Background: We introduce a simple, cost-effective bio-occlusive dressing to be used for primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA). Methods: The gauze-Tegaderm™ (GT) dressing consists of a 5cm wide 8-layered gauze covered by 3 to 5 medium-sized Tegaderm transparent films. We prospectively evaluated 100 consecutive primary THA’s and 107 consecutive primary TKA’s utilizing this dressing with a minimum of one-year follow-up. Results: In the primary THA group, there was one surgical site infection (SSI) requiring oral antibiotic treatment. There were no cases of periprosthetic joint infection (PJI). In the primary TKA group, there were two surgical site infections requiring oral antibiotic treatment and one case of chronic PJI requiring a two-stage exchange protocol. Discussion: Our SSI and PJI rates are comparable to published rates in the literature. The GT dressing is a simple, inexpensive dressing that can compete against the many proprietary bio-occlusive dressings that are more expensive and are not readily available worldwide. Our favorable review has merited a large volume randomized controlled study comparing the GT dressing to another proprietary bio-occlusive dressing.
{"title":"Bio-Occlusive Gauze with Tegaderm: A Dressing for Surgical Wounds in Primary THA and TKA","authors":"Madhav Chowdhry, M. Dipane, E. McPherson","doi":"10.15438/RR.7.4.197","DOIUrl":"https://doi.org/10.15438/RR.7.4.197","url":null,"abstract":"Background: We introduce a simple, cost-effective bio-occlusive dressing to be used for primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA). Methods: The gauze-Tegaderm™ (GT) dressing consists of a 5cm wide 8-layered gauze covered by 3 to 5 medium-sized Tegaderm transparent films. We prospectively evaluated 100 consecutive primary THA’s and 107 consecutive primary TKA’s utilizing this dressing with a minimum of one-year follow-up. Results: In the primary THA group, there was one surgical site infection (SSI) requiring oral antibiotic treatment. There were no cases of periprosthetic joint infection (PJI). In the primary TKA group, there were two surgical site infections requiring oral antibiotic treatment and one case of chronic PJI requiring a two-stage exchange protocol. Discussion: Our SSI and PJI rates are comparable to published rates in the literature. The GT dressing is a simple, inexpensive dressing that can compete against the many proprietary bio-occlusive dressings that are more expensive and are not readily available worldwide. Our favorable review has merited a large volume randomized controlled study comparing the GT dressing to another proprietary bio-occlusive dressing.","PeriodicalId":20884,"journal":{"name":"Reconstructive Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2017-12-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42627183","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The geriatric population in general and specifically recipients of total knee arthroplasty (TKA) have increasing functional demands along with an increasing life expectancy. Certain intraoperative aspects of the index procedure, revision TKA, or the patient’s physiology (i.e.- osteoporosis, rheumatoid arthritis, neurologic disease) predispose the patient to post-operative periprosthetic distal femur fractures (PDFF). This review describes the epidemiology, classification, examination, and treatment options of PDFF. Osteoporosis and intraoperative anterior femoral cortex notching are primary patient and surgeon specific factors, respectively. The two most commonly used classification systems were described by Rorabeck and Kim and should be used to guide the surgeon’s choice of treatment. The non-operative treatment of PDFF is rare, requires close radiographic follow up, and delayed union is common. Open reduction with internal fixation (ORIF) is best accomplished with minimally invasive techniques and distal locking screws. Retrograde, intra-medullary nail fixation is technically difficult, but provides earlier weight bearing and comparable time to union as ORIF. Revision TKA is indicated in patients with adequate bone stock, a simple fracture pattern without ligamentous instability, and a loose or malaligned femoral component. Allograft-prosthetic composite (APC) or distal femoral replacement (DFR) is indicated for patients presenting with a PDFF about poor or deficient bone stock. Patients with PDFF present a challenge to the arthroplasty surgeon in regards to choice of treatment and increased morbidity and mortality post-operatively. Close follow up is required and fracture union is often delayed.
