JAAOS

JAAOS, Volume 26, No. 20


Management of the Failed Medial Unicompartmental Knee Arthroplasty

With recent design modifications, proper patient selection, and sound surgical technique, medial unicompartmental knee arthroplasty has demonstrated long-term success in the management of degenerative joint disease. Nevertheless, complications do occur, most often aseptic loosening, tibial fracture, polyethylene wear, bearing dislocation, disease progression, infection, and unexplained pain. Some failures can be managed with retention of the implant, whereas others require revision to total knee arthroplasty (TKA), possibly including augments and stems. Although outcomes of unicompartmental knee arthroplasty may not match those of a primary TKA, they tend to exceed results of revision of a previous TKA.

      • Subspecialty:
      • Adult Reconstruction

    Alignment and Balance Methods in Total Knee Arthroplasty

    Total knee arthroplasty is one of the most commonly performed orthopaedic surgical procedures in the United States. Primary concepts in the surgical technique include restoring limb alignment and soft-tissue balance about the knee. Currently, traditional mechanical alignment concepts that focus on restoring neutral limb alignment have been challenged by the principle of kinematic alignment. In addition to these recent philosophical challenges, new technologies have been introduced to help the surgeon more accurately achieve optimal limb alignment and soft-tissue balance.

        • Subspecialty:
        • Adult Reconstruction

      Evaluation and Management of Failed Hemiarthroplasty

      Hemiarthroplasty is a common procedure for treatment of displaced femoral neck fractures in low-demand patients. As hip fracture incidence continues to increase, the need for revision hemiarthroplasty is also expected to increase. Multiple etiologies can result in a failed hemiarthroplasty, including persistent pain, infection, instability, leg-length discrepancy, and trauma. Preoperative clinical, radiographic, and laboratory assessments are critical in determining the etiology of the painful hemiarthroplasty. The standard of care for surgical management of failed hemiarthroplasty is conversion to a total hip arthroplasty. However, establishing the etiology preoperatively is essential to planning before treating the failed hemiarthroplasty.

          • Subspecialty:
          • Adult Reconstruction

        Antibiotic-laden Bone Cement in Primary and Revision Hip and Knee Arthroplasty

        Antibiotic-laden bone cement (ALBC) has a number of different uses in primary and revision total joint arthroplasty. However, considerable controversy remains regarding how and when it is best used. The prophylactic use of low-dose ALBC in primary cemented total hip arthroplasty is well supported by the literature, conferring both clinical and economic benefits. In contrast, conclusive evidence on the clinical efficacy or economic benefit of the routine use of ALBC in primary total knee arthroplasty remains elusive. Given the currently available evidence, we cannot determine definitively whether the routine use of ALBC in primary total knee arthroplasty is justified, although selective use in patients with a high risk of infection seems warranted. The routine use of ALBC in revision total joint arthroplasty is well accepted, with good supporting evidence in studies of both aseptic and first-stage revision procedures. Although limited clinical evidence exists on the use of ALBC at the time of definitive component reimplantation after septic revision, the rationale for its use is strong.

            • Subspecialty:
            • Adult Reconstruction

          Management of Osteoarthritis of the Hip

          The American Academy of Orthopaedic Surgeons has developed the Appropriate Use Criteria (AUC) for the Management of Osteoarthritis of the Hip. Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to improve patient care and obtain best outcomes while considering the subtleties and distinctions necessary in making clinical decisions. The Management of Osteoarthritis of the Hip AUC clinical patient scenarios were derived from indications typical of patients presenting with osteoarthritis of the hip in clinical practice. The 270 patient scenarios and 9 treatments were developed by the Writing Panel, a group of clinicians who are specialists in this AUC topic. Next, a separate multidisciplinary, Voting Panel (made up of specialists and nonspecialists) rated the appropriateness of treatment of each patient scenario using a 9-point scale to designate a treatment as Appropriate (median rating, 7 to 9), May Be Appropriate (median rating, 4 to 6), or Rarely Appropriate (median rating, 1 to 3).

              • Subspecialty:
              • Adult Reconstruction

            Usefulness of Culturing the Periprosthetic Membrane or Neosynovium for the Diagnosis of Infection During Hip and Knee Revision Arthroplasty

            Introduction: Identification of microorganisms is critical for correct management of an infected arthroplasty. Our hypothesis is that the culture yield depends on the location around the prosthesis from which samples are obtained.

            Methods: This prospective study included 298 revisions of the hip (123) and knee (175). We compared the yield of the intraoperative samples obtained, which included synovial fluid (two), neosynovium (two), and periprosthetic membrane (two).

            Results: Cultures were positive in 28 cases, in which 15 had the same diagnosis considering either the neosynovium or the membrane, and there were 3 cases in which the infection could have been diagnosed only by considering the combination of both. In all, there were 8 cases in which the infection might have been misdiagnosed unless considering a combination of both solid tissue samples (P = 0.004).

            Conclusions: The yields of the periprosthetic membrane and neosynovium do not differ significantly, and we recommend considering a combination of both.

            Level of Evidence: Diagnostic Level II

                • Subspecialty:
                • Adult Reconstruction

              Predicting Adverse Outcomes After Total Hip Arthroplasty: A Comparison of Demographics, the American Society of Anesthesiologists class, the Modified Charlson Comorbidity Index, and the Modified Frailty Index

              Introduction: No known study has compared the predictive power of the American Society of Anesthesiologists (ASA) class, modified Charlson Comorbidity Index, modified Frailty Index, and demographic characteristics for general health complications after total hip arthroplasty (THA).

              Methods: Comorbidity indices and demographics from National Surgical Quality Improvement Program THA patients were evaluated for discriminative ability in predicting adverse outcomes using the area under the curve analysis from the receiver operating characteristic curves. Perioperative outcomes included any adverse event, severe adverse events, minor adverse events, extended hospital stay, and discharge to higher-level care.

              Results: In total, 64,792 THA patients were identified. The most predictive comorbidity index was ASA, and demographic factor was age. Of these, age had the greatest discriminative ability for four of the five adverse outcomes.

              Conclusion: For THA, easily obtained patient ASA and age are more predictive of perioperative adverse outcomes than the more complex and numerically tabulated modified Charlson Comorbidity Index and modified Frailty Index.

                  • Subspecialty:
                  • Adult Reconstruction

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