Background

The advent of highly cross-linked polyethylene has resulted in improved wear rates and reduced osteolysis with at least intermediate follow-up when compared to conventional polyethylene. However, the role of alternative femoral head bearing materials in decreasing wear is less clear. The purpose of this study was to determine in-vivo polyethylene wear rates across ceramic, Oxinium, and cobalt chrome femoral head articulations.

Adequate fixation of implant components is an important goal for all arthroplasty procedures. Aseptic loosening is one of the leading causes of revision surgery in total knee arthroplasty. Radiostereometric analysis (RSA) is an imaging technique to measure implant migration, with established migration thresholds for well-fixed, at risk, and unacceptably migrating components. The purpose of the present study was to examine the long-term fixation of a cemented titanium fixed bearing polished tibial baseplate.

Patients enrolled in a previous two-year prospective trial were recalled at ten years. All patients received a cemented, posterior-stabilised total knee replacement of the same design implanted by one of three surgeons. Of the original 35 patients, 16 were available for long-term follow-up, with one patient lost to follow-up, nine patients deceased, and a further nine patients unwilling to return to the clinic. Each patient underwent RSA imaging in a supine position using a conventional RSA protocol. Migration of the tibial component in all planes as well as maximum total point motion (MTPM) was compared between all time points (baseline, six weeks, three months, six months, one year, two years) up to the ten year follow-up visits. Outcome scores including the Knee Society Score (KSS), WOMAC, SF-12, and UCLA Activity Score were recorded.

At ten years, the mean migrations of the tibial component were less than 0.1 mm and 0.1 degree in all planes relative to the post-operative RSA exam. There was no significant difference in tibial component migration between time points. However, MTPM increased significantly over time (p = 0.002), from 0.23 ± 0.18 mm at six weeks to 0.42 ± 0.20 mm at ten years. At one year, 13 patients had an acceptable MTPM level, three patients had an ‘at risk’ level, and no patient had an ‘unacceptable’ level. No patients were revised at ten years. WOMAC and KSS were significantly improved (p < 0.0001) at the latest follow-up compared to pre-operatively, but there was no difference in SF-12. The median UCLA Activity Score at latest follow-up was six (range, two to eight).

The tibial baseplate demonstrated solid fixation at ten years. No patients had an unacceptable MTPM level at one year and no patients were revised at ten years, supporting the use of RSA to predict long-term loosening risk. The low level of tibial baseplate migration found in the present study correlates to the low rate of revision for this implant as reported in individual studies and in joint replacement registries.

Infection following total hip arthroplasty (THA) represents a devastating complication and is one of the main causes for revision surgery. This complication may be treated by irrigation and debridement with head and polyethylene exchange (IDHPE) or a two-stage revision (2SR). Previous studies have reported on the eradication success rates but few have reported patient outcome scores. The purpose of this study was to report patient outcome scores for both IDHPE and 2SR and compare these to a non-infected matched cohort. We hypothesised that both cohorts would have worse outcomes than the control group, and that those who failed an initial IDHPE and required a 2SR would have a worse outcome than those treated initially with a 2SR.

A retrospective review identified 137 patients from our institutional arthroplasty database who had an infected primary THA between 1986–2013. We excluded patients with less than one-year follow-up. Mean follow-up was 60 months (12–187 months). A control cohort was identified and matched according to age and Charlton Comorbidity Index (CCI). Harris Hip Scores, Short Form 12 and WOMAC scores were compared between our control group and our infected cohort.

Sixty-eight patients were treated with a 2SR and 69 patients were treated with an IDHPE. There was a 59% success rate in eradicating the infection with an IDHPE. All of the 28 patients who failed an IDHPE later went on to a 2SR. Outcome scores for the 2SR cohort were significantly worse than the non-infected controls (p0.05). There was no difference in outcome scores when comparing our 2SR cohort to our failed IDHPE (p>0.05).

