Surgical Techniques
Debridement, Antibiotics, and Implant Retention for an Early Periprosthetic Infection After Unicompartmental Knee Arthroplasty: A Technical Note
Early periprosthetic joint infection in unicompartmental knee arthroplasty (UKA) is shown to have a detrimental effect on the success of UKA surgery not only because of the sequences of the infection but also due to the other healthy lateral compartment. It is well known that Oxford meniscal bearing UKA is a very precise procedure that the use of any excessive force may have an injurious effect on the future prosthesis stability with a higher risk of bearing dislocation. This technical note aims at describing how to deal with a case of early periprosthetic joint infection in a female patient who underwent debridement, wash, implant retention and change of the mobile bearing insert including the demonstration of a difficult step during this procedure.Direct Anterior Cup-Half Cage for Revision and Complex Primary Total Hip Arthroplasty: Surgical Technique
As surgeons' comfort with the direct anterior approach (DAA) for total hip arthroplasty continues to increase, there is a growing interest in performing complex surgeries through this approach. Acetabular bone loss and/or pelvic discontinuity in the primary or revision setting often requires specialized implants such as a cup-cage construct. We describe our surgical technique for implanting modified cup-half cages through the DAA and show 2 case examples of how this technique was utilized in the setting of complex acetabular bone loss.Utilizing a Prefabricated Antibiotic-Impregnated Articular Spacer Combined With an Intramedullary Device for Significant Femoral Bone Loss in Periprosthetic Hip Infection
Periprosthetic joint infection can be a devastating complication following total hip arthroplasty, which often requires a lengthy treatment course that is fraught with complications. There are various types of antibiotic-impregnated spacers that can be used to treat periprosthetic hip infections, with articulating spacers being utilized frequently with the goal of preserving patient range of motion and functionality. Many of these articulating spacers have pre-set sizes and stem options, which accommodate the majority of patients.Tibial Tubercle Screw Fixation on Custom Metaphyseal Cone: Surgical Tip in Severe Metaphyseal Tibia Bone Loss
Tibial tubercle osteotomy (TTO) facilitates exposure in knee arthroplasty revision. However, it comes with complications, especially if it invades the intramedullary canal. Most revisions are characterized by compromised femur and/or tibia bone stock, and the use of metaphyseal cones or sleeves for implant fixation has become increasingly frequent. Several methods of fixation of the tibial tubercle have been proposed, such as screw fixation, cerclage wiring, and suture repair. Despite screws providing the strongest fixation for TTO, their placement around a tibial intramedullary stem or a metaphyseal tibial cone may be difficult.Flip Autograft Technique for Anterolateral Femoral Deficiency in Total Knee Arthroplasty
Anterolateral bone loss of the femur within the trochlear groove presents a unique and rare issue in primary total knee arthroplasty (TKA). Unlike distal and posterior femur bone loss for which most contemporary TKA systems have modular augments, the same does not exist for anterolateral bone loss. We present a technique in which a patient’s host bone from the standard distal femoral cuts was used to augment and provide a stable base for cementing of final femoral implants. Currently, the patient has 3-year follow-up with excellent results in terms of pain control with no evidence of component failure on the most recent radiographs.Computer-Aided Surgery-Navigated, Functional Alignment Total Knee Arthroplasty: A Surgical Technique
The decision on which technique to use to perform a total knee arthroplasty has become much more complicated over the last decade. The shortfalls of mechanical alignment and kinematic alignment has led to the development of a new alignment philosophy, functional alignment. Functional alignment uses preoperative radiographic measurements, computer-aided surgery, and intraoperative assessment of balance, to leave the patient with the most “normal” knee kinematics achievable with minimal soft-tissue release.A Modified Surgical Technique of Patellar Tendon Reconstruction in Total Knee Arthroplasty Using Achilles Tendon Allograft
