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Martin JR, Coronado R, Wilson JM, Polkowski GG, Shinar AA, Bruehl S. Central Sensitization: The Missing Link Between Psychological Distress and Poor Outcome Following Primary Total Knee Arthroplasty. J Arthroplasty 2024; 39:1201-1206. [PMID: 38128626 PMCID: PMC11032226 DOI: 10.1016/j.arth.2023.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND While preoperative psychological distress is known to predict risk for worse total knee arthroplasty (TKA) outcomes, distress may be too broad and nonspecific a predictor in isolation. We tested whether there are distinct preoperative TKA patient types based jointly on psychological status and measures of altered pain processing that predict adverse clinical outcomes. METHODS In 112 TKA patients, we preoperatively assessed psychological status (depression, anxiety, and catastrophizing) and altered pain processing via a simple quantitative sensory testing protocol capturing peripheral and central pain sensitization. Outcomes (pain, function, opioid use) were prospectively evaluated at 6 weeks and 6 months after TKA. Cluster analyses were used to empirically identify TKA patient subgroups. RESULTS There were 3 distinct preoperative TKA patient subgroups identified from the cluster analysis. A low-risk (LR) group was characterized by low psychological distress and low peripheral and central sensitization. In addition, 2 subgroups with similarly elevated preoperative psychological distress were identified, differing by pain processing alterations observed: high-risk centralized pain and high-risk peripheral pain. Relative to LR patients, high-risk centralized pain patients displayed significantly worse function and greater opioid use at 6 months after TKA (P values <.05). The LR and high-risk peripheral pain patient subgroups had similar 6-month outcomes (P values >.05). CONCLUSIONS Among patients who have psychological comorbidity, only patients who have central sensitization were at elevated risk for poor functional outcomes and increased opioid use. Central sensitization may be the missing link between psychological comorbidity and poor TKA clinical outcomes. Preoperative testing for central sensitization may have clinical utility for improving risk stratification in TKA patients who have psychosocial risk factors.
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Affiliation(s)
- J. Ryan Martin
- Vanderbilt University Medical Center, Department of Orthopedics, 1211 Medical Center Dr, Nashville, TN 37232
| | - Rogelio Coronado
- Vanderbilt University Medical Center, Department of Orthopedics, 1211 Medical Center Dr, Nashville, TN 37232
| | - Jacob M. Wilson
- Vanderbilt University Medical Center, Department of Orthopedics, 1211 Medical Center Dr, Nashville, TN 37232
| | - Gregory G. Polkowski
- Vanderbilt University Medical Center, Department of Orthopedics, 1211 Medical Center Dr, Nashville, TN 37232
| | - Andrew A. Shinar
- Vanderbilt University Medical Center, Department of Orthopedics, 1211 Medical Center Dr, Nashville, TN 37232
| | - Stephen Bruehl
- Vanderbilt University Medical Center, Department of Anesthesia, 1211 Medical Center Dr, Nashville, TN 37232
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Flynn JB, Yokhana SS, Wilson JM, Schultz JD, Hymel A, Martin JR. Not So Fast: Extended Oral Antibiotic Prophylaxis Does Not Reduce 90-Day Infection Rate Following Joint Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00412-1. [PMID: 38685337 DOI: 10.1016/j.arth.2024.04.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 04/19/2024] [Accepted: 04/21/2024] [Indexed: 05/02/2024] Open
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) is a devastating complication following both total hip (THA) and knee (TKA) arthroplasty. Extended oral antibiotic prophylaxis (EOA) has been reported to reduce PJI following TJA in high-risk patients. The purpose of this study was to determine if EOA reduces PJI in all-comers and high-risk THA and TKA populations. METHODS This is a retrospective cohort study, including 4,576 patients undergoing primary THA or TKA at a single institution from 2018 to 2022. Beginning in 2020, EOA prophylaxis was administered for 10 days following THA or TKA at our institution. Patients were separated into two cohorts (1,769 EOA, 2,807 no EOA) based on whether they received postoperative EOA. The 90-day and 1-year outcomes, with a focus on PJI, were then compared between groups. A subgroup analysis of high-risk patients was also performed. RESULTS There was no difference in 90-day PJI rates between cohorts (EOA 1 versus no EOA 0.8%; P = 0.6). The difference in the rate of PJI remained insignificant at 1 year (EOA 1 versus no EOA 1%; P = 0.9). Similarly, our subgroup analysis of high-risk patients demonstrated no difference in postoperative PJI between EOA (n = 254) and no EOA (n = 396) (0.8 versus 2.3%, respectively; P = 0.2). Reassuringly, we also found no differences in the incidence of Clostridium difficile infection (CDI) (EOA 0.1 versus no EOA 0.1%; P > 0.9) or in antibiotic resistance among those who developed PJI within 90 days (EOA 59 versus no EOA 83%; P = 0.2). DISCUSSION With the numbers available for analysis, extended oral antibiotic prophylaxis was not associated with PJI risk reduction following primary TJA when universally deployed. Furthermore, among high-risk patients, there was no statistically significant difference. While we did not identify increased antibiotic resistance or CDI, we cannot recommend wide-spread adoption of EOA prophylaxis, and clarification regarding the role of EOA, even in high-risk patients, is needed.
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Affiliation(s)
- Jade B Flynn
- Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, 37232.
| | - Sanar S Yokhana
- Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, 37232
| | - Jacob M Wilson
- Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, 37232
| | - Jacob D Schultz
- Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, 37232
| | - Alicia Hymel
- Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, 37232
| | - J Ryan Martin
- Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, 37232
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Mika AP, Mulvey HE, Engstrom SM, Polkowski GG, Martin JR, Wilson JM. Can ChatGPT Answer Patient Questions Regarding Total Knee Arthroplasty? J Knee Surg 2024. [PMID: 38442904 DOI: 10.1055/s-0044-1782233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
The internet has introduced many resources frequently accessed by patients prior to orthopaedic visits. Recently, Chat Generative Pre-Trained Transformer, an artificial intelligence-based chat application, has become publicly and freely available. The interface uses deep learning technology to mimic human interaction and provide convincing answers to questions posed by users. With its rapidly expanding usership, it is reasonable to assume that patients will soon use this technology for preoperative education. Therefore, we sought to determine the accuracy of answers to frequently asked questions (FAQs) pertaining to total knee arthroplasty (TKA).Ten FAQs were posed to the chatbot during a single online interaction with no follow-up questions or repetition. All 10 FAQs were analyzed for accuracy using an evidence-based approach. Answers were then rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification."Of the 10 answers given by the chatbot, none received an "unsatisfactory" rating with the majority either requiring minimal (5) or moderate (4) clarification. While many answers required nuanced clarification, overall, answers tended to be unbiased and evidence-based, even when presented with controversial subjects.The chatbot does an excellent job of providing basic, evidence-based answers to patient FAQs prior to TKA. These data were presented in a manner that will be easily comprehendible by most patients and may serve as a useful clinical adjunct in the future.
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Affiliation(s)
- Aleksander P Mika
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hillary E Mulvey
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen M Engstrom
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregory G Polkowski
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - J Ryan Martin
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jacob M Wilson
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Chan PYW, Mika AP, Martin JR, Wilson JM. Glucagon-like Peptide-1 Agonists: What the Orthopaedic Surgeon Needs to Know. JBJS Rev 2024; 12:01874474-202401000-00003. [PMID: 38181103 DOI: 10.2106/jbjs.rvw.23.00167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Abstract
» Orthopaedic surgeons are increasingly likely to encounter patients with obesity and/or type 2 diabetes taking glucagon-like peptide-1 (GLP-1) agonists for weight loss.» GLP-1 agonists are an effective treatment for weight loss with semaglutide and tirzepatide being the most effective agents. Randomized controlled trials using these agents have reported weight loss up to 21 kg (46 lb).» The use of GLP-1 agonists preoperatively can improve glycemic control, which can potentially reduce the risk of postoperative complications. However, multiple cases of intraoperative aspiration/regurgitation have been reported, potentially related to the effect of GLP-1 agonists on gastric emptying.» While efficacious, GLP-1 agonists may not produce sufficient weight loss to achieve body mass index cutoffs for total joint arthroplasty depending on individual patient factors, including starting bodyweight. Multifactorial approaches to weight loss with focus on lifestyle modification in addition to GLP-1 agonists should be considered in such patients.» Although GLP-1 agonists are efficacious agents for weight loss, they may not be accessible or affordable for all patients. Each patient's unique circumstances should be considered when creating an ideal weight loss plan during optimization efforts.
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Affiliation(s)
- Peter Y W Chan
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
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Zamanzadeh RS, Seilern Und Aspang JRM, Schwartz AM, Martin JR, Premkumar A, Wilson JM. Age-Adjusted Modified Frailty Index Predicts 30-Day Complications and Mortality in Aseptic Revision Total Hip and Knee Arthroplasty. J Arthroplasty 2024; 39:198-205. [PMID: 37380143 DOI: 10.1016/j.arth.2023.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/09/2023] [Accepted: 06/19/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND The age-adjusted modified frailty index (aamFI) has been demonstrated to effectively predict postoperative complications and healthcare resource utilization in patients undergoing primary total joint arthroplasty. The purpose of this study was to evaluate the applicability of aamFI in patients undergoing aseptic revision total hip (rTHA) and knee arthroplasty (rTKA). METHODS A national database was queried for patients undergoing aseptic rTHA and rTKA from 2015 to 2020. A total of 13,307 rTHA and 18,762 rTKA cases were identified. The aamFI was calculated by adding 1 additional point for age ≥73 years to the previously described 5-item modified frailty index (mFI-5). The area under the curve was calculated and compared to compare predictive accuracy between mFI-5 and aamFI. Logistic regression was used to investigate the relationship between aamFI and 30-day complications. RESULTS The incidence of incurring any (≥1) complication increased from 15% for aamFI 0 to 45% for aamFI ≥5 after rTHA and from 5 to 55% after rTKA. Patients who had an aamFI ≥3 (reference aamFI = 0) had increased odds (rTHA: odds ratio (OR) 3.5, 95% confidence interval (CI) 2.9 to 4.1, P < .001; rTKA: OR 4.2, 95% CI 4.4 to 5.1, P < .001) of incurring at least 1 complication. The aamFI, compared to mFI-5, was a more accurate predictor of any complication (rTHA P < .001; rTKA P < .001) and 30-day mortality (rTHA P < .001; rTKA P < .003). CONCLUSION The aamFI is an excellent predictor of complications in patients undergoing rTHA and rTKA. The addition of chronological age to the previously described mFI-5 improves the predictive value of this simple metric.
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Affiliation(s)
- Ryan S Zamanzadeh
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia
| | | | - Andrew M Schwartz
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - J Ryan Martin
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ajay Premkumar
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia
| | - Jacob M Wilson
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Abstract
BACKGROUND The contemporary patient has access to numerous resources on common orthopaedic procedures before ever presenting for a clinical evaluation. Recently, artificial intelligence (AI)-driven chatbots have become mainstream, allowing patients to engage with interfaces that supply convincing, human-like responses to prompts. ChatGPT (OpenAI), a recently developed AI-based chat technology, is one such application that has garnered rapid growth in popularity. Given the likelihood that patients may soon call on this technology for preoperative education, we sought to determine whether ChatGPT could appropriately answer frequently asked questions regarding total hip arthroplasty (THA). METHODS Ten frequently asked questions regarding total hip arthroplasty were posed to the chatbot during a conversation thread, with no follow-up questions or repetition. Each response was analyzed for accuracy with use of an evidence-based approach. Responses were rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," "satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification." RESULTS Of the responses given by the chatbot, only 1 received an "unsatisfactory" rating; 2 did not require any correction, and the majority required either minimal (4 of 10) or moderate (3 of 10) clarification. Although several responses required nuanced clarification, the chatbot's responses were generally unbiased and evidence-based, even for controversial topics. CONCLUSIONS The chatbot effectively provided evidence-based responses to questions commonly asked by patients prior to THA. The chatbot presented information in a way that most patients would be able to understand. This resource may serve as a valuable clinical tool for patient education and understanding prior to orthopaedic consultation in the future.
