Thirty patients with isolated patellofemoral complications after total knee arthroplasty were com... more Thirty patients with isolated patellofemoral complications after total knee arthroplasty were compared with 20 patients with well functioning total knee replacements without patellofemoral complications. The epicondylar axis and tibial tubercle were used as references on computed tomography scans to measure quantitatively rotational alignment of the femoral and tibial components. The group with patellofemoral complications had excessive combined (tibial plus femoral) internal component rotation. This excessive combined internal rotation was directly proportional to the severity of the patellofemoral complication. Small amounts of combined internal rotation (1'4") correlated with lateral tracking and patellar tilting. Moderate combined internal rotation (3"-So) correlated with patellar subluxation. Large amounts of combined internal rotational (7"-17") correlated with early patellar dislocation or late patellar prosthesis failure. The control group was in combined external rotation (10"-Oo). The direct correlation of combined (femoral and tibial) internal component rotation to the severity of the patellofemoral complication suggests that internal From the
With the increasing interest in fast recovery and outpatient joint arthroplasty, short-acting loc... more With the increasing interest in fast recovery and outpatient joint arthroplasty, short-acting local anesthetic agents and minimal narcotic use are preferred. Lidocaine is a fast-onset, short-duration local anesthetic that has been used for many years in spinal anesthesia. However, lidocaine spinal anesthesia has been reported to have a risk of transient neurologic symptoms (TNSs). The purpose of this study is to determine the safety and efficacy of single-dose lidocaine spinal anesthesia in the setting of outpatient joint arthroplasty. We performed a prospective study on 50 patients who received lidocaine spinal anesthesia in the setting of outpatient hip and knee arthroplasty. All patients received a single-shot spinal injection, with 2% isobaric lidocaine along with titrated propofol sedation. We evaluated demographic data, length of motor blockage, time to ambulation, time to discharge readiness, patient-reported symptoms of TNS. Of the 50 patients studied, 11 had total hip arthr...
ABSTRACT Extensor mechanism disruption (patellar tendon, patella, quadriceps tendon, or combinati... more ABSTRACT Extensor mechanism disruption (patellar tendon, patella, quadriceps tendon, or combination) is an uncommon but catastrophic complication in total knee arthroplasty (TKA). This paper describes a technique of reconstructing disruptions of the extensor mechanism after TKA using an extensor mechanism allograft; tibial tubercle, with attached patellar tendon with patella, and quadriceps tendon. The results of extensor mechanism allograft reconstruction in TKA are dependent on initial allograft tensioning. Loosely tensioned allografts resulted in a persistent extension lag and clinical failure. Allografts tightly tensioned in full extension resulted in restoration of active knee extension and clinical success with no significant loss of flexion. Extensor mechanism allografts are a successful treatment for extensor mechanism failure. However, the allograft must be initially tightly tensioned in full extension. Using this technique, extensor mechanism allografts provide superior functional results compared with other methods of reconstruction.
We reviewed 27 patients who underwent revision for an adverse local tissue reaction (ALTR) second... more We reviewed 27 patients who underwent revision for an adverse local tissue reaction (ALTR) secondary to corrosion at the head-neck junction in patients with a metal on polyethylene (MOP) bearing. Preoperative serum cobalt levels were elevated to a greater degree than were chromium levels in all cases, with a mean cobalt of 11.2 ppb (range, 1.1 to 49.8) and chromium of 2.2 ppb (range, 0.2 to 9.8). Patients were treated with a modular bearing exchange, including a ceramic head with a titanium sleeve in 23 of 27 cases with only one recurrence of ALTR in one of the four patients not treated with a ceramic head. The diagnosis of ALTR secondary to corrosion is associated with cobalt levels of > 1 ppb with cobalt levels consistently elevated above chromium. Retention of a well-fixed stem and modular exchange to a ceramic head leads to resolution of symptoms and decreases in metal levels.
Unicompartmental knee arthroplasty (UKA) has been done for more than 30 years with variable resul... more Unicompartmental knee arthroplasty (UKA) has been done for more than 30 years with variable results and evolving indications and techniques. It is indicated in sedentary, non-obese patients with isolated unicompartmental arthritis, mild to moderate deformity, and an intact anterior cruciate ligament. The most commonly used implants are fixed-bearing devices, which are resurfacing components on the femoral and tibial side with at least 8 mm of polyethylene on the tibial side and minimally conforming topography. The surgical technique uses an exposure similar to that of total knee arthroplasty (TKA). Recent interest in minimally invasive techniques may transform this procedure from an inpatient to an outpatient or short-stay procedure. Short-term results with respect to pain relief and function are equal to or better than those of TKA. However, with longer-term follow-up, the failure rate is higher than that of TKA. The most common mechanism of failure is component loosening and progression of disease in the unresurfaced compartment. Conversion of failed modern UKA to TKA is usually straightforward and may or may not require particulate grafting of contained defects. The results of revision of failed UKA to TKA approach the results seen after primary TKA. The indications for UKA continue to evolve, and the procedure remains a valuable option for patients with unicompartmental osteoarthritis.
