Comparative Efficacy of the Different Surgical Approaches in Total Knee Arthroplasty: A Systematic-Review and Network Meta-Analysis.

BACKGROUND: Several surgical approaches including midvastus, subvastus, mini-parapatellar, quadriceps-sparring (QS) and parapatellar are currently used to perform total knee arthroplasty (TKA). Since none of published study exhibited a simultaneous comparison of all of them, a network meta-analysis has been conducted to compare the most widely used knee surgical approaches regarding the improvement of functional outcomes and the range of motion (ROM). METHODS: Randomised controlled trials (RCTs) comparing TKA approaches were searched in electronic databases, major orthopedics journals, and oral communications, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform until May 1st, 2020. Two reviewers independently selected trials and extracted data. The primary outcomes were functional scores at 6 months post-surgeryevaluated by KSS and WOMAC, and the ROM. RESULTS: Sixty RCTs involving 5042 patients with 5107 TKA were included. No significant differences between different approaches were found for the KSS assessment or the WOMAC at 6 months. The mean of ROM at 6 months post-surgery were higher in the subvastus group than in all the others surgical approaches. The difference of ROM with subvastus approach was 7.3° (95% CI -14.1 to -0.1) with the midvastus approach, 11.1° (95% CI -18.7 to -2.8) with mini-parapatellar, 8.9° (95% CI -14.2 to -3.1) with standard parapatellar, and 9.2° (95% CI -16.1 to -1.8) with QS. CONCLUSION: No differences were found in functional outcomes over short or medium terms but subvastus seemed to increase the ROM at 6 months post-surgery. Until or unless future studies can demonstrate a long-term benefit, based on these results all studied surgical approaches to perform a TKA are equal. LEVEL OF EVIDENCE: Network meta-analysis. Level 1.

Return to Competitive Level of Play and Performance in Regular Golfers After Total Hip Arthroplasty: Analysis of 599 Patients at Minimum 2-Year Follow-Up.

BACKGROUND: Total hip arthroplasty (THA) is performed in an increasingly younger and athletic population. Regular and competitive golfers are concerned with the likelihood of recovering their preoperative level of play. The purpose of this study was to assess the impact of primary THA on golfers' game, with a minimum follow-up of two years. METHODS: Questionnaires were sent to the French Golf Federation's golfing members. Those who were older than 40 years and had undergone a unilateral primary THA provided information on the timing of return to play, pain during golfing, transportation mode, drive length, handicap and weekly playtime, before hip replacement, and postoperatively. In addition, data relating to the surgical procedure were collected. RESULTS: Surveys were completed by 883 competitive golfers of which 599 were eligible for inclusion. The mean time to return to a complete 18-hole course was 4.73 months (SD 4.15, range: 0.7-36). Participants surveyed at a minimum 2 years after THA played at a higher level than before surgery with a handicap improvement of 1.8 (P < .01) and increased their mean weekly playtime from 8.8 to 9.3 hours (P = .24, NS). Eighty-eight percent reported an increased or no change in drive distance. Hip pain while playing golf decreased after surgery (6.8 to 2.5 on the visual analog scale, P < .001). CONCLUSION: This study highlighted that hip arthroplasty allowed regular and competitive golfers to return to the course with better golfing comfort than before surgery and with an objective improvement in driving distance and level of play.

Are There Differences in Accuracy or Outcomes Scores Among Navigated, Robotic, Patient-specific Instruments or Standard Cutting Guides in TKA? A Network Meta-analysis.