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Affiliation(s)
- Aleksander P Mika
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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7
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Wilson JM, Mika A, Martin JR. Removing Cemented Dual Mobility Liners From Acetabular Components: A Technical Tip for a Challenging Surgical Problem. Arthroplast Today 2023; 23:101211. [PMID: 37781023 PMCID: PMC10541465 DOI: 10.1016/j.artd.2023.101211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/11/2023] [Accepted: 08/01/2023] [Indexed: 10/03/2023] Open
Abstract
Dislocation remains the leading cause of failure following revision total hip arthroplasty. Dual mobility (DM) constructs, including monoblock cups designed for cementation, reduce but do not eliminate this risk. Cemented DM constructs offer several unique advantages in revision total hip arthroplasty, and as such, they have gained popularity. Despite their advantages, a portion of these implants will require revision for infection or recurrent dislocation. Removal of a cemented DM cup presents numerous challenges, and there is no effective published technique. Here, we present an effective technique for the safe removal of one design of cemented DM cup.
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Affiliation(s)
- Jacob M. Wilson
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aleksander Mika
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - J. Ryan Martin
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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8
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Seilern Und Aspang J, Zamanzadeh RS, Schwartz AM, Premkumar A, Hussain ZB, Boissonneault A, Martin JR, Wilson JM. The Impact of Frailty on Outcomes Following Primary Total Hip Arthroplasty in Patients of Different Sex and Race: Is Frailty Equitably Detrimental? J Arthroplasty 2023; 38:1668-1675. [PMID: 36868329 DOI: 10.1016/j.arth.2023.01.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/29/2023] [Accepted: 01/31/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND Whether frailty impacts total hip arthroplasty (THA) patients of different races or sex equally is unknown. This study aimed to assess the influence of frailty on outcomes following primary THA in patients of differing race and sex. METHODS This is a retrospective cohort study utilizing a national database (2015-2019) to identify frail (≥2 points on the modified frailty index-5) patients undergoing primary THA. One-to-one matching for each frail cohort of interest (race: Black, Hispanic, Asian, versus White (non-Hispanic), respectively; and sex: men versus women) was performed to diminish confounding. The 30-day complications and resource utilizations were then compared between cohorts. RESULTS There was no difference in the occurrence of at least 1 complication (P > .05) among frail patients of differing race. However, frail Black patients had increased odds of postoperative transfusion (odds ratio [OR]: 1.34, 95% confidence interval [CI]: 1.02-1.77), deep vein thrombosis (OR: 2.61, 95% CI: 1.08-6.27), as well as >2-day hospitalization and nonhome discharge (P < .001). Frail women had higher odds of having at least 1 complication (OR: 1.67, 95% CI: 1.47-1.89), nonhome discharge, readmission, and reoperation (P < .05). Contrarily, frail men had higher 30-day cardiac arrest (0.2% versus 0.0%, P = .020) and mortality (0.3 versus 0.1%, P = .002). CONCLUSION Frailty appears to have an overall equitable influence on the occurrence of at least 1 complication in THA patients of different races, although different rates of some individual, specific complications were identified. For instance, frail Black patients experienced increased deep vein thrombosis and transfusion rates relative to their non-Hispanic White counterparts. Contrarily, frail women, relative to frail men, have lower 30-day mortality despite increased complication rates.
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Affiliation(s)
| | - Ryan S Zamanzadeh
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Andrew M Schwartz
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Ajay Premkumar
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Zaamin B Hussain
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Adam Boissonneault
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - J Ryan Martin
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jacob M Wilson
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Seilern Und Aspang J, Schwartz AM, Martin JR, Wilson JM. Reply to Letter to the Editor on "The Impact of Frailty on Outcomes Following Primary Total Hip Arthroplasty in Patients of Different Gender and Race: Is Frailty Equitably Detrimental?". J Arthroplasty 2023; 38:e30-e31. [PMID: 37573090 DOI: 10.1016/j.arth.2023.04.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 08/14/2023] Open
Affiliation(s)
| | - Andrew M Schwartz
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - J Ryan Martin
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jacob M Wilson
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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10
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Elrod RW, Pelt CE, Mason JB, Volkmar AJ, Polkowksi GG, Coronado RA, Martin JR. Could Novel Radiographic Findings Help Identify Aseptic Tibial Loosening? J Arthroplasty 2023:S0883-5403(23)00051-7. [PMID: 36716899 DOI: 10.1016/j.arth.2023.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/17/2022] [Accepted: 01/20/2023] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Aseptic loosening following total knee arthroplasty remains one of the leading causes of long-term failure. Radiographic identification of loose implants can be challenging with standard views. The purpose of this study was to compare the incidence of novel radiographic findings of anterior heterotopic bone formation and medial or lateral cyst formation in patients who have aseptic loosening to patients who have well-fixed implants. METHODS A retrospective radiographic review was performed on 48 patients' revised secondary to aseptic tibial loosening. This cohort was compared to two additional cohorts; 48 patients returning for routine postoperative follow-up (control 1), and 48 patients revised secondary to infection or instability who had well-fixed implants (control 2). RESULTS There were 41 of 48 (85%) patients who had implant loosening and were noted to have anterior heterotopic bone formation compared to 1 of 48 (2%) patients in control 1 and 3 of 48 (6%) patients in control 2 (P ≤ .0001). There were 43 of 48 (90%) patients who had implant loosening and had medial cyst formation compared to 3 of 48 (6%) patients in control 1 and 5 of 48 (10%) in control 2 (P ≤ .0001). There were 42 of 48 (88%) patients who had implant loosening and had lateral cyst formation compared to 2 of 48 (4%) patients in control 1 and 4 of 48 (8%) in control 2 (P ≤ .0001). CONCLUSION In this study, we describe novel radiographic findings of anterior heterotopic bone formation and cysts that develop in patients who have aseptic loosening following primary total knee arthroplasty. We believe that these radiographic features may lead to easier identification of aseptic loosening.
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Affiliation(s)
- Robert W Elrod
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher E Pelt
- Department of Orthopaedic Surgery, University of Utah Health, Salt Lake City, Utah
| | - J Bohannan Mason
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Alexander J Volkmar
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregory G Polkowksi
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rogelio A Coronado
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - J Ryan Martin
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Beaver WB, Martin JR, Bates M, Ellison BS, Sodhi N, Mont MA. Mid-term Follow Up of a Highly Porous Acetabular Component for Primary Total Hip Arthroplasty. Surg Technol Int 2023; 42:sti42/1638. [PMID: 36602172 DOI: 10.52198/23.sti.42.os1638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
INTRODUCTION As implant technology has continued to improve over the past decade, there has been an increase in the utilization of highly porous metal substrate acetabular components for primary total hip arthroplasty (THA). These implants have several theoretical benefits including a lower modulus of elasticity, which may result in a reduction in stress shielding, a higher coefficient of friction, which may enable better initial implant fixation, as well as higher porosity that may facilitate improved biological fixation. Although these components are implanted frequently, there are some studies that have posed concerns regarding radiographic evidence of loosening. Therefore, the purpose of this study was to assess: 1) The quality of fixation of porous metal acetabular components based on radiographs; 2) clinical outcomes; and 3) revision rates. MATERIALS AND METHODS A total of 159 patients (169 hips) who had undergone a primary THA utilizing a porous metal primary acetabular cup with minimum two-year follow up were assessed. The study cohort consisted of 51% women, had a mean age of 65 years (range, 30 to 92 years), a mean body mass index (BMI) of 29kg/m2 (range, 15 to 54), and a mean follow up of approximately four years (range, three to six years). Acetabular revision for component failure was documented. Radiographic assessments were independently performed by two fellowship-trained arthroplasty surgeons to determine implant stability and radiolucencies. Clinical evaluations were made by assessing the hip disability and osteoarthritis outcome score (HOOS-Jr) survey scores. Failure was defined as the need to revise the acetabular component, for either septic or aseptic pathology. RESULTS At final follow up, one patient had definitive loosening, one had probable loosening, and three patients had possible loosening. Only 3.0% had radiolucencies or radiosclerotic lesions in at least one zone. Of these patients, three developed progressive radiolucencies. All patients achieved excellent postoperative HOOS-Jr scores, and no significant differences were noted between patients who did not have loosening compared to patients who had possible or probable loosening. Only two patients underwent revision for aseptic loosening of the cup (success rate for this implant was 98.8% [2/169]). DISCUSSION There is a paucity of studies focused on the results of this porous metal substrate acetabular component, with some of the current literature reporting conflicting outcomes. Our study reported a low acetabular revision rate of only 1.2% at an approximate mean follow up of four years. The incidence of radiolucencies and progressive radiolucencies were lower (3.0%) than has been found in some studies. Overall, the results of this study support the utilization of this acetabular component in appropriately indicated patients. CONCLUSION These data show a low rate of acetabular revision at mean four-year follow up.
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Affiliation(s)
- Walter B Beaver
- Department of Orthopaedic Surgery, OrthoCarolina, Charlotte, NC
| | - J Ryan Martin
- Department of Orthopaedic Surgery, Vanderbilt University, Nashville, TN
| | - Michael Bates
- Department of Orthopaedic Surgery, OrthoCarolina, Charlotte, NC
| | | | - Nipun Sodhi
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center; North Shore, University; Northwell Health, New York, NY
| | - Michael A Mont
- Department of Orthopaedic Surgery, Rubin Institute for Advanced Orthopaedics, Baltimore, MD
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Cox ZC, Engstrom SM, Shinar AA, Polkowski GG, Mason JB, Martin JR. Is cement mantle thickness a primary cause of aseptic tibial loosening following primary total knee arthroplasty? Knee 2023; 40:305-312. [PMID: 36592499 DOI: 10.1016/j.knee.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 11/27/2022] [Accepted: 12/13/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Aseptic tibial loosening following primary total knee replacement is one of the leading causes of long-term failure. Cement mantle thickness has been implicated as a source of aseptic tibial loosening. Therefore, the following study was designed to determine (1) what is the cement mantle thickness in patients that develop aseptic tibial loosening, and (2) is there a difference in cement mantle thickness based on the interface of failure? METHOD This retrospective cohort included 216 patients revised for aseptic tibial loosening. Patient demographics, operative data, and clinical outcomes were recorded. A preoperative radiographic assessment was performed to determine the interface of failure and the thickness of the cement mantle using the Knee Society Radiographic Evaluation System zones. RESULTS The average patient age was 65 years and body mass index was 33.7 kg/m2. 203 patients demonstrated radiographic failure at the implant-cement interface and 13 patients demonstrated failure at the cement-bone interface. The average cement mantle thickness of each radiographic zone for the entire cohort on the AP and lateral views was 4.4 and 4.5 mm, respectively. The average cement mantle thickness of patients that developed failure at the implant-cement interface was significantly greater than patients that failed at the cement-bone interface in each radiographic zone (p < 0.001). CONCLUSIONS Patients that develop implant loosening at the cement-bone interface were noted to have a significantly decreased cement mantle compared to patients that failed at the implant-cement interface. Methods for decreasing tibial implant loosening should likely focus on improving the fixation at the implant-cement interface.
