Jill Jasperson Branson

Minimal-incision total hip arthroplasty.

The concept of minimally invasive total joint arthroplasty has recently received enormous attention from a variety of sources. The interest in this subject was clearly evident at the 2003 Annual Meeting of the American Academy of Orthopaedic Surgeons, with numerous technical exhibits, scientific exhibits1, paper presentations2,3, and symposia4,5 making reference to minimally invasive approaches to joint replacement surgery. Whether this represents the future of orthopaedic surgery or is just a fad is unclear, as a true definition of the term minimally invasive has not been established. The purpose of this study is to present our experience with total hip arthroplasty performed through a minimal incision. We retrospectively studied the results of 170 total hip arthroplasties performed by the senior author during a one-year time period. Eighty-five hips in seventy-six patients were operated on with use of a minimal-incision total hip arthroplasty technique (the minimal-incision group). These hips were compared with eighty-five hips in seventy-eight patients who had a total hip arthroplasty with a standard-length-incision technique (the standard-incision group). The length of the incision was determined by the surgeon at the time of the operation, generally on the basis of the patients body habitus. Demographic data for each patient group are presented in Table I. View this table: TABLE I Demographic Data ### Preoperative Blood Product Protocol If there were no contraindications preoperatively, all patients scheduled for unilateral total hip arthroplasty donated one or two units of autologous blood and individuals scheduled for bilateral total hip arthroplasty donated three units of autologous blood. The preoperative hemoglobin level was determined after all units had been donated. ### Operative Technique For the standard-incision technique, a posterolateral approach to the hip was performed with use of a standard-length (12 to 24-in [30 to 61-cm]) curved incision. The minimal-incision technique is begun with an incision 2 cm posterior …

Prevalence of Dislocation After Total Hip Arthroplasty Through a Posterolateral Approach with Partial Capsulotomy and Capsulorrhaphy

Abstract The senior author altered his surgical technique during total hip arthroplasty from capsulectomy and capsulotomy with closure of the external rotator muscles to capsulotomy and capsulorrhaphy. One thousand patients (500 treated with each procedure) were studied retrospectively in order to determine the prevalences of dislocation after surgery with the two different techniques. The prevalence of dislocation was 2.8% after the capsulectomy and capsulotomy, whereas it was 0.6% after the new technique; this was a significant decrease in the rate of dislocation (p < 0.005, = 0.10).

Posterior-lateral approach to minimal incision total hip arthroplasty

As surgeons learn to perform minimally invasive hip arthroplasty procedures, the various techniques will evolve and one or two approaches may eventually become the standard. Currently, most of these procedures are reserved for the nonmorbidly obese patients; however, as techniques are perfected and surgeons gain experience, this patient population may eventually be served. Surgeons must present information to patients in a responsible manner and clarify the actual versus perceived advantages of the MITH. It is unfortunate that some patients may abandon an experienced surgeon (who will likely give an excellent long-term clinical outcome) for an inexperienced surgeon who can provide a smaller incision (with long-term benefits thus far unknown). Surgeons must also address the same comorbidities and complications for MITH arthroplasty as with the conventional approaches such as DVT, fat embolism, pain control, and wound healing. Routines for postoperative care and screening for complications must remain within the plan of care for the standard incision and MITH patient.information to patients in a responsible manner and clarify the actual versus perceived advantages of the MITH. It is unfortunate that some patients may abandon an experienced surgeon (who will likely give an excellent long-term clinical outcome) for an inexperienced surgeon who can provide a smaller incision (with long-term benefits thus far unknown). Surgeons must also address the same comorbidities and complications for MITH arthroplasty as with the conventional approaches such as DVT, fat embolism, pain control, and wound healing. Routines for postoperative care and screening for complications must remain within the plan of care for the standard incision and MITH patient.

Why posterior cruciate-retaining and substituting total knee replacements have similar ranges of motion. The importance of posterior condylar offset and cleanout of posterior condylar space.

Introduction luoroscopic studies of cruciate-retaining total knee replacements have shown paradoxical anterior slide in flexion. Without rollback, the tibial component may impinge earlier on the posterior part of the femur. Cruciateretaining and cruciate-sacrificing total knee replacements have been reported to have similar ranges of motion. It is possible that the position and function of the tibial post that substitutes for the posterior cruciate ligament in the cruciatesacrificing implant may not optimize rollback enough to create a clinically important difference between these two designs. Recent newer high-flexion knee designs have moved the post posteriorly and extended the available posterior condylar surface proximally for greater articulation in flexion. These designs may demonstrate a larger flexion difference in the future. With modern implant designs, which began with the cementless porous-coated cruciate-retaining components, less posterior condylar bone was resected than was the case with early condylar implants. Removal of less bone was a result of new instrumentation that was based on a measured resection. The maintenance of posterior bone created a larger posterior offset. Offset is measured by the distance between the apex of the posterior condyle surface and the cortex of the posterior metaphysis (Fig. 1). F

Primary total hip arthroplasty

TOTAL HIP ARTHROPLASTY (THA) has been proven to decrease a patients pain and improve function and quality of life. This procedure has been performed in the United States since 1960. Follow-up data suggest long-term success with a decreasing rate of complications and low rate of revision. MORE THAN 168,000 THA procedures are performed in the United States every year. There is an 80% chance these hip replacements will last at least 20 years. CURRENT IMPROVEMENTS in hip designs, surgical techniques, fixation methods, prophylactic therapies, preadmission education, and rehabilitation have contributed to improved patient outcomes.

