15-year survivorship of a unique dual-modular femoral stem in primary hip arthroplasty.

BACKGROUND: Hip offset, version, and length are interdependent femoral variables which determine stability and leg length. Balancing these competing variables remains a core challenge in hip arthroplasty. The potential benefits of modular femoral stems have been overshadowed by higher rates of failure. The objective of this study was to assess the survivorship of a unique dual-modular femoral stem at an average 15-year follow-up period. METHODS: The records of all patients with osteoarthritis who underwent primary total hip arthroplasty with this device between 2004-2009 were reviewed. There were no exclusions for BMI or other factors. We examined the data with Kaplan-Meier survival analysis. The primary endpoint for survival was mechanical failure of the modular neck-body junction. RESULTS: The survivorship of this device in 172 subjects was 100% with none experiencing mechanical failure of the modular junction at an average of 15 years. 60 patients died of causes unrelated to their THA and 9 patients were lost to follow-up. There were three early (≤ 12 months) dislocations (1.7%), and seven total dislocations (4.1%). 16 patients underwent reoperations during the follow-up period, none for any complication of the modular junction. Radiographic results showed well-fixed femoral stems in all cases. There were no leg length discrepancies of greater than 10 mm, and 85% were within 5 mm. CONCLUSION: There were no mechanical failures of the modular junction in any of the subjects over the average 15-year period, demonstrating that this dual-modular design is not associated with increased failure rates. We achieved a 1.7% early dislocation rate and a 4.1% total dislocation rate without any clinically significant leg length discrepancies.

Evaluation of the Safety of Uninterrupted Warfarin Anticoagulation With Tranexamic Acid in Total Joint Arthroplasty.

BACKGROUND: The continuation of long-term warfarin therapy is gaining acceptance in minor surgeries but maintaining therapeutic international normalized ratio (INR) values among patients during major orthopedic procedures raises concern. While bridging therapy with low-molecular-weight heparin is currently recommended for patients receiving anticoagulation, few studies have evaluated the safety of continuing warfarin during total joint arthroplasty. This study evaluated the safety and efficacy of continuous warfarin anticoagulation through total joint arthroplasty with and without prophylactic tranexamic acid (TXA). MATERIALS AND METHODS: We conducted a retrospective, matched-pair analysis of two experimental groups of patients who underwent primary total hip arthroplasty or total knee arthroplasty performed by a single surgeon. Our first experimental group, warfarin plus TXA (warfarin+TXA), consisted of 21 patients who underwent arthroplasty while receiving therapeutic anticoagulation with warfarin (INR, 2.0-3.0) and who received prophylactic TXA. Our second experimental group, warfarin without TXA (warfarin-TXA), consisted of 40 patients who underwent arthroplasty while receiving therapeutic anticoagulation with warfarin (INR, 2.0-3.0) without prophylactic TXA. RESULTS: The percent change in hemoglobin value after surgery, red blood cells transfused, surgical site infections, bleeding complications, and thrombotic complications were similar between both experimental and control groups. When comparing the historical group with the warfarin+TXA group, the addition of TXA resulted in a statistical decrease in mean red blood cells transfused and estimated blood loss, with no statistically significant increase in complications. CONCLUSION: Many factors must be considered when choosing perioperative thromboembolic prophylaxis for arthroplasty candidates with medical comorbidities requiring long-term anticoagulation. This study presents data indicating that it could be safe and effective to continue therapeutic warfarin while using prophylactic TXA. [Orthopedics. 2024;47(4):211-216.].

A prospective comparison of total knee arthroplasty using ultra-congruent, condylar-stabilizing, and posterior-stabilized devices implanted with kinematic alignment: better 2-year outcomes with ultra-congruent.

