ABSTRACT
Hinged knee arthroplasties are commonly used in scenarios where there are major ligament deficiencies or bone loss around the knee. They are applicable in native knees with major deformities and during revisions. They can also be used as a salvage procedure after distal femoral resection. The new modular hinged device system, namely the Triathlon Hinge Knee (THK) System (Stryker, Mahwah, New Jersey), reflects the advancements of third-generation design and enhances surgical flexibility by allowing streamlined integration with the Triathlon Total Stabilized (TS) System (Stryker, Mahwah, New Jersey) and the Global Modular Replacement System (GMRS, Stryker, Mahwah, New Jersey). Additionally, the Triathlon Revision Tibial Baseplate (Stryker, Mahwah, New Jersey) has been launched as part of THK and is compatible with the Modular Rotating Hinge (MRH , Stryker, Mahwah, New Jersey) femur, which allows the Revision Baseplate to replace the existing tibial component while leaving the existing MRH Femoral Component in place. The Triathlon Revision Tibial Baseplate enables orthopaedic surgeons to use constrained or hinged prostheses, including both distal and total femoral replacement options, without changing the Tibial Baseplate. This is because the TS, MRH, THK, and GMRS femurs are compatible with the new Triathlon Revision Tibial Baseplate. Additionally, the system can be augmented with metaphyseal cone constructs to help provide a stable foundation for reconstruction. This report explores the application of a new modular hinged device system in various scenarios, starting with (1) complex primary hinged knee arthroplasty, followed by revision hinged knee arthroplasty cases including (2) failed TKA with medial collateral ligament (MCL) dysfunction, (3) severe arthrofibrosis post-TKA, (4) revisions for prosthetic joint infection, (5) extensor mechanism deficiency, and (6) arthrofibrosis with extensor mechanism disruption, concluding with a case of (7) distal femoral arthroplasty for periprosthetic fracture post-failed TKA.
ABSTRACT
BACKGROUND: Systemic intravenous antimicrobials yield poor outcomes during treatment of periprosthetic joint infection due to the inability to obtain minimum biofilm eradication concentrations. This study evaluated the safety of a novel method of optimized local delivery of intra-articular antibiotics (IAAs). METHODS: This was a Phase II, multicenter, prospective randomized trial evaluating safety of a rapid (seven-day) two-stage exchange arthroplasty with IAA irrigation compared to standard two-stage exchange. The Experimental Group received irrigation using 80 mg tobramycin daily with a 2-hour soak, followed by hourly irrigation using 125 mg vancomycin with a 30-minute soak via an intramedullary irrigation device. The Control Group received an antibiotic-loaded cement spacer with vancomycin (average 8.4 g) and tobramycin (average 7.1 g, total 16 g antibiotics). Both groups received 12 weeks of systemic antibiotics following Stage 2. Safety measures included adverse events, peak vancomycin/tobramycin serum concentrations (Experimental Group), blood transfusion, and mortality. There were thirty-seven patients randomized to the Experimental Group and 39 to control. There was no difference in baseline demographics or comorbidities. RESULTS: There were no antibiotic medication-related adverse events and 2 serious adverse events related to antibiotic instillation. Of 188 vancomycin peak measurements, 69% had detectable serum level concentrations, with all concentrations well below the maximum acceptable trough threshold of 20 µg/mL. Of the 103 tobramycin peak measurements, 45% had detectable levels, with all below the maximum acceptable peak threshold of 18 to 24 µg/mL. There was no difference in blood transfused per subject (Experimental: 655 mL versus Control: 792 mL; P = .4188). There were two (2) deaths in the Experimental Group and four (4) in the control. CONCLUSIONS: The use of IAA is safe with minimal systemic antibiotic exposure. There was no difference in the rates or severity of serious adverse events between groups. Further research is being conducted to examine treatment efficacy.
