Brian P. Chalmers

Diagnosis of adverse local tissue reactions following metal-on-metal hip arthroplasty

Metal-on-metal (MOM) bearing surfaces in hip arthroplasty have distinct advantages that led to the increase in popularity in North America in the early 2000s. However, with their increased use, concerns such as local cytotoxicity and hypersensitivity reactions leading to soft tissue damage and cystic mass formation (known collectively as adverse local tissue reactions (ALTR)) became apparent. The clinical presentation of ALTR is highly variable. The diagnosis of ALTR in MOM articulations in hip arthroplasty can be challenging and a combination of clinical presentation, physical examination, implant track record, component positioning, serum metal ion levels, cross-sectional imaging, histopathologic analysis, and consideration of alternative diagnoses are essential.

Iliopsoas Impingement After Primary Total Hip Arthroplasty: Operative and Nonoperative Treatment Outcomes

Background: A potential cause of persistent groin pain after total hip arthroplasty is impingement of the iliopsoas tendon. Treatment options include conservative management, tenotomy, and acetabular revision, but the literature, to our knowledge, has been limited to small case series on each technique. We present a series of patients with iliopsoas impingement after total hip arthroplasty and evaluate efficacy and risk factors for success or failure of each treatment strategy. Methods: Forty-nine patients treated at one institution for a diagnosis of iliopsoas impingement after primary total hip arthroplasty with hemispherical acetabular component and polyethylene bearing were retrospectively reviewed. Twenty-one patients underwent acetabular revision, 8 patients underwent tenotomy, and 20 patients had nonoperative management. The mean follow-up was 4 years. Anterior acetabular component prominence was measured on true lateral hip radiographs. Results: At the most recent follow-up, 10 patients (50%) in the nonoperative group had groin pain resolution compared with 22 patients (76%) in the operative group (p = 0.06). In patients with <8 mm of component prominence, tenotomy provided resolution of groin pain in 5 (100%) of 5 patients and a mean Harris hip score of 89 points. In patients with ≥8 mm of prominence, acetabular revision led to groin pain resolution in 12 (92%) of 13 patients compared with 1 (33%) of 3 patients treated with tenotomy (p = 0.07). Conclusions: Nonoperative management of iliopsoas impingement led to groin pain resolution in 50% of patients. In patients with minimal acetabular component prominence, iliopsoas release provided a high rate of success. Acetabular revision was more predictable for groin pain resolution in patients with ≥8 mm of anterior component prominence. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Survivorship of Metaphyseal Sleeves in Revision Total Knee Arthroplasty

BACKGROUND Metaphyseal fixation has promising early results in providing component stability and fixation in revision total knee arthroplasty (TKA). However, there are limited studies on midterm results of metaphyseal sleeves. We analyzed complications, rerevisions, and survivorship free of revision for aseptic loosening of metaphyseal sleeves in revision TKA. METHODS Two hundred eighty patients with 393 metaphyseal sleeves (144 femoral, 249 tibial) implanted during revision TKA from 2006-2014 were reviewed. Sleeves were most commonly cemented (55% femoral, 72% tibial). Mean follow-up was 3 years, mean age was 66 years, and mean body mass index was 34 kg/m2. Indications for revision TKA included 2-stage reimplantation for deep infection (37%), aseptic loosening of the tibia (14%), femur (12%), or both components (9%), and instability (14%). RESULTS There was a 12% rate of perioperative complications, most commonly intraoperative fracture (6.5%). Eight sleeves (2.5%) required removal: 6 (2%) during component resection for deep infection (all were well-fixed at removal) as well as 1 (0.8%) femoral sleeve and 1 (0.8%) tibial sleeve for aseptic loosening. Five-year survivorship free of revision for aseptic loosening was 96% and 99.5% for femoral and tibial sleeves, respectively. Level of constraint, bone loss, sleeve and/or stem fixation, and revision indication did not significantly affect outcomes. CONCLUSION Metaphyseal sleeve fixation to enhance component stability during revision TKA has a 5-year survivorship free of revision for aseptic loosening of 96% and 99.5% in femoral and tibial sleeves, respectively. Both cemented and cementless sleeve fixation provides reliable durability at intermediate follow-up.

Primary Total Knee Arthroplasty After Solid Organ Transplant: Survivorship and Complications

BACKGROUND Clinical outcomes remain largely unknown beyond perioperative and short-term follow-up of solid organ transplant (SOT) patients undergoing total knee arthroplasty (TKA). METHODS Patient mortality, implant survivorship, and complications of 96 TKAs (76 patients) after SOT were retrospectively reviewed through an internal joint registry. Mean age at index arthroplasty was 66 years, and mean follow-up was 4 years. RESULTS Overall mortality rates at 1 year, 2 years, and 5 years from TKA were 2.6%, 7.9%, and 13.2%, respectively, and combined SOT patient survivorship was 92% at 2 years and 82% at 5 years. Implant survivorship free of any component revision or implant removal was 98% at 2 years and 93% at 5 years. There was a high rate of perioperative complications (12.5%), including periprosthetic fractures (5.2%) and deep periprosthetic infection (3.2%). CONCLUSION TKA does not appear to have any effect on SOT patient survivorship following the procedure. However, SOT patients may have a higher risk of perioperative complications and a lower implant survivorship than the general population of TKA patients at midterm follow-up.

