Unanswered questions, unmet needs in venous thromboprophylaxis.

Although significant progress has been made over the past 25 years in preventing thromboembolic disease in patients undergoing total hip and total knee arthroplasty, important questions remain unanswered. Few would debate the need to seek a balance between maximal antithrombotic efficacy and minimal bleeding in choosing a thromboprophylactic strategy, but there is less agreement as to how efficacy should be defined, and whether efficacy and safety (however each is defined) are intrinsic to the thromboprophylactic agent chosen or depend as well on exogenous factors, ranging from the timing of drug administration to surgical technique. Differences between recent guidelines from the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) illustrate these unanswered questions.

Subtalar fusion after displaced intra-articular calcaneal fractures: does initial operative treatment matter? Surgical technique.

Background: Many patients with displaced intra-articular calcaneal fractures require subtalar arthrodesis for the treatment of posttraumatic arthritis. We hypothesized that patients who underwent initial operative treatment would have better functional outcomes as compared with those who underwent initial nonoperative treatment before undergoing a subtalar arthrodesis.

Methods: A consecutive series of sixty-nine patients with seventy-five displaced intra-articular calcaneal fractures underwent subtalar arthrodesis for the treatment of painful posttraumatic subtalar arthritis.

High-flexion total knee arthroplasty.

High-flexion total knee arthroplasty is considered flexion beyond 125 degrees . Certain activities and a number of workplace demands benefit from this greater range of motion. Some cultures and religions place more emphasis on deep knee flexion.

Porous tantalum cones for large metaphyseal tibial defects in revision total knee arthroplasty: a minimum 2-year follow-up.

Sixteen cases of revision total knee arthroplasty requiring the use of porous tantalum tibial cones for 2 T2A, 3 T2B, 4 T3A, and 7 T3B tibial bone defects (Anderson Orthopaedic Research Institute classification) after 13 cases of aseptic loosening and 3 cases of staged reimplantation for infection were reviewed. At an average 31 months (24-38), no patients were lost to follow-up. There were 2 cases of recurrent sepsis requiring removal of a well-fixed cone.

The accuracy of subacromial corticosteroid injections: a comparison of multiple methods.

Corticosteroids are commonly used in the treatment of the impingement syndrome. Efficacy, as well as accurate placement, have been questioned. The purpose of this prospective, randomized study is to assess the accuracy of subacromial injections and to correlate accuracy with short term clinical outcome at 3 months.

The impact of smart tools on total knee arthroplasty.

Smart tools and robotic surgery are helping us take a step into the operating room of the future. As this technology develops, it can potentially help surgeons perform total knee arthroplasty (TKA) faster and with increased accuracy. In addition, this technology will reduce the number of instruments needed for the procedure, thus improving efficiency.

Management of flexion contracture in total knee arthroplasty.

Flexion contracture is a common deformity encountered during total knee arthroplasty. Most deformities are mild and can be passively corrected at the time of surgery. Severe fixed deformities require surgical correction with release of the contracted soft tissues and appropriate management of the femoral bone resection.

Minimally invasive total knee arthroplasty: surgical technique.

The surgical techniques associated with the variety of minimally invasive surgery (MIS) approaches for total knee arthroplasty (TKA), including the limited parapatellar, limited midvastus, limited subvastus, and quadriceps-sparing approaches, are reviewed. The patient selection criteria for mini-incision TKA are detailed. Although clinical experience with these approaches is limited, initial results seem promising and potentially adaptable to a majority of cases with modifications in either instruments or components customized for the procedure.

Preoperative planning and perioperative management for minimally invasive total knee arthroplasty.

The introduction of minimally invasive surgery (MIS) has led to new clinical pathways for total knee arthroplasty (TKA). MIS TKA outcomes are affected by multiple factors--the surgery itself; preoperative planning and medical management; preoperative patient education; preemptive perioperative and postoperative analgesia; mode of anesthesia; optimal rehabilitation; and enlightened home care and social services-and therefore an integrated team approach to patient and surgery is required.

Incidence of lateral release in total knee arthroplasty in standard and mini-incision approaches.