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Affiliation(s)
- Zach C Cox
- OrthoCarolina Hip and Knee Center, Charlotte, NC, 250 N Caswell Rd Suit 200A, Charlotte, NC 28207, USA
| | - Stephen M Engstrom
- Vanderbilt University Medical Center, 1215 21st Ave S Suite 4200, Nashville, TN 37232, USA
| | - Andrew A Shinar
- Vanderbilt University Medical Center, 1215 21st Ave S Suite 4200, Nashville, TN 37232, USA
| | - Gregory G Polkowski
- Vanderbilt University Medical Center, 1215 21st Ave S Suite 4200, Nashville, TN 37232, USA
| | - J Bohannon Mason
- OrthoCarolina Hip and Knee Center, Charlotte, NC, 250 N Caswell Rd Suit 200A, Charlotte, NC 28207, USA
| | - J Ryan Martin
- Vanderbilt University Medical Center, 1215 21st Ave S Suite 4200, Nashville, TN 37232, USA.
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Martin JR, Archibeck MJ, Gililland JM, Anderson LA, Polkowski GG, Schwarzkopf R, Seyler TM, Pelt CE. Trends in Total Knee Arthroplasty Cementing Technique Among Arthroplasty Surgeons-A Survey of the American Association of Hip and Knee Surgeons Members. J Arthroplasty 2022:S0883-5403(22)01109-3. [PMID: 36596429 DOI: 10.1016/j.arth.2022.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/14/2022] [Accepted: 12/18/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Aseptic loosening persists as one of the leading causes of failure following cemented primary total knee arthroplasty (TKA). Cement technique may impact implant fixation. We hypothesized that there is variability in TKA cement technique among arthroplasty surgeons. METHODS A 28-question survey regarding variables in surgeons' preferred TKA cementation technique was distributed to 2,791 current American Association of Hip and Knee Surgeons (AAHKS) members with a response rate of 30.8% (903 respondents). Patterns of responses were analyzed by grouping respondents by their answers to certain questions including cementing technique, tibial cement location, and femoral cement location. RESULTS A total of 73.5% reported performing at least 7 of 8 of the highest consensus techniques, including vacuum mixing (79.9%), using two bags (76.1%), tibial implant first (95.2%), single-stage cementing (96.9%), compression of the implants in extension (91.7%), and use of a tourniquet (84.3%). Medium and high viscosity cement was most commonly used (37.9 and 37.8%, respectively). Finger pressurization was most common (76.1%) compared to a gun (29.8%). There were 26.5% of respondents performing 6 or fewer of the most common majority techniques and seemed to perform other less common techniques (eg, use of a single bag of cement, trialing or closure prior to cement curing, and heating to accelerate cement curing). Cement was most commonly applied to the entire bone and implant surface on both the tibia (46.4%) and femur (47.7%), leaving much variation in the remaining cement application location responses. DISCUSSION There appears to be variability in cemented TKA technique among arthroplasty surgeons. There were 26.5% of respondents performing less of the majority techniques and also performed other additional low-response rate techniques. Further studies that look at the impacts of variation in techniques on outcomes may be warranted. Our study demonstrates the need for defining best practices for cement technique given the substantial variability identified.
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Affiliation(s)
- J Ryan Martin
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Jeremy M Gililland
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Lucas A Anderson
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Gregory G Polkowski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Thorsten M Seyler
- School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Christopher E Pelt
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
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Dilbone ES, Moore-Lotridge SN, Gabbard M, Schultz JD, Rees AB, Martin JR, Polkowski GG. Location of Initial Closed Reduction Attempt Significantly Increases Cost and Length of Stay in Total Hip Arthroplasty. Arthroplast Today 2022; 15:102-107. [PMID: 35509290 PMCID: PMC9058571 DOI: 10.1016/j.artd.2022.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 03/03/2022] [Indexed: 01/05/2023] Open
Abstract
Background Prosthetic hip dislocation remains one of the most frequent complications following total hip replacement. Dislocations are predominantly managed by a closed reduction in the emergency department (ED) or the operating room (OR). This study aimed to evaluate how the location of an initial closed reduction attempt impacts a patient's course of care including length of stay (LOS) and cost of care. Material and methods A retrospective chart review was performed on all patients presenting to a single ED with a unilateral prosthetic hip dislocation from 2009 to 2019. A total of 108 patients were identified. Data collected included patient demographics, ED/hospital course, and hospital charges. Results Seventy-four patients (69%) had initial reduction attempted in the ED (65/74, 88% were successful), while 34 patients (31%) went directly to OR (100% successful with closed reduction). Failed closed reduction in ED or direct to OR resulted in a greater LOS and rate of placement to a skilled nursing facility following discharge. Median hospital charges for successful ED reduction were $6,837, while failed ED closed reduction or direct to OR resulted in median charges of $27,317 and $20,481, respectively. Conclusion Many patients successfully underwent closed reduction in the ED, and there was no difference in complications, independent of where the reduction was first performed. Patients undergoing reduction in the OR had greater LOS and cost of care, independent of whether a reduction attempt was performed and failed in the ED, than those successfully reduced in the ED.
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Affiliation(s)
- Eric S. Dilbone
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephanie N. Moore-Lotridge
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Bone Biology, Vanderbilt University, Nashville, TN, USA
| | - Michael Gabbard
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Andrew B. Rees
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - J. Ryan Martin
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gregory G. Polkowski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Seilern Und Aspang J, Zamanzadeh RS, Schwartz AM, Premkumar A, Martin JR, Wilson JM. The Age-Adjusted Modified Frailty Index: An Improved Risk Stratification Tool for Patients Undergoing Primary Total Hip Arthroplasty. J Arthroplasty 2022; 37:1098-1104. [PMID: 35189289 DOI: 10.1016/j.arth.2022.02.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/10/2022] [Accepted: 02/12/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Frailty and increasing age are well-established risk factors in patients undergoing total hip arthroplasty (THA). However, these variables have only been considered independently. This study assesses the interplay between age and frailty and introduces a novel age-adjusted modified frailty index (aamFI) for more refined risk stratification of THA patients. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2015 to 2019 for patients undergoing primary THA. First, outcomes were compared between chronologically younger and older frail patients. Then, to establish the aamFI, one additional point was added to the previously described mFI-5 for patients aged ≥73 years (the 75th percentile for age in our study population). The association of aamFI with postoperative complications and resource utilization was then analyzed categorically. RESULTS A total of 165,957 THA patients were evaluated. Older frail patients had a higher incidence of complications than younger frail patients. Regression analysis demonstrated a strong association between aamFI and complications. For instance, an aamFI of ≥3 (compared to aamFI of 0) was associated with an increased odds of mortality (OR: 22.01, 95% confidence interval [CI] 11.62-41.68), any complication (OR: 3.50, 95% CI 3.23-3.80), deep vein thrombosis (OR: 2.85, 95% CI 2.03-4.01), and nonhome discharge (OR 9.61, 95% CI 9.04-10.21; all P < .001). CONCLUSION Chronologically, older patients are impacted more by frailty than younger patients. The aamFI accounts for this and outperforms the mFI-5 in prediction of postoperative complications and resource utilization in patients undergoing primary THA.
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Affiliation(s)
| | - Ryan S Zamanzadeh
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | | | | | - J Ryan Martin
- Department of Orthopaedics, Vanderbilt University, Nashville, Tennessee
| | - Jacob M Wilson
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
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Martin JR, Wronski PT, Schilkowsky RM, Orfanos AV, Fehring TK, Mason JB. Chitranjan S. Ranawat Award: Motion During Total Knee Cementing Significantly Decreases Tibial Implant Fixation Strength. J Arthroplasty 2022; 37:S12-S18. [PMID: 35231563 DOI: 10.1016/j.arth.2022.02.091] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/17/2022] [Accepted: 02/21/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Aseptic tibial loosening following primary total knee arthroplasty persists despite technique and device-related advancements. The mechanisms for this mode of failure are not well understood. We hypothesized that knee movement while the cement was curing dispersed lipids at the implant-cement interface and would result in decreased tibial fixation strength. METHODS A cadaveric study was performed utilizing 32 torso-to-toe specimens (64 knees). Four contemporary total knee arthroplasty designs were evaluated. Each implant design was randomly assigned to a cadaveric specimen pair with side-to-side randomization. Specimen densitometry was recorded. Each tibial implant was cemented using a standard technique. On one side, the tibial component was held without motion following impaction until complete cement polymerization. The contralateral knee tibial implant was taken through gentle range of motion and stability assessment 7 minutes after cement mixing. Axial tibial pull-out strength and interface failure examination was performed on each specimen. RESULTS The average pull-out strength for the no motion cohort (5,462 N) exceeded the motion cohort (4,473 N) (P = .001). The mean pull-out strength between implant designs in the no motion cohort varied significantly (implant A: 7,230 N, B: 5,806 N, C: 5,325 N, D 3,486 N; P = .007). Similarly, the motion cohort inter-implant variance was significant (P ≤ .001). Intra-implant pull-out strength was significantly higher in implant A than D. The average pull-out strength was significantly lower in specimens that failed at the implant-cement interface vs bone failures (4,089 ± 2,158 N vs 5,960 ± 2,010 N, P < .0025). CONCLUSION Knee motion during cement polymerization is associated with significant decreases in tibial implant fixational strength. Reduction in implant pull-out strength was identified with each implant design with motion and varied between designs. Across all tested designs, we recommend limiting motion while cementing the tibial implant to improve fixation strength.
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Affiliation(s)
- J Ryan Martin
- Vanderbilt University Medical Center, Nashville, Tennessee
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Cox ZC, Green CC, Otero JE, Mason JB, Martin JR. Varus Collapse in Total Knee Arthroplasty: Does Fixation or Bone Fail First? J Arthroplasty 2022; 37:162-167. [PMID: 34592354 DOI: 10.1016/j.arth.2021.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/13/2021] [Accepted: 09/20/2021] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Aseptic tibial loosening is now considered the most common reason that total knee arthroplasties (TKA) fail long term. There are unique subsets of patients that fail into varus alignment of the tibial tray with collapse of the medial proximal tibia. It is currently unknown if the implant fixation fails first or if the proximal medial tibia collapses first. MATERIALS We performed a retrospective analysis of 88 patients that were revised at our institution secondary to aseptic varus collapse of the proximal tibia. Two fellowship-trained arthroplasty surgeons performed a retrospective analysis on sequential precollapse radiographs in each patient to determine which failed first: the implant fixation (implant-cement or cement-bone interface) or the medial proximal tibia. DISCUSSION 36/88 (40.9%) patients had a series of precollapse radiographs that could be reviewed. Failure at the implant-cement interface before varus collapse in 23 vs 22 patients, failure at the implant-cement and cement-bone interface before varus collapse in two patients, and contemporaneous failure at the implant-cement interface and varus collapse in 11 vs 12 patients were identified by reviewers one and two, respectively. CONCLUSION The most frequent mechanism of failure identified was failure of the implant-cement interface followed by subsequent medial tibial varus collapse. Improving implant fixation may decrease the incidence of this unique failure mechanism. We advocate the use of supplemental stem fixation in high-risk patients and optimal cement techniques for all patients as methods of potentially avoiding tibial varus collapse, one of the most frequent modes of long-term failure.
