Lateral Unicompartmental Knee Arthroplasty for Osteoarthritis Secondary to Lateral Meniscectomy: High Functional Results and Survivorship and Low Osteoarthritis Progression at a Mean 10 Years of Follow-up.

BACKGROUND: Meniscectomy, whether partial or total, is a common knee surgery, but it considerably increases the risk of knee osteoarthritis (OA). Lateral meniscectomy has more severe consequences than medial meniscectomy, leading to faster OA progression and worse clinical outcomes. Unicompartmental knee arthroplasty (UKA) is a suitable treatment option for lateral OA and has demonstrated better outcomes than total knee arthroplasty (TKA). The aims of this study were to evaluate the clinical and functional results, OA progression in the medial compartment, and implant survivorship following lateral UKA in patients with OA secondary to lateral meniscectomy and to compare these outcomes with those of patients who underwent lateral UKA for primary lateral OA. METHODS: Between 2001 and 2017, 214 lateral UKAs were performed. Of these, 42 were performed for OA secondary to lateral meniscectomy. The control group was composed of patients who underwent lateral UKA for primary lateral OA and was formed through a 1:1 case-control matching process based on sex, age, body mass index, and operation date. The outcomes that were studied included range of motion, Knee Society Score, University of California Los Angeles (UCLA) Activity Score, Tegner Activity Scale, Forgotten Joint Score, visual analog scale for pain, OA progression in the medial compartment, and implant survivorship. RESULTS: At a mean follow-up of 10.2 years, both groups demonstrated significant improvements (p < 0.01) after lateral UKA in all clinical and functional scores except the UCLA Activity Score and Tegner Activity Scale. No significant differences in clinical and functional scores were found between the groups. However, patients with OA secondary to meniscectomy exhibited significantly less OA progression in the medial compartment (p = 0.035) and higher 10-year implant survival (97.6% versus 83.3%). CONCLUSIONS: Lateral UKA is an effective treatment option for OA secondary to lateral meniscectomy, providing excellent functional outcomes and survivorship. Patients with post-meniscectomy OA exhibited less OA progression in the medial compartment than patients with primary OA and, consequently, had better 10-year implant survivorship. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Mild Valgus Alignment After Lateral Unicompartmental Knee Arthroplasty Led to Lower Functional Results and Survivorship at Mean 8-Year Follow-Up.

BACKGROUND: In medial unicompartmental knee arthroplasty (UKA), the best results and the highest survivorship are found by mild undercorrection of varus deformities. In lateral UKA, the desirable amount of valgus undercorrection has not yet been determined. The purposes of this study were to present the results of a consecutive series of lateral UKAs and to investigate the effect of postoperative limb alignment on them. METHODS: A total of 161 lateral UKA were reviewed. Outcomes studied included range of motion (ROM), Knee Society Score (KSS), University of California Los Angeles Activity Score, Tegner Activity Scale, Forgotten Joint Score, visual analogue scale (VAS) for pain, and survivorship. Patients were divided into two groups according to postoperative alignment: group A (hip-knee-ankle ≥184°, 79 UKA) and group B (hip-knee-ankle <184°, 82 UKA). RESULTS: At a mean follow-up of 8 years (range, 2-18), ROM (P < .01); KSS-C (P < .01); KSS-F (P < .01); VAS (P < .01) improved from baseline. No differences were noted in postoperative ROM, VAS, University of California Los Angeles, Tegner Activity Scale, and Forgotten Joint Score between groups. Group A showed higher postoperative clinical and functional KSS (P < .01) and higher survivorship (96.2 versus 91.5%, P = .01) than group B. CONCLUSION: Mild valgus alignment (3° or less) after lateral UKA is linked to lower clinical and functional scores and lower survivorship compared to moderate valgus (over 4°) at mean 8-year follow-up. More undercorrection of the coronal deformity in lateral UKA compared to medial UKA is desirable to get the best results.

