Charles L. Nelson

Femoral Bone Loss in Revision Total Hip Arthroplasty: Evaluation and Management

&NA; As the number of primary total hip arthroplasty (THA) procedures performed continues to rise, the burden of revision THA procedures is also expected to increase. Proper evaluation and management of acetabular bone loss at the time of revision surgery will be an increasing challenge facing orthopaedic surgeons. Proper preoperative patient assessment and detailed preoperative planning are essential in obtaining a good clinical result. Appropriate radiographs are critical in assessing acetabular bone loss, and specific classification schemes can identify bone loss patterns and guide available treatment options. Treatment options include impaction grafting and cementation of the acetabulum, noncemented hemispheric acetabular reconstruction, structural allograft reconstruction, noncemented reconstruction with modular porous metal augments, ring and cage reconstruction, oblong cup reconstruction, cup‐cage reconstruction, and triflange reconstruction.

Prospective Results of Uncemented Tantalum Monoblock Tibia in Total Knee Arthroplasty Minimum 5-Year Follow-up in Patients Younger Than 55 Years

A significant increase in younger patients undergoing total knee arthroplasty raises the theoretical concern for revision secondary to micromotion and fixation failure with cemented components. We prospectively studied 100 consecutive tantalum monoblock uncemented tibial components and 312 concurrent cemented controls. Patients younger than 55 years with adequate bone stock were enrolled. This cementless patient group was younger and had higher preoperative functional status. Prostheses were posterior-substituting uncemented femoral and tibial components with a cemented patellar button. Knee Society pain and function scores and radiographs were obtained, and a cost analysis was performed. Knee Society scores were excellent and equivalent beyond 6 months. There was no significant difference in perioperative blood loss, complication rates, or cost. There was a significant decrease in operative time in the uncemented group. Radiographs revealed no failures of ingrowth at last follow-up. There were 3 uncemented group failures, but none were due to failure of fixation. The use of a porous tantalum tibia at minimum 5 years has yielded promising clinical and radiographic results in a younger patient population.

Modern Total Hip Arthroplasty in Patients Younger Than 21 Years

Total hip arthroplasty (THA) is not commonly performed in adolescents. However, it may be the only option for pain control with continued mobility for advanced disease. We report our experience with modern alternative-bearing THA in patients younger than 21 years. Twenty-one THAs (18 patients) were followed. Preoperative and postoperative Harris hip scores were recorded, and radiographs were reviewed. Average follow-up was 49 months (range, 25-89). Underlying etiology was chemotherapy-induced osteonecrosis (33%), steroid-induced osteonecrosis (29%), sickle cell disease (24%), and chronic dislocation (14%). Articulation bearings were ceramic/ceramic (67%), metal/highly cross-linked polyethylene (29%), and metal resurfacing (5%). Mean age was 18 years (range, 13-20). Harris hip scores improved from 43.6 to 83.6 (P < .001). At final follow-up, there was no radiographic loosening; 1 THA was revised for a cracked ceramic liner. At intermediate-term follow-up, clinical and radiographic results are favorable after alternative-bearing THA in patients younger than 21 years.

Defining Racial and Ethnic Disparities in THA and TKA

BackgroundFor minority populations in the United States, especially African Americans, Hispanics, and Native Americans, healthcare disparities are a serious problem. The literature documents racial and ethnic utilization disparities with regard to THA and TKA.Questions/purposesWe therefore (1) defined utilization disparities for total joint arthroplasty in racial and ethnic minorities, (2) delineated patient and provider factors contributing to the lower total joint arthroplasty utilization, and (3) discussed potential interventions and future research that may increase total joint arthroplasty utilization by racial and ethnic minorities.MethodsWe searched the MEDLINE database and identified 67 articles, 21 of which we excluded. By searching Google and Google Scholar and reference lists of the included articles, we identified 40 articles for this review. Utilization disparities were defined by documented lower utilization of THA or TKA in specific racial or ethnic groups.ResultsLower utilization of THA and TKA among some racial and ethnic minority groups (African Americans, Hispanics) is not explained by decreased disease prevalence or disability. At least some utilization disparities are independent of income, geographic location, education, and insurance status. Causal factors related to racial and ethnic disparities may be related in part to patient factors such as health literacy, trust, and preferences. Provider unconscious or conscious biases or beliefs also play a role in at least some healthcare disparities.ConclusionsRacial and ethnic THA and TKA utilization disparities exist. These disparities are not explained by lower disease prevalence. The existing data suggest patient education, improved health literacy regarding THA and TKA, and a patient-provider relationship leading to improved trust would be beneficial. Research providing a better understanding of the root causes of these disparities is needed.

Disparities in orthopaedic surgical intervention.

&NA; Race‐ and ethnicity‐based health disparities have been identified both in health care generally and in orthopaedics specifically. Despite this body of research, it remains unclear why these disparities exist. Research has been done on disparities in patients with cardiovascular disease and diabetes, as well as in patients who are candidates for hip or knee arthroplasty. With regard to disparities in orthopaedics, differences in the rates of total hip and knee replacement surgery have been studied the most extensively. To better understand health disparities in orthopaedics and in health care as a whole, patient‐, provider‐, and health care‐related factors must be examined more fully.