{"title":"Periprosthetic Distal Femur Fractures: Review of Current Treatment Options","authors":"J. M. Head","doi":"10.15438/RR.7.4.188","DOIUrl":"https://doi.org/10.15438/RR.7.4.188","url":null,"abstract":"The geriatric population in general and specifically recipients of total knee arthroplasty (TKA) have increasing functional demands along with an increasing life expectancy. Certain intraoperative aspects of the index procedure, revision TKA, or the patient’s physiology (i.e.- osteoporosis, rheumatoid arthritis, neurologic disease) predispose the patient to post-operative periprosthetic distal femur fractures (PDFF). This review describes the epidemiology, classification, examination, and treatment options of PDFF. Osteoporosis and intraoperative anterior femoral cortex notching are primary patient and surgeon specific factors, respectively. The two most commonly used classification systems were described by Rorabeck and Kim and should be used to guide the surgeon’s choice of treatment. The non-operative treatment of PDFF is rare, requires close radiographic follow up, and delayed union is common. Open reduction with internal fixation (ORIF) is best accomplished with minimally invasive techniques and distal locking screws. Retrograde, intra-medullary nail fixation is technically difficult, but provides earlier weight bearing and comparable time to union as ORIF. Revision TKA is indicated in patients with adequate bone stock, a simple fracture pattern without ligamentous instability, and a loose or malaligned femoral component. Allograft-prosthetic composite (APC) or distal femoral replacement (DFR) is indicated for patients presenting with a PDFF about poor or deficient bone stock. Patients with PDFF present a challenge to the arthroplasty surgeon in regards to choice of treatment and increased morbidity and mortality post-operatively. Close follow up is required and fracture union is often delayed.","PeriodicalId":20884,"journal":{"name":"Reconstructive Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2017-12-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46731083","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: The use of elevated lip polyethylene liners with the acetabular component is relatively common in Total Hip Arthroplasty (THA). Elevated lip liners increase stability of the THA by increasing the jump distance in one direction. However, the elevated lip, conversely, also reduces the primary arc in the opposite direction and leads to early impingement of the neck on the elevated lip, potentially causing instability. The aim of the present study is to determine the total range of motion of the femoral head component within the acetabular component with the elevated lip liner in different orientations within the acetabular cup. Methods: We introduce a novel experimental (ex-vivo) framework for studying the effects lip liner orientation on the range of motion of the femoral component. For constant acetabular cup orientation, the elevated lip liner was positioned superiorly and inferiorly. The femoral component range of motion in the coronal, sagittal and axial plane was measured. To avoid any confounding influences of out of plane motion, the femoral component was constrained to move in the tested plane. Results: This experimental set up introduces a rigorous framework in which to test the effects of elevated lip liner orientations on the range of motion of the femoral head component in abduction, adduction, flexion, extension and rotation. The movements of this experimental set-up are directly informative of patient’s maximum potential post-operative range of motion. Initial results show that an inferior placement of the elevated lip increases the effective superior lateral range of motion (abduction) for the femoral component, whilst the anatomy of the patient (i.e. their other leg) prevents the point of femoral component – acetabular lip impingement being reached (in adduction).
{"title":"Elevated Lip Liner Positions Improving Stability in Total Hip Arthroplasty – An Experimental Study","authors":"S. Qurashi, W. Parr, Bob Jang, W. Walsh","doi":"10.15438/RR.7.4.195","DOIUrl":"https://doi.org/10.15438/RR.7.4.195","url":null,"abstract":"Background: The use of elevated lip polyethylene liners with the acetabular component is relatively common in Total Hip Arthroplasty (THA). Elevated lip liners increase stability of the THA by increasing the jump distance in one direction. However, the elevated lip, conversely, also reduces the primary arc in the opposite direction and leads to early impingement of the neck on the elevated lip, potentially causing instability. The aim of the present study is to determine the total range of motion of the femoral head component within the acetabular component with the elevated lip liner in different orientations within the acetabular cup. Methods: We introduce a novel experimental (ex-vivo) framework for studying the effects lip liner orientation on the range of motion of the femoral component. For constant acetabular cup orientation, the elevated lip liner was positioned superiorly and inferiorly. The femoral component range of motion in the coronal, sagittal and axial plane was measured. To avoid any confounding influences of out of plane motion, the femoral component was constrained to move in the tested plane. Results: This experimental set up introduces a rigorous framework in which to test the effects of elevated lip liner orientations on the range of motion of the femoral head component in abduction, adduction, flexion, extension and rotation. The movements of this experimental set-up are directly informative of patient’s maximum potential post-operative range of motion. Initial results show that an inferior placement of the elevated lip increases the effective superior lateral range of motion (abduction) for the femoral component, whilst the anatomy of the patient (i.e. their other leg) prevents the point of femoral component – acetabular lip impingement being reached (in adduction).","PeriodicalId":20884,"journal":{"name":"Reconstructive Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2017-12-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41676186","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Michael B. Canales, Grace C Craig, J. Boyd, M. Markovic, R. Chmielewski
Background: Superficial wound complications are among the most prevalent problems associated with any surgical procedures. Infection rates of the primary hip and knee joint arthroplasty have been reduced with modern aseptic techniques but this rate may reach 20% in some revision procedures. Mobile phones are frequently used in the hospital and operating room settings, regardless of their microbial load. This study aimed to: 1) determine the level of bacterial contamination of mobile phones from resident physicians at Saint Vincent Charity Medical Center (SVCMC) in Cleveland, Ohio; 2) determine the effectiveness of quaternary ammonium compound (QAC) wipes; and 3) heighten awareness of potential dissemination of pathogens by mobile phones in the hospital setting. Materials & Methods: A total of fifty mobile phones were randomly sampled from podiatric surgical resident physicians and internal medicine resident physicians at SVCMC. For each mobile phone, a swab was collected from the touch screen prior to use of QAC wipes and following use of QAC wipes. Results: The results demonstrated that 82% (41/50) of mobile phone touch screens possessed polymicrobial organisms and 30% (15/50) of mobile phones possessed pathogenic organisms. The vast majority of residents, 98% (49/50) used their phones within the hospital and 37% (18/49) used their phones inside patients’ room. Most of the residents, 86% (43/50), did not clean their phones on a daily basis and of the residents who did, a majority of them, 71% (5/7) used either dry wipes or alcohol wipes. Discussion: Sanitizing mobile phones with QAC disposable wipes was shown to be an effective infection control intervention as mobile phone touch screens showed no growth after two minutes of sanitization. QAC could potentially decrease the transmission of microorganisms that cause diseases and reduce the risk of cross contamination infections from mobile phones.