The AAHKS 23rd Annual Meeting is designed to provide practicing orthopaedic surgeons with state-o... more The AAHKS 23rd Annual Meeting is designed to provide practicing orthopaedic surgeons with state-of-the-art information about the surgical applications and treatment protocols for the diagnosis and management of total hip and knee replacement, and to enhance the care of patients with arthritis and degenerative diseases. Both free paper presentations and interactive symposia will be utilized. Upon completion of this activity, participants should be able to: • Update clinical skills and basic knowledge through research findings and biomechanical studies. • Discuss the various surgical and non-surgical treatments and management of conditions related to the hip and knee joints. • Determine indications and complications in total hip and knee arthroplasty. • Critique presentations of surgical techniques and demonstrations of treatment options. • Evaluate the efficacy of new treatment options through evidence-based data.
Results: Mean postoperative tiblofemoral alignment was 6 ° valgus in all 3 groups of patients. De... more Results: Mean postoperative tiblofemoral alignment was 6 ° valgus in all 3 groups of patients. Despite similar postoperative arcs of motion in the workers' compensation group and primary osteoarthrosis control group (111 ° and 113 °, respectively) and an average of 15 ° more than the PTA group, knee scores were less in the workers' compensation group (81 compared to 93 and 88) because of significant deductions for pain. Function scores were also significantly less (64 compared to 76 and 69). At most recent followup, there were no significant differences, between the groups, in the incidence of complete radiolucencies at component interfaces. No patients in the workers' compensation group have required revision for aseptic failure. Only 30% of workers' compensation patients returned to work. Conclusion: Workers' compensation patients have demonstrated worse results after primary TKA compared to matched controls, despite comparable objective clinical findings such as alignment, arc of motion, and stability. Subjective complaints, such as pain and functional limitations, may compromise the results in this group of patients. Therefore, physician and patient expectations may be different for patients with workers' compensation claims than those for the general population.
We evaluated the performance of a contemporary cementless acetabular component at a minimum of 5 ... more We evaluated the performance of a contemporary cementless acetabular component at a minimum of 5 years postoperatively. One hundred eighty-seven consecutive acetabular component revisions were performed using a hemispherical porous-coated component. Patients were followed prospectively with radiographs and Harris hip scores. Twenty patients died, leaving 158 patients (166 hips) available for follow-up at a mean of 91 months. No patients were lost. Eleven acetabular components (7%) required repeated revision, including 4 (2%) for aseptic loosening. Seven of the 145 unrevised acetabular components with radiographic follow-up (5%) were loose. The results of acetabular revision with this contemporary acetabular component were good but inferior to those of earlier-generation implants. This difference is likely multifactorial.
Fifty-five consecutive revision total hip arthroplasties (THAs) in 51 patients in which a constra... more Fifty-five consecutive revision total hip arthroplasties (THAs) in 51 patients in which a constrained acetabular liner was used (Duraloc Constrained Liner, DePuy, Warsaw, Ind) were reviewed. In these revisions, 41 constrained liners were placed for recurrent instability and 14 for inadequate stability at the time of revision THA. The mean age of the cohort was 62 years, and 38 of the hips were in female patients (69%). At a minimum of 2 years, 9 of the 55 hips (16%) dislocated. Of these 9 dislocations, 8 occurred in patients who had undergone revision to a constrained liner for recurrent instability without femoral or acetabular component revision. Revision THA for recurrent instability by placing a constrained liner without optimizing other aspects of the reconstruction leads to a high rate of recurrent failure.
The goal of this study is to evaluate the efficacy of using an extended trochanteric osteotomy (E... more The goal of this study is to evaluate the efficacy of using an extended trochanteric osteotomy (ETO) as part of a 2-stage exchange procedure for prosthetic hip infections. Twenty-three consecutive infected total hip arthroplasties in which an ETO was used as part of a 2-stage exchange procedure were retrospectively reviewed. An ETO was used when the femoral component could not be extracted using standard techniques. Clinical and radiographic parameters were evaluated at an average of 49 months of follow-up. Postoperatively, 20 of 23 (87%) patients had resolution of their infection, with healing of the ETO in 22 of 23 patients at a mean of 11.5 weeks. Preoperative modified D'Aubigne and Postel score means of 2.4 for pain and 2.6 for walking ability significantly improved (P b .001) to 5.3 and 4.9. Use of an ETO as part of a 2-stage exchange arthroplasty can be performed safely and effectively in appropriately selected cases.
One hundred five consecutive painful knee arthroplasties were evaluated by a single surgeon for t... more One hundred five consecutive painful knee arthroplasties were evaluated by a single surgeon for the presence of infection using a uniform protocol that included an erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), perioperative aspiration with synovial fluid white blood cell (WBC) count and differential, intraoperative frozen section analysis, and culture. A synovial fluid WBC count of greater than 3000 was the most precise test with a sensitivity of 100%, specificity of 98%, and accuracy of 99%. The preoperative use of an ESR and CRP proved to be an excellent screening modality with only one infection identified with both values being normal. A rational approach to perioperative testing for sepsis includes a screening ESR and CRP, and if elevated, aspiration with synovial fluid WBC count or an intraoperative frozen section.