Previous studies have focused on eradication rates. However, it is important to consider patient outcome scores when deciding the best treatment. Infected patients treated with a successful IDHPE had similar outcomes to non-infected patients. Patients that failed IDHPE and went onto 2SR had similar outcomes to those that had a 2SR alone. IDHPE should still be considered in the treatment algorithm of infected THA.

Studies that have previously examined the relationship between inclination angle and polyethylene wear have shown increased wear of conventional polyethylene with high inclination angles. To date, there have been no long term in vivo studies examining the correlation between cup position and polyethylene wear with highly crosslinked polyethylene.

An institutional arthroplasty database was used to identify patients who had metal-on-highly crosslinked polyethylene primary total hip arthroplasty (THA) using the same component design with a minimum follow up of 10 years ago. A modified RSA examination setup was utilised, recreating standard anteroposterior (AP) and cross-table lateral exams in a single biplane RSA acquisition. Three dimensional head penetration was measured using the centre index method. The same radiographs were used to measure inclination angle and anteversion. Spearman correlation was used to show an association between the parameters of acetabular position and wear rate.

A total of 43 hips were included for analysis in this study. Average follow-up was 12.3 ± 1.2 years. The average linear wear rate was calculated to be 0.066 ± 0.066 mm/year. Inclination angle was not correlated with polyethylene wear rate (p=0.82). Anteversion was also not correlated with polyethylene wear rate (p=0.11). There was no statistical difference between wear rates of hips within Lewinnek's “safe zone” and those outside this “safe zone” (p=0.11). Males had a higher wear rate of 0.094 ± 0.089 mm/year compared to females with a wear rate of 0.046 ± 0.032 mm/year (p=0.045).

At long term follow up of greater than 10 years, highly cross linked polyethylene has very low wear rates. This excellent tribology is independent of acetabular position, but gender did impact wear rates. Due to the low wear rates, follow-up of even longer term is suggested to examine variables affecting wear.

Complications involving the patellofemoral joint are a source of anterior knee pain, instability, and dysfunction following total knee arthroplasty. “Overstuffing” the patello-femoral joint refers to an increase in the thickness of the patellofemoral joint after a total knee replacement compared to the preoperative thickness. While biomechanical studies have indicated that overstuffing the patellofemoral joint may lead to adverse clinical outcomes, limited clinical evidence exists to support this notion. The purpose of this study is to evaluate the effect of changing the thickness of the patellafemoral joint on functional outcomes following total knee arthroplasty.

Our institutional arthroplasty database was used to identify 1347 patients who underwent a primary total knee arthroplasty between 2006 and 2012 with the same component design. Standard preoperative and postoperative anteroposterior, lateral, and skyline radiographs were collected and measured for patello-femoral overstuffing. These measurements included anterior patellar displacement, anterior femoral offset, and anteroposterior femoral size. These measurements were correlated with patient outcome data using WOMAC, KSS scores, and postoperative range of motion. Multiple linear regression analysis was used to assess the association between stuffing and functional outcomes.

A total of 1031 patients who underwent total knee arthroplasty were included. Increased anterior patellar displacement, a measure of patellofemoral joint thickness, was associated with decreased WOMAC scores (p=0.02). Anterior femoral offset (p=0.210) and anteroposterior femoral size (p=0.091) were not significantly associated with patient functional outcomes. Postoperative range of motion (ROM) was not associated with patellofemoral stuffing (p=0.190).

The current study demonstrated that functional outcomes are adversely affected by patellofemoral overstuffing. Based on these results, caution is encouraged against increasing the thickness of the patellofemoral joint, particularly on the patellar side of the joint.

Trunnionosis in modular hip arthroplasty has recently been recognised to be clinically important. Gaining an understanding of how the material interface at the head-trunnion affects the tribology at the modular junctions has current clinical implications as well as an implication on future implant selection and material choice. This matched-cohort study aims to compare tribocorrosion between ceramic and cobalt-chromium trunnions and to investigate other factors that contribute to the difference in tribocorrosion if present.

