BACKGROUND:Pelvic axial rotation affects the functional orientation of an acetabular component. Every 1° of axial rotation changes functional acetabular anteversion by 1°. There is limited information on pelvic rotation in THA patients, since it is difficult to measure on routine radiographs. Therefore, we used spine-to-ankle biplanar radiography to investigate variability in pelvic rotation in patients before and after THA.METHODS:In 156 patients undergoing primary unilateral THA, we measured preoperative, 6 weeks and 1 year postoperative pelvic rotation in both standing and sitting positions using a biplanar radiography system. Patients with fixed pelvic rotation had a similar magnitude and direction of pelvic rotation in all standing or sitting images. We further identified patients with position-independent or position-dependent fixed pelvic rotation.RESULTS:Pelvic rotation was common in THA patients, with 82 patients (53% of 156 patients) having at least 1 image with > 7° of rotational deformity. 12 patients (8% of 156 patients) had fixed rotation, 6 patients (4%) had position-independent fixed axial rotation and 6 patients (4%) had position-dependent fixed axial rotation.CONCLUSIONS:It may be important to recognise whether a THA patient has a fixed pelvic axial rotational deformity, where 1 hip is consistently forward or backward in functional imaging. Fixed rotation will increase or decrease the functional anteversion of an acetabular component depending on THA side. Further research might better characterise associations and predictors of fixed axial rotation and its impact on patient outcomes after THA.

Background: Residual pain is an important cause of patient dissatisfaction after total knee arthroplasty (TKA). A recent study at our institution found that a modern prosthesis was associated with less residual and anterior knee pain at 2-year follow-up when compared to its predecessor. The aim of this study is to evaluate these implants at 5-year follow-up. Methods: From July 2012 to December 2013, 100 consecutive modern TKAs were identified from our prospective Institutional Review Board approved database. All patients with 5-year clinical follow-up (n = 77) were matched in a one-to-one fashion based on age, gender, body mass index, and follow-up with a predecessor TKA. Clinical outcomes were assessed with a patient-administered questionnaire for specifically anterior knee pain, painless noise, painful crepitation, and satisfaction. Overall function was assessed using Knee Society Scores and Western Ontario and McMaster University Osteoarthritis Index. Results: At 5-year follow-up, there were no significant differences between the modern TKA and a predecessor TKA in the Knee Society pain or function scores (P = .24 and P = .54, respectively). The overall prevalence of residual pain was less with the modern TKA compared to its predecessor (19.5% vs 36.3%; P = .02), but the prevalence of isolated anterior knee pain was similar in both cohorts (11.7% vs 22.1%; P = .09). There was no difference in painless noise (19.5% vs 13.3%; P = .28) or satisfaction scores (7.9 +/- 2.4 vs 7.6 +/- 2.6; P = .25) between the modern and predecessor cohorts. Conclusion: At 5-year follow-up, we found that both the modern and predecessor prostheses provided excellent clinical outcomes. The modern TKA was associated with less residual pain compared to its predecessor, but we were unable to detect differences in the prevalence of isolated anterior knee pain, painless noise, Knee Society Scores, or radiographic evaluation. (C) 2020 Elsevier Inc. All rights reserved.

Background: Cultural differences between continents may also affect the outcome on interventions. This study compared an Asian and North American cohort of total knee replacement (TKR) patients. Questions/purposes: This study aims to compare the patient-reported outcome measures as well as a functional outcome after TKR between these two different patient populations with a different cultural societal background in two different countries. Patients and Methods: A retrospective study on two cohorts of 76 Asian TKR patients and 64 North American TKR patients were compared. Demographics, patient-reported outcome measures (Knee Society Score (KSS), Patient-Administered Questionnaire (PAQ), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), knee range of motion (RoM), and radiographic component position were compared. Results: The Asian cohort had more females compared to the North American and significantly worse preoperative RoM, and worse KSS function score and PAQ pain scores. The preoperative KSS knee score and WOMAC scores were comparable between the two groups. Postoperatively, the differences in WOMAC and KSS knee scores were significant, while KSS function and PAQ were comparable between groups. Conclusions: Even though Asian TKR patients had significantly worse preoperative scores, their postoperative outcomes were comparable to North Americans. The higher preoperative functional deficit and the higher pain levels in the Asian population might be due to cultural differences and/or socioeconomic reasons, which made Asian patients present with more severe conditions in the preoperative consultation for a possible surgical treatment compared to North Americans. More research is needed to investigate the difference between these cultural impacts on TKR outcomes. Level of Evidence: Level III/Retrospective cohort study.