Patellar tendon disruption is one of the most dreaded complications after total knee arthroplasty (TKA) impacting joint function and implant longevity. Management of this condition remains controversial, and no one treatment has provided consistent clinical success. Here we propose a modified technique from the standard Achilles allograft procedure to reconstruct a ruptured patellar tendon after TKA. A fresh-frozen Achilles tendon allograft with attached calcaneal bone graft was used. Our technique offers the advantage of a more stable graft fixation by relying on both quadriceps tendon and transosseous patellar fixation and bone-to-bone allograft fixation to the tibial tuberosity.Development of a Self-made Cement Bead Maker and Its Clinical Application for the Treatment of Periprosthetic Joint Infection
Antibiotic-loaded acrylic cement beads have a large surface area and excellent sustained-release properties. However, there are some difficulty manufacturing reasonably sized beads and their careful handling. We developed a self-made cement bead maker using a mold of a sphere with a diameter of 8 and 10 mm with a 2-mm-diameter connecting hole. With this instrument, approximately 32 beads can be made from 40 g of bone cement. We clinically applied this technique to 11 cases of periprosthetic joint infection.Variability of Sagittal Plane Proximal Tibial Morphology and Its Effect on Stem Placement in Total Knee Arthroplasty
The tibial joint line is offset posteriorly relative to the tibial sagittal anatomic axis. This can have consequences when using stemmed implants during total knee arthroplasty. We retrospectively analyzed native knee lateral radiographs in 100 patients. The distance between the sagittal anatomic axis and the center of a simulated tibial resection was calculated as a percentage of overall tibial width. Analysis of 5 manufacturers’ baseplates showed that the tibial stem attached on average 10% anterior to the midline.Modular Total Femur Replacement for Staged Total Femur Replacement
As the numbers of arthroplasties performed worldwide increase, so do complications such as prosthetic joint infection. Cases that require a two-stage revision of a total femur replacement in the femur pose an ongoing challenge to the modern orthopedic surgeon. Unlike antibiotic spacers in hip and knee arthroplasty, there lacks a commercially available cement spacer for use in total femur replacements. We describe a novel technique for the intraoperative fabrication of a total femur spacer which uses modular components.Removing Well-Fixed, Collared and Noncollared Tapered Hip Stems Without an Extended Trochanteric Osteotomy Using a Novel Stem Removal System
Improvements in materials, components, and surgical techniques in cementless total hip arthroplasty are resulting in improved femoral stem fixation through bony ongrowth or ingrowth. While improved femoral stem fixation is one reason for the current excellent total hip survivorship, indications for stem removal such as infection, implant fracture, or osteolysis remain. A commonly used technique for fully ingrown femoral stems is an extended trochanteric osteotomy which can result in comminuted fractures of the proximal femur during stem removal requiring additional fixation.A Modified Technique for Artificial Fusion in Unreconstructable Revision Total Knee Arthroplasty
Knee arthrodesis is an acceptable treatment that leads to a stable joint with a lower rate of recurrence of infection in periprosthetic joint infections. One of the major problems in some revision cases is the bone loss that interferes with the bony union; therefore, some studies suggest artificial arthrodesis, which does not require bony union. The present descriptive retrospective study was conducted by reviewing the medical records of patients with periprosthetic joint infection complications.Saddle to Incision Relationship: A Novel Approach to Localizing the Incision for Direct Anterior Hip Arthroplasty
The direct anterior approach for total hip arthroplasty has grown in popularity over the last decade. Incision for this approach is often based on a standardized distance from the anterior superior iliac spine. Despite this method, wound complications remain a known complication during direct anterior approach. We describe a simple and reproducible technique using fluoroscopy to identify the incision during direct anterior total hip arthroplasty. This method allows for accurate placement of incision while adding only a minimal amount of time to the procedure.Surgical Technique of a Cement-On-Cement Removal System for Hip and Knee Arthroplasty Revision Surgery
Cement removal during hip or knee arthroplasty revision surgery is technically demanding and prone to severe complications such as periprosthetic fractures, incomplete cement removal, or perforations. Several alternative techniques have been developed to enable complete, accurate, and safe removal of cement from bone, including osteotomies and cortical windows, endoscopic instruments, ultrasound devices, lithotripsy, and laser-assisted removal. We describe a cement-on-cement technique with a sterile, single-use tool for cement removal.Safety and Efficacy of Using Fracture Tables for Prosthetic Hip Dislocations
