Intra-articular osteotomy for ankle arthritis

Ankle arthritis is a condition affecting a wide age range of patients. There are a variety of surgical treatment options available when non-operative treatments are not providing adequate symptom control. These are broadly classified into joint-preserving or joint-sacrificing surgery with arthroplasty or arthrodesis. The joint-preserving operations include soft tissue and bone debridement, osteochondral defect surgery, distraction arthroplasty and realignment osteotomies. For the younger patients with high activity and work demands the development of realignment osteotomies as a measure to delay joint sacrificing procedures is appealing. The realignment surgery aims to alter the mechanical axis and alter the joint contact pressures. Depending on the arthritis pattern, the osteotomy can be intra-articular or extra-articular or a combination of osteotomies. The focus of this article is an in-depth review of the biomechanics, surgical techniques and results of intra-articular osteotomies performed for ankle arthritis.     

Septic complications of knee replacements and their treatment

The introduction of the modern total knee replacement has been revolutionary in treatment of degenerative joint disease. Over recent years there has been a significant increase in the number of primary replacements and revision procedures. Prosthetic joint infection is an important and devastating complication which has not been eliminated by modern day practice. Patient selection, operating environment, surgical technique and soft tissue management can reduce but not eliminate the incidence of infection. When infection occurs, it should be managed as part of a multidisciplinary team to ensure an optimal outcome. Revision for infection can be performed as a single-stage or two-stage procedure. When revision surgery fails, salvage options should be considered including: salvage arthroplasty, arthrodesis, resection arthroplasty and amputation. The challenges for the surgeon to overcome include: a poor soft tissue envelope, ligamentous or extensor mechanism disruption and bone loss. Complications are not uncommon with salvage options and therefore meticulous preoperative planning and a thorough consent process are mandatory. The management of patients with an infected implant should performed by consultants who have specialized expertise and who work in networks. This is necessary to achieve the best results. This article will also discuss the salvage options.     

Surgical strategies for management of infection following knee arthroplasty and arthroscopic procedures

Infection is one of the most feared complications following knee arthroplasty and soft tissue arthroscopic procedures. This article summarizes the current understanding on the management of this rare but devastating problem. The healthcare and economic burden of periprosthetic joint infection (PJI) is highlighted, together with how the classification of infection and host staging can aid decision-making. Surgical treatment options will be described. These consist of ‘debridement, antibiotics and implant retention’ (DAIR), revision arthroplasty (single- or two-stage), as well as salvage procedures (arthrodesis, permanent resection, and amputation). In selected cases, chronic antibiotic suppression may be the only viable option. All implant-related orthopaedic infections must be managed using a multidisciplinary team (MDT) approach, ideally within dedicated bone infection units, in order to optimize clinical outcomes.     

Bone cement in arthroplasty

Bone cement, or polymethylmethacrylate (PMMA) cement, is widely used to fix joint replacement prostheses to host bone. It acts as a grout, adapting the surface irregularities of the surrounding bone tissue to the surface of the inserted prosthesis.Knowledge of the components, exothermic reaction, exact mixing and handling times is important. Pressurizing the cement during insertion improves penetration into cancellous bone interstices, enabling better mechanical interdigitation. Optimal fixation of a cemented arthroplasty is critical to obtain long-term durability.Despite the increasing use of uncemented implants, there are many advantages of cemented fixation. This is particularly so in cemented femoral stem fixation. Advantages include the ability to implant components in femurs with a diverse bone shapes and quality, easy adjustment of the angle of anteversion of the femoral stem and the ability to achieve accurate leg lengths. Another advantage is to allow the addition of antibiotics in patients with a history or predisposition to infection.Despite revolutionary changes in joint replacement technology for the treatment of hip and knee arthritis, the use of PMMA bone cement in arthroplasty has not significantly changed although the evolution of improved cementing techniques have helped to improve long-term results.     

Implications of the spinopelvic relationship for total hip arthroplasty

Total hip arthroplasty is one of the most successful procedures in medicine. It aims to replicate the anatomy of the patient's hip joint to allow mobilization and reduce pain. To maintain stability, the changes in pelvic positioning between sitting and standing need to be considered. The spinopelvic relationship normally adjusts the position of the pelvis on sitting to antevert the acetabulum and reduce the amount of flexion at the hip. When this relationship is affected by normal variation or pathological changes, this can have implications for the arthroplasty surgeon. An anteverted or retroverted pelvis can lead to edge loading, wear, impingement and dislocation. Therefore, strategies to identify patients at risk are important to reduce complications. Sitting and standing lateral radiographs, and measurement of the change in sacral slope, can identify those with a stiff spinopelvic junction. Mitigation has mainly focused on adjusting the placement of the acetabular component within safe zones. However, use of dual mobility components, increasing offset and head size, have also been identified as possible methods. To date, there is a lack of prospective evidence or biomechanical studies assessing hip arthroplasty in these patients.     