Porous tantalum patellar components in revision total knee arthroplasty minimum 5-year follow-up.

Revision total knee arthroplasty can be complicated by severe patellar bone loss, precluding the use of standard cemented patellar components. This study evaluated the midterm outcomes of porous tantalum (PT) patellar components. Twenty-three PT components were used in 6 men and 17 women (average age, 62 years). All patellae had less than 10-mm residual thickness. The PT shell was secured to host bone, and a 3-peg polyethylene component was cemented onto the shell. In 2 patients, the PT component was sutured directly to extensor mechanism. Average follow-up was 7.7 years (range, 5-10 years). At follow-up, the Knee Society scores for pain and function averaged 82.7 and 33.3, respectively, whereas the mean Oxford knee score was 32.6. Four patients underwent revision surgery. Survivorship was 19 (83%) of 23 patients. Porous tantalum patellar components can provide fixation where severe bone loss precludes the use of traditional implants. Failures were associated with avascular residual bone and fixation of components to the extensor mechanism.

Breakout session: Diversity, cultural competence, and patient trust.

BackgroundThe patient population served by orthopaedic surgeons is becoming increasingly more diverse, but this is not yet reflected in our workforce. As the cultural diversity of our patient population grows, we must be adept at communicating with patients of all backgrounds.Where Are We Now?Efforts to improve the diversity of our workforce have been successful in increasing the number of female residents, but there has been no improvement in the number of African American and Hispanic residents. There is currently no centralized effort to recruit minority and female students to the specialty of orthopaedic surgery. The American Academy of Orthopaedic Surgeons has been leading workshops to train residents and practicing surgeons in communication skills and cultural competency.Where Do We Need to Go?We must train the current generation of orthopaedic surgeons to become adept at interacting with patients of all backgrounds. While initiatives for crosscultural communication in orthopaedic surgery have been established, they have not yet been universally incorporated into residency training and Continuing Medical Education programs.How Do We Get There?We must continue to recruit the brightest students of all backgrounds, with a concerted effort to provide equal opportunities for early guidance to all trainees. Opportunities to improve diversity among orthopaedic surgeons exist at many stages in a future physician’s career path, including “shadowing” in high school and college and continuing with mentorship in medical school. Additional resources should be dedicated to teaching residents about the immediate relevancy of cultural competency, and faculty should model these proficiencies during their patient interactions.

AAOS/ORS/ABJS Musculoskeletal Healthcare Disparities Research Symposium: Editorial Comment: A Call to Arms: Eliminating Musculoskeletal Healthcare Disparities

‘‘I swear to fulfill, to the best of my ability and judgment, this covenant: ...I will apply, for the benefit of the sick, all measures [that] are required...I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug...I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.’’—The Hippocratic Oath: Modern Version [7] Providing disparate care to patients violates the very oath we have taken as physicians. Unknowingly some of us provide such care. We are not always cognizant of the complex issues that impact our ability to provide optimal care to every patient. We may have insufficient education and knowledge regarding the influence of patient characteristics on risk of disease and treatment outcomes, yet our patients need us to understand them as individuals and it is our privilege to care for them. We must constantly look for ways to improve the care we provide and the context in which we provide it. Disparities in musculoskeletal health care are farreaching and impact the lives of many of our patients today. These disparities are multifaceted and range from inadequate information in both the clinical and basic sciences to unconscious practitioner bias. Some of these gaps in knowledge lead to differential treatment by providers. Differential utilization of specific elective surgical interventions has been well documented, although it is not clear an appropriate utilization rate is known upon which assessment of true underor overutilization can be determined. As we move forward, delineation of the indications for our elective orthopaedic procedures and development of evidence-based criteria for when to perform surgery are needed. Such efforts will help us answer the question of whether specific patient groups underor overutilize a given orthopaedic procedure. An understanding of the appropriate use of procedures is critical, not just in orthopaedics but for all of medicine. However, unlike determining usage, determining ‘‘appropriate use’’ is not as straightforward as it might seem. In May 2010, the American Academy of Orthopaedic Surgery (AAOS), the Orthopaedic Research Society (ORS), and the Association of Bone and Joint Surgeons (ABJS) sponsored a research symposium to better understand musculoskeletal healthcare disparities. The symposium addressed both general musculoskeletal topics and some specific focused areas, namely osteoporosis, lower extremity arthroplasty, diabetes, amputations, and pain management. Papers from these presentations are published in this proceedings with the goal of publicizing our knowledge of these disparities and, ultimately, eliminating such inequities. During the symposium, we held breakout sessions to synthesize the material and reach M. I. O’Connor (&) Department of Orthopaedic Surgery, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224, USA e-mail: oconnor.mary@mayo.edu