Jad Bou Monsef

The value of valgus stress radiographs in the workup for medial unicompartmental arthritis.

BackgroundHigh tibial osteotomy and unicompartmental knee arthroplasty are surgical treatment options for unicompartmental knee arthritis; these procedures are indicated for patients who do not have severe arthritis in the lateral compartment. Valgus stress radiographs sometimes are used to make this evaluation, but this test has not been critically evaluated.Questions/purposesWe sought to determine (1) whether valgus stress radiographs help to evaluate the integrity of the cartilage in the lateral compartment in patients undergoing TKA for noninflammatory arthritis, and (2) whether valgus stress radiographs can identify patients whose varus deformity is correctable.MethodsWe reviewed preoperative hip-to-ankle standing radiographs, AP standing radiographs, and valgus stress radiographs of 84 patients (91 knees) who underwent TKA for varus knee arthritis between July 2010 and January 2012. Valgus stress radiographs were obtained with the patient supine with the knee 20° flexed and a firm manual valgus force was applied through the knee. On valgus stress radiographs, the lateral compartment joint space width and the corrected mechanical alignment were measured. Intraoperative cartilage assessment (Outerbridge grade) was compared with lateral compartment joint space width. Knees with mechanical leg alignment of 3° varus to 3° valgus on valgus stress radiographs were considered correctable deformities.ResultsThe lateral compartment joint space width on valgus stress radiographs did not correlate with the intraoperative Outerbridge grading of the lateral compartment cartilage (rs = −0.154; p = 0.146). The majority of knees (93%; 55 of 59) with 10° or less mechanical varus on hip-to-ankle standing radiographs were correctable within the range of 3° varus to 3° valgus.ConclusionsValgus stress radiographs provided no added benefit to the radiographic assessment of the lateral compartment cartilage and regarding the correctability of the varus deformity.Level of EvidenceLevel III, diagnostic study. See the Instructions for Authors for a complete description of levels of evidence.

The Impact of Blood Management on Length of Stay After Primary Total Knee Arthroplasty

The current study investigates the impact of patient factors, surgical factors, and blood management on postoperative length of stay (LOS) in 516 patients who underwent primary total knee arthroplasty. Age, gender, type of anticoagulation, but not body mass index (BMI) were found to be highly significant predictors of an increased LOS. Allogeneic transfusion and the number of allogeneic units significantly increased LOS, whereas donation and/or transfusion of autologous blood did not. Hemoglobin levels preoperatively until 48 hours postoperatively were negatively correlated with LOS. After adjusting for confounding factors through Poisson regression, age (p = 0.001) and allogeneic blood transfusion (p = 0.002) were the most significant determinants of LOS. Avoiding allogeneic blood plays an essential role in reducing the overall length of stay after primary total knee arthroplasty.

Achilles tendon allograft for augmentation of the Hanssen patellar bone grafting.

PurposeSevere patellar bone loss precludes the insertion of another patellar implant in revision total knee arthroplasty (TKA) and weakens the attachment of the patella to the quadriceps tendon. Hanssen described securing a tissue flap to the patellar rim allows the delivery of cancellous bone graft into the patellar bone defect. The purpose of this study is to describe the surgical technique and early clinical results of a modified Hanssen patelloplasty with an Achilles tendon allograft.MethodsThe modified technique described in three patients undergoing revision TKA aims to augment the extensor mechanism by securing an Achilles tendon allograft to the proximal part of the patellar tendon and the distal quadriceps tendon using mattress sutures. This serves to reinforce the extensor mechanism and decrease the risk of a tear of its patellar attachment. The patellar bone defect is grafted using corticocancellous bone chips.ResultsOver a 12- to 48-month follow-up, all reconstructions healed with an increase in patellar bone thickness. No patient had any extensor lag, and all patients achieved 110°–125° of flexion. The Western Ontario and McMaster University knee scores improved from 53 (23–88) preoperatively to 88.5 (66–100) at last follow-up, with no reported complications.ConclusionsAugmentation of the extensor mechanism with an Achilles tendon allows for early mobilization and excellent postoperative range of motion in patients with large patella bone defects and imminent patella fracture.Level of evidenceIV.

Hypotensive Anesthesia may Result in False Anemia and Increase Transfusion Requirements in Total Hip Arthroplasty

Background: Deliberate hypotension under spinal or epidural anesthesia is a readily available and effective method to reduce intraoperative blood loss in total hip arthroplasty. However, induced hypotension has been shown to alter the physiologic handling of crystalloid solutions, with blood volume increasing in proportion to the drop in blood pressure. This study aims to investigate the effect of hemodilution secondary to hypotensive anesthesia and volume loading on postoperative hemoglobin levels. Methods: 211 non-anemic adult patients who underwent primary total hip arthroplasty utilizing a minimal invasive posterior approach with hypotensive spinal-epidural anesthesia were evaluated retrospectively. The effect of fluid loading under hypotensive anesthesia was investigated by calculating the blood loss that corresponds to patients’ preoperative and postoperative hemoglobin levels, as well as calculating the hemoglobin levels expected for known volumes of blood loss. Results: There was a large discrepancy between the calculated blood loss (1358 mL) and the actual measured blood loss (212 mL). Patients received an average of 4488 (SD 1209) mL of intravenous fluid within 24 hours of surgery. There was also a large difference between the calculated hemoglobin level based on the measured blood loss (13.6 g/dL) and the actual measured mean hemoglobin (10.8 g/dL). Conclusion: Blood volume expansion and hemodilution with hypotensive epidural anesthesia leads to decreased hemoglobin levels in the early postoperative period and likely impacts on transfusion requirements. Hypotensive anesthesia might have a detrimental effect on transfusion requirements in procedures with relatively low blood loss.

Management of Blood Products in Orthopedic Surgery

Major orthopedic procedures entail significant blood loss in patient groups with high prevalence of anemia. The vital role of allogeneic blood is widely established in managing life-threatening blood loss. However, the safety profile of such transfusions is still far from perfect. Various perioperative modalities have proven capable of minimizing or even eliminating transfusion requirements in elective orthopedic procedures. Perioperative blood management is a multimodal planned approach to patient care. It should be regarded as the standard of care in elective orthopedic procedures.

Optimal management of perioperative anemia: current perspectives

Anemia is prevalent in surgical patients and is associated with increased morbidity and mortality. Allogeneic blood transfusions have long been the first choice in addressing the perioperative anemia in surgical patients. Such transfusions have been shown to adversely influ - ence clinical outcome, prolong hospital stay, and increase complications and costs. Evidence of benefit from red blood cell (RBC) transfusion is hard to find, and most benefit from RBC transfusion is assumed and not scientifically proven. As such, perioperative anemia bears a significant clinical and economic impact on the health care landscape. Blood management relies on sustainable and cost-efficient interventions individualized to each patient and risk level. Restrictive transfusion triggers coupled to a multimodal strategy for reducing blood loss should be adopted as the standard of care in surgical patients. The approach aims at optimizing patient preoperative status and RBC stock as well as minimizing perioperative blood loss.