Eighty-five fixed bearing medial unicompartmental arthroplasties were performed in 42 men and 33 ... more Eighty-five fixed bearing medial unicompartmental arthroplasties were performed in 42 men and 33 women with a mean age of 49 years (range, thirty-three to fifty-five years old) at the time of surgery. At a mean of 4.0 years (range two to twelve years), the mean pre-operative Knee Society score improved from 49 to 95.1 points (Pb0.0001) and the mean UCLA activity score was 7.5 (range 5 to 9). Three knees underwent revision to a total knee arthroplasty; two for arthritic progression in the lateral compartment and one for pain. At the time of final follow-up, two knees (2.4%) demonstrated progressive Grade 4 arthritis of the patellofemoral compartment but were asymptomatic. There was no radiographic evidence of loosening, osteolysis, or premature polyethylene wear. Estimated survivorship was 96.5% at 10 years. UKA offered excellent early outcomes in this cohort of younger, active patients.
Periprosthetic femur fractures after total hip arthroplasty are a growing concern as their preval... more Periprosthetic femur fractures after total hip arthroplasty are a growing concern as their prevalence is expected to rise. A retrospective review was performed of all patients undergoing revision total hip arthroplasty with an extended trochanteric osteotomy (ETO) for treatment of a Vancouver B2/B3 fracture at our institution. Fourteen patients were identified having a minimum of 2-year follow-up. Clinical and radiographic evaluation was performed for all patients. At a mean 44.5 months of follow-up, mean modified D'Aubigne and Postel scores were 8.6. In all cases the ETO and fracture healed with radiographic evidence of osseointegration of the femoral component. Use of an ETO for the treatment of periprosthetic femur fractures provides excellent exposure, facilitates component implantation, and is compatible with fracture healing and good short-term clinical results.
Clinical Orthopaedics & Related Research, 2010
Background A third-generation TKA system was designed to address problems encountered with earlie... more Background A third-generation TKA system was designed to address problems encountered with earlier designs including a high rate of patellofemoral complications. At a minimum of 5 years, we previously reported survivorship of 98.7% using revision for any reason as the endpoint for a cohort that includes the patients described in this report. That cohort was unique in that a tibial component that uses four short pegs for fixation was used in a subset of patients undergoing cruciate-retaining TKA and the tibial and femoral components were precoated with polymethylmethacrylate. Questions/purposes We now report the survival rate, postoperative function, complications, radiographic loosening, and osteolysis at a minimum of 10 years postoperatively. Patients and Methods We retrospectively reviewed 161 patients who underwent 179 TKAs. The patella was resurfaced in all cases and all components were cemented. Patients were evaluated clinically and radiographically for evidence of component loosening and osteolysis. Forty of the 161 patients (with 44 TKAs) had died and eight patients (nine knees) were lost to followup. For the remaining 113 patients (126 knees), the minimum followup was 10 years (mean, 11.7 years; range, 10.0-13.9 years). Results Survivorship at a minimum of 10 years postoperatively using revision for any reason and revision for aseptic loosening were 97.7% and 100%, respectively. Three knees were revised: one for infection, one for periprosthetic fracture, and one for postoperative arthrofibrosis. There were no reoperations for patellar component maltracking, wear or loosening, tibiofemoral polyethylene wear, osteolysis, or aseptic loosening. Hospital for Special Surgery scores improved from a mean of 47.7 (range, 23-78) preoperatively to 85.4 (range, 33-100). Conclusions This cruciate-retaining design had a low risk of implant failure or revision and the design changes eliminated the patellar failures seen with earlier iterations at up to 10 years. Level of Evidence Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Advancements in the surgical approach, anesthetic technique, and the initiation of rapid rehabili... more Advancements in the surgical approach, anesthetic technique, and the initiation of rapid rehabilitation protocols have decreased the duration of hospitalization and subsequent length of recovery following elective total hip arthroplasty. We assessed the feasibility and safety of outpatient total hip arthroplasty in 150 consectutive patients. A comprehensive perioperative anesthesia and rehabilitation protocol including preoperative teaching, regional anesthesia, and preemptive oral analgesia and antiemetic therapy was implemented around a minimally invasive surgical technique. A rapid rehabilitation pathway was started immediately after surgery and patients had the option of being discharged to home the day of surgery if standard discharge criteria were met. All 150 patients were discharged to home the day of surgery, at which time 131 patients were able to walk without assistive devices. Thirty-eight patients required some additional intervention outside the pathway to resolve nausea, hypotension, or sedation prior to discharge. There were no readmissions for pain, nausea, or hypotension yet there was one readmission for fracture and nine emergency room evaluations in the three month perioperative period. This anesthetic and rehabilitation protocol allowed outpatient total hip arthroplasty to be routinely performed in these consectutive patients undergoing primary total hip arthroplasty. With current reimbursement approaches the modest savings to the hospital in length of stay may be outweighed by the additional costs of personnel, thereby making this outpatient system more expensive to implement. Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
