Science method

Arthroplasty - Science method

Surgical reconstruction of a joint to relieve pain or restore motion.
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How many of us think that an academic society or organisation helps us, like AOTrauma helps us in professional growth, academic growth and helps us move up the ladder in our career. Does it really remove the obstacles. If yes please mention the name of such organization ( like Indian Orthopaedic association, AOTrauma, OTA, BOA, Arthroplasty, Arthroscopic or trauma societies of different countries states etc) which really help you. Please write your thoughts if you have a different point of view.
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These help if the association offers various fellowship program or award paper sessions in the society conferences as membership is usually required. May also be helpful in professional networking purpose..
And if one wishes to climb the leadership roles within an association, long term loyalty and association with the concerned association helps.
These are major helpful issues regarding membership of an association... Waiting for other opinions....
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I am currently doing a meta-analysis on outcome of arthroplasty and come across different outcome measure across the literature. After discussion with a generic statistician, the suggestion is either perform Standard Mean Difference (SMD) or Ratio of Mean (RoM) for pooling the data of different outcome.
Cochrane has described the use of RoM; however, I am not able to find a way of performing the meta-analysis on Review Manager Softward.
Any idea how do we perform RoM meta-analysis?
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What is the course of action in an arthroplasty which is infected clinically but is culture negative? I find this a difficult situation in many orthopaedic infections not only arthroplasty where the clinical features from a weeping wound to local signs cry infection and even the deeper swabs grow nothing. How does one tailor the antibiotics in such situations?
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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. )
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Incorporation of bone into the components of the non-cemented arthroplasty takes time, and it is difficult to know when the incorporation is sufficient enough to withstand full load.
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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
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Urethral catheters are frequently associated with urinary infections. This may set the arthroplasty at risk for early or late infections. Nevertheless many surgeons and anesthesiologists use urethral catheters for monitoring of diuresis in the perioperative period. Is it indispensable ?
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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.
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Why VMO is the first muscle to undergo disuse atrophy following any knee joint pathological or traumatic condition?
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Yes sir, some say it's due to embryological development. But I am searching for confirm ans. Thank you Sir
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Greetings.
How do you aply Spotorno score when facing a hip arthroplasty revision with severe bone defect in proximal femur, how do you rate Singh index in thse cases in the decision process of employing a cemented or non cemented stem?
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Congratulations for this excellent review, in line with the 2012 consensus initiative I participated in.
The question rises directly from your last sentence "...needs to be prioritized is the investigation of potential systemic risks due to accumulation of metal ions". Do you think that european health authorities are ready to wait for this answer to take definite decision about MoM (whatsoever the head size ?) market retrieval, according to the "precaution principle" that currently governs political deciders in the health field ? What is the trend in Germany thus far ? In France, MoM THA use decreased from 7% of the market at its top (2010) to only 2% in 2013 ...
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I agree with Dr Picardi, I do not think there is a future for the friction pair MoM
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He has severe knee deformity and stiffness. Urging to regain knee movements (pain free!)
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Good question
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The incidence of Total knee replacement is on a rise. In another decade the incidence of revisions will rise too. Is there any way to predict the lifespan of implants nowadays so that we can prepare for the inevitable tomorrow
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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.
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ORIF or Hemi Arthroplasty?
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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
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I am looking for an outpatient total joint arthroplasty risk assessment to use in my research and in my orthopedic practice. Specifically, I am looking for the Outpatient Arthroplasty Risk Assessment score developed by R. Michael Meneghini but I am open to other recommendations as well.
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Dear Melanie
This article may be useful for you:
Outpatient Arthroplasty Risk Assessment (OARA) screening tool may help identify candidates for rapid discharge after THA
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
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Interpositional arthroplasty has gained in success and popularity in non load bearing joints in recent years. All of the joints that have had great success have been sheer force joints and not in load bearing joints. Any thoughts or experience in performing this procedure in load bearing joints as to integration of graft or graft breakdown due to loads. Is there any graft that is more durable with load than others?
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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
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When should the weight bearing be allowed in these cases with uncemented arthroplasty?
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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.
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The rationale of the new cruciate (ACL and PCL) sparing TKR seems feasible but I cannot find any clinical data on this.