The incidence of prosthetic hip dislocation continues to increase because of the overall increase in volume of total hip replacement surgery. Closed reduction is often the preferred treatment, particularly in the first few months after surgery. No matter the closed reduction technique, linear traction is a requirement, thus posing a physically demanding stress opening both surgeon and patient to potential injury. We describe a fracture table closed reduction technique along with outcomes and safety data for a sample of patients.Conversion of Hip Arthrodesis Using Robotic Arm Technology
Recent advancements in computer-assisted surgery have led to a renewed interest in robotic-assisted hip arthroplasty. This technology assists with component position which is especially useful in prior trauma or dysplasia cases. We present a case of a surgical hip fusion conversion to total hip arthroplasty with the use of robotic-assisted technology. Enhanced preoperative planning with the ability to manipulate implant position before execution can be invaluable during complex procedures. Further research is warranted before revision cases using computerized navigation systems becomes more prevalent.Technical Note for Transfemoral Implantation of Tapered Revision Stems. The Advantage to Stay Short
The aim was to test the hypothesis that during transfemoral implantation of a conical revision stem, the fixation of the stem at the distal tip leads to a low rate of periprosthetic fractures.Use of Fulcrum Positioning as a Balancing Tool During Total Knee Arthroplasty on a Robotic Platform
Total knee arthroplasty is a common procedure performed to improve pain and dysfunction attributed to arthritis, yet postoperative patient dissatisfaction rates remain relatively high. Patient satisfaction and outcomes have been linked to successful joint gap balancing in the coronal and sagittal planes intraoperatively. In previously described balancing techniques, the fulcrum used for alignment changes is customarily centered on the intramedullary axis generating symmetric changes in medial and lateral gaps.Complex Primary Total Hip Arthroplasty: Small Stems for Big Challenges
Total hip arthroplasty is one of the most successful operations in all of medicine. Femoral deformities from malunion, prior osteotomy, and retained surgical implants all present unique challenges. Corrective osteotomy and hardware removal add significant morbidity to an operation that typically has a fast recovery. Short stems can be used in these cases to spare patients' increased morbidity. We present a case-based illustration and surgical technique for the use of short stems in complex primary total hip arthroplasty with femoral deformity and retained hardware.Single-Sided Reciprocating Saw for Tibial Component Removal During Revision Total Knee Arthroplasty
Revision total knee arthroplasty often necessitates removing well-fixed components. Tibial tray removal is challenging becaue of 1) physical barriers posed by the component pegs, keel, or stem in accessing the implant-bone interface circumferentially and 2) proximity of vulnerable structures including the patellar tendon, collateral ligaments, popliteal artery, and distal femur. In this report, we present a step-by-step technique for removal of a well-fixed tibial component using a single-sided reciprocating saw.What to Do When Revision Procedures Fail to Prevent Recurrent Hip Dislocation in THA? A Novel Simple Technique for Selected Patients
Failure to achieve postoperative stability is disappointing for both surgeons and patients after revision total hip arthroplasty. In particular, when available revision options have been exhausted. We describe our modification of previously reported surgical techniques without revising any component in a high-risk female patient with persistent hip dislocation despite multiple cup revisions using different implants. To stabilize the hip through the posterolateral approach, a synthetic polyethylene tube was used.The Value of the Direct Lateral Hip Radiograph in an Adult Reconstruction Practice
The specialty evaluation of hip pain, stiffness, and/or dysfunction usually includes patient history, physical examination, and radiographic evaluation. Radiographic views of the hip are not standardized, and basic studies may include an anteroposterior pelvis, anteroposterior hip, frog lateral, and direct lateral of the hip. In this article, we discuss the importance of obtaining a direct lateral radiograph of the hip in all patients being evaluated by a specialist for hip pain and its value in hip arthroplasty care.Protection of the Femoral Trunnion During Acetabular Revision Hip Surgery—A Novel Technique
