Non--Operative Management:

Non
AAOS GUIDELINE
 Accupuncture: equivocal

 Glucosamine/Chondroitin: recommend AGAINST

(NIH trial negative)

 Weight loss: recommended

 Low impact exercise: recommended

 Hyaluronates: inconclusive
 Cemented Stem Surface
 Matte
M tt or polished
li h d preferred
f d because
b cement/implant
t/i l t
interface can preferentially fail

 Precoatt or roughened:
P h d higher
hi h rates
t off failure
f il and
d
osteolysis because causes cement/bone interface to
preferentially fail
 Cementless design
 More flexible materials: more similar to elasticity of
bone. Less stem related thigh pain

 Circumferential coating. Reduces effective joint space.

 Ingrowth or ongrowth surface finish

 Fit-and-fill or press-fit

 P i l or distal
Proximal di t l fixation.
fi ti
 MOM Tidbits

 Higher failure rates associated with SMALLER

resurfacingg implants
p due to smaller coverage
g arc

 Higher failure rates associated with LARGER THR

components
p due to wear of the trunnion
 Dislocation incidence

• Primary 1-2%
• Revision 5-7%
• Post traumatic: highest incidence!
reported incidence up to 80% in
elderly treated with THR for failed
femoral neck ORIF
 Stem Failure Modes
 Pi t i
Pistoning

 Mid-stem pivot

 varus

 retroversion

 cantilever bending (potted stem): stem breakage

 HTO and Uni

 Osteotomy for medial compartment disease only in the young and active

 Correction to Fujisawa point unloads medial compartment

 Reliable longevity of ostotomy only 6 years. Undercorrction correlated with poor

result

 Protect popliteal artery during osteomy

 Opening wedge construct are weak in rotation

 Opening wedge a good choice for PCL deficient

 Quicker recovery for Uni vs. total

 Uni failures due to patellar impingement, medial overload, or progression of

disease
 Polyethylene

 Increased VEGF expression, Increased RANK expression, Increased

RANKL expression, Macrophages produce VEGF

 Adh i wear iin hi

Adhesive hips, subsurface
b f d l i ti in
delamination i kknees

 Crystalline phase confers strength, amorphous region allows cross-linking

 Optimum crystallinity 45-65%

45 65%

 Crosslinked poly has decreased SIZE and NUMBER of particles

 Gamma in Air sterilization=

sterilization Oxidation and Delamination

 Cross linked and annealed= residual free radicals and oxidation

 Cross linked and remelted= reduced mechanical strength

g

 2nd generation= better material strength and equivalent wear performance

 Avascular Necrosis

 SPONK is a stress fracture of the medial femoral

condyle in women in their 60s
 True AVN of the knees behaves like AVN of the hip
 Be aware of the possibility of multifocal AVN
 No Uni for true AVN, Uni may work for small
SPONK
 Use stemmed components for large lesions
 FAI and PAO

 Remember the angles

 Don
Don’tt be fooled by isolated anterior deficiency
 Consider opening hip to find associated labral tear
 Isolated labral resection in patient with DDH is a mistake!
 PAO (Ganz/Bernese) is standard
 Chiari
Chi i for
f salvage
l
 Salter, Dega, Pemberton for kids
 RAO, Dial, condemned
 Steele, Shelf- no longer used
 TKR

• Distal Femoral cut- extension gap only. Posterior condyle resection- flexion gap
only. Proximal tibial cut- flexion and extension gap. Proximal tibial slope- flexion
gap only

• 9 degrees less contracture for 2mm additional resection

• Peroneal N. palsy associated with preop valgus of greater than 15

degrees and a flexion contracture

• Immediate treatment for nerve palsy: Loosen dressings and flex knee!

• Knees with WBCs > 2500 and neutrophils> 60% COULD be infected

• If infection workup is equivocal: re-aspirate

• infection is the most common cause for knee revision

• If you must use constraint in revision knee, then you must use stems!
 Resurfacing

 Varus, Notching, Cystic head associated with early

failure

 Correct stem position follows the calcar (slight

valgus)
g )

 ALVAL- more common in females, small

components,
p , vertical cup
p
 CHEST Guidelines 2004/7
 THR
 LMWH,
LMWH or C Coumadindi (Adj
(Adjusted
dd dose))
 NO aspirin alone, or mechanical alone

 TKR
 LMWH, or Coumadin (Adjusted dose)
 Intermittant compression as alternative (1b)
 NO aspirin alone

 Duration at least 10 days,

days recommend 28 to 35 days (new
for 2007)
 Academy Guidelines/
THR TKR
THR,
 Standard PE risk, standard bleeding risk
 Aspirin 325mg BID X 6 weeks
 LMWH X 7-12 days
 Arixtra X 7-12 days
 Warfarin INR <= 2, 2-6 weeks

 Considered bleeding and clinically significant

endpoints
 Academy Guidelines/
THR TKR
THR,
 Patients with elevated PE risk and standard bleeding
risk
 LMWH X 7-12 days
 Arixtra X 7-12 days
 Warfarin INR <= 2, 2-6 weeks
 Aspirin is off the menu!
 Academy Guidelines/
THR TKR
THR,
 Patients with standard PE risk and elevated bleeding
risk
 Aspirin 325mg BID X 6 weeks
 Warfarin INR <= 2, 2-6 weeks
 NO LMWH or Pentasaccharides!