Purpose: Infection after TJA is a rare but devastating complication. Horizontal laminar airflow has been advocated to reduce infection rate.

Methods: 896 consecutive primary and revision total joint arthroplasties of the hip and knee were retrospectively reviewed. The first 751 were performed before February 2004 in a horizontal laminar air flow room; the final 146 were performed without laminar flow from February 2004 through May 2005. All patients received the same perioperative antibiotics, wound management, and rehabilitation program. Body exhaust systems were worn in all cases.

Results: There were a total of 10 infections (1.1%) requiring surgical treatment, including 6 deep knee infections (0.67%), and four (0.45%) wounds (3 knees and 1 hip) with delayed healing or superficial infections. 9 of the infections occurred in the laminar flow group (1.2%), including all 6 deep knee infections (6/456=1.3%), 2 knee and 1 hip wound infection. Only 1 infection (0.68%), in a knee wound, occurred in the non-laminar flow group. There were no deep hip infections. Statistically, more knees became infected than hips overall (9/550=1.64% vs 1/346=0.29%)(p< 0.01) and more knees developed deep infection with laminar flow than without (6/456=1.2% vs 0/94=0.00%)(p< 0.1).

Conclusions: Laminar air flow did not alter the infection rate in THA, but may have increased infection rate in TKA. Infection is multifactorial, and longer follow up of the non-laminar flow group may reduce the differences seen. Nevertheless, this data agrees with other published data and is of significant concern for the TKA surgeon and patient alike.

Purpose: Double-tapered polished cemented femoral stems have demonstrated excellent long-term clinical results, but subsidence with cement mantle fracture, distal stress transfer and proximal stress shielding persist as problems. Adding a third taper from broad lateral to narrow medial purportedly reduces subsidence and improves proximal bone loading and preservation. We report our independent experience with a triple-tapered collarless polished cemented stem.

Methods: Between May 1999 and July 2001, 66 C-Stems (DePuy, Warsaw, IN, USA) were implanted in 45 females and 15 males, with a mean age of 67 years (R 35–86) and mean weight of 77 Kg (R 42–117). Diagnoses were OA in 62, RA in 1, AVN in 2 and fracture in 1. Average follow-up was 58 months (R 45–71).

Results: Harris hip scores improved from a mean of 43 (R17–100) to 84 (R 10–100). SF36 and WOMAC scores improved similarly. Six hips dislocated, but there were no reoperations. Subsidence was less than 1 mm in all cases. There was no radiographic stress shielding. Bone quality was maintained, especially in the critical medial calcar region, with positive bone remodeling along radial stress lines and improvement over time of some bone-cement interfaces.

Conclusions: The C-Stem, a triple-tapered collarless polished cemented stem, engages the surrounding cement mantle in an axially stable manner, minimizing subsidence to within the creep tolerances of cement. The radial stresses so generated favorably load the proximal bone, stimulating positive bone remodeling and eliminating stress-shielding. The clinical results at short to mid-term follow-up in this non-designer series are outstanding.

Purpose: Proximal femur fracture occurring at the time of femoral canal preparation or insertion of the femoral component is a recognized complication of primary total hip arthroplasty.

Methods: Two hundred seventy three consecutive primary THAs were reviewed retrospectively for occurrence of intraoperative fracture. 146 cemented femoral components and 127 cementless femoral components were implanted. Intraoperative management of non- or minimally-displaced proximal femur fractures involved placement of either one or two cerclage cables, with postoperative weightbearing to tolerance using an assistive device for approximately six weeks.

Results: Eight (2.9%) hips sustained an intraoperative non- or minimally-displaced fracture of the proximal femur: six (75%) occurred using cementless stems and two (25%) occurred using cemented stems. At an average follow-up of 57 months (R 26–90 months), all patients in the fractured cohort have remained radiographically stable, with well-fixed femoral components showing no evidence of subsidence. All of the patients in this fractured group have achieved good or excellent functional results.

Conclusions: Midterm follow-up results suggest that non- or minimally-displaced proximal femur fractures occurring at the time of primary THA can safely and effectively be managed by placement of single or multiple cerclage cables, and without significant modification of standard postoperative rehabilitation protocols. No compromise in functional outcome has been observed with this treatment method.

Purpose: Dislocation after THA is a multifactorial challenge involving patient, surgical and implant variables. The extramedullary features of a hip implant—offset, neck length, height, version, and head/neck ratio—significantly impact the stability of the reconstruction. We report a significant difference in dislocation rate between two different femoral stems.

Methods: Between May, 1998 and October, 2003, 263 primary THAs were performed by a single surgeon, utilizing identical surgical technique. Acetabular fixation was cementless with 3 varieties of cups in 262 hips and cemented in one hip. 141 hips had a single cemented femoral component (C-Stem, DePuy, Warsaw, Indiana), and 122 hips had a single cementless design (S-ROM, DePuy, Warsaw, Indiana).

