Total hip and knee arthroplasty is known to have a significant blood loss averaging 3–4 g/dL. Historically, transfusion rates have been as high as 70%. Despite years of work to optimise blood management, some published data suggests that transfusion rates (especially with allogeneic blood) are rising. There is wide variability between surgeons as well, suggesting that varying protocols can influence transfusion rates. Multiple studies now associate blood transfusions with negative outcomes including increased surgical site infection, costs, and length of stay.

Preoperative measures can be employed. Identify patients that are at increased risk of blood transfusion. Smaller stature female patients, have pre-operative anemia (Hgb less than 13.0 gm/dl), or are undergoing revision or bilateral surgery are at high risk. We identify these patients and check a hemoglobin preoperatively, using a non-invasive finger monitor for screening. For anemic patients, iron administration (oral or IV) can be given, along with Procrit/Epogen in select cases. Insurance coverage for that medication has been challenging.

Intraoperative measures that have been linked to reduced postoperative transfusions include regional anesthesia and intraoperative hypotension (mean arterial pressure <60mm/hg). Lowering the surgical time by practicing efficient, organised, and quality surgery, along with leaving a dry field at the completion of surgery can reduce blood loss.

Tranexemic acid (TXA) is an antifibrinolytic agent that has been shown to be effective, reducing average blood loss by 300 cc per case. There are multiple different administration protocols: IV using either a weight-based dosing 10–20 mg/kg or standardised dosing for all patients. Our current regimen is 1 gm IV preoperatively, 1 gm IV in PACU. Topical TXA can be used, usually 2–3 gm mixed in 50–100 cc of saline, sprayed in wound and allow to soak for 3–5 minutes. Oral administration is attractive for ease of use and reduced cost, standard oral dosing is 1950 mg PO 2 hours prior to surgery.

The American Association of Hip and Knee Surgeons, in collaboration with the American Association of Orthopedic Surgeons, American Society of Regional Anesthesiologists, and the Hip & Knee Society have developed a Clinical Practice Guideline with 8 recommendations for TXA as follows: All individual formulations are effective at reducing blood loss – strong; No method of administration is clearly superior at reducing blood loss and the risk of transfusion; The dose of IV or topical TXA does not significantly affect the drug's ability to reduce blood loss and risk of transfusion; Multiple doses of IV or oral TXA compared to a single dose does not significantly alter the risk of blood transfusion; Pre-incision IV TXA administration potentially reduces blood loss and risk of transfusion compared to post-incision administration; Administration of all TXA formulations in patients without history of VTE does not increase the risk of VTE; Administration of all TXA formulations in patients with a history of VTE, MI, CVA, TIA, or vascular stent does not appear to increase the risk of VTE; Administration of all TXA formulations does not appear to increase the risk of arterial thrombotic events; Postoperative measures to reduce transfusion rates include changing transfusion triggers. Instead of treating a “number”, use lower thresholds and employ safe algorithms established.

In conclusion, a comprehensive blood management program can reduce transfusion rates to less than 3% for THA and 1% for TKA and facilitate outpatient total joint arthroplasty.

It is estimated that approximately 3.1 – 7.7% of the general population suffers from primary osteoarthritis of the hip, with up to 42% of these cases being bilateral. The odds of undergoing a contralateral THA after index unilateral THA range from 16–85%. Up to 20% of these patients have the contralateral THA within 5 years. For this patient population, simultaneous bilateral THA may be an appealing option but it remains controversial. Proponents of bilateral simultaneous THA cite advantages such as a single anesthetic exposure, overall shorter length of hospital stay, quicker recovery, earlier return to function, less time off of work, and potential economic advantages. Only recently has there been more data emerging on patients undergoing simultaneous bilateral THA through the direct anterior approach (DAA). The DAA has the distinct advantage of supine positioning that facilitates easy exposure to both hips without the need to reposition the patient onto a fresh surgical incision while performing the second operation. Recent publications suggest that bilateral simultaneous DAA is a safe procedure and may have economic benefits as well.

At our institution between 2010 and 2016, a consecutive series of 105 patients (210 hips) undergoing simultaneous bilateral DAA THA and a matched group of 217 patients undergoing unilateral DAA THA by the same surgeon at a single institution were reviewed. The two groups were matched by gender, age, body mass index and date of surgery. There were no significant differences between the two groups in terms of early complications. There were 2 complications in the unilateral group that were intraoperative nondisplaced calcar fractures that were treated with a single cerclage cable and 50% weight bearing for four weeks. There were 6 in-hospital systemic complications in the unilateral group compared to 7 in the bilateral group (p = 0.129). In-hospital systemic complications were similar between the two groups and included urinary retention, cardiopulmonary abnormalities, alcohol withdrawal, and nausea / vomiting.

