William Mihalko

The University of Tennessee Health Science Center · Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering

Background: Femoral neck retaining prostheses have gained popularity in Europe, but the United States (US) has not seen the same trends occurring. Previous reports demonstrate high survivorship for these implants, but to our knowledge, there are no reports examining US data. Methods: After Institutional Review Board approval, 824 primary total h...

Background: Cryoneurolysis utilizes temperatures below -20°C for nonpermanent analgesia to control pain in total knee arthroplasty (TKA). There is concern that body habitus could limit pain control because of accuracy of cryoneurolysis to subcutaneous nerves. This study aimed to determine the relationship between body habitus and effectiveness of...

Background: Robotic-assisted total knee arthroplasty (RA-TKA) has become more popular in the United States. With the significant trend towards performing TKA in outpatient and ambulatory surgery center (ASC) settings, this study was implemented to determine the safety and efficacy of RA-TKA in an ASC. Method: A retrospective review identified 17...

Introduction: This study evaluated the effect of bupivacaine versus mepivacaine spinal anesthesia and preoperative adductor canal block (ACB) on recovery, length of stay, pain, and complications of same-day discharge total knee arthroplasty (TKA) at a free-standing ambulatory surgery center. Methods: We performed a retrospective review of patien...

ZrN-multilayer coating is clinically well established in total knee arthroplasty [1–3] and has demonstrated significant reduction in polyethylene wear and metal ion release [4,5]. The goal of our study was to analyze the biotribological behaviour of the ZrN-multilayer coating on a polished cobalt-chromium cemented hip stem. CoCr28Mo6 alloy hip stem...

Advances in operative techniques, anesthesia, and perioperative analgesia have allowed same-day total knee arthroplasty (TKA) to become a reality. Outpatient total joint arthroplasty has become more popular, with the goal to decrease costs while still providing high-value care. To ensure an efficient, effective, and safe outpatient TKA program, it...

During my time in training with Dr. Krackow, he always emphasized the steps taken to cement the implants into place. He was very meticulous and deliberate in this step, and it was never taken for granted or assumed to be unimportant. As we have seen improvements in polyethylene and a decrease in wear, aseptic loosening continues to be one of the to...

Background: Periprosthetic femoral fractures (PFF) in total hip arthroplasty (THA), especially those in contact with the diaphyseal stem, carry high morbidity. This study evaluated how stem design influences the risk of early Vancouver B PFF or other PFF requiring operative intervention after THA. Methods: A multi-center, retrospective study of...

Background Early TKA failures continue to surface in the literature. Cementation technique and implant design are two of the most important scenarios that can affect implant survivorship. Our objectives were to develop a more suitable pre-clinical test to evaluate the endurance of the implant-cement-bone interface under anterior shear and internal-...

Update This article was updated on June 17, 2022, because of a previous error. In the note on page 231, the name “Armin Arish” now reads “Armin Arshi.” An erratum has been published: J Bone Joint Surg Am. 2022 Aug 3;104(15):e70.

Background Patients have received cobalt-chromium-molybdenum (CoCrMo) implants for their joint replacement for decades. There have been reports of inflammatory cell-induced corrosion (ICIC) of these implants from retrieval studies. The goal of this study is to see if we could recreate ICIC in vitro and whether electrocautery damage to alloy surface...

A correlation between patellar kinematics and anterior knee pain is widely accepted. However, there is no consensus on how they are connected or what profile of patellar kinematics would minimize anterior knee pain. Nevertheless, answering this question by merging existing studies is further complicated by the variety of ways to describe patellar k...

Necrotizing soft-tissue infections are a rare complication following hip arthroplasty procedures. These rapidly spreading infections have a high mortality rate and must be diagnosed and treated in an expeditious manner. This article discusses the epidemiology, classification, diagnosis, and treatment of these conditions and describes 2 related case...

This study compares anterior supine intermuscular total hip arthroplasty performed at an ambulatory surgery center with the same procedure performed in a hospital setting in regard to complications and costs. The ambulatory surgery center had significantly shorter postoperative stays and superior visual analog pain scores at 3 months. No difference...

