Pamela A. Pulido

Press-fit condylar design total knee arthroplasty. Fourteen to seventeen-year follow-up.

BACKGROUND The Press-Fit Condylar total knee arthroplasty implant design has been used by many orthopaedic surgeons over the last twenty years. The design has survived with relatively minor modifications and remains a popular implant system today. The present study represents the fourteen to seventeen-year results for our patients who were described in our previous report on the eight to ten-year results. METHODS The senior author performed 160 consecutive total knee arthroplasties with use of the Press-Fit Condylar cruciate-retaining device in 134 patients between 1986 and 1989. The mean age of the patients at the time of the index procedure was 70.5 years. Follow-up data were available for sixty-three of sixty-four surviving knees. Surviving patients were followed for a mean of 15.8 years. The knees were evaluated on the basis of Knee Society function and clinical scores, radiographs, and survivorship analysis. RESULTS The mean Knee Society function score was 65, and the mean clinical score was 89. The overall survival rate of the knee was 91.5% with revision for any reason as the end point and 97.2% with aseptic loosening as the end point. The rate of revision of the tibial insert because of wear-related aseptic loosening was 2.5%. We found no relationship between revision and the shelf life or method of sterilization of the polyethylene insert. Radiolucent lines were present in 62% (twenty-one) of thirty-four knees; all radiolucent lines were nonprogressive. None of the implants were loose according to the criteria of the Knee Society. CONCLUSIONS This long-term analysis indicates that the Press-Fit Condylar total knee implant is a successful implant system with excellent longevity.

A mobile compression device for thrombosis prevention in hip and knee arthroplasty.

BACKGROUND Venous thromboembolic events, either deep venous thrombosis or pulmonary embolism, are important complications in patients undergoing knee or hip arthroplasty. The purpose of this study was to evaluate the effectiveness of a mobile compression device (ActiveCare+S.F.T.) with or without aspirin compared with current pharmacological protocols for prophylaxis against venous thromboembolism in patients undergoing elective primary unilateral arthroplasty of a lower-extremity joint. METHODS A multicenter registry was established to capture the rate of symptomatic venous thromboembolic events following primary knee arthroplasty (1551 patients) or hip arthroplasty (1509 patients) from ten sites. All patients were eighteen years of age or older with no known history of venous thromboembolism, coagulation disorder, or solid tumor. Use of the compression device began perioperatively and continued for a minimum of ten days. Patients with symptoms of deep venous thrombosis or pulmonary embolism underwent duplex ultrasonography and/or spiral computed tomography. All patients were evaluated at three months postoperatively to document any evidence of deep venous thrombosis or pulmonary embolism. RESULTS Of 3060 patients, twenty-eight (0.92%) had venous thromboembolism (twenty distal deep venous thrombi, three proximal deep venous thrombi, and five pulmonary emboli). One death occurred, with no autopsy performed. Symptomatic venous thromboembolic rates observed in patients who had an arthroplasty of a lower-extremity joint using the mobile compression device were noninferior (not worse than), at a margin of 1.0%, to the rates reported for pharmacological prophylaxis, including warfarin, enoxaparin, rivaroxaban, and dabigatran, except in the knee arthroplasty group, in which the mobile compression device fell short of the rate reported for rivaroxaban by 0.06%. CONCLUSIONS Use of the mobile compression device with or without aspirin for patients undergoing arthroplasty of a lower-extremity joint provides a noninferior risk for the development of venous thromboembolism compared with current pharmacological protocols.

Fresh Osteochondral Allograft Transplantation for Isolated Patellar Cartilage Injury

