General Principles: All repairs should be repaired in full extension. Repairs should be immobilised in full extension for 6–12 weeks. Gradual resumption of motion in a hinged brace over an additional 6–8 weeks almost always yields flexion to at least 90 degrees. Marlex Mesh has been shown to be an excellent replacement as well as an augment for deficient soft tissue.

Acute tibial tuberosity avulsion: Open repair is best accomplished with a non-absorbable heavy Krackow suture, secured distally around a screw and washer followed by 6–8 weeks of immobilization. Augmentation with a semitendinosus graft or Marlex can provide additional support.

Acute Patella Tendon Rupture: End-to-end repair is standard, but re-rupture is not uncommon, so supplemental semitendinosus reconstruction is recommended. The tendon is harvested proximally, left attached distally and passed through a transverse hole in the inferior patella. The gracilis tendon can be harvested and sutured to semitendinosus for additional length if needed.

Acute Quadriceps Tendon Rupture: These can be repaired end-to-end with a non-absorbable heavy Krackow suture. A superficial quadriceps fascial turndown or mesh may be a useful adjunct.

Patella Fracture: Treatment depends on the status of the patellar component and the loss of active extension. If the component remains well fixed and the patient has less than a 20 degree lag. A loose component and/or > 20 degree extensor lag requires ORIF +/− component revision.

Chronic Disruptions: While standard repair techniques are possible, tissue retraction usually prevents a “tension-free” repair. In most chronic disruptions allograft extensor mechanism reconstruction is preferable. If the patella remains viable and has not retracted proximally an Achilles tendon graft is appropriate while in any patellar tendon defect, mesh repair has been shown to be effective.

The orthopaedist may need to act as an important adjunct to the oncologist in management of the cancer patient with hip disease. Management of the cancer patient with routine hip pathology may be relatively straightforward but the surgeon should note that the cancer patient may be on treatment protocols which affect wound healing, the immune system and the risk of DVT. The principles of managing metastatic disease include recognising the presence of lesions in bone about the hip, the occasional need for biopsy, the use of radiation in sensitive tumors and finally surgical stabilization or replacement when needed. In some cases percutaneous cementation of metastatic disease or radiofrequency ablation may be appropriate. Factors which can complicate management of patients who have completed treatment of peri-pelvic cancer, may include radiation therapy which can lead to osteonecrosis of the acetabulum. Greater than 500Cgy of radiation has been associated with high rates of acetabular fixation failure regardless of fixation type in several series. Decision making in these patients can be aided by consultation with previous radiation therapy providers to estimate the dose sustained by the local tissues under consideration. Increased rates of infection and wound healing have also been noted secondary to long term lymphatic obliteration caused by radiation. These concerns also affect the surgeon who must manage patients with acute metastatic disease where radiation and immune-compromise secondary to chemotherapy are often present.

The initial application of bone ingrowth technology to the fixation of total knee arthroplasty (TKA) components without bone cement was based on the premise that bone cement was “not biologic”, and so over time would undergo fatigue failure with subsequent loosening. It was hoped that this problem could be obviated by cementless fixation by bone ingrowth, which would remodel over time and not fatigue. In addition, it was anticipated that the failed cementless TKA might be easier to revise and leave the surgeon with more bone to work with. Whether or not cementless fixation of TKA components was justified on any of these counts was uncertain through the first 2 decades of their use. Much of the data accumulated during that period poorly supported these contentions, while cemented TKA was increasingly reported as a reliable, consistent and less complicated form of TKA fixation. However, over the past decade, new evidence has accumulated demonstrating greater success with this technology in several well designed studies as well as from registry studies. Most of this evidence involves the use of Porous Tantalum. However, increasing evidence that loosening of well done, well designed cemented TKA is rare along with some evidence that a certain percentage of cementless TKA patients fail to achieve stability remains concerning. In addition, no studies have justified improved longevity to the extent that the increased cost of cementless devices can be justified.

Laxity Differences in CR & PS TKA -Achieving Total Knee Balancing Using Bone Cut Adjustments and Correlation with Varus-Valgus Lift-Off

The Incidence and Mid Term Functional Effect of Partial PCL Recession in Fixed and Mobile Bearing PCL Retaining TKA

Clinical and Radiographic Results of a Modern Design, Onlay Patellofemoral Arthroplasty at a Minimum Two-Year Follow-Up

Custom Cutting Guides Do Not Improve Total Knee Arthroplasty Outcomes at 2 Years Follow-up

Tourniquet Use During TKA -Effect on Recovery of Strength and Function: a randomised, double-blind, control trial

Prospective, Randomised Trial of Standard vs Cross-linked Tibial Poly

Crosslink vs. Conventional TKA Poly Retrieval Analysis

Unplanned Readmissions after TKA Using a Statewide Database

Does Prior Cartilage Restoration Negatively Impact Outcomes of TKA

Periprosthetic Femur Fracture: Better to Revise than to Fix

Increased Non-stemmed Tibial Failures in Patients with a BMI ≥ 35

The Effect Of Canal Fit And Fill in Revision THA With Modular, Fluted, Tapered Stems

The Wagner Cone Stem For The Challenging Femur In Primary Total

Will Metal Heads Restore Integrity of Corroded Trunnions at Revision THR?