Subject(s)
Anti-Bacterial Agents , Prosthesis-Related Infections , Therapeutic Irrigation , Tobramycin , Vancomycin , Humans , Anti-Bacterial Agents/administration & dosage , Prosthesis-Related Infections/drug therapy , Female , Male , Tobramycin/administration & dosage , Tobramycin/adverse effects , Vancomycin/administration & dosage , Vancomycin/adverse effects , Aged , Prospective Studies , Middle Aged , Therapeutic Irrigation/methods , Treatment Outcome , Aged, 80 and over , Arthroplasty, Replacement, Knee/adverse effects , Arthroplasty, Replacement, Hip/adverse effectsABSTRACT
There is renewed interest in cemented femoral fixation in total hip arthroplasty in the United States, and to fully appreciate the evolution of cemented femoral stem designs, an understanding of their history and design rationale is essential. To adequately study the outcomes of modern-day designs, a comprehensive classification system is also necessary. The biomechanical principles, failure mechanisms, and clinical outcomes associated with various cemented femoral stems are described in this comprehensive review. In addition, an updated version of an existing classification system is described that incorporates the primary design characteristics which differentiate implants currently in use. In this classification, implants are categorized as taper-slip (Type I), which are subdivided by Anatomic (IA), Double-Taper (IB), and Triple-Taper (IC) with subclassification for Traditional and Line-to-Line implants. Composite beam (Type II) implants are similarly divided into Anatomic (IIA), Straight (IIB), and Wedge (IIC) with subclassification for Polished, Satin, or Roughened finish. This classification system provides a basis for comparing cemented femoral stems, thereby improving our understanding of the effect of design characteristics on survivorship to guide future advancements and improve clinical outcomes.
Subject(s)
Arthroplasty, Replacement, Hip , Bone Cements , Hip Prosthesis , Prosthesis Design , Arthroplasty, Replacement, Hip/methods , Humans , Hip Prosthesis/classification , Biomechanical Phenomena , Prosthesis Failure , Cementation , Femur/surgeryABSTRACT
Revision total hip arthroplasty (THA) is a procedure with many challenges, especially when patients exhibit femoral bone defects. The causes of these defects vary, ranging from removal of prior implants to aseptic loosening. As surgeons navigate these challenges, a reliable surgical system is important. One modular fluted tapered system provides surgeons with tools to address complex hip revision cases. Introduced in 2003, this system has been utilized in over 180,000 procedures, demonstrating its reliability and effectiveness. Previously, the body stem came in sizes 155mm to 235mm. In the discussed case series, we present six distinct patient cases that highlight the advantages and efficacy of a newly introduced modification of the system; that is the use of smaller stemmed components (now 115mm). With each patient presenting unique challenges, we have demonstrated the use of this new short-stem version for multiple applications for various revision scenarios.
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Background: Cementless metaphyseal filling stems rely on fixation in the medial-to-lateral and anterior-to-posterior (AP) planes. The purpose of this preclinical study was to develop Insignia, a new metaphyseal filling system to match the anatomy of the proximal femur, and then compare it to clinically successful stems in multiple simulations. Methods: In this preclinical study, the geometry of the proximal femur in the AP plane among 1321 healthy subjects was evaluated using computed tomography. This data was then used to design insignia. Preclinical studies were performed to compare the broaching effort required to prepare a canal using this system, assess the reliability of seating heights for the stem, and compare in vitro micromotion testing of the stem under simulated stair climb activity. Results: The proximal femur decreased approximately 50% in the AP plane spanning 20 mm above the lesser trochanter to 30 mm below the lesser trochanter. Additional bench top testing was performed, and the new stem system was found to demonstrate significantly reduced broaching effort (average 6 vs 29 hits, P-value = .000), reliable seating heights on stem placement, and 70% less proximal micromotion on 10,000-cyclic testing (P < .05) compared to another clinically successful metaphyseal filling stem. Conclusions: The AP dimension of the proximal femur decreases nearly 50% throughout its length. Metaphyseal filling stems that match the AP anatomy of the proximal femur may require fewer hits during broaching, yield reproducible seating heights, and reduce micromotion on cyclic testing.
