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Pivec R.,Rubin Institute for Advanced Orthopedics | Johnson A.J.,Rubin Institute for Advanced Orthopedics | Mears S.C.,Johns Hopkins University | Mont M.A.,Rubin Institute for Advanced Orthopedics
The Lancet | Year: 2012

Total hip arthroplasty is a cost-effective surgical procedure undertaken to relieve pain and restore function to the arthritic hip joint. More than 1 million arthroplasties are done every year worldwide, and this number is projected to double within the next two decades. Symptomatic osteoarthritis is the indication for surgery in more than 90% of patients, and its incidence is increasing because of an ageing population and the obesity epidemic. Excellent functional outcomes are reported; however, careful patient selection is needed to achieve best possible results. The present economic situation in many developed countries will place increased pressure on containment of costs. Future demand for hip arthroplasty, especially in patients younger than 65 years, emphasises the need for objective outcome measures and joint registries that can track lifetime implant survivorship. New generations of bearing surfaces such as metal-on-metal, ceramic-on-ceramic, and metal-on-ceramic, and techniques such as resurfacing arthroplasty have the potential to improve outcomes and survivorship, but findings from prospective trials are needed to show efficacy. With the recall of some metal-on-metal bearings, new bearing surfaces have to be monitored carefully before they can be assumed to be better than traditional bearings.


Mont M.A.,Rubin Institute for Advanced Orthopedics
The journal of knee surgery | Year: 2012

Total knee arthroplasty (TKA) is a procedure with excellent clinical results in older patients with a primary diagnosis of osteoarthritis. Many younger patients undergo unicompartmental or high tibial osteotomy rather than TKA, but are not always good candidates for these joint-preserving procedures. The purpose of this study was to review the outcomes of patients 40 years of age and under who underwent TKA. We identified 33 patients (38 knees) who were 40 years of age or less at the time of surgery. These patients had a mean age of 36 years (range, 23 to 40 years), and were followed for a mean of 49 months (range, 16 to 101 months). The survival rate in the study cohort was 97%. For the young patient who is not a candidate for other types of joint preserving procedures, in the senior authors' experience total knee arthroplasties have performed well.


Johnson A.J.,Rubin Institute for Advanced Orthopedics
The journal of knee surgery | Year: 2013

Knee osteoarthritis causes debilitating pain, and results in characteristic gait changes. Some authors believe that a system of neuromuscular retraining may improve these parameters. We therefore evaluated a novel brace that combines pneumatic joint unloading and active swing-assist to assess: (1) differences in pain levels or medication usage; (2) reductions in additional interventions; (3) changes in quadriceps muscle strength; and (4) improvements in specific gait measurements after 3 months. A prospective pilot series of 10 knee osteoarthritis patients who had exhausted other nonoperative treatment measures were enrolled. These patients were compared with the previous 15 knee osteoarthritis patients who met similar criteria, but were not braced. Quadriceps muscle strength was measured, as were pain levels, and additional interventions such as injections or total knee arthroplasty procedures. Gait parameters measured included: walking speed, total range-of-motion, knee flexion at foot-strike, and knee adduction moment. All but one of the compliant patients reported a decrease of at least two pain points after 3 months of use. There was one additional intervention in the brace cohort versus a statistical increase of 10 in the nonbrace cohort. All patients who were compliant with the brace showed an increase in thigh girth measurements, compared with none in the nonbrace cohort. Braced patients experienced retained improvements in at least one gait parameter including improved walking speed, total range of motion, and improved knee-angle at heel strike. The mean improvement in knee adduction moment was a decrease of 0.2255 Nm/kg (range, 0.56 to 0.564 Nm/kg), showing a mean improvement of 48% (range, 16 to 76% of original peak moment). The use of a brace that has features including a combination of unloader characteristics along with active swing-assist, provided neuromuscular retraining benefits for patients who have knee osteoarthritis. In summary, although quite encouraging, future larger scale and prospective randomized studies need to assess the potential benefits of this brace for treating knee osteoarthritis. Level II. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.


