Orthopaedic Knowledge Update Hip and Knee Reconstruction 5 2018

Orthopaedic
Knowledge
Update
Hip and Knee Reconstruction
The Hip Society

The Knee Society
Editors
Michael A. Mont, MD
Michael Tanzer, MD, FRCSC
Orthopaedic
Knowledge
Update
Hip and Knee Reconstruction
Editors
Michael A. Mont, MD Michael Tanzer, MD, FRCSC
Chairman Jo Miller Chair and Professor of Surgery
Department of Orthopaedic Surgery Division of Orthopaedic Surgery
Cleveland Clinic Foundation McGill University
Cleveland, Ohio Montreal, Quebec, Canada
Developed by The Hip Society

and The Knee Society
Board of Directors, 2016-2017 The material presented in Orthopaedic
Gerald R. Williams Jr, MD Knowledge Update: Hip and Knee Recon-
President struction 5 has been made available by the
American Academy of Orthopaedic Surgeons
William J. Maloney, MD for educational purposes only. This material is
First Vice-President not intended to present the only, or necessarily
David A. Halsey, MD best, methods or procedures for the medical
Second Vice-President situations discussed, but rather is intended
to represent an approach, view, statement, or
M. Bradford Henley, MD, MBA
opinion of the author(s) or producer(s), which
Treasurer
may be helpful to others who face similar
David D. Teuscher, MD situations.
Past-President Some drugs or medical devices demonstrated
Basil R. Besh, MD in Academy courses or described in Academy
print or electronic publications have not been
Lisa K. Cannada, MD
cleared by the Food and Drug Administration
Howard R. Epps, MD (FDA) or have been cleared for specific uses
Daniel C. Farber, MD only. The FDA has stated that it is the respon-
sibility of the physician to determine the FDA
Brian J. Galinat, MD, MBA clearance status of each drug or device he or
Daniel K. Guy, MD she wishes to use in clinical practice.
Lawrence S. Halperin, MD Furthermore, any statements about commer-
cial products are solely the opinion(s) of the
Amy L. Ladd, MD author(s) and do not represent an Academy
Brian G. Smith, MD endorsement or evaluation of these products.
These statements may not be used in advertis-
Ken Sowards, MBA
ing or for any commercial purpose.
Karen L. Hackett, FACHE, CAE (ex officio) All rights reserved. No part of this publica-
tion may be reproduced, stored in a retrieval
Staff system, or transmitted, in any form, or by any
Ellen C. Moore, Chief Education Officer means, electronic, mechanical, photocopying,
Hans Koelsch, PhD, Director, Department of recording, or otherwise, without prior written
Publications permission from the publisher.
Lisa Claxton Moore, Senior Manager, Book
Published 2017 by the
Program
American Academy of Orthopaedic Surgeons
Steven Kellert, Senior Editor 9400 West Higgins Road
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Courtney Dunker, Editorial Production Copyright 2017
Manager by the American Academy of Orthopaedic
Abram Fassler, Publishing Systems Manager Surgeons
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Library of Congress Control Number:
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iv Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 © 2017 American Academy of Orthopaedic Surgeons
Acknowledgments
Editorial Board The Knee Society Executive Board, 2016
Orthopaedic Knowledge Update: Hip and Thomas P. Sculco, MD
Knee Reconstruction 5 President
Michael A. Mont, MD Adolph V. Lombardi, Jr, MD, FACS
Chairman 1st Vice President
Department of Orthopaedic Surgery
Robert L. Barrack, MD
Cleveland Clinic Foundation
2nd Vice President
Cleveland, Ohio
Mark W. Pagnano, MD
3rd Vice President
Jo Miller Chair and Professor of Surgery Michael E. Berend, MD
Division of Orthopaedic Surgery Secretary
McGill University John J. Callaghan, MD
Montreal, Quebec, Canada Treasurer
Thomas P. Vail, MD
The Hip Society Executive Board, 2016 Immediate Past President
Harry E. Rubash, MD
Thomas K. Fehring, MD
President
Past President
Kevin L. Garvin, MD
Stephen J. Incavo, MD
1st Vice President
Education Committee Chair
Douglas E. Padgett, MD
Keith R. Berend, MD
2nd Vice President
Education Committee Chair Elect
Craig J. Della Valle, MD
Mark P. Figgie, MD
Secretary
Membership Committee Chair
Joshua J. Jacobs, MD
Christopher L. Peters, MD
Treasurer
Membership Committee Chair Elect
Daniel J. Berry, MD
Michael J. Dunbar, MD, FRCSC, PhD
Immediate Past President
Research Committee Chair
Kevin J. Bozic, MD, MBA
Education Committee Chair
Member-At-Large
Richard Iorio, MD
Membership Committee Chair
Member-At-Large
Richard Iorio, MD
Bassam A. Masri, MD, FRCSC
Research Committee Chair
Technology Committee Chair (Ex-Officio)
Donald Garbuz, MD, MHSc, FRCSC
Member-At-Large
Adolph V. Lombardi, Jr, MD, FACS
Fellowship & Mentorship Committee Chair
(Ex-Officio)
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 v
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Contributors
Mansour Abolghasemian, MD John W. Barrington, MD
Assistant Professor Co-Director, Surgeon
Department of Orthopedic Surgery Joint Replacement Center at Baylor Medical
Shafa Hospital, Iran University of Medical Center of Frisco
Sciences Plano Orthopedic Sports Medicine & Spine
Tehran, Iran Center
Plano, Texas
Anthony Albers, MD, FRCSC
Adult Hip and Knee Reconstruction Fellow Wael K. Barsoum, MD
Department of Orthopaedics Vice Chairman
University of British Columbia Department of Orthopaedic Surgery
Vancouver, British Columbia, Canada Cleveland Clinic
Cleveland, Ohio
Ram K. Alluri, MD
Research Fellow Paul E. Beaulé, MD, FRCSC
Department of Orthopaedic Surgery Head, Division of Orthopaedics
Keck School of Medicine Department of Surgery, Division of
Los Angeles, California Orthopaedic Surgery
The Ottawa Hospital
Hussain Al-Yousif, MD Ottawa, Ontario, Canada
Fellow, Surgeon
Department of Orthopaedic Surgery David M. Beck, MD
The Ottawa Hospital, King Saud Medical City Resident
Ottawa, Ontario, Canada Department of Orthopaedic Surgery
Thomas Jefferson University Hospital
Matthew S. Austin, MD Philadelphia, Pennsylvania
Professor
Department of Orthopaedic Surgery Keith R. Berend, MD
Sidney Kimmel Medical College President and CEO
Rothman Institute at Thomas Jefferson White Fence Surgical Suites
University Senior Partner
Philadelphia, Pennsylvania Joint Implant Surgeons
New Albany, Ohio
David C. Ayers, MD
Professor, Arthur M. Pappas Chair Daniel J. Berry, MD
Department of Orthopedics and Physical L.Z. Gund Professor of Orthopedic Surgery
Rehabilitation Department of Orthopedic Surgery
University of Massachusetts Medical School Mayo Clinic
Worchester, Massachusetts Rochester, Minnesota
David Backstein, MD, MEd, FRCSC Mathias P.G. Bostrom, MD

Head, Granovsky Gluskin Division of Professor of Orthopaedic Surgery
Orthopaedics Senior Research Scientist
Mount Sinai Hospital Chief of Hip Service
University of Toronto Department of Orthopaedic Surgery
Toronto, Ontario, Canada Hospital for Special Surgery
New York, New York
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 vii
Charles R. Bragdon, PhD John C. Clohisy, MD
Research Scientist Professor
Department of Orthopedics Department of Orthopaedic Surgery
Massachusetts General Hospital Washington University School of Medicine
Boston, Massachusetts St. Louis, Missouri
Justin G. Brothers, MD Benjamin R. Coobs, MD

Fellow Assistant Professor
Department of Orthopaedics Department of Orthopaedic Surgery
University of Utah Virginia Tech Carilion School of Medicine and
Salt Lake City, Utah Research Institute
Roanoke, Virginia
J.W. Thomas Byrd, MD
President and Orthopaedic Surgeon Fred D. Cushner, MD
Nashville Sports Medicine Foundation Chief
Nashville, Tennessee Division of Orthopaedic Surgery at South Side
Hospital
John J. Callaghan, MD Northwell Health
Lawrence and Marilyn Dorr Chair and New York, New York
Professor
Department of Orthopaedics and Rehabilitation Sachin Daivajna, MS, FRCS (Orth)
University of Iowa Fellow
Iowa City, Iowa Department of Adult Reconstructive Surgery
Division of Reconstructive Orthopaedics
Alberto Carli, MD, MSc, FRCSC University of British Columbia
Orthopaedic Surgeon Vancouver, British Columbia, Canada
Division of Orthopaedic Surgery
The Ottawa Hospital Rocco D’Apolito MD
Ottawa, Ontario, Canada Research Fellow
Complex Joint Reconstruction Center
Sasha Carsen, MD, MBA, FRCSC Hospital for Special Surgery
Assistant Professor of Surgery New York, New York
Department of Surgery
Children’s Hospital of Eastern Ontario, The Gregory K. Deirmengian, MD
Ottawa Hospital Associate Professor
University of Ottawa Department of Orthopaedic Surgery
Ottawa, Ontario, Canada Rothman Institute at Thomas Jefferson
University
Morad Chughtai, MD Philadelphia, Pennsylvania
Research Fellow
Department of Orthopaedics Ronald E. Delanois, MD
Rubin Institute for Advanced Orthopaedics Fellowship Director
Baltimore, Maryland Center for Joint Preservation and Replacement
Rubin Institute for Advanced Orthopaedics,
Henry D. Clarke, MD Sinai Hospital of Baltimore
Professor of Orthopedics Baltimore, Maryland
Department of Orthopedic Surgery
Mayo Clinic Craig J. Della Valle, MD
Phoenix, Arizona Orthopaedic Surgeon
Midwest Orthopaedics at Rush
Rush University Medical Center
Chicago, Illinois
viii Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 © 2017 American Academy of Orthopaedic Surgeons
Ivan De Martino, MD Roger H. Emerson, Jr, MD
Fellow Director
Complex Joint Reconstruction Center Joint Replacement Institute
Hospital for Special Surgery Texas Health Plano
New York, New York Texas Health Resources
Plano, Texas
Douglas A. Dennis, MD
Adjunct Professor Jeffrey R. Engorn, DO
Department of Bioengineering Resident
University of Denver Department of Orthopaedic Surgery
Assistant Clinical Professor The Center for Advanced Orthopedics
Department of Orthopaedics Larkin Community Hospital
University of Colorado School of Medicine South Miami, Florida
Denver, Colorado
Thomas K. Fehring, MD
Nicholas M. Desy, MD, FRCSC Co-Director and Surgeon
Clinical Fellow in Adult Lower Extremity OrthoCarolina Hip & Knee Center
Reconstruction Charlotte, North Carolina
Mayo Clinic Tiffany Feltman, DO
Rochester, Minnesota Adult Reconstruction Fellow
Christopher A. Dodd, FRCS Virginia Commonwealth University Health
Consultant Orthopaedic Surgeon System
University of Oxford Richmond, Virginia
Oxford, England
Andrew N. Fleischman, MD
Michael J. Dunbar, MD, FRCSC, PhD Postdoctoral Research Fellow
Professor of Surgery Department of Orthopaedics
Department of Surgery Rothman Institute at Thomas Jefferson
Dalhousie University University
Halifax, Nova Scotia, Canada Philadelphia, Pennsylvania
Clive P. Duncan, MD, MSc, FRCSC Patricia D. Franklin, MD, MBA, MPH
Professor Professor
Department of Orthopaedics Department of Orthopedics and Physical
University of British Columbia Rehabilitation
Vancouver, British Columbia, Canada University of Massachusetts Medical School
Worcester, Massachusetts
John M. Dundon, MD
Fellow Andrew A. Freiberg, MD
Department of Orthopedics, Adult Arthroplasty Service Chief and Vice Chair
Reconstruction Department of Orthopaedic Surgery
New York University Massachusetts General Hospital
New York, New York Boston, Massachusetts
Randa K. Elmallah, MD Rajiv Gandhi, MD, MSc, FRCSC

Orthopaedic Research Fellow Orthopaedic Surgeon, Associate Professor
Rubin Institute for Advanced Orthopaedics Department of Surgery
Sinai Hospital of Baltimore University of Toronto
Baltimore, Maryland University Health Network
Toronto, Ontario, Canada
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 ix
Donald Garbuz, MD, FRCSC Allan E. Gross, MD, FRCSC
Professor and Head Order of Ontario
Division of Reconstructive Orthopaedics Orthopaedic Surgeon
University of British Columbia Department of Orthopaedic Surgery
Vancouver, British Columbia, Canada Mount Sinai Hospital
Professor of Surgery
Kevin L. Garvin, MD Department of Surgery
Professor and Chair University of Toronto,
Department of Orthopaedic Surgery and Toronto, Ontario, Canada
Rehabilitation
University of Nebraska Medical Center Steven B. Haas, MD
Omaha, Nebraska Chief Knee Service
Emmanuel Gibon, MD Hospital for Special Surgery
Research Fellow New York, New York
Stanford University Fares S. Haddad, FRCS (Orth)
Stanford, California Professor
Andrew H. Glassman, MD, MS Institute of Sport, Exercise and Health
Professor and Chairman University College London Hospitals
Department of Orthopaedics London, England
The Ohio State University Wexner Medical
Center Mohamad J. Halawi, MD
Columbus, Ohio Adult Reconstructive Surgery Fellow
Gregory J. Golladay, MD Cleveland Clinic
Associate Professor, Fellowship Director, Cleveland, Ohio
Adult Reconstruction
Department of Orthopaedic Surgery Erik Hansen, MD
Virginia Commonwealth University Health Assistant Professor
System Department of Orthopaedic Surgery
Richmond, Virginia University of California
San Francisco, California
Stuart B. Goodman, MD, PhD, FRCSC, FACS
Professor Amir Herman, MD, PhD
Department of Orthopaedic Surgery and Orthopaedic Surgeon
Bioengineering Department of Orthopaedic Surgery
Stanford University Tel-Hashomer Medical Center
Stanford, California Ramat-Gan, Israel
William L. Griffin, MD Shane R. Hess, DO

Orthopedic Surgeon Orthopaedic Surgeon
Department of Orthopedics Department of Adult Reconstruction
OrthoCarolina Hip & Knee Center The CORE Institute
Charlotte, North Carolina Phoenix, Arizona
Daniel J. Holtzman, MD
Fellow
Massachusetts General Hospital
Boston, Massachusetts
x Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 © 2017 American Academy of Orthopaedic Surgeons
James L. Howard, MD, MSc, FRCS(C) Michael M. Kheir, MD
Program Director, Assistant Professor Resident
Division of Orthopaedic Surgery Department of Orthopaedics
Western University, London Health Sciences Indiana University
Centre Indianapolis, Indiana
London, Ontario, Canada
Christopher Kim, MD, MSc
William Hozack, MD Department of Orthopaedic Surgery
Annenberg Professor Toronto Western Hospital
Department of Orthopaedic Surgery Toronto, Ontario, Canada
Rothman Institute at Thomas Jefferson
University Yatin Kirane, MD, PhD
Philadelphia, Pennsylvania Adult Reconstruction Fellow
Stephen J. Incavo, MD Lenox Hill Hospital
Section Chief, Adult Reconstructive Surgery New York, New York
Department of Orthopaedics and Sports
Medicine Viktor E. Krebs, MD
Houston Methodist Hospital Vice Chairman
Houston, Texas Department of Orthopaedic Surgery
Cleveland Clinic
Richard Iorio, MD Cleveland, Ohio
Chief of Adult Reconstruction
Department of Orthopaedic Surgery Steven M. Kurtz, PhD
NYU Langone Medical Center Hospital for Research Professor
Joint Diseases Implant Research Center
New York, New York Drexel University
Philadelphia, Pennsylvania
David J. Jacofsky, MD
Orthopaedic Surgeon Young-Min Kwon, MD, PhD
Department of Adult Reconstruction Fellowship Director, Professor
The CORE Institute Department of Orthopaedic Surgery
Phoenix, Arizona Massachusetts General Hospital
Boston, Massachusetts
William A. Jiranek, MD
Professor Paul F. Lachiewicz, MD
Department of Orthopaedic Surgery Consulting Professor
Virginia Commonwealth University Health Department of Orthopaedic Surgery
System Duke University
Richmond, Virginia Durham, North Carolina
Bryan T. Kelly, MD Kyle W. Lacy, MD, MS

Chief Arthroplasty Fellow
Sports Medicine and Shoulder Service Department of Orthopaedic Surgery
Hospital for Special Surgery Massachusetts General Hospital
New York, New York Boston, Massachusetts
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 xi
Jeffery Lange, MD Adolph V. Lombardi, Jr, MD, FACS
Orthopaedic Fellow Clinical Assistant Professor
Department of Orthopaedic Surgery Department of Orthopaedics
Hospital for Special Surgery Joint Implant Surgeons
New York, New York New Albany, Ohio
Carlos J. Lavernia, MD William J. Long, MD, FRCSC

Director Senior Director
The Center for Advanced Orthopaedics Clinical Associate Professor
Larkin Community Hospital NYU Langone Medical Center
South Miami, Florida Insall Scott Kelly Institute
New York, New York
Cameron K. Ledford, MD
Lower Extremity Reconstruction Fellow Jess H. Lonner, MD
Department of Orthopedic Surgery Associate Professor
Mayo Clinic Department of Orthopaedic Surgery
Rochester, Minnesota Sidney Kimmel Medical College
Rothman Institute at Thomas Jefferson
Gwo-Chin Lee, MD University
Associate Professor Philadelphia, Pennsylvania
University of Pennsylvania Steven J. MacDonald, MD, FRCSC
Philadelphia, Pennsylvania Professor, Chairman
Yadin D. Levy, MD University of Western Ontario
Adult Reconstruction and Joint Replacement London, Ontario, Canada
Fellow
Specialist Orthopaedic Group Nizar N. Mahomed, MD, MPH, ScD
Mater Clinic Professor
Sydney, New South Wales, Australia Department of Surgery
Toronto Western Hospital
David G. Lewallen, MD University of Toronto
Professor of Orthopedic Surgery Toronto, Ontario, Canada
Mayo Clinic Arthur L. Malkani, MD
Rochester, Minnesota Chief Adult Reconstruction
Clinical Professor
Guoan Li, PhD Department of Orthopedics
Director, The Bioengineering Laboratory University of Louisville
Department of Orthopaedic Surgery Louisville, Kentucky
Boston, Massachusetts William J. Maloney, MD
Professor and Chairman
Jay R. Lieberman, MD Department of Orthopaedic Surgery
Professor and Chairman Stanford University, School of Medicine
Department of Orthopaedic Surgery Redwood City, California
Keck School of Medicine of University of
Southern California Dean J. Marshall, DO
Los Angeles, California Clinical Fellow
Department of Hip and Knee Reconstruction
Joint Implant Surgeons
New Albany, Ohio
xii Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 © 2017 American Academy of Orthopaedic Surgeons
Bassam A. Masri, MD, FRCSC Bernard F. Morrey, MD
Professor and Chairman Professor of Orthopedic Surgery, Mayo Clinic
Department of Orthopaedics Clinical Professor, Shoulder & Elbow Total
University of British Columbia Joint Arthroplasty, University of Texas Health
Vancouver, British Columbia, Canada Science Center
Department of Orthopedics
James P. McAuley, MD, FRCS(C) Mayo Clinic
Professor Rochester, Minnesota
Department of Orthopaedic Surgery The University of Texas Health Science Center
Western University at San Antonio
London, Ontario, Canada San Antonio, Texas
Richard W. McCalden, MD, MPhil (Edin.), Matthew C. Morrey, MD, MS

FRCS(C) Adjunct Associate Professor
Professor of Surgery Department of Adult Reconstruction and
Western University Orthopedics
Division of Orthopaedic Surgery The University of Texas Health Science Center
London Health Sciences Centre at San Antonio
London, Ontario, Canada San Antonio, Texas
R. Michael Meneghini, MD Orhun K. Muratoglu, PhD

Associate Professor Co-Director, Harris Orthopaedic Lab,
Department of Orthopaedic Surgery Massachusetts General Hospital
Indiana University School of Medicine Professor, Harvard Medical School
Indianapolis, Indiana Department of Orthopaedic Surgery
Harvard Medical School
William M. Mihalko, MD, PhD Boston, Massachusetts
Professor
Campbell Clinic James Nace, DO, MPT
JR Hyde Chair of Excellence in Biomechanical Orthopaedic Surgeon
Engineering Center for Joint Preservation and Replacement
University of Tennessee Health Science Center Rubin Institute for Advanced Orthopaedics,
University of Tennessee Sinai Hospital of Baltimore
Memphis, Tennessee Baltimore, Maryland
Jaydev B. Mistry, MD Abbas Naqvi, MD

Orthopaedic Research Fellow Resident
Center for Joint Preservation and Replacement Department of Orthopaedic Surgery
Rubin Institute for Advanced Orthopaedics, Howard University Hospital
Sinai Hospital of Baltimore Washington, District of Columbia
Baltimore, Maryland
Philip C. Noble, PhD
Michael A. Mont, MD Professor
Chairman Joseph Barnhart Department of Orthopaedic
Department of Orthopaedic Surgery Surgery
Cleveland Clinic Foundation Baylor College of Medicine
Cleveland, Ohio Houston, Texas
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 xiii
Andrew B. Old, MD Christopher L. Peters, MD
Fellow Professor
NYU Langone Medical Center University of Utah
New York, New York Salt Lake City, Utah
Ebru Oral, PhD Luis F. Pulido, MD

Assistant Professor Orthopaedic Surgeon
Department of Orthopaedic Surgery Department of Orthopedics and Sports
Massachusetts General Hospital, Harvard Medicine
Medical School Houston Methodist Hospital
Boston, Massachusetts Houston, Texas
Feroz Osmani, BS James J. Purtill, MD

Research Fellow Vice Chairman
Department of Orthopaedic Surgery Department of Orthopaedic Surgery
NYU Langone Medical Center, Hospital for Rothman Institute at Thomas Jefferson
Joint Diseases University
New York, New York Philadelphia, Pennsylvania
Douglas E. Padgett, MD Rohit Rambani, MBBS, MS Ortho, FIMSA,

Chief, Adult Reconstruction and Joint FRCS
Replacement Consultant, Orthopaedics
Hospital for Special Surgery United Lincolnshire Hospital NHS Trust
New York, New York Boston, Lincolnshire, England
Mark W. Pagnano, MD Amar Ranawat, MD

Professor and Chairman Surgeon
Department of Orthopedic Surgery Department of Orthopaedic Surgery
Mayo Clinic Hospital for Special Surgery
Rochester, Minnesota New York, New York
Javad Parvizi, MD, FRCS Anil Ranawat, MD

Professor, Director, Vice Chairman of Research Surgeon
Department of Orthopaedic Surgery Department of Sports Medicine and Joint
Rothman Institute at Thomas Jefferson Preservation
University Hospital for Special Surgery
Philadelphia, Pennsylvania New York, New York
Nirav K. Patel, MD, FRCS Andrew B. Richardson, MD

Clinical Fellow Adult Hip and Knee Reconstruction Fellow
Center for Joint Preservation and Replacement Joint Implant Surgeons
Rubin Institute for Advanced Orthopedics, Sinai New Albany, Ohio
Hospital of Baltimore
Baltimore, Maryland Michael D. Ries, MD
Professor Emeritus
Colin T. Penrose, MD Department of Orthopaedic Surgery
Resident University of California, San Francisco
Department of Orthopaedic Surgery San Francisco, California
Duke University Medical Center
Durham, North Carolina
xiv Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 © 2017 American Academy of Orthopaedic Surgeons
Martin Roche, MD Emil Schemitsch MD, FRCS(C)
Robotics Director Richard Ivey Professor and Chairman
Department of Orthopedic Surgery Department of Surgery
Holy Cross Orthopedic Institute Western University
Fort Lauderdale, Florida London, Ontario, Canada
Harry E. Rubash, MD W. Norman Scott, MD, FACS

Chief of Orthopaedic Surgery Clinical Professor, NYU Langone Medical
Department of Orthopaedic Surgery Center
Massachusetts General Hospital Founding Director, Insall Scott Kelly Institute
Boston, Massachusetts for Orthopaedics and Sports Medicine
Department Orthopaedic Surgery, NYU
Robert Russell, MD Langone Medical Center
Surgeon Department of Orthopaedics and Sports
Department of Orthopedics Medicine, Insall Scott Kelly Institute for
W.B. Carrell Clinic Orthopaedics and Sports Medicine
Dallas, Texas NYU Langone Medical Center Hospital for
Joint Diseases
New York, New York
Christopher Samujh, MD
Staff Surgeon
Department of Orthopedics Giles R. Scuderi, MD
Scranton Orthopaedic Specialists Northwell Health Orthopaedic Institute
Dickson City, Pennsylvania Department of Orthopaedic Surgery
Lenox Hill Hospital
New York, New York
Adam A. Sassoon, MD, MS
Assistant Professor
Department of Orthopaedic Surgery Peter K. Sculco, MD
University of Washington Assistant Attending Orthopaedic Surgeon
Seattle, Washington Department of Adult Reconstruction and Joint
Replacement
Hospital for Special Surgery
Jibanananda Satpathy, MD, MRCSEd New York, New York
Assistant Professor
Department of Adult Reconstruction and
Orthopaedics Thomas P. Sculco, MD
Virginia Commonwealth University Health Attending Orthopaedic Surgeon
System Professor of Orthopaedic Surgery
Richmond, Virginia Department of Orthopaedic Surgery
Hospital for Special Surgery
New York, New York
Siraj A. Sayeed, MD, MEng
President
South Texas Bone and Joint Institute Bryan D. Springer, MD
San Antonio, Texas Fellowship Director
OrthoCarolina Hip & Knee Center
Charlotte, North Carolina
Yousuf Sayeed, MS
Research Fellow
Department of Orthopedics, Adult S. David Stulberg, MD
Reconstruction Clinical Professor, Orthopaedic Surgery
New York University Department of Orthopaedic Surgery
New York, New York Northwestern University, Feinberg School of
Medicine
Chicago, Illinois
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 xv
Eric Szczesniak, MD Bradford S. Waddell, MD
Clinical Fellow Fellow
Department of Orthopaedic Surgery, Adult Hip Department of Adult Reconstruction
and Knee Reconstruction Hospital for Special Surgery
Rubin Institute for Advanced Orthopaedics New York, New York
Baltimore, Maryland
William L. Walter, MBBS, PhD
Michael Tanzer, MD, FRCSC Assistant Professor, Orthopaedic Surgeon
Jo Miller Chair and Professor of Surgery Mater Hospital
Division of Orthopaedic Surgery Department of Orthopaedics
McGill University Wollstonecraft, New South Wales, Australia
Montreal, Quebec, Canada
Derek Ward, MD
Savyasachi C. Thakkar, MD Fellow
Adult Reconstruction Surgery Fellow Department of Adult Reconstruction
Department of Orthopaedic Surgery Rothman Institute at Thomas Jefferson
New York University, Hospital for Joint University
Diseases Philadelphia, Pennsylvania
New York, New York
Jennifer S. Wayne, PhD
Gregory A. Tocks, DO Professor
Adult Reconstruction Fellow Department of Biomedical Engineering
Department of Orthopaedic Surgery Virginia Commonwealth University
Virginia Commonwealth University Richmond, Virginia
Richmond, Virginia
Geoffrey Westrich, MD
Robert T. Trousdale, MD Surgeon, Adult Reconstruction and Joint
Professor of Orthopedic Surgery Replacement
Department of Orthopedic Surgery Department of Orthopaedic Surgery
Mayo Clinic Hospital for Special Surgery
Rochester, Minnesota New York, New York
Slif D. Ulrich, MD Geoffrey P. Wilkin, MD, FRCSC

Adult Reconstruction Fellow Assistant Professor
Department of Orthopedics Division of Orthopaedic Surgery
University of Louisville University of Ottawa
Louisville, Kentucky Ottawa, Ontario, Canada
Kartik Mangudi Varadarajan, PhD Joseph L. Yellin, MD

Assistant Director, Technology Implementation Resident
Research Center Harvard Combined Orthopaedic Residency
Department of Orthopaedic Surgery Program
Massachusetts General Hospital Harvard University
Boston, Massachusetts Boston, Massachusetts
Kelly G. Vince, MD, FRCSC

Consultant Surgeon
Northland District Health Board
Whangarei, New Zealand
xvi Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 © 2017 American Academy of Orthopaedic Surgeons
Preface
Orthopaedic Knowledge Update: Hip state-of-the-art technologies. All of the
and Knee Reconstruction 5 comple- chapters have been written by experts
ments and updates information that in each subject, with a concerted effort
was published in the four previous edi- to reflect the current state of hip and
tions. The first edition was published knee reconstruction knowledge with
in 1995, the second in 2000, the third objectivity and a minimal amount of
in 2006, and the fourth in 2011. This personal bias by basing material pri-
edition encompasses a comprehensive marily on evidence-based information
review of the past 5 years of published from these recent reports.
literature on hip and knee arthro-
plasty. This fifth edition serves as an We, the editors, would like to thank
update that can stand on its own. all of the authors for their efforts to
complete their chapters, and putting
This edition should provide residents, up with our relentless constructive
fellows, and practicing orthopaedic criticism. We also gratefully acknowl-
surgeons with a clear understanding of edge the invaluable assistance of
the state-of-the-art knowledge relevant the Publications Department of the
to adult hip and knee reconstruction. American Academy of Orthopaedic
As with the previous four publications, Surgeons. This includes Hans Koelsch,
it can be used as a resource for both PhD, Director; Lisa Claxton Moore,
general orthopaedic surgeons as well Senior Manager, Book Program; Ste-
as hip and knee specialists. ven Kellert, Senior Editor; Courtney
Dunker, Editorial Production Man-
The fifth edition, like the fourth edi- ager; Abram Fassler, Publishing Sys-
tion, is composed of three distinct tems Manager; and Sylvia Orellana,
sections: basic and applied science Publications Assistant. Their work and
relevant to both knee and hip arthro- diligence helped to make this book of
plasty; specific total knee arthroplasty the highest quality.
topics; and specific total hip arthro-
plasty topics. There is updated mate- Michael A. Mont, MD
rial related to controversial topics and Michael Tanzer, MD, FRCSC
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 xvii
Table of Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Chapter 8
Minimally Invasive Surgical Approaches
Section 1: Hip and Knee to Knee Arthroplasty
Giles R. Scuderi, MD; Henry D.
Editors: Michael A Mont, MD and Clarke, MD; Christopher A. Dodd, FRCS . . . . . 95
Chapter 9
Chapter 1 Kinematics in Total Knee Arthroplasty
Imaging of the Hip and Knee for Primary William M. Mihalko, MD, PhD . . . . . . . . . . . . 105
and Revision Arthroplasty
Luis F. Pulido, MD; Stephen J. Incavo, MD . . . . . 3 Chapter 10
Implant Designs of Total Knee
Chapter 2 Arthroplasty
Perioperative Assessment and Kartik Mangudi Varadarajan, PhD;
Management Daniel J. Holtzman, MD; Guoan Li, PhD;
Jay R. Lieberman, MD; Jeffrey Lange, MD; Steven B. Haas, MD;
Ram K. Alluri, MD . . . . . . . . . . . . . . . . . . . . . . 15 Harry E. Rubash, MD;
Andrew A. Freiberg, MD . . . . . . . . . . . . . . . . . 113
Chapter 3
Blood Management Chapter 11
Yatin Kirane, MD, PhD; Special Considerations in Primary Total
Fred D. Cushner, MD . . . . . . . . . . . . . . . . . . . . . 27 Knee Arthroplasty
Andrew B. Old, MD; William J. Long, MD, FRCSC;
Chapter 4 W. Norman Scott, MD, FACS . . . . . . . . . . . . . 131
Osteonecrosis of the Hip and Knee
Nirav K. Patel, MD, FRCS; Jaydev B. Mistry, MD; Chapter 12
Randa K. Elmallah, MD; Morad Chughtai, Bicruciate-Retaining Total Knee
MD; James Nace, DO, MPT; Michael A. Arthroplasty
Mont, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Justin G. Brothers, MD;
Christopher L. Peters, MD . . . . . . . . . . . . . . . . 143
Chapter 5
Economics and Cost Implications of Total Chapter 13
Hip and Total Knee Arthroplasty Unicompartmental, Patellofemoral, and
Richard Iorio, MD; Feroz Osmani, BS; Bicompartmental Knee Arthroplasty
Savyasachi C. Thakkar, MD . . . . . . . . . . . . . . . . 63 Mohamad J. Halawi, MD; Joseph L. Yellin, MD;
Anil Ranawat, MD; Jibanananda Satpathy, MD,
Chapter 6 MRCSEd; Gregory J. Golladay, MD; Jess H. Lonner,
National Joint Registries MD; Wael K. Barsoum, MD . . . . . . . . . . . . . . . 149
Daniel J. Berry, MD; David G. Lewallen, MD;
Fares S. Haddad, FRCS (Orth) . . . . . . . . . . . . . . 73 Chapter 14
Robotic-Assisted Knee Arthroplasty
Martin Roche, MD . . . . . . . . . . . . . . . . . . . . . 163
Section 2: Knee
Editor: Michael A. Mont, MD Chapter 15
Computer-Assisted Knee Arthroplasty
Chapter 7 S. David Stulberg, MD; Michael Dunbar, MD,
Biomechanics of the Knee FRCSC, PhD; Gwo-Chin Lee, MD . . . . . . . . . . 173
Gregory A. Tocks, DO; William A. Jiranek, MD;
Jibanananda Satpathy, MD, MRCSEd; Chapter 16
Jennifer S. Wayne, PhD . . . . . . . . . . . . . . . . . . . 85 The Difficult Primary Total Knee
Arthroplasty
Jaydev B. Mistry, MD; Siraj A. Sayeed, MD,
MEng; Morad Chughtai, MD;
Randa K. Elmallah, MD; Michael A. Mont, MD;
Ronald E. Delanois, MD . . . . . . . . . . . . . . . . . 183
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 xix
Chapter 17
Section 3: Hip
Management of Extra-Articular
Deformities in Knee Arthroplasty Editor: Michael Tanzer, MD, FRCSC
Abbas Naqvi, MD; Jaydev B. Mistry, MD;
Randa K. Elmallah, MD; Morad Chughtai, MD; Chapter 25
Michael A. Mont, MD . . . . . . . . . . . . . . . . . . . 197 Arthroplasty Management of Hip
Fractures: Hemiarthroplasty Versus
Chapter 18 Total Hip Arthroplasty—Results and
Outcomes of Primary Total Knee Complications
Arthroplasty Michael Tanzer, MD, FRCSC . . . . . . . . . . . . . . 313
David C. Ayers, MD; Patricia D. Franklin, MD,
MBA, MPH; Rajiv Gandhi, MS, MD, FRCSC; Chapter 26
Christopher Kim, MD, MSc; Jeffrey Lange, MD;
Nizar N. Mahomed, MD, MPH, ScD; Nonarthroplasty Joint-Preserving Surgery
Philip C. Noble, PhD . . . . . . . . . . . . . . . . . . . . 207 for Hip Disorders
Paul E. Beaulé, MD, FRCSC; J.W. Thomas Byrd,
Chapter 19 MD; Geoffrey P. Wilkin, MD, FRCSC;
Bryan T. Kelly, MD; Sasha Carsen, MD, MBA,
Outpatient Total Knee Arthroplasty FRCSC; Hussain Al-Yousif, MD; Benjamin R.
Adolph V. Lombardi, Jr, MD, FACS; Coobs, MD; John C. Clohisy, MD . . . . . . . . . . 321
Dean J. Marshall, DO . . . . . . . . . . . . . . . . . . . 223
Chapter 27
Chapter 20 Alternatives to Conventional Total Hip
Complications of Knee Arthroplasty Arthroplasty for Osteoarthritis
Viktor E. Krebs, MD; Arthur L. Malkani, MD; Adam A. Sassoon, MD, MS; William J. Maloney,
Slif D. Ulrich, MD; David Backstein, MD, MEd, MD; John C. Clohisy, MD . . . . . . . . . . . . . . . . 339
FRCSC; Mansour Abolghasemian, MD;
Bryan D. Springer, MD;
Christopher Samujh, MD . . . . . . . . . . . . . . . . . 233 Chapter 28
Surgical Approaches and Bearing Surfaces
Chapter 21 William Hozack, MD; Clive P. Duncan, MD, MSc,
Revision Total Knee Arthroplasty FRCSC; Amir Herman, MD, PhD; Erik Hansen,
MD; Mark W. Pagnano, MD; James L. Howard,
R. Michael Meneghini, MD; Kelly G. Vince, MD, MD, MSc, FRCS(C); James P. McAuley, MD,
FRCSC; Bradford S. Waddell, MD; FRCS(C); William A. Jiranek, MD; Tiffany Feltman,
Geoffrey Westrich, MD . . . . . . . . . . . . . . . . . . 267 DO; Orhun K. Muratoglu, PhD; Ebru Oral, PhD;
Gregory K. Deirmengian, MD; William L. Wal-
Chapter 22 ter, MBBS, PhD; Yadin D. Levy, MD; Richard W.
Perioperative Pain Management in Knee McCalden, MD, MPhil (Edin.), FRCS(C); Emil
Arthroplasty Schemitsch, MD, FRCS(C) . . . . . . . . . . . . . . . . 345
Colin T. Penrose, MD;
John W. Barrington, MD . . . . . . . . . . . . . . . . . 279 Chapter 29
The Biologic Response to Bearing
Chapter 23 Materials
Retrieval Analysis of Knee Prostheses Emmanuel Gibon, MD; Stuart B.
Steven M. Kurtz, PhD; Jaydev B. Mistry, MD; Goodman, MD, PhD, FRCSC, FACS . . . . . . . . 367
Eric Szczesniak, MD; Randa K. Elmallah, MD;
Morad Chughtai, MD; Chapter 30
Michael A. Mont, MD . . . . . . . . . . . . . . . . . . . 291 Primary Total Hip Arthroplasty
Craig J. Della Valle, MD; Daniel J. Berry, MD;
Chapter 24 Charles R. Bragdon, PhD; John J. Callaghan, MD;
Nonarthroplasty Management of Knee Rocco D’Apolito, MD; Douglas A. Dennis, MD;
Arthritis Ivan De Martino, MD; Roger H. Emerson, Jr, MD;
Andrew A. Freiberg, MD; Young-Min Kwon, MD,
David J. Jacofsky, MD; PhD; Kyle W. Lacy, MD, MS; Steven J. MacDonald,
Shane R. Hess, DO . . . . . . . . . . . . . . . . . . . . . . 299 MD, FRCSC; R. Michael Meneghini, MD; Matthew
C. Morrey, MD, MS; Bernard F. Morrey, MD; Amar
Ranawat, MD; Harry E. Rubash, MD;
Thomas P. Sculco, MD . . . . . . . . . . . . . . . . . . . 377
xx Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 © 2017 American Academy of Orthopaedic Surgeons
Chapter 31 Chapter 35
Primary Total Hip Arthroplasty in Chal- Complications of Total Hip Arthroplasty
lenging Conditions Michael M. Kheir, MD; Javad Parvizi, MD, FRCS;
Andrew H. Glassman, MD, MS; Michael Tanzer, Andrew N. Fleischman, MD;
MD, FRCSC; Richard Iorio, MD; Anthony Albers, MDCM, FRCSC;
John M. Dundon, MD; Yousuf Sayeed, MS; Mathias Clive P. Duncan, MD, MSc, FRCSC;
P.G. Bostrom, MD; Michael D. Ries, MD; Bassam A. Masri, MD, FRCSC; Derek Ward, MD;
Robert T. Trousdale, MD; Keith R. Berend, MD; Matthew S. Austin, MD;
Nicholas M. Desy, MD, FRCSC . . . . . . . . . . . . 393 Peter K. Sculco, MD; Thomas K. Fehring, MD;
David M. Beck, MD; James J. Purtill, MD;
Jeffrey R. Engorn, DO;
Chapter 32 Carlos J. Lavernia, MD . . . . . . . . . . . . . . . . . . 473
Computer Navigation and Robotics in
Total Hip Arthroplasty Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507
Bradford S. Waddell, MD;
Douglas E. Padgett, MD . . . . . . . . . . . . . . . . . . 423
Chapter 33
Rapid Recovery in Total Hip Arthroplasty
Adolph V. Lombardi, Jr, MD, FACS; Andrew B.
Richardson, MD; Kevin L. Garvin, MD . . . . . . 437
Chapter 34
Revision Total Hip Arthroplasty
Anthony Albers, MD, FRCSC; Alberto Carli, MD,
MSc, FRCSC; Sachin Daivajna, MS, FRCS (Orth);
William L. Griffin, MD; Robert Russell, MD;
Allan E. Gross, MD, FRCSC;
Paul F. Lachiewicz, MD; Cameron K. Ledford, MD;
David G. Lewallen, MD; Douglas E. Padgett, MD;
Rohit Rambani, MBBS, MS Ortho, FIMSA, FRCS,
Tr & Orth; Donald Garbuz, MD, FRCSC . . . . 453
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 xxi
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Chapter 1
Imaging of the Hip and Knee for

Primary and Revision Arthroplasty
Luis F. Pulido, MD Stephen J. Incavo, MD
Abstract Introduction
1: Hip and Knee

The myriad diagnostic imaging modalities currently The myriad diagnostic imaging modalities available are
available are important tools for the diagnosis and important tools for the diagnosis and management of
treatment of patients with musculoskeletal disorders, musculoskeletal disorders, including for patients under-
including patients undergoing hip and knee arthroplasty. going hip and knee arthroplasty. Picture archiving and
The digitization of radiographs with picture archiving communication systems have improved the storage of and
and communication systems has improved the storage access to digitized radiography. Plain radiographs are used
of and access to medical images. Plain radiographs are as the first-line diagnostic test in orthopaedics. A method-
the first-line diagnostic test in orthopaedics. A methodic ic approach to the evaluation of hip and knee radiographs
approach to the evaluation of hip and knee radiographs is is usually sufficient to determine a diagnosis and establish
usually sufficient to determine a diagnosis and establish a treatment plan. The accuracy and efficiency of total hip
a treatment plan. Preoperative planning using digital arthroplasty (THA) and total knee arthroplasty (TKA)
templating of calibrated radiographs aids the accuracy is increased using digital templates of calibrated radio-
and efficiency of total hip and total knee arthroplasty. graphs. Recent advances in other imaging techniques such
Recent advances in other imaging techniques such as as low-dose radiation imaging systems, nuclear medicine,
low-dose radiation systems, nuclear medicine, ultra- ultrasonography, CT, and MRI have a complementary
sonography, CT, and MRI have a complementary role role in the clinical evaluation patients before and after hip
in the evaluation of different clinical scenarios before and knee arthroplasty. The use of digital radiographs is
and after hip and knee arthroplasty. important in the evaluation and preoperative planning of
primary and revision THA and TKA. The advances and
clinical usefulness of newer diagnostic imaging tests are
Keywords: hip arthroplasty; knee arthroplasty; discussed, including the supplementary role of modern nu-
diagnostic imaging in arthroplasty; nuclear clear medicine in the evaluation of the painful total joint
medicine; digital radiographs in arthroplasty arthroplasty and the use of ultrasonography in patients
with hip disorders or in whom hip arthroplasty was un-
successful. In addition, the role of advanced imaging such
as CT in the evaluation of implant position, osteolysis,
and bone loss after hip and knee arthroplasty, as well as
Dr. Incavo or an immediate family member has received the use of modern MRI modalities in the evaluation of
royalties from Biomet, Innomed, Smith & Nephew, Wright hip and knee osteochondral lesions and periprosthetic
Medical Technology, and Zimmer, serves as a paid consultant soft-tissue injuries or adverse soft-tissue reactions are also
to Zimmer, has stock or stock options held in Zimmer, and reviewed. Radiographs are the initial diagnostic test used
serves as a board member, owner, officer, or committee for the evaluation of patients with hip and knee problems.
member of the Knee Society. Neither Dr. Pulido nor any Weight-bearing views provide a more reliable evaluation
immediate family member has received anything of value of limb alignment and joint space narrowing in patients
from or has stock or stock options held in a commercial with hip and knee osteoarthritis.
company or institution related directly or indirectly to the
subject of this chapter.
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 3
Section 1: Hip and Knee
Preoperative Planning and Digital Templating

Digital templating is an important tool in planning pri-
mary and revision THA.1 Digital implant template overlay
helps determine the best implant fit, size, and position
with the goal of restoring hip biomechanics. Restoration
of the normal center of rotation, the femoral lateral offset,
and leg lengths are important goals to achieve in the pre-
operative planning and execution of THA. A methodical,
stepwise approach for templating THA is described in
Figure 1.
Hip Dysplasia
Preoperative planning for THA in patients with end-stage
hip disease resulting from hip dysplasia has unique ace-
tabular and femoral anatomic features. Plain radiographs
1: Hip and Knee
Figure 1 Weight-bearing AP pelvic radiograph with are sufficient for surgical planning and digital templating.
lower extremities in 10 to 15° of internal The dysplastic acetabulum is small, shallow, steep, and
rotation demonstrates stepwise approach for
templating total hip arthroplasty. (1) Digital
elongated.2 The cup should ideally be placed at the hip’s
image is calibrated with markers. (2) Pelvic true center of rotation. Femoral head autograft can be
axis orientation is determined using a line used to reconstitute large superolateral acetabular defects.
(long orange) across the teardrops. (3) Leg
lengths are determined using the distance The use of a high hip center is less favorable because
from a line (short orange) perpendicular to the of abnormal hip biomechanics, increased joint reaction
pelvic axis and the tops of the lesser or greater forces, and increased risk of failure. The dysplastic femur
trochanters. (4) The acetabular component
(blue outline) is placed to restore the hip center has a high femoral neck-shaft angle with increased fem-
of rotation with the cup apex just lateral to the oral anteversion. The use of a femoral stem that allows
teardrop at 40° to 45° of abduction from the
pelvic axis. (5) The femoral component (blue adjustment of femoral version is preferable.3 This can be
outline) is templated to determine the best accomplished with a cemented or modular noncemented
fitting stem and stem sizes to restore femoral stem. A subtrochanteric shortening osteotomy is useful
lateral offset and equalize leg lengths.
for the management of hip dysplasia with high-grade dis-
location to avoid iatrogenic stretch injury to the peroneal-
sciatic nerve4 (Figure 2).
Total Hip Arthroplasty
Femoral Deformity
Standard views for the evaluation of hip disorders in- Biplanar radiographs with magnification markers of the
clude a weight-bearing AP view of the pelvis and AP and pelvis and entire femur are recommended in the surgical
cross-table lateral views of the hip. The proper technique planning of THA in patients with proximal femoral defor-
to obtain a pelvic AP view for accurate determination of mity. Digital templating helps plan the management of
neck length and femoral lateral offset includes direct- different deformity sites (greater trochanter, femoral neck,
ing the x-ray beam perpendicularly and centered on a metaphysis, and diaphysis) and types (angular, transla-
midpoint between the symphysis pubis and the anterior tional, and torsional). The use of modular stems with
superior iliac spine with the lower extremities in 10° to distal stability or fixation may become more important
15° of internal rotation. The cross-table lateral radiograph in this clinical scenario.
is obtained with the patient supine, the contralateral hip
flexed, and the affected limb in 15° of internal rotation Pelvic Obliquity
and the x-ray beam oriented at 45° to the affected hip. The pelvic axis orientation is corrected during preop-
Other hip radiographic views such as the frog-leg lateral, erative templating and surgical completion of THA for
Dunn views, and false profile views are recommended in accurate acetabular abduction angle placement and leg
the evaluation of the young adult (age 15 to 45 years) with length equalization. In most cases, restoration of the
hip pain resulting from femoroacetabular impingement coronal balance of the pelvis following THA is associ-
and hip dysplasia. Judet views are supplemental in the ated with compensation of the coronal alignment of the
evaluation of pelvic bone loss and column integrity in spine. As a result, spinal imbalance and back pain can
acetabular revision. worsen in some patients with rigid degenerative scoliosis
4 Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 © 2017 American Academy of Orthopaedic Surgeons
Chapter 1: Imaging of the Hip and Knee for Primary and Revision Arthroplasty
1: Hip and Knee

Figure 2 A, Preoperative AP pelvic radiograph in a young patient with hip dysplasia and high-grade dislocation (Crowe-
Ranawat stage IV). B, Postoperative AP pelvic radiograph obtained following complex noncemented total hip
arthroplasty. The noncemented acetabular implant was placed to restore the hip center of rotation.
following THA.5 Weight-bearing radiographs obtained and fractures. Preoperative templating is also an impor-
using a block on the shortened leg can help determine tant aspect of revision THA.
the target for any planned leg lengthening. Any pelvic
obliquity resulting from rigid scoliosis, if corrected, will Implants
result in spinal imbalance and should be avoided. Plain radiographs are used to determine the type of fem-
oral and acetabular implants as well as bearing surfaces.
Pelvic Tilt The poor performance of certain hip implants warns
Lumbopelvic lordosis and kyphosis present a challenge in about specific causes and mechanisms of failure after
THA because pelvic tilt determines functional anteversion THA. Weight-bearing AP pelvic and cross-table lateral
and inclination of the acetabulum. Sagittal lumbopelvic views are used to evaluate acetabular and femoral com-
plane deformities can be rigid or flexible. Pelvic tilt varies ponent malposition. The etiology of hip instability is mul-
during simple activities such as standing, sitting, or lying tifactorial, and problems such as lack of femoral offset,
down, which makes functional acetabular position a diffi- excessive acetabular inclination, and version abnormali-
cult, mobile target when considered in the setting of THA. ties can be seen on plain radiographs. Iliopsoas impinge-
Recently, interest has been generated in adjustment of the ment resulting from retroverted acetabular components
acetabular component position based on the functional with prominent, uncovered metal anteriorly results in a
pelvic tilt seen on weight-bearing radiographs.6 painful hip following arthroplasty and is easily evaluated
using the cross-table lateral view. Sequential radiographic
evaluation can be extremely helpful to determine femoral
Revision THA and acetabular fixation with and without cement.
The key principle in revision surgery is understanding the
cause of failure and determining a successful treatment Osteolysis and Bone Loss
plan. The most common causes of failure after hip ar- Plain radiographic findings tend to underestimate peri-
throplasty include aseptic loosening, instability, osteolytic prosthetic osteolysis and bone loss. However, in the set-
wear, periprosthetic fractures, and deep infection.7 Plain ting of mechanical failure and migration of the acetabular
radiographs allow evaluation of the type of prosthesis, component, AP pelvic, cross-table lateral, and Judet views
implant position, fixation, wear, periprosthetic bone loss, can help assess major segmental bone defects and the
knee anatomic and mechanical axes. These images also

provide evidence of possible hip disorders, which must
be ruled out in all painful knees, and help identify any
deformities of the femur and/or tibia. The axial alignment
of the knee seen in two-dimensional (2D) frontal views
is influenced by the lower extremity rotation. Excessive
internal rotation simulates valgus alignment, and exces-
sive external rotation simulates varus alignment.10 A 30°
weight-bearing flexion view helps to more accurately de-
termine joint space narrowing in the native knee.
In primary TKA, digital templates allow assessment
of a deformity and help plan the correction using femoral
and tibial bone cuts to restore mechanical axis. Digital
templating also allows determination of the femoral im-
plant size to restore posterior condylar offset and avoid
1: Hip and Knee
notching.
A stepwise approach for templating TKA should be fol-
Figure 3 AP radiographs of the left hip of a 64-year-old
man who had undergone femoral revision for lowed. First, the digital image is calibrated with markers.
periprosthetic femur fracture complicated by For the lateral view, the size of the femoral implant on the
a deep prosthetic joint infection and a chronic lateral view to restore posterior condylar offset and avoid
draining sinus. A, Preoperative view used to
plan length and type of osteotomy to remove anterior notching should be established. Next, sagittal
a well-fixed noncemented modular titanium femoral bowing, patellar height, and tibial slope should
stem. B, Postoperative view obtained following
posterior extended trochanteric osteotomy, be assessed. For the AP view (long leg or short knee),
removal of hip implants, placement of high- the mechanical axis should be determined on AP view.
dose antibiotic cement dynamic spacer, and Distal femoral and proximal tibia resection angles should
extended trochanteric osteotomy reduction
with wires. be planned to restore the mechanical axis, depending on
the surgeon’s preferred technique. Long leg radiographs
are important to obtain in patients with extra-articular
deformity (Figure 4).
presence of pelvic discontinuity.8 The evaluation of fem-
oral diaphyseal bone loss on radiographs is important
in preoperative planning to help define the method used Revision TKA
for femoral revision. The quality and length of the isth- Aseptic loosening, instability, malalignment, and peri-
mus is evaluated because distally fixed tapered modular prosthetic joint infection are the most common causes of
fluted titanium stems have been universally adopted in failure after TKA.11 Plain radiographs are used to help
femoral revision because of superior clinical results and determine the cause of failure, for surveillance, and for
versatility.9 surgical planning.
Extended Trochanteric Osteotomy Implant Position

Plain radiographs are needed to determine the need for, The knee implant position can be determined using the
type, and length of a femoral osteotomy. An extended standard knee series views noted previously. Neutral,
trochanteric osteotomy is important to facilitate implant varus, or valgus alignment of the femur and tibia is
removal, cement removal, and femoral revision (Figure 3). determined using coronal AP views. The lateral knee
radiographs help determine the amount of tibial slope,
posterior femoral offset, and sagittal position of the fem-
Total Knee Arthroplasty oral implant. In revision TKA for flexion instability or in
The standard knee radiographic series includes a patients with flexion contracture, the distance from the
weight-bearing AP view obtained with neutral rotation medial epicondyle to the femoral joint line is measured
of the limbs, a lateral view with the knee flexed 30°, and to determine if the femoral component is too distal. The
a Merchant axial view. The advantage of a full-length posterior femoral offset and tibial slope are also measured
weight-bearing AP view of the lower extremity over short- on the lateral radiographs and corrected in revision sur-
er images is that it allows more precise measurement of gery for flexion instability.12
Figure 4 Lateral (A) and full-length bilateral AP weight-bearing (B) radiographs demonstrate right knee degenerative joint
disease with associated right femoral extra-articular deformity. AP (C) and lateral (D) radiographs of the right knee
demonstrate successful simultaneous total knee arthroplasty and deformity correction with femoral osteotomy
1: Hip and Knee

and retrograde nail fixation.
Implant Fixation models of the spine, pelvis, and lower limbs.13,14 In THA,
Standard knee views, sequential radiographs, and occa- the EOS system can be used to accurately determine the
sionally, fluoroscopic views, can help determine femoral acetabular position. However, this system is limited when
and tibial loosening after TKA. The size, percentage, used in the evaluation of periprosthetic loosening and
and location of radiolucent lines help determine loosen- osteolysis. The potential role for the EOS system in THA
ing. Technologies such as radiostereometric analysis are includes the evaluation and planning of the functional
more accurate to measure implant migration after TKA. position of the acetabulum relative to the lumbopelvic
Radiostereometric analysis has limited clinical use and changes during standing and sitting positions.14,15
is mainly used for clinical research.
Multidetector CT
Multidetector CT is superior to plain radiography and
Advanced Imaging Techniques can be used as a supplementary diagnostic test to help
Digital Radiographic Imaging Systems diagnose prearthritic conditions of the hip as well as hip
New and advanced imaging technologies such as the EOS and knee implant fixation, loosening, position, and peri-
imaging system (EOS Imaging) provides functional radio- prosthetic bone loss. Multidetector CT has improved effi-
graphic information in different positions such as stand- ciency and imaging quality compared with conventional
ing, squatting, and sitting. The role of low-dose radiation CT. Narrower collimation and low pitch adjustments in
imaging in THA has not been established; however, 2D multidetector CT reduces metal artifacts and improves
and three-dimensional (3D) functional images obtained the image quality of bone and soft tissues around hip and
with low-dose radiation imaging are important in de- knee implants.16
termining the hip-spine relationship in THA. The EOS The evaluation and planning of hip preservation sur-
imaging system is capable of providing weight-bearing gery in patients with hip dysplasia and femoroacetabular
biplanar digital radiographs and 3D reconstructions of impingement (FAI) can be supplemented using CT (Fig-
the entire body. The EOS imaging system consists of two ure 6). In addition, CT can be used in hip preservation to
pairs of perpendicularly positioned, vertically moving, evaluate the patient’s femoral version and torsion. Patients
linked units of x-ray tubes that produce thin collimated with hip osteoarthritis secondary to severe hip dysplasia
x-ray beams collected by the detectors, resulting in si- have small, elongated acetabula and excessive femoral
multaneous, spatially calibrated weight-bearing AP and anteversion, which can be determined with a preoperative
lateral images. Static functional views in standing, sitting, CT scan.2
or squatting positions (Figure 5) can be obtained in 10 to CT can be used in the evaluation of patients with
25 seconds with a fraction of the radiation used with plain painful THAs and equivocal radiographic findings. CT
radiographs (sixfold to ninefold reduction in radiation) is more accurate than radiography for the evaluation of
or CT (600-fold reduction in radiation). implant position and fixation. CT is used to evaluate im-
The EOS system also can create 3D reconstruction plant position in patients with hip instability or anterior
1: Hip and Knee
Figure 5 Biplanar digital AP (A, C, E) and lateral (B, D, F) radiographs obtained using the EOS (EOS Imaging) low-dose
radiation imaging system in weight-bearing (A, B), sitting (C, D), and squatting (E, F) positions. (Copyright Jean
Yves Lazennec, MD, PhD, Paris, France.)
Figure 6 Images from a 17-year-old girl with symptomatic mild hip dysplasia whose nonsurgical treatment was unsuccessful.
A and B, Preoperative AP radiographs. C, CT scan with three-dimensional reconstruction confirms the lack
of anterior and lateral coverage of the femoral head. E and F, Postoperative radiographs obtained following
successful periacetabular osteotomy demonstrate improved anterior and lateral coverage.
hip pain secondary to iliopsoas impingement (Figure 7). In of the periacetabular osteolysis and vascular anatomy
addition, periacetabular osteolysis is more accurately de- are helpful when complex acetabular revision surgery is
termined with CT than plain radiography: CT facilitates considered.
for better detection, characterization, and quantification Rotational malalignment of the femur and/or tibia can
of bone loss around acetabular and femoral implants, as be the cause of knee pain, patella maltracking, stiffness,
well as more accurate determination of implant fixation.17 or instability after TKA. 2D axial CT scans have weak
CT scans have limited use for the evaluation of peri- interobserver and intraobserver reliability in determining
articular masses and fluid collections following THA. In the rotation of the tibial and femoral implants relative to
patients whose metal-on-metal hip arthroplasties were bony landmarks.19 3D reconstruction images are superior
unsuccessful, the sensitivity for diagnosising pseudotu- and more reliable in obtaining rotational measurements
mors is only 44%.17 In this setting, the use of MRI with of TKA components.20
metal suppression or ultrasonography is recommended.
Preoperative CT angiography with 3D reconstruction Magnetic Resonance Imaging
can help with surgical planning and awareness of abnor- MRI is used routinely in the evaluation of the young
mal vascular anatomy around the acetabulum.18 Details adult with hip pain. Metal artifact reduction sequence
1: Hip and Knee

Figure 7 Images of a patient with persistent anterior groin pain following noncemented total hip arthroplasty. AP (A)
and cross-table lateral (B) views demonstrate no radiographic evidence of retroversion. Axial (C) and sagittal (D)
CT scans demonstrate a noncemented acetabular implant with a prominent anterior rim. Postoperative AP (E)
and cross-table lateral (F) radiographs obtained following acetabular revision to treat iliopsoas impingement.
(Copyright Rafael J. Sierra, MD, Mayo Clinic, Rochester, MN.)
MRI (MARS MRI) has the capability to produce high- layers in healthy articular cartilage. Cartilage damage
resolution images of periprosthetic tissues in patients with shows an increased amount of free water and increased
THA implants.21 MARS MRI is commonly used for pa- T2-signal intensity (Figure 8).
tients with metal-on-metal bearing surfaces, modular T1ρ mapping measures low-frequency interactions be-
neck prostheses, or in cases for which concern exists for tween hydrogen and the macromolecules in free water.
adverse soft-tissue reaction following THA. T1ρ values are correlated with the hyaline cartilage pro-
Magnetic resonance arthrography has been the pre- teoglycan content. T1ρ values increase as proteoglycan
ferred imaging test in the evaluation of FAI and associated content decreases in articular cartilage.22
labral pathology. However, modern 3-T MRI provides The dGEMRIC technique uses a negatively charged
high-quality hip images, including osseous and soft-tissue gadolinium-based contrast agent to measure the gly-
structures. The labrum can be well visualized without cosaminoglycan content of the cartilage. The loss of
using intra-articular contrast injection. Other advances in glycosaminoglycan in cartilage is an early biochemical
MRI include the use of biochemical imaging techniques change that precedes structural damage. The recent use
such as T2 mapping, T1 rho (T1ρ) imaging, and delayed of dGEMRIC imaging in the evaluation of hip cartilage
gadolinium-enhanced MRI of cartilage (dGEMRIC). has demonstrated a correlation of low dGEMRIC index
These techniques were developed to detect cartilage bio- and hip pain in patients with underlying hip dysplasia
chemical changes, which precede structural damage or and FAI.23 A low dGEMRIC index is also associated
degeneration, and are used in the evaluation of patients with poor early outcomes in hip preservation surgery for
with hip dysplasia or FAI.22 hip dysplasia.24
T2 mapping measures the changing interactions be- MARS MRI is used in patients with THA implants for
tween water and collagen molecules of the cartilage, better visualization of periprosthetic bone and soft-tissue
including the zonal variations in articular cartilage. structures. MARS MRI is recommended when suspi-
T2 mapping values increase from deep to transitional cion exists for corrosion-related metal-adverse soft-tissue
Figure 8 Sagittal MRIs obtained from a 23-year-old man with femoroacetabular impingement. A, Fast spin-echo image
demonstrates no cartilage defect, with visible intralabral ossification (arrow). Parametric T1ρ (B) and T2 (C)
mapping demonstrate prolonged relaxation times anteriorly (blue arrows) and posterosuperiorly (white arrow).
1: Hip and Knee
(Copyright Hollis G. Potter, MD, Hospital for Special Surgery, New York, NY, 2016.)
prosthetic joint infections can all have positive bone scans.

Despite recent advances and efforts that use bone scintig-
raphy to diagnose infection using labeled leukocyte scans
or F-18 fluorodeoxyglucose–positron emission tomogra-
phy, no role has been established for nuclear medicine
in the diagnosis of prosthetic joint infection following
THA or TKA.27
The new single photon emission computed tomog-
raphy (SPECT)/CT arthrography is a hybrid technique
that could be useful in the evaluation of the painful
THA and TKA. SPECT/CT can be used in cases for
which traditional tests such as radiography, serial radio-
graphs, or fluoroscopy are inconclusive for determining
THA and TKA implant loosening. Although SPECT/CT
is not established in current clinical practice, one study
showed promising results with sensitivity of 100%,
specificity of 96.0%, positive predictive value of 92.9%,
Figure 9 Coronal T1-weighted metal artifact
negative predictive value of 100%, and accuracy of
reduction sequence MRI demonstrates large, 97.4% in the evaluation of aseptic loosening of hip and
heterogeneous pseudotumor with disruption of knee prostheses. 28
the abductors.
Ultrasonography
Ultrasonography is commonly used to guide intra-articular
reactions in patients with metal-on-metal bearings, injections or aspirations of the hip. In clinical practice,
modular femoral necks, or in patients with larger metal ultrasound guided intra-articular hip injections are used
cobalt-chromium femoral heads25,26 (Figure 9). In addi- to differentiate hip pain secondary to hip pathology from
tion, MARS MRI can help determine the presence of other sources of hip pain29 (Figure 10). Ultrasonography
pseudotumors around non–metal-on-metal and modular is also used in the evaluation and surveillance of patients
THAs. with metal-on-metal THA, modular femoral neck stems,
or those in whom corrosion-related metal-adverse soft-
Nuclear Imaging tissue reactions are suspected. This imaging technique
Traditional nuclear medicine has limited use in total joint is operator-dependent and the sensitivity for detecting
arthroplasty because of its low specificity and high cost. pseudotumors varies from 69%30 to 100%31 when using
Patients with stress reactions, aseptic loosening, or deep MRI findings as reference.
Figure 10 Ultrasonographically guided intra-articular hip injection. A, Image demonstrates the smooth contour of the
femoral head and neck. B, Image demonstrates the needle placement, inserted to the femoral neck. C, Image
demonstrates the injected fluid filling the hip capsule.
Summary Annotated References
Digital radiographs are the main diagnostic test in the

1. Levine B, Fabi D, Deirmengian C: Digital templating in
1: Hip and Knee

evaluation of the adult hip and knee. Templating and primary total hip and knee arthroplasty. Orthopedics
preoperative planning is commonly performed in total 2010;33(11):797. Medline
joint arthroplasty. Advanced imaging techniques have a
In this report, the clinical success of digital templating
complimentary role to radiographs in the evaluation of with the Advanced Case Plan system in primary THA and
multiple conditions related to hip and knee replacement TKA shows it was an effective means for predicting com-
issues. Narrower collimation and low- pitch adjustments ponent size, thus remaining a viable option transitioning
in multidetector CT reduces metal artifacts and improves into the era of digital radiography.
the image quality of bone and soft tissues around hip and
2. van Bosse H, Wedge JH, Babyn P: How are dysplastic hips
knee implants. MARS MRI has the capability to produce different? A three-dimensional CT study. Clin Orthop
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because of the increased awareness of corrosion related dysplasia and pelvic 3D CT scans for other reasons, dys-
adverse effects following THA. MRI techniques such as plastic acetabuli were not deficient in a single dimension
T2 mapping, T1ρ imaging, and dGEMRIC are sophisti- but rather globally; early detection and/or treatment are
emphasized. Level of evidence: III.
cated techniques that evaluate the biochemical cartilage
changes that precede structural damage. 3. Tamegai H, Otani T, Fujii H, Kawaguchi Y, Hayama T,
Marumo K: A modified S-ROM stem in primary total
Key Study Points hip arthroplasty for developmental dysplasia of the hip.
J Arthroplasty 2013;28(10):1741-1745. Medline DOI
• Weight-bearing radiographs of the hip and knee pro- In this clinical study, 220 hips (Asian patients) under-
vide a more reliable determination of the joint space. went primary THA for developmental dysplasia using
• Multidetector CT is superior to plain radiography an S-ROM-A stem designed for Asian patients. For de-
and can be used as a supplementary diagnostic test velopmental dysplasia of the hip with femoral rotational
deformity, the freely rotating modular stem provided fa-
to help diagnose prearthritic conditions of the hip, vorable short-term outcomes and afforded morphologic
periprosthetic bone loss, and implant position and and functional advantages.
fixation.
• MARS MRI is used in patients in whom there is con- 4. Krych AJ, Howard JL, Trousdale RT, Cabanela ME, Berry
cern for corrosion-related adverse soft-tissue reaction DJ: Total hip arthroplasty with shortening subtrochanteric
osteotomy in Crowe type-IV developmental dysplasia:
following THA such as patients with metal-on-metal Surgical technique. J Bone Joint Surg Am 2010;92
bearing surfaces and modular neck prostheses. (suppl 1 Pt 2):176-187. Medline
• MRI techniques such as T2 mapping, T1ρ imaging,
This study reported the results of noncemented arthro-
and dGEMRIC have a promising role in the evalu- plasty with simultaneous subtrochanteric shortening
ation of prearthritic hip conditions such as FAI and osteotomy in patients with Crowe type IV developmental
adult hip dysplasia. dysplasia of the hip. The mean Harris hip score increased
• Traditional nuclear medicine has limited use in total from 43 to 89 points preoperatively and the complication
rate was substantially higher than with primary THA in
joint arthroplasty because of its low specificity and patients with degenerative arthritis.
high cost.
5. Abe Y, Sato S, Abe S, Masuda T, Yamada K: The impact TKA to establish recalculation using existing radiographic
of the leg-lengthening total hip arthroplasty on the coro- landmarks. Limb rotation was highly significant on mea-
nal alignment of the spine. Scoliosis 2015;10(suppl 2):S4. sured anatomic alignment and mechanical angles.
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In this study, patients were radiologically analyzed to clas- 11. Sharkey PF, Lichstein PM, Shen C, Tokarski AT, Parvizi
sify coronal alignment of the spine after THA. More than J: Why are total knee arthroplasties failing today:
3.5° in pelvic obliquity was significantly correlated with a Has anything changed after 10 years? J Arthroplasty
change in lumbar scoliosis. Compensation in lumbar sco- 2014;29(9):1774-1778. Medline DOI
liosis in the coronal plane after leg-lengthening THA was This study examined frequency and cause of failure after
classified regarding pelvic obliquity and the Cobb angle. TKA, compared with an earlier report, and reported the
most common failure mechanisms remained loosening,
6. Maratt JD, Esposito CI, McLawhorn AS, Jerabek SA, infection, instability, periprosthetic fracture, and arthro-
Padgett DE, Mayman DJ: Pelvic tilt in patients undergoing fibrosis, although the rates were decreased from earlier re-
total hip arthroplasty: When does it matter? J Arthroplas- ports. Polyethylene wear was no longer the primary cause.
ty 2015;30(3):387-391. Medline DOI
This study reviewed patients who underwent unilateral 12. Abdel MP, Pulido L, Severson EP, Hanssen AD: Step-
primary THA, most with some degree of pelvic tilt and wise surgical correction of instability in flexion after total
reported that tilt-adjustment of the acetabular component knee replacement. Bone Joint J 2014;96-B(12):1644-1648.
1: Hip and Knee
position based on weight-bearing preoperative imaging Medline DOI

will likely improve functional component position in most Identifying factors leading to instability in flexion, degree
patients undergoing THA. of correction determined radiologically and required at
revision surgery, and clinical outcomes for revision TKA
7. Melvin JS, Karthikeyan T, Cope R, Fehring TK: Early patients revealed significant improvement in mean Knee
failures in total hip arthroplasty: A changing paradigm. Society Score for knee and function and no instability
J Arthroplasty 2014;29(6):1285-1288. Medline DOI using this stepwise approach.
This study reviewed revision THAs for early failures (with-
in 5 years of primary THA). The emergence of metallosis 13. Illés T, Somoskeöy S: The EOS™ imaging system
and aseptic loosening of metal-on-metal shells as leading and its uses in daily orthopaedic practice. Int Orthop
causes of early failure was a concern, and early adoption 2012;36(7):1325-1331. Medline DOI
of new innovations before evidence-based medicine is The authors of this study used the new EOS imaging
available was cautioned. system to perform routine orthopaedic diagnostics in
5,700 standard examinations since 2007: one-third in
8. Sheth NP, Nelson CL, Springer BD, Fehring TK, Paprosky spine deformity and the rest in lower limb orthopaedic
WG: Acetabular bone loss in revision total hip arthroplas- cases. This mini-review summarizes principles and inte-
ty: Evaluation and management. J Am Acad Orthop Surg gration in clinical practice.
2013;21(3):128-139. Medline DOI
The increase in primary THAs prompted an increase in 14. Lazennec JY, Rousseau MA, Brusson A, et al: Total Hip
revision THAs, which demands proper management of Prostheses in Standing, Sitting and Squatting Positions: An
and appropriate radiographs in assessing acetabular bone Overview of Our 8 Years Practice Using the EOS Imaging
loss. Specific classification schemes can identify bone loss Technology. Open Orthop J 2015;9(9):26-44. Medline
patterns and guide available treatment options. This study compared 8 years of experience using low-dose
EOS imaging on the first 300 THA patients with actual
9. Sheth NP, Nelson CL, Paprosky WG: Femoral bone loss literature on this innovative technology, contributing to
in revision total hip arthroplasty: Evaluation and man- the discussion of an aging spine associated with the process
agement. J Am Acad Orthop Surg 2013;21(10):601-612. of aging hips continues to evolve.
Medline DOI
In this study, the indications for revision THA include in- 15. Lazennec JY, Rousseau MA, Rangel A, et al: Pelvis and
stability, aseptic loosening, infection, and other conditions total hip arthroplasty acetabular component orienta-
that can be associated with mild or advanced bone loss. tions in sitting and standing positions: Measurements
Bone loss classification guides preoperative planning. Non- reproductibility with EOS imaging system versus con-
cemented fixation has provided the best results, although ventional radiographies. Orthop Traumatol Surg Res
cemented fixation is required in some cases. 2011;97(4):373-380. Medline DOI
In this prospective diagnostic study, five angular parame-
10. Radtke K, Becher C, Noll Y, Ostermeier S: Effect of limb ters characterizing pelvic tilt and acetabular cup orienta-
rotation on radiographic alignment in total knee arthro- tion were determined using the same digital measurement
plasties. Arch Orthop Trauma Surg 2010;130(4):451-457. imaging software based on two series of standard radio-
Medline DOI graphs and EOS 2D images, and standing and sitting po-
sitions of unilateral THA patients. Level of evidence: III.
This study used synthetic femora and tibiae to evaluate
the effect of limb rotation on radiographic alignment after
16. Roth TD, Maertz NA, Parr JA, Buckwalter KA, Chop- 21. Choi SJ, Koch KM, Hargreaves BA, Stevens KJ, Gold GE:
lin RH: CT of the hip prosthesis: Appearance of com- Metal artifact reduction with MAVRIC SL at 3-T MRI
ponents, fixation, and complications. Radiographics in patients with hip arthroplasty. AJR Am J Roentgenol
2012;32(4):1089-1107. Medline DOI 2015;204(1):140-147. Medline DOI
This study reported that metal implants present some Matched 2D fast spin-echo and multiacquisition vari-
challenges in the performance and interpretation of CT ex- able-resonance image combination selective (MAVRIC
aminations; however, metal artifacts can be minimized by SL) images of 21 hips (19 with hip arthroplasty) showed
decreasing the detector collimation and pitch, increasing MAVRIC SL can significantly reduce metal artifact on 3-T
kilovolt peak and milliampere-seconds, and using appro- MRI compared with 2D fast spin-echo sequence and in-
priate reconstruction algorithms and section thickness. crease diagnostic confidence of 3-T MRI in THA patients.
17. Robinson E, Henckel J, Sabah S, Satchithananda K, Skin- 22. Jazrawi LM, Alaia MJ, Chang G, Fitzgerald EF, Recht
ner J, Hart A: Cross-sectional imaging of metal-on-metal MP: Advances in magnetic resonance imaging of articular
hip arthroplasties: Can we substitute MARS MRI with cartilage. J Am Acad Orthop Surg 2011;19(7):420-429.
CT? Acta Orthop 2014;85(6):577-584. Medline DOI Medline DOI
This study reported that compared with MARS MRI New diagnostic tools for detecting and interpreting early
in evaluating metal-on-metal hip arthroplasty patients cartilaginous degeneration, including biochemical-based
with unexplained painful prostheses, CT was superior MRI, T2 mapping, T1ρ, sodium MRI, and dGEMRIC
1: Hip and Knee

for detecting osteolysis adjacent to metal-on-metal hip were assessed and may eventually enhance the diagnosis
arthroplasty, although it was unable to classify and failed and management of osteoarthritis.
to detect many pseudotumors and was unreliable in mus-
cle atrophy assessment. Therefore, CT was an unsuitable 23. Bittersohl B, Hosalkar HS, Hesper T, Tiderius CJ, Zilkens
substitute for MARS MRI. C, Krauspe R: Advanced imaging in femoroacetabular
impingement: Current state and future prospects. Front
18. Kawasaki Y, Egawa H, Hamada D, Takao S, Nakano Surg 2015;2(2):34. Medline
S, Yasui N: Location of intrapelvic vessels around the
acetabulum assessed by three-dimensional comput- This study assessed advanced MRI techniques (dGEM-
ed tomographic angiography: Prevention of vascular- RIC, T1ρ, T2/T2* mapping) to determine specific roles
related complications in total hip arthroplasty. J Orthop and the basics of each technique in FAI assessment, as
Sci 2012;17(4):397-406. Medline DOI well as current limitations and the future direction of
biochemical imaging in early identification of articular
This study reported using 3D CT angiography on subjects cartilage degeneration.
without hip disease to clarify the location of the external
iliac, femoral, and obturator vessels at risk of vascular 24. Kim SD, Jessel R, Zurakowski D, Millis MB, Kim YJ:
injury when penetrating the inner cortex of the pelvis Anterior delayed gadolinium-enhanced MRI of cartilage
during THA. values predict joint failure after periacetabular oste-
otomy. Clin Orthop Relat Res 2012;470(12):3332-3341.
19. Konigsberg B, Hess R, Hartman C, Smith L, Garvin KL: Medline DOI
Inter- and intraobserver reliability of two-dimensional
CT scan for total knee arthroplasty component mal- In this study, the dGEMRIC index of the anterior joint
rotation. Clin Orthop Relat Res 2014;472(1):212-217. compared with coronal dGEMRIC of 43 hips that un-
Medline DOI derwent Bernese periacetabular osteotomy for hip dys-
plasia better predicted premature joint failure than did
To determine the interobserver and intraobserver reli- radiographic measures of hip osteoarthritis and coronal
ability and repeatability of TKA component rotation dGEMRIC index. Level of evidence: II.
measurement using 2D CT, scans of 52 revision TKA
candidates were measured. TKA component rotation vari- 25. Kwon YM, Fehring TK, Lombardi AV, Barnes CL,
able results increased concern about CT scan diagnostics Cabanela ME, Jacobs JJ: Risk stratification algorithm
in this assessment. for management of patients with dual modular taper total
hip arthroplasty: Consensus statement of the American
20. Hirschmann MT, Konala P, Amsler F, Iranpour F, Fried- Association of Hip and Knee Surgeons, the American
erich NF, Cobb JP: The position and orientation of total Academy of Orthopaedic Surgeons and the Hip Society.
knee replacement components: A comparison of conven- J Arthroplasty 2014;29(11):2060-2064. Medline DOI
tional radiographs, transverse 2D-CT slices and 3D-CT
reconstruction. J Bone Joint Surg Br 2011;93(5):629-633. This study recommends a systematic treatment approach
Medline DOI based on available data to optimize patient management.
Specialized tests such as metal ion analysis and MARS
Comparing radiographs with axial 2D and 3D recon- MRI are useful in evaluating for adverse tissue reactions,
structed CT images, intraobserver and interobserver reli- although overreliance on any single investigative tool
ability of measurements of component position after TKA should be avoided.
showed rotational measurements should be performed
on 3D-reconstructed CT images. For poorly functioning 26. Kwon YM, Lombardi AV, Jacobs JJ, Fehring TK, Lewis
TKA with concerns over component positioning, 3D CT CG, Cabanela ME: Risk stratification algorithm for man-
is preferred. agement of patients with metal-on-metal hip arthroplasty:
Consensus statement of the American Association of Hip femoroacetabular impingement: A systematic review.
and Knee Surgeons, the American Academy of Orthopae- O rthop J Sports Med 2015;3(9):2325967115601030.
dic Surgeons, and the Hip Society. J Bone Joint Surg Am Medline DOI
2014;96(1):e4. Medline DOI
In this meta-analysis that evaluated the usefulness of in-
To prevent significant adverse biologic reactions, system- tra-articular hip injection in the diagnosis/management
atic evaluation and validation of current diagnostic tools of FAI, eight studies were categorized into diagnostic,
in the early diagnosis of patients with metal-on-metal therapeutic, and prognostic applications. Pain relief from
hip arthroplasty are important to further diminish wear intra-articular hip injections supported FAI diagnosis,
and corrosion. negative response to preoperative injections may predict
poor short-term surgical outcomes.
27. Workgroup Convened by the Musculoskeletal Infection
Society: New definition for periprosthetic joint infection. 30. Siddiqui IA, Sabah SA, Satchithananda K, et al: A com-
J Arthroplasty 2011;26(8):1136-1138. Medline DOI parison of the diagnostic accuracy of MARS MRI and
ultrasound of the painful metal-on-metal hip arthroplasty.
This communication presents the diagnostic criteria and Acta Orthop 2014;85(4):375-382. Medline DOI
definition for periprosthetic joint infection proposed by
a work group convened by the Musculoskeletal Infection In comparing MARS MRI and ultrasonography in uni-
Society in an effort to standardize a field that has experi- lateral metal-on-metal hip patients, poor agreement was
enced extensive variability and heterogeneity. found. Ultrasonography was inferior in detecting pseudo-
1: Hip and Knee
tumors and muscle atrophy but superior in detecting joint

28. Abele JT, Swami VG, Russell G, Masson EC, Flemming effusion and tendinous pathologies. MARS MRI was pref-
JP: The accuracy of single photon emission computed erable in preoperative planning, longitudinal comparison.
tomography/computed tomography arthrography in Level of evidence: IV.
evaluating aseptic loosening of hip and knee prostheses.
J Arthroplasty 2015;30(9):1647-1651. Medline DOI 31. Garbuz DS, Hargreaves BA, Duncan CP, Masri BA, Wil-
son DR, Forster BB: The John Charnley Award: Diagnostic
This study retrospectively evaluated nuclear medicine accuracy of MRI versus ultrasound for detecting pseudo-
arthrography with hybrid SPECT/CT, in 21 hips and tumors in asymptomatic metal-on-metal THA. Clin Or-
17 knee patients compared with reference standards and thop Relat Res 2014;472(2):417-423. Medline DOI
suggests nuclear medicine arthrography with SPECT/CT
may be useful in the clinical evaluation of suspected aseptic This study compared ultrasonography with MRI for
loosening. pseudotumor detection and assessment of growth in an
asymptomatic cohort of patients with metal-on-metal
29. Khan W, Khan M, Alradwan H, Williams R, Simunovic THAs and reported that ultrasonography and MRI agreed
N, Ayeni OR: Utility of intra-articular hip injections for in 37 of 40 patients. Ultrasonography is recommended as
the initial screening tool for pseudotumors.
Chapter 2
Perioperative Assessment
and Management
Jay R. Lieberman, MD Ram K. Alluri, MD
1: Hip and Knee

Hip and knee arthroplasty are highly successful pro- Hip and knee arthroplasty represent two of the largest
cedures that are associated with excellent functional cost centers in healthcare. With the shift of the Centers
outcomes for most patients. Recently, increased attention for Medicare & Medicaid Services (CMS) toward bundled
has been given to preoperative risk optimization aimed payment programs for total hip arthroplasty (THA) and
at limiting complications in patients with specific comor- total knee arthroplasty (TKA), healthcare centers are
bidities. Venous thromboembolic prophylaxis remains attempting to minimize perioperative complications, de-
of great interest because of concerns associated with crease readmission rates, maximize patient outcomes, and
the development of symptomatic pulmonary embolism reduce costs. The optimization of perioperative medical
and death, as well as the potential for excess antico- management, venous thromboembolism (VTE) prophy-
agulation, which may lead to bleeding. Advancements laxis, anesthesia, and postoperative pain in patients un-
in neuraxial anesthesia and postoperative multimodal dergoing THA and TKA can have a critical effect on
pain regimens have helped minimize postoperative outcomes.
complications, decrease inpatient length of stay, and
improve patient satisfaction.
Medical Management and Optimization
Patients undergoing hip and knee arthroplasty are older
Keywords: perioperative management; venous and often have an increased burden of medical comor-
thromboembolism prophylaxis; anesthesia; bidities1-3 (Table 1). Between 1991 to 2010, the number
multimodal pain management of comorbidities in this patient population doubled, the
prevalence of diabetes increased from 10% to 24%, and
obesity increased from 4% to 10%.2 Because the increase
in comorbidities in this patient population is expected to
continue, interest in preoperative medical optimization
has increased. The perioperative orthopaedic surgery
Dr. Lieberman or an immediate family member has re- home model may allow for risk stratification and early
ceived royalties from DePuy Synthes and serves as a paid identification of patients at increased risk for experiencing
consultant to DePuy Synthes; has stock or stock options perioperative complications while triggering the preoper-
held in Hip Innovation Technology; and serves as a board ative intervention of modifiable risk factors.4
member, owner, officer, or committee member of the The identification of preoperative modifiable risk fac-
American Academy of Orthopaedic Surgeons, the Western tors for complications depends on a careful review of each
Orthopaedic Association, and the American Association of patient’s medical history, a thorough preoperative physical
Hip and Knee Surgeons. Dr. Alluri or an immediate family examination, performing basic laboratory studies, and
member has received nonincome support (such as equip- cardiac risk stratification. Several risk prediction models
ment or services), commercially derived honoraria, or other have been developed on the basis of a variety of outcomes,
non–research-related funding (such as paid travel) from including 30-day complications, readmission, mortality,
TriMed; has stock or stock options held in Zimmer Biomet, functional outcomes, and discharge disposition. These
Stryker, and Medtronic. models have resulted in the identification of several
Table 1 body mass index (BMI) with patients who were morbid-
ly obese.9 There is no absolute BMI at which patients’
Comorbidity Prevalence in Total Hip risk of the development of postoperative complications
and Total Knee Arthroplasty Patients significantly increases; however, many studies stratify
Comorbidity Prevalence patients as having a BMI greater or less than 40 kg/m2.
Additionally, the exact amount or percentage of weight
Hypertension 60% to 70%
loss needed preoperatively to improve postoperative out-
Diabetes mellitus 11% to 20% comes remains unclear, and a weight loss greater than
Obesity 14% to 18% 5% may be needed to decrease the risk of postoperative
Dyslipidemia 35% to 55% complications.10 Although bariatric surgery has been
Chronic kidney disease 0.2% to 4.0% proved to decrease BMI, the timing of bariatric surgery
Tobacco use 9% to 22%
before arthroplasty and its effect on postoperative ar-
throplasty outcomes remains unclear and requires further
Congestive heart failure 0.2% to 4.0%
investigation.
Data from Yu S, Garvin KL, Healy WL, Pellegrini VD Jr, Iorio R:
Preventing hospital readmissions and limiting the complications
1: Hip and Knee
associated with total joint arthroplasty. J Am Acad Orthop Surg Smoking

2015;23(11):e60-e71; Gonzalez Della Valle A, Chiu YL, Ma Y, Tobacco use is thought to be one of the most important
Mazumdar M, Memtsoudis SG: The metabolic syndrome in patients
undergoing knee and hip arthroplasty: trends and in-hospital
risk factors contributing to postoperative complications,
outcomes in the United States. J Arthroplasty 2012;27(10):1743- particularly wound complications, which are nearly dou-
1749; and Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR: Total knee bled in active smokers compared with nonsmokers.11 Pre-
arthroplasty volume, utilization, and outcomes among Medicare
beneficiaries, 1991-2010. JAMA 2012;308(12):1227-1236. vious studies have demonstrated that a smoking cessation
program started 6 to 8 weeks before surgery can decrease
postoperative complications; however, monitoring com-
pliance remains a challenge.12 Nicotine screening tests
important risk factors for postoperative complications. assessing the blood level of cotinine allow for the iden-
tification of noncompliance with cessation, potentially
Diabetes decreasing postoperative complication rates.
Studies have consistently identified diabetes as a risk fac-
tor for postoperative complications, and it is included Cardiovascular Disease
in most risk-stratification algorithms. The preoperative Cardiovascular complications represent one of the most
screening of patients with hyperglycemia by checking common systemic adverse events after arthroplasty, and
hemoglobin A1c (HbA1c) has been an area of increased in- these complications can result in death. Major risk factors
terest. HbA1c levels greater than 6.7 have been associated for postoperative cardiovascular complications include
with an increased risk of postoperative wound complica- preoperative cardiovascular disease and older age.13,14 Pa-
tions.5 However, the target HbA1c level for ideal preoper- tients with cardiac stents present a challenging situation
ative optimization remains unclear, and not all patients for the arthroplasty surgeon, and different stent types
may be able to achieve a target level.6 Strict adherence mandate different forms of management. The current
to a certain target level may needlessly delay surgery. recommendation is for elective noncardiac surgery to be
Additionally, HbA1c may not be the best surrogate for delayed in patients in whom dual antiplatelet therapy will
quantifying the severity of a patient’s diabetes, as it is a need to be discontinued within 30 days after bare-metal
measure of chronic glycemic control, and acute glycemic stent implantation or 12 months after drug-eluting stent
control—measured via fasting glucose levels—may also implantation.15
be considered.7 No evidence-based guidelines exist for antiplatelet
therapy cessation and total joint arthroplasty. Howev-
Obesity er, if the surgeon and cardiologist elect to discontinue
Obesity has been consistently identified as a risk factor clopidogrel, it is recommended that aspirin be continued
for postoperative complications after THA and TKA. if possible and clopidogrel be restarted as soon as possible
Specifically, obesity increases the risk of acute kidney after surgery. Stopping clopidogrel 7 days before sur-
failure, cardiovascular complications, and postopera- gery may decrease postoperative bleeding-related events
tive infection.8 One study’s findings demonstrated an and decrease the need for perioperative transfusion from
increase of greater than 100% in postoperative infec- 31.8% to 7.7% without increasing perioperative adverse
tion rates in a comparison of patients who had a normal cardiac events.16
Chapter 2: Perioperative Assessment and Management
Blood Transfusion or duration for VTE prophylaxis after THA and TKA (Ta-
Perioperative blood transfusion has been previously ble 2). The ACCP recommends one of the following agents:
associated with significant postoperative complications, vitamin K antagonists (such as warfarin), low-molecular–
including sepsis, VTE, readmissions, and mortality.17 Mul- weight heparins (LMWHs; such as enoxaparin), aspirin,
tiple randomized controlled trials have demonstrated the factor Xa inhibitors (such as apixaban and rivaroxaban),
capability of tranexamic acid to decrease intraoperative pentasaccharides (such as fondaparinux), direct thrombin
and postoperative blood loss, thereby minimizing post- inhibitors (such as dabigatran), and mobile portable com-
operative transfusion rates and decreasing postoperative pression devices (Table 3). ACCP guidelines recommend
complications.18 10 to 14 days of VTE prophylaxis after THA and TKA,
with a potential extension for up to 35 days.24
Renal Disease Recently, interest increased regarding the use of an-
Patients undergoing THA and TKA are at 10 to 20 times tiplatelet agents and mobile mechanical compression
greater risk of experiencing complications when already devices for VTE prophylaxis as surgeons continue to in-
receiving dialysis.19 Evidence suggests patients with end- vestigate the ideal balance between efficacy and safety.
stage renal disease receiving dialysis may have improved The ideal anticoagulation regimen for each patient needs
1: Hip and Knee

postoperative outcomes if they elect to undergo renal to be based on risk stratification, attempting to mini-
transplantation before undergoing total joint arthroplas- mize complications caused by inadequate or excessive
ty.20 In patients undergoing THA or TKA, the compara- anticoagulation.
tive risk of transient septicemia during dialysis versus the Increased interest in aspirin as an agent of VTE
risk of immunosuppression after kidney transplantation prophylaxis was largely driven by the Pulmonary Em-
needs to be fully considered. bolism Prevention (PEP) trial. This international study
demonstrated a significant difference between aspirin and
Methicillin-Resistant Staphylococcus aureus placebo, without an increase in bleeding complications,
Methicillin-resistant Staphylococcus aureus (MRSA) with respect to the rate of VTE in patients with a hip
colonization, particularly in the nares, is thought to be a fracture treated using arthroplasty.28 However, no dif-
risk factor for postoperative surgical site infections. Some ferences were noted in the VTE rates between the aspirin
surgeons elect to screen patients for MRSA colonization and placebo groups in THA patients. A retrospective
and, in the setting of a positive test result, decoloniza- registry study demonstrated similar VTE complication
tion is attempted with various regimens. Both mupirocin rates when aspirin was compared with LMWH, 29 but
ointment and chlorhexidine wipes have demonstrated mortality was higher in patients receiving aspirin prophy-
efficacy in decreasing surgical site infections in some stud- laxis. In a randomized trial of extended-duration VTE
ies, 21,22 but the overall efficacy of these regimens has not prophylaxis efficacy, researchers noted that aspirin and
been definitively demonstrated.23 dalteparin were associated with similar rates of VTE
events.30 However, the findings of a prospective study in
which the investigators compared warfarin with aspirin
Venous Thromboembolism Prophylaxis after THA and TKA demonstrated increased rates of VTE
VTE is one the most common perioperative complications complications in patients receiving aspirin.31
after TKA and THA, and orthopaedic surgeons are high- Aspirin remains an attractive agent for VTE prophy-
ly interested in VTE prophylaxis because it can prevent laxis after THA and TKA given its oral administration,
significant postoperative complications, including death. high rate of patient compliance, and cost-effectiveness.
The American College of Chest Physicians (ACCP) first Aspirin is likely not as powerful an anticoagulant as other
established VTE prophylaxis guidelines in 1986 and have available chemoprophylaxis agents but bleeding rates
updated them approximately every 3 years. Initially, the seem to be lower. Appropriately powered randomized
orthopaedic community had significant concerns regard- trials are needed to determine its true efficacy and safety.
ing these guidelines because of an increased emphasis on Interest has also increased in mobile pneumatic com-
efficacy of a prophylaxis regimen and a limited focus on pression devices for VTE prophylaxis following THA
bleeding. However, the most recent guidelines, published and TKA because of shorter hospital lengths of stay. The
in 2012, recommended a variety of new regimens, in- findings of studies from 2010 and 2014 in which investi-
cluding aspirin and portable mechanical compression24-27 gators compared current pharmacologic protocols with
(Table 2). the use of a mobile compression device suggested similar
The American Academy of Orthopaedic Surgeons efficacy between the two modalities.32,33 However, in
(AAOS) guidelines26 do not recommend a specific regimen these studies, 60% of patients using mobile compression
Table 2
Prevention of Venous Thromboembolic Disease after THA and TKA: Select Guidelines
Grade of
American College of Chest Physicians Recommendations Recommendation
In patients undergoing THA or TKA, one of the following agents should be used for a minimum of
10 to 14 days rather than no venothrombotic prophylaxis:
LMWH 1B
Fondaparinux 1B
Apixaban 1B
Dabigatran 1B
Rivaroxaban 1B
Low-dose unfractionated heparin 1B
Adjusted-dose vitamin K antagonist 1B
1: Hip and Knee
Aspirin 1B
IPCD 1C
In patients undergoing THA or TKA, regardless of the use of an IPCD or length of treatment,
LMWH should be used in preference to other alternative agents:
Fondaparinux 2B
Apixaban 2B
Dabigatran 2B
Rivaroxaban 2B
Low-dose unfractionated heparin 2B
Adjusted-dose vitamin K antagonist 2C
Aspirin 2C
For patients undergoing THA or TKA, thromboprophylaxis should be extended in the outpatient 2B
period for up to 35 days following surgery rather than for only 10 to 14 days.
In patients undergoing THA or TKA, dual prophylaxis with an antithrombotic agent and an IPCD 2C
during the hospital stay is recommended.
Strength of
American Academy of Orthopaedic Surgeons Recommendations Recommendation
The workgroup suggests the use of pharmacologic agents, mechanical compressive devices, or Moderate
both for the prevention of venous thromboembolism in patients undergoing elective THA
or TKA who are not at elevated risk beyond that of the surgery itself of experiencing venous
thromboembolism or bleeding.
The workgroup cannot recommend for or against a specific prophylactic regimen in these patients, Consensus
as current evidence is unclear about which strategy or strategies is or are optimal or suboptimal.
In the absence of reliable evidence regarding the duration of prophylactic strategies, it is the Consensus
opinion of the panel that patients and physicians should discuss the duration of prophylaxis.
In the absence of reliable evidence, it is the opinion of the panel that patients should undergo Consensus
early mobilization following elective THA or TKA.
The use of neuraxial anesthesia for patients undergoing THA or TKA is recommended to help Moderate
limit blood loss, even though evidence suggests that neuraxial anesthesia does not affect the
occurrence of venous thromboembolic disease.
ICPD = intermittent pneumatic compression device, LMWH = low-molecular–weight heparin, THA = total hip arthroplasty, TKA = total knee
arthroplasty.
Data from Falck-Ytter Y, Francis CW, Johanson NA, et al: Prevention of VTE in orthopaedic surgery patients: Antithrombotic Therapy and
Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(2
suppl):e278S-e325S; Lieberman JR, Pensak MJ: Prevention of venous thromboembolic disease after total hip and knee arthroplasty. J Bone Joint
Surg Am 2013;95(19):1801-1811; Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty. 2011;
available at http://www.aaos.org/research/guidelines/VTE/VTE_guideline.asp; Lieberman JR: The new AAOS clinical practice guidelines on
venous thromboembolic prophylaxis: How to adapt them to your practice. J Am Acad Orthop Surg 2011;19(12):717-721.
Table 3 more favorable recovery profiles associated with general

anesthesia than with regional anesthesia.38,39 However,
Common Venous Thromboembolism these prospective studies assessed primarily postoperative
Prophylaxis Dosing Regimens pain, nausea, and length of stay.38,39 Authors of a system-
Pharmacologic Common Dosing or atic review comparing both anesthetic types in THA and
Agent Therapeutic Level TKA patients concluded there is limited evidence suggest-
ing a potential benefit of neuraxial anesthesia with respect
Warfarin International normalized ratio, 2.0
to perioperative outcomes.40 However, these studies did
Enoxaparin 30 mg subcutaneously two times
not assess the combination of regional anesthesia with
per day
or 40 mg subcutaneously per day
the use of preemptive analgesia, regional blocks, or both
in TKA that are currently in use.
Apixaban 2.5 mg orally two times per day
Rivaroxaban 10 mg orally per day
Fondaparinux 2.5 mg subcutaneously per day Pain Management
Dabigatran 150 mg orally two times per day The primary goal of postoperative pain management is
1: Hip and Knee

Aspirin 325 mg orally one or two times per to reduce pain, thereby improving early postoperative
day mobilization, patient-perceived outcomes, and length of
inpatient hospital stay. These regimens use both phar-
macologic and nonpharmacologic interventions that tar-
also took aspirin.33 The aforementioned results led to get several different regions of the pain pathway, thus
the ACCP’s recommending (grade IC) mobile pneumatic decreasing the total required dose of each drug. Many
compression devices as a stand-alone measure for VTE of these regimens involve the use of medications with
prophylaxis after THA and TKA only if worn for at different durations of action and are administered on a
least 18 hours per day.24 Appropriately powered trials are scheduled basis.
needed to define the true efficacy of mobile compression,
and concerns related to the cost of these devices also exist. Oral Medications
As multimodal pain management regimens have evolved,
increased focus has been placed on decreasing postopera-
Anesthesia Options tive opioid consumption. Many prospective randomized
THA and TKA are commonly performed under neuraxial studies assessing the efficacy of multimodal regimens have
anesthesia. Neuraxial, or regional, anesthesia has been used opioid consumption as a primary outcome. A major
hypothesized to lower postoperative complications be- reason for the continued focus on decreasing postarthro-
cause of decreased sympathetic activation and inflamma- plasty opioid intake is that opioid-related adverse effects
tion, thus decreasing the overall surgical stress response (sedation, nausea, vomiting, urinary retention) can have a
when compared with general anesthesia. However, robust negative effect on the rehabilitation process, prolong inpa-
evidence demonstrating the purported benefits of neurax- tient stays, and increase healthcare resource consumption.
ial anesthesia is lacking, and the optimal anesthetic tech- The findings of one study demonstrated that more than
nique for THA and TKA has not yet been determined. 50% of postarthroplasty complications were caused by
Several studies since 2010 have demonstrated poten- opioid-related adverse drug events.41 Although many of
tial clinical benefits of neuraxial anesthesia versus gen- these multimodal pain regimens have decreased opioid
eral anesthesia. The findings of a retrospective registry consumption during inpatient hospitalization, orthopae-
study demonstrated decreased mortality in THA patients dic surgeons still rely on opioid and nonopioid-based oral
receiving spinal versus general anesthesia;34 however, a pain medications to control postdischarge pain.
similar study did not demonstrate decreased mortality The use of oral pain medications may start before
in TKA patients.35 Several retrospective database studies surgery. The use of NSAIDs for preemptive analgesia, par-
have shown neuraxial anesthesia to be associated with ticularly selective cyclooxygenase-2 (COX-2) inhibitors,
decreased surgical time, surgical site infections, post- has demonstrated improved postoperative pain scores,
operative cardiovascular and pulmonary complications, decreased opioid consumption, and greater active range
transfusion rates, and overall length of inpatient stay after of motion (ROM) without increasing perioperative bleed-
THA and TKA.36,37 Prospective studies comparing general ing.42,43 The use of pregabalin preoperatively has also been
versus neuraxial anesthesia in patients undergoing THA shown to decrease opioid consumption, decrease overall
and TKA are sparse, but their findings have demonstrated pain scores, and improve ROM outcomes.44,45
Periarticular Injections interest in the adductor canal block has developed with
Periarticular injections (PAIs) are often a concoction of the underlying thought that isolated blockade of sensory
several medications, including local anesthetics, opioids, nerves with an adductor canal block may minimize the
NSAIDs, and corticosteroids. These mixtures are injected muscular weakness associated with femoral nerve blocks.
into the capsule and periarticular tissue during THA Findings of subsequent studies have demonstrated ad-
and TKA. Comparative studies are difficult to analyze, ductor canal blocks to result in postoperative quadriceps
given the variability of when and where these injections strength and ambulation outcomes superior to those seen
are placed and the different drugs used in these injection with femoral nerve blocks while providing similar levels
cocktails. of pain control.51,52 Some surgeons combine a PAI with
Several well-designed level I studies have compared an adductor canal block, but the efficacy of this regimen
the efficacy of PAIs with that of femoral nerve blocks needs to be determined in randomized trials. The use of
in TKA patients and have demonstrated that PAIs had a sciatic nerve block after TKA, although controversial,
equivalent analgesic outcomes.46,47 Either a peripheral is thought to help decrease posterior knee pain.53
nerve block or a PAI can be used for postoperative pain
control in these patients, but PAIs may be safer, cheaper,
Summary
1: Hip and Knee
and easier to perform.

The literature assessing the efficacy of PAIs in THA THA and TKA continue to remain some of the most suc-
is not as robust as that in the TKA population. In THA, cessful surgical procedures, resulting in high patient satis-
PAIs demonstrated improved postoperative pain control, faction. The burden of comorbidities in patients electing
decreased opioid consumption, and better early func- to undergo these procedures is likely to continue rising,
tional outcomes when compared with placebo in one and therefore preoperative optimization is of paramount
study,48 although another study failed to demonstrate a importance. Recent research has helped identify patients
similar result.49 The drugs used in the injection cocktail at risk for postoperative complications, but further re-
may influence these results. search is needed to identify the optimal strategy to best
modify these factors and their effect on outcomes. VTE
Peripheral Nerve Blocks continues to be one of the most common complications
Both single and continuous peripheral nerve blockades after THA and TKA, and recent guidelines do not specify
have demonstrated improvement in postoperative pain, a single agent or regimen for postoperative prophylaxis.
length of stay, and patient satisfaction after THA and Risk stratification is the key in selecting an appropriate
TKA. A potential disadvantage of these peripheral nerve VTE prophylaxis regimen, but the critical factors associ-
blocks is the resultant muscular weakness, which poten- ated with a pulmonary embolism need to be determined.
tially increases the risk of postoperative falls. The inte- Furthermore, appropriately powered randomized trials
gration of ultrasonography to facilitate localization of with well-defined parameters for VTE complications are
the desired nerve or plexus has enhanced the safety of needed to directly assess the efficacy of various agents.
these blockades. The choice of general versus neuraxial anesthesia remains
Common peripheral nerve blocks executed after THA important, and neuraxial anesthesia may offer clinically
include lumbar plexus blocks, psoas compartment blocks, relevant advantages, but adequately powered randomized
femoral nerve blocks, and sciatic nerve blocks. Patients trials assessing these clinical outcomes are still needed.
undergoing TKA may receive a femoral nerve, adductor Multimodal pain regimens after THA and TKA have
canal, or sciatic nerve block, or a combination thereof. resulted in decreased postoperative opioid consumption,
Continuous nerve blocks have demonstrated improved fewer postoperative complications, shorter inpatient
pain control with postoperative motion and less opioid lengths of stay, and higher patient satisfaction.
consumption versus single-injection blocks.50 Increased
This review article emphasizes the need to minimize peri-

Key Study Points
operative complications and readmissions in the setting of
increased arthroplasty prevalence. Specifically discussed
• As the burden of medical comorbidities in patients risk factors for perioperative complications include morbid
undergoing THA and TKA continues to increase, obesity, diabetes, nutritional deficiencies, tobacco use,
preoperative optimization of modifiable risk fac- thromboembolic disease, cardiovascular disease, neuro-
tors is critical in achieving excellent postoperative cognitive dysfunction, psychological or behavioral prob-
lems, physical deconditioning, and S aureus colonization.
outcomes. Level of evidence: V.
• Neuraxial versus general anesthesia potentially
limits postoperative complications after THA and 4. Boraiah S, Joo L, Inneh IA, et al: Management of modi-
TKA, but the ideal anesthetic technique needs to fiable risk factors prior to primary hip and knee arthro-
plasty: A readmission risk assessment tool. J Bone Joint
be determined.
Surg Am 2015;97(23):1921-1928. Medline DOI
• VTE prophylaxis after THA and TKA is of para-
The authors of this study developed the Readmission Risk
mount importance. The ideal prophylaxis regimen Assessment Tool (RRAT) scoring system, which demon-
and duration remain undetermined and are depen- strated a significant association with readmission. The
dent on risk stratification of each patient. A validat- most common risk factors for readmission included dia-
ed risk stratification system needs to be developed. betes (odds ratio [OR], 2.96), history of VTE disease (OR,
1: Hip and Knee

8.13), and smoking (OR, 1.66).
• Multimodal postoperative pain regimens are impor-
tant in achieving high levels of patient satisfaction, 5. Stryker LS, Abdel MP, Morrey ME, Morrow MM, Kor
and early mobilization, and in minimizing opioid- DJ, Morrey BF: Elevated postoperative blood glucose
related adverse effects. Preemptive analgesia com- and preoperative hemoglobin A1c are associated with
increased wound complications following total joint ar-
bined with periarticular injections are becoming
throplasty. J Bone Joint Surg Am 2013;95(9):808-814,
increasingly popular and may be used in addition S1-S2. Medline DOI
to or in lieu of peripheral nerve blocks.
The authors of this study identified patients with elevated
preoperative hemoglobin A1 c (HbA1c) and postoperative
blood glucose levels who also had postoperative wound
Annotated References complications. The OR was 3.75 for developing a wound
complication in patients with postoperative mean glucose
values greater than 200 mg/dL, and the OR was 9.0 in pa-
1. Gonzalez Della Valle A, Chiu YL, Ma Y, Mazumdar
tients with preoperative HbA1c values greater than 6.7%.
M, Memtsoudis SG: The metabolic syndrome in pa-
Level of evidence: III.
tients undergoing knee and hip arthroplasty: Trends and
in-hospital outcomes in the United States. J Arthroplasty
2012;27(10):1743-1749.e1. Medline DOI 6. Giori NJ, Ellerbe LS, Bowe T, Gupta S, Harris AH: Many
diabetic total joint arthroplasty candidates are unable to
The authors of this database study evaluated the effect of achieve a preoperative hemoglobin A1c goal of 7% or less.
metabolic syndrome on perioperative outcomes in patients J Bone Joint Surg Am 2014;96(6):500-504. Medline DOI
undergoing TKA or THA. The prevalence of metabolic
syndrome from 2000 to 2008 progressively increased and The authors of this study identified patients with preopera-
was a risk factor for major perioperative complications. tive hemoglobin A1c (HbA1c) levels greater than 7%. Of the
Level of evidence: III. patients identified, 60% were able to achieve HbA1c levels
less than 7% after a mean 232 days. Typically, patients
with higher HbA1c values were less likely to achieve levels
2. Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR: To-
less than 7%. Certain patients may not be able to achieve
tal knee arthroplasty volume, utilization, and outcomes
HbA1c levels below 7% and perhaps surgery should not be
among Medicare beneficiaries, 1991-2010. JAMA
delayed in these patients. Level of evidence: IV.
2012;308(12):1227-1236. Medline DOI
The authors of this study identified patients who under- 7. Hwang JS, Kim SJ, Bamne AB, Na YG, Kim TK: Do gly-
went TKA between 1991 and 2010 by using Medicare data cemic markers predict occurrence of complications after
files. Significant findings included an increase of 162% in total knee arthroplasty in patients with diabetes? Clin Or-
primary TKA volume during this period and a doubling thop Relat Res 2015;473(5):1726-1731. Medline DOI
in the number of comorbidities in this patient population.
In primary TKA, length of stay decreased from 7.9 days In this study, the authors attempted to identify a correla-
to 3.5 days, but 30-day readmission rates increased from tion between postoperative complications after TKA in
4.2% to 5.0%. Level of evidence: III. patients with diabetes and the following glycemic markers:
preoperative fasting blood glucose, postprandial glucose,
hemoglobin HbA1c, and random postoperative glucose
3. Yu S, Garvin KL, Healy WL, Pellegrini VD Jr, Iorio R:
levels. Only hemoglobin HbA1c values greater than 8 or
Preventing hospital readmissions and limiting the com-
fasting blood glucose levels greater than 200 mg/dL were
plications associated with total joint arthroplasty. J Am
associated with superficial surgical site infections. Level
Acad Orthop Surg 2015;23(11):e60-e71. Medline DOI
of evidence: III.
8. Ward DT, Metz LN, Horst PK, Kim HT, Kuo AC: Com- undergoing hip or knee arthroplasty: The role of anemia.
plications of morbid obesity in total joint arthroplasty: Transfusion 2011;51(1):82-91. Medline DOI
Risk stratification based on BMI. J Arthroplasty 2015;30
(9suppl):42-46. Medline DOI The authors of this study identified patients who died
as a result of myocardial infarction within 30 days of
The authors of this database review identified patients undergoing THA or TKA. Preoperative anemia was not
undergoing THA or TKA and stratified these patients identified as a risk factor for death or nonfatal myocardi-
according to BMI. Increasing BMI led to an increase in al infarction. The most important risk factors identified
postoperative complications (15.2% versus 17.4%). Spe- included cardiovascular and pulmonary disease. Level of
cific complications found to have increased incidence in- evidence: III.
cluded acute kidney injury (1.9% versus 3.9%), cardiac
arrest (0.2% versus 0.6%), revision surgery (2.4% versus 14. Belmont PJ Jr, Goodman GP, Kusnezov NA, et al: Postop-
3.4%), and superficial infection (0.8% versus 1.7%). Level erative myocardial infarction and cardiac arrest follow-
of evidence: III. ing primary total knee and hip arthroplasty: Rates, risk
factors, and time of occurrence. J Bone Joint Surg Am
9. Jameson SS, Mason JM, Baker PN, Elson DW, Deehan 2014;96(24):2025-2031. Medline DOI
DJ, Reed MR: The impact of body mass index on pa-
tient reported outcome measures (PROMs) and complica- The authors of this study identified all patients with cardi-
tions following primary hip arthroplasty. J Arthroplasty ac complications within 30 days of THA or TKA in a na-
tional data set. The cardiac complication rate was 0.33%.
1: Hip and Knee
2014;29(10):1889-1898. Medline DOI

The most significant risk factors for cardiac complications
The authors of this registry review identified patients un- for the individual TKA and THA groups included age
dergoing THA. All patients, irrespective of BMI, demon- older than 80 years (OR, 28.0 and 3.7), hypertension
strated large improvements in postoperative outcomes, but requiring medication (OR, 4.7 and 2.6), and a history of
patients with increasing BMI demonstrated marginally cardiac disease (OR, 4.5 and 2.8). The average cardiac
smaller improvement and higher rates of bleeding compli- complication occurred within 7 days of the index proce-
cations (3.7% versus 4.4%), wound complications (7.2% dure. Level of evidence: III.
versus 15.0%), revision surgery (1.6% versus 4.4%) and
readmission (6.2 versus 11.2%). Level of evidence: III. 15. Fleisher LA, Fleischmann KE, Auerbach AD, et al:
2014 ACC/AHA guideline on perioperative cardiovascu-
10. Inacio MC, Kritz-Silverstein D, Raman R, et al: The im- lar evaluation and management of patients undergoing
pact of pre-operative weight loss on incidence of surgi- noncardiac surgery: executive summary: a report of the
cal site infection and readmission rates after total joint American College of Cardiology/American Heart Asso-
arthroplasty. J Arthroplasty 2014;29(3):458-464.e1. ciation Task Force on Practice Guidelines. Circulation
Medline DOI 2014;130(24):2215-2245. Medline DOI
The authors of this database study identified patients This is an executive summary of the American College of
undergoing THA or TKA. They calculated changes in Cardiology and American Heart Association 2014 guide-
patients’ preoperative weight and stratified patients ac- lines on perioperative cardiovascular management for
cording to weight loss (>5% weight loss, no change, and patients undergoing noncardiac surgery. The guidelines
>5% weight gain): 80% of patients maintained the same recommend not performing elective surgery in patients in
weight. The risk of surgical site infection and readmission whom dual antiplatelet therapy will need to be discontin-
was not significantly different among the three groups. ued within 30 days after bare-metal stent implantation and
Level of evidence: III. 12 months after drug-eluting stent implantation.
11. Duchman KR, Gao Y, Pugely AJ, Martin CT, Noiseux NO, 16. Jacob AK, Hurley SP, Loughran SM, Wetsch TM, Trous-
Callaghan JJ: The effect of smoking on short-term compli- dale RT: Continuing clopidogrel during elective total hip
cations following total hip and knee arthroplasty. J Bone and knee arthroplasty: Assessment of bleeding risk and
Joint Surg Am 2015;97(13):1049-1058. Medline DOI adverse outcomes. J Arthroplasty 2014;29(2):325-328.
Medline DOI
The authors identified patients who underwent THA and
TKA according to smoking status. Current smokers had a The authors of this registry study identified patients under-
higher rate of wound complications compared with non- going THA or TKA and analyzed the relationship between
smokers (1.8% versus 1.1%). Former smokers had a higher perioperative use or discontinuation of clopidogrel and
rate of total complications compared with current smokers intraoperative blood loss and postoperative complications.
(6.9% versus 5.9%). Increased pack-years of smoking his- Patients who continued clopidogrel were more likely to
tory resulted in increased total complication risk. Level receive a transfusion within 24 hours after surgery (31.8%
of evidence: III. versus 7.7%). The incidence of adverse cardiac effects
within 30 days was not different between the two groups.
12. Møller AM, Pedersen T, Villebro N, Munksgaard A: Effect Level of evidence: III.
of smoking on early complications after elective ortho-
paedic surgery. J Bone Joint Surg Br 2003;85(2):178-181. 17. Browne JA, Adib F, Brown TE, Novicoff WM: Transfu-
Medline DOI sion rates are increasing following total hip arthroplasty:
Risk factors and outcomes. J Arthroplasty 2013;28(8sup-
13. Mantilla CB, Wass CT, Goodrich KA, et al: Risk for peri- pl):34-37. Medline DOI
operative myocardial infarction and mortality in patients
The authors of this database study assessed transfusion knee arthroplasty. Patients with a positive preoperative
trends in patients undergoing THA. From 2005 to 2008, nares screen for MRSA or methicillin-susceptible S aureus
transfusion rates increased from 18% to 21%. The most were instructed to apply mupirocin intranasally twice
significant predictors of need for transfusion were age daily and bathe daily in chlorhexidine gluconate for up to
older than 85 years (OR, 2.9) and a high Charlson Co- 5 days before surgery. Compared with the preintervention
morbidity Index score (OR, 2.2). Patients receiving trans- period, the rate ratio for complex surgical site infections
fusions had increased in-hospital mortality rates, longer in the postintervention period was 0.48 for hip and knee
hospital lengths of stay, and higher total charges. Level arthroplasty. Level of evidence: III.
of evidence: III.
22. Kapadia BH, Johnson AJ, Daley JA, Issa K, Mont MA:
18. Aguilera X, Martinez-Zapata MJ, Bosch A, et al: Efficacy Pre-admission cutaneous chlorhexidine preparation re-
and safety of fibrin glue and tranexamic acid to prevent duces surgical site infections in total hip arthroplasty.
postoperative blood loss in total knee arthroplasty: A J Arthroplasty 2013;28(3):490-493. Medline DOI
randomized controlled clinical trial. J Bone Joint Surg
Am 2013;95(22):2001-2007. Medline DOI Investigators identified patients who participated in a 2%
chlorhexidine gluconate surgical preparation protocol
The authors assessed the efficacy of fibrin glue and with two applications (the night before and the morning
tranexamic acid in decreasing total blood loss and need for of surgery). A lower incidence of deep incisional and peri-
blood transfusions postoperatively. They divided patients prosthetic infections occurred in the chlorhexidine group
into four treatment groups (1, fibrin; 2, fibrinogen and (0.5% versus 1.7%). Level of evidence: III.
1: Hip and Knee

thrombin; 3, intravenous tranexamic acid; 4, no treatment
[control]). The tranexamic acid group had significantly
lower blood loss compared with the control group and 23. Baratz MD, Hallmark R, Odum SM, Springer BD: Twenty
had the lowest blood transfusion rate. Level of evidence: I. percent of patients may remain colonized with methicil-
lin-resistant Staphylococcus aureus despite a decoloniza-
tion protocol in patients undergoing elective total joint
19. Ponnusamy KE, Jain A, Thakkar SC, Sterling RS, Sko- arthroplasty. Clin Orthop Relat Res 2015;473(7):2283-
lasky RL, Khanuja HS: Inpatient mortality and morbid- 2290. Medline DOI
ity for dialysis-dependent patients undergoing primary
total hip or knee arthroplasty. J Bone Joint Surg Am Researchers identified patients who had positive results
2015;97(16):1326-1332. Medline DOI for MRSA or methicillin-sensitive S aureus after nares
screening. These patients were treated with intranasal
The authors of this study identified dialysis-dependent
mupirocin ointment twice daily and daily skin cleansing
patients who underwent THA or TKA and compared them
with 4% chlorhexidine soap for 5 days before surgery.
with not receiving dialysis. Dialysis-dependent patients
had higher inpatient mortality rates after THA (1.9% ver- Patients’ nares were rescreened on the day of surgery for
sus 0.13%) and overall complication rates (10.0% versus methicillin-sensitive S aureus or MRSA: 22% of patients
5.0%); dialysis-dependent patients also had higher inpa- remained colonized after the protocol. The test group
tient mortality rates after TKA (0.92% versus 0.10%) and demonstrated no difference in infection risk compared
overall complications rates (12.5% versus 1.9%). Level of with the control group. Level of evidence: III.
evidence: III.
24. Falck-Ytter Y, Francis CW, Johanson NA, et al; American
20. Cavanaugh PK, Chen AF, Rasouli MR, Post ZD, Orozco College of Chest Physicians: Prevention of VTE in ortho-
FR, Ong AC: Complications and mortality in chronic re- pedic surgery patients: Antithrombotic therapy and pre-
nal failure patients undergoing total joint arthroplasty: A vention of thrombosis, 9th ed: American College of Chest
comparison between dialysis and renal transplant patients. Physicians Evidence-Based Clinical Practice Guidelines.
J Arthroplasty 2016;31(2):465-472. Medline DOI Chest 2012;141(2 suppl):e278S-e325S. Medline DOI
This database study compared patients undergoing THA This is the American College of Chest Physicians’ most
or TKA with chronic kidney disease or end-stage renal recent recommendation for VTE prophylaxis for patients
disease with patients with normal renal function. A sub- undergoing orthopaedic surgery, including total THA and
analysis compared patients with end-stage renal disease on TKA. The major changes in the ninth edition included the
dialysis to those following kidney transplantation. Patients addition of aspirin for VTE prophylaxis and an increased
receiving dialysis had higher rates of surgical site infections emphasis on safety of VTE prophylaxis (prior guidelines
(OR, 2.9), transfusion (OR, 2.3), and in-hospital mor- emphasized efficacy).
tality (OR, 6.3) compared with patients who underwent
kidney transplantation. The authors concluded that renal 25. Lieberman JR, Pensak MJ: Prevention of venous
transplantation before total joint arthroplasty should be thromboembolic disease after total hip and knee arthro-
considered. Level of evidence: III. plasty. J Bone Joint Surg Am 2013;95(19):1801-1811.
Medline DOI
21. Schweizer ML, Chiang HY, Septimus E, et al: Association
This is a review article discussing the most recent AAOS
of a bundled intervention with surgical site infections
and ACCP guidelines for VTE prophylaxis after total
among patients undergoing cardiac, hip, or knee surgery.
joint arthroplasty. The need for balancing the safety and
JAMA 2015;313(21):2162-2171. Medline DOI
efficacy of VTE prophylaxis in each individual patient was
Researchers assessed the rates of surgical site infection emphasized. Further randomized trials are still needed to
in patients undergoing cardiac procedures requiring a select the optimal prophylaxis regimen.
median sternotomy and in patients undergoing hip or
26. American Academy of Orthopaedic Surgeons: Clinical Investigators enrolled consecutive patients undergoing
Practice Guidelines on Preventing Venous Thromboem- THA or TKA into different VTE prophylaxis regimens.
bolic Disease in Patients Undergoing Elective Hip and Group 1 received VTE risk stratification based on AAOS
Knee Arthroplasty. Rosemont, IL, American Academy guidelines and received either aspirin 325 mg twice dai-
of Orthopaedic Surgeons, 2011. Available at: http://www. ly (standard risk) or warfarin with a goal international
aaos.org/research/guidelines/VTE/VTE_guideline.asp normalized ratio of 1.8 to 2.5 (elevated risk). Group 2, a
comparator group, received warfarin with a goal interna-
This is the most recent AAOS clinical practice guideline tional normalized ratio of 2.5 based on ACCP guidelines.
for VTE prophylaxis after THA and TKA. The AAOS The rate of VTE complications in patients receiving aspirin
guideline panel was unable to make a specific recommen- was significantly higher than the comparator group (7.9%
dation regarding type and duration of VTE prophylaxis. versus 1.2%) and most of these events occurred in patients
receiving TKA. Level of evidence: II.
27. Lieberman JR: The new AAOS clinical practice guide-
lines on venous thromboembolic prophylaxis: How to 32. Colwell CW Jr, Froimson MI, Anseth SD, et al: A mo-
adapt them to your practice. J Am Acad Orthop Surg bile compression device for thrombosis prevention in hip
2011;19(12):717-721. Medline DOI and knee arthroplasty. J Bone Joint Surg Am 2014;96(3):
This commentary reviews the 2011 AAOS VTE prophy- 177-183. Medline DOI
laxis guideline for THA and TKA. The author commends The authors of this study analyzed patients who underwent
the AAOS workgroup for focusing on the importance
1: Hip and Knee
hip or knee arthroplasty and received mobile compression

of symptomatic VTE events and bleeding complications VTE prophylaxis with or without the use of aspirin. The
when selecting a prophylaxis regimen. However, no specif- VTE rate was 0.92%, the therapy was considered noninfe-
ic regimen or duration of prophylaxis was recommended. rior to warfarin, enoxaparin, rivaroxaban, and dabigatran
therapy. Level of evidence: II.
28. Pulmonary Embolism Prevention (PEP) trial Collabo-
rative Group: Prevention of pulmonary embolism and 33. Colwell CW Jr, Froimson MI, Mont MA, et al: Thrombo-
deep vein thrombosis with low dose aspirin: Pulmonary sis prevention after total hip arthroplasty: A prospective,
Embolism Prevention (PEP) trial. Lancet 2000;355(9212): randomized trial comparing a mobile compression device
1295-1302. Medline DOI with low-molecular-weight heparin. J Bone Joint Surg Am
2010;92(3):527-535. Medline DOI
29. Jameson SS, Charman SC, Gregg PJ, Reed MR, van
der Meulen JH: The effect of aspirin and low-molecu- Investigators randomly assigned patients undergoing THA
lar-weight heparin on venous thromboembolism after to receive VTE prophylaxis with a mobile compression
hip replacement: A non-randomised comparison from device or low-molecular–weight heparin. There was no
information in the National Joint Registry. J Bone Joint significant difference between the two groups with regard
Surg Br 2011;93(11):1465-1470. Medline DOI to the prevalence of postoperative VTE complications;
however, aspirin was given in 63% of patients receiving
The authors identified patients undergoing THA and then mobile compression devices. Level of evidence: II.
compared patients receiving LMWH with those receiving
aspirin for VTE prophylaxis. No significant differences 34. Hunt LP, Ben-Shlomo Y, Clark EM, et al; National
were reported between aspirin and LMWH in rates of Joint Registry for England, Wales and Northern Ireland:
pulmonary embolism (0.68% versus 0.64%) or deep vei- 90-day mortality after 409,096 total hip replacements
nous thrombosis (0.99% versus 0.84%). Mortality was for osteoarthritis, from the National Joint Registry for
significantly higher in the aspirin group (0.65% versus England and Wales: A retrospective analysis. Lancet
0.51%). Level of evidence: III. 2013;382(9898):1097-1104. Medline DOI
30. Anderson DR, Dunbar MJ, Bohm ER, et al: Aspirin versus The authors of this study assessed mortality within 90 days
low-molecular-weight heparin for extended venous throm- after THA: the rate decreased from 0.56% to 0.29% from
boembolism prophylaxis after total hip arthroplasty: A 2003 to 2011. Factors decreasing the mortality risk includ-
randomized trial. Ann Intern Med 2013;158(11):800-806. ed a posterior surgical approach and spinal versus general
Medline DOI anesthesia. Level of evidence: III.
Patients in this study initially received dalteparin for 35. Hunt LP, Ben-Shlomo Y, Clark EM, et al; National Joint
10 days of VTE prophylaxis after THA, and then were Registry for England and Wales: 45-day mortality af-
randomly assigned to receive either 28 days of addition- ter 467,779 knee replacements for osteoarthritis from
al dalteparin or aspirin. No significant difference was the National Joint Registry for England and Wales: An
reported in postoperative VTE events between the two observational study. Lancet 2014;384(9952):1429-1436.
groups, and patients receiving dalteparin had more sig- Medline DOI
nificant bleeding events. Level of evidence: I.
The authors of this study assessed mortality within 45 days
31. Intermountain Joint Replacement Center Writing Com- after knee arthroplasty: the rate decreased from 0.37%
mittee: A prospective comparison of warfarin to aspirin to 0.20% from 2003 to 2011. Factors associated with
for thromboprophylaxis in total hip and total knee arthro- increased mortality included myocardial infarction, cere-
plasty. J Arthroplasty 2012;27(1):1-9.e2. Medline DOI brovascular disease, and liver disease. The type of anes-
thesia (spinal versus general) did not affect the mortality
rate. Level of evidence: III.
36. Helwani MA, Avidan MS, Ben Abdallah A, et al: Effects This systematic review included prospective studies com-
of regional versus general anesthesia on outcomes after paring regional versus general anesthesia in patients un-
total hip arthroplasty: A retrospective propensity-matched dergoing hip or knee arthroplasty. In the final analysis of
cohort study. J Bone Joint Surg Am 2015;97(3):186-193. 29 studies involving 10,488 patients, no differences were
Medline DOI reported in mortality, postoperative infection, nausea,
vomiting, or VTE complications between regional and
Researchers assessed patients who underwent THA and general anesthesia. Level of evidence: II.
then stratified them according to type of anesthesia re-
ceived. After propensity score matching, regional anes-
thesia was associated with a reduction in deep surgical 41. Halawi MJ, Vovos TJ, Green CL, Wellman SS, Attari-
site infection, length of stay, cardiovascular complications, an DE, Bolognesi MP: Opioid-based analgesia: Impact
and respiratory complications in comparison to general on total joint arthroplasty. J Arthroplasty 2015;30(12):
anesthesia; no difference in mortality was reported. Level 2360-2363. Medline DOI
of evidence: III. The authors of this study assessed inpatient complications
after THA or TKA in 575 patients: 98 patients had compli-
37. Pugely AJ, Martin CT, Gao Y, Mendoza-Lattes S, Cal- cations, 57 (58%) of which were caused by opioid use. The
laghan JJ: Differences in short-term complications be- most common opioid-related complications were urinary
tween spinal and general anesthesia for primary total knee retention, nausea, and delirium. The overall opioid-related
arthroplasty. J Bone Joint Surg Am 2013;95(3):193-199. complication rate was 8.5%. Level of evidence: III.
1: Hip and Knee

Medline DOI
The authors of this study evaluated patients who under- 42. Lin J, Zhang L, Yang H: Perioperative administration of
went primary TKA and assessed 30-day complications in selective cyclooxygenase-2 inhibitors for postoperative
patients receiving spinal versus general anesthesia. The pain management in patients after total knee arthroplasty.
spinal anesthesia group had lower superficial wound in- J Arthroplasty 2013;28(2):207-213.e2. Medline DOI
fections (0.68% versus 0.92%), blood transfusions (5.02% This systematic review of randomized trials evaluating
versus 6.07%), and overall complications (10.7% versus the use of selective COX-2 inhibitors for postoperative
12.3%). Mortality rates were similar between the two pain control after TKA included eight studies and 571 pa-
groups. Level of evidence: III. tients. The results demonstrated decreased postoperative
pain, less opioid consumption, and increased postopera-
38. Harsten A, Kehlet H, Ljung P, Toksvig-Larsen S: Total in- tive active knee ROM in patients receiving perioperative
travenous general anaesthesia vs. spinal anaesthesia for to- COX-2 inhibitors. No increased blood loss was associ-
tal hip arthroplasty: A randomised, controlled trial. Acta ated with the use of selective COX-2 inhibitors. Level of
Anaesthesiol Scand 2015;59(3):298-309. Medline DOI evidence: II.
Patients undergoing THA were randomly assigned to
receive either spinal or general anesthesia. General anes- 43. Schroer WC, Diesfeld PJ, LeMarr AR, Reedy ME: Benefits
thesia resulted in shorter lengths of stay and less nausea. of prolonged postoperative cyclooxygenase-2 inhibitor
Patients in the regional anesthesia group had lower pain administration on total knee arthroplasty recovery: A
scores during the first 2 hours postoperatively, but higher double-blind, placebo-controlled study. J Arthroplasty
pain scores after 6 hours postoperatively. Patients who 2011;26(6suppl):2-7. Medline DOI
received general anesthesia were more satisfied and re- The authors enrolled 107 patients who underwent TKA.
ported they would request a change in anesthesia type All patients received celecoxib preoperatively and during
less frequently. Level of evidence: I. hospitalization. At the time of discharge, patients were
randomly assigned to continue celecoxib for 6 weeks or
39. Harsten A, Kehlet H, Toksvig-Larsen S: Recovery after receive a placebo for the same duration. The treatment
total intravenous general anaesthesia or spinal anaesthesia group had better pain scores, less narcotic use, better
for total knee arthroplasty: A randomized trial. Br J An- ROM, and better functional scores. Level of evidence: I.
aesth 2013;111(3):391-399. Medline DOI
Patients undergoing TKA were randomly assigned to re- 44. Lee JK, Chung KS, Choi CH: The effect of a single dose
ceive either spinal or general anesthesia. General anes- of preemptive pregabalin administered with COX-2 in-
thesia resulted in shorter hospital length of stay and less hibitor: A trial in total knee arthroplasty. J Arthroplasty
nausea and vomiting. Regional anesthesia resulted in 2015;30(1):38-42. Medline DOI
lower pain scores during the first 2 hours postoperative- Researchers compared patients undergoing TKA who
ly, but higher pain scores after 6 hours postoperatively. received preoperative pregabalin along with a COX-2 in-
Patients who received general anesthetic used less postop- hibitor with patients who received only a COX-2 inhib-
erative morphine and ambulated earlier, and were more itor. Pregabalin administration resulted in lower acute
satisfied with their anesthetic and reported they would pain scores and less analgesic consumption. Functional
request a change in anesthetic type less frequently. Level outcomes were similar between the two groups. Level of
of evidence: I. evidence: I.
40. Johnson RL, Kopp SL, Burkle CM, et al: Neuraxial vs gen- 45. Buvanendran A, Kroin JS, Della Valle CJ, Kari M,
eral anaesthesia for total hip and total knee arthroplasty: Moric M, Tuman KJ: Perioperative oral pregabalin re-
A systematic review of comparative-effectiveness research. duces chronic pain after total knee arthroplasty: A
Br J Anaesth 2016;116(2):163-176. Medline DOI
prospective, randomized, controlled trial. Anesth Analg demonstrated no difference in opioid consumption, mean
2010;110(1):199-207. Medline DOI time for stair activities, early mobilization, or length of
stay. Level of evidence: I.
Investigators compared a treatment group receiving prega-
balin administered before TKA and for 14 days postoper-
atively with a control group. Patients receiving pregabalin 50. Chan EY, Fransen M, Sathappan S, Chua NH, Chan
had less neuropathic pain, less opioid consumption, and YH, Chua N: Comparing the analgesia effects of sin-
greater knee ROM over the first 30 days postoperatively. gle-injection and continuous femoral nerve blocks with
However, sedation and confusion were more common on patient controlled analgesia after total knee arthroplasty.
the day of and the day after surgery in patients receiving J Arthroplasty 2013;28(4):608-613. Medline DOI
pregabalin. Level of evidence: I. In this study, 200 patients undergoing TKA were ran-
domly assigned to receive one of three postoperative pain
46. Spangehl MJ, Clarke HD, Hentz JG, Misra L, Blocher JL, control interventions: (1) patient-controlled analgesia, (2)
Seamans DP: The Chitranjan Ranawat Award: Periarticu- single-injection femoral nerve block, or (3) continuous
lar injections and femoral & sciatic blocks provide similar femoral nerve block. Femoral nerve block, both single-in-
pain relief after TKA: a randomized clinical trial. Clin jection and continuous, resulted in less pain with knee
Orthop Relat Res 2015;473(1):45-53. Medline DOI motion, less opioid consumption, and fewer episodes of
nausea and vomiting compared with patient-controlled
This randomized trial involved comparison of femoral and
anesthesia. Continuous nerve blocks were superior to sin-
sciatic nerve blocks with PAIs in patients receiving a mul-
1: Hip and Knee
gle-injection nerve blocks. Level of evidence: I.

timodal pain regimen after TKA. Patients received either
an indwelling femoral nerve block and single-shot sciatic
block or a periarticular injection consisting of ropiva- 51. Shah NA, Jain NP: Is continuous adductor canal block
caine, epinephrine, ketorolac, and morphine. Mean pain better than continuous femoral nerve block after total
scores and morphine consumption were similar between knee arthroplasty? Effect on ambulation ability, early
the two groups on postoperative day 1. More patients in functional recovery and pain control: A randomized
the nerve block group had signs of nerve injury (12%) at controlled trial. J Arthroplasty 2014;29(11):2224-2229.
6-week follow-up. Level of evidence: I. Medline DOI
In this study, patients undergoing TKA were allocated
47. Ng FY, Ng JK, Chiu KY, Yan CH, Chan CW: Multimodal to receive either a continuous adductor canal block or a
periarticular injection vs continuous femoral nerve block continuous femoral nerve block. Ambulatory outcomes
after total knee arthroplasty: A prospective, crossover, such as staircase competency and ambulation distance
randomized clinical trial. J Arthroplasty 2012;27(6): were superior in the adductor canal block group, and pain
1234-1238. Medline DOI control outcomes were similar between the two groups.
This randomized crossover clinical trial involved 16 pa- Level of evidence: I.
tients with bilateral knee osteoarthritis who underwent
staged bilateral TKA. Patients were randomized to either 52. Kim DH, Lin Y, Goytizolo EA, et al: Adductor canal block
receive a PAI consisting of ropivacaine, adrenaline, and tri- versus femoral nerve block for total knee arthroplasty: A
amcinolone or an indwelling femoral nerve block. During prospective, randomized, controlled trial. Anesthesiology
the second stage of the bilateral TKA, the patients received 2014;120(3):540-550. Medline DOI
the opposite treatment. Pain and functional outcomes
Investigators compared adductor canal versus femoral
were similar between the two groups. Level of evidence: I.
peripheral nerve blocks in 93 patients undergoing TKA. In
the early postoperative period (6 to 8 hours), the adductor
48. Liu W, Cong R, Li X, Wu Y, Wu H: Reduced opioid con- canal group demonstrated greater quadriceps strength.
sumption and improved early rehabilitation with local Quadriceps strength at hours 24 and 48 after surgery,
and intraarticular cocktail analgesic injection in total hip as well as opioid consumption and overall pain control
arthroplasty: A randomized controlled clinical trial. Pain at all time points, were similar between the two groups.
Med 2011;12(3):387-393. Medline DOI Level of evidence: I.
Investigators enrolled patients undergoing THA in a study
of a PAI consisting of morphine, bupivacaine, betameth- 53. Abdallah FW, Brull R: Is sciatic nerve block advantageous
asone, and epinephrine that was compared with placebo when combined with femoral nerve block for postoperative
treatment. The treatment group demonstrated improved analgesia following total knee arthroplasty? A system-
pain control, less opioid consumption, and earlier mobi- atic review. Reg Anesth Pain Med 2011;36(5):493-498.
lization. Level of evidence: I. Medline DOI
In this systematic review, researchers assessed the efficacy
49. Dobie I, Bennett D, Spence DJ, Murray JM, Beverland of adding a sciatic nerve block to a femoral nerve block in
DE: Periarticular local anesthesia does not improve patients undergoing TKA. Seven studies involving 391 pa-
pain or mobility after THA. Clin Orthop Relat Res tients were incorporated in the final analysis. The review
2012;470(7):1958-1965. Medline DOI demonstrated no clinically important analgesic advantages
This study involved 96 patients undergoing THA to re- of a sciatic nerve block beyond 24 hours postoperatively.
ceive either placebo or a periarticular injection consisting However, only two studies assessed posterior knee pain.
of levobupivacaine and adrenaline. Postoperative results Level of evidence: II.
Chapter 3
Blood Management
Yatin Kirane, MD, PhD Fred D. Cushner, MD
Abstract Keywords: blood conservation has been

suggested; total hip arthroplasty; total knee
Total hip arthroplasty and total knee arthroplasty are arthroplasty
associated with significant perioperative blood loss,
resulting in postsurgical anemia that in turn can ne-
cessitate blood transfusions. Perioperative blood loss Introduction
1: Hip and Knee

can also result in significant surgical site hemarthrosis, Total hip arthroplasty (THA) and total knee arthroplasty
which may lead to wound complications, increased (TKA) are two of the most commonly performed ortho-
risk of development of infection, and delayed recovery. paedic procedures in the United States and around the
Allogeneic blood transfusions have been associated world. It has been estimated that more than 500,000 THA
with serious complications, such as incorrect blood and more than 1 million TKA procedures (primary and
component transfusion, disease transmission, allergic revision procedures combined) will be performed in the
reactions, fluid overload, transfusion reactions, and United States alone in 2020.1 Historically, these proce-
immunosuppression. Overall, perioperative anemia and dures have been associated with substantial perioperative
blood transfusions are associated with greater morbidity
blood loss. In addition to the visible blood loss, a sub-
and mortality, longer hospital stay, and significantly
stantial amount of “hidden” blood loss is associated with
higher hospital costs. Therefore, in this current climate
these procedures as a result of extravasation into the
of bundled payments, minimizing surgical blood loss and
tissues, residual blood accumulation into the joint, and
preventing postoperative anemia are critical to achiev-
blood loss attributable to hemolysis. The average total
ing successful clinical outcomes and reducing hospital
blood loss has been reported to be approximately 1.5 L
costs. Numerous interventions have been suggested to
with both THA and TKA procedures; more hidden blood
minimize perioperative blood loss; however, orthopaedic
loss is associated with TKA (49% of total blood loss) than
surgeons lack consensus on the topic, and allogeneic
THA (26% of total blood loss).2
transfusion rates still remain high at some institutions.
Revision and bilateral arthroplasty procedures are
An evidence-based multimodal individualized approach
associated with even greater blood loss. Anemia has been
for blood conservation has been suggested.
associated with higher rates of postoperative cardiovas-
cular, genitourinary, and other complications, as well as
mortality following total joint arthroplasty (TJA).3 Hem-
Dr. Cushner or an immediate family member has received orrhage within the joint and periarticular tissues may re-
royalties from Smith & Nephew; is a member of a speakers’ sult in hematoma formation, leading not only to drainage
bureau or has made paid presentations on behalf of Center from the incision site but also delayed wound healing,
for Healthcare Education, San Diego, CA, Pacira Pharma- wound dehiscence, and hence an increased risk of devel-
ceuticals, and Smith & Nephew; serves as a paid consultant oping infection. Excessive hematoma also contributes to
to Pacira Pharmaceuticals and Smith and Nephew; has pain, swelling, decreased range of motion (ROM), pro-
stock or stock options held in Aperion Biologic and Alter G; longed rehabilitation, and a longer hospital stay. Anemia
has received research or institutional support from Pacira may further contribute to prolonged recovery by causing
Pharmaceuticals; and serves as a board member, owner, fatigue and inability to adequately participate in physical
officer, or committee member of the Knee Society. Neither therapy. Furthermore, anemia may cause greater adverse
Dr. Kirane nor any immediate family member has received effects in the presence of other coexisting medical con-
anything of value from or has stock or stock options held ditions among elderly patients, a situation that is quite
in a commercial company or institution related directly or common in the joint arthroplasty patient population.
indirectly to the subject of this chapter. Approximately 25% of patients undergoing an elective
THA or TKA have been reported to have anemia before hemoglobin level and medical comorbidities, the com-
surgery, whereas the prevalence of postoperative anemia plexity of the planned procedure, the anticipated blood
has been reported to be approximately 51%.4 Periop- loss, and the need for transfusion.
erative blood loss may result in acute anemia, delayed
recovery, and increased mortality risk, all of which may
necessitate allogeneic blood transfusion. Blood transfu- Blood Conservation Strategies
sion rates for postoperative anemia have been reported to Preoperative Strategies: Preoperative Screening
be 37% to 53% for primary THA (51% for hip arthritis and Treatment of Anemia
and 61% following a femur neck fracture), 69% for hip Approximately 24% to 44% of patients have been re-
hemiarthroplasty, 43% to 46% for primary TKA, 72% ported to be anemic before THA or TKA surgery.4 Pre-
for bilateral TKA, 41% for revision TKA, and 72% for operative anemia has been associated with higher rates
revision THA.5 With a unit of transfused blood costing of postoperative complications and mortality following
an estimated $787.37,6 the incremental total hospital- TJA.3 Therefore, timely detection and management of
ization costs have been found to be $2,477, $4,235, and preoperative anemia, nutritional or metabolic deficiencies,
1: Hip and Knee
$8,594 higher for patients who underwent primary TKA, and other modifiable risk factors is extremely important in
bilateral TKA, and revision TKA procedures, respec- optimizing patient physiology before surgery. Preoperative
tively, and received blood transfusion as compared with assessment should include a complete workup for anemia
those who did not receive transfusion.7 Furthermore, in and nutritional status in addition to routine investigations
addition to higher costs, allogeneic blood transfusion car- and consultation with a hematologist or other appropriate
ries a risk— albeit a small risk—of serious complications specialist if deemed necessary. Authors of a 2016 study
such as incorrect blood component transfusion, disease recommended hemoglobin screening at the time of indi-
transmission, allergic reactions, fluid overload, trans- cation for arthroplasty by using a noninvasive cutaneous
fusion reactions, and immunosuppression. In contrast, pulse co-oximeter followed by complete blood count. They
reduced blood loss translates to better wound healing, recommended additional laboratory testing and referral to
quicker rehabilitation, shorter length of hospital stay, a hematologist for patients with hemoglobin levels lower
higher hemoglobin levels at discharge, fewer medical than 12.10 Specifically, the preoperative evaluation should
complications, faster recovery, and improved patient include obtaining patients’ personal and family history of
satisfaction. Predictors of marked blood loss necessi- bleeding, thromboembolic disease, current medication
tating blood transfusion include preoperative anemia, review, complete blood count with differential, and other
older age, higher body weight, multiple comorbidities, appropriate patient-specific laboratory investigations. Op-
increased surgical time, lateral retinacular release, and timization of the patient’s general health—which may
use of postoperative anticoagulation.8,9 Despite known include smoking cessation, weight loss, management of
risks, surgical anemia due to acute blood loss has been blood pressure and diabetes, prescribing vitamins, iron,
considered by many to be a routine and an acceptable and other nutritional supplements, and stopping use of
complication of major surgical procedures. The need for antiplatelet and anticoagulation medications— should be
blood management protocols to reduce the perioperative accomplished early.11 Preoperative hemoglobin levels lower
blood loss, the associated morbidity, and the allogene- than 11 g/dL, body mass index (BMI) less than 27 kg/m2 ,
ic blood transfusion rates to improve clinical outcomes age older than 75 years, and male sex all are factors that
of joint arthroplasty surgery is increasingly recognized. have been associated with an increased requirement for
Minimizing surgical blood loss and preventing postop- postoperative blood transfusion. Therefore, individual-
erative anemia are critical to achieving successful clinical ized risk stratification and a multidisciplinary approach
outcomes. Numerous interventions have been suggested have been suggested for early diagnosis and treatment of
to minimize perioperative blood loss; however, orthopae- preoperative anemia. The goal should be to optimize the
dic surgeons lack consensus on the topic, and allogeneic patient’s hemoglobin level above 12 g/dL because lower
transfusion rates remain unacceptably high. Several au- levels have been correlated with a threefold increase in
thors have suggested evidence-based multimodal blood transfusion requirement.
management protocols to minimize perioperative blood
loss and to achieve improved clinical outcomes, decreased Nonsteroidal Anti-inflammatory and
procedural costs, and shorter hospital stays. Furthermore, Anticoagulant Medications
blood conservation protocols need to be individualized by NSAIDs are widely used for perioperative analgesia. Non-
means of algorithms based on the patient’s preoperative selective NSAIDs are known to impair platelet aggregation
Chapter 3: Blood Management
and prolong bleeding time by acting on cyclo-oxygenase Table 1

(COX)-1 and -2 enzymes of the prostaglandin formation
process. However, COX-2–selective NSAIDs such as ce- Erythropoietin Dosing Schedules
lecoxib and etoricoxib are believed to reduce pain and Dose Schedule
inflammation without affecting platelet aggregation or
4 doses: Preoperative days 21,14, 7,
bleeding time. COX-2 inhibitors are often an aspect of 600 IU/kg
and 0
multimodal pain management after arthroplasty,12 and
15 daily doses: Preoperative day 10 to
they can be safely used in most patients with consideration 300 IU/kg
postoperative day 4
given to their cardiovascular and other side effects. Sev-
9 daily doses: Preoperative day 5 to
eral other allopathic and alternative herbal medications 150 IU/kg
postoperative day 3
can prolong bleeding time by affecting various levels of
Reproduced from Levine BR, Haughom B, Strong B, Hellman M, Frank
the coagulation cascade and can substantially increase RM: Blood management strategies for total knee arthroplasty. J Am
perioperative bleeding. Therefore, all medications with Acad Orthop Surg 2014;22(6):361-371.
known side effects on coagulation should be stopped

before surgery. According to the current clinical practice
1: Hip and Knee

guidelines, anticoagulant and antiplatelet medications injections have been more effective than has preoperative
such as warfarin, aspirin, clopidogrel, and rivaroxaban autologous blood donation (PAD) in maximizing preop-
should be stopped before the planned surgery to normal- erative hemoglobin in patients undergoing TKA15 and
ize bleeding time.13 However, benefits of stopping these reducing the need for allogeneic blood transfusions even
medications before surgery need to be weighed against the in high-risk patients with anemia.16 Several preoperative
patient’s cardiac risk, and the treatment needs to be indi- and postoperative dosing regimens have been described17
vidualized. To maximize patient safety, the prescribing (Table 1).
physician should weigh in regarding if and when to stop Although effective, EPO treatment is expensive: the
these medications rather than use a general rule applied average price per patient is equivalent to two to three
to all patients undergoing arthroplasty procedures. units of PAD or three to four units of allogenic blood.18 In
a 2015 efficacy/cost-analysis study, EPO treatment was
Vitamins and Iron Supplementation found to have no effect on the length of hospital stay
Patients with preoperative anemia can be treated with a and was not cost effective despite the reduced need for
healthy diet, vitamin B12 , folate, oral or intravenous (IV) postoperative blood transfusions. Nevertheless, the use of
iron, and erythropoiesis-stimulating agents. Approxi- EPO is recommended for patients at higher risk of allo-
mately 4 to 6 weeks of nutritional supplementation before genic transfusion, such as those with preoperative anemia
the planned surgery is necessary for effective treatment. (hemoglobin level less than 13 g/dL) and low body weight
Lower transfusion and infection rates have been reported (less than 50 kg) who are undergoing revision or bilateral
following TKA in patients with hemoglobin levels be- surgery for which considerable blood loss is expected.
low 8 mg after receiving daily supplementation of iron
(256 mg; 80 mg Fe2+), vitamin C (1,000 mg), and folate Autologous Blood
(5 mg) for 30 to 45 days.14 However, higher levels of iron PAD involves procuring one to two units of the patient’s
supplementation, especially when administered in the own blood before surgery. The donated autologous blood
absence of iron deficiency, have been associated with is processed, stored, and transfused back to the patient
constipation, heartburn, abdominal pain, and other side during or after surgery. PAD can be performed at least
effects. 3 weeks before the planned surgery, for anticipated major
blood loss in patients with hemoglobin greater than 11
Erythropoietin g/dL and weight greater than 110 lb.19 PAD was popular
Erythropoietin (EPO), a glycoprotein that is naturally in the United States in the late 1980s, when decreased
secreted by renal pericapillary cells in response to reduced need for allogeneic blood transfusions with the use of
tissue oxygen tension such as occurs in an anemic state, PAD was reported.20,21 However, in recent years, PAD
acts on bone marrow to increase red blood cell differ- has become less common for a variety of reasons. First,
entiation and maturation. Epoetin α, which is human patients with preoperative anemia are not candidates for
EPO produced in a laboratory by means of recombinant PAD. This severely limits the usefulness of this modality,
technology, has the same physiologic effects and is com- because patients with anemia are most likely to require
monly used for patients with chronic renal disease and allogeneic transfusion postoperatively. The procedure is
those undergoing chemotherapy. Preoperative epoetin inconvenient and expensive; it requires advance planning
as well as storage and preparation of the donated blood, during cementing. Use of a tourniquet only during ce-
and it carries a risk of clerical error. Phlebotomy-induced menting led to lower serum markers for inflammation and
anemia, bacterial contamination, and infection are addi- muscle damage, such as C-reactive protein, interleukin-6,
tional risks associated with an autologous blood donation creatine kinase, and myoglobin. However, there was no
program. In addition, it may be wasteful and unnecessary difference in the clinical outcomes in terms of Hospital for
for patients who do not have anemia.22,23 Furthermore, Special Surgery knee scores, ROM, estimated blood loss,
preoperative epoetin α treatment has been more effective swelling ratio, visual analog scale pain score, and length
than PAD in maximizing preoperative hemoglobin for pa- of hospital stay. Release of the tourniquet after wound
tients undergoing TKA.15 There is currently no consensus closure has been shown to significantly decrease surgical
regarding the efficacy/cost-benefit of PAD and, therefore, time without affecting overall perioperative blood loss, or
its routine use is not recommended. drop in hemoglobin level or transfusion requirement.27 In
a poll at the 2009 Annual Meeting of the American As-
Hemodilution sociation of Hip and Knee Surgeons regarding current
Acute normovolemic hemodilution (ANH) involves har- practice patterns in primary THA and TKA, 37% of the
vesting a patient’s whole blood along with simultaneous respondents used a tourniquet in all cases irrespective
1: Hip and Knee
infusion of acellular fluids (colloids or crystalloids) at the of any prior vascular problems, 58% of the respondents
time of or just before surgery. This is followed by peri- avoided tourniquet use if a patient has known vascular
operative reinfusion of the procured autologous blood, problems, and 5% of the respondents used a tourniquet
thereby resulting in a reduced net loss of red blood cells. only during exposure and cementation.28
This procedure has been indicated for patients who have
preoperative hemoglobin levels higher than 10 g/dL and Hypotensive Anesthesia
for whom procedures in which substantial blood loss is With the use of hypotensive epidural anesthesia, blood
anticipated are planned. Although cumbersome and time loss is reduced by maintaining a low mean arterial blood
consuming, ANH has been found to be equal to PAD pressure (typically 50 to 60 mm Hg) throughout the sur-
in effectiveness for patients undergoing THA and TKA gical procedure. This is achieved by decreasing the con-
procedures. Furthermore, ANH is less expensive and has duction of the cardioacceleratory fibers of the thoracic
a smaller risk of clerical error, bacterial contamination, sympathetic chain via an epidural dermatome block at
and blood wastage as compared with PAD.24 The utility T2 level. Hypotensive anesthesia has been shown to ef-
of hemodilution currently is limited as a result of consider- fectively reduce intraoperative blood loss by about 38%
ably reduced blood loss due to multimodal blood conser- to 45%; however, it may lead to tissue hypoperfusion,
vation protocols and newer drugs such as tranexamic acid bradycardia, and other serious cardiopulmonary com-
(TXA). Hemodilution may still be valuable in patients plications, and it should be used with extreme caution
who refuse allogeneic blood transfusion due to religious in patients with cardiopulmonary, renal, cerebral, or pe-
beliefs (for example, Jehovah’s Witnesses). ripheral vascular diseases.29,30
Intraoperative Strategies Surgical Technique

Tourniquets The importance of meticulous surgical techniques in
Thigh tourniquets have been routinely used for TKA limiting the amount of intraoperative blood loss cannot
because they allow a bloodless surgical field, improved be overstated. Examples of surgical techniques that are
cement interdigitation, and decreased surgical time. particularly helpful for blood conservation include careful
However, the local tissue ischemia and subsequent re- dissection, limited incision and soft-tissue release, gentle
active hyperperfusion with tourniquet use can result in handling of soft tissues, appropriate use of electrocautery,
local muscle damage, neurapraxia, thigh pain, delayed and administration of periarticular and intra-articular
wound healing, increased joint swelling and stiffness, epinephrine mixed with saline and other medications.
and thromboembolic events.25 There is some controversy
regarding the optimal time for release of a tourniquet. Bipolar Sealer Versus Electrocautery
Researchers compared clinical outcomes in relation to Bipolar sealer uses radiofrequency to achieve coagulation
the timing of tourniquet use in a 2014 nonrandomized of blood vessels. Because of continuous simultaneous flow
prospective cohort study involving 90 patients.26 The par- of saline, the tip of the bipolar sealer remains cool, caus-
ticipants were divided into three groups on the basis of the ing less damage to the surrounding tissues. There have
timing of tourniquet use—that is, from incision to wound been mixed reports regarding the efficacy of the bipolar
closure, from incision to after cement hardening, and only sealer as compared with the conventional electrocautery
in terms of amount of perioperative blood loss, the need that the fibrin sealant and other topical hemostatic agents
for blood transfusion, and other clinical outcomes. Some do not have any substantial effect on reducing blood loss
authors have reported substantially reduced blood loss, or transfusion requirement.38,39 Currently, routine use of
postoperative hemoglobin drop, and transfusion require- these agents remains controversial.
ment with the use of a bipolar sealer as compared with
electrocautery in TJA.31 Bipolar sealers are expensive Antifibrinolytic Agent: Tranexamic Acid
tools; the incremental costs per case have been estimated Several antifibrinolytic agents have been used to lim-
to be approximately $676.32 Researchers in one study it blood loss in TJA, including desmopressin, TXA,
observed significantly fewer blood transfusions, lower ε-aminocaproic acid, and aprotin. TXA is by far the most
incidence of hematomas, and significantly shorter lengths studied and widely accepted drug, and it is being increas-
of hospital stay after primary THA involving the use of ingly incorporated into perioperative blood management
a bipolar sealer. However, no effect on the total hospital protocols. Originally discovered in 1962, TXA (trans
costs was found. It was concluded that the higher supply form of 4-aminomethyl-cyclohexane-carbonic acid) com-
costs associated with the use of a bipolar sealer were likely petitively binds to the lysine-binding site on plasminogen,
offset by the reduced hospital inpatient and operating which prevents fibrin from binding to the plasminogen–
1: Hip and Knee

room costs.32 Another group of investigators reported plasmin tissue activator complex and thus inhibits fibrin
that the use of a bipolar sealer for simultaneous bilateral clot degradation and bleeding.40 With a half-life of 80 to
TKA was associated with a 35% lower blood transfusion 120 minutes, TXA has been reported to rapidly pene-
rate as compared with the use of conventional electrocau- trate the synovial fluid and membrane, reaching the same
tery.33 However, no significant difference was observed in concentration as in plasma within 15 minutes and peak
terms of decrease in hemoglobin level, total blood loss, or concentration within 1 hour after IV administration. The
length of stay. In other studies by members of the same usual dose of IV TXA is 20 mg/kg, and the maximum
group of investigators, the use of a saline-coupled bipo- dose is 2,000 mg. Because the kidneys provide the major
lar sealing device in revision of infected THA resulted route of elimination, the IV dose of TXA needs to be
in shorter surgical times, less blood loss, and smaller reduced to 50% for patients with renal impairment for a
perioperative decrease in hemoglobin level,34 whereas glomerular filtration rate (GFR) of 0.5 mL/min, 25% for
the device’s use in revision procedures for infected TKA a GFR 10 to 50 mL/min, and 10% for a GFR of 10 mL/
was not clinically or economically justified.35 The bipolar min.40 The absolute contraindications to TXA include a
sealing device shows promise as a blood-loss reduction known allergy to the agent, an ongoing acute venous or
tool, especially in simultaneous bilateral TKA and revi- arterial thrombosis, and an intrinsic risk or a history of
sion THA procedures; however, the savings and clinical thrombosis or thromboembolism. Subarachnoid hemor-
benefits associated with the reduced transfusion rates need rhage also can be considered an absolute contraindication.
to be evaluated against the per-case expense of the device. Caution needs to be exerted when using TXA in the
presence of cardiac or peripheral vascular disease, sei-
Topical Hemostatic Agents zures, and acute renal failure, although further studies
A variety of topical hemostatic agents such as platelet-rich are needed to fully define all the risks associated with
plasma, fibrin sealant, cellulose, collagen agents, and TXA.41 Recent reports indicate that TXA has been associ-
thrombin have been used to reduce blood loss during TJA. ated with decreased perioperative blood loss, higher post-
Typically, the selected topical hemostatic agent is sprayed operative hemoglobin levels, lower blood transfusion
inside the wound before closure. Although there were a rates, lower complication rates, and decreased length
few early favorable results regarding efficacy,36 there is of hospital stay.41,42 In patients undergoing TKA, TXA
no conclusive evidence in support of routine use of these has been shown to decrease total blood loss by 30%,
agents. In a 2014 meta-analysis comprising eight ran- the drainage volume by nearly 50%, and the transfusion
domized controlled trials (RCTs) involving 641 patients, requirement by 47%.43 For patients in whom intravenous
substantially reduced postoperative drainage and blood TXA is contraindicated, 2 to 4 g of TXA can be safely
transfusion rates were observed, as well as improved post- injected inside the joint before deflation of the tourniquet.
operative knee ROM, with the use of a fibrin sealant Intra-articular administration of TXA has been found
product.37 However, there were no substantial differences to have clinical outcomes comparable with those seen
in terms of total blood loss or other adverse events such as after IV administration, with significantly higher hemo-
fever, infection, or hematoma. It was concluded that the globin levels during the immediate postoperative period
use of fibrin sealant was effective and safe as a hemostatic and at discharge. The requirement for blood transfusion
therapy during TKA.37 However, other reports suggest was seen to decrease to 5% after intra-articular TXA
as compared with 22% among those who did not re- thus increasing the hospital costs by $538 for THA and
ceive TXA.42 Intra-articular injection of TXA results in $455 for TKA.51
70% of the plasma concentration after IV administration Increasing impetus to reduce hospital costs has caused
with minimal systemic hypercoagulability effects.44 Intra- many to reevaluate the postoperative protocol and ques-
articular use of TXA has been associated with improved tion the usefulness of wound drains. Several authors now
knee function in the initial 6 weeks of the immediate recommend against using wound drains and propose
postoperative period, as evidenced by significantly im- same-day discharge following TJA.51 With a multimodal
proved Knee Society Scores (ability to walk, negotiate blood conservation protocol including medications such
stairs up and down, arise from a chair, and the use of as TXA, the risk of hematoma formation and the need
support).42 Furthermore, combined intra-articular admin- for blood transfusion after a TJA are greatly reduced.
istration of TXA and epinephrine significantly reduced In a double-blind randomized placebo-controlled trial,
total blood loss, hidden blood loss, and transfusion rate as investigators reported that TXA treatment without drain-
compared with TXA alone—without increasing the risks age results in substantial reduction in blood loss and the
of thromboembolic and hemodynamic complications—in amount of blood transfusions required without increasing
both THA45 and TKA.46 There are several recommenda- the rate of adverse events.52 In a prospective cohort study,
1: Hip and Knee
tions regarding TXA dosing, and further investigations investigators categorized 63 patients undergoing bilateral
are warranted to determine the optimal dosing and dosing TKA into bilateral-drain, unilateral-drain and no-drain
regimen of TXA. Typically, two 20-mg/kg (approximately groups, and no substantial differences in the short- or
2 g) doses of IV TXA are administered; the first dose is long-term clinical outcomes were observed. It was con-
given before inflation of the tourniquet, and the other dose cluded that wound suction drains are not necessary after
is given postoperatively. Recent evidence indicates that TKA.53 In a meta-analysis of six RCTs, a research team
additional topical TXA doses higher than 2 g appear to concluded that wound drains did not offer any significant
be more efficacious than are lower doses.47 In per-patient benefits in terms of postoperative recovery.54 In another
cost analysis studies, TXA ($103.08) was found to be meta-analysis of 20 RCTs, investigators observed a re-
significantly more cost effective than preoperative 3-week duced need for dressing reinforcement but an increased
iron supplementation ($1773.48),1-week EPO regimen need for blood transfusion with the use of a closed suction
($268.88),48 and reinfusion drains ($581.89),49 as well as drain after THA, and it was concluded that wound drains
autologous blood transfusion ($787).6 following THA likely do more harm than good.55
Postoperative Strategies Cold Compressive Dressing

Wound Drains Cold compressive dressing is thought to decrease the
Wound drains have been used in orthopaedic surgery for amount of internal blood loss, pain, and swelling. Despite
decades to prevent fluid collection and hematoma for- the lack of adequate scientific evidence to support these
mation at the surgical site. Traditionally, closed suction beliefs, cold compressive dressings (such as Cryo/Cuff,
drains have been used after TJA to prevent hematoma DJO Global) are routinely used following TKA.
formation, and thereby to reduce the risk of infection,
relieve pain and stiffness, prevent wound dehiscence, Blood Salvage and Reinfusion
improve wound healing, and allow for early mobiliza- Blood salvage and reinfusion techniques involve collection
tion and a shorter length of hospital stay.50 However, of the blood shed during surgery using a cell saver system,
the use of wound drains has become controversial in and postoperatively, using a recollection drain. The col-
recent years. Opponents of wound drains consider them lected blood is filtered, washed, and then reinfused into
a channel for potential retrograde transmission of bac- the patient within 6 to 8 hours. There are mixed reports
teria. Complications such as accidental suturing of the regarding the efficacy of blood salvage and reinfusion.
drain, entrapment, and drain breakage during removal Some authors have reported lower total blood loss and
are well known, and these may require reopening the higher postoperative hemoglobin levels with the imple-
surgical wound in the operating room. Furthermore, mentation of reinfusion technique following THA as well
closed suction drains are thought to result in increased as TKA.56 However, reinfusion systems are expensive
blood loss because of continuous negative pressure. There and have potential complications such as contamination,
have been various recommendations regarding optimal infection, and coagulopathy due to circulating fibrin-split
drain management, releasing pressure, clamping, and products and cytokines. In a prospective RCT involving
the timing of drain removal. Typically, patients need to 1,759 patients undergoing THA or TKA procedure, au-
be hospitalized for a day or two for drain management, tologous intraoperative and postoperative blood salvage
devices were found to be expensive and ineffective.57 The Table 2

unit cost of a reinfusion system ($581.89) is substantially
higher than those of a standard drain ($7.56) and TXA Complication Risks Associated With
($35.91/g).49 In a recent meta-analysis of 43 RCTs involv- Allogeneic Blood Transfusion
ing 5,631 patients, investigators observed that although Complication Incidence
cell salvage reduced bleeding and transfusion require-
Infectious
ments in THA and TKA in earlier studies, more recently
published studies (2010 to 2012) indicate contradictory HIV infection 1:1,900,000
results. The investigators attributed this finding to the Hepatitis B virus infection 1:180,000
changes in blood transfusion management practices.58 In Hepatitis C virus infection 1:1,600,000
another recent meta-analysis, researchers confirmed the Bacterial contamination 1:3,000
efficacy of the reinfusion technique in reducing the need Cardiopulmonary
for allogeneic blood transfusion after THA and TKA,
Transfusion-associated
but they emphasized that further research is warranted circulatory overload
1:5,000
regarding the risks of serious complications and safety
Acute lung injury 1:50,000
1: Hip and Knee

of this technique.59
Systemic
Allogeneic Blood Transfusion Fever or allergic reaction 1:200
Historically, THA and TKA procedures have resulted Hemolytic transfusion
1:6,000
in substantial perioperative blood loss, often requiring reaction
the transfusion of one or more units of blood, which Fatal hemolytic reaction 1:1,000,000
has been a part of the routine postoperative protocol Anaphylaxis 1:50,000
for years. However, allogeneic blood transfusion has
Reproduced from Levine BR, Haughom B, Strong B, Hellman M, Frank
significant risks, including incorrect blood component RM: Blood management strategies for total knee arthroplasty. J Am
transfusion, disease transmission, allergic reactions, Acad Orthop Surg 2014;22(6):361-371.
fluid overload, transfusion reaction, and immunosup-
pression.60 The risks17 have been quantified in Table 2.
Furthermore, allogeneic blood transfusion is associated not only on the laboratory values, but also on objective
with significant costs. The costs associated with collect- signs and symptoms such as tachycardia, feeling of weak-
ing, testing, processing, storing, and cross-matching one ness or dizziness, comorbidities, severity of illness, rate
unit of blood have been estimated to be approximately and amount of hemorrhage, and the patient’s capacity to
$787.6 Compared with patients who did not require a cope with the hemorrhage. Blood transfusion rates for
blood transfusion, the incremental total hospitalization postoperative anemia have been reported to be as high
costs for those who required a transfusion have been as 37% to 53% for primary THA (51% for hip arthritis
estimated to be $2,477 (12%), $4,235 (15%), and $8,594 and 61% after a femoral neck fracture), 69% for hip
(35%) higher for a primary TKA, a bilateral TKA, and a hemiarthroplasty, 43% to 46% for primary TKA, 72%
revision TKA, respectively.7 The concept of transfusion for bilateral TKA, 41% for revision TKA, and 72% for
triggers has been popular in the past couple of decades. revision THA.5 With implementation of an individualized
Traditionally, the 10/30 rule dictated that a blood trans- patient blood management protocol, researchers reported
fusion was required in postsurgical patients if the hemo- a 44% decrease in the transfusion rate and a significant
globin level fell below 10 g/dL, the hematocrit level fell reduction in complications, readmissions, and length of
below 30%, or both. In recent years, more restrictive hospital stay.63 With the implementation of a practical
transfusion triggers have been followed. Evidence-based multimodal blood conservation protocol and adherence
restrictive transfusion strategy has been recommended to evidence-based guidelines, it is possible to significantly
by the American Society of Anesthesiologists Task Force reduce blood transfusion rates following TJA.
on Perioperative Blood Transfusion and Adjuvant Thera-
pies61 as well as the AABB (formerly the American Asso- Complex Cases
ciation of Blood Banks).62 According to these guidelines, Bilateral TJA
the threshold for transfusion for a hemodynamically sta- An increasing number of patients are undergoing simul-
ble postsurgical patient is a hemoglobin level lower than taneous bilateral THA (especially via the direct anterior
7 to 8 g/dL with clinical symptoms of anemia. Thus, the approach) or TKA procedures because of the convenience
decision to undertake transfusion in a patient is based of a single trip to the operating room, one-time anesthesia,
and one-time surgery. However, simultaneous bilateral Researchers reported excellent outcomes of TKA proce-
TJA procedures can result in substantially greater blood dures in patients who are Jehovah’s Witnesses using a
loss, and there is an increased risk of requiring a blood specific blood management strategy.68 Preoperative eval-
transfusion in the perioperative period. Blood transfusion uation and treatment were conducted by a coordinated
rates for bilateral TKA have been reported to be as high as team consisting of internists, hematologists, intensivists,
72%.5 A multimodal patient-specific blood conservation and anesthesiologists. Preoperative optimization of pa-
protocol becomes critical when planning bilateral THA tients’ red blood cell mass was achieved using iron and fo-
or TKA procedures. Of all the different modalities, TXA late supplements. Patients with hemoglobin levels between
seems to have the greatest effect on blood conservation. In 13 g/dL and 15 g/dL were treated with a combination
a retrospective study involving 103 patients who under- of acute normovolemic hemodilution and EPO therapy.
went simultaneous bilateral TKA, investigators observed Patients with a hemoglobin level of less than 13 g/dL were
significantly higher hemoglobin levels on the first postop- initially treated with EPO alone, followed by combination
erative day and almost a 70% decrease in the incidence therapy of intravenous iron and blood salvage if their
of blood transfusion with the administration of TXA.64 hemoglobin levels remained lower than 13 g/dL. Surgery
was performed using a less invasive approach, with em-
1: Hip and Knee
Revision Knee Arthroplasty phasis given to meticulous hemostasis, decreased surgical

With the growth of the aging population and the increas- time, and avoidance of a drain if possible. Postoperative
ing number of primary THA and TKA procedures being measures included microvenipunctures, iron supplements,
performed each year, the number of revision arthroplas- and EPO therapy.
ties is on the rise. Blood transfusion rates for revision
arthroplasty procedures have been quite high. Based on
nationwide hospital and blood bank data, researchers Summary
reported 72% and 41% blood transfusion rates for revi- Perioperative management of patients undergoing TJA
sion THA and TKA procedures, respectively.5 A blood is evolving. Blood loss following THA or TKA proce-
conservation protocol incorporating TXA was shown to dures that necessitates postoperative blood transfusion
significantly decrease the blood transfusion rates among is no longer accepted as routine. Several authors have
patients undergoing revision TKA.65 emphasized the importance of implementing individual-
ized risk stratification and multimodal blood conserva-
Sickle Cell Anemia tion protocols. Such multimodal approaches consist of
Patients with sickle cell disease undergoing THA or TKA numerous preoperative, intraoperative, and postoperative
have an increased risk of perioperative complications, measures. Preoperative measures are focused on timely
especially when a blood transfusion is required.66 There diagnosis and treatment of preoperative anemia, as well
is no consensus regarding the optimal blood management as on optimization of the patient’s red blood cell mass
for patients with sickle cell anemia who are undergoing and general health using iron and vitamin supplementa-
TJA. A multimodal blood conservation protocol is of tion, EPO injections, or both. Intraoperative strategies
utmost importance for these patients to avoid a sickle cell focus on minimizing blood loss by means of meticulous
crisis. In a 2013 multicenter randomized trial, researchers surgical technique, hypotensive anesthesia, bipolar seal-
found that preoperative blood transfusions in patients er, topical hemostatic agents, and antifibrinolytic agents
with the hemoglobin SS form of sickle cell disease were such as TXA. Postoperative measures include reinfusion
associated with decreased risks of serious complications, and allogeneic blood transfusion in select patients. The
particularly acute chest syndrome.67 Maintenance of hy- evidence-based restrictive transfusion trigger strategy is
dration and optimal pain control are essential to prevent recommended for allogeneic blood transfusion in hemo-
sickle cell crisis. In general, the patient should be treated in dynamically stable patients to avoid unnecessary risks
consultation with a hematologist during the perioperative associated with blood transfusion. The ultimate goal is
period.67 to minimize not only the need for blood transfusion for
patients undergoing TJA procedures, but also to limit
Religious Objections to Blood Transfusions surgical site hemarthrosis and wound complications.
Some patients may refuse blood transfusions because
of their religious beliefs, such as those who are Jeho-
vah’s Witnesses. Therefore, effective blood conservation
protocol is critical in these patients to ensure safe and
transfusion-free procedures with minimal complications.
higher rate of complications (odds ratio, 2.11), including

Key Study Points
cardiovascular 26.5% versus 11.8%, and genitourinary
3.9% versus 0.9%, and preoperative optimization was
• TJA procedures are associated with substantial recommended to reduce these complications.
blood loss, which can compromise patient recov-
ery and overall clinical outcomes by causing greater 4. Spahn DR: Anemia and patient blood management in hip
morbidity and mortality, longer hospital stay, and and knee surgery: A systematic review of the literature.
significantly higher hospital costs. Anesthesiology 2010;113(2):482-495. Medline DOI
• Multimodal blood conservation strategies compris- In this systematic literature review, the characteristics
ing preoperative, intraoperative, and postoperative of perioperative anemia, its association with clinical
outcomes, and the effects of patient blood management
measures can effectively reduce blood loss associ- interventions on these outcomes in patients undergoing
ated with TJA. major orthopaedic surgery were determined. Among pa-
• Preoperative anemia is a major factor in predict- tients undergoing THA or TKA and hip fracture surgery,
preoperative anemia was highly prevalent (24% to 44%,
ing transfusion requirements; therefore, patients respectively), and so was postoperative anemia (51% and
should be adequately screened and treated for ane- 87%, respectively) in patients undergoing THA or TKA.
mia preoperatively. Perioperative anemia was associated with a blood trans-
fusion rate of 45% ± 25% and 44% ± 15%, postoperative
1: Hip and Knee

• TXA is now the gold standard in blood loss preven-
infections, poorer physical functioning and recovery, in-
tion in TJA, and intravenous or intra-articular TXA creased length of hospital stay and mortality.
should be considered for every patient undergoing
TJA. 5. Verlicchi F, Desalvo F, Zanotti G, Morotti L, Tomasini
I: Red cell transfusion in orthopaedic surgery: A bench-
mark study performed combining data from different data
sources. Blood Transfus 2011;9(4):383-387. Medline
Annotated References The authors report on a study done by combining informa-

tion from different data sources about blood transfusion
practices. They observed that 56.8% of cases required
1. Kurtz SM, Ong KL, Lau E, Bozic KJ: Impact of the eco- transfusion of red blood cells, and that the likelihood of
nomic downturn on total joint replacement demand in the receiving a transfusion varied depending on the patient’s
United States: Updated projections to 2021. J Bone Joint sex (49% for males, 60% for females), age, and on the
Surg Am 2014;96(8):624-630. Medline DOI surgical procedure. About 70% of patients undergoing
procedures following femoral fractures and for revisions
Data from the Nationwide Inpatient Sample (1993 to of hip replacement required transfusion.
2010) with United States Census and National Health
Expenditure data were used to quantify historical trends 6. Tuttle JR, Ritterman SA, Cassidy DB, Anazonwu WA,
in TJA rates, including the two economic downturns in Froehlich JA, Rubin LE: Cost benefit analysis of topical
the 2000s. Future TJA procedures were estimated using a tranexamic acid in primary total hip and knee arthroplas-
regression model incorporating the growth in population ty. J Arthroplasty 2014;29(8):1512-1515. Medline DOI
and rate of arthroplasty procedures as a function of age,
sex, race, and census region using the National Health This retrospective cohort study, which involved 591 con-
Expenditure as the independent variable. secutive patients (311 experimental and 280 controls), was
designed to perform cost-benefit analysis of topical TXA
2. Sehat KR, Evans RL, Newman JH: Hidden blood loss in patients with primary THA and TKA. The authors
following hip and knee arthroplasty. Correct management observed that the use of topical TXA during THA and
of blood loss should take hidden loss into account. J Bone TKA procedures resulted in reduction in the blood trans-
Joint Surg Br 2004;86(4):561-565. Medline fusion rate from 17.5% to 5.5%, significant increase in the
postoperative hemoglobin level, and significant decrease
3. Viola J, Gomez MM, Restrepo C, Maltenfort MG, Parvizi in delta hemoglobin without an increase in adverse events
J: Preoperative anemia increases postoperative compli- (all P < 0.001). This resulted in a savings of $83.73 per
cations and mortality following total joint arthroplasty. patient, and disposition of patients to home rather than a
J Arthroplasty 2015;30(5):846-848. Medline DOI subacute nursing facility.
This single-institution, large case-controlled study was 7. Nichols CI, Vose JG: Comparative risk of transfusion
designed to examine the association between preoperative and incremental total hospitalization cost for primary
anemia and adverse outcomes following TJA. Data were unilateral, bilateral, and revision total knee arthroplas-
collected from the authors’ institutional database of pa- ty procedures. J Arthroplasty 2016;31(3):583-589.e1.
tients who underwent primary and aseptic revision TJA. Medline DOI
Multivariate analysis was used to determine the effect of
preoperative anemia on the incidence of medical compli- This retrospective chart review of 513,558 primary
cations, infection, hospital length of stay, and mortality. unilateral, 33,977 bilateral, and 32,494 revision TKA
The authors observed that patients with anemia had a procedures performed between January 2008 and June
2014 evaluated the comparative risk of autologous and
allogeneic blood transfusion, in-hospital complications, In this review article on perioperative blood management
and incremental total hospitalization costs for prima- for patients undergoing TJA, data from the Australian
ry unilateral, simultaneous bilateral, and revision TKA Better Safer Transfusion program indicate that one-third
procedures. Patient age older than 65 years, female sex, of patients undergoing hip or knee arthroplasty receive
Northeastern location, large hospitals, and higher Charl- perioperative blood transfusions. Practical management
son score were significantly associated with higher trans- recommendations for perioperative bleeding in joint ar-
fusion risk. Incremental total hospitalization cost among throplasty surgery were developed, based on available
those receiving a transfusion was $2477 (primary unilat- evidence and expert consensus opinion, to promote a
eral), $4235 (bilateral), and $8594 (revision), respectively, new, responsible approach to transfusion management.
compared with those without transfusion. The authors A comprehensive blood management program was rec-
concluded that transfusion risk remains a significant bur- ommended for hemodynamically stable patients involv-
den in select patient populations and procedures with ing preoperative evaluation and optimization of patients’
significant incremental cost of receiving a transfusion after medical health.
knee arthroplasty procedures.
12. Parvizi J, Miller AG, Gandhi K: Multimodal pain man-
8. Sizer SC, Cherian JJ, Elmallah RD, Pierce TP, Beaver WB, agement after total joint arthroplasty. J Bone Joint Surg
Mont MA: Predicting blood loss in total knee and hip Am 2011;93(11):1075-1084. Medline DOI
arthroplasty. Orthop Clin North Am 2015;46(4):445-459.
Medline DOI In this article, the authors reviewed various potential
1: Hip and Knee
measures for pain management after TJA, and recom-

This review article evaluated the role of various factors mended multimodal pain management for optimal pain
associated with increased blood loss in TKA and THA. control with less reliance on opioids and fewer side effects.
Published literature was reviewed to identify modifiable Based on recent reports, the authors recommend using the
risk factors that increase the likelihood of perioperative traditional and COX-2 NSAIDs. Nearly all multimodal
blood loss. Preoperative anemia was identified as one of the pain management modalities have a safe side-effect profile
strongest predictors of needing postoperative transfusion. when they are added to existing methods with the excep-
tion of drugs such as DepoDur. Adequate postoperative
9. Ahmed I, Chan JK, Jenkins P, Brenkel I, Walmsley P: pain control after TJA allows faster rehabilitation.
Estimating the transfusion risk following total knee
arthroplasty. Orthopedics 2012;35(10):e1465-e1471. 13. Mont MA, Jacobs JJ, Boggio LN, et al; AAOS: Preventing
Medline DOI venous thromboembolic disease in patients undergoing
elective hip and knee arthroplasty. J Am Acad Orthop
This study was a retrospective review of a prospectively Surg 2011;19(12):768-776. Medline DOI
collected database of 2281 patients who underwent uni-
lateral TKA in a district general hospital over a 10-year In this review article, the available literature concerning
period. The goal of the study was to identify risk factors patient screening, risk factor assessment, and prophylac-
independently associated with the risk of requiring a blood tic treatment against venous thromboembolic disease by
transfusion following TKA. The authors recognized con- means of postoperative mobilization, neuraxial agents,
siderable variation in the transfusion practices among and vena cava filters was evaluated. The purpose of this
orthopaedic surgeons following elective TKA. Risk fac- work was to recommend updated guidelines originally
tors associated with postoperative blood transfusion were published in 2007 article on the same topic. The updated
identified using predictive models based on the multiple recommendations included further assessment of patients
regression analysis. with a history of prior venous thromboembolism, known
bleeding disorders such as hemophilia, and for the pres-
10. Holt JB, Miller BJ, Callaghan JJ, Clark CR, Willenborg ence of active liver disease, and early mobilization for
MD, Noiseux NO: Minimizing blood transfusion in total patients following elective hip and knee arthroplasty.
hip and knee arthroplasty through a multimodal approach.
J Arthroplasty 2016;31(2):378-382. Medline DOI 14. Cuenca J, García-Erce JA, Martínez F, Cardona R,
Pérez-Serrano L, Muñoz M: Preoperative haematinics
This prospective cohort study determined the effects of a and transfusion protocol reduce the need for transfusion
multimodal, multidisciplinary approach of perioperative after total knee replacement. Int J Surg 2007;5(2):89-94.
blood management on the rate of blood transfusions for Medline DOI
1,010 consecutive patients undergoing primary TKA (488)
or THA (522). The protocol included preoperative hemo-
globin optimization through a multidisciplinary approach, 15. Cushner FD, Lee GC, Scuderi GR, Arsht SJ, Scott WN:
minimization of perioperative blood loss, and adherence Blood loss management in high-risk patients undergoing
to evidence-based transfusion guidelines. It was concluded total knee arthroplasty: A comparison of two techniques.
that adoption of a multimodal blood management al- J Knee Surg 2006;19(4):249-253. Medline DOI
gorithm can significantly reduce blood transfusions in
primary joint arthroplasty. 16. Weber EW, Slappendel R, Hémon Y, et al: Effects of epoe-
tin alfa on blood transfusions and postoperative recovery
11. Bruce W, Campbell D, Daly D, Isbister J: Practical rec- in orthopaedic surgery: The European Epoetin Alfa Sur-
ommendations for patient blood management and the gery Trial (EEST). Eur J Anaesthesiol 2005;22(4):249-257.
reduction of perioperative transfusion in joint replacement Medline DOI
surgery. ANZ J Surg 2013;83(4):222-229. Medline DOI
17. Levine BR, Haughom B, Strong B, Hellman M, Frank 22. Pierson JL, Hannon TJ, Earles DR: A blood-conservation
RM: Blood management strategies for total knee arthro- algorithm to reduce blood transfusions after total hip
plasty. J Am Acad Orthop Surg 2014;22(6):361-371. and knee arthroplasty. J Bone Joint Surg Am 2004;86-
Medline DOI A(7):1512-1518. Medline
A multimodal blood management protocol for patients un-
dergoing TKA is discussed. Thorough patient evaluation 23. Lee GC, Hawes T, Cushner FD, Scott WN: Current trends
is recommended to individualize blood management and in blood conservation in total knee arthroplasty. Clin
conservation pathways to maximize efficacy and avoid Orthop Relat Res 2005;440:170-174. Medline DOI
associated complications. Evidence regarding various pre-
operative, intraoperative, and postoperative strategies of 24. Goodnough LT, Despotis GJ, Merkel K, Monk TG: A
blood management to prevent the need for blood trans- randomized trial comparing acute normovolemic hemo-
fusion and the associated risks of clerical error, infection, dilution and preoperative autologous blood donation in
and immunologic reactions is presented. total hip arthroplasty. Transfusion 2000;40(9):1054-1057.
Medline DOI
18. Bedair H, Yang J, Dwyer MK, McCarthy JC: Preoperative
erythropoietin alpha reduces postoperative transfusions in 25. Tai TW, Lin CJ, Jou IM, Chang CW, Lai KA, Yang CY:
THA and TKA but may not be cost-effective. Clin Orthop Tourniquet use in total knee arthroplasty: A meta-analysis.
Relat Res 2015;473(2):590-596. Medline DOI Knee Surg Sports Traumatol Arthrosc 2011;19(7):1121-
1130. Medline DOI
1: Hip and Knee

The purpose of this single-blind prospective cohort study
was to determine the efficacy of preoperative EPO in re- In this meta-analysis of eight RCTs and three high-quality
ducing postoperative transfusions in TKA and THA; prospective studies involving 634 knees, clinical outcomes
whether patients treated with EPO had a reduced length of TKA with and without tourniquet use were compared.
of hospital stay or a different discharge disposition; and The authors observed that tourniquet use could shorten
whether the use of EPO reduces overall blood manage- the surgical time if released after wound closure; how-
ment costs. The study involved a total of 80 patients who ever, early release did not shorten the surgical time. It was
underwent primary THA or TKA with a preoperative concluded that using tourniquet in TKA may save time
hemoglobin less than 13 g/dL over a 10-month period and but may not reduce blood loss, and a tourniquet should be
were recommended preoperative treatment with EPO. A used with caution because of the higher risks of thrombo-
total of 24 patients who received at least one dose of EPO embolic complications.
were compared with 56 control patients in terms of trans-
fusion frequency, length of hospital stay and discharge 26. Huang ZY, Pei FX, Ma J, et al: Comparison of three differ-
disposition, and overall blood management costs. None ent tourniquet application strategies for minimally invasive
of the patients treated with preoperative EPO required total knee arthroplasty: A prospective non-randomized
transfusions and 23 of 56 patients (41%) who did not clinical trial. Arch Orthop Trauma Surg 2014;134(4):
receive EPO needed to be transfused. It was concluded 561-570. Medline DOI
that EPO significantly reduced the need for postoperative
transfusions in high-risk patients undergoing THA and In this nonrandomized prospective cohort study involv-
TKA; however, it was not found to be cost effective. Level ing 90 patients, clinical outcomes were investigated in
of evidence: III. relation to the timing of tourniquet use--from incision to
wound closure, from incision to after cement hardening,
and only during cementing. Using a tourniquet only during
19. Bezwada HR, Nazarian DG, Henry DH, Booth RE Jr, cementing led to lower serum markers for inflammation
Mont MA: Blood management in total joint arthroplas- and muscle damage, such as C-reactive protein, inter-
ty. Am J Orthop (Belle Mead NJ) 2006;35(10):458-464. leukin-6, creatine kinase and myoglobin; however, there
Medline was no difference in the clinical outcomes in Hospital for
Special Surgery knee scores, ROM, estimated blood loss,
20. Bou Monsef J, Figgie MP, Mayman D, Boettner F: Target- swelling ratio, visual analog scale pain score, and length
ed preoperative autologous blood donation: A prospective of hospital stay. It was concluded that using a tourniquet
study of two thousand and three hundred and fifty total during the entire TKA surgery causes less intraoperative
hip arthroplasties. Int Orthop 2014;38(8):1591-1595. blood loss but more excessive inflammation and muscle
Medline DOI damage. Part-time tourniquet use was associated with less
This prospective study involving 2,351 THA patients was inflammation and muscle damage but did not affect the
designed to investigate the effectiveness of targeted PAD early functional outcomes.
protocol on reducing transfusion rates in 2,350 unilateral
primary THA procedures. The authors concluded that 27. Hernández-Castaños DM, Ponce VV, Gil F: Release of
targeted PAD reduces the need for allogeneic blood trans- ischaemia prior to wound closure in total knee arthro-
fusion in anemic patients and the number of transfusions plasty: A better method? Int Orthop 2008;32(5):635-638.
compared to routine preoperative autologous donation. Medline DOI
21. Gandini G, Franchini M, Bertuzzo D, et al: Preoperative 28. Berry DJ, Bozic KJ: Current practice patterns in primary
autologous blood donation by 1073 elderly patients un- hip and knee arthroplasty among members of the Ameri-
dergoing elective surgery: A safe and effective practice. can Association of Hip and Knee Surgeons. J Arthroplasty
Transfusion 1999;39(2):174-178. Medline DOI 2010;25(6suppl):2-4. Medline DOI
A poll was conducted at the 2009 Annual Meeting of were matched for age, sex, BMI, American Society of
the American Association of Hip and Knee Surgeons to Anesthesiologists classification, and preoperative hemo-
determine current practices among its members in primary globin. In comparison with the electrocautery group, the
THA and TKA. This article summarizes the audience members of the bipolar sealer group were 35% less likely
responses to several multiple choice questions concerning to require a transfusion, and had a significantly lower
perioperative management and surgical practice patterns median number of transfusions per case. However, the
and preferences. hemoglobin change, the total blood loss, and the length
of hospital stay were not significantly different between
29. Juelsgaard P, Larsen UT, Sørensen JV, Madsen F, Søballe the groups. The experimental group had longer surgical
K: Hypotensive epidural anesthesia in total knee replace- times. It was concluded that bipolar sealing could be a
ment without tourniquet: Reduced blood loss and transfu- good blood loss reduction tool in simultaneous bilateral
sion. Reg Anesth Pain Med 2001;26(2):105-110. Medline TKA; however, the marginal savings attributed to reduced
transfusion rates with use of the bipolar sealer did not
30. Eroglu A, Uzunlar H, Erciyes N: Comparison of hypo- exceed the additional per-case expense of using the device.
tensive epidural anesthesia and hypotensive total intra-
venous anesthesia on intraoperative blood loss during 34. Clement RC, Kamath AF, Derman PB, Garino JP, Lee
total hip replacement. J Clin Anesth 2005;17(6):420-425. GC: Bipolar sealing in revision total hip arthroplasty
Medline DOI for infection: Efficacy and cost analysis. J Arthroplasty
2012;27(7):1376-1381. Medline DOI
1: Hip and Knee
31. Suarez JC, Slotkin EM, Szubski CR, Barsoum WK, Patel This case-matched study of 76 consecutive revision THAs
PD: Prospective, randomized trial to evaluate efficacy for infection included an experimental bipolar sealing
of a bipolar sealer in direct anterior approach total hip group and a control group of conventional electrocautery.
arthroplasty. J Arthroplasty 2015;30(11):1953-1958. Groups were matched for sex, BMI, American Society of
Medline DOI Anesthesiologists classification, and surgery type. Total
In this prospective, double-blind RCT, the hemostatic ef- blood loss, intraoperative blood loss, and perioperative
ficacy of a bipolar sealer in direct anterior approach THA hemoglobin drop were significantly less, and the surgical
on surgical blood loss and transfusion requirements was time was significantly shorter in the experimental group,
investigated in 118 patients. The authors observed a lower which translated into gross savings approximately equal
transfusion rate in the treatment group (3.5% vs 16.4%, to the cost of the device. The authors concluded that the
P = 0.03), and differences in hemoglobin level (P = 0.04), decreases in total blood loss and perioperative hemoglobin
calculated blood loss (P = 0.02), and hidden blood loss (P = decline, along with financial savings, may support the use
0.02) favoring the treatment group. The authors concluded of bipolar sealing in infected revision THA.
that the use of a bipolar sealer decreased intraoperative
blood loss and transfusion requirements in THA via direct 35. Derman PB, Kamath AF, Lee GC: Saline-coupled bipo-
anterior approach. lar sealing in revision total knee arthroplasty for infec-
tion. Am J Orthop (Belle Mead NJ) 2013;42(9):407-411.
32. Ackerman SJ, Tapia CI, Baik R, Pivec R, Mont MA: Use of Medline
a bipolar sealer in total hip arthroplasty: Medical resource This single-surgeon, case-control study was designed to
use and costs using a hospital administrative database. evaluate if the choice of an electrocautery device affected
Orthopedics 2014;37(5):e472-e481. Medline DOI total blood loss, transfusion requirements, and total cost in
A retrospective, comparative cohort study was conducted revision TKA for infection. The study involved 80 patients
using a nationwide all-payer hospital administrative data- with infected TKA (test group) who underwent revision
base to assess medical resource use, associated costs, and surgery that involved the use of a saline-coupled bipolar
the incidence of transfusion and complications among sealing device. Results were compared with those of 40 pa-
patients undergoing THA with or without the use of a tients (control group) who underwent similar surgery with-
bipolar sealer. The bipolar sealer group had higher supply out the use of a bipolar sealing device, and were matched
costs, which were offset by reduced hospital inpatient for age, BMI, and American Society of Anesthesiologists
room and board and operating room costs; there was no classification. No statistical differences were found be-
significant difference in total hospital costs between the tween the test and control groups in terms of blood loss
two groups ($18,937 vs $18,734; P = 0.56). The authors or transfusion requirements. However, the surgical time
concluded that a bipolar sealer decreases postoperative was significantly lower and the average net additional
blood transfusions and length of hospital stay after pri- cost was about $70 per case in the bipolar sealer group.
mary THA without increasing total hospital costs. The authors concluded that the use of a saline-coupled
bipolar sealing device in patients with infected TKAs is
not clinically or economically justified.
33. Kamath AF, Austin DC, Derman PB, Clement RC, Garino
JP, Lee GC: Saline-coupled bipolar sealing in simultane-
ous bilateral total knee arthroplasty. Clin Orthop Surg 36. Yang TQ, Geng XL, Ding MC, Yang MX, Zhang Q: The
2014;6(3):298-304. Medline DOI efficacy of fibrin sealant in knee surgery: A meta-analy-
sis. Orthop Traumatol Surg Res 2015;101(3):331-339.
In this study, clinical outcomes were investigated in Medline DOI
71 consecutive patients undergoing simultaneous bilateral
TKA with the use of bipolar sealing or conventional elec- In this meta-analysis of 9 RCTs and 4 prospective com-
trocautery. The bipolar sealer and electrocautery groups parative trials involving a total of 1,299 patients, the use
of fibrin sealant was associated with a decrease in hemo- This is a review article based on nine past studies aimed
globin reduction, transfusion rate, number of transfusion at evaluating and presenting evidence regarding current
units, and hospital stay as well as the incidence of compli- practices regarding the use of TXA in THA and TKA
cations. It was concluded that high-dose fibrin sealant may procedures. The authors provided this comprehensive re-
be beneficial during knee surgery; however, the effects of a view regarding various aspects of TXA use in the recent
low dose of fibrin during knee surgery remain inconclusive. past including its pharmacology, intravenous versus intra-
articular routes of administration, drug-drug interactions,
37. Wang H, Shan L, Zeng H, Sun M, Hua Y, Cai Z: Is fibrin safety profile, current trends in the use of TXA in THA
sealant effective and safe in total knee arthroplasty? A and TKA procedures.
meta-analysis of randomized trials. J Orthop Surg Res
2014;9:36. Medline DOI 41. Tengborn L, Blombäck M, Berntorp E: Tranexamic
acid—an old drug still going strong and making a revival.
The objective of this meta-analysis study of 8 RCTs involv- Thromb Res 2015;135(2):231-242. Medline DOI
ing 641 patients was to evaluate the efficacy and safety
of fibrin sealant in patients following TKA. The authors Historical perspective and clinical information regarding
observed that the use of fibrin sealant significantly reduced the use of TXA in different surgical subspecialties are
postoperative drainage and blood transfusions and led presented in this review. Indications, contraindications,
to a significant improvement in the postoperative ROM. pharmacology, routes of administration, drug-drug in-
However, the use of a fibrin sealant did not significantly teractions, safety profile, and current trends in the use of
reduce the total blood loss. No significant differences were TXA are presented.
1: Hip and Knee

observed in any adverse events including fever, infection,
or hematoma among the study groups. The use of fibrin 42. Serrano Mateo L, Goudarz Mehdikhani K, Cáceres L, Lee
sealant was determined to be effective and safe as a he- YY, Gonzalez Della Valle A: Topical tranexamic acid may
mostatic therapy for patients with TKA. improve early functional outcomes of primary total knee
arthroplasty. J Arthroplasty 2016; Jan. 21 (Epub ahead
38. Randelli F, D’Anchise R, Ragone V, Serrao L, Cabitza of print]. Medline DOI
P, Randelli P: Is the newest fibrin sealant an effective
strategy to reduce blood loss after total knee arthro- In this retrospective review, clinical outcomes during the
plasty? A randomized controlled study. J Arthroplasty first 4 postoperative months after TKA were investigated
2014;29(8):1516-1520. Medline DOI in 166 consecutive patients (TXA group, 179 TKA pro-
cedures) who received 3 g topical TXA before tourniquet
In this prospective RCT, 62 patients who underwent pri- deflation, and compared with those in 197 consecutive
mary TKA were categorized according to the topical use patients (control group, 209 TKA procedures) in whom
of a fibrin sealant (Evicel) into a sealant group (n = 31) TXA was not used. Compared to the control group, the
and a control group (n = 31). Topical application of a TXA group had significantly higher hemoglobin on post-
fibrin sealant resulted in a mean total blood loss of 1.8 L operative day 1, day 2, and at discharge, and a lower
as compared to 1.9 L in the control group (n = 31), and a blood transfusion rate (5% vs 22%). The clinical benefit
transfusion rate of 25.8% in the sealant group vs 32.3% of topical TXA administration extends beyond the hos-
in the control group The transfusion rate decreased linear- pitalization period, with improved knee function during
ly with increasing preoperative hemoglobin levels in the the first 6 postoperative weeks.
treatment group. It was concluded that topical application
of a fibrin sealant did not reduce perioperative blood loss 43. Good L, Peterson E, Lisander B: Tranexamic acid de-
and the need for allogeneic blood transfusion. creases external blood loss but not hidden blood loss in
total knee replacement. Br J Anaesth 2003;90(5):596-599.
39. Maheshwari AV, Korshunov Y, Naziri Q, Pivec R, Mont Medline DOI
MA, Rasquinha VJ: No additional benefit with use of
a fibrin sealant to decrease peri-operative blood loss 44. Wong J, Abrishami A, El Beheiry H, et al: Topical appli-
during primary total knee arthroplasty. J Arthroplasty cation of tranexamic acid reduces postoperative blood
2014;29(11):2109-2112. Medline DOI loss in total knee arthroplasty: A randomized, controlled
This is a retrospective study involving chart review of trial. J Bone Joint Surg Am 2010;92(15):2503-2513.
113 consecutive patients who underwent primary TKA Medline DOI
with the use of a fibrin sealant and 70 patients without the This prospective, double-blind placebo-controlled trial
use of a fibrin sealant. The authors found no significant was designed to assess the efficacy and safety of the topical
difference in hemoglobin levels up to 3 days after surgery. application of TXA on postoperative blood loss in patients
There was no difference in the intraoperative or post- undergoing primary unilateral cemented TKA. It was con-
operative or total perioperative blood loss. The authors cluded that topical application of TXA directly into the
concluded that fibrin sealant offered no additional benefit surgical wound reduced postoperative bleeding by 20% to
regarding perioperative blood loss associated with TKA, 25%, or 300 to 400 mL, resulting in 16% to 17% higher
and ceased using the product based on the study findings. postoperative hemoglobin levels compared with placebo,
with no clinically important increase in complications
40. Kim C, Park SS, Davey JR: Tranexamic acid for the preven- such as deep vein thrombosis or pulmonary embolism.
tion and management of orthopedic surgical hemorrhage:
Current evidence. J Blood Med 2015;6:239-244. Medline 45. Gao F, Sun W, Guo W, Li Z, Wang W, Cheng L: Topical
application of tranexamic acid plus diluted epinephrine
reduces postoperative hidden blood loss in total hip 49. Springer BD, Odum SM, Fehring TK: What is the benefit of
arthroplasty. J Arthroplasty 2015;30(12):2196-2200. tranexamic acid vs reinfusion drains in total joint arthro-
Medline DOI plasty? J Arthroplasty 2016;31(1):76-80. Medline DOI
In a RCT involving 107 patients undergoing THA, pa- In this RCT, the efficacy and cost of TXA and standard
tients were randomized into two groups: 53 received intra- and reinfusion drains were compared in 186 primary
articular TXA 3 g plus 1:200,000 diluted epinephrine TJAs (71 hips, 115 knees). The authors observed a sig-
0.25 mg; 54 received topical TXA 3 g alone. It was ob- nificant decrease in hemoglobin level in the TXA group
served that combined administration of TXA and diluted compared with standard drains and reinfusion drains;
epinephrine significantly reduced total blood loss, hidden however, there was no significant difference in transfusion
blood loss, and transfusion rate as compared with TXA rates. The unit cost of the reinfusion system ($581.89) was
alone, without increasing the risks of thromboembolic substantially higher than the standard drain ($7.56) and
and hemodynamic complications. TXA ($35.91 per gram). TXA was determined to be more
efficacious and less expensive than reinfusion drains as a
46. Gao F, Sun W, Guo W, Li Z, Wang W, Cheng L: Topical blood management tool for TJA.
administration of tranexamic acid plus diluted-epineph-
rine in primary total knee arthroplasty: A random- 50. Koyano G, Jinno T, Koga D, Hoshino C, Muneta T,
ized double-blinded controlled trial. J Arthroplasty Okawa A: Is closed suction drainage effective in early
2015;30(8):1354-1358. Medline DOI recovery of hip joint function? Comparative evaluation in
1: Hip and Knee
one-stage bilateral total hip arthroplasty. J Arthroplasty

In this RCT, the efficacy of TXA plus diluted epinephrine 2015;30(1):74-78. Medline DOI
was evaluated in primary unilateral TKA without drain-
age. One hundred patients scheduled to undergo TKA In this prospective study, single-stage primary bilateral
were randomized into two groups: 50 patients received noncemented THA with unilateral closed suction drainage
intra-articular 3 g TXA plus 0.25 mg diluted epinephrine (CSD) was performed for 51 patients (102 hips) and the
(1:200,000), and 50 patients received 3 g topical TXA local effects of CSD were quantitatively evaluated after
alone. Topical combined administration of TXA and dilut- surgery. CSD for hip arthroplasty was found to be advan-
ed epinephrine significantly reduced total blood loss, hid- tageous in reducing postoperative local inflammation and
den blood loss, and transfusion rate without increasing the can be recommended to facilitate postoperative pain relief
risk of thromboembolic and hemodynamic complications. and early recovery of hip joint function.
47. Melvin JS, Stryker LS, Sierra RJ: Tranexamic acid in 51. Bjerke-Kroll BT, Sculco PK, McLawhorn AS, Christ
hip and knee arthroplasty. J Am Acad Orthop Surg AB, Gladnick BP, Mayman DJ: The increased total cost
2015;23(12):732-740. Medline DOI associated with post-operative drains in total hip and
knee arthroplasty. J Arthroplasty 2014;29(5):895-899.
This study provided comprehensive evidence in high- Medline DOI
quality studies regarding clinical efficacy of TXA. TXA,
both topical and intravenous administration, has been In a consecutive series of 536 unilateral primary THAs and
effective in decreasing perioperative blood loss and trans- 598 unilateral primary TKAs, the use of a postoperative
fusion requirements in both primary and revision hip and drain was associated with $538 additional cost per THA,
knee arthroplasty. It is recommended that an initial intra- and $455 for TKA. The use of a drain increased hospital
venous dose be given before the procedure, with at least length of stay for THA, but not for TKA. In both groups,
one additional intravenous postoperative dose. Topical the use of a drain increased estimated blood loss and in-
TXA doses of 2 g or more appear to be more effective creased the amount of allogeneic blood transfused. Drain
than lower doses. Few adverse reactions have been re- use was associated with a total cost of $432,972 over a
ported in arthroplasty patients, and no study to date has 10-week period. A selective approach to the use of drains
demonstrated an increased risk of symptomatic venous in primary joint arthroplasties is favored.
thromboembolic events in these patients.
52. Wang CG, Sun ZH, Liu J, Cao JG, Li ZJ: Safety and
48. Phan DL, Ani F, Schwarzkopf R: Cost analysis of efficacy of intra-articular tranexamic acid injection
tranexamic acid in anemic total joint arthroplasty patients. without drainage on blood loss in total knee arthroplas-
J Arthroplasty 2016;31(3):579-582. Medline DOI ty: A randomized clinical trial. Int J Surg 2015;20:1-7.
Medline DOI
The material and administration costs of TXA and packed
red blood cells were compared with those of the standard This double-blind randomized placebo-control trial in-
treatment of preoperative anemia using iron supplemen- volved 60 patients who underwent primary unilateral
tation (FE) and EPO. Approximately 18.5% (45/243) pa- cemented TKA. The subjects were randomized into a
tients had preoperative anemia. The cost of the treatment TXA group (30 knees received 500 mg intra-articular
of preoperative anemia with FE or EPO without a postop- injection without drainage) and a control group (30 knees
erative packed red blood cells ranged from 2 to 17 times received saline intra-articular injection. As compared with
more than treatment with TXA. TXA was determined the control group, the TXA group had less of a decrease
to be significantly less expensive than FE or EPO as a in hemoglobin level at postoperative day 3 (9.10 vs 10.51
treatment option for patients with TJA presenting with g/dL), and significantly less mean blood loss at postop-
preoperative anemia, and it serves as a cost-effective ad- erative day 5 (1,000 vs 1,560 mL). The TXA group had
junct for limiting transfusion rates. lower D-dimer levels at days 3 and 5 after TKA. The
TXA group also had significantly greater red blood cell randomised controlled trial. Blood Transfus 2014;12(sup-
mass and hematocrit, and lower transfusion rates and pl 1):s176-s181. Medline
average amount transfused blood than the control group.
No significant differences were observed in the coagula- One hundred fifteen patients undergoing TKA were
tion markers, rates of symptomatic deep vein thrombosis, randomly allocated to an autotransfusion drain or no-
pulmonary embolism, or wound healing problems. The drainage system. In the autotransfusion group, retransfu-
authors concluded that TXA treatment without drainage sion of 515 mL (0-1,500 mL) of drained blood was done
during TKA reduces the blood transfusions requirement within the first 6 hours after surgery. Compared with the
without increasing the rate of adverse events. no-drainage group, the autotransfusion group had sig-
nificantly higher hemoglobin levels on postoperative day
1 (11.6 vs 11.0 g/dL), day 2 (11.0 vs 10.3 g/dL) and day 3
53. Watanabe T, Muneta T, Yagishita K, Hara K, Koga H, (10.5 vs 9.8 g/dL), and lower total perioperative net blood
Sekiya I: Closed suction drainage is not necessary for total loss (1,576 mL vs 1,837 mL) and allogeneic transfusion
knee arthroplasty: A prospective study on simultaneous rates (10.2% vs 19.6%). There were no differences in pain
bilateral surgeries of a mean follow-up of 5.5 years. J Ar- scores, ROM, or adverse events during hospital stay and
throplasty 2016;31(3):641-645. Medline DOI the first 3 months after surgery. The authors concluded
In this prospective study, 63 patients (126 knees) who that the use of a postoperative autologous blood retrans-
underwent bilateral simultaneous TKA using a cemented fusion drainage system following TKA results in higher
posterior stabilized prosthesis were classified into 3 groups hemoglobin levels after surgery and less total blood loss
based on the use of a suction drain – a bilateral closed suc- than no drainage.
1: Hip and Knee

tion drain group (20 patients), a unilateral closed suction
drain group (22 patients), and a no-drain group (21 pa- 57. So-Osman C, Nelissen RG, Koopman-van Gemert AW,
tients). After short- and long-term clinical outcomes were et al: Patient blood management in elective total hip- and
evaluated, it was determined that there were no significant knee-replacement surgery (part 2): A randomized con-
differences in incidence of short-term or long-term compli- trolled trial on blood salvage as transfusion alternative
cations, knee ROM, or circumference between the knees using a restrictive transfusion policy in patients with a
with drainage and those without drainage. Therefore, preoperative hemoglobin above 13 g/dl. Anesthesiology
closed suction drainage was deemed unnecessary after 2014;120(4):852-860. Medline DOI
TKA using cemented posterior-stabilized prostheses.
In this prospective randomized study on the integrated use
of erythropoietin, cell saver, and/or postoperative drain
54. Quinn M, Bowe A, Galvin R, Dawson P, O’Byrne J: The reinfusion devices (DRAIN), 1,759 patients undergoing
use of postoperative suction drainage in total knee ar- THA or TKA were randomized between autologous rein-
throplasty: A systematic review. Int Orthop 2015;39(4): fusion by cell saver or DRAIN or no blood salvage device.
653-658. Medline DOI The authors observed no difference in erythrocyte use be-
This systematic review and meta-analysis of six RCTs tween cell saver and DRAIN groups. The transfusion rate
was conducted to investigate the effect of postoperative was 7.7% in patients in the autologous group compared
suction drainage on clinical outcomes in TKA patients. with 8.3% in patients in the control group while applying
No significant difference was seen between the individuals a restrictive transfusion threshold. Blood salvage increased
who received a drain and those who did not in terms of the per-patient costs by €298. The authors concluded that
knee ROM, reduction in swelling, length of hospital stay autologous intra- and postoperative blood salvage devices
and postoperative hemoglobin level. The authors conclud- were not effective as transfusion alternatives especially
ed that closed suction drains are possibly not required in patients with preoperative hemoglobin levels greater
following TKA. than 13 g/dl.
55. Zhou XD, Li J, Xiong Y, Jiang LF, Li WJ, Wu LD: Do we 58. van Bodegom-Vos L, Voorn VM, So-Osman C, et al: Cell
really need closed-suction drainage in total hip arthroplas- salvage in hip and knee arthroplasty: A meta-analysis
ty? A meta-analysis. Int Orthop 2013;37(11):2109-2118. of randomized controlled trials. J Bone Joint Surg Am
This meta-analysis study of 20 RCTs involving 3,186 pa- In the meta-analysis of 43 trials (5,631 patients), cell sal-
tients investigated whether closed-suction drainage is safe vage reduced the exposure to allogeneic RBC transfusion
and effective in promoting wound healing and reducing in THA (risk ratio 0.66) and TKA (risk ratio, 0.51). How-
blood loss and other complications compared with no ever, the authors observed that unlike the findings in the
drainage in THA. No significant difference was observed studies earlier than 2010, cell salvage did not reduce either
in the incidence of infection, blood loss, changes in he- the exposure rate or the volume of transfused RBCs in
moglobin and hematocrit, functional assessment, or other THA and TKA patients in more recently published trials
complications when the drainage group was compared (2010 to 2012). The authors attributed this discrepancy
with the no-drainage group. It was concluded that the to the changes in blood transfusion management practice.
routine use of closed-suction drainage for elective THA
may not be beneficial. 59. Xie J, Feng X, Ma J, et al: Is postoperative cell salvage nec-
essary in total hip or knee replacement? A meta-analysis of
56. Horstmann W, Kuipers B, Ohanis D, Slappendel R, randomized controlled trials. Int J Surg 2015;21:135-144.
Kollen B, Verheyen C: Autologous re-transfusion drain Medline DOI
compared with no drain in total knee arthroplasty: A
In this meta-analysis involving 19 RCTs (3,482 patients), complications, 30-day readmissions and hospital length
postoperative cell salvage significantly reduced the al- of stay.
logeneic blood transfusion requirement after TKA (risk
ratio = 0.46) and THA (risk ratio = 0.46), and resulted in 64. Bagsby DT, Samujh CA, Vissing JL, Empson JA, Pomeroy
a greater postoperative hemoglobin level. No significant DL, Malkani AL: Tranexamic acid decreases incidence
differences were noted regarding length of hospital stay, of blood transfusion in simultaneous bilateral total knee
incidence of febrile reaction, wound infection, and deep arthroplasty. J Arthroplasty 2015;30(12):2106-2109.
vein thrombosis. Medline DOI
60. Klein HG: How safe is blood, really? Biologicals The goal of this retrospective review involving 103 pa-
2010;38(1):100-104. Medline DOI tients undergoing simultaneous bilateral TKA (46 TXA
group and 57 controls) was to examine if administration
Updated information regarding safety issues and potential of TXA would decrease blood loss and requirement for
risks and complications associated with blood transfusion allogeneic blood transfusion. The authors observed signifi-
is presented. Although current blood transfusion practices cantly higher hemoglobin levels (4.33 vs 2.95) and lower
are safe, they do not come without risk. transfusion incidence (17.4% vs 57.9%) in patients who
received TXA on the postoperative day 1 than those who
61. American Society of Anesthesiologists Task Force on did not. The authors concluded that TXA was effective
Perioperative Blood Transfusion and Adjuvant Therapies: in reducing the transfusion rates by almost 70% in simul-
1: Hip and Knee
Practice guidelines for perioperative blood transfusion and taneous bilateral TKA.
adjuvant therapies: An updated report by the American
Society of Anesthesiologists Task Force on Perioperative 65. Samujh C, Falls TD, Wessel R, Smith L, Malkani AL:
Blood Transfusion and Adjuvant Therapies. Anesthesiol- Decreased blood transfusion following revision total
ogy 2006;105(1):198-208. Medline DOI knee arthroplasty using tranexamic acid. J Arthroplasty
2014;29(9suppl):182-185. Medline DOI
This update includes data published since the “Practice
Guidelines for Blood Component Therapy” were adopt- The goal of this retrospective review was to examine the
ed by the American Society of Anesthesiologists (ASA) efficacy of TXA in patients undergoing revision TKA.
in 1995. The authors provided practical preoperative, Of 111 patients, 43 patients (TXA group) who received a
intraoperative, and postoperative guidelines regarding single intravenous TXA dose of 10 mg/kg required fewer
detection and treatment of anemia, blood conservation, transfusions as compared to the 68 patients (controls) who
and transfusion. did not receive TXA. When stratified by type of revision,
patients undergoing femoral and tibial component revision
62. Carson JL, Grossman BJ, Kleinman S, et al; Clinical Trans- had lower transfusion rates than control patients. Given
fusion Medicine Committee of the AABB: Red blood cell the drawbacks of allogeneic blood transfusion, the authors
transfusion: A clinical practice guideline from the AABB*. recommended the use of TXA in revision TKA, especially
Ann Intern Med 2012;157(1):49-58. Medline DOI when both components are being revised.
This article presents guidelines formulated by the AABB 66. Perfetti DC, Boylan MR, Naziri Q, Khanuja HS, Urban
based on a systematic review of RCTs regarding transfu- WP: Does sickle cell disease increase risk of adverse out-
sion thresholds published from 1950 to 2011. The authors comes following total hip and knee arthroplasty? A nation-
discussed the clinical consequences of restrictive trans- wide database study. J Arthroplasty 2015;30(4):547-551.
fusion strategies in terms of overall mortality, nonfatal Medline DOI
myocardial infarction, cardiac events, pulmonary ede-
ma, stroke, thromboembolism, renal failure, infection, The authors used the Nationwide Inpatient Sample to
hemorrhage, mental confusion, functional recovery, and identify all THA and TKA admissions between 1998 and
length of hospital stay. According to the AABB, a restric- 2010, and investigated the associated complications and
tive transfusion strategy (7 to 8 g/dL) is recommended in comorbidities in patients with sickle cell disease who un-
hospitalized, stable patients, even with preexisting cardio- dergo THA or TKA procedures. After controlling for
vascular disease and to consider transfusion for patients patient age, sex, insurance, race, and comorbidities, the
with symptoms or a hemoglobin level of 8 g/dL or less. risk of complications among admissions with sickle cell
disease was 152% higher for THA and 137% higher for
63. Loftus TJ, Spratling L, Stone BA, Xiao L, Jacofsky DJ: TKA, and the length of hospital stay was 42% and 20%
A patient blood management program in prosthetic joint longer for THA and TKA procedures, respectively. It was
arthroplasty decreases blood use and improves outcomes. suggested that potential THA and TKA candidates with
J Arthroplasty 2016;31(1):11-14. Medline DOI sickle cell disease be informed before admission of these
risks.
The authors studied whether a patient blood management
program for patients undergoing THA or TKA would 67. Howard J, Malfroy M, Llewelyn C, et al: The Transfusion
result in a decrease in the percentage of transfused packed Alternatives Preoperatively in Sickle Cell Disease (TAPS)
red blood cells and improve outcomes. This retrospective study: A randomised, controlled, multicentre clinical trial.
cohort study included 12,590 patients and demonstrated Lancet 2013;381(9870):930-938. Medline DOI
a 44% decrease in the percentage of patients transfused,
which was associated with a significant reduction in This multicenter RCT was designed to evaluate if pre-
operative blood transfusions are beneficial to avoiding
complications in patients with sickle cell disease (hemoglo- SS subtype, who are scheduled to undergo low-risk and
bin SS or Sβ(0) thalassemia subtype) undergoing various medium-risk surgeries.
surgical procedures including joint arthroplasty. Patients
were randomly assigned to no transfusion or transfusion 68. Issa K, Banerjee S, Rifai A, et al: Blood management
within 10 days before surgery, and the analysis was based strategies in primary and revision total knee arthroplasty
on an intention-to-treat basis. A total of 13 of 33 pa- for Jehovah’s Witness patients. J Knee Surg 2013;26(6):
tients (39%) in the no-transfusion group had clinically 401-404. Medline DOI
important complications within 30 days after surgery
compared with 5 of 34 patients (15%) in the transfusion An overview of various potential preoperative, intraop-
group. The unadjusted odds ratio of clinically important erative, and postoperative blood management measures
complications was 3.8, whereas the duration of hospital that may be used for the care of Jehovah’s Witnesses who
stay and readmission rates did not differ between study undergo knee arthroplasty procedures is presented. Re-
groups. It was concluded that preoperative transfusion was ported outcomes of primary and revision TKA in these
associated with decreased perioperative complications in patients are reviewed. Because Jehovah’s Witnesses usu-
patients with sickle cell disease, especially hemoglobin ally refuse blood transfusions because of their religious
beliefs, this may create clinical or ethical challenges for
the treating physicians.
1: Hip and Knee
Chapter 4
Osteonecrosis of the Hip and Knee

Nirav K. Patel, MD, FRCS Jaydev B. Mistry, MD Randa K. Elmallah, MD
Morad Chughtai, MD James Nace, DO, MPT Michael A. Mont, MD
Abstract Osteonecrosis most commonly occurs in the femoral

head, with an incidence of 10,000 to 20,000 new cases
Osteonecrosis is a debilitating condition that can re- annually in the United States, which is expected to con-
sult in structural collapse. It most commonly affects tinue to increase.1,2 Osteonecrosis is seen more commonly
1: Hip and Knee

the femoral head, followed by the knee and shoulder in males and typically presents in patients 35 to 50 years
joints. Although osteonecrosis of the hip and knee can of age.3 The knee is the second most common location
be treated nonsurgically, the disease often progresses, of osteonecrosis, comprising 10% of all cases, and most
which inevitably requires surgical intervention. The frequently the distal femur is affected.4
surgeon treating osteonecrosis of the hip and knee Treatment options can vary depending on the stage of
joint should understand the etiology, diagnosis, and disease at presentation. In the early stage of osteonecrosis,
management of the disease. there is little or no structural collapse and prognosis is
often better than in advanced stages of disease. Occa-
sionally, patients with early, or precollapse, disease can
Keywords: osteonecrosis; hip; knee; collapse; be treated nonsurgically, particularly if asymptomatic;
management however, surgery is often indicated. In osteonecrosis of the
hip, almost 80% of cases are bilateral, and the eventual
joint destruction and loss of function comprise 10% of all
total hip arthroplasties (THAs).5 Advanced cases of knee
Introduction
osteonecrosis comprise 2% of all total knee arthroplas-
Osteonecrosis is a condition with debilitating results ties (TKAs).6 Therefore, it is important for orthopaedic
that can cause structural collapse in the joints affected. surgeons to be comfortable with managing osteonecrosis
of both the hip and knee. Understanding the etiology
and pathology, evaluation and diagnosis, and treatment
Dr. Nace or an immediate family member serves as a paid (surgical and nonsurgical modalities) all help the surgeon
consultant to InforMD and has received research or insti- managing osteonecrosis of the hip and knee.
tutional support from Stryker. Dr. Mont or an immediate
family member has received royalties from Microport and
Osteonecrosis of the Hip
Stryker; serves as a paid consultant to DJ Orthopaedics,
Johnson & Johnson, Merz, Orthosensor, Pacira, Sage Prod- Etiology and Pathogenesis
ucts, Stryker, TissueGene, and US Medical Innovations; has Despite much research, the etiology of osteonecrosis is
received research or institutional support from DJ Orthopae- not well characterized, although many risk factors have
dics, Johnson & Johnson, the National Institutes of Health been identified (Table 1). The process common with all
(NIAMS & NICHD), Ongoing Care Solutions, Orthosensor, etiologies is circulatory obstruction, the causes of which
Stryker, and Tissue Gene; and serves as a board member, include coagulation of intraosseous circulation, venous
owner, officer, or committee member of the American thrombosis, and retrograde arterial occlusion. Intraos-
Academy of Orthopaedic Surgeons. None of the following seous pressure increases, causing femoral head ischemia
authors or any immediate family member has received and eventual osteonecrosis. Even when a repair process
anything of value from or has stock or stock options held is initiated, subchondral fracture and collapse are al-
in a commercial company or institution related directly or most always inevitable. Osteonecrosis does not develop
indirectly to the subject of this article/chapter: Dr. Patel, in all patients with risk factors, suggesting some genetic
Dr. Mistry, Dr. Elmallah, and Dr. Chughtai. predisposition.
Table 1 are inconsistent in explaining the relationship between

osteonecrosis and dosage, route, or treatment; however,
Risk Factors for the Development several studies have shown the cumulative dose to be
of Osteonecrosis an important factor.9,10 In bone marrow stromal cells,
Direct Risk Factors Indirect Risk Factors corticosteroids cause cell apoptosis and a decrease in
precursor cell proliferation, altering bone homeostasis
Trauma: fracture or Corticosteroids
dislocation and causing cellular injury.11 In addition, corticosteroids
can impair blood flow by enhancing femoral head arterial
Sickle cell disease Alcohol abuse
constriction, as seen with 24 hours of methylprednisolone
HIV infection Tobacco use treatment.12 Moreover, corticosteroids can activate proin-
Chemotherapy Systemic lupus flammatory pathways and are linked to various gene
erythematosus
alterations (for example, interleukin (IL)-23, IL-1α, trans-
Radiation Organ transplantation forming growth factor-beta, IL-10 and tumor necrosis
Myeloproliferative Renal failure factor-alpha).13 These pathways also include decreased
disorders expression of bone marker genes and increased expression
1: Hip and Knee
Gaucher disease Coagulation of adipogenic gene 422 (aP2) when bone marrow stromal
abnormalities cells are exposed to dexamethasone in culture. Corti-
Pregnancy costeroids can also induce extravascular fat deposition,
Genetic factors adipocyte hypertrophy, and oxidative stress, suggesting
Caisson disease a multifactorial pathophysiology.13
Data from Mont MA, Cherian JJ, Sierra RJ, Jones LC, Lieberman JR:
Nontraumatic osteonecrosis of the femoral head: Where do we stand Alcohol Abuse
today? A ten-year update. J Bone Joint Surg Am 2015;97[19]:1604- Alcohol abuse is also a well-known risk factor for osteo-
1627.
necrosis of the hip with a clear dose-response relation-
ship.14 Suspected causes of osteonecrosis of the hip and
knee include impaired mesenchymal cell differentiation,
Trauma impaired blood flow, and direct cellular toxicity. Alcohol
Hip dislocation and femoral head/neck fractures interrupt reduces osteogenic differentiation and increases adipogen-
the medial circumflex artery, which is the main blood sup- ic cell differentiation, thus increasing adipogenic volume
ply to the femoral head. Hip dislocation, which can cause in the femoral head and altering blood flow. This has
osteonecrosis in 5% to 40% of patients, increases with been shown in studies of mesenchymal stem cells (MSCs)
the degree of initial displacement, and possibly with time retrieved from proximal femora bone marrow from al-
to reduction (greater than 6 hours).7 The rate of osteone- coholics with osteonecrosis, which have demonstrated
crosis following femoral head fracture (usually with hip reduced osteogenic gene expression when cultured with
dislocation) ranges from 1% to 50%, depending on the alcohol.15 Many of the mechanisms are similar to those
location of an associated acetabular fracture and increas- of corticosteroids, including cell apoptosis and possibly
ing with the Pipkin classification type (commonly used lipopolysaccharide interactions, which activate proin-
for uncommon femoral head fractures associated with hip flammatory pathways.
dislocations [four types]). The rate of osteonecrosis for
femoral neck fracture is as high as 10% in nondisplaced Coagulation Disorders
injuries and 30% in displaced injuries, increasing with Coagulation disorders, including inherited thrombo-
the Garden classification type (for femoral neck fractures; philia and hypofibrinolysis, are risk factors for blood
can help predict risk of osteonecrosis [four types]). The flow interruption.16 In addition, endothelial progenitor
risk of osteonecrosis can be reduced with prompt ana- cells required for angiogenesis can become dysfunc-
tomic reduction and surgical fixation. Less commonly, tional.11 A study examined 200 patients with sickle
cervicotrochanteric and intertrochanteric fractures can cell disease at 15-year follow-up and reported that the
cause osteonecrosis.7 incidence of osteonecrosis was 43% in the SS geno-
type, 38% in the SC genotype, and 19% in the Sβ+
Corticosteroids thalassemia genotype.17 Hypofibrinolysis from familial
High-dose corticosteroid use is a well-known risk fac- high plasminogen activator inhibition was associated
tor for osteonecrosis, with rates of 3% to 23% seen in with osteonecrosis, and these patients were more likely
patients following transplantation.8,9 The available data to carry a hypofibrinolytic 4G polymorphism of the
Chapter 4: Osteonecrosis of the Hip and Knee
plasminogen activator inhibitor-1 gene compared with

control patients.16
Autoimmune Disease
Osteonecrosis has been linked with various conditions
such as systemic lupus erythematosus (SLE), Behçet dis-
ease, and rheumatoid arthritis. SLE has been shown to be
an independent risk factor for osteonecrosis, especially in
the presence of Raynaud phenomenon, hyperlipidemia,
and raised anticardiolipin/antiphospholipid antibodies.
Corticosteroid use in patients with SLE has a significant-
ly higher risk of osteonecrosis compared with nonusers
(37% versus 21%).18
Evaluation and Diagnosis Figure 1 Radiographs of a left hip demonstrate femoral
1: Hip and Knee

