Arthroplasty - Science method

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This may help. https://bmcmedresmethodol.biomedcentral.com/articles/10.1186/1471-2288-8-32

Negative culture results weren’t really terrible

One-stage revision arthroplasty demonstrated similar outcomes including reinfection, re-revision, and readmission rates for the treatment of chronic culture-negative PJI after TKA and THA compared to two-stage revision （van den Kieboom J, . One-stage revision is as effective as two-stage revision for chronic culture-negative periprosthetic joint infection after total hip and knee arthroplasty. Bone Joint J. 2021 Mar;103-B(3):515-521. ）

Our 10 -year experience on early weight bearing did not show any problems with early weight bearing (Day 1)

However for those patients whose proximal femur were wired following fractures we delayed weight bearing for 6 weeks.Our choice of implants were mainly Depuy and Biomet

Thank you very much for the very interesting and relevant question.

Considering the morbidity that can be caused by urinary catheterization in THR and TKR patients, where early ambulation and bed-pan use is possible, it appears to be reasonable and feasible for not using it. At maximum, drainage of bladder can be done once immediately after operation by clean technique. However in practice, it is often done. This is because

1. Some patients are co-morbid and needs hourly urine output monitoring

2. These cases are done often under spinal or combined spinal epidural, which can cause postop urinary retention (comparatively more than general anesthesia- https://doi.org/10.1016/j.egja.2014.12.002)

3. Many a hospital and surgeon do not do same day ambulation

4. Surgical time is another factor. Although these procedure should not take longer duration in expert hand, but, not all of us are so fast. This point leads to addition of adjuvant in the spinal anesthesia, which further increases the urinary retention.

Yes sir, some say it's due to embryological development. But I am searching for confirm ans. Thank you Sir

You can read our paper about the hip joint

I agree with Dr Picardi, I do not think there is a future for the friction pair MoM

Good question

I agree completely with Mr Vaishya's opinion about the registries' limitations and their statistical interpretations, but registries are the "crude" way to understand behaviour of a prosthesis when this is implanted by the "general population" of Mr Average of the surgeons.

thanks Dr. Raju for this nice case

I totally agree with you that taking the risk in this patient is benefecial because not only the durability of hemiarthroplasty but also the low functional outcome. But please if possible to publish the radiological and functional outcome in his follow up visits

thanks again

Dear Melanie

This article may be useful for you:

Written by Editor-in-ChiefCategory: Editors ChoicePublished: 09 April 2018 Last Updated: 09 April 2018

According to a study published online in The Journal of Arthroplasty, use of the Outpatient Arthroplasty Risk Assessment (OARA) screening tool may help identify candidates for safe and early discharge following total hip arthroplasty (THA). 

Regards

Yes the procedure went through IRB/ethical committee.  It isn't considered as experimental since it has been used extensively in the elbow, shoulder, first MPJ of the foot, and many other small joints.  We just don't have long term data as of yet in a load bearing joint but I will be doing a larger group of patients in a few years with the results that will either show it works for the long term or the timing to failure.  This is being done by several other surgeons in the US so hopefully we can make it a multicenter study for better data

This is a very demanding procedure.AS is a disease of the whole organism which makes more probable complications, especially when done bilaterally. As far as the local tips are concerned I always prefer lower neck cut and long necks to oppose the effect of ectopic ossifications that are more common in AS patients.

Thank you

I routinely excise the hypertrophied synovium in the suprapatellar pocket because it can be source for inflammation and a stubborn and very troublesome  synovitis postoperatively. It is important to excise only the synovial membrane and leave in situ the prefemoral fat tissue. Sometimes both structures are removed together which can lead to restricted ROM postoperatively.

The following are both not clinical studies but it may be interesting to read.

1. Establishing a role for vancomycin powder application for prosthetic joint infection prevention-results of a wear simulation study.

Qadir R, Ochsner JL, Chimento GF, Meyer MS, Waddell B, Zavatsky JM.

