Obesity is associated with poor outcomes and increased risk of failure after rotator cuff (RC) repair surgery. The effect of diet-induced obesity (DIO) on enthesis healing has not been well characterised and whether its effects can be reversed with dietary intervention is unknown. We hypothesised that DIO would result in inferior enthesis healing in a rat model of RC repair and that dietary intervention in the peri-operative period would improve enthesis healing. A total of 78 male Sprague-Dawley rats were divided into three weight-matched groups from weaning and fed either: control diet (CD), high-fat diet (HFD), or HFD until surgery, then CD thereafter (HF-CD). After 12 weeks the left supraspinatus tendon was detached, followed by immediate surgical repair. At 2 and 12 weeks post-surgery, animals were cullers and RCs harvested for biomechanical and histological evaluation. Body composition and metabolic markers were assessed via DEXA and plasma analyses, respectively. DIO was established in the HFD and HF-CD groups prior to surgery, and subsequently reversed in the HF-CD group after surgery. At 12 weeks post-surgery, plasma leptin concentrations were higher in the HFD group compared to the CD group (5.28 vs. 2.91ng/ml, P=0.003). Histologically, the appearance of the repaired entheses was poorer in both the HFD and HF-CD compared to the CD group at 12 weeks (overall histological score 6.20 (P=0.008), 4.98 (P=0.001) and 8.68 out of 15, respectively). The repaired entheses in the HF-CD group had significantly lower (26.4 N, P=0.028) load-at-failure 12 weeks post-surgery compared to the CD group (34.4 N); while the HFD group was low, but not significantly different (28.1 N, P=0.096). Body mass at the time of surgery, plasma leptin and body fat percentage were negatively correlated with histological scores and plasma leptin with load-at-failure 12 weeks post-surgery. DIO impaired enthesis healing in this rat RC repair model, with inferior biomechanical and histological outcomes. Restoring normal weight with dietary change after surgery did not improve healing outcomes. Exploring interventions that improve the metabolic state of obese patients and counselling patients appropriately about their modest expectations after repair should be considered.
We hypothesised that diet-induced obesity (DIO) would result in inferior enthesis healing in a rat model of rotator cuff (RC) repair and that dietary intervention in the peri-operative period would improve enthesis healing. A total of 78 male Sprague-Dawley rats were divided into three weight-matched groups from weaning and fed either: control diet (CD), high-fat diet (HFD), or HFD until surgery, then CD thereafter (HF-CD). After 12 weeks, the left supraspinatus tendon was detached, followed by immediate surgical repair. At 2 and 12 weeks post-surgery, animals were culled, and RCs harvested for biomechanical and histological evaluation. Body composition and metabolic markers were assessed via DEXA and plasma analyses, respectively. DIO was established in the HFD and HF-CD groups before surgery and subsequently reversed in the HF-CD group after surgery. Histologically, the appearance of the repaired entheses was poorer in both the HFD and HF-CD groups compared with the CD group at 12 weeks after surgery, with semiquantitative scores of 6.2 (p<0.01), 4.98 (p<0.01), and 8.7 of 15, respectively. The repaired entheses in the HF-CD group had a significantly lower load to failure (P=0.03) at 12 weeks after surgery compared with the CD group, while the load to failure in the HFD group was low but not significantly different (P=0.10). Plasma leptin were negatively correlated with histology scores and load to failure at 12 weeks after surgery. DIO impaired enthesis healing in this rat RC repair model, with inferior biomechanical and histological outcomes. Restoring normal weight with dietary change after surgery did not improve healing outcomes. Circulating levels of leptin significantly correlated with poor healing outcomes. This pre-clinical rodent model demonstrates that obesity is a potentially modifiable factor that impairs RC healing and increases the risk of failure after RC surgery.
