Acetabular component positioning, offset, combined anteversion, leg length, and soft tissue envelope around the hip plays an important role in hip function and durability. In this paper we will focus on acetabular positioning of the cup. The axis of the pelvis is identified intra-operatively as a line drawn from the highest point of the iliac crest to the middle of the greater trochanter. Prior to reaming the acetabulum, an undersized trial acetabular component is placed parallel and inside the transverse ligament, inside the anterior column and projecting posterior to the axis of the pelvis. This direction is marked and the subsequent reaming and final component placement is performed in the same direction. The lateral opening is judged based on the 45-degree angle from the tear drop to the lateral margin of the acetabulum on anteroposterior pelvic radiographs. The final anteversion of the cup is adjusted based on increased or decreased lumbar lordosis and combined anteversion.Introduction
Technique
Fixation of cemented femoral stems is reproducible and provides excellent early recovery of hip function in patients 60–80 years old. The durability of fixation has been evaluated up to 20 years with 90% survivorship. The mode of failure of fixation of cemented total hip arthroplasty is multi-factorial; however, good cementing techniques and reduction of polyethylene wear have been shown to reduce its incidence. The importance of surface roughness for durability of fixation is controversial. This presentation will describe my personal experience with the cemented femoral stem over 30 years with 3 designs and surface roughness (RA) ranging from 30 to 150 microinches. Since 1978, three series of cemented THA have been prospectively followed using periodic clinical and radiographic evaluations. All procedures were performed by the author using the posterior approach. Excellent results and Kaplan-Meier survivorship ranges from 90% to 99.5% in the best case scenario were noted at 10 to 20 year follow-up. With a properly-designed femoral stem, good cement technique, proper cement mantle, and surface roughness of 30 to 40 microinches, the cemented femoral stem provides a durable hip replacement in patients 60 to 80 years old with up to 95% survivorship at 10 to 20 year follow-up.Results
Conclusion
Introduction: Although volumetric wear reduction has been demonstrated in knee simulator studies, there is no long-term in-vivo evidence supporting wear reduction and durability with uni-directional rotating platform PS design. This design was introduced to reduced spin-out and provide greater range of motion. This is the first long-term report of this implant, a prospective study investigating clinical and radiographic survivorship with 10 years follow-up. Material and Methods: Between January 2000 to March 2001, 118 consecutive patients (141 knees) received cemented RP TKRs. All patients were followed prospectively using clinical and radiographic criteria as defined by the Knee Society. At minimum nine years follow-up 20 patients were deceased, 11 were lost to follow-up and two refused to participate in the study, leaving 85 patients (100 knees) for final analysis. Results: Good to excellent results were achieved in 95% of patients. There were no cases of malalignment, spinout, aseptic loosening or osteolysis. The mean ROM improved from 111.2 ± 15.2 degrees to 119 ± 3.8 degrees. The mean WOMAC score was 30 ± 14, KSS scores improved from an average of 48 to 96. Sporting activities such as golf, tennis and walking was 29%, 12% and 32%, respectively. Anterior knee pain was present in 15% of cases. The incidence of asymptomatic crepitation and painful crepitation requiring scar excision was 10% and 4% respectively. During this period we had one case of infection and one revision for fracture. Kaplan-Meier survivorship at 10 years for mechanical failure and failure for all failures was 100% and 95.7%, respectively. Discussion and Conclusion: Ten-year follow-up of RP-PS design demonstrates excellent clinical and radiographic results with no failures for mechanical reasons. There were no spin-out and average ROM was 119 ± 3.8 degrees.
