Seminars in Arthroplasty RSS feed: Current Issue. Each issue of Seminars in Arthroplasty provides a comprehensive, current overview of a single topic in arthroplasty. The journal addresses orthopedic surgeons, providing authoritative reviews with emphasis on new developments relevant to their practice. 2009 Issues/Topics February Current Concepts in Hip and Knee Replacement A. Seth Greenwald May Current Concepts in Shoulder Replacement A. Seth Greenwald August Disorders and Treatment of the Patellofemoral Joint David Hungerford December TBD http://www.semarthroplasty.com/?rss=yesElsevier Inc.en © 2010 Published by Elsevier Inc. All rights reserved. Seminars in Arthroplasty1045-4527212June 2010 © 2010 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.semarthroplasty.com/article/PIIS1045452710000301/abstract?rss=yesEditorial Board10.1053/S1045-4527(10)00030-1Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-7iiiihttp://www.semarthroplasty.com/article/PIIS1045452710000325/abstract?rss=yesContents10.1053/S1045-4527(10)00032-5Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-7iiiivhttp://www.semarthroplasty.com/article/PIIS1045452710000313/abstract?rss=yesIssue Topics10.1053/S1045-4527(10)00031-3Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-7vvhttp://www.semarthroplasty.com/article/PIIS1045452710000246/abstract?rss=yesI would like to welcome the journal readership to the second of 3 companion issues of Seminars in Arthroplasty dedicated to selected papers presented at the Spring 2009 Current Concepts in Joint Replacement meeting held in Las Vegas, Nevada. The papers provide commentaries from orthopedic thought leaders with recognized expertise in joint reconstruction.IntroductionA. Seth Greenwald10.1053/j.sart.2010.02.006Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-77171http://www.semarthroplasty.com/article/PIIS1045452709001072/abstract?rss=yesCartilage restoration may be a misnomer as our current technologies fail to produce true native hyaline cartilage. There are multiple techniques and technologies available as a potential solution for symptomatic full thickness chondral or osteochondral defects. This review will discuss the indications and contraindications of various procedures. It should be emphasized that any effort to repair an osteochondral defect should be made if possible. If not, then factors such as alignment, status of the meniscus, patient factors such as obesity, and more should be considered and addressed before any restoration technologies. Specific lesion-specific parameters, most importantly size, should be considered before deciding which procedure should be used. Multiple technologies are on the forefront of cartilage regeneration and the answer of which to use is unknown. Future research to create the ideal cartilage regeneration system will include a favorable biological and biomechanical environment in an effort to truly restore articular cartilage.Articular Cartilage Restoration: The Shape of Things to ComePradeep Kodali, Richard D. Parker10.1053/j.sart.2009.12.021Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-77276http://www.semarthroplasty.com/article/PIIS1045452709001011/abstract?rss=yesClearly, total knee replacements are what orthopedic surgeons are doing for most really significant arthrosis. Unicondylar replacements have been receiving increased attention over the past few years. People are beginning to see some new entries involving novel approaches to resurfacing arthroplasties. One of the “old standby's” though has been knee osteotomy either varus or valgus for medial or lateral compartment degeneration, respectively. However, our US population is particularly demanding, litigious, and web literate. Also, many cohorts involving clinical results for knee osteotomies are corrupted by inclusion of significant numbers of workers' compensation patients. This group is commonly known to have less good results on average, compared with most of the others.Unloading the Compartments: The Role of OsteotomyKenneth A. Krackow10.1053/j.sart.2009.12.015Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-77779http://www.semarthroplasty.com/article/PIIS1045452709000972/abstract?rss=yesIncreasing numbers of total joint replacement surgeries are being performed in the United States. One of the most frequent complications from these procedures is venous thromboembolism. Prophylaxis is accepted as the standard of care by all the stakeholders: physicians, patient advocacy groups, payers, and government agencies. Debate and disagreement persist with regard to the most clinically efficacious and safe prophylaxis regimen. There are differences between the guideline recommendations