J Arthroplasty. 2014 Jul;29(7):1449-56. doi: 10.1016/j.arth.2014.02.012. Feb 12.

PMID: 24636904

2. Regional Intraosseous Administration of Prophylactic Antibiotics is More Effective Than Systemic Administration in a Mouse Model of TKA.

Young SW, Roberts T, Johnson S, Dalton JP, Coleman B, Wiles S.

Clin Orthop Relat Res. 2015 Nov;473(11):3573-84. doi: 10.1007/s11999-015-4464-x.

PMID: 26224291

I share the indications pointed out by Dr. Vaishya. Arthroscopic wash out gives little or no benefit for advanced OA-patients.  

Hello everyone, haven't gone through all the discussions above. I also can't add much to the IL-6 topic, but just wanted to share The Musculoskeletal Infection Society criteria for PJI. I find them somewhat useful. Please excuse me if I am slightly off topic.

One of the following is necessary for diagnosing PJI:

(1) A sinus tract communicating with the prosthesis

(2) A pathogen is isolated by culture from two separate tissue or fluid samples obtained from the affected prosthetic joint

(3) Four of the following six criteria exist:

(a) Elevated ESR and CRP (ESR > 30 mm/hour; CRP > 10 mg/L)

(b) Elevated synovial fluid WBC count (> 3000 cells/μL)

(c) Elevated synovial fluid neutrophil percentage (> 65%)

(d) Presence of purulence in the affected joint

(e) Isolation of a microorganism in one periprosthetic tissue or fluid culture

(f) > 5 neutrophils per highpowered field in 5 highpower fields observed from histologic analysis of periprosthetic tissue at ×400 magnification

Sincerely,

Hristo

Thank you. We need to take their pre op ASA grade also in account. We do not take pts higher than grade II. Moreover, these patients and family members must be quite motivated and understand the risks and benefits of the proc edure .

Dear Rene Attal,

I think that article could be useful to you!

Harsten, A. 2015 Tourniquet versus no tourniquet on knee-extension strength early after fast-track total knee arthroplasty; a randomized controlled trial

Knee

Have a nice day!

Giacomo

As far as hip resurfacing is concerned, it is a high demand surgery meant only for high demand individuals. It fell into disrepute because of design issues of ASR from DePuy and few others (Durom from Zimmer) leading to very high failure rates. However, BHR from Smith & Nephew has had excellent results at both the designing centers as well as other centers. A recent results' analysis is available at http://www.ncbi.nlm.nih.gov/pubmed/25708400

 Personally, I reserve this implant for high demand individuals but not to be used in avascular necrosis. Revising a well integrated resurfacing cup can be a pain. Fortunately, we don't have to revise many. In case you have to revise any, my published technique (copy attached) for revising the same is available at  http://journals.lww.com/techortho/Abstract/publishahead/Revision_of_a_Well_fixed_Brimingham_Hip.99971.aspx

Refer the following publication.

G. Mansour, S. Mitsi., and K. . Bouzakis, “A Kinematic and Dynamic Model of the Human Upper Extremity,” in Proc. of International Conference on Manufacturing Engineering, 2008, pp. 885–892.

Dear Dr. Kleuber, in my practive I keep to the approach that you propose. One should try to restore the situation before the first replacement. The preoperative planning for revision should incorporate these data. Unfortunately, this is a difficult task because of bone stock loss at that moment. One should need to restore and augment bone by structural grafts and bone cement. 

Dear Dr. Klueber, 

The primary question is whether MSRA should be pre-operatively treated (i.e decolonized)  in patients who are prepared for THK or TKR ? Should we test all candidates for arthroplasty for MSRA, and if some of them are positive should we treat them (and how) before being subjected to arthroplasty surgery.