BACKGROUND: Several kinds of cutting guides, including patient-specific instrumentation, navigation, standard cutting guides, accelerometer-based navigation, and robotic guidance, are available to restore a planned alignment during TKA. No previous study has simultaneously compared all of these devices; a network meta-analysis is an especially appealing method because it allows comparisons across approaches that were not compared head-to-head in individual randomized controlled trials. QUESTIONS/PURPOSES: We performed a network meta-analysis to determine whether novel approaches to achieving implant alignment, such as patient-specific instrumentation, navigation, accelerometer-based navigation, and robotic guidance, provide any advantage over standard cutting guides in terms of: (1) hip-knee-ankle (HKA) alignment outliers greater than ± 3°, (2) outcome scores (1989 - Knee Society Score and WOMAC score) measured 6 months after surgery, or (3) femoral and tibial implant malalignment (greater than ± 3°), taken separately, in the frontal and sagittal plane, as well as other secondary outcomes including validated outcome scores 1 and 2 years after surgery. METHODS: In our network meta-analysis, we included randomized controlled trials comparing the different cutting guides by using at least one of the previously specified criteria, without limitation on language or date of publication. We searched electronic databases, major orthopaedic journals, proceedings of major orthopaedic meetings, ClinicalTrials.gov, and the World Health Organization's International Clinical Trials Registry Platform until October 1, 2018. This led to the inclusion of 90 randomized controlled trials involving 9389 patients (mean age 68.8 years) with 10,336 TKAs. Two reviewers independently selected trials and extracted data. The primary outcomes were the proportion patients with malalignment of the HKA angle (defined as HKA > 3° from neutral) and the Knee Society Score and WOMAC scores at 6 months postoperatively. We combined direct and indirect comparisons using a Bayesian network meta-analysis framework to assess and compare the effect of different cutting guides on outcomes. Bayesian estimates are based on the posterior distribution of an endpoint and are called credible intervals. Usually the 95% credible interval, corresponding to a posterior probability of 0.95 that the endpoint lies in the interval, is computed. Unlike the frequentist approach, the Bayesian approach does not allow the calculation of the p value. RESULTS: The proportion of HKA outliers was lower with navigation than with patient-specific instrumentation (risk ratio 0.46 [95% credible interval (CI) 0.34 to 0.63]) and standard cutting guides (risk ratio 0.45 [95% CI 0.37 to 0.53]); however, this corresponded to an actual difference of only 12% of patients for navigation versus 21% of patients for patient-specific instrumentation, and 12% of patients for navigation versus 25% for standard cutting guides. We found no differences for other comparisons between different cutting guides, including robotics and the accelerometer. We found no differences in the Knee Society Score or WOMAC score between the different cutting guides at 6 months. Regarding secondary outcomes, navigation reduced the risk of frontal and sagittal malalignments for femoral and tibial components compared with the standard cutting guides, but none of the other cutting guides showed superiority for the other secondary outcomes. CONCLUSIONS: Navigation resulted in approximately 10% fewer patients having HKA outliers of more than 3°, without any corresponding improvement in validated outcomes scores. It is unknown whether this incremental reduction in the proportion of patients who have alignment outside a window that itself has been called into question will justify the increased costs and surgical time associated with the approach. We believe that until or unless these new approaches either (1) convincingly demonstrate superior survivorship, or (2) convincingly demonstrate superior outcomes, surgeons and hospitals should not use these approaches since they add cost, have a learning curve (during which some patients may be harmed), and have the risks associated with uncertainty of novel surgical approaches. LEVEL OF EVIDENCE: Level I, therapeutic study.

Arthroscopic evaluation and treatment of a squeaking hip. A case report.

BACKGROUND: Squeaking of ceramic-on-ceramic total hip arthroplasty is an unexpected complication which occurs in 1- 30% of patients. Revision surgery is required in 0.2% of the cases, when a ceramic fracture is suspected, or in case of severe malposition of the implants, subluxation, or impingement. Hip arthroscopy may be a useful diagnostic and therapeutic option in squeaking hips. CASE PRESENTATION: A patient presenting with a pain-free squeaking underwent hip arthroscopy to examine the sliding surfaces and the rim of the acetabulum, and to search for signs of impingement. Thorough lavage and debridement of hip synovitis and fibrous tissue was performed. The squeaking noise immediately disappeared after the surgery. The patient was allowed to fully weight bear as tolerated with 2 crutches for 2 weeks. Two years after the arthroscopy, the patient remained symptom-free. CONCLUSIONS: The potential reasons for hip squeaking in our patient are discussed. Hip arthroscopy may prove useful as a diagnostic and therapeutic option for some patients presenting with a squeaking ceramic-on ceramic hip replacement.

