Predeposited Autologous Blood Transfusion in Single-Anesthetic Bilateral Total Knee Arthroplasty with Modern Blood Conservation Strategy.

This study was performed to examine the hypothesis that the rate of allogeneic blood transfusion in patients who did not predeposit an autologous blood transfusion before single-anesthetic bilateral total knee arthroplasty (TKA) would be noninferior to that in patients who did predeposit blood. Methods: We assessed the number of allogeneic transfusions required in 338 patients undergoing single-anesthetic bilateral TKA with a preoperative hemoglobin level of ≥11.0 g/dL. All TKAs were performed by a single surgeon according to the same operative and postoperative protocol. All patients received a combination of intravenous and intra-articular tranexamic acid. Neither a pneumonic tourniquet nor a drain was used. The difference in the risk of allogeneic transfusion between patients without and with autologous blood predeposit was compared with a noninferiority margin of 10 percentage points. Results: Allogeneic transfusion was required in 1 (0.5%) of 194 patients who predeposited autologous blood and 3 (2.1%) of 144 patients who did not predeposit blood. The difference in risk was -1.6 percentage points (95% confidence interval, -4.1 to 1.0 percentage points); the confidence interval did not include the noninferiority margin and included zero. Conclusions: In single-anesthetic bilateral TKA, allogeneic transfusion requirements in patients who did not predeposit autologous blood were noninferior to those in patients who predeposited blood. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Total hip arthroplasty using an alkali- and heat-treated titanium Zweymüller stem with no trochanteric shoulder: results at 5-year follow-up.

BACKGROUND: A trochanteric shoulder is 1 of the characteristics of the original Zweymüller femoral stem for total hip arthroplasty (THA). There have been few clinical reports of THA using recently available versions of Zweymüller-type stems with eliminated trochanteric shoulder. METHODS: 82 consecutive THAs with a Zweymüller-type stem without trochanteric shoulder were analyzed. The stem was made of alkali- and heat-treated titanium, straight, tapered, with rectangular cross-section. Survivorship was estimated with the Kaplan-Meier method. RESULTS: 76 of 82 hips (92.7%) were followed for more than 5 years or until revision. 35 of 82 hips (42.7%), were revised and the predominant reason for revision was aseptic loosening of the femoral stem (34 of 35 hips, 97.1%). Survival with revision for any reason as the endpoint was 71.3% (95% CI, 51.8% to 80.1%) at 5 years. CONCLUSIONS: The survival of the modified Zweymüller-type stem with no trochanteric shoulder was unacceptably low.

Uncemented total hip arthroplasty using alumina ceramic bearings at a minimum of 14 years of follow-up.

INTRODUCTION: The effectiveness of modern ceramic bearings has been well established in reducing the osteolysis associated with wear of the bearing surfaces in total hip arthroplasty (THA). However, there are limited mid- to long-term follow-up data for complications associated with ceramic bearings. MATERIALS AND METHODS: This case series analyzed 124 consecutive primary uncemented THAs in 108 patients with a mean age of 61 years using alumina ceramic-on-alumina ceramic bearing couples. Seventy THAs (56%) were evaluated at a minimum 14 years of follow-up; the mean follow-up period was 16 ± 1 years (14-20 years). Kaplan-Meier survivorship was determined with revision surgery for any reason as the end point. Complications were recorded focusing on osteolysis, ceramic fracture, and abnormal sounds until the final follow-up. Clinical data were scored according to the Merle d'Aubigne and Postel hip score at 14 years after THA. RESULTS: The survivorship was 93.5% (95% CI 86.7-97.0%) at 14-years postoperatively. Five patients (4.0%) underwent revision surgery due to instability or infection before 1-year postoperatively. Two patients (1.6%) underwent revision surgery due to ceramic liner fracture at 9- and 12-years postoperatively, respectively. There was no radiographic evidence of osteolysis. A total of 27 complications occurred: dislocations (n = 7/124), squeaking sounds (n = 3/124), clicking sounds (n = 6/124), ceramic liner fractures (n = 2/124), periprosthetic fractures (n = 4/124), deep infections (n = 2/124), transient sciatic nerve palsy (n = 2/124), and femoral stem breakage (n = 1/124). The Merle d'Aubigne and Postel hip score was 16.8 ± 1.4 points. CONCLUSIONS: The survivorship analysis demonstrates the uncemented THA using alumina ceramic bearings may provide favorable clinical outcome and can offer minimal wear at a minimum 14-year follow-up. Revision surgery was mostly required due to instability and infection in the short-term, and implant breakage in the mid- to long-term.