Staged BiCompartmental Knee Arthroplasty has Greater Functional Improvement, but Equivalent Midterm Survivorship, as Revision TKA for Progressive Osteoarthritis After Partial Knee Arthroplasty.

BACKGROUND: Progressive arthritis in the unresurfaced compartments of the knee is one failure mode after partial knee arthroplasty (PKA). While progressive arthritis after PKA is typically treated with revision to TKA (rTKA), staged bicompartmental knee arthroplasty (sBiKA) -the addition of another PKA - is an alternative. This study compared outcomes of sBiKA and rTKA for progressive arthritis after PKA. METHODS: A retrospective comparative study of non-consecutive cases at four institutions were performed in patients with an intact PKA, without loosening or wear, who underwent sBiKA (n = 27) or rTKA (n = 30), for progressive osteoarthritis. Outcomes studied were new Knee Society Function and Objective Scores (KSSF, KSSO), KOOS, Jr., ROM, operative times, length of stay, complication rates and the need for reoperations. RESULTS: Mean time to conversion was 7.4 ± 6 years for sBiKA and 9.7 ± 8 for rTKA, P = .178. Patient demographics and pre-operative outcomes were similar among cohorts. At an average of 5.7 ± 3 (sBiKA) and 3.2 ± 2 years (rTKA), KOOS, Jr. significantly improved, P < .001, by an equivalent amount. Post-operative KSSO and KSSF were significantly higher in the sBiKA cohort, respectively, (90.4 ± 10 vs 72.1 ± 20, P < .001) and (80.3 ± 18 vs 67.1 ± 19, P = .011). sBiKA patients had significantly greater improvement in KSSO (30.7 ± 33 vs 5.2 ± 18, P = .003). One sBiKA patient underwent reoperation for continued pain. CONCLUSION: SBiKA has equivalent survivorship, but greater improvement in functional outcomes as rTKA at short to midterm follow-up. Given the shorter operative times and length of stay, sBiKA is a safe and cost-effective alternative to rTKA for progressive osteoarthritis following PKA. Nevertheless, further follow-up is necessary to determine whether sBiKA is a durable option.

Patellofemoral arthroplasty: obesity linked to high risk of revision and progression of medial tibiofemoral osteoarthritis.

PURPOSE: The purpose of this study was to determine the effect of obesity on patient outcome, procedure failure rate and osteoarthritis (OA) progression in the tibiofemoral compartments in a series of isolated patellofemoral arthroplasty (PFA) performed with a third-generation implant. METHODS: The study population was patients who had undergone third-generation PFA at a specialized orthopedic center between 2007 and 2017. Patients were categorized by body-mass index (BMI) as obese (O, BMI > 30 kg/m2) or nonobese (NO, BMI < 30 kg/m2). Preoperative and postoperative clinical and functional assessment included knee range of motion, Knee Society Score (KSS), University of California Los Angeles (UCLA) Activity Score, Tegner Activity Level Scale, and visual analogue scale (VAS) for pain. Preoperative and postoperative radiographs were evaluated for progression of tibiofemoral compartment OA, changes in patellar height and in knee coronal alignment. Multiple logistic regression models were used to assess the effect of BMI on outcomes together with other covariates. RESULTS: A total of 120 PFAs with a mean follow-up of 6.9 ± 2.5 years were included: 25 in the O group and 95 in the NO group. Significant improvement was noted in in knee range of motion (P < 0.001), clinical and functional KSS (P < 0.001), UCLA Activity Score (P < 0.001), Tegner score (P < 0.001) and VAS pain (P < 0.001) without inter-groups differences. Worsening of the medial Kellgren-Lawrence (KL) grade (but not the lateral KL grade) was more frequent in the O than the NO group during the follow-up period (P = 0.014). Failure occurred in 4.2% of NO and in 20% of O group patients; the difference was solely due to failure because of OA progression in the tibiofemoral compartment (16% in the O group). There were no between group differences in the failure rate for any cause other than OA progression (4.2% in the NO group, 4.0% in the O group). CONCLUSIONS: An equal improvement in function after PFA was noted in both obese and nonobese patients; however, the high failure rate due to OA progression in the medial tibiofemoral compartment warrants caution when considering PFA in obese patients.