A Playtime and Handicap Analysis of 143 Regular Golfers After Total Knee Arthroplasty at Minimum 2-Year Follow-Up.

BACKGROUND: Regular and competitive golfers are concerned by the ability to recover their previous activity golfing after total knee arthroplasty (TKA). The purpose of this study was to conduct targeted analysis of the effect of unilateral total knee replacement on the playtime and golf level in a population of experienced golfers, with a minimum follow-up of two years. METHODS: Questionnaires were distributed to the French Golf Federation's golfing members. Those who were older than 50 years and had undergone a unilateral primary TKA provided information on the timing of return to play, mode of movement on the course, pain during golfing, physical activity via University of California Los Angeles scale, level of golf and weekly playing time, before and after surgery. In addition, surgeons' recommendations and level of arthroplasty satisfaction were collected. RESULTS: Questionnaires were completed by 290 competitive golfers, of which 143 were eligible for inclusion. The average time to return to the 18-hole course was 3.7 months. Participants surveyed at a minimum 2 years after TKA played at a higher level than before surgery with a handicap improvement of 0.85 and increased their average weekly playtime from 8.9 to 10.2 hours. Knee pain while playing golf decreased after surgery (6.13 to 1.27 on the visual analog scale) and the University of California Los Angeles score improved (7.02 to 7.85). CONCLUSION: This study demonstrated the ability of regular golfers to return to golf within six months after unilateral total knee replacement, with increasing level of golf and weekly playtime and better golfing comfort.

Platelet activation and aggregation after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Endovascular techniques have proven beneficial in the treatment of aneurysmal subarachnoid hemorrhage (aSAH), but with high risk of arterial clotting, emboli and dissection. Platelet activation and alterations in hemostasis may contribute to these complications. We investigated platelet activation and aggregation pathways in aSAH patients who underwent endovascular treatment. METHODS: Two blood samples were taken, in the early days after bleeding and during the period at risk of vasospasm. We studied platelet activation through the expression of GpIIbIIIa and P-selectin as well as aggregation rate in the presence of agonists. Platelets from aSAH patients were compared with those from orthopedic postoperative patients (POSTOP). RESULTS: Platelets in aSAH were initially spontaneously activated and remained so over time. aSAH platelets were further activated with rapid aggregation in the presence of agonists, particularly ADP, with behavior comparable to POSTOP platelets. CONCLUSIONS: aSAH platelets showed prolonged increases in activation and aggregation. Therapies targeting the ADP pathway might reduce the risk of clotting and ischemic events in this context among patients requiring multiple endovascular procedures. TRIAL REGISTRATION: Not applicable.

Ultrasound imaging of the thenar motor branch of the median nerve: a cadaveric study.

INTRODUCTION: Anatomic variations of the median nerve (MN) increase the risk of iatrogenic injury during carpal tunnel release surgery. We investigated whether high-frequency ultrasonography could identify anatomic variations of the MN and its thenar motor branch (MBMN) in the carpal tunnel. METHODS: For each volar wrist of healthy non-embalmed cadavers, the type of MN variant (Lanz classification), course and orientation of the MBMN, and presence of hypertrophic muscles were scored by 18-MHz ultrasound and then by dissection. RESULT: MBMN was identified by ultrasound in all 30 wrists (15 subjects). By dissection, type 1, 2 and 3 variants were found in 84%, 3%, and 13% of wrists, respectively. Ultrasound had good agreement with dissection in identifying the variant type (kappa =0.9). With both techniques, extra-, sub-, and transligamentous courses were recorded in 65%, 31%, and 4% of cases, respectively. With both techniques, the bifid nerve, hypertrophic muscles, and bilateral symmetry for variant type were identified in 13.3%, 13.3%, and 86.7% of wrists, respectively. Agreement between ultrasound and dissection was excellent for the MBMN course and orientation (kappa =1). CONCLUSION: Ultrasound can be used reliably to identify anatomic variations of the MN and MBMN. It could be a useful tool before carpal tunnel release surgery. KEY POINTS: • Ultrasound can identify variations of the motor branch of the median nerve. • Ultrasound mapping should be used prior to carpal tunnel release surgery. • All sub-, extra-, and transligamentous courses were accurately identified. • Type 3 variants (bifid nerve), hypertrophic muscles, and bilateral symmetry were accurately identified.