Background: The treatment of patellofemoral cartilage injuries can be challenging. Osteochondral allograft (OCA) transplantation has been used as a treatment option for a range of cartilage disorders. Purpose: To evaluate functional outcomes and survivorship of the grafts among patients who underwent OCA for patellar cartilage injuries. Study Design: Case series; Level of evidence, 4. Methods: An institutional review board–approved OCA database was used to identify 27 patients (28 knees) who underwent isolated OCA transplantation of the patella between 1983 and 2010. All patients had a minimum 2-year follow-up. The mean age of the patients was 33.7 years (range, 14-64 years); 54% were female. Twenty-six (92.9%) knees had previous surgery (mean, 3.2 procedures; range, 1-10 procedures). The mean allograft area was 10.1 cm2 (range, 4.0-18.0 cm2). Patients returned for clinical evaluation or were contacted via telephone for follow-up. The number and type of reoperations were assessed. Any reoperation resulting in removal of the allograft was considered a failure of the OCA transplantation. Patients were evaluated pre- and postoperatively using the modified Merle d’Aubigné-Postel (18-point) scale, the International Knee Documentation Committee (IKDC) pain, function, and total scores, and the Knee Society function (KS-F) score. Patient satisfaction was assessed at latest follow-up. Results: Seventeen of the 28 knees (60.7%) had further surgery after the OCA transplantation; 8 of the 28 knees (28.6%) were considered OCA failures (4 conversions to total knee arthroplasty, 2 conversions to patellofemoral knee arthroplasty, 1 revision OCA, 1 patellectomy). Patellar allografting survivorship was 78.1% at 5 and 10 years and 55.8% at 15 years. Among the 20 knees (71.4%) with grafts in situ, the mean follow-up duration was 9.7 years (range, 1.8-30.1 years). Pain and function improved from the preoperative visit to latest follow-up, and 89% of patients were extremely satisfied or satisfied with the results of the OCA transplantation. Conclusion: OCA transplantation was successful as a salvage treatment procedure for cartilage injuries of the patella.

In vivo changes after mechanical injury.

Chondrocytes undergo apoptosis in response to mechanical injury in vitro. The current clinical study correlates arthroscopic and magnetic resonance imaging results with biopsy specimens of cartilage from patients with knee injury. Twenty patients were evaluated at a mean 2.7 months after acute knee injury. The mean age of the patients was 32 years and the mean weight was 83 kg. Cartilage lesions were graded separately on magnetic resonance images and arthroscopy in a blinded manner. During arthroscopy, a 1.8 mm diameter biopsy specimen was obtained from the edge of cartilage lesion. The biopsy specimen underwent histologic examination by safranin O staining and detection of chondrocyte apoptosis by the presence of deoxyribonucleic acid fragmentation. There was a positive correlation in 50% (10 of 20) when the presence or absence of cartilage lesions by magnetic resonance imaging was correlated with arthroscopy. All cases of partial thickness or full-thickness cartilage loss that were seen by arthroscopy also were detected by magnetic resonance images. Apoptotic cells were significantly more numerous in biopsy specimens from lesions compared with control biopsy specimens. The findings of reduced cell viability attributable to apoptosis may have profound implications for cartilage repair. This opens potential therapeutic avenues for the treatment of posttraumatic cartilage lesions through apoptosis prevention.

Portable Compression Device and Low-Molecular-Weight Heparin Compared With Low-Molecular-Weight Heparin for Thromboprophylaxis After Total Joint Arthroplasty

This preliminary prospective study to determine the rate of deep venous thrombosis (DVT) examined 277 patients undergoing total knee or total hip arthroplasty (TKA or THA) who were randomized to use a portable, continuous enhanced circulation therapy (CECT) compression device and low-molecular-weight heparin (LMWH) or to receive LMWH alone. Patients were screened for DVT using duplex ultrasound at hospital discharge and followed clinically for 3 months. In TKA, 5 DVTs (6.6%) occurred in the CECT + LMWH group compared with one pulmonary embolism and 14 DVTs (19.5%) in the LMWH group (P = .018). In THA, 1 DVT (1.5%) occurred in the CECT + LMWH group and 2 DVTs (3.4%) occurred in the LMWH group. This preliminary study demonstrated significant reduction in rate of DVT after TKA when the CECT device was combined with LMWH.

Fresh Osteochondral Allografts in the Knee Comparison of Primary Transplantation Versus Transplantation After Failure of Previous Subchondral Marrow Stimulation

