Yona Kosashvili

Acetabular revision using an anti-protrusion (ilio-ischial) cage and trabecular metal acetabular component for severe acetabular bone loss associated with pelvic discontinuity

Pelvic discontinuity with associated bone loss is a complex challenge in acetabular revision surgery. Reconstruction using ilio-ischial cages combined with trabecular metal acetabular components and morsellised bone (the component-cage technique) is a relatively new method of treatment. We reviewed a consecutive series of 26 cases of acetabular revision reconstructions in 24 patients with pelvic discontinuity who had been treated by the component-cage technique. The mean follow-up was 44.6 months (24 to 68). Failure was defined as migration of a component of > 5 mm. In 23 hips (88.5%) there was no clinical or radiological evidence of loosening at the last follow-up. The mean Harris hip score improved significantly from 46.6 points (29.5 to 68.5) to 76.6 points (55.5 to 92.0) at two years (p < 0.001). In three hips (11.5%) the construct had migrated at one year after operation. The complications included two dislocations, one infection and one partial palsy of the peroneal nerve. Our findings indicate that treatment of pelvic discontinuity using the component-cage construct is a reliable option.

Holding power of variable pitch screws in osteoporotic, osteopenic and normal bone: Are all screws created equal?

INTRODUCTION Biomechanical properties of four different commercially available small fragment cannulated screws (Twin fix (Stryker, Freiburg, Germany), Herbert, (Zimmer, Warsaw, USA), Omnitech (Unimedical, Torino, Italy), Barouk (Depuy, Warsaw, USA)), with variable pitch, used for fracture fixation were compared. MATERIALS AND METHODS Polyurethane foam blocks of three different densities with mechanical properties similar to osteoporotic, osteopenic and normal bones were used to conduct the tests. Each screw was tested for pushout and pullout holding power after a primary insertion and for pullout after a repeated insertion into the respective foam blocks. RESULTS The mean pullout and pushout strengths of all screws correlated to the foam density, and were significantly (p<0.001 and <0.001, respectively) better in foam with higher density. The mean pullout strength of each screw was consistently lower after reinsertion into the osteoporotic, osteopenic and normal bone densities by 4-30%, when compared to the index insertion (Fig. 4b). Yet, this difference was not found to be statistically significant (p=0.23). The Barouk screw performed significantly (p<0.0001) better than the other screws in all three different densities of foam for both for pushout and pullout after index insertion as well as for pullout tests after reinsertion. CONCLUSION The holding power of screws is directly correlated to bone density, thread design and number of threads engaging the bone. Reinsertion through the same hole could reduce the ultimate pullout strength. The surgeon should consider the advantages and disadvantages of each implant, depending on the clinical situation and choose accordingly.

Dislocation and Infection After Revision Total Hip Arthroplasty: Comparison Between the First and Multiply Revised Total Hip Arthroplasty

Dislocation and infection are common complications of total hip arthroplasty (THA). This study evaluated the correlation between the number of revision THAs and the incidence of these complications. Data were obtained from 749 revision THAs. Average follow-up was 13.2 ± 5.9 years. Patients were grouped as first, second, third, and fourth or greater revision THA. Dislocation rates (5.68%, 7.69%, 8.33%, and 27.45%) and infection rates (1.35%, 1.92%, 2.5%, and 7.84%) in the first, second, third, and fourth or greater groups, respectively, correlated directly with the revision number and were highest (P < .001) in the fourth or greater group. Dislocation and infection are exponentially correlated with the number of revision THA. From the fourth revision onward, those risks are multiplied.

An inexpensive and accurate method for hip injections without the use of imaging.

Background:Intraarticular injections of the hip have traditionally required sonographic or fluoroscopic guidance assistance. Previous studies report high failure rates with injections based solely on anatomic landmarks. Objectives:To examine the accuracy of a lateral injection technique in osteoarthritic patients without using image assistance. Methods:This study was conducted in the operating room in 40 consecutive patients about to undergo total hip arthroplasty. Before sedation, each patient was positioned in a lateral decubitus position. Under sterile conditions, methylene blue dye was injected through an 18G spinal needle that was inserted 1 cm proximal to the midline of the greater trochanter, and directed toward the superolateral aspect of the femoral neck, according to preoperative hip x-rays. Accuracy was assessed intraoperatively by examining the joint and surrounding tissues for the presence of dye. Results:Injections were successful in 6 of the first 10 (60%) patients and in 25 of the remaining 30 (83.3%) patients. Overall, injections were successful in 31 of 40 (77.5%) patients with disseminated dye solely in the intracapsular space. In all 9 unsuccessful injections, the dye was located distal to the joint, along with the more lateral aspect of the femoral neck. Conclusion:Accuracy of injections, to the hip joint, based on anatomic landmarks and preoperative x-rays is similar to those documented for knee injections in the literature. When unsuccessful, the injected material was not found close to neurovascular structures. This technique has an acceptable learning curve and can be used safely in a standard office setting.

Cardiovascular disease predicts complications following bilateral total knee arthroplasty under a single anesthetic

INTRODUCTION This study evaluated the rate of perioperative complications of single anesthetic bilateral total knee arthroplasties (TKA) compared with staged procedures. METHODS The records of all single anesthetic bilateral TKA performed between 1997 and 2007 at one large community hospital and one university hospital were retrospectively reviewed. Complete demographic data, preoperative co-morbidities and complications for 156 patients were compared to a matched staged bilateral TKA (n=78) cohort. RESULTS In the single anesthetic bilateral TKA cohort, cardiovascular disease predicted postoperative myocardial (p<0.01, Odds Ratio - 67.6), need for ICU admission (p<0.01, Odds Ratio - 88.8), and days spent in ICU (p<0.01), while cardiovascular disease did not significantly predict postoperative MI in the staged bilateral (p=0.99, OR - 0). CONCLUSION Patients with cardiovascular disease are at higher risk for perioperative MI after single anesthetic bilateral TKA.