Percutaneous periarticular analgesic injection at one day after simultaneous bilateral total knee arthroplasty: an open-label randomized control trial.

BACKGROUND: The postoperative pain after total knee arthroplasty (TKA) remains a critical issue. The aim of this study was to assess the clinical effectiveness of percutaneous periarticular injection at 1 day following simultaneous bilateral TKA. METHODS: A total of 88 knees in 44 patients who underwent simultaneous bilateral TKA were randomly assigned to receive a percutaneous periarticular injection at 1 day following surgery (n = 22 patients) or no injection (n = 22 patients). In the additional injection group, we injected a solution including methylprednisolone, ropivacaine, and epinephrine into the muscle belly of the vastus medialis at 1 day after surgery. In both groups, patients received an intraoperative periarticular multi-drug injection and postoperative intravenous and oral nonsteroidal anti-inflammatory drugs. The primary outcome measure was the postoperative pain at rest using a visual analog scale (VAS) and analyzed with Student's t test. RESULTS: Compared to the no additional injection group, the additional periarticular injection group had significantly lower VAS score at 8:00 PM postoperative day 1, 6:00 AM postoperative day 2, 12:00 PM postoperative day 2, 6:00 AM postoperative day 5, 12:00 PM postoperative day 5, and 8:00 PM postoperative day 5 (p < 0.05). The rate of complication did not differ between groups (p > 0.05). CONCLUSION: Additional percutaneous periarticular injection at 1 day following TKA adding to intraoperative periarticular injection provided better postoperative pain relief. TRIAL REGISTRATION: Registered at the University Hospital Medical Information Network (registration number: UMIN000029759 ).

Percutaneous periarticular multi-drug injection at one day after total knee arthroplasty as a component of multimodal pain management: a randomized control trial.

BACKGROUND: Although intraoperative periarticular multi-drug injection has been used for postoperative pain control after total knee arthroplasty (TKA), the injection has the inherent shortcoming of limited acting time. This randomized controlled trial was performed to assess whether adding percutaneous periarticular multi-drug injection at the day following TKA would improve the postoperative pain relief. METHODS: A total of 43 participants were randomly assigned to receive additional periarticular injection at 08:30, postoperative day 1 or no additional injection. The multi-drug solution including 40 mg of methylprednisolone, 150 mg of ropivacaine, and 0.1 mg of epinephrine was infiltrated into the muscle belly of the vastus medialis. In both groups, patients were treated with intraoperative periarticular multi-drug injection and postoperative intravenous and oral nonsteroidal anti-inflammatory drugs. We did not use any narcotic pain medications postoperatively. The primary outcome was the patients' global assessment of postoperative pain at rest measured using a visual analog scale (VAS) and quantified as the area under the curve (AUC) of serial assessments until 20:00, postoperative day 5. RESULTS: The mean AUC for the postoperative pain VAS at rest was 1616 ± 1191 in patients received the additional periarticular injection versus 2808 ± 1494 in those received no injection (mean difference, - 1192; 95% confidence interval, - 2043 to - 340; p = 0.007). No wound complication or surgical site infection was observed in either groups. CONCLUSIONS: Adding percutaneous periarticular multi-drug injection at the day following TKA may provide better postoperative pain relief. Further studies are needed to confirm the safety of the percutaneous injection. TRIAL REGISTRATION: University Hospital Medical Information Network UMIN000029003 . Registered 5 September 2017.

Intravenous tranexamic acid only versus combined intravenous and intra-articular tranexamic acid for perioperative blood loss in patients undergoing total knee arthroplasty.

