Kevin I. Perry

Functional and Radiographic Outcomes Following Distal Ulna Implant Arthroplasty

PURPOSE To determine the outcome of ulnar head endoprostheses in the treatment of distal radioulnar joint instability, arthrosis, or both. METHODS We conducted a retrospective review of 47 patients to analyze the outcome of a single ulnar head replacement over a 10-year period. All patients reported pain or instability at the distal radioulnar joint. Standardized assessments included a patient-rated pain score, forearm range of motion, grip strength, and Mayo wrist score. We examined preoperative and postoperative radiographs for final implant position, loosening, and osteolysis. RESULTS We observed 47 patients for a median of 56 months (minimum, 16 mo). There was a statistically significant decrease in pain scores from 4.6 to 2.2 and improvement in the mean Mayo wrist score from 14 to 69 points after surgery. There was no significant improvement in forearm rotation and wrist function. Kaplan-Meier analysis demonstrated 83% survival at 6 years. A total of 14 patients (30%) required additional surgical procedures after primary arthroplasty. Risk factors for failure included history of previous surgery, use of an extended collar, lucency greater than 2 mm around the implant stem, and pedestal formation at the tip of the implant. CONCLUSIONS Distal ulna implant arthroplasty reduces pain and improves function in patients with distal radioulnar joint instability, arthrosis, or both.

Arthroscopic management of native shoulder septic arthritis

BACKGROUND There is little information on the results of arthroscopic treatment of native shoulder sepsis. Therefore, the purpose of this study was to determine the presentation, preoperative indices, intraoperative findings, and outcomes related to native shoulder sepsis treated with arthroscopy. MATERIALS AND METHODS We retrospectively reviewed 50 consecutive native shoulders with septic arthritis between 1994 and 2008. Patients (75% male) were an average age of 66 years. Four patients had bilateral involvement. All underwent arthroscopic irrigation and debridement. The mean follow-up was 31 months (range, 1-185 months). RESULTS Patients were immunocompromised in 57% of cases. The mean preoperative values (normal reference ranges) included white blood cell count, 13 × 10(9)/L (3.5-10.5 × 10(9)/L); erythrocyte sedimentation rate, 66 mm/h (0-29 mm/h), and C-creative protein, 83 mg/L (0-10 mg/L). The average aspiration cell count was 110,988, with a mean differential of 87% neutrophils. The most common organisms were methicillin-susceptible Staphylococcus aureus (44%). Repeat irrigation and debridement was required within the first month in 16 of 50 shoulders (32%). Within 1 year, 17% of patients had died. Final Gächter staging was I or II for 32 shoulders and III or IV for 18 shoulders. CONCLUSIONS Most patients with native shoulder sepsis are elderly and immunocompromised and present with increased inflammatory markers and a supporting aspiration cell count. Patients and surgeons must be aware that after initial arthroscopy, 1 in 3 patients will require additional surgical intervention, whether anticipated or not. LEVEL OF EVIDENCE Level IV, Case Series, Treatment Study.

Femoral considerations for total hip replacement in hip dysplasia.

THAin the dysplastic hip is a technically demanding procedure that requires careful preoperative planning. The common deformities associated with the dysplastic femur include hypoplasia, excessive neck anteversion, a valgus neck-shaft angle, metaphyseal-diaphyseal mismatch, and a posteriorly displaced greater trochanter. In selected cases, osteotomy of the femur may be performed to correct anteversion and/or avoid excessive leg lengthening and stretch of the sciatic nerve. All of these issues mandate careful preoperative planning. With the advent of modern surgical techniques and implants, the bone deformities in hip dysplasia can be successfully addressed and THA has proved to be a successful and durable operation.

Diagnosis of adverse local tissue reactions following metal-on-metal hip arthroplasty

Metal-on-metal (MOM) bearing surfaces in hip arthroplasty have distinct advantages that led to the increase in popularity in North America in the early 2000s. However, with their increased use, concerns such as local cytotoxicity and hypersensitivity reactions leading to soft tissue damage and cystic mass formation (known collectively as adverse local tissue reactions (ALTR)) became apparent. The clinical presentation of ALTR is highly variable. The diagnosis of ALTR in MOM articulations in hip arthroplasty can be challenging and a combination of clinical presentation, physical examination, implant track record, component positioning, serum metal ion levels, cross-sectional imaging, histopathologic analysis, and consideration of alternative diagnoses are essential.

Hip dysplasia in the young adult: an osteotomy solution

The treatment of hip dysplasia should be customised for patients individually based on radiographic findings, patient age, and the patients overall articular cartilage status. In many patients, restoration of hip anatomy as close to normal as possible with a PAO is the treatment of choice.