Issa K.,Rubin Institute for Advanced Orthopedics
The journal of knee surgery | Year: 2013

Magnetic resonance imaging (MRI) or computed tomography-based patient-specific instrumentation (PSI) may allow for reliable alignment and fewer outliers when compared with conventionally instrumented total knee arthroplasty (TKA). However, some authors have suggested that frequent intraoperative surgeon-directed changes may still be required. This study evaluated the accuracy of PSI to predict component sizing and alignment during TKA. A total of 84 patients (89 knees) who underwent a TKA using a PSI system were evaluated. An MRI-based preoperative plan of every knee was provided and approved by the surgeons. This demonstrated the proposed prosthetic component alignment, as well as the femoral, tibial, and bearing insert component size and position. Intraoperative changes to these components were prospectively recorded and compared with the computerized preoperative plan. Major changes were defined as any changes in femoral or tibial resection, size, and position of the components. Minor changes were defined as any change in the size of the polyethylene bearing insert. The preoperative plan was able to correctly predict the size of the implanted tibial and femoral component in 93 and 95.5% of the cases, respectively. Thirteen major intraoperative changes were made. In one knee, the proposed femoral resection was not acceptable (because of the presence of significant amount of osteophytes) and was abandoned in favor of a manual extramedullary guide. In another patient, the proposed femoral and tibial components were upsized. In two other patients, the femoral components were downsized, in four patients, the tibial components were downsized, and in another patient, it was upsized. There were also 16 minor changes, which included 2-mm upsizing of the polyethylene liner in 13 knees and 4-mm upsizing in 3 knees. Surgical experience is necessary to recognize improper component size, incorrect surgical resection, or nonideal alignment when performing TKA using PSI. The authors believe that the design and manufacture of PSI combined with a comprehensive templating resulted in excellent intraoperative concordance of the preoperative plan at the default settings with minimal changes. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.


Costa C.R.,Rubin Institute for Advanced Orthopedics
The journal of knee surgery | Year: 2013

Despite high survivorship for total knee arthroplasty, many reports have described low patient-satisfaction rates. Standard parapatellar approaches have been linked with decreased quadriceps muscle strength, which may in turn lead to prolonged rehabilitation and altered kinematics. Although technically demanding, minimally invasive techniques offer the potential for shorter recovery times and improved strength. Our purpose was to compare perioperative factors, the clinical and radiographic outcomes, complications, and survivorship of several minimally invasive approaches to each other and to the conventional medial parapatellar approach. A total of 23 level I or II studies were reviewed. There were no statistically significant differences in perioperative factors, clinical or radiographic outcomes, survivorship, or complication rates between patients the various minimally invasive approaches to a standard approach. The only significant difference observed was in recovery of quadriceps muscle function (shorter in patients who had a minimally invasive approach). The minimally invasive lateral approach had more complications than the other minimally invasive approaches. The mini-midvastus approach had the best clinical outcomes at 1 and 3 months when compared with other minimally invasive approaches and standard approaches. The mini-subvastus approach had the lowest rate of complications, overall. Further multicenter randomized trials are needed to determine the minimally invasive approach that best improves outcomes while minimizing complications. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.


Banerjee S.,Rubin Institute for Advanced Orthopedics
The journal of knee surgery | Year: 2013

Blood loss is a serious concern during lower extremity total joint arthroplasty with the estimated reduction in hemoglobin concentration known to vary between 2 and 4 g/dL after total knee arthroplasty (TKA). Allogeneic transfusions are commonly used to treat the acute blood loss and postoperative anemia to diminish the potential cardiovascular risks in up to 50% of such cases with a high volume of blood loss. However, these transfusions are associated with the risks of immunologic reactions, immunosuppression, and infection transmission. Multiple blood-saving strategies have been developed to minimize blood loss, to reduce transfusion rates, to decrease complications, and to improve outcomes in the postoperative period. Currently, there are no clear guidelines on the blood management strategies adopted to lessen the blood loss associated with TKA. The aim of this study was to review the literature and provide a broad summary of the efficacy and complications associated with several blood-saving measures that are currently used in the postoperative period. Evidence suggests that simple techniques such as limb elevation, cryotherapy, compression dressings, and drain clamping may reduce external drainage, however, whether these techniques lead to less allogeneic transfusions is currently debatable. Further research on using a combination of these strategies and their cost-effectiveness are needed. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.