Minimally invasive total knee arthroplasty is a relatively new technique. There are limited clinical data on outcomes in patients having this procedure. We report the incidence of lateral release of the patella during total knee arthroplasty performed by one surgeon in 106 consecutive knees.

Management of bone loss: augments, cones, offset stems.

Unlabelled: Trabecular metal augmentation has added new treatment options for severe proximal tibial bone defects in revision knee arthroplasty. Porous tantalum tibial cones provide mechanical support for the tibial component and have the potential for long-term biologic fixation. These cones facilitate restoration of the proximal tibia metaphysis in Type 2 and 3 defects.

Current trends in blood conservation in total knee arthroplasty.

There is a lack of consensus with regard to ways to minimize blood transfusions after total knee arthroplasty. We surveyed 434 members of the American Association of Hip and Knee Surgeons, each of whom averaged 18 years in practice and performed an average of between 100 and 150 knee replacements a year, about their preferences and practices regarding blood conservation during total knee arthroplasty. Of those surveyed, only 24% reported that there was a blood conservation program in place at their institutions.

The effect of total knee arthroplasty on body weight.

This prospective study quantified the weight change in 20 consecutive patients undergoing total knee arthroplasty. Resected bone, soft tissues, and bone reamings were collected during surgery and weighed using a digital scale at the end of the procedure. Results were compared to the cumulative weights of the prosthesis, bone cement, patellar component, and polyethylene liner.

Orthopaedic-induced anemia: the fallacy of autologous donation programs.

Total knee arthroplasty is associated with significant blood loss. Despite the initiation of various blood conservation modalities, allogeneic transfusion has yet to be eliminated. One hundred forty-eight patients who had unilateral primary total knee arthroplasties during a 3-year period were evaluated retrospectively for blood loss and transfusion rates.

Surgical approaches in mini-incision total knee arthroplasty.

Mini-incision total knee arthroplasty can be accomplished through versions of exposures used in standard total knee arthroplasty. Modifications of the medial parapatellar, subvastus, and midvastus approaches are presented, and potential advantages and disadvantages of each approach are reviewed. When making the transition to smaller incisions and arthrotomies, the medial parapatellar seems to be the most versatile.

Optimizing patellofemoral tracking during total knee arthroplasty.

Fifty-seven patients who underwent 65 primary TKAs between 1993-1994 were retrospectively studied to identify the technical challenges and pitfalls associated with patellar resurfacing and to improve patellar tracking during total knee arthroplasty (TKA). Average patient age was 69 years. All surgeries were performed by a single surgeon (J.

Primary total knee arthroplasty for complex distal femur fractures in elderly patients.

Fractures of the distal femur in the geriatric population are associated with a high incidence of postoperative complications and poor results. Nonunion, loss of fixation, and malunion of these fractures occur with all types of treatment. The postoperative treatment of these patients demands a lengthy period of limited weightbearing that can increase the rate of medical complications.

Polyethylene post failure in posterior stabilized total knee arthroplasty.

Posterior-stabilized (PS) prostheses have been used extensively in total knee arthroplasty (TKA), with excellent long-term results. The key feature of these prostheses is the femoral cam and tibial post mechanism that limits posterior displacement and produces femoral rollback. Although articular-surface polyethylene wear of the tibial component has not been a significant clinical problem, tibial post wear has been reported.

Blood management in patients with deep prosthetic hip and knee infections.

Patients undergoing treatment for infected hip and knee replacements often have significant blood loss and require allogeneic blood transfusions. In the setting of sepsis, traditional methods of blood management such as preoperative blood donations, cell savers, and reinfusion drains are contraindicated. Pharmacologic agents can minimize transfusion requirements by increasing erythropoiesis, or minimize perioperative blood loss.

Intraoperative blood management in joint replacement surgery.

Interest is growing in blood conservation and avoidance of transfusion in patients undergoing orthopedic surgery, especially in the field of joint replacement. Several methods have proven successful in reducing intraoperative blood loss, which can translate into lessened allogeneic and autologous transfusion requirements. Available techniques include acute normovolemic hemodilution, hypotensive anesthesia, intraoperative blood salvage, specialized cautery, topical hemostatic agents, and pharmacologic agents given in the perioperative period.