from different organizations: American College of Chest Physicians and American Academy of Orthopaedic Surgeons. This review focuses on summarizing some of the differences in the recommended chemoprophylaxis for orthopedic patients undergoing total joint replacement surgery. We have also included a discussion of newer agents in clinical development.Deep Vein Thrombosis Propylaxis: Better Living Through Chemistry-AffirmsBryant Ho, Michael H. Huo10.1053/j.sart.2009.12.011Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-78084http://www.semarthroplasty.com/article/PIIS1045452709000868/abstract?rss=yesThe risk for venous thromboembolic events after total joint arthroplasty is well known. Use of pharmacologic prophylaxis is recommended by many guidelines, but with pharmacologic prophylaxis comes the possibility of bleeding with a major surgical incision. With a new mobile compression device that can be worn in or out of bed, in the hospital, or at home, or a rehabilitation facility, the concern for major bleeding is eliminated, and the rate of venous thromboembolic events is similar to that of pharmacologic prophylaxis.Deep Vein Thrombosis Prophylaxis: Better Living Through Chemistry—OpposesClifford W. Colwell10.1053/j.sart.2009.12.003Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-78586http://www.semarthroplasty.com/article/PIIS1045452710000027/abstract?rss=yesThe study reviews the outcome of total knee arthroplasty in obese patients. Knee arthroplasty in obese patients is a more technically challenging procedure. It carries a higher risk of postoperative infection, and the final functional score may not be as good as that of the nonobese patient. However, the pain relief and improvement in knee function are significant, and implant survival is equivalent to nonobese patients. Knee arthroplasty should not be denied to obese patients despite the concerns, as the overall improvement of quality of life is highly significant.Patient Obesity: A Growing Concern of Successful Total Knee ArthroplastyEric Yeung, Paul Thornton-Bott, William L. Walter10.1053/j.sart.2010.01.001Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-78791http://www.semarthroplasty.com/article/PIIS1045452709001023/abstract?rss=yesMinimally invasive surgery (MIS) techniques have been developed with the goal of reducing recovery and improving outcomes. Critics argue that MIS reduces visualization and compromises technique, causing wound problems secondary to surgical trauma and increasing early failure. To determine whether MIS techniques lead to increased complications and early revisions, we reviewed our experience using a limited medial parapatellar approach in 3631 primary total knee arthroplasties (TKA) since 2003, in comparison with a historic control of 1291 primary TKA performed in 1994-1996 using a standard medial parapatellar approach. Fewer MIS than standard TKA required manipulation (5.4% vs 8.9%; P = 0.0001), had complications requiring reoperation (1.0% vs 2.1%; P = 0.0047), and required revision of one or more component parts for any reason (0.8% vs 4.4%; P = 0.0000). In our experience with more that 3600 primary MIS TKA with a rapid recovery protocol, excellent outcomes have been seen at up to 6 years follow-up, with a concomitant reduction compared with standard approach TKA in rates of manipulation and early complications requiring reoperation.Minimally Invasive Surgery Is Not a Risk Factor of Early Total Knee Arthroplasty FailureAdolph V. Lombardi, Keith R. Berend, Joanne B. Adams10.1053/j.sart.2009.12.016Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-79296http://www.semarthroplasty.com/article/PIIS1045452709001035/abstract?rss=yesThe title of this debate is inherently preposterous; the prefix mal- is derived from Latin and refers to bad, abnormal, or defective, and thus, by definition malalignment is bad, abnormal, or defective alignment. No one then wants a “malaligned” knee. The intellectually curious, however, might switch the focus to the other end of the spectrum and ask what does an ideally aligned knee look like in 2009? Is there really one simple target value for alignment in all patients undergoing total knee arthroplasty (TKA)? Is that target broad (0 ± 3 degrees from the mechanical axis) or is it a narrow target in which a penalty, in regard to durability or function, is incurred as soon as you deviate even 1 degree? Is that ideal target the same if we are evaluating the functional performance of the TKA vs the durability of the TKA or could there be 2 different targets, one that maximizes function and the other that maximizes durability? Is that target adequately described by a single 2-dimensional value (varus/valgus alignment in the frontal plane) as measured on a static radiograph? Is that value the same if the patient has a fixed pelvic obliquity, a varus thrust in the contralateral knee, or an abnormal foot progression angle?The Consequences of Malalignment: Few If Any-AffirmsErik P. Severson, Mark W. Pagnano10.1053/j.sart.2009.12.017Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-79798http://www.semarthroplasty.com/article/PIIS1045452709000959/abstract?rss=yes“Failure” in TKA remains multifactorial. Alignment plays an important role in loading of the underlying bone and has been associated with osseous failure and implant loosening in both metal backed and all poly tibial components in long term studies on large cohorts of total knee arthroplasties. Importantly, varus malalignment of a TKA in obese patients (BMI >33) has resulted in early tibial component loosening via medial tibial osseous collapse. Furthermore, in a multivariate analysis, varus limb alignment has been associated with accelerated poly wear in both TKA and UKA. Certainly not all knees in varus coronal alignment fail. We have further examined implant, surgical, and patient factors associated with this pathophysiology both clinically and in our laboratory.Consequences of Malalignment in Total Knee Arthroplasty: Few if Any-OpposesMichael Berend10.1053/j.sart.2009.12.009Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-799101http://www.semarthroplasty.com/article/PIIS1045452710000039/abstract?rss=yesAdequate surgical exposure is one key to successful total knee arthroplasty. The approach selected is dependent on surgeon knowledge and experience, individual patient anatomy, and location of prior surgical incisions. This article summarizes various exposure techniques, and then describes and illustrates the author's preference for exposure of the difficult knee—tibial tubercle osteotomy. This procedure allows exposure without radical undermining of the soft tissues. Steps for extended intraosseous tibial exposure are described for revision total knee arthroplasty cases that require even more exposure. The use of vascularized soft-tissue flaps is also described to ensure adequate wound closure.Extensile Exposure Options: Exposing the Stiff Knee in Total Knee ArthroplastyLeo A. Whiteside10.1053/j.sart.2010.01.002Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-7102107http://www.semarthroplasty.com/article/PIIS1045452709000844/abstract?rss=yesStiffness after total knee arthroplasty, with limitations in range of motion, is present in approximately 2% of knees. In patients with increased risk for motion loss, appropriate patient education is important. Early in the postoperative period, manipulation under anesthesia is successful in 90% of cases. Revision for stiffness is more successful if an etiology can be identified and if pain is combined with the loss of motion.Revision of the Stiff Total Knee Arthroplasty: An Operation to Try to AvoidMichael Berend10.1053/j.sart.2009.12.001Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-7108109http://www.semarthroplasty.com/article/PIIS104545270900090X/abstract?rss=yesBony deficiencies are commonly encountered during revision total knee arthroplasty. Stems are used routinely to offload epiphyseal fixation, and both fully cemented and press-fit stems have demonstrated excellent survivorship in recent studies. Ease of removal, if needed, end of stem pain concerns, anatomic variability, and bone quality can influence stem-fixation method selection. Metal augments are available in various shapes and sizes to allow efficient management of epiphyseal defects and a modular approach to gap balancing. Larger defects can be managed with trabecular metal cones and metaphyseal filling sleeves, which have demonstrated encouraging results in recent studies. These newer implants are available in a variety of shapes and sizes and allow the efficient management of larger defects not handled easily by other methods.Rebuilding the Skeleton, Stems, Metal Augments, and DisciplineGeorge J. Haidukewych10.1053/j.sart.2009.12.007Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-7110112http://www.semarthroplasty.com/article/PIIS104545270900100X/abstract?rss=yesMost problems encountered in difficult revision total knee arthroplasty can be managed by the wide range of systems now available. Modular metaphyseal sleeves or trabecular metal augments will provide stability even with significant bone loss, and hinged systems substitute for ligamentous deficiencies. Catastrophic failure that precludes reconstruction can be encountered. The alternative to arthroplasty in such drastic situations is knee arthrodesis, resection arthroplasty, and