Jeffery L. Pierson

A Blood-Conservation Algorithm to Reduce Blood Transfusions After Total Hip and Knee Arthroplasty

BACKGROUND Donation of autologous blood before total joint arthroplasty is inconvenient and costly, causes a phlebotomy-induced anemia, and may be wasteful and unnecessary for the nonanemic patient. We developed a blood-conservation algorithm that does not require predonation of autologous blood, employs selective use of epoetin alfa, and uses evidence-based transfusion criteria. Our hypothesis was that use of this algorithm would reduce the rate of transfusion after unilateral total hip and knee arthroplasty as compared with the rates described in previous reports. METHODS We retrospectively reviewed the records of 500 consecutive patients in whom unilateral primary total hip or knee arthroplasty had been performed by a single surgeon. The same blood-conservation algorithm was recommended to all patients. Two groups of patients were identified: the first group consisted of 433 patients in whom the algorithm was followed, and the second group consisted of sixty-seven patients in whom the algorithm was not followed. RESULTS In the group in which the algorithm was followed, the rates of allogeneic transfusion after total knee and total hip arthroplasty were 1.4% (three of 220) and 2.8% (six of 213), respectively. The overall rate of transfusion in this group was only 2.1% (nine of 433). The prevalence of transfusion in the group in which the algorithm was not followed was 16.4% (eleven of sixty-seven). This difference was significant (p = 0.0001). CONCLUSIONS The use of this blood-conservation algorithm resulted in a significant reduction in the need for allogeneic blood transfusions after unilateral total hip and knee arthroplasty, and the results compare favorably with the rates of transfusion described in previous reports.

Brake Response Time After Total Knee Arthroplasty When Is it Safe for Patients to Drive

Total knee arthroplasty (TKA) dramatically decreases pain and improves mobility and quality of life. However, little has been reported on its effect on driving ability in the early postoperative period. This prospective study was conducted to compare preoperative and postoperative brake response times (BRTs) in patients undergoing TKA for osteoarthritis. The results showed that patients returned to preoperative BRT as early as 3 weeks after surgery, and at 9 weeks after surgery, BRTs were significantly improved over baseline. Based on BRT analysis patients undergoing TKA may be allowed to return to driving 6 weeks after surgery.

The Effect of Stuffing the Patellofemoral Compartment on the Outcome of Total Knee Arthroplasty

BACKGROUND The effect of so-called stuffing of the patellofemoral compartment at the time of total knee arthroplasty (that is, increasing the anterior patellar displacement, the anteroposterior femoral size, or the combined anteroposterior patellofemoral size) has not been well studied. The purpose of the present study was to evaluate the effect of stuffing the patellofemoral compartment on the outcome of primary total knee arthroplasty. METHODS A retrospective review of 1100 primary total knee arthroplasties that had been performed in 1997 and 1998 was conducted. Eight hundred and thirty arthroplasties (75.5%) met the diagnostic and minimum two-year follow-up criteria for inclusion in this report. Radiographic measurements were made to determine preoperative and postoperative anterior patellar displacement, anteroposterior femoral size, combined anteroposterior patellofemoral size, anterior femoral offset, and posterior femoral offset. Regression analysis was performed to determine the effects of changes in these variables on the range of motion, the Knee Society Knee Score, the Knee Society Function Score, the Knee Society Pain Score, and the rate of lateral retinacular release. RESULTS Preoperative to postoperative changes in anterior patellar displacement, anteroposterior femoral size, combined anteroposterior patellofemoral size, anterior femoral offset, and posterior femoral offset had no clinically meaningful effect on the range of motion of the knee or on any of the Knee Society scores. Increases in anterior patellar displacement were associated with a lower probability of the need for a lateral retinacular release. Increases in measured anteroposterior femoral size were associated with a higher probability of the need for lateral release. Even when combined, however, these relationships explained only 10.1% of the observed variance in the need for lateral retinacular release. Moreover, analyses indicated that patient gender, large as opposed to medium patellar size, and absolute femoral component size influenced the likelihood of lateral release more than did anterior patellar displacement and measured anteroposterior femoral size. CONCLUSIONS Our findings do not support the widely held belief that stuffing of the patellofemoral joint results in adverse outcomes after total knee arthroplasty. Furthermore, the need for lateral release appears to be multifactorial and likely involves a more complex set of factors. Thus, without evidence of other identifiable causes of failure, we do not recommend revision for the treatment of pain of an overstuffed knee joint.

Failure mechanisms of total hip resurfacing: implications for the present.

