Total hip arthroplasty (THA) is reliable and reproducible in relieving pain and improving function in patients with end-stage arthritis of the hip joint. With improvements in surgical technique and advances in implant and instrument design, there has been a shift in focus from the technical aspects of the surgical procedure to improving the overall patient experience. In addition, shifts in medico-economic trends placed a premium on early patient mobilization, early discharge, and maximizing patient satisfaction. Arguably, a single most important advance in arthroplasty over the past 2 decades has been the development of multimodal pain protocols that form the foundation of many of the rapid recovery protocols today.

The principal concept of multimodal analgesia is pain reduction through the utilization of multiple agents that synergistically act at various nodes of the pain pathway, thus, minimizing patient exposure to each individual agent and opioids in order to prevent opioid related adverse events (ORAE). Regional anesthesia has been shown to reduce post-operative pain, morphine consumption, and nausea and vomiting compared to general anesthesia but not length of stay. Additionally, general anesthesia has been shown to be associated with increased rates of post-operative adverse events, The use of peripheral nerve blocks in the form of sciatic, femoral or fascia iliaca blocks have not been shown to significantly reduce post-operative pain compared to controls.

Periarticular infiltration of local anesthetics has been shown in some settings to reduce pain during the immediate post-operative period (<24 h). However, no significant differences were noted in terms of early recovery or complications. The use of liposomal bupivacaine (LB) local infiltration decreased pain and shortened length of stay comparable to patients receiving a fascia iliaca compartment block, and has been shown in relatively few randomised trials to provide improved pain relief at 24 hours only compared to conventional bupivacaine. Continuous intra-articular infusion of bupivacaine after THA did not significantly further reduce post-operative pain compared to placebo.

In summary, the use of regional anesthesia when appropriate along with local anesthetic infiltration in the setting of a robust multimodal pain protocol minimises pain and complications while maximizing patient satisfaction following THA.

Infection following total knee arthroplasty (TKA) can cause significant morbidity to the patient and be associated with significant costs and burdens to the health care system. Wound complications often initiate the cascade that can eventually lead to deep infection and implant failure. Galat et al. reported that wound complications following TKA requiring surgical treatment were associated with a 2-year cumulative risk of major reoperation and deep infection of 5.3% and 6.0%, respectively. Consequently, developing a systematic approach to the management of wound problems following TKA can potentially minimise subsequent complications.

Unlike the hip, the vascular supply to the soft tissue envelope to the knee is less robust and more sensitive to the trauma of surgery. Therefore, proper soft tissue handling and wound closure at the time of surgery can minimise potential wound drainage and breakdown post-operatively. Kim et al. showed, using a meta-analysis of the literature, that primary skin closure with staples demonstrated lower wound complications, decreased closure times, and lower resource utilization compared to sutures. However, a running subcuticular closure enables the most robust skin perfusion following TKA. Finally, the use of hydrofiber surgical dressings following surgery was associated with increased patient comfort and satisfaction and reduced the incidence of superficial surgical site infection.

A wound complication following TKA needs to be managed systematically and aggressively. A determination of whether the extent of the involvement is superficial or deep is critical. Antibiotics should not be started without first excluding the possibility of a deep infection. Weiss and Krackow recommended return to the operating room for wound drainage persisting beyond 7 days. While incisional negative pressure wound therapy can occasionally salvage the “at risk” draining wound following TKA, its utilization should be limited only to the time immediately following surgery and should not delay formal surgical debridement, if indicated. Finally, early wound flap coverage and co-management of wound complications with plastics surgery is associated with increased rates of prosthesis retention and limb salvage.

Aims

To evaluate the effectiveness of an institutionally developed algorithm for evaluation and diagnosis of prosthetic joint injection and to determine the impact of this protocol on overall hospital re-admissions.p

Total knee arthroplasty (TKA) is reliable, durable, and reproducible in relieving pain and improving function in patients with arthritis of the knee joint. Cemented fixation is the gold standard with low rates of loosening and excellent survivorship in several large clinical series and joint registries. While cementless knee designs have been available for the past 3 decades, changing patient demographics (i.e. younger patients), improved implant designs and materials, and a shift towards TKA procedures being performed in ambulatory surgery centers has rekindled the debate of the role of cementless knee implants in TKA.

