diseases, and Quadriceps Muscle
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Introduction Fixation remains a challenge in Revision TKR. Irregular and cavitary bone loss may precludeproper metaphyseal cementation and pressurization. Metaphyseal sleeves have been proposed to improve theinherent rotational stability... more
Introduction Fixation remains a challenge in Revision TKR. Irregular and cavitary bone loss may precludeproper metaphyseal cementation and pressurization. Metaphyseal sleeves have been proposed to improve theinherent rotational stability of the implant bone interface. The goal of this study was to assess the effect of the use of metaphyseal sleeves on the quality of the cement fixation achieved. Methods Fifty consecutive revision TKRs for AORI type 2 and 3 bone loss between January 2005 through January 2008 with average 2 years follow up were assessed retrospectively. Twelve patients were excluded for inadequate follow up. Nineteen patients with 26 cemented metaphyseal sleeves (15 tibiae and 11 femora) formed group 1 and 19 patients with 36 revision components (without metaphyseal sleeves) served as control (group 2). Patients were assessed clinically with knee society scores (KSS) and radiographically by quality of metaphyseal cement mantle and radiolucent lines(RLL). Groups were matched for pre-op bone loss and length of follow-up. Results The presence of uniform cement mantle was 100% in group 1as opposed to only 70% (25 out of 36) in group 2. Incidence of metaphyseal RLL was 3.8% (1 out of 26 components) in group 1; as opposed to 16.7% (6 out of 36 components) in group 2. The average postoperative knee society and function score in group 1 was 90 and 80 and in group 2 was 88 and 81 respectively at final follow-up. Conclusion Cemented metaphyseal sleeves along with press fit stems provided reproducible cement mantle with minimal radiolucencies when compared to similar cases in whom only stems were used. This minimal incidence of RLLs at 2 years possibly has potential for better survivorship over the long term.
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Research Interests:
While the clinical value of routine pathologic examination of tissues removed during orthopaedic procedures has not been determined, limited cost-effectiveness and a low prevalence of findings that alter patient management have been... more
While the clinical value of routine pathologic examination of tissues removed during orthopaedic procedures has not been determined, limited cost-effectiveness and a low prevalence of findings that alter patient management have been previously demonstrated with arthroscopy. The purpose of this study was to examine the clinical value and cost-effectiveness of routine histological examination of knee arthroscopy specimens.METHODS: Retrospective chart analysis of 3797 consecutive knee arthroscopies by two surgeons from 2004 to 2013 at three affiliated hospitals within one health-care system was undertaken. Pathology reports regarding tissue removed during partial meniscectomies and anterior cruciate ligament reconstructions were reviewed to determine if the results altered patient care. The total costs of histological examination were estimated in 2012-adjusted U.S. dollars. The cost per health effect was determined by calculating the cost per discrepant and discordant diagnosis.RESULT...
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Patient-specific instrumentation (PSI) in total knee arthroplasty (TKA) has been introduced to obtain consistent alignment, prevent instrumentation of the medullary canal and improve operating room efficiency. This article compares... more
Patient-specific instrumentation (PSI) in total knee arthroplasty (TKA) has been introduced to obtain consistent alignment, prevent instrumentation of the medullary canal and improve operating room efficiency. This article compares simultaneous bilateral TKA performed with and without the use of PSI in terms of surgical time; blood loss and transfusion requirements; length-of-stay, early thromboembolic events and complication rates. There was a trend to reduced total blood loss (as measured by drop in hemoglobin values) and lower transfusion rate after surgery. Further research in the form of high quality randomized trials and cost-benefit analyses may help in further consolidation of these findings.
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The use of tapered, fluted, modular, distally fixing stems has increased in femoral revision surgery. The goal of this retrospective study was to assess mid-term to long-term outcomes of this implant. Seventy-one hips in 70 patients with... more
The use of tapered, fluted, modular, distally fixing stems has increased in femoral revision surgery. The goal of this retrospective study was to assess mid-term to long-term outcomes of this implant. Seventy-one hips in 70 patients with a mean age of 69 years were followed for an average of 10 years. Preoperative HHS averaged 50 and improved to 87 postoperatively. Seventy-nine percent hips had Paprosky type 3A or more bone-loss. All stems osseointegrated distally (100%). Two hips subsided >5mm but achieved secondary stability. Sixty-eight percent hips had evidence of bony reconstitution and 21% demonstrated diaphyseal stress-shielding. One stem fractured near its modular junction and was revised with a mechanical failure rate of 1.4%. Distal fixation and clinical improvement were reproducibly achieved with this stem design.