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Background: No objective radiographic scoring system exists to classify metaphyseal cone stability. Our purpose was to create a novel, systematic method to radiographically evaluate metaphyseal cone fixation based on radiographic findings suggestive of cone stability. Methods: A retrospective analysis was conducted of revision total knee arthroplasty patients (6/2015-12/2017) using porous titanium femoral or tibial metaphyseal cones in conjunction with short cemented stems (50 mm-75 mm). Minimum follow-up was 2 years. Survivorship free of aseptic loosening and reoperation, as well as radiographic evaluation using a novel cone zone scoring system were analyzed. Results: Forty-nine revision total knee arthroplasties were included in the study (12 femoral, 48 tibial cones), the majority, performed for aseptic loosening (25/49, 51%). Median follow-up was 39 months (range 25-58). Using the radiographic cone zone scoring method, >90% of all femoral cones were classified as likely stable or stable with strong, statistically significant intraclass correlations between all 3 reviewers. Similarly, >97% of all tibial cones were classified as likely stable or stable, with moderate, statistically significant intraclass correlations between all 3 reviewers. Only 1 femoral and 1 tibial cone were considered at risk of loosening. The study sample demonstrated 100% survivorship free of revision for aseptic loosening without evidence of radiographic loosening in any case. Conclusions: Using a novel systematic cone zone scoring and classification method, the overwhelming majority of femoral and tibial cones were classified as likely stable or stable, with no identified cases of aseptic loosening or related revision. Further studies are needed to validate this objective classification method.
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BACKGROUND: In collaboration with the Orthopedic Data Evaluation Panel (ODEP), the American Joint Replacement Registry (AJRR) investigated the consistency of hip and knee arthroplasty survivorship results compared to the UK National Joint Registry (NJR). METHODS: A total of three primary knee devices and three primary hip devices were selected by AJRR and ODEP with known variation in performance. Implant manufacturers independently produced Kaplan Meier survivorship based on NJR data and submitted to ODEP for comparison. The AJRR mirrored the methodology, and results from both sources were stratified into three cohorts (all-age, < 65, and ≥ 65 years). RESULTS: There were 42,671 AJRR and 60,439 NJR primary knee cases and 70,169 AJRR and 422,657 NJR primary total hip arthroplasty cases. For TKA, performance between the AJRR and NJR were consistent, showing similar trends for comparatively high and low performing devices. Both PS and CR devices showed statistical agreement in survivorship for all 3 cohorts. Unicompartmental comparison also showed statistical agreement for the Medicare cohort. The all-age and < 65-year-old cohorts showed similar trends and reached statistical agreement through 7 and 6 years. For total hip arthroplasty, performance between the AJRR and NJR were consistent, showing similar trends for comparatively high and low performing devices; 0.18% average difference in survivorship at final follow-up (8 years). One femoral device did not reach statistical agreement but showed only 0.61% difference in survivorship. The remaining acetabular and femoral devices reached statistical agreement in all-ages and through 7 and 8 years in the ≥ 65-year-old cohort. CONCLUSIONS: AJRR and NJR performance trends and survivorship were similar across hip and knee arthroplasty with greatest consistency in the all-age and ≥ 65 cohorts. This focused comparison of survivorship showed encouraging results for reliability of patient outcomes in AJRR compared to the world's largest joint arthroplasty registry which has strong implications for global improvement in patient safety.
Subject(s)
Arthroplasty, Replacement, Hip , Arthroplasty, Replacement, Knee , Prosthesis Failure , Registries , Humans , Arthroplasty, Replacement, Hip/instrumentation , Arthroplasty, Replacement, Knee/instrumentation , Aged , United States , Middle Aged , Male , Female , Knee Prosthesis , Hip Prosthesis , United Kingdom , Aged, 80 and over , Kaplan-Meier EstimateABSTRACT
BACKGROUND: Manipulation under anesthesia (MUA) occurs in 4% of patients after total knee arthroplasty (TKA). Anti-inflammatory medications may target arthrofibrosis pathogenesis, but the data are limited. This multicenter randomized clinical trial investigated the effect of adjuvant anti-inflammatory medications with MUA and physical therapy on range of motion (ROM) and outcomes. METHODS: There were 124 patients (124 TKAs) who developed stiffness after primary TKA for osteoarthritis enrolled across 15 institutions. All received MUA when ROM was < 90° at 4 to 12 weeks postoperatively. Randomization proceeded via a permuted block design. Controls received MUA and physical therapy, while the treatment group also received one dose of pre-MUA intravenous dexamethasone (8 mg) and 14 days of oral celecoxib (200 mg). The ROM and clinical outcomes were assessed at 6 weeks and 1 year. This trial was registered with ClinicalTrials.gov. RESULTS: The ROM significantly improved a mean of 46° from a pre-MUA ROM of 72 to 118° immediately after MUA (P < .001). The ROM was similar between the treatment and control groups at 6 weeks following MUA (101 versus 99°, respectively; P = .35) and at one year following MUA (108 versus 108°, respectively; P = .98). Clinical outcomes were similar at both end points. CONCLUSIONS: In this multicenter randomized clinical trial, the addition of intravenous dexamethasone and a short course of oral celecoxib after MUA did not improve ROM or outcomes. However, MUA provided a mean ROM improvement of 46° immediately, 28° at 6 weeks, and 37° at 1 year. Further investigation in regards to dosing, duration, and route of administration of anti-inflammatory medications remains warranted. LEVEL OF EVIDENCE: Level 1, RCT.