Survivorship After Primary Total Hip Arthroplasty in Solid-Organ Transplant Patients

BACKGROUND Although a growing number of primary total hip arthroplasties (THAs) are being performed on solid-organ transplant (SOT) recipients, long-term patient and implant survivorships have not been well studied in contemporary transplant and arthroplasty practices. METHODS A total of 136 THAs (105 patients) with prior SOT were retrospectively reviewed from 2000 to 2013 at mean clinical follow-up of 5 years. The mean age was 59 years, with 39% being females. The most common SOT was renal (56%), followed by liver (24%). RESULTS Patient mortality was 3.8% and 13.3% at 2 and 5 years, respectively. There were 9 revisions (6.6%), including 5 (4%) for deep periprosthetic infection. Implant survivorship free of any revision was 95% and 94% at 2 and 5 years, respectively. Transplant type or surgical indication did not significantly impact patient or implant survivorship. CONCLUSION Compared with the general population, SOT patients undergoing THA have slightly higher mortality rates at 5 years. Implant survivorship free of revision was slightly lower than the general population, primarily due to an increased risk of periprosthetic joint infection.

Conversion of Hip Hemiarthroplasty to Total Hip Arthroplasty Utilizing a Dual-Mobility Construct Compared With Large Femoral Heads

BACKGROUND Conversion of hemiarthroplasty to total hip arthroplasty (THA) has a historically high, up to 20%, postoperative dislocation rate. As such, dual-mobility (DM) constructs are an attractive option to mitigate this complication. We analyzed survivorship free of revision, complications, and clinical outcomes of hemiarthroplasties conversion to THAs utilizing DM constructs compared with large femoral heads (≥36 mm). METHODS Conversion of 16 hemiarthroplasties to THAs with a specific DM construct compared with 13 conversions utilizing large femoral heads (≥36 mm) from 2011 to 2014 were reviewed. Mean age at conversion in the DM group was 75 years (range, 57-93 years); 75% were female. Significantly more patients with a dislocated hemiarthroplasty were converted to DM constructs compared to large femoral heads (44% vs 0%; P = .01). Mean follow-up was 3 years. RESULTS Survivorship free of revision was 100% in the DM group compared with 92% in the large femoral head cohort at 2 years (P = .7). One (8%) patient converted to a large femoral head underwent revision to a constrained liner for recurrent dislocations while no patients experienced a postoperative dislocation in the DM group (P = .4). Harris Hip Scores improved from 54 to 82 (P < .01) in the DM group, and from 52 to 86 in the large femoral head group (P < .01). CONCLUSION Larger effective femoral heads used during conversion of hemiarthroplasties to THAs resulted in high survivorship free of revision, minimal complications, and excellent clinical outcomes at short-term follow-up. In patients at highest risk for postoperative dislocation, including those with dislocating hemiarthroplasties, DM constructs resulted in no postoperative dislocations.

Perioperative management in total knee arthroplasty: Patient selection, pain management, thromboprophylaxis, and rehabilitation

Optimization of patient expectations in TKA requires understanding the risk profile of each patient and tailoring preoperative counseling appropriately. There are numerous postoperative thromboprophylaxis regimens, but aspirin has gained consensus approval from the American Academy of Orthopaedic Surgeons and American College of Chest Physicians and may decrease the risk of bleeding when compared to other agents. Early mobilization or mechanical compression remain useful adjuncts to chemical thromboprophylaxis. Pre-emptive multimodal pain control is effective and minimizes narcotic-related side effects. Regional blockade and periarticular injection are effective strategies for site-specific pain control and avoid opioid induced side effects. Strategies for perioperative physical therapy vary widely and there are no well-defined guidelines for postoperative rehabilitation. Rehabilitation lacks durable clinical benefits long-term for the average patient. However, targeted utilization of perioperative rehabilitation to the most debilitated patients may be beneficial.

Primary Total Hip Arthroplasty for Charcot Arthropathy is Associated With High Complications but Improved Clinical Outcomes

BACKGROUND Neuropathic (Charcot) arthropathy of the hip is rare but can lead to joint destruction, bone loss, and dysfunction. While total hip arthroplasty (THA) may be considered a treatment option, only very limited data in the form of case reports are available on the results of THA. The goal of this study was to analyze the outcomes of primary THA for Charcot arthropathy with emphasis on implant survivorship, complications, and clinical outcomes. METHODS Eleven patients undergoing 12 primary THAs for Charcot arthropathy from 2007 to 2014 were retrospectively reviewed. All patients had a severe underlying neuropathy and clear radiographic evidence of Charcot arthropathy. Mean age was 54 years with 4 patients being female. Mean follow-up was 5 years. RESULTS Survivorship free of any revision was 75% at both 2 and 5 years. Three THAs (3/12) were revised: 2 for recurrent instability and 1 for femoral component loosening. Survivorship free of any reoperation was 67% at both 2 and 5 years. One additional THA underwent open reduction and internal fixation of a Vancouver B1 periprosthetic fracture. The overall complication rate (including revisions and reoperations) was high at 58% with 3 recurrent dislocations, 2 periprosthetic fractures, 1 femoral component loosening, and 1 delayed wound healing. Harris Hip Scores improved from a mean of 43 preoperatively to 81 postoperatively (P < .001). CONCLUSION In this study, the largest to date, we found that patients undergoing primary THA for Charcot arthropathy have a significant improvement in clinical outcomes but that there was a high risk of early complications and revisions, mostly related to recurrent instability. Specific precautions to avoid early complications, namely utilization of components that provide robust fixation and strategies that provide enhanced hip stability, should be considered. LEVEL OF EVIDENCE Level IV.