The purpose of this study is to compare the mid-term outcomes between rotating platform(RP) and posterior cruciate substitute(PS) bearings in LCS-total knee arthroplasty (TKA). This is a prospective randomized matched-pairs case–control study of patients who underwent primary TKAs with a minimum 2 years follow-up. The inclusion criteria was degenerative arthritis, and exclusion criteria was arthritis other than degeneration, previous operations such as osteotomy, body mass index (BMI) over 30 kg/m2. The matching criteria were set as age, BMI, preoperative ROM, gender, and the Knee Society (KS) and Hospital for Special Surgery (HSS) scores. After 1:1 matching, 50 cases involved the LCS RP bearing system as group 1 and 50 cases involved LCS PS bearing system group as group 2. Clinical and radiographic outcomes were evaluated.Purpose
Methods
The fourth generation ceramic, in which zirconia is incorporated into the alumina matrix, was developed to reduce the risk of ceramic fractures. The purpose of this study was to evaluate the survivorship, clinical and radiographic results, and bearing-related failures associated with total hip arthroplasty using zirconia-toughened alumina ceramic-on-ceramic bearings over a minimum follow-up of 5 years. We retrospectively analysed 135 patients (151 hips) who underwent cementless total hip arthroplasty using zirconia-toughened alumina ceramic-on-ceramic bearings. There were 58 men and 77 women with mean age of 55.9 years (range, 20 to 82 years) at index surgery. Acetabular and femoral components were cementless in all hips. A 36 mm head was used in 81 of 151 hips and a 32 mm head was used in 70 hips with smaller acetabular shells. The mean duration of follow-up was 6.1 years (range, 5 to 6.8 years).Purpose
Materials and methods
The use of tranexamic acid (TXA) in primary total hip arthroplasty (THA) is supported by many studies that confirm its efficacy for decreasing blood loss, but the comparison between topical intra-articular (IA) and intra-venous (IV) is unclear, especially combined with chemical prophylaxis. The purpose of this study is to verify non-inferior efficacy of topical IA TXA compared with IV TXA in primary THA. A single center, randomized, controlled clinical trial was performed to compare topical IA TXA (2 g of TXA in 100 cc of normal saline) with two IV doses of TXA (1 g dose before surgery and another 1 g dose 3 hours later) on blood loss. The primary outcome was total blood loss as calculated from the difference between the preoperative hemoglobin (Hb) and the lowest postoperative Hb. The secondary outcome included drained blood loss, transfusion volume, and thromboembolic events. The sample size of 112 patients was calculated to give a statistical power of 99% for demonstrating inferiority. Fifty-six patients each was assigned to receive topical IA TXA (IA group) and IV TXA (IV group). There were no significant differences in demographics and preoperative laboratory values between the two groups. Non-inferiority was estimated by comparing the confidence interval with a delta of 10%. All subjects took oral direct factor Xa inhibitor to prevent venous thromboembolism included during 2 weeks after surgery.Introduction
Methods & Methods
The range of motion (ROM) obtained after total knee arthroplasty (TKA) is an important measurement to evaluate the postoperative outcomes impacting other measures such as postoperative function and satisfaction. Flexion contracture is a recognized complication of TKA, which reduces ROM or stability and is a source of morbidity for patients. The purpose of this study was to evaluate the influence of intra-operative soft tissue release on correction of flexion contracture in navigated TKA.Introduction
Objectives
As the proximal femoral bone is generally compromised in failed total hip arthroplasty, achievement of solid fixation with a new component can be technically demanding. Clinical studies have demonstrated good medium-term results after revision total hip arthroplasty using modular fluted and tapered distal fixation stems, but, to our knowledge, long-term outcomes have been rarely reported in the literature. The purpose of this study was to report the minimum ten-year results of revision total hip arthroplasty using a modular fluted and tapered distal fixation stem. We analyzed 40 revision THAs performed in using a modular fluted and tapered distal fixation stem (Fig. 1) between December 1998 and February 2004. There were 11 men (12 hips) and 28 women (28 hips) with a mean age of 59 years (range, 38 to 79 years) at the time of revision THA. According to the Paprosky classification of femoral defects, 5 were Type II, 24 were Type IIIA, and 11 were Type IIIB. An extended trochanteric osteotomy was carried out in 21 (52%) of the 40 hips. Patients were followed for a mean of 11.7 years (range, 10 to 15 years).Introduction
Materials & Methods
Patients with osteonecrosis of the femoral head are typically younger, more active, and often require high rates of revision following primary total hip arthroplasty. However, outcomes of revision hip arthroplasty in this patient population have been rarely reported in the literature. The purpose of this study was to report the intermediate-term clinical and radiographic outcomes of revision hip arthroplasty in patients with osteonecrosis of the femoral head. Between November 1994 and December 2009, 187 revision hip arthoplasty were performed in 137 patients who had a diagnosis of osteonecrosis of the femoral head. Exclusion criteria included infection, recurrent instability, isolated polyethylene liner exchange, and inadequate follow-up (less than 3 years). The final study cohort of this retrospective review consisted of 72 patients (75 hips) with a mean age of 53.3 years (range, 34 to 76). Components used for the acetabular revision included a cementless porous-coated cup in 58 hips and an acetabular cage in 2 hips. Components used for the femoral revision included a fully grit-blasted tapered stem in 30 hips and a proximally porous-coated modular stem in 9 hips. The mean duration of follow-up was 7 years (range, 3 to 17).Introduction