Revision of a failed acetabular component in the presence of an intact femoral prosthesis comprises approximately 20% of revision total hip replacements performed by the senior author. During this procedure, the femoral trunnion is at risk of damage because of scratching from retractors, reamers, or other instruments. Scratching can result in mechanically assisted crevice corrosion or adverse local-tissue reaction or trunnionosis leading to implant failure. We have used a variety of techniques for protection of the femoral taper over the last 30 years.Robotic-Arm Assistance Simplifies Hip Arthrodesis Conversion to Total Hip Arthroplasty
Hip fusion takedown to total hip replacement is a challenging operation. Neck osteotomy and acetabular component placement are technically demanding and often require fluoroscopic guidance. Robotic arm–assisted total hip arthroplasty enhances accuracy of preoperative planning and provides navigated guidance for neck osteotomy and haptic guidance on acetabular reaming and cup implantation. Fluoroscopic guidance is replaced by real-time navigation and on-screen data. This article describes how robotic arm assistance can simplify this complex operation.Balanced, Stemmed, and Augmented Articulating Total Knee Spacer Technique
Explantation and placement of an antibiotic spacer is a well-recognized treatment for periprosthetic infection after total knee replacement. Although static spacers may be occasionally indicated, many patients benefit from an articulating spacer that preserves the function and range of motion. However, many articulating spacer techniques provide an imbalanced cement-on-cement articulating knee that cannot tolerate full weight-bearing or provide adequate stability for daily function. A more durable articulating spacer may be ideal by permitting unrestricted weight-bearing, a functional range of motion, and potentially delayed reimplantation for medically complex patients.Centralizing the Cemented Exeter Femoral Stem Using the Direct Lateral Approach: Surgical Tips and Radiological Evaluation
Varus malalignment in total hip arthroplasty has been associated with poor long-term outcomes and complications including abnormal load distribution, endosteal osteolysis, frank loosening, and periprosthetic fractures. Postoperative radiographic assessment was performed on 224 patients from our case series who underwent cemented Exeter total hip arthroplasty using the direct lateral approach alone. No patient had a true varus-aligned stem (ie, ≤−5° on the coronal assessment). We describe our surgical technique, with 4 easily reproducible technical tips to achieve positional consistency of the femoral stem: commencing stem insertion from the piriform fossa entry point, using a femoral stem distal centralizer, aiming the tip of the component to the center of the patella, and placing the thumb between the calcar and inferior neck of the femoral component to prevent the stem from tipping into varus.A Simple, Personalized Opioid Stratification Pathway Dramatically Reduces Opioid Utilization
Orthopaedic surgeons account for the largest proportion of opioid prescriptions in the United States among surgical specialties. In total joint arthroplasty, increased opioid use has been associated with poorer clinical and functional outcomes. Despite an abundance of literature on opioid mitigation strategies, most fail to provide personalized prescriptions. Typically, most protocols prescribe the same opioid regimen regardless of patient factors or the extent of the planned procedure. We present a simple opioid stratification pathway that can be used by physicians and office staff as they prepare patients for arthroplasty.Combating the Opioid Epidemic: Experience with a Single Prescription for Total Joint Arthroplasty
Despite advances in perioperative total joint arthroplasty (TJA) pain protocols, opiates continue to play a major role in postoperative pain control. This brief communication reports our experience with a restrictive opioid protocol allowing patients only a single prescription of low-dose opioids.A Novel Technique to Detect Femoral Shaft Perforation during Direct Anterior Total Hip Arthroplasty
Despite its popularity, the direct anterior approach for hip arthroplasty is not without complications. Intraoperative femoral shaft perforation using this approach ranges from 0.8% to 7%. A missed perforation can lead to fracture with the need for further surgery if not detected intraoperatively. We describe a reproducible and cost-effective technique using a plastic Yankauer suction handle to help identify proximal femoral perforations during direct anterior total hip arthroplasty. Careful attention to the visual, tactile, and auditory feedback provided by the suction handle can help ensure the cortical continuity of the proximal femur.Clinical Experience With a Coordinated Multidisciplinary Approach to Treating Prosthetic Joint Infection