All hip prostheses retrieved between 1999 and 2015 at one centre were reviewed. Fifty two ceramic heads were retrieved, and these were matched to a cobalt-chromium cohort according to taper design, head size, neck length and implantation time in that order. The two cohorts were similar in male:female ratio (p=0.32) and body mass index (p=0.15) though the ceramic group was younger than the cobalt-chromium group (56.6 (+/−)13.5 years for ceramic group vs 66.3 (+/−14.4) years for cobalt-chromium group; p=0.001). There was no significant difference in the reasons for revision between the two groups (p=0.42). The femoral head trunnions were examined by two independent observers using a previously published 4-point scoring technique. The trunnions were divided into three zones: apex, middle and base. The observers were blinded to clinical and manufacturing data where possible.

Ceramic head trunnions demonstrated a lower median fretting and corrosion score at the base zone (p<0.001), middle zone (p<0.001) and in the combined score (p<0.001). In a subgroup analysis by head size, ceramic heads had a lower fretting and corrosion score at 28mm head diameter (p<0.001). Within the ceramic group, taper design had a significant effect on fretting and corrosion in the apex zone (p=0.04). Taper design also had a similar effect in the cobalt-chromium group in the apex zone (p=0.03). For the ceramic trunnions, the largest effect was contributed by the difference between the 11/13 taper and the 12/14 taper. For the cobalt-chromium trunnions, the largest effect was contributed by the difference between the 5 degree 38′ 37″ taper and type 1 taper.

Ceramic head trunnions showed a significantly lower fretting and corrosion score as compared to cobalt-chromium trunnions. Ceramic heads had a lower score than cobalt-chromium heads at 28mm head diameter. Taper design had an effect on fretting and corrosion within each cohort.

The advent of highly cross-linked polyethylene has resulted in improved wear rates and reduced osteolysis with at least intermediate follow-up when compared to conventional polyethylene. However, the role of alternative femoral head bearing materials in decreasing wear is less clear. The purpose of this study was to determine in-vivo polyethylene wear rates across ceramic, Oxinium, and cobalt chrome femoral head articulations.

A review of our institutional database was performed to identify patients who underwent a total hip arthroplasty using either ceramic or oxidised zirconium (Oxinium) femoral head components on highly cross-linked polyethylene between 2008 and 2011. These patients were then matched on implant type, age, sex and BMI with patients who had a cobalt chrome bearing implant during the same time period. RSA analysis was performed using the centre index method to measure femoral head penetration (polyethylene wear). Secondary quality of life outcomes were collected using WOMAC and HHS Scores. Paired analyses were performed to detect differences in wear rate (mm/year) between the cobalt chrome cohorts and their matched ceramic and Oxinium cohorts. Additional independent group comparisons were performed by analysis of variance with the control groups collapsed to determine wear rate differences between all three cohorts.

A total of 68 patients underwent RSA analysis. Fifteen patients with a ceramic femoral head component and 14 patients with an Oxinium femoral head component along with the same number of matched patients with cobalt chrome femoral head component were included in the analysis. The time in vivo for the Oxinium (5.17 +/− 0.96 years), Oxinium matched cohort (5.13 +/− 0.72 years), ceramic (5.15 +/− 0.76 years) and ceramic matched cohort (5.36 +/− 0.63 years) were comparable. The demographics of all bearing surface cohorts were similar. The paired comparison between the Oxinium and cobalt chrome cohorts (0.33 vs. 0.29 mm/year, p=0.284) and ceramic vs cobalt chrome cohorts (0.26 vs. 0.20 mm/year, p=0.137) did not demonstrate a significant difference in wear rate. The independent groups analysis revealed a significantly higher wear rate of Oxinium (0.33 mm/year) compared to cobalt chrome (0.24 mm/year) (p = 0. 038). There were no differences in HHS and WOMAC scores between the Oxinium and cobalt chrome cohorts (HHS: p = 0.71, WOMAC: p=0.08) or the ceramic and cobalt chrome cohorts (HHS: p=0.15, WOMAC: p=023).