Introduction: Acetabular component positioning, offset, combined anteversion, leg length, and soft tissue envelope around the hip plays an important role in hip function and durability. In this paper we will focus on acetabular positioning of the cup. Technique: The axis of the pelvis is identified intra-operatively as a line drawn from the highest point of the iliac crest to the middle of the greater trochanter. Prior to reaming the acetabulum, an undersized trial acetabular component is placed parallel and inside the transverse ligament, inside the anterior column and projecting posterior to the axis of the pelvis. This direction is marked and the subsequent reaming and final component placement is performed in the same direction. The lateral opening is judged based on 45-degree angle from the tear drop to the lateral margin of the acetabulum on anteroposterior pelvic radiographs. The final anteversion of the cup is adjusted based on increase or decrease of lumbar lordosis and combined anteversion. Methods: Anteroposterior pelvic radiographs of 100 consecutive patients undergoing posterior THR between September 2010 and March 2011 with this method were evaluated for cup inclination angle and anteversion using EBRA software. Results: There were no malalignment or dislocation. The mean cup inclination angle and anteversion were 41 ± 5.1 degrees (range 37.1 – 48.4) and 22.1 ± 4.8 degrees (range 16.6 – 29.3), respectively. Conclusion: This is a reproducible method of cup positioning and with proper femoral component position, restores leg length, offset, combined anteversion, and balances soft tissue around the hip. These factors affect the incidence of dislocation, infection, reduced wear, and durability.
Introduction: I always aim for neutral mechanical axis alignment. My principles of a successful TKA are proper alignment in all 3 planes, soft tissue balance in extension first, flexion gap balancing by parallel to tibial cut technique, maintenance of joint line, correct sizing of femoral component, and proper cement fixation. Long-term Survivorship: There is long-term data that supports the efficacy and durability of the neutral position of the proximal tibial cut. Over a 20-year follow-up there was a 92.6% success rate in my study. Other authors have found similarly successful survivorship for mechanical failure. Balance Technique in TKR: My technique to balance the knee is a balance extension gap first, which requires medial soft tissue balancing. Next, I balance the flexion gap parallel to the tibial cut. Our Results: In one study, I examined the clinical and radiographic data of 68 varus knees. Average post-operative mechanical alignment was 0 ± 3 degrees. There were no outliers which displays the reproducibility of the technique. This is the method of choice in the hands of most surgeons.
There has not been a comparison of patients and outcomes between two separate countries for any knee prosthesis. This study compares total knee replacement outcomes between an Indonesian and American cohort. We aim to compare the clinical results between two different hospitals in two different countries using post-operative range of motion as the primary clinical result. 177 Indonesian RPF TKR patients were compared to 84 American patients. Demographics, patient recorded outcomes scores (KSS, PAQ, WOMAC), flexion, and component size were compared between the groups. Standard t-test was used to compare the variables between the two countries and regression analysis adjusting for age, BMI, length of follow-up, sex, preoperative WOMAC and PAQ score, preoperative KSS knee score, preoperative KSS function score, and preoperative UCLA was used to compare outcomes.Introduction
Materials and Methods
Mastering the Art of Cemented Femoral Stem Fixation: Fixation of cemented femoral stems is reproducible and provides excellent early recovery of hip function in patients 60 to 80 years old. The durability of fixation has been evaluated up to 20 years with 90% survivorship. The mode of failure of fixation of cemented total hip arthroplasty is multi-factorial; however, good cementing techniques and reduction of polyethylene wear have been shown to reduce its incidence. The importance of surface roughness for durability of fixation is controversial. This presentation will describe my personal experience with the cemented femoral stem over 30 years with 3 designs and surface roughness (RA) ranging from 30 to 150 microinches. Cemented Primary Acetabulum: I am going to present a technique of cementing an all-poly socket. We have looked at our all-poly socket from 1992 to 1998 and the total number of hips are over 1,000, with a follow-up of 2 to 8 years. We have not revised a single socket for fixation failure.
The goals of any rehabilitation protocol should be to control pain, improve ambulation, maximise range of motion, develop muscle strength, and provide emotional support. Over 85% of TKA patients will recover knee function regardless of which rehabilitation protocol is adopted but the process can be facilitated by proper pain control, physical therapy, and emotional support. The remaining 15% of patients will have difficulty obtaining proper knee function secondary to significant pain, limited preoperative motion, and/or the development of arthrofibrosis. This subset will require a special, individualised rehabilitation program, which may involve prolonged oral analgesia, continued physical therapy, more diagnostic studies and occasionally manipulation. Controlling pain is the mainstay of any treatment plan. The program described herein has been used at Ranawat Orthopaedics over the last 10 years in more than 2000 TKAs.