Influence of Head Size, Materials and Taper Design on Fretting and Corrosion of Metal on Polyethylene THR

Delta Ceramic on Ceramic THA – Midterm IDE Study Results

Refining Acetabular Safe Zone for Posterior Approach in THA

Comparison of a Pain Program for THA with and without Liposome Bupivacaine

General Principles

Repairs should be immobilised in full extension for 6–8 weeks. Gradual resumption of motion in a hinged brace over an additional 6–8 weeks almost always yields flexion to at least 90 degrees.

Acute tibial tuberosity avulsion - Open repair is best accomplished with a non-absorbable heavy Krackow suture, secured distally around a screw and washer followed by 6 to 8 weeks of immobilization. Augmentation with a semitendinosus graft can provide additional structural support.

Acute Patella Tendon Rupture - End to end repair is standard, but re-rupture is not uncommon, so supplemental semitendinosus reconstruction is recommended. The tendon is harvested proximally, left attached distally and passed through a transverse hole in the inferior patella. The gracilis tendon can be harvested and sutured to semitendinosus for additional length if needed.

Acute Quadriceps Tendon Rupture - These can be repaired end to end with a non-absorbable heavy Krackow suture. A superficial quadriceps fascial turn-down may be a useful adjunct.

Patella Fracture - Treatment depends on the status of the patellar component and the loss of active extension. If the component remains well fixed and the patient has less than a 20-degree lag. A loose component and/or >20-degree extensor lag requires ORIF +/− component revision.

Chronic Disruptions - While standard repair techniques are possible, tissue retraction usually prevent a “tension-free” repair. In most chronic disruptions complete allograft extensor mechanism reconstruction is preferable. If the patella itself has not retracted proximally and remains intact other allograft soft tissues are a viable alternative. All grafts should be repaired tightly with the knee in full extension.

General Principles

Repairs should be immobilised in full extension for 6–8 weeks. Gradual resumption of motion in a hinged brace over an additional 6–8 weeks almost always yields flexion to at least 90 degrees.

Acute tibial tuberosity avulsion

Open repair is best accomplished with a non-absorbable heavy Krackow suture, secured distally around a screw and washer followed by 6–8 weeks of immobilisation. Augmentation with a semitendinosus graft can provide additional structural support.

Acute Patella Tendon Rupture

End to end repair is standard, but re-rupture is not uncommon, so supplemental semitendinosus reconstruction is recommended. The tendon is harvested proximally, left attached distally and passed through a transverse hole in the inferior patella. The gracilis tendon can be harvested and sutured to semitendinosus for additional length, if needed.

Acute Quadriceps Tendon Rupture

These can be repaired end to end with a non-absorbable heavy Krackow suture. A superficial quadriceps fascial turn-down may be a useful adjunct.

Patella Fracture

Treatment depends on the status of the patellar component and the loss of active extension if the component remains well fixed and the patient has less than a 20 degree lag. A loose component and/or >20 degree extensor lag requires ORIF +/− component revision.

Chronic Disruptions

While standard repair techniques are possible, tissue retraction usually prevent a “tension-free” repair. In most chronic disruptions complete allograft extensor mechanism reconstruction is preferable. If the patella itself has not retracted proximally and remains intact, other allograft soft tissues are a viable alternative. All grafts should be repaired tightly with the knee in full extension.

Several disadvantages can be attributed to suture knots in wound closure: they are tedious to tie, may be a nidus for infection and can strangulate tissue. They may extrude through skin weeks after surgery. Additional needle manipulations during knot-tying may predispose to glove perforation. A self-anchoring barbed suture has been developed that requires no knots (or slack suture management) for wound closure. The elimination of knot tying has demonstrated some advantages over conventional wound closure methods. It has demonstrated comparable efficacy for the long term closure of C section wounds. The lack of bulk afforded by the knotless suture proves useful in mid face lift applications where knots are a drawback to traditional suture use and cosmesis is of primary importance.