This study presents evidence of a greater wear rate (mm/year) of the Oxinium femoral head component compared to a cobalt chrome femoral head component. This difference was not demonstrated in the ceramic femoral head component. Despite this difference, there were no clinical differences as measured by the HHS and WOMAC. Future research should focus on factors that may contribute to the higher wear rate seen in the Oxinium cohort.

Total joint arthroplasty is commonly associated with post-operative anemia. Blood conservation programs have been developed to optimise patients prior to surgery. Epoetin Alfa (Eprex) or intravenous (IV) iron transfusions are two modalities that can be used pre-operatively to optimise hemoglobin and ferritin levels. There are, however, potential complications and increased costs associated with their use. Oral iron is a less costly option for those undergoing surgery but requires more time to take effect. There are no studies to date that examine the effects of an early screening program utilising oral iron supplementation prior to total joint arthroplasty. The purpose of this study is to evaluate the effect of implementing early pre-operative oral iron supplementation on patients prior total joint arthroplasty.

A retrospective review of patients undergoing total joint arthroplasty was performed using our institution clinical informatics database. We identified all patients seen in pre-admission clinic (PAC) between Jan 1, 2009 and March 31, 2010 representing our control group. We then identified all patients seen in PAC between October 1, 2012 and December 31, 2013. Patients in this cohort received screening blood work when booked for surgery, and oral iron supplementation was given to patients with hemoglobin of less than 135g/L or ferritin less than 100ug/L, thus representing our treatment group. Patients undergoing revision, uni-compartment knee arthroplasty and bilateral arthroplasties were excluded from the study. Pearson Chi-Square tests were used to calculate significance between groups with main outcomes including pre-admission hemoglobin, and pre-operative requirements for Eprex or IV iron.

In our control group, we identified 354 patients (25.6%) with hemoglobin less than 130 g/L at time of pre-admission clinic. In our treatment group, this number dropped significantly to only 16.4% of patients (p<0.005).

Implementation of an early screening program using oral iron supplementation resulted in a decrease in the number of patients with hemoglobin lower than 130 g/L at the time of pre-admission clinic. There was also a significant decrease in the use of Eprex and IV iron pre-operatively in the patients in the early screening program. These results encourage the use of early oral iron supplementation for patients with hemoglobin less than 135 g/L or ferritin less than 100ug/L in order to optimise patients prior to total joint arthroplasty.

The posterior tibial slope angle (PTS) in posterior cruciate retaining total knee arthroplasty influences the knee kinematics, knee stability, flexion gap, knee range of motion (ROM) and the tension of the posterior cruciate ligament (PCL). The current technique of using an arbitrary (often 3–5 degrees) PTS in all cases seldom will restore native slope in cruciate retaining TKA. Questions/Purposes: The primary objective was to determine if we could surgically reproduce the native PTS in cruciate-retaining total knee arthroplasty. The second objective was to determine if reproduction of native slope was significant – ie influenced clinical outcome.

We evaluated the radiographic and clinical outcomes of a series of consecutive total knee arthroplasties using the PFC sigma cruciate-retaining total knee system in 215 knees. The tibial bone cut was planned to be parallel to the patient's native anatomical slope in the sagittal plane. An “Angel Wing” instrument was placed on the lateral tibial plateau and the slope of the cutting guide adjusted to make the cutting block parallel to the patient's native tibial slope. All true lateral radiographs of the knee were measured for PTS using a picture achieving and communication system (PACS). PTSs were measured with reference to the proximal tibial medullary canal (PTS-M) and the proximal tibial anterior cortex (PTS-C). The knee ROM, Knee Society Score, Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and SF-12 at the last follow-up were evaluated as clinical outcomes.

The mean preoperative PTS-M was 6.9±3.3 degrees and the mean postoperative PTS-M was 7±2.4 degrees. The mean preoperative PTS-C was 12.2±4.2 degrees and the mean postoperative PTS-M was 12.6±3.4 degrees. There was no significant difference form the preoperative and postoperative PTS measurement in both techniques (p>0.05). We used an arbitrary 3 degrees as an acceptable range for PTS-M reproduction. The PTS-M was reproduced within 3 degrees in 144 knees (67%); designated as Group A. The 71 knees with a difference more than 3 degrees in (33%) were designated as Group B. Group A showed significantly larger gain in ROM compared with group B (p=0.04). Group A also had significantly better improvement in Knee society score and WOMAC score and SF-12 physical score when compare with group B (p<0.01).