Background: In most treatment algorithms, osteochondral allograft (OCA) transplantation is regarded as an alternative salvage procedure when other, previous reparative treatments have failed. Purpose: To compare the outcomes of a retrospective matched-pair cohort of (1) primary OCA transplantation and (2) OCA transplantation after failure of previous subchondral marrow stimulation. Study Design: Cohort study; Level of evidence, 3. Methods: An OCA database was used to identify 46 knees that had OCA transplantation performed as a primary treatment (group 1) and 46 knees that underwent OCA transplantation after failure of previous subchondral marrow stimulation (group 2). All patients had a minimum of 2 years’ follow-up. Patients in each group were matched for age (±5 years), diagnosis (osteochondral lesion, degenerative chondral lesion, traumatic chondral injury), and graft size (small, <5 cm2; medium, 5-10 cm2; large, >10 cm2). The groups had similar body mass indexes, sex distributions, and graft locations (femoral condyle, patella, and trochlea. The number and type of further surgeries after the OCA transplantation were assessed; failure was defined as any reoperation resulting in removal of the graft. Functional outcomes were evaluated by use of the modified Merle d’Aubigné-Postel (18-point) scale, International Knee Documentation Committee (IKDC) subjective knee evaluation form, Knee injury and Osteoarthritis Outcomes Score (KOOS), and the Knee Society function (KS-F) scale. Patient satisfaction, according to a 5-point scale from “extremely satisfied” to “dissatisfied,” was recorded at the latest follow-up. Results: Eleven of 46 knees (24%) in group 1 had reoperations, compared with 20 of 46 knees (44%) in group 2 (P = .04). The OCA was classified as a failure in 5 knees (11%) in group 1 and 7 knees (15%) in group 2 (P = .53). At 10 years of follow-up, survivorship of the graft was 87.4% and 86% in groups 1 and 2, respectively. Both groups showed improvement in pain and function on all subjective scores from preoperatively to the latest follow-up (all P < .001). Results showed that 87% of patients in group 1 and 97% in group 2 were “satisfied” or “extremely satisfied” with the OCA transplantation. Conclusion: Favorable results were shown in both groups with significant improvement of functional scores and excellent survivorship. Despite the higher reoperation rate in the previously treated group, previous subchondral marrow stimulation did not adversely affect the survivorship and functional outcome of OCA transplantation.

Fifteen-Year to Twenty-Year Results of Cementless Harris-Galante Porous Femoral and Harris-Galante Porous I and II Acetabular Components

This study examined long-term survivorship of primary total hip arthroplasty (THA) using cementless Harris-Galante porous femoral and Harris-Galante porous I or II acetabular components. Of 113 hips (101 patients) studied, 60 hips (53 patients) were available for follow-up at a mean of 17.2 years after surgery. A total of 10 hips had documented revision, and 2 hips had failed radiographically. The average Harris hip score was 82. Radiographically, 12 hips demonstrated eccentric wear, 8 had osteolysis, and 1 had a broken tine. The overall survival rate was 87.7%; the mean volumetric wear rate was 74.96 mm(3); and the mean polyethylene linear penetration rate was 0.153 mm/y, similar to that of well-cemented THA in other series. This long-term outcome for an early-generation cementless THA is promising and provides a standard by which to judge the newer generation of cementless implants.

The efficacy of continuous bupivacaine infiltration following arthroscopic rotator cuff repair.

PURPOSE This prospective, randomized, double-blind study with a placebo group and 2 experimental groups evaluated the efficacy of continuous low-dose bupivacaine infiltration by infusion pump after arthroscopic rotator cuff repair. METHODS Sixty patients undergoing arthroscopic rotator cuff repair received a bolus injection in the subacromial space of 35 mL of 0.25% bupivacaine with 1:200,000 epinephrine at surgical closure and were randomized to 1 of 3 groups: 0.25% bupivacaine at 2 mL/hr (n = 20), 0.25% bupivacaine at 5 mL/hr (n = 20), or saline at 5 mL/hr (n = 20) via infusion pump into the subacromial space. Pain was evaluated using the visual analog scale (VAS) and narcotic consumption was measured until 48 hours after surgery and converted to dose equivalents (DE). RESULTS Sixty patients used the infusion pump for a mean of 43.9 hours (range, 15.50 to 50.75 hrs). Mean total narcotic consumption, expressed in DEs, was 2.24 for the 2-mL group, 3.52 for the 5-mL group, and 2.32 for the placebo group. Mean pain score was 2.9 for the 2-mL group, 3.6 for the 5-mL group, and 3.3 for the placebo group. There were no differences in operating room time or infusion pump use time among groups. The 2-mL group had a nonsignificant trend toward less pain and lower narcotic consumption. The 5-mL group evidenced a nonsignificant trend toward more pain and higher narcotic consumption. CONCLUSIONS This study neither supports nor refutes the use of infusion pumps. We hypothesized that the placebo group would experience greater pain than the 5-mL group; however, a nonsignificant trend toward the contrary occurred. A trend toward less pain in the 2-mL group was not significant. LEVEL OF EVIDENCE Level II, randomized controlled trial of therapeutic treatment that lacks statistical significance and narrow confidence intervals.