The drive towards achieving biologic implant fixation in TKA is also driven by the successful transition from cemented hip implants to uncemented THA. However, new technologies and new techniques must be adopted as a result of an unmet need, significant improvement, and/or clinical advantage. Thus, the questions remain: 1) Why switch; and 2) Is cementless TKA more reliable, durable, or reproducible compared to cemented TKA?

There are several advantages to using cement during TKA. First, the technique can be universally applied to all cases without exception and without concerns for bone health or structure. Second, cement can mask imprecisions in bone cuts and is a remarkably durable grout. Third, cement allows for antibiotic delivery at the time surrounding surgery which has been shown in some instances to reduce the risk of subsequent infection. Finally, cement fixation has provided successful and durable fixation across various types knee designs, surface finishes, and articulations.

On the other hand, cementless knee implants have had an inconsistent track record throughout history. While some have fared very well, others have exhibited early failures and high revision rates. Behery et al. reported on a series of 70 consecutive cases of cementless TKA matched with 70 cemented TKA cases based on implant design and demographics and found that cementless TKA was associated with a greater risk of aseptic loosening and revision surgery at 5 years follow up. Finally, to date, there has not been a randomised controlled clinical trial demonstrating superiority of cementless fixation compared to cemented fixation in TKA.

Improvements in materials and designs have definitely made cementless TKA designs viable. However, concerns with added cost, reproducibility, and durability remain. Cement fixation has withstood the test of time and is not the main cause of TKA failure. Therefore, until there is significant data showing that cementless TKA is more durable, reliable, and reproducible compared to cemented TKA, the widespread use of these implants cannot be recommended.

Improvements in ceramic materials, component design, and surgical technique have made ceramic bearing complications increasingly rare. However, when it happens, a fractured ceramic component can cause significant pain and morbidity following total hip arthroplasty (THA). The hard and sharp particulate debris from fractured ceramic components can cause damage to the existing hip prosthesis and jeopardise subsequent revision THA results due to third body wear.

Patients with ceramic fractures can present with sudden onset of pain and dysfunction. Often, the patient will report a noisy hip articulation. Radiographs can range from subtle densities surrounding the hip implant to complete disintegration and loss of sphericity of the femoral head or acetabular liner.

Ceramic component fractures should be treated expeditiously. Revision options for failed ceramic components depend on existing component fixation, position, and locking mechanism and femoral trunnion integrity. In order to retain the implants, the components must be well-fixed, in good position, and have tapers and locking mechanisms that can accept new modular components. Additionally, an extensile exposure and complete synovectomy are necessary to remove as much of the sharp particulate debris. Finally, a new ceramic ball head with a titanium inner sleeve should be used in revisions for fractured ceramics due to their hardness and scratch resistance.

Early results for revision surgery for fractured ceramic components were inconsistent. Allain et al. reported on a series of 105 revisions performed for ceramic head fractures and found that the survivorship at 5 years was only 63%. The authors reported a high reoperation rate and also worse survivorship when the acetabular component was retained, a metal head was used for revisions, age younger than 50 years, and when a complete synovectomy was not performed at the time of revision. More recently, Sharma and colleagues reported on a series of 8 ceramic fractures revised to a metal-on-polyethylene articulation performed with a complete synovectomy. At 10-year follow-up, the authors reported on failures; increased wear; or lesser function compared to 6 matched patients undergoing revision using similar implants for other diagnoses. Others have also reported catastrophic failures when revising fractured ceramic components using metal ball heads.

In summary, ceramic bearing complications in THA are rare but catastrophic events. A systematic approach to evaluation and management is necessary to ensure a safe return.

Total hip arthroplasty (THA) is effective, reproducible, and durable in the treatment of hip joint arthritis. While improvements in polyethylene materials have significantly reduced wear rates and osteolysis, aseptic loosening of implants remains one of the leading causes of revision THA. Additionally, fears of dislocation and instability have driven the increase in the utilization of larger diameter femoral heads in primary THA which can lead to increased wear when coupled with a polyethylene articulation. Finally, the increasing number of younger and active patients undergoing THA raises questions with regards to the ability of modern conventional bearings to provide durability and longevity beyond second and third decades following joint implantation.