Unicompartmental vs. total knee replacement in patients with failed high tibial osteotomy.

INTRODUCTION: The influence of a previous high tibial osteotomy (HTO) on the outcome and survival of a knee arthroplasty is a debated issue. The purpose of this study is to compare subjective, radiographic, and functional outcomes of unicompartmental knee replacement (UKR) and total knee replacement (TKR) after failed open wedge HTO. METHODS: 26 post-HTO UKRs (group A) with an average follow-up of 7.8 years (range 2-13), and 33 post-HTO TKRs (group B) with an average follow-up of 11.2 years (range 4-16) operated between 2001 and 2017, were retrospectively reviewed. Assessment included Knee Society Score (KSS), University of California at Los Angeles Activity Score (UCLA), and Western Ontario and McMaster University Osteoarthritis Index (WOMAC). Standard knee X-rays, and long-standing X-rays were performed pre-operatively and at follow-up to evaluate prosthesis survival, coronal alignment, and patellar height. RESULTS: Improvements regarding KSS, UCLA and WOMAC scores were noted at follow-up in both groups compared to pre-operatory status (p < 0.001). No statistically significant differences in clinical and functional postoperative scores were reported between groups (p = n.s.) at follow-up. Group B presented a more neutral mean mechanical axis of 0.5° compared to 2.7° in Group A (p < 0.001). CONCLUSIONS: Performing UKR after previous failed HTO is a safe and effective procedure which leads to clinical, radiological and functional outcomes comparable to TKR after HTO.

Medial Unicompartmental Knee Arthroplasty After Failed Open-Wedge High Tibial Osteotomy.

BACKGROUND: Controversy exists whether or not a previous high tibial osteotomy (HTO) influences the outcome and survival of a unicompartmental knee arthroplasty (UKA). The aim of this retrospective study was to evaluate clinical, radiological, and functional outcomes of UKA after failed open-wedge HTO compared with UKA with no previous HTO. METHODS: Between 2001 and 2017, 24 post-HTO UKAs (group A) with an average follow-up of 8.1 years (range: 5 to 13) were compared with a control group of 30 patients undergoing simple UKA (group B) with an average follow-up of 9.5 years (range: 2 to 16). All patients were evaluated preoperatively and postoperatively using Knee Society Score, University of California at Los Angeles Activity Score, Western Ontario and McMaster University Osteoarthritis Index, and through objective evaluation. Mechanical coronal alignment and Caton-Deschamps index were measured both preoperatively and postoperatively. RESULTS: In both groups, Knee Society Score, University of California at Los Angeles Activity Score, and Western Ontario and McMaster University Osteoarthritis Index scores significantly improved at follow-up (P < .001). In addition, statistically significant greater improvements in clinical and functional scores were reported in group B compared with group A (P < .001). No statistically significant differences concerning postoperative mechanical axis were observed between groups (2.7° and 3.2°, respectively, P = .27) and with regard to Caton-Deschamps index (1.0° and 1.1°, respectively, P = .44). CONCLUSION: This study demonstrated improvements in clinical and functional outcomes compared with preoperatory status in both groups irrespective of a previous HTO. A prior HTO was a determinant for having reduced postoperative clinical and functional outcomes after UKA.

Clinical outcomes and survivorship of two-stage total hip or knee arthroplasty in septic arthritis: a retrospective analysis with a minimum five-year follow-up.