Can Dislocation of a Constrained Liner Be Salvaged With Dual-mobility Constructs in Revision THA?

Background Revision THA to treat recurrent instability can itself be complicated by recurrent instability, and when this occurs, this problem is difficult to treat. Some patients’ THAs will continue to dislocate despite use of a constrained liner. One option in this difficult-to-treat group is conversion to a dual-mobility (DM) construct, but there are few data on this approach. Questions/purposes (1) What were the Harris hip scores in a small group of patients whose constrained liners were converted to DM constructs to treat recurrent dislocation? (2) What were the redislocation, rerevision, and DM construct retention rates in these patients? Methods We conducted a retrospective analysis of a longitudinally maintained institutional database maintained by individuals other than the treating surgeons to identify patients undergoing conversion of constrained liners to DM constructs in revision THA from 2011 to 2014. We identified 16 patients who underwent revision of dislocated constrained liners to DM constructs. Two patients died before 2-year followup, leaving 14 patients available for followup at a minimum of 24 months and a median of 37 months (range, 24–71 months). Indications for conversion to DM constructs included patients with dislocation of multiple prior constrained liners, patients with at least partial abductor functioning and soft tissue tensioning, and patients at very high risk for recurrent instability as an alternative to resection arthroplasty. Ten patients (10 of 14) underwent DM conversion at the time of cup revision, whereas four patients (four of 14) had a DM construct cemented into a preexisting cup. Median age was 65 years (range, 53–93 years). Median number of prior hip surgeries was five (range, three to 10) and seven patients (seven of 14) had dislocated more than one constrained liner. Results Harris hip score improved from a median of 57 (range, 55–67) to 84 (range, 68–96) postoperatively (p < 0.001). Three patients (three of 14) experienced a redislocation. Two (two of 14) of these patients were closed reduced and treated successfully nonoperatively; one (one of 14) patient experienced an intraprosthetic dislocation and underwent modular exchange. One patient (one of 14) underwent early resection arthroplasty for acetabular loosening after complex acetabular reconstruction. Overall, all other patients (13 of 14) retained a DM construct at final followup. Conclusions Conversion to a DM construct shows promise as a salvage option in high-risk, multiply operated on patients with dislocated constrained liners undergoing revision THA for recurrent instability. The ability to close reduce a dislocated DM construct is a distinct advantage over constrained liners. However, longer followup is required given that three of 14 redislocated, and one of those underwent revision for persistent instability at short-term followup. Level of Evidence: Level IV, therapeutic study.

Mid-term Results of Total Hip and Total Knee Arthroplasty in Patients With Human Immunodeficiency Virus

With antiretroviral therapy, patients who are human immunodeficiency virus (HIV)-positive are increasingly becoming candidates for total hip arthroplasty (THA) and total knee arthroplasty (TKA). Prior reports focus on perioperative complications, but longer-term outcomes remain unclear. The authors specifically analyzed clinical outcomes, perioperative complications, and survivorship free of periprosthetic joint infection (PJI) of THAs and TKAs in HIV-positive patients who had extended follow-up. A total of 21 HIV-positive patients who underwent 29 primary arthroplasties (14 THAs, 15 TKAs) from 1992 to 2012 were retrospectively reviewed. Mean age was 43 years and mean follow-up was 8 years. Mean perioperative CD4 cell count was 450 cells/mL; only 2 patients had perioperative CD4 cell counts less than 200 cells/mL. At mid-term follow-up, THAs and TKAs were reliable in improving function (mean postoperative Harris Hip Score: 87, P<.01; mean postoperative Knee Society Score: 83, P<.01). The rate of perioperative complications was high (17%). Patients with both hemophilia and HIV were at particular risk for complications at 33% (P=.04). Survivorship free of deep PJI was 100% in THAs at 10 years and 93% in TKAs at 10 years. Only 1 (7%) patient (1 TKA), who had a perioperative CD4 cell count of less than 200 cells/mL, was revised for deep PJI. In HIV-positive patients, both THAs and TKAs are reliable in alleviating pain and improving clinical function at mid-term follow-up. However, HIV-positive patients are at substantial risk of perioperative complications, especially with comorbid hemophilia. With antiretroviral therapy and maintained CD4 cell counts above 200 cells/mL, survivorship free of deep PJI approaches 100%. [Orthopedics. 2017; 40(4):e699-e702.].