Liberal Indications for Minimally Invasive Oxford Unicondylar Arthroplasty Provide Rapid Functional Recovery and Pain Relief

Abstract:

The Oxford unicompartmental knee arthroplasty (UKA) was recently approved for implantation in America. Recovery was evaluated and the efficacy of a musculoskeletal hospital was addressed for an initial group of patients who underwent medial compartment UKA with the Oxford device. Between October 2004 and December 2005, 142 medial UKAs were performed in 125 patients and included 11 simultaneous and six staged bilateral UKA procedures, and one simultaneous UKA/TKA procedure. The patients' ages averaged 62 (range: 41-87) years, weight 90 kg, and body mass index (BMI) 31.6 kg/m2. Sixty-one UKAs were performed in obese patients (BMI >32). The length of stay averaged 1.3 days. In 121 (97%) cases, patients were discharged directly to home. In 23 (18%) cases, home health physical therapy was used. Outpatient physical therapy was used in 95 (76%) cases. Only four (3%) patients required a skilled nursing or post-discharge rehabilitation stay. Five reoperations were required: one revision to TKA for tibial plateau fracture, one revision to TKA for tibial loosening, one radical debridement and staged reimplantation of primary TKA for sepsis, and two arthroscopic procedures (one retained cement, and one synovitis). The average arc of motion at initial six-week follow up was 116º, with 56% of knees having greater than 120º and 82% more than 110º. Absent, or only mild, pain was reported in 85% of knees. Seventy-five percent of patients had good or excellent Knee Society scores by six weeks postoperatively. UKA provides excellent early function and pain relief with rapid recovery when performed at a specialty musculoskeletal hospital. Early discharge appears to be safe and does not transfer the burden of care to other facilities or home health rehabilitation services.

Authors:

Keith R. Berend, M.D., Joint Implant Surgeons, Inc., New Albany Surgical Hospital, The Ohio State University, New Albany, Ohio, USA; Adolph V. Lombardi, Jr., M.D., F.A.C.S., Joint Implant Surgeons, Inc., New Albany Surgical Hospital, The Ohio State University, New Albany, Ohio, USA

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Early Experience with a New Total Knee Implant: Maximizing Range of Motion and Function with Gender-Specific Sizing

Abstract:

Patients considering total knee arthroplasty (TKA) now have higher expectations of performance including long-term implant survival and a rapid return of normal function. While modern implant systems have many sizes available, implant fit - especially in women - is often imperfect. The ability to achieve outstanding outcomes has many factors, requiring excellent implant fit, alignment, stability, range of motion, and kinematics, as well as long-lasting bearing surfaces and durable fixation. We present the initial two years of experience of 668 consecutive cemented total knee arthroplasties using an implant and bearing surface specifically designed to address these issues. The Triathlon™ TKA uses anthropomorphic sizing, taking into account the gender-specific variable aspect ratio for a better fit. Modified posterior femoral condylar geometry coupled with a rotary arc polyethylene design allows for flexion greater than 150° while rotating 20° internally and externally both in flexion and extension. The X3™ polyethylene insert has demonstrated superior wear characteristics. Early outcomes revealed mean Knee Society pain and function scores, improving from a preoperative total score of 78 to a postoperative score of 182. Patients exhibited a rapid return of knee motion from a mean preoperative flexion of 102° to 116° at 6 weeks, 124° at 3 months, and 128° at 1 year. Whereas long-term results cannot be predicted, no early failures or serious complications were encountered. A prospective long-term outcome study of this cohort is underway.

Authors:

Steven F. Harwin, M.D., F.A.C.S., Beth Israel Medical Center, Albert Einstein College of Medicine, New York, New York, USA; Kenneth A. Greene, M.D., Northeast Ohio Universities College of Medicine, Crystal Clinic Akron, Ohio, USA; Kirby Hitt, M.D., Texas A&M University, Scott and White Clinic, Temple, Texas, USA

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Modular Calcar Replacement Prosthesis with Strengthened Taper Junction in Total Hip Arthroplasty

Abstract:

Whereas femoral component modularity allows the surgeon to address a variety of femoral defects in complex total hip arthroplasty (THA), breakage of modular stems is a known complication that typically occurs at the taper junction. In response, a proprietary process of taper roller-hardening that increases taper strength by a factor of 3.5 was introduced in 1999. The authors reviewed a consecutive series of patients by a single surgeon who underwent cementless revision or difficult primary THA with a taper roller-hardened modular calcar replacement prosthesis, and have the potential for a minimum of two-year follow up. In 116 patients, 123 hips were involved. Two surgeries were primary, 101 were revision/conversion, 18 were for reimplantation after treatment of infection, and two were intramedullary total femur constructs, one of which was a reimplantation after sepsis. The patients' ages at surgery averaged 71 years, and BMIs averaged 28.12 kg/m2. Nine of the patients, all with single hip involvement, were lost to contact. Twenty-one patients, three of whom had bilateral hip involvement, expired during the follow-up period with implant outcome known. Follow up in the patients who survived averaged 44 (range: 18-78) months. Six femoral components have been revised: two (1.6%) due to recurrent sepsis, three (2.4%) due to sepsis, one (0.8%) from periprosthetic fracture, and none from septic loosening or component breakage. Survivorship with aseptic loosening as the end-point was 100%. In this series, roller-hardening appears to improve the durability of the tapered junction. No roller-hardened modular calcar devices have failed due to component breakage. However, their use is not recommended in the totally deficient proximal femur, as fatigue breaks of distally fixed monoblock extensively coated stems have been reported. Caution is advised when potting or anchoring any stem in the femoral diaphysis without reconstituting proximal bone stock and support.

Authors:

Adolph V. Lombardi, Jr., M.D., F.A.C.S., Joint Implant Surgeons, Inc., New Albany Surgical Hospital, The Ohio State University, New Albany, Ohio, USA; Keith R. Berend, M.D., Joint Implant Surgeons, Inc., New Albany Surgical Hospital, The Ohio State University, New Albany, Ohio, USA; Thomas H. Mallory, M.D., F.A.C.S., Joint Implant Surgeons, Inc., The Ohio State University, New Albany, Ohio, USA; Joanne B. Adams, B.F.A., Joint Implant Surgeons, Inc., New Albany, Ohio, USA

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A Lateralized Tapered Titanium Cementless Femoral Component Does Not Increase Thigh or Trochanteric Pain

Abstract:

Increased femoral component lateralization has been reported to recreate femoral offset accurately, and should provide better function. Concerns exist that negative effects may occur such as increased thigh pain, trochanteric bursitis, and loosening. The current study aims to examine whether a lateralized femoral component design is associated with increase in thigh pain, trochanteric pain, or implant failure when used to recreate hip soft tissue balance and stability. The authors reviewed 98 total hip arthroplasties (THA) using the Mallory-Head Porous femoral component. Group 1 had 49 consecutive THA performed before the lateralized stem was available. Group 2 had 49 consecutive THA in which lateralization was deemed necessary, based upon preoperative templating and intraoperative soft tissue balancing. Follow up averaged 46 and 38 months, respectively. No stems failed. Group 1 had three dislocations and Group 2 had none with increased offset. Six (12%) patients in Groups 1 and 3 (6%) patients in Group 2 had trochanteric pain (p<0.05). Three (6%) patients had moderate thigh pain in Group 1 and none in Group 2. Significantly less trochanteric and thigh pain was observed in those patients in whom a lateralized stem was deemed necessary. The use of a lateralized stem improves the accuracy of hip soft tissue reconstruction and does not increase thigh pain, trochanteric pain, or loosening. Accurate soft tissue reconstruction may decrease trochanteric and thigh pain and improve function following THA.