amputation. The relative indications for selection of alternatives are recurrent deep infection, immunocompromised patient, and extensive nonreconstructible hard- or soft-tissue loss. Techniques for each alternative will be reviewed.Alternatives to Revision Total Knee ArthroplastyRichard E. Jones10.1053/j.sart.2009.12.014Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-7113115http://www.semarthroplasty.com/article/PIIS1045452710000076/abstract?rss=yesPainful knees are selected to stimulate discussion on the topic of “alignment.” The depiction of “mechanical” and “anatomic” axes as well as the indications and preferred alignment for osteotomy, unicompartmental arthroplasty, and total knee arthroplasty illustrate areas of consensus and disagreement.What Would You Do? Challenges in Knee SurgeryKelly G. Vince, Keith R. Berend, Richard E. Jones, Mark W. Pagnano, Aaron G. Rosenberg, Leo A. Whiteside10.1053/j.sart.2010.01.006Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-7116127http://www.semarthroplasty.com/article/PIIS104545271000026X/abstract?rss=yesThe following 3 papers were originally scheduled to be part of the issue entitled “Management of Patellofemoral and Extensor Mechanism Problems” (2009; #3), edited by Drs. Wayne B. Leadbetter and Michael A. Mont. The value of these papers is self-evident and contributes in a meaningful way to the current issue.Erratum10.1053/j.sart.2010.02.008Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-7128128http://www.semarthroplasty.com/article/PIIS1045452710000234/abstract?rss=yesPatellar instability (PI) after total knee replacement (TKR) is one of the more frequent complications following the procedure. It is nearly completely avoidable with attention to detail during the procedure and particularly at the time of trial reduction. PI may be the result of malalignment of any of the components, not just malalignment of the patellar component. Most patients do not present for TKR with PI. Therefore if PI is evident at the time of tiral reduction, a check for component malalignment should ALWAYS be carried out, and not an immediate default to lateral release. Preoperative PI increases the risk of postoperative PI. The surgeon must be prepared to do whatever is necessary to be certain that there is no PI when the surgery is finished. This can include lateral release, but in some cases, medialization of the tibial tubercle may be necessary. When PI is encountered in follow-up after TKR, a careful evaluation of component malalignment is essential, including rotational malalignment of the femoral or tibial components that might not be obvious of standard radiographs.Technical Factors Contributing to Patellar Instability in TKADavid S. Hungerford10.1053/j.sart.2010.02.005Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-7129133http://www.semarthroplasty.com/article/PIIS1045452710000222/abstract?rss=yesExtensor mechanism failure after a total knee arthroplasty can be a devastating complication that is difficult to manage. Although primary repair of the extensor mechanism may be attempted acutely, similar management of a chronic disruption is associated with a substantial rate of failure and associated complications. Several options for secondary reconstruction exist, but a full extensor mechanism allograft that is tightly tensioned in full extension followed by immobilization for 6 weeks has been associated with the most consistent results. With this technique, the extensor allograft can be completely covered with host tissue, facilitating healing and restoration of active knee extension. The reconstruction requires attention to secure distal fixation and maximal extensor tension to achieve optimal outcomes.Extensor Mechanism Allograft for the Treatment of Extensor Mechanism Disruption After Total Knee ArthroplastyAlexander P. Sah, Craig J. Della Valle10.1053/j.sart.2010.02.004Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-7134138http://www.semarthroplasty.com/article/PIIS1045452710000210/abstract?rss=yesComplications involving the extensor mechanism following total knee arthroscopy may account for up to 50% of all revision procedures associated with early clinical failures, with the reported incidence of patellar fractures as high as 21% in some reports. The purpose of this review article was to provide an overview of the risk factors and treatment options for this potential complications of total knee arthroscopy.The Treatment of Patellar Fractures After Total Knee ArthroplastySiraj A. Sayeed, Aaron Johnson, Ronald E. Delanois10.1053/j.sart.2010.02.003Seminars in Arthroplasty 21, 2 (2010)2010-06-01Seminars in Arthroplasty2010-06-01212S1045-4527(10)X0003-7139141