The duration of hospitalization and subsequent length of recovery after elective knee arthroplast... more The duration of hospitalization and subsequent length of recovery after elective knee arthroplasty have decreased. We hypothesized same-day discharge following either a unicompartmental (UKA) or total knee arthroplasty (TKA) in an unselected group of patients would not result in a higher perioperative complication rate than standardlength hospitalization when following a comprehensive perioperative clinical pathway, including preoperative teaching, regional anesthesia, preemptive oral analgesia, preemptive antiemetics, and a rapid rehabilitation protocol. We prospectively followed 111 of all 121 patients who had primary knee arthroplasty completed by noon and who agreed to be followed prospectively; 25 had UKA and 86 TKA. Of the 111 patients, 104 (94%, 24 with UKA and 80 with TKA) met discharge criteria and were discharged directly to home the day of surgery. Nausea requiring additional treatment before discharge was the most common reason for a delay in discharge. There were four (3.6%) readmissions (all with TKA) and one emergency room visit without readmission (in a patient with a TKA) within the first week after surgery, while there were four subsequent readmissions (3.6%) and one additional emergency room visit without readmission within three months of surgery, all among patients undergoing TKA. There were no deaths, cardiac events, or pulmonary complications during this study. Outpatient knee arthroplasty surgery is feasible in a large percentage of patients yet early readmissions may be decreased with a prolonged hospitalization. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Background Diagnosis of periprosthetic joint infection (PJI) can be difficult in the early postop... more Background Diagnosis of periprosthetic joint infection (PJI) can be difficult in the early postoperative period after total hip arthroplasty (THA) because normal cues from the physical examination often are unreliable, and serological markers commonly used for diagnosis are elevated from the recent surgery. Questions/purposes The purposes of this study were to determine the optimal cutoff values for erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), synovial fluid white blood cell (WBC) count, and differential for diagnosing PJI in the early postoperative period after primary THA. Methods We reviewed 6033 consecutive primary THAs and identified 73 patients (1.2%) who underwent reoperation for any reason within the first 6 weeks postoperatively. Thirty-six of these patients were infected according to modified Musculoskeletal Infection Society criteria. Mean values for the diagnostic tests were compared between groups and receiver operating characteristic curves generated along with an area under the curve (AUC) to determine test performance and optimal cutoff values to diagnose infection. Results The best test for the diagnosis of PJI was the synovial fluid WBC count (AUC = 98%; optimal cutoff value 12,800 cells/lL) followed by the CRP (AUC = 93%; optimal cutoff value 93 mg/L), and synovial fluid differential (AUC = 91%; optimal cutoff value 89% PMN). The mean ESR (infected = 69 mm/hr, not infected = 46 mm/hr), CRP (infected = 192 mg/L, not infected = 30 mg/L), synovial fluid WBC count (infected = 84,954 cells/lL, not infected = 2391 cells/lL), and differential (infected = 91% polymorphonuclear cells [PMN], not infected = 63% PMN) all were significantly higher in the infected group. Conclusions Optimal cutoff values for the diagnosis of PJI in the acute postoperative period were higher than those traditionally used for the diagnosis of chronic PJI. The serum CRP is an excellent screening test, whereas the synovial fluid WBC count is more specific. Level of Evidence Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
Journal of the American Academy of Orthopaedic Surgeons, 2003
Once used routinely, trochanteric osteotomy in total hip arthroplasty now is usually limited to d... more Once used routinely, trochanteric osteotomy in total hip arthroplasty now is usually limited to difficult primary and revision cases. There are three types: the standard trochanteric osteotomy and its variations, the trochanteric slide, and the extended trochanteric osteotomy. Each has unique indications, fixation techniques, and complications. Primary total hip arthroplasty procedures requiring the enhanced exposure provided by trochanteric osteotomy may be needed in patients with hip ankylosis or fusion, protrusio acetabuli, proximal femoral deformities, developmental dysplasia, or abductor muscle laxity. Trochanteric osteotomies in revision arthroplasties, primarily the extended trochanteric osteotomy, facilitate the removal of well-fixed femoral components, provide direct access to the diaphysis for distal fixation, and enhance acetabular exposure.
Early wound healing complications and persistent drainage are associated with an increased risk o... more Early wound healing complications and persistent drainage are associated with an increased risk of infection following knee arthroplasty. However, the scenario in which a patient sustains an acute, traumatic wound dehiscence has not been investigated. The purpose of this study is to determine the outcomes of an acute traumatic wound dehiscence following arthroplasty treated with an urgent irrigation and debridement and primary wound closure. Using a single institution's arthroplasty registry, patients sustaining an acute, traumatic wound dehiscence within 30 days of undergoing a primary knee arthroplasty were identified. Patients experiencing chronic wound drainage without injury or a history of prior infection were excluded. Patients were followed for the occurrence of complications and clinical outcomes using the Knee Society Score. From 2006 to 2016, 14 of 25,819 eligible patients (0.05%) were identified as having a traumatic wound dehiscence. The mean time from arthroplasty ...
The goal of this study is to evaluate the efficacy of using an extended trochanteric osteotomy (E... more The goal of this study is to evaluate the efficacy of using an extended trochanteric osteotomy (ETO) as part of a 2-stage exchange procedure for prosthetic hip infections. Twenty-three consecutive infected total hip arthroplasties in which an ETO was used as part of a 2-stage exchange procedure were retrospectively reviewed. An ETO was used when the femoral component could not be extracted using standard techniques. Clinical and radiographic parameters were evaluated at an average of 49 months of follow-up. Postoperatively, 20 of 23 (87%) patients had resolution of their infection, with healing of the ETO in 22 of 23 patients at a mean of 11.5 weeks. Preoperative modified D'Aubigne and Postel score means of 2.4 for pain and 2.6 for walking ability significantly improved (P b .001) to 5.3 and 4.9. Use of an ETO as part of a 2-stage exchange arthroplasty can be performed safely and effectively in appropriately selected cases. Key words: prosthetic infection, extended trochanteric osteotomy.