Banerjee S.,Rubin Institute for Advanced Orthopedics
The journal of knee surgery | Year: 2013

Substantial amounts of perioperative blood loss occur during total knee arthroplasty (TKA) that may require allogeneic transfusion in more than 30% of patients. Increased blood loss leads to poor physical functioning, increases infection risks, and prolongs hospitalization, which may eventually affect the overall clinical outcomes of TKA. In addition, allogeneic blood transfusions are associated with increased risks of transfusion reactions, immunosuppression, and a variety of immunological reactions. These concerns have led surgeons and anesthesiologists to develop various strategies to conserve blood, reduce costs, and decrease complications related to blood transfusions. Multiple nonpharmacologic intraoperative blood-saving measures have been used including acute normovolemic hemodilution, hypotensive anesthesia, tourniquets, bipolar sealants, intraoperative blood salvage systems, intramedullary femoral plugs, computer-assisted surgery, and the use of patient-specific instrumentation. However, no clear protocol exists currently to help surgeons choose the appropriate method for blood preservation. The aim of this article was to review the various nonpharmacologic intraoperative blood management strategies that have been used in TKA and to analyze their effectiveness and potential complications according to current evidence. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.


The purpose of this prospective controlled trial was to determine whether decrease in contamination could be achieved in nonnavigated and navigated total knee arthroplasties by replacing traditional saws, cutting blocks, and trials with specialized saws and single-use cutting blocks and trials. Various tray wrapping metrics during total knee arthroplasty were measured in 400 procedures performed by 8 different surgeons at 6 institutions. Instrumentation contamination was determined by counting the number of tray sterility indicators, pans, and instruments that were compromised. The results show that a decrease in contamination was evident in 57% (nonnavigated) and 32% (navigated) fewer compromises of tray sterility indicators, pans, and instruments. Single-use instruments show promising benefits, but further study is needed to confirm safety and efficacy before they can be widely adopted. The authors believe that the use of single-use instruments, cutting guides, and trial implants for total knee arthroplasty will play an increasing role in decreasing operating room contamination and potential deep infections. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.


Johnson A.J.,Rubin Institute for Advanced Orthopedics
The journal of knee surgery | Year: 2013

The purpose of this study was to evaluate the incidence of surgical site infections in total knee arthroplasty patients using a preadmission cutaneous skin preparation protocol compared with a cohort of patients undergoing standard in-hospital perioperative preparation only. Records between 2007 and 2010 were reviewed to identify deep incisional and periprosthetic infections among patients using the chlorhexidine protocol (478 patients) and patients who did not use the protocol (1,735 patients). Patients using the chlorhexidine cloths were given two packets of six chlorhexidine gluconate-impregnated cloths, with instructions for use, the evening before and morning of surgery. A statistically lower incidence of surgical site infection was found in patients using the chlorhexidine cloths (0.6%) compared with patients undergoing in-hospital perioperative skin preparation only (2.2%). On the basis of the results of this study, a preadmission chlorhexidine protocol seems to be an effective method to prevent surgical site infections in total knee arthroplasty procedures. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.


Conway J.D.,Rubin Institute for Advanced Orthopedics
Orthopedic Clinics of North America | Year: 2010

This article focuses on comparing patient morbidity with harvesting bone graft for the treatment of nonunions from three different sites. Anterior iliac crest graft is the most commonly used site; however, the posterior iliac crest and intramedullary canal provide greater quantities of bone. The anterior and posterior iliac crests also have some donor site complications such as nerve injury and persistent pain. The intramedullary canal, when compared with anterior and posterior iliac crest, offers the largest quantity of bone graft with the least amount of patient donor site morbidity. The intramedullary canal also appears to be a bone graft source that can be reharvested, unlike the anterior and posterior iliac crest donor sites. © 2010 Elsevier Inc. All rights reserved.

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