There were a total of 14 30-day follow-up hip-related complications in the unilateral group compared to 5 in the bilateral group (p = 0.06) These complications were similar between the two groups and included wound healing issues, tendinitis / bursitis, deep infection, nerve palsy, stem subsidence, and instability. Intraoperative estimated blood loss (EBL) was 360cc in the unilateral group compared to 555cc in the bilateral group (p < 0.001). The bilateral group had lower postoperative day one (POD1) hemoglobin (9.5 g/dl vs. 10.2 g/dl; p < 0.001). Four percent of unilateral patients required blood transfusion compared to 11% in the bilateral group. There were significant differences between the two groups in terms of distance ambulated on POD1 and length of stay (LOS). On average, the unilateral patients walked 235 feet on POD1 compared to 182 feet for the bilateral patients (p < 0.001). Length of stay was significantly longer in the bilateral group (1.95 days vs. 1.12 days; p < 0.001). All 322 patients involved in the study were discharged to home except for a single patient in the bilateral group who was discharged to a skilled nursing facility.

In conclusion, we found no difference in in-hospital or 30-day complication rates when comparing the simultaneous bilateral group to the unilateral group. The main difference when compared to unilateral surgery is increased blood loss yet this did not directly result in specific complications. Simultaneous bilateral DAA THA can be performed safely and without an unacceptably high perioperative complication rate.

Using an institutional database we have identified over 1000 femoral revisions using extensively porous-coated stems. Using femoral re-revision for any reason as an endpoint, the survivorship is 99 ± 0.8% (95% confidence interval) at 2 years, 97 ± 1.3% at 5 years, 95.6 ± 1.8% at 10 years, and 94.5 ± 2.2% at 15 years. Similar to Moreland and Paprosky, we have identified pre-revision bone stock as a factor affecting femoral fixation. When the cortical damage involved bone more than 10cm below the lesser trochanter, the survivorship, using femoral re-revision for any reason or definite radiographic loosening as an endpoint, was reduced significantly, as compared with femoral revisions with less cortical damage.

In addition to patients with Paprosky Type 3B and 4 femoral defects, there are rare patients with femoral canals smaller than 13.5mm or larger than 26mm that are not well suited to this technique. Eight and 10 inch stems 13.5 or smaller should be used with caution if there is no proximal bone support for fear of breaking. Patients with canals larger than 18mm may be better suited for a titanium tapered stem with flutes. While a monolithic stem is slightly more difficult for a surgeon to insert than a modular femoral stem there is little worry about taper junction failure.

The debate regarding the superiority of retaining (CR) or substituting (PS) for the PCL in total knee arthroplasty (TKA) has continued for a generation, without a clear consensus as to which is superior. That debate continues today.

Many studies on this subject have been published, including recent meta-analyses, which demonstrate similar outcomes between CR and PS TKA. Pain scores and functional outcomes appear quite similar between the groups. One outcome measure that appears superior in PS knees, although by a small margin, is in final range of motion, with higher final flexion observed in PS knees. Another study demonstrated superior extensor mechanism efficiency in PS designs compared to CR.

The primary explanation for improved motion is the rollback induced by the cam and post mechanism of the PS knee. By insuring rollback of the femur on the tibia, the chance of impingement between the back of the femur and polyethylene is diminished. This cam and post induced rollback has been shown to be more consistent with native knee kinematics compared to the CR knee, which can be subject to “paradoxical motion”, the forward sliding of the femur on the tibia during knee flexion.

The clear downsides of the PS knee include an increased rate of patellar clunk and crepitus, intercondylar femur fracture, post failure, and bone loss due to the box cut. The gaps must be carefully balanced to prevent a loose flexion gap which can allow the cam to “jump the post”. With improved implant design and materials, each of these complications has been reduced, but surgeons need to recognise these possibilities to reduce the incidence and identify them when they occur. Improvements in the trochlear geometry have significantly reduced the patellofemoral complications, a significant historical problem for patients with PS devices.

Indications for using a PS knee include patients with a prior patellectomy, patients with PCL deficiency, or those with a higher risk of late PCL rupture such as patients with poor neuromuscular control or rheumatoid arthritis, although there are reports successful use of CR TKA in rheumatoid arthritis.

Introduction

With the introduction of new technology in orthopaedics, surgeons must balance anticipated benefits in patient outcomes with challenges or complications associated with surgical learning curve for the technology. The purpose of this study was to determine whether the surgeon learning curve with a new multi-radius primary TKA system (primary TKA implant and instruments) designed for surgical team ease would impact clinical outcomes, surgical time and complications.

The direct anterior approach to total hip arthroplasty (THA) is growing in popularity. This growth is fueled by interest from surgeons and patients alike, both of whom are in search of improved outcomes in THA.