Patients may be asymptomatic, but those who present head collapse. A, AP view shows a subchondral
fracture (crescent sign) and precollapse lesion
with pain often report deep, throbbing anterior hip and of the femoral head (arrows). B, AP view
thigh pain with insidious onset. A history of antecedent shows a postcollapse lesion of the femoral
head (circle). (Reproduced with permission
trauma may not always be present. The pain is worse with from Mont MA, Cherian JJ, Sierra RJ, Jones LC,
activity, with weight bearing, and at night. The presence Lieberman JR: Nontraumatic osteonecrosis of
of risk factors should always be explored (Table 1). In the the femoral head: Where do we stand today?
A ten-year update. J Bone Joint Surg Am
early stages of osteonecrosis, physical examination can 2015;97[19]:1604-1627.)
be unremarkable. Specific joint examination can show an
antalgic gait and a positive Trendelenburg sign because
of pain. The leg may be held in a position of maximal
comfort, with a possible limb-length discrepancy (sec- Staging
ondary to collapse) and surgical scars. Range of motion Disease staging helps to determine prognosis and plan
is preserved, but is generally painful at the groin. treatment options for osteonecrosis. Various staging sys-
tems use radiologic features to stage osteonecrosis. The
Imaging most frequently used system is Ficat and Arlet, which
Initially, plain radiographs including AP and frog-lateral includes four stages that range from normal radiographic
views, are required, particularly for staging. The findings findings (stage 1) to femoral head collapse and acetabular
on these views are often normal, unless osteonecrosis has involvement (stage 4). Other commonly used classifica-
progressed enough to show subchondral collapse, acetab- tion systems are the Association Research Circulation
ular involvement, and secondary osteoarthritis (Figure 1). Osseous system, the Japanese Orthopaedic Association
Radiographs can also demonstrate radiolucencies and system, and the University of Pennsylvania system (Ta-
opacities. MRI has at least 99% sensitivity and specificity, ble 2). The four radiographic factors that are useful in
and therefore is the gold standard for evaluating osteo- evaluation are stage (before/after collapse), lesion size,
necrosis of the femoral head. MRI is particularly useful amount of femoral head depression, and acetabular in-
in detecting precollapse lesions that can occur without volvement.21 Increased lesion size specifically correlates
subchondral fracture19 (Figure 2). Additionally, MRI helps with poorer prognosis. The Kerboul classification22 can
with diagnosis, lesion sizing, and disease staging. Bone help delineate prognosis and disease progression by using
marrow edema also can be detected on MRI, and has the combined necrotic angle, which is defined as the sum
been shown to correlate with the presence of hip pain of the angles subtended by the necrotic segment in both
and disease progression in 61 asymptomatic or minimally midcoronal and midsagittal MRIs. Results showed no hip
symptomatic hips at 60-month follow-up.20 collapse with angles up to 190° in 4 hips, half-collapsed
If radiographs are normal or unclear, CT also can hips at angles between 190° to 240° in 4 hips, and fully
detect subchondral collapse. Bone scans have a high collapsed hips at angles of 240° or greater in 25 hips.22 A
false-negative rate, and positron emission tomography 2010 study demonstrated 101 asymptomatic hips with
scan, which is expensive and less commonly available, medially located small lesions (Kerboul angle less than
is sensitive but not specific, making these modalities less 200°) had a rate of collapse less than 10%, compared
useful.19 with 25% for the remainder.23
Figure 2 T1-weighted coronal MRIs of the femoral head showing a precollapse lesion of the femoral head (arrows). The
separate coronal images demonstrate the extent of the lesion (dark areas). (Reproduced with permission from
Mont MA, Cherian JJ, Sierra RJ, Jones LC, Lieberman JR: Nontraumatic osteonecrosis of the femoral head: Where
do we stand today? A ten-year update. J Bone Joint Surg Am 2015;97[19]:1604-1627.)
1: Hip and Knee
Table 2
Overview of Commonly Used Plain Radiographic Staging Systems
Association Research Japanese Orthopaedic University of
Circulation Osseous Association Ficat and Arlet Pennsylvania
Stage Findings Stage Findings Stage Findings Stage Findings
0 Normal hip 1 Demarcation 1 Normal 0 Normal hip
line radiograph
1 MRI findings 2 Early femoral 2 Diffuse sclerotic/ 1 MRI findings
only head cystic lesions only
flattening
2 Focal 3 Cystic lesions 3 Crescent sign 2 Diffuse cystic/
osteoporosis, (subchondral sclerotic lesions
cystic lesions, fracture)
sclerosis
3 Crescent sign 4 Acetabular 3 Subchondral
(subchondral involvement, step-off
fracture) femoral head
collapse
4 Acetabular 4 Femoral head
involvement flattening
5 Acetabular
involvement
or joint space
narrowing
6 Advanced joint
degeneration
Treatment small and 80% of large lesions (Kerboul angle greater

The course of treatment for osteonecrosis depends on than 240°) collapsed in 8 years.25 Spontaneous resolution
the stage of progression and the presence of symptoms. can occur in small asymptomatic lesions, and treatment
A study of the contralateral asymptomatic hip in 40 hips should be considered in moderate to large asymptomatic
showed that 88% became symptomatic and 73% col- lesions.26Figure 3 is a suggested algorithm for manage-
lapsed in 11 years.24 Another study showed that 7% of ment of hip osteonecrosis.
1: Hip and Knee

Figure 3 Algorithm for the management of hip osteonecrosis. NVBG = nonvascularized bone grafting, THA = total hip
arthroplasty, VBG = vascularized bone grafting. (Reproduced with permission from Mont MA, Cherian JJ, Sierra RJ,
Jones LC, Lieberman JR: Nontraumatic osteonecrosis of the femoral head: Where do we stand today? A ten-year
update. J Bone Joint Surg Am 2015;97[19]:1604-1627.)
Nonsurgical Management Core Decompression

The use of several drug types such as lipid-lowering Good outcomes have been demonstrated in hips with
drugs, antiplatelet and anticoagulant agents, and di- symptomatic, precollapse, and small- to medium-sized
phosphonates can have some benefit with osteonecrosis. lesions, with failure rates of 14% to 25%.5 Trephines (8-
Lipid-lowering agents such as statins can manipulate to 10-mm) or multiple (two to three) percutaneous holes
lipid deposition and target thrombosis. Antiplatelet and drilled (3.2 mm) into the area of subchondral necrosis are
anticoagulant agents have been hypothesized to prevent used to reduce intraosseous pressure and prevent further
progression of early osteonecrosis and may improve compression.26 More selective indications for core decom-
blood flow, more likely in patients who have inher- pression (only smaller precollapse lesions) and improved
ited coagulation disorders. Diphosphonates are used techniques, particularly since 1992, 27 have resulted in
to increase bone mineral density and improve clinical better outcomes. Multiple drilling has also been com-
function. Alternative modalities such as extracorporeal pared with traditional core decompression with equally
shock wave therapy and hyperbaric oxygen have shown good results.28 One study demonstrated that of 120 hips
improvement in pain and functional scores. Although that underwent multiple drilling, 93 (78%) survived at
these nonsurgical modalities have reported benefits, 5-year follow-up; of 59 hips with small to medium-sized
studies are limited and insufficient evidence exists to lesions, 52 (88%) required no additional surgery.29 One
support such claims. study evaluated the outcomes of multiple percutaneous
drillings in precollapse osteonecrosis of the femoral
Surgical Management head and reported successful outcomes, with minimal
Surgical treatment includes either joint preservation tech- morbidity in 80% of patients who had Ficat and Arlet
niques (core decompression with or without adjunctive stage 1 disease.30 A 2010 study evaluated 76 precollapse
procedures and rotational osteotomies) in precollapse hips in patients who underwent treatment with core de-
lesions, or arthroplasty in advanced disease. compression and implantation of a biomaterial-loaded
allograft threaded cage and reported a 91% success rate Vascularized

and significantly improved functional outcomes (63 to Like NVBG, vascularized bone grafting (VBG) provides
82 points on the Harris Hip Score) compared with core structural support to allow subchondral bone healing
decompression alone.31 Core decompression can be used and remodeling and also restores vascular supply (pedicle
as the first surgical treatment option for symptomatic grafting). This revascularization can be from bone, such
small to medium-sized precollapse lesions only. Adjunc- as from the fibula to the lateral circumflex artery and from
tive treatments have not influenced outcomes and cannot the iliac crest to deep circumflex iliac vessels; or from
currently be recommended. muscle, such as from the quadratus femoris, sartorius,
tensor fascia lata, and gluteus medius. VBG is used for
Femoral Osteotomy early postcollapse lesions, ideally from reversible caus-
Rotational or angular osteotomies aim to redistribute es. Survival rates are 80% to 100%; however, outcomes
weight-bearing forces from necrotic areas to healthy car- are poorer after collapse occurs.5 One study followed
tilage. Success rates range from 82% to 100% at 3- to 15- 103 patients for a minimum of 5 years following treat-
year follow-up (evidence levels II to IV) for rotational, and ment for osteonecrosis of the hips using a vascularized
82% to 98% at 6- to 18-year follow-up (evidence levels III fibular graft. The study demonstrated that the treatment
1: Hip and Knee
and IV) for angular osteotomy.13,32 One study examined of small and medium precollapse lesions had the best re-
angular osteotomy in 73 hips and reported 92% survi- sults. Of 75 patients who answered a questionnaire, 81%
vorship at 12 years.33 Despite good outcomes, the use of were satisfied with the results. Of 24 of 62 hips (39%)
femoral osteotomy is less popular because of the inherent with a more advanced lesion, only 5 of 22 hips (23%)
technical challenges, limited use in small lesions, associ- had satisfactory results, and 2 of 19 hips (11%) with a
ated complications (delayed union and nonunion, loss precollapse injury were converted to a THA.35 One study
of position and or/fixation), and complex conversions to produced an 88% success rate with VBG and the mean
THA. One study demonstrated longer surgical time and Harris Hip Scores improved from 50 to 91 points.36 An-
higher transfusion rates in 14 patients with conversion other study of 120 hips that underwent multiple drilling
of osteotomy to THA, compared with routine THA.32 reported a 78% survivorship (93 hips) at 5-year follow-up,
and 88% of hips (52 of 59) with small- to medium-sized
Bone Graft lesions required no additional surgery. 29 Age may be
Nonvascularized a factor with mixed outcomes in patients older than
Nonvascularized bone grafting (NVBG) is often used 40 years.23,31 One study of VBG augmented with MSCs
in patients in whom core decompression has failed. The mixed with β-tricalcium-phosphate reported a 94% sur-
necrotic segment is decompressed and the autograft or vival in 30 hips at 99-month follow-up. Despite the lack
allograft material is implanted in the femoral head to of randomized controlled trials, VBG results in good
provide structural support and allow healing and sub- outcomes in precollapse disease.
chondral bone remodeling.23 The segment is accessed
through a core track or cortical window at the base of Mesenchymal Stem Cells
the femoral head-neck junction known as the lightbulb, MSCs are usually delivered into the core decompression
trapdoor, or Phemister technique, which is indicated for track to allow them to differentiate into osteoblasts. MSCs
medium-sized or larger precollapse or early postcollapse can be derived from bone marrow and adipose tissue
lesions. Several studies of NVBG have reported success which, although unconfirmed in humans, have survived,
rates that range from 67% to 91%. In one study, the proliferated, and differentiated in animal models.37 Ran-
lightbulb technique (NVBG with bone morphogenetic domized controlled trials examining core decompression
protein 7 through a cortical window) had a 67% success and MSCs compared with core decompression alone have
rate in 39 hips, which improved to 81% (18 of 22 hips) shown favorable outcomes regarding Harris Hip Score, le-
with early-stage lesions.34 A level II study showed that sion size, and time to collapse in 100 patients followed up
an allograft procedure had 84% survival (46 of 55 hips) for 60 months.36 In a literature review that compared the
at 3-year follow-up.31 One study on NVBG used the clinical and radiologic improvement of autologous MSC
trapdoor technique in 33 hips and reported at 2-year implantation into the core decompression track versus
follow-up that 80% of hips with Ficat and Arlet stage II using the core compression alone, it was suggested that the
disease did not need additional surgery.34 These studies survival of the femoral head would improve and minimize
show that NVBG can delay the need for THA in young the need for hip arthroplasty when autologous MSCs are
patients with small to medium-sized precollapse or early used during the precollapse stages of osteonecrosis of the
postcollapse lesions. femoral head.38 Despite these promising results for the use
of MSCs in core decompression and bone grafting tech- bone grafting, hemiresurfacing, and total hip resurfac-
niques, the process is currently experimental and more ing; however, survival was 95%, 97%, 88%, and 91%,
research on the mechanism of treatment of osteonecrosis respectively, at 6-year follow-up.26
of the femoral head is needed. In addition, the restrictions
on MSC use in some countries and substantial resource
requirement present a barrier to widespread use. Osteonecrosis of the Knee
The specific cause of osteonecrosis of the knee is still
Total Hip Arthroplasty largely unknown. There are three types of knee osteo-
THA is indicated when there is femoral head collapse necrosis: primary (or spontaneous osteonecrosis of the
with or without secondary osteoarthritis, and nonsurgical knee [SONK]), secondary (also called atraumatic, idio-
management has failed. Advances in techniques and im- pathic, or ischemic osteonecrosis), and postarthroscopic.
plant technology such as highly cross-linked polyethylene, SONK has an incidence of 9.4% in women older than
newer-generation ceramic bearings, and more completely 65 years.44 Secondary osteonecrosis affects younger pa-
porous coated surfaces have improved outcomes and have tients (younger than 45 years) and women more often than
shown excellent results at short- to midterm follow-up.13 A men (a ratio of 4:1), similarly to hip osteonecrosis.45 Few
1: Hip and Knee

2013 study reported a 100% survivorship and a mean cases of postarthroscopic osteonecrosis are reported each
Harris Hip Score of 93 points (range, 77 to 98 points) for year, usually occurring in patients in their fifth decade,
THA patients with osteonecrosis using highly cross-linked and it commonly occurs at the medial femoral condyle
polyethylene after a minimum follow-up of 5 years.39 In (Table 3). One study of 50 patients reported that in 2 pa-
addition, a 2012 study evaluated patients younger than tients (4%), postarthroscopic osteonecrosis developed.46
20 years who received a ceramic-on-ceramic bearing In the acute phase, all patients may have an effusion
surface and reported an implant survival rate of 96% with reduced range of motion. Plain weight-bearing radio-
and a mean Harris Hip Score of 93 points (range, 66 to graphs should be obtained initially with all types of os-
100 points) after a mean follow-up of 52 months (range, teonecrosis, although the images appear normal in the
25 to 123 months).40 Previously, THA performed for os- early stages of disease.45 Additionally, radiographs may
teonecrosis has had poor outcomes, with rates of aseptic show increased bone density from new bone formation
loosening between 8% and 37% and a revision rate of next to the necrotic bone, accentuated by surrounding
17% at 9 years.41 These patients tended to be younger and osteopenia. Diagnosis of each type of osteonecrosis is
placed high demands on their THAs, risking polyethylene confirmed using MRI, which has positive findings in the
wear, osteolysis, and ceramic fracture. Newer studies early stages of disease for bone edema, focal epiphyseal
with follow-up of more than 10 years42,43 demonstrate depressions, and low-signal subchondral and deep linear
low wear rates on radiostereometric analysis, suggesting signal intensities on T2-weighted images.47
that osteonecrosis is no longer a substantially negative Management of osteonecrosis of the knee depends on
factor for THA.42,43 the type, symptoms, and stage of disease. Classification
Previously, concerns existed that osteonecrosis could systems (Table 4) can help guide staging: the Koshino
hinder ingrowth in noncemented implants. However, a classification48 was later modified so that stage 1 is nor-
2013 study reported significantly lower rates of aseptic mal, stage 2 is a mild flattening of weight-bearing surface,
loosening in noncemented implants compared with ce- stage 3 is a subchondral lucency, stage 4 is a collapse of
mented implants.42 In addition, a 2013 study of nonce- the subchondral bone, and stage 5 is characterized by
mented implants in 64 hips showed survival rates of 100% secondary degenerative change.49
for aseptic loosening and 94% for all causes at a mean The size of the osteonecrotic lesion is prognostic, and
follow-up of 15.8 years.43 In addition, the etiology of the various methods are available for measurement. The first
osteonecrosis may influence the rate of aseptic loosening. method multiplies the width of the lesion measured on AP
In a meta-analysis of 3,277 hips, higher failure rates were and lateral radiographs. Small lesions (less than 3.5 cm 2)
reported in patients who had osteonecrosis secondary to usually regress, medium lesions (range, 3.5 to 5.0 cm 2)
sickle cell disease, Gaucher disease, and following renal may or may not progress, and large lesions (larger than
transplantation. Lower rates of osteonecrosis were seen 5 cm2) usually progress to condylar collapse.49,50 The sec-
in patients with idiopathic disease, with SLE, and fol- ond method calculates the lesion size as a percentage
lowing heart transplantation.41 The overall quality of of the affected femoral condyle on the AP radiograph.
the bone stock still remains important for the outcomes. One study showed that 6 of 23 patients (26%) with a
Finally, many of these patients had undergone other sur- mean involvement of 32% of the medial femoral con-
gical procedures before THA such as core decompression, dyle required surgery, whereas all 79 patients with more
Table 3
Clinical Presentation and Etiology in Osteonecrosis of the Knee
Other Joint Associated Risk
Type Age Bilaterality Involvement Factors Lesion Description
Spontaneous Older < 5% No Microtrauma, Bony fibrosis, healing
osteonecrosis of than chronic fracture, osteoarthritis,
the knee 50 mechanical stress, osteopenia, necrosis
years idiopathic only at distal portion of
fractured segment
Secondary Younger > 80% > 90% Indirect causes: Necrotic bone
osteonecrosis than (commonly corticosteroid
45 shoulder, use, inflammatory
years hip, ankle) bowel disease,
smoking,
systemic lupus
erythematosus,
1: Hip and Knee
coagulation
abnormalities
(hypofibrinolysis,
thrombophilia)
Direct causes:
chemotherapy,
radiation, trauma,
caisson disease,
Gaucher disease
Postarthroscopic Any No No Anterior cruciate Healing fracture and
osteonecrosis ligament bony fibrosis; bone
reconstruction, necrosis after direct
meniscectomy, thermal or acoustic
laser- or injury
radiofrequency-
assisted surgery,
or cartilage
débridement
than 50% involvement progressed to collapse without edema, focal ischemia, and eventual necrosis.44,45 A
surgery and ultimately required arthroplasty.51 In second- 2009 study of 22 patient specimens reported no evidence
ary osteonecrosis, large epiphyseal lesions were found to of osteonecrosis was found; however, 64% (14 of 22)
have a substantially worse prognosis than metaphyseal showed evidence of osteopenia and 68% showed evidence
or diaphyseal lesions.45 Postarthroscopic osteonecrosis of osteoarthritis (15 of 22).44 Overall, SONK is thought to
does not correlate as well with lesion size. Algorithms can be underdiagnosed, and many patients who present with
be used to plan the management of primary (Figure 4), osteoarthritis may actually have occult SONK.
secondary (Figure 5), and postarthroscopic (Figure 6)
osteonecrosis of the knee. Evaluation and Diagnosis
SONK causes acute, severe medial knee pain, which is
Spontaneous Osteonecrosis of the Knee worse on weight bearing and typically occurs at night.
Etiology and Pathogenesis Usually, no history of trauma is reported, although a few
SONK typically presents as a unilateral, focal, subchon- patients report preceding trauma. With SONK, tender-
dral lesion affecting a single joint and condyle. The medial ness is found on the medial femoral condyle (or affected
femoral condyle is most commonly involved (more than area).
90% of cases). It is theorized that minor trauma in the
setting of osteopenic bone, which affects 75% of patients Imaging
with SONK, causes subchondral insufficiency fractures. On plain radiographs, radiolucencies with a surround-
Fluid accumulates in these potential spaces, causing ing sclerotic halo and flattening of the femoral condyle
may be seen, mainly affecting the epiphysis. Late disease Table 4

stages show a crescent sign from collapse of the necrot-
ic bone segment from the subchondral bone, followed Staging Systems for Osteonecrosis of the Knee
by full collapse, femoral condyle flattening, and osteo- Classification Description
arthritis (Figure 7). An early MRI for SONK may have and Stage
normal findings; therefore, it should be performed 4 to
Koshino For primary/spontaneous
6 weeks following symptom onset. Usually, one necrotic osteonecrosis of the knee
lesion with a low signal intensity is seen on T1- and T2- I Knee symptoms, radiographs
weighted images, surrounded by marrow edema, affecting normal
the whole condyle. Other findings can include articular II Radiographic flattening and
cartilage abnormalities, loose bodies, and sclerosis. subchondral lucencies on weight-
bearing area, surrounded by
Nonsurgical Treatment osteosclerosis
Protected weight bearing for 4 to 6 weeks, physical thera- III Radiographic extension of
py, analgesics, and NSAIDs are indicated for small lesions subchondral lucencies around
affected area and subchondral
1: Hip and Knee

(less than 3.5 cm2). Some patients in the early stages of collapse
SONK who are treated nonsurgically usually experience
IV Radiographic degenerative
resolution of symptoms and MRI findings within 3 to change with osteosclerosis and
8 months.4 One study showed none of the 10 patients osteophyte formation
with less than 20% involvement required surgery at Modified Ficat For secondary and
9-year follow-up.52 Another study of 79 cases of stage and Arlet postarthroscopic
1 SONK of the medial femoral condyle showed 89% I Normal joint space, no
resolution after nonsurgical treatment; only 1 patient subchondral collapse,
required TKA.51 Diphosphonates can prevent or delay the osteoporosis mottled areas
need for surgery by inhibiting bone resorption and were II Normal joint space, no
shown to prevent subchondral collapse in femoral head subchondral collapse, wedge
osteonecrosis.53 After a minimum of 6 months of treat- sclerosis in trabeculae
ment with alendronate, subchondral collapse developed III Normal or slightly narrowed joint
in 3 of 17 patients (18%) with SONK (all 3 stopped treat- space, subchondral collapse,
trabecular sequestration
ment prematurely).52 However, a randomized controlled (‘crescent sign’)
trial compared diphosphonates with NSAIDs for early
IV Narrowed joint space, subchondral
SONK and reported no benefit regarding pain scores and collapse, extensive destruction
radiologic outcomes.54 A promising nonsurgical treatment
Data from Woehnl AN, Naziri Q, Costa C, et al: Osteonecrosis of
is pulsed electromagnetic field therapy, which has been the knee. Orthopaedic Knowledge Online Journal 2012;10(5); and
shown to reduce pain and the size of the necrotic lesion Koshino T, Okamoto R, Takamura K, Tsuchiya K: Arthroscopy in
spontaneous osteonecrosis of the knee. Orthop Clin North Am
in SONK at 6 months.55 1979;10(3):609-618.
Surgical Treatment
Surgery is indicated when no clinical or radiographic im- postoperative knee pain in all 16 patients (15 with stag-
provement is seen after 3 months of nonsurgical treatment es 1 and 2, 1 with stage 3), and those with early-stage
or in patients with large osteonecrotic lesions (larger than disease had normalization of bone marrow signal inten-
3.5 cm2 or greater than 50% of the condyle). However, sity on latest follow-up MRI.57 Core decompression is
the risk of progression to collapse is high.6,45,51 Initially, effective in delaying the need for TKA, and the addition
joint preservation techniques can be used, ideally in the of calcium hydroxyapatite bone graft to the core track
precollapse state, including arthroscopy (microfracture, has also demonstrated good outcomes.58 Osteochondral
chondroplasty, or meniscectomy), core decompression, allograft techniques allow restoration of the articular
osteochondral allograft techniques, and high tibial cartilage following subchondral collapse. The principles
osteotomy. of osteochondral allografting are to remove the collapsed
Using the Cincinnati Knee Rating System, micro- tissue and replace it with structurally sound osteochon-
fracture resulted in clinical improvement in 25 of 26 pa- dral tissue. Outcomes have been excellent, despite small
tients (96%) with SONK at 27-month follow-up.56 In numbers, including a study in which eight of nine patients
another study, core decompression improved immediate with SONK had a successful outcome with postoperative
1: Hip and Knee
Figure 4 Algorithm for the management of spontaneous osteonecrosis of the knee. SONK = spontaneous osteonecrosis
of the knee, TKA = total knee arthroplasty, UKA = unicompartmental knee arthroplasty. (Reproduced with
permission from Karim AR, Cherian JJ, Jauregui JJ, Pierce T, Mont MA: Osteonecrosis of the knee: Review. Ann
Transl Med 2015;3[1]:6).
Figure 5 Management of secondary osteonecrosis of the knee. TKA = total knee arthroplasty. (Reproduced with permission
from Karim AR, Cherian JJ, Jauregui JJ, Pierce T, Mont MA: Osteonecrosis of the knee: Review. Ann Transl Med
2015;3[1]:6).
mean Knee Society Score (KSS) of 85 points at 40-month scores (KSS knee, 50 points preoperatively to 88 points
follow-up.58 For younger, more active patients, high tibial postoperatively; KSS functional, 57 points preoperatively
osteotomy shifts the weight-bearing axis to offload the to 89 points postoperatively) at 6.5-year follow-up.59 Im-
affected condyle, reduces pain, and potentially allows portantly, the results were equally good in those older
healing. Although it cannot be used in multifocal (such than 70 years. Core decompression also can be successful-
as secondary) osteonecrosis, it has demonstrated excel- ly implemented with this technique.4 In advanced disease
lent outcomes in other cases.6 One study of 78 knees (in with collapse, and/or when joint preservation techniques
64 patients) that underwent high tibial osteotomy with fail, arthroplasty should be considered.
bone substitute reported significantly improved mean Unicompartmental knee arthroplasty (UKA) is an
Figure 7 Images of a patient with secondary

osteonecrosis undergoing hemodialysis. A,
Bilateral AP radiographs demonstrate collapse
of the medial femoral condyle in the right
knee and total knee arthroplasty in the left.
1: Hip and Knee

B, T1-weighted coronal MRI of the right knee
shows osteonecrosis and collapse of the medial
femoral condyle from secondary osteonecrosis
(arrows).
Figure 6 Management of postarthroscopic osteonecrosis

of the knee. SONK = spontaneous osteonecrosis (bilateral in 80% of cases), possibly extending into the
of the knee. (Reproduced with permission from
Karim AR, Cherian JJ, Jauregui JJ, Pierce T, Mont diaphysis and metaphysis. Multiple joints are also in-
MA: Osteonecrosis of the knee: Review. Ann volved, such as the femoral head (90% of cases) and prox-
Transl Med 2015;3[1]:6).
imal humerus.6 As with the hip, numerous risk factors,
both direct and indirect, are involved.
option for involvement of only one condyle, but historical- Evaluation and Diagnosis
ly has had poor outcomes. More recently, outcomes have Secondary osteonecrosis presents with gradual onset of
been good with improved techniques and implants.59 A pain, usually over the femoral condyles, but also the tibial
retrospective study of 52 patients who underwent UKA condyles (20%) and other joints.6 Secondary osteonecro-
for SONK demonstrated improved KSS from 85 points sis presents with more diffuse tenderness from possible
preoperatively to 173 points at 10-year follow-up.60 Sur- multifocal lesions.
vival was 93% and 91% at 10 and 15 years, respectively.
Another study compared the medial Oxford UKA (Biom- Imaging
et) in 29 knees (27 patients) with SONK in 28 knees Secondary osteonecrosis has multiple larger lesions with
(26 patients) with osteoarthritis and reported similar serpentine appearance of radiodense bony infarcts on
Oxford UKA knee scores at 5 years postoperatively radiographs. A similar appearance can be noted on MRI
(38 and 40 points, respectively). No failures were reported and bone scintigraphy: multiple areas of central fatty mar-
in either group at 5-year follow-up.61 When more than row signal intensity surrounded by a serpentine border of
one compartment is affected, TKA is recommended. A reactive bone with low signal intensity on T1- and high
systematic review of 148 patients reported those who signal intensity on T2-weighted images.
underwent TKA for SONK had the best outcomes com-
pared with TKA for secondary osteonecrosis and UKA for Nonsurgical Treatment
SONK; those who underwent TKA for SONK had better Nonsurgical treatment is only recommended in
postoperative knee scores and lower revision rates,59 mak- asymptomatic cases of secondary osteonecrosis be-
ing them comparable to patients with osteoarthritis. cause symptomatic patients tend to be younger, with
larger lesions and poor prognosis. In one study, 8 of
Secondary Osteonecrosis 10 asymptomatic patients had no disease progression
Etiology and Pathogenesis on radiographs, and did not require surgery at 8-year
With secondary osteonecrosis, multiple diffuse lesions follow-up.50 The same study also had 41 symptomatic
are usually seen in both the femoral and tibial condyles patients, 8 (19%) of whom had satisfactory outcomes
(KSS greater than 80 and no surgery) with this approach, 28 patients demonstrated an 89% success rate in post-
and 29 patients (70%) required TKA. Diphosphonates collapse disease at 2-year follow-up, with an increase in
may also play a role in secondary osteonecrosis. One functional KSS preoperatively from 60 points to 86 points
study62 of 28 symptomatic patients treated with pami- at final follow-up.66 Importantly, caution is recommended
dronate followed by alendronate reported improvements in corticosteroid-related osteonecrosis because treating
in pain scores at 6 weeks and greater improvements at patients with inadequate graft revascularization and graft
6 months. In addition, 15 patients (53%) had complete subsidence may occur.
resolution of pain and 18 patients (64%) had complete Finally, arthroplasty should be considered with joint
reversal of bone marrow edema on MRI at 6-month fol- collapse and when joint preservation techniques have
low-up. Prostaglandin I2 has been shown to improve pain, failed. Unlike SONK, more diffuse disease occurs in
function, and bone marrow edema in early disease, but secondary osteonecrosis, warranting TKA. One study
not in advanced disease.62 reported a survival rate of 97% in 30 patients, with an
increase in mean KSS from 54 points preoperatively to
Surgical Treatment 95 points at 108-month follow-up.67
Secondary osteonecrosis of the knee can be treated using
1: Hip and Knee
joint-preservation techniques in precollapse disease stag- Postarthroscopic Osteonecrosis

es. In addition, bone impaction grafting can be performed Etiology and Pathogenesis
to help delay the need for arthroplasty. Arthroscopy treats Postarthroscopic osteonecrosis of the knee is usually
any coexisting chondral and/or meniscal pathologies and seen following meniscectomy, chondroplasty, and less
is also useful to assess the chondral surface.6 Core decom- commonly, anterior cruciate ligament reconstruction. In
pression can be performed with a small (3 mm) drill into one study of medial meniscal root tears, elevated hoop
the affected condyle via the metaphysis, under fluoroscop- stresses caused increased tibiofemoral contact pressures
ic guidance, followed by partial weight bearing for 4 to and subchondral insufficiency fractures in 80% of cas-
6 weeks. This technique relieves pain with low morbidity es.68 Synovial fluid ingress causes edema, subchondral
and delays further surgery. One study reported a 92% vascular insufficiency, and necrosis. In addition, overly
success rate after core decompression, defined as a KSS aggressive early rehabilitation before adequate postopera-
higher than 80 points in 56 of 61 knees (38 patients):48 of tive remodeling has occurred can also cause insufficiency
these, success was noted in all small lesions as well as in fractures.
86% of large lesions (32 of 37 knees) at 3-year follow-up.
In addition, only 2 knees (3%) required TKA at 3-year Evaluation and Diagnosis
follow-up.63 Impaction bone grafting is used in solitary Postarthroscopic osteonecrosis also results in acute onset
early lesions because it involves removal of the osteone- of pain in the area of pathology and surgery, usually 6 to
crotic area via a metaphyseal window, and impaction 8 weeks postoperatively, which becomes persistent.68 Each
of autograft or allograft to prevent collapse and restore patient will have stiffness and swelling, with potential-
condylar sphericity.45 ly worsening pain from progressive collapse. Postar-
Although there are few studies assessing impaction throscopic osteonecrosis presents with tenderness in the
bone grafting, early results demonstrate that it may delay area of the lesion and/or surgical compartment.4
the need for TKA in early collapse disease. A study of
three patients demonstrated improvements in mean KSS Imaging
from 63 points preoperatively to 89 points and func- Two criteria must be fulfilled for diagnosis of postar-
tional KSS from 19 points preoperatively to 81 points at throscopic osteonecrosis: absence of osteonecrosis on
2-year follow-up, with no complications and near-nor- preoperative MRI 4 to 6 weeks after symptom onset and
mal function and activity levels.64 Another prospective a recent history of arthroscopy and development of sus-
study of nine patients reported no progression of col- picious bone marrow edema pattern in the surgical com-
lapse: three patients had signs of early osteoarthritis and partment on postoperative MRI.45,68 In one study, edema
overall scores (KSS objective, 63 points preoperatively to was shown to occur in 32 of 93 patients (34%) undergoing
89 points postoperatively; functional, 19 points preopera- arthroscopic meniscectomy within 8 months, and osteo-
tively to 81 points postoperatively) improved at 51-month necrosis developed in none.69 Bone scans show uptake in
follow-up, and none required TKA.65 Osteochondral al- the affected condyle in all three phases after 72 hours,
lograft transplantation restores the articular cartilage but are not recommended because of poor sensitivity and
and subchondral bone, including that affected by large specificity. Scintigraphy detects only 56% of multifocal
lesions. Current data are limited; however, one study with lesions seen on MRI and confirmed histopathologically.4
Nonsurgical Treatment Key Study Points

Nonsurgical treatment should be used only in patients
• Osteonecrosis of the hip and knee can have various
with early-stage, precollapse lesions and includes pro-
etiologies; however, interruption of the blood supply
tected weight bearing, NSAIDs, and analgesics. One
ultimately is the main culprit.
study showed that 44 of 47 patients (97.6%) continued
to have the same MRI appearance after 6 weeks of pro- • Effective imaging modalities for osteonecrosis of
tected weight bearing.68 Diphosphonates such as intrave- the hip or knee include plain radiographs, MRI,
nous pamidronate followed by oral alendronate for 4 to and CT. Bone scintigraphy and positron emission
6 months resulted in a decreased pain score at 6 weeks tomography do not yet have definitive roles in
and at 6 months (80% reduction) in 22 patients with diagnosis.
osteonecrosis following meniscectomy.70 • In general, nonsurgical treatment can be used in
early, precollapse lesions. Surgical intervention is
Surgical Treatment indicated in the setting of collapse and/or degener-
Surgical intervention is indicated when there is collapse ation of the articular surface.
and/or degeneration of the articular surface. With ear-
1: Hip and Knee

ly disease, joint preservation techniques are indicated,
depending on patient age and activity level.6 However,
the outcomes of the limited studies on these techniques Annotated References
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This review article discusses the latest findings in patho- evaluation of osteonecrosis of the femoral head over the
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following osteonecrosis of the femoral head. Severe disease have been made, studies continue to frequently use limited,
treated with total joint arthroplasty has shown excellent nonquantitative methods.
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22. Ha YC, Jung WH, Kim JR, Seong NH, Kim SY, Koo KH: 30. Mont MA, Ragland PS, Etienne G: Core decompression
Prediction of collapse in femoral head osteonecrosis: A of the femoral head for osteonecrosis using percutaneous
modified Kerboul method with use of magnetic resonance multiple small-diameter drilling. Clin Orthop Relat Res
images. J Bone Joint Surg Am 2006;88(suppl 3):35-40. 2004;429:131-138. Medline DOI
Medline DOI
31. Yang S, Wu X, Xu W, Ye S, Liu X, Liu X: Structural
23. Mont MA, Zywiel MG, Marker DR, McGrath MS, Del- augmentation with biomaterial-loaded allograft thread-
anois RE: The natural history of untreated asymptomatic ed cage for the treatment of femoral head osteonecrosis.
osteonecrosis of the femoral head: A systematic literature J Arthroplasty 2010;25(8):1223-1230. Medline DOI
review. J Bone Joint Surg Am 2010;92(12):2165-2170.
Medline DOI In this prospective analysis, 76 patients with osteonecrosis
of the femoral head were allocated to receive either core
This review examined asymptomatic osteonecrosis of decompression alone or core decompression and implan-
the femoral head and the prevalence of progression to tation of a biomaterial-loaded allograft threaded cage. Pa-
symptomatic disease or femoral head collapse. Of 16 stud- tients in the latter group had significantly improved Harris
ies examined, 394 of 664 hips (59%) had progression to Hip Scores and better clinical success rates at 36 months
symptoms or collapse. postoperatively.
24. Hernigou P, Poignard A, Nogier A, Manicom O: Fate of 32. Issa K, Johnson AJ, Naziri Q, Khanuja HS, Delanois
very small asymptomatic stage-I osteonecrotic lesions of RE, Mont MA: Hip osteonecrosis: Does prior hip sur-
1: Hip and Knee

the hip. J Bone Joint Surg Am 2004;86-A(12):2589-2593. gery alter outcomes compared to an initial primary total
Medline hip arthroplasty? J Arthroplasty 2014;29(1):162-166.
Medline DOI
25. Nakamura J, Harada Y, Oinuma K, Iida S, Kishida S, In this study, clinical and radiographic outcomes in 87 pa-
Takahashi K: Spontaneous repair of asymptomatic osteo- tients who underwent hip preservation techniques were
necrosis associated with corticosteroid therapy in systemic compared with those of 105 patients who underwent
lupus erythematosus: 10-year minimum follow-up with THA. No differences were observed in survivorship, or
MRI. Lupus 2010;19(11):1307-1314. Medline DOI clinical or radiographic outcomes at a mean of 75 months.
This retrospective analysis on the use of corticosteroid
therapy in patients with SLE having asymptomatic os- 33. Zhao G, Yamamoto T, Ikemura S, et al: Radiological out-
teonecrosis reported that almost one-half of all joints come analysis of transtrochanteric curved varus osteotomy
demonstrated spontaneous repair in the necrotic area at for osteonecrosis of the femoral head at a mean follow-up
final follow-up. of 12.4 years. J Bone Joint Surg Br 2010;92(6):781-786.
Medline DOI
26. Banerjee SK, Cherian JJ, Jauregui JJ, Mont MA: Multi- This retrospective review of 73 hips separated into two
focal Osteonecrosis .New York, Springer, 2014. DOI groups based on radiologic findings of osteonecrosis re-
This study used MRI to document the long-term natural ported a postoperative intact ratio cutoff point to prevent
history of asymptomatic osteonecrosis associated with both progression of collapse and joint space narrowing
corticosteroid therapy in SLE patients. of 41.9%.
27. Marker DR, Seyler TM, Ulrich SD, Srivastava S, Mont 34. Seyler TM, Marker DR, Ulrich SD, Fatscher T, Mont
MA: Do modern techniques improve core decompression MA: Nonvascularized bone grafting defers joint ar-
outcomes for hip osteonecrosis? Clin Orthop Relat Res throplasty in hip osteonecrosis. Clin Orthop Relat Res
28. Al Omran A: Multiple drilling compared with standard 35. Urbaniak JR, Coogan PG, Gunneson EB, Nunley JA:
core decompression for avascular necrosis of the femoral Treatment of osteonecrosis of the femoral head with free
head in sickle cell disease patients. Arch Orthop Trauma vascularized fibular grafting. A long-term follow-up study
Surg 2013;133(5):609-613. Medline DOI of one hundred and three hips. J Bone Joint Surg Am
1995;77(5):681-694. Medline
Classic and multiple-drilling approaches were compared
for the management of osteonecrosis of the femoral head 36. Zhao D, Cui D, Wang B, et al: Treatment of early stage
in patients with sickle cell disease. Multiple drilling was osteonecrosis of the femoral head with autologous implan-
found to be safer and less invasive in this population. tation of bone marrow-derived and cultured mesenchymal
However, no differences were reported in outcomes or stem cells. Bone 2012;50(1):325-330. Medline DOI
complications between cohorts.
Ex vivo expansion of autologous bone marrow–derived
29. Song WS, Yoo JJ, Kim YM, Kim HJ: Results of mul- MSCs can reliably provide a greater number of bone mar-
tiple drilling compared with those of conventional row–derived MSCs for femoral head implantation.
methods of core decompression. Clin Orthop Relat Res
2007;454(454):139-146. Medline DOI 37. Wang B, Zhao D, Liu B, Wang W: Treatment of osteone-
crosis of the femoral head by using the greater trochanteric
bone flap with double vascular pedicles. Microsurgery The authors of this study suggested that noncemented
2013;33(8):593-599. Medline THA with a modular stem is a promising procedure for
young, active patients with osteonecrosis of the femoral
In this study, outcomes following the use of greater tro- head.
chanteric bone flaps in 32 patients with osteonecrosis of
the femoral head were assessed. Only 2 patients required
hip replacement at a mean follow-up of 99.5 months. The 44. Mears SC, McCarthy EF, Jones LC, Hungerford DS, Mont
authors advocated for the use of this easier, less morbid MA: Characterization and pathological characteristics
procedure in young patients with stage II or III disease. of spontaneous osteonecrosis of the knee. Iowa Orthop
J 2009;29:38-42. Medline
38. Papakostidis C, Tosounidis TH, Jones E, Giannoudis PV:
The role of “cell therapy” in osteonecrosis of the femoral 45. Mont MA, Marker DR, Zywiel MG, Carrino JA: Osteo-
head. Acta Orthop 2016;87(1):72-78. Medline DOI necrosis of the knee and related conditions. J Am Acad
Orthop Surg 2011;19(8):482-494. Medline DOI
The authors of this study suggest that implantation of
autologous MSCs into the core decompression track, par- The authors of this study suggest that secondary osteo-
ticularly at early (precollapse) stages of osteonecrosis of necrosis frequently progresses to end-stage disease, and
the femoral head, improves the survivorship of femoral early surgical intervention is recommended. Initial man-
heads and reduces the need for hip arthroplasty. agement of spontaneous osteonecrosis of the knee and
postarthroscopic osteonecrosis is typically nonsurgical,
1: Hip and Knee
with observation for clinical or radiographic progression.

39. Min BW, Lee KJ, Song KS, Bae KC, Cho CH: Highly
cross-linked polyethylene in total hip arthroplasty for
osteonecrosis of the femoral head: A minimum 5-year 46. Cetik O, Cift H, Comert B, Cirpar M: Risk of osteone-
follow-up study. J Arthroplasty 2013;28(3):526-530. crosis of the femoral condyle after arthroscopic chondro-
Medline DOI plasty using radiofrequency: A prospective clinical series.
Knee Surg Sports Traumatol Arthrosc 2009;17(1):24-29.
This study evaluated 162 hips with osteonecrosis of the Medline DOI
femoral head that underwent THA using highly cross-
linked polyethylene liners. After a minimum follow-up of 47. Fotiadou A, Karantanas A: Acute nontraumatic adult
5 years, there was no radiographic evidence of loosening knee pain: The role of MR imaging. Radiol Med
or osteolysis, and no revisions were reported. 2009;114(3):437-447. Medline DOI
40. Finkbone PR, Severson EP, Cabanela ME, Trousdale 48. Koshino T, Okamoto R, Takamura K, Tsuchiya K: Ar-
RT: Ceramic-on-ceramic total hip arthroplasty in pa- throscopy in spontaneous osteonecrosis of the knee. Or-
tients younger than 20 years. J Arthroplasty 2012;27(2): thop Clin North Am 1979;10(3):609-618. Medline
213-219. Medline DOI
This study reports promising results at short-term to mid- 49. Aglietti P, Insall JN, Buzzi R, Deschamps G: Idiopathic
term follow-up in young patients who undergo THA using osteonecrosis of the knee. Aetiology, prognosis and treat-
ceramic-on-ceramic components. ment. J Bone Joint Surg Br 1983;65(5):588-597. Medline
41. Johannson HR, Zywiel MG, Marker DR, Jones LC, 50. Mont MA, Baumgarten KM, Rifai A, Bluemke DA, Jones
McGrath MS, Mont MA: Osteonecrosis is not a predic- LC, Hungerford DS: Atraumatic osteonecrosis of the knee.
tor of poor outcomes in primary total hip arthroplasty: J Bone Joint Surg Am 2000;82(9):1279-1290. Medline
A systematic literature review. Int Orthop 2011;35(4):
465-473. Medline DOI 51. Lotke PA, Abend JA, Ecker ML: The treatment of osteo-
necrosis of the medial femoral condyle. Clin Orthop Relat
This study reported that osteonecrosis, alone or associated Res 1982;171:109-116. Medline
with the most common risk factors and/or diagnoses, is
not associated with poor outcomes in THA.
52. Juréus J, Lindstrand A, Geijer M, Robertsson O, Tägil M:
The natural course of spontaneous osteonecrosis of the
42. Bedard NA, Callaghan JJ, Liu SS, Greiner JJ, Klaas- knee (SPONK): A 1- to 27-year follow-up of 40 patients.
sen AL, Johnston RC: Cementless THA for the treat- Acta Orthop 2013;84(4):410-414. Medline DOI
ment of osteonecrosis at 10-year follow-up: Have we
improved compared to cemented THA? J Arthroplasty The authors of this study suggest that the size of the osteo-
2013;28(7):1192-1199. Medline DOI necrotic lesion can be used to predict the outcome. Patients
with early signs of osteoarthritis or with a large area of
For noncemented fixation in THAs for osteonecrosis, this osteonecrosis have a high risk of later major knee surgery.
study reported durable results with bearing surface wear
as the major long-term problem.
53. Lee YK, Ha YC, Cho YJ, et al: Does Zoledronate Prevent
Femoral Head Collapse from Osteonecrosis? A Prospec-
43. Kim SM, Lim SJ, Moon YW, Kim YT, Ko KR, Park YS: tive, Randomized, Open-Label, Multicenter Study. J Bone
Cementless modular total hip arthroplasty in patients Joint Surg Am 2015;97(14):1142-1148. Medline DOI
younger than fifty with femoral head osteonecrosis: Min-
imum fifteen-year follow-up. J Arthroplasty 2013;28(3): The authors of this study suggest that zoledronate for
504-509. Medline DOI Steinberg stage I or II osteonecrosis of the femoral head,
with a medium to large necrotic area, did not prevent the 62. Marulanda G, Seyler TM, Sheikh NH, Mont MA: Percu-
collapse of the femoral head or reduce the need for THA taneous drilling for the treatment of secondary osteonecro-
sis of the knee. J Bone Joint Surg Br 2006;88(6):740-746.
54. Meier C, Kraenzlin C, Friederich NF, et al: Effect of Medline DOI
ibandronate on spontaneous osteonecrosis of the knee:
A randomized, double-blind, placebo-controlled trial. 63. Lee K, Goodman SB: Cell therapy for secondary os-
Osteoporos Int 2014;25(1):359-366. Medline DOI teonecrosis of the femoral condyles using the Cellect
DBM System: A preliminary report. J Arthroplasty
In this study of patients with spontaneous osteonecrosis 2009;24(1):43-48. Medline DOI
of the knee, diphosphonate treatment (intravenous iban-
dronate) had no beneficial effect over and above anti-in-
flammatory medication. 64. Rijnen WH, Luttjeboer JS, Schreurs BW, Gardeniers
JW: Bone impaction grafting for corticosteroid-associ-
ated osteonecrosis of the knee. J Bone Joint Surg Am
55. Marcheggiani Muccioli GM, Grassi A, Setti S, et al: Con- 2006;88(suppl 3):62-68. Medline DOI
servative treatment of spontaneous osteonecrosis of the
knee in the early stage: Pulsed electromagnetic fields ther-
apy. Eur J Radiol 2013;82(3):530-537. Medline DOI 65. Görtz S, De Young AJ, Bugbee WD: Fresh osteochondral
allografting for steroid-associated osteonecrosis of the fem-
In this study, pulsed electromagnetic field stimulation sig- oral condyles. Clin Orthop Relat Res 2010;468(5):1269-
nificantly reduced knee pain and necrosis area in Koshino 1278. Medline DOI
1: Hip and Knee

stage I SONK. No correlation was found between MRI
and clinical scores. In this prospective analysis, 28 knees underwent osteo-
chondral allografting for high-grade, corticosteroid-as-
sociated osteonecrosis. At a mean 67-month follow-up,
56. Akgun I, Kesmezacar H, Ogut T, Kebudi A, Kanbero- graft survival rate was 89% with improvement of various
glu K: Arthroscopic microfracture treatment for osteo- outcome measures.
necrosis of the knee. Arthroscopy 2005;21(7):834-843.
Medline DOI
66. Mont MA, Rifai A, Baumgarten KM, Sheldon M, Hun-
gerford DS: Total knee arthroplasty for osteonecrosis.
57. Forst J, Forst R, Heller KD, Adam G: Spontaneous os- J Bone Joint Surg Am 2002;84-A(4):599-603. Medline
teonecrosis of the femoral condyle: Causal treatment by
early core decompression. Arch Orthop Trauma Surg
1998;117(1-2):18-22. Medline DOI 67. Pape D, Seil R, Anagnostakos K, Kohn D: Postarthroscop-
ic osteonecrosis of the knee. Arthroscopy 2007;23(4):
58. Duany NG, Zywiel MG, McGrath MS, et al: Joint-pre-
serving surgical treatment of spontaneous osteonecrosis of
the knee. Arch Orthop Trauma Surg 2010;130(1):11-16. 68. Kobayashi Y, Kimura M, Higuchi H, Terauchi M, Shira-
Medline DOI kura K, Takagishi K: Juxta-articular bone marrow signal
changes on magnetic resonance imaging following arthro-
This report is an overview of the characteristics of SONK scopic meniscectomy. Arthroscopy 2002;18(3):238-245.
and reports the surgeon experience with joint preservation Medline DOI
methods of this condition: 87% of patients had a mean
KSS of 81 points at a mean follow-up of 40 months. 69. Kraenzlin ME, Graf C, Meier C, Kraenzlin C, Friedrich
NF: Possible beneficial effect of bisphosphonates in osteo-
59. Myers TG, Cui Q, Kuskowski M, Mihalko WM, Saleh necrosis of the knee. Knee Surg Sports Traumatol Arthrosc
KJ: Outcomes of total and unicompartmental knee ar- 2010;18(12):1638-1644. Medline DOI
throplasty for secondary and spontaneous osteonecrosis
of the knee. J Bone Joint Surg Am 2006;88(suppl 3):76-82. In this prospective analysis, the effect of diphosphonate
Medline DOI treatment in patients with SONK or arthroscopy-induced
osteonecrosis of the knee was investigated. Diphospho-
nate treatment helped resolve symptoms in 54% of pa-
60. Langdown AJ, Pandit H, Price AJ, et al: Oxford medial tients. Bone marrow edema resolved completely in 64%
unicompartmental arthroplasty for focal spontaneous of patients.
osteonecrosis of the knee. Acta Orthop 2005;76(5):
70. Garino JP, Lotke PA, Sapega AA, Reilly PJ, Esterhai JL
Jr: Osteonecrosis of the knee following laser-assisted
61. Jäger M, Tillmann FP, Thornhill TS, et al: Rationale for arthroscopic surgery: A report of six cases. Arthroscopy
prostaglandin I2 in bone marrow oedema—from theo- 1995;11(4):467-474. Medline DOI
ry to application. Arthritis Res Ther 2008;10(5):R120.
Medline DOI
Chapter 5
Economics and Cost

Implications of Total Hip and
Total Knee Arthroplasty
Richard Iorio, MD Feroz Osmani, BS Savyasachi Thakkar, MD
1: Hip and Knee

Abstract
Total joint arthroplasty (TJA) is a successful, cost-effective procedure that requires an increasing amount of
healthcare resources. Decreased hospital and physician reimbursement and increased costs have put a financial
strain on stakeholders involved in the delivery of TJA. Cost analysis of TJA procedures across the United States
shows a wide variation in the cost of the surgery. In some cases, newer technology, with no proven track record,
has increased the cost of implants, thereby contributing to the increased expense of the procedure. Medicare and
Medicaid have implemented alternative payment models such as the Bundle Payment for Care Improvement Initiative
and the Comprehensive Care for Joint Arthroplasty, with the purpose of improving the quality of TJA care while
reducing cost. Various quality and cost effectiveness improvement measures have been implemented by surgeons
and hospitals and have proved to be effective. These programs have included patient risk optimization, multimodal
pain management, blood management protocols, implant cost negotiation, and care management initiatives. The
goal of these programs is to deliver TJA in a more cost-effective manner without sacrificing quality. In the future,
TJA in a value-based purchasing environment will require more attention to cost-effective care delivery.
Keywords: total joint arthroplasty; bundled

Introduction
payments; cost effectiveness; alternative payment
models; Total joint arthroplasty (TJA) is one of the most com-
monly performed and successful procedures in the United
Dr. Iorio or an immediate family member serves as a paid States. The number of primary TJA procedures performed
consultant to DJ Orthopaedics, MCS ActiveCare, and Paci- annually is expected to increase to 4 million by the year
ra; has stock or stock options held in Wellbe; has received 2030.1 Most of these patients are ensured through the
research or institutional support from APOS Medical & Centers for Medicare and Medicaid Services (CMS),
Sports Technologies, Bioventis, Ferring Pharmaceuticals, which is challenged by financial constraints. This issue
Orthofix, Orthosensor, Pacira, and Vericel; and serves as a is further exacerbated by the Patient Protection and Af-
board member, owner, officer, or committee member of the fordable Care Act (PPACA) of 2010, which has increased
American Association of Hip and Knee Surgeons, Clinical insurance coverage of 11 million formerly uninsured pa-
Orthopaedics and Related Research, the Hip Society, JBJS tients. For hospitals and physicians, Medicare payments
Reviews, the Journal of Arthroplasty, the Journal of Bone have not increased to match inflation.1
and Joint Surgery, the Journal of the American Academy
of Orthopaedic Surgeons, and the Knee Society. Neither of
Reducing Costs Associated With TJA
the following authors nor any immediate family member
has received anything of value from or has stock or stock The Medicare hospital payment for primary TJA has
options held in a commercial company or institution relat- increased at 50% of the rate of inflation over the past 2 de-
ed directly or indirectly to the subject of this chapter: Dr. cades, whereas hospital and implant costs have continued
Thakkar and Mr. Osmani. to increase.1 TJA costs account for a higher percentage of
Medicare spending than any other inpatient procedure. because of a reduction in hospital length of stay. The cost
Medicare funding for TJA is a continual target for cost allocation to the operating room service center decreased
containment.1 TJA is the largest diagnosis related group 38.0% for TKA in inflation-adjusted dollars because of
(DRG) expenditure for CMS.1 Additional projected cuts reduced surgical time; however, the cost allocation in-
in Medicare reimbursement for TJA and the downstream creased slightly by 2.4% in THA during the same interval.
effects on other healthcare insurance products have poten- The supplies service center decreased 53.0% in TKA and
tially negative effects on access to an orthopaedic surgeon 2.4% in THA in inflation-adjusted dollars because of a
specializing in adult reconstruction for TJA.1 In 1992, reduction in knee and hip implant costs.5,6 Overall, the
the national Medicare physician reimbursement rate for hospital converted a $2,172 loss per case for primary
total knee arthroplasty (TKA) was $2,102. In 2010, the TKA into a $2,986 profit per case and a $3,848 loss per
reimbursement had declined by 30% to $1,470.45.2 An case for primary THA into a $2,359 profit per case.5,6
inflation-adjusted comparison performed using the dollar Additional changes in utilization and unit costs were
value in 1992 reported that the reimbursement for TKA also made to improve economic results.7 Clinical path-
in 2010 is equivalent to $666.58, a 68% reduction in ways focused on reducing hospital length of stay were
Medicare reimbursement of TKA.2 For the 2014 fiscal implemented:6 operating room routines were standardized
1: Hip and Knee
year, the average Medicare Physician Fee Schedule cut to reduce length of surgery, routine pathologic evalua-
in payments for orthopaedic procedures was 1%. The tion of surgical specimens was eliminated,7 wound drains
American Academy of Orthopaedic Surgeons and the were eliminated, urinary catheter utilization was stan-
American Association of Hip and Knee Surgeons have dardized, routine postoperative TKA radiographs were
worked to minimize these cuts, and in 2015, and no fur- eliminated,6 routine postoperative noninvasive testing
ther reductions were made by CMS. for thromboembolic disease was eliminated,8 and au-
tologous transfusions, reinfusion drains, and cell savers
Cost Analysis were reduced. In addition, methods were implemented
According to a BlueCross BlueShield study of cost vari- to reduce unit costs of services and supplies associated
ations for TJA in the United States, the average hospital with TKA such as standardizing operating room packs,
cost of TKA was $31,124 in the 64 markets studied3 and reducing inventory, stocking implants on consignment,
the average cost of total hip arthroplasty (THA) was and reducing cost of implants by developing a single-price/
$30,124.3 A wide price variation exists, depending on case-price implant purchasing program.6
geographic location. The price of TKA in Montgomery, Similar cost control strategies were used for THA cas-
Alabama is $11,327, but the price of TKA in New York, es. However, THA-related hospital economics also merit
5
New York can be as much as $69,654.3 The hospital cost a discussion of alternative joint-bearing surfaces. Several
of THA followed similar trends: $11,327 in Birmingham, studies suggest that reduced wear rates are related to
Alabama and $73,987 in Boston, Massachusetts.3 alternative bearing surfaces, but little long-term clinical
Previous studies have reported that more than 75% benefit exists from such surfaces.9 The cost-effectiveness
of hospital expenditures for TJA derive from three main of alternative bearing surfaces depends highly on patient
sources: the hospital room cost, the operating room cost, age at the time of surgery, implant cost, and associated
and the implant cost.4-6 Efforts to control these costs can reduction in the probability of revision relative to conven-
result in substantial improvement in the overall hospital tional bearing surfaces.9 The cost burden of alternative
economic performance for TJA.1,6 bearing surfaces was calculated, and the hospital would
have lost $1,147 per patient for ceramic-on-ceramic im-
Inpatient Costs plants and $534 per patient for metal-on-metal implants.5
Hospital revenues for TJA increased at a lower rate than
did inflation; hospital expenses increased at a rate greater Implant Costs
than that of inflation.6 The hospital economics of primary The total cost of THA in the United States was reported
TKA and THA were reported on for an 18-year period be- as twice the cost of the same procedure in Canada, and
tween 1990 and 2008 at a single teaching hospital.5,6 The higher direct costs were explained by the great disparity
hospital room, operating room, and supplies (medical and in implant costs.2 Previous emphasis to contain in-hos-
surgical) were the three most cost-intensive service cen- pital costs relied on reducing length of stay, but such
ters, comprising more than 70% of hospital expenditures reductions do not necessarily translate to substantial
related to primary TJA.5,6 The hospital cost allocation to decreases in hospital costs because the volume of ser-
the hospital room service center decreased 42% in TKA vices rendered is not substantially reduced by shorter
and 5% in THA in inflation-adjusted dollars, primarily hospitalization.5 Modern cost containment efforts should
Chapter 5: Economics and Cost Implications of Total Hip and Total Knee Arthroplasty
include controlling the costs of hospital supplies, especial- to decrease the price of TJA implants.1 The Journal of
ly implants, because a large national variation has been Bone and Joint Surgery endorsed these cost-containment
reported in the cost of THA prostheses, with identical methods, but only if quality of care remained as the focus
implants from a single manufacturer varying by as much of any implant selection decision-making process. This
as 700%.10 A recent cost-effectiveness study for inno- philosophy has been extended to the current value-based
vative TKA implants showed that newer implants must purchasing movement.
reduce TKA failure by 50% to 55% to be considered In 2012, the New York University Langone Medical
cost effective and that patient comorbidities and their Center (NYULMC) Hospital for Joint Diseases imple-
remaining lifespan are important variables to keep in mented a price ceiling implant cost control program.1 The
mind while developing new implants.11 Several factors average implant cost per case was effectively reduced by
are associated with implant costs. Patient-specific factors 22% to 33%. In addition, cost variability among phy-
including age and comorbidities are minor factors, but sicians decreased by 50% to 90% in all categories. The
hospital characteristics and physician preference are major program resulted in over $2 million saved within its first
considerations.1,6 Establishing a price ceiling on implants year.
is recommended as one method to control and forecast Physician alignment with the hospital as well as other
1: Hip and Knee

costs. Another effect of standardizing prices was that cost physicians is crucial for effective ceiling price implemen-
variability among physicians decreased by 50% to 90% tation. If alignment is not achieved, vendors will continue
in all categories.1 In addition, 96% of requests for higher to sell higher priced implants, and the implant companies
cost implants were approved because of patient-specific may not limit available implant models and will provide
anatomic variations, and surgeons collaborated on the whatever physicians request.1 Physicians must be educated
process of price standardization. Vendors were amenable on cost consciousness and the value of patient care. Im-
to negotiation because of the threat of price competi- plants with higher price and newer technology must either
tion.1 No evidence exists that implants with higher price demonstrate a solution to a clinical problem not treated
or newer technology have better clinical outcomes com- by using standard implants or improved patient benefit.
pared with standard or traditional implants.12 Therefore, Defining new technology and preventing rising costs
newer technology should be adopted on the basis of evi- resulting from innovation are important factors to consid-
dence of cost-effectiveness or the solution of a document- er. If the contract is defined by specific components and
ed clinical problem not addressed by current technology. the components change in any way during the contract,
the institution is vulnerable to the implant vendor as to
Implant Price Negotiation how that new component or part is priced.1 Defining
Because CMS does not get involved in setting markets for truly new technology and how it is to be implemented are
implants or drugs, the hospital must negotiate the best important components of any cost containment program.
price possible to limit the cost of TJA.1 An economic anal- If truly new technology with improved outcome perfor-
ysis demonstrated that although implant cost was affected mance is introduced during the contract, then a price
by hospital factors including volume, number of vendors for that technology can be agreed on. New technology
present, and hospital bed size, a substantial amount for introduced during an existing contract should not be
cost variation among hospitals could not be accounted accepted at higher prices without clinical performance
for.1 In addition, substantial cost variation was reported justification.1
as a result of physician preference.1 Typically, hospitals Another method of implant cost control is to ensure
pay a portion of the list price of an implant, a portion that proper demand matching. Demand matching provides the
can vary by case and by hospital. This makes defining the appropriate implant based on the functional demand of
prices paid for implants difficult. List price is generally the patient. It is difficult to demonstrate in the literature
the starting point in implant negotiations and is not the that more expensive implants have better survivorship
price paid by most hospitals. Most hospital purchasing than less expensive implants.13 Implant selection guide-
contracts have confidentiality clauses that make trans- lines tend to direct more expensive, newer technology
parency on average implant costs difficult to determine. implants for younger, heavier, higher activity patients.
The price of TKA implants was defined as a percent- Defining these selection guidelines is highly controversial.
age of hospital reimbursement:12 The increasing price of The Lahey Clinic developed a cost reduction and implant
TJA implants offset the gains made in cost control with selection program based on demand matching.12 Patients
utilization review. In the 1990s, an education program were assigned to demand groups based on five measures:
was instituted for surgeons and a hospital prosthesis ap- age, weight, bone stock, general health, and the expect-
plication program that began a competitive bid system ed postoperative patient activity as determined by the
surgeon. The implants were assigned to demand function 7.2 mg) and experienced a threefold increase in nausea.
categories based on an implant’s expected capacity to In addition, those in the patient-controlled analgesia
manage the patient’s predicted demand. This program group were twice as likely to miss therapy and almost
was used in primary TKA. The use of all-polyethylene two times more likely to be discharged to an extended
tibial components in lower-demand categories afforded care facility. The use of preemptive oxycodone and a
the greatest cost savings. A follow-up study assessed the selective cyclooxygenase-2 inhibitor decreased postoper-
use of a clinical pathway and the TKA implant standard- ative narcotic requirements and increased participation
ization program as a regulator of resource utilization and in rehabilitation. In addition, patients who received pre-
hospital costs for TKA.6 The hospital cost, adjusted for emptive analgesics had decreased hospital length of stay
medical inflation, was reduced 19%, whereas short-term and reduced likelihood of discharge to a skilled nursing
patient outcome remained unaffected. A similar program facility.15
was successful in decreasing THA hospital costs. To facilitate rapid recovery after TJA, a single-dose
To further decrease the price of orthopaedic implants, spinal anesthetic is preferred to avoid the complications
the Lahey Clinic developed a Single Price/Case Price Pur- of other neuroaxial anesthetics such as hypotension, uri-
chasing Program13 to eliminate potential conflicts between nary retention, poor muscle control, and delayed mobi-
1: Hip and Knee
hospital administrators and surgeons concerning the price lization.16 Postoperatively, peripheral nerve blockade has
and selection of TJA implants. The vendor provided a become widely available for inclusion in multimodal regi-
single price for knee implants for every case irrespective mens, but it is costly and has some important limitations,
of the implant used. The cost of knee implants decreased including an increased incidence of falls, inefficient use of
23% without switching vendors. The vendor offered a the operating room, muscular weakness, and associated
price based on 3 years of historical implant selection delays in physical therapy and rapid rehabilitation.14 Re-
data. Similar findings were reported for THA implants. cently, periarticular injection of anesthetic and analgesic
The cost of revision arthroplasty has been found to be medications has gained importance and appears to offer
more difficult to regulate than the cost of primary TJA. comparable benefits to nerve blocks in joint arthroplasty
Revision arthroplasty procedures are not suitable for a without the limitations associated with peripheral motor
demand-matching system because of substantial differ- blockade. The benefits of local periarticular injection
ences in case severity and implant requirements. Applying are that it is simple to administer, surgeon directed, and
cost reduction strategies to revision TJA implants will be allows an infiltration of anesthetic directly into the pain
challenging; however, implant systems are now available source.16 Ropivacaine-based periarticular injections were
with fewer options, less complicated instrumentation, and compared with peripheral nerve blocks (continuous fem-
lower cost. Whether these revision implant systems will oral and single-injection sciatic) and both methods were
deliver value to patients is still undetermined. found to be equally effective in controlling postoperative
pain, but the patients who underwent periarticular injec-
tion had a shorter length of stay and decreased peripheral
Pain Management nerve dysesthesia.17 Another study that compared post-
Postoperative pain can affect hospital stay, patient satis- operative epidural analgesia with periarticular injection
faction, postsurgical rehabilitation, and a range of other after TKA with spinal anesthesia found that patients who
clinical and administrative outcomes.14 The emergence underwent periarticular injection had better postoperative
of procedure-specific multimodal pain management has pain relief, earlier recovery of knee flexion, and a lower
been one of the most important advances in hip and knee incidence of postoperative nausea.18 Optimizing these
arthroplasty. The goal of multimodal pain management parameters is important when trying to enable rapid re-
is to allow accelerated postoperative recovery while recovery after TJA. The use of liposomal bupivacaine as
ducing the use of parenteral narcotics with the side effects a longer acting local anesthetic after TJA remains con-
of nausea, pruritus, constipation, delirium, and urinary troversial and depends greatly on technique.19 Although
retention. some studies have indicated that liposomal bupivacaine
Multimodal preemptive analgesics are important ad- decreases narcotic use and results in earlier achievement
juncts in pain management for patients undergoing TJA. of physiotherapeutic milestones,19 the cost effectiveness
The average length of hospital stay for patients in the of liposomal bupivacaine is unknown and is currently
preemptive analgesia group was 2.74 versus 3.28 days being studied.19
for patient-controlled analgesia in patients undergoing
TJA.15 Patients in the patient-controlled analgesia group
used substantially more intravenous morphine (17.7 versus
Table 1
Bundled Payment for Care Improvement Program Models
Type Description
Model 1 Retrospective payment for acute hospitalization covering Medicare Part A services
Model 2 Retrospective payment for entire episode of care (72 hours preoperative to 90 days
postoperative) covering Medicare Part A and Part B services
Model 3 Retrospective payment for the period after hospitalization covering Medicare Part A and B
services
Model 4 Prospective payment for acute hospitalization
high-quality care with improved outcomes. In 2011, the

Revision Surgery
CMS created a Bundled Payment for Care Improvement
1: Hip and Knee

In recent years, the number of revision TJAs has in- (BPCI) initiative that focused on high-quality coordinated
creased, which is most likely a result of the increasing care that is outcome based.23,24
prevalence of primary TJA, expansion of indications to
younger patients, more high-demand patients, and an BPCI Organization
increasing presence of patient factors such as obesity and Through the BPCI initiative, hospitals are paid one stan-
diabetes.20 From 2006 to 2010, 23% and 40% increases dard predetermined sum for an all-inclusive episode of
in the number of hospitalizations were noted in patients care, or “bundle,” that can begin a certain time before an
undergoing revision THA and TKA, respectively.20,21 The episode and continues for an established length of time
reasons for revision TJA are mostly attributed to mechan- after surgery. For TJA, the episode includes preoperative
ical loosening and periprosthetic joint infection.20 services 72 hours before surgery, inpatient services in-
The differences in resource utilization between THA cluding surgery and postoperative care for a period of 30,
and TKA were analyzed, including length of stay and 60, or 90 days from surgery.25 In this risk-sharing model,
cost.20 Periprosthetic joint infection and mechanical loos- the healthcare provider is responsible for all care episodes
ening were the most common indications for revision within the at-risk postoperative period, including read-
TKA, and dislocation and mechanical loosening were missions, without any additional reimbursement. Under
the most common indications for revision THA.20 Peri- this program, if the total costs of all services rendered
prosthetic joint infection and periprosthetic fracture were in that episode are less than the bundled payment, the
associated with the greatest length of stay and costs for provider is entitled to the remainder. However, if the costs
revision THA and TKA.20 The mean (± SD) length of stay exceed the bundled payment target price, the provider will
was 4.8 ± 10.5 days for revision TKA and 5.8 ± 14.0 days sustain a financial loss. The bundled care model incentiv-
for revision THA.20 The mean (±SD) hospital cost was izes high-quality care with the goal of reducing readmis-
$23,130 ± $36,643 for revision TKA and $24,697 ± sions and improving cost effectiveness.2 This alternative
$40,489 for revision THA.20 The study concluded that payment model will also shift a higher burden of costs to
the revision burden for length of stay and hospitalization the provider in cases where patients have complications,
costs for THA is greater than that for TKA, but revision require extended post–acute care, are readmitted, or re-
costs varied widely for both procedures. quire repeat procedures within the 90-day postoperative
period after the index procedure.24
In addition to risk sharing, CMS also specifically au-
Bundled Payments and Alternative Payment thorizes gain sharing with stakeholders, with the idea
Models that healthcare providers should be rewarded for restruc-
Traditionally, TJA services have been reimbursed with the turing their services to become more coordinated and
fee-for-service model, which incentivizes the delivery of cost effective.24 Gain sharing can vary depending on the
health care services in volume without much regard for negotiations between hospitals, surgeons, other episode
quality and outcomes related to those services.22 How- initiators or stakeholders. The American Association of
ever, financial challenges have shifted the focus to creat- Hip and Knee Surgeons Bundled Payment Task Force ad-
ing more value for the money allocated to TJA services vises that for gain-sharing arrangements, a specific base-
and these new measures strive to reward the delivery of line should be used to measure cost savings and quality
measurements.24 Also, hospitals and surgeons must look of care.” The episode can include inpatient services such
beyond just implant-related costs to focus on streamlining as surgery and postoperative care for a period of up to
the entire episode of care to maximize the benefits of the 90 days following surgery. The at-risk postoperative pe-
BPCI model.24 There are four models of BPCI currently riod under BPCI includes readmissions, which are usu-
being tested (Table 1). ally unplanned after TJA procedures. The initiator of
the episode is responsible for all related costs within the
Results of BPCI in TJA agreed-on postoperative period, including readmissions,
Early findings were published on BPCI model 2 for a without any additional reimbursement.24,25
90-day TJA episode of care at an urban, academic, or- Reducing readmissions involves managing preoperative
thopaedic specialty hospital.23 In the first year of the pro- comorbidities that are associated with postoperative com-
gram, the average length of hospital stay for 721 patients plications, which can be surgical and medical in nature.
decreased from 4.27 to 3.53 days. Discharge to inpatient Providers must be able to select appropriate patients for
facilities for rehabilitation also decreased from 65% to TJA and identify high-risk patients and potentially modify
43%. The total 90-day readmission rate was 11%. Re- risk factors that can be associated with worse outcomes.
admissions from a facility were higher (13.7%) when This selection process has obvious ethical implications
1: Hip and Knee
compared with readmissions from home (9.0%). Medicare because some patients may need to delay surgery until
costs were reduced by up to 10% using the BPCI mod- their health status is optimized.
el.23 Infrastructure costs and the costs of implementing
the program were not included in these calculations.23 The Short-Term Readmissions
implementation of clinical care pathways and intensive Healthcare providers must understand the nuances of the
care management services for TJA patients to improve risk-sharing model focused on an episode of care. The cost
efficiency and quality of care were important factors in burden of 30-day readmissions after primary and revision
generating cost reductions in BCPI.24 THA and TKA procedures was studied at a high-vol-
After year 1 of the BCPI program, an unacceptably ume orthopaedic subspecialty hospital.29 Using a hospital
high 90-day readmission of 11% was reported.26 Ninety database for primary and revision TJA procedures per-
percent of patients requiring readmission had at least formed from 2009 to 2012, direct costs were obtained
one modifiable risk factor, which could have been opti- for each unplanned admission along with the total Part
mized before surgery, and 50% of patients had two or A Medicare payments. The 30-day readmission rate was
more.26 Therefore, a risk factor stratification and modi- 2.4 per 100 cases for primary TJA, 9.5 per 100 cases for
fication program (the Perioperative Orthopaedic Surgical revision THA, and 11.9 per 100 cases for revision TKA.
Home) designed to delay surgery in high-risk patients with The mean cost for readmission after primary THA and
potentially modifiable risk factors was instituted as a vol- TKA was $17,103 and $13,008, respectively. The mean
untary program for the surgeons involved in BPCI.27 Pre- cost of readmission was $27,272 per case following revi-
liminary results demonstrated that readmission rates have sion THA and $29,893 per case following revision TKA.
been lowered from 15% in 2009 and 17% in 2011 to 11% The readmission cost burdens per admission were 4.3%
at 90 days in 2013. The average length of stay decreased for THA, 2.8% for TKA, 8.3% for revision THA, and
from 4.27 to 3.58 days and discharge to inpatient post– 11.9% for revision TKA.
acute care facilities decreased from 71% to 44%.23 The three primary causes for readmission following
Across all model 2 episodes, the percentage of BPCI TJA are wound complications, surgical site infections,
patients discharged to a post–acute care facility declined and medical problems.30-32 Readmission risk is related to
from 66% to 47%. Overall, the largest relative declines a patient’s severity of illness (SOI) and preoperative co-
in payments occurred during the anchor hospital stay morbidities. The readmission burden was stratified by SOI
(consistent with reduced length of stay) and for physician using the All Patients-Refined–Diagnosis-Related Group
evaluation and treatment visits.28 Unless a shift occurs (APR-DRG) severity classification system.25 The APR-
in legislative mandate, alternative payment models are DRG-SOI system has four categories of severity: minor,
expected to continue to displace fee-for-service models moderate, major, and extreme.31 Among 2,026 patients,
over the next several years. the readmission rate was as low as 2.6% for patients
with moderate SOI and as high as 26.1% for patients
Reducing Readmissions with extreme SOI. The average readmission costs were
Alternative payment models are based on a risk-sharing directly proportional to the SOI scale, with $12,781 for
system in which the health care provider and institution minor SOI, $17,575 for moderate SOI, $19,120 for ma-
are compensated based on outcome for the entire “episode jor SOI, and $21,216 for extreme SOI. The readmission
burden was also directly proportional to SOI with lower TJA.36 The study also examined hospitalization rates
categories of SOI bearing a burden of approximately 4% before elective TJA and reported that 12.9% of pa-
to 5% and the extreme SOI group, with a readmission tients undergoing elective THA and 10.2% of patients
burden of 18.5%. undergoing elective TKA were hospitalized in the year
In addition to risk factor modification, it is also es- before their index surgery. Hospitalizations increased to
sential to understand the preventable causes for read- 14.8% of patients undergoing elective THA and 15.5%
missions. One study stated that, “for readmission rates of patients undergoing elective TKA patients in the year
to be a useful measure in assessing quality of care, they following surgery, indicating 15% and 52% increases,
must capture only those readmissions that could have respectively. Patients undergoing emergency THA (usually
been prevented.”30 The major causes for readmission are hip fractures treated using a prosthesis) were the most
infections, wound issues, workup of deep vein thrombo- resource intensive: 26.7% having hospital admissions
sis and/or pulmonary emboli, and other medical com- before THA and 27.8% readmissions in the year after
plications.30,31,33 Current strategies to tackle infection surgery. For all patients, the most common reason for
prevention include timely, weight-based administration readmission was an implant-related complication fol-
of preoperative antibiotics, prescreening and treatment lowed by complications associated with the procedure.
1: Hip and Knee

of methicillin-resistant Staphylococcus aureus carriers, However, for patients undergoing emergency THA, the
hepatitis C screening and treatment, ensuring adequate second most common reason for readmission was cardiac
perioperative glucose control, creating hand hygiene pro- complications. Revision surgery within 1 year was 1.3%
grams, and maintaining normothermia and patient oxy- for patients undergoing elective surgery and 2.0% for
genation.30,32 Another potential strategy aimed at reducing patients undergoing emergency surgery. Most commonly,
readmissions may involve outpatient deep vein thrombosis THA cases were revised for mechanical complications
screening and treatment. and TKA cases were revised for infections. In addition, a
2015 study showed that TKA revision has an 8.5% higher
Long-Term Readmissions rate and THA revision has a 3.4% higher rate of repeat
A study that compared the 30-day and 90-day readmis- procedures such as irrigation and débridement or modular
sion data at a tertiary care urban hospital reported that components exchange in the 90-day postoperative period.
surgical reasons accounted for slightly more than one- CMS does not proportionately compensate surgeons for
half of overall readmissions.34 However, the study also the increased time and effort associated with performing
reported that medical reasons for readmissions includ- revision TJA.37 The current reimbursement model makes
ed problems such as cardiac complications, pulmonary it challenging for surgeons to provide revision TJA ser-
complications, and venous thrombosis, which became vices to patients.5,6,37 Alternative payment models have
more important factors in the 90-day postoperative pe- not yet been applied to revision TJA.
riod. The authors found that age (younger than 50 years
and older than 80 years), Medicare or self-payer sta-
tus, coronary artery disease, diabetes mellitus, weight Summary
(body mass index less than 18.5 kg/m 2 and greater than The economics and cost implications of TJA are becoming
30 kg/m2), and increased length of hospital stay (more increasingly challenging to understand, implement, and
than 5 days) were associated with substantial readmis- control. Creating value for patients undergoing arthro-
sions in the 90-day period.34 Similar findings have been plasty requires efficient, integrated, and evidence-based
reported in other studies.33,35 One study reported a direct clinical pathways that can deliver services to patients in
correlation between increasing SOI and increasing costs of a cost-effective manner. Intensive patient education, care
TJA-related readmissions.35 Patients who are transferred management, optimization of health status, and align-
from rehabilitation facilities or outside hospitals tend to ment of stakeholder incentives will provide more value
have higher categories of SOI and are more likely to be to patients undergoing TJA. Alternative payment mod-
associated with higher readmission costs than patients els may help facilitate these care delivery improvements.
who do not originate from such facilities.35 Value-based purchasing will demand more attention to
One study evaluated readmissions, revisions, infec- the cost-effective delivery of care in the future.
tions, and hospital resource use in the first year after
Key Study Points 4. Antoniou J, Martineau PA, Filion KB, et al: In-hospital
cost of total hip arthroplasty in Canada and the United
• TJA is a successful, cost-effective procedure that re- States. J Bone Joint Surg Am 2004;86-A(11):2435-2439.
Medline
quires an increasing amount of healthcare resources,
but decreasing reimbursement and increased costs 5. Rana AJ, Iorio R, Healy WL: Hospital economics of pri-
have put a financial strain on the healthcare system. mary THA decreasing reimbursement and increasing cost,
• Cost analysis of TJA procedures across the United 1990 to 2008. Clin Orthop Relat Res 2011;469(2):355-
States shows a wide variation in the cost of surgery. 361. Medline DOI
• Medicare and Medicaid have implemented alterna- This article discusses the concern of decreasing economic
feasibility of hospitals providing THA. If hospital revenue
tive payment models such as the Bundle Payment for
continues to decrease and no innovations are associated
Care Improvement Initiative and the Comprehensive with an increased cost, earning profit will prove difficult.
Care for Joint Replacement, with the purpose of im- Reform must occur to provide adequate reimbursements
proving the quality of TJA care while reducing cost. for hospitals and surgeons performing THA. Level of
evidence: III.
• Various quality and cost effectiveness improve-
ment measures include patient risk optimization, 6. Healy WL, Iorio R, Ko J, Appleby D, Lemos DW: Impact
1: Hip and Knee
multimodal pain management, blood management of cost reduction programs on short-term patient outcome
protocols, implant cost negotiation, and care man- and hospital cost of total knee arthroplasty. J Bone Joint
agement initiatives. TJA in a value-based purchasing Surg Am 2002;84-A(3):348-353. Medline
environment will require more attention to cost
7. Kocher MS, Erens G, Thornhill TS, Ready JE: Cost and
effective care delivery. effectiveness of routine pathological examination of op-
erative specimens obtained during primary total hip and
knee replacement in patients with osteoarthritis. J Bone
Joint Surg Am 2000;82-A(11):1531-1535. Medline
Annotated References 8. Schwarcz TH, Matthews MR, Hartford JM, et al: Sur-
veillance venous duplex is not clinically useful after total
1. Bosco JA, Alvarado CM, Slover JD, Iorio R, Hutzler LH: joint arthroplasty when effective deep venous thrombosis
Decreasing total joint implant costs and physician spe- prophylaxis is used. Ann Vasc Surg 2004;18(2):193-198.
cific cost variation through negotiation. J Arthroplasty Medline DOI
2014;29(4):678-680. Medline DOI
9. Bozic KJ, Morshed S, Silverstein MD, Rubash HE, Kahn
More than $2 million was saved at the authors’ institution JG: Use of cost-effectiveness analysis to evaluate new tech-
during the first year of the intervention to reduce implant nologies in orthopaedics. The case of alternative bearing
costs. The study concluded the initiative is important to surfaces in total hip arthroplasty. J Bone Joint Surg Am
negotiate lower implant prices from vendors. Level of 2006;88(4):706-714. Medline DOI
evidence: III.
10. Metz CM, Freiberg AA: An international comparative
2. Nordt J, Gregorian J, Connair M: As Medicare Costs study of total hip arthroplasty cost and practice patterns.
Rise, Reimbursements Drop. 2015. Available at: http:// J Arthroplasty 1998;13(3):296-298. Medline DOI
www.aaos.org/news/aaosnow/dec12/cover1.asp. Accessed
October 6, 2015. 11. Suter LG, Paltiel AD, Rome BN, et al: Placing a price on
This article discusses the increasing cost of medical prac- medical device innovation: The example of total knee ar-
tice along with decreasing reimbursement rates for prac- throplasty. PLoS One 2013;8(5):e62709. Medline DOI
titioners, which lag behind inflation. The gap between This study reported that new technology is associated
operational costs and reimbursements for those procedures with a premium cost. Innovative implants must decrease
continues to widen. Level of evidence: V. actual TKA failure by 50% to 55% to be considered cost
effective. Level of evidence: III.
3. BlueCross BlueShield: A Study of Cost Variations For Knee
And Hip Replacement Surgeries In The U.S. Blue Health 12. Iorio R, Healy WL, Kirven FM, Patch DA, Pfeifer BA:
Intelligence; 2015:5-9. Available at: http://www.bcbs.com/ Knee implant standardization: An implant selection and
healthofamerica/BCBS_BHI_Report-Jan-_21_Final.pdf. cost reduction program. Am J Knee Surg 1998;11(2):
Accessed October 30, 2015. 73-79. Medline
This survey conducted by one of the nation’s largest insur-
ance companies analyzes the costs of orthopaedic proce- 13. Healy WL, Iorio R, Lemos MJ, et al: Single price/case
dures across the United States. The average total costs of price purchasing in orthopaedic surgery: Experience at the
TKA and THA in various cities are listed and compared. Lahey Clinic. J Bone Joint Surg Am 2000;82(5):607-612.
Level of evidence: V. Medline
14. Springer BD: Transition from nerve blocks to periartic- Although the cost-effectiveness of liposomal bupivacaine
ular injections and emerging techniques in total joint is not yet determined, it has shown decreased narcotic use
arthroplasty. Am J Orthop (Belle Mead NJ) 2014;43 and earlier achievement of physiotherapy milestones after
(10 suppl):S6-S9. Medline TJA in some studies. Level of evidence: I.
This study reviewed the efficacy of postoperative pain
control using peripheral nerve blockade and bupivacaine 20. Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ:
liposome injection in both TKA and THA. Sciatic nerve Future young patient demand for primary and revision
block and bupivacaine liposome injection were compared joint replacement: National projections from 2010 to
and bupivacaine liposome injection resulted in a consid- 2030. Clin Orthop Relat Res 2009;467(10):2606-2612.
erable reduction in pain scores following THA and TKA Medline DOI
as well as 6 to 12 hours postoperatively. A substantial
reduction was also reported in postoperative opioid use 21. Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M:
with bupivacaine liposome injection, and an overall cost Prevalence of primary and revision total hip and knee
reduction of both THA and TKA. Level of evidence: I. arthroplasty in the United States from 1990 through
2002. J Bone Joint Surg Am 2005;87(7):1487-1497.
15. Duellman TJ, Gaffigan C, Milbrandt JC, Allan DG: Medline DOI
Multi-modal, pre-emptive analgesia decreases the length
of hospital stay following total joint arthroplasty. Ortho- 22. Luft HS: Economic incentives to promote innova-
pedics 2009;32(3):167. Medline DOI tion in healthcare delivery. Clin Orthop Relat Res
1: Hip and Knee

2009;467(10):2497-2505. Medline DOI
16. Sculco PK, Pagnano MW: Perioperative solutions for rapid
recovery joint arthroplasty: Get ahead and stay ahead. 23. Iorio R, Clair AJ, Inneh IA, Slover JD, Bosco JA, Zuck-
J Arthroplasty 2015;30(4):518-520. Medline DOI erman JD: Early results of medicare’s bundled payment
initiative for a 90-day total joint arthroplasty episode of
This article reviewed the transition from a sick patient care. J Arthroplasty 2016;31(2):343-350. Medline DOI
model to the well patient model for recovery following
TJA. Controlling volume depletion, blood loss, pain, and Medicare initiated a program in 2011 to introduce a
nausea perioperatively results in a more rapid recovery. payment model that would result in higher quality, more
Level of evidence: III. coordinated care at a lower cost to Medicare. With the
implementation of this program, average length of stay
17. Spangehl MJ, Clarke HD, Hentz JG, Misra L, Blocher JL, decreased, discharges to inpatient facilities decreased, and
Seamans DP: The Chitranjan Ranawat Award: Periarticu- readmission decreased slightly. Cost savings was evident.
lar injections and femoral & sciatic blocks provide similar Level of evidence: III.
pain relief after TKA: a randomized clinical trial. Clin
Orthop Relat Res 2015;473(1):45-53. Medline DOI 24. Froimson MI, Rana A, White RE Jr, et al: Bundled pay-
ments for care improvement initiative: the next evolution
This study compared a commonly used combination of a of payment formulations: AAHKS Bundled Payment
continuous femoral block administered with a single-in- Task Force. J Arthroplasty 2013;28(8suppl):157-165.
jection sciatic block with a periarticular injection (ropiva- Medline DOI
caine, epinephrine, ketorolac, and morphine) after TKA.
Patients who received the periarticular injections had sim- This study reported that the initiation of the bundled
ilar paint scores, shorter length of stay, reduced likelihood payment model has the potential to enhance quality and
of peripheral nerve dysesthesia, and increased narcotic use reduce cost, thereby increasing the value of the services
on the day of surgery compared with peripheral blocks. administered. How providers can be successful in this new
Level of evidence: I. environment is detailed. Level of evidence: III.
18. Tsukada S, Wakui M, Hoshino A: Postoperative epidur- 25. Kiridly DN, Karkenny AJ, Hutzler LH, Slover JD, Iorio
al analgesia compared with intraoperative periarticular R, Bosco JA III: The effect of severity of disease on cost
injection for pain control following total knee arthro- burden of 30-day readmissions following total joint ar-
plasty under spinal anesthesia: A randomized controlled throplasty (TJA). J Arthroplasty 2014;29(8):1545-1547.
trial. J Bone Joint Surg Am 2014;96(17):1433-1438. Medline DOI
Medline DOI The cost of TJA as well as all additional related medical
Traditionally, epidurals have been used for TKA but are costs for up to 90 days are bundled into one lump sum.
associated with the risk of adverse effects; recent studies In this study, 2,026 patients undergoing TJA were re-
have reported fewer adverse effects associated with peri- viewed to analyze costs of readmission and readmission
articular injection. Periarticular injection offers better rate. Both increased as the severity of illness increased.
postoperative pain relief, earlier recovery of knee flexion Level of evidence: III.
angle, and reduced incidence of nausea compared with
epidural anesthesia. Level of evidence: I. 26. Yu S, Garvin KL, Healy WL, Pellegrini VD Jr, Iorio R;
Journal of the American Academy of Orthopaedic Sur-
19. Yu SW, Szulc AL, Walton SL, Davidovitch RI, Bosco JA, geons: Preventing hospital readmissions and limiting
Iorio R: Liposomal bupivacaine as an adjunct to postoper- the complications associated with total joint arthro-
ative pain control in total hip arthroplasty. J Arthroplasty plasty. J Am Acad Orthop Surg 2015;23(11):e60-e71.
2016 [Epub ahead of print]. Medline DOI Medline DOI
This study reported that after the implementation of the and decolonization on hospital-acquired MRSA bur-
BPCI Program at the NYULMC, the 90-day readmission den. Clin Orthop Relat Res 2013;471(7):2367-2371.
rate of 11% was unacceptably high. The study also re- Medline DOI
ported that 90% of patients requiring readmission had at
least one modifiable risk factor that could be optimized In this study, the prevalence of methicillin-resistant Staph-
preoperatively, and 50% of patients had two or more. ylococcus aureus was determined at a specialty ortho-
These modifiable risk factors could further limit readmis- paedic hospital before and after the implementation of
sion rate. Level of evidence: III. a screening and decolonizing protocol. Protocol use de-
creased the prevalence density of methicillin-resistant S
aureus. Level of evidence: III.
27. Boraiah S, Joo L, Inneh IA, et al: Management of Mod-
ifiable Risk Factors Prior to Primary Hip and Knee Ar-
throplasty: A Readmission Risk Assessment Tool. J Bone 33. Husted H, Otte KS, Kristensen BB, Orsnes T, Kehlet H:
Joint Surg Am 2015;97(23):1921-1928. Medline DOI Readmissions after fast-track hip and knee arthroplas-
ty. Arch Orthop Trauma Surg 2010;130(9):1185-1191.
This study created a readmission risk assessment tool Medline DOI
(RRAT) to identify associations between total joint
arthroplasty related readmissions and RRAT. Level of With new patient optimization strategies, length of stay
evidence: III. has been successfully decreased overall in TKA and THA.
Fast-track TJAs do not increase the rate of readmissions.
1: Hip and Knee
28. Dummit L, Marrufo G, Marshall J, et al: CMS Bundled

Payments for Care Improvement (BPCI) Initiative Models
2-4: Year 1 Evaluation & Monitoring Annual Report. 34. Saucedo JM, Marecek GS, Wanke TR, Lee J, Stulberg SD,
Falls Church, VA, The Lewin Group, 2015. Available at Puri L: Understanding readmission after primary total
https://innovation.cms.gov/Files/reports/BPCI-EvalRpt1. hip and knee arthroplasty: Who’s at risk? J Arthroplasty
pdf. 2014;29(2):256-260. Medline DOI
Across all Model 2 episodes, the percentage of BPCI pa- The most common reasons for readmission were infection
tients discharged to a post–acute care facility declined and procedure-related complications. However, risk fac-
from 66% to 47%, and the proportion discharged home tors such as coronary artery disease, diabetes, increased
remained steady. Although not significant, the largest length of stay, underweight status, obese status, age older
relative declines in payments occurred during the anchor than 90 years or younger than 50 years, and Medicare
hospital stay (consistent with the reduced length of stay) were associated with an increased likelihood of readmis-
and for physician evaluation and treatment visits. Level sion. Level of evidence: III.
of evidence: III.
35. Plate JF, Brown ML, Wohler AD, Seyler TM, Lang JE:
29. Bosco JA III, Karkenny AJ, Hutzler LH, Slover JD, Io- Patient factors and cost associated with 90-day read-
rio R: Cost burden of 30-day readmissions following mission following total hip arthroplasty. J Arthroplasty
Medicare total hip and knee arthroplasty. J Arthroplasty 2016;31(1):49-52. Medline DOI
2014;29(5):903-905. Medline DOI Average surgical readmissions were more costly than med-
This study quantified the readmission burden of TJA as a ical readmissions. Costs of imaging, laboratories, medi-
function of reimbursement and readmission in a bundled cations, transfusions and hospital cost increased as SOI
payment model. Any decrease in hospital cost margins increased. Level of evidence: III.
can make performing TJA economically unfeasible. Level
of evidence: III. 36. Bohm ER, Dunbar MJ, Frood JJ, Johnson TM, Morris
KA: Rehospitalizations, early revisions, infections, and
30. McCormack R, Michels R, Ramos N, Hutzler L, Slover hospital resource use in the first year after hip and knee
JD, Bosco JA: Thirty-day readmission rates as a measure arthroplasties. J Arthroplasty 2012;27(2):232-237.e1, e1.
of quality: Causes of readmission after orthopedic surger- Medline DOI
ies and accuracy of administrative data. J Healthc Manag In this study, a 15% and 52% increase was reported in
2013;58(1):64-76, discussion 76-77. Medline the hospitalization of patients who underwent THA and
This analysis was stratified to determine the cause of read- TKA, respectively. The increased rehospitalization illus-
mission: 30% of readmissions were planned, and almost trates an incremental cost of 10% over the index hospital
60% were a result of infection. Nonsurgical complications stay. Level of evidence: III.
accounted for 18.2% of the unplanned readmission. Level
of evidence: III. 37. Tokarski AT, Deirmengian CA, Lichstein PM, Austin
MS, Deirmengian GK: Medicare fails to compensate
31. Shah AN, Vail TP, Taylor D, Pietrobon R: Comorbid additional surgical time and effort associated with re-
illness affects hospital costs related to hip arthroplasty: vision arthroplasty. J Arthroplasty 2015;30(4):535-538.
Quantification of health status and implications for fair Medline DOI
reimbursement and surgeon comparisons. J Arthroplasty Revision TKA and THA are time and resource intensive.
2004;19(6):700-705. Medline DOI Practices undertaking revision surgery will see decreased
reimbursements compared to practices focused on prima-
32. Mehta S, Hadley S, Hutzler L, Slover J, Phillips M, ry TJA. Patient access to physicians performing revision
Bosco JA III: Impact of preoperative MRSA screening arthroplasty procedures may become challenging. Level
of evidence: III.
Chapter 6
National Joint Registries

Daniel J. Berry, MD David G. Lewallen, MD Fares S. Haddad, FRCS (Orth)
Abstract knee arthroplasty. Registries come in many categories,

including national registries, regional or state registries,
National joint registries can provide descriptive infor- institutional registries, and industry-based registries. Each
mation about patients undergoing joint arthroplasty, type of registry has its own advantages, disadvantages,
including survivorship rates and outcomes data about limitations, and applications.
joint arthroplasty based on patient, hospital, and implant Registries are designed to enroll patients who have un-
1: Hip and Knee

factors. Registries also can provide information about dergone joint arthroplasty and systematically collect data
the most common reasons for implant failure and associ- related to the patient, the procedure, and the outcomes of
ated complications. These data can provide a real-time the procedure. Registries can provide many useful func-
feedback loop to all stakeholders—patients, surgeons, tions to both the orthopaedic community and patients.
hospitals, payers, and implant manufacturers—that can Registries can provide descriptive data about patients be-
lead to quality improvement. It is helpful to be aware of ing treated with joint arthroplasty and the characteristics
the current status and what has been learned from the of the joint arthroplasties being used. This information
American Joint Replacement Registry and the United provides real-time observations about the practice of joint
Kingdom National Joint Registry. Registries have lim- arthroplasty. Registries can provide high-level data about
itations, however; the most important limitation is that the overall revision rate for hip and knee replacement
although they provide information about associations and how demographic factors and generic implant char-
between outcomes and patient and implant factors, acteristics affect rates of implant revision. Registries can
they cannot prove such associations as being causal. provide information on the most common reasons for
implant failure and the rates of the most common com-
plications, thereby guiding thoughtful innovation aimed
Keywords: American Joint Replacement Registry at solving real problems. Registries show how specific
(AJRR); arthroplasty; joint registries; National implants are performing (thereby guiding implant se-
Joint Registry (NJR) for England; Wales; Northern lection) and also serve as a trigger to identify implants
Ireland; and the Isle of Man that are not performing well.1 Registries can examine
associations between specific patient characteristics and
comorbidities and the risks of adverse outcomes, which
Introduction
can result in risk stratification. Increasingly, registries may
Daniel J. Berry MD collect global or joint-specific patient-reported outcome
Registries for hip and knee arthroplasty have been used measures or clinical joint scores that provide a more nu-
for 4 decades and have a profound and increasing effect on anced understanding of the results of joint arthroplasty
the clinical practice of total hip arthroplasty (THA) and compared with revision as the main end point. In all these
Dr. Berry or an immediate family member has received royalties from DePuy; serves as a paid consultant to DePuy; has
received research or institutional support from DePuy; and serves as a board member, owner, officer, or committee
member of the American Joint Replacement Registry, the Hip Society, the International Hip Society, and the Mayo Clinic
Board of Governors. Dr. Lewallen or an immediate family member has received royalties from Mako/Stryker, Pipeline,
and Zimmer; serves as a paid consultant to Link Orthopaedics and Zimmer; serves as an unpaid consultant to Ketai
Medical Devices; has stock or stock options held in Acuitive and Ketai Medical Devices; and serves as a board member,
owner, officer, or committee member of the American Joint Replacement Registry and the Orthopaedic Research and
Education Foundation. Dr. Haddad or an immediate family member has received royalties from Corin, Matortho, and
Smith & Nephew; serves as a paid consultant to Smith & Nephew and Stryker; and has received research or institutional
support from Smith & Nephew.
roles, registries provide a feedback loop to stakeholders in certain types of patients or by certain surgeons, with
(patients, surgeons, hospitals, and implant manufactur- better or worse results, which results in bias in outcomes.
ers), which allows stakeholders to compare relevant out- Registries primarily reporting revision as an end point
comes with benchmarks and subsequently make choices will not pick up failures that do not lead—or have not
or changes that improve the results of joint arthroplasty.2 yet led—to revision. This can affect results, particularly if
revision surgery is delayed in a systematic fashion, such as
in countries with long waiting lists for such surgical pro-
Registry End Points cedures. Registries also are limited by the data collected
The most common registry end point has been revision for each registry. For example, a lack of specificity about
surgery. Revision is a hard end point that is not sub- what part of an implant has failed and the reasons for
ject to interpretation. However, the way in which revi- that failure may limit the conclusions that can be drawn.
sions are categorized from one registry to another varies National registries have the advantage of extremely
considerably, which has consequences for what can be large numbers, but for practical reasons, they cannot
learned.3,4 One registry may combine revisions for osteol- collect data at the level of detail of some institutional
ysis with revisions for aseptic loosening, whereas another registries. For this reason, institutional registries that
1: Hip and Knee
may consider the two as separate categories. More specific collect detailed surgical patient data often can address
categorization may not only be valuable for interpreting different questions compared with those of national reg-
results but also increase the risk of miscategorization at istries. Likewise, many questions cannot be answered by
the time of data entry. Many registries cannot identify a registry; therefore, well-designed randomized controlled
which of several implant parts in a joint arthroplasty trials, case-control studies, and detailed case series com-
have failed and required revision. Therefore, separating plement the work of registries.8 Data from registries may
failures such as aseptic loosening for a specific implant provide information that results in hypothesis generation
(for example, acetabular versus femoral components of that can be proven or refuted by subsequent prospective
a THA) may not be possible. or more in-depth studies.
Because many registries consider only revision as the
end point, some important complications may not be
identified. If only infections that result in revision are Trends in Registries
captured, then all infections treated without implant re- Registries allow surgeons and hospitals to compare their
vision are overlooked. If only hip dislocations resulting individual results with large national cohorts. For this
in revision are captured, all other dislocations are not comparison to be meaningful, the cohorts must be risk
identified.5 stratified. Risk stratification for different end points is
Some registries collect clinical outcome scores, includ- complex and is still being optimized. To perform good
ing patient-reported data, which can provide valuable risk stratification, registries are increasingly collecting
information about the results of surgery that is more more data about medical comorbidities, patient charac-
nuanced than just revision as an end point.6 However, teristics, and orthopaedic factors that can influence hip
for such outcome measures to be useful for comparison and knee replacement outcomes.
purposes, considerable patient information is needed to Patient-reported outcome measures and joint-specific
allow risk stratification. Registries are increasingly trying outcome measures are being collected more commonly as
to gain more detail about patient characteristics, including surgeons, payers, regulatory agencies, and patients seek
comorbidities before surgery (so-called level 2 data) to more nuanced measures of the results of joint arthroplasty
allow the development of better risk stratification models. versus only revision. Although these measures have great
value, they are time consuming and expensive to collect;
simplifying how these measures are collected, reducing
Limitations of Registries the number of questions to minimal necessary datasets,
Registries can provide big-picture information about what and identifying the circumstances under which outcome
is being done and the results being produced. They also measures are most valuable to collect is an ongoing effort.
can provide associations between outcomes and patient Each registry has its own advantages and d isadvantages.
and implant characteristics. However, it is important to Merging or sharing data between different registries can
understand that such associations do not necessarily arise provide synergies.9 Currently, the International Society
from causality, and confounding variables often are pres- of Arthroplasty Registries is working to standardize ter-
ent.7 Registries are subject to selection bias; that is, some minology and define minimal collected datasets. These
procedures or implants may be used disproportionately efforts may allow collaboration of registries to evaluate
Chapter 6: National Joint Registries
serious problems that arise infrequently, identify concerns itself to allow long-term tracking of implant survivor-
with respect to specific implants or procedures earlier, ship. Level 2 data on comorbidities and complications
and confirm or deny observations reported from just one and level 3 data on patient-reported outcomes also are
registry. being collected by the AJRR on an expanding subset of
patients from hospitals that have elected to collect and
report these data.
National Joint Registries In the most recent AJRR annual report published in
David G. Lewallen, MD November 2015, information on the cumulative experi-
The American Joint Replacement Registry ence from 2012 through the end of 2014 was summarized.
Background This report presented data on hip and knee arthroplasty
The American Joint Replacement Registry (AJRR) is a procedures of all types, totaling more than 225,000 cases
not-for-profit 501(c)(3) tax-exempt organization that was through the end of 2014. These procedures were per-
established to collect data on THA and total knee arthro- formed by more than 2,300 surgeons located in all
plasty (TKA) performed in the United States to improve 50 states from institutions that represented the full range
the quality of care. It is the result of a multiple stakeholder of hospital types, sizes, and locations. Patients undergoing
1: Hip and Knee

collaborative effort by the American Academy of Ortho- arthroplasty in this large US sample were predominantly
paedic Surgeons; the American Association of Hip and female (56.8% of hips, 61.6% of knees), with a mean age
Knee Surgeons; the Hip Society; the Knee Society; hospi- of 67.7 years for hip arthroplasty and 66.1 years for knee
tals within the American Hospital Association; individual arthroplasty. Thus, almost one-half of all procedures in
participating institutions, health insurance plans, and the United States were performed in individuals older
medical device manufacturers; and both volunteer and than 65 years and were not well represented in studies
direct financial contributions from individual orthopaedic solely of Medicare datasets. In this sample of the national
surgeons. All stakeholders and the public are represented experience, osteoarthritis was the predominant diagnosis
on the 15-person board of directors, which is responsible prompting arthroplasty. Rheumatoid arthritis was indi-
for the AJRR’s strategic direction and oversight of its cated in fewer than 1% of these procedures, likely related
activities and operations. to advances in the medical management of inflammatory
The goal of the AJRR is to capture data on more than arthropathies during the past decade.
90% of all hip and knee arthroplasties performed in the In the initial few years of any registry operation, data
United States, while also developing the comprehensive available are mainly descriptive, pending longer-term
data needed to enhance orthopaedic quality of care, there- follow-up and survivorship data on implant performance
by improving patient outcomes and safety, reducing costs, (which can be further studied by hospital, surgeon, sur-
and advancing orthopaedic science and bioengineering. gical technique, and patient factors). Another example of
The American Academy of Orthopaedic Surgeons pro- important descriptive information on the national experi-
vided initial support for the AJRR. After formalizing the ence is the most recent annual report that demonstrated
multiple-stakeholder model, the AJRR evolved to include that femoral neck fracture accounts for more than 1 in
varying levels of support from virtually all the participat- 10 hip arthroplasties currently performed in the United
ing stakeholder groups. It is currently evolving into an or- States. Short-term shifts in practice patterns also can
ganization that will be mainly supported by subscriptions be documented. For surface replacement arthroplasty,
or software licensing fees, which are currently paid by which once widely performed, the percentage decreased
a subset of hospitals and, more recently, some physician to fewer than 0.5% of hip procedures between 2012 and
practice groups (and soon to include individual surgeons) 2014 and was limited to a handful of hospitals and sur-
desiring on-demand access and display of their own data geons. Implant-specific information and patterns of use
benchmarked to the national sample. of specific implant technology can be documented as such
technology evolves in the initial years of a registry such as
Current Status the AJRR, which is shown by the example of ceramic head
As of March 2016, the AJRR had gathered level 1 data use in THA (Figure 1). The relative percentage of ceramic
on more than 365,000 procedures performed by more versus cobalt-chromium heads used in hip arthroplasty
than 4,600 surgeons as reported by 670 participating in the United States from 2012 to 2014 can be tracked
hospitals located in all 50 states. Level 1 data represent by year (Figure 1).
the minimum information required on all cases for par- Ceramic head usage also can be shown to be biased
ticipation in the AJRR and include details on the patient, toward younger patients, comprising most arthroplasties
the procedure, the hospital, the surgeon, and the implant in those younger than 60 years and diminishing usage
Figure 2 Line graph of ceramic femoral head usage by

patient decade of life (N = 35,956). (Reproduced
with permission from the American Joint
1: Hip and Knee
Replacement Registry: Annual Report, 2014.

Rosemont, IL, American Joint Replacement
Registry, 2015, pp 14-15.)
Figure 1 Bar graph of ceramic versus cobalt-chromium
femoral head usage between 2012 and
2014. (Adapted with permission from the
American Joint Replacement Registry: Annual
Report, 2014. Rosemont, IL, American Joint
Replacement Registry, 2015, pp 14-15.)
the collection of hospital- and provider-specific informa-
tion that can be benchmarked against national data. Such
data will become increasingly valuable in the next several
years with the addition of risk-adjusted implant survivor-
with each decade of patient age thereafter (Figure 2); how- ship and complication data, helping to further drive im-
ever, the percentage of older patients receiving a ceramic provements in care for patients undergoing arthroplasty.10
femoral head has grown each year since 2012.
Data on knee arthroplasties has shown that these The United Kingdom and International Experience
procedures are performed almost exclusively for osteo- Fares S. Haddad, FRCS (Orth)
arthritis, with tricompartmental replacement and Background
posterior-stabilized components used in most primary Hip, knee, ankle, elbow, and shoulder joint arthroplasties
knee arthroplasties. Cruciate-retaining implants were have become common and highly successful procedures
used in fewer than one-third of the procedures. that bring many patients improved mobility and pain
Revision burden also can be tracked by a national reg- relief. The National Joint Registry (NJR) for England,
istry effort such as AJRR, and it is defined as the percent- Wales, Northern Ireland, and the Isle of Man has been in
age of total joint arthroplasty cases performed per year existence for more than a decade and was developed based
that were revisions of prior implants. Revision burden is on the success of the Scandinavian registries. During the
one measure of the success and long-term durability of same time period, the Australian registry developed a use-
these procedures. In the AJRR annual report, the revision ful output of information from the Southern Hemisphere,
burden was 10% of all hip arthroplasties performed an- and the hope is that multiple registries will be developed
nually; for knee arthroplasties, the revision burden was worldwide, for not only hip and knee arthroplasty but
slightly lower, at 8.1% of all knee arthroplasties per year. also other orthopaedic subspecialties, and harmonized
The AJRR is actively expanding data collection from in such a way that they can be assessed together and
hospitals with comprehensive level 2 (comorbidity and information gleaned across cohorts and populations.11,12
complications) and optional level 3 (patient-reported Registry data are now clearly a valuable part of the
outcome measures) data available for local data analysis orthopaedic surgeon’s armamentarium. In orthopaedic
needs to support the extramural payment and quality medicine, physicians have significantly relied on expert
reporting needs of institutions and providers. A surge in opinion and the outcome of case series to guide man-
interest and participation in the AJRR has followed the agement. More recently, physicians have increasingly
introduction of incentives by payers and certifying bodies recognized the importance of prospective randomized
for registry participation as a quality improvement indica- studies, but these are expensive and not always practical,
tor. The AJRR currently provides a robust foundation for focusing on specific refined questions. Registry data and
studies add great value because they provide information hospital, and surgeon and highlight where these fall below
regarding the entire population.13 an expected performance to allow prompt investigation
Registry analysis helps identify trends and potential and support follow-up action; (2) inform patients, clini-
problems. The great advantages of any registry are that cians, providers, and commissioners of healthcare, reg-
registries are cross-sectional across an entire population ulators, and implant suppliers of the outcomes achieved
and provide objective primary data on what happens to in joint arthroplasty surgery; (3) showcase variations in
patients or implants and procedures. The registries also outcomes achieved across surgical practices to inform
provide a real-time view because the data come from best practice; (4) enhance patient awareness of joint ar-
more than just major centers or design surgeons. In effect, throplasty outcomes to better inform patient choice and
the data are a real-time check of the generalizability of patients’ quality of experience by engaging with patients
a procedure or an implant. It also has been shown that and patient organizations; (5) support evidence-based
feedback improves performance.14-18 purchasing of joint arthroplasty implants for healthcare
If a registry has good compliance and produces clean providers to support quality and cost effectiveness; and
validated data, the optimal treatment modalities (ap- (6) support suppliers in the routine after-market sur-
proaches, implants, or procedures) can be identified. veillance of implants and provide information to clini-
1: Hip and Knee

Great learning and research potential is possible for the cians, patients, hospital management, and the regulatory
entire community, at potentially large savings for health- authorities.
care providers, which is predicated on clear, impartial,
statistically sound, and unbiased interpretation. Such Orthopaedic Registries and Data Interpretation
potential has been effectively shown in the Scandinavian The NJR is a powerful resource that can contribute to
model.19-23 research into the full range of biologic, mechanical, clini-
Registries have great potential for identifying early cal, economic, and social factors influencing the outcome
failure of a new implant or technique. Registries also of joint arthroplasty. The data also can help establish the
can be used to identify a poor performer within a sub- effect of joint arthroplasty on the well-being of patients
group, for example, a certain type of knee replacement and the general population. However, problems and chal-
or hip resurfacing. Registries also can identify outlying lenges exist with some registries. Many have limited data
implants or surgeon performance, which should generate capture and data quality, which makes data interpretation
questions related to why outliers are occurring and what, and use difficult.
if anything, should be done.24-26 Registries are now a critical part of surgeon decision
The NJR has an Outlier Committee that examines making, but it is important to interpret registries given
both outlier surgeon and implant performance. This sys- that they are not always necessarily relevant to individual
tem effectively alerts surgeons and units to potential prob- practice and do not prove causation. They merely provide
lems with performance. The data can be checked locally, a means for analysis and to generate hypotheses.
and changes in practice can be made. This system has Registries also need to be studied longitudinally. Cer-
improved performance and outcomes for both surgeons tain aspects, such as cementation of the femoral stem that
and patients. The process also is confidential initially; makes one type of implant, the cemented femoral stem,
although it is perhaps important that such evaluations might look much better than aspects for a noncemented
and their outcomes are within the public domain, the stem in the first decade, but follow-up during the second
process itself does not need to be revealed publically.27 decade may show that noncemented arthroplasty comes
to the fore later.29,30
The Remit of NJR Any dataset within a registry needs to be interpreted
The NJR collects information on joint arthroplasty sur- in the light of confounders. For example, using registry
gery and monitors the performance of joint arthroplasty data to promote one approach or anesthetic technique
implants. It was established in 2002 by the UK Department over another needs to somehow control for the type of
of Health. The registry helps monitor the performance of patients in each group and some form of selection bias.31,32
implants and the effectiveness of different types of surgery. An important issue is that the end point in registries
It currently collects data on all hip, knee, ankle, elbow, and is revision, not clinical outcome or function. Because of
shoulder joint arthroplasties across the National Health a large bias toward revision as the key end point for any
Service and the independent healthcare sector and has arthroplasty, it is difficult to say whether a procedure or
more than 1 million procedures registered.28 an implant that has functioned well for 10 years should
The six goals of NJR are as follows: (1) Monitor in be discarded in favor of one that functions poorly but
real time the outcomes achieved by brand of prosthesis, survives 10 or 15 years or longer because it is difficult to
revise. Moreover, if the data are analyzed poorly, a single what the exercise is aiming to achieve. It would be a detri-
poor performer in a subgroup can negatively affect the ment if surgeons started avoiding the most complex cases.
remainder of the subgroup and skew the data. The data have not yet been validated, and in the
Registries are strongly affected by revision bias. Data first 10 years of the registry, data capture was incon-
can be either misinterpreted or overinterpreted, thus sistent.37,38 The data to separate and control for ortho-
opening registries to inappropriate use by colleagues, paedic and medical case mix complexity is inadequate
industry, and politicians.32,33 and limited to age, body mass index, American Society
Revisions and other complications also vary with case of Anesthesiologists grade, and the use of bone graft.
complexity and orthopaedic and medical comorbidity. The dataset is incomplete: the national average is 92%
Limitations in the accuracy of any inferred conclusions complete; although some units have 100% compliance,
include difficulties in adjusting for case-mix complexity, several are much closer to 50%, which should raise con-
inaccuracy of propensity scores, a lack of data validation, cerns regarding any inferences made at individual sur-
missing data, incomplete capture of preexisting covari- geon-level reporting. It is fully appreciated that the NJR
ates, limitations of Cox regression analysis, and inferring is getting better each year, but another 10 years may be
causation from observational data.34,35 necessary before the dataset is sufficiently validated and
1: Hip and Knee
One key issue is that registries are not sufficiently devel- appropriately evaluated to consider the publication of
oped for patient-level analysis. They provide population surgeon-level data.
data that are ideal for hypothesis generation. The findings
from such data need to be tested in appropriately con- The Future
structed studies. When circumstances determine that this The NJR recently celebrated its tenth anniversary and has
is not possible, the data need to be interpreted for what registered more than 1.7 million procedures. Combined
they are and acted on appropriately. In the United King- with other national registries, the NJR has had a huge
dom, NJR data are not owned by the profession, which effect on the practice of joint arthroplasty worldwide.
creates a disadvantage. Data can be published without Registries realize the epidemiologic goals of enhancing
knowledge, agreement, or validation by the profession. general awareness; supporting evidence-based practice;
providing after-market implant surveillance; and monitor-
Risks and Challenges ing outcomes achieved by brands of prosthesis, hospitals,
Although physicians are aware of the many potential and surgeons. Therefore, registries cater to the patients,
benefits of registries, they continue to grapple with the clinicians, providers, and commissioners of healthcare,
difficulties that registry data can present. Recent infor- regulators, and implant suppliers. The ability to link reg-
mation demonstrating that some retrieved metal-on-metal istry data to patient-reported outcome measures as well
revision procedures were not incorporated into the NJR as other population-based data sources enhances their
implants survival curve is concerning,3,36-40 and two recent usefulness for monitoring outcomes and trends.
articles highlighted missing data from the national reg- Registries, and the NJR in particular, have inherent
istry.37,38 Such instances should be interpreted in light of disadvantages that limit the interpretation of the data
ongoing initiatives to validate NJR data locally, setting up made available by them. Compliance issues associated
a more robust and centralized process to understand and with any data collection and the reporting process limit
evaluate the data in a more transparent way. Nevertheless, the quality of the registry data. No robust system is in
these studies raise questions about the potential use of place to tackle confounding data and capture underre-
NJR (and other registry) data and particularly about the ported data or unreported outcomes. Registries were
publication of surgeon-level data. set up to capture survival, but the ancillary data that
The headline outcome results of the NJR are similar have been collected are not validated. Caution must be
to those of all other national registries. With 1.7 million exercised when using registries as high-level evidence.
entries, even 1,000 missing cases will have little effect. At Registry-based study results cannot infer causative ex-
the individual surgeon level, however, where the denom- planations. Any trend identified should be used to test
inator may be only a few hundred procedures, the effect hypotheses, not as a study conclusion. Focused studies
may be greater. Using parametric statistical techniques also will be necessary to introduce new technology be-
and standard deviations about a norm, to rank and com- cause registries only are surrogates to this process.
pare surgeon performance, is problematic. There will The best registry data are complete, validated, and
always be a bottom 1%, 2%, 5%, and 10%. If these are peer-reviewed and have good source data verification.
removed, then the process starts again with a new bottom Such data have systems in place to determine the ap-
of 1%, 2%, 5%, and 10%. Such parameters may not be propriate research questions and methods to be used;
high-level database integration techniques and outputs 2. Delaunay C: Registries in orthopaedics. Orthop Trauma-
are required to create important messages and result in tol Surg Res 2015;101(1 suppl):S69-S75. Medline DOI
practice change. The authors examined the different needs of various stake-
Registries have an ongoing role. They will get improve holders when using registry data.
as good practice is integrated across different medical
3. Liebs TR, Splietker F, Hassenpflug J: Is a revision a revi-
societies. It is important that registries are used appro- sion? An analysis of national arthroplasty registries’ defi-
priately to avoid politically biased interpretations or poor nitions of revision. Clin Orthop Relat Res 2015;473(11):
health economic analyses. Ultimately, registries should 3421-3430. Medline DOI
help surgeons make their decisions by providing needed This study compared the definitions of revision among
and desired data. registry reports and apply common clinical scenarios to
these definitions. Revision, which is the most common
end point used by arthroplasty registries, is not univer-
Summary sally defined. This implies that some reoperations that are
considered a revision in one registry are not considered
National registries are becoming more common and are a revision in another registry. Therefore, comparisons of
maturing. The data provided by these registries is having implant performance using data from different registries
should be performed with caution.
1: Hip and Knee

more beneficial effects on orthopaedic practices. The ad-
vantages and limitations of joint registries are important 4. Niinimäki TT: The reasons for knee arthroplasty revisions
to understand when evaluating data. are incomparable in the different arthroplasty registries.
Knee 2015;22(2):142-144. Medline DOI
Key Study Points Joint revisions are categorized differently in registries,

which may result in some observed discrepancies in out-
come results from different registries.
• National joint registries can provide descriptive in-
formation about patients undergoing joint arthro- 5. Devane PA, Wraighte PJ, Ong DC, Horne JG: Do joint
plasty, survivorship rates, and outcomes data about registries report true rates of hip dislocation? Clin Orthop
joint arthroplasty based on patient, hospital, and Relat Res 2012;470(11):3003-3006. Medline DOI
implant factors. Dislocations not resulting in revision often were not cap-
• Registries also can provide information about the tured in the New Zealand Joint Registry.
most common reasons for implant failure and
complications. 6. Patel J, Lee JH, Li Z, SooHoo NF, Bozic K, Huddleston JI
III: Predictors of low patient-reported outcomes response
• Data provide a real-time feedback loop to all stake- rates in the California Joint Replacement Registry. J Ar-
holders (patients, surgeons, hospitals, payers, and throplasty 2015;30(12):2071-2075. Medline DOI
implant manufacturers), which can lead to quality The critical factor in ongoing participation after surgery in
improvement. patient-reported outcome reporting in the California Joint
• Registries have limitations, the most important of Arthroplasty Registry (now part of the American Joint
Replacement Registry) was preoperative participation in
which is that they provide information about asso- survey collection.
ciations between outcomes and patient and implant
factors, but they cannot prove that such associations 7. Whitehouse SL, Bolland BJ, Howell JR, Crawford RW,
are causal. Timperley AJ: Mortality following hip arthroplasty—in-
appropriate use of National Joint Registry (NJR) data.
The authors explored confounding variables in mortality
Annotated References reporting in the NJR.
1. de Steiger RN, Miller LN, Davidson DC, Ryan P, 8. Inacio MC, Paxton EW, Dillon MT: Understanding ortho-
Graves SE: Joint registry approach for identification of paedic registry studies: A comparison with clinical studies.
outlier prostheses. Acta Orthop 2013;84(4):348-352. J Bone Joint Surg Am 2016;98(1):e3. Medline DOI
Medline DOI This article explains the complimentary nature of registry
This article describes the methods used by the Australian studies to randomized controlled trials and cohort studies.
Orthopaedic Association National Joint Registry to iden-
tify outlier prostheses. 9. Stea S, Comfort T, Sedrakyan A, et al: Multinational
comprehensive evaluation of the fixation method used in
hip replacement: Interaction with age in context. J Bone
Joint Surg Am 2014;96(suppl 1):42-51. Medline DOI
The authors reported on collaboration between six na- mortality after knee replacement decreased substantially
tional and regional joint registries to evaluate fixation in between 2003 and 2011.
hip replacement.
16. Jameson SS, Charman SC, Gregg PJ, Reed MR, van der
10. American Joint Replacement Registry: Annual report Meulen JH: The effect of aspirin and low-molecular-
2014: Second AJRR annual report on hip and knee arthro- weight heparin on venous thromboembolism after hip
plasty data. Available at http://www.ajrr.net/images/annu- replacement: A non-randomised comparison from infor-
al_reports/AJRR_2014_Annual_Report_final_11-11-15. mation in the National Joint Registry. J Bone Joint Surg
pdf. Accessed July 10, 2016. Br 2011;93(11):1465-1470. Medline DOI
The authors analyzed NJR data that were linked to an
11. Malchau H, Porter ML: Editorial comment: 2014 meet- administrative database of hospital admissions in the UK
ing of the International Society of Arthroplasty Regis- National Health Service. The rate of pulmonary embolism
ters. Clin Orthop Relat Res 2015;473(11):3368-3369. was 0.68% in both groups, and the 90-day mortality
Medline DOI was 0.65% with aspirin and 0.61% with low-molecular–
The authors summarized the output of a meeting of the weight heparin (odds ratio = 0.93; 95% CI: 0.77-1.11).
International Society of Arthroplasty Registers and iden-
tified a need for registries to work together to collect com- 17. Malchau H, Garellick G, Eisler T, Kärrholm J, Herberts
parable data. P: Presidential guest address: The Swedish Hip Registry.
1: Hip and Knee
Increasing the sensitivity by patient outcome data. Clin

12. Graves SE: The value of arthroplasty registry data. Acta Orthop Relat Res 2005;441:19-29. Medline DOI
Orthop 2010;81(1):8-9. Medline DOI
18. Smith AJ, Dieppe P, Porter M, Blom AW; National Joint
13. Bedair H, Lawless B, Malchau H: Are implant designer Registry of England and Wales: Risk of cancer in first sev-
series believable? Comparison of survivorship between en years after metal-on-metal hip replacement compared
designer series and national registries. J Arthroplasty with other bearings and general population: Linkage study
2013;28(5):728-731. Medline DOI between the National Joint Registry of England and Wales
and hospital episode statistics. BMJ 2012;344:e2383.
Fifteen different hip and knee implant results published Medline DOI
by designers were identified and compared with four
national registries. Thirty-two percent of the compari- NJR data were linked to National Health Service hospital
sons performed demonstrated greater survivorship in the episode statistics data to examine the incidence of all can-
designer series compared with the registries, and 68% cers and the incidence of malignant melanoma and pros-
demonstrated no difference. Two implants accounted for tate, renal tract, and hematologic cancers. The incidence
most (12 of 16) of the discordances. of new diagnoses of cancer was low after hip replacement
(1.25% at 1 year; 95% CI: 1.21%-1.30%) and lower than
14. Hunt LP, Ben-Shlomo Y, Clark EM, et al; National Joint that predicted from the age- and sex-matched normal
Registry for England and Wales: 45-day mortality af- population (1.65% at 1 year; 95% CI: 1.60%-1.70%).
ter 467,779 knee replacements for osteoarthritis from Compared with alternative bearings, no evidence was
the National Joint Registry for England and Wales: An shown that metal-on-metal bearing surfaces were associ-
observational study. Lancet 2014;384(9952):1429-1436. ated with an increased risk of any cancer diagnosis in the
Medline DOI 7 years after surgery.
The authors looked at NJR data for hip replacements be- 19. Gøthesen O, Espehaug B, Havelin L, et al: Survival rates
tween April 2003 and December 2011. Patient identifiers and causes of revision in cemented primary total knee
were used to link these data to the national mortality replacement: A report from the Norwegian Arthroplasty
database and the Hospital Episode Statistics database. Register 1994-2009. Bone Joint J 2013;95-B(5):636-642.
A secular decrease in mortality, from 0.56% in 2003 to Medline DOI
0.29% in 2011, occurred, even after adjusting for age,
sex, and comorbidities. The authors evaluated the rates of survival and cause of
revision of seven different brands of cemented primary
15. Hunt LP, Ben-Shlomo Y, Clark EM, et al; National TKA in the Norwegian Arthroplasty Register. The risk
Joint Registry for England, Wales and Northern Ireland: of revision for aseptic tibial loosening was higher in the
90-day mortality after 409,096 total hip replacements mobile-bearing LCS Classic, the LCS Complete, the fixed
for osteoarthritis, from the National Joint Registry for modular-bearing Duracon, and the fixed nonmodular
England and Wales: A retrospective analysis. Lancet bearing AGC Universal, compared with the Profix. These
2013;382(9898):1097-1104. Medline DOI results suggested that aseptic loosening is related to design
in TKA.
The authors looked at NJR data for knee arthroplasty for
osteoarthritis. Patient identifiers were used to link these 20. Jameson SS, Lees D, James P, et al: Lower rates of dis-
data to the national mortality database and the Hospital location with increased femoral head size after primary
Episode Statistics database. Compared with TKA, uni- total hip replacement: A five-year analysis of NHS patients
compartmental knee replacement had a substantially low- in England. J Bone Joint Surg Br 2011;93(7):876-880.
er mortality (hazard ratio [HR] = 0.32; 95% confidence Medline DOI
interval [CI] = 0.19 to 0.54; P < 0.0005). Postoperative
The authors used the NJR to examine the relationship 25. Jameson SS, Baker PN, Mason J, Porter ML, Deehan DJ,
between the use of femoral head diameters greater than Reed MR: Independent predictors of revision following
or equal to 36 mm and dislocation and revision rates. The metal-on-metal hip resurfacing: A retrospective cohort
increased use of larger diameter heads was associated study using National Joint Registry data. J Bone Joint
with a lower rate of dislocation, without an increase in Surg Br 2012;94(6):746-754. Medline DOI
revision rate.
NJR data were used to report associations between demo-
graphic, implant, and surgeon factors and need for revision
21. Mäkelä KT, Matilainen M, Pulkkinen P, et al: Coun- of metal-on-metal hip resurfacing implants.
trywise results of total hip replacement: An analysis of
438,733 hips based on the Nordic Arthroplasty Register
Association database. Acta Orthop 2014;85(2):107-116. 26. Smith AJ, Dieppe P, Vernon K, Porter M, Blom AW;
Medline DOI National Joint Registry of England and Wales: Fail-
ure rates of stemmed metal-on-metal hip replacements:
This study assessed THA survival according to country, Analysis of data from the National Joint Registry of En-
based on the Nordic Arthroplasty Register Association gland and Wales. Lancet 2012;379(9822):1199-1204.
database. The 15-year survival rate, with any revision as Medline DOI
an end point, for all THAs was 86% (95% CI: 85.7%-
86.9%) in Denmark, 88% (95% CI: 87.6%-88.3%) in In an analysis of NJR data for primary THAs undertaken
Sweden, 87% (95% CI: 86.4%-87.4%) in Norway, and between 2003 and 2011, hip resurfacing resulted in similar
84% (95% CI: 82.9%-84.1%) in Finland. Revision risk for implant survivorship to other surgical options in only two
1: Hip and Knee

all THAs was less in Sweden than in the three other coun- cases: men with large femoral heads and inferior implant
tries during the first 5 years. The differences in survival survivorship in other patients, particularly women.
rates were considerable, with inferior results in Finland.
Brand-level comparison of THAs in the Nordic countries 27. Rowden NJ, Harrison JA, Graves SE, Miller LN, de Stei-
will be required. ger RN, Davidson DC: Loss to follow-up after arthro-
plasty: A new use for registry data. J Bone Joint Surg Br
22. Malchau H, Graves SE, Porter M, Harris WH, Troelsen 2012;94(4):493-496. Medline DOI
A: The next critical role of orthopedic registries. Acta The authors assessed the outcome of patients who were
Orthop 2015;86(1):3-4. Medline DOI lost to follow-up after arthroplasty by a single surgeon.
The authors proposed a strategy of phased introduction A significantly higher mortality rate occurred in those
of new implants with concomitant monitoring of results patients lost to follow-up. This study demonstrated that
using registries. individual surgeons can use a national joint registry to
establish more accurate revision rates in their patients
undergoing arthroplasty.
23. Pedersen AB, Baron JA, Overgaard S, Johnsen SP: Short-
and long-term mortality following primary total hip
replacement for osteoarthritis: A Danish nationwide ep- 28. National Joint Registry annual report. http://www.njrcentre.
idemiological study. J Bone Joint Surg Br 2011;93(2): org.uk/njrcentre/Reports,PublicationsandMinutes/
172-177. Medline DOI Anualreports/tabid/86/Default.aspx. Accessed August
15, 2016.
A 1-month period of increased mortality occurred imme-
diately after surgery among patients undergoing THA, but 29. Mäkelä KT, Matilainen M, Pulkkinen P, et al: Failure rate
overall short-term mortality (0 to 90 days) was signifi- of cemented and uncemented total hip replacements: Reg-
cantly lower (mortality rate ratio, 0.8; 95% CI: 0.7-0.9) ister study of combined Nordic database of four nations.
compared with controls. Long-term mortality was lower BMJ 2014;348. Medline DOI
among patients undergoing THA compared with controls
(mortality rate ratio, 0.7; 95% CI: 0.7-0.7). The absolute The authors assessed the failure rate of cemented, nonce-
risk of death was small. mented, hybrid, and reverse hybrid THAs in patients at
least 55 years old.
24. Jameson SS, Baker PN, Mason J, et al: The design of the
acetabular component and size of the femoral head influ- 30. Troelsen A, Malchau E, Sillesen N, Malchau H: A review
ence the risk of revision following 34 721 single-brand of current fixation use and registry outcomes in total hip
cemented hip replacements: A retrospective cohort study of arthroplasty: The uncemented paradox. Clin Orthop
medium-term data from a National Joint Registry. J Bone Relat Res 2013;471(7):2052-2059. Medline DOI
Joint Surg Br 2012;94(12):1611-1617. Medline DOI The current use of noncemented fixation in primary THAs
This retrospective cohort study recorded the survival time varied between 15% in Sweden and 82% in Canada. From
to revision following primary cemented THA using the 2006 to 2010, the registries of all countries reported over-
most common combination of components that accounted all increases in the use of noncemented fixation.
for almost 25% of all cemented THAs, exploring risk
factors independently associated with failure. The risk 31. de Steiger RN, Liu YL, Graves SE: Computer navigation
of revision for dislocation was significantly higher with for total knee arthroplasty reduces revision rate for pa-
a plus offset head (HR = 2.05; P = 0.003) and a hooded tients less than sixty-five years of age. J Bone Joint Surg
acetabular component (HR = 2.34; P < 0.001). Am 2015;97(8):635-642. Medline DOI
This study analyzed data from the Australian Orthopaedic 36. Huotari K, Peltola M, Jämsen E: The incidence of late
Association National Joint Registry to examine the effect prosthetic joint infections: A registry-based study of
of computer navigation on the rate of revision of primary 112,708 primary hip and knee replacements. Acta Or-
TKA. A significant difference in the rate of revision oc- thop 2015;86(3):321-325. Medline DOI
curred following nonnavigated TKA compared with that
following navigated TKA patients younger than 65 years The incidence rate of late prosthetic joint infections after
(HR = 1.13; 95% CI: 1.03-1.25; P = 0.011). hip or knee arthroplasty was approximately 0.07% per
prosthesis-year. The incidence of late prosthetic infections
appeared to increase.
32. Anand R, Graves SE, de Steiger RN, et al: What is the
benefit of introducing new hip and knee prostheses? J Bone
Joint Surg Am 2011;93(suppl 3):51-54. Medline DOI 37. Sabah SA, Henckel J, Cook E, et al: Validation of primary
metal-on-metal hip arthroplasties on the National Joint
An analysis was performed on all new hip and knee pros- Registry for England, Wales and Northern Ireland using
theses introduced into the market between January 1, data from the London Implant Retrieval Centre: A study
2003, and December 31, 2007, and used on at least 100 oc- using the NJR dataset. Bone Joint J 2015;97-B(1):10-18.
casions. The findings were compared with the combined Medline DOI
results of the three best-performing established hip and
knee prostheses with a minimum duration of follow-up This study suggested that NJR reports may underestimate
of 5 years. This study indicated that no benefit was found rates of revision for many types of metal-on-metal hip
replacement.
1: Hip and Knee
in introducing new prostheses into this national market

during the 5-year study period. Importantly, 30% of the
new prostheses were associated with a significantly worse 38. Sabah SA, Henckel J, Koutsouris S, et al: Are all met-
outcome compared with prostheses with a minimal dura- al-on-metal hip revision operations contributing to the
tion of follow-up of 5 years. National Joint Registry implant survival curves? A study
comparing the London Implant Retrieval Centre and
33. Griffiths EJ, Stevenson D, Porteous MJ: Cost savings of National Joint Registry datasets. Bone Joint J 2016;
using a cemented total hip replacement: An analysis of 98-B(1):33-39. Medline DOI
the National Joint Registry data. J Bone Joint Surg Br The authors analyzed metal-on-metal hip revision proce-
2012;94(8):1032-1035. Medline DOI dures performed between 2003 and 2013 that linked NJR
The authors undertook a simplistic assessment of the face to retrieval center data. Only one-third of the retrieved
value cost of cemented and noncemented implants used components contributed to survival curves on the NJR.
in the NJR. The potential savings for primary THAs
were calculated to be £10 million, with an additional 39. Witso E: The rate of prosthetic joint infection is under-
savings during the first 5 years between £5 million and estimated in the arthroplasty registers. Acta Orthop
£8.5 million. 2015;86(3):277-278. Medline DOI
The authors reported that the rate of capture of prosthetic
34. Konan S, Haddad FS: Joint registries: A Ptolemaic model joint infections in several Scandinavian registries is less
of data interpretation? Bone Joint J 2013;95-B(12):1585- than 100% and is caused by incomplete reporting, varying
1586. Medline DOI definitions of infection, and varying registry end point
The authors highlighted the problems of confounding definitions of failure.
bias and selection bias, which render the interpretation of
registry data difficult and warned against behavior change 40. Gundtoft PH, Pedersen AB, Schønheyder HC, Over-
based on these data unless the data are corroborated in gaard S: Validation of the diagnosis “prosthetic joint in-
other ways. fection” in the Danish Hip Arthroplasty Register. Bone
Joint J 2016;98-B(3):320-325. Medline DOI
35. Perry DC, Parsons N, Costa ML: ‘Big data’ reporting The purpose of this study was to validate the diagnosis
guidelines: How to answer big questions, yet avoid of prosthetic joint infections in the Danish Hip Arthro-
big problems. Bone Joint J 2014;96-B(12):1575-1577. plasty Register. Only two-thirds of the revisions for such
Medline DOI infections were captured in the register, and only 77% of
This article reinforces both the benefits and the pitfalls of the infections reported to the register could be confirmed
using data that were not designed to answer the questions as being actual infections.
posed.
Section 2
Knee
Section Editor:
Michael A. Mont, MD
Chapter 7
Biomechanics of the Knee

Gregory Tocks, DO William A. Jiranek, MD Jibanananda Satpathy, MD, MRCSEd Jennifer S. Wayne, PhD
The biomechanical changes that occur in both an osteo-

Abstract
arthritic knee and the knee following arthroplasty, includ-
Key biomechanical characteristics of the knee joint in- ing the mechanical differences between cruciate-sparing
clude the tibiofemoral and patellofemoral articulations, and cruciate-sacrificing total knee arthroplasty (TKA)
their kinematics, and associated soft-tissue mechanics. designs, will be helpful to the orthopaedic surgeon.
Recent data report on alterations in biomechanics of
the osteoarthritic knee and differences in biomechanics
Knee Anatomy and Its Biomechanical Function
of various total knee arthroplasty designs. Surgeons
will benefit from summaries of recent research on the Tibiofemoral Articulation and Kinematics
biomechanics of patients after total knee arthroplasty. The convexity of the medial tibial plateau articular sur-
face supplements the more extended dimensions of the
medial femoral condyle, whereas the lateral tibial plateau
Keywords: knee; biomechanics; osteoarthritis; has a more convex anteroposterior surface. The tibio-
arthroplasty femoral joint maintains its stability through a relationship
among static and dynamic features. Dynamic features
describe muscles acting on or across the knee joint. The
quadriceps muscle group is the primary eccentric decel-
erator of the knee and reduces posterior subluxation.
Introduction
The hamstring muscles decrease anterior subluxation
Important parts of human knee anatomy relate to its and capsular laxity through their insertion into the me-
2: Knee
biomechanical function, including the articular shape of dial and lateral capsular ligaments. The gastrocnemius
all three knee compartments, and soft-tissue mechanics, muscle heads and the iliotibial band supplement stability
which contribute to normal and abnormal kinematics. through attachments to capsular ligaments. Static stability
is derived from a combination of tibiofemoral ligaments,
the menisci, the anatomy of the articular surfaces, and
Dr. Jiranek or an immediate family member has received the inherent intra-articular joint loads.1
royalties from DePuy; serves as a paid consultant to Cay- Although the tibiofemoral articulation resembles a
enne Medical and DePuy; has stock or stock options held in hinge joint, it actually possesses six degrees of freedom:
Johnson & Johnson; has received research or institutional three rotations and three translations about axes in
support from DePuy and Stryker; and serves as a board three-dimensional space. Three of the primary motions
member, owner, officer, or committee member of the include flexion-extension, internal-external rotation, and
American Association of Hip and Knee Surgeons, Lifenet anterior-posterior translation.2 The tibiofemoral joint has
Health and the Orthopaedic Learning Center. Dr. Wayne or a passive range of motion up to 160° of flexion in the
an immediate family member has received nonincome sup- sagittal plane, with up to 130° of active flexion.3 During
port (such as equipment or services), commercially derived flexion, there are coupled rotations in the other two
honoraria, or other non–research-related funding (such as planes causing incongruency between articulating sur-
paid travel) from DePuy, OrthoSensor, Synthes, and Trimed. faces across part of the range of motion. The knee prefers
Neither of the following authors nor any immediate family weight support and stability in full extension. Flexion
member has received anything of value from or has stock or contractures are disabling and tiring because the quadri-
stock options held in a commercial company or institution ceps muscle force increases to maintain posture because
related directly or indirectly to the subject of this chapter: the ground reaction force passes posterior to the knee
Dr. Tocks and Dr. Satpathy. joint.4
Section 2: Knee
concave surface. The lateral condyle rolls posteriorly to-

ward the posterior horn of the mobile lateral meniscus
until the meniscus starts resisting further translation.
As the knee flexes, the anterior cruciate ligament (ACL)
comes under more tension and resists further posterior
translation of the femur relative to the tibia. Consequently,
the femur slides anteriorly while rolling posteriorly on the
tibia during flexion.1
Patellofemoral Articulation and Kinematics

The patella is the largest sesamoid bone in the body. Prox-
imally, the patella attaches to the quadriceps tendon,
and distally, it has attachments to the deeper layer of the
patellar tendon. The convex articular surface contains a
broader lateral facet, a medial facet, and a smaller, more
medial odd facet. The patellar surface articulates with
the femoral trochlea, which has a broader, higher lateral
ridge than the medial portion to match the patella.1
The primary motor unit of the extensor mechanism is
Figure 1 The screw-home mechanism. The tibia
externally rotates with extension, and internally the quadriceps muscle group. The rectus femoris muscle
rotates with flexion. (Reproduced with courses parallel to the vastus intermedius muscle but more
permission from Scott WN: Anatomy, in Scott superficially in the retinacular layer. The retinacular layer
WN, ed: Insall & Scott Surgery of the Knee, ed 5.
Philadelphia, PA, Elsevier Churchill Livingstone, is an aponeurosis of the rectus femoris, vastus medialis
2012, pp 1-43.) obliquus, vastus medialis, vastus lateralis, and vastus
lateralis obliquus muscles and unites into the anterior
third-joint capsule. The vastus lateralis muscle is the larg-
During gait, the knee flexes approximately 70° for the est of the quadriceps group and comprises approximately
foot of the swinging leg to clear the ground. When the leg 50% of its mass.1
passes the contralateral leg before heel strike, the quadri- At full knee joint extension, the patellofemoral joint
ceps muscles contract to bring the knee into full extension contact occurs at the distal end of the patella. The nearly
2: Knee
and to elevate the foot forward. As the knee extends from colinear vectors of the patellar tendon and quadriceps
approximately 30° to 0° of flexion, the tibia externally muscle forces in the sagittal plane result in a small resul-
rotates up to 30°. This refers to the screw-home mech- tant joint contact force. During flexion, the patella artic-
anism (Figure 1). This tightens the soft-tissue structures ulates with the femoral trochlear groove, spreading the
and locks the knee before accommodating the weight- contact area and load across the width of the patella. The
bearing impact load. After heel strike in midstance, the vector angle between the patellar tendon and the quadri-
knee joint flexes up to 15°, and the quadriceps muscle ceps increases, resulting in increasing patellofemoral joint
absorbs energy. If locked in full extension, a rigid strut force up to approximately 70° of flexion. In deep flexion,
would be incapable of absorbing the impact load. After patella contact occurs only laterally and medially.4
heel strike during knee flexion, the tibia internally rotates,
and this couples with foot eversion, thus accommodating Soft-Tissue Mechanics
energy absorption.4 The motion of the knee joint is facilitated by ligaments,
The circumference of the femoral condyles in the sagit- menisci, and retinacular structures, providing static sta-
tal plane is greater than the anterior-posterior dimension bility by resisting excessive displacements between the
of the tibial plateau. Hence, the femur would posteriorly femur, tibia, and fibula. The biomechanical functions of
roll off the tibial plateau at full flexion if this were only a the menisci consist of load bearing, enlarging the area
rolling motion. During flexion, contact moves posteriorly, of contact, guiding rotation, and stabilizing transla-
and the contact area with the tibial plateau is reduced tion.2 The menisci elongate circumferentially and radially
as lesser radii of curvature of the femoral condyles are to accommodate the force as the femur applies a pressure
sequentially coming into contact (Figure 2). The center of on the tibia. The menisci do not displace secondary to
contact on the medial side remains relatively stationary the insertional ligaments at the bone attachments, but the
in the anterior-posterior position due to the tibia’s medial lateral meniscus is more mobile. Direct cartilage contact
Chapter 7: Biomechanics of the Knee
Figure 2 Sagittal plane knee joint kinematics. A, Extension: contact is located centrally. B, Early flexion: posterior rolling,
contact continuously moves posteriorly. C, Deep flexion: femoral sliding, contact is located posteriorly, the
unlocking of the ACL prevents further femoral roll back. ACL = anterior cruciate ligament. (Reproduced with
permission from Masourus SD, Bull AM, Amis AA: Biomechanics of the knee joint. Orthopaed Trauma 2010;24:84-
91.)
and contact stress is decreased secondary to the increased rotation. Specifically, the meniscofemoral ligaments are
contact area afforded by the menisci. The importance of important restraints to posterior drawer, and the deep
the menisci increasing the contact area and reducing the MCL is a secondary restraint to valgus at 60° to 90° of
contact stresses on the articular cartilage is supported by flexion.9 The complex acts as a secondary restraint to
many experimental studies and the prevalence of osteo- anterior-posterior translation.
arthrosis after meniscectomy.5 The lateral and medial retinacular structures are the
The ACL is the primary restraint to anterior tibial passive stabilizers of the patellofemoral joint. The strong
translation, prevents hyperextension, and functions as a transverse attachment from the patella to the iliotibial
secondary restraint to internal and valgus tibial rotations tract is tightened as the knee flexes, whereas the capsu-
2: Knee
at full extension. The posterior cruciate ligament (PCL) lar lateral patellofemoral ligament is tightest in exten-
is the primary restraint to posterior tibial translation, sion.10 The medial patellofemoral ligament acts as the
primarily in mid to deep flexion. In extension, the PCL re- primary passive restraint to lateral patellar displacements
laxes, and the primary posterior restraint is supported by and supports guiding the patella into the trochlear groove
the posterolateral structures. Together, the ACL and PCL in early knee flexion. The medial patellofemoral ligament
control the anterior-posterior rolling and sliding kinemat- is damaged with excessive lateral subluxation of the pa-
ics of the tibiofemoral joint during flexion-extension.6 tella or any lateral dislocation.10
The medial collateral ligament (MCL) is the primary
restraint to valgus angulation and internal tibial rotation Articular Mechanics
specifically, the superficial MCL portion. It functions as The knee joint sustains external and muscular forces that
a secondary restraint to external tibial rotation and large create loading to enable posture and support body move-
anterior tibial translations. The posteromedial corner ment. Two studies estimated tibiofemoral joint forces at
acts as a stabilizer to the extended knee, especially in 3.4 times that of body weight when walking, 4.3 times
the presence of concurrent internal tibial rotation and that of body weight when ascending stairs, and 4.0 times
posterior drawer.7 The lateral collateral ligament is the that of body weight when descending a ramp.11,12 A
primary restraint to varus angulation in extension. It is 1994 study reported forces of up to 8.5 times that of body
a secondary restraint to large posterior translations. The weight tibiofemoral joint when walking downhill.13 Rising
lateral collateral ligament and posterolateral corner are from a seated position requires up to 100° of knee flexion,
primary restraints to external tibial rotation.8 resulting in a tibiofemoral joint force of approximately
The meniscus–meniscal ligament complex (meniscus, 3.5 times body weight and a patellofemoral joint force of
meniscal insertional ligaments, meniscofemoral liga- approximately 5.5 times body weight. This attests to the
ments, and deep MCL) act as primary restraints to tibial amount of load across the patellofemoral joint despite not
Section 2: Knee
being in the line of load transfer from the torso through varus alignment, less flexion, greater knee adduction mo-
the knee to the foot. ment, and greater absolute medial loads when compared
In the coronal plane, the extended normal leg has a with control subjects. They also maintained a greater
valgus angle of approximately 6° between the anatomic percentage of total load on the medial compartment.18
axes of the femur and the tibia. The mechanical axis A 2012 study compared patients with knee osteo-
aligning the centers of the hip, knee, and ankle is primar- arthritis with healthy individuals and the effects that
ily straight. Also in the coronal plane, there is a resultant knee osteoarthritis had on select spatial and temporal
lateral force acting on the patella secondary to the pull gait variables during stair climbing. Patients with knee
of the quadriceps and patellar tendons. This results from osteoarthritis demonstrated less time in single support,
the Q-angle, which is defined as the angle between the greater time in double support, decreased step length,
vector of the patellar tendon and quadriceps muscles in greater step width, less stride length, decreased total gait
the extended knee (12° to 15° in males, 15° to 18° in velocity, greater total time in support, and less total time
females). The Q-angle reduces during flexion because in swing, compared with control subjects.19
of a reversal of the screw-home mechanism and internal As part of the kinetic chain, the position of the foot
rotation of the tibia causing medialization of the tibial may alter knee biomechanics, in particular load on the
tubercle. The lateral pull of the patella from the Q-angle medial tibiofemoral joint and the knee adduction moment
effect is resisted by the depth of the trochlear groove, (KAM). The KAM is an important surrogate measure
with the sulcus angle being the single best predictor of for the mediolateral distribution of force across the knee
symptoms of instability.14 Prior to engaging the trochlear joint in individuals with knee osteoarthritis. A 2013 study
groove, the patella is most unstable at approximately 10° investigated the relationship between tibia, rearfoot, and
to 30° of knee flexion.15 forefoot motion in the frontal and transverse planes as
well as the KAM in patients who had medial compart-
ment knee osteoarthritis. Increased rearfoot eversion,
Alterations in Biomechanics of the Native rearfoot internal rotation, and forefoot inversion are
Osteoarthritic Knee associated with reduced knee adduction moments during
Differences in knee biomechanics between individuals the stance phase of gait, suggesting that medial knee joint
with knee osteoarthritis and those with normal joints loading could be reduced for those who walk with greater
have been the subject of numerous experimental and foot pronation. These findings have implications for the
clinical studies under various motion patterns such as design of load-modifying interventions in patients who
simple gait, stair climbing, and stair descending. Focus on have medial knee osteoarthritis.20
2: Knee
preventive measures for stabilization of the osteoarthritic Obesity has become a major epidemic in the United
knee may assist in postoperative TKA rehabilitation. States. A 2013 study determined whether a reduction
During functional activities, knee instability may result in body weight of 10% or greater induced by diet, with
from impaired proprioception and poor muscular stabi- or without exercise, would improve knee compressive
lization in the frontal plane in individuals with medial forces and clinical outcomes more than exercise alone. A
knee osteoarthritis. A 2014 study found impaired varus randomized clinical trial analyzed intensive diet-induced
proprioception acuity, decreased normalized varus muscle weight loss plus exercise, intensive diet-induced weight
strength, and an impaired ability to actively stabilize the loss, or exercise. Among overweight and obese adults with
knee in the frontal plane. This demonstrates that the knee knee osteoarthritis, after 18 months participants in the
frontal plane sensorimotor control system is compromised diet and exercise and diet groups had more weight loss
in individuals with medial knee osteoarthritis.16 than those in the exercise group; those in the diet group
Impaired proprioception may alter joint loading and had greater reductions in knee compressive force than
contribute to the progression of knee osteoarthritis. A those in the exercise group.21
2011 study found the threshold for detection of passive The 2013 study used a subset of these participants to
movement to be significantly higher in osteoarthritis determine the influence of frontal plane knee alignment
patients in varus, valgus, flexion, and extension. This and obesity on knee joint loads in older, overweight, and
suggests a global, not a direction-specific, reduction in obese adults with knee osteoarthritis.21 Alignment was
sensation in knee osteoarthritispatients.17 Patients who more closely associated with the asymmetry or imbalance
have knee osteoarthritis are believed to walk with high of loads across the medial and lateral knee compartments
loads at the knee. When compared with healthy subjects, as reflected by the frontal plane KAM, and body mass
a 2013 study showed osteoarthritis subjects walked more index (BMI) was associated with the magnitude of total
slowly and had greater laxity and static and dynamic tibiofemoral force. These data may help select treatment
options for knee osteoarthritis patients (for example, in high flexion) among themselves and with motion data
diet to reduce compression loads or bracing to change from native knees determined in a previous study.27 A
alignment).22 2015 study evaluated the effect of tibial posterior slope
on posterior-stabilized TKAs and noticed anterior sliding
of the tibial component and anterior impingement of the
Biomechanics of Specific TKA Designs anterior aspect of the tibial post with tibial posterior
TKA systems are continually being developed by design slopes of at least 5° and 10°, respectively.28 Tibial posterior
engineers and surgeons in an effort to reproduce normal slopes of less than 5° in posterior-stabilized TKAs were
knee biomechanical patterns. These patterns can vary recommended.
from normal after TKA and may be less predictable and Another TKA design feature is the rotating-platform
reproducible particularly given the different design pa- mobile bearing and its comparison with fixed-bearing de-
rameters among systems. In general, TKAs have provided signs. A 2011 study assessed kinematics in fixed-bearing
good mid to long-term survivorship. and rotating-platform mobile-bearing TKAs with femoral
Surgeons currently debate whether a cruciate-retaining malrotation in a cadaver model tested in an Oxford-type
or posterior-stabilized TKA provides the ideal biomechan- knee rig. In a fixed-bearing TKA, femoral component
ics and postsurgical outcomes in patients. A 2015 study internal and external malrotation increased tibiofemoral
compared the maximum laxity of a cruciate-retaining and rotation by 3.4° and 4°, respectively. Malrotation affected
posterior-stabilized single-radius TKA. The laxity mea- patellofemoral lateral shift by up to 2.5 mm. When the
sured for the cruciate-retaining and posterior-stabilized malrotated femoral component was tested against a ro-
TKAs revealed no significant differences across the stud- tating bearing, the change in tibiofemoral rotation and
ied flexion arc (0° to 110°; P = 0.3) Compared with the na- patellofemoral lateral shift was less than 1° and 1 mm,
tive knee, both TKAs exhibited slightly increased anterior respectively.29 A 2013 study analyzed kinematic outcomes
drawer and decreased varus-valgus and internal-external pre- and postoperatively in a subset of patients who had
rotational laxities.23 A 2015 study evaluated the in vivo rotating-platform posterior-stabilized TKAs. These pa-
kinematics of stair climbing after posterior-stabilized tients achieved an average posterior femoral rollback of
and cruciate-retaining TKA. Cruciate-retaining TKAs the lateral condyle of −5.4 mm, and the average tibio-
were more sagittally stable in midflexion during stair femoral axial rotation from full extension to maximum
climbing than posterior-stabilized TKAs. When using weight-bearing flexion was 3.9°.30 A 2014 study exam-
late cam-post–engaging posterior-stabilized TKA designs, ined the differences in weight-bearing knee kinematics
attention must focus on minimizing posterior tibial slope in patients who had mobile-bearing and fixed-bearing
2: Knee
to avoid unintended impingement of the anterior tibial TKAs performing step-up activities 1 year after surgery.
post with knee extension.24 Another 2015 study identified Minimal kinematic differences were noted between the
greater laxity with cruciate-retaining TKA compared with two TKAs.31
the native knee (P = 0.006) and bicruciate-retaining TKA
(P = 0.039), but no differences in laxity were seen between
the native and the bicruciate-retaining TKA.25 Bicruciate- Lower Limb Biomechanics After TKA
retaining TKAs may improve knee stability without using Multiple studies have analyzed the effects of TKA on knee
conforming geometry in the implant design. kinematics postoperatively. The altered gait mechanics
Cruciate-retaining TKA designs also differ from pos- exhibited by patients after TKA may increase the loading
terior-stabilized designs in their degree of flexion as well. on the nonsurgical knee, thus predisposing it to disease
A 2010 study investigated the biomechanics of posterior- progression. In unilateral TKAs, a 2011 study examined
stabilized TKA patients during high flexion using du- the frontal plane kinetics and kinematics during walking.
al-plane fluoroscopy. Initial cam-post engagement was The nonsurgical knees had higher adduction angles and
observed at 100.3° ± 6.7° flexion, and five knees had higher dynamic loading, knee adduction moment, and
cam-post disengagement before maximum flexion. Lat- impulse compared with the surgical knee. Measures of
eral femoral condylar liftoff was found in five of seven loading in the control knee did not differ from that of the
knees at maximum flexion.26 Posterior-stabilized TKAs nonsurgical knee in the TKA group.32 A 2013 study inves-
with different geometries can vary from one another and tigated the biomechanical changes that occur in the lower
from native knees. Four current posterior-stabilized de- limb before and at 12 months after TKA compared with
signs showed major differences in motion characteristics controls. No significant changes (P = 0.654 and P = 0.686,
(symmetric mediolateral motion, susceptibility to exces- respectively) in knee joint kinematics and kinetics after
sive anterior-posterior medial laxity, and reduced laxity TKA were noted despite significant improvements in pain
Section 2: Knee
and function.33 When data from 1 week before and 1 year posterior-stabilized group. The cruciate-retaining group
following TKA were compared, a 2011 study reported had significantly larger contact areas than did the pos-
increases in the early-stance knee flexion moment and the terior-stabilized group, but no significant differences in
late-stance knee extension moment, indicating improved pressures were reported between the two TKA designs.40
impact attenuation and function. Most changes moved
toward an asymptomatic pattern and would be considered
Summary
improvements in motion, function, and loading.34
A 2012 study investigated whether an abnormal flexor The interaction of the tibiofemoral joint, the patello-
moment pattern at 12 months postoperative could be femoral joint, and the soft-tissue environment contributes
predicted by using biomechanical gait measures assessed to the complex biomechanics of the knee joint. The artic-
before surgery and at 4 months postoperative. The gait ular geometry and soft- tissue restraints enable the specific
pattern at 4 months was significantly associated with the kinematic movements for the knee during motion. These
12-month postoperative gait pattern with more than one- kinematics and loading conditions are markedly altered in
half of those with a flexor moment pattern at 4 months arthritic conditions of the knee, and are considerably im-
retaining this pattern at 12 months.” A 2011 study com- proved in most cases following TKA. Debate continues on
pared the knee kinematics of patients after TKA with the optimal biomechanics for TKA designs, and further
unimpaired control subjects during comfortable and fast research is needed with randomized controlled studies to
walking speeds. For both speeds, the TKA group walked explore these conc lthough current TKA systems
with significantly reduced cadence, reduced stride length, do not replicate the tics of the normal native knee,
less knee flexion during stance and swing phases, and they can impMi‘ chanics over the arthritic knee
less knee extension during stance phase.36 A 2010 study and allow long-term function.
compared neuromuscular activation patterns of the knee
musculature during level walking 1 week before and
Key Study Points
1 year after TKA and found significantly lower overall
activation amplitudes for the quadriceps and hamstri 0 de standing the mechanics of the three compart-
muscles, with significant increases in gastrocnemius S nts of the knee as well as its static and dynam-
tivity found in late stance}7 In general, the postsur ° ic restraints will help the surgeon understand its
changes favored more typical asymptomatic pat kinematics.
supporting improved neuromuscular strateg' . 0 Identification of the mechanical changes in osteo-
walking.3 arthritis of the knee will help in the understanding
Although TKA improves functio pa- of its biomechanical effects.
tients with end-stage knee osteoarthriti subjects
0 Recent biomechanical studies assessing differences
have reported continued difficulty t scent and
in TKA designs have helped explain their postop-
descent after surgery. A 2010 stud er ined preoper-
erative biomechanical effects. 1
ative predictors of handrail stair ascent and
descent after primary un° . Prior to surgery,
63 of 105 subjects require ha drail. Two years after
surgery, 60 required a handr '1. At 2 years, the preop-
erative ability to ascend and descend stairs without a
handrail was the best predictor of individuals who would
not require a handrail after surgery.38 1. Flandry F, Hommel G: Normal anatomy and biomechan-
ics of the knee. Sports Med Arthrosc 2011;19:82-92.
The need for high-flexion TKA designs has been in- Medline D01
vestigated. A 2009 study documented the prevalence of
knee flexion greater than 90° in 20 consecutive patients 2. Blaha JD, Wojtys E: Motion and stability of the normal
who received high-flexion TKAs, at a minimum of 2 years knee, in Scott WN, ed: Insall 86 Scott Surgery of the Knee.
of follow-up. The knees flexed more than 90° for an New York, NY, Churchill Livingstone, 2005, vol 1, pp
227-239. Medline D01
average of 10 i 3.8 minutes (0.5%) over a 35-hour pe-
riod.39 A 2014 study assessed kneeling and kinematics of 3. Yildirim G, Walker PS, Sussman-Fort J, Aggarwal G,
TKAs and found tibial posterior translation and external White B, Klein GR: The contact locations in the knee
rotation at all flexion angles. Moving from double- to during high flexion. Knee 2007;14:379-384.
single-stance kneeling tended to increase pressures in the
cruciate-retaining group but decreased pressures in the
Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 © 2017 American Academy of Orthopaedic Surgeons
4. Masouros SD, Bull AM, Amis AA: Biomechanics of the This study compared 14 persons with medial knee osteo-
knee joint. Orthopaedics and Trauma 2010;24(2):84-91. arthritis and 14 healthy control subjects with findings
DOI suggesting varus-valgus control deficits in both the affer-
ent input (proprioceptive acuity) and muscular effectors
This review article addressed the geometric, anatomic, (muscle strength and capacity to stabilize the joint). Level
and structural considerations of the knee joint and its of evidence: III.
biomechanical roles in allowing gait, flexion, and rotation
in activities of daily life.
17. Cammarata ML, Schnitzer TJ, Dhaher YY: Does knee
osteoarthritis differentially modulate proprioceptive acu-
5. McDermott ID, Amis AA: The consequences of menis- ity in the frontal and sagittal planes of the knee? Arthritis
cectomy. J Bone Joint Surg Br 2006;88:1549-1556. Rheum 2011;63:2681-2689. Medline DOI
Medline DOI
Proprioceptive acuity was assessed in varus, valgus, flex-
6. Butler DL, Noyes FR, Grood ES: Ligamentous restraints ion, and extension by using the threshold to detection of
to anterior-posterior drawer in the human knee: A biome- passive movement in 13 persons with knee osteoarthrisis
chanical study. J Bone Joint Surg Am 1980;62:259-270. and 14 healthy control subjects. The threshold to detection
Medline of passive movement was significantly higher in the group
with knee osteoarthritis for all directions tested, indicating
7. Robinson JR, Bull AM, Thomas RR, Amis AA: The role of reduced proprioceptive acuity. Level of evidence: III.
the medial collateral ligament and posteromedial capsule
in controlling knee laxity. Am J Sports Med 2006;34: 18. Kumar D, Manal KT, Rudolph KS: Knee joint loading
1815-1823. Medline DOI during gait in healthy controls and individuals with knee
osteoarthritis. Osteoarthritis Cartilage 2013;21:298-305.
8. Davies H, Unwin A, Aichroth P: The posterolateral corner Medline DOI
of the knee: Anatomy, biomechanics and management of Osteoarthritis subjects walked more slowly and had
injuries. Injury 2004;35:68-75. Medline DOI greater laxity, static, and dynamic varus alignment, less
flexion, and greater knee adduction moment. They also
9. Masouros SD, McDermott ID, Amis AA, Bull AM: had greater absolute medial load than control subjects and
Biomechanics of the meniscus-meniscal ligament con- maintained a greater percentage total load on the medial
struct of the knee. Knee Surg Sports Traumatol Arthrosc compartment. Level of evidence: II.
2008;16:1121-1132. Medline DOI
19. Hicks-Little CA, Peindl RD, Fehring TK, Odum SM,
10. Feller JA, Amis AA, Andrish JT, Arendt EA, Erasmus PJ, Hubbard TJ, Cordova ML: Temporal-spatial gait adap-
Powers CM: Surgical biomechanics of the patellofemoral tations during stair ascent and descent in patients with
joint. Arthroscopy 2007;23:542-553. Medline DOI knee osteoarthritis. J Arthroplasty 2012;27:1183-1189.
Medline DOI
11. Morrison JB: Function of the knee joint in various activ-
2: Knee
Knee osteoarthritis subjects demonstrated less time in
ities. Biomed Eng 1969;4:573-580. Medline single support, more time in double support, decreased
step length, greater step width, less stride length, decreased
12. Morrison JB: Bioengineering analysis of force actions trans- total gait velocity, greater total time in support, and less
mitted by the knee joint. Biomed Eng 1968;3:164-170. total time in swing compared with control subjects. Level
of evidence: III.
13. Kuster M, Wood GA, Sakurai S, Blatter G: 1994 Nicola
Cerulli Young Researchers Award. Downhill walking: A 20. Levinger P, Menz HB, Morrow AD, Bartlett JR, Feller
stressful task for the anterior cruciate ligament? A bio- JA, Bergman NR: Relationship between foot function
mechanical study with clinical implications. Knee Surg and medial knee joint loading in people with medial com-
Sports Traumatol Arthrosc 1994;2:2-7. Medline DOI partment knee osteoarthritis. J Foot Ankle Res 2013;6:33.
Medline DOI
14. Davies AP, Costa ML, Shepstone L, Glasgow MM,
Donell S: The sulcus angle and malalignment of the Thirty-two patients with clinically and radiographically
extensor mechanism of the knee. J Bone Joint Surg Br confirmed osteoarthritis that was predominantly medial
2000;82:1162-1166. Medline DOI experienced increased rearfoot eversion, rearfoot internal
rotation, and forefoot inversion. Level of evidence: III.
15. Farahmand F, Senavongse W, Amis AA: Quantitative
study of the quadriceps muscles and trochlear groove ge- 21. Messier SP, Mihalko SL, Legault C, et al: Effects of inten-
ometry related to instability of the patellofemoral joint. sive diet and exercise on knee joint loads, inflammation,
J Orthop Res 1998;16:136-143. Medline DOI and clinical outcomes among overweight and obese adults
with knee osteoarthritis: The IDEA randomized clinical
trial. JAMA 2013;310:1263-1273. Medline DOI
16. Chang AH, Lee SJ, Zhao H, Ren Y, Zhang LQ: Impaired
varus-valgus proprioception and neuromuscular stabili- Three hundred ninety-nine overweight and obese older
zation in medial knee osteoarthritis. J Biomech 2014;47: subjects with pain and radiographic knee osteoarthritis
360-366. Medline DOI were selected for intensive diet-induced weight loss plus
exercise, intensive diet-induced weight loss, or exercise.
Section 2: Knee
At 18 months, knee compression forces were lower in diet This study used dual-plane fluoroscopy in seven knees with
participants than in those in the exercise group. Level of a posterior-stabilized TKA and weight-bearing flexion
evidence: I. >130°. Posterior femoral translation and internal tibial
rotation increased steadily beyond 90° flexion, and a sharp
22. Messier SP, Pater M, Beavers DP, et al: Influences of increase in varus rotation was noted at maximum flexion.
alignment and obesity on knee joint loading in osteoar- Level of evidence: III.
thritic gait. Osteoarthritis Cartilage 2014;22:912-917.
Medline DOI 27. Walker PS, Lowry MT, Kumar A: The effect of geometric
variations in posterior-stabilized knee designs on motion
In 157 participants with radiographic knee arthritis, a characteristics measured in a knee loading machine. Clin
higher BMI was associated with greater peak knee com- Orthop Relat Res 2014;472:238-247. Medline DOI
pression forces and greater shear forces independent of
alignment. Varus alignment was associated with greater This study analyzed four different posterior-stabilized de-
peak external knee adduction moments, independent of signs under machine load and showed major differences in
BMI. Level of evidence: II. motion characteristics among themselves and with motion
data from anatomic knees determined in a previous study.
23. Hunt NC, Ghosh KM, Blain AP, Rushton SP, Longstaff Level of evidence: III.
LM, Deehan DJ: No statistically significant kinematic dif-
ference found between a cruciate-retaining and posterior- 28. Okamoto S, Mizu-uchi H, Okazaki K, Hamai S, Nakaha-
stabilised Triathlon knee arthroplasty: A laboratory study ra H, Iwamoto Y: Effect of tibial posterior slope on knee
involving eight cadavers examining soft-tissue laxity. Bone kinematics, quadriceps force, and patellofemoral contact
Joint J 2015;97-B:642-648. Medline DOI force after posterior-stabilized total knee arthroplasty.
J Arthroplasty 2015;30:1439-1443. Medline DOI
Eight loaded cadaver knees underwent subjective stress
testing. The laxity for the cruciate-retaining and posterior- In posterior-stabilized TKAs, the maximum quadriceps
stabilized TKAs was not significantly different, but both force and patellofemoral contact force decreased with
TKAs exhibited slightly increased anterior drawer and de- increasing posterior slope. Anterior sliding of the tibial
creased varus-valgus and internal-external rotational lax- component and anterior impingement of the anterior as-
ities compared with the native knee. Level of evidence: III. pect of the tibial post were observed at slopes of 5° and
10°, respectively. Level of evidence: III.
24. Hamai S, Okazaki K, Shimoto T, Nakahara H, Hi-
gaki H, Iwamoto Y: Continuous sagittal radiological 29. Colwell CW Jr, Chen PC, D’Lima D: Extensor malalign-
evaluation of stair-climbing in cruciate-retaining and ment arising from femoral component malrotation in knee
posterior-
stabilized total knee arthroplasties using arthroplasty: Effect of rotating-bearing. Clin Biomech
image-matching techniques. J Arthroplasty 2015;30: (Bristol, Avon) 2011;26:52-57. Medline DOI
Cadaver knees were tested with fixed-bearing and rotating-
Evaluated the in vivo kinematics of stair climbing af- platform mobile-bearing TKAs. The rotating platform
2: Knee
ter posterior-stabilized and cruciate-retaining TKAs. TKAs had less tibiofemoral rotation and patellofemoral
Cruciate-retaining TKA was more sagittally stable in lateral shift. Level of evidence: III.
midflexion during stair climbing, and posterior-stabilized
TKAs with increased posterior tibial slope was linked to 30. Komistek RD, Murphy JA, O’Dell TL: Clinical and ki-
unintended impingement of the anterior tibial post at knee nematic outcomes of a rotating platform posterior stabi-
extension. Level of evidence: III. lized total knee system. J Arthroplasty 2013;28:624-630.
Medline DOI
25. Halewood C, Traynor A, Bellemans J, Victor J, Amis AA:
Anteroposterior laxity after bicruciate-retaining total knee Ten patients with rotating-platform posterior-stabilized
arthroplasty is closer to the native knee than ACL-resect- TKA achieved an average posterior femoral rollback of
ing TKA: A biomechanical cadaver study. J Arthroplasty the lateral condyle of −5.4 mm, and the average tibio-
2015;30(12):2315-2319. Medline DOI femoral axial rotation from full extension to maximum
weight-bearing flexion was 3.9°. Level of evidence: III.
A bicruciate-retaining TKA was designed and com-
pared with cruciate-retaining TKA and the native knee. 31. Okamoto N, Nakamura E, Nishioka H, Karasugi T, Oka-
Anterior-posterior laxity with the cruciate-retaining TKA da T, Mizuta H: In vivo kinematic comparison between
was greater than with the native knee and bicruciate- mobile-bearing and fixed-bearing total knee arthroplasty
retaining TKA, but no difference was found between the during step-up activity. J Arthroplasty 2014;29:2393-
bicruciate-retaining TKA and the native knee. Level of 2396. Medline DOI
evidence: II.
Knee kinematics were fluoroscopically evaluated during
26. Moynihan AL, Varadarajan KM, Hanson GR, et al: step-up activity 1 year after surgery in 20 mobile-bearing
In vivo knee kinematics during high flexion after a TKAs and 20 fixed-bearing TKAs. The total extent of
posterior-substituting total knee arthroplasty. Int Orthop rotation and kinematic differences were minor between
2010;34:497-503. Medline DOI the two TKAs. Level of evidence: II.
32. Alnahdi AH, Zeni JA, Snyder-Mackler L: Gait after uni- Patients were assessed walking at comfortable and fast
lateral total knee arthroplasty: Frontal plane analysis. gait speeds 1 year after TKA. Compared with control
J Orthop Res 2011;29:647-652. Medline DOI subjects, the TKA group walked with significantly reduced
cadence, reduced stride length, less knee flexion during
This study evaluated frontal plane kinematics and kinetics stance and swing phases, and less knee extension during
in control subjects and during walking 6 months after stance phase. Level of evidence: III.
TKA, and 1 year after unilateral TKA. The nonsurgical
knee loading was not different from that of controls except
for shorter step length. Level of evidence: III. 37. Hubley-Kozey CL, Hatfield GL, Astephen Wilson JL, Dun-
bar MJ: Alterations in neuromuscular patterns between
pre and one-year post-total knee arthroplasty. Clin Bio-
33. Levinger P, Menz HB, Morrow AD, Feller JA, Bartlett mech (Bristol, Avon) 2010;25:995-1002. Medline DOI
JR, Bergman NR: Lower limb biomechanics in individ-
uals with knee osteoarthritis before and after total knee Patients were analyzed during walking 1 week before and
arthroplasty surgery. J Arthroplasty 2013;28:994-999. 1 year after TKA. There were significantly lower overall
Medline DOI activation amplitudes for the quadriceps and hamstrings,
with decreased activity during midlate stance after surgery.
This study evaluated lower-limb joint kinematics and ki- Significant increases in gastrocnemius activity were found
netics in control subjects and before and 12 months after in late stance. Level of evidence: III.
TKA. No significant changes in knee joint kinematics and
kinetics were noted despite significant improvements in
pain and function. Level of evidence: III. 38. Zeni JA Jr, Snyder-Mackler L: Preoperative predictors
of persistent impairments during stair ascent and de-
scent after total knee arthroplasty. J Bone Joint Surg Am
34. Hatfield GL, Hubley-Kozey CL, Astephen Wilson JL, 2010;92:1130-1136. Medline DOI
Dunbar MJ: The effect of total knee arthroplasty on knee
joint kinematics and kinetics during gait. J Arthroplasty In 105 patients, at 2 years following TKA, the preoperative
2011;26:309-318. Medline DOI ability to ascend and descend stairs without a handrail was
the best predictor of who would not require a handrail
Three-demensional kinematic and kinetic gait patterns of after surgery. Level of evidence: I.
42 patients with severe knee osteoarthritis were collected
1 week before and 1 year after TKA. Most changes moved
toward an asymptomatic pattern and would be considered 39. Huddleston JI, Scarborough DM, Goldvasser D, Freiberg
improvements in motion, function, and loading. Level of AA, Malchau H: 2009 Marshall Urist Young Investigator
evidence: II. Award: How often do patients with high-flex total knee
arthroplasty use high flexion? Clin Orthop Relat Res
2009;467:1898-1906. Medline DOI
35. Levinger P, Menz HB, Morrow AD, et al: Knee biome-
chanics early after knee replacement surgery predict ab- This study analyzed the prevalence of knee flexion greater
normal gait patterns 12 months postoperatively. J Orthop than 90° in patients who received high-flexion TKAs, at
Res 2012;30:371-376. Medline DOI a minimum 2-years follow-up. The 21 knees flexed more
2: Knee
than 90° for an average of 10 ± 3.8 minutes (0.5%). Level
In 32 TKA patients, analysis indicated that peak knee of evidence: IV.
flexion during early stance, peak knee extension, and peak
knee extension moment at 4 months postoperative were
independent predictors of the gait pattern at 12 months. 40. Lee TQ: Biomechanics of hyperflexion and kneeling be-
Level of evidence: II. fore and after total knee arthroplasty. Clin Orthop Surg
2014;6(2):117-126. Medline DOI
36. McClelland JA, Webster KE, Feller JA, Menz HB: Knee ki- In cadaver studies after cruciate-retaining and posterior-
nematics during walking at different speeds in people who stabilized TKAs, the cruciate-retaining group had signifi-
have undergone total knee replacement. Knee 2011;18:151- cantly larger contact areas, but no significant differences
155. Medline DOI in pressures were noted between the two TKA designs.
Chapter 8
Minimally Invasive Surgical

Approaches to Knee Arthroplasty
Giles R. Scuderi, MD Henry D. Clarke, MD Christopher A. Dodd, FRCS
Knee arthroplasty can be performed using a variety The goals in knee arthroplasty are to relieve pain and
of skin and arthrotomy incisions. Improving the early restore function in a joint that has been compromised
recovery of patients undergoing knee arthroplasty by by mechanical wear, trauma, or other etiologies. To
using shorter skin incisions and reducing damage to accomplish these goals, accurate bony preparation and
the quadriceps muscle with minimally invasive surgical implantation of the prosthetic components is necessary
techniques was pioneered in unicondylar knee arthro- with restoration of soft-tissue balance to the periarticu-
plasty and then continued with total knee arthroplasty. lar stabilizers. Historically, this has been accomplished
Important work has been undertaken over the past through an extensile exposure using an anterior skin
decade to identify the optimal method for exposure in incision combined with a medial parapatellar arthrotomy.
total knee arthroplasty. However, questions remain. In the early 2000s, a resurgence of unicondylar knee
Understanding the individual techniques is important for arthroplasty (UKA) performed through smaller skin and
the surgeon performing knee arthroplasty. The decision capsular incisions stimulated interest in performing total
to use any particular approach should be made by the knee arthroplasty (TKA) using similar minimally invasive
surgeon performing the procedure after considering concepts to improve recovery time and pain after surgery.
patient variables, the prosthesis system to be used, and Consequently, TKA performed through shorter skin inci-
2: Knee
their individual experience with the exposure options. sions using various alternative arthrotomy incisions that
were perceived to be less damaging to the quadriceps
muscle and extensor mechanism were investigated and
Keywords: total knee arthroplasty; unicondylar adopted. These so-called minimally invasive techniques
knee arthroplasty; minimally invasive surgery; broadly adhere to some or all of the following principles: a
surgical exposures smaller skin incision, no eversion of the patella; avoidance
of disruption of the suprapatellar pouch; and minimal or
no incision of the quadriceps tendon.1 After using these
Dr. Scuderi or an immediate family member has received royalties from Zimmer Biomet; is a member of a speakers’
bureau; or has made paid presentations on behalf of ConvaTec, Medtronic, Pacira, and Zimmer Biomet; serves as a
paid consultant to Medtronic, Merz Pharmaceuticals, Pacira, and Zimmer Biomet; has received research or institutional
support from Pacira; and serves as a board member, owner, officer, or committee member of Operation Walk USA. Dr.
Clarke or an immediate family member has received royalties from ConforMIS; serves as a paid consultant to ConforMIS
and Smith and Nephew; serves as an unpaid consultant to ConforMIS; has received research or institutional support
from Stryker and Vidacare; and serves as a board member, owner, officer, or committee member of the American Acad-
emy of Orthopaedic Surgeons, the Association of Bone and Joint Surgeons, and the International Congress for Joint
Reconstruction. Dr. Dodd or an immediate family member has received royalties from Zimmer Biomet; is a member of
a speakers’ bureau or has made paid presentations on behalf of Zimmer Biomet; serves as a paid consultant to or is
an employee of Zimmer Biomet; has received research or institutional support from Stryker, Biomet, and Zimmer; and
serves as a board member, owner, officer, or committee member of the Knee Society.
Section 2: Knee
alternative exposures for more than a decade, no single

technique has demonstrated unequivocal superiority. In-
stead, several alternatives appear to be reasonable choices
with relative risks and benefits afforded by each exposure.
Indeed, the most appropriate exposure choice in a partic-
ular case may depend on patient characteristics, prosthesis
and instrumentation variables, and the individual experi-
ence and skill of the surgeon performing the procedure.
It is important to review the surgical techniques for each
of the most widely used exposures for UKA and TKA,
along with the relative advantages and disadvantages of
each technique.
Minimally Invasive UKA

UKA and TKA were both developed in the early 1970s,
and surgical exposure was critical. Initially, both pro-
cedures were performed via a long medial parapatellar
incision, with the patella everted laterally to aid exposure.
In 1992, UKAs were implanted via a shorter inci-
sion, and it was shown that patellar eversion was un-
necessary and that relative preservation of the extensor
mechanism resulted in accelerated recovery and early
discharge.2 These early presentations stimulated great
interest in minimally invasive surgery (MIS), not only
for UKA, but also later resulted in the development of
MIS TKA. Figure 1 Illustration depicts planned medial skin incision
In 1998, the phase 3 mobile UKA development infor a medial unicondylar arthroplasty.
troduced the technique for medial unicompartmental
arthroplasty used with a MIS. The instruments were
2: Knee
miniaturized for use via a small parapatellar arthrot- synovial cavity. The anterior cruciate ligament (ACL), lat-
omy. The functional results and the speed of recovery eral side, and patellofemoral joint can now be inspected. If
of phase 3 were found to be better than those of phase the ACL appears damaged, its integrity should be checked
2 mobile-bearing UKA. Since then, most surgeons now by pulling on the ligament with a tendon hook. Absence
implant UKA using an MIS approach. This procedure is of a functioning ACL is a contraindication for a mo-
ideal for the reduced-incision surgical approach. bile-bearing UKA.
Medial Approach Lateral Approach

For the medial approach, a paramedial skin incision is For a lateral approach, the incision is made over the junc-
made from the medial pole of the patella to a point 3 cm tion of the central and lateral thirds of the patella and
distal to the joint line just medial to the tibial tubercle: begins at the level of the superior pole of the patella and
two-thirds above the joint line to one-third below (Fig- extends down and just lateral to the tibial tubercle. The
ure 1). The medial margin of the patella is identified. retinacular incision is made on the lateral side of the
The retinacular incision is made along the medial side patella and down beside the patellar tendon. The antero-
of the patella and patellar tendon. The anterior tibia is lateral portion of the tibia is exposed and the Gerdy tu-
exposed. At its upper end, the retinacular incision is ex- bercle and attachment of the iliotibial tract are identified.
tended proximally for 2 to 3 cm into the vastus medialis The incision is extended proximally around the patella
obliquus (VMO) muscle. The direction is not critical, but and up into the extensor mechanism. Generous excision
most surgeons carry the incision proximally up toward of the fat pad is required. If concern exists regarding the
the quadriceps tendon. Part of the retropatellar fat pad is ACL, its status can be assessed by pulling it with a tendon
excised and the anterior portion of the medial meniscus hook. In general, the lateral MIS UKA incision is 2 to
is removed. Self-retaining retractors are inserted into the 3 cm longer than the medial incision.
Chapter 8: Minimally Invasive Surgical Approaches to Knee Arthroplasty
Clinical Results
In comparison with MIS TKA, few studies compare the

effect of reduced incisions. Clearly, fewer UKAs are per-
formed (10% of registered knee arthroplasties are UKAs),
and surgical approaches are not as varied as in MIS TKA.
In essence, the aforementioned medial approach has at-
tained near-universal use.3
The only direct comparison describes the effect of the
medial MIS approach.4 This study compared the rate of
recovery in 40 mobile-bearing UKAs performed via an
MIS incision with modified instruments without patellar
eversion with the rate in 20 mobile-bearing UKAs per-
formed via an open approach with patellar eversion. Both Figure 2 Images of a limited medial parapatellar
arthrotomy. A, Illustration depicts planned
groups were compared with 40 TKAs performed during arthrotomy. B, Intraoperative photograph
the same period, which were used as controls. The average demonstrates exposure.
rate of recovery after the MIS approach was twice as fast
as that of open UKA and three times as fast as that of
TKA. The authors of this chapter know of no study that usually facilitates lateral subluxation of the patella and
assesses the effect of the lateral MIS UKA approach.5 exposure to the joint. If necessary, the arthrotomy can be
easily extended to a more traditional approach by gradual
lengthening into the quadriceps tendon. This approach is
Total Knee Arthroplasty commonly used because of its familiarity, simplicity, and
The surgical approach for TKA has evolved over the past exposure of all knee joint compartments. Furthermore,
decade to less invasive exposures following the experience this approach is extensile when needed, can be applied to
gained from MIS UKA. Several approaches have become all deformities, and is easily extended with a quadriceps
popular, including the limited medial parapatellar ap- snip when necessary.9
proach, the subvastus approach, the midvastus approach,
and the quadriceps-sparing approach. The Subvastus Approach
Originally, the subvastus approach was commonly used
2: Knee
The Medial Parapatellar Approach in TKA to preserve the attachment of the VMO muscle
The earliest description of the medial parapatellar ap- on the quadriceps tendon and follow the natural plane
proach has been credited to von Langenbeck, who de- of dissection.10 In the original description, this technique
scribed detachment of the VMO muscle from its insertion was performed through a standard-length anterior skin
onto the quadriceps tendon and continuing the arthrot- incision and the patella was typically everted. However,
omy around the medial border of the patella and along subsequent modifications allowed the exposure to be
the medial border of the patellar tendon.6 This approach performed through a limited skin incision of 3 to 4 inches
was modified by Insall with a straight incision along the when preferred.1 Following exposure of the extensor
medial border of the quadriceps tendon, over the medial mechanism via a midline skin incision and development of
border of the patella with a subperiosteal elevation of limited medial and lateral subcutaneous flaps, an incision
the medial retinaculum, and a straight incision along the is made along the medial border of the patellar tendon
medial border of the patellar tendon.7 The limited medial and medial border of the patella to the attachment of the
patellar arthrotomy evolved from the Insall technique. VMO tendon on the patella (Figure 3). The insertion of
Following a midline skin incision from the superior pole the VMO occurs at an angle of approximately 50° at ap-
of the patella to the tibial tubercle, limited medial and proximately the midportion of the patella.11 However, this
lateral subcutaneous flaps are developed. The arthrotomy insertion point varies among individuals, with three broad
begins approximately 2 to 4 cm proximal to the superior types described: type 1 has a high insertion of the VMO
pole of the patella and extends distally along the medial above the medial aspect of the patella, type 2 inserts at the
border of the quadriceps tendon.8 The incision is contin- superior medial border of the patella, and type 3 inserts
ued in a straight manner and the medial retinaculum is as low as the middle of the patella and is usually seen in
elevated from the medial border of the patella and along muscular male patients.12 Other reports have described
the medial border of the patellar tendon (Figure 2). This an even more distal insertion of the VMO tendon on the
Section 2: Knee
Figure 3 Illustration depicts the subvastus approach.
Figure 4 Illustration depicts the midvastus approach.
patella. In one study, approximately 25% of patients had

an insertion that occurred distally in excess of 60% of the
patellar length.13 With this exposure, the insertion of the approach include obesity, especially with a short femur;
VMO remains attached to the patella, and the dissection heavy, muscular thighs; hypertrophic osteoarthritis with
2: Knee
proceeds transversely along the lower border of the VMO limited range of motion or substantial flexion contracture;
muscle belly. This procedure can often be performed with prior high tibial osteotomy with patella infera; knees with
blunt finger dissection beneath the inferior border of the excessive valgus; and revision TKA. In addition, when
VMO and along the intermuscular septum. Care should combined with a small skin incision, increased trauma to
be taken as the dissection extends above the adductor the skin can occur, especially with the stretching required
tubercle approaching the Hunter canal. This area has to perform the proximal, medially directed portion of the
neurovascular structures at risk, including the descending arthrotomy; this can result in an increased risk of wound
geniculate artery and its branches, the intermuscular sep- healing problems.
tal arteries, and the saphenous nerve. Following dissection
of the VMO, the synovial fold in the suprapatellar pouch The Midvastus Approach
is released and the patella is subluxated laterally as the The midvastus approach was described as a compro-
knee is moved into flexion. During closure, the horizontal mise between the medial parapatellar and subvastus
portion of the arthrotomy along the inferior border of approaches.14 Following exposure of the extensor mech-
the VMO may be closed with the knee at 90° to prevent anism via a midline skin incision and development of
overtightening of the medial structures that could cause limited medial and lateral subcutaneous flaps, an incision
iatrogenic patella baja.1 is made along the medial border of the patellar tendon and
Proponents of the subvastus approach report exposure the medial border of the patella to the attachment of the
comparable with the medial parapatellar arthrotomy, with VMO on the superomedial border of the patella. With the
preservation of the extensor mechanism and minimization knee in flexion to maintain tension in the extensor mech-
of patella instability. The major criticisms of the subvastus anism, the full thickness of the VMO is divided in line
approach are poor exposure and difficulty with patellar with its muscle fibers, starting at the superomedial border
mobilization. The contraindications for the subvastus of the patella and extending proximally approximately
3 cm (Figure 4). The patella is subluxated laterally to

expose the knee joint. Inadvertent fascia or muscle fiber
tears while exposing the joint have no adverse effects on
the outcome.
Proponents of the midvastus approach report less post-
operative pain, preservation of the patella vascularity,
improved patellar tracking, better quadriceps strength,
decreased blood loss, and more rapid recovery. Relative
contraindications to this approach include obesity, hy-
pertrophic osteoarthritis with limited range of motion
or substantial flexion contracture, heavy muscular thigh,
patella baja, and revision TKA.
Quadriceps-Sparing Approach
The quadriceps-sparing approach for TKA was described
based on experience with minimally invasive UKA.15 The
goal of this approach is to perform a TKA through a less
invasive approach that permits more rapid recovery with
less morbidity.
A curvilinear medial skin incision is made from the
superior pole of the patella to the tibial joint line. The
medial arthrotomy is in line with the skin incision and
begins at the superior medial border of the patella at the
insertion of the VMO. It ends approximately 2 cm distal
Figure 5 Illustration depicts the quadriceps-sparing
to the tibial joint line just medial to the insertion of the approach.
patellar tendon at the tibial tubercle. The arthrotomy does
not cut the quadriceps tendon or divide the fibers of the
VMO (Figure 5). As noted in the discussion of the sub- lateral border of the quadriceps tendon and continued dis-
vastus exposure, some variation exists in the insertion of tally 1 to 2 cm lateral to the border of the patella, through
the VMO along the medial border of the patella. For type the medial edge of the Gerdy tubercle, and extended into
2: Knee
3, in which the insertion is at the midportion of patella or the lateral compartment fascia 1 to 2 cm lateral to the
more distal, it can be argued that this surgical approach edge of the tibial tubercle (Figure 6). During exposure,
releases the VMO and is not truly quadriceps sparing. incision through the fat pad should be avoided because
When performing TKA using the quadriceps-sparing mobilization of the vascularized fat pad is used at the
approach, specialized instruments are necessary that al- end of the case to close the gap that will form in the lat-
low resection of the femur and tibia from the medial side eral capsule as a result of valgus deformity correction.
of the knee joint. Complications following the quadriceps- Instead, the fat pad is preserved with the intermeniscal
sparing approach, including patellar tendon avulsion, ligament and the anterior rim of the lateral meniscus by
rupture of the medial or lateral collateral ligaments, and dissecting medially, deep to the patellar tendon. This
cement retention, appear to decline with increased sur- soft-tissue mass is preserved as a laterally based flap with
geon experience.16 preserved blood supply from the inferior geniculate artery
and should be protected during the subsequent surgery.
Lateral Approach The patella is subluxated medially during arthroplasty.
The lateral approach to the knee was introduced in North At the time of closure, the vascularized, laterally attached
America for use in patients undergoing TKA who had a fat pad with the meniscal remnant is mobilized. The fat
preoperative valgus deformity.17 When this approach was pad is expanded with relaxing incisions made in line with
first described, a standard-length laterally based anterior the retained lateral meniscal rim. This soft-tissue mass
incision was used, but the exposure has been subsequently is sutured to the lateral edge of the capsule that runs
modified for use with a small, minimally invasive skin along the border of the extensor mechanism to close the
incision.18 The original technique follows the skin inci- capsular defect.
sion, and medial dissection is contraindicated.17 A lateral Proponents of the lateral approach note that valgus
arthrotomy is performed beginning proximally along the deformity correction is optimized with this exposure
Section 2: Knee
been identified.24-29 Certainly, no definitive statements can

be made that MIS approaches are superior in all ways to
traditional exposures, nor does it appear that any single
approach is superior to the others. Meta-analyses and
systematic reviews have been performed on this topic over
the past 5 years. However, the results of these studies also
are equivocal with those that fail to identify any clinical
advantages or problems30,31 versus those that note small
differences in early recovery or complications.32,33
A broad summary of the published literature suggests
that small, early advantages in quadriceps strength, range
of motion, and pain relief during the first few weeks af-
ter surgery may be possible with minimally invasive ap-
proaches versus traditional exposures. However, these
benefits appear to be realized at the expense of a small
but important increase in wound healing complications,
increased surgical time, and potential concerns about
long-term loosening resulting from less accurate pros-
thesis alignment.30-33
Summary
The goal of knee arthroplasty is to restore function and
eliminate pain in a knee joint that is compromised by
mechanical damage or disease. Optimal surgical exposure
Figure 6 Illustration depicts the lateral arthrotomy.
is required to allow accurate preparation of the bones for
implant placement and to perform soft-tissue balancing.
Although most knee arthroplasties have been historically
because the tight lateral structures are either released performed through a skin incision 20 cm or longer and
during the exposure or directly accessible for release after a medial parapatellar arthrotomy, alternative surgical
2: Knee
the lateral exposure has been performed.17 The disadvan- exposures using shorter incisions and more limited ar-
tages of the technique include the relative lack of familiar- throtomies have been investigated to determine if less
ity most surgeons have with a lateral perspective during theoretical damage to the quadriceps muscle and periar-
TKA; instruments for TKA that are mostly designed for ticular soft tissue would result in better outcomes. In the
a medial approach; and problems with poor capsular setting of UKA, MIS approaches have become the stan-
closure, especially if the fat pad flap is damaged, which dard exposure for the procedure. After studying the use of
can contribute to postoperative drainage and infection alternative techniques for more than a decade, including
or slow rehabilitation.17,18 mini-medial parapatellar arthrotomy, modified subvas-
tus, midvastus, and quadriceps-sparing approaches, no
Clinical Results conclusive evidence has demonstrated the superiority of
The clinical outcomes of TKA performed with different any one technique in TKA. Although small, short-term
exposures have been compared in many trials to deter- advantages have been demonstrated by some authors with
mine whether MIS exposures are superior to traditional some techniques, the available literature instead suggests
approaches, and also to determine which MIS exposure that each technique has relative minor advantages and
is optimal. Even with the peer-reviewed publications from disadvantages. Indeed, patient, instrumentation, prosthe-
the past decade, limited conclusions can be drawn from the sis, and surgeon factors likely influence the most suitable
literature. Information from early reports that compared exposure in any given case. Based on the available data,
MIS techniques to traditional exposures demonstrated each surgical approach is reasonable for use with TKA.
advantages; however, most of these were case-control The specific exposure selected in each case should be
studies using historic or contemporary control patients made by the operating surgeon based on an evaluation
instead of randomized subjects.19-23 In more recent ran- of patient factors, the prosthetic system used, and his or
domized studies, no significant clinical advantages have her experience.
5. Weston-Simons JS, Pandit H, Kendrick BJ, et al: The

Key Study Points
mid-term outcomes of the Oxford Domed Lateral uni-
compartmental knee replacement. Bone Joint J 2014;
• Exposure for knee arthroplasty was traditionally 96-B(1):59-64. Medline DOI
achieved with an anterior skin incision and a medial
parapatellar arthrotomy. This study reported on a prospective, independent eval-
uation of 265 consecutive knees with isolated lateral
• Less invasive exposures using short skin incisions compartmental disease. The survival rate at 8 years was
and capsular arthrotomies were first used in UKA 92.1% with 12 reoperations, 4 of which were for bearing
to reduce pain and speed rehabilitation, and have dislocation (1.5%). The MIS lateral approach was con-
sidered to be one of the factors that helped decrease the
become widely accepted. dislocation rate.
• Similar concepts to improve early recovery gener-
ated significant interest in the 2000s in so-called 6. von Langenbeck B: Zur resection des kniegelenke. Verh
minimally invasive TKA using a variety of expo- Dtsch En Geseuch F Chir 1879;7:23.
sures performed through short skin incisions that
7. Insall J: A midline approach to the knee. J Bone Joint Surg
theoretically caused less damage to the quadriceps Am 1971;53(8):1584-1586. Medline
muscle and extensor mechanism. These exposures
included the mini-parapatellar, modified subvastus, 8. Scuderi GR, Tenholder M, Capeci C: Surgical approaches
mini-midvastus, and quadriceps-sparing approaches in mini-incision total knee arthroplasty. Clin Orthop
to the knee. Relat Res 2004;428:61-67. Medline DOI
• After more than a decade of use in TKA, the pub- 9. Garvin KL, Scuderi G, Insall JN: Evolution of the quad-
lished randomized prospective studies comparing riceps snip. Clin Orthop Relat Res 1995;321:131-137.
both MIS techniques with a standard medial para- Medline
patellar arthrotomy, and different minimally inva-
sive techniques to each other, have failed to identify 10. Hofmann AA, Plaster RL, Murdock LE: Subvastus (South-
ern) approach for primary total knee arthroplasty. Clin
a single approach that is clearly optimal. Orthop Relat Res 1991;269:70-77. Medline
• TKA can be successfully performed using a variety
of surgical exposures that have relative advantages 11. Pagnano MW, Meneghini RM, Trousdale RT: Anatomy of
and disadvantages. The optimal technique in any the extensor mechanism in reference to quadriceps-sparing
TKA. Clin Orthop Relat Res 2006;452(452):102-105.
case likely depends on several variables, including Medline DOI
patient characteristics, implant and instrumentation
design, and surgeon experience.
2: Knee
12. Tria AJ Jr: Minimally invasive total knee arthroplasty
using quadriceps-sparing approach, in Scuderi GR, Tria
AJ Jr, Berger RA, eds: MIS Techniques in Orthopaedics.
New York, Springer, 2005, p 349.
Annotated References 13. Holt G, Nunn T, Allen RA, Forrester AW, Gregori A:
Variation of the vastus medialis obliquus insertion and its
relevance to minimally invasive total knee arthroplasty.
1. Pagnano MW, Meneghini RM: Minimally invasive total
knee arthroplasty with an optimized subvastus approach.
J Arthroplasty 2006;21(4suppl 1):22-26. Medline DOI
14. Engh GA, Holt BT, Parks NL: A midvastus muscle-split-
ting approach for total knee arthroplasty. J Arthroplasty
2. Repicci JA, Eberle RW: Minimally invasive surgical tech-
1997;12(3):322-331. Medline DOI
nique for unicondylar knee arthroplasty. J South Orthop
Assoc 1999;8(1):20-27, discussion 27. Medline
15. Tria AJ Jr, Coon TM: Minimal incision total knee ar-
throplasty: Early experience. Clin Orthop Relat Res
3. Pandit H, Jenkins C, Barker K, Dodd CA, Murray DW:
2003;416:185-190. Medline DOI
The Oxford medial unicompartmental knee replacement
using a minimally-invasive approach. J Bone Joint Surg
Br 2006;88(1):54-60. Medline DOI 16. Jackson G, Waldman BJ, Schaftel EA: Complications
following quadriceps-sparing total knee arthroplasty.
Orthopedics 2008;31(6):547. Medline DOI
4. Price AJ, Webb J, Topf H, Dodd CA, Goodfellow JW,
Murray DW; Oxford Hip and Knee Group: Rapid recov-
ery after oxford unicompartmental arthroplasty through 17. Keblish PA: The lateral approach to the valgus knee.
a short incision. J Arthroplasty 2001;16(8):970-976. Surgical technique and analysis of 53 cases with over
Medline DOI two-year follow-up evaluation. Clin Orthop Relat Res
1991;271:52-62. Medline
Section 2: Knee
18. Seyler TM, Bonutti PM, Ulrich SD, Fatscher T, Marker 27. Heekin RD, Fokin AA: Mini-midvastus versus mini-me-
DR, Mont MA: Minimally invasive lateral approach to dial parapatellar approach for minimally invasive total
total knee arthroplasty. J Arthroplasty 2007;22(7suppl 3): knee arthroplasty: Outcomes pendulum is at equilibrium.
21-26. Medline DOI J Arthroplasty 2014;29(2):339-342. Medline DOI
In this report, 40 patients who underwent staged bilateral
19. Chen AF, Alan RK, Redziniak DE, Tria AJ Jr: Quadriceps TKA were prospectively randomized for a mini-midvastus
sparing total knee replacement. The initial experience exposure on one side and a mini-medial parapatellar ap-
with results at two to four years. J Bone Joint Surg Br proach on the other. Clinical outcomes revealed inconsis-
2006;88(11):1448-1453. Medline DOI tent patterns of differences at various intervals. Surgical
outcomes were not different. No major differences were
20. Dutton AQ, Yeo SJ, Yang KY, Lo NN, Chia KU, Chong reported in outcomes between the two approaches. The
HC: Computer-assisted minimally invasive total knee authors recommended that surgeons use the surgical ap-
arthroplasty compared with standard total knee arthro- proach with which they are most familiar.
plasty. A prospective, randomized study. J Bone Joint Surg
Am 2008;90(1):2-9. Medline DOI 28. Kim YH, Kim JS, Kim DY: Clinical outcome and rate of
complications after primary total knee replacement per-
21. Haas SB, Cook S, Beksac B: Minimally invasive total formed with quadriceps-sparing or standard arthrotomy.
knee replacement through a mini midvastus approach: J Bone Joint Surg Br 2007;89(4):467-470. Medline DOI
A comparative study. Clin Orthop Relat Res 2004;428:
68-73. Medline DOI 29. Nestor BJ, Toulson CE, Backus SI, Lyman SL, Foote
KL, Windsor RE: Mini-midvastus vs standard medial
22. McAllister CM, Stepanian JD: The impact of minimally parapatellar approach: A prospective, randomized, dou-
invasive surgical techniques on early range of motion ble-blinded study in patients undergoing bilateral total
after primary total knee arthroplasty. J Arthroplasty knee arthroplasty. J Arthroplasty 2010;25(6suppl):5-11.
2008;23(1):10-18. Medline DOI Medline DOI
23. Tashiro Y, Miura H, Matsuda S, Okazaki K, Iwamoto This study reported on 27 patients who underwent bilat-
Y: Minimally invasive versus standard approach in total eral TKA with a mini-midvastus exposure on one side and
knee arthroplasty. Clin Orthop Relat Res 2007;463(463): a standard medial parapatellar arthrotomy on the other.
144-150. Medline At 3 weeks, strength in the limb with the mini-midvastus
exposure had improved, but no other clinically significant
differences were reported.
24. Aglietti P, Baldini A, Sensi L: Quadriceps-sparing versus
mini-subvastus approach in total knee arthroplasty. Clin
Orthop Relat Res 2006;452(452):106-111. Medline DOI 30. Bourke MG, Buttrum PJ, Fitzpatrick PL, Dalton PA, Jull
GA, Russell TG: Systematic review of medial parapatel-
lar and subvastus approaches in total knee arthroplasty.
25. Bonutti PM, Zywiel MG, Ulrich SD, Stroh DA, Seyler J Arthroplasty 2010;25(5):728-734. Medline DOI
2: Knee
TM, Mont MA: A comparison of subvastus and mid-

vastus approaches in minimally invasive total knee ar- This systematic review compared the outcomes of the
throplasty. J Bone Joint Surg Am 2010;92(3):575-582. medial parapatellar and subvastus surgical approaches for
Medline DOI TKA. Only five published studies (from 1993 and 2001)
met the inclusion quality standards for the review. The
This prospective, randomized study reported on 51 pa- evidence was insufficient to demonstrate a clinical or sig-
tients who underwent bilateral TKA using short skin nificant difference across all outcomes. The poor quality
incisions with a subvastus exposure on one side and a of these studies was an important limitation; additional
midvastus exposure on the other. Early clinical outcomes high-quality studies are needed.
at 2-year follow-up did not identify any significant differ-
ences between the exposures. Level of evidence: I.
31. Smith TO, King JJ, Hing CB: A meta-analysis of ran-
domised controlled trials comparing the clinical and
26. Bourke MG, Jull GA, Buttrum PJ, Fitzpatrick PL, Dalton radiological outcomes following minimally invasive to
PA, Russell TG: Comparing outcomes of medial para- conventional exposure for total knee arthroplasty. Knee
patellar and subvastus approaches in total knee arthro- 2012;19(1):1-7. Medline DOI
plasty: A randomized controlled trial. J Arthroplasty
2012;27(3):347-353.e1. Medline DOI This meta-analysis compared the clinical and radiologic
outcomes of minimally invasive and conventional expo-
This study compared 90 patients who underwent TKA sure TKAs for 18 studies including 1,582 TKAs (822 mini-
with either a standard medial parapatellar arthrotomy mally invasive versus 760 conventional exposure TKAs).
or a subvastus exposure. The only significant differences The incision length was significantly smaller, and flexion
identified were better Knee Society functional scores at range of motion was significantly greater following MIS,
12 and 18 months and less surgeon-perceived difficulty but no significant differences were reported for all other
performing the surgery in the medial parapatellar group outcomes between the approaches.
versus fewer days postoperatively to perform the straight
leg raise in the subvastus group. The authors concluded
that no clinically significant benefits to using the subvastus
exposure exist.
32. Cheng T, Liu T, Zhang G, Peng X, Zhang X: Does 33. Gandhi R, Smith H, Lefaivre KA, Davey JR, Mahomed
minimally invasive surgery improve short-term recov- NN: Complications after minimally invasive total knee
ery in total knee arthroplasty? Clin Orthop Relat Res arthroplasty as compared with traditional incision tech-
2010;468(6):1635-1648. Medline DOI niques: A meta-analysis. J Arthroplasty 2011;26(1):29-35.
Medline DOI
This article reports on the results of a systematic review
and meta-analysis of 13 trials published from 2007 to This meta-analysis compared the incidence of compli-
2009 that compared minimally invasive knee arthroplasty cations between MIS and standard TKA approaches in
versus standard TKA. MIS results in faster recovery than randomized controlled trials. A higher rate of complica-
conventional surgery, with similar rates of component tions was identified in the MIS group but alignment was
malalignment but is associated with more frequent inno different. The authors noted that knee MIS should be
stances of delayed wound healing and infections. approached with caution.
2: Knee
Chapter 9
Kinematics in Total
Knee Arthroplasty
William M. Mihalko, MD, PhD
of the design rationales are driven by normal knee kine-

Abstract
matic variables as well as the desire to improve patient
Understanding how different total knee implant design satisfaction and function after surgery. In reality, design
variations affect knee kinematics is essential to opti- variables in a TKA implant may not result in the motion
mize surgical techniques and outcomes for patients. that was desired by the designers. Many reports in the
Different levels of constraint and posterior cruciate literature and in vivo studies show kinematic profiles of
retention, sacrifice, or substitution will all affect the TKAs that do not follow normal knee kinematic pro-
resulting kinematic profile of the knee after surgery. It files.1-7 Reports of in vivo kinematics most likely rely on
is important to review aspects of different designs and multiple variables, including patient anatomy, surgical
evidence in the literature of how these designs may technique, and even excessive body mass index and joint
affect kinematics after surgery. loads.8-14 Implant design can also be dependent on sur-
gical technique, about which there is active debate (eg,
mechanical versus kinematic alignment; gap balancing
Keywords: knee; implant; kinematics; constraint versus matched resection).15-18
Implant Design and Effects on Kinematics
2: Knee
A large degree of variability exists in the kinematics of the
Introduction
replaced knee, and no consensus exists on a definitive de-
Condylar total knee arthroplasty (TKA) has seen many sign that best re-creates the kinematics of the normal knee.
implant design changes over the last two decades, but the This in part has to do with the fact that arthritis—whether
concept of total condylar arthroplasty remains largely inflammatory, posttraumatic, or osteoarthritis—affects
unaltered. Some design changes include an increase in more than just the surface geometry of the joint. Some
the number of available sizes; others use mobile bearings, designs have centered on the effect and importance of
others are bicruciate-substituting or -retaining, and yet the posterior cruciate ligament (PCL). Functionally, the
others incorporate medial pivot-driven constraints. Many PCL provides most of the total restraining force against
posterior translation of the tibia relative to the femur, and
it supports stability of the knee and the joint space in flex-
Dr. Mihalko or an immediate family member has received ion.19 In the PCL-retaining knee, the conservation of this
royalties from Aesculap/B. Braun; is a member of a speak- ligament is designed to reduce the posterior translation of
ers’ bureau or has made paid presentations on behalf of the tibia and to contribute to femoral rollback in deep knee
Aesculap/B.Braun and CeramTec; serves as a paid consultant flexion.20-22 Retention of the PCL theoretically enables roll-
to Aesculap/B. Braun, Medtronic, and the Department of back of the femur on the tibia with knee flexion, allowing
Defense; has received research or institutional support for more efficient use of extensor musculature.23 However,
from Aesculap/B. Braun, MicroPort, Smith & Nephew, and a debate continues in the literature regarding the benefits
Stryker; and serves as a board member, owner, officer, or of retaining the PCL in TKA.24-26 The design of a poste-
committee member of the American Academy of Ortho- rior stabilized TKA requires additional anterior-posterior
paedic Surgeons, the American Orthopaedic Association, stability, which is effectively achieved by placement of a
and ASTM International. femoral cam and tibial post. Proponents of the posterior
Section 2: Knee
Figure 1 A, Illustration of cam and post interaction. A cam that is positioned at the top and most posterior aspect of the
femoral posterior condyles will tend to interact with the tibial post later in the flexion arc, but will tend to remain
at the base of the post in the extremes of flexion, thereby maximizing the jump height of the cam on the post. As
the cam moves anteriorly across the box (dark circle), the interaction will tend to occur earlier in flexion and will
articulate higher on the post late in the flexion arc, thereby decreasing the jump height. B, Lateral radiograph
of the knee of a patient after total knee arthroplasty with a posterior stabilized implant who felt a "pop" while
working under his vehicle and could not bend his knee. A jumped post in a posterior stabilized design implant is a
complication that occurs when the flexion space is greater than the jump height of the post.
stabilized designs purport that it offers a more reproduc- within the tibial polyethylene insert, and the cam spanned
ible kinematic profile and increased range of motion than the posterior femoral condyles. This design engaged the
the cruciate-retaining design, whereas opponents argue cam on the post at approximately 60° and then drove
that increased femoral bone loss and added implant con- rollback of the posterior femoral condyles on the tibial
straint, possibly increasing the risk of aseptic loosening, polyethylene insert symmetrically until edge loading of
are pitfalls of the design. Several studies report no differ- the posterior femoral condyles on the polyethylene insert
2: Knee
ence in functional outcome between posterior-stabilizing occurred at approximately 120° of flexion. This was the
or cruciate-retaining TKAs.25,27,28 Opponents of posterior basis of design for all posterior stabilized TKA implants
stabilized TKA-designed implants also argue that the knee going forward.
is more stable in flexion without affecting the flexion gap, By examining how the post and cam positioning affect
and important mechanoreceptors in the PCL are retained both when and how the interaction of the post and cam
that can affect function after surgery.29 occurs, a basic understanding of the design attributes
can be inferred. If the post is positioned centrally in the
baseplate, it is possible to determine how moving the cam
Post and Cam Positioning in Posterior Stabilized affects the interaction of the two and drives the motion
Implant Design of the femur with respect to the tibia. If the cam is posi-
The posterior stabilized TKA implants afford stability tioned more anteriorly across the sides of the box, then
to the knee by blocking posterior translation of the tibia the post will interact with the cam at an earlier point
on the femur through a post (on the polyethylene insert) during the flexion arc; once engaged, the contact of the
and a cam (on the posterior femoral condyles or bridg- cam will be maintained in the midportion of the post.
ing a box between the condyles of the femur). Design If the cam is moved to a more posterior position on the
changes, for example, the position and shape of the post femur, or at the top of the femoral condyles, then the
and cam, affect the guided or constrained motion of the cam will contact the post at a later point in the flexion
femur on the tibia and have consequences as well on the arc, move down the post, and remain at the base of the
amount of congruency and subsequent wear on the tibial post, even with extremes of flexion, thereby maximizing
polyethylene.30 the jump height.6,30,32 This keeps the knee stable in flex-
In the initial posterior stabilized designs, the post and ion and prevents a jumped-post dislocation after surgery
cam were symmetric.31 The post was positioned centrally (Figure 1). Some implants now incorporate an articulating
Chapter 9: Kinematics in Total Knee Arthroplasty
Figure 3 Photographs of a posterior stabilized knee

implant retrieved at necropsy after more
than 10 years' implantation. A, The post has
a more rounded cross-section and the cam is
located more toward the base of the posterior
femoral condyles. B, The lateral aspect of the
post shows an impingement wear scar from
the inner aspect of the lateral condyle of the
femoral implant as well as an impingement scar
at the top of the straight post, where a patellar
Figure 2 Photograph of a knee implant retrieved at button post conflict occurred in flexion.
necropsy after more than 10 years' implantation
shows an example of a rectangular post
cross-section with sharp edges and a cam Asymmetric cam designs have now been introduced
that is located midway along the height of in which one side of the cam has a larger diameter. The
the posterior condyles. This configuration
provides contact earlier in the flexion arc and smaller diameter is typically placed on the medial side,
moves contact up the post after around 90° of and the varying larger diameter on the lateral side (Fig-
flexion. The medial and lateral wear scars are
symmetric and do not force as much rollback in ure 4). This design feature is intended to guide a medial
this configuration with edge impingement, as is pivot. This pivot occurs with increasing flexion from the
seen in the posterior aspect of the polyethylene wider diameter of the cam on the lateral side and pushes
insert where it impinged on the posterior
aspect of the femur in flexion. the lateral femoral condyle posteriorly to effect rollback,
whereas the smaller diameter on the medial side tends to
keep the medial femoral condyle centrally located with
area on the anterior aspect of the post on the anterior more sliding motion.
aspect of the box to guide motion in terminal extension.
This type of dual-cam design adds another articulating
surface, but may guide motion in terminal extension more Cruciate-Retaining TKA Implant Design Attributes
2: Knee
consistently. and Kinematics
Cam and post geometry in the transverse plane will Cruciate-retaining TKA implants have evolved from flat-
also change the way the femur and tibia interact. If the on-flat minimal constraint designs (in the early 1990s) to
post has a rectangular cross-section, then it may con- those that tend to balance the amount of implant con-
strain rotation of the femur on the tibia in the transverse straint to aid in guiding femoral tibial motion. To prevent
plane, depending on the overall width of the post. This the medial femoral condyle from sliding forward, many
design feature will cause edge loading of the post on the designs incorporate a deep-dish or ultracongruent option
condylar edges of the femoral component. This can be for a tibial polyethylene insert. This design feature makes
seen in the retrieved implant shown in Figure 2. This certain the medial femoral condyle does not slide forward,
implant shows the square edges of the polyethylene post creating an anterior block to the medial femoral condyle
and a wear scar along the sides from overconstraint in on the medial tibial polyethylene. Many designs, how-
the transverse plane. If the post has a rounded transverse ever, have shown a tendency for the femoral articulation
plane geometry with less condylar constraint to internal to slide forward with increasing flexion. A single radius
and external rotation, then less burnishing and edge wear femoral condylar design can aid in keeping the medial
may result30 (Figure 3). femoral condyle from sliding forward.33 Range of motion
Post height and position can also affect flexion and ki- after posterior cruciate-retaining TKA has been reported
nematics in other ways. If the post is straight and too tall, to be improved when the posterior condylar offset is re-
with a more anterior position, there is risk of impingement established.8,9 If the posterior condyles are overresected,
of the top of the post on the inferior aspect of the patellar the posterior aspect of the tibia may come in contact with
button (known as post–patellar conflict). When this oc- the posterior aspect of the femur and result in suboptimal
curs, the patient typically feels a block to further flexion flexion. Later reports have shown that measuring this
and pain as the post collides with the patella. variable radiographically is difficult, and a combination of
Section 2: Knee
consistent motion, but not one that is always comparable

to that of the normal knee. Although a lunge-type move-
ment is rarely used in daily activities, it does give a basis of
comparison for TKA patients; some studies have analyzed
more demanding activities, such as rising from a chair
and kneeling.1 Patients with a posterior stabilized implant
design tend to have a neutral or anterior position of the
femoral component at full extension, with progressive
posterior femoral rollback being achieved with increasing
knee flexion. Therefore, although the cruciate-retaining
design has been used with great clinical success, the ki-
Figure 4 Photograph of an asymmetric cam with a larger
lateral diameter, used to guide lateral rollback
nematics and flexion performance differ from those of a
and a medial pivot. normal knee.
In the transverse plane, both posterior stabilized and
cruciate-retaining designs have been reported to have
variables (including implant design and tibial slope) may significant variations. Both designs have been shown in
also play a role in the amount of flexion obtained as well some studies to have important variations, with 25% or
as in the function of the PCL after surgery.8,34 more of patients showing internal tibial rotation with
respect to the femur as the knee goes into flexion. This
motion has not been completely explained, but it has been
Mobile-Bearing Design Rationale and Kinematics suggested that patients who experience it tend to be less
Potential advantages of mobile-bearing knee implants satisfied with the surgery. 3
include lower contact stresses at the articulating surfaces, Fluoroscopy has also been used to report cam-post
rotational motion of the tibial polyethylene during gait, interactions. One study investigated when the cam-post
and self-alignment of the tibial polyethylene compensating interaction occurred throughout flexion, the location of
for small rotational malalignment of the tibial baseplate the cam on the tibial post when contact occurred, and
during implantation. Recent studies have found a higher the height of contact of the cam on the tibial post during
revision rate in both the early and midterm follow-up deep knee bending for three types of implants: bicru-
periods with a mobile-bearing insert compared with a ciate-stabilized, fixed-bearing posterior stabilized, and
fixed-bearing TKA.35,36 Whether mobile-bearing designs rotating-platform posterior stabilized design.2 The study
2: Knee
will outperform fixed-bearing designs is yet to be deter- found that the bicruciate-stabilized TKA had lower con-
mined, and performance may be specific to individu- tact angles, lower cam-post distance throughout flexion,
al manufacturer designs. A recent meta-analysis found and a higher height of contact on the tibial post compared
moderate- to low-quality evidence that cruciate-retaining to both posterior stabilized designs. It also found that the
mobile-bearing TKA was as good as fixed-bearing TKA.37 location of contact on the tibial post remained centered in
the rotating-platform posterior stabilized design, where-
as in fixed-bearing posterior stabilized designs, contact
In Vivo TKA Kinematics moved from the medial aspect of the tibial post to the
Numerous kinematic fluoroscopic studies have been con- center of the tibial post during flexion.2
ducted comparing cruciate-retaining with posterior sta- Another fluorokinematic study looked at how the max-
bilized designed implants.1-5,33 The results of kinematic imum flexion angle affected two different groups after
studies performed in a normal human knee have shown TKA, one with greater than 15° of normal rotation and
increased posterior motion in the lateral condyle, com- one with greater than 3° of reverse rotation in the trans-
pared to the medial condyle, throughout flexion, and these verse plane.3 The study found that the group with reverse
studies are typically used to compare the measured kine- axial rotation had lower maximum flexion angles than
matics after TKA.38 Although neither posterior stabilized the group with normal rotation. Therefore, axial rotation
nor cruciate-retaining in vivo fluorokinematic studies was found to influence weight-bearing knee flexion. Knees
completely replicate normal knee kinematics, variations with normal rotation obtained deeper flexion than those
are worth noting. In the sagittal plane, cruciate-retain- with reverse rotation. Therefore, the reverse rotation pat-
ing designs have shown a forward sliding of the medial tern may limit flexion. This study suggests that patients
femoral condyle during a lunge and or squatting-type of may be less satisfied with the surgery when this type of
maneuver.39 Posterior stabilized designs have shown more motion pattern occurs after TKA surgery.3
Another study that investigated a TKA implant with a The literature is abundant in joint kinematic studies
dual cam design tested the theory that the design would that evaluate the physiologic representation of numerous
decrease intersurgeon variability in patient knee kine- component designs. One kinematic study, using a model
matics after surgery.4 Three different groups were created designed with a highly congruent medial compartment
from three different surgeons. The overall motion patterns and less conforming lateral compartment, successfully
among the groups were similar, but intrasurgeon differ- replicated kinematics of a normal knee and achieved sat-
ences were found in in vivo kinematics. One group had a isfactory clinical outcomes.41
greater relative axial rotation than the other two groups.
This difference shows that this type of implant does not
function as a mechanically constrained system and that Summary
surgical technique and soft-tissue handling play a role in Constant innovations in design and technique have im-
the outcome of implant function.4 proved functional results of TKA, but no clear consensus
In vivo fluorokinematic studies of mobile-bearing has been reached concerning the superiority of different
designs have shown that the bearing rotation in the designs. Implants that sacrifice or retain the posterior
transverse plane may be nonphysiologic in some pa- cruciate ligament, implants with different positioning and
tients.2,5,9 This internal transverse plane motion has been shapes of the post and cam, and mobile- or fixed-bear-
reported in all types of TKA bearings and does not seem ing designs all have advantages and disadvantages in the
to be specific to any single design. restoration of normal knee kinematics. Outcomes also
can be affected by surgical technique, about which debate
continues (eg, mechanical or kinematic alignment, gap
TKA Computational Kinematic Models balancing or matched resection), as well as patient-related
Several TKA kinematic models have been validated using factors (eg, age, body mass index, preexisting deformity,
the Oxford knee rig.12,13 This testing frame simulates a individual anatomy).
squat maneuver under applied muscle control. Both cruci-
ate-retaining and posterior stabilized implants have been Key Study Points
modeled with several assumptions and loading/boundary
conditions to assess TKA kinematics and study variables • An understanding of normal knee kinematics and
that may effectively change kinematics after surgery. One individual patient characteristics are essential to
common variable that has been studied is component choosing the appropriate implant design for each
suboptimal rotation in the transverse plane. Externally patient.
2: Knee
rotated femoral components introduced varus alignment • TKA implant designs have evolved over the past
in flexion, whereas internally rotated femoral components two decades to a number of modifications intended
induced valgus alignment. Anterior-posterior transla- to improve knee kinematics after surgery; how-
tion for both cruciate-retaining and posterior stabilized ever, not all have been successful in improving
implants was more sensitive to tibial than femoral align- functional outcomes.
ment. The medial condyle of the cruciate-retaining im- • Several recent reports in the literature show no dif-
plant exhibited anterior translation, whereas the lateral ference in functional outcomes between posterior-
contact point exhibited posterior translation when the stabilizing and cruciate-retaining implants.
tibial component was internally rotated. In the poste- • Whether mobile-bearing designs will outperform
rior stabilized implant, all combinations of component fixed-bearing designs is yet to be determined, but
rotation exhibited posterior translations. In this model, recent studies have found a higher revision rate
more posterior femoral rollback was seen for the posterior in both the early and midterm follow-up periods
stabilized implant compared to the cruciate-retaining with a mobile-bearing insert compared to a fixed-
implant, which is consistent with in vivo studies.12 bearing TKA.
In one study, a three-dimensional computational • In addition to restoration of joint kinematics,
model was used to show how small rotational variations outcomes can be affected by surgical technique,
of the femoral and tibial components in the transverse about which debate continues (eg, mechanical or
plane can alter the femorotibial contact patterns.40 These kinematic alignment, gap balancing or matched
variations may be a contributing factor to reverse ro- resection), as well as patient-related factors (eg,
tation of the femur with respect to the tibia, which has age, body mass index, preexisting deformity, in-
been reported in some of the aforementioned fluoroki- dividual anatomy).
nematic studies.
Section 2: Knee
Annotated References the valgus knee operated by the gap-balancing technique.