Thirty patients with isolated patellofemoral complications after total knee arthroplasty were com... more Thirty patients with isolated patellofemoral complications after total knee arthroplasty were compared with 20 patients with well functioning total knee replacements without patellofemoral complications. The epicondylar axis and tibial tubercle were used as references on computed tomography scans to measure quantitatively rotational alignment of the femoral and tibial components. The group with patellofemoral complications had excessive combined (tibial plus femoral) internal component rotation. This excessive combined internal rotation was directly proportional to the severity of the patellofemoral complication. Small amounts of combined internal rotation (1'4") correlated with lateral tracking and patellar tilting. Moderate combined internal rotation (3"-So) correlated with patellar subluxation. Large amounts of combined internal rotational (7"-17") correlated with early patellar dislocation or late patellar prosthesis failure. The control group was in combined external rotation (10"-Oo). The direct correlation of combined (femoral and tibial) internal component rotation to the severity of the patellofemoral complication suggests that internal From the
With the increasing interest in fast recovery and outpatient joint arthroplasty, short-acting loc... more With the increasing interest in fast recovery and outpatient joint arthroplasty, short-acting local anesthetic agents and minimal narcotic use are preferred. Lidocaine is a fast-onset, short-duration local anesthetic that has been used for many years in spinal anesthesia. However, lidocaine spinal anesthesia has been reported to have a risk of transient neurologic symptoms (TNSs). The purpose of this study is to determine the safety and efficacy of single-dose lidocaine spinal anesthesia in the setting of outpatient joint arthroplasty. We performed a prospective study on 50 patients who received lidocaine spinal anesthesia in the setting of outpatient hip and knee arthroplasty. All patients received a single-shot spinal injection, with 2% isobaric lidocaine along with titrated propofol sedation. We evaluated demographic data, length of motor blockage, time to ambulation, time to discharge readiness, patient-reported symptoms of TNS. Of the 50 patients studied, 11 had total hip arthr...
ABSTRACT Extensor mechanism disruption (patellar tendon, patella, quadriceps tendon, or combinati... more ABSTRACT Extensor mechanism disruption (patellar tendon, patella, quadriceps tendon, or combination) is an uncommon but catastrophic complication in total knee arthroplasty (TKA). This paper describes a technique of reconstructing disruptions of the extensor mechanism after TKA using an extensor mechanism allograft; tibial tubercle, with attached patellar tendon with patella, and quadriceps tendon. The results of extensor mechanism allograft reconstruction in TKA are dependent on initial allograft tensioning. Loosely tensioned allografts resulted in a persistent extension lag and clinical failure. Allografts tightly tensioned in full extension resulted in restoration of active knee extension and clinical success with no significant loss of flexion. Extensor mechanism allografts are a successful treatment for extensor mechanism failure. However, the allograft must be initially tightly tensioned in full extension. Using this technique, extensor mechanism allografts provide superior functional results compared with other methods of reconstruction.
We reviewed 27 patients who underwent revision for an adverse local tissue reaction (ALTR) second... more We reviewed 27 patients who underwent revision for an adverse local tissue reaction (ALTR) secondary to corrosion at the head-neck junction in patients with a metal on polyethylene (MOP) bearing. Preoperative serum cobalt levels were elevated to a greater degree than were chromium levels in all cases, with a mean cobalt of 11.2 ppb (range, 1.1 to 49.8) and chromium of 2.2 ppb (range, 0.2 to 9.8). Patients were treated with a modular bearing exchange, including a ceramic head with a titanium sleeve in 23 of 27 cases with only one recurrence of ALTR in one of the four patients not treated with a ceramic head. The diagnosis of ALTR secondary to corrosion is associated with cobalt levels of > 1 ppb with cobalt levels consistently elevated above chromium. Retention of a well-fixed stem and modular exchange to a ceramic head leads to resolution of symptoms and decreases in metal levels.
Unicompartmental knee arthroplasty (UKA) has been done for more than 30 years with variable resul... more Unicompartmental knee arthroplasty (UKA) has been done for more than 30 years with variable results and evolving indications and techniques. It is indicated in sedentary, non-obese patients with isolated unicompartmental arthritis, mild to moderate deformity, and an intact anterior cruciate ligament. The most commonly used implants are fixed-bearing devices, which are resurfacing components on the femoral and tibial side with at least 8 mm of polyethylene on the tibial side and minimally conforming topography. The surgical technique uses an exposure similar to that of total knee arthroplasty (TKA). Recent interest in minimally invasive techniques may transform this procedure from an inpatient to an outpatient or short-stay procedure. Short-term results with respect to pain relief and function are equal to or better than those of TKA. However, with longer-term follow-up, the failure rate is higher than that of TKA. The most common mechanism of failure is component loosening and progression of disease in the unresurfaced compartment. Conversion of failed modern UKA to TKA is usually straightforward and may or may not require particulate grafting of contained defects. The results of revision of failed UKA to TKA approach the results seen after primary TKA. The indications for UKA continue to evolve, and the procedure remains a valuable option for patients with unicompartmental osteoarthritis.