Ceramic-on-ceramic articulations are ideally suited for today's young and high demand patients undergoing primary THA. It has the lowest in-vitro wear properties of any bearing couple and the wear characteristics further improved by its wettability and lubrication particularly when larger heads are utilised. Additionally, improvements in material properties and prosthesis design have significantly decreased fracture rates and increased the reliability of these implants. Furthermore, reported outcomes and longevity of modern ceramic-on-ceramic THAs in younger patients have all shown excellent survivorship despite patients achieving and maintaining a very high level of activity and function. In short, it is the bearing couple most in tune with current market demands and utilization trends.

While registry data and meta-analyses of published literature have failed to show the superiority of ceramic-on-ceramic articulations compared to conventional bearings at 10 years, there is evidence that even highly crosslinked polyethylene (HXPE) is not immune to wear. Selvarajah et al. reported steady, in-vivo wear rates of HXPE exceeding 0.1 mm/year threshold in young THA patients with 36 mm ceramic ball heads. Additionally, small osteolytic lesions have been observed in hips with HXPE bearings at 12–14 years follow up. Finally, analysis of all controlled randomised studies have shown less osteolysis of ceramic-on-ceramic hips compared to polyethylene articulations. The significance of these lesions are unclear but the question remains: Can HXPE as a bearing be able to provide over 30 years of service needed to outlast patients younger than 60 years?

Concerns with cost, squeaking, and fractures do not make ceramic-on-ceramic bearings suitable for all patients undergoing primary THA. However, in young, healthy and active patients, a modern ceramic-on-ceramic articulation is most likely to provide the lowest wear rates, lowest risk of osteolysis, and greatest chance for life-long durability.

Infection following primary total knee arthroplasty (TKA) is fortunately a relatively uncommon complication with an incidence of approximately 1%. However, because the morbidity and cost of treatment of deep prosthetic TKA infections is so high, effective prevention strategies are key quality improvement initiatives. The cause of post-operative infections are multifactorial and complex but can generally be categorised into 1) host, 2) surgical, and 3) environmental factors. The purpose of this abstract to provide an outline of these factors and their influences on the infection risk following TKA.

Patient factors and optimization of modifiable risk factors have been shown to decrease the risk for infection. While the individual contributions of factors such as body mass index (BMI), diabetes, nutritional status, Charlson Comorbidity Index (CCI), and renal disease are unknown, together, they have been shown to influence infection risk. Additionally, Tayton et al. analyzed 64,566 primary TKAs in the New Zealand Joint Registry and found that male gender and prior knee surgery were also independent risk factors of development of PJI 12 months following TKA. Finally, Crowe and colleagues also identified tobacco use and Staphylococcus aureus colonization as modifiable risk factors for minimizing PJI following primary TKA.

Timely administration of prophylactic antibiotics prior and after surgery has been shown to be the most effective strategy to reduce infection risk. The optimal prophylaxis regimen for all patients is unknown and in certain situations, administration of Vancomycin in additional to a conventional cephalosporin may be beneficial. However, universal administration of Vancomycin has not been shown to decrease the incidence of surgical site infections and could actually increase the risk for renal failure. Conversely, addition of antibiotics to cement during primary TKA has not been shown to reduce long term infection risk. The use of dilute betadine lavage has been shown by some authors to be beneficial. Finally, good surgical technique, proper soft tissue handling, and meticulous wound closure are all critical factors influencing the risk for infectious complications following TKA.

Environmental factors have also been shown to affect infection rates following TKA. While the use of laminar flow and body exhaust suits have not been shown to significantly influence the risk for infection, minimizing operating room traffic has been shown effective in reducing the risk for contamination. Some authors have shown ultraviolet light systems to decrease airborne contaminants.

In summary, factors influencing infection risk following TKA are complex and multifactorial. Patient selection, optimization of modifiable risk factors, appropriate use of antibiotics, and minimization of OR traffic are among the most common strategies to minimizing infection.

Purpose

Failure resulting from a recurrent infection in total knee arthroplasty (TKA) is a challenging problem. Knee arthrodesis is one treatment option, however fusion is not always successful, as there is huge bone defect. The authors reports a new arthrodesis technique that uses a bundle of flexible intramedullary rods and an antibiotic-loaded cement spacer.