Ceramic-on-ceramic THA Implants in Patients Younger Than 20 Years.

BACKGROUND: Poor survival of THA implants in very young patients has been attributed to use of cemented implants, wear of conventional polyethylene, and the presence of morphologic deformities in the proximal femur or in the acetabulum. Few studies have reported the long-term results of ceramic-on-ceramic implants in THAs in patients younger than 20 years. QUESTION/PURPOSES: We determined: (1) the proportion of patients who experienced complications related to the ceramic bearing (squeaking, fracture); (2) the survivorship free from loosening and free from revision for any reason; (3) whether patients with osteonecrosis had inferior survivorship compared with patients whose surgical indication was all other diagnoses including sequelae of pediatric hip disorders (developmental dysplasia of the hip, Legg-Calvé-Perthes disease, slipped capital femoral epiphysis); and (4) clinical function. METHODS: Between 1979 and 2013, we performed 113 primary THAs in 91 patients younger than 20 years at the time of surgery. Of those, 105 THAs (83 patients) were done with ceramic-on-ceramic bearings (91% of the 91 patients); during that period, a ceramic-on-ceramic bearing couple was indicated in all patients younger than 20 years. In eight patients (eight hips), a cemented polyethylene cup was implanted because the diameter of the acetabulum was smaller than the smallest available ceramic cup (46 mm), or because adequate fixation of a ceramic press-fit cup could not be achieved despite careful reaming of the acetabulum. The most common diagnosis indicating THA was avascular necrosis of the femoral head (56.2%; 59 hips). Thirty-five patients (40 hips) had undergone previous operations before the replacement. Three patients (4%; four hips) died from unrelated causes, nine patients (11%; 13 hips) were lost to followup, and four patients (five hips) had a followup greater than 8.5 years but have not been seen in the last 5 years. Patients were assessed clinically (using the Merle d'Aubigne-Postel score, Hip disability and Osteoarthritis Outcome score (HOOS), and the SF-12(®) Health Survey, and radiographically for signs of radiolucencies, subsidence, or osteolysis on plain films. The mean followup was 8.8 ± 6.1 years (range, 2-34.4 years). RESULTS: Five patients experienced transient noise generation, defined as a snap in four patients and squeaking in one. Seventeen hips underwent revision surgery-16 for aseptic loosening and one for septic loosening. The implant survival rate at 10 years with aseptic loosening as the endpoint was 90.3% (95% CI, 82.4%-98.9%). No hip had acetabular or femoral osteolysis. Survivorship in patients with osteonecrosis did not differ from survivorship in patients with other diagnoses. The Merle d'Aubigne-Postel score increased from 10.1 ± 4.0 to 17.6 ± 1.1 (p < 0.01); the mean HOOS score was 79.3 ± 13.8 (range, 50.6-100); the mean SF-12(®) physical and mental component scores were 48.1 ± 7.9 (range, 21.4-57.6), and 47.4 ± 12.2 (range, 24.5-99.4), respectively. CONCLUSIONS: We found that patient-reported outcomes scores improved in most patients undergoing THA in this very young study group. Underlying diagnosis did not affect long-term survivorship. However, the revision-free survival rate at 10 years is lower than published estimates in older patients, and with 11% of patients lost to followup, our estimates may represent a best-case scenario. Therefore, we believe THA should be performed as a last resort in this population. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Effectiveness of Virtual Reality Training in Orthopaedic Surgery.