Osteochondral Allograft Transplantation in Patients With Osteochondritis Dissecans of the Knee

Background: Osteochondritis dissecans (OCD) of the knee can be difficult to treat. Cartilage restoration techniques are often indicated when the lesion or fragment cannot be salvaged and the patient remains symptomatic. Fresh osteochondral allograft (OCA) transplantation can restore both bone and cartilage defects characteristic of OCD. Hypothesis: We hypothesized that osteochondral allografting is a successful method for treating OCD of the knee. Study Design: Case series; Level of evidence, 4. Methods: This study comprised 135 patients (149 knees) who underwent OCA for OCD of the knee (type III or IV) between 1997 and 2013 and had a minimum follow-up of 2 years. The median age was 21 years (range, 12-55 years) and 75.8% of the patients were male. The mean allograft size was 7.3 cm2 (range, 2.2-25 cm2). Evaluation included the following: frequency and type of reoperations; modified Merle d’Aubigné and Postel (18-point) scale; International Knee Documentation Committee (IKDC) pain, function, and total scores; and Knee Society function (KS-F) and knee (KS-K) scores. Clinical failure was defined as revision OCA or conversion to arthroplasty. Graft survivorship was determined. Results: The median follow-up time was 6.3 years (range, 1.9-16.8 years) and 62% of participants had more than 5-year follow-up. Thirty-four of 149 knees (23%) had reoperations, of which 12 (8%) were classified as allograft failures (7 OCA revisions, 3 unicompartmental knee arthroplasties, and 2 total knee arthroplasties). OCA survivorship was 95% at 5 years and 93% at 10 years. Of the 137 knees whose grafts were still in situ at the latest follow-up, the mean modified Merle d’Aubigné and Postel (18-point) score was 16.8; IKDC pain, function, and total scores were 2.1, 8.1, and 82.3; and KS-F and KS-K scores were 95.7 and 94.3, respectively. The majority of patients (95%) reported being satisfied with the outcome of their procedure. Conclusion: OCA transplantation was an effective treatment for OCD of the knee, with a low rate of graft failure, significant improvement in pain and function scores, and high patient satisfaction.

Osteochondral Allograft Transplantation of the Femoral Trochlea

Background: Osteochondral allograft (OCA) transplantation is a recognized treatment modality for cartilage damage in the knee. Few reports are available on outcomes of OCA in the patellofemoral joint, and there are no reports on lesions isolated to the femoral trochlea. Purpose: To evaluate graft survivorship and clinical outcomes in patients who had an OCA to the femoral trochlea. Study Design: Case series; Level of evidence, 4. Methods: An OCA database was used to identify 29 knees in 28 patients (mean age, 30.2 years; range, 12-47 years; 8 female, 20 male) who were treated with a fresh OCA transplant limited to the femoral trochlea. The primary outcome was graft survivorship, and the minimum follow-up was 2 years. Clinical outcomes were assessed by the modified Merle d’Aubigné-Postel (18-point) score; Knee Society function (KS-F) score; International Knee Documentation Committee (IKDC) pain, function, and total scores; and University of California, Los Angeles (UCLA) activity score. The OCA patient satisfaction score (5-point scale from extremely satisfied to dissatisfied) was also reported. Results: The mean follow-up period was 7.0 years (range, 2.1-19.9 years). Graft survivorship was 100% at 5 years and 91.7% at 10 years. One patient was converted to a total knee arthroplasty 7.6 years after OCA surgery. The mean modified Merle d’Aubigné-Postel score improved from 13.0 to 16.1, the mean KS-F score from 65.6 to 85.2, and the mean IKDC total score from 38.5 to 71.9; the mean UCLA score was 7.9 postoperatively. Eighty-nine percent of patients were extremely satisfied or satisfied with the outcome of surgery. Conclusion: Fresh OCA transplantation resulted in excellent clinical outcomes in this patient cohort with articular cartilage damage to the femoral trochlea. The procedure resulted in improved pain and function and high patient satisfaction.