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hashi D: Posterior femoral condylar offset after total
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2. Zingde SM, Leszko F, Sharma A, Mahfouz MR, Komistek This study analyzed 100 radiographs in Japanese subjects
RD, Dennis DA: In vivo determination of cam-post en- and compared anatomic femoral offset to implant poste-
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This study analyzed 15 fixed-bearing posterior stabilized
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One hundred thirty-five patients undergoing total hip
more than 3° of reverse axial rotation with internal rota-
arthroplasty and TKA were enrolled in this study, and
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were evaluated. Higher patient activation measures led
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a range of motion was closer to the normal knee pattern computed tomography and fluoroscopic evaluations. BMC
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Using a dynamic knee model, this study reported differenc- translation.
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7. Suzuki K, Hara N, Mikami S, et al: In vivo kinematic ponent internal rotation resulted in the largest antero-
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mass index subjects during sit-to-stand. Gait Posture changes to simulate the risk of PCL avulsion with zero, 3°,
2015;41(2):640-645. Medline DOI or 5° posterior slope resection, the study concluded that
This study compared 9 patients with high body mass index those patients with more posterior slope are at lower risk
to 10 normal control patients during sit-to-stand tasks of PCL avulsion after cruciate retaining TKA.
in a gait analysis laboratory. The high body mass index
group had 50% greater abduction throughout the entire 22. Fukubayashi T, Torzilli PA, Sherman MF, Warren RF:
sit-to-stand cycle. An in vitro biomechanical evaluation of anterior-poste-
rior motion of the knee: Tibial displacement, rotation,
15. Howell SM, Papadopoulos S, Kuznik K, Ghaly LR, Hull and torque. J Bone Joint Surg Am 1982;64(2):258-264.
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knee arthroplasty? Int Orthop 2015;39(11):2117-2124. 23. Bolanos AA, Colizza WA, McCann PD, et al: A com-
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patients with posterior cruciate-retaining and substituting
This study prospectively followed 219 kinematically knee arthroplasties. J Arthroplasty 1998;13(8):906-915.
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not affect survivorship or function. Level of evidence: III.
24. Li G, Zayontz S, Most E, Otterberg E, Sabbag K, Rubash
HE: Cruciate-retaining and cruciate-substituting total
16. Ishikawa M, Kuriyama S, Ito H, Furu M, Nakamura S, knee arthroplasty: An in vitro comparison of the kine-
Matsuda S: Kinematic alignment produces near-normal matics under muscle loads. J Arthroplasty 2001;16(8 sup-
knee motion but increases contact stress after total knee pl 1):150-156. Medline DOI
arthroplasty: A case study on a single implant design. Knee
2015;22(3):206-212. Medline DOI
25. Scott DF, Smith RR: A prospective, randomized compari-
This study used a computer model to show that kinemati- son of posterior stabilized versus cruciate-substituting to-
cally aligned TKAs produce greater femoral rollback and tal knee arthroplasty: A preliminary report with minimum
more external rotation of the component compared to 2-year results. J Arthroplasty 2014;29(9 suppl):179-181.
mechanically aligned TKAs. Medline DOI
Comparing 56 patients with a posterior-stabilized TKA
17. Roth JD, Howell SM, Hull ML: Native knee laxities to 55 TKA patients with an anterior lipped cruciate-
at 0°, 45°, and 90° of flexion and their relationship to substituting insert at 45 months found equal outcomes
2: Knee
the goal of the gap-balancing alignment method of total in these two groups functionally and radiographically.
knee arthroplasty. J Bone Joint Surg Am 2015;97(20):
26. Berend KR, Lombardi AV Jr, Adams JB: Which total
Ten cadaver knees were tested at different flexion angles knee replacement implant should I pick? Correcting the
to determine the normal laxity in all three planes. Greater pathology: The role of knee bearing designs. Bone Joint
laxity measures in 45° and 90° of flexion were found, and J 2013;95-B(11 suppl A):129-132. Medline DOI
these findings did not support the goals of gap balancing.
This study compared motion and manipulation rates in
cruciate-retaining TKA patients with a cruciate-retaining
18. Hommel H, Perka C: Gap-balancing technique com- 3° posterior slope insert (1,334 patients), no slope and
bined with patient-specific instrumentation in TKA. small posterior lip (803 patients), and a deep dished in-
Arch O rthop Trauma Surg 2015;135(11):1603-1608. sert (312 patients). More manipulations occurred in the
Medline DOI posterior lipped and 3° sloped insert.
Twenty-five TKAs were prospectively followed after
patient-specific instrumentation and gap balancing. Trans- 27. Lozano-Calderón SA, Shen J, Doumato DF, Greene DA,
verse plane femoral rotation varied from 3° internal to Zelicof SB: Cruciate-retaining vs posterior-substituting
6° external rotation with a 1.2-mm elevation in the joint inserts in total knee arthroplasty: Functional outcome
line on average. comparison. J Arthroplasty 2013;28(2):234-242.e1.
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19. Mihalko WM, Krackow KA: Posterior cruciate ligament A comparison of 412 cruciate-retaining to 328 posterior-
effects on the flexion space in total knee arthroplasty. stabilized TKA patients found that no difference in func-
Clin Orthop Relat Res 1999;360:243-250. Medline DOI tional outcomes or patient satisfaction occurred.
20. DesJardins JD, Walker PS, Haider H, Perry J: The use of 28. Joglekar S, Gioe TJ, Yoon P, Schwartz MH: Gait anal-
a force-controlled dynamic knee simulator to quantify the ysis comparison of cruciate retaining and substituting
mechanical performance of total knee replacement designs TKA following PCL sacrifice. Knee 2012;19(4):279-285.
during functional activity. J Biomech 2000;33(10):1231- DOI Medline
1242. Medline DOI
Section 2: Knee
Nine matched patients were compared who underwent and functional outcome in total knee arthroplasty? A
TKA with either a cruciate-retaining or posterior- randomised controlled clinical trial with 5-year follow-up.
stabilized TKA, with all undergoing PCL sacrifice. No J Arthroplasty 2015;30(11):1931-1937. Medline DOI
differences between the two groups occurred when com-
paring stair ascent and descent and gait when analyzed When groups of patients with fixed or mobile bearing
in a motion analysis laboratory. TKA were compared, outcomes between the two groups
were similar but revision rates were higher in the patients
with mobile bearings.
29. Zhang K, Mihalko WM: Posterior cruciate mecha-
noreceptors in osteoarthritic and cruciate-retaining
TKA retrievals: A pilot study. Clin Orthop Relat Res 36. Namba R, Graves S, Robertsson O, et al: International
2012;470(7):1855-1859. Medline DOI comparative evaluation of knee replacement with fixed
or mobile non-posterior-stabilized implants. J Bone Joint
This study reports that the number of mechanoreceptors Surg Am 2014;96(suppl 1):52-58. Medline DOI
in a PCL in knees with osteoarthritis does not differ when
compared to PCL obtained at the time of necropsy from Using national registries to compare mobile- to fixed-
cruciate-retaining TKAs. bearing TKAs with an advanced harmonized distribution
analysis found that mobile-bearing nonposterior stabilized
designs had higher rates of revision.
30. Mihalko WM, Lowell J, Higgs G, Kurtz S: Total knee post-
cam design variations and their effects on kinematics and
wear patterns. Orthopedics 2016;39(3 suppl):S45-S49. 37. Hofstede SN, Nouta KA, Jacobs W, et al: Mobile bearing
Medline DOI vs fixed bearing prostheses for posterior cruciate retaining
total knee arthroplasty for postoperative functional status
Using retrievals of different post-cam mechanism designs, in patients with osteoarthritis and rheumatoid arthri-
the authors show how design variations can affect trans- tis. Cochrane Database Syst Rev 2015;2(2):CD003130.
verse plane and sagittal plane motion and wear. Medline
Using the Cochrane database, the authors found 19 studies
31. Indelli PF, Aglietti P, Buzzi R, Baldini A: The In- to analyze and that there was moderate to low-quality
sall-Burstein II prosthesis: A 5- to 9-year follow-up study evidence to suggest that mobile-bearing implants have a
in osteoarthritic knees. J Arthroplasty 2002;17(5):544- similar effect on knee pain, revision, mortality, and quality
549. Medline DOI of life compared with fixed posterior cruciate-retaining
implants.
32. Walker PS, Lowry MT, Kumar A: The effect of geometric
variations in posterior-stabilized knee designs on motion 38. Komistek RD, Dennis DA, Mahfouz M: In vivo fluoro-
characteristics measured in a knee loading machine. Clin scopic analysis of the normal human knee. Clin Orthop
Orthop Relat Res 2014;472(1):238-247. Medline DOI Relat Res 2003;410:69-81. Medline DOI
Using a custom testing machine, the authors tested four
posterior-stabilized TKA designs and compared with one 39. Ploegmakers MJ, Ginsel B, Meijerink HJ, et al: Physical
2: Knee
experimental asymmetric design. Variations from symmet- examination and in vivo kinematics in two posterior cru-
ric rollback in the current designs to more medial pivot in ciate ligament retaining total knee arthroplasty designs.
the experimental design were reported. Knee 2010;17(3):204-209. Medline DOI
Comparison of the PFC Sigma to Continuum Knee System
33. Shimizu N, Tomita T, Yamazaki T, Yoshikawa H, Suga- PS TKAs was carried out using fluoroscopic kinematic
moto K: In vivo movement of femoral flexion axis of analysis. This design showed less tibial rotation during
a single-radius total knee arthroplasty. J Arthroplasty flexion and more anterior sliding of the femur on the tibia.
2014;29(12):2407-2411. Medline DOI
Twenty TKA patients underwent fluoroscopic analyses 40. Mihalko WM, Williams JL: Total knee arthroplasty ki-
with a Triathlon PS implant. No paradoxical motion was nematics may be assessed using computer modeling: A
reported in up to 70° of flexion. feasibility study. Orthopedics 2012;35(10suppl):40-44.
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34. Ishii Y, Noguchi H, Takeda M, Sato J, Toyabe S: Posterior Using a computational model and computer navigation
condylar offset does not correlate with knee flexion after registration landmarks, the study reported similar intra-
TKA. Clin Orthop Relat Res 2013;471(9):2995-3001. operative kinematics along with similar comparisons in
Medline DOI the literature.
One hundred seventy TKA patients were analyzed 1 year
after surgery with either a PCL-retaining or PCL-sacrific- 41. Schmidt R, Komistek RD, Blaha JD, Penenberg BL, Ma-
ing implant. Differences in posterior condylar offset did loney WJ: Fluoroscopic analyses of cruciate-retaining
not seem to correlate with knee flexion in either group. and medial pivot knee implants. Clin Orthop Relat Res
2003;410:139-147. Medline DOI
35. Fransen BL, Hoozemans MJ, Keijser LC, van Lent ME,
Verheyen CC, Burger BJ: Does insert type affect clinical
Chapter 10
Implant Designs of Total

Knee Arthroplasty
Kartik Mangudi Varadarajan, PhD Daniel J. Holtzman, MD Guoan Li, PhD Jeffrey Lange, MD
Steven B. Haas, MD Harry E. Rubash, MD Andrew A. Freiberg, MD
Abstract
The continued development of implant geometries and materials used in total knee arthroplasty is motivated by
the recognition of patient dissatisfaction, increased use in young and active patients, and concerns regarding metal
hypersensitivity. Single-radius and multiradius femoral designs appear to be associated with equivalent clinical
outcomes. Anatomic tibial trays can reduce the likelihood of internal rotation if tibial coverage is maximized
to guide placement. Recent meta-analyses and registry studies suggest equivalent outcomes for all-polyethylene
and metal-backed tibial components. Anatomic or biomimetic articular surfaces together with anterior cruciate
ligament retention or substitution may be key to restoring normal kinematics following total knee arthroplasty.
Restoration of the native joint line by using surgical technique or asymmetric thickness components may also play
an important role in improving function following TKA. Several materials have shown promise as alternatives
to cobalt-chromium-molybdenum alloys. Bulk ceramics and oxidized zirconia have shown particularly excellent
mid- to long-term outcomes and may be viable options for patients with suspected metal hypersensitivity.
2: Knee
Keywords: anatomic articular surface; anterior Implant Geometry
cruciate ligament; ACL function; anatomic joint
line; all-polyethylene tibial component; ceramics The implant geometry directly influences joint biome-
chanics, including function of the native soft tissues, tibio-
femoral kinematics, and patellar tracking. Previously,
sex-specific implants were proposed to better fit male
or female knee anatomy. Subsequent research has not
Introduction
supported the need for sex-specific designs, but instead
Total knee arthroplasty (TKA) implant designs continue has shown a need for size-specific aspect ratios and/or
to evolve, given that 20% to 30% of patients are dis- provisions for sufficient implant sizes. Similarly, although
satisfied with how their knee feels and functions after high-flexion designs reduce tibiofemoral contact stresses
surgery; use of these procedures has increased in active in deep flexion, they do not provide increased range of
patients younger than 65 years; and concerns exist re- motion (ROM). In addition, these newer designs do not
garding metal hypersensitivity in some patients. New treat the underlying kinematic limitations of contempo-
implant technologies, together with improvements in rary implants, which have been associated with func-
technique and instrumentation, can hopefully result in a tional limitations and patient dissatisfaction. One study
more normal-feeling knee postoperatively, with longevity reported that patients who underwent TKA have greater
extending to the second and third decade. It is important difficulty performing activities such as kneeling, carrying
for the orthopaedic surgeon to be aware of the consider- loads, playing tennis, dancing, and gardening compared
ations and developments related to implant geometry and with their age-matched peers; only 40% of the functional
implant materials, with a focus on issues that continue to deficit seemed attributable to the normal effects of ag-
be debated and new technologies that are being explored. ing.1 Research and development efforts are ongoing to
Section 2: Knee
Figure 1 Photographs of a single-radius total knee arthroplasty femoral component (Triathlon, Stryker) (A) with a constant
radius over 10° to 110° of flexion (red outline) and a multiradius femoral component (Genutech, Surgival) (B)
with one radius from 0° to 45° of flexion (black outline) and a different radius from 45° to 130° of flexion (orange
outline). (Reproduced with permission from Hinarejos P, Puig-Verdie L, Leal J, et al: No differences in functional
results and quality of life after single-radius or multiradius TKA. Knee Surg Sports Traumatol Arthrosc 2015;12:1-7.)
create implant designs that can provide more normal designs use a changing radius of curvature with increased
kinematics via modifications of the femoral and tibial ar- knee flexion that results in a center of rotation that shifts
ticular surfaces, the provision of asymmetric components through the ROM. Single-radius designs have a consistent
to reduce rotational malpositioning, and the restoration radius of curvature throughout the flexion-extension arc
of anterior cruciate ligament (ACL) and posterior cruciate and a more posterior center of rotation, which theoretically
ligament (PCL) function via retention or substitution. creates more consistent soft-tissue/collateral ligament ten-
sion to minimize instability in mid flexion and increases
2: Knee
Femoral Implant quadriceps muscle strength. A 2015 study examined three

Single-Radius Versus Multiradius Designs cohorts of patients (16 patients after single-radius TKA,
Both single-radius and multiradius femoral implant de- 16 patients after multiradius TKA, and 16 healthy control
signs are commercially available (Figure 1). Multiradius patients) in a gait analysis laboratory.2 Preoperatively, no
Dr. Varadarajan or an immediate family member has received royalties from Stryker; serves as a paid employee of Merck;
serves as a paid consultant to CeramTec and Orthopaedic Technology Group; has stock or stock options held in Merck
and Orthopaedic Technology Group; and serves as a board member, owner, officer, or committee member of the Or-
thopaedic Research Society. Dr. Li or an immediate family member has received royalties from Stryker. Dr. Haas or an
immediate family member has received royalties from Smith & Nephew and Innovative Medical Products; is a member
of a speakers’ bureau or has made paid presentations on behalf of Smith & Nephew; serves as a paid consultant to Smith
& Nephew; has stock or stock options held in OrthoSecure; has received research or institutional support from Smith
& Nephew; and has received nonincome support (such as equipment or services), commercially derived honoraria, or
other non–research-related funding (such as paid travel) from APOS Medical & Sports Technologies. Dr. Rubash or an
immediate family member has received royalties from CeramTec and Stryker; serves as a paid consultant to Flexion Ther-
apeutics and Pacira Pharmaceuticals; has stock or stock options held in Orthopaedic Technology Group; and serves as a
board member, owner, officer, or committee member of the Hip Society. Dr. Freiberg or an immediate family member
has received royalties from Biomet and Zimmer; serves as a paid consultant to Zimmer, Biomet, and Medtronic; and has
stock or stock options held in ArthroSurface and Orthopaedic Technology Group. Neither of the following authors nor
any immediate family member has received anything of value from or has stock or stock options held in a commercial
company or institution related directly or indirectly to the subject of this chapter: Dr. Holtzman and Dr. Lange.
Chapter 10: Implant Designs of Total Knee Arthroplasty
Figure 2 Illustrations of the distal femur and proximal tibia in the coronal plane demonstrate symmetric distal femoral
condylar resurfacing, which causes depression of the lateral joint line. A, The area of planned resection for a
standard total knee arthroplasty (TKA) is between the two red lines. B, The area of planned resection noted in
A has been replaced by a schematic of a TKA (shaded area). Note the medial joint line remains in its anatomic
location, and the lateral joint line is translated distal to its anatomic location. Lines parallel to the cut proximal
tibial surface clarify the relationship between the native and resurfaced joint line positions medially (dotted line)
and laterally (dashed line). L = lateral, M = medial.
2: Knee
significant differences in gait cycle parameters existed designs and found no difference in Knee Society scores,
between patients in the single-radius and multiradius knee flexion, complications, isometric peak torque of the
groups. Postoperatively, several significant differences knee, or survival rates.4 Thus, the theoretical advantages
were noted between the patients in the multiradius group of a single-radius design are not supported by available
and control patients in several gait parameters, including clinical data. This finding may be because the actual
increased knee extension and decreased power absorption geometric difference between single-radius and multira-
in the multiradius group. No significant differences be- dius femoral designs for most of the active flexion range
tween the single-radius group and control patients were (10° to 110°) is small. Implant systems with single-radius
detected. Despite these findings, no functional differences versus multiradius designs also vary substantially in the
were observed in patient-reported outcome measures. geometry of other components, such as the tibial articular
A lack of functional difference between single-radius geometry. Therefore, it may be difficult to ascertain the
and multiradius designs has been reported. A prospective effects of femoral design alone from clinical data.
cohort study with a standardized surgical and rehabil-
itation protocol reported on 250 patients who under- Restoration of the Anatomic Joint Line
went single-radius TKA and 224 patients who underwent Historically, the two primary approaches to coronal plane
multiradius TKA with 5-year follow-up.3 No significant positioning of the joint line were anatomic and functional
differences existed between the single-radius and mul- alignment. Anatomic alignment, along with its modern
tiradius groups at 1 and 5 years following surgery in iteration termed kinematic alignment, aims to restore the
Knee Society scores, Medical Outcomes Study 36-Item natural joint line orientation to promote natural knee
Short Form physical scores, postoperative ROM, or pa- mechanics. Functional alignment, also termed mechanical
tient satisfaction. In addition, a recent meta-analysis of alignment, is the prevailing convention and aims to create
15 studies compared single-radius and multiradius TKA a joint line perpendicular to the overall mechanical axis
Section 2: Knee
Figure 3 Illustrations of the distal femur and proximal tibia in the coronal plane demonstrate asymmetric distal femoral
condylar morphology matched using implant design. A, The area of planned resection for a standard total knee
arthroplasty (TKA) is located between the two red lines. B, The area of planned resection as noted in A has been
replaced by a schematic of a TKA with asymmetric distal femoral condylar surfaces (shaded area). Asymmetry of
the femoral component is matched by asymmetry of the tibial component, restoring both the medial and lateral
joint lines to their anatomic locations. Lines parallel to the cut proximal tibial surface clarify the relationship
between the native and resurfaced joint line positions medially (dotted line) and laterally (dashed line). L = lateral,
M = medial.
2: Knee
of the lower limb. This approach is thought to load each of depression.6 Alternatively, if distal femoral resection
compartment equally, avoiding an overload of the tibial increases by 2 mm, the lateral joint line will remain ana-
component medially.5 tomic and the medial joint line will be elevated. Joint line
Although mechanical alignment has produced excel- elevation also is not ideal because it is linked to patellar
lent results in millions of patients, natural knee kinematics impingement on the tibial component, midflexion insta-
are not maintained when this method is used. This is, bility, and patellofemoral pain at deviations as small as
in part, because although the implants generally have 5 mm of elevation.6 Furthermore, because mechanical
equal medial and lateral condylar thicknesses, the cor- alignment does not re-create natural knee kinematics,
responding bone cuts have asymmetric thicknesses. For collateral ligament tension and strain are significantly
example, in a typical varus knee, approximately 9 mm of altered during knee ROM.7
bone is removed from the distal medial femoral condyle, One approach to restoration of the anatomic joint
which equals the implant thickness, and approximately line is to use standard nonanatomic implants positioned
7 mm of bone is removed from the distal lateral femoral parallel to the native joint line. However, placing nonan-
condyle, which is less than the thickness of the implant. atomic implants in an anatomic coronal position can be
In this situation, the medial joint line will remain ana- problematic. Placing the tibial component in varus has
tomic but the lateral joint line will be displaced distally been associated with high failure rates in many stud-
by approximately 2 mm with standard femoral implants ies.8 In addition, placing the tibial component in varus
(Figure 2). Joint line depression is not ideal because it is necessitates internal rotation of the femoral component to
linked to patellofemoral pain, subluxation, and dimin- create a symmetric flexion gap, which elevates the lateral
ished functional gains at deviations as small as 3 mm anterior femoral flange and rotates the trochlear groove
Figure 4 Illustration depicts anatomic, symmetric, and asymmetric tibial trays overlaid on a proximal tibial surface. The
maximum tibial coverage and resulting rotation for each tray design are also indicated. (Reproduced with
permission from Stulberg SD, Goyal N: Which tibial tray design achieves maximum coverage and ideal rotation:
Anatomic, symmetric, or asymmetric? An MRI-based study. J Arthroplasty 2015;30[10]:1839-1841.)
medially. Furthermore, by placing the femoral component and rotation may be conflicting, prompting reduction of
in relative valgus, the proximal trochlear groove is shifted the tibial component size and coverage to optimize ro-
medially, which potentially predisposes the patella to tational alignment. Increased recognition of population
tilt and maltracking.9 Despite these issues, proponents and ethnic differences in proximal tibial morphology has
of kinematic alignment report reasonable short-term re- resulted in more tibial tray implant design options. Cur-
sults.10 Long-term studies are necessary to clarify the role rently, symmetric, asymmetric, and anatomic designs are
of this method in TKA. commercially available (Figure 4). A 2014 study com-
Instead of placing components in anatomic position, pared proximal tibial morphology obtained from the CT
another option is to restore the anatomic joint line using scans of Caucasian cadavers and living Indian, Korean,
the implant design. This restoration is achieved in some Chinese, and Japanese subjects with six contemporary
designs by using the concept of anatomic contour match- TKA designs.11 Compared with asymmetric and sym-
2: Knee
ing to match the thickness of the bone removed to the metric designs, the anatomic design demonstrated better
thickness of the bone replaced. To restore an anatomic conformity to tibial size/shape and tibial coverage (92%
varus joint line orientation of 3°, the lateral side of the versus 85% to 87%, respectively), and a lower incidence
tibial insert is thicker than the medial side. Concomi- of downsizing (3% versus 39% to 60%, respectively) to
tantly, the distal medial side of the femoral component ensure rotational alignment. An MRI-based study of sym-
is thicker than the distal lateral side. Using asymmetric metric, asymmetric, and anatomic tibial trays from a single
implant thicknesses allows these designs to more closely manufacturer showed significantly higher proximal tibial
match the normal anatomy of the typical femur and tibia coverage with the anatomic design (80.8%) compared
while using standard mechanical alignment bone cuts with the symmetric (76.3%) and asymmetric (75.8%) de-
(Figure 3). Thus, an anatomic joint line can be achieved signs when rotational alignment was constrained to the
while maintaining a tibial cut perpendicular to the tibial anterior-posterior axis.12 In contrast, another 2014 study
mechanical axis, thereby minimizing shear forces and found similar tibial coverage for symmetric, asymmetric,
the potential for mechanical failure at the tibial interface. and anatomic trays aligned to the tibial anterior-posterior
Restoration of the anatomic joint line in conjunction with axis,13 as well as similar variations in rotational position
other design features such as anatomic tibial articular when maximizing tibial coverage. However, in that study,
geometry and bicruciate substitution, may contribute to symmetric and asymmetric designs were biased toward
the reproduction of near-normal knee kinematics. internal rotation and the anatomic design was biased to-
ward external rotation, which indicates that anatomic
Tibial Tray designs may provide only a slight advantage regarding
Symmetric/Asymmetric Versus Anatomic Design tibial coverage. However, anatomic designs may reduce
Tibial tray design has the potential to influence tibial the incidence of internal tibial rotation if maximal tibial
coverage and rotational alignment. In practice, coverage coverage is used to guide tray placement.
Section 2: Knee
All-Polyethylene Versus Modular Tibial Components all-polyethylene tibial component (P = 0.002). Cox multi-
All-polyethylene tibial components have been used since ple regression analysis demonstrated that all-polyethylene
the earliest tibial component designs were developed. tibial components had a lower risk of revision for any
However, most knee implants currently use modular reason, with an adjusted relative risk of 0.75 (95% confi-
metal-backed tibial components because of advantages dence interval: 0.64-0.89), compared with metal-backed
such as intraoperative flexibility, the potential for isolated tibial components.
bearing exchange, and the availability of a press-fit fix- In addition, all-polyethylene tibial components may
ation option. Modular metal-backed tibial components provide the added benefit of reduced costs. One study
also are proposed to diminish stress and strain at the showed a 20% to 30% reduction in cost when using
implant-cement interface. all-polyethylene components compared with metal-backed
Initial poor results and early failures for all-polyethylene components; another study calculated $95,000 in savings
tibial components were attributed to surgical technique on implant costs for every 100 patients who received an
and implant design problems, specifically, the lack of all-polyethylene component instead of a metal-backed
articular congruity of the tibial component. However, component.18,19
recent meta-analyses and registry-level studies suggest
that clinical outcomes of all-polyethylene tibial compo-
nents are equivalent to those of metal-backed components. PCL Function: Retention, Substitution, or Sacrifice
A systematic review and meta-analysis of 1,798 TKA The debate regarding the merits of PCL retention in
implants in 12 studies published from 1990 to 2011 iden- cruciate-retaining designs versus PCL substitution in
tified all-polyethylene tibial components as one of the posterior-stabilized designs has been long-standing.
treatment arms.14 Although no findings were significant, However, no clinically relevant differences have been
respective risk reductions of 29% and 14% were iden- found in ROM, pain, clinical, or radiologic outcomes for
tified at 10 and 15 years after the index procedure for cruciate-retaining versus posterior-stabilized designs.20 In
revision for all-polyethylene components compared with a cruciate-substituting or ultracongruent design, the
metal-backed components. Furthermore, no significant PCL is sacrificed, with no cam-post mechanism (unlike
difference was found in functional outcome or adverse posterior-stabilized designs) to substitute its function.
events between the all-polyethylene and metal-backed One potential advantage of ultracongruent designs over
groups. Additional meta-analyses of previously pub- posterior-stabilized designs is greater bone preservation
lished studies also demonstrated no significant differ- resulting from the absence of a femoral box cut. Potential
ences in functional outcomes and complications between disadvantages of ultracongruent designs include increased
2: Knee
all-polyethylene and metal-backed tibial components.15 wear resulting from greater contact area and reduced
A 2013 study published data from a large ROM because of reduced rollback or greater paradox-
community-based total joint registry of 27,657 patients ical anterior sliding. These designs generally share the
who underwent TKA with the same implant (91.7% in same tibial articular geometries as their cruciate-retaining
the metal-backed group and 8.3% in the all-polyethylene counterparts, except for a higher anterior lip (and often
group).16 The surface geometry of the tibial implant was the a higher posterior lip), which is designed to minimize
same for both the metal-backed and all-polyethylene tibial anterior femoral sliding in flexion. However, some studies
components. The revision rate was lower for all etiologies show greater anterior femoral translation in flexion for ul-
in the all-polyethylene group than in the metal-backed tracongruent designs compared with posterior-stabilized
group (1.95% versus 2.17%, P < 0.001). After adjusting and cruciate-retaining designs, 21-24 indicating that the
for age and sex, the risk of revision for all etiologies of an anterior lip may not fully compensate for the stability
all-polyethylene tibial component was 0.51 times higher provided by the PCL or the post-cam mechanism. No
than the risk of revision for a metal-backed component significant differences in clinical outcomes, including
(95% confidence interval: 0.33-0.78). A 2014 study pub- ROM, function scores, and radiographic evaluation, have
lished the comparative revision rates of cruciate-retaining been noted for ultracongruent versus cruciate-retaining or
all-polyethylene and metal-backed tibial components posterior-stabilized designs.22-24 Similarly, a multicenter
performed with the same implant with identical surface study found no difference in 10-year survivorship for
geometry in 27,733 patients from the Swedish Knee Ar- ultracongruent, cruciate-retaining, or posterior-stabilized
throplasty Register (median follow-up, 4.5 years; 57.7% TKA designs.25
metal-backed components, 42.3% all-polyethylene com- The similar outcomes among ultracongruent,
ponents).17 Unadjusted 10-year survival was 96.6% for cruciate-retaining, and posterior-stabilized designs may
the metal-backed tibial component and 97.2% for the partly be explained by their relatively similar kinematics,
Figure 5 Illustration depicts simulated deep knee bend kinematics of a biomimetic cruciate-retaining implant
(Biomimetic CR) and three contemporary cruciate-retaining implants (NextGen CR, ZimmerBiomet; Vanguard
CR, ZimmerBiomet; and Triathlon CR, Stryker). The biomimetic cruciate-retaining implant exhibited an overall
medial pivot with greater lateral rollback compared with medial rollback, and no paradoxical anterior sliding.
Contemporary cruciate-retaining implants exhibited no medial pivot, the NexGen cruciate-retaining implant
exhibited paradoxical anterior sliding, and the Triathlon cruciate-retaining implant exhibited minimal rollback.
(Reproduced with permission from Varadarajan KM, Zumbrunn T, Rubash HE, Malchau H, Li G, Muratoglu OK:
Cruciate retaining implant with biomimetic articular surface to reproduce activity dependent kinematics of the
normal knee. J Arthroplasty 2015;30[12]:2149-2153.)
compared with their kinematic differences from the pre- pivot patterns.27,28 Nevertheless, for its full ROM and
operative or normal condition. Two separate studies during high-flexion activities, the knee shows an overall
both found paradoxical anterior translation approxi- medial pivot with greater rollback of the lateral femoral
mately 2 mm greater for ultracongruent designs than for condyle.28
posterior-stabilized and cruciate-retaining designs.21,22 In In contrast to asymmetric native tibial anatomy, most
2: Knee
contrast, another study measured the intraoperative ki- contemporary implants (for example, cruciate-retaining
nematics of patients receiving ultracongruent implants and posterior-stabilized implants) have identical me-
and reported 8 mm of anterior translation of the medial dial and lateral articular geometries. 29 A notable ex-
condyle and 20 mm of anterior translation of the lateral ception is the ball-in-socket medial pivot concept that
condyle relative to the preoperative condition.24 was first introduced in the mid 1990s. Several newer
versions of these designs that maintain this original phi-
losophy have been introduced in recent years. In vivo
Tibial Articular Surface and in vitro studies show that the design objectives of
One important factor responsible for kinematic limita- minimizing medial condyle motion and paradoxical an-
tions of contemporary implants is the nonanatomic tib- terior sliding are achieved via these ball-in-socket im-
ial articular geometry.26 In the native knee, the medial plants.29,30 However, the extent of medial pivot rotation
tibial plateau has a shallow dish profile, and the lateral and lateral condyle rollback are smaller in magnitude
plateau is convex. This geometry, coupled with the dif- compared with normal knees.29,30 This feature may be
ferential stability of the medial versus lateral menisci, a result of the prominent posterior lip or the absence of
results in differential anterior-posterior excursion of normal lateral convexity, which limits lateral condyle
the medial and lateral femoral condyles during flexion. rollback. Other concerns with the strict ball-in-socket
However, the ball-in-socket analogy commonly used to concept are the inability to accommodate normal pivot
describe the medial condyle is only partially true because center variations during low-flexion activities and con-
its motion is not completely restricted. During activi- flicts with the PCL if used in the cruciate-retaining set-
ties of limited flexion such as walking or stair climbing, ting.27,31,32 The conflict with native PCL may explain why
the anterior-posterior motion of the medial and lateral ball-in-socket implants are generally indicated for use
condyles can be similar, resulting in lateral or variable with a PCL-sacrificing technique.29,30 Thus, development
Section 2: Knee
Figure 6 Illustration depicts in vivo medial and lateral condyle motion in patients with a bicruciate-substituting implant
(Journey, Smith & Nephew) during deep knee bend activity. Although the surgical technique affected the
kinematics, the characteristic motion patterns of normal knees, including greater lateral condyle rollback and
absence of anterior sliding, were typically observed. (Reproduced with permission from Victor J, Mueller JK,
Komistek RD, Sharma A, Nadaud MC, Bellemans J: In vivo kinematics after a cruciate-substituting TKA. Clin Orthop
2: Knee
Relat Res 2010;468[3]:807-814.)
continues of advanced articular surfaces that allow res- than contemporary cruciate-retaining implants during
toration of activity-dependent kinematics of the knee. various simulated activities33 (Figure 5). The biomimetic
In 2015, a new biomimetic technique was described to cruciate-retaining implant particularly showed medial
create articular surfaces directly from the in vivo kinemat- pivot motion during the deep knee bend and chair sit
ics of healthy knees, which was achieved by moving the while accommodating pivot center variations during stair
femoral component in virtual space along the in vivo ki- ascent. This concept has not been evaluated in vivo.
nematics to carve a compatible biomimetic tibial articular In contrast, an ACL-/ PCL-substituting
surface.26 Theoretically, this method accounts for normal (bicruciate-substituting) implant with anatomic tibial
anatomy and kinematics, allows hand-in-hand design of articular surfaces has been available since 2005, and
femoral and tibial articular surfaces, and incorporates a cruciate-retaining version of the same design was re-
the effect of surgical placement. The resulting biomimetic cently introduced (Figure 6). Positive results regarding
surface has an anatomic profile, including a shallow me- the restoration of normal kinematic patterns have been
dial surface similar to some conventional implants, and reported for the bicruciate-substituting design. One study
a convex lateral plateau with a relatively low anterior reported profiles of the patellar tendon angle and pa-
and minimal posterior lip. Progressive deviations from tellar flexion for the bicruciate-substituting knee to be
the biomimetic geometry resulted in increasingly abnor- more normal than other TKA designs.34 During a deep
mal kinematics during a simulated knee bend.26 In an- knee bend activity, another study measured medial and
other study, a biomimetic cruciate-retaining implant was lateral condyle rollback of 14 and 23 mm, respectively,
found to more closely mimic normal kinematic patterns in bicruciate-substituting knees. Average axial rotation
Figure 7 Illustration depicts motion of the medial and lateral femoral condyles relative to the tibia of a biomimetic
bicruciate-retaining (Biomimetic BCR), contemporary cruciate-retaining (NextGen CR, ZimmerBiomet),
contemporary bicruciate-retaining (TKO BCR, BioPro), and biunicompartmental (MCK Bi-Uni) implants during a
simulated deep knee bend. Unlike the cruciate-retaining implant, contemporary bicruciate-retaining and bi-
unicompartmental implants did not exhibit paradoxical anterior sliding. However, these implants did not restore
normal differential medial and lateral rollback like the biomimetic bicruciate-retaining implant. (Reproduced with
permission from Zumbrunn T, Varadarajan KM, Rubash HE, Malchau H, Li G, Muratoglu OK: Regaining native knee
kinematics following joint arthroplasty: A novel biomimetic design with ACL and PCL preservation. J Arthroplasty
2015;30[12]:2143-2148.)
patterns were similar but lower in magnitude than in can help reduce the risk of bone island failure. Despite
normal knees35 (Figure 6). the aforementioned challenges, some clinical series have
shown excellent long-term outcomes. The clinical aspects
2: Knee
of ACL retention are beyond the scope of this chapter.
ACL Function Patients with bicruciate-retaining implants generally
Currently, three strategies are being explored to incor- have been reported to exhibit more normal kinematics
porate ACL function in TKA: native ACL and PCL re- than patients with ACL-sacrificing implants. However,
tention, ACL substitution and native PCL retention, and a 2015 study noted that the analysis of available kine-
ACL and PCL substitution. matic data shows that contemporary bicruciate-retaining
implants do not fully restore normal kinematics.36 Ab-
ACL and PCL Retention normal early posterior femoral shift and subsequent
Retention of the ACL and PCL during TKA is a concept paradoxical anterior sliding, which are observed with
that was introduced in the 1970s (for example, the Geo- ACL-sacrificing implants, are generally not observed with
medic knee and the anatomic knee). However, ACL and contemporary bicruciate-retaining implants.36,37 How-
PCL retention did not attain widespread acceptance be- ever, as with ACL-sacrificing implants, contemporary
cause of perceived difficulties in balancing both the ACL bicruciate-retaining implants also show symmetric me-
and PCL, concerns regarding the viability of the ACL in dial/lateral condylar rollback, and thus, minimal axial
the arthritic knee, fracture of the tibial bony eminence, rotation.36,37 The 2015 study used dynamic computer
polyethylene wear, and the strength of the tibial base- simulations to compare the kinematics of a biomimetic
plate.36 Many of these challenges were specific to a few bicruciate-retaining design with an anatomic tibial articu-
designs as well as older-generation polyethylene, which lar surface with that of contemporary bicruciate-retaining
was susceptible to oxidative degradation. Avoiding keels and cruciate-retaining implants36 (Figure 7). The bio-
in the tibial baseplate that can weaken the tibial bone is- mimetic bicruciate-retaining implant exhibited kine-
land, minimizing the removal of cortical bone anterior to matics most similar to healthy knees. Another study
the tibial eminence, and avoiding eminence undercutting compared biomimetic bicruciate-retaining and biomimetic
Section 2: Knee
Figure 8 Illustration depicts mean femoral rollback of the medial and lateral condyles during a simulated deep knee bend
for an anterior cruciate ligament (ACL)–substituting and posterior cruciate ligament (PCL)–retaining (ASCR), two
ACL-retaining (BCR-A, BCR-B), and a contemporary cruciate-retaining (CR) TKA. Both the ASCR and ACL-retaining
designs avoided the abnormal early posterior shift and subsequent paradoxical anterior slide that were observed
in the cruciate-retaining implant. (Reproduced with permission from Varadarajan KM, Zumbrunn T, Duffy MP,
Rubash HE, Malchau H, Muratoglu OK: Poster No. 1885. Is retention of native ACL the only option for addressing
abnormal anteroposterior kinematics of cruciate retaining TKA? Proceedings of the 62nd Annual Meeting of the
Orthopaedic Research Society. Rosemont, IL, Orthopaedic Research Society, 2016, p 146.)
cruciate-retaining implants and reported that the absence used dynamic simulations to compare the kinematics of
of the ACL in the cruciate-retaining design resulted in a the ASCR design with ACL-retaining and ACL-sacrificing
more posterior location of the femur and reduced femoral (that is, cruciate-retaining) implants during deep knee
2: Knee
rollback.26 However, restoration of the native articular bend, chair sit, stair ascent, and walking. 39 As with
geometry in the biomimetic cruciate-retaining implant ACL-retaining implants, the ASCR design provides kine-
preserved medial rotation features, which may indicate matic improvements over contemporary ACL-sacrificing
that restoration of the native anatomy together with ACL implants by reducing abnormal early posterior femoral
preservation is required to achieve kinematics close to shift and avoiding paradoxical anterior sliding. However,
those of the native knee.26 this concept has not been evaluated clinically.
ACL Substitution ACL and PCL Substitution

ACL Substitution and PCL Retention In a bicruciate-substituting design, ACL and PCL func-
An alternative to native ACL retention is to substitute its tion are substituted using anterior and posterior cam-post
function to avoid the potential challenges discussed previ- interaction, respectively. The bicruciate-substituting
ously and to provide an option for patients with an absent concept can be considered as an extension of the
or nonfunctional ACL at surgery (approximately 14% to posterior-stabilized philosophy that substitutes not only
75% of patients).38 The concept of an ACL-substituting for the missing PCL but also for the ACL. First-generation
and PCL-retaining implant (ASCR) has been proposed bicruciate-substituting designs were introduced in
recently as an evolution of the cruciate-retaining implant 2005 and showed promising kinematic results. Several
in which the ACL is sacrificed with no mechanism to in vivo studies showed more normal kinematics than
substitute for its function.39 In the ASCR implant, the contemporary TKA, including the magnitude of inter-
anterior surface of a post on the tibia engages with the nal tibial rotation and posterior femoral rollback as
femoral intercondylar notch in low flexion to substitute well as the absence of paradoxical anterior sliding34,35
for the absent ACL (Figure 8). The tibial post also is (Figure 6). Reported rates of clinical complications
designed to accommodate the native PCL. A 2016 study were higher than expected, including dislocation and
iliotibial band syndrome.40,41 These complications seem to during intraoperative impaction were reported. Subse-
be related to insufficient jump height, excessively forced quent analysis showed hard impaction at high velocity and
rollback by posterior cam, and a prominent anterior fem- the femoral resection angle to be likely causes of failure.46
oral flange.42 However, no complications were reported
regarding fracture of the bicruciate-substituting tibial Ceramicized Metals
post or wear of the anatomic tibial articular surface. TKA implants with various ceramic coatings are
Second-generation bicruciate-substituting designs have currently in clinical use, including titanium nitride
been introduced to address these design issues. Additional (TiN) on Ti6Al4V (a grade 5 titanium alloy), TiN on
studies are needed to assess the clinical significance of cobalt-chromium (CoCr), zirconium nitride (ZrN)–coated
these design improvements.42 CoCr, and titanium niobium nitride (TiNbN)–coated
CoCr. Although many preclinical studies indicate favor-
able tribologic properties (for example, high scratch resis-
Implant Materials tance, low coefficient of friction, less UHMWPE wear) of
The most commonly used materials in TKA implants are these ceramic coatings, other studies have not replicated
cobalt-chromium-molybdenum (CoCrMo) alloy for the these findings and concerns have been noted regarding
femoral component, conventional (minimally cross-linked loss of coating and increased wear.47 However, the coating
or non–cross-linked) ultra-high–molecular-weight poly- process may have a substantial effect on coating perfor-
ethylene (UHMWPE) for the tibial insert, and titanium mance. One particular ZrN coating technology uses a top
alloy for the tibial baseplate. However, the pursuit of coat of ZrN, five layers of chromium nitride–chromium
improved implant survivorship via the reduction of poly- carbonitride (CrN-CrCN), and a thin chromium bond
ethylene damage and concerns regarding metal hyper- coat on top of a standard CoCr alloy (overall thickness,
sensitivity have motivated the exploration of alternative 3.5 to 5.0 μm).48 The multilayer coating provides a gra-
materials. Clinical and registry studies continue to mon- dient between the hard coating and the relatively soft sub-
itor the long-term performance of highly cross-linked strate to improve the mechanical integrity of the coating.
UHMWPE, which was introduced in the early 2000s, A 2011 study reported no scratches, pitting, or coating
and newer antioxidant-stabilized polyethylene, which damage during a 3-million-cycle knee simulator study
was introduced in 2008. of a mobile-bearing implant with ZrN-coated metallic
components created with this coating technology.48 A
Bulk Ceramics few recent studies have published clinical performance
Ceramics have several advantages, including reduced data for such ceramic-coated knee implants. A 2015 ret-
2: Knee
coefficient of friction, increased lubricity due to reduced rospective study compared short-term (mean follow-up,
wetting angle, high hardness and abrasion resistance, and 2 years) clinical results for a TiNbN-coated implant with
excellent biocompatibility. In the past 5 years, mid- to CoCr implants of the same design. This study found no
long-term clinical data have been published for several differences in clinical, radiographic, or patient-reported
ceramic TKA implants. One study reported 5-year sur- outcomes, and no patients underwent revision in either
vivorship of 98.6% with no revisions for aseptic loos- group.49 A 2014 retrospective study of 305 TiN-coated
ening, osteolysis, or ceramic fractures for an alumina mobile-bearing implants reported 10-year survivorship
medial-pivot TKA.43 Another study published 10-year of 95.1% with revision for any reason as the end point
clinical results for an alumina ceramic implant that has and 99.1% with revision for aseptic loosening as the end
been used in Japan since 1992.44 At a mean follow-up point.50
of 11.7 years, the mean Knee Society score was 93.3, Oxidized zirconium (OxZr) knee implants were
survivorship with any reoperation or radiographic fail- introduced in 1997.51 Unlike the ceramic coating ap-
ure as an end point was 95.9%, and no fractures of the plied to a metal substrate, OxZr is created via thermal
ceramic femoral component occurred. Another study re- diffusion, which transforms the surface of wrought
ported on the clinical outcomes of a ceramic TKA with zirconium-niobium (2.5% niobium) alloy to a ZrO2
an alumina matrix composite femoral component that (monoclinic) layer approximately 5 μm thick. Although
was strengthened with yttria-stabilized tetragonal zirco- numerous laboratory wear studies have demonstrated
nia particles.45 At 5-year follow-up, implant survivorship a reduction in polyethylene wear with OxZr versus
was 96.0%, with no implant migration or loosening. In CoCr femoral components (range, 42% to 85%), until
one case, a midline longitudinal crack was noted on the recently, in vivo data have been lacking.51 That recent
ceramic femoral component following a traumatic event, retrieval study found significantly lower femoral com-
and two fractures of the femoral component that occurred ponent roughness as well as lower damage scores for
Section 2: Knee
both femoral components and polyethylene inlays with following TKA. However, such new implant designs do
OxZr compared with matched paired CoCr TKAs.51 A not preclude the importance of surgical technique. Tech-
2011 study published results of a randomized controlled niques designed to facilitate more normal collateral lig-
trial with patients with bilateral TKA who received a ament function via anatomic joint line restoration may
CoCr femoral implant in one knee and an OxZr im- play a crucial role in achieving normal knee function
plant in the contralateral knee.52 At 5-year follow-up, no following TKA.
significant differences were reported between the two Several materials continue to be evaluated as an al-
groups regarding mean Knee Injury and Osteoarthritis ternative to CoCrMo alloy. Bulk ceramics and oxidized
Outcome Scores or radiologic evaluation findings. In a zirconia have demonstrated excellent mid- to long-term
retrospective review of 109 OxZr TKAs performed in outcomes and may be viable options for patients with
82 patients with a mean follow-up of 5.9 years, no revi- suspected metal hypersensitivity. Early clinical results of
sions were performed for wear, loosening, osteolysis, or ceramic-coated metal seem to be positive, but more clini-
infection.53 The mean Knee Society score was 92 points cal data are needed to determine whether ceramic-coated
(range, 49 to 100 points) and the mean function score was metals are a cost-effective alternative.
81 points (range, 30 to 100 points). A 2014 study reported
10-year results of a prospective study for 84 patients at
Key Study Points
final follow-up.54 Overall survivorship was 97.8%; two
knees needed revision for femoral component loosen- • Both anatomic articular geometry and ACL func-
ing. The mean knee score was 84 points (range, 64 to tion (via retention or substitution) may be required
100 points) and the mean function score was 83 points to restore normal knee kinematics following TKA.
(range, 55 to 100 points). • Anatomic joint line restoration via the appropriate
positioning of standard implants or implants with
Summary asymmetric thicknesses may facilitate more normal
soft-tissue function.
Implant design has a major influence on both short- and
• All-polyethylene tibial components have been shown
long-term outcomes following TKA. Important issues
to have long-term clinical outcomes equivalent to
pertaining to implant geometry and materials are cur-
those of metal-backed components.
rently being debated, and new technologies are under
• OxZr and bulk ceramics are alternatives to CoCr
investigation.
that have excellent mid- to long-term survivorship
Available evidence does not indicate superiority of
2: Knee
and favorable clinical outcomes.

single-radius or multiradius femoral designs in relation
to clinical outcomes. Anatomic tibial trays may offer
only a slight advantage for increased tibial coverage;
however, they could reduce the probability of internal
Annotated References
rotation if attainment of maximal tibial coverage is used
to guide tray placement. Cost advantages coupled with
equivalent outcomes to metal-backed components could 1. Noble PC, Gordon MJ, Weiss JM, Reddix RN, Conditt
MA, Mathis KB: Does total knee replacement restore
increase the use of all-polyethylene tibial components.
normal knee function? Clin Orthop Relat Res 2005;431:
PCL-retaining (cruciate-retaining), PCL-substituting 157-165. Medline DOI
(posterior-stabilized), and PCL-sacrificing (ultracongru-
ent) designs seem to have similar clinical outcomes and 2. Larsen B, Jacofsky MC, Jacofsky DJ: Quantitative, com-
long-term survivorship. However, the high anterior tibial parative assessment of gait between single-radius and
multi-radius total knee arthroplasty designs. J Arthro-
lips in ultracongruent designs may not fully compensate plasty 2015;30(6):1062-1067. Medline DOI
for PCL function, resulting in increased anterior femoral
sliding. This study compared gait analysis, electromyography,
and patient-reported outcome measures in patients who
Contemporary implants show significant kinematic underwent single-radius and multiradius TKA with those
alterations relative to the preoperative and normal knee, of healthy control patients. Decreased power absorption
which may partly explain the similar patient outcomes and increased knee extension were noted in the multira-
observed with cruciate-retaining, posterior-stabilized, dius group, but no functional differences were detected
in outcome measures. Level of evidence: II.
and ultracongruent designs. Provision of anatomic or
biomimetic articular surfaces together with ACL retention
or substitution may be key to restoring normal kinematics
3. Hinarejos P, Puig-Verdie L, Leal J, et al: No differences in 9. Matsuda S, Miura H, Nagamine R, Urabe K, Hirata G,
functional results and quality of life after single-radius or Iwamoto Y: Effect of femoral and tibial component posi-
multiradius TKA. Knee Surg Sports Traumatol Arthrosc tion on patellar tracking following total knee arthroplasty:
2015 [Epub ahead of print]. Medline DOI 10-year follow-up of Miller-Galante I knees. Am J Knee
Surg 2001;14(3):152-156. Medline
This prospective study demonstrates no significant differ-
ences between single-radius and multiradius TKA groups
at 1- or 5-year follow-up for Knee Society scores (knee, 10. Dossett HG, Estrada NA, Swartz GJ, LeFevre GW, Kwas-
function, or total), Medical Outcomes Study 36-Item Short man BG: A randomised controlled trial of kinematically
Form physical scores, postoperative ROM, or patient sat- and mechanically aligned total knee replacements: Two-
isfaction. Level of evidence: II. year clinical results. Bone Joint J 2014;96-B(7):907-913.
Medline DOI
4. Liu S, Long H, Zhang Y, Ma B, Li Z: Meta-analysis of This randomized controlled trial compared the results of
outcomes of a single-radius versus multi-radius femoral de- mechanically aligned versus kinematically aligned TKAs
sign in total knee arthroplasty. J Arthroplasty 2016;31(3): in 88 patients. Function, ROM, and pain improvement
646-654. Medline DOI scores were superior among patients with kinematically
aligned TKAs 2 years postoperatively. Level of evidence: I.
This meta-analysis incorporated data from 15 studies
comparing single-radius and multiradius TKA designs.
No differences were found between the groups in Knee 11. Dai Y, Scuderi GR, Bischoff JE, Bertin K, Tarabichi S,
Society scores, complications, knee flexion, isometric peak Rajgopal A: Anatomic tibial component design can in-
torque, and survivorship; however, decreased ROM was crease tibial coverage and rotational alignment accuracy:
noted for single-radius knees. Level of evidence: II. A comparison of six contemporary designs. Knee Surg
Sports Traumatol Arthrosc 2014;22(12):2911-2923.
Medline DOI
5. Cherian JJ, Kapadia BH, Banerjee S, Jauregui JJ, Issa K,
Mont MA: Mechanical, anatomical, and kinematic axis This study examined 479 healthy tibiae in Asian and Cau-
in TKA: Concepts and practical applications. Curr Rev casian patients. Compared with asymmetric and symmet-
Musculoskelet Med 2014;7(2):89-95. Medline DOI ric designs, the anatomic tibial tray design demonstrated
better conformity and tibial coverage, and less downsizing
This review provides an overview of alignment strategies to ensure rotational alignment. Level of evidence: III.
in TKA and discusses the implications for outcome. Level
of evidence: V.
12. Stulberg SD, Goyal N: Which tibial tray design achieves
maximum coverage and ideal rotation: Anatomic, sym-
6. Babazadeh S, Dowsey MM, Swan JD, Stoney JD, Choong metric, or asymmetric? An MRI-based study. J Arthro-
PF: Joint line position correlates with function after pri- plasty 2015;30(10):1839-1841. Medline DOI
mary total knee replacement: A randomised controlled
trial comparing conventional and computer-assisted This MRI-based study of 100 knees evaluated three
surgery. J Bone Joint Surg Br 2011;93(9):1223-1231. different tibial tray designs: anatomic, symmetric, and
2: Knee
Medline DOI asymmetric. Equivalent coverage was observed across the
three tibial tray designs; however, the anatomic tibial tray
This randomized controlled trial compared joint line required less malrotation to maximize coverage. Level of
maintenance and outcomes between patients undergoing evidence: III.
computer-assisted and conventional TKA. No significant
difference in joint line maintenance was found between
the techniques. However, TKAs with a depressed joint im- 13. Clary C, Aram L, Deffenbaugh D, Heldreth M: Tibial
proved the least in functional scores. Level of evidence: I. base design and patient morphology affecting tibial cov-
erage and rotational alignment after total knee arthro-
plasty. Knee Surg Sports Traumatol Arthrosc 2014;22(12):
7. Delport H, Labey L, De Corte R, Innocenti B, Vander 3012-3018. Medline DOI
Sloten J, Bellemans J: Collateral ligament strains during
knee joint laxity evaluation before and after TKA. Tibial anthropometric measurements for 14,791 patients
Clin Biomech (Bristol, Avon) 2013;28(7):777-782. who underwent TKA were compared across four commer-
Medline DOI cial tibial tray designs. All designs provided similar bone
coverage. Rotating the tibial tray to maximize coverage did
This study compared medial collateral ligament and lateral not significantly increase coverage but induced variability
collateral ligament strains in six cadaver knees before and in tray alignment. Level of evidence: III.
after posterior-stabilized TKA. Strain was significantly
different before and after TKA at some but not all points
measured throughout the flexion arc. Level of evidence: V. 14. Voigt J, Mosier M: Cemented all-polyethylene and met-
al-backed polyethylene tibial components used for primary
total knee arthroplasty: A systematic review of the liter-
8. Gromov K, Korchi M, Thomsen MG, Husted H, Tro- ature and meta-analysis of randomized controlled trials
elsen A: What is the optimal alignment of the tibial and involving 1798 primary total knee implants. J Bone Joint
femoral components in knee arthroplasty? Acta Orthop Surg Am 2011;93(19):1790-1798. Medline DOI
2014;85(5):480-487. Medline DOI
This systematic review and meta-analysis of 1,798 pa-
An overview of alignment strategies in TKA is provided tients who underwent TKA from 12 studies reported no
and implications on outcome are discussed. Level of significant differences in revision or radiographic failure
evidence: III.
Section 2: Knee
between all-polyethylene and metal-backed components outcomes were noted between PCL retention and sacrifice.
at 2-, 10-, or 15-year follow-up. No functional difference Level of evidence: II.
was identified. Level of evidence: I.
21. Iwamoto K, Tomita T, Yamazaki T, et al.: Comparison
15. Nouta KA, Verra WC, Pijls BG, Schoones JW, Nelis- of in vivo kinematics of total knee arthroplasty between
sen RG: All-polyethylene tibial components are equal to cruciate retaining and condylar stabilized insert. Ortho-
metal-backed components: Systematic review and meta- paedic Proceedings 2014;96-B(suppl 11):167.
regression. Clin Orthop Relat Res 2012;470(12):3549-
3559. Medline DOI The in vivo kinematics of Triathlon cruciate-retaining
implants (10 knees) and cruciate-stabilizing insert implants
This meta-analysis included 26 articles with more than (10 knees) were evaluated during deep knee bending.
12,500 patients who underwent TKA and reported no Cruciate-stabilizing knees showed significantly greater
differences in revision rates, functional outcomes, ROM, medial anterior translation, indicating that the increased
or alignment between the all-polyethylene and metal-back anterior lip could not fully control anterior sliding. Level
components, except for higher component migration in of evidence: III.
the metal-backed group. Level of evidence: I.
22. Kim TW, Lee SM, Seong SC, Lee S, Jang J, Lee MC:
16. Mohan V, Inacio MC, Namba RS, Sheth D, Paxton EW: Different intraoperative kinematics with comparable
Monoblock all-polyethylene tibial components have clinical outcomes of ultracongruent and posterior stabi-
a lower risk of early revision than metal-backed mod- lized mobile-bearing total knee arthroplasty. Knee Surg
ular components. Acta Orthop 2013;84(6):530-536. Sports Traumatol Arthrosc 2015 [Epub ahead of print].
Medline DOI Medline DOI
This study examined a large community-based total In this randomized controlled study, the intraoperative
joint registry of 27,657 patients undergoing TKA with kinematics and clinical outcomes (3-year follow-up)
the same implant (91.7% were metal-backed; 8.3% were were compared for mobile ultracongruent and mobile
all-polyethylene). The revision rate for all etiologies was posterior-stabilized TKAs. Ultracongruent knees showed
lower for the all-polyethylene group than for the metal- greater paradoxical anterior translation, but no difference
backed group (1.95% versus 2.17%; P < 0.001). Level of in clinical outcomes was detected between groups. Level
evidence: III. of evidence: II.
17. Gudnason A, Hailer NP, W-Dahl A, Sundberg M, Rob- 23. Lützner J, Firmbach FP, Lützner C, Dexel J, Kirschner S:
ertsson O: All-Polyethylene Versus Metal-Backed Tibial Similar stability and range of motion between cruciate-re-
Components-An Analysis of 27,733 Cruciate-Retaining taining and cruciate-substituting ultracongruent insert
Total Knee Replacements from the Swedish Knee Ar- total knee arthroplasty. Knee Surg Sports Traumatol Ar-
throplasty Register. J Bone Joint Surg Am 2014;96(12): throsc 2015;23(6):1638-1643. Medline DOI
Intraoperative stability and ROM were compared before
2: Knee
This study examined patients who underwent TKA with and after TKA with cruciate-retaining or ultracongru-
metal-backed (57.7%) or all-polyethylene (42.3%) tibial ent inserts. Stability and ROM were similar between the
components at a median follow-up of 4.5 years. All-poly- two insert types, and both showed significant increases
ethylene tibial components had superior 10-year survival, in postoperative anterior-posterior translation in flexion.
reduced risk of revision for any reason, and reduced risk Level of evidence: II.
of revision because of infection. Level of evidence: III.
24. Massin P, Boyer P, Sabourin M: Less femorotibial rotation
18. Gioe TJ, Sinner P, Mehle S, Ma W, Killeen KK: Ex- and AP translation in deep-dished total knee arthroplasty.
cellent survival of all-polyethylene tibial components An intraoperative kinematic study using navigation. Knee
in a community joint registry. Clin Orthop Relat Res Surg Sports Traumatol Arthrosc 2012;20(9):1714-1719.
2007;464(464):88-92. Medline Medline DOI
This study tested the intraoperative kinematics of 10 knees
19. Pomeroy DL, Schaper LA, Badenhausen WE, et al: Re- replaced with hypercongruent inserts. Significant changes
sults of all-polyethylene tibial components as a cost-saving in kinematics relative to the nonsurgical condition were
technique. Clin Orthop Relat Res 2000;380:140-143. detected, including abnormal posterior location at full
Medline DOI extension, reduced rollback, and persistent forward rolling
on the medial side. Level of evidence: II.
20. Verra WC, van den Boom LG, Jacobs W, Clement DJ,
Wymenga AA, Nelissen RG: Retention versus sacrifice of 25. Argenson JN, Boisgard S, Parratte S, et al; French Society
the posterior cruciate ligament in total knee arthroplasty of Orthopedic and Traumatologic Surgery (SOFCOT):
for treating osteoarthritis. Cochrane Database Syst Rev Survival analysis of total knee arthroplasty at a mini-
2013;10(10):CD004803. Medline mum 10 years’ follow-up: A multicenter French nationwide
This study used systematic review and meta-analysis of study including 846 cases. Orthop Traumatol Surg Res
randomized and quasirandomized controlled trials to com- 2013;99(4):385-390. Medline DOI
pare PCL retention and sacrifice in TKA. No clinically
relevant differences in ROM, pain, clinical, or radiologic
This retrospective study assessed 826 TKA patients. Most 32. Lew WD, Lewis JL: The effect of knee-prosthesis geometry
TKAs sacrificed the PCL (65% posterior-stabilized versus on cruciate ligament mechanics during flexion. J Bone
35% ultracongruent): 10-year TKA survivorship was 92% Joint Surg Am 1982;64(5):734-739. Medline
independent of the design and level of mechanical stress.
Revision was mainly performed for infection or loosening. 33. Varadarajan KM, Zumbrunn T, Rubash HE, Malchau
Level of evidence: IV. H, Li G, Muratoglu OK: Cruciate retaining implant
with biomimetic articular surface to reproduce activity
26. Varadarajan KM, Zumbrunn T, Rubash HE, Malchau dependent kinematics of the normal knee. J Arthroplasty
H, Muratoglu OK, Li G: Reverse engineering nature 2015;30(12):2149-53. Medline DOI
to design biomimetic total knee implants. J Knee Surg
2015;28(5):363-369. Medline DOI In this study, simulated kinematics of a cruciate-retaining
implant with an anatomic (biomimetic) articular surface
This report described a novel design process to create were compared with those of contemporary cruciate-
biomimetic tibial articular surfaces directly from the in retaining implants. The biomimetic implant more closely
vivo kinematics of normal knees. Geometric comparisons mimicked normal kinematic patterns than contemporary
and kinematic simulations are used to demonstrate the cruciate-retaining implants across different simulated ac-
role of articular geometry in the restoration of normal tivities. Level of evidence: V.
kinematics. Level of evidence: V.
34. van Duren BH, Pandit H, Price M, et al: Bicruciate substi-
27. Li JS, Hosseini A, Cancre L, Ryan N, Rubash HE, Li tuting total knee replacement: How effective are the added
G: Kinematic characteristics of the tibiofemoral joint kinematic constraints in vivo? Knee Surg Sports Trauma-
during a step-up activity. Gait Posture 2013;38(4): tol Arthrosc 2012;20(10):2002-2010. Medline DOI
The in vivo kinematics of 10 Journey bicruciate-substitut-
The in vivo kinematics of 21 healthy subjects were eval- ing knees were compared with that of 20 normal knees.
uated using biplanar fluoroscopy during step-up activity. The Journey knees showed no paradoxical anterior move-
Medial-pivot motion was not observed during this activity. ment, and the patellar tendon angle and patellar flexion
Mean (±SD) medial and lateral tibiofemoral contact points profiles were more normal than other TKA designs. Level
moved almost equally with knee extension (13.5 ± 3.2 and of evidence: III.
10.7 ± 5.0 mm, respectively). Level of evidence: IV.
35. Victor J, Mueller JK, Komistek RD, Sharma A, Nadaud
28. Johal P, Williams A, Wragg P, Hunt D, Gedroyc W: MC, Bellemans J: In vivo kinematics after a cruciate-
Tibio-femoral movement in the living knee. A study of substituting TKA. Clin Orthop Relat Res 2010;468(3):
weight bearing and non-weight bearing knee kinemat- 807-814. Medline DOI
ics using ‘interventional’ MRI. J Biomech 2005;38(2):
269-276. Medline DOI 36. Zumbrunn T, Varadarajan KM, Rubash HE, Malchau
H, Li G, Muratoglu OK: Regaining native knee kine-
29. Shimmin A, Martinez-Martos S, Owens J, Iorgulescu matics following joint arthroplasty: A novel biomimetic
2: Knee
AD, Banks S: Fluoroscopic motion study confirming the design with ACL and PCL preservation. J Arthroplasty
stability of a medial pivot design total knee arthroplasty. 2015;30(12):2143-2148. Medline DOI
Knee 2015;22(6):522-526. Medline DOI
Computer simulations were used to compare the kine-
In vivo kinematics during pivoting, kneeling, lunge, and matics of a bicruciate-retaining TKA with an anatomic
step-up/-down activities were studied using fluoroscopy (biomimetic) articular surface with that of contempo-
in 14 patients who underwent TKA. Observed kinematics rary bicruciate-retaining and cruciate-retaining implants.
were similar in pattern but smaller in magnitude compared Restoration of native knee geometry together with ACL
with normal knees. No paradoxical anterior motion was preservation provided kinematic patterns closest to normal
observed for any activity. Level of evidence: IV. knees. Level of evidence: V.
30. Barnes CL, Blaha JD, DeBoer D, Stemniski P, Obert R, 37. Stiehl JB, Komistek RD, Cloutier JM, Dennis DA: The
Carroll M: Assessment of a medial pivot total knee ar- cruciate ligaments in total knee arthroplasty: A kinematic
throplasty design in a cadaveric knee extension test model. analysis of 2 total knee arthroplasties. J Arthroplasty
J Arthroplasty 2012;27(8):1460-1468. Medline DOI 2000;15(5):545-550. Medline DOI
Knee extension kinematics of medial-pivot TKAs were
evaluated in cadaver knees. Tibiofemoral rotation and 38. Johnson AJ, Howell SM, Costa CR, Mont MA: The ACL
translation were similar in direction but reduced in mag- in the arthritic knee: How often is it present and can pre-
nitude for prosthetic knees compared with intact knees. operative tests predict its presence? Clin Orthop Relat
Quadriceps force was not statistically different between Res 2013;471(1):181-188. Medline DOI
prosthetic and intact knees. Level of evidence: V. In this study, ACL integrity was evaluated using the Lach-
man test in 200 patients who underwent TKA and in
31. Koo S, Andriacchi TP: The knee joint center of rotation is 100 patients using MRI. The ACL was intact in 78% of
predominantly on the lateral side during normal walking. knees. The Lachman test alone had poor sensitivity; when
J Biomech 2008;41(6):1269-1273. Medline DOI combined with MRI, sensitivity of 93.3% and specificity
of 99% were attained. Level of evidence: IV.
Section 2: Knee
39. Varadarajan KM, Zumbrunn T, Duffy MP, Rubash HE, 44. Nakamura S, Kobayashi M, Ito H, Nakamura K, Ueo
Malchau H, Muratoglu OK: Poster No. 1885. Is retention T, Nakamura T: The Bi-Surface total knee arthroplasty:
of native ACL the only option for addressing abnormal Minimum 10-year follow-up study. Knee 2010;17(4):
anteroposterior kinematics of cruciate retaining TKA? In: 274-278. Medline DOI
Proceedings of the 62nd Annual Meeting of the Ortho-
paedic Research Society; March 5-8, 2016; Orlando, FL. 45. Bergschmidt P, Bader R, Ganzer D, et al: Prospective
Rosemont, IL, Orthopaedic Research Society, p 146. multi-centre study on a composite ceramic femoral
This study compared the simulated kinematics of an ASCR component in total knee arthroplasty: Five-year clinical
design with an ACL-sacrificing cruciate-retaining implant and radiological outcomes. Knee 2015;22(3):186-191.
and ACL-retaining bicruciate-retaining implant. The re- Medline DOI
sults showed that the ACL substitution mechanism could Clinical and radiologic assessments were performed for
successfully replicate the kinematic function of the ACL 107 TKA patients with Multigen-Plus ceramic knees.
across different activities. Level of evidence: V. Nonprogressive radiolucent lines were observed around
the femoral component in four cases. Neither implant
40. Christen B, Neukamp M, Aghayev E: Consecutive series migration nor loosening was registered. Kaplan-Meier sur-
of 226 journey bicruciate substituting total knee replace- vivorship was 96.0% at 60 months. Level of evidence: IV.
ments: Early complication and revision rates. BMC Mus-
culoskelet Disord 2014;15:395. Medline DOI 46. Kluess D, Bergschmidt P, Mueller I, Mittelmeier W, Bader
Complication and revision rates in 226 Journey bicruciate- R: Influence of the distal femoral resection angle on the
substituting TKA patients were studied (average implan- principal stresses in ceramic total knee components. Knee
tation time, 3.5 years): 33 complications in 25 patients 2012;19(6):846-850. Medline DOI
(14.6%) required minor or major revision. Caution was This study used finite-element analysis to evaluate the
advised for less-experienced surgeons using this implant. influence of distal femur preparation on stresses within
Level of evidence: IV. a ceramic femoral component. A deviation of 3° from
the intended resection angle was shown to cause critical
41. Arnout N, Vandenneucker H, Bellemans J: Posterior dis- stresses, thus underscoring the importance of precise fem-
location in total knee replacement: A price for deep flex- oral resection. Level of evidence: V.
ion? Knee Surg Sports Traumatol Arthrosc 2011;19(6):
911-913. Medline DOI 47. van Hove RP, Sierevelt IN, van Royen BJ, Nolte PA: Ti-
In this study, four cases of posterior dislocation were de- tanium-nitride coating of orthopaedic implants: A review
scribed for patients with Journey bicruciate-substituting of the literature. Biomed Res Int 2015;2015:485975.
TKAs. The authors concluded that specific design features Medline DOI
contributed to higher-than-expected dislocation rates. This review discussed preclinical studies and clinical out-
Level of evidence: IV. comes of TiN-coated implants. Although TiN coating was
reported to have positive effects on biocompatibility and
2: Knee
42. Halewood C, Risebury M, Thomas NP, Amis AA: Kine- tribology, several cases of third-body wear were reported
matic behaviour and soft tissue management in guided as a result of delamination and cohesive failure of the TiN
motion total knee replacement. Knee Surg Sports Trau- coating. Level of evidence: V.
matol Arthrosc 2014;22(12):3074-3082. Medline DOI
Ligament length changes and tibiofemoral kinematics were 48. Affatato S, Spinelli M, Lopomo N, Grupp TM, Marcacci
evaluated in cadaver knees with three TKAs: Journey M, Toni A: Can the method of fixation influence the wear
bicruciate-substituting, Journey II bicruciate-substituting, behaviour of ZrN coated unicompartmental mobile knee
and Genesis II posterior-stabilized implants. The results prostheses? Clin Biomech (Bristol, Avon) 2011;26(2):152-
supported the hypothesis that increased internal rotation 158. Medline DOI
and rollback in the original Journey bicruciate-substituting Knee simulator wear tests were conducted for a multilayer
system caused excessive soft-tissue tightening. Level of ZrN-coated mobile-bearing unicompartmental prosthesis.
evidence: V. No loss of coating was observed following 3 million test
cycles. Both new and tested components showed macro-
43. Iida T, Minoda Y, Kadoya Y, et al: Mid-term clinical pores and micropores, which were likely created by the
results of alumina medial pivot total knee arthroplasty. coating process. Level of evidence: V.
Knee Surg Sports Traumatol Arthrosc 2012;20(8):
1514-1519. Medline DOI 49. Thienpont E: Titanium niobium nitride knee implants
The clinical results of 107 alumina medial-pivot TKAs are not inferior to chrome cobalt components for pri-
were evaluated at a mean follow-up of 5 years. Significant mary total knee arthroplasty. Arch Orthop Trauma Surg
improvements in Knee Society scores and postoperative 2015;135(12):1749-1754. Medline DOI
ROM were noted. No knees exhibited aseptic loosening, This retrospective study compared 40 TiNbN-coated
osteolysis, or ceramic fractures. Survivorship was 98.6%. TKAs with 80 conventional CoCr implants at a mean
Level of evidence: IV. follow-up of 2 years. No differences in clinical, radio-
logic, or patient-reported outcomes were observed. No
patients had been revised as of the last evaluation. Level This study reported on 40 consecutive patients who un-
of evidence: IV. derwent bilateral cruciate-retaining TKA with an OxZr
femoral component in one knee and CoCr component in
50. Mohammed A, Metcalfe A, Woodnutt D: Medium-term the contralateral knee. No significant differences were
outcome of titanium nitride, mobile bearing total knee reported in clinical, subjective, or radiographic outcomes
replacement. Acta Orthop Belg 2014;80(2):269-275. at 5-year follow-up. Level of evidence: I.
Medline
53. Hofer JK, Ezzet KA: A minimum 5-year follow-up of an
This retrospective study examined the outcomes of oxidized zirconium femoral prosthesis used for total knee
305 TiN-coated mobile-bearing TKAs. The 10-year sur- arthroplasty. Knee 2014;21(1):168-171. Medline DOI
vival with revision for any reason as the end point was
95.1%, and with revision for aseptic loosening as the end This study retrospectively reviewed 109 TKAs in 82 pa-
point was 99.1%. Level of evidence: IV. tients at minimum follow-up of 5 years. Survivorship free
of bearing-related complications was 100%. No revisions
51. Schüttler KF, Efe T, Heyse TJ, Haas SB: Oxidized zirco- were reported for loosening, osteolysis, implant failure,
nium bearing surfaces in total knee arthroplasty: Lessons or deep infection. Level of evidence: IV.
learned. J Knee Surg 2015;28(5):376-381. Medline DOI
54. Innocenti M, Matassi F, Carulli C, Nistri L, Civinini R:
This review of both in vitro and in vivo studies evaluated Oxidized zirconium femoral component for TKA: A fol-
the performance of oxidized zirconium TKAs and the low-up note of a previous report at a minimum of 10 years.
results from retrieval analyses. Level of evidence: V. Knee 2014;21(4):858-861. Medline DOI
52. Hui C, Salmon L, Maeno S, Roe J, Walsh W, Pinczewski This prospective study reported 10-year outcomes for
L: Five-year comparison of oxidized zirconium and co- 94 patients with oxidized zirconium TKA. Survivorship
balt-chromium femoral components in total knee arthro- was 97.8% at 10 years. Two knees were revised for asep-
plasty: A randomized controlled trial. J Bone Joint Surg tic loosening of the femoral component. No other major
Am 2011;93(7):624-630. Medline DOI complications were observed clinically or radiologically.
Level of evidence: IV.
2: Knee
Chapter 11
Special Considerations in Primary

Total Knee Arthroplasty
Andrew B. Old, MD William J. Long, MD, FRCSC W. Norman Scott, MD, FACS
The number of total knee arthroplasties is projected to Total knee arthroplasty (TKA) is routinely performed
increase annually. Two patient groups, young patients across the United States in a range of hospital settings,
(age 55 years and younger) and patients with obesity, including large academic institutions, small community
will contribute most to that number. Both groups have hospitals, and increasingly, outpatient surgicenters. A
unique surgical challenges and should be given special large percentage of the TKAs are performed by practi-
consideration before total knee arthroplasty is per- tioners who are not fellowship trained in adult reconstruc-
formed. Concerns regarding early failure secondary to tion. Despite being commonplace, TKA in certain patient
aseptic loosening, infection, and implant positioning cohorts requires special consideration. Young patients
should prompt the surgeon to counsel patients pre- and obese patients are susceptible to complications such
operatively and maximize outcomes in the operating as early aseptic loosening or infection. Technical tips are
room by means of thorough planning. Proper implant available to maximize results in these difficult patient
positioning and fixation are essential for a successful cohorts.
outcome.
TKA in Young Patients
2: Knee
Keywords: obesity; young patient; total knee The rate of TKAs is expected to increase dramatically,
arthroplasty; infection; aseptic loosening; and a higher percentage of these patients will be catego-
malalignment rized as young, usually defined as age 55 years or younger.
By 2030, primary TKAs in the United States are projected
to increase by 637% and revisions by 601% compared
with numbers reported in 2005.1 Similar trends have been
observed in the United Kingdom and New Zealand, sug-
gesting that these are international phenomena.2,3 With
Dr. Long or an immediate family member is a member of a these staggering projections and the financial burden to
speakers’ bureau or has made paid presentations on behalf the healthcare system, the young patient undergoing TKA
of Pacira Pharmaceuticals; serves as a paid consultant to requires special consideration.
Biomet, Ortho Development, and Pacira Pharmaceuticals; Young patients generally will place higher physical
and serves as a board member, owner, officer, or committee demands on their implants. Although constant improve-
member of the American Academy of Orthopaedic Sur- ments have been made in prosthetics and implants overall,
geons. Dr. Scott is a previous royalty-bearing designer for the same implants initially designed for low-demand,
Zimmer; serves as a paid consultant to the Board of Trustees somewhat frail community ambulators are now expected
for Ortho Development; and serves as the President of the to withstand the high demands of the younger patient.
International Congress for Joint Reconstruction. Neither Expectations are much higher than simply pain relief
Dr. Old nor any immediate family member has received and the renewed ability to walk on level ground, climb
anything of value from or has stock or stock options held stairs, and perhaps engage in light activity. The original
in a commercial company or institution related directly or Knee Society scoring system assessed only the patient’s
indirectly to the subject of this chapter. ability to walk and climb stairs and was later modified
Section 2: Knee
to accommodate patients’ expanded expectations.4 The A 2014 study10 evaluated the increased revision rate for
young patient’s expectations now include strenuous ac- TKA secondary to infection in young patients and re-
tivity and higher impact sports and recreation, and they ported that patients younger than 50 years underwent
are reflected in the updated Knee Society scoring system.5 revision TKA because of infection at approximately twice
Despite these higher expectations, young patients may the rate of patients age 65 years or older (1.36% versus
report greater residual symptoms following TKA. A na- 0.73% incidence). This result excludes patients with in-
tional multicenter study6 assessed 661 young patients flammatory arthritis, who have a higher rate of infection.
(mean age, 54 years) regarding residual symptoms and The study also noted male sex and African American
daily functional deficits. Although 89% of young patients race as independent risk factors for infection. Congestive
were satisfied with their ability to perform activities of heart failure, obesity, psychosis, and diabetes were all
daily living, 33% reported pain, 41% reported stiffness, comorbidities that independently increased the risk of
33% reported swelling, and 38% and 31% reported diffi- periprosthetic infections. Reasons for increased rates of
culties getting in and out of a car and a chair, respectively. infection in young patients can be a result of patients in
More than one-half of young patients reported difficulty this group having a higher percentage of posttraumatic
navigating stairs. Given this outcome, the surgeon must arthritis or more surgical attempts at joint preservation
manage patients’ expectations preoperatively and counsel (such as multiple injections, arthroscopies, or meniscal
them appropriately regarding the goals of care. allografts).7
Along with higher expectations and greater residual
symptoms, the young patient also requires the implant Aseptic Loosening
to last longer to avoid revision arthroplasty. Currently, The literature has shown that young patients also have a
the likelihood is much greater that the implant will not higher rate of aseptic loosening. A 2014 study reported
outlive the recipient,7 so the primary TKA should last that revision for aseptic mechanical failure was 1.15% but
for as long as possible. At 10-year follow-up, researchers increased to 3.49% for those younger than 50 years and
found that patients younger than 47 years at the time of decreased to 0.75% for those 65 years or older.9 Aseptic
their index TKA were twice as likely to require a revision loosening has been reported to account for 27% of early
as they were to die. Patients approximately 58 years old failures. Early aseptic revisions have been performed for
at the time of their index TKA had a 50:50 likelihood of loosening, continued pain, poor range of motion, and
requiring revision versus dying. Patients approximately instability.7 Given the poor performance of revision pro-
62 years or older at the time of their index TKA were more cedures in the young patient cohort, the surgeon must
likely to die within 10 years before requiring revision.7 clearly delineate the diagnosis and the reason a revision
2: Knee
Given the increased demands on the prosthesis, the will resolve the patient’s problem. Persistent pain with-
young patient population would be expected to expe- out a clear cause is a poor indication for revision TKA
rience loosening of their implants over time; however, and will likely result in patient dissatisfaction after the
prostheses seem to be failing even earlier than would be procedure.
expected.8 Generally, osteolysis resulting from polyeth-
ylene wear particles would cause loosening, but evidence Success in the Young Cohort
suggests that TKAs performed in young patients are fail- Some investigators have documented good success rates
ing before obvious polyethylene wear occurs. One study and longevity with their younger patient cohorts.11,12 The
retrospectively compared a cohort of patients younger findings of an ongoing longitudinal outcome study showed
than 50 years with a matched cohort of patients age 60 to that overall survivorship without revision for any cause
70 years9 and determined the etiology of failure for the after 30 years was 70.1%, and the survivorship for tibial
index procedure and any subsequent revisions that were or femoral loosening was 82.5%.11 The mean Hospi-
performed. The mean time from the initial TKA to the tal for Special Surgery score improved from 57.9 points
first revision in the younger cohort was 36 months (range, preoperatively to 85.3 points at 30-year follow-up. The
1 to 210 months) compared with 59 months (range, 1 to mean Knee Society score was 87.4, and the mean func-
230 months) in the older cohort. Essentially, TKA failure tional Knee Society score was 62.1. The mean Tegner
occurred in a shorter time frame in younger patients. and Lysholm activity score improved from 1.5 points
preoperatively to 3.0 points postoperatively.
Infection A literature review that included 908 TKAs in 671 pa-
Infection has been reported as the second major cause tients12 reported that implant survivorship was between
of early revision TKA in the young patient population 90.6% and 99.0% during the first decade in patients
(after aseptic loosening),9 comprising 23% of failures. younger than 55 years. This decreased to between 85.0%
Chapter 11: Special Considerations in Primary Total Knee Arthroplasty
and 96.5% during the second decade. Patients showed Table 1

functional improvement, with the mean Knee Society clin-
ical and functional scores improving by 47 and 37 points, Body Mass Index Classification
respectively. Body Mass
Classification Index (kg/m2)
TKA in Patients With Obesity Underweight <18
Normal weight 18.0–24.9
Obesity has now reached epidemic proportions, with
slightly more than one-third of adults in the United Overweight 25.0–29.9
States being classified as having obesity.13 Patients pre- Obesity class I: obese 30.0–34.9
senting to an orthopaedic clinic for osteoarthritis are Obesity class II: severely obese 35.0–39.9
more likely to have obesity than persons in the general Obesity class III: morbidly obese 40.0–40.9
population.14 The consequences of obesity to a person’s
Super obese ≥50
general health are well documented, as are the subsequent
increases in healthcare costs.15-18 In addition, improvement
in body mass index (BMI) may not return these patients
to baseline risk levels.19 Studies show that obese patients handling, surgical exposure, implant alignment, and
are at higher risk for overall complications, 20 including postoperative rehabilitation.
infection,18,21,22 respiratory complications, poor wound
healing,17 malalignment, and suboptimal component po- Infection
sitioning,16 and that obesity is an independent risk factor Patients with obesity are at higher risk for the develop-
for revision TKA.23 In patients who had already under- ment of infection21 because of several factors: increased
gone revision TKA, those with a BMI higher than 40 kg/ complexity of the surgical procedure, poor wound healing
m2 were reported to have a 2.9-fold increased likelihood because of poor nutrition, decreased tissue oxygen sup-
of requiring a second revision.9 A recent study showed ply, inappropriate dosing of antibiotics, 25 and increased
a significant increase in obesity (from 31.5% to 38.1%) comorbidities. Patients with obesity must be informed
for women between 60 and 65 years of age (P = 0.006), a about the increased risk of infection and the consequences
population subset that commonly undergoes TKA.24 The of infection. It is not uncommon for patients undergoing
population that undergoes TKA is expanding, and giv- arthroplasty to have obesity; however, no consensus on
en that obesity is considered an independent risk factor BMI or weight exists that clearly denotes the increased
2: Knee
for knee osteoarthritis and more than one-half of those risk of infection. Researchers have investigated for a BMI
undergoing TKA are obese, 24 surgeons must give special that should be used as a threshold for safely perform-
consideration to these challenging cases. ing TKA. One study’s findings showed that for patients
Patients with obesity are those whose BMI is higher with a BMI of 35.0 to 39.9 kg/m2 , the risk of prosthetic
than 30 kg/m2 (Table 1). Obesity is then categorized into joint infection was twice as high as for those with a BMI
three classes: I (obese), BMI 30 to 35 kg/m2; II (severely of less than 35 kg/m 2 , and the risk was four times as
obese), BMI 35 to 40 kg/m2; and III (morbidly obese), BMI high for those with a BMI of 40 kg/m 2 or higher.24 The
higher than 40 kg/m 2. A patient is considered morbidly study also identified 100 kg as an absolute weight thresh-
obese if he or she satisfies one of the following criteria: old for safely performing TKA. A 2016 study26 found
a BMI greater than 40 kg/m 2 (class III), weight in ex- all-cause (not just infection-related) revision arthro-
cess of 100 lb (45.5 kg) more than his or her ideal body plasty to be increased in those with a BMI higher than
weight, or a BMI higher than 35 kg/m2 and obesity-related 35 kg/m2. The revision rate was more than twofold great-
health problems such as hypertension, diabetes, sleep er for those with a BMI of 35 kg/m2 as for those with a
apnea, or coronary artery disease. Patients with a BMI of BMI of less than 35 kg/m2. For patients with a BMI of
50 kg/m 2 or higher are considered super obese. Obesity 35 kg/m 2 or higher or less than 35 kg/m 2 , survivorship
has an International Classification of Diseases, Tenth at 5 years was 96.4% and 98.3%, respectively, and at
Revision (ICD-10) code that allows it to be added to 10 years was 93.7% and 97.2%, respectively.
TKA procedure codes. Although increased BMI is an independent risk factor
Surgeons must be willing to accept the unique chal- for revision TKA,9 several potential reasons exist. The
lenges that accompany performing TKA in patients with complexity of the case can result in increased surgical
obesity. Special consideration should be given to preoper- time in patients with obesity, which has been associated
ative counseling regarding the surgical risks: soft-tissue with an increased rate of infection. For every additional
Section 2: Knee
15 minutes of surgical time, the infection risk increases Preoperative Counseling

by 9%.21 Patients with obesity may require longer surgical Because TKA is a purely elective procedure, sometimes it
time for exposure, correct component position, and com- is in the patient’s best interest to postpone surgery until
plex, multilayer closure, all secondary to excessive adipose preoperative health is optimized. Despite minimal evi-
tissue. During arthroplasty, the knee needs to bend at least dence that suggests weight loss before surgery will im-
75° to 90° for component placement; therefore, it is also prove the patient outcome,31,32 optimizing the patient’s
important to consider not only the overall BMI but also overall health will be beneficial. Weight loss can be
the calf-to-thigh ratio. If the knee cannot bend because achieved by diet, exercise, or even surgical intervention,
the posterior calf meets the thigh and prevents it from as well as by addressing any nutritional deficits.33,34
flexing, the surgery cannot be performed.
Component Position Surgical Recommendations

Adipose tissue that creates a large soft-tissue envelope The approach to TKA for both young and obese patients
can make component positioning a challenge. It can be requires special consideration and planning on the sur-
argued that component positioning is even more criti- geon’s behalf. Neither case should be considered typical;
cal in the patient with obesity because of the increased therefore, surgeons experienced in adult reconstruction
mechanical loads placed throughout the joint.27 Exces- should handle these challenging cases. Both young and
sive effort required to sufficiently externally rotate the obese patients have higher-than-normal rates of revision
tibial component or lateralize the femoral component surgery because of infection or aseptic loosening, which
can result in implant malposition, increased mechanical compromise implant longevity. These complications can
strain on the bearing surfaces, and eventual premature be minimized by resurfacing the patella, limiting handling
implant failure. Increased BMI was associated with an of soft tissues, distalizing the surgical incision, proper
increased risk of postoperative malalignment (P = 0.076), component positioning, and adequate fixation.
and the surgeon should aim for a deviation of ±3° from
neutral of the mechanical axis. This is supported by a Resurface the Patella
2011 study28 that reported that patients with a BMI higher Although no definitive evidence suggests that the patella
than 41 kg/m 2 had a higher failure rate than did those should be resurfaced,35,36 the rate of revision surgery is
with a BMI between 23 and 26 kg/m 2. The increase was higher in patients whose patellae are not resurfaced during
from 0.7% to 2.6% (P = 0.0046) in well-aligned knees, the index TKA. This may occur because patients still
from 1.6% to 2.9% (P = 0.0180) in varus-aligned knees, reporting anterior knee pain after arthroplasty without
2: Knee
and from 1.0% to 7.1% (P = 0.0260) in valgus-aligned patellar resurfacing provide the surgeon with a poten-
knees. In addition, a 10.8% increased risk of failure was tial reason for their continued discomfort and therefore
reported for those who had a BMI higher than 41 kg/m 2. may undergo a secondary patellar resurfacing. In both
The data showed that, for implant longevity, it is vital to the young and the obese patient populations, which al-
ensure that the tibia is not cut in varus for those with a ready face higher revision surgery rates, resurfacing the
BMI higher than 41 kg/m 2. A failure rate of 21.9% was patella during the index procedure eliminates the temp-
reported for a varus tibial cut in patients with a BMI tation to perform a second surgery to treat the patient’s
higher than 41 kg/m 2. anterior knee pain that will typically be unsuccessful.
Accurate placement of standard cutting guides can Meta-analyses have not been able to establish a superior
be difficult in obese patients, and patient-specific cut- technique; however, resurfacing the patella during the
ting guides have been developed to address this issue. index procedure will eliminate the potential need for
Authors have reported satisfactory results with patient- additional surgery.
specific guides.29 Although the guides are based on CT/ It is important to ensure the component is well posi-
MRI specific to the patient, the bony cuts must be dou- tioned, which is achieved by placing the component on
ble-checked, as with standard instrumentation, to ensure the superomedial edge of the patella. After partial lateral
that appropriate cuts are made. Although an experienced facetectomy, a symmetric, domed, all-polyethylene three-
surgeon may think that he or she is able to align the joint peg button can be used to ensure the component is fully
within a 3° range, evidence suggests that patient-specif- seated on bone with no overlap into the soft tissues.
ic instrumentation can limit the outliers of component
malpositioning.29,30 No-Hands Technique for Incision
Wound complications after an otherwise successful
TKA are frustrating. Infection is responsible for a large
percentage of TKA revisions7,9 in both obese and young

patient cohorts; therefore, attention to the soft tissues
is paramount. To optimize wound healing, handling of
the soft tissues should be minimized. The surgeon can
perform the skin incision with the knee in deep flexion
with a “no-hands” technique during which no assistants
are required to hold skin retractors (Figure 1). Sharp
dissection is performed through skin and subcutaneous
tissue down to the level of the vastus medialis oblique.
A medial parapatella arthrotomy can be performed, but
either a midvastus or a subvastus approach can be used.
The surgeon can avoid undermining the soft tissues by
making thick soft-tissue flaps. Delaminating the subcu-
taneous adipose tissue from the fascia creates dead space
for fluid to occupy and compromises the blood supply,
which can result in incision-related complications.37,38
Assuming the location of the skin incision is correct,
the arthrotomy will require no additional soft-tissue dis-
section. The soft tissue is left attached to the patella, and
resurfacing is performed as the last of the three steps.
Usually, additional tissue dissection is not needed to place
the patellar clamp because at the end of the procedure,
the tissue has been manipulated enough to allow correct
placement of the patellar clamp.
The arthrotomy should be performed with the knee
in deep flexion and should be as straight as possible to
avoid the creation of acute angles around the patella. The Figure 1 Intraoperative photograph demonstrates the
“no-hands” skin incision with the knee in
surgeon can bring the arthrotomy as close to the patellar hyperflexion to minimize additional trauma to
tendon as possible and not be concerned if a few fibers the peri-incisional soft tissue.
of the patellar tendon are included on the medial aspect
2: Knee
of the arthrotomy. This reduces the amount of tissue to
mobilize laterally when placing a retractor in the lateral Component Positioning: External Rotation of the
aspect of the knee to expose the entire tibia. In the obese Tibial Component
patient, for whom exposure can be challenging because of External rotation of both the femoral and tibial compo-
a substantial fat pad, this facilitates the surgeon’s access to nents is well documented to optimize flexion gaps and
the knee. After the arthrotomy is performed, the knee is patellar tracking. Conventionally, the center of the tibial
moved out of flexion and a medial exposure is performed. component should align with the medial one-third of the
This is the first time a retractor will be required. tibial tubercle. Poor exposure of the posterolateral corner
can result in malpositioning of the tibial component into
Incision Location relative internal rotation if care is not taken to external-
Although it is important to obtain adequate visualization, ly rotate the tibial component appropriately (Figure 3).
the incision can be limited to only the necessary length. Slightly more external rotation should result in optimal
Instead of centering the incision over the patella, it should tracking and reduce the need for a lateral release.
be biased slightly more distal so that less of the incision
length is required proximal to the superior pole of the Obtain Adequate Fixation
patella and more length is required distal to the inferior Metaphyseal fixation is necessary to counteract the shear
pole of the patella (Figure 2). Generally, any extension forces placed across the tibial component. For younger or
of the incision for exposure will be required distally. To obese patients, every attempt should be made to maximize
perform a satisfactory medial release, the incision likely tibial fixation.39 Several manufacturers provide an exten-
will have to extend past the tibial tubercle. sion to the tibial baseplate keel to support the primary
components without adding a large stem that would be
more commonly used in a revision. Although there is
Section 2: Knee
Figure 3 Intraoperative photographs obtained during

total knee arthroplasty show external rotation
of the tibial component (A) and a superior view
that shows a lateralized tibial component with
some uncovered medial tibia (B).
Figure 2 Intraoperative photograph shows the skin

incision used during exposure for total knee
arthroplasty. The distalized incision allows good
visualization of the joint without unnecessary
length.
2: Knee
still some debate in the literature,39,40 a stemmed compo-

nent can be used in patients whose BMI is higher than
35 kg/m2 (Figure 4) because it provides additional fixation
and alignment.
A more liberal approach to the use of metaphyseal Figure 4 AP radiograph of the knee obtained following
total knee arthroplasty shows the tibial
fixation by using trabecular metal cones that provide component with stem extension used for
excellent fixation and bony ingrowth can be implement- additional fixation of the tibial component in
ed, although their use rarely is required in the primary the authors’ patients who have a body mass
index higher than 35 kg/m2.
setting (Figure 5). Studies have reported good results
with metaphyseal sleeves to provide metaphyseal fixa-
tion.41,42 However, cones can be placed independently of
the tibial component, which allows for optimal orienta- revision of TKA in those younger than 55 years, and so
tion, depending on where the metaphyseal region requires secure fixation must be obtained in the primary TKA.9
supplementation.
One of the disadvantages of placing a metaphyseal cone
or sleeve is the amount of bone that has to be removed Summary
for placement. Although removal of bone is generally With the increase in the number of people requiring TKA,
discouraged, it may be necessary, and bone should be sac- the surgeon performing arthroplasty will be expected
rificed if the surgeon thinks the extra fixation will secure to take the lead for challenging patient cohorts: both
the implant. Aseptic loosening is the primary reason for the young patient and the obese patient require special
Key Study Points
• Young patients are at increased risk for requiring

revision surgery or even revision arthroplasty be-
cause of infection or aseptic loosening.
• Obesity is an independent risk factor for knee ar-
thritis. A large percentage of the US population
is considered overweight or obese; therefore, the
expected number of arthroplasties in obese patients
is expected to increase, and these individuals are at
increased risk for the development of perioperative
complications.
• Obese patients need to be counseled preoperatively
regarding their risk of requiring revision secondary
to infection, loosening, implant positioning, and
wound complications.
1. Kurtz S, Ong K, Lau E, Mowat F, Halpern M: Projections

of primary and revision hip and knee arthroplasty in the
United States from 2005 to 2030. J Bone Joint Surg Am
2007;89(4):780-785. Medline DOI
Figure 5 Intraoperative photograph shows the insertion 2. Patel A, Pavlou G, Mújica-Mota RE, Toms AD: The epide-
of a tibial trabecular metal cone to obtain miology of revision total knee and hip arthroplasty in En-
metaphyseal fixation during total knee gland and Wales: A comparative analysis with projections
arthroplasty and thus minimize the likelihood for the United States. A study using the National Joint
of loosening. This technique can be applied to Registry dataset. Bone Joint J 2015;97-B(8):1076-1081.
2: Knee
both young patients and obese patients. Medline DOI
This article is a direct response to Kurtz et al,1 which
focused on projections for the occurrence of joint arthro-
plasty in the United States. The projections of the authors
consideration. Both groups are at risk for experiencing mirrored those found in the US study, suggesting that this
early failure secondary to aseptic loosening and infection. phenomenon is not limited to the United States. Analysis
Unique challenges include correct implant positioning of the data for England and Wales suggests that by 2030,
and obtaining adequate fixation. Arthroplasty performed the volume of primary and revision TKAs will increase
by 117% and 332%, respectively.
in either of these two patient populations should not be
regarded as routine, and greater care must be taken to 3. Hooper G, Lee AJ, Rothwell A, Frampton C: Current
reduce the number of revisions performed in these groups. trends and projections in the utilisation rates of hip and
Meticulous surgical technique when handling the tissues, knee replacement in New Zealand from 2001 to 2026.
N Z Med J 2014;127(1401):82-93. Medline
adequate exposure to allow optimal implant orientation,
and satisfactory implant fixation are key to success in This study offered projections for primary and revision
these demanding cases. TKA in New Zealand. By using a Poisson regression anal-
ysis to compare the trend in other countries, a dramatic
increase in demand for arthroplasty procedures was pro-
jected, with the absolute number of TKAs expected to
increase by 183% by 2026.
4. Insall JN, Dorr LD, Scott RD, Scott WN: Rationale of

the Knee Society clinical rating system. Clin Orthop Relat
Res 1989;248:13-14. Medline
Section 2: Knee
5. Scuderi GR, Bourne RB, Noble PC, Benjamin JB, Lon- the etiologies of TKA failures were analyzed. The most
ner JH, Scott WN: The new Knee Society Knee Scor- common cause of failure in the younger patient cohort
ing System. Clin Orthop Relat Res 2012;470(1):3-19. was aseptic loosening, followed by infection. The most
Medline DOI common cause of failure in the older patient cohort was
infection. The most common cause of failure of revision
The authors of this study attempted to update the old Knee arthroplasty was infection.
Society knee scoring system for younger patients undergo-
ing TKA, who have higher expectations and demands on
their implant that exceed walking and climbing stairs. The 10. Meehan JP, Danielsen B, Kim SH, Jamali AA, White
new scoring system is both physician and patient derived. RH: Younger age is associated with a higher risk of early
periprosthetic joint infection and aseptic mechanical fail-
ure after total knee arthroplasty. J Bone Joint Surg Am
6. Parvizi J, Nunley RM, Berend KR, et al: High level of 2014;96(7):529-535. Medline DOI
residual symptoms in young patients after total knee ar-
throplasty. Clin Orthop Relat Res 2014;472(1):133-137. The authors of this study analyzed the relationship be-
Medline DOI tween periprosthetic joint infection and patient age at the
time of arthroplasty. Patients younger than 50 years and
This national multicenter study assessed 661 young pa- those 65 years or older were compared on the principal
tients (mean age, 54 years) following TKA for residual outcome of revision arthroplasty undertaken because of
symptoms, including difficulty in performing activities of infection or aseptic mechanical loosening. In the young-
daily living, pain, difficulty climbing stairs, and difficulty er patient group, the incidence of revision within 1 year
getting into and out of a car. Despite being satisfied with after implantation was 1.36% for periprosthetic joint in-
their TKAs, a high percentage of patients reported residual fection and 3.49% for aseptic mechanical loosening. In
symptoms, which suggests that physicians must counsel the younger patient group, the risk of joint infection was
their younger patients regarding the goals of care. 1.8 times higher and the rate of mechanical loosening was
4.7 times higher.
7. Wainwright C, Theis JC, Garneti N, Melloh M: Age at
hip or knee joint replacement surgery predicts likelihood 11. Long WJ, Bryce CD, Hollenbeak CS, Benner RW, Scott
of revision surgery. J Bone Joint Surg Br 2011;93(10): WN: Total knee replacement in young, active patients:
1411-1415. Medline DOI Long-term follow-up and functional outcome. A concise
The authors of this study compared revision rates with follow-up of a previous report. J Bone Joint Surg Am
mortality rates of 4,668 patients treated with arthroplasty 2014;96(18):e159. Medline DOI
between 1989 and 2007. Patients younger than 50 years The authors of this study reviewed 114 TKAs in 88 pa-
were more likely to require revision arthroplasty than tients 55 years and younger and assessed clinical out-
to die 10 years after surgery. At approximately 58 years comes, survival analysis, and radiographs. At 30-year
of age, the likelihood of revision or dying was 50:50. At follow-up, survivorship without revision for any cause
approximately 62 years of age, the patient was more likely was 70.1%. Survivorship with aseptic loosening of the
to not undergo revision, and by approximately 77 years tibial or femoral component was 82.5%. The average
2: Knee
of age, there was a greater than 90% likelihood of pa- Hospital for Special Surgery score had improved from
tient death before requiring a revision. At approximately 57.9 to 85.3 points. The average Knee Society score was
47 years of age, patients were twice as likely to require a 87.4 points, and the average Knee Society functional score
revision as they were to die. was 62.1 points. The mean Tegner and Lysholm activity
score improved from 1.5 to 3.0 points.
8. Vince KG: You can do arthroplasty in a young patient,
but...: Commentary on articles by John P. Meehan, MD, 12. Keeney JA, Eunice S, Pashos G, Wright RW, Clohisy
et al: “Younger age is associated with a higher risk of JC: What is the evidence for total knee arthroplasty in
early periprosthetic joint infection and aseptic mechan- young patients? A systematic review of the literature. Clin
ical failure after total knee arthroplasty,” and Vinay K. Orthop Relat Res 2011;469(2):574-583. Medline DOI
Aggarwal, et al: “Revision total knee arthroplasty in the
young patient: Is there trouble on the horizon?” J Bone This study assessed TKA, its durability, and literature
Joint Surg Am 2014;96(7):e58. Medline DOI recommendations for it in the young patient. Mean Knee
Society clinical and functional scores improved; implant
The author of this study discussed two articles on arthro- survivorship was greater than 90% for the first decade
plasty in the young and highlighted the alarming trend of postoperatively and higher than 85% during the second
early primary TKA failure. More consistent reporting of decade. TKA could be performed safely with good results
revision TKAs and the etiologies of their failures is needed. in the young patient; however, no specific recommenda-
tions were identified for the young patient.
9. Aggarwal VK, Goyal N, Deirmengian G, Rangavajulla A,
Parvizi J, Austin MS: Revision total knee arthroplasty in 13. Ogden CL, Carroll MD, Kit BK, Flegal KM: Prevalence
the young patient: Is there trouble on the horizon? J Bone of childhood and adult obesity in the United States, 2011-
Joint Surg Am 2014;96(7):536-542. Medline DOI 2012. JAMA 2014;311(8):806-814. Medline DOI
The authors of this study conducted a retrospective re- The authors of this study used data for 9,120 participants
view of TKAs performed in young patients. The data for from the 2011-2012 National Health and Nutrition Ex-
patients 50 years or younger were matched with the data amination Survey to analyze obesity trends in the United
for a comparison group of patients age 60 to 70 years and
States: 8.1% of infants and toddlers had high weight for The authors of this study performed a literature review of
recumbent length (the equivalent of obesity in the infant), studies involving patients in different weight groups who
and 16.9% of 2- to 19-year-olds and 34.9% of adults underwent TKA. Infection occurred more often in obese
20 years or older were obese. Despite the lack of an overall patients, with an odds ratio of 1.90 (95% confidence in-
increase in obesity from the 2003-2004 study, the numbers terval, 1.46-2.47). Revision for any reason occurred more
remained high. A significant increase in obesity was noted often in obese patients, with an odds ratio of 1.30 (95%
among women 60 years or older. confidence interval, 1.02-1.67).
14. Welton KL, Gagnier JJ, Urquhart AG: Proportion of 19. Inacio MC, Paxton EW, Fisher D, Li RA, Barber TC, Singh
obese patients presenting to orthopedic total joint ar- JA: Bariatric surgery prior to total joint arthroplasty may
throplasty clinics. Orthopedics 2016;39(1):e127-e133. not provide dramatic improvements in post-arthroplasty
Medline DOI surgical outcomes. J Arthroplasty 2014;29(7):1359-1364.
Medline DOI
This study investigated whether the proportion of obese
people seeking evaluation at a public tertiary hospital for The authors of this study studied overweight patients who
total joint arthroplasty was greater than the proportion had undergone total joint arthroplasty, comparing patients
of obese people in the general population. Of the patients who underwent bariatric surgery with those who were
who presented for evaluation, 55% were obese, compared candidates but did not undergo the surgery. Patients who
with the national average of 34.9%. Obese patients had had undergone bariatric surgery more than 2 years before
significantly more comorbidities and higher functional their total joint arthroplasty had higher 90-day readmis-
comorbidity index scores than did patients who were not sion rates than those who were candidates for bariatric
obese. surgery but did not undergo it. Despite having improved
BMIs compared with those who had not undergone bar-
15. Cawley J, Meyerhoefer C: The medical care costs of obe- iatric surgery, patients who underwent bariatric surgery
sity: An instrumental variables approach. J Health Econ were still susceptible to complications and readmissions.
2012;31(1):219-230. Medline DOI
20. Issa K, Pivec R, Kapadia BH, et al: Does obesity affect
The authors of this study showed that medical care costs the outcomes of primary total knee arthroplasty? J Knee
associated with obesity were actually underestimated in Surg 2013;26(2):89-94. Medline DOI
previous research and that greater resources will be re-
quired to care for obese patients as the obesity epidemic The authors of this study compared the clinical and radio-
increases. graphic outcomes of primary TKA in obese and nonobese
patients. The mean BMI was 34 kg/m 2 in the obese group
16. Workgroup of the American Association of Hip and and less than 30 kg/m 2 in the nonobese group. Implant
Knee Surgeons Evidence Based Committee: Obesity survivorship, Knee Society objective and functional scores,
and total joint arthroplasty: A literature based review. complication rates, radiographic outcomes, University
J Arthroplasty 2013;28(5):714-721. Medline DOI of California–Los Angeles (UCLA) activity score, and
the length of hospital stay were analyzed in obese versus
2: Knee
A task force of members of the American Association nonobese patients. Although the obese group had more
of Hip and Knee Surgeons reviewed data regarding ar- postoperative complications (10.5% versus 3.8%) and a
throplasty in the obese patient. Key areas were identified lower UCLA score, the length of stay and survivorship
to develop a review that could be used to guide patient- were similar between the two groups, suggesting that TKA
physician communication regarding arthroplasty in the can be successfully performed in obese patients.
obese patient.
21. Namba RS, Inacio MC, Paxton EW: Risk factors associ-
17. D’Apuzzo MR, Novicoff WM, Browne JA: The John Insall ated with deep surgical site infections after primary total
Award: Morbid obesity independently impacts complica- knee arthroplasty: An analysis of 56,216 knees. J Bone
tions, mortality, and resource use after TKA. Clin Orthop Joint Surg Am 2013;95(9):775-782. Medline DOI
Relat Res 2015;473(1):57-63. Medline DOI
Given the severity of deep surgical site infection after
This study examined whether morbid obesity is an in- TKA, the authors examined the risk factors associated
dependent risk factor for postoperative complications, with periprosthetic joint infection in the United States. A
including mortality, after TKA. Matched control pa- Cox regression analysis was performed on identified cases
tients were used to analyze postoperative complications to assess the risk factors associated with deep surgical site
of morbidly obese patients. These patients had a higher infection. The incidence of periprosthetic infection was
in-hospital infection rate, more wound complications, and 0.72%. A BMI of 35 kg/m 2 or greater was found to be an
a greater likelihood of mortality after TKA compared with independent risk factor for infection. Other risk factors
nonobese patients. Hospital costs and length of stay were included diabetes, male sex, osteonecrosis, and posttrau-
also higher in morbidly obese patients. matic arthritis. Surgical time was a risk factor, with a 9%
increase in risk per 15-minute increment.
18. Kerkhoffs GM, Servien E, Dunn W, Dahm D, Bramer
JA, Haverkamp D: The influence of obesity on the com- 22. Jämsen E, Nevalainen P, Eskelinen A, Huotari K, Kallio-
plication rate and outcome of total knee arthroplasty: A valkama J, Moilanen T: Obesity, diabetes, and preoper-
meta-analysis and systematic literature review. J Bone ative hyperglycemia as predictors of periprosthetic joint
Joint Surg Am 2012;94(20):1839-1844. Medline DOI infection: A single-center analysis of 7181 primary hip
Section 2: Knee
and knee replacements for osteoarthritis. J Bone Joint This study aimed to establish a BMI threshold for TKA
Surg Am 2012;94(14):e101. Medline DOI given that obese patients experience higher rates of postop-
erative complications. Of 2,442 primary TKAs performed,
The 1-year incidence of periprosthetic joint infections was 71 required revision. A significant increase was reported
analyzed in a single-center study. Patients with diabetes, in all-cause revision in patients with a BMI greater than
adjusting for age, sex, BMI, diabetic status, American 35 kg/m 2 , which suggests that a BMI of approximately
Society of Anesthesiologists risk score, and arthroplasty 35 kg/m 2 should perhaps mark a threshold beyond which
site, were assessed. Patients who were morbidly obese had the patient would be required to reduce his or her BMI
a 1-year postoperative infection rate of 4.66%. Diabetes before undergoing the elective procedure.
more than doubled the risk of periprosthetic joint infection
independent of obesity.
27. Estes CS, Schmidt KJ, McLemore R, Spangehl MJ, Clarke
HD: Effect of body mass index on limb alignment after
23. Paxton EW, Inacio MC, Khatod M, Yue E, Funahashi T, total knee arthroplasty. J Arthroplasty 2013;28(8sup-
Barber T: Risk calculators predict failures of knee and hip pl):101-105. Medline DOI
arthroplasties: Findings from a large health maintenance
organization. Clin Orthop Relat Res 2015;473(12):3965- The authors of this study retrospectively reviewed the
3973. Medline DOI relationship between postoperative alignment and BMI
for patients undergoing primary TKA performed with
The authors of this study developed a TKA and total hip mechanical instruments. Both preoperative alignment and
arthroplasty revision risk calculator by using a cohort of BMI had a significant effect on postoperative alignment
patients from a health maintenance organization. They after TKA. Increased preoperative malalignment and BMI
identified patients who had undergone revision of any were found to increase the likelihood of postoperative
component for any reason within 5 years of their index malalignment.
procedure. The best predictors for the TKA revision risk
calculator were age, sex, square root BMI, diabetes, os-
teoarthritis, posttraumatic arthritis, and osteonecrosis. 28. Ritter MA, Davis KE, Meding JB, Pierson JL, Berend
ME, Malinzak RA: The effect of alignment and BMI on
failure of total knee replacement. J Bone Joint Surg Am
24. Lübbeke A, Zingg M, Vu D, et al: Body mass and weight 2011;93(17):1588-1596. Medline DOI
thresholds for increased prosthetic joint infection rates
after primary total joint arthroplasty. Acta Orthop The authors of this study assessed implant survival after
2016;87(2):132-138. Medline DOI TKA (6,070 knees in 3,992 patients) and how it was affect-
ed by tibiofemoral alignment, femoral and tibial compo-
The authors of this study aimed to establish a BMI thresh- nent alignment, and BMI. The end point was revision for
old that would indicate a higher rate of prosthetic joint any reason other than infection. Using Cox regression, the
infection. Reviewing data for patients in five BMI catego- authors found that failures most likely occurred in those
ries and five weight categories, similar infection rates were with tibial component orientation less than 90° relative
noted for those with a BMI lower than 35 kg/m 2. The rates to the tibial axis and those with a femoral component
were twice as high for those with a BMI between 35 and orientation greater than 8° of valgus. A higher BMI was
2: Knee
39.9 kg/m 2 and four times as high for those with a BMI associated with an increase in failure rate. Those with a
of 40 kg/m 2 or higher. Those with a BMI of 35 kg/m 2 or BMI of 41 kg/m 2 or higher had a failure rate of 2.6% in
higher had a higher infection rate and required greater well-aligned knees, 2.9% in varus-aligned knees, and 7.1%
doses of antibiotics. in valgus-aligned knees.
25. Brill MJ, Houwink AP, Schmidt S, et al: Reduced subcu- 29. Anwar R, Kini SG, Sait S, Bruce WJ: Early clinical and
taneous tissue distribution of cefazolin in morbidly obese radiological results of total knee arthroplasty using
versus non-obese patients determined using clinical mi- patient-specific guides in obese patients. Arch Orthop
crodialysis. J Antimicrob Chemother 2014;69(3):715-723. Trauma Surg 2016;136(2):265-270. Medline DOI
Medline DOI
Using patient-specific cutting guides, 100 obese patients
The amount of cefazolin in the tissues of morbidly obese (105 knees) were assessed for overall alignment of their
and nonobese patients was studied. Patients in both groups TKA. All patients had a BMI of 30 kg/m 2 or higher. More
received 2 g of cefazolin before undergoing a laparoscopic than 86% of the study group had a mechanical alignment
procedure. Microdialysis was used to collect samples of within 3° of neutral, suggesting that patient-specific cut-
adipose tissue and then used pharmacokinetic model- ting guides are a valid option in the obese patient.
ing and Monte Carlo simulations to assess the tissues.
The amount of cefazolin available in the morbidly obese
patients was much lower than in the nonobese patients, 30. Heyse TJ, Tibesku CO: Improved tibial component
which suggests that morbidly obese patients require higher rotation in TKA using patient-specific instrumenta-
doses of cefazolin. tion. Arch Orthop Trauma Surg 2015;135(5):697-701.
Medline DOI
26. Zingg M, Miozzari HH, Fritschy D, Hoffmeyer P, Lübbeke MRI was used to analyze 58 TKAs, 30 of which had
A: Influence of body mass index on revision rates after pri- been performed with patient-specific instrumentation
mary total knee arthroplasty. Int Orthop 2016;40(4):723- (PSI) and 28 with conventional jigs. Eight components
729. Medline DOI were placed in excessive external rotation (28.6%) and
one component was placed in relative internal rotation
(5.4°) in the conventionally treated group, and there were complications among those who were malnourished was
two components in excessive external rotation in the PSI 12%. Obesity was present in 43% of the malnourished
group (6.7%). Seven components were placed in excessive patients, and there was a significantly higher complication
external rotation (21.4%) and one component in relative rate in that cohort.
internal rotation (4.4°) in the conventional group; two
components were in excessive external rotation in the PSI 35. Pilling RW, Moulder E, Allgar V, Messner J, Sun Z,
group (6.7%). These differences were significant (P < 0.05). Mohsen A: Patellar resurfacing in primary total knee
PSI could limit the outliers in tibial component positioning. replacement: A meta-analysis. J Bone Joint Surg Am
2012;94(24):2270-2278. Medline DOI
31. Lui M, Jones CA, Westby MD: Effect of non-surgical,
non-pharmacological weight loss interventions in patients The authors of this study performed a meta-analysis to
who are obese prior to hip and knee arthroplasty surgery: investigate whether patellar resurfacing during prima-
A rapid review. Syst Rev 2015;4:121. Medline DOI ry TKA would improve patient outcome in 3,465 knees
(1,710 with patellar resurfacing and 1,755 without). No
The authors of this study performed a literature review difference was noted in the functional component of the
to analyze preoperative weight loss and short- and long- Knee Society score, although the knee component of the
term outcomes. The review was limited to four studies, Knee Society score was significantly higher in the resurfac-
the findings of which overall did not support the loss of ing group. No difference was noted in reports of anterior
weight in the year before total joint arthroplasty. knee pain between the two groups. However, significantly
more additional procedures were performed in the patients
32. Severson EP, Singh JA, Browne JA, Trousdale RT, Sarr who did not undergo patellar resurfacing.
MG, Lewallen DG: Total knee arthroplasty in morbid-
ly obese patients treated with bariatric surgery: A com- 36. Pavlou G, Meyer C, Leonidou A, As-Sultany M, West R,
parative study. J Arthroplasty 2012;27(9):1696-1700. Tsiridis E: Patellar resurfacing in total knee arthroplasty:
Medline DOI Does design matter? A meta-analysis of 7075 cases. J Bone
Joint Surg Am 2011;93(14):1301-1309. Medline DOI
The authors of this study evaluated the outcomes with
respect to anesthesia time, total surgical time, tourni- The authors of this study analyzed the data regarding
quet time, length of hospital stay, 90-day complication patellar resurfacing during TKA in 18 level I randomized
rates, and transfusion rates for patients who underwent controlled trials (7,075 knees) to assess residual anteri-
bariatric surgery before or after undergoing TKA. Pa- or knee pain, rates of revision surgery, and functional
tients undergoing TKA more than 2 years after bariatric outcome measures in patients with and without patellar
surgery had shorter anesthesia time, shorter total surgical resurfacing. No difference was noted in anterior knee
time, and shorter tourniquet time. The 90-day complica- pain or functional scores; however, the rates of revision
tion and transfusion rates approached but did not reach surgery were higher in patients who had not undergone
significance. patellar resurfacing.
33. Nelson CL, Elkassabany NM, Kamath AF, Liu J: Low 37. Vince KG, Abdeen A: Wound problems in total knee ar-
2: Knee
albumin levels, more than morbid obesity, are associated throplasty. Clin Orthop Relat Res 2006;452(452):88-90.
with complications after TKA. Clin Orthop Relat Res Medline DOI
2015;473(10):3163-3172. Medline DOI
The authors of this study assessed obesity and malnutri- 38. Vince K, Chivas D, Droll KP: Wound complications
tion as independent and discrete risk factors for periopera- after total knee arthroplasty. J Arthroplasty 2007;22(
tive complications. The serum albumin level was analyzed 4suppl 1):39-44. Medline DOI
to establish that malnutrition was an independent risk
factor for perioperative mortality and other complica- 39. Abdel MP, Bonadurer GF III, Jennings MT, Hanssen AD:
tions. Morbid obesity was not an independent risk factor Increased aseptic tibial failures in patients with a BMI
for complications. Serum albumin level is a more mod- ≥35 and well-aligned total knee arthroplasties. J Arthro-
ifiable risk factor than obesity and should be addressed plasty 2015;30(12):2181-2184.
before undertaking an elective procedure. Although BMI The authors of this study retrospectively assessed
is important, the authors recommended that practitioners 5,088 primary TKAs for aseptic loosening in patients
attempt to modify the patient’s serum albumin level rather with a BMI greater than 35 kg/m 2. Fifty-two patients re-
than his or her weight. quired revision, with a 15-year risk of 2.7%. There was no
difference in tibial alignment between those who required
34. Huang R, Greenky M, Kerr GJ, Austin MS, Parvizi J: revision for loosening and those who did not. The surgeon
The effect of malnutrition on patients undergoing elective should consider augmenting the tibial fixation on patients
joint arthroplasty. J Arthroplasty 2013;28(8suppl):21-24. with a BMI greater than 35 kg/m 2. Level of evidence: III.
Medline DOI
Malnutrition has been linked with obesity, which can 40. Parratte S, Ollivier M, Lunebourg A, Verdier N, Argenson
result in complications in patients who are undergoing JN: Do stemmed tibial components in total knee arthro-
total joint arthroplasty. The authors of this study pro- plasty improve outcomes in patients with obesity? Clin
spectively evaluated 2,161 patients for malnutrition by Orthop Relat Res 2016; Mar 18 [Epub ahead of print].
analyzing serum albumin or transferrin levels. The overall Medline DOI
incidence of malnutrition was 8.5%, and the rate of overall
Section 2: Knee
Recent studies have alluded to increased fixation for tibial arthroplasty: Good short-term outcomes. J Arthroplasty
components in those with elevated BMIs. A controlled 2015;30(11):1990-1994. Medline DOI
randomized study with two arms, those with a BMI be-
tween 30 and 35 kg/m 2 and those with a BMI greater The authors of this study analyzed a cohort of 35 re-
than 35 kg/m 2 , was performed. The patients in each arm vision TKAs with metaphyseal bone loss treated with
were then randomly assigned to receive either a standard metaphyseal sleeve prostheses. Knee Society scores were
tibial component or a stemmed (10 mm/100 mm) tibial good or excellent in 83% of the patients. Only one patient
component. The patients were followed for 2 years post- sustained a sleeve-related complication with femoral con-
operatively and assessed using the Knee Society score, dyle fractures.
the Knee Injury and Osteoarthritis Outcome Score, the
Medical Outcomes Study 12-Item Short Form score, and 42. Graichen H, Scior W, Strauch M: Direct, cementless,
a visual analog pain scale. Despite small improvements metaphyseal fixation in knee revision arthroplasty with
in functional outcome in those who received a stemmed sleeves: Short-term results. J Arthroplasty 2015;30(12):
component, these differences were deemed clinically 2256-2259. Medline DOI
nonsignificant. It was concluded that the use of stemmed This prospective study assessed 121 patients with
components could not be supported. Level of evidence: I. 193 sleeves, with a mean follow-up of 3.6 years. Range
of motion, Knee Society scores, and functional scores all
41. Bugler KE, Maheshwari R, Ahmed I, Brenkel IJ, Walms- improved. The rate of secondary revision surgery was
ley PJ: Metaphyseal sleeves for revision total knee 11.4%.
2: Knee
Chapter 12
Bicruciate-Retaining Total
Knee Arthroplasty
Justin G. Brothers, MD Christopher L. Peters, MD
this procedure was reserved for elderly patients with low

Abstract
physical demands and has been shown to have excellent
Total knee arthroplasty is an extremely successful proce- long-term results and survivorship in this population.
dure with excellent durability and outcomes. However, Demographics for TKA are changing, and candidates
many patients remain unsatisfied after surgery. Changes for surgery are currently younger, more active, and living
in expectations and altering the biomechanics of the longer. These patients demand more from the artificial
native knee joint by sacrificing the anterior cruciate knee, and subsequently, some are unsatisfied with their
ligament may play a role. Bicruciate-retaining total knee surgical results. Studies have reported that 18% or more
arthroplasty aims to solve these issues by maintaining of patients undergoing primary TKA and 41% of pa-
native knee kinematics. The orthopaedic surgeon should tients undergoing revision TKA are unsatisfied at 1-year
be knowledgeable about history, design, indications, follow-up.1,2 Similarly, when compared with age-matched
contraindications, and concerns related to treatment. control patients, patients undergoing TKA demonstrated
lower activity levels.3 This dissatisfaction may be partially
explained by abnormal knee kinematics and loss of pro-
Keywords: bicruciate-retaining TKA; anterior prioception secondary to ACL deficiency.
cruciate ligament–sparing TKA; total knee Sixty percent to 80% of patients undergoing rou-
arthroplasty; TKA tine TKA have a competent anterior cruciate ligament
2: Knee
(ACL).4,5 Although most implant designs sacrifice one
or both cruciate ligaments, bicruciate-retaining TKA
could be indicated for patients with a competent ACL.
Introduction
Retaining the ACL has the theoretical advantage of main-
Total knee arthroplasty (TKA) is the primary surgical taining more natural knee kinematics, preserving the
treatment option for severe knee arthritis. Historically, proprioceptive nerve fibers in the ACL, and limiting the
required prosthetic constraint. This may improve both
patient satisfaction and implant survivorship. Although
Dr. Peters or an immediate family member has received several designs have shown promising early results, the
royalties from Biomet; is a member of a speakers’ bureau or use of bicruciate-retaining TKA is not widespread because
has made paid presentations on behalf of Biomet; serves as of concerns regarding surgical technique and ligament
a paid consultant to or is an employee of Biomet; has stock balancing, implant fixation, and possible late ACL rup-
or stock options held in CoNextions Medical; has received ture.6,7 New technology has been developed to address
research or institutional support from Biomet; and serves some of these potential issues.
as a board member, owner, officer, or committee member
of the American Academy of Orthopaedic Surgeons, the
American Association of Hip and Knee Surgeons, the Hip History
Society, and the Knee Society. Neither Dr. Brothers nor any As early as the 1960s, alternatives to the hinged TKA
immediate family member has received anything of value design were developed to retain both cruciate ligaments.
from or has stock or stock options held in a commercial The Gunston polycentric knee used cemented semicircular
company or institution related directly or indirectly to the stainless steel bands that capped the femoral condyles
subject of this chapter. and articulated with independent polyethylene tibial
Section 2: Knee
increments to facilitate soft-tissue balancing and address

polyethylene wear. Also available is the third-generation
BioPro Total Knee Original (BioPro). This implant re-
quires less bony resection, has a noncemented option,
and has more size options than the earlier generations.
Kinematics
The native knee is a complex joint with many muscle
forces and capsular/ligamentous restraints controlling
its motion. The cruciate ligament complex plays a pivotal
role in rotational stability as well as translation through-
out range of motion. The ACL is composed of two bundles
that restrict anterior tibial translation. The anteromedial
bundle is taut in flexion, and the posterolateral bundle
is taut in extension.13 When approaching full extension,
the tibia externally rotates relative to the femur because
of asymmetry between the femoral condyles and restraint
from the taut ACL.14 This “screw home” mechanism con-
tributes to knee stability in extension. As the knee flexes,
the PCL tightens and causes the femoral condyles to roll
posteriorly and internally rotate the tibia. This increases
Figure 1 Photograph of a bicruciate-retaining total knee the lever arm of the quadriceps muscle and improves
arthroplasty device. patellar tracking.15
The ACL also has proprioceptive nerve fibers that may
aid in normal knee kinematics. A 2003 study compared
components. Designs such as the Geomedic evolved to proprioception between patients undergoing a bicruciate-
a single femoral component for ease of preparation.8 Al- retaining arthroplasty with that in healthy control pa-
though these designs maintained the ACL, each had poor tients.16 Using a force platform, the sway in projected
survivorship secondary to poor fixation, difficult surgical center of gravity was recorded. No significant difference
2: Knee
technique, and imperfect implant geometry.9-11 was reported in this outcome between the surgical and
More modern designs incorporated condylar-style native knees. The authors of the study concluded that a
femoral components and one-piece modular tibial base- “total knee arthroplasty that retains all intraarticular
plates. Improved instrumentation with alignment guides ligaments achieves proprioceptive results comparable with
and distractors also facilitated more reliable results. The healthy subjects.”
Cloutier bicruciate TKA (Hermes 2C, Ceraver-Osteal), Despite the important role of the cruciate ligaments,
although successful clinically, was not accepted because many implants have been designed to sacrifice one or
of difficulty with the surgical technique.12 Several other both ligaments. Cruciate ligament sacrifice allows wider
bicruciate-retaining implants such as the Anatomic Total exposure, ease of surgical technique, avoidance of in-
Knee (DePuy) were available in the 1980s and 1990s; tercondylar impingement, and improved ability to cor-
however, with the widespread use and clinical success of rect deformity and contractures.16 Ultimately, however,
posterior cruciate ligament (PCL)–retaining and PCL– cruciate-sacrificing designs may balance the ease of surgi-
substituting designs, bicruciate-retaining TKA became cal technique with loss of normal knee kinematics, which
less common. has been supported in several studies.17-19
In 2013, the Vanguard XP bicruciate TKA (Zimmer Kinematically, PCL-retaining TKAs have been shown
Biomet) was made available and addressed several design to move in the same way as an ACL-deficient native knee
issues. It used an anatomically shaped modern cobalt- in which there is paradoxical motion with excessive fem-
chromium condylar femoral component, a U-shaped oral rollback with flexion.19,20
tibial component with augmented tibial fixation, and a Gait analysis studies have reported abnormal mo-
reinforced anterior bridge (Figure 1). Also, independent tion with stair ascent or descent in patients with PCL-
medial and lateral tibial bearings composed of vitamin sacrificing or PCL-retaining designs. Bicruciate-retaining
E–impregnated polyethylene were available in 1-mm TKA designs have demonstrated normal knee kinematics
Chapter 12: Bicruciate-Retaining Total Knee Arthroplasty
and motion with stair climbing. This is possibly a result Aseptic loosening of the tibial component occurred in
of more reliable posterior translation of the tibia-femur fewer than 2% of patients in this series.
contact point and better reproduction of the screw-home One study that published the 10-year results of
mechanism, both of which increase the moment arm and 163 b icruciate-retaining knees using the Hermes 2C pros-
function of the quadriceps muscle.17 thesis (Ceraver-Osteal) reported 97% good and excellent
Another study compared bicruciate-retaining TKA results and a 95% survivorship with revision for any rea-
with PCL-retaining TKA using in vivo fluorosco- son as the end point.23 The indication for bicruciate TKA
py.19 Bicruciate-retaining TKAs had a more normal ki- was a negative anterior drawer test result. Consequently,
nematic appearance with gradual femoral rollback and many bicruciate-retaining TKAs were performed on pa-
limited translation in flexion. PCL-retaining TKA had a tients with an abnormal or apparently degenerate ACL at
substantially more posterior contact point in extension, the time of surgery, which did not translate to early failure
more anterior translation with flexion, and increased for this subset. At 22-year follow-up for these patients,
anterior-posterior translation in deep flexion. Further- another study reported that survivorship dropped to 82%
more, patients with bicruciate-retaining TKA and sub- with revision for any reason as the end point.24 The most
sequent ACL failure demonstrated abnormal kinematics common reasons for revision were polyethylene wear
similar to PCL-retaining knees. (12%) and aseptic loosening (4%). No difference was
Two other studies reported similar differences in flu- noted in outcomes in patients with a degenerate-appearing
oroscopic kinematics. A 2007 study reported differences ACL at the time of the index procedure.
in posterior condylar translation between bicruciate- Two small prospective studies compared bicruciate-
retaining and cruciate-retaining knees.21 This was most retaining TKA with PCL-retaining TKA.25,26 At 2-year
evident in maximum flexion and stair climbing in which follow-up, no difference was reported in surgical time,
bicruciate knees exhibited more posterior translation of complications, outcome scores, range of motion, and
the lateral femoral condyle, mimicking native knee ki- radiographic findings between 32 bicruciate-retaining
nematics. A 2002 study demonstrated that posteriorly and 93 PCL-retaining TKAs.25 At 5.5-year follow-up, one
stabilized knees had less consistent and reproducible ki- study reported no differences in outcomes scores or range
nematic motion when compared with bicruciate-retaining of motion between 38 bicruciate retaining and 30 PCL-
knees.18 In this study, bicruciate-retaining knees main- retaining TKA. 26 However, anterior tibial translation
tained more native kinematics and less variability in ro- was significantly higher in knees with a posterior tibial
tation, femoral rollback, and contact patterns. slope greater than 10°. Tibial slope had a greater effect
on stability than preservation of the ACL in this study.26
2: Knee
A 2011 study reported implant preferences of 440 pa-
Outcomes tients who underwent staged bilateral TKA using several
Clinical results with the early bicruciate-retaining TKA different designs.6 Included in this study were bicruci-
designs were poor. A 1979 study reported 11% and 16% ate-retaining, PCL-retaining, posterior-stabilized, medial
failure rates at 3.5 years using polycentric and geometric pivot, and mobile-bearing prostheses. The most profound
knee replacements, respectively.8 However, good results differences were between the bicruciate-retaining and
were noted in more than 80% of patients, with excellent posterior-stabilized designs. At 2-year follow-up, 89.1%
pain relief. of patients preferred the bicruciate-retaining knee to the
A 10-year follow-up study of 209 polycentric TKAs posterior-stabilized knee.
demonstrated a dismal 42% success rate.9 Success was A follow-up study using the same design reported
defined as patients having no or mild pain and not re- symptoms related to noise production of different TKA
quiring an assistive ambulation device. A better outcome designs.27 Patients reported the most noise production
of 66% success was estimated when patients doing well in mobile-bearing (42%) and posterior-stabilized (33%)
before death and lost to follow-up were accounted for. knees and the least in bicruciate-retaining (4%) knees.
The most common causes of failure included instability, In 2015, a report was published on the 23-year
aseptic loosening, patellofemoral pain, and infection. follow-up on 489 bicruciate-retaining knees.7 Although
Another study reported 89% good to excellent re- more than one-half of this cohort died or was lost to
sults in 532 patients with the Townley anatomic follow-up, the remaining 214 knees demonstrated ex-
bicruciate-retaining TKA (DePuy) at a mean follow-up cellent outcomes. The survivorship was 89% with an
of 11 years.22 Excellent results were defined as motion end point of revision for any reason, and the mean Knee
greater than 90°, little to no pain or activity limitation, Society Score improved from 42 to 91. The most com-
and no reliance on an assistive device for ambulation. mon reason for revision was polyethylene wear. ACL
Section 2: Knee
rupture was exceedingly rare and only noted in two re- Contraindications
visions. A current review of various historical outcomes
of bicruciate-retaining TKAs was published in 2014.28 ACL Deficiency
As discussed previously, ACL deficiency is a contraindi-
cation to bicruciate-retaining TKA. Absence of the ACL
Indications is linked to failure in mobile-bearing unicompartmental
Intact ACL arthroplasty, and concern for failure may be extrapolated
The most essential requirement to perform a bicruciate- to the results in this setting.22,23 Partial ACL degeneration
retaining TKA is functionally intact cruciate ligaments. is a controversial contraindication because two studies
Most current designs have little constraint and therefore have shown good results in this subset of patients.5,12 The
require the native stability of these ligaments. Although key requirement in this setting is functional ACL stability
late failure of the ACL may not cause catastrophic failure, with a negative anterior drawer test result.
patients with a bicruciate-retaining TKA and subsequent
ACL tear demonstrate more abnormal kinematics, and Excessive Deformity
functional instability may develop.19 ACL competency can Bicruciate-retaining TKA does not have the capability to
be determined intraoperatively using direct visualization correct severe malalignment because of the internal con-
or preoperatively using MRI, physical examination, or straint of the cruciate ligaments. The following deformity
radiography to evaluate for posterior medial wear. A parameters should be considered relative contraindica-
study that evaluated the predictability of an intact ACL in tions: greater than 10° of varus or valgus joint deformity,
patients undergoing TKA identified an intact ACL in 78% less than 90° of flexion, and greater than 10° of flexion
of patients.5 The Lachman test performed with the patient contracture and recurvatum deformity.7
under anesthesia had poor sensitivity (33%) when used
alone. MRI had 90% sensitivity when an indeterminate Incompetent Extensor Mechanism
reading was considered to be intact. Sagittal wear was An intact extensor mechanism is required for appropriate
also evaluated. All patients with anterior wear of the me- function of any TKA. The retained ACL does not provide
dial tibial plateau had an intact ACL, and all patients with any additional benefit in the setting of an incompetent
posterior medial tibial wear had an incompetent ACL. extensor mechanism.
A 2013 study reported on the 22-year follow-up of
the Hermes bicruciate retaining knee (Ceraver-Osteal) in
163 knees: 67 (41%) had a partially degenerated but still Concerns
2: Knee
functional ACL at time of implantation.24 The survival Despite the possibility of retaining both cruciate liga-
rate was 82.1% for revision for any reason at 22 years. ments in TKA, several challenges exist for attaining this
Polyethylene wear was the most common reason for revi- goal reliably. Surgical exposure is more difficult. Retain-
sion (present in 41.4% of cases) and was associated with ing the ACL limits anterior subluxation of the tibia for
instability and loosening. No difference was reported preparation. Because restoration of the normal joint line
in revision rates between patients with an intact and a is paramount, increased tibial bone resection is required
partially degenerated ACL. It was concluded that bicru- relative to PCL-sacrificing or PCL-retaining TKA, which
ciate-retaining TKA can be performed in this setting as allows joint line elevation. Furthermore, the ACL must
long as the ACL remains functional. be protected from iatrogenic injury throughout the pro-
cedure by using smaller saw blades and protective guides.
Tricompartmental Osteoarthritis or Inflammatory The central bone block at the ACL insertion determines
Arthritis tibial component rotation and becomes another possible
In contrast to unicompartmental arthroplasty, for which area for failure. Joint line manipulation is not well tol-
the nonresurfaced compartments are a concern, bicru- erated by the cruciate ligaments. Altering the joint line
ciate-retaining TKA manages disease in all three knee (primarily by means of joint line elevation) can result
compartments. Furthermore, without retained cartilage, in late ligament failure, and bone island fractures have
progression of inflammatory disease is not a concern. The been reported.29 This also limits tibial component fixation
ideal candidate for bicruciate-retaining TKA may be the options because the capability to have a central keel for
young, active patient with bicompartmental arthritis and fixation augmentation is eliminated. Also, the connection
intact cruciate ligaments. between the medial and lateral tibial plateau is an area
at risk for mechanical fatigue fracture (island fracture).
Chapter 12: Bicruciate-Retaining Total Knee Arthroplasty
In this study, an accelerometer was used to measure 97 pa-

Summary tients before and after TKA. Postoperatively, patients had
increased walking and number of moderate to vigorous
The demographics of patients undergoing TKA is chang- steps. However, only 16.5% achieved the guidelines for
ing, and incomplete patient satisfaction with current TKA walking activity. Body mass index, sex, and comorbidities
were correlated. Level of evidence: III.
techniques continues to be an issue. Multiple studies have
demonstrated a link between abnormal knee kinematics 4. Cushner FD, La Rosa DF, Vigorita VJ, Scuderi GR, Scott
with both PCL-sacrificing and PCL-retaining designs and WN, Insall JN: A quantitative histologic comparison: ACL
patient dissatisfaction. The development of bicruciate-re- degeneration in the osteoarthritic knee. J Arthroplasty
2003;18(6):687-692. Medline DOI
taining TKA potentially addresses this issue. Despite tech-
nical challenges, research on bicruciate-retaining designs 5. Johnson AJ, Howell SM, Costa CR, Mont MA: The ACL
is promising and could result in a reliable, high-function- in the arthritic knee: How often is it present and can pre-
ing TKA. operative tests predict its presence? Clin Orthop Relat
Res 2013;471(1):181-188. Medline DOI
Of 200 knees evaluated for ACL integrity at the time
Key Study Points of TKA, 78% had an intact ACL. Performed alone, the
Lachman test had poor diagnostic ability; MRI had good
• Bicruciate-retaining TKA reproduces normal native diagnostic ability. All knees with anterior tibial wear had
knee kinematics more reliably than cruciate-retain- an intact ACL. All knees with posterior tibial wear had
ing or posterior-stabilized TKA designs. a deficient ACL.
• Patients report less noise generation with a bi-
6. Pritchett JW: Patients prefer a bicruciate-retaining or
cruciate-retaining TKA compared with cruciate- the medial pivot total knee prosthesis. J Arthroplasty
retaining or posterior-stabilized designs. 2011;26(2):224-228. Medline DOI
• Polyethylene wear is the most common cause of In this study, 440 patients underwent staged bilateral
failure in conventional bicruciate-retaining TKA. TKA using different designs. At 2 years, 89% of patients
• ACL rupture is an uncommon mode of failure in preferred the bicruciate knee over the PCL-sacrificing
knee; 76% preferred the medial pivot TKA over the PCL-
conventional bicruciate-retaining TKA. sacrificing knee. Bicruciate and medial pivot TKAs were
• There is increased interest in new bicruciate- preferred equally.
retaining designs, although no long-term follow-up
is available to support their use. 7. Pritchett JW: Bicruciate-retaining Total Knee Replace-
ment Provides Satisfactory Function and Implant Survi-
vorship at 23 Years. Clin Orthop Relat Res 2015;473(7):
2: Knee
This retrospective study evaluated 489 bicruciate-retaining
Annotated References TKAs with a 23-year follow-up. Survivorship at 23 years
was 29% for revision for any reason at the end point. The
most common reason for revision was polyethylene wear.
1. Robertsson O, Dunbar M, Pehrsson T, Knutson K,
Lidgren L: Patient satisfaction after knee arthroplasty:
A report on 27,372 knees operated on between 1981 and
1995 in Sweden. Acta Orthop Scand 2000;71(3):262-267. 8. Cracchiolo A III, Benson M, Finerman GA, Horacek K,
Medline DOI Amstutz HC: A prospective comparative clinical analy-
sis of the first-generation knee replacements: Polycentric
vs. geometric knee arthroplasty. Clin Orthop Relat Res
2. Scott CE, Howie CR, MacDonald D, Biant LC: Predict-
1979;145:37-46. Medline
ing dissatisfaction following total knee replacement: A
prospective study of 1217 patients. J Bone Joint Surg Br
2010;92(9):1253-1258. Medline DOI 9. Lewallen DG, Bryan RS, Peterson LF: Polycentric total
knee arthroplasty: A ten-year follow-up study. J Bone
This prospective study evaluated patients undergoing Joint Surg Am 1984;66(8):1211-1218. Medline
TKA. Outcome scores were recorded preoperatively and
6 months postoperatively: 18.6% of patients were unsure 10. Mont MA, Elmallah RK, Cherian JJ, Banerjee S, Ka-
of or dissatisfied with their knee replacement. Predictors padia BH: Histopathological Evaluation of the Anterior
for dissatisfaction included low preoperative mental health Cruciate Ligament in Patients Undergoing Primary Total
scores, depression, and other pain sources. Expectations Knee Arthroplasty. J Arthroplasty 2016;31(1):284-289.
were correlated with satisfaction. Medline DOI
3. Lützner C, Kirschner S, Lützner J: Patient activity after This study evaluated the ACL in 174 knees undergoing
TKA depends on patient-specific parameters. Clin Orthop TKA. The ACL was present in 143 of knees (82%). Mac-
Relat Res 2014;472(12):3933-3940. Medline DOI roscopically, it was intact in 43 (30%), frayed in 85 (59%),
Section 2: Knee
and torn in 15 (11%). Histopathologic changes such as 23. Cloutier JM, Sabouret P, Deghrar A: Total knee arthro-
myxoid degeneration, vascular proliferation, and chon- plasty with retention of both cruciate ligaments: A nine
droid metaplasia were seen in 85%. Increased age and to eleven-year follow-up study. J Bone Joint Surg Am
body mass index were associated with histologic change. 1999;81(5):697-702. Medline
11. Rand JA, Coventry MB: Ten-year evaluation of geo- 24. Sabouret P, Lavoie F, Cloutier JM: Total knee replace-
metric total knee arthroplasty. Clin Orthop Relat Res ment with retention of both cruciate ligaments: A 22-
1988;232:168-173. Medline year follow-up study. Bone Joint J 2013;95-B(7):917-922.
Medline DOI
12. Cloutier JM: Results of total knee arthroplasty with This study reported long-term follow-up of 163 bicruci-
a non-constrained prosthesis. J Bone Joint Surg Am ate-retaining Hermes 2C TKAs, even in those with ap-
1983;65(7):906-919. Medline parently degenerate ACLs: 82% survivorship for revision
for any reason was reported at 22 years. A 4.3% rate of
13. Petersen W, Zantop T: Anatomy of the anterior cruciate aseptic loosening was found. A degenerative ACL at the
ligament with regard to its two bundles. Clin Orthop Relat time of the procedure was not a risk factor for revision.
Res 2007;454(454):35-47. Medline DOI
25. Jenny JY, Jenny G: Preservation of anterior cruciate lig-
14. Bull AM, Kessler O, Alam M, Amis AA: Changes in knee ament in total knee arthroplasty. Arch Orthop Trauma
kinematics reflect the articular geometry after arthro- Surg 1998;118(3):145-148. Medline DOI
plasty. Clin Orthop Relat Res 2008;466(10):2491-2499.
Medline DOI 26. Migaud H, De Ladoucette A, Dohin B, Cloutier JM, Gou-
geon F, Duquennoy A: [Influence of the tibial slope on
15. Pinskerova V, Johal P, Nakagawa S, et al: Does the tibial translation and mobility of non-constrained total
femur roll-back with flexion? J Bone Joint Surg Br knee prosthesis]. Rev Chir Orthop Reparatrice Appar
2004;86(6):925-931. Medline DOI Mot 1996;82(1):7-13. Medline
16. Fuchs S, Tibesku CO, Genkinger M, Laass H, Rosen- 27. Pritchett JW: A comparison of the noise generated
baum D: Proprioception with bicondylar sledge prosthe- from different types of knee prostheses. J Knee Surg
ses retaining cruciate ligaments. Clin Orthop Relat Res 2013;26(2):101-104. Medline
2003;406:148-154. Medline DOI
This study prospectively monitored noise following bi-
17. Andriacchi TP, Galante JO, Fermier RW: The influence lateral TKA using several implant designs, including bi-
of total knee-replacement design on walking and stair- cruciate-retaining implants. Noise was less common in
climbing. J Bone Joint Surg Am 1982;64(9):1328-1335. both the bicruciate-retaining implants and medial-pivot
Medline implants compared with all other prostheses. Only 4%
of patients with the bicruciate-retaining and 12% of pa-
2: Knee
tients with the medial-pivot implant reported noise-related

18. Komistek RD, Allain J, Anderson DT, Dennis DA, Goutal- symptoms compared with 31% to 42% of patients with
lier D: In vivo kinematics for subjects with and without other implant types.
an anterior cruciate ligament. Clin Orthop Relat Res
2002;404:315-325. Medline DOI
28. Cherian JJ, Kapadia BH, Banerjee S, Jauregui JJ, Har-
win SF, Mont MA: Bicruciate-retaining total knee ar-
19. Stiehl JB, Komistek RD, Cloutier JM, Dennis DA: The throplasty: A review. J Knee Surg 2014;27(3):199-205.
cruciate ligaments in total knee arthroplasty: A kinematic Medline DOI
analysis of 2 total knee arthroplasties. J Arthroplasty
2000;15(5):545-550. Medline DOI This review article of the history, kinematics, clinical out-
comes, and future outlook of bicruciate-retaining TKA
20. Mahoney OM, Noble PC, Rhoads DD, Alexander JW, reported that the bicruciate-retaining TKA may better
Tullos HS: Posterior cruciate function following total mimic the natural knee in a population of younger, more
knee arthroplasty: A biomechanical study. J Arthroplasty athletic patients requiring TKA.
1994;9(6):569-578. Medline DOI
29. Lombardi A, McCanahan A, Berend K: The bicruciate-
21. Moro-oka TA, Muenchinger M, Canciani JP, Banks retaining TKA: Two is better than one. Semin Arthro-
SA: Comparing in vivo kinematics of anterior cruci- plasty 2015;26(2):51-58. DOI
ate-retaining and posterior cruciate-retaining total knee This review article discusses the history and evolution of
arthroplasty. Knee Surg Sports Traumatol Arthrosc bicruciate-retaining TKA. The design, changes, and early
2007;15(1):93-99. Medline DOI experience with a contemporary bicruciate-retaining TKA
are detailed.
22. Townley CO: The anatomic total knee resurfacing arthro-
plasty. Clin Orthop Relat Res 1985;192:82-96. Medline
Chapter 13
Unicompartmental, Patellofemoral,
and Bicompartmental
Knee Arthroplasty
Mohamad J. Halawi, MD Joseph L. Yellin, MD Anil Ranawat, MD Jibanananda Satpathy, MD, MRCSEd
Gregory J. Golladay, MD Jess H. Lonner, MD Wael K. Barsoum, MD
Abstract Keywords: knee arthroplasty; unicompartmental;

patellofemoral; bicompartmental
The use of unicompartmental knee arthroplasty and
patellofemoral arthroplasty is increasing because of
enhanced instrumentation, newer implant designs, and Introduction
interest in kinematic preservation and rapid recovery. It
Although unicompartmental knee arthroplasty (UKA)
is important to be knowledgable about indications and
and patellofemoral arthroplasty (PFA) are not n ovel con-
contraindications for optimal outcomes.
cepts, evolving indications for these procedures, enhanced
instrumentation, newer implant designs, and interest
Dr. Yellin or an immediate family member has stock or stock options held in Eli Lilly and Merck. Dr. Ranawat or an im-
2: Knee
mediate family member has received royalties from ConforMIS; is a member of a speakers’ bureau or has made paid
presentations on behalf of CONMED Linvatec, DePuyMitek, and Stryker MAKO; serves as a paid consultant to CONMED
Linvatec, DePuyMitek, and Stryker MAKO; has stock or stock options held in ConforMIS; and serves as a board member,
owner, officer, or committee member of the EOA. Dr. Golladay or an immediate family member has received royalties
from OrthoSensor; is a member of a speakers’ bureau or has made paid presentations on behalf of OrthoSensor; serves
as a paid consultant to Cayenne Medical, OrthoSensor, and Stryker; has stock or stock options held in OrthoSensor; has
received research or institutional support from OrthoSensor; and serves as a board member, owner, officer, or commit-
tee member of the American Association of Hip and Knee Surgeons, the Medical Society of Virginia, and the Virginia
Orthopaedic Society. Dr. Lonner or an immediate family member has received royalties from Zimmer Biomet, Blue Belt
Technologies, and Smith & Nephew; is a member of a speakers’ bureau or has made paid presentations on behalf of
Zimmer Biomet, Blue Belt Technologies, and Smith & Nephew; serves as a paid consultant to Blue Belt Technologies,
CD Diagnostics, Smith & Nephew, and Zimmer Biomet; has stock or stock options held in Blue Belt Technologies, CD
Diagnostics, and Healthpoint Capital; has received research or institutional support from Zimmer Biomet and Blue Belt
Technologies; and serves as a board member, owner, officer, or committee member of the Knee Society. Dr. Barsoum
or an immediate family member has received royalties from Exactech, Stryker, and Zimmer Biomet; is a member of a
speakers’ bureau or has made paid presentations on behalf of Stryker; serves as a paid consultant to Stryker; has stock or
stock options held in Custom Orthopaedic Solutions, iVHR, and OtisMed; has received research or institutional support
from Active Implants, Cool Systems, DJO, OrthoSensor, Orthovita, Stryker, and Zimmer Biomet; has received nonincome
support (such as equipment or services), commercially derived honoraria, or other non–research-related funding (such as
paid travel) from KEF Healthcare (Board Member). Neither of the following authors nor any immediate family member
has received anything of value from or has stock or stock options held in a commercial company or institution related
directly or indirectly to the subject of this chapter: Dr. Halawi and Dr. Satpathy.
Section 2: Knee
among both patients and surgeons in kinematic pres- perform a fixed-bearing UKA in an ACL-deficient knee,
ervation and rapid recovery have further expanded the as long as there is no functional instability and the tibial
adoption of these procedures (in isolation or combined chondral wear pattern is in the anterior half of the pla-
as bicompartmental knee arthroplasty, BKA). Because teau. Another traditional contraindication to medial UKA
of the increase in the number of patients with arthritis is the presence of anterior knee pain and/or degeneration
of the knee, the merits of partial knee arthroplasty can of the patellofemoral joint, despite recent studies showing
be realized by a larger segment of the population with otherwise. One study analyzed a cohort of 100 knees
focal knee arthritis by using appropriate indications and (in 91 patients) that underwent medial UKA; 54% had
educational efforts. anterior knee pain, and 54% demonstrated degenerative
changes of the patellofemoral joint.8 No significant dif-
ferences in outcome (Oxford knee score and Knee Soci-
Medial UKA ety Score, KSS) were noted between the two cohorts at
Indications/Contraindications 2-year follow-up. In fact, anteromedial pain is common in
The indications for medial UKA are not universally agreed isolated medial compartment osteoarthritis and is effec-
upon, but the stringent criteria originally proposed in tively treated with both fixed- and mobile-bearing UKA.
19891 have continued to provide a fundamentally sound Anterolateral pain and lateral patellar facet and lateral
and broadly accepted framework. These indications in- trochlear arthritis may be best managed with total knee
clude osteoarthritis isolated to the medial compartment, arthroplasty (TKA) or BKA.
age older than 60 years, weight less than 82 kg (181 lb), The primary indication for medial UKA should be
low activity level, minimal pain at rest (noninflammatory isolated, end-stage medial compartment osteoarthritis in
etiology), intact anterior cruciate ligament (ACL), flexion a knee with at least 90° flexion arc, less than 5° flexion
arc of at least 90°, and minimal fixed deformities (less than contracture, and less than 10° coronal angulation. Data
5° flexion contracture and less than 10° varus angulation).1 continue to emerge in obese patients, younger patients,
Although contraindications to UKA are considered to and those with high activity levels with limited long-term
be any violations of the aforementioned criteria, several experience. Management of expectations is important in
recent studies have called these into question, especially those patients. Inflammatory arthritis and presence of
with regard to activity level, obesity, ACL insufficiency, severe pain or advanced osteoarthritis in another com-
and the presence of anterior pain or anterior chondroma- partment are contradictions to isolated medial UKA. The
lacia. One study demonstrated a 94% UKA survival rate requirement of an intact ACL is controversial. Although
in a cohort of 62 patients aged 60 years or younger (mean short- and mid-term evidence does not show adverse
2: Knee
age, 54 years) at 12 years postoperatively, with more than outcomes in fixed-bearing UKA, long-term studies are
80% of the patients returning to sports activities.2 UKA needed to ascertain the validity of this requirement.
in obese patients also continues to lack consensus in the
literature. A 2011 study demonstrated a higher failure Preoperative Evaluation
rate in the obese cohort at a minimal 2-year follow-up A thorough preoperative history and physical examina-
because of progression of painful arthritis, tibial compo- tion must be performed, in addition to the evaluation of
nent loosening, and/or intractable pain.3 Other studies, in appropriate radiographic studies, to ensure the aforemen-
contrast, found no significant association between body tioned indications and contraindications for medial UKA
mass index (BMI) and implant survival at short- and have been addressed. A surgical candidate’s history should
long-term follow-up, respectively.4,5 reveal progressive medial knee pain that has markedly
ACL deficiency has traditionally been a contraindica- affected the patient’s quality of life and/or has interfered
tion to medial UKA, particularly for mobile-bearing im- with normal daily activities. A history of inflammatory
plants. Because the ACL primarily restrains anterior tibial arthritis should be ruled out as the etiology. Surgery
translation relative to the femur, patients with deficient should be recommended only after an osteoarthritic eti-
ACLs have altered biomechanics that result in posterior ology has been determined and all nonsurgical treatment
contact loading and increased strain of the anterior tibial options have failed. The patient’s activity level, weight,
bone–cement interface that can result in tibial loosen- BMI, and age should also be assessed.
ing.6 However, a recent study7 reported no significant dif- Physical examination should not reveal erythema or
ference in the survivorship of fixed-bearing UKA (majority increased temperature over the affected area, as this may
medial UKA, 62 of 68) between ACL-intact patients and indicate an infectious or systemic etiology. Range of mo-
ACL-deficient patients in the absence of clinical instability tion (ROM) should be greater than 90°. A flexion contrac-
at 6 years postoperatively.7 Therefore, it is reasonable to ture, if present, should not exceed 5° to 10°. The lateral
Chapter 13: Unicompartmental, Patellofemoral, and Bicompartmental Knee Arthroplasty
Figure 1 A, Preoperative AP (left) and lateral (right) radiographs obtained from a 49-year-old woman with a 5-year history
of right knee pain. B, AP (left) and lateral (right) views for this patient 4 weeks after medial unicompartmental
knee arthroplasty.
meniscus should be evaluated, with no lateral pathology Regardless of implant type used, the key predictors
evident on the flexion McMurray test or palpation of the of successful outcomes with medial UKA procedures in-
lateral joint line. The integrity of the ACL should be as- clude accuracy of the mechanical axis, accurate implant
sessed with both the Lachman and pivot shift tests. Varus positioning, and proper ligament balancing.12 Earlier sur-
deformities should be partially correctable with valgus gical techniques relied on standard jigs, based on tech-
stressing in 20° of flexion on physical examination or un- niques used in TKA, to produce accurate intraoperative
der 10° if fixed, although accurate determination of cor- alignment. This so-called conventional UKA uses either
rectability is not possible until osteophytes are removed.9 extramedullary or intramedullary instrumentation to
On radiographic assessment, only the medial compart- make appropriately angled tibial and femoral osteoto-
ment should demonstrate signs of osteoarthritis to be a mies.13 However, the literature has demonstrated that
strong medial UKA candidate (Figure 1). Standing AP, many conventional systems are inherently limited and
bilateral PA in flexion, and lateral views are used to assess possibly inaccurate (conceivably because of the limited
the degree of osteoarthritis and may reveal osteophytes, visibility/exposure of UKA compared with TKA), thus
sclerosis, joint space narrowing, subchondral cysts, and requiring a great deal of surgical judgment both preop-
signs of bone loss. Minimal tibiofemoral subluxation is eratively and intraoperatively.12
acceptable. On the lateral view, identification of postero- Computer-assisted or computer-navigated UKA uses
2: Knee
medial tibial wear can be a sign of chronic ACL insuffi- infrared stereoscopic cameras to monitor position sensors
ciency. A sunrise view can help assess degeneration of the attached to the patient’s femur and tibia and surgical
patellofemoral joint. Long leg radiographs are useful in instruments to create a digital model of the joint.14 Re-
assessing overall alignment and surgical planning. MRI al-time visualization of this model is then used throughout
may be obtained if there is concern for ligamentous, chon- the case, especially during implant positioning, to ensure
dral, or meniscal injury in the lateral and patellofemoral proper alignment.14 However, in a recent study comparing
compartments. mechanical axis, hip-knee-ankle angle, coronal implant
The preoperative evaluation should also include a de- alignment, and tibial implant posterior slope between
scription of the intended operation and common risks conventional and navigated cohorts, a significant differ-
and benefits of the procedure, including the potential ence was noted only in the tibial posterior slope.14
conversion to TKA if deemed necessary. Robotic-assisted UKA is rapidly gaining popularity.
In 2006, MAKO Surgical Corporation produced the
Surgical Technique first FDA-approved haptic-controlled passive robotic
In medial UKA, the two prevailing bearing designs are arm (such as using tactile feedback and control to inter-
fixed and mobile bearing. In the fixed-bearing design, sta- act with the computer interface) for medial UKA. The
bility is mildly restricted by its nonconforming articulat- preoperative computer planning interface and intraop-
ing surface, thus predisposing the implants to peripheral erative surgeon-controlled high-speed burr, controlled
wear and repetitive edge loading.10 However, proponents by tactile guidance, allows the surgeon to resurface only
of fixed-bearing UKA favor its relative technical ease degenerative knee surfaces and to preserve healthy bony
of implantation, specifically regarding ligamentous bal- and soft-tissue structures, while ensuring optimal me-
ancing, and its decreased risk of implant dislocation, chanical axis, femorotibial alignment, tibial slope, and
compared with mobile-bearing UKA.11 implant alignment.15 In a comparison of 44 conventional
Section 2: Knee
and 33 robotic-assisted UKAs, implant positioning ac- Medial UKA Versus TKA
curacy in the sagittal plane in robotic-assisted UKA was
improved by a factor of 2.8 compared with conventional UKA survival rates have been consistently reported as
methods. Additionally, the robotic-assisted cohort demon- inferior to those of TKA.22 Large-scale national registry
strated an improved average root-mean-square error of data, based on patient-reported outcome scores, demon-
3.2° in the coronal plane.16 Newer image-free robotic strated no advantage in satisfaction or functional im-
technology that uses a freehand sculpting tool has shown provement in UKA compared with TKA.23 However, in
equivalent precision and an ability to quantify soft-tissue a study during which a matched comparison of UKA and
balance without the need for preoperative CT scan. Reg- TKA based on data from the National Joint Registry for
istration and mapping are performed entirely intraoper- England and Wales was performed, myriad advantages
atively, and protection against inadvertent bone removal of UKA over TKA were described, including significant
is performed by modulating the exposure or speed of reductions in morbidity and mortality.24 Furthermore,
the sculpting burr.17,18 Additionally, by eliminating the UKA patients were found to have reduced intraoperative
CT scan required for preoperative planning, this robotic complications, a shorter hospital stay (mean reduction,
device minimizes exposure to unnecessary radiation. 1.4 days), and a lower readmission rate within the first
year.24
Outcomes Although revision rates tend to be higher in UKA,
When examining outcomes of medial UKA, useful it is important to remember the potential numerous
information can be gleaned through comparisons be- short-term benefits detailed above. It is worth noting
tween fixed versus mobile bearings, metal-backed ver- that higher UKA revision rates may be driven by the fact
sus all-polyethylene tibial components, and medial UKA that UKA revision is generally a far less complicated and
versus TKA. time-intensive procedure, thus potentially lowering the
threshold for revision surgery.25
Fixed Versus Mobile-Bearing Components
No consensus currently exists as to whether fixed- or
mobile-bearing UKA provides better overall long-term Lateral UKA
results. In a prospective, randomized, controlled trial,19 no Isolated lateral compartment arthritis is seen in about
significant difference in clinical outcomes was noted be- 5% to 10% of patients with knee osteoarthritis.26 Ac-
tween the different designs.19A systematic review was cordingly, lateral UKA accounts for only a small pro-
recently conducted, including only comparative studies portion of the partial knee arthroplasty procedures and
2: Knee
between fixed- and mobile-bearing implants, focusing on approximately 1% of all lower extremity arthroplasties
complications.11 The most common reason for reopera- performed.
tion in mobile-bearing UKA was progression of arthritis,
followed by aseptic loosening and bearing dislocation. Indications/Contraindications
In the fixed-bearing group, the most common reason Ideal candidates for lateral UKA are similar to those de-
for reoperation was wear, followed by progression of scribed for medial UKA. Patients should have exhausted
arthritis, aseptic loosening, and persistent unexplained all nonsurgical management of their condition and expe-
pain. However, the overall rate of reoperation in the two rience pain and functional deficits that affect their daily
groups was nearly identical. quality of life. Osteoarthritis, traumatic arthropathy, and
osteonecrosis are the most frequent diagnoses. Inflamma-
Metal-Backed Versus All-Polyethylene Components tory arthropathy is generally considered a relative con-
A 2013 study analyzed 160 metal-backed, fixed-bearing traindication. Comorbid conditions need to be optimized
medial UKAs at mean follow-up of 20 years (range, 0 to as for any elective surgery, and patient expectations need
20 years) and reported 74% implant survival and ex- to be set appropriately relative to expected outcomes,
cellent clinical outcomes as measured by KSS knee and recovery, and risk.
function scores at most recent follow-up.20 A 2014 study
demonstrated similar improvements in KSS knee and Preoperative Evaluation
function scores using all-polyethylene tibial components Patients with isolated lateral compartment arthrosis will
in 53 medial UKAs.21 However, there have been no ef- have pain localized exclusively laterally. Physical examina-
fective head-to-head trials comparing metal-backed with tion should confirm ROM greater than 90° to 100° with
all-polyethylene UKA. less than 10° of flexion contracture, less than 10° of fixed
valgus deformity, stable collateral and cruciate ligaments,
Figure 2 A, Preoperative AP (left) and lateral (right) radiographs obtained from a 61-year-old man with right knee pain for
approximately 10 years following a skiing accident. B, AP (left) and lateral (right) views for this patient 4 weeks
after lateral unicompartmental knee arthroplasty.
and ideally, BMI less than 30 kg/m 2. Imaging, including lateralized to fill the flexion gap to minimize impingement
weight-bearing AP, lateral, PA flexion, sunrise, and long on the lateral patellar facet and to promote congruent
leg alignment radiographs, are used to confirm advanced articulation with the tibia in terminal extension because
radiographic changes (Figure 2). The PA flexion view is of the screw home mechanism. Conversely, care should
helpful because of the predictable posterior tibial wear be taken to internally rotate the tibial component to aid
pattern. The deformity should be passively correctable, in tibiofemoral congruency in terminal extension.28 It
so stress radiographs can be useful. is important not to overload the medial compartment,
A history of anterior knee pain, examination demon- and typically, lateral UKAs feel slightly looser compared
strating patellofemoral crepitus or apprehension, or ra- with medial UKAs. Natural tibial slope should be repro-
diographic findings of joint space narrowing, sclerosis, or duced. To avoid edge loading due to excessive external
osteophytes in other compartments are relative contra- rotation of the tibial component, it is advisable to check
indications to lateral UKA. If patellofemoral arthrosis is in full extension before doing the sagittal cut of the tibia.
present, lateral facet changes are more likely well tolerated Undercutting or damaging the ACL insertion should be
than medial disease, because deformity correction will carefully avoided.
tend to shift patellar contact medially.
2: Knee
Outcomes
Surgical Technique Survivorship of lateral UKA is similar to that reported for
The surgical approach can be either medial or lateral TKA and is equivalent to medial UKA: 93% at 5 years
parapatellar, depending on the surgeon’s preference. A (mean, 3.5 years; range, 0 to 7 years) in one registry
lateral parapatellar incision facilitates a less-invasive study.29 In this database, revisions were most common
technique and allows easier soft-tissue balancing. Expo- for aseptic loosening or unexplained pain. Other stud-
sure is facilitated with figure-of-4 positioning of the leg. ies reported approximately a 1% risk of failure per year
Extension tightness can be alleviated with release of the with 92% survivorship at 10 years and 84% at 16 years
posterolateral capsule and arcuate ligament. Care should (mean, 12.6 years; range, 3 to 23 years).30 In an analysis
be taken to avoid damage to the intermeniscal ligament to of 16 revised UKAs, the mean time to failure was approx-
preserve the functional integrity of the medial meniscus. imately 9 years, with 43.8% of the revisions occurring in
Some surgeons prefer a medial parapatellar approach the first 5 years.31 The longest follow-up so far reported
for all cases in the event that intraoperative conversion in the literature showed 72% survivorship at 25 years
to TKA is necessary.27 (mean, 10.6 years; range, 1 to 22 years) using a cemented
Bony preparation is performed by several possible all-polyethylene tibia.32
means, including standard instrumentation with or Less invasive approaches may adversely affect implant
without navigation, custom instrumentation, or robotic positioning33 and risk loosening or reoperation.34 Al-
assistance. It is important to size the femoral component though computer- or robotic-assisted procedures im-
appropriately to avoid encroachment on the trochlea, prove radiographic alignment,35 especially in the sagittal
which results in patellar impingement. Minimal femoral plane, there are no long-term data to suggest superiority
resection is recommended to avoid joint line elevation. of one method versus another. Nevertheless, maintaining
The femoral component should be rotated externally and a tibial slope of less than 7° results in lower loosening
Section 2: Knee
rates.36 In addition, 10° to 15° of internal rotation of the isolated patellofemoral resurfacing. Patients with inap-
tibial component28 and residual valgus alignment of 3° propriate expectations and those with unusually excessive
to 7° compared with overcorrection appear to favorably pain requiring narcotics may not be suitable candidates.
affect survivorship.37 Flexion contractures and limited ROM as discussed pre-
Lateral UKA provides good-to-excellent outcomes for viously are contraindications because they subject the
isolated valgus osteoarthritis in the majority of patients, patellofemoral articulation to excessive loads and are
and survivorship is equivalent to medial UKA and TKA, indicative of knee pathology that extends beyond the
even in patients younger than 60 years. Patient selec- patellofemoral compartment. Although there are intuitive
tion, appropriate implants, and surgical technique are concerns, there are no data available on whether obesity
the primary determinants of outcomes. Most revisions or cruciate ligament insufficiency puts the PFA at risk
are due to progression of arthritis,38 aseptic loosening, for failure.
wear, or unexplained pain and have results equivalent to
TKA revision.29 Caution should be exercised with implant Preoperative Evaluation
choice, as there is a higher risk of bearing dislocation A detailed history and physical examination are usually
with flat mobile-bearing implants, with rates as high as sufficient to localize the pain to the anterior compartment
6.2% at 3 years.39 Technical and recent implant design of the knee. Several key components of the history include
modifications appear to have reduced the incidence of determining whether there was previous trauma, a his-
lateral meniscal bearing dislocation.40 Conversion of a tory of subluxation or dislocation, or previous treatments
failed UKA to TKA is technically comparable to revision that failed or succeeded in relieving the pain. The pain
TKA and has similar results.41 associated with patellofemoral chondromalacia is almost
always directly retropatellar or just medial or lateral to
the patella. Typically, patellofemoral pain worsens when
Patellofemoral Arthroplasty walking stairs or hills, squatting, sitting for a long time,
PFA is an effective treatment of isolated patellofemoral and rising from a seated position. Patellofemoral crepitus
arthritis, which has been reported to occur in 9.2% of is also very common. Other causes of anterior knee pain
patients younger than 40 years.42 In symptomatic knees, must be ruled out, including patellar tendinitis, quadri-
11% of men and 24% of women may have isolated pa- ceps tendinitis, prepatellar or pes anserine bursitis, medial
tellofemoral arthritis.43 The predilection for patellofem- or lateral meniscal tear, and concomitant tibiofemoral
oral arthritis in women may arise from subtle patellar arthritis.
malalignment and an increased incidence of trochlear The physical examination should assess patellar track-
2: Knee
dysplasia. ing, determine whether the pain is localized to the pa-

tellofemoral compartment, and confirm that it is caused
Indications/Contraindications by arthritis. Patellar inhibition and compression should
The primary indication for PFA is isolated patellofemo- produce pain and crepitus. Any associated tenderness
ral degenerative disease. Pain should be restricted to the along the medial or lateral joint lines should raise the
retropatellar and/or peripatellar areas, and it is increased suspicion of more diffuse chondral injury and menis-
with provocative activities such as stair or hill ambulation, cal pathology and are contraindications to isolated PFA.
squatting, or prolonged sitting. Contraindications to PFA Careful assessment of patellar tracking and the Q angle
include considerable uncorrectable patellar maltracking or are extremely important. If there appears to be associ-
malalignment, inflammatory arthritis, and degenerative ated malalignment or evidence of subluxation, then pa-
changes in the tibiofemoral surfaces. Moderate patellar tellar realignment may be needed before or during PFA.
tilt or subluxation observed on preoperative tangential ROM testing should show full extension and a reasonable
radiographs or at the time of arthrotomy and trochlear amount of flexion.
dysplasia can easily be corrected with a lateral retinacu- Radiographic evaluation with weight-bearing AP and
lar recession or release and are ideal conditions for PFA. midflexion PA views are important to rule out tibiofem-
Patients with excessive Q angles should undergo tibial oral arthritis (Figure 3). Mild squaring of the femoral
tubercle realignment before or during PFA (although some condyles and small marginal osteophytes are acceptable
trochlear prosthesis shapes may accommodate a slightly provided there is no pain or chondromalacia. Lateral
increased Q angle). There are no age criteria for PFA pro- radiographs may show patellofemoral osteophytes, joint
vided the other criteria are met.44 The presence of medial space narrowing, and the presence of patella alta or baja
or lateral joint line pain suggests more diffuse chondral (Figure 4). Axial films can demonstrate the position of the
disease and should be considered a contraindication to patella in the trochlear groove and whether there is any
Figure 4 Preoperative lateral radiograph demonstrates

Figure 3 Preoperative weight-bearing AP radiograph
patellofemoral arthritis. (Reproduced
demonstrates patellofemoral arthritis.
from Newman MT, Lonner JH, Ries M:
(Reproduced from Newman MT, Lonner JH,
Unicompartmental, patellofemoral, and
Ries M: Unicompartmental, patellofemoral,
bicompartmental arthroplasty, in Glassman
and bicompartmental arthroplasty, in
AH, Lachiewicz PF, Tanzer M, eds: Orthopaedic
Glassman AH, Lachiewicz PF, Tanzer M, eds:
Knowledge Update: Hip and Knee
Orthopaedic Knowledge Update: Hip and Knee
Reconstruction 4. Rosemont, IL, American
Academy of Orthopaedic Surgeons, 2011, pp
Academy of Orthopaedic Surgeons, 2011, pp
107-118.)
107-118.)
trochlear dysplasia, patellar tilt, or subluxation (Figure 5).

MRI can help determine whether there is cartilage loss in
2: Knee
the tibiofemoral compartments. Although patients with
patellofemoral pain may show increased activity within
the patellofemoral joint with technetium scans, this im-
aging modality is unnecessary for evaluating the patient
with PF arthritis. If applicable, previous arthroscopy pho-
tos should be reviewed to confirm isolated patellofemoral
arthritis and rule out associated tibiofemoral pathology.
Surgical Technique
Several key steps in the procedure will enhance surgical
outcomes. The first is ensuring that the trochlear com- Figure 5 Preoperative axial radiograph demonstrates
ponent is externally rotated so that it is parallel to the bilateral patellofemoral arthritis. (Reproduced
from Newman MT, Lonner JH, Ries M:
epicondylar axis (or perpendicular to the AP axis of the Unicompartmental, patellofemoral, and
femur), thus ensuring proper patellar tracking. This pre- bicompartmental arthroplasty, in Glassman
requisite is impossible with inlay designs, which tend to AH, Lachiewicz PF, Tanzer M, eds: Orthopaedic
Knowledge Update: Hip and Knee
be internally rotated as a result of their alignment with Reconstruction 4. Rosemont, IL, American
the anterior trochlear peaks, accounting for the very high Academy of Orthopaedic Surgeons, 2011, pp
incidence of patellar catching and subluxation.45 Mar- 107-118.)
ginal osteophytes bordering the intracondylar notch are

removed. The trochlear component should not overhang
the medial-lateral femoral margins or impinge on the in- be flush with or recessed approximately 1 mm from the
tercondylar notch. Preparation of the trochlear bed should adjacent articular condylar cartilage. Resurfacing the
Section 2: Knee
Figure 6 AP (A), lateral (B), and axial (C) radiographs of a knee obtained following patellofemoral arthroplasty.
(Reproduced from Newman MT, Lonner JH, Ries M: Unicompartmental, patellofemoral, and bicompartmental
arthroplasty, in Glassman AH, Lachiewicz PF, Tanzer M, eds: Orthopaedic Knowledge Update: Hip and Knee
Reconstruction 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2011, pp 107-118.)
patella should follow the same principles as TKA, with

restoration of proper patellar thickness and medializa-
tion of the component. The lateral patellar facet should
be removed or beveled to avoid lateral impingement and
enhance patellar tracking (Figure 6).
With the trial components in place, patellar tracking
is assessed. If patellar tilt, subluxation, or catching of
components is present, proper component position must
be ensured and any deficiencies corrected. A lateral reti-
nacular recession or release can be performed. In severe
cases of subluxation, a proximal realignment may be nec-
essary; if the Q angle is high, tibial tubercle realignment
should be considered.
2: Knee
Outcomes
The critical distinction between success and failure af-
ter PFA is determined by whether the patellar prosthesis
Figure 7 Axial CT scan shows internal rotation of
tracks well in the trochlear prosthesis because a poorly inlay-style trochlear components relative
tracking patellar prosthesis, other than slight tilt and mild to the anterior-posterior axis of the femur,
subluxation, will be evident and compromise function resulting in lateral patellar subluxation.
Revision of the trochlear component to
and outcome within 6 months of surgery.45 an onlay-type prosthesis was successful.
Several trochlear design features, including its sagittal (Reproduced from Newman MT, Lonner JH,
Ries M: Unicompartmental, patellofemoral,
radius of curvature, proximal extension, width, thickness, and bicompartmental arthroplasty, in
tracking angle, asymmetry, constraint, and perhaps most Glassman AH, Lachiewicz PF, Tanzer M, eds:
importantly, whether it is an inlay- or onlay-style prosthe- Orthopaedic Knowledge Update: Hip and Knee
sis, can affect patellar tracking. Thorough review of the Academy of Orthopaedic Surgeons, 2011, pp
literature provides evidence that the need for secondary 107-118.)
surgery to correct patellar maltracking and frank failures
caused by patellar instability are substantially higher with
inlay-style trochlear implants compared with onlay-style axis of the femur, flush with the anterior femoral cortex.
trochlear implants.45 Inlay-style trochlear components, These components have resulted in more optimal patellar
which are positioned flush with the peaks of the articu- tracking and minimized the need for secondary surgeries
lar cartilage surfaces of the anterior trochlea, tend to be to address patellar tracking45 (Figure 7). Component loos-
internally rotated, leading to a high incidence of patellar ening and wear are rare. In the event that conversion to
instability. However, onlay-style components are posi- TKA is necessary, retaining a well-positioned and unworn
tioned perpendicular to the anteroposterior (Whiteside) all-polyethylene patellar component is recommended.
Figure 8 Preoperative AP (A) and Merchant (B) views obtained from a 36-year-old woman with a history of patellar
dislocations in the left knee, a medical history indicative of Ehlers-Danlos syndrome hypermobility-type, as well
as patellar realignment surgery. AP (C) and Merchant (D) views obtained 6 weeks after patellofemoral and lateral
unicompartmental arthroplasty.
Although PFA can be provided safely, management inflammatory arthritis, and previous ligamentous recon-
of patients undergoing PFA can be challenging because struction or periarticular osteotomies.49
of unique perceptions of pain and an abundance of psy-
chiatric conditions, which may have an effect on clinical Preoperative Evaluation
outcomes, including patient satisfaction. For instance, Preoperative evaluation is important for appropriate
narcotic consumption for pain was found to be common, patient selection. History should elicit pain location,
and as many as 42% of PFA patients had a diagnosis of duration of symptoms, and presence of inflammatory
a preoperative psychiatric condition (usually anxiety or arthropathy, as well as prior injuries and treatment. Ten-
depression).46 Additionally, fewer than two-thirds of pa- derness on examination must be limited to the patellofem-
tients were satisfied or had their expectations met despite oral joint and one tibiofemoral compartment. Assessment
significant clinical improvements.47 Dissatisfied patients of ROM, coronal alignment, ligamentous stability, and
and those whose expectations were not met had signifi- presence of fixed-flexion contracture is necessary. Preop-
cantly lower mental health scores. erative imaging studies should include weight-bearing AP,
45° flexion, lateral, and patellofemoral (Merchant) views
(Figure 8). A stress view may be obtained if the coronal
2: Knee
Bicompartmental Arthroplasty deformity does not correct on clinical examination, al-
BKA is a relatively new alterative to TKA that seeks to though complete correction is not a requirement.51 MRI
address degenerative disease in the patellofemoral joint may aid in evaluating the quality of articular cartilage
and one compartment of the tibiofemoral joint. Among but is not routinely indicated.
patients undergoing knee arthroplasty in the United
States, the incidence of bicompartmental arthritis was Surgical Technique
reported to be 28%.48 Given the growing demand for knee Either a standard midline or medial curvilinear incision
arthroplasty in younger patients with bicompartmental is used. A medial parapatellar, lateral parapatellar, or
disease pattern, there has been a resurgence of interest subvastus arthrotomy is performed. Two implant types
in BKA as a bone- and bicruciate-preserving procedure, are available: a monolithic (single-piece) component or
especially given increased risk of future revision surgery modular, unlinked components (separate implants for
in this patient population and the desire for more normal each compartment). The complexity of surgery depends
kinematics and function. on the implant design used, with higher technical de-
mands reported using the monolithic implant. In a sin-
Indications/Contraindications gle-surgeon retrospective study, the learning curve for this
The indications for BKA are evolving. Current indications design was 40 cases, which correlated with a reduction
are similar to UKA, except that changes of any extent in surgical time from 114 minutes to 65 minutes.49 The
in the patellofemoral joint are permitted. Coronal and primary challenge with the monolithic design is that cor-
sagittal deformities should not exceed 10°, all ligaments onal alignment is dictated by the opposition of the lateral
should be clinically intact,49 and ROM should be more edge of the trochlear component on the nonresurfaced
than 90°.50 Contraindications include global knee pain, lateral femoral condyle.52 With high variability in the
advanced changes or symptoms in the third compartment, morphology of the distal femur, relying on implant fit
Section 2: Knee
in one compartment may lead to a sizing and alignment Preserving the cruciate ligaments and minimizing bone
mismatch in the other linked compartment. A custom-de- loss are appealing as increasingly younger patients have
signed monolithic implant based on CT of the individ- emerged as candidates for knee arthroplasty. Modular
ual knee is available and may theoretically allow more BKA appears to be a promising alternative to TKA, with
accurate positioning. Preparation of the proximal tibia equivalent preliminary outcomes. However, larger long-
is usually performed first in a similar manner to UKA. term prospective studies are needed to clearly establish
The tibia is cut perpendicular to the anatomic axis. The the utility, cost-effectiveness, and survival of BKA.
femoral condyle is then prepared after intramedullary
instrumentation. The flexion-extension gaps are assessed
with spacer blocks to ensure equal gaps after preparation, Summary
usually with the goal of 2° of undercorrection. Overcor- With appropriate patient selection and technique, UKA,
rection of the deformity should be avoided. The patella PFA, and BKA can be successful, less-invasive options for
is resurfaced in a manner similar to TKA. Robotic-arm localized degenerative knee disease. Surgical indications
assistance is available, which can optimize component and implant designs continue to evolve with promising
position and alignment.52 outcomes. Revision of a failed surgery to TKA is the
most commonly performed procedure and is favorably
Outcomes compared with revision TKA.
The outcomes of BKA are widely variable, with most
long-term studies reporting unacceptable results.53 The Key Study Points
monolithic design has been particularly associated with
higher incidence of patellofemoral complications. In a • The indications for UKA, PFA, and BKA continue
mid-term follow-up of 40 patients who had BKA using to evolve and have led to widespread use of these
one design, the rate of persistent anterior knee pain was procedures.
24%.51 These results were attributed to technical diffi- • Outcomes of each procedure are affected by im-
culties with this design, which could also compromise plant survival rates, common modes of failure, and
the appropriate patellar tracking. In another prospective revision surgery.
randomized trial of cruciate-retaining TKA versus BKA
followed for 2 years, there were no advantages of BKA
in clinical scores, functional testing, or patient satisfac- Annotated References
tion.54 Similar findings were identified in a 2014 study,55 in
2: Knee
which it was concluded that despite improvement in West- 1. Kozinn SC, Scott R: Unicondylar knee arthroplasty. J Bone
ern Ontario and McMaster Universities Osteoarthritis Joint Surg Am 1989;71:145-150. Medline
Index stiffness scores in those undergoing BKA, this
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JN: Function and quality of life following medial uni-
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The specific BKA design has since been withdrawn from age or younger. Orthop Traumatol Surg Res 2010;96:
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In contrast with the limited success of the monolithic Sixty-two UKAs in patients younger than 60 years were
design, excellent outcomes have been reported with use retrospectively reviewed with a minimum follow-up of
of modular, unlinked designs. These designs allow inde- 2 years (range, 2 to 19 years). UKA was associated with
improvements in Knee Injury and Osteoarthritis Out-
pendent sizing and alignments of each implant, thereby come Score, KSS, and UCLA score; 83.4% of patients
eliminating the technical problems of monolithic im- returned to preoperative sports activities and 90% re-
plants. A prospective, randomized trial compared TKA ported no or slight limitation during sports activities.
with BKA in 48 patients.56 At 5-year follow-up, there
were no significant differences between the two groups 3. Bonutti PM, Goddard MS, Zywiel MG, Khanuja HS,
in ROM, pain scores, and knee-specific scores. However, Johnson AJ, Mont MA: Outcomes of unicompartmental
there was significantly less intraoperative blood loss in the knee arthroplasty stratified by body mass index. J Arthro-
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BKA patients (29 received medial UKA and 1 lateral This study prospectively investigated the effect of BMI
UKA) were retrospectively reviewed.51 At a minimum on the clinical and radiographic outcomes in 80 UKAs
with a minimum follow-up of 2 years. Five UKAs were
follow-up of 2 years, there was significant improvement revised in the group with BMI greater than 35 kg/m 2 and
in functional scores, with no cases of patellar instability, none in the group with BMI less than 35 kg/m 2. Although
implant loosening, or progressive arthritis. all surviving UKAs showed no radiographic evidence of
loosening, KSS was lower in the group with BMI greater This article provides a review of UKA using either a mo-
than 35 kg/m 2. Level of evidence: II. bile- or fixed-bearing technique.
4. Naal FD, Neuerburg C, Salzmann GM, et al: Association 11. Ko YB, Gujarathi MR, Oh KJ: Outcome of unicompart-
of body mass index and clinical outcome 2 years after uni- mental knee arthroplasty: A systematic review of compar-
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Surg 2009;129:463-468. Medline DOI on complications. Knee SurgRelat Res 2015;27:141-148.
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5. Cavaignac E, Lafontan V, Reina N, et al: Obesity has no This is a systematic review comparing fixed and mobile
adverse effect on the outcome of unicompartmental knee UKA. Ten studies with variable levels of evidence were
replacement at a minimum follow-up of seven years. Bone included. No significant differences were reported in the
Joint J 2013;95-B:1064-1068. Medline DOI reoperation or complication rates among the two bearing
This study retrospectively reviewed the effects of weight designs. Level of evidence: II.
and BMI on implant survival in 212 UKAs with a mean
follow-up of 12 years (range, 7 to 22 years). The 10-year 12. Cossey AJ, Spriggins AJ: The use of computer-assisted
implant survival rates were not significantly different surgical navigation to prevent malalignment in unicom-
among those with BMI less than 30 kg/m 2 versus 30 kg/ partmental knee arthroplasty. J Arthroplasty 2005;20:
m 2 or greater, or weight less than 82 kg versus 82 kg or 29-34. Medline DOI
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13. Song EK, N M, Lee SH, Na BR, Seon JK: Comparison
6. Chen L, Liang W, Zhang X, Cheng B: Indications, out- of outcome and survival after unicompartmental knee
comes, and complications of unicompartmental knee arthroplasty between navigation and conventional tech-
arthroplasty. Front Biosci (Landmark Ed ) 2015;20: niques with an average 9-year follow-up. J Arthroplasty
689-704. Medline DOI 2016;31:395-400. Medline DOI
This article provides a review of the contemporary indi- Sixty-eight patients (average age, 64.0 years; range, 50 to
cations, outcomes, and complications of UKA. 81 years) who underwent UKA with either conventional
or navigational technique were prospectively followed.
7. Engh GA, Ammeen DJ: Unicondylar arthroplasty in knees Clinical evaluations were performed preoperatively. Out-
with deficient anterior cruciate ligaments. Clin Orthop comes at final follow-up included knee ROM, Hospital for
Relat Res 2014;472:73-77. Medline DOI Special Surgery scores, Western Ontario and McMaster
Universities Osteoarthritis Index scores, and visual analog
Sixty-eight fixed-bearing UKAs with intraoperatively con- scale pain score. For radiologic evaluation, the mechanical
firmed ACL deficiency were retrospectively reviewed with alignment of the lower limb was measured by using me-
a minimum follow-up of 2.9 years (range, 2.9 to 10 years). chanical femorotibial angle and Kennedy protocol. After
This cohort was compared with 706 UKAs in ACL-intact an average 9-year follow-up (range, 7.4 to 10.8 years), the
knees performed by the same surgeon using the same navigation group showed better coronal alignments of the
implant system. The results relating ACL deficiency to
2: Knee
components, fewer radiologic outliers, and better clinical
revision rates and implant survival were not significant. scores but similar estimated 10-year prosthesis survival
Level of evidence: III. rates. Level of evidence: III.
8. Beard DJ, Pandit H, Ostlere S, Jenkins C, Dodd CA, Mur- 14. Valenzuela GA, Jacobson NA, Geist DJ, Valenzuela RG,
ray DW: Pre-operative clinical and radiological assessment Teitge RA: Implant and limb alignment outcomes for con-
of the patellofemoral joint in unicompartmental knee re- ventional and navigated unicompartmental knee arthro-
placement and its influence on outcome. J Bone Joint Surg plasty. J Arthroplasty 2013;28:463-468. Medline DOI
Br 2007;89:1602-1607. Medline DOI
Fifty-eight UKAs performed with computer navigation
were retrospectively compared with 71 conventional UKAs
9. Kreitz TM, Maltenfort MG, Lonner JH: The valgus to assess postoperative alignment accuracy. No signifi-
stress radiograph does not determine the full extent of cant differences were reported between the two groups
correction of deformity prior to medial unicompartmental in both coronal and sagittal plane alignments. Level of
knee arthroplasty. J Arthroplasty 2015;30:1233-1236. evidence: III.
Medline DOI
Fifty medial UKAs performed with robotic navigation 15. Roche M: Robotic-assisted unicompartmental knee ar-
were prospectively studied to assess the value of preoper- throplasty: The MAKO experience. OrthopClin North
ative stress radiography. Although osteophyte resection Am 2015;46:125-131. Medline DOI
was important in correcting limb alignment, most defor-
mities (74% of knees) could not achieve neutral alignment This article provides a review of UKA with emphasis on
despite osteophyte resection. This finding questions the implant design, bony fixation, surgical instrumentation,
value of the preoperative valgus stress radiograph as an and technique.
indicator of whether limb alignment can be corrected.
Level of evidence: II. 16. Coon TM, Driscoll MD, Conditt MA: Robotically assisted
UKA is more accurate than manually instrumented UKA.
10. Scott RD: Mobile- versus fixed-bearing unicompartmen- J Bone Joint Surg Br 2010;92-B(suppl 1):157.
tal knee arthroplasty. Instr Course Lect 2010;59:57-60. Thirty-three UKAs performed with robotic navigation
Medline were retrospectively compared with 44 conventional
UKAs. The robotically navigated UKAs demonstrated
Section 2: Knee
significantly less variance in tibial slope (3.5o versus 1.4o) 23. Robertsson O, Dunbar M, Pehrsson T, Knutson K,
and coronal plane alignment (3.3° versus 0.1°). Lidgren L: Patient satisfaction after knee arthroplasty:
A report on 27,372 knees operated on between 1981 and
17. Lonner JH: Robotically assisted unicompartmental knee 1995 in Sweden. Acta Orthop Scand 2000;71:262-267.
arthroplasty with a handheld image-free sculpting tool. Medline DOI
OrthopbClin North Am 2016;47:29-40. Medline DOI
24. Liddle AD, Judge A, Pandit H, Murray DW: Adverse out-
This article reviews the next-generation robotic technol-
comes after total and unicompartmental knee replacement
ogy, an imageless handheld robotic sculpting tool, in UKA.
in 101,330 matched patients: A study of data from the
National Joint Registry for England and Wales. Lancet
18. Lonner JH, Smith JR, Picard F, Hamlin B, Rowe PJ, 2014;384:1437-1445. Medline DOI
Riches PE: High degree of accuracy of a novel image-free
handheld robot for unicondylar knee arthroplasty in Data on 25,334 UKAs and 75,996 TKAs were extracted
a cadaveric study. Clin Orthop Relat Res 2015;473: from the National Joint Registry for England and Wales
206-212. Medline DOI at 8-year follow-up. Implant survival and revision/reop-
eration rates were higher in the UKA group, whereas the
The accuracy of a novel, imageless robotic sculpting sys- mortality, length of hospital stay, and complication rates
tem in UKA was tested in 25 cadaver specimens. The were higher in the TKA group. Level of evidence: III.
femoral implant rotational mean error was 1.04° to 1.88°,
and mean translational error was 0.72 to 1.29 mm across 25. Murray DW, Liddle AD, Dodd CA, Pandit H: Uni-
the three planes. The tibial implant rotational mean error
compartmental knee arthroplasty: Is the glass half full
was 1.48° to 1.98°, and the mean translational error was
0.79 to 1.27 mm across the three planes. or half empty? Bone Joint J 2015;97-B(suppl A):3-8.
Medline DOI
19. Confalonieri N, Manzotti A, Pullen C: Comparison of This article provides a review of UKA with emphasis on
a mobile with a fixed tibial bearing unicompartimen- its merits and disadvantages compared with TKA.
tal knee prosthesis: A prospective randomized trial us-
ing a dedicated outcome score. Knee 2004;11:357-362. 26. Ghomrawi HM, Eggman AA, Pearle AD: Effect of age on
Medline DOI cost-effectiveness of unicompartmental knee arthroplasty
compared with total knee arthroplasty in the U.S. J Bone
20. Argenson JN, Blanc G, Aubaniac JM, Parratte S: Mod- Joint Surg Am 2015;97:396-402. Medline DOI
ern unicompartmental knee arthroplasty with cement: A The cost-effectiveness of UKA was compared to TKA
concise follow-up, at a mean of twenty years, of a pre- in patients undergoing surgery at age 45, 55, 65, 75, or
vious report. J Bone Joint Surg Am 2013;95:905-909. 85 years using a Markov decision analysis model. UKA
Medline DOI was found to be a more cost-effective procedure for pa-
Of 160 hundred sixty UKAs retrospectively reviewed with tients aged 65 years and older, but not in the cohorts ages
a mean follow-up of 20 years, 63 were available for fol- 45 and 55 years, in which TKA was more cost-effective.
2: Knee
low-up. The most common reason for revision to TKA

was progression of osteoarthritis followed by polyethylene
wear and aseptic loosening. Level of evidence: IV. 27. Berend KR, Kolczun MC II, George JW Jr, Lombardi AV
Jr: Lateral unicompartmental knee arthroplasty through a
21. Manzotti A, Cerveri P, Pullen C, Confalonieri N: A flat lateral parapatellar approach has high early survivorship.
all-polyethylene tibial component in medial unicom- Clin Orthop Relat Res 2012;470:77-83. Medline DOI
partmental knee arthroplasty: A long-term study. Knee One hundred lateral UKAs were retrospectively reviewed
2014;21(suppl 1):S20-S25. Medline DOI with a minimum follow-up of 24 months (range, 24 to
Fifty-three UKAs performed using all-polyethylene tibial 81 months). High early implant survivorship was re-
components were retrospectively reviewed at 5-, 10-, and ported: only 3 reoperations, including one revision. Level
14.7-year follow-up. Although there were no changes in of evidence: IV.
patient-reported outcomes during the course of the study,
the mechanical axis had significantly worsened at the last 28. Scott RD: Lateral unicompartmental replacement: A road
follow-up. Level of evidence: IV. less traveled. Orthopedics 2005;28:983-984. Medline
22. Niinimäki T, Eskelinen A, Mäkelä K, Ohtonen P, Puhto 29. Pennington DW, Swienckowski JJ, Lutes WB, Drake GN:
AP, Remes V: Unicompartmental knee arthroplasty sur- Lateral unicompartmental knee arthroplasty: Survivorship
vivorship is lower than TKA survivorship: A 27-year and technical considerations at an average follow-up of
Finnish registry study. Clin Orthop Relat Res 2014;472: 12.4 years. J Arthroplasty 2006;21:13-17. Medline DOI
Data on 4,713 UKAs and 83,511 TKAs were extracted 30. Baker PN, Jameson SS, Deehan DJ, Gregg PJ, Porter M,
from the Finnish Arthroplasty Register to assess the rates Tucker K: Mid-term equivalent survival of medial and
of revision performed for any reason. The implant survi- lateral unicondylar knee replacement: An analysis of
vorship rates at 5, 10, and 15 years were 89.4%, 80.6%, data from a National Joint Registry. J Bone Joint Surg
and 69.6% respectively for UKA; and 96.3%, 93.3%, Br 2012;94:1641-1648. Medline DOI
and 88.7% respectively for TKA. Level of evidence: III. The failure rates and mechanisms of failure for UKAs were
assessed using the National Joint Registry for England
and Wales. The 5-year implant survival rates were 93.1% Postoperative valgus alignment of 3° to 7° correlated most
for medial UKAs and 93.0% for lateral UKAs. At 8-year with good functional outcomes. No correlation was re-
follow-up, the survival rates were similar. The most com- ported between functional outcomes and BMI, sex, age,
mon modes of failure were aseptic loosening/lysis and or preoperative valgus alignment. Level of evidence: III.
unexplained pain. Level of evidence: III.
39. Walton MJ, Weale AE, Newman JH: The progression of
31. Argenson JN, Parratte S, Bertani A, Flecher X, Auba- arthritis following lateral unicompartmental knee replace-
niac JM: Long-term results with a lateral unicondylar re- ment. Knee 2006;13:374-377. Medline DOI
placement. Clin Orthop Relat Res 2008;466:2686-2693.
Medline DOI 40. Robinson BJ, Rees JL, Price AJ, et al: Dislocation of the
bearing of the Oxford lateral unicompartmental arthro-
32. Citak M, Cross MB, Gehrke T, Dersch K, Kendoff D: plasty: A radiological assessment. J Bone Joint Surg Br
Modes of failure and revision of failed lateral unicom- 2002;84:653-657. Medline DOI
partmental knee arthroplasties. Knee 2015;22:338-340.
Medline DOI 41. Weston-Simons JS, Pandit H, Kendrick BJ, et al: The mid-
Sixteen failed lateral UKAs were retrospectively reviewed term outcomes of the Oxford Domed Lateral unicompart-
to determine the modes of failure with a mean follow-up mental knee replacement. Bone Joint J 2014;96-B:59-64.
of 9.4 years. The 5-year implant revision rate was 43.8%, Medline DOI
with progression of arthritis being the most common Two hundred sixty-five consecutive knees with isolated
mode of failure followed by aseptic loosening. Level of disease of the lateral compartment and a mean patient age
evidence: IV. of 64 years at surgery (range, 32 to 90 years) were prospec-
tively studied to assess the survival and clinical outcomes
33. O’Rourke MR, Gardner JJ, Callaghan JJ, et al: The John of the domed lateral Oxford UKA. At a mean follow-up
Insall Award: Unicompartmental knee replacement: a of 4 years (range, 0.5 to 8.3 years), the mean Oxford
minimum twenty-one-year followup, end-result study. knee score was 40 out of 48: 13 knees (4.9%) underwent
Clin Orthop Relat Res 2005;440::27-37. Medline DOI reoperation, 4 (1.5%) of which were for dislocation. All
dislocations occurred in the first 2 years. Two (0.8%) were
34. Fisher DA, Watts M, Davis KE: Implant position in knee secondary to significant trauma that resulted in ruptured
surgery: A comparison of minimally invasive, open uni- ligaments, and two (0.8%) were spontaneous. In four
compartmental, and total knee arthroplasty. J Arthro- patients (1.5%), the UKA was converted to primary TKA.
plasty 2003;18(suppl 1):2-8. Medline DOI Survival at 8 years, with failure defined as any revision,
was 92.1% (95% confidence interval: 81.3-100.0). Level
of evidence: II.
35. Hamilton WG, Collier MB, Tarabee E, McAuley JP,
Engh CA Jr, Engh GA: Incidence and reasons for reop-
42. McAuley JP, Engh GA, Ammeen DJ: Revision of failed
eration after minimally invasive unicompartmental knee
unicompartmental knee arthroplasty. Clin Orthop Relat
arthroplasty. J Arthroplasty 2006;21(suppl 2):98-107.
Res 2001;392:279-282. Medline DOI
Medline DOI
2: Knee
43. Davies AP, Vince AS, Shepstone L, Donell ST, Glasgow
36. Lonner JH, John TK, Conditt MA: Robotic arm-assisted
MM: The radiologic prevalence of patellofemoral osteo-
UKA improves tibial component alignment: A pilot study.
arthritis. Clin Orthop Relat Res 2002;402:206-212.
Clin Orthop Relat Res 2010;468:141-146. Medline DOI
Medline DOI
Thirty-one UKAs performed with robotic navigation were
prospectively compared with 27 conventional UKAs to 44. McAlindon TE, Snow S, Cooper C, Dieppe PA: Radio-
assess postoperative tibial alignment accuracy. There was graphic patterns of osteoarthritis of the knee joint in the
higher accuracy with less variance in the robotic naviga- community: The importance of the patellofemoral joint.
tion group both in the coronal and sagittal planes. No Ann Rheum Dis 1992;51:844-849. Medline DOI
statistical differences were noted between the two groups
in both coronal and sagittal plane alignments. Level of
evidence: II. 45. Leadbetter WB, Seyler TM, Ragland PS, Mont MA: Indi-
cations, contraindications, and pitfalls of patellofemoral
arthroplasty. J Bone Joint Surg Am 2006;88(suppl 4):
37. Hernigou P, Deschamps G: Posterior slope of the tibial 122-137. Medline DOI
implant and the outcome of unicompartmental knee ar-
throplasty. J Bone Joint Surg Am 2004;86-A:506-511.
Medline 46. Lonner JH, Bloomfield MR: The clinical outcome of
patellofemoral arthroplasty. Orthop Clin North Am
2013;44:271-280, vii. Medline DOI
38. van der List JP, Chawla H, Villa JC, Zuiderbaan HA,
Pearle AD: Early functional outcome after lateral UKA is This review highlights the effect of trochlear design fea-
sensitive to postoperative lower limb alignment. Knee Surg tures on outcomes and patellar tracking after PFA, with a
Sports Traumatol Arthrosc 2015; Nov 26 [Epub ahead of particular emphasis on how onlay trochlear components,
print]. Medline DOI positioned perpendicular to the anteroposterior axis of the
femur, have substantially reduced the incidence of patellar
Thirty-nine lateral UKAs were retrospectively reviewed instability seen with inlay designs.
with a minimum follow-up of 2 years (range 2–4 years).
Section 2: Knee
47. Dahm DL, Al-Rayashi W, Dajani K, Shah JP, Levy BA, 51. Kamath AF, Levack A, John T, Thomas BS, Lonner JH:
Stuart MJ: Patellofemoral arthroplasty versus total knee Minimum two-year outcomes of modular bicompart-
arthroplasty in patients with isolated patellofemoral osteo- mental knee arthroplasty. J Arthroplasty 2014;29:75-79.
arthritis. Am J Orthop (Belle Mead NJ) 2010;39:487-491. Medline DOI
Medline
Twenty-nine unlinked BKAs were prospectively stud-
Twenty-three PFAs and 22 TKAs performed for isolated ied, with a minimum follow-up of 2 years (range, 24 to
patellofemoral arthritis were retrospectively compared. 46 months). The cohort demonstrated significant improve-
Mean age was 60 and 69 years, respectively (P = 0.01). ments in KSS, Knee Injury and Osteoarthritis Outcome
Mean follow-up was 29 months (range, 24 to 49 months) Score, Short Form-12, and Western Ontario and Mc-
in the PFA group and 27 months (range, 24–33 months) in Master Universities Osteoarthritis Index scores. Level of
the TKA group. Mean preoperative clinical and function evidence: IV.
KSS, as well as Tegner and UCLA scores, were statistically
similar. Mean postoperative clinical KSS were statistically 52. Tria AJ Jr: Bicompartmental knee arthroplasty: The clin-
similar in the PFA and TKA cohorts, but functional out- ical outcomes. Orthop Clin North Am 2013;44:281-286,
comes and activity levels were significantly better in the vii. Medline DOI
PFA group when both the UCLA and Tegner scores were
analyzed (P < 0.0001 for both groups). Mean blood loss This article provides a review of BKA, highlighting some
(P = 0.03) and hospital stay (P = 0.001) were significantly of the surgical challenges and concluding in favor of mod-
lower among PFA patients. Level of evidence: III. ular, unlinked implants.
48. Kazarian GS, Tarity TD, Hansen EN, Cai J, Lonner 53. Lonner JH: Modular bicompartmental knee arthroplasty
JH: Significant functional improvement at 2 years af- with robotic arm assistance. Am J Orthop (Belle Mead
ter isolated patellofemoral arthroplasty with an onlay NJ) 2009;38(suppl):28-31. Medline
trochlear implant, but low mental health scores predis-
pose to dissatisfaction. J Arthroplasty 2016;31:389-394. 54. Parratte S, Pauly V, Aubaniac JM, Argenson JN: Survival
Medline DOI of bicompartmental knee arthroplasty at 5 to 23 years.
In a study of 70 PFAs performed by using a contemporary Clin Orthop Relat Res 2010;468:64-72. Medline DOI
onlay design, at a minimum follow-up of 2 years (mean, Eighty-four patients (100 knees) with BKA and 71 patients
4.9 years), the mean ROM and KSS and function scores (77 knees) with medial UKA or PFA were retrospectively
improved significantly (P < 0.0001), and less than 4% of reviewed. Clinical and radiographic evaluations were per-
patients required revision arthroplasty for progressive formed at a minimum follow-up of 5 years (range, 5 to
tibiofemoral arthritis. There was no radiographic evi- 23 years). Implant survivorship at 17 years was 78% in
dence of component loosening or wear and no clinical or the BKA group and 54% in the medial UKA/PFA group.
radiographic evidence of patellar instability. Despite these Level of evidence: IV.
improvements, new KSSs indicated that fewer than two-
thirds of patients were satisfied or had their expectations
55. Engh GA, Parks NL, Whitney CE: A prospective random-
met. Dissatisfied patients and those whose expectations
2: Knee
were not met had significantly lower Mental Health scores ized study of bicompartmental vs. total knee arthroplasty
according to the Medical Outcomes Study 36-Item Short with functional testing and short term outcome. J Arthro-
Form. Therefore, despite the clinical and radiographic suc- plasty 2014;29:1790-1794. Medline DOI
cess of onlay-style PFAs, patient satisfaction may be lower This prospective study reported on 100 patients with
than expected, which may be partially explained by poor osteoarthritis in the medial and patellofemoral compart-
mental health. Surgeons should consider screening patient ments who were randomized into either BKA or TKA. At
mental health as a criterion for surgical intervention in the 24-month follow-up, no differences were reported between
setting of patellofemoral arthritis. Level of evidence: IV. the two interventions in KSS, Oxford scores, or functional
testing. Level of evidence: I.
49. Heekin RD, Fokin AA: Incidence of bicompartmen-
tal osteoarthritis in patients undergoing total and uni- 56. Morrison TA, Nyce JD, Macaulay WB, Geller JA: Early
compartmental knee arthroplasty: Is the time ripe for adverse results with bicompartmental knee arthroplasty: A
a less radical treatment? J Knee Surg 2014;27:77-81. prospective cohort comparison to total knee arthroplasty.
Medline DOI J Arthroplasty 2011;26(suppl):35-39. Medline DOI
In a consecutive series of 259 Knee Registry subjects un- This prospective study reported on 54 patients with osteo-
dergoing TKA or UKA, all three compartments of the knee arthritis in the medial and patellofemoral compartments
joint were assessed radiographically and intraoperatively who underwent either BKA and TKA. At 2 years follow-up
by using Outerbridge classification. Fifty-nine percent had there were no differences between the two interventions
osteoarthritis in all three compartments, 28% had bicom- in Short Form-12 or Western Ontario and McMaster
partmental disease, 4% had unicompartmental disease, Universities Osteoarthritis Index scores. However, there
and 9% exhibited an inconclusive osteoarthritis pattern. were higher complication rates in the BKA group. Level
of evidence: II.
50. Tria AJ Jr: Bicompartmental arthroplasty of the knee.
Instr Course Lect 2010;59:61-73. Medline
This instructional course provides a review of combined
PFA and medial UKA with an emphasis on surgical tech-
nique, implant design, and outcomes.
Chapter 14
Robotic-Assisted Knee Arthroplasty

Martin Roche, MD
Abstract
Robotic-assisted knee arthroplasty is increasingly used
by joint arthroplasty surgeons in the surgical treatment
of knee arthritis. Multiple robotic devices are now
available and FDA approved for unicompartmental, bi-
compartmental, and total knee arthroplasty. Therefore,
it is essential to review the available robotic devices,
their intraoperative applications, and the indications
for their use.
Keywords: robotic; knee; arthroplasty;

Figure 1 Intraoperative photograph shows a semiactive
replacement; assisted robotic arm with computer display used during
unicompartmental knee arthroplasty.
Introduction
Robotics have been used for decades in automotive, and intraoperative planning with computer modeling and
industrial, and aerospace applications for consistency, assists the surgeon in executing the surgical plan in a pre-
reproducibility, and efficiency. The integration of robot- cise, efficient manner5 (Figure 1). The improved accuracy
ics into knee arthroplasty procedures began in the early of the procedure, with customization to the patient’s spe-
2: Knee
2000s1 and has seen wide-scale adoption in the past sev- cific knee pathology, improves implant congruency, limb
eral years. alignment, gap balancing, and potential errors for failure
Conventional implant systems provide manual in- and poor outcomes (Figures 2 and 3). The benefits of po-
struments to prepare the bone surfaces and to assist in tentially minimizing bone resection, through minimally
achieving appropriate alignment.2 Registry and outcome invasive approaches, and anterior cruciate ligament (ACL)
data have shown that technical issues now account for up retention should lead to improved kinematics, stability,
to 30% of knee revisions and poor patient outcomes.3,4 and proprioception.
Patient and surgeon expectations are the driving forces The value of robotics to achieve consistency in ob-
behind the resurgence of a modular approach to a pa- taining appropriate alignment, implant congruency, and
tient’s specific knee pathology enabled through robotics. gap balancing is that it has shown improved accuracy
Robotic applications are an extension of computer navi- compared with conventional instrumentation.6,7
gation, and are part of a haptically enabled systematic ap- Furthermore, the 2-year reported revision rate for
proach to knee surgery. Robotics integrates preoperative robotic-assisted unicompartmental knee arthroplasty
(UKA) of 1.2% is far less than the national registry–
documented outcomes of conventional instrumentation
Dr. Roche or an immediate family member has received of greater than 4%.8
royalties from Mako-Stryker and OrthoSensor, is a member
of a speakers’ bureau or has made paid presentations on
Surgical Indications
behalf of Mako-Stryker and OrthoSensor, is an employee of
Orthosensor, and is a paid consultant to Mako-Stryker has The indications for robotic utilization are multifacto-
stock or stock options held in OrthoSensor, and has received rial. The primary driver is the patient’s clinical presen-
research or institutional support from Makosurgical-Stryker. tation, combined with the surgeon’s preference for the
Section 2: Knee
Figure 2 Radiographs show a preoperative arthritic lateral joint (A) that underwent robotic-assisted lateral
unicompartmental knee arthroplasty (UKA, B). C, Radiograph shows conventional lateral UKA. The tibia is
positioned in varus and overcorrected alignment.
2: Knee
Figure 3 Radiographs show a robotic-assisted medial unicompartmental knee arthroplasty (UKA) (A), a preoperative medial
arthritic joint (B), and a manual UKA with coronal implant incongruency (C).
technologic benefits of robotically assisted surgery. FDA (medial/lateral unicompartmental with a patellofemoral
clearance for the robotic application defines its specific arthroplasty), and total knee arthroplasty (TKA).
use in the continuum of knee arthroplasty. Robotic ap- Preoperative level of disability, physical findings, and
plications allow a surgeon to define the patient-specific patient expectations determine the suitability of a can-
approach for procedures including UKAs (medial, lat- didate for robotic knee surgery. Similarly, for the con-
eral, patellofemoral), bicompartmental knee arthroplasty ventional approach, gait, alignment, knee motion and
Chapter 14: Robotic-Assisted Knee Arthroplasty
stability, skin integrity, neurovascularity, and the patient’s or instrument accelerates too fast, the cutting instrument
hip and ankle are evaluated to rule out fixed deformities shuts off. Standard soft-tissue protection is required be-
or ligamentous instability that would interfere with a cause the haptic boundary is defined by the implant re-
consistent surgical outcome. Preoperative films should section planning volume. The evolution of this technology
include standard weight-bearing films. CT is used for into the orthopaedic arena was enabled by the ability of
several robotic systems and can aid in surgical registration the surgeon to obtain an accurate reproducible surgical
as well as in preoperative bone density and subchondral result in all six degrees of freedom (three translational and
bone evaluation. Contraindications are similar to those three rotational), which the human eye cannot reproduce
for conventional knee arthroplasty surgery, but would to the same level of precision.6,12
include poor bone stock if concerns about navigation pin Compared with passive robotic systems that position
stability are present. cutting jigs for use with a handheld saw, haptic robots
The specific surgical procedure and risks should be may better protect periarticular soft tissues from harm,
discussed with the patient. Postoperative protocols and by more effectively constraining the cutting tool within
expectations need to be defined. With a modular robot- a specified working field.
ic approach, surgeons have the ability to modify their
plans intraoperatively based on intraoperative findings.
In a unicompartmental plan, the need to resurface the Surgical Integrated Robotic Systems
patellofemoral joint in the presence of advanced arthritic Two companies currently have systems used for unicom-
findings is currently debated.9 partmental and bicompartmental knee arthroplasty. Both
Robotic technologies include three systems. Active systems use a semiactive robotic approach. One integrates
systems have a robotic arm automated to perform a func- image-based navigation, whereas the other uses imageless
tion as prescribed by the surgeon. Currently there is no navigation.
FDA-approved robotic application in knee arthroplasty.
With semiactive systems, the robot augments the sur- Preoperative Image Planning
geon’s ability to control resections by guiding and physi- The two approaches to integrated surgical navigation
cally constraining the surgeon within a three-dimensional within the robotic applications are extensions of stan-
(3D) space, but it does not autonomously perform bone dard computer-assisted surgery. Image-based navigation
resection. With the passive system, the robot positions a uses preoperative CT for intraoperative referencing with
cutting guide at a computer-navigated position, but does surgical tracking technologies for surgical execution. Im-
not perform surgical manipulation of the patient and does ageless navigation uses intraoperative acquisition of the
2: Knee
not constrain the surgeon.10 patient’s anatomy and landmarks to integrate into the
surgical plan and execution.
Although imageless systems reduce costs and minimize
Haptics radiation, preoperative image-based planning enables
The integration of haptics has advanced the safety and anatomic implant matching and potentially improves
efficiency of robotic knee surgery. Robotic arm assistance operating room efficiency. Imageless systems provide
allows a surgeon to have a controlled, highly accurate sys- information regarding bone cysts, osteophytes, and hip-
tem that is integrated into the surgical workflow.11 Haptics to-ankle bone pathology and bone density evaluation.
is the science of applying touch or tactile sensation and The sagittal and axial CT scans are digitized to create a
control to interactions with computer applications. The 3D bone model. The CT scan enables patient matching
surgeon receives a tactile sensation of the arm physically and millimetric intraoperative registration and tracking
resisting a surgeon’s applied force when the haptic bound- accuracy. The surgeon can position the implant on the
ary is approached. Boundaries are specified to match the CT scan in the preferred angulation, depth, and rotation.
implant shape, size, and placement based on surgical The joint line can be defined, and the personalized fit to
planning. the cortical boundaries can be obtained. A virtual model
During bone resection, the surgeon receives real-time of the surgical plan is presented for review.
feedback through auditory, tactile, and visual applica- The placement is mainly for anatomic fit and can be
tions as the surgical plan is being executed. The safety adjusted based on the patient’s intraoperative kinematics.
factors include push-back when the surgical wall is being The parameters that will adjust the initial plan are the
approached and shutting down the surgical instrument preferred mechanical alignment, the implant gap dis-
if the haptic boundary is breached. Because the leg and tances, and an optimized implant articulation through a
robotic arm are being tracked simultaneously, if the limb full range of motion. It is common to adjust the implants
Section 2: Knee
sensors to define the patient’s specific kinetic signature

and achieve balance through bone and angular adjust-
ments instead of soft-tissue releases.15,16 The development
of haptics allows the surgeon to efficiently burr or resect
bone within a safety zone defined by the implant size
and location to be prepared. This allows the surgeon to
use mobile windows to execute the plan while receiving
feedback and visualization on a computer screen. The
system defines a 3D resection volume that moves with
the limb, restricting the robotic arm’s movements within
the planned volume and adjusting for motion of the knee.
After registration of the robotic arm, the surgeon uses
a high-speed burr or saw blade mounted on the robotic
arm to prepare the femur and tibia for component im-
plantation. The surgeon maneuvers the robotic arm while
visualizing the execution on a computer screen. The robot
uses audible and tactile feedback mechanisms to keep the
cutting instrument within predefined margins. The sys-
tem uses independent tracking probes to confirm implant
placement. The implants are all presently cemented and
are specific for the system (Figure 4).
Another robotic system was recently cleared for uni-
compartmental knee surgery. It uses an open implant
platform and imageless registration intraoperatively.17 The
instrumented burr is tracked, and when the boundaries
of the surgical plan are approached, the burr retracts into
Figure 4 Intraoperative photograph shows a cemented its sheath. Standard soft-tissue protection is required, and
unicompartmental knee arthroplasty.
the implant-planned boundaries are also defined by the
virtual implant placement. This system does not have a
robotic arm but rather puts haptics on a handheld surgical
2: Knee
after kinematic inputs in unicompartmental knee sur- instrument by using exposure-control and speed-control
gery because balance and alignment are modified via mechanisms to prevent the motorized burr from func-
bone resection and implant position. Both systems allow tioning outside a predefined working field. The surgeon
cartilage mapping intraoperatively to improve transition controls power to the burr during exposure control, but
zones.13 One system is a robotic-enabled application that a guard covers the burr unless it is within the planned
is image based and is used for a unicompartmental mod- cutting zone. The amount of burr exposure is modulated
ular approach, and now a TKA application. by the system based on the depth and angle of resection
The first clinical medial unicompartmental case was remaining. During speed control, the burr is allowed
performed in 2006.11 Indications have expanded to in- to turn on only within the cutting zone, and the speed
clude bicompartmental14 and TKA applications. The sys- and power are reduced rapidly to zero after the desired
tem integrates preoperative planning with a robotic arm bone is removed or the burr is brought to the edge of the
that executes the defined surgical plan. The system uses planned cutting zone.
burring for modular implants and a saw system for the
TKA application. The patient’s anatomy is registered, as
well as the robotic arm, and tracked by using an infrared Robotic Utilization in UKA
tracking system. The surgeon modifies the implant place- The value of robotic applications focuses on patient cus-
ment based on preresection inputs to optimize alignment, tomization and an efficient, accurate execution of the sur-
gap distance, and component congruity. By using kine- gical plan. Relative to surgical technique, early failure of
matic inputs, a surgeon can balance a robotically assisted UKAs often results from poor bone preparation, implant
UKA preresection, by modifying the depth of angular malposition, aseptic loosening of the tibial and femoral
resection. In a robotically assisted TKA, the accuracy of component, overloading the contralateral compartment,
the robotic arm allows the surgeon to use intraoperative and poor cement technique.
Figure 5 Photograph shows a surgeon evaluating the

kinematic tracking before bone resection. Figure 6 Photograph shows a unicompartmental knee
prepared for final implantation.
Intraoperative data and precision bone preparation balancing based on the corrected poses. The femoral and
may minimize outliers. Both systems use optical motion tibial components can now be adjusted to obtain a cen-
capture technology to dynamically track marker arrays tered tracking path and an appropriate gap distance of
fixed to the robotic arm, femur, and tibia, allowing the 1 to 2 mm through a full range of motion.16 The compo-
surgeon to freely adjust limb position and orientation nents can be rotated, flexed, extended, translated, or ad-
during tactile-guided bone cutting. The ability to obtain justed in the coronal and sagittal planes on the computer
accurate implant placement includes avoiding independent screen to obtain the appropriate preresection positions.
as well as combined potential errors.6,12 The sagittal, coro- Before surgical bone preparation, the surgeon can mod-
nal, and axial planes on each prepared condyle, as well as ify and adjust the surgical plan to define the mechanical
the preservation of the joint line and limb alignment, are alignment, implant tracking, bone resection depths, joint
critical to obtain a successful outcome. The bone resec- line, and gap distances in millimeters (Figure 5). The
tion depth, mechanical alignment, cortical rim coverage, surgical plan is then executed with the robotic-controlled
2: Knee
rotation, and slope are defined. The surgeon performs instrument.
a standard approach, inspects the knee pathology, and The surgical leg is controlled in a modular leg holder,
assesses the ligament stability. The surgeon can modify and soft-tissue retractors are positioned. The robotic arm
the plan to include resurfacing of other compartments activates when it enters the volume of bone resection to
if required. The surgeon attaches the navigation track- be prepared. The safety elements include deactivation of
ers and registers the limb and knee anatomy with the the burr if the planned resection levels are breached on
trackers. Probes are used to collect bony and cartilage any plane.
registration points. The registration is now verified to be After the bone has been prepared, residual meniscus
within the submillimeter accuracy required by the sys- and/or osteophytes are removed (Figure 6). Then trial
tem specifications to allow progression to the next steps. implants allow a kinematic assessment, and the execut-
Cartilage mapping in bicompartmental knee arthroplasty ed plan is confirmed. The final implants are cemented,
can be performed to provide a smooth transition for the the navigation pins are removed, and standard closure
patella across the trochlear groove because it articulates is performed.
on the femoral component in early flexion.
The surgeon removes osteophytes and moves corrected
limb positions through a full range of motion. The sur- TKA Applications
geon uses the navigation to obtain a corrected position Two companies provide an implant-specific FDA-cleared
and ensures that the mechanical axis has not been over- approach to TKA robotic surgery. One has developed a
corrected. Multiple pose captures are taken and displayed robotic arm semiactive assisted application that integrates
on the computer screen. From these pose captures, the a surgical saw to prepare the bone cuts. The preoperative
surgeon inspects the femorotibial tracking on the com- plan is image based, and the size, position, and angulation
puter to define implant-to-implant articulation and gap of the implants are customized to the patient’s anatomy.
Section 2: Knee
osteotomies. The system uses imageless navigation. The

surgeon uses a standard saw to perform the bone cuts
through the controlled jig. The trial implants and limb
kinematics are assessed under surgical navigation inputs,
and soft-tissue balancing is performed according to the
surgeon’s preference. The implant is cemented and stan-
dard wound closure performed.
Surgical Efficiencies
As with any new technology, a dedicated surgical team
will improve efficiency and shorten the overall learning
curve. The surgeon, if not accustomed to navigation and
robotic technology, should slowly integrate the systems
into their surgical day.
Preoperative CT has the potential advantages of de-
fining implant choice preoperatively and minimizing the
required instrumentation during surgery. The patient is
positioned in a standard supine fashion, and an articu-
lating leg holder is used. The robotic arms are sterilely
draped, positioned for access into the knee, and registered
to the navigation tracking system. The navigation cam-
era system is positioned to prevent tracking interference.
Surgeon learning curve has been documented; when the
surgeon used the system’s interactive feedback, after ap-
proximately 13 cases, steady-state surgical times were
Figure 7 Photograph of a robotic-assisted total knee reached.
arthroplasty demonstrates the surgeon
resecting the tibia under haptic control using
the interactive computer screen.
Semiactive Safety Checks
2: Knee
Although the robotic arm ensures accurate implant

placement, many additional factors are required for a
The surgical approach is surgeon specific, and initial reg- successful surgical outcome.5,8,11 There are several safety
istration defines the limb alignment and femoral-tibial systems in place throughout the procedure to ensure that
bone registration. This system uses optical motion capture accuracy is achieved. Tibial and femoral checkpoints must
technology to dynamically track marker arrays fixed to be verified before each section of bone is prepared. At any
the robotic arm, femur, and tibia, allowing the surgeon point throughout the procedure, the robotic arm and me-
to freely adjust limb position and orientation during tac- chanical burr/saw can be removed from the surgical zone,
tile-guided bone cutting. The robot is registered and in and a tracker probe can be used to visualize accuracy and
a defined sequence, and the resection plan is executed cuts directly on the patient’s CT scan.
(Figure 7). The patella is not tracked and prepared by The navigation pins must be placed so they will not
using standard instruments. The surgeon removes pos- interfere with the robotic arm during knee motion. The
terior osteophytes and meniscus and trials the implant. pins should be placed in standard fashion to minimize
Soft-tissue balancing is performed by using navigation risk of bone fractures. Checkpoints should be placed in an
input and surgical preference. The implants are cemented accessible area but away from cortical margins to avoid
and standard closure is performed. stress risers. Care must be taken to avoid water, debris,
Another system uses passive robotic application inte- or lights directly on the reflective disks. Care must also be
grated with standard surgical navigation with a motorized made not to knock or move the arrays after registration.
arm that is tracked and that controls the attached cutting When adjusting the knee’s flexion angle, it is important
jig position and angulation.18 This eliminates the need to do so in a stable manner. The robotic platform will
for multiple femoral cutting blocks because the robotic identify velocity and rapid movements and will halt burr/
guide moves to a new position for each of the five femoral saw activation.
The current semiactive systems provide irrigation to

keep the burr tips cool and avoid thermal bone injury.
In passive systems, the surgeon visualizes the saw blade
and irrigates the area in a standard manner. The risk of
malfunction of the robotic system is minimal in current
systems,19 but the surgeon should understand the surgi-
cal plan and have access to conventional instruments if
desired.
Soft tissue can be injured if the prepared haptic allows
transition into these areas during preparation. Retractors
are used to protect soft tissues. Knee positioning is adjust-
ed throughout the surgical procedure to allow maximal
access through a minimal incision. To date, there has
not been a documented increase in infection, neurovas-
cular injury, or soft-tissue injury when using passive or
active-assisted robotic systems for knee arthroplasty.
Economic Issues
Figure 8 Photograph shows a press-fit unicompartmental
As with any new technology in this healthcare environ- implant.
ment, value must be proved before widespread accep-
tance. Currently, without a reimbursement for robotics,
the hospital system or ambulatory surgery center must
make a significant investment in this technology. The Future Applications
hospital determines the initial return on investment by Robotics enables engineers and surgeons to design fu-
looking at their orthopaedic product line and marketing ture implants that may change geometries and articular
potential. Surgeons are required to invest time and evalu- bearings as bone resection techniques advance. Enabling
ate clinical data to ensure this approach improves patient accurate bone resection will increase the use of bone-in-
outcomes. Robotic systems will potentially take cost out growth implants (Figure 8), fixation options, and their
of the system by minimizing surgical errors that can lead potential kinematic advantages.22
2: Knee
to revisions. As robotic systems evolve, surgical efficiency Robotics will enable a surgeon to define the initial
should improve, and earlier discharges will be supported. bone resections, implant positions, and alignment. These
variables can be precisely adjusted intraoperatively based
on an individual’s soft-tissue balance. Integrated sensors
Clinical Studies for Robotic Systems will provide real-time data on the individual’s soft-tissue
Initial data have shown that robotic-assisted UKAs are tension, enabling the surgeon to optimize the knee bal-
two to three times more accurate and three times more re- ance based on implant or axis adjustments.13 These data
producible than conventionally performed manual UKAs. will allow evaluation of the short- and long-term effects
Results from a randomized controlled clinical trial on mechanical and kinematic constitutional approaches
performed in 2013 revealed lower visual analog scale in all three planes.22-24
pain scores during the first 8 weeks postoperatively com- The potential benefits of an ACL-preserved TKA have
pared with manual surgery, with improved alignment as been reevaluated recently with a manual approach.25 The
assessed by CT scans.7 potential to achieve appropriate intercompartmental
Two-year follow-up of 701 RIO (Stryker MAKO) ro- alignment, slope, joint line, and optimal tension on the
botic-assisted UKAs from a multicenter trial revealed a cruciate and collateral ligaments should allow a more
1.1% revision rate,8 lower than the 4.5% to 4.8% rates consistent surgical result in which outcome data can be
for revision 2 years after conventional UKA in an inter- evaluated (Figure 9). Promising results have been reported
national registry data.20,21 Currently, no clinical outcome with no postoperative complications and more accurate
data on TKA robotic-assisted applications exist that are joint line reconstruction in a group of modular bicom-
FDA cleared. partmental arthroplasties using the RIO platform.26
Section 2: Knee
Key Study Points
• Robotics is evolving in the care of symptomatic

knee arthritis. Integrating patient-specific data with
intraoperative flexibility and improved accuracy will
enable a modular approach to address the continu-
um of knee pathologies.
• Current robotic devices are either semipassive or
passive, which maintain the surgeon’s control. The
integration of haptics enables efficient, accurate, and
safe execution of the defined intraoperative plan.
• Robotics has shown promising early results to
Figure 9 Photograph shows a prepared bicruciate- minimize surgical errors that result in a significant
retaining knee and the final implant with number of revisions and poor patient satisfaction.
independent tibial implants.
Further long-term studies are required to support
the capital investment and sustained improvement
in patient outcomes.
Summary
The use of passive and semiactive robotic platforms con-
tinues to increase. Robotic systems incorporate specific
patient planning with accurate execution of the surgical Annotated References
plan. This precision and consistency can be documented
and then tracked to evaluate these variables on patient 1. Cobb J, Henckel J, Gomes P, et al: Hands-on robotic
outcomes.27 Integration of alignment, implant rotation, unicompartmental knee replacement: A prospective, ran-
and soft-tissue balance are the cornerstones of successful domised controlled study of the acrobot system. J Bone
Joint Surg Br 2006;88:188-197. Medline DOI
knee arthroplasty outcomes.28 To date, imprecise manual
instruments and subjective decisions are used to assess 2. Mihalko WM, Boyle J, Clark LD, Krackow KA: The
these variables. Robotic technologies have the potential variability of intramedullary alignment of the femoral
to create an efficient approach to individual arthritic pre- component during total knee arthroplasty. J Arthroplasty
sentations by using modular implant systems that extend 2005;20:25-28. Medline DOI
2: Knee
from UKAs to TKAs.

3. Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby
Customization of the knee arthroplasty procedure and SM: Insall Award paper: Why are total knee arthroplas-
use of objective navigation and sensor inputs will enable ties failing today? Clin Orthop Relat Res 2002;404:7-13.
precise robotic modifications and execution, possibly Medline DOI
leading to improved outcomes and patient satisfaction.
The future of robotics will be driven by the consumer’s re- 4. Babazadeh S, Stoney JD, Lim K, Choong PF: The rele-
vance of ligament balancing in total knee arthroplasty:
quest, surgeon acceptance, and economic considerations. How important is it? A systematic review of the literature.
Long-term studies will allow the orthopaedic community Orthop Rev (Pavia) 2009;1:e26. Medline DOI
to assess the data, compare approaches, and translate this
into efficient and safe surgical procedures. 5. Roche M, O’Loughlin PF, Kendoff D, Musahl V, Pearle
AD: Robotic arm-assisted unicompartmental knee arthro-
plasty: Preoperative planning and surgical technique. Am
J Orthop (Belle Mead NJ) 2009;38:10-15. Medline
6. Citak M, Suero EM, Citak M, et al: Unicompartmental

knee arthoplasty: Is robotic technology more accurate
than conventional technique? Knee 2013;20:268-271.
Medline DOI
This cadaver study compared traditional manual instru-
mentation versus haptic robotic-assisted UKA techniques
and found that the robotic system was more precise com-
pared with the manual technique.
7. Bell SW, Anthony I, Jones B, MacLean A, Rowe P, Blyth 15. Anderson C, Roche M, Golladay G, Elson L: Bony cuts or
M: Improved accuracy of component positioning with ro- soft-tissue release? Using intra-operative sensors to refine
botic-assisted unicompartmental knee arthroplasty: Data balancing techniques in TKA. Bone Joint J 2016;98-B(-
from a prospective, randomized controlled study. J Bone suppl 1):16. Medline DOI
This was a retrospective multicenter study on sensor-as-
This study compared conventional Oxford UKA with sisted TKA comparing bony correction versus soft-tissue
MAKO robotic-assisted UKA in 120 patients and deter- release with a minimum follow-up of 1 year. Three cohorts
mined that the MAKO robotic-assisted technique offers were studied: Group A – candidates for bony correction,
a higher rate of accuracy. but received soft-tissue correction; Group B – candidates
for soft-tissue/receiving soft-tissue; Group C – candidates
8. Conditt M, Coon T, Roche M, et al: Two year survivorship for bony correction/receiving bony correction. This study
of robotically guided unicompartmental knee arthroplas- found higher clinically significant KSS and WOMAC
ty. Bone Joint J 2013;95-B(suppl 34):294. scores in utilizing the sensor.
This study investigated 2-year survivorship of robotic-as- 16. Plate JF, Mofidi A, Mannava S, et al: Achieving accurate
sisted UKA. The study reported a 1.1% revision rate, with ligament balancing using robotic-assisted unicompartmen-
71% of patients reporting a “very satisfied” feeling of knee tal knee arthroplasty. Adv Orthop 2013;2013:837167.
function. These results were found to be promising and
accentuated the use of robotic assistance in UKA. This was a prospective study investigating the accuracy
of utilizing a robotic-assisted UKA system in ligament
9. Beard DJ, Pandit H, Gill HS, Hollinghurst D, Dodd CA, balancing in 51 patients (52 knees). The robotic-assisted
Murray DW: The influence of the presence and severity of UKA is highly accurate and precise for soft-tissue bal-
pre-existing patellofemoral degenerative changes on the ancing and potentially improving implant survival and
outcome of the Oxford medial unicompartmental knee functional outcomes.
replacement. J Bone Joint Surg Br 2007;89:1597-1601.
Medline DOI 17. Lonner JH, Smith JR, Picard F, Hamlin B, Rowe PJ,
Riches PE: High degree of accuracy of a novel image-free
10. Picard F, Moody JE, DiGioia AM, Jaramaz B: Clinical handheld robot for unicondylar knee arthroplasty in a
classification of CAOS systems, in DiGioia AM, Jaramaz cadaveric study. Clin Orthop Relat Res 2015;473:206-
B, Picard F, Nolte LP, eds: Computer and Robotic As- 212. Medline DOI
sisted Hip and Knee Surgery. New York, NY, Oxford This cadaver study investigated the use of an imageless
University Press, 2004, pp 43-48. Medline DOI robotic system in 25 specimens that underwent UKA and
found that the imageless system achieved a high level of
11. Conditt MA, Roche MW: Minimally invasive robot- accuracy with small errors in implant placement.
ic-arm-guided unicompartmental knee arthroplasty.
J Bone Joint Surg Am 2009;91:63-68. 18. Nwokeyi KM, Mohideen M, van der Jagt D: Com-
2: Knee
This study investigated medial UKA component accura- puter assisted surgery using motorized mini-robotic
cy when utilizing surgical navigation and tactile robotic jig in knee replacement: Are we there yet? Bone Joint
assistance. The results showed that implant placement J 2013;95-B(suppl 29):27.
errors were comparable between tactile robotics and rigid This study compared standard computer-assisted cutting
stereotactic fixation. jigs with mini–robotic-assisted cutting jigs in patients un-
dergoing TKA. The study found that use of the jigs had a
12. Dunbar NJ, Roche MW, Park BH, Branch SH, Conditt substantially reduced surgical time and equivalent blood
MA, Banks SA: Accuracy of dynamic tactile-guided loss compared with the standard cutting jigs.
unicompartmental knee arthroplasty. J Arthroplasty
2012;27(5):803-808,e1. Medline DOI 19. Lonner JH, Kerr GJ: Robotically assisted unicompart-
mental knee arthroplasty. Oper Tech Orthop 2012;22(4):
13. Gustke KA: Soft-tissue and alignment correction: The 182-188. DOI
use of smart trials in total knee replacement. Bone Joint
J 2014;96-B:78-83. Medline DOI This review compared conventional cutting guides with
semiautonomous robotic UKA. Robotics have improved
This study investigated the use of smart trials that use early functional results and precision of bone and com-
load-bearing sensors in TKA patients. The smart trials ponent alignment.
improved patient outcomes through assisted soft-tissue
release or bone cuts in 135 knees. 20. Swedish Knee Arthroplasty Register: Annual report 2014.
Available at: http://www.myknee.se/pdf/SKAR2014_En-
14. Lonner JH: Modular bicompartmental knee arthroplasty g_1.1.pdf. Accessed May 9, 2016.
with robotic arm assistance. Am J Orthop (Belle Mead
NJ) 2009;38:28-31. Medline The history of the Swedish Knee Arthroplasty Register is
reviewed and the methods used and lessons learned are
described.
Section 2: Knee
21. Australian Orthopaedic Association National Joint Re- 25. Sabouret P, Lavoie F, Cloutier JM: Total knee replace-
placement Registry: Annual report 2013. Available at: ment with retention of both cruciate ligaments: A 22-
https://aoanjrr.sahmri.com/en/annual-reports-2013. Ac- year follow-up study. Bone Joint J 2013;95-B(7):917-922.
cessed May 9, 2016. Medline DOI
An overview of the 2013 annual report is presented, out- The authors reported long-term follow-up of 130 patients
lining additions to the registry analysis, as well as high- who underwent bicruciate-retaining TKA at a mean of
lighting major findings. 22.4 years. The study found that the ACL remained func-
tional and provided adequate stability.
22. Koenig JH, Hepinstall MS: Available robotic platforms
in partial and total knee arthroplasty. Oper Tech Orthop 26. Pourmoghaddam A, Kreuzer SW, Freedhand A: Early
2015;25(2):85-94. DOI clinical outcomes in robotic assisted bi-unicompartmen-
tal total knee replacement compared to unicompart-
A review of the currently available robotic platforms in mental and conventional knee arthroplasty. Bone Joint
relation to outcomes and future direction is discussed J 2013;95-B(suppl 34):381.
within this article.
This study compared the clinical outcomes of robotic-as-
23. Bellemans J, Colyn W, Vandenneucker H, Victor J: The sisted bi-UKA with conventional TKA. The study found
Chitranjan Ranawat award: Is neutral mechanical align- higher Knee Injury and Osteoarthritis Outcome Scores
ment normal for all patients? The concept of constitu- in the biunicompartmental cohort with no postoperative
tional varus. Clin Orthop Relat Res 2012;470:45-53. complications.
Medline DOI
27. Bourne RB, Chesworth BM, Davis AM, Mahomed NN,
This cross-sectional study of 250 asymptomatic patients Charron KD: Patient satisfaction after total knee arthro-
(age range, 20 to 27 years) sought to determine if con- plasty: Who is satisfied and who is not? Clin Orthop Relat
stitutional varus knees should be corrected to neutral Res 2010;468:57-63. Medline DOI
alignment. Mechanical alignment to neutral would not
be natural and therefore is not preferred in these patients. This study sought to determine the satisfaction rate of
patients undergoing TKA. A 19% unsatisfactory rate was
24. Howell SM, Howell SJ, Kuznik KT, Cohen J, Hull ML: reported, with patient expectations being the largest driver
Does a kinematically aligned total knee arthroplasty re- of satisfaction rate.
store function without failure regardless of alignment
category? Clin Orthop Relat Res 2013;471:1000-1007. 28. Kim Y-H, Park J-W, Kim J-S, Park S-D: The relation-
Medline DOI ship between the survival of total knee arthroplasty and
postoperative coronal, sagittal and rotational align-
This study investigated patients who underwent kinemat- ment of knee prosthesis. Int Orthop 2014;38:379-385.
ically aligned TKA in relation to catastrophic failure and Medline DOI
reported a low risk of catastrophic failure when cutting
2: Knee
the tibia perpendicular to the mechanical axis. This study investigated 3,048 TKA knees for alignment
in relation to postoperative failure by using radiography
and CT.
Chapter 15
Computer-Assisted
Knee Arthroplasty
S. David Stulberg, MD Michael Dunbar, MD, FRCSC, PhD Gwo-Chin Lee, MD
real-time surgical feedback regarding the alignment of the

Abstract
extremity and placement of instruments, cutting guides,
One of the basic tenets of knee arthroplasty is that and resection planes. The concepts and mechanics of
clinical outcomes are related in an important way to applying computer-assisted surgery (CAS) to total knee
the accuracy with which the procedure is performed. arthroplasty (TKA) and unicondylar knee arthroplasty
The consequences of performing a total or partial are essentially the same.
knee arthroplasty inaccurately have been extensively
documented. Computer-assisted surgery techniques
CAS System Types
were developed in the 1990s to address the inherent
limitations of mechanical instrumentation. The types The three types of navigated computer-assisted techniques
of computer-assisted systems that are currently available used in knee arthroplasty are preoperative image-based
for knee arthroplasty and the outcomes that have been (for example, CT or MRI), intraoperative image-based
achieved with these systems have been described in the (such as, fluoroscopy), and imageless. These techniques
literature. It is important for orthopaedic surgeons who can be used to acquire anatomic information to be used
perform total knee arthroplasties to have current infor- for presurgical or intraoperative surgical planning. With
mation to assess the appropriateness of this technology image-based systems, the presurgical or intraoperative
for their practices. surgical plan helps with intraoperative placement of
cutting tools and to establish knee alignment and sta-
2: Knee
bility.1 Although potentially extremely useful for knee
Keywords: total knee arthroplasty; lower limb reconstruction, imaging with CAS knee systems has been
alignment; implant alignment; ligament balance perceived by surgeons as requiring additional and cum-
and stability bersome steps without providing substantial benefits.
Consequently, imageless computer-assisted systems have
been recognized as the most preferred and widely used
Introduction
form of CAS for knee reconstruction.
The goal of computer-assisted knee arthroplasty de- The computers used in CAS integrate information
vices is to provide the surgeon with reliable and precise from medical images, implant data, and intraoperatively
Dr. Stulberg or an immediate family member has received royalties from Aesculap/B.Braun, Biomet, Innomed, and
Stryker; is a member of a speakers’ bureau or has made paid presentations on behalf of Stryker, Aesculap/B.Braun, and
Zimmer; serves as a paid consultant to Aesculap/B.Braun, Stryker, and Zimmer; and has stock or stock options held in
Blue Belt Technologies, Johnson & Johnson, Styker, and Zimmer. Dr. Dunbar or an immediate family member has received
royalties from Stryker; serves as a paid consultant to Stryker; has received research or institutional support from EMOVI,
Kinduct, Stryker, Zimmer, and DePuy; and serves as a board member, owner, officer, or committee member of the Ca-
nadian Joint Replacement Registry the Canadian Orthopaedic Association, the Canadian RSA Network, and the Knee
Society. Dr. Lee or an immediate family member is a member of a speakers’ bureau or has made paid presentations on
behalf of DePuy, Johnson & Johnson, and Ceramtec; serves as a paid consultant to DePuy, Johnson & Johnson, Pacira,
and Stryker; has received research or institutional support from CD Diagnostics, Zimmer, and Smith and Nephew; and
serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons.
Section 2: Knee
Figure 1 Computer-generated illustration demonstrates kinematic referencing of the center of the femoral head that
involves circumducting the hip joint. The center of the femoral head is identified as the point of a cone (the base
of the cone is the circumference of rotation of the knee). (Copyright BrainLab, Feldkirchen, Germany.)
acquired data that become the basis for a surgical plan contacting multiple points on the surface of the distal
during knee surgery. The speed of computing, memory, femur and proximal tibia with a digitizing device that
storage capacity, and communication ability with pe- communicates with the computer. The information is
2: Knee
ripherals have reached levels where even midrange, less- processed by the computer to extrapolate the shape, sur-
expensive personal computers can satisfy the requirements face contour, and relative size of the distal femur and
of imageless CAS knee applications. All current CAS knee proximal tibia3,4 (Figure 2). Furthermore, cardinal axes
applications use a range of platforms usually based on of alignment and rotation are also imputed, such as the
either UNIX or Windows operating systems. The com- transepicondylar axis, anterior-posterior axis of the distal
puters are currently mounted on transportable carts (or femur, and relative rotation of the tibia. The accuracy of
operating room booms) that include the computer, mon- the information collected by using surface registration
itor, keyboard, mouse, power transformer, and isolation requires that the surgeon correctly identify specific points.
unit and tracker controller units with ports to plug in the All conventional imageless systems use a combination of
tracker and tracking markers. surface and kinematic registration to identify the mechan-
Communication between the surgeon and computer is ical axis of the limb.
necessary for the continuous monitoring of the procedure.
This communication can be achieved with single or dou-
ble foot pedals, keypads, touch screens, pointer-integrated Features of Imageless CAS TKA Systems
controls, or voice-activated controls. All CAS systems determine the frontal and sagittal me-
Imageless systems use a combination of kinematic chanical axes of the bone being referenced and use these
and surface registration techniques to create a virtual axes to base the position of the cutting guides. Com-
bone map. Kinematic registration is used to character- prehensive optical systems (defined below) can link the
ize important anatomic landmarks outside of the inci- mechanical axis of the femur and tibia to compute the
sion.2 The center of the femoral head can be located by alignment of the limb2,3 (Figure 3). The mechanical axis
circumducting the femur around the hip with the pelvis of the femur is defined as a line between the center of the
stabilized (Figure 1). Surface registration involves directly femoral head, which is determined by using kinematic
Chapter 15: Computer-Assisted Knee Arthroplasty
Figure 2 Image shows digitized points (green dots)

that create a point cloud and allow the
computer software to create a virtual image
of the bone (bone morphing). (Copyright
Stryker, Kalamazoo, MI.)
registration, and the center of the distal femur, which

is determined by using surface registration techniques
(sometimes in combination with kinematic techniques).2
The mechanical axis of the tibia is defined as a line
between the center of the proximal tibia and the center of
the distal tibia.3 The center of the tibia is located by using
surface registration techniques and can be just anterior to
the insertion of the anterior cruciate ligament. The center
of the distal tibia is identified by using surface (sometimes
in combination with kinematic) registration techniques,
and can be calculated in several ways, depending on the Figure 3 Illustration shows the mechanical axis of the
lower limbs, which is defined as the angle
system used and the surgeon’s preference. One meth- subtended by a line between the center of the
od involves the computer software calculating the point femoral head and the center of the distal femur
2: Knee
and one between the center of the proximal
along the digitized transmalleolar axis located 56% of tibia and the center of the ankle.
the transmalleolar distance from the lateral malleolus
and 44% from the medial malleolus. Another method of
calculating the center of the distal tibia uses a point on cut, the accelerometer component is first calibrated to
the anterior aspect of the ankle that the software then the horizontal plane. After calibration, the accelerom-
intersects with the transmalleolar axis.3 eter is attached to the center of the femur by threaded
pins or an intramedullary guide. In this way, the system
recognizes the position of the center of the distal femur.
Imageless CAS Systems The hip is moved through a range of motion, and the
Accelerometer-Based Systems accelerometer detects the center of the femoral head by
Although the technology has been used in other fields using a kinematic registration algorithm. The device then
(such as aviation) for decades, accelerometer-based CAS calculates the mechanical axis of the femur. The cutting
systems are relatively recent additions to the arthroplasty guide with the sensor attached is maneuvered into the
surgeon’s CAS armamentarium. The systems use two appropriate position based on the information (varus/
components, an accelerometer attached to bone, which valgus and flexion/extension) provided by the system.
identifies the mechanical axis of the limb, and a sensor After the distal femur has been cut, conventional TKA
attached to the cutting guide, which identifies the position instrumentation is used to determine the appropriate size
of the cutting guide relative to the accelerometer.5 This and rotation of the femoral implant. The appropriate
information is displayed within the surgical field, either conventional four-in-one cutting block is used to complete
on a digital display or via a light-emitting display (LED) preparation of the femur.
system. The accelerometer component is attached to the cen-
To calculate the mechanical axis of the bone being ter of the tibia, and the mechanical axis of the tibia is
Section 2: Knee
determined. The distal tibia is identified differently based the need for cables. These batteries require recharging,
on the system chosen, either by moving the limb and using making their use for sequential procedures more difficult.
kinematic referencing or by identifying the medial and lat- Passive trackers do not require cords. However, automatic
eral malleoli via a jig attached to the accelerometer.5 After tool identification is more difficult for passive systems,
the mechanical axis of the tibia has been registered, the because all spheres in view reflect the light flashes equally.
cutting guide (and sensor) can be moved to the selected A unique identification of each tracker is possible with
alignment in the coronal and sagittal planes guided by the sequentially pulsed LEDs of the active trackers. The
the system display. The resection depth is determined by reflecting spheres must constantly be kept clean to obtain
conventional instrumentation, and the cut is made. accurate signal transmission. Moreover, the spheres are
Unlike conventional optical navigation systems, disposable and, therefore, a source of additional per-case
accelerometer-based CAS TKA systems do not require expense.
that a clear line of sight be maintained between the sur-
gical extremity and the computer system. All computer Limited Optical Navigation Systems
hardware is contained within the sterile surgical field. Limited optical navigation systems use a technique and
However, the information provided to the surgeon is lim- provide types of information similar to that used by
ited to the distal femoral and proximal tibial resections. accelerometer-based systems. In place of an accelerom-
Conventional instruments are required to set the depth eter, an infrared emitter or reflective ball transmits the
and rotation of the femoral and tibial cuts and to deter- position of the cutting guide to a stand-alone optical
mine the size of the components. localizer (camera).
The surgeon registers points on the distal femur and
Optical Navigation Systems proximal tibia. The system then calculates the position in
Optical navigation systems, which have been used to assist the coronal and sagittal planes of bone resection.3 Resec-
with knee arthroplasty since the late 1990s, commonly tion depth is incorporated into the bony cuts and compo-
use optical localization to communicate between the sur- nent rotation can be calculated but not used to position
gical extremity and the computer. Two types of optical the cutting guide. Conventional posterior referencing
tracking are used: active and passive. Active tracking cutting guides are used to position the cutting blocks for
systems use markers (also called trackers or rigid bod- correct femoral rotation.
ies) that have LEDs that emit light pulses to a camera Because the same tracking device is used for the fe-
(optical localizer). Three or (for redundancy) more of mur and the tibia, the relative position of the femur to
these LEDs are attached to screws or pins that are rigidly the tibia (the limb alignment axis) cannot be calculated.
2: Knee
attached to the femur and tibia. The camera system to Moreover, these systems cannot provide information re-
which the light is transmitted consists of two planar or garding ligament balance or limb alignment through a
three linear charge couple devices (CCD) rigidly mounted range of motion.
onto a solid. Passive systems use reflecting spheres placed Because these systems use a less cumbersome registra-
on tracking markers that are attached to screws or pins tion process than do conventional navigation systems, the
rigidly implanted in the femur and tibia. Infrared flashes surgical times associated with their use is often shorter.
sent by LED arrays on the camera housing illuminate the However, as with conventional navigation systems, these
spheres. The two planar or three linear CCDs detect the limited systems depend on precise surface registration of
reflections and interpolate the spatial location of each anatomic landmarks for accuracy.
light source. It is important for surgeons and staff to
realize that the arrays on the tracking markers, whether Comprehensive Optical Navigation Systems
active or passive, are specific to each CAS system. One Most prosthesis companies offer a comprehensive CAS
company’s trackers cannot be used on another company’s system for TKA. The kinematic and surface registration
CAS system, although the trackers may appear to be sim- processes are similar to those used with the limited optical
ilar. The advantages of optical localizing systems are that systems. However, data collected during the procedure
they are reliable, flexible, highly accurate, and have good are available throughout the procedure; data collection
operating room compatibility. A disadvantage of these is achieved by utilization of two trackers rigidly fixed
systems is that a free line of sight is necessary between the to the distal femur and proximal tibia, either within the
LED/spheres and the CCD arrays on the camera (optical incision or through separate stab incisions. Information
localizer). Active trackers may require cables to power and regarding prosthesis position, including femoral and tibial
synchronize the LEDs. These cables may be cumbersome. rotation, implant size, and gap balancing, can then be
Active trackers can be powered by batteries that eliminate displayed. In addition to static coronal limb alignment,
Figure 4 Illustration shows comprehensive optical

navigation, which displays information Figure 5 Illustration shows the rotational axes of
regarding alignment throughout range of the limb digitized for the surgeon. Correct
motion. (Copyright Stryker, Kalamazoo, MI.) identification of these landmarks is critical
to maximize precision. (Copyright Stryker,
Kalamazoo, MI.)
comprehensive optical navigation displays the alignment

of the limb throughout range of motion3,6 as an alignment
“curve” (Figure 4).
Femoral component rotation can be established relative
to any of the conventionally used axes (transepicondylar,
posterior condylar, or Whiteside line)2,3,6 (Figure 5). All
axes are digitized by the surgeon using a pointer. Precise
identification of landmarks is imperative. For example, a
large potential for error exists in detecting the transepi-
condylar axis, with combined errors reported as high as
13.5 mm.3,7
Comprehensive optical navigation systems also provide
information on implant size (based on registered bone
morphology) and can be modified by using either anterior
2: Knee
or posterior referencing according to surgeon preference.
Adjustments to implant size or position may have impli-
cations for notching and medial and lateral overhang,
which can also be displayed. The distance between the
planned femoral and tibial cuts can be shown, allowing
for a gap balancing technique. The surgeon can use a Figure 6 Illustration shows comprehensive optical
navigation system, which allows sophisticated
planning screen (Figure 6), which will show the real-time intraoperative planning before bone resection.
effect of any potential changes to the surgical plan, such (Copyright Stryker, Kalamazoo, MI.)
as changing component size or resection level, which also
provides an excellent teaching and learning platform.
This type of system offers the most detailed intraop- theoretically may result in fracture and increase infection
erative information currently available to the surgeon. risk. Key features of the accelerometer, limited optical,
All digitized points are stored on the navigation unit and and comprehensive optical systems are summarized in
can be reviewed during the surgical procedure. As a re- Table 1.
sult, the validity of the points can be assessed during the
procedure. The surgeon is also able to alter bone cuts
and assess the effect of this change on ligament balance. Outcomes With CAS TKA
Drawbacks to comprehensive optical navigation sys- The true measure of a new technology’s utility is the abil-
tems include increased surgical time, the need to maintain ity to improve and change existing practice. Regarding
a direct line of sight from the trackers to the sensors on the the various forms of computer-assisted TKA technolo-
navigation unit, and the need for additional drill holes in gies (CAS, patient-specific instrumentation, robotics),
the distal femur and proximal tibia (for the trackers) that the outcomes of interest include their effect on accuracy,
Section 2: Knee
Table 1
Features of Currently Available Navigation Technologies in Total Knee Arthroplasty
Limited Comprehensive
Feature Accelerometer
Optical Optical
Provides real-time surgical feedback Y Y Y
Provides information for placement of guides for Y Y Y
bone cuts
Preoperative radiographic image necessary N N N
Requires precise digitization of multiple anatomic N Y Y
points
Calculates coronal alignment of the limb N N Y
Calculates sagittal alignment of the limb N N Y
Requires separate trackers rigidly fixed to bones N N Y
Requires stand-alone tower in operating room N Y Y
Displays component rotation N N Y
Calculates implant size N N Y
Calculates flexion/extension gaps N N Y
Displays femoral implant notching and mediolateral N N Y
overhang
Displays alignment curve of limb throughout range of N N Y
movement
Facilitates measured resection technique Y Y Y
Facilitates gap balancing technique N N Y
Permits real-time digital manipulation of implant N N Y
position to aid surgical planning
N = no, Y = yes.
2: Knee
efficiency, and clinical results. In the current medical- femoral component position in the sagittal plane (2°) but
economic landscape, the costs of the technology need no significant differences in tibial sagittal component pos-
to be included in the final analysis to derive true value. iton were noted.11 Recent studies focused on component
rotation have also highlighted the potential benefits of
Computer-Assisted Navigation computer navigation in TKA. A 2014 prospective study
Proposed advantages of CAS include increased accuracy demonstrated that femoral component rotation was sig-
in component position, decreased blood loss and poten- nificantly more accurate when using CAS compared with
tially fewer complications, and better clinical function conventional instrumentation, and the precision increased
and implant survivorship secondary to improved com- with increasing preoperative deformity. However, tibial
ponent position.2 component rotation accuracy was not improved with nav-
Several studies have shown similar accuracy with fewer igation.12 Consequently, CAS is successful in improving
outliers from the traditional mechanical axis between component position accuracy in primary TKA.
CAS and conventional instrumentation in terms of align- An advantage of CAS compared with conventional in-
ment. A meta-analysis of all 23 randomized controlled strumentation is the elimination of the need to violate the
8,9
trials in the literature from 1986 to 2009 reported that medullary canal, thus potentially reducing blood loss and
patients undergoing CAS TKA had a significantly lower thromboembolic complications. A 2012 study compared
risk of implant malalignment in both coronal and sagittal total blood loss in patients undergoing TKA by using
planes for both components.10 A 2012 meta-analysis also CAS versus conventional instruments and found that
showed that CAS decreased the number of femoral and patients in the CAS group had significantly lower total
tibial component outliers in the coronal plane (±3°) and blood loss (1,137 versus 1,362 mL; P = 0.016) compared
with control patients.9 A review of 47 studies involving Association National Joint Arthroplasty Registry showed
7,151 TKAs reported that imageless navigation provid- that, although overall component survivorship was not
ed lower blood loss compared with that of traditional significantly different between patients undergoing TKA
TKA.13 Furthermore, a retrospective study compared a using CAS, patients younger than 65 years undergoing
group of 100 patients undergoing TKA by using an abbre- TKA using CAS had significantly lowered risks for revi-
viated CAS protocol (distal femoral and proximal tibial sion for aseptic loosening and lysis compared with knees
navigation) with traditional intramedullary instrumen- not undergoing CAS.18 The reasons for these findings
tation and found that navigation resulted in less hourly are unclear, but the study emphasizes the importance of
drain output, hemoglobin change, and estimated blood reasonable component position on implant survivorship
loss.8 However, despite a clinical advantage in blood loss in the younger and more active patient.
reduction, comparative studies have not shown a signif-
icant decrease in overall complications between the two Handheld Navigation (Accelerometers)
techniques.8,13 A systematic review that included 21 com- Handheld or portable navigation devices have been shown
parative studies and 2,333 TKAs showed similar rates of effective in improving bone resection accuracy with-
early postoperative complications in patients undergoing out adding significant cost or time to the procedure. A
TKA by using navigation compared with convention- 2013 study compared a portable accelerometer-based nav-
al instrumentation.11,14 In addition, navigation can be igation to an imageless, large-console navigation system
associated, although rarely, with pin site fractures and in primary TKA and the accelerometer-based navigation
infections. Therefore, CAS does not markedly reduce was found to be equally accurate in restoring alignment
postoperative complications compared with conventional within the traditional mechanical axis target with a sig-
instrumentation, and the immediate clinical benefits of nificant decrease in surgical time.19 Another study found
CAS remain unclear. that the portable accelerometer was more accurate in
The principal argument for the use of CAS in TKA restoring tibial alignment compared with conventional
centers on the premise that improved component position extramedullary tibial cutting guides.20 These findings may
will lead to improved clinical ratings (such as the Knee force a recalculation of the cost-benefit equation for the
Society Score and the Western Ontario and McMaster use of navigation in primary TKA. As newer generations
Universities Osteoarthritis Index) and increased implant of navigation systems become more compact, portable,
survivorship. Several recent comparative studies have not and accurate and less costly, the application and use of
shown significant differences in terms of clinical rating this technology may broaden and increase over time.
scores between the two techniques. One retrospective
2: Knee
study reported that in a group of patients with valgus
arthritic knees CAS TKA resulted in fewer component Summary
position outliers and lower lateral release rates compared Computer navigation and computer-assisted technologies
with traditional instrumentation, but there were no sig- can improve accuracy and minimize outliers in TKA. Al-
nificant differences in survivorship, Hospital for Special though CAS is more reliable and reproducible in achieving
Surgery, and International Knee Society scores between the planned targets compared with conventional instru-
the two groups at a mean follow-up of 46 months.15 A mentation, clinical outcomes have not been shown to be
trial of 108 patients were randomly assigned to CAS or significantly different when the traditional mechanical
conventional TKA; at 9 years no significant differenc- axis target is used. Additionally, cost and time consid-
es in survivorship, radiographic analysis, and clinical erations currently place navigation at a disadvantage for
functional scores were found.16 These observations have routine use in TKA.
also been confirmed at the registry level. Another study However, as the norms and conventions of optimal
analyzed 9,054 CAS TKA procedures in the New Zea- alignment, rotation, and balance for TKA are challenged,
land National Joint Registry performed between 2006 to it is clear that more precise instruments such as naviga-
2012 and found no differences in revision rates and Ox- tion and/or robotics will be needed to individualize these
ford Knee Scores at 6 months and 5 years between pa- targets. As newer devices continually come to market
tients undergoing CAS TKA compared with TKA using with improved portability, lower cost, and fewer disrup-
conventional instrumentation.17 However, navigation in tions to surgical workflow, CAS eventually will become
TKA may be of benefit in younger patients undergoing a mainstay in the performance of TKA.
TKA. A recent analysis of the Australian Orthopaedic
Section 2: Knee
Key Study Points 6. iASSIST Knee surgical technique 2-pod version. Montre-
al, QC, Zimmer CAS, 2015. http://www.zimmer.com/
• Computer navigation and computer-assisted tech- content/dam/zimmer-web/documents/en-US/pdf/surgi-
cal-techniques/knee/iassist-knee-surgical-technique-2-
nologies have been shown to be more accurate in pod-version.pdf. Accessed August 4, 2016.
mechanically aligned primary TKA than conven-
tional instrumentation. 7. Pitto RP, Graydon AJ, Bradley L, Malak SF, Walker CG,
• No data support the superiority of any computer- Anderson IA: Accuracy of a computer-assisted navigation
assisted or navigation-assisted technologies over system for total knee replacement. J Bone Joint Surg Br
2006;88:601-605. Medline DOI
another.
• Comparative studies of TKAs performed using nav- 8. Licini DJ, Meneghini RM: Modern abbreviated com-
igation have not showed significant advantages in puter navigation of the femur reduces blood loss in total
pain relief, function, and survivorship compared knee arthroplasty. J Arthroplasty 2015;30:1729-1732.
Medline DOI
with TKAs performed using modern conventional
instrumentation. This retrospective study shows that the use of CAS TKA
without violation of the intramedullary canals resulted
• The increased accuracy of navigation technologies in decreased blood loss and drain output compared with
in TKA have to be weighed against the increased TKA performed by using conventional intramedullary
capital costs and time expenditures associated with instrumentation.
the use of these devices.
9. McConnell J, Dillon J, Kinninmonth A, Sarungi M, Picard
F: Blood loss following total knee replacement is reduced
when using computer-assisted versus standard methods.
Annotated References Acta Orthop Belg 2012;78:75-79. Medline
This retrospective study compared sequentially performed
TKAs by using CAS with conventional instrumentation.
1. da Mota E Albuquerque RF: Navigation in total knee The use of CAS was associated with less blood loss but
arthroplasty. Rev Bras Ortop 2015;46:18-22. Medline no significant difference in transfusion rates.
A concise history and basic outline of the various computer
navigation options available includes a brief discussion of 10. Hetaimish BM, Khan MM, Simunovic N, Al-Harbi HH,
complications and disadvantages. Bhandari M, Zalzal PK: Meta-analysis of navigation vs
conventional total knee arthroplasty. J Arthroplasty
2. Bae DK, Song SJ: Computer assisted navigation in 2012;27:1177-1182. Medline DOI
knee arthroplasty. Clin Orthop Surg 2011;3:259-267. A meta-analysis of 23 randomized controlled trials com-
2: Knee
Medline DOI pared CAS to conventional instrumentation. CAS was

This is a review of the various navigation modalities used associated with fewer outliers greater than 3° from me-
in TKA that discusses the technology behind computer chanical axis.
navigation systems and includes a brief discussion of clin-
ical results, advantages, and disadvantages. 11. Cheng T, Pan XY, Mao X, Zhang GY, Zhang XL: Lit-
tle clinical advantage of computer-assisted navigation
3. OrthoMap Express Knee Navigation: Surgical technique over conventional instrumentation in primary total knee
manual for the OrthoMap Express Knee Navigation soft- arthroplasty at early follow-up. Knee 2012;19:237-245.
ware. Kalamazoo, MI, Stryker, 2012. Available at http:// Medline DOI
www.stryker.com/en-us/products/OREquipmentConnec- This meta-analysis of 21 randomized controlled trials
tivity/SurgicalNavigation/SurgicalNavigationSoftware/ compared clinical parameters of TKA performed by using
KneeNavigationSoftware/OrthoMapExpress/index.htm. CAS compared with conventional instruments. Except for
Accessed August 3, 2016. a longer surgical time, CAS TKA was not associated with
lower complications or improved Knee Society Scores.
4. OrthoMap Express Knee Navigation: Surgical technique
manual for the OrthoMap Precision Knee Navigation 12. Hernandez-Vaquero D, Noriega-Fernandez A, Fernan-
Software. Kalamazoo, MI, Stryker, 2012. http://www. dez-Carreira JM, Fernandez-Simon JM, Llorens de los
stryker.com/en-us/products/OREquipmentConnectivity/ Rios J: Computer-assisted surgery improves rotational
SurgicalNavigation/SurgicalNavigationSoftware/Knee- positioning of the femoral component but not the tibial
NavigationSoftware/orthomapprecision/index.htm. Ac- component in total knee arthroplasty. Knee Surg Sports
cessed August 3, 2016. Traumatol Arthrosc 2014;22:3127-3134. Medline DOI
5. KneeAlign 2 System: Surgical technique manual, tibal and This prospective study found that the use of CAS was
distal femur navigation. Aliso Viejo, CA, OrthoAlign, associated with more accurate femoral component rotation
2012. as measured by CT scans compared with conventional
instrumentation.
13. Moskal JT, Capps SG, Mann JW, Scanelli JA: Navigated An analysis of the New Zealand National Joint Registry
versus conventional total knee arthroplasty. J Knee Surg reported on the effect of CAS TKA on revision rates and
2014;27:235-248. Medline DOI clinical outcomes. There were no differences in revision
rates or mean Oxford Knee Scores.
A meta-analysis of 7,151 pooled TKAs from 47 studies
found that computer navigation was associated with im-
proved component alignment, reduced blood loss, higher 18. de Steiger RN, Liu YL, Graves SE: Computer navigation
clinical ratings, and fewer adverse events. for total knee arthroplasty reduces revision rate for pa-
tients less than sixty-five years of age. J Bone Joint Surg
Am 2015;97:635-642. Medline DOI
14. Cheng T, Zhao S, Peng X, Zhang X: Does computer-as-
sisted surgery improve postoperative leg alignment and An analysis of the Australian Orthopaedic Association
implant positioning following total knee arthroplasty? National Joint Registry reported on the effect of CAS TKA
A meta-analysis of randomized controlled trials? Knee on revision rates. Overall, navigation did not significantly
Surg Sports Traumatol Arthrosc 2012;20:1307-1322. affect reoperation rates when CAS TKA was compared
Medline DOI with conventionally instrumented TKAs. However, CAS
TKAs were associated with lower revision rates at 9 years
A meta-analysis of randomized controlled trials found that for aseptic failures in patients younger than 65 years.
CAS reduced the number of component outliers in both
the coronal and sagittal planes.
19. Nam D, Weeks KD, Reinhardt KR, Nawabi DH, Cross
MB, Mayman DJ: Accelerometer-based, portable nav-
15. Huang TW, Kuo LT, Peng KT, Lee MS, Hsu RW: Com- igation vs imageless, large-console computer-assisted
puted tomography evaluation in total knee arthroplasty: navigation in total knee arthroplasty: A comparison of
Computer-assisted navigation versus conventional instru- radiographic results. J Arthroplasty 2013;28:255-261.
mentation in patients with advanced valgus arthritic knees. Medline DOI
This study discusses a retrospective comparison of the ac-
A retrospective study of the effectiveness of CAS in cases curacy of a handheld accelerometer navigation device to a
of severe valgus deformity indicated that the use of CAS traditional large-console CAS TKA system. The portable,
improved component position and lowered lateral release handheld accelerometer was as accurate as traditional
rates but did not significantly affect clinical performance. CAS TKA regarding resection of the distal femur and
proximal tibia.
16. Zhu M, Ang CL, Yeo SJ, Lo NN, Chia SL, Chong HC:
Minimally invasive computer-assisted total knee arthro- 20. Nam D, Cody EA, Nguyen JT, Figgie MP, Mayman
plasty compared with conventional total knee arthro- DJ: Extramedullary guides versus portable, accelerom-
plasty: A prospective 9-year follow-up. J Arthroplasty eter-based navigation for tibial alignment in total knee
2016;31:1000-1004. Medline DOI arthroplasty: a randomized, controlled trial: winner of the
A randomized controlled trial compared the midterm 2013 HAP PAUL award. J Arthroplasty 2014;29:288-294.
results of TKA performed by using CAS with TKA per- Medline DOI
2: Knee
formed with conventional instruments. There were no This was a randomized controlled trial of primary TKA
differences in clinical function or implant survivorship comparing the accuracy of a handheld accelerometer nav-
between the two techniques. igation system with conventional extramedullary tibial
alignment guides. The accuracy of conventional extra-
17. Roberts TD, Clatworthy MG, Frampton CM, Young medullary tibial guides was 68% in the coronal plane (±2°
SW: Does computer assisted navigation improve func- from perpendicular) and 72% in the sagittal plane (±2°
tional outcomes and implant survivability after total from 3° posterior slope) compared with 95% accuracy in
knee arthroplasty? J Arthroplasty 2015;30(suppl):59-63. the accelerometer group.
Medline DOI
Chapter 16
The Difficult Primary Total

Knee Arthroplasty
Jaydev B. Mistry, MD Siraj A. Sayeed, MD, MEng Morad Chughtai, MD Randa K. Elmallah, MD
Michael A. Mont, MD Ronald E. Delanois, MD
Primary total knee arthroplasty has been proved to be Most total knee arthroplasties (TKAs) are performed
an effective treatment of knee arthritis. As surgical tech- in patients with minimal deformities of the knee. These
niques and implant design have evolved, the indications procedures can be performed with a standard medial
for primary total knee arthroplasty have expanded to parapatellar arthrotomy exposure with the use of stan-
include more complex cases. Surgical exposure may dard instrumentation. Although these basic guidelines
be difficult, and outcomes may not be as successful in can be used for most situations, patients with various
patients with large deformities, severe knee stiffness, or deformities, diseases, and comorbidities may pose a
posttraumatic arthritis. Moreover, special consideration challenge for reconstruction surgeons because they may
and planning should be undertaken for patients with require extra attention during preoperative management
cardiovascular disease, obesity, inflammatory arthritis, and modification of surgical techniques to optimize the
Charcot arthropathy, or other comorbidities. Therefore, postoperative results. This may include more advanced
it is important for orthopaedic surgeons to be familiar surgical approaches, the use of additional hardware, and
with general principles that may help reduce the inci- greater soft-tissue releases about the knee.
dence of complications while also improving outcomes
after total knee arthroplasty.
2: Knee
Knee-Specific Conditions
Large Intra-articular Varus/Valgus
Keywords: valgus/varus deformity; posttraumatic Deformities at the Knee
arthritis; comorbidity; inflammatory arthritis; Patients with greater preoperative varus/valgus deformity
Charcot arthropathy have a greater risk of failure after TKA, independent of
postoperative alignment.1 This higher failure rate may be
attributed to inadequate intraoperative balancing of the
Dr. Sayeed or an immediate family member serves as a paid consultant to Medtronic and serves as a board member,
owner, officer, or committee member of the American Academy of Orthopaedic Surgeons and the American Association
of Hip and Knee Surgeons. Dr. Mont or an immediate family member has received royalties from MicroPort Orthopedics
and Stryker; serves as a paid consultant to or is an employee of DJ Orthopaedics, Johnson & Johnson, Merz, Ortho-
Sensor, Pacira, Sage Products, Stryker, TissueGene, and U.S. Medical Innovations; has received research or institutional
support from DJ Orthopaedics, Johnson & Johnson, the National Institutes of Health (NIAMS and NICHD), Ongoing Care
Solutions, OrthoSensor, Stryker, and TissueGene; and serves as a board member, owner, officer, or committee member
of the American Academy of Orthopaedic Surgeons. Dr. Delanois or an immediate family member is a member of a
speakers’ bureau or has made paid presentations on behalf of Cayenne Medical; serves as a paid consultant to or is an
employee of Cayenne Medical; and serves as a board member, owner, officer, or committee member of the Maryland
Orthopaedic Association. None of the following authors or any immediate family member has received anything of
value from or has stock or stock options held in a commercial company or institution related directly or indirectly to
the subject of this chapter: Dr. Mistry, Dr. Chughtai, and Dr. Elmallah.
Section 2: Knee
joint. Achievement of sufficient soft-tissue balance and release may be necessary if the medial compartment does
restoration of neutral limb alignment are necessary for not open 1 to 3 mm throughout the arc of motion. The
favorable outcomes after TKA. Undercorrection of defor- release can be performed by using a 19-gauge needle to
mity may result in joint instability and polyethylene over- place five punctures in the tightest fibers, as determined
load. Surgeons should not only aim to restore alignment via direct palpation.2 Medial asymmetric tightness in ex-
but also should be aware of the appropriate balancing tension requires multiple needle punctures of the posterior
and release techniques to help manage large preoperative aspect of the MCL with the knee in extension and under
varus or valgus deformity. tension. Medial asymmetric tightness in flexion can be
addressed with multiple punctures of the anterior aspect
Severe Varus Deformity of the superficial MCL with the knee in flexion and under
Varus alignment is the most common deformity in pa- tension. Each series of five needle punctures should be
tients undergoing primary TKA. Varus knees have a no- followed with serial stress examinations until the medial
table loss of tibial bone and/or cartilage in the medial compartment opens 1 to 2 mm during extension and 2 to
compartment and are associated with proximal tibial 3 mm in flexion. Surgeons should be cautious because
varus deformity. Many knees have a correctable varus these techniques may place the MCL at increased risk
deformity requiring minimal releases; however, patients of iatrogenic transection or overrelease. If the MCL is
with a rigid, noncorrectable varus deformity often require completely released or is not sufficient to affect balancing,
medial releases to achieve proper balance and alignment.2 a constrained condylar implant should be used.
Preoperatively, an examination under anesthesia Different techniques for management of the varus
should be performed to determine if the knee has a fixed knee have shown promising results. One study reported
deformity or is correctable. Fixed deformities may require on 34 knees that underwent TKA with a preoperative
extensive soft-tissue balancing, whereas correctable defor- fixed-varus deformity and flexion contracture.3 These
mities may require only a few releases. After exposure, the knees required the use of the inside-out technique, which
anteromedial capsule and deep medial collateral ligament involves a posteromedial capsulotomy at the level of the
(MCL) should be released to the semimembranosus bursa tibial cut along with pie-crusting of the superficial MCL.
with concomitant removal of osteophytes from the medial Coronal alignment was corrected from 21.1° of varus
femoral condyle. Patients with flexion contracture may preoperatively to 4.5° of valgus postoperatively, and
require release of the semimembranosus if the deformity there were no cases of instability at a mean follow-up of
persists after bony preparation. 3.1 years. Another report examined a multiple-needle-
The distal femoral resection should be in 5° to 7° of puncture technique used to balance the MCL in 35 knees
2: Knee
valgus. In varus knees, the more normal condyle is often with a mean of 12.5° of varus (range, 9° to 23°) before
the lateral condyle; therefore, the amount of bone resect- TKA.4 Thirty-four knees (97%) were successfully cor-
ed from the medial condyle should equal the thickness rected with 2 to 4 mm of maximum opening during exten-
of the implant. However, this resection may be adjusted sion, and 2 to 6 mm of maximum opening during flexion.
based on the amount of wear and degeneration present Similar results were seen in another study in which 62 of
within the joint. The degree of external rotation of the 65 varus knees (95%) were successfully corrected by mul-
femur can be guided by assessment of the anteroposterior tiple needle punctures of the MCL (based on 2 to 4 mm of
axis, transepicondylar axis, posterior condylar axis, and joint opening during extension, and 2 to 6 mm of opening
mediolateral flexion gap asymmetry. Excessive external during flexion).2
rotation may result in posteromedial laxity in flexion and
tightness of lateral structure, whereas internal rotation Severe Valgus Deformity
may present with posterolateral laxity with flexion and Valgus deformity is seen in almost 10% of patients un-
tightness of the medial structures. The lateral tibial pla- dergoing TKA and is characterized by bone loss of the
teau, which usually is more normal compared with the lateral femoral condyle and central and posterior tibial
medial plateau, can be referenced to guide tibial resection. plateau.5 This is often seen with contracted soft tissues
By referencing approximately two-thirds of the lateral laterally and stretched soft tissues medially. Stabilizers
plateau in an anterior-to-posterior manner, the extent of in the lateral compartment include the popliteus tendon,
proximal tibial resection can be determined to accom- the lateral collateral ligament (LCL), the iliotibial band
modate the implant. When trial components are in place, (ITB), and the posterolateral capsule. Although cadaver
mediolateral stability should be assessed throughout the studies have demonstrated involvement of the popliteus
range of motion (ROM), including medial-lateral stress tendon and LCL throughout the ROM, they appear to
testing to tension the medial soft-tissue sleeve. Soft-tissue contribute more to flexion than to extension. Additionally,
Chapter 16: The Difficult Primary Total Knee Arthroplasty
the ITB and posterolateral capsule provide stability pri- Flexion gaps may be balanced with adjustment of poly-
marily during flexion.6 ethylene insert thickness. The knee should be extended,
Similar to treatment for varus knees, a preoperative and balance should be checked medially and laterally. If
examination under anesthesia should be performed to lateral tightness exists only in flexion, assessment should
determine if the knee has a fixed or correctable deformity. be performed for possible errors in femoral rotation. If
Fixed-valgus deformities will likely require substantial rotation is determined to be satisfactory, the LCL can be
soft-tissue balancing, whereas correctable deformities released via pie-crusting or incremental release off of the
may require few, if any, releases. Although forceful flex- femur. Additionally, the popliteus tendon can be released
ion and external rotation of the tibia can help provide if there is an internal rotation contracture associated
exposure in varus knees, this technique may stretch the with lateral tightness during flexion. Knees with lateral
already compromised medial structures in valgus knees, tightness in both flexion and extension can be addressed
and therefore should be avoided. Osteophytes in the lat- with release of the popliteus tendon, the LCL, or both.
eral compartment should be removed, and any soft-tissue Any remaining lateral tightness during extension can
releases should be addressed after bony preparation. Pos- be addressed laterally with release of the posterolateral
terior cruciate ligament (PCL) contractures may require capsule or pie-crusting of the ITB. Serial examinations
balancing or releasing during TKA. If the PCL is to be and stress testing should be performed until the knee
released, the component should be a cruciate-substituting opens 2 to 4 mm laterally and 2 to 3 mm medially in
implant. Severe valgus deformities also may present with flexion and 1 to 3 mm laterally and 1 to 2 mm medially
patellar maltracking that necessitates lateral retinacular in extension. If instability persists even after these re-
release during TKA. If maltracking issues are noted after leases, a more constrained implant should be used. One
trial components have been tested, component alignment study investigated TKA in valgus knees and reported 91%
should be reevaluated. survival of 66 knees (46 patients) at 13-year follow-up;
When the distal femur is prepared, the initial in- however, an instability rate of 24% led the authors to
tramedullary entry hole should be made medial to the develop alternative methods for lateral release.7 Another
anteroposterior axis and in the notch located anterior report examining 78 valgus knees (53 patients) after TKA
to the PCL attachment. This is performed to account described significant improvement in mean Hospital for
for the lateral bowing of the distal femur in a valgus Special Surgery knee scores (48 to 91 points; P < 0.001),
knee. A 3° to 5° resection of the distal femur can help mean tibiofemoral alignment (valgus 20° to 5°; P < 0.001),
prevent undercorrection in a valgus knee as well as and mean ROM (65 to 110°; P < 0.001) at a mean follow-
reduce stress on the compromised medial structures. up of 10 years (range, 8 to 14 years).6 These studies high-
2: Knee
The amount of bone resected off of the medial condyle, light the importance of adequate soft-tissue release and
which is usually more normal, should be equal to the implant selection when performing TKA in knees with
thickness of the metallic medial condyle of the implant. severe valgus deformity.
Patients with severe lateral condyle deformities should
not have this area of bone resected because it can create Knee Stiffness
flexion-extension balancing difficulties and raise the Stiff knees can involve limitations in extension or flex-
joint line, resulting in midflexion instability. Rotational ion or a combination of both. This may be a product of
alignment should be derived from the anteroposteri- contractures, posttraumatic or septic arthritis, hetero-
or and epicondylar axes. This is performed to avoid topic ossification, and patella baja. Limitations in knee
referencing of the posterior condyle that may result ROM are often functionally debilitating. For example,
in internal rotation of the femoral component. When basic activities such as walking (95°), ascending stairs
preparing the tibia for resection, the extramedullary (105°), descending stairs (107°), and picking up objects
alignment guides should be placed at a 90° angle to the off the floor (117°) require a greater ROM.8,9 Moreover,
longitudinal axis of the tibia. In severely valgus knees, the most important predictor of ROM after TKA is pre-
intramedullary alignment should be used with caution operative ROM.10 One study demonstrated a direct cor-
because of the valgus bowing of the tibial shaft. The relation between preoperative and postoperative flexion
degree of posterior slope is dependent on particular at 6 months, 1 year, 3 years, and 5 years postoperatively
implant design and the status of the PCL. In general, (Pearson correlation coefficient, 0.363, 0.403, 0.406,
a posterior slope of 0° can be used in posterior cruci- 0.359, respectively; P < 0.0001 for all).10 Flexion defor-
ate-substituting and cruciate-sacrificing designs. If the mities frequently occur in patients having osteoarthritis
PCL is to be retained, the slope can vary between 3° and place patients at greater risk of a postoperative re-
and 5°, based on implant specifications. sidual flexion deformity. Knees that cannot attain full
Section 2: Knee
(Figure 1). This approach allows preservation of both

the tendinous insertion of the vastus lateralis and lateral
superior genicular blood flow to the patella, and therefore
should be used as the first option.12,13 One study com-
pared 31 patients who underwent a quadriceps snip with
63 patients who underwent the standard medial parapa-
tellar incision and demonstrated equivalent objective and
functional outcomes, total Knee Society Scores (KSSs),
ROM, patient satisfaction, and incidence of extension
lag and patellofemoral pain.14 Another study compared
Western Ontario and McMaster Universities Osteoar-
thritis Index function, pain, stiffness, and satisfaction
scores between 50 patients who underwent a quadriceps
snip and 57 patients who underwent a standard medial
parapatellar approach and reported that no negative ef-
fect was associated with the quadriceps snip at a mean
follow-up of 41 months.15
Figure 1 Illustration shows a planned quadriceps snip. Tibial Tubercle Osteotomy

The tibial tubercle osteotomy (TTO) may be used when
extension during ambulation require increased energy further exposure of the stiff knee is necessary where the
expenditure for quadriceps contraction to maintain sta- quadriceps snip approach is not sufficient. In addition,
bility.11 Additionally, these deformities may cause a limb- the TTO may aid in difficult stem extraction, tibial tuber-
length discrepancy or affect gait kinematics. It also is cle malposition, and patellar ligament contracture.12,13 A
imperative to rule out other etiologies of knee stiffness 2016 study compared 106 patients who underwent TTO
such as structural deformities, infections, or ankylosis.11 with 474 patients who underwent the standard medial
Preoperative planning should include assessing parapatellar approach and demonstrated no significant
ROM, presence of deformities, neurovascular status, difference in clinical outcomes (Western Ontario and
and the prosthesis design that will be used. Full-length McMaster Universities Osteoarthritis Index, KSS knee
weight-bearing radiographs of the limb can provide in- and function scores, and knee flexion ROM) after 1 year
2: Knee
formation on bony landmarks and any existing structural following TKA (P = 0.337, 0.278, 0.269, 0.318, respec-
deformity or ankylosis. In cases of stiff knees with par- tively).16 A 2011 study compared 22 patients who under-
ticularly difficult surgical exposure, it may be necessary went TTO with 22 patients who underwent the standard
to use a standard medial parapatellar approach, an addi- medial parapatellar approach and found no significant
tional proximal extension of the quadriceps tendon, and difference in postoperative International Knee Society
a lateral retinacular release. After a medial arthrotomy, System Scores at 7-year follow-up (P < 0.05).17
adhesions of the suprapatellar pouch and lateral and
medial gutters should be treated. To enhance patellar V-Y Quadriceps Turndown
mobilization, it may be necessary to carefully elevate the The V-Y quadriceps turndown uses the medial parapatel-
subperiosteum of the deep MCL along the proximal tibia lar approach with a diverging incision through the quad-
from the posteromedial corner (just anterior to the semi- riceps tendon distally and laterally through the vastus
membranosus insertion) and place the tibia in external lateralis tendon. The incision is extended inferolaterally
rotation. If 90° of knee flexion still cannot be achieved, at a 45° angle over the lateral retinaculum toward the
other extensile approaches may be required. These ap- tibia (Figure 2). Although this approach provides excel-
proaches include the quadriceps snip, tibial tubercle oste- lent exposure because the entire patella may be everted
otomy, and the V-Y turndown. distally, it should be used with caution because of the risk
of interruption of the blood supply to the patella, which
Quadriceps Snip may potentially result in necrosis of the extensor mech-
The quadriceps snip involves the proximal extension of anism. However, the knee may be kept immobilized in
the arthrotomy along the quadriceps tendon directed full extension for a minimum of 2 weeks after surgery to
in the proximal-lateral direction approximately 30° to minimize the degree of extensor lag.12 One study assessing
45° in line with the fibers of the vastus lateralis muscle this approach in 29 revision TKAs (27 patients) noted
Table 1
Anderson Orthopaedic Research Institute
Classification of Bone Defects
Type Severity of Deficiency
1 Minor femoral/tibial defects with intact
metaphyseal bone
2 Damaged metaphyseal bone and loss of
cancellous metaphyseal femoral bone
requiring reconstruction (prosthetic
augment, cement fill, or bone graft)
2A Defects in one femoral or one tibial condyle
2B Defects in both femoral or both tibial
condyles
3 Deficient metaphyseal segment
compromising a major portion of either
femoral condyles or tibial plateau; may
Figure 2 Illustration shows a planned V-Y turndown. be associated with collateral or patellar
ligament detachment
Reproduced from Engh GA, Ammeen DJ: Bone loss with revision
postoperative radiographic evidence of osteonecrosis in total knee arthroplasty: Defect classification and alternatives for
eight patellae.18 At 6 weeks postoperatively, all patients reconstruction. Instr Course Lect 1999;48:167-175.
had significant extensor lag, with recovery of quadriceps
strength occurring gradually up to 1 year after surgery.
Another study used bone scanning to demonstrate re- appropriate method for bone reconstruction20(Table 1).
duced isotope uptake in 56.4% of knees that underwent Instability of the knee in the setting of bone loss should
a lateral release associated with the V-Y quadriceps turn- be treated with a posterior stabilized implant or a more
down, compared with 15% of knees that did not undergo constrained prosthesis. Patients with AORI type 2 or
a lateral release.19 This finding was attributed to the com- smaller type 3 bone defects will have improved outcomes
promised blood supply of the patella associated with this by using prostheses with lesser degrees of constraint.21 In
approach. Given these complications, the V-Y quadriceps cases with high degrees of type 3 bone loss and loss of
2: Knee
turndown is reserved as a last resort. ligamentous stability, a hinged knee prosthesis is more
appropriate.22
Posttraumatic Arthritis Small contained defects of 5 mm or less may be re-
Posttraumatic arthritis can be difficult to manage in the constructed with bone cement. When cement is used to
setting of intra-articular bony defects, malunion, limb reconstruct these defects, screws may be added to enhance
malalignment, retained hardware, and stiffness. Careful the biomechanical properties of the construct.23 How-
preoperative planning should be performed before TKA ever, in vitro studies have shown that metal wedge aug-
is undertaken. This includes assessment of the degree of ments are superior to bone cement alone and bone cement
intra-articular bone loss, prosthetic choice regarding con- with screw fixation for reconstruction of these smaller
straint, the need for hardware removal if it is in the way of defects.24 One study reported no revision surgeries in
the prosthesis, and possible performance of an osteotomy 22 TKAs (20 patients) that were followed for a mini-
for extra-articular deformity. The goal of achieving an mum of 2 years (mean follow-up, 37 months).24 No com-
anatomic joint line will optimize ligamentous stability ponent failures and no loosening of tibial components
and restore joint kinematics. were associated with this technique. Another study of
Evaluation of intra-articular bone defects may include 24 TKAs (21 patients) with a metal wedge augmentation
CT to evaluate the extent of intra-articular bone defects. for tibial bone deficiency demonstrated excellent and good
Three-dimensional CT may be beneficial to gain a com- clinical outcomes in 67% and 29% of knees, respective-
plete assessment of the degree of bone loss. Several clas- ly, at 5.6-year follow-up.25 At 4.8 years after surgery,
sification systems have been developed to describe the radiolucent lines were seen beneath the metal wedge at
extent of bone loss. The widely used Anderson Orthopae- the cement-bone interface in 13 knees: 11 were less than
dic Research Institute (AORI) classification system helps 1 mm wide and 2 were between 1 and 3 mm wide. No
categorize the degree of bone loss and predict the most radiolucencies were progressive.
Section 2: Knee
Type 2 and 3 defects are typically managed with metal and resuming anticoagulation therapy postoperatively
augments to include modular blocks and wedges, porous remains controversial.
cones, and metal sleeves. The use of structural allograft Studies have shown varying outcomes after TKA in
has declined in the past several years, partly because patients with cardiovascular pathology. A 2011 study
of the advent of porous cones and metallic sleeves, and reported that 16.7% of patients who had a previous car-
long-term data have shown a reoperation rate of up to diac event (n = 514) and 2% of patients with no his-
23% with allograft failure.26-30 Metal augmentation using tory of cardiac event (n = 1,094) experienced a cardiac
modular blocks or wedges can be used to reconstruct event (for example, congestive heart failure, myocardial
areas of small- to moderate-size uncontained segmental infarction, arrhythmia) after TKA.36 Additionally, 20.7%
femoral and tibial defects of 5 to 20 mm deep.31 Most patients with a history of thromboembolism and 3.6%
TKA systems offer varied sizes of augments that attach of patients without a history of thromboembolism expe-
directly to the components. In one study evaluating type rienced a thromboembolic event (deep vein thrombosis
2 defects treated with modular augments and stems, suc- [DVT] or pulmonary embolism) after TKA. Conversely,
cessful long-term survivorship of 92% was reported at a 2014 study reported no increased risk of mortality after
11 years.32 Porous metal sleeves and cones are advanta- TKA in patients with a history of cardiac disease.37 How-
geous because they offer immediate mechanical support ever, it should be noted that these patients had an increased
to the prosthesis, allow osseous integration in the case risk of minor local complications (P = 0.01), including
of porous cones, obviate the risk of disease transmission superficial wound infection and wound dehiscence.
and graft resorption leading to failure and reoperation, Thorough assessment of a patient’s cardiovascular his-
and allow immediate weight bearing postoperatively. One tory is necessary before performing TKA. It is vital that
study examined 15 knees with porous metaphyseal cones surgeons identify these potentially high-risk patients to
and demonstrated improved KSS scores from 52 points ensure sufficient preoperative management and education.
preoperatively to 85 points at short-term follow-up of
34 months.33 Additionally, all cones showed evidence Obese Patients
of osseointegration with reactive osseous trabeculation The worldwide incidence of obesity (body mass index
at contact points with the tibia. Loosening or migra- [BMI] greater than 30 kg/m2) has increased over the past
tion of these components was not seen at the time of 2 decades.38 Patients with obesity have a greater risk of
follow-up. The only study providing midterm results, the development of early osteoarthritis compared with
mean follow-up of 5.8 years, of tibial cone implantation nonobese patients. With the projected increase in number
has shown revision-free survival greater than 95%.34 Of of total joint arthroplasties (TJAs) that will be performed
2: Knee
66 tibial cones implanted for AORI type 2 or 3 defects, over the next several decades, 39 orthopaedic surgeons
only 3 were revised; 1 for aseptic loosening, 1 for peri- should be familiar with how to treat patients with obesity.
prosthetic fracture, and 1 for infection.34 Following TKA, obese patients are at greater risk
of delayed wound healing, infection, prolonged wound
drainage, poor mobilization, and reduced tolerance for
Additional Considerations rehabilitation.38 Although many agree that obesity is
Patients With Cardiovascular Pathology associated with these complications, no definitive cut-
Patients who undergo TKA may have cardiovascular, pe- off exists that places patients at a substantially higher
ripheral vascular, and cerebrovascular diseases, which are risk.40 However, some authors have noted that morbidly
associated with a variety of surgical risks and complica- obese patients (BMI greater than 40 kg/m2) may have a
tions. Thorough evaluation of a patient’s cardiac history, greater risk of wound dehiscence and postoperative infec-
including determination of arrhythmias, fluid shifts, oxy- tion, suggesting that this BMI threshold may be used as
gen saturation, smoking status, effects of anesthesia, his- a cutoff to reassess treatment options as well as provide
tory of cardiovascular surgery, and history of hematologic patient education.41
and pulmonary disease, is necessary before performing Patients with a BMI less than 30 kg/m 2 have demon-
TKA. These patients can be more challenging to treat strated greater implant survivorship compared with their
if they are receiving anticoagulants such as clopidogrel. obese or morbidly obese counterparts.42 One study re-
Although guidelines recommend cessation of clopidogrel ported that 5-year implant survivorship (with revision as
for 5 days before surgery, there is an increased risk of the endpoint) was significantly lower in morbidly obese
cardiovascular and thromboembolic events if it is dis- patients compared with those who had a BMI less than
continued for an extended period of time.35 The decision 30 kg/m2 (72% vs 98%).42 Another study demonstrated
of withholding anticoagulation therapy preoperatively significantly lower implant survivorship in morbidly obese
patients (BMI of 40 kg/m 2 or greater) compared with of perioperative complications and improve functional
obese patients (BMI between 30 and 40 kg/m 2) and non- outcomes.
obese patients (BMI less than 30 kg/m2) at a mean 5-year
follow-up (88% vs 95% vs 97%, respectively; P < 0.05). Metabolic Syndrome
However, a 2013 study noted no difference in implant Metabolic syndrome is a series of risk factors that place
survivorship between nonobese patients and superobese patients at an increased risk of development of type 2 dia-
(greater than 50 kg/m2) patients (98% vs 94%) at a mean betes mellitus and cardiovascular disease.51 Patients must
5-year follow-up.43 have three of the following five components to meet the
criteria for diagnosis of metabolic syndrome: hyperten-
Patients With Other Comorbidities sion, elevated fasting blood glucose levels, elevated tri-
Diabetes Mellitus glyceride levels, low levels of high-density lipoprotein, and
The prevalence of diabetes mellitus is rising in the United increased abdominal circumference (greater than 102 cm
States and is becoming an increasingly common comor- for men and greater than 88 cm for women).52 Patients
bidity in patients undergoing TKA. Diabetes mellitus is with metabolic syndrome require special consideration
known to delay collagen synthesis and impair wound because they have an increased risk of complications af-
healing, which may lead to poor recovery and increased ter TJA.
risk of infection.44 Some studies have demonstrated al- A 2013 study investigated the association between
tered bone metabolism in patients with diabetes melli- control of metabolic syndrome components and incidence
tus,45 which can potentially delay fracture healing and of perioperative complications (including but not limited
contribute to component loosening in TJA. Additionally, to DVT, pulmonary embolism, wound infection, peripros-
diabetes mellitus is associated with poorer outcomes46 and thetic infection, and acute renal failure) after TJA.53 One
increased risk of DVT.47 Therefore, patients with this hundred thirty-three patients undergoing TJA with all
disease require special preoperative consideration, as tight components of metabolic syndrome were matched with
control of blood glucose levels may help reduce postop- patients who did not have metabolic syndrome. Within
erative morbidity. the metabolic syndrome cohort, 35 patients (26%) were
In a 2015 study of 462 patients with diabetes found to have at least one uncontrolled component. The
(714 TKAs), those with hemoglobin A1c levels greater complication rates for patients with uncontrolled, con-
than 8% had an increased likelihood of having super- trolled, and no metabolic syndrome were 49%, 8%, and
ficial surgical site infections (odds ratio [OR], 6.1; 95% 8%, respectively. Additionally, the metabolic syndrome
confidence interval [CI], 1.6 to 23.4; P = 0.008).48 This cohort had significantly greater length of hospital stay
2: Knee
association also was seen in patients who had a fasting (5.1 vs 4.0 days; P < 0.001) and higher complication rate
blood glucose of 200 mg/dL or higher (OR, 9.2; 95% (18.3% vs 8.3%; P = 0.018) compared with patients with-
CI, 2.2 to 38.2; P = 0.038). In another study, patients out metabolic syndrome. In a 2013 study examining the
with diabetes mellitus had a significantly higher rate of incidence of pulmonary embolism after THA or TKA, pa-
revision compared with patients without diabetes mel- tients with metabolic syndrome had a significantly greater
litus (3.6% vs 0.4%; P < 0.05).49 A 2013 retrospective likelihood of this complication compared with patients
analysis of 245 patients undergoing TKA, 53 of whom without metabolic syndrome (OR, 1.6; 95% CI, 1.01 to
had diabetes mellitus, showed that patients with diabetes 2.56; P = 0.043).54 Moreover, the odds of pulmonary
mellitus were 2.76 times more likely to have DVT.47 More- embolism increased 1.23 times (95% CI, 1.02 to 1.48;
over, a 2012 study examining functional outcomes after P = 0.028) per each additional component of metabolic
TKA in 367 patients with diabetes mellitus and a cohort syndrome. Another study evaluated 1,460 TKA patients
without diabetes mellitus matched for age, sex, BMI, to determine the relationship of metabolic syndrome on
and baseline functional movement showed worse out- the incidence of DVT.55 In total, 65 patients (4.4%) ex-
comes in those with diabetes.50 At 1-year follow-up, the perienced DVT (P < 0.001), of whom 21 patients had
cohort with diabetes mellitus had significantly lower total metabolic syndrome (15.5%, n = 135) compared with
ROM (P < 0.001), KSS (P = 0.034), and maximal flexion 45 patients without metabolic syndrome (3.4%, n =
(P < 0.001). Similar results were seen at 5-year (except 1,325). In addition, this analysis demonstrated that the
for KSS) and 10-year follow-up. risk of DVT in patients with metabolic syndrome was
Given the rising prevalence of diabetes, orthopaedic 3.2 times the risk in patients without metabolic syndrome
surgeons must be prepared to treat an increasing number (95% CI, 1.0 to 15.4; P = 0.04).
of surgical patients with this disease. Adequate glycemic Overall, patients with comorbidities may have poor-
control in patients with diabetes may help reduce the risk er outcomes after TKA compared with those without
Section 2: Knee
comorbidities. It is crucial for orthopaedic surgeons to increased constraint.57 However, prostheses with great-
identify these high-risk patients to ensure appropriate er constraint can impart increased rotational and shear
preoperative education and management. Additionally, forces on the bone-cement interface, potentially resulting
surgeons may have to counsel these patients regarding in early failure.
expectations for postoperative outcomes. Numerous reports have described higher complication
rates in patients with rheumatoid arthritis compared with
Inflammatory Arthropathies patients with osteoarthritis. A meta-analysis59 comparing
Patients with bone damaged as a result of inflammatory complications in lower extremity TJA between rheuma-
arthropathies and their associated medications are often toid arthritis and osteoarthritis demonstrated an increased
considered challenging candidates for TKA because of risk of infection as well as an increased likelihood of early
concerns regarding implant ingrowth, stability, and in- revision in rheumatoid arthritis patients (OR, 1.24; 95%
fection. However, as both medical and surgical manage- CI, 1.1-1.4). In a 2015 study, a Nationwide Inpatient
ment of these patients have evolved, better postoperative Sample database was used to examine acute postopera-
outcomes have been observed after TKA. tive outcomes in patients with TKA with various types
of inflammatory arthropathies compared with patients
Rheumatoid Arthritis with osteoarthritis.60 The authors noted a significantly
Rheumatoid arthritis is a systemic, progressive inflam- greater likelihood of hematoma/seroma (OR, 1.3; 95%
matory process that can result in joint destruction and CI, 1.2-1.3), infection (OR, 1.1; 95% CI, 1.0-1.2), and
instability. Medical management of rheumatoid arthri- periprosthetic fracture (OR, 1.6; 95% CI, 1.4-1.9) in
tis typically includes a combination of glucocorticoids, patients with rheumatoid arthritis (P < 0.05 for all) com-
NSAIDs, and disease-modifying antirheumatic drugs. pared with patients who have osteoarthritis. Additionally,
Although NSAIDs are effective in symptomatic manage- a 2016 study described a significantly greater incidence of
ment, they should be withheld for 1 week before surgery pneumonia in patients with rheumatoid arthritis within
to minimize the risk of bleeding.56 Surgeons also should 30 days postoperatively (2.1% vs 0.4%; P = 0.003).61 De-
be aware that patients with rheumatoid arthritis who have spite these complications, favorable long-term results also
undergone chronic treatment with corticosteroids are at have been shown after TKA in patients with rheumatoid
risk of poor wound healing, weakening of the immune arthritis. At a mean follow-up of 10.5 years, one study
system, and reduced bone quality. Additionally, these reported good or excellent results in 95% of 46 knees with
patients are susceptible to adrenal insufficiency second- rheumatoid arthritis treated with a cruciate-retaining
ary to prolonged suppression of corticotrophin-releasing component.62 In a 2013 study,63 297 patients who under-
2: Knee
hormones from the hypothalamus.57 Moreover, the cer- went TKA, of whom 47 had rheumatoid arthritis, were
vical spine is often affected in patients with rheumatoid evaluated.63 The 10- and 15-year implant survivorship
arthritis and may present in the form of atlantoaxial sub- in the rheumatoid arthritis group was 88% and 78%,
luxation.58 This involvement is often asymptomatic, and respectively.
therefore, patients scheduled to receive general anesthesia
should undergo a comprehensive radiographic assessment Juvenile Rheumatoid Arthritis
of the cervical spine. Patients with substantial atlantoaxial Juvenile rheumatoid arthritis (JRA) is a conglomerate
instability should be considered for alternative methods of disorders with a common presentation of persistent
of anesthetic management, such as fiberoptic intubation arthritis in at least one joint that typically presents within
or epidural/spinal anesthesia. the first 2 decades of life. As the leading cause of child-
Intraoperatively, orthopaedic surgeons must be aware hood disability, it has an estimated incidence of 6 cases
of the poor quality of bone and soft tissue in patients with per 10,000 children, or 294,000 total cases in the United
rheumatoid arthritis. Chronic use of corticosteroids, as States.64 In addition to flexion contractures and poor bone
well as the autoimmune nature of the disease, can lead to quality, patients with JRA often have complex deformi-
inferior subchondral bone stock and osteopenia.57 These ties such as valgus alignment as well as trumpet-shaped
deficiencies may result in inadequate implant fixation, femurs and tibias as a result of prematurely closed growth
reduced implant longevity, and the formation of bone plates.65 Nonetheless, TKA in patients with JRA can re-
cysts. Small bone cysts may be filled during cementation; store function and provide pain relief with appropriate
however, larger cysts may require filling with allograft medical and surgical management.
from morcellized femoral head or autologous graft from Patients with JRA are managed with similar medi-
prior bone cuts. Additionally, the ligamentous laxity seen cations as those used in rheumatoid arthritis, including
in these patients may require the use of components with corticosteroids, disease-modifying antirheumatic drugs,
and biologic agents. As such, they also are at risk of im- osteoarthritis who underwent TKA with respect to pain,
paired wound healing, compromise of the immune sys- function, activity, and quality of life.73 As TKA continues
tem, and adrenal crises.65 JRA presents with multiple to demonstrate favorable outcomes, it should be presented
joint involvement, especially in the lower extremities. It as an option to patients who have SLE.
is difficult to maintain full knee extension with a flexion
contracture of the hip, complicating rehabilitation of the Charcot Arthropathy
knee. Therefore, THA should be performed before TKA. Charcot arthropathy, also known as neuropathic arthrop-
Patients with contractures in both knees, who are athy, is a degenerative condition associated with nerve
otherwise healthy, are recommended to undergo simul- damage, decreased proprioception, and periarticular in-
taneous bilateral TKA.65 Severe deformities can make the sensitivity, secondary to a deterioration of periarticular
initial exposure more difficult and therefore may require sensation resulting in joint destruction and fragmentation.
more extensive exposures. Osteotomies of the tibial tu- Clinically, this disorder presents with joint effusion, crepi-
bercle are not recommended, particularly in the setting tus, lack of proprioception, and instability.74 Additionally,
of osteopenia.65 Moreover, the proximal tibia may be patients are often unaware of pain in the affected joint,
dysplastic and present with rapid tapering of the metaph- potentially contributing to the substantial destruction of
ysis, which necessitates careful placement of retractors to the articular surfaces.
avoid compression fractures. In addition, the patella may It is believed that the knee joint is the most frequently
be ankylosed to the femur; therefore, patellar resurfacing affected large joint in the setting of neuropathic disease;
is recommended.66 Complications experienced by these therefore, early detection and treatment of patients with
patients include fractures, arthrofibrosis, periprosthetic Charcot arthropathy is key. Immobilization through the
infection, and sciatic nerve injury. Despite these potential use of casts or non–weight-bearing devices is thought to
setbacks, TKA has shown success in patients with JRA. A inhibit osteolytic processes within the joint. Moreover, it
study examining 349 TKAs in patients with JRA reported has been suggested that joint destruction may potentially
10- and 20-year implant survivorship at 95% and 82%, be delayed with joint aspiration, NSAID use, supportive
respectively.67 However, other studies have shown long- orthoses, exercise, and gait training.75 However, definitive
term failure rates ranging from 6% to 42% in patients guidelines for bracing and casting for the neuropathic
with JRA.68,69 knee have not been firmly established.
Orthopaedic surgeons encounter several challenges
Systemic Lupus Erythematosus with these patients, including bone loss, instability, and
Systemic lupus erythematosus (SLE) is a chronic, multisys- deformity. In the past, Charcot arthropathy of the knee
2: Knee
tem, autoimmune disease that commonly occurs in young joint was managed with arthrodesis or bracing. How-
women, mostly prevalent among African Americans. It ever, as implant designs and surgical techniques have
typically presents along a wide spectrum of symptoms, advanced, more favorable postoperative outcomes have
including rash, fever, and polyarthralgia. Patients with been achieved.74 Moreover, as the staging of Charcot
a diagnosis of SLE are twice as likely to require TKA arthropathy has become better understood, surgeons can
compared with the general population.70 Furthermore, more accurately assess for the most appropriate time for
the incidence of lower extremity TJA in patients with surgical intervention. Patients whose disease process is in
SLE in the United States increased from 0.17 to 0.83 per the early inflammatory or fragmentation stages should
100,000 people from 1991 to 2005.71 Because of the com- postpone TKA until the reconstruction or coalescence
plexity of SLE, these patients often require involvement of stages.76,77
several medical specialties to ensure they are adequately Recently, the successful use of porous tantalum cones
treated. has been reported at short-term follow-up. 33 These
Patients with SLE who undergo TKA tend to be young- implants are thought to aid in reconstruction of bony
er than patients without SLE;70 however, good postoper- defects while simultaneously providing an anchor for
ative outcomes are possible. A 2016 study comparing a the fragmented proximal tibia.74 Other commonly used
cohort of patients with SLE who underwent TKA with reconstruction methods to address these technical chal-
a matched cohort that did not have the disease revealed lenges include bone grafting, hinged or semiconstrained
similar outcomes with respect to implant survivorship, implants, and stem extensions.78 One study described
complication rates, functional outcomes, physical and results after TKA in 10 patients (19 knees) with Charcot
mental scores, and activity scores at midterm follow-up arthropathy.79 A cemented condylar, constrained prosthe-
of 6 years.72 Another study demonstrated similar out- sis was used in all but two knees. At a mean follow-up
comes between patients with SLE and patients with of 5.2 years (range, 5 to 6 years), the mean Hospital for
Section 2: Knee
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17. Nikolopoulos DD, Polyzois I, Apostolopoulos AP, Rossas
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Res 2012;470:199-204. Medline DOI obesity, diabetes, and obesity-related health risk factors,
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195-199. Medline DOI morbidly obese patients. It was concluded that these pa-
tients should be advised to lose weight before surgery or
33. Meneghini RM, Lewallen DG, Hanssen AD: Use of po- to consider bariatric surgery.
rous tantalum metaphyseal cones for severe tibial bone
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34. Kamath AF, Lewallen DG, Hanssen AD: Porous tantalum Relat Res 2015;473:57-63. Medline DOI
metaphyseal cones for severe tibial bone loss in revision Morbid obesity was associated with a higher risk of some
knee arthroplasty: A five to nine-year follow-up. J Bone in-hospital postoperative complications and mortality,
Joint Surg Am 2015;97:216-223. Medline DOI even after matching for comorbid medical conditions
Porous tantalum tibial cones can serve as an option for linked to obesity.
tibial bone loss. At 5- to 9-year follow-up, porous tantalum
tibial cones had durable clinical results and radiographic 42. Amin AK, Clayton RA, Patton JT, Gaston M, Cook RE,
fixation. Brenkel IJ: Total knee replacement in morbidly obese pa-
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35. Nandi S, Aghazadeh M, Talmo C, Robbins C, Bono J: Joint Surg Br 2006;88:1321-1326. Medline DOI
Perioperative clopidogrel and postoperative events af-
ter hip and knee arthroplasties. Clin Orthop Relat Res 43. Naziri Q, Issa K, Malkani AL, Bonutti PM, Harwin SF,
2012;470:1436-1441. Medline DOI Mont MA: Bariatric orthopaedics: Total knee arthroplasty
in super-obese patients (BMI > 50 kg/m2). Survivorship
The authors found that withholding clopidogrel for at and complications. Clin Orthop Relat Res 2013;471:3523-
least 5 days before hip or knee arthroplasty may lower the
3530. Medline DOI
2: Knee
rate of bleeding events, and that an American Society of

Anesthesiologists score of 4, advanced age, and revision The authors found that complications were more fre-
surgery may be risk factors for bleeding events. quent and functional outcomes were significantly lower
in superobese patients. No differences in aseptic implant
36. Singh JA, Jensen MR, Harmsen WS, Gabriel SE, Le- survivorship were noted between superobese patients and
wallen DG: Cardiac and thromboembolic complications those with lower BMI.
and mortality in patients undergoing total hip and total
knee arthroplasty. Ann Rheum Dis 2011;70:2082-2088. 44. Han HS, Kang SB: Relations between long-term glycemic
Medline DOI control and postoperative wound and infectious compli-
cations after total knee arthroplasty in type 2 diabetics.
This study reported on 90-day complications following Clin Orthop Surg 2013;5:118-123. Medline DOI
TKA or THA. They noted that older age, higher comor-
bidity, higher American Society of Anesthesiologists clas- The authors found that poorly controlled hyperglycemia
sification, and history of cardiac/thromboembolic disease before surgery may increase the incidence of wound com-
were associated with increased risk of complications. plications among diabetic patients after TKA.
37. Belmont PJ Jr, Goodman GP, Waterman BR, Bader 45. Einhorn TA, Boskey AL, Gundberg CM, Vigorita VJ,
JO, Schoenfeld AJ: Thirty-day postoperative complica- Devlin VJ, Beyer MM: The mineral and mechanical prop-
tions and mortality following total knee arthroplasty: erties of bone in chronic experimental diabetes. J Orthop
Incidence and risk factors among a national sample of Res 1988;6:317-323. Medline DOI
15,321 patients. J Bone Joint Surg Am 2014;96:20-26.
Medline DOI 46. Singh JA, Lewallen DG: Diabetes: A risk factor for poor
Diabetes and age increased the risk of mortality after functional outcome after total knee arthroplasty. PLoS
primary unilateral TKA. Predictive factors for postop- One 2013;8(11):e78991. Medline DOI
erative complications included an American Society of The authors found that diabetes, as well as its severity, was
Anesthesiologists classification of 3 or greater, increased independently associated with poorer functional outcome.
age, increased surgical time, and greater body mass.
47. Wang S, Zhao Y: Diabetes mellitus and the incidence The authors of this study found that patients with met-
of deep vein thrombosis after total knee arthroplasty: abolic syndrome are at increased risk of pulmonary em-
A retrospective study. J Arthroplasty 2013;28:595-597. bolism after TJA. The increasing number of metabolic
Medline DOI syndrome components significantly increased the inci-
dence of pulmonary embolism.
This retrospective study examined the risk of DVT in
patients with diabetes mellitus undergoing TKA within
55. Gandhi R, Razak F, Tso P, Davey JR, Mahomed NN:
14 days. Patients with diabetes had a 2.76-fold greater risk
of DVT compared with those without diabetes mellitus. Metabolic syndrome and the incidence of symptomatic
deep vein thrombosis following total knee arthroplasty.
J Rheumatol 2009;36:2298-2301. Medline DOI
48. Hwang JS, Kim SJ, Bamne AB, Na YG, Kim TK: Do gly-
cemic markers predict occurrence of complications after
total knee arthroplasty in patients with diabetes? Clin 56. Lee JK, Choi CH: Total knee arthroplasty in rheumatoid ar-
Orthop Relat Res 2015;473:1726-1731. Medline DOI thritis. Knee Surg Relat Res 2012;24(1):1-6. Medline DOI
A positive correlation was found among the various avail- The authors of this study suggested that patients with
able glycemic markers among patients with diabetes mel- rheumatoid arthritis have additional risk of late compli-
litus undergoing TKA, and patients undergoing surgery cations, which must be considered to improve the results
with hemoglobin A1c of 8 or higher and/or fasting blood of TKA in these patients.
glucose of 200 mg/dL or greater were associated with
superficial surgical site infection. 57. Danoff JR, Moss G, Liabaud B, Geller JA: Total knee
arthroplasty considerations in rheumatoid arthritis. Au-
49. Meding JB, Reddleman K, Keating ME, et al: Total knee toimmune Dis 2013;2013:185340. Medline
replacement in patients with diabetes mellitus. Clin Or- The authors of this study suggested that providers share an
thop Relat Res 2003;416:208-216. Medline DOI understanding of the special considerations in this unique
population of patients to ensure success in the immediate
50. Robertson F, Geddes J, Ridley D, McLeod G, Cheng K: perioperative and postoperative periods, including specific
Patients with Type 2 diabetes mellitus have a worse func- modalities to maximize success.
tional outcome post knee arthroplasty: A matched cohort
study. Knee 2012;19:286-289. Medline DOI 58. Neva MH, Häkkinen A, Mäkinen H, Hannonen P,
Kauppi M, Sokka T: High prevalence of asymptomatic
This study demonstrated that diabetes mellitus leads to
cervical spine subluxation in patients with rheumatoid
worse outcomes after knee arthroplasty, although no sig-
nificant difference was demonstrable in KSSs at 5 years arthritis waiting for orthopaedic surgery. Ann Rheum
(P = 0.35), suggesting patient satisfaction remains high Dis 2006;65:884-888. Medline DOI
during this period.
59. Ravi B, Escott B, Shah PS, et al: A systematic review
51. Isomaa B, Henricsson M, Almgren P, Tuomi T, Taskinen and meta-analysis comparing complications following
MR, Groop L: The metabolic syndrome influences the risk total joint arthroplasty for rheumatoid arthritis versus
2: Knee
of chronic complications in patients with type II diabetes. for osteoarthritis. Arthritis Rheum 2012;64:3839-3849.
Diabetologia 2001;44:1148-1154. Medline DOI Medline DOI
The authors of this study found that their literature review
52. National Cholesterol Education Program (NCEP) Ex- and meta-analysis indicate that, compared with patients
pert Panel on Detection, Evaluation, and Treatment of with osteoarthritis, patients with rheumatoid arthritis are
High Blood Cholesterol in Adults (Adult Treatment Panel at higher risk of dislocation and higher risk of infection
III): Third Report of the National Cholesterol Education after TKA.
Program (NCEP) Expert Panel on Detection, Evalua-
tion, and Treatment of High Blood Cholesterol in Adults 60. Schnaser EA, Browne JA, Padgett DE, Figgie MP,
(Adult Treatment Panel III) final report. Circulation D’Apuzzo MR: Perioperative complications in patients
2002;106:3143-3421. Medline with inflammatory arthropathy undergoing total knee
arthroplasty. J Arthroplasty 2015;30(suppl):76-80.
53. Zmistowski B, Dizdarevic I, Jacovides CL, Radcliff KE, Medline DOI
Mraovic B, Parvizi J: Patients with uncontrolled compo- The authors of this study found that inflammatory sub-
nents of metabolic syndrome have increased risk of compli- types had a higher rate of orthopaedic complications post-
cations following total joint arthroplasty. J Arthroplasty operatively compared with patients with osteoarthritis.
2013;28:904-907. Medline DOI Ankylosing spondylitis had the highest mortality rate as
The authors’ analysis confirmed independent associations well as medical complication rate among the subtypes.
between control of metabolic syndrome components as
well as both length of stay and perioperative complications. 61. Jauregui JJ, Kapadia BH, Dixit A, et al: Thirty-day compli-
cations in rheumatoid patients following total knee arthro-
54. Mraovic B, Hipszer BR, Epstein RH, et al: Metabolic plasty. Clin Rheumatol 2016;35:595-600. Medline DOI
syndrome increases risk for pulmonary embolism after The authors of this study suggested that patients who have
hip and knee arthroplasty. Croat Med J 2013;54:355-361. rheumatoid arthritis with end-stage knee arthritis may
Medline DOI benefit from TKA; these patients should be preoperatively
optimized to minimize complication risks.
Section 2: Knee
62. Archibeck MJ, Berger RA, Barden RM, et al: Posteri- The authors of this study found that patients with lupus
or cruciate ligament-retaining total knee arthroplasty in who underwent TKA or THA were younger than their
patients with rheumatoid arthritis. J Bone Joint Surg Am peers without lupus. In addition, they appeared to have
2001;83-A:1231-1236. Medline a significantly increased risk of TKA, but the increased
risk of THA did not remain after adjustment for alcohol
consumption and steroid use.
63. Feng B, Weng X, Lin J, Jin J, Wang W, Qiu G: Long-term
follow-up of cemented fixed-bearing total knee arthroplas-
ty in a Chinese population: A survival analysis of more 71. Mertelsmann-Voss C, Lyman S, Pan TJ, Goodman S, Figgie
than 10 years. J Arthroplasty 2013;28(10):1701-1706. MP, Mandl LA: Arthroplasty rates are increased among
Medline DOI US patients with systemic lupus erythematosus: 1991-
2005. J Rheumatol 2014;41:867-874. Medline DOI
The authors of this study found that Chinese patients with
rheumatoid arthritis had lower long-term survivorship The authors of this study suggested that patients with SLE
compared with patients who had osteoarthritis. Younger are now living long enough for osteoarthritis to develop
patients had better Hospital for Special Surgery scores. and are healthy enough to undergo elective surgery.
64. Behrens EM, Beukelman T, Gallo L, et al: Evaluation 72. Issa K, Pierce TP, Scillia AJ, et al: Midterm outcomes
of the presentation of systemic onset juvenile rheuma- following total knee arthroplasty in lupus patients. J Ar-
toid arthritis: Data from the Pennsylvania Systemic On- throplasty 2016;31:655-657. Medline DOI
set Juvenile Arthritis Registry (PASOJAR). J Rheumatol The authors of this study suggest excellent clinical and
2008;35:343-348. Medline patient-reported outcomes of TKA in patients with or
without SLE. Prospective studies are necessary to evaluate
65. Abdel MP, Figgie MP: Surgical management of the juvenile these outcomes at longer follow-up.
idiopathic arthritis patient with multiple joint involvement.
Orthop Clin North Am 2014;45:435-442. Medline DOI 73. Shah UH, Mandl LA, Mertelsmann-Voss C, et al: Systemic
The authors of this study discussed TJAs in patients who lupus erythematosus is not a risk factor for poor out-
have juvenile idiopathic arthritis. Focus is placed on over- comes after total hip and total knee arthroplasty. Lupus
all epidemiology, coordination of care, and medical and 2015;24:900-908. Medline DOI
surgical managements of these patients undergoing THA The authors of this study found that although patients
and TKA. with SLE have more comorbidities than those with osteo-
arthritis, and those with SLE who have had THA have
66. Parvizi J, Lajam CM, Trousdale RT, Shaughnessy WJ, worse preoperative pain and function compared with
Cabanela ME: Total knee arthroplasty in young patients osteoarthritis controls, SLE was not an independent risk
with juvenile rheumatoid arthritis. J Bone Joint Surg Am factor for poor short-term pain or function after either
2003;85-A:1090-1094. Medline hip or knee arthroplasty.
67. Heyse TJ, Ries MD, Bellemans J, et al: Total knee arthro- 74. Troyer J, Levine BR: Proximal tibia reconstruction with a
2: Knee
plasty in patients with juvenile idiopathic arthritis. Clin porous tantalum cone in a patient with Charcot arthrop-
Orthop Relat Res 2014;472(1):147-154. Medline DOI athy. Orthopedics 2009;32:358. Medline DOI
The authors of this study showed that patients with ju-
75. Fullerton BD, Browngoehl LA: Total knee arthroplasty
venile rheumatoid arthritis typically have lower TKA
survivorship rates than patients with osteoarthritis or in a patient with bilateral Charcot knees. Arch Phys Med
rheumatoid arthritis. Functional limitations also are quite Rehabil 1997;78:780-782. Medline DOI
common in this population.
76. Sugitani K, Arai Y, Takamiya H, Minami G, Higuchi T,
68. Thomas A, Rojer D, Imrie S, Goodman SB: Cemented Kubo T: Total knee arthroplasty for neuropathic joint dis-
total knee arthroplasty in patients with juvenile rheuma- ease after severe bone destruction eroded the tibial tuber-
toid arthritis. Clin Orthop Relat Res 2005;433:140-146. osity. Orthopedics 2012;35:e1108-e1111. Medline DOI
Medline DOI The authors of this study described a patient who un-
derwent TKA for neuropathic joint disease secondary to
69. Malviya A, Foster HE, Avery P, Weir DJ, Deehan DJ: diabetes mellitus after severe bone destruction eroded the
Long term outcome following knee replacement in patients tibial tuberosity.
with juvenile idiopathic arthritis. Knee 2010;17:340-344.
Medline DOI 77. Parvizi J, Marrs J, Morrey BF: Total knee arthroplasty
for neuropathic (Charcot) joints. Clin Orthop Relat Res
This study retrospectively analyzed the long-term out-
comes of 34 TKAs in 20 patients with juvenile idiopathic 2003;416:145-150. Medline DOI
arthritis. At median follow-up of 16 years, various func-
tion and satisfaction scores were improved. At 20 years, 78. Long WJ, Scuderi GR: Porous tantalum cones for large
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plasty: A minimum 2-year follow-up. J Arthroplasty
70. Mukherjee S, Culliford D, Arden N, Edwards C: 2009;24:1086-1092. Medline DOI
What is the risk of having a total hip or knee replace-
ment for patients with lupus? Lupus 2015;24:198-202. 79. Kim YH, Kim JS, Oh SW: Total knee arthroplasty in
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Chapter 17
Management of Extra-Articular
Deformities in Knee Arthroplasty
Abbas Naqvi, MD Jaydev B. Mistry, MD Randa K. Elmallah, MD Morad Chughtai, MD Michael A. Mont, MD
mechanical axis, appropriate soft-tissue stabilization,

Abstract
and the establishment of adequate flexion and extension
The success of total knee arthroplasty depends on ad- gaps.1-3 However, achieving these goals can be compli-
equate restoration of the lower extremity mechanical cated by the presence of femoral or tibial extra-articular
axis. However, the presence of extra-articular deformity deformities, which can be the result of malunion, congen-
can substantially complicate the attainment of this goal. ital or metabolic bone disease, prior osteotomy, tumor,
Therefore, it is important to understand the various or Paget disease. The presence of such deformities can
etiologies of extra-articular deformity, evaluation and render conventional TKA instrumentation ineffective.
diagnosis, the critical principles and approaches to Therefore, adequate preoperative patient evaluation and
deformity correction, outcomes, and new treatments identification of these deformities is critical to proper sur-
for extra-articular deformities. gical planning and success. It is important to understand
the etiology and cause of extra-articular knee deformities,
evaluation and diagnosis, principles of treatment, and the
Keywords: extra-articular; deformity; varus; use of new techniques to aid in the surgical correction of
valgus; correction extra-articular knee deformities.
2: Knee
Etiologies of Extra-Articular Knee Deformities
The etiologies for extra-articular deformities of the fe-
Introduction
mur and/or tibia range from congenital conditions to
The long-term success of total knee arthroplasty (TKA) malunion of a previous fracture. Adequate patient his-
depends on accurate restoration of the lower extremity tory and physical examination are critical to identifying
such deformities and their etiologies in the preoperative
setting. However, although numerous etiologies can affect
Dr. Mont or an immediate family member has received royal- the femur or tibia, the subsequent deformities are usually
ties from MicroPort and Stryker, serves as a paid consultant similar and, as such, are managed in a similar manner.
to DJ Orthopaedics, Johnson & Johnson, Merz, OrthoSensor,
Pacira, Sage Products, Stryker, TissueGene, and US Medical Fracture Malunion
Innovations; has received research or institutional support One of the most common etiologies of extra-articular
from DJ Orthopaedics, Johnson & Johnson, the National deformity is prior femoral or tibial fracture. Distal fem-
Institutes of Health (NIAMS & NICHD), Ongoing Care Solu- oral fractures can occur in young patients (younger than
tions, OrthoSensor, Stryker, and Tissue Gene; and serves 60 years) secondary to high-energy trauma and in the el-
as a board member, owner, officer, or committee member derly secondary to falls. In addition, arthritis can develop
of the American Academy of Orthopaedic Surgeons. None subsequent to such injury as a result of poor alignment or
of the following authors or any immediate family member direct intra-articular insult. This can be the underlying
has received anything of value from or has stock or stock cause of arthritis in up to 7.2% of patients undergoing
options held in a commercial company or institution related TKA.4,5 Patients with a history of distal femoral fracture
directly or indirectly to the subject of this chapter: Dr. Naqvi, are at risk for poor outcomes following TKA because of a
Dr. Mistry, Dr. Elmallah, and Dr. Chughtai. combination of factors, including altered joint mechanics
Section 2: Knee
and the presence of hardware.5 As with distal femoral no significant difference in outcomes between TKAs that
fractures, patients with a history of proximal tibial frac- had or had not undergone HTO.12 The study noted a
tures are at increased risk of the development of arthritis, higher incidence of valgus alignment and patella infera
with rates as high as 44%.6 Furthermore, this patient pop- in the HTO cohort. Therefore, the relationship between
ulation is at increased risk of postoperative complications HTO and TKA outcomes requires further investigation.
including ankyloses, infection, and patellar subluxation Nevertheless, orthopaedic surgeons should be aware of
following TKA. Knowledge of previous distal femoral previous HTO because of the potential adhesions in the
or proximal tibial fractures is critical for both surgical surgical field as well as changes in joint alignment. The
planning and avoiding postoperative complications. surgical techniques to treat TKA after HTO or DFO
are not specifically discussed in this chapter, but several
Congenital or Metabolic Bone Disease descriptions have been published.12-14
Congenital conditions, such as osteogenesis imperfecta
or Blount disease, as well as metabolic diseases such as Tumor
hereditary hypophosphatemia or hyperparathyroidism, Tumors violating the structural integrity of the femur
also can result in substantial extra-articular deformity. or tibia can result in extra-articular deformity affecting
Osteogenesis imperfecta is a genetic condition that affects the knee. Bone quality and prosthesis stability can be
the formation of bone and is characterized by the defective further complicated by factors such as the pharmacologic
formation of type 1 collagen.7 There are multiple subtypes treatment and surgical removal of such tumors. Chemo-
of osteogenesis imperfecta that range in severity from therapeutic agents such as methotrexate, ifosfamide, and
perinatal death and severe skeletal deformities to asymp- imatinib have been shown to adversely affect bone me-
tomatic individuals predisposed to fractures. In patients tabolism.15-17 Long-term use of methotrexate can result in
who have osteogenesis imperfecta, metaphyseal flaring, osteopathy.17 Patients typically present with osteoporosis,
which exhibits a “popcorn-like” appearance, can develop. severe bone pain, and bony changes resembling scurvy
In addition, bowing and thinning of the lower extremities that are especially prominent in the lower extremities.
can develop. The poor bone quality and frequent fractures Ifosfamide has been shown to adversely affect bone turn-
in these patients may necessitate placement of intramed- over and healing.18 Imatinib use may result in hypophos-
ullary rods and may further complicate TKA.8 Blount phatemia with secondary hyoparathryoidism;15 therefore,
disease has been linked to obesity and typically affects knowledge of previous tumor management as well as
the posteromedial aspect of the tibial growth plate, re- cessation, if possible, of chemotherapeutic agents before
sulting in bowing of the lower extremity.9 Although the surgery may help improve postoperative outcomes in this
2: Knee
tibial physis is more commonly affected, the late-onset high-risk patient population.
variant of Blount disease can result in distal femoral varus
deformity. Metabolic states such as hypophosphatemia Paget Disease of Bone
and hyperparathyroidism primarily affect the quality of Paget disease of bone is characterized by accelerated bone
the bone by shifting the balance between osteogenesis remodeling. Instead of the smooth, lamellar pattern that
and osteolysis in favor of osteolysis, which results in poor typically results, bone deposition occurs in a disorga-
bone stock that may be more susceptible to implant loos- nized manner and can cause bone to become increasingly
ening and subsequent failure.10 In addition, the presence sclerotic and thickened, and subsequently replace normal
of such conditions may compromise tendon integrity and bone marrow with fibrous and vascular tissue.19 This
increase the risk for tendon rupture that could complicate may result in pathologic stress fractures as well as bony
postoperative recovery after TKA. deformity due to secondary osteoarthritis and altered
biomechanical forces.20 Deformities in patients with Paget
Prior High Tibial or Distal Femoral Osteotomy disease following TKA include distal femoral varus angu-
High tibial osteotomy (HTO) and distal femoral oste- lation and excessive bowing of the anterior tibia. Further-
otomy (DFO) are used to alleviate symptoms and de- more, increases in bone vascularity and marrow fibrosis
lay time to joint arthroplasty.11 These procedures are present substantial risks for perioperative blood loss and
typically reserved for young patients and those with component fixation, respectively.20,21 It is imperative that
unicompartmental osteoarthritis with varus or valgus orthopaedic surgeons recognize these challenges during
deformity. However, an overcorrected HTO or DFO can preoperative planning to provide optimal postoperative
result in a varus or valgus deformity that can further outcomes in these patients.
complicate TKA. An analysis of 39 consecutive bilateral
TKAs performed in patients with previous HTO found
Chapter 17: Management of Extra-Articular Deformities in Knee Arthroplasty
Evaluation and Diagnosis
Key Points of History and Physical Examination

A detailed history and thorough physical examination
are necessary to identify and evaluate extra-articular de-
formities. Patient history should include identification of
any congenital or metabolic diseases of the bone, as well
as any history of trauma to the lower extremity. In addi-
tion, any conditions such as rheumatoid arthritis or drugs
that affect bone quality such as corticosteroids should be
identified. Furthermore, prior surgeries, incisions, and
placement of previous implants should be noted.
The physical examination should begin with visual
inspection of both the femur and the tibia for any gross
deformity. The knee should be palpated for any tenderness
and range of motion should be assessed. Varus-valgus
stress should be applied in full extension, midexten-
sion, and 90° of flexion to assess for any ligamentous
laxity. In addition, patient gait should be assessed for
any abnormalities.
Imaging Modalities
Full-length long-leg weight-bearing AP and lateral radio-
graphs of the lower extremity are critical to preopera-
tive planning and should be obtained. Such imaging is Figure 1 Illustration demonstrates the effect of distance
especially necessary if the patient has a history of previ- on magnitude of knee joint deformity (green
ous femoral or tibial fracture. In addition, CT can help dot) as it progresses closer to the knee joint
from A to B to C. (Red lines = anatomic axis
identify rotational deformities. However, the advent of a proximal to deformity, blue lines = anatomic
“kneeling view” radiograph, an imaging technique that axis distal to deformity, black lines = planned
osteotomies, dashed lines = mechanical axis.)
obtains a view that facilitates assessment of rotational
2: Knee
deformity and alignment of the distal femur, can provide
similar information given the time and expense associated
with CT.22,23 MRI may be indicated if concern exists for This product of the proportional distance and the an-
ligamentous injury and helps plan for adequate soft-tissue gulation of the deformity yields the contribution of the
balancing. angulation to the knee deformity. It can be reasoned that
The importance of the extra-articular deformity is deformities of greater magnitude, whether determined by
determined by two criteria: the magnitude of the defor- greater angulation or proportional distance to the joint,
mity and the distance of the deformity from the knee contribute to an increased severity of deformities. There-
joint.24,25 The magnitude of the deformity can be calcu- fore, these relevant factors warrant special consideration
lated using full-length weight-bearing AP views, which is during preoperative planning. Furthermore, the closer the
accomplished by drawing a line proximal to distal from deformity is to the knee joint, the greater effect it has on
the center of the femoral head to the center of the knee the joint24,25 (Figure 1). Deformities closer to the knee
joint. Another line is drawn from proximal to distal from translate to greater alterations in the joint space angle
the center of the knee joint to the center of the ankle. Fi- and mechanics compared with those deformities farther
nally, the angle between the intersection of the two lines away. Deformities closer to the hip or ankle have minimal
is calculated. In addition, the product of the femoral or effect on the knee joint itself.
tibial shaft angulation and the proportional distance from
the hip or ankle to the knee can calculate the amount of
deformity at the knee joint. If the patient presents with Treatment Principles and Options
a knee deformity with an angulation of 15°, the propor- Standard Intra-articular Corrections
tional distance can be calculated via the division of the Although TKA with simultaneous or staged osteotomy for
proximal femoral segment by the length of the femur. deformity correction has resulted in anatomic alignment
Section 2: Knee
and adequate ligament stabilization, the potential also

exists for substantial complications.25,26 Osteotomy may
require additional incisions and introduces the poten-
tial for nonunion, arthrofibrosis, and greater risk of
infection. 25-27 In addition, nonunion of the osteotomy
can compromise joint alignment. 25 DFOs are techni-
cally demanding and display inferior results compared
with a constrained prosthesis or proximal tibial oste-
otomy. 28,29 Proximal tibial osteotomies involve longer
surgical time and result in decreased knee flexion and
increased incidence of patellar subuxation.27 In addition,
staged procedures can prolong rehabilitation time.25
An intra-articular approach can be used to manage
extra-articular deformities and avoid the potential mor-
bidity associated with performing an osteotomy. Satis-
factory outcomes have been demonstrated in patients
who underwent TKA with intra-articular resection and
soft-tissue balancing in knees with average extra-artic-
ular varus deformities of 15.1° in the coronal plane and
8.1° in the sagittal plane.25 In patients undergoing this
approach, the mechanical axis was corrected from 23°
of varus preoperatively to 0.3° of varus postoperatively.
The Knee Society Score improved from 22 to 92 points
and function scores from 28 to 87 at final follow-up. In
addition, the range of motion increased from 78° preoper-
atively to 104° at 38 months. This approach uses oblique Figure 2 Illustration demonstrates valgus femoral
deformity that requires medial overresection.
bone cuts of the distal femur or proximal tibia to achieve A, Schematic of deformity. B, Preoperative
normal anatomic alignment and eliminates the need for planning for medial femoral overresection.
osteotomy. However, intra-articular resection may not be C, Schematic after deformity correction.
(Green dot = center of deformity, red lines
an option or may require ligament reconstruction if the = anatomic axis proximal to deformity, blue
2: Knee
resection jeopardizes insertion of the collateral ligaments lines = anatomic axis distal to deformity, black
or affects ligament balancing. Intra-articular management lines and shaded area = planned osteotomies,
dashed lines = mechanical axis, LDTA = lateral
of a distal femoral deformity is more challenging than a distal tibial angle, LPFA = lateral proximal
proximal tibial deformity as a result of the instability that femoral angle.)
can occur during extension.24 Valgus femoral (Figure 2)
and tibial (Figure 3) deformities require medial overres-
ection, which should be performed with caution because resection can result in compromise of the collateral lig-
medial collateral ligament laxity during extension can aments, which can be treated by using either a more
occur. Varus femoral (Figure 4) and tibial (Figure 5) defor- constrained prosthesis or ligament reconstruction.31 How-
mities require lateral overresection. However, the tensor ever, the excellent healing potential of the collateral liga-
fascia lata and the extensor mechanism can compensate ments as well as the disadvantages of a more constrained
for any lateral collateral ligament laxity during extension device favor ligament reconstruction. In addition, severe
secondary to lateral femoral overresection. femoral deformity may require hip adduction or abduc-
tion for proper gait even after adequate restoration of
TKA With Simultaneous or Staged Osteotomy the knee axis.24,26 Such gait abnormalities can potentially
Although studies have demonstrated the success of intra- predispose patients to accelerated degeneration of the hip
articular resection in patients with as much as 15° of joint.26 Therefore, TKA performed with simultaneous
deformity in the coronal plane, some concern still exists or staged osteotomy may be advantageous to achieve
for patients with an extra-articular deformity at any level adequate mechanical joint balance and to avoid use of a
of 10° or more in the coronal plane or 20° or more in constrained implant.22,26
the sagittal plane as a result of the extensive resection Preoperative planning is critical to the success of such
required to achieve proper balance.22,25,26,30 Such extensive a simultaneous or staged procedure. The presence of
Figure 3 Illustration demonstrates valgus tibial

deformity that requires medial overresection. Figure 4 Illustration demonstrates varus femoral
A, Schematic of deformity. B, Preoperative deformity that requires lateral overresection.
planning for medial tibial overresection. A, Schematic of deformity. B, Preoperative
C, Schematic after deformity correction. planning for lateral femoral overresection.
(Green dot = center of deformity, red lines C, Schematic after deformity correction.
2: Knee
= anatomic axis proximal to deformity, blue (Green dot = center of deformity, red lines
lines = anatomic axis distal to deformity, black = anatomic axis proximal to deformity, blue
lines and shaded area = planned osteotomies, lines = anatomic axis distal to deformity, black
dashed lines = mechanical axis, LDTA = lateral lines and shaded area = planned osteotomies,
distal tibial angle, LPFA = lateral proximal dashed lines = mechanical axis. LDTA = lateral
femoral angle.) distal tibial angle, LPFA = lateral proximal
femoral angle.)
previously placed hardware and the decision to perform 10 cm inferior to the tibial tubercle while simultaneously
the surgery in one stage instead of two substantially using another incision 6 cm superior to the patella and
increases the complexity of the procedure.26 A lateral medial to quadriceps tendon in 71 TKAs.34 This approach
approach enables hardware removal, osteotomy, and in- offers the advantage of attaining adequate exposure with-
ternal fixation to be performed through the same incision. out violating the quadriceps muscle, which could com-
In addition, the use of a precontoured blade plate or a promise recovery, and excellent exposure and complete
locked intramedullary nail has led to adequate stabiliza- union was achieved in all osteotomies.
tion and union of the osteotomy. Patients who underwent
this approach demonstrated a mean postoperative knee Highly Constrained TKA
score of 87 points and a function score of 81 points, Increased implant constraint results in an increased
and all patients achieved a limb alignment within 2° of ability to withstand forces about the knee.35 However,
normal. This approach demonstrates restoration of the this translates to greater forces placed on the implant
mechanical axis and subsequent functional improvement, and bone-implant interface. Increased constraint can re-
pain reduction, and stability.26,32,33 Another successful sult in greater wear, loosening, and subsequent implant
approach described extending the TKA incision to 8 to failure. Therefore, it is often advantageous to select an
Section 2: Knee
usually reserved for patients undergoing TKA following

tumor resection.37 However, distal femoral replacements
have been used in patients with poor bone stock, ex-
treme ligamentous instability, and severe deformity.37,38 A
study conducted on outcomes following salvage knee
reconstruction using a rotating hinged device showed
suboptimal outcomes.38 Although patients demonstrated
a mean increase of 53 points in Knee Society pain score,
3 cases of infected prostheses, 4 cases of aseptic loosen-
ing, and 1 case of periprosthetic fracture were reported.
In addition, the rate of implant survival was 79.6% at
1 year and 68.2% at 5 years. The authors of this study
recommended that this approach should be reserved for
patients who are elderly and sedentary.38 Although not
ideal and certainly not a long-term solution, a constrained
implant may offer the benefit of pain reduction as well as
other satisfactory outcomes in a select group of patients
who are not candidates for other approaches.
Preoperative Templating and Intraoperative

Measurement
Because poor functional outcomes are associated with
ligamentous compromise, preoperative deformity mea-
surements and templating are necessary to assess the feasi-
bility of an intra-articular approach. In addition, accurate
intraoperative measurements are critical to the placement
Figure 5 Illustration demonstrates varus tibial deformity of cutting guides and precise bone cuts. Distortion of
that requires lateral overresection. A, Schematic bony anatomy secondary to deformity can decrease the
of deformity. B, Preoperative planning for
lateral tibial overresection. C, Schematic after accuracy of an intramedullary guide. Therefore, an ex-
deformity correction. (Green dot = center of tramedullary guide used with localization of the femoral
2: Knee
deformity, red lines = anatomic axis proximal

to deformity, blue lines = anatomic axis distal head can result in more accurate measurements and better
to deformity, black lines and shaded area = subsequent coronal alignment.28 Extensive varus angula-
planned osteotomies, dashed lines = mechanical tion of the femur can be corrected by performing lateral
axis, LDTA = lateral distal tibial angle, LPFA =
lateral proximal femoral angle.) overresection of the distal femur before implantation of
components (Figure 6).
implant that offers the least amount of constraint while New Treatments
still achieving restoration of the mechanical axis and Computer-Assisted Navigation
patient function. Use of a highly constrained implant is The advent of computer-assisted navigation resulted in a
typically reserved for the most severe cases of deformity more accurate alternative to the use of medullary guides.
resulting in instability that cannot be corrected via in- Unlike medullary guides, computer-assisted navigation
tra-articular resection or extra-articular osteotomy alone, systems can accurately measure the mechanical axis
and has demonstrated good results in the most severe irrespective of bony landmarks that are susceptible to
cases of deformity.35,36 A study conducted on outcomes variation and human error.39 In addition, the presence
following primary and revision TKA for severe deformity of deformity further increases the inaccuracy of medul-
using a condylar constrained prosthesis demonstrated a lary guides. Computer-assisted navigation systems have
postoperative knee score of 86 points; 82% of patients consistently demonstrated more accurate and reliable
were classified as having a good outcome or better fol- implant placement in TKA compared with conventional
lowing TKA at 5-year follow-up.36 Another constrained techniques.39-43 These patients have shown substantial
option includes distal femoral arthroplasty, which used a improvement in femoral alignment, femoral rotation,
rotating hinged distal femoral prosthesis. This implant is tibial alignment, tibial rotation, tibial posterior slope,
Figure 6 Images obtained from a 65-year-old man demonstrate posttraumatic osteoarthritis of the left knee secondary to a
distal femur fracture sustained when the patient was 24 years old. Physical examination findings included obvious
varus deformity of the left knee, a 15° flexion contracture, and an antalgic gait. Bilateral AP long-leg weight-
bearing (A) lateral (B), and AP (C) radiographs demonstrate a total of 22° of varus angulation at the knee (18°
varus deformity at the knee and 4° varus deformity at the tibia.) Lateral (D) and AP (E) views obtained following
total knee arthroplasty with lateral femoral overresection demonstrate correction of the deformity to neutral.
and femorotibial mismatch compared with patients who mechanical alignment similar to computer-assisted nav-
underwent TKA with a conventional jig-based technique. igation. A retrospective multicenter analysis of patients
Studies conducted on patients with extra-articular with extra-articular deformity undergoing TKA with pa-
deformities using computer navigation reported a sig- tient-specific instrumentation demonstrated promising re-
nificant increase in postoperative Knee Society Scores, sults.46 A mean Knee Society function score increase from
function scores, and range of motion.1,39,44 One study 44 to 92 points was reported. In addition, Knee Society
assessed the outcomes following TKA performed with pain scores increased from 38 to 91 points. Moreover, as
computer navigation in patients with femoral extra-ar- with computer-assisted navigation, patient-specific instru-
2: Knee
ticular deformities.39 Knee Society and functional scores mentation does not violate the medullary canal and may
improved from 62 to 92 and from 52 to 83, respectively; decrease the incidence of fat embolism.46 Therefore, the
flexion range of motion increased from 4° to 74° preop- use of patient-specific instrumentation may be beneficial
eratively to 0.6° to 98.0° at final follow-up. Furthermore, for TKA in patients with extra-articular deformity.46
the use of navigation systems has been associated with
decreased blood loss and incidence of fat emboli because
the medullary canal was avoided.39,40,45 Therefore, com- Summary
puter-assisted navigation may help surgeons substantially The decision on how to best approach TKA in patients
improve outcomes in patients with extra-articular defor- with extra-articular deformity should be based on exten-
mity undergoing TKA. sive patient history, physical examination, and thorough
evaluation of the magnitude and proximity of the defor-
Patient-Specific Instrumentation mity to the knee joint. Obtaining long-leg weight-bearing
Patient-specific instrumentation is another viable op- radiographs with AP and lateral views are necessary to
tion that may help restore anatomic alignment under evaluate the deformity. Although numerous techniques
conditions in which normal anatomic landmarks are are available for performing TKA in patients with extra-
no longer useful, such as extra-articular deformity. CT articular deformity, most patients can be treated using
or MRI are used to construct positioning guides and standard techniques that do not require osteotomy or
cutting blocks specific to the patient’s altered anatomy ligament reconstruction. In addition, computer-assisted
with the ultimate goal of increasing the accuracy of the navigation may further help achieve adequate alignment
knee implant.46-48 This instrumentation relies on direct in this challenging patient population.
Section 2: Knee
Key Study Points 7. Steiner RD, Adsit J, Basel D: COL1A1/2-Related Osteo-

genesis Imperfecta, in Pagon RA, Adam MP, Ardinger
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disease, prior history of osteotomy, presence of a acteristics, differential diagnoses, as well as treatment of
tumor, or Paget disease. COL1A1/2-related osteogenesis imperfecta.
• Deformities closer to the knee joint are of greater 8. Luhmann SJ, Sheridan JJ, Capelli AM, Schoenecker
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1998;18(1):88-94. Medline DOI
• Various treatment options are available, including
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25. Wang JW, Wang CJ: Total knee arthroplasty for arthritis
of the knee with extra-articular deformity. J Bone Joint 39. Bottros J, Klika AK, Lee HH, Polousky J, Barsoum
Surg Am 2002;84-A(10):1769-1774. Medline WK: The use of navigation in total knee arthroplasty for
patients with extra-articular deformity. J Arthroplasty
26. Lonner JH, Siliski JM, Lotke PA: Simultaneous femoral 2008;23(1):74-78. Medline DOI
osteotomy and total knee arthroplasty for treatment of
osteoarthritis associated with severe extra-articular defor- 40. Chauhan SK, Scott RG, Breidahl W, Beaver RJ: Comput-
mity. J Bone Joint Surg Am 2000;82(3):342-348. Medline er-assisted knee arthroplasty versus a conventional jig-
based technique. A randomised, prospective trial. J Bone
27. Haddad FS, Bentley G: Total knee arthroplasty after high Joint Surg Br 2004;86(3):372-377. Medline DOI
tibial osteotomy: A medium-term review. J Arthroplasty
2000;15(5):597-603. Medline DOI 41. Bäthis H, Perlick L, Lüring C, Kalteis T, Grifka J: [CT-
based and CT-free navigation in knee prosthesis implan-
28. Nelson CL, Saleh KJ, Kassim RA, et al: Total knee ar- tation. Results of a prospective study]. Unfallchirurg
throplasty after varus osteotomy of the distal part of the 2003;106(11):935-940. Medline
femur. J Bone Joint Surg Am 2003;85-A(6):1062-1065.
Medline 42. Bäthis H, Perlick L, Tingart M, Lüring C, Zurakowski
D, Grifka J: Alignment in total knee arthroplasty. A com-
29. Windsor RE, Insall JN, Vince KG: Technical consider- parison of computer-assisted surgery with the convention-
ations of total knee arthroplasty after proximal tibial al technique. J Bone Joint Surg Br 2004;86(5):682-687.
osteotomy. J Bone Joint Surg Am 1988;70(4):547-555. Medline
Medline
Section 2: Knee
43. Hernández-Vaquero D, Suarez-Vazquez A, Sandoval-Gar- with extra-articular deformity. Knee 2013;20(6):407-411.

cia MA, Noriega-Fernandez A: Computer assistance in- Medline DOI
creases precision of component placement in total knee
arthroplasty with articular deformity. Clin Orthop Relat This retrospective review of 10 patients with multipla-
Res 2010;468(5):1237-1241. Medline DOI nar deformities had knee components aligned using pa-
tient-specific instrumentation. Function, range of motion,
This prospective study compared the radiographic align- and limb alignment demonstrated significant improvement
ment in TKAs performed with and without comput- at a mean follow-up of 3.4 years.
er-assisted navigation. The authors found more accurate
placement of the femoral and tibial component in the 47. Nunley RM, Ellison BS, Zhu J, Ruh EL, Howell SM,
group treated with computer-assisted navigation. Barrack RL: Do patient-specific guides improve coronal
alignment in total knee arthroplasty? Clin Orthop Relat
44. Catani F, Digennaro V, Ensini A, Leardini A, Giannini Res 2012;470(3):895-902. Medline DOI
S: Navigation-assisted total knee arthroplasty in knees
with osteoarthritis due to extra-articular deformity. Knee This retrospective review assessed whether mean coronal
Surg Sports Traumatol Arthrosc 2012;20(3):546-551. alignment after TKA performed with conventional vs pa-
Medline DOI tient-specific instrumentation better restored the kinematic
and mechanical axes and determined which group had
This prospective study assessed the outcomes of naviga- more outliers. Both methods were effective at restoring
tion-assisted TKA in patients with arthritis secondary to the axes but had similar numbers of outliers.
extra-articular deformity with a mean 3-year follow-up.
More than 90% of patients had good or excellent results. 48. Ng VY, DeClaire JH, Berend KR, Gulick BC, Lombardi
AV Jr: Improved accuracy of alignment with patient-specif-
45. Kalairajah Y, Cossey AJ, Verrall GM, Ludbrook G, Sprig- ic positioning guides compared with manual instrumenta-
gins AJ: Are systemic emboli reduced in computer-assisted tion in TKA. Clin Orthop Relat Res 2012;470(1):99-107.
knee surgery?: A prospective, randomised, clinical trial. Medline DOI
J Bone Joint Surg Br 2006;88(2):198-202. Medline DOI
This retrospective review compared the effectiveness of
patient-specific positioning guides with that of manual
46. Thienpont E, Paternostre F, Pietsch M, Hafez M, Howell S: instrumentation to restore mechanical axis and neutral
Total knee arthroplasty with patient-specific instruments coronal alignment. Patient-specific guides were useful in
improves function and restores limb alignment in patients achieving neutral mechanical axis.
2: Knee
Chapter 18
Outcomes of Primary Total

Knee Arthroplasty
David C. Ayers, MD Patricia D. Franklin, MD, MBA, MPH Rajiv Gandhi, MS, MD, FRCSC
Christopher Kim, MD, MSc Jeffrey Lange, MD Nizar N. Mahomed, MD, MPH, ScD Philip C. Noble, PhD
Abstract Keywords: survivorship; scoring systems; patient

satisfaction; patient-reported outcome measures
Total knee arthroplasty can relieve arthritic pain and im-
prove quality of life in patients with debilitating arthritis.
Currently, long-term survivorship rates of total knee Introduction
arthroplasties have been demonstrated through multiple Jeffrey Lange, MD; Patricia D. Franklin, MD, MBA,
clinical and registry-based studies. Studies comparing MPH; David C. Ayers, MD
survivorship rates of various knee arthroplasty designs Total knee arthroplasty (TKA) has proved to be a major
and systems have provided guidance for optimizing the success, with long-term survivorship rates exceeding 90%
results of surgery. Patient-reported outcome measures in most studies. It has also provided marked and consis-
have historically been used in clinical research and have tent quality-of-life improvements for recipients. The pa-
become increasingly prevalent in clinical practice. These rameters governing success rates in TKA, including TKA
instruments provide patient-centered benchmarks for implant design, bearing surface material, fixation tech-
measuring the success of total knee arthroplasties by niques, alignment strategies, and patient-related factors,
comparing patient-reported pain and function both have been studied extensively over the past few decades.
before and after total knee arthroplasty, and by doc- In 2016, there is the benefit of decades of experience with
2: Knee
umenting improvement and effect on quality of life. multiple TKA strategies. Many clinical studies, and now
Patient satisfaction has historically lagged behind the multiple national registries, provide a large amount of
success of total knee arthroplasty in relieving pain and high-quality data that can inform current strategies and
represents an area of continued focus for optimization. drive future optimization of total TKA. Multiple tools
exist to allow evaluation of the success of these surgeries.
It is important to review the current landscape regarding
Dr. Ayers or an immediate family member serves as a board member, owner, officer, or committee member of the
American Academy of Orthopaedic Surgeons and the American Orthopaedic Association. Dr. Franklin or an immediate
family member has received research or institutional support from Zimmer Biomet. Dr. Mahomed or an immediate fam-
ily member is a member of a speakers’ bureau or has made paid presentations on behalf of Smith & Nephew and has
stock or stock options held in Arthritis Innovation Corporation. Dr. Noble or an immediate family member has received
royalties from Stryker, Springer, and Zimmer Biomet; serves as a paid consultant to Zimmer Biomet; has stock or stock
options held in Joint View; has received research or institutional support from CeramTech, DJO, Smith & Nephew, and
Zimmer Biomet; has received nonincome support (such as equipment or services), commercially derived honoraria, or
other non–research-related funding (such as paid travel) from the Musculoskeletal Transplant Foundation and AMTI; and
serves as a board member, owner, officer, or committee member of Advanced Technology in Orthopedics, Orthopedic
Discovery, Cognoscenti, the International Society of Technology in Orthopaedics, and the Knee Society. None of the
following authors or any immediate family member has received anything of value from or has stock or stock options
held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. Gandhi, Dr.
Kim, and Dr. Lange.
Section 2: Knee
Figure 1 Graph shows revision rates following primary total knee arthroplasty, stratified by age. (Reproduced with
permission from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man: 12th Annual
Report, 2015. Available at: http://www.njrcentre.org.uk/njrcentre/. Accessed July 6, 2016.)
objective and subjective outcomes following TKA, as well analyzed by primary diagnosis, findings for osteoarthritis
as some of the tools used to track outcomes. and rheumatoid arthritis were similar at 10- and 14-year
follow-up with 5% to 7% revision rates. For other in-
flammatory arthritis diagnoses, osteonecrosis, and other
Survivorship Assessments diagnoses, the revision rates were higher at 10 years.
Jeffrey Lange, MD; Patricia D. Franklin, MD, MBA, When comparing outcomes of cemented versus nonce-
MPH; David C. Ayers, MD mented TKA at 14 years, rates of revision were higher
Annual Registry Reports for noncemented TKA.
2: Knee
The increasing utilization of research registries has im- The 2015 British National Registry Report2 demon-
proved the ability to analyze outcomes following TKA. strates an overall revision rate following primary TKA of
Currently, multiple national registries provide detailed 3.62% for cemented constructs, 4.91% for noncemented
information regarding longitudinal outcomes after TKA. constructs, and 3.57% for hybrid constructs at 11-year
The outcome measures collected in many registries en- follow-up. Revision rate is inversely correlated with in-
compass patient demographics, implant details, and creasing age (Figure 1). For patients younger than 55 years,
patient-reported outcomes. The following paragraph the revision rate at 10 years was 12.08% for males and
summarizes some of the patient- and implant-specific 11.05% for females. For patients age 75 years and older,
data reported by two national total joint arthroplasty the revision rate at 10 years was 2.22% for men and
registries with long-term follow-up. Information regard- 1.94% for women. For cemented versus noncemented/
ing patient-reported outcomes is detailed subsequently hybrid constructs in patients younger than 55 years, the
in this chapter. revision rates at 10 years were 9.03% and 9.87%, respec-
The 2015 annual report of the Australian National tively, for males and 7.66% and 8.44%, respectively, for
Joint Arthroplasty Registry1 notes an overall range of females. For cemented versus noncemented/hybrid con-
between 2.6% and 11.2% cumulative revision rates at structs in patients 75 years and older, the revision rates
10-year follow-up for all tracked primary TKA femoral at 10 years were 1.92% and 2.11%, respectively, for men
and tibial implant combinations. A total of 43 compo- and 1.64% and 2.07%, respectively, for women.
nent combinations with 350 or more procedures recorded Registries are also able to track which implant types
per year were included in this analysis. Of the 43 com- have performed poorly compared to their counterparts;
binations, 13 (30.2%) demonstrated revision rates less these analyses are important applications of registry data.
than 5% at 10 years. These 13 combinations included However, the most accurate assessment of outcomes over
cruciate-retaining and cruciate-sacrificing designs. When time requires longitudinal monitoring. Furthermore, it is
Chapter 18: Outcomes of Primary Total Knee Arthroplasty
Table 1
Ten-Year Survivorship Rates of TKA Designs
Mean 10-yr Overall
No. of Patient Clinical Score Survivorship (95%
Clinical Study Patientsa Implant Age (yr) (Knee/Function) confidence interval)
Fixed-bearing TKAs
Hoffman et al 176/300 Natural Knee CR 65 – 95.1% (93.2-98.0)
Barrington et al 87/127 Nexgen PS 70 94/75 (KSS) 97% (94-100)
Schwartz et al 126/179 Nexgen PS 62.4 85.4 (HSS) 97.7% (96.3-99.0)
Nakamura et al 309/507 Bisurface PS 68.5 93.3/52.7 (KSS) 97.4% (95.8-99.0)
Moutet et al 80/117 Europ CR 73 88/80 (KSS) 97.8% (91.5-99.5)
Present series 846/942 Multiple PS+CR 71 83/74 (KSS) 92% (90-94)
Mobile-bearing TKAs
Callaghan et al 82/114 LCS PS 70 90/75 100%
Buechel 309/309 LCS CR 71 – 97.4% (95-100)
Vogt and Saarbach 59/101 LCS PS 70 78/66 (KSS) 95%
Metsovitis et al 326 Rotaglide UC 66.7 92.6/66.7 (KSS) 96% (93-98)
Meftah et al 106/138 LCS PS 69.2 94 (HSS) 98.3% (97.1-99.5)
Argenson et al 108/116 Nexgen Flex PS 69 94/88 (KSS) 98.3% (97.1-99.5)
Present series 846/942 Multiple PS+CR 71 83/74 (KSS) 92% (90-94)
CR = cruciate (posterior cruciate ligament) retention, HSS = Hospital for Special Surgery score, KSS = Knee Society score, PS = posterior-stabilized;
TKA = total knee arthroplasty, UC = ultracongruent.
a
Data are the number of patients followed-up/total number of patients.
Adapted from Argenson J-N, Boisgard S, Parratte S, et al; French Society of Orthopedic and Traumatologic Surgery (SOFCOT): Survival analysis
of total knee arthroplasty at a minimum 10 years' follow-up: A multicenter French nationwide study including 846 cases. Orthop Traumatol Surg
Res 2013;99(4):385-390.
2: Knee
important to note that summary results reported through survivorship based on 15 peer-reviewed studies comprising
national registries cannot be generalized to all patients. It 4,025 TKAs in addition to 233,843 knee arthroplasties
is the combination of both clinical studies aimed at eval- identified among five national joint arthroplasty regis-
uating the results of TKA in specific patient populations tries.5 Based on peer-reviewed literature alone, survivor-
and registry reports that can inform the management of ship was found to be 97% at 13 years postoperatively, and
specific patient populations. pooled registry data showed a 10-year survivorship rate
of 95.7%.5 A comparison between data from Norway’s
Peer-Reviewed Studies National Joint Arthroplasty Registry and Kaiser Perma-
Peer-reviewed clinical and registry-based studies continue nente’s Total Joint Arthroplasty Registry (United States)
to corroborate the high survivorship rates of TKAs. A reported survivorship at midterm follow-up of TKAs at
recent multicenter nationwide study followed 846 TKA 94.8% and 96.3%, respectively.6 A review of survivorship
recipients for at least 10 years and reported an overall of TKAs across multiple national registries and clinical
survivorship rate of 92%. When subcategorized by implant studies reported the overall survivorship rate to be 93.8%
type, the range in survivorship was 90% to 95%, without at 10 years.7 Thus, in studies spanning multiple follow-up
any significant differences among implant types. These intervals, implant types, and patient demographics, TKA
results were comparable to those of multiple contemporary has proven to exhibit high survivorship rates.
single-center studies3 (Table 1). A study of 117 consecu-
tive cruciate-sacrificing (CS) mobile-bearing TKAs at a Cruciate-Retaining Versus Cruciate-Sacrificing
mean follow-up of 10 years demonstrated a survivorship Designs
rate of 97.7%.4 A systematic review of studies analyzing Over the past decades, multiple studies have evaluated the
outcomes after primary TKA using one device reported relative efficacy of cruciate-retaining (CR) versus CS TKA
Section 2: Knee
implant designs. Most studies found similar survivorship at 2-year follow-up. These findings corroborate multiple
and clinical outcomes. A systematic review of 17 ran- earlier studies.12 No data are yet available to demonstrate
domized controlled trials comparing the results of CR reduced wear in mobile-bearing designs, as longer follow-
and CS implants at short- to midterm follow-up showed up is needed.
no clinically relevant differences in outcomes after TKA Registry data also reflect these relationships. The
with respect to range of motion, pain, and clinical and 2015 Australian registry report demonstrates a slightly
radiographic outcome measures.8 A recent meta-analy- lower revision rate in fixed bearing versus mobile bearing
sis of eight randomized controlled trials comparing the designs, which are of three types: rotating, sliding, and
outcomes of CR and CS implants in 963 primary TKAs rotating-sliding.1 The revision rates reported at 10 years
found no significant differences in survivorship or clinical postoperatively are 5.1% (95% CI: 5.0-5.2) for fixed-
outcomes, with the exception of a modest improvement bearing designs, 6.5% (95% CI: 6.3-6.7) for rotating
in range of motion scores with CS constructs at short- to designs, 7.4% (95% CI: 6.6-8.2) for rotating-sliding de-
midterm follow-up.9 The clinical relevance of this statis- signs, and 6.6% (95% CI: 5.1-8.4) for sliding designs. The
tically significant finding was not assessed. 2015 British registry report separates results by sex, age,
International registry data demonstrate similar sur- and stability.2 At 10 years postoperatively, cumulative
vivorship rates between CR and CS TKAs. At 10 years revision rates for fixed-bearing versus mobile-bearing
postoperatively, the 2015 Australian National Joint Ar- designs show no significant differences: 8.52% (95%
throplasty Annual Report1 notes revision rates of 5.2% CI: 7.43-9.77) and 9.91% (95% CI: 7.22-13.52) for CR
(95% confidence interval [CI]: 5.1-5.3) and 6.3% (95% constructs in males younger than 55 years; 6.94% (95%
CI: 6.0-6.5) for CR and CS constructs, respectively. CI: 6.09-7.90) and 10.16% (95% CI: 6.84-14.97) for CR
The 2015 British National Joint Registry Annual Re- constructs in females younger than 55 years; 10.34%
port2 demonstrates a similar pattern, but separates its (95% CI: 8.35-12.77) and 7.14% (95% CI: 4.96-10.21)
results by sex and age. At 10 years postoperatively, cumu- for CS constructs in males younger than 55 years; and
lative revision rates of fixed-bearing cemented CR versus 7.74% (95% CI: 6.36-9.39) and 10.19% (95% CI: 6.09-
CS constructs are as follows: 8.52% (95% CI: 7.43-9.77) 16.80) for CS constructs in females younger than 55 years,
and 10.34% (95% CI: 8.35-12.77) in males younger than respectively.
55 years; 6.94% (95% CI: 6.09-7.90) and 7.74% (95% CI:
6.36-9.39) in females younger than 55 years; 1.82% (95% Cemented Versus Noncemented Constructs
CI: 1.60-2.06) and 2.07% (95% CI: 1.70-2.51) in men Over the past few decades, many investigators have assessed
age 75 years and older; and 1.53% (95% CI: 1.36-1.71) the survivorship of noncemented and cemented primary
2: Knee
and 1.82% (95% CI: 1.56-2.12) in women age 75 years TKAs. Conflicting reports exist. Reported survivorship
and older. rates have ranged from 85% to 98% and 76% to 99% at
10- to 20-years’ follow-up for cemented and noncemented
Mobile-Bearing Versus Fixed-Bearing Designs constructs, respectively.13 These reports reflect varying lev-
Mobile-bearing TKA implant designs were developed els of evidence. A recent meta-analysis of 15 randomized
in an effort to reduce polyethylene wear by decreasing controlled trials or observational studies demonstrated
the degree of constraint in the implant system. Multiple likelihood of revision that were 4.2 times greater after
investigators have reported satisfactory results using these noncemented fixation (95% CI: 2.7-6.5).14 Follow-up for
implants, with similar survivorship of mobile-bearing studies included in this meta-analysis ranged from 2 to
designs compared to fixed-bearing designs. A recent pro- 11 years. The 2015 Australian registry report1 notes a
spective randomized trial evaluating rotating-platform hazard ratio of 1.12 for revision of noncemented versus
versus fixed-bearing designs, using a single implant type, cemented primary TKAs at 14-year follow-up (P < 0.001)
in 444 patients with simultaneous bilateral TKA (mobile (Figure 2). This reflects an average revision rate of 8.2%
bearing on one side, fixed bearing on the other) demon- (95% CI: 7.6-8.8) for noncemented constructs and 6.7%
strated no significant differences in survivorship or radio- (95% CI: 6.4-7.0) for cemented constructs. When analyzed
graphic outcomes at a minimum 10-year follow-up (mean, by sex, the revision of noncemented versus cemented pri-
12.1 years).10 Another recent prospective randomized mary TKAs in females at 13-year follow-up was found to
trial compared mobile-bearing to fixed-bearing cruciate- have a hazard ratio of 1.21 (P < 0.001, 2014 data). The
substituting primary TKAs (PFC Sigma PS) with and 2015 annual report of the British registry2 notes 11-year
without patellar resurfacing;11 no single combination of revision rates of 3.62% (95% CI: 3.51-3.75) and 4.91%
bearing type and patellar surface showed a significant (95% CI: 4.38-5.50) for cemented versus noncemented
benefit, and all constructs resulted in clinical improvement primary TKAs, respectively.
Figure 2 Graph shows Kaplan-Meier estimates of the cumulative percentage probability of a first revision of primary
total knee replacement by age and at increasing years after primary surgery. (Adapted with permission from the
Australian Orthopaedic Association: National Joint Arthroplasty Registry Annual Report 2015. Available at: https://
aoanjrr.sahmri.com/annual-reports-2015. Accessed July 6, 2016.)
Furthermore, most reports indicate that most primary As noted previously, cemented TKA constructs have
TKAs being performed worldwide use cement. In 2015, been considered the gold standard for use in primary
the Australian registry reported using noncemented tech- TKA. With the introduction of highly porous metal tech-
nique in 16.5% of all primary TKAs.1 The British registry nology, however, short-term radiographic survivorship is
demonstrated an even more dramatic trend, with non- promising. For instance, a recent randomized controlled
cemented TKA constructs comprising 2.5% of all knee trial compared traditional modular cemented tibial com-
arthroplasty procedures in 2014.2 Thus, whereas some ponents to highly porous metal tibial components, either
reports suggest reasonable outcomes after noncemented cemented or noncemented, in primary TKA.17 The all-
TKA in specific situations, many large-scale reports cause revision rates were equivalent among constructs at
2: Knee
suggest that cemented primary TKA remains the gold a mean of 5 years. A retrospective review of 115 TKAs
standard and, on average, confers superior survivorship. using porous tantalum implants noted a 95.7% cumula-
tive survivorship at a mean of 7 years’ follow-up, with no
evidence of aseptic loosening as cause for revision.18 An-
Improving Survivorship other study reported on a prospectively collected cohort
Jeffrey Lange, MD; Patricia D. Franklin, MD, MBA, of 105 consecutive porous tantalum TKAs, demonstrating
MPH; David C. Ayers, MD no aseptic loosening at a minimum 3 years follow-up
New Technologies and an overall revision rate of 1%.19 Further studies are
Despite its excellent track record, TKA is not a perfect necessary to clarify the role and long-term results of using
intervention. Close to 20% of patients may experience highly porous metal surfaces in the setting of primary
dissatisfaction after surgery.15 In addition to patient TKA.
dissatisfaction, a certain percentage of primary TKAs The advent of highly cross-linked polyethylene has
fail, requiring revision surgery. A recent United States provided the potential for improved wear characteristics
multicenter retrospective review of 844 failed TKAs of TKA designs. Multiple investigators have assessed wear
requiring revision documented the incidence of failure rates at midterm and long-term follow-up, and the results
mechanisms,16 with aseptic loosening, instability, infec- are not yet clear. The Australian Orthopaedic Associa-
tion, and polyethylene wear among the most common tion National Joint Arthroplasty Registry was assessed
mechanisms affecting the original implant longevity. In regarding differential wear rates between highly cross-
an effort to optimize TKA surgery outcomes, many in- linked and conventional polyethylene bearing TKAs over
vestigators continue to develop new strategies to tackle a 5- to 10-year period.20 Study results indicated improved
these challenges. Two current areas of focus have been wear rates at 5 to 10 years for some designs, but not for
fixation methods and alternative bearing surfaces. others. Wear rate changes were both design and vendor
Section 2: Knee
specific. In a prospective randomized study evaluating are subject to the attitudes, abilities, and expectations of
the performance of highly cross-linked versus conven- patients as well as to their motivations to undergo surgery.
tional polyethylene, a single implant system was used in
patients undergoing simultaneous bilateral TKA.21 Study Generic and Disease-Specific Outcome Measures
results indicated no radiographic or clinical differences One approach to assessing the outcome of knee arthro-
between knees at a minimum follow-up of 5 years. Al- plasty is through evaluation of the general health of the
though no clear benefit to the use of highly cross-linked patient before and after treatment. This approach as-
polyethylene in primary TKA has been reported, more sumes that the value of medical intervention is reflected
long-term follow-up is needed to clarify the role of this in a measurable improvement in patients’ health-related
new technology. quality of life. Thus, items that assess a patient’s physical
The development of new technologies, such as porous health, physiologic function, emotional health, and social
metal components and highly cross-linked polyethylene, function are expected to provide insight into the effect
has the potential to improve survivorship of primary of a given treatment on the overall outcome of a broad
TKAs going forward, although current data do not demographic of patients.
demonstrate that these technologies confer survivorship One of the most frequently cited instruments for mea-
benefits. Therefore, routine use of these new technologies surement of generic health outcomes is the Medical Out-
in general orthopaedic practice is not yet supported. comes Study 36-Item Short Form (SF-36), which was
developed to measure the effect of interventions, includ-
ing TKA, on the overall health and quality of life of pa-
Scoring Systems tients23,24 (Table 2). Demand resulted in the development
Philip C. Noble, PhD and validation of a shorter version, the 12-Item Short
Scoring systems provide a numerical rating of each pa- Form (SF-12), which consists of the 12 items from the
tient’s outcome after TKA. The scores generated through functional status and well-being sections of the SF-36 that
administration of outcome instruments (typically vali- were found to be most predictive of the original outcome
dated patient questionnaires) provide the most concise, score.3 The SF-36 and SF-12 have been used extensively to
clear measure, especially when comparing large groups evaluate patients before and after treatment of a wide va-
of patients and treatments. In the past, outcome scores riety of disease and surgical procedures, including TKA.
were generated by the treating surgeon during systematic Although scores generated by the SF-36 and SF-12 in-
assessment of the patient. Recent focus has shifted to- struments demonstrate that the patient’s quality of life
ward the patient’s own assessment of his or her pain and dramatically improves after TKA, these instruments are
2: Knee
function before and after TKA, as well as the extent to not highly sensitive or responsive to subtle changes among
which his or her expectations have been fulfilled by the individual subjects with varied severity of knee problems
procedure. Patient-reported outcomes measures (PROM), or levels of recovery.25 They are also affected by the pa-
traditionally used in clinical research, have now moved tients’ medical and musculoskeletal comorbid conditions.
into routine clinical practice. These scoring systems are To provide a more comprehensive assessment of patient
generally measures of the patient’s global or disease-spe- outcomes, both a generic and a specific outcome measure
cific health. Global scoring systems consist of one or more are often administered. Disease-specific outcome mea-
domains relating to a particular facet of health (such as sures in TKA patients focus all questions on the knee to
pain, function, satisfaction, or mental health). Summary specifically assess symptoms and function of that individ-
global scores may be calculated by combining related ual joint.26 Because disease-specific scales have a narrower
domain scores that reflect the patients’ overall physical focus, they are often more responsive than generic health
health (physical composite score) or emotional health measures. The most commonly used disease-specific out-
(mental composite score); physical composite score and come measures are the Western Ontario and McMaster
mental composite score have proven to be very useful mea- Universities Arthritis Index (WOMAC), the Knee Injury
sures in TKA patients. Despite methodologic differences, and Osteoarthritis Outcome Score (KOOS), and the Ox-
scoring systems that have undergone formal validation ford Knee Score.27
have broad applicability and are generally accepted for The KOOS was developed as an extension of the
measurement of outcomes after joint arthroplasty.22 When WOMAC, using some of its subscales to measure the
developing or selecting a scoring system for quantification condition of the knee in younger, more active patients
of outcomes, it must be recognized that every outcome who have early-stage osteoarthritis or knee symptoms28
score will be affected by the multidimensional facets of (Table 2). Five scores are generated from the subscales of
each patient’s experience. Thus, all outcome measures the KOOS (pain [9 items]; symptoms [7 items]; activities
Table 2
Generic and Disease-Specific Outcome Measurement Instruments
Scoring System Section Subsection Deductions
Medical Outcomes Functional status Physical functioning
Study 36-Item Social functioning
Short Form Role limitations attributed to physical problems
Well-being Mental health
Energy/fatigue
Pain
Overall evaluation
of health
Knee Society score Objective score Pain (50 points) Flexion
(100 points) Range of motion (25 points) contracture
Stability (25 points) Extension lag
Malalignment
Function score Walking (50 points) Reliance on
(100 points) Stair climbing (50 points) walking aids
The new Knee Objective knee Anteroposterior alignment (25 points) Flexion
Society score score (100 Stability/instability (25 points) contracture
points) Range of motion (25 points) Extension lag
Symptoms (25 points) Malalignment
Satisfaction score Pain level while sitting (8 points)
(40 points) Pain level while lying in bed (8 points)
Knee function while getting out of bed (8 points)
Knee function while performing light household
duties (8 points)
Knee function while performing recreational
activities (8 points)
Expectations score Pain relief (5 points)
2: Knee
(15 points) Ability to perform ADL (5 points)
Ability to perform leisure, recreational, or sports
activities (5 points)
Functional activity Walking and standing (30 points)
score (100 Standard activities (30 points)
points) Advanced activities (25 points)
Discretionary activities (15 points)
Knee Society Score Symptoms
Short Form (3 items)
Satisfaction Satisfaction while performing light household
(1 item) activities
Functional score How long can you walk? (20 points)
(100 points) Walking on an uneven surface (15 points)
Climbing and descending stairs (15 points)
Getting up from low couch or chair without arms
(15 points)
Running (20 points)
Discretionary activities (15 points)
ADL = activities of daily living;
Section 2: Knee
Table 2
Generic and Disease-Specific Outcome Measurement Instruments (continued)
Scoring System Section Subsection Deductions
The Oxford 12- Pain
Item Knee Score
Physical function
Limitations
Knee Injury and Self-administered Pain (9 items)
Osteoarthritis queries Symptoms (7 items)
Outcome Score Function during ADL (17 items)
Sport and recreation function (5 items)
Quality of life (4 items)
Total Knee Symptoms and ADL (17 items)
Function activities Movement and lifestyle activities (8 items)
Questionnaire Recreational activities (8 items)
Additional items Walking and running (5 items)
Satisfaction (1 item)
Activity level and expectations (3 items)
Pain and other symptoms (4 items)
Patient information (9 items)
Knee Replacement Patient Pain (1 item)
Expectations expectations Psychologic well-being (1 item)
Survey Physical functions (15 items)
of daily living function [17 items]; sport and recreation Functional Rating Systems
function [5 items]; and quality of life [4 items]) using Although knee arthroplasty primarily aims to relieve
item responses on a five-point Likert scale. The KOOS the pain of joint degeneration, an important goal for
2: Knee
has been demonstrated as a valid, reliable, and respon- most patients is maximum restoration of function. The
sive assessment instrument, especially for patients with functional outcome of the procedure is often linked to
expectations of physical activity or for those investigating the patient’s satisfaction with the procedure and has as-
physical function as a primary outcome. A CAT (com- sumed greater importance as increasingly younger and
puter adaptive technology) version of the KOOS that is more active patients have undergone the procedure. Func-
under development will minimize the number of questions tional rating systems have been designed with a primary
a patient answers while improving the accuracy of the focus on the ability of patients to participate in activities
score by using an item bank of questions.29 related to daily living, sports, and recreation. Thus, the
The 12-Item Oxford Knee Score (Oxford-12) was de- ability of PROM to provide separate scores for function
veloped to assess the health outcomes of TKA patients is considered very important. Another tool that may be
on the basis of responses to 12 items that query pain, used to measure knee function is the Total Knee Function
physical function, and limitations associated with the Questionnaire, which is a self-administered instrument
knee, each scored on a five-point scale26 (Table 2). The that collects information relating to physical activities in
scoring system expresses the status of the knee in terms of terms of their importance to each patient, the frequency
a single score, rather than as separate subscores, and has with which each patient performs the activity, and the oc-
demonstrated reliability and validity. The Oxford-12 has currence of symptoms when the patient performs the ac-
been considered a simple and reliable tool for assessment tivity30 (Table 2). The Total Knee Function Questionnaire
of outcome. However, because there is only one score, the queries participation in 33 different activities, ranging
ability to evaluate improvement in pain relief or improve- from least demanding (walking and standing) to most de-
ment in function as discrete scores is not possible. This manding (running, downhill skiing); these are condensed
limitation is significant, because pain relief and functional from a larger battery of activities considered in pilot stud-
improvement after TKA may be different. ies. Additional items ask patients about satisfaction with
TKA outcome and the extent to which the outcome has Performance-Based Measures
fulfilled expectations. Philip C. Noble, PhD
Performance-based tools, such as the timed up-and-go
Applications of PROM in Clinical Practice test39 and the 6-minute walk test,40 examine changes
David C. Ayers, MD; Patricia D. Franklin, MD, MBA, in physical function after TKA and capture objective
MPH; Jeffrey Lange, MD information about patients’ actual function that is not
Routine use of PROM in clinical practice is in keeping evaluated by patient-reported measures. Unlike patient-
with the Institute of Medicine’s vision for medicine in the reported measures, performance-based measures are de-
21st century: to use information technology to support rived from objective measures of function rather than
patient-centered evidence-based decisions. PROM have from the patient’s perceived function and are not body-
moved into clinical practice for TKA patients.31,32 Or- part or body-function specific.41 One study of TKA pa-
thopaedic surgeon reimbursement in the United States is tients has shown poor correlation between preoperative
currently increased by reporting PROM through a qual- patient-reported measures (WOMAC and SF-36) and
ified clinical data repository in the Physician Quality a performance-based measure (timed up-and-go test),
Reporting System of the Centers for Medicare & Med- highlighting the importance of both types of tests for
icaid Services (CMS) program. Commercial insurance a comprehensive assessment of disability.42 Recently,
programs are expected to follow the lead of CMS. In Mas- an expert group of 138 clinicians and researchers from
sachusetts, for example, there is a pilot pay-for-perfor- 16 countries was commissioned to recommend a set of
mance quality-reporting program offered by a commercial performance-based tests for use following TKA. The
insurer, and patient-reported outcomes are increasingly Osteoarthritis Research Society International consensus
being used as a measure of quality. As health care moves group suggested five tools: 30-second chair stand test,
from a volume-based to a value-based reimbursement 40-meter fast-paced walk test, stair-climb test, timed up-
system, PROM are being used as the numerator of the and-go test, and 6-minute walk test. The first three were
value equation.33-35 suggested as the minimal core set of performance-based
PROM can be collected in a busy practice on a rou- tests for knee osteoarthritis.43 Further research is required
tine basis with data that is more than 85% complete at to fully assess the psychometric properties of these mea-
1-year follow-up.31 Data collection should be invisible to sures (reliability and validity) and to define the minimally
the surgeon and be efficient enough not to affect/delay clinically important difference for relevant time points
the flow of the patient visit. To accomplish this, Inter- following TKA.
net-based electronic platforms have been developed so
2: Knee
data can be entered before the office visit (either in the Global Knee Rating Systems
waiting room or at home before the visit); real-time scor- Philip C. Noble, PhD
ing, using computer adaptive technology, allows scores A global knee rating system has been operationally de-
to be used for decision-making during the same office fined as an outcome instrument that includes, at a mini-
visit. PROM bring value to the visit by showing both the mum, assessments of pain, function, and range of motion
surgeon and the patient how the patient’s function and and summarizes these outcomes as a single score on a
pain compare to that of age-matched control patients as global scale.
well as how they have changed after treatment prescribed The American Knee Society Clinical Rating System,
at the previous visit.31 The measures are increasingly used or Knee Society Score (KSS), recognized some of the lim-
for shared decision-making, including when to proceed itations of the earlier Hospital for Special Surgery Score
with elective TKA, and to gather objective data about a and implemented a scoring method that has been widely
patient’s recovery after TKA.35 The addition of PROM adopted and supported.44 The KSS consists of two sepa-
to risk-adjustment models significantly increases the ac- rate subscores, each on a 100-point scale (Table 2): the
curacy of models used to predict the risk of readmission clinician-administered “Objective Knee Score” and the
after total joint arthroplasty.36,37 PROM have also been “Function Score.” This separation enables surgeons to
used to assess patient selection and timing of TKA surgery assess patients’ knee conditions independent of any func-
across the United States and have been added to modern tional deterioration due to comorbidities. Psychometric
joint arthroplasty registries. The combination of PROM testing has shown that the KSS Objective component has
with demographic data and information relating to im- poor reliability with acceptable responsiveness, whereas
plant selection and survivorship now enables registries to the KSS Functional component has good reliability with
provide valuable feedback regarding factors associated questionable responsiveness.45 In view of these deficien-
with pain and function after TKA.38 cies, both of these KSS subscores are often administered
Section 2: Knee
to assess outcome, a practice that had previously been Patient Satisfaction

widely accepted in clinical use.45
Given that the KSS functional component is only based Christopher Kim, MD, MSc; Rajiv Gandhi, MS, MD,
on the patient’s ability to walk and climb stairs, the KSS FRCSC; Nizar N. Mahomed, MD, MPH, ScD
is not indicative of a patient’s ability to perform func- Patient satisfaction is an important component of success
tional tasks that are more demanding (such as running, following TKA. Despite improvements in pain and func-
cycling, and yoga). Thus the KSS functional component tion imparted by TKA, patient satisfaction rates following
has a marked ceiling effect, with many patients receiving TKA have been reported at 85% or less in several stud-
the maximum possible score. This deficiency has become ies.15,49-51 Many investigators have begun to focus on opti-
increasingly apparent in assessing contemporary TKA mizing patient satisfaction in an effort to improve overall
patients, approximately one-third of whom are 55 years subjective success rates following TKA. Although there
or younger and who frequently participate in sporting and are several studies on this topic, many conflicting reports
workout activities.46 In recognition of this deficiency, a exist about determinants of satisfaction following TKA.
new KSS System was developed and formally validated in
2011 to account for the preoperative patient expectations, Determinants of Satisfaction in TKA
satisfaction, and physical activities of the younger, more Most studies of patient satisfaction have focused on fac-
diverse population of contemporary TKA patients.47 This tors related to a patient’s subjective experience following
new KSS preserves the original objective and functional TKA.52 Lack of improvement in pain after TKA has been
subscores and includes items relating to patient satisfac- shown to be the most significant predictor of dissatis-
tion; it also surveys the patient’s ability to participate in faction.53,54 It has been consistently demonstrated that
a broad range of activities, both preoperatively and at unmet preoperative patient expectations predict dissat-
follow-up (Table 2). The functional activity score in the isfaction.15,50,53 One study reported that satisfaction after
new KSS places greater emphasis on the patient’s assess- TKA was primarily determined by patients’ expectations
ment of the importance of specific activities by allowing and not their absolute level of function.50 In a large study
him or her to select some of the activities forming the basis of more than 1,700 patients, the main contributing factor
of the assessment of outcome; in addition, a wide variety to patient dissatisfaction was not meeting patient expec-
of activities, ranging from walking to running, is included. tations.15 According to a related study,53 patients satisfied
Despite the advantages of the new KSS, a deficiency with knee arthroplasty had had their expectations met.
revealed in initial trials was a higher-than-expected in- Counseling patients on realistic expectations of surgical
cidence of incomplete responses during self-administra- recovery appears paramount for optimizing satisfaction.
2: Knee
tion.47 This resulted in the development and validation Satisfaction following TKA has been associated with
of a short-form version of the new KSS to increase the several other patient factors. Some investigators have
usefulness of the instrument for routine follow-up of shown increasing age to be a risk factor for dissatisfaction
patients after TKA48 (Table 2). During validation, the following TKA, whereas others have shown no correlation
short form still provided acceptable discrimination be- between age and postoperative satisfaction.15,50,53,55 Many
tween clinically different groups of patients before and authors have shown that patient sex does not affect sat-
after TKA, with virtually the same estimated effect size isfaction following TKA.15,50,53,55 Poor mental health has
as the original functional activities subscale of the new been linked to dissatisfaction after TKA.53 One study
KSS. This resulted in the conclusion that the short-form recognized helplessness as a significant negative predic-
version of the KSS was practical, valid, reliable, and re- tor of WOMAC score change and found that patients
sponsive for assessing functional outcome of TKA. It reporting higher levels of mental health dysfunction had a
was recommended that the long-form version of the new statistically higher chance of being dissatisfied 1 year after
KSS be used for research studies and for more sensitive TKA.56 One study noted that patients with poorer preop-
measurement of the outcomes of individual patients. In erative WOMAC scores for pain and function exhibited
addition, it was recommended that the short-form version higher postoperative dissatisfaction rates, whereas another
be adopted in general clinical practice for use with large has shown no significant effect of preoperative WOMAC
patient populations based on expected improvement in the scores on patient satisfaction.15,57 Some investigators have
rate of patient completion and ease of administration.48 linked the presence of back pain, depression, and other
painful joints to higher dissatisfaction rates following
TKA, whereas others have found no relationship between
medical comorbidity and satisfaction15,53,57 Interestingly,
one study noted higher satisfaction rates following TKA
in patients with rheumatoid arthritis than in patients with Annotated References

a preoperative diagnosis of osteoarthritis, osteonecrosis,
or posttraumatic arthritis.49
1. Australian Orthopaedic Association: National Joint Ar-
Several factors extrinsic to patients may also affect throplasty Registry—Annual Report 2015. 2015. Avail-
postoperative satisfaction.52 Choice of anesthetic pro- able at: https://aoanjrr.sahmri.com/annual-reports-2015.
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all been implicated in the degree of patient satisfaction This report summarizes the results of a large number of
after TKA.58-60 Several studies have reported that com- TKAs performed in Australia over more than 1 decade.
ponent choices in TKA do not correlate with postopera- Level of evidence: II.
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2. 12th Annual Report: National Joint Registry for England,
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difference in patient satisfaction.66 Not surprisingly, the 6, 2016.
occurrence of a postoperative complication requiring hos- This report summarizes the results of a large number of
pital admission has been associated with dissatisfaction.15 total joint arthroplasties performed in England, Wales,
Northern Ireland, and the Isle of Man over more than
1 decade. Level of evidence: II.
Summary
3. Argenson J-N, Boisgard S, Parratte S, et al; French Society
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2: Knee
This prospective review of 138 consecutive mobile-
Key Study Points bearing TKAs in 117 patients shows an all-cause revision
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• Overall survivorship rates of primary TKA are 90% evidence: IV.
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6. Paxton EW, Furnes O, Namba RS, Inacio MC, Fenstad
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Section 2: Knee
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modest flexion benefits; otherwise, both interventions Ontario, authors found that 81% of patients expressed
have similar clinical and functional outcomes. Level of overall satisfaction after TKA, and the most significant
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2: Knee
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were evident at a mean follow-up of 12.1 years. Level of predominance of failure mechanism as a function of pri-
evidence: II. mary implant time in situ.
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for cross-linked polyethylene systems, but this effect was to the KSS. The floor effect was absent before surgery but
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Medline DOI inclusion criteria), the KOOS demonstrated a high level of
A systematic review of PROM after TKA was performed responsiveness and clinically acceptable reliability; how-
of 38 articles that reported outcomes from 47 different ever, the reliability and construct validity of the KOOS
patient-reported outcome measures; however, only six sport and recreation subscale was poor.
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ric properties. Those most commonly studied were the 30. Weiss JM, Noble PC, Conditt MA, et al: What func-
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Health Survey: Construction of scales and preliminary Standardized patient-reported outcomes are invaluable
in informing treatment and in making shared decisions
Section 2: Knee
regarding treatment. This article provides evidence that models as an effort to provide more accurate information
the methods can be extrapolated to various settings. on patients at higher risk for readmission after total joint
arthroplasty.
32. Ayers DC, Bozic KJ: The importance of outcome mea-
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value-based reimbursement is discussed. In analyses of data from a large cohort of TKA patients in
which surgeons used consistent patient criteria in schedul-
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EM, Bennell KL: Measurement properties of perfor-
In this article, the research program funded by the Agency mance-based measures to assess physical function in hip
for Healthcare Research and Quality, the Function and and knee osteoarthritis: A systematic review. Osteoarthri-
Outcomes Research for Comparative Effectiveness in To- tis Cartilage 2012;20(12):1548-1562. Medline DOI
tal Joint Replacement is discussed, which has pioneered
a patient-centered approach to the collection of arthro- The authors performed a systematic review of measure-
plasty data from more than 200 centers in 26 states in ment properties of performance-based measures to as-
the United States. sess physical function in patients with hip and/or knee
osteoarthritis; 24 of 1,792 publications were eligible for
inclusion, and 21 performance-based measures were eval-
35. Ayers DC, Franklin PD: Joint replacement registries in uated, including 15 single-activity measures and 6 mul-
the United States: A new paradigm. J Bone Joint Surg Am tiactivity measures. The 40-meter self-paced test was the
2014;96(18):1567-1569. Medline DOI best-rated walk test, the 30-second chair stand test and
2: Knee
This commentary provides an overview of existing total timed up-and-go test were the best-rated sit-to-stand tests,
joint arthroplasty registries and outlines the need for ar- and the Stratford battery as well as the Physical Activity
throplasty registries to collect and report data in addition Restrictions and Functional Assessment System were the
to survivorship of the implant. Modern registries have best-rated multiactivity measures.
moved to a patient-centered approach rather than an im-
plant-centered approach. 42. Gandhi R, Tsvetkov D, Davey JR, Syed KA, Mahomed
NN: Relationship between self-reported and perfor-
36. Ayers DC, Li W, Oatis C, Rosal MC, Franklin PD: Pa- mance-based tests in a hip and knee joint replacement
tient-reported outcomes after total knee replacement vary population. Clin Rheumatol 2009;28(3):253-257.
on the basis of preoperative coexisting disease in the lum- Medline DOI
bar spine and other nonoperatively treated joints: The need
for a musculoskeletal comorbidity index. J Bone Joint Surg 43. Dobson F, Hinman RS, Roos EM, et al: OARSI rec-
Am 2013;95(20):1833-1837. Medline DOI ommended performance-based tests to assess physical
function in people diagnosed with hip or knee osteo-
This prospective study of a cohort of TKA patients high- arthritis. Osteoarthritis Cartilage 2013;21(8):1042-1052.
lights the influence of preoperative musculoskeletal pain in Medline DOI
low back and nonsurgical joints on postsurgery functional
improvements. An expert group of 138 clinicians and researchers from
16 countries was commissioned to recommend a set of
37. Ayers DC, Fehring T, Odum S, Franklin PD: Using joint performance-based tests for use following TKA. The Os-
registry data from FORCE-TJR to improve the accura- teoarthritis Research Society International advisory group
cy of risk-adjustment prediction models for thirty-day suggested five tools: 30-second chair-stand test, 40-meter
readmission after total hip replacement and total knee fast-paced walk test, stair-climb test, timed up-and-go test,
replacement. J Bone Joint Surg Am 2015;97(8):668-671. and 6-minute walk test. The first three were suggested as
Medline DOI the minimal core set of performance-based tests for knee
osteoarthritis.
The authors demonstrate the importance of adding clin-
ical measures to administrative data in risk-adjustment
44. Insall JN, Dorr LD, Scott RD, Scott WN: Rationale of 52. Sitzia J, Wood N: Patient satisfaction: A review of is-
the Knee Society clinical rating system. Clin Orthop Relat sues and concepts. Soc Sci Med 1997;45(12):1829-1843.
Res 1989;248:13-14. Medline Medline DOI
45. Lingard EA, Katz JN, Wright RJ, Wright EA, Sledge CB; 53. Scott CE, Howie CR, MacDonald D, Biant LC: Predict-
Kinemax Outcomes Group: Validity and responsiveness ing dissatisfaction following total knee replacement: A
of the Knee Society Clinical Rating System in compari- prospective study of 1217 patients. J Bone Joint Surg Br
son with the SF-36 and WOMAC. J Bone Joint Surg Am 2010;92(9):1253-1258. Medline DOI
2001;83-A(12):1856-1864. Medline
This study investigated preoperative and postoperative
predictors of dissatisfaction in 1,217 consecutive patients
46. Dahm DL, Barnes SA, Harrington JR, Sayeed SA, Berry DJ: undergoing TKA, both before and 6 months afterward,
Patient-reported activity level after total knee arthroplasty. using the SF-12 and Oxford Knee Score. Significant pre-
J Arthroplasty 2008;23(3):401-407. Medline DOI dictors at 1 year included the preoperative SF-12 mental
component score, depression, pain in other joints, 6-month
47. Noble PC, Scuderi GR, Brekke AC, et al: Development SF-12 score, and poor Oxford Knee Score pain subscale
of a new Knee Society scoring system. Clin Orthop Relat scores. The most significant predictor of dissatisfaction
Res 2012;470(1):20-32. Medline DOI was a painful TKA.
This article describes the process of development of the
new Knee Society scoring system, including collection of 54. Dunbar MJ: Subjective outcomes after knee arthro-
comprehensive activity data from TKA patients, creation plasty. Acta Orthop Scand Suppl 2001;72(301):1-63.
of a prototype scoring system, and final validation using Medline DOI
item-response theory. Interesting data are presented re-
garding the activities and perceptions of contemporary 55. Gandhi R, Davey JR, Mahomed NN: Predicting pa-
TKA patients. tient dissatisfaction following joint replacement surgery.
J Rheumatol 2008;35(12):2415-2418. Medline DOI
48. Scuderi GR, Sikorskii A, Bourne RB, Lonner JH, Benja-
min JB, Noble PC: The Knee Society short form reduces 56. Gandhi R, Razak F, Tso P, Davey JR, Mahomed NN:
respondent burden in the assessment of patient-reported Greater perceived helplessness in osteoarthritis predicts
outcomes. Clin Orthop Relat Res 2016;474(1):134-142. outcome of joint replacement surgery. J Rheumatol
This article describes the development and validation
of the short-form version of the KSS system with a set 57. Gandhi R, Davey JR, Mahomed N: Patient expectations
of 497 TKA patients recruited from 15 medical institu- predict greater pain relief with joint arthroplasty. J Ar-
tions in the United States and Canada. The original set throplasty 2009;24(5):716-721. Medline DOI
of 25 patient-reported outcome items on the long-form
version was reduced to only eight items (six function, 58. Thorsell M, Holst P, Hyldahl HC, Weidenhielm L: Pain
2: Knee
one expectation, one satisfaction). The final short-form control after total knee arthroplasty: A prospective study
score was found to be valid, reliable, and responsive, with comparing local infiltration anesthesia and epidural anes-
virtually the same estimated effect size as the functional thesia. Orthopedics 2010;33(2):75-80. Medline DOI
activities subscale of the original new Knee Society scor- This study compared local infiltration anesthesia with
ing system. epidural anesthesia for postoperative pain relief in 85 pa-
tients; 76% percent of patients who had received local
49. Robertsson O, Dunbar M, Pehrsson T, Knutson K, infiltration anesthesia were very satisfied with their post-
Lidgren L: Patient satisfaction after knee arthroplasty: operative pain control compared to 40% of patients who
A report on 27,372 knees operated on between 1981 and received epidural anesthesia.
1995 in Sweden. Acta Orthop Scand 2000;71(3):262-267.
Medline DOI 59. Hernandez-Vaquero D, Noriega-Fernandez A, Su-
arez-Vazquez A: Total knee arthroplasties performed
50. Noble PC, Conditt MA, Cook KF, Mathis KB: The John with a mini-incision or a standard incision: Similar re-
Insall Award: Patient expectations affect satisfaction sults at six months follow-up. BMC Musculoskelet Disord
with total knee arthroplasty. Clin Orthop Relat Res 2010;11:27. Medline DOI
2006;452(452):35-43. Medline DOI
The authors matched 26 minimally invasive TKA incisions
51. Mahomed N, Gandhi R, Daltroy L, Katz JN: The self- to 36 standard TKA incisions at 6 months postoperatively
administered patient satisfaction scale for primary hip and found no differences between the groups in range of
and knee arthroplasty. Arthritis 2011;2011:591253. motion, KSS results, physical and mental SF-12 score,
Medline DOI pain, satisfaction, or subjective improvement.
In this series on satisfaction with TKA, using a patient 60. Spencer JM, Chauhan SK, Sloan K, Taylor A, Beaver
satisfaction scale that is valid and reliable as tested on RJ: Computer navigation versus conventional total knee
TKA patients, the authors reported on 857 TKA patients replacement: No difference in functional results at
and described an overall satisfaction rate of 88% at 1 year two years. J Bone Joint Surg Br 2007;89(4):477-480.
postoperatively. Medline DOI
Section 2: Knee
61. Park JW, Kim YH: Simultaneous cemented and cementless 64. Gioe TJ, Bowman KR: A randomized comparison of
total knee replacement in the same patients: A prospec- all-polyethylene and metal-backed tibial components. Clin
tive comparison of long-term outcomes using an identi- Orthop Relat Res 2000;380:108-115. Medline DOI
cal design of NexGen prosthesis. J Bone Joint Surg Br
2011;93(11):1479-1486. Medline DOI 65. Hui C, Salmon L, Maeno S, Roe J, Walsh W, Pinczewski
This prospective randomized study evaluated the L: Five-year comparison of oxidized zirconium and co-
clinical and radiologic results of identical cemented or balt-chromium femoral components in total knee arthro-
noncemented NexGen TKA prostheses implanted bilat- plasty: A randomized controlled trial. J Bone Joint Surg
erally in the same patient. Sequential simultaneous bi- Am 2011;93(7):624-630. Medline DOI
lateral TKAs were performed in 50 patients (100 knees). This study evaluated 40 consecutive patients (80 knees)
There were no differences in KSS, WOMAC, range of who underwent simultaneous bilateral cruciate-retaining
motion, or patient satisfaction; no advantage of nonce- primary TKA. For each patient, knees were randomized
mented over cemented components in TKA was shown. to receive the oxidized zirconium femoral component,
with the contralateral knee receiving the cobalt-chromium
62. Harato K, Bourne RB, Victor J, Snyder M, Hart J, Ries component; 5-year outcomes after TKA with oxidized
MD: Midterm comparison of posterior cruciate-retaining zirconium and cobalt-chromium femoral components
versus -substituting total knee arthroplasty using the Gen- showed no significant differences in clinical, subjective,
esis II prosthesis. A multicenter prospective randomized or radiographic outcomes.
clinical trial. Knee 2008;15(3):217-221. Medline DOI
66. Mahomed NN, Davis AM, Hawker G, et al: Inpatient com-
63. Kim TK, Chang CB, Kang YG, Kim SJ, Seong SC: pared with home-based rehabilitation following primary
Causes and predictors of patient’s dissatisfaction after unilateral total hip or knee replacement: A randomized
uncomplicated total knee arthroplasty. J Arthroplasty controlled trial. J Bone Joint Surg Am 2008;90(8):1673-
2009;24(2):263-271. Medline DOI 1680. Medline DOI
2: Knee
Chapter 19
Outpatient Total Knee Arthroplasty

Adolph V. Lombardi, Jr., MD, FACS Dean J. Marshall, DO
Total knee arthroplasty (TKA) is one of the most suc- Total knee arthroplasty (TKA) has traditionally been
cessful and frequently performed procedures by all thought of as an inpatient surgical procedure. The reasons
orthopaedic surgeons. As with all joint arthroplasties, vary, but most resistance to outpatient surgery is because
this procedure has evolved, and so has the arena in which of fear of pain control after surgery, limited mobility of
these procedures are performed. As arthroplasty has the patients, and increased risk of complications.1 Over
progressed to the outpatient setting, the goal remains the past decade, it has been shown that length of stay in
to provide patients with a durable, well-functioning the hospital after TKA has declined without any increase
joint while minimizing complications. Thorough patient in perioperative complications.2-8 This has been the main
selection and preoperative education is of paramount driver for the growing worldwide trend for outpatient
importance. Also, developing protocols with the med- joint arthroplasty.9
ical and anesthesia teams regarding perioperative pain As the movement toward outpatient TKA progresses,
management is as critical as all intraoperative aspects the focus must be on the patient’s rapid recovery. This
of the procedure. Blood management and postoperative starts with defined protocols for patient selection, patient
care should also be conducted carefully to decrease education, perioperative medical management, careful
any complications and readmissions. These steps are pain control, and well-coordinated postoperative care
necessary to make surgery in the outpatient setting by surgeons and other medical providers (Table 1). It is
feasible and reduce the risk to the patient. Outpatient important to highlight the objectives necessary for safe,
TKA likely will continue to increase; however, not all successful outpatient TKA.
patients who would benefit from TKA are candidates
2: Knee
for outpatient arthroplasty. Providers, with the help of
independent medical staff, need to be diligent in patient Patient Selection
selection when moving patients from an inpatient to an When evaluating a patient, the first and foremost factor
outpatient setting. to be considered is whether the specific disease pattern
makes him or her a candidate for TKA. After the disease
pattern is confirmed, inpatient versus outpatient TKA can
Keywords: total knee arthroplasty; outpatient be planned. Arthroplasty is an elective procedure focused
TKA; outpatient arthroplasty; TKA on improving the patient’s mobility and quality of life.
Most patients may have minimal medical comorbidities
Dr. Lombardi or an immediate family member has received and are able to return to their previous living environ-
royalties from Innomed, OrthoSensor, and Zimmer Biomet; ment. An increasing number of physicians believe that the
serves as a paid consultant to OrthoSensor, Pacira Phar- hospital is where sick people are treated, and if patients
maceuticals, and Zimmer Biomet; has received research or electing to undergo TKA are not sick, why should they
institutional support from Kinamed, OrthoSensor, Pacira have their surgery performed in the hospital?
Pharmaceuticals, and Zimmer Biomet; and serves as a board However, some patients with degenerative conditions
member, owner, officer, or committee member of The Hip of the knee also have myriad medical comorbidities.
Society, The Knee Society, The Mount Carmel Education When these conditions place the patient at higher risk
Center at New Albany, and Operation Walk USA. Neither for complications, outpatient TKA should be avoided.
Dr. Marshall nor any immediate family member has received All patients should undergo a medical examination by a
anything of value from or has stock or stock options held licensed practitioner to be evaluated for underlying risk.
in a commercial company or institution related directly or The role of the medical team is to identify these issues,
indirectly to the subject of this chapter. correct any comorbid conditions that can be corrected,
Section 2: Knee
Table 1
Outpatient Total Knee Arthroplasty Protocol
1. Patient Selection 7. Home Medications
Orthopaedic evaluation and scheduling for surgery Hydrocodone/acetaminophen 5/325 mg 1–2 pills
every 4–6 h as required for pain
Preoperative medical history and physical
examination, including laboratory testing Oxycodone 5 mg orally 1–2 pills every 4–6 h as
required for severe pain
2. Patient Education
Hydromorphone 2 mg 1 pill every 4–6 h as required
Educational materials are provided
for breakthrough pain
Physical therapy evaluation and instruction
Celecoxib 200 mg orally daily for 2 weeks
Preoperative educational class or video focused on
8. Blood Management
outpatient total knee arthroplasty
Intravenous crystalloid hydration is started
3. Pain Management
Tranexamic acid 1 g IV preoperatively (if no
Night before surgery
contraindications are present)
Acetaminophen 1 g orally
Tranexamic acid 1 g IV 3 h after first dose (topical
Day of surgery tranexamic acid is used in selected patient with
increased risk of clot formation)
Acetaminophen 1 g orally
9. Surgery
Celecoxib 400 mg orally (not used if cardiac
history or other contraindications) Light general anesthesia: propofol ± short-acting
inhalants
Dexamethasone 10 mg IV
Ketamine 0.5 mg/kg IV before incision
Scopolamine 1.5-mg patch (not used if history of
BPH or glaucoma) Preoperative IV antibiotic
Pregabalin/gabapentin 600 mg orally (300 mg for Minimum of 2 L crystalloid IV hydration
patients older than 65 years)
Ondansetron 4 mg IV
4. Regional Anesthesia
10. Postoperative Care
Sciatic nerve block: 15 mL 0.1% ropivacaine
Minimum 1 L crystalloid IV hydration
Adductor canal block: 15 mL 0.5% bupivacaine
Ondansetron 4 mg IV as required for nausea/
2: Knee
5. Intraoperative Medications vomiting

Pericapsular injection: 50 mL 0.5% ropivacaine, 0.5 Promethazine 6.25 mg IV as required for nausea/
mL 1:1000 epinephrine, 1 mL vomiting
30 mg ketorolac (not used in patients with renal Urecholine 20 mg in male patients with BPH or risk
impairment) of urinary retention
Narcotics are titrated and used sparingly Discharge instructions are provided by the nursing
6. Postoperative Medications staff
Hydromorphone 0.5 mg IV every 10 min as required Postoperative antibiotics are administered orally
up to 2 mg for 3 doses
Acetaminophen 1 g orally (4 h after first dose) Aspirin 325 mg orally for 6 weeks for DVT
prophylaxis (low–molecular weight heparin is
Oxycodone 5 mg orally for pain levels 1–3 used in obese or high-risk patients)
Hydrocodone/acetaminophen 5/325 mg 1 pill for Battery-powered pneumatic-compression
pain levels 1–3 ambulatory calf pumps are worn for 2 weeks
Hydrocodone/acetaminophen 5/325 mg 2 pills for Follow-up telephone communication at 24 h by
pain levels 4–10 nursing staff
Diazepam 2.5 mg IV as required for spasms Office evaluation at 6 weeks
BPH = benign prostatic hyperplasia, DVT = deep vein thrombosis, IV = intravenously.
Chapter 19: Outpatient Total Knee Arthroplasty
and to identify the uncorrectable. A 2007 study reported step-by-step procedure from preoperative to postopera-
a substantial number of new diagnoses during patient tive stages. Most questions the patients have should be
prescreening, and 2.5% of patients were deemed unac- answered by the provided readings, but staff must always
ceptable as surgical candidates.10 After these patients are be available to answer specific and detailed queries. The
identified, they should undergo treatment in an acute patients must also be encouraged before surgery to view
care setting equipped to handle any unforeseen compli- the facility and meet with staff (including but not limit-
cations. A 2015 study reported that established diagno- ed to the physical therapy and nursing staff) providing
ses of chronic obstructive pulmonary disease, congestive postoperative care. The physical therapist can teach the
heart failure, coronary artery disease, and cirrhosis are patients how to use walkers or other ambulatory aides and
the most likely medical conditions to require additional help patients and family anticipate how to manage activ-
intervention more than 24 hours after arthroplasty.11 Pa- ities of daily living after discharge. Nursing staff will be
tients with these conditions should be of greatest concern able to explain to both patient and family proper wound
when selecting for outpatient TKA. care and how to assess for any signs of complications.
If minimal medical comorbidities are present and Studies have shown that patient anxiety and fear can be
the patient is a candidate for outpatient arthroplasty, decreased when he or she is aware of functional capacity
a conversation to access his or her comfort level with in the immediate postoperative period.13-15
undergoing this outpatient procedure must occur. The After proper patient selection, an established pathway
expectations of the patient, family, and surgeon must all is set with a multidisciplinary approach to rapid recovery.
be in concordance. It should also be the priority of all This has been shown to markedly reduce readmission
involved that the patient has adequate family support and rates and to reduce lengths of stay, while enabling earlier
safety after he or she is discharged home. patient ambulatory ability.16 These protocols focus on
When moving patients to the outpatient setting, fi- perioperative pain control, surgical technique, and post-
nancial issues must be considered as well as medical is- operative care, and should be set to improve the patient’s
sues. In the United States, outpatient TKA and total hip experience and to decrease any errors. The focus should
arthroplasty do not have a defined Medicare code, but be on educating the patient that outpatient TKA can be
there is a code for partial knee arthroplasties.12 Because of performed safely and with low risk of complications.
this, irrespective of the patient’s health status, Medicare
guidelines state that the TKA must be coded as inpatient
and performed in a hospital. Pain Management
A multimodal approach to pain control must be used,
2: Knee
starting before surgery and including after the patient is
Patient Education discharged home. Many high-volume centers have suc-
Many patients may be unaware of the ability to undergo cessfully established pathways to reduce hospital length of
TKA and be discharged on the same day. The patient may stay and to expedite recovery13-21 that combine minimally
have a parent or sibling who underwent a similar proce- invasive surgery with efficient anesthesia to decrease side
dure and were admitted to the hospital for an extended effects and complications in the early postoperative pe-
period. This treatment may represent the standard of riod. The goal is to minimize pain, sedation, and nausea,
care to them. Preoperative education regarding outpatient while promoting early mobilization and safe discharge.
arthroplasty can eliminate any fears and explain the ad- Peripheral pain caused by surgical trauma can be sep-
vantages of recovering from surgery at home. arated into two categories: neurogenic and inflammato-
Full details of the procedure—pain management proto- ry.22,23 After incision, a cascade of nociceptive signals will
cols, minimally invasive techniques, and physical therapy cause the neurogenic pain and secondary inflammation
requirements after surgery—should be discussed before will follow.22,23 Any multimodal approach should start
surgery to decrease the patient’s anxiety and improve his with preoperative administration of analgesic and anti-
or her satisfaction with what will be done, while providing inflammatory medications to reduce the perception of
ample time for questions and answers. The surgeon, along pain from reaching the central nervous system. This pre-
with all who come in contact with the patient during emptive blocking of the nociceptive signals before painful
preoperative education, should be of the same mindset stimulus has been proposed to decrease the intensity of
and present a unified approach so that the patient feels postoperative pain;22 however, it is most effective when
comfortable and fully supported by all staff members. continued through the postoperative period.23
All patients should be provided with complete, up-to- To combat these pain pathways, patients are typically
date educational materials before surgery, including the given preoperative steroidal drugs and NSAIDs, regional
Section 2: Knee
anesthesia, and a nonnarcotic analgesic medication such for blood storage are not available, so it is important to
as acetaminophen. The goal is to control the patient’s pain identify any patients who may be at risk for postoper-
while minimizing narcotics to avoid side effects such as ative transfusion. Medical screenings and preoperative
sedation, nausea, and hypoventilation, which will deter blood work to evaluate hemoglobin level can be used to
the rapid recovery process and make outpatient TKA identify these patients. It has been shown that preopera-
difficult. Nausea and vomiting are aggressively controlled tive hemoglobin level is one of the greatest predictors of
by administering antiemetics both before and after sur- postoperative hemoglobin levels.35 A 2000 study showed
gery and maintaining adequate hydration throughout the if the hemoglobin level was higher than 13 g/dL, the trans-
procedure. Medications such as dexamethasone can be fusion rate approaches zero.36 Preoperative assessment
used for both anti-inflammatory and antiemetic purpos- and screening, along with other tools discussed later,
es; metoclopramide and scopolamine patches also can may alleviate the anxiety regarding blood loss and the
be sufficient options. In addition, other NSAIDs such need for transfusions.
as gabapentin and pregabalin can be used effectively to Regional and hypotensive anesthesia is another intra-
decrease pain and the need for narcotics.24 operative technique that can help decrease blood loss and
In addition to oral and intravenous medications, re- the need for transfusion.37-40 Using regional anesthesia
gional anesthesia in the form of adductor canal and par- and maintaining the mean arterial pressure at less than
tial sciatic nerve blocks are useful in pain management. 60 mm Hg has been found to decrease blood loss and
Peripheral blocks have been found to improve pain con- keep the rate for postoperative transfusion exceedingly
trol, decrease the need for narcotics, allow earlier func- low.37-40 Another adjunct to decrease blood loss is the use
tion, and to reduce readmissions and hospital length of of tranexamic acid.
stay.25,26 Femoral nerve blocks have been shown to place Tranexamic acid has most recently been used during ar-
patients at an increased risk of falls because of quad- throplasty to effectively minimize blood loss. Tranexamic
riceps muscle weakness;25,27 therefore, adductor canal acid reduces the rate of clot breakdown without increasing
blocks have been advocated.28 This type of block can be the rate of clot formation,41 which has been shown to
performed with ultrasonographic guidance and is pure- decrease blood loss in several studies and substantially
ly sensory, thus avoiding any motor impairment of the decrease the transfusion rate.42-46 Tranexamic acid can be
quadriceps. Other methods that can be used are epidural administered intravenously, topically, or orally. All routes
and spinal injections, and both can be advantageous for have been shown to effectively reduce blood loss and
pain control. Epidurals have been shown to decrease post- transfusion rates associated with arthroplasty.42-46 The
operative narcotic use.29,30 Narcotics should be avoided intravenous and oral dosing typically administered is
2: Knee
in these injections not only because of pruritus, nausea, 1 g before incision and 1 g after surgery in the recovery
and sedation, but also because patients will require more room, but several methods of administration have been
than 23 hours of observation. published. Topical solution is usually prepared by mixing
During the surgical procedure, local infiltration of 2 to 3 g of tranexamic acid in 50 to 100 mL of normal
the periarticular tissue with local anesthetics can help saline and placed in the wound at closure. Because blood
markedly with pain control.31 It has been shown that is a well-known irritant and cause of pain, awareness of
adding a long-acting narcotic to local injections can re- blood loss can limit any need for transfusion, as well as
duce the need for narcotics postoperatively as well as to serve as a form of pain control.
improve pain control and range of motion.31 Recently,
a liposomal-bound bupivacaine has been developed to
provide up to 72 hours of local effects. This agent has Surgical Approach
been shown to be safe and to reduce postoperative pain The aim of any surgical procedure should be to complete
in several different types of surgical procedures.32-34 The all steps efficiently with the least amount of trauma to the
combination of these factors provides the patient with patient. This is just as important when performing outpa-
adequate pain control, while limiting side effects and tient TKA. A minimally invasive approach is always an
complications, making outpatient TKA a reality. attractive option because the least amount of soft-tissue
damage will allow a more rapid recovery.
Several described methods have been described to gain
Blood Management access to the knee joint for TKA, and attention has been
Along with pain control, the possibility of blood loss can given to limiting damage to the quadriceps tendon. In
be another valid reason for skepticism about the safety of some studies, these minimally invasive techniques have
outpatient TKA. In most outpatient settings, resources been shown to decrease pain and improve postoperative
function.47,48 However, other randomized controlled trials is recommended for 10 days followed by aspirin. Other
have reported no differences in the approach used.49,50 The oral agents such as warfarin and factor Xa inhibitors
surgeon should be comfortable with the approach chosen have also been used.
and must be diligent with the placement of retractors to After patients have met all goals and are ready for
avoid any aberrant cuts or damage to structures such as discharge, they are provided with instructions and ma-
the medial collateral ligament, patellar tendon, or popli- terials to help at home. The nursing staff will review
teal vessels.51 This will result in the most efficient surgery all medications prescribed, proper wound care, and all
and best outcome for the patient. other discharge instructions, including follow-up in the
Efficiency trumps speed, and surgeons should make surgeon’s office. How to proceed with outpatient physical
decisions and surround themselves with staff in the oper- therapy and rehabilitation is outlined. After the patients
ating room to make the procedure run as smoothly as pos- are discharged home they are contacted within 24 to
sible. The procedure should be a repeated choreographed 48 to assess their progress and to answer any questions.
set of steps that everyone involved knows and understands In this new age of outpatient TKA, surgeons must
to limit errors, streamline the rapid recovery process, and be certain they are still providing proper care for their
make outpatient TKA as successful as possible. patients without any undue risk of complications. Many
studies have shown outcomes for outpatient arthroplasty
to be successful.53,54 In one series, selected patients for
Postoperative Care and Management outpatient TKA had low rates of complications or read-
The immediate postoperative period can be separated into missions.1,2,53,54 However, outpatient arthroplasty is not
two distinct phases: the acute phase and the step-down something that should be attempted without preestab-
phase. During the acute phase, the patient is transferred lished protocols and multimodal approaches for proper
directly from the operating room and delivered to the patient care.
postanesthesia unit. During this time, the patient must The easiest way for surgeons to transition to outpatient
be stabilized medically while pain and nausea are man- TKA is by implementing rapid recovery protocols in their
aged. Experienced anesthesia and nursing staff are typi- current practice, which will provide a safety net of tradi-
cally able to control pain and nausea using hydration and tional pathways to fall back on until the rapid recovery
limited narcotics. protocols are refined. By working diligently, surgeons will
The step-down phase begins after the patient is sta- be able to progress to outpatient surgery.
bilized and comfortable and is transferred to a private
recovery area. During this phase, family and friends are
2: Knee
allowed to be with the patient. The patient is administered Summary
oral fluids and given a light snack, and will sit up in bed TKA is one of the most successful and most common
and then stand. The physical therapy staff teaches the procedures performed by a practicing orthopaedic sur-
patient proper use of ambulatory aides, and the patient geon. As the paradigm shifts from inpatient to outpatient
will ambulate and attempt using the restroom. The goals TKA, it is paramount that surgeons must work to ensure
for each patient are to ambulate safely and to be able to proper patient selection. This can be done with the help of
negotiate stairs. The physical therapy staff will also work medical and anesthesia personnel to identify the patient’s
with patients and family on activities of daily living after risks for complications. After patient selection, developing
discharge. a system to educate patients about outpatient TKA should
Deep vein thrombosis (DVT) prophylaxis is a major follow. Comprehensive multimodal pain management and
concern that should be addressed before surgery, but is blood conservation protocols must be set up to ensure
reinforced before discharge. DVT prophylaxis should be that patients will be safe and comfortable after discharge
based on a patient’s risk for this complication.52 The goal from the hospital. Meticulous surgical techniques with
is to decrease the likelihood of DVT while minimizing minimally invasive approaches can also aid in perform-
postoperative bleeding. Most patients can be treated with ing outpatient TKA. Finally, appropriate postoperative
compression stockings, ambulatory calf pumps, and aspi- care with physical therapy, DVT prophylaxis, and close
rin. In high-risk patients, low–molecular-weight heparin follow-up will make outpatient TKA a reality.
Section 2: Knee
Key Study Points arthroplasty. Clin Orthop Relat Res 1997;345:125-133.