PURPOSE: Septic arthritis of the native joint is challenging for orthopedic surgeons because it may lead to wide bone defects and severe impairment of joint function. This study aimed to analyze clinical functional outcomes, the rate of infection eradication, and survival of implants of patients who underwent two-stage arthroplasty for septic arthritis of the hip and knee. METHODS: A retrospective single-centre analysis was conducted of patients treated for septic arthritis of the hip and knee joints through a two-stage surgery between 2012 and 2015. Clinical and radiological records were gathered from the prospectively collected Institutional Arthroplasty Registry. Patients' pre-operative Harris hip scores and Knee Society scores were compared with those obtained at the latest follow-up. Kaplan-Meier curves were generated to assess survival of implants. RESULTS: Forty-seven patients were included. The mean follow-up was 85.2 ± 15.4 months. The Harris hip score improved from 39.4 ± 9.9 to 84.5 ± 10.8 points (p < 0.001). The Knee Society score improved from 40.7 ± 8.4 to 86.0 ± 7.8 points (p < 0.001). Knee Society score-function increased from 25.7 ± 14.2 to 85.4 ± 23.4 points (p < 0.001). The infection eradication rates were 92.0% and 90.9% in patients who underwent hip and knee operation, respectively (p = 0.891). Overall survivorship of implants after the second stage was 93.6%. CONCLUSIONS: Two-stage arthroplasty provides good to excellent clinical outcomes in cases of active septic arthritis of the hip and the knee, high rates of infection control, and implant survival.

Conical Primary Cementless Stem in Revision Hip Arthroplasty: 94 Consecutive Implantations at a Mean Follow-Up of 12.7 years.

BACKGROUND: Revision of a failed total hip arthroplasty (THA) poses technical challenges. The use of primary stems for revision can be advantageous for maintaining bone stock and reducing complications: small case series have reported promising results in the short-term to mid-term follow-up. The aim of this study was to evaluate the long-term clinical and functional results and survivorship of a consecutive series of THA femoral component revisions using a conical primary cementless stem (PCS). METHODS: Ninety-four stem revisions with a preoperative Paprosky I or II defect were analyzed at an average follow-up of 12.7 ± 5.4 years. Aseptic loosening was the reason for revision in 92.5% of cases. Twenty patients were lost to follow-up. Two subgroups were created: Group 1 (n = 59) underwent isolated stem revision; Group 2 (n = 15) underwent complete THA revision. All were evaluated preoperatively and postoperatively based on the Harris Hip Score (HHS), the Western Ontario and McMaster Universities Index (WOMAC) score, and the visual analog scale for pain (VAS). Residual trochanteric pain and length discrepancies were recorded. Radiographic evaluation included signs of osteolysis, subsidence, loosening, and heterotopic ossification. RESULTS: PCS survivorship was 100% at 5 years and 95.9% at 10 years. Overall, significant postoperative improvements (P < .01) were observed on the HHS (44.3 vs 86.9), WOMAC (42.8 vs 82.8), and VAS (7.0 vs 3.0). Postoperative scores on all scales were higher for Group 1 (P < .01). Three patients (4.1%) underwent further stem revision. Demarcation lines (1 mm) were found in 12 (16.2%) patients and significant heterotopic ossifications in 22 (29.7%). CONCLUSION: The use of PCS for stem revision in failed THA with a limited femoral bone defect is a reliable option for both isolated stem revision and concomitant cup revision in well-selected patients.

Outcomes of lateral unicompartmental knee arthroplasty in post-traumatic osteoarthritis, a retrospective comparative study.