Materials & Methods
The purpose of this study is to investigate the relationship between the angles made by the reference axes on the computerized tomography (CT) images and comparison of the knee alignment between healthy young adults and patients who is scheduled to have total knee arthroplasty. This study was conducted in 102 patients with osteoarthritis of knee joint who underwent preoperative computerized tomography (CT). The control group included 50 patients having no arthritis who underwent CT of knee. Axial CT image of the distal femur were used to measure the angles among the the anteroposterior (AP) axis, the posterior condylar axis (PCA), clinical transepicondylar axis (cTEA) and the surgical transepicondylar axis (sTEA). Then, the differences in amounts of rotation between normal and osteoarthritic knee was evaluated.Purpose
Materials and Methods
Management of the patella with poor bone stock remains a challenge in revision total knee arthroplasty (TKA). The purpose of this study was to evaluate the results of a novel surgical technique in which widely available wires and acrylic bone cement are used in the reconstruction of a deficient patella. Twenty-eight patients (30 knees) underwent revision TKA in which a deficient patella was treated with an onlay-type prosthesis and bone-augmenting procedure, using transcortical wiring. The technique was indicated when the thickness of remnant patella was less than 8mm with variable amounts of the peripheral rim. The remaining patellar height ranged from 3.2mm to 7.3mm. Follow-up was available for all patients with a mean of 36.6 months (range, 24 to 55 months). The respective mean Knee Society scores for knee and function improved from 34.2 points (range, 18 to 65 points) and 23 points (range, 18 to 46 points) preoperatively to 73.5 points (range, 30 to 88 points) and 61points (range, 34 to 80 points) at final follow-up. The mean thickness of the patellar construct was 14.6mm (range, 12.2 – 18.3mm). One patient experienced patellar fracture during knee flexion one week after surgery. There were no complications associated with implanted hardware. A patellar bone-augmenting procedure using transcortical wiring is a straightforward technique that potentially allows firm fixation. Considering the satisfactory short- to mid-term results, we believe that this technique provides a good alternative option in addressing this challenging problem in revision TKA.
Modern ceramic-on-ceramic bearings have become attractive alternatives to conventional polyethylene due to their low wear and minimal particle production. However, ceramic-on-ceramic implants have been associated with ceramic fracture and squeaking. To address these issues, large ceramic heads with a titanium-alloy sleeve have been introduced although limited data are available on their clinical outcomes. The purpose of this study was to report the midterm results of primary total hip arthroplasty using a 32mm with a titanium-alloy sleeve. We reviewed 245 patients who had 274 total hip arthroplasties with a 32 mm ceramic head with a titanium-alloy sleeve and had been followed for more than 5 years (average, 6.5 years; range, 5–9 years). The mean patient age at the time of surgery was 55.1 years (range, 16–82 years). All operations were performed at a single center. All of the ceramic implants were hot isostatic pressed, laser-marked, proof-tested third-generation alumina (Fig. 1). We determined the implant survival, Harris hip scores, incidence of ceramic fracture or noisy hips, and presence of osteolysis.Introduction
Materials & Methods
Management of the patella with poor bone stock remains a challenge in revision total knee arthroplasty (TKA). The purpose of this study was to evaluate the results of a novel surgical technique in which widely available wires and acrylic bone cement are used in the reconstruction of a deficient patella. Twenty-eight patients (30 knees) underwent revision TKA in which a deficient patella was treated with an onlay-type prosthesis and bone-augmenting procedure, using transcortical wiring. The technique was indicated when the thickness of remnant patella was less than 8mm with variable amounts of the peripheral rim. The remaining patellar height ranged from 3.2mm to 7.3mm. Follow-up was available for all patients with a mean of 36.6 months (range, 24 to 55 months).Background
Methods
Highly cross-linked polyethylene has been introduced to decrease osteolysis secondary to polyethylene wear debris generation, but there are few long-term data on revision total hip arthroplasty using highly cross-linked polyethylene liners. The purpose of this study was to report the long-term radiographic and clinical outcomes of a highly cross-linked polyethylene liner in revision total hip arthroplasty. We analyzed 63 revision total hip arthoplasties that were performed in 63 patients using a highly cross-linked polyethylene liner between April 2000 and February 2005. Of these, nine died and four were lost to follow-up before the end of the 10-year evaluation. Thus, the final study cohort consisted of 50 patients (50 hips). There were 26 males and 24 females with a mean age at time of revision total hip arthoplasty of 53 years (range, 27–75 years). Mean duration of follow-up was 11 years (range, 10–14 years).Introduction