{"title":"Dissemination of Pathogens by Mobile Phones in a Single Hospital","authors":"Michael B. Canales, Grace C Craig, J. Boyd, M. Markovic, R. Chmielewski","doi":"10.15438/RR.7.3.192","DOIUrl":"https://doi.org/10.15438/RR.7.3.192","url":null,"abstract":"Background: Superficial wound complications are among the most prevalent problems associated with any surgical procedures. Infection rates of the primary hip and knee joint arthroplasty have been reduced with modern aseptic techniques but this rate may reach 20% in some revision procedures. Mobile phones are frequently used in the hospital and operating room settings, regardless of their microbial load. This study aimed to: 1) determine the level of bacterial contamination of mobile phones from resident physicians at Saint Vincent Charity Medical Center (SVCMC) in Cleveland, Ohio; 2) determine the effectiveness of quaternary ammonium compound (QAC) wipes; and 3) heighten awareness of potential dissemination of pathogens by mobile phones in the hospital setting. Materials & Methods: A total of fifty mobile phones were randomly sampled from podiatric surgical resident physicians and internal medicine resident physicians at SVCMC. For each mobile phone, a swab was collected from the touch screen prior to use of QAC wipes and following use of QAC wipes. Results: The results demonstrated that 82% (41/50) of mobile phone touch screens possessed polymicrobial organisms and 30% (15/50) of mobile phones possessed pathogenic organisms. The vast majority of residents, 98% (49/50) used their phones within the hospital and 37% (18/49) used their phones inside patients’ room. Most of the residents, 86% (43/50), did not clean their phones on a daily basis and of the residents who did, a majority of them, 71% (5/7) used either dry wipes or alcohol wipes. Discussion: Sanitizing mobile phones with QAC disposable wipes was shown to be an effective infection control intervention as mobile phone touch screens showed no growth after two minutes of sanitization. QAC could potentially decrease the transmission of microorganisms that cause diseases and reduce the risk of cross contamination infections from mobile phones.","PeriodicalId":20884,"journal":{"name":"Reconstructive Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2017-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43280674","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: The complexity of hip reconstruction has been and continues to be a perplexing problem with restoring leg length, femoral offset, joint stability and overall hip implant fixation. These were contributing factors that lead to the development of a novel proximal femoral component design “Apex Modular Stem” (Omni, Raynham, MA). The basic stem geometry features a straight stem with a metaphyseal fit and fill cone, a medial triangle and a modular neck junction that allows for version and offset adjustment. In recent years, there has been great concern with the use of modularity in total hip arthroplasty. The goals of this study are (1) to identify complications with the use of a proximal modular design and (2) demonstrated factors that have eliminated those complications. Methods: This is a retrospective study of a single surgeon series (Design A and Design B) of using the same cementless stem and proximal modular neck body (Apex Modular Stem and Omni Mod Hip Stem) from 2000 to 2016 totaling 2,125 stems. 483 stems were the Design A and 1,642 stems, were of the Design B style. Results: Design A, 483 stems were implanted between 2000 and 2004. 31 alignment pins sheared resulting in a revision rate of 6.4%. Design B, 1,642 stems have been implanted between 2004 and 2016 all by the same surgeon, with no failures of the modular junction. Conclusion: All implant devices entail a multitude of risks and benefits. The Apex Modular Stem (Design A), provided excellent fixation, minimal risk of modular junction corrosion, and simple control of anteversion and femoral offset. The limitation was found to be the risk of the alignment pin shearing (6.4%). The pin was enlarged to make it 225% stronger in torsional resistance, and in a subsequent series of over 1,600 femoral stems in a single surgeon series, there were no pin failures over a 12 year duration.