Results: Diagnosis, gender, and side were similar between the groups. Mean age of the cemented group was 68.9 years(R 33 to 92) and of the cementless group was 51.9 years (R 19 to 79). The 3 acetabular designs were equally distributed between groups. All hips were implanted with 28 mm heads. There were 12/141 (8.5%) dislocations in the cemented group, and 3/122 (2.5%) dislocations in the cementless group (p < 0.10).

Conclusions: Stability after THA is affected by design features of a femoral implant, including height, neck length, offset, and version. The use of a single stem in all patients may not adequately address individual biomechanic variability. Careful preoperative templating, and the availability of multiple stem designs within a single fixation philosophy, may facilitate matching of extramedullary features to an individual patient’s anatomy in order to optimize postoperative hip stability.

Purpose: Mobile Bearing TKA has been reported to improve patellofemoral tracking due to the self-aligning impact of the mobile bearing. However, limited rotation of the mobile bearing may be insufficient to impact patellar tracking in an otherwise well-balanced TKA.

Methods: Between December 1998 and October, 2003, 445 primary TKAs were performed via transpatellar arthrotomy. The same posterior stabilized femoral component was implanted in all knees. There were 312 fixed bearings and 133 rotating platforms implanted. In order to optimize patellar tracking, a neutral mechanical axis was established, femoral components were lateralized and externally rotated, patellar buttons were medialized, tibial components were externally rotated, and gaps and ligaments were meticulously balanced. Lateral release was performed based on intraoperative assessment of patellar tracking.

Results: Lateral releases were performed in 47 of 312 (15%) fixed bearing knees, and in 14 of 133 (11%) mobile bearing knees (p=NS). Average preoperative alignment in the fixed bearing knees was –5 degrees (R-7 to 20), and in the mobile bearing knees was 0 degrees (R-10 to 20).

Conclusions: Careful surgical technique with attention to the details of optimizing patellar tracking may be the most important factor determining the rate of lateral release. The self-aligning ability of mobile bearing TKA, which has been postulated to improve patellar tracking, may not reduce the need for lateral release in the cohort of patients in whom lateral tilt and subluxation of the patella persist even after other factors affecting patellar tracking have been surgically addressed.

Purpose: Mobile bearing total knee arthroplasty (MBTKA) has been complicated by bearing spinout and dislocation. Balancing the flexion and extension gaps is a basic principle of knee reconstruction, but is often achieved in a haphazard manner. This balance is critical to prevent bearing spinout and dislocation. A surgical technique is presented which actively balances flexion and extension gaps, and avoids spinout and dislocation in MBTKA.

Methods: Between February, 2002 and May, 2004 , 180 primary MBTKAs were performed, utilizing the PFC ∑RP (DePuy, Warsaw, Indiana, USA) system with a PS femoral component. The surgical technique consisted of distal femur and proximal tibia resection, followed by ligament balancing and measurement of the extension gap utilizing laminar spreaders. With laminar spreaders placed in the knee at 90 degrees of flexion, an AP cutting block with free rotation and AP translation, attached to an intramedullary rod was positioned on the distal femur in order to create a symmetric flexion gap matching the thickness of the previously established extension gap. After AP resections, gap balance was verified using spacer blocks. Preparation of the bony surfaces to accept the prostheses was completed in a standard fashion.

Results: No bearing spinout or dislocation, or instability has occurred.

Conclusions: Meticulous surgical technique directed toward strict balance of the flexion and extension gaps prevents bearing spinout and dislocation in MBTKA, and is critical to the success of this technology which offers the potential long-term benefits of lower wear, soft tissue load sharing and improved overall knee mechanics.

While cemented THA has been considered the gold-standard, cementless THA has become a common and even preferred approach for younger individuals and those with acceptable bone stock. Which technology provides superior results and in which patients, however, remains controversial, and has not been systematically studied.

The literature suggests that well-fixed cementless prostheses, and even composite beam cemented prostheses cause stress shielding and progressive osteopenia in the surrounding bone. This compromises and complicates subsequent surgery, particularly in young patients who are at risk for multiple revisions, and may increase the risk of periprosthetic fracture, component failure, and aseptic loosening.

In contrast, polished tapered stems, by behaving according to a taper-slip philosophy, favorably load bone, converting shear stress into radially directed hoop stresses, through the medium of the surrounding visco-elastic cement and its resulting ability to creep.

The C-Stem, (DePuy, Warsaw, Indiana, USA) a cemented triple tapered polished stem is the only stem with published data demonstrating positive remodeling of bone in as many as 20% of patients, and preservation of the critical proximal medial calcar bone. Additional anectdotal reports confirm these results.

The long-term results of cemented stems, which necessarily involve the surviving youngerst cohort in any series, are outstanding. The tapered polished stem technology may improve these historical results, and, by limiting periprosthetic stress shielding and osteopenia, may revolutionize the application of cemented THA in younger patients for whom preservation of bone stock through favorable bone loading is so critical to sustained success of the primary and subsequent revision surgeries.