Background: Anterior knee pain (AKP) remains a complex issue affecting patient satisfaction after total knee arthroplasty. Several radiographic parameters have been shown to be causative factors with various designs. The aim of this study is to evaluate the known radiographic parameters of AKP and clinical outcomes (ie, AKP) in the setting of a modern prosthesis with an anatomic patella button. Methods: Between July 2012 and December 2013, 90 total knee arthroplasties received 3 skyline views taken at 30 degrees, 45 degrees, and 60 degrees. A patient-administered questionnaire was administered at 2-year follow-up to assess the incidence of AKP, painless noise, and satisfaction. Radiographs were analyzed for patellofemoral overstuffing, patellar tilt, and patellar displacement, and evaluated the patella resection angle. Results: On the patient-administered questionnaire, 10 (11.1%) patients reported AKP of a mild-to-moderate nature. Thirty-one had the best view at 30 Merchant views, 24 had best views at 45, and 35 had best views at 60. We found that patellar resection angle correlated with AKP (odds ratio 1.21, P =.044) and painless noise (odds ratio 1.22, P =.034). Patellar displacement and patellofemoral stuffing did not correlate with AKP or painless noise. No radiographic measurements correlated with changes in Knee Society Score pain or function scores or range of motion. Conclusion: We found that a patellar resection angle correlated with the incidence of AKP and painless noise at 2-year follow-up. We failed to find any correlation with patellofemoral overstuffing, patellar displacement, or patellar tilt with clinical outcomes. We recommend the use of 3 Merchant views to fully evaluate the patellofemoral joint. (c) 2019 Elsevier Inc. All rights reserved.

Heterotopic ossification (HO) is prevalent after total hip arthroplasty (THA). Oral nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 (COX-2) inhibitors have reduced the incidence of HO; however, to the authors' knowledge, no studies have reported the incidence and severity of HO with a pain protocol highlighted by celecoxib in the pre- and postoperative period with a posterolateral approach. Between October 2014 and October 2015, a retrospective study was conducted of 687 consecutive primary THAs with minimum 1-year follow-up performed between January 2009 and December 2013. All patients underwent a posterolateral THA with a multimodal pain protocol consisting of preoperative celecoxib; local steroid infiltration intraoperatively; postoperative celecoxib, dexamethasone, and ketorolac; and aspirin or warfarin thromboprophylaxis. For all patients, pre- and postoperative radiographs were examined and classified for HO using the Brooker classification. Interobserver reliability was calculated for both incidence of HO and Brooker classification. Overall, HO was present around 98 (14.3%) THAs. The incidence of Brooker I, II, and III HO was 38 (5.5%), 47 (6.8%), and 12 (1.7%), respectively. No patients required surgical excision or had radiographic evidence of Brooker IV HO. Multivariate logistic regression identified male sex and hypertrophic osteoarthritis as significant risk factors. The use of aspirin for thromboprophylaxis significantly reduced the incidence of HO. This study found the overall incidence of HO when using celecoxib during a posterior THA to be 14.3%, which is similar to what others have reported with the direct lateral approach and with other COX-2 inhibitors for a posterior approach. Risk factors include male sex and preoperative hypertrophic osteoarthritis. [Orthopedics. 2018; 41(1):e92-e97.].

Introduction:Successful total joint arthroplasty requires accruate and reproducible acetabular component position. Acetabular component malposition has been associated with complications inlcuding dislocation, implant loosening, and increased wear. Recent literature had demonstrated that high-volume fellowship trained arthroplasty surgeons are in the “safe zone” for cup inclination and anteversion only 47% of the time. (1) Computer navigation has improved accuracy and reproducibility but remains expensive and cumbersome to many hospital and physicians. Patient specific instrumentation (PSI) has been shown to be effective and efficient in total knee replacements. The purpose of this study was to determine in a cadaveric model the anteversion and inclination accuracy of acetabular guides compared to a pre-operitive plan.Methods:8 fresh-frozen cadaveric pelvis specimens underwent Computer Tomography (CT) in order to create a 3D reconstruction of the acetabulum. Based on these 3D reconstruction, a pre-operati...