There exists a variety of options for a medial compartment knee with osteoarthritis, specifically a unicompartmental knee, high tibial osteotomy, and total knee arthroplasty. This surgeon prefers a rotating platform posterior stabilised total knee to the unicompartmental knee. Unicompartmental knee arthroplasty (UKA) in younger patients is being performed with increasing frequency. While UKA is a powerful marketing tool because of its minimally invasive nature and quality of knee function that is superior to the total knee arthroplasty (TKA), it has tremendous drawbacks. These include: the selection criteria is very specific and the number of patients that fit in that category is small, there is a steep learning curve for the surgeon to perfect the technique, higher failure due to wear and loss of fixation, and unexplained pain. Based on level 1 and 2 evidence available it is not justified to do more UKAs at present when the results of a TKA are so successful.
Acetabular fixation is one of the major factors affecting long-term longevity and durability of total hip arthroplasty (THA). Limited data exist regarding mid-term performance of modern non-cemented rim-fit cups with HA coating. The aim of this study was to assess the minimum 5 year clinical and radiographic performance of PSL cups. Therefore we retrospectively analyzed results of this component in patients that had adequate followup from a prospective institutional database. A retrospective analysis of a prospective database was performed to identify patients that underwent non-cemented THA between 2003 and 2007. 223 primary THA (210 patients) were performed by single surgeon via posterolaeral approach using a grit-blasted, HA coated rim-fit design and highly cross-linked polyethylene and were followed with minimum 5 years. The mean age was 62.5 years ± 10.8. The majority of the stems were non-cemented (87%) and the majority of the femoral heads were metal (75%), 22- or 28-mm diameter. 72% of the cups were solid and 28% were multi-hole. Clinical assessment included the Hospital for Special Surgery (HSS) hip score [18] at final follow-up, and Kaplan-Meier survivorship. All patients received pre- and post-operative anteroposterior (AP) weight bearing pelvis radiograph as well as a false profile view of the hip. Cup positioning was analyzed using the EBRA software (Einzel-Bild-Roentgen-Analysis; University of Innsbruck, Innsbruck, Austria) for functional abduction angle, anteversion, and cup migration. Osseointegration was assessed on the DeLee and Charnley's zones on both AP and false profile views. Osseointegration was defined based on the following characteristics: presence of Stress Induced Reactive Cancellous Bone (SIRCaB), where new bone condensation (not apparent on preoperative radiographs) was present at the load bearing area of the cup (Figure 1) presence of radial trabeculae that project in continuum from the shell into the pelvis, suggesting integration of the trabecular bone onto the metal surface at the load bearing area, (Figure 2) absence of radiolucency. Radiolucency was determined by radiolucent lines that were at least 1–2 mm wide and were seen in sequential radiographs, not apparent on the initial postoperative radiograph. Linear and rotational migration was defined as > 3 mm or > 5°change in the cup position, respectively, as measured on serial radiographs. Any changes in cup position or presence of circumferential radiolucencies were considered as loosening.Introduction
Materials and Methods
Wear and osteolysis are major contributors, which limit the durability of total hip Arthroplasty (THA) and ultimately cause it to fail. Efforts were made to decrease wear by highly cross-linked polyethylene (HXLPE) and using ceramic bearings. The purpose of this study is to analyze and compare the five year performance of large sized (32mm and 36mm) ceramic and metal heads on X3 HXLPE (Stryker, Mahwah, NJ, USA).Background
Questions/Purposes
Highly cross-linked polyethylene (HCLPE) was introduced to reduce wear and osteolysis in total hip arthroplasty (THA). There is no reported data regarding wear rates and clinical performance of Crossfire HCLPE (Stryker, Mahwah, New Jersey) in young and active patients. The purpose of this prospective study is to assess minimum 10-year wear rates and survivorship of Crossfire in young and active patients. Between January 2001 to December 2003, 52 consecutive THAs (43 patients; 26 males and 17 females), 55 years and younger, with an average University of California Los Angeles activity (UCLA) score of 7.3 ± 1.5 (5 – 10) at the time of surgery were prospectively followed. The mean age of patients was 47.4 ± 7.8 years old (range 24 to 55 years). Indication for surgery included osteoarthritis in all cases. All operations were performed by the senior surgeon via a posterolateral approach. All components were non-cemented SecurFit femoral stem, 28 mm Cobalt-Chromium (Co-Cr) femoral head, and Trident PSL cup with Crossfire HCLPE acetabular liner (Stryker, Mahwah, New Jersey). At minimum 10-years follow-up (mean 11.5 ± 0.94 years), wear rates were assessed using the Roman software. Hospital for Special Surgery (HSS) scores and survivorship data were analyzed.Background
Material and Methods
Accurate and reproducible cup positioning is one the most important technical factors that affects outcomes of total hip arthroplasty (THA). Although Lewinnek's safe zone is the most accepted range for anteversion and abduction angles socket orientation, the effect of fixed lumbosacral spine on pelvic tilt and obliquity is not yet established.
