Todd C. Kelley

Role of navigation in total hip arthroplasty.

Current uses of computed tomography-based and imageless navigation systems for total hip arthroplasty include proper placement of the acetabular component, measurement of limb-length changes, enablement of minimally invasive surgery, and proper placement of components for hip resurfacing procedures. This article provides an overview of the rationale for computer-assisted surgery in total hip arthroplasty and hip resurfacing. The experience of the senior author (M.L.S.) with computer-assisted surgery for hip arthroplasty has demonstrated improved position of the acetabular component as compared with the position attainable with use of mechanical instruments, maintenance of appropriate position of the acetabular component during minimally invasive surgery, and appropriate positioning of the femoral and acetabular components during the learning curve for hip resurfacing procedures.

Efficacy of multimodal perioperative analgesia protocol with periarticular medication injection in total knee arthroplasty: A randomized, double-blinded study

Pain control is necessary for successful rehabilitation and outcome after total knee arthroplasty. Our goal was to compare the clinical efficacy of periarticular injections consisting of a long-acting local anesthetic (ropivacaine) and epinephrine with and without combinations of an α2-adrenergic agonist (clonidine) and/or a nonsteroidal anti-inflammatory agent (ketorolac). In a double-blinded controlled study, we randomized 160 patients undergoing total knee arthroplasty to receive 1 of 4 intraoperative periarticular injections: Group A, ropivacaine, epinephrine, ketorolac, and clonidine; Group B, ropivacaine, epinephrine, and ketorolac; Group C, ropivacaine, epinephrine, and clonidine; Group D (control), ropivacaine and epinephrine. Compared with Group D, Group A and B patients had significantly lower postoperative visual analog pain scores and nurse pain assessment and Group C patients had a significantly greater reduction in physical therapist pain assessment. We found no differences in other parameters analyzed.

Use of tranexamic acid results in decreased blood loss and decreased transfusions in patients undergoing staged bilateral total knee arthroplasty

Tranexamic acid (TXA) is an antifibrinolytic that reduces blood loss and transfusion rates in total joint arthroplasty. Blood loss and allogenic transfusion rates have not been well studied in patients receiving TXA and undergoing bilateral staged total knee arthroplasty (TKA). The purpose was to evaluate the effect of TXA on blood loss, hemoglobin (Hb) changes, and transfusion in patients undergoing staged bilateral TKA.

Modern Proximally Tapered Uncemented Stems Can Be Safely Used in Dorr Type C Femoral Bone

Cementless femoral fixation has become widely accepted in modern total hip arthroplasty. Treating patients who have a stovepipe-shaped femur (Dorr type C) with cementless implants has traditionally been challenging. We treated 53 consecutive patients (60 hips) who had type C bone with identical tapered, proximally coated implants and postoperative weight bearing as tolerated. At 6 weeks, all 60 hips had radiographically documented bony integration, and at 1 year, there was no evidence of fracture, subsidence, thigh pain, stress shielding, loose stems, or risk of failure. Of those patients, 40 (43 hips) had midterm follow-up (average, 6 years; range, 4-9 years); the findings were the same. We conclude that modern proximally tapered stems can be used with early weight bearing in patients with type C bone.

All-Polyethylene Tibial Components in Obese Patients Are Associated With Low Failure at Midterm Followup

BackgroundIn the United States, the obese population has increased markedly over the last four decades, and this trend continues. High patient weight places additional stress on TKA components, which may lead to increased polyethylene wear, osteolysis, radiolucencies, and clinical failure. Metal-backed tibial components and all-polyethylene tibial components in the general population have comparable osteolysis and failure, but it is unclear whether these components yield similar osteolysis and failure in obese patients.Questions/purposesWe therefore determined the (1) function, (2) occurrence of osteolysis, and (3) complications in a cohort of obese patients receiving all-polyethylene tibial components.Patients and MethodsBetween September 17, 1996, and December 19, 2002, we implanted all-polyethylene tibial components in 90 obese patients (125 knees); 24 patients (33 knees) died and 13 patients (17 knees) were lost to followup, leaving 53 patients (59%) with 75 knees. All surgeries were cruciate-retaining, tricompartmental TKAs. We evaluated patients with Knee Society Scores and serial radiographs. Minimum followup was 7 years (mean, 10.4 years; range, 7–14 years).ResultsAt latest followup, mean Knee Society Score was 92 points. There were five tibial radiolucencies, all less than 1 mm and characterized as nonprogressive. We observed minimal, nonprogressive osteolysis in one knee. One patient required reoperation after a traumatic event. There were no implant-related failures and no implants at risk of failure.ConclusionsAt an average 10-year followup, all-polyethylene tibial components were functioning well in this obese group. These findings confirm the effectiveness of all-polyethylene tibial components in obese patients.Level of EvidencePrognostic—Level IV—Case Series, uncontrolled. See Guidelines for Authors for a complete description of levels of evidence.

Medial UKA: Favorable Mid-Term Results in Middle-Aged Patients

In middle-aged patients with knee arthritis, surgical treatment options include arthroscopic procedures, osteotomies, and unicompartmental and total knee arthroplasty. Unicompartmental knee osteoarthrosis is particularly challenging and controversial in such patients. From December 2001 through October 2005, we treated 32 consecutive middle-aged patients (46 to 59 years old) with 40 medial unicompartmental knee arthroplasties. Three patients were lost to follow-up, leaving 29 for our study. There were two reoperations: one for loosening at 3 years, and one for disease progression at 5 years. Implant survival was modeled using Kaplan-Meier survival function with observations censored if lost to follow-up. At the 6-year survivorship in this group, the overall implant survival rate was 94.1% (95% CI, 78.3-98.5). Knee Society scores had improved significantly (p < 0.001). There were no other instances of osteolysis or radiographic failure. We concluded that, at mid-term follow-up, unicompartmental knee arthroplasty provided satisfactory results for this challenging population.

Patient-Specific Guides for Total Hip Arthroplasty: A Paired Acetabular and Femoral Implantation Approach

While total hip arthroplasty (THA) is a common orthopedic procedure for treatment of hip arthritis, current techniques demonstrate poor implant alignment accuracy and precision, which is critical to the replacements long-term survivorship. Patient-specific instruments to guide bone preparation and implantation could improve accuracy, thereby improving replacement survivorship. A single cadaver was CT (computer tomography) scanned to extract the 3D bone geometry, from which the operating surgeon planned a THA. Patient-specific guides were designed, 3D printed, and used in the cadaveric THA procedure. Postprocedural CT data were used to compare measured implant positioning versus the preprocedural template. Implanted component accuracy ranged from 1 deg–12 deg.