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Affiliation(s)
- Zach C Cox
- OrthoCarolina Hip and Knee Center, Charlotte, NC
| | - Cody C Green
- OrthoCarolina Hip and Knee Center, Charlotte, NC
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18
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Martin JR, Otero JE, Mason JB, Fehring TK. Where Is the "Weak Link" of Fixation in Contemporary Cemented Total Knee Replacements? J Arthroplasty 2021; 36:2497-2501. [PMID: 33676813 DOI: 10.1016/j.arth.2021.02.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Aseptic tibial loosening is a frequent cause of long-term failure following primary cemented total knee replacement. Failure of the tibial implant can occur at the implant-cement interface or at the cement-bone interface. Currently, it is unknown at which interface failure occurs in cases of aseptic tibial loosening. The following study was designed to determine which interface represents the "weak link" for tibial implant fixation. METHODS We performed a retrospective analysis of 149 patients who were revised secondary to aseptic tibial loosening at our institution from 2005 to 2017. Operative reports and radiographs were reviewed on each patient to determine the location and pattern of fixation failure. RESULTS Implant failure was more prevalent at the implant-cement than cement-bone interface, 140/149 (94.0%) vs 9/149 (6.0%). Additionally, we noted 2 distinct patterns of failure in patients that loosened at the implant-cement interface. Ninety of 140 (64.3%) patients developed varus collapse pattern of failure. Forty-nine of 140 (35.0%) patients developed failure between the implant-cement interface without angulation. All 149 patients had heterotopic bone formation anterior to the tibial baseplate, which was consistent regardless of which interface failed. CONCLUSION The most frequent interface failure identified in our study was at the implant-cement interface, 140/149 (94.0%). This finding has substantial clinical ramifications. Because failure was predominantly at the implant-cement interface there may be design opportunities for increasing implant fixation to cement. Implants with improved undersurface tibial tray features may be necessary to mitigate the risk of failure at this interface, especially in overly active patients or those with elevated body mass indices.
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Affiliation(s)
- J Ryan Martin
- OrthoCarolina Matthews, Matthews, NC; OrthoCarolina Research Institute, Charlotte, NC
| | - Jesse E Otero
- OrthoCarolina Research Institute, Charlotte, NC; OrthoCarolina Hip & Knee Center, Charlotte, NC; Department of Orthopaedic Surgery, Atrium Health/Atrium Musculoskeletal Institute, Charlotte, NC
| | - J Bohannon Mason
- OrthoCarolina Research Institute, Charlotte, NC; OrthoCarolina Hip & Knee Center, Charlotte, NC; Department of Orthopaedic Surgery, Atrium Health/Atrium Musculoskeletal Institute, Charlotte, NC
| | - Thomas K Fehring
- OrthoCarolina Research Institute, Charlotte, NC; OrthoCarolina Hip & Knee Center, Charlotte, NC; Department of Orthopaedic Surgery, Atrium Health/Atrium Musculoskeletal Institute, Charlotte, NC
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Martin JR, Masonis JL, Mason JB. Anatomic Total Hip Component Position Is More Reproducible With the Direct Anterior Approach Using Intraoperative Fluoroscopy. Arthroplast Today 2020; 6:777-783. [PMID: 32964086 PMCID: PMC7490589 DOI: 10.1016/j.artd.2020.07.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 11/19/2022] Open
Abstract
Background Total hip arthroplasty (THA) has demonstrated excellent results regardless of the surgical approach. However, the approach used may be a factor in final positioning of implants. We hypothesized that the direct anterior approach (DAA) with fluoroscopy would be associated with more anatomic implant positioning than the posterior approach (PA). Methods A retrospective review of 200 patients was performed. One hundred patients underwent THA utilizing the PA, and 100 patients, with the DAA. All patients had an anterior-posterior pelvis radiograph preoperatively and postoperatively with a magnification marker present to standardize each radiograph. Exclusion criteria included contralateral THA or any pelvic or femoral deformity. Results Preoperative radiographs demonstrated identical cohorts with respect to leg length, femoral offset, and total offset. Postoperatively, the DAA achieved more accurate anatomic restoration of leg length (1.6 mm vs 5.5 mm; P < .0001), femoral offset (4.8 mm vs 9.3 mm; P < .0001), and total offset (0.5 mm vs 4.7 mm; P < .0001) compared with the PA. Ideal cup abduction and anteversion were significantly superior to the DAA (96% vs 78%, P = .0002, and 69% vs 24%, P < .0001, respectively). Conclusions This study is the first to compare anatomic implant positioning between patients undergoing THA with these 2 approaches. All parameters were significantly closer to anatomic implant positioning with the DAA. There are at least 2 potential explanations for this: (1) The DAA implant positioning was performed under fluoroscopic guidance, whereas the PA was not. (2) The PA disrupts the posterior capsule and external rotators, and therefore, increased offset or leg length may be necessary to achieve comparable hip stability with the DAA.
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Affiliation(s)
| | | | - J. Bohannon Mason
- OrthoCarolina Hip and Knee Center, Charlotte, NC, USA
- Corresponding author. OrthoCarolina Hip and Knee Center, 2001 Vail Avenue, Charlotte, NC 28207, USA. Tel.: +1 704 323 2564.
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Abstract
INTRODUCTION Screening protocols for asymptomatic patients with metal on metal (MoM) total hip arthroplasty (THA) are evolving. Most surgeons began screening patients around 2010 by obtaining cobalt (Co) and chromium (Cr) metal ion levels. There is currently no data available to guide repeat screening in this familiar clinical scenario. Therefore, the following study evaluated how metal ion levels change after an initial metal ion level in patients with MoM THAs. MATERIALS AND METHODS 171 consecutive patients (265 hips) underwent primary MoM THA. All patients had at least one Co and Cr ion level draw. 84 patients (136 hips) had 2 ion level draws. Ion levels were divided into elevated levels (⩾4.5 ppb) and normal levels (<4.5 ppb). The probability of an ion level returning elevated after an initial normal level was identified. Additionally, a threshold value was determined that reliably identified every patient that did not subsequently rise above 4.5 ppb. RESULTS 12 metal ion levels were ⩾4.5 ppb on the first lab draw. On the second draw, all 12 remained ⩾4.5 ppb. Of the 121 hips with initial metal ion levels <4.5 ppb, 5 metal ion levels became ⩾4.5 ppb. Utilising an initial screening cutoff of 3.0 ppb, no patient was identified with a second lab value ⩾4.5 ppb. DISCUSSION Initial metal ion levels reliably predicted those that would remain elevated or remain normal with a subsequent metal ion level. An initial metal ion level above 3.0 ppb may represent a cutoff at which further workup is necessary.
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Affiliation(s)
| | - Susan M Odum
- OrthoCarolina Research Institute, Charlotte, NC, USA
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21
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Jackson JB, Martin JR, Christal A, Masonis JL, Springer BD, Mason JB. The Direct Anterior Approach Total Hip Arthroplasty Reliably Achieves "Safe Zones" for Combined Anteversion. Arthroplast Today 2020; 6:651-654. [PMID: 32875014 PMCID: PMC7451890 DOI: 10.1016/j.artd.2020.07.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 06/19/2020] [Accepted: 07/11/2020] [Indexed: 11/26/2022] Open
Abstract
Background In total hip arthroplasty (THA), component position is critical to avoid instability and improve longevity. Appropriate combined femoral and acetabular component anteversion is important for improved THA stability and increased impingement-free range of motion. In direct anterior THA (DA-THA), concern has been expressed regarding the accuracy of femoral component positioning. This study seeks to quantify acetabular, femoral, and combined component orientation relative to the accepted “safe zones” in patients who have undergone DA-THA. Methods Twenty-nine patients who had THA performed via direct anterior approach had postoperative computerized tomography scans done to assess femoral anteversion. Stem rotational alignment was measured relative to the transepicondylar axis (TEA) and the posterior condylar axis (PCA) of the femur at the knee. Acetabular abduction and version were recorded on anteroposterior pelvis radiographs. Results The mean stem anteversion was 17.5° (standard deviation = 10.8°) from the TEA and 21.7° (standard deviation = 11.3°) from the PCA. Ten of 30 cups were appropriately anteverted; however, all the cups had appropriate abduction. Combined version when using the TEA resulted in 79% (23/29) of patients within the “safe zone” of 25°-50°. Pearson correlation coefficients were high for both stem anteversion from the TEA (R = 0.96) and PCA (R = 0.98); however, interobserver reliability for combined component anteversion was greater for the TEA (kappa, 0.83 vs 0.65). Conclusions Combined anteversion within the “safe zone” was achieved 79% of the time with DA-THA. Interestingly, most of the “excessive” combined anteversion appears to be related to increased anteversion of the acetabular component with only 10 patients within the acetabular cup “safe zone” of 5°-25°.
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Abstract
Aims Aseptic loosening of the tibial component is a frequent cause of failure in primary total knee arthroplasty (TKA). Management options include an isolated tibial revision or full component revision. A full component revision is frequently selected by surgeons unfamiliar with the existing implant or who simply wish to “start again”. This option adds morbidity compared with an isolated tibial revision. While isolated tibial revision has a lower morbidity, it is technically more challenging due to difficulties with exposure and maintaining prosthetic stability. This study was designed to compare these two reconstructive options. Methods Patients undergoing revision TKA for isolated aseptic tibial loosening between 2012 and 2017 were identified. Those with revision implants or revised for infection, instability, osteolysis, or femoral component loosening were excluded. A total of 164 patients were included; 88 had an isolated tibial revision and 76 had revision of both components despite only having a loose tibial component. The demographics and clinical and radiological outcomes were recorded. Results The patient demographics were statistically similar in the two cohorts. The median follow-up was 3.5 years (interquartile range (IQR) 1 to 12.5). Supplementary femoral metaphyseal fixation was required in five patients in the full revision cohort. There was a higher incidence of radiological tibial loosening in the full component revision cohort at the final follow-up (8 (10.5%) vs 5 (5.7%); p = 0.269). Three patients in the full component revision cohort developed instability while only one in the isolated tibial cohort did. Three patients in the full revision cohort developed a flexion contracture greater than 5° while none in the isolated tibial cohort did. Conclusion Isolated tibial revision for aseptic tibial loosening has statistically similar clinical and radiological outcomes at a median follow-up of 3.5 years, when compared with full component revision. Substantial bone loss can occur when removing a well-fixed femoral component necessitating a cone or sleeve. Femoral component revision for isolated tibial loosening can frequently be avoided provided adequate ligamentous stability can be obtained. Cite this article: Bone Joint J 2020;102-B(6 Supple A):123–128.
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Affiliation(s)
- J. Ryan Martin
- OrthCarolina Hip & Knee Center, Charlotte, North Carolina, USA
| | - Michael B. Geary
- Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Michael Ransone
- Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - David Macknet
- Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Keith Fehring
- OrthCarolina Hip & Knee Center, Charlotte, North Carolina, USA
| | - Thomas Fehring
- OrthCarolina Hip & Knee Center, Charlotte, North Carolina, USA
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Owens J, Otero JE, Noiseux NO, Springer BD, Martin JR. Risk Factors for Post-Operative Blood Transfusion Following Total Knee Arthroplasty. Iowa Orthop J 2020; 40:69-73. [PMID: 32742211 PMCID: PMC7368508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND As the population ages, rate of total knee arthroplasty increases and thus, it is important to maximize efficiency and minimize risk. Identifying patients who are at higher risk for transfusion can help streamline care provided and minimize superfluous, costly hemoglobin monitoring in low risk patients. METHODS Adult patients who underwent total knee arthroplasty (TKA) in 2015 were identified in the National Surgical Quality Improvement Project (NSQIP) database. Patients were divided into two cohorts: those who required transfusion post operatively and those who did not. Patient demographics and comorbidities were compared using univariate analysis; and multivariate analysis was used to determine risk factors for short-term complications. RESULTS Of 48,055 TKA patients, 3.0% required transfusion. The patients who required transfusion were older, had higher BMI, higher rates of comorbidities and were more frequently ASA class 3-4 (p<0.005). Univariate analysis revealed that patients who required transfusion had higher rates of any complication (9.19% v. 4.23%, p<0.001). Multivariate regression analysis identified the following as risk factors for transfusion requirement: Black race (adjusted odds ratio [OR] 1.2, 95% confidence interval [CI] 1.01-1.4), COPD (OR 1.6, 95% CI 1.3-2.0), corticosteroids (OR 1.4, 95% CI 1.1-1.8), bleeding disorder (OR 1.4, CI 1.1-1.9), ASA class 4 (OR 2.3, CI 1.5-4.8), operative time >2 hours (OR 1.3, 95% CI 1.2-1.5) and lack of functional independence (OR 1.6, 95% CI 1.1-2.3). CONCLUSIONS In a cohort of patients undergoing primary TKA in 2015, history of COPD, black race, operative time, steroid use, bleeding disorder, lack of functional independence and ASA class 3-4 were independent predictors of need for blood transfusion. Additionally, we found that patients who received transfusion demonstrated a significantly higher rate of the following: any complication, pneumonia, urinary tract infection, septic shock, deep vein thrombosis, renal insufficiency, cardiac arrest, myocardial infarction, unplanned readmission, reoperation and mortality. Presence of these risk factors in TKA patients could represent an indication for hemoglobin monitoring post-operatively.Level of Evidence: IV.