The AAHKS 23rd Annual Meeting is designed to provide practicing orthopaedic surgeons with state-o... more The AAHKS 23rd Annual Meeting is designed to provide practicing orthopaedic surgeons with state-of-the-art information about the surgical applications and treatment protocols for the diagnosis and management of total hip and knee replacement, and to enhance the care of patients with arthritis and degenerative diseases. Both free paper presentations and interactive symposia will be utilized. Upon completion of this activity, participants should be able to: • Update clinical skills and basic knowledge through research findings and biomechanical studies. • Discuss the various surgical and non-surgical treatments and management of conditions related to the hip and knee joints. • Determine indications and complications in total hip and knee arthroplasty. • Critique presentations of surgical techniques and demonstrations of treatment options. • Evaluate the efficacy of new treatment options through evidence-based data.
Results: Mean postoperative tiblofemoral alignment was 6 ° valgus in all 3 groups of patients. De... more Results: Mean postoperative tiblofemoral alignment was 6 ° valgus in all 3 groups of patients. Despite similar postoperative arcs of motion in the workers' compensation group and primary osteoarthrosis control group (111 ° and 113 °, respectively) and an average of 15 ° more than the PTA group, knee scores were less in the workers' compensation group (81 compared to 93 and 88) because of significant deductions for pain. Function scores were also significantly less (64 compared to 76 and 69). At most recent followup, there were no significant differences, between the groups, in the incidence of complete radiolucencies at component interfaces. No patients in the workers' compensation group have required revision for aseptic failure. Only 30% of workers' compensation patients returned to work. Conclusion: Workers' compensation patients have demonstrated worse results after primary TKA compared to matched controls, despite comparable objective clinical findings such as alignment, arc of motion, and stability. Subjective complaints, such as pain and functional limitations, may compromise the results in this group of patients. Therefore, physician and patient expectations may be different for patients with workers' compensation claims than those for the general population.
We evaluated the performance of a contemporary cementless acetabular component at a minimum of 5 ... more We evaluated the performance of a contemporary cementless acetabular component at a minimum of 5 years postoperatively. One hundred eighty-seven consecutive acetabular component revisions were performed using a hemispherical porous-coated component. Patients were followed prospectively with radiographs and Harris hip scores. Twenty patients died, leaving 158 patients (166 hips) available for follow-up at a mean of 91 months. No patients were lost. Eleven acetabular components (7%) required repeated revision, including 4 (2%) for aseptic loosening. Seven of the 145 unrevised acetabular components with radiographic follow-up (5%) were loose. The results of acetabular revision with this contemporary acetabular component were good but inferior to those of earlier-generation implants. This difference is likely multifactorial.
Fifty-five consecutive revision total hip arthroplasties (THAs) in 51 patients in which a constra... more Fifty-five consecutive revision total hip arthroplasties (THAs) in 51 patients in which a constrained acetabular liner was used (Duraloc Constrained Liner, DePuy, Warsaw, Ind) were reviewed. In these revisions, 41 constrained liners were placed for recurrent instability and 14 for inadequate stability at the time of revision THA. The mean age of the cohort was 62 years, and 38 of the hips were in female patients (69%). At a minimum of 2 years, 9 of the 55 hips (16%) dislocated. Of these 9 dislocations, 8 occurred in patients who had undergone revision to a constrained liner for recurrent instability without femoral or acetabular component revision. Revision THA for recurrent instability by placing a constrained liner without optimizing other aspects of the reconstruction leads to a high rate of recurrent failure.
The goal of this study is to evaluate the efficacy of using an extended trochanteric osteotomy (E... more The goal of this study is to evaluate the efficacy of using an extended trochanteric osteotomy (ETO) as part of a 2-stage exchange procedure for prosthetic hip infections. Twenty-three consecutive infected total hip arthroplasties in which an ETO was used as part of a 2-stage exchange procedure were retrospectively reviewed. An ETO was used when the femoral component could not be extracted using standard techniques. Clinical and radiographic parameters were evaluated at an average of 49 months of follow-up. Postoperatively, 20 of 23 (87%) patients had resolution of their infection, with healing of the ETO in 22 of 23 patients at a mean of 11.5 weeks. Preoperative modified D'Aubigne and Postel score means of 2.4 for pain and 2.6 for walking ability significantly improved (P b .001) to 5.3 and 4.9. Use of an ETO as part of a 2-stage exchange arthroplasty can be performed safely and effectively in appropriately selected cases.
One hundred five consecutive painful knee arthroplasties were evaluated by a single surgeon for t... more One hundred five consecutive painful knee arthroplasties were evaluated by a single surgeon for the presence of infection using a uniform protocol that included an erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), perioperative aspiration with synovial fluid white blood cell (WBC) count and differential, intraoperative frozen section analysis, and culture. A synovial fluid WBC count of greater than 3000 was the most precise test with a sensitivity of 100%, specificity of 98%, and accuracy of 99%. The preoperative use of an ESR and CRP proved to be an excellent screening modality with only one infection identified with both values being normal. A rational approach to perioperative testing for sepsis includes a screening ESR and CRP, and if elevated, aspiration with synovial fluid WBC count or an intraoperative frozen section.