{"title":"The 16-Year Evolution of Proximal Modular Stem Design – Eliminating Failure of Modular Junction","authors":"T. Tkach, T. Mctighe","doi":"10.15438/RR.7.3.193","DOIUrl":"https://doi.org/10.15438/RR.7.3.193","url":null,"abstract":"Background: The complexity of hip reconstruction has been and continues to be a perplexing problem with restoring leg length, femoral offset, joint stability and overall hip implant fixation. These were contributing factors that lead to the development of a novel proximal femoral component design “Apex Modular Stem” (Omni, Raynham, MA). The basic stem geometry features a straight stem with a metaphyseal fit and fill cone, a medial triangle and a modular neck junction that allows for version and offset adjustment. In recent years, there has been great concern with the use of modularity in total hip arthroplasty. The goals of this study are (1) to identify complications with the use of a proximal modular design and (2) demonstrated factors that have eliminated those complications. Methods: This is a retrospective study of a single surgeon series (Design A and Design B) of using the same cementless stem and proximal modular neck body (Apex Modular Stem and Omni Mod Hip Stem) from 2000 to 2016 totaling 2,125 stems. 483 stems were the Design A and 1,642 stems, were of the Design B style. Results: Design A, 483 stems were implanted between 2000 and 2004. 31 alignment pins sheared resulting in a revision rate of 6.4%. Design B, 1,642 stems have been implanted between 2004 and 2016 all by the same surgeon, with no failures of the modular junction. Conclusion: All implant devices entail a multitude of risks and benefits. The Apex Modular Stem (Design A), provided excellent fixation, minimal risk of modular junction corrosion, and simple control of anteversion and femoral offset. The limitation was found to be the risk of the alignment pin shearing (6.4%). The pin was enlarged to make it 225% stronger in torsional resistance, and in a subsequent series of over 1,600 femoral stems in a single surgeon series, there were no pin failures over a 12 year duration.","PeriodicalId":20884,"journal":{"name":"Reconstructive Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2017-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48266309","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
I. Clarke, J. Shelton, J. Bowsher, C. Savisaar, T. Donaldson
Background: Adverse-wear phenomenon in metal-on-metal (MOM) arthroplasty has been attributed to “edge-loading” of the CoCr cups. Simulator studies of steeply-inclined cups run in the ‘Anatomic-cup’ model represented many variations in design and test parameters with no coherent rationale. We created an algorithm to synthesize MOM test parameters and noted that wear areas typically averaged only 10-15% of cup surface. In contrast, retrievals showed wear areas extending to 60% of cup surface. We hypothesized that MOM wear studies run in the orbital hip simulator with the ‘Inverted-cup’ model would, (i) differentiate normal-loading versus edge-loading, (ii) demonstrate cup wear areas x3.8-times larger than on femoral heads, cover 30% of cup surface, and (iii) double the wear-rates measured in prior Anatomic-cup study. Methods: Edge-loading occurs when the cup rim is allowed to truncate the habitual wear area that provides optimal tribological conditions. A MOM algorithm was developed to synthesize relevant test parameters. The 60mm MOM bearings donated for this study were run in an orbital hip simulator using the Inverted-cup model. Tests #1 and #2 to one million cycles (1-Mc) duration assessed wear at peak cup inclinations 40° and 50°. Test #3 evaluated edge-loading with peak cup inclinations achieving 70° (5-Mc duration). Results: Wear areas in Inverted-cups averaged 1663mm2 in tests #1 and 2, were fully contained within cup rims, and covered 30% of cup surface as predicted by algorithm. Test-3 with 70° cup inclination produced the predicted edge-loading with volumetric wear-rates averaging 2mm3/Mc, approximately 5-fold greater wear than prior Anatomic-cup study. Discussion and Conclusions: Simulator studies of steep-cup mechanisms necessitate production of clinically-relevant wear-patterns such that the biomechanical and tribological functionality is respected. As an aid to steeply-inclined cup analyses, the MOM algorithm allowed integration of confounding test parameters. The algorithm successfully differentiated between “normal” and “edge loaded” cups and the MOM wear areas were as predicted for three cup inclinations. Also as predicted, wear-patterns in Inverted-cup model exactly reversed those of the Anatomic-cup model. Even with only intermittent edge-loading, Test-3 produced 5-fold greater wear than our prior Anatomic study. Clinical Significance: The Inverted-cup simulator model successfully mobilized the cup to produce larger wear areas that were more representative of those in-vivo and therefore reproduced more realistic test conditions for studies of edge-loaded cups.