Medline
• Patient selection is perhaps the most important fac-
tor when considering outpatient TKA. Surgeons 8. Pearson S, Moraw I, Maddern GJ: Clinical pathway
management of total knee arthroplasty: A retrospective
should be aware of any medical comorbidities and comparative study. Aust N Z J Surg 2000;70(5):351-354.
which ones cause the highest risk for complications Medline DOI
or readmission.
• Patients need to be educated at every step of the 9. Courtland LG: Same-day outpatient TJR gains popu-
process for outpatient TKA. Staff, materials, and larity, but careful considerations must be made. Ortho-
pedics Today 2015. Available at: http://www.healio.
educational sessions outlining all aspects of the pro- com/orthopedics/total-joint-reconstruction/news/print/
cess should be readily available. orthopedics-today/%7B275b9278-29aa-4c1f-b090-
• An extensive, complete pain management protocol 101b38b03493%7D/same-day-outpatient-tjr-gains-popu-
for preemptive pain control that continues into the larity-but-careful-considerations-must-be-made. Accessed
March 22, 2016.
postoperative period should be created.
• Limiting blood loss by using minimally invasive This article of surgeon’s experiences with outpatient ar-
throplasty reports on proper patient selection and a multi-
techniques and efficient surgical steps will help modal approach to pain control, which are key points that
to avoid any complications. Adjuncts such as need to be discussed. Advocates for and against outpatient
tranexamic acid and intraoperative hypotension arthroplasty are represented and indicate that patient care
also can be beneficial. and safety should be top priority.
• Postoperative patient care should be comprehensive
10. Meding JB, Klay M, Healy A, Ritter MA, Keating EM,
and focused on pain control with early mobility. Berend ME: The prescreening history and physical in
Protocols should be set for proper DVT prevention. elective total joint arthroplasty. J Arthroplasty 2007;22
(6 suppl 2):21-23. Medline DOI
11. Courtney PM, Rozell JC, Melnic CM, Lee GC: Who
Annotated References should not undergo short stay hip and knee arthroplasty?
risk factors associated with major medical complications
1. Berger RA, Kusuma SK, Sanders SA, Thill ES, Sporer following primary total joint arthroplasty. J Arthroplasty
SM: The feasibility and perioperative complications of 2015;30(9 suppl):1-4. Medline DOI
outpatient knee arthroplasty. Clin Orthop Relat Res
This study is a retrospective review of 1,012 patients who
2009;467(6):1443-1449. Medline DOI
underwent both total knee and total hip arthroplasty to
2: Knee
identify postoperative complications: 70 complications

2. Kolisek FR, McGrath MS, Jessup NM, Monesmith (6.9%) were reported, with 84% of these complications
EA, Mont MA: Comparison of outpatient versus inpa- occurring after 24 hours. Chronic obstructive pulmonary
tient total knee arthroplasty. Clin Orthop Relat Res disease, congestive heart failure, coronary artery disease,
2009;467(6):1438-1442. Medline DOI and cirrhosis were identified as the most common diseases
to increase risk of developing complications.
3. Teeny SM, York SC, Benson C, Perdue ST: Does short-
ened length of hospital stay affect total knee arthro- 12. Centers for Medicare and Medicaid Services: Am-
plasty rehabilitation outcomes? J Arthroplasty 2005;20 bulatory Surgical Center Payment – Proposed Rule,
(7 suppl 3):39-45. Medline DOI CMS-1633-P, 2016 Available at: https://www.cms.
gov/Medicare/Medicare-Fee-for-Service-Payment/
4. Isaac D, Falode T, Liu P, I’Anson H, Dillow K, Gill P: ASCPayment/ASC-Regulations-and-Notices-Items/
Accelerated rehabilitation after total knee replacement. CMS-1633-
Knee 2005;12(5):346-350. Medline DOI
13. Berend KR, Lombardi AV Jr, Mallory TH: Rapid recovery
5. Cleary PD, Greenfield S, Mulley AG, et al: Variations in protocol for peri-operative care of total hip and total knee
length of stay and outcomes for six medical and surgi- arthroplasty patients. Surg Technol Int 2004;13:239-247.
cal conditions in Massachusetts and California. JAMA Medline
1991;266(1):73-79. Medline DOI
14. Lombardi AV Jr, Viacava AJ, Berend KR: Rapid recovery
6. Kim S, Losina E, Solomon DH, Wright J, Katz JN: Ef- protocols and minimally invasive surgery help achieve high
fectiveness of clinical pathways for total knee and to- knee flexion. Clin Orthop Relat Res 2006;452(452):117-
tal hip arthroplasty: Literature review. J Arthroplasty 122. Medline DOI
2003;18(1):69-74. Medline DOI
15. Lombardi AV, Berend KR, Adams JB: A rapid recov-
7. Mabrey JD, Toohey JS, Armstrong DA, Lavery L, Wam- ery program: Early home and pain free. Orthopedics
mack LA: Clinical pathway management of total knee 2010;33(9):656. Medline
This study reported that rapid recovery programs help 24. Buvanendran A, Kroin JS, Della Valle CJ, Kari M,
patients recover faster, safer, and with few complications. Moric M, Tuman KJ: Perioperative oral pregabalin re-
Patient selection, efficient minimally invasive techniques, duces chronic pain after total knee arthroplasty: A pro-
use of peripheral and local anesthesia, and early and ag- spective, randomized, controlled trial. Anesth Analg
gressive rehabilitation were highlighted. 2010;110(1):199-207. Medline DOI
In this randomized placebo-controlled double-blinded
16. Dowsey MM, Kilgour ML, Santamaria NM, Choong study of pregabalin to decrease chronic neuropathic pain
PF: Clinical pathways in hip and knee arthroplasty: A after TKA, 240 patients comprised two groups: one was
prospective randomised controlled study. Med J Aust given pregabalin, and the other was given a placebo. The
1999;170(2):59-62. Medline incidence of neuropathic pain was less in the pregabalin
group with increased flexion. These advantages of pre-
17. Berger RA, Sanders SA, Thill ES, Sporer SM, Della Valle gabalin came at the cost of increased early postoperative
C: Newer anesthesia and rehabilitation protocols enable sedation and confusion.
outpatient hip replacement in selected patients. Clin Or-
thop Relat Res 2009;467(6):1424-1430. Medline DOI 25. Beaupre LA, Johnston DB, Dieleman S, Tsui B: Impact
of a preemptive multimodal analgesia plus femoral nerve
18. Berend KR, Lombardi AV Jr: Liberal indications for mini- blockade protocol on rehabilitation, hospital length of
mally invasive oxford unicondylar arthroplasty provide stay, and postoperative analgesia after primary total knee
rapid functional recovery and pain relief. Surg Technol arthroplasty: A controlled clinical pilot study. Scientific
Int 2007;16:193-197. Medline World Journal 2012;2012:273821. Medline DOI
19. Carmichael NM, Katz J, Clarke H, et al: An intensive This prospective, controlled study of patients undergoing
perioperative regimen of pregabalin and celecoxib reduc- TKA compared preemptive multimodal analgesia with
es pain and improves physical function scores six weeks and without the addition of femoral nerve blocks in 39 pa-
after total hip arthroplasty: A prospective randomized tients. No differences were found in patient-recorded out-
controlled trial. Pain Res Manag 2013;18(3):127-132. come, except for quadriceps motor blockage on patients
Medline DOI receiving femoral nerve blocks.
This randomized double-blind placebo-controlled pilot 26. Lovald ST, Ong KL, Lau EC, Joshi GP, Kurtz SM, Mal-
study reported on two groups. Group 1 was given prega- kani AL: Readmission and complications for catheter and
balin and celecoxib; group 2 was given a placebo. Results injection femoral nerve block administration after total
showed improved pain control and function with use of knee arthroplasty in the Medicare population. J Arthro-
pregabalin and celecoxib. plasty 2015;30(12):2076-2081. Medline DOI
20. Mears DC, Mears SC, Chelly JE, Dai F, Vulakovich KL: This study examined femoral nerve blocks used in the
THA with a minimally invasive technique, multi-mod- Medicare population between 2003 and 2011. It was hy-
al anesthesia, and home rehabilitation: Factors associ- pothesized that patients receiving femoral nerve blocks
would have lower risk of readmission but higher risk for
2: Knee
ated with early discharge? Clin Orthop Relat Res
2009;467(6):1412-1417. Medline DOI falls, which was found to be true.
21. Sculco PK, Pagnano MW: Perioperative solutions for rapid 27. Sharma S, Iorio R, Specht LM, Davies-Lepie S, Healy
recovery joint arthroplasty: Get ahead and stay ahead. WL: Complications of femoral nerve block for total knee
J Arthroplasty 2015;30(4):518-520. Medline DOI arthroplasty. Clin Orthop Relat Res 2010;468(1):135-140.
Medline DOI
This article stresses the need for patients to get ahead and
stay ahead of four impediments to early rehabilitation and This study examined the complication rate of femoral
discharge: volume depletion, blood loss, pain, and nausea. nerve blocks for TKA in 1,018 procedures, with 709 femo-
Hydration, tranexamic acid, adequate anesthesia, and ral nerve blocks performed: 12 patients (1.6%) sustained a
limited narcotics were used to get ahead and stay ahead fall along with other adverse effects. It was recommended
for rapid recovery after joint arthroplasties. to modify protocols to account for quadriceps impairment
after surgery.
22. Woolf CJ, Chong MS: Preemptive analgesia—treating
postoperative pain by preventing the establishment of 28. Jaeger P, Nielsen ZJ, Henningsen MH, Hilsted KL,
central sensitization. Anesth Analg 1993;77(2):362-379. Mathiesen O, Dahl JB: Adductor canal block versus
Medline DOI femoral nerve block and quadriceps strength: A random-
ized, double-blind, placebo-controlled, crossover study in
healthy volunteers. Anesthesiology 2013;118(2):409-415.
23. Vadivelu N, Mitra S, Schermer E, Kodumudi V, Kaye AD, Medline DOI
Urman RD: Preventive analgesia for postoperative pain
control: A broader concept. Local Reg Anesth 2014;7: This randomized double-blind placebo-controlled cross-
17-22. Medline over study reported on 11 healthy young men receiving
adductor canal blocks or femoral nerve blocks in one leg
This report discusses how to decrease postoperative pain with placebo in the contralateral limb to measure quad-
by using preventive and preemptive anesthesia. Using mul- riceps strength. Adductor canal blocks reduced quadri-
timodal preoperative and postoperative analgesic therapies ceps strength by 8%, and femoral nerve blocks reduced
results in decreased postoperative pain and consumption strength by 49%. Patients in the adductor canal group
of analgesics.
Section 2: Knee
were better able to ambulate than those in the femoral 35. Rosencher N, Kerkkamp HE, Macheras G, et al; OS-
nerve block group. THEO Investigation: Orthopedic Surgery Transfusion
Hemoglobin European Overview (OSTHEO) study: Blood
29. DeWeese FT, Akbari Z, Carline E: Pain control after knee management in elective knee and hip arthroplasty in Eu-
arthroplasty: Intraarticular versus epidural anesthesia. rope. Transfusion 2003;43(4):459-469. Medline DOI
36. Hatzidakis AM, Mendlick RM, McKillip T, Reddy RL,
30. Williams-Russo P, Sharrock NE, Haas SB, et al: Random- Garvin KL: Preoperative autologous donation for total
ized trial of epidural versus general anesthesia: Outcomes joint arthroplasty. An analysis of risk factors for allogenic
after primary total knee replacement. Clin Orthop Relat transfusion. J Bone Joint Surg Am 2000;82(1):89-100.
Res 1996;331:199-208. Medline DOI Medline
31. Lombardi AV Jr, Berend KR, Mallory TH, Dodds KL, 37. Sharrock NE, Salvati EA: Hypotensive epidural anesthesia
Adams JB: Soft tissue and intra-articular injection of for total hip arthroplasty: A review. Acta Orthop Scand
bupivacaine, epinephrine, and morphine has a beneficial 1996;67(1):91-107. Medline DOI
effect after total knee arthroplasty. Clin Orthop Relat
Res 2004;428:125-130. Medline DOI 38. Eroglu A, Uzunlar H, Erciyes N: Comparison of hypo-
32. Golf M, Daniels SE, Onel E: A phase 3, randomized, pla- venous anesthesia on intraoperative blood loss during
cebo-controlled trial of DepoFoam® bupivacaine (extend- total hip replacement. J Clin Anesth 2005;17(6):420-425.
ed-release bupivacaine local analgesic) in bunionectomy. Medline DOI
Adv Ther 2011;28(9):776-788. Medline DOI
39. Park JH, Rasouli MR, Mortazavi SM, Tokarski AT,
In this multicenter, randomized double-blind phase III Maltenfort MG, Parvizi J: Predictors of perioperative
clinical study on the use of bupivacaine for local injection blood loss in total joint arthroplasty. J Bone Joint Surg
during bunionectomy compared with placebo, 193 pa- Am 2013;95(19):1777-1783. Medline DOI
tients were enrolled and their postoperative pain score
was assessed. Patients receiving bupivacaine had decreased This study identified any clinical predictors for peri-
pain and decreased opioid use after surgery compared with operative blood loss and allogenic blood transfusion in
the placebo group. 11,373 patients reviewed from 2000 to 2008 who under-
went either total hip or total knee arthroplasty. Multiple
33. Cohen SM: Extended pain relief trial utilizing infiltration risk factors were identified and can be used to implement
of Exparel(®), a long-acting multivesicular liposome for- blood-conserving pathways.
mulation of bupivacaine: A Phase IV health economic trial
in adult patients undergoing open colectomy. J Pain Res 40. Juelsgaard P, Larsen UT, Sørensen JV, Madsen F, Søballe
2012;5:567-572. Medline DOI K: Hypotensive epidural anesthesia in total knee replace-
ment without tourniquet: Reduced blood loss and transfu-
2: Knee
In this single-center, sequential-cohort study of sion. Reg Anesth Pain Med 2001;26(2):105-110. Medline
39 adults undergoing open colectomy, one group received
patient-controlled analgesia with opioids and the other
received multimodal analgesia and injection of liposomal 41. Duncan CM, Gillette BP, Jacob AK, Sierra RJ, Sanchez-So-
bupivacaine. The group receiving liposomal bupivacaine telo J, Smith HM: Venous thromboembolism and mortali-
required fewer opioids postoperatively, while resulting in ty associated with tranexamic acid use during total hip and
lower costs and decreased length of stay compared with knee arthroplasty. J Arthroplasty 2015;30(2):272-276.
the opioid-based regimen. Medline DOI
This large, single-center retrospective review reported
34. Marcet JE, Nfonsam VN, Larach S: An extended pain on 13,262 total hip or knee arthroplasties for which
relief trial utilizing the infiltration of a long-acting mul- tranexamic acid was used. The likelihood of venothrom-
tivesicular liposome formulation of bupivacaine, EX- boembolism or death was not significant with tranexamic
PAREL (IMPROVE): A Phase IV health economic trial acid administration.
in adult patients undergoing ileostomy reversal. J Pain Res
2013;6:549-555. Medline DOI 42. Wind TC, Barfield WR, Moskal JT: The effect of tranexam-
In this open-label, multicenter, sequential cohort study, ic acid on transfusion rate in primary total hip arthroplas-
27 patients underwent ileostomy reversal and had either ty. J Arthroplasty 2014;29(2):387-389. Medline DOI
standard intravenous patient-controlled analgesia opi- This retrospective review reported on 1,595 total hip
oid therapy or multimodal analgesia with injection of arthroplasties that used tranexamic acid applied intra-
liposome bupivacaine. The use of liposome bupivacaine venously, topically, or neither to examine the need for
reduced opioid consumption, length of stay, and inpatient transfusion after surgery. Intravenous tranexamic acid
costs when compared with intravenous patient-controlled significantly reduced the need for transfusion; topical
analgesia opioid regimen. tranexamic acid did not reach significance. The occur-
rence of transfusion was 19.86% without tranexamic acid,
4.39% with intravenous tranexamic acid, and 12.86% 48. Curtin B, Yakkanti M, Malkani A: Postoperative pain and
with topical tranexamic acid. contracture following total knee arthroplasty comparing
parapatellar and subvastus approaches. J Arthroplasty
43. Konig G, Hamlin BR, Waters JH: Topical tranexamic 2014;29(1):33-36. Medline DOI
acid reduces blood loss and transfusion rates in total hip This retrospective review reported on 801 patients un-
and total knee arthroplasty. J Arthroplasty 2013;28(9): dergoing TKA using either the standard parapatellar ap-
1473-1476. Medline DOI proach or a subvastus approach to evaluate the incidence of
This study examined 290 patients who underwent ei- contracture. No difference was reported in operating room
ther total hip arthroplasty or TKA performed by a single time, blood loss, body mass index, or length of stay. The
surgeon to determine if topical tranexamic acid would manipulation rate was 4% for the standard parapatellar
decrease bleeding and transfusion postoperatively. Top- approach and 2% for the subvastus approach.
ical tranexamic acid significantly reduced postoperative
bleeding and transfusion. 49. Guy SP, Farndon MA, Conroy JL, Bennett C, Grainger
AJ, London NJ: A prospective randomised study of mini-
44. Gilbody J, Dhotar HS, Perruccio AV, Davey JR: Topical mally invasive midvastus total knee arthroplasty compared
tranexamic acid reduces transfusion rates in total hip and with standard total knee arthroplasty. Knee 2012;19(6):
knee arthroplasty. J Arthroplasty 2014;29(4):681-684. 866-871. Medline DOI
Medline DOI This randomized controlled trial reported on 80 patients
This retrospective review reported on 155 patients un- undergoing either a mini-midvastus approach or a medi-
dergoing total hip and knee arthroplasty while receiv- al parapatellar approach. No statistical differences were
ing topical tranexamic acid and 149 patients who did found in any parameters measured apart from blood loss
not. Significant reduction in blood loss, hemoglobin loss, and scar length. The mini-midvastus approach does not
and length of stay were reported with the use of topical appear to provide any benefit aside from a smaller scar.
tranexamic acid.
50. Tomek IM, Kantor SR, Cori LA, et al: Early patient out-
45. Alshryda S, Sarda P, Sukeik M, Nargol A, Blenkinsopp J, comes after primary total knee arthroplasty with quadri-
Mason JM: Tranexamic acid in total knee replacement: ceps-sparing subvastus and medial parapatellar techniques:
A systematic review and meta-analysis. J Bone Joint Surg A randomized, double-blind clinical trial. J Bone Joint
Br 2011;93(12):1577-1585. Medline DOI Surg Am 2014;96(11):907-915. Medline DOI
This meta-analysis of randomized controlled trials eval- This prospective double-blinded study of 129 patients
uated the effectiveness of tranexamic acid in 19 studies. undergoing TKA compared the quadriceps-sparing ap-
Tranexamic acid showed significant reduction in blood proach with the medial parapatellar approach. The quad-
loss and transfusion while not increasing DVT or pulmo- riceps-sparing approach showed lower pain at rest and
nary embolism. during activity, but showed no early functional advantage
or decrease in opioid consumption when compared with
the medial parapatellar approach.
2: Knee
46. Irwin A, Khan SK, Jameson SS, Tate RC, Copeland C,
Reed MR: Oral versus intravenous tranexamic acid in
enhanced-recovery primary total hip and knee replace- 51. Berend KR, Lombardi AV Jr: Avoiding the potential pit-
ment: Results of 3000 procedures. Bone Joint J 2013;95- falls of minimally invasive total knee surgery. Orthopedics
B(11):1556-1561. Medline DOI 2005;28(11):1326-1330. Medline
This retrospective study compared the safety and efficacy 52. Jacobs JJ, Mont MA, Bozic KJ, et al: American Academy
of oral (302 patients) and intravenous (2,698 patients) of Orthopaedic Surgeons clinical practice guideline on:
tranexamic acid. When adjusted, oral tranexamic acid Preventing venous thromboembolic disease in patients
showed decreased rates of transfusion compared with undergoing elective hip and knee arthroplasty. J Bone
intravenous administration. There is also a financial ben- Joint Surg Am 2012;94(8):746-747. Medline DOI
efit of oral compared with intravenous tranexamic acid.
Ten recommendations are provided on the practice of
47. Liu HW, Gu WD, Xu NW, Sun JY: Surgical approaches preventing DVT in patients undergoing total hip arthro-
in total knee arthroplasty: A meta-analysis comparing plasties and TKAs. Recommendations are given by grade
the midvastus and subvastus to the medial peripatel- of recommendation.
lar approach. J Arthroplasty 2014;29(12):2298-2304.
Medline DOI 53. Berger RA, Sanders S, Gerlinger T, Della Valle C, Jacobs
JJ, Rosenberg AG: Outpatient total knee arthroplasty
This meta-analysis reported on 32 randomized controlled with a minimally invasive technique. J Arthroplasty
trials of 2,451 TKAs in 2,129 patients. When compared 2005;20(7 suppl 3):33-38. Medline DOI
with the medial parapatellar approach, the midvastus
approach showed better pain and range of motion at 1 to
2 weeks postoperatively, but with longer surgical time. 54. Berger RA, Sanders S, D’Ambrogio E, et al: Minimal-
The subvastus approach showed better range of motion ly invasive quadriceps-sparing TKA: Results of a com-
1 week postoperatively as well as straight leg raise and prehensive pathway for outpatient TKA. J Knee Surg
lateral retinacular release. 2006;19(2):145-148. Medline
Chapter 20
Complications of Knee Arthroplasty

Viktor E. Krebs, MD Arthur L. Malkani, MD Slif D. Ulrich, MD David Backstein, MD, MEd, FRCSC
Mansour Abolghasemian, MD Bryan D. Springer, MD Christopher Samujh, MD
by consultant partners. Currently, the most frequent,

Abstract
researched, and potentially difficult complications an
Total knee arthroplasty (TKA) has been one of the orthopaedic surgeon can work to prevent and manage
most beneficial surgical procedures in the history of after total knee arthroplasty (TKA) include periprosthetic
medicine, with survival rates reported at more than fractures, surgical site and deep periprosthetic infections,
90% in patients followed up to 20 years. Despite out- and the sequelae of long-term polyethylene wear. It is
standing results, the complication risk associated with important to be knowledgeable about the most up-to-date
TKA can have an extremely negative effect on patients, research and currently accepted guidelines for the assess-
surgeons, and the healthcare economy. The rare comment, diagnosis, and management of these complications.
plications are being closely scrutinized and monitored
due to the Comprehensive Care for Joint Replacement
Periprosthetic Knee Fractures
program in the United States, bundled payments, and
similar quality- and cost-containment initiatives. Given Mansour Abolghasemi, MD; Viktor E. Krebs, MD;
the needs of an aging population, TKA has become a David Backstein, MD, MEd, FRCSC
standardized treatment. Governments, corporations, Periprosthetic fractures can be a debilitating complication
institutions, and individuals expect all TKAs to occur of knee arthroplasty and can result in extremely poor
without any initial problems, to allow function at a high joint function and pain. This complication is a steadily
level within months, and to last indefinitely. It is helpful increasing cause for revision surgery as noted in national
2: Knee
for surgeons to define modifiable patient risk factors, registries and large database-derived publications.1,2 The
provide concepts for continuous practice improvement, incidence after primary knee a rthroplasty is r eportedly
and outline successful methods for decreasing compli- 2.5% to 38.0% after revision surgery3,4 (Table 1). In
cations and improving measured outcomes. general, periprosthetic fracture rates have increased
in proportion to the increased number of TKAs being
performed because of expanded indications, obesity, in-
creased survival of the implants, and the aging society.
Keywords: total knee arthroplasty, complications,
Although the percentages do not comprise most of the
periprosthetic infections, periprosthetic knee
knee revisions being performed, the numbers and con-
fractures, polyethylene wear
sequences are substantial, at an estimated occurrence of
15,000 procedures per year in the United States.5 Peri-
prosthetic fracture treatment after knee arthroplasty can
be extremely challenging for the patient and surgeon be-
Introduction
cause of its unplanned and emergent nature; complication
Complications after knee arthroplasty, although infre- rates up to 40% have been reported, as well as revision
quent, interfere with the recovery and optimal function rates of up to 29%, and a 1-year mortality rate that ranges
of the joint. Improved surgical training, instrumentation, from 4.6% to 13.0%.6
and advanced implants have improved outcomes and de-
creased the unfavorable issues encountered in the past. Epidemiology and Risk Factors
Although general perioperative complications related to In addition to poor outcomes, the socioeconomic con-
medical comorbidities and anesthesia can and do occur, sequences of periprosthetic knee fracture are consider-
these are typically evaluated and expertly co-managed able. According to projections by one study, by 2030 the
Section 2: Knee
Table 1
Periprosthetic Fracture Rates After Total Knee Arthroplasty
Fracture Type and Location Primary TKA (range) Revision TKA (range)
Intraoperative
Femur 0.1%–0.4% 0.8%
Tibia 0.07%–0.67% 0.36%–0.8%
Patella Not reported 0.2%
Postoperative
Femur 0.3%–5.5% 0.3%–38%
Tibia 0.39%–0.4% 0.48%–0.9%
Patella 0.61%–1.19% 0.15%–2%
TKA = total knee arthroplasty. Data from Schütz M, Perka C: Periprosthetic Fracture Management. New York, Thieme, 2013, pp 782-795.
demand for primary TKA is expected to increase by Risk factors for periprosthetic knee fractures can
673% to 3.48 million procedures per year, with a sub- be patient- and/or procedure-related9 (Table 2). Some
sequent increase of revisions of 601%. This equates to patient factors are modifiable and should be evaluated
more than 80,000 periprosthetic knee fractures requiring diligently and optimized before performing elective TKA.
emergent treatment every year. Costs have been estimated In situations in which nonmodifiable patient-related risk
per occurrence for periprosthetic hip fractures to be be- factors predict short-term fracture complications, sur-
tween $20,000 to $200,000, and are likely similar for geons should counsel patients and families to consider
knees.7 Periprosthetic infection and fracture were associ- continuation of nonsurgical management to avoid the
ated with the greatest length of stay and costs for revision known morbidity and mortality. Unfortunately, many
TKA.8 Bundled payments and pay-for-performance proof the risk factors for periprosthetic knee fracture evolve
grams will shift these cost burdens to hospitals and physi- long after the primary procedure has been performed. The
cians, increasing the pressures on the already-diminishing most difficult fractures to treat occur following minor
2: Knee
orthopaedic surgeon population. Appropriate care for trauma and falls in frail patients, often those with loose
patients with periprosthetic fractures will only be sus- or failing implants. Periprosthetic knee fractures from
tainable by organizing regional centers with adult recon- higher-energy trauma tend to occur in more active pa-
struction and trauma-trained orthopaedic surgeon teams tients with functioning implants; these are often amenable
to manage these volumes efficiently.6 to treatment with standard fracture fixation techniques.
Dr. Krebs or an immediate family member has received royalties from Stryker; is a member of a speakers’ bureau or has
made paid presentations on behalf of Stryker; and serves as a paid consultant to Stryker. Dr. Malkani or an immediate
family member has received royalties from Stryker; is a member of a speakers’ bureau or has made paid presentations on
behalf of Stryker; serves as a paid consultant to Stryker Orthopaedics; and serves as a board member, owner, officer, or
committee member of the American Academy of Orthopaedic Surgeons. Dr. Backstein or an immediate family member
has received royalties from Microport Orthopaedics; is a member of a speakers’ bureau or has made paid presentations
on behalf of Microport Orthopaedics and Zimmer; serves as a paid consultant to Microport Orthopaedics and Zimmer;
has stock or stock options held in Intellijoin Orthopaedics; and has received research or institutional support from Zim-
mer. Dr. Springer or an immediate family member has received royalties from Stryker; serves as a paid consultant to or
is an employee of Convatec and Stryker; has received nonincome support (such as equipment or services), commercially
derived honoraria, or other non–research-related funding (such as paid travel) from Joint Purification Systems; and
serves as a board member, owner, officer, or committee member of the American Joint Replacement Registry and the
Knee Society. None of the following authors or any immediate family member has received anything of value from or
has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of
this chapter: Dr. Ulrich, Dr. Abolghasemian, and Dr. Samujh.
Chapter 20: Complications of Knee Arthroplasty
Table 2 studies. Clinical data from a series of 36 periprosthetic

supracondylar femoral fractures showed that 25% of
Risk Factors for Periprosthetic Fracture the cohort had radiographically diagnosed notching of
Procedure/Implant- the anterior femoral cortex.11 The association between
Patient-Related (Intrinsic) Related (Extrinsic) notching as a stress riser and predisposition to peripros-
thetic distal femoral fractures was strengthened by data
Osteoporosis: reduced Plate and hardware
bone mineral density removal that demonstrated a significant temporal association with
Inflammatory arthritis Previous osteotomy
the arthroplasty procedure (37.5 months notched versus
80.3 months), and a significant reduction in the fracture
Advanced age Anterior notching of the
femoral cortex
origin distance (3.2 mm notched versus 39.0 mm) from
the anterior flange on the femoral component.11
Female sex Central box preparation
for stabilized implants
Classification and Planning
Body mass index Implant malalignment
Classification systems should provide a way to communi-
Multiple comorbid Instability cate clinically, guide treatment, offer a prognosis, predict
medical conditions
complications, and permit the meaningful comparison of
Chronic steroid usage Rotationally constrained outcomes among different surgeons and centers. Knee
implants
periprosthetic fracture classifications have evolved since
Malnutrition Poor knee motion the early supracondylar fracture classification system was
Neuromuscular disorders Manipulation proposed in 1967. Classification systems have focused
Dementia Revision procedures on a specific anatomic region: distal femoral/supracon-
Osteolysis dylar, proximal tibial, and patellar. Each new classifica-
Stress shielding
tion has added to the previous with more detail focused
on fracture pattern, site, distance from the prosthesis,
Loose implants
chronology, bone quality, prosthetic fixation stability/
condition, fixation recommendations, and outcomes of
treatment. Most have followed the principles of the prox-
imal femoral periprosthetic Vancouver fracture classifi-
Procedure-related risk factors can occur intraopera- cation. The most used and cited current classifications
tively or any time after the procedure. The incidence of are the Rorabeck and Su classifications for distal femoral/
2: Knee
intraoperative knee fracture has been reported at less supracondylar fractures, the Felix classification for tibial
than 1% in primary and revision procedures10 (Table 1). fractures, and the Ortiguera and Berry classification for
These fractures occur during exposure, bone preparation, patellar fractures.
implant trialing, or final implantation. Intraoperative The AO Foundation published a comprehensive book
vigilance, judicious use of force when inserting implants, that includes a Unified Classification System (UCS) for
and meticulous technique may reduce fracture complica- all periprosthetic fractures.12 The UCS, based on the core
tions both intraoperatively and postoperatively. The most principles of fracture location, component fixation, and
problematic fractures occur in poor-quality distal femoral bone strength/stock, which are pertinent to any joint
bone at the implant-bone interfaces. When fractures occur during or after an arthroplasty procedure, was codevel-
during the acute postoperative 90-day recovery period, oped by experts in arthroplasty and orthopaedic trau-
they are generally the result of unrecognized intraopera- matology to modernize the principles of periprosthetic
tive fractures, falls, or aggressive therapy in deconditioned fracture management. The UCS builds on all previous
patients. Anterior distal femoral notching, especially that classifications, expands them where needed, and com-
greater than 3 mm with sharp corners located exactly bines their principles to deliver a refined system. Although
at the proximal end of the prosthesis, is a likely cause; seemingly more complex and detailed than previous clas-
biomechanical cadaver studies and finite-element models sifications, the UCS is very straightforward, clinically
clearly show increased local stress concentration reducing applicable, and more detailed when needed for databases
torsional bone strength by 30% to 40%, and flexural and registries. The UCS has substantial interobserver
strength by 18%. These observations have been disputed reliability and near-perfect intraobserver reliability when
by clinical data that have not proven a statistical associ- used for periprosthetic fractures in association with knee
ation between notching and fracture, conceivably due to arthroplasties in the hands of experienced and inexpe-
the low incidence and a lack of statistical power in the rienced users.13
Section 2: Knee
Table 3
AO/Unified Classification System Periprosthetic Fracture Classification
V Knee
V.3 V.4 V.34
Type Femur, distal Tibia, proximal Patella
A A1 Lateral epicondyle Medial or lateral Disrupted extensor,
Apophyseal Avulsion of plateau, proximal pole
or extra- nondisplaced
articular/ A2 Medial epicondyle Tibial tubercle Disrupted extensor,
periarticular distal pole
Avulsion of
B B1 Proximal to stable Stem and component Intact extensor,
Bed of the Prosthesis stable, stem, good bone stable, good bone implant stable, good
implant or good bone bone
around the
B2 Proximal to loose stem, Loose component/ Loose implant, good
implant
Prosthesis loose, good bone stem, good bone bone
good bone
B3 Proximal to loose stem, Loose component/ Loose implant, poor
Prosthesis loose, poor bone, defect stem, poor bone, bone, defect
poor bone or defect
bone defect
C - Proximal to the implant Distal to the implant -
Clear of or and cement mantle and cement mantle
distant to
the implant
D - Between hip and knee Between ankle and Between ankle and
Dividing arthroplasties, close knee arthroplasties, knee arthroplasties,
the bone to knee close to knee close to knee
between
two
implants
2: Knee
or inter
prosthetic
or inter
calary
E - Femur and tibia/patella
Each of two
bones
supporting
one
arthroplasty
or polyperi
prosthetic
F - Fracture of femoral - Fracture of the patella
Facing and condyle articulating that has no surface
articulating with tibial replacement and
with a hemiarthroplasty articulates with the
hemi femoral component
arthroplasty of the total knee
arthroplasty
Data from Duncan CP, Haddad FS: The Unified Classification System (UCS): Improving our understanding of periprosthetic fractures. Bone
Joint J B 2014;96(6):713-716.
Classification is initially based on a plain radiographic to a surgeon with experience and a wide experience of
diagnosis. Whole-femur views should be available from surgical options is preferable.
the hip to the knee; CT is recommended to further de-
lineate the extent and location of the fracture, to assess Distal Femoral Fracture
the bone stock quality, and to evaluate for osteolysis and Distal femoral fracture, the most common periprosthetic
loosening. The primary purpose of periprosthetic knee knee fracture, may be difficult to treat because of the mag-
fracture classification is to differentiate those that can be nitude of deforming forces concentrated in the metaphysis
fixed with osteosynthesis from those that require revision and at the implant interfaces. These mostly occur adjacent
or segmental replacement.12 When planning treatment, to a well-fixed femoral component.16 The current con-
the critical issues are implant fixation and bone quality, sensus on treatment of the most common fracture type
factors that are classified as UCS type B12 (Table 3). The reported, stable implants with bone that will hold screws
distinction between loose and well-fixed implants is not (AO/UCS V.3 B1 - Rorabeck type II), is to use internal
always clear, and studies have shown that a high number fixation with periarticular locking plates or retrograde
of periprosthetic fractures classified as stable implants are intramedullary nails.17-20 Several clinical and biomechani-
actually found to be loose implants at the time of surgery. cal studies have clearly shown the superiority of these two
The possibility of infection should be routinely evaluated options over conventional plates.21 Knee implant design
using inflammatory markers.9 In addition, classification frequently determines the fixation method required; a
does not address soft-tissue, tendon, or ligament integ- closed posterior-stabilized box, presence of a stem, or a
rity. For these reasons, classifications are considered as canal/notch mismatch preclude the use of intramedullary
guides and not rigid decision algorithms. Surgeons treat- fixation. One study using a sawbone model created a table
ing periprosthetic knee fractures must understand and be demonstrating the compatibility and technical feasibility
prepared to adapt to multiple fixation and reconstruction of inserting commonly used retrograde nails through the
alternatives. 10 most frequently used femoral implants for primary
TKA in the United Kingdom using the National Joint
Treatment Registry.22 The study found that most are not compatible
The management of periprosthetic fractures is compli- because of excessive force required for insertion, damage
cated by several variables, which include osteopenic bone to the nail during insertion, posterior location of the en-
in the distal femoral metaphyseal region, short distal trance, and risk of anterior cortex perforation.
segments for adequate fixation, surgical exposure and One definite advantage of intramedullary fixation
blood loss, nonunion, malunion, and malalignment.14 is that the implant is inserted through a midline knee
2: Knee
Periprosthetic knee fractures that occur in patients incision, in contrast to plate fixation, which normally
with well-fixed, aligned, and stable joints can be treated necessitates the addition of a lateral incision to the knee
using standard fracture fixation techniques when the ar- (with potential for soft-tissue complications). However,
throplasty hardware does not interfere with the ability to recent clinical publications report varied results and do
achieve anatomic reduction and alignment. When this is not consistently favor one method over the other. A multi-
not the situation, treatment requires a combined knowl- center study of 36 retrospectively reviewed cases reported
edge of the latest techniques and biomechanical principles successful healing using three locked-plate designs in
of fracture fixation and revision arthroplasty.1 Treatment 28 patients (77.8%), with malunion in 5 patients (13.9%)
complication and failure rates have been reported in up and failure requiring arthroplasty in 3 (8.4%).11 Patients
to a third of patients, an indication of the procedure who underwent submuscular plate insertion, compared
technicality and the encumbered patient population to those who had an extensive lateral approach, had a
that is typically affected.15 Individual patient prefracture reduced nonunion risk (P = 0.05).22 Another study re-
function, comorbidities, and lifestyle goals should also ported on 42 fractures proximal to posterior-stabilized
be considered when deciding on the treatment method. TKAs; 24 were treated with periarticular locking plates
Surgical treatment is indicated in most cases, but non- and 18 with retrograde intramedullary nails.23 Nonunion
surgical management can be acceptable when fractures was seen in 29.2% of patients (7 of 24) in the plating
are nondisplaced, implants are stable, anesthesia risks group, and failure occurred in 27.8% (5 of 18 patients)
are high, and patients are nonambulatory. The choice of the nail group (2 fractures at the level of the proxi-
of surgical intervention is best determined by the team mal nail tip and 3 nonunions). No difference was found
on the basis of fracture characteristics as well as the ca- in clinical results in those that healed.23 A multicenter
pabilities of the surgeon and operating theater/hospital. study retrospectively reviewed 63 patients with Rora-
Given the complexity of these reconstructions, transfer beck type II fractures, 24 in which 35 patients were treated
Section 2: Knee
Figure 1 AP (A) and lateral (B) radiographs demonstrate a distal femoral periprosthetic fracture sustained after
arthroplasty performed for femoral supracondylar fracture in a 59-year-old woman. AP (C) and lateral (D)
radiographs were obtained following revision arthroplasty with a locking plate. The implant components were
well fixed.
with intramedullary femoral nailing and 28 with a lock- cortical locking with a gliding proximal screw hole has
ing screw plate. Radiographic union was significantly been introduced in an attempt to decrease stiffness while
greater in the locking screw plate group, and the rate retaining strength, and early results have been promis-
of revision surgery was only 14%, although it reached ing.15 Figure 1 shows a distal femoral periprosthetic frac-
40% in the intramedullary nail group.24 Another study ture treated with internal fixation using a locking plate.
compared modern retrograde intramedullary nails with Clinical outcomes of treated periprosthetic fractures are
2: Knee
a locked distal screw to periarticular locking plates in a often poor. Range of motion was reduced in most of the
retrospective consecutive series of 91 patients (29 nails, patients treated with plating in one study, with the cohort
66 plates) with 95 periprosthetic supracondylar femoral averaging 101° of flexion (range 0° to 140°), and 65.7%
fractures. Follow-up of 85 knees showed that 83.5% went required long-term ambulatory aid assistance.11 The
on to union at an average of 16 weeks:25 2 nonunions 10-year systematic review reported complication rates
(9%) were reported in the intramedullary nail group and of 35% for locking plates and 53% for intramedullary
12 nonunions/delayed unions (19%) were reported in the nailing.20 In addition, reported radiographic results are
locking plate group (P = 0.34). A recent systematic liter- concerning. A total of 56% of intramedullary nails and
ature review included 41 studies published from 2004 to 41% of locking plates fell outside of acceptable alignment
2014 and supported this consensus by showing that lock- at final radiographic follow up.25 In response to persistent
ing plates and intramedullary nail/rods have the highest failures, the addition of an intramedullary allograft to the
healing rates (87% and 84%, respectively).20 Another plating technique has been reported. Recent biomechan-
systematic review pooling 719 cases found comparable ical studies have addressed this issue. A finite-element
union rates with locking plates or intramedullary nails, comparison study showed that the biomechanical perfor-
but the malunion rate was significantly higher with the mances of the nail and less invasive stabilization system
use of nails.17 Some evidence also suggests better perfor- (LISS) plate were comparable, but addition of an intra-
mance of polyaxial locking plates compared to monoaxial medullary allograft to a LISS plate significantly stabi-
plates.2 When applying a locking plate, involvement of the lized the fracture gap, reduced the implant stress, and
far cortex by the locking screws decreases the screw cut- was recommended as the preferred fixation method for
out rate as well as the risk of varus displacement. Howev- periprosthetic distal femur fractures.26 These findings were
er, it also potentiates the stiffness of the construct, which refuted by another study evaluating the stability of four
is not biologically favorable. Recently, the concept of far methods of fixation for supracondylar periprosthetic femur
Figure 2 AP (A) and lateral (B) radiographs of a distal femoral fracture in an elderly patient following total knee
arthroplasty. AP (C) and lateral (D) radiographs obtained distal femoral replacement performed to address poor
distal bone stock.
fractures.27 Composite femurs with a well-fixed cemented stock after removal of the old implant, a stemmed revision
TKA femoral component underwent nondestructive tests prosthesis can be used to address the loosening as well as
to determine construct stiffness in axial and torsional to fix the fracture.9 The stem should press-fit and be long
cyclic loading followed by quasi-static axial loading un- enough to bypass the fracture site by at least two femoral
til failure. They showed that the intramedullary fibular diameters.29 Current controversy exists when implant
strut allograft with polyaxial locking plate did not prove fixation is questionable, bone quality is poor, and patient
to be significantly better than the polyaxial locking plate demand is low. No consensus exists on the treatment of
only.27 This discrepancy might be due to the biomechanical unstable fractures with bone that will not reliably hold
advantage of polyaxial plates over the fixed-angle locking screws (AO/UCS V.3 B2, V.3 B3: Rorabeck type III).
2: Knee
system of the LISS plates, which could potentially obvi- The goal of fracture fixation is to reestablish preinjury
ate the need for additional strut graft. The devices have function and a pain-free knee joint, with fracture union
advanced over the past 10 years, and promising clinical within 6 months, and to achieve the following parameters:
results have been reported with polyaxial locking plates range of motion, 0° to 90°; a maximum shortening of
and intramedullary locking nails that allow the distal 2 cm; up to 5° of coronal varus/valgus malalignment, and
screws to be locked to the nail, creating a fixed-angle up to 10° of sagittal plane deviation. These goals do not
device.2,25,27,28 Further research and clinical follow-up is parallel those of primary or revision knee arthroplasty,
needed to ascertain if one type of fixation method is supe- and suggest that fractures may be better managed by
rior. The current preference is to use a modern retrograde other means. Treatment challenges arise from the typ-
nail with multiple distal locking screws when the femoral ical distal fracture location and poor bone quality, the
component is compatible with nailing and the fracture is technical challenges associated with the femoral implant
sufficiently proximal to allow insertion of at least two and varying designs, suboptimal bone biology, and the
locking screws to the distal segment. In cases not fulfilling elderly patient population in which these fractures typi-
these criteria but still suitable for fixation, the use of a cally occur. Revision TKA with a stemmed prosthesis or
polyaxial locking plate is preferred. The polyaxial design a distal femoral arthroplasty is possibly a better option
incorporates locking screws that have 15 degrees of free- for many reasons. Although no randomized trials have
dom in all directions.2 In addition to the biomechanical been reported, multiple case-control studies have shown
advantage of nonparallel screws, this enables the surgeon acceptable early results of distal femoral replacement in
to accommodate a maximum number of screws to the elderly, low-demand patients with poor bone quality,
distal segment. regardless of the femoral component fixation30-32 (Fig-
When the femoral component is loose or malaligned, ure 2). When dealing with poor distal fragment bone
it should be revised. In the presence of adequate bone stock in a relatively young patient, a composite distal
Section 2: Knee
Figure 3 A, AP radiograph obtained from a young patient demonstrates a severely comminuted fracture of the distal femur
and loose components. AP (B) and lateral (C) radiographs were obtained following revision with a prosthesis-
allograft composite.
2: Knee
Figure 4 Algorithm for the management of distal femoral periprosthetic fracture.
Figure 5 AP (A) and lateral (B) radiographs demonstrate type 1B proximal tibial periprosthetic fracture. C, Lateral
radiograph obtained following revision arthroplasty with a trabecular metal cone performed to address poor bone
stock.
femoral allograft-prosthesis can be considered as an op- reports presenting new data on treatment methods and
tion32 (Figure 3). An algorithm for treating distal femoral outcomes are limited. Tibial fracture is the least common
periprosthetic fractures is shown in Figure 4. fracture around TKA, with a reported incidence of less
Knee periprosthetic fractures are associated with very than 1%.34 With the increasing number of TKA surgeries
high morbidity and mortality rates.6 Mortality rates can being done, tibial periprosthetic fractures are likely to be
be as high as 17% at 6 months and 30% at 1 year.15 These seen more frequently, and orthopaedic surgeons should be
2: Knee
fractures carry a much higher risk of mortality than do familiar with the principles of treatment. In contrast to
isolated distal femoral fractures or TKA, and are more supracondylar periprosthetic fractures, which frequently
aligned with the reported mortality rate of proximal fem- occur around a well-fixed component, tibial fractures are
oral fractures in the elderly. An epidemiologic study found more often associated with a loose implant.35 Other risk
that when compared with patients admitted for other factors include revision surgery and conditions compro-
arthroplasty-related diagnoses, individuals admitted with mising physical strength of the tibia, such as osteoporosis
periprosthetic fracture were more often admitted emer- and osteolysis. Malalignment of the tibial component is
gently/urgently, had longer hospital lengths of stay (only also correlated with fracture of the tibial plateau.34
second to those with periprosthetic joint infection [PJI]), Treatment of tibial periprosthetic fractures has been
had higher rates of discharge to locations other than most commonly reported based on the Felix classi-
home, and had the highest level of mortality.6 In addition, fication system, which correlates with the AO/UCS
reduced functional capability is a usual outcome.33 Post- V.4 A-D.12,13 The most common are V.4 B fractures,
operative mobility of patients with periprosthetic distal which involve the tibial plateau. For nondisplaced frac-
femoral fractures is reduced, with a large proportion tures with a stable implant, nonsurgical management with
of patients needing ambulatory aid assistance.33 Other cast immobilization is acceptable. Most are not traumatic
common complications include reduced range of motion, in origin, and many occur intraoperatively due to poor
extensor mechanism weakness, and infection and wound bone stock or osteolysis (V.4 B2-3 fractures). These are
complications. most common, and when associated with loosening, revi-
sion of the implant is required, which is often a complex
Tibial Fractures procedure that requires advanced revision TKA tech-
Relative to the femur, periprosthetic fractures of the tibia niques to deal with bone loss and instability (Figure 5).
and patella are relatively uncommon (Table 1), and current When the bone stock is solid and the implants remain
Section 2: Knee
Figure 6 Algorithm for the management of periprosthetic tibial fracture.
well fixed (V.4 B1fracture), the fracture mechanism is Most patellar fractures after TKA are asymptomatic.
usually traumatic and can be treated with internal plate In a systematic review of 752 patellar periprosthetic frac-
fixation.36 Figure 6 shows an algorithm of a simplified tures, one study reported that nearly 88% of cases were
2: Knee
approach to tibial fractures around TKA. identified during routine follow-up. Another study found
that significant trauma was not reported in more than
Patellar Fracture 60% of cases. The most common objective finding was
Patellar fracture is the second most common peripros- extensor lag of the knee. Treatment of patellar peripros-
thetic fracture around the knee, with reported incidence thetic fracture has been most commonly reported on the
rates of 0.12% to 3.90%. Resurfacing of the patella is con- basis of the Ortiguera and Berry classification system,
sidered a risk factor, and few AO/UCS V.34 F fractures which also correlates with the AO/ UCS.
of unresurfaced patellae have been reported. Another As reported in a systematic review, fractures with an
risk factor is lateral retinacular release, likely a result intact extensor mechanism and loosening of the patel-
of vascular compromise of the patella. One study found lar component (AO/UCS V.34 B2-3 fractures) are the
that a history of a lateral release was present in 51% of most common, and they comprise more than half of
all such cases. In addition, any condition that weakens all periprosthetic patellar fractures. The least common
the patella can be a risk factor, including osteoporosis, are those with disruption of the extensor mechanism,
rheumatoid arthritis, corticosteroid use, overresection with or without loosening of the implant (V.34 A or B
that leaves less than 10- to 15-mm patellar thickness, fractures).37
and use of implants with a large central peg. In addition, Treatment should have a functional rather than an
situations that increase patellar loads may increase the anatomic goal and should focus on restoration of the
risk of fracture, including younger age, male sex, patellar extensor mechanism to preserve knee function. Attempts
underresection resulting in anterior overstuffing of the at internal fixation of these fractures have been almost
knee, use of posterior-stabilized (PS) prostheses, patellar uniformly unsuccessful, with a reported nonunion rate
maltracking, active lifestyle (including repetitive loaded of 92% after tension-band or cerclage wiring. This is in
knee flexion), and high knee range of motion. contrast to the accepted strategy of treating the native
Figure 7 Algorithm for the management of periprosthetic patellar fracture (asterisk indicates patellar component is left
alone if stable and resected or replaced if loose).
patella, in which anatomic reconstruction of the bone is extensor mechanism can be performed using synthetic
usually possible. A general consensus exists for employing mesh.41 An algorithm for treating patellar fracture after
nonsurgical treatment of fractures with an intact exten- TKA is shown in Figure 7. Nonsurgical treatment should
2: Knee
sor mechanism and a stable implant. Treatment with a be considered for all painless cases with less than 10° of
cast or a brace until confirmed healing at the fracture extension lag at the time of initial examination, regardless
site usually results in excellent outcomes with minimal of the radiographic features.
residual extension lag.38,39
Surgical treatment is recommended for fractures with Interprosthetic Fracture
disruption of the extensor mechanism, with or without Femoral fractures in the presence of ipsilateral knee and
loosening of the implant (AO/UCS V.34 A or B frac- hip implants are rare, but they are on the rise, in tandem
tures), and those with an intact extensor mechanism and with the increasing population of multiarthroplasty pa-
loosening of the patellar component (AO/UCS V.34 B2- tients. These fractures are classified as AO/UCS V.3-D;
B3 fractures). However, surgical treatment has a modest the incidence has been reported to be from as low as 0.4%
outcome and high complication rate. Restoration of the for primary implants to up to 24% for revision prosthe-
extensor mechanism may be accomplished using a par- ses.42 The same risk factors for periprosthetic hip and knee
tial or total patellectomy to avoid the high failure rate of fractures also increase the risk of interprosthetic fracture.42
fixation techniques, with the surgeon understanding the Appropriate treatment primarily depends on the sta-
potential for a residual extension lag. Internal fixation bility of the components and the bone quality. Most frac-
may be performed in cases in which good bone stock tures located between stable hip and knee implants can
and a good patellar blood supply are evident.40 In most be fixed with a locking plate.42 Poor bone quality can be
cases in which patellar components are loose, reimplan- augmented with strut cortical allograft. Preferably, the
tation is not recommended. In the most extreme cases, plate should support the whole length of the femur, but a
in which extensor mechanism tissue is of poor quality minimum requirement is involvement of 10 cortices distal
and is not amenable to repair, an allograft of the knee to the fracture and bypassing the femoral stem by at least
extensor can be transplanted, or reconstruction of the twice the diameter of the femur.42,43 Using a cerclage wire
Section 2: Knee
Figure 8 Algorithm for the management of interprosthetic fracture.
at the upper end of the plate will decrease the load concen-
Periprosthetic Joint Infections
tration, leading to less risk of future fracture.44 Polyaxial
locking screws have outperformed monoaxial screws in Bryan D. Springer, MD; Viktor E. Krebs, MD
2: Knee
reported studies.42,45 The minimally invasive technique of PJIs and surgical site infections (SSIs) after knee arthro-
plate application is rewarded by higher union and lower plasties are exceedingly problematic and constitute cost-
complication rates.43 As a general rule, if the surgical site ly complications for patients, surgeons, and healthcare
is opened adequately, the addition of autologous bone systems. The orthopaedic community has put forth great
graft or bone morphogenetic protein materials may en- efforts to control SSIs, and the rate of PJIs has decreased
hance the biology and healing.45 over the past decade. The elective nature of the procedures
In the scenario of interprosthetic fracture, any loose makes them challenging at every level, from diagnosis
implants should be revised. On occasion, the fracture through (the usually prolonged) treatment. When surgical
can be stabilized by the stem of the revision compo- intervention is required for infection, it negatively affects
nents.45 Otherwise, a plate should be added to the con- a patient’s perception of the procedure and strains the
struct following the criteria just described. If one or both doctor-patient relationship. The recent implementation
of the old implants were revision implants, inadequate of bundled payments and accountable care models has
bone may remain for stabilization of the new implants in made the financial, physical, and emotional effects of this
the broken bone. Conventional or intramedullary total problem more deeply impactful on all involved. Despite
femoral replacements are an option in this case. An al- the monumental efforts that have been put forth in ortho-
gorithm for approaching interprosthetic fractures of the paedic surgery to eliminate infection, it is a complication
femur is shown in Figure 8. Acceptable results have been of joint arthroplasty surgery that can be reduced but can
reported for internal fixation of interprosthetic fractures, never be completely eliminated.
with a union rate of approximately 90%.45 However,
a decline in function and quality of life is a common PJI Incidence and Risk
outcome.46 With their detrimental repercussions, SSIs are estimated
to occur in nearly 1 million patients annually in the
Table 4 Table 5
Patient-Related Risk Factors for the Risk Factors for the Development of
Development of Periprosthetic Joint Infection Periprosthetic Joint Infection
Risk Factors Modifiable Surgical- and/or Procedure-Related Modifiable
Male sex No (Extrinsic) Factors
Obesity (body mass index greater Yes Prolonged surgical time greater than Yes
than 35 kg/m2) 2 hours
Inflammatory arthritis No Antibiotics prophylaxis greater than Yes
24 hours
Diabetes/preoperative hyperglycemia Yes/No
(HbA1c is a poor predictor) Use of antibiotic bone cement Yes
American Society of Anesthesiologists No Blood loss and transfusion Yes
score greater than 3 Excessive wound drainage Yes
Smoking/tobacco use Yes Wound healing problems Yes
Pulmonary disease No Constrained and hinged prostheses Yes/No
Chronic steroid medication use No Previous revision for infection No
Osteonecrosis No
Staphylococcus aureus/methicillin- Yes/No
resistant S aureus colonization have been associated with an increase in PJI. The in-
creased demand for TKA and the accompanying predicted
Posttraumatic arthritis No
future financial burden of PJI points to a need for better
Anemia/transfusion Yes/No preoperative medical optimization and a possible shift in
Bacteremic events No the indications for PJI in this high-risk population.50 The
Prior joint infection No cumulative yearly expenditure from infection after total
Retained hardware Yes/No joint arthroplasty is expected to exceed $1.62 billion by
Malnutrition Yes
2020, with an estimated cost related to a single PJI being
as high as $130,000.51,52
Modifiable intrinsic patient risk factors must be iden-
United States, and approximately 355,500 occur after tified and addressed in a manner that is best for the in-
2: Knee
orthopaedic procedures according to the National Nos- dividual. Nonmodifiable intrinsic risk factors should be
ocomial Infections Surveillance System. The current SSI managed or used to guide patients to appropriate nonsur-
rate after primary TKA is reported at 1.0% to 2.3%. PJI, gical management (Table 4). A study of 300 hip and knee
a deep SSI as defined by the Centers for Disease Control arthroplasty cases revealed that only 20% of all cases
and Prevention, is reported to occur in 0.5% to 1.8% of and 7% of revision cases for infection had no modifiable
primary TKAs. PJI is most common the first 2 years after risk factors. The most common risk factors were obesity
the index procedure, and the incidence between 2 and (46%), anemia (29%), malnutrition (26%), and diabetes
10 years is 0.46% in the Medicare population.47 The (20%). The high prevalence of several modifiable risk
incidence after revision knee arthroplasty is considerably factors demonstrates that opportunities for perioperative
higher and has been reported as high as 46%. One study optimization are many.53 Despite abundant reports in the
recently reported much lower rates for 1,802 index knee literature, consensus has not been reached with regard to
revisions performed for aseptic reasons in 1,615 patients; the efficacy of many preventive methods. In knee arthro-
the cumulative risk of infection at 1, 5, 10, and 20 years plasty, use of a prehospital admission skin preparation
after index revision was 1.0%, 2.4%, 3.3%, and 5.6%, protocol using 2% chlorhexidine gluconate (CHG) cloth
respectively.48 PJI itself is the most common reason for was been shown to reduce PJI in a large single-institution
knee arthroplasty revision, reported in up to 25% of cohort of 3,717 patients having primary or revision pro-
cases.49 PJI after primary and revision knee arthroplasty cedures. This retrospective study demonstrated a 0.3%
is also associated with tremendous morbidity, and its incidence of PJI in the CHG cloth group versus a 1.9%
presence doubles the mortality risk. rate in the control group at 1 year.54 Another large ret-
Risk factors for infection-related complications after rospective study that included 2,055 TKA patients who
knee arthroplasty have been the focus of numerous recent used the CHG wipes an hour before the procedure did
studies. Alone or in combination, many of these factors not show a statistically significant benefit, with PJI rates
Section 2: Knee
Table 6 deep SSI for each 15-minute increase in procedure length

(95% confidence interval [CI]: 4%-13%).57 Also, surgical
Musculoskeletal Infection Society
times longer than 210 minutes showed an increased risk of
Definition of PJI According to the infection in the Medicare population when compared to
International Consensus Group those less than 120 minutes.47 Wound healing problems
PJI is present when 1 major criterion exists or 3 of 5 should be addressed expediently and aggressively to pre-
minor criteria exist vent deep progression and implant involvement. The use
of antibiotic bone cement to decrease the occurrence of
PJI has been controversial. A 43,149 patient study from
Major criteria the Finnish Arthroplasty Register in 2009 showed fewer
Two positive periprosthetic cultures with infections when antibiotics were administered, both in-
phenotypically identical organisms travenously and in the cement, for primary and revision
Sinus tract communicating with the joint/implant knee arthroplasty. Another study of 1,625 patients in
which antibiotic cement was used in half of the implants
Minor criteria
did not find a reduction in the prevalence of deep infec-
Elevated serum C-reactive protein level and tion following TKA. Recently, a study reported on an
erythrocyte sedimentation rate
analysis of 56,216 knees in which use of antibiotic-laden
Elevated synovial fluid white blood cell count or ++ cement was associated with a paradoxical increase in the
change on leukocyte esterase test strip
risk of infection; the effect was theorized to be a result of
Elevated synovial fluid polymorphonuclear surgeon selection of high-risk patients. It was reported
neutrophil percentage
that the addition of antibiotics to the irrigation solution
Positive histologic analysis of periprosthetic tissue was protective against deep SSI, although the dosage,
Single positive culture from periprosthetic tissue or antibiotics, and technique were not specified.57
fluid
PJI = periprosthetic joint infection. Adapted from Whitehouse MR, PJI Definition
Mehendale S: Periprosthetic fractures around the knee: Current
concepts and advances in management. Curr Rev Musculoskelet Med The definition of PJI was established by the Musculoskel-
2014;7(2):136-144. etal Infection Society (MSIS) and was modified by the
International Consensus group to standardize the criteria
for the diagnosis of PJI15,58 (Table 6). The American Acad-
of 0.8% in those using wipes and 1.2% in those who did emy of Orthopaedic Surgeons (AAOS) clinical practice
2: Knee
not.55 Unfortunately, attempts by health care institutions guideline on the diagnosis of periprosthetic joint infec-
to improve a patient’s overall health and decrease the risks tion also provides a standardized approach.59 Adoption
of complications such as PJI are often disregarded. A is already apparent in the literature; both have improved
recent study showed that 78% of patients (3,716/ 4,751), research consistency and have contributed to updated
regardless of age or sex, were noncompliant with simple evidence that has guided clinicians who evaluate and
preoperative disinfection protocols.56 Risk factor optimi- treat painful knee replacements. Recent updates further
zation requires patient participation and accountability, define the thresholds for the MSIS minor criteria58 (Ta-
and the focus should be on improving patient education ble 7). The definition and guidelines are as dynamic as
and comprehension at all levels to effectively reduce com- the PJI complication, and as evidence mounts, they will
plications such as SSI and PJI. be further refined to incorporate new techniques and
Extrinsic risk factors are attributable to the surgeon tests as they become available, validated, and shown to
and hospital facility and must be always factored into the be cost effective.
primary and revision knee arthroplasty procedure risk
profile (Table 5). Most procedure-related risk factors can PJI Diagnosis
be managed with preoperative planning and the use of When evaluating a painful knee arthroplasty, it is imper-
standardized procedural/clinical pathways. Preoperative ative that the diagnosis of infection be highly suspected,
blood management programs for anemia, intraoperative ruled out, or definitively established before proceeding
use of tranexamic acid, and techniques to minimize bleed- with other treatment options. The diagnosis of PJI can be
ing have been shown to decrease allogeneic blood trans- challenging, as most tests do not evaluate specifically for
fusion and subsequent infection risk. Prolonged surgical the presence of PJI, but rather are indirect measures. The
time, as a proxy for the complexity of the surgical proce- history, physical examination, and clinician’s astuteness
dure, has been associated with a 9% increase in the risk of remain the foundation for inquiry and the basis for more
Table 7
Threshold for the Musculoskeletal Infection Society Minor Diagnostic Criteria
Criterion Acute PJI (Before 90 Days) Chronic PJI (After 90 Days)
Erythrocyte sedimentation rate (mm/h) Not helpful; no threshold 30
determined
C-reactive protein level (mg/L) 100 10
Synovial white blood cell count (cells/μL) 10,000 3,000
Synovial polymorphonuclear neutrophils (%) 90 80
Leukocyte esterase test strip + or ++ + or ++
Histologic analysis of tissue >5 Neutrophils per high-power Same as for acute PJI
field in 5 fields (×400)
PJI = periprosthetic joint infection.
advanced screening. Blood tests should be performed in serologic parameters, and an initial negative aspiration
patients with risk factors for PJI as well as for all patients based on cell counts, differential counts, and cultures. The
undergoing revision. C-reactive protein (CRP) level and International Consensus on PJI recognizes this popula-
erythrocyte sedimentation rate (ESR) have been shown tion of patients and has declared that PJI may be present
to have a high sensitivity and a good negative predic- without meeting the criteria, specifically in the case of
tive value, and they are cost effective. Joint aspiration is less-virulent organisms.58 If suspicion is high or prior cul-
based on elevation of both CRP level (>N10 mg/L) or ESR tures have been negative, the addition of acid-fast bacilli
(>N30 mm/h) or a high index of clinical suspicion.60 All and fungal cultures should be considered during the initial
synovial fluid aspirates should be evaluated for total white or repeat aspiration. Additionally, incubating cultures
blood cell count, with particular attention paid to the for a longer duration (21 days) may assist in identifying
differential count (% polymorphonuclear neutrophils). In fastidious organisms, such as Propionibacterium acnes,
addition, the fluid should be sent for aerobic and anaero- or strains of coagulase-negative staphylococci. Despite
bic cultures. The thresholds for the MSIS minor criteria attempts to identify the infecting organism, cultures may
2: Knee
should be followed to establish the diagnosis of chronic remain negative in as many as 20% of cases in which there
periprosthetic infection58 (Table 6). is true infection. The use of synovial fluid biomarkers has
Aerobic and anaerobic cultures remain the most effec- expanded in situations in which the diagnosis is ambig-
tive method for diagnosis and organism identification. uous. Alpha-defensin, a human antimicrobial peptide
Office specimens should be optimized by being placed in produced by neutrophils in response to infection, can
blood culture vials, and swabs should be avoided.61 Mul- be measured in synovial fluid aspirates. Using immuno-
tiple publications report that Gram stains lack sensitivity assay, its presence has shown very high sensitivity (96%
and specificity, and they are no longer recommended at to 100%) and specificity (95% to 99%) for the diagnosis
any point in the diagnosis of PJI. Synovial fluid cultures of PJI.64-66
have high specificity but poor sensitivity; a negative cul- The utility of radiology in the diagnosis of PJI is
ture does not rule out PJI. A recent international mul- limited, and the AAOS clinical practice guideline does
ticenter study reported that preoperative synovial fluid not recommend the routine use of plain radiographs,
aspirations yielded organisms in only 45.2% of cases CT scans, or MRI for the diagnosis of PJI.59 Enhanced
with confirmed knee PJI, with false-negative rates relative imaging techniques, such as single-photon emission
to intraoperative cultures of 46.0%, and a discordance CT/positron emission tomography (SPECT/PET) scans,
rate of 21.4%.62 The addition of rapid “point-of-service” may improve future diagnostic capabilities, as nuclear
leukocyte esterase testing has been shown to be highly imaging is not obstructed by the implants.67
sensitive and specific for the presence of PJI and is part
of the MSIS minor criteria, but the test requires clear PJI Treatment Results
synovial fluid for accuracy.63 The treatment of PJI remains a formidable challenge. A
Difficulty arises when assessing persistently painful significant amount of variability exists with regard to the
knee joints that are not obviously infected, have normal best treatment options, timing, outcomes, and definition
Section 2: Knee
Table 8 anticipate. A 2002 meta-analysis evaluated 530 patients

treated with open irrigation and débridement for acute PJI
Risk Factors for Irrigation/Débridement and showed an overall success rate of 33.6%. This study
and Polyethylene Exchange included acute postoperative infections and late acute
Increasing age hematogenous infections. The wide range of success and
failure suggests that numerous variables affect outcomes,
Duration of symptoms (> 2 weeks)
including the timing of surgery, patient risk factors, sur-
Presence of prolonged wound drainage gical technique, and the infecting organism. Of these
Staphylococcus aureus infection variables, timing of surgery has been thought to be the
Resistant organisms most controversial factor in the success of irrigation and
Immunocompromised host débridement with polyethylene exchange. Several studies
have reported that the time from onset of symptoms (less
Rheumatoid arthritis
than 4 weeks) to surgical irrigation and débridement was
Diabetes mellitus
not a factor in the outcome; however, most studies have
Malnourishment shown improved success when treatment is initiated after
Presence of sinus tract a shorter duration of symptoms (less than 2 weeks).
Radiographic evidence of osteitis Primary exchange arthroplasty involves the removal of
Radiographic evidence of component loosening all components and the reinsertion of another prosthesis
in a single operation. Although an attractive option, data
in the literature are limited, based on only small numbers
of patients. The two largest historical published series in-
of success. The optimal treatment of each scenario has yet volve only 22 and 18 patients.69,70 Although a success rate
to be elucidated, and failure rates remain high. A recent ranging from 89% to 91% was reported, it is important
evaluation of nearly 1.5 million patients in the Medicare to keep in mind that strict inclusion and exclusion criteria
database, treated by various techniques for PJI, showed exist to increase success of this procedure. Factors that
a 26% overall recurrence rate of infection.68 influence a successful single-stage exchange include a host
Antibiotic suppression alone as a treatment of PJI is who was not immunocompromised, a known organism
recommended only in a patient who is medically debil- with absence of antibiotic resistance, meticulous surgical
itated and unable to undergo surgery. The infectious technique, adequate bone stock for reconstruction, and
agent should be a low-virulence organism, and the pa- a targeted antibiotic approach. Using these criteria, a
2: Knee
tient should be in stable condition, have well-fixed com- study reported an infection-free survivorship of 100%
ponents, and be able to be treated with a suitable oral in 28 patients undergoing single-stage revision TKA at a
antibiotic agent. The literature suggests that the success minimum 3-year follow-up.70 These results merit contin-
rate of antibiotic suppression is extremely variable and ued evaluation of the technique, as it has potential benefit
should be used only when the preceding criteria are met; to the patient and to healthcare system economics.
success ranges from approximately 20% to 80%. Irriga- Two-stage exchange arthroplasty is considered the
tion and débridement with polyethylene exchange is an gold standard for the treatment of a chronic periprosthet-
attractive, low-morbidity option for both the surgeon ic infection. The procedure involves the removal of the
and patient (Table 8). It is generally performed in one infected prosthesis and thorough débridement to remove
operation and creates minimal functional disruption. any necrotic and foreign material, including all cement. A
The results in the literature have been inconsistent, how- high-dose antibiotic cement spacer is placed at the time of
ever, and many treatment variables exist. Historically, it the initial surgery, and the patient is treated with a course
is generally agreed that open irrigation and débridement of intravenous antibiotics tailored to treat the infecting
for an infected TKA should be reserved for patients with organism. Treatment variables include the amount and
an acute onset of infection, as irrigation, débridement, type of antibiotics to be used in the spacer, the type of
and component retention for treatment of a chronic spacer (mobile versus articulating), the length of intrave-
infection (signs and symptoms for more than 4 weeks) nous antibiotic therapy, and the interval between resection
have been associated with high failure rates and poor and reimplantation.
outcomes, and therefore should not be considered. Re- Two general categories of antibiotic spacer are de-
sults of treatment with open irrigation and débridement scribed in the literature: static and articulating. Static
have been quite variable and, when viewed as a whole, spacers preserve the joint space and minimize the gener-
probably much more sobering that most surgeons would ation of cement debris, but do not allow motion during
the interval period. Static preformed blocks have been this situation has been successfully performed using mul-
associated with increased bone loss, migration, and tiple techniques, including intramedullary nails, locked
extensor mechanism necrosis, and generally should be compression nails, modular fusion implants, plating, and
avoided. A molded static spacer, in which the cement is external fixation. In a recent systematic literature review,
placed in a doughy state to allow it to mold to the bony a decision analysis was performed to determine the treat-
surfaces, can prevent many of the problems associated ment method most likely to yield the highest quality of
with a preformed block spacer. The published results life for patients whose two-stage TKA reimplantation
suggest equal rates of infection eradication with both was unsuccessful. Given the best available evidence, knee
spacer types but a marginal functional advantage with an arthrodesis should be strongly considered as the treatment
articulating spacer.71 Several prior studies in the literature of choice for patients with a persistently infected TKA.77 A
have shown clinical success in eradication of infection case series of 26 patients treated with intramedullary nail-
rate between 85% and 91%.72,73 However, recent reports ing following septic failure of revision TKA reported that
suggest more sobering outcomes, with high failure rates one-half had a persistent infection requiring additional
attributed to numerous risk factors.74 A review of the surgery, 73% had persistent pain, and all outcome scores
outcomes of patients undergoing two-stage exchange in showed marked quality-of-life impairment.78
infection following TKA reported on 504 patients who A national database was used to compare 2,634 ar-
underwent resection arthroplasty and placement of an throdeses and 5,001 transfemoral amputations in the
antibiotic spacer. The mean follow-up after initial spacer treatment of failed septic TKAs from 2005 to 2012. Pa-
implantation was 56.2 months; 81.4% had successful tients who underwent transfemoral amputation tended to
reimplantation. Of 87 patients who did not undergo re- be older and have more medical comorbidities. Arthrode-
implantation, 6 (6.9%) required amputation, 5 (5.7%) sis patients had a significantly higher rate of postoperative
underwent a Girdlestone procedure, 4 (4.6%) underwent infection (14.5% versus 8.3%; P < 0.0001) and transfusion
arthrodesis, and 72 (82.8%) underwent spacer retention; (55.1% versus 46.8%; P < 0.0001), whereas patients who
36 patients died during the interstage period.75 underwent transfemoral amputation had a higher rate of
Because of the poor reported outcomes in the man- systemic complications (31.5% versus 25.9%; P < 0.0001)
agement of PJI across all treatment spectrums, the role of and in-hospital mortality (3.7% versus 2.1%; P < 0.0001).
prolonged antibiotic therapy following treatment is being The transfemoral amputation cohort had lower hospi-
evaluated more closely. A retrospective review reported tal charges ($79,686 versus $84,747; P < 0.004), longer
on a cohort of patients who received 6 months of oral an- length of stay (11 versus 7 days; P < 0.0001), and a higher
tibiotics following treatment of PJI (either irrigation and 90-day readmission rate (19.4% versus 16.9%). The data
2: Knee
débridement or two-stage exchange). The patients were suggested an increasing trend toward transfemoral am-
matched to a similar cohort of patients who did not re- putation compared with arthrodesis for the treatment of
ceive oral antibiotics. The 5-year infection-free prosthetic a failed infected TKA.79
survival was higher for the irrigation and débridement
group as well as the two-stage group receiving a course
Polyethylene Wear and Associated Complications
of oral antibiotics.76
Knee fusion and transfemoral amputation are the sal- Slif D. Ulrich, MD; Christopher Samujh, MD;
vage options when all attempts to treat and recover a Viktor E. Krebs, MD; Arthur L. Malkani, MD
functional knee arthroplasty have been exhausted. When The number of TKAs performed continues to increase,
multiple treatments fail to eradicate knee PJI, or the re- and improvements in secure long-term survivorship are
petitive procedures have resulted in the loss of supportive necessary to decrease costs and revision rates.80 The com-
bone and/or functional musculotendinous attachments, mon causes for failure and revision surgery are varied,
revision reimplantation of a functioning durable knee with infection and instability accounting for most. Poly-
prosthesis may not be possible. In these situations, sur- ethylene wear and subsequent particle-induced osteolysis
geons must decide on more drastic measures to either sal- still remains an important cause of midfailure to late
vage the extremity, save the patient from systemic sepsis, failure. Recent studies show a decline in wear-related revi-
or avoid recurrent unsuccessful surgery. These end-stage sions.81-84 One study reported that the number of late revi-
salvage options are fortunately necessary in only a small sions for polyethylene wear has decreased from more than
percentage of patients, but when performed, they result 40% in 2002 to 4.3% in 2012.82 A recent study showed
in disability and decreased patient mobility. a change in failure distribution of polyethylene wear; the
Limb salvage obviously appeals to patients and sur- overall occurrence of failure because of polyethylene wear
geons after failed infection treatment. Knee fusion in was 7% compared with a polyethylene wear failure rate
Section 2: Knee
of 10% to 25% in earlier studies.81 Polyethylene wear, undertaken at a higher temperature to convert the crys-
however, was responsible for 18.5% of late TKA failures. talline structure of polyethylene back to an amorphous
The causes of premature polyethylene wear are related to state that releases free radicals. Free-radical elimination
methods of polyethylene manufacturing, implant design, by this method is nearly complete, but it reduces the
patient factors (eg, body mass index [BMI]), surgical tech- crystallinity of the polyethylene and makes the material
nique, and component alignment. As the need for knee potentially more brittle and less resistant to fatigue-crack
arthroplasty continues to increase, surgeons and the in- propagation. Despite promising results of sequentially
dustry will continue to work to reduce polyethylene wear irradiated and annealed second-generation HXLPE in the
and osteolysis by advancing the science of polyethylene literature on THA, there are concerns about its benefits
manufacturing, implant design, component positioning/ in TKA. The knee bearing surface has a wear mechanism
alignment, and patient-related factors to further improve different from that of the hip, in which wear is abrasive
implant survival and durability. and adhesive; in TKA, pitting and delamination are seen.
One study proposes that the reduction of mechanical
Evolution of Polyethylene properties by newer generations of polyethylene and re-
The science and manufacturing of polyethylene have sistance to fatigue and crack propagation may lead to
undergone considerable advancement in the past 10 to breakage and failure of the insert over time.85 Recent
15 years, and improvements may be one factor contrib- studies, however, have demonstrated the safety of first-
uting to decreased TKA failure rates related to wear and second-generation HXLPE in the setting of TKA. A
and osteolysis.81-84 Issues with polyethylene were initial- multicenter minimum 5-year follow-up study of second-
ly much larger in total hip arthroplasty (THA) failure generation HXLPE versus conventional polyethylene did
and stimulated the overall improvements that have been not demonstrate any osteolysis or insert failure in either
continued with TKA, which some authors believe is pre- group.86 Another study compared two first-generation
mature because of the long-term success of conventional HXLPEs with conventional polyethylene and no revisions
polyethylene and 90% to 98% survivorship reported at were noted as a direct result of insert failure.87
15 to 20 years. The TKA bearing surface, with its sliding, Antioxidant vitamin–infusing polyethylene with vita-
rolling, and rotational behavior, is not as conforming as min E is another method developed recently to improve
in THA; therefore, contact stresses on the polyethylene on earlier-generation polyethylenes. Synthetically derived
are much higher in THA, and wear mechanisms differ. vitamin E is either added to the polyethylene powder be-
The shift away from polyethylene irradiation in air is fore cross-linking or diffused into irradiated polyethylene
considered by many to be the most important improve- to stabilize free radicals.88 Knee simulator studies have
2: Knee
ment in reducing free-radical formation that ultimately attempted to answer the question of whether VEPE is a vi-
results in osteolysis. Considerable research has focused on able alternative to conventional polyethylene. Convention-
sterilization, packaging, cross-linking, and manufactur- al polyethylene laced with vitamin E was compared with
ing techniques. The industry has come a long way with plain conventional polyethylene with both samples under-
contemporary polyethylene knee bearings being gamma going the same postprocessing sterilization.89 The VEPE
sterilized and packaged in inert environments or ethylene showed no signs of oxidation or reduction in mechanical
oxide–sterilized. Many proprietary manufacturing pro- properties, whereas the conventional polyethylene did.
cesses have also been developed, and each company has Concerns with VEPE lie mainly in the intra-articular and
published data defining advantages and improved wear systemic effects of vitamin E.85 The natural form of vita-
resistance that generally fall into one of two categories: min E, α-tocopherol, is nontoxic to humans; however, the
highly cross-linked polyethylene (HXLPE) or vitamin effects on the structure of vitamin E of steps in the VEPE
E-infused polyethylene (VEPE). The use of newer gen- manufacturing process, such irradiation, are unknown.88
erations of polyethylene in TKA is still controversial as
conventional polyethylene has good long-term clinical Etiology and Risk Factors
outcomes and is cheaper than HXLPE and VEPE. Addi- The true incidence of polyethylene wear and osteoly-
tional work is needed to determine if newer generations sis is difficult to quantify because the only information
of polyethylene are not only safe to use but also clearly published is related to failures and revisions. As an iso-
beneficial, to justify increased costs. lated cause of failure, rates of wear and osteolysis range
HXLPE is already in its second generation, with ther- from 4.3% to 7.0% in recent literature.82,83 The true
mal stabilization added to the manufacturing process by incidence is likely much higher, as wear and osteolysis
remelting or annealing the plastic to minimize oxida- always occur in conjunction with all other failure mech-
tion and maximize cross-linking. Remelting is a process anisms, and a patient can remain asymptomatic up to
the point of implant failure. Numerous studies suggest Table 9

that polyethylene wear–induced periprosthetic osteolysis
is a time-related progression that is closely associated Factors That Affect Polyethylene Wear and
with mechanical and biologic etiologic dynamics.90 The Osteolysis in Total Knee Arthroplasty
wear particle accumulation in TKA results from a com- Implant Design
bination of delamination, pitting, adhesion, abrasion,
Bearing conformity, congruity, and constraint
and burnishing backside wear.91 Decreasing wear and
bioactive particle generation has been the prime strategy Locking mechanisms
for elimination of osteolysis and aseptic loosening. Un- Fixed versus mobile bearing
fortunately, these causes of failure are multifactorial and Materials and finish
involve the inseparable aspects of TKA: biology, implant
Patient Factors
design, patient factors, and, most important, surgical
technique (Table 9). Body mass index/weight
Advances in the basic science of particle-induced os- Activity level
teolysis are becoming clinically relevant, as the under- Age
standing of the process is allowing the development of
Surgical Technique
interventions that may effectively retard or stop the pro-
gression. Polyethylene particles accumulating in the joint Alignment
space activate several cell lines of innate and adaptive im- Balance and stability
munity. The activation of macrophages into an M1 pheno- Kinematics
type is accountable for the triggering and maintenance of
chronic inflammation, which enables growth of the inter-
face membrane. In addition, polarized M2 macrophages may be more responsible for osteolysis due to the high-vol-
produce anti-inflammatory cytokines (such as CCL2, ume submicron particles that are generated. One study
CCL5, CXCL12, and CX3CL1) and homeostatic repair showed that wear rates were lower for rotating-platform
molecules.92,93 The predominant feature of periprosthetic inserts than for fixed-bearing inserts. In addition, the
osteolysis is an overactivation of the receptor activator nu- backside wear rate was lower for fixed-bearing inserts
clear factor kappa-B ligand (RANKL)–induced osteoclas- mated to polished cobalt-chromium trays than for in-
togenesis caused by an interaction of the RANKL/RANK/ serts from rough titanium trays.96 However, two groups
osteoprotegerin axis.94 Elevated RANKL expression leads of researchers showed that rotating-platform and fixed-
2: Knee
to osteolysis and, subsequently, to bone loss. However, bearing inserts had similar tibiofemoral damage.97 The
osteoprotegerin blocks the activation of osteoclasts and level of constraint also has an effect on wear patterns.
thereby decreases bone resorption. In the future, phar- One study compared 18 valgus-varus constrained (VVC)
macologic interventions may be able to target chronic liners to a matched group of posterior-stabilized liners in
inflammation and osteoclast maturation in a local or a retrieval analysis and showed statistically more damage
systemic application. Comparable studies are available for in the posts of the VVC group (13.0 ± 5.0, compared to
other osteolysis-targeted therapies including anticytokine 4.7 ±1.9 in the PS group; P < 0.001).98
(such as antitumor necrosis factor and anti-interleukin-1/ The polyethylene wear patterns are influenced by
interleukin-6), antienzyme (such as inhibition of matrix patient factors such as age, BMI, and activity level. As
metalloproteinase-9), hormonal (such as parathyroid indications have expanded, younger patients are under-
hormone and calcitonin), and pharmacologic (such as going arthroplasty with unrealistic expectations to re-
simvastatin and diphosphonate). turn to age-appropriate activity levels. In a recent study,
Knee prostheses begin to wear down the moment they the following definitions of high activity in arthroplas-
are implanted; polyethylene properties and design ele- ty patients were proposed: more than 3 million cycles/
ments of the metallic components have been shown to year; 1 hour/day in high-activity mode; 40% of cycles in
influence the durability timeline. Polyethylene quality, high-activity mode.99 The Finnish Arthroplasty Registry
sterilization, processing, and thickness have been shown revealed that patients younger than 55 years had worse
to have the greatest effect on debris generation and os- 5-year implant survival rates (92%) compared with those
teolysis. Polyethylene inserts at least 8 mm in thickness between ages 56 and 65 years (95%) and those older than
are recommended in mobile bearings and obese pa- 65 years (97%; P < 0.001). In a retrospective cohort study
tients.95 The introduction of tibial tray modularity is likely of 1,291 revisions for aseptic loosening, patients with
the next most important cause of wear debris, and these morbid obesity had an increased risk of repeat revision,
Section 2: Knee
reoperation, and infection. The implant survival rates follow-up radiographs or CT and MRI scans obtained
were significantly different for morbidly obese and non- for other reasons. Symptomatic osteolysis should be eval-
morbidly obese patients, 96% and 100% at 5 years, and uated like all painful knee arthroplasties, with infection
81% and 93% at 10 years, respectively.100 However, a ruled out first, as the radiographic findings can be similar.
literature search of 209 knee revisions identified no host The use of CT or MRI is highly effective for assessing
factors associated with aseptic loosening. They found that osteolysis and wear and has been shown to be superior
obesity (BMI of 30 kg/m2 or greater) was not associated to radiographs in sensitivity and accuracy.105 There is no
with aseptic loosening.101 currently accepted or validated classification system to
Surgical technique and factors are becoming the most evaluate patients or guide treatment of wear and oste-
important modifiable aspects of knee arthroplasty sur- olysis in TKA.
gery to decrease implant wear and failure. Deviations
from the optimal alignment of the mechanical axis can Treatment and Results
lead to a localized increase in surface contact pressures. Radiographic observation may be reasonable manage-
Alterations also lead to subtle instability, and a comment for focal asymptomatic and nonprogressive tibial
bination of the two can lead to increased polyethylene and femoral lesions. In the absence of clinical symptoms,
wear and mechanical overload of the underlying bone. stable osteolytic lesions less than 1 cm can be closely
Mechanical axis alignment of the tibial component in 3° monitored with serial radiographic follow-up and referral
of varus leads to almost double the polyethylene volumet- to a metabolic bone specialist versed in the use of osteol-
ric penetration rate.102 This malalignment and instability ysis-targeted therapies.106 There is no real consensus on
permutation results in wear debris, direct bone damage, a lesion size that warrants surgery. The decision tree is
synovial fluid access to the implant bone interface, and multifactorial and is based on the location of the lesion,
osteolysis.98,103 Increasing the level of constraint to balance the level of progression, the frailty of the patient, and the
a poorly aligned knee also affects joint wear. One study symptoms. Surgical indications are based on the risk of
showed significantly more damage in the posts of the VVC failure or periprosthetic fracture with continued obser-
inserts versus posterior-stabilized inserts (P < 0.001). In vation. Surgical treatment of a periosteolytic lesion in a
addition, within the VVC group, the total damage score well-fixed tibial and femoral component is guided by the
and cold flow damage were significantly higher with ex- size of the lesion, any progressive change in that size, and
cessive joint line changes (5 mm or greater; P = 0.01). the presence of any associated symptoms.
Damage scores were increased with femoral component Focal defects can be treated intralesionally with im-
malposition (P = 0.04), anterior tibial slope (P = 0.04), paction grafting and polyethylene exchange when the
2: Knee
and tibial component malposition (P = 0.04).98 existing implants are well fixed, appropriately aligned
One study assessed the effect of limb alignment, im- in all planes, and the joint is well balanced with intact
plant position, and joint line position on the pattern of ligaments.106 This treatment requires that the defects be
wear in a retrieval analysis of 83 posterior stabilized tibial peripherally accessible through a cortical window. One
inserts. The total damage score was significantly higher study of 10 knees with a mean follow-up of approximately
in knees with postoperative varus alignment greater than 5 years after window bone grafting and polyethylene
3° (P = 0.03). In addition, the total damage score to the exchange showed total incorporation of the graft mate-
post was significantly more in knees with joint line el- rial into previously lytic regions on radiographs at final
evation greater than 9.7 mm ± 3.9 mm, compared to follow-up; no revisions were required. The indications
6.5 mm ± 3.7 mm in knees with less joint line elevation included lytic lesions that could potentially compromise
(P = 0.05).104 In another retrieval study of 17 inserts that mechanical stability and smaller lesions that showed ex-
were implanted with a tibial varus angle of greater than 3°, pansion on serial radiographs. The lesion size in this study
twice the medial compartment wear was observed.102 In ranged from 2 to 6 cm on standard radiographs.107
contrast, previous studies have reported that mechanical Revision options are limited and are more challeng-
alignment outliers with a radiographic axis of 0° ± 3° had ing in larger, symptomatic, or progressive lesions that
a lower revision rate than those that were mechanically are at risk for fracture or catastrophic loosening. These
aligned within ±3° of anatomic alignment resulting from defects require more complex reconstruction techniques.
aseptic loosening, mechanical failure, or wear. Metaphyseal bone defects that preserve the peripheral
cortical rim with a thin shell and larger contained de-
Diagnosis fects require distal stem fixation, structural allograft, or
Wear-induced osteolysis is often asymptomatic, and the newer-generation porous metal sleeves or cones (Figures
lesions are frequently identified incidentally on routine 9 and 10). The use of a structural allograft has decreased
2: Knee
Figure 9 AP (A) and lateral (B) radiographs of a failed right total knee arthroplasty (TKA), osteolysis, and bone loss
along the medial tibial metaphysis in a 71-year-old patient. Intraoperative photographs demonstrate significant
osteolytic segmental (C) and cavitary (D) defects along the medial tibial metaphysis. E, Intraoperative
photograph obtained following revision TKA and augmentation of tibial defect using a femoral head allograft.
F, Postoperative lateral radiograph demonstrates revision TKA and treatment of osteolytic defect using a femoral
head allograft.
in recent years due to high failure rates with long-term constrained or hinged prostheses is suggested to maintain
follow-up as well as with the advent of highly porous met- coronal stability and to prevent failure.
al augments, cones, and sleeves that accentuate biologic
metaphyseal fixation.108 Several midterm clinical studies
Summary
(range, 1.0 to 8.8 years) with porous tantalum cones for
bone loss in the revision setting have shown promising The demographics of the population with indications for
results, with a cumulative mean revision rate for aseptic TKA is not only growing, it is changing to include young-
cone loosening of 1.1%.109,110 In addition, the clinical outer, actively working patients with ligament damage and
comes of titanium sleeves at short-term follow-up (range, posttraumatic arthritis in addition to older patients with
2.0 to 5.3 years) have been excellent, with a 2.6% revision multiple comorbidities and poor bone stock. Surgeons
rate for aseptic loosening.111-113 Surgical goals include suit- performing knee arthroplasty must scrupulously select
able management of bone loss and a strategy to restore and prepare patients (and themselves) to avoid complica-
or maintain implant stability and limb alignment. In ad- tions and achieve lasting results. It is important to educate
dition, it is crucial to assess the status of the epicondyles patients on the risks and explain that they cannot be
to best determine the patency of the collateral ligaments. completely eliminated; only modified. Industry partners
In the absence of functional collateral ligaments, a more have helped develop, study, and refine knee implants to a
Section 2: Knee
Figure 10 AP (A) and lateral (B) radiographs of failed left total knee arthroplasty (TKA) in a 65-year-old woman with
tibial baseplate subsidence and a large osteolytic lesion along the anterior tibial metaphysis. C, Intraoperative
photograph of the explanted polyethylene liner shows delamination and pitting. AP (D) and lateral (E)
radiographs obtained following revision TKA with a press-fit tibial cone for reconstruction of the metaphyseal
defect.
point at which durability is no longer a common reason

Key Study Points
for failure. Periprosthetic fracture, infection, and wear
are all aspects of knee arthroplasty that surgeons can • Major risk factors for periprosthetic fracture, PJI,
directly address and manage before, during, and after and accelerated wear complications after knee ar-
performing the surgery. Patient selection and optimiza- throplasty should be identified.
tion have been shown to improve outcomes and decrease • The AO Foundation UCS should be applied to peri-
these complications. Early to midterm complications are prosthetic knee fractures for a rational approach
a function of how well the surgery is performed and how to treatment.
accurately the implants are fixed and aligned; when done • The MSIS definition of PJI and criteria for diag-
well, data confirms a decreased risk for instability, wear, nosis, and the AAOS clinical practice guidelines
and periprosthetic fracture. A painful knee arthroplasty on the diagnosis of periprosthetic joint infection
that does not function for the patient is a complication, should be applied for standardized approaches to
2: Knee
and the surgeon’s evaluation and management remains diagnosis and treatment.
a critical responsibility. A systematic, cost-effective ap- • The different evidence-based treatment options
proach to the evaluation and workup of a painful knee for periprosthetic fracture, PJI/infection, and poly-
arthroplasty should be undertaken to rule out infection ethylene wear complications after knee a rthroplasty
and avoid perpetuation or escalation of any potential should be adhered to so that new techniques are
problem. Consensus on PJI evaluation and treatment has incorporated as available.
become more organized and evidence-based, but many
controversies still exist regarding optimal strategies be-
cause of the extreme variability that exists in patients,
organisms, and treatment. It is important to be aware of
the current information on important knee arthroplasty 1. Tosounidis TH, Giannoudis PV: What is new in dis-
complications; emphasis should be placed on the need tal femur periprosthetic fracture fixation? Injury
to support the mandatory implementation of a global 2015;46(12):2293-2296. Medline DOI
implant registry, standardize clinical data collection, and The number of periprosthetic fractures related to TKA is
establish large-scale prospective clinical trials to evaluate increasing. Most are treated surgically, with nonsurgical
the multitude of factors that influence knee arthroplasty management reserved for medically unfit patients who
cannot tolerate anesthesia and those who were nonam-
complications, function, and longevity. bulatory before the injury.
2. Hanschen M, Aschenbrenner IM, Fehske K, et al: Mono-

versus polyaxial locking plates in distal femur fractures:
A prospective randomized multicentre clinical trial. Int
Orthop 2014;38(4):857-863. Medline DOI
In this study, 27 patients with a distal femoral fracture TKA. Clin Orthop Relat Res 2015;473(6):2131-2138.
(native knee and periprosthetic) were randomized for treat- Medline DOI
ment with either a monoaxial LISS or a polyaxial locking
plate. Polyaxial osteosynthesis tended to result in better The authors of this study investigated 235,857 revision
functional knee scores and a higher range of motion and THAs and 301,718 revision TKAs. Mean (±SD) hospi-
to lead to more rapid fracture healing. Level of evidence: I. talization costs were slightly higher for revision THA
($24,697 ± $40,489) than revision TKA ($23,130 ±
$36,643). PJI and periprosthetic fracture were associated
3. Meek RM, Norwood T, Smith R, Brenkel IJ, Howie CR: with the greatest length of stay and highest cost for revi-
The risk of peri-prosthetic fracture after primary and re- sion THAs and TKAs. Level of evidence: III.
vision total hip and knee replacement. J Bone Joint Surg
Br 2011;93(1):96-101. Medline DOI
9. Johnston AT, Tsiridis E, Eyres KS, Toms AD: Peripros-
The authors of this study retrospectively evaluated a large thetic fractures in the distal femur following total knee
series of THAs and TKAs (including 44,511 primary and replacement: A review and guide to management. Knee
3,222 revision TKAs). At 5 years postoperatively, the rate 2012;19(3):156-162. Medline DOI
of fracture was 0.6% after primary TKA and 1.7% after
revision TKA. Comparison of survival analyses showed This article describes the risk factors for development of
periprosthetic fractures to be more likely in females, pa- distal periprosthetic fractures and the options available
tients older than 70 years, and after revision arthroplasty. for management, which requires equipment, perioperative
Level of evidence: III. support, and surgical skills of both trauma and revision
arthroplasty services.
4. Schütz M, Perka C: Periprosthetic Fracture Management.
New York, NY, Thieme, 2013, pp 782-795. 10. Märdian S, Wichlas F, Schaser KD, et al: Periprosthetic
fractures around the knee: Update on therapeutic algo-
rithms for internal fixation and revision arthroplasty.
5. Drew JM, Griffin WL, Odum SM, Van Doren B, Weston Acta Chir Orthop Traumatol Cech 2012;79(4):297-306.
BT, Stryker LS: Survivorship after periprosthetic femur Medline
fracture: Factors affecting outcome. J Arthroplasty
2016;31(6):1283-1288. Medline DOI This article presents an algorithm for the epidemiology
of periprosthetic fractures related to TKA. Progressive
In this retrospective review of 291 patients treated sur- development of new implant methods and refinement of
gically for periprosthetic fracture, patients had a 24% soft-tissue preserving surgical techniques are key to re-
risk of either death or revision surgery at 1 year. Factors gaining prefracture levels of function.
contributing to increased mortality were nonmodifiable.
Risk of reoperation was minimized with greater span of
fixation and performance of revision arthroplasty. Level 11. Hoffmann MF, Jones CB, Sietsema DL, Koenig SJ, Tor-
of evidence: III. netta P III: Outcome of periprosthetic distal femoral
fractures following knee arthroplasty. Injury 2012;43(7):
6. Toogood PA, Vail TP: Periprosthetic fractures: A common
2: Knee
problem with a disproportionately high impact on health- In a retrospective study of 55 consecutive distal femoral
care resources. J Arthroplasty 2015;30(10):1688-1691. periprosthetic fractures treated with locked-plate fixation,
Medline DOI 25 fractures (69.4%) healed after the index procedure,
nonunion developed in 8 fractures (22.2%), and 9 patients
In a review of 30,624 patients with primary or revision (25%) had radiographic diagnoses of anterior femoral
THA or TKA, the proportion of admissions for peri- cortex notching. The distance from the anterior flange
prosthetic fracture ranged from 4.2% to 7.4% annually. of the femoral component to the fracture was shorter in
Compared with patients admitted for other diagnoses, patients with anterior notching. Level of evidence: III.
individuals admitted with periprosthetic fracture were
older, more often female, and more often admitted emer-
gently/urgently; they also had longer lengths of hospital 12. Duncan CP, Haddad FS: The Unified Classification Sys-
stay, higher rates of discharge to places other than home, tem (UCS): Improving our understanding of peripros-
and elevated mortality. Level of evidence: III. thetic fractures. Bone Joint J 2014;96-B(6):713-716.
Medline DOI
7. Phillips JR, Boulton C, Morac CG, Manktelov AR: What The principles that underpin evaluation and treatment of
is the financial cost of treating periprosthetic hip fractures? periprosthetic fractures are common across the musculo-
Injury 2011;42(2):146-149. Medline DOI skeletal system. The UCS presents a rational approach to
treatment, irrespective of the bone that is broken or the
In 146 patients treated for periprosthetic femoral fracture joint involved.
after THA, fixation of the fracture was performed in
61 cases, revision arthroplasty in 62 cases, and nonsurgical
treatment in 23. Mean cost of treatment was £23,469 per 13. Van der Merwe JM, Haddad FS, Duncan CP: Field testing
patient. Level of evidence: III. the Unified Classification System for periprosthetic frac-
tures of the femur, tibia and patella in association with
knee replacement: An international collaboration. Bone
8. Bozic KJ, Kamath AF, Ong K, et al: Comparative ep- Joint J 2014;96-B(12):1669-1673. Medline DOI
idemiology of revision arthroplasty: Failed THA pos-
es greater clinical and economic burdens than failed
Section 2: Knee
To evaluate reliability of the UCS, an international panel Records of 19 patients with a distal femoral periprosthetic
of experts and preexperts in orthopaedic surgery evaluated fracture following TKA treated by locked-plate osteosyn-
15 radiographs. After 6 weeks they evaluated the same thesis were evaluated. Successful union was achieved in
radiographs again, but in a different order. The interob- 18 patients. Significant reduction in the range of motion
server reliability κ values for the experts and the preexperts and (Western Ontario and McMaster Universities Arthri-
were 0.741 and 0.765, respectively. The weighted κ values tis Index score were evident at follow-up. Secondary pro-
for intraobserver reliability for the experts and preexperts cedures were required in six patients to achieve union or
were 0.898 and 0.878, respectively. Level of evidence: I. to address reduced range of motion. Level of evidence: IV.
14. Alden KJ, Duncan WH, Trousdale RT, Pagnano MW, 19. Shin YS, Kim HJ, Lee DH: Similar outcomes of locking
Haidukewych GJ: Intraoperative fracture during pri- compression plating and retrograde intramedullary nail-
mary total knee arthroplasty. Clin Orthop Relat Res ing for periprosthetic supracondylar femoral fractures
2010;468(1):90-95. Medline DOI following total knee arthroplasty: A meta-analysis. Knee
Surg Sports Traumatol Arthrosc 2016;Feb:20. Medline
The authors of this study reviewed 17,389 primary TKAs
performed between 1985 and 2005 and identified 67 intra- Among eight studies in this meta-analysis, patients were
operative fractures, including 49 femur fractures, 18 tibia treated with either locking plates or intramedullary nail-
fractures, and no patella fractures. Intraoperative fracture ing were similar in mean times to union, proportion of
occurred more commonly in women (80.6%) and in the nonunions, and proportion of revisions.
femur (73.1%). Most fractures occurred during expo-
sure and bone preparation and trialing of components. In 20. Ebraheim NA, Kelley LH, Liu X, Thomas IS, Steiner
14 patients (21%), revision was performed at an average RB, Liu J: Periprosthetic distal femur fracture after to-
of 2.8 years. Level of evidence: III. tal knee arthroplasty: A systematic review. Orthop Surg
2015;7(4):297-305. Medline DOI
15. Whitehouse MR, Mehendale S: Periprosthetic fractures
around the knee: Current concepts and advances in In this systematic review of 41 articles, the most common
management. Curr Rev Musculoskelet Med 2014;7(2): treatments of distal femoral periprosthetic fractures were
136-144. Medline DOI reported to be locked plating and intramedullary nailing,
with similar healing rates of 87% and 84%, respectively.
This review focuses on the incidence, risk factors, clas- The complication rate for locked plating was lower than
sification, investigation, and treatment options for TKA for intramedullary nailing.
periprosthetic fractures.
21. Bae DK, Song SJ, Yoon KH, Kim TY: Periprosthetic
16. Kim W, Song JH, Kim JJ: Periprosthetic fractures of supracondylar femoral fractures above total knee ar-
the distal femur following total knee arthroplasty: Even throplasty: Comparison of the locking and non-locking
very distal fractures can be successfully treated using plating methods. Knee Surg Sports Traumatol Arthrosc
internal fixation. Int Orthop 2015;39(10):1951-1957. 2014;22(11):2690-2697. Medline DOI
Medline DOI
2: Knee
A retrospective comparison between locking compression

A review of 32 periprosthetic fractures of the distal fe- plates and nonlocking condylar buttress plates for treat-
mur was undertaken, including 21 extremely distal frac- ment of distal femoral periprosthetic fractures showed
tures. Of the 21 Su type III fractures, 14 (66.7%) were healing without additional surgery in 13 of 14 patients
treated using double plating and the minimally invasive with locking plates and 11 of 19 patients with nonlocking
plate osteosynthesis technique, whereas other fractures plates. Locking plate fixation reduced the incidence of
received a single plate. One nonunion was reported. Level overall complications, nonunion, malunion, loss of reduc-
of evidence: IV. tion, and additional surgery compared with nonlocking
plate fixation Level of evidence: III.
17. Ristevski B, Nauth A, Williams DS, et al: Systematic review
of the treatment of periprosthetic distal femur fractures. 22. Jones MD, Carpenter C, Mitchell SR, Whitehouse M,
J Orthop Trauma 2014;28(5):307-312. Medline DOI Mehendale S: Retrograde femoral nailing of peripros-
thetic fractures around total knee replacements. Injury
In a systematic review of 44 studies and 719 distal fem- 2016;47(2):460-464. Medline DOI
oral periprosthetic fractures, both locked plating and
retrograde intramedullary nailing (RIMN) offered sig- Eight different designs of primary TKA prostheses and
nificant advantages over nonsurgical treatment and non– four designs of retrograde femoral intramedullary nails
locked-plating techniques. Locked plating demonstrated were evaluated for compatibility using actual implants
a trend toward increased nonunion rates when compared and Sawbones anatomic models. A nail was deemed
with RIMN. Malunion was significantly higher with compatible if insertion was possible through the femoral
RIMN than with locked plating. prosthesis. In most nails, insertion through most TKA
components was technically feasible, but they were not
18. Gavaskar AS, Tummala NC, Subramanian M: The out- compatible due to excessive force required for insertion,
come and complications of the locked plating management damage to the nail during insertion, or risk of anterior
for the periprosthetic distal femur fractures after a total cortex perforation. Level of evidence: II.
knee arthroplasty. Clin Orthop Surg 2013;5(2):124-128.
Medline DOI
23. Gondalia V, Choi DH, Lee SC, et al: Periprosthetic supra- Sawbones anatomic model femurs were implanted with a
condylar femoral fractures following total knee arthro- femoral component of TKA. Femurs were osteotomized
plasty: Clinical comparison and related complications to produce an AO/OTA 33-A3 fracture pattern, and four
of the femur plate system and retrograde-inserted supra- different constructs were tested: (1) nonlocking plate; (2)
condylar nail. J Orthop Traumatol 2014;15(3):201-207. polyaxial locking plate; (3) intramedullary fibular strut
Medline DOI allograft with polyaxial locking plate; and (4) retrograde
nail. The intramedullary fibular strut allograft with plate
The study included 42 cases of periprosthetic fractures did not prove to be significantly better to the plate only.
proximal to TKA, with 24 cases being treated with the
femur plate system and 18 cases with retrograde-inserted
supracondylar. Fixation method and fracture type did 28. Pekmezci M, McDonald E, Buckley J, Kandemir U: Ret-
not cause an increase in the complication rate, but there rograde intramedullary nails with distal screws locked to
was a trend toward higher nonunion rates with the fe- the nail have higher fatigue strength than locking plates in
mur plate method and a higher refracture rate with the the treatment of supracondylar femoral fractures: A cadav-
retrograde-inserted supracondylar nails method. Level er-based laboratory investigation. Bone Joint J 2014;96-
of evidence: III. B(1):114-121. Medline DOI
The fixation achieved with an intramedullary locking nail
24. Horneff JG III, Scolaro JA, Jafari SM, Mirza A, Parvizi that allows the distal interlocking screws to be locked to
J, Mehta S: Intramedullary nailing versus locked plate the nail was compared with fixation using either a con-
for treating supracondylar periprosthetic femur fractures. ventional nail or a locking plate in a laboratory simulation
Orthopedics 2013;36(5):e561-e566. Medline DOI of an osteoporotic fracture of the distal femur. Fifteen
human cadaver femora were used to simulate an AO 33-
A retrospective review of 63 patients with Rorabeck type A3 fracture pattern. When compared with locking plate
II periprosthetic fractures of the distal femur was under- constructs, locking nail constructs had significantly longer
taken: 35 patients were treated with nailing and 28 with mean fatigue life and mean axial stiffness, but lower mean
a locked plate. At 36 weeks, radiographic union was sig- torsional stiffness. Locking nail constructs had signifi-
nificantly greater in the locked-plate group. A greater peri- cantly longer mean fatigue life than did nonlocking nail
operative transfusion rate was observed in the locked-plate constructs.
group, but an overall lower rate of reoperation for any
reason was also seen in this group. Level of evidence: III.
29. Agarwal S, Sharma RK, Jain JK: Periprosthetic fractures
after total knee arthroplasty. J Orthop Surg (Hong Kong)
25. Meneghini RM, Keyes BJ, Reddy KK, Maar DC: Mod- 2014;22(1):24-29. Medline
ern retrograde intramedullary nails versus periarticular
locked plates for supracondylar femur fractures after total After evaluating outcomes of 20 patients treated for peri-
knee arthroplasty. J Arthroplasty 2014;29(7):1478-1481. prosthetic fracture after TKA, locked plates were effective
Medline DOI in managing distal femoral periprosthetic fractures. Peri-
prosthetic patellar and tibial fractures were uncommon.
Of 95 distal femoral periprosthetic fractures after TKA, Tibial fractures often warranted revision arthroplasty as
29 were treated with a retrograde intramedullary nailing
2: Knee
a result of the loose implant. Technical aspects of fixa-
(RIMN) and 66 with locked plates. Two nonunions (9%) tion or revision surgeries were also described. Level of
were seen in the RIMN group, and 12 nonunions/delayed evidence: IV.
unions (19%) were seen in the locked-plate group (P =
0.34). Despite a greater quantity of screws in the distal
fragment, the failure rate of locked plating was twice that 30. Jassim SS, McNamara I, Hopgood P: Distal femoral re-
of RIMN fixation. Level of evidence: III. placement in periprosthetic fracture around total knee
arthroplasty. Injury 2014;45(3):550-553. Medline DOI
26. Chen SH, Chiang MC, Hung CH, Lin SC, Chang HW: Ten patients (mean age, 81 years) had TKA implant revi-
Finite element comparison of retrograde intramedullary sion with a distal femoral replacement for periprosthetic
nailing and locking plate fixation with/without an in- fracture with associated poor bone stock. At a mean fol-
tramedullary allograft for distal femur fracture follow- low-up of 33 months (range, 4 to 72 months), all implants
ing total knee arthroplasty. Knee 2014;21(1):224-231. survived without need for reoperation. Mean postopera-
Medline DOI tive Oxford Knee Score for the patients was 22.5 (range,
5 to 34). Level of evidence: IV.
This study used a finite-element method to evaluate the
differences between nail, locked-plate, and locked-plate/
allograft fixation in treatment of TKA-related distal fem- 31. Cannon SR: The use of megaprosthesis in the treat-
oral periprosthetic fractures. The locked-plate/allograft ment of periprosthetic knee fractures. Int Orthop
construct stabilized the fracture gap and reduced the im- 2015;39(10):1945-1950. Medline DOI
plant stress more efficiently than the other two methods. The authors reported outcomes of 27 patients treated with
an endoprosthetic replacement for periprosthetic frac-
27. Mäkinen TJ, Dhotar HS, Fichman SG, et al: Peripros- ture of the distal femur. All patients mobilized rapidly,
thetic supracondylar femoral fractures following knee and there were no cases of further revision in patients
arthroplasty: A biomechanical comparison of four for whom clinical follow-up was available. Average Knee
methods of fixation. Int Orthop 2015;39(9):1737-1742. Society Score following treatment was 88 at 6 months
Medline DOI postoperatively. Level of evidence: IV.
Section 2: Knee
32. Saidi K, Ben-Lulu O, Tsuji M, Safir O, Gross AE, Back- Major advantages were lower rates of soft-tissue compli-
stein D: Supracondylar periprosthetic fractures of the knee cations and implant failures.
in the elderly patients: A comparison of treatment using
allograft-implant composites, standard revision compo- 37. Sarmah SS, Patel S, Reading G, El-Husseiny M, Douglas
nents, distal femoral replacement prosthesis. J Arthroplas- S, Haddad FS: Periprosthetic fractures around total knee
ty 2014;29(1):110-114. Medline DOI arthroplasty. Ann R Coll Surg Engl 2012;94(5):302-307.
Three different treatment methods for comminuted distal Medline DOI
femoral periprosthetic fractures in 23 patients older than Based on review of 43 studies of periprosthetic fractures
70 years (average, 80 years) were compared. Techniques in- after TKA, this article outlines pathways to aid the sur-
cluded seven allograft prosthesis composites, nine revision geon’s choice of an appropriate treatment method.
systems, and seven distal femoral endoprostheses. Surgical
time and blood loss were significantly less in revision and 38. Jujo Y, Yasui T, Nagase Y, Kadono Y, Oka H, Tana-
distal femoral endoprostheses groups compared to the ka S: Patellar fracture after total knee arthroplasty for
allograft prosthesis composites groups. Hospital stay was rheumatoid arthritis. J Arthroplasty 2013;28(1):40-43.
shortest for the distal femoral endoprostheses patients. No Medline DOI
significant difference was found in the 6-week or 6-month
Knee Society Scores. Level of evidence: III. This article reported on a study of 329 TKAs performed
in 230 female patients with rheumatoid arthritis at a mean
33. Lizaur-Utrilla A, Miralles-Muñoz FA, Sanz-Reig J: follow-up of 6.2 years. Patellar resurfacing was performed
Functional outcome of total knee arthroplasty after in all cases. Five postoperative patellar fractures (1.51%)
periprosthetic distal femoral fracture. J Arthroplasty were identified; thin residual patellar thickness and the
2013;28(9):1585-1588. Medline DOI use of posterior-stabilized components were identified as
significant risk factors. Level of evidence: III.
This prospective matched-cohort study compared func-
tional outcomes between 28 patients with femoral peri- 39. de Alencar PG, De Bortoli G, Ventura Vieira IF, Uliana
prosthetic fractures and 28 with primary TKA. At a mean CS: Periprosthetic fractures in total knee arthroplasty.
follow-up of 6.7 years, Knee Society Scores, knee motion, Rev Bras Ortop 2015;45(3):230-235. Medline
Western Ontario and McMaster Universities Arthritis
Index, and Medical Outcomes Study 12-Item Short Form This review article states that for treatment of peripros-
(SF-12) scores were significantly lower in the fracture thetic fracture around the knee, the surgeon should have
group and were significantly decreased in comparison to broad knowledge of arthroplasty techniques and osteosyn-
preinjury status. Level of evidence: II. thesis as well as access to an extensive therapeutic arsenal,
including a bone bank.
34. Ebraheim NA, Ray JR, Wandtke ME, Buchanan GS, San-
ford CG, Liu J: Systematic review of periprosthetic tibia 40. Adigweme OO, Sassoon AA, Langford J, Haidukewych
fracture after total knee arthroplasties. World J Orthop GJ: Periprosthetic patellar fractures. J Knee Surg
2: Knee
The authors of this study reviewed 13 articles that included The epidemiology and risk factors associated with peri-
157 patients with tibial periprosthetic fractures. Based prosthetic patellar fractures are outlined in this article.
on the Felix classification, type 1 fractures were the most Treatment options are discussed as they relate to injury
common. Subclass A was most commonly treated with mechanism, fracture severity, patellar component stability,
locking plates, type B required a revision TKA, and type and remaining bone.
C was treated intraoperatively or nonsurgically.
41. Nam D, Abdel MP, Cross MB, et al: The management of
35. Yoo JD, Kim NK: Periprosthetic fractures following total extensor mechanism complications in total knee arthro-
knee arthroplasty. Knee Surg Relat Res 2015;27(1):1-9. plasty. AAOS exhibit selection. J Bone Joint Surg Am
Medline DOI 2014;96(6):e47. Medline DOI
The authors of this study emphasize good clinical out- This article focuses on six of the most commonly en-
comes after nonsurgical treatment of minimally displaced countered problems associated with the knee extensor
periprosthetic fractures, especially involving the patella; mechanism during TKA: (1) patellar tendon disruption,
however, open reduction or revision arthroplasty was re- (2) quadriceps tendon rupture, (3) patellar crepitus and
quired in displaced fractures or fractures with unstable soft-tissue impingement, (4) periprosthetic patellar frac-
prostheses. Considerations in choosing the appropriate ture, (5) patellofemoral instability, and (6) osteonecrosis
treatment method should include stability of the prosthe- of the patella. The results in patients with a prior TKA
sis, fracture displacement, and bone quality. are inferior to those in young adults with native patella.
Surgical attempts at restoration of the extensor mech-
36. Ruchholtz S, Tomás J, Gebhard F, Larsen MS: Peripros- anism are warranted; however, outcomes of treatment
thetic fractures around the knee-the best way of treatment. are often poor.
Eur Orthop Traumatol 2013;4(2):93-102. Medline DOI
42. Solarino G, Vicenti G, Moretti L, Abate A, Spinarelli A,
Based on a review of available techniques for treating Moretti B: Interprosthetic femoral fractures-A challenge
distal femoral periprosthetic fractures, less invasive proof treatment. A systematic review of the literature. Injury
cedures present a valuable alternative to open techniques. 2014;45(2):362-368. Medline DOI
This article provides an updated and comprehensive list The 2001-2009 Nationwide Inpatient Sample was used
of diagnostic and therapeutic protocols for interprosthetic to identify the relative incidence of PJI, which ranged
femoral fractures. Most fractures are best treated using from 2.0% to 2.4% of THAs and TKAs and increased
appropriate plating techniques. over time. The mean cost to treat PJI of the hip was
$5,965 greater than for knee PJI. The annual cost to US
43. Ehlinger M, Czekaj J, Adam P, Brinkert D, Ducrot G, hospitals of infected revisions increased from $320 million
Bonnomet F: Minimally invasive fixation of type B and to $566 million during the study period and was projected
C interprosthetic femoral fractures. Orthop Traumatol to exceed $1.62 billion by 2020. Level of evidence: II.
Surg Res 2013;99(5):563-569. Medline DOI
48. Nikolaus OB, McLendon PB, Hanssen AD, Mabry TM,
Eight patients with interprosthetic femoral fractures were Berbari EF, Sierra RJ: Factors associated with 20-year
treated with minimally invasive locked-plate fixation. Ear- cumulative risk of infection after aseptic index revi-
ly construct failure at 3 weeks in one patient required sion total knee arthroplasty. J Arthroplasty 2016;31(4):
surgical revision. Healing was achieved in all eight patients 872-877. Medline DOI
after a mean of 14 weeks. One patient had malalignment,
with greater than 5° of varus. No general or infectious The authors reported that the cumulative risk of PJI was
complications occurred. Level of evidence: IV. 1%, 2.4%, 3.3%, and 5.6% at 1, 5, 10, and 20 years,
respectively, after revision TKA.
44. Alexander J, Morris RP, Kaimrajh D, et al: Biomechan-
ical evaluation of periprosthetic refractures following 49. Kamath AF, Ong KL, Lau E, et al: Quantifying the
distal femur locking plate fixation. Injury 2015;46(12): burden of revision total joint arthroplasty for peripros-
2368-2373. Medline DOI thetic infection. J Arthroplasty 2015;30(9):1492-1497.
Medline DOI
A segmental defect was created 6 cm proximal to the
knee joint on a synthetic bone model and was fixed with The authors present an evaluation of costs and patient
a 246-mm locking plate. Fixation in the most proximal characteristics associated with revision arthroplasty for
hole varied: a cerclage cable, a unicortical locking screw, PJI.
or a bicortical locking screw was used. Proximal hole
stabilization with a cerclage wire tolerated significantly 50. Crowe B, Payne A, Evangelista PJ, et al: Risk factors
higher failure forces while distributing forces distal to the for infection following total knee arthroplasty: A se-
area within the plate fixation. ries of 3836 cases from one institution. J Arthroplasty
2015;30(12):2275-2278. Medline DOI
45. Hoffmann MF, Lotzien S, Schildhauer TA: Clinical out-
come of interprosthetic femoral fractures treated with This study reported that optimizing modifiable risk factors
polyaxial locking plates. Injury 2016;47(4):934-938. (such as patient tobacco use) before TKA may reduce the
Medline DOI incidence of PJIs.
A segmental defect was created in 21 synthetic osteopo- 51. Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J:
2: Knee
rotic adult femurs 6 cm proximal to the joint level, and Economic burden of periprosthetic joint infection in the
specimens were stabilized with a 246-mm locking femur United States. J Arthroplasty 2012;27(8 suppl):61-5.e1.
plate. Fixation in the most proximal hole varied: either Medline DOI
a cerclage cable, a unicortical locking screw, or a bicor-
tical locking screw was used. Proximal cerclage fixation The annual hospital cost of revision surgery resulting from
demonstrated higher mean maximum axial force at fail- PJI is estimated to exceed $1.62 billion by 2020.
ure, stiffness, and maximum torque. Level of evidence: III.
52. Kapadia BH, Johnson AJ, Issa K, Mont MA: Economic
46. Platzer P, Schuster R, Luxl M, et al: Management and evaluation of chlorhexidine cloths on healthcare costs due
outcome of interprosthetic femoral fractures. Injury to surgical site infections following total knee arthroplas-
2011;42(11):1219-1225. Medline DOI ty. J Arthroplasty 2013;28(7):1061-1065. Medline DOI
In a study of 23 patients with interprosthetic femoral The use of chlorhexidine cloths before TKA demonstrated
fracture who were treated either by lateral plate fixation the potential to reduce SSIs and, therefore, decrease health-
(n = 19), by revision arthroplasty using a long stem (n = care costs.
2), or by plate fixation and revision arthroplasty (n = 2),
16 patients returned to preinjury activity level and were 53. Pruzansky JS, Bronson MJ, Grelsamer RP, Strauss E, Mou-
satisfied. In six patients, decrease of hip or knee function cha CS: Prevalence of modifiable surgical site infection risk
as well as severe limitation in gait and activities of daily factors in hip and knee joint arthroplasty patients at an
living were noted. Fracture healing was achieved in 19 of urban academic hospital. J Arthroplasty 2014;29(2):272-
22 patients (86%) within 6 months. Failures of reduction 276. Medline DOI
and fixation were noted in 4 of 22 patients (18%). Level
of evidence: IV. Modifiable patient risk factors for SSI include obesity,
anemia, malnutrition, and diabetes. The prevalence of
these risk factors allows opportunities to optimize the
47. Kurtz SM, Ong KL, Lau E, Bozic KJ, Berry D, Parvizi J: condition of patients prior to TKA.
Prosthetic joint infection risk after TKA in the Medicare
population. Clin Orthop Relat Res 2010;468(1):52-56.
Medline DOI
Section 2: Knee
54. Kapadia BH, Zhou PL, Jauregui JJ, Mont MA: Does pre- The authors determined the best diagnostic strategy for
admission cutaneous chlorhexidine preparation reduce knee and hip PJI in the ambulatory setting for Medicare
surgical site infections after total knee arthroplasty? Clin patients, using benefits, opportunities, costs, and risks
Orthop Relat Res 2016;474(7):1592-1598. Medline DOI evaluation through multicriteria decision analysis. Screen-
ing with serum markers before arthrocentesis was found
The authors calculated relative risk reductions with use to be the best strategy for diagnosing PJI in Medicare
of a preoperative chlorhexidine cloth skin preparation patients. Level of evidence: II.
protocol, and demonstrated a reduced relative risk of peri-
prosthetic infection after TKA (infections with protocol:
three of 991 [0.3%]; infections in control: 52 of 2,726 61. Aggarwal VK, Higuera C, Deirmengian G, Parvizi J, Aus-
[1.9%]; relative risk: 6.3 [95% CI, 1.9-20.1]; P = 0.002). tin MS: Swab cultures are not as effective as tissue cultures
Level of evidence: III (therapeutic). for diagnosis of periprosthetic joint infection. Clin Orthop
55. Farber NJ, Chen AF, Bartsch SM, Feigel JL, Klatt BA: No The study compared the yield of intraoperative tissue sam-
infection reduction using chlorhexidine wipes in total joint ples versus swab cultures in the diagnosis of PJI. Tissue
arthroplasty. Clin Orthop Relat Res 2013;471(10):3120- cultures demonstrated higher sensitivity, specificity, pos-
3125. Medline DOI itive predictive value, and negative predictive value than
swab cultures. Swab cultures had more false-negative and
The use of chlorhexidine wipes was not found to reduce false-positive results than tissue cultures, and their use
the incidence of SSI. Level of evidence: III. in obtaining intraoperative culture specimens should be
discouraged. Level of evidence: II.
56. Kapadia BH, Cherian JJ, Issa K, Jagannathan S, Daley JA,
Mont MA: Patient compliance with preoperative disinfec- 62. Shanmugasundaram S, Ricciardi BF, Briggs TW, Suss-
tion protocols for lower extremity total joint arthroplasty. mann PS, Bostrom MP: Evaluation and management of
Surg Technol Int 2015;26:351-354. Medline periprosthetic joint infection: An international, multi-
Seventy-eight percent of patients (3,716 of 4,751 patients) center study. HSS J 2014;10(1):36-44. DOI
were noncompliant with preoperative disinfection proto- This retrospective review of prospective registry data from
cols. Although preoperative decolonization protocols may 2008-2011 was done to determine the effectiveness of
reduce SSIs, their efficacy is limited by patient compliance preoperative and intraoperative cultures to isolate organ-
and comprehension. isms in cases of PJI. Preoperative synovial fluid aspiration
yielded an organism in only 45.2% of knee PJI cases.
57. Namba RS, Inacio MC, Paxton EW: Risk factors associ- False-negative rates of preoperative aspiration relative
ated with deep surgical site infections after primary total to intraoperative culture were 46% in knee PJI. Rates of
knee arthroplasty: An analysis of 56,216 knees. J Bone negative intraoperative cultures were 20.7% in knee PJI.
A retrospective review of a cohort followed from 2001 to 63. Tischler EH, Cavanaugh PK, Parvizi J: Leukocyte esterase
strip test: Matched for Musculoskeletal Infection Society
2: Knee
2009 included 56,216 primary TKAs. Patient factors

associated with deep SSI included a BMI of 35 kg/m 2 or criteria. J Bone Joint Surg Am 2014;96(22):1917-1920.
greater (hazard ratio [HR] = 1.47), diabetes mellitus (HR Medline DOI
= 1.28), male sex (HR =1.89), an American Society of A retrospective review of prospective registry data from
Anesthesiologists score of 3 or greater (HR= 1.65), a di- 2008-2011 was done to determine the effectiveness of
agnosis of osteonecrosis (HR = 3.65), and a diagnosis of preoperative and intraoperative cultures to isolate organ-
posttraumatic arthritis (HR = 3.23). Surgical time was isms in cases of PJI. Preoperative synovial fluid aspiration
a risk factor, with a 9% increased risk per 15-minute yielded an organism in only 45.2% of knee PJI cases.
increment. False-negative rates of preoperative aspiration relative
to intraoperative culture were 46% in knee PJI. Rates of
58. Parvizi J, Gehrke T; International Consensus Group on negative intraoperative cultures were 20.7% in knee PJI.
Periprosthetic Joint Infection: Definition of peripros-
thetic joint infection. J Arthroplasty 2014;29(7):1331. 64. Deirmengian C, Kardos K, Kilmartin P, Cameron A, Schil-
Medline DOI ler K, Parvizi J: Combined measurement of synovial fluid
A group of experts determine a definition for PJI. α-defensin and C-reactive protein levels: Highly accurate
for diagnosing periprosthetic joint infection. J Bone Joint
59. Parvizi J, Della Valle CJ: AAOS Clinical Practice Guide- Surg Am 2014;96(17):1439-1445. Medline DOI
line: Diagnosis and treatment of periprosthetic joint in- The presence of leukocyte esterase was prospectively eval-
fections of the hip and knee. J Am Acad Orthop Surg uated in synovial joint aspirates from hips and knees.
2010;18(12):771-772. Medline DOI When matched to the current MSIS criteria, the leuko-
The AAOS clinical practice guideline for PJI of the hip cyte esterase strip test yielded a high specificity, positive
and knee is presented. predictive value, negative predictive value, and moderate
sensitivity. The test should be considered an adjunct to
the current battery of diagnostic tests available for PJI.
60. Diaz-Ledezma C, Lichstein PM, Dolan JG, Parvizi J: Diag-
nosis of periprosthetic joint infection in Medicare patients:
Multicriteria decision analysis. Clin Orthop Relat Res 65. Bingham J, Clarke H, Spangehl M, Schwartz A, Beauchamp
2014;472(11):3275-3284. Medline DOI C, Goldberg B: The alpha defensin-1 biomarker assay can
be used to evaluate the potentially infected total joint 70. Haddad FS, Sukeik M, Alazzawi S: Is single-stage revision
arthroplasty. Clin Orthop Relat Res 2014;472(12):4006- according to a strict protocol effective in treatment of
4009. Medline DOI chronic knee arthroplasty infections? Clin Orthop Relat
Res 2015;473(1):8-14. Medline DOI
All patients undergoing workup for a PJI were retrospec-
tively reviewed. Sixty-one alpha defensin-1 (AD-1) assays The study compared the degree to which a highly selective
were done in 57 patients. The sensitivity and specificity single-stage revision approach to TKA PJI achieved infec-
of the AD-1 synovial fluid assay was compared with the tion control compared with a two-stage revision approach.
synovial fluid cell count, culture, erythrocyte sedimenta- None of the patients in the single-stage revision group
tion rate, and C-reactive protein level. The sensitivity and experienced recurrent infection, and reinfection developed
specificity of the synovial fluid AD-1 assay exceeded the in five patients (93%) in the two-stage revision group (P
sensitivity and specificity of the other currently available = 0.16). Patients treated with a single-stage approach had
clinical tests evaluated but did not reach significance. Level higher Knee Society Scores than did patients treated with
of evidence: III (diagnostic). the two-stage approach (88 versus 76, P <0.001). Level of
evidence: III (therapeutic).
66. Frangiamore SJ, Gajewski ND, Saleh A, Farias-Kovac
M, Barsoum WK, Higuera CA: α-Defensin accuracy to 71. Pivec R, Naziri Q, Issa K, Banerjee S, Mont MA: System-
diagnose periprosthetic joint infection:Best available test? atic review comparing static and articulating spacers used
J Arthroplasty 2016;31(2):456-460. Medline DOI for revision of infected total knee arthroplasty. J Arthro-
plasty 2014;29(3):553-7.e1. Medline DOI
This prospective study tested the diagnostic accuracy of
α-defensin for PJI in revision THA and TKA. For first- In this systematic review, the outcomes of static to artic-
stage and single-stage revisions, the α-defensin test had ulating antibiotic spacers used in two-stage revision TKA
a sensitivity of 100% (95% CI, 86%-100%) and a spec- are compared. Both groups had similar improvement in
ificity of 98% (95% CI, 90%-100%) with a positive pre- Knee Society Scores (83 versus 82 points); however, the
dictive value of 96% (95% CI, 80%-99%) and negative articulating spacer groups had significantly higher range
predictive value of 100% (95% CI, 93%-100%). Level of of motion (100° versus 92°). There was no difference in the
evidence: III. rates of reinfection, complications, or reoperation between
the two groups.
67. Cooper HJ, Della Valle CJ: Advances in the diagnosis of
periprosthetic joint infection. Expert Opin Med Diagn 72. Mahmud T, Lyons MC, Naudie DD, Macdonald SJ, Mc-
2013;7(3):257-263. Medline DOI Calden RW: Assessing the gold standard: A review of
253 two-stage revisions for infected TKA. Clin Orthop
The authors outline an algorithmic approach for diag- Relat Res 2012;470(10):2730-2736. Medline DOI
nosis of PJI. Emerging technology is reviewed, including
advanced imaging, serum markers, synovial fluid biomark- Midterm survivorship of 239 patients who underwent
ers, and point-of-care modalities. 253 two-stage revision TKAs for PJI was retrospectively
reviewed. The functional results after control of PJI and
the outcome of the two-stage failures were also reported.
2: Knee
68. Cochran AR, Ong KL, Lau E, Mont MA, Malkani
AL: Risk of reinfection after treatment of infected total Thirty-three patients experienced a failed two-staged
knee arthroplasty. J Arthroplasty 2016;S0883-5403(16) TKA. Sixteen patients experienced failure due to recur-
00304-1. Medline rent sepsis. There were 17 failures for aseptic causes. The
overall infection-free survivorship for two-stage revision
The study used Medicare data of 1,493,924 primary TKA was 85% at 5 years and 78% at 10 years. Level of
TKAs performed between 2005 and 2011 to determine evidence: IV (therapeutic).
the incidence of subsequent reinfections after initial treat-
ment of an infected TKA. PJI was diagnosed in a total of 73. Romanò CL, Gala L, Logoluso N, Romanò D, Drago L:
16,622 patients (1.1%). The Kaplan-Meier risk of PJI was Two-stage revision of septic knee prosthesis with articu-
0.77% at 1 year and 1.58% at 6 years. After first-line lating knee spacers yields better infection eradication rate
treatment, 26% of patients with PJI had a subsequent than one-stage or two-stage revision with static spacers.
PJI. Patients undergoing irrigation and débridement as a Knee Surg Sports Traumatol Arthrosc 2012;20(12):2445-
first-line treatment had the highest risk of reinfection, with 2453. Medline DOI
risks of 28.2% at 1 year and 43.2% at 6 years. Patients in
the one-stage revision group had 33.9% greater adjusted The infection eradication rate after two-stage versus one-
risk of reinfection than patients in the two-stage revision stage revision and static versus articulating spacers in two-
group (P <0.001). Two-stage reimplantation, despite 19% stage procedures was compared in a systematic review. Six
recurrence, had the highest success rate. original articles reporting the results after one-stage knee
exchange arthroplasty (n = 204) and 38 papers reporting
69. George DA, Konan S, Haddad FS: Single-stage hip and on two-stage revision (n = 1,421) were reviewed. The aver-
knee exchange for periprosthetic joint infection. J Arthro- age success rate in the eradication of infection was 89.8%
plasty 2015;30(12):2264-2270. Medline DOI after a two-stage revision and 81.9% after a one-stage
procedure at a mean follow-up of 44.7 and 40.7 months,
The study describes the patient selection criteria and peri- respectively. The average infection eradication rate after a
operative steps in a single-stage exchange for hip and knee two-stage procedure was slightly, although significantly,
arthroplasty. higher when an articulating spacer rather than a static
spacer was used (91.2% versus 87%). Level of evidence: IV.
Section 2: Knee
74. Houdek MT, Wagner ER, Watts CD, et al: Morbid obesity: performed after septic failure of revision total knee ar-
A significant risk factor for failure of two-stage revision throplasty. J Bone Joint Surg Am 2015;97(4):298-301.
total hip arthroplasty for infection. J Bone Joint Surg Am Medline DOI
2015;97(4):326-332. Medline DOI
The authors retrospectively evaluated the outcomes of
The Mayo Clinic total joint registry was used to review knee fusion with an intramedullary nail following septic
653 patients treated with two-stage revision THA for PJI failure of revision TKA. Twenty-six patients were included
over a 20-year period (1987 to 2007). Compared with in the study. Thirteen (50%) had a persistent infection
nonobese patients, morbidly obese patients had signifi- requiring additional revision surgery. Nineteen patients
cantly greater rates of reinfection (18% compared with (73%) reported persistent pain (visual analog scale score
2%, P <0.005), revision (42% compared with 11%, P of 3 or higher). All scores showed marked impairment of
<0.001) and reoperation for any reason (61% compared quality of life.
with 12%, P <0.001).
79. Carr JB II, Werner BC, Browne JA: Trends and outcomes
75. Gomez MM, Tan TL, Manrique J, Deirmengian GK, in the treatment of failed septic total knee arthroplasty:
Parvizi J: The fate of spacers in the treatment of peri- comparing arthrodesis and above-knee amputation. J Ar-
prosthetic joint infection. J Bone Joint Surg Am throplasty 2016;31(7):1574-1577. Medline DOI
2015;97(18):1495-1502. Medline DOI
The authors used a national database to identify pa-
The Jefferson institutional database was used to review tients who underwent either knee arthrodesis or above-
504 cases of PJI (326 knees and 178 hips) treated with knee amputation (AKA) for an infected TKA. A total of
resection arthroplasty and spacer insertion as part of a 2,634 patients underwent arthrodesis and 5,001 patients
two-stage exchange arthroplasty. Reimplantation oc- underwent AKA for septic TKA. The percentage of to-
curred in the joints of 417 of 504 cases (82.7%). Of these tal patients who underwent AKA increased significantly
417 cases, 329 (78.9%) had a minimum 1-year follow-up, throughout the study period compared to knee arthro-
and 81.4% of these had successful treatment. Sixty of the desis. Arthrodesis patients had a significantly higher rate
504 joints (11.9%) required interim spacer exchange(s). Of of postoperative infection (14.5% vs. 8.3%, P < 0.0001)
the 87 cases in which reimplantation was not performed, 6 and transfusion (55.1% vs. 46.8%, P < 0.0001), whereas
(6.9%) required amputation, 5 (5.7%) underwent a Girdle- AKA patients had a higher rate of systemic complications
stone procedure, 4 (4.6%) underwent arthrodesis, and 72 (31.5% vs. 25.9%, P < 0.0001) and in-hospital mortality
(82.8%) underwent spacer retention. Thirty-six patients (3.7% vs. 2.1%, P < 0.0001). The AKA cohort had lower
died during the interstage period. hospital charges ($79,686 vs. $84,747, P = 0.004), longer
length of stay (11 vs. 7 days, P < 0.0001), and higher 90-
76. Siqueira MB, Saleh A, Klika AK, et al: Chronic suppres- day readmission rate (19.4% vs. 16.9%).
sion of periprosthetic joint infections with oral antibiotics
increases infection-free survivorship. J Bone Joint Surg 80. Kurtz SM, Ong KL, Lau E, Bozic KJ: Impact of the eco-
Am 2015;97(15):1220-1232. Medline DOI nomic downturn on total joint replacement demand in the
United States: Updated projections to 2021. J Bone Joint
2: Knee
The study retrospectively compared infection-free pros- Surg Am 2014;96(8):624-630. Medline DOI
thetic survival rates between patients who received chronic
oral antibiotics and those who did not following irrigation The authors of this study examined data from the Na-
and débridement with polyethylene exchange or two-stage tionwide Inpatient Sample (1993 to 2010), which was
revision for PJI. The 5-year infection-free prosthetic sur- used with United States Census and National Health Ex-
vival rate was 68.5% (95% CI = 59.2% to 79.3%) for penditure data to quantify historical trends in total joint
the antibiotic-suppression group and 41.1% (95% CI = arthroplasty rates, including during the two economic
34.9% to 48.5%) for the non-suppression group (hazard downturns in the 2000s. The growth trend for the inci-
ratio = 0.63, P = 0.008). Chronic suppression with oral dence of joint arthroplasty for the overall US population as
antibiotics increased the infection-free prosthetic survival well as for the US workforce was insensitive to economic
rate following surgical treatment for PJI. downturns. From 2009 to 2010, the total number of pro-
cedures increased by 6.0% for primary THAs, 6.1% for
77. Wu CH, Gray CF, Lee GC: Arthrodesis should be primary TKAs, 10.8% for revision THA, and 13.5% for
strongly considered after failed two-stage reimplantation revision TKA. The National Health Expenditure model
TKA. Clin Orthop Relat Res 2014;472(11):3295-3304. projections for primary hip replacement in 2020 were
Medline DOI higher than a previously projected model, whereas the
current model estimates for TKA were lower.
A systematic review and decision analysis was performed
to determine the treatment method likely to yield the high- 81. Thiele K, Perka C, Matziolis G, Mayr HO, Sostheim M,
est quality of life for a patient after a failed two-stage Hube R: Current failure mechanisms after knee arthro-
reimplantation. Based on best available evidence, knee plasty have changed: Polyethylene wear is less common
arthrodesis should be strongly considered as the treatment in revision surgery. J Bone Joint Surg Am 2015;97(9):
of choice for patients who have persistent infected TKA 715-720. Medline DOI
after a failed two-stage reimplantation procedure.
The authors studied failure after TKA as a function of
78. Röhner E, Windisch C, Nuetzmann K, Rau M, Arnhold time. The most common indications for revision were asep-
M, Matziolis G: Unsatisfactory outcome of arthrodesis tic loosening (21.8%), instability (21.8%), malalignment
(20.7%), PJI (14.5%), and polyethylene wear (7%). In annealed XLPE in 64 TKAs. Clinical outcomes (as mea-
the early revision group, major causes of revision were sured by Medical Outcomes Study 36-Item Short Form
PJI (26.8%) and instability (23.9%). In the intermedi- survey [SF-36], Knee Society Score, and lower extremity
ate revision group, instability (23.3%) and malalignment activity score) and radiographic outcomes were evaluated
(29.4%) necessitated revision surgery, whereas late-failure at a mean of 5 years in 103 TKAs. Mean Knee Society
mechanisms were aseptic loosening (34.7%), instability Scores were 12 points higher (P = 0.01) and SF-36 physical
(18.5%), and polyethylene wear (18.5%). function subset scores 14 points higher (P = 0.005) in the
XLPE group. No radiographic osteolysis or mechanical
82. Sharkey PF, Lichstein PM, Shen C, Tokarski AT, Parvizi failure related to the tibial polyethylene was present in
J: Why are total knee arthroplasties failing today: either group. At 5-year follow-up, no deleterious effects
Has anything changed after 10 years? J Arthroplasty related to XLPE posterior-stabilized tibial polyethylene
2014;29(9):1774-1778. Medline DOI inserts were observed.
The study shows that polyethylene wear is no longer the 87. Paxton EW, Inacio MC, Kurtz S, Love R, Cafri G, Namba
major cause of failure in revision TKA. The most com- RS: Is there a difference in total knee arthroplasty risk of
mon failure mechanisms were loosening (39.9%), infection revision in highly crosslinked versus conventional poly-
(27.4%), instability (7.5%), periprosthetic fracture (4.7%), ethylene? Clin Orthop Relat Res 2015;473(3):999-1008.
and arthrofibrosis (4.5%). Medline DOI
83. Schroer WC, Berend KR, Lombardi AV, et al: Why are The authors of this study compared HXLPE with conven-
total knees failing today? Etiology of total knee revision in tional polyethylene in a large database of 77,084 patients
2010 and 2011. J Arthroplasty 2013;28(8 suppl):116-119. at 5-year follow-up and found no difference in revision
Medline DOI rates. The incidence of revision for conventional poly-
ethylene and HXLPE were 2.7% and 3.1%, respectively.
This study reports that polyethylene wear is not a leading
failure mechanism in TKA. Mechanisms of failure were 88. Gigante A, Bottegoni C, Ragone V, Banci L: Effectiveness
aseptic loosening (31.2%), followed by instability (18.7%), of vitamin-E-doped polyethylene in joint replacement: A
infection (16.2%), polyethylene wear (10.0%), arthrofi- literature review. J Funct Biomater 2015;6(3):889-900.
brosis (6.9%), and malalignment (6.6%). Medline DOI
84. Khan M, Osman K, Green G, Haddad FS: The epidemi- The authors of this study performed a Medline search for
ology of failure in total knee arthroplasty: Avoiding your articles on VEPE spanning the past 15 years to specifi-
next revision. Bone Joint J 2016;98-B(1 suppl A):105-112. cally examine oxidative stability, mechanical properties,
Medline DOI biocontamination, and biocompatibility. Several in vitro
studies have shown that vitamin E-stabilized ultra-high–
This review of the epidemiology of failed TKAs using molecular-weight polyethylene (UHMWPE) has a higher
data from worldwide national joint registries rates the oxidative resistance than that of irradiated UHMWPE, as
risk of failure of TKA requiring revision surgery at 5% well as equivalent wear and improved mechanical strength
2: Knee
at 10 years after surgery. compared with irradiated and melted UHMWPE. They
also found that in vitro and animal studies did not show
85. Sakellariou VI, Sculco P, Poultsides L, Wright T, Sculco adverse biologic responses to vitamin E-stabilized UHM-
TP: Highly cross-linked polyethylene may not have an WPE, and that debris particles found therein had a lower
advantage in total knee arthroplasty. HSS J 2013;9(3): osteolytic potential.
This systematic literature review searched for advantag- 89. Haider H, Weisenburger JN, Kurtz SM, et al: Does vita-
es and disadvantages of XLPE in TKA. Several in vitro min E-stabilized ultrahigh-molecular-weight polyethylene
studies found XLPE to have significantly better wear prop- address concerns of cross-linked polyethylene in total
erties than conventional polyethylene. However, the two knee arthroplasty? J Arthroplasty 2012;27(3):461-469.
clinical investigations that directly compared conventional Medline DOI
polyethylene and XLPE found no difference in clinical Researchers compared the in vitro strength, oxidation,
or radiographic outcomes. Additionally, clinical studies fatigue-crack propagation resistance, and wear of highly
with long-term follow-up on TKA with conventional poly- cross-linked UHMWPE with vitamin E to the same prop-
ethylene did not find wear-induced osteolysis to be a major erties of standard compression-molded UHMWPE. After
cause of failure. Four studies found cost was significantly accelerated aging, the compression-molded UHMWPE
higher for XLPE than for conventional polyethylene. showed elevated oxidation, loss of mechanical proper-
ties, and loss of fatigue-crack propagation resistance; the
86. Meneghini RM, Lovro LR, Smits SA, Ireland PH: vitamin E-stabilized material had minimal changes and
Highly cross-linked versus conventional polyethylene in exhibited 73% to 86% reduction in wear for TKA.
posterior-stabilized total knee arthroplasty at a mean
5-year follow-up. J Arthroplasty 2015;30(10):1736-1739. 90. Gallo J, Goodman SB, Konttinen YT, Wimmer MA,
Medline DOI Holinka M: Osteolysis around total knee arthroplasty:
The authors conducted a prospective cohort study of A review of pathogenetic mechanisms. Acta Biomater
114 consecutive posterior-stabilized TKAs that used con- 2013;9(9):8046-8058. Medline DOI
ventional polyethylene in 50 TKAs and second-generation
Section 2: Knee
In a review of several causes of osteolysis related to TKA, This review article explains the cellular/molecular mech-
patient activity level appeared to be the most important anism of osteolysis. At the cellular level, cells of the mono-
factor in long-term development of periprosthetic oste- cyte/macrophage lineage initiate the inflammatory cascade
olysis. Surgical technique, implant design, and material that leads to osteolysis. The biologic processes involved are
factors are the most important preventive factors because complex, based on the unique properties of the monocytes/
they influence both the generation of wear debris and macrophages, including sensing, chemotaxis, phagocyto-
excessive mechanical stresses. sis, and adaptive stimulation. The interaction with wear
debris triggers the release of proinflammatory factors, such
91. Goldvasser D, Marchie A, Bragdon LK, Bragdon CR, as tumor necrosis factor-α, interleukin-1, and others, with
Weidenhielm L, Malchau H: Incidence of osteolysis in to- pro-osteoclastic factors (such as RANKL) and chemok-
tal knee arthroplasty: Comparison between radiographic ines (such as MCP-1 and MIP-1) all being crucial to the
and retrieval analysis. J Arthroplasty 2013;28(2):201-206. recruitment, migration, differentiation, and, ultimately,
Medline DOI activation of bone-resorbing osteoclasts.
The authors of this study used a joint registry to identify 95. Pijls BG, Van der Linden-Van der Zwaag HM, Nelissen
TKA revisions and developed a radiographic scoring sys- RG: Polyethylene thickness is a risk factor for wear necessi-
tem. Radiographs were analyzed for osteolysis and implant tating insert exchange. Int Orthop 2012;36(6):1175-1180.
alignment, and polyethylene liner retrievals were visually Medline DOI
and optically graded for surface damage. When osteolysis
was found, radiographic and delamination scores were This study of 84 patients treated with TKA (follow-up
significantly higher (P = 0.047 and P = 0.014, respectively). range, 11 to 16 years) all of whom received the same
It was concluded that delamination is a good indicator for prosthesis design, showed that polyethylene thickness,
polyethylene wear and osteolysis. diagnosis, and BMI are risk factors for insert exchange.
For each millimeter of decrease in polyethylene thickness,
92. Fritton K, Ren PG, Gibon E, et al: Exogenous the risk of insert exchange increases threefold; this risk
MC3T3 preosteoblasts migrate systemically and mitigate remains after correction for age, sex, weight, diagnosis,
the adverse effects of wear particles. Tissue Eng Part A and femorotibial angle. Insert exchange was 4.73-fold
2012;18(23-24):2559-2567. Medline DOI more likely in patients with osteoarthritis than in those
with rheumatoid arthritis. For every unit increase in BMI
In this animal study, either UHMWPE particles or saline and weight, the risk for insert exchange increases 1.40-fold
was infused into the left femur of mice, and luciferase- and 1.14-fold, respectively.
expressing preosteoblasts (MC3T3 cells) were injected
into each mouse’s left ventricle. Immunostaining revealed 96. Berry DJ, Currier JH, Mayor MB, Collier JP: Knee wear
a greater number of osteoblasts and osteoclasts in the measured in retrievals: A polished tray reduces insert
particle-infused femora, indicating greater bone turnover. wear. Clin Orthop Relat Res 2012;470(7):1860-1868.
The bone mineralization of the particle-infused femora Medline DOI
increased significantly when compared to saline-infused
femora (an increase of 146.4 ± 27.9 versus 12.8 ± 8.7 mg/ Two series compared wear in retrieved knee devices:
2: Knee
mL; P = 0.008). These results show that infused preosteo- 94 had rotating-platform mobile bearings with polished
blasts can migrate to the site of wear particles. cobalt-chromium trays, and 218 had fixed bearings with
both rough titanium and polished cobalt-chromium trays.
Minimum implantation time was 0.4 months (median,
93. Gibon E, Ma T, Ren PG, et al: Selective inhibition of
36 months; range, 0.4 to 124 months) and 2 months
the MCP-1-CCR2 ligand-receptor axis decreases sys- (median, 72 months; range, 2 to 179 months) for the
temic trafficking of macrophages in the presence of rotating-platform and fixed-bearing series, respectively.
UHMWPE particles. J Orthop Res 2012;30(4):547-553. Wear rate was lower for rotating-platform inserts than
Medline DOI for fixed-bearing inserts. Backside wear rate was lower for
This animal study used mice to examine the mechanism fixed-bearing inserts mated to polished cobalt-chromium
of macrophage recruitment in the setting of osteolysis. A trays than for inserts from rough titanium trays. Inserts
murine macrophage cell line and primary wild type and against polished trays (rotating-platform or fixed-bear-
CCR2 knockout murine macrophages were used as the re- ing) showed no increase in wear rate over time. Wear
porter cells. Particles were infused into the femoral canal. rate of posterior-stabilized knees was similar to that of
Bioluminescence and immunohistochemical staining were cruciate-retaining knees.
used to confirm the migration of reporter cells. Locally in-
fused MCP-1 induced systemic macrophage trafficking to 97. Stoner K, Jerabek SA, Tow S, Wright TM, Padgett DE:
bone. Injection of MCP-1 receptor antagonist significantly Rotating-platform has no surface damage advantage over
decreased reporter cell recruitment to bone infused with fixed-bearing TKA. Clin Orthop Relat Res 2013;471(1):76-
UHMWPE particles; osteolysis also decreased. 85. Medline DOI
In this study, damage grading and damage mapping
94. Nich C, Goodman SB: Role of macrophages in the bio- were performed on 25 rotating-platform and 17 fixed-
logical reaction to wear debris from joint replacements. bearing inserts. The patient demographic data from
J Long Term Eff Med Implants 2014;24(4):259-265. each of these cohorts were comparable. Inserts were also
Medline DOI laser-scanned to obtain thicknesses, and inferior surface
three-dimensional scans were used to determined dimen-
sional changes. The rotating-platform and fixed-bearing
inserts were found to have similar tibiofemoral damage 102. Srivastava A, Lee GY, Steklov N, Colwell CW Jr, Ezzet
scores. However, scores were greater for the inferior sur- KA, D’Lima DD: Effect of tibial component varus on
face of rotating-platform implants, often as a result of wear in total knee arthroplasty. Knee 2012;19(5):560-563.
third-body debris scratching, which was observed on both Medline DOI
damage mapping and three-dimensional scans.
Researchers found that tibial components placed in greater
than 3° of varus were associated with almost twice the
98. Pang HN, Bin Abd Razak HR, Jamiecson P, Teeter MG,
volumetric penetration rate. They concluded that in ad-
Naudie DD, MacDonald SJ: Factors affecting wear of con-
dition to local destruction of the bearing surface, tibial
strained polyethylene tibial inserts in total knee arthroplas-
varus was associated with increased medial compartment
ty. J Arthroplasty 2016;31(6):1340-1345. Medline DOI
wear and total wear, thus affecting osteolysis.
The authors of this study performed a retrieval analysis
(macroscopic and radiographic) of 18 VVC liners collected 103. Ritter MA, Davis KE, Davis P, et al: Preoperative
from patients who underwent TKA revision surgery from malalignment increases risk of failure after total knee
1999 to 2011. Patients were matched to another group arthroplasty. J Bone Joint Surg Am 2013;95(2):126-131.
with posterior-stabilized inserts who underwent TKA Medline DOI
revision in the same time period. The authors found sig-
nificantly more damage in the posts of the VVC group This analysis of the effect of preoperative knee alignment
compared with those in the posterior-stabilized group on implant survival after TKA found that patients with
(13.0 ± 5.0 and 4.7 ± 1.9, respectively; P < 0.001). excessive preoperative alignment (greater than 8° of varus
or greater than 11° of valgus) have a greater risk of failure
99. Robertson NB, Battenberg AK, Kertzner M, Schmalzried (2.3%) compared with knees in neutral alignment preop-
TP: Defining high activity in arthroplasty patients. Bone eratively (0.71%).
Joint J 2016;98-B(1 suppl A):95-97. Medline DOI
104. Pang HN, Jamieson P, Teeter MG, McCalden RW, Naudie
The authors of this study used a validated ankle accelerom- DD, MacDonald SJ: Retrieval analysis of posterior stabi-
eter to quantify activity in 20 arthroplasties of the lower lized polyethylene tibial inserts and its clinical relevance.
limbs performed in 13 patients who had active lifestyles. J Arthroplasty 2014;29(2):365-368. Medline DOI
They determined that high levels of physical activity fol-
lowing arthroplasty of the hip or knee can lead to a need Retrieval analysis of 83 posterior-stabilized inserts was
for early revision. done to assess the effect of limb alignment, implant po-
sition, and joint line position on the pattern of wear. The
100. Watts CD, Wagner ER, Houdek MT, Lewallen DG, Mabry results showed a significantly higher total damage score
TM: Morbid obesity: Increased risk of failure after asep- in knees with postoperative varus alignment greater than
tic revision TKA. Clin Orthop Relat Res 2015;473(8): 3° (P = 0.03). The total damage score to the post was sig-
nificantly greater in knees with joint line elevation greater
than 5 mm (P = 0.05). Limb malalignment and joint line
The authors of this study concluded that morbid obesity elevation resulted in more damage to posterior-stabilized
(BMI greater than 40 kg/m 2) is associated with increased inserts.
2: Knee
rates of rerevision, reoperation, and PJI after aseptic revi-
sion TKA. In addition, Knee Society Scores for pain and 105. Solomon LB, Stamenkov RB, MacDonald AJ, et al: Im-
function were significantly higher in patients with a BMI aging periprosthetic osteolysis around total knee arthro-
less than 30 kg/m2 compared with those in morbidly obese plasties using a human cadaver model. J Arthroplasty
patients at 10-year follow-up. 2012;27(6):1069-1074. Medline DOI
Sensitivity and accuracy of measuring osteolysis around
101. Cherian JJ, Jauregui JJ, Banerjee S, Pierce T, Mont MA: TKAs using radiographs, CT, and MRI were examined
What host factors affect aseptic loosening after THA and in a cadaver model of 54 simulated osteolytic defects in
TKA? Clin Orthop Relat Res 2015;473(8):2700-2709. 6 knees implanted with either a cemented or a noncement-
Medline DOI ed TKA. Investigators assessed the presence, location, and
A systematic review was performed to determine which volume of defects on radiographs, CT, and MRI with met-
host factors play a role in the development of clinical and/ al reduction protocols. Results showed that CT and MRI
or radiographic failure from aseptic loosening after THA had significantly higher sensitivities and specificities than
and TKA. Two searches on THA and TKA, respectively, did plain radiographs (P < 0.005), thereby demonstrating
were done using four electronic databases (EMBASE, the limitations of radiographs.
CINAHL Plus, PubMed, and Scopus). For THA, male sex
(odds ratio, 1.39; 95% CI, 1.22 to 1.58; P = 0.001) and 106. Dalling JG, Math K, Scuderi GR: Evaluating the progres-
high activity level (University of California Los Angeles sion of osteolysis after total knee arthroplasty. J Am Acad
activity score of 8 points or higher; odds ratio, 4.24; 95% Orthop Surg 2015;23(3):173-180. Medline DOI
CI, 2.46-7.31; P = 0.001) were associated with aseptic This review article summarizes the risk factors, diagnosis,
loosening. For TKA, no host factors associated with loos- and treatment options for osteolysis after TKA.
ening were found. Level of evidence: IV.
Section 2: Knee
107. Nunez L, Broome B, Pace T, Harman M: Treatment for migration of the constructs, and no evidence of complica-
wear and osteolysis in well-fixed uncemented TKR. ISRN tions was noted in correlation with the use of trabecular
Orthop 2013;2013:398298. Medline DOI metal cones. Level of evidence: IV
This study retrospectively analyzed the clinical outcomes
for selective bone grafting in patients with osteolysis who 111. Barnett SL, Mayer RR, Gondusky JS, Choi L, Patel JJ,
did not undergo complete revision of the TKA in 10 TKAs. Gorab RS: Use of stepped porous titanium metaphyseal
The surgical technique for treating the osteolysis included sleeves for tibial defects in revision total knee arthroplasty:
removal of necrotic bone tissue using curettage, filling of Short term results. J Arthroplasty 2014;29(6):1219-1224.
the defect with bone graft materials, and polyethylene Medline DOI
insert exchange. At final follow-up of 5 years, the revisions In this study, data from 51 patients who underwent revi-
did not exhibit any further complications associated with sion TKA using a metaphyseal sleeve for Anderson Ortho-
osteolysis. The radiographs show total incorporation of paedic Research Institute type II and III tibial defects were
the graft material into the previously lytic regions in all reviewed. At final follow-up (mean, 38 months) 36 patients
patients. Level of evidence: IV. had complete clinical and radiographic data. Significant
improvements in knee range of motion and Knee Society
108. Sculco PK, Abdel MP, Hanssen AD, Lewallen DG: The Scores were observed postoperatively (P <0.001). Four
management of bone loss in revision total knee arthro- revision procedures were needed, but none for aseptic
plasty: Rebuild, reinforce, and augment. Bone Joint implant fixation failure. Level of evidence: IV.
J 2016;98-B(1suppl A):120-124. Medline DOI
This review article summarizes midterm results of highly 112. Huang R, Barrazueta G, Ong A, et al: Revision total
porous metal augments for bone loss in TKA revisions. knee arthroplasty using metaphyseal sleeves at short-
Use of structural allografts has recently decreased because term follow-up. Orthopedics 2014;37(9):e804-e809.
of both an increased failure rate and the introduction of Medline DOI
highly porous metal augments that emphasize biologic
metaphyseal fixation. A prospective analysis was done for 83 knees (minimum
2-year follow-up) in which metaphyseal sleeves were used
in 36 femoral revisions and 83 tibial revisions. The defects
109. Kamath AF, Lewallen DG, Hanssen AD: Porous tantalum were classified according to the Anderson Orthopaedic
metaphyseal cones for severe tibial bone loss in revision Research Institute classification. The mean Knee Society
knee arthroplasty: A five to nine-year follow-up. J Bone function scores improved from 47.9 to 61.1, and mean
Joint Surg Am 2015;97(3):216-223. Medline DOI Medical Outcomes Study 36-Item Short Form physical
The authors reviewed 66 porous tantalum tibial cones at scores improved from 43.3 to 56.3. None of the implants
a mean follow-up of 70 months to assess the intermediate- demonstrated progressive radiolucent lines around the
term clinical and radiographic results. Revision-free sur- metaphyseal sleeves. At final follow-up, two tibial com-
vival of the tibial cone component was greater than 95% ponents (2.7%) required revision for aseptic loosening.
at the time of the latest follow-up. Level of evidence: IV. Level of evidence: III.
2: Knee
110. Derome P, Sternheim A, Backstein D, Malo M: Treat- 113. Alexander GE, Bernasek TL, Crank RL, Haidukewych
ment of large bone defects with trabecular metal cones GJ: Cementless metaphyseal sleeves used for large tibial
in revision total knee arthroplasty: Short term clinical defects in revision total knee arthroplasty. J Arthroplasty
and radiographic outcomes. J Arthroplasty 2014;29(1): 2013;28(4):604-607. Medline DOI
122-126. Medline DOI A retrospective study of 30 revision TKAs using a porous
The authors prospectively analyzed 29 cases of revision titanium tibial sleeve for Anderson Orthopaedic Research
TKA using highly porous trabecular metal cone implants Institute type 2B and 3 defects was undertaken (2-year
for femoral and tibial major bone deficit reconstruction. follow-up). At final follow-up, tibial components were well
At final follow-up at 33 months, the mean Knee Society fixed, with osseous ingrowth. However, seven patients had
Scores and functional scores improved statistically. Ra- end-of-stem pain, which resolved in four patients. Level
diologic follow-up revealed no evidence of loosening or of evidence: IV.
Chapter 21
Revision Total Knee Arthroplasty

R. Michael Meneghini, MD Kelly G. Vince, MD, FRCSC Bradford S. Waddell, MD Geoffrey Westrich, MD
Abstract Keywords: revision total knee arthroplasty;

revision total knee replacement; bone loss;
Diagnosis of the failed total knee arthroplasty (TKA) metaphyseal cones; metaphyseal sleeves;
should proceed in a systematic manner, with insight outcomes; patient satisfaction
into the most common etiologies of failure. Other than
infection, flexion instability has emerged as the most
common reason for early revision TKA. Methods for
reconstruction of bone loss include cement and screws
Introduction
and block augments for moderate defects, and large
defects are managed with metaphyseal porous metal With increasing annual rates of total knee arthroplasty
cones or partially porous modular stepped sleeves. (TKA), the current and projected incidence of revision
Adequate short-term clinical results have been obtained procedures is expected to increase dramatically. One
with both methods. Registry data document a 22% study reported projections that predict that the number
reoperation rate at 10 years after revision TKA. Clinical of knee revision procedures in the United States will dou-
outcomes of revision TKA in young patients and those ble from the year 2005 to 2015 and increase 601% by
undergoing revision for infection are associated with the year 2030.1 Compared with primary TKA, revision
an increased risk of poor outcome. Patient satisfaction procedures are more technically demanding and generally
is also reportedly lower with revision TKA than with have higher risks of complications. Therefore, it is critical
primary TKA, and is even lower for those undergoing that surgeons understand the principles of the evaluation,
revision for infection. etiologies of failure, surgical reconstruction and clinical
outcomes associated with revision TKA.
2: Knee
Diagnosis and Surgical Treatment of Revision TKA
Dr. Meneghini or an immediate family member has received
royalties from DJ Orthopaedics and Stryker; serves as a paid R. Michael Meneghini, MD
consultant to DJ Orthopaedics and Stryker; and serves as a Despite the long-term clinical success of TKA, with re-
board member, owner, officer, or committee member of ported survivorship greater than 95% at 15 years,2,3 some
the Knee Society. Dr. Vince or an immediate family member patients will experience clinical failure. Many etiolo-
has received royalties from Zimmer and is a member of a gies of dysfunction and pain can be reported following
speakers’ bureau or has made paid presentations on behalf TKA;4-6 however, they are often systematically grouped
of Zimmer. Dr. Westrich or an immediate family member into two large categories to consider: intrinsic or intra-
is a member of a speakers’ bureau or has made paid pre- articular and extrinsic or extra-articular.
sentations on behalf of DJ Orthopaedics, Exactech, and
Mallinckrodt Pharmaceuticals; serves as a paid consultant Systematic Approach
to DJ Orthopaedics, Exactech, and Stryker; has received A stepwise approach to management of the painful TKA
research or institutional support from DJ Orthopaedics, should use the history, physical examination, and plain
Exactech, and Stryker; and serves as a board member, owner, radiographs to identify many of the causes. The history
officer, or committee member of the Eastern Orthopedic and physical examination can help identify and/or elim-
Association and the Knee Society. Neither Dr. Waddell nor inate most extrinsic etiologies. The final requisite test
any immediate family member has received anything of val- is a plain radiograph, which can identify many of the
ue from or has stock or stock options held in a commercial intrinsic causes of pain, particularly if serial examina-
company or institution related directly or indirectly to the tions are available. The radiographic evaluation of revi-
subject of this chapter. sion TKA varies and is not well described.7 However, a
Section 2: Knee
recent update to the Knee Society Radiographic System adjunct to confirm intra-articular and extra-articular
has expanded to include recommendations for radio- pathology, particularly aseptic loosening, soft-tissue im-
graphic evaluation of the revision TKA.8 Every painful pingement, and pes anserinus bursitis. It can also be a
knee arthroplasty should undergo a full evaluation with useful diagnostic modality to help differentiate psycho-
plain radiography that should include weight-bearing AP, somatic issues from true pathology in certain patients.
lateral, and Merchant (patellar) views. For most patients However, if the etiology for pain after TKA cannot be
with a painful TKA, basic laboratory tests that include determined, revision TKA is not recommended. A low
a complete blood cell count, erythrocyte sedimentation probability of success has been reported with revision
rate, and C-reactive protein can identify the possibility of TKA for unexplained pain.13
an occult infection. If the etiology of pain has not been The goals of revision TKA include proper axial limb
conclusively determined following those efforts, advanced alignment, accurate positioning and adequate fixation
imaging such as CT or MRI can be performed. Bone of prosthetic components, symmetric ligament balance
scanning is rarely indicated because of high false-positive in flexion and extension, satisfactory patellofemoral me-
and false-negative rates. Knee aspiration or injection may chanics, and an acceptable knee range of motion. These
also provide further confirmatory evidence of a suspected goals, particularly proper ligamentous balance and pros-
etiology for pain. thetic fixation, depend greatly on the management of
bone loss. The magnitude of bone loss has important
Flexion Instability implications for decisions regarding the use of bone graft
Flexion instability has emerged as a leading early cause or prosthetic augmentation, choice of prosthesis sizing,
of revision, in addition to periprosthetic infection, in selection of prosthetic articular constraint, and need for
TKA.9 The diagnosis can be challenging, although it can supplemental stem fixation.
be typically made with an appropriate clinical and radio-
graphic evaluation. Patients present with pain and a sense
of instability, typically on stairs or with flexion activities. Reconstruction for Bone Loss
A physical examination demonstrates increased antero- Bone Loss Assessment
posterior translation or coronal plane instability with the The critical step in determining the appropriate recon-
knee at 90° of flexion as well as pes anserinus tenderness. struction method in revision TKA is to accurately deter-
Radiographs typically will demonstrate one or more of mine the quantity, location, and extent of the bone loss.
the following radiographic findings: increased posterior After the components are removed, it is important to
tibial slope, inadequate posterior condylar offset, or dis- determine whether the defects are contained or uncon-
2: Knee
talization of the femoral component typically resulting tained (segmental). In addition, the location of supportive
from inadequate distal femoral bone resection. One study bone that surrounds the bone loss is essential because it
described successful surgical correction that increased the determines the type and size of augmentation required.
posterior condylar offset, removed the posterior slope, Smaller contained defects can be treated with either ce-
and in some cases, raised the joint line.10 The published ment fill with screw augmentation or morcellized allograft
clinical reports document that successful surgical correc- fill, particularly in older patients. However, larger, un-
tion of patients with flexion instability with revision TKA contained defects typically require larger reconstruction
will improve their function and outcomes.10,11 However, measures such as modular block augments, bulk allograft,
the degree of improvement in function after revision TKA or highly porous metal metaphyseal cones.
for flexion instability will not typically be as great as that
in patients who undergo revision for aseptic loosening Cement and Screws
and other traditional diagnoses, which is partly a result The use of cement as a reconstruction augment has the
of unmet patient expectations.12 benefits of being simple, inexpensive, and efficient because
the revision TKA is already using the material for fixation
Establish Etiology Prior to Revision TKA in most instances. This reconstruction method is typically
It is critical to identify the etiology of the painful TKA indicated for smaller, contained defects less than 5 mm
before surgical intervention, particularly revision surgery. deep,14,15 although some authors have advocated its use
Use of a systematic approach as described previously will in larger defects with excellent clinical results.16-18 When
facilitate identification of the correct diagnosis and guide cement is used for defects in revision TKA, augmentation
the surgical intervention, as well as help the surgeon to with bone screws are typically recommended to enhance
discuss and outline the appropriate expectations for the the biomechanical properties of the construct. A series of
patient. Intra-articular lidocaine injection can be a useful 609 revision TKAs reported an excellent survivorship of
Chapter 21: Revision Total Knee Arthroplasty
98.6% at 17-year follow-up in knees that received screws clinical outcomes.21,22 Favorable early results have been
and cement augmentation for bone defects.18 The smaller, recently supported, with longer term results on the tibial
contained defects encountered in revision TKA, partic- side:23 66 revisions with porous tantalum metaphyseal
ularly in older or less active patients, are appropriate for cones were reported at 5- to 9-year clinical follow-up.
the use of screws and cement, which is a viable, successful One patient had progressive radiolucencies about the
method of reconstruction that is inexpensive, relatively tibial stem and cone on radiographs. One patient had
simple, and efficient. complete radiolucencies about the tibial cone, a concern
for fibrous ingrowth. A revision-free survival rate for the
Structural Allograft porous metal metaphyseal cones greater than 95% was
Bulk structural allograft historically has been used to reported at latest follow-up. Recently, early results of the
reconstruct large bone defects with the intention of pro- treatment of femoral metaphyseal bone loss with these
viding mechanical support and reconstituting bone, which porous tantalum cones has been encouraging. Porous
are considered advantages of this technique. However, tantalum cones were implanted in femoral metaphyseal
the disadvantages are the potential for graft resorption, defects during revision TKA and all cones were radio-
collapse, and graft-host nonunion. Patient factors, in- graphically well fixed at a minimum 2-year clinical and
cluding health status, physiologic age, bone quality, and radiographic follow-up.24 These encouraging results for
activity level, must be considered when contemplating durable short- and longer term fixation in the setting of
this reconstruction technique over other strategies such as bone loss have resulted in a substantial increase in clinical
using porous metal cones. A retrospective study reviewed use with surgeons who perform revision TKA.
65 knees that underwent revision TKA with bulk allograft
for large bone defects and reported a 10-year revision-free Partially Porous, Stepped Metaphyseal
survivorship of 76%.19 Sixteen patients (22.8%) had un- Modular Sleeves
successful outcomes and underwent additional surgery; Noncemented, partially porous, tapered titanium sleeves
eight were a result of allograft failure, and three were a re- have been used to treat larger metaphyseal tibial and
sult of failure of a component unsupported by allograft. A femoral defects in revision TKA. The indications for these
recent review of the treatment of revision TKA using bony titanium sleeves are similar to those for metaphyseal po-
structural allografts (476 cases) and porous metal cones rous metal cones discussed in the previous section. The
(223 cases) reported a decreased rate of loosening for advantages of these implants are the ease of insertion with
porous metal cones in Anderson Orthopaedic Research an aggressive and accurate broaching system, as well as a
Institute classification 2 and 3 defects. The overall failure robust modular taper connecting the sleeve to the tibial
2: Knee
rate was also substantially lower in the porous metal cone and femoral components, which obviates the need for
group than the structural allograft group.20 These reports cement to unite the sleeve and bearing implant.
suggest that reconstruction of bone defects in revision Excellent clinical results with the noncemented, par-
TKA are likely more reliable with modern porous metal tially porous titanium sleeves have been reported and
augments. early-term success was demonstrated.25-29 A prospective
study followed 121 patients with 193 titanium sleeves that
Porous Metal Metaphyseal Cones included 119 tibial and 74 femoral sleeves for a mean of
Highly porous metal metaphyseal cones have recent- 3.6 months;25 of these, 14 patients underwent revision:
ly been developed for large tibial and femoral defects 3 for infection and 11 for loosening, instability, or me-
and were designed to avoid the incidence of nonunion chanical failure.25 In another series, 35 revision TKAs
and resorption associated with bulk allograft recon- in 34 patients were reported at a minimum clinical and
structions. Highly porous metals, particularly porous radiographic follow-up of 2 years.26 Stem extensions were
tantalum, are biomaterials that offer several potential used in only a portion of the procedures in which bone
advantages over traditional materials and include low loss was more severe. In the revision TKAs performed for
stiffness, high porosity, and a high coefficient of friction. mild or moderate bone loss, only the sleeve and cemented
These porous metal metaphyseal cones are designed to tibial tray or femoral component were used for fixation
treat the various patterns of severe bone loss encoun- without the use of a stem extension, and only one re-
tered during revision TKA, in addition to providing me- revision was reported for femoral cone failure at 3 years
chanical support with biologic integration and to avoid postoperatively. In a 2013 series of 40 revision TKAs
allograft nonunion and resorption. Initial excellent re- using a tibial porous coated titanium sleeve for Anderson
sults were reported for highly porous tibial metaphyseal Orthopaedic Research Institute type 2B or 3 defects,
cones, with excellent radiographic osseointegration and 10 patients were lost to follow-up and no mechanical
Section 2: Knee
failures related to the tibial cone were reported at a min- Clinical Outcomes
imum follow-up of 2 years.29
The surgical techniques described previously vary Kelly G. Vince, MD, FRCSC
and include allowing the tibial baseplate to sit proxi- Understanding the results of revision TKA is problem-
mal to the tibial metaphyseal bone surface as long as atic.33 Confusion exists in the literature regarding what
the titanium sleeve is rotationally and axially stable, comprises a revision arthroplasty: some series include
as well as allowing the sleeve to be implanted without single-component revisions or modular polyethylene ex-
stem extensions in cases of adequate sleeve mechanical changes and others do not. Few series have a minimum
stability. 25,26,29 However, these practices should be fol- 10-year follow-up. Cases are divided differently as to the
lowed cautiously because of the short-term follow-up of cause of failure: the results of septic and aseptic revisions
these reports and the unknown clinical consequences of differ, as do the results for tibiofemoral instability and
surgical techniques that place large stresses and forces poor motion. No consistency exists for describing mode
at the taper junction of the sleeve and tibial or femoral of failure, even among registries.34 Radiographic report-
component via unsupported implants or lack of stem ing is not uniform.7 An unwitting bias exists against the
extensions that engage the femoral or tibial diaphysis. publication of poor results and many series report the
One series reported two cases of implant failure be- experience with a specific prosthesis, which suggests a
cause of mechanical breakage at the stem-sleeve junc- selection bias, of cases that were appropriate for the de-
tion, likely secondary to fatigue failure.25 Therefore, it is vice studied.
recommended that stem extensions be used, along with Only registries in Australia35 and New Zealand36 regu-
careful optimization of the tibial and femoral component larly publish the results of revision arthroplasty. Australia
cementation technique to ensure interdigitation with the reports only first revisions and only those performed for
host bone at the joint level to avoid large cyclic in vivo aseptic failure. With this optimistic bias, aseptic first revi-
loads at the modular taper junction interfaces over the sions are re-revised at 10 years in more than 22% of cases
long term. (29.7% if the first revision was insert only, 25.2% for
femur only, 22.2% for tibia only, and 24.3% for complete
Cemented or Noncemented Stems revisions). The discrepancy between registry data and
The use of cemented or noncemented stems to augment published series suggests that superior results should not
tibial and femoral prosthetic fixation remains contro- be assumed without requisite knowledge and experience.
versial. It is generally accepted that for revision TKA Registry data are a tremendous, but imperfect re-
performed in the setting of bone deficiency, stem aug- source37,38 that may be skewed by the fact that to be iden-
2: Knee
mentation is required to supplement implant fixation by tified as a failure, a revision will have to be re-revised.
bypassing the deficient bone and achieving fixation in Some failures will be abandoned as inoperable and so
the viable metaphyseal or diaphyseal bone. Also, when become “successes” in registry data. Registries do not
additional tibiofemoral constraint is used, it is accepted track procedures that indicate failure such as amputation,
that stem supplementation is necessary to help resist the arthrodesis, and resection arthroplasty. Many clinical
articular forces transmitted from the constraint to the series that describe new techniques for complex surgical
implant fixation interface. Adequate long-term results problems lack control subjects and are extremely diffi-
have been reported with both cemented and press-fit cult to evaluate.39 Other series evaluate variables (such
noncemented stem fixation in revision TKA, with greater as joint line position and patellar resurfacing) that are
than 90% survivorship at 10-year follow-up with both confounding variables associated with the severity of the
fixation types.30-32 However, given the lack of compar- failure being treated.
ative studies, the choice of cemented or noncemented The failed unicompartmental knee arthroplasty (UKA)
stems remains a choice based on personal philosophy, has unique challenges. A case-control study from the
past experience, and intraoperative judgment. Irrespec- New Zealand Joint Registry reported 205 UKAs revised
tive of fixation type, close attention should be given to to TKA and 31 revised to UKA. When UKA was revised
cement techniques to ensure adequate implant stability. to another UKA, the rate of re-revision was 13 times
However, if supplemental press-fit noncemented stem higher than for primary TKA. The re-revision rate for
fixation is used, it is advised to ensure adequate tibial UKA converted to TKA was four times higher than for
or femoral prosthesis cementation into the metaphyseal primary TKA. The study concluded, “The poor outcome
region while achieving intimate endosteal contact and of a UKA converted to a primary TKA compared with a
interference fit of the noncemented stem into the meta- primary TKA should contraindicate the use of a UKA as a
diaphyseal region.31,32 more conservative procedure in the younger patient.”36 An
alternative might be a more aggressive approach to revi- classification higher than 2, wound classification higher
sion of the failed UKA, similar to revision of a failed TKA. than 2, emergency surgery, and pulmonary comorbidity
were factors associated with major complications.44 The
Revision TKA in the Younger Patient risk of prosthetic joint infection developing after aseptic
The young patient is at higher risk of poor outcome. As TKA revision was 1.0%, 2.4%, 3.3%, and 5.6% at 1,
with primary TKA,40 age is a strong predictor of revision 5, 10, and 20 years, respectively. Male sex, constrained
arthroplasty failure. In one study, 84 patients younger than implants, increased surgical times, increased Charlson
50 years were matched for date of surgery, sex, and body Comorbidity Index, and a history of liver disease were
mass index. The most common reason for the original significantly associated with prosthetic joint infection; less
revision in the younger group was aseptic loosening (27%) strongly associated factors were cardiovascular disease,
and infection in the older group (30%). Of 25 re-revisions endocrine disorders, and renal disease.45
in patients in the younger group and 26 in patients in In a retrospective study of 175 revision TKAs, male
the older group, 32% and 50%, respectively, were per- sex, lower Charlson Comorbidity Index, and higher pre-
formed for septic failure. Cumulative survival rates were operative functional KSS predicted superior functional
comparable: 71.0% for the younger group and 66.1% for outcome as measured by using KSS. Lower preoperative
the older group, which indicates a large burden of failed pain and higher clinical KSS were associated with better
arthroplasties. Infection and body mass index in excess of outcome as measured by the pain scale of the Western
40 kg/m2 were associated with higher risks of failure over- Ontario and McMaster Universities Osteoarthritis Index
all.41 Another study noted similar problems with revision score 2 years postoperatively.46
TKA in patients younger than 55 years, when compared
with a control group of young patients matched for age,
sex, body mass index, and comorbidities undergoing pri- Patient Satisfaction After Revision TKA
mary TKA. Revision arthroplasties required re-revision Bradford S. Waddell, MD; Geoffrey Westrich, MD
in 17% of cases at a mean of 4.6 years. Although the rates Patient Expectations and Characteristics
of minor complications and UCLA activity scores were Patient satisfaction begins with the patient’s expectations
similar in the two groups, improvements in Knee Society as they begin their surgical process. More importantly, it
Score (KSS) were lower in the revision group. Peripros- is necessary to define and contrast patient expectations
thetic infection and instability were the most common and patient desires. One study found patient expecta-
problems in the revision group. A failed revision TKA is tions to be the scenario that the patient likely thinks will
ominous in the young patient; subsequent revisions fail occur in the surgical scenario, contrasted to patient de-
2: Knee
at an even higher rate in all patients, and patients in the sires, which are the patient’s wishes that a given event
younger group generally have higher levels of physical occurs.47 One study reported patient expectations to be
activity for longer periods following revision. Revision highly indicative of improved postoperative outcomes and
TKA in the young patient is technically demanding, with satisfaction after total joint arthroplasty.48 Patients who
little allowance for poor decisions or technique. expected fewer complications and complete pain relief
had better pain relief and functional improvement than
Predictors of Outcome Following Revision TKA those who expected complications or lack of pain relief.
Several studies have identified risk factors for adverse Expectations can differ by region.49 The expectations of
results after revision TKA. The outcome of revision for patients undergoing TKA in the United States, United
infection is worse than for aseptic failure by several cri- Kingdom, and Australia were compared and differing
teria, including mortality rates. When 88 septic revisions levels of expectations were reported, ranging from pain
were compared with matched aseptic revisions, the overall relief to functional outcome. These differences could
mortality rate at median 4 years was 10.7%.42 However, not be explained by sociodemographic factors, clinical
the mortality after septic revision (18%, 16 patients) was characteristics, or pain and functional status. A study
six times higher than that of aseptic revision (3%, 3 pa- on satisfaction after knee arthroplasty, including some
tients) (P = 0.003). In one study, the risk of readmission to knee revisions, reported regional variations after primary
hospital within 30 days of revision TKA was associated and revision knee arthroplasty.50 In addition, lower level
with female sex, general anesthesia, and a past history of education, presence of obesity, and revision surgery
of transient ischemic attack.43 were factors reported to be associated with lower patient
Preoperative dialysis was associated with minor com- satisfaction.
plications within 30 days of revision TKA and male sex, Of similar importance as expectations, certain patient
increased age, American Society of Anesthesiologists factors can affect outcome after total joint arthroplasty.
Section 2: Knee
One prospective study reported preoperative depression than did patients undergoing revision TKA (22% versus
and anxiety symptoms to predict more pain at 1 year 13%; P < 0.001). Overall, 83% of those undergoing pri-
after TKA.51 Furthermore, heightened preoperative pain mary TKA were satisfied; 66% reporting being satisfied
was found to be an independent risk factor for poor out- following revision TKA. General well-being was assessed
come. A 2012 meta-analysis reported that in TKA, low using the EuroQol Five Dimension score and the highest
preoperative mental health and increased pain resulted postoperative scores in revision cases were found in those
in worse outcomes and increased pain after surgery.52 A patients with revision for aseptic loosening or lysis. The
2015 retrospective study evaluated patient-reported al- lowest scores were found in patients who underwent re-
lergies as they relate to postoperative patient satisfaction vision for stiffness. In contrast, another prospective study
and outcomes after lower extremity arthroplasty and found that although physical function scores improved
reported that increasing patient-reported allergies were significantly from preoperative scores for both prima-
associated with less satisfaction and decreased pain and ry and revision TKA, mental scores did not statistically
function scores after lower extremity arthroplasty.53 improve from preoperative to postoperative.58 The study
Although these are average values and trends and do followed 100 consecutive TKAs and 60 revision TKAs
not apply to every patient in every scenario, it must be and compared preoperative pain, function, and mental
recognized that patient satisfaction after surgery cannot scores with those obtained at 6 months and 12 months
simply be measured by proper alignment of the prosthesis. postoperatively. However, the mental scores showed no
The patient as a whole must be assessed and the patient significant change from preoperative levels in both pri-
should be educated on what to expect postoperatively. mary and revision cases. This study highlights the po-
Further, these studies are based on primary total joint tential differences in patient pain and function compared
arthroplasty and must be evaluated in that context. with patient satisfaction. In a study of 175 consecutive
patients, functional and satisfaction outcomes were re-
Patient Satisfaction With Primary TKA ported in patients undergoing aseptic revision TKA.59 In
TKA has a high level of success.2,54 One study reported all patients, approximately 37% were “very satisfied,”
15-year clinical survivorship of 94.6% in the total con- 32% were “somewhat satisfied, 27% were “somewhat
dylar knee. Using the Hospital for Special Surgery Knee dissatisfied, and less than 5% “very dissatisfied.” Al-
Score, which measures satisfaction by rates of pain and though revision for both aseptic loosening and instability
function, good results were reported in 34% of patients provided improvement in patient satisfaction, revision
and excellent results (score 85+) were reported in 58% of for instability did not provide the level of satisfaction in
patients. A 2015 meta-analysis found patient satisfaction patients undergoing revision for aseptic loosening. Of all
2: Knee
to generally be high after TKA: approximately 75% of patients, 63% said they would undergo the procedure
patients were satisfied, and 79.5% would undergo the again, 16% would not, and 21% were “unsure.” A pro-
surgery again.55 spective study of 94 patients undergoing revision TKA
over a 5-year period reported on the health-related quality
Patient Satisfaction With Revision TKA of life.60 Those patients undergoing their first revision had
Although primary TKA offers objective goals and typi- higher health-related quality of life than those undergoing
cally follows standard intraoperative and postoperative a second revision and those undergoing more than two
protocols, revision arthroplasty performed for any reason revisions (postoperative KSS was 138, 131, and 110, re-
has many more variables. These variables provide less spectively). Similarly, those patients undergoing revision
definitive information for the patient and can leave many for septic reasons had lower health-related quality of life
questions unanswered before the procedure. Therefore, than those undergoing revision for aseptic reasons (post-
a retrospective review was conducted of the differences operative KSS was 113 and 128, respectively). Finally,
between 60 revision TKAs and 199 primary TKAs.56 The those patients who were revised to constrained prosthesis
study compared preoperative and postoperative pain, achieved the lowest health-related quality of life scores
function, and satisfaction scores between the two groups (postoperative KSS, 103).
and concluded that patient-reported satisfaction at 2-year Many studies compare satisfaction after aseptic revi-
follow-up was inferior in revision cases when compared sion to satisfaction after septic revision. A clinical out-
with primary cases. One retrospective study analyzed pro- comes study compared 33 revision knee arthroplasties
spectively collected patient-reported outcome measures with 15 revised for sepsis.61 The patients were followed
in 24,190 patients with 23,393 TKAs and 797 aseptic for 30 to 130 months, and overall, patients with revisions
revision TKAs.57 Almost twice as many patients rated for sepsis were less satisfied than those with revisions for
their postoperative results as “excellent” in primary TKA aseptic reasons. Furthermore, although aseptic revisions
had significantly better knee scores and range of motion Summary

than did septic revisions, the difference in pain and func-
tional scores did not differ significantly. However, both The basic principles of revision TKA are to ensure an
septic and aseptic revisions had an overall satisfaction after accurate diagnosis and etiology via a detailed systematic
surgery of approximately 85%. In a prospective series of approach, with subsequent reconstruction with modern
revision TKAs performed at three centers, patient satis- methods such as highly porous metal metaphyseal cones
faction and outcomes were compared in cases treated for or partially porous modular stepped sleeves. Patients and
septic and aseptic reasons.62 No significant difference in surgeons should be aware that clinical outcomes and pa-
pain scores was reported between the two groups. Patients tient expectations are diminished compared with those for
treated for septic causes were more likely to be dissatisfied primary TKA. However, if an appropriate reconstruction
with their ability to return to activities of daily living com- is performed for an identified diagnosis, revision TKA
pared with those with aseptic revisions; however, overall can result in improved clinical outcomes.
“dissatisfaction” ratings with the results of surgery were
similar between the two groups (12% and 11% for septic Key Study Points
and aseptic revision, respectively; P > 0.5). One study
• Flexion instability is the leading cause of revision
followed 54 patients who underwent septic or aseptic re-
TKA; clinical and radiographic evaluation are crit-
vision TKA for 40 months. Regarding functional score,
ical for diagnosis.
revisions for patellar maltracking and loosening had the
• Porous metal metaphyseal cones and partially po-
highest preoperative functional scores (KSS, 44.8) and im-
rous modular stepped sleeves are modern recon-
proved to the highest postoperative functional scores (KSS,
struction options associated with favorable early
82.2). In addition, these patients had the highest preoper-
results.
ative and postoperative Medical Outcomes Study 36-Item
• Patient satisfaction can be associated with certain
Short Form (SF-36) scores at 60.8 and 60.2, respectively.
patient factors and trends, and is higher with pri-
Comparing the septic revisions with aseptic loosening
mary TKA than with revision TKA.
and aseptic stiffness, revision for infection had the largest
improvement from preoperative to postoperative scores
in KSS (35.1 to 77.1) and SF-36 mental (42.3 to 55.5).
Revision for stiffness started with the lowest preoperative Annotated References
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2: Knee
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2: Knee
An American Society of Anesthesiologists classification of Psychologic factors that affect outcomes of TKA include
3 or higher, increased surgical time, older age, and greater low preoperative mental health and pain catastrophizing.
body mass are predictive factors affecting development of
postoperative complications, and patient age and diabetes
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Improvement in pain and function was reported, leading
46. Kasmire KE, Rasouli MR, Mortazavi SM, Sharkey PF, to patient satisfaction. Level of evidence: II (therapeutic).
Parvizi J: Predictors of functional outcome after revision
56. Greidanus NV, Peterson RC, Masri BA, Garbuz DS: 60. Deehan DJ, Murray JD, Birdsall PD, Pinder IM: Quali-
Quality of life outcomes in revision versus primary total ty of life after knee revision arthroplasty. Acta Orthop
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outcomes. Level of evidence: III (therapeutic). ment. Knee 2010;17(3):200-203. Medline DOI
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RW: Early patient outcomes after primary and revision sion TKA than in those undergoing aseptic revision TKA.
total knee arthroplasty. A prospective study. J Bone Joint However, revision TKA for stiffness in those undergoing
Surg Br 2002;84(7):994-999. DOI Medline aseptic revision TKA was associated with the poorest
outcomes.
59. Malviya A, Brewster NT, Bettinson K, Holland JP, Weir
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2: Knee
Chapter 22
Perioperative Pain Management

in Knee Arthroplasty
Colin T. Penrose, MD John W. Barrington, MD
Pain control is an important component of the peri- Total knee arthroplasties (TKAs) and unicompartmen-
operative care of patients undergoing total knee arthro- tal knee arthroplasties represent definitive treatment of
plasty. Successful analgesia requires active involvement advanced arthritis and osteonecrosis of the knee with
and pathways designed for the preoperative, intraopera- unsuccessful nonsurgical management. Knee arthroplasty
tive, and postoperative periods. Modern approaches seek improves functionality and quality of life and relieves
to minimize complications and overreliance on opioids, pain in the long run; however, it can be associated with
instead using various modes of analgesia modulating the marked pain and a difficult recovery process. Fear of pain
pain pathway. Recent advances in preemptive analgesia, is a reason patients commonly cite in delaying surgical
neuraxial and peripheral nerve blockade, periarticular intervention.1 Recent efforts to improve patient control
injections, and combinations of oral and intravenous have shifted the paradigm to preemptive, multimodal,
medications seek to optimize pain control and facilitate and opioid-sparing analgesic approaches. These pathways
early recovery from total knee arthroplasty. and advances in neuraxial and peripheral nerve blockade,
periarticular injections, and adjuvant therapies seek to
make knee arthroplasty safer and less painful. The im-
Keywords: total knee arthroplasty; multimodal portance of pain management in the perioperative period
2: Knee
analgesia; preemptive analgesia; neuraxial and cannot be overemphasized. Uncontrolled pain may limit
peripheral blockade; periarticular injection participation in the physical rehabilitation process. Early
mobilization is one of the tenets of successful recovery
from knee arthroplasty and has been shown to increase
satisfaction and decrease rates of thromboembolism, re-
operation, and manipulation under anesthesia. The goals
of minimizing pain in the postoperative period must be
balanced with the risks of the analgesic modalities. Addi-
Dr. Barrington or an immediate family member has received tionally, the cost benefit question can be considered from
royalties from Zimmer Biomet; serves as a paid consultant an economic standpoint. Multimodal therapy involving a
to Zimmer Biomet, Mallinckrodt Pharmaceuticals, Pacira team of coordinated professionals may appear to be costly
Pharmaceuticals, and Smith & Nephew; has stock or stock in both time and money, but it yields proven savings in
options held in Iconacy Orthopedic Implants; has received the long run.2
research or institutional support from Zimmer Biomet and
Pacira Pharmaceuticals; and has received nonincome sup-
port (such as equipment or services), commercially derived Preoperative Pain Management
honoraria, or other non–research-related funding (such as Pain management should begin in the preoperative pe-
paid travel) from Tier 1 Healthcare Education & Research. riod with clear expectations and communication be-
Neither Dr. Penrose nor any immediate family member tween the patient and the surgeon. Modifications such
has received anything of value from or has stock or stock as patient education classes, prehabilitation physical
options held in a commercial company or institution related therapy, and facility tours may help patients under-
directly or indirectly to the subject of this chapter. stand what will be involved in the recovery and may
Section 2: Knee
even improve postoperative pain control, outcomes, and involves the use of inhalational gases and intravenous
satisfaction.3-6 Documenting preoperative opioid use is medications to render the patient unconscious and unable
important because it may necessitate deviation from the to register pain. Intubation is required because patients
normal pain management protocol and is predictive of are temporarily paralyzed and unable to protect their
increased postoperative pain.7-9 Other preoperative fac- airways. In neuraxial anesthesia, medications are injected
tors important for pain control, including assessment of or administered via continuous catheter infusion into the
allergies and risk stratification, should also be used for epidural or spinal compartments to prevent sensation be-
venous thromboembolism risk, antibiosis, and bleeding low the selected spinal level. Patients retain consciousness,
risk. For many patients, aspirin and early mobilization though they often receive amnestic medications. Studies
are sufficient protection from deep vein thrombosis. Ce- have found that neuraxial and regional anesthesia and
fazolin and/or vancomycin provide antibiotic coverage. analgesia produce better pain control with fewer adverse
To prevent excessive bleeding, hematoma, anemia, and effects compared with general anesthesia.20,21
transfusion, surgeons pursue meticulous hemostasis, use
tourniquets,10 and administer off-label intravenous or Regional Anesthesia and Nerve Blocks
intra-articular medications such as tranexamic acid11-14 or Local anesthetic agents or morphine derivatives can be
aminocaproic acid.15-17 Assessment of stress and patients’ administered into the epidural or intrathecal space either
stress response may also help predict which patients will as a one-time injection or via continuous dosing with
have good results after knee arthroplasty.18 Although each an epidural catheter. This allows significant pain relief
of these may not be traditionally considered pain control that can be maintained for several days postoperatively.
therapies, they do prevent painful complications. Several studies have demonstrated the safety and efficacy
of this approach. The risk of bleeding leading to epidural
hematoma, especially in patients receiving anticoagula-
Surgical Factors tion therapy, has prompted the use of extended-release
Knee arthroplasty is performed through a longitudinal epidural morphine derivatives. There are other important
medial parapatellar approach with several variations: the risks of which to be aware, including respiratory depres-
midvastus, subvastus, quadriceps snip, V-Y turndown, and sion, hypotension, nausea, pruritis, and motor blockade,
tibial tubercle osteotomy. The more invasive approaches which can delay early physical therapy programs.
are generally needed only for revision TKA. Retained Peripheral nerve blocks target pain transmission in a
hardware from previous surgical procedures to manage more specific fashion and avoid many of these adverse
tibial plateau fractures, anterior cruciate ligament recon- effects. In knee arthroplasty, combinations of targets may
2: Knee
structions, and osteotomies can make knee arthroplasty include the femoral, 22 fascia canal, 23 adductor canal, 24 sci-
more challenging. Revision TKA tends to be more painful atic, and saphenous nerves. Similar to epidurals, strategies
and results in a difficult recovery process that requires include either single-shot administration or continuous or
additional attention to pain control. Medial unicompart- intermittent dosing of peripheral nerve blocks via cath-
mental knee arthroplasty involves minimal bone cuts and eter.25,26 Depending on the dosing, the target nerve, and
preserves the native ligaments, but still warrants careful how proximally the nerve is blocked, motor deficits can
attention to pain control. The treatment of the patella is a occur with peripheral blocks. Studies show that different
topic of ongoing debate; some surgeons routinely resurface combinations of peripheral nerve blocks have demon-
it and others do so only if evidence of arthritic change strated good results, 27,28 but more trials are needed to
exists. Circumferential patellar deinnervation with elec- demonstrate superiority compared with local infiltration,
trocautery can decrease transmission of pain.19 epidural, or spinal analgesia.29
Local Periarticular Injections

Anesthesia Intraoperative infiltration of combinations of medications
The anesthesiology team plays an important role in TKA, in the periarticular tissues can help decrease postoperative
and many of the advances in this realm have resulted in pain. Combinations of medications may include local
less postoperative pain and earlier patient participation in anesthetic agents (often of varying durations), morphine
rehabilitation. Several modalities for intraoperative anes- sulfate, epinephrine, corticosteroids,30 and antibiotics.
thesia and postoperative analgesia are currently available Abundant evidence supports local periarticular injections
to the anesthesiology team. as part of a multimodal regimen.31-33 The local anesthetic
The anesthesia component consists of general anes- bupivacaine has been produced in a new multivesicular
thesia, neuraxial anesthesia, or both. General anesthesia liposomal formulation, which has been shown to prolong
Chapter 22: Perioperative Pain Management in Knee Arthroplasty
Table 1
List of Commonly Used Perioperative Pain Medications for Knee Arthroplasty
Routes of
Class Example Administration Mechanism Comments
NSAID Ketorolac Oral/intravenous/ COX inhibition Potent NSAID; limit
intramuscular to several doses
Ibuprofen Oral/intravenous
Celecoxib Oral COX-2 specificity
limits
gastrointestinal
side effects
Opioid Morphine Intravenous/ Opioid receptor Short-acting
patient-controlled modulation
analgesia
Fentanyl Intravenous/ Short-acting, less
patient-controlled nausea
analgesia
Hydromorphone Oral/intravenous/ Potent, fewer side
patient-controlled effects
analgesia
Oxycodone Oral Intermediate-acting
Oxycodone Oral Long-acting
sustained release
Neuromodulator Gabapentin Oral CNS calcium Targets neuropathic
channel pain
Pregabalin Oral
modulation
Other Acetaminophen Intravenous/oral Unknown, CNS
Tramadol Oral Unknown Some opioid
agonist effect
2: Knee
CNS = central nervous system; COX = cyclooxygenase.
the effects and decrease its diffusion.34 Liposomal bupiv- intravenous opioids may still play a role,41 especially for
acaine has been shown in several studies to be both safe some patients, modern pain management protocols rely
and effective in relieving pain with TKA.34-39 Others have more heavily on alternative classes of medications. This is
not found liposomal bupivacaine to improve pain con- mainly because of the numerous common adverse effects
trol.40 It is likely that injection technique plays a critical of opioids rather than their level of effectiveness. Nausea,
role in the efficacy of liposomal bupivacaine. Because of somnolence, dizziness, pruritis, urinary retention, and
the limited diffusion capability liposomal bupivacaine, it respiratory depression all are risks, and use of this class
must be injected into 50 to 100 sites with small volumes of medication has been associated with prolonged hospi-
through a small needle (22 gauge or similar), covering the talization.42 In addition to these side effects, dependence
entire field at multiple depths and superficially focusing on on cumbersome machines interferes with early mobili-
the medial aspect of the incision because of the orientation zation and physical therapy. Carefully monitored doses
of the nerve fibers. The capsule, synovium, extensor mech- administered on an as-needed basis and alternative routes
anism, collateral ligaments, iliotibial band, pes anserinus of administration (such as sublingual administration of
tendons, and posteromedial and posterolateral structures sufentanil) may alleviate some of these risks.43 Although
should all be targeted. opioid-sparing, multimodal analgesia is becoming the
standard of care, a recent nationwide study showed vari-
Oral and Intravenous Medications ations in widespread adoption remain.44
Traditionally, patient-controlled analgesia (PCA) with In addition to the previously mentioned anesthetic and
intravenous opioid pain medication was the mainstay of analgesic modalities, several classes of oral and intrave-
postoperative treatment after TKA. Although oral and nous medications have been shown to provide greater
Section 2: Knee
Table 2
Sample Opioid-Sparing Regimen
Preemptive Intraoperative With Anesthesia Input Postoperative
Celecoxib 200 mg Straight general anesthesia for Acetaminophen 3,000–
unicompartmental knees, combined spinal 4,000 mg total daily in divided
low-dose general anesthetic for total knee doses (scheduled)
arthroplasty, ± intrathecal morphine
Tramadol 100 mg (if the Zofran and ketorolac available as needed Ketorolac with transition to oral
patient is older than 65 acetaminophen every 6 hours
years) or oxycodone 10 mg
(if the patient is younger
than 65 years)
Pregabalin 75 mg or Soft-tissue injection of combination Second dose of tranexamic acid
gabapentin 300 mg containing 0.25% bupivacaine with
epinephrine 30 mL, liposomal bupivacaine
Dexamethasone 8 mg Long-acting NSAID for which
20 mL
intravenously patient demonstrates
tolerance or previous effective
use (meloxicam, naproxen,
celecoxib, nubatone)
Acetaminophen 1,000 g Ultram every 4 hours orally, as
intravenously needed
Tranexamic acid 1 g Doses of hydrocodone and/or
intravenously oxycodone as needed, usually
only if previous opioid usage
pain relief while minimizing opioid requirements (Ta- adverse effects should be considered. Table 2 provides
ble 1). NSAIDs may have a role both as preemptive and an example of a multimodal pain management regimen.
as scheduled postoperative pain management.45-47 Acet- Pain is often considered the “fifth vital sign” and can
aminophen, which can be administered intravenously be an important indicator of underlying problems. How-
2: Knee
in the perioperative period and then orally in outpatient ever, pain is expected after an invasive surgical procedure
treatment, has demonstrated efficacy and safety.48 Addi- during which bones and soft tissue are cut.56 Frequent
tional classes of medications, including neuromodulators, assessment of pain using a visual analog scale pain score
have been studied as a component of multimodal anal- or other similar modality can be useful in determining
gesia; however, recent studies have suggested evidence is how well the current treatment is working and appro-
currently mixed for the roles of gabapentin and pregab- priate titration. The patient and family are an important
alin.49-51 Dexmedetomidine, a central-acting α1 agonist part of the team in this endeavor, as are the nursing staff,
with anxiolytic, sedative, and analgesic properties, can be orthopaedic surgeon, physical therapists, and anesthesia
used during spinal anesthesia.52 Scheduled doses of agents provider.
such as promethazine, ondansetron, and corticosteroids
can be useful for postoperative or medication-induced
nausea and as an adjunct in multimodal analgesia.53-55 Physical Therapy
Several important principles for pain control as it Patients undergoing knee arthroplasty should be pre-
pertains to medications exist. Combinations of medica- pared mentally and physically to begin physical therapy
tions from various classes and varying duration of action the same day as surgery. Advances in pain control have
should be used to target the various types of pain and cov- shortened the length of hospitalization and even allowed
er patients with around-the-clock pain relief. Preemptive some orthopaedic surgeons to shift a marked proportion
analgesia should be used to pretreat pain and dampen the of their practice to outpatient care. The first 2 weeks
nervous system response to stimuli such as the scalpel and after surgery will be the most challenging and may re-
bone saw. When prescribed medications, patients should quire traveling to physical therapy centers or home health
be made aware of common side effects such as pruritis, after hospital discharge. Early mobilization requires a
constipation, and nausea. Preemptive treatment of these team effort and commitment from the patient, the family,
2. Duncan CM, Hall Long K, Warner DO, Hebl JR: The

the nursing staff, physical therapists, and the surgical economic implications of a multimodal analgesic regi-
and anesthesiology teams. Patient kinesiophobia (fear of men for patients undergoing major orthopedic surgery: A
movement) has been shown to result in increased acute comparative study of direct costs. Reg Anesth Pain Med
postoperative pain perception, difficult recovery, and poor 2009;34(4):301-307. Medline DOI
final outcome.57 Sleep is another important and often
3. Calatayud J, Casaña J, Ezzatvar Y, Jakobsen MD, Sund-
overlooked component of the recovery process.58 Sleep strup E, Andersen LL: High-intensity preoperative train-
hygiene and melatonin are often employed as first-line ing improves physical and functional recovery in the early
modalities, and melatonin has also been investigated for post-operative periods after total knee arthroplasty: A
randomized controlled trial. Knee Surg Sports Trauma-
anxiolytic effects.59-61
tol Arthrosc 2016; January 14 [Epub ahead of print].
Medline DOI
The authors of this study reported finding decreased
Summary length of stay and faster functional and physical recovery
from TKA in patients randomly assigned to preoperative
Multimodal pain management protocols after knee ar- high-intensity strength training. Level of evidence: I.
throplasty improve satisfaction and pain scores, facil-
itate faster recovery, decrease narcotic usage, and are 4. Cremeans-Smith JK, Boarts JM, Greene K, Delahanty
DL: Patients’ reasons for electing to undergo total knee
cost-effective.62,63 Although more surgeons are incorpo- arthroplasty impact post-operative pain severity and
rating these principles into their care of TKA patients, range of motion. J Behav Med 2009;32(3):223-233.
substantial variability remains and this is an area of ac- Medline DOI
tive, ongoing research. Knee arthroplasty has provided
5. Louw A, Diener I, Butler DS, Puentedura EJ: Preopera-
excellent patient satisfaction and long-term outcomes, and
tive education addressing postoperative pain in total joint
recent improvements have enhanced the perioperative ex- arthroplasty: Review of content and educational delivery
perience. Ongoing efforts seek to provide evidence-based methods. Physiother Theory Pract 2013;29(3):175-194.
analgesia for patients. Medline DOI
The authors of this study reviewed 13 randomized con-
trolled trials totaling 1,017 patients who underwent THA
Key Study Points or TKA and a preoperative educational delivery method.
Such courses have limited effect in decreasing postoper-
• Pain management begins preoperatively with a ative pain but may still have value. Level of evidence: I.
thorough discussion and documentation of history
including opioid use and a dialog regarding expec- 6. Wilson RA, Watt-Watson J, Hodnett E, Tranmer J: A ran-
2: Knee
tations for recovery. domized controlled trial of an individualized preoperative
education intervention for symptom management after
• The goals of minimizing pain in the postoperative total knee arthroplasty. Orthop Nurs 2016;35(1):20-29.
period must be balanced with the risks of the an- Medline DOI
algesic modalities. The authors of this study randomly assigned 143 patients
• Peripheral nerve blocks, neuraxial techniques, gen- to either preoperative educational intervention or standard
eral anesthesia, and periarticular injections can be care. No difference in pain or nausea was found, and fur-
ther research was recommended to determine the effect
used in a variety of combinations to achieve surgical of preoperative patient education on pain and outcomes.
analgesic coverage with varying duration of effect. Level of evidence: II.
• Oral and intravenous pain medications from a va-
riety of classes including NSAIDs, acetaminophen, 7. Goesling J, Moser SE, Zaidi B, et al: Trends and predictors
of opioid use after total knee and total hip arthroplasty.
neuromodulators, antiemetics, and opioids should Pain 2016;157(6):1259-1265. Medline DOI
be used in combination in appropriate patients.
The authors of this study examined postoperative trends
for opioid use after TKA and THA, comparing patients
who were opioid naïve with those who were taking opioids
preoperatively. Opioid-naïve patients had a lower rate of
Annotated References receiving opioids at 6 months (8.2% rate in TKA, 4.3%
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2: Knee
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plications; the difference, although small, was significant The authors of this study administered continuous femoral
and increased with patients who had more comorbidities. nerve blocks to 140 patients and divided them into two
Level of evidence: III. groups: one receiving a continuous sciatic catheter in addi-
2: Knee
tion and the other receiving an intermittent sciatic catheter
22. Olive DJ, Barrington MJ, Simone SA, Kluger R: A ran- with an initial bolus and on demand only. No difference in
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Anaesth Intensive Care 2015;43(4):454-460. Medline 27. Barrington MJ, Olive D, Low K, Scott DA, Brittain J,
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24 hours and required more morphine than the other
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There was no difference in this study between continuous infiltration analgesia with femoral nerve block for total
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The authors of this study compared local infiltration with
23. McMeniman TJ, McMeniman PJ, Myers PT, et al; Bris- femoral nerve block in a randomized, double-masked,
bane Orthopaedic & Sports Medicine Centre Writing single-center study of 157 patients. The local infiltration
Committee: Femoral nerve block vs fascia iliaca block group had lower pain with movement on postoperative
for total knee arthroplasty postoperative pain control: A day 1, but overall the two groups were similar, with a low
prospective, randomized controlled trial. J Arthroplasty rate of complications in both groups. Level of evidence: I.
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were noted at 12 hours or 36 hours. The fascia iliaca Medline
Section 2: Knee
The authors of this review article concluded that in major The authors of this study evaluated current approaches
knee surgery, peripheral nerve blocks reduced pain when to perioperative pain management, focusing on changing
combined with systemic analgesia, compared with sys- paradigms in which surgeons play a more active role in
temic analgesia alone. Level of evidence: I. multimodal pain management.
30. Tsukada S, Wakui M, Hoshino A: The impact of including 35. Bramlett K, Onel E, Viscusi ER, Jones K: A randomized,
corticosteroid in a periarticular injection for pain control double-blind, dose-ranging study comparing wound in-
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controlled trial. Bone Joint J 2016;98-B(2):194-200. liposomal bupivacaine, to bupivacaine HCl for post-
Medline DOI surgical analgesia in total knee arthroplasty. Knee
2012;19(5):530-536. Medline DOI
In a randomized controlled trial of patients undergoing
TKA, patients received periarticular injections random- The authors of this study evaluated the duration of liposo-
ized to include corticosteroid or not. When corticosteroid mal bupivacaine’s analgesic effects in patients undergoing
was included, patients had a significant decrease in early TKA and observed a dose-dependent relationship with
postoperative pain. Level of evidence: I. increased analgesia compared to bupivacaine hydrochlo-
ride. Level of evidence: I.
31. Chaumeron A, Audy D, Drolet P, Lavigne M, Vendit-
toli PA: Periarticular injection in knee arthroplasty 36. Chughtai M, Cherian JJ, Mistry JB, Elmallah RD, Ben-
improves quadriceps function. Clin Orthop Relat Res nett A, Mont MA: Liposomal bupivacaine suspension can
2013;471(7):2284-2295. Medline DOI reduce lengths of stay and improve discharge status of
patients undergoing total knee arthroplasty. J Knee Surg
The authors of this study reported less pain at rest and 2016;29(3):224-227. Medline DOI
reduced opioid consumption in the first 8 hours in patients
who received periarticular injections compared with pa- The authors of this study performed a retrospective re-
tients who received femoral nerve block. Additionally, the view of a large hospital database study to determine the
periarticular injection group was better able to perform effect of liposomal bupivacaine on length of stay and dis-
straight leg raise, active knee extension, and walk farther charge status and found that both were improved. Level
with zero motor block compared with 37% in the femoral of evidence: III.
nerve block group. Level of evidence: I.
37. Dasta J, Ramamoorthy S, Patou G, Sinatra R: Bupivacaine
32. Spangehl MJ, Clarke HD, Hentz JG, Misra L, Blocher JL, liposome injectable suspension compared with bupivacaine
Seamans DP: The Chitranjan Ranawat Award: Periarticu- HCl for the reduction of opioid burden in the postsurgi-
lar injections and femoral & sciatic blocks provide similar cal setting. Curr Med Res Opin 2012;28(10):1609-1615.
pain relief after TKA: A randomized clinical trial. Clin Medline DOI
Orthop Relat Res 2015;473(1):45-53. Medline DOI
The authors of this study compared liposomal bupivacaine
The authors of this study compared the commonly used with bupivacaine hydrocloride in a variety of surgical in-
2: Knee
TKA pain control combination of a continuous femoral terventions, including TKA. Pain was improved and there
nerve block and a single-shot sciatic block with a peri- was a significant reduction in opioid use and opioid-related
articular injection. It was concluded that periarticular adverse events in the liposomal bupivacaine group.
injections achieved similar pain control and were associ-
ated with shorter lengths of stay, fewer peripheral nerve 38. Heim EA, Grier AJ, Butler RJ, Bushmiaer M, Queen
dysesthesias, and higher postoperative day 1 opioid con- RM, Barnes CL: Use of liposomal bupivacaine instead of
sumption. Level of evidence: I. an epidural can improve outcomes following total knee
arthroplasty. J Surg Orthop Adv 2015;24(4):230-234.
33. Vaishya R, Wani AM, Vijay V: Local infiltration analgesia Medline
reduces pain and hospital stay after primary TKA: Ran-
domized controlled double blind trial. Acta Orthop Belg This authors of this study compared liposomal bupiv-
2015;81(4):720-729. Medline acaine periarticular injection with epidural analgesia in
a retrospective review and found patients who received
In this study, 80 patients undergoing TKA were randomly liposomal bupivacaine had improved pain scores, func-
assigned to receive periarticular injections of either normal tional level, and length of stay compared with those who
saline or a mixture of bupivacaine, ketorolac, morphine, received epidural analgesia. Level of evidence: III.
and adrenaline. The patients receiving the periarticular
drug combination had improvements in visual analog 39. Lonner JH, Scuderi GR, Lieberman JR: Potential utility of
score for pain at rest and with activity and required less liposome bupivacaine in orthopedic surgery. Am J Orthop
PCA. Level of evidence: I. (Belle Mead NJ) 2015;44(3):111-117. Medline
34. Barrington JW, Halaszynski TM, Sinatra RS, Expert The applications for liposomal bupivacaine were discussed
Working Group on Anesthesia and Orthopaedics Crit- and its safety profile in published studies was examined.
ical Issues in Hip and Knee Replacement Arthroplas- The authors conclude that it is safe and can fulfill an
ty FT: Perioperative pain management in hip and knee important clinical role as a periarticular injection in TKA
replacement surgery. Am J Orthop (Belle Mead NJ) and other orthopaedic procedures. Level of evidence: I.
2014;43(4suppl):S1-S16. Medline
40. Bagsby DT, Ireland PH, Meneghini RM: Liposomal COX-2 inhibitor: A trial in total knee arthroplasty. J Ar-
bupivacaine versus traditional periarticular injection for throplasty 2015;30(1):38-42. Medline DOI
pain control after total knee arthroplasty. J Arthroplasty
2014;29(8):1687-1690. Medline DOI The authors of this study studied a single dose of pregaba-
lin as part of a multimodal treatment regimen. One patient
The authors of this study performed a retrospective co- group received one dose of pregabalin combined with a
hort study comparing their traditional ropivacaine-based COX-2 inhibitor; the other received only a COX-2 inhibi-
periarticular injection with liposomal bupivacaine and tor. The group receiving pregabalin required less fentanyl
found the liposomal bupivacaine to be inferior. Level of for breakthrough pain and had less pain, with no differ-
evidence: III. ence in functional recovery. Level of evidence: I.
41. Park YB, Ha CW, Cho SD, et al: A randomized study 46. Sarridou DG, Chalmouki G, Braoudaki M, Siafaka I,
to compare the efficacy and safety of extended-release Asmatzi C, Vadalouka A: Parecoxib possesses anxiolytic
and immediate-release tramadol HCl/acetaminophen in properties in patients undergoing total knee arthroplas-
patients with acute pain following total knee replacement. ty: A prospective, randomized, double-blind, placebo-
Curr Med Res Opin 2015;31(1):75-84. Medline DOI controlled, clinical study. Pain Ther 2016; February 9
[Epub ahead of print]. Medline DOI
The authors of this study compared two forms of tra-
madol/acetaminophen—extended release (administered Parecoxib and its role in pain management and specifically
every 12 hours) and immediate release (administered every perioperative anxiety levels were studied. A randomized
6 hours)—in a double-blind randomized study of patients controlled trial of 90 TKA patients, all of whom received
who underwent TKA and had moderate to severe pain in continuous femoral nerve blocks, was performed; one-half
the postoperative period. Noninferiority and similar side of the patients received parecoxib, and the other half re-
effect rates were shown. Level of evidence: II. ceived placebo. Anxiety levels were assessed preoperatively
and postoperatively, and the parecoxib group’s postopera-
42. Halawi MJ, Vovos TJ, Green CL, Wellman SS, Attari- tive level was decreased both relative to the placebo group
an DE, Bolognesi MP: Opioid-based analgesia: Impact and the preoperative level. Level of evidence: I.
on total joint arthroplasty. J Arthroplasty 2015;30(12):
2360-2363. Medline DOI 47. Singla N, Rock A, Pavliv L: A multi-center, random-
ized, double-blind placebo-controlled trial of intra-
The authors of this study retrospectively reviewed the re- venous-ibuprofen (IV-ibuprofen) for treatment of pain
cords regarding 673 THAs and TKAs and found an 8.5% in post-operative orthopedic adult patients. Pain Med
rate of opioid-related adverse drug events. This comprised 2010;11(8):1284-1293. Medline DOI
most complications in this cohort and was associated with
increased length of hospital stay and higher-level discharge Patients in this randomized controlled trial received either
destination. Level of evidence: III. placebo or 800 mg intravenous ibuprofen beginning pre-
operatively and continuing every 6 hours. The group that
43. Jove M, Griffin DW, Minkowitz HS, Ben-David B, received ibuprofen had significantly lower visual analog
scale scores with movement and at rest, and they required
2: Knee
Evashenk MA, Palmer PP: Sufentanil sublingual tablet
system for the management of postoperative pain af- less rescue morphine than did control patients. Level of
ter knee or hip arthroplasty: A randomized, placebo- evidence: I.
controlled study. Anesthesiology 2015;123(2):434-443.
Medline DOI 48. Lachiewicz PF: The role of intravenous acetaminophen
in multimodal pain protocols for perioperative ortho-
The authors of this study evaluated a sublingual sufentanil pedic patients. Orthopedics 2013;36(2suppl):15-19.
tablet system compared with placebo in a double-blind, Medline DOI
randomized, multicenter fashion after total joint arthro-
plasty and noted improved pain control with the added The role of intravenous acetaminophen as part of peri-
bonus of the sufentanil being a patient-controlled pain operative multimodal pain control was examined. The
management modality. However, because sufentanil is theorized mechanism of action, safety profile, and clin-
an opioid, nausea and pruritus were more common in the ical evidence for its use in a variety of orthopaedic ap-
group receiving it. Level of evidence: I. plications, including knee arthroplasty, were reviewed.
Because IV administration of acetaminophen achieves
44. Ladha KS, Patorno E, Huybrechts KF, Liu J, Rathmell JP, higher cerebrospinal fliud concentrations while avoiding
Bateman BT: Variations in the use of perioperative mul- the first-pass effect of the liver, it should be incorporated
timodal analgesic therapy. Anesthesiology 2016;124(4): into multimodal pain protocols in orthopaedics. Level of
837-845. Medline DOI evidence: IV.
The authors of this nationwide database study examined a 49. Lunn TH, Husted H, Laursen MB, Hansen LT, Kehlet
variety of surgical procedures, including TKA, and found H: Analgesic and sedative effects of perioperative gab-
significant variation in the utilization of multimodal ther- apentin in total knee arthroplasty: A randomized, dou-
apy. Level of evidence: III. ble-blind, placebo-controlled dose-finding study. Pain
2015;156(12):2438-2448. Medline DOI
45. Lee JK, Chung KS, Choi CH: The effect of a sin-
gle dose of preemptive pregabalin administered with The authors of this study performed a randomized double-
masked placebo-controlled study with 300 opioid-naïve
Section 2: Knee
patients receiving gabapentin 1,300 mg or 900 mg or 55. Deitrick CL, Mick DJ, Lauffer V, Prostka E, Nowak
placebo daily from 2 hours preoperatively until postop- D, Ingersoll G: A comparison of two differing doses of
erative day 6 as part of a multimodal regimen. No signif- promethazine for the treatment of postoperative nau-
icant improvements were noted in pain control, a slight sea and vomiting. J Perianesth Nurs 2015;30(1):5-13.
improvement in sleep quality, and an increased rate of Medline DOI
complications with the gabapentin. Therefore, it was
not recommeded as part of the standard of care. Level This double-blind trial featured randomization but no
of evidence: I. placebo control and compared two different doses of pro-
methazine for patients undergoing a variety of different
types of ambulatory surgery. They concluded that the two
50. Singla NK, Chelly JE, Lionberger DR, et al: Pregabalin doses were equally effective in controlling postoperative
for the treatment of postoperative pain: Results from three nausea and vomiting, but the lower dose featured less
controlled trials using different surgical models. J Pain Res sedation. Level of evidence: II.
2014;8:9-20. Medline DOI
The authors of this study examined the results of three 56. Park CN, White PB, Meftah M, Ranawat AS, Ranawat
studies of pregabalin for postoperative pain in different CS: Diagnostic algorithm for residual pain after total
surgical settings, one of which was TKA. It was conclud- knee arthroplasty. Orthopedics 2016;39(2):e246-e252.
ed that there was no difference between pregabalin and Medline DOI
placebo and that further studies are needed to determine
potential pain control benefit. Level of evidence: II. The authors of this study discussed patient dissatisfaction
and residual pain after TKA and proposed an algorithm
for diagnosing problems after TKA. Level of evidence: V.
51. YaDeau JT, Lin Y, Mayman DJ, et al: Pregabalin and pain
after total knee arthroplasty: A double-blind, random-
ized, placebo-controlled, multidose trial. Br J Anaesth 57. Filardo G, Roffi A, Merli G, et al: Patient kinesiophobia
2015;115(2):285-293. Medline DOI affects both recovery time and final outcome after total
knee arthroplasty. Knee Surg Sports Traumatol Arthrosc
The authors studied the addition of doses of pregabalin 2015;December 19 [Epub ahead of print]. Medline DOI
ranging from 0 to 150 mg administered two times per day
until postoperative day 15 as part of a multimodal pain The authors of this study evaluated the effects of kine-
management regimen. They found no effect on pain or on siophobia on early recovery and final results after TKA.
opioid use, but they observed that pregabalin did increase Fear of pain, especially fear of movement, correlated with
drowsiness on postoperative day 1. Because no beneficial acute pain perceptions and a worse final outcome. Level
effects were noted, pregabalin should not be routinely used of evidence: IV.
in TKA pain control. Level of evidence: I.
58. Gong L, Wang Z, Fan D: Sleep quality effects recov-
52. Chan IA, Maslany JG, Gorman KJ, O’Brien JM, McKay ery after total knee arthroplasty (TKA): A random-
WP: Dexmedetomidine during total knee arthroplasty ized, double-blind, controlled study. J Arthroplasty
performed under spinal anesthesia decreases opioid 2015;30(11):1897-1901. Medline DOI
2: Knee
use: A randomized-controlled trial. Can J Anaesth The authors of this study studied the effect of sleep qual-
2016;63(5):569-576. Medline DOI ity using the sleep aid medication zolpidem for 2 weeks
This randomized-controlled trial found decreased mor- postoperatively compared with placebo in a randomized,
phine use and delayed first request for analgesia in patients double-blind fashion. They noted improvements in range
who received intraoperative dexmedetomidine compared of motion, decreased requirement for antiemetics or opioid
with placebo control patients who received standardized analgesics with improved pain scores and less postoper-
spinal anesthetic. Level of evidence: I. ative nausea and vomiting. They also found better sleep
efficacy, satisfaction, and quality of life in the zolpidem
group. The study emphasizes the importance of sleep and
53. Richardson AB, Bala A, Wellman SS, Attarian DE, Bolog- the potential role for sleep aids. Level of evidence: I.
nesi MP, Grant SA: Perioperative dexamethasone admin-
istration does not increase the incidence of postoperative
infection in total hip and knee arthroplasty: A retrospective 59. Kirksey MA, Yoo D, Danninger T, Stundner O, Ma Y,
analysis. J Arthroplasty 2016;S0883-5403(16)00088-7. Memtsoudis SG: Impact of melatonin on sleep and pain
Medline after total knee arthroplasty under regional anesthesia
with sedation: A double-blind, randomized, placebo-con-
The authors of this study performed a retrospective chart trolled pilot study. J Arthroplasty 2015;30(12):2370-2375.
review of 6,294 patients undergoing THA or TKA who Medline DOI
were divided into either a group that received perioperative
dexamethasone or a group that did not. No difference in In this pilot study, 50 TKA patients wore wrist actigraphy
the incidence of infection in either group was found, and it and were randomized to placebo or melatonin for 3 nights
was concluded that dexamethasone does not increase the preoperatively and 3 nights postoperatively. Both groups
risk of infection and can be used as a pain control adjunct had significant sleep disruption and decreased efficien-
and to prevent nausea and vomiting. Level of evidence: III. cy on the last preoperative night and the postoperative
nights with corresponding fatigue. However, exogenous
melatonin did not demonstrate significant improvement
54. Lombardi AV, Berend KR, Adams JB: A rapid recov- in the study parameters at the timing and dose utilized
ery program: Early home and pain free. Orthopedics in this study. There was a nonsignificant trend toward
2010;33(9):656. Medline
improvement in sleep efficiency and sleep time in the mel- period for patients undergoing a variety of surgeries. Level
atonin cohort in this pilot study. Level of evidence: I. of evidence: I.
60. Yousaf F, Seet E, Venkatraghavan L, Abrishami A, Chung 62. Lamplot JD, Wagner ER, Manning DW: Multimodal pain
F: Efficacy and safety of melatonin as an anxiolytic and management in total knee arthroplasty: A prospective
analgesic in the perioperative period: A qualitative sys- randomized controlled trial. J Arthroplasty 2014;29(2):
tematic review of randomized trials. Anesthesiology 329-334. Medline DOI
2010;113(4):968-976. Medline DOI
The authors of this study randomly assigned 36 patients
This literature review examined ten studies of melatonin to receive periarticular injection (including bupivacaine
vs placebo premedication and its effects on preoperative and ketorolac) with multimodal therapy or hydromor-
anxiety and postoperative opioid-sparing effects. The ma- phone PCA. The multimodal pain management cohort
jority of studies showed anxiolytic efficacy and conflicting had improved pain scores, satisfaction, and improved early
results on reduced pain scores or opioid consumption. recovery while using fewer opioids. Level of evidence: I.
Level of evidence: I.
63. Moucha CS, Weiser MC, Levin EJ: Current strategies in
61. Hansen MV, Halladin NL, Rosenberg J, Gögenur I, Møller anesthesia and analgesia for total knee arthroplasty. J Am
AM: Melatonin for pre- and postoperative anxiety in Acad Orthop Surg 2016;24(2):60-73. Medline DOI
adults. Cochrane Database Syst Rev 2015;4:CD009861.
Medline The authors of this study reviewed the current strategies
in pain control for patients undergoing TKA, with an em-
This Cochrane Database systematic review considered phasis on multimodal approaches that include preemptive
12 studies comparing melatonin to placebo or to benzo- analgesia, neuraxial and peripheral blockade, periarticular
diazepines and concluded that it is more effective than injections, and avoidance of opioid-based strategies when
placebo and equal to midazolam for preoperative anxiety possible. Level of evidence: I.
with attenuation of the effect into the early postoperative
2: Knee
Chapter 23
Retrieval Analysis of
Knee Prostheses
Steven M. Kurtz, PhD Jaydev B. Mistry, MD Eric Szczesniak, MD Randa K. Elmallah, MD
Morad Chughtai, MD Michael A. Mont, MD
Although total knee arthroplasties have an excellent The demand for total knee arthroplasty (TKA) continues
clinical track record, issues with wear and fatigue to rise as surgical technique and component design con-
damage have historically limited the longevity of both tinue to evolve. Consequently, these advancements have
unicondylar and bicondylar arthroplasty components. allowed for TKAs to be performed in patients who were
In evaluation of these and other failure mechanisms, previously not considered acceptable candidates.1 More-
retrieval analyses of explanted components can provide over, TKAs have demonstrated a long-term survivorship
valuable insight. Careful assessment of these components of more than 90% after 10 years of implantation.2,3 De-
may allow for improvement and modification of future spite this excellent clinical track record, problems with
implant designs. It is important for orthopaedic surgeons component wear and damage have historically limited
to have information about collection of explanted com- the longevity of TKA.4 There is currently a paucity of
ponents during revision total knee arthroplasty as well information regarding how to monitor and track the in
as be knowledgable about important factors to consider vivo performance of TKA components. Therefore, the
during an analysis of retrieved components. most effective way to assess the in vivo performance of
these implants continues to be the analysis of retrieved
5: Knee
components from revision surgery or autopsy donation.
Keywords: retrieval analysis; component wear; Careful analysis of explanted devices will allow better
polyethylene; corrosion determination of failure patterns, as well as confirmation
that design choices are appropriate. Only then will it be
possible to take the proper steps to minimize component
Dr. Kurtz or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of
Exponent; serves as a paid consultant to Exponent; has received research or institutional support from Active Implants,
Aesculap (A B. Braun Company), Ferring Pharmaceuticals, Simplify Medical, Smith & Nephew, Stryker, Zimmer Biomet,
DePuy Synthes, Medtronic, Invibio, StelKast, Celanese, Formae, Kyocera Medical, Wright Medical Technology, CeramTec,
and DJO Global; and has received nonincome support (such as equipment or services), commercially derived honoraria,
or other non–research-related funding (such as paid travel) from Exponent. Dr. Szczesniak or an immediate family
member serves as a paid consultant to ConforMIS. Dr. Mont or an immediate family member has received royalties from
MicroPort and Stryker; serves as a paid consultant to DJO Global, Johnson & Johnson, Merz Pharma, OrthoSensor, Pacira
Pharmaceuticals, Sage Products, Stryker, TissueGene, and US Medical Innovations; has received research or institutional
support from DJO Global, Johnson & Johnson, the National Institute of Arthritis and Musculoskeletal and Skin Diseases,
the Eunice Kennedy Shriver National Institute of Child Health and Development, Ongoing Care Solutions, OrthoSensor,
Stryker, and TissuGene; and serves as a board member, owner, officer, or committee member of the American Academy
of Orthopaedic Surgeons. None of the following authors nor any immediate family member has received anything of
the subject of this chapter: Dr. Mistry, Dr. Elmallah, and Dr. Chughtai.
Section 5: Knee
failure, through either technical or design changes. For for shipment to the collaborating implant analysis centers
researchers who are interested in establishing a retrieval for testing and scientific analysis.
program, an international standard on-retrieval analysis
report published by the American Society for Testing and Biohazard Management
Materials International is recommended.5 When handling explanted components, standard precau-
tions should be used until a detoxification protocol has
been completed. Implants are shipped to the retrieval
Retrieval Procurement analysis collection center as biohazards, in appropriately
Explantation and Storage labeled and sealed plastic bags. In accordance with Inter-
The most reliable and accurate method of wear assess- national Air Transport Association shipping regulations
ment in TKA is component inspection following revi- and an academic institutional biosafety board, implant
sion surgery or autopsy removal. Throughout the entire transfer protocols between analysis centers and the par-
retrieval process, explanted devices should be handled ticipating clinical revision centers have been developed.
with care to avoid causing extra damage. Following re- On arrival at the implant analysis center, retrieved compo-
moval, implants should be handled in small cloth tow- nents are ultrasonically cleaned with soap and deionized
els to prevent scratching or other damage. Components water, rinsed, and sterilized with a 10% bleach solution.
should be gently cleaned with distilled water and light Implants awaiting analysis should be stored individually
antibacterial detergents to remove extraneous blood or in a dry, size-appropriate container that is properly labeled
tissue, with care being taken to avoid disturbing areas of without patient information.
corrosion, fracture, or damage. It is recommended that
ultra–high-molecular-weight polyethylene (UHMWPE)
components be stored in temperatures below 0°C after Surface Damage Analysis
removal from the body. Based on the kinetics of oxidative The continued advancement of TKA depends on an ap-
degradation in UHMWPE after gamma irradiation in air, proach to accurately quantify surface damage mecha-
the reaction rate is expected to decrease by a factor of 3 to nisms in retrieved components. To determine the effects
4 for every 10°C that the temperature is lowered.6 There- of mechanical degradation on implant performance, it is
fore, storage of UHMWPE at subzero temperatures (ide- of paramount importance that a method to characterize
ally, in a freezer set at –80°C) is predicted to impede the changes in the structure of retrieved implants is de-
chemical reaction in the polymer by one to two orders veloped. An assessment system was devised7 and, using
of magnitude, compared to the reaction rates at normal a light microscope at ×10 magnification, seven modes of
5: Knee
body temperature. Moreover, if the device is going to be surface damage were identified (Table 1).
stored in ambient temperature for more than 1 year, the The presence and extent of each of the seven modes
time lapse between explantation, evaluation, and testing of damage are graded on a scale from 0 to 3 as they
should be recorded as an independent variable known as pertain to each surface region of the tibial or patel-
postimplantation time. lar component.7 A score of 0 signifies the absence of
the given damage mode within the region of interest.
Clinical Documentation Scores of 1, 2, and 3 correspond to assessment of the
Although retrieval analyses are primarily focused on damage mode—less than 10%, 10% to 50%, or more
examining the effect of material behavior on clinical than 50%—within the region of interest, respectively
performance, it is necessary to track patient- and sur- (Table 2). To obtain an overall assessment of each dam-
geon- related variables (Figures 1 and 2). The purpose age mode, the clinician should sum scores across all of
of this documentation is to account for the influence of the surface regions. For each damage mode, the tibial
these factors during statistical analysis. Most of the re- component has a maximum score of 30 (maximum
quired patient data can be collected prospectively from score of 3 multiplied by 10 regions), whereas the patel-
the medical records. lar component has a maximum score of 12 (maximum
In addition, it may be beneficial to obtain bacteriologic score of 3 multiplied by 4 regions). The total damage
cultures and histologic specimens from the removal site. score is calculated by summing the individual damage
Any specimens for histologic examination should be taken mode scores. This corresponds with a maximum score
from the synovial, capsular, or pseudocapsular tissue sur- of 210 for the tibial component (maximum score of 3 ×
rounding the implants. Moreover, all retrieved implants 10 regions × 7 damage modes) and 84 for the patellar
and specimens should be deidentified (no name, medical component (maximum score of 3 × 4 regions × 7 dam-
record number, or other identifiers visible) and prepared age modes).
Chapter 23: Retrieval Analysis of Knee Prostheses
5: Knee
Figure 1 Sample form for recording minimum data regarding hip/knee implant retrieval.
This method is semiquantitative and allows analysts abrasion (41%), and delamination (4%).7 A significant
to compare the region of damage (such as anterior versus correlation between the patient’s weight and total damage
posterior or lateral condyle versus medial condyle), the score and between duration of implantation and damage
prevalence of particular damage modes within an im- score was noted. These relationships may indicate that fa-
plant design, and variations in damage between implant tigue mechanisms due to cyclic mechanical loading likely
designs. In an assessment of retrieved total condylar pros- contributed to knee component deterioration.
theses, it was reported that the most prevalent form of Digital techniques have been commonly used to quan-
surface damage was scratching (noted in 90% of retrieved titatively assess surface damage and wear.8
tibial components), followed by pitting (81%), burnishing During initial assessment, digital images should be
(75%), surface deformation (62%), cement debris (48%), obtained and examined so as to quantify areas on each
Section 5: Knee
5: Knee
Figure 2 Sample form for recording information regarding hip and knee tissue retrieval.
condyle observed with fatigue damage modes (that is, digitized by means of an electronic stylus and inscrip-
delamination and pitting scores greater than 1). The ex- tional software. The undamaged region should be used
tent of delamination and pitting will be quantified by a in commercial surface modeling software to interpolate
comparison of the damaged area with the total area of a “best fit” control (undamaged) surface, which will be
the condyles. The location of the centroid for the regions used to determine the depth of maximum wear. A linear
of pitting, delamination, or both on each condyle should wear rate can be calculated on the basis of the maximum
also be analyzed. The surface of the components can be wear depth divided by the time of implantation.
Table 1
Modes of Surface Damage
Mode Description
Scratching Identified as linear features on the articulating surface and produced by collision of
microscopic asperities on the opposed metallic surface
Pitting Also known as cratering; classified as a mode of fatigue wear and involves the release
of small, millimeter-sized fragments of wear debris from the articulating surface;
considered a more benign wear mechanism than abrasive wear because the wear
debris produced by pitting damage is too large to provoke an osteolytic response
Delamination More severe than pitting; involves the removal of sheets of UHMWPE from the
articulating surface; if the tibial component has sufficient thickness, the underlying
UHMWPE may continue to serve as a functional bearing surface, but if the tibial
component becomes too thin and weakened, simple delamination can result in
catastrophic wear of the UHMWPE and require revision
Abrasion Shredding or “tufting” of the UHMWPE surface; the resultant wear can allow for the
formation of other modes of damage
Surface deformation Irreversible alteration in implant surface geometry but does not cause material
removal and, therefore, does not solely correspond to component wear
Embedded debris Debris, bone chips, or metallic fragments from the back surface of metallic
components can become embedded in the UHMWPE, which may result in third-
body wear and scratches of the metallic surfaces and UHMWPE
Burnishing Also described as wear polishing and is similar to abrasive wear; the wear debris
produced from burnishing damage is within the size range that can stimulate an
osteolytic response.
UHMWPE = ultra-high–molecular-weight polyethylene.
tibial components.9 Using their digital models, the inves-

Table 2
tigators also noted that posterior strains and peripheral
Component Damage Scoring Scale anterior surface strains were increased by greater prox-
5: Knee
imal tibial resection (between 12% and 209% increase;
Score Description
P < 0.05). Although FEA is not necessarily conducted on
0 Absence of damage
retrieved implants, it can be used to better ascertain the
1 Less than 10% of damage over surface predominant modes of failure in implants that have a
region
clinical track record of poor survivorship. Understanding
2 10% to 50% of damage over surface how and why components fail affords orthopaedic sur-
region
geons the opportunity to modify and improve existing
3 More than 50% of damage over surface techniques and implant designs.
region
Adapted with permission from Hood RW, Wright TM, Burstein Surface Damage Versus Wear
AH: Retrieval analysis of total knee prostheses: A method and its
application to 48 total condylar prostheses. J Biomed Mater Res It is important to distinguish between visible changes to
1983;17(5):829-842 . an implant component, which are characterized as dam-
age, and measurements of material loss. Damage may or
may not imply wear, which reflects material loss. This is
Component damage can also be assessed through fi- especially important when analyzing highly cross-linked
nite element analysis (FEA), which digitally predicts how UHMWPE tibial inserts, which, because of their low
components behave in response to applied forces and can wear, accumulate surface damage that may be mislead-
also be used to compare implants of differing design. ing.10 For example, a dent in the door of a car reflects
One study used FEA to demonstrate that metal-backed undesirable damage, but it does not indicate that any
implants maintained more evenly balanced and lower material has been removed.
surface strains on the tibial metaphysis as compared with Measuring material loss in TKA components is much
tibiae implanted with otherwise identical all-polyethylene more challenging than in total hip arthroplasty (THA)
Section 5: Knee
components, because the implant components for the contemporary innovation provides the surgeon with
knee are nonspherical and are produced with generally greater freedom to restore knee stability and function
unknown manufacturing tolerances that are usually on for the patient. However, modular taper connections in
the order of magnitude of the material loss or, in some TKA are exhibiting fretting and corrosion similar to the
cases, even greater. One promising technology for quan- modular connections in THA. This wear can cause metal
tifying changes in geometry of retrieved TKA compo- ion release, which has the potential for adverse local and
nents is micro-CT.11 However, other methods are under systemic consequences. Moreover, the extent of damage
investigation for use with retrieved TKA components, can be affected by factors both patient related (such as
including laser scanning and optical coordinate measure- weight, age, and activity level) and implant related (such
ment machines. Finally, even if differences in the shape as alloy composition, stem diameter, and flexural rigidity).
of a retrieved component can be quantified accurately, it Overall, the prevalence of fretting and corrosion has
is even more complicated to separate changes in shape not been studied in great detail for TKA as it has been for
caused by long-term loading (creep) from the material THA. A retrieval analysis of 198 modular TKA compo-
loss. All of these issues remain at the forefront of retrieval nents reported mild to severe fretting corrosion in the ta-
research for UHMWPE in TKA. pers of 94 of 101 modular femoral components and 90 of
97 modular tibial components.19 Additionally, the authors
noted an association with taper corrosion and taper de-
Other Considerations sign (P < 0.001), mixed alloy composition (P = 0.003), and
Consequences of Polyethylene Wear component type (P = 0.02). Their analysis showed that
The wear and release of UHMWPE particles can provoke the decreased elastic modulus of titanium-aluminum-va-
osteolysis of the surrounding bone. Macrophages are nadium allows for more component micromotion, which
activated and recruited by the presence of UHMWPE damages the protective coating on implants and thereby
particles within the joint. With particle phagocytosis and contributes to galvanic corrosion. A case report regarding
subsequent cytokine release, osteoclasts become activated, modular TKA described an adverse local tissue reaction
resulting in bone resorption.12 Osteolytic bone loss at the following taper corrosion.20 Black, flaky encrustations
bone-implant (or bone-cement) interface diminishes im- were observed intraoperatively around the proximal fem-
plant stability. Implant failure begins with micromotion at oral component. Currently, the long-term consequences
this bone-implant interface, which, when combined with of fretting and corrosion for TKA remain unclear, and
hydrostatic pressure, disseminates particle-laden syno- further research should be conducted to investigate its
vial fluid throughout the effective joint space.13 Macro- clinical implications.
5: Knee
phage-mediated osteolysis progresses within these spaces

and further destabilizes the implant, ultimately progress-
ing to gross component motion and implant failure and, Summary
in turn, necessitating revision. Retrieval analysis will continue to play a crucial role in
Wear debris particles need access to periprosthetic the advancement of TKA components. Explanted compo-
bone for osteolysis to expand. This may explain why nents should be prepared, documented, and transported
cemented knee components have a lower incidence of with care so as to avoid incurring any unnecessary wear
osteolysis than do uncemented components. Studies of and damage. Furthermore, appropriate wear assessment
cemented components have reported the incidence of should be structured and systematic in an effort to main-
osteolysis as zero to 20%,14-16 whereas uncemented com- tain consistency of damage scores between components.
ponents have a reported incidence as high as 30% within Although the damage modes described in this chapter
the first 5 years after implantation.13,17,18 might not all contribute to the need for revision surgery,
they are still vital in any assessment of the long-term
Implant Corrosion performance of TKA. Additionally, orthopaedic surgeons
In the past several decades, fretting and corrosion of should be aware of the consequences of implant corrosion
modular components have been studied, particularly in and polyethylene wear. Ultimately, more comprehensive
terms of THA. More recently, cases of instability-related retrieval analyses will allow for the development of future
or revision TKA are being managed with designs that components, which may improve postoperative outcomes
can include one or more modular taper junctions. This and patient satisfaction.
The authors of this study compared 38 polyethylene inserts

Key Study Points
that had a dished articular surface (conforming group)
with 31 unconstrained and nonconforming inserts to as-
• Implants considered for retrieval analysis must be sess surface pitting, delamination, deformation, and pol-
explanted and stored carefully to avoid causing ad- ishing. The conforming inserts were associated with higher
ditional damage that will affect analysis. Thorough delamination and pitting scores but lower polishing scores.
documentation of patient- and surgery-related vari-
ables is necessary to account for the influence of 5. American Society for Testing and Materials Internation-
al: ASTM F561-13: Standard Practice for Retrieval and
these factors on component wear. Analysis of Medical Devices, and Associated Tissues and
• Understanding the effects of mechanical degra- Fluids. West Conshohocken, PA, American Society for
dation on implant performance is vital to the ad- Testing and Materials International, 2013.
vancement of future TKA components. Component This report highlights basic practices for the retrieval,
damage can be assessed using several methods in- handling, and analysis of explanted devices and associated
cluding light microscopy, digital imaging, and finite tissues and fluids, to limit damage to them and therefore
help ensure investigational results. Methodology and ex-
elemental analysis. planation are provided.
• Polyethylene wear and implant corrosion can pro-
voke both local and systemic responses. If com- 6. Kurtz SM, Pruitt LA, Crane DJ, Edidin AA: Evolution
ponents become destabilized, they may fail, and of morphology in UHMWPE following accelerated ag-
ing: The effect of heating rates. J Biomed Mater Res
require revision. Orthopaedic surgeons must be 1999;46(1):112-120. Medline DOI
cognizant of this issue during follow-up patient care.
7. Hood RW, Wright TM, Burstein AH: Retrieval analysis
of total knee prostheses: A method and its application
to 48 total condylar prostheses. J Biomed Mater Res
1983;17(5):829-842. Medline DOI
8. Grochowsky JC, Alaways LW, Siskey R, Most E, Kurtz
1. Kurtz S, Ong K, Lau E, Mowat F, Halpern M: Projections SM: Digital photogrammetry for quantitative wear anal-
of primary and revision hip and knee arthroplasty in the ysis of retrieved TKA components. J Biomed Mater Res
United States from 2005 to 2030. J Bone Joint Surg Am B Appl Biomater 2006;79(2):263-267. Medline DOI
2007;89(4):780-785. Medline DOI
9. Tokunaga S, Rogge RD, Small SR, Berend ME, Ritter
2. Meftah M, White PB, Ranawat AS, Ranawat CS: Long- MA: A finite-element study of metal backing and tibial
term results of total knee arthroplasty in young and resection depth in a composite tibia following total knee
5: Knee
active patients with posterior stabilized design. Knee arthroplasty. J Biomech Eng 2016;138(4). Medline DOI
2016;23(2):318-321. Medline DOI
The relationship between tibial component design and
The authors of this study evaluated long-term quality bone resection on tibial loading was studied. Study find-
and performance of cemented posterior-stabilized total ings showed elevated strains in all-polyethylene implant-
knee arthroplasty in young and active patients by used tibias across the proximal tibial cortex, as well as a
ing a gap-balancing technique. At a mean follow-up of posterior shift in tibial loading in cases involving greater
12.3 years, no instability, malalignment, or patellofemoral resection depth.
maltracking were found. The overall survival rate accord-
ing to the Kaplan-Meier estimator was excellent at 98%. 10. Muratoglu OK, Ruberti J, Melotti S, Spiegelberg SH,
Greenbaum ES, Harris WH: Optical analysis of surface
3. Jauregui JJ, Cherian JJ, Pierce TP, Beaver WB, Issa K, changes on early retrievals of highly cross-linked and
Mont MA: Long-term survivorship and clinical out- conventional polyethylene tibial inserts. J Arthroplasty
comes following total knee arthroplasty. J Arthroplasty 2003;18(7suppl 1):42-47. Medline DOI
2015;30(12):2164-2166. Medline DOI
The long-term outcomes of 125 patients who underwent 11. MacDonald D, Bowden AE, Kurtz SM: MicroCT analysis
primary TKAs with dual-radius prostheses were assessed. of wear and damage in UHMWPE, in Kurtz SM, ed: The
At 11-year follow-up, outcomes—including UCLA hip UHMWPE Biomaterials Handbook: Ultra-High Molec-
function score, Knee Society Scores (both objective and ular Weight Polyethylene in Total Joint Replacement and
functional), mental and physical scores on the Medical Medical Devices, ed 3. Burlington, MA, Academic Press,
Outcomes Study 36-Item Short Form, and patient satis- 2009. DOI
faction scores—were good to excellent. The survivorship
rate was 99%. 12. Chen Y, Hallab NJ, Liao YS, Narayan V, Schwarz EM, Xie
C: Antioxidant impregnated ultra-high molecular weight
4. Wimmer MA, Laurent MP, Haman JD, Jacobs JJ, Galante polyethylene wear debris particles display increased bone
JO: Surface damage versus tibial polyethylene insert remodeling and a superior osteogenic:osteolytic profile vs.
conformity: A retrieval study. Clin Orthop Relat Res conventional UHMWPE particles in a murine calvaria
2012;470(7):1814-1825. Medline DOI model. J Orthop Res 2016;34(5):845-851. Medline DOI
Section 5: Knee
The authors of this study evaluated the effects of cross- 17. Peters PC Jr, Engh GA, Dwyer KA, Vinh TN: Osteolysis
linked UHMWPE wear debris particles in two types of after total knee arthroplasty without cement. J Bone Joint
polyethylene inserts. Their findings showed that antioxi- Surg Am 1992;74(6):864-876. Medline
dant-impregnated UHMWPE particles have less potential
to destroy bone and can even support bone remodeling. 18. Kim YH, Oh JH, Oh SH: Osteolysis around cementless
porous-coated anatomic knee prostheses. J Bone Joint
13. Cadambi A, Engh GA, Dwyer KA, Vinh TN: Osteolysis Surg Br 1995;77(2):236-241. Medline
of the distal femur after total knee arthroplasty. J Arthro-
plasty 1994;9(6):579-594. Medline DOI 19. Arnholt CM, MacDonald DW, Tohfafarosh M, et al; Im-
plant Research Center Writing Committee: Mechanically
14. Weber AB, Worland RL, Keenan J, Van Bowen J: A study assisted taper corrosion in modular TKA. J Arthroplasty
of polyethylene and modularity issues in >1000 posterior 2014;29(9suppl):205-208. Medline DOI
cruciate-retaining knees at 5 to 11 years. J Arthroplasty
2002;17(8):987-991. Medline DOI In this study, 198 modular TKA components were assessed
to determine the prevalence of taper damage. Mild to se-
vere fretting was observed in 94 of 101 modular femoral
15. Mikulak SA, Mahoney OM, dela Rosa MA, Schmalzried tapers and in 90 of 97 modular tibial tapers. It was con-
TP: Loosening and osteolysis with the press-fit condylar cluded that corrosion was associated with modular TKA.
posterior-cruciate-substituting total knee replacement.
J Bone Joint Surg Am 2001;83-A(3):398-403. Medline
20. McMaster WC, Patel J: Adverse local tissue response le-
sion of the knee associated with Morse taper corrosion.
16. O’Rourke MR, Callaghan JJ, Goetz DD, Sullivan PM, J Arthroplasty 2013;28(2):375.e5-375.e8. Medline DOI
Johnston RC: Osteolysis associated with a cemented mod-
ular posterior-cruciate-substituting total knee design: Five In this case report, an adverse local tissue reaction associ-
to eight-year follow-up. J Bone Joint Surg Am 2002;84- ated with corrosion of a Morse taper in a revision TKA is
A(8):1362-1371. Medline described. Intraoperative findings included black encrusta-
tions at the taper junction and a thick fibrotic joint capsule.
Following the revision procedure, no clinical abnormalities
were noted.
5: Knee
Chapter 24
Nonarthroplasty Management
of Knee Arthritis
David J. Jacofsky, MD Shane R. Hess, DO
epidemic, and by 2030, the incidence of total knee arthro-