The successful treatment of prosthetic joint infection (PJI) is difficult, requiring coordination across multiple specialties. In 2017, we formed a collaboration between our infectious disease clinicians and our orthopaedic arthroplasty surgeons in an effort to optimize care, accommodate patients, and expedite clinical decision-making in the treatment of PJI. The model consisted of combined infectious disease and arthroplasty clinics, standardized lab results, and planned staged revision procedures.A Vertical Measurement System to Predict the Change in Leg Length in Total Hip Arthroplasty
The management of leg lengths in total hip arthroplasty continues to challenge orthopaedic surgeons. The aim of this study is to test the reliability of a measuring device used to measure the resected femoral head and how the resulting intra operatively calculated change in leg length compares to the radiographically measured change in leg length. Four orthopaedic surgeons measured 20 femoral heads and the intra class coefficients of the raters were between 0.955 and 0.990 with a mean difference less 1 mm, indicating the reliability of the device.Rapidly Progressive Osteoarthritis and Acetabular Bone Loss Outcomes for Patients Undergoing Primary Total Hip Replacement
Rapidly progressive osteoarthritis (RPO) is a rare condition which is poorly understood. Limited published literature is available. Reported here is a cohort of patients with RPO and acetabular bone loss who underwent primary THA. Risk factors, degree of acetabular bone loss and outcomes are presented. A typical case of RPO is described and investigations discussed. A retrospective audit was undertaken. 49 patients over an 18-year period were included. RPO patients were significantly older (P < 0.01) and had a lower BMI (P = 0.03).Total Hip Arthroplasty for the Sequelae of Femoral Neck Fractures in the Pediatric Patient
Although rare, total hip arthroplasty (THA) may be indicated in pediatric patients with degenerative changes of the hip joint after previous trauma. To illustrate management principles in this patient population, this study describes the case of a 15-year-old female who sustained bilateral femoral neck fractures after a generalized tonic-clonic seizure, an atypical, low-energy mechanism for this injury. These fractures were not diagnosed until 14 weeks after the seizure episode, at which point they had progressed to nonunion on the left side, malunion on the right side, and degenerative hip joint changes were developing bilaterally.A Novel Method of Determining Acetabular Component Size to Guide Explant in Revision Hip Arthroplasty
Revision hip arthroplasty is a frequently performed procedure and is projected to increase annually. Removal of a well-fixed acetabular component can involve loss of much needed bone stock. Contemporary instruments allow acetabular removal with minimal morbidity; however, their use requires accurate knowledge of the component size. We describe a technique that allows sizing to be determined accurately, without specialized equipment, in situations where component details are unavailable. Our technique multiplies ratio of head:cup on pre-operative X-ray by the diameter of the index femoral head which is removed intra-operatively to predict index cup size.Drug-Induced Thrombocytopenia Secondary to Commonly Used Antibiotics in Total Joint Arthroplasty
Drug-induced thrombocytopenia secondary to antibiotic exposure is a rare complication more commonly associated with other medications. In this review, we present a case of antibiotic-induced thrombocytopenia and discuss the clinical picture and approach to identifying the complication. With increasing use of antibiotics that may be associated with drug-induced thrombocytopenia in perioperative prophylaxis protocols, surgeons need to be cognizant of this cause of thrombocytopenia in the postoperative patient.Direct anterior approach total hip arthroplasty for Crowe III and IV dysplasia
High-dislocated hip dysplasia is challenging to treat with total hip arthroplasty via the direct anterior approach (DAA). The DAA has potential advantages including optimizing component positioning, enhanced hip stability, and a more rapid postoperative recovery. We present a surgical technique for DAA total hip arthroplasty for hip dysplasia that includes preoperative planning, soft tissue releases, subtrochanteric osteotomy, component placement, and intraoperative nerve monitoring and imaging.Total knee arthroplasty in hemophilia A