Subject(s)
Arthroplasty, Replacement, Knee , Celecoxib , Dexamethasone , Osteoarthritis, Knee , Range of Motion, Articular , Humans , Male , Female , Aged , Middle Aged , Celecoxib/administration & dosage , Range of Motion, Articular/drug effects , Dexamethasone/administration & dosage , Osteoarthritis, Knee/surgery , Postoperative Complications/etiology , Treatment Outcome , Awards and Prizes , Anti-Inflammatory Agents/administration & dosage , Physical Therapy Modalities , Knee Joint/surgery , Knee Joint/physiopathologyABSTRACT
BACKGROUND: The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Procedure Coding System (ICD-10-PCS) was adopted in the U.S. in 2015. Proponents of the ICD-10-PCS have stated that its granularity allows for a more accurate representation of the types of procedures performed by including laterality, joint designation, and more detailed procedural data. However, other researchers have expressed concern that the increased number of codes adds further complexity that leads to inaccurate and inconsistent coding, rendering registry and research data based on ICD-10-PCS codes invalid and inaccurate. We aimed to determine the accuracy of the ICD-10-PCS for identifying cemented fixation in primary total hip arthroplasty (THA). METHODS: We retrospectively reviewed all cemented primary THAs performed at 4 geographically diverse, academic medical centers between October 2015 and October 2020. Cemented fixation was identified from the ICD-10-PCS coding for each procedure. The accuracy of an ICD-10-PCS code relative to the surgical record was determined by postoperative radiograph and chart review, and cross-referencing with institution-level coding published by the American Joint Replacement Registry (AJRR) was also performed. RESULTS: A total of 552 cemented THA cases were identified within the study period, of which 452 (81.9%) were correctly coded as cemented with the ICD-10-PCS. The proportion of cases that were correctly coded was 187 of 260 (72%) at Institution A, 158 of 185 (85%) at Institution B, 35 of 35 (100%) at Institution C, and 72 of 72 (100%) at Institution D. Of the 480 identified cemented THA cases at 3 of the 4 institutions, 403 (84%) were correctly reported as cemented to the AJRR (Institution A, 185 of 260 cases [71%]; Institution B, 185 of 185 [100%]; and Institution C, 33 of 35 [94%]). Lastly, of these 480 identified cemented THA cases, 317 (66%) were both correctly coded with the ICD-10-PCS and correctly reported as cemented to the AJRR. CONCLUSIONS: Our findings revealed existing discrepancies within multiple institutional data sets, which may lead to inaccurate reporting by the AJRR and other registries that rely on ICD-10-PCS coding. Caution should be exercised when utilizing ICD-10 procedural data to evaluate specific details from administrative claims databases as these inaccuracies present inherent challenges to data validity and interpretation.