MSRA infection in patients with THR and TKR is another topic. Here the problems are different. Do the colleagues in the ENDO-Klinik in Hamburg still apply the Buchholz procedure of immediate prosthesis exchange in case of periprosthetic infection ?  

Of course, Dr. Wu, your proposal is also possible. Unfortunately, the x-ray cosmesis is not the only drawback. I have in mind the unhappy situation of repeated dislocations.

First you should be sure to use antibiotic loaded cement, which works for the antibiogram. Microbiologic specialist is Lars Frommelt/Hamburg (here in Reasearch center too).

Second: you have to stabilize the fracture either by wire or plate or by a longer hip stem (cemented).

Thank You Drs Tanchev and Poduval for this interesting, relevant discussion on a significant dilemna in lower limb arthroplasty surgery.

In my clinical practice, i have moved away from using a catheter routinely, unless the patient's past medical history and co-morbidities dictate the use of one.

There is a lot of evidence out there regarding the increased incidence of urinary retention in lower limb arthroplasty, increased prevalence of UTIs with the use of urinary catheters with the duration of catheterisation being the most significant risk factor, and post-op UTIs leading to haematogenous bacteremia, seeding of the implant and subsequent Prosthetic Joint Infections. 

Neuraxial anaesthesia has long been considered to be an indication for the use of a urinary catheter because of the potential lack of ability to sense bladder distention and subsequent neurogenic bladder problems. It has been shown previously that post-op urinary retention following spinal anaesthesia is significantly lower than that after epidural anaesthesia.

Anaesthetic practices have changed in recent years. Epidural anaesthesia is less commonly utilised for lower limb arthroplasty. In spinal anaesthesia, no intrathecal opiates are used and the current emphasis is on enhanced recovery and rapid rehab with multimodal analgesia which has conclusively shown a significant reduction in the need and use of opiates. 

Based on these facts and also because i would like to emphasise and reassure my arthroplasty patients that they are not ill and only have had a procedure done, i have given up the use of a urinary catheter routinely as it is one less tube that these patients are attached to.

I would recommend this publication from the Parvizi group at the Rothman Institute which discusses all these relevant points. 

I agree, but this (usingYoung's modulus and poisson's ratio) will allow you simulate only the elastic response of the bone-implant interphase and this is merely a comparative indicator for a very complex system.

If you want to get information concerning the fracture and/or loosening of the stent then you should use non-linear properties and consider anisotropy. Optimally you could also incorporate a failure criterion.

Another aspect I would suggest is to use second order elements (to reduce shear locking) this preferential to first order elements when simulating bending.

Dear all,

I understand that BS cage can be an option for acetabular reconstruction in severe bone defect, it is well documented in literature that it works in old patients with low functional requests but in young patients long term results are poor.  In my experience in severe bone defects Paprosky 3a-b or pelvic disjunction an iliac screw modular cup is reliable safe and it is a relatively straight procedure. I really do suggest in case of acetabular cup revision in severe bone defect this method of reconstruction.

Equations are not common in orthopedic surgery. However, I would proceed as follows:

         180 cm  height        -         4 cm lengthening

          150 cm height        -           x    

          x =   (150 x 4) : 180 = 3.33 cm

This seems very simplified, but there is also logics in it, not only mathematics.  

In my internship in Centro Hospitalar São João, Porto, Portugal, we've done a study (that is still in writing phase) that compared ARPE arthroplasty vs LRTI, and the same showed that they had similar results in pain relief and range of motion, but arthroplasty showed better results (statistically significant) in recovering pinch and grip strength.

Both groups had similar gender and age parameters, mean follow up was 3,4years and both procedures had same rate of complications

Dear Prof Poduval,

I would like to share my thoughts and experience on the topic and hope you will find this helpful.