Abstract
plasty (TKA) will increase to nearly 3.5 million proce-
Several nonarthroplasty options are available for the dures annually.2 Despite the great number of patients who
management of symptomatic knee osteoarthritis with must undergo this procedure, a recent study indicated that
the goal to reduce pain, improve function, improve almost one-third of TKAs were deemed inappropriate
quality of life, and to delay or potentially avoid total using a modified version of validated appropriateness
knee arthroplasty. Nonarthroplasty options include criteria.3 The increase in procedures is associated with
lifestyle changes, mechanical treatments, pharmaco- the burden and high cost of complications. In an era of
logic therapies, and other surgical options. Examples payment reform, it is paramount that the management
of lifestyle modifications include weight loss, exercise, of osteoarthritis include nonarthroplasty measures to
and strengthening. Flexible knee sleeves, corrective reduce costs, lessen pain, preserve function, and improve
knee braces, and lateral heel wedges are illustrations of the quality of life for patients.
mechanical treatments. Pharmacologic options include
oral formulations and intra-articular injections. Lavage,
Lifestyle Changes
chondroplasty, débridement, marrow stimulation, au-
tologous chondrocyte implantation, osteochondral Increased stress across the knee can have negative ef-
autograft transfer, and osteochondral allograft trans- fects on the articular structure and function, and weight
plantation are examples of surgical options other than gain and decreased strength play important roles in in-
2: Knee
arthroplasty. creasing this stress. The risk of developing symptomatic
knee osteoarthritis can be reduced by as much as 50%
with a weight loss as little as 5 kg.4 Pain and physical
dysfunction compromise weight reduction, with a dose-
Keywords: knee; osteoarthritis; nonarthroplasty response relationship between the percent change in body
management weight and Western Ontario and McMaster Universities
Arthritis Index scores; those who gained 10% of body
weight or more had worse scores.5 Weight loss, combined
Introduction
with exercise and strength training, are key in improving
Osteoarthritis is the most common cause of disability pain, function, and the quality of life. Land-based ex-
among adults in the United States.1 Osteoarthritis is an ercises have been shown to be beneficial, at least in the
short term,6 and aquatic exercises have shown similar
results.7 In a 2015 review examining high-intensity versus
Dr. Jacofsky or an immediate family member has received low-intensity physical activity, insufficient evidence was
royalties from Stryker and Smith & Nephew, serves as a available to determine the effects of different exercise
paid consultant to Stryker, has stock or stock options held programs, but high-intensity exercise produced a slightly
in Secure Independence, and has received research or in- greater improvement in pain and function at the end of
stitutional support from Biomet, Stryker, Smith & Nephew, the treatment program.8
and Arthrex. Neither Dr. Hess nor any immediate family In 2013, the randomized controlled Intensive Diet
member has received anything of value from or has stock or and Exercise for Arthritis trial compared the 18-month
stock options held in a commercial company or institution outcomes among three study groups of overweight and
related directly or indirectly to the subject of this chapter. obese adults with knee osteoarthritis.9 The interventions
Section 2: Knee
included intensive diet-induced weight loss plus exercise, Corrective Knee Braces
intensive diet-induced weight loss alone, or exercise alone. The medial compartment of the knee is affected by pain
Intensive weight loss was defined as losing 10% of body and osteoarthritis more commonly than the lateral com-
weight or more, and exercise was defined as 1 hour of partment because most of the joint load passes through
physical activity per day, 3 days per week. The investi- the medial compartment during gait.14 In osteoarthritis,
gators found greater weight loss in the diet-plus-exercise wearing down of the cartilage occurs, inducing malalign-
and diet groups. Knee compression forces were lower in ment, which then compromises the surrounding dynamic
diet participants, and interleukin-6 (IL-6, a marker for structures and interferes with joint stabilization. In the-
systemic inflammation and higher odds of knee osteo- ory, corrective bracing redistributes the load to the un-
arthritis) levels were lower in the diet and diet-plus-ex- affected compartment and provides stability to the joint.
ercise participants. In addition, Western Ontario and A 2015 review of braces and orthoses in the treatment
McMaster Universities Arthritis Index pain scores de- of osteoarthritis of the knee found inconclusive evidence
clined to little or no pain in 20% of the weight loss–only for the benefits of bracing as measured by relief of symp-
group, 22% of the exercise-only group, and 40% of the toms and improved quality of life in patients with medial
weight loss–plus–exercise group. compartment osteoarthritis.15 However, intolerance to
The benefits of strength training cannot be underesti- wearing knee braces is common.
mated. However, the manner in which strength training
actually relieves pain in patients with osteoarthritis is Lateral Heel Wedges
unknown. Many theories exist regarding joint stability, The goal of a lateral heel wedge is to unload the medial
proprioception, increasing glycosaminoglycan content, compartment of the knee to alter alignment and reduce
inflammatory mediation, and so forth. A recent system- pain. The external knee adduction moment is a surro-
atic review of the literature evaluated physiologic factors gate for the load placed across the medial compartment
associated with osteoarthritis symptoms and exercise and and is a reliable outcome measure for treatment as well
reported that increasing upper leg strength, decreasing as a predictor of worsening medial compartment osteo-
extension impairments and proprioception improvement arthritis.16 Studies have demonstrated a change in the
had a positive association with improvement in osteo- external knee adduction moment in patients with osteo-
arthritis symptoms.10 Exercise is known to produce an arthritis of the medial compartment and in nonarthritic
anti-inflammatory effect and protocols using exercise knees when the lateral heel wedge is used.17 This change
therapy in patients with osteoarthritis has statistically is estimated to produce a 5% to 6% reduction in the
been shown to decrease IL-6 levels while decreasing pain knee adduction moment,17 and modifying the load placed
2: Knee
and increasing function.11 Exercise therapy also plays a across the medial compartment, even by this amount,
positive role in health-related quality of life.12 With the may slow disease progression. The gold standard for the
many physical and mental benefits, exercise therapy will obliquity of a heel wedge traditionally has been 5° of
always play a vital role in the symptomatic management inclination.
of patients with knee osteoarthritis. In a systematic review and meta-analysis of random-
ized controlled trials, lateral wedges were not efficacious
for the treatment of knee pain in patients who have osteo-
Mechanical Therapies arthritis of the medial compartment compared with con-
Common forms of mechanical therapy include flexible trolled interventions.18 A 2015 review reported a lack
knee sleeves (neoprene sleeves), corrective knee braces, of evidence for recommending a laterally wedged insole
and lateral heel wedges. versus no treatment, with moderate-quality evidence
showing the lack of an effect when compared with neutral
Flexible Knee Sleeves insoles.15 Even though these results question the efficacy of
Soft knee sleeves are used most commonly in early knee lateral heel wedges in medial compartment osteoarthritis,
osteoarthritis and are usually obtained over the counter. the low cost of lateral heel wedges may be an option in the
The sleeves commonly are recommended as a first-line treatment of osteoarthritis before surgical intervention,
treatment, along with weight loss, exercise, and muscle especially in patients who have deformities amenable to
strengthening. Some authors believe that the heat pro- wedges or in those for whom surgical intervention is high
duced from the knee sleeve is the mechanism of symptom risk or not desired.
alleviation, but recent evidence suggests that an anal-
gesia effect may be produced through enhanced joint
proprioception.13
Chapter 24: Nonarthroplasty Management of Knee Arthritis
Glucosamine sulfate, glucosamine hydrochloride, and

Oral and Topical Medications
chondroitin sulfate are symptomatic, slow-acting drugs
Oral medications play an important role in the modern in osteoarthritis treatment. In a multicenter, random-
treatment algorithm for symptomatic osteoarthritis. The ized double-blind noninferiority trial, glucosamine and
clinician must be aware of the efficacy and safety pro- chondroitin sulfate showed comparable efficacy to cele-
files of each medication, because the prevalence of osteo- coxib after 6 months of treatment as measured by pain,
arthritis increases with age, and older individuals may stiffness, functional limitation, and joint effusion.27 Cele-
be more susceptible to side effects and potential adverse coxib was superior at 1 to 4 months, however. The over-
events. Acetaminophen is a common first-line medication the-counter formulation of glucosamine is glucosamine
used in the pharmacologic management of knee osteo- hydrochloride, which has up to 75% less bioavailability
arthritis and has been shown to be superior to placebo than prescription formulations, which is a crystalline
but less effective than NSAIDs.19 Concerns exist over the glucosamine sulfate.28 The results of the Pharmaco-Ep-
safety profile of NSAIDs and acetaminophen because of idemiology of Gonarthrosas (PEGASus) study found
the possibility of increased adverse gastrointestinal events that crystalline glucosamine sulfate reduced the use of
and substantial increases in liver enzymes. Acetamino- NSAIDs in symptomatic osteoarthritis patients by up
phen has far less of an adverse effect on renal function to 36%.29
than do NSAIDs. Nevertheless, acetaminophen should Opioids are a common medication frequently pre-
be used conservatively with respect to dosing and dura- scribed by many providers for pain relief, and have
tion. A recent study evaluated the gastrointestinal and recently been highlighted by the Centers for Disease
cardiovascular risk profiles of patients with osteoarthritis Control and Prevention as a growing problem in the
who were prescribed NSAIDs and found that 15.5% of United States.30 Therefore, opioid use for the manage-
patients had a high risk profile.20 This study showed that ment of osteoarthritis symptoms should be used with
NSAIDs often were prescribed regardless of the presence caution. This opinion is supported by a recent review that
of risk factors in patients. This finding is concerning, found a significant increase in the risk of adverse events
because the side effects often are underestimated, leading with opioid use with questionable clinical relevance for
to over 100,000 NSAID-related hospitalizations and over pain outcomes in symptomatic osteoarthritis.31 Trama-
16,000 NSAID-related deaths annually in the United dol or tramadol/paracetamol produces small benefits in
States.21 Selective cyclooxygenase-2 inhibitors, such as pain, symptom relief, and function, but the potential
celecoxib, have been shown to be associated with a lower for adverse events often limits its use and therefore its
risk of gastrointestinal complications when compared usefulness.32 Each patient should have an individualized
2: Knee
with nonselective NSAIDs. This benefit is accompanied by approach weighing the risks and benefits of each medi-
a moderately higher risk of cardiovascular complications, cation in order to optimize the desired results.
however.22 The lowest effective dose and duration of these
medications should be used to minimize the potential for
adverse events. Additionally, when using a nonselective Injection Therapy
NSAID, a gastrointestinal protective medication generally Corticosteroid Injections
should be coprescribed. Intermittent corticosteroid injections have played an
Topical diclofenac sodium 1% gel may be an alterna- important role in the management of osteoarthritis
tive to oral NSAIDs. Diclofenac sodium has been shown symptoms for quite some time. The FDA has labeled five
to be efficacious in mild to moderate osteoarthritis of injectable corticosteroids for use in intra-articular injec-
the knee and has an excellent safety profile. 23 Diclofenac tion, including methylprednisolone acetate, triamcino-
sodium has up to a 17-fold lower systemic bioavailabil- lone acetate, triamcinolone hexacetonide, betamethasone
ity compared with oral diclofenac, with less inhibition acetate, betamethasone sodium phosphate, and dexa-
of the cyclooxygenase pathway and no inhibition of methasone.33 The mechanism of action of corticosteroids
platelet aggregation. 24 Pooled data from five randomized is complex, producing anti-inflammatory and immuno-
double-blind placebo-controlled trials in patients with suppressive effects. The inflammation experienced with
mild to moderate osteoarthritis of the knee showed that osteoarthritis is painful, and the inflammatory mediators
diclofenac sodium is well tolerated in those with an ele- released in the process are thought to come from the bone,
vated risk profile during a 12-week study period. 25 The cartilage, and synovium.34 These inflammatory mediators
safety of diclofenac sodium in patients with a high risk play a substantial role in the progression and structural
profile also has been demonstrated at 12 months of con- changes observed in the osteoarthritis process.33 Drivers
tinuous use. 26 of synovial inflammation remain somewhat unproven,
Section 2: Knee
but are thought to include a response to cartilage degra- through validated minimal important differences using
dation products. the Western Ontario and McMaster Universities Arthritis
Randomized controlled trials have shown that intra- Index scale for pain, function, and stiffness and the visual
articular corticosteroids are effective, but the benefit over analog scale for pain.43 Using only the best evidence, this
placebo is generally short lived. Most patients experience level 1 systematic review does not support using hyal-
pain relief for 2 to 4 weeks, with a possibility of longer uronic acid when considering clinical significance as the
relief for up to 26 weeks.33,35 The presence of an effu- outcome measure. However, important structural and
sion and less radiographic osteoarthritis severity may evidence-based differences between products clearly exist
be predictors of longer pain relief from intra-articular in this category. Sources from the literature or recommen-
corticosteroids.35 Other authors have found no consistent dations that group all of these products together should
predictors of response.36 A recent systematic review con- be viewed with great caution.
cluded that triamcinolone hexacetonide may be favorable
over methylprednisolone for knee arthritis based on a Platelet-Rich Plasma
faster onset of action, whereas triamcinolone acetate and Platelet-rich plasma (PRP) is a byproduct of the centri-
methylprednisolone seem to be equally efficacious for the fugation of autologous blood, which produces a concen-
knee.37 Physical therapy and activity are encouraged and trated platelet sample containing four to five times the
generally comprise part of the nonsurgical management concentration of bioactive factors and platelets per volume
scheme, but intra-articular corticosteroid injection be- as normal blood.44 Platelets are rich in growth factors
fore exercise in patients with painful knee osteoarthritis and bioactive materials that participate in the healing
appears to have no benefit.38 and inflammatory cascades. PRP is showing promise as
a pain reliever and improves knee function and the qual-
Viscosupplementation ity of life with short-term efficacy in patients with knee
The FDA has approved three injectable hyaluronan osteoarthritis. Potentially better results have been seen in
products, including sodium hyaluronate, hylan G-F 20, younger patients and in those with less cartilage degen-
and high–molecular-weight hyaluronan.33 The injection eration.45 A recent randomized controlled trial showed
schedule varies by product but usually includes a series that PRP reduced pain and improved function better than
of one to five weekly injections, which may be repeated hyaluronic acid.46 Additional level I evidence is needed to
at 6 months. Hyaluronic acid is a naturally occurring best define the patient population in which this modality
glycosaminoglycan and, in normal concentrations, acts ideally would be indicated.
as a viscous lubricant during slow movement and as an
2: Knee
elastic shock absorber during rapid movement.33 During

the inflammatory osteoarthritis cascade, the synovial Management of Cartilage Lesions
membrane becomes more permeable to hyaluronic acid, The true incidence of cartilage lesions is unknown and
decreasing its concentration in the joint. Postinjection a substantial percentage of lesions go undetected until
synovitis is a potential adverse effect after viscosupple- arthroscopy.47 Several procedures are used to manage
mentation and can occur in up to 4% of patients.33,39 cartilage lesions (Table 1). These procedures include la-
Results are mixed regarding the potential benefit of vage, chondroplasty, débridement, marrow stimulation
viscosupplementation. A recent systematic review and (microfracture), autologous chondrocyte implantation
meta-analysis suggested that hyaluronic acid intra-
(ACI), osteochondral autograft transfer (OAT), and os-
articular injection is not significantly different from con- teochondral allograft transplantation (OCA). The pri-
tinuous oral NSAIDs at 4 and 12 weeks.40 Hyaluronic acid mary goal is to produce a normal and biomechanically
therefore may be a safe alternative in patients who are sound articular surface that can prevent or delay further
unable to tolerate oral NSAIDs for knee pain related to intra-articular destruction.
osteoarthritis. Another systematic review and meta-anal-
ysis suggests that intra-articular corticosteroids provide Lavage, Chondroplasty, and Débridement
pain relief superior to hyaluronic acid for up to 4 weeks Lavage, chondroplasty, and débridement are arthroscopic
after injection, whereas hyaluronic acid has greater ef- procedures that have extremely low infection rates and
ficacy beyond week 8.41 A review found a 28% to 54% minimal surgical trauma. A randomized trial examined
improvement in pain and a 9% to 32% improvement the outcomes of five self-reported scores and one objective
in function over a 5- to 13-week postinjection period test of walking and stair climbing over a 24-month interval
compared with placebo.42 A 2015 systematic review ex- in patients with knee osteoarthritis.48 The trial found that
amined the clinical significance of viscosupplementation the outcomes after arthroscopic lavage or débridement
Table 1 cartilage specimen is taken from the host, and several

million chondrocytes are generated from the articular
Osteochondral Lesion Size and cartilage specimen during a 3-week enzymatic degra-
Indicated Procedures dation and culturing process. These cells are replanted
Osteochondral into the chondral defect and secured by one of the three
Lesion Size (cm2) Procedure generations of ACI. First-generation ACI involves a peri-
osteal patch, second-generation ACI is collagen based,
<2 Microfracture
and third-generation ACI involves matrix-based patches.
Osteochondral autograft transfer
2–4 Osteochondral autograft transfer
First-Generation Techniques
Autologous chondrocyte
implantation The technique requires the harvesting of healthy chondro-
cytes, usually from the non–weight-bearing portion of the
>4 Autologous chondrocyte
implantation knee, which then are cultured ex vivo for 14 to 21 days.
Osteochondral allograft Transplantation of these cells back into the host occurs
transplantation during a second operation, when a periosteal flap that is
harvested from the proximal tibia is stitched into place
over the cartilage defect to create a pocket. The cultured
were no better than those of a sham procedure consisting chondrocytes are injected into the pocket, and the pocket
of a skin incision only. However, 63% of individuals with is stitched closed.
radiographic evidence of knee osteoarthritis and knee Improved clinical outcomes in pain relief and func-
symptoms have meniscal tears, compared with 60% in tion after first-generation ACI are seen at a mean of
those without symptoms.49 The outcomes of the arthro- 96 months.55 First-generation ACI produces satisfying
scopic management of meniscal tears in the setting of knee clinical results with a reduction in pain, improvement
osteoarthritis have been shown to be no better than those in knee function, and satisfaction in 77% of patients at
of nonsurgical management.50,51 In general, patients with a mean follow-up of 10.9 years.56 Interestingly, when
underlying osteoarthritis, with or without a meniscal tear, comparing first-generation ACI to bone marrow–derived
do not benefit much from this procedure unless they have mesenchymal stem cells and periosteal flap coverage, bone
associated mechanical symptoms from a meniscal tear. marrow–derived mesenchymal stem cells were not only
as effective as chondrocytes for articular cartilage repair,
Marrow Stimulation but also resulted in reduced costs and less knee surgery,
2: Knee
The theory behind marrow stimulation (microfracture) and donor-site morbidity was minimized.57
is the formation of a stable articular-like surface created
from mesenchymal cells that are introduced into the car- Second-Generation and
tilage defect by directed subchondral penetration. Over Third-Generation Techniques
time, these cartilage progenitor cells develop fibrocarti- Second-generation collagen-based techniques involve
lage, which lacks the mechanical properties of typical using a membrane of porcine type I/III collagen instead
hyaline cartilage, thus leaving the area vulnerable to re- of a periosteal flap.58 This technique avoids the need for
current degeneration with time. Small lesions less than periosteal flap harvesting from the proximal tibia and
2 to 3 cm2 that are less than 1 year old in younger patients the associated comorbidity. The literature suggests re-
tend to have the best results, although failure remains sults that include decreased hypertrophy and satisfac-
relatively common after 5 years.52 Results can begin to tory clinical outcome compared with periosteal flap
deteriorate as soon as 18 months postoperatively.53 Worse techniques.58 Third-generation matrix-based ACI uses a
results are observed in those older than 40 years, likely three-dimensional bioscaffold to arrange chondrocytes
secondary to the repair tissue having a reduced regener- into a stable structure. A recent MRI study demonstrated
ation capacity compared with that of younger individu- that graft maturation and complete cartilage regeneration
als.53 Survival of the repair tissue after microfracture is can take up to 2 years after surgery.59
89%, 68% and 46% at 5, 10, and 12 years, respectively.54 The four most common major complications leading
to revision surgery among the three generations of ACI
Autologous Chondrocyte Implantation included graft hypertrophy, disturbed fusion, insufficient
Unlike microfracture, autologous chondrocyte implan- regenerative cartilage, and delamination.60 Graft hyper-
tation (ACI) has the capability to generate hyaline or trophy is most prevalent after the first-generation tech-
hyaline-like cartilage. In this procedure, an articular nique. When examining several outcome measures, no
Section 2: Knee
difference is apparent between first- and third-generation Osteochondral Allograft Transplantation

ACI at 12 and 24 months. A systematic review of clinical
trials found no significant evidence that any generation OCA is a technique in which chondral and osteochondral
of ACI is more effective than other articular cartilage defects can be treated with size-matched allografts. The
repair techniques.61 A level II systematic review indicated success of OCA directly correlates with chondrocyte vi-
improved intermediate-term clinical outcomes with ACI ability, specifically in the superficial zone, with storage at
compared to microfracture, but no difference between physiologic temperatures producing the highest amount
ACI and OAT procedures.62 In addition, no differences of viable chondrocytes.68 Long-term outcomes of femoral
were observed between first- and second-generation ACI condyle OCA can claim up to 82% and 66% survivorship
in clinical outcomes. Further studies including larger, at 10 and 20 years, respectively.69 Younger patients who
long-term, multicenter randomized controlled trials with underwent one previous procedure or none were found to
adequate power are needed. However, those patients with be the best candidates for OCA of the femoral condyle,
symptomatic large cartilage defects of a short duration whereas patients older than 30 years and who underwent
who are also younger, active, and have had no previous two or more previous surgeries experienced the highest
cartilage surgery appear to be the best candidates for ACI. association with graft failure.69
Osteochondral Autograft Transfer Summary

Osteochondral autograft transfer (OAT) is a technique Several nonarthroplasty options are used for the man-
in which osteochondral plugs are harvested from a non– agement of knee osteoarthritis. Weight loss, exercise, and
weight-bearing portion of the knee and transplanted into strength training should be the first lines of treatment.
the cartilage defect. A single plug or several plugs used in Mechanical therapy, including flexible knee sleeves, cor-
a mosaic pattern, called mosaicplasty, can be used. The rective knee braces, and lateral heel wedges, have mixed
main advantage of this technique is that mature healthy results in the literature, but may be an option early in
hyaline cartilage is immediately available to fill the defect the course of disease. The dosage and duration of acet-
instead of fibrocartilage from other cartilage procedures. aminophen, nonselective NSAIDs, and selective cyclo
Problems associated with OAT procedures include donor oxygenase-2 inhibitors must be monitored, especially in
site morbidity, failure to restore joint surface congruity, high-risk patients. Topical diclofenac may be an alterna-
and fitting and fixation of the plugs. Graft prominence tive to oral medications. Opioid use for the management
of more than 1 mm is tolerated poorly.63 Mosaicplasty is of osteoarthritis symptoms should be used with caution.
2: Knee
recommended for defects of 1 to 4 cm2.64 The knee also Glucosamine and chondroitin sulfate may have effects
should be aligned mechanically and should be stable, and over the long term, with better results seen in prescription-
extension of the defect into the subchondral bone should strength glucosamine. Intra-articular corticosteroids are
be less than 10 mm.63 The size of the cartilage defect to an option for acute and persistent synovitis; however,
be treated using this technique may be determined by the there is no consensus in the literature regarding any risk
donor site, however. associated with injection timing and periprosthetic joint
A rapid decline in outcome 2 years after the OAT pro- infection. PRP may be a reasonable option for younger
cedure can occur. The proposed etiology of failure is patients with mild symptoms given its safety profile, low
the development of weaker fibrocartilage between the cost, and simple preparation technique, however high
osteochondral plugs within the mosaicplasty.65 Long- quality evidence is lacking. Important differences exist in
term follow-up beyond 10 years demonstrates up to 40% viscosupplementation products, and attempts to group all
failure or a poor outcome.66 Increased failure rates tend of them together should be viewed with caution. Lavage,
to occur in patients older than 40 years, in women, and chondroplasty, and débridement have shown no advan-
in cartilage defects larger than 3 cm2. A recent systematic tage when compared with the nonsurgical management
review with a meta-analysis of randomized controlled of osteoarthritis unless mechanical symptoms are present.
trials compared short-term and long-term outcomes be- For the management of chondral lesions, the literature
tween ACI and OAT.67 Heterogeneity made conclusions is mixed. Small lesions that are less than 1 year old in
difficult, but it appeared that, at short-term follow-up, no younger patients tend to have the best results after micro-
significant difference between ACI and OAT was present. fracture, although results can deteriorate in 18 months.
OAT may be more likely to produce worse outcomes than Those patients with symptomatic large cartilage defects
ACI at long-term follow-up, however. of a short duration who are also younger, active, and
without previous cartilage surgery appear to be the best
5. Riddle DL, Stratford PW: Body weight changes and cor-

candidates for ACI. Patients older than 40 years, women, responding changes in pain and function in persons with
and cartilage defects greater than 3 cm 2 tend to show symptomatic knee osteoarthritis: A cohort study. Arthritis
increased failure rates after OAT. Younger patients with Care Res (Hoboken) 2013;65(1):15-22. Medline DOI
no more than one previous operation were the best can- Using data from the Osteoarthritis Initiative and the
didates for OCA of the femoral condyle. Patients older Multicenter Osteoarthritis datasets, 1,410 persons with
than 30 years with two or more previous surgeries had symptomatic function-limiting knee osteoarthritis were
studied.
the highest graft failure.
6. Fransen M, McConnell S: Exercise for osteoarthritis of the
knee. Cochrane Database Syst Rev 2008;8(4):CD004376.
Key Study Points Medline
• Weight loss and exercise combined are preferred to
7. Bartels EM, Lund H, Hagen KB, Dagfinrud H, Chris-
either one alone in the management of symptomatic tensen R, Danneskiold-Samsøe B: Aquatic exercise for
knee osteoarthritis. the treatment of knee and hip osteoarthritis. Cochrane
• Acetaminophen, nonselective NSAIDs, and celecox- Database Syst Rev 2007;4:CD005523. Medline
ib use must be monitored in the aging population
8. Regnaux J-P, Lefevre-Colau M-M, Trinquart L, et al:
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medications despite an increased risk profile. ercise in people with hip or knee osteoarthritis. Cochrane
• Intra-articular corticosteroids are an option for Database Syst Rev 2015;10:CD010203. Medline
acute and persistent synovitis while viscosupple- This 2015 Cochrane review found insufficient evidence to
mentation outcomes may be product dependent. determine the effect of different types of intensity of ex-
ercise programs in people with hip or knee osteoarthritis.
• Lavage, chondroplasty, and débridement have
shown no advantage when compared with nonsur- 9. Messier SP, Mihalko SL, Legault C, et al: Effects of inten-
gical management of osteoarthritis, while marrow sive diet and exercise on knee joint loads, inflammation,
stimulation, ACI, OAT, and OCA are treatment and clinical outcomes among overweight and obese adults
options for isolated cartilage lesions with knee osteoarthritis: The IDEA randomized clinical
trial. JAMA 2013;310(12):1263-1273. Medline DOI
The Intensive Diet and Exercise for Arthritis single-blind,
single-center randomized controlled trial evaluated the
outcomes in three treatment groups categorized by in-
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This review of the literature discusses the key features
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unable to identify any specific predictors of response to
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tomatic Slow-Acting Drugs in osteoarthritis found that ly, triamcinolone acetonide and methylprednisolone are
crystalline glucosamine sulfate was the only drug that equally efficacious in patients with symptomatic knee
decreased NSAID use in patients with symptomatic knee osteoarthritis.
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38. Henriksen M, Christensen R, Klokker L, et al: Eval-
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2: Knee
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42. Bellamy N, Campbell J, Robinson V, Gee T, Bourne between patients in the arthroscopy group and those in
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This systematic review and meta-analysis evaluated the trolled trial of 146 patients aged 35 to 65 years with me-
clinical significance of viscosupplementation for osteo- niscal symptoms and no knee osteoarthritis found no
arthritis of the knee based on the minimal important dif- difference in the clinical outcomes at 12 months between
ference for Western Ontario and McMaster Universities those who underwent arthroscopy and those who under-
Arthritis Index and the visual analog scale. A total of went a sham procedure. Level of evidence: I.
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2: Knee
Med 2012;40(12):2822-2827. Medline DOI

microfracture with a mean follow-up of 11.2 years. The
This randomized controlled trial of 120 patients found survival rate was 88.8% and 67.9% at 5 and 10 years,
that PRP had a better clinical outcome than viscosupple- respectively. Almost 40% (51 knees) of all knees proceeded
mentation for up to 24 weeks. Level of evidence: I. to TKA at a mean of 6.8 years after microfracture. Level
of evidence: IV.
47. Figueroa D, Calvo R, Vaisman A, Carrasco MA, Moraga
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N Engl J Med 2002;347(2):81-88. Medline DOI a first-generation autologous chondrocyte implantation
of a full-thickness chondral defect with a mean size of
49. Englund M, Guermazi A, Gale D, et al: Incidental meniscal 5.33 cm 2 had excellent outcomes at a mean follow-up of
findings on knee MRI in middle-aged and elderly persons. 96 months. Level of evidence: IV.
N Engl J Med 2008;359(11):1108-1115. Medline DOI
56. Niemeyer P, Porichis S, Steinwachs M, et al: Long-term
50. Katz JN, Brophy RH, Chaisson CE, et al: Surgery versus outcomes after first-generation autologous chondrocyte
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This multicenter randomized controlled trial of 351 pa- This case series of 86 patients treated with ACI for a mean
tients age 45 or older with a meniscal tear and mild to defect size of 6.5 ± 4.0 cm 2 found satisfying clinical re-
moderate knee osteoarthritis found no significant dif- sults at a mean follow-up of 10.9 ± 1.1 years. Level of
ferences in functional improvement at 6 and 12 months evidence: IV.
57. Nejadnik H, Hui JH, Feng Choong EP, Tai B-C, Lee EH: 64. Hangody L, Ráthonyi GK, Duska Z, Vásárhelyi G, Füles
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This cohort study evaluated the clinical outcomes for 65. Bentley G, Biant LC, Vijayan S, Macmull S, Skinner JA,
24 months of 72 matched patients who underwent carti- Carrington RW: Minimum ten-year results of a prospective
lage repair with chondrocytes or bone marrow–derived randomised study of autologous chondrocyte implantation
mesenchymal stem cells, which were found to be as effec- versus mosaicplasty for symptomatic articular cartilage
tive as chondrocytes. Level of evidence: III. lesions of the knee. J Bone Joint Surg Br 2012;94(4):
58. Haddo O, Mahroof S, Higgs D, et al: The use of chon- This long-term randomized comparison of ACI and mo-
drogide membrane in autologous chondrocyte implanta- saicplasty in 100 patients at a minimum follow-up of
tion. Knee 2004;11(1):51-55. Medline DOI 10 years found better functional outcomes in those who
underwent ACI than in those who udnerwent mosaicplas-
59. Niethammer TR, Safi E, Ficklscherer A, et al: Graft matu- ty. The mean lesion size was approximately 4.41 cm 2 in
ration of autologous chondrocyte implantation: Magnetic the ACI group and 4.0 cm 2 in the mosaicplasty group.
resonance investigation with T2 mapping. Am J Sports
Med 2014;42(9):2199-2204. Medline DOI 66. Solheim E, Hegna J, Øyen J, Harlem T, Strand T: Results
at 10 to 14 years after osteochondral autografting (mo-
This case series of 13 patients with a mean cartilage de- saicplasty) in articular cartilage defects in the knee. Knee
fect of 5.6 cm 2 who received a matrix-based ACI found 2013;20(4):287-290. Medline DOI
that graft maturation needs at least 1 year. Level of
evidence: IV. This study evaluated the medium-term and long-term out-
comes of mosaicplasty in 73 patients with an average age
60. Niemeyer P, Pestka JM, Kreuz PC, et al: Characteristic of 34 and found that, at 10 to 14 years, a poor outcome
complications after autologous chondrocyte implantation based on outcome measures or failure occurred in 40%
for cartilage defects of the knee joint. Am J Sports Med of patients. Male gender, age younger than 40 years, and
2008;36(11):2091-2099. Medline DOI a defect size less than 3 cm 2 were good prognostic signs.
61. Samsudin EZ, Kamarul T: The comparison between the
different generations of autologous chondrocyte implanta- 67. Li Z, Zhu T, Fan W: Osteochondral autograft transplan-
tion with other treatment modalities: A systematic review tation or autologous chondrocyte implantation for large
of clinical trials. Knee Surg Sports Traumatol Arthrosc cartilage defects of the knee: A meta-analysis. Cell Tissue
2015;May 24[Epub ahead of print]. Medline DOI Bank 2016;17(1):59-67. Medline DOI
This systematic review of 20 studies on 1,094 patients This meta-analysis of five level II randomized controlled
2: Knee
found insufficient data to conclude that any ACI tech- trials found no significant difference in outcomes between
nique is superior to other treatment modalities. Level of ACI and osteochondral autograft transplantation at short-
evidence: II. term follow-up. Level of evidence: II.
62. Harris JD, Siston RA, Pan X, Flanigan DC: Autologous 68. Pallante AL, Chen AC, Ball ST, et al: The in vivo perfor-
chondrocyte implantation: A systematic review. J Bone mance of osteochondral allografts in the goat is diminished
Joint Surg Am 2010;92(12):2220-2233. Medline DOI with extended storage and decreased cartilage cellularity.
Am J Sports Med 2012;40(8):1814-1823. Medline DOI
This systematic review of 13 level I and II studies that
included 917 subjects found that intermediate-term clin- This controlled laboratory study found that the reduced
ical outcomes trended toward improved outcomes with cellularity at the articular surface resulting from the 4°C
ACI when compared with microfracture. This study was storage was associated with variable long-term outcomes.
unable to conclude any difference between ACI and os-
teochondral autologous transplantation. No differences 69. Levy YD, Görtz S, Pulido PA, McCauley JC, Bugbee
were noted between first- and second-generation ACI. WD: Do fresh osteochondral allografts successfully
Level of evidence: II. treat femoral condyle lesions? Clin Orthop Relat Res
2013;471(1):231-237. Medline DOI
63. McCoy B, Miniaci A: Osteochondral autograft trans- This therapeutic study of 129 knees in 122 patients who
plantation/mosaicplasty. J Knee Surg 2012;25(2):99-108. underwent femoral condyle osteochondral allograft trans-
Medline DOI plantation found improvement in pain and function and a
This review describes the diagnosis, indications, technical 10-year graft survivorship of 82%. Level of evidence: IV.
considerations, postoperative management, and outcomes
of osteochondral autograft transplantation.
Section 3
Hip
Section Editor:
Chapter 25
Arthroplasty Management of
Hip Fractures: Hemiarthroplasty
Versus Total Hip Arthroplasty—
Results and Complications
treated using internal fixation; displaced fractures were

Abstract
treated with hemiarthroplasty. More recently, total hip
The choice between total hip arthroplasty (THA) and arthroplasty (THA) has been increasingly used to treat
hemiarthroplasty for the treatment of femoral neck these fractures.1,2 Because patients with hip fractures vary
fracture remains a controversial issue in orthopaedic from those who are active and healthy to those who are
surgery. The recent scientific literature and registry data institutionalized and frail, a modern treatment algorithm
indicate that THA is associated with improved clinical for FNF needs to account for not only the fracture, but
outcomes, but at the cost of a higher dislocation rate. also the patient’s age and activity level, the presence or
The same data provide conflicting results regarding absence of coexisting hip arthritis, and medical comor-
implant survivorship; therefore, both treatments can bidities (Figures 1 and 2).
be appropriate and treatment algorithms have been In general, internal fixation is performed for mini-
developed to simplify the choice and optimize the re- mally displaced FNFs and the treatment of selected
sults of THA and hemiarthroplasty in the treatment of fractures in younger patients. The remaining cases are
femoral neck fractures. treated with either THA or hemiarthroplasty; both are
widely accepted for the treatment of FNF. The optimal
treatment of displaced FNF is currently debated among
Keywords: hip fracture; hemiarthroplasty; total orthopaedic surgeons. 3-5 Various advantages and dis-
hip arthroplasty; outcomes advantages need to be considered when deciding which
type of arthroplasty to use for the treatment of displaced
FNF in the elderly.
Introduction Recent clinical trials and systematic reviews have fo-
Historically, the treatment of femoral neck fractures cused on the survivorship, complications, and clinical
(FNF) was determined solely by the displacement of the outcomes of hemiarthroplasty and THA for the treatment
fracture. Fractures with little or no displacement were of FNF. It is important for the orthopaedic surgeon to
have an up-to-date understanding of the indications and
results for these two treatment modalities.
3: Hip
Dr. Tanzer or an immediate family member serves as a paid

consultant to Pipeline Biotechnology and Zimmer, has re-
Reoperation and Revision Rates
ceived research or institutional support from Zimmer, has
received nonincome support (such as equipment or services), Systematic Reviews and Meta-Analyses
commercially derived honoraria, or other non–research- Several systematic reviews and meta-analyses have been
related funding (such as paid travel) from Zimmer, and performed to synthesize the literature and determine the
serves as a board member, owner, officer, or committee best arthroplasty treatment of FNFs. Overall, the pooled
member of the Hip Society. data demonstrate a trend of fewer reoperations and better
Section 3: Hip
Figure 1 A, Preoperative AP radiograph of the left hip obtained from an 80-year-old sedentary, frail woman demonstrates
a displaced femoral neck fracture. B, Postoperative AP radiograph obtained immediately following cemented
hemiarthroplasty.
functional outcome scores for patients with FNFs treated pooled RR of reoperation after hemiarthroplasty com-
with THA compared with hemiarthroplasty. pared with THA was 2.43 (P = 0.0002).7 A 2012 me-
Five meta-analyses demonstrated substantially fewer ta-analysis reviewed eight randomized controlled trials
early and late reoperations following THA than following that included 1,014 patients and reported a higher reop-
hemiarthroplasty. A 2015 study analyzed eight random- eration rate, more than 4 years postoperatively, following
ized controlled trials that included 977 patients.3 Overall, bipolar hemiarthroplasty than following THA (RR =
a 69% reduced risk of revision was reported for patients 3.31; P = 0.002).3 A 2014 meta-analysis reported the risk
treated with THA compared with hemiarthroplasty for of revision following hemiarthroplasty was more than
all follow-up periods up to 13 years (relative risk [RR] twofold higher than following THA for an FNF (RR =
= 0.31, P = 0.0003). Similar findings were noted in a 4.14).4 In part, this resulted from the high prevalence of
2012 meta-analysis of 12 randomized controlled trials acetabular erosion, which accounted for 78.1% of revision
3: Hip
with 1,320 patients:6 a risk reduction of approximate- surgery in patients who underwent hemiarthroplasty.
ly 50% was reported when comparing the reoperation
rate following THA with that of hemiarthroplasty
for displaced FNFs (4.6% with THA versus 8.6% for Registry and Large Databases
hemiarthroplasty; RR = 0.53; P = 0.006). Subsequent Data from national registries or from large databases
meta-analyses have reported even greater reductions in contradict the conclusions from the meta-analyses, gen-
reoperation following THA for FNFs. A 2012 meta- erally reporting bipolar hemiarthroplasty revision rates
analysis of nine studies with 1,208 patients reported a lower than or equal to those of THA when used to treat
Chapter 25: Arthroplasty Management of Hip Fractures: Hemiarthroplasty Versus Total Hip Arthroplasty—Results and Complications
Figure 2 A, Preoperative AP radiograph of the left hip obtained from a 70-year-old active, healthy man demonstrates a
displaced femoral neck fracture. B, Postoperative AP radiograph obtained immediately following noncemented
total hip arthroplasty.
FNFs.8 The advantage of using data from these sources is different in patients who underwent bipolar hemiarthro-
the population level data from a large number of patients plasty (5.6%) or THA (7.8%) (HR, 1.22; P = 0.11). In
and implants, from surgeons with all levels of experience, this age group, unipolar modular hemiarthroplasty had
and almost no exclusions. Therefore, the data can be a significantly higher cumulative 10-year revision rate
considered more representative of community practice. (10.3%) compared with bipolar hemiarthroplasty (5.6%)
In 2013, The Australian National Joint Registry first (HR, 2.3; P < 0.001). In patients 80 years and older,
addressed the 65,891 arthroplasties used in the man- no difference was reported in the rate of revision when
agement of FNFs. 2 Between 2003 and 2012, the use comparing unipolar modular and bipolar hip prosthe-
of unipolar modular hemiarthroplasty increased from ses, with a 10-year cumulative revision of 3.4% and
13.2% to 48.1% and THA increased from 10.2% to 3.9%, respectively. However, unipolar modular prosthe-
18.9%. Overall, bipolar hemiarthroplasty had the low- ses had a lower cumulative rate of revision at 10 years
est cumulative revision at 10 years (5.6%), followed by compared with THA (3.4% and 6.4% respectively; HR,
unipolar modular hemiarthroplasty (8.5%) and THA 1.66; P < 0.001). Subsequent annual reports from the
3: Hip
(9.3%). In patients younger than 70 years, no differences Australian National Joint Arthroplasty Registry have
were reported in the 10-year cumulative revision when reported the outcomes of arthroplasty performed for
comparing bipolar hemiarthroplasty (10.0%) with THA FNF, but have not analyzed the results between implant
(12.2%) (hazard ratio [HR] = 0.91; P = 0.49). However, classes.9 In 2015, bipolar hemiarthroplasty had the low-
the revision rate was significantly higher in unipolar est cumulative revision rate at 10 years (although slightly
modular hemiarthroplasty (18.1%) than in THA (9.3%) higher than previously reported) when used to treat FNF
after 3 months (HR, 1.78; P < 0.001). The 10-year cu- (6.1%), followed by THA (8.0%) and unipolar modular
mulative revision in patients age 70 to 79 years was no hemiarthroplasty (8.1%).10
Section 3: Hip
The Swedish Hip Arthroplasty Register 2013 annu- confer any additional protection against revision for dislo-
al report evaluated 6,005 patients who underwent ar- cation.2 In patients younger than 70 years and older than
throplasty for the treatment of hip fractures.10 Similar 80 years, THA performed with a femoral head smaller
to the Australian Registry, the revision rate depended than 32 mm had a higher rate of revision for dislocation
on the type of prosthesis and patient age. Overall, 3.7% (HR, 2.25; P = 0.03) than did those with a femoral head
of unipolar hemiarthroplasties, 4.7% of bipolar hemi- of 32 mm (HR, 2.33; P = 0.02). In patients age 70 to
arthroplasties, and 5.0% of THAs required reoperation 79 years, the rate of revision for dislocation is more than
over an 8-year period. It was thought that the improved 2.5-fold greater for head sizes smaller than 32 mm com-
results with hemiarthroplasty might reflect their use in pared with those for head sizes 36 mm or larger (HR,
older and sicker patients with limited lifespans. Therefore, 2.62; P = 0.04). For all age groups, no difference was
complications have more time to develop in patients in reported in the dislocation rate between head size groups.
the THA group, and because these patients are in better
health, they will likely undergo more reoperations. When General Complications
sex, age, reason for surgery, approach, use of cement, In general, the short-term complication rates appear to be
and prosthesis type were analyzed using Cox regression, similar following hemiarthroplasty and THA for FNF;
bipolar hemiarthroplasty exhibited a substantially in- however, in-hospital complications may be higher follow-
creased reoperation risk compared with THA and uni- ing hemiarthroplasty.
polar hemiarthroplasty. THA had the lowest and bipolar A 2014 study14 reported on whether in-hospital ad-
hemiarthroplasty had the highest reoperation risk in all verse events, postoperative length of stay, and mortality
three age groups (younger than 75 years, 75 to 85 years, differed after THA or hemiarthroplasty for isolated FNFs
and older than 85 years). in patients 60 years of age or older. The study included
A 2012 study used data from 2,437 patients under- 82,951 patients (74,088 underwent hemiarthroplasty;
going THA and 38,328 undergoing hemiarthroplasty 8,863 underwent THA) from the US National Hospi-
for FNF from the California Office of Statewide Health tal Discharge Survey database who were treated over a
Planning and Development.11 Cox regression analysis 2-year period. Controlling for demographics and comor-
demonstrated no significant difference in risk of revision bidities, patients who underwent hemiarthroplasty had a
surgery between THA and hemiarthroplasty during the 40% higher risk of in-hospital adverse events than those
11-year observation period (HR, 1.06; P = 0.65). who underwent THA (P < 0.001). Length of stay and in-
hospital mortality did not differ between these groups.
It was postulated that these results may reflect the use
Complications of hemiarthroplasty in patients who are more infirm,
Dislocation and that this was not entirely revealed by the analysis of
The major reported disadvantage of treating FNF with comorbidities.
THA and not hemiarthroplasty is the increased risk of A 2013 retrospective analysis of the American College
dislocation. Five recent meta-analyses have shown a sub- of Surgeons National Surgical Quality Improvement Pro-
stantially greater risk of dislocation following THA for gram from January 2005 through December 2009 was
FNF compared with hemiarthroplasty.3,6,7,12,13 In these performed to determine the 30-day postoperative out-
studies, the pooled analyses showed the RR of dislo- comes of 2,231 THAs and 428 hemiarthroplasties used to
cation with THA ranged from 1.51 to 2.53, compared treat FNFs in patients older than 65 years.15 Overall, the
with hemiarthroplasty, an increase seen with up to 13- patients who had undergone THA had the lowest rate of
year follow-up.6,7,12,13 Only one meta-analysis showed no postoperative complications. The risk-adjusted multivari-
difference in dislocation rates, although a trend existed ate analysis demonstrated that respiratory complications
toward a higher dislocation rate with THA.4 were less likely to develop in patients who underwent
Dislocation after THA is multifactorial in etiology. The hemiarthroplasty than in patients who underwent THA
3: Hip
meta-analyses comparing THA and hemiarthroplasty for within 30 days (odds ratio, 0.43). The lowered respira-
the treatment of FNF have not addressed femoral head tory complication rates with hemiarthroplasty may be
size regarding dislocation. The Australian registry has attributed to the shorter procedural time.
specifically analyzed the cumulative revision rate for dislo- Using the large database of the California Office
cation following THA for the treatment of FNF and found of Statewide Health Planning and Development, a
that a femoral head smaller than 32 mm has a higher rate 2013 study reported that at 90 days postoperatively,
of revision for dislocation in all age groups.2 Increased patients undergoing THA for FNF had no significant
femoral head size from 32 to 36 mm or larger does not increase in complication rates compared with patients
undergoing hemiarthroplasty (14.4% versus 17.4%; hemiarthroplasty in patients younger than 70 years were
P = 0.06).11 Outcomes were influenced by the scores on the not significant). Concerning health-related quality of life,
Charlson Comorbidity Index, with increased comorbid- patients in the THA group had the highest mean EQ-5D
ity increasing the risk of complications. Therefore, with index (0.70 in patients younger than 70 years; 0.71 in
appropriate patient selection, THA was considered to be patients older than 70 years). In patients younger than
a safe alternative to hemiarthroplasty following acute 70 years, the lowest mean EQ-5D index (0.48) was found
FNFs. Also, a meta-analysis of 8 trials with 986 patients in the hemiarthroplasty group (P < 0.001). Patient-report-
reported equal rates of major (RR = 1.07) and minor ed pain was significantly higher in the hemiarthroplasty
(RR = 0.94) complications in patients undergoing THA group than the THA group in patients older than 70 years.
or hemiarthroplasty for FNF.13 Moderate to unbearable pain (adjusted for sex and age)
for patients older than 70 years was significantly higher
in the hemiarthroplasty group (RR, 1.8; P < 0.001) than
Clinical Outcomes in the THA group. Among patients older than 70 years,
Perhaps the greatest impetus to the recent interest in THA those who underwent hemiarthroplasty were not as satis-
for FNF is the reported improvement in functional out- fied as those who underwent THA (P < 0.001). For those
come and quality of life when compared with hemiarthro- patients older than 70 years, dissatisfaction with their
plasty. This finding is supported by four meta-analyses that outcome was higher in the hemiarthroplasty group (RR =
analyzed patient clinical outcomes after hemiarthroplasty 2.3; P < 0.001) than in the THA group.
or THA for the treatment of FNF.3,4,6,13 A 2015 study
reported that patients who underwent THA had signifi-
cantly better EuroQol five dimensions (EQ-5D) health Treatment Algorithm
outcome scores (P = 0.01), higher mobility rates within The goal of hip fracture management is to restore the
5 years of follow-up (RR = 0.76), and significantly lower patient’s preoperative function with the lowest possible
pain (RR = 1.44) than patients who underwent hemi- complication and revision rates. Given the risk/benefit
arthroplasty.3 Although no difference was found in Harris profile of arthroplasty to treat FNFs, an algorithm was
Hip Scores between the groups, the score tended to be proposed to help consider arthroplasty for treatment of a
higher after THA. A 2014 study reported that the Harris displaced FNF.1 THA was recommended in all cases with
Hip Score improved substantially more with THA than preexisting osteoarthritis or inflammatory arthritis and in
with hemiarthroplasty 2 years following treatment for patients older than 65 years who have a displaced FNF.
FNF.4 Similarly, a 2012 study reported the mean Harris However, because the dislocation rate is higher for THA
Hip Scores were higher after THA (P < 0.001) at 3- to than for hemiarthroplasty, in the cognitively impaired
4-year follow-up.6 Another 2012 meta-analysis reported patient or the patient at high risk of dislocation, unipolar
that the mean Harris Hip Score was 81 points after THA or bipolar hemiarthroplasty or THA with a dual mobility
versus 77 points after hemiarthroplasty.13 The subdomain cup is recommended.
pain of the weighted mean Harris Hip Score (42 after In December 2015, the American Academy of Ortho-
THA 42; versus 39 after hemiarthroplasty), the rate of paedic Surgeons Board of Directors adopted the Appro-
patients reporting mild to no pain (75% versus 56%), and priate Use Criteria for the acute treatment of hip fractures
the Western Ontario and McMaster Universities Arthritis in patients older than 60 years.17 These criteria were de-
Index score (94 versus 78) all favored THA. Quality of veloped to address the most common clinical scenarios to
life measured using the EQ-5D index (0.69 versus 0.57) treat hip fractures to improve patient care and to obtain
also favored THA. the best outcomes while considering the subtleties and
The superiority in functional outcome with THA has distinctions necessary in clinical decision making. Patient
recently been corroborated by a large registry study of scenarios were created based on the fracture type, the
patient-reported outcomes following surgical treatment patient’s preoperative mobility and functional status, and
3: Hip
of FNFs.16 Through collaboration between the Swed- whether there was preexisting hip arthritis. Treatments
ish Hip Arthroplasty Register and the Swedish National of 30 various patient scenarios (that is, criteria) were
Hip Fracture Register, 2,204 patients who underwent classified as appropriate, may be appropriate, or rarely
hemiarthroplasty and 808 who underwent THA for a appropriate. These criteria were developed as guidelines
displaced femoral neck fracture were surveyed. Overall, and are not meant to supersede a clinician’s expertise and
patients who underwent THA reported less pain and were experience or patient preference.
more satisfied compared with those who underwent hemi- Overall, strong evidence was presented for the guide-
arthroplasty (although the differences between THA and lines for displaced FNFs and moderate evidence for the
Section 3: Hip
Table 1
Indications for the Treatment of Acute Nondisplaced Femoral Neck Fracturesa
Scenario Total Hip Arthroplasty Hemiarthroplasty
Nondisplaced femoral neck, high functioning/high-demand Appropriate Rarely appropriate
patient, preexisting and symptomatic arthritis
Nondisplaced femoral neck, moderate to low functioning Appropriate May be appropriate
Nondisplaced femoral neck, nonambulatory/bed- May be appropriate Appropriate
dependent/palliative (low-function/low-demand) patient,
preexisting and symptomatic arthritis
Nondisplaced femoral neck, high functioning/high-demand Rarely appropriate May be appropriate
patient, no preexisting and symptomatic arthritis
Nondisplaced femoral neck, moderate to low functioning Rarely appropriate May be appropriate
Nondisplaced femoral neck, nonambulatory/bed- Rarely appropriate Rarely appropriate
dependent/palliative (low-function/low-demand) patient,
no preexisting and symptomatic arthritis
a
Indications based on the American Academy of Orthopaedic Surgery Appropriate Use Criteria (AUC) for the acute treatment of hip fractures
in patients older than 60 years. Available at: http://www.aaos.org/uploadedFiles/PreProduction/Quality/AUCs_and_Performance_Measures/
appropriate_use/Hip%20Fx%20Tx%20AUC.pdf. Accessed online December 11, 2015.
Table 2
Indications for the Treatment of Acute Displaced Femoral Neck Fracturesa
Scenario Total Hip Arthroplasty Hemiarthroplasty
Displaced femoral neck, high functioning/high-demand Appropriate Appropriate
Displaced femoral neck, high functioning/high-demand Appropriate Appropriate
Displaced femoral neck, moderate to low functioning patient, Appropriate Appropriate
preexisting and symptomatic arthritis
Displaced femoral neck, moderate to low functioning patient, May be appropriate Appropriate
no preexisting and symptomatic arthritis
Displaced femoral neck, nonambulatory/bed-dependent/ May be appropriate Appropriate
palliative (low-function/low-demand) patient, preexisting
and symptomatic arthritis
Displaced femoral neck, nonambulatory/bed-dependent/ Rarely appropriate Appropriate
palliative (low-function/low-demand) patient, no pre-
existing and symptomatic arthritis
a
Indications based on the American Academy of Orthopaedic Surgery Appropriate Use Criteria (AUC) for the acute treatment of hip fractures
in patients older than 60 years. Available at: http://www.aaos.org/uploadedFiles/PreProduction/Quality/AUCs_and_Performance_Measures/
appropriate_use/Hip%20Fx%20Tx%20AUC.pdf. Accessed online December 11, 2015.
3: Hip
guidelines for stable FNFs, the use of hemiarthroplasty Regarding specific patient scenarios, the indications
versus THA, and the need to cement the femoral stem. for THA or hemiarthroplasty varied for nondisplaced
Regarding the use of hemiarthroplasty versus THA, the (Garden type 1 or 2) or displaced (Garden type 3 or 4)
AAOS Clinical Practice Guideline on the Management FNFs (Tables 1 and 2). In general, if arthroplasty is cho-
of Hip Fractures in the Elderly indicates that moderate sen to treat a nondisplaced FNF, THA is appropriate if
evidence exists to support the benefit to THA in properly there is concomitant arthritis, except for patients with
selected patients with unstable (displaced) FNFs.17 low functional demands, in whom hemiarthroplasty
3. Wang F, Zhang H, Zhang Z, Ma C, Feng X: Comparison

is considered appropriate. For displaced FNFs, hemi- of bipolar hemiarthroplasty and total hip arthroplasty for
arthroplasty is appropriate for all cases, and THA is ap- displaced femoral neck fractures in the healthy elderly: A
propriate for those cases of preexisting arthritis and in meta-analysis. BMC Musculoskelet Disord 2015;16:229.
high-function, high-demand patients who do not have Medline DOI
preexisting arthritis. This meta-analysis of eight randomized controlled trials
compared the outcomes of bipolar hemiarthroplasty with
THA for treating displaced FNFs in 1,014 patients old-
Summary er than 65 years: 523 underwent hemiarthroplasty and
491 underwent THA.
The choice between THA and hemiarthroplasty for the
treatment of FNF remains a controversial issue in or- 4. Zhao Y, Fu D, Chen K, et al: Outcome of hemiarthro-
thopaedic surgery. The recent scientific literature and plasty and total hip replacement for active elderly patients
with displaced femoral neck fractures: A meta-analysis of
registry data indicate that THA is associated with im- 8 randomized clinical trials. PLoS One 2014;9(5):e98071.
proved clinical outcomes, but with a higher dislocation Medline DOI
rate. The same data provide conflicting results regarding This meta-analysis of eight studies with 983 patients as-
implant survivorship. Therefore, both procedures have a sessed the outcome of hemiarthroplasty and THA for
role in treatment, and algorithms have been developed to active elderly patients with displaced FNFs.
simplify the choice and optimize the results of THA and
hemiarthroplasty in the treatment of FNFs. 5. Jonas SC, Shah R, Al-Hadithy N, Norton MR, Sexton
SA, Middleton RG: Displaced intracapsular neck of femur
fractures in the elderly: Bipolar hemiarthroplasty may
be the treatment of choice; a case control study. Injury
Key Study Points 2015;46(10):1988-1991. Medline DOI
• The choice between THA and hemiarthroplasty for This retrospective case-control study compared 55 matched
patients who underwent contemporary bipolar hemi-
the treatment of FNF remains controversial. arthroplasty or THA for displaced FNFs. THA does not
• THA for the treatment of femoral neck fractures confer greater clinical outcome but had a significantly
results in improved clinical outcomes. higher rate of dislocation, suggesting that hemiarthro-
plasty may be the treatment of choice for displaced FNFs.
• THA for the treatment of femoral neck fractures
can result in a higher risk of dislocation. A femoral 6. Yu L, Wang Y, Chen J: Total hip arthroplasty versus
head size of at least 32 mm should be used. hemiarthroplasty for displaced femoral neck fractures:
• Hemiarthroplasty with a bipolar head continues to Meta-analysis of randomized trials. Clin Orthop Relat
Res 2012;470(8):2235-2243. Medline DOI
have an important role in the treatment of femoral
neck fractures. Unipolar heads are best reserved for This meta-analysis of 12 randomized controlled trials
included 1,320 patients.
patients older than 80 years.
7. Zi-Sheng A, You-Shui G, Zhi-Zhen J, Ting Y, Chang-Qing
Z: Hemiarthroplasty vs primary total hip arthroplasty
for displaced fractures of the femoral neck in the elderly:
Annotated References A meta-analysis. J Arthroplasty 2012;27(4):583-590.
Medline DOI
1. Su EP, Su SL: Femoral neck fractures: A changing paradigm. This meta-analysis of nine studies including 1,208 patients
Bone Joint J 2014;96-B(11suppl A):43-47. Medline DOI compared the outcomes of hemiarthroplasty with primary
THA for displaced femoral neck fractures in patients older
The authors propose an algorithm for the treatment of than 60 years.
FNFs based on the results of the literature and modern
arthroplasty options. 8. Kannan A, Kancherla R, McMahon S, Hawdon G, Soral
A, Malhotra R: Arthroplasty options in femoral-neck
3: Hip
2. Australian National Joint Replacement Registry 2013: fracture: Answers from the national registries. Int Orthop
Available at: https://aoanjrr.dmac.adelaide.edu.au/docu- 2012;36(1):1-8. Medline DOI
ments/10180/127202/Annual%20Report%202013?ver-
sion=1.2&t=1385685288617. Accessed online December This data analysis from national registries compared sur-
11, 2015. vival rates of prostheses used in FNFs; identified prognos-
tic factors for failure and identified the important modes
This 2013 annual report on hip and knee arthroplasty was of failure of these prostheses. The Swedish, Italian, En-
published by the Australian Joint Registry. glish and Australian registries together contained data of
83,309 hemiarthroplasty procedures and 12,380 THA
procedures for FNF.
Section 3: Hip
9. Australian National Joint Replacement Registry: 2015. 14. Voskuijl T, Neuhaus V, Kinaci A, Vrahas M, Ring D:
Available at: https://aoanjrr.dmac.adelaide.edu.au/docu- In-hospital outcomes after hemiarthroplasty versus total
ments/10180/217745/Hip%20and%20Knee%20Arthro- hip arthroplasty for isolated femoral neck fractures. Arch
plasty. Accessed online December 11, 2015. Bone Jt Surg 2014;2(3):151-156. Medline
This 2015 annual report on hip and knee arthroplasty was This study included 82,951 patients (hemiarthroplasty,
published by the Australian Joint Registry. 74,088; THA, 8,863) from the US National Hospital
Discharge Survey database treated over a 2-year pe-
10. Swedish Hip Arthroplasty Register Annual Report 2013. riod and addressed whether in-hospital adverse events,
Available at: http://www.shpr.se/Libraries/Documents/ postoperative length of stay, and mortality differed after
AnnualReport_2013-04-1_1.sflb.ashx. Accessed online THA or hemiarthroplasty for isolated FNFs in patients
December 11, 2015. age 60 years or older.
This 2015 annual report on hip and knee arthroplasty 15. Fisher MA, Matthei JD, Obirieze A, et al: Open reduc-
was published by the Swedish Joint Registry. tion internal fixation versus hemiarthroplasty versus total
hip arthroplasty in the elderly: A review of the National
11. SooHoo NF, Farng E, Chambers L, Znigmond DS, Li- Surgical Quality Improvement Program database. J Surg
eberman JR: Comparison of complication rates between Res 2013;181(2):193-198. Medline DOI
hemiarthroplasty and total hip arthroplasty for intracap-
sular hip fractures. Orthopedics 2013;36(4):e384-e389. This retrospective analysis of the American College of Sur-
Medline DOI geons National Surgical Quality Improvement Program
for January 2005 through December 2009 determined
In this study, data on hospitalizations from 1995 through the 30-day postoperative outcomes of 2,231 THAs and
2005 were obtained from California’s Office of Statewide 428 hemiarthroplasties used to treat FNFs in patients
Health Planning and Development. Regression analyses older than 65 years.
compared rates of short-term complications and midterm
revision surgeries in 2,437 patients undergoing THA and 16. Leonardsson O, Rolfson O, Hommel A, Garellick G,
38,328 undergoing hemiarthroplasty for FNF. Åkesson K, Rogmark C: Patient-reported outcome af-
ter displaced femoral neck fracture: A national survey of
12. Carroll C, Stevenson M, Scope A, Evans P, Buckley S: 4467 patients. J Bone Joint Surg Am 2013;95(18):1693-
Hemiarthroplasty and total hip arthroplasty for treating 1699. Medline DOI
primary intracapsular fracture of the hip: A systematic
review and cost-effectiveness analysis. Health Technol In this study, 2,204 patients who underwent hemiarthro-
Assess 2011;15(36):1-74. Medline DOI plasty and 808 who underwent THA responded to a
patient-reported outcomes questionnaire. The patients
This systematic review and meta-analysis assessed the were treated for displaced femoral neck fracture during
clinical effectiveness and cost-effectiveness evidence of a 12-month period.
THA compared with hemiarthroplasty in patients with
displaced intracapsular fracture who are cognitively intact 17. American Academy of Orthopaedic Surgeons Appropriate
and had high preinjury mobility or function. Although Use Criteria (AUC) for the acute treatment of hip fractures
THA was associated with increased costs in the initial in patients over 60 years of age. Available at: http://www.
2-year period, it was associated with lower longer term aaos.org/uploadedFiles/PreProduction/Quality/AUCs_
costs, owing to potentially lower revision rates. and_Performance_Measures/appropriate_use/Hip%20
Fx%20Tx%20AUC.pdf. Accessed online December 11,
13. Burgers PT, Van Geene AR, Van den Bekerom MP, et 2015.
al: Total hip arthroplasty versus hemiarthroplasty for
displaced femoral neck fractures in the healthy elderly: A These guidelines were recently adopted by the American
meta-analysis and systematic review of randomized trials. Academy of Orthopaedic Surgeons Board on the acute
Int Orthop 2012;36(8):1549-1560. Medline DOI treatment of hip fractures in patients older than 60 years.
This meta-analysis of eight trials with 986 patients re-

ported that THA was associated with higher patient-based
outcomes, but with a higher dislocation rate.
3: Hip
Chapter 26
Nonarthroplasty Joint-Preserving
Surgery for Hip Disorders
Paul E. Beaulé, MD, FRCSC J.W. Thomas Byrd, MD Geoffrey P. Wilkin, MD, FRCSC Bryan T. Kelly, MD
Sasha Carsen, MD, MBA, FRCSC Hussain Al-Yousif, MD Benjamin R. Coobs, MD John C. Clohisy, MD
The understanding of nonarthroplasty treatment of The understanding of prearthritic hip conditions has
hip disorders has grown in breadth and depth in recent increased greatly in the past decade. And although the
years. Surgeons are better able to recognize the causes hip joint is often referred to as a simple ball-and-socket
of hip abnormalities and the treatments that are most articulation, the complexities of its functional anatomy as
appropriate. Recent evidence on common disorders of well as the various pathologies affecting it has spurred a
the hip, as well as their treatment and results, have been tremendous amount of research and surgical innovation.
reported in studies that have examined labral tears, Surgeons in the field of joint-preserving surgery of the hip
chondral injuries, femoroacetabular impingement, and should have a thorough understanding of the diagnosis
dysplasias. The safety, efficacy, and patient outcomes of and management of the most common conditions, ranging
alternate diagnostic techniques, treatment, and surgical from labral tears to corrective osteotomy for dysplasia.
techniques (including but not limited to physical exam-
ination, radiographs, CT, MRI, surgical dislocation, Labral Tears
arthroscopy, and periacetabular osteotomy) have also
been reported. A broad yet thorough understanding Thomas Byrd, MD
by the orthopaedic surgeon of various hip preservation The etiology of labral tears varies, but most are secondary
techniques can improve the quality of care and life for to bony dysmorphism, either femoroactabular impinge-
patients and provide incentive for further research. ment (FAI) or dysplasia.1 Sometimes the coexistence of
FAI and dysplasia creates a challenge in deciphering which
is the principal catalyst for joint damage.2 The fibrocar-
Keywords: arthroscopic treatment; labral tears; tilaginous labrum is triangular in cross-section and rings
imaging; impingement; periacetabular osteotomy the acetabulum (Figure 1). Unlike in the shoulder, no
Dr. Beaulé or an immediate family member has received royalties from Corin USA, Medacta, and MicroPort Orthope-
dics; is a member of a speakers’ bureau or has made paid presentations on behalf of MicroPort, Smith & Nephew, and
Medacta; serves as a paid consultant to Corin USA, Smith & Nephew, Medacta, DePuy, and Zimmer; and has received
research or institutional support from Corin USA, DePuy, and MicroPORT. Dr. Byrd or an immediate family member has
received royalties from Smith & Nephew, serves as a paid consultant to Smith & Nephew, serves as an unpaid consultant 3: Hip
to A 3 Surgical, has stock or stock options held in A 3 Surgical, has received research or institutional support from Smith &
Nephew, and serves as a board member, owner, officer, or committee member of the Arthroscopy Association of North
America, the American Orthopaedic Society for Sports Medicine, and the International Society for Hip Arthroscopy. Dr.
Kelly or an immediate family member serves as a paid consultant to or is an employee of Arthrex, serves as an unpaid
consultant to A 3 Surgical, and has stock or stock options held in A3 Surgical. Dr. Clohisy or an immediate family member
serves as a paid consultant to MicroPort Orthopedics and has received research or institutional support from Pivot
Medical, Smith & Nephew, and Zimmer. None of the following authors or any immediate family member has received
anything of value from or has stock or stock options held in a commercial company or institution related directly or
indirectly to the subject of this chapter: Dr. Wilkin, Dr. Carsen, Dr. Al-Yousif, and Dr. Coobs.
Section 3: Hip
have demonstrated superior outcomes of labral refix-

ation.6,7 However, poorer results of débridement have
been seen in older patients, and substantial joint space
narrowing and advanced osteoarthritis are general con-
traindications to arthroscopy.8 No finite age cutoff at
which restoration is contraindicated has been defined.
Repair/Refixation
Primary repair of the labrum, or simply restoring a torn
labrum, is a less common procedure. More commonly,
refixation is performed for pincer impingement by mo-
bilizing the labrum to trim the bony rim and reanchor-
ing the labrum. Isolated repair of a labrum without rim
trimming does not imply a primary labral tear because
it is uncommon for labral tears to occur without a bony
deformity present.
Various portal combinations have been popularized
for labral restoration. Avoiding perforation of the ar-
ticular surface of the acetabulum with the anchors is
of paramount importance. In addition, the direction of
anchor placement should be sufficiently divergent from
the subchondral surface. Far medial anchors for anterior
Figure 1 Illustration shows the relationship of the labrum fixation run the risk of penetrating the inner cor-
acetabular labrum and capsule including tex of the pelvis, causing irritation of the iliopsoas. In this
the bone of the acetabulum (B), labrum (L), instance, a more anterior portal site may lessen the risk, as
articular cartilage (A), tidemark (TM), and
capsule (C). (Reproduced with permission from the anchor is directed more anterior to posterior, and not
Thomas Byrd JW: Labral management: An medial. Suture placement in the labrum depends on the
overview, in Thomas Byrd JW: Operative Hip
Arthroscopy, ed 3. New York, NY, Springer.
following variables: the pattern of tearing, the size of the
2012, pp 171-184.) labrum, and the morphology of the labrum. For primary
repair, the anchor may be placed against the rim on the
articular side of the labrum and the sutures passed in a
capsulolabral complex is present in the hip; the capsule horizontal mattress fashion or looped around the labrum
attaches to the rim of the acetabulum, separate from the (Figure 2). In refixation, the anchor is more commonly
labrum. Labral function is different in the hip, and a tear placed on the capsular side. A labrum-based stitch can
is not pathognomonic of instability as in the shoulder. restore the chondrolabral junction without leaving sutures
The main function of the labrum in the hip is to contain interposed between the labrum and the articular surface
fluid within the joint; this seal aids in even distribution of of the femoral head; however, if the labrum is small or the
contact forces across the articular surface and enhances tissue quality is poor, a loop suture may be appropriate9,10
stability. A study of open correction of FAI illustrates (Figure 3 and Figure 4).
the negative influence of total labrectomy on advanced
arthritis.3 Based on observations in both animal models Reconstruction
and humans, the labrum has been shown to be a hardy The literature increasingly supports the role of labral
structure with excellent healing capacity.4 reconstruction.11,12 The clearest indication is symptomatic
iatrogenic labral deficiency from excessive labral resection
3: Hip
in a young person with good joint space preservation.

Treatment Strategies However, in the case of revision, reasons for pain may
Débridement be numerous, and a thoughtful and thorough approach
The goal of labral débridement is to remove the damaged is necessary to determine whether insufficient labrum is
tissue, preserve the healthy tissue, and create a stable a principal cause of pain. Reconstruction has also been
transition zone to minimize the risk of further tearing. proposed for an irreparable or otherwise severely defi-
Selective débridement without bony correction has shown cient labrum. Use of both autograft and allograft sources
durable outcomes at 10 years,5 although several studies has been reported, without compelling evidence that one
Chapter 26: Nonarthroplasty Joint-Preserving Surgery for Hip Disorders
Figure 2 Arthroscopic views of the anterior labral tear of a right hip obtained from the anterolateral portal. A, View shows
two anchors placed in the acetabular rim, with the sutures passed through the labrum in a mattress fashion.
B, View shows the sutures tied securely, reapproximating the labrum to the rim of the acetabulum. C, View from
the peripheral compartment shows the completed repair and approximation of the labrum against the femoral
head is shown, with the sutures well removed from the articular surface. (Reproduced with permission from
Thomas Byrd JW: Labral management: An overview, in Thomas Byrd JW: Operative Hip Arthroscopy, ed 3. New
York, NY, Springer, 2012, pp 171-184.)
Figure 3 Arthroscopic anterior views from the anterolateral portal of the left hip. A, View shows one limb of view shows
an anchor placed on the capsular side of the labrum passed through the chondrolabral junction. B, View shows
the limb retrieved with a soft-tissue–penetrating device, pulling it back to the capsular side and creating a labrally
based stitch. C, Views shows the sutures tied on the capsular side of the labrum, reconstituting the chondrolabral
junction and restoring the labral anatomy. (Reproduced with permission from Thomas Byrd JW: Labral
management: An overview, in Thomas Byrd JW: Operative Hip Arthroscopy, ed 3. New York, NY, Springer, 2012, pp
171-184.)
source is superior. Graft choices include iliotibial band, Chondral Injuries

semitendinosus, or gracilis (autografts or allografts) and
tibialis anterior (allografts). Local sources for augmenta- Geoffrey P. Wilkin, MD, FRCSC; Bryan T. Kelly, MD
tion of the labrum include incorporating a strip of capsule Articular cartilage injury in the hip can occur in several
or a portion of the reflected head of the rectus tendon types of hip conditions, including FAI, trauma/disloca-
(Figure 5). tion/subluxation, dysplasia, Legg-Calvé-Perthes disease,
and osteonecrosis. Chondral injury is seen most frequently
Rehabilitation in the setting of cam-type FAI and is typically located
3: Hip
Some precautions are necessary to protect the repair in the anterosuperior portion of the acetabulum.13 The
site. Excessive flexion and external rotation are g enerally asphericity of the femoral cam deformity causes shearing
avoided for the first few weeks because they can place forces across the articular surface that eventually results
shear or traction forces on the repair site. Use of crutches in disruption of the articular cartilage at the chondro-
with some protected weight-bearing is also recommended labral junction and progressive delamination of the ar-
for a few weeks. Healing is probably complete by 10 to ticular cartilage from the subchondral bone.
12 weeks, although more time is usually needed for full
functional recovery from the overall surgical procedure.
Section 3: Hip
Figure 4 Arthroscopic anterior views from the anterolateral portal in the right hip. A, View shows the labrum refixed with
loop sutures. B, View obtained 1 year postoperatively shows the healed labrum. The morphology of the labrum is
also restored by normal joint contact and motion, irrespective of the suture configuration used.
Figure 5 Arthroscopic view from the anterolateral portal of the right hip reveals an 8-cm fascia lata allograft fixed
with seven anchors. A, View with the joint in traction. B, View with traction released and the joint reduced
demonstrates restoration of the labral seal coapted against the femoral articular surface. (Reproduced with
permission from White BJ, Stapleford AB, Hawkes TK, Finger MJ, Herzog MM: Allograft use in arthroscopic
3: Hip
labral reconstruction of the hip with front-to-back fixation technique: Minimum 2-year follow up. Arthroscopy
2016;32[1]:26-32.)
Diagnosis and Imaging the joint. However, chondral injury patterns are ideally
Several classification systems exist for the intraopera- identified preoperatively to allow appropriate surgical
tive grading of macroscopic chondral injury14 (Table 1). planning and/or to counsel patients about the relative
These classification systems can help guide treatment and likelihood of success of any joint-preserving procedure.
provide prognostic information about the integrity of The hip joint’s anatomy—thin articular cartilage,
Table 1
Classification Systems for Intraoperative Grading of Macroscopic Chondral Injury
Classification Grade Description
Outerbridge 0 Macroscopically normal cartilage
1 Cartilage softening and swelling
2 Fragmentation and fissuring involving area <1.5 cm in diameter
3 Fragmentation and fissuring involving area >1.5 cm in diameter
4 Loss of cartilage and exposed subchondral bone
Beck 0 Macroscopically normal cartilage
1 Malacia: Roughening of surface, fibrillation
2 Pitting malacia: Roughening, partially thinning and full-thickness defects or
deep fissuring to bone
3 Debonding: Loss of fixation to subchondral bone, macroscopically sound
cartilage (carpet phenomenon)
4 Cleavage: Loss of fixation to subchondral bone, frayed edges, thinning of
cartilage
5 Defect: Full thickness defect
ALAD 0 Macroscopically normal cartilage
1 Cartilage softening
2 Early peel back of cartilage
3 Large flap of cartilage or delamination
4 Complete loss of cartilage and exposed subchondral bone
Data from El Bitar YF, Lindner D, Jackson TJ, Domb BG: Joint-preserving surgical options for management of chondral injuries of the hip. J Am
Acad Orthop Surg 2014;22(1):46-56.
ighly curved and congruent surface, oblique orientation,

h microfracture, autologous chondrocyte implantation,
and eccentric anatomic location—creates several logistic mosaicplasty, and osteochondral allograft transplant.
challenges for accurate MRI.15 Nevertheless, pooled data Although many of these techniques are being used with
from multiple studies comparing conventional MRI and greater frequency, long-term follow-up studies of their
magnetic resonance arthrography show that although efficacy in the hip are lacking.
specificity is generally high (94% and 86%, respective-
ly), sensitivity of both modalities remains low (59% and
62%, respectively).15 The use of 3-T conventional MRI Microfracture
shows promise as a diagnostic tool for the identification Microfracture treatment of full-thickness cartilage defects
of femoral and acetabular chondral injuries: one prelim- has had promising results in the knee, with sustained clin-
inary report shows 94% sensitivity and 100% (femoral) ical improvement beyond 10 years, and microfracture has
and 67% (acetabular) specificity.16 recently been applied to full-thickness chondral lesions
in the hip.17,18 The technique involves débridement of the
Treatment injured cartilage to a stable rim to create a contained
3: Hip
The degree of cartilage degeneration in the hip has con- defect with vertical sidewalls. Any underlying calcified
sistently been associated with poor long-term success cartilage is removed while the integrity of the subchondral
of arthroscopic or open joint-preserving treatments. In bone is maintained. An awl is used to make a series of
patients with remaining cartilage that is well preserved, perforations in the subchondral bone, 3 to 4 mm apart
focal chondral lesions may be more amenable to treat- and to a depth of 3 to 4 mm. The perforations allow
ment. Many of the techniques available for treating focal mesenchymal stem cells from the bone marrow to enter
chondral lesions have been extrapolated from techniques the lesion and differentiate into fibrocartilage to fill the
pioneered in the knee and include simple débridement, defect.14 Lesions smaller than 400 mm2 have had better
Section 3: Hip
clinical outcomes in the knee than have larger lesions, plugs are harvested from the lateral trochlear knee carti-
although a critical size defect has not yet been identified lage or from the inferior femoral head.25
in the hip.19 Contraindications to microfracture include Management of posttraumatic osteochondral injury
partial-thickness chondral injury and cartilage lesions and lesions of focal osteonecrosis have been the primary
with associated bony defects. A variable period of pro- indications for mosaicplasty in published reports of the
tected weight bearing is usually recommended, although technique. Mosaicplasty may have limitations in larger
it is not universal. Similarly, the use of continuous passive defects (greater than 3 cm 2) because of donor site mor-
motion has been variable and of differing durations.20 bidity. Fresh ostechondral allograft transplantation may
The microfracture procedure is usually performed offer an alternative for larger defects, and preliminary
concurrently with other arthroscopic procedures (such reports of this technique have been promising.26
as labral repair or femoral osteochondroplasty), so it can
be difficult to determine the degree to which the micro-
fracture component influences the final clinical outcome. Synovectomy
No difference was detected in the rate of return to play Synovectomy of the hip joint has a limited role in modern
among elite athletes who underwent hip arthroscopy with orthopaedic treatment of hip pathologic conditions. Open
microfracture versus those who did not. In a study of synovectomy has historically been used for the treatment
207 hips that underwent arthroscopic FAI treatment, pa- of juvenile inflammatory arthropathy before joint arthro-
tients who underwent microfracture experienced a similar plasty. However, advances in medical management and
improvement in their Harris Hip Score as patients who the demonstrated efficacy of total joint arthroplasty in
underwent isolated treatment of cam FAI.21 Similarly, patients with inflammatory arthritis have eliminated the
in a matched-cohort comparative study, patients who need for synovectomy in most of these patients.
underwent microfracture had similar patient-related out- In patients with symptomatic synovial chondromatosis,
comes (modified Harris Hip Score, Non-Arthritic Hip arthroscopic partial or complete synovectomy has been
Score, Hip Outcome Score) up to 2 years postoperatively combined with loose body removal in most published
compared with patients without chondral defects.22 At reports. A recent systematic review demonstrated a cu-
revision or second-look arthroscopy, patients treated with mulative recurrence rate of 7.1% with this technique,
microfracture generally had high levels of defect filling although the rate of secondary surgery for any reason
(91% to 93%), with good macroscopic appearance of was 40.1%.27 A modified complete synovectomy through
the repair tissue (Blevins grade I to II).23 Histologic ex- a surgical hip dislocation while preserving the retinacular
amination of the repair tissue confirmed its primarily vessels has also been suggested as a method for decreasing
fibrocartilaginous appearance.13 recurrence rates.28
Autologous matrix–induced chondrogenesis (AMIC) is Arthroscopic irrigation and débridement of septic ar-
a technique that may be a useful adjunct to the fibrocarti- thritis of the hip is a safe and effective alternative to open
lage repair process; it uses a scaffold to stabilize the blood treatment.29 This technique is frequently combined with
clot in the chondral defect after microfracture.24 This arthroscopic synovectomy; however, not all reports indi-
technique has shown sustained 5-year improvements in cate specifically whether synovectomy was performed.30,31
modified Harris Hip Score (85.5 versus 44.9 preopera-
tively) and superior 5-year clinical outcomes compared
with those of microfracture alone.18 Ligamentum Teres Ruptures
The ligamentum teres arises from a broad origin along
the transverse acetabular ligament and the periosteum of
Mosaicplasty the ischium and pubis in the cotyloid fossa of the acetab-
Mosaicplasty is an alternate technique for managing ulum.32 Its role as a stabilizer of the hip is controversial.
full-thickness chondral defects; it involves transplanta- In linear distraction, the ligamentum teres can elongate
3: Hip
tion of autologous osteochondral plugs into the defect. approximately 15 mm before ultimate failure at 204 N,
Current evidence for this procedure in the hip is limited which suggests injury is unlikely during routine joint dis-
to small case series and case reports. The procedure is traction for hip arthroscopy.33 Experimental models have,
performed through open surgical hip dislocation, and however, shown that greatest simulated ligament tension
the lesion is prepared in a similar manner to that used occurs in two general positions: flexion, partial abduc-
for microfracture (that is, stable peripheral cartilage with tion, and external rotation; and extension, adduction, and
vertical sidewalls). Drill holes are created perpendicular internal rotation.34,35 More recently, it has been proposed
to the articular surface, and size-matched osteochondral that microinstability and/or altered contact forces from
ligamentum teres disruption can result in progressive Iliopsoas Tendon Disorders

cartilage wear. The role of ligamentum teres tears in hip
microinstability and progression of osteoarthritis are an The iliopsoas muscle unit functions as an active hip
area of potential future research.36 flexor and a postural muscle preventing excessive hip
Hypertrophy of the ligamentum teres has been found extension; it can also act as a secondary stabilizer of the
in patients with hip dysplasia and in patients who rou- hip joint, especially in patients with increased femoral
tinely place their hips in extremes of motion (such as anteversion.47 Occasionally the iliopsoas tendon may snap
gymnasts).37 Acute disruption of the ligamentum teres can medially over the iliopectineal eminence, the femoral
occur after traumatic hip dislocation or during surgical head, or a ridge on the lesser trochanter. This condition
hip dislocation, although injury can also occur because of is referred to as coxa saltans, or internal snapping hip.
acute or repetitive hyperabduction without frank disloca- Impingement of the iliopsoas tendon on the labrum has
tion. Magnetic resonance arthrography is likely the best also been implicated as a potential cause for labral tears
modality for assessing the integrity of the ligamentum and/or inflammation at the 3-o’clock position.48
teres preoperatively, especially for degenerative or partial Patients typically report anterior groin pain, usually
tears38-40 (Table 2). with a painful snapping sensation in a specific position or
Treatment options for ligamentum teres tears are gen- activity. Moving the leg into extension from a position of
erally limited to arthroscopic débridement or shrinkage flexion, abduction, and external rotation typically elicits
with radiofrequency probes.32 In a series of 27 patients a palpable and/or audible “clunk” over the anterior hip.
undergoing isolated débridement of ligamentum teres Historically, contrast iliopsoas bursography was used to
tears, 82% did not require further surgery, and mean demonstrate dynamic snapping of the tendon; dynamic
Harris Hip Scores improved from 70 to 86.41 Recently, ultrasonography can be used similarly. MRI can be useful
case reports and small series of arthroscopic ligamentum in the setting of acute traumatic injury to the iliopsoas
teres reconstruction have been published.42-44 muscle-tendon unit and may demonstrate bursal inflam-
mation or tendinopathic changes.49
A period of rest, anti-inflammatory medications, and
Bursectomy physical therapy can be successful in most cases. Open and
Trochanteric bursitis is frequently encountered in ortho- arthroscopic iliopsoas tendon lengthening or release have
paedic and primary care practice. Its typical features are been performed. Three sites of arthroscopic lengthening
lateral hip pain, pain with direct palpation over the great- have been described: at the level of the labrum; through
er trochanter, pain while lying on the affected side, and, the central compartment (transcapsular); or at the level
occasionally, snapping of the iliotibial band. Although of the lesser trochanter. Fractional lengthening is usually
trochanteric bursitis is quite common, its symptoms can done by dividing the tendon only, and leaving the muscle
mimic those of other pathologic, mechanical, and struc- fibers of the iliacus intact, to prevent excessive lengthening
tural causes of hip pain (for example, abductor tendon of the iliopsoas muscle-tendon unit. Patient-reported out-
tears, developmental dysplasia of the hip, osteonecrosis, comes after arthroscopic lengthening have generally been
osteoarthritis), and these conditions should be ruled out positive, although recurrence of snapping and hip flexion
before a diagnosis of isolated bursitis is made. weakness have been reported.50 Marked atrophy of the
Most patients respond well to a period of rest, anti- iliacus and psoas muscles has been identified on MRI in
inflammatory medications, physical therapy with abduc- 85% of patients (17 of 20) after arthoscopic lengthening
tor strengthening, and, occasionally, steroid injections. at the lesser trochanter, with 55% (11 of 20) showing
For cases refractory to nonsurgical management, both grade 4 atrophic changes.51 Because of concerns regarding
open and arthroscopic bursectomy have been used. Open potential hip flexion weakness and iatrogenic hip instabil-
or arthroscopic bursectomy has often been combined ity, iliopsoas lengthening should only be undertaken after
with iliotibial band release to address the supposed con- prolonged nonsurgical treatment has been unsuccessful.
3: Hip
tracture of the iliotibial band.45 In a series of 25 patients

with recalcitrant trochanteric bursitis who underwent
arthroscopic bursectomy and iliotibial band release, im- Cam, Pincer, and Combined Impingement
provements were noted in physical function (54 versus Sasha Carsen, MD, MBA; Hussain Al-Yousif, MD;
33.6) and pain (51.5 versus 28.7) on Medical Outcomes Paul E. Beaulé, MD
Study 36-Item Short Form subscale scores and on the Presentation and History
Harris Hip Score (77 versus 51) at a minimum follow-up A dynamic pathology, FAI is a result of a combination
of 13 months.46 of underlying morphology and hip motion that leads to
Section 3: Hip
pathological impingement or abutment of the femur and indicate inflammation or tightness secondary to intra-ar-
the acetabulum. The two broad categories of FAI are ticular pathology.
based on the main site of the deformity: cam type and
pincer type. The cam type is due to an aspherical femoral Radiography
head and/or lack of concavity of the femoral head-neck An AP pelvic radiograph is most important and provides
junction, leading to “outside-in” damage of the acetab- an overview of the whole pelvis and proximal femora,
ular cartilage; the pincer type can be due to either focal with standardized and validated measurements of the ac-
overcoverage (such as acetabular retroversion) or global etabulum possible for the assessment of hip dysplasia and
overcoverage (such as acetabular protrusio), leading to hip osteoarthritis. Pincer deformity is also visualized on
primary labral pathology. Cam and pincer morphology, the AP pelvic radiograph, with signs such as “crossover”
as well as impingement, are not mutually exclusive; as of the anterior wall and the ischial spine sign (viewing the
“mixed” impingement, they can exist both independently ischial spine clearly above the brim of the pelvis) indicates
and jointly.52 A patient may also report a history of Legg- possible pincer deformity and/or acetabular retroversion.
Calvé-Perthes disease or slipped capital femoral epiphysis, A negative Tönnis angle or a lateral center-edge angle
which are possible causes of FAI.53 greater than 40° are also indicators of global overcov-
The typical patient is both young and active and re- erage. The radiographic finding of coxa profunda is no
ports mostly activity-related or positional pain. Although longer itself considered to be overcoverage as it has been
most patients will present with prototypical groin pain, described in patients with dysplasia.57 The various lateral
or a “C-sign,” it is not uncommon for pain to be referred views of the proximal femur (frog lateral view, Dunn
to other locations or to be multifactorial in origin. Pain 45° and 90° views, cross-table lateral view, profile view)
is typically of insidious onset or associated with only a provide different two-dimensional views of different parts
minor trauma, and it is aggravated by athletic activities of the proximal femoral head-neck junction, whereas the
as well as walking or prolonged sitting. The development false-profile view allows for assessment of joint space,
of the femoral-side cam deformity has particularly been anterior acetabular coverage, and the subspine region.
noted to develop in adolescence, with a link to physical Cross-table and frog lateral images are focused mainly on
activities.54 Female patients have been found to have more the anterior head-neck junction, whereas the 45° flexion
significant symptoms with milder morphologic abnor- Dunn view gives a better view of the anterior and the
malities, whereas male patients have a higher activity anterosuperior head-neck junction; it can also be used
level with larger morphologic changes and more extensive to calculate the α-angle, which measures femoral head-
associated intra-articular findings. Therefore, a large pro- neck junction asphericity and quantifies the cam defor-
portion of the normal population will have radiographic mity.58 An α-angle greater than 50° is consistent with
abnormalities consistent with FAI, which emphasizes the cam morphology.
importance of physical examination.55
Magnetic Resonance Imaging
Physical Examination Dedicated MRI of the hip is key in diagnosing FAI and
Examination should begin with an observation of the associated pathology. An axial-oblique view of the fem-
patient’s gait, with a focus on antalgic, pain-avoidance, oral neck and head is the standard (and is the view on
or Trendelenburg gait. Physical examination of the hip which the α-angle was first described), but radial imaging
includes checking range of motion, particularly flexion, of the femoral neck provides a more complete view and
extension, and internal and external rotation (usually quantification of the cam deformity. 59 One study has
performed with the patient’s hip flexed at 90°, but can demonstrated that α-angle measurement varies on average
also be performed with patient prone or seated), as well by 10°, with a cutoff of 50° at the 3-o’clock position and
as abduction and adduction. Decreased internal rotation 60° at the 1:30 position, suggesting insufficient head-neck
and flexion, in particular, is typical of FAI. Provocative offset.55 Other researchers have shown that the 60° cutoff
3: Hip
tests of the hip joint include the log roll test (gently rolling at the 1:30 sitting position is most likely to be associated
the limb such that rotation occurs through the hip); the with symptomatic cam FAI.26
impingement or flexion, adduction, internal rotation test;
and the flexion, abduction, external rotation test.56 Tests Computed Tomography
of active hip flexion or resisted flexion, tenderness around Although standard imaging protocols for FAI primarily
the bursae or bony prominences, and tight or tender ab- involve plain radiographs and MRI, recent advances in
ductors can all indicate extra-articular sources of pain; CT have allowed for low-radiation three-dimensional
however, these signs can also be challenging, as they may (3D) reconstruction models, which can provide a clearer
picture and, therefore, a better understanding of the 3D Open

element of the cam deformity (acetabular deformity as With advances in arthroscopic techniques and skills,
well as both femoral and acetabular version).60 Several arthroscopic surgery has become more common for the
strategies and protocols have been developed that use a treatment of FAI. However, if the deformity cannot be
combination of decreased radiation and imaging opti- fully managed arthroscopically, it should be treated with
mization for FAI that now allow the clinician to obtain open surgery, which has been shown to have excellent
accurate 3D osseous images with greatly reduced radi- and safe clinical results.69 For intra-articular pathology
ation exposure compared with that required for pelvic concomitant with femoral head, femoral neck, or tro-
CT imaging.61,62 chanteric deformity requiring correction, surgical dis-
location should be considered, as this approach allows
Diagnostic Hip Injection for full assessment of the acetabulum and the proximal
Intra-articular analgesia has shown good sensitivity and femur. The trochanteric osteotomy can be converted to
specificity for determining the location of pain, even when an advancement where necessary, the femoral neck can
extra-articular pain generators are also present.63 This be treated with osteotomy or modification, and global
hip injection can be performed using either fluoroscopy acetabular overcoverage can be assessed and managed.
or ultrasonography while patients assess their relief, as Acetabular retroversion, or pincer impingement second-
well as a clinical assessment with provocative testing, if ary to a retroverted acetabulum (essentially an externally
possible. Although local anesthetic is often injected along rotated hemipelvis, posterior wall sign on radiography,
with contrast for magnetic resonance arthrography, inter- signficant crossover sign, and ischial spine sign) can be
pretation of clinical response to the arthrogram is made addressed by an open procedure. Acetabuloplasty, or rim
more challenging because of possible discomfort or pain trimming, performed on an acetabulum of normal size
resulting from capsular distension from the contrast dye. and volume that is retroverted, will effectively decrease its
volume and acetabular contact area, which can lead to mi-
cro-instability or, in the extreme, macroinstability of the
Surgical Treatment of FAI hip.66 A study of short- and long-term clinical outcomes
Arthroscopic of periacetabular osteotomy anteversion (sometimes re-
The incredible growth and progress in hip arthroscopy ferred to as a reverse periacetabular osteotomy) showed
surgical techniques and technology have facilitated a excellent clinical outcomes, with survivorship of 100%
significant shift toward arthroscopic management of of 29 hips at 10 years.70 As with standard periacetabular
most standard cases of FAI.64 As an important intra- osteotomy, it is important that the procedure is performed
operative adjunct, most hip arthroscopic specialists use by an experienced surgeon; whereas periacetabular oste-
fluoroscopic imaging to understand both the deformity otomy performed for hip dysplasia can result in anterior
and the morphologic effects of osteoplasty and/or osteo- impingement, an overrotated anteverting periacetabular
chondroplasty.65 Acetabuloplasty of the acetabular rim osteotomy can result in deficient anterior coverage or
or subspinous region can be beneficial in cases of focal posterior overcoverage.70
pincer impingement or subspinous impingement, but given
the potential for development of iatrogenic hip instability, Combined Open-Arthroscopic
this procedure must be undertaken with caution.66 Global A role exist for combined open and arthroscopic ap-
acetabular overcoverage or large pincer deformities may proaches to FAI and mixed FAI with dysplasia.71 Recent
be better served with an open procedure, such as a reverse experience with symptomatic hip dysplasia treated with
periacetabular osteotomy. Because the most common periacetabular osteotomy and hip arthroscopy has shown
reason for revision hip arthroscopy is residual deformity, that in up to one-third of cases, intra-articular pathology
it is important that the index procedure fully treat the was ultimately managed arthroscopically, in addition to
underlying morphology.67 Although it is challenging to the redirectional periacetabular osteotomy. An open or
3: Hip
isolate the effect of surgical correction of impingement mini-open approach can also be a useful adjunct for the
without the effects of intra-articular surgery (such as hip arthroscopic specialist in challenging cases in which
labral and cartilage repair), reported clinical outcomes further visualization or perspective is required.72
in arthroscopic surgical correction have been excellent,
indicated by both significant improvement in clinical out-
come scores and patient return to physical activities.68 Periacetabular Osteotomy
Benjamin R. Coobs, MD; John C. Clohisy, MD
Section 3: Hip
Acetabular dysplasia is a well-recognized cause of pain, arthrograms must be carefully analyzed to ensure ap-
functional limitation, and secondary osteoarthritis of the propriate articular cartilage health and joint viability.
hip.73 Goals of early intervention through corrective oste- Evidence of substantial secondary osteoarthritis (Tönnis
otomy are to decrease pain, improve function, and prevent grade of 2 or greater) or joint incongruity represents a
development of secondary osteoarthritis.74 The original contraindication to periacetabular osteotomy. Addition-
description of periacetabular osteotomy75 has become the ally, adequate preoperative hip range of motion before
preferred technique at many centers; this technique should periacetabular osteotomy (greater than 95° of flexion,
be considered safe and effective in alleviating pain and greater than 30° of abduction) is necessary because the re-
improving function.76 duction maneuver performed to correct classic acetabular
dysplasia may reduce hip range of motion postoperatively.
Clinical Presentation Radiographic measurement definitions of acetabular
Symptomatic acetabular dysplasia in the skeletally mature dysplasia have been described in detail, and a lateral
adolescent or young adult typically presents with the in- center-edge angle less than 20°, acetabular index greater
sidious onset of activity-related groin or lateral hip pain. than 10°, and anterior center-edge angle less than 18°
In one study, patients were predominantly female (72%) constitute appropriate radiographic diagnostic criteria of
with an average age of 24 years.73 Common physical ex- the need for periacetabular osteotomy in the symptomatic
amination findings in the patient with acetabular dys- patient. Treatment with periacetabular osteotomy of com-
plasia include a positive impingement sign (97%), a limp mon variants of classic acetabular dysplasia, including ac-
(48%), and a positive Trendelenburg sign (38%).73 Limited etabular retroversion and secondary acetabular dysplasia
hip range of motion in the setting of acetabular dysplasia (typically associated with Legg-Calvé-Perthes disease),
may indicate combined impingement pathology that re- has achieved good to excellent results in most patients.
quires additional management at the time of periacetab- Recent studies have shown that approximately 17% of
ular osteotomy; it may also suggest advanced underlying patients with acetabular dysplasia have retroversion, and
arthrosis. Increased femoral antetorsion may decrease that even higher rates are seen in patients with secondary
the threshold to proceed with periacetabular osteotomy acetabular dysplasia resulting from Legg-Calvé-Perthes
in a patient with structural instability, and concomitant disease.80-82 Additionally, isolated acetabular retrover-
femoral osteotomy may be required for complete defor- sion in the nondysplastic hip has been observed to cause
mity correction. symptomatic FAI and possible early hip arthritis. Cor-
Standardized radiographic views should be obtained rection of acetabular retroversion through anteverting
in all patients to properly characterize hip anatomy. The periacetabular osteotomy is reliable and has shown good
views should include anteoposterior pelvis, false-pro- clinical results. Relative contraindications to periacetabu-
file, frog lateral, and 45° Dunn views. Techniques for lar osteotomy are increasingly being defined to optimize
acquiring reproducible radiographs have been published expected patient outcomes83 (Table 3).
previously.77 These images permit detailed interpretation
of acetabular and proximal femoral morphology as well Surgical Technique
as measurement of the lateral center-edge angle, acetab- The Bernese periacetabular osteotomy is performed by
ular index, and anterior center-edge angle. MRI with creating four orthogonal periacetabular cuts, which allow
intra-articular magnetic resonance arthrography should reproducible multidirectional correction of the mobilized
be considered in all patients to evaluate for chondrolabral acetabular fragment. Surgery is performed with the pa-
pathology that may require additional treatment through tient in the supine position on a radiolucent table with a
concomitant hip arthroscopy or open arthrotomy at the modified Smith-Petersen approach, and the leg prepped
time of corrective osteotomy.78,79 Additionally, CT with free. Preservation of the posterior column allows excel-
3D reconstruction provides enhanced understanding of lent acetabular fragment stability following correction
bony morphology and should be obtained selectively in and screw fixation, promoting early mobilization and
3: Hip
patients with a complex deformity to assist with preop- reliable healing.75

erative planning. Muscle-sparing approaches that preserve the gluteal
muscle attachments to the lateral ilium and the rectus
Indications and Contraindications femorus attachment to the anterior inferior iliac spine
In general, patients for whom periacetabular osteotomy have improved postoperative recovery and decreased
is indicated should be active, physiologically young (typi- rates of heterotopic ossification. Comprehensive man-
cally younger than 40 years), and relatively healthy. Preop- agement of severe hip deformities through concomitant
erative radiographs and, if available, magnetic resonance proximal femoral osteotomies to address femoral-side
Table 2
Indications and Negative Prognostic Factors for Bernese Periacetabular Osteotomy
Indications Negative Prognostic Factors
Lateral central-edge angle <20°, acetabular index >10°, Obesity (body mass index >30 kg/m2)
anterior center-edge angle <18°
Adequate range of motion (flexion>95°, abduction Secondary arthritis (Tönnis grade ≥2)
>30°)
Active and healthy Medical comorbidities
Physiologically young (<35 yr) Previous reconstructive surgery
Severe or secondary dysplasia Suboptimal joint congruity
Acetabular retroversion Poor preoperative hip function
pathology has shown promise, with good to excellent the end point, was 96% at 5 years and 84% at 10 years.
results achieved in most patients.84 Another study presented a unique retrospective cohort of
Intra-articular pathology is common in patients with the first 75 hips (63 patients) after periacetabular oste-
symptomatic acetabular dysplasia and most frequently in- otomy at the institution where the technique was initially
volves labral tears or early cartilage injury.85 To optimize developed.90 Of this group, 68 hips (58 patients) were
outcomes, open femoral head-neck osteochondroplasty available for follow-up at a mean of 20.4 years (minimum,
is frequently required following acetabular correction to 19.0 years) postoperatively. When corrected for Tönnis
relieve secondary impingement; this has been shown to grade, hips with a preoperative Tönnis grade of 0 or 1 had
be safe and effective.86 Historically, management of chon- a survivorship of 75%. In both studies, several factors
drolabral pathology during periacetabular osteotomy was predicted poor outcome: advanced age, low preoperative
done through open arthrotomy, which offers only limited functional scores, positive anterior impingement test,
exposure to the hip joint, thereby making accurate repair limp, increasing severity of osteoarthritis (Tönnis grade
of labral tears difficult. The use of hip arthroscopy as an of 2 or greater), poor joint congruency, and increased
adjuvant procedure performed with periacetabular oste- extrusion index. Another study, a retrospective review
otomy has been expanded for joint inspection and repair of 39 hips (36 patients) with preoperative UCLA activity
of chondrolabral pathology, given the improved access scores of 7 or greater, evaluated the ability of patients
to the central compartment.85 Early experience with hip to return to high-level athletic activity following peri-
arthroscopy executed at the time of periacetabular oste- acetabular osteotomy.74 Most patients (97%) reported
otomy for labral repairs has been encouraging; however, satisfaction following surgery, with most (71%) return-
further research is necessary to confirm improved clinical ing to presurgical or higher activity levels after surgery.
results with this approach. Performing hip arthroscopy A recent cross-sectional survey of 68 hips (52 patients)
without correction of structural instability in patients explored these alternative functional and quality-of-life
with hip dysplasia should be avoided.87 outcome measures 9 to 12 years after periacetabular oste-
otomy.91 Publication of more recent complication data
Clinical Results from a group of experienced surgeons who were past
After the necessary training and expected learning curve, their learning curve showed a 5.9% complication rate.76
the periacetabular osteotomy has become quite safe when
performed by experienced surgeons.76,88 Long-term out-
comes studies evaluating the clinical effectiveness and Summary
3: Hip
durability of periacetabular osteotomy have consistently Structural abnormalities of the hip joint ranging from
demonstrated favorable results. One study reported on dysplasia to impingement are the leading causes of ace-
mid- to long-term experience with periacetabular oste- tabular labral tears, often presenting in skeletally mature
otomy.89 Results in 135 hips (109 patients) were available adolescents or young adults. Advancements in imaging
for retrospective review at an average of 9 years postop- (3D and high-resolution MRI) have expanded the use of
eratively, with clinical failure defined as conversion to hip arthroscopy for the management of hip impingement,
total hip arthroplasty or a pain score ≥of 10 or more. with excellent results in patients younger than 45 years.
Survivorship, using conversion to total hip arthroplasty as The standard management of classic acetabular dysplasia
Section 3: Hip
is the Bernese periacetabular osteotomy. Although hip 5. Byrd JW, Jones KS: Hip arthroscopy for labral pathology:
arthroscopy remains controversial as a stand-alone pro- Prospective analysis with 10-year follow-up. Arthroscopy
2009;25(4):365-368. Medline DOI
cedure for the treatment of hip dysplasia, its role as an
adjunct procedure to the periacetabular osteotomy is be- A review of 59 cases of isolated arthroscopic labral
débridement for tears showed 45% combined poor results
coming better defined and it is performed more frequently. when failure was defined as repeat surgery or abnormal
hip rating.
Key Study Points 6. Larson CM, Giveans MR, Stone RM: Arthroscop-
ic debridement versus refixation of the acetabular la-
• Tears of the chondrolabral complex most commonly brum associated with femoroacetabular impingement:
occur secondary to a bony abnormality. Mean 3.5-year follow-up. Am J Sports Med 2012;40(5):
• FAI covers a wide spectrum of hip pathology on 1015-1021. Medline DOI
both the femoral and acetabular sides. A study of patients with labral tears showed increased
• Both arthroscopic and open techniques have proved good to excellent results after labral refixation at a mean
follow-up of 3.5 years compared with an earlier cohort
effective in the surgical management of FAI. with focal labral excision/débridement.
• Acetabular dysplasia is best treated with reorien-
tation pelvic osteotomy, periacetabular osteotomy. 7. Krych AJ, Thompson M, Knutson Z, Scoon J, Coleman
• The role of hip arthroscopy as an adjunct procedure SH: Arthroscopic labral repair versus selective labral de-
bridement in female patients with femoroacetabular im-
in the management of dysplasia is increasing while pingement: A prospective randomized study. Arthroscopy
its role in isolation remains undefined. 2013;29(1):46-53. Medline DOI
A study of arthroscopic labral repair and selective labral
débridement in 36 female patients with FAI showed supe-
rior improvement in hip functional outcomes with arthro-
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for 25 patients who underwent isolated, primary, unilat-
41. Haviv B, O’Donnell J: Arthroscopic debridement of the eral iliopsoas release and presented at a minimum 1-year
isolated ligamentum teres rupture. Knee Surg Sports Trau- follow-up, physical ability was self-described as much
matol Arthrosc 2011;19(9):1510-1513. Medline DOI improved in 10 patients, improved in 12, and having no
In this study of 29 patients with isolated ligamentum teres change in 1.
rupture of the hip treated with arthroscopic débridement
from 2003 to 2008, arthroscopic débridement of the lig- 49. Bui KL, Ilaslan H, Recht M, Sundaram M: Iliopsoas in-
amentum teres rupture had a short-term beneficial result jury: An MRI study of patterns and prevalence correlated
in greater than 80% of cases. with clinical findings. Skeletal Radiol 2008;37(3):245-249.
Medline DOI
42. Philippon MJ, Pennock A, Gaskill TR: Arthroscopic re-
construction of the ligamentum teres: Technique and early 50. Ilizaliturri VM Jr, Buganza-Tepole M, Olivos-Meza A,
outcomes. J Bone Joint Surg Br 2012;94(11):1494-1498. Acuna M, Acosta-Rodriguez E: Central compartment
Medline DOI release versus lesser trochanter release of the iliopsoas
tendon for the treatment of internal snapping hip: A
This study describes a technique for arthroscopic ligamen- comparative study. Arthroscopy 2014;30(7):790-795.
tum teres reconstruction using iliotibial band autograft Medline DOI
and reports the early outcomes of the technique in four
patients. This case series of 20 patients treated with endoscopic
release of the iliopsoas tendon found that both central
43. Lindner D, Sharp KG, Trenga AP, Stone J, Stake CE, compartment release and release at the lesser trochanter
Domb BG: Arthroscopic ligamentum teres reconstruction. produced favorable results, based on Western Ontario
Arthrosc Tech 2012;2(1):e21-e25. Medline DOI and McMaster Universities Arthritis Index scores, for
treatment of internal snapping hip syndrome. Level of
This study describes a technique for arthroscopic ligamen- evidence: IV.
tum teres reconstruction using either a semitendinosus
autograft or allograft, with the patient in a supine position. 51. Hain KS, Blankenbaker DG, De Smet AA, Keene JS,
Del Rio AM: MR appearance and clinical significance
44. Mei-Dan O, McConkey MO: A novel technique for of changes in the hip muscles and iliopsoas tendon after
ligamentum teres reconstruction with “all-suture” an- arthroscopic iliopsoas tenotomy in symptomatic patients.
chors in the medial acetabular wall. Arthrosc Tech HSS J 2013;9(3):236-241. Medline DOI
2014;3(2):e217-e221. Medline DOI
This study of 169 consecutive adults, evaluated after ilio-
This study describes a technique for ligamentum teres psoas tenotomy at the lesser trochanter level, found that
allograft reconstruction using anchors made of suture most patients with postoperative symptoms had atrophy of
and seated in the acetabular floor. the iliacus and psoas muscles and distortion and disruption
of the iliopsoas tendon.
3: Hip
45. Farr D, Selesnick H, Janecki C, Cordas D: Arthroscopic

bursectomy with concomitant iliotibial band release for 52. Ganz R, Leunig M, Leunig-Ganz K, Harris WH: The etiol-
the treatment of recalcitrant trochanteric bursitis. Arthros- ogy of osteoarthritis of the hip: An integrated mechanical
copy 2007;23(8):905.e1-905.e5. Medline DOI concept. Clin Orthop Relat Res 2008;466(2):264-272.
Medline DOI
46. Baker CL Jr, Massie RV, Hurt WG, Savory CG: Ar-
throscopic bursectomy for recalcitrant trochanteric bur- 53. Millis MB, Lewis CL, Schoenecker PL, Clohisy JC:
sitis. Arthroscopy 2007;23(8):827-832. Medline DOI Legg-Calvé-Perthes disease and slipped capital femoral
epiphysis: Major developmental causes of femoroace-
Section 3: Hip
tabular impingement. J Am Acad Orthop Surg 2013;21 61. Milone MT, Bedi A, Poultsides L, et al: Novel CT-
(suppl 1):S59-S63. Medline based three-dimensional software improves the charac-
terization of cam morphology. Clin Orthop Relat Res
54. Siebenrock KA, Ferner F, Noble PC, Santore RF, Werlen 2013;471(8):2484-2491. Medline DOI
S, Mamisch TC: The cam-type deformity of the proximal In this retrospective review of 100 symptomatic cam le-
femur arises in childhood in response to vigorous sporting sions treated by using arthroscopy, comparison of plain
activity. Clin Orthop Relat Res 2011;469(11):3229-3240. radiographs and CT scans with a prototype 3D modeling
Medline DOI program showed greater α-angles with the 3D mapping,
This retrospective study compared 72 hips in adolescent which shows promise in better understanding the location
basketball players with 76 hips of age-matched volunteers and size of cam deformities. Level of evidence: III.
and found a tenfold increased likelihood of having an α-an-
gle greater than 55° in the athletes. Level of evidence: II. 62. Kang RW, Park C, Ranawat A: Computer tomography
scan of the hip and pelvis, in Nho SJ, Leunig M, Larson
55. Hack K, Di Primio G, Rakhra K, Beaulé PE: Prevalence CM, Bedi A, Kelly BT, eds: Hip Arthroscopy and Hip
of cam-type femoroacetabular impingement morpholo- Joint Preservation Surgery .New York, NY, Springer,
gy in asymptomatic volunteers. J Bone Joint Surg Am 2015. DOI
2010;92(14):2436-2444. Medline DOI This article reviews the use of CT in the assessment of
various hip pathologies and establishes its emergence as
56. Byrd JW: Physical examination, in Byrd JW, ed: Operative the gold standard for detecting osseous deformities of the
Hip Arthroscopy ,ed 2. New York, NY, Springer, 2005, hip and pelvis.
pp 36-50. DOI
63. Kivlan BR, Martin RL, Sekiya JK: Response to diagnostic
57. Nepple JJ, Lehmann CL, Ross JR, Schoenecker PL, injection in patients with femoroacetabular impingement,
Clohisy JC: Coxa profunda is not a useful radiographic labral tears, chondral lesions, and extra-articular pathol-
parameter for diagnosing pincer-type femoroacetabular ogy. Arthroscopy 2011;27(5):619-627. Medline DOI
impingement. J Bone Joint Surg Am 2013;95(5):417-423.
Medline DOI This retrospective review of 72 patient-case series assessed
the association between response to diagnostic analgesic
This retrospective review, performed to determine the intra-articular hip injection and intra-articular pathology.
prevalence of coxa profunda in four groups of hips, found Results showed a strong association between intra-ar-
that coxa profunda should be considered a normal radio- ticular pathology and pain relief with injection, but no
graphic finding in females. association with severity of pain or degree of relief. Level
of evidence: IV.
58. Barton C, Salineros MJ, Rakhra KS, Beaulé PE: Validity
of the alpha angle measurement on plain radiographs in 64. Gupta A, Suarez-Ahedo C, Redmond JM, et al: Best prac-
the evaluation of cam-type femoroacetabular impinge- tices during hip arthroscopy: Aggregate recommenda-
ment. Clin Orthop Relat Res 2011;469(2):464-469. tions of high-volume surgeons. Arthroscopy 2015;31(9):
Medline DOI 1722-1727. Medline DOI
This retrospective assessment of the Dunn view radio- A cross-sectional survey of 27 high-volume hip arthros-
graph in 68 patients showed 91% sensitivity, 88% specific- copy surgeons reported consistent practices of intraop-
ity, 93% positive predictive value, 84% negative predictive erative fluoroscopy, heterotopic ossification prophylaxis,
value, and 94% accuracy for diagnosing cam lesions. Level and labral repair, with higher variability in postoperative
of evidence: I. rehabilitation protocols and use of intra-articular injec-
tions at the end of the procedure. Level of evidence: V.
59. Rakhra KS, Sheikh AM, Allen D, Beaulé PE: Compar-
ison of MRI alpha angle measurement planes in fem- 65. Ross JR, Bedi A, Stone RM, et al: Intraoperative fluoro-
oroacetabular impingement. Clin Orthop Relat Res scopic imaging to treat cam deformities: Correlation with
2009;467(3):660-665. Medline DOI 3-dimensional computed tomography. Am J Sports Med
2014;42(6):1370-1376. Medline DOI
60. Heyworth BE, Dolan MM, Nguyen JT, Chen NC, Kelly
BT: Preoperative three-dimensional CT predicts intraop- In a prospective cohort of 50 hips with both preoperative
erative findings in hip arthroscopy. Clin Orthop Relat Res CT scan and six consistent intraoperative fluoroscopy
views of the head-neck junction, the fluoroscopic views
3: Hip
2012;470(7):1950-1957. Medline DOI

were found to effectively localize and visualize the cam
In this retrospective review of 118 patients who under- deformity from clockface reference locations 11:45 to 2:45.
went hip arthroscopy and preoperative CT scans, the κ Level of evidence: II.
score and intraoperative findings of cam impingement was
moderate (0.48), and increased α-angles were correlated 66. Bhatia S, Lee S, Shewman E, et al: Effects of acetabular
with increased labral disruption. Level of evidence: III. rim trimming on hip joint contact pressures: How much
is too much? Am J Sports Med 2015;43(9):2138-2145.
Medline DOI
A laboratory study using load sensors to measure the con- This review describes a combined arthroscopic and limited
tact area, pressure, and peak force after anterosuperior open approach as an alternative to surgical management
acetabular rim trimming on six nondysplastic hemipelvis of hip impingement and provides a summary of the indica-
specimens found that resecting more than 4 to 6 mm may tions, technique, and preliminary results of the approach.
significantly alter hip biomechanics, increasing reactive
forces and subsequent chondrolabral degeneration. 73. Nunley RM, Prather H, Hunt D, Schoenecker PL, Clo-
hisy JC: Clinical presentation of symptomatic acetabular
67. Ross JR, Larson CM, Adeoye O, Kelly BT, Bedi A: Resid- dysplasia in skeletally mature patients. J Bone Joint Surg
ual deformity is the most common reason for revision hip Am 2011;93(suppl 2):17-21. Medline DOI
arthroscopy: A three-dimensional CT study. Clin Orthop
Relat Res 2015;473(4):1388-1395. Medline DOI A prospective case series of 57 patients (65 hips) with
symptomatic acetabular dysplasia examines common
A retrospective case series examining symptomatic hips presenting symptoms and 2-year clinical outcomes after
requiring revision showed that 45 of 50 hips (90%) had periacetabular osteotomy. Hip dysplasia most commonly
residual impingement morphology. Level of evidence: III. presented with insidious onset of activity-related groin or
lateral hip pain in skeletally mature, young, active patients.
68. Kweon C, Welton KL, Kelly BT, Larson CM, Bedi A: Level of evidence: IV.
Arthroscopic treatment of cam-type impingement of the
hip. JBJS Rev 2015;3(9). DOI 74. Bogunovic L, Hunt D, Prather H, Schoenecker PL, Clohisy
JC: Activity tolerance after periacetabular osteotomy. Am
This article reviews arthroscopic techniques for the treat- J Sports Med 2014;42(8):1791-1795. Medline DOI
ment of cam-type impingement of the hip and effects on
pain, motion, and overall function in short- and interme- This retrospective case series of 36 patients treated with
diate-term outcomes. periacetabular osteotomy found that most active patients
(71%) with hip dysplasia returned to presurgical activity
69. Sink EL, Fabricant PD, Pan Z, Dayton MR, Novais levels or higher after open hip preservation surgery with
E: Results of treatment of femoroacetabular impinge- periacetabular osteotomy. Level of evidence: IV.
ment in adolescents with a surgical hip dislocation ap-
proach. Clin Orthop Relat Res 2013;471(8):2563-2569. 75. Ganz R, Klaue K, Vinh TS, Mast JW: A new periace-
Medline DOI tabular osteotomy for the treatment of hip dysplasias:
Technique and preliminary results. Clin Orthop Relat
In a retrospective review of a series of 52 adolescent hips Res 1988;1988(232):26-36. Medline
treated with a surgical hip dislocation approach (minimum
of 12 months of postoperative follow-up), modified Harris
Hip Scores showed significant improvement (preoperative 76. Zaltz I, Baca G, Kim YJ, et al: Complications associ-
mean, 57.5; postoperative, 85.8) and improvements in ated with the periacetabular osteotomy: A prospective
Medical Outcomes Study 12-Item Short Form scores and multicenter study. J Bone Joint Surg Am 2014;96(23):
hip range of motion. Level of evidence: IV. 1967-1974. Medline DOI
A prospective analysis of perioperative complications
70. Siebenrock KA, Schaller C, Tannast M, Keel M, Büchler in 205 consecutive patients who underwent unilateral
L: Anteverting periacetabular osteotomy for symptomatic periacetabular osteotomy found that although the pro-
acetabular retroversion: Results at ten years. J Bone Joint cedure is safe, there is an associated 5.9% risk of grade
Surg Am 2014;96(21):1785-1792. Medline DOI III or IV complications beyond the learning curve. Level
of evidence: IV.
The case series results of 27 hips at more than 10 years
after anteverting periacetabular osteotomy showed sig-
nificant improvements in clinical outcome scores and hip 77. Clohisy JC, Carlisle JC, Beaulé PE, et al: A systematic
range of motion. No hips required conversion to total approach to the plain radiographic evaluation of the young
hip arthroplasty; predictors of poor outcome were lack adult hip. J Bone Joint Surg Am 2008;90(suppl 4):47-66.
of femoral offset creation and overcorrection of version, Medline DOI
resulting in excessive anteversion. Level of evidence: IV.
78. Beaulé PE, O’Neill M, Rakhra K: Acetabular labral tears.
71. Domb BG, LaReau J, Redmond JM: Combined hip J Bone Joint Surg Am 2009;91(3):701-710. Medline DOI
arthroscopy and periacetabular osteotomy: Indications,
advantages, technique, and complications. Arthrosc Tech 79. Smith TO, Hilton G, Toms AP, Donell ST, Hing CB: The
diagnostic accuracy of acetabular labral tears using mag-
3: Hip
2014;3(1):e95-e100. Medline DOI
netic resonance imaging and magnetic resonance arthrog-
This case series and technique article highlights the option raphy: A meta-analysis. Eur Radiol 2011;21(4):863-874.
of using combined hip arthroscopy with periacetabular Medline DOI
osteotomy, with significant clinical success and minimal
complications. Level of evidence: IV. A meta-analysis of 19 articles was performed to assess the
sensitivity and specificity of conventional MRI in compar-
72. Nassif NA, Clohisy JC: Combined Techniques in FAI: Hip ison with magnetic resonance arthrography in diagnosing
Arthroscopy Followed by Mini-Anterior Approach. Fem- acetabular labral tear in 881 hips, with both techniques
oroacetabular Impingement .Berlin, Germany, Springer, referenced against surgical findings (arthroscopic or open)
2012, pp 159-166. to verify the diagnosis of labral tear. Sensitivity of MRI
Section 3: Hip
was 66%, compared to 87% for magnetic resonance ar- two-year follow-up cohort study. J Bone Joint Surg Am
thrography, and specificity of MRI was 79%, compared 2012;94(21):1959-1966. Medline DOI
to 64% for magnetic resonance arthrography. Diagnostic
accuracy for detecting acetabular labral tears was superior In this comparison of 40 patients who underwent peria-
for magnetic resonance arthrography on receiver operating cetabular osteotomy in conjunction with a femoral head-
characteristic curve interpretation. neck osteochondroplasty with 48 patients who underwent
an isolated periacetabular osteotomy, the combined peri-
acetabular osteotomy and osteochondroplasty was not
80. Li PL, Ganz R: Morphologic features of congenital ace- associated with increased complication rates. Level of
tabular dysplasia: One in six is retroverted. Clin Orthop evidence: III.
Relat Res 2003;416:245-253. Medline DOI
87. Bogunovic L, Gottlieb M, Pashos G, Baca G, Clohisy JC:
81. Sankar WN, Flynn JM: The development of acetabular Why do hip arthroscopy procedures fail? Clin Orthop
retroversion in children with Legg-Calvé-Perthes disease. Relat Res 2013;471(8):2523-2529. Medline DOI
J Pediatr Orthop 2008;28(4):440-443. Medline DOI
In this retrospective review of 58 patients (60 hips) who
82. Ezoe M, Naito M, Inoue T: The prevalence of acetabular had revision hip preservation surgery (38 hips) or con-
retroversion among various disorders of the hip. J Bone version to total hip arthroplasty (22 hips) after failed hip
Joint Surg Am 2006;88(2):372-379. Medline DOI arthroscopy, the most common reasons for failure were
residual FAI (68%) and uncorrected acetabular dysplasia
83. Novais EN, Potter GD, Clohisy JC, et al: Obesity is a (24%). Advanced osteoarthritis was the most common
major risk factor for the development of complications cause of failure for cases requiring total hip arthroplasty.
after peri-acetabular osteotomy. Bone Joint J 2015; Level of evidence: IV.
97-B(1):29-34. Medline DOI
88. Clohisy JC, Schutz AL, St John L, Schoenecker PL, Wright
The risk of a major complication following periacetabular RW: Periacetabular osteotomy: A systematic literature
osteotomy was 11 times higher for obese patients with a review. Clin Orthop Relat Res 2009;467(8):2041-2052.
body mass index greater than 30 kg/m 2 (22%) compared Medline DOI
with nonobese patients with a body mass index less than
30 kg/m 2 (3%). 89. Matheney T, Kim YJ, Zurakowski D, Matero C, Millis
M: Intermediate to long-term results following the Ber-
84. Clohisy JC, Nunley RM, Curry MC, Schoenecker PL: nese periacetabular osteotomy and predictors of clinical
Periacetabular osteotomy for the treatment of acetabular outcome. J Bone Joint Surg Am 2009;91(9):2113-2123.
dysplasia associated with major aspherical femoral head Medline DOI
deformities. J Bone Joint Surg Am 2007;89(7):1417-1423.
Medline DOI 90. Steppacher SD, Tannast M, Ganz R, Siebenrock KA:
Mean 20-year followup of Bernese periacetabular oste-
85. Ross JR, Zaltz I, Nepple JJ, Schoenecker PL, Clohisy JC: otomy. Clin Orthop Relat Res 2008;466(7):1633-1644.
Arthroscopic disease classification and interventions as Medline DOI
an adjunct in the treatment of acetabular dysplasia. Am
J Sports Med 2011;39(suppl):72S-78S. Medline DOI 91. Klit J, Hartig-Andreasen C, Jacobsen S, Søballe K, Troelsen
This case series of 73 hips, with hip arthroscopy performed A: Periacetabular osteotomy: Sporting, social and sexual
before periacetabular osteotomy to identify intra-articular activity 9-12 years post surgery. Hip Int 2014;24(1):27-31.
disease patterns and to examine the role of arthroscopy as Medline DOI
an adjunct to acetabular reorientation osteotomy, noted This cross-sectional survey of patients with 68 preserved
labral disease and articular cartilage pathology amenable hip joints following periacetabular osteotomy reported
to arthroscopic intervention in 63% of cases. on alternative functional and quality-of-life measures.
Patients reported lasting improvements in sex life, social
86. Nassif NA, Schoenecker PL, Thorsness R, Clohisy life, and ability to participate in sports 9 to 12 years fol-
JC: Periacetabular osteotomy and combined femoral lowing periacetabular osteotomy.
head-neck junction osteochondroplasty: A minimum
3: Hip
Chapter 27
to C o n v e n ti o n a l T o ta l
Alternatives
la S tY fo r O ste o a rth r iti
Hip Arthrop
Adam A. Sassoon, MD, MS William I. Maloney, MD John C. Clohisy, MD
Total hip arthroplasty remains an extremely reliable Nonsurgical treatment of hip osteoarthritis is a viable
treatment of advanced osteoarthritis refractory to option in the early stages or disease. Typical proven
conservative management with respect to improve- strategies used include activity modification, the use of
ments in pain and function. Despite a relatively small gait-assistance aids, weight 10 i-inflammatory med-
postoperative complication rate, a risk still exists, ication, and steroid injection e symptoms progress
giving pause to patients and surgeons alike, especially 30 that nonsurgical tre ides inadequate relief
in extremely young, active patients with arthritis. Ad- and pain limits un P formance of activities of
ditionally, some patients with end-stage osteoarthritis daily living, sur 111 considered. However, some
are not acceptable surgical candidates, but some form patients are not i S for surgical treatment second-
of treatment is required to help mitigate their pain as ary t0 medi idities. Other forms of nonsurgi-
a long—term solution or to help temporize them until cal t at 0 d be explored for these patients. The
they can be medically optimized to undergo total hip surge I these patients should have a thorough
arthroplasty. It is important to review recent advances un 'ng of alternative and less conventional non-
in nonarthroplasty treatment of hip arthritis, with a surgical treatments for hip osteoarthritis.
focus on nonsurgical options including long-acting
intra-articular corticosteroid injections, platelet-rich‘ Platelet-Rich Plasma
plasma, stem cell therapies, and nerve ablatio ~ ' %
dures, and nonarthroplasty surgical options inc Platelet-rich plasma (PRP) remains a nonsurgical ther-
steotomies and hip resurfacing. apy that is currently under review regarding its efficacy
in treating osteoarthritis. Most existing literature
focuses on its use in osteoarthritis of the knee rather
Keywords: hip arthritis; nonsur ' tio s; than in the hip. PRP is rich in cytokines and other anti-
platelet-rich plasma; nerve ablati inflammatory modulators including, but certainly not
resurfacing limited to, platelet-derived growth factor, transforming
growth factor-5, fibroblast growth factor (FGF), and vas-
cular endothelial growth factor. Two recent systematic
Dr. Maloney or an immediate family member has received royalties from Stryker and Zimmer; serves as a paid consul-
tant to Flexion Therapeutics — Scientific Advisory Board and ISTO Technologies - Board of Directors; has stock or stock
options held in Abbott, Flexion Therapeutics, Gillead, ISTO Technologies, Johnson & Johnson, Merck, Moximed, Pfizer,
Pipeline Orthopaedics, Stemedica, and TJO; and serves as a board member, owner, officer, or committee member of
the American Academy of Orthopaedic Surgeons, the American Joint Replacement Registry, the American Association
of Hip and Knee Surgeons, Flexion Therapeutics, ISTO Technologies, Stemedica, and the Western Orthopaedic Asso-
ciation. Dr. Clohisy or an immediate family member serves as a paid consultant to Microport Orthopaedics and has
received research or institutional support from Pivot Medical, Smith & Nephew, and Zimmer. Neither Dr. Sassoon nor
any immediate family member has received anything of value from or has stock or stock options held in a commercial
company or institution related directly or indirectly to the subject of this chapter.
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5
Section 3: Hip
Table 1
Summary of Level of Evidence and Purported Effect of Nonsurgical Treatments of Hip Osteoarthritis
Therapy Highest Level of Evidence Available Effect Summary
Sustained-release Not applicable: experimental, Suppression of osteoarthritis
corticosteroids/NSAIDs/ nonhuman studies progression
kartogenin
Platelet-rich plasma injection IV Reduction in hip pain by 57% at
6 months
Stem cells IV Improvement in 91% of patient-
reported outcomes by 50% at
12 months
Nerve ablation III Greater than 50% pain relief at
6 months
reviews investigating the therapeutic potential of PRP Nerve Blockade and Ablation
in the management of osteoarthritis concluded that the
existing data are not robust enough to make any firm In patients who are not surgical candidates, blockade and
conclusions regarding clinical benefit.1,2 Both systematic ablation procedures for articular branches of the obtu-
reviews contained only a single reference that examined rator and femoral nerves exist, which have shown some
the effects of PRP in hip osteoarthritis.3 This uncontrolled promise in achieving pain reduction for osteoarthritis.
study demonstrated a clinically relevant reduction in pain A retrospective study reviewed 20 patients with chronic
in 57% of patients after treatment with three weekly PRP hip pain who underwent sensory nerve blockade and
injections administered with ultrasonographic guidance3 found reduced rates of NSAID consumption and a high
(Table 1). rate of satisfaction in 71% of patients.6 A nother study
using CT-guided nerve blockade in 15 patients demon-
strated that 4 patients achieved excellent pain relief for
Stem Cell Therapies 3 to 11 months and another 7 achieved pain relief for 1 to
Mesenchymal stem cell therapy, in the form of injectable 8 weeks.7 Looking toward a more reliably long-acting
cell suspensions, for the treatment of osteoarthritis has treatment, radiofrequency ablation of these articular
been given attention recently as a potential nonsurgical sensory branches of the obturator and femoral nerves
option. Despite this increasing interest, there is a pau- has also been described and investigated in several case
city of high-quality clinical data supporting its use. A reports.8-10 The largest of these series includes 18 patients
systematic review of the literature performed in 2013 re- undergoing ablation who had chronic hip pain and could
vealed 18 clinical studies of stem cell therapy; none of not undergo total hip arthroplasty (THA).8 This pro-
these studies was randomized, 5 were comparative studies, spective series demonstrated at least a 50% increase in
6 were case series, and 7 were case reports.4 There is also pain relief in eight patients at more than 6 months after
high variability regarding the treatment regimens used the procedure8 (Table 1). Additional results at 6-month
in these studies, which differ with respect to cell type, follow-up revealed a decrease in visual analog scale scores
source, and number. There is a recent highly powered and Western Ontario and McMaster Universities Os-
(N = 1,856 joints), uncontrolled, retrospective series of teoarthritis Index scores, and an increase of Harris Hip
patients treated with autologous stromal vascular frac- Scores.8
tion harvested from liposuction and used to treat hip and
3: Hip
knee osteoarthritis.5 Hip Disability and Osteoarthritis

Outcome Score/Knee Injury and Osteoarthritis Outcome Intra-articular Injections of Sustained Release
Score improvement by 50% was noted in 91% of patients Medication Preparations
12 months after treatment5 (Table 1). Longer healing times Interest in sustained-release preparations of local anes-
were noted in patients with higher-grade osteoarthritis and thetics used for pain control after surgery is parallel to an
obesity.5 Further controlled and randomized studies will interest in using these drug delivery techniques for intra-
be required to make a stronger recommendation for stem articular injections of corticosteroids11,12 and other anti-
cell therapy in the treatment of osteoarthritis. inflammatory growth factors.13 These preparations remain
Chapter 27: Alternatives to Conventional Total Hip Arthroplasty for Osteoarthritis
in development and have not been used in human clinical Table 2

trials to date, but their performance in animal models is
encouraging. A 2015 study investigated the efficacy of Relative Indications and Contraindications
a single injection of an extended-release formulation of for Hip Resurfacing Arthroplasty
triamcinolone acetonide in poly(lactic-co-glycolic acid) Good Candidate Poor Candidate
microspheres compared with standard immediate-release
Male Female
preparations in a rat model induced toward three flares of
synovitis over the course of 4 weeks.12 Gait scores were Age 65 years or younger Age older than 65 years
improved with the extended-release formulation across all Large femoral head Small femoral head
three activations of the synovitis; the immediate-release High activity Low demand
preparation provided no long-term benefit.12 Additionally Osteoarthritis Osteonecrosis
improved histologic scores were noted at the end of the
Dysplasia
study period with the extended-release group compared
with the immediate-release group.12 A 2006 study inves-
tigated gelatin hydrogel microsphere delivery of basic
FGF in an anterior cruciate ligament–deficient rabbit Hip Resurfacing
model and showed sustained release of basic FGF for
more than 7 days after injections with induced anabolic Hip resurfacing remains a controversial topic within adult
effects on rabbit cartilage.13 Suppression of osteoarthritis reconstruction regarding indications and outcomes, giv-
progression was noted in the anterior cruciate ligament– en the concern for metal-on-metal wear and particle-
deficient model, and this may represent a feasible, novel, induced–soft-tissue reactions.19 The initial case series that
nonsurgical treatment of osteoarthritis.13 A more recent generated attraction for a large hard-on-hard bearing
experimental preparation conjugating kartogenin with couple to mitigate risks of dislocation and polyethylene
chitosan nanoparticles was used in a rat osteoarthritis wear–related osteolysis in a younger, more active patient
model.14 Kartogenin promotes preferential differentiation population20 has waned given registry data noting poor
of mesenchymal stem cells into chondrocytes and, when survivorship and unique modes of failure, including fem-
conjugated to the chitosan nonparticles, demonstrated in oral neck fractures and activated lymphocytic vasculitis
vitro sustained release for 7 weeks.14 In vivo effects were associated lesions.21 Most data from either case series or
also noted in the rat models with degenerative changes registries note that the best results after hip resurfacing
that were less severe when compared with untreated con- are demonstrated when performed by high-volume sur-
trol rats.14 geons in active young males with large femoral heads
and who have a diagnosis of osteoarthritis20,21 (Table 2).
When compared with THA, hip resurfacing performs
Osteotomies as well or better in this select patient population. Hip
Osteotomies, both femoral and acetabular, are typically resurfacing has not performed as well in older patients
used as a means of hip preservation as opposed to surgical (age 60 years and older), 22 in women, or in patients with
treatment of an arthritic hip. altered anatomy, such as developmental dysplasia of the
Femoral osteotomies have been historically more likely hip.21 This reduction of indications makes maintaining
performed in the setting of preexisting arthritis than their a high-volume hip resurfacing practice difficult for most
acetabular counterparts. The long-term results of varus- surgeons performing adult reconstruction, a factor that
producing femoral osteotomies for the treatment of osteo- may translate to poorer outcomes, even in ideal patient
arthritis secondary to dysplasia have been documented in candidates. Currently, for ideal candidates, hip resurfac-
numerous series.15-18 The most recent series detailed the ing represents a surgical option that has returned patients
long-term results of 52 ostetomized hips and noted that to high levels of activity; however, long-term data are
3: Hip
THA was delayed for more than 10 years in 40% of pa- needed to determine if these increased activity levels affect
tients.15 Furthermore, the length of delay to THA seemed implant survivorship.
to correlate inversely with Tönnis grade: all osteotomies
that delayed THA more than 15 years were preoperative
Tönnis grade I and 4 of 5 osteotomies revised to THA Summary
within 5 years had Tönnis grade III arthritis. 15
Alternatives to conventional nonsurgical treatment for
hip osteoarthritis exist and are being explored. Although
there remains a paucity of high-level evidence to support
Section 3: Hip
routine use, early low-level evidence has demonstrated a and demonstrated improvements in pain and function in
benefit in pain relief and function from these discussed a noncontrolled group of subjects. Level of evidence: IV.
modalities. Additional studies are required to confirm
4. Filardo G, Madry H, Jelic M, Roffi A, Cucchiarini M, Kon
these benefits prior to widespread use of these strategies E: Mesenchymal stem cells for the treatment of cartilage
as first-line treatments; however, their role in patients lesions: From preclinical findings to clinical application
with symptoms refractory to conventional treatments, in orthopaedics. Knee Surg Sports Traumatol Arthrosc
2013;21:1717-1729. Medline DOI
who are not surgical candidates, should be considered.
This systematic review confirmed a paucity of data regard-
ing clinical use of mesenchymal stem cells in the treatment
Key Study Points of osteoarthritis. Level of evidence: IV.
• Nonsurgical treatment options for end-stage hip 5. Michalek J, Moster R, Lukac L, et al: Autologous adipose
osteoarthritis have expanded to include radio- tissue-derived stromal vascular fraction cells application
frequency sensory nerve ablation, stem cell suspen- in patients with osteoarthritis. Cell Transplant 2015;June
20 [Epub ahead of print]. Medline
sion injections, PRP, and injections.
• High-level evidence does not currently support rou- This case control study evaluated the efficacy of stromal
vascular fraction autograft in the treatment of large-joint
tine use of these modalities, but consideration for osteoarthritis. Level of evidence: III.
their use may be warranted in patients who are
not surgical candidates and who have intractable 6. Yavuz F, Yasar E, Ali Taskaynatan M, Goktepe AS, Tan
pain that has not responded to more conventional AK: Nerve block of articular branches of the obturator
and femoral nerves for the treatment of hip joint pain.
measures.
J Back Musculoskelet Rehabil 2013;26:79-83. Medline
• Hip resurfacing remains an alternative to t raditional
This retrospective review examined the efficacy of blocks
THA; the best results after hip resurfacing per- of the articular sensory branches from the obturator and
formed by high-volume surgeons are demonstrated femoral nerves in the management of chronic hip pain.
in active young males with large femoral heads with Level of evidence: IV.
a diagnosis of osteoarthritis.
7. Heywang-Köbrunner SH, Amaya B, Okoniewski M,
Pickuth D, Spielmann RP: CT-guided obturator nerve
block for diagnosis and treatment of painful conditions of
the hip. Eur Radiol 2001;11:1047-1053. Medline DOI
8. Rivera F, Mariconda C, Annaratone G: Percutaneous
radiofrequency denervation in patients with contra-
1. Dold AP, Zywiel MG, Taylor DW, Dwyer T, Theodoro-
indications for total hip arthroplasty. Orthopedics
poulos J: Platelet-rich plasma in the management of artic-
2012;35:e302-e305. Medline
ular cartilage pathology: A systematic review. Clin J Sport
Med 2014;24:31-43. Medline DOI This low-powered study examined the effect of radio-
frequency ablation of sensory nerve branches for intrac-
This systematic review of the use of PRP for osteoarthritis
table hip pain. Level of evidence: III.
demonstrates a paucity of high-quality, unbiased, studies
regarding its use in the treatment of hip osteoarthritis.
9. Malik A, Simopolous T, Elkersh M, Aner M, Bajwa ZH:
Percutaneous radiofrequency lesioning of sensory branches
2. Tietze DC, Geissler K, Borchers J: The effects of plate-
of the obturator and femoral nerves for the treatment of
let-rich plasma in the treatment of large-joint osteoarthritis:
non-operable hip pain. Pain Physician 2003;6:499-502.
A systematic review. Phys Sportsmed 2014;42:27-37.
Medline
Medline DOI
This systematic review of the use of PRP in the treatment 10. Kawaguchi M, Hashizume K, Iwata T, Furuya H: Per-
of knee osteoarthritis noted an overall low level of evi- cutaneous radiofrequency lesioning of sensory branches
dence for available studies, concluding that no definitive of the obturator and femoral nerves for the treatment of
3: Hip
recommendations could be made regarding its use. hip joint pain. Reg Anesth Pain Med 2001;26:576-581.
Medline DOI
3. Sánchez M, Guadilla J, Fiz N, Andia I: Ultrasound-guided
platelet-rich plasma injections for the treatment of osteo- 11. Dhanaraju MD, Elizabeth S, Gunasekaran T: Triamcin-
arthritis of the hip. Rheumatology (Oxford) 2012;51: olone-loaded glutaraldehyde cross-linked chitosan mi-
144-150. Medline DOI crospheres: Prolonged release approach for the treatment
of rheumatoid arthritis. Drug Deliv 2011;18:198-207.
This study evaluated the effect of ultrasound-guided PRP
Medline DOI
injections in the hip for the treatment of osteoarthritis
Chapter 27: Alternatives to Conventional Total Hip Arthroplasty for Osteoarthritis
Linkage of triamcinolone to chitosan microspheres led to 16. Voos JE, Ranawat AS, Pellicci PM, Buly RL, Salvati EA:
a uniform release pattern within the joints of arthritic rats Varus rotational osteotomies for adults with hip dysplasia:
and extended release for up to 63 days. A 20-year followup. Clin Orthop Relat Res 2007;457:
138-143. Medline
12. Kumar A, Bendele AM, Blanks RC, Bodick N: Sustained
efficacy of a single intra-articular dose of FX006 in a rat 17. Koulouvaris P, Stafylas K, Aznaoutoglou C, Zacharis K,
model of repeated localized knee arthritis. Osteoarthritis Xenakis T: Isolated varus intertrochanteric osteotomy for
Cartilage 2015;23:151-160. Medline DOI hip dysplasia in 52 patients: Long-term results. Int Orthop
2007;31:193-198. Medline DOI
In a rat model for localized synovitis, an extended release
formulation of triamcinolone resulted in improved anal-
gesia and histologic scores when compared to immediate 18. Werners R, Vincent B, Bulstrode C: Osteotomy for osteo-
release formulations. arthritis of the hip: A survivorship analysis. J Bone Joint
Surg Br 1990;72:1010-1013. Medline
13. Inoue A, Takahashi KA, Arai Y, et al: The therapeutic
effects of basic fibroblast growth factor contained in gel- 19. Pandit H, Glyn-Jones S, McLardy-Smith P, et al: Pseudo-
atin hydrogel microspheres on experimental osteoarthritis tumours associated with metal-on-metal hip resurfacings.
in the rabbit knee. Arthritis Rheum 2006;54:264-270. J Bone Joint Surg Br 2008;90:847-851. Medline DOI
Medline DOI
20. McMinn DJ, Daniel J, Ziaee H, Pradhan C: Indications
14. Kang ML, Ko JY, Kim JE, Im GI: Intra-articular delivery and results of hip resurfacing. Int Orthop 2011;35:
of kartogenin-conjugated chitosan nano/microparticles for 231-237. Medline DOI
cartilage regeneration. Biomaterials 2014;35:9984-9994. This study demonstrated excellent clinical results of Bir-
Medline DOI mingham Hip Resurfacings, with a revision rate of 2.2%
Rats treated with kartogenin-conjugated chitosan demon- and survivorship of 96% at 13 years postoperatively. Level
strated less articular degeneration when compared with of evidence: IV.
controls and unconjugated kartogenin recipients.
21. Graves S, Davidson D, de Steiger R: Australian Ortho-
15. Zweifel J, Hönle W, Schuh A: Long-term results of inter- paedic Association National Joint Replacement Registry
trochanteric varus osteotomy for dysplastic osteoarthritis Annual Report. Available at: http://www.surfacehippy.
of the hip. Int Orthop 2011;35:9-12. Medline DOI info/pdf/australian-nat-reg-2011.pdf 2011. Accessed June
8, 2016.
This retrospective study evaluated the long-term results
of varus-producing osteotomy in the setting of develop- 22. Della Valle CJ, Nunley RM, Raterman SJ, Barrack RL:
mental dysplasia of the hip and reported good outcomes Initial American experience with hip resurfacing following
in patients with early or mild osteoarthritis. Level of FDA approval. Clin Orthop Relat Res 2009;467:72-78.
evidence: IV. Medline DOI
3: Hip
Chapter 28
Surgical Approaches and

Bearing Surfaces
William Hozack, MD Clive Duncan, MD, MSc, FRCSC Amir Herman, MD, PhD Erik Hansen, MD
Mark W. Pagnano, MD James L. Howard, MD, MSc, FRCS(C) James P. McAuley, MD, FRCS(C)
William A. Jiranek, MD Tiffany Feltman, DO Orhun K. Muratoglu, PhD Ebru Oral, PhD
Greg Deirmengian, MD William L. Walter, MBBS, PhD Yadin D. Levy, MD
Richard W. McCalden, MD, MPhil (Edin.), FRCS(C) Emil Schemitsch, MD, FRCS(C)
intermuscular approach; and the direct anterior approach

Abstract
is a single-incision, intermuscular approach that exploits
The many surgical approaches to the hip continue the plane between the sartorius and the tensor fascia lata
to evolve and progress has been made over the past (anterior-intermuscular)1 (Table 1).
10 years. Perioperative patient management has helped
optimize outcomes. Advances in component design have Anterolateral and Lateral Approaches
led to the generation of improved bearing surfaces, which Clive Duncan, MD, MSc, FRCSC; Amir Herman, MD, PhD
has led to increased wear resistance and decreased rates The anterolateral approach is commonly known as the
of osteolysis. Watson-Jones approach. In a minimally invasive modifi-
cation of this approach, the patient is placed in a lateral
position on a split table, with the inferior-posterior part of
Keywords: anterolateral approach; direct anterior the table dropped to accommodate hyperextension of the
approach; posterior approach; minimally invasive hip to prepare the medullary canal. The incision is made
surgery; extended trochanteric osteotomy; metal- from the anterior superior corner of the greater trochan-
on-metal bearing; ceramic-on-ceramic bearing ter 3 inches in the direction of the anterior superior iliac
spine. The deep fascia is incised along the line of the skin
incision, which is posterior to the tensor fascia lata. The
gluteus medius is retracted posteriorly. The intermuscular
plane used is posterior to the tensor fascia lata and an-
Classification of Surgical Approaches to the Hip
terior to the gluteus medius. After either a capsulotomy
Clive Duncan, MD, MSc, FRCSC, Amir Herman, MD, PhD or a capsulectomy, the femoral neck is cut at the head-
Numerous surgical approaches or “corridors” to the hip neck junction and trimmed back to the required level to
joint have been described. For clarity of description, a expose the acetabulum; after cup implantation, the limb
classification system that systematically describes these is dropped into a draped pocket created by splitting the
approaches was proposed based on the relationship of lower end of the table, thus placing the limb and femur
the corridor to the gluteus medius (in front, behind, or into hyperextension and external rotation to access the
3: Hip
through it), the number of incisions used (single or mul- femoral canal.2
tiple), and whether the approach was intermuscular. For The direct lateral approach was introduced in
example, the Kocher-Langenbeck approach is classified 1982.3 The patient is placed in a lateral position. The
as a single-incision, posterior approach and divides the skin incision is centered over the greater trochanter, and
external rotators (posterior-transmuscular); the Hardinge the deep fascia is incised parallel to the skin incision. The
approach is a single-incision, direct lateral approach that anterior one-third of the gluteus medius is elevated from
goes through the gluteus medius (lateral-transmuscular); the greater trochanter in continuity with an anterior flap
the Watson-Jones approach is single-incision, anterolateral of the vastus and kept in continuity with that structure.
Section 3: Hip
The proximal extent of the gluteal split is limited to avoid transmuscular or transgluteal approach because it splits
damaging the superior gluteal neurovascular bundle. The and goes through the gluteus medius.
gluteus minimus and the capsule are incised in line with Several randomized controlled trials (RCTs) have com-
the gluteus medius split, and the three structures (glu- pared the anterolateral-intermuscular, lateral-transmuscu-
teus medius, gluteus minimus, and capsule) are mobi- lar, and posterior-transmuscular approaches.4-7 At 1 year
lized as one composite flap. This approach is called a postoperatively, no clinically and statistically significant
Dr. Hozack or an immediate family member has received royalties from Stryker, serves as a paid consultant to Struler,
and has received research or institutional support from Stryker. Dr. Duncan or an immediate family member is a member
of a speakers’ bureau or has made paid presentations on behalf of Zimmer Biomet. Dr. Pagnano or an immediate family
member has received royalties from DePuy and Stryker; serves as a paid consultant to Pacira; and serves as a board
member, owner, officer, or committee member of the Hip Society and the Knee Society. Dr. Howard or an immediate
family member is a member of a speakers’ bureau or has made paid presentations on behalf of DePuy and Stryker; serves
as a paid consultant to DePuy and Stryker; has received research or institutional support from DePuy; and has received
nonincome support (such as equipment or services), commercially derived honoraria, or other non–research-related
funding (such as paid travel) from DePuy, Microport, Smith & Nephew, Stryker, and Zimmer Biomet. Dr. McAuley or
an immediate family member has received royalties from DePuy; is a member of a speakers’ bureau or has made paid
presentations on behalf of DePuy; serves as a paid consultant to DePuy; has received nonincome support (such as equip-
ment or services), commercially derived honoraria, or other non–research-related funding (such as paid travel) from the
Canadian Institutes of Health Research, Inova Health Care Services, Smith & Nephew, and Zimmer Biomet; and serves as
a board member, owner, officer, or committee member of the Canadian Orthopaedic Association and the Knee Society.
Dr. Jiranek or an immediate family member has received royalties from DePuy; serves as a paid consultant to Cayenne
Medical and DePuy; has stock or stock options held in Johnson & Johnson; has received research or institutional support
from DePuy and Stryker; and serves as a board member, owner, officer, or committee member of the American Associ-
ation of Hip and Knee Surgeons, Lifenet Health, and the Orthopaedic Learning Center. Dr. Muratoglu or an immediate
family member has received royalties from Arthrex, Aston Medical, Conformis, Corin USA, Iconacy, Meril Healthcare,
Renovis, Stryker, and Zimmer Biomet; is a member of a speakers’ bureau or has made paid presentations on behalf of
Corin USA; has stock or stock options held in Alchimist, Cambridge Polymer Group, and Orthopedic Technology Group;
has received research or institutional support from DePuy and Stryker; and has received nonincome support (such as
equipment or services), commercially derived honoraria, or other non–research-related funding (such as paid travel)
from Biomet. Dr. Oral or an immediate family member has received royalties from Arthrex, Aston Medical, Conformis,
Corin USA, Mako/Stryker, Meril Healthcare, Pipeline, Renovis, and Zimmer Biomet and serves as a board member, owner,
officer, or committee member of the Society for Biomaterials. Dr. Deirmengian or an immediate family member is a
member of a speakers’ bureau or has made paid presentations on behalf of Zimmer Biomet; serves as a paid consultant
to Synthes, Zimmer Biomet, and Biomet; has stock or stock options held in CD Diagnostics, Biostar Ventures, Domain,
and Trice; and has received research or institutional support from CD Diagnostics and Zimmer Biomet. Dr. Walter or an
immediate family member has received royalties from Matortho and Stryker; serves as a paid consultant to Matortho
and Stryker; has stock or stock options held in NAVBiT; has received research or institutional support from DePuy; and
serves as a board member, owner, officer, or committee member of the Australian Institute of Musculoskeletal Research
and the International Society of Orthopaedic Centers. Dr. McCalden or an immediate family member is a member of a
speakers’ bureau or has made paid presentations on behalf of Smith & Nephew; serves as a paid consultant to Smith &
Nephew; and has received research or institutional support from Smith & Nephew, DePuy, and Stryker. Dr. Schemitsch
3: Hip
or an immediate family member has received royalties from Stryker; serves as a paid consultant to Acumed, Sano-
fi-Aventis, Smith & Nephew, Stryker, and Zimmer Biomet; has received research or institutional support from Smith &
Nephew; has received nonincome support (such as equipment or services), commercially derived honoraria, or other
non–research-related funding (such as paid travel) from the Canadian Institutes of Health Research, OMEGA, Smith &
Nephew, Zimmer Biomet, Stryker, and Synthes; and serves as a board member, owner, officer, or committee member
of the Orthopaedic Trauma Association, the Canadian Orthopaedic Association, and the Osteosynthesis and Trauma
Care Foundation. None of the following authors or any immediate family member has received anything of value from
or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of
this chapter: Dr. Herman, Dr. Hansen, Dr. Feltman, and Dr. Levy.
Chapter 28: Surgical Approaches and Bearing Surfaces
Table 1
Classification of Surgical Approaches to the Hip
No. of Approach
Classification Incisions to the Hip Deep Dissection Previous Designation
Anterior- Single Anterior Intermuscular Modified Smith-Peterson
intermuscular
Anterolateral- Single Anterolateral Intermuscular Modified Watson-Jones/
intermuscular Roettinger
Lateral-transmuscular Single Lateral Transmuscular Modified Bauer/Hardinge/Dall
Posterior- Single Posterior Transmuscular Modified Moore/Kocher-
transmuscular Langenbeck
differences were observed among the three approaches. avoid damaging the lateral femoral cutaneous nerve.
Similarly, two recent small sample gait analysis studies The deep dissection proceeds between the rectus femoris
comparing the anterolateral-intermuscular approach with and the gluteus medius, during which point branches of
an unspecified two-incision approach and another study the lateral femoral circumflex artery must be identified
comparing the anterolateral-intermuscular approach with and cauterized. An anterior capsulotomy or capsulec-
the lateral-transmuscular approach found no differenc- tomy is performed depending on surgeon preference.
es in gait analysis parameters and forces across the hip Commonly, an in situ “napkin ring” femoral neck oste-
joint. A larger retrospective report that included 1,273 pa- otomy is performed to avoid the need for femoral head
tients with a mean follow-up of 30 months showed that dislocation. Although the acetabulum is prepared in
the anterior-intermuscular and posterior-transmuscular standard fashion, to prepare the femur the hip must be
approaches perform the same and are both superior to hyperextended, adducted, and externally rotated. Some
the lateral-transmuscular approach in terms of patient- surgeons use a fracture table and specialized retractors
reported outcomes and any limp after surgery. A joint to facilitate this step, whereas other surgeons “break”
registry-based study demonstrated that surgical ap- the table or use a bump under the sacrum. Many but
proaches influenced the rate and reasons for revision.8 A not all surgeons use offset instrumentation and intra-
higher relative risk of revision caused by loosening oc- operative fluoroscopy to optimize component sizing
curred with the lateral-transmuscular approach compared and placement.
with the posterior-transmuscular approach, and a higher In recent years, an increasing number of published
relative risk for revisions caused by dislocation occurred studies have compared the direct anterior approach with
with the posterior-transmuscular approach compared other surgical approaches regarding clinical outcomes as
with the lateral-transmuscular approach. assessed according to muscle damage, patient-reported
and perioperative outcomes, and gait analysis. Although
Direct Anterior Approach most earlier clinical studies were consecutive cohort series
Erik Hansen, MD of surgeon innovators with notable limitations in study
The direct anterior approach for total hip arthroplasty design and methodologic rigor, numerous high-quality
(THA), originally described in 1939, has recently become studies have recently been performed, with several meta-
common again because of a new focus on minimally in- analyses and prospective RCTs on the topic.9-13
vasive surgery. Because the anterior approach represents The first prospective RCT of the direct anterior ap-
an intermuscular and internervous approach to the hip, proach was published in 2010, wherein 100 patients were
3: Hip
it can potentially avoid disruption of the anatomy and randomized to either the direct anterior approach or the
minimize soft-tissue injury compared with other surgical direct lateral approach, and perioperative variables and
approaches. Moreover, because it is performed in a supine functional outcomes were evaluated up to 2 years post-
position, it may facilitate patient monitoring during anes- operatively.9 From 6 weeks to 1 year postoperatively, the
thesia as well as more accurate assessment of component direct anterior group demonstrated significantly better
positioning and leg-length equality. improvement in both the mental and physical health di-
Superficial dissection develops the interval between mensions of the Medical Outcomes Study 36-Item Short
the tensor fascia lata and the sartorius, with care to Form (SF-36) and the Western Ontario and McMaster
Section 3: Hip
Universities Osteoarthritis Index, whereas at 2 years, the who performed fewer than 100 procedures were twofold
results in both groups were the same. more likely to see complications in their patients (20.2%
A recently published RCT of slightly more than versus 9.8%; P < 0.05).13 It has been suggested that the
50 patients focused on early functional recovery dif- learning curve was approximately 40 to 50 procedures
ferences between the direct anterior and posterior ap- and 6 months in a high-volume joint surgeon’s practice.
proaches.14 Hospital stays were significantly shorter for Wound-healing problems are a consistently reported
patients in the direct anterior approach group (1.4 ver- complication seen with the direct anterior approach for
sus. 2.0 days; P = 0.01), and the change in pain scores THA, which is often attributed to the more tenuous skin
was significantly greater for the direct anterior approach and soft-tissue envelope of the anterior hip compared
group (P = 0.04). The direct anterior approach group with the lateral and posterior hip. Because of challenges
also discontinued using a walking aid at an earlier time in elevating the femur to the skin incision as well as ex-
(33.0 versus 43.1 days; P = 0.03). posure and visualization in certain cases, the reported
A systematic review and meta-analysis comparing the risks of cortical perforation (for example, lateral perfora-
direct anterior and posterior approaches for THA was re- tion caused by varus malposition or posterior perforation
cently published and included 17 studies and slightly more caused incomplete posterior release and obstruction by
than 2,300 patients.11 Regarding postoperative pain and the anterior superior iliac spine) and periprosthetic frac-
function, the anterior approach was favored substantially ture are greater. Based on an individual’s anatomy and the
in four studies at short-term follow-up. Furthermore, surgeon’s technique, the lateral femoral cutaneous nerve
pooled estimates showed a significant difference in favor may be at risk during superficial dissection in the direct
of the anterior approach regarding the length of hospital anterior approach. Depending on the degree to which
stay and dislocations. the nerve is damaged (minor stretch versus transection),
A systematic review and meta-analysis published in the symptoms can range from transient to permanent
2015 compared the direct anterior approach with the lat- numbness along the lateral thigh to dysesthesias (termed
eral approach and included 12 trials involving 4,901 pro- meralgia paresthetica). The exact incidence of this com-
cedures.10 This analysis indicated that the direct anterior plication is unknown because the magnitude of the injury
approach was associated with significantly shorter hos- can range from transient sensory numbness to a burning
pital stays, greater functional rehabilitation, and lower dysesthesia; many surgeons have not explicitly asked their
pain scores during the early postoperative period. The patients about this, relying instead on self-reporting.
two approaches (direct anterior and lateral) were found In the next 10 years, it is anticipated that an increasing
to have similar rates of perioperative surgical complica- number of patients who have previously undergone a
tions and transfusions as well as similar radiographic THA with the direct anterior approach will need revision
analytic results. surgery. Although partly caused by the expected revision
In addition to improved clinical outcomes, many sur- rates based on epidemiologic data, this number also may
geons have noted that the supine patient position facil- be inflated to some degree by surgeons who are still going
itates the use of fluoroscopy and image interpretation, through the learning curve in adopting this technique.
which allows this position to be used as an adjunct tool The technique for extending the direct anterior approach
to help optimize component position. Numerous recent to adequately perform revision surgery or address an
publications support increased accuracy of component intraoperative periprosthetic fracture has been discussed
position using the direct anterior approach, compared in the literature.
with other approaches even when fluoroscopy is used, The direct anterior approach can be considered ideal
which many authors often attribute to the difference in for performing THA because it has the potential to
image interpretation from the supine position to the lat- minimize iatrogenic soft-tissue injury, which has been
eral decubitus position. confirmed by multiple cadaver, radiographic, and bio-
Most surgeons currently using the direct anterior ap- chemical studies. Many authors have further demon-
3: Hip
proach for THA were taught a different approach to the strated that this tissue-sparing technique translates into
hip during their residency and fellowship training. There- early functional gains, improved gait, and better clini-
fore, adoption of this technique frequently has come by cal outcomes compared with other surgical approaches.
way of a learning curve, in which an initially higher rate of However, conclusions on the superiority of the direct
complications and less-than-optimal outcomes have been anterior approach must be interpreted cautiously because
seen. A large multicenter effort by the Anterior Total Hip few prospective RCTs have been published on the subject.
Arthroplasty Collaborative reported the clinical results Future comparative studies using rigorous research meth-
and complications on 1,152 patients, noting that surgeons odology are desperately needed to determine whether
the direct anterior approach is truly superior to other distal insertion on the femur. A retractor is placed under
surgical approaches. the gluteus medius to expose the underlying gluteus min-
At the same time, the direct anterior approach has a imus and the piriformis tendon.
unique set of challenges and complications. Most sur- The subsequent exposure of the hip joint can be done
geons in practice were not trained on this technique, so with either one or two layers. Taking down the hip capsule
adopting this approach necessitates a learning curve. Also, and the external rotators as one layer in the shape of an
the intricacies, indications, and limitations of performing L is done with a cautery by starting the capsulotomy at
revision surgery through the anterior interval have been the edge of the acetabular rim parallel to the piriformis
only recently described in the literature. If responsible tendon and continuing toward the greater trochanter.
adoption of this technique is performed, this approach The capsulotomy is then turned distally to take down
to hip replacement can be successfully used on the vast the capsule and the tendinous insertion of the piriformis
majority of patients. tendon and the remaining external rotators in turn. Al-
ternatively, the two-layer approach involves taking down
Posterior Approach the piriformis tendon and the external rotators first and
Mark W. Pagnano, MD tagging them with a stitch, followed by a separate capsu-
The posterior approach to the hip and its various permuta- lotomy to expose the underlying femoral head.
tions (posterolateral or mini-posterior) have a long record Traditionally, the quadratus femoris is taken down
of accomplishment when used for THA. The posterior with the posterior approach, although some surgeons
approach spares the abductor musculature of the hip and now prefer to save some or all of the quadratus insertion
allows for excellent visualization of the acetabulum and during routine exposures. The femoral head is then dis-
straightforward access to the femur. If intraoperative located by internally rotating and adducting the femur.
challenges are encountered, the posterior approach can An accurate femoral neck osteotomy is performed by
be readily extended proximally or distally to provide measuring from the lesser trochanter in accordance with
wider exposure of the acetabulum and the femur, re- the preoperative plan.
spectively. Changes in surgical technique to routinely Some surgeons move directly to femoral canal prepa-
include formal repair of the external rotators and/or the ration; other surgeons prepare the acetabulum first. To
posterior capsule, combined with using larger diameter expose the femur, the hip is flexed, internally rotated,
prosthetic femoral heads, have dramatically—but not and adducted; a skilled assistant can determine the ideal
completely—reduced the higher risk of dislocation after combination of these positions to facilitate visualization.
posterior versus anterior or direct lateral approaches to Typically, the leg should be flexed until positioned in-
THA. A combination of familiarity, versatility, and re- line with the skin incision, internally rotated to move
producibility with the posterior approach likely makes the the greater trochanter out of the way, and adducted to
posterior approach the most widely used approach by hip minimize impingement on the posterior skin flap. A fem-
arthroplasty surgeons in the United States. oral elevating retractor is typically placed on the anterior
The patient is placed in the lateral decubitus position, (deep) surface of the femoral neck, and a second retrac-
and the limb is draped to allow easy positioning of the tor is placed medially to view the calcar region; femoral
leg throughout surgery, along with visualization and/or reaming and/or broaching is then completed.
palpation of the anterior superior iliac spine, the posterior Good acetabular exposure is obtained by strategically
superior iliac spine, and the iliac crest. The typical incision placing retractors anteriorly, posteriorly, and inferiorly.
for a standard posterior or posterolateral approach is The femur is captured and translated forward by the
centered over the tip of the greater trochanter, with equal anterior retractor; a posterior retractor holds the capsule
portions of the incision extending distally and proximally and external rotators away from the acetabular rim, and
from that point. Some surgeons choose to make a straight an inferior retractor is placed just distal to the transverse
skin incision, whereas others use a curvilinear incision, acetabular ligament to allow visualization of the floor of
3: Hip
such that the proximal limb diverges posteriorly in par- the acetabulum. Many surgeons will ream the acetabulum
allel with the fibers of the gluteus maximus. The iliotibial while standing posterior to the patient, whereas others
band is split in-line with the distal portion of the incision, ream from the front of the patient to better visualize the
whereas proximally the gluteus maximus fascia is incised, acetabular anatomy.
and the muscle fibers are bluntly dissected parallel to the Most surgeons choose to do a trial reduction to assess
posterior border of the underlying gluteus medius. In for leg length, offset, and hip stability. A typical sequence
particularly stiff or previously operated hips, the gluteus would be to assemble the trial components, assess leg
maximus can be incised partially or completely from its length, and proceed with tests of stability with the hip in
Section 3: Hip
maximal extension and maximal external rotation (does management protocols account for most differences in
the neck impinge against the posterior edge of the liner?), patient experience. Until recently, most patients undergo-
flexed 45° and maximally adducted (does the femoral ing THA were treated in a traditional sick-patient model
head subluxate?), and flexed 90° in neutral abduction of care because they were assumed to require substantial
(can internal rotation be performed to an acceptable de- hospital intervention, with many cumbersome and costly
gree without dislocation?). If the stability test results are interventions (for example, indwelling urinary catheters,
unacceptable, then various combinations of neck length, patient-controlled-analgesic pumps, autologous blood
hip offset, head diameter, and liner options can be trialed. transfusion, restricted weight bearing) that were a routine
The final implants are placed, and the hip is reduced. part of the early postoperative experience. Currently, the
A formal repair of the posterior capsule and the external paradigm has shifted to a well-patient model, with the
rotators is then performed. Traditionally, this repair is working assumption that a patient medically optimized
done in a transosseous fashion, passing sutures through for surgery is unlikely to become a sick patient after THA.
drill holes in the greater trochanter. A soft-tissue-only Instead, it is expected that most patients can be treated
repair that pulls the posterior-inferior capsule and the safely and more effectively with less intensive hospital
external rotators back to the anterior-superior capsule intervention. For most medically healthy patients, con-
and the posterior border of the gluteus minimus also has temporary THA can be performed using various surgical
proved effective. approaches (anterior, posterior, or direct lateral), with
The posterior approach to the hip appears to be associ- incision sizes ranging from less than 10 cm to greater
ated with a slightly lower risk of heterotopic ossification, than 20 cm. No matter the approach or incision size,
abductor insufficiency, intraoperative femoral fracture, patients have similar expectations of excellent early pain
superior gluteal nerve palsy, and neurapraxia of the lat- relief because of advanced anesthetic and pain manage-
eral femoral cutaneous nerve compared with the anterior ment techniques, a low risk of blood transfusion, the
or direct lateral approaches. Conversely, the posterior ability to begin ambulation early after surgery, and a
approach is associated with a slightly higher risk of dislo- rapid discharge from the hospital—the timing of which
cation and sciatic nerve injury compared with the anterior is influenced more by social and economic factors rather
or direct lateral approaches. Pooled data from multiple than surgical approach factors.
sources suggest that the risk of dislocation after a con- Surgeons continue to discuss the relative merits of one
temporary direct anterior or direct lateral approach THA surgical approach versus another, but it is increasingly
likely ranges from 0.5% to 1.25%, whereas the risk after uncommon to frame that discussion using the concepts of
a contemporary posterior approach likely is in the 1.0% minimally invasive versus standard THA. No agreement
to 2.5% range. A recent meta-analysis showed that the has been achieved regarding the definition of minimally
risk of dislocation after a posterior approach was lowered invasive THA, and the term itself has become less useful
by sevenfold when a formal repair of the soft tissues was across time. Nonetheless, numerous comparative studies
performed.15 Emerging data suggest that in the presence have reported the outcomes of standard versus minimally
of formal repair of the soft tissues, the traditional post- invasive approaches to THA. For every standard THA
operative hip precautions to avoid dislocation may not surgical approach, numerous iterations of minimally inva-
alter the risk of dislocation after a contemporary posterior sive approaches have been used during the past decade (in
approach.15-19 addition to several combined or two-incision approaches).
It has become apparent that most early studies that pur-
An Update on Minimally Invasive Approaches ported to demonstrate advantages of minimally invasive
Mark W. Pagnano, MD THA over standard THA were confounded by dramatic
The entirety of the patient experience after contempo- differences in the perioperative management of patients.
rary THA has dramatically improved from that of just Such differences are still present, even among otherwise
10 years ago. This improvement is largely attributable well-done RCTs that compare surgical approaches, and
3: Hip
to various components of perioperative patient manage- need to be accounted for when interpreting the results.
ment (multimodal pain management, advanced blood Nonetheless, it is clear that for many patients, THA can
management, and rapid rehabilitation protocols) that be done relatively safely with a smaller surgical incision
were bundled together under the umbrella of so-called and less muscle dissection than was traditionally associ-
minimally invasive THA. The smaller skin incision and ated with the procedure.
lesser soft-tissue dissection associated with minimally One recent meta-analysis of standard and minimally
invasive approaches may provide some small incremental invasive posterior approaches to THA included almost
improvements; however, advanced perioperative patient 1,500 patients from 12 RCTs and 4 nonrandomized
trials.20 Although significant differences were reported with patients in the direct anterior group. In patients in
in favor of the minimally invasive posterior group, none of both groups, the postoperative C-reactive protein levels
these differences appear clinically meaningful. The mini- were similar.
mally invasive posterior approach was a safe, acceptable In an RCT of 43 patients with the direct anterior ap-
alternative to the standard posterior approach. proach for THA and 44 patients with a posterior ap-
Another systematic review and meta-analysis broadly proach for THA, the direct anterior group had more
assessed a single mini-incision for THA and included patients climbing stairs normally and walking unlimited
1,857 patients from 15 RCTs and 5 quasi-randomized distances by 6 weeks postoperatively and higher hip scores
clinical trials. 21 Small perioperative advantages were at 3 months.25 In that study, the patients with the posterior
found regarding less blood loss, shorter surgical time, approach were treated postoperatively with substantial
and a shorter hospital stay, but it was concluded that none hip precautions, whereas patients in the direct anterior
of the differences reached the threshold of clinical signifi- group were not. Some surgeons have questioned whether
cance. Insufficient evidence was available to comment on the differences in hip precautions and rehabilitation pro-
differences in complications or the durability between tocols, not the difference in surgical technique, accounted
the minimally invasive and the standard incision groups. for the observed differences in that RCT.
A third systematic review and meta-analysis was A smaller RCT of the direct anterior approach versus
done with broader search terms to include limited in- the mini-posterior approach was halted at 54 patients,
cision versus standard incision for THA and included which is substantially short of the target enrollment of
3,548 patients in 30 separate studies.22 Some small clini- 100 patients, because of difficulties with patient accrual.
cal differences were found in favor of the limited incision Approximately 20 different outcome variables were exam-
approaches, including a shorter hospital stay, less blood ined and the SF-36 mental component scores were found
loss, less pain at discharge, and a higher Harris hip score to favor the mini-posterior group at 3 weeks, whereas the
at 3 months. The lack of consistent reporting of compli- direct anterior group demonstrated a 6-day advantage
cations made comparisons between the two groups diffi- in eliminating all gait aids (22 versus 28 days). Larg-
cult. Two well-done RCTs compared minimally invasive er, well-designed RCTs of the direct anterior approach,
posterior THA to a minimally invasive two-incision THA in which the perioperative management protocols for
and found no advantages for the technically more chal- both the direct anterior group and the comparator group
lenging two-incision approach.23,24 One trial found that are equivalent, would be of value to the orthopaedic
the minimally invasive posterior group actually achieved community.20,21,25,26
functional milestones faster, whereas the other trial found
that the attainment of functional milestones was similar Trochanteric Osteotomy and Extensile Approaches
between the two groups. James L. Howard, MD, MS, FRCS(C);
Several RCTs have compared a minimally invasive James P. McAuley, MD, FRCS(C)
direct anterior approach with other approaches. In one To achieve successful reconstruction in revision THA,
trial of 100 minimally invasive direct anterior procedures the surgeon must obtain adequate exposure of the pa-
versus 100 direct lateral procedures, no differences were tient’s anatomy, existing implants, and associated bone
found in the in-hospital outcomes, including pain, the deficits while protecting vital structures and minimizing
need for transfusion, and the length of stay or discharge to unnecessary surgical dissection. A variety of osteotomies
skilled nursing versus home.9 That study found that some and extensile exposures can be employed in the revision
individual components of the SF-36 score and the Western setting. The surgeon’s choice of technique will depend on
Ontario and McMaster Universities Osteoarthritis Index several factors, including the patient’s anatomy, any bone
favored the minimally invasive direct anterior approach defects, the design and position of existing components,
at 6 weeks; however, those early differences disappeared previous surgical exposures, complications of previous
by 2 years postoperatively. surgery, and anticipated postoperative patient compliance.
3: Hip
Another recent RCT of the direct anterior approach The surgeon must balance these factors along with pre-
versus the direct lateral approach used biomarkers of mus- vious training and experience to determine the optimal
cle damage (creatine kinase) and inflammation (C-reactive approach for a patient. This section summarizes trochan-
protein) in addition to traditional functional outcome teric osteotomy techniques and extensile exposures for
measures to compare results.25 In a study of 163 patients, revision THA.
patients in the direct lateral group had slightly higher vi- Sir John Charnley first described trochanteric oste-
sual analog scale scores postoperatively but substantially otomy as a principal component of primary THA. With
lower creatine kinase levels postoperatively compared the limitations of early THA designs in terms of leg
Section 3: Hip
length, offset, and femoral head size, the trochanteric escape. Four patients (4.8%) who had bony union of the
osteotomy was used to optimize abductor function and osteotomy had postoperative dislocations. The technique
maintain stability. With advances in THA component also has been shown to be reliable in patients who have
design across time, a trochanteric osteotomy is no longer had a previous trochanteric osteotomy. In a matched co-
required for routine primary THA. However, trochan- hort comparison of patients with a repeat trochanteric
teric osteotomy techniques can still play a role in complex osteotomy to patients who had their first osteotomy, sim-
primary and revision cases. ilar rates of bony union, fibrous union, and nonunion
In the classic description of a trochanteric osteotomy, rates were seen.31 In addition, rates of residual abductor
the resection plane exits at the vastus ridge, which allows lurch, persistent trochanteric pain, and dislocation were
the surgeon to reflect the trochanteric segment proximally similar between the two groups.
and then proceed with a capsulotomy, dislocation, and The extended trochanteric osteotomy (ETO) extends
the remainder of the procedure. The technique also allows the standard femoral osteotomy distally along the diaph-
for lateralization and advancement of the trochanteric ysis a variable distance to provide direct access to the
segment when the procedure is completed to improve endosteal surface of the femur. Indications for its use
tension and function of weakened abductors and soft include removal of a well-fixed noncemented stem to
tissues about the hip. However, several complications, facilitate access for cement removal with cemented stems
including trochanteric nonunion and escape, have been and in periprosthetic fractures treated with revision THA
identified with the classic trochanteric osteotomy. to facilitate safe component removal in cases display-
The trochanteric slide has been described as a method ing femoral remodeling. The technique was originally
of addressing the complications seen with the classic tro- described for use in conjunction with a posterior ap-
chanteric osteotomy.27,28 The key feature of this technique proach to the hip. The length of the osteotomy can vary
is retention of the attachment of the vastus lateralis to the depending on the indication for surgery but must be
osteotomized trochanteric segment. The modified oste- long enough to provide sufficient space for fixation with
otomy is longer, thinner, and more vertically oriented than two circumferential wires (minimum, 10 to 12 cm). The
a traditional osteotomy. Retention of the vastus lateralis osteotomy should encompass one-third of the circumfer-
helps resist proximal trochanteric migration if escape ence of the femur. Posterior and distal osteotomies are
does occur. The longer osteotomy also allows for more completed under direct visualization, with a controlled
proximal fixation of the trochanteric segment in revision fracture anteriorly to mobilize the osteotomy segment.
cases when significant lengthening occurs. Initial series The osteotomy is more easily completed with the femoral
published on this technique demonstrated a nonunion stem removed, but this may not be possible in cases with
rate of 10%.27 Among patients with nonunions, few cases a well-fixed femoral stem. The ETO has been shown to
demonstrated cephalad migration of more than 1 cm. The have good clinical results, with nonunion rates of less
results supported the contention that the vastus lateralis than 2%. For many surgeons, the ETO is the osteotomy
was a restraint to proximal migration, and the functional of choice for exposure in complex primary and revision
deficit seen in migrated cases was less severe than that THA cases.32-35
seen with conventional osteotomies. Modifications to the ETO technique have been re-
A modification of the trochanteric slide has been de- ported. An ETO technique completed by means of a
scribed to maintain continuity of the short external ro- modified direct lateral approach has been reported.36 In
tators and the posterior capsule to improve postoperative this technique, the anterior and distal cuts of the oste-
stability.29 With this technique, the posterior portion of otomy are made under direct visualization, and the oste-
the greater trochanter is left in continuity with the femur. otomy segment is displaced posteriorly. The results using
The greater trochanteric segment is retracted anteriorly this technique demonstrated a lower dislocation rate but
with the gluteus medius and the vastus lateralis attached, a higher incidence of trochanteric fracture and escape
and an anterior capsulotomy is used to access the joint. In than described previously with ETOs using the posterior
3: Hip
a retrospective comparison of consecutive series of acetab- approach.

ular revisions, the dislocation rate was 14.8% in patients More recently, an extended version of the modified
receiving a conventional trochanteric slide and 3.3% in sliding trochanteric osteotomy has been reported.37 Sim-
patients who received the modified trochanteric slide. ilar to what was described for a modified trochanteric
The results for 83 cases using this modified technique slide, the approach preserves the posterior capsule and
were reported in 2010:30 70 patients (84.4%) had bony external rotators by leaving a posterior segment of the
union, 9 patients (9%) had fibrous union without escape, greater trochanter on the femur and approaches the joint
and 4 patients (4.8%) had nonunion and trochanteric anteriorly. The technique has demonstrated union rates
comparable to those of traditional ETOs, with a low rate are dissected free of surrounding tissue. Vessel loops are
of dislocation postoperatively.37,38 placed around the iliac artery and vein and brought out
ETOs have been shown to be useful in a variety of clin- through the wound. Revision THA then proceeds in the
ical settings. In a retrospective review of 34 patients with usual fashion through a standard exposure. If hemorrhage
Vancouver B2 or B3 periprosthetic fractures managed is encountered, bleeding can be rapidly controlled by
with a modified ETO, all patients experienced healing tensioning the abdominal vessel loops, with subsequent
at a mean follow-up of 57 months.39 One patient experi- reexposure of the retroperitoneal approach for definitive
enced a postoperative dislocation, and two patients had control.
subsidence of the femoral stem that required subsequent
revision. Harris hip scores demonstrated that 23 patients
had an excellent result, 7 had a good result, and 4 had a Bearing Surfaces
poor result. Similarly, in the setting of periprosthetic in- Metal on Cross-Linked Polyethylene
fection, safe use of an ETO as part of a two-stage revision William Jiranek, MD, Tiffany Feltman, DO
for infection has been reported. Postoperative outcome When metal on highly cross-linked polyethylene (XLPE)
scores, ETO union rate, time to healing of the ETO, stem is compared with metal on conventional polyethylene,
stability, and complication rates have been shown to be investigators agree that wear and wear-related compli-
similar to noninfected revision cases.40 Finally, in a review cations such as osteolysis and loosening dramatically
of the mid- to long-term results of 18 cases of femoral decrease. Two RCTs using radiographic stereometric
impaction allograft revision that required an ETO at analysis compared XLPE and conventional polyethylene
the time of surgery, all patients were clinically healed at in cemented cups and noncemented cups and showed sig-
a mean of 6 months and had a significant improvement nificant reductions in wear at 5 years with XLPE.42 After
in clinical scores.41 No ETO nonunions were observed. a steady state was achieved, no further penetration in the
Although most revision arthroplasty procedures can XLPE occurred; however, penetration was 0.057 mm/y
be completed using standard soft-tissue exposures com- for conventional polyethylene. The RCTs showed that the
bined with one of the trochanteric osteotomies outlined XLPE reached a steady state after 1 to 2 years, in which
previously, obtaining wide exposure of the acetabulum the wear rate decreased to greater than 95% of the wear
and the pelvic columns is occasionally necessary. This rates for conventional polyethylene.
exposure may be required in cases of certain tumor resec- These wear reductions are associated with improve-
tions or when massive acetabular allografts are required. ments in clinical survival. In 2013, the Swedish Hip
The ilioinguinal, extended iliofemoral, and triradiate ap- Arthroplasty Register43 reported the following: “Unlike
proaches are potential options that provide increased previous years, when the observation time has increased,
access to the anterior and/or posterior acetabular col- a trend toward reduced number of cup/liner revisions
umns. These exposures are associated with risks, such as concerning the use of XLPE.” In 2004, the Australian
devitalization of bone fragments, heterotopic ossification, Arthroplasty Registry44 stated, “the lower revision rate of
or severe abductor muscle function, and are rarely used cross-linked polyethylene compared to non cross-linked
in revision THA. polyethylene is becoming increasingly apparent as time
The retroperitoneal approach is used in patients who progresses.”
are at risk of injury to the pelvic visceral and neurovas- Multiple studies have shown that liner thickness does
cular structures. This approach is most commonly used not affect the wear rate of XLPE. Larger femoral heads,
when cement and/or acetabular components have migrat- which decrease dislocation rates, require thinner poly-
ed medially. In these cases, removal from a standard ap- ethylene liners. A recent in vitro study examined the ef-
proach on the outer side of the pelvis could result in injury fect of decreasing the size of 36-mm XLPE liners from
to the external iliac vessels, resulting in life-threatening 6 mm to 3 mm and showed no increase in the wear rate
blood loss. Therefore, when severe medial component among different liner thicknesses.45 It also showed no
3: Hip
migration has occurred, surgeons should consider ad- differences between a 28-mm and a 36-mm femoral head
vanced imaging, such as CT angiography, to evaluate the in corresponding liners, which has given surgeons confi-
proximity of the visceral and neurovascular structures. dence in using larger femoral heads as a way to decrease
If imaging demonstrates that the structures are at risk, dislocation rates.
revision should be undertaken in a combined fashion Another problem with liner thickness has been changes
with a vascular surgeon performing the retroperitoneal in material properties created by cross-linking poly-
portion of the procedure. The patient first undergoes a ethylene, which could result in a catastrophic failure
retroperitoneal incision, and the iliac artery and vein such as fracture. The incidence has been quite low, but
Section 3: Hip
one report examined a series of retrieved liners that frac- a metal on cross-linked bearing couple, and tolerance of
tured.46 The takeaway points were as follows: material malposition of metal-on-polyethylene bearings suggest
failure has not been an issue except in cups that were that this bearing couple should be the predominant bear-
more vertically oriented and when the rim thickness at ing couple for THA in 2016.42,45,46,48,50,51
the locking mechanism was less than 4 mm.
Theoretical worries of increased femoral head pene- Antioxidant Cross-Linked Polyethylene
tration in highly cross-linked liners have not been sub- Orhun K. Muratoglu, PhD; Ebru Oral, PhD
stantiated by clinical studies. One study examined the Ultra-high–molecular-weight polyethylene (UHMWPE)
penetration rate at a minimum follow-up of 6 years for is the bearing surface of choice for total joint implants.
both 28- and 32-mm femoral head sizes.47 No correla- Radiation cross-linking has been an important advance
tion of the magnitude of penetration and head size and that has increased wear resistance and decreased the rate
no evidence of loosening and osteolysis were found. A of osteolysis. First-generation cross-linked UHMWPEs
multicenter study (eight centers) reviewed 768 patients used annealing or melting after irradiation to improve ox-
who underwent primary THA with femoral head sizes idation resistance. Melting effectively eliminated detect-
ranging from 26 mm to 36 mm.48 No differences were able residual free radicals but also decreased crystallinity,
found with the 28- and 32-mm heads; however, linear resulting in some loss of fatigue strength of the material.
and volumetric wear increased in patients in the 36-mm Annealing resulted in partial elimination of free radicals
femoral head group in one data analysis but not in two and, thus, some oxidation potential, but annealing had
other data analyses. This study could not make conclu- better retention of fatigue strength. More recently, antiox-
sions about larger femoral head penetration because the idant stabilization of radiation cross-linked U HMWPEs
differences were small, and the wear rate was still below eliminated the need for melting after irradiation for im-
the accepted threshold for those producing periprosthetic proved oxidation resistance, better retaining the mechan-
osteolysis. When this study is compared with historical ical properties. The addition of antioxidants, such as
controls of conventional polyethylene, the incidence of vitamin E or pentaerythritol tetrakis (3-[3,5-di tertiary
osteolysis has dramatically decreased. butyl-4-hydroxyphenyl] propionate) (PBHP), substantial-
The most commonly used metal femoral head is a mod- ly improved oxidation resistance and the strength of the
ular head constructed from a cobalt-chromium (CoCr) UHMWPEs compared with radiation cross-linked and
alloy. Because most noncemented femoral components are thermally treated, first-generation XLPEs.52 The presence
constructed from a titanium alloy, a situation of mixed of these antioxidants does not alter the wear resistance
metals is created and increases the risk of corrosion at of the base highly cross-linked material under either ad-
the modular junction. Several reports in the past 5 years hesive or abrasive conditions. In addition, in vitro and
have been published on corrosion at the trunnion, in- in vivo animal data support lowered functional biologic
creased metal wear at the trunnion, and adverse local activity of particulate debris containing antioxidants in
tissue reactions to products emanating from the trunnion. terms of their propensity to cause osteolysis.53,54 Vitamin
Although reports of severe reactions have led many to E-stabilized highly cross-linked UHMWPEs have been in
advocate a wholesale change to ceramic femoral heads clinical use in hips since 2007 and in knees since 2008.
in all patients, it appears from the national registries that Clinical use of PBHP stabilization started in 2011, but
the prevalence of trunnion reactions related to modular only in total knee applications.
CoCr femoral heads resulting in failure is relatively low. Certain challenges arise when adding antioxidants to
The Australian registry reported no significant differenc- UHMWPE, which is meant to be cross-linked for im-
es in revision rates between ceramic femoral heads on proved wear resistance. Antioxidants scavenge free radi-
cross-linked polyethylene articulations compared with cals and, hence, can lower the cross-linking efficiency of
metal on cross-linked polyethylene articulations at 10- UHMWPE during irradiation. The two primary methods
year follow-up.49 The significantly higher cost of ceramic of antioxidant incorporation into UHMWPE are as fol-
3: Hip
femoral heads has led some investigators to conclude that lows: radiation cross-linking of previously blended and
they are not cost effective for most patients. consolidated UHMWPE and antioxidant, and diffusion
Most observers have concluded that XLPE acetabular of the antioxidant into previously radiation cross-linked
liners are the most tolerant of component malpositioning, UHMWPE.
which several studies have suggested occurs in a higher In the method of blending followed by irradiation, the
percentage of cases than might be expected (more than antioxidant concentration and the radiation dose must
50% in some studies). The improved wear characteristics be optimized because it is necessary to use higher-dose
of cross-linked polyethylene, the comparative low cost of irradiation in the presence of antioxidants than in virgin
UHMWPE to obtain the preferred cross-link density or of polyethylene in the presence of cyclic loading.58 Ex-
wear rate. The concentration of vitamin E typically ranges planted tibial knee inserts show higher oxidation levels
between 0.1% and 0.3%. At the lower end of concen- below loaded articular surfaces compared with parts of
tration (0.1%), 120 to 130 kGy of radiation is needed the components that are not typically loaded, for exam-
to achieve a cross-link density and wear rate equivalent ple, around the eminence.59,60 Surgically explanted poly-
to that of 100 kGy–irradiated and melted polyethylene ethylene components typically show a variety of absorbed
without any antioxidant. At higher antioxidant concen- lipids, namely squalene (a precursor of cholesterol) and
trations, the radiation dose level needs to be higher to esters of cholesterol.61 Primarily, squalene and other ab-
compensate for the loss of cross-linking efficiency of sorbed lipids act as prooxidants. Artificial aging exper-
the polymer. Surprisingly, at elevated temperatures, the iments in the presence of such lipids have shown higher
cross-linking efficiency of polyethylene increases, even rates of oxidation in polyethylene.62 The incorporation of
in the presence of vitamin E. Some clinically available an antioxidant before or after radiation cross-linking can
formulations contain vitamin E concentrations greater effectively minimize or even eliminate oxidation caused
than 0.2% and are electron beam cross-linked at elevat- by preexisting residual free radicals, cyclic loading, and/
ed temperatures, providing high cross-link density and or absorbed lipids. Antioxidant stabilized XLPEs are now
high oxidation resistance with high potency of residual commonly used in both total knee and THA applications.
vitamin E. The other antioxidant, PBHP, is used only for First-generation highly cross-linked UHMWPE for-
one total knee arthroplasty application. This formulation mulations are showing excellent outcomes during the
contains 0.75% of antioxidant, and the final blended and first 15 years of use in THA.63 Data from the Australian
consolidated material is irradiated to 75 kGy. With both Arthroplasty Registry have already demonstrated signif-
types of antioxidants, the radiation cross-linking step also icant benefits in reducing the revision rate in total knee
allows for chemical grafting of the antioxidant molecules arthroplasty caused by lysis and loosening with the use
to the polyethylene, reducing the extent of antioxidant of XLPE tibial inserts. Antioxidant stabilization can help
elution from components during in vivo use. continue these excellent outcomes beyond the second
Another antioxidant incorporation approach is to ir- decade of use in both THA and total knee arthroplasty,
radiate virgin UHMWPE and subsequently diffuse the largely by minimizing any potential degradation of prop-
antioxidant into the polymer. The diffusion method is erties caused by long-term oxidation and improving the
exclusively used with vitamin E and allows larger concen- mechanical properties.49,53,64,65
trations of antioxidant incorporation into an previously
irradiated polyethylene. The amount of incorporated vi- Ceramic on Cross-Linked Polyethylene
tamin E is limited only by the saturation limit of the anti- Gregory Deirmengian, MD
oxidant in the cross-linked polymer at body temperature, The combination of ceramic and UHMWPE provides
which is approximately 0.7 wt% for vitamin E.55 Typ- many advantages as a bearing choice in THA. Surgeons
ically, irradiated polyethylene preforms are soaked in prefer the bearing combination that minimizes the risk of
vitamin E at an elevated temperature for a prescribed complications, optimizes implant longevity, and achieves
time followed by homogenization in an inert gas oven cost effectiveness. Previously, ceramic-on-ceramic and
below the melting point of the polymer. The preforms are metal-on-metal bearings became popular as a means to
then machined into final components. Homogenization is address the limited implant longevity associated with
necessary to have a uniform distribution of diffused an- older-generation polyethylene liners.
tioxidant in the entire component. Terminal sterilization Both ceramic-on-ceramic and metal-on-metal
is by gamma irradiation to allow chemical grafting of the bearings promise superior wear properties compared
antioxidant to the polyethylene, minimizing the elution with older-generation polyethylene liners, and large-
of vitamin E during in vivo use. THA implants manufac- head metal-on-metal bearings provide the additional
tured from 100-kGy–irradiated, vitamin-E–diffused, and advantage of increased excursion distance and range
3: Hip
terminally gamma-sterilized UHMWPEs have been clin- of motion to impingement. Yet, metal-on-metal and
ically used since 2007 and have no detectable wear.56,57 c eramic-on-ceramic bearings introduce the risk of
Recently, researchers realized that polyethylene can unique complications that may result in premature
oxidize in vivo, through not only preexisting residual failure and the need for revision surgery. Ceramic-
free radicals from gamma sterilization or radiation cross- on-ceramic bearings are associated with the risk of
linking but also mechanisms accelerated by cyclic load- device-generated squeaking and ball and liner fracture.
ing and/or absorbed lipids. Laboratory evidence shows Metal-on-metal bearings are associated with the risk
increased rates of oxidation with different formulations of metallosis and associated lymphocyte-driven adverse
Section 3: Hip
soft-tissue reactions. Because of these unique risks and Squeaking

the advent of UHMWPE as an alternative bearing with Squeaking, a well-documented complication of ceramic-
improved wear properties that have challenged those on-ceramic articulation, deters surgeons from using such
with metal-on-metal and ceramic-on-ceramic hips, sur- bearings in primary and revision THA, despite its su-
geons have decreased their use of metal-on-metal and perior wear characteristics. A recent meta-analysis that
ceramic-on-ceramic bearings. included data acquired from the Australian National Joint
When using UHMWPE acetabular bearings, options Registry reported that the rate of squeaking was 4.2%,
for the femoral head bearing couple include CoCr, ce- and the rate of revision for squeaking was 0.2%.71 Over-
ramic, and ceramicized metal. Historically, CoCr has all, in studies that used specific questionnaires to assess
been the most commonly used bearing couple with poly- squeaking, the rate of squeaking was 4.5%, whereas in
ethylene, yet the use of ceramic or ceramicized metal for studies that captured only self-reported squeaking, the
the femoral head has been argued to decrease the rate of rate was 1.2%. Thus, it is legitimate to conclude that the
polyethylene wear.66 More recently, the phenomenon of overall rate of squeaking is underestimated in studies that
so-called trunnionosis, most commonly caused by fret- did not use a specific questionnaire.
ting and corrosion between a CoCr femoral head and the Specific patient evaluation is required to assess for
femoral component trunnion, has been recognized as a squeaking. At first, a differentiation should be made be-
mode of catastrophic failure in metal-on-polyethylene tween squeaking that occurs in every step (pathologic
hips. The process may not be exceedingly rare, and it squeaking) and squeaking that happens only with deep
is unclear if trunnionosis was previously unrecognized hip flexion (benign squeaking). Pathologic squeaking
or if it is the result of more recent changes in implant was shown to be associated with anterosuperior edge
design.67-69 Although the epidemiology and tribology of loading secondary to excessive inclination and antever-
the process are becoming better understood with time, sion of the acetabular component; this type of squeaking
the use of a ceramic femoral head may help avoid this has a social and psychological effect on patients, such
mechanism of catastrophic failure. as embarrassment, harassment, and anxiety, and such
Certainly, the use of a ceramic femoral head has po- patients commonly seek further surgical intervention.
tential disadvantages. With any ceramic component, in- Benign squeaking is frequently associated with posterior
cluding the ceramic on polyethylene combination, the risk edge loading and generally can be improved with patient
of ceramic fracture exists. To address the risk of ceramic education by avoiding specific positions and reassuring
fracture associated with older generations of ceramic, the patient.72,73 Most instances of squeaking detected with
mixed oxide ceramic materials with increased fracture a questionnaire will be benign.
strength were developed. The fracture of such modern It is important to assess squeaking with CT analy-
ceramic femoral heads is extremely rare.70 In addition, sis to evaluate component positioning and identify any
ceramic femoral heads typically are associated with an possible ceramic fractures. Other noises associated with
increased cost compared with the CoCr alternative. Al- ceramic-on-ceramic bearings include clicks, pops, clunks,
though these disadvantages should certainly be consid- grinding, and gratings; however, the nature of these noises
ered in deciding on the optimal bearing combination for is yet to be fully understood. Because squeaking is an
patients, ceramic on UHMWPE may be the best choice ongoing issue that can result in significant patient con-
at this time, weighing the advantages and disadvantages cerns, open discussion regarding bearing selection with
of all the bearing combinations. the patient is advocated before THA is performed; this
also may reduce litigation against surgeons if bearing-
Ceramic-on-Ceramic Bearings related complications occur.
Yadin D. Levy, MD; William L. Walter, MBBS, PhD Squeaking in ceramic-on-ceramic bearings can be
Ceramic-on-ceramic bearings are designed to reduce both caused by the physics of the fluid film lubrication. If the
wear and osteolysis that are traditionally associated with fluid film is lost at the bearing interface, an increase in
3: Hip
ceramic-on-polyethylene bearings. The trade-off of the surface friction will occur. Loss of fluid film lubrication
superior tribological properties of ceramic-on-ceramic most commonly occurs with edge loading, which may
bearings, such as low wear and low soft-tissue reactions, be a result of either component malpositioning or a well-
is their association with noise generation and fracture. positioned component at the extremes of motion. Loss
Squeaking, wear and the biologic response to the ceramic of fluid film also can result from ceramic debris particles
debris, ceramic fractures, and the results and debate with or damage to the bearing surface. The combination of
respect to large-diameter (greater than 36 mm) ceramic- higher surface friction and a metallic stem that can reso-
on-ceramic bearings are related issues. nate can produce an audible sound. Therefore, inherent
stem resonance, which is related to stem design, is an Fracture

important variable. A more flexible stem in the sagittal Ceramic fracture is linked to the internal brittleness of
plane will resonate more and will allow vibration in the ceramics. With the evolution of ceramic manufacturing
audible range. and processing, stronger crack resistance materials have
Although no clear evidence shows that squeaking re- been produced, which has further improved the already
duces the overall survival rate of THA, some suggestions low rate of ceramic fractures. Overall, it is estimated
associate squeaking with implant wear. A retrieval study that the rate of fracture for Delta ceramic heads and lin-
evaluating components revised because of squeaking ers is 0.003% and 0.03%, respectively.79 A comparison
showed a higher rate of wear among patients who un- study between the fracture rates of third-generation and
derwent revision because of squeaking relative to patients fourth-generation ceramic-on-ceramic bearings esti-
who underwent revision because of other issues.74 Another mated that the rate of head fracture has been reduced,
study determined that the rate of volumetric wear was but the rate of cup liner fracture did not change. Con-
significantly higher in ceramic-on-ceramic THA retriev- tributing factors to head fractures are the cleanliness
als, demonstrating anterosuperior edge loading compared of the taper, impaction of the head onto the taper, and
with retrievals with posterior edge loading.75 It might be femoral head size and length. A taper covered with
that excessive bearing wear results in implant damage and debris and blood and/or insufficient impaction and in-
noise generation, which is the first sign received from the adequate bore centralization can result in uneven load
hip joint, indicating that the fine balance between compo- distribution on the head, which may facilitate fracture
nent positioning and joint mechanics, biomaterials, and formation. Smaller sizes and shorter heads are observed
the periarticular tissue is malfunctioning. A link between to have a higher rate of fractures.80 Hence, 28-mm heads
noise and catastrophic implant failure such as a ceramic have a relative higher fracture rate than 32- and 36-mm
fracture has been suggested by others.76 heads. This higher rate is caused by a reduced distance
between the corner of the bore and the circumferential
Wear surface of the head, which can facilitate fracture for-
Ceramic-on-ceramic bearings have the lowest rate of mation resulting from the ease of crack propagation.
wear among all the bearings available. The tissue re- Overall, a 36-mm head can prevent impingement be-
action to ceramic debris differs from the reaction to tween the cup rim and the neck of the stem, reducing
metal or polyethylene debris, especially with respect to metallosis and the rate of microseparation and ceramic
the destruction of surrounding soft tissues (metal) and liner chipping or fracture.
bone (osteolysis). This result was derived from an eval- The bearing to be used in revision surgery for fractured
uation of synovium and periarticular tissue obtained ceramic components is still being debated; however, it is
from revised third-generation ceramic-on-ceramic ar- generally agreed that a revision to a ceramic-on-ceramic
ticulations.77 The etiology for revision varied among or a ceramic-on- polyethylene bearing is acceptable.81 A
patients, but none had a revision because of osteolysis. conversion to a metal-on-polyethylene bearing is not rec-
The tissue evaluation demonstrated small numbers of ommended because of the scratching effect of the ceramic
macrophages predominantly in the fibrous connective particles on the metal femoral head, potentially resulting
tissue, rare multinucleated giant cells, and minimal in excessive wear of the head and the polyethylene.
necrosis. Interestingly, when a large amount of another
type of debris (titanium) was found, association could Large-Diameter Bearings
be documented with impingement between the neck Understanding of the clinical implications of trunniono-
of the stem and the cup rim. These findings further sis and the interaction of the head taper junction has
stress the importance of component positioning when increased. Trunnionosis is a concern when metal heads
ceramic-on-ceramic bearings are used. Overall, the se- are used; however, it seems that trunnionosis is not an
verity of synovial changes did not correlate with either issue when ceramic heads are used. The importance of
3: Hip
the degree of volumetric wear or the revision diagnosis. trunnions regarding ceramic fractures results from main-
Therefore, the inflammatory changes in the pseudo- taining equilateral force distributions from the trunnion
capsule of ceramic-on-ceramic hips may be clinically to the ceramic head, which provides cylindrical force
insignificant.77 Other authors have suggested that the distribution and eliminates point stress occurrence. Thus,
lack of periprosthetic foreign body reaction, together in revision surgery when the stem is retained, careful in-
with the dense fibrous tissue observed during ceramic- spection of any damage to the trunnion is critical. Placing
on-ceramic revision surgery, has a role in joint stabili- a ceramic head on a visibly damaged trunnion may fa-
zation and dislocation prevention.78 cilitate ceramic head fracture. Therefore, when retaining
Section 3: Hip
a femoral stem, it is recommended that a metal-sleeved OxZr is manufactured from the element zirconium and
ceramic head be used. a small amount of niobium. This zirconium alloy is then
Large-diameter monoblock (greater than 36 mm) heated in air, causing the zirconium alloy metal substrate
fourth-generation ceramic-on-ceramic articulations were to transition into a ceramic zirconium oxide outer surface
introduced at the end of 2008. These monoblock cups can with a thickness of approximately 5 µm. In essence, the
accommodate larger femoral heads within small acetabu- surface is transformed into a ceramic oxide layer and has
lae. A larger head size can potentially improve the head- all the material properties inherent to ceramic, including
neck ratio, increase the jump distance, and reduce the more scratch resistance, a smoother surface, and increased
overall impingement and dislocation rate. Currently, the hardness and wettability compared with CoCr. Prior to
literature is limited to short-term clinical follow-up that clinical release, extensive in vitro tests demonstrated that
indicates good clinical functional outcomes.82 However, the material is scratch resistant and demonstrates sig-
the overall rate of squeaking is high, with up to 21.7% nificantly decreased polyethylene wear, especially when
seen in a single series. A possible explanation is related articulating against XLPE.85
to the effect of the large femoral head on the resonant The theoretical advantages of OxZr as a bearing sur-
properties of the metallic stem. The larger head has a face for THA are numerous. Because the surface is a
greater mass and a greater radius, thus producing a larger ceramic oxide, it has the advantage of improved wear
moment. Both factors act to lower the resonant frequency properties against polyethylene related to its resistance to
of the stem-head combination, thereby increasing the scratching and increased surface hardness, smoothness,
propensity to squeak. and wettability. Unlike a ceramic head, the material is
A recent concern with the use of large femoral head composed of a zirconium alloy metal substrate, so frac-
sizes is related to the increased forces acting on the head– ture of a OxZr femoral head is not possible. In addition,
Morse taper junction. The evolution of taper design has OxZr femoral heads maintain all their modularity (that is,
reduced both the height and the width of the trunnion, all sizes and lengths) because they are not limited by any
resulting in shorter, narrower trunnions. The rationale mechanical properties. Furthermore, the ceramic oxide
for these design changes was to reduce impingement by layer is a stable monoclinic phase and cannot undergo
increasing the head-neck ratio. However, the excessive phase transformation, which has been described in both
forces generated by the large femoral head on the trun- previous zirconium ceramic and current alumina ceramic
nion, especially in suboptimal lubrication conditions, femoral heads. In the setting of ongoing concerns about
can amplify the forces acting at the taper junction. The trunnionosis, a further potential advantage of OxZr fem-
implant bone interface also will experience high force oral heads may relate to their relatively high resistance
transmission; however, the clinical implications of these to corrosion and fretting (compared with CoCr), thus
forces are not clearly understood. The use of a prefab- potentially decreasing the likelihood of trunnion-related
ricated cup liner coupling in young patients with small problems. Because OxZr contains no nickel, it is well
acetabulae (less than 48 mm) may allow the use of 32- to suited for use with patients who have a suspected metal
36-mm heads, optimizing the head-neck ratio and reduc- allergy.
ing the dislocation rate. To reduce the forces at the taper The main disadvantage of OxZr (as with ceramic
junction, stem resonance, and the forces transmitted to heads) relates to its increased cost compared with CoCr.
the bone stem interface, a relatively long and stiff stem Also, OxZr it is currently manufactured by only one
with a large taper can be used.71,74,77,79,83 company and therefore should be used only with that
manufacturer’s femoral stem systems to ensure taper
Ceramicized Metal Heads compatibility. Although this material has demonstrated
Richard W. McCalden, MD, MPhil (Edin), FRCS(C) scratch resistance in vitro and in vivo under normal joint
Strong clinical evidence now shows that the use of XLPE conditions, the oxide surface can be damaged if subjected
has proven advantageous compared with conventional to abnormal contact against other metal surfaces (such
3: Hip
polyethylene and therefore represents the gold standard as a titanium acetabular shell), especially in the setting
for polyethylene bearings.84 The surgeon now has several of a joint dislocation. Consequently, similar to ceramic
options for femoral head material, namely, CoCr, alumina femoral heads, care must be taken when reducing the
ceramic, or ceramicized metal. Ceramicized metal, also femoral head at the time of the index procedure to avoid
known as oxidized zirconium (OxZr), was first used in damage to the OxZr head or metal transfer to its surface.
the nuclear industry, after which it was adapted for or- Overall, the reported clinical results of this bearing
thopaedic implant use and released for clinical application couple (that is, OxZr against XLPE) have been excel-
in THA in approximately 2003. lent with more than a decade of use. In particular, the
Australian Joint Registry continues to report the lowest of younger patients with osteoarthritis. Metal-on-metal
revision rate (3.3% at 11 years) with this bearing couple bearings exist as both stemmed THA and hip resurfacing
compared with all other bearing options.1 However, the devices. The benefits of metal-on-metal bearings include
registry points out that this result should be interpreted lower volumetric wear rates compared with conventional
with caution because this bearing is associated with a metal- on-polyethylene bearings, greater implant stabil-
single manufacturer and, therefore, has a small number ity because of the larger femoral head sizes, and greater
of femoral stem and acetabular component combinations. femoral bone conservation in hip resurfacing.
This situation may have a confounding effect on the out- Despite the resurgence of metal-on-metal bearings
come, making it unclear if the lower rate of revision is an during the past 20 years, their use in stemmed THA is
effect of the bearing surface or reflects the limited combi- not currently recommended because of poor outcomes
nation of femoral and acetabular implants. Nevertheless, that have been reported in the literature. Many nation-
this combination of bearing has performed extremely well al joint registries have reported that the failure rates of
and has demonstrated excellent clinical results since its stemmed THA with metal-on-metal bearings are sig-
clinical release. nificantly higher than in stemmed THA with alternative
With respect to its measured wear performance in vivo, bearings. Furthermore, the use of large metal-on-metal
mixed evidence supports the improved wear performance bearings in THA has resulted in reports of soft-tissue
of OxZr femoral heads compared with CoCr femoral reactions that result in implant failure and associated
heads against XLPE. Several recent publications have complications. Therefore, hip resurfacing is the only vi-
demonstrated no significant difference in femoral head able metal-on-metal bearing option. Although metal ion
penetration, both in RCT study designs, comparing CoCr complications associated with metal-on-metal bearings
heads to OxZr heads against XLPE.2,4 However, other for THA also have occurred in metal-on-metal hip re-
studies have demonstrated either a trend or a statistically surfacing, numerous reports have been published of suc-
significant decrease in wear associated with the use of cessful outcomes of metal-on-metal hip resurfacing in a
OxZr against XLPE.5,6 Perhaps most important, every select patient population. The most compelling evidence
study has clearly demonstrated that the use of XLPE, indicating that metal-on-metal bearings should be aban-
rather than conventional polyethylene, has the greatest doned for THA comes from the National Joint Registry
effect on wear reduction when compared with the femoral for England, Wales.91 The data included 402,051 THAs
head material. Even with sophisticated imaging tech- and 31,171 stemmed metal-on-metal THAs implanted
niques such as radiostereometric analysis, it will be diffi- between 2003 and 2011. Overall, stemmed metal-on-met-
cult to demonstrate a clear in vivo difference with respect al articulations had a 5-year revision rate of 6.2% (95%
to femoral head material (even if one does exist) because confidence interval = 5.8% to 6.6%). Large head sizes and
the steady-state wear is very low with XLPE, arguably the use of these prostheses in younger women were iden-
well below the resolution of the imaging technique. tified as risk factors that were associated with the highest
The use of a OxZr femoral head against an XLPE liner rate of early revision surgery. The most common reasons
is an excellent choice for an alternate bearing in a young, for the revision of stemmed metal-on-metal bearings for
active patient who requires THA. This unique material THA in both men and women were aseptic loosening and
combines the beneficial features of a metal and a ceramic. pain. It is now known that a higher than normal release
In addition, it is a good choice for patients in whom a of metal ions occurs with metal-on-metal bearings. The
metal allergy is suspected. Furthermore, the corrosion- high metal ion release from stemmed metal-on-metal
and fretting-resistant properties of this material, com- implants can be partially explained by debris generated
pared with CoCr, may make it beneficial with respect to from nonarticular sources, such as implant impingement
ameliorating the potential for long-term trunnion-related or taper micromotion that is made worse by the use of
problems. The outstanding results following a decade of large-diameter femoral heads.
clinical use support its ongoing role as a viable bearing The current literature is varied with respect to reported
3: Hip
option for THA.86-90 outcomes of metal-on-metal hip resurfacing. Outcomes

for metal-on-metal hip resurfacing are influenced by
Metal-on-Metal Bearings several factors, including implant positioning, implant
Emil Schemitsch, MD, FRCS(C) design, and specific patient characteristics. Evidence has
The ideal bearing surface for young, active patients under- shown that outcomes equal to or better than THA can
going THA remains a point of contention. During the past be achieved in select patient populations. The ideal hip
two decades, metal-on-metal bearings were considered an resurfacing patient is a male younger than 55 years who
option when endeavoring to meet the high expectations has advanced primary osteoarthritis and a femoral head
Section 3: Hip
that is 50 mm or larger in diameter. Equally, the ideal Patients who are symptomatic and have had a metal-
implant positioning should avoid vertical and excessively on-metal THA should undergo a thorough clinical his-
anteverted or retroverted cup placement and varus femo- tory, a detailed physical examination, and radiographic
ral component alignment. Using data from the National and laboratory tests to rule out causes such as aseptic
Joint Registry, the results for 31,932 hip resurfacing loosening and infection as a source of pain. These patients
procedures were studied, and it was found that implant should then be considered for revision THA. Patients
survival in hip resurfacing depends on two factors: the who are asymptomatic and considered a low risk (male,
size of the femoral head and the sex of the patient.92 The ideal implant placement, and implant design) should be
survivorship of the Birmingham Hip Resurfacing com- followed up annually. Patients considered to be at moder-
ponent outperformed the other implant designs in male ate risk (whether they are symptomatic or asymptomatic)
patients with large femoral heads and had survivorship should undergo serum metal ion assessment and ultraso-
comparable to noncemented ceramic-on-ceramic and ce- nography to identify soft-tissue reactions.96
mented metal-on-polyethylene THA. These findings align
with other published literature on hip resurfacing in this
patient population. Summary
In a systematic review comparing hip resurfacing with With the various surgical approaches to the hip, classi-
THA, no differences were found in the revision and re- fication of these approaches and attention to changes or
operation rates between the two procedures when the evolution in techniques is important for the best treatment
discontinued metal-on-metal devices were removed from outcome. The surgeon has several choices for bearing
the analysis.93 Also, the Canadian Arthroplasty Society surfaces and should be knowledgeable about issues that
conducted a multicenter study of hip resurfacing and can lead to wear-related complications.
found that the incidence of revisions as a result of high
metal ions in their cohort was very low (9 of 2773 hips, or
Key Study Points
0.32%).94 Ultimately, the Canadian Arthroplasty Society
concluded that the 5-year survivorship results justified its • It is anticipated that an increasing number of pa-
continued use in select patients. tients who have undergone THA using the direct
The long-term biologic effects of metal ions released anterior approach will likely require revision
from metal-on-metal prostheses are not yet fully under- surgery.
stood. Theoretically, increased metal ions are associated • Perioperative patient management (including mul-
with risks for carcinogenesis, delayed hypersensitivity timodal pain management, advanced blood man-
reactions, and organ toxicity. Furthermore, the presence agement, and rapid rehabilitation protocols) has
of metal ions in periprosthetic tissue can induce a spec- improved the patient experience after THA.
trum of necrotic and inflammatory responses, includ- • Because of its improved wear characteristics, low
ing pseudotumors. Timely and accurate diagnosis of a cost of metal on a cross-linked bearing couple, and
pseudotumor is important in limiting soft-tissue damage. tolerance of malposition of metal-on-polyethylene
Both ultrasonography and MRI with metal artifact re- bearings, a metal on cross-linked polyethylene
duction sequences are identified as suitable modalities bearing is potentially the most suitable bearing
for pseudotumor detection. However, the choice of the couple for THA.
monitoring modality is significant because of cost impli-
cations. Therefore, a prospective study compared ultraso-
nography and MRI for the detection of pseudotumors in
asymptomatic metal-on-metal THAs.95 Ultrasonography Annotated References
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3: Hip
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In this retrospective review, 83 cases underwent a modified
3: Hip
trochanteric sliding osteotomy: 70 patients had bony union 40. Lim S-J, Moon Y-W, Park Y-S: Is extended trochanteric
(84.4%), 9 had fibrous union without escape (9%), and osteotomy safe for use in 2-stage revision of periprosthet-
4 (4.8%) had nonunion and trochanteric escape. There ic hip infection? J Arthroplasty 2011;26(7):1067-1071.
were four postoperative dislocations (4.8%), all in patients Medline DOI
with bony union of the osteotomy. In this retrospective comparison, 23 patients underwent
ETO in the revision of infected hip arthroplasty and 46 pa-
31. Lakstein D, Kosashvili Y, Backstein D, Safir O, Gross tients underwent ETO in the revision of noninfected hip
AE: Trochanteric slide osteotomy on previously oste- arthroplasty. Postoperative outcome scores, ETO union
otomized greater trochanters. Clin Orthop Relat Res rate, time to healing of ETO, stem stability, and compli-
2010;468(6):1630-1634. Medline DOI cation were similar between cases.
41. Charity J, Tsiridis E, Gusmão D, Bauze A, Timperley J, 52. Oral E, Neils AL, Wannomae KK, Muratoglu OK: Nov-
Gie G: Extended trochanteric osteotomy followed by ce- el active stabilization technology in highly cross-linked
mented impaction allografting in revision hip arthroplasty. UHMWPEs for superior stability. Radiat Phys Chem
J Arthroplasty 2013;28(1):154-160. Medline DOI 2014;105:6-11. DOI
In this retrospective review, the mid- to long-term results
of 18 cases of femoral impaction allografting revision that 53. Bichara DA, Malchau E, Sillesen NH, Cakmak S, Niel-
required ETO at the time of surgery were reported. All sen GP, Muratoglu OK: Vitamin E-diffused highly
patients experienced clinical healing at a mean of 6 months cross-linked UHMWPE particles induce less osteolysis
with a significant improvement in their clinical scores. No compared to highly cross-linked virgin UHMWPE par-
ETO nonunions were observed. ticles in vivo. J Arthroplasty 2014;29(9 suppl):232-237.
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42. Digas G, Kärrholm J, Thanner J, Herberts P: 5-year ex-
perience of highly cross-linked polyethylene in cemented 54. Bladen CL, Teramura S, Russell SL: Analysis of wear, wear
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43. Swedish Hip Arthroplasty Register: Annual report 2014.
Available at http://www.shpr.se/en/. Accessed July 13, 55. Rowell SL, Oral E, Muratoglu OK: Comparative oxidative
2016. stability of α-tocopherol blended and diffused UHMWPEs
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44. Australian Orthopaedic Association: National joint
replacement registry annual report 2014. Available at
https://aoanjrr.sahmri.com/documents/10180/172286/ 56. Lindalen E, Nordsletten L, Høvik Ø, Röhrl SM: E-vitamin
Annual%20Report%202014. Accessed July 13, 2016. infused highly cross-linked polyethylene: RSA results from
a randomised controlled trial using 32 mm and 36 mm
45. Shen FW, Lu Z, McKellop HA: Wear versus thickness and ceramic heads. Hip Int 2015;25(1):50-55. Medline DOI
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ular liners. Clin Orthop Relat Res 2011;469(2):395-404. 57. Sillesen NH, Greene ME, Nebergall AK, et al: Three Year
Medline DOI RSA Evaluation of Vitamin E Diffused Highly Cross-
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46. Tower SS, Currier JH, Currier BH, Lyford KA, Van Cit- plasty 2015;30(7):1260-1264. Medline DOI
ters DW, Mayor MB: Rim cracking of the cross-linked
longevity polyethylene acetabular liner after total hip ar- 58. Medel F, Kurtz S, MacDonald D, Pascual FJ, Puérto-
throplasty. J Bone Joint Surg Am 2007;89(10):2212-2217. las JA: Does cyclic stress play a role in highly cross-
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2015;473(3):1022-1029. Medline DOI
47. Bragdon CR, Kwon YM, Geller JA, et al: Minimum 6-year
followup of highly cross-linked polyethylene in THA. Clin 59. Reinitz SD, Currier BH, Levine RA, Van Citters DW:
Orthop Relat Res 2007;465:122-127. Medline Crosslink density, oxidation and chain scission in re-
trieved, highly cross-linked UHMWPE tibial bearings.
48. Bragdon CR, Doerner M, Martell J, Jarrett B, Palm H, Biomaterials 2014;35(15):4436-4440. Medline DOI
Malchau H; Multicenter Study Group: The 2012 John
Charnley Award: Clinical multicenter studies of the wear 60. Reinitz SD, Currier BH, Van Citters DW, Levine RA,
performance of highly crosslinked remelted polyethylene Collier JP: Oxidation and other property changes of re-
in THA. Clin Orthop Relat Res 2013;471(2):393-402. trieved sequentially annealed UHMWPE acetabular and
Medline DOI tibial bearings. J Biomed Mater Res B Appl Biomater
2015;103(3):578-586. Medline DOI
49. de Steiger RN, Muratoglu O, Lorimer M, Cuthbert AR,
Graves SE: Lower prosthesis-specific 10-year revision 61. Costa L, Bracco P, del Prever EB, Luda MP, Trossarelli L:
rate with crosslinked than with non-crosslinked poly- Analysis of products diffused into UHMWPE prosthetic
ethylene in primary total knee arthroplasty. Acta Orthop components in vivo. Biomaterials 2001;22(4):307-315.
2015;86(6):721-727. Medline DOI Medline DOI 3: Hip
50. Zhang L, Sawae Y, Yamaguchi T, Murakami T, Yang H: 62. Oral E, Ghali BW, Neils A, Muratoglu OK: A new
Effect of radiation dose on depth-dependent oxidation and mechanism of oxidation in ultrahigh molecular weight
wear of shelf-aged gamma-irradiated ultra-high molecular polyethylene caused by squalene absorption. J Biomed
weight polyethylene (UHMWPE). Tribol Int 2015;89: Mater Res B Appl Biomater 2012;100(3):742-751.
78-85. DOI Medline DOI
51. Cooper HJ, Della Valle CJ, Berger RA, et al: Corrosion 63. Kurtz SM, Gawel HA, Patel JD: History and systematic
at the head-neck taper as a cause for adverse local tissue review of wear and osteolysis outcomes for first-generation
reactions after total hip arthroplasty. J Bone Joint Surg highly crosslinked polyethylene. Clin Orthop Relat Res
Am 2012;94(18):1655-1661. Medline 2011;469(8):2262-2277. Medline DOI
Section 3: Hip
64. Bracco P, Oral E: Vitamin E-stabilized UHMWPE for 74. Walter WL, Kurtz SM, Esposito C, et al: Retrieval analysis
total joint implants: A review. Clin Orthop Relat Res of squeaking alumina ceramic-on-ceramic bearings. J Bone
2011;469(8):2286-2293. Medline DOI Joint Surg Br 2011;93(12):1597-1601. Medline DOI
This multicenter study analyzed the rates and wear pat-
65. Narayan VS: Spectroscopic and chromatographic terns of 12 alumina ceramic-on-ceramic components re-
quantification of an antioxidant-stabilized ultrahigh- trieved from squeaking THAs compared with 33 silent
molecular-weight polyethylene. Clin Orthop Relat Res hips (matched THA controls). All squeaking hips showed
2015;473(3):952-959. Medline DOI evidence of edge-loading wear. Volumetric wear analysis
demonstrated up to 45 times greater wear in the squeaking
66. Selvarajah E, Hooper G, Grabowski K, Frampton C, hips compared with the silent hips.
Woodfield TB, Inglis G: The rates of wear of X3 highly
cross-linked polyethylene at five years when coupled with 75. Esposito CI, Walter WL, Roques A, et al: Wear in alu-
a 36 mm diameter ceramic femoral head in young patients. mina-on-alumina ceramic total hip replacements: A re-
Bone Joint J 2015;97-B(11):1470-1474. Medline DOI trieval analysis of edge loading. J Bone Joint Surg Br
2012;94(7):901-907. Medline DOI
67. Tan SC, Teeter MG, Del Balso C, Howard JL, Lant-
ing BA: Effect of taper design on trunnionosis in metal 76. Abdel MP, Heyse TJ, Elpers ME, et al: Ceramic liner
on polyethylene total hip arthroplasty. J Arthroplasty fractures presenting as squeaking after primary total hip
2015;30(7):1269-1272. Medline DOI arthroplasty. J Bone Joint Surg Am 2014;96(1):27-31.
Medline DOI
68. Plummer DR, Berger RA, Paprosky WG, Sporer SM, Ja-
cobs JJ, Della Valle CJ: Diagnosis and management of 77. Esposito C, Maclean F, Campbell P, Walter WL, Walter
adverse local tissue reactions secondary to corrosion at WK, Bonar SF: Periprosthetic tissues from third generation
the head-neck junction in patients with metal on poly- alumina-on-alumina total hip arthroplasties. J Arthro-
ethylene bearings. J Arthroplasty 2016;31(1):264-268. plasty 2013;28(5):860-866. Medline DOI
Medline DOI
Histopathologic analysis performed on synovial-like
69. Del Balso C, Teeter MG, Tan SC, Lanting BA, Howard pseudocapsules collected from 21 patients with alumina
JL: Taperosis: Does head length affect fretting and corro- ceramic-on-ceramic THAs showed viable pseudocapsules
sion in total hip arthroplasty? Bone Joint J 2015;97-B(7): with few foreign body type giant cells and occasional
911-916. Medline DOI lymphocytes. This pattern differs from the reaction ob-
served both in metal-on-polyethylene and metal-on-metal
articulations. Soft-tissue inflammation was not associated
70. Baek SH, Kim WK, Kim JY, Kim SY: Do alumina matrix
with failure of the hip arthroplasties, and may be clinically
composite bearings decrease hip noises and bearing frac-
insignificant in alumina-on-alumina THAs.
tures at a minimum of 5 years after THA? Clin Orthop
78. Sedel L, Walter WL, Pitto RP: Clinical faceoff: Ceramic-
on-ceramic THA: do the advantages outweigh the limita-
71. Owen DH, Russell NC, Smith PN, Walter WL: An estima- tions? Clin Orthop Relat Res 2014;472(10):2927-2931.
tion of the incidence of squeaking and revision surgery for Medline DOI
squeaking in ceramic-on-ceramic total hip replacement: A
meta-analysis and report from the Australian Orthopaedic
Association National Joint Registry. Bone Joint J 2014;96- 79. Massin P, Lopes R, Masson B, Mainard D; French Hip &
B(2):181-187. Medline DOI Knee Society (SFHG): Does Biolox Delta ceramic reduce
the rate of component fractures in total hip replacement?
This meta-analysis of 16,828 hips estimated that the inci- Orthop Traumatol Surg Res 2014;100(6 suppl):S317-S321.
dence of squeaking was 4.2% and the incidence of revision Medline DOI
for squeaking was 0.2%. Higher rates were calculated
with the Accolade femoral component. The fracture rates of third- and fourth-generation ceramic-
on-ceramic heads and liners were identified and compared
with the manufacturer’s data (CeramTec) and to the Na-
72. Walter WL, Yeung E, Esposito C: A review of squeak- tional Agency for Safety of Drugs and Medical Products.
ing hips. J Am Acad Orthop Surg 2010;18(6):319-326. This study estimated that the liner and head fracture rates
Medline DOI are 0.025% and 0.0013%, respectively. Overall, the frac-
ture rate is low and there is a further reduction in the
73. Walter WL, Insley GM, Walter WK, Tuke MA: Edge fracture rate between the third- and fourth-generation
3: Hip
loading in third generation alumina ceramic-on-ceramic ceramics.