Background: Postoperative urinary retention (POUR) is among the reasons for delay in discharge after outpatient total hip arthroplasty (THA), occurring in 2%-46% of patients. We hypothesized that the frequency of POUR following outpatient THA in the ambulatory surgery center (ASC) is low compared to previously reported rates and that management ca...

Based on a series of 407 outpatient total hip arthroplasties performed by a single surgeon, a standardized protocol for blood loss management in outpatient arthroplasty was developed consisting of a presurgical hematocrit of greater than 36%, administration of tranexamic acid, prophylactic introduction of albumin, hypotensive epidural anesthesia, m...

Background We hypothesized that preoperative cryoneurolysis of the superficial genicular nerves in patients with osteoarthritis would decrease postoperative opioid use relative to standard of care (SOC) treatment in patients undergoing total knee arthroplasty (TKA). Methods Patients received either cryoneurolysis (intent-to-treat [ITT]: n = 62) or...

Over the last three decades, there have been significant advancements in knee and hip replacement technology. The implants and the surgical technology we now have to aid in their implantation are advancing and improving functional outcomes and survivorship. Despite these advancements, there are still issues with patient satisfaction, functional lim...

Introduction: The term "outpatient" has a variety of meanings regarding the location of arthroplasty and the duration of stay postoperatively. The purpose of this systematic review was to evaluate the literature and more accurately define the term "outpatient." Methods: A PubMed search (2014 to 2019) using the terms "outpatient AND arthroplasty"...

Background Pitting damage on implants has been reported and attributed to the use of electrocautery. This study aimed to determine how different total knee arthroplasty bearing surfaces are susceptible to this type of damage and whether surgeons are aware that this damage can occur. Methods A survey was sent to Hip and Knee Society members to dete...

Background The authors compared a matched cohort of outpatient total knee arthroplasties (TKA) performed in a free-standing ambulatory surgery center (ASC) with those performed in a standard inpatient hospital setting to determine the safety, efficacy, and expense associated with both locations. Methods Retrospective review identified 82 patients...

Aims: This study aimed to determine if macrophages can attach and directly affect the oxide layers of 316L stainless steel, titanium alloy (Ti6Al4V), and cobalt-chromium-molybdenum alloy (CoCrMo) by releasing components of these alloys. Methods: Murine peritoneal macrophages were cultured and placed on stainless steel, CoCrMo, and Ti6Al4V discs...

Background The purpose of this study was to determine and compare the glenoid vault bone volumes in patients undergoing reverse total shoulder arthroplasty (RTSA) for inflammatory arthritis to determine if a threshold exists where baseplate fixation is at risk for failure. Methods Fourteen patients who had primary RTSA for inflammatory arthritis w...

Background Deltoid muscle function is paramount to the success of reverse total shoulder arthroplasty. The purpose of this study was to investigate the role of deltoid volume on shoulder range of motion and patient-reported outcomes following reverse total shoulder arthroplasty in rotator cuff-intact and rotator cuff-deficient conditions. Methods...

Over the last three decades there has been significant advancements in knee and hip replacement technology that has been driven by issue in the past concerning adverse local tissue reactions, aseptic and septic loosening. The implants and the materials we utilize have improved over the last two decades and in knee and hip replacement there have bee...

Background Total knee arthroplasty (TKA) with posterior-stabilized (PS) or posterior cruciate-retaining (CR) implants have high success rates and survivorship. However, it is uncertain how laxity and constraint are associated with polyethylene wear long-term under physiological conditions. Methods To answer this question, we measured the laxity pa...

Recently, inflammatory cell-induced corrosion (ICIC), a unique type of damage, has been reported in cobalt-chromium (CoCr) implants, but the mechanism remains poorly understood and controversial because electrocautery damage has also been shown to produce similar findings. This study aimed to distinguish between these two damage mechanisms. Forty-o...

Surgical techniques used to decrease the amount of blood lost during the procedure range from tourniquets to electrocautery and, more recently, the use of antifibrinolytics. Currently, tranexamic acid is the most commonly used antifibrinolytic in arthroplasty procedures. It was previously thought that intravenous tranexamic acid was more effective...