#1. Timing: As you pointed out this is a dilemma. There is limited data on the optimal time point, I am unaware of high quality trials on the topic. The risk for preoperative complications is generally higher in patients with chronic kidney disease (CKD) as compared to those with normal renal function. Following transplantation patients are particularly susceptible to infection due to immunosuppressive therapy. On the other hand, perioperative VTE prophylaxis is more complicated in patients on hemodialysis (HD). Anticoagulants are usually eliminated renally (NOADs are contraindicated) so there is a marked risk for overdosing and subsequent coagulopathy in CKD patients. This is why patients on HD undergoing THA are at higher risk for hematoma. 

Prosthetic joint infection (PJI) is, however, the most dreadful complication. Moreover, in case of PJI immuno-suppressive therapy can not be stopped in transplanted patients and control of infection becomes even more difficult. Personally, I would therefore definitely go for THA before transplantation (btw this is in accordance with a study of Shrader et al. published in J Arthroplasty in 2006) In an effort to reduce the risk of preoperative bleeding and hematoma we usually recommend

a) using a citrate-based (as opposed to heparine-based) HD protocol for the perioperative period

b) daily controls of factor Xa activity (4 hours after last VTE prophylaxis shot) until a proper level has been established

c) use of at least one drain (I am aware of the evidence...)

#2. Cemented or uncemented:

In a 24 yr old patient I would go for uncemented THA. Despite steroid therapy and CKD most of those young patients will have a bone stock good enough for uncemented arthroplasty. 

#3. I have pointed out on the risks. Personally, I do not change my antibiotic regime (single shot cefuroxime, if on HD no dose adjustment necessary either) as compared to those with normal renal function. As said above the risk for infection is higher in CKD patients but to my knowledge there is no clear evidence indicating that this can be further reduced by additional antibiotics.

#4. You said the patient has unable to walk for 6 months and is on the transplantation list. I would therefore recommend one-stage bilateral THA. If Hb is low (as often in CKD patients), you might want to consider using a cell-saver or preoperative EPO. However, I think it would not be a major problem to do one side at a time with a short interval. 

#5: I can´t really say much about indication. But a patient unable to walk with AVN is usually a good candidate for THA.

Kind regards,

Oliver Hauschild

I find the following quite useful especially if used together:

1. Pre-op templating with measurement of LLD: Plan the relative stem/cup position to correct for any LLD; measure distance from top of lesser trochanter to level of planned neck osteotomy medially.

2. Pre-op measurement of the level of the head centre in relation to the tip of the greater trochanter on AP pelvic radiograph.

3. Visualise the LLD at the knee when patient secured in lateral position and draped (Heels together & operated limb lying onto contralateral limb (adducted)). Keep this image in your head and compare at trial reduction.

4. Intra-op confirmation of the approximate level of head centre in relation to tip of GT just before neck osteotomy.

5. Measure accurately where to make the neck osteotomy to match pre-op plan using a sterile paper ruler.

6. At trial reduction, check level of head centre in relation to tip of GT & think about any change that has happened.

If all these checks are done, you will significantly minimise the LLD post-op.

This is a great question. I encounter this situation commonly in my uninsured patients that have gone a long time without care.