This type of suture has demonstrated improved “water tightness” in knee arthrotomy closure compared to a standard interrupted suture technique in a cadaver model, has demonstrated reduced time for total surgery by 10% and time for closure by 33%. Use of this suture has been shown to be safe and effective in many other surgical specialties, while proving easier and faster than traditional suturing technique. Its use is highly recommended.

Direct Anterior vs Mini-posterior THA with Advanced Pain & Rehab Protocols

Intra-articular Injection Within a Year of THA Predicts Early Revision

Specific Screening of MoM Hip Patients Significantly Increases Revision Surgery

Taper Analysis Supports Retention of Well-fixed Stem in Revision of MoM THA

Variables Influencing Corrosion of Modular Junctions in Metal-on-Poly THR

Lysis and Wear of Large and Standard Metal on Highly Crosslinked Poly

A Decade of Highly Crosslinked Poly in THA: A Review of 1,484 Cases

Wear of Highly Crosslinked Poly with 36mm Heads – 5 Yr Follow Up

Fixation and Wear of Contemporary Acetabulum and Crosslinked Poly at 10 Years

Prospective, Randomised Study of 2 Skin Preps in Reducing SSI after TJA

Diagnostic Threshold for Synovial Fluid Analysis in Late Peri-prosthetic Infection, Diabetes, Hyperglycemia, Hemoglobin A1c and the Risk of Joint Infections

Infection Risk Stratification in THA and TKA

Risk Factors for Infection After THA: Preventable vs Non-preventable

Do Space Suits Increase Contamination and Deep Infection in TJA

Improving Detection of PJI in THA Through Multiple Sonicate Fluid Cultures

Sonication for the Enhanced Diagnosis of Prosthetic Joint Infection

Aspiration During 2-Stage Knee Revision Inadequate for Infection Detection

Revision Rates and Outcomes Related to Duration of TKA Surgery

Does Operative Time Affect Infection Rate Following Primary TKA?

Liposomal Bupivacaine: The First 1,000 Cases in a New Era

Cement Depth and Stem Stability in Revision TKA with Hybrid Fixation

The presentations to be discussed by the panel are: 1.) No Increased Risk of Knee Arthroplasty Failure in Metal Hypersensitive Patients: A Matched Cohort Study; 2.) Knee Arthrodesis is Most Likely to Control Infection and Preserve Function Following Failed 2 Stage Procedure for Treatment of Infected TKA: A Decision Tree Analysis; 3.) Does Malnutrition Correlate with Septic Failure of Hip and Knee Arthroplasties?; 4.) Diagnosing Periprosthetic Joint Infection: The Era of the Biomarker Has Arrived; 5.) Are Patient Reported Allergies a Risk Factor for Poor Outcomes in Total Hip and Knee Arthroplasty?; 6.) Revising an HTO or UKA to TKA: Is it more like a Primary TKA or a Revision TKA?; 7.) At 5 Years Highly-Porous-Metal Tibial Components Were Durable and Reliable: A Randomised Clinical Trial of 389 Patients; 8.) Current Data Does Not Support Routine Use of Patient-Specific Instrumentation in Total Knee Arthroplasty; 9.) Barbed vs. Standard Sutures for Closure in Total Knee Arthroplasty: A Multicenter Prospective Randomised Trial; 10.) Particles from Vitamin-E-diffused HXL UHMWPE Induce Less Osteolysis Compared to Virgin HXL UHMWPE in a Murine Calvarial Bone Model; 11.) Construct Rigidity: Keystone for Reconstructing Pelvic Discontinuity; 12.) Do You Have to Remove a Corroded Femoral Stem?; 13.) Direct Anterior Versus Mini-Posterior Total Hip Arthroplasty with the Same Advanced Pain Management and Rapid Rehabilitation Protocol: Some Surprises in Early Outcome; 14.) Adverse Clinical Outcomes in a Primary Modular Neck/Stem System.

The orthopaedic surgeon may need to act as an important adjunct to the oncologist in management of the cancer patient with metastatic hip disease. Management of the cancer patient with routine hip pathology may be relatively straightforward but the surgeon should note that the cancer patient may be on treatment protocols which affect wound healing, the immune system and the risk of DVT. The principles of managing metastatic disease include recognising the presence of lesions in bone about the hip, the occasional need for biopsy, the use of radiation in sensitive tumors and finally surgical stabilisation or replacement when needed. In some cases percutaneous cementation of metastatic disease or radiofrequency ablation may be appropriate. Factors which may complicate management of patients who have completed treatment of peri-pelvic cancer, may include radiation therapy which can lead to osteonecrosis of the acetabulum. Greater than 500 Cgy of radiation has been associated with high rates of acetabular fixation failure regardless of fixation type in several series. Decision making in these patients can be aided by consultation with previous radiation therapy providers to estimate the dose sustained by the local tissues under consideration. Increased rates of infection and wound healing have also been noted secondary to long term lymphatic obliteration caused by radiation. These concerns also affect the surgeon who must manage patients with acute metastatic disease who may also be undergoing chemotherapy as well as radiation.