Our modification of standard surgical technique reliably reproduced the native tibial slope in cruciate-retaining total knee arthroplasty. More importantly, reproduction of the patient's native PTS within 3 degrees resulted in better clinical outcomes manifested by gain in ROM and knee functional outcome scores.

Purpose

Unicompartmental versus total knee arthroplasty has been a debated topic for decades. The purpose of this study was to compare the survivorship and clinical outcomes of a large primary total knee arthroplasty versus unicompartmental knee arthroplasty cohort.

Purpose

The pros and cons of general anesthesia versus spinal anesthesia in total hip arthroplasty has been a long debated topic. The purpose of this study was to compare the surgical times, blood loss and transfusion requirements between anesthetic types in patients undergoing primary total hip arthroplasty.

Purpose: Radiographic signs of osseointegration have been well established for cementless femoral components, but not for cementless acetabular components. At our institution using principles similar to those applied to cementless femoral components, we have observed apparent radiographic signs of osseointegration of porous-coated cups. We then hypothesized that these signs could be used to predict bone ingrowth of porous-coated acetabular components

Methods: In a series of 119 total hip arthroplasties with porous-coated cementless cups, we reviewed post-primary and prerevision serial radiographs and proposed five radiographic signs for detecting osseointegration of a porous-coated acetabular component: absence of radiolucent lines, presence of a superolateral buttress, medial stress shielding, radial trabeculae, and an infero-medial buttress. We compared the predictability of each sign to intraoperative findings of cup stability and measured the sensitivity, specificity, and intra-observer agreement of each sign

Results: . In our population, ninety-eight cups had three to five radiographic signs of osseointegration; of these, ninety-five cups (97%) were found to be bone-ingrown at the revision operation. Conversely, twelve cups had only one or no sign; of these, ten (83%) were clinically unstable at the revision operation.

Conclusions: We concluded these five, readily detectable signs of acetabular osseointegration are very useful in predicting acetabular component stability found at surgery.

Purpose: A retrospective review was done to evaluate survival of unicondylar arthroplasty and identify factors that increased the odds of revision. Our hypothesis was that younger age, increased weight, use of a thinner tibial component, polyethylene shelf aging.

Methods: 411 medial compartment unicondylar arthroplasties encompassing 12 designs were performed at one institution from 1984 to 1998. Patient age and weight averaged 67 ± 8 years and 83 ± 15 kg, respectively. Eighty-seven percent of the tibial components were metal-backed. Initial tibial component thickness averaged 8.5 ±1mm. Polyethylene shelf age averaged 1.3 ± 1.2 years.

Results: Four factors made revision more likely (p < 0.05, Cox proportional hazards regression): younger patient age, thinner tibial component, longer polyethylene shelf age. Gender and weight did not influence survival. With an endpoint of any component revision, Kaplan-Meier survival at nine postoperative years was 80% (95% confidence interval: 75% to 84%). In knees in which tibial component initial thickness was greater than 7mm and polyethylene shelf age was under 1 year, nine-year survival was 94% (95% confidence interval: 91% to 99%).

Conclusions: A 94% likelihood of survival at nine postoperative years may be a reasonable expectation when the procedure is performed with appropriate materials and designs..

Funding : Commerical funding

Funding Parties : Inova Health Care Services

We reviewed 32 deep-frozen irradiated allografts used for the reconstruction of bone defects in 20 knees. They were subdivided into bulk grafts, cortical strut grafts, and morsellised bone. The average follow-up was 4.2 years (2 to 7.2). Radiographs showed union of the allograft to the host in all cases. Two allografts later fractured and three knees required further surgery because of infection. The allografts effectively filled large bone defects around the knee, lessening the need for custom-made and constrained prostheses.