What is the change in anteversion and abduction angle from standing to sitting in a consecutive cohort of patients undergoing THA? What is the effect of fixed and flexible spinal deformities on acetabular cup orientation after THA? Between July 2011 and October 2011, 68 consecutive unilateral THAs were implanted in 68 patients with a mean age of 71 ± 6 years old. Radiographic evaluation included standing anteroposterior (AP) and lateral pelvic radiographs, and sitting lateral pelvic radiograph, measuring lumbosacral angle (LSA), sacral angle (SA), and sagittal pelvic tilt angle (SPTA). Computer generated 3D pelvis models were used to analyze the correlation between different pelvic tilts and acetabular cup orientation in abduction and anteversion.Introduction
Material and Methods
Anterior knee pain (AKP) is a recognized cause of patient's dissatisfaction after total knee arthroplasty. Potential implant/technique related contributors to AKP are patellofemoral maltracking, trochlear geometry, femoral malrotation, patellar tilt and overstuffing. The primary aim of this prospective, matched pair study was to assess the safety, efficacy and performance of an anatomic patella and its effect on AKP in in a matched pair analysis. Between July 2012 and May 2013, 55 consecutive posterior stabilized cemented Attune TKAs (Depuy) were matched to the PFC Sigma group based on age, gender, and body mass index (BMI). All surgeries were performed via medial parapatellar approach with patellar resurfacing. Clinical and radiographic analysis was performed prospectively with minimum 6 month follow-up. Radiographic measurements included overall limb alignment, anterior offset, posterior offset, joint line, patellar thickness, patellar tilt and patellar displacement by two independent observers.Introduction
Material and Methods
A) Mastering the Art of Cemented Femoral Stem Fixation Fixation of cemented femoral stems is reproducible and provides excellent early recovery of hip function in patients 60–80 years old. The durability of fixation has been evaluated up to 20 years with 90% survivorship. The mode of failure of fixation of cemented total hip arthroplasty is multi-factorial; however, good cementing techniques and reduction of polyethylene wear have been shown to reduce its incidence. The importance of surface roughness for durability of fixation is controversial. This presentation will describe my personal experience with the cemented femoral stem over 30 years with 3 designs and surface roughness (RA) ranging from 30 to 150µm. Since 1978, three series of cemented THA have been prospectively followed using periodic clinical and radiographic evaluations. All procedures were performed by the author using the posterior approach. Excellent results and Kaplan-Meier survivorship ranged from 90% to 99.5% in the best case scenario were noted at 10–20 year follow-up.Abstract:
Results:
The goals of any rehabilitation protocol should be to control pain, improve ambulation, maximise range of motion, develop muscle strength, and provide emotional support. Over 85% of TKA patients will recover knee function regardless of which rehabilitation protocol is adopted but the process can be facilitated by proper pain control, physical therapy, and emotional support. The remaining 15% of patients will have difficulty obtaining proper knee function secondary to significant pain, limited preoperative motion, and/or the development of arthrofibrosis. This subset will require a special, individualised rehabilitation program, which may involve prolonged oral analgesia, continued physical therapy, more diagnostic studies and occasionally manipulation. Controlling pain is the mainstay of any treatment plan. The program described herein has been used at Ranawat Orthopaedics over the last 10 years in more than 2000 TKAs.