{"title":"Simulator Study of MOM using Steep-cup Flexion - A Clinically Relevant Incorporation of Intermittent Edge-loading","authors":"I. Clarke, J. Shelton, J. Bowsher, C. Savisaar, T. Donaldson","doi":"10.15438/RR.7.3.190","DOIUrl":"https://doi.org/10.15438/RR.7.3.190","url":null,"abstract":"Background: Adverse-wear phenomenon in metal-on-metal (MOM) arthroplasty has been attributed to “edge-loading” of the CoCr cups. Simulator studies of steeply-inclined cups run in the ‘Anatomic-cup’ model represented many variations in design and test parameters with no coherent rationale. We created an algorithm to synthesize MOM test parameters and noted that wear areas typically averaged only 10-15% of cup surface. In contrast, retrievals showed wear areas extending to 60% of cup surface. We hypothesized that MOM wear studies run in the orbital hip simulator with the ‘Inverted-cup’ model would, (i) differentiate normal-loading versus edge-loading, (ii) demonstrate cup wear areas x3.8-times larger than on femoral heads, cover 30% of cup surface, and (iii) double the wear-rates measured in prior Anatomic-cup study. Methods: Edge-loading occurs when the cup rim is allowed to truncate the habitual wear area that provides optimal tribological conditions. A MOM algorithm was developed to synthesize relevant test parameters. The 60mm MOM bearings donated for this study were run in an orbital hip simulator using the Inverted-cup model. Tests #1 and #2 to one million cycles (1-Mc) duration assessed wear at peak cup inclinations 40° and 50°. Test #3 evaluated edge-loading with peak cup inclinations achieving 70° (5-Mc duration). Results: Wear areas in Inverted-cups averaged 1663mm2 in tests #1 and 2, were fully contained within cup rims, and covered 30% of cup surface as predicted by algorithm. Test-3 with 70° cup inclination produced the predicted edge-loading with volumetric wear-rates averaging 2mm3/Mc, approximately 5-fold greater wear than prior Anatomic-cup study. Discussion and Conclusions: Simulator studies of steep-cup mechanisms necessitate production of clinically-relevant wear-patterns such that the biomechanical and tribological functionality is respected. As an aid to steeply-inclined cup analyses, the MOM algorithm allowed integration of confounding test parameters. The algorithm successfully differentiated between “normal” and “edge loaded” cups and the MOM wear areas were as predicted for three cup inclinations. Also as predicted, wear-patterns in Inverted-cup model exactly reversed those of the Anatomic-cup model. Even with only intermittent edge-loading, Test-3 produced 5-fold greater wear than our prior Anatomic study. Clinical Significance: The Inverted-cup simulator model successfully mobilized the cup to produce larger wear areas that were more representative of those in-vivo and therefore reproduced more realistic test conditions for studies of edge-loaded cups.","PeriodicalId":20884,"journal":{"name":"Reconstructive Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2017-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45464759","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: This is a case report of a 36mm constrained cup (Freedom™, Biomet IN) that performed successfully for 7-years in a salvage case involving a total-femur implanted in a leg already short by 3-4 inches. The goal was to enhance hip motion and stability using a 36mm head instead of the usual 32mm size. Templating indications were for a 50mm cup (Freedom™; Arcom™ liner). The proximal femur inserted in 2008 incorporated the 36mm constrained THA and was anchored distally to bone using the Compress™ fixator. By 2012 the fixator loosened and was replaced by hinged total-knee arthroplasty (TKA). The THA was retained at revision and patient’s clinical follow-up was satisfactory for 4 years. As indicated by Martel radiographic method, the Arcom™ liner showed minimal wear over this period. Radiographs in Feb-2016 showed the cup’s constraint ring had rotated slightly but the patient had no symptoms. By Dec-2016, the patient had experienced three falls and also had heard a popping sound in her hip. At Dec-2016 office visit, radiographs indicated additional rotation of the constraint ring and CT scans showed an eccentric head position contacting the metal shell. At revision, 50% of the Arcom rim was ablated and the remainder present as a loose fragment. Following insertion of new Freedom liner and 36mm head, her follow-up appears satisfactory 10-months later. Her leg shortening remains but she walks to office visits using a cane and doesn’t need the cane at home. Methods: Retrieved Arcom liner and detached rim fragment were reconstructed, photographed, and then bi-valved for comparison to similarly prepared exemplar liners, one identical to our revision and one with a thicker wall. Details of liner sections were taken from photographs and reconstructed by computer graphics (Canvas Draw-3™). Wear performance over the first 7 years was assessed using the Martel x-ray method. Results: Inspection of retrieved liner showed a large oval depression in the ablated rim. The contra-rim featured the large Arcom fragment and the underlying liner wall was less than 1mm thick. Comparison to exemplar liners showed that the large fragment had separated along the lower edge of the constraint groove. Exemplars demonstrated a substantial rim buttress spanning 13mm, which had been ablated in our retrieval. Discussion and Conclusion: Although this was not a high-demand patient, the considerable hip-impingement forces in a flail limb likely levered the head repeatedly against the liner’s constrained rim. Neck impingement was clearly evident in the damaged liner. A subluxing femoral head would also thin the contra-wall, as would backside wear. We do not know if the eccentric ring image in Feb-2016 radiographs depicted failure. The liner may have escaped from the shell’s locking-ring and with activity, ablated the Arcom contours and led to rim fracture. It is also possible that the liner constraint was damaged when the patient fell, thereby allowing the liner to mobilize.