Hemophilia A is a rare genetic disorder involving a deficiency of clotting factor VIII. Coagulation factor replacement therapy has prolonged the life expectancy of patients with hemophilia, but recurrent hemarthrosis of major joints is often a common occurrence. Therefore, orthopaedic adult reconstructive surgeons increasingly encounter hemophilic arthropathy in young adults and consider treating with total joint arthroplasty. In this report, the authors describe a patient with hemophilia A and severe knee osteoarthritis, who was subsequently treated with primary total knee arthroplasty.Elephant’s ear sign: a new radiographic finding indicative of acetabular retroversion
Acetabular retroversion is a relatively common condition affecting the hip that can result in symptoms in some patients. Diagnosis of acetabular retroversion relies on obtaining a proper anteroposterior radiograph of the pelvis. Cross-over, posterior wall, and ischial spine signs are usually present in patients on the radiographs of patients with acetabular retroversion. In this illustrative case report, we describe an additional radiographic sign, elephant’s ear sign, associated with acetabular retroversion that we have seen to be present in patients with acetabular retroversion.Algorithmic soft tissue femoral release in anterior approach total hip arthroplasty
Although the anterior approach for total hip arthroplasty has gained increasing utilization, some studies have suggested a higher risk of femoral complications, as well as difficulty with femoral exposure. Techniques of soft tissue releases have been described to offer better femoral exposure, and to help mitigate complications. The purpose of the study is to describe an algorithmic soft tissue femoral release in direct anterior approach total hip arthroplasty and to assess the clinical outcomes of patients upon which this algorithm of femoral soft tissue releases was utilized.Creating a dual articulating antibiotic spacer for management of an infected total femur prosthesis hemiarthroplasty
The gold standard for management of chronic periprosthetic joint infections is a 2-stage revision arthroplasty with the first stage being explantation, debridement, and placement of a spacer. While there are implants designed to manage periprosthetic infections in hip and knee arthroplasty, there are not any commercially available implants designed to specifically manage an infected total femur megaprosthesis. This creates a unique surgical challenge and requires custom construction of a spacer to be performed by the surgeon intraoperatively.Robotic arm assisted total knee arthroplasty workflow optimization, operative times and learning curve
Robotic arm assisted total knee arthroplasty (RTKA) has many potential benefits including advanced preoperative templating, restoration of mechanical alignment, accuracy of bony resection, robust safety mechanisms, and dynamic gap balancing. One of the most frequently quoted drawbacks preventing experienced surgeons from adopting this technology is the perceived increase in surgical time. This technique paper outlines the general concepts used to improve operating room efficiency as well as the step-by-step workflow to consistently perform RTKA with surgical times under 60 minutes.The anterior approach for conversion hip arthroplasty
Conversion of prior proximal femoral fracture fixation to hip arthroplasty is a fairly common and successful procedure, necessitated by various modes of failure. The procedure is well described utilizing a posterior or anterolateral surgical approach. The anterior approach for total hip arthroplasty has gained in popularity. The approach allows for supine positioning and facilitates live fluoroscopic imaging. We present possible advantages and disadvantages, as well as the surgical technique, of conversion to total hip arthroplasty via the direct anterior approach.Intraoperative povidone-iodine irrigation for infection prevention
Although prevention of infection following arthroplasty requires a multifaceted approach, the use of intraoperative irrigation is an important component of any protocol. Recent clinical practice guidelines from the Centers for Disease Control, World Health Organization, and International Consensus Meeting on Musculoskeletal Infection advocate the use of a dilute povidone-iodine solution prior to wound closure. Our experience suggests that this practice is safe, inexpensive, and easily implemented.External fixator arthrodesis antibiotic spacer in two-stage revision total knee arthroplasty for eradication of periprosthetic joint infection