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Periprosthetic distal femoral fractures can present significant reconstructive challenges when associated with poor bone stock, comminution, or component loosening. Revision arthroplasty with stemmed components or distal femoral... more
Periprosthetic distal femoral fractures can present significant reconstructive challenges when associated with poor bone stock, comminution, or component loosening. Revision arthroplasty with stemmed components or distal femoral replacement arthroplasty often becomes necessary. This retrospective study reviewed the results of femoral revision arthroplasty in 16 knees with acute, extreme distal (Su type 3), supracondylar periprosthetic fractures using cemented, midlevel constrained implants. The mean patient age was 71 years and mean follow-up was 5 years. All fractures united with mean Knee Society scores of 86 and 55, at the last follow-up. All patients returned to preinjury activity level. Complications included one valgus malunion with shortening and one reoperation for functional lateral instability. This treatment modality achieved reliable fracture union and return of function. Moreover, the final salvage option of distal femoral arthroplasty is preserved.
... 2. Ashok PW,Penney GC,Flett GM et al.An effective regi-men for early medical abortion.A report of 2000 conse-qutive cases.Hum Reprod 1998,13;2962-65. 3. Schaff EA, Eisinger SH, Stadalins LS et al. ... 5. Arun Boruah ;Early medical... more
... 2. Ashok PW,Penney GC,Flett GM et al.An effective regi-men for early medical abortion.A report of 2000 conse-qutive cases.Hum Reprod 1998,13;2962-65. 3. Schaff EA, Eisinger SH, Stadalins LS et al. ... 5. Arun Boruah ;Early medical abortion evaluation of vari-ous methods. ...
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There are limited data on the influence of a reduced tourniquet time strategy on the clinical outcome of primary total knee arthroplasty (TKA). The aim of our study was to prospectively compare clinical recovery in two groups of patients... more
There are limited data on the influence of a reduced tourniquet time strategy on the clinical outcome of primary total knee arthroplasty (TKA). The aim of our study was to prospectively compare clinical recovery in two groups of patients undergoing TKA based on differences in tourniquet strategy at the same institution. Group A (40 patients) consisted of TKAs performed by a surgeon using tourniquet from incision to arthrotomy closure, and group B (40 patients) consisted of TKAs performed by another surgeon using tourniquet only during cementation. The surgical technique, implants, perioperative management, and patient demographics were similar between groups. Average tourniquet time was significantly higher in group A (71.7 minutes) as compared with group B (36.8 minutes). The maximum hemoglobin (Hb)/hematocrit (Hct) drop was statistically higher in group B (Hb drop = 3.5 ± 0.9 g/dL; Hct drop = 11 ± 3) as compared with group A (Hb drop = 2.9 ± 0.9 g/dL; Hct drop = 9 ± 2; Hb drop p = 0.01; Hct drop p = 0.002). There were no significant differences in visual analogue scale pain scores, narcotic consumption, ability to straight leg raise during hospital stay, range of motion (ROM) at discharge, as well as isometric quadriceps strength, ROM, Short Form 36 scores, Knee Society scores at 6 weeks, 3 months, and 1 year follow-up with a similar multimodal pain management protocol. Radiographic analysis revealed no differences in cement penetration around the tibial component in any zone. Four patients developed pulmonary embolism (three in group A, one in group B) and five patients underwent manipulation under anesthesia for stiffness (four in group A, one in group B). Thus, the use of a tourniquet only during cementing in TKA increases the hemoglobin drop and does not significantly influence pain or clinical recovery with available numbers, but was associated with a lower incidence of early complications. It is a learned surgical skill which significantly reduces tourniquet time and achieves a similar quality of cementing.
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We present a case of peroneal nerve palsy which occurred 12 years after primary total knee arthroplasty as a result of extensive tibial osteolysis. The tibial osteolytic cyst extended through a cortical defect in the proximal tibia into... more
We present a case of peroneal nerve palsy which occurred 12 years after primary total knee arthroplasty as a result of extensive tibial osteolysis. The tibial osteolytic cyst extended through a cortical defect in the proximal tibia into the anterolateral compartment of the leg causing compressive neuropathy of the peroneal nerve. Imaging included radiographs, CT scan and MRI. At revision surgery, the tibial component was found loose with significant proximal tibial osteolysis. The cyst in the leg was decompressed through the cortical defect in the proximal tibia and analysis of cystic fluid revealed polyethylene debris. At 7-year follow-up after revision, the osteolytic cyst had resolved but the peroneal palsy did not recover.