Using an age- and comorbidity-matched cohort, we compared patients who underwent unicompartmental knee arthroplasty in an ambulatory surgery center with those who underwent the procedure in a traditional hospital inpatient setting. Postoperatively, the ambulatory surgery center cohort had fewer major complications than the inpatient cohort. No ambu...

Background: The objectives of this study are to (1) evaluate if there is a potential difference in cemented implant fixation strength between tibial components made out of cobalt-chromium (CrCoMo) and of a ceramic zirconium nitride (ZrN) multilayer coating and to (2) test their behavior with 5 different bone cements in a standardized in vitro mode...

Background: The purpose of this study is to determine the preferred sampling location for tissue analysis in total knee arthroplasty (TKA) and to evaluate metal concentrations, inflammatory cytokines, component damage, and tissue metallosis. Methods: Twenty TKA systems were collected at necropsy along with tissue samples from 5 distinct location...

Functional limitations persist in obese patients after total knee arthroplasty (TKA). This study assessed the effect of an exercise program (EP) and fitness trackers (FT) in obese patients with TKA. Sixty patients 1 year after orthopedic surgery were recruited and received a 16-week tailored EP; half were randomized to receive an FT. FT had no meas...

Orthopaedic surgeons should be aware of the variety of applications of three-dimensional printing, which range from rough-and-ready applications, such as rapid prototyping of implant designs with the use of polymers to the fabrication of patient-specific implants and custom implants with the use of the principles of metallurgy. The local manufactur...

Additive manufacturing and three-dimensional printing technology may revolutionize tissue-engineering strategies. Many clinical needs, including multitissue regeneration, remain unmet among patients with orthopaedic conditions. Ongoing research efforts in three-dimensional printing, including cell-containing bioinks for bioprinting, have resulted i...

Additive manufacturing involves the construction of devices via the layer-by-layer deposition of materials. Additive manufacturing, which also is referred to as three-dimensional printing, is different from traditional machining, which involves the subtraction of material from a workpiece. Although traditional machining methods have been used in th...

Increased joint laxity is associated with excessive polyethylene wear, but the correlation between laxity and metal wear has not been established. Fifteen necropsy-retrieved primary total knee replacements were mounted into a custom knee-testing machine that measured anterior-posterior, varus-valgus, and internal-external rotational laxity at 0°, 3...

Patients often present for orthopaedic surgery with multiple medical conditions and comorbidities. A comprehensive understanding of these comorbidities would lead to proper perioperative medical management, which, if done thoroughly and appropriately, would positively affect postoperative outcomes and reduce resource utilization. This goal can be a...

The method by which surgeons conduct outpatient total knee procedures has yet to be fully elucidated. Literature demonstrates different experiences from various care protocols in place across the nation. This article reviews current recommendations for implementing successful total knee arthroplasty (TKA) and unicompartmental knee arthroplasty outp...

The method by which surgeons conduct outpatient total hip arthroplasty (THA) procedures has yet to be fully standardized. Careful examination of components involved in the preoperative phase of outpatient hip arthroplasty procedures may lead to improved outcomes. This article will discuss methods for implementing successful outpatient THA protocols...

Total joint arthroplasty (TJA) has demonstrated tremendous benefits to patients with osteoarthritis. Health care reform has influenced surgeons to optimize TJA care pathways as well as playing a role in the formation of outpatient TJA protocols. Understanding the outcomes of outpatient TJA is imperative to surgical predicate decision making. The ai...

The intra- and postoperative phases of outpatient total hip arthroplasty (THA) vary by institution and surgeon. An understanding of an evidence-based approach to enhancing the intra- and postoperative phases of the care continuum is warranted to offer high-value care to outpatient candidates. This article will discuss methods for implementing succe...

Recent trends in total joint care have moved toward outpatient surgery. Total knee arthroplasty (TKA) remains a definitive management for end-stage osteoarthritis and has experienced increased utilization over the past several decades. The method by which surgeons conduct outpatient total knee procedures has yet to be fully elucidated as different...