PURPOSE: This study compared the 5-year results of posterior cruciate ligament (PCL)-sacrificing total knee arthroplasty (TKA) with either a post and cam posterior-stabilized (PS) device, a dished, congruent condylar-stabilizing (CS) device, or a deep-dished ultra-congruent (UC) device. The hypothesis was that the clinical and radiographic outcomes would be equivalent. CS and PS participants were part of a prospective, randomized trial, and UC participants were part of a separate prospective, non-randomized protocol that was otherwise identical. A kinematic alignment surgical technique was utilized. METHODS: Participants were assessed preoperatively, and postoperatively at 6 weeks, 6 months, and annually for 5 years by Knee Society Score (KSS), SF-36 v2, Lower Extremity Activity Scale (LEAS), and physical and radiographic evaluation. There were 116 CS/PS participants and 69 UC participants who participated in the study. RESULTS: Tourniquet (P = .02) and operative (P = .01) times for the CS and UC groups were significantly shorter than the PS group. KSS Function scores were better for the UC group than the CS and PS groups at 6 months (P = .04) and 1 year (P = .03), and better in the UC group vs. CS at 2 years (P = .04). The KSS Pain-only score was also better in the UC compared to PS at 6 months (P = .04). There were no significant differences for the KSS Pain/Motion scores, flexion, SF-36, and LEAS scores at any time. CONCLUSION: These data confirm the hypothesis that there are no clinically meaningful significant differences in outcomes between the three groups at a 5-year minimum follow-up, though there is a trend toward less pain and better function at earlier visits in the UC group. LEVEL OF EVIDENCE: II.

Mid-Flexion, Anteroposterior Stability of Total Knee Replacement Implanted with Kinematic Alignment: A Randomized, Quantitative Radiographic Laxity Study with Posterior-Stabilized and Medial-Stabilized Implants.

UPDATE: This article was updated on January 4, 2023, because of a previous error, which was discovered after the preliminary version of the article was posted online. On page 16, in Figure 5, the x-axis that had read "P<0.0086" now reads "KSS Pain (p=0.02)," and the value for the MS group that had read "48.9" now reads "48.8."This article was updated on January 6, 2022, because of a previous error. On page 13, in the section entitled "Results," the sentence that had read "However, when only the subset of female subjects was considered, the MS group demonstrated significantly less anteroposterior laxity in 90° of flexion than the MS group (2.3 versus 5.4 mm; p = 0.008)." now reads "However, when only the subset of female subjects was considered, the MS group demonstrated significantly less anteroposterior laxity in 90° of flexion than the PS group (2.3 versus 5.4 mm; p = 0.008)." BACKGROUND: Stability in mid-flexion is important for satisfactory clinical outcomes following total knee arthroplasty (TKA). The purpose of the present study was to compare the anteroposterior stability of knees that had been treated with a posterior-stabilized (PS) device or a medial-stabilized (MS) device. We hypothesized that mid-flexion laxity would be greater in the PS group and that clinical outcome scores would be better for the group with lower laxity. METHODS: Sixty-three patients who had been randomly selected from a larger randomized, prospective, blinded clinical trial underwent primary TKA with either a PS implant (n = 30) or an MS implant (n = 33). Range of motion, the Knee Society Score (KSS), and the Forgotten Joint Score (FJS) were collected, and anteroposterior laxity with the knee in 45° and 90° of flexion was evaluated with stress radiographs. RESULTS: In 45° of flexion, the MS group demonstrated significantly less total anteroposterior displacement than the PS group (mean, 3.6 versus 16.5 mm; p ≤ 0.0001). In 90° of flexion, the total anteroposterior displacement was not significantly different for the 2 groups when both male and female patients were included (mean, 3.9 versus 5.9; p = 0.07). However, when only the subset of female subjects was considered, the MS group demonstrated significantly less anteroposterior laxity in 90° of flexion than the PS group (2.3 versus 5.4 mm; p = 0.008). The groups did not differ significantly in terms of preoperative age, body mass index, sex distribution, FJS, KSS, or range of motion, and they also did not differ in terms of postoperative FJS or range of motion. However, all 33 patients in the MS group returned to sports as indicated in question 12 of the FJS, compared with 19 subjects in the PS group (p = 0.0001). The postoperative KSS Pain, Pain/Motion, and Function scores were all significantly higher in the MS group than the PS; specifically, the mean KSS Pain score was 48.8 in the MS group, compared with 44.8 in the PS group (p = 0.02); the mean KSS Pain/Motion score was 98.4 in the MS group, compared with 89.5 in the PS group (p < 0.0001); and the mean KSS Function score was 95.5 in the MS group, compared with 85.7 in the PS group (p = 0.003). CONCLUSIONS: Mid-flexion laxity was greater in patients with PS implants than in those with MS implants, and laxity in 90° was greater in the subset of female patients in the PS group. The decreased laxity observed in the MS group correlated with higher KSS Pain, Pain/Motion, and Function scores as well as with a higher rate of return to sports activities. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Prospective Randomized Comparison of Posterior-Stabilized Versus Condylar-Stabilized Total Knee Arthroplasty: Final Report of a Five-Year Study.