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Affiliation(s)
- Jessell Owens
- University of Iowa, Department of Orthopedics and Reabilitation, Iowa City, IA
| | | | - Nicholas O. Noiseux
- University of Iowa, Department of Orthopedics and Reabilitation, Iowa City, IA
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Kesler KK, Brown TS, Martin JR, Springer BD, Otero J. Risk Factors for Blood Transfusion After Primary Total Hip Arthroplasty. ReconRev 2019. [DOI: 10.15438/rr.9.1.226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Aims: In the setting of rising healthcare costs, more cost efficiency in total hip arthroplasty (THA) is required. Following THA, most patients are monitored with serial hemoglobin testing despite few needing blood transfusions. This testing adds cost and may not be necessary in most patients. This study aims to identify factors associated with transfusion, therefore guiding hemoglobin monitoring following THA.Patients and Methods: Patients who underwent primary THA in 2015 were identified using the National Surgical Quality Improvement Project (NSQIP) database. Patient discharged on the day of surgery were excluded. Patients were classified into those receiving transfusion versus no transfusion. Demographics and comorbidities were compared between groups followed by univariate and multivariate analysis, allowing identification of patient characteristics and comorbidities associated with transfusion. Results: Overall, 28664 patients who underwent THA patients were identified. Within this group, 6.1% (n=1737) had a post-operative transfusion. Patients receiving a blood transfusion were older, had lower body mass index, and had higher rates of chronic obstructive pulmonary disease (COPD), heart failure, dialysis, prior transfusion, and were more frequently ASA class 3-4 (p<0.001). Univariate analysis demonstrated that patients requiring transfusion had higher complication rates (4.3% vs. 12.8%, p<0.0001). Multivariate analysis identified age >70, diabetes, smoking, COPD, prior transfusion, and operative time >2 hours as independent risk factors for transfusion.Conclusion: Among THA patients, characteristics and comorbidities exist that are associated with increased likelihood of transfusion. Presence of these factors should guide hemoglobin monitoring post-operatively. Selective hemoglobin monitoring can potentially decrease the cost of THA.
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Martin JR, Odum S, Griffin W. Long-Term Screening is Necessary in Patients with Metal on Metal Total Hip Arthroplasty. ReconRev 2019. [DOI: 10.15438/rr.9.1.225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Introduction: Adverse reactions to metal debris with catastrophic failures have been seen with a number of metal on metal (MoM) total hip designs. Understanding survivorship and factors associated with failure will allow for more targeted surveillance of those patients at highest risk for failure. The purpose of this study was to assess the mid to long term survivorship and specific factors associated with failure for a large cohort of a single modular MoM design.Methods: Consecutive patients treated with a modular metal on metal bearing with a five to fourteen year follow-up were included. Clinical outcome scores and radiographic data were prospectively collected. Failure was defined as revision of either component for any reason during the study period. Multiple implant, surgical, and patient factors were analyzed for associations with elevated ion levels or revision due to adverse reactions to metal debris.Results: The average age at the time of surgery for the 253 patients included in the study was 55. There were 28 revisions (7.5%), eight due to metallosis (2%). Survivorship was 89% at 12.6 years with revision for any reason as the end point. Survivorship was 93% when limited to revision for ALTR as the end point. Time in situ was the only variable that was statistically associated with an increased risk of failure due to ALTR (p<0.0001)Conclusion: In this large series of a single design modular metal-metal total hip we found relatively low rates of revision due to adverse reactions to metal debris. The only variable associated with a statistically significant risk of ALTR was time in situ. Therefore, long-term surveillance is necessary in patients with a MoM THA.
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Martin JR, Stefanidis D, Dorin RP, Goh AC, Satava RM, Levy J. Demonstrating the Effectiveness of The Fundamentals of Robotic Surgery (Frs) on the Robotix Mentor Virtual Reality Simulation Platform. J Minim Invasive Gynecol 2019. [DOI: 10.1016/j.jmig.2019.09.683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Martin JR, Otero J, Springer B, Griffin W. Can We Improve Screening Costs in Asymptomatic Metal on Metal Total Hip Arthroplasties? ReconRev 2019. [DOI: 10.15438/rr.9.1.214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Introduction:
Metal on Metal (MoM) total hip arthroplasty (THA) has been largely abandoned in the United States secondary to high failure rates. Many of the failures are attributed to adverse local tissue reactions (ALTR). Therefore, patients that have a MoM THA are routinely screened by checking serum metal ion levels every two years, as was recommended by the FDA. However, there is limited data on the costs of current screening protocols.
Materials and Methods:
318 consecutive patients who underwent a MoM THA at a single institution were retrospectively enrolled. The average follow-up was 8.2 years. Clinical data, metal ion levels, revision and reoperation rates were prospectively collected. The costs of clinical screening for this patient population was calculated and compared to the cost of an annual screening protocol.
Results:
12 patients had either an elevated Co or Cr level (>4.5 ppb). Eight patients were revised secondary to ALTR. The total cost of screening during the study was $612,250. Additionally, if annual screening had been performed, total screening costs would be approximately $1,719,200.
Discussion:
Eight patients in the following study were revised secondary to ALTR with a total cost of screening of $612,500. These costs are substantially less than the cost of annual screening ($1,719,200). Due to the considerable costs of screening asymptomatic MoM THA patients, we recommend both optimizing the frequency of screening and evaluating the specific risk of the implant being screened.
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Martin JR, Otero J, Beaver W, Springer B, Griffin W. Is Utilizing a Modular Stemmed Tibial Component in Obese Patients Undergoing Primary Total Knee Replacement Cost-Effective? ReconRev 2018. [DOI: 10.15438/rr.8.2.215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Introduction: There has been recent enthusiasm for the use of modular stemmed tibial components in obese (BMI ≥35kg/m2) patients undergoing primary total knee arthroplasty (TKA). This has been mainly driven by studies demonstrating statistically significant increases in the rates of aseptic tibial loosening (ATL) in this patient population. However, to our knowledge, no study has specifically evaluated the cost effectiveness of this current recommendation.Methods: The following study was performed utilizing previously obtained data on the incidence of ATL in obese patients undergoing primary TKA. This data was then utilized to create a cost calculator that can evaluate the price point at which the use of a stemmed tibial component in all obese patients would be less than or equal to the costs of revision surgery if a stemmed implant was not utilized.Results: Utilizing historical data with a revision rate of 4% for aseptic loosening of the tibia on obese patients, a cost calculator was developed. The cost calculator requires the input of expected or known incidence of ATL utilizing a stem extension and the expected or known costs of revision for ATL.Conclusion: The following cost calculator quickly determines a price point at which the use of a tibial stem offsets the costs of revision surgery. While this study may not provide an exact cost-effectiveness of modular stem fixation due to model limitations, it will hopefully initiate the discussion for providing more cost-effective individualized care for this patient population.
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Al Yami MS, McBride A, Katragadda C, Martin JR, Badreldin HA, Mohammed AH, Elmubark AM, Alzahrani MY, Alsheri AM, Abraham I. Correction to: Direct oral anticoagulants for the treatment of venous thromboembolism in patients with active malignancy: a systematic review and meta-analysis. J Thromb Thrombolysis 2018; 47:166. [PMID: 30478721 DOI: 10.1007/s11239-018-1777-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Unfortunately the author list in the original article is incomplete. The correct list of contributing authors is given in this Correction.
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Affiliation(s)
- M S Al Yami
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - A McBride
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona Cancer Center, Banner University Medical Center, University of Arizona, Tucson, AZ, USA
| | - C Katragadda
- Center for Health Outcomes and Pharmacoeconomic Research, University of Arizona, Tucson, AZ, USA
| | - J R Martin
- Department of Pharmacy Practice and Science, College of Pharmacy, Arizona Health Sciences Library, University of Arizona, Tucson, AZ, USA
| | - H A Badreldin
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - A H Mohammed
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - A M Elmubark
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - M Y Alzahrani
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - A M Alsheri
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - I Abraham
- Center for Health Outcomes and Pharmacoeconomic Research, Department of Pharmacy Practice and Science, College of Pharmacy, Department of Family and Community Health, College of Medicine, University of Arizona Cancer Center, University of Arizona, Tucson, AZ, USA
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Rutherford RW, Jennings JM, Levy DL, Parisi TJ, Martin JR, Dennis DA. Revision Total Knee Arthroplasty for Arthrofibrosis. J Arthroplasty 2018; 33:S177-S181. [PMID: 29681492 DOI: 10.1016/j.arth.2018.03.037] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/13/2018] [Accepted: 03/19/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Arthrofibrosis after TKA is a significant cause of patient dissatisfaction. There is little evidence regarding revision arthroplasty in this patient population. The purpose of this study is to evaluate outcomes after revision TKA for arthrofibrosis. METHODS We retrospectively reviewed 46 consecutive revision TKAs for arthrofibrosis between 2007 and 2015 with minimum 2-year follow-up. Range of motion (ROM), complication rates, and Knee Society Scores (KSS) were recorded. RESULTS Patients were followed for a mean of 59 months. ROM and KSS significantly improved: with flexion improving from 88° to 103° and extension improving from 11° to 3° (P < .001). There was not a relationship between patient or surgical factors and outcomes in this study. The rate of complications was 28.2% with a 17.4% reoperation rate. CONCLUSION While revision for arthrofibrosis after TKA can be associated with significant improvements in ROM and KSS, caution is advised given high rates of revisions, reoperations, and complications. Thirty percent of patients in this series had a decrease in one or more component of the KSS or a net decrease in arc of motion after revision surgery.
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Affiliation(s)
| | - Jason M Jennings
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, Colorado; Department of Mechanical and Materials Engineering, Denver University, Denver, Colorado
| | - Daniel L Levy
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, Colorado
| | - Thomas J Parisi
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, Colorado
| | | | - Douglas A Dennis
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, Colorado; Department of Mechanical and Materials Engineering, Denver University, Denver, Colorado; Department of Biomedical Engineering, University of Tennessee, Knoxville, Tennessee; Department of Orthopaedics, University of Colorado School of Medicine, Denver, Colorado
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Martin JR, Jennings JM, Watters TS, Levy DL, Miner TM, Dennis DA. Midterm Prospective Comparative Analysis of 2 Hard-on-Hard Bearing Total Hip Arthroplasty Designs. J Arthroplasty 2018; 33:1820-1825. [PMID: 29429884 DOI: 10.1016/j.arth.2018.01.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/15/2018] [Accepted: 01/17/2018] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Hard-on-hard (HoH) bearing surfaces in total hip arthroplasty (THA) are commonly utilized in younger patients and may decrease mechanical wear compared to polyethylene bearing surfaces. To our knowledge, no study has prospectively compared the 2 most common HoH bearings, ceramic-on-ceramic (CoC) and metal-on-metal (MoM) THA. MATERIALS AND METHODS We prospectively enrolled 40 patients to undergo an MoM THA and 42 patients to undergo a CoC THA utilizing the same acetabular component. Patients were followed up for a minimum of 2 years. Comparative outcomes included clinical scores, revision or reoperation for any reason, complication rates, and radiographic outcomes. RESULTS The average follow-up was significantly longer in the CoC cohort (94 vs 74 months; P = .005). The CoC cohort had significantly improved Harris Hip Scores (95 vs 84; P = .0009) and pain scores (42 vs 34; P = .0003). The revision (0% vs 31%; P = .0001), reoperation (7.5% vs 36%; P = .004), and complication rates (10% vs 56%; P = .0001) were significantly lower in the CoC cohort. There were no statistically significant differences in radiographic parameters. CONCLUSION The clinical outcomes in the CoC cohort exceeded the MoM cohort. It is unlikely that another prospective comparative study of HoH THAs will be conducted. Our midterm results support the use of CoC THA as a viable option that may reduce long-term wear in younger patients. Close surveillance of MoM THA patients is recommended considering the higher failure and complication rates reported in this cohort.
