Seminars in Arthroplasty

Editorial Board

2012-03-01

Issue Topics

2012-03-01

Introduction

A. Seth Greenwald — 2012-03-01

I would like to welcome the journal readership to the first of 3 companion issues of Seminars in Arthroplasty dedicated to selected knee papers presented at the Spring 2011 Current Concepts in Joint Replacement (CCJR) meeting held in Las Vegas, Nevada. This issue provides commentaries from orthopedic thought leaders with recognized expertise in joint reconstruction.

Strategies in Articular Cartilage Restoration—Present Advances in Biologic Intervention for Adult Knee Problems

Waqas M. Hussain, Michael J. Griesser, Brett W. McCoy, Richard D. Parker — 2012-03-01

Although a number of new methods have improved our ability to treat articular injuries of the knee, no procedures have yet been proven to restore injured hyaline cartilage to its original state. Multiple techniques are used to address full-thickness chondral or osteochondral defects. This review briefly examines surgical options for this pathology. If amenable, all attempts should be made to repair osteochondral injuries. If unable to do so, preoperative anatomic factors, such as alignment, ligamentous stability, and meniscal integrity, should be carefully considered. Additionally, indications for surgery and patient factors must be thoroughly reviewed to identify appropriate candidates for treatment. Size and previous attempts at treatment often dictate care, which may include microfracture, osteochondral transplantation (osteoarticular transfer system and mosaicplasty), or autologous chondrocyte implantation. Upcoming advances intend to minimize surgical morbidity while improving cartilage regeneration and articular incorporation. Despite the new developments surrounding this field, much is still unknown, and novel treatments should be addressed with caution.

Role of Osteotomy: Unloading the Compartments

Mark W. Pagnano, Emily J. Brand — 2012-03-01

Opening-wedge high tibial osteotomy continues to have a role in young active patients today. It is being used in combination with ligamentous and cartilage procedures for improved joint homeostasis with satisfactory early results. Our described technique with a single bone cut allows incremental increases in distraction for precise deformity correction, achieving satisfactory survival in midterm follow-up. The modern opening-wedge high tibial osteotomy represents a valid alternative for young patients for correction of varus deformity and early medial compartment osteoarthritis.

Obesity and Total Joint Arthroplasty

Edward M. Vasarhelyi, Steven J. MacDonald — 2012-03-01

Obesity is an increasing epidemic in North America and across most developed and developing countries around the world. This poses challenges for the orthopedic surgeon with regard to the management of osteoarthritis and the role of hip and knee arthroplasty in these patients. An increasingly heavy population has profound effects on arthroplasty surgeons, affecting the number of procedures required, the perioperative management of obese patients, the complications, and outcomes. Controversial questions exist such as, what influence obesity should have on access to arthroplasty procedures and what role the orthopedic surgeon should play in weight loss for these patients.

Computer Navigation in Total Joint Arthroplasty: Promising in Hips, More of a Bother in Knees

Eric R. Wagner, Robert T. Trousdale — 2012-03-01

Computer-assisted navigation has been successfully used in many surgical procedures throughout medicine. During the past 10 years, navigation has been used to improve accuracy and reproducibility of component orientation and limb alignment in total joint arthroplasty. This has theoretical advantages to improve pain and function, while potentially reducing dislocation and revision arthroplasty rates. However, these clinical benefits of navigation arthroplasty have yet to be demonstrated. Additionally, although proper component orientation has been shown to decrease dislocation rates in total hip arthroplasty, precise limb alignment along the mechanical axis after total knee arthroplasty has not shown any definitive significant long-term clinical advantage. Navigated surgeries have many disadvantages, including increased surgical times, increased costs, and intraoperative time. We review the advantages and disadvantages of computer-assisted navigation in total joint arthroplasty.

Benefits of Computer Navigation in Total Knee Arthroplasty

Arun Mullaji, Gautam M. Shetty — 2012-03-01

Computer navigation enables the surgeon to accurately quantify deformity and gap balance during total knee arthroplasty (TKA), ensuring greater accuracy in component alignment, full correction of deformity, and well-balanced gap throughout the range of knee motion. This translates into significant improvements in clinical function and may result in increased long-term survival of the implant. Computer navigation in TKA may be even more useful in knees with complex deformities, extra-articular deformities, and in the obese. Hence, navigation complements the surgeon's skill to provide an unbeatable combination of technique and technology in TKA to ensure that all goals of the surgical procedure are achieved.

Patient-Specific Cutting Blocks

S. David Stulberg — 2012-03-01

The numbers and costs of revision total knee arthroplasties are increasing and are projected to represent a significant burden to the health care system (). Moreover, the epidemiology of the revisions being performed is troublesome. A significant proportion of revisions are performed within the first 5 years of the index primary arthroplasty, and an estimated 70% of revisions performed within the first 2 years of the index arthroplasty are related to surgical technique. There is, therefore, a compelling need to assure that primary TKA procedures performed by orthopedic surgeons of all ranges of experience are carried out accurately and reproducibly.

Correction of Severe Deformity in Total Knee Arthroplasty: Decision Making and Key Technical Considerations

Arun Mullaji, Gautam M. Shetty — 2012-03-01

Treating complex arthritic knee deformities with hinged total knee arthroplasty may be technically simpler but involves issues of higher cost, uncertain long-term implant survival, particularly in younger and active patients. Using a graduated, step-wise intra-articular correction technique with or without an osteotomy performed concomitantly during total knee arthroplasty allows the surgeon to achieve a well-balanced and well-aligned knee. Full correction of knee deformity and optimum soft-tissue balance can be achieved in the vast majority of arthritic knees with complex deformities using the patient's own soft-tissue envelope and without resorting to use of hinged implants.

Rethinking Patellar Replacement: Is It Really Necessary?

Michael J. Dunbar, Glen Richardson, Otto Robertsson — 2012-03-01

Recent meta-analyses and registry data suggest that patients without resurfaced patellae have higher early revision rates and may have more anterior knee pain and lower satisfaction rates. The incidence of patellar resurfacing in total knee arthroplasty varies significantly between countries. Rates in Sweden have fallen from approximately 80% in the 1980s to <5% today. This may be related to the realization that the long-term complications of a resurfaced patella are significant and potentially avoidable. In a young total knee arthroplasty patient, the patellar bone stock should be preserved, whereas there is little reason not to resurface in the older population.

Resurface the Patellae in Total Knee Arthroplasty? Always!

Rajrishi Sharma, Steven J. MacDonald — 2012-03-01

Whether to resurface the patellae during the index total knee arthroplasty procedure is actively debated in current literature. Looking at surgical practice, this inconsistency within the literature has translated into 2 segregated camps. Despite the ongoing debate of whether to resurface patellae, if viewed from the perspective of revision rate, survivorship, patient preference, or current literature, there is an abundance of support to resurface all patellae. Therefore, from the perspective of the surgeon and the patient, we take the stance that all patellae should be resurfaced.

Contemporary Bone Loss Management Options for Revision Total Knee Arthroplasty

George J. Haidukewych, Benjamin Service — 2012-03-01

Bony defects are common during revision total knee arthroplasty, therefore, having effective treatment strategies is important. Defects can range from small-contained deficiencies to massive structural loss of epiphyseal bone. Distal and posterior femoral and central tibial defects are common. Stems should be used to off-load deficient epiphyseal bone. Both press-fit and cemented stems have good long-term performance, but trade-offs exist. Various metal augments as well as metaphyseal-engaging sleeves and cones are available to effectively manage larger defects. Familiarity with the various defect management strategies is important to obtain durable implant fixation and well-balanced flexion and extension gaps.

What Would You Do? Challenges in Knee Surgery

2012-03-01

Dr. Vince: We have an expert panel assembled—David Blaha, Gerry Engh, Dickey Jones, Matthew Kraay, and Jay Parvizi—who will describe how they would handle the following clinical cases. I would like to make 2 points about these presentations: first, for most of CCJR, we deal in idealized situations, describing what experience and clinical research teaches us to do “in general.” Specific cases, however, deal with the vagaries, and the multiple variables involved in the care of real patients. Second, our literature is a magnificent body of information, but are we always guided by it, even when the right path may be difficult?

Seminars in Arthroplasty

Editorial Board

Contents

Issue Topics

Introduction

Strategies in Articular Cartilage Restoration—Present Advances in Biologic Intervention for Adult Knee Problems

Role of Osteotomy: Unloading the Compartments

Obesity and Total Joint Arthroplasty

Computer Navigation in Total Joint Arthroplasty: Promising in Hips, More of a Bother in Knees

Benefits of Computer Navigation in Total Knee Arthroplasty

Patient-Specific Cutting Blocks

Correction of Severe Deformity in Total Knee Arthroplasty: Decision Making and Key Technical Considerations

Rethinking Patellar Replacement: Is It Really Necessary?

Resurface the Patellae in Total Knee Arthroplasty? Always!

Contemporary Bone Loss Management Options for Revision Total Knee Arthroplasty

What Would You Do? Challenges in Knee Surgery