BACKGROUND: This report presents the minimum 5-year results of a prospective, randomized, Level of Evidence I study that evaluated cruciate-sacrificing total knee arthroplasty using either a posterior-stabilized (PS) device or a condylar-stabilized (CS) device. We hypothesized that the clinical outcomes of both groups would be equivalent and that there would be differences in operative time and/or blood loss parameters. METHODS: One-hundred eleven patients undergoing total knee arthroplasty were randomized to receive either a post-cam style tibial insert (PS, n = 56) or a more congruent anterior-lipped tibial insert (CS, n = 55). All posterior cruciate ligaments were sacrificed. RESULTS: Comparison of the clinical scores and radiographic results between both groups were essentially equivalent with no statistically significant differences at the final 5-year evaluation, although the CS knee group had significantly fewer incidences of postoperative mechanical sensations (P = .01). CONCLUSION: These results demonstrate that the CS knee provides excellent clinical, functional, and radiographic outcomes that are comparable to the results achieved with the PS knee, with a lower incidence of mechanical sensations, and support the use of a CS device as an alternative to the PS device.

Surgical capacity building in Timor-Leste: a review of the first 15 years of the Royal Australasian College of Surgeons-led Australian Aid programme.

BACKGROUND: Timor-Leste suffered a destructive withdrawal by the Indonesian military in 1999, leaving only 20 Timorese-based doctors and no practising specialists for a population of 700 000 that has now grown to 1.2 million. METHODS: This article assesses the outcomes and impact of Royal Australasian College of Surgeons (RACS) specialist medical support from 2001 to 2015. Three programmes were designed collaboratively with the Timor-Leste Ministry of Health and Australian Aid. The RACS team began to provide 24/7 resident surgical and anaesthesia services in the capital, Dili, from July 2001. The arrival of the Chinese and Cuban Medical Teams provided a medical workforce, and the Cubans initiated undergraduate medical training for about 1000 nationals both in Cuba and in Timor-Leste, whilst RACS focused on specialist medical training. RESULTS: Australian Aid provided AUD$20 million through three continuous programmes over 15 years. In the first 10 years over 10 000 operations were performed. Initially only 10% of operations were done by trainees but this reached 77% by 2010. Twenty-one nurse anaesthetists were trained in-country, sufficient to cover the needs of each hospital. Seven Timorese doctors gained specialist qualifications (five surgery, one ophthalmology and one anaesthesia) from regional medical schools in Papua New Guinea, Fiji, Indonesia and Malaysia. They introduced local specialist and family medicine diploma programmes for the Cuban graduates. CONCLUSIONS: Timor-Leste has developed increasing levels of surgical and anaesthetic self-sufficiency through multi-level collaboration between the Ministry of Health, Universidade Nacional de Timor Lorosa'e, and sustained, consistent support from external donors including Australian Aid, Cuba and RACS.