Modular Femoral Component for Conversion of Previous Hip Surgery in Total Hip Arthroplasty

The conversion of previous hip surgery to total hip arthroplasty creates a durable construct that is anatomically accurate. Most femoral components with either cemented or cementless design have a fixed tapered proximal shape. The proximal femoral anatomy is changed due to previous hip surgery for fixation of an intertrochanteric hip fracture, proximal femoral osteotomy, or a fibular allograft for avascular necrosis. The modular S-ROM (DePuy Orthopaedics Inc., Warsaw, Ind) hip stem accommodates these issues and independently prepares the proximal and distal portion of the femur. In preparation and implantation, the S-ROM hip stem creates less hoop stresses on potentially fragile stress risers from screws and thin bone. The S-ROM hip stem also prepares a previously distorted anatomy by milling through cortical bone that can occlude the femoral medullar canals and recreate proper femoral anteversion and reduces the risk of intraoperative or postoperative periprosthetic fracture due to the flexible titanium-slotted stem. The S-ROM femoral stem is recommended for challenging total hip reconstructions.

Leg length inequality in total hip arthroplasty.

Postoperative leg length inequality after total hip arthroplasty frequently leads to medical liability issues because no standard exists regarding the acceptable disparity. Modular stems allow control of offset, independent sizing of the distal femoral anatomy, as well as proximal medullary sizing. The authors compared the restoration of leg length in two cohort protocols. In the 2001 cohort, tapered stems were exclusively used, giving priority to fit and fill of the medullary canal. In the 2004 cohort, porous-tapered stems, or an S-ROM modular stem (DePuy Orthopaedics Inc., Warsaw, Ind) when needed, were used based on preoperative templating to restore the center of femoral head rotation. Prior to and after surgery, length from center measurements were taken (center of rotation of the femoral head to the top of the lesser trochanter) and the vertical vector to compare the difference in actual leg length. In the 2001 cohort, the mean increase of length from center was 9 mm (7 mm leg length). In the 2004 cohort, 25% of the hips were inappropriate for tapered stems. S-ROMs were used because a tapered stem would lengthen the leg. In the standard offset tapered stem, the mean increase of length from center was 6 mm (4 mm leg length). In the high offset tapered stem, the mean increase of length from center was 7 mm (5 mm leg length). In the S-ROM stem with varying offsets, the mean increase of length from center was 6 mm (4 mm leg length). Only the S-ROM consistently avoids overlengthening in the majority of patients.

Comparison of Patient Satisfaction With Incision Cosmesis After Standard and Minimally Invasive Total Hip Arthroplasty

This study evaluated patient assessments and attitudes regarding incision cosmesis following standard and minimally invasive total hip arthroplasty 1 to 3 years postoperatively. A cosmesis questionnaire designed to elicit a score evaluating scar satisfaction was mailed to patients. Although the difference in total cosmesis score between the standard and minimally invasive groups was not statistically significant, patients with a standard incision had better scores at <1 year. One significant finding was worse responses in the minimal incision patients regarding sinking and curling of scar edges.

Sequential Bilateral Total Knee Arthroplasty

As the senior citizen population has grown, the incidence of osteoarthritis and joint replacement has increased. Bilateral total knee arthroplasty (BTKA) can be performed sequentially during one anesthetic. Studies have shown the complication rates differ only slightly for total knee arthroplasty procedures performed sequentially during one anesthetic or separately requiring two hospitalizations. With the use of staggered tourniquet deflation times, efficient OR time and motion techniques, and careful postoperative management, patients can achieve successful outcomes after BTKA during one anesthetic.

Stress over the anterior aspect of the knee with kneeling.

Many patients inquire if they will be able to kneel after total knee arthroplasty. We have cautioned patients regarding issues related to the patella that are associated with kneeling, yet, despite discomfort, many continue to kneel during various activities around the home or for religious reasons. While new high-flexion knee implant designs allow patients to get lower to the ground, the acts of cleaning a floor, gardening, exercising, and kneeling in prayer require bending down on both knees, and patients often state that they cannot kneel after total knee arthroplasty because of pain or that they do not attempt to kneel because the position feels awkward. Kneeling is part of daily life in certain cultures and, as elderly patients are more active, it is becoming an activity of increasing interest. Kneeling can be divided into three positions: kneeling at <90° (for example, while praying on a riser in a place of worship), kneeling at 90° (for example, while gardening or scrubbing a floor), and kneeling at full flexion (for example, while praying on the floor). Several studies1,2 have evaluated mechanical foot stresses to improve footwear design and comfort. The Apex Harris Mat (Aetrex, Teaneck, New Jersey) captures a dynamic pressure print of the foot, with areas of highest pressure clearly identified. When a load is applied to the mat, ink will be deposited at the locations of highest pressure because all layers of the mat are compressed by the applied load. This information can be used to prevent harmful in-shoe conditions and can allow clinicians to provide better health care for patients with peripheral neuropathies1. We applied this technology to healthy volunteers and patients to determine high-stress areas during kneeling and created a pressure imprint of the knee that we called a kneelprint. We hypothesized …