While a tourniquet is traditionally used to obtain a dry field during primary TKA (and is also thought to reduce perioperative blood loss), adverse effects of tourniquet use have been reported. Avoiding routine use of the tourniquet during TKA can minimise certain complications while improving the quality of the early result.

Most studies of TKA with and without tourniquet show little difference in all forms of blood loss except for intraoperative. Some studies even show less overall blood loss in groups without tourniquet use. Modern techniques to minimise intraoperative loss have included topical treatments, systemic medications, as well as a bipolar tissue sealer. Visualisation of bleeding vessels and their management intra-operatively can substantially reduce early post-op hemarthrosis.

Tourniquet use has also been related to post-operative thigh pain. This is a negative aspect of tourniquet use that can interfere with physical therapy and rehabilitation. Occasionally it can be a significant factor in post-op recovery. Data supports the fact that avoiding a tourniquet or at least reducing pressure to the minimum necessary may help to reduce post-operative thigh pain.

Ischemia and tissue damage can affect neuromuscular function and rehabilitation following TKA. The time necessary to achieve straight leg raising and knee flexion is delayed by tourniquet use during TKA. Compressive nerve injury also may result in secondary effects of denervation on distal tissues. This denervation can delay recovery of blood flow and increase vessel spasm, hemorrhage and edema. The degree of dysfunction is related to the magnitude of tourniquet compression.

Tension in the lateral retinaculum is directly affected by tourniquet use. Observations from these studies would indicate that lateral release should be performed only if found necessary after tourniquet deflation in order to minimise the potential morbidity that accompanies this procedure.

Although thromboembolic events can occur during TKA without, tourniquet use is associated with more frequent events when it is used.

Finally, it is prudent to avoid the use of a tourniquet in patients with vascular calcifications around the knee or abdomen due to advanced arteriosclerosis, previous bypass grafts, or reduced limb or tissue blood supply for any reason. Routine TKA with minimal tourniquet use greatly simplifies its performance in those settings where it is contra-indicated.

1.

Reconstruction of Failed Hip Abductors following THA-A New Surgical Technique using Graft Jacket Matrix

While a tourniquet is traditionally used to obtain a dry field during primary TKA (and is also thought to reduce peri-operative blood loss), adverse effects of tourniquet use have been reported. Avoiding routine use of the tourniquet during TKA can minimise certain complications while improving the quality of the early result.

Most studies of TKA with and without tourniquet show little difference in all forms of blood loss except for intra-operative. Some studies even show less overall blood loss in groups without tourniquet use. Modern techniques to minimise intra-operative loss have included topical treatments, systemic medications, as well as a bipolar tissue sealer. Visualisation of bleeding vessels and their management intra-operatively can substantially reduce early post-op hemarthrosis.

Tourniquet use has also been related to post-operative thigh pain. This is a negative aspect of tourniquet use that can interfere with physical therapy and rehabilitation. Occasionally it can be a significant factor in post-op recovery. Data supports the fact that avoiding a tourniquet or at least reducing pressure to the minimum necessary may help to reduce post-operative thigh pain.

Ischemia and tissue damage can affect neuromuscular function and rehabilitation following TKA. The time necessary to achieve straight leg raising and knee flexion is delayed by tourniquet use during TKA. Compressive nerve injury also may result in secondary effects of denervation on distal tissues. This denervation can delay recovery of blood flow and increase vessel spasm, hemorrhage and edema. The degree of dysfunction is related to the magnitude of tourniquet compression.

Tension in the lateral retinaculum is directly affected by tourniquet use. Observations from these studies would indicate that lateral release should be performed only if found necessary after tourniquet deflation in order to minimise the potential morbidity that accompanies this procedure.

Although thrombo-embolic events can occur during TKA without, tourniquet use is associated with more frequent events when it is used.

Finally, it is prudent to avoid the use of a tourniquet in patients with vascular calcifications around the knee or abdomen due to advanced arteriosclerosis, previous bypass grafts, or reduced limb or tissue blood supply for any reason. Routine TKA with minimal tourniquet use greatly simplifies its performance in those settings where it is contra-indicated.

1.

Patient Factors