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Thank you
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Sometimes during the surgical procedure for TKR, one comes across hypertrophied synovium especially in suprapatellar pouch. I have only occasionally excised the synovium. Should it be excised as a routine or not, or what is the indication to remove it?
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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.
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Intrawound use of vancomycin has been shown in several publications to reduce the incidence of infection following spine surgery.
However, there appears to be sparse, if any, data supporting the use of intrawound vancomycin in arthroplasty patients. Despite the lack of data, some arthroplasty surgeons have extrapolated the results from the spine literature and have begun placing vancomycin in the intra-capsular and sub-fascial spaces during closure following total knee and total hip arthroplasty procedures. 
Is there any published data showing this practice reduces infection rates for total hip and total knee arthroplasty patients? Is there any data showing that vancomycin does not negatively affect the wear properties of highly cross-linked polyethylene or other bearing surfaces?
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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
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In a recent paper published in BMJ, the authors have condemned the arthroscipic surgery in degenerative knee reporting more harm than good even in patients around 40 years of age.
I have been doing this surgery for the last more than 20 years as a first choice in patients below fifties, and selectively in elderly patients who, due to economic/ social/ personal reasons do not want joint replacement. After this paper I compiled my data of last 10 years. Out of 40 knees, only 3 have converted into TKR. During surgery I use meniscal/ synovial debridement, osteophytectomy, microfractures etc depending upon pathologies. In some patients I also combined viscosupplementation at 4- 6 weeks post surgery.
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I share the indications pointed out by Dr. Vaishya. Arthroscopic wash out gives little or no benefit for advanced OA-patients.  
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Sometimes, It is difficult to differentiate between postoperative hematoma and imminent deep infection the first postoperative days after THA. Early debridement is reported to be very effective if it is done after 4-7 days of wound drainage. We need a biomarker to make the exact diagnosis and to act adequately.
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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
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Does the chronological age really matters in this decision making?
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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 .
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Every year a lot of studies are published on tourniquet time and blood loss and outcome after TKA. I do not use a tourniquet at any time of the TKA procedure. I am interested in conducting a study to assess quad muscle function and outcome of TKA without using a tourniquet.
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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
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In the last 10-15 years there is a certain trend to the appliaction of this type of hip replacement. In any case, I do not know if the long-term results are satisfactory. In the past, some 30-40 years age the Wagner cup has been very popular but the long- term results have not been  satisfactory. What is the situation today based on your personal experience with resurfacing hip arthroplasty ?
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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
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For modeling hand and forearm and upperarm, I supposed 7 degrees of freedom: 3 degrees for rotations for shoulder, 1 degree for elbow and 3 degrees for wrist. But I know that I can rotate my forearm about its axis from wrist place while I supposed the seventh degree of freedom for rotating the hand about its axis. Should I import the effect of angular velocity of this degree for computing angular velocity of forearm? (Dynamic model of this degree is somehow complicated for me and I appreciate your help)
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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.
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Currently several landmarks are used to identify the joint line level in revision knee arthroplasty. However, I wonder which one is a suitable method? Does anyone have an idea? Thank you for your contributions.
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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. 
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I am conducting a meta-analysis on the efficacy of MRSA decolonization in total joint arthroplasty (total hip replacement and total knee replacement) patients as part of a class project. Has anyone conducting research on this area which has not yet been published? Specifically, I am looking for the number of surgical site infections or periprosthetic joint infections and the number of patients in both the study group and control group. I am particularly interested in finding studies which have not been published to date -- but would welcome any data that you are willing to share on the topic. Thanks!
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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 ?  
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It's also a very tricky scenario when deal with a moderate deficient acetabulum as for choosing the proper bone coverage and abduction of the cup in THA., in case of avoiding bone graf,  does anyone have a practical technique and surgic philosophy in this aspect to share with me?
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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.
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This is a very unhappy situation and presents a serious intraoperative and postoperative challenge. Unfortunately, it happens sometimes in cases with poor bone quality and deficient bone stock. On the one hand one should have to treat the deep infection, while on the other hand the femur should be stabilized (wiring, bands, plates, IM, new implant - all of them are foreign bodies).
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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).