The bi-cruciate retaining (BCR) total knee arthroplasty (TKA) is based on sound biomechanics to produce kinematics close to normal, which is the goal of BCR TKA. This assumes that the joint line is maintained and both cruciates are functional with a range of motion greater than 125 degrees. The technical difficulties of implanting such a knee in correct anatomical position with preservation of both cruciate ligaments with proper tension is challenging and may not be possible in the hands of most surgeons. Patient selection for consideration of BCR TKA assumes that both ligaments are normal and ROM is greater than 125 degrees. If this assumption is correct, why does one need a knee replacement in such a patient? If we assume that the patient has normal cruciate ligaments, there is no scientific evidence to suggest that they will remain normal in the environment of a TKA with longer follow-up. Lastly, fixation with cement may be compromised because of the lack of a stem and less surface area. This can be argued both ways, but the long-term data on this matter favors stemmed designs. Moreover, insertion of cruciate ligaments (ACL) limits the robustness of the connecting bar for bicruciate knees. Lastly over 30 years, surgeons have tried BCR TKA without significant market share. Remember “all good things in life should ultimately prevail”.
Cup positioning in total hip arthroplasty (THA) is an important variable for short and long term durability of any hip implant. This novel method utilises internal and external bony landmarks, and the transverse acetabular ligament for positioning the acetabular component. The cup is placed parallel and superior to the transverse ligament and inside the anterior wall notch of the true acetabulum, and then adjusted for femoral version and pelvic tilt, fixed obliquity, and transverse rotational deformity based on weight bearing pre-operative radiographs. Seventy consecutive THRs (68 patients) were performed using the above technique. The cup radiographic and functional anteversion and abduction angle were measured on post-operative weight bearing pelvic radiographs using EBRA software.Introduction
Methods
Proper balance and stability is essential to the longevity of total knee arthroplasty (TKA). The aim of this study was to evaluate long-term quality and performance of cemented total knee arthroplasty (TKA) in young and active patients using posterior stabilised designs. From a prospective database between January 2000 and October 2001, 62 patients (81 TKAs, mean age 53 ± 1.5 years) with University of California Los Angeles (UCLA) activity score of 5 or above were identified. All implants received Posterior-Stabilised (PS) TKA: 43 Rotating-Platform (RP-PS) and 38 Fixed-Bearing (FB-PS) and were followed prospectively for a minimum of 10 years. The femoral component was identical in both groups and all TKAs were cemented. Extension first gap balancing technique was utilised in all cases.Introduction
Methods
The common causes of failure leading to revision Total Knee Replacement (TKR) include instability, infection, improper alignment, implant wear and osteolysis and improper cementation. This presentation outlines the details of the art of cementation. Proper exposure with adequate length of incision Avoid cutting of quadriceps tendon in oblique direction (medial-lateral plain) Reduced Tissue Trauma Surgery (RTTS), no tourniquet except for cementing Deliver the tibia in front of the femur (Ran-Sall maneuver) Preserve supra-patellar pouch, coagulate lateral genicular artery 8 to 10 mm tibial cut from the uninvolved side, identify the cortical tibial cut Adequate rotation, alignment, lateralisation and restoration of the posterior offset of the femoral component Pulseatile lavage the cut surfaces to clean the cancellous bone Drill holes in the sclerotic bone surface Heated Simplex cement at a doughy state Apply cement on the bone surfaces including posterior femoral condyles and pressurise, apply cement on the components as well Apply manual constant pressure Remove excess cement from posterior femoral condyles, tibia and patella (if resurfaced) Further pressurisation in extension with trial insert Release of the tourniquet and throughout irrigation Closure in flexion without tourniquet and with good approximation of dermis and epidermis.Introduction
Technique