Introduction:Non-cemented, porous-coated metaphyseal sleeves have been designed to improve biologic fixation and stability in revision total knee arthroplasty (TKA) with major bone defects. The aim...

The goals of any rehabilitation protocol should be to control pain, improve ambulation, maximise range of motion, develop muscle strength, and provide emotional support. Over 85% of TKA patients will recover knee function regardless of which rehabilitation protocol is adopted but the process can be facilitated by proper pain control, physical therapy, and emotional support. The remaining 15% of patients will have difficulty obtaining proper knee function secondary to significant pain, limited preoperative motion, and/or the development of arthrofibrosis. This subset will require a special, individualised rehabilitation program, which may involve prolonged oral analgesia, continued physical therapy, more diagnostic studies and occasionally manipulation. Controlling pain is the mainstay of any treatment plan. The program described herein has been used at Ranawat Orthopaedics over the last 10 years in more than 2000 TKAs.

Introduction The goal of revision total hip arthroplasty (THA) for acetabular defects is to achieve the best stability and fixation with available host bone. Tritanium is a highly porous metal construct with a titanium matrix coating. We are reporting our experience of utilizing this material in patients with major acetabular defects. Methods Between February 2007 and August 2010, 24 consecutive hips (23 patients) underwent acetabular reconstruction using the Tritanium cups. The acetabular defects were assessed using the Paprosky classification. Anteroposterior and lateral radiographs were analyzed at follow-up based for the presence of radiolucent lines more than 2 mm in any of the 3 zones. Results Mean follow-up was 3.6 ± 1.1 years (range 1.5–5 years). There were 12 males and 11 females. The acetabular defects were type 2a (2 hips), 2b (3 hips), 2c (5 hips), 3a (8 hips), and 3b (6 hips). Two patients had pelvic dissociation. Mean anteversion and abduction angles were 43 ± 4.6 and 19.5 ± 4.4 degrees respectively. All hips had radiographic evidence of osteointegration. Four hips had small demarcation at zones 1 and 3 ( Discussion and Conclusion The short-term results of titanium cups in major acetabular defects are encouraging. Our results demonstrate excellent safety and efficacy of this material in revision THA.

This is the first long-term (mean 11.6 years), prospective, matched-pair study (based on age, gender, BMI and UCLA scores) using MAVRIC (multi-acquisition variable-resonance image combination) magnetic resonance imaging to analyze reactive synovitis and osteolysis between rotating-platform posterior-stabilized (RP-PS), fixed-bearing metal-back (FB-MB), and all-polyethylene tibial (APT) in active patients (24 total, 8 in each group, mean age of 64 years, mean UCLA of 8.5) with identical femoral component and polyethylene. Reactive synovitis was observed in 6 RP-PS (75%), all 8 FB-MB (100%), and 6 APT (75%). There was a significant difference between the RP-PS and FB-MB knees in volumetric synovitis (P=0.023). Osteolysis with bone loss more than 4mm was seen in 3 FB-MB, 2 APT and none for RP-PS. These were not statistically significant.

IntroductionThere has not been a comparison of patients and outcomes between two separate countries for any knee prosthesis. This study compares total knee replacement outcomes between an Indonesian and American cohort. We aim to compare the clinical results between two different hospitals in two different countries using post-operative range of motion as the primary clinical result.Materials and Methods177 Indonesian RPF TKR patients were compared to 84 American patients. Demographics, patient recorded outcomes scores (KSS, PAQ, WOMAC), flexion, and component size were compared between the groups. Standard t-test was used to compare the variables between the two countries and regression analysis adjusting for age, BMI, length of follow-up, sex, preoperative WOMAC and PAQ score, preoperative KSS knee score, preoperative KSS function score, and preoperative UCLA was used to compare outcomes.ResultsBetween the Indonesian and American RPF cohorts there was significant difference between age (64.6±7.08 vs. 67...