PURPOSE: This study was performed to assess the effectiveness of the combined intravenous and intra-articular tranexamic acid (TXA) regimen in total knee arthroplasty (TKA). METHODS: The perioperative blood loss in 75 consecutive patients undergoing unilateral TKA that received both 1000 mg of TXA intravenously and 1000 mg of intra-articular TXA (combined TXA group) was compared with a consecutive series of 77 patients that received 1000 mg of TXA intravenously (intravenous TXA group). An additional 1000 mg of intravenous TXA was administered 6 h after the initial administration in both groups. Neither a pneumatic tourniquet nor drain was used. The primary outcome was the perioperative blood loss at 3 days after TKA calculated using the blood volume and change in haemoglobin from the preoperative value. RESULTS: The perioperative blood loss was significantly lower in the combined TXA group at 3 days after TKA than the intravenous TXA group (686 ± 303 vs. 830 ± 317 mL; 95% CI 44-244 mL; p = 0.0049). The perioperative blood loss was also lower in the combined TXA group at 1 and 7 days after TKA (374 ± 265 vs. 459 ± 226 mL; 95% CI 7-165 mL; p = 0.034 and 751 ± 320 vs. 871 ± 327 mL; 95% CI 16-224 mL; p = 0.024, respectively). No thrombotic events were observed during the study periods. CONCLUSIONS: Combined intra-articular and intravenous TXA regimen significantly reduced perioperative blood loss compared with only intravenous TXA until 7 days after TKA.

Continuing versus discontinuing antiplatelet drugs, vasodilators, and/or cerebral ameliorators on perioperative total blood loss in total knee arthroplasty without pneumatic tourniquet.

BACKGROUND: Although studies have supported the utility of perioperative continuation of antiplatelet drugs, vasodilators, and cerebral ameliorators in most procedures, no study compared total volume of blood loss after total knee arthroplasty (TKA) in patients continuing and discontinuing these drugs. METHODS: We retrospectively reviewed 266 consecutive patients undergoing TKA, and included 67 patients (25.2%) taking antiplatelet drugs, vasodilators, or cerebral ameliorators in this study. All TKAs were performed without a pneumatic tourniquet. The primary outcome was perioperative total blood loss calculated from blood volume and change in hemoglobin. As subgroup analysis, we compared perioperative total blood loss in patients taking antiplatelet drugs. RESULTS: There was no significant difference between the continuing group (n = 38) and discontinuing group (n = 29) in terms of the perioperative total blood loss (1025 ± 364 vs 1151 ± 327 mL, respectively; mean difference 126 mL; 95% confidence interval -45 to 298 mL; P = .15). No major bleeding or thrombotic events occurred in either group until postoperative 3-month follow-up. In patients taking antiplatelet drugs (n = 51), no significant difference was observed in the total blood loss between the continuing group (n = 30) and discontinuing group (n = 21) (1056 ± 287 vs 1151 ± 305 mL, respectively; mean difference 95 mL; 95% confidence interval -75 to 264 mL; P = .27). CONCLUSIONS: No significant differences in terms of perioperative total blood loss were observed between patients continuing and discontinuing study drugs. Continuing these drugs may be preferable in the perioperative period of TKA.

Intravenous Acetaminophen in Multimodal Pain Management for Patients Undergoing Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Although multimodal pain management including periarticular multidrug injection can provide excellent pain relief in the early postoperative period after total knee arthroplasty (TKA), rebounding pain remains an important challenge. A randomized, double-blind, placebo-controlled trial was performed to investigate the efficacy of adding intravenous acetaminophen to multimodal pain management for TKA. METHODS: We enrolled 67 patients scheduled for unilateral TKA. Patients were randomly assigned to receive either 1000 mg of intravenous acetaminophen at 6-hour intervals or normal saline at the same intervals. All patients were treated with intraoperative periarticular multidrug injection and intravenous and oral nonsteroidal anti-inflammatory drugs. The primary outcome was the postoperative 100-mm visual analog pain scale at the time of administration of study drugs. RESULTS: In the intention-to-treat analysis, the pain score was significantly better in the intravenous acetaminophen group than the placebo group at 17:00 one day after TKA (15.3 ± 17.0 mm vs 26.8 ± 19.0 mm; P = .013). There were no significant differences in terms of the rate of complications between groups. CONCLUSION: Even in the setting of multimodal pain management including periarticular multidrug injection, intravenous acetaminophen provided better pain relief for patients undergoing unilateral TKA.