Management of the osteoarthritic and rheumatoid wrist

Arthritis of the wrist has multiple causes, with post-traumatic being the most common non-inflammatory cause, and rheumatoid arthritis the most common inflammatory condition. Management starts with detailed history, examination and functional assessment. Surgical options include wrist denervation, correction of carpal deformities (distal radius osteotomy, ligament tenodesis), excision of the affected articulations (scaphoidectomy, styloidectomy, proximal row carpectomy), arthrodesis (four corner fusion, limited carpal fusions, total wrist arthrodesis) and total wrist arthroplasty. Similar procedures can be performed at the distal radioulnar joint. This article reviews the causes of wrist arthritis and evidence behind the management options.     

Hip dislocations and femoral head fractures

Traumatic dislocation of the hip joint is a rare injury with significant long-term implications for patients. The most common mechanism is a dashboard injury, when the knee impacts the dashboard with force during a high speed road traffic accident. Hip dislocation is a surgical emergency, and early reduction of the hip reduces long-term complications such as avascular necrosis (AVN) and osteoarthritis. Once reduced CT scanning is use to determine the size of the fragment, assess reduction and identify any foreign bodies in the joint. Injuries can then be classified according to the size and location of the fractured fragments. The aim of definitive management is anatomical reconstruction of the femoral head, and reduction of the joint and weight bearing surface. Good outcome can be achieved in patients who have early, stable reduction of the hip. Congruent reduction and fixation of large articular fragments, or removal of small comminuted intraarticular fragments reduces the occurrence of late complications affecting function and quality of life, such as AVN or post-traumatic arthritis. Long-term follow-up is required to identify patients who may need further intervention or revision to total hip arthroplasty in the years following injury.     

Total temporomandibular joint replacement. Who? What? When? Where?

The temporomandibular joint, like other joints such as the hip and knee, can be affected by a number of conditions that may lead to joint failure, necessitating total joint replacement. The TMJ Implants, Inc., or Christensen alloplastic reconstruction prostheses, play an important role in the treatment of these conditions. Patients with severely degenerated and/or nonfunctioning joints who undergo reconstruction with the Christensen total joint replacement prosthesis experience an increase in quality of life similar to that experienced by orthopedic patients with total joint replacement of the knee or hip.     

(i) Informed consent and pre-operative planning for total hip arthroplasty

This article reviews informed consent in general and with particular reference to total hip arthroplasty, including the legal and ethical issues. It then reviews the remainder of the pre-operative planning process for joint replacement to show that this is a continuous process rather than a series of separate events.     

(i) Basics of orthopaedic biomechanics

An outline of the basic principles of orthopaedic biomechanics is presented. Joint moments, muscle moment arms, in vivo forces, contact stresses and joint stability are all discussed with recent clinical examples to demonstrate their importance. These clinical examples focus on the hip and the knee and include: the effects of femoral offset and reducing the abductor moment arm on hip arthroplasty, how the knee adduction moment causes an asymmetric load distribution between the condyles, the magnitude of in vivo forces and their implications for wear, the consequences of meniscectomy on cartilage contact stresses, extreme contact stresses caused by edge loading in hip replacements, the effect of femoral head size and capsular repair in total hip replacement stability, knee medial rotation and the role of the anterior cruciate ligament in joint stability.     

Complications in knee surgery

This is a comprehensive review of complications that can occur with common knee surgical procedures. Procedures have been grouped into arthroscopic & soft-tissue knee surgery, articular cartilage restoration procedures, osteotomy, and arthroplasty. As newer implants and procedures are developed it is anticipated that new complications may arise. However, the overall trend will be towards a generalized reduction. At the same time, patient expectations are increasing in tandem with improvements in health and longevity. It is important to counsel patients regarding any risks of potential complications associated with any intervention as part of the informed consent process.     

(ii) Complications of total hip arthroplasty

Total hip replacement is a common procedure, but it is still classified as major surgery. Despite advances in technology and patient safety, complications do exist. However, approximately 90% of hip arthroplasties performed will be uncomplicated.This paper aims to present the complications of total hip arthroplasty and the principles of their management. Complications such as dislocation, intraoperative fracture, infection, venous thromboembolism, bleeding, neurovascular injury, leg length discrepancy along with the long-term complications of wear and loosening are discussed and their management outlined.     