Effect of zoledronic acid on reducing femoral bone mineral density loss following total hip arthroplasty: preliminary results of a prospective randomized trial.

This randomized trial evaluated the effect of zoledronic acid on femoral bone mineral density (BMD) following primary total hip arthroplasty. Bone mineral density was compared for up to 2years in 27 patients receiving 5mg zoledronic acid intravenous infusion and in 24 patients receiving placebo at 2weeks and 1year after surgery. Zoledronic acid prevented loss of bone mineral density at 1year (+13.8% vs +1.4%, P=.0065) and 2years (+14.3% vs -4.0%, P<.0001) in Gruen zone 1, at 1year (-8.4% vs -25.4%, P<.0001) and 2years (-9.6% vs -27.3%, P<.0001) in Gruen zone 7, at 6weeks, 6months, and 1 or 2years in Gruen zones 4 and 6. For all Gruen zones, prevention of BMD loss by ZOL was significant at 6weeks, 6months, 1year (+0.80% vs -6.03%, P<.0001) and 2years (-0.16% vs -7.13%, P<.0001).

A systematic review of laparoscopic live-donor nephrectomy.

BACKGROUND: A systematic review was undertaken to assess the safety and efficacy of laparoscopic live-donor nephrectomy (LLDN) compared with open live-donor nephrectomy (OLDN). METHODS: Literature databases were searched from inception to March 2003 inclusive. Comparative studies of LLDN versus OLDN (randomized and nonrandomized) were included. RESULTS: There were 44 included studies, and the quality of the available evidence was average. There was only one randomized controlled trial and six nonrandomized comparative studies with concurrent controls identified. In terms of safety, for donors, there did not seem to be any distinct difference between the laparoscopic and open approaches. No donor mortality was reported for either procedure, and the complication rates were similar although the types of complications experienced differed between the two procedures. The conversion rate for LLDN to an open procedure ranged from 0% to 13%. In terms of efficacy, LLDN seemed to be a slower operation with longer warm ischemia times than OLDN, but this did not seem to have resulted in increased rates of delayed graft function for recipients. Donor postoperative recovery and convalescence seemed to be superior for LLDN, making it a potentially more attractive operation for living donors. Although in the short-term, graft function and survival did not seem to differ between the two techniques, long-term complication rates and allograft function could not be determined and further long-term follow-up is required. CONCLUSIONS: LLDN seems to be at least as safe and efficacious as OLDN in the short-term. However, it remains a technique in evolution. Further high-quality studies are required to resolve some of the outstanding issues surrounding its use, in particular, long-term follow-up of donor complications and recipient graft function and survival.

Postoperative pain control: contribution of psychological factors and transcutaneous electrical stimulation.

The influence of transcutaneous electrical stimulation (TES) and psychological factors in determining the intensity of acute postoperative pain was examined in a prospective, double-blind controlled trial completed by 30 patients having elective surgery. Psychometric tests were administered prior to surgery. Postoperative pain was assessed by cumulative morphine requirement (M48) administered intramuscularly, and the mean score of a visual analogue scale of pain (VAS), in the first 48 h following surgery. M48 was significantly correlated with the VAS score (r = 0.62, P less than 0.001), and with the psychometric test scores for trait-anxiety (r = 0.70, P less than 0.001) and neuroticism (r = 0.67, P less than 0.001). Though patients treated with TES required 25% less morphine than those treated with placebo, the difference was not significant using monovariate analysis and applying unpaired two-tailed Student's t-test (P less than 0.2). When the contribution of neuroticism to the variance of M48 was adjusted using multiple regression analysis, the effect of TES became significant at the 0.05 level. Covariance analysis showed that TES contributed some 19% to the explained variance of M48 while neuroticism contributed about 80%, and there was no interaction between these two factors. These findings allow a degree of prediction of the individual patient's postoperative pain and narcotic requirement, and point to a strong correlation between postoperative pain perception and personality.