Hip And Knee Arthroplasty - Science topic

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. ）

Thanks!

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

Risk stratified approach ensures patient safety. An interesting comparative study of 3 common agaents is: Administering aspirin, rivaroxaban and low-molecular-weight heparin to prevent deep venous thrombosis after total knee arthroplasty.

Available at http://www.ncbi.nlm.nih.gov/pubmed/24695091

What would  be really interesting is to find studies with surgery site and systemic complications following aggressive thromboprophlylaxis as an end point rather than diagnosis of DVT!!! Surprisingly, the number is extremely limited. 

This is a subject that I have special interest in.

I have been involved with the design and surgical techniques of total hip stems since 1980 and have altered my opinion over the years as we have grown in knowledge and experience.

 Over the past 10 years, the orthopedic community has witnessed an increased interest in more conservative surgical techniques for hip arthroplasty. During this time, second-generation hip resurfacing and minimally invasive surgery (MIS) enjoyed extensive marketing attention. After a decade of this renewed interest, both of these methods for THA have met with serious concerns. As hip resurfacing numbers decline, both patients and surgeons are looking for other potentially successful conservative treatments to THA. This search has recently focused surgeon interest toward short-stem designs.

 Most reports on short stems have appeared as oral presentations and posters at continuing medical education (CME) meetings. The international experience precedes that of the United States by at least a decade. The initial response in the U.S. market was simply to modify certain current standard cementless stems by truncating the diaphyseal portion of the stem. Short-and midterm follow-up studies of a number of these stems suggest that stable, durable fixation and excellent clinical outcomes can be achieved.

 Today, a variety of short-stem implants are available with very little clarification of design rationale, fixation features, surgical technique, and clinical outcomes. Virtually every major implant company now offers a “short stem,” and now there are a plethora of different designs. It is important to note, however, that not all short stems achieve initial fixation at the same bone interface region. Furthermore, surgical techniques vary greatly, and postoperative radiographic interpretation of short-stem position and fixation needs to be carefully scrutinized. Finally, the surgeon who is new to short-stem technology is often unaware of the surgical preparation difference for a short metaphyseal style stem versus a neck-persevering style stem. For example, a number of neck-preserving stems prefer rasping the medial femoral curve versus impaction broaching. This has a back-and-forth technique that cuts and shapes the bone to the rasp and final implant. The broach impacts cancellous bone into a dense material and can increase hoop tension, resulting in distal fractures in some cases.

 Short stems offer numerous advantages. First, with some short-stem designs, a majority of the femoral neck is preserved. Surgically, this requires less surgical dissection and mitigates soft tissue and bone damage. Ultimately, preservation of the femoral neck provides a more natural barrier to migration of particulate debris, is associated with less blood loss and less time and energy to rehabilitate the hip, reduces stress shielding of the proximal femur (i.e., load redistribution and subsequent loss of proximal femoral bone mass), and reduces end-of-stem thigh pain. In consideration of all these aforementioned advantages, the use of a short stem can make patient rehabilitation faster and less painful. Because of its smaller size, the short stem is easier to insert, and this facilitates a more minimally invasive surgical approach. The novel design feature inherent in short-stem implants—namely, preservation of proximal native bone and tissue—theoretically affords easier revision surgery if or when it becomes necessary. For these reasons, short-stem procedures also have broader indications compared with hip resurfacing. Finally, many short-stem designs do not require many stem sizes. This translates to simplified instrumentation and reductions in requisite surgical inventory (e.g., instruments and implants). This can provide a significant net savings to healthcare facilities.

 The influx of short-stem designs can be confusing because of myriad competing design philosophies.