While the benefits of the approach are likely less pronounced than some marketing claims made, delivering a surgical recovery that has less pain and faster function is of significant value to today's patient. Published data has demonstrated subtle improvement in pain and function when compared with both the lateral and posterior approaches. Usually these clinical results are equivalent by 2 or 3 months post-operative. This can lead to accelerated recovery, a shorter length of stay, and a more cost-effective result. Some surgeons have utilised this approach as they implement outpatient THA as well.

Another added benefit is that a supine patient positioning allows for easy implementation of intra-operative fluoroscopy, which has been shown to reduce outliers in component positioning. Improved component positioning has the potential to reduce dislocation rates, lower bearing wear, and improve longevity. While image guided implant positioning can be used with any approach or patient position, it is efficient, affordable, and available to implement with the anterior approach. Using intra-operative imaging requires learning how to use and interpret the image, because incorrect utilization of fluoroscopy can be as harmful as it can be helpful.

Surgeons who are contemplating adapting the approach in practice must be aware of the potential pitfalls and learning curve, as studies have demonstrated increased operative time, blood loss, and peri-operative complications in the early cases. However, with appropriate training, patient selection, and implementation, the approach can be safely used in all THA patients.

Using an institutional database we have identified over 1000 femoral revisions using extensively porous-coated stems. Using femoral re-revision for any reason as an endpoint, the survivorship is 99 ± 0.8% (95% confidence interval) at 2 years, 97 ± 1.3% at 5 years, 95.6 ± 1.8% at 10 years, and 94.5 ± 2.2% at 15 years. Similar to Moreland and Paprosky, we have identified pre-revision bone stock as a factor affecting femoral fixation. When the cortical damage involved bone more than 10 cm below the lesser trochanter, the survivorship, using femoral re-revision for any reason or definite radiographic loosening as an endpoint, was reduced significantly, as compared with femoral revisions with less cortical damage.

In addition to patients with Paprosky type 3B and 4 femoral defects, there are rare patients with femoral canals smaller than 13.5 mm or larger than 26 mm that are not well suited to this technique. Eight and 10 inch stems 13.5 or smaller should be used with caution if there is no proximal bone support for fear of breaking. Patients with canals larger than 18 mm may be better suited for a titanium tapered stem with flutes. While a monolithic stem is slightly more difficult for a surgeon to insert than a modular femoral stem there is little worry about taper junction failure.

With the introduction of new technology in orthopaedics, surgeons must balance anticipated benefits in patient outcomes with challenges or complications associated with surgical learning curve for the technology. The purpose of this study was to determine whether surgeon learning curve with a new multi-radius primary TKA system and instruments designed to improve surgical team ease would impact clinical outcomes, surgical time, and complications.

From November 2012 to July 2015, 2369 primary TKAs were prospectively enrolled in two multicentre studies across 50 sites in 14 countries with a new knee system (NEW-TKA) evenly balanced across four configurations: cruciate retaining or posterior stabilised with either fixed bearing or rotating platform (CRFB, CRRP, PSFB, PSRP). 2128 knees had a<1 year visit and 1189 had a minimum 1 year visit. These knees were compared to a reference dataset of 843 primary TKAs from three manufacturers in the same four configurations with currently available products (CA-TKA). Demographics for NEW-TKA and CA-TKA were similar and typical for primary TKA. Operative times, clinical outcomes and a series of five patient reported outcomes were compared for NEW-TKA vs. CA-TKA. The first 10 New-TKA subjects for each surgeon were defined as learning curve cases (N=520) and were compared to all later subjects (N=1849). Patient reported outcome measure and clinical outcome analyses were covariate adjusted for patient demographics, pre-op assessment and days post-op.

Mean (SD) surgical time for NEW-TKA learning curve cases was 79.1 (24.3) minutes, which reduced thereafter to 73.6 (24.3) (p=0.002). Beyond 10 cases, there was a continued reduction in NEW-TKA surgical time (R-Squared = 0.031). After 10 cases, surgical time was on par with the mean (SD) 71.9 (21.6) for CA-TKA (p=0.078). PROM outcomes of the first 10 learning curve cases for NEW-TKA were not statistically different from later cases at less than 1 year or later when adjusted for relevant covariates including configuration, patient demographics, pre-op functional status, and time post-op (p-values > 0.01). PROM outcomes for NEW-TKA vs. CA-TKA under the same covariate adjustments showed a trend favoring KOOS ADL, Symptoms, and Sport and Recreation subscores at minimum 1 year (p-values < 0.01). The incidence of intraoperative operative site complications was 1.3% for the NEW-TKA learning curve cases which was similar to the 0.6% rate for historical CA-TKA (p=0.231) and the intraoperative complication rate for the NEW-TKA later cases was consistent with learning curve cases (p=0.158).

The introduction of new implants into the market place needs to have adequate data to support that they are safe and effective. Except for a minor increase in surgical time during the first 10 patients, this study found that surgeon learning curve with this new primary TKA system does not adversely affect patient short term outcomes and complication rates.