Gregory G. Polkowski

Total hip arthroplasty in the very young patient.

&NA; The surgical management of end‐stage hip disease in patients aged <30 years remains a challenge. Hip‐preserving surgical procedures in the setting of advanced disease often do not provide adequate pain relief, but the implications of joint arthroplasty surgery in the very young patient are a matter of concern. The outcome of total hip arthroplasty (THA) in these patients varies, largely because of the wide spectrum of diagnoses associated with hip disease in this group, the complexity of deformities requiring THA, and the need for prolonged durability. The greatest number of THAs in this population is performed for secondary osteoarthritis or osteonecrosis, whereas most reports in the orthopaedic literature have focused on the outcomes of cemented THA in patients with juvenile rheumatoid arthritis. Given the frequent complexity of THA in the very young patient, special attention should be given to preoperative planning, implant selection, and patient education as well as to joint‐preservation techniques to facilitate future hip arthroplasty surgery.

Platelet-Rich Plasma Increases Anti-inflammatory Markers in a Human Coculture Model for Osteoarthritis

Background: Platelet-rich plasma (PRP) has anti-inflammatory effects with potential applications in the treatment of osteoarthritis (OA). Purpose: To use an in vitro coculture model of OA in human cartilage and synovium to investigate the anti-inflammatory effects of 2 different PRP preparations. Study Design: Controlled laboratory study. Methods: A coculture system was created using osteoarthritic cartilage and synovium from 9 patients undergoing total knee arthroplasty. Interleukin-1β (IL-1β) was added to each coculture to induce inflammation. Two PRP preparations were obtained—one yielding low white blood cell and platelet concentrations (PRPLP) and one yielding high platelet and white blood cell concentrations (PRPHP). Either PRPLP, PRPHP, or medium was added to the coculture wells. Control wells contained OA cartilage and synovium but neither IL-1β nor PRP. Normal, non-OA cartilage was obtained to establish baseline gene expression levels. Quantitative polymerase chain reaction was used to measure changes in markers of inflammation in the tissues (a disintegrin and metalloproteinase with thrombospondin motifs–5 [ADAMTS-5], tissue inhibitor of metalloproteinases–1 [TIMP-1], vascular endothelial growth factor [VEGF], aggrecan, and type I collagen) at 0, 24, 48, and 72 hours. Results: Treatment with PRPLP or PRPHP significantly decreased expression of TIMP-1 and ADAMTS-5 in cartilage, increased aggrecan expression in cartilage, and decreased ADAMTS-5, VEGF, and TIMP-1 expression in synovium compared with control cocultures (P < .05). There was significantly less nitric oxide production in the PRPLP and PRPHP groups compared with controls (P < .05). There were significant differences in gene expression in the normal cartilage compared with all 4 groups of OA cartilage at all 4 time points. Treatment with either PRPLP or PRPHP returned some gene expression to the same levels in normal cartilage but not for all markers of inflammation. Conclusion: This coculture model assessed 2 different PRP preparations and their anti-inflammatory effects over time on human OA cartilage and synovium. Both had a significant anti-inflammatory effect on gene expression; however, there was no difference in the anti-inflammatory effect between the 2 preparations. Clinical Relevance: Osteoarthritis is a leading cause of chronic disability, and less invasive treatment methods are needed. Study results suggest that PRP injections may be an effective alternative anti-inflammatory agent in the treatment of OA.

One-stage versus two-stage exchange.

Liaison: Paul Lichstein MD, MSLeaders: Thorsten Gehrke MD (International), Adolph Lombardi MD, FACS (US), Carlo RomanoMD (International), Ian Stockley MB, ChB, MD, FRCS (International)Delegates: George Babis MD, Jerzy Bialecki MD, La´szlo´ Bucsi MD, Xu Cai MD, Li Cao MD, Briande Beaubien MD, Johannes Erhardt MD, Stuart Goodman MD, PhD, FRCSC, FACS, FBSE,William Jiranek MD, Peter Keogh, David Lewallen MD, MS, Paul Manner MD, WojciechMarczynski MD, J. Bohannon Mason MD, Kevin Mulhall MB, MCh, FRCSI, Wayne PaproskyMD, Preetesh Patel MD, Francisco Piccaluga MD, Gregory Polkowski MD, Luis Pulido MD, IanStockley MBBS, ChB, FRCS, Juan Suarez MD, Fritz Thorey MD, Rashid Tikhilov MD, JobDiego Velazquez MD, Heinz Winkler MD

One-stage vs two-stage exchange.