Impact of Soft Tissue Imbalance on Knee Flexion Angle After Posterior Stabilized Total Knee Arthroplasty.

BACKGROUND: This study was performed to assess the impact of soft tissue imbalance on the knee flexion angle 2 years after posterior stabilized total knee arthroplasty (TKA). METHODS: A total of 329 consecutive varus knees were included to assess the association of knee flexion angle 2 years after TKA with preoperative, intraoperative, and postoperative variables. All intraoperative soft tissue measurements were performed by a single surgeon under spinal anesthesia in a standardized manner including the subvastus approach, reduced patella, and without use of a pneumonic tourniquet. RESULTS: Multiple linear regression analysis showed no significant correlations in terms of intraoperative valgus imbalance at 90-degree flexion or the difference in soft tissue tension between 90-degree flexion and 0-degree extension (ß = -0.039; 95% confidence interval [CI], -0.88 to 0.80; P = .93 and ß = 0.015; 95% CI, -0.29 to 0.32; P = .92, respectively). Preoperative flexion angle was significantly correlated with knee flexion angle 2 years after TKA (ß = 0.42; 95% CI, 0.33 to 0.51; P < .0001). CONCLUSION: Avoiding valgus imbalance at 90-degree flexion and aiming for strictly equal soft tissue tension between 90-degree flexion and 0-degree extension had little practical value with regard to knee flexion angle 2 years after posterior stabilized TKA.

Is overcorrection preferable for repair of degenerated articular cartilage after open-wedge high tibial osteotomy?

PURPOSE: This study was performed to determine whether the overcorrected knee could obtain a higher ratio of articular cartilage repair in the medial compartment of the femorotibial joint after open-wedge high tibial osteotomy (HTO). The hypothesis of the study was that overcorrected knees had a higher ratio of articular cartilage repair than moderately corrected knees. METHODS: A total of 71 knees that underwent arthroscopy to evaluate the articular cartilage during open-wedge HTO and second-look arthroscopy were reviewed. The articular cartilage was classified as no repair or repair according to Koshino et al. Overcorrection was defined as knees with femorotibial angle ≤166°. RESULTS: Second-look arthroscopy was performed 410 ± 64 days after HTO. Based on arthroscopic observations, 45 knees (63.4 %) showed no repair and 26 knees (36.6 %) showed repair. In terms of the ratio of cartilage repair, there was no difference between overcorrected knees with mean femorotibial angle of 165° ± 1° and moderately corrected knees with mean femorotibial angle of 170° ± 2° (n.s.). CONCLUSIONS: No significant differences were found in the ratio of cartilage repair between overcorrected and moderately corrected knees. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Combined Intravenous and Intra-Articular Tranexamic Acid in Simultaneous Bilateral Total Knee Arthroplasty without Tourniquet Use.

BACKGROUND: A combined intravenous and intra-articular regimen is one of the most effective administration routes of tranexamic acid (TXA) to reduce perioperative blood loss in unilateral total knee arthroplasty. However, there have been few reports regarding use of the combined regimen for patients undergoing simultaneous bilateral total knee arthroplasty, in which blood-management strategy is more challenging. METHODS: We compared perioperative blood loss in 30 consecutive patients undergoing simultaneous bilateral total knee arthroplasty who received both 1,000 mg of TXA intravenously and 1,000 mg of intra-articular TXA in each knee (combined TXA group) with that in a consecutive series of 51 patients who only received 1,000 mg of TXA intravenously (intravenous TXA group). Additional intravenous TXA was administered 6 hours after the initial administration in both groups. Except for the intraoperative TXA administration regimen, an identical perioperative blood-management strategy was applied to both groups; this consisted of transfusion of 800 or 400 mL of predeposited autologous blood except for patients with a preoperative hemoglobin level of <11.0 g/dL, who received 4 units of allogenic blood. All surgical procedures were performed with spinal anesthesia and without use of a pneumatic tourniquet. Perioperative blood loss was calculated using the blood volume and change in hemoglobin level from the preoperative measurement to postoperative day 3. RESULTS: There was significantly less perioperative blood loss in the combined TXA group compared with the intravenous TXA group (mean and standard deviation, 1,201 ± 347 versus 1,638 ± 400 mL, respectively; mean difference, 437 mL; 95% confidence interval, 263 to 613 mL; p < 0.0001). No patient in the combined TXA group and 1 patient (2%) in the intravenous TXA group required additional allogenic blood transfusion. No thrombotic events occurred in either group. CONCLUSIONS: In a nonrandomized comparison, combined intra-articular and intravenous TXA significantly reduced the calculated perioperative blood loss in simultaneous bilateral total knee arthroplasty compared with that found in patients treated only with intravenous TXA. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Three-Dimensional Computed Tomographic Analysis for Comminution of Pertrochanteric Femoral Fracture: Comminuted Anterior Cortex as a Predictor of Cutting Out.