PURPOSE: The purpose of this study was to conduct a systematic review to determine the effectiveness of virtual reality (VR) training in orthopaedic surgery. METHODS: A comprehensive systematic review was performed of articles of VR training in orthopaedic surgery published up to November 2014 from MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases. RESULTS: We included 10 relevant trials of 91 identified articles, which all reported on training in arthroscopic surgery (shoulder, n = 5; knee, n = 4; undefined, n = 1). A total of 303 participants were involved. Assessment after training was made on a simulator in 9 of the 10 studies, and in one study it took place in the operating room (OR) on a real patient. A total of 32 different outcomes were extracted; 29 of them were about skills assessment. None involved a patient-related outcome. One study focused on anatomic learning, and the other evaluated technical task performance before and after training on a VR simulator. Five studies established construct validity. Three studies reported a statistically significant improvement in technical skills after training on a VR simulator. CONCLUSIONS: VR training leads to an improvement of technical skills in orthopaedic surgery. Before its widespread use, additional trials are needed to clarify the transfer of VR training to the OR. LEVEL OF EVIDENCE: Systematic review of Level I through Level IV studies.

Comparison of treatment effect estimates from prospective nonrandomized studies with propensity score analysis and randomized controlled trials of surgical procedures.

OBJECTIVE: We aimed to compare treatment effect estimates from NRSs with PS analysis and RCTs of surgery. BACKGROUND: Evaluating a surgical procedure in randomized controlled trials (RCTs) is challenging. Nonrandomized studies (NRSs) involving use of propensity score (PS) analysis to limit bias are of increasing interest. DESIGN: Meta-epidemiological study. METHODS: We systematically searched MEDLINE via PubMed for all prospective NRSs with PS analysis evaluating a surgical procedure. Related RCTs, addressing the same clinical questions, were systematically retrieved. Our primary outcome of interest was all-cause mortality. We also selected 1 subjective outcome. We calculated the summary odds ratios (OR) for each study design, the ratio of OR (ROR) between the designs and the summary ROR across clinical questions. An ROR<1 indicated that the experimental intervention is more favorable in NRSs with PS analysis than RCTs. RESULTS: We retrieved 70 reports of NRSs with PS analysis and 94 related RCTs evaluating 31 clinical questions, of which 22 assessed all-cause mortality and 26 a subjective outcome. The combined ROR for all-cause mortality was 0.83 (95% confidence interval: 0.65-1.04). For subjective outcomes, the combined ROR was 1.07 (0.87-1.33). CONCLUSIONS: There was no statistically significant difference in treatment effect between NRSs with PS analysis and RCTs. Prospective NRSs with suitable and careful PS analysis can be relied upon as evidence when RCTs are not possible.

Comparative efficacy of the different cutting guides in unicompartmental knee arthroplasty: A systematic-review and network meta-analysis.

BACKGROUND: Several cutting guides including conventional, navigation, patient specific instrumentation (PSI) and robotic are currently used in unicompartmental knee arthroplasty (UKA). A network meta-analysis was conducted to compare the most widely used cutting guides regarding the improvement of radiological, functional outcomes and the rate of complications. METHODS: Randomised controlled trials (RCTs) comparing UKA cutting guides were searched in electronic databases, major orthopaedics journals, and oral communications in major orthopaedics meetings, until May 1st, 2022. The primary outcomes were the rate of outliers for the tibial and femoral components in the frontal plane, KSS score and the complication rate. RESULTS: Eighteen RCTs involving 1562 patients with 1564 UKA were included Regarding the prosthetic components' positions, we found a significant increase of the outliers rate using PSI for the femoral component, compared to robotic surgery (risk ratio 0.00 [95% CI 0.00 to 0.55]) and navigated surgery (risk ratio 305.1 [95% CI 1.50 to 1,27e + 07]). We didn't emphasize any difference regarding the tibial component's position, the KSS value at 24 months postoperatively, and the complication rate. Regarding secondary outcomes, robotics provided a better precision in bone cuts in the sagittal plane for the tibial component and the lower limb alignment. No other differences were observed. CONCLUSION: In the light of these results, the robot seems to be the most precise cutting instrument to perform UKA. However, this did not demonstrate any difference in functional or clinical outcome. The cost of this technology can be a major economic brake, especially in surgical centers that do not have an exclusive prosthetic activity. Further outcome and survivorship data is needed to recommend one cutting instrument over the other.