bearings: Stripe wear. J Arthroplasty 2004;19(4):402-413.
Medline DOI 80. Koo KH, Ha YC, Jung WH, Kim SR, Yoo JJ, Kim HJ:
This retrospective analysis reviewed 206 THAs using Isolated fracture of the ceramic head after third-generation
large-diameter ceramic-on-ceramic bearing. The mean alumina-on-alumina total hip arthroplasty. J Bone Joint
Harris hip score improved from 54 to 92 with an average Surg Am 2008;90(2):329-336. Medline DOI
follow-up of 38 months: 7.3% of the hips squeaked and
none required revision surgery. 81. Traina F, De Fine M, Di Martino A, Faldini C: Fracture of
ceramic bearing surfaces following total hip replacement:
A systematic review. Biomed Res Int 2013;2013:157247. 89. Jassim SS, Patel S, Wardle N, et al: Five-year compari-
Medline DOI son of wear using oxidised zirconium and cobalt-chrome
femoral heads in total hip arthroplasty: A multicentre
82. McDonnell SM, Boyce G, Baré J, Young D, Shimmin randomised controlled trial. Bone Joint J 2015;97-B(7):
AJ: The incidence of noise generation arising from the 883-889. Medline DOI
large-diameter Delta Motion ceramic total hip bearing. This study investigated polyethylene wear, function-
Bone Joint J 2013;95-B(2):160-165. Medline DOI al outcomes, and complications, comparing OxZr and
CoCr as part of a three-arm, multicenter randomized
83. Tai SM, Munir S, Walter WL, Pearce SJ, Walter WK, controlled t rial. Penetration was significantly higher in the
Zicat BA: Squeaking in large diameter ceramic-on- U HMWPE liner group compared with both XLPE liner
ceramic bearings in total hip arthroplasty. J Arthroplasty groups but no significant difference was noted between
2015;30(2):282-285. Medline DOI CoCr and OxZr when articulating with XLPE. There is
a nonsignificant trend toward lower wear, coupling OxZr
84. Kuzyk PR, Saccone M, Sprague S, Simunovic N, Bhan- rather than CoCr with XLPE but long-term analysis is
dari M, Schemitsch EH: Cross-linked versus conventional required to determine if this observation changes with
polyethylene for total hip replacement: A meta-analysis time and becomes significant.
of randomised controlled trials. J Bone Joint Surg Br
2011;93(5):593-600. Medline DOI 90. Karidakis GK, Karachalios T: Oxidized zirconium head on
crosslinked polyethylene liner in total hip arthroplasty: A
85. Good V, Ries M, Barrack RL, Widding K, Hunter G, 7- to 12-year in vivo comparative wear study. Clin Orthop
Heuer D: Reduced wear with oxidized zirconium femoral Relat Res 2015;473(12):3836-3845. Medline DOI
heads. J Bone Joint Surg Am 2003;85-A(suppl 4):105-110. In this study, 199 hips were enrolled in a randomized trial
Medline in which patients received either a ceramic or Oxinium
head on either CPE or XLPE. The in vivo wear parameters
86. Australian Orthopaedic Association: National joint re- were lower when the combination of an oxidized zirconi-
placement registry annual report 2015. Available at https:// um head on XLPE liner was used at an average follow-up
aoanjrr.sahmri.com/documents/10180/217745/Hip%20 of 9 years (range, 7 to 12 years).
and%20Knee%20Arthroplasty. Accessed July 13, 2016.
The 2015 Hip and Knee Arthroplasty Report is based on 91. Smith AJ, Dieppe P, Vernon K, Porter M, Blom AW;
the analysis of 988,667 primary and revision hip and knee National Joint Registry of England and Wales: Fail-
procedures recorded by the Registry since its inception in ure rates of stemmed metal-on-metal hip replacements:
2003. Based on 14,016 cases, the bearing combination Analysis of data from the National Joint Registry of En-
of OxZr against XLPE demonstrated a revision rate of gland and Wales. Lancet 2012;379(9822):1199-1204.
3.3% at 10 years, the lowest of all bearing combinations Medline DOI
used for THA.
92. Smith AJ, Dieppe P, Howard PW, Blom AW; National
87. Morison ZA, Patil S, Khan HA, Bogoch ER, Schemitsch Joint Registry for England and Wales: Failure rates of
EH, Waddell JP: A randomized controlled trial comparing metal-on-metal hip resurfacings: Analysis of data from the
Oxinium and cobalt-chrome on standard and cross-linked National Joint Registry for England and Wales. Lancet
polyethylene. J Arthroplasty 2014;29(9suppl):164-168. 2012;380(9855):1759-1766. Medline DOI
Medline DOI
93. Marshall DA, Pykerman K, Werle J, et al: Hip resurfacing
In this randomized controlled trial, 80 patients (91 THAs)
versus total hip arthroplasty: A systematic review com-
received one of four bearing combinations: CoCr and
UHMWPE; CoCr and XLPE; Oxinium and UHMWPE; paring standardized outcomes. Clin Orthop Relat Res
and Oxinium and XLPE. At a mean follow-up of 6.8 years, 2014;472(7):2217-2230. Medline DOI
no significant differences were reported in clinical out-
comes. HXLPE resulted in significantly less wear than 94. Canadian Arthroplasty Society: The Canadian Arthroplas-
UHMWPE but no significant reduction in wear rate was ty Society’s experience with hip resurfacing arthroplasty:
observed using Oxinium over CoCr heads. An analysis of 2773 hips. Bone Joint J 2013;95-B(8):1045-
1051. Medline DOI
88. Jonsson BA, Kadar T, Havelin LI, et al: Oxinium modu-
lar femoral heads do not reduce polyethylene wear in ce- 95. Garbuz DS, Hargreaves BA, Duncan CP, Masri BA, Wil-
mented total hip arthroplasty at five years: A randomised son DR, Forster BB: The John Charnley Award: Diagnostic
trial of 120 hips using radiostereometric analysis. Bone accuracy of MRI versus ultrasound for detecting pseudo-
3: Hip
Joint J 2015;97-B(11):1463-1469. Medline DOI tumors in asymptomatic metal-on-metal THA. Clin

In this study, the 5-year outcomes were reported for a
randomized controlled trial that used radiostereometric 96. Kwon YM, Lombardi AV, Jacobs JJ, Fehring TK, Lewis
analysis to assess the influence of surface-oxidized zir- CG, Cabanela ME: Risk stratification algorithm for man-
conium on polyethylene wear in vivo. Patients received agement of patients with metal-on-metal hip arthroplasty:
either a conventional polyethylene or a highly cross-linked Consensus statement of the American Association of Hip
acetabular liner and a 28-mm CoCr or OxZr head. XLPE and Knee Surgeons, the American Academy of Orthopae-
had a significant advantage over conventional polyethylene
dic Surgeons, and the Hip Society. J Bone Joint Surg Am
but no advantage was reported for OxZr over CoCr in
2014;96(1):e4. Medline DOI
polyethylene wear after 5-year follow-up.
Chapter 29
The Biologic Response to

Bearing Materials
Emmanuel Gibon, MD Stuart B. Goodman, MD, PhD, FRCSC, FACS
Total joint arthroplasty (TJA) is a common and highly The use of implanted devices in orthopaedic surgery has
successful orthopaedic procedure for which surgeons can increased dramatically; this industry is expected to in-
use different bearing materials. The materials used for crease to $41.1 billion by 2016.1 Bearing materials are
TJA must be both biocompatible to minimize adverse permanent biomaterials and generally intended to be used
local tissue reactions and robust enough to support for joint arthroplasty. An understanding of the biologic
weight bearing during common daily activities. Modern response to bearing materials used for total joint arthro-
bearing materials for TJA are made from metals and plasty (TJA) is important for optimal outcomes.
their alloys, polymers, and ceramics. The orthopaedic The first interposition arthroplasties were performed
surgeon should be knowledgeable about the biologic using tissues such as muscle, fat, or pig bladder; cur-
response to the different bearing materials used for TJA, rent bearing materials for TJA have become much more
as well as the wear by-products generated. complex. The goals of these implants are efficaciousness,
no local or systemic adverse effects, and cost effective-
ness. Several bearing materials are currently available for
Keywords: orthopaedic bearing materials; consideration for the design of an artificial joint. These
biocompatibility; foreign body response; materials include metals and their alloys, polymers, and
inflammation; hypersensitivity ceramics. The metal most frequently used for bearing
surfaces in joint arthroplasty is a cobalt-chromium (CoCr)
alloy. Polymers include polyethylene: mainly ultra-high–
Dr. Goodman or an immediate family member has received molecular-weight polyethylene (UHMWPE) and highly
royalties from Biomaterials; serves as a paid consultant to cross-linked polyethylene (XLPE). The other main ma-
DePuy and Integra; serves as an unpaid consultant to Ac- terial group for bearing surfaces is ceramics. Ceramics
celalox and Biomimedica; has stock or stock options held are made of either alumina (Al2O3), or alumina combined
in Biomimedica and StemCor; has received research or in- with zirconia (ZrO2).
stitutional support from Baxter and DJ Orthopaedics; has
received nonincome support (such as equipment or services),
Polyethylene Use
commercially derived honoraria, or other non–research-
related funding (such as paid travel) from Biomaterials; Metal-on-polyethylene (MOP) is the most widely used
serves as a board member, owner, officer, or committee bearing couple for total hip arthroplasty (THA) in the
member of the American Academy of Orthopaedic Sur- United States. The alternative is ceramic-on-polyethylene
(COP), which is used less frequently. Second-generation
3: Hip
geons, Clinical Orthopaedics and Related Research, the

Journal of Arthroplasty, the Journal of Biomedical Material highly cross-linked polyethylene includes the doping of
Research, the Journal of Orthopaedic Research, the Open the antioxidant vitamin E within the polyethylene, and
Orthopaedics Journal, Orthopedics, Regenerative Engi- repeated treatment with heating and annealing of the
neering and Translational Medicine, and the Society for polymer. The size of the polyethylene particles generat-
Biomaterials. Neither Dr. Gibon nor any immediate family ed by MOP joint surfaces is generally submicron. These
member has received anything of value from or has stock or particles are often needlelike and can be up to 1 mm or
stock options held in a commercial company or institution longer, but most particulate debris is 0.3 to 5.0 µm long.
related directly or indirectly to the subject of this chapter. Polyethylene particles will interact with local cells, mainly
Section 3: Hip
macrophages, 2 and trigger a foreign body inflammatory giant cells or polykaryons, have been identified within the
response resulting in a granuloma if the particles are not bone-implant interface. Locally, the presence of multinu-
cleared and remain locally in sufficient numbers. The cleated giant cells increases both osteoclastic bone resorp-
cascade of proinflammatory responses is initiated after tion and osteoclastlike cell growth and differentiation
activation of the macrophages by the particles, either because of their capability to release TGF-α and other
through phagocytosis or cell contact with the polyeth- factors. One study compared retrieved tissues from loos-
ylene particles. Cell contact activation occurs through ened aseptic and septic MOP hip implants with synovial
different membrane receptors known as toll-like receptors membrane samples from osteoarthritic patients.8 In sam-
(TLRs). TLR2 and TLR4 have been found to be critical ples obtained from cases of aseptic loosening, an intense
for polyethylene-induced osteolysis.3 After polyethylene foreign body reaction was found with large infiltrates of
particle–induced activation, TLRs act primarily through CD68+ and CD163+ monocyte/macrophages, foreign
an adaptor protein called myeloid differentiation primary body giant cells, sometimes organized into foreign body
response gene 88 to induce the transcription factor nu- granulomas. Macrophages mostly expressed TLR4 and
clear factor kappa-B (NFκB) and others. This transcrip- TLR9. Macrophages outnumbered other cell types and
tion factor has been shown to have great relevance to only scattered T cells, B cells, and neutrophils were seen.
periprosthetic osteolysis associated with wear particles. Another retrieval study investigated the inflammatory
Activation of the NFκB results in the release of a pleth- processes at the protein level in periprosthetic tissues from
ora of proinflammatory factors including chemokines loosened MOP THAs.9 When compared with patients
(microphage inflammatory protein 1α, monocyte che- with primary THAs, patients with loosened THAs had
moattractant molecule 1 [MCP-1]), cytokines (such as higher receptor activator of NF-κB ligand (RANKL) ex-
tumor necrosis factor α [TNF-α]), interleukins ([IL]-1β, -6, pression on osteoblastic stromal cells and higher levels of
-8, and others), prostaglandins (especially prostaglandin RANKL, IL-6, IL-8, IL-10, interferon-γ-inducible protein
E2), nitric oxide, and peroxide metabolic intermediates. 10, MCP-1, and monokine induced by interferon-γ (MIG)
High levels of polyethylene-induced inflammatory fac- in the synovial fluid from the hip joint.
tors will have consequences on the local and systemic Polyethylene particles may be responsible for initiat-
tissues. Release of MCP-1 and microphage inflammatory ing periprosthetic inflammation. With the intense mac-
protein 1α induce the systemic recruitment of macro- rophage particle–induced secretion of chemokines and
phages and mesenchymal stem cells.4,5 Locally activat- cytokines, the local inflammation can progress to peri-
ed macrophages undergo polarization toward the M1 prosthetic osteolysis, jeopardizing mechanical support of
(proinflammatory) phenotype.6 M1 macrophages produce the implant, limiting its longevity. MOP bearing surfaces
primarily proinflammatory mediators, including TNF-α, have several main biologic effects (Figure 1).
IL-1, and IL-6, and express inducible nitric oxide syn-
thase.7 TNF-α released by locally activated macrophages
will stimulate osteoblasts to release granulocyte macro- Ceramics Use
phage–colony-stimulating factor, IL-6, and prostaglandin As a bulk material, ceramic has been shown to be non-
Ea2. Granulocyte macrophage–colony-stimulating factor immunogenic and induces a minor fibrotic response.
will enhance the release of reactive oxygen species such as However, with a high quantity of ceramic particles, the
nitric oxide, which activates osteoclastic bone resorption. induced biologic response is similar to that seen with
Locally, osteoclast-like cell growth and differentiation polyethylene particles.
are enhanced by TGF-α and osteoclastic bone resorption. Regarding particle size, ceramic particles follow a bi-
Osteoclast mobility is also increased by local release of modal distribution. Particles are either nanometric (range,
IL-8 from activated macrophages, mesenchymal stem 5 to 90 nm) or micrometric (range, 0.05 to 3.2 µm). Thus,
cells, and osteoblasts. Retrieval studies have documented the size of the ceramic wear particles differs dramatically
that particles derived from XLPE bearings are substantial- from the polyethylene particles generated at the bearing
3: Hip
ly smaller than those from UHMWPE. When challenged surface. Current ceramics used for joint arthroplasty are
with XLPE particles, macrophages have been shown to actually composites of two ceramics: AL2O3 and ZrO2 ,
release substantially more TNF-α than with UHMWPE of which alumina is the primary or continuous phase
particles. However, for the same bearing surface, many (70% to 95% composition) and zirconia is the second-
more UHMWPE particles are generated than with XLPE. ary phase (30% to 5% composition).10 A study using
Retrieval studies have helped in the understanding of clinically relevant alumina particles showed that these
the effects of polyethylene particles on the surrounding tis- particles exhibit cytotoxicity to human histiocytes.11 An-
sues. Foreign body giant cells, also called multinucleated other study analyzed the effect of two different sizes of
Chapter 29: The Biologic Response to Bearing Materials
Figure 1 Illustration demonstrates metal-on-polyethylene bearing surfaces. IL = interleukin, MΦ = macrophage, MCP-1 =

monocyte chemoattractant molecule 1, MGC = multinucleated giant cell, MIP-1α = macrophage inflammatory
protein 1 alpha, MSC = mesenchymal stem cells, NFκB = nuclear factor kappa-B, TLR = toll-like receptors,
ROS = reactive oxygen species, TNF-α = tumor necrosis factor alpha.
ceramic particles (23 versus 179 nm) on the viability of from macrophages. Surprisingly, the same group did
osteoblasts.12 The nanophase particles (23 nm) showed not measure any detectable IL-1α and IL-1β production
no substantial effects on cell viability; larger size particles after exposure of macrophages to ceramic as well as
dramatically decreased the viability of the osteoblasts. A polyethylene particles. The effects of particle size, con-
study that focused on the effects of concentration and size centration, and composition on cell death were investi-
of AL2O3 and ZrO2 particles on the J774 macrophage cell gated using the same J774 macrophage cell line.14 Using
reported that for AL2O3 particles up to 2 µm, the phago- fluorescence microscopy and DNA laddering techniques,
cytosis index (an indicator of the number of stimulated the effect of ceramic particles on apoptotic nuclear mor-
macrophages) increased with particle size and concentra- phology was shown to be size and concentration depen-
3: Hip
tion but reached a plateau for larger particles.13 No sub- dent and reached a plateau higher than 150 particles per
stantial difference was found between Al2O3 and ZrO2. macrophage at 1.3 µm.
Regarding cytotoxicity, large AL2O3 particles (larger than TLRs also play a role in the biologic response to ce-
2 µm) became substantially cytotoxic for concentrations ramic particles. Nanoparticles of ZrO2 have a selective
higher than 500 particles per macrophage. No difference capacity for inducing/increasing expression of TLR3,
was noted in TNF-α release between AL2O3 and ZrO2. TLR7, and TLR10 on macrophages. Moreover, there
However, when compared with polyethylene particles, was a limited stimulatory effect on IL-1β, no effect on
AL2O3 particles induced substantially less TNF-α release TNF-α production, and a proinflammatory effect of
Section 3: Hip
Figure 2 Illustration demonstrates ceramic-on-ceramic bearing surfaces. MΦ = macrophage, NFκB = nuclear factor kappa-B,
TLR = toll-like receptor, TNF-α = tumor necrosis factor alpha.
ZrO2 nanoparticles with decreased production of IL- released in the peri-implant area. The metal particles
1Ra (a marker of M2 anti-inflammatory macrophages) generated by MOM implant surfaces are substantial-
by M1-polarized macrophages. A study that challenged ly smaller than the polyethylene particles (range, 40 to
human macrophages with commercial alumina particles 50 nm). Alloys used for MOM implants for joint arthro-
(mean size 0.23 ± 0.1 μm) reported a limited increase in plasty are CoCr alloys that are either cast or wrought,
IL-1β and MCP-1 production.15 In another study, RANK, with either low or high carbon content. The effect of
TNF-α, and osteoprotegerin (OPG) messenger RNA were metallic particles on the surrounding bone and soft tissues
only slightly upregulated when human monocytic cells has been studied extensively. Metalloprotein complexes
were challenged with alumina particles.16 Alumina par- made from CoCr degradation byproducts are capable
ticles have been shown to be only weakly genotoxic to of inducing a lymphocytic proliferative response.18 This
primary human fibroblasts.17 reaction was greatest with high–molecular weight protein
In summary, ceramic particles might be harmful, espe- (range, 180 to 250 kDa); a possible trigger for the re-
cially in the nanometer size range and in large numbers; sponse is crosslinking of the metalloprotein complex with
however, that rarely occurs. Ceramic surfaces have several lymphocyte receptors (BV17 or CDR1 T-cell receptor).
main biologic effects (Figure 2). Moreover, the particle size matters.19 When comparing
nanoparticles and microparticles in an in vitro study with
3: Hip
human fibroblasts, the nanoparticles released substan-

Metal-on-Metal Bearing Couples tially more free radicals and induced more DNA damage
Well-functioning metal-on-metal (MOM) articulations than did micron-size particles.19 Furthermore, challenges
generate low volumes of wear debris because the smaller with CoCr particles did not increase the release of IL-6,
clearance of the articulation generates a thin fluid-film IL-10, TNF-α, or FGF-23, possibly due to cell death.
lubrication and self-polishing capability of this bearing This was confirmed in a study that challenged human
couple. With an estimated wear rate of 2 μm per year macrophages with CoCr particles (mean size ± SD, 0.48
for MOM articulations, approximately 1012 particles are ± 0.3 μm).15 The CoCr particles were mildly stimulatory
for cytokine release: challenged macrophages released components), bilateral implants, hip dysplasia, subopti-
two- to fivefold greater levels of IL-1a, IL-6, IL-10, and mal implant position, edge loading, and impingement of
GM-CSF than unchallenged cells. the components.
Human implant retrieval studies with more modern Pseudotumors have also been reported with MOP
MOM implants were first reported in a study that har- implants. A 2015 study reported a case of crevice corro-
vested and analyzed tissues from 19 second-generation sion of the head-neck junction in an MOP, resulting in a
MOM hip revision procedures. The indications for re- pseudotumor around the joint.23 Similar cases have been
vision were increasing pain and the occurrence of oste- reported, all demonstrating trunnionosis.24-26 A 2012 case
olysis.20 At surgery, the hip components were well fixed report of a pseudotumor around an MOP arthroplasty
in nine patients. In a classic description of the findings, described extensive eccentric wear of the polyethylene
it was reported that: “the characteristic histological fea- liner that resulted in MOM articulation.27
tures were diffuse and perivascular infiltrates of T and B MOM bearing couples simulate a nonspecific innate
lymphocytes and plasma cells, high endothelial venules, macrophage-dominated immune reaction and, in some
massive fibrin exudation, accumulation of macrophages patients, a type IV delayed hypersensitivity immune re-
with drop-like inclusions, and infiltrates of eosinophilic action as well. MOM bearing couples are associated with
granulocytes and necrosis.”20 Tissues were analyzed from the now well-established risk of pseudotumor that often
25 MOM hips, including 14 THA and 11 surface-replace- compromises later function; therefore, MOM bearing
ment designs, and compared with tissues retrieved MOP couples are generally limited to resurfacing procedures
implants. 21 The MOM retrievals showed pronounced in males. MOM bearing surfaces have several biologic
ulceration superficial to the areas demonstrating peri- effects (Figure 3).
lymphocytic vascular infiltration; lymphocytic infiltra-
tion was more pronounced in specimens from MOM
cases with prosthesis loosening compared with autopsy Bearing Materials and Hypersensitivity
specimens or those undergoing arthrotomy for primary The immune system is a highly complex network of cells
THA (control patients). Tissues retrieved from MOM and molecules, the goal of which is to maintain homeosta-
hip replacements demonstrated osteolysis.22 Perivascular sis and mitigate/eradicate noxious stimuli that jeopardize
accumulation of CD63 positive T cells, CD68 macro- the organism. The immune response to orthopaedic wear
phages, and high levels of IL-1β and TNF-α were found. debris from bearing materials can stimulate the innate or
Skin-patch tests were also performed to assess hyper- adaptive immune system, or both simultaneously. The
sensitivity to metal, which had positive results (higher innate immune system reacts in a nonspecific manner to
rate of hypersensitivity) for patients with early osteolysis. a potentially injurious stimulus, and the adaptive immune
Neocapsule tissue samples from 46 hips with modern system is antigen specific.
second-generation MOM articulations were analyzed. A The innate immune response to orthopaedic wear de-
distinct lymphocytic infiltration was seen in all cases, con- bris was first described in 1977.28 The key cells in the
sisting of CD20-positive B lymphocytes and CD3-positive innate immune system are macrophages, neutrophils, and
T lymphocytes. These different retrieval studies suggest a dendritic cells.29 The adaptive immune system has four
type IV delayed hypersensitivity immune reaction. Metal different reaction types. Regarding bearing materials,
ion studies reported elevation of CoCr serum in patients the cell-mediated type IV immunologic reaction is the
who underwent MOM THA. Although high levels of most important. This hypersensitivity reaction has been
ions are associated with specific types of cancer in animal estimated to be less than 1% of patients undergoing joint
models, to date, no conclusive association is known of arthroplasty.30 In addition to antigen-presenting cells, T
cancer in humans with MOM prostheses. Pseudotumors lymphocytes are the key cells for the type IV immunologic
associated with MOM implants are small or more exten- response. T lymphocytes can be activated via antigen-
sive solid or fluid-filled periprosthetic masses that can be presenting cells (CD68+ macrophages, dendritic cells, and
3: Hip
painful, resulting in substantial destruction of the sur- so forth). Metalloprotein complexes are formed through a
rounding tissues. In conjunction with resurfacing or THA bond between metal ions (the hapten) and specific serum
components with MOM bearings, the pseudotumors are proteins (for example, albumin, chromodulin, nickel/
composed of granulomatous masses of inflammatory cells cobalt transporters). Thereafter, these new metalloprotein
(such as macrophages, T lymphocytes, plasma cells), fi- complexes can act as antigens. Moreover, T cells can be
brous tissue, and widespread tissue necrosis. Several risk activated using metal ions alone, without any metallo-
factors have been identified for pseudotumor formation, protein complexes, by means of tyrosine kinase activa-
including young age, female sex (especially with small-size tion induced by cross-linking of the thiols of cell surface
Section 3: Hip
Figure 3 Illustration demonstrates metal-on-metal bearing surfaces. GM-CSF = granulocyte macrophage–colony-stimulating

factor, MCP-1 = monocyte chemoattractant molecule 1, MSC = mesenchymal stem cell, PGE2 = prostaglandin E2,
ROS = reactive oxygen species.
proteins. Locally, metal particles undergo phagocytosis by macrophages. Debris from MOP can be associated with
using CD68+ macrophages, which will act as antigen-pre- a foreign body granuloma and periprosthetic osteolysis,
senting cells to T lymphocytes, resulting in a cell-mediated depending on the amount and type of particles generat-
type IV immunologic reaction. High levels of IL-2 recep- ed and patient characteristics. Ceramic bearings usually
tor expression (a sign of T-lymphocyte activation) were generate little wear debris, but if high amounts of ceramic
seen when tissues (retrieved tissues or blood cells) were particles are generated, the subsequent biologic response is
challenged with metal particles. Following activation, similar to that of MOP bearings. MOM bearings release
T-lymphocyte responses are increased by costimulation metallic ions and nano-size particles that trigger, in some
with CD28/CD86 between antigen presenting cells and patients, a delayed type IV immune response with the risk
3: Hip
activated T cells (Table 1). of inducing local pain, allergic reactions, and in some
cases, tissue destruction and pseudotumor. As a result, the
use of MOM bearings is now limited. Bioactive (coated)
Summary implants and other methods of drug delivery, which could
The biologic response to orthopaedic bearings is con- modulate the local periprosthetic environment, represent
trolled by the immune system. MOP bearing byprod- novel technologies to potentially improve the longevity
ucts, which are currently the ones most commonly used, of joint arthroplasties. Research studies are currently
induce a nonspecific innate immune response driven by ongoing to test these promising possibilities.
Table 1
Interaction Between Bearing Materials and the Immune System
Adaptive (Antigen Specific)
Immune Reaction Innate (Nonspecific)
Type IV (Cell Mediated)
Specific receptors PAMPs, PRRs, TLRs, DAMPs, IL-2R, CD69 activation antigen
NLRs, RLRs
Cells Macrophages, neutrophils, Lymphocytes
dendritic cells
Wear particles involved Polymers, ceramics, metals In some cases, metals
Ultimate adverse reaction Foreign body granuloma Necrosis, fibrosis, possible
pseudotumor
CD69 = cluster of differentiation 69, DAMP = damage-associated molecular pattern, IL-2R = interleukin 2 receptor, NLR = nucleotide-binding
oligomerization domain–like receptors, PAMP = pathogen-associated molecular pattern, PRR = pattern recognition receptor, RLR = retinoid acid
inducible gene-I–like receptor, TLR = toll-like receptor.
Data from Kawai T, Akira S: Toll-like receptors and their crosstalk with other innate receptors in infection and immunity. Immunity
2011;34(5):637-650; Kumar H, Kawai T, Akira S: Pathogen recognition by the innate immune system. Int Rev Immunol 2011;30(1):16-34; and Takagi
M: Toll-like receptor: A potent driving force behind rheumatoid arthritis. J Clin Exp Hematop 2011;51(2):77-92.
2. Nich C, Goodman SB: Role of macrophages in the bio-

Key Study Points
logical reaction to wear debris from joint replacements.
J Long Term Eff Med Implants 2014;24(4):259-265.
• Polyethylene is the most widely used bearing cou- Medline DOI
ple for THA in the United States: wear debris are
needlelike and are 0.3 to 5.0 µm long, and polyeth- Macrophages are key cells in periprosthetic osteolysis asso-
ciated with wear particles. This review presents thorough
ylene particles activate macrophages by means of details regarding their role in the initiation and mainte-
phagocytosis or cell contact. nance of the host inflammation.
• The local inflammation can progress to peripros-
thetic osteolysis. 3. Valladares RD, Nich C, Zwingenberger S, et al: Toll-like
receptors-2 and 4 are overexpressed in an experimental
• Ceramic particles are either nanometric (range, 5 to model of particle-induced osteolysis. J Biomed Mater Res
90 nm) or micrometric (range, 0.05 to 3.2 µm); A 2014;102(9):3004-3011. Medline DOI
compared with polyethylene particles, alumina par- Toll-like receptors (TLRs) are involved in the activation of
ticles induced substantially less TNF-α release from macrophages. The authors showed that TLRs 2 and 4 are
macrophages. upregulated in polyethylene particle–induced osteolysis.
• MOM articulations generate low volumes of wear
4. Gibon E, Ma T, Ren PG, et al: Selective inhibition of
debris: metal particles generated by MOM implant the MCP-1-CCR2 ligand-receptor axis decreases sys-
surfaces are reported to be 40 to 50 nm. temic trafficking of macrophages in the presence of
• Metalloprotein complexes composed of CoCr deg- UHMWPE particles. J Orthop Res 2012;30(4):547-553.
Medline DOI
radation byproducts are capable of inducing a lym-
phocytic proliferative response. TLRs play a major role in macrophage activation. Using
polyethylene particles, the authors showed that TLR-2 and
TLR-4 are overexpressed in polyethylene particle–induced
osteolysis.
Annotated References 5. Gibon E, Yao Z, Rao AJ, et al: Effect of a CCR1 re-
3: Hip
ceptor antagonist on systemic trafficking of MSCs and

polyethylene particle-associated bone loss. Biomaterials
1. Richards RG, Moriarty TF, Miclau T, McClellan RT, 2012;33(14):3632-3638. Medline DOI
Grainger DW: Advances in biomaterials and surface
technologies. J Orthop Trauma 2012;26(12):703-707. MCP-1 is a potent chemokine involved in macrophage sys-
Medline DOI temic trafficking. Using a murine model and via selective
inhibition of its receptor (CCR2), a decrease was showed
This review provides details on surface modifications in the systemic recruitment of macrophages.
for orthopaedic implants. Osseointegration and anti-
infectious surfaces are discussed.
Section 3: Hip
6. Mantovani A, Biswas SK, Galdiero MR, Sica A, Loca- 16. Bylski D, Wedemeyer C, Xu J, Sterner T, Löer F, von
ti M: Macrophage plasticity and polarization in tissue Knoch M: Alumina ceramic particles, in comparison
repair and remodelling. J Pathol 2013;229(2):176-185. with titanium particles, hardly affect the expression of
Medline DOI RANK-, TNF-alpha-, and OPG-mRNA in the
THP-1 human monocytic cell line. J Biomed Mater Res
Depending on their microenvironment, macrophages can A 2009;89(3):707-716. Medline DOI
be polarized. This review discusses their plasticity and
role in tissue repair.
17. Tsaousi A, Jones E, Case CP: The in vitro genotoxicity
of orthopaedic ceramic (Al2O3) and metal (CoCr alloy)
7. Murray PJ, Allen JE, Biswas SK, et al: Macrophage acti- particles. Mutat Res 2010;697(1-2):1-9. Medline DOI
vation and polarization: Nomenclature and experimental
guidelines. Immunity 2014;41(1):14-20. Medline DOI
18. Hallab NJ, Mikecz K, Vermes C, Skipor A, Jacobs JJ:
This study provides a consensus collection of the markers Orthopaedic implant related metal toxicity in terms of
used to identify polarized macrophages. human lymphocyte reactivity to metal-protein complexes
produced from cobalt-base and titanium-base implant
8. Pajarinen J, Cenni E, Savarino L, et al: Profile of toll-like alloy degradation. Mol Cell Biochem 2001;222(1-2):
receptor-positive cells in septic and aseptic loosening of 127-136. Medline DOI
total hip arthroplasty implants. J Biomed Mater Res A
2010;94(1):84-92. Medline DOI 19. Papageorgiou I, Brown C, Schins R, et al: The effect
of nano- and micron-sized particles of cobalt-chromi-
9. Wang C-T, Lin Y-T, Chiang B-L, Lee SS, Hou SM: um alloy on human fibroblasts in vitro. Biomaterials
Over-expression of receptor activator of nuclear factor- 2007;28(19):2946-2958. Medline DOI
kappaB ligand (RANKL), inflammatory cytokines, and
chemokines in periprosthetic osteolysis of loosened to- 20. Willert H-G, Buchhorn GH, Fayyazi A, et al: Metal-
tal hip arthroplasty. Biomaterials 2010;31(1):77-82. on-metal bearings and hypersensitivity in patients with ar-
Medline DOI tificial hip joints. A clinical and histomorphological study.
J Bone Joint Surg Am 2005;87(1):28-36. Medline DOI
10. Kurtz SM, Kocagöz S, Arnholt C, Huet R, Ueno M, Walter
WL: Advances in zirconia toughened alumina biomaterials 21. Davies AP, Willert HG, Campbell PA, Learmonth ID,
for total joint replacement. J Mech Behav Biomed Mater Case CP: An unusual lymphocytic perivascular infiltra-
2014;31:107-116. Medline DOI tion in tissues around contemporary metal-on-metal joint
replacements. J Bone Joint Surg Am 2005;87(1):18-27.
This study discusses details regarding the structure and Medline DOI
mechanical properties as well as the clinical performance
of alumina implants for TJA.
22. Park Y-S, Moon Y-W, Lim S-J, Yang J-M, Ahn G, Choi
Y-L: Early osteolysis following second-generation met-
11. Germain MA, Hatton A, Williams S, et al: Comparison al-on-metal hip replacement. J Bone Joint Surg Am
of the cytotoxicity of clinically relevant cobalt-chromium 2005;87(7):1515-1521. Medline DOI
and alumina ceramic wear particles in vitro. Biomaterials
2003;24(3):469-479. Medline DOI
23. Watanabe H, Takahashi K, Takenouchi K, et al: Pseudo-
tumor and deep venous thrombosis due to crevice corro-
12. Gutwein LG, Webster TJ: Increased viable osteoblast sion of the head-neck junction in metal-on-polyethylene
density in the presence of nanophase compared to con- total hip arthroplasty. J Orthop Sci 2015;20(6):1142-1147.
ventional alumina and titania particles. Biomaterials Medline DOI
2004;25(18):4175-4183. Medline DOI
The authors report a case of pseudotumor around an MOP
13. Catelas I, Huk OL, Petit A, Zukor DJ, Marchand R, Ya- arthroplasty performed for trunnionosis.
hia L: Flow cytometric analysis of macrophage response
to ceramic and polyethylene particles: Effects of size, 24. Stahnke JT, Sharpe KP: Pseudotumor formation in a
concentration, and composition. J Biomed Mater Res metal-on-polyethylene total hip arthroplasty due to
1998;41(4):600-607. Medline DOI trunnionosis at the head-neck taper. Surg Technol Int
2015;27:245-250. Medline
14. Catelas I, Petit A, Zukor DJ, Marchand R, Yahia L, This case report describes an acute lymphocytic vasculitis
3: Hip
Huk OL: Induction of macrophage apoptosis by ce- associated lesion around MOP implants.
ramic and polyethylene particles in vitro. Biomaterials
1999;20(7):625-630. Medline DOI
25. Scully WF, Teeny SM: Pseudotumor associated with met-
al-on-polyethylene total hip arthroplasty. Orthopedics
15. Kaufman AM, Alabre CI, Rubash HE, Shanbhag AS: Hu- 2013;36(5):e666-e670. Medline DOI
man macrophage response to UHMWPE, TiAlV, CoCr,
and alumina particles: Analysis of multiple cytokines us- This article is a case report of a pseudotumor involving
ing protein arrays. J Biomed Mater Res A 2008;84(2): MOP implants.
26. Mao X, Tay GH, Godbolt DB, Crawford RW: Pseudotu- 28. Willert HG, Semlitsch M: Reactions of the articular
mor in a well-fixed metal-on-polyethylene uncemented hip capsule to wear products of artificial joint prostheses.
arthroplasty. J Arthroplasty 2012;27(3):493.e13-493.e17. J Biomed Mater Res 1977;11(2):157-164. Medline DOI
Medline DOI
This article is a case report of a pseudotumor formation re- 29. Goodman SB, Konttinen YT, Takagi M: Joint replacement
lated to femoral head-neck corrosion with MOP implants. surgery and the innate immune system. J Long Term Eff
Med Implants 2014;24(4):253-257. Medline DOI
27. Murgatroyd SE: Pseudotumor presenting as a pelvic mass: This paper focused on the innate immune system and its
A complication of eccentric wear of a metal on poly- role after joint replacement.
ethylene hip arthroplasty. J Arthroplasty 2012;27(5):820.
e1-e4. Medline DOI 30. Hallab N, Merritt K, Jacobs JJ: Metal sensitivity in pa-
In this case report, extensive eccentric polyethylene liner tients with orthopaedic implants. J Bone Joint Surg Am
wear resulted in a MOM articulation. Pseudotumors de- 2001;83-A(3):428-436. Medline
veloped subsequently.
3: Hip
Chapter 30
Primary Total Hip Arthroplasty

Craig J. Della Valle, MD Daniel J. Berry, MD Charles R. Bragdon, PhD John J. Callaghan, MD
Rocco D’Apolito, MD Douglas A. Dennis, MD Ivan De Martino, MD Roger H. Emerson Jr, MD
Andrew A. Freierg, MD Young-Min Kwon, MD, PhD Kyle W. Lacy, MD, MS Steven J. MacDonald, MD, FRCSC
R. Michael Meneghini, MD Matthew C. Morrey, MD, MS Bernard F. Morrey, MD Amar Ranawat, MD
Harry E. Rubash, MD Thomas P. Sculco, MD
The results of total hip arthroplasty continue to im- Total hip arthroplasty (THA) continues to be one of the
prove over time, and with careful study of component most successful and commonly performed surgical pro-
performance, more data are available to help guide cedures in North America. Although there has been an
decision making. Although noncemented stem fixation overall convergence of surgical designs and techniques,
has become more common and proved to have superior some controversies still exist. Further advancements, par-
results in many patient populations, there is still a role ticularly in bearing materials, have improved outcomes
for cemented femoral fixation in older patient groups. and a better understanding of their performance will help
However, noncemented stem length has recently been the surgeon make appropriate choices for their patients.
debated, and the optimal length for a noncemented stem
is unclear given that some short-stemmed designs a re
associated with excellent results. On the acetabular side, Femoral Component Selection and Results
modular noncemented cups are used most frequently Daniel J. Berry, MD
with excellent reported results; however, cemented cups The femoral component of a THA must effectively restore
may still have a role in certain populations, particularly the biomechanics of the proximal femur and hip joint
because cost containment is increasingly focused on. and achieve and maintain durable fixation to the prox-
Although a metal or ceramic femoral head articulating imal femur. Both cemented and noncemented femoral
with a highly cross-linked polyethylene liner seems to components have demonstrated the capability to achieve
perform best in most situations, the ideal femoral head reliable and durable fixation. However, results vary con-
size is still unclear and a topic of controversy. Larger siderably according to implant design. In North America,
femoral head sizes have been associated with a lower noncemented femoral fixation is used in most patients,
risk of dislocation and are used far more commonly whereas cemented femoral fixation remains common in
in contemporary practice; however, they have their the United Kingdom and in some Scandinavian countries.
own risks and potential complications. Dual-mobility Data from several sources suggest noncemented THA
bearings are a unique, appealing solution for primary or is outperforming cemented and hybrid THA in younger
revision total hip arthroplasties in which the patient is patients, but most data suggest cemented implants have
considered to be at high risk for dislocation. However, the lowest revision rate in older patients.1 Joint regis-
far less is known regarding their midterm and longer tries2-4 provide some of the best high-level information
term performance, and appropriate caution should be on factors that influence performance of different implant
3: Hip
exercised when choosing this bearing option. categories in different circumstances. Information from
the Australian registry demonstrates that noncemented
THA outperforms cemented and hybrid THA in patients
Keywords: primary total hip arthroplasty; femoral age 64 years and younger at 10 to 14 years postopera-
stems; acetabular component; femoral head size; tively. However, information from the Australian, UK,
dual mobility and Scandinavian registries demonstrate that cemented
THA has a lower revision rate than noncemented THA
in older patients.
Section 3: Hip
All registries show that 1% to 3% of THAs fail in the Recent literature has compared the use of nonce-
first year after surgery, and for noncemented THAs, many mented stems to cemented stems for the specific diagnosis
early failures are related to periprosthetic fractures or of femoral neck fracture. Most of the larger series and
failure of osteointegration.5 A recent study characterized registry-based studies suggest that noncemented stems
the stereotypical pattern of early periprosthetic fractures are associated with a slightly lower risk of perioperative
as being a single, roughly triangular fragment containing death (probably because of less fat embolization) than for
the lesser trochanter, which exits a variable distance down cemented stems in the same population. However, most
the femoral medial cortex.6 series also report a tradeoff, with a higher revision rate
Dr. Della Valle or an immediate family member has received royalties from Zimmer Biomet; serves as a paid consultant
to DePuy, Smith & Nephew, and Zimmer Biomet; has stock or stock options held in CD Diagnostics; has received research
or institutional support from Smith & Nephew, Stryker and Zimmer Biomet; and serves as a board member, owner,
officer, or committee member of the American Association of Hip and Knee Surgeons, the Arthritis Foundation, the
Hip Society, the Knee Society, and the Mid-America Orthopaedic Association. Dr. Berry or an immediate family member
has received royalties from DePuy, serves as a paid consultant to DePuy, has received research or institutional support
from DePuy, and serves as a board member, owner, officer, or committee member of the American Joint Replacement
Registry, the Hip Society, the International Hip Society, and the Mayo Clinic Board of Governors. Dr. Bragdon or an im-
mediate family member has received royalties from Zimmer Biomet and has received research or institutional support
from MAKO Surgical and Zimmer Biomet. Dr. Callaghan or an immediate family member has received royalties from
DePuy, serves as a paid consultant to DePuy, and serves as a board member, owner, officer, or committee member of
the International Hip Society, the Knee Society, and the Orthopaedic Research and Education Foundation. Dr. Dennis
or an immediate family member has received royalties from DePuy and Innomed, is a member of a speakers’ bureau
or has made paid presentations on behalf of DePuy, serves as a paid consultant to DePuy, has stock or stock options
held in Joint Vue, and has received research or institutional support from DePuy. Dr. Emerson or an immediate family
member has received royalties from Zimmer Biomet; is a member of a speakers’ bureau or has made paid presenta-
tions on behalf of Medtronic, Zimmer Biomet, and Pacira; serves as a paid consultant to DePuy, Medtronic, Zimmer
Biomet, and Pacira; has stock or stock options held in Pacira; and has received research or institutional support from
Zimmer Biomet and Pacira. Dr. Freiberg or an immediate family member has received royalties from Zimmer Biomet;
serves as a paid consultant to CeramTec and Zimmer Biomet; and has stock or stock options held in ArthroSurface and
the Orthopaedic Technology Group. Dr. Kwon or an immediate family member has received research or institutional
support from Stryker and Zimmer Biomet. Dr. MacDonald or an immediate family member has received royalties from
DePuy, serves as a paid consultant to DePuy, has stock or stock options held in Hip Innovations Technology and Joint
Vue, and has received research or institutional support from DePuy, Smith & Nephew, and Stryker. Dr. Meneghini or an
immediate family member has received royalties from DJ Orthopaedics and Stryker and serves as a paid consultant to
DJ Orthopaedics and Osteoremedies. Dr. M. Morrey or an immediate family member has stock or stock options held in
Tenex Health. Dr. B. Morrey or an immediate family member has stock or stock options held in DJ Orthopaedics, SBI, and
Zimmer Biomet; is an employee of Tenex Health; serves as a paid consultant to Zimmer Biomet; and has stock or stock
options held in Tenex Health. Dr. Ranawat or an immediate family member has stock or stock options held in DePuy,
Stryker, MAKO Surgical, ConforMis, and Pipeline; is a member of a speakers’ bureau or has made paid presentations on
behalf of DePuy, Stryker, MAKO Surgical and Convatec; serves as a paid consultant to Arthrex, Ceramtec, and DePuy;
has stock or stock options held in ConforMis and Strathspey Crown; has received research or institutional support from
DePuy, Stryker, and Ceramtec; has received nonincome support (such as equipment or services), commercially derived
3: Hip
honoraria, or other non–research-related funding (such as paid travel) from DePuy and Stryker; and serves as a board
member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the American
Association of Hip and Knee Surgeons, the Eastern Orthopaedic Association, the Hip Society, and the Knee Society. Dr.
Rubash or an immediate family member has received royalties from Ceramtec and Stryker, serves as a paid consultant
to Flexion and Pacira, and has stock or stock options held in Orthopaedic Technology Group. Dr. Sculco or an immedi-
ate family member has received royalties from Exactech and serves as a board member, owner, officer, or committee
member of the Knee Society. None of the following authors or any immediate family member has received anything
of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to
the subject of this chapter: Dr. D’Apolito, Dr. De Martino, and Dr. Lacy.
Chapter 30: Primary Total Hip Arthroplasty
for noncemented stems, mostly due to early periprosthetic combinations of noncemented stems and noncemented
femur fractures and failed fixation.7-9 cups listed in the Australian registry (which has the most
The results of using various femoral component cate- robust data on noncemented implants) demonstrate cumu-
gories are discussed in the following sections. Although lative rates of revision at 10 years of less than 5%.10 Sev-
series with level IV evidence are valuable, they are subject eral case series have explored the long-term results of
to potential selection and publication bias, with perhaps standard-length noncemented implants at 15 to 25 years
the most successful results being most likely to be re- after surgery.11,12 These case series demonstrate that the
ported. Therefore, cross-referencing case series data with long-term loosening rate of standard-length noncemented
large national registry data is important to gain the most stems can be low. Randomized head-to-head comparison
comprehensive understanding of the performance of each of femoral components from different implant geometry
implant category. It is also important to be aware that categories is uncommon, and registry data are subject
each implant category may have unique advantages and to selection bias, making absolute comparison of results
disadvantages. For example, some implants may be easier within this general implant category challenging. For
to accomplish with certain surgical approaches, but they implants offered in versions with porous coating or hy-
may have lower overall long-term fixation rates. Some droxyapatite coating, clinical series comparing the two
implants may be associated with higher intraoperative surface finishes (including randomized trials) have shown
and early postoperative periprosthetic fracture rates, or a equivalent fixation rates and clinical outcomes.13
different pattern of long-term periprosthetic bone remod- Standard-length noncemented stems load the femur
eling (stress shielding), or a different degree of thigh pain. differently than do short stems or cemented stems, with
consequent effects on bone remodeling, which also dif-
Standard-Length Noncemented Stems fers with each stem category.14 With the exception of
Daniel J. Berry, MD extensively porous-coated stems, which exhibit more
Standard-length noncemented femoral stems are by far pronounced bone remodeling changes in some patients,
the most commonly used category of THA femoral com- modest bone remodeling changes have not been shown
ponent in North America and many other parts of the to have notable clinical consequences.
world. This preference is attributable to favorable short-
and long-term clinical results with a high rate of implant Short Noncemented Stems
fixation, ease and consistency of insertion, and broad Roger Emerson, MD
applicability to most (but not all) femoral geometries. Interest is increasing in shorter stems for noncemented
Standard-length noncemented stems provide early and primary THA. Optimal femoral stem length for non-
long-term fixation over a relatively broad surface area, cemented primary THA has not been determined, and
thereby distributing stress and avoiding extreme stress different stem lengths are available. Shorter stem lengths
concentration. The stem length also helps the surgeon to are attractive because they are less invasive of the femur
attain consistent alignment in the femoral canal, which and require less surgical exposure. Seldom discussed is
creates predictable hip biomechanics. the ease of revising a shorter stem if it becomes necessary.
Several different categories of noncemented standard- A shorter stem, in theory, will promote more proximal
length femoral components are in common use. Based femoral loading, which may prevent stress shielding from
on geometry, these include double-tapered stems, single- more distal stem fixation. The concern, however, is that
tapered (blade-shaped) stems, extensively porous-coated the shorter length may be less stable, resulting in a higher
stems, and anatomic stems. These stem designs all are rate of failure of osteointegration.
engineered to gain initial stability by interference press There are two general types of short stems: ultrashort
fit and long-term stability through osteointegration via stems, which are placed in the femoral neck and upper
bone ingrowth or ongrowth to different surface finishes metaphysis and are usually less than 90 mm long, and the
or coatings (including porous coatings, plasma spray, more common metaphyseal filling short stem, which does
3: Hip
surface roughening with grit blasting, and hydroxyapatite not engage the actual diaphysis, and varies from 90 to
coatings). Early implant stability, which is key to oste- 140 mm in length, which increases proportionally to the
ointegration and long-term fixation, depends on optimal size of the stem. Various stem geometries are available,
implant sizing and geometry to achieve stable fixation. with new and unique designs; other, shorter stem alter-
Numerous standard-length noncemented stems natives have been previously available as a longer stem.
from each of the main categories previously listed have As with any other noncemented stem, initial stable
shown high rates of fixation and good clinical success fixation must be achieved for osteointegration to occur.
in many case series as well as in registry studies. Several This requires sufficient fill of the canal and, ideally, a
Section 3: Hip
neutral or valgus stem position, which requires line-to- noted in survival or clinical scores at a mean follow-up
line fill on the AP radiograph and three-point fixation on of 29.2 months.19
the lateral projection. It is important to consider that a Reports on shorter femoral stems in the literature have
shorter stem is less forgiving than a longer stem. Hence, been encouraging; shorter stems compare favorably to
until the surgeon has adequate experience with a shorter standard-length stems for clinical outcomes and ana-
stem, an intraoperative radiograph may help ensure that tomic hip restoration. Bone density studies have shown
the planned endosteal positioning of the stem has been a smaller reduction in bone loss from stress shielding.
achieved. For maximal contact of the porous coating on Importantly, short-stem revision allows for less complex
the proximal metaphyseal bone, metaphyseal fill is more revision surgery. Finally, the stems may be ideal for pa-
important than distal fill. Potting the tip of the stem with- tients with certain bony morphologies (such as a narrow
out proximal fill may result in failure of fixation. diaphysis or an exaggerated bow) that would be hard to
One study reported experience with two differ- fit with a longer stem.
ent titanium flat-tapered stems, including 849 longer
stems (135 to 170 mm) and 902 shorter stems (97.5 to Modular Stems
132.0 mm). At a mean follow-up of 36 months (range, Douglas A. Dennis, MD
6 to 88 months), stem survivorship was not significantly Restoration of the hip center is crucial for restoring na-
different (99% in both groups).15 Another study com- tive hip biomechanics following primary THA, which is
pared an ultrashort and a standard stem using dual-en- beneficial for both functional performance and longevity
ergy x-ray absorptiometry at 2 years postoperatively. The of the implant. In addition to modular femoral heads,
results showed reduced bone loss with the short stem in several implant systems have incorporated a second mod-
all zones, but indicated an especially remarkable differ- ular junction to allow surgeons to independently adjust
ence in zone 1. There was more subsidence of the short femoral anteversion, lateral offset, and limb length, along
stem at 6 weeks, but at 2 years, the clinical outcome with fit and fill of the proximal or distal femur. These im-
was not significantly different.16 However, a different plants provide the surgeon with intraoperative flexibility
study compared a short stem and standard stem in a to accommodate variation among patients’ native anat-
prospective randomized double-blind study, with 40 hips omy and manage complex proximal femoral deformities.
in each group. Group comparison at 6 weeks showed no Furthermore, these modular features offer the potential
difference in clinical scores, Harris hip score , Medical advantages of reduced neck-cup impingement, more pre-
Outcomes Study 36-Item Short Form score, or Western cise limb length and hip biomechanics restoration, and
Ontario and McMaster Universities Arthritis Index (WO- enhanced fixation in cases of femoral anatomic variances.
MAC).17 Radiographic comparison showed no difference All dual modular stems are not the same, however.
in the restoration of the femoral offset between the two Most dual modular stems used in primary THA have a
stem groups. proximal modular connection, either at the neck-stem
Another group undertook a bench study with 16 syn- junction or within the metaphyseal region of the proximal
thetic bones and two sets of matched cadaver femurs to femur. Modularity at the neck-stem junction is generally
assess the effect of femoral stem length on the torsional proximal to the femoral neck osteotomy and, therefore,
resistance to periprosthetic fracture.18 The specimens were unsupported by host bone. This results in different physio-
mounted and rapidly rotated to simulate stumbling. Cus- logic loads placed on the taper, whereas in other proximal
tom three-dimensional cutting guides were created to modular stems, the junction lies below the neck osteotomy
ensure the accuracy of the placement of the stem. For both and within the metaphyseal region of the femur.
models, the shorter stems failed at a significantly higher The S-ROM stem (DePuy) is a metaphyseal modular
torque, and the researchers concluded that shorter stems femoral component with a clinical history of more than
may allow more femoral flexibility and confer a higher 30 years of use in the United States. The implant consists
resistance to periprosthetic fracture. of a porous- or hydroxyapatite-coated sleeve, which is
3: Hip
Quantifying ease of component placement is difficult, inserted into the metaphysis, and a polished titanium cy-
due to varying surgical skill sets. A study compared a lindrical stem with distal splines, which is placed through
series of shorter stems (389 hips) to standard-length the sleeve to engage a taper proximally via a cold weld;
wedge-fit stems (269 hips), all placed through an antero- rotational stability is also gained via endosteal cortical
lateral approach. A reduced number of intraoperative contact in the diaphysis. The stem is available in several
complications (trochanteric and femoral shaft fractures) height and offset options, and because it can be freely
was reported with the shorter stem than with the longer rotated within the sleeve, wide variations in native ver-
stem (0.4% and 3.1%, respectively). No difference was sion can be treated while also allowing accommodation
Figure 1 AP pelvic radiographs of a patient with developmental dislocation of the hip (Crowe stage 4). A, Preoperative
view. B, View obtained 5 years following total hip arthroplasty with a dual modular femoral component.
of a metaphyseal-diaphyseal size mismatch. Despite observed with modular necks, leading to questioning the
theoretical concerns of fretting and junctional failure, use of dual modularity in routine primary THA.
long-term clinical results have shown low rates of aseptic In July 2012, Stryker issued a voluntary recall of its
loosing or failure at 15 to 20 years. 20 The S-ROM stem ABG II and Rejuvenate modular neck femoral compo-
has proved particularly useful in complex primary THA nents due to higher-than-expected early revision rates
in the setting of severe dysplasia in which a concurrent for excessive fretting and corrosion at the modular junc-
femoral shortening osteotomy is required at the time of tion resulting in adverse local tissue reactions (ALTR)
THA (Figure 1). and osteolysis. This design used a mixed-alloy couple in
The M/L Taper with Kinectiv Technology system which the neck was cobalt chromium and the stem was
(Zimmer) is a dual modular femoral component with titanium alloy. Some studies have shown that mixed-alloy
neck-stem modularity. The system offers a wide variety couples can produce more corrosion and fretting than a
of head center options with a variable titanium alloy neck single-alloy interface and can be susceptible to galvanic
that mates with a titanium stem via a modular taper. corrosion. A series of 123 Rejuvenate stems (97 of which
Although early reports noted more accurate restoration were the modular version) reported elevated serum metal
of the hip center, more recent reports have questioned the levels in 48% of the modular group and a 28% revision
clinical significance of these findings. One study reported rate at a mean follow-up of 2.7 years.22 Diagnosis of an
results from 284 patients who underwent THA with a ALTR associated with a modular stem is generally made
3: Hip
nonmodular neck and 594 patients in whom a modular by measurement of serum cobalt and chromium levels
neck that with the M/L Taper femoral component was combined with cross-sectional imaging in the form of
used.21 Patients in whom the modular femoral component an ultrasound or metal artifact reduction sequence MRI.
had been implanted demonstrated a higher percentage of Treatment includes revision surgery with removal of the
equal radiographic limb lengths and offset restoration, femoral component.
although these results did not translate to differences in Although corrosive wear appears to be more significant
clinical outcome scores at 2-year follow-up. No reduction with cobalt-chromium modular necks, resulting in metal
in the incidence of complications or reoperations was ion release and ALTR, titanium modular necks are not
Section 3: Hip
without their own unique set of problems. Most reports cemented nor noncemented fixation provides superior
of fatigue fracture of dual modular femoral stems have survivorship.
occurred with implants that use a titanium alloy coupling. In contemporary North American practice, the use
Titanium alloy components are also more susceptible of cemented stems has declined substantially. As previ-
to cold welding, which may complicate revision surgery ously outlined, these stems may have substantial advan-
and necessitate complete removal of a well-fixed stem tages in certain patient demographic groups, including
in circumstances in which simple modular head-neck elderly females or patients whose bone quality is other-
exchange would suffice. wise compromised, in which groups noncemented stems
Modular femoral components offer the surgeon excel- have shown a higher rate of periprosthetic fracture and
lent intraoperative flexibility to adjust anteversion, offset, cemented stems have shown outstanding durability.
and limb lengths, with the goal of restoring the native
hip center in primary THA. Modularity also allows ac-
commodation of complex proximal femoral deformities, Acetabular Component Selection and Results
especially in the setting of developmental dysplasia of the Craig J. Della Valle, MD
hip or other proximal femoral deformities. Although some Whereas THA in North America was initially performed
dual modular devices maintain a strong clinical history of with a cemented, all-polyethylene acetabular component,
success, recent device recalls secondary to taper corrosion most surgeons quickly migrated to use of noncemented
and early breakage have reduced surgeon preferences for acetabular components in the mid- to late 1980s, given the
dual modular implants. ease of insertion and the perceived benefits of modularity.
With time, this choice has proved sound, with several
Cemented Stems long-term studies showing survivorship exceeding 90%
Amar Ranawat, MD when component loosening is considered as the end point.
Since the early 1960s, cemented fixation of the femo- However, wear was a problem, and near the year 2000,
ral component has been considered the gold standard three options were available to decrease wear-related
in THA. Despite increasing trends toward noncemented complications: highly cross-linked polyethylene, ceram-
fixation in North America, cemented fixation remains ic-on-ceramic bearings, and metal-on-metal bearings.
common in many countries. The trend toward nonce- Most large databases support highly cross-linked poly-
mented fixation initially began because of concerns of ethylene as the preferred option for most patients, given
loosening and osteolysis, but ultimately became com- the low wear rates, low risk of complications and sub-
mon because noncemented fixation is more efficient and sequent revision, and lower cost when compared to the
the surgical technique is less demanding. The results of alternative choices. Although a metal femoral head has
cemented THA initially showed excellent femoral com- traditionally been used as the counterbearing on highly
ponent survivorship with rates of approximately 95% at cross-linked polyethylene, ceramic heads have become
10 years, but in one series of cemented THAs in young more common in the past 5 years because of the lower
patients, survivorship decreased to 77% and 68% at risk of head-neck corrosion, improvements in material
20 and 25 years, respectively; these findings are typical strength (which have lowered the risk of head break-
of other reported results.23 age), and a theoretical lower wear rate. Demonstrating
Four generations of cement technique have been de- a lower wear rate, however, has been challenging given
scribed in the literature. The goal of advancing cement the already low wear rates observed with highly cross-
techniques has ultimately been to achieve a 2- to 5-mm linked polyethylene, and demonstrating a clinical benefit
symmetrical cement mantle around the component to in a lower risk of revision has yet to be proved. Ceramic
achieve long-term fixation. As cement techniques have im- heads remain substantially more costly than their metal
proved, so have survivorship rates, with several studies re- counterparts, and in most health models, cost is still an
porting cemented survivorship rates of 95% at more than important factor.
3: Hip
20 years. Another study recently reported similar outcome Although fixation and wear-related complications
scores and survivorship rates (98.1% and 99.6%, respec- appear to have been reduced over time, dislocation con-
tively) for cemented and noncemented fixation using the tinues to be among the most common complications and
same femoral component at 20-year follow-up.24 Other causes of revisions following THA in North America. In
studies have also reported similar survivorship rates (96% response to the lower wear observed with highly cross-
and 95%) at 25-year follow-up in the same patients, all linked polyethylene, many surgeons have started using
of whom were younger than 50 years.25 These studies larger femoral heads. One randomized trial that com-
demonstrate that at 20- to 25-year follow-up, neither pared a 36-mm head with a 28-mm femoral head showed
a significant reduction in risk.26 Dual mobility has also

become an option that may be appropriate for patients
known to be at high risk for instability;27 however, con-
cerns persist regarding these novel constructs, and more
experience is necessary to ensure that the risks of wear
and intraprosthetic dislocation have been reduced in com-
parison with those of earlier designs.
Press-Fit Modular Component With and Without

Screws
In contemporary practice, a modular, noncemented ac-
etabular component is most commonly used (Figure 2).
Contraindications to use are rare; however, severe osteo-
porosis that cannot mechanically support a noncemented
cup while ingrowth occurs and radiation necrosis of the
pelvis are the two most common. Radiation necrosis of
the pelvis can be recognized by a chalky appearance of
the retroacetabular bone when reamed, indicating avas-
cularity that will not support osteointegration. In these
cases, cemented acetabular components do not perform
much better than noncemented ones, and a mechanical
construct, such as a reconstruction cage with multiple
Figure 2 AP radiograph obtained following primary
screws, should be used. total hip arthroplasty performed with a
Although several different noncemented designs were noncemented modular cup with screws and a
produced in the late 1980s and early 1990s, a convergence noncemented stem.
of designs has occurred, and most contemporary compo-
nents use a porous titanium surface. Given the high rates
of successful osteointegration with these components, components have resulted in more robust locking mech-
surface coatings such as hydroxyapatite are rarely used anisms in contemporary designs. The benefits of mod-
because of the cost. Coatings are now primarily reserved ularity are thought by most surgeons to outweigh the
for specialized components, such as monoblock dual-mo- potential concerns of the past.
bility and resurfacing cups; in these cases, the ingrowth The most important part of the surgical technique
surface consists of cobalt-chromium alloy (which has been for noncemented acetabular reconstruction is adequate
shown to be inferior to titanium as an ingrowth surface) exposure; if the femur is not adequately mobilized, and
and the addition of hydroxyapatite may be important to if the field of view is not clear, the accuracy of implanta-
ensure that osteointegration occurs. tion will be compromised. The amount of underreaming
Although the use of screws has been controversial, performed is based on surgeon preference; other variables
with the advent of contemporary bearing surfaces (such include whether screws will be used, surface roughness
as highly cross-linked polyethylene), osteolysis appears and stiffness of the component, and the differential be-
to be rare, so concerns about screws and screw holes as tween the labeled and true size of the component to be
access pathways for particulate debris are probably no inserted. The true size of the component is an important
longer relevant. Screws provide the mechanical stability variable; the consistent use of one component is probably
that is critical for bone ingrowth, and if the surgeon has beneficial because it results in surgeon comfort with the
3: Hip
any doubt regarding the initial mechanical stability of amount of underreaming that is required to safely insert
the cup, screws should be used, if not used routinely. The the cup while obtaining an adequate press fit. With most
screw holes also allow the surgeon to visualize the floor designs, a 1-mm underream is adequate, although line-
of the acetabulum, providing confirmation of full com- to-line reaming may certainly be acceptable (particularly
ponent seating. Similarly, although modularity has been if screws are used for adjunctive fixation), depending on
identified to contribute to backside wear of the modular the surface roughness of the component and the size of
liner among the first iterations of noncemented acetabular the cup inserted. Specifically, in a smaller-diameter ace-
components, lessons learned from these earlier generation tabulum in a female patient, even a 1-mm underream may
Section 3: Hip
result in a pelvic fracture during insertion, whereas a large The cumulative 10- to 15-year survival rates of several
male patient with a much larger-diameter acetabulum designs of monoblock cups, considering revision for cup
may easily tolerate 2 mm of underreaming. loosening as the end point, are all excellent. A recent
Positioning of the acetabular component is one of the randomized controlled trial reporting the 12-year results
most challenging and difficult problems in contemporary of 113 patients receiving either a tantalum monoblock or
practice. Recent studies have shown a large number of a porous-coated titanium monoblock cup showed survi-
cups placed outside of the safe zone, even by experienced vorship of 100% in the porous tantalum group, although
surgeons, 28 whereas other studies have challenged the idea one cup was revised for aseptic loosening at 12 years
of a safe zone, showing that many hips that subsequently after implantation in the porous-coated titanium group;
dislocate are within acceptable parameters.29 Hence, chal- significantly diminished radiolucencies were found in the
lenges exist both in achieving what is considered an ideal porous tantalum group.31
target and in understanding what the ideal target should
be (and whether that target is different depending on Highly Porous Cups for Primary and Revision THA
individual patient anatomic considerations). Recent work R. Michael Meneghini, MD
has also highlighted the complex interplay between the Third-generation highly porous titanium and tantalum
spine and the pelvis, suggesting that these relationships surfaces have been developed to further improved os-
may change over time.30 Given the importance of cup teointegration and longevity (Figure 3). These surfaces
positioning on the risk of instability and complications are rougher, providing greater initial press-fit fixation
related to bearing surface wear, more work is needed in and stability,32 and allow greater amounts of bone in-
this area. growth because they are more porous. The generally
greater flexibility may reduce the risk of stress shielding
Press-Fit Monoblock Components while also allowing greater degrees of osteointegration.
Thomas P. Sculco, MD; Ivan De Martino, MD; One recent randomized trial suggested improved fixation
Rocco D’Apolito, MD when highly porous cups were compared to a standard
The predominant failure mode of cemented and nonce- porous-coated titanium cup.31
mented acetabular component fixation has traditionally Although highly porous metal acetabular components
been osteolysis produced by a biologic reaction to par- have demonstrated excellent durability and clinical results
ticulate debris. Both metallic and polyethylene wear de- in primary THA, the revision setting represents the great-
bris have been implicated as stimuli for an inflammatory est opportunity for enhanced fixation surfaces to have a
response resulting in osteolysis and resorption of bone at substantial clinical effect because of the frequency with
the prosthetic interfaces. Although polyethylene debris is which bone loss and poor bone quality are encountered.
generated primarily at the bearing surface, wear can occur In a large clinical database review of 3,448 revision THA
secondary to motion at the interface between the liner and procedures with a noncemented acetabular component, the
the metallic shell. Fretting of screws used for adjunctive overall survival rate at 15 years was only 69%.33 Com-
fixation can occur, resulting in debris generation. Finally, pared with titanium wire mesh designs, cup revision for
the locking mechanism itself can potentially produce par- aseptic loosening was significantly more common with
ticulate debris if a ring-type configuration is used. beaded designs, but less common with highly porous tan-
In the late 1990s, noncemented monoblock acetabular talum designs. Similarly, in a 2-year retrospective clinical
components were introduced as an alternative to combat follow-up of 599 porous tantalum acetabular implants
these issues. Monoblock cups consist of nonmodular ac- used in the revision setting, no cups were revised for aseptic
etabular components in which the liner is compression- loosening.34 These implants can also be combined with
molded directly into the metallic shell framework, highly porous-coated augments, and their use in con-
eliminating the locking mechanism and dome screw holes temporary practice has superseded the use of structural
and associated concerns with backside wear and access grafts and reconstruction cages in most centers. There is
3: Hip
channels for wear debris. The polyethylene thickness also an exception for the most complex cases, for which the
tends to be greater for the same cup diameter and femoral use of combining porous-coated cups and cages has been
head sizes. Monoblock cups tend to be more difficult to advocated. Cost, however, is greater with these implants,
implant because the acetabular floor cannot be visualized and further studies will be required to determine in which
through screw holes in the surface of the shell at the time scenarios the increased costs associated with these highly
of implantation. Additionally, if revision is necessary for porous implants are justified.
acetabular wear or dislocation, the liner alone cannot be
exchanged, and full cup revision is necessary.
Figure 3 Photograph demonstrates four acetabular

components of various highly porous metal
fixation surfaces. A, P5 highly porous titanium
(DJO Surgical). B, Tritanium highly porous
revision cup (Stryker). C, Tritanium highly
porous titanium primary cup (Stryker).
D, Trabecular Metal highly porous tantalum
revision cup (Zimmer Biomet).
Figure 4 AP radiograph of a fully cemented total hip
arthroplasty in a 72-year-old man.
Cemented Cups
Matthew C. Morrey, MD; Bernard F. Morrey, MD
Although the use of cemented all-polyethylene acetabu- had a twofold higher rate of implant revision for aseptic
lar components has been reduced dramatically in North loosening than females (25-year survivorship was 95%
America, in certain areas of the world the technique is for females and 81% for males; P < 0.0001). Similar
still common, with excellent reported results (Figure 4). outcomes have subsequently been observed from the
Most North American series showed initial excellent du- larger European registries and meta-analyses, hence the
rability through the first decade; however, a higher rate of practice and recommendation that the ideal population
radiographic loosening and revision was observed beyond for cemented cups is patients older than 70 years. Ce-
10 years. To reduce the rate of failure, metal backing mented cups also have a role in the revision setting, in
was added to cemented polyethylene components in the which they have been used successfully in conjunction
early 1980s. Although the metal backing theoretically with impaction grafting or cementation into a well-fixed
reduced strains in the cement mantle, the clinical results cup, a highly porous cup with no locking mechanism, or
were worse, and use of these components was univer- a reconstruction cage.36
sally abandoned. Although reduced cost is a real benefit, The surgical technique includes reaming to subchon-
a more demanding surgical technique and the lack of dral bone; reaming is generally 2 to 4 mm greater than
modularity are disadvantages to be considered with a the diameter of the cup to be inserted. A series of pilot
cemented all-polyethylene component. holes or footings measuring 3 mm in diameter and 3 mm
Current indications for a cemented all-polyethylene in depth are then made circumferentially around the rim
component primarily include patient age older than of the acetabulum, especially in any residual sclerotic
70 years or cases in which bone stock is thought to be areas, to allow better cement intrusion and anchoring
3: Hip
inadequate to mechanically support a noncemented ac- of the implant. The acetabulum is cleansed with pulsed
etabular component while ingrowth is occurring. In one lavage to clear the interspaces of blood and fat, followed
study of 2,000 primary Charnley arthroplasties followed by the insertion of cement in the earlier stages of harden-
for 25 years, age and length of follow-up correlated most ing. Thumb pressure is used to encourage interdigitation,
strongly with outcomes.35 Survivorship free of revision followed by use of a silicone plunger to further pressurize
for aseptic loosening was poorer foreach subsequent de- the cement. The interface is carefully dried, and a com-
cade and varied from 68.2% in patients younger than ponent 2 to 4 mm smaller than the largest reamer used is
40 years to 100% for patients older than 80 years. Males inserted. To ensure a uniform cement mantle that is 2 to
Section 3: Hip
dislocation rates from 0% to 5% when used for primary

THA. A large series of 2,480 THAs reported a 0.88%
dislocation rate at an average of 7 years, and a cup survi-
vorship of 93% at 10 years.37 The 2015 Australian Ortho-
paedic Association National Joint Replacement Registry
reported on 1,702 dual-mobility hips with a 5-year cu-
mulative revision rate of 4.4% (compared with 3.3% for
294,830 non–dual-mobility acetabular components).10
Another common indication for dual-mobility bear-
ings is revision THA, and in some centers, dual-mobility
bearings have been used as an alternative to constrained
liners.38 These patients are at a significantly increased risk
of perioperative instability, and the use of dual-mobility
bearings has been advocated as a means to reduce this
complication. In cases of previous instability, the use of a
Figure 5 Intraoperative photograph of a total hip dual-mobility bearing at the time of revision has proven
arthroplasty demonstrates a dual-mobility
bearing. successful in minimizing recurrence. In a series of 51 pa-
tients with a history of recurrent dislocation who were
given a dual-mobility bearing during revision, the redislo-
cation rate was 4.3% at a mean follow-up of 51 months,
3 mm thick, cups with polymethyl methacrylate studs on which is impressive when compared to findings of prior
the surface can be used. series.39
Dual-Mobility Articulations
Steven J. MacDonald, MD
Femoral Head Size
Dual-mobility articulations were first introduced in Charles R. Bragdon, PhD; John J. Callaghan, MD;
France in the 1970s and to the North American market Andrew A. Freiberg, MD; Young-Min Kwon, MD;
in approximately 2010. This bearing is available in either Harry E. Rubash, MD; Kyle W. Lacey, MD, MS
monoblock or modular design, which includes a highly Early debate concerning the optimal head size in THA
polished inner bearing that articulates with a large poly- focused on those between 22 and 32 mm. This was based
ethylene head that has a smaller-diameter ball inserted on the low frictional torque associated with small femoral
into the polyethylene in a manner similar to that in a bipo- heads (that is, frictional torque is related to the radius
lar head (Figure 5). The primary advantage of this design squared) and the large contact area; hence, low contact
is that it helps reduce the risk of dislocation, with some stress was associated with large femoral heads (stress =
advocating its use in patients at high risk for dislocation force/area). A classic study showed higher linear wear
following primary and revision surgery.27 The primary associated with 22-mm heads and high volumetric wear
risks associated with this design include accelerated wear, associated with 32-mm heads.40 This resulted in 28-mm
as two bearing surfaces are present; one of these surfaces heads as the most common choice in the 1980s and 1990s.
is convex, which is suboptimal for wear. Further, if wear In the 1990s, long-term wear studies demonstrated lower
occurs around the introitus, where the smaller ball artic- linear and volumetric wear with 22-mm heads. The expla-
ulates with the polyethylene, intraprosthetic dislocation nation for the reduction of wear with smaller head sizes
can occur, in which the smaller head dislocates from the was related to the decrease in sliding distance during gait.
polyethylene bearing. All of these studies were performed on polyethylene that
Current suggested indications for dual-mobility bear- had been gamma-irradiated in air.
3: Hip
ings include high risk for dislocation, including high pre- In the late 1990s, moderately and highly cross-linked
operative range of motion, advanced age or cognitive polyethylene became available. With time, cross-linked
impairment, history of alcohol or substance abuse, ab- polyethylene was shown to provide a 5-fold to 10-fold
ductor deficiency, femoral neck fractures, or underlying improvement in wear resistance when compared to poly-
neuromuscular disorders. Their use is relatively contrain- ethylene sterilized by gamma-radiation in air. Because
dicated in younger patients because the literature is insuf- dislocation has been recognized as a leading cause of
ficient to support this application. Many published series failure, larger femoral heads have been preferred given
with short-term to midterm results have demonstrated their association with an increased head-to-neck ratio,
an increased primary arc range of motion before compo- which can increase contact stresses, may be at highest
nent-to-component impingement, and an increased jump risk for liner fracture. Although rim fractures have been
distance, all of which result in greater THA stability. A reported with highly cross-linked polyethylene, these re-
randomized trial in patients undergoing primary THA ports are rare.
performed via a posterior approach compared 28- and 36- An additional concern is the increased forces at the
mm femoral heads (on highly cross-linked polyethylene) head-neck junction caused by use of larger heads that may
and showed a significant decrease (five times lower) in result in a greater risk of corrosion at the modular head-
incidence of dislocation within the first year after primary neck junction. One experimental study on biomechanics
THA.26 A similar benefit has been found with patients un- has demonstrated increased frictional torque with a larger
dergoing THA with an anterolateral approach and using metal head and with a metal head articulating with vi-
larger head sizes (36 mm or larger); a lower dislocation tamin E, compared to highly cross-linked polyethylene.
rate was reported than for those with heads less than This could result in increased stresses at the modular
36 mm in diameter.41 Finally, in a study of 501 patients head-neck junction43 and a concomitant increase in the
undergoing primary THA, all of whom were considered risk of corrosion that could result in ALTR.44
to be at high risk for dislocation, 282 of the patients The development and use of highly cross-linked poly-
given 36-mm femoral heads were compared with 219 pa- ethylene liners in THA has resulted in significantly lower
tients with anatomic femoral heads greater than 36 mm; long-term wear rates when compared to conventional
a significant difference in dislocation rate was observed (ultra-high–molecular-weight) polyethylene. This has al-
between the two groups favoring the anatomic femoral lowed for use of larger femoral head sizes, which appear
heads (4.6% and 0.5%, respectively).27 to reduce the risk of dislocation, with wear rates reduced
Larger femoral head size increases range of motion to what is believed to be the threshold for the development
by increasing the primary arc range as well as the jump of clinically relevant osteolysis. However, a recent long-
distance, resulting in greater range of motion before term follow-up study of highly cross-linked polyethylene
neck-cup impingement occurs. Although an increase in has demonstrated some osteolysis at 10 to 14 years in 14%
impingement-free range of motion following THA is the- of hips and median volumetric wear rates of 3.1, 12.3,
oretically advantageous, an improvement in functional 12.9, and 26.1 mm3 per year with head sizes of 26, 28, 32,
outcome through the use of larger heads has limited sup- and 36 to 40 mm, respectively.45 Given these concerns, a
port in the literature. A prospective study of 726 THAs, 32-mm head is favored by many surgeons for the patient
investigating functional outcomes at 6 and 12 months who is at low risk for dislocation, whereas other surgeons
postoperatively as measured by the Oxford hip score, routinely use the largest size femoral head that can be
WOMAC, High-Activity Arthroplasty Score, and Uni- accommodated by the system that they use.
versity of California Los Angeles activity score, compared
femoral head size groups: less than 36 mm, 36 mm, and
greater than 36 mm. Although a significant increase was Summary
seen in the High-Activity Arthroplasty Score 3 (over-
all), University of California Los Angeles, and WOMAC Improvements in both materials and design continue to
scores between groups with the large and smaller heads improve the durability of THA. Although noncemented
at 6 months, there was no statistically significant differ- fixation predominates in North America, cemented fixa-
ence seen in any of the functional outcome measures at tion clearly still has a role. As instability remains among
12 months. A decrease in dislocation rate was seen in the the most common modes of failure for THA, increased
group with femoral heads 36 mm or larger.42 interest has been shown in both the routine use of larger
However, concerns exist about larger femoral heads, femoral head sizes as well as dual-mobility bearings; how-
including the requirement for thinner polyethylene, espe- ever, both concepts require further evaluation to ensure
cially peripherally, at the capturing mechanism of mod- durability over the longer term. The continued careful
3: Hip
ular acetabular shells. This is especially concerning with evaluation of implant performance over time will yield
highly cross-linked polyethylene, which has decreased even greater clarity on the optimal techniques for opti-
strength and decreased fatigue properties related to the mizing outcomes following THA.
cross-linking process. Cups that are positioned vertically,
Section 3: Hip
Key Study Points 4. Wechter J, Comfort TK, Tatman P, Mehle S, Gioe TJ:
Improved survival of uncemented versus cemented fem-
• Noncemented femoral fixation has proved superior oral stems in patients aged < 70 years in a community
total joint registry. Clin Orthop Relat Res 2013;471(11):
for younger patients; however, overall survivorship 3588-3595. Medline DOI
for older patients may still favor cemented femoral
fixation. In 6,498 primary noncemented THAs in a community-
based North American Registry, noncemented stems had
• Contemporary modular cementless cups are ap- a lower risk of revision for aseptic loosening or wear than
propriate for most patients; however, cemented all- cemented stems in patients younger than 70 years.
polyethylene components have shown good results
in older patient populations. 5. Thien TM, Chatziagorou G, Garellick G, et al: Peripros-
thetic femoral fracture within two years after total hip
• Highly porous metals have the advantages of replacement: Analysis of 437,629 operations in the nordic
greater surface roughness, increased porosity, and arthroplasty register association database. J Bone Joint
a modulus of elasticity more similar to that of Surg Am 2014;96(19):e167. Medline DOI
bone; however, concise advantages over standard In a study of 325,730 cemented and 111,899 noncemented
titanium ingrowth surfaces have been difficult to stems, the risk of periprosthetic fracture at 2 years was
demonstrate. 0.47% for noncemented stems and 0.07% for cemented
stems. The risk of periprosthetic fracture increased with
• Dual-mobility articulations appear to be a reason- increasing age for noncemented stems.
able option for primary and revision THA in the
patient considered to be at high risk for dislocation. 6. Taunton MJ, Dorr LD, Long WT, Dastane MR, Berry
DJ: Early postoperative femur fracture after uncemented
• Highly crossed-linked bearings have allowed for
collarless primary total hip arthroplasty: Characterization
the safe use of larger femoral head sizes that have and results of treatment. J Arthroplasty 2015;30(11):2008-
been shown to reduce the risk of dislocation, al- 2011. Medline DOI
though concerns remain regarding longer term Early periprosthetic fractures occurred in 0.7% of non-
performance. cemented collarless primary THAs and the fractures had
a stereotypical pattern of a displaced triangular frag-
ment, which included the medial femoral neck and lesser
trochanter.
Annotated References 7. Gjertsen JE, Lie SA, Vinje T, et al: More re-operations after
uncemented than cemented hemiarthroplasty used in the
treatment of displaced fractures of the femoral neck: An
1. McMinn DJ, Snell KI, Daniel J, Treacy RB, Pynsent PB,
observational study of 11,116 hemiarthroplasties from a
Riley RD: Mortality and implant revision rates of hip ar-
national register. J Bone Joint Surg Br 2012;94(8):1113-
throplasty in patients with osteoarthritis: Registry based
1119. Medline DOI
cohort study. BMJ 2012;344:e3319. Medline DOI
More reoperations took place after noncemented hemi-
In a study of 275,000 THAs from the UK National Joint
arthroplasty (mainly resulting from periprosthetic
Registry, the risk of revision was slightly higher for non-
fractures and aseptic loosening) than after cemented
cemented THAs, but the risk of death was slightly higher
hemiarthroplasties in this study of 8,639 cemented and
for patients with cemented THAs.
2,477 noncemented hemiarthroplasties performed for
femoral neck fractures from the Norwegian Joint Registry.
2. Pedersen AB, Mehnert F, Havelin LI, et al: Association
between fixation technique and revision risk in total hip
8. Hossain M, Andrew JG: Is there a difference in peri-
arthroplasty patients younger than 55 years of age. Results
operative mortality between cemented and uncemented
from the Nordic Arthroplasty Register Association. Osteo-
implants in hip fracture surgery? Injury 2012;43(12):2161-
arthritis Cartilage 2014;22(5):659-667. Medline DOI
2164. Medline DOI
In a study of 29,558 primary THAs from the Nordic Ar-
Perioperative death was more common after cemented
throplasty registry, noncemented THAs had a lower rate
than noncemented hemiarthroplasty in patients with hip
3: Hip
of revision for aseptic loosening than cemented or hybrid

fracture.
THAs in patients younger than 55 years.
9. Yli-Kyyny T, Ojanperä J, Venesmaa P, et al: Periop-
3. Stea S, Comfort T, Sedrakyan A, et al: Multinational
erative complications after cemented or uncemented
comprehensive evaluation of the fixation method used in
hemiarthroplasty in hip fracture patients. Scand J Surg
hip replacement: Interaction with age in context. J Bone
2013;102(2):124-128. Medline DOI
Joint Surg Am 2014;96(suppl 1):42-51. Medline DOI
In 222 hip fracture patients treated with hemiarthroplasty
Using a distributed registry network, for patients age
(100 noncemented, 122 cemented) more deaths (4.1%
75 years or older, noncemented THA fixation had a higher
versus 1%) occurred in the cemented group, but more
risk of revision than hybrid fixation.
perioperative periprosthetic fractures occurred in the non- and radiographic comparison showed no difference in the
cemented group (7.0% versus 0.8%). restoration of femoral offset.
10. Australian Orthopaedic Association: National Joint Re- 18. Jones C, Aqil A, Clarke S, Cobb JP: Short uncemented
placement Registry: 2015 Annual Reports. Available at stems allow greater femoral flexibility and may reduce
https://aoanjrr.sahmri.com/. Accessed August 9, 2016. peri-prosthetic fracture risk: A dry bone and cadav-
eric study. J Orthop Traumatol 2015;16(3):229-235.
11. Capello WN, D’Antonio JA, Jaffe WL, Geesink RG, Man- Medline DOI
ley MT, Feinberg JR: Hydroxyapatite-coated femoral com- In this biomechanical study, shorter stems failed at a sig-
ponents: 15-year minimum followup. Clin Orthop Relat nificantly higher torque. Shorter stems allow more femoral
Res 2006;453:75-80. flexibility and confer a higher resistance to periprosthetic
fracture.
12. Loughead JM, O’Connor PA, Charron K, Rorabeck
CH, Bourne RB: Twenty-three-year outcome of the po- 19. Molli RG, Lombardi AV Jr, Berend KR, Adams JB, Sneller
rous coated anatomic total hip replacement: a concise MA: A short tapered stem reduces intraoperative compli-
follow-up of a previous report. J Bone Joint Surg Am cations in primary total hip arthroplasty. Clin Orthop
2012;94(2):151-155. Relat Res 2012;470(2):450-461. Medline DOI
13. Parvizi J, Sharkey PF, Hozack WJ, Orzoco F, Bissett GA, In a comparison of 389 shorter stems with 269 standard-
Rothman RH: Prospective matched-pair analysis of hy- length wedge-fit stems, the number of intraoperative com-
droxyapatite-coated and uncoated femoral stems in total plications (fractures) was reduced with the shorter stem,
hip arthroplasty. A concise follow-up of a previous report. and no difference in survival or clinical scores was found
J Bone Joint Surg Am 2004;86-A(4):783-786. at a mean follow-up of 29.2 months.
14. Petis SM, Howard JL, McAuley JP, Somerville L, Mc- 20. Le D, Smith K, Tanzer D, Tanzer M: Modular femoral
Calden RW, MacDonald SJ: Comparing the long-term sleeve and stem implant provides long-term total hip sur-
results of two uncemented femoral stems for total hip vivorship. Clin Orthop Relat Res 2011;469(2):508-513.
arthroplasty. J Arthroplasty 2015;30(5):781-785. Medline DOI
Medline DOI In 26 patients implanted with 31 modular femoral com-
In a study that compared longer-term results of two stems, ponents, clinical follow-up at a mean of 17 years demon-
one extensively porous-coated and one proximally porous- strated 100% osseous integration radiographically. No
coated, survivorship was equivalent, but thigh pain oc- revisions for aseptic femoral loosening were observed.
curred more often and proximal femoral stress shielding Osteolysis was seen in 18 cases.
was more severe in the group with the extensively po-
rous-coated stem. 21. Duwelius PJ, Burkhart B, Carnahan C, et al: Modular
versus nonmodular neck femoral implants in primary total
15. Barrington JW, Emerson RH Jr: The short and “shorter” hip arthroplasty: Which is better? Clin Orthop Relat Res
of it: >1750 tapered titanium stems at 6- to 88-month 2014;472(4):1240-1245. Medline DOI
follow-up. J Arthroplasty 2013;28(8suppl):38-40. In this study, a group of 284 patients who received a non-
Medline DOI modular stem implant was compared with 594 patients
At a mean follow-up of 36 months, stem survivorship who received a dual modular neck. More patients in the
was not significantly different between shorter and longer modular component group had equal limb lengths and
stems. offset restoration, but the two groups showed no difference
in clinical outcome scores.
16. Salemyr M, Muren O, Ahl T, et al: Lower peripros-
thetic bone loss and good fixation of an ultra-short 22. Meftah M, Haleem AM, Burn MB, Smith KM, Incavo
stem compared to a conventional stem in uncemented SJ: Early corrosion-related failure of the rejuvenate
total hip arthroplasty. Acta Orthop 2015;86(6):659-666. modular total hip replacement. J Bone Joint Surg Am
In this study of an ultrashort stem and a standard stem, Of 97 patients who received a modular neck femoral
dual-energy x-ray absorptiometry showed less bone loss component (Rejuvenate), review at a mean follow-up of
with the short stem in all zones. Subsidence was greater 2.7 years showed that 28% required revision related to
3: Hip
among short stems at 6 weeks, but at 2 years the clinical corrosion associated with the modular junction; 4-year
outcome was not different. survival was 40%.
17. von Roth P, Perka C, Mayr HO, et al: Reproducibility of 23. Lampropoulou-Adamidou K, Georgiades G, Vlamis J,
femoral offset following short stem and straight stem to- Hartofilakidis G: Charnley low-friction arthroplasty in
tal hip arthroplasty. Orthopedics 2014;37(7):e678-e684. patients 35 years of age or younger. Results at a mini-
Medline DOI mum of 23 years. Bone Joint J 2013;95-B(8):1052-1056.
Medline DOI
In this randomized study of short and standard stems, no
differences were reported in clinical scores at 6 weeks,
Section 3: Hip
In this long-term study of 41 consecutive young patients, Stability is multifactorial and the ideal implant position
survivorship of the femoral component was 95.1% at may lie outside of standard parameters for some patients.
10 years, 77.1% at 20 years, and 68.2% at 25 years.
30. Buckland AJ, Vigdorchik J, Schwab FJ, et al: Acetabu-
24. Meding JB, Ritter MA, Davis KE, Hillery M: Ce- lar anteversion changes due to spinal deformity correction:
mented and uncemented total hip arthroplasty using the Bridging the gap between hip and spine surgeons. J Bone
same femoral component. Hip Int 2016;26(1):62-66. Joint Surg Am 2015;97(23):1913-1320. Medline DOI
Medline DOI
In this 20-year study of 507 cemented and 510 nonce- 31. Wegrzyn J, Kaufman KR, Hanssen AD, Lewallen DG:
mented stems of the same design, the survivorship at Performance of porous tantalum vs. titanium cup in total
20 years was 98.1% and 99.6%, respectively. hip arthroplasty: Randomized trial with minimum 10-
year follow-up. J Arthroplasty 2015;30(6):1008-1013.
Medline DOI
25. Kim YH, Park JW, Kim JS, Kim IW: Twenty-five- to
twenty-seven-year results of a cemented vs a cementless In this randomized trial of 113 patients receiving either
stem in the same patients younger than 50 years of age. tantalum monoblock or a porous-coated titanium mono-
J Arthroplasty 2016;31(3):662-667. Medline DOI block cup, survivorship was 100% in the tantalum group,
with one hip requiring revision for loosening in the tita-
In this study of 171 patients (mean age, 47.7 years) who nium group; fewer radiolucencies were reported in the
underwent simultaneous bilateral THA with a cemented tantalum group.
stem on one side and a noncemented stem on the other, no
difference was reported in the survivorship of the femoral
components. 32. Meneghini RM, Meyer C, Buckley CA, Hanssen AD,
Lewallen DG: Mechanical stability of novel highly porous
metal acetabular components in revision total hip arthro-
26. Howie DW, Holubowycz OT, Middleton R; Large Ar- plasty. J Arthroplasty 2010;25(3):337-341. Medline DOI
ticulation Study Group: Large femoral heads decrease
the incidence of dislocation after total hip arthroplasty: In this biomechanical study simulating revision THA with
A randomized controlled trial. J Bone Joint Surg Am a superolateral acetabular defect, highly porous designs
2012;94(12):1095-1102. Medline DOI were associated with superior initial implant stability
when compared to a traditional noncemented cup.
In this randomized study of 644 primary and revision
THAs, patients received either a 28- or 36-mm femoral
head. Those who received the 36-mm head group had a 33. Kremers HM, Howard JL, Loechler Y, et al: Comparative
significantly lower incidence of dislocation (1.3% versus long-term survivorship of uncemented acetabular compo-
5.4%). nents in revision total hip arthroplasty. J Bone Joint Surg
Am 2012;94(12):e82. Medline DOI
27. Haughom BD, Plummer DR, Moric M, Della Valle CJ: In this review of 3,448 revision THAs, the overall sur-
Is there a benefit to head size greater than 36 mm in to- vival rate at 15 years was 69%. Compared with titanium
tal hip arthroplasty? J Arthroplasty 2016;31(1):152-155. wire mesh designs, aseptic loosening was more common
Medline DOI with beaded designs but less common with highly porous
tantalum designs.
In this retrospective review of 501 patients at higher risk
for dislocation undergoing primary THA, 36-mm fem-
oral heads had a higher dislocation rate than anatomic 34. Long WJ, Noiseux NO, Mabry TM, Hanssen AD, Le-
head sizes (such as large diameter metal-on-metal THA, wallen DG: Uncemented porous tantalum acetabular
dual-mobility, or hip resurfacing arthroplasty). components: Early follow-up and failures in 599 revision
rotal hip arthroplasties. Iowa Orthop J 2015;35:108-113.
Medline
28. Callanan MC, Jarrett B, Bragdon CR, et al: The John
Charnley Award: risk factors for cup malpositioning: In this short-term follow-up study, no cases of aseptic
quality improvement through a joint registry at a tertiary loosening were seen with a highly porous-coated cup used
hospital. Clin Orthop Relat Res 2011;469(2):319-329. for revision THA.
Medline DOI
In this series of 1,823 hips, only 50% were in the safe zone 35. Berry DJ, Harmsen WS, Cabanela ME, Morrey BF: Twen-
for abduction and anteversion. Lower patient volume for ty-five-year survivorship of two thousand consecutive
primary Charnley total hip replacements: Factors affect-
3: Hip
the surgeon, minimally invasive approaches, and obesity

were associated with cup malposition. ing survivorship of acetabular and femoral components.
J Bone Joint Surg 2002;84-A(2):171-177. Medline
29. Abdel MP, von Roth P, Jennings MT, Hanssen AD, Pag- In this 25-year study of 2,000 Charnley THAs, age was
nano MW: What safe zone? The vast majority of dis- the strongest factor that affected survivorship, ranging
located THAs are within the Lewinnek safe zone for from 69% for patients younger than 40 years to 100%
acetabular component position. Clin Orthop Relat Res for patients older than 80 years.
2016;474(2):386-391. Medline DOI
In a review of 206 hips that dislocated after THA from 36. Tan TL, LeDuff MJ, Ebramzadeh E, Bhaurla SK, Ans-
one institution, 58% were in the Lewinnek safe zone. tutz HC: Long-term outcomes of liner cementation into
a stable retained shell: A concise follow0up of a previ- 42. Allen CL, Hooper GJ, Frampton CM: Do larger fem-
ous report. J Bone Joint Surg Am 2015;97(11):920-924. oral heads improve the functional outcome in total
Medline DOI hip arthroplasty? J Arthroplasty 2014;29(2):401-404.
Medline DOI
37. Combes A, Migaud H, Girard J, Duhamel A, Fessy After THA, 726 patients were divided into small (less than
MH: Low rate of dislocation of dual-mobility cups in 36 mm), medium (36 mm), and large (36 mm or larger)
primary total hip arthroplasty. Clin Orthop Relat Res head-size groups. The large femoral head group showed a
2013;471(12):3891-3900. Medline DOI reduced dislocation rate, but no significant improvement
In this series of 2,480 primary THAs (2,179 patients), the in functional outcome.
dislocation rate was 0.88% at a mean of 7 years.
43. Meneghini RM, Lovro LR, Wallace JM, Ziemba-Davis
38. Plummer DR, Christy JM, Sporer SM, Paprosky WG, M: Large metal heads and vitamin E polyethylene increase
Della Valle CJ: Dual-Mobility Articulations for Patients frictional torque in total hip arthroplasty. J Arthroplasty
at High Risk for Dislocation. J Arthroplasty 2016;Mar 2016;31(3):710-714. Medline DOI
17 [Epub ahead of print]. Medline DOI This experimental study demonstrated increased fric-
In this minimum 2-year study of 36 patients at high risk tional torque of vitamin E polyethylene and larger cobalt-
for dislocation following revision THA (including abduc- chromium femoral head constructs when compared to
tor deficiency), four failures occurred, but none was related smaller heads and cross-linked polyethylene.
to recurrent instability.
44. Plummer DR, Berger RA, Paprosky WG, Sporer SM, Ja-
39. Hamadouche M, Biau DJ, Huten D, Musset T, Gau- cobs JJ, Della Valle CJ: Diagnosis and management of
cher F: The use of a cemented dual mobility socket to adverse local tissue reactions secondary to corrosion at
treat recurrent dislocation. Clin Orthop Relat Res the head-neck junction in patients with metal on poly-
2010;468(12):3248-3254. Medline DOI ethylene bearings. J Arthroplasty 2016;31(1):264-268.
Medline DOI
40. Livermore J, Ilstrup D, Morrey B: Effect of femoral head A study of 27 patients with metal-on-polyethylene bear-
size on wear of the polyethylene acetabular component. ings who underwent revision surgery for ALTR secondary
J Bone Joint Surg Am 1990;72(4):518-528. to corrosion at the head-neck junction showed that modu-
lar bearing exchange, with the use of a ceramic head with
41. Stroh DA, Issa K, Johnson AJ, Delanois RE, Mont MA: a titanium sleeve, was successful for treatment.
Reduced dislocation rates and excellent functional out-
comes with large-diameter femoral heads. J Arthroplasty 45. Lachiewicz PF, Soileau ES, Martell JM: Wear and osteol-
2013;28(8):1415-1420. Medline DOI ysis of highly crosslinked polyethylene at 10 to 14 years:
In this 5-year comparison of 248 THAs with large diam- The effect of femoral head size. Clin Orthop Relat Res
eter (greater than 36 mm) and 559 THAs with smaller 2016;474(2):365-371. Medline DOI
diameter heads (smaller than 36 mm) performed via an In 84 hips with 10-kGy irradiated and remelted poly-
anterolateral approach, a higher rate of dislocation was ethylene femoral components, evaluated at 10 to 14 years,
noted in the small-diameter group (1.8% versus 0%). no difference was seen in linear wear between head sizes,
but larger heads demonstrated more volumetric wear.
Small osteolytic lesions were seen in 14% of hips.
3: Hip
Chapter 31
Primary Total Hip Arthroplasty

in Challenging Conditions
Andrew H. Glassman, MD, MS Michael Tanzer, MD, FRCSC Richard Iorio, MD
John M. Dundon, MD Yousuf Sayeed, MS Mathias PG. Bostrom, MD Michael D. Ries, MD
Robert T. Trousdale, MD Nicholas M. Desy, MD, FRCSC
and acetabular sides on both sides of the hip joint. It is

Abstract
important to be knowledgeable about the general princi-
Challenging conditions in the context of total hip arthro- ples and outcomes of these techniques.
plasty are those in which the likelihood of intraoperative
technical difficulties, perioperative complications, or
Developmental Dysplasia of the Hip
premature failure is more likely than usual. Such condi-
tions can be of congenital, genetic, metabolic, endocrine, Michael Tanzer, MD, FRCSC; Andrew Glassman, MD, MS
neurologic, or traumatic origin. Success in managing Background
such conditions requires a thorough understanding of Primary THA for management of developmental dyspla-
the underlying condition and its implications relevant sia of the hip (DDH) presents unique challenges on both
to total hip arthroplasty. All such conditions require the acetabular and femoral sides. An understanding of the
careful preoperative planning, adequate exposure, and bony and soft-tissue deformities that occur in dysplasia
familiarity with a variety of adjunctive techniques such is crucial for the success of the THA and to minimize
corrective osteotomy, the use of structural allografts, the risk of complications. The techniques and outcomes
and trochanteric osteotomy. The surgeon must also be of primary THA for dysplasia depend on the severity
familiar with a variety of different femoral and ace- of DDH. Recent techniques of acetabular and femoral
tabular components including modular stems, bipolar, reconstruction have yielded significant improvements in
dual mobility and constrained acetabular components, clinical outcomes with survivorship rates similar to those
and occasionally, custom implants. A team approach to of THA for osteoarthritis.
assist in the management of the medical comorbidities
associated with certain of these conditions may enhance Acetabulum
patient care and reduce complications. Changes in the acetabular anatomy range from mild dys-
plasia to subluxation and complete dislocation of the hip.
The reconstructive techniques and outcomes are depen-
Keywords: developmental dysplasia; femoral dent on the severity of these changes.
deformity; neuromuscular disease; posttraumatic The acetabulum in DDH has a shallow articular cavity,
osteoarthritis; metabolic bone disease; Paget increased anteversion, insufficient acetabular coverage of
disease; fibrous dysplasia; achondroplasia; the femoral head, and a deficient anterior wall.1 In the case
of a low hip dislocation, there is a false acetabulum that
3: Hip
acetabular fracture; protrusion

partially covers the true acetabulum and the femoral head
is typically contained within the false acetabulum. The
acetabulum usually has an anterior segmental defect or a
posterior wall deficiency, is oval shaped, and has increased
Introduction
anteversion.1 In the case of a high hip dislocation, the fem-
Various difficult, but not necessarily uncommon, con- oral head migrates posterosuperiorly and the acetabulum
ditions result in a challenging primary total hip arthro- is narrow, shallow, and triangular in shape; the iliac wing
plasty (THA). The difficulties may involve the femoral is also anteverted and the entire rim of the acetabulum
Section 3: Hip
may be deficient.1 Implanting an acetabular component host-bone coverage is usually obtained from the anterior
in patients with DDH can be challenging because the and posterior walls of the true acetabulum. Finally, the
anatomic landmarks are difficult to identify and the bony acetabular component should be anteverted based on the
anatomy can be severely compromised. As a result, careful combined orientation of both the acetabular and femoral
preoperative templating is imperative to characterize the component to maximize stability and range of motion.
patient’s individual anatomy and available bone stock. Acetabular reconstruction with restoration of the hip
Doing so will minimize the risk of the acetabular compo- center has yielded good results. The results of 50 Crowe
nent malposition and unplanned medial wall penetration. type III and IV hips with mean 6.4-year follow-up (range,
Ideally, the acetabular component should be placed close 2.2 to 11.5 years) using noncemented cups placed in the
to the teardrop, in the true acetabulum, as a platform for anatomic position were reported in a 2012 study.3 No hip
the restoration of hip offset and restoration of hip biome- had any adjuvant lateral bone graft. At final follow-up,
chanics. However, depending on the age of the patient the Harris hip score increased from 40 preoperatively to
and the anatomy, this ideal may be modified to provide 86 (P = 0.03) and no cups were revised. One study re-
sufficient acetabular implant coverage.2 ported the outcome of 52 hips with DDH with 30% to
The typical acetabular reconstructive technique in- 50% lateral uncoverage of uncemented acetabular com-
cludes several steps.1,2 The center of rotation should be ponents at the time of THA.4 The uncovered portion
restored as close as possible to the native hip center. above the component was reconstructed by filling with
Noncemented components should be used, whereby the particulate bone autograft. At a mean of 4.8 years (range,
anteroposterior dimension of the native acetabulum dic- 3 to 7 years) there were no loose or revised cups. Based
tates the size of the cup. In cases of subluxation, slight on these findings, it was proposed that a cup that has
medialization of the hip center of rotation can be used to initial stability and up to 17 mm of lateral uncoverage,
avoid the use of a bulk autograft for reconstruction. In supplemented with particulate bone grafting, would have
cases of low hip dislocation, socket uncoverage (generally an acceptable outcome.
>30%) usually requires augmentation with a femoral head The technique of bulk autogenous grafting to achieve
autograft (Figure 1). In cases of high dislocation, a small superolateral bone coverage was first described in
noncemented acetabular component (average outside di- 1977.5 Although the early results were promising, lon-
ameter 38 to 44 mm) is placed in the native acetabulum. ger-term outcomes have been mixed. In an 11.6-year fol-
A femoral head autograft is not required because complete low-up study (range, 7 to 24 years), 115 hips with DDH
Dr. Glassman or an immediate family member has received royalties from Exactech Inc., Innomed, is a member of a
speakers’ bureau or has made paid presentations on behalf of Exactech Inc., serves as a paid consultant to Exactech
Inc., has received research or institutional support from Stryker, andserves as a board member, owner, officer, or com-
mittee member of the AAOS, The Columbus (Ohio) Orthopaedic Society: President. Dr. Tanzer or an immediate family
member serves as a paid consultant to Pipeline Biotechnology, Zimmer, has received research or institutional support
from Zimmer, has received nonincome support (such as equipment or services), commercially derived honoraria, or
other non–research-related funding (such as paid travel) from Zimmer, and serves as a board member, owner, officer,
or committee member of I – Society. Dr. Ries or an immediate family member has received royalties from Smith & Neph-
ew, Stryker, serves as a paid consultant to Smith & Nephew, Stryker, has stock or stock options held in OrthAlign, and
serves as a board member, owner, officer, or committee member of the Foundation for the Advancement of Research
in Medicine. Dr. Iorio or an immediate family member serves as a paid consultant to DJ Orthopaedics, MCS ActiveCare,
Pacira, has stock or stock options held in Wellbe, has received research or institutional support from APOS Medical &
Sports Technologies Ltd., Bioventis, Ferring Pharmaceuticals, Orthofix Inc., Orthosensor, Pacira, Vericel, and serves as a
3: Hip
board member, owner, officer, or committee member of the American Association of Hip and Knee Surgeons, the Hip
Society, the Knee Society.Dr. Bostrom or an immediate family member serves as a paid consultant to Smith & Nephew,
has received research or institutional support from Bone Support, Smith & Nephew, and serves as a board member,
owner, officer, or committee member of the Orthopaedic Research Society. Dr. Trousdale or an immediate family mem-
ber has received royalties from DePuy, Medtronic, serves as a paid consultant to or is an employee of DePuy, and serves
as a board member, owner, officer, or committee member of the American Association of Hip and Knee Surgeons, the
Hip Society, the Knee Society. None of the following authors or any immediate family member has received anything
of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to
the subject of this chapter: Dr. Dundon, Mr. Sayeed, and Dr. Desy.
Chapter 31: Primary Total Hip Arthroplasty in Challenging Conditions
Figure 1 A, Preoperative AP pelvis radiograph from a 48-year-old woman with developmental dysplasia of the hip
demonstrating severe arthritis of the left hip with superior subluxation of the femoral head. B, AP pelvis
radiograph 4 years following THA with a noncemented acetabular component fixed with screws, a bulk femoral
head autograft to the pelvis, and a modular femoral stem. C, Lateral radiograph of the hip demonstrating that the
modular femoral stem is retroverted, relative to the anatomically placed proximal sleeve, to correct the excessive
femoral anteversion.
had an acetabular reconstruction using a bulk autograft when the cup is placed at least 20 mm superior, but not
at the time of THA.5 The overall rate of revision for asep- lateral to the anatomic hip center.10
tic loosening was 16%. The Kaplan-Meier survivorship
curves predicted a rapid increase in the failure rate at Femur
15 years, bringing into question the long-term results In DDH, the femur has a shorter neck, increased antever-
of this reconstructive technique. A novel technique was sion, a smaller canal width, thinner cortices, a straight
described that combines the use of a bulk femoral head contour, and the anterior bow of the femur displaced fur-
autograft with a beveled slot created in the ilium, thereby ther distally with increasing degrees of dysplasia.7 The
allowing impaction of the graft to achieve primary sta- femoral implant and reconstruction technique must take
bility of the graft.6 At 8.1-year follow-up, all grafts had into account these anatomic changes in the femur. Addi-
united and there was no radiographic evidence of graft tionally, it must be determined whether femoral shortening
collapse or loosening. will be required if the prosthetic hip center is placed in the
It may not always be feasible to re-create the anatomic anatomic position. Both cemented and noncemented stems
hip center at the time of THA due to excessive acetabu- have been successfully used in DDH. Modular stems, nar-
lar deficiencies.7 An alternative technique to obtain ac- row diaphyseal-fixed cone-type tapered stems, and narrow
etabular bony coverage is to use a high hip center with cemented stems are most commonly used to allow correc-
superior placement of the cup. The influence of a high tion of the excessive femoral anteversion and to reconcile
hip center on hip abductor strength and the presence of the metaphyeal-diaphyseal size mismatch seen in DDH
a Trendelenburg sign in patients with DDH was assessed (Figure 1). Femoral shortening with a subtrochanteric
in a 2013 study.8 As long as the femoral component re- femoral shortening osteotomy and implantation of an
stored the femoral offset and the abductor lever arm, a uncemented stem is most commonly performed in Crowe
high center of hip rotation (up to approximately 30 mm IV hips to prevent overlengthening of the leg when the hip
from the interteardrop line) resulted in only 10% of the is brought down to the anatomic hip center. This technique
patients with DDH having a Trendelenburg sign. How- requires that the femur is reamed or broached before the
ever, a higher loosening and revision rate of both the osteotomy. Next, a transverse osteotomy is created in the
femoral and acetabular components has been reported in subtrochanteric region, and a trial component is inserted
DDH when a cemented acetabular cup is placed superior into the proximal fragment. The hip is reduced, and the
3: Hip
and/or lateral to the anatomic position.9 It would there- amount of femoral shortening necessary is determined in-
fore seem prudent to reserve this technique for the elderly traoperatively by overlapping the two fragments. A second
patient in whom an anatomic position would leave more cut is made, removing the overlapping proximal portion
than 40% to 50% of the socket surface uncovered or of the distal femur. The tip of the trial component is then
covered by bone graft.2 If a high hip center is required for inserted and reduced into the distal fragment while adjust-
reconstruction, it is important to avoid lateral placement ing for anteversion. The goal of the osteotomy is to avoid
of the cup. One study showed no acetabular loosening at overlengthening of the leg and subsequent sciatic nerve
10-year follow-up in their series of 30 noncemented cups injury when the hip is reduced in the anatomic hip center.
Section 3: Hip
Two fixation techniques for stabilizing a transverse subtro- Anatomic Hip (Zimmer) was used in 135 hips with good
chanteric osteotomy were compared in 79 hips.9 Both bone quality, neck–shaft angles less than 160°, femoral
techniques involved splitting the removed bone segment anteversion less than 50°, and a canal diameter 10 mm or
longitudinally without the removal of any soft tissue, larger. Intraoperatively, a nondisplaced metaphyseal frac-
wrapping the bone fragments around the osteotomy site. ture occurred in 3.7% of the cases. At a mean f ollow-up
The fragments were stabilized either with a cable in one of 13.5 years (range, 10 to 18 years), there were no cases
group, or with a plate and screws in the second group. of aseptic loosening of the femoral component.
Overall, fixation with a cable had an average union time Two- to 5-year follow-up of a modular S-ROM stem
of 113 days and nonunion developed in 1 hip, whereas the (DePuy) modified for Asian patients was reported in
plate technique had an average union time of 152 days and 220 hips with DDH.15 In 74% of the hips, the stem re-
nonunion developed in 3 hips.11 quired rotational correction so that the version of the stem
Progressive resection of the lesser trochanter is another did not match the version of the femur. Overall, bone
technique described to prevent overlengthening of the ingrowth was achieved in 99.5% of the stems. Another
limb when performing a THA in a Crowe IV hip. One study reported results at a mean follow-up of 18.7 years
study reported on 28 THAs with a lesser trochanteric (range, 15.8 to 21.8 years) in 25 Crowe III and IV hips,
osteotomy used for Crowe type IV DDH.12 Shortening in which the S-ROM stem was used in conjunction with
of the femur was performed with progressive resection of a low resection of the femoral neck.16 Two patients sus-
the neck cut distally, into the lesser trochanter, until the tained an intraoperative fracture of the calcar, which
surgeon thought there was appropriate tension in the soft was stabilized with cerclage wires at the time of surgery.
tissue. As a result, the extent of femoral shortening was At final follow-up, the mean modified Harris hip score
usually less than in a subtrochanteric osteotomy using improved from 46 points preoperatively to 90 points
an overlapping technique. The acetabular component (P < 0.001), all stems were bone ingrown, and none re-
was placed in the anatomic position and noncemented quired revision. The mean postoperative increase in leg
femoral stems were used in all cases. An intraoperative length was 21 mm (6 to 56 mm). No patients had a sciatic
fracture of the proximal femur occurred in three hips and nerve injury. It was concluded that a low femoral neck
was treated with cerclage wires. At a mean follow-up of osteotomy combined with a noncemented, modular femo-
55.3 months, there were no femoral stem failures and the ral component and anatomic restoration of the hip center
modified Merle d’Aubigné scale improved from 9.3 pre- is a successful technique of THA for DDH and avoids the
operatively to 15.9 postoperatively. A partial sciatic nerve need for femoral shortening osteotomy
palsy occurred in 2 hips (7%), both of which completely
recovered by 6 months postoperatively. It was concluded THA Following Prior Surgery
that this technique of femoral shortening proved to be It is not uncommon for patients with DDH to have un-
safe and effective in THA for Crowe IV DDH. dergone prior surgical procedures before requiring a
Insufficiency of the hip abductors is classically associ- THA. Periacetabular osteotomy is one of the most effec-
ated with a limb-length discrepancy (LLD) in patients tive procedures for reorientation of the acetabulum in
with DDH due to abductor muscle contracture and disuse. patients with symptomatic dysplasia. When necessary,
Forty-five patients with unilateral DDH were evaluated be- THA can be done with reasonable safety and can be
fore and following their THA.13 The greatest improvement expected to have an excellent outcome, with significant
in abductor strength was seen within the first 6 months improvement in functional scores in most patients who
after THA. However, in some patients with a good recon- have undergone previous periacetabular osteotomies.17 In
struction, affected hip abductor muscle strength remained a 2015 study, 23 hips of patients who underwent a THA
poor because of severely contracted tissues and insufficient after periacetabular osteotomy were compared with those
abductor strength. Abductor strength was consistently of 23 patients with DDH undergoing THA without a his-
greater in patients with mild dysplasia (Crowe I and II) tory of periacetabular osteotomy that were matched for
3: Hip
than in patients with severe dysplasia (Crowe III and IV). age, sex, and body mass index.18 At a mean follow-up of
Overall, in patients with DDH, the extent of preoperative 10 ± 4 years in the osteotomy group and 6 ± 4 years in
LLD and the increase in abductor length were related to the nonosteotomy group, there was no difference in the
post-THA abductor strength recovery. complication or revision rates between the two groups.
Excellent outcomes have been reported with varying However, according to a post hoc power analysis, the
types of femoral implants. In selected patients with DDH, study was underpowered to detect a difference in the rate
one study found that an anatomic noncemented femoral of postoperative complications or revision THA. There
stem can provide excellent long-term outcomes.14 The was no difference in the mean postoperative Harris hip
score at final follow-up between the study groups (93 ± risk = 1.0) following noncemented THA.21 DDH with
7 and 95 ± 10, respectively). In this study, 44% of the dislocation (n = 445 hips) had, in fact, less risk for revision
acetabula with a periacetabular osteotomy were found than osteoarthritis (relative risk = 0.8).
to be retroverted. As a result, trimming of the anterior A 2016 study specifically addressed the long-term
wall and/or bone grafting of a deficient posterior wall results of THA with a shortening subtrochanteric oste-
were required to place the acetabular component in the otomy in Crowe IV DDH.22 In all hips, a porous-coated
proper position. Overall, the mean acetabular component acetabular component with screws was placed at the true
anteversion was decreased by 17° in the periacetabular anatomic hip center. Structural femoral head autograft
osteotomy group. It was concluded that THA in patients fixed with screws was used in 10 of the acetabular recon-
after a periacetabular osteotomy offers major improve- structions to improve superolateral coverage of the cup.
ments in function with acceptable complication and revi- Cementless femoral components were used in all cases.
sion rates when compared with THA for DDH in patients A subtrochanteric osteotomy was performed in all hips,
without a prior periacetabular osteotomy. with the osteotomy site augmented with cortical auto-
Similarly, a 2015 study found that 22 patients under- graft struts cut from the resected femoral bone fragment
going a THA for DDH following a successful rotation- in 20 hips and by cortical allograft struts in 2 hips. At
al acetabular osteotomy had results similar to those of mean follow-up 10 years, there was a significant improve-
30 matched patients undergoing THA for DDH who had ment in the Harris hip score from the preoperative value
not undergone previous surgery.19 At an average follow-up (43 versus 87). Twenty-nine percent of patients had an
of 8.2 years (range, 7 to 11 years), no patient in either early complication, but these did not have long-term del-
group required revision surgery. No significant difference eterious effects on the reconstruction, and there were no
in total Harris hip scores, pain scores, function scores, reoperations for any reason after 7 years. Complications
intraoperative blood loss, and surgical time was found included intraoperative femur fractures (four hips) and
between the two groups. dislocations (three hips). There were two femoral non-
unions of the osteotomy site (7%). At 10 years, one ace-
Results tabular component was revised for aseptic loosening and
The results of a 2015 study highlight the potential three stems were revised—two for aseptic loosening and
complications that can occur when performing THA one for fracture. Overall, the survivorship of the compo-
for DDH.20 Complications developed in 25 of 102 hips nents free of revision for aseptic loosening was 89%, with
(24.5%) and revision surgery was performed in 15 of these no radiographic evidence of additional loosening. It was
patients (14.7%). The possibility of undergoing revision concluded that reliable 10-year results could be obtained
surgery was 5.95 times higher in Crowe IV hips compared with noncemented THAs and simultaneous shortening
to Crowe type I hips. Complications included acetabular subtrochanteric osteotomies in patients with Crowe IV
component aseptic loosening (seven hips), dislocation (five DDH. If early complications are managed appropriately,
hips), delayed union of the subtrochanteric osteotomy subsequent sequelae or new problems are rare.
(three hips), femoral component aseptic loosening (two Despite the numerous acetabular and femoral com-
hips), superficial wound infection (two hips), heterotopic plexities inherent to THA in patients with DDH, a
ossification (two hips), acetabular and femoral component 2012 study demonstrated comparable short-term func-
loosening (one hip), iliac artery and vein rupture during tional outcomes (Oxford Hip Score) and revision rates
acetabular cup-screw preparation (one hip), intraopera- in 1,205 hips with DDH compared to 40,589 hips with
tive femur fracture treated with a cerclage wire (one hip), osteoarthritis at 6 months following THA. 23 Overall,
sciatic nerve palsy that fully recovered (one hip), deep the hips with DDH required bone grafting more fre-
vein thrombosis (one hip), and pulmonary embolism (one quently (4% vs. 0.9%; P < 0.001), received uncemented
hip). In the low dislocations, absence of the superior wall implants more often (68.3% vs. 28.1%; P < 0 0.001), and
and anterolateral segmental deficiency made acetabular required a longer surgical time than the osteoarthritis
3: Hip
reconstruction challenging and caused the acetabular group (mean time, 94.4 versus 79.7 minutes; P < 0.001).
component to be partially uncovered. This uncoverage Unexpectedly, this analysis of the New Zealand Regis-
was postulated to have led to the early failures of the try did demonstrate a higher-than-expected 6-month
acetabular components in this series.17 In a previous study mortality rate in the DDH group. In a subsequent study,
of the Norwegian Arthroplasty Register, there was no registry data were presented on the functional response
increased risk for revision following THA in patients to THA in patients with hip dysplasia with a minimum
with DDH but without dislocation (n = 2,425 hips) and 1-year follow-up. 24 The 33 patients with DDH under-
patients with osteoarthritis (n = 5,229 hips) (relative going THA demonstrated more severe preoperative
Section 3: Hip
Figure 2 AP pelvis radiograph shows developmental Figure 3 Lateral radiograph of the right hip shows
dysplasia of the hip bilaterally and right developmental dysplasia of the hip bilaterally
proximal femoral deformity from multiple and right proximal femoral deformity from
previous surgeries. multiple previous surgeries.
Figure 5 A, AP radiograph of right hip treated with THA

using a modular stem. B, Lateral view of the
hip, postarthroplasty.
Figure 4 CT femoral version study showing retroversion

of the right femur.
impairment of disease-specific functions (Oxford hip function to those patients undergoing THA for primary
score and Western Ontario and McMaster Universities osteoarthritis (Figures 2, 3, 4, and 5).
Osteoarthritis Index) and general health measures (Short
3: Hip
Form-12 physical health and mental health scores) than

the 968 patients with primary osteoarthritis undergoing Proximal Femur Deformity and
THA. Despite their poor preoperative function, and in Proximal Femur Fracture
spite of the challenges and complexities inherent to THA Richard Iorio, MD; John Dundon, MD; Yousuf Sayeed, MS
in hip dysplasia, the DDH patients achieved superior Background
postoperative functional improvements compared to the Both proximal femur fracture and proximal femur defor-
osteoarthritis patients. It was concluded that patients mity can be challenging in total joint arthroplasty. Proper
with DDH requiring THA could expect comparable imaging and preoperative planning help guide surgical
Table 1 Table 2
Etiology of Proximal Femoral Deformity Paprosky Classification for Femoral Deficiency
Previous surgery Type I Minimal loss
Femoral neck nonunion/malunion Type II Metaphyseal loss with intact diaphysis
Intertrochanteric hip fracture nonunion/malunion
Type IIIa Metadiaphyseal bone loss with at least
Developmental dysplasia of the hip 4 cm of intact cortical bone in the
Paget disease diaphysis
Achondroplasia Type IIIb Metadiaphyseal bone loss with less
Multiple epiphyseal dysplasia than 4 cm of intact cortical bone in
Mucopolysaccharidosis the diaphysis
Osteogenesis imperfecta Type IV Metadiaphyseal bone loss with non-
Osteopetrosis supportive diaphysis
Rickets Adapted with permission from Park JH, Paprosky WG, Jablonsky WS,
Fibrous dysplasia Lawrence JM: Femoral strut allografts in noncemented revision total
Down syndrome hip arthroplasty. Clin Orthop Relat Res 1993;295:172-178.
Slipped capital femoral epiphysis
Legg-Calvé-Perthes disease
Multiple hereditary exostoses
treatment and are crucial for success. Moreover, a phys- those with retained proximal femoral hardware will
ical examination assessing for range of motion, abductor continue to be prevalent and challenging for the ortho-
strength, and gait is necessary to verify patient status. paedic surgeon.
For failed fixation for femoral neck or intertrochanteric Proximal femur deformity is caused by several factors
hip fractures, retained hardware must be removed before that can be categorized by abnormalities due to develop-
THA is performed. DDH, Paget disease of bone, hip ment, trauma, metabolic bone disease, or previous sur-
instability associated with Down syndrome, and achon- gical intervention (Table 1). The Paprosky classification
droplasia all present unique challenges. These cases are system is commonly used to describe bone stock damage
individualized, based on the type and degree of femoral in the revision setting, and can be used in these cases.
deformity. Proximally coated implants can often be used Femoral bone loss is categorized as outlined in Table 2.
in these patients, but modular and diaphyseal fixation im- Another methodology was created for classifying
plants should be available for severe deformities. If direct femoral deformity based on anatomic site26 (Table 3).
access to the femoral canal is not obtainable, extended Subclassifications were determined by geometry. Using
trochanteric or diaphyseal osteotomy should be consid- an alphabetical system, A represents torsional deformity
ered to obtain appropriate fixation. As a group, these resulting in excessive anteversion or retroversion, B is
patients are more technically challenging and have higher angular deformity (varus/valgus or flexion/extension), C is
complications rates than patients with uncomplicated translational deformity, and D represents size alterations
osteoarthritis. With thoughtful and carefully planned (larger or smaller bone than usual) along with the cause
management, patients with proximal femur fracture and of the deformity.
proximal femur deformity should realize significant pain
relief and improved function following THA. Contraindications to Arthroplasty
The aging population is growing and individuals aged Contraindications to arthroplasty in cases of proxi-
65 years and older are expected to exceed 77.2 million in mal femur deformity parallel those for primary THA
3: Hip
the United States by 2040. 25 Concomitantly, the rate of in other conditions. Absolute contraindications would
hip fractures is expected to double. An increased number include active infection, a medically unstable condition,
of patients presenting for THA secondary to degenera- and inability to comply with postoperative instructions.
tive arthritis or failure of treatment of hip fractures is Relative contraindications include active Paget disease,
therefore expected. Currently, there are 258,000 hip uncontrolled diabetes, previous hip infection, uncon-
fractures in the United States annually, with a reported trolled rheumatoid arthritis with active use of immuno-
rate as high as 957.3 per 100,000 people. 25 THA in suppressants, alcoholism, morbid obesity, renal failure,
patients with severe proximal femoral deformities and and undiagnosed anemia.
Section 3: Hip
Table 3 infection is warranted. Medical comorbidities and under-

lying disease processes must be evaluated. Standard pre-
Berry Classification for Proximal operative laboratory studies are performed to screen for
Femoral Deformity anemia, nutritional deficiencies, or uncontrolled diabetes,
Site of deformity Greater trochanter which may predispose to infection. Disease-specific labo-
Femoral neck ratory studies should also be performed to show adequate
Metaphysis control, such as alkaline phosphatase in Paget disease.
Diaphysis Standard AP views of the pelvis, along with AP and
Geometry of Torsional
lateral views of the hip and proximal femur, should be
deformity Angular obtained and are important for a successful outcome.
Translational Judet views of the acetabulum can be obtained if there is
any concern for an associated anterior or posterior wall
Size of abnormality
deficiency or columnar discontinuity. The proximal femur
Cause of deformity Developmental (ie, DDH) needs to be assessed for the suspected version alteration or
Metabolic (ie, Paget disease)
canal disruption and to assess for any varus remodeling
Previous osteotomy
of the femur. AP, lateral, and flexion/extension films of
Previous fracture
the lumbar spine should be obtained if there is a history
DDH = developmental dysplasia of the hip. of previous spinal surgery or lumbar spine deformity.
Adapted with permission from Berry DJ: Total hip arthroplasty in
patients with proximal femoral deformity. Clin Orthop Relat Res Full-length standing radiographs can also be useful if
1999;369:262-272. there is concern for any additional deformity or if there is
a limb-length discrepancy that must be addressed during
surgery. MRI is typically not useful in these patients.
CT scans are essential if there are concerns regarding
abnormal femoral or acetabular anteversion. If there is
Preoperative Planning a limb-length discrepancy, a scanogram or full-length
As is true for all patients, preoperative workup and plan- radiographs may be indicated. EOS body imaging
ning are essential prerequisites for successful outcomes. A (Cambridge, MA) is an evolving, low-radiation dose slot
thorough physical examination is required with a focus scanning radiograph system allowing the acquisition of
on hip range of motion (ROM), and leg length inequality. radiographic images while the patient is standing, sitting,
Gait pattern should be observed and assessed. Abductor or squatting. EOS can be used to study spinal deformi-
strength and Trendelenburg status should be recorded. ties simultaneously with pelvic, acetabular, and femoral
Evaluation of the lower back and lumbar spine of the parameters along with limb-length discrepancy, three-
patient should be documented. Lumbar spine deformities dimensional evaluation, and impingement/dislocation
and previous spinal surgery and fusion can alter the pelvic evaluation.27-30
incidence of the patient and functional anteversion of Implant choice should be determined preoperatively
the acetabulum. A fixed pelvic deformity in conjunction and there are multiple options available. Cementless stems
with proximal femoral deformity can affect the combined have become the mainstay of treatment in the United
anteversion of the total hip components. Functional status States, and are used in most cases31 (Figure 6). Proxi-
and realistic patient outcomes need to be discussed with mally coated metaphyseal engaging stems can be used
patients, many of whom have had multiple operations on in patients with minimal deformity and good proximal
the hip with subsequent poor ROM, and outcomes similar bone stock. Modular implants that allow for metaphyseal
to uncomplicated primary THA may not be realistic. fixation and the ability to independently adjust version
For patients with a previous hip operation, the possi- are useful in proximal femoral deformities, They can also
bility of latent infection is always considered. The eryth- be used to reconcile proximal-distal femoral canal dis-
3: Hip
rocyte sedimentation rate (ESR) and C-reactive protein proportion32 (Figure 7). Extensively porous coated stems
(CRP) level should be obtained. If inflammatory markers can be used as well, but have higher failure rates when
are elevated, a hip aspiration and/or biopsy is indicated to stem sizes are larger than 19 mm in diameter. Monoblock
rule out infection before hip replacement surgery. Frozen tapered splined stems, such as Wagner type stems, are
sections and cultures may be indicated if there is any quite useful in providing initial diaphyseal fixation and
concern at the time of surgery. An antibiotic spacer as rotational control, especially in those patients with poor
a backup plan and preoperative discussion with the pa- metaphyseal bone stock. Monoblock components also
tient about a staged procedure is suggested if suspicion of avoid the concerns of junctional fretting and fracture
Figure 6 A, AP pelvis radiograph from a 61-year-old man with multiple hereditary exostoses with right hip pain. B, AP pelvis
radiograph after right THA performed with a proximally coated femoral stem.
Figure 7 A and B, AP pelvis radiographs from a patient with Crowe IV developmental dysplasia and a high hip center
treated with a modular stem for the proximal femoral deformity.
associated with modular implants. Modular diaphyseal Technical Considerations

engaging stems provide good fixation while allowing for THA after failed fixation for femoral neck or inter-
independent adjustment of length, offset, and version of trochanteric hip fracture can be technically challenging,
the femoral stem, although stem fracture can occur with and has a higher complication rate than primary THA,
distally fixed, small-diameter stems.31-40 including an elevated risk of periprosthetic fracture and
3: Hip
Greater trochanteric deformity may be present in the dislocation.32 An approach that permits extensile expo-
form of trochanteric overhang or proximal femoral varus sure of the femur is recommended. Minimally invasive
malalignment. Either may prevent direct access to the techniques may need to be avoided because the anatomy
femoral canal, lead to fracture of the greater trochanter, and bone are already deformed and the risk of compo-
malalignment of the implant, and/or early failure. To nent malposition is high. A posterior or lateral approach
access the femoral diaphysis, an extended trochanteric provides improved visualization and the ability to expose
osteotomy (ETO), trochanteric slide or a subtrochanteric the femur in the event of fracture or the need for an
osteotomy can be used. ETO. Capsulotomy and exposure of the hardware to be
Section 3: Hip
Figure 9 Lateral view of previous intertrochanteric hip

fracture, in which osteonecrosis developed,
treated with a sliding hip screw construct.
Figure 8 AP radiograph shows a previous

intertrochanteric hip fracture, in which
osteonecrosis developed, treated with a sliding
hip screw construct.
removed is accomplished before dislocation of the hip.

When exposure is obtained, appropriate gentle dislocation
of the hip is then performed before removal of hardware.
The hip is then reduced and the implants are removed.
The hip can then be dislocated again and the femoral
neck cut can be made (Figures 8, 9, and 10).
Failed treatment of femoral neck fracture usually re-
sults in a varus deformity and retroversion of the femo-
ral head. Bone quality is often poor.34 The metaphyseal
bone may also be compromised due to the previous sur-
gery. Typically, nonunion or malunion of femoral neck
fractures can be managed with a metaphyseal engaging Figure 10 AP pelvis radiograph after removal of the
sliding hip screw shows left THA with a modular
proximally porous coated stem, or with a cemented stem. diaphyseal engaging stem. The most distal
If there is severe retroversion or loss of metaphyseal bone screw hole was bypassed by greater than two
cortical diameters, and a prophylactic cerclage
stock, a modular or tapered titanium Wagner type stem wire was placed before reaming the femur to
can be used. These stems can accommodate smaller distal prevent fracture.
diameters, which may be useful for patients with small
femoral canals and proximal femoral deformity.31-40
Failed fixation for intertrochanteric fractures man- Hardware should be removed after dislocation of the
aged with THA are more difficult to manage and are hip to prevent fracture propagation through screw or nail
associated with increased surgical time, blood loss, tracts. Metaphyseal fixation is not reliable after failed
transfusion requirements, and hospital stay than THA fixation of intertrochanteric fractures. Longer femoral
3: Hip
for failed femoral neck fractures.35 Patients with failed components should be used to bypass the most distal
cephalomedullary nail fixation tend to be more difficult stress riser by at least two cortical diameters. Calcar-
to treat than those patients treated with failed sliding hip replacing stems should be considered in those patients
screws, requiring longer surgical time and greater blood in whom the calcar has been disrupted and is no longer
loss.36 Failed fixation of intertrochanteric fractures with supportive. A diaphyseal engaging, tapered stem can pro-
a cephalomedullary nail often results in proximal femoral vide good fixation and allow for control of femoral stem
varus and retroversion, and the greater trochanter also anteversion. These stems have shown good short-term
may be compromised. results.37,38 Modular stems provide the option to change
length and offset in the case of instability and have shown for loosening at long-term follow-up.41 Cementless fix-
good survivorship at 5-year follow-up.39 Care should be ation is currently preferred over cemented fixation in
taken to maintain the continuity of the abductors to the pagetoid bone. A modular or tapered titanium Wagner
greater trochanter. type stem capable of providing distal fixation and inde-
pendent adjustment of femoral version is ideal41 (Figures
Paget Disease of Bone 11, 12, and 13).
Paget disease of bone is a rare disease characterized by
intense focal resorption of normal bone by abnormal Down Syndrome
osteoclasts. There are three distinct phases: an initial Patients with Down syndrome typically have multiple or-
bone resorption phase, followed by a mixed phase in thopaedic problems. Hip pathology is common in Down
which there is concurrent bone resorption and deposi- syndrome, with hip instability occurring in 2% to 5% of
tion, followed by a sclerotic phase in which bone depo- this population. The hip instability typically occurs later
sition is greater than bone resorption. Proximal femoral than hip dysplasia, occurring in adolescence to adult-
deformity is characterized typically by a very sclerotic- hood. The typical deformity involves decreased acetabular
appearing bone with multiple microfractures of the bone anteversion, increased femoral anteversion, coxa valga,
that eventually result in varus deformity of the bone. and a narrow femoral canal. Prior to surgery, lumbar
The bone is also hypervascular and increased blood loss spine films should be obtained, because there is a signifi-
is often encountered during surgery if performed during cant association with scoliosis and previous spinal fusion,
the resorption or mixed phases. Treatment with potent which can alter hip version and stability. EOS imaging
diphosphonates has been shown to reduce blood loss in may be useful in determining the functional position and
these patients and to decrease metabolic turnover.41 Intra- acetabular version for these patients. Flexion-extension
operative blood salvage should be considered to decrease films of the cervical spine should also be obtained to
blood loss. assess upper cervical spine instability before any surgical
Heterotopic ossification after THA is common in pa- procedure. Proximal metaphyseal engaging noncemented
tients with Paget disease (23% to 52%) and needs to stems can often be used in these patients as long as care
be addressed.40 Prophylaxis with either irradiation or is taken to address the version. Good long-term results
NSAIDs should be planned. THA should be avoided in have been reported using these stems.43 Hip instability
active Paget disease due to increased bleeding risk and is a common problem, and constrained liners often are
poor ingrowth potential. Elevated alkaline phosphatase necessary for stability.
or urinary hydroxyproline levels, both indicative of bone
turnover, can help determine the presence of active Paget Achondroplasia
disease. Achondroplasia is caused by mutations of the gene encod-
There is debate concerning the optimal surgical tech- ing fibroblast growth factor receptor-3 on chromosome
nique for THA in Paget disease. The coxa vara deformity 4, resulting in underdevelopment and shortening of the
produced by the disease can make femoral stem compo- long bones formed by endochondral ossification. Proxi-
nent placement difficult and can lead to varus placement mal femoral deformity consisting of a short femur with
of the femoral stem. Retroversion of the proximal femur a very narrow canal can render placement of standard
can further complicate the deformity. If appropriate ac- femoral stems difficult or impossible. Significant femoral
cess to the femoral canal is not possible, ETO should be anteversion may be present, along with significant varus
performed to obtain appropriate stem size and position. of the tibia with decreased external tibial torsion, alter-
Some authors suggest performing a cemented THA in ing the perceived normal anatomy of the hip joint. Spine
these patients, believing that the bone is abnormal and in- pathology is also common in these patients. Hyperlordo-
growth may be difficult or impossible to reliably achieve. sis affects up to 80% of children with achondroplasia,
The revision rate for cemented THA in this population is making lumbar films mandatory before any hip surgery
3: Hip
high, with revision rates reported between 9.5% and 15% to account for the abnormality in pelvic incidence. Cus-
at 5-year follow-up.41,42 The revision rates have been cor- tom femoral implants have been used in this population
related with high serum alkaline phosphatase levels. For but failure is common, with 21% requiring revision at
cemented femoral fixation, cement extravasation around an average 36-month follow-up.44 Some authors have re-
and through any corrective femoral osteotomy site is a ported good results in the presence of femoral hypoplasia
concern and must be prevented. Cementless femoral stem by cementing a small stem instead of using a noncement-
fixation is currently a favorable choice, with multiple ed component. Preoperative assessment is recommended
studies showing good fixation without need for revision to determine the potential of a metaphyseal engaging
Section 3: Hip
Figure 11 Radiograph shows femoral deformity from Figure 12 AP pelvis radiograph shows Paget disease
longstanding Paget disease. managed with a noncemented acetabular and
femoral stem. The femoral deformity was mild
and was managed with a monoblock proximally
coated stem.
other deformities of the femur may need to be addressed.

Up to 91% of these patients will have proximal femoral
pathology.45 Diphosphonate therapy has been shown to
result in major improvements in bone quality, filling of
lytic lesions, improved cortical thickness, and improved
bone mineral density. Diphosphonate therapy can lead
to partial resolution of fibrous dysplasia.45 The techni-
cal difficulty of THA in this population will depend on
the severity of the deformity. Implant requirements can
range from standard metaphyseal engaging noncemented
Figure 13 Radiograph shows Paget disease with varus implants to surgery requiring an ETO and diaphyseal
remodeling of the femur.
engaging implants. The severity of the coxa vara defor-
mity will determine implant choice and requirement for
an ETO.
wedge-type implant. If the bone is too small or there is
too great of a metaphyseal/diaphyseal mismatch, a mod-
ular or tapered titanium Wagner type noncemented stem THA in the Neuromuscular Hip
can be used to achieve fixation and appropriate version Mathias P.G. Bostrom, MD
(Figures 14 and 15). Background
Patients with neuromuscular hip disorders comprise a
Fibrous Dysplasia rare but challenging population of patients. Because
Fibrous dysplasia is a disease of bone in which the normal of the different degrees of muscle imbalance or paral-
lamellar cancellous bone is replaced with immature fibro- ysis, the pathology in these hips is quite variable. The
3: Hip
osseous tissue, resulting in poorly formed trabeculae of severity of spasticity and contractures depends on the
immature woven bone, having a monostotic or polyos- underlying neuromuscular disease. These patients are
totic effect. Deformities of the proximal femur can be often debilitated and their functional goals may be lim-
severe, with extensive widening and loss of the metaph- ited. Treatment goals are to achieve pain relief, optimize
ysis leading to microfracture and pain. This results in the physical function, and improve care. Conservative and/or
classic shepherd’s crook deformity of the proximal femur nonarthroplasty treatment options are usually indicated.
as it falls into coxa vara. Although coxa vara may be the However, in ambulatory patients with hip pain and dys-
most common deformity, associated lateral bowing and function, THA with varying degrees of constraint can
Figure 14 AP pelvis radiograph shows achondroplasia in Figure 15 AP pelvis radiograph from a 59-year-old
a 59-year-old patient with bilateral hip pain patient with achondroplasia managed with
and a previous right femoral neck fracture that staged bilateral THA, treated on the left with
proceeded to malunion. a metaphyseal engaging stem and on the right
treated with a mini stem.
be an appropriate and successful treatment option with

relatively low complication rates. and flaccid type pareses are found in both intrinsic and
Neuromuscular diseases resulting in hip pathology in extrinsic disorders.
adults include myopathies, muscular dystrophies, upper Extrinsic movement disorders, such as dyskinesis, athe-
and lower motor neuron diseases/injuries, neurodegen- tosis, Parkinson disease, and multiple sclerosis (which may
erative disorders, movement disorders, and diseases of be more specifically classified as a demyelinating disorder)
the neuromuscular junction. These patients comprise a may have elements of spasticity, but hip subluxation-
heterogeneous group that requires individualized care of dislocation is rare in this group of patients because the
their hip disease. onset of disease is usually after growth is complete. How-
Muscle imbalance about the hip secondary to an un- ever, movement disorders are frequently associated with
derlying neuromuscular disease can result in subluxation contractures about the hip, and painful degenerative ar-
and dislocation of the hip in growing children and may thritis often develops in these patients.
predispose adult patients to degenerative joint disease of Children who are born with intrinsic neuromuscu-
the hip. Specifically, the muscle imbalance that directly lar disorders (eg, cerebral palsy, myelomeningocele), or
causes acquired hip instability and dysfunction is the in whom a neuromuscular affliction occurs while the
presence of strong hip flexors and adductors that over- hip is still in early development (eg, poliomyelitis, en-
power weaker or absent hip extensors and abductors. cephalitis, cerebral vascular accidents, childhood spinal
Although the direct cause of the instability is due to cord injuries, brain trauma), are at increased risk for
this muscle imbalance, the underlying etiology of the hip subluxation-dislocation. In these children, frequent
hip dysfunction may be caused by either intrinsic or ex- examinations and hip radiographs can detect and even
trinsic factors. Intrinsic muscle imbalance about the hip predict those hips at risk. Botulinum toxin A injections,
manifests during childhood and plays a primary role early muscle releases or transfers, and appropriate varus
in subsequent hip problems. Extrinsic causes of neu- rotation femoral osteotomies can improve hip stability.
romuscular imbalance occur in stable hips, and play Still, despite treatment, hips can remain subluxated or
a secondary role in development of osteoarthritis and dislocated and thus can be a source of pain and disability
contractures in later life. in the adult.
3: Hip
The two basic types of paralysis or paresis are flaccid Although sensation in general does not play a role in hip
paralysis, which is caused by injury to the lower motor instability, compromised proprioception may play a role
neurons or peripheral nerves, and spastic paralysis, which in hip instability. Diminished or absent proprioception,
is caused by injury to the upper motor neurons or the whether it existed preoperatively or was compromised as
cortex of the brain. Spastic muscle has increased tone the result of surgery about the hip, may cause instability
and often functions in both phases of gait (ie, in phase after THA. Unfortunately, assessing proprioception about
and out of phase). Flaccid muscle has decreased tone, but the hip is challenging clinically and accurately assessing
always functions according to its normal role. Both spastic its role is therefore difficult.
Section 3: Hip
Intrinsic Disorders paralysis as the dominant feature. Each of the disorders

Spasticity will be reviewed individually, although the treatment
Among the intrinsic neuromuscular hip disorders, the algorithms are similar.
major causes of spasticity are cerebral palsy, cerebral
vascular accidents, and spinal cord injuries in the young Charcot Neuropathic Hip Joint
child. Despite differing etiologies, the hip pathology seen Neuropathic or Charcot joints present a special problem
in these patients is quite similar and thus, their treatment for the orthopaedic surgeon, regardless of the specific
may be approached in a like manner. Early treatment joint involved. The critical element in treating a patient
during childhood consists of nonsurgical measures such with a neuropathic hip joint is to establish the diagnosis.
as physical therapy, bracing, wheelchair modifications, Charcot joints can be caused by a variety of diseases and
botulinum toxin A injections, and surgical treatment disease processes, including tertiary syphilis, diabetes
including muscle releases and transfers to obtain muscle mellitus, and syringomyelia. Any joint presenting with
balance as well as early varus-rotation femoral osteoto- atypical findings such as painless joint dysfunction and
mies to better stabilize the hip(s). When the acetabulum radiographic evidence of a relentless destructive process
is deficient, acetabuloplasty should also be considered. should alert the clinician to the possibility of a neuro-
Although these procedures may be suitable for the grow- pathic joint.
ing child, salvage operations are usually necessary in the If the joint remains painless and functional, no treat-
treatment of adult patients. ment is recommended. If pain is present and function is
The goals of treatment of the adult spastic neuromus- impaired, conservative treatment with protected weight
cular hip, regardless of the etiology or ambulatory sta- bearing should be extended as long as possible before
tus, include preventing contractures, eliminating pain, any type of surgical procedure is considered. If non-
and optimizing function. Salvage procedures are often surgical treatment fails, the surgical options available
required if contractures result in pain, sitting imbalance, include arthrodesis, THA, and resection arthroplasty.
or difficulty with perineal care. Historically, arthrodesis and THA have demonstrated
As outlined by the treatment algorithm in Figure 16, high failure rates, especially in those patients with sig-
the three traditional surgical options for managing the nificant neurologic findings or ataxia.46-48 Resorting to a
painful, dislocated hip in an adult are head-neck resection resection arthroplasty may be the only viable solution in
with or without interposition arthroplasty; hip arthro- the treatment of the painful hip in these patients.
desis; and total hip replacement. Although resection ar-
throplasty or arthrodesis have been advocated in the past, Parkinson Disease
there is currently increasing preference for THA in the Degenerative arthritis of the hip in patients with Par-
ambulatory adult. kinson disease may occur through natural processes or
following hip fractures. The treatment of hip fractures
Flaccid Paralysis in these patients remains problematic with a high rate
The intrinsic neuromuscular disorders associated with of complications, including frequent dislocation of hips
flaccid paralysis include poliomyelitis, myelomeningocele, treated with hemiarthroplasty. Whether these higher com-
and Charcot-Marie-Tooth disease. Fortunately, the inci- plication rates can be extrapolated to those patients with
dence of these disorders is decreasing worldwide. In the Parkinson disease undergoing THA is not known. With
adult with a painful arthritic hip, surgical treatment is aggressive pharmacologic treatment it is possible that
often necessary. The risk of instability after THA with those patients with degenerative hip disease undergoing
flaccid paralysis must be addressed. If the muscle weak- elective THA may have fewer complications than the pa-
ness is so profound that the arthroplasty is unstable, a tients with more debilitating Parkinson disease who have
constrained device is often necessary to provide stability hip fractures. Thus, optimal medical management before
(Figure 17). elective THA is highly recommended. Further, the use of
3: Hip
supplemental calcium, vitamin D, and diphosphonates

Extrinsic Disorders may be an important pharmacologic intervention to help
Extrinsic neuromuscular disorders comprise a diverse prevent hip fractures in this population.49
group of problems that secondarily involve the hip joint. In
these disorders, muscle imbalance with hip subluxation- Multiple Sclerosis
dislocation plays a secondary role, but contractures about Painful hip flexion adduction contractures in patients with
the hip frequently develop. Some of these disorders are advanced multiple sclerosis are very difficult to treat. In
associated with spasticity whereas others have flaccid the end stages of the disease, treatment is complicated by
3: Hip
Figure 16 Treatment algorithm for the spastic hip. THR = total hip replacement, VRO = varus rotational osteotomy.
Section 3: Hip
in restoring balance. Balance is critically important in

this population to lessen their risk of falls and fragility
fractures of the hip or femur. Still, the functional recov-
ery after surgical treatment of hip fractures is similar to
that of patients who have not had a prior cerebrovascular
accident.
Another problem in these patients, especially those
suffering traumatic brain injuries, is the propensity for
heterotopic ossification, which can also limit joint mo-
tion. This excessive bone must be allowed to fully mature
before attempting resection; otherwise, more extensive
heterotopic bone formation may occur postresection.
After surgical resection of heterotopic ossification, mul-
timodal prophylaxis to prevent recurrence must be insti-
tuted, including low-dose radiation, NSAIDs, and early
Figure 17 AP pelvis radiograph shows flaccid paralysis mobilization.
treated with a constrained acetabular Older stroke patients are more prone to degenerative
component.
joint disease of the hip and should be treated with the
same guidelines as the general population. They may,
however, require release of contracted adductor or hip
flexor muscles at the time of the THA. Adductor tenotomy
knee flexion contractures and contracted upper extrem- can be performed percutaneously just before positioning
ities. Early release of contracted hip adductors, flexors, the patient for the hip arthroplasty, and the iliopsoas can
and iliopsoas muscles, as well as hamstrings, is essential be released from its insertion on the lesser trochanter
to prevent painful fixed joint deformities. during the exposure of the joint.
When contractures are fixed and severe, painful decu- THA is also recommended for younger patients who,
bitus ulcers and/or pelvic obliquity develop, and patients in addition to sustaining head injuries, develop painful
are often unable to sit or even lie down comfortably. De- posttraumatic arthritis or even osteonecrosis.
spite the fact that these patients are essentially considered
terminally ill, multiple extensive soft-tissue procedures Spinal Cord Injury
may provide pain relief and some improvement in sitting. As in juvenile patients, spinal cord injuries in adults can
Occasionally, a proximal femoral resection or THA is result in significant spasticity of the muscles around the
warranted for pain relief. Because of prolonged steroid hip. Although subluxation and dislocation are usually
use and diminished function and strength, fractures about not as problematic in the adult patient as they are in
the hip, particularly the femoral neck and trochanter, are children, spasticity can lead to contractures that require
also a concern. appropriate early releases. If degenerative arthritis does
develop, THA may be indicated for pain relief. However,
Adult-Onset Cerebrovascular Vascular Accident (Stroke), if the patient is nonambulatory with severe contractures
Upper Motor Neuron Spinal Cord Injury, and Head Injury and skin breakdown, resection arthroplasty may be a
As noted earlier, hip subluxation-dislocation rarely oc- more viable option. Although not as prevalent as in trau-
curs in adult-onset spasticity due to brain or upper spinal matic brain injury patients, heterotopic ossification does
cord injury. Hip joint contractures are frequent, however. occur with some frequency and should be approached in
Thus, early, intensive physical therapy is important for a similar fashion.
maintenance of hip range of motion. Unless regularly
3: Hip
manipulated through a normal range of motion, signifi-

cant contractures will develop in these hips. If the patient Primary THA Following Acetabular Fracture
survives the initial insult, whether it is due to a traumatic Michael D. Ries, MD
event or a cerebrovascular accident, efforts should be Background
directed toward regaining functional ambulation. None- Acetabular fractures may result in considerable damage
theless, patients with significant residual neurologic im- to the periacetabular bone and soft tissues. Open reduc-
pairment will most likely be rendered wheelchair bound. tion and internal fixation (ORIF) of acetabular fractures
Simple tenotomies of the involved muscles may be helpful can be associated with extensive soft-tissue dissection.
Posttraumatic arthritis requiring THA is a frequent com- of the sciatic nerve, which is often surrounded by scar
plication after acetabular fracture. The technical com- tissue. Mobilization of the nerve may be necessary to re-
plexity and results of THA after prior acetabular fracture move posterior hardware. Only that hardware protruding
may be affected by many factors, including bony defor- into the acetabulum during reaming requires removal
mity, prior infection, retained hardware, limb shortening, (Figure 19). Intra-articular screws that are not accessible
sciatic nerve palsy, abductor deficiency, and heterotopic from the outer surface of the pelvis can be removed with
bone formation. a metal-cutting burr. This avoids unnecessary dissection
Acetabular fractures in young patients are typically along the outer pelvic bone or a separate ilioinguinal
high-energy injuries, which can result in damage to the approach to remove anteriorly placed screws.
articular cartilage, bony columns, and surrounding soft Both noncemented and cemented acetabular com-
tissues. Low-energy injuries in elderly patients with os- ponents have been used with successful results. 50 For
teoporosis can also result in acetabular fractures, which protrusio defects, a large rim-fit cup provides relative
may have considerable comminution. Nerve and vascular lateralization of the hip to its anatomic center (Figure 18).
injuries are not uncommon. Treatment with ORIF can Use of a large-diameter reamer to ream the rim of the
require extensive soft-tissue dissection to achieve bony re- acetabular cavity prevents medialization that can occur
duction, and the application of multiple plates and screws. with a smaller reamer. Morcellized bone obtained from
Posttraumatic arthritis, osteonecrosis, and heterotopic acetabular reamings or the femoral head can be used to
bone formation are common complications after ORIF fill cavitary defects. Segmental bone loss may require
of acetabular fractures. THA for posttraumatic arthritis revision THA techniques and implants including aug-
after prior acetabular fracture is effective in improving ments and cages. If heterotopic bone is removed during
hip pain and function, but also associated with greater THA, perioperative radiation therapy or postoperative
surgical time, blood loss, and complications in compari- treatment with NSAIDs should be considered to mini-
son to THA for primary osteoarthritis.50-52 mize the risk of recurrent heterotopic bone formation
following THA.
Preoperative Planning
In addition to an AP pelvis radiograph, Judet views and Results
a CT scan can be helpful to delineate bony deformity, the Results of THA after prior acetabular fracture are gen-
location of retained hardware, and the presence, extent, erally less favorable than for THA for primary osteo-
and location of any heterotopic bone. Surgical scars and arthritis. Surgical time and blood loss are increased. In
prior medical records are reviewed to determine what a systematic review of 659 hips (654 patients) with THA
surgical approaches have been used and the location of after acetabular fracture, the 10-year survivorship with
retained hardware. Preoperative templating is performed loosening, osteolysis or revision as the end point was
to determine the implant size and position, and any ex- 76% for the acetabular component and 85% for the fem-
pected change in leg length and offset. oral component.43 Eighty-one percent of the acetabular
Pelvic deformity should be considered if nonanatom- components and 59% of the femoral components used
ic reduction or loss of fracture fixation has resulted in were uncemented. Heterotopic ossification was the most
malunion. Transverse fractures that have healed with common complication (30%), followed by infection (6%),
some displacement typically present with medialization dislocation (4%), and nerve injuries (2%). These findings
of the inferior pelvis, which creates a protrusio acetabular demonstrate a more frequent rate of complications than
deformity (Figure 18). Restoration of the anatomic hip conventional THA for primary osteoarthritis. However,
center, rather than relative medial or lateral cup place- patients with posttraumatic arthritis are often more de-
ment, is associated with a lower risk of aseptic cup loos- bilitated than those with primary OA as a result of leg
ening after THA for protrusio deformity.53 Segmental length inequality, sciatic nerve palsy, limited hip motion,
bone defects may require structural augments. A cage and complications from prior surgery.51 THA for post-
3: Hip
may be necessary for large cavitary lesions in osteopo- traumatic arthritis is associated with favorable improve-
rotic bone. ments in pain and function. In a retrospective review of
53 patients after THA following prior acetabular fracture,
Technical Considerations all but 3 were satisfied or very satisfied with the proce-
Any standard surgical approach can be used, but if poste- dure, indicating that despite the technical complexity of
rior hardware requires removal, a posterior approach will the procedure, patient satisfaction with the outcomes are
provide access to both the acetabulum and the hardware. relatively high.52
This approach also permits exposure and identification
Section 3: Hip
Figure 18 AP pelvis radiographs show a transverse acetabular fracture. A, After open reduction and internal fixation of
a transverse acetabular fracture, the inferior hemipelvis has healed in a medialized position as indicated by
the location of the teardrop (white arrow), whereas the superior hemipelvis remains in its normal anatomic
relationship to the sacroiliac joint and the lateral acetabulum (black arrow) is not displaced. B, If the acetabular
component is templated adjacent to the medial wall, the component will be medialized relative to the upper
pelvis. C, The acetabular component should be templated relative to the normally aligned superior acetabular rim
and upper pelvis. D, A slightly oversized rim fit acetabular component is used to provide relative lateralization of
the component relative to the medial wall (arrow) and restoration of the anatomic hip center.
THA in Osteoporosis
THA in Metabolic Bone Disease
Osteoporosis is the most common metabolic bone disease,
Nicholas M. Desy, MD, FRCSC; Robert T. Trousdale, MD particularly in the elderly population. It is characterized
Background by a decreased bone mineral density that is below 2.5 SD,
THA in patients with metabolic bone disease offers as measured on a bone dual-energy x-ray absorptiom-
unique challenges to the surgeon to achieve a satisfacto- etry scan. Because in many countries people are living
ry outcome. The bone quality and/or alignment is typi- longer, osteoporosis is more often seen as a comorbidi-
cally affected to such a degree that it forces the surgeon ty in patients undergoing THA. Approximately 26% of
3: Hip
to adjust surgical technique and implant choice to avoid patients undergoing THA and total knee arthroplasty
complications. Such conditions include osteoporosis, os- for osteoarthritis also have osteoporosis.54 Furthermore,
teopetrosis, Paget disease, and renal osteodystrophy. It is THA is becoming increasingly used in patients with
important to recognize each disease preoperatively and to low-energy acetabular fractures and femoral neck frac-
specially plan intraoperative precautions and techniques tures.55,56 Osteoporosis is characterized as high turnover
for each scenario (Table 4). Preoperative templating is or low turnover. High-turnover osteoporosis is seen in
essential to reduce complications and achieve a successful postmenopausal women with declining levels of estro-
outcome. gen, which leads to increased osteoclast-mediated bone
Figure 19 A, AP pelvis radiograph demonstrates anterior (white arrow) and posterior (black arrow) retained plates.
B, Postoperative AP radiograph after THA shows that portions of the posterior hardware were removed while
anterior hardware was retained.
resorption. Low-turnover osteoporosis is characterized it is important to carefully impact the broaches during
by diminished osteoblastic activity that can result from proximal femoral preparation and to cautiously insert
medications such as chemotherapy and steroids, and some the final implant. With proper patient selection, implant
antiosteoporotic medications. Medical management can choice, and surgical technique, clinical outcomes can be
consist of an adequate intake of calcium and vitamin D optimized and complications can be avoided.
as well as antiresorptive medication (eg, diphosphonates)
or anabolic agents (eg, teriparatide [parathyroid hormone THA in Osteopetrosis
1-34]). Osteopetrosis is a rare inherited bone disease that is char-
Diminished bone quality is of major concern to the acterized by decreased function in osteoclasts leading to
orthopaedic surgeon during THA in patients with os- decreased bone resorption, which results in increased
teoporosis. Historically, cemented fixation has been the cortical bone and calcified cartilage. Two autosomal re-
preferred technique for these patients, especially on the cessive types of osteopetrosis are lethal and one autosomal
femoral side, to avoid intraoperative iatrogenic femur dominant type is nonlethal. Patients with the nonlethal
fractures. Recent evidence has demonstrated efficacy form typically live a full lifespan; however, they can ex-
and safety with uncemented femoral components.57-59 In perience various orthopaedic issues including frequent
North America, the use of uncemented femoral stems is fractures, coxa vara, osteoarthritis, osteomyelitis, frac-
increasing, whereas in Europe cemented femoral com- ture nonunion, and long bone malalignment.
ponents are favored.60 However, in a large cohort of pa- The usual indications for THA in patients with osteo-
tients (32,644 primary THAs) intraoperative fractures petrosis are hip osteoarthritis or periarticular hip fracture
occur 14 times more often with uncemented femoral nonunion. It is important to preoperatively appreciate
components, particularly in female patients older than the technical difficulties that can be encountered intra-
65 years.60 operatively to avoid complications. Bone associated with
Therefore, in patients with osteoporosis, it is important osteopetrosis is typically brittle and it often lacks a med-
to consider cemented femoral components (Figure 20) as ullary canal, which can make implantation challenging
3: Hip
a strategy to prevent iatrogenic femur fractures. Optimum (Figure 21). Techniques to circumvent these obstacles
cement technique is critical to obtaining a proper cement include (1) use of a burr, high-speed drills, and ream-
mantle and includes proper preparation of the bony bed ers under fluoroscopic guidance to re-create a medullary
of the proximal femur with pulsatile lavage and suction, canal in the proximal femur; (2) use of a smaller femo-
retrograde filling of the femoral canal using a cement gun ral component to obviate the need for the creation of a
and long nozzle as well as the maintenance of pressur- larger femoral canal; and (3) screw augmentation of the
ization during the cementation period and implant inser- acetabular component for increased initial stability due
tion.61 If an uncemented femoral component is chosen, to the increased presence of sclerotic bone. Some authors
Section 3: Hip
Table 4
Summary of Surgical Challenges for Total Hip Arthroplasty in Patients With Metabolic Bone Disease
With Specific Recommendations for Each Condition
Metabolic Bone
Disease Intraoperative Challenges Recommendations
Osteoporosis Weak bone quality Consideration of a cemented femoral stem
Careful proximal femoral preparation and implant
insertion with uncemented femoral components
Screw augmentation of the acetabular component
Osteopetrosis Hard, brittle bone quality Use of a high-speed burr, drills, and reamers to re-create
Obliterated femoral a medullary canal
medullary canal Use of fluoroscopic guidance during canal preparation
Use of smaller femoral stems
Paget disease Hypervascularity Appropriate intraoperative fluid and blood management
Acetabular protrusio Consideration of a blood salvage system
Hard, sclerotic bone Medial acetabular bone grafting
Varus deformity of the Oversized acetabular hemispherical cup
proximal femur Offset acetabular liners
Use of a high-speed burr, drills, and reamers to re-create
a medullary canal
Use of fluoroscopic guidance during canal preparation
Possible need for femoral osteotomy(ies)
Renal osteodystrophy Weak bone quality Consideration of a cemented femoral stem
Use of alternative bearing surfaces in younger patients
have used computer-assisted navigation for femoral ca- patients are also at risk for femoral neck fractures, stress
nal preparation62,63 or customized instrumentation and fractures, and nonunions, which can further complicate
femoral stems.62,64 It also should be recognized that these treatment. Medical management has included the use of
cases take much longer, and averaged almost 5 hours in nitrogen-containing diphosphonates to inhibit osteoclast-
one study.65 The few reports on the outcomes of THA in mediated bone resorption and in turn decrease bone turn-
patients with osteopetrosis have consisted of case reports over in conjunction with analgesics.66
and case series, which have included fully cemented THA, Before performing THA in patients with Paget disease
a hybrid construct, or uncemented THA. Most patients of bone, it is imperative to preoperatively identify the etiol-
have experienced significant benefit. ogy of the hip pain. Although osteoarthritis is a common
source of hip pain in these patients, other causes include
THA for Paget Disease bone pain, femoral neck stress fracture, spinal radicu-
Paget disease of bone (osteitis deformans) is characterized lopathy, or even Paget sarcoma. If nonsurgical treatment
by a localized osteoclast dysfunction that causes an in- has failed and THA is contemplated (Figure 22), it is
crease in bone resorption with the subsequent formation important to predict potential intraoperative difficulties.
of new unorganized woven bone. It is the second most Preoperative radiographs should include an AP view of
3: Hip
common metabolic bone disease after osteoporosis and the pelvis as well as AP and cross-table lateral views of
more commonly affects the elderly. Patients can present the involved hip. Full-length views of the femur and full-
with monostotic or polyostotic patterns; however, the length standing extremity films are important to assess
pelvis and proximal femur are the most common sites in- the extent of disease and femoral deformity.
volved in 20% to 80% of patients, leading to frequent hip Special intraoperative technical challenges that can be
disease. Osseous deformities about the hip joint include anticipated include hypervascularity, altered bone qual-
coxa vara, femoral bowing, acetabular protrusio, and ity, and bone deformity. It is important to recognize the
bone enlargement, which can lead to arthropathy. These potential need for increased fluid and blood replacement
Figure 20 Radiographs show THA in a patient with osteoporosis. AP view of the pelvis (A) and cross-table 1ateral radiograph
of the left hip (B) demonstrate severe osteoarthritis of the left hip. Evidence of osteoporosis can also be seen
with loss of the trabeculae in the proximal femur and cortical thinning. Severe lumbar spine osteoarthritis and
deformity can also be noted in panel A. Postoperative radiograph of the patient’s pelvis (C) centered over the
pubic symphysis and cross-table lateral view of the left hip (D) show a left hybrid THA. An uncemented acetabular
cup was used and reinforced with multiple screws because of the patient’s poor bone quality. A dual-mobility
articulation was placed to address the patient’s risk of instability from the severe spinal deformity. A cemented
collarless, polished, double-tapered femoral stem was implanted to minimize the risk of fracture resulting from the
weak bone quality.
resulting from the hypervascularity of bone affected by acetabular bone grafting or the use of an oversized hemi-
Paget disease. In these cases, an intraoperative blood sal- spherical cup. Offset acetabular liners can also be used in
vage system can decrease the need for allogeneic blood situations where the cup has been placed too far medially.
3: Hip
products.42 If cemented components are planned, it is Multiple acetabular screws are useful to increase cup
important to recognize the difficulty in obtaining a dry stability, especially with compromised bone quality. The
bony bed for cement interdigitation. Visualization may choice of cemented versus uncemented acetabular compo-
also be impaired due to the increased hypervascularity nents is at the discretion of the treating surgeon. Sclerotic
and bleeding. Acetabular protrusio can be encountered femoral bone and varus deformity are two challenges that
in these patients, which can in turn lead to medialization must be anticipated. The use of high-speed burrs and
of the acetabular component and hip center. Techniques reamers in conjunction with intraoperative radiographs
employed to prevent overmedialization include medial can be used to ensure proper preparation of the proximal
Section 3: Hip
Figure 21 Images show THA in a patient with osteopetrosis. AP plain radiograph of the pelvis (A) shows osteopetrosis
in a patient who also has a right femoral neck fracture nonunion that has progressed to varus. The loss of the
medullary canals within both femurs is also evident. AP (B) and cross-table lateral (C) views of the right hip further
demonstrates the patient’s femoral neck nonunion and absence of any medullary canal. Postoperative AP views
of the pelvis (D) as well as AP (E) and cross-table lateral (F) views of the right hip demonstrate a right hybrid THA
that was performed for the patient’s femoral neck nonunion. An uncemented acetabular component was used
with augmented screw fixation. The creation of a new femoral intramedullary canal was required with the use
of multiple burr sizes and drill bits. Intraoperative fluoroscopy was also used to ensure proper placement of the
femoral broach. The smallest cemented collarless, polished, double-tapered femoral component was ultimately
used.
femur as well as position and fit of the trial components. point. However, postoperative heterotopic ossification is
Simultaneous or staged osteotomy may also be necessary also common in these patients, with a reported incidence
to address any varus deformity that compromises femoral as high as 56%. Postoperative radiation or chemopro-
component placement. phylaxis should be considered for patients undergoing
Cemented THA has been traditionally used in patients THA in the setting of Paget disease of bone to prevent
3: Hip
with Paget disease of bone; however, recently reported heterotopic bone formation.
midterm to long-term results of uncemented components
demonstrate satisfactory outcomes.67 In a 2014 study, THA in Renal Osteodystrophy
results were reported for 14 noncemented THAs in 11 pa- Chronic kidney disease can lead to an alteration in cal-
tients with a mean follow-up of 12.3 years (range, 10- cium and phosphate regulation that translates into a
17).68 The survival rate at 10-year follow-up for both cup deficiency in bone mineralization resulting in renal os-
and stem was 86% using revision for any cause as the end teodystrophy. Two forms of renal osteodystrophy have
point and was 95.5% using aseptic loosening as the end been described: high-turnover renal osteodystrophy and
Figure 22 Images from a patient with Paget disease who underwent THA. AP radiograph of the pelvis (A) as well as AP (B)
and cross-table lateral (C) radiographs of the right hip shows a femoral neck fracture nonunion that is also in varus
in a patient who also has Paget disease, which can be appreciated by the coarsened trabeculae and remodeled
cortices. AP view of the distal femur (D) demonstrates the distal extent of the disease and a previous united
diaphyseal femur fracture. Postoperative AP radiograph of the pelvis (E), AP (F) and cross-table lateral (G) views
of the right hip as well as an AP view of the distal femur (H) demonstrates the cemented THA that was placed for
reconstruction. A cemented all-polyethylene acetabular cup and a long cemented femoral component were placed
3: Hip
to address the femoral neck nonunion and underlying bone quality associated with Paget disease. Femoral canal
preparation required the use of multiple flexible reamers, a high-speed burr, and conical reamers.
low-turnover renal osteodystrophy. High-turnover renal bone turnover, and ultimately osteitis fibrosa cystica.
osteodystrophy is the classic form of this disease and is Low-turnover renal osteodystrophy develops following
characterized by an increase in parathyroid hormone the improved management of renal disease, such as ap-
secretion, parathyroid gland hyperplasia, increased os- propriate dialysis. Parathyroid hormone levels are nor-
teoblast and osteoclast activity, maintenance of high mal with low bone formation and unmineralized bone
Section 3: Hip
formation is not increased. Bone density is typically re- until after renal transplantation has taken place.71 A
duced in renal osteodystrophy and adult patients present 2014 study examined the outcomes of hip and knee total
with bone pain, muscle weakness, skeletal deformity, and joint arthroplasty in patients with various solid organ
heterotopic calcification. Furthermore, with the use of transplants.73 In 97% of patients who underwent THA
corticosteroids to treat chronic renal disease or for the after a renal transplant, outcomes were good to excellent
prevention of renal transplant rejection, osteopenia and at a mean follow-up of 35 months. This same cohort had
osteonecrosis are common in this patient population. a 28% rate of perioperative medical complications and
THA for patients with renal osteodystrophy is usually an 8% reoperation rate for periprosthetic fractures alone.
for management of osteonecrosis or osteoarthritis. In
one study, a five to eight times higher incidence of THA
was identified in patients following renal transplantation Summary
compared to the general population and osteonecrosis was Various conditions render THA technically challenging.
the most frequent reason for THA (72% of cases).69 Hip However, favorable outcomes are possible if key principles
replacement surgery in this population requires a multi- are followed, including understanding of the pathophys-
disciplinary approach, including anesthesia, nephrology, iology and pathoanatomy of the condition, meticulous
and possibly transplant services (in the setting of renal preoperative planning to ensure the availability of all nec-
transplantation) for proper preoperative optimization and essary implants and instruments to execute the primary
postoperative care. Careful preoperative planning and surgical plan, and having one or more contingency plans
templating are necessary to address any bony malalign- if needed. Adequate exposure is imperative. A variety of
ment and weakness. Radiographs of the entire femur femoral and acetabular implant designs are available in
are helpful to fully appreciate the overall alignment and order to achieve initial and lasting fixation, navigate de-
bone quality. Templating is needed to help choose the formities, approximate normal leg length and offset, op-
appropriate femoral implant that can accommodate the timize abductor function, and maximize stability against
proximal femur. In the face of severely compromised bone dislocation.
density, cemented implants should be considered to avoid THA in DDH can be technically demanding because
intraoperative iatrogenic fractures. Patients with renal of acetabular bone stock deficiency and excessive femoral
osteodystrophy also present for THA at a younger age, anteversion. In some cases, high acetabular fixation is
which makes it important to contemplate alternative bear- possible. In other cases, augmentation with structural
ing surfaces for their improved wear rates. allograft or a metallic augment is necessary. Excessive
Postoperative care for these patients requires avoidance femoral anteversion may require a conical or modular
of perioperative medical complications, such as further implant. The need for and ability to perform a short-
kidney injury. Proper postoperative hydration is critical ening osteotomy, with or without derotation, should be
as is the adjustment, cessation, or prevention of the use anticipated.
of any renal toxic agents such as NSAIDs or angiotensin- Prior trauma or corrective osteotomy may result in a
converting enzyme inhibitors. proximal femoral deformity, which may be further com-
Contemporary studies examining the outcomes of THA plicated by retained hardware, which interferes with THA
in patients with chronic renal disease demonstrate a high and leaves significant stress risers upon removal. There
postoperative complication rate, including mortality, es- should be a low threshold for performing an extended
pecially among patients who are dialysis-dependent.70-72 A trochanteric osteotomy to facilitate hardware removal,
recently published study compared the complications and canal preparation, and corrective osteotomy, and apply
mortality between patients with chronic renal failure and structural allograft if necessary. The femoral component
patients who had a history of renal transplantation who should be of sufficient length to bypass stress risers and
underwent either THA or total knee arthroplasty.70 These also allow for correction of anteversion.
patients were shown to have a statistically significant in- Although conservative and nonarthroplasty modalities
3: Hip
crease in postoperative complications such as surgical site remain the mainstays of care for patients with neuromus-
infections, wound complications, transfusions, deep vein cular hip disorders, THA is becoming more widely accept-
thrombosis, and mortality compared with patients with- ed as appropriate for the ambulatory adult with painful
out kidney disease. Furthermore, patients on dialysis had degenerative hip disease. Constrained THA designs must
increased rates of surgical site infections, wound complica- be considered in more severely affected patients, whereas
tions, transfusions, and mortality compared with patients those with less involvement may benefit from newer im-
who had undergone renal transplant. Therefore, some plant designs such as dual mobility bearings.
authors have advocated delaying joint arthroplasty surgery THA for posttraumatic arthritis after acetabular
fracture is increasingly considered as a primary inter- Annotated References

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Metabolic bone disease comprises a heterogeneous 3. Wu X, Li SH, Lou LM, Cai ZD: The techniques of soft
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ditions are generally outside the expertise of experienced A follow-up study of 50 Crowe III and IV hips that under-
went acetabular reconstruction at the anatomic hip center
hip surgeons. If possible, THA is deferred until bone qual- is presented. Level of evidence: IV.
ity is optimized and bone turnover minimized. Cement
fixation is considered in the face of significant osteopenia. 4. Li H, Mao Y, Oni JK, Dai K, Zhu Z: Total hip replace-
Regardless of the type of treatment chosen, it is essen- ment for developmental dysplasia of the hip with more
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Key Study Points pelvic radiograph with medical imaging software. Level
of evidence: IV.
• Meticulous preoperative planning with consider-
ation of physical findings, plain films, and advanced 5. Zahar A, Papik K, Lakatos J, Cross MB: Total hip ar-
imaging is critical. The need for selective retained throplasty with acetabular reconstruction using a bulk
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• Various femoral implant designs and fixation with DDH were examined. Level of evidence: IV.
philosophies are optimum in different situations.
6. Pizarro FC, Young SW, Blacutt JH, Mojica R, Cruz JC:
One should be experienced in the use of cemented Total hip arthroplasty with bulk femoral head autograft
stems, cementless “primary” components, conical for acetabular reconstruction in developmental dyspla-
monobloc stems, modular stems including those sia of the hip. ISRN Orthop 2013;2013(2013):794218.
with distal tapers, and extensively porous coated Medline 3: Hip
cylindrical stems. This study describes a technique variation combining an

iliac osteotomy with bulk autograft in cases of DDH.
• When stability against dislocation is of particular The results of these THAs showed satisfactory clinical
concern, jumbo heads, dual mobility constructs, and radiologic outcomes in the medium term. Level of
and constrained components should be considered. evidence: IV.
• Close collaboration with medical consultants is
7. Yang S, Cui Q: Total hip arthroplasty in developmen-
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Section 3: Hip
Acetabular and femoral techniques to reconstruct the DDH hip arthroplasty for developmental dysplasia of the hip.
at the time of THA are reviewed. Level of evidence: III. J Arthroplasty 2013;28(10):1741-1745. Medline DOI
This clinical study outlines the need for a small modular
8. Fukui K, Kaneuji A, Sugimori T, Ichiseki T, Matsumoto femoral stem in the Asian population with DDH. The
T: How far above the true anatomic position can the ac- authors report their short-term results with this modified
etabular cup be placed in total hip arthroplasty? Hip Int S-ROM stem for THA. Level of evidence: IV.
2013;23(2):129-134. Medline DOI
Two hundred hips with DDH were evaluated after THA 16. Imbuldeniya AM, Walter WL, Zicat BA, Walter WK: Ce-
to determine how high the center of rotation can be placed mentless total hip replacement without femoral osteotomy
without development of a Trendelenburg sign postopera- in patients with severe developmental dysplasia of the hip:
tively. Level of evidence: IV. Minimum 15-year clinical and radiological results. Bone
Joint J 2014;96-B(11):1449-1454. Medline DOI
9. Stans AA, Pagnano MW, Shaughnessy WJ, Hanssen This study reports the successful long-term results of us-
AD: Results of total hip arthroplasty for Crowe Type ing the modular S-ROM femoral stem in THA for DDH.
III developmental hip dysplasia. Clin Orthop Relat Res Level of evidence: IV.
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17. Parvizi J, Burmeister H, Ganz R: Previous Bernese peria-
10. Kaneuji A, Sugimori T, Ichiseki T, Yamada K, Fukui K, cetabular osteotomy does not compromise the results of
Matsumoto T: Minimum ten-year results of a porous ac- total hip arthroplasty. Clin Orthop Relat Res 2004;423:
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an elevated hip center. J Arthroplasty 2009;24(2):187-194.
Medline DOI
18. Amanatullah DF, Stryker L, Schoenecker P, et al: Sim-
ilar clinical outcomes for THAs with and without
11. Çatma MF, Ünlü S, Öztürk A, Aksekili AM, Ersan Ö, Ateş prior periacetabular osteotomy. Clin Orthop Relat Res
Y: Femoral shortening osteotomy in total hip arthroplasty 2015;473(2):685-691. Medline DOI
for severe dysplasia: A comparison of two fixation tech-
niques. Int Orthop 2016 March 3 [Epub ahead of print]. This multicenter study specifically addresses the issues of
Medline performing a THA after a previous periacetabular oste-
otomy. Level of evidence: III.
This study compared two techniques to stabilize a subtro-
chanteric transverse osteotomy to shorten the femur
during THA for DDH. Level of evidence: II. 19. Fukui K, Kaneuji A, Sugimori T, Ichiseki T, Matsumoto
T: Does rotational acetabular osteotomy affect subse-
quent total hip arthroplasty? Arch Orthop Trauma Surg
12. Bao N, Meng J, Zhou L, Guo T, Zeng X, Zhao J: Lesser 2015;135(3):407-415. Medline DOI
trochanteric osteotomy in total hip arthroplasty for treat-
ing CROWE type IV developmental dysplasia of hip. Int This study evaluates the effect of a previous rotational
Orthop 2013;37(3):385-390. Medline DOI acetabular osteotomy on a subsequent THA in patients
with DDH. Level of evidence: III.
The authors describe their technique of shortening the me-
dial femoral neck cut in 28 hips with DDH to avoid over-
lengthening of the leg during THA. Level of evidence: IV. 20. Yildirim T, Guclu B, Karaguven D, Kaya A, Akan B,
Cetin I: Cementless total hip arthroplasty in develop-
mental dysplasia of the hip with end stage osteoarthritis:
13. Liu R, Li Y, Bai C, Song Q, Wang K: Effect of preoperative 2-7 years’ clinical results. Hip Int 2015;25(5):442-446.
limb-length discrepancy on abductor strength after total Medline DOI
hip arthroplasty in patients with developmental dysplasia
of the hip. Arch Orthop Trauma Surg 2014;134(1):113- This study’s review of 78 patients who underwent a THA
119. Medline DOI for end stage DDH demonstrates a significant complica-
tion rate. Level of evidence: IV.
The authors examine the post-THA recovery course of
abductor muscle strength and its relationship to limb-
length discrepancies and THA placement in patients with 21. Ollivier M, Abdel MP, Krych AJ, Trousdale RT, Berry DJ:
DDH. Level of evidence: II. Long-term results of total hip arthroplasty with shortening
subtrochanteric osteotomy in Crowe IV developmental
dysplasia. J Arthroplasty 2016 February 4 [Epub ahead
14. Kaneuji A, Sugimori T, Ichiseki T, Fukui K, Takahashi of print]. Medline DOI
E, Matsumoto T: Cementless anatomic total hip femo-
3: Hip
ral component with circumferential porous coating for This long-term study of THA for DDH with a subtro-
hips with developmental dysplasia: A minimum ten-year chanteric osteotomy demonstrates reassuring long-term
follow-up period. J Arthroplasty 2013;28(10):1746-1750. results and highlights the short-term complications. Level
Medline DOI of evidence: IV.
This study presents the minimum 10-year outcomes of
THA in DDH using an anatomic femoral stem designed 22. Boyle MJ, Frampton CM, Crawford HA: Early results
for primary osteoarthritis. Level of evidence: IV. of total hip arthroplasty in patients with developmen-
tal dysplasia of the hip compared with patients with
osteoarthritis. J Arthroplasty 2012;27(3):386-390.
15. Tamegai H, Otani T, Fujii H, Kawaguchi Y, Hayama T, Medline DOI
Marumo K: A modified S-ROM stem in primary total
This study reviews the short-term data from the New system can provide an alternative to CT analysis of lower-
Zealand Joint Registry comparing the results of THA limb torsion. Level of evidence: III.
for DDH with that of THA for osteoarthritis. Level of
evidence: III. 29. Buck FM, Guggenberger R, Koch PP, Pfirrmann CW:
Femoral and tibial torsion measurements with 3D models
23. Boyle MJ, Singleton N, Frampton CM, Muir D: Functional based on low-dose biplanar radiographs in comparison
response to total hip arthroplasty in patients with hip dys- with standard CT measurements. AJR Am J Roentgenol
plasia. ANZ J Surg 2013;83(7-8):554-558. Medline DOI 2012;199(5):W607-12. Medline DOI
This study compares the minimum 1-year functional out- The authors compared CT to three-dimensional mod-
come data from the New Zealand Joint Registry for THA els in the measurement of tibial and femoral torsion in
in DDH versus osteoarthritis. Level of evidence: IV. 35 patients with osteoarthritis of the knee undergoing
prosthesis insertion. The measurements were compared
24. Engesaeter LB, Furnes O, Havelin LI: Developmen- by Bland-Altman plots and descriptive statistics. It was
tal dysplasia of the hip—good results of later total hip demonstrated that three-dimensional models and CT mea-
arthroplasty: 7135 primary total hip arthroplasties af- surements are interchangeable in the role of imaging of
ter developmental dysplasia of the hip compared with osteoarthritic knees.
59774 total hip arthroplasties in idiopathic coxarthrosis
followed for 0 to 15 years in the Norwegian Arthroplasty 30. Journé A, Sadaka J, Bélicourt C, Sautet A: New method
Register. J Arthroplasty 2008;23(2):235-240. Medline for measuring acetabular component positioning with
EOS imaging: Feasibility study on dry bone. Int Orthop
This long-term study of THA for DDH with a subtro- 2012;36(11):2205-2209. Medline DOI
chanteric osteotomy demonstrates reassuring long-term
results and highlights the short-term complications. The authors compared EOS imaging to standard radi-
ography in the measurement of acetabular anteversion
25. Roberts KC, Brox WT, Jevsevar DS, Sevarino K: Manage- and inclination. An acetabular cup was implanted in dry
ment of hip fractures in the elderly. J Am Acad Orthop bone and cup anteversion and inclination measured with
Surg 2015;23(2):131-137. Medline DOI scanography. Interobserver and intraobserver reproduc-
ibility and accuracy were calculated. Results demonstrated
The authors suggest a treatment protocol for hip fractures that EOS imaging is superior to standard radiography
in the elderly, strongly recommending regional analgesia when measuring acetabular anteversion and inclination.
to improve preoperative pain control, arthroplasty for
patients with unstable femoral neck fractures, cephalo 31. Mortazavi SM, Restrepo C, Kim PJ, Parvizi J, Hozack
medullary devices for the treatment of patients with WJ: Cementless femoral reconstruction in patients with
subtrochanteric or reverse obliquity fractures, blood trans- proximal femoral deformity. J Arthroplasty 2011;26(3):
fusion thresholds of 8 g/dL in asymptomatic postoperative 354-359. Medline DOI
patients, intensive physical therapy postdischarge, and the
use of an interdisciplinary care program to assist patients The authors examined the role of noncemented femoral
with unique medical requirements such as dementia. reconstruction in patients with proximal femur deformity.
They examined 58 hips undergoing THA in 51 patients
26. Berry DJ: Total hip arthroplasty in patients with proximal from 1998 to 2006. All hips except two were treated with
femoral deformity. Clin Orthop Relat Res 1999;369:262- noncemented prostheses. Noncemented femoral recon-
272. Medline DOI struction was found to be reliable and durable in patients
with proximal femur deformity. Functional scores were
improved after an average 4-year follow-up.
27. Lazennec JY, Rousseau MA, Rangel A, et al: Pelvis and
total hip arthroplasty acetabular component orienta-
tions in sitting and standing positions: Measurements 32. Kang JS, Moon KH, Kim RS, Park SR, Lee JS, Shin SH: To-
reproductibility with EOS imaging system versus con- tal hip arthroplasty using S-ROM prosthesis for dysplastic
ventional radiographies. Orthop Traumatol Surg Res hip. Yonsei Med J 2011;52(4):655-660. Medline DOI
2011;97(4):373-380. Medline DOI The authors evaluated the clinical and radiologic results
The authors compared the EOS two-dimensional imag- of THA with a modular femoral stem in patients with
ing system to conventional radiographic imaging. They secondary coxarthrosis associated with dysplastic hips. In
suggest that EOS two-dimensional imaging may one day 45 hips in 42 patients, there was an increase in Hospital
replace radiographic imaging in the assessment and moni- for Special Surgery score from a preoperative average of
toring of pelvic acetabular cup orientation in THA. Level 52.2 points to 88.5 points postoperatively. Most patients
of evidence: III. (91.9%) exhibited excellent or good clinical results.
3: Hip
28. Folinais D, Thelen P, Delin C, Radier C, Catonne Y, La- 33. Archibeck MJ, Carothers JT, Tripuraneni KR, White
zennec JY: Measuring femoral and rotational alignment: RE Jr: Total hip arthroplasty after failed internal fix-
EOS system versus computed tomography. Orthop Trau- ation of proximal femoral fractures. J Arthroplasty
matol Surg Res 2013;99(5):509-516. Medline DOI 2013;28(1):168-171. Medline DOI
The authors compared EOS imaging to CT in the assess- The authors analyzed 102 THAs after failed internal fix-
ment of femoral and tibial rotational alignment using ation of prior hip fracture. Of these, 39 were trochanteric
43 lower limbs in 30 patients. They found that the EOS fractures and 63 were femoral neck fractures. Failure oc-
curred via osteonecrosis in 35 cases, arthritis in 32 cases,
Section 3: Hip
failure of fixation in 25 cases, and nonunion in 10 cases. benefit of salvage THA using nonmodular noncemented
It was concluded that THA after failed internal fixation of long-stem prosthesis after failed intertrochanteric fixation.
hip fractures is clinically successful but there is an elevated
risk of periprosthetic fracture and dislocation. 39. Abouelela AA: Salvage of failed trochanteric fracture
fixation using the Revitan curved cementless modular
34. Petrie J, Sassoon A, Haidukewych GJ: When femo- hip arthroplasty. J Arthroplasty 2012;27(7):1382-1388.
ral fracture fixation fails: Salvage options. Bone Joint Medline DOI
J 2013;95-B(11suppl A):7-10. Medline DOI
The authors studied 16 patients treated with Revitan
Salvage options for femoral fracture fixation failure are re- curved noncemented modular stems. At a mean follow-up
viewed. Factors such as patient age are crucial in decision- period of 60 months, all patients had significant pain relief
making. For younger patients, the focus is on preserving and returned to ambulation after salvage THA; Hospital
the native femoral head via osteotomies and repeat internal for Special Surgery scores improved from 17.8 to 87.7.
fixation, whereas hip replacement is generally reserved for Eight patients reported slight lateral trochanteric pain but
older patients. Patients with osteopenia, deformity, bone their activities were not compromised, and one patient
loss, and stress risers from previous internal fixation de- experienced nonunion of the greater trochanter.
vices all present treatment challenges.
40. Reikerås O, Haaland JE, Lereim P: Femoral shortening in
35. DeHaan AM, Groat T, Priddy M, et al: Salvage hip arthro- total hip arthroplasty for high developmental dysplasia of
plasty after failed fixation of proximal femur fractures. the hip. Clin Orthop Relat Res 2010;468(7):1949-1955.
J Arthroplasty 2013;28(5):855-859. Medline DOI Medline DOI
A review of 46 patients undergoing salvage THA for failed Researchers studied the treatment of DDH and found that
internal fixation is detailed. There was a stronger correla- femoral osteotomy and shortening at the subtrochanteric
tion between surgical demand/patient morbidity and index level can allow a stable reduction in patients with high
device than fracture pattern during the salvage operation. DDH without leading to reduction in long-term survival.
36. Bercik MJ, Miller AG, Muffly M, Parvizi J, Orozco F, Ong 41. Wegrzyn J, Pibarot V, Chapurlat R, Carret JP, Béjui-Hu-
A: Conversion total hip arthroplasty: A reason not to use gues J, Guyen O: Cementless total hip arthroplasty in
cephalomedullary nails. J Arthroplasty 2012;27(8sup- Paget’s disease of bone: A retrospective review. Int Orthop
pl):117-121. Medline DOI 2010;34(8):1103-1109. Medline DOI
The outcomes of conversion to THA from screw and side Noncemented THA in the presence of Paget disease of
plate versus cephalomedullary nail fixation are compared bone was reviewed in 39 cases using uncemented fully-
for 76 patients. The cephalomedullary nail group had coated hydroxyapatite stems. Functional scores improved
significantly greater blood loss and surgical time, but significantly and 84% of patients had excellent clinical
length of stay and perioperative complications were not outcomes.
significantly different.
42. Lewallen DG: Hip arthroplasty in patients with Pag-
37. Chu X, Liu F, Huang J, Chen L, Li J, Tong P: Good short- et’s disease. Clin Orthop Relat Res 1999;369:243-250.
term outcome of arthroplasty with Wagner SL implants Medline DOI
for unstable intertrochanteric osteoporotic fractures. J Ar-
throplasty 2014;29(3):605-608. Medline DOI 43. Kosashvili Y, Taylor D, Backstein D, et al: Total hip ar-
The authors present clinical and radiographic results throplasty in patients with Down’s syndrome. Int Orthop
in 47 patients with unstable intertrochanteric fractures 2011;35(5):661-666. Medline DOI
treated with THA using the Wagner SL stem. Patients The authors evaluated seven patients with Down syndrome
had favorable short-term clinical and radiologic outcomes. with coxarthrosis undergoing a total of nine THAs. Hos-
Mean Hospital for Special Surgery scores were 89.4 for pital for Special Surgery scores improved significantly, no
THA and 87.7 for hemiarthroplasty at 2.7-year average dislocations or deep infections occurred, and two patients
follow-up. Radiologic and clinical healing was evident at required revision arthroplasty for stem loosening at 16 and
an average of 3.7 months. 6 years following THA due to osteolysis and trauma,
respectively.
38. Shi X, Zhou Z, Yang J, Shen B, Kang P, Pei F: To-
tal hip arthroplasty using non-modular cementless 44. Osagie L, Figgie M, Bostrom M: Custom total hip ar-
long-stem distal fixation for salvage of failed internal throplasty in skeletal dysplasia. Int Orthop 2012;36(3):
3: Hip
fixation of intertrochanteric fracture. J Arthroplasty 527-531. Medline DOI

2015;30(11):1999-2003. Medline DOI
The authors analyzed the results of THA using custom
Salvage THA for failed internal fixation of inter- hip implants in nine patients with dwarfism. A total of
trochanteric fracture in 31 patients were analyzed at a 14 hips were assessed using CT scans to create custom
mean follow-up of 47.5 months. All patients reported pain titanium stems. Midterm outcomes were reported as
relief and return to ambulation, and mean Hospital for satisfactory as all patients walked independently, mean
Special Surgery scores increased from 28.4 to 85.6. Seven Hospital for Special Surgery scores improved from 45 to
patients had intraoperative or early complications but were 71, and limb-length discrepancies were restored to within
treated successfully; no infections, re-fractures, loosen- 3 mm of equal.
ing, or revisions occurred. This study demonstrated the
45. Boyce AM, Kelly MH, Brillante BA, et al: A random- score improved from 49.5 to 90.1 points and all but three
ized, double blind, placebo-controlled trial of alendronate patients were satisfied or very satisfied with the procedure.
treatment for fibrous dysplasia of bone. J Clin Endocrinol Level of evidence: III.
Metab 2014;99(11):4133-4140. Medline DOI
This study assessed the efficacy of alendronate for polyos- 53. Baghdadi YM, Larson AN, Sierra RJ: Restoration of the
totic fibrous dysplasia in 35 individuals. The study demon- hip center during THA performed for protrusio acetabuli
strated that the alendronate-treated group exhibited lower is associated with better implant survival. Clin Orthop
levels of NTX-telopeptides, which are markers used to Relat Res 2013;471(10):3251-3259. Medline DOI
determine bone resorption. However, osteocalcin, pain, One hundred twenty-seven patients (162 hips) undergoing
and functional parameters were not significantly different primary THA with acetabular protrusio were retrospec-
between treatment and control groups. tively reviewed. The risk of aseptic cup revision signifi-
cantly increased by 24% for every 1 mm medial or lateral
46. Johnson JT: Neuropathic fractures and joint injuries. distance away from the native hip center of rotation to the
Pathogenesis and rationale of prevention and treatment. prosthetic head center. Level of evidence: III.
J Bone Joint Surg Am 1967;49(1):1-30. Medline
54. Labuda A, Papaioannou A, Pritchard J, Kennedy C,
47. Ritter M, DeRosa G: Total hip arthroplasty in a Charcot DeBeer J, Adachi JD: Prevalence of osteoporosis in os-
joint. A case report with six year follow-up. Orthop Rev teoarthritic patients undergoing total hip or total knee
1977;6:51-77. arthroplasty. Arch Phys Med Rehabil 2008;89(12):2373-
2374. Medline DOI
48. Robb JE, Rymaszewski LA, Reeves BF, Lacey CJ: Total
hip replacement in a Charcot joint: Brief report. J Bone 55. Jauregui JJ, Clayton A, Kapadia BH, Cherian JJ, Issa K,
Joint Surg Br 1988;70(3):489. Medline Mont MA: Total hip arthroplasty for acute acetabular
fractures: A review of the literature. Expert Rev Med
49. Sato Y, Honda Y, Iwamoto J: Risedronate and ergocal- Devices 2015;12(3):287-295. Medline DOI
ciferol prevent hip fracture in elderly men with Parkinson The authors review the current use of THA for the acute
disease. Neurology 2007;68(12):911-915. Medline DOI treatment of acetabular fractures. Level of evidence: III.
50. Makridis KG, Obakponovwe O, Bobak P, Giannoudis PV: 56. Miller BJ, Callaghan JJ, Cram P, Karam M, Marsh JL,
Total hip arthroplasty after acetabular fracture: incidence Noiseux NO: Changing trends in the treatment of fem-
of complications, reoperation rates and functional out- oral neck fractures: A review of the american board of
comes: evidence today. J Arthroplasty 2014;29(10):1983- orthopaedic surgery database. J Bone Joint Surg Am
1990. Medline DOI 2014;96(17):e149. Medline DOI
In a systematic review of 659 hips (654 patients) with This study reviewed the American Board of Orthopaedic
THA after acetabular fracture, the 10-year survivorship Surgery database to identify trends in the treatment of
with loosening, osteolysis, or revision as the end point femoral neck fractures. The use of THA has increased
was 76% for the acetabular component and 85% for the from 0.7% in 1999 to 7.7% in 2011, whereas both hemi-
femoral component. Heterotopic ossification was the arthroplasty and internal fixation have slightly declined.
most common complication (30%), followed by infection Level of evidence: III.
(6%), dislocation (4%), and nerve injuries (2%). Level of
evidence: III.
57. Kim Y-H, Park J-W, Kim J-S: Is diaphyseal stem fixation
necessary for primary total hip arthroplasty in patients
51. Lai O, Yang J, Shen B, Zhou Z, Kang P, Pei F: Midterm with osteoporotic bone (Class C bone)? J Arthroplasty
results of uncemented acetabular reconstruction for post- 2013;28(1):139-46.e1. Medline DOI
traumatic arthritis secondary to acetabular fracture. J Ar-
throplasty 2011;26(7):1008-1013. Medline DOI A prospective cohort study analyzed patients treated with
THA with various bone quality (three groups) using a
Thirty-one hips with THA for posttraumatic arthritis short, metaphyseal-fitting uncemented femoral stem.
after acetabular fracture at an average 6.3 years follow-up All three groups of bone quality had equal clinical out-
demonstrated improvement in Harris hip score from 49 to comes and survivorship at the 7-year follow-up. Level of
89 points and 100% survivorship for revision or acetabu- evidence: II.
lar loosening. Length of surgery and blood loss were great-
er in patients treated with open reduction and internal
58. Patel RM, Smith MC, Woodward CC, Stulberg SD: Stable
fixation of prior acetabular fracture compared to patients
3: Hip
fixation of short-stem femoral implants in patients 70 years

treated conservatively for prior acetabular fracture. Level
of evidence: II. and older. Clin Orthop Relat Res 2012;470(2):442-449.
Medline DOI
52. Zhang L, Zhou Y, Li Y, Xu H, Guo X, Zhou Y: Total hip This retrospective study compared uncemented short fem-
arthroplasty for failed treatment of acetabular fractures: oral stems in patients age 70 years and older to patients
A 5-year follow-up study. J Arthroplasty 2011;26(8):1189- younger than 70 years. The short uncemented stems pro-
1193. Medline DOI vided reliable fixation in osteoporotic bone at a mean
follow-up of 35 months. Level of evidence: IV.
A retrospective review of 53 patients after THA following
prior acetabular fracture demonstrated that Harris hip
Section 3: Hip
59. Rhyu KH, Lee SM, Chun YS, Kim KI, Cho YJ, Yoo MC: disease at long-term follow-up (average of 12.3 years).
Does osteoporosis increase early subsidence of cementless J Arthroplasty 2014;29(5):1063-1066. Medline DOI
double-tapered femoral stem in hip arthroplasty? J Arthro-
plasty 2012;27(7):1305-1309. Medline DOI A long-term follow-up study of 14 hips with Paget disease
who underwent noncemented THA with a minimum fol-
This comparative study examined the amount of subsi- low-up of 10 years is presented. Survivorship for all causes
dence of a noncemented double-tapered femoral stem and for aseptic loosening as the endpoint was 86% and
in patients younger than 50 years and those older than 95.5%, respectively. Level of evidence: IV.
70 years with a T-score of the proximal femur less than
−2.5. Subsidence in both groups was equal, with all 69. Bucci JR, Oglesby RJ, Agodoa LY, Abbott KC: Hospitaliza-
stems showing stable fixation at final follow-up. Level tions for total hip arthroplasty after renal transplantation
of evidence: III. in the United States. Am J Transplant 2002;2(10):999-
1004. Medline DOI
60. Abdel MP, Watts CD, Houdek MT, Lewallen DG, Berry
DJ: Epidemiology of periprosthetic fracture of the femur in 70. Cavanaugh PK, Chen AF, Rasouli MR, Post ZD, Orozco
32 644 primary total hip arthroplasties: A 40-year experi- FR, Ong AC: Complications and mortality in chronic re-
ence. Bone Joint J 2016;98-B(4):461-467. Medline DOI nal failure patients undergoing total joint arthroplasty: A
This study defined the epidemiology of periprosthetic frac- comparison between dialysis and renal transplant patients.
tures of the femur associated with primary THA over the J Arthroplasty 2016;31(2):465-472. Medline DOI
course of 40 years of experience. Intraoperative fractures A study of the Nationwide Inpatient Sample database
were more common using uncemented femoral compo- compared THA in patients on dialysis with that in patients
nents in female patients older than 65 years. Postoperative following renal transplantation. Patients with chronic
periprosthetic fractures were also more common with renal disease had a higher complication rate following
uncemented stems. Level of evidence: IV. THA compared to the general population. Dialysis-
dependent patients had a higher complication rate fol-
61. Sierra RJ, Timperley JA, Gie GA: Contemporary cement- lowing THA compared to renal transplant patients. Level
ing technique and mortality during and after Exeter to- of evidence: III.
tal hip arthroplasty. J Arthroplasty 2009;24(3):325-332.
Medline DOI 71. Ponnusamy KE, Jain A, Thakkar SC, Sterling RS, Sko-
lasky RL, Khanuja HS: Inpatient mortality and morbid-
62. Benum P, Aamodt A, Nordsletten L: Customised femoral ity for dialysis-dependent patients undergoing primary
stems in osteopetrosis and the development of a guiding total hip or knee arthroplasty. J Bone Joint Surg Am
system for the preparation of an intramedullary cavity: A 2015;97(16):1326-1332. Medline DOI
report of two cases. J Bone Joint Surg Br 2010;92(9):1303-
1305. Medline DOI This retrospective study reviewed the National Inpatient
Sample to determine outcomes of dialysis-dependent
patients following primary THA and knee replacement
63. Egawa H, Nakano S, Hamada D, Sato R, Yasui N: Total surgery. Dialysis dependency was found to be an indepen-
hip arthroplasty in osteopetrosis using computer-assisted dent risk factor for mortality and overall complications
fluoroscopic navigation. J Arthroplasty 2005;20(8):1074- in patients undergoing THA and total knee arthroplasty.
1077. Medline DOI Level of evidence: IV.
64. Ramiah RD, Baker RP, Bannister GC: Conversion of failed 72. Warth LC, Pugely AJ, Martin CT, Gao Y, Callaghan
proximal femoral internal fixation to total hip arthroplas- JJ: Total joint arthroplasty in patients with chronic re-
ty in osteopetrotic bone. J Arthroplasty 2006;21(8):1200- nal disease: Is it worth the risk? J Arthroplasty 2015;30
1202. Medline DOI (9suppl):51-54. Medline DOI
65. Strickland JP, Berry DJ: Total joint arthroplasty in pa- Total joint arthroplasty in patients with chronic renal
tients with osteopetrosis: A report of 5 cases and review disease was examined in a registry study. A greater over-
of the literature. J Arthroplasty 2005;20(6):815-820. all complication rate was noted in patients with moder-
Medline DOI ate to severe renal impairment. Mortality was also twice
as high in patients with chronic renal disease. Level of
evidence: IV.
66. Delmas PD, Meunier PJ: The management of Paget’s
disease of bone. N Engl J Med 1997;336(8):558-566.
Medline DOI 73. Ledford CK, Watters TS, Wellman SS, Attarian DE, Bo-
3: Hip
lognesi MP: Risk versus reward: Total joint arthroplasty

outcomes after various solid organ transplantations. J Ar-
67. Tudor F, Ariamanesh A, Potty A, Hashemi-Nejad A: Resur- throplasty 2014;29(8):1548-1552. Medline DOI
facing hip arthroplasty in neuromuscular hip disorders - A
retrospective case series. J Orthop 2013;10(3):105-110. In a retrospective review, 76 primary THAs and total
Medline DOI knee arthroplasties were assessed following various organ
transplantations. Patients who underwent a THA after re-
A review of 11 patients with neuromuscular hip disease is nal transplantation experienced significant improvement;
presented. Pain improvement is reported, with 1 of 11 pa- however, a 28% perioperative complication rate and an
tients sustaining a dislocation. Level of evidence: IV. 8% reoperation rate due to periprosthetic fractures were
noted. Level of evidence: III.
68. Imbuldeniya AM, Tai SM, Aboelmagd T, Walter WL, Wal-
ter WK, Zicat BA: Cementless hip arthroplasty in Paget’s
Chapter 32
Computer Navigation and Robotics

in Total Hip Arthroplasty
Bradford S. Waddell, MD Douglas E. Padgett, MD
exists in the placement of femoral components in THA

Abstract
performed with or without cement, femoral geometry
Computer navigation and robotics play substantial often determines the ultimate position of the stem. Despite
roles in total hip arthroplasty. It is important to re- the use of anatomic landmarks or external guides, the
view the types of navigation currently utilized, as well acetabular component position is the factor most suscep-
as newer technologies such as robotic assistance and tible to suboptimal position.1,2 Variation in the acetabular
precision-manufactured aligning guides. A review of position has been attributed to numerous factors, ranging
the recently published data confirms the precision of from patient position on the operating table (supine versus
these enabling technologies compared with freehand lateral), pelvic movement during the procedure (affecting
techniques. Evolving technologies have the potential spatial orientation), and the effect of the lumbosacral
to improve surgical accuracy and reproducibility in a spine. In addition to component orientation, changes in
time- and cost-efficient manner. the longitudinal direction (hip or limb length) as well as
the lateral direction (offset) are known to affect perfor-
mance and satisfaction after THA.
Keywords: computer-assisted; haptics; hip These observations have inspired studies exploring the
arthroplasty; navigation; robotics potential of supporting technologies such as computer-
assisted navigation and robotics to overcome the limita-
tions of freehand techniques. It is important to review
Introduction
some basic concepts of navigation and robotics relevant
Optimization of component orientation in total hip ar- to THA, recent results of these technologies, and future
throplasty (THA) has been known for some time to max- directions.
imize long-term success. Suboptimal position has been
associated with instability, accelerated bearing wear, and
the potential for impingement at nonintended interfaces, Navigation
all of which result in early failure. Although some latitude Computer navigation is a useful means to accurately de-
termine the location in space of the pelvis and/or femur
during THA. Recognizing that hip kinematics rely on
Dr. Padgett or an immediate family member has received proper spatial orientation of the components to each other
royalties from Mako Medical Laboratories; is a member of a and to the body is key to proper component preparation
speakers’ bureau or has made paid presentations on behalf and insertion. Several methods of navigation have evolved
of Mako Medical Laboratories; serves as a paid consultant to to address the requirements for both tracking and imaging
3: Hip
Mako Medical Laboratories, Medical Compression Systems, for rigid bodies such as bone, instruments, or implants.
and Stryker; and serves as a board member, owner, officer,
or committee member of the Hospital for Special Surgery,
the Journal of Arthroplasty, and the Hip Society. Neither Types of Navigation
Dr. Waddell nor any immediate family member has received Tracking is essential for all aspects of computer-assisted
anything of value from or has stock or stock options held surgery. The computer must be able to recognize where
in a commercial company or institution related directly or in space the patient and instruments are located relative
indirectly to the subject of this chapter. to one another. The most common type of tracking is
© 2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip & Knee Reconstruction 5 423
Section 3: Hip
Figure 1 Illustration shows a standard infrared sensor

and reflectors based on the intraoperative Figure 2 Illustration shows registration points on the
instruments. (Reproduced with permission from pelvis. (Reproduced with permission from
BrainLab, Feldkirchen, Germany. Available at: Spencer JMF, Day RE, Sloan KE, Beaver RJ:
https://www.brainlab.com/en/surgery-products/ Computer navigation for the acetabular
orthopedic-surgery-products/hip-navigation/. component: A cadaver reliability study. J Bone
Accessed July 7, 2016.) Joint Surg Br 2006;88[7]:972-975.)
optical tracking (Figure 1), which uses infrared stereo- However, imageless systems have several distinct dis-
scopic technology in which a light source emits a signal advantages. First, although the initial reference points
that is reflected back and captured. Although simple and are acquired in the supine position, the patient must be
reliable, optical tracking is limited by line-of-sight issues reprepped and redraped if the procedure is performed in
(for example, drapes or personnel) that block the signal the lateral position. Second, errors in point acquisition
and disrupt the workflow. Alternatively, some systems use can occur during digitization. Landmarks are difficult to
electromagnetic tracking systems, which have the distinct confirm in patients with obesity, which can result in errors
advantage of avoiding line-of-sight issues. However, these in establishing the coordinate plane and incorrect version
systems have fallen out of favor because of numerous and abduction values. Because no reference images exist,
issues with noise created by instruments and power tools these errors can go undetected.
that distort the electromagnetic signal. Image-based techniques have been promoted to im-
Imaging methods used in computer-assisted surgery prove the precision and accuracy of computer naviga-
have two major categories: image-based and imageless. tion. Fluoroscopically based navigation (Figure 3) uses
Image-based systems can use CT (preoperative CT is real-time images of anatomic landmarks coupled with
required), fluoroscopy, or more recently, ultrasonogra- tracking of the pelvis or femur to facilitate accurate de-
phy.3 Imageless systems do not require preoperative or termination of spatial orientation. In addition, fluoro-
intraoperative radiologic studies and rely on the identi- scopically based navigation can help confirm position
fication of the anterior pelvic plane, which is typically and reacquisition can be performed at any time during
done with the patient supine. After a reference tracking surgery to ensure optimal positioning. Although pre-
device is attached to the pelvis (typically at the iliac crest), operative imaging is not needed with fluoroscopically
anatomic landmarks are digitized (that is, points obtained based navigation, access to fluoroscopic equipment and
from the anterior superior iliac spine and pubic symphy- disruption of workflow while obtaining images are dis-
3: Hip
sis) to allow the computer to determine the plane of the tinct disadvantages of this method.
pelvis (Figure 2), which is used to reference instrument Ultrasonography-based navigation has gained popular-
and implant positions. ity in some centers as an alternative to fluoroscopy-based
One advantage of an imageless system is that the cost and imageless systems. Although no preoperative plan-
of preoperative imaging is negated. In addition, intraop- ning is necessary, the main advantage of ultrasonogra-
erative procedures involving fluoroscopy or ultrasonog- phy-based navigation is the more precise determination of
raphy are not needed. Imageless systems are relatively anatomic landmarks such as the anterior pelvic spines and
simple to use, and surgeons can quickly adapt to them. pubic symphysis. Patients are placed in a supine position
424 Orthopaedic Knowledge Update: Hip & Knee Reconstruction 5 © 2017 American Academy of Orthopaedic Surgeons
Chapter 32: Computer Navigation and Robotics in Total Hip Arthroplasty
registration error is too large, the registration process can

be repeated to reduce error. CT-based navigation is the
most accurate method of computer navigation and does
not require intraoperative equipment or intraoperative
imaging. CT-based navigation can be performed in both
supine and lateral positions without affecting precision.
However, the time and cost of any CT-based technology
will always be a concern.
Results of Navigation
A large body of literature supports the theory that both
the precision and accuracy of acetabular component po-
sitioning are improved when using navigation. Most of
the recent literature focuses on the use of imageless tech-
niques, which have been favored over CT-based systems
because of the cost associated with preoperative imaging.
Figure 3 Intraoperative fluoroscopic views demonstrate
an implanted acetabular cup.
Several early clinical experiences with imageless tech-
niques have been reported. A 2009 study reported that
192 THAs using conventional imaging guidance and
and a pelvic tracking device is placed, and ultrasono- 450 THAs using computer navigation (125 CT-based
graphic capture of the pelvic points is performed. Care and 325 imageless procedures) exhibited similar abduc-
should be taken to ensure that the ultrasound probe is tion and anteversion measurements.5 However, when the
vertical to the bony landmark being captured. Compared transverse acetabular ligament was registered for ver-
with manual palpation of bony landmarks, ultrasono- sion alignment, a substantial improvement was reported
graphic digitization is not affected by overlying adipose in acetabular version alignment with navigation. This
tissue, resulting in more precise measurements of acetab- observation resulted in discussion of the learning curve
ular position, especially version.4 The limitations of ultra- associated with novel technologies such as navigation.
sonographic-based navigation include user experience, the The learning curve for navigation was similarly re-
need for intraoperative ultrasonographic equipment, and ported in a 2009 study.6 The study reviewed the surgeon’s
the need to adhere to sterile techniques during prepping, ability to implant the c up in 45° of abduction and 20° to
draping, and registration. In addition, registration in the 30° of anteversion (based on patient-specific anatomy).
lateral decubitus position can be challenging, and can be a It sequentially compared the surgeon’s experience among
barrier to acceptance of this technique by some surgeons. 55 cases using conventional guides, then the initial experi-
CT-based navigation is considered by many to be the ence of 50 cases using an imageless navigation system, and
gold standard for both navigation and robotics. Precise the next 50 cases using the same navigation system. Cup
computer models are generated from the preoperative abduction and version were measured using postoperative
CT scan, providing in-depth assessment of morpholo- cross-table lateral radiographs. For the initial 50 cases
gy and orientation. CT-based systems have the greatest with imageless navigation, variation was significantly
capacity in preoperative planning for implant sizing and reduced in both abduction and anteversion compared
positioning, which ultimately affect limb length, offset, with conventional mechanical guides. A further decrease
and virtual range of motion. The key element in CT- in variation was demonstrated in the second group of
based navigation is to couple the virtual bone model with 50 cases with imageless navigation compared with the
the patient’s actual anatomy at the time of surgery. This initial 50 cases (P < 0.01).
3: Hip
linkage is accomplished via the process of registration. Although cohort studies provide insight into the ap-
Using an instrumented pointer for discrete locations or an plicability of new technologies, the ultimate challenge is
instrumented probe to identify a larger area for surface to test the results in the context of a randomized clinical
registration, this process maps the registered points on trial.7 A prospective randomized clinical trial compared
the computer model (Figure 4). The degree of accuracy imageless navigation with a freehand conventional tech-
of this matching process can be quantified by placing a nique for noncemented THA: 65 patients were enrolled
probe on the bone surface and determining the distance in each group, with target goals of 40° of cup inclination
between the model position and actual position. If the and 15° of anteversion. Postoperative assessment of cup
Section 3: Hip
Figure 4 Illustration demonstrates CT-based hip navigation. (Reproduced with permission from Kelly TC, Swank ML: Role of
navigation in total hip arthroplasty. J Bone Joint Surg Am 2009;91(suppl 1):53-58.)
position was performed using a multislice CT scan. Out- between the computer-assisted and freehand-placed ac-
come measures included a modified hip score, Western etabular cups. However, the standard deviations in the
Ontario and McMaster Universities Arthritis Index score, computer-assisted group were smaller, indicating a more
and surgical time. No differences were reported between homogenous group of angles compared with the free-
the groups. The mean surgical time was 18.1 minutes hand-placed group. In addition, only 6 of 30 (20%) were
longer in the navigation group, which can be attributed outliers in the computer-assisted group compared with
to tracker placement and registration. Regarding cup 17 of 30 (57%) in the freehand-placed group, according to
position, no significant difference was reported in mean the safe zone described by Lewinnek.8 A 2012 study eval-
cup abduction between the navigated and freehand group uated the postoperative cup position of 39 hips in 38 pa-
(38.6° versus 37.7°) but a significant difference was re- tients following computer-navigated THA.9 The average
ported in anteversion (19.5° versus 17.3°, P = 0.007). In intraoperative navigated versus postoperative abduction
addition, there was a significant reduction in deviation angles was 41.5° and 40.8°, respectively. Similarly, intra-
from target position between the navigated and freehand operative navigated and postoperative anteversion angles
group. This study is one of the first to confirm the use of were 23.7° and 21.4°, respectively. Overall, the navigation
3: Hip
navigation, especially in the reduction of outliers, but also system demonstrated 90% accuracy for abduction and
demonstrated that improvement in cup position may not 87% accuracy for anteversion.
be manifested by early clinical improvement. A 2011 study compared acetabular position in 25 com-
A randomized controlled study of 60 patients undergo- puter-navigated THAs with 25 conventionally placed
ing THA compared the accuracy of acetabular component THAs.10 The computer navigation was abandoned in-
position in an anterolateral approach with and without traoperatively in 3 patients because of excessive pelvic
the use of computer-assisted navigation.8 The anteversion tilt and unreliable registration. In the other 22 patients
and abduction angles were not substantially different who underwent computer-guided THA, the mean (± SD)
abduction and anteversion angles were 40.0° ± 2.9° and observed between groups. However, a significant differ-
17.7° ± 3.5°, respectively; for the 25 patients who under- ence was reported in the number of outliers beyond the
went conventional placement, the angles were 42.5° ± 6.3° Lewinnek safe zones. A risk ratio of 0.21 was reported,
and 20.3° ±7.6°, respectively. The mean (± SD) placement which translated to a risk difference of 37% in favor of
error for abduction and anteversion in the computer-navi- computer navigation. The meta-analysis concluded that
gated group was 2.3° ± 1.5° and 3.4° ± 2.7°, respectively; navigation significantly reduces the possibility of placing
for the conventional placement group, the error was 5.5° the acetabular component outside the safe zone. Howev-
± 3.8° and 7.3° ± 5.7°, respectively. The placement error er, the study authors cautioned that many other factors
was significantly less for the computer-navigated group contribute to long-term satisfaction and longevity of the
than the conventionally placed group for both the abduc- prosthesis, and that component position is only a single
tion and anteversion angles. The study authors concluded factor in this complex equation.
that navigation results in less variance in the placement A 2014 meta-analysis14 compared computer nav-
of the acetabular component of THA, but cautioned that igation with freehand techniques for THA to corrob-
pelvic morphology may necessitate abandoning the use orate acetabular component positioning reported in a
of navigation under certain circumstances. 2009 meta-analysis.13 Although no significant difference
In a study that used an imageless computer-assisted was reported in abduction angle (P = 0.346) between
surgery system, the postoperative abduction and antever- freehand and computer navigation, a significant difference
sion angles of acetabular components placed with com- in anteversion and fewer outliers were reported in the
puter guidance were measured in 25 patients.11 The mean computer-navigated acetabular components (P < 0.001).
(±SD) angles measured intraoperatively for abduction and An increase in surgical time also was observed in the
anteversion using the navigation system were 39.4° ± 4.0° computer-navigated cases.
and 32.6° ± 7.0°, respectively; whereas postoperative CT
measurements were 38.8° ± 3.5° and 32.2° ± 6.8°, respec-
tively. The accuracy of the guidance system (the absolute Robotics in THA
difference between the angles measured by the navigation Although interest remains steady in the use of computer-
and the angles measured on postoperative CT) was 1.8° assisted navigation in joint arthroplasty, the application of
± 1.2° for abduction and 2.0° ± 2.0° for anteversion. robotic technology and its application in joint arthroplas-
Furthermore, precision was 3.4° for abduction and 5.5° ty has entered an exciting period. The features that dif-
for anteversion. ferentiate robotics from navigation are bone preparation
Another study of computer-navigated assistance in and implant insertion. All robotic-guided surgery requires
THA investigated the accuracy of acetabular compo- preoperative CT scanning. As with CT-based navigation,
nent positioning.12 The study included 30 patients with tracking of the pelvis and/or femur is required, along
30 hips undergoing computer-assisted THA compared with exact bone registration. Robotic-assisted surgery
with 101 hips in 99 patients undergoing THA with sur- then combines three-dimensional preoperative planning
geon-guided acetabular placement. Computer-assisted with a precisely guided bone resection and implant place-
navigation was accurate within 5° for all cases, with a pre- ment. Robotic guidance falls into two main categories:
cision of 4.4° for abduction and 4.1° for anteversion. For active or passive. Active robotic systems used in surgi-
all angles, the intraoperative navigation angle estimates cal practice are best thought of as automated. Cutting
were within 1° of the angles measured on postoperative tools and instruments are controlled by the robotic arm,
CT. When the computer-navigated and surgeon-guided with no need for surgeon control. Registration accuracy
acetabular angles were compared, the computer and the is of paramount importance for active robotic systems.
experienced surgeon had similar abduction estimates, but Passive, or haptic, systems require surgical guidance: if
the computer estimate of anteversion was more accurate. deviation beyond the boundaries created by the surgical
A meta-analysis of articles reported on computer- plan occurs, tactile, auditory, or visual feedback alerts
3: Hip
navigated cup implantation using four systems in five the surgeon to the possibility of error. Haptic systems
studies published from 2002 to 2007.13 The combined allow the surgeons to “drive” the robot, thereby allowing
average navigated cup inclination was 43° (confidence surgeons to retain some element of control.
interval [CI]: 40° to 46°) and the average conventional The first robot that aided in hip surgery was the
inclination was 44° (CI: 40° to 48°). The average cup ROBODOC (Curexo Technology)15,16 (Figure 5). This
anteversion was 15° (CI: 11° to 18°) in the navigated active robotic system was designed to be used with the
group and 17° (CI: 11° to 22°) in the conventional group; ORTHODOC software (IBM) and was used on the ba-
no significant differences in average cup anteversion were sis of a preoperative CT scan. The five-axis robot used
Section 3: Hip
sensors and a high-speed cutting tool to prepare the bone scan) in the greater trochanter and distal femur. Although
for the femoral prosthesis. One disadvantage of this robot early results were encouraging, the system gained little
was the use of pins placed preoperatively (prior to the CT popularity in the United States.
Another active robotic system available for hip ar-
throplasty is the CASPAR (Computer Assisted Surgical
Planning and Robotics-System; URS orto).17 This system
also uses a preoperative CT scan and sensors attached to
the patient to help prepare the bone for the femoral pros-
thesis. Although this system was once commonly used in
Germany, it failed to gain traction in the United States.
The introduction of haptic-guided robotic technology
has had global success. This technology has been used in
both partial knee arthroplasty as well as THA. The sur-
gical protocol starts with three-dimensional preoperative
planning (Figure 6) based on the preoperative CT scan.
Preoperative limb length discrepancy and native femoral
version are noted. Planning of the implant position begins
with virtual placement of the acetabular socket in the
model with preferred abduction and version angles. The
virtual center of rotation (COR) can be compared with
the native COR, and any effect such as medialization or
cephalization is noted. A virtual femoral stem is placed,
Figure 5 Illustration of the ROBODOC surgical system
(Curexo Technology). (Reproduced with and the resultant effect of length and offset is noted. The
permission from Compass Designs, Pleasanton, level of neck osteotomy and/or type or size of the femoral
CA. Available at http://compassdesign.com/ stem can be adjusted to achieve the intended length and
robodoc1/. Accessed July 7, 2016.)
offset target.
3: Hip
Figure 6 Illustration demonstrates preoperative CT-based planning with the Mako robot (MAKO Surgical, Stryker).
(Copyright Hospital for Special Surgery, New York, NY, 2016.)
Figure 7 Illustration demonstrates acetabular reaming in the preferred position using computer-assisted imaging (MAKO
Surgical Stryker.) (Copyright Hospital for Special Surgery, New York, NY, 2016.)
Following placement of a femoral tracking array, Final cup position is confirmed using a tracking probe,
femoral registration and navigated resection level of accessing multiple points around the periphery of the
the femoral neck is performed. The femur is prepared, acetabular component.
tracking array is placed on the trial femoral implant, and
the femoral version is calculated. Based on the femoral
version, the planned acetabular version can be adjusted Robotic Results
accordingly to obtain an adequate combined version. A 2003 prospective study compared 74 patients who un-
Acetabular preparation begins with the application of derwent THA augmented using the ROBODOC system
a pelvic tracking array, followed by acetabular regis- with 80 patients treated manually:18 13 of 74 procedures
tration of multiple points around the bony socket. The (18%) performed using the robotic system were converted
robot is registered, and the end effector (working end of to manual implantation because of robotic system failure.
the robotic arm) is verified. Acetabular reaming in the In addition, the mean robotic surgery lasted 25 minutes
preferred degree of abduction and version is performed longer than did manual insertion (P < 0.001). Regard-
with visual feedback showing real-time bone removal ing femoral component placement, the robotic system
(Figure 7). Reaming is permitted within the confines of restored limb length (mean discrepancy [±SD], 0.18 ±
3: Hip
a virtual haptic cone, allowing the robotic arm small 0.30 cm in the robotic group versus 0.96 ± 0.93 cm in the
degrees of freedom to work outside of the preferred tar- manual group; P < 0.001) and varus-valgus orientation of
get. After the planned acetabular reaming diameter is the femoral stem compared with manual insertion (mean
reached, the acetabular component is inserted. Unlike angle between the femur and the prosthetic shaft, 0.34°
reaming, which allows some latitude during bone re- ± 0.67° for the robotic group versus 0.84° ± 1.23° for the
section, robotic cup insertion (Figure 8) is performed manual group; P < 0.001). However, a greater likelihood
with the haptics fully engaged, corresponding to the of heterotopic ossification was noted with robot-assisted
final planned cup position, including depth of insertion. surgery. Dislocation was higher in the robotic group (11 of
Section 3: Hip
Figure 8 Illustration demonstrates robotic-assisted cup insertion (MAKO Surgical Stryker.) (Copyright Hospital for Special
Surgery, New York, NY, 2016.)
61) than the manual group (8 of 80). Initially, the Mayo In a 2015 study, 54 patients undergoing THA were
hip scores were better in the robotic group than the man- randomly assigned to either THA with manual rasping
ual group, but no difference was observed at 24-month (27 patients) or THA augmented with the ROBODOC
follow-up. Damage to the gluteus medius muscle was seen system (27 patients):20 24 patients completed follow-up
in the robotic group, and was considered a disadvantage in the robotic group, as did 25 in the manual group.
of robot augmentation. Mean surgical time was longer in the robotic group
A 2010 study involving the ROBODOC system com- than the manual group (103 minutes versus 78 minutes;
pared 75 hips that underwent THA augmented by the P < 0.012). At follow-up, no significant difference be-
ROBODOC system with 71 patients who underwent tween the robot-assisted and manual groups was found
THA using the manual hand-rasping technique.19 Use in Harris Hip Scores (mean, 93; range, 85 to 100 versus
of the robotic system was abandoned in three patients. mean, 95; range, 89 to 100; P = 0.0512) or Western On-
Robotic-assisted surgeries lasted an average 12 minutes tario and McMaster Universities Arthritis Index scores
longer than manual cases. More accurate placement of (mean, 11; range, 6 to 17 versus mean, 12; range, 5 to 15;
the femoral component was observed in the robotic group P = 0.30). No dislocations were reported in either group
(mean limb-length discrepancy, 5 mm; range, 0 to 12 mm) at 24 months. The robot-assisted group had better mean
3: Hip
compared with the manual rasping group (mean limb- varus-valgus alignment (0.3° versus 2.2° for the manu-
length discrepancy, 6 mm; range, 0 to 29 mm). Four al group) and less limb-length discrepancy (1.9 versus
dislocations (5.3%) occurred in the robotic group; one 4.9 mm for the manual group).
(1.4%) occurred in the manual group. At 2- and 5-year
follow-up, less stress shielding was noted in the robotically
placed femoral prostheses than in the manually placed Haptic Results
prostheses, which the authors suggested could be a result The role of haptically guided hip arthroplasty requires
of the accuracy of implant placement. preclinical validation to demonstrate the precision and
accuracy of the component placement. A 2013 experiment

used a robot (MAKO Surgical) for placement of an ace-
tabular prosthesis in 12 cadaver pelvises: the acetabular
component was placed with the robot on one side and
manually on the other side.21 In all cases, surgery was per-
formed using a posterior approach by an experienced sur-
geon. Measures included mediolateral, anteroposterior,
and superointerior COR compared with the native socket.
In addition, the abduction and anteversion angles were
compared with respect to the Lewinnek safe zones. The
robot was more accurate than the experienced surgeon for
all COR measurements: for cup abduction, the mean error
between the planned and actual cup abduction was 2.31°
Figure 9 Illustration shows a patient-specific
and 11.6°, respectively (P < 0.01); the mean anteversion intraoperative protractor (HipXpert).
error between the planned and actual cup position was (Reproduced with permission from HipXpert.
2.63° and 8.94°, respectively (P < 0.01). MI. Available at: https://hipxpert.com/. Accessed
July 7, 2016.)
A 2014 study compared robot-assisted THA performed
in 50 patients with manual THA performed in 50 pa-
tients and reported that the robot-assisted group was 5° and 10°; none were reported that exceeded 10°. COR
more accurate for acetabular component insertion.22 Of measurements compared with preoperative measurements
50 patients who underwent robotic-assisted acetabular were within a mean of 3 mm vertical (superior) and 5 mm
insertion, 100% were within the Lewinnek safe zones horizontally (medial).
for inclination and anteversion and 92% (46 of 50) were Another 2015 study used the Mako robot system to
within the modified zones described by Callanan. In augment THA in obese patients to address problems with
contrast, of the patients who underwent manual inser- acetabular cup placement.24 Acetabular positioning can
tion, only 80% were inside the safe zone of Lewinnek be difficult in obese patients because soft-tissue interpo-
and 62% were inside the modified zone described by sition can affect the tools used to align the cup. A total of
Callanan (P = 0.001 and 0.001, respectively). Although 105 patients were prospectively followed in three groups:
the robot-assisted positioning is more accurate, which those with a body mass index (BMI) less than 30 kg/m 2 ,
is important to long-term success, the clinical results of those with a BMI 30 to 35 kg/m2 , and those with a BMI
improved accuracy have not yet been proved. greater than 35 kg/m2. All patients underwent THA with
A 2015 study evaluated acetabular placement with the assistance from the Mako robot. No difference was noted
Mako robot using postoperative CT scans to assess cup in the number of cases outside the safe zones of Lewinnek
position, and compared it with the position measured in or Callanan across the three groups (P > 0.63). The mean
the operating room using the Mako sensors.23 Although inclination angles (±SD) for the patients in the groups with
the use of the Mako robotic arm was abandoned in five BMI less than 30 kg/m2 , BMI from 30 to 35 kg/m2 , and
hips in three patients because of soft-tissue constraints, BMI greater than 35 kg/m2 were 39.9° ± 3.0°, 39.72° ±
the Mako sensors were used to evaluate cup position 3.29°, and 41.02° ± 2.27°, respectively. The mean (±SD)
on insertion in these patients. Excluding these patients, anteversion angles were 16.8° ± 4.0°, 17.02° ± 3.6°, and
43 hips in 40 patients were evaluated using postoperative 16.73° ± 2.74°, respectively. No significant differences
CT scans. The planned mean inclination (±SD) for the were reported in any of these values (P > 0.75). The study
hips was 39.9° ± 0.8° (range, 35° to 40°); the intraoper- authors concluded that the Mako robot can be used re-
ative robotic measurement was 38.8° ± 1.6° (range, 25° liably in obese patients to achieve accurate acetabular
to 43°). The mean anteversion (±SD) on postoperative cup position.
3: Hip
CT scans was 39.1° ± 3.8° (range, 33° to 48°). Five out-

liers (12%) were noted between 5° and 10°; none were
reported that exceeded 10°. For anteversion, the planned Emerging Techniques and Technologies
mean angle (±SD) for the hips was 21.2° ± 2.4° (range, Many technologies investigating alternatives to tradition-
15° to 25°); the intraoperative robotic measurement was al navigation and robotics have been recently introduced.
20.7° ± 2.4° (range, 16° to 26°). The mean anteversion The HipXpert (Surgical Planning Associates) is a mechan-
(±SD) on postoperative CT scans was 18.9° ± 4.1° (range, ical alignment navigation tool that uses a preoperative CT
7° to 26°). Seven outliers (16%) were reported between scans calibrated to the HipXpert protractor (Figure 9).
Section 3: Hip
Figure 10 Intraoperative photograph shows the Intellijoint HIP surgical device (Intellijoint HIP Surgical). (Reproduced with
permission from Intellijoint HIP, Waterloo, ON, Canada. Available at: http://www.intellijointsurgical.com/product.
htm. Accessed July 7, 2016.)
After preoperative planning is completed, the protractor 23.4% of cups were outside 5° of the safe zone for antever-
is used intraoperatively. The device is attached to the sion.11 This technology, which was designed as a simple
patient’s ipsilateral pelvis using three Steinman pins and tool to use in the navigation of the acetabular cup, now
set to the preferred alignment for the patient. The cup is provides leg length and offset navigation. In addition,
inserted into the prepared socket but not impacted. The the company has morphed into a cloud-based THA sys-
guide bar of the HipXpert is aligned, and the impac- tem that augments the intraoperative navigation tool.
tion handle is aligned with that bar, which allows the Although this technology offers a promising alternative
surgeon to follow the guide of the alignment bar when to expensive robotic systems, the use of a preoperative CT
inserting the cup to achieve the preferred anteversion and scan is required, which exposes the patient to radiation.
inclination. A 2011 study used this device in 70 THAs Another new technology is the Intellijoint (Intellijoint
compared with historic data from 146 CT-based naviga- Surgical) (Figure 10). This device uses a camera attached
tion THAs and reported that the HipXpert had higher to a standard pin near the anterior superior iliac spine,
accuracy than did CT-based navigation.25 HipXpert de- which then obtains measurements based off a small plat-
creased the error of inclination (±SD) (1.3° ± 3.4°; range, form attached to the greater trochanter. Measurements
−6.6° to 8.2°) compared with CT-based navigation (3.5° are obtained prior to cutting the femoral neck. After
± 4.2°; range, −12.7° to 6.9°). Regarding anteversion, implant insertion, measurements are obtained again to
3: Hip
HipXpert was more accurate (1.0° ± 4.1°; range, −8.8° to ensure that appropriate leg length and offset have been
9.5°) than CT-based navigation (3.0° ± 5.8°; range, −11.8° restored. This second measurement also can allow the
to 19.6°). Furthermore, surgical time with the HipXpert surgeon to add or subtract offset or leg length based on
was 20 minutes faster than CT-based navigation. In a preoperative planning. Furthermore, the technology can
study of 54 THAs performed with this device, the HipX- be added to the acetabular component insertion handle
pert eliminated all outliers exceeding 10° from the safe to precisely measure anteversion and inclination angles.
zone in anteversion and inclination.26 However, 12.8% of OrthAlign (OrthAlign) is a new device that uses a
cups were outside 5° of the safe zone for inclination6 and gyroscope-based system that was initially used for total
Figure 11 Photograph shows the OrthAlign Plus system (OrthAlign). (Reproduced with permission from OrthAlign, Aliso
Viejo, CA. Available at: http://www.orthalign.com/orthalign-plus/. Accessed July 7, 2016.)
knee arthroplasty (Figure 11). Since the device received Summary