Management of osteoarthritis of the wrist and hand

Osteoarthritis of the wrist and hand can cause significant functional impairment and disability. Its management is as much an art as it is science, as one has to consider increasing patient expectations, functional demands, pain relief and preserving motion. A sound knowledge of the wrist and hand anatomy, biomechanics, appreciation of the specific location and grade of wrist and hand joints arthritis and various treatment options and their pros and cons is important to successfully manage patients with this condition. Wrist osteoarthritis can be idiopathic, however more commonly it is secondary to distal radius and/or carpal fractures and ligamentous injuries. A small proportion still can occur due to avascular necrosis of carpus or congenital and developmental causes. Osteoarthritis of the hand is often idiopathic with a high familial tendency, especially in younger patients but can be secondary to other causes such as trauma, gout and ligamentous laxity. Once the non-surgical management options such as analgesia, activity modifications, steroid injections and splints have been exhausted, then there are various surgical options available for wrist and hand osteoarthritis. These are tailored to the exact location of arthritis and patient factors. For the wrist, these include anterior and posterior interosseous nerve neurectomy, arthroscopic debridement, selective bony excisions, wrist arthroplasty and focal or total fusion. Whilst for finger osteoarthritis, surgical options include arthroplasty and arthrodesis. This article aims to describe the pathology of wrist and hand arthritis and various treatment options available.     

Anatomic shoulder arthroplasty

Arthroplasty has become a reliable treatment for degenerative joint diseases of the shoulder. Implant designs have developed over the last 60 years to address the initial problems encountered in arthroplasty: restoration of function and implant loosening. Although reverse shoulder arthroplasty (RSA) has become the most commonly performed type of shoulder replacement in the UK, total anatomical shoulder arthroplasty (TSA) has remained as a well-established treatment for osteoarthritis in patients with a competent rotator cuff. Patients with osteoarthritis treated with TSA can nowadays expect a lasting, significant improvement in pain and function. Nonetheless, controversies exist regarding the indications for humeral hemiarthroplasty and the use of stemless prostheses and other, newer implant designs. Interestingly, changes in the design of glenoid components have not led to significant improvements in clinical performance with time, and cemented all-polyethylene components remain the most reliable option. Lower glenoid aseptic loosening rates are probably best achieved by optimizing the restoration of natural humeral head anatomy.     

Metal-on-metal hips: current status

One of the greatest technological advances in the history of medicine is the total joint replacement. Hip, knee, and shoulder replacements are routine throughout the world. They reduce pain in a cost-effective way and improve quality of life for millions of patients with end stage arthritis. Total hip replacement (THR) is considered a landmark surgery in modern medical history. The THR has developed with research and experimentation over the last 40–50 years with progressive improvement in materials used, fixation techniques, and peri-operative care. With improving life expectancy and increasing demand at a younger age, clinicians and scientists are always trying to find better performing implants to reduce the revision burden. This paper provides an up-to-date account of the relevant history of metal-on-metal (MoM) hips, problems associated with their use, current status, and guidance about how to continue surveillance of patients with MoM hip replacements.     

Dental procedures and subsequent prosthetic joint infections: findings from the Medicare Current Beneficiary Survey

BackgroundThe publication of the 2009 American Academy of Orthopedic Surgeons’ (AAOS’) guidelines for antibiotic prophylaxis after joint replacement (arthroplasty) has renewed debate concerning appropriate prophylaxis for dental patients. The authors examined an administrative data set to assess whether dental procedures were associated with prosthetic joint infections (PJIs).MethodsUsing data for the years 1997 through 2006 from the Medicare Current Beneficiary Survey (MCBS), the authors identified participants who had undergone total joint arthroplasty and those who had experienced a PJI. They explored associations between dental procedures and subsequent PJIs by using time-to-event analyses (N = 1,000). A nested case-control study included case participants who had had PJIs (n = 42) and matched control participants who had had total arthroplasty but had no PJIs (n = 126). The authors calculated hazard ratios (HRs) and odds ratios (ORs).ResultsControl participants (people without PJIs) were more likely than were case participants (those with PJIs) to have undergone an invasive dental procedure, though this trend was not statistically significant in either the time-to-event analysis (HR = 0.78; 95 percent confidence interval [CI], 0.18–3.39) or the case-control analysis (OR = 0.56; 95 percent CI, 0.18–1.74). Only four of 42 case participants had undergone an invasive dental procedure in the 90 days before the infection occurred. Consideration of all dental procedures yielded similar results.ConclusionsDental procedures were not associated significantly with subsequent risk for PJIs, although this study's power was somewhat low. The clinical importance of prophylactic antibiotics in dentistry for patients who have undergone joint arthroplasty, therefore, may be questioned.Clinical ImplicationsThese results support the view that the 2009 AAOS Information Statement on antibiotic prophylaxis for people with prosthetic joints should be reconsidered for patients in that population who are receiving oral health care.     