Risk of simultaneous and delayed breakage of total hip replacement ceramic implants in patients with trauma induced periprosthetic fracture and acetabular shell loosening.

BACKGROUND: Ceramic implant breakage (CIB) in total hip replacement (THR) is a rare incident. A confusion exists between the fragile mechanical behaviour of ceramic materials (brittleness) and fragility in the common sense (easy to break), leading to the misconception that trauma is to blame for these breakages. Trauma has been reported as a cause of breakage by several authors and it is debated whether the burst force can be reached in one single trauma in-vivo. We did a retrospective investigation aiming to determine the risk of CIB associated with a major trauma defined as a periprosthetic femoral fracture (PPFF) or a traumatic loosening of the acetabular shell (TLAS) in ceramic-on-ceramic (CoC) THR. HYPOTHESIS: The impact forces responsible of PPFF and TLAS, which are probably the most important impact forces sustained by patients, are not sufficient to induce immediate or delayed CIB. MATERIAL AND METHODS: We conducted a retrospective study on 31 patients (62 ceramic implants, 31 acetabular liners and 31 femoral heads) with a PPFF or TLAS between January 2010 and January 2022. We reviewed the records and X-rays at the time of the major trauma and at the last follow-up. We searched for simultaneous CIB, and those occurring on the non-explanted ceramic implants at last follow up (delayed CIB). These major traumas occurred in 9 men and 22 women. Median age was 75 years old [20-97years old]. There were 28 PPFF and 3 TLAS. Mean time from THR to trauma was 91.2±67months [2.4-240months]. RESULTS: On X-rays and after intraoperative confirmation, we do not report any simultaneous CIB on the 62 ceramic implants. Treatment consisted of internal fixation for 20 patients with preservation of both ceramic implants for Vancouver A, B1 and C fractures, 8 stem revisions with preservation of acetabular liner for Vancouver B2 and B3 fractures and 3 acetabular shell revisions to dual mobility and ceramic head change for TLAS. Thus, a total of 48 ceramic implants remained implanted (28 acetabular liners and 20 femoral heads). At last follow-up after the index revision (median=36 months [6-100months]), no patient had a delayed CIB. DISCUSSION: Major trauma resulting in a PPFF or TLAS in patient withs a CoC THR did not result in simultaneous CIB. The impact forces during these traumas are not sufficient to induce immediate breakage of the ceramic implants. At a median 3years follow-up we found no delayed CIB. Because CIB is a rare event, longer follow up and larger cohort study is needed to determine if a single high impact trauma can initiate and favour the spread of a crack in the ceramic material leading to a breakage. Considering the high mechanical resistance of the ceramic implants and the absence of CIB during or after a major trauma in our study, patients with CoC bearings should not be restricted in their daily activity to prevent CIB. LEVEL OF EVIDENCE: IV, retrospective cohort study.

Effect of Prehabilitation Before Total Knee Replacement for Knee Osteoarthritis on Functional Outcomes: A Randomized Clinical Trial.