{"title":"Successes and Failures of a Freedom™ Constrained Cup Used in a Major Salvage Procedure","authors":"T. Donaldson, I. Clarke","doi":"10.15438/RR.7.3.191","DOIUrl":"https://doi.org/10.15438/RR.7.3.191","url":null,"abstract":"Background: This is a case report of a 36mm constrained cup (Freedom™, Biomet IN) that performed successfully for 7-years in a salvage case involving a total-femur implanted in a leg already short by 3-4 inches. The goal was to enhance hip motion and stability using a 36mm head instead of the usual 32mm size. Templating indications were for a 50mm cup (Freedom™; Arcom™ liner). The proximal femur inserted in 2008 incorporated the 36mm constrained THA and was anchored distally to bone using the Compress™ fixator. By 2012 the fixator loosened and was replaced by hinged total-knee arthroplasty (TKA). The THA was retained at revision and patient’s clinical follow-up was satisfactory for 4 years. As indicated by Martel radiographic method, the Arcom™ liner showed minimal wear over this period. Radiographs in Feb-2016 showed the cup’s constraint ring had rotated slightly but the patient had no symptoms. By Dec-2016, the patient had experienced three falls and also had heard a popping sound in her hip. At Dec-2016 office visit, radiographs indicated additional rotation of the constraint ring and CT scans showed an eccentric head position contacting the metal shell. At revision, 50% of the Arcom rim was ablated and the remainder present as a loose fragment. Following insertion of new Freedom liner and 36mm head, her follow-up appears satisfactory 10-months later. Her leg shortening remains but she walks to office visits using a cane and doesn’t need the cane at home. Methods: Retrieved Arcom liner and detached rim fragment were reconstructed, photographed, and then bi-valved for comparison to similarly prepared exemplar liners, one identical to our revision and one with a thicker wall. Details of liner sections were taken from photographs and reconstructed by computer graphics (Canvas Draw-3™). Wear performance over the first 7 years was assessed using the Martel x-ray method. Results: Inspection of retrieved liner showed a large oval depression in the ablated rim. The contra-rim featured the large Arcom fragment and the underlying liner wall was less than 1mm thick. Comparison to exemplar liners showed that the large fragment had separated along the lower edge of the constraint groove. Exemplars demonstrated a substantial rim buttress spanning 13mm, which had been ablated in our retrieval. Discussion and Conclusion: Although this was not a high-demand patient, the considerable hip-impingement forces in a flail limb likely levered the head repeatedly against the liner’s constrained rim. Neck impingement was clearly evident in the damaged liner. A subluxing femoral head would also thin the contra-wall, as would backside wear. We do not know if the eccentric ring image in Feb-2016 radiographs depicted failure. The liner may have escaped from the shell’s locking-ring and with activity, ablated the Arcom contours and led to rim fracture. It is also possible that the liner constraint was damaged when the patient fell, thereby allowing the liner to mobilize.","PeriodicalId":20884,"journal":{"name":"Reconstructive Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2017-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48387180","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Brandon H. Naylor, A. King, S. Voges, T. Blackwell, Robin A Huff, H. Schutte
Background: The importance of appropriate serum 25-hydroxy vitamin D [25(OH)D] for multiple health measures is widely described, however, the prevalence of vitamin D deficiency remains remarkably high. The goal of our study is to explore the distribution of vitamin D deficiency among an elective total joint arthroplasty (TJA) population within a lower latitude climate with relatively abundant sunshine. We hypothesize this group will demonstrate a high prevalence of vitamin D deficiency, thus exposing a potential opportunity to improve outcomes with proper management. Methods: From January to December, 2014, serum 25(OH)D levels were collected during a standard preoperative workup prior to primary or revision joint arthroplasty in South Carolina. Mean serum 25(OH)D, seasonal variation, and patient demographics were recorded. We defined Vitamin D deficiency consistent with the current Endocrine Society classification: serum 25(OH)D < 20 ng/ml, 21-29 ng/ml, and 30-100 ng/ml representing deficiency, insufficiency, and normal, respectively. Results: A total of 308 patients underwent evaluation. 