The JISRF has developed and advocated a stem classification system by primary stabilization contact regions to help identify, differentiate, and catalog short-stemmed total hip replacements. This classification system should help clarify the design principles inherent in each type and provide some guidance when researchers and other investigators are reporting on the outcomes of the various implant styles. The classification system is formally structured as follows:

1. Head stabilized

A. Hip resurfacing

B. Mid-head stem

2. Neck stabilized

A. Short curved stems

B. Short lateral engaging stem

C. Neck plugs or neck only

3. Metaphyseal stabilized

A. Taper stems

B. Bulky/fit-and-fill stems

4. Conventional metaphyseal/diaphyseal stabilized

 Short stems can facilitate surgical technique for THA. Specifically, when one is using DAA, the neck-sparing curved design significantly facilitates cases of stem insertion. The curved stem can be introduced anteriorly rather than leaning toward the greater trochanter. Less trochanteric levering reduces the risk of proximal femur fractures. Furthermore, with larger-sized patients, proximal extension of the incision is avoided. When utilizing a posterior hip approach, surgeons must note that a true neck-sparing implant provides a distinct advantage for soft tissue closure. Specifically, the capsular envelope is not extensively removed. This allows for a more robust closure of the posterior hip capsule, which may translate to improved posterior hip stability. Furthermore, since a majority of the femoral neck is preserved, the short external complex is successfully closed in a consistent fashion. This adds an additional soft tissue layer that is protective.

Short stems have a definite role in modern THA, as greater emphasis is being placed on soft tissue and bone sparing techniques and as refinements continue in the understanding of proximal femoral fixation.

 Many short-stem designs have considerably different style features that may alter bone remodeling. Bony adaptation around new implants might have different time frames before these changes occur. Only detailed follow-up will render the results. Knowing the design and the required technique is vital to fit the device properly to the patient. The variations of short stems available call for caution in their overall use until there is better understanding of how dependent these stems are on individual stem features, bone quality, and surgical techniques.

I have attached a few articles of recent publication for your review.

My Colleagues and I are optimistic about short stems being a viable option for THA. Although careful understanding of design and technique are necessary for an optimum outcome.

Note: We can design features into explanting a stem without compromising long-term fixation.

 Tim

This is great as, if I am correct, there are within the culture some local habits, like to sit in deep flexion or using a cross leg position, so your choice accommodates these movements.

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

Very interesting question, because we are facing in our everyday practice.

According my opinion this is very complex problem and evaluation of reduction of femoral head in acetabulum must be first of all clinically, by ultrasound: static and dynamic, X-ray and in some cases MRI. It's depends from the level of pathology according Graf's Classification and type: decentrered hips, unstable hips or stable but dysplastic hips. Ultrasound can provide an assessment of the position, stability and morphology of the hip until the child is one year old. I prefer more Tubingen Hip Flexion orthosis designed by Prof Bernau, because this orthosis is better for saving reduction in human position. But anyway diagnostic, evaluation and treatment is very complex and specific for every patients.  

You are right that the interest in applying of antifibrinolytics in arthroplasty has increased.Multiple reports appeared. However, there are still concerns as far as eventual thrombotic complications are not excluded. Mortality associated with another antifibrinolytic (aprotinin) was an early concern. 

AAOS (2013) recommended future studies on reductions in transfusions, costs, and longer-term mortality data in designing the optimal administration regimen for perioperative antifibrinolytic therapy. The TA application appears to be efficacious for reducing blood loss in arthroplasty, but the optimal route, timing and dosages have not be still defined unambiguously.

Dear Antonio, 

Thats exactly what we did. The urological problem is being sorted out.

Dear Matt, I agree but like Dr Tanchev said, the problem does arise when spinal lasts too long.

Thanks for the opinions

Murali

THERE ARE TWO NEW PAPERS WHICH ARE WORTH DISCUSSING IN THIS CONTEXT. HERE THEY ARE

Total Joint Arthroplasty: Should Patients Have Preoperative Dental Clearance?

Alexander Lampley, MD, Ronald C. Huang, MD, William V. Arnold, MD, PhD, Javad Parvizi, MD, FRCS

Received 20 May 2013; accepted 24 November 2013. published online 04 December 2013.