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Urethral catheters are associated with urinary infections which could set an arthroplastry at risk for early or late infection. Nevertheless, some surgeons and anesthesilogists use urethral catheter for control of diuresis in the perioperative period. Is it really necessary?
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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. 
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I want to analyze a hip implant in Ansys 14. so i want to know which type of element i should use to support torque and bending moments besides i cant use this software help very well. furthermore where can i enter yield and ultimate strength? 
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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.
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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.
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I am an arthroplasty surgeon with a lot of revision reconstruction and complex hip surgery under my belt and I have done a few of DDH in my career achieving lengthening of 4-5cm. After my first complication following a Crowe IV hip in a patient of short stature (sciatic nerve palsy), I am questioning if the given "safe" length is just a number or if this has to follow a 'relative to the height of the patient' equation. As mentioned the present patient is of short stature and all my previous experiences were on taller patients. Anybody with any knowledge to this specific problem?
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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.  
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I doubt if new implants really improve results, making surgery more expensive and increasing the number of complications (dislocations, infections...)
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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
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Dear friends
A 24, year old male was sent by our nephrologists today. He is a case of renal failure on dialysis. He has undergone live donor transplant and the graft was rejected. Now he has graft rejection and reaction. Hematuria and is likely to undergo graft nephrectomy. To compound his woes, he has been unable to walk since 6 months. He has bilateral steroid induced osteonecrosis of hips. He is severely painful.
He has a related donor ready and is in queue for a transplant also.
No doubt he needs a total hip bilaterally
My queries after a detailed discussion with the senior transplant nephrologist who referred me this case, one of many we will need to tackle in the future.
1. Timing-- Do we do the hips before or after the transplant. Nephrologist feels preoperative management is easier before . afterwards he will be on multiple immune suppressants and steroids. They do not plan a steroid sparing regimen.
If the hips are not done first he will remain severely handicapped following the transplant for an extended period of time till he gets fit for surgery and the risks are higher following the transplant
2. Cemented or uncemented
I would go uncemented as I want to save time. The difference with cemented hips is that i end up spending longer in component implantation.
3. Risks-- Is the risk of infection higher-- As far as knees go we have excellent data from the scottish registry which says the risk is higher with patients with renal failure. (BJJ- published somewhere in the last two years). What other significant risks exist?
Do we change antibiotic prophylaxis? What happens if he does get infected, it will screw up his chances for a replacement as well as a transplant.
4. One side or both at a time. Honestly, we don't have the set up for one sitting bilateral hips. But here my advantage is that preoperatively the nephrologists will take over.
5. Cannot use alendronate and head conserving surgeries. I believe THA is the least invasive and best option here. All subject to how my anaesthetists view the patient.
Requesting experiences and opinions
Murali Poduval
Pondicherry
India
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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
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Statistically LLD is one of the most often complications that is underestimated by surgeons and exaggerated by patients. In the USA it is one of the most often reasons for legal problems to the surgeons after THR.
After several years of experience with THR I found some patients (several % of patients) with an elongation of operated leg 2cm. Currently, I perform THR with an additional tool for measuring distance between pelvis and femur during surgery and it improved a lot the results. I wonder what are the others opinions to this problem?
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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.
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We get neglected cases of OA knee with badly stretched LCL. Weight bearing Xrays show even medial subluxation of tibia with posteromedial bone loss on tibia. The options at surgery include use of metallic wedges/ bone grafting to reconstruct the bone loss combined with intramedullary extension rods in tibia. The option of use of a larger tibial post to provide stability against subluxation is another option. What should be the algorithm of treating such cases?
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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.
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In one of my recent surgeries on an obese female, the extension and flexion gaps (after the releases) were just sufficient enough for the largest insert (17.5) I had available. I was wondering what the options to tackle this situation would be if the gap was bigger.
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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 .
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Some surgeons do so in the attempt to diminish blood loss. It is very controversial. Some do not use any drains at all.
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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
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I am doing a meta analysis on TKR. There are so many outcomes measures (WOMAC, TUG,quadriceps lag etc) available. Which outcome measures will be the best predictor of the functional improvement?
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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.
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Can you explain the definition of the patellofemoral offset for me?
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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
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Failure rate of ASR XL is approximately 22% at 5 years and ASR Resurfacing is 14% at 5 years
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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.