Eighty-five fixed bearing medial unicompartmental arthroplasties were performed in 42 men and 33 ... more Eighty-five fixed bearing medial unicompartmental arthroplasties were performed in 42 men and 33 women with a mean age of 49 years (range, thirty-three to fifty-five years old) at the time of surgery. At a mean of 4.0 years (range two to twelve years), the mean pre-operative Knee Society score improved from 49 to 95.1 points (Pb0.0001) and the mean UCLA activity score was 7.5 (range 5 to 9). Three knees underwent revision to a total knee arthroplasty; two for arthritic progression in the lateral compartment and one for pain. At the time of final follow-up, two knees (2.4%) demonstrated progressive Grade 4 arthritis of the patellofemoral compartment but were asymptomatic. There was no radiographic evidence of loosening, osteolysis, or premature polyethylene wear. Estimated survivorship was 96.5% at 10 years. UKA offered excellent early outcomes in this cohort of younger, active patients.
Periprosthetic femur fractures after total hip arthroplasty are a growing concern as their preval... more Periprosthetic femur fractures after total hip arthroplasty are a growing concern as their prevalence is expected to rise. A retrospective review was performed of all patients undergoing revision total hip arthroplasty with an extended trochanteric osteotomy (ETO) for treatment of a Vancouver B2/B3 fracture at our institution. Fourteen patients were identified having a minimum of 2-year follow-up. Clinical and radiographic evaluation was performed for all patients. At a mean 44.5 months of follow-up, mean modified D'Aubigne and Postel scores were 8.6. In all cases the ETO and fracture healed with radiographic evidence of osseointegration of the femoral component. Use of an ETO for the treatment of periprosthetic femur fractures provides excellent exposure, facilitates component implantation, and is compatible with fracture healing and good short-term clinical results.
Clinical Orthopaedics & Related Research, 2010
Background A third-generation TKA system was designed to address problems encountered with earlie... more Background A third-generation TKA system was designed to address problems encountered with earlier designs including a high rate of patellofemoral complications. At a minimum of 5 years, we previously reported survivorship of 98.7% using revision for any reason as the endpoint for a cohort that includes the patients described in this report. That cohort was unique in that a tibial component that uses four short pegs for fixation was used in a subset of patients undergoing cruciate-retaining TKA and the tibial and femoral components were precoated with polymethylmethacrylate. Questions/purposes We now report the survival rate, postoperative function, complications, radiographic loosening, and osteolysis at a minimum of 10 years postoperatively. Patients and Methods We retrospectively reviewed 161 patients who underwent 179 TKAs. The patella was resurfaced in all cases and all components were cemented. Patients were evaluated clinically and radiographically for evidence of component loosening and osteolysis. Forty of the 161 patients (with 44 TKAs) had died and eight patients (nine knees) were lost to followup. For the remaining 113 patients (126 knees), the minimum followup was 10 years (mean, 11.7 years; range, 10.0-13.9 years). Results Survivorship at a minimum of 10 years postoperatively using revision for any reason and revision for aseptic loosening were 97.7% and 100%, respectively. Three knees were revised: one for infection, one for periprosthetic fracture, and one for postoperative arthrofibrosis. There were no reoperations for patellar component maltracking, wear or loosening, tibiofemoral polyethylene wear, osteolysis, or aseptic loosening. Hospital for Special Surgery scores improved from a mean of 47.7 (range, 23-78) preoperatively to 85.4 (range, 33-100). Conclusions This cruciate-retaining design had a low risk of implant failure or revision and the design changes eliminated the patellar failures seen with earlier iterations at up to 10 years. Level of Evidence Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Advancements in the surgical approach, anesthetic technique, and the initiation of rapid rehabili... more Advancements in the surgical approach, anesthetic technique, and the initiation of rapid rehabilitation protocols have decreased the duration of hospitalization and subsequent length of recovery following elective total hip arthroplasty. We assessed the feasibility and safety of outpatient total hip arthroplasty in 150 consectutive patients. A comprehensive perioperative anesthesia and rehabilitation protocol including preoperative teaching, regional anesthesia, and preemptive oral analgesia and antiemetic therapy was implemented around a minimally invasive surgical technique. A rapid rehabilitation pathway was started immediately after surgery and patients had the option of being discharged to home the day of surgery if standard discharge criteria were met. All 150 patients were discharged to home the day of surgery, at which time 131 patients were able to walk without assistive devices. Thirty-eight patients required some additional intervention outside the pathway to resolve nausea, hypotension, or sedation prior to discharge. There were no readmissions for pain, nausea, or hypotension yet there was one readmission for fracture and nine emergency room evaluations in the three month perioperative period. This anesthetic and rehabilitation protocol allowed outpatient total hip arthroplasty to be routinely performed in these consectutive patients undergoing primary total hip arthroplasty. With current reimbursement approaches the modest savings to the hospital in length of stay may be outweighed by the additional costs of personnel, thereby making this outpatient system more expensive to implement. Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