Subject(s)
Arthroplasty, Replacement, Hip , Humans , United States , International Classification of Diseases , Retrospective StudiesABSTRACT
BACKGROUND: Studies have demonstrated increased complication risk after total hip arthroplasty (THA) in patients who smoke cigarettes. It is unclear if smokeless tobacco use confers a similar impact. The purpose of this study was to (1) evaluate rates of postoperative complications after THA in smokeless tobacco users and people who smoke compared to matched controls, and (2) compare rates of postoperative complications in smokeless tobacco users versus patients who smoke. METHODS: A retrospective cohort study was conducted using a large national database. For patients who underwent primary THA, smokeless tobacco users (n = 950) and people who smoke (n = 21,585) were matched 1:4 with controls (n = 3,800 and 86,340, respectively), and smokeless tobacco users (n = 922) were matched 1:4 with people who smoke (n = 3,688). Joint complication rates within 2 years and medical complications within 90 days postoperatively were compared using multivariable logistic regressions. RESULTS: Within 90 days of primary THA, smokeless tobacco users demonstrated significantly higher rates of wound disruption, pneumonia, deep vein thrombosis, acute kidney injury (AKI), cardiac arrest, transfusion, readmission and longer length of stay compared to tobacco naïve controls. Within 2 years, smokeless tobacco users demonstrated significantly higher rates of prosthetic joint dislocations and overall joint-related complications compared to tobacco naïve controls. CONCLUSION: Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary THA. Smokeless tobacco use may be under-diagnosed in patients undergoing elective THA. Surgeons may consider delineating between smoking and smokeless tobacco use during preoperative counseling.
Subject(s)
Arthroplasty, Replacement, Hip , Tobacco, Smokeless , Humans , Arthroplasty, Replacement, Hip/adverse effects , Tobacco, Smokeless/adverse effects , Retrospective Studies , Risk Factors , Length of Stay , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Treatment OutcomeABSTRACT
Glucagon-Like Peptide agonists have traditionally been used for glycemic control in diabetic patients. However, there has been a dramatic rise in their utilization for weight loss management. As such, arthroplasty surgeons will encounter an increasing number of patients on these medications, and therefore it is important to understand the implications of their use in the perioperative period. This review will describe the pharmacological actions of these medications as well as the impact on hip and knee arthroplasty patients, and considerations for perioperative management. Because of the rapid adaption and utilization of these drugs, the science is evolving at a fast pace. More and longer-term studies are needed to truly understand the impact of these medications on total joint arthroplasty utilization and in management of these patients in the perioperative period.
Subject(s)
Arthroplasty, Replacement, Hip , Surgeons , United States , Humans , Knee Joint/surgery , Knee/surgeryABSTRACT
Intraoperative periprosthetic fracture is an uncommon but notable complication that can occur during primary total knee arthroplasty. These fractures may occur at various stages during the procedure, including surgical exposure, implant preparation, implant trialing, and final implantation. Management of femoral and tibial fractures necessitates intraoperative recognition, including attentiveness of preoperative patient and surgical risk factors. This comprehensive review article focuses on the patient and surgical risk factors, diagnosis, management, and outcomes related to intraoperative fractures during primary total knee arthroplasty.
Subject(s)
Arthroplasty, Replacement, Knee , Femoral Fractures , Periprosthetic Fractures , Tibial Fractures , Humans , Arthroplasty, Replacement, Knee/adverse effects , Periprosthetic Fractures/diagnosis , Periprosthetic Fractures/etiology , Periprosthetic Fractures/surgery , Femoral Fractures/diagnosis , Femoral Fractures/etiology , Femoral Fractures/surgery , Tibial Fractures/diagnostic imaging , Tibial Fractures/etiology , Risk Factors , Retrospective StudiesABSTRACT
The prevalence of obesity in the United States is at a record high of 42%. In 1999, the Centers for Disease Control and Prevention recognized the obesity epidemic as a national problem, spurring the first generation of interventions for obesity prevention and control. Despite billions of dollars in funding, legislative changes, and public health initiatives, the trajectory of American obesity has not waivered. Obesity is also strongly associated with the development of osteoarthritis. The growing population of young, obese, and sick patients presents a unique dilemma for orthopedic surgeons performing joint replacement, as obesity levels and the demand for joint replacement are only expected to rise further.