Long-Term Results After Total Knee Arthroplasty with Contemporary Rotating-Hinge Prostheses

Background: Total knee arthroplasty (TKA) with a rotating-hinge prosthesis is considered a salvage procedure. While excellent immediate stability is achieved, the historically high failure rate has tempered its use. The goal of this study was to determine clinical outcomes, radiographic results, and survivorship after TKA with contemporary rotating-hinge components. Methods: We identified 408 consecutive TKAs performed with rotating-hinge components for nononcologic indications from 2002 to 2012 at a single academic institution. Two hundred and sixty-four knees (65%) had rotating-hinge TKA components implanted for aseptic etiologies, while 144 knees (35%) were managed with the components in 2-stage reimplantation following infection. Rotating-hinge TKA implants were used for complex primary procedures in 74 knees (18%) and as a revision construct in 334 knees (82%). Clinical outcomes were assessed with the Knee Society scoring system, survivorship analyses, and cumulative incidence of revision. The mean age of the patients at the time of the index arthroplasty was 69 years, and the mean duration of follow-up was 4 years (range, 2 to 12 years). Results: At the most recent follow-up, the mean Knee Society knee score had increased from 51 points preoperatively to 81 points (p < 0.0001), and the mean Knee Society functional score had increased from 26 to 36 points (p < 0.0001). At a mean of 4 years, loosening of components was observed in 13 (3.7%) of 349 knees. At the most recent follow-up, 59 revision procedures and 25 reoperations had been performed. The cumulative incidence of any revision was 9.7% at 2 years and 22.5% at 10 years. The cumulative incidence of revision for aseptic loosening was 1.7% at 2 years and 4.5% at 10 years. Metaphyseal cones were used in 114 knees (28%). Survivorship analysis revealed a trend toward a lower risk of revision (hazard ratio [HR] = 0.69; 95% confidence interval [CI] = 0.39 to 1.22; p = 0.20) and reoperation (HR = 0.51; 95% CI = 0.22 to 1.19; p = 0.12) in patients with metaphyseal cones, despite their use in the most severe of bone defects. Conclusions: Contemporary rotating-hinge TKA implants had a low 10-year cumulative incidence of revision for aseptic loosening of 4.5%. Greater use of metaphyseal fixation has aided this improvement. Patients can expect substantial improvements in clinical outcomes with this revision strategy. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Primary Total Knee Arthroplasty After Solid Organ Transplant: Survivorship and Complications

BACKGROUND Clinical outcomes remain largely unknown beyond perioperative and short-term follow-up of solid organ transplant (SOT) patients undergoing total knee arthroplasty (TKA). METHODS Patient mortality, implant survivorship, and complications of 96 TKAs (76 patients) after SOT were retrospectively reviewed through an internal joint registry. Mean age at index arthroplasty was 66 years, and mean follow-up was 4 years. RESULTS Overall mortality rates at 1 year, 2 years, and 5 years from TKA were 2.6%, 7.9%, and 13.2%, respectively, and combined SOT patient survivorship was 92% at 2 years and 82% at 5 years. Implant survivorship free of any component revision or implant removal was 98% at 2 years and 93% at 5 years. There was a high rate of perioperative complications (12.5%), including periprosthetic fractures (5.2%) and deep periprosthetic infection (3.2%). CONCLUSION TKA does not appear to have any effect on SOT patient survivorship following the procedure. However, SOT patients may have a higher risk of perioperative complications and a lower implant survivorship than the general population of TKA patients at midterm follow-up.

Survivorship After Primary Total Hip Arthroplasty in Solid-Organ Transplant Patients

BACKGROUND Although a growing number of primary total hip arthroplasties (THAs) are being performed on solid-organ transplant (SOT) recipients, long-term patient and implant survivorships have not been well studied in contemporary transplant and arthroplasty practices. METHODS A total of 136 THAs (105 patients) with prior SOT were retrospectively reviewed from 2000 to 2013 at mean clinical follow-up of 5 years. The mean age was 59 years, with 39% being females. The most common SOT was renal (56%), followed by liver (24%). RESULTS Patient mortality was 3.8% and 13.3% at 2 and 5 years, respectively. There were 9 revisions (6.6%), including 5 (4%) for deep periprosthetic infection. Implant survivorship free of any revision was 95% and 94% at 2 and 5 years, respectively. Transplant type or surgical indication did not significantly impact patient or implant survivorship. CONCLUSION Compared with the general population, SOT patients undergoing THA have slightly higher mortality rates at 5 years. Implant survivorship free of revision was slightly lower than the general population, primarily due to an increased risk of periprosthetic joint infection.

Use of a Modular Tapered Fluted Femoral Component in Revision Total Hip Arthroplasty Following Resection of a Previously Infected Total Hip: Minimum 5-year Follow-Up

Femoral reconstruction in the setting of two stage reimplantation can be difficult and substantial reoperation rates due to implant loosening have been reported. We retrospectively reviewed 28 male and 29 female patients who underwent a two-stage reimplantation using a modular, tapered femoral stem. The mean clinical follow-up was 62 months. The mean Harris Hip score at 5-year follow-up was 76. Two stems were revised for aseptic loosening. Reinfection occurred in 16% of patients. Stem survivorship was 87% at 5-years. Use of a modular tapered stem provided a high rate of stable femoral fixation and acceptable rate of reinfection in two stage treatment of infected THA.

Orthopaedic Infection: Prevention and Diagnosis.

Host optimization, reduction of bacteria, and establishing proper wound environment in the preoperative, intraoperative, and postoperative periods are the traditional cornerstones of infection prevention. Most institutions have standardized a systems approach to reduce the incidence of surgical site infections. Typically, these systems-based approaches promote protocols for hand and environmental hygiene, patients risk assessment and screening, surgical delays for identifiable and modifiable risk factors, infection surveillance, antibiotic stewardship programs, communication/coordination of care, physician 360° reporting, and unit-based safety programs. Despite the institution of these prevention efforts, there remains controversy about the efficacy and cost-effectiveness of a number of these approaches.