Current practice patterns in primary hip and knee arthroplasty among members of the American Association of Hip and Knee Surgeons.
ABSTRACT A poll was conducted at the 2009 Annual Meeting of the American Association of Hip and Knee Surgeons to determine current practices among its members in primary total hip arthroplasty and total knee arthroplasty. This article summarizes the audience responses to a number of multiple choice questions concerning perioperative management and operative practice patterns and preferences including anesthetic choices, blood management, surgical approaches, implant selection, implant fixation, bearing surface choice, postoperative rehabilitation, recommended postoperative activity restrictions, and antibiotic prophylaxis.
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ABSTRACT: BACKGROUND: Acute postoperative infection after total hip arthroplasty (THA) is typically treated with irrigation and débridement and exchange of the modular femoral head and acetabular liner. Given a rate of failure exceeding 50% in some series, a one-stage exchange has been suggested as a potential alternative because it allows more thorough débridement and removal of colonized implants. To date, most studies published on the one-stage exchange have used microbe-specific antibiotic-laden bone cement with only one small single-institution series that reported outcomes after a cementless one-stage exchange. QUESTIONS/PURPOSES: We determined whether a one-stage cementless exchange for treating acute postoperative infection after THA would result in infection control with component retention and normalization of infection markers. METHODS: We retrospectively identified 27 patients who underwent a one-stage exchange performed for an acute (≤ 6 weeks) postoperative infection after THA from April 2004 to December 2009. Primary cementless components were used both at the time of the index arthroplasty and the revision in all patients. Surgery was followed by a 6-week course of culture-specific antibiotics in all patients and a variable course of oral antibiotics. Our primary outcome was retention of the implants at most recent followup and our secondary outcome was normalization of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) at most recent followup. Patients were followed until failure or a minimum of 2 years. RESULTS: At a minimum followup of 27 months (mean, 50 months; range, 27-89 months), 19 of the 27 patients (70%) retained their implants but four required further operative débridement with component retention at a mean of 3 weeks (range, 2-6 weeks) to obtain control of infection. Thus, an isolated single-stage exchange was successful in 15 of the 27 patients (56%). Eight patients (30%) ultimately had a two-stage exchange for persistent infection; seven of these patients required no further surgery, whereas one patient required a second two-stage exchange. Of those patients retaining their prosthesis after one-stage exchange and tracked with ESR and CRP, four (33% [four of 12]) had elevated values without other signs or symptoms of recurrent infection. CONCLUSIONS: For acute postoperative infection after primary THA, a one-stage cementless exchange allowed 70% of patients to retain their implants at most recent followup. Of those patients who ultimately went on to a two-stage exchange, only one required a second two-stage exchange. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.Clinical Orthopaedics and Related Research 06/2013; · 2.79 Impact Factor
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ABSTRACT: Implant-related infections are a serious complication in prosthetic surgery, substantially jeopardizing implant fixation. As porous coatings for improved osseointegration typically present an increased surface roughness, their resulting large surface area (sometimes increasing with over 700% compared to an ideal plane) renders the implant extremely susceptible to bacterial colonization and subsequent biofilm formation. Therefore, there is particular interest in orthopaedic implantology to engineer surfaces that combine both the ability to improve osseointegration and at the same time reduce the infection risk. As part of this orthopaedic coating development, the interest of in vitro studies on the interaction between implant surfaces and bacteria/biofilms is growing. In this study, the in vitro staphylococcal adhesion and biofilm formation on newly developed porous pure Ti coatings with 50% porosity and pore sizes up to 50 μm is compared to various dense and porous Ti or Ti-6Al-4V reference surfaces. Multiple linear regression analysis indicates that surface roughness and hydrophobicity are the main determinants for bacterial adherence. Accordingly, the novel coatings display a significant reduction of up to five times less bacterial surface colonization when compared to a commercial state-of-the-art vacuum plasma sprayed coating. However, the results also show that a further expansion of the porosity with over 15% and/or the pore size up to 150 μm is correlated to a significant increase in the roughness parameters resulting in an ascent of bacterial attachment. Chemically modifying the Ti surface in order to improve its hydrophilicity, while preserving the average roughness, is found to strongly decrease bacteria quantities, indicating the importance of surface functionalization to reduce the infection risk of porous coatings. © 2013 Wiley Periodicals, Inc. J Biomed Mater Res Part A, 2013.Journal of Biomedical Materials Research Part A 05/2013; · 2.83 Impact Factor
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ABSTRACT: The purpose of this research is to evaluate the effects of a tourniquet in total knee arthroplasty (TKA). The study was done by randomized controlled trials (RCTs) on the effects of a tourniquet in TKA. All related articles which were published up to June 2013 from Medline, Embase, and Cochrane Central Register of Controlled Trails were identified. The methodological quality of the included studies was assessed by the Physiotherapy Evidence Database (PEDro) scale. The meta-analysis was performed using Cochrane RevMan software version 5.1. Thirteen RCTs that involved a total of 689 patients with 689 knees were included in the meta-analysis, which were divided into two groups. The tourniquet group included 351 knees and the non-tourniquet group included 338 knees. The meta-analysis showed that using a tourniquet in TKA could reduce intraoperative blood loss (weighted mean difference (WMD), -198.21; 95% confidence interval (CI), -279.82 to -116.60; P < 0.01) but did not decrease the calculated blood loss (P = 0.80), which indicates the actual blood loss. Although TKA with a tourniquet could save the operation time for 4.57 min compared to TKA without a tourniquet (WMD, -4.57; 95% CI, -7.59 to -1.56; P < 0.01), it had no clinical significance. Meanwhile, the use of tourniquet could not reduce the possibility of blood transfusion (P > 0.05). Postoperative knee range of motion (ROM) in tourniquet group was 10.41[degree sign] less than that in the non-tourniquet group in early stage (<=10 days after surgery) (WMD, -10.41; 95% CI, -16.41 to -4.41; P < 0.01). Moreover, the use of a tourniquet increased the risk of either thrombotic events (risk ratio (RR), 5.00; 95% CI, 1.31 to 19.10; P = 0.02) or non-thrombotic complications (RR, 2.03; 95% CI, 1.12 to 3.67; P = 0.02). TKA without a tourniquet was superior to TKA with a tourniquet in thromboembolic events and the other related complications. There were no significant differences between the two groups in the actual blood loss. TKA with a tourniquet might hinder patients' early postoperative rehabilitation exercises.Journal of Orthopaedic Surgery and Research 03/2014; 9(1):13. · 1.01 Impact Factor