Authors:

Ronald Mineo, D.O., Joint Implant Surgeons, Inc. and New Albany Surgical Hospital, New Albany, Ohio, USA, Associate, Crystal Clinic Kent; Kent, Ohio, USA; Keith R. Berend, M.D., Joint Implant Surgeons, Inc., New Albany, Ohio, USA, The Ohio State University, Columbus, Ohio, USA, New Albany Surgical Hospital, New Albany, Ohio, USA; Thomas H. Mallory, M.D., F.A.C.S., Joint Implant Surgeons, Inc., New Albany, Ohio, USA, The Ohio State University, Columbus, Ohio, USA; Adolph V. Lombardi, Jr., M.D., F.A.C.S., Joint Implant Surgeons, Inc., New Albany, Ohio, USA, New Albany Surgical Hospital, New Albany, Ohio, USA, The Ohio State University, Columbus, Ohio, USA

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Proximal Opening-Wedge Osteotomy of the First Metatarsal for Correction of Hallux Valgus

Abstract:

Osteotomy of the proximal metatarsal in combination with a distal soft tissue procedure for the correction of moderate to severe hallux valgus deformity is commonly performed. All described techniques have complications such as non-union and malunion, and many are extremely technically demanding. The purpose of this study is to review the results of a novel technique for the correction of hallux valgus, an opening-wedge osteotomy of the proximal first metatarsal with plate fixation. A review was performed of the results of 23 patients who underwent correction of hallux valgus with proximal metatarsal opening-wedge osteotomy, in combination with a distal soft tissue procedure and exostectomy, if indicated. All osteotomies were secured with plate fixation on the medial side. Indications for surgery included a painful bunion for greater than one year and the failure of nonoperative treatment. Mean corrections of 15° and 7° were achieved for the hallux valgus and 1-2 intermetatarsal angles, respectively. Four complications occurred, including one wound dehiscence, two incidences of drifting of the hallux valgus angle, and one delayed union. We find the opening-wedge osteotomy of the proximal first metatarsal to be a technically straightforward procedure for correcting moderate to severe hallux valgus. The correction obtained is comparable to other described techniques with a complication rate equal to or lower than most published data at this time.

Authors:

Minton T. Cooper, M.D., Ohio State University Columbus, Ohio, USA; Gregory C. Berlet, M.D., Ohio State University, Ohio, USA; Paul S. Shurnas, M.D., Columbia Orthopaedic Group, Columbia, Missouri, USA; Thomas H. Lee, M.D., Orthopedic Foot and Ankle Center, Columbus, Ohio, USA

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Minimally Invasive Thoracolumbar Costotransversectomy and Corpectomy via a Dual-Tube Technique: Evaluation in a Cadaver Model

Abstract:

Minimally invasive surgery (MIS) is a promising new tool in the treatment of a variety of spinal disorders. MIS laminectomy techniques provide an effective means of achieving lumbar decompression. MIS corpectomy techniques have not been described. If feasible, such a technique would be optimal in the treatment of spinal metastatic disease, where traditional open techniques can result in a significant burden to a compromised patient. In this study, we explored the feasibility of a dual-tube minimally invasive thoracic corpectomy approach in a cadaver model. A minimally invasive thoracolumbar costotransversectomy and corpectomy were perfumed in eight adult cadavers. A dual-tube technique was used to perform a costotransversectomy followed by a corpectomy on one side, and through the opposite tube a transpedicular approach on the contralateral side. Pre- and postoperative CT scans of all cadavers were obtained to measure the cross-sectional area of the vertebral bodies in each specimen via a CT workstation. Reconstruction of the anterior column was attempted in some cadavers using polymethylmethacrylate (PMMA) cement. A successful costotransversectomy and corpectomy were completed in each cadaver. A percutaneous delivery system was successful in allowing an anterior column reconstruction using PMMA as a strut graft in selected cadavers. We demonstrated that a dual-tube MIS approach to thoracic corpectomy is technically feasible. Additionally, spinal stabilization can be achieved via percutaneous PMMA administration. This approach may provide a minimally invasive option in the treatment of select spinal metastases.

Authors:

Michael Musacchio, M.D.; Rush University, Chicago, Illinois, USA; Nimesh Patel, M.D., Rush University, Chicago, Illinois, USA; Bradley Bagan, M.D., Rush University, Chicago, Illinois, USA; Harel Deutsch, M.D., Rush University, Chicago, Illinois, USA; Alexander R. Vaccaro, M.D., Thomas Jefferson University, Philadelphia, Pennsylvania, USA; John Ratliff, M.D., Rush University, Chicago, Illinois, USA, Thomas Jefferson University, Philadelphia, Pennsylvania, USA

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