Steven F Harwin

Heterotopic ossification following primary total knee arthroplasty

Heterotopic ossification is a rare complication following primary total knee arthroplasty and may be symptomatic if massive enough. The authors retrospectively reviewed 158 primary total knee arthroplasties from 1985 to 1989 and found 6 cases (3.8%) of heterotopic ossification. Patients were graded before and after surgery according to the Hospital for Special Surgery total knee arthroplasty score and their histories were reviewed for the presence of recognized risk factors for heterotopic ossification and whether a manipulation under anesthesia was performed. This report describes the incidence of, appearance of, and clinical risk factors for heterotopic ossification following primary total knee arthroplasty in this series. A radiographic grading system is proposed.

Primary bateman-leinbach bipolar prosthetic replacement of the hip in the treatment of unstable intertrochanteric fractures in the elderly

The results of primary Bateman-Leinbach bipolar prosthetic replacement for comminuted intertrochanteric fractures of the hip in the elderly are examined. In an effort to avoid the postoperative complications seen in open reduction and internal fixation of severely comminuted fractures with osteoporotic bone, and to avoid postoperative restrictions when fixation is suboptimal, a group of 58 patients were treated with a bipolar Bateman-Leinbach prosthesis. They were followed for an average of 28 months. Surgery was performed using an anterolateral approach, which is recommended. A detailed description of the surgical approach and operative technique are provided. Eighty-eight percent of patients were able to ambulate within the first week, weight bearing as tolerated with no postoperative restrictions, except for a simple abduction pillow for 2 weeks while in bed. Ninety-one percent of patients ambulated prior to discharge. Morbidity and mortality was no greater in this group than in groups treated by open reduction and internal fixation for these types of fractures. Complications were few. Primary Bateman-Leinbach bipolar prosthetic replacement is recommended as the preferred treatment of selected unstable comminuted intertrochanteric fractures in the elderly.

Does obesity affect the outcomes of primary total knee arthroplasty

The purpose of this study was to compare the clinical and radiographic outcomes of primary total knee arthroplasty (TKA) in obese and nonobese patients. A total of 210 knees in 174 obese patients who had a mean body mass index (BMI) of 34 kg/m2 (range, 30 to 39.9 kg/m2) and who had undergone a primary TKA between 2006 and 2010 were reviewed. There were 115 women and 59 men who had a mean age of 62 years (range, 36 to 84 years) and a mean follow-up of 57 months (range, 24 to 82 months). These patients were compared with a group of nonobese patients who had a BMI of less than 30 kg/m2 (range, 19 to 29.9 kg/m2). The evaluated outcomes included implant survivorship, Knee Society objective and functional scores, complication rates, radiographic outcomes, University of California Los Angeles (UCLA) activity score, and the length of hospital stay between obese and nonobese patients. There were no significant differences in the overall septic and aseptic implant survivorship (98.8 vs. 98.6%) and mean postoperative Knee Society objective and function scores (90 and 87 points vs. 91 and 89 points), respectively. Obese patients had significantly higher complication rates (10.5 vs. 3.8%) and had achieved a significantly lower mean postoperative UCLA activity score (5 vs. 6 points). However, there were no differences in the length of hospital stay for the two cohorts. Although the authors encourage all patients to lose weight as much as possible prior to their TKA, it is encouraging that obese patients had achieved excellent clinical outcomes at early to mid-term follow-up.

Outcomes of short stems in total hip arthroplasty

Short-stem total hip arthroplasty has been proposed as a bone-conserving procedure for the younger and more active population undergoing total hip arthroplasty. Although various short stems are currently available, no studies compare the outcomes between these stems. The aim of the current study was to conduct a systematic review of the clinical and radiographic outcomes of the various short stems that have been approved for use in the United States by the Food and Drug Administration. Outcomes that were assessed included implant survivorship, Harris Hip scores, thigh pain, periprosthetic fracture, subsidence, proximal stress shielding, and the prevalence of stem malalignment and inappropriate implant sizing.

Excellent results of primary THA using a highly porous titanium cup.