PURPOSE: We asked whether the clinical and radiographic outcomes and survivorship after unicompartmental knee arthroplasty (UKA) for osteoarthritis (OA) consequent to lateral tibial plateau fracture were comparable with those obtained after lateral UKA for primary OA. METHODS: A total of 13 patients receiving lateral UKA for OA secondary to tibial plateau fracture (post-traumatic UKA, P-UKA) were compared with 13 patients who underwent lateral UKA for primary OA (OA-UKA). Patients were matched for age at surgery, gender, body mass index, and follow-up length. Pre- and post-operative clinical and radiographic assessments included clinical (KSS-c) and functional (KSS-f) Knee Society Score, Hip-Knee-Ankle (HKA) angle, and signs of osteolysis. RESULTS: Mean follow-up was similar in both groups: 9.9 ± 4.6 years for P-UKA and 9.3 ± 2.4 years for OA-UKA. The two way ANOVA procedure followed by the Bonferroni multiple comparisons test highlighted a baseline difference in KSS-c with P-UKA having greater scores than OA-UKA (+ 12; p < 0.05) and both groups showed large improvements in KSS-c (p < 0.001), KSS-f (p < 0.001), and HKA angle (p < 0.001) at follow-up. The nine year prosthesis survival rate, tested by the Kaplan-Meier methods, was 92% in both groups. CONCLUSION: Lateral UKA for OA secondary to tibial plateau fracture was efficient in restoring joint function, improving clinical results, and correcting lower limb alignment. Clinical outcomes and nine year survivorship did not differ from lateral UKA for primary OA. Consequently, lateral UKA should be considered a valid option in treating lateral posttraumatic OA in carefully selected patients. TRIAL REGISTRATION NUMBER: ( clinicaltrials.gov ) NCT04198389.

Oral Supplementation with Sucrosomial Ferric Pyrophosphate Plus L-Ascorbic Acid to Ameliorate the Martial Status: A Randomized Controlled Trial.

Altered martial indices before orthopedic surgery are associated with higher rates of complications and greatly affect the patient's functional ability. Oral supplements can optimize the preoperative martial status, with clinical efficacy and the patient's tolerability being highly dependent on the pharmaceutical formula. Patients undergoing elective hip/knee arthroplasty were randomized to be supplemented with a 30-day oral therapy of sucrosomial ferric pyrophosphate plus L-ascorbic acid. The tolerability was 2.7% among treated patients. Adjustments for confounding factors, such as iron absorption influencers, showed a relevant response limited to older patients (≥ 65 years old), whose uncharacterized Hb loss was averted upon treatment with iron formula. Older patients with no support lost -2.8 ± 5.1%, while the intervention group gained +0.7 ± 4.6% of circulating hemoglobin from baseline (p = 0.019). Gastrointestinal diseases, medications, and possible dietary factors could affect the efficacy of iron supplements. Future opportunities may consider to couple ferric pyrophosphate with other nutrients, to pay attention in avoiding absorption disruptors, or to implement interventions to obtain an earlier martial status optimization at the population level.

Simultaneous bilateral unicompartmental knee replacement improves gait parameters in patients with bilateral knee osteoarthritis.

BACKGROUND: Unicompartmental knee replacement (UKR) can provide reliable clinical and functional outcomes when performed simultaneously in both knees for treating bilateral osteoarthritis (OA). No studies to date have evaluated gait pattern after simultaneous bilateral UKR. The aim of this study was to evaluate changes in gait variables after bilateral single-stage UKR (B-UKR) and to compare them with the outcomes after unilateral UKR in two other groups of patients: one with bilateral knee OA (P-UKR) and one with the contralateral knee unaffected (H-UKR). METHODS: Three-dimensional motion cohort data were prospectively collected before and six months after surgery; 37 were allocated to the B-UKR (n = 13), P-UKR (n = 12) or H-UKR (n = 12) group. Spatiotemporal variables (stride length, gait speed, gait cadence, stance phase, swing phase, and double support phase) and kinematic parameters (knee flexion and extension peak values, knee range of motion (ROM), and hip abduction peak value) were analyzed using mixed analysis of variance (ANOVA). The magnitude of effect for significant outcomes (ES) was determined using Cohen's d. RESULTS: Postoperative improvement in gait cadence (P < 0.01; ES = 1.20), walking speed (P < 0.05; ES = 0.58), stride length (P < 0.05; ES = 0.67), knee ROM (P < 0.05; ES = 0.89), knee flexion (P < 0.05; ES = 0.94), and hip abduction (P < 0.001; ES = 1.16) was noted for the B-UKR group, whereas only stride length improved (P < 0.05; ES = 0.48) for the H-UKR group, and no changes in any gait parameter were seen for the P-UKR group. CONCLUSIONS: Postoperative improvement in gait parameters was observed in the B-UKR patients with bilateral OA. Whenever possible, simultaneous bilateral UKR should be considered in such patients.