Subject(s)
Arthroplasty, Replacement, Hip , Arthroplasty, Replacement, Knee , Arthroplasty, Replacement , Obesity, Morbid , Osteoarthritis, Knee , Osteoarthritis , Humans , United States/epidemiology , Obesity, Morbid/complications , Obesity, Morbid/surgery , Osteoarthritis/surgery , Prevalence , Osteoarthritis, Knee/surgery , Osteoarthritis, Knee/epidemiologyABSTRACT
BACKGROUND: Increasingly, dual mobility (DM) articulations have been used in revision total hip arthroplasty (THA), which may prevent postoperative hip instability. The purpose of this study was to report on outcomes of DM implants used in revision THA from the American Joint Replacement Registry (AJRR). METHODS: Revision THA cases performed between 2012 and 2018 Medicare were eligible and categorized by 3 articulations: DM, ≤32 mm, and ≥36 mm femoral heads. The AJRR-sourced revision THA cases were linked to Centers for Medicare and Medicaid Services (CMS) claims data to supplement (re)revision cases not captured in the AJRR. Patient and hospital characteristics were described and modeled as covariates. Using multivariable Cox proportional hazard models, considering competing risk of mortalities, hazard ratios were estimated for all-cause re-revision and re-revision for instability. Of 20,728 revision THAs, 3,043 (14.7%) received a DM, 6,565 (31.7%) a ≤32 mm head, and 11,120 (53.6%) a ≥36 mm head. RESULTS: At 8-year follow-up, the cumulative all-cause re-revision rate for ≤32 mm heads was 21.9% (95%-confidence interval (CI) 20.2%-23.7%) and significantly (P < .0001) higher than DM (16.5%, 95%-CI 15.0%-18.2%) and ≥36 mm heads (15.2%, 95%-CI 14.2%-16.3%). At 8-year follow-up, ≥36 heads had significantly (P < .0001) lower hazard of re-revision for instability (3.3%, 95%-CI 2.9%-3.7%) while the DM (5.4%, 95%-CI 4.5%-6.5%) and ≤32 mm groups (8.6%, 95%-CI 7.7%-9.6%) had higher rates. CONCLUSION: The DM bearings are associated with lower rates of revision for instability compared to patients who had ≤32 mm heads and higher revision rates for ≥36 mm heads. These results may be biased due to unidentified covariates associated with implant selection.
Subject(s)
Arthroplasty, Replacement, Hip , Registries , Reoperation , Humans , Aged , Aged, 80 and over , Male , Female , Medicare , United States/epidemiologyABSTRACT
BACKGROUND: Periprosthetic joint infection (PJI) continues to challenge surgeons and patients. The burden of fungal organisms may represent approximately 1% of all PJI. Additionally, fungal PJI is difficult to treat. Most available case series are small and report poor success rates. Fungi are opportunistic pathogens and patients who have fungal PJI are believed to be immunocompromised. Additionally, fungal biofilms are more complex than those formed by other pathogens and confer additional drug resistance. Due to these factors, treatment failure is common. METHODS: A retrospective review of our institutional registry was performed to identify patients treated for fungal PJI. There were 49 patients identified with 8 excluded for not having follow-up, which left 22 knees and 19 hips for analyses. Demographics, clinical characteristics, and surgical details were collected. The primary outcome was failure defined as reoperation for infection following the index surgery for fungal PJI within 1 year of the index surgery. RESULTS: Failure occurred in 10 of 19 knees and 11 of the 22 hips. A higher proportion of patients who have extremity grade C failed treatment, and every patient who failed was host grade 2 or 3. The average number of prior surgeries and time from resection to reimplantation were similar between groups. CONCLUSION: To our knowledge, this represents the largest cohort of fungal PJIs reported in the literature to date. This data supports other literature in that failure rates were high. More study is needed to further understand this entity and improve care for these patients.
Subject(s)
Arthroplasty, Replacement, Hip , Arthroplasty, Replacement, Knee , Prosthesis-Related Infections , Humans , Arthroplasty, Replacement, Knee/adverse effects , Prosthesis-Related Infections/drug therapy , Prosthesis-Related Infections/surgery , Treatment Outcome , Treatment Failure , Arthroplasty, Replacement, Hip/adverse effects , Reoperation/adverse effects , Retrospective StudiesABSTRACT
Orthopaedics has seen a rapid transition to value-based care. As we transition away from fee-for-service models, healthcare systems, groups, and surgeons are being asked to take on an increasing amount of risk. While on the surface risk may have a negative connotation, managing risk allows surgeons to maintain autonomy while taking on value-based care to the next level. The purpose of this paper, the first in a series of 2, is to walk through the impact that value-based care has had on musculoskeletal surgeons, to understand the continued movement healthcare is making into risk sharing models, and to introduce the concept of surgeon specialist-led care.