FDA approval for hip arthroplasty in 2014, studies have
been underway to test its capability and accuracy in ace- Component position in THA has been shown to affect dis-
tabular cup placement, leg length restoration, and offset location rates and the longevity of the prosthesis. Several
restoration. This system uses a disposable gyrometer fixed studies have shown that standard methods for cup place-
to the patient via a standard pelvic pin. The system uses ment are less accurate when positioning the acetabular
arms and sensors that attach to the gyrometer and the component. Over the past decade, many technologies have
patient’s femur to measure offset, leg length, and cup emerged to aid in the orientation of the acetabular com-
position. Although this device is in the early stages of ponent. Several computer-based navigation systems have
its development, this product should be available in the been shown to reduce errors in the placement of the ace-
near future. tabular component, leg length, and offset. Furthermore,
Another technology on the horizon is a patient-specific robotic-assisted surgery has been introduced to aid in
guide assist in the correct placement of the acetabular the preparation and placement of the implants. Although
component for THA. This guide is prefabricated based on these systems continue to evolve, surgeon reliance on these
a preoperative CT scan and sterilized for use in surgery. devices will increase as they become more affordable, as
The guide is made using Visualization Toolkit libraries well as faster and easier to use in the operating room. In
(Kitware) and is initially placed inside the native acetab- addition, although some technologies have emerged for
ular position before cup insertion, and a Kirschner wire preparation and insertion of the femoral component, these
is placed into the pelvis inside the surgical wound. Based technologies are not commonly used in the United States.
on the preoperative planning and guide construction, this
wire will have the planned anteversion and inclination
3: Hip
Key Study Points

so that during insertion, the handle can be aligned with
this wire for proper cup orientation. The guide was tested • Despite the use of anatomic landmarks or external
in 2010 in a prospective series of 31 patients in which guides, acetabular component position is most sus-
the guide was used, compared with 38 patients who un- ceptible to suboptimal position.
derwent standard THA without the guide.27 The guide • Computer navigation systems currently available
reduced outliers (greater than 10° from the safe zones as for clinical use help reduce errors in component
described by Lewinnek) from 23% in the standard group placement.
to 0% in the CT-based model-guided group.
Section 3: Hip
Annotated References subtle changes in less than ideal cup orientation. Level of
evidence: IV.
1. Padgett DE, Hendrix SL, Mologne TS, Peterson DA, Hol- 10. Lin F, Lim D, Wixson RL, Milos S, Hendrix RW, Makh-
ley KA: Effectiveness of an acetabular positioning device sous M: Limitations of imageless computer-assisted
in primary total hip arthroplasty. HSS J 2005;1(1):64-67. navigation for total hip arthroplasty. J Arthroplasty
2. Digioia AM III, Jaramaz B, Plakseychuk AY, et al: Com- This study compared the placement of acetabular compo-
parison of a mechanical acetabular alignment guide nents with and without the use of computer navigation.
with computer placement of the socket. J Arthroplasty Computer navigation resulted in less variance in com-
2002;17(3):359-364. Medline DOI ponent placement. However, computer navigation was
abandoned in three cases because of excessive pelvic tilt or
other morphologic aberrations that resulted in unreliable
3. Parratte S, Kilian P, Pauly V, Champsaur P, Argenson
registration. Level of evidence: III.
JN: The use of ultrasound in acquisition of the anterior
pelvic plane in computer-assisted total hip replacement: A
cadaver study. J Bone Joint Surg Br 2008;90(2):258-263. 11. Ryan JA, Jamali AA, Bargar WL: Accuracy of com-
Medline DOI puter navigation for acetabular component placement
in THA. Clin Orthop Relat Res 2010;468(1):169-177.
4. Hasart O, Perka C, Tohtz S: Comparison between point- Medline DOI
er-based and ultrasound-based navigation technique This study used postoperative CT to evaluate cup po-
in THA using a minimally invasive approach. Ortho- sition after placement with computer navigation, and
pedics 2008;31(10suppl 1):orthosupersite.com/view.as- found accuracy to be within 1.8° for inclination and 2.0°
p?rID=35540. Medline for anteversion. The authors of the study concluded that
imageless computer navigation provides precision for ac-
5. Kelley TC, Swank ML: Role of navigation in total hip etabular cup positioning in THA. Level of evidence: IV.
arthroplasty. J Bone Joint Surg Am 2009;91(suppl 1):
153-158. Medline DOI 12. Dorr LD, Malik A, Wan Z, Long WT, Harris M: Precision
and bias of imageless computer navigation and surgeon
6. Najarian BC, Kilgore JE, Markel DC: Evaluation of estimates for acetabular component position. Clin Orthop
component positioning in primary total hip arthroplas- Relat Res 2007;465(465):92-99. Medline
ty using an imageless navigation device compared with
traditional methods. J Arthroplasty 2009;24(1):15-21. 13. Beckmann J, Stengel D, Tingart M, Götz J, Grifka J,
Medline DOI Lüring C: Navigated cup implantation in hip arthroplasty.
Acta Orthop 2009;80(5):538-544. Medline DOI
7. Lass R, Kubista B, Olischar B, Frantal S, Windhager R,
Giurea A: Total hip arthroplasty using imageless com- 14. Li YL, Jia J, Wu Q, Ning GZ, Wu QL, Feng SQ: Evi-
puter-assisted hip navigation: A prospective randomized dence-based computer-navigated total hip arthroplasty:
study. J Arthroplasty 2014;29(4):786-791. Medline DOI An updated analysis of randomized controlled trials.
Eur J Orthop Surg Traumatol 2014;24(4):531-538.
This study compared the placement of acetabular com-
ponents with and without the use of computer navigation Medline DOI
(65 patients in each group). Computer navigation was This meta-analysis grouped studies comparing abduc-
found to more accurately reproduce preferred antever- tion angles, anteversion angles, percentage of acetabular
sion and inclination compared with a freehand technique. outliers, and surgical time in THA with and without the
However, no significant difference in clinical outcomes was use of computer navigation. A more precise anteversion
observed between the two groups. Level of evidence: III. angle and fewer outliers were found among THAs per-
formed with computer navigation. However, computer
8. Parratte S, Argenson JN: Validation and usefulness of navigation increased surgical time and did not affect the
a computer-assisted cup-positioning system in total hip precision of the inclination. The authors concluded that
arthroplasty. A prospective, randomized, controlled study. more high-quality studies will be needed to fully evaluate
J Bone Joint Surg Am 2007;89(3):494-499. Medline DOI the use of computer navigation. Level of evidence: III.
3: Hip
9. Snyder GM, Lozano Calderón SA, Lucas PA, Russinoff 15. Bargar WL, Bauer A, Börner M: Primary and revision total
S: Accuracy of computer-navigated total hip arthroplasty. hip replacement using the Robodoc system. Clin Orthop
J Arthroplasty 2012;27(3):415-420. Medline DOI Relat Res 1998;354:82-91. Medline DOI
This study evaluated postoperative anteroposterior and
16. Paul HA, Bargar WL, Mittlestadt B, et al: Development
lateral views of the pelvis to determine cup orientation
of a surgical robot for cementless total hip arthroplasty.
after computer-navigated placement, and found high spec-
Clin Orthop Relat Res 1992;285:57-66. Medline
ificity and positive predictive value for determining if the
cup was placed in the preferred position. However, sub-
optimal cup placement was not reliably identified by the 17. Thomsen MN, Breusch SJ, Aldinger PR, et al: Robotical-
computer program, yielding a low sensitivity in detecting ly-milled bone cavities: A comparison with hand-broaching
in different types of cementless hip stems. Acta Orthop 23. Kanawade V, Dorr LD, Banks SA, Zhang Z, Wan Z:
Scand 2002;73(4):379-385. Medline DOI Precision of robotic guided instrumentation for acetabular
component positioning. J Arthroplasty 2015;30(3):392-
18. Honl M, Dierk O, Gauck C, et al: Comparison of robot- 397. Medline DOI
ic-assisted and manual implantation of a primary total This study used the Mako robot to place acetabular
hip replacement. A prospective study. J Bone Joint Surg components and postoperative CT scans to assess cup
Am 2003;85-A(8):1470-1478. Medline position. The Mako robot accurately placed the cup in
the appropriate anteversion and inclination and properly
19. Nakamura N, Sugano N, Nishii T, Kakimoto A, Miki restored the COR. The robot achieved 88% precision
H: A comparison between robotic-assisted and manual in inclination, 84% in anteversion, and 81.5% in COR.
implantation of cementless total hip arthroplasty. Clin Or- Level of evidence: IV.
thop Relat Res 2010;468(4):1072-1081. Medline DOI
This group compared acetabular cups inserted with the 24. Gupta A, Redmond JM, Hammarstedt JE, Petrakos AE,
Mako robot and manually. Cup position was analyzed via Vemula SP, Domb BG: Does robotic-assisted computer
postoperative radiographs. The Mako robot system was navigation affect acetabular cup positioning in total hip
found to improve cup positioning according to the safe arthroplasty in the obese patient? A comparison study.
zones of Lewinnek and Callanan. Level of evidence: III. J Arthroplasty 2015;30(12):2204-2207. Medline DOI
This study used the Mako robot to place acetabular cups
20. Lim SJ, Ko KR, Park CW, Moon YW, Park YS: Robot-as- and found accurate placement of the cup with robotic as-
sisted primary cementless total hip arthroplasty with a sistance. Furthermore, BMI did not affect cup placement
short femoral stem: A prospective randomized short-term when using the Mako robot. Level of evidence: IV.
outcome study. Comput Aided Surg 2015;20(1):41-46.
Medline DOI 25. Steppacher SD, Kowal JH, Murphy SB: Improving cup
This study used the ROBODOC robot to assist in the positioning using a mechanical navigation instrument. Clin
placement of a short-stemmed noncemented component. Orthop Relat Res 2011;469(2):423-428. Medline DOI
Compared with the manual rasp group, the robotic group This study compared acetabular cup placement using a
had a longer surgical time but better alignment of the stem mechanical protractor-like device with placement using
and better reproduction of leg length. No difference in CT-based computer assistance. This provided accurate
clinical outcomes between the two groups was observed placement while decreasing surgical time compared with
in short-term follow-up. Level of evidence: III. CT-based navigation. Level of evidence: IV.
21. Nawabi DH, Conditt MA, Ranawat AS, et al: Hapti- 26. Jennings JM, Randell TR, Green CL, Zheng G, Wellman
cally guided robotic technology in total hip arthroplas- SS: Independent evaluation of a mechanical hip socket
ty: A cadaveric investigation. Proc Inst Mech Eng H navigation system in total hip arthroplasty. J Arthroplasty
In this cadaver validation study of haptically guided The authors used a mechanical navigation device to im-
robotic-assisted acetabular cup placement, the authors prove precision and accuracy of acetabular placement.
found that robot-assisted placement resulted in a fivefold This CT-based tool is planned using a web-based program
decrease in the error in inclination and a 3.4-fold decrease and was shown to reduce all outliers within 10° for both
in the error in anteversion. The authors concluded that version and abduction. When the criteria is reduced to ± 5°,
placement of the acetabular component was more accu- 64% of patients were within the target zone, confirming
rate with robotic-assisted placement than with manual the utility of this tool. Level of evidence: IV.
implantation. Level of evidence: III.
27. Hananouchi T, Saito M, Koyama T, Sugano N, Yoshi-
22. Domb BG, El Bitar YF, Sadik AY, Stake CE, Botser IB: kawa H: Tailor-made surgical guide reduces incidence
Comparison of robotic-assisted and conventional acetab- of outliers of cup placement. Clin Orthop Relat Res
ular cup placement in THA: A matched-pair controlled 2010;468(4):1088-1095. Medline DOI
study. Clin Orthop Relat Res 2014;472(1):329-336.
Medline DOI The authors report on two groups of patients undergoing
THR: the first used conventional mechanical guides and
This study compared manual implantation of acetabular the second group used a custom targeting device to align
cups with robotic-assisted placement and found that 92% for both acetabular version and inclination. This CT-based
3: Hip
of cups placed with the Mako robot were within the safe guide is manufactured out of a resin mold that is placed
zone as defined by Callanan, whereas only 62% of manu- into the acetabulum and fixed with a wire. Acetabular
ally placed cups were within the safe zone. The authors of preparation and insertion follows the trajectory of the
this study concluded that the Mako robot helped to achieve wire. There were no outliers in the custom guide group
a higher degree of precision in acetabular cup placement. confirming the devices usefulness. Level of evidence: III.
Chapter 33
Rapid Recovery in Total

Hip Arthroplasty
Adolph V. Lombardi Jr, MD, FACS Andrew B. Richardson, MD Kevin L. Garvin, MD
Significant advances have been made in the perioperative Total hip arthroplasty (THA) is among the most success-
care of patients undergoing total hip arthroplasty, ful surgeries in all of orthopaedics. The goals of THA
enabling rapid recovery with mobilization hours after have changed little since they were originally described
the surgical intervention. Rapid recovery programs in 1961:1 to perform a durable joint arthroplasty, thereby
following total hip arthroplasty have become the gold providing substantial pain relief, restoration of function,
standard of care worldwide. These programs provide and improvement in quality of life, all while minimiz-
a standardized multidisciplinary multimodal approach ing complications and maintaining patient safety. When
to the care of the patient. Proper preoperative patient these goals first were set out, patients undergoing THA
selection, education, and rehabilitation will ensure that were treated in a traditional sick-patient model of care, in
the expectations of the patient, family, and surgeon which it was assumed that these patients required long-
are aligned. Preoperative optimization of the patient’s term hospitalization and significant costly postoperative
comorbidities allows for the patient to be treated un- interventions (for example, indwelling urinary catheters,
der a healthy-patient model rather than a traditional patient-controlled analgesia, autologous blood transfu-
sick-patient model. Preoperative evaluation combined sions, and continuous passive motion devices). During the
with multimodal anesthesia techniques, efficient sur- past decade, the paradigm of perioperative care has shift-
gery, and aggressive postoperative pain management ed from the sick-patient model to a well-patient model,
and rehabilitation will allow rapid recovery of the pain which the understanding is that after a patient has
tient who undergoes total hip arthroplasty. Successful been medically optimized before surgery, the procedure
implementation of rapid recovery programs has been itself will not create a sick patient with the required large
shown to result in decreased hospital lengths of stay, burden of prolonged in-hospital care that was previously
significant cost savings, and improved functional patient assumed to be necessary.2 This paradigm shift began with
outcomes without increasing the hospital readmission the advent of minimally invasive surgery and an increased
rate or complication rate. emphasis on a shorter recovery. From this movement came
an enhanced understanding of multimodal approaches to
pain management, blood conservation, and early mobi-
Keywords: Total hip arthroplasty; rapid recovery lization therapy protocols. These advances have resulted
Dr. Lombardi or an immediate family member has received royalties from Innomed, OrthoSensor, and Zimmer Bio
3: Hip
met; serves as a paid consultant to OrthoSensor, Pacira Pharmaceuticals, and Zimmer Biomet; has received research or
institutional support from Kinamed, OrthoSensor, Pacira Pharmaceuticals, and Zimmer Biomet; and serves as a board
member, owner, officer, or committee member of the Hip Society, the Knee Society, the Mount Carmel Education Cen-
ter at New Albany, and Operation Walk USA. Dr. Garvin or an immediate family member serves as a board member,
owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the American Orthopaedic
Association, and the Hip Society. Neither Dr. Richardson nor any immediate family member has received anything of
the subject of this chapter.
Section 3: Hip
in significant improvements in the way care is provided and mental or cognitive disorders.4,5 It is the role of the
to patients following THA and the development of rapid medical team to identify these modifiable risk factors
recovery care programs. and medically optimize them before the patient enters
Rapid recovery care programs for THA are clinical the operating room.
care pathways that use a multidisciplinary care team to Specific protocols should be implemented to treat
develop a safe, cost-efficient, and patient-friendly ex- specific common medical conditions. Patients with ob-
perience. These clinical care pathways standardize the structive sleep apnea can be managed with a hospital
entire patient experience, from the preoperative period protocol that includes bringing personal continuous pos-
through the operating room and into the postoperative itive airway pressure or bilevel positive airway pressure
period. Standardization of care for THA is an ideal way equipment to the hospital, continuous pulse oximetry
to increase the efficiency of care; the surgical intervention while an inpatient, keeping the head of the bed elevated,
of THA is similar for most patients, who respond and and minimizing use of narcotics for pain relief. Patients
recover in a highly predictable fashion. Coordination whose diabetes is poorly managed (hemoglobin A1c 7.5%
between all of the medical providers involved in the care or greater) have a higher rate of postoperative complica-
of the patient, including the surgeon, anesthesiology team, tions,6 and their procedure should be delayed until strict
medical consultants, occupational and physical therapists, glycemic control is attained. Patients suspected of having
nursing staff, and clinical care managers, is vital. Use cardiac disease or who have a significant medical history
of rapid recovery care programs in THA have success- should undergo appropriate stress tests with further in-
fully expedited recovery from THA; many patients are terventions as necessary. Patients with thromboembolic
discharged the same day, need to remain in the hospital disease or bleeding disorders should undergo appropriate
only overnight, or even are able to leave as outpatients. laboratory tests to determine the safest and most effective
Certain factors must act in concert throughout each phase management of the coagulopathy. If necessary, preoper-
of the patient care experience to develop a successful rapid ative venous filters may be placed.
recovery THA program. Attention should be made to individual risk strati-
fication for deep vein thromboembolism (DVT) in the
preoperative medical screening examination. Plans can be
Preoperative Phase made preemptively for DVT prophylaxis in all patients.
A successful rapid recovery program begins well before This will help to minimize delays and confusion in the
the patient ever enters the operating room. Proper patient postoperative period for high-risk patients. Patients can
selection and medical optimization, patient education, be educated about the risks of DVT and the importance of
and preoperative rehabilitation are key components in compliance with DVT prophylaxis. Patients who require
the preoperative phase of care. low-molecular–weight heparin or other agents such as
warfarin sodium may receive proper instruction on dosing
Patient Selection and administration. Similarly, patients who are at high
An appropriate orthopaedic assessment of the patient and risk of undergoing postoperative transfusion can be iden-
determination of the need for surgery is the first step in tified and steps taken to help reduce the transfusion rate.
evaluation of the THA patient. After the patient is deter- One of the biggest predictors of postoperative hemoglobin
mined to be a candidate for THA, his or her medical his- levels is the preoperative hemoglobin level,7 and when a
tory should be reviewed thoroughly. Although a detailed specific preoperative threshold is reached (13 g/dL), the
medical history should be obtained by every orthopaedist, transfusion rate reduces to almost zero.8
a comprehensive prescreening physical examination and
medical optimization by an experienced general medical Patient Education and Preoperative Rehabilitation
consultant is recommended. In a study that evaluated effi- Patient preoperative education has been demonstrated
cacy of prescreening examinations, a remarkable number to be an effective means of reducing undue anxiety and
3: Hip
of new medical diagnoses were established, and 2.5% of fear.9,10 Patient education begins in the office during the
the patients were considered unacceptable surgical candi- initial visit. A full discussion of the disease process and
dates.3 Several medical comorbidities have been identified the entire phase of care in chronologic order should be dis-
that increase the relative risk of readmission following cussed, including minimally invasive surgical techniques,
total joint arthroplasty, including uncontrolled diabetes, pain management protocols, physical therapy require-
chronic obstructive pulmonary disease, bleeding disor- ment, and postoperative goals. Visual aids with simple
ders, obesity (body mass index [BMI] greater than 40 kg/ illustrations of arthritic conditions and THA prostheses
m2), active tobacco use, substance abuse, malnutrition, can be valuable adjuncts during this process. Patients
Chapter 33: Rapid Recovery in Total Hip Arthroplasty
can also be provided with written educational materials Perioperative Phase

that review each phase of care in full detail. Patients can
reference or review the material, which helps reinforce Variables in the perioperative phase that may delay the
their expectations. recovery of the patient following THA must be accounted
The preoperative visit also provides an opportunity for and controlled in a successful rapid recovery pro-
to discuss potentially modifiable risk factors for compli- gram. Postoperative pain control as well as management
cations, such as malnutrition, tobacco use, and obesity. of surgical trauma and intraoperative blood and fluid
Patients at risk of malnutrition may be referred for a must be considered to minimize pain and avoid costly
nutritional assessment, and optimization by a nutritionist side effects caused by medication (dizziness, sedation,
may be required. Smokers are counseled regarding preop- and nausea), while still promoting early mobilization
erative cessation to optimize wound healing and reduce and safe discharge.
anesthesia-associated risks. Preoperative nicotine blood
levels may be obtained to confirm cessation of smok- Preemptive Analgesia
ing and allow appropriate delay of elective surgery until Successfully controlling postoperative pain begins in the
the patient has successfully quit using tobacco products. preoperative period. Irrespective of surgical approach,
Obese patients should understand the increased risks trauma to bone and soft tissue is inevitable during THA.
associated with obesity; weight loss can be recommended, Noxious stimuli are released on incision in the form of
but often this is difficult for obese patients with end-stage nociceptive signals that stimulate both the peripheral and
arthritis to accomplish. central nervous systems. Peripheral nociceptors become
Particular attention should be given to information more responsive owing to the repetitive surgical trauma
about the hospital stay and to discharge planning. The and are vulnerable to the delayed inflammatory response
process of educating the patient and the family about the from surgery. This subsequently results in hypersensi-
anticipated length of stay (LOS) and the patient’s antic- tization of the peripheral and central nervous systems
ipated postoperative functional status can help identify and increased levels of postoperative pain. Preemptive
specific discharge needs, which can be addressed in a analgesia blocks the noxious stimuli before sensitization
coordinated fashion and discharge planning can be set and minimizes the amplification of the pain response to
up ahead of time, avoiding wasted hospital days spent in further stimulus.2,12,13
coordinating discharge planning. This becomes particu- The goals of preemptive analgesia are to minimize
larly important in the outpatient setting, where delays in postoperative pain while preventing nausea and sedation
discharge result in costly admissions to a hospital setting. to ensure early mobilization on the day of surgery. A
Preoperative rehabilitation prepares the patient for multimodal analgesic approach that includes a combi-
postoperative therapy protocols. Patients should be en- nation of anti-inflammatory medications, nonnarcotic
couraged to visit the facility and meet with staff mem- analgesics, neuraxial anesthesia, and use of antiemetic
bers who will be providing care for them postoperatively, agents has been shown to effectively achieve these goals.
including physical therapy and nursing staff. Therapists Preoperative use of NSAIDs (meloxicam, celecoxib) and
are able to teach the patient the postoperative exercises steroidal anti-inflammatory drugs (dexamethasone,
and how to use walkers or other ambulatory aids. Addi- methylprednisolone) has been demonstrated to reduce
tionally, they are able to anticipate hurdles with activities postoperative narcotic usage, nausea, sedation, and con-
of daily living and teach patients and families how to fusion.14-16 Use of intravenous (IV) corticosteroids in the
overcome them when discharged home. Nursing staff is preoperative period has not been associated with increased
able to demonstrate proper wound care and educate the risk of infection.17 Nonnarcotic analgesics such as acet-
patients regarding signs of complications that could arise. aminophen, gabapentin, and pregabalin can also be used
Joint education classes that encompass the entire spec- effectively to minimize pain and postoperative narcotic
trum of preoperative education and rehabilitation have usage.18 Preemptive narcotics use has been described as an
3: Hip
been provided by some institutions. These have been effective means of reducing postoperative pain; however,
effective in improving patient outcomes and have been narcotic medication may increase the risk of side effects
demonstrated to decrease LOS by 49.5% and increase the such as nausea, confusion, and sedation. Narcotics should
likelihood of discharge home by 62.0%.11 Irrespective of be used sparingly preoperatively in patients who have an
the method used, ensuring proper patient education be- increased risk of experiencing these adverse effects. The
fore surgery will reduce anxiety and improve satisfaction addition of antiemetic agents (metoclopramide, ondanse-
in the immediate postoperative period. tron, scopolamine) preoperatively and postoperatively, in
combination with adequate hydration in the perioperative
Section 3: Hip
period, has been demonstrated to decrease the incidence complications following neuraxial or regional anesthesia
of postoperative nausea and vomiting.2 include prolonged limb dysfunction with a reduced ca-
pability for early mobilization, urinary retention, and,
Anesthesia rarely, neurologic deficits.19,20,23 Spinal analgesia with
The anesthesia team is a vital component of a rapid re- intrathecal morphine has been advocated in the past
covery clinical care pathway. Cooperation between the because this can result in substantial, prolonged post-
surgical and anesthesiology teams to ensure a mutual operative pain relief. However, use of intrathecal narcot-
understanding of the intraoperative and postoperative ics has been associated with unacceptably high rates of
goals is necessary to ensure early mobilization and an postoperative pruritus, urinary retention, and respiratory
efficient recovery process. The goals of anesthesia are to depression24 and is therefore no longer recommended. Re-
provide adequate sedation and pain control intraopera- gional techniques have been reported to provide effective
tively as well as maintain an appropriate level of pain con- intraoperative anesthesia and postoperative pain control
trol postoperatively while minimizing nausea, sedation, when combined with oral narcotics, NSAIDs, and local
and confusion. Described anesthetic therapies include use wound infiltration.25-28 These peripheral nerve blocks may
of general anesthesia, neuraxial or regional anesthesia, result in shorter muscle inhibition and promote early
and a combination of general and regional anesthesia. mobilization when compared with traditional neuraxial
Recently, local infiltration anesthesia (LIA) has also been techniques; however, they often require larger amounts
described as an effective means of postoperative pain of postoperative oral medications and may not have the
control. Again, a multimodal approach is recommended; same sympathetic blockade and protective benefits as
however, the determination of the appropriate combina- short-acting spinal blocks. Additionally, these peripheral
tion is currently debated in the literature. The specific nerve blocks are challenging to perform and require ad-
benefits and drawbacks to each modality will be reviewed ditional training and experience to be effective.
in this section. Local infiltration anesthesia involves a pericapsular
Historically, general anesthesia has been the most fre- soft-tissue injection that combines a local anesthetic solu-
quently used anesthetic technique for both hip and knee tion combined with several analgesic agents at the end
arthroplasty. General anesthetic techniques may result of the surgical procedure. Commonly described com-
in hemodynamic fluctuations and cardiac arrhythmia, binations include bupivacaine or ropivacaine, variably
and they have been shown to cause an increased risk of combined with adjuncts such as epinephrine, clonidine,
thromboembolic events and cardiac arrest. In addition, ketorolac, morphine, and steroids (methylprednisolone
there have been concerns about unacceptably high rates or betamethasone). The injection is given directly into
of postoperative nausea, sedation, and confusion.19,20 Sub- the capsule, muscles, and fascial planes, as well as sub-
sequently, interest in the use of neuraxial and regional cutaneously. Strong support in the total knee arthro-
anesthetic techniques over general anesthetics has in- plasty (TKA) literature with weaker support in the
creased. Data from a 2015 study, however, demonstrated THA literature demonstrates that local infiltration is
that modern general anesthetic techniques with target- a safe technique that provides excellent pain relief and
controlled infusions may result in clinically equivalent re- reduces opioid requirement in the early postoperative
sults to neuraxial anesthesia alone following THA.21 Use period. 29-31 Liposome-bound bupivacaine is a novel
of a general anesthetic in combination with neuraxial agent that may provide a local analgesic benefit for up
anesthesia has been noted to decrease patient discomfort to 72 hours following tissue infiltration. Several studies
associated with intraoperative surgical positioning as well have demonstrated that addition of liposomal bupivacaine
as allow for easier induction of hypotensive anesthesia can improve pain control and decrease hospital LOS com-
than does either modality alone.22 pared with routine tissue infiltrates and regional blocks
Several types of neuraxial and regional anesthetic reg- alone.32-34
imens have been described, including single-shot spinal
3: Hip
anesthesia, epidural catheters, and blocks of the lumbar Surgical Considerations

plexus, fascia iliaca, and proximal sciatic nerves. Spinal Several surgical factors are important to consider when
and epidural anesthesia have been demonstrated to have attempting to maximize the potential for early mobili-
several positive effects on patients undergoing THA, zation. Since the advent of minimally invasive surgery,
including better postoperative pain control, decreased several modifications to traditional approaches have been
cardiopulmonary morbidity, decreased risk of thrombo- described, with popular approaches including the mini-
embolic events, decreased blood loss, and optimal muscle posterior, limited-incision direct lateral, and the direct
relaxation, which facilitates surgical exposure. Potential anterior approach. Of these described approaches, the
direct anterior approach has generated the most atten- early mobilization. Ensuring that component position is
tion regarding rapid recovery protocols. This approach optimized through adequate exposure and visualization
is an abductor-sparing approach that has been reported will reduce the risk of dislocation postoperatively. Use
to have improved early recovery and mobilization in the of intraoperative fluoroscopy or radiographs has been
immediate postoperative period (first 6 weeks) when debated, but these modalities may be useful in ensuring
compared with the miniposterior and limited-incision appropriate intraoperative placement of the components.41
direct lateral approaches.35-37 Recently the direct anterior
approach was compared to the miniposterior approach, Blood and Fluid Management
with both groups receiving the same rapid recovery reha- Optimization of blood and fluid management with min-
bilitation and pain management protocol. No significant imization of postoperative transfusions is critical to en-
differences were seen between the two groups regarding suring rapid recovery following THA. Most outpatient
improvement in postoperative pain, LOS, or ability to centers do not have the capability for transfusing blood,
mobilize.38 Although advances in minimally invasive sur- nor is it feasible for patients to undergo transfusion be-
gery and tissue-sparing techniques have certainly made fore a planned same-day discharge. Although patients
significant contributions to improvements in the patient treated in an inpatient setting still have access to blood
experience, it has been recognized that advances in peri- transfusions as necessary, transfusions remain costly not
operative pain management, blood conservation, and only in a monetary sense but also in terms of time and
aggressive rehabilitation protocols are responsible for psychologic effect. Blood transfusions delay patients from
most of the improvements in the patient recovery seen achieving early mobilization through both physical re-
in the last decade. The specific type of approach used is striction and subliminal reinforcement of the sick-patient
not as important as is performing the procedure in an model. Additionally, patients experiencing side effects of
efficient manner that minimizes surgical time and intraop- postoperative anemia (dizziness, sedation, lethargy) are
erative complications. Surgeons should use the approach often unable to fully participate in therapy, thus causing
that they are most comfortable with to be efficient while further delays. Meticulous attention to blood and fluid
minimizing surgical time, tissue trauma, and blood loss. management strategies will reduce perioperative blood
The introduction of new surgical techniques is associated loss and can almost eliminate the need for postoperative
with a learning curve that may result in higher blood loss transfusions.
and longer surgical times.39,40 The surgeon should achieve As discussed previously, development of an effective
comfort and consistency with any procedure before en- blood management strategy begins with identification
acting a rapid recovery protocol to reduce the likelihood of preexisting anemia in the preoperative setting. In the
for complications. operating room, several steps can be undertaken to reduce
Meticulous attention to surgical technique and de- blood loss. Performing an efficient surgical procedure
tail irrespective of the surgical approach remains a cor- to minimize surgical trauma and maintain hemostasis
nerstone of surgical efficacy. The procedure should be will decrease surgical times and reduce overall blood
performed in an efficient manner with attention to bio- loss. Hypotensive anesthesia with mean arterial pressure
mechanical reconstruction, leg length restoration, com- of 60 mm/hg or less is an effective adjunct to reduce
ponent position, and minimal soft-tissue trauma. The blood loss.42,43 A combination of general and regional or
emphasis is on surgical efficiency, not speed. Surgeons neuraxial anesthesia can safely and effectively provide
should concentrate on maximizing surgical efficiency hypotensive anesthesia during hip and knee arthroplasty.
and streamlining the surgical procedure, removing any Hypotensive anesthesia combined with efficiency in the
extraneous steps or delays to reduce the time in the op- operating room will result in substantial reduction in
erating room. Focus should not be placed on how fast a intraoperative blood loss.
procedure can be completed because this will increase Use of perioperative tranexamic acid to reduce blood
mistakes and result in poor outcomes. Maintaining an loss may be one of the greatest advancements in modern
3: Hip
efficient, streamlined surgical process will indirectly re- arthroplasty. Tranexamic acid is an antifibrinolytic agent
sult in decreased surgical time while preventing missed that decreases the rate of fibrinolysis without affecting
steps and intraoperative complications. As postoperative the rate of clot formation.44 The efficacy of tranexamic
weight-bearing status has significant ramifications for the acid in substantially reducing calculated blood loss has
patient’s ability to mobilize, avoidance of complications been well documented in the literature.44-49 Tranexamic
such as intraoperative femoral fracture through careful acid is administered intravenously, topically, or orally,
surgical technique will ensure patients are able to fully with similar bioavailability and effectiveness through
bear weight immediately following surgery and allow for each route.46-49 Contraindications have been debated in
Section 3: Hip
the literature, particularly surrounding administration of Recovery in both the hospital and outpatient setting can
IV tranexamic acid in patients with a clotting disorder, be separated into two phases. The stabilization or acute
previous DVT, or history of cardiac stenting. However, phase occurs when the patient is transferred from the
there is compelling evidence to indicate that perioperative operating room to the postanesthesia care unit, where
use of tranexamic acid is safe in all patients irrespective of the patient should be medically stabilized and acute pain
medical history.44,50 Specific dosing regimens vary based and nausea should be addressed. After stabilization, the
on the route of administration. IV tranexamic acid can be patient enters the second phase of postoperative recovery.
either based on weight or given according to a standard- In the outpatient setting, patients can be transferred to
ized regimen. Typically, IV tranexamic acid is given as one private recovery areas and enter a step-down phase of
dose preoperatively and a second dose postoperatively. care. In the inpatient setting, patients are transferred to
Topical dosing is usually administered toward the end the orthopaedic ward to begin the recovery process. Ir-
of the procedure. Oral administration typically occurs respective of the setting, this process should be relatively
within two hours preoperatively. similar; however, inpatients will typically spend 24 to
Proper fluid management and maintenance of adequate 48 hours as an inpatient and most outpatients are able
hydration plays an important role in aggressive blood to be discharged within a few hours from the facility.
management strategies. Proper IV hydration of the patient
intraoperatively will help to ensure that intravascular Pain Management
volumes are sufficient to minimize symptoms of volume As discussed previously, effective postoperative pain
depletion such as orthostatic hypotension, tachycardia, management strategies begin before the patient ever en-
and low urine output. These symptoms are often attribut- ters the operating room. Preemptive analgesia in combi-
ed to anemia and, in many centers, result in a blood trans- nation with multimodal anesthetic techniques typically
fusion. Intraoperative IV hydration should be titrated on will provide effective pain control in the postoperative
the basis of the individual patient’s profile, but appropriate period. When breakthrough pain occurs, a multimodal
hydration protocols should aim for approximately 2 L approach of oral and IV medications can quickly con-
of IV crystalloid intraoperatively with an additional 1 L trol pain while ensuring minimal side effects and early
of IV crystalloid postoperatively. In addition to helping mobilization. Typical medications used in the postop-
mitigate the symptoms of volume depletion, maintain- erative period are similar to those used preoperatively
ing hydration may help with postoperative pain control and can include NSAIDs (ketorolac, celecoxib, ibupro-
because dehydration has been demonstrated to decrease fen), nonopioid analgesics (acetaminophen, tramadol),
pain thresholds and amplify sensitivity to painful stimuli.2 neuromodulatory agents (gabapentin, pregabalin), oral
Classic transfusion triggers involve numerical thresh- opioids (oxycodone, hydrocodone, hydromorphone) and
olds for administering transfusions (such as hemoglobin IV opioids (fentanyl, morphine, hydromorphone). Al-
of 10 g/dL) set without regard for the clinical evaluation though oral narcotics remain the cornerstone of adequate
of the patient. Modern transfusion protocols have evolved pain control in many patients, minimizing the use of
to include both the hemoglobin level and symptoms be- strong narcotics (hydromorphone) and sustained-release
fore initiation of transfusion. Patients without significant narcotics if possible will help to minimize sedation and
medical comorbidities may tolerate substantially lower confusion postoperatively. IV narcotics are associated
hemoglobin levels than historically thought. Current with adverse effects such as nausea, sedation, confusion,
transfusion protocols have described avoidance of trans- urinary retention, dizziness, and respiratory depression
fusion unless the hemoglobin level is 7 g/dL or less, or and should be used only to treat severe breakthrough
if the patient’s hemoglobin is less than 8 g/dL and the pain early in the postoperative phase of care to prevent
patient is experiencing symptoms of anemia that do not delays in mobilization. Patient-controlled analgesic pumps
respond to volume resuscitation, thus supporting the need were often used to treat acute pain immediately following
for transfusion.2 surgery. Patient-controlled analgesic pumps, although
3: Hip
potent, have been associated with unacceptably high rates

of adverse effects and inhibit mobility with their bulky
Postoperative Phase apparatus. Additionally, owing to the short-acting nature
In both inpatient and outpatient settings, the postopera- of IV narcotics, patient-controlled analgesic pumps often
tive phase of care focuses on minimizing pain and early provide inferior pain control compared with a multimodal
mobilization of the patient. If the proper preoperative oral regimen with IV breakthrough control.
planning and preemptive analgesia has been performed,
delays to recovery and discharge can easily be avoided.
Deep Vein Thrombosis Prophylaxis Outcomes

Venous thromboembolism is a major concern postoper-
atively. Patient education and medical planning for DVT In the past decade, rapid recovery programs in THA
prophylaxis should occur before surgery. Appropriate have become the standard of care in most high-volume
prophylaxis is determined by risk stratification on the orthopaedic centers worldwide. Implementation of rapid
basis of an individual specific risk profile.51 Patients with- recovery clinical care pathways has been associated with
out additional risk of experiencing DVT can be treated decreased LOS and a significant reduction in the cost of
with twice-daily aspirin (enteric-coated formulations care per episode.52-56 Although it is generally accepted
may decrease the risk of gastrointestinal complications), that rapid recovery programs are successful in reduc-
compression stockings, and ambulatory calf-compression ing the hospital LOS following THA, reports regarding
devices. In patients with increased risk of experiencing the specific reduction are highly varied in the literature,
DVT, low-molecular–weight heparin, warfarin, or factor ranging from 1.5 to 4.3 days, or an overall reduction of
Xa inhibitors should be considered instead of aspirin for 15% to 57%. This variability represents the widespread
the first 14 days. These patients should also be encour- variability in LOS before enactment of rapid recovery
aged to use compression stockings and ambulatory calf- programs and should be interpreted accordingly. Reports
compression devices. on the amount of cost savings are similarly variable, with
reports of the mean cost reduction per episode of care
Rehabilitation and Preparation for Discharge ranging from $700 to $7,500. In addition to monetary
Aggressive rehabilitation programs emphasizing mobil- savings, rapid recovery programs have been shown to
ity and independence are the crux of any rapid recovery result in a net gain of 0.08 quality-adjusted life-years
program. Preoperative education, preemptive analgesia, when compared with traditional recovery programs.11,53-56
meticulous minimally invasive surgical technique, and Although rapid recovery programs have been demon-
multimodal anesthesia and pain control are all performed strated to be successful in reducing cost and LOS, there
with the aim of mobilizing the patient within hours of have been several concerns that early mobilization and
arrival at the recovery unit. Nursing staff should evaluate discharge will result in an increased risk of readmission in
the patient immediately on arrival to the unit and mobilize the early postoperative period. This has not been demon-
the patient to a chair as soon as possible. Ambulation strated in the literature. There is strong evidence that rapid
with the physical therapist should occur on the day of recovery protocols can safely reduce the LOS without
surgery, and proper use of ambulatory aids as well as falls increasing the rate of postoperative complications in the
precautions should be reinforced. Early mobilization will short term.53,55 It has been suggested that the early mo-
help the patient recover from anesthesia and is an effective bilization and more aggressive rehabilitation protocols
means of preventing thromboembolic disease. used in the rapid recovery programs may even result in
Patients treated as inpatients should receive therapy improved postoperative recovery and that the likelihood
twice per day before discharge. Irrespective of the treat- of readmission for a THA under a rapid recovery protocol
ment setting, requisites for discharge to home should is reduced by more than 60%.56
include stair climbing and the ability to independently Overall, LOS in rapid recovery programs has been
transfer into and out of a bed and chair. Typically, pa- reported to be between 1 and 3 days for most patients,
tients do not require the use of outpatient or home health with a small percentage of outliers staying longer owing
therapy following THA. Ensuring that patients are able to to unforeseen medical complications. The most common
mobilize appropriately and understand appropriate safety reasons cited for delayed discharge include pain, dizzi-
precautions is essential to a safe and early discharge. Case ness, and weakness, with nausea, vomiting, confusion,
management teams are valuable members of the rapid and sedation being somewhat common reasons. Logistic
recovery team. They are invaluable in discharge planning issues, including delay of initiation of therapy, obtaining
and can be extremely effective in ensuring that patients postoperative radiographs, and need for blood trans-
3: Hip
are adhering to surgeon-advised protocols, participating fusion, are rare but important issues to address in any
in therapy, and setting daily goals, and they can reinforce care pathway.57,58 In the United States, Medicare requires
patient educational materials. When the patient is ready beneficiaries to have an inpatient stay of at least 3 con-
for discharge, nursing staff should review prescriptions, secutive nights to qualify for discharge to an extended
proper wound care, and all discharge instructions, in- care facility. This subsequently represents a delay in any
cluding physician follow up. rapid recovery protocol, as this rule has been shown to
unnecessarily increase the average LOS by 1 day in this
patient population.59
Section 3: Hip
Table 1 Table 2
Risk Factors Stratification Modifiable Risk Factors Requiring Management
Patient-related factors Morbid obesity
Obesity (body mass index greater than 40 kg/m ) 2
Poorly controlled diabetes
Skin colonization Nutritional deficiencies
Bleeding disorders Hepatitis C
Venous thromboembolism Tobacco use
High American Society of Anesthesiologists Venous thromboembolic disease
Physical Status score Cardiovascular disease
Smoking Neurocognitive, psychologic, or behavioral
problems (including drug and alcohol abuse)
Steroid use
Physical conditioning and comorbidities that
Diabetes
affect ambulation
Coronary artery disease
Anemia
Other medical comorbidities (more than 3)
Cognitive function
of a complication compared with others. Patients who
have medical comorbidities may be poor candidates for
Socioeconomic factors
rapid recovery. If their risk factors are not identified and
Age improved, then the risk of complication and readmission
Race is significant.
Sex The first step in the process is to define the risk factors
Income status of the patients who are more likely to have a compli-
cation or a hospital readmission. The risk factors can
Urban versus rural environment
be further grouped as patient-related, socioeconomic,
Surgical factors and surgical (Table 1). Several patient-related factors can
Blood loss be improved preoperatively (Table 2), after which the
Length of surgery patients may proceed to a rapid recovery with low risk
Complexity of surgery of complications and readmission. The identification of
Surgeon volume
so-called modifiable risk factors for these patients and
preventing or stopping surgery until they are corrected
Hospital volume
has also been well described.63,64 Morbid obesity (BMI
greater than 40 kg/m2) is one such risk factor for patients
undergoing total joint arthroplasty.67 Patients who are su-
perobese (BMI greater than 45 kg/m2) have a risk of com-
Complications, Disadvantages, and Readmission
plications that is 8.44 times higher than that of patients
Rates in Rapid Versus Non-Rapid Recovery in THA
of healthy weight.66 Delaying surgery until the patient’s
Improvements in THA over the past decade are truly weight is improved may be an effective strategy. Weight
remarkable, including more rapid recovery from surgery, loss is not always successful, and when it is not successful,
and this has become the standard of care for patients treating the disabled patient poses a challenge and even
treated by the authors of this chapter. The tips for rapid an ethical dilemma.65 Uncontrolled diabetes (blood glu-
recovery have been well described, typically involving up cose greater than 200 mg/dL) is another risk factor that
3: Hip
to 2 days of hospital stay. Patients are then able to return must be addressed preoperatively to help lessen the risk
to a high level of function within weeks. In contrast to this of complications associated with diabetes. A 2015 study
definition, some researchers have described rapid recovery evaluated the frequency of medical comorbidities, iden-
as a recovery that improves patient care and reduces the tifying patients who may be poor candidates for a rapid
LOS in the general population undergoing surgery.60-62 If recovery protocol.68 Few patients (THAs 16.7%, TKAs
this definition is applied, no true disadvantages or com- 12.7%) had no comorbidities. This study highlights the
plications are associated with rapid recovery; rather, there surgeon’s challenge of identifying the patients who may
are patients who recover more quickly and with less risk be treated with a rapid recovery protocol.68
The second group of factors is socioeconomic, which prevention of nausea, dizziness, and sedation will allow
are rarely amenable to improvement or change. Socioeco- for early mobilization and aggressive therapy on the day
nomic factors have a major effect on the hospital LOS, of surgery. With proper coordination and enrollment of
and patients of disadvantaged socioeconomic status are all caregivers involved, rapid recovery programs following
not typical candidates for a rapid recovery program. THA can be effective in both outpatient and inpatient
Researchers assessed the effect of socioeconomic status settings for most patients.
on 30-day readmission rates of patients who underwent
THA and TKA.69 Patients who are minorities and those
Key Study Points
who are socioeconomically disadvantaged patients had
a higher readmission rate, and a risk reduction strategy • Preoperative identification of medical comorbidities
was helpful only for the few THA patients who were not allows appropriate risk stratification and medical
economically disadvantaged. Another research team also optimization prior to surgery and can significantly
reported on treating patients of different socioeconomic decrease the risk of perioperative complications.
status.63 Patients of low socioeconomic status, advanced • Use of standardized perioperative pain, blood man-
age (older than 65 years), and minority race or ethnicity agement, and IV hydration protocols in conjunction
were associated with the longest hospital LOS (greater with an efficient surgical technique and meticulous
than 7 days). attention to component position will help minimize
Elderly patients are also at high risk of experiencing delays in postoperative rehabilitation and discharge
complications and readmission. Investigators have argued and, most importantly, help minimize postoperative
that older patients have the most to gain from orthopaedic complications.
advanced recovery programs.60 In their study, before in-
• Development of a multidisciplinary team with co-
troducing the enhanced recovery program, these research-
ordination between all medical providers involved
ers found that most patients age 85 years or older had a
in patient care is vital to ensure appropriate care
hospital LOS of 9 days. Patients younger than 85 years
while avoiding delays to discharge.
had an average LOS of 6 days. After the enhanced re-
covery program, elderly patients had an average LOS
of 5 days and all other patients had an average LOS of
4 days. In addition, the 30-day readmission for elderly
patients dropped from 6% to 5.2% and for all patients
from 5.5% to 4.7%. The mortality was unchanged, and
the enhanced or rapid recovery protocol benefited the 1. Charnley J: Arthroplasty of the hip: A new operation.
Lancet 1961;1(7187):1129-1132. Medline DOI
elderly patients the most.
2. Sculco PK, Pagnano MW: Perioperative solutions for rapid
recovery joint arthroplasty: Get ahead and stay ahead.
Summary J Arthroplasty 2015;30(4):518-520. Medline DOI
With increasing pressure to improve the efficiency of and The authors reviewed rapid recovery, focusing on four
decrease the costs associated with THA while continu- impediments to early rehabilitation and discharge: volume
ing to provide safe, high-quality care to patients, rapid depletion, blood loss, pain, and nausea. They describe
specific interventions for each impediment that are aimed
recovery programs have now become the gold-standard at maximizing early recovery and describe the transition
of care in many institutions worldwide. Use of a stan- from the sick-patient model to the well-patient model.
dardized multidisciplinary approach can effectively im- Level of evidence: V.
prove the recovery process. Proper preoperative patient
selection, education, and rehabilitation will ensure that 3. Meding JB, Klay M, Healy A, Ritter MA, Keating EM,
Berend ME: The prescreening history and physical in
the expectations of the patient, family, and surgeon are
3: Hip
elective total joint arthroplasty. J Arthroplasty 2007;22

aligned. Preoperative optimization of the patient’s med- (6suppl 2):21-23. Medline DOI
ical comorbidities allows for the patient to be treated
under a healthy-patient model rather than the traditional 4. Mednick RE, Alvi HM, Krishnan V, Lovecchio F, Man-
sick-patient model. Coordination with the anesthesiology ning DW: Factors affecting readmission rates following
primary total hip arthroplasty. J Bone Joint Surg Am
team to provide effective pain management and minimize 2014;96(14):1201-1209. Medline DOI
intraoperative complications is crucial. The surgeon must
The authors of this study used the National Surgical
perform an efficient operation, minimizing soft-tissue Quality Improvement Program database to identify pre-
trauma and blood loss. Appropriate pain control and operative comorbidities and postoperative conditions that
Section 3: Hip
increase the risk of readmission following THA. There 10. Lombardi AV, Berend KR, Adams JB: A rapid recov-
were 345 readmissions (3.65%) within the first 30 days ery program: Early home and pain free. Orthopedics
following surgery. Comorbidities that increased the risk 2010;33(9):656. Medline
for readmission were diabetes, chronic obstructive pul-
monary disease, bleeding disorders, preoperative blood The authors review a rapid recovery program designed to
transfusion, corticosteroid use, dyspnea, previous cardiac help patients recover in a safe and efficient manner. The
surgery, and hypertension. The authors controlled for article highlights specific areas of focus that should be de-
potential confounders by using a multivariate regression veloped in a rapid recovery protocol. Level of evidence: V.
model and determined that having a BMI of 40 kg/m 2 and
using corticosteroids preoperatively were independently 11. Tait MA, Dredge C, Barnes CL: Preoperative patient ed-
associated with a higher likelihood of readmission, and ucation for hip and knee arthroplasty: Financial benefit?
a high preoperative serum albumin was independently J Surg Orthop Adv 2015;24(4):246-251. Medline
associated with a lower risk of readmission. Level of The authors examined the effect of a preoperative edu-
evidence: III. cational class of the LOS following THA or TKA. The
patients who participated in the educational class had
5. Boraiah S, Joo L, Inneh IA, et al: Management of modi- an average LOS that was 2.12 days (49.5%) shorter than
fiable risk factors prior to primary hip and knee arthro- those patients who did not attend a class. A significant
plasty: A readmission risk assessment tool. J Bone Joint cost savings of $4,016 was seen when patients attended
Surg Am 2015;97(23):1921-1928. Medline DOI the preoperative class. Level of evidence: II.
The authors developed a scoring system, the Readmission
Risk Assessment Tool (RRAT), to perform risk stratifi- 12. Woolf CJ, Chong MS: Preemptive analgesia—treating
cation in patients undergoing elective primary total joint postoperative pain by preventing the establishment of
arthroplasty. The purpose of this study was to retrospec- central sensitization. Anesth Analg 1993;77(2):362-379.
tively analyze the relationship between the RRAT score Medline DOI
and readmission after primary hip or knee arthroplasty.
There were 207 (2.08%) readmissions over the 6-year 13. Vadivelu N, Mitra S, Schermer E, Kodumudi V, Kaye AD,
study period, and the most common cause of readmis- Urman RD: Preventive analgesia for postoperative pain
sion was surgical site infection. The RRAT score had a control: A broader concept. Local Reg Anesth 2014;7:
significant association with readmission after arthroplasty 17-22. Medline
and could be a useful tool for risk mitigation. Level of
evidence: III. The authors discuss how preventive and preemptive anes-
thesia can reduce postoperative pain. Multimodal preop-
erative and postoperative analgesic therapies are discussed
6. Goldstein DT, Durinka JB, Martino N, Shilling JW: Effect and the results are reviewed. Level of evidence: V.
of preoperative hemoglobin A(1c) level on acute postopera-
tive complications of total joint arthroplasty. Am J Orthop
(Belle Mead NJ) 2013;42(10):E88-E90. Medline 14. Mallory TH, Lombardi AV Jr, Fada RA, Dodds KL, Ad-
ams JB: Pain management for joint arthroplasty: Preemp-
The authors retrospectively investigated the effects of tive analgesia. J Arthroplasty 2002;17(4suppl 1):129-133.
hemoglobin A1c (HbA1c) level on immediate postopera- Medline DOI
tive complication rates following total joint arthroplasty.
Postoperative complication rates were directly correlated 15. Buvanendran A, Kroin JS, Tuman KJ, et al: Effects of
to HbA1c levels; HbA1c levels higher than 7.5% correlated perioperative administration of a selective cyclooxygenase
strongly with a higher rate of postoperative complications. 2 inhibitor on pain management and recovery of function
Level of evidence: III. after knee replacement: A randomized controlled trial.
JAMA 2003;290(18):2411-2418. Medline DOI
7. Rosencher N, Kerkkamp HE, Macheras G, et al; OS-
THEO Investigation: Orthopedic Surgery Transfusion 16. Backes JR, Bentley JC, Politi JR, Chambers BT: Dexameth-
Hemoglobin European Overview (OSTHEO) study: Blood asone reduces length of hospitalization and improves post-
management in elective knee and hip arthroplasty in operative pain and nausea after total joint arthroplasty: A
Europe. Transfusion 2003;43(4):459-469. Medline DOI prospective, randomized controlled trial. J Arthroplasty
2013;28(8suppl):11-17. Medline DOI
8. Hatzidakis AM, Mendlick RM, McKillip T, Reddy RL,
Garvin KL: Preoperative autologous donation for total The authors performed a prospective, randomized con-
trolled trial to investigate the effects of perioperative
3: Hip
joint arthroplasty: An analysis of risk factors for allogenic

transfusion. J Bone Joint Surg Am 2000;82(1):89-100. dexamethasone to a multimodal regimen in 120 patients
Medline undergoing THA and TKA. The addition of perioperative
dexamethasone decreased postoperative nausea while sig-
nificantly improving postoperative pain control and mo-
9. Lee A, Gin T: Educating patients about anaesthesia: Effect bility, and ultimately lead to shorter hospital stays. The
of various modes on patients’ knowledge, anxiety and authors did not report an increase in adverse events with
satisfaction. Curr Opin Anaesthesiol 2005;18(2):205-208. the administration of the intraoperative and/or postoper-
Medline DOI ative dexamethasone. Level of evidence: I.
17. Buvanendran A, Kroin JS, Della Valle CJ, Kari M, anesthesia resulted in reduced LOS, less nausea and dizzi-
Moric M, Tuman KJ: Perioperative oral pregabalin re- ness, as well as improved orthostatic function compared
duces chronic pain after total knee arthroplasty: A pro- with spinal anesthesia. Level of evidence: II.
spective, randomized, controlled trial. Anesth Analg
2010;110(1):199-207. Medline DOI 22. Borghi B, Casati A, Iuorio S, et al; Study Group on
The authors conducted a randomized, placebo-controlled Orthopedic Anesthesia of the Italian Society of Anes-
double-blinded study of pregabalin administration to de- thesia, Analgesia, and Intensive Care (SIAARTI): Fre-
termine if it resulted in decreased chronic neuropathic pain quency of hypotension and bradycardia during general
after TKA: 240 patients were placed in either a pregabalin anesthesia, epidural anesthesia, or integrated epidural-
cohort or a placebo cohort. The incidence of neuropathic general anesthesia for total hip replacement. J Clin Anesth
pain was less in the pregabalin group. Advantages of pre- 2002;14(2):102-106. Medline DOI
gabalin were tempered by increased early postoperative
sedation and confusion. Level of evidence: I. 23. Memtsoudis SG, Sun X, Chiu YL, et al: Perioperative
comparative effectiveness of anesthetic technique in or-
18. Richardson AB, Bala A, Wellman SS, Attarian DE, Bolog- thopedic patients. Anesthesiology 2013;118(5):1046-1058.
nesi MP, Grant SA: Perioperative dexamethasone admin- Medline DOI
istration does not increase the incidence of postoperative The authors studied the effect of anesthetic technique on
infection in total hip and knee arthroplasty: A retrospec- perioperative outcomes by using a large national sample
tive analysis. J Arthroplasty 2016; Jan 21 [Epub ahead of of primary joint arthroplasty recipients. When neuraxial
print]. Medline DOI anesthesia was used, 30-day mortality, LOS, cost, and
The authors conducted a retrospective chart review of in-hospital complications were significantly lower. Level
6,294 patients who underwent THA or TKA to determine of evidence: III.
if dexamethasone administration was associated with
increased risk of periprosthetic joint infection. Patients 24. Cousins MJ, Mather LE: Intrathecal and epidural admin-
were subdivided into two cohorts: those who received istration of opioids. Anesthesiology 1984;61(3):276-310.
perioperative dexamethasone and those who did not. The Medline DOI
overall incidence of infection was 1.2%. Incidence of in-
fection was not significant between the two groups (1.3% 25. Singelyn FJ, Gouverneur JM: Postoperative analgesia
versus 1.2%). Level of evidence: III. after total hip arthroplasty: i.v. PCA with morphine,
patient-controlled epidural analgesia, or continuous
19. Parvizi J, Rasouli MR: General compared with neuraxial “3-in-1” block? A prospective evaluation by our acute
anesthesia for total hip and knee arthroplasty. Ann Transl pain service in more than 1,300 patients. J Clin Anesth
Med 2015;3(20):318. Medline 1999;11(7):550-554. Medline DOI
The authors reviewed the relative benefits and disadvan- 26. Indelli PF, Grant SA, Nielsen K, Vail TP: Region-
tages of general versus neuraxial anesthesia. Level of al anesthesia in hip surgery. Clin Orthop Relat Res
evidence: V. 2005;441(441):250-255. Medline DOI
20. Kehlet H, Aasvang EK: Regional or general anesthesia for 27. Horlocker TT, Kopp SL, Pagnano MW, Hebl JR: Anal-
fast-track hip and knee replacement: What is the evidence? gesia for total hip and knee arthroplasty: A multimodal
F1000Res 2015;4:F1000 Faculty Rev-1449. Medline pathway featuring peripheral nerve block. J Am Acad
This article reviews the current literature and clinical Orthop Surg 2006;14(3):126-135. Medline DOI
practice trends in anesthetic protocol in total joint ar-
throplasty. The evidence for regional and general anes- 28. Capdevila X, Macaire P, Dadure C, et al: Continuous
thesia is reviewed and the positive and negative effects of psoas compartment block for postoperative analgesia after
each are highlighted. The primary conclusion made by the total hip arthroplasty: New landmarks, technical guide-
authors is that the paucity of data from large randomized lines, and clinical evaluation. Anesth Analg 2002;94(6):
controlled trials comparing modern general and regional 1606-1613. Medline
anestheitic techniques precludes a definitive recommen-
dation for general or regional anesthesia in total joint 29. Lombardi AV Jr, Berend KR, Mallory TH, Dodds KL,
replacement. Level of evidence: V. Adams JB: Soft tissue and intra-articular injection of
bupivacaine, epinephrine, and morphine has a beneficial
21. Harsten A, Kehlet H, Ljung P, Toksvig-Larsen S: Total in- effect after total knee arthroplasty. Clin Orthop Relat
3: Hip
travenous general anaesthesia vs. spinal anaesthesia for to- Res 2004;428:125-130. Medline DOI
tal hip arthroplasty: A randomised, controlled trial. Acta
Anaesthesiol Scand 2015;59(3):298-309. Medline DOI 30. Essving P, Axelsson K, Åberg E, Spännar H, Gupta A,
The purpose of this study was to compare general anes- Lundin A: Local infiltration analgesia versus intrathecal
thesia with regional anesthesia to determine which pro- morphine for postoperative pain management after total
vided a more favorable recovery profile. The authors knee arthroplasty: A randomized controlled trial. Anesth
randomized 120 patients to either intrathecal bupivacaine Analg 2011;113(4):926-933. Medline DOI
or general anesthesia with target-controlled infusion of This study investigated the effects of intrathecal morphine
remifentanil and propofol. The authors found that general versus local infusion anesthesia after TKA to determine
Section 3: Hip
the effect on postoperative pain control. The authors en- the same standardized multimodal pain control regimen
rolled 50 patients in a double-blinded fashion. The pa- with additional liposomal bupivacaine LIA. Although
tients were randomized into an intrathecal group, in which patient-reported pain scores did not demonstrate signifi-
0.1 mg of intrathecal morphine was administered with the cant difference, the liposomal bupivacaine cohort demon-
spinal anesthetic, or into an LIA group and received a local strated a significant decrease in total narcotic use. Level
infiltrate of ropivacaine, ketorolac, and epinephrine. The of evidence: II.
LIA technique provided better postoperative analgesia
and earlier mobilization, resulting in shorter hospital stay. 35. Meneghini RM, Pagnano MW, Trousdale RT, Hozack
Level of evidence: I. WJ: Muscle damage during MIS total hip arthroplasty:
Smith-Petersen versus posterior approach. Clin Orthop
31. Kuchálik J, Granath B, Ljunggren A, Magnuson A, Lundin Relat Res 2006;453:293-298. Medline DOI
A, Gupta A: Postoperative pain relief after total hip arthro-
plasty: A randomized, double-blind comparison between 36. Meneghini RM, Smits SA: Early discharge and recovery
intrathecal morphine and local infiltration analgesia. with three minimally invasive total hip arthroplasty ap-
Br J Anaesth 2013;111(5):793-799. Medline DOI proaches: A preliminary study. Clin Orthop Relat Res
This study assessed intrathecal morphine compared with 2009;467(6):1431-1437. Medline DOI
LIA to assess postoperative pain control. The authors
enrolled 80 patients in a randomized double-blind study. 37. Berend KR, Lombardi AV Jr, Seng BE, Adams JB: En-
The patients receiving LIA demonstrated reduced analge- hanced early outcomes with the anterior supine intermus-
sic consumption, pain intensity on mobilization, and side cular approach in primary total hip arthroplasty. J Bone
effects; however, reduced pain intensity was recorded early Joint Surg Am 2009;91(suppl 6):107-120. Medline DOI
after surgery in the intrathecal morphine group. Level of
evidence: I. 38. Poehling-Monaghan KL, Kamath AF, Taunton MJ,
Pagnano MW: Direct anterior versus miniposterior
32. Emerson RH, Barrington JW, Olugbode O, Lovald S, Wat- THA with the same advanced perioperative protocols:
son H, Ong K: Comparison of local infiltration analgesia Surprising early clinical results. Clin Orthop Relat Res
to bupivacaine wound infiltration as part of a multimodal 2015;473(2):623-631. Medline DOI
pain program in total hip replacement. J Surg Orthop Adv The authors investigated the effect of surgical approach
2015;24(4):235-241. Medline on postoperative rehabilitation following THA. The direct
This study compared a routine LIA drug combination with anterior approach was compared to the miniposterior ap-
a liposomal-bupivacaine LIA drug combination. Patients proach for THA using the same advanced pain and rapid
who received the non–liposomal bupivacaine combina- rehabilitation protocols for both groups. The authors saw
tion reported significantly higher visual analog scale pain no significant difference in the mean LOS, perioperative
scores and demonstrated increased opioid usage compared complication rate, narcotic use, functional capacity, or
to the liposomal bupivicaine group. The authors concluded discharged disposition. Level of evidence: III.
that liposomal bupivacaine infiltration may be a useful
adjunct in multimodal pain control regimens. Level of 39. Seng BE, Berend KR, Ajluni AF, Lombardi AV Jr: An-
evidence: II. terior-supine minimally invasive total hip arthroplasty:
Defining the learning curve. Orthop Clin North Am
33. Joshi GP, Cushner FD, Barrington JW, et al: Techniques 2009;40(3):343-350. Medline DOI
for periarticular infiltration with liposomal bupivacaine
for the management of pain after hip and knee arthro- 40. Woolson ST, Pouliot MA, Huddleston JI: Primary total
plasty: A consensus recommendation. J Surg Orthop Adv hip arthroplasty using an anterior approach and a frac-
2015;24(1):27-35. Medline ture table: Short-term results from a community hospital.
This article discusses the optimal use of liposomal-bu-
pivacaine. Expert opinion was elicited to determine a
consensus on the best practice for periarticular injection 41. Hofmann AA, Bolognesi M, Lahav A, Kurtin S: Minimiz-
technique in total joint arthroplasty. The authors provided ing leg-length inequality in total hip arthroplasty: Use of
technique instruction and tips as well as recommendations preoperative templating and an intraoperative x-ray. Am
for drug combination for infiltration in total joint arthro- J Orthop (Belle Mead NJ) 2008;37(1):18-23. Medline
plasty. Level of evidence: V.
42. Sharrock NE, Salvati EA: Hypotensive epidural anesthesia
3: Hip
34. Yu SW, Szulc AL, Walton SL, Davidovitch RI, Bosco JA, for total hip arthroplasty: A review. Acta Orthop Scand
Iorio R: Liposomal bupivacaine as an adjunct to postoper- 1996;67(1):91-107. Medline DOI
ative pain control in total hip arthroplasty. J Arthroplasty
2016;S0883-5403(16)00064-4. Medline 43. Eroglu A, Uzunlar H, Erciyes N: Comparison of hypo-
The authors prospectively investigated the effects of venous anesthesia on intraoperative blood loss during
the addition of liposomal bupivacaine on postoperative total hip replacement. J Clin Anesth 2005;17(6):420-425.
pain control. Patients were randomized into a control Medline DOI
group that received a standardized multimodal pain
control regimen without LIA or a group that received
44. Duncan CM, Gillette BP, Jacob AK, Sierra RJ, Sanchez- Results of 3000 procedures. Bone Joint J 2013;95-
Sotelo J, Smith HM: Venous thromboembolism and mor- B(11):1556-1561. Medline DOI
tality associated with tranexamic acid use during total
hip and knee arthroplasty. J Arthroplasty 2015;30(2): The authors conducted a retrospective study of 302 pa-
272-276. Medline DOI tients who received oral tranexamic acid and 2,698 pa-
tients who received IV tranexamic acid to compare the
This study retrospectively reviewed the outcomes in high- safety and efficacy of the two routes of tranexamic acid
risk orthopaedic patients undergoing TKA and THA fol- administration. Oral tranexamic acid showed decreased
lowing administration of tranexamic acid. The authors rates of transfusion with significant cost savings compared
identified all patients over a 5-year period who underwent with IV tranexamic acid. Level of evidence: III.
primary or revision TKA or THA. The authors report no
increased risk of postoperative DVT or 30-day mortality. 50. Gillette BP, DeSimone LJ, Trousdale RT, Pagnano MW,
Level of evidence: III. Sierra RJ: Low risk of thromboembolic complications
with tranexamic acid after primary total hip and knee
45. Alshryda S, Sarda P, Sukeik M, Nargol A, Blenkinsopp J, arthroplasty. Clin Orthop Relat Res 2013;471(1):150-154.
Mason JM: Tranexamic acid in total knee replacement: Medline DOI
A systematic review and meta-analysis. J Bone Joint Surg
Br 2011;93(12):1577-1585. Medline DOI The authors performed a retrospective review of 2,046 pa-
tients who underwent primary THA or TKA and received
The authors conducted a meta-analysis of randomized tranexamic acid from 2007 to 2009 to determine whether
controlled trials evaluating the effectiveness of tranexamic the rate of symptomatic DVT differed when three differ-
acid. In the nine studies the authors examined, tranexamic ent postoperative prophylactic regimens were used. The
acid showed significant reduction in blood loss and trans- three chemical regimens included aspirin alone, warfarin,
fusion while not increasing DVT or pulmonary embolism. and dalteparin. The authors demonstrated that use of
Level of evidence: I. tranexamic acid during primary total joint arthroplasty
was associated with a low complication rate in the setting
46. Wind TC, Barfield WR, Moskal JT: The effect of tranexam- of less aggressive thromboprophylactic regimens. Level
ic acid on transfusion rate in primary total hip arthroplas- of evidence: III.
ty. J Arthroplasty 2014;29(2):387-389. Medline DOI
51. Jacobs JJ, Mont MA, Bozic KJ, et al: American Academy
This retrospective review studied the need for postopera- of Orthopaedic Surgeons clinical practice guideline on:
tive transfusion in 1,595 THAs in patients who received Preventing venous thromboembolic disease in patients
tranexamic acid intravenously, topically, or not at all. IV undergoing elective hip and knee arthroplasty. J Bone
tranexamic acid significantly reduced the need for trans- Joint Surg Am 2012;94(8):746-747. Medline DOI
fusion, whereas the effect of topical tranexamic acid was
not significant. Transfusion rate without tranexamic acid These clinical practice guidelines addressed the practice of
was 19.86%, with IV tranexamic acid 4.39%, and with preventing DVT in patients undergoing THA and TKA.
topical tranexamic acid 12.86%. Level of evidence: III. The guidelines were developed by experts in the field on
the basis of reviews of the literature. Graded recommen-
47. Konig G, Hamlin BR, Waters JH: Topical tranexamic dations are given. Level of evidence: I.
acid reduces blood loss and transfusion rates in total hip
and total knee arthroplasty. J Arthroplasty 2013;28(9): 52. Healy WL, Ayers ME, Iorio R, Patch DA, Appleby D,
1473-1476. Medline DOI Pfeifer BA: Impact of a clinical pathway and implant
standardization on total hip arthroplasty: A clinical and
In this study, 290 patients underwent either THA or economic study of short-term patient outcome. J Arthro-
TKA by a single surgeon to determine results of topi- plasty 1998;13(3):266-276. Medline DOI
cal tranexamic acid regarding bleeding and transfusion
postoperatively. Topical tranexamic acid significantly re-
duced postoperative bleeding and transfusion. Level of 53. Kim S, Losina E, Solomon DH, Wright J, Katz JN: Ef-
evidence: II. fectiveness of clinical pathways for total knee and to-
tal hip arthroplasty: Literature review. J Arthroplasty
2003;18(1):69-74. Medline DOI
48. Gilbody J, Dhotar HS, Perruccio AV, Davey JR: Topical
tranexamic acid reduces transfusion rates in total hip and
knee arthroplasty. J Arthroplasty 2014;29(4):681-684. 54. Mears DC, Mears SC, Chelly JE, Dai F, Vulakovich
Medline DOI KL: THA with a minimally invasive technique, multi-
modal anesthesia, and home rehabilitation: Factors
3: Hip
The findings of this retrospective review of patients under- associated with early discharge? Clin Orthop Relat Res
going THA and TKA while receiving topical tranexamic 2009;467(6):1412-1417. Medline DOI
acid demonstrated a significant reduction in blood loss, he-
moglobin loss, and LOS with the use of topical tranexamic 55. Larsen K, Hansen TB, Thomsen PB, Christiansen T, Søbal-
acid. Level of evidence: III. le K: Cost-effectiveness of accelerated perioperative care
and rehabilitation after total hip and knee arthroplasty.
49. Irwin A, Khan SK, Jameson SS, Tate RC, Copeland C, J Bone Joint Surg Am 2009;91(4):761-772. Medline DOI
Reed MR: Oral versus intravenous tranexamic acid in en-
hanced-recovery primary total hip and knee replacement:
Section 3: Hip
56. Stambough JB, Nunley RM, Curry MC, Steger-May K, Given the authors’ analysis of data from Hospital Episode
Clohisy JC: Rapid recovery protocols for primary total Statistics, patients 85 years or older receive the most bene-
hip arthroplasty can safely reduce length of stay with- fits from enhanced recovery programs in terms of reduced
out increasing readmissions. J Arthroplasty 2015;30(4): LOS and readmission. When compared with data before
521-526. Medline DOI the introduction of enhanced recovery programs, the dif-
ference in LOS for this cohort was most pronounced.
The authors retrospectively reviewed the effects of an in- Level of evidence: II.
cremental implementation of a recovery protocol following
THA. Changes on hospital LOS and readmission rates
were analyzed. Four protocol cohorts were defined based 61. Husted H, Troelsen A, Otte KS, Kristensen BB, Holm
on the era in which the primary THA was performed; G, Kehlet H: Fast-track surgery for bilateral total knee
traditional, enhanced pain management, early mobility, replacement. J Bone Joint Surg Br 2011;93(3):351-356.
and rapid recovery. Implementation of a rapid recovery Medline DOI
protocol was associated with a significant reduction in Based on the authors’ findings, fast-track surgery with
the LOS between sequential eras, with a total reduction multidisciplinary multimodal approach to patient care
of 52% between the traditional and rapid recovery path- may provide the means by which bilateral simultaneous
ways. No increase in 30-day readmission rates was noted TKA can be safely performed. The study shows short-
and the likelihood of readmission during the the rapid er lengths of stay with few perioperative and anesthetic
recovery era was nearly one-third of the traditional era. complications compared with findings of previous studies.
Level of evidence: III. Level of evidence: II.
57. Husted H, Lunn TH, Troelsen A, Gaarn-Larsen L, Kris- 62. Kehlet H, Wilmore DW: Evidence-based surgical care
tensen BB, Kehlet H: Why still in hospital after fast-track and the evolution of fast-track surgery. Ann Surg
hip and knee arthroplasty? Acta Orthop 2011;82(6):679- 2008;248(2):189-198. Medline DOI
684. Medline DOI
63. Inneh IA, Iorio R, Slover JD, Bosco JA III: Role of so-
58. Husted H, Hansen HC, Holm G, et al: What determines ciodemographic, co-morbid and intraoperative factors in
length of stay after total hip and knee arthroplasty? A length of stay following primary total hip arthroplasty.
nationwide study in Denmark. Arch Orthop Trauma Surg J Arthroplasty 2015;30(12):2092-2097. Medline DOI
2010;130(2):263-268. Medline DOI
The authors of this study sourced and reviewed patient-
The authors identified patients using a national registery level administrative and electronic health record data from
to determine areas of clinical practice that influenced LOS a large metropolitan single-specialty orthopaedic hospital.
following THA or TKA. The clinical care pathways These included demographic characteristics, socioeconom-
were assessed to identify logistical and clinical factors ic characteristics, preoperative comorbidities, intraopera-
leading to early rehabilitation and discharge. Logistical tive surgical factors, and postoperative hospital LOS data
factors that aided in early discharge included homogenous for 2,445 primary THAs. The findings demonstrated that
entities, regular staff, high continuity, managing patient low socioeconomic status, advanced age, and nonwhite
expectation, and development of functional discharge cri- race or ethnicity combined with certain comorbidities
teria. Clinical factors that lead to early discharge included was significantly associated with prolonged LOS. Level
multimodal opioid-sparing analgesia, early mobilization, of evidence: III.
and discharge when criteria were met.
64. Yu S, Garvin KL, Healy WL, Pellegrini VD Jr, Iorio R:
59. Halawi MJ, Vovos TJ, Green CL, Wellman SS, Attarian Preventing hospital readmissions and limiting the com-
DE, Bolognesi MP: Current evidence does not support plications associated with total joint arthroplasty. J Am
Medicare’s 3-day rule in primary total joint arthroplasty. Acad Orthop Surg 2015;23(11):e60-e71. Medline DOI
Am J Orthop (Belle Mead NJ) 2015;44(10):E370-E372.
Medline Identification of modifiable risk factors in the total joint
arthroplasty patient using standardized definitions and
The authors assessed the effect of Medicare’s 3-day rule stratification of complications and adverse events is critical
on LOS following total joint arthroplasty. Using readi- for predictive modeling. Improved perioperative optimi-
ness-for-discharge criteria, the authors determined that zation and posthospital coordination of care is expected
delaying discharge until postoperative day 3 resulted in to result in fewer readmissions; however, comprehensive
an increased LOS by 1.08 days. The authors reported studies have shown great difficulty in decreasing readmis-
no increased risk for 30-day readmission. The patients sions for high-risk patients. Therefore, it is the authors’
3: Hip
continued to improve from a rehabilitation standpoint, recommendation to stratify patients on the basis of their
but these gains did not affect discharge destination. Level risk factors, thereby risk-adjusting their readmission and
of evidence: III. preventing the hospital and surgeon from being penal-
ized or discouraged from providing care for the high-risk
60. Starks I, Wainwright TW, Lewis J, Lloyd J, Middleton patient.
RG: Older patients have the most to gain from ortho-
paedic enhanced recovery programmes. Age Ageing 65. Bronson WH, Fewer M, Godlewski K, et al: The ethics
2014;43(5):642-648. Medline DOI of patient risk modification prior to elective joint replace-
ment surgery. J Bone Joint Surg Am 2014;96(13):e113.
Medline DOI
The authors explore the principles of autonomy, benefi- underwent primary THA. On the basis of the authors’
cence, and nonmaleficence in a discussion regarding gov- findings, there was a strong correlation between increased
ernance of the decision to make reduction of modifiable BMI and higher rates of reoperation, implant revision or
risks mandatory before elective total joint arthroplasty. removal, and common complications after THA. Level
They also discuss the shift of financial responsibility for of evidence: III.
complications from the federal government and the CMS
to hospitals, as well as the initiatives aimed at the redi- 68. Callaghan JJ, Pugely A, Liu S, Noiseux N, Willenborg M,
rection of resources from treatment and intervention to Peck D: Measuring rapid recovery program outcomes: Are
prevention. Data suggest that surgeons who do not identify all patients candidates for rapid recovery. J Arthroplasty
and address all modifiable risk factors before elective total 2015;30(4):531-532. Medline DOI
joint arthroplasty do not promote the patient’s overall
well-being. Level of evidence: II. The authors state the need for established metrics to eval-
uate the outcomes of rapid recovery programs following
66. Issa K, Harwin SF, Malkani AL, Bonutti PM, Scillia A, THA and TKA. Based on the limited data and literature
Mont MA: Bariatric Orthopaedics: Total hip arthroplasty regarding rapid recovery programs and on the authors’
in super-obese patients (those with a BMI of ≥50 kg/m2). studies using the National Inpatient Sample and National
J Bone Joint Surg Am 2016;98(3):180-185. Medline DOI Surgical Quality Improvement Program databases, vari-
ables related to the success of rapid recovery programs
The authors reviewed 48 hips in 45 super-obese patients following THA and TKA include preoperative consider-
who underwent THA at one of four high-volume institu- ations, hospital stay considerations, and posthospitaliza-
tions between 2001 and 2010. They were compared in tion accomplishment of milestones. Level of evidence: II.
a 1:3 ratio with a nonobese matched group that under-
went THA during the same time period and by the same 69. Keeney JA, Nam D, Johnson SR, Nunley RM, Clohisy
surgeons. The authors assessed patient outcome and ex- JC, Barrack RL: The impact of risk reduction initia-
periences in finding a surgeon. It is suspected that the pau- tives on readmission: THA and TKA readmission rates.
city of THA cases in superobese patients reflects a higher J Arthroplasty 2015;30(12):2057-2060. Medline DOI
rate of refusal by surgeons to perform surgery owing to
the more demanding procedure and the fear of higher The authors identified 4,131 primary THA and 3,372 pri-
complications and poor surgical outcomes. Though the mary TKA procedures performed between January 1,
superobese patients experienced significant improvement 2006, and September 30, 2013. The authors’ findings
compared with their preoperative status, they still had low- showed that structured institutional efforts to reduce
er clinical outcome scores, higher revision rates, and higher readmission rates had significant positive effects in risk
complication rates compared with the matched group at a reduction when applied to patients undergoing TKA, but
mean follow-up of 6 years. Level of evidence: III. not those undergoing THA. Higher mean Charlson Co-
morbidity Index scores among readmitted THA patients
67. Wagner ER, Kamath AF, Fruth KM, Harmsen WS, Berry than among readmitted TKA patients likely contributed
DJ: Effect of body mass index on complications and re- to the decreased effects of risk reduction after THA. The
operations after total hip arthroplasty. J Bone Joint Surg authors supported the development of risk models that de-
Am 2016;98(3):169-179. Medline DOI fine risk factors for hospital readmission following elective
THA and TKA to prevent penalization of hospitals that
The authors used data collected from the institutional provide care to a higher proportion of high-risk patients.
total joint registry of a single institution between 1985 and Level of evidence: III.
2012 to review 21,361 consecutively treated hips that
3: Hip
Chapter 34
Revision Total Hip Arthroplasty

Anthony Albers, MD, FRCSC Alberto Carli, MD, MSc, FRCSC Sachin Daivajna, MS, FRCSC, Orth
William L. Griffin, MD Robert Russell, MD Allan E. Gross, MD, FRCSC, O Ont Paul F. Lachiewicz, MD
Cameron K. Ledford, MD David G. Lewallen, MD Douglas E. Padgett, MD
Rohit Rambani, MBBS, MS Ortho, FIMSA, FRCS, Tr & Orth Donald Garbuz, MD, FRCSC
acetabulum remains somewhat spherical, even with a

Abstract
loose or migrated component, the techniques for prepa-
The goals of revision total hip arthroplasty are to achieve ration and insertion are relatively simple. With the large
both a stable mechanical construct and joint and to im- component, the need for bone graft material, especially
prove quality of life for patients. Many reconstruction bulk allograft, is minimized. This technique is more likely
options are available for both acetabular and femoral to normalize the center of rotation of the hip joint com-
reconstruction. Various options are available to achieve pared to a high hip center placement or other techniques.
these goals. This technique also has specific disadvantages when
used for revision. It does not restore acetabular bone
structure, as is described with other techniques (such as
Keywords: revision total hip arthroplasty; impaction grafting). The center of rotation of the hip may
acetabular reconstruction; femoral reconstruction be elevated 10 mm or more.3 Preparation of the acetabular
bone for a jumbo cup will require some reaming of the
anterior and posterior walls or columns, and without
careful technique, excess bone from the posterior column
could be removed inadvertently. Some surgeons may con-
Introduction
sider the need for modular acetabular components and
Acetabulum screws, for secure fixation, to be a disadvantage of the
Acetabular revision has evolved in the past 10 to 15 years, jumbo cup. However, modular components and screws
and although newer techniques help treat larger defects, are generally used in all revision THAs.2,4 The amount of
hemispherical cups can be used in most cases. Newer tech- bone that will grow into the porous coating from the dam-
niques involve use of augments and cup-cage constructs. aged acetabular surface is unknown, and less is expected
than in primary hip arthroplasty. It is unclear whether
a relatively small amount of bone ingrowth will provide
Noncemented Hemispherical Components durable fixation or will predispose to late loosening.
The noncemented hemispherical acetabular cup is the
most widely used, reproducible, and reliable technique Technique
for acetabular revisions. Many acetabular revisions use Because the implantation of the noncemented hemispheri-
an extra-large or jumbo size noncemented hemispherical cal acetabular cup requires preparation and insertion of a
component. The accepted parameters for this component, component much larger than a primary component, good
3: Hip
defined by surgeons at the Mayo Clinic, are as follows: exposure is recommended, with a longer skin and fascial
62 mm or greater in women and 66 mm or greater in incision. The posterolateral approach involves release
men.1 This definition was based on a size that is 10 mm of the femoral insertion of the gluteus maximus tendon
greater than the mean size of acetabular components to facilitate and improve the retraction of the femur or
used in primary total hip arthroplasty (THA). Use of retained femoral component anterosuperior to the acetab-
the jumbo cup has numerous advantages over other tech- ulum. Occasionally (such as in a stiff or protruded hip),
niques.1,2 Weight bearing occurs over a large area of the some type of greater trochanteric osteotomy (either a
pelvis, and surface contact is maximized. Because the slide or extended osteotomy) may be necessary to provide
Section 3: Hip
adequate exposure of the entire rim of the acetabulum. cavitary defects should be packed with allograft bone or
After removal of the failed acetabular component and bone substitute to improve bone stock. Screw fixation is
any residual membrane or bone cement, the acetabulum important for both initial and long-term fixation of the
should be evaluated carefully for pelvic discontinuity by noncemented revision cup.2,4,5 The intrapelvic neural and
inspection and performing manual tests. If there is no vascular structures may be more at risk when a jumbo cup
discontinuity, the surgeon may proceed with preparation is used.5 The so-called safe zones for insertion of multiple
for using a jumbo cup. If pelvic discontinuity is present, acetabular screws in the superior and posterior quadrants
then techniques described later in the chapter will likely are used routinely. In addition, screw fixation into the
need to be used. ischium (posterior and inferior), although difficult, can
Reaming of the acetabulum for a noncemented hemi- be performed in most revisions; this is recommended to
sphere seems to be an unnecessary step, as the surgeon prevent late cup breakout, or pulling away from the infe-
should be conservative in bone preparation. Often, only rior acetabulum. After placement of three to four screws,
the use of a high-speed burr at the periphery of the ace- the empty screw holes are also filled with allograft before
tabulum is needed to remove a sclerotic bony edge, and modular liner trial placement or insertion.
then the hemispherical reamer shells are used as a guide There are specific contraindications to the use of the
for proper sizing of the jumbo cup. Forceful reaming noncemented hemispherical cup. This technique usually
could destroy the damaged or deficient remaining bone. cannot be used alone in the presence of pelvic discon-
The goal of the technique is to fill the acetabulum from tinuity, when the surgeon is unable to obtain stability
the ilium to the acetabular teardrop (from top to bot- with a large reamer shell or trial component, or if screw
tom) with the new porous metal shell, for which some fixation cannot be achieved. Additional implants and
bone from the anterior and posterior acetabulum may techniques are required in these scenarios.6 It has been
need to be removed to create a new hemisphere. A trial reported that host bone–acetabular cup contact of less
acetabular component or reamer shell is then inserted to than 50% may be a contraindication to the use of a jumbo
determine if rim stability can be obtained. Depending on noncemented cup alone.7,8 However, with the availabil-
the design of the component (hemispherical or elliptical), ity of enhanced (or second-generation) porous surfaces,
the type of porous coating, and the bone quality, a mul- such as tantalum, this may no longer be the case; in a
tihole component that is 0- to 2-mm larger than the final 2012 study of 53 hips in which an enhanced surface jum-
reamer shell is selected. Before inserting the new compo- bo acetabular component was implanted, and there was
nent, all fibrous membrane should be curetted, and any less than 50% host bone–cup contact, the rate of failure
Dr. Griffin or an immediate family member has received royalties from DePuy, is a member of a speakers’ bureau or has
made paid presentations on behalf of DePuy, serves as a paid consultant to DePuy, has received research or institutional
support from DePuy, Zimmer, and serves as a board member, owner, officer, or committee member of the American
Association of Hip and Knee Surgeons, the Knee Society, and the AAOS. Dr. Gross or an immediate family member is a
member of a speakers’ bureau or has made paid presentations on behalf of Zimmer, serves as a paid consultant to Zim-
mer, has stock or stock options held in Intellijoint System, and serves as a board member, owner, officer, or committee
member of the Canadian Orthopaedic Association, the Knee Society, and the Hip Society. Dr. Lachiewicz or an immediate
family member has received royalties from Innomed, is a member of a speakers’ bureau or has made paid presentations
on behalf of Mallinckrodt, Pacira, serves as a paid consultant to Gerson Lehrman Group, Guidepoint Global Advisors,
Pacira, and has received research or institutional support from Zimmer. Dr. Lewallen or an immediate family member
has received royalties from Mako/Stryker, Pipeline, Zimmer, serves as a paid consultant to Link Orthopaedics, Zimmer,
serves as an unpaid consultant to Ketai Medical Devices, has stock or stock options held in Acuitive, Ketai Medical De-
vices, and serves as a board member, owner, officer, or committee member of the American Joint Replacement Registry
3: Hip
and the Orthopaedic Research and Education Foundation. Dr. Padgett or an immediate family member has received
royalties from Mako, is a member of a speakers’ bureau or has made paid presentations on behalf of Mako, serves as
a paid consultant to Mako, Medical Compression Systems, Stryker, and serves as a board member, owner, officer, or
committee member of the Hip Society and the Hospital for Special Surgery. Dr. Garbuz or an immediate family member
serves as a paid consultant to Zimmer, has received research or institutional support from DePuy, Zimmer, and serves as
a board member, owner, officer, or committee member of the Hip Society and Mueller Foundation of North America.
None of the following authors or an immediate family member has received anything of value from or has stock or
stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter:
Dr. Albers, Dr. Carli, Dr. Daivajna, Dr. Russell, Dr. Ledford, and Dr. Rambani.
Chapter 34: Revision Total Hip Arthroplasty
was only 7.5% at a mean follow-up of 72 months (range, paragraph, the sizes of the femoral heads ranged from
60 to 102 months).7 Two other studies have also reported 22 to 32 mm, with 28 mm being the most common. In
successful fixation using cups with this enhanced porous a 2013 study, hips with a femoral head that is 32 mm or
surface in difficult acetabular revisions.9,10 larger had a significantly lower risk of dislocation.2 The
suggestion that acetabular revisions using a larger femoral
Recent Results head may have a lower risk of dislocation has been con-
Three studies over the past 5 years have reported results firmed. In a 2012 randomized controlled trial, 36-mm
of noncemented jumbo acetabular components being femoral heads (with highly cross-linked polyethylene) had
implanted without augments or cages in revision hip ar- a lower incidence of dislocation, compared to 28-mm
throplasty. A 2014 study reported on a group of 196 jum- femoral heads, at 1-year follow-up, in both primary and
bo component revisions, with a minimum follow-up of revision hip arthroplasty.14 However, the revision group
2 years and mean follow-up of 10 years.11 Three patients included hips with all sizes of acetabular components, and
had revision for acetabular loosening at 7 months, 9 years, with the numbers available, the difference in dislocation
and 11 years, respectively. Two patients had resection after revision (5% dislocation with the 36-mm component
arthroplasty for infection and recurrent dislocation. and 12% with the 28-mm component; P = 0.273) was
There were nine cases (4.2%) of dislocation, but seven not significant. In another 2012 study (a randomized
of these were recurrent and required additional surgery. In controlled trial in hip revisions only), the rate of dislo-
a 2013 study of 129 acetabular revisions with jumbo com- cation was significantly lower (P = 0.035) for the group
ponents, three infections occurred at less than 2 years, with 36- and 40-mm femoral heads (1%; 1 of 92 hips)
and the components were removed.2 Complete clinical and than for the group with 32-mm femoral heads (9%; 8 of
radiographic data at mean 8.1 years’ follow-up were given 92 hips).14 However, in both of these studies of dislocation
for 108 hips, with survival analysis reported to 15 years. and femoral head size, the number of hip revisions using
One additional late infection was seen. Aseptic loosening jumbo cups was not stated.14,15 Thus, the rate of disloca-
of the jumbo cup was seen in four patients (3.1%), three tion of large femoral heads (36 mm or larger) with only
of whom underwent re-revision. With failure defined as jumbo hemispherical cups in acetabular revision may
acetabular revision for loosening or definite radiographic actually be greater than the 5% and 1%, respectively, re-
evidence of loosening, 10-year survival was 97.3% (95% ported. Although this information is not evidence based,
confidence interval [CI], 89.6-99.3) and 15-year survival a prophylactic hip orthosis may be prescribed for 6 weeks
was 82.8% (95% CI, 59.0-97.6). Dislocation occurred in after revisions with a jumbo hemispherical cup to allow
12 patients (9.3%), and 3 of these patients had additional for greater soft tissue healing. Dislocation after a jumbo
surgery. In 2015, an updated review of the Mayo Clinic cup revision often becomes recurrent and requires revision
jumbo acetabular revision study was published, with a to either a dual mobility or constrained liner.
mean follow-up time of 20 years.12 This study reported
an increased rate of failure in the second decade after
revision, with three additional acetabular components Acetabular Augments
needing revision for aseptic loosening. A total of seven The number of revision hip arthroplasty procedures is
jumbo components were revised at an overall mean fol- increasing steadily, as are complex cases needing more
low-up time of 11 years. There were no late infections or specialized reconstruction.16 One of the challenges in re-
dislocations. Cup survival, with failure defined as need vision of acetabular components is bone loss. Bone loss
for acetabular revision or definite radiographic evidence defects are frequently classified with the Paprosky clas-
of loosening, was 85% at 20 years. sification, which categorizes the acetabulum into three
types, depending on the degree of osteolysis affecting
Complications the acetabular teardrop and ischium and the amount and
Dislocation is the most frequent complication after revi- direction of component migration.17 Different techniques,
3: Hip
sion hip arthroplasty in which a noncemented hemispher- mainly cemented or noncemented, have been described
ical cup, usually jumbo size, is implanted. The frequency to manage these defects. Common cemented techniques
has been generally reported to be 10% to 15% in several involve either impaction bone grafting or bulk allograft
studies.1,2,4,5 The etiology of dislocation with the jumbo with a cemented component or reconstruction reinforce-
cup is multifactorial and may be related to the usually ment rings with allograft and a cemented cup. These tech-
extensile exposure required for implantation as well as the niques produce acceptable results but can be difficult to
acetabular component–femoral head size mismatch.13 In execute, and reports of early failure have been published,
the three studies of jumbo cups described in the preceding especially in type III defects.18,19 Noncemented acetabular
Section 3: Hip
sockets have good results in primary THA, and similar The main indications for using an augment with a cup
technology has been used in revision scenarios. They are Paprosky acetabular defects types IIB, C, and IIIA
can be used in the form of a jumbo cup, bilobed cup, and IIIB. The most common locations of the defects are
cup-in-cup stacking, or reconstruction cages.1,20-25 Chal- in the superolateral and posterosuperolateral parts of the
lenges related to these techniques include development acetabulum. They affect the superomedial segment less
of adequate healthy host bone to achieve bone ingrowth; commonly, in which setting it is imperative to rule out
replacement of segmental bone loss (Paprosky type IIIA pelvic discontinuity before surgery. This will profoundly
and IIIB defects); and reproduction of a normal or close- influence management and outcome and will often neces-
to-normal hip center of rotation. sitate a cup-cage reconstruction. The need for an augment
To optimize the likelihood for biologic fixation of the is anticipated on the basis of preoperative templating on
interface, techniques in surface technology, such as hy- an anteroposterior pelvic radiograph; however, a defin-
droxyapatite and porous coatings, have been used. One itive decision to use an augment intraoperatively can be
material used is porous metal with characteristics that made if an oblong bone defect that cannot be supported
are similar to that of bone (strength, flexibility, three- by the hemispherical component without augmentation by
dimensional infrastructure). Porous metal has a high co- acetabular bone stock is recognized. When dealing with
efficient of surface friction, which assists the surgeon in segmental bone loss, Judet views are useful preoperatively
achieving initial interface stability. It also has impressive to help characterize the location and extent of bone loss.
bone ingrowth and incorporation characteristics, best In cases of greater complexity, CT may be required.
demonstrated in the canine model.26 In addition to using To effectively insert an augment, the normal acetabu-
a highly porous coated shell, porous metal augments can lum is prepared in its normal location, and the shell size
replace bone loss, resulting in less reliance on structur- is determined based on the AP dimension, not the oblong
al allografts to reduce the risk of graft resorption and superior inferior dimension. The trial cup is positioned,
potential disease transmission. The first example of this and the location and extent of the segmental defect is
technology available for general use was Trabecular Metal characterized. The defect is then prepared to accept an
(TM) (Zimmer). Subsequently, other manufacturers have augment of suitable size, such that it has good contact
developed highly porous acetabular components with with the remaining host bone and provides the required
augments. support for the hemispherical trial cup. This often re-
quires secondary but gentle reaming with a hemispherical
Indications and Technique of Using TM Cup and reamer to maximize the augment-bone interface contact
Augment and stability. This reaming is done with a reamer that
TM is available in the form of a variety of acetabular matches the diameter of the augment chosen. The metal
shells and augments. The three types of cups are the jum- augment is then secured with a minimum of two 4.5-mm
bo cup as a modular titanium/TM shell for ring lock liner titanium cortical screws. If the location of the screw hole
fixation; the revision TM shell for cemented liner fixation; within the augment is inconvenient, a new screw hole can
and the continuum titanium/TM shell for internal taper be created in the augment using a 4-mm high-speed burr.
lock liner fixation. The types of TM augments available Particulate allograft, or bone from reamings, if available,
are the roof and rim pure TM “semilunar” augments is then packed within the augment. Any additional small
and the column buttress pure TM semilunar and keel contained bone defects can be packed by impaction graft-
augments for severe defects. ing using cancellous allograft while maintaining adequate
Any of the three cups can be used alone in the jumbo contact with host bone.28 After the augment is secured,
cup configuration, although the revision TM shell has the revision TM shell is inserted and fixed with screws.
the advantage of allowing independent alignment of the The TM augment and shell can be unitized with cement
cemented liner if optimal alignment of the shell itself is either when the shell is inserted or later, when the defin-
difficult to achieve because of the location and sever- itive polyethylene liner is cemented in place. Care should
3: Hip
ity of bone loss. In addition, in the presence of pelvic be taken to achieve appropriate alignment of the cemented
discontinuity, the revision TM shell can be used with a liner independent of the shell if some malalignment of
reconstruction cage (cup-cage technique).27 the shell has to be accepted, so as to maximize host bone
The most commonly used augment is the semilunar, contact and secure screw fixation.
almost always in combination with a revision TM shell.
Rarely, the column buttress augment or a combina- Results of Using a Cup-Augment Construct
tion of stacked augments may be considered in difficult Studies have been published on the use of porous metal
cases. cups with augments since 2004. Most studies, except
two, had fewer than 50 patients, 28,29 with follow-up shells with augments are successful for treating acetabular
ranging from 24 to 107 months, and survivorship rang- defects and have good short-term and midterm results.
ing from 94% to 100%. The prominent results of one Therefore, continued use of these implants in cases of
study described results of 55 revisions (mean follow-up, large acetabular defects is recommended.
53.7 months) with 96.4% survival at 2 years and 92.8%
survival at 5 years.28 Another study presented 53 patients Cup-Cage Construct
(mean follow-up, 110 months; range, 88 to 128 months) Major acetabular deficiency and pelvic discontinuity in
with survival of 92% at 10 years.29 The survivorship for revision THA procedures mandate acetabular reconstruc-
this construct seems to be 94% to 100% at 2 years, 92% tion that can provide initial stability and the potential for
to 100% at 5 years, and 92% at 10 years. durable fixation.33 Antiprotrusio cage and ring techniques
have historically been used in revision settings with sig-
Discussion nificantly deficient bone stock to protect the healing of
Acetabular defects have been managed in different ways bulk or cancellous allograft. Midterm survivorship free
over the past few decades. Cemented acetabular compo- from revision has been reported at between 72% and 80%
nents have been used with allograft techniques, recon- with the use of a variety of rings and cages.34-36 However,
struction meshes, or reinforcement rings. However, results the use of such methods independently has decreased
of these constructs have not been quite successful due to with the advent of alternative specially fabricated porous
resorption of allograft and failure of the reconstruction metal ingrowth hemispherical acetabular components,
rings, in some cases up to 12% at 5 years and 21% to porous metal acetabular augments, and even custom tri-
37% at 10 to 15 years.30,31 A systematic review comparing flange noncemented implants. Cup-cage reconstruction
the results of TM implants to reinforcement rings have is another option when major bone deficiency or pelvic
shown that TM results are significantly better.18 In North dissociation is encountered. This technique was first re-
America, success of noncemented hip arthroplasty has ported in 2004 as an alternative to traditional cages.37 The
resulted in an increased use of noncemented implants in development of the cup-cage technique evolved from pre-
revision acetabular surgery. Scientific advances in surface vious acetabular reconstructive techniques, by combining
technology, such as hydroxyapatite coatings, have im- a highly porous metal acetabular component with an
proved bony ingrowth. It has been suggested that bony antiprotrusio cage. Initially, off-the-shelf antiprotrusio
ingrowth into the implant can be obtained with highly cages were used to provide fixation advantages of the
porous materials, such as TM.14 This concept is quite cage in combination with the longer-term bone ingrowth
unique and theoretically suggests a long-term survival and more durable fixation of the ingrowth cup. Subse-
of this construct. A study involving a large cohort of quently, made-for-purpose cages have become available
827 cases from the Finnish Arthroplasty Register, using for use with porous tantalum acetabular components in a
TM implants, found a survival rate of 92% for all causes range of sizes for cages that match those of the available
of revisions at 3 years.32 The short-term and midterm acetabular implants.
results have shown 94% to 100% survival, whereas a The main indication for the use of an ilioischial cage
long-term study has shown approximately 92% survival in combination with a porous ingrowth cup is inadequate
at 10 years. Like all new technology, a large number of initial acetabular component support or fixation. This can
cases with long follow-up are needed to find differences be due to poor bone quality, the size and location of bone
between techniques and implants. The drawbacks of pre- defects, or the presence of associated pelvic dissociation.
vious studies are that they are mainly case series rather In many cases, a combination of these factors prompts
than randomized controlled studies, and the data can be selection of a cup-cage construct. Because of this, cup-
heterogeneous. A TM cup with an augment has several cage constructs are most commonly used in select cases
advantages, including that it can be conformed to the type of marked superolateral (Paprosky type IIIA) or supero-
of defect and custom built to suit a patient’s anatomy. medial (Paprosky type IIIB) acetabular bone loss, with
3: Hip
There is less reliance on bulk allografts, and expensive or without pelvic discontinuity. Other indications include
computer-generated implants are not required. There the presence of pelvic discontinuity with less severe bone
have been no reports of augment failures or breakage in loss or markedly impaired bone quality, as is sometimes
the literature. One article has reported two cases with seen following therapeutic pelvic radiation.
loosening of the shell, which has created metal debris, After adequate, usually extensile, surgical exposure
suggesting that cup-augment junction failure may occur and removal of components, a decision must be made
if there is no ingrowth of host bone into the acetabular about sufficiency of the available bone stock for use of a
shell.25 It would be reasonable to conclude that use of TM hemispherical cup with multiple screws, with or without
Section 3: Hip
an augment. If the pattern of bone deficiency and quality the quadrilateral surface. This inferior screw can add
of the bone requires additional support, a cup-cage con- additional important inferior ischial fixation, especially
struct can be used. Reconstruction usually begins with in the presence of pelvic dissociation. A variation of the
cancellous bone grafting of residual cavitary deficiencies, cup-cage technique involves the use of a half cup-cage
and even some segmental defects, followed by placement construct to ease insertion; one of the flanges of the cage
of a highly porous acetabular component. This compo- (usually the ischial flange) is removed with a carbide burr
nent must allow for multiple screws in an array across to allow screws to be used in the area of the flange. In this
the dome, down the posterior column, and into the base case, the iliac portion of the cage is contoured to fit the
of the ischium. It is especially important in all recon- outer table, and the half cage is rotated into position and
structions with significant bone loss, with or without fixed with screws through the iliac flange of the dome in
a cage, to achieve inferior fixation in zone 3 to prevent a manner similar to that used for the full cage construct.
early separation of the cup from the inferior aspect of the The half cup-cage technique is most useful when large
acetabulum, as well as subsequent migration and frank cavitary ischial defects preclude fixation of the iliac flange
loosening (Figure 1). Acetabular augments may be used alone. It may also be useful with an intact acetabulum that
for segmental defects or elliptical acetabular cavities to has a major defect and a tenuous residual bony bridge,
improve host bone contact before placement of the cage. in which case impaction of the cage may cause pelvic
A slot must be created in the ischium for the ischial flange dissociation. Hence the insertion of the half cage can be
of the cage; this is best done early in the case to allow accomplished in a much more atraumatic manner, with
positional adjustment of the acetabular component and less surgical exposure.
access by the ischial flange into the ischial slot. Occa- Because the technique of cup-cage reconstruction was
sionally, the cup requires repositioning in a slightly more first introduced approximately 1 decade ago, long-term
horizontal and neutral position to uncover the ischium. In results are not available, but early to midterm outcomes in
other cases, modest superior migration of the hip center of clinical series of small to moderate numbers report good
1 cm or so may allow for lack of coverage of the ischium, clinical results and durable fixation in most patients with
despite standard cup version and inclination. After the major acetabular defects at intermediate-term follow-up.
acetabular component has been fixed into position with One study reported on 26 consecutive acetabular revision
multiple screws, trials for the cage system of choice are cases with a cage and TM component used for pelvic dis-
used to determine the proper bend of the ischial and iliac continuity.27 No clinical or radiographic evidence of loos-
flanges to achieve slotting into the ischium and contact ening was seen in 89% of hips at 4 years, with only three
against the outer table of the ilium, while also providing components migrating farther than 5 mm and requiring
for seating of the cage into the cup. The use of cage trials reoperation. Midterm follow-up comparison studies of
is especially helpful as a template to minimize contouring the same cohort confirmed that cup-cage reconstruction
of the flanges of the real cage. The real cage is impacted performed significantly better than conventional cages,
into position beginning with the ischial flange, seating with septic or aseptic loosening failure rates of 15% versus
the cage into the cup and then impacting the iliac flange 68%, respectively.38 The largest retrospective review of
down into position on the outer table of the ilium. A screw 67 cup-cage constructs for large acetabular defects and
is then placed through the cage and through the dome of pelvic discontinuity has demonstrated the most promising
the cup into the host bone. When an existing screw hole results thus far.39 Only four revisions (9%) for aseptic
lines up with that of the cage, this screw hole can be used loosening were performed in the 45 pelvic discontinuity
if a screw is not already present within the cup. If a screw cases at 6-year average follow-up. Additionally, postoper-
is present, the cage may be removed, the screw backed ative patient outcome scores improved significantly, and
out, the cage replaced, and the screw repositioned into the 10-year survival rate was 85%. The rate of complica-
the original hole. The presence of the dome screw unites tions, most commonly infection and instability, was 12%.
the reconstruction and brings the cage into good contact Further acetabular stabilization techniques may also be
3: Hip
against the cup for subsequent iliac flange fixation. The applied to the cup-cage reconstruction, especially when
screw holes in the iliac flange are then filled with screws additional initial stability is preferred. A small cohort of
(generally at least three or four screws used in a trans- cup-cage reconstructions demonstrated no short-term
verse manner to provide rigid fixation) in combination failure from aseptic loosening when modular buttress aug-
with the dome screws in the cup, which run relatively ments were used in conjunction with the cup-cage.40 One
perpendicular to the transverse iliac flange screws. It is study described a successful pelvic discontinuity stabiliza-
sometimes possible to place a screw through the shoulder tion technique of acetabular distraction used in combina-
region of the cage and into the base of the ischium through tion with a porous ingrowth component and, if needed,
Figure 1 Images of a revision total hip arthroplasty. Intraoperative photograph (A) demonstrates a Paprosky type IIIA
acetabular defect treated by using Trabecular Metal revision shell and superior buttress augment with multiple
pelvic screws (B), followed by ilioischial cage placement on top of the construct. C, The polyethylene liner is
cemented within, unitizing the construct. D, Postoperative AP left hip radiograph shows cup-cage construct.
acetabular augments.41 Distraction can also be combined America, fully porous-coated stem implants have long
with the cup-cage technique to further enhance stability been the gold standard for femoral revision. In cases of
and initial fixation, with good survivorship in chronic larger defects (such as Paprosky type IV), in which stems
pelvic discontinuity cases.42 cannot achieve fixation, proximal femoral replacement
Longer-term follow-up of the results of cup-cage re- with metal and bone has been the treatment of choice.
construction, as well as study of the various adjunctive In recent years, the use of modular tapered stems to
measures used, including augment, distraction, and half- treat all types of femoral deficiency has increased. These
cup cage, would be of interest. However, available data techniques, as well as impaction grafting (which is much
suggest that the cup-cage technique provides a useful more common in parts of Europe), are described in the
tool for selective application in revision hip arthroplas- following paragraphs.
ty; it also appears to offer reliable alternatives for major
3: Hip
acetabular defects with pelvic discontinuity, in which Fully Porous-Coated Stems in Revision THA
case stable fixation cannot be obtained using standard Historically, fully porous-coated cylindrical stems have
porous hemispherical acetabular components with mul- demonstrated excellent midterm and long-term clinical
tiple screws. results in revision THA. Mechanical failure rates of
less than 5% have been reported at a mean follow-up
The Femur of 14 years.43,44 Long-term fixation is dependent on rig-
With the aging population and the increasing number id initial stability of the femoral component. Fully po-
of hip implants, revision rates are on the rise. In North rous-coated stems bypass the deficient proximal bone
Section 3: Hip
and gain fixation in the relatively intact isthmus. Ini-

tial stability of these stems requires a scratch fit over
a minimum of 5 cm of intact isthmus. Therefore, ful-
ly porous-coated stems are indicated in revision THAs
with mild or moderate femoral defects, such as Paprosky
type II or IIIA defects42,45,46 (Figure 1). Clinical scenarios
in which fully porous-coated stems have higher failure
rates include femoral bone defects with less than 4 cm
of intact diaphysis, and canal diameters greater than
19 mm.43-45,47 Clinical failure rates of 18% have been
reported for fully porous-coated stems in type IIIB de-
fects and canal diameters greater than 19 mm; this rate
increases to 37.5% for type IV defects.44
Despite the long-term success of fully porous-coated
stems, there are concerns. The surgical technique relies
on a 0.5-mm underream of the femur to achieve a tight Figure 2 AP radiographs of the right femur with loose
fit in the isthmus. In cases of damaged bone, the margin cemented femoral component and type
IIIA bone deficiency. A, Preoperative view.
for error between a tight fit and an intraoperative femoral B, Postoperative view shows an extensively
fracture is small. In addition, longer straight stems are at porous-coated stem for type IIIA bone loss.
risk for anterior femoral perforation. An extended tro-
chanteric osteotomy may be required for accurate access
down the canal for femoral preparation. Two studies monoblock) tapered fluted titanium stems in the revision
have reported intraoperative fracture rates of 13% and setting. These clinical findings were objectively measured
15% and occurrence of anterior perforations of 4% and in a recent biomechanical study comparing the initial
10%.48,49 fixation stability of fully porous-coated stems to tapered
There are long-term concerns regarding stress shielding fluted stems in a model of femoral bone deficiency. The
and implant fracture. With diaphyseal fixation, a well- average loads required to produce 150 μm of axial mo-
fixed stem transfers load through the distal portion of the tion, as well as macroscopic subsidence (greater than
stem directly to the distal femur, resulting in proximal 4 mm), were significantly higher for the tapered fluted
bone resorption, or stress shielding. This process typi- stem than for the fully porous-coated stem with a short
cally occurs within the first 2 years after surgery, then fixation segment.52 With longer fixation segments (6 or
stabilizes.50 In a series of 208 fully porous-coated implants 9 cm), there was no difference in the average load required
reviewed at a mean of 13.9 years, the rate of stress shield- to produce subsidence between the two stem types.
ing was 23%.50 Risk factors for radiographically evident Current indications for a fully porous-coated cylindri-
stress shielding included female sex, type C bone, and cal stem include patients with type II or IIIA bone loss
large stem diameter.50 Moreover, because the stems are (Figure 2) and patients who are young, active, and have
fixed distally, they are subject to cantilever bending, and a high body mass index, who may not be ideally suited
the potential exists for implant fracture. Stem fractures for a modular stem.
are rare and tend to occur in smaller implant sizes (less
than 13.5-mm diameter). Tapered Fluted Titanium Stems
A recent review of 925 fully porous-coated stems in Anthony Albers, MD, FRCSC
revision THA with mean follow-up of 10 years demon- Tapered fluted titanium stems of both modular and mono-
strated 97% survivorship free of aseptic loosening or block designs are increasingly used in all revision settings,
stem fracture.51 The stem fracture rate was 1.1%, and even when the proximal femoral bone stock is deficient, of
3: Hip
9 of 10 stem fractures occurred with stem diameters of poor quality, or both. Their tapered geometry is designed
13.5 mm or less. Patient age, sex, reason for revision, to provide axial stability and the flutes/splines allow for
stem diameter, and stem length were not associated with rotational stability. Tapered fluted titanium stems are
risk of re-revision. typically used in Paprosky type II, IIIA, and IIIB femo-
The inability of fully porous-coated cylindrical stems ral defects. Although they are also used to reconstruct
to gain reliable fixation in the more severe Paprosky type Paprosky type IV defects, achieving adequate femoral
IIIB and IV femoral defects, along with the other con- fixation can be difficult. In cases in which adequate axial
cerns outlined, has resulted in greater use of modular (or and rotational stability cannot be achieved with tapered
stems, reconstruction may require a proximal femoral re- to independently size the metaphyseal segment for op-
placement or use of more demanding techniques, such as timal leg length, femoral offset, version, and soft-tissue
impaction grafting or an allograft-prosthetic composite. tension. This intraoperative customization has resulted
Although many different tapered fluted stems are now in decreased rates of stem subsidence and is thought to
available for use, no prospective studies comparing dif- contribute to the reconstitution of proximal femoral bone
ferent designs are present in the literature to recommend stock by allowing better contact between the proximal
the use of one over another. femoral bone and stem body. Several authors have re-
Compared to extensively porous-coated cylindrical ported favorable clinical and radiologic outcomes at mid-
monoblock stems, tapered fluted titanium stems are more term follow-up for various pathologies requiring complex
versatile and more reliable in patients with advanced fem- revision THA.56-58 Although the advantage of modularity
oral defects.44 Tapered fluted stems, especially the modu- seems to help with distal implant fit and minimization of
lar type, allow the surgeon to readily re-create anatomic subsidence, a high rate of dislocations and periprosthetic
leg length, femoral offset, and version, which can result fractures was noted, as seen in most studies evaluating
in better functional outcomes. A 2010 study comparing similarly complex revisions. A 2015 study evaluating the
a tapered fluted modular stem to a fully porous-coated use of a tapered fluted modular femoral stem in patients
monolithic cylindrical stem showed improved functional with marked proximal femoral bone loss showed a dislo-
outcomes and increased patient satisfaction in the for- cation rate of 19% and an intraoperative fracture rate of
mer, despite more significant preoperative femoral de- 12%, but only 7% showed subsidence greater than 5 mm.
fects.53 When severe femoral bone loss leaves the proximal One of 92 stems had subsidence greater than 1 cm and
stem unsupported, tapered fluted titanium designs have required revision for aseptic loosening.59
the advantage of minimizing stress shielding and decreas- The modular tapered fluted design has also shown
ing the risk of implant fatigue failure seen with extensively superior results to modular cylindrical femoral stems.
porous-coated cylindrical stems.43 A 2013 study comparing these two designs in Paprosky
Several studies have demonstrated successful diaphy- type IIIB/IV femoral defects showed clinically significant
seal osteointegration and good long-term survivorship us- superiority of the tapered fluted modular stem in recurrent
ing monoblock tapered fluted titanium stems for revision femoral component loosening, re-revision surgery, and
THA. A 2014 literature review of medium- to long-term stem-related failures, despite more severe femoral defects
results of the Wagner self-locking stem (Zimmer), a nonin the tapered fluted group.60 This portends the tapered
modular tapered fluted titanium stem, showed excellent design’s gaining better stability within a shorter segment
survivorship (at least 92% to 15.8 years), high rates of of bone (less than 4 cm), which likely favors osseointegra-
implant stability (83.5% to 97.0% osteointegration and tion in compromised diaphyseal bone. Similar findings
8% to 15% fibrous stability), good clinical and func- have also been confirmed in cadaver and biomechanical
tional results, and even regeneration of proximal femo- studies in which identical axial and torsional loads result-
ral bone stock in cases without major proximal femoral ed in significantly less axial and rotational displacement
deficits.54 Although long-term survival and osseointe- with tapered fluted stems.61 Few biomechanical studies
gration have not been a problem with these stems, leg have looked at the effect of different tapered fluted designs
length inequality, periprosthetic fracture, and subsidence on implant stability. A 2015 biomechanical study showed
have been quite common, resulting from the difficulty of that increasing the taper angle and broadening spline
seating the tapered cone in the correct station without geometry exhibited significantly greater axial stability,
fracturing the femur. A 2011 study examining 10- to 15- but had little effect on initial torsional stability.62
year follow-up of the Wagner self-locking stem showed Despite the cited benefits of implant modularity, con-
subsidence greater than 10 mm in 20% of cases. This is cern exists regarding long-term implant survivorship of
thought to be due to achieving three-point fixation as the modular stems because of reports of fracture at the mod-
mode of initial fixation. In the majority of these cases, ular stem/body junction. Furthermore, although there
3: Hip
however, subsidence was limited to the first 12 months are no published data, the theoretical risk of corrosion
postoperatively, and although subsidence was quite com- and adverse local tissue reaction arising from the taper
mon, few stems required revision.55 junction is concerning. Failure at the modular junction
Modularity between the distal diaphyseal fitting por- seems to be related to smaller-dimension stems (less than
tion and the proximal stem body facilitates stem inser- 19 mm), which are unsupported in patients with deficient
tion and increases the implant’s versatility in the revision proximal bone stock, after an extended trochanteric oste-
setting. Specifically, the advantage of modularity is the otomy, in patients with higher body mass index, and in
ability to achieve optimal diaphyseal fixation and then those with first-generation taper designs.63 A 2013 study
Section 3: Hip
assessing 5- to 10-year follow-up of the Zimmer modular least two cortical diameters. The threaded femoral plug
revision hip system showed an 18.5% fracture rate. In should also be templated, and it usually lies at least 2 cm
light of this unacceptably high failure rate, the modular distal to the tip of the stem to permit adequate distal
junction of this particular stem has been modified.64 De- graft filling. Multiple allograft fresh-frozen femoral heads
spite much stronger newer generation modular stem should be ordered from a bone bank; other necessary
junctions, implant failures have been described. For this equipment includes a bone mill and additional reconstruc-
reason, certain high-volume centers have gone back to the tion implants, including metallic mesh, cerclage cables,
nonmodular tapered fluted design in hopes of avoiding and femoral plates.
stem fractures.65 Detailed preoperative planning, careful Following adequate exposure of the proximal femur,
intraoperative trials, and experience with nonmodular removal of the previous femoral component, and removal
stems are requirements for avoiding the aforementioned of intramedullary cement or membrane, the threaded
complications of monoblock stems. Gaining this experi- femoral plug can be placed, and the bone graft can be
ence requires a higher volume of revision cases; thus, for inserted. Appropriate graft preparation has been shown
the surgeon with a lower volume of cases, modular stems to be critical to the success of femoral impaction grafting.
may still be the best and most forgiving option. Although optimal size remains contentious, the presence
of allograft bone chips greater than 4.5 mm in diameter
Impaction Grafting have been found to provide improved stability within in
Impaction grafting involves using milled allograft bone vitro models,70,71 and having some heterogeneity in chip
to reconstitute a deficient medullary canal. Cement is size provides higher shear resistance across the entire graft
then inserted within the reconstituted canal followed by structure.72 Bone chips should be washed to remove fat
a collarless double-tapered polished stem. This technique particles, reduce lubrication, increase frictional resistance,
permits femoral bone stock restoration resulting from and improve graft interdigitation.73
incorporation and remodeling of the impacted graft by Several instrument sets have been designed for impac-
the host skeleton. Although technically demanding, re- tion grafting. A collarless polished taper stem impaction
finement in technique and the development of specialized system (CPT, Zimmer), which uses cannulated instru-
instruments have improved the consistency of impaction ments and modular femoral tamps, permits easy, reli-
grafting results, with favorable outcomes in independent able impaction of diaphyseal and then metaphyseal graft
clinical centers worldwide.66,67 material. Graft material is introduced and compacted
Femoral impaction grafting is indicated for Paprosky distally with cylindrical packers, followed by additional
type IIIC and IV femoral defects in which the replenish- diaphyseal and metadiaphyseal graft impaction using
ment of bone stock is preferred, but insufficient intact femoral tamps that are oversized relative to the actual
diaphysis is available for noncemented interference (Fig- prosthesis; this permits a 2-mm cement mantle. Modular
ure 3). Furthermore, impaction grafting should be con- proximal tamps are then used to re-create the metaphyseal
sidered when medullary canal diameters exceed 18 mm, a canal without affecting what has been produced distally.
limit that is associated with a higher risk of postoperative The final result is a reconstructed, tapered femoral canal
thigh pain with noncemented fixation.68 The need for an (Figure 3).
extended trochanteric osteotomy for implant removal When encountering cortical bone loss, a reconstruction
does not preclude the use of impaction grafting, with one technique involving use of metallic mesh can be used
study finding no difference in midterm results when an (Figure 3). The size of mesh required to cover the cortical
extended trochanteric osteotomy was performed.69 Al- defect is first determined using a flexible template, and
though no absolute contraindications exist, femoral im- then the mesh itself is cut with scissors. For a distal cor-
paction grafting is not ideal in elderly or medically unfit tical defect, the mesh is applied and secured with several
patients, in which cases recovery of bone stock is either cables before impaction grafting. For a proximal defect,
not required or biologically infeasible. Furthermore, distal grafting is completed first, followed by mesh ap-
3: Hip
whereas small cortical defects can be managed through plication around the proximal tamp, taking care to leave
careful placement of steel mesh, cortical defects larger sufficient space for the graft and cement mantle.
than 10 cm may preclude the use of impaction grafting. Long-term results of femoral impaction grafting have
Detailed preoperative planning is necessary, including been satisfactory. A prospective cohort study of 208 cases
high-quality radiographs from which stem length, size, implanted with a cemented polished Exeter (Stryker) stem
and offset can be templated. Cortical defects involving reported a 10-year femoral component survival rate of
more than 50% of femoral circumference on two radio- 94.9%.74 An additional retrospective study of 37 patients
graphic views must be bypassed by the prosthesis by at with a preoperative Endo-Klinik score of 3 or 475 found
Figure 3 Intraoperative photographs of a revision total hip arthroplasty. A, A capacious femoral canal with 5 cm proximal
posterior tenuous cortical defect. B, Following distal bone grafting, steel mesh is applied and secured with
cables. A Cobb elevator is used to preserve space for the graft and cement mantle. C, Proximal bone grafting
is performed, reconstituting the femoral canal. D, Cement and the double-tapered, polished femoral stem are
inserted.
that at 9-year follow-up, 96.3% of femoral components Allograft-Prosthetic Composite and Proximal
did not require subsequent revision.76 Both series reported Femoral Replacement
intraoperative fracture rates of 15.9% and 5.7%, respec- Femoral reconstruction with an allograft-prosthetic com-
tively, a complication that has been reported in 5% to 12% posite has been in use since the 1980s.77 The technique
of patients in most studies. This finding reinforces the im- of allograft-prosthetic composite reconstruction uses a
3: Hip
portance of regularly assessing cortical integrity during the long-stem prosthesis that spans the host-allograft bone
grafting procedure. Another series of 41 patients followed junction. A femoral prosthesis is placed distally with-
up for 19 years reported a femoral component survival rate in the medullary canal of the host femur, whereas the
for any reason of 93%, and the rate of aseptic loosening proximal portion of the stem is positioned and cemented
was 98%.67 Given these findings, femoral impaction bone within a proximal femur allograft. The allograft provides
grafting has a high survival rate in long-term follow-up initial stability by acting as a strut graft and enhances
and continues to be an attractive option in challenging future bone stock. The potential for enhanced future bone
femoral revisions in which there is severe bone loss. stock may simplify future additional revision surgery
Section 3: Hip
and provides an attachment surface for soft tissue and reconstruction is much easier and faster and allows for
bone. Current understanding of the allograft-prosthetic reduced surgical time and blood loss.80
composite is that the allograft femur provides an organic The failure modes of proximal femoral replacement in-
scaffold for the prosthesis. Bone ingrowth occurs at the clude instability (because of poor soft-tissue and trochan-
host-allograft bone junction and at the greater trochanter teric attachment), aseptic loosening, severe stress shielding
junction. Initial stability is achieved with a step-cut or with adaptive bone remodeling, infection, difficulty with
oblique osteotomy and can be augmented with a cortical revision due to destruction of soft tissues and limited re-
strut and/or plate. This initial stability is crucial for union. maining host bone, and mechanical failure. The incidence
A recent meta-analysis identified 16 studies with a of mechanical failure decreased significantly in polyaxial
minimum 2 years’ follow-up.78 A total of 498 patients endoprostheses compared to uniaxial endoprostheses.81
were included in the analysis, with a mean follow-up of One study reported 52 patients with megaprosthe-
8.1 years. The pooled success rate was 81%; pooled struc- ses after tumor resection, with a median follow-up of
tural failure rate, 15%; and pooled infection rate, 8%. 146 months.82 Kaplan-Meier survivorship was reported
Another study reported 21 cases of failed allograft- to be 86% at 10 years. A 5- to 10-year megaprosthesis
prosthetic composite that underwent revision with a new survivorship of 58% to 84% was reported.82 A retrospec-
allograft-prosthetic composite, with a mean follow-up of tive review of 403 proximal femoral arthroplasties (en-
96 months (24 to 168 months).78 The authors reported doprosthetic reconstructions) from five institutions after
Kaplan-Meier overall survival at 10 years of 83.5% (95% tumor resection reported a 10- and 15-year survival rate
CI, 79-100). The ability to revise an allograft-prosthetic of 75%, with mechanical causes being the most common
composite adds strength to the decision to initially choose mode of failure.81
the allograft-prosthetic composite as the surgical solu- A recent systematic review of 356 proximal femoral
tion in a situation in which bone loss is significant. In replacements for nonneoplastic conditions reported a
young and active patients with proximal femoral bone reoperation rate of 23.8% and dislocation rate of 15.7%
loss, allograft-prosthetic composite should be consid- at a mean follow-up of 3.8 years.82 When the studies
ered a preferred option, whereas it is contraindicated in were compared, based on reports published before and
elderly patients with multiple comorbidities for whom after the year 2000, the dislocation rate decreased from
immediate mobilization and weight-bearing is necessary 23.3% to 13.3%, aseptic loosening decreased from 6.6%
and infection is present.79 to 1.1%, and no component fractures were reported in the
Several studies have outlined encouraging long-term publications after the year 2000. The overall component
results following the use of an allograft-prosthetic com- retention rate in the review was 83%.
posite for femoral reconstruction. The evidence supports Proximal femoral bone loss continues to be a chal-
the use of allograft-prosthetic composites when the tech- lenging condition for the arthroplasty surgeon, which is
nique is performed by trained and experienced surgeons compounded by the fact that most patients have already
in institutions with the facilities to support such complex had multiple hip operations, have severe abductor muscle
surgery. With the advent of modular femoral components, loss and possible acetabular bone stock deficiency, and
the use of allograft-prosthetic composites has decreased, are commonly elderly persons with preexisting comorbid-
but it is a viable option for the young patient or when ities. Allograft-prosthetic composites and proximal fem-
bone loss extends well into the diaphysis. oral replacements are useful options in severe proximal
The use of a proximal femoral replacement for non- femoral deficiencies. Postoperative instability remains a
neoplastic indications, such as periprosthetic femoral concern and can be treated by using a dual mobility cup
fractures, massive proximal femoral bone loss, and asep- or a constrained liner.
tic loosening, was extended after the success of mega-
prostheses in neoplastic surgery.80 A proximal femoral
replacement has the advantages of no host bone inter- Summary
3: Hip
face allograft healing; no problems of graft fracture, Revision THA can be categorized into a series of steps.
resorption, or disease transmission; relative ease of re- Adequate exposure and safe implant removal are crit-
construction; and no adverse effects from chemothera- ical to success. Once these are accomplished, several
py or irradiation to the implant. The ideal patient for techniques are available for reconstruction of both the
proximal femoral replacement is an elderly person with acetabulum and femur. On the acetabular side, hemi-
a sedentary lifestyle. A sufficient amount of bone must spherical cups with screws can be used to treat at least
be present distally to allow for secure noncemented or 90% of cases. In patients with larger segmental defects,
cemented fixation of the megaprosthesis. This form of midterm results of augments used to enhance cup stability
have been excellent. Results into the second decade will Annotated References
be viewed with great interest to determine whether aug-
ments are as durable as or better than allografts, which
1. Whaley AL, Berry DJ, Harmsen WS: Extra-large unce-
were previously used, but for the most part have been mented hemispherical acetabular components for revi-
replaced by augments. Pelvic dissociation continues to be sion total hip arthroplasty. J Bone Joint Surg Am 2001;
a challenge, but early results of the cup-cage technique 83-A(9):1352-1357. Medline
are encouraging for this indication.
Tapered fluted modular stems have become the ac- 2. Lachiewicz PF, Soileau ES: Fixation, survival, and dislo-
cation of jumbo acetabular components in revision hip
cepted technique for femoral reconstruction. Other tech- arthroplasty. J Bone Joint Surg Am 2013;95(6):543-548.
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grafting, can still be used with high rates of success. In The authors of this study reported shell survival of 97% at
bigger defects (Paprosky types IIIB and IV), tapered stems 10 years and 83% at 15 years in a group of 129 acetabular
have become invaluable. Over the next decade, the role of revisions with jumbo cups. Dislocation occurred in 9.3%
nonmodular tapered titanium stems will become clearer. of hips. Level of evidence: IV.
Although these stems can be used in most cases in which
3. Nwankwo CD, Ries MD: Do jumbo cups cause hip
a modular stem had been used, for the low-volume sur- center elevation in revision THA? A radiographic eval-
geon, modular stems will be technically easier. However, uation. Clin Orthop Relat Res 2014;472(9):2793-2798.
for surgeons who are comfortable performing femoral Medline DOI
revisions, nonmodular tapered titanium stems will likely The authors of this study reported a radiographic review
become more common in the next decade. As midterm to only of 98 patients with a unilateral jumbo cup implanted
long-term results of the newer techniques become avail- for revision and a contralateral normal hip or anatomically
placed THA. The jumbo cup showed a mean hip center
able, the gold standard in acetabular and femoral revision elevation of 11 mm. Level of evidence: III.
will continue to evolve.
4. Jones CP, Lachiewicz PF: Factors influencing the lon-
ger-term survival of uncemented acetabular components
Key Study Points used in total hip revisions. J Bone Joint Surg Am 2004;
86-A(2):342-347. Medline
• Hemispherical cups with screws can be used to treat
at least 90% of cases. 5. Meldrum R, Johansen RL: Safe screw placement in acetab-
• In cases with larger segmental defects, midterm ular revision surgery. J Arthroplasty 2001;16(8):953-960.
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6. Sheth NP, Nelson CL, Springer BD, Fehring TK, Paprosky
• The cup-cage reconstruction involves placement of WG: Acetabular bone loss in revision total hip arthroplas-
a spanning ilioischial cage on top of a highly porous ty: Evaluation and management. J Am Acad Orthop Surg
metal revision acetabular component. The construct 2013;21(3):128-139. Medline DOI
provides acute stabilization of major acetabular de- The authors of this study reviewed the classification sys-
fects or pelvic discontinuity to potentially allow for tems for acetabular bone loss in revision arthroplasty as
well as a variety of treatment options based on bone loss
long-term healing and biologic fixation. patterns, including hemispherical noncemented compo-
• Early to midterm clinical results of cup-cage con- nents, augments, cages, and cup-cage constructs. Level
structs are encouraging, with low rates of asep- of evidence: V.
tic loosening and excellent long-term implant
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revision shells for management of contained acetabular
• Tapered fluted modular stems have become the ac- bone defects at a mean follow-up of six years: A com-
cepted technique for femoral reconstruction. parison between up to 50% bleeding host bone contact
3: Hip
and more than 50% contact. J Bone Joint Surg Br 2012;

• Other techniques, such as fully porous-coated stems
94(2):158-162. Medline DOI
and impaction grafting, can still be used with high
rates of success. The authors of this study reported a rate of mechanical
failure of 7.5% (4 of 53) of TM revision shells in hips with
• Allograft-prosthetic composites and proximal femo- less than 50% acetabular bleeding host-bone contact and
ral replacements are useful options in cases of severe no failures reported in 49 hips with greater than 50% con-
proximal femoral deficiencies. tact at a mean follow-up of 6 years. Level of evidence: III.
Section 3: Hip
8. Lakstein D, Backstein D, Safir O, Kosashvili Y, Gross The authors of this study reported a dislocation rate of
AE: Trabecular Metal cups for acetabular defects with 0.8% (2 of 258) after primary arthroplasty with a 36-
50% or less host bone contact. Clin Orthop Relat Res mm head and a rate of 4.4% (12 of 275) with a 28-mm
2009;467(9):2318-2324. Medline DOI head at 1-year follow-up (P = 0.012). A dislocation rate
of 4.9% (2 of 41) was noted after revision with a 36-mm
9. Jafari SM, Bender B, Coyle C, Parvizi J, Sharkey PF, head, and a rate of 12.2% (5 of 41) with a 28-mm head
Hozack WJ: Do tantalum and titanium cups show simi- at 1-year follow-up; with the small revision sample size,
lar results in revision hip arthroplasty? Clin Orthop Relat this was not significant (P = 0.273). Level of evidence: I.
Res 2010;468(2):459-465. Medline DOI
16. Kurtz S, Ong K, Lau E, Mowat F, Halpern M: Projections
The authors of this study reported mechanical failure of of primary and revision hip and knee arthroplasty in the
24% of titanium cups and 12% of tantalum cups in hips United States from 2005 to 2030. J Bone Joint Surg Am
with major bone deficiency. Level of evidence: III. 2007;89(4):780-785. Medline DOI
10. Lachiewicz PF, Soileau ES: Tantalum components in 17. Paprosky WG, Perona PG, Lawrence JM: Acetabular de-
difficult acetabular revisions. Clin Orthop Relat Res fect classification and surgical reconstruction in revision
2010;468(2):454-458. Medline DOI arthroplasty. A 6-year follow-up evaluation. J Arthroplas-
The authors of this study reported 97% well-fixed tan- ty 1994;9(1):33-44. Medline DOI
talum components in 39 acetabular revisions with se-
vere bone loss at a mean follow-up of 3.3 years. Level of 18. Beckmann NA, Weiss S, Klotz MC, Gondan M, Jaeger
evidence: IV. S, Bitsch RG: Loosening after acetabular revision: Com-
parison of trabecular metal and reinforcement rings. A
11. Gustke KA, Levering MF, Miranda MA: Use of jumbo systematic review. J Arthroplasty 2014;29(1):229-235.
cups for revision of acetabulae with large bony defects. Medline DOI
J Arthroplasty 2014;29(1):199-203. Medline DOI This literature review compared revision rings (1,541 cases;
The authors of this study reported on 196 jumbo cups mean follow-up, 5.7 years) and TM implants (1,959 cases;
with a minimum follow-up of 2 years, with 96% survival mean follow-up, 3.7 years) for acetabular revision and
at 16 years; 3 revisions were required for loosening, and found that TM shows significantly decreased loosening
7 for recurrent dislocation. Level of evidence: IV. rates relative to revision rings. Level of evidence: III.
12. von Roth P, Abdel MP, Harmsen WS, Berry DJ: Unce- 19. Garcia-Cimbrelo E, Cruz-Pardos A, Garcia-Rey E, Or-
mented jumbo cups for revision total hip arthroplasty: tega-Chamarro J: The survival and fate of acetabular
A concise follow-up, at a mean of twenty years, of a pre- reconstruction with impaction grafting for large de-
vious report. J Bone Joint Surg Am 2015;97(4):284-287. fects. Clin Orthop Relat Res 2010;468(12):3304-3313.
Medline DOI Medline DOI
The authors of this study reported 85% survival, defined This study retrospectively reviewed 165 patients (181 hips)
as aseptic loosening or radiographic loosening, at 20 years. who underwent re-revision for major bone loss. Using the
Level of evidence: IV. Paprosky classification, 98 hips had grade IIIA defects
and 83 had grade IIIB defects. Minimum follow-up until
13. Kelley SS, Lachiewicz PF, Hickman JM, Paterno SM: re-revision or the latest evaluation was 0.3 years (mean,
Relationship of femoral head and acetabular size to 7.5 years; range, 0.3 to 17.7 years). The survival rate for
the prevalence of dislocation. Clin Orthop Relat Res revision at 8 years was 84% (95% CI, 61-100) for grade
1998;355:163-170. Medline DOI IIIA defects and 82% (95% CI, 68-100) for grade 3B de-
fects. Re-revision was required in 12 hips; grafts showed
bone resorption in 17 hips. Acetabular cup position was
14. Garbuz DS, Masri BA, Duncan CP, et al: The Frank anatomically restored in both grades IIIA and IIIB.
Stinchfield Award: Dislocation in revision THA: do large
heads (36 and 40 mm) result in reduced dislocation rates
in a randomized clinical trial? Clin Orthop Relat Res 20. Perka C, Ludwig R: Reconstruction of segmental de-
2012;470(2):351-356. Medline DOI fects during revision procedures of the acetabulum with
the Burch-Schneider anti-protrusio cage. J Arthroplasty
The authors of this study reported a dislocation rate of 2001;16(5):568-574. Medline DOI
1.1% with a 36- or 40-mm femoral head compared to
3: Hip
8.7% with a 32-mm head. Level of evidence: I. 21. Ng TP, Chiu KY: Acetabular revision without cement.
15. Howie DW, Holubowycz OT, Middleton R; Large Ar-
ticulation Study Group: Large femoral heads decrease 22. Park DK, Della Valle CJ, Quigley L, Moric M, Rosenberg
the incidence of dislocation after total hip arthroplas- AG, Galante JO: Revision of the acetabular component
ty: A randomized controlled trial. J Bone Joint Surg Am without cement. A concise follow-up, at twenty to twen-
2012;94(12):1095-1102. Medline DOI ty-four years, of a previous report. J Bone Joint Surg Am
2009;91(2):350-355. Medline DOI
23. Dearborn JT, Harris WH: Acetabular revision arthroplasty loosening as the end point and 97.7% (95% CI: ± 8.8)
using so-called jumbo cementless components: An average with radiographic evidence of loosening as the end point.
7-year follow-up study. J Arthroplasty 2000;15(1):8-15. Level of evidence: IV.
Medline DOI
31. Abolghasemian M, Tangsataporn S, Sternheim A, Back-
24. Chen WM, Engh CA Jr, Hopper RH Jr, McAuley JP, stein D, Safir O, Gross AE: Combined trabecular met-
Engh CA: Acetabular revision with use of a bilobed com- al acetabular shell and augment for acetabular revision
ponent inserted without cement in patients who have ac- with substantial bone loss: A mid-term review. Bone Joint
etabular bone-stock deficiency. J Bone Joint Surg Am J 2013;95-B(2):166-172. Medline DOI
2000;82(2):197-206. Medline
This midterm review of 34 patients after revision with TM
acetabular shell and augment (mean follow-up, 64 months)
25. Blumenfeld TJ, Bargar WL: Surgical technique: A cup-in- reported three cases of aseptic loosening. Two of these
cup technique to restore offset in severe protrusio acetab- were in cases of pelvic discontinuity, and survival for
ular defects. Clin Orthop Relat Res 2012;470:435-441. aseptic loosening of the construct was 91% at 5 years.
Medline DOI Using this construct alone for pelvic discontinuity is not
Short-term results are described for a novel technique of recommended. Level of evidence: IV.
reconstructing protrusion acetabular defects using a po-
rous tantalum hemispherical shell. Level of evidence: IV. 32. Skyttä ET, Eskelinen A, Paavolainen PO, Remes VM:
Early results of 827 trabecular metal revision shells in
26. Bobyn JD, Stackpool GJ, Hacking SA, Tanzer M, Kry- acetabular revision. J Arthroplasty 2011;26(3):342-345.
gier JJ: Characteristics of bone ingrowth and interface Medline DOI
mechanics of a new porous tantalum biomaterial. J Bone The survival of 827 acetabular revisions with TM revision
Joint Surg Br 1999;81(5):907-914. Medline DOI shell using data from a nationwide arthroplasty register
was evaluated. Mean patient age was 69.1 years. Overall
27. Kosashvili Y, Backstein D, Safir O, Lakstein D, Gross AE: survivorship at 3 years was 92% (95% CI: 88-95). Level
Acetabular revision using an anti-protrusion (ilio-ischial) of evidence: IV.
cage and trabecular metal acetabular component for severe
acetabular bone loss associated with pelvic discontinuity. 33. Berry DJ, Lewallen DG, Hanssen AD, Cabanela ME: Pel-
J Bone Joint Surg Br 2009;91(7):870-876. Medline DOI vic discontinuity in revision total hip arthroplasty. J Bone
Joint Surg Am 1999;81(12):1692-1702. Medline
28. Grappiolo G, Loppini M, Longo UG, Traverso F, Mazziot-
ta G, Denaro V: Trabecular Metal augments for the 34. Zehntner MK, Ganz R: Midterm results (5.5-10 years) of
management of Paprosky type III defects without pel- acetabular allograft reconstruction with the acetabular re-
vic discontinuity. J Arthroplasty 2015;30(6):1024-1029. inforcement ring during total hip revision. J Arthroplasty
The outcomes of acetabular reconstruction in 55 hips
with TM-coated cup and TM augments were reviewed at 35. Goodman S, Saastamoinen H, Shasha N, Gross A:
an average follow up of 53.7 months (36 to 91 months). Complications of ilioischial reconstruction rings in re-
Survival rate at 2 and 5 years was 96.4% and 92.8%, vision total hip arthroplasty. J Arthroplasty 2004;19(4):
respectively. Level of evidence: IV. 436-446. Medline DOI
29. Whitehouse MR, Masri BA, Duncan CP, Garbuz DS: 36. Regis D, Sandri A, Bonetti I, Bortolami O, Bartolozzi P: A
Continued good results with modular trabecular metal minimum of 10-year follow-up of the Burch-Schneider cage
augments for acetabular defects in hip arthroplasty at 7 to and bulk allografts for the revision of pelvic discontinuity.
11 years. Clin Orthop Relat Res 2015;473(2):521-527. J Arthroplasty 2012;27(6):1057-63.e1. Medline DOI
Medline DOI
The outcomes are reported for 18 hips with pelvic discon-
This study reported results of 56 THAs (53 revision and tinuity treated with bulk allografts and a Burch-Schneider
3 primary) using TM augments in combination with a TM antiprotrusio cage, with a minimum 10-year follow-up.
acetabular component. Survivorship of the augments at Cumulative survival rate from any acetabular revision
10 years was 92% (95% CI, 81-97). Level of evidence: IV. was 72%.
30. Trumm BN, Callaghan JJ, Liu SS, Goetz DD, Johnston 37. Hanssen AD, Lewallen DG: Acetabular cages: A ladder
3: Hip
RC: Revision with cementless acetabular components: across a melting pond. Orthopedics 2004;27(8):830-832,
A concise follow-up, at a minimum of twenty years, of 832. Medline
previous reports. J Bone Joint Surg Am 2012;94(21):
2001-2004. Medline DOI 38. Abolghasemian M, Tangsaraporn S, Drexler M, et al: The
This study reports 61 consecutive revision THAs per- challenge of pelvic discontinuity: Cup-cage reconstruction
formed in 55 patients using a noncemented acetabular does better than conventional cages in mid-term. Bone
component and screw-augmented fixation. At minimum Joint J 2014;96-B(2):195-200. Medline DOI
20-year follow-up, survival was 100% with aseptic
Section 3: Hip
This retrospective review was performed comparing the 47. Egan KJ, Di Cesare PE: Intraoperative complications of re-
use of conventional ilioischial cage reconstruction versus vision hip arthroplasty using a fully porous-coated straight
cup-cage technique for pelvic discontinuity. The 7-year cobalt-chrome femoral stem. J Arthroplasty 1995;10(sup-
survivorship was 50% for the conventional cage and 87% pl):S45-S51. Medline DOI
for the cup-cage construct.
48. Lachiewicz PF, Soileau ES: What is the survivorship of
39. Amenabar T, Rahman WA, Hetaimish BM, Kuzyk PR, fully coated femoral components in revision hip arthro-
Safir OA, Gross AE: Promising mid-term results with a plasty? Clin Orthop Relat Res 2015;473(2):549-554.
cup-cage construct for large acetabular defects and pel- Medline DOI
vic discontinuity. Clin Orthop Relat Res 2016;474(2):
408-414. Medline DOI The authors of this study reported a 96% 10-year survi-
vorship for 104 monoblock fully porous-coated femoral
The results of 67 hip revision procedures using a cup-cage stems. Radiographic loosening was present in 10%, and
construct (61% pelvic discontinuity cases), with an average 6 were revised. There was a significant incidence of intra-
follow-up of 74 months, were reviewed. Six total fail- operative complications, with 17% sustaining fractures or
ures (four for aseptic loosening) were reported; however, perforations, and 14% requiring cables and struts. Level
outcome scores improved significantly, and the 10-year of evidence: IV.
survival rate was estimated to be 85%.
49. Russell RD, Pierce W, Huo MH: Tapered vs cylindri-
40. Ballester Alfaro JJ, Sueiro Fernández J: Trabecular Metal cal stem fixation in a model of femoral bone deficien-
buttress augment and the Trabecular Metal cup-cage con- cy in revision total hip arthroplasty. J Arthroplasty
struct in revision hip arthroplasty for severe acetabular 2016;31(6):1352-1355. Medline DOI
bone loss and pelvic discontinuity. Hip Int 2010;20(sup-
pl 7):S119-S127. Medline DOI This study compared the mechanical resistance to subsi-
dence between tapered fluted stems and cylindrical fully
This review of five patients with pelvic discontinuity un- porous-coated stems in a model of severe bone loss. Using
dergoing cup-cage reconstruction with a porous shell, progressively shorter bone segments of 9, 6, and 3 cm,
modular buttress augment, and antiprotrusio cage demon- axial loads to both subsidence (1.5 mm) and failure (4 mm)
strated no early failures for aseptic loosening. were tested. The tapered stems provided better initial fix-
ation stability in the shortest segments (3 cm), and there
41. Sporer SM, Bottros JJ, Hulst JB, Kancherla VK, Moric M, were no differences between the stem designs with the
Paprosky WG: Acetabular distraction: An alternative for 6- and 9-cm segments.
severe defects with chronic pelvic discontinuity? Clin Or-
thop Relat Res 2012;470(11):3156-3163. Medline DOI 50. Sporer SM, Paprosky WG: Extensively coated cementless
femoral components in revision total hip arthoplasty: An
In a review of acetabular distraction with porous tantalum update. Surg Technol Int 2005;14:265-274. Medline
components in 20 patients, which is an alternative tech-
nique for severe acetabular defects and chronic pelvic dis-
continuity, only 1 required revision for aseptic loosening. 51. Sculco PK, Haight H, Howard J, Abdel M, Berry DJ: [Pa-
per] Long term outcomes of 925 extensively porous-coated
stems in revision total hip arthroplasty. American Associ-
42. Nadaud MC, Griffin WL, Fehring TK, et al: Cementless ation of Hip and Knee Surgeons. Nov 5-8, 2015, Dallas,
revision total hip arthroplasty without allograft in severe TX.
proximal femoral defects. J Arthroplasty 2005;20(6):
738-744. Medline DOI The authors examined long-term outcomes in a large se-
ries of 925 fully porous-coated cylindrical stems. A 97%
43. Weeden SH, Paprosky WG: Minimal 11-year follow-up survivorship was found at 15 years, and there was a 4%
of extensively porous-coated stems in femoral revision rate of femoral revision for any reason. The incidence
total hip arthroplasty. J Arthroplasty 2002;17(4suppl 1): of intraoperative femoral fractures was 15%. Level of
134-137. Medline DOI evidence: IV.
44. Sporer SM, Paprosky WG: Revision total hip arthroplasty: 52. Thomsen PB, Jensen NJ, Kampmann J, Bæk Hansen
The limits of fully coated stems. Clin Orthop Relat Res T: Revision hip arthroplasty with an extensively po-
2003;417:203-209. Medline rous-coated stem: Excellent long-term results also in se-
vere femoral bone stock loss. Hip Int 2013;23(4):352-358.
Medline DOI
3: Hip
45. McAuley JP, Engh CA Jr: Femoral fixation in the face

of considerable bone loss: Cylindrical and extensive- This small series of fully porous-coated femoral stems with
ly coated femoral components. Clin Orthop Relat Res 10- to 18-year follow-up reported a survivorship of 94%
2004;429:215-221. Medline DOI at 18 years. A high rate (25%) of intraoperative shaft frac-
tures and perforations was noted. Level of evidence: IV.
46. Aribindi R, Barba M, Solomon MI, Arp P, Paprosky W:
Bypass fixation. Orthop Clin North Am 1998;29(2): 53. Richards CJ, Duncan CP, Masri BA, Garbuz DS: Femo-
319-329. Medline DOI ral revision hip arthroplasty: A comparison of two stem
designs. Clin Orthop Relat Res 2010;468(2):491-496.
DOI Medline
In a retrospective review of patients who underwent re- In a retrospective review of 57 patients who underwent
vision THA with either a nonmodular cobalt chrome or a two-stage reimplantation for infection using a tapered
a tapered fluted modular femoral stem, the tapered fluted fluted modular femoral stem at a mean follow-up of
cohort had higher outcomes scores, fewer intraoperative 62 months, stem survivorship was 87% at 5 years, and
fractures, and better restoration of the proximal femoral only two stems required revision for aseptic loosening.
host bone, despite worse preoperative bone loss. Level of Level of evidence: IV.
evidence IV.
59. Amanatullah DF, Howard JL, Siman H, Trousdale RT,
54. Konan S, Garbuz DS, Masri BA, Duncan CP: Non- Mabry TM, Berry DJ: Revision total hip arthroplasty in
modular tapered fluted titanium stems in hip revision sur- patients with extensive proximal femoral bone loss using
gery: Gaining attention. Bone Joint J 2014;96-B(11Suppl a fluted tapered modular femoral component. Bone Joint
A):56-59. Medline DOI J 2015;97-B(3):312-317. DOI Medline
A literature review of the Wagner self-locking stem shows In this retrospective review of 92 revision THAs using a ta-
excellent survivorship (greater than 92%, 15.8 years or pered fluted modular femoral stem for various pathologies,
younger), high rates of implant stability (83.5% to 97% including aseptic loosening, infection, and periprosthetic
osseointegration and 8% to 15% stable fibrous ingrowth), fracture, stem survivorship was 97% at a mean follow-up
good clinical and functional results, and regeneration of of 6.4 years. Complications were frequent, including dis-
proximal femoral bone stock. location (19%), intraoperative fracture (12%), and stress
shielding (22%). Level of evidence: IV.
55. Regis D, Sandri A, Bonetti I, Braggion M, Bartolozzi
P: Femoral revision with the Wagner tapered stem: A 60. Revision Total Hip Arthroplasty Study Group: A com-
ten- to 15-year follow-up study. J Bone Joint Surg Br parison of modular tapered versus modular cylindrical
2011;93(10):1320-1326. Medline DOI stems for complex femoral revisions. J Arthroplasty
2013;28(8suppl):71-73. DOI Medline
A retrospective study of use of the Wagner self-locking
stem in revision THA showed cumulative survival of 92% In a multicenter review of 105 femoral revisions in patients
at 15.8 years. Major complications included dislocation with Paprosky type III/IV femoral defects using modular
(4 of 41) and subsidence greater than 10 mm (8 of 41). titanium stems, either tapered fluted or cylindrical, with an
Level of evidence: IV. average follow-up of 5 years, the tapered component group
had fewer osseointegration failures (1.6% versus 15.9%)
56. Munro JT, Garbuz DS, Masri BA, Duncan CP: Tapered and fewer re-revisions (4.9% versus 22.7%), despite hav-
fluted titanium stems in the management of Vancouver ing had more severe femoral defects. Level of evidence: IV.
B2 and B3 periprosthetic femoral fractures. Clin Orthop
Relat Res 2014;472(2):590-598. DOI Medline 61. Kirk KL, Potter BK, Lehman RA Jr, Xenos JS: Effect of
distal stem geometry on interface motion in uncemented
In a retrospective review of 55 type B2 or B3 periprosthetic revision total hip prostheses. Am J Orthop (Belle Mead
femoral fractures treated with a tapered fluted titanium NJ) 2007;36(10):545-549. Medline
stem, two stems required revision (one for loosening and
subsidence greater than 10 mm and one for infection).
Maintenance or improvement of bone stock was seen in 62. Pierson JL, Small SR, Rodriguez JA, Kang MN, Glassman
89% of cases, and subsidence was noted in 24% of cases, AH: The effect of taper angle and spline geometry on the
but only two patients had subsidence greater than 10 mm. initial stability of tapered, splined modular titanium stems.
Level of evidence IV. J Arthroplasty 2015;30(7):1254-1259. DOI Medline
In a biomechanical study evaluating the effects of taper
57. Rodriguez JA, Deshmukh AJ, Robinson J, et al: Repro- angle and spline width on the stability of tapered fluted
ducible fixation with a tapered, fluted, modular, titanium modular titanium stems, it was found that increased tape
stem in revision hip arthroplasty at 8-15 years follow-up. angle and broader spline geometry improved axial stability
J Arthroplasty 2014;29(9suppl):214-218. DOI Medline but had minimal effect on torsional stability.
In this retrospective study, 71 hips received a tapered fluted
modular titanium stem for revision THA, and 79% had 63. Lakstein D, Eliaz N, Levi O, et al: Fracture of cement-
Paprosky type 3A or worse femoral defects. All stems were less femoral stems at the mid-stem junction in modular
osseointegrated distally; two hips subsided greater than revision hip arthroplasty systems. J Bone Joint Surg Am
5 mm, 68% of hips had evidence of bony reconstitution, 2011;93(1):57-65. DOI Medline
and 21% demonstrated diaphyseal stress shielding. Level
3: Hip
In a retrospective analysis of six patients who sustained a
of evidence: IV. stem fracture at the modular junction after revision THA
with a tapered fluted modular stem, it was found that those
58. Houdek MT, Perry KI, Wyles CC, Berry DJ, Sierra RJ, with fractured stems had a significantly higher body mass
Trousdale RT: Use of a modular tapered fluted femoral index, lacked osseous support for the proximal stem body,
component in revision total hip arthroplasty following and had smaller-sized implants. Level of evidence: IV.
resection of a previously infected total hip: Minimum
5-year follow-up. J Arthroplasty 2015;30(3):435-438.
DOI Medline
Section 3: Hip
64. Van Houwelingen AP, Duncan CP, Masri BA, Greida- 70. Eldridge JD, Smith EJ, Hubble MJ, Whitehouse SL, Lear-
nus NV, Garbuz DS: High survival of modular tapered month ID: Massive early subsidence following femoral
stems for proximal femoral bone defects at 5 to 10 years impaction grafting. J Arthroplasty 1997;12(5):535-540.
followup. Clin Orthop Relat Res 2013;471(2):454-462. Medline DOI
DOI Medline
In a retrospective review of 65 patients who received a 71. Wallace I, Ammon P, Day R, et al: Does size mat-
tapered fluted modular femoral stem for revision THA, ter? An investigation into the effects of particle size
with a mean follow-up of 84 months, stem survivorship on impaction grafting in vitro. J Bone Joint Surg Br
was found to be 95% at 5 years. One particular stem 1997;79B(suppl 3):366.
design, the ZMR stem by Zimmer had an 18.5% frac-
ture rate (5 of 27) at the modular junction. The modular 72. Brewster NT, Gillespie WJ, Howie CR, Madabhushi
junction of this stem design has since been reinforced. SP, Usmani AS, Fairbairn DR: Mechanical consider-
Level of evidence: IV. ations in impaction bone grafting. J Bone Joint Surg Br
1999;81(1):118-124. Medline DOI
65. Sandiford NA, Duncan CP, Garbuz DS, Masri BA: Ta-
pered, fluted titanium stems in revision total hip arthro- 73. Höstner J, Hultmark P, Kärrholm J, Malchau H, Tveit M:
plasty: Role and results in contemporary practice. Instr Impaction technique and graft treatment in revisions of the
Course Lect 2015;64:359-366. Medline femoral component: Laboratory studies and clinical vali-
dation. J Arthroplasty 2001;16(1):76-82. Medline DOI
This instructional course lecture emphasizes the role and
results of tapered fluted titanium stems in revision THA. 74. te Stroet MA, Rijnen WH, Gardeniers JW, van Kampen A,
Schreurs BW: The outcome of femoral component revision
66. Gehrke T, Gebauer M, Kendoff D: Femoral stem impac- arthroplasty with impaction allograft bone grafting and a
tion grafting: Extending the role of cement. Bone Joint cemented polished Exeter stem: A prospective cohort study
J 2013;95-B(11Suppl A):92-94. Medline DOI of 208 revision arthroplasties with a mean follow-up of ten
The role of cancellous bone impaction grafting in revision years. Bone Joint J 2015;97-B(6):771-779. Medline DOI
hip arthroplasty is reviewed, including the indications and This report summarizes data from 130 patients with a
the evolution of the technique over the past 2 decades. mean follow-up of 10.6 years (range, 4.7 to 20.0 years).
Emphasis on bone restoration using allograft bone chips Kaplan-Meier survival with femoral re-revision as the end
to create a neoendosteum, into which a taper stem is ce- point was 99.4%. The results suggest that impaction graft-
mented, is well described. Level of evidence: V. ing revision is durable at a mean follow-up of 10 years.
67. Garvin KL, Konigsberg BS, Ommen ND, Lyden ER: What
is the long-term survival of impaction allografting of the 75. Gie GA, Linder L, Ling RS, Simon JP, Slooff TJ, Timperley
femur? Clin Orthop Relat Res 2013;471(12):3901-3911. AJ: Impacted cancellous allografts and cement for revision
Medline DOI total hip arthroplasty. J Bone Joint Surg Br 1993;75(1):14-
A follow-up report of initial experience with impaction 21. Medline
grafting in revision hip arthroplasty, at a mean follow-up
of 10.6 years, showed 98% survivorship for loosening. 76. Te Stroet MA, Bronsema E, Rijnen WH, Gardeniers JW,
Failure could not be correlated with bone loss severity or Schreurs BW: The use of a long stem cemented femoral
use of longer stems. Level of evidence: IV. component in revision total hip replacement: A follow-up
study of five to 16 years. Bone Joint J 2014;96-B(9):
68. Blake SM, Gie GA, Howell JR: Impaction grafting of the 1207-1213. Medline DOI
femur, in Cui B, Mihalko S, eds: Arthritis and Arthro- This study examines the results of impaction grafting
plasty: The Hip. Philadelphia, PA, Saunders, 2009. revision using longer stem cemented femoral components
(205 mm or larger). In 70% of the cases, preoperative bone
69. García-Rey E, Cruz-Pardos A, Madero R: The evolution loss (Endo-Klinik score of 3 or 4) was present, and 22 pa-
of the technique of impaction bone grafting in femoral tients were available for follow-up at a mean of 9 years.
revision surgery has improved clinical outcome: A prospec- There were five intraoperative periprosthetic fractures
tive mid-term study. J Arthroplasty 2015;30(1):95-100. and two postoperative periprosthetic fractures, both
Medline DOI treated with plate fixation. Survival for femoral all-cause
re-revision was 96%. Impaction grafting in the setting of
3: Hip
Two cohorts of patients undergoing impaction grafting extensive femoral defects in an older population appears
revision were compared: group I (short stems) and group to yield satisfactory results. Level of evidence: IV.
II (long stems). Group II patients had better clinical scores,
reduced risk of periprosthetic fractures and lower rates of
subsidence. These data support the use of longer stems in 77. Head WC, Berklacich FM, Malinin TI, Emerson RH Jr:
impaction grafting. Level of evidence: IV. Proximal femoral allografts in revision total hip arthro-
plasty. Clin Orthop Relat Res 1987;225:22-36. Medline
78. Sternheim A, Drexler M, Kuzyk PR, Safir OA, Backstein were matched by age-decade to a control group of patients
DJ, Gross AE: Treatment of failed allograft prosthesis undergoing conventional revision THA.
composites used for hip arthroplasty in the setting of
severe proximal femoral bone defects. J Arthroplasty 81. Henderson ER, Groundland JS, Pala E, et al: Failure mode
2014;29(5):1058-1062. Medline DOI classification for tumor endoprostheses: Retrospective
This study assessed failures of allograft-prosthesis com- review of five institutions and a literature review. J Bone
posites and revisions with a new allograft-prosthesis com- Joint Surg Am 2011;93(5):418-429. Medline DOI
posite in 21 patients. The 5- and 10 year-survival rates In this study, notes were reviewed from 2,174 skeletally
were 83.5% These results suggest that failed allograft mature patients from five institutions who received a large
prosthesis composites may be revised to a new allograft endoprosthesis for tumor resection: 534 failures were iden-
prosthesis composite with a predictable outcome. Level tified with five modes of failure, with infection being the
of evidence: IV, therapeutic study. most common mode. Mode of failure and time to failure
also show a significant dependence. Level of evidence: IV
79. Maury AC, Pressman A, Cayen B, Zalzal P, Backstein D, (case series).
Gross A: Proximal femoral allograft treatment of Vancou-
ver type-B3 periprosthetic femoral fractures after total hip 82. Farid Y, Lin PP, Lewis VO, Yasko AW: Endoprosthetic
arthroplasty. J Bone Joint Surg Am 2006;88(5):953-958. and allograft-prosthetic composite reconstruction of the
Medline DOI proximal femur for bone neoplasms. Clin Orthop Relat
Res 2006;442:223-229. Medline DOI
80. Al-Taki MM, Masri BA, Duncan CP, Garbuz DS: Quality
of life following proximal femoral replacement using a A systematic literature review was performed to determine
modular system in revision THA. Clin Orthop Relat Res the failure rates, mortality rates, and outcome scores when
2011;469(2):470-475. Medline DOI proximal femoral allografts were used in nonneoplastic
conditions. In 14 studies with an average follow-up of
A retrospective review of 63 patients undergoing com- 3.8 years, reoperation for any reason occurred in 23.8% of
plex revision THA using a modular replacement system cases. The most common complications were dislocation
for nonneoplastic conditions is described. Study patients (15.7%) and infection (7.6%).
3: Hip
Chapter 35
Complications of Total
Hip Arthroplasty
Michael M. Kheir, MD Javad Parvizi, MD, FRCS Andrew N. Fleischman, MD Anthony Albers, MDCM, FRCSC
Clive P. Duncan, MD, MSc, FRCSC Bassam A. Masri, MD, FRCSC Derek Ward, MD Keith R. Berend, MD
Matthew S. Austin, MD Peter K. Sculco, MD Thomas K. Fehring, MD David M. Beck, MD
James J. Purtill, MD Jeffrey R. Engorn, DO Carlos J. Lavernia, MD
Abstract Periprosthetic Joint Infection

Total hip arthroplasty (THA) is one of the most success- Michael M. Kheir, MD; Andrew N. Fleischman, MD;
ful surgical procedures developed in the past century. Javad Parvizi, MD, FRCS
The number of revision THAs has risen along with the Although progress has occurred in infection prevention
increased demand for THAs, and this has occurred at after THA, periprosthetic joint infection (PJI) remains one
a time of greater national attention to readmission and of the most feared complications. Despite all efforts, in-
complication rates to demonstrate accountability in fection occurs in 0.3% to 2.2% of cases of primary THA
health care and to reduce costs. Because complications and in 1.35% to 7.84% of cases of revision THA.1 The
seriously affect patient outcomes, and public reporting number of patients treated for an infected THA nearly
of complication rates is often used as a proxy for quality doubled from 2001 to 2011.2 After instability and me-
of care, it is vital to examine complications to prevent chanical loosening, PJI is the third most common reason
their occurrence. for revision THA (14.8% of all revisions)3 and is the most
common reason for failure after a revision THA.4
Recent evidence demonstrates that patients with PJI
Keywords: complications after THA; periprosthetic have a mortality rate of 25.9% at 5 years, which is fourfold
joint infection; periprosthetic fracture; instability; higher than a matched group of patients undergoing revi-
leg-length discrepancy; heterotopic ossification; sion arthroplasty for a reason other than infection.5 The
neurovascular injury 5-year survivorship of patients with PJI is worse than that
for patients treated for breast cancer, melanoma, Hodgkin
lymphoma, and testicular cancer.5 Furthermore, the need
for multiple surgical procedures and resultant morbidity
often necessitates prolonged hospitalization.
Introduction
Although an uncommon occurrence, serious complica- Definition and Diagnosis

tions after total hip arthroplasty (THA) can delay or PJI is not just an infection of the prosthetic interface, but
hinder complete functional recovery. Even though major also an infection of the surrounding bone and soft tissues.
medical complications, such as myocardial infarction or Accurate and efficient diagnosis of PJI is a true clinical
3: Hip
pulmonary embolism, can occur and should be on the sur- challenge. For all patients with a painful hip prosthesis,
geon’s radar, they are less frequent and are often related even those without obvious clinical signs of infection (eg,
to the patient’s comorbidities, medications, allergies, and erythema or swelling), infection needs to be ruled out.
so on. It is important to be knowledgeable about poten- Until recently, no universally adopted “gold standard”
tial surgical complications, including periprosthetic joint definition existed for PJI. According to criteria developed
infection, periprosthetic fractures, instability, limb-length by the Musculoskeletal Infection Society and later mod-
discrepancy, heterotopic ossification, and neurovascular ified by the International Consensus Meeting (ICM) on
injuries. PJI, a definite PJI exists when one of two major criteria
Section 3: Hip
are met,6 or when three of five minor criteria are met sedimentation rate (ESR) and C-reactive protein (CRP).
(Table 1). In patients with abnormal serology or a strong suspicion
The major criteria are pathognomonic for PJI, whereas of PJI, joint aspiration is performed. The fluid sample
minor criteria are traditional hematologic or synovial fluid is sent for white blood cell (WBC) count, percentage of
diagnostic tests. It is important to note that PJI may exist polymorphonuclear leukocytes (PMN%), and culture.
clinically even if these criteria are not met, especially with The ESR and CRP are highly sensitive biomarkers of in-
less virulent organisms, such as Propionibacterium acnes. fection, but they have relatively poor specificity and can be
An algorithmic approach to diagnosing PJI is presented influenced by other systemic infectious or noninfectious
in Figure 1. The diagnosis of PJI begins with a medical his- inflammatory processes.8 Simultaneous elevation of ESR
tory and physical examination and obtaining appropriate and CRP is more accurate for predicting PJI than is the
radiographs. Timing of onset, location, and character of isolated elevation of either marker independently.9 Syno-
pain should be noted as well as any history of fever, chills, vial WBC and PMN% are well-established and accurate
or wound drainage. The hip joint should be examined predictors of PJI, but they can occasionally be elevated in
for drainage, erythema, or swelling. Plain radiographs an aseptic joint.9 In contrast, serum WBC and differential
should be taken and compared to prior radiographs, in- cell count have been shown to be poor indicators of PJI
cluding the initial postoperative radiographs. Infection and are not included in the diagnostic algorithm.10
may manifest as periosteal elevation, subchondral bony Histologic analysis of periprosthetic tissue has some
resorption, progressive radiolucency, or localized osteol- utility in the diagnosis of PJI; a meta-analysis demon-
ysis. However, 30% to 50% of bone loss is necessary for strated that intraoperative frozen sections are helpful
radiographic visualization, and the sensitivity for identi- in the diagnosis of culture-positive PJI, but had only
fying osteomyelitis is low. Typically, findings lag behind moderate accuracy as a rule-out test.11 Thus, frozen
the clinical onset of disease by at least 1 to 2 weeks.7 section is especially valuable if suspicion for infection
First-line laboratory screening is performed using remains high even after a negative preoperative evalu-
serum inflammatory markers, including erythrocyte ation. The optimum diagnostic threshold, the number
Dr. Parvizi or an immediate family member serves as a paid consultant to Smith & Nephew and Zimmer; has stock or
stock options held in CD Diagnostics, Hip Innovation Technology, and PRN; has received research or institutional support
from 3M, Cempra, CeramTec, DePuy, National Institutes of Health (National Institute of Arthritis and Musculoskeletal
and Skin Diseases and National Institute of Child Health and Human Development), the Orthopaedic Research and Ed-
ucation Foundation, Smith & Nephew, StelKast, Stryker, and Zimmer; and serves as a board member, owner, officer, or
committee member of the Eastern Orthopaedic Association and the Muller Foundation. Dr. Duncan or an immediate
family member is a member of a speakers’ bureau or has made paid presentations on behalf of Zimmer. Dr. Masri or an
immediate family member has received research or institutional support from DePuy and serves as a board member,
owner, officer, or committee member of the Canadian Orthopaedic Association. Dr. Berend or an immediate family
member has received royalties from Zimmer Biomet; serves as a paid consultant to Zimmer Biomet; has stock or stock
options held in SPR Therapeutics; has received research or institutional support from OrthoSensor, Pacira, SPR Thera-
peutics, and Zimmer Biomet; and serves as a board member, owner, officer, or committee member of the AAOS Board
of Specialty Societies (Knee Education Representative), the American Association of Hip and Knee Surgeons, and the
Knee Society. Dr. Austin or an immediate family member has received royalties from Zimmer; serves as a paid consul-
tant to Link Orthopaedics and Zimmer; and serves as a board member, owner, officer, or committee member of the
American Association of Hip and Knee Surgeons and the American Academy of Orthopaedic Surgeons. Dr. Fehring or
an immediate family member has received royalties from DePuy; is a member of a speakers’ bureau or has made paid
3: Hip
presentations on behalf of DePuy; serves as a paid consultant to DePuy; has received research or institutional support
from DePuy; and serves as a board member, owner, officer, or committee member of the American Association of Hip
and Knee Surgeons and the Knee Society. Dr. Purtill or an immediate family member serves as a board member, owner,
officer, or committee member of the OMeGA Medical Grants Association. Dr. Lavernia or an immediate family member
has received royalties from MAKO Surgical/Stryker; serves as a paid consultant to Biomet and Zimmer; and has stock
or stock options held in Johnson & Johnson, Stryker, Symmetry Medical (Tecomet), Wright Medical Technology, and
Zimmer. None of the following authors or any immediate family member has received anything of value from or has
stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this
chapter: Dr. Kheir, Dr. Fleischman, Dr. Albers, Dr. Ward, Dr. Sculco, Dr. Beck, and Dr. Engorn.
Chapter 35: Complications of Total Hip Arthroplasty
Table 1 Intraoperative cultures may be negative in up to 23% of

infections.14 Attempts need to be made to optimize the
Criteria for Defining PJI yield of traditional cultures; aspiration should be per-
Major criteria (presence of 1 definitive for PJI) formed before the administration of antibiotics or after
antibiotics have been withheld for 14 days.10 It is further
2 positive periprosthetic cultures with phenotypically
identical organisms or recommended that incubation of bacteriologic cultures
continue for 10 to 14 days to allow time for the emergence
Sinus tract that communicates with the joint
of slow-growing organisms or small colony variants.
Minor criteria (presence of 3 to 5 definitive for
P acnes and Peptostreptococcus species may be detected
PJI)
on routine culture plates only after incubation between
Elevated serum CRP and ESR
10 and 12 days.15 With regard to culture specimen, tissue
Acute PJI (<90 d): CRP, 100 mg/L; ESR, No cultures were shown to be positive in a higher percentage
threshold
of septic cases than were swab cultures (93% versus 70%,
Chronic PJI (>90 d): CRP, 10 mg/L; ESR, respectively); they also demonstrated a lower false-positive
30 m/h
rate in aseptic cases (2% versus 12%, respectively). Tissue
Elevated SF WBC count or 2+ change on LE test cultures should be given priority for diagnosis of PJI.16
strip
Leukocyte esterase is an enzyme secreted by activated
Acute PJI (<90 d): SF WBC, 10,000 cells/µL; neutrophils that have been recruited to areas of infection,
LE, 1+ or 2+
and its presence can be used as a proxy for infection in
Chronic PJI (>90 d): SF WBC 3000 cells/µL; the form of a colorimetric dipstick test for synovial flu-
LE, 1+ or 2+
id.17 This diagnostic method continues to gain acceptance
Elevated synovial fluid PMN% and has now been incorporated into the diagnostic criteria
Acute PJI (<90 d): 90% for PJI. The leukocyte esterase test may have a valuable
Chronic PJI (>90 d): 80% role in the point-of-care diagnosis of PJI, as early results
Positive histological analysis of periprosthetic have yielded a sensitivity and specificity of 80.6% and
tissue 100%, respectively.17 Although as many as one-third of
Acute PJI (<90 d): >5 PMN/5 HPFs (x400) synovial aspirates may be blood-tinged, which can in-
Chronic PJI (>90 d): >5 PMN/5 HPFs (x400)
terfere with colorimetric readings, most samples can be
effectively read after undergoing centrifugation for 2 to
Single positive culture
3 minutes.18 Human α-defensin, another new promising
Acute PJI (<90 d): Positive biomarker for infection, is an antimicrobial peptide that
Chronic PJI (>90 d): Positive is generated from neutrophils in response to pathogens.
CRP = C-reactive protein, ESR = erythrocyte sedimentation rate, Testing synovial fluid for α-defensin demonstrated a sensi-
HPF = high-power field, PJI = periprosthetic joint infection, SF PMN% tivity of 100% and specificity of 95% for the diagnosis of
= percentage of synovial polymorphonuclear leukocytes,
WBC = white blood cells.
PJI, and it has been shown to respond to a wide spectrum
Adapted with permission from Zmistowski B, Della Valle C, Bauer of organisms without being affected by prior antibiotic
TW, et al: Diagnosis of periprosthetic joint infection. J Orthop Res administration.19,20
2014;32(suppl S1):S98-S107.
Serum biomarkers (eg, interleukin ([IL]-6 and pro-
calcitonin) remain controversial. A recent meta-analysis
demonstrated a higher diagnostic accuracy for IL-6 in
of polymorphonuclear leukocytes per high-power field comparison to ESR, CRP, and even WBC count.8 An-
(PMN/HPF) could not be discerned; however, the current other study identified both IL-6 and IL-1b as potential
definition of PJI uses a threshold of 5 PMN/HPF. biomarkers for monitoring resolution of infection before
Intra-articular purulence, once considered a minor reimplantation, as these markers showed the greatest
3: Hip
criterion, is no longer part of the diagnostic criteria. decline during the interval between stages.21
Although it has a strong association with WBC count, Novel culture-independent methods, such as multiplex
purulence alone is not a reliable indicator of PJI.12 Gram polymerase chain reaction (PCR) and mass spectrometry,
stain has also been found to be of limited value, with have been used for identification of infecting organisms
sensitivities less than 23%.13 and antibiotic-resistant genes. The molecular diagnostic
Identifying an organism is critical not only for di- technique PCR is used to identify genetic material of in-
agnosis, but also for indicating the most appropriate fecting pathogens by amplifying a single copy of a piece of
method of treatment and effectiveness of antibiotics. DNA. Multiplex PCR uses a series of primers for a specific
Section 3: Hip
3: Hip
Figure 1 Diagnostic algorithm for periprosthetic joint infection.
panel of organisms. In 23 cases of PJI, PCR-based meth- inadequate, as it is not prognostic of complications.26 Ex-
ods were found to be concordant with culture results and treme obesity, defined as body mass index higher than
further identified one or more suspect organisms in four of 40 kg/m 2 , the presence of malnutrition, and vascular
five culture-negative infections.22 However, an organism insufficiency all need to be addressed. Additionally,
was also identified in 88% of cases for which revision heavy smoking (>25 cigarettes/day), alcohol consump-
arthroplasty was performed for a presumed noninfectious tion (>400 g/wk), and intravenous drug abuse should
etiology.22 It remains unclear how to best approach the be stopped 4 to 6 weeks before surgery.27,28 Systemic or
use of such a highly sensitive diagnostic test. local infections at the surgical site or in a distant organ
Radionuclide scanning tests may be helpful for a spe- should be eradicated. Patients taking immunosuppressive
cific subset of patients, although these tests are costly and drugs, typically disease-modifying antirheumatic drugs
cumbersome. For a previously well-functioning hip pros- used in rheumatoid arthritis, are at an increased risk for
thesis more than 2 years after implantation, a three-phase infection. Although the risks of discontinuation should
bone scan or F-18 fluorodeoxyglucose positron emission be considered, the ICM states that disease-modifying
tomography (FDG-PET) may assist in the diagnosis of antirheumatic drugs should be stopped at an interval of
infection. A negative three-phase bone scan can effectively 3 to 5 half-lives before any elective procedure (eg, metho-
exclude both infection and aseptic loosening. Although trexate should be withheld a full week before surgery and
abnormal uptake around the prosthesis can indicate ei- adalimumab 8 weeks before surgery).29 Finally, decoloni-
ther of these, differentiation may be possible based on zation may be considered for carriers of Staphylococcus,
patterns of uptake; loosening demonstrates focal uptake although routine screening is not recommended in the
around the tip of the prosthesis, whereas more generalized United States due to high rates of recolonization.
uptake is indicative of infection. When performed with In addition to limiting host risk factors, surgeons can
CT, FDG-PET offers more precise anatomic localization use an arsenal of perioperative measures to reduce the
of a lesion, and it has a reported sensitivity greater than risk for infection. The night before admission, all pa-
95% and a specificity of 75% to 99% for diagnosis of tients should perform whole-body skin cleansing with
acute and subacute soft-tissue or bone infection. It is also alcohol-based chlorhexidine gluconate to reduce the risk
particularly useful for diagnosis of chronic or low-grade for surgical site infection.30 Intravenous antibiotics should
infection, with a sensitivity of 100% and a specificity be administered within 1 hour of incision and an adequate
of 88% to 92% in these instances. 23 Another nuclear concentration maintained until after closure. First- or
test, indium 111–labeled leukocyte scanning, may have second-generation cephalosporins are generally effective
diagnostic value in suspicion of acute PJI, with a reported and provide high bioavailability. Alternatively, vanco-
sensitivity and specificity of 80% to 90% for diagnosis mycin should be considered for patients who are known
of osteomyelitis. However, chronic infections, infections carriers of a methicillin-resistant strain of Staphylococ-
of the spine, and previous antibiotic therapy have been cus, patients at high risk for a resistant strain (health-
shown to reduce sensitivity.7 The ICM workgroup did not care workers or those previously institutionalized), and
find clear evidence to support the use of bone scintigraphy patients with a cephalosporin allergy. Dosing is weight-
for diagnosis of PJI due to inconsistent results and a high based, with a repeated dose necessary with a surgical
level of bias in early studies.24 duration greater than the drug half-life or with blood
loss greater than 3 L.
Risk Factors and Prevention In the operating room, maintenance of a relatively
To limit the incidence of PJI, all surgeons should use an particle-free environment (by limiting the number of oper-
evidence-based prevention strategy to minimize host risk ating room personnel and using laminar airflow, as avail-
factors in the preoperative period and use effective peri- able, to limit particulates, for example) has been associated
operative prophylactic measures. with a lower rate of surgical site infection.31,32 The duration
Before any elective arthroplasty procedure, all patients of surgery should be limited without compromising surgi-
3: Hip
should be screened to identify conditions that would pre- cal quality, as the risk for surgical site infection increas-
dispose to an unacceptable risk for PJI, particularly modes by 9% for each 15-minute increment.33 Additionally,
ifiable conditions that can be optimized before THA. the most current methods, including hypotensive anes-
Hyperglycemia, typically found in patients with poorly thesia and tranexamic acid, should be used to minimize
controlled diabetes, impairs bacterial defense mechanisms blood loss, as blood transfusions can impair the immune
and wound healing.25 As such, hemoglobin A1c (HbA1c) response and increase risk for acute infection.34,35 Simi-
level should be maintained at less than 7% with no ac- larly, preexisting anemia may require mitigation before
tive ulcers before THA. However, HbA1c alone may be surgical intervention. Various intraoperative measures,
Section 3: Hip
including the use of dilute povidone-iodine for irrigation determined by numerous factors, including those relating
and antibiotic-laden cement, have been shown to support to the patient host, infecting organism, and treatment
a significant reduction in PJI.36 method, and is thus difficult to predict. Poor functional
Postoperatively, prophylactic antibiotics administration outcomes must sometimes be considered in lieu of risk
for more than 24 hours should be avoided, as there is little for recurrent infection.
evidence of benefit, and such a practice may contribute to
the emergence of antibiotic-resistant bacteria. Application Prosthesis-Retaining Treatment
of an occlusive dressing and venous thromboembolism In certain patients with PJI, suppressive antibiotic ther-
prophylaxis with aspirin reduce the risk of hematoma for- apy (SAT) with prosthesis retention may be the optimal
mation and persistent wound drainage.37 Wound drain- treatment method. Indications for SAT include: (1) in-
age should be treated aggressively with compression or ability to undergo surgical intervention, due to unaccept-
negative pressure, and even incision and drainage when ably high risk or patient refusal; (2) inadequate surgical
persistent, so as to avoid the development of PJI. intervention, such as débridement alone with implant
retention for late chronic PJI; (3) suboptimal previous
Microbiology antibiotic therapy (eg, no rifampin for gram-positive PJI,
Compared with a native joint, a significantly lower inoc- no fluoroquinolone for gram-negative PJI or fungal infec-
ulum of bacteria is necessary to initiate infection in the tions); or (4) suspected failure to eradicate infection.41 It
presence of a foreign body. Bacteria may colonize the is important to ensure that the prosthesis is well fixed,
surface of an implant and form a biofilm, which is an ag- the pathogen is not overtly virulent according to suscep-
gregate of microorganisms embedded in an extracellular tibility studies, and oral antibiotics against the organism
matrix. Bacteria in a biofilm exist in a relatively dormant are readily available. Relative contraindications for SAT
state, making them less likely to be identified in culture include the presence of other well-functioning implants
and poorly susceptible to antibiotics. After biofilm forma- and the presence of an artificial heart valve. Ideally, SAT
tion, infection eradication is generally deemed to require should be administered continuously for the remainder
implant removal. Thus, the treatment method is most of a patient’s life; however, a high rate of adverse reac-
often based on timing and acuity of infectious symptoms. tions with chronic antibiotic use may limit oral antibiotic
Various organisms differ in the number and type of cul- therapy. There is little clinical evidence evaluating the
tures needed for positive identification, and less virulent consequences of stopping SAT and the risk for recurrent
bacteria may require longer periods of growth. Increasing infection or infection dissemination and secondary sepsis.
evidence suggests that PJI may commonly result from Treatment of PJI with open débridement and antibi-
multiple organisms, with only a dominant organism iden- otics with implant retention (DAIR) can be successful
tified in culture. Whereas only 14% of hip infections are for controlling infection. However, growing evidence
overtly polymicrobial, nearly 70% of treatment failures suggests increasingly narrow indications for this treat-
for PJI have demonstrated growth of a different organ- ment method, and certain important variables must be
ism.38,39 Coagulase-negative Staphylococcus species make carefully assessed to establish DAIR as a viable approach.
up nearly 30% of all hip infections. Compared to infec- Classically, aggressive open débridement, irrigation, and
tions of the knee, Staphylococcus aureus is less frequently exchange of the polyethylene liner should only be reserved
the culprit in hip infections (13%), but is more common in for treatment of relatively acute infections in patients
early infections. Streptococcal, enterococcal, anaerobic, with well-fixed components and an adequate soft-tissue
and aerobic gram-negative bacteria each make up less mass. DAIR should be avoided in patients with risk fac-
than 10% of organisms responsible for hip PJI.39 Fungi, tors for persistent or recurrent infection, including those
most commonly Candida, are found in fewer than 1% who are immunocompromised or have poor-quality local
of cases of PJI.40 Culture-negative infections have been tissue.42 Staphylococcal species, especially methicillin-
reported in as many as 23% of all infections, more typi- resistant organisms, may be particularly difficult to erad-
3: Hip
cally those of late onset.14 Without microbiologic evidence icate with DAIR.43
of infection, PJI is diagnosed on the basis of clinical and Successful treatment with DAIR hinges on proper tech-
laboratory markers of physiologic response. nique in performing irrigation and débridement. Exten-
sive irrigation and débridement considerably reduces the
Treatment bioburden of the infecting organism, which thereafter
The treatment of PJI remains both challenging and con- can be effectively eliminated by synergistic activity of the
troversial for several reasons. First, a definitive diagnosis patient’s immune system and antibiotics. According to the
may be difficult to obtain. The outcome of treatment is ICM, aggressive débridement should include mechanical
perturbation of all periarticular tissues and component be achieved at the same time as reimplantation. Multiple
surfaces, and all nonbleeding and necrotic osseous and previous one-stage failures and spread of infection into
soft tissues need to be thoroughly extracted.44 The poly- the pelvis and/or neurovascular structures are additional
ethylene liner should be removed and exchanged, as liner contraindications.
retention has been associated with a higher risk for fail- The requisite radical débridement in one-stage ex-
ure.45 In addition, the interfaces of all components should change is homologous to tumor resection and requires
be exposed to allow for inspection for loosening.46 These resection of all osteolytic bony and necrotic soft-tissue
steps cannot be adequately performed with arthroscopic structures. Three to six tissue samples should be sent for
portals, and the highest rate of success is achieved with a full routine infectious workup. All efforts should focus
an open approach. Postoperatively, long-term intrave- on limiting destruction to surrounding bone stock. After
nous antibiotics should be continued for 4 to 6 weeks, removal, dead space may be filled with antibiotic-laden
followed by rifampin for 6 months.41 Administration of cement beads and bony defects augmented with puri-
local antibiotics circumvents compromised vasculature fied antibiotic-laden bone graft or tantalum augments.
and is less likely to cause systemic side effects; methods Extensive lavage of about 10 L should be followed by
include topical powdered antibiotics, antibiotic-laden ce- packing with antiseptic chlorhexidine-soaked swabs into
ment beads, antibiotic-laden calcium sulfate, antibiotic the intramedullary canal and around the surgical wound.
collagen sponges, and intra-articular antibiotic pumps. The wound should be covered, and a second dose of pro-
phylactic antibiotics administered in preparation for re-
Exchange Arthroplasty draping before reimplantation.
In most cases of PJI, especially those that are not clearly Although use of cemented revisions has been custom-
acute in nature (more than 3 weeks) or with loose com- ary to allow for local delivery of antibiotics, the infe-
ponents, exchange arthroplasty with implant removal rior long-term outcomes of cemented fixation are well
and replacement is definitive treatment. Traditionally, known.49 In recent years, noncemented one-stage THA
two-stage exchange has been favored as the optimal revision has been performed with good results.50 In such
treatment method in the United States. However, many cases, antibiotic-laden bone graft can be used to achieve
surgeons have reported excellent outcomes with one-stage the necessary local therapeutic level of antibiotics.51 Af-
exchange, which is performed in up to 85% of orthopae- ter reimplantation, systemic intravenous antibiotics are
dic centers in Europe.47 No single study has demonstrated continued for 10 to14 days postoperatively.52 Early and
a statistically significant advantage for either approach. aggressive mobilization is preferred, and full weight bear-
One-stage exchange arthroplasty is a viable option for ing is possible in most patients with adequate bone stock.
definitive treatment of late infection, especially in patients Unlike one-stage exchange, treatment of the active in-
for whom a single operation would be particularly advan- fection with débridement and local antibiotics is separated
tageous. Proponents of the one-stage approach cite lower in time from definitive prosthesis reimplantation in two-
overall costs, faster mobilization, and reduced hospital- stage exchange. Theoretically, a two-stage exchange relies
ization.48 However, one-stage exchange is not without less heavily on radical débridement, and a recent system-
significant morbidity and must be carefully considered atic review demonstrated slightly better infection control
on the basis of individual clinical scenarios. than with direct exchange, though direct comparisons are
Without a delay before reimplantation during which difficult and have been quite variable.53 In most instances,
the residual infective bioburden can be eradicated, one- the indications for performing two-stage exchange are the
stage exchange relies heavily on the efficient delivery of same as those for direct exchange. However, all patients
local antibiotics at levels above which can typically be at- with specific contraindications for one-stage exchange,
tained systemically. Therefore, a positive bacterial culture including those with systemic manifestations, an uniden-
and antibiotic susceptibility testing is mandatory when tifiable or difficult-to-treat organism, previous one-stage
considering a one-stage approach. One-stage exchange failures, or involvement of pelvic or neurovascular struc-
3: Hip
should not be performed for cases of culture-negative PJI tures should undergo two-stage exchange.53
or for highly resistant organisms for which effective local The first stage of a two-stage exchange has similarities
antibiotics are not available. Further, sepsis is a definitive to that of a direct exchange. An aggressive débridement
contraindication to one-stage exchange, as priority is and synovectomy is performed to remove all infected and
given to timely administration of wide-spectrum antibiot- nonviable tissue surrounding the hip joint. Again, three
ics and prompt implant removal for bioburden reduction. to six tissue samples should be sent for a full routine in-
Patients requiring surgical soft-tissue flap coverage may fectious workup. Although loose implants may be easily
not be eligible for one-stage exchange, as coverage must removed, well-fixed prostheses should be removed with
Section 3: Hip
considerable care to prevent iatrogenic bone loss. After and débridement with exchange of the spacer. In a re-
removal, reamers and curets should be used to débride cent study, more than 11% of patients required an in-
the intramedullary canals. Prior to redraping, the deep terim spacer exchange.57 Further, 23% of patients never
wound and canals should be extensively irrigated and underwent reimplantation; of these, 83% retained the
packed with antiseptic swabs. A second dose of prophy- implanted spacer, 12% underwent a salvage operation,
lactic antibiotics is administered at this time. and several patients died.57 The most common reasons
After extensive preparation, an antibiotic-impregnated for retaining a spacer were surgical contraindication due
cement spacer is placed with the goal of delivering high to general health, patient preference, or severe bone or
therapeutic levels of antibiotic locally while preserving soft-tissue loss. For proper patient selection for two-stage
the joint spaces and reducing soft-tissue contracture. This exchange, risk factors that could preclude execution of a
is a temporizing measure to allow residual bioburden to second-stage operation must be considered.
be eradicated before definitive reimplantation. Although After the infection appears to be well controlled, reim-
the use of a spacer is well accepted, whether a spacer plantation should be attempted. Medical contraindications
should allow for full weight-bearing range of motion may sometimes preclude reimplantation. In these patients,
(dynamic or articulating spacer) or immobilize the hip spacer retention may provide reasonable function, particu-
(static spacer) is unclear, and both strategies have demon- larly with articulating spacers; however, tissue contraction
strated success.54 The most commonly used antibiotics are can progress over time, and reimplantation may be more
gentamicin, tobramycin, and vancomycin; all three are difficult at a later date. Prior to definitive reconstruction,
thermostable and water soluble, and the combination of thorough irrigation and débridement should be performed
one of two aminoglycosides with vancomycin provides to remove residual debris in surrounding tissues. The op-
broad coverage. Fungal infections have been successfully erative area is redraped, and hip joint reconstruction pro-
treated with cement elution of amphotericin B or fluco- ceeds in the typical fashion. Surgeons must select revision
nazole.55 Total antibiotic dose should still not exceed components based on the quality of available bone stock
10% by weight to prevent cement fracture. Antibiotic and surrounding soft tissues. Postoperatively, intravenous
doses from 2.4 g of tobramycin with 1 g of vancomycin antibiotics may be continued for 24 to 72 hours.
per 40-g cement bag up to 4.6 g of tobramycin with 4 g Although there is no clear limit on attempting exchange
of vancomycin have been used with similar success. arthroplasty for recurrent infections, reimplantation may
Postoperatively, patients are usually given toe-touch not be suitable for rare, uncontrollable hip infections. For
weight-bearing precautions and are allowed to ambu- patients who are severely immunocompromised or medi-
late with a walker or crutches. Typically, an antibiotic- cally compromised, in whom empyema has developed, or
impregnated spacer is placed for 8 to 12 weeks to allow who have grossly deficient bone stock and muscle func-
for local and systemic antibiotic treatment to eradicate tion to support a reconstructed joint, the most common
residual infective organisms. Based on antibiotic sensitiv- surgical option is permanent excision arthroplasty, also
ity testing, a regimen of tailored parenteral antibiotics is known as Girdlestone arthroplasty. In this procedure,
continued for 4 to 6 weeks. Most commonly, the decision the femoral head is not replaced, but instead is allowed
to move forward with reimplantation is not made until to heal and develop a pseudarthrosis with its own fibrous
after a 3- to 6-week antibiotic-free (“antibiotic holiday”) scar. Infection control has been achieved in 81% to 96%
monitoring period for resolution of infection. Typically, of patients after excision arthroplasty.58 Although func-
surgeons use improvement in clinical symptoms, such tional outcomes are unpredictable, patients typically can
as pain relief, swelling, and proper wound healing, as ambulate short distances (with or without assistive de-
a proxy for infection control. Inflammatory markers, vices) and have acceptable pain control. Severe abductor
ESR and CRP, also may be useful adjuncts to evaluate weakness and a limb-length discrepancy often hinder a
for persistence of infection. Although no real threshold better functional outcome. Hip disarticulation is a rarely
exists, and values remain elevated in nearly one-fourth performed last resort and is used for uncontrollable and
3: Hip
of patients with adequate infection control, a serial trend life-threatening infection.

can be a helpful predictor of successful eradication.56 Ad-
ditionally, hip aspiration for culture and cell count can be
performed near the end of the antibiotic-free period before Periprosthetic Fractures
reimplantation. Unfortunately, no test exists to reliably Anthony Albers, MDCM, FRCSC; Clive P. Duncan, MD,
rule out the existence of infection before reimplantation. MSc, FRCSC; Bassam A. Masri, MD, FRCSC
If signs of persistent infection are appreciated, the Periprosthetic fractures (PPFs) are a challenging problem
decision should be made to perform a repeat irrigation for surgeons; they can be difficult to manage and have
a 1-year mortality comparable to that of hip fractures. Table 2

Registry data and large retrospective series suggest an
incidence from 0.4% to 4.0%.59-61 The Australian joint Vancouver Classification Fracture
registry reported that PPFs accounted for 10% of revisions Types and Subtypes
in 2014.62 The increasing use of noncemented, press-fit • Type A: Fracture of an apophysis. For the femur, the
implants has seen the rate of intraoperative fractures rise designation AL or AG are used for fractures of the
from virtually nil63 for cemented acetabular components lesser and greater trochanter, respectively.
to around 5% for modern noncemented femoral compo- • Type B: Fracture of the femur around the implant.
nents.64 Although there are many risk factors for PPFs, The fracture thus involves the proximal femur to a
revision arthroplasty shows the highest risk, with reports point just distal to the tip of the femoral stem. Type
B fractures are further subdivided into three types:
of a rate as high as 30%.65
Diagnosis of PPFs should be made promptly and classi- • Type B1: A fracture around a stable implant.
fied appropriately to guide treatment, evaluate prognosis, • Type B2: A fracture around or leading to a loose
and anticipate complications. This is achieved by compre- implant; adequate bone stock is available for
revision.
hensive radiographic evaluation and careful assessment of
fracture morphology, available bone stock, and implant • Type B3: A fracture with a loose implant; severe
bone loss requires a complex reconstruction
stability. or a salvage procedure. (This also applies
when the quality of the bone stock is poor,
Classification such as after high-dose radiation for adjacent
The most widely used classification scheme for peripros- malignant disease.)
thetic femur fractures is the Vancouver classification sys- • Type C: Fracture that is clear of the component. This
fracture would involve the femoral shaft distant
tem (VCS).66 Although the femur is the most commonly
from the femoral stem.
injured bone during or after joint arthroplasty of any
type, recent additions to the VCS have led to a Unified
Classification System allowing for generalizability to any
joint. The Unified Classification System has recently been
endorsed by the AO/Orthopaedic Trauma Association reconstruction plates followed by cup reinsertion and
and has been validated as a simple and common lan- multiple screw fixation.
guage to assist with the evaluation and treatment of such
injuries.67-69 Postoperative Acetabular Fractures
The VCS remains the gold standard for periprosthetic Postoperative periprosthetic acetabular fractures are un-
femoral fractures, as it is simple to remember and provides common. Stable fractures or unstable fractures with good
treatment guidance. The three main fracture types and bone stock can be treated as outlined in the preceding
three subtypes are outlined in Table 2. paragraph. Late postoperative fractures can often present
as pathologic fractures through an area of extensive oste-
Treatment olysis. These unstable fractures with advanced bone loss
Intraoperative Acetabular Fractures are frequently called pelvic discontinuity or dissociation,
Most intraoperative acetabular fractures occur during because the bone stock between the anterior and posterior
insertion of a noncemented component using a press-fit columns is deficient. Because these injuries are typically
technique in which the outer diameter of the cup is larger seen in the context of complex revision acetabular surgery
than the last-used reamer. Fracture morphology and im- and are not acute injuries, they are outside the scope of
plant stability should be assessed via direct observation, this discussion.
and intraoperative radiography can be a useful adjunct.
Treatment principles involve fracture stabilization, pre- Intraoperative Femur Fractures
3: Hip
vention of fracture propagation, and maintenance of im- Intraoperative femur fractures are subclassified on the
plant position to achieve fracture union and long-term basis of configuration: subtype 1 represents a simple cor-
implant fixation.66 tical perforation; subtype 2, a nondisplaced linear frac-
Stable minimally displaced fractures can be treated ture; and subtype 3, a displaced or unstable fracture. It
without additional fixation, although supplemental screw is important to differentiate intraoperative classification
fixation and protected weight bearing should be consid- from postoperative classification, especially for type B
ered. Displaced fractures leading to unstable components fractures. Although the classification nomenclature dif-
will require fracture fixation, most commonly using pelvic fers, treatment principles are similar to those used for
Section 3: Hip
postoperative fractures and will therefore not be described stems can still be used in this setting unless marked seg-
separately. mental bony deficiency exists. In cases in which stable
distal fixation cannot be achieved with a conventional
Postoperative Femur Fractures long stem (especially in elderly, low-demand patients),
Fractures of the greater trochanter (type AG) can arise use of a megaprosthesis with cemented distal fixation is
from a traumatic event or as a pathologic fracture in the warranted.78 Although impaction grafting or allograft
setting of osteolysis, most commonly due to polyethylene prosthetic composites are conceivable options and have
wear. These fractures are usually treated conservatively, had favorable published results in expert hands, the level
with protected weight bearing and limitation of active of expertise required and high-risk profile have limited
abduction until the fracture is clinically and radiograph- their use in contemporary practice.
ically healed (6 to 12 weeks). Surgical indications are still Femur fractures that are distant to the femoral stem
debated, but they include significant fracture displace- (type C) should be treated with reduction and internal
ment (1 to 2 cm), hip instability or nonunion leading to fixation using standard AO Foundation principles. Min-
persistent pain, and abductor weakness. Various fixation imally invasive plate osteosynthesis is used increasingly
methods have been described with good results, including as a biologically friendly technique with good results.
use of wires, cables, and claw-plate fixation. If the fracture Important principles to follow are accurate realignment
occurs in the setting of osteolysis, the underlying cause of the anatomic femoral axis, use of long plates to allow
should be identified and treated appropriately.70 appropriate force transmission away from the fracture,
Avulsion fractures of the lesser trochanter (type A L) spanning the femoral stem over at least 50% of its length,
are uncommon and should be treated symptomatically, and minimizing soft-tissue disruption.79,80
regardless of displacement. A common mistake is to clas-
sify intraoperative fractures of the medial calcar and/or
lesser trochanter as type A L fractures. Femoral fractures Instability After THA
arising from high hoops stresses during broaching or im- Derek Ward, MD; Keith R. Berend, MD;
plant insertion are type B2 fractures by definition and are Matthew S. Austin, MD
best managed with stem or broach extraction, application Dislocation is one of the most common complications in
of a cerclage wire or cable, and reinsertion of a femoral modern hip replacement. Despite the overwhelming suc-
stem that bypasses the most distal extent of the fracture.71 cess of THA, instability remains a challenging problem.
Fractures around a stable femoral stem (type B1) are Reports on the incidence of dislocation vary widely, from
traditionally treated with open anatomic reduction and 0.3% to 10.0% after primary THA and up to 28% after
rigid internal fixation. More recently, minimally inva- revision THA. There are patient-specific and surgery-
sive techniques have been gaining in popularity, with specific risk factors for dislocation, and managing this
reports in the literature of various fixation constructs. problem requires a clear diagnosis and an understanding
The highest success rates and strongest biomechanical of the etiology of instability. Whereas many dislocations
constructs are seen when a combination of screws and can be managed with closed reduction alone, revision for
cables are used proximally, and at least three bicortical recurrent instability may be necessary. Success requires an
screws are inserted distal to the stem.72,73 Use of lock- algorithmic approach as well as appropriate expectations
ing-plate technology is still debated, as is the routine use from both the surgeon and patient.
of strut allografts.74,75 Cortical onlay allografts are most Hip instability after THA is a particularly challenging
beneficial when there is doubt that stable fixation using problem for the adult reconstruction surgeon. Patient-spe-
standard plating techniques would be successful, and they cific risk factors for dislocation include prior hip surgery,
are rarely required. neuromuscular or cognitive disorders, noncompliance,
Fractures around an unstable stem (type B2 or B3), the alcoholism, and THA for femoral neck fracture. Sur-
most commonly encountered types of PPF, require revi- gery-specific risk factors include the surgical approach,
3: Hip
sion to a longer femoral component. When bone quality inadequate soft-tissue balancing, component malposition-
is adequate (type B2) with a minimum of 4 cm of intact ing, impingement (bony and/or implant), smaller head
diaphysis for distal fixation, revision using a long, tapered, size, and surgeon experience. Appropriate management
fluted titanium stem has provided good results.76,77 A cer- of dislocation after THA requires a clear understanding
clage cable just distal to the fracture site should be used of the cause of dislocation, which begins with a detailed
to prevent fracture propagation. history, physical examination, and radiographic evalua-
In fractures with severe bony deficiency (type B3), re- tion. Although most early dislocations can be managed
construction can be challenging. Tapered, fluted titanium with closed reduction, revision surgery may be necessary;
however, it should only be undertaken when the cause of Table 3

the dislocation is apparent and a clear surgical plan has
been developed. Classification System for Instability
Type Etiology
Epidemiology and Financial Effect
I Isolated acetabular malposition
Although hip revision for instability has decreased sig-
II Isolated femoral malposition
nificantly, instability remains a major cause for revi-
sion. A study using the Medicare sample from 1998 to III Abductor deficiency
2007 found that the dislocation rate at 6 months had IV Impingement
decreased from 4.21% to 2.14%, and overall early and V Polyethylene wear
late dislocation rates were 3.92% and 1.15%, respectively. VI Unknown
The authors found a significant decrease in early (less than
2 years) and late (more than 5 years) dislocation rates by
35% (P < 0.001) and 43% (P = 0.01), respectively, from
patients operated on from 2004 to 2007. This appears to loosening, trochanteric osteolysis or stress shielding, a
coincide with the increase in use of larger-diameter femo- new-onset neuromuscular disorder, or muscle atrophy.
ral heads (≥32 mm). Notably, low surgeon volume (fewer Early and intermediate dislocations are more likely to
than 5 THAs per year), medical comorbidities, age older be successfully treated with closed reduction, whereas
than 85 years, and longer procedure duration were inde- late dislocation more often requires surgery.87 One ana-
pendent risk factors for dislocation (P < 0.04).81 A study of tomic classification system categorized instability into six
one large referral center examined 870 consecutive THA types88 (Table 3). Regardless of classification system, the
revisions from 2004 to 2014 and found instability to be primary focus for successful treatment is identifying the
the third most common cause for revision (21.4%), closely specific source of the dislocation and careful planning,
followed by aseptic loosening (31.3%) and osteolysis should revision surgery be undertaken.
(21.8%).82 Additionally, revision for instability continues
to have higher failure rates. One study found the cumula- Patient Risk Factors
tive risk of re-dislocation in 539 patients who had revision Patient-related risk factors, although not always modifi-
for instability to be 34.5% at 15 years.83 This problem has able, are important to identify, as they may contribute to
substantial financial effect. The cost of a closed reduction instability. Sex is a risk factor for dislocation after pri-
was found to be 19% of the cost of primary THA in one mary THA, with a higher incidence in women. However,
study,84 and the overall cost of a single dislocation was sex does not predict success for revision and is therefore
shown to increase the cost of THA by 342% in another unlikely to contribute to a treatment plan.89 A history of
study.85 Recurrent dislocation is exceedingly expensive, prior hip surgery has been found to significantly increase
costing 300% more than a single dislocation accord- the risk for dislocation.90 Alcoholism and cognitive dis-
ing to a study by another group of authors.86 Notably, orders that increase the risk of falls and noncompliance
the authors found that surgical intervention for current with restrictions can also increase the risk. Age may be a
dislocation was significantly less expensive (40%) than risk factor for dislocation, although studies show varying
continued closed treatment. risk, and it is possible that the increased risk is related to
the increased incidence of neuromuscular and cognitive
Pathophysiology of Instability deficits as well as increased prevalence of arthroplasty
It is important to recognize that the cause of instability is related to femoral neck fractures in the elderly.
often multifactorial. Two classifications of instability may It is important to identify anatomic and neuromus-
prove useful: temporal and anatomic. The classification cular patient-related risk factors, as they directly affect
related to timing is grouped as early, intermediate, and treatment decisions. The primary soft-tissue restraints to
3: Hip
late. An early dislocation occurs within the first 6 months, dislocation are the abductor mechanism of the gluteus
an intermediate dislocation occurs between 6 months medius and minimus and the hip capsule (iliofemoral,
and 5 years, and a late dislocation occurs after 5 years. pubofemoral, and ischiofemoral ligaments). A history of
Early and intermediate dislocations have distinct patho- hip dysplasia and femoral or acetabular osteotomies can
logic features and are more likely related to preexisting contribute to muscle imbalance and changes in anatomy
neuromuscular disorders, patient noncompliance, com- that heighten instability. Conditions that result in soft-
ponent malposition, or impingement. Late dislocation is tissue laxity, including rheumatoid arthritis, hypermobil-
more likely related to wear and osteolysis, component ity, and ligamentous laxity, have been shown to increase
Section 3: Hip
the risk of dislocation. Significant weight loss can also approach may give clues to acetabular positioning. Exces-
change soft-tissue tension, leading to dislocation. Addi- sive anteversion of the acetabulum may result in anterior
tionally, conditions that require THA in which the normal instability, perhaps more commonly in an anterior-based
soft-tissue contractures associated with hip osteoarthritis or anterolateral approach. In contrast, underanteverted
are absent (eg, femoral neck fracture, osteonecrosis), are or retroverted acetabular components may risk posterior
also associated with a higher rate of dislocation.91 Neu- dislocation, perhaps more commonly in posterior ap-
romuscular disorders, including cerebral palsy, muscular proaches. Excessive abduction may result in late disloca-
dystrophy, myasthenia gravis, Parkinson disease, multiple tion secondary to increased edge loading and subsequent
sclerosis, and severe spinal stenosis, also increase the risk accelerated wear at the superior edge of the liner.
of dislocation, presumably due to abductor weakness. Evaluation of acetabular component position should
Higher preoperative range of motion has been shown to be done carefully. However, it should also be noted that
be an independent risk factor for instability after primary many dislocations occur with components positioned
THA. within the established “safe zones” (abduction 40° ± 10°,
and anteversion 20° ± 5°). One study of 206 THA dislo-
Surgical Risk Factors cations found that most (58%) had a socket within the
Prior Approach safe zone for both abduction and anteversion, 84% were
Although not modifiable, the surgical approach for pri- within the safe zone for abduction, and 69% were within
mary THA may have an effect on the cause of dislocation. the safe zone for anteversion.94 A safe zone based solely
Surgical approaches that disrupt the posterior soft-tissue on these measurements gives a false sense of security, as
envelope (capsule and external rotators) have a higher risk the true safe zone is different for each patient and likely
of dislocation, although meticulous attention to posterior depends on anatomic relationships that have yet to be
capsular repair has greatly reduced this risk. A published fully quantified (such as spinopelvic parameters).
meta-analysis that included more than 13,000 patients Dislocation is also related to femoral position, and
found a dislocation rate of 3.20% for the posterior ap- combined anteversion helps determine stability. Com-
proach, 2.18% for the anterolateral approach, 1.27% for bined anteversion is determined with the cup and stem
the transtrochanteric approach, and 0.55% for the direct in place. The lower limb is positioned in neutral (or slight
lateral approach.92 More recent studies evaluating posteri- hip flexion) and is internally rotated until the femoral
or and direct lateral approaches indicate that dislocation head is symmetrically seated (coplanar) in the cup. The
rates are not statistically different when the posterior amount of internal rotation in degrees needed to produce
approach includes a posterior soft-tissue repair.93 a coplanar head and cup is the combined anteversion.
One study recommended combined anteversion of 45° in
Impingement women and 20° to 30° in men.95 Femoral components can
Impingement is a broad diagnosis that takes multiple be malrotated, particularly in hip replacements that use
issues into account. It is often related to component modular implants; this is difficult to determine on plain
position, inadequate offset, head size, and liner choice. radiographs but can be ascertained from either a lateral
Impingement is a result of the contact of two nonarticu- view of the femur or a CT scan.
lar prosthetic surfaces during extremes of motion (most
commonly the trunnion and the liner), from unresected Head Size
osteophytes (most commonly anteriorly), from heterotopic Femoral head size has a significant effect on dislocation
ossification, contact of the ischium with the posterior risk secondary to both range of motion before impinge-
femur, or capsular scar tissue. Greater femoral head-neck ment (related to the head-neck ratio) and increased jump
ratio and larger femoral heads increase range of motion distance (Figure 2). The acceptable thickness of acetab-
before the occurrence of this type of impingement and ular liners has decreased with the introduction of highly
increase the jump-distance to dislocation once impinge- cross-linked polyethylene. Although the appropriateness
3: Hip
ment occurs. Skirted necks, larger trunnions, and smaller of this trend is debatable, average head sizes have in-
femoral heads decrease the range of motion. creased recently, and a corresponding decrease in dislo-
cations has been observed.81
Component Positioning
Component malposition (acetabular, femoral, or both) Liners
is one of the most common causes of dislocation. Mal- Acetabular liners can help make minor changes to ac-
position leads to a lack of restraint and/or impingement etabular position (with elevated rims or increased off-
from the implant, soft tissue, or bone. The prior surgical set through lateralized liners) and their use has become
commonplace in primary THA. When an elevated rim strength testing, assessment of limb length and gait, and
liner is present in a patient prone to dislocation, it is neurologic status, as well as evaluation for soft-tissue
important to remember that elevated rims decrease range laxity or hypermobility disorders. Infection should al-
of motion to impingement, as the trunnion contacts the ways be ruled out with appropriate laboratory testing,
elevated rim. This may increase the risk of instability. including aspiration.
Face-changing or oblique-type liners may decrease the Adequate radiographs are also critical, both prereduc-
risk of impingement by providing coverage without de- tion and postreduction. Additionally, radiographs from
creasing range of motion. Different types of liners are the index procedure should be obtained, if possible, to
shown in Figure 3. determine signs of wear or changes in component posi-
tion. Cross-sectional imaging with CT scans can also
Diagnosis be useful. Imaging should start with an AP view of the
Defining the cause of a dislocation event is critical for pelvis and an AP view of the hip. The orientation of the
management. A thorough history should be obtained face of the acetabulum in these two radiographs can help
that includes the patient position and action at the time determine if the cup is retroverted. It is important to
of dislocation. This can give clues regarding the direction note that an AP view of the pelvis can give a false ap-
of dislocation, possible impingement, or component mal- pearance of cup anteversion compared to an AP of the
position. Physical examination should include abductor hip, as shown in Figure 4. Lateral radiographs are also
helpful in determining version of the cup, and several
measurement techniques have been described. One study
described the anterversion on a lateral radiograph as an
angle formed between the line parallel to the plane of
the radiograph and a line tangential to the face of the
acetabulum; however, wide standard deviations exist with
this method, as it depends on the radiograph being per-
fectly positioned.90 Another study attempted to improve
on this method and described the ischiolateral method
as an angle formed between a line parallel to the long
axis of the ischium and a line tangential to the face of
the acetabulum.96 The mean standard deviation between
this technique and the technique described earlier90 was
found to be 3.7° (P < 0.001). Lateral radiographs can give
clues to relative version but cannot be used in isolation for
diagnosis, and cross-sectional imaging can be very useful.
Management
Early dislocations can often be managed successfully with
Figure 2 Schematic drawings of femoral head in closed reduction. Dislocations that occur within the first
acetabular cup. An increase in head size affects 6 weeks that are successfully relocated have a more than
both jump distance (A and B) as well as range 80% likelihood of maintaining reduction.87 Conversely,
of motion before impingement (C and D).
for dislocations that occur three or more times, or occur
3: Hip
Figure 3 Schematic drawings of liner options: Neutral (A), lateralized (B), elevated rim (C), and face-changing (D)
Section 3: Hip
section), including component revision if malposition is

noted, dual mobility and constrained liners, and soft-tis-
sue procedures in some cases. It is important to note that
studies have shown that an increase in head size cannot
make up for abductor deficiency.97 Revision of type IV
dislocations should address any impingement found intra-
operatively, and revision of the components may be neces-
sary. A lateralized liner and increased neck length can be
used to improve offset. Elevated and face-changing liners
can also be used in combination with other options or to
make minor corrections. General strategies to decrease
impingement via the components include increasing the
head-neck ratio (usually through increased head size) and
increasing offset. Type V dislocations should be treated
Figure 4 AP radiographs of the pelvis and right as one would treat wear and osteolysis, with possible
hip of the same patient after dislocation,
demonstrating an under-anteverted acetabular revision of the components. Isolated liner exchange can
component. This is much more clearly be considered, but this may not make the hip stable and,
appreciated on the hip radiograph.
as mentioned earlier, is predictive of recurrent failure.
Type VI dislocations should be carefully examined intra-
operatively and any pathologic conditions treated. If no
at a late stage, the failure rate is high (33% to 55%) with pathology is identified, dual mobility constrained liners
closed reduction, and revision should be strongly consid- or salvage procedures can be considered. Close attention
ered.91 If closed reduction is successful, patients should to hip biomechanics should be observed in all cases. A
be counseled extensively on positions to avoid and the systematic intraoperative approach is warranted, and the
use of bracing (although evidence supporting the use of algorithm in Figure 5 should be followed.
bracing is limited). In noncompliant patients or those with
cognitive or neuromuscular disorders, a spica cast can be Dual Mobility
applied (however, this option should be performed with An important option in the treatment of THA instability
caution, because of hygiene issues). has been the widespread introduction of dual mobility
Surgical management should be undertaken when liners. Adding an articulation increases the range of mo-
appropriate—after the surgeon has gained a clear un- tion to impingement and several series have examined
derstanding of the possible cause of dislocation and has the results of dual mobility. One study, using the Swedish
created a management plan. Attempts should be made hip replacement registry, examined 228 hip revisions for
to obtain the prior surgical report or to contact the prior instability using a dual mobility liner. Re-revision for
surgeon to determine the components used. Multiple sur- dislocation at a median follow-up of 2 years was 2%
gical options should be available, and the surgeon should (four hips). The study did not examine closed reductions
be prepared to revise the components if necessary. for dislocations.98 A study of 88 THA revisions using
Surgical management should focus on the cause of dual mobility liners resulted in one revision for recur-
dislocation. Type I dislocations should be treated with rent dislocation and two for aseptic loosening at 2-year
revision of the acetabular component. If the component follow-up.99 Another study examined acetabular revi-
is close to optimum position, then an elevated or face- sion surgery in 163 hips with a dual mobility cup, which
changing liner can be considered; however, this should showed a dislocation rate of 4% at a mean follow-up of
be used to correct only minor degrees of malposition. 12 years.100 A 2015 study examined 24 revision THAs
Isolated liner exchange was an independent predictor using dual mobility liners for dislocation (18 revisions)
3: Hip
(P = 0.004) for recurrent dislocation after revision for in- or instability (6 revisions with a diagnosis requiring re-
stability in a study of 156 revisions.89 Type II dislocations vision THA combined with abductor deficiency). At a
usually necessitate revision of the femoral component mean follow-up of 22 months, no recurrent dislocations
unless the primary component is a modular implant that were seen.101
allows for changes in version. Combined malposition Although dual mobility offers the surgeon an option
should address the most-malpositioned component first. without the downside of constraint, no long-term studies
Type III dislocations are the most challenging to treat, are available, and unforeseen problems may appear in
and multiple strategies may be used (discussed later in this the future. A study of 100 patients with dual mobility
Figure 5 Algorithm for intraoperative assessment and management of the unstable THA. Troch = trochanteric.
articulations found elevated cobalt levels in 21 patients and escape, this technique is rarely used. Several different
(21%) and elevated chromium levels in 4 patients (4%). soft-tissue augmentation techniques have been described,
Two patients with a painful THA and elevated cobalt including using Achilles tendon allograft, advancement
levels had MRI results consistent with adverse soft-tissue of the gluteus medius, and rerouting of the tensor fasciae
reactions; however, at the time of the study none of the latae.107 Small case series have shown moderate success;
patients had undergone revision.102 It appears that use of however, no large studies or long-term outcomes have
dual mobility liners is less successful in cases of abductor been reported. In general, these techniques are reserved
deficiency and should be cautioned against. for the challenging scenario of abductor insufficiency.
Bipolar and Tripolar Treatment Constrained Liners

Bipolar hemiarthroplasty with removal of the acetab- Constrained liners are an important option and can ei-
ular component has been reported in small series and ther be implanted into a previously placed acetabular
is a salvage option for treatment of dislocation, but its component de novo or cemented in place; however, they
use is limited because of groin pain and acetabular ero- have limitations and should be used selectively. Several
sion.103,104 A study reported on eight patients treated with series have reported on the use of constrained liners with
tripolar articulars (a large acetabular component with a a moderately high success rate (84% to 98%) at midterm
bipolar hemiarthroplasty) with no recurrent dislocations follow-up, but failure due to loosening (3.6% to 14%) or
at an average of 4.2 years’ follow-up.105 As with dual re-dislocation (up to 17.5%) poses substantial concerns.
mobility, this treatment strategy has a high failure rate Long-term studies show lower success rates in preventing
in the presence of abductor deficiency. re-dislocation (~70%) with failure rates higher than 40%.
This failure rate does not reflect poor surgical choices,
Trochanteric Advancement and Soft-Tissue but rather the complex nature of the problem. In gener-
3: Hip
Augmentation al, constrained liners are placed in patients at very high

Trochanteric advancement is an option for patients with risk