Wayne M. Goldstein

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 …

A comparison of the perioperative morbidity in total joint arthroplasty in the obese and nonobese patient

The goal of this study was to determine if obesity is a risk factor for total joint arthroplasty. This was a retrospective review of 130 patients treated with either primary total hip arthroplasty or primary total knee arthroplasty during a two-year period (154 consecutive arthroplasties). The patients were placed in the nonobese or obese group. Obesity was defined as 20% above ideal weight for height, based on life insurance tables. There were 51 in the nonobese groups and 103 in the obese group. Charts were reviewed for a number of factors associated with postoperative complications. Operative time, intravenous fluids administered, and total blood loss were found to be slightly higher in the obese group. Only the difference in operative time proved statistically significant, however. The hospitalization time, number of days with a fever, number of transfusions, preoperative and postoperative hemoglobin levels, and days requiring intramuscular narcotics were very similar between the two groups. There were 0.29 minor complications per nonobese patient, but only 0.22 per obese patient. Major complications were encountered 0.22 times per nonobese patient and 0.10 times per obese patient. The patient is not necessarily at a higher risk for peroperative complications in total joint arthroplasty. The longevity of the implant in the obese patient was not determined in this perioperative study.

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.

Temporary articulating methylmethacrylate antibiotic spacer (TAMMAS). A new method of intraoperative manufacturing of a custom articulating spacer.

Abstract A temporary articulating antibiotic-impregnated cement spacer for use during the first stage of a two-stage revision of a total knee replacement that had failed because of infection was developed by one of us (W.M.G.). It is simply a knee prosthesis made of methylmethacrylate and antibiotics that is manufactured intraoperatively with use of instruments, medications, and supplies that are already available at most hospitals. This construct allows for motion of the knee during treatment of the infection, thereby reducing the risk of loss of motion after subsequent revision. The technique has been successfully utilized in five patients since 1999 and has now become our standard treatment method.

Unilateral vs Bilateral Total Knee Arthroplasty : Risk Factors Increasing Morbidity

Because surgeons are electing to perform simultaneous bilateral total knee arthroplasty (TKA), it is important to identify which patients are at increased risk. We performed a retrospective cohort analysis of 150 patients with unilateral TKA vs 150 patients with simultaneous bilateral TKA. The bilateral group demonstrated a 2.1 times greater mean overall complication rate as well as increased transfusion rates. Patients older than 70 years exhibited significantly higher complication rates. Having a preexisting pulmonary disorder in the bilateral cohort carried nearly a 3-fold risk of complications. Patients with body mass indices greater than 30 displayed a complication rate of 0.97 in the bilateral group as opposed to 0.44 in the control group. Our study demonstrated that age, body mass index, and a preexisting pulmonary disorder resulted in increased complications.

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.

A comparison between arthrotomy and irrigation and multiple aspirations in the treatment of pyogenic arthritis: a histological study in a rabbit model.

Staphylococcus aureus pyogenic arthritis was produced in a group of eight rabbits. After 24 hours, all rabbits were treated with systemic procaine and benzathine penicillin for five days. Four rabbits were treated with daily aspiration, and four rabbits were treated with arthrotomy and irrigation. A study of the histology of cartilage of the lateral femoral condyle was made in the two groups. Animals treated with aspiration showed a greater degree of thinning of cartilage, acelluiarity, and cloning of chondrocytes than animals treated with arthrotomy and irrigation.