Background: We proposed to determine the complication and hospital admission rates for patients with total hip arthroplasty (THA) done by a single surgeon in a stand-alone ambulatory surgical center with same-day discharge. Given the recent emphasis on bundled payments for a 90-day episode of care, this same time frame after surgery was chosen to...

579 45 Background Although additive manufacturing, which also is referred to as three-dimensional (3D) printing, has been used for three decades, recent advances in additive manufacturing have allowed the fabrication of new product designs across most industries, including medicine and orthopaedics. The first description of an additive manufacturin...

Additive manufacturing and three-dimensional printing technolog y may revolutionize tissue-engineering strategies. Many clinical needs, including multitissue regeneration, remain unmet among patients with orthopaedic conditions. Ongoing research efforts in three-dimensional printing, including cell-containing bioinks for bioprinting, have resulted...

The use of three-dimensional (3D) printing is increasing in the field of orthopaedic surgery. The ease of segmenting bone from CT scans, the low cost of 3D printing, and the variety of available 3D printers enables researchers , manufacturers, and surgeons to use 3D printing technology. 3D printing is used for education, skills development (via sim...

The objective of our study was to evaluate the impact of the tibial keel & stem length in surface cementation, of a full cemented keel and of an additional tibial stem on the primary stability of a posterior stabilised tibial plateau (VEGA® System Aesculap Tuttlingen, Germany) under dynamic compression-shear loading conditions in human tibiae. We p...

Obese patients are more likely to have osteoarthritis and total knee arthroplasty (TKA). This investigation sought to evaluate physical function, activity level, and quality of life (QOL). Obese participants near 1-year postsurgical follow-up appointment were recruited. Evaluation included QOL and activity questionnaire, medical histories, anthropo...

Total knee arthroplasty (TKA) has become an increasingly common treatment option for patients who have debilitating knee arthritis. TKA is a relatively safe and efficient procedure that results in promising outcomes and has a positive effect on a patient's quality of life. More TKAs are being performed annually because the procedure substantially r...

Single-stage revision total knee arthroplasty has become an increasingly common treatment option for patients with failed knee prostheses. Periprosthetic knee infection is the leading and most devastating cause of revision total knee arthroplasty. Although periprosthetic knee infection has been extensively studied in the orthopaedic literature, the...

Two-stage revision total knee arthroplasty (TKA) is the standard of care for patients who require a revision procedure for the mangement of a late or chronic periprosthetic knee infection. A careful examination of two-stage revision TKA is warranted as the number of patients who require revision TKA in the United States continues to rise. Surgeons...

Background: Multiple factors contribute to range of motion of the hip joint in the transverse plane: bony anatomy, hip capsule, corresponding ligaments, articular labrum, ligamentum teres, and negative intra-articular pressure. We hypothesized that violation of the negative pressure of the hip and simulation of an effusion would increase range of...

Background This bilateral squat study tests whether people with anterior cruciate ligament (ACL) reconstruction have symmetric three-dimensional ground reaction forces (GRFs) and symmetric anterior–posterior (AP) translation rates of the femur with respect to the tibia when compared with healthy control subjects. We hypothesized that there would b...

The introduction of new devices, biologics, and combination products to the orthopaedic marketplace is increasing rapidly. ➢ The majority of these new technologies obtain clearance to market by demonstrating substantial equivalence to a predicate (previously approved device) according to the U.S. Food and Drug Administration (FDA) 510(k) process. ➢...

The objective of this study was to describe how tibiofemoral internal/external rotation varies in patients after total knee arthroplasty (TKA) when compared with control participants during a sit-to-stand (STS) maneuver. Motion analysis was used to measure internal/external knee rotation during STS in the control and TKA groups. Fourteen participan...

Tibial anatomical landmarks for transverse plane rotation of the tibial tray have not been validated. The current authors propose aligning the tibial tray with both the anterior tibial center point of rotation (ATCPR) and the femoral trochlear groove (FTG) to establish the ideal tibial tray rotation in total knee arthroplasty (TKA). When the tibial...