Cementless acetabular cups for primary total hip arthroplasty have had excellent results, with failure rates typically less than 5% at up to 10-year follow-up. Tritanium is a 3-dimensional metal interface that has been used for porous biological fixation. The purpose of this study was to review the clinical and radiographic results of the use of Tritanium cups (Stryker Orthopaedics, Mahwah, New Jersey) for primary total hip arthroplasty. Two hundred eighty-eight total hip arthroplasties performed using a porous titanium acetabular cup in 252 patients between 2008 and 2010 were reviewed. One hundred thirty-three men and 119 women with a mean age of 58 years (range, 18-88 years) were included. Mean follow-up was 36 months (range, 24-56 months). Outcomes evaluated were implant survivorship, Harris Hip Score, complications, and radiographic outcomes. At final follow-up, no cup failures had occurred. Mean Harris Hip Score improved from 53 points (range, 33-82 points) preoperatively to 91 points (range, 64-100 points) postoperatively. One complication occurred; a 64-year-old woman with recurrent postoperative effusions underwent hip exploration and required abductor mechanism repair. On radiologic evaluation, no signs existed of progressive radiolucencies or changes in cup position. The survivorship of the Tritanium cup and the low complication rate is comparable with previous studies using other porous-metal prostheses. Longer follow-up study is needed and assessment of the results of using this implant in the revision setting is important.

Intraoperative pharmacotherapeutic blood management strategies in total knee arthroplasty.

Bone and soft tissue bleeding often results in substantial amounts of blood loss following total knee arthroplasty. Multiple studies have reported that cumulative blood loss varies between 500 and 1,500 mL in primary settings. Increased perioperative blood loss frequently requires allogeneic blood transfusions to improve the hematocrit and the hemoglobin levels. However, allogeneic transfusion is associated with risks of immunosuppression, transfusion reactions, graft versus host disease, and transmission of infections. To avoid these problems and reduce costs of transfusion, multiple intraoperative pharmacotherapeutic strategies have been developed. The various pharmacotherapeutic agents currently used are tranexamic acid, epsilon-aminocaproic acid, fibrin, thrombin, lavage with epinephrine, and norepinephrine. However, the relative efficacy and the cost-effectiveness of these techniques may vary. Thus, the purpose of this study was to provide a brief overview of the relative efficacy of various intraoperative pharmacological methods currently in use for decreasing blood loss following total knee arthroplasty and describe their potential complications associated with their use.

Subcutaneous Lateral Retinacular Release for Chondromalacia Patellae: A Preliminary Report

When chondromalacia patellae is caused by lateral capsular and retinacular tightness, subcutaneous lateral release affords relief of pain. The operation, performed at the time of arthroscopy, causes minimal morbidity, and it is advantageous when cosmetics are of concern. Range-of-motion exercises are begun on the second postoperative day to keep the retinaculum open. In the postoperative examination of 25 knees at 24 to 45 months in 15 patients, there were 20 excellent and five good results; none was made worse. There were two postoperative hemarthroses. The procedure is most effective in the carefully selected patient with demonstrable tightness of the lateral capsule and retinaculum. Abnormal attachments of the iliotibial band and synovial plicae are also significant in the etiology of this syndrome.

Cementless Total Knee Arthroplasty: A Review

There is ongoing debate over the use of cementless fixation in total knee arthroplasty (TKA). Previous generation prostheses resulted in less than optimal outcomes which was somewhat attributed to design issues. As the demand for TKA is continuously increasing and the current U.S. age population is getting younger, cemented fixation may not provide adequate long-term outcomes due to failure of fixation. Thus, there has been a reemergence of the development and use of cementless TKA. Recent short-term trials have demonstrated that modern cementless TKA has comparable survivorship and functional outcomes as cemented prostheses. However, more prospective, randomized trials are needed to clearly delineate any differences between these two fixation options.

Is the routine examination of surgical specimens worthwhile in primary total knee arthroplasty

Two thousand two hundred eighty-nine consecutive primary total knee arthroplasties performed between 1993 and 1996 were reviewed retrospectively to assess the utility and cost effectiveness of the routine examination of surgical specimens. In those cases where a discrepancy was seen between the clinical and pathologic diagnoses, the records were reviewed carefully and those patients were contacted to determine whether their subsequent treatment was altered as a result of the pathologic findings. In 10 cases there was a potentially important discrepancy between the clinical and pathologic diagnoses. In none of those 10 cases was the subsequent treatment of the patient altered as a result of the pathologic findings. This study suggests a reexamination of regulations that mandate the routine pathologic review of surgical specimens from primary total knee arthroplasties.

Spontaneous and simultaneous rupture of both quadriceps tendons.

The seventh case known to be reported in the literature on simultaneous rupture of both quadriceps tendons occurred in a 60-year-old man with diabetes mellitus. The patient was treated by surgical repair of both tendon ruptures with a satisfactory return of function. Diabetes mellitus may be a predisposing condition for the bilateral rupture, but does not prevent either the tendon or wound from healing.