Liaison: Paul Lichstein MD, MSLeaders: Thorsten Gehrke MD (International), Adolph Lombardi MD, FACS (US),Carlo Romano MD (International), Ian Stockley MB, ChB, MD, FRCS (International)Delegates: GeorgeBabisMD,JerzyBialeckiMD,LaszloBucsiMD,XuCaiMD,LiCaoMD,BriandeBeaubienMD,Johannes Erhardt MD, Stuart Goodman MD, PhD, FRCSC, FACS, FBSE, William Jiranek MD,PeterKeoghFRCSI,DavidLewallenMD,MS,PaulMannerMD,WojciechMarczynskiMD,J.BohannonMasonMD,Kevin Mulhall MB, MCh, FRCSI, Wayne Paprosky MD, Preetesh Patel MD, Francisco Piccaluga MD,Gregory Polkowski MD, Luis Pulido MD, Ian Stockley MBBS, ChB, FRCS, Juan Suarez MD, Fritz Thorey MD,Rashid Tikhilov MD, Job Diego Velazquez MD, Heinz Winkler MD

Does Standing Affect Acetabular Component Inclination and Version After THA

BackgroundAvoiding complications after hip arthroplasty with hard-on-hard bearings, especially metal-on-metal, correlates with the position of the acetabular component. Supine imaging with conventional radiography has traditionally been utilized to assess component inclination (abduction), as well as anteversion, after THA and surface replacement arthroplasty (SRA). However, most adverse events with hard bearings (excessive wear and squeaking) have occurred with loading. Standing imaging, therefore, should provide more appropriate measurements.Questions/purposesWe determined whether standing changed standard measurements of acetabular component position using a novel biplanar imaging system compared to traditional supine imaging.MethodsWe performed simultaneous biplanar standing imaging of the lower extremity with a novel imaging system using low radiation collimated beam on 46 patients who underwent THA (23) or SRA (23). Patients who had previously undergone THA had standard CT scans performed. For patients who underwent SRA, we compared acetabular inclination in the supine versus double-limb and single-limb standing.ResultsStanding anteversion differed from supine anteversion by greater than 5° for 12 of 23 patients who underwent THA (range, 5°–16°). For patients who underwent SRA, 13 of 23 patients exhibited a difference of greater than 3° in inclination between supine and double-limb standing images, and six of 23 patients exhibited a difference of greater than 3° in inclination between supine and single-limb standing images.ConclusionsStanding changed the acetabular inclination and version in a substantial percentage of patients undergoing hip arthroplasty.

Osteonecrosis of the knee - which joint preservation procedures work?

There is no consensus with respect to the best procedures to preserve the knee joint in patients with osteonecrosis of the knee. We performed a systematic review of the literature between 1999 and 2012. Only 10 of 1057 studies met our inclusion criteria. Core decompression prevented additional surgical treatment in pre-collapse knees with a failure rate of 10.4% (7 of 67 knees). Autogenous and osteochondral grafts decreased the need for additional surgery in both pre-collapse (0%, 20 of 20) and post-collapse knees (10.5%, 8 of 76 knees). Although these results are quite promising multi-center randomized trials are needed to identify the optimal procedures to treat this disease.

Screening for Deep Vein Thrombosis After Periacetabular Osteotomy in Adult Patients: Is It Necessary?