Materials & Methods
A large proportion of patients with osteoarthritis of the knee, present with bilateral symptoms at the outpatient department. A simultaneous total knee arthroplasty (TKA) procedure is available for such patients. The first operation in a simultaneous surgery may provide information to the operator to determine component size, soft tissue balancing, and estimate gap size for the second operation, while the second team usually conducts an operation in a confined space on the contralateral side during closure for the first operation, which can disturb cooperation during the second operation and may lead to more intra-operative surgical errors. We hypothesized that the circumstances of the two consecutive operations of a simultaneous bilateral TKA are different, could lead to different outcomes of overlapping bilateral TKAs. We therefore addressed the following research questions to determine whether there would be differences in short-term clinical outcomes, radiographic results, and implanted component size between the two sides A retrospective review of 451 consecutive patients, who underwent simultaneous bilateral TKA between January 2011 and April 2012, was conducted. Bilateral TKAs were performed with the senior surgeon conducting the main procedure (from skin incision to implantation of first prosthesis until prior closure of the first knee) on the right side first and subsequently the left side with a second team. At 1 year after surgery, clinical outcome scores (the Knee Society Knee and Function scores, WOMAC score), radiologic findings were evaluated and clinical results as postoperative blood loss, operation time were compared between bilateral sides.Introduction
Methods
Cementless grit-blasted tapered-wedge titanium femoral stems are being used with increasing frequency in hip arthroplasty because of excellent long-term outcomes. However, periprosthetic femur fracture is a potentially worrisome phenomenon in these types of femoral stems. The aim of this study is to report the incidence of stem loosening in association with periprosthetic femur fractures following hip arthroplasty using cementless grit-blasted tapered-wedge stems. A total of 36 Vancouver Type B1 and B2 periprosthetic femur fractures following either hemiarthroplasty or total hip arthroplasty using cementless grit-blasted tapered-wedge titanium femoral stems (GB group) were identified from a retrospective review of the medical records at three participating academic institutions. The control group consisted of 21 Vancouver Type B1 and B2 periprosthetic femur fractures following either hemiarthroplasty or total hip arthroplasty using cementless proximal porous-coated femoral stems (PC group) at the same institutions during the same period of the study. All femoral stems included in this study had been a well-fixed state before the occurrence of periprosthetic femur fractures. All patients in both groups were treated surgically with either open reduction and internal fixation or femoral stem revision. Femoral stem stability was assessed by preoperative radiographs and was confirmed by intraoperative scrutinization. The incidence of stem loosening was compared between the groups.Introduction
Materials & Methods
Micro-arc oxidation (MAO) is an electrochemical method used to treat metal surfaces. It provides nanoporous pits, and thick oxide layers, and incorporates calcium and phosphorus into the coating layer of titanium alloy. This modification on the surface of titanium alloy by MAO coating would improve the ability of cementless stems to osseointegrate. In spite of these structural and chemical advantages, clinical study of total hip arthroplasty (THA) using MAO coated stem has not yet been reported. In this study, we evaluated the clinical and radiographic results associated with cementless grit-blasted tapered-wedge stems that were identical in geometry but differed with regard to surface treatment with or without MAO coating. We performed a retrospective review of 141 THAs using MAO coated stem for a minimum of 5 years and compared them to 219 THAs using the same geometry stem without MAO coating. A cementless Bencox femoral component (Corentec, Seoul, Korea) was used in all hips. It is made of titanium alloy with a straight, double wedged, tapered stem with a rectangular cross-section. Surface treatment was performed using grit blasting with a roughness of 5.5ųm that was available either with or without MAO coating. Clinical and radiographic evaluations were performed preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively, and then annually.Introduction
Materials & Methods