Importance: Multidisciplinary prehabilitation before total knee replacement (TKR) for osteoarthritis may improve outcomes in the postoperative period. Objective: To compare multidisciplinary prehabilitation with usual care before TKR for osteoarthritis in terms of functional independence and activity limitations after surgery. Design, Setting, and Participants: This prospective, open-label randomized clinical trial recruited participants 50 to 85 years of age with knee osteoarthritis according to the American College of Rheumatology criteria for whom a TKR was scheduled at 3 French tertiary care centers. Recruitment started on October 4, 2012, with follow-up completed on November 29, 2017. Statistical analyses were conducted from March 29, 2018, to March 6, 2019. Interventions: Four supervised sessions of multidisciplinary rehabilitation and education (2 sessions per week, at least 2 months before TKR, delivered to groups of 4-6 participants at each investigating center; session duration was 90 minutes and included 30 minutes of education followed by 60 minutes of exercise therapy) or usual care (information booklet and standard advice by the orthopedic surgeon) before TKR. Main Outcomes and Measures: The short-term primary end point was the proportion of participants achieving functional independence a mean (SD) of 4 (1) days after surgery defined as level 3 on the 4 functional tests. The midterm primary end point was activity limitations within 6 months after TKR assessed by the area under the receiver operating characteristic curve of the self-administered Western Ontario Questionnaire and McMaster Universities Osteoarthritis Index function subscale. Results: A total of 262 patients (mean [SD] age, 68.6 [8.0] years; 178 women [68%]) were randomized (131 to each group). A mean (SD) of 4 (1) days after surgery, 34 of 101 (34%) in the experimental group vs 26 of 95 (27%) in the control group achieved functional independence (risk ratio, 1.4; 97.5% CI, 0.9-2.1; P = .15). At 6 months, the mean (SD) area under the curve for the Western Ontario Questionnaire and McMaster Universities Osteoarthritis Index function subscale was 38.1 (16.5) mm2 in the experimental group vs 40.6 (17.8) mm2 in the control group (absolute difference, -2.8 mm2; 97.5% CI, -7.8 to 2.3; P = .31 after multiple imputation). No differences were found in secondary outcomes. Conclusions and Relevance: This randomized clinical trial found no evidence that multidisciplinary prehabilitation before TKR for osteoarthritis improves short-term functional independence or reduces midterm activity limitations after surgery. Trial registration: ClinicalTrials.gov Identifier: NCT01671917.

Thirty years of experience with alumina-on-alumina bearings in total hip arthroplasty.

Alumina-on-alumina bearings in total hip arthroplasty have been developed in an attempt to minimise debris and the occurrence of osteolytic lesions. The outstanding tribological properties of this bearing system are explained by low surface roughness, high hardness for major scratch resistance, and high wettability. Since the 1970s, technological improvements in the manufacturing process of alumina components together with a better understanding of Morse taper technology have provided a surgical grade material with high density, high purity and small grains. Published studies on the outcome of total hip arthroplasty performed with this new generation of implants showed high survivorship especially in young and active patients, with survival rates free of revision of 90.8% to 97.4% at ten years. However, concern remains over ceramic liner fracture and squeaking, which has been noted recently with increasing prevalence. This review will discuss the current knowledge on the use of alumina-on-alumina bearings.

Is there a risk in placing a ceramic head on a previously implanted trunion?

BACKGROUND: Strategies for revising a ceramic-on-ceramic total hip prosthesis are controversial. Some consider reimplantation of a ceramic head on a well-fixed femoral stem inadvisable as it may lead to a fracture of the newly implanted head. QUESTIONS/PURPOSES: We assessed (1) the risk of fracture when a new ceramic head was placed on a previously implanted trunion; (2) the survival rate of the revised hips; and (3) hip function and acetabular and femoral component loosening at midterm followup. PATIENTS AND METHODS: We retrospectively reviewed all 126 patients (139 hips) who had revision of alumina-alumina hip arthroplasties between January 1977 and December 2005. Of these, 99 patients (110 hips) had revision of the socket only with retention of the femoral component. The femoral head was left in place in 33 hips, the same alumina head was re-implanted in seven hips, a new alumina head was implanted in 45 hips, a metallic head in 16, and a zirconia head in nine. Twenty-six patients (29 hips) died and nine (10 hips) were lost to followup before 5 years; this left 71 hips for review. Minimum followup was 60 months (mean, 112 months; range, 60-319 months). RESULTS: Eighteen hips required rerevision surgery, 11 for aseptic loosening, two for septic loosening, two for fracture of a ceramic liner, one for recurrent dislocation, one for ipsilateral femoral fracture, and one for unexplained pain. Among the 61 ceramic heads implanted on a well-fixed stem, no fracture of the head occurred at a mean 88 months' followup. The survival rate at 10 years with mechanical failure as the end point was 81.6%. CONCLUSIONS: We observed no fractures of the ceramic heads implanted on a previous titanium trunion. This approach is possible if inspection shows no major imperfection of the Morse taper.