BACKGROUND: Fixed angle sliding hip screw devices allow controlled impaction between the head neck fragment and the femoral shaft fragment in the surgical treatment of pertrochanteric fractures. This study was performed to evaluate the frequency and pattern of comminution at the fracture site, which may prevent the intended impaction. MATERIALS AND METHODS: Three-dimensional computed tomography was used to investigate 101 pertrochanteric fractures treated with fixed angle sliding hip screw devices, with emphasis on the comminuted cortex. A comminuted fracture was defined as a fracture that had a third fracture fragment at the main fracture line. RESULTS: There were 40 fractures without comminution and 61 with comminution. All 61 comminuted fractures had a comminuted posterior cortex, and 3 of 61 fractures also had comminution at the anterior cortex. The prevalence of cutting out of the implant from the femoral head was significantly higher in cases involving comminution at both the posterior and anterior cortices than in cases involving comminution only at the posterior cortex (66.7 % and 3.4 %, p < 0.0001). CONCLUSION: The posterior cortex was comminuted in 60.4% of pertrochanteric fractures and the anterior cortex in 3.0%. Intended impaction at the fracture site could not be obtained at any cortex in cases with comminution at both the anterior and posterior cortices; comminution at the anterior cortex may be a predictor of cutting out.

A Case Series of Total Hip Arthroplasty Using Cementless Hip Stem Customized for Patients of a Specific Race: 10- to 15-Year Results.

We report a minimum of 10-year results of patients undergoing total hip arthroplasty (THA) using the cementless BiCONTACT N stem, which was developed to fit the femur in a specific race in which the predominant etiology of hip diseases was developmental dysplasia. A total of 108 hips were evaluated with a mean follow-up of 11.9 ± 1.4 years. The etiology for THA was secondary osteoarthritis due to developmental dysplasia in 90.3% of patients. No evidence of aseptic loosening of the BiCONTACT N stem was observed. The survivorship with the end point as revision surgery for any reason was 94.4% (95% confidence interval 88.7%-97.3%) at 15.0 years postoperatively. BiCONTACT N stem may be an effective alternative for patients with developmental dysplasia of the hip.

Impact of postoperative compression dressing using polyethylene foam pad on the multimodal protocol for swelling control following total knee arthroplasty: a randomized controlled trial.

BACKGROUND: The multimodal approach is commonly applied to improve knee swelling after total knee arthroplasty. Although the use of a knee compression pad may improve knee swelling, its impact in the multimodal protocol remains unclear. METHODS: A total of 57 knees were randomly assigned to one of 2 groups receiving treatment with either a compression dressing using a polyethylene foam pad designed to effectively compress the postoperative knee combined with an elastic bandage or a compression dressing with use of an elastic bandage only. All patients were treated with the multimodal approach, including an external cooling system, intravenous tranexamic acid, no pneumonic tourniquet, and periarticular multidrug injection. RESULTS: In intention-to-treat analysis, the circumferences of the thigh measured on postoperative days 1 and 7 were not significantly different between the 2 groups. In addition, there were no differences between the 2 groups in knee flexion angle, perioperative total blood loss, or complication rate. CONCLUSIONS: The polyethylene foam pad had no significant beneficial effect on knee swelling in patients undergoing total knee arthroplasty using the multimodal approach.