The Journal of Arthroplasty

Volume 29, Issue 6 , Pages 1091-1097, June 2014

Abstract

Obtaining dental clearance prior to elective total joint arthroplasty is a common practice; however, little published data exist to justify this requirement. Dental clearance data for 365 elective total knee and total hip arthroplasty patients were gathered prospectively. Of these patients, 358 (average age of 62.4years; 157 men and 201 women; 152 primary total knee arthroplasties (TKAs), 16 revision TKA arthroplasties, one conversion TKA, 168 primary total hip (THAs) arthroplasties and 21 revision THA arthroplasties) proceeded to surgery and follow-up data were available for 355. A comparison group of 218 hip fracture patients (average age of 78.7years; 52 men and 109 women; 137 THA and 81 hemiarthroplasties) with no preoperative dental clearance who were treated with hip arthroplasty was extracted retrospectively from an institutional database. Follow-up data were available for 161 of these patients. The incidence of dental pathology in the elective arthroplasty group was 8.8%. Early postoperative infection requiring surgical treatment occurred in six patients (1.7%) in the dental clearance elective arthroplasty group and in four patients (2.5%) in the hip fracture arthroplasty group. No statistical difference was found between the two groups. This suggests that the perceived need for routine preoperative dental screening for all hip and knee arthroplasty patients should be reassessed.

2. Antibiotic Prophylaxis for Dental Procedures at Risk of Causing Bacteremia Among Post-Total Joint Arthroplasty Patients: A Survey of Canadian Orthopaedic Surgeons and Dental Surgeons

Tristan Colterjohn, BAS, Justin de Beer, MD, FRCSC, Danielle Petruccelli, MLIS, MSc, Nazar Zabtia, MD, FRCSC, Mitch Winemaker, MD, FRCSC

Abstract

To elicit current practice and attitudes toward use of antibiotic-prophylaxis among TJA patients prior to dental procedures, a cross-sectional survey of practicing Canadian orthopaedic (OS) and dental surgeons (DS) was undertaken. Of respondents, 77% of OS and 71% of DS routinely prescribe antibiotic-prophylaxis, but while 63% of OS advocate lifelong use, only 22% of DS choose to do so (P<0.0001). Both groups nonetheless recognize the importance of treatment within 2-years post-TJA as per AAOS/ADA guidelines. However, greater duration of practice pointed to potential inadequacy of these guidelines based on reported experience with late-hematogenous infection post-TJA. While discrepancies in attitude toward antibiotic-prophylaxis between surgeon groups remain, both groups agreed that the evidence to support decision making regarding antibiotic-prophylaxis for TJA patients undergoing dental procedures remains inadequate.

The Journal of Arthroplasty

Volume 29, Issue 6 , Pages 1087-1090, June 2014

Dear Murali

It was a pleasure

Regards

In case of reading the pioneers of total knee replacement as well as if you follow the scoring systems all values must be positive. Any hyper extension has to be reported as a positive value with the addition hyperextention. I am afraid that the confusion started when some health workers than surgeons started to publish their results and started to make negative markings. Following this some of the surgeons followed. So I will urge the authors of any paper to define clearly the ROM in the correct way either the value of their work will be diminished

Both questionnaires require a licence - the licence for the EQ-5D may be free (but may cost if it is a commercial project). The project can be registered on the EQ-5D website (www.euroqol.org).

Licensing for the SF-36 is slightly more complex and can be expensive depending on the number of participants and the method of analysis chosen. The most convenient way is the online scoring, a web-based database of your study scores. You can expect to be charged an annual usage fee for this database and then pay separate for the number of times you use the test. Prices for this will again depend on the type of study you are planning (commercial, non-commercial, student lead, etc.). More info can be found on www.sf-36.org under the Tab "I want SF" (located at the top of the page).

DOI: researcher who's been through the process of obtaining both licences

We published a paper (The painful knee after TKA: a diagnostic algorithm for failure analysis. KSSTA). There you find our algorithm. Hope this is helpful for you.

Obesity is associated with an overabundance of pro-inflammatory markers which have impact on various tissues, probably contributing to OA.