The outcome of previous cemented total hip arthroplasty has been reported to be inferior in renal transplant patients because of poor bone stock resulting from long-term steroid use. Moreover, as renal transplant patients remain on immunosuppressant therapy for life, higher levels of overall morbidity must be considered. We evaluated the mid-term results of cementless total hip arthroplasty in renal transplant recipients with osteonecrosis of the femoral head, and compared those with age and sex matched osteonecrosis patients that had not undergone organ transplantation or been treated with long-term steroid. Between October 1997 and October 2008, 45 consecutive primary cementless total hip arthroplasties were performed in 30 patients with advanced osteonecrosis of the femoral head after renal transplantation. There were 18 males (27 hips) and 12 females (18 hips) of overall mean age 44 years (22 to 68). The clinical and radiographic results of cementless total hip arthroplasty in these 45 hips were compared with those of 96 sex and age-matched osteonecrotic hips of 72 patients that had not undergone organ transplantation or long-term steroid use. Patients were evaluated at surgery and at a mean of 7.2 years (range, 2–13 years) postoperatively.Introduction:
Materials & Methods:
Ceramic head with titanium-alloy sleeve offers a modular ceramic head solution for the damaged taper in revision total hip arthroplasty (THA). It can also be used in primary THA to reduce the risk of ceramic head fracture. The purpose of the present study was to report the intermediate-term outcomes of primary ceramic-on-ceramic THA with use of ceramic head with titanium-alloy sleeve. We evaluated 244 patients (271 hips) who had undergone primary ceramic-on-ceramic THA with use of BIOLOX® forte 32 mm ceramic head with titanium-alloy sleeve between November 2005 and August 2009. There were 158 males (175 hips) and 86 female (96 hips) patients with a mean age of 55.5 years. Clinical and radiographic evaluation was performed at a mean of 4.6 years (range, 2–7 years) postoperatively.Introduction:
Materials & Methods:
The management strategy regarding optimally addressing polyethylene wear with a well-fixed acetabular shell remains controversial. The purpose of the present study was to document outcomes of cementation of a highly cross-linked polyethylene (PE) liner into a well-fixed acetabular metal shell in 36 hips We identified 37 patients (39 hips) who had undergone revision THA by cementation of a highly cross-linked PE liner into a well-fixed metal shell between June 2004 and April 2009. Of these patients, one (1 hip) died before the end of the 3-year evaluation and another was lost to follow-up. Thus, the study cohort consisted of 35 patients (36 hips). There were 23 males (24 hips) and 12 female (12 hips) patients with a mean age at time of revision surgery of 57.6 years (range, 38–79 years). All operations were performed by a single surgeon using only one type of liner. Clinical and radiographic evaluation was performed at a mean of 6.1 years (range, 3–8 years) postoperatively.Introduction:
Materials & Methods:
A functional total knee replacement has to be well aligned, which implies that it should lie along the mechanical axis and in the correct axial and rotational planes. Incorrect alignment will lead to abnormal wear, early mechanical loosening, and patellofemoral problems. There has been increased interest of late in total knee arthroplasty with robot assistance. This study was conducted to determine if robot-assisted total knee arthroplasty is superior to the conventional surgical method with regard to the precision of implant positioning. Twenty knee replacements of ten robot-assisted and another ten conventional operations were performed on ten cadavers. Two experienced surgeons performed the surgery. Both procedures were undertaken by one surgeon on each cadaver. The choice of which was to be done first was randomized. After the implantation of the prosthesis, the mechanical-axis deviation, femoral coronal angle, tibial coronal angle, femoral sagittal angle, tibial sagittal angle, and femoral rotational alignment were measured via three-dimensional CT scanning. These variants were then compared with the preoperative planned values. In the robot-assisted surgery, the mechanical-axis deviation ranged from −1.94 to 2.13° (mean: −0.21°), the femoral coronal angle ranged from 88.08 to 90.99° (mean: 89.81°), the tibial coronal angle ranged from 89.01 to 92.36° (mean: 90.42°), the tibial sagittal angle ranged from 81.72 to 86.24° (mean: 83.20°), and the femoral rotational alignment ranged from 0.02 to 1.15° (mean: 0.52°) in relation to the transepicondylar axis. In the conventional surgery, the mechanical-axis deviation ranged from −3.19 to 3.84°(mean: −0.48°), the femoral coronal angle ranged from 88.36 to 92.29° (mean: 90.50°), the tibial coronal angle ranged from 88.15 to 91.51° (mean: 89.83°), the tibial sagittal angle ranged from 80.06 to 87.34° (mean: 84.50°), and the femoral rotational alignment ranged from 0.32 to 4.13° (mean: 2.76°) in relation to the transepicondylar axis. In the conventional surgery, there were two cases of outlier outside the range of 3° varus or valgus of the mechanical-axis deviation. The robot-assisted surgery showed significantly superior femoral-rotational-alignment results compared with the conventional surgery (p=0.006). There was no statistically significant difference between robot-assisted and conventional total knee arthroplasty in the other variants. All the variants were measured with high intraobserver and interobserver reliability. In conclusion, Robot-assisted total knee arthroplasty showed excellent precision in the sagittal and coronal planes of the three-dimensional CT. Especially, better accuracy in femoral rotational alignment was shown in the robot-assisted surgery than in the conventional surgery despite the fact that the surgeons who performed the operation were more experienced and familiar with the conventional surgery than with robot-assisted surgery. It can thus be concluded that robot-assisted total knee arthroplasty is superior to the conventional total knee arthroplasty.