BackgroundThe periacetabular osteotomy has become a common procedure for treating symptomatic acetabular dysplasia. Like other major hip procedures, there is concern regarding the risk of associated venous thromboembolic disease. Nevertheless, there is limited information regarding the need for screening, and optimal prophylactic measures have not been established.Questions/purposesWe sought to determine the frequency of thromboembolic events (deep vein thrombosis [DVT] and symptomatic pulmonary embolism [PE]) associated with the periacetabular osteotomy in in patients receiving aspirin and mechanical compression prophylaxis.MethodsWe performed a retrospective review of 134 adult patients (149 hips) treated with the periacetabular osteotomy during an 8-year period. During this period, 136 (91%) of the hips treated with a periacetabular osteotomy were screened within 1 week for DVT, whereas 13 (9%) could not be evaluated for various reasons. The mean age of the patients at the time of surgery was 30 years (range, 18–60 years), and no patients were lost to followup during the 4 to 6 months after surgery. The same thromboembolic prophylactic regimen was used for all patients. This consisted of 325 mg aspirin twice a day and compression stockings for 6 weeks and lower extremity pneumatic compression devices while hospitalized. Screening bilateral lower extremity ultrasonography was performed within 1 week (mean, 4 days) of the procedure to detect asymptomatic DVTs.ResultsOf the 134 patients, two patients (two hips) with negative postoperative screening ultrasounds presented at 14 and 38 days postoperatively with clinical symptoms of DVT. Repeat ultrasound confirmed this diagnosis in both cases. There were no symptoms of PE. Screening venous ultrasonography did not identify any DVTs during the early postoperative period before discharge. These two patients were treated with 3 to 6 months of warfarin anticoagulation. Neither patient had persistent symptoms related to the DVT.ConclusionsThese data indicate that the risk of symptomatic DVT associated with periacetabular osteotomy is low (1%) with use of aspirin and mechanical compression prophylaxis. Furthermore, routine postoperative screening did not detect any patients with an asymptomatic DVT.Level of Evidence Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Characterizing the Acute Phase Response in Healthy Patients Following Total Joint Arthroplasty: Predictable and Consistent

BACKGROUND During surgery, trauma to musculoskeletal tissue induces a systemic reaction known as the acute phase response (APR). When excessive or prolonged, the APR has been implicated as an underlying cause of surgical complications. The purpose of this study was to determine the typical APR following total joint arthroplasty in a healthy population defined by the Charlson Comorbidity Index (CCI). METHODS This retrospective study identified 180 healthy patients (CCI < 2) who underwent total joint arthroplasty by a single surgeon for primary osteoarthritis from 2013 to 2015. Serial measurements of C-reactive protein (CRP) and fibrinogen were obtained preoperative, perioperative, and at 2 and 6 weeks postoperative. RESULTS Postoperative CRP peaked during the inpatient period and returned to baseline by 2 weeks. Fibrinogen peaked after CRP and returned to baseline by 6 weeks. Elevated preoperative CRP correlated with a more robust postoperative APR for both total hip arthroplasty and total knee arthroplasty, suggesting that a patients preoperative inflammatory state correlates with the magnitude of the postoperative APR. CONCLUSION Measurement of preoperative acute phase reactants may provide an objective means to predict a patients risk of postoperative dysregulation of the APR and complications.

Practice Management Strategies Among Current Members of the American Association of Hip and Knee Surgeons

BACKGROUND A survey was conducted at the 2015 annual meeting of the American Association of Hip and Knee Surgeons (AAHKS) to determine current practice management patterns among AAHKS members. METHODS A survey was conducted by the session moderator during the annual AAHKS meeting using an audience response system. A series of practice management issues were reviewed with AAHKS members. The survey contained multiple choice and yes and no questions. The audience responses were collected in a central database and then immediately displayed for the audience to review. RESULTS The survey responses provided interesting data on a variety of topics including: surgeon demographics, surgical activity, practice status, use of physician extenders, sources of ancillary income, the use of electronic medical records and surgeon satisfaction. Interestingly, 51% of AAHKS members remain in private practice and fee for service remains the most common form of compensation (48%). The vast majority of AAHKS members do not perform hip arthroscopy (86%) or hip preservation procedures (87%). CONCLUSION Valuable information regarding practice patterns of AAHKS members was obtained from this survey. Future surveys will need to focus on 3 areas of activity: surgeon involvement in bundled payment programs frequency of submission of patient data to a joint registry and the frequency of outpatient total joint arthroplasty.

Metal-Backed Versus All-Polyethylene Tibias in Megaprostheses of the Distal Femur

In megaprostheses, the tibial component is rarely a source of failure. The evolution of these implants has followed standard arthroplasty trends moving from majority use of all-polyethylene tibias (APT) to high volume use of metal-backed tibial (MBT) components. We report the results of 72 endoprostheses using either MBT (n = 42) or APT (n = 30) implanted between 1994 and 2006. Failures of the implant related to the tibial component were isolated, and 5-year survival of the tibial implant of the MBT cohort was 94%, and for the APT cohort, 87% (P = .39). The difference in tibial component failures between the 2 groups was not statistically significant (Pearson χ(2) = 0.1535, P = .6952). Revision rates for the entire implant and infection rates were not significantly different between the 2 groups.