One-staged combined hip and knee arthroplasty: retrospective comparative study at mid-term follow-up.

BACKGROUND: To date, few knowledge is available about safety and effectiveness of one-staged combined hip and knee arthroplasty. The aim of our study was to evaluate, in a comparative fashion, complications and outcomes in patients who underwent one-staged hip and knee arthroplasty. METHODS: Forty-two patients were enrolled and allocated into two groups of 21 patients each: one-staged hip and knee arthroplasty (group A) and two-staged hip and knee arthroplasty (group B). The follow-up averaged 50.2 months. Postoperative complications and implant survivorship were assessed prospectively. Outcomes were evaluated with Harris Hip score (HSS), Western Ontario Mc-Ministry score for the hip (h-WOMAC), Knee Society score (KSS), and Western Ontario Mc-Ministry knee score (k-WOMAC). Hip and knee range of motion (ROM) were measured both preoperatively and at the last follow-up. RESULTS: Two (9.5%) patients in group A and three (14.3%) patients in group B developed complications (P = 0.8). Although a significant decrease in postoperative haemoglobin (Hgb) values was found in group A patients during the hospital stay, no differences in blood transfusions were found (P = 0.8). No significant differences were found comparing clinical-functional outcomes between the two groups, while a significant reduction of hospital length of stay was shown in group A patients. CONCLUSIONS: One-staged combined hip and knee arthroplasty could be considered in patients with co-existing severe hip and knee osteoarthritis, providing similar complications and mid-term outcomes of two-staged procedures. However, the reproducibility safety and reliability of these procedures should be confirmed in prospective comparative randomised trials with more numerous patients. TRIAL REGISTRATION: Retrospectively registered.

Mid-Term Clinical, Functional, and Radiographic Outcomes of 105 Gender-Specific Patellofemoral Arthroplasties, With or Without the Association of Medial Unicompartmental Knee Arthroplasty.

BACKGROUND: The purpose of this study is to evaluate clinical and radiographic outcomes after gender-specific patellofemoral arthroplasty (PFA) either isolated or combined with unicompartmental knee arthroplasty (UKA). METHODS: A total of 105 PFAs in 85 patients were reviewed: 64 knees had isolated patellofemoral osteoarthritis and received an isolated PFA, and 41 knees with bicompartmental osteoarthritis were treated with medial UKA and PFA. Preoperative and postoperative clinical and functional assessment included knee range of motion, Knee Society Score, University of California Los Angeles Activity Score, Tegner Activity Level Scale, and visual analogue scale pain. Preoperative and postoperative radiographs were evaluated for patellofemoral and tibiofemoral compartment osteoarthritis, trochlear dysplasia, changes in patellar height, and signs of osteolysis. RESULTS: At a mean follow-up of 5.5 ± 1.6 years, both groups showed improvement in knee joint range of motion (P < .001), clinical and functional Knee Society Score (P < .001), University of California Los Angeles Activity Score (P < .001 in the PFA group and P = .004 in the UKA + PFA group), and visual analogue scale pain (P < .001). There were no statistically significant postoperative differences between the 2 groups. No signs of osteolysis or subsidence were recorded. Survivorship of these 105 implants was 95.2%. CONCLUSION: Excellent clinical and radiographic outcomes were achieved after PFA with a gender-specific implant both as isolated replacement and when combined with medial UKA. Bicompartmental replacement with small implants can be considered in patients with bicompartmental osteoarthritis and intact anterior cruciate ligament.

Bi-unicompartmental and combined uni plus patellofemoral replacement: indications and surgical technique.