Lower Dislocation Rate Following Total Hip Arthroplasty via Direct Anterior Approach than via Posterior Approach: Five-Year-Average Follow-Up Results.

OBJECTIVE: The aim of the study was to compare the dislocation rate between total hip arthroplasty (THA) via direct anterior approach (DAA) and via posterior approach (PA). METHODS: We compared a consecutive series of 139 THAs via DAA with 177 THAs via PA. All study patients received ceramic-on-ceramic bearing surfaces and similar uncemented prostheses. Dislocation-free survival after THA was estimated using the Kaplan-Meier survival method and compared between groups using the log-rank test. RESULTS: In the DAA group, none of 139 hips experienced dislocations in five-year-average follow-up. In the PA group, seven hips experienced dislocations among 177 hips (4 %). The dislocation was significantly less in the DAA group compared to the PA group (p = 0.033). CONCLUSION: The dislocation rate of THA via DAA was significantly less than that of THA via PA.

Pain control after simultaneous bilateral total knee arthroplasty: a randomized controlled trial comparing periarticular injection and epidural analgesia.

BACKGROUND: Periarticular injection is becoming more commonly utilized for pain relief following total knee arthroplasty. However, we are aware of no randomized controlled trial that has investigated the efficacy of periarticular injection for pain relief after simultaneous bilateral total knee arthroplasty. METHODS: We performed a randomized controlled trial of patients scheduled for simultaneous bilateral total knee arthroplasty. Seventy-one patients with 142 involved knees were randomly assigned to receive periarticular injection or epidural analgesia. Other perioperative interventions, including spinal anesthesia, surgical techniques, and postoperative medication protocols, were identical for all patients. The primary outcome was postoperative pain at rest, measured with the use of a 100-mm visual analog scale (VAS) during the initial twenty-four-hour postoperative period. The cumulative VAS score was calculated with use of the area under the curve and compared between the groups. RESULTS: Postoperative pain at rest, quantified as the area under the curve of serial assessments during the initial twenty-four-hour postoperative period, was significantly less in the periarticular injection group than in the epidural analgesia group (174.9 ± 181.5 mm × day compared with 360.4 ± 360.6 mm × day; p = 0.0073). The prevalences of nausea on the night of surgery and postoperative day 1 and of pruritus were significantly lower in the periarticular injection group than in the epidural analgesia group (14% and 45%, p = 0.0031; 14% and 55%, p = 0.0003; and 0% and 15%, p = 0.014, respectively). CONCLUSIONS: Periarticular injection was associated with better pain relief during the first twenty-four hours following simultaneous bilateral total knee arthroplasty and decreased opioid-related side effects compared with epidural analgesia. Periarticular injection may be preferable to epidural analgesia for pain relief after simultaneous bilateral total knee arthroplasty.

Postoperative epidural analgesia compared with intraoperative periarticular injection for pain control following total knee arthroplasty under spinal anesthesia: a randomized controlled trial.

BACKGROUND: Although epidural analgesia has been used for postoperative pain control after total knee arthroplasty, its usefulness is being reevaluated because of possible adverse effects. Recent studies have proven the efficacy of periarticular analgesic injection and its low prevalence of adverse effects. The present study compares the clinical efficacies of epidural analgesia and periarticular injection after total knee arthroplasty. METHODS: This is a prospective, single-center, randomized controlled trial involving patients scheduled for unilateral total knee arthroplasty. One hundred and eleven patients were randomly assigned to periarticular injection or epidural analgesia groups. All patients were managed with spinal anesthesia. The surgical technique and postoperative medication protocol were identical in both groups. The primary outcome was postoperative pain at rest, quantified as the area under the curve of the scores on a visual analog pain scale to seventy-two hours postoperatively. The Student t test and chi-square test were used to compare the data between groups. RESULTS: In the intention-to-treat analysis, the periarticular injection group had a significantly lower area under the curve for pain score at rest (788.0 versus 1065.9; p = 0.0059). In the periarticular injection group, the mean knee flexion angle was small but significantly better at postoperative day 1 (64.2° versus 54.6°; p = 0.0072) and postoperative day 2 (70.3° versus 64.6°; p = 0.021) than in the epidural analgesia group. The incidence of nausea at postoperative day 1 was significantly lower in the periarticular injection group (4.0% versus 44.3%; p < 0.0001). Transient peroneal nerve palsy was frequently seen in the periarticular injection group (12.0% versus 1.6%; p = 0.026). CONCLUSIONS: Compared with epidural analgesia, periarticular injection offers better postoperative pain relief, earlier recovery of knee flexion angle, and lower incidence of nausea. Care should be taken to avoid transient peroneal nerve palsy when using periarticular injection. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Metal block augmentation for bone defects of the medial tibia during primary total knee arthroplasty.