Two-stage revision total knee arthroplasty remains the gold standard for management of chronic periprosthetic joint infection in North America. Static cement antibiotic spacers used after knee resection to deliver high-dose antibiotics lack primary stability, potentially leading to spacer migration or dislocation, additional bone loss, extensor mechanism erosion, and even knee subluxation or frank dislocation. A custom brace or cast is often required to augment knee stability, which is time-consuming, costly, and prevents monitoring or wound care of the soft tissues.Optimum anatomic socket position and sizing for the direct anterior approach: impingement and instability
A comprehensive strategy is important for ensuring reproducible and safe acetabular component sizing and positioning. Presented here is our approach for anatomic acetabular component positioning in direct anterior total hip arthroplasty. This strategy has evolved with our understanding of the ramifications of socket sizing and positioning on instability and impingement. Data collected by a single surgeon (J.A.R.) between 2009 and 2011 influenced our current paradigm. We compare the sizing and positioning parameters of the anterior and posterior approach, thus demonstrating how the 2 are different.Femoral artery injury during total hip arthroplasty
There are an increasing number of vascular complications after hip replacement, some of which can be life-threatening. However, there are few reports of lower limb ischemic symptoms after undergoing an otherwise uncomplicated classic total hip replacement. We report a patient with low weight who developed postoperative limb ischemia resulting from blood clots caused by insertion of a Hohmann retractor close to small anterior acetabular osteophytes. Ultrasonography and angiography revealed her symptoms to be the result of femoral artery intimal injury with lower extremity arterial thrombosis, which led to pain, numbness, and decreased skin temperature.Hip arthroplasty for osteonecrosis of the femoral head secondary to alcohol abuse
Although the challenges of hip arthroplasty for avascular necrosis (AVN) are known, limited data exist to describe patient demographics and outcomes in the setting of AVN attributed to alcoholism. We retrospectively identified 43 patients (62 hips) who underwent primary hip arthroplasty between 1999 and 2016 for a diagnosis of AVN of the femoral head with a concomitant diagnosis of alcohol abuse and minimum follow-up of 2 years (mean, 8.6 years). The mean age was 51 years, predominantly male (88%), with a high rate of comorbidities.Total knee replacement in patients with osteoarthritis and concomitant inveterate patellar dislocation
The inveterate patellar dislocation is an uncommon entity. The most frequent findings correspond to a misaligned valgus associated with lateral patellar dislocation. When severe knee osteoarthritis is present, total knee arthroplasty is an option, whether it is associated or not with realignment of the extensor apparatus. We present a review of published literature on correction of inveterate patellar dislocation associated with knee arthritis and our surgical technique with a case of inveterate patellar dislocation associated with tricompartmental knee osteoarthritis, in which a total knee arthroplasty was performed associated with proximal and distal realignment of the extensor apparatus.Acetabular wedge augments for uncontained tibial plateau defects in revision total knee arthroplasty
Tibial bone loss is a common scenario encountered during revision total knee arthroplasty. Reconstructive options depend on the amount and location of bone loss, but few good solutions exist to address large, uncontained tibial defects where cortical support is lost in the metadiaphyseal region. We describe a novel technique using acetabular augments to buttress a revision tibial component and recreate a hemiplateau during tibial revision total knee arthroplasty. In selected scenarios, this construct can create a biomechanically friendlier surface onto which to support the tibial tray and a less expensive option when compared to traditional stacked augments or cones.What can the surgeon do to reduce the risk of junction breakage in modular revision stems?
Modular revision stems are very common in hip arthroplasty, but junction fracture remains a known failure mechanism. A review of the literature with description of cases with junction breakage of modular revision stems showed that in all 24 analyzed cases, there was a common finding: the combination of an effective osteointegration of the distal component and missing medial bone support of the proximal component. The result was a bending stress point of the stem construction in the region of the junction.