46.8% (144) of the participants were female, and 89.6% (276) identified as Caucasian. The mean patient age was 68.3 years + 13.8 (32-88). The average serum 25(OH)D was 29.8 ng/ml + 12.8 (5.1-79.9), with only 46.2% of patients having a normal serum 25(OH)D (p=0.0001). Caucasian and non-white patients averaged 33 ng/ml [56% normal 25(OH)D] and 25 ng/ml [36% normal 25(OH)D], respectively (p = 0.22). Patients over the age of 65 demonstrated lower serum 25(OH)D (28.5ng/ml) compared to those under 65 (30.7ng/ml)(p=.12). As expected, serum 25(OH)D demonstrated variation throughout the year: January to March, April to June, July to September, and October to December recorded 28.5 ng/ml, 31.73 ng/ml, 36.57 ng/ml, and 23.03 ng/ml 25(OH)D, respectively. Conclusion: The majority (53.8%) of an otherwise classically low risk patient population present with vitamin D insufficiency or deficiency prior to undergoing elective total joint arthroplasty, with elderly non-white patients in the winter months at the highest risk. Appropriate vitamin D management is associated with favorable influences on both skeletal and non-skeletal outcomes. Potential complications of total joint arthroplasty (TJA), including periprosthetic joint infection and aseptic loosening, can possibly be decreased with proper identification and treatment, which can be elucidated by future high quality studies.
{"title":"Exploration of Serum 25-Hydroxy Vitamin D in Total Joint Arthroplasty within a Subtropical Climate","authors":"Brandon H. Naylor, A. King, S. Voges, T. Blackwell, Robin A Huff, H. Schutte","doi":"10.15438/rr.7.3.186","DOIUrl":"https://doi.org/10.15438/rr.7.3.186","url":null,"abstract":"Background: The importance of appropriate serum 25-hydroxy vitamin D [25(OH)D] for multiple health measures is widely described, however, the prevalence of vitamin D deficiency remains remarkably high. The goal of our study is to explore the distribution of vitamin D deficiency among an elective total joint arthroplasty (TJA) population within a lower latitude climate with relatively abundant sunshine. We hypothesize this group will demonstrate a high prevalence of vitamin D deficiency, thus exposing a potential opportunity to improve outcomes with proper management. Methods: From January to December, 2014, serum 25(OH)D levels were collected during a standard preoperative workup prior to primary or revision joint arthroplasty in South Carolina. Mean serum 25(OH)D, seasonal variation, and patient demographics were recorded. We defined Vitamin D deficiency consistent with the current Endocrine Society classification: serum 25(OH)D < 20 ng/ml, 21-29 ng/ml, and 30-100 ng/ml representing deficiency, insufficiency, and normal, respectively. Results: A total of 308 patients underwent evaluation. 46.8% (144) of the participants were female, and 89.6% (276) identified as Caucasian. The mean patient age was 68.3 years + 13.8 (32-88). The average serum 25(OH)D was 29.8 ng/ml + 12.8 (5.1-79.9), with only 46.2% of patients having a normal serum 25(OH)D (p=0.0001). Caucasian and non-white patients averaged 33 ng/ml [56% normal 25(OH)D] and 25 ng/ml [36% normal 25(OH)D], respectively (p = 0.22). Patients over the age of 65 demonstrated lower serum 25(OH)D (28.5ng/ml) compared to those under 65 (30.7ng/ml)(p=.12). As expected, serum 25(OH)D demonstrated variation throughout the year: January to March, April to June, July to September, and October to December recorded 28.5 ng/ml, 31.73 ng/ml, 36.57 ng/ml, and 23.03 ng/ml 25(OH)D, respectively. Conclusion: The majority (53.8%) of an otherwise classically low risk patient population present with vitamin D insufficiency or deficiency prior to undergoing elective total joint arthroplasty, with elderly non-white patients in the winter months at the highest risk. Appropriate vitamin D management is associated with favorable influences on both skeletal and non-skeletal outcomes. Potential complications of total joint arthroplasty (TJA), including periprosthetic joint infection and aseptic loosening, can possibly be decreased with proper identification and treatment, which can be elucidated by future high quality studies.","PeriodicalId":20884,"journal":{"name":"Reconstructive Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2017-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46484245","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background : Patellar resurfacing in total knee arthroplasty remains a point of controversy within the literature and the generally followed paradigm varies among regions. Methods : In effort to elucidate a difference following the change from universal patellar resurfacing to universal non-resurfacing, 32 patients with bilateral TKA that included one resurfaced and one native patella were retrospectively reviewed at average follow up 21.4 months from the most recent surgery. Results : No difference was observed in patient satisfaction, KOOS-ADL score, and VAS scores. No complications or secondary patellar resurfacing occurred. Conclusions : Therefore, patients perceive no difference between knees with native patella retention or a resurfaced patella in regards to pain and function.