BACKGROUND: Stable and well-aligned placement of tibial components during primary total knee arthroplasty is challenging in patients with bone defects. Although rectangular block-shaped augmentations are widely used to reduce the shearing force between the tibial tray and bone compared with wedge-shaped augmentations, the clinical result remains unclear. This study aimed to evaluate the outcome of primary total knee arthroplasty with metal block augmentation. METHODS: We retrospectively reviewed the 3- to 6-year follow-up results of 33 knees that underwent total knee arthroplasty with metal block augmentation (metal-augmented group) for bone defects of the medial tibia and 132 varus knees without bone defects as the control group. All surgeries were performed using posterior-stabilized cemented prostheses in both groups. Cemented stems were routinely augmented when the metal block was used. RESULTS: There were no differences in implant survival rates (100% in metal-augmented and 99.2% in control) or knee function scores (82 points in metal-augmented and 84 points in control) between the two groups at the final follow-up examination (P = 0.60 and P = 0.09, respectively). No subsidence or loosening of the tibial tray was observed. Of 33 metal-augmented total knee arthroplasties, a nonprogressive radiolucent line beneath the metal was detected in 10 knees (30.3%), and rounding of the medial edge of the tibia was observed in 17 knees (51.5%). CONCLUSIONS: The clinical results of total knee arthroplasty with metal augmentation were not inferior to those in patients without bone defects. However, radiolucent lines were observed in 30.3%.

Uncemented third-generation ceramic-on-ceramic total hip arthroplasty using metal acetabular shell with direct taper locking liner.

BACKGROUND: The ceramic-on-ceramic (CoC)-bearing couple in total hip arthroplasty (THA) was developed to reduce the wear debris and osteolysis. Although the mechanical strength of third-generation ceramic has improved over previous generations, the risk of osteolysis and ceramic fracture is still an important concern. METHODS: We studied 124 uncemented THAs with third-generation CoC-bearing couple implanted between 2000 and 2004. The ceramic liner and head were secured with the direct taper locking mechanism. One hundred and eleven hips were followed-up for minimum of 8 years, with an average follow-up period of 10.1 years (range 8.0-12.8 years). Patients were evaluated with a particular emphasis on the prevalence of the osteolysis and the ceramic fracture. RESULTS: The survivorship with the end point as implant revision for any reason was 94.9 % (95 % confidence intervals 90.0-99.3 %) at 12.8 years. Revisions were performed because of one ceramic liner fracture, three dislocations, and two deep infections. No radiographic evidence of wear or osteolysis was observed. The preoperative Merle d'Aubigne and Postel hip score increased from 11.6 to 17.1. CONCLUSIONS: Patients, who received third-generation CoC THA had no detectable wear and osteolysis. One ceramic fracture occurred, and the main reason for revision was dislocation.

Bulk femoral head autograft without decortication in uncemented total hip arthroplasty: seven- to ten-year results.

Superolateral acetabular bone defect is a serious challenge in uncemented total hip arthroplasty for acetabular dysplasia. We report a bulk bone autografting technique without decortication of the acetabulum and femoral head contact surfaces in 22 joints. Mean follow-up time was 8.3 years, and survival rates were 100% for loosening and revision end points. The preoperative Japanese orthopedic association hip score increased from 49.5 to 94.0. Although trabecular bridging and graft remodeling occurred in all cases, complete trabecular reorientation was observed in only 15 joints. Eccentric polyethylene wear was observed in 8 of 22 joints, and osteolysis, in 1 joint. Our technique is easy to perform, and midterm results were favorable; thus, we conclude that it may be an effective option for bulk bone autografting.