The registries: what do they tell us about knee arthroplasty? A narrative review of six national arthroplasty registers

Joint replacement registers are well established and have an important influence on decision-making and clinical practice. The objectives of this paper were to review orthopaedic registries in order to consider aspects of patient demographics, implant usage and revision outcomes in relation to knee replacement surgery. Six national arthroplasty registers with over 10 years of data were selected for review. Despite the geographical diversity, the demographics of patients presenting for surgery and subcategories of surgery were remarkably similar. For total knee replacement cemented, minimally stabilized devices were preferred in most countries and a revision-free outcome can be expected in greater than 94% of cases at 10 years. Some commonly used devices achieved revision rates of about half of this. Partial replacements were used in between 6% and 15% of primary cases and had higher revision rates than total replacements but had lower post-surgery mortality and fewer infections. Patellofemoral replacements are used in 1% or less of cases and have high revision rates.     

Fragility fractures of the acetabulum

There are limited epidemiological data dedicated to geriatric acetabular fractures. The incidence in individuals older than 60 years of age has more than doubled in the past three decades and expected to double further over the next 20 years. These fractures represent a challenging subset of acetabular trauma patients to treat. Conservative treatment is a valid option in those with minimal displaced fractures and a preserved congruent hip joint. Similarly the frail patient with multiple medical co-morbidities and those unlikely to tolerate surgical intervention should have appropriate analgesia and their fracture managed or ignored by watchful neglect. Surgical treatment options include percutaneous fixation or open reduction and internal fixation techniques. Good outcomes may be expected should a concentric reduction be achieved. Age-related involutional osteoporosis associated with fracture comminution and acetabular dome impaction complicate surgical fixation with higher complication rates and the need for further surgery recognised. Historically described as central fracture dislocations, stoved in hip or burst fracture, acute arthroplasty is advocated in the setting of femoral head damage and in significant acetabular impaction injuries. Controversy remains whether geriatric patients should be treated by open reduction and internal fixation or total hip arthroplasty either acute or delayed and needs to be assessed based on the patient and personality of the fracture.     

(iii) Patient selection and consent

Appropriate patient selection and consent for a total hip replacement or hip resurfacing is a serious undertaking and one that should not be taken lightly.From the patients’ first presentation, we cover the common pitfalls that can be encountered in the patients’ history and examination as well as specific indications and contraindications to hip resurfacing and hip replacement.Possible alternatives to arthroplasty are discussed ranging from simple analgesia to the more controversial treatments such as hyaluronic acid injections.The different options available for a total hip replacement are considered including the choice of a cemented or uncemented implant, the bearing surface and the reasons for making those choices.Unfortunately hip arthroplasty is not without risk and these potential complications are discussed. The incidence of a lower extremity thrombosis has been quoted as high as 70% but this can be mitigated with thromboembolic prophylaxis. The risk of infection varies from approximately 0.4 to 1.5%.The risk of dislocation between 0 and 2% and fracture less than 1%. Nerve injury can be as high as 3% but is commonly quoted nearer to 1%, and is higher in revision operations at up to 4 %.As well as possible complications, patients should also be made aware of the normal post-operative course from what to expect when they wake up to the type of tests they will have in their immediate post-operative recovery.With the pressures of clinic and operating lists it can be all to easy to rush through these important issues, however, time invested at this stage of the proceedings is well spent.     

Fragility fractures of the acetabulum

There are limited epidemiological data dedicated to geriatric acetabular fractures. The incidence in individuals older than 60 years of age has more than doubled in the past three decades and expected to double further over the next 20 years. These fractures represent a challenging subset of acetabular trauma patients to treat. Conservative treatment is a valid option in those with minimal displaced fractures and a preserved congruent hip joint. Similarly the frail patient with multiple medical co-morbidities and those unlikely to tolerate surgical intervention should have appropriate analgesia and their fracture managed or ignored by watchful neglect. Surgical treatment options include percutaneous fixation or open reduction and internal fixation techniques. Good outcomes may be expected should a concentric reduction be achieved. Age-related involutional osteoporosis associated with fracture comminution and acetabular dome impaction complicate surgical fixation with higher complication rates and the need for further surgery recognised. Historically described as central fracture dislocations, stoved in hip or burst fracture, acute arthroplasty is advocated in the setting of femoral head damage and in significant acetabular impaction injuries. Controversy remains whether geriatric patients should be treated by open reduction and internal fixation or total hip arthroplasty either acute or delayed and needs to be assessed based on the patient and personality of the fracture.