{"title":"Native Patella Retention Versus Resurfacing in a Cohort of Staged Bilateral Total Knee Patients","authors":"J. M. Head, R. Nelson, M. Dyball, B. Lawrence","doi":"10.15438/RR.7.3.175","DOIUrl":"https://doi.org/10.15438/RR.7.3.175","url":null,"abstract":"Background : Patellar resurfacing in total knee arthroplasty remains a point of controversy within the literature and the generally followed paradigm varies among regions. Methods : In effort to elucidate a difference following the change from universal patellar resurfacing to universal non-resurfacing, 32 patients with bilateral TKA that included one resurfaced and one native patella were retrospectively reviewed at average follow up 21.4 months from the most recent surgery. Results : No difference was observed in patient satisfaction, KOOS-ADL score, and VAS scores. No complications or secondary patellar resurfacing occurred. Conclusions : Therefore, patients perceive no difference between knees with native patella retention or a resurfaced patella in regards to pain and function.","PeriodicalId":20884,"journal":{"name":"Reconstructive Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2017-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41314993","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Delaying total knee arthroplasty (TKA) carries an increased likelihood of poor rehabilitation outcomes. Reasons behind choosing to delay surgery are under investigated. This study explores potential factors related to the decision to delay a TKA procedure and preferences for post-surgical pain management. Methods: A cross-sectional online survey was conducted among TKA candidates in the US. Results: 6,298 persons received a screening questionnaire; 2,571 (41%) completed screening with 680 (26%) meeting survey eligibility criteria. 654 of 680 persons (96%) completed surveys. 154 (24%) respondents had delayed TKA. Interference with work and concerns about insufficient post-discharge pain management were found to be significant factors in this decision. A one unit increase in the ten point interference with work scale was associated with a 22% increase in the odds of delaying surgery (OR: 1.219; 95%CI: 1.095-1.356). Surgical candidates concerned about experiencing pain during the first several weeks following surgery had significantly higher odds of delaying surgery (OR: 1.64, 95% CI: 0.881-3.06). Ninety-two percent of respondents indicated they would seek surgeons who offered effective non-opiate pain management options during the first several weeks of the rehabilitation period; 66 percent indicated they would likely switch surgeons for access to a non-opioid pain management approach. Conclusions: Delaying a TKA is significantly influenced by concerns about interference with work and experiencing an extended period of post-surgical pain during a potentially prolonged recovery period. Access to postoperative pain management methods that reduce or eliminate opioid use during post-discharge rehabilitation and recovery is an important factor in the selection of a joint replacement surgeon.
{"title":"Patient Factors Affecting Surgeon Selection and the Decision to Delay Total Knee Arthroplasty","authors":"K. Berend, R. Zhao, A. Carlson, M. Stultz","doi":"10.15438/RR.7.2.176","DOIUrl":"https://doi.org/10.15438/RR.7.2.176","url":null,"abstract":"Background: Delaying total knee arthroplasty (TKA) carries an increased likelihood of poor rehabilitation outcomes. Reasons behind choosing to delay surgery are under investigated. This study explores potential factors related to the decision to delay a TKA procedure and preferences for post-surgical pain management. Methods: A cross-sectional online survey was conducted among TKA candidates in the US. Results: 6,298 persons received a screening questionnaire; 2,571 (41%) completed screening with 680 (26%) meeting survey eligibility criteria. 654 of 680 persons (96%) completed surveys. 154 (24%) respondents had delayed TKA. Interference with work and concerns about insufficient post-discharge pain management were found to be significant factors in this decision. A one unit increase in the ten point interference with work scale was associated with a 22% increase in the odds of delaying surgery (OR: 1.219; 95%CI: 1.095-1.356). Surgical candidates concerned about experiencing pain during the first several weeks following surgery had significantly higher odds of delaying surgery (OR: 1.64, 95% CI: 0.881-3.06). Ninety-two percent of respondents indicated they would seek surgeons who offered effective non-opiate pain management options during the first several weeks of the rehabilitation period; 66 percent indicated they would likely switch surgeons for access to a non-opioid pain management approach. Conclusions: Delaying a TKA is significantly influenced by concerns about interference with work and experiencing an extended period of post-surgical pain during a potentially prolonged recovery period. Access to postoperative pain management methods that reduce or eliminate opioid use during post-discharge rehabilitation and recovery is an important factor in the selection of a joint replacement surgeon.","PeriodicalId":20884,"journal":{"name":"Reconstructive Review","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2017-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47077070","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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