The duration of hospitalization and subsequent length of recovery after elective knee arthroplast... more The duration of hospitalization and subsequent length of recovery after elective knee arthroplasty have decreased. We hypothesized same-day discharge following either a unicompartmental (UKA) or total knee arthroplasty (TKA) in an unselected group of patients would not result in a higher perioperative complication rate than standardlength hospitalization when following a comprehensive perioperative clinical pathway, including preoperative teaching, regional anesthesia, preemptive oral analgesia, preemptive antiemetics, and a rapid rehabilitation protocol. We prospectively followed 111 of all 121 patients who had primary knee arthroplasty completed by noon and who agreed to be followed prospectively; 25 had UKA and 86 TKA. Of the 111 patients, 104 (94%, 24 with UKA and 80 with TKA) met discharge criteria and were discharged directly to home the day of surgery. Nausea requiring additional treatment before discharge was the most common reason for a delay in discharge. There were four (3.6%) readmissions (all with TKA) and one emergency room visit without readmission (in a patient with a TKA) within the first week after surgery, while there were four subsequent readmissions (3.6%) and one additional emergency room visit without readmission within three months of surgery, all among patients undergoing TKA. There were no deaths, cardiac events, or pulmonary complications during this study. Outpatient knee arthroplasty surgery is feasible in a large percentage of patients yet early readmissions may be decreased with a prolonged hospitalization. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Background Diagnosis of periprosthetic joint infection (PJI) can be difficult in the early postop... more Background Diagnosis of periprosthetic joint infection (PJI) can be difficult in the early postoperative period after total hip arthroplasty (THA) because normal cues from the physical examination often are unreliable, and serological markers commonly used for diagnosis are elevated from the recent surgery. Questions/purposes The purposes of this study were to determine the optimal cutoff values for erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), synovial fluid white blood cell (WBC) count, and differential for diagnosing PJI in the early postoperative period after primary THA. Methods We reviewed 6033 consecutive primary THAs and identified 73 patients (1.2%) who underwent reoperation for any reason within the first 6 weeks postoperatively. Thirty-six of these patients were infected according to modified Musculoskeletal Infection Society criteria. Mean values for the diagnostic tests were compared between groups and receiver operating characteristic curves generated along with an area under the curve (AUC) to determine test performance and optimal cutoff values to diagnose infection. Results The best test for the diagnosis of PJI was the synovial fluid WBC count (AUC = 98%; optimal cutoff value 12,800 cells/lL) followed by the CRP (AUC = 93%; optimal cutoff value 93 mg/L), and synovial fluid differential (AUC = 91%; optimal cutoff value 89% PMN). The mean ESR (infected = 69 mm/hr, not infected = 46 mm/hr), CRP (infected = 192 mg/L, not infected = 30 mg/L), synovial fluid WBC count (infected = 84,954 cells/lL, not infected = 2391 cells/lL), and differential (infected = 91% polymorphonuclear cells [PMN], not infected = 63% PMN) all were significantly higher in the infected group. Conclusions Optimal cutoff values for the diagnosis of PJI in the acute postoperative period were higher than those traditionally used for the diagnosis of chronic PJI. The serum CRP is an excellent screening test, whereas the synovial fluid WBC count is more specific. Level of Evidence Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
Journal of the American Academy of Orthopaedic Surgeons, 2003
Once used routinely, trochanteric osteotomy in total hip arthroplasty now is usually limited to d... more Once used routinely, trochanteric osteotomy in total hip arthroplasty now is usually limited to difficult primary and revision cases. There are three types: the standard trochanteric osteotomy and its variations, the trochanteric slide, and the extended trochanteric osteotomy. Each has unique indications, fixation techniques, and complications. Primary total hip arthroplasty procedures requiring the enhanced exposure provided by trochanteric osteotomy may be needed in patients with hip ankylosis or fusion, protrusio acetabuli, proximal femoral deformities, developmental dysplasia, or abductor muscle laxity. Trochanteric osteotomies in revision arthroplasties, primarily the extended trochanteric osteotomy, facilitate the removal of well-fixed femoral components, provide direct access to the diaphysis for distal fixation, and enhance acetabular exposure.
Early wound healing complications and persistent drainage are associated with an increased risk o... more Early wound healing complications and persistent drainage are associated with an increased risk of infection following knee arthroplasty. However, the scenario in which a patient sustains an acute, traumatic wound dehiscence has not been investigated. The purpose of this study is to determine the outcomes of an acute traumatic wound dehiscence following arthroplasty treated with an urgent irrigation and debridement and primary wound closure. Using a single institution's arthroplasty registry, patients sustaining an acute, traumatic wound dehiscence within 30 days of undergoing a primary knee arthroplasty were identified. Patients experiencing chronic wound drainage without injury or a history of prior infection were excluded. Patients were followed for the occurrence of complications and clinical outcomes using the Knee Society Score. From 2006 to 2016, 14 of 25,819 eligible patients (0.05%) were identified as having a traumatic wound dehiscence. The mean time from arthroplasty ...
The goal of this study is to evaluate the efficacy of using an extended trochanteric osteotomy (E... more The goal of this study is to evaluate the efficacy of using an extended trochanteric osteotomy (ETO) as part of a 2-stage exchange procedure for prosthetic hip infections. Twenty-three consecutive infected total hip arthroplasties in which an ETO was used as part of a 2-stage exchange procedure were retrospectively reviewed. An ETO was used when the femoral component could not be extracted using standard techniques. Clinical and radiographic parameters were evaluated at an average of 49 months of follow-up. Postoperatively, 20 of 23 (87%) patients had resolution of their infection, with healing of the ETO in 22 of 23 patients at a mean of 11.5 weeks. Preoperative modified D'Aubigne and Postel score means of 2.4 for pain and 2.6 for walking ability significantly improved (P b .001) to 5.3 and 4.9. Use of an ETO as part of a 2-stage exchange arthroplasty can be performed safely and effectively in appropriately selected cases. Key words: prosthetic infection, extended trochanteric osteotomy.
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Papers by Richard Berger