Iliopsoas Tendonitis due to the Protrusion of an Acetabular Component Fixation Screw After Total Hip Arthroplasty

Postoperative pain after total hip arthroplasty can have a wide range of underlying causes. Iliopsoas tendonitis secondary to the impingement of this tendon is a relatively rare cause of pain after arthroplasty. This condition is characterized by pain on active flexion and an absence of signs or symptoms of loosening or infection. In this report, we describe the case of a patient who had signs and symptoms of iliopsoas tendonitis secondary to the protrusion of an acetabular fixation screw through the ilium after primary total hip arthroplasty. Nonoperative treatment was ineffective, and the patient ultimately underwent surgical removal of the screw. The severity of the patients symptoms decreased significantly after the operation.

Total Knee Arthroplasty After Failed Distal Femoral Varus Osteotomy Using Selectively Stemmed Posterior Stabilized Components

The purpose of this study was to evaluate the outcomes of patients treated with total knee arthroplasty (TKA) for progression of arthritis after distal femoral varus osteotomy. Twenty-two consecutive distal femoral varus osteotomies converted to TKA were reviewed at a mean follow-up of 5 years (range, 2-14 years). Stemmed femoral or tibial components were used in 5 knees with poor bone quality, while the remaining 17 knees were treated with unstemmed components. The mean Knee Society knee and function scores in surviving knees were 91 points (range, 67-100 points) and 64 points (range, 50-70 points) respectively at final follow-up. Two patients underwent revision arthroplasty for polyethylene wear and component loosening at 8 and 11 years after the index arthroplasty, respectively. Standard components provide satisfactory stability in TKA after distal femoral varus osteotomy after appropriate ligamentous balancing, without the need for stemmed or highly constrained components in the majority of patients.

Total Hip Arthroplasty in Down Syndrome Patients: An Improvement in Quality of Life: Replacement Arthroplasty in Down Syndrome (RADS) Study Group

The purpose this study was to assess survival rates, clinical outcomes, and radiographic outcomes of total hip arthroplasty in Down syndrome patients. We reviewed 26 total hip arthroplasties (21 patients) performed by four experienced hip surgeons. These patients had a mean age of 35 years and a mean follow-up of 106months. Clinical outcomes were assessed using Harris Hip scores, and radiographic evaluation for component fixation and migration was performed. The overall survival with aseptic failure as an endpoint was 85%. The mean Harris Hip score improved to 84 points at final follow-up. While these patients can be challenging to treat, excellent surgical technique and selective use of acetabular constraint can reliably provide patients with excellent pain-relief and improved function.

Immediate recovery room radiographs after primary total knee arthroplasty—why do we keep doing them?

Recovery room radiographs (RRR) are routinely performed after total knee arthroplasty (TKA). This study investigates the utility of these radiographs. Twenty four arthroplasty surgeons were surveyed to rank the value of RRRs. Since RRRs were primarily valued for educational purposes, we examined the ability of 49 orthopaedic trainees to determine the coronal alignment of TKA performed in cadaveric specimens based on these radiographs in neutral, 10° internal and external rotations. Surgeons rated the quality of the RRRs to be significantly lower than the radiographs taken in the radiology suite (5.5 ± 2.5 versus 8.9 ± 0.9, p < 0.0001). Of an estimated 65,910 TKAs performed by these surgeons, only eight cases (0.01%) required same day revision based on the RRR. Neutral alignment was significantly more accurately (p < 0.0001) interpreted than valgus or varus (69.4% versus 42.9% and 16.3%, respectively). Surprisingly, internal rotation of the limb significantly improved interpretation of both varus (from 16.3% to 40.8%, p = 0.014) and valgus (from 42.9% to 63.3%, p = 0.048). Increased level of orthopaedic training did not significantly affect the accuracy of interpretation (p = 0.46). Interpretation of RRRs for coronal malalignment is inaccurate and has a limited educational value.

Noninvasive biomechanical therapy improves objective and subjective measurements of pain and function in patients with knee osteoarthritis: a retrospective analysis

Background:Biomechanical interventions for the management of knee osteoarthritis (OA) are emerging. AposTherapy is one type of biomechanical therapy that has been shown to reduce knee adduction moment and improve gait patterns and clinical symptoms. The purpose of the current study was to further investigate the changes in gait patterns after this biomechanical therapy and to define its possible clinical benefits for patients with knee OA. Methods:Four hundred and twelve patients with knee OA were evaluated using a computerized gait test, as well as the Western Ontario and McMaster Osteoarthritis Index (WOMAC) and the SF-36 Health Survey self-evaluation questionnaires. After these measurements, the Apos system was individually calibrated to each patient according to his or her gait patterns and clinical evaluation. All patients received exercise guidelines and underwent 3 months of therapy. A second evaluation of gait and clinical symptoms was conducted after 3 months of therapy. Results:After 3 months of therapy, a significant improvement was found in all gait parameters (all P<0.01), as well as in the level of pain, function, and quality of life (all P<0.01). High correlations were found between the improvement in gait parameters and the improvement in self-evaluation questionnaires. Conclusions:The examined biomechanical therapy led to a significant reduction in pain and improvement in function, quality of life, and gait patterns. These findings support previous findings and deepen the understanding of this new noninvasive biomechanical therapy in patients with knee OA.