The anatomy and orientation of the condyles and the trochlea are not standard, but related to morphotype, gender and race. Consequently, the extreme variability in their dimension, and in the distance and angle between the axis of the condyles and of the trochlea, often necessitates a "custom-made" replacement. This may be achieved through the use of small implants. Bicompartmental osteoarthritis with intact ligaments should be addressed with bi-unicompartmental (bi-UKR) or UKR plus patellofemoral replacement (PFR). These options allow selective replacement of the worn compartments and a customised fit of the small implants to the native knee anatomy. Clinical consequences are restoration of the native knee kinematics and overall better function.

Onsets of complications and revisions are not increased after simultaneous bilateral unicompartmental knee arthroplasty in comparison with unilateral procedures.

PURPOSE: The advantages of simultaneous bilateral procedures in joint arthroplasty have been widely described for in total joint replacements of both the hip and the knee. In contrast, unicompartmental knee arthroplasties, despite their effectiveness in pain relieving and functional improvement, are underinvestigated in these terms. The purpose of this study is to assess the possible benefits and risks of bilateral simultaneous knee replacements, in comparison with unilateral procedures. METHODS: A total of 567 surgery reports of bilateral simultaneous (220) or unilateral (347) unicompartmental knee arthroplasties were analysed to collect study parameters. Information like the onset of complications and need for revisions were recorded by phone interview (at least two years after surgery). All surgeries were performed by the same orthopaedic surgeon, assisted by the same anesthesiologist. RESULTS: Complication and revision rates, as well as the length of hospital stay were similar between the two study groups, while blood and haemoglobin losses, and consequently the use of transfusion of allogeneic and autologous blood units, were higher in the simultaneous bilateral group. CONCLUSIONS: Simultaneous bilateral unicompartmental knee arthroplasties could significantly reduce, if both joints are affected, the length of hospital stay and, therefore, patient management costs. At the same time, they do not lead to more frequent revisions or complications. The higher transfusion of allogeneic blood units could be reduced to unilateral surgery levels by the application of currently available protocols of autologous blood reinfusion.

Simultaneous bilateral total hip arthroplasties do not lead to higher complication or allogeneic transfusion rates compared to unilateral procedures.

PURPOSE: About 20 % of patients undergoing a primary total hip arthroplasty could undergo a second contralateral procedure within five years. The possibility to perform simultaneous bilateral hip replacements instead of two-stage surgery could reduce hospitalisation time and patient management costs, but concerns exist because of risks related to massive blood loss and possible increase in complication rates. The purpose of this study is to assess the veracity of these concerns. METHODS: Parameters like blood loss, transfused blood units, total hospital length of stay (surgical and rehabilitation) and presence of in-hospital complications were collected from surgery reports of two different groups of patients. The first group comprised patients undergoing simultaneous bilateral total hip arthroplasty (n = 63), while the second group consisted of patients undergoing unilateral surgery (n = 97). Occurrence of complications within six post-operative months was assessed by phone interview. RESULTS: No differences were observed in complication, revision and mortality rates between the study groups. On the contrary, blood loss was significantly higher in the bilateral group, but the application of appropriate transfusion protocols reduced the use of allogeneic blood transfusion to the levels recorded for unilateral patients. Moreover, the difference in length of hospital stay (about two days) between the two groups was not clinically relevant. CONCLUSIONS: Our data show that simultaneous bilateral procedures do not lead to higher complication or allogeneic transfusion rates in comparison to unilateral hip replacement, and that, in cases of bilateral disease, they could significantly reduce the total length of hospital stay and, therefore, patient management costs.

Blood management and transfusion strategies in 600 patients undergoing total joint arthroplasty: an analysis of pre-operative autologous blood donation.