Many of these knees can be balanced with an implant that does not have varus/valgus constraint but certainly it would be reasonable to have semi constrained implants available as back up. I'll with a standard distal femur cut (the thickness of the implant) regardless of the presence of a flexion contracture. I template the angle of my distal femoral cut and in a situation like this if the templated angle is between 2 degrees I pick the lower number or even a degree less cheating the femur in 0.5-1.5 degrees of varus from the mechanical axis. This will make the knee easier to balance and in my opinion will likely not affect the durability of the knee replacement. The tibia however should be cut perpendicular to its axis. At this point you have to decide how much lateral bone your willing to take and/or how much medial bone you will leave un resurfaced to accomplish this task. With the system I use, downsizing a single size does not require a big lateral shift so I have no problem doing this. Releasing and excising the uncovered medial bone will also greatly facilitate balancing the knee. From the lateral side I don't want to take more than 12mm after which the lateral laxity seems to markedly worsen. If a tibial downsize, slight lateral shift, and a 12mm cut from the lateral side will not give a flat tibia perpendicular to its axis then I will use a 5mm medial block augment along with a short/stubby cemented stem. At this point I'll check the alignment of my tibial cut but I'm not going to try to completely balance the extension space. Given the fexion contracture I'm pretty sure that removal of posterior femoral osteohytes and release of the capsule from the posterior femur will be required so I'll do this before any further releases from the tibia. For the femoral cuts I am a believer in posterior referencing for sizing because I want to maintain native femoral offset. For femoral rotation, I'll use anatomic landmarks for multiple reasons (that is another discussion). At this point I'll use spacer blocks or laminar spreaders to balance the knee. Given the flexion contracture and severe varus most of the release with be posterior. The sequence I will use is first the posterior oblique ligament then semimenbranosous. If I'm still too tight medial in extension a gentle fractional lengthening of the MCL will almost always get me there. I'll use an 18 gauge needle to slowly pie crust the MCL while applying gentle traction and valgus. What I'm looking for in a perfect world is 1mm of opening medial and 2mm of opening lateral. Depending on the patient, Ill accept a little more lateral opening. What I wont accept is a completely incompetent lateral side, more than 2mm of opening on the medial side, or a medial side that is so tight that it is springing open the lateral side. In these rare situations, rather than risk making the medial side completely incompetent, I'm going with short cemented stems, and a semi constrained poly with a thickness that will allow for full extension and no springing open of the lateral side.

In principle for the primary case you don't have such problems. The previous answer is correct to look at https://www.researchgate.net/go.Deref.html?url=http%3A%2F%2Fwww.orthobullets.com%2Frecon%2F5016%2Fsagittal-plane-gap-balancing.

But for this special situation a revision prosthesis is necessary .

Yes i use closed suction drains for 24 hrs and if the drainage is more than 300 ml then tend to recharge the drain partially irrespective of the time frame.

No reclapiming of the drain is done

i do mostly uncemented implants in thr and feel that the femoral side open cancellous area is an area from where this comes

in revision surgeries i would drain for 72 hrs or when the drain is less then 50mml in 24 hrs we would remove

in few patients where we did not drain we had to go in to evacuate the hematoma as it was oozing through the stitch area and not acceptable ( less than 5 % cases but we did for about 45 cases only ). Stopped as there was more pain ? In there in post op time irrespective of the same protocol in post op pain control ? Hematoma ? No usg confirmation was done

have seen more drainage in ra patients and ostoporotic patients with tkr

at present using lmwh for dvt prophylaxis and am not sure of omitting the drains

drains are not coming in way of the physio; ankle physio day zero;

day of surgery we take as zero so physio starts from day0 and ambulation from day 2

If I understand your question right ".. which outcome measure will be the best PREDICTOR of .. functional improvement.." you will have to consider the time axis: Outcome measure on dismission from the hospital, at 3 months follow-up, 12 months ... Talking about the early p.op. time as an inpatient, full extension is a powerfull predictor of good results 1 year pop. The quality of life tools (SF36, short form and others) in our hands are neither sensitive nor specific. Comparing quality of life in pts with calcaneal fractures, tibial head fractures, diverticulitis, HIV, osteoporosis and the life as a medical student, score values for med studs were lower than for HIV. Patients with a rural home do better than those in a city ' s apartment block. Otherwise the "usual clinical" scores - HSS, nontheless are inevitably to be used in any meta analysis.

Dear Guo

There is a normal simetry (offset) of the patellofemoral joint (sulcus angle)n and if this simetry is compromised signs of pain and instability will occur in the knee joint. This simetry is best viewed in axial incidence of the knee

Attached see fig. in the left side normal offset and in the right side compromised offset

We are now in the process in studying failure mecanisms in Biomet magnum M2A THA. Edge loading could well be more important than trunion problems in this implant.