IntroductionCup positioning in total hip arthroplasty (THA) is an important variable for short and long term durability of any hip implant. This novel method utilises internal and external bony landmarks, and the transverse acetabular ligament for positioning the acetabular component.MethodsThe cup is placed parallel and superior to the transverse ligament and inside the anterior wall notch of the true acetabulum, and then adjusted for femoral version and pelvic tilt, fixed obliquity, and transverse rotational deformity based on weight bearing pre-operative radiographs.Seventy consecutive THRs (68 patients) were performed using the above technique. The cup radiographic and functional anteversion and abduction angle were measured on post-operative weight bearing pelvic radiographs using EBRA software.ResultsThe mean follow-up was 8.1 ± 2.4 months (4.3 – 11.8 months). There were no dislocations. The mean anteversion and abduction angle was 41.8 degrees ± 4.6 degrees and 18.5 degrees ± 4.4 degrees, respectiv...

Introduction All current methods of cup placement use anterior pelvic plane (APP) as the reference. However, the majority of studies investigating the measurement of anteversion (AV) and abduction angles (AA) are inaccurate since the effect of pelvic tilt and obliquity are not considered. The aim of this study was to describe a reproducible, novel technique for functional cup positioning using internal and external bony landmarks and the transverse acetabular ligament (TAL). Methods The pelvic obliquity and tilt are measured on the pre-operative weight bearing AP and lateral pelvic radiographs. Intra-operatively, the highest point of the iliac crest is identified and a line is drawn to the middle of the greater trochanter with knee flexed to 90 degrees and leg thigh horizontal to the floor, parallel to the APP. The cup is placed parallel to the TAL and inside the anterior acetabular wall notch, and then is adjusted for the femoral anteversion, pelvic tilt and obliquity. The angle between the drawn line and the cup handle is the operative anteversion. 78 consecutive total hip replacements (76 patients) were performed using this technique. The functional cup orientation was measured on post-operative weight bearing pelvic radiographs using EBRA software. Results The mean follow-up was 1.2 ± 0.3 years. There were no fracture, dislocation or infection. The mean functional AV and AA were 17.9° ± 4.7° (7.8–28.7) and 41.7° ± 3.8° (33.4–50), respectively. The mean pelvic tilt and obliquity were −3.1° ± 9.7° (−25–9) and −1.5° ± 3.2° (−9.9–7.4), respectively. 96% of functional AV and 100% of functional AA measurements were within the safe zone. Discussion and Conclusion This is an easy, accurate, and reproducible technique, which uses bony landmarks and TAL, adjusted for femoral anteversion and pelvis tilt and obliquity. Weight-bearing radiographs should be used to standardise the measurements with the goal to reproduce the functional cup orientation within the safe zone.

IntroductionTotal hip arthroplasty (THR) is one of the most successful procedures performed today. Uncemented acetabular components have by and large replaced cemented cups. As such, optimal fixati...

Introduction: I always aim for neutral mechanical axis alignment. My principles of a successful TKA are proper alignment in all 3 planes, soft tissue balance in extension first, flexion gap balanci...

Introduction:Hard-on-hard bearings and surface replacement (SR) have been used in young and active patients due to the reduced wear and lower rates of osteolysis. However, neither of these options ...

Fixation of cemented femoral stems is reproducible and provides excellent early recovery of hip function in patients 60–80 years old. The durability of fixation has been evaluated up to 20 years wi...

IntroductionPotential implant and technique related factors to improve patellofemoral (PF) kinematics in total knee arthroplasty (TKA) are design of trochlear geometry and patella, restoration of posterior offset, patellar tilt and avoid overstuffing. The primary aim of this prospective, matched pair study was to assess the radiographic features of PF kinematics with an anatomic patella.Material and MethodsBetween July 2012 and May 2013, 49 consecutive posterior stabilized cemented Attune TKAs (Depuy Synthes Warsaw Indiana) were matched to the 49 PFC Sigma (Depuy) based on age, gender, and body mass index (BMI). All surgeries were performed via medial parapatellar approach with patellar resurfacing. Radiographic analysis was performed prospectively with minimum 1-year follow-up and included overall limb alignment, anterior offset, posterior offset, joint line, patellar thickness, patellar tilt and patellar displacement by two independent observers.ResultsWe found significant improvement in all post-operat...