With the large number of total knee arthroplasties being performed and expectations that these numbers will be on the rise over the coming decades, efforts to provide cost-efficient care are of greater interest. The preferred design of knee arthroplasty implants has changed over time, with the original all-polyethylene tibial (APT) design being rep...

Different biomechanical designs are incorporated into various total knee arthroplasty (TKA) implants. The posterior-stabilized prosthesis design utilizes a polyethylene post and femoral cam in place of the posterior cruciate ligament. This produces a more stable component interface, increased range of motion, and potentially a less technical proced...

Post-cam designs for posterior-stabilized total knee arthroplasy (TKA) implants have evolved over the last 2 decades. These designs have evolved from symmetric post and cam to asymmetric designs that include anterior post interactions to affect a kinematic change in full extension. All design changes have consequences on the resulting femorotibial...

Proprioceptive mechanoreceptors provide neural feedback for position in space and are critical for three-dimensional interaction. Proprioception is decreased with osteoarthritis of the knees, which leads to increased risk of falling. As the prevalence of osteoarthritis increases so does the need for total knee arthroplasty (TKA), and knowing the ef...

Obesity is a problem that is increasing in prevalence in the US and in other countries, and it is a common comorbidity in patients seeking total joint arthroplasty for degenerative musculoskeletal diseases. Obesity, as well as commonly associated comorbidities such as diabetes mellitus, cardiovascular disease and those contributing to the diagnosis...

Heart disease is the leading cause of death in the United States. Cardiovascular complications are associated with higher morbidity and mortality rates for patients who undergo orthopaedic surgery. Therefore, the clinical importance of a comprehensive preoperative evaluation and medical clearance is crucial and may substantially improve postoperati...

Because orthopaedic surgeons focus on identifying serious potential complications, such as heart attack, stroke, and deep vein thrombosis, during the preoperative assessment, correctable factors, such as smoking, may be overlooked. Chronic exposure to nicotine has been correlated with perioperative complications that lead to worse outcomes, includi...

Vitamin D is a steroid hormone that affects not only bone metabolism and strength but also a variety of musculoskeletal health and surgical outcomes that are relevant to orthopaedic medicine. Risk factors for vitamin D deficiency include sex, age, skin pigmentation, obesity, and preexisting conditions such as nephritic syndrome and malabsorption sy...

Anterior knee pain, Total knee arthroplasty, Primary, Knee replacement, Arthroplasty

Acrylic bone cement has a variety of applications in orthopaedic surgery. Primary uses in total arthroplasties are limited to prostheses fixation and antibiotic delivery. With the large number of total joint arthroplasties expected to continue to rise, understanding the role bone cement plays in the success of total joint arthroplasty can have a si...

Despite improvements in technique and technology for total knee arthroplasty (TKA), anterior knee pain impacts patient outcomes and satisfaction. Addressing the prosthetic and surgical technique related causes of pain after TKA, specifically as it relates to anterior knee pain, can aid surgeons in addressing these issues with their patients. Design...

Rheumatoid arthritis is an autoimmune disease mediated by a widespread chronic systematic inflammatory process that causes joint deterioration, which leads to pain, disability, and poor quality of life. The increased use of disease-modifying antirheumatic drugs has been shown to markedly slow disease progression, which has translated into a decreas...

Background: This meta-analysis compares the clinical performance of all-polyethylene tibial (APT) to the metal-backed tibial (MBT) components. Methods: We included comparative studies in primary total knee arthroplasty involving APT and MBT implant components. The primary outcomes were function, durability, and reports of adverse events. Result...

The polyethylene bearing on the tibial side of a total knee replacement (TKR) is subjected to large forces from the metal femoral component while allowing the required motions of rolling, gliding and rotation. Over time the polyethylene bearing surface topography is expected to undergo change due to creep and wear. We hypothesized that changes in s...

Obesity, one of the most common health conditions, affects an ever-increasing percentage of orthopaedic patients. Obesity is also associated with other medical conditions, including diabetes, cardiovascular disease, pulmonary disease, metabolic syndrome, and obstructive sleep apnea. These comorbidities require specific preoperative and postoperativ...