BACKGROUND: Blood loss during total joint arthroplasty strongly influences the time to recover after surgery and the quality of the recovery. Blood conservation strategies such as pre-operative autologous blood donation and post-operative cell salvage are intended to avoid allogeneic blood transfusions and their associated risks. Although widely investigated, the real effectiveness of these alternative transfusion practices remains controversial. MATERIALS AND METHODS: The surgery reports of 600 patients undergoing total joint arthroplasty (312 hip and 288 knee replacements) were retrospectively reviewed to assess transfusion needs and related blood management at our institute. Evaluation parameters included post-operative blood loss, haemoglobin concentration measured at different time points, ASA score, and blood transfusion strategies. RESULTS: Autologous blood donation increased the odds of receiving a red blood cell transfusion. Reinfusion by a cell salvage system of post-operative shed blood was found to limit adverse effects in cases of severe post-operative blood loss. The peri-operative net decrease in haemoglobin concentration was higher in patients who had predeposited autologous blood than in those who had not. DISCUSSION: The strengths of this study are the high number of cases and the standardised procedures, all operations having been performed by a single orthopaedic surgeon and a single anaesthesiologist. Our data suggest that a pre-operative autologous donation programme may often be useless, if not harmful. Conversely, the use of a cell salvage system may be effective in reducing the impact of blood transfusion on a patient's physiological status. Basal haemoglobin concentration emerged as a useful indicator of transfusion probability in total joint replacement procedures.

Comparing in vivo kinematics of unicondylar and bi-unicondylar knee replacements.

Preserving both cruciate ligaments in unicondylar knee arthroplasty likely provides more normal knee mechanics and contributes to enhanced patient function. It follows that preserving both cruciate ligaments with total knee arthroplasty should provide functional benefit compared to arthroplasty sacrificing one or both cruciates. The purpose of this study was to compare knee kinematics in patients with optimally functioning cruciate-preserving medial unicondylar and bi-unicondylar arthroplasty to determine if knee motions differed. Eight consenting patients with seven medial unicondylar and five bi-unicondylar arthroplasties were studied using lateral fluoroscopy during treadmill gait, stair stepping, and maximum flexion activities. Patient-specific geometric models based on CT and CAD data were used for shape matching to determine the three-dimensional knee kinematics. Tibiofemoral contact locations were computed for the replaced compartments. Maximum flexion in kneeling was 135 degrees +/-14 degrees for unicondylar knees and 123 degrees +/-14 degrees for bi-unicondylar knees (p=0.22). For 0 degrees -30 degrees flexion during the stair activity, the medial condyle translated posterior 3.5+/-2.5 mm in unicondylar knees and 4.7+/-1.9 mm in bi-unicondylar knees (p>0.05). Lateral posterior translation was 5.0+/-2.3 mm in bi-unicondylar knees for 0 degrees -30 degrees flexion. From heel-strike to mid-stance phase, there was little tibial rotation, but unicondylar knees showed 1.5+/-1.6 mm posterior translation of the medial condyle, while bi-unicondylar knees showed 5.1+/-2.2 mm (p<<0.05). The bi-unicondylar knees showed 3.8+/-3.4 mm posterior lateral condylar translation. Preserving both cruciate ligaments in knee arthroplasty appears to maintain some basic features of normal knee kinematics. Knees with bi-unicondylar arthroplasty showed kinematics closer to motions observed in total knee arthroplasty, slightly less weight-bearing flexion, and greater dynamic laxity in gait than unicondylar knees. Despite kinematic differences, knees with unicondylar and bi-unicondylar arthroplasty can provide excellent functional outcomes in appropriately selected patients.

Case challenges in knee surgery: what would you do?

In an interactive case presentation session, the faculty discussed management of complex primary and revision knee arthroplasty issues. Principles discussed included: preoperative evaluation of the failed knee arthroplasty, intra-articular versus extra-articular deformity correction, ligamentous balancing, managing the unstable total knee arthroplasty, bone deficiency management, rotational positioning of prosthetic components, selection of articular constraint in the revision knee, and extensor mechanism balancing.