Introduction

The utilization of ceramic components in Total Hip Arthroplasty has experienced an expanded acceptance by the orthopedic community. This increased acceptance has been largely due to the lower risk of fracture due to the introduction of zirconia toughened alumina ceramics. This extra-high strength ceramic composite has been proven clinically over the past 13 years and found to be much more reliable than previous ceramic materials. The goal is to verify this finding by published registry data as well as clinical outcome.

Post-traumatic avascular necrosis of the femoral head usually occurs after hip dislocation and femoral neck fracture. Recently along the development of hip arthroscopy, early stage of avascular necrosis of the femoral head can be treated rthroscopically. We hereby present two cases of post-traumatic avascular necrosis patients treated with hip arthroscopy.

Case 1

Twenty one year old female patient came to the hospital because of fall from height of 3 floors. Left acetabular fracture, both superior pubic rami fractures and severely displaced left femoral neck fracture were identified at the emergency department (Fig. 1-A). She underwent surgery at the injury day. After the repair of ruptured urinary bladder, internal fixation of the femoral neck was done. Four cannulated screws with washers were inserted for displaced femoral neck fracture, consistent with garden stage IV (Fig. 1-B). Skeletal traction of ipsilateral lower extremity was applied four weeks after the surgery for acetabular fracture. She visited us for painful limitation of motion on left hip at eight months postoperatively. Plain radiograph showed collapse of femoral head and osteophyte formation which were caused by post-traumatic avascular necrosis (Fig. 1-C,D). Femoral head was perforated by a screw. She was planned to remove the screw and resect the osteophyte arthroscopically. On arthroscopic examination, severe synovitis and folded, collapsed femoral cartilage were identified (Fig. 1-E). Screws were removed and osteophyte were also resected (Fig. 1-F). We filled the cavity caused by the screws with allogenic strut graft for structural support. After the surgery, pain was relieved and she came back to her active daily living and for six months, no other complication nor further collapse were identified postoperatively.

Case 2

Fourty year old male patient was admitted to the hospital for fall from height about fifteen feet from the ground. Left femoral neck fracture was identified on the emergency department. Previously he had underwent intramedullary nailing for the femoral shaft fracture about five years ago. Urgent internal fixation with four cannulated screws was done on the day of injury. The fixation was unsatisfactory because previously inserted intramedullary nail hindered the proper trajectory of screws. Furthermore, direction of cephalad interlocking holes of the nail were not consistent with the anteversion of femoral neck, we could not place the screws through the nail. Four months after the index surgery, collapse of femoral head and loosening of screws have occurred. MRI showed the collapse of femoral head and posttraumatic avascular necrosis. Prominent bony beak of femoral neck were identified and he complained difficulty and pain on his hip during abduction. We left two screws for secure fixation and resected the bony beak using arthroscopic burr. After the surgery, he felt free from the pain on abduction of hip.

Introduction

During revision surgery with a well-fixed stem, a titanium sleeve can be used in conjunction with a ceramic head to achieve better stress distribution across the taper surface. Previous studies have observed that the use of a ceramic head can mitigate the extent of corrosion damage at the taper. Moreover, in vitro testing suggests that corrosion is not a concern in sleeved ceramic heads [1]; however, little is known about the in vivo fretting corrosion of the sleeves. The purpose of this study was to investigate fretting corrosion in sleeved ceramic heads.

Ceramic bearing complications are rare, but can be a catastrophic complication following total hip arthroplasty (THA). Particulate debris from fractured ceramics can cause damage to the hip prosthesis and jeopardise subsequent revision THA. Patients with ceramic fractures can present with sudden onset of pain and dysfunction. Often, the patient will report a noisy hip articulation. Radiographs can range from subtle densities surrounding the hip implant to complete disintegration and loss of sphericity of the femoral head or acetabular liner.

Ceramic component fractures should be treated expeditiously. Revision options for failed ceramic components depend on existing component fixation, position, and type. In order to retain the implants, the components must be well fixed, appropriately positioned, and have tapers that are undamaged and can accept current femoral heads. Additionally, an extensile exposure and complete synovectomy are necessary to remove the sharp ceramic particulate debris. Finally, a ceramic ball head should be used to revise a fractured ceramic THA. Newer, alumina composite ceramic ball heads are harder, reliable, and more scratch resistant compared to metal ball heads. However, when retaining the femoral component, a ceramic ball head with a titanium sleeve should be used to prevent subsequent failures.