In the past decade, there has been a renewed interest in hip resurfacing due to recent design improvements. It is unclear whether the recent improvements have accounted for all of the previous failure mechanisms. We determined the long-term performance of hip resurfacing, while paying special attention to the mechanisms of failure. We retrospectively reviewed 62 patients (65 hips) who had Indiana conservative hip prostheses implanted between 1977 and 1981. Forty-one of 62 joints had failed, representing a failure rate of 66%. The time to failure averaged 9.7 years with a range of 6 months to 21.5 years. There were 23 femoral failures (37%). Eleven were caused by femoral fracture, and 12 were caused by femoral loosening. All late femoral failures (greater than 10 years postoperatively) showed narrowing of the femoral neck secondary to stress shielding. There were 18 acetabular failures (29%) with 10 failing secondary to polyethylene wear and eight failing secondary to acetabular loosening. Failure of the Indiana conservative hip prosthesis continues over time related to femoral and acetabular failure mechanisms. These data should be considered in the context of growing enthusiasm for resurfacing with new bearing surfaces and cementless fixation.Level of Evidence: Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.

Effect of improved cementing techniques on the longevity of fixation in revision cemented femoral arthroplasties. Average 8.8-year follow-up period.

Forty-six revision cemented femoral arthroplasties in which second-generation cementing techniques were used have been reviewed. After an average follow-up period of 8.8 years, 91% of the femoral components remained in place and 87% remained well fixed. Only 7% were rerevised for aseptic loosening. These results demonstrate a marked improvement over those of first-generation cementing techniques.

Cemented revision for femoral osteolysis in cemented arthroplasties. Results in 29 hips after a mean 8.5-year follow-up

We reviewed 29 consecutive patients after cemented femoral revision of cemented hip arthroplasties for osteolysis. After an average follow-up of 8.5 years, osteolysis had recurred in only two cases (6.9%) and 25 femoral components (86%) remained well fixed.

Extensive osteolysis behind an acetabular component that was well fixed with cement. A case report.

Extensive lysis of bone has been reported to occur around loose femoral components that had been inserted with and without cement5’4’7’92533 37, loose acetabular components that had been inserted with cement55 , and, more recently, loose acetabular components that had been inserted without cement5. Focal osteolysis also has been reported around well fixed fernoral components, inserted with cement5 and without cement4. These osteolytic granulomatous processes are widely considered to be the result of a foreign-body reaction to particulate debris. This process may be associated with metallic :i s polyrnethylmethacrylate7---37. or polyethylene ’5 I’.:. :s.su. debris of appropriate size and amount. although polyethylene debris is generally considered to be the most damaging of the three. We report the case of a patient who had extensive osteolysis behind a well fixed acetahular component that had been inserted with cement. There was histological evidence indicating that the lysis was probably caused by particulate polyethylene debris.

Functional outcomes of simultaneous bilateral versus unilateral total knee arthroplasty.

Many patients in need of total knee arthroplasty (TKA) have bilateral symptoms and require surgery to both extremities. Performance of a bilateral procedure under a single anesthetic provides a reduced hospitalization time, an isolated anesthesia risk, a single rehabilitation, and substantial cost savings. While most current research examines postoperative complication rates, the primary purpose of TKA is the alleviation of pain and improved quality of life. The purpose of this study was to assess pain and functional outcomes associated with simultaneous bilateral TKA. The authors believe that patients with advanced destructive arthritis to numerous joints cannot achieve complete restoration of their functional status until comprehensive treatment of their disease process occurs. A retrospective review of 697 TKAs in 511 consecutive patients with bilateral knee arthritis was performed. Patients underwent either simultaneous bilateral TKA (n=186), performed sequentially under the same anesthetic, or unilateral TKA (n=325). The same intra- and postoperative protocols were followed in each group. There was no statistically significant difference in postoperative pain, represented by Knee Society Score (P=.161). However, there was a significantly higher postoperative functional outcomes-including increased total range of motion (P=.001), flexion (P=.003), and function score (P<.001)-associated with bilateral TKA. Simultaneous bilateral TKA is an effective treatment option and may be worth possible added risk in appropriate patients because it produces a better functional outcome.

The Effect of Taper Angle and Spline Geometry on the Initial Stability of Tapered, Splined Modular Titanium Stems

Design parameters affecting initial mechanical stability of tapered, splined modular titanium stems (TSMTSs) are not well understood. Furthermore, there is considerable variability in contemporary designs. We asked if spline geometry and stem taper angle could be optimized in TSMTS to improve mechanical stability to resist axial subsidence and increase torsional stability. Initial stability was quantified with stems of varied taper angle and spline geometry implanted in a foam model replicating 2cm diaphyseal engagement. Increased taper angle and a broad spline geometry exhibited significantly greater axial stability (+21%-269%) than other design combinations. Neither taper angle nor spline geometry significantly altered initial torsional stability.