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Affiliation(s)
| | | | | | | | | | - Douglas A Dennis
- Colorado Joint Replacement, Denver, CO; Department of Biomedical Engineering, University of Tennessee, Knoxville, TN; Bioengineering, University of Denver, Denver, CO; Department of Orthopaedics, University of Colorado School of Medicine, Denver, CO
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Martin JR, Fehring KA, Watts CD, Springer BD, Fehring TK. Radiographic Findings in Patients With Catastrophic Varus Collapse After Total Knee Arthroplasty. J Arthroplasty 2018; 33:241-244. [PMID: 28899593 DOI: 10.1016/j.arth.2017.08.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 07/31/2017] [Accepted: 08/14/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Catastrophic varus collapse is an uncommon mechanism of failure in primary total knee arthroplasty (TKA). Varus collapse has been associated with obesity and smaller implant sizes. However, to our knowledge, preoperative radiographic characterization of this cohort has not been performed. Therefore, the following study evaluated preoperative alignment and how this correlates with the degree of eventual varus collapse identified in this patient population prior to revision. METHODS Utilizing our institutional database, 1106 revision TKAs were performed from 2004 to 2017. Of these, 35 patients were revised secondary to tibial varus collapse. Twenty-seven patients had their primary TKA performed at our institution. Coronal alignment of the knee was recorded from anteroposterior knee radiographs. Medial tibial bone loss was recorded at final follow-up. RESULTS The average body mass index was 38 kg/m2. Twenty-six of 27 patients had a preoperative varus deformity (4.2° varus) and all were corrected to a valgus coronal alignment immediately postoperatively (5.2° valgus, P = .0001). Twenty-four of 27 patients' coronal alignment after varus collapse was within 2° of their preoperative alignment (5.8° varus). Twenty-five of 27 patients had radiographic medial tibial bone loss prior to varus collapse. CONCLUSION Tibial varus collapse in an uncommon cause of failure after primary TKA. Preoperative varus deformity, postoperative medial tibial bone loss, and obesity were common findings in this series of patients. Therefore, increased tibial stem lengths should be considered in patients with a preoperative varus deformity, small tibial implant size, and a body mass index ≥35 kg/m2 undergoing primary TKA.
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Affiliation(s)
| | | | - Chad D Watts
- OrthoCarolina Hip & Knee Center, Charlotte, North Carolina
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Ryan Martin J, Vestermark G, Mullis B, Anglen J. A Retrospective Comparative Analysis of the Use of Implantable Bone Stimulators in Nonunions. J Surg Orthop Adv 2017; 26:128-133. [PMID: 29130872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This study details the use of implantable bone stimulators in the setting of nonunion. A retrospective comparative analysis was used to evaluate the efficacy of implantable bone stimulators in achieving union in the setting of atrophic or oligotrophic nonunion by two fellowship-trained orthopaedic trauma surgeons. Initially, 72 patients underwent surgical intervention for nonunion. Twenty-one patients had an implantable bone stimulator placed at the time of nonunion surgery. Thirty-eight patients had a minimum of 1-year follow-up. An implantable bone stimulator was used in 13 patients and 25 patients did not have a bone stimulator. The use of implantable bone stimulators was found to be significantly associated with increased union rates (p = .042). (Journal of Surgical Orthopaedic Advances.
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Affiliation(s)
- J Ryan Martin
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana.
| | - George Vestermark
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Brian Mullis
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jeffrey Anglen
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Martin JR, Fehring KA, Watts CD, Levy DL, Springer BD, Kim RH. Coronal alignment predicts the use of semi-constrained implants in contemporary total knee arthroplasty. Knee 2017; 24:863-868. [PMID: 28576689 DOI: 10.1016/j.knee.2017.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 03/20/2017] [Accepted: 03/25/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Semi-constrained, or varus-valgus constrained, implants are occasionally necessary to achieve stability in primary total knee arthroplasty (TKA). However, outcomes with these implants are largely unknown. Therefore, the primary goals of this study were to determine 1) can we identify preoperatively which patients might require a semi-constrained implant and 2) are there any clinical and or radiographic differences for those that require a semi-constrained implant? METHODS A multicenter retrospective study was performed to retrospectively review patients that had a Stryker Triathlon (Kalamazoo, MI) TKA with a Total Stabilized (TS) tibial insert (n=75). This TS cohort was subsequently matched 1:1 based on age, gender, and BMI to a cohort of patients with the same primary TKA design with a PS insert (n=75). Preoperative and postoperative radiographic and clinical data were compared between the two groups. RESULTS Preoperatively, the TS cohort had significantly greater varus (9.72 vs. 3.48; p=0.0001) and valgus (14.1 vs. 7.57; p=0.0001) deformity. Post-operatively, there were no statistically significant differences in revisions (p=1), reoperations (p=1), or complications (p=1). Mean clinical and radiographic follow-ups were equivalent between groups (25.5 vs. 25.8months, p=0.8851). CONCLUSION As suspected, use of a semi-constrained insert to achieve intraoperative coronal stability was most predicted by preoperative coronal deformity (either varus or valgus). Longer follow-up and larger patient cohorts are necessary to determine.
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Affiliation(s)
- J Ryan Martin
- OrthoCarolina Hip and Knee Center, Charlotte, NC, United States
| | - Keith A Fehring
- OrthoCarolina Hip and Knee Center, Charlotte, NC, United States
| | - Chad D Watts
- OrthoCarolina Hip and Knee Center, Charlotte, NC, United States
| | - Daniel L Levy
- Colorado Joint Replacement, Denver, CO, United States
| | | | - Raymond H Kim
- Colorado Joint Replacement, Denver, CO, United States; Dept. of Mechanical and Materials Engineering, University of Denver, Denver, CO, United States; Department of Orthopedic Surgery, Joan C. Edwards School of Medicine at Marshall University, United States.
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Fehring KA, Martin JR, Sculco PK, Kalantari S, Trousdale RT. Posterior Femoral Single Limb Osteotomy for the Removal of Well-Fixed Modular Femoral Neck Components. ReconRev 2017. [DOI: 10.15438/rr.7.2.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Modular neck femoral components were introduced to optimize femoral neck anteversion, leg length, offset, and stability in total hip arthroplasty. However, concerns have been raised in recent years regarding early failure of these implants due to corrosion, pseudotumor, as well as fracture of the modular neck. Removing modular neck femoral implants is challenging as removal of the modular femoral neck leaves a proximally coated femoral stem level with the proximal bone of the femoral neck. We describe a posterior femoral single limb osteotomy (posterior cut of an extended trochanteric osteotomy) for the removal of a modular neck femoral component.
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Kim RH, Martin JR, Dennis DA, Yang CC, Jennings JM, Lee GC. Midterm Clinical and Radiographic Results of Mobile-Bearing Revision Total Knee Arthroplasty. J Arthroplasty 2017; 32:1930-1934. [PMID: 28209272 DOI: 10.1016/j.arth.2017.01.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/27/2016] [Accepted: 01/10/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Constrained implants are frequently required in revision total knee arthroplasty (TKA) and are associated with an increase in aseptic component loosening and damage or wear to the constraining mechanisms, compared with primary TKA. The purpose of the following study was to evaluate the midterm clinical and radiographic results including the incidence of bearing complications in a group of patients undergoing revision TKA using mobile-bearing revision TKA implants. METHODS We retrospectively reviewed 316 consecutive mobile-bearing revision TKAs performed at 2 centers between 2006 and 2010. There were 183 women and 133 men with a mean age of 66 years. The patients were evaluated clinically using the Knee Society scores. A radiographic analysis was performed. Bearing specific complications (ie, instability or dislocation) were recorded. RESULTS Patients were followed-up for a minimum of 24 months and a median of 59.88 months (range 24-121.2). The average Knee Society knee score and function scores increased from 40.8 and 47.9 points preoperatively to 80 points and 70.3 points, respectively (P < .01). The average knee flexion improved from 105.6° preoperatively to 117.4° postoperatively (P < .01). Eight patients required subsequent implant revision. No cases of bearing complications were observed. CONCLUSION Revision TKA using mobile-bearing revision components demonstrated favorable midterm clinical and radiographic results with no occurrence of bearing instability or dislocation. Longer follow-up is required to evaluate for potential advantages of mobile-bearings over fixed-bearing revision components in terms of polyethylene wear reduction, reduced stress transmission across fixation interfaces, and reduced stress on the polyethylene post.
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Affiliation(s)
- Raymond H Kim
- Colorado Joint Replacement, Denver, Colorado; Department of Mechanical and Materials Engineering, University of Denver, Denver, Colorado; Department of Orthopedic Surgery, Marshall University, Huntington, West Virginia
| | | | - Douglas A Dennis
- Colorado Joint Replacement, Denver, Colorado; Department of Mechanical and Materials Engineering, University of Denver, Denver, Colorado; Department of Biomedical Engineering, University of Tennessee, Knoxville, Tennessee; Department of Orthopedics, University of Colorado Health Sciences Center, Aurora, Colorado
| | | | | | - Gwo-Chin Lee
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
BACKGROUND Pelvic discontinuity is uncommon and presents the surgeon with complex reconstructive challenges. The objective of this study is to report the results of current strategies used in the treatment of pelvic discontinuity. METHODS We retrospectively analyzed prospectively collected data on 113 consecutive revision total hip arthroplasties performed for the treatment of unilateral pelvic discontinuity at a single institution. The study included 18 male and 95 female patients with a mean age of 63 years at the time of revision surgery. Preoperative, immediate postoperative, and latest follow-up radiographs were reviewed to assess healing of the discontinuity as well as acetabular component stability. Treatment modalities included an uncemented cup with a posterior column plate (50 hips; 44%), a cup-cage construct (27 hips; 24%), an antiprotrusio cage with or without a posterior column plate (26 hips; 23%), and an uncemented cup alone (10 hips; 9%). The average duration of follow-up for each of these types of surgical reconstruction was similar (range, 3.9 to 7.2 years). RESULTS Five-year revision-free survivorship of the implant was best with a cup-cage construct (100%) and worst with an uncemented cup with a posterior column plate (80%) and a cup alone (80%). Healing of the discontinuity was achieved in 50% of the hips with an uncemented cup alone, 74% of the hips with an uncemented cup and a posterior column plate, 74% of the hips with a cup-cage construct, and 88% of the hips with an antiprotrusio cage construct (91% of these hips when structural allograft was used). The overall complication rate was 26.5%. The average Harris hip score improved from 54 preoperatively to 69 postoperatively (95% confidence interval: 50 to 57 preoperatively and 65 to 72 postoperatively; p = 0.017). CONCLUSIONS Improved survivorship and healing rates were seen in this series when a reconstruction cage was used as an adjunct to an uncemented cup (cup-cage) or in combination with structural allograft bone that bridged the discontinuity. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- J Ryan Martin
- 1Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Martin JR, Levy D, Miner T, Conrad D, Jennings J, Dennis D. Medial Tibial Reduction Osteotomy is Associated with Excellent Outcomes and Improved Coronal Alignment. ReconRev 2017. [DOI: 10.15438/rr.7.1.166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background: The medial tibial reduction osteotomy (MTRO) was introduced to achieve coronal ligamentous balance in total knee arthroplasty (TKA) patients with substantial preoperative varus deformity. Limited data exists on the outcomes of patients requiring an MTRO. This study compares outcomes of a matched cohort of patients that either required or did not require an MTRO during TKA.Methods: A retrospective review was performed on 67 patients that underwent an MTRO during primary TKA to achieve coronal balance. This patient population was matched 1:1 to another cohort of TKA patients by age, gender, and BMI that did not require an MTRO. A clinical and radiographic evaluation was utilized to compare the two cohorts.Results: Preoperatively, the tibiofemoral angle was 3.42° valgus versus 6.12° varus in the control and MTRO cohorts respectively (p=0.01). Mean postoperative tibiofemoral angles were 3.40° versus 2.43° valgus respectively. Postoperative Knee Society Scores were superior in the MTRO cohort (183.84 versus 174.58; p=0.04). Intraoperatively, no superficial MCL releases were required to achieve coronal balance in either cohort. Complications were similar and limited in both groups. Medial tibial bone resorption was observed in 64% of MTRO subjects averaging 2.02mm versus only 0.3mm in the control cohort ( p=0.01).Conclusion: Patients requiring an MTRO achieved similar alignment and superior knee scores compared to a control cohort with less varus deformity. This procedure eliminated the need for release of the superficial MCL. Resorption of medial tibial bone was commonly observed, possibly secondary to saw-induced thermal necrosis associated with performing an MTRO.
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Martin JR, Fout A, Stoeckl AC, Dennis DA. Diagnosing and Treating Popliteal Tendinopathy After Total Knee Arthroplasty. ReconRev 2017. [DOI: 10.15438/rr.7.1.172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The following office tip describes four patients that underwent primary total knee arthroplasty and developed posterolateral knee pain at a mean follow-up duration of 1.6 months postoperatively. The first patient in this series noted substantial pain lying in bed (in a lateral decubitus position with the operative leg up) while attempting to abduct her leg to adjust her sheet in bed. A thorough clinical and radiographic work-up was performed. This patient’s posturing in bed (and subsequent physical exam maneuver) led to a presumptive diagnosis of popliteal tendinopathy. The diagnosis was confirmed arthroscopically by identifying a frayed and inflamed popliteal tendon. After undergoing arthroscopic popliteal tendon release, the patient noted complete pain relief while retaining coronal stability in both flexion and extension. The following office tip defines a previously undescribed clinical diagnostic examination for popliteal tendinopathy that was identified based on a patient’s symptomatology and subsequently utilized to identify three additional cases of arthroscopically confirmed popliteal tendinopathy.
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Jennings JM, Martin JR, Kim RH, Yang CC, Miner TM, Dennis DA. Metal Artifact Reduction Sequence MRI Abnormalities in Asymptomatic Patients with a Ceramic-on-Polyethylene Total Hip Replacement. J Bone Joint Surg Am 2017; 99:593-598. [PMID: 28375892 DOI: 10.2106/jbjs.16.00910] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is a commonly utilized screening modality in patients with a metal-on-metal (MoM) total hip replacement. The prevalence of clinically important fluid collections may be overestimated since these collections have been reported to occur in asymptomatic patients with MoM and other bearing surfaces. The purpose of this study was to determine the frequency and types of MRI-documented adverse local tissue reactions in asymptomatic patients with a ceramic-on-polyethylene (CoP) total hip replacement. METHODS Forty-four patients (50 hips) with a minimum 2-year follow-up after total hip arthroplasty with CoP implants and a Harris hip score of >90 were enrolled in this study. The inclusion criteria were the absence of hip pain and the availability of appropriate follow-up radiographs. All patients underwent a metal artifact reduction sequence (MARS) MRI scan to determine the presence of fluid collections in asymptomatic patients with a CoP bearing surface. RESULTS Fluid collections were observed in 9 (18%) of 50 asymptomatic hips in this cohort. There were 5 hips with intracapsular synovitis, and 2 of these hips had a thickened synovium. Extra-articular fluid collections with direct intracapsular communication were identified in 4 additional hips. Two of these hips had a thickened synovium. No signs of osteolysis or evidence of adverse local tissue reactions were noted on radiographs at the most recent follow-up. CONCLUSIONS This study revealed that fluid collections are not uncommon after total hip arthroplasty with CoP implants. Synovial thickening may be present and is more prevalent than has been reported in previous studies involving metal-on-polyethylene (MoP) bearing surfaces. The clinical importance and natural history of these findings remain unknown. LEVEL OF EVIDENCE Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jason M Jennings
- 1Colorado Joint Replacement, Denver, Colorado 2Department of Biomedical Engineering, University of Denver, Denver, Colorado 3Department of Orthopedic Surgery, Joan C. Edwards School of Medicine at Marshall University, Huntington, West Virginia 4Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado 5Department of Biomedical Engineering, University of Tennessee, Knoxville, Tennessee
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Martin JR, Jennings JM, Watters TS, Levy DL, McNabb DC, Dennis DA. Femoral Implant Design Modification Decreases the Incidence of Patellar Crepitus in Total Knee Arthroplasty. J Arthroplasty 2017; 32:1310-1313. [PMID: 28012722 DOI: 10.1016/j.arth.2016.11.025] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 10/31/2016] [Accepted: 11/14/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Patellar crepitus is a complication most commonly seen in patients implanted with a posterior-stabilized total knee arthroplasty (TKA). Recently, design changes in the patellofemoral geometry and the intercondylar box ratio have been optimized in newer TKA designs. A comparative study was performed to analyze the incidence of patellar crepitus between a historical vs modern TKA design. METHODS A retrospective review of all patients at our institution that underwent a primary TKA with either a PFC Sigma or Attune posterior-stabilized TKA (DePuy, Inc, Warsaw, IN), with a minimum of 1-year follow-up duration was performed. A total of 1165 participants implanted with the PFC Sigma and 728 with the Attune design were analyzed. Patellar crepitus incidence, functional scores, and range of motion were recorded at each follow-up appointment. Statistical analyses were performed between the 2 groups to determine if there were differences in clinical outcomes. RESULTS The incidence of crepitus in participants implanted with the Attune was 0.55% vs 6.26% in the PFC Sigma cohort (P < .001) at 1 year vs. 0.83% vs 9.4%, respectively at 2 years post operatively (P < .001). There were small differences in extension, flexion, and Knee Society Scores between the 2 groups that were not clinically meaningful. CONCLUSION The Attune posterior-stabilized TKA demonstrated substantially less patellofemoral crepitus incidence than the historical control. We hypothesize that these findings are related to femoral component changes including a thinner and narrower anterior flange and a reduced femoral intercondylar box ratio.
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Affiliation(s)
- J Ryan Martin
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, Colorado
| | - Jason M Jennings
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, Colorado
| | - Tyler S Watters
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, Colorado
| | - Daniel L Levy
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, Colorado
| | | | - Douglas A Dennis
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, Colorado; Department of Mechanical and Materials Engineering, University of Denver, Denver, Colorado; Department of Biomedical Engineering, University of Tennessee, Knoxville, Tennessee; Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado
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Martin JR, Jennings JM, Levy DL, Watters TS, Miner TM, Dennis DA. What Preoperative Radiographic Parameters Are Associated With Increased Medial Release in Total Knee Arthroplasty? J Arthroplasty 2017; 32:771-776. [PMID: 27665245 DOI: 10.1016/j.arth.2016.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 07/11/2016] [Accepted: 08/15/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Preoperative varus deformity of the knee is a common malalignment in patients undergoing primary total knee arthroplasty (TKA). We are unaware of any studies that have correlated how various preoperative radiographic parameters can predict the amount of medial releases performed to achieve optimal coronal alignment and ligamentous balance. METHODS A retrospective review was performed on 67 patients who required at least a medial tibial reduction osteotomy (MTRO) during primary TKA to achieve coronal balance. This patient population was matched 1:1 to another cohort of TKA patients by age, gender, and body mass index who did not require an MTRO. A radiographic evaluation was used to compare the 2 cohorts. RESULTS Preoperatively, the MTRO cohort was noted to have significantly increased varus tibiofemoral (86.12° vs 93.43°), tibial articular surface (85.79° vs 87.54°), and medial tibial articular surface angles (75.22° vs 85.34°) compared to the control cohort. The MTRO cohort had 3.13 mm of medial tibial offset and 9.06 mm of lateral joint space opening and the control cohort had 0.09 mm and 4.07 mm, respectively. The medial tibial articular surface angle and lateral joint space widening were statistically associated with the MTRO cohort. The final tibiofemoral angle in the MTRO cohort was 92.43° and was 93.40° in the control cohort. CONCLUSION The MTRO cohort was noted to have several preoperative radiographic parameters that were significantly different than the control cohort. However, the medial tibial articular surface angle and lateral joint space widening were the only radiographic parameters that were statistically associated with requiring an MTRO.
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Affiliation(s)
- J Ryan Martin
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, Colorado
| | - Jason M Jennings
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, Colorado
| | - Daniel L Levy
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, Colorado
| | | | - Todd M Miner
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, Colorado
| | - Douglas A Dennis
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, Colorado; Department of Biomedical Engineering, University of Tennessee, Knoxville, Tennessee; Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
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Watters TS, Zhen Y, Martin JR, Levy DL, Jennings JM, Dennis DA. Total Knee Arthroplasty After Anterior Cruciate Ligament Reconstruction: Not Just a Routine Primary Arthroplasty. J Bone Joint Surg Am 2017; 99:185-189. [PMID: 28145948 DOI: 10.2106/jbjs.16.00524] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite the success of restoring joint stability and improving early functional outcomes after anterior cruciate ligament (ACL) reconstruction, the long-term risk of developing symptomatic osteoarthritis requiring total knee arthroplasty is higher than that in the uninjured population. The purpose of this study was to compare operative characteristics and early outcomes of patients undergoing total knee arthroplasty after ACL reconstruction with those of a matched cohort of control subjects with primary osteoarthritis and no history of ligament reconstruction. METHODS All patients who had undergone total knee arthroplasty from 2005 to 2013 at our institution with a history of ACL reconstruction and a minimum 2-year follow-up were identified from a prospective research database. These patients were matched by demographic and surgeon variables to patients who had not undergone prior ACL reconstruction. Outcomes included Knee Society Scores (KSS), range of motion, operative variables, complications, and reoperations. RESULTS A cohort of 122 patients was identified as the ACL study group and was compared with the matched control cohort. The mean age at the time of the surgical procedure was 58 years, and 55% of the patients were male. The mean follow-up was 3.3 years in the ACL group and 3.0 years in the control group. There was no significant difference in the latest KSS outcomes between groups postoperatively (p > 0.05). Although preoperative flexion was significantly lower (p = 0.01) in the ACL group (119°) than in the control group (123°), there was no difference between groups postoperatively. Fifty percent (61 of 122) of patients in the ACL group required implant removal at the time of total knee arthroplasty. The operative time was significantly longer (p < 0.001) in the ACL group (88 minutes) compared with the control group (73 minutes). There were a total of 11 reoperations in the ACL group, including 4 for periprosthetic infection, whereas there were only 2 reoperations in the control group. The risk of reoperation in the ACL group was more than 5 times higher than in the control group (relative risk, 5.5 [95% confidence interval, 1.2 to 24.3]; p = 0.01). CONCLUSIONS The results of this retrospective matched cohort study suggest that prior ACL reconstruction results in longer operative time and increased risk of early reoperation after total knee arthroplasty. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Tyler Steven Watters
- 1Colorado Joint Replacement, Porter Adventist Hospital, Denver, Colorado 2Bone and Joint Department, Qianfoshan Hospital, Shandong University, Jinan, China
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Martin JR, Watts CD, Levy DL, Kim RH. Medial Tibial Stress Shielding: A Limitation of Cobalt Chromium Tibial Baseplates. J Arthroplasty 2017; 32:558-562. [PMID: 27593733 DOI: 10.1016/j.arth.2016.07.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 07/08/2016] [Accepted: 07/22/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Stress shielding is a well-recognized complication associated with total knee arthroplasty. However, this phenomenon has not been thoroughly described. Specifically, no study to our knowledge has evaluated the radiographic impact of utilizing various tibial component compositions on tibial stress shielding. METHODS We retrospectively reviewed 3 cohorts of 50 patients that had a preoperative varus deformity and were implanted with a titanium, cobalt chromium (CoCr), or an all polyethylene tibial implant. A radiographic comparative analysis was performed to evaluate the amount of medial tibial bone loss in each cohort. In addition, a clinical outcomes analysis was performed on the 3 cohorts. RESULTS The CoCr was noted to have a statistically significant increase in medial tibial bone loss compared with the other 2 cohorts. The all polyethylene cohort had a statistically significantly higher final Knee Society Score and was associated with the least amount of stress shielding. CONCLUSION The CoCr tray is the most rigid of 3 implants that were compared in this study. Interestingly, this cohort had the highest amount of medial tibial bone loss. In addition, 1 patient in the CoCr cohort had medial soft tissue irritation which was attributed to a prominent medial tibial tray which required revision surgery to mitigate the symptoms.
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Affiliation(s)
| | | | | | - Raymond H Kim
- Colorado Joint Replacement, Denver, Colorado; Department of Mechanical and Materials Engineering, University of Denver, Denver, Colorado; Department of Orthopedic Surgery, Joan C. Edwards School of Medicine at Marshall University, Huntington, West Virginia
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Martin JR, Watts CD, Levy DL, Miner TM, Springer BD, Kim RH. Tibial Tray Thickness Significantly Increases Medial Tibial Bone Resorption in Cobalt-Chromium Total Knee Arthroplasty Implants. J Arthroplasty 2017; 32:79-82. [PMID: 27421584 DOI: 10.1016/j.arth.2016.06.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 05/19/2016] [Accepted: 06/06/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Stress shielding is an uncommon complication associated with primary total knee arthroplasty. Patients are frequently identified radiographically with minimal clinical symptoms. Very few studies have evaluated risk factors for postoperative medial tibial bone loss. We hypothesized that thicker cobalt-chromium tibial trays are associated with increased bone loss. METHODS We performed a retrospective review of 100 posterior stabilized, fixed-bearing total knee arthroplasty where 50 patients had a 4-mm-thick tibial tray (thick tray cohort) and 50 patients had a 2.7-mm-thick tibial tray (thin tray cohort). A clinical evaluation and a radiographic assessment of medial tibial bone loss were performed on both cohorts at a minimum of 2 years postoperatively. RESULTS Mean medial tibial bone loss was significantly higher in the thick tray cohort (1.07 vs 0.16 mm; P = .0001). In addition, there were significantly more patients with medial tibial bone loss in the thick tray group compared with the thin tray group (44% vs 10%, P = .0002). Despite these differences, there were no statistically significant differences in range of motion, knee society score, complications, or revision surgeries performed. CONCLUSION A thicker cobalt-chromium tray was associated with significantly more medial tibial bone loss. Despite these radiographic findings, we found no discernable differences in clinical outcomes in our patient cohort. Further study and longer follow-up are needed to understand the effects and clinical significance of medial tibial bone loss.
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Affiliation(s)
- J Ryan Martin
- Department of Orthopaedic Surgery, Colorado Joint Replacement, Denver, Colorado
| | - Chad D Watts
- Department of Orthopaedic Surgery, OrthoCarolina, Charlotte, North Carolina
| | - Daniel L Levy
- Department of Orthopaedic Surgery, Colorado Joint Replacement, Denver, Colorado
| | - Todd M Miner
- Department of Orthopaedic Surgery, Colorado Joint Replacement, Denver, Colorado
| | - Bryan D Springer
- Department of Orthopaedic Surgery, OrthoCarolina, Charlotte, North Carolina
| | - Raymond H Kim
- Department of Orthopaedic Surgery, Colorado Joint Replacement, Denver, Colorado; Department of Mechanical and Materials Engineering, University of Denver, Denver, Colorado; Department of Orthopedic Surgery, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
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Martin JR, Beahrs TR, Fehring KA, Trousdale RT. Rotating platform versus fixed bearing total knee arthroplasty at mid-term follow-up. Knee 2016; 23:1055-1058. [PMID: 27815014 DOI: 10.1016/j.knee.2016.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/26/2016] [Accepted: 06/12/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Rotating platform posterior stabilized (RP) total knee arthroplasty (TKA) was initially developed in part to decrease polyethylene wear and to improve patellar tracking. There have been limited studies evaluating the longevity and causes of reoperation or revision for this implant. The following study compares mid-term survival rates and causes for reoperation between fixed bearing (FB) TKAs. METHODS We identified 11,416 patients who underwent a primary posterior stabilized TKA between 2001 and 2013. This group was stratified to include patients with a RP (n=926) and FB (n=10,490) TKA design. Kaplan-Meier survival rates for each complication that led to reoperation were determined at five- and 10-years. Univariate hazard ratios were determined for the most common causes for reoperation and overall implant survival rates. A multivariate analysis was performed to account for the age, gender and preoperative diagnosis discrepancy between groups. RESULTS The reoperation data demonstrated statistically increased all-cause reoperation rate (p=<0.001) and reoperation rate for stiffness in the RP group (p=0.001). After adjusting for demographic variables we noted no statistically significant differences in reoperation rate and reoperation for stiffness. Additionally, a statistically significant decrease was noted in all-cause revision (p=0.024) and revision for aseptic loosening or osteolysis in the RP group (p=0.029). CONCLUSION After adjusting for patient demographic differences, we noted a statistically significant decrease in the overall revision and revision for aseptic loosening or osteolysis rates in the RP group.
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Affiliation(s)
- J Ryan Martin
- Mayo Clinic, Department of Orthopedic Surgery, 200 First Street SW, Rochester, MN 55905, United States.
| | - Taylor R Beahrs
- Mayo Clinic, Department of Orthopedic Surgery, 200 First Street SW, Rochester, MN 55905, United States.
| | - Keith A Fehring
- Mayo Clinic, Department of Orthopedic Surgery, 200 First Street SW, Rochester, MN 55905, United States.
| | - Robert T Trousdale
- Mayo Clinic, Department of Orthopedic Surgery, 200 First Street SW, Rochester, MN 55905, United States.
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Martin JR, Bonafede MM, Nelson JK, Booth AJ, Miller JD. Treatment Patterns Among Women with Newly Diagnosed Abnormal Uterine Bleeding. J Minim Invasive Gynecol 2016. [DOI: 10.1016/j.jmig.2016.08.235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Yoder N, Tal R, Martin JR. Abdominal ectopic pregnancy after in vitro fertilization and single embryo transfer: a case report and systematic review. Reprod Biol Endocrinol 2016; 14:69. [PMID: 27760569 PMCID: PMC5070159 DOI: 10.1186/s12958-016-0201-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 10/06/2016] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Ectopic pregnancy is the leading cause of maternal morbidity and mortality during the first trimester and the incidence increases dramatically with assisted-reproductive technology (ART), occurring in approximately 1.5-2.1 % of patients undergoing in-vitro fertilization (IVF). Abdominal ectopic pregnancy is a rare yet clinically significant form of ectopic pregnancy due to potentially high maternal morbidity. While risk factors for ectopic pregnancy after IVF have been studied, very little is known about risk factors specific for abdominal ectopic pregnancy. We present a case of a 30 year-old woman who had an abdominal ectopic pregnancy following IVF and elective single embryo transfer, which was diagnosed and managed by laparoscopy. We performed a systematic literature search to identify case reports of abdominal or heterotopic abdominal ectopic pregnancies after IVF. A total of 28 cases were identified. RESULTS Patients' ages ranged from 23 to 38 (Mean 33.2, S.D. = 3.2). Infertility causes included tubal factor (46 %), endometriosis (14 %), male factor (14 %), pelvic adhesive disease (7 %), structural/DES exposure (7 %), and unexplained infertility (14 %). A history of ectopic pregnancy was identified in 39 % of cases. A history of tubal surgery was identified in 50 % of cases, 32 % cases having had bilateral salpingectomy. Transfer of two embryos or more (79 %) and fresh embryo transfer (71 %) were reported in the majority of cases. Heterotopic abdominal pregnancy occurred in 46 % of cases while 54 % were abdominal ectopic pregnancies. CONCLUSIONS Our systematic review has revealed several trends in reported cases of abdominal ectopic pregnancy after IVF including tubal factor infertility, history of tubal ectopic and tubal surgery, higher number of embryos transferred, and fresh embryo transfers. These are consistent with known risk factors for ectopic pregnancy following IVF. Further research focusing on more homogenous population may help in better characterizing this rare IVF complication and its risks.
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Affiliation(s)
- Nicole Yoder
- Division of Reproductive Endocrinology & Infertility, Department of Obstetrics, Gynecology, & Reproductive Sciences, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
| | - Reshef Tal
- Division of Reproductive Endocrinology & Infertility, Department of Obstetrics, Gynecology, & Reproductive Sciences, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
| | - J. Ryan Martin
- Division of Reproductive Endocrinology & Infertility, Department of Obstetrics, Gynecology, & Reproductive Sciences, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
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Abstract
BACKGROUND Total knee arthroplasty in patients with severe preoperative deformity, ligamentous instability, and/or marked bone loss occasionally requires a varus and valgus constrained or rotating-hinge design prosthesis. The purpose of this study was to compare patient populations that underwent primary total knee arthroplasty with constrained or unconstrained total knee arthroplasty implants to determine patient demographic characteristics, long-term survival, and reasons for reoperation and revision for each group. METHODS We identified 28,667 primary total knee arthroplasties performed from 1979 to 2013 at our institution. A total of 427 knees had a varus and valgus constrained design and 246 knees underwent rotating-hinge total knee arthroplasties. Patient demographic information and preoperative diagnoses were analyzed by implant type. A multivariate analysis was performed to account for age, sex, and body mass index (BMI). Kaplan-Meier survival rates for each complication leading to reoperation or component revision were determined at 10 and 20 years. Adjusted hazard ratios were determined for the most common causes for reoperation and revision compared with a routine total knee arthroplasty control group. RESULTS Patient demographic characteristics were significantly different (p < 0.05) between all groups for age, sex, and BMI. The varus and valgus constrained and rotating-hinge groups had decreased survival free of all-cause reoperation at 10 and 20 years compared with the unconstrained total knee arthroplasty group, with a hazard ratio of 1.74 (95% confidence interval [95% CI], 1.36 to 2.23) for the valgus and varus constrained group and 2.07 (95% CI, 1.58 to 2.70) for the rotating-hinge group. The adjusted hazard ratio for all-cause revision was significantly higher for the varus and valgus constrained group at 1.65 (p = 0.007) but not for the rotating-hinge group at 1.48 (p = 0.054) compared with the unconstrained total knee arthroplasty group. Wear and osteolysis, infection, and fracture were the most common reasons for component revision in both groups. CONCLUSIONS We found increased reoperation and revision rates associated with the use of constrained implants at the time of index total knee arthroplasty. The rate of component revision for any reason at 10 years was >2 times higher in the constrained total knee arthroplasty groups compared with the unconstrained total knee arthroplasty group. At 20 years postoperatively, the component revision rate was >3 times higher. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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