In summary, ceramic bearing complications are rare but catastrophic events. A systematic approach to evaluation and management is necessary to ensure a safe return.

Revision total knee arthroplasty (TKA) can pose significant challenges. Successful reconstruction requires a systematic approach with the ultimate goal being a well fixed and balanced knee prosthesis. Careful preoperative planning is necessary for safe exposure, component removal, and appropriate management of bone loss during revision knee surgery.

Prior to surgery, the cause of failure must be understood. Revision TKA without a clear diagnosis has been shown to lead to predictable poor results. A careful history and physical examination for both intrinsic and extrinsic causes of knee pain need to be performed. An ESR and C-reactive protein should be obtained in every patient with a painful TKA and in cases of serologic abnormalities, a joint aspiration performed.

The integrity of the collateral ligaments and the degree of anticipated bone loss at the time of revision needs to be established. In cases of severe collateral ligament deficiency, the need for constrained or hinged knee implants should be anticipated. Plain radiographs are needed to evaluate present component position, loosening, and osteolysis. Oblique radiographs and advanced imaging (i.e. CT or MRI) have been shown to more accurately quantify the severity of lysis compared to standard radiographs. This careful assessment can help prepare for the need of special implants, stems, wedges, or augments.

Finally, patient risk stratification and medical co-management can help minimise complications following revision TKA. Optimization of potentially modifiable risk factors such as glycemic control, BMI, and preoperative hemoglobin can reduce perioperative morbidity and complications.

While total hip arthroplasty (THA) has been shown successful at relieving pain and improving function in patients with coxarthrosis, wear and instability remain leading causes for revision surgery. Highly crosslinked polyethylene (HXPE) has significantly reduced wear and osteolysis but volumetric wear associated with the use of larger diameter ball heads may be an issue in the long-term. Finally, concerns with femoral taper corrosion have increased the utilization of ceramic ball heads in recent years.

Ceramic on ceramic articulations are optimised for both minimizing implant wear and instability. It is biocompatible, wettable, and possesses the lowest in vitro and in vivo wear rates among all bearing couples. In fact, wear rates are lowest when the ceramic ball head size is maximised. Additionally, modern ceramic on ceramic THA designs have had an excellent clinical track record with low rates of loosening, failure, and no reports of osteolysis in even highly active, young patients.

Concerns with ceramics center around issues related to fracture risk, squeaking, and cost. While the phenomenon of squeaking remains poorly understood, the reliability of ceramic implants have steadily improved with better materials, design, and manufacturing. The fracture risk for modern pure alumina implants and the newer alumina matrix composite ceramics are 1 in 5000 and 1 in 100,000, respectively.

The advantages of ceramic on ceramic THAs will not be realised on every patient and therefore, should be selectively used. However, with expected increases in life expectancy and more young, active patients undergoing THA, ceramic on ceramic THA should be strongly considered in patients under age 60 years.

Infection following primary total knee arthroplasty (TKA) is fortunately a relatively uncommon complication with an incidence of approximately 1%. However, because the morbidity and cost of treatment of deep prosthetic TKA infections is so high, effective prevention strategies are key quality improvement initiatives. The cause of post-operative infections are multifactorial and complex but can generally be categorised into 1) host, 2) surgical, and 3) environmental factors. The purpose of this abstract is to provide an outline of these factors and their influences on the infection risk following TKA.

Patient factors and optimization of modifiable risk factors have been shown to decrease the risk for infection. While the individual contributions of factors such as body mass index (BMI), diabetes, nutritional status, Charlson Comorbidity Index (CCI), and renal disease are unknown, together, they have been shown to influence infection risk. Additionally, Tayton et al. analyzed 64,566 primary TKAs in the New Zealand Joint Registry and found that male gender and prior knee surgery were also independent risk factors of development of PJI 12 months following TKA. Finally, Crowe and colleagues also identified tobacco use and Staphylococcus aureus colonization as modifiable risk factors for minimizing PJI following primary TKA.

Timely administration of prophylactic antibiotics prior and after surgery has been shown to be the most effective strategy to reduce infection risk. The optimal prophylaxis regimen for all patients is unknown and in certain situations, administration of Vancomycin in additional to a conventional cephalosporin may be beneficial. However, universal administration of Vancomycin has not been shown to decrease the incidence of surgical site infections and could actually increase the risk for renal failure. Conversely, addition of antibiotics to cement during primary TKA has not been shown to reduce long term infection risk. The use of dilute betadine lavage has been shown by some authors to be beneficial. Finally, good surgical technique, proper soft tissue handling, and meticulous wound closure are all critical factors influencing the risk for infectious complications following TKA.

Environmental factors have also been shown to affect infection rates following TKA. While the use of laminar flow and body exhaust suits have not been shown to significantly influence the risk for infection, minimizing operating room traffic has been shown effective in reducing the risk for contamination. Some authors have shown ultraviolet light systems to decrease airborne contaminants.

In summary, factors influencing infection risk following TKA are complex and multifactorial. Patient selection, optimization of modifiable risk factors, appropriate use of antibiotics, and minimization of OR traffic are among the most common strategies to minimizing infection.

Ceramic bearing complications are rare but can cause significant pain and morbidity following total hip arthroplasty (THA). The hard and sharp particulate debris from fractured ceramic components can cause damage to the existing hip prosthesis and jeopardise subsequent revision THA results due to third body wear.

Patients with ceramic fractures can present with sudden onset of pain and dysfunction. Often, the patient will report a noisy hip articulation. Radiographs can range from subtle densities surrounding the hip implant to complete disintegration and loss of sphericity of the femoral head or acetabular liner.

Ceramic component fractures should be treated expeditiously. Revision options for failed ceramic components depend on existing component fixation, position, and locking mechanism and femoral trunnion integrity. In order to retain the implants, the components must be well-fixed, in good position, and have tapers and locking mechanisms that can accept new modular components. Additionally, an extensile exposure and complete synovectomy are necessary to remove the sharp particulate debris. Finally, a new ceramic ball head with a titanium inner sleeve should be used in revisions for fractured ceramics due to their hardness and scratch resistance.

Early results for revision surgery for fractured ceramic components were inconsistent. Allain et al. reported on a series of 105 revisions performed for ceramic head fractures and found that the survivorship at 5 years was only 63%. The authors reported a high reoperation rate and also worse survivorship when the acetabular component was retained, a metal head was used for revisions, age younger than 50 years, and when a complete synovectomy was not performed at the time of revision. More recently, Sharma and colleagues reported on a series of 8 ceramic fractures revised to a metal-on-polyethylene articulation performed with a complete synovectomy. At 10-year follow up, the authors reported on failures; increased wear; or lesser function compared to 6 matched patients undergoing revision using similar implants for other diagnoses. Others have also reported catastrophic failures when revising fractured ceramic components using metal ball heads.

In summary, ceramic bearing complications in THA are rare but catastrophic events. A systematic approach to evaluation and management is necessary to ensure a safe return.

Purpose

There are still some controversies over the routine use of negative suction drainage after primary total hip arthroplasty (THA). In this study we are to know the benefits of new suction drainage management strategy after primary THA.

Introduction

Highly crosslinked polyethylene (HXLPE) was clinically introduced approximately a decade and a half ago to reduce polyethylene wear rates and subsequent osteolysis. Clinical and radiographic studies have repeatedly shown increased wear resistance, however concerns of rim oxidation and fatigue fracture remain. Although short to intermediate term retrieval studies of these materials are available, the long-term behavior of these materials remains unclear.

Introduction

Total hip arthroplasty (THA) is the most common surgery performed for complications of bipolar arthroplasty. The present study evaluated the functional results and complications associated with this surgery.

Introduction

Previous studies of retrieved CoCr alloy femoral heads have identified imprinting of the stem taper surface features onto the interior head bore, leading researchers to hypothesize that stem taper microgrooves may influence taper corrosion. However, little is known about the role of stem taper surface morphology on the magnitude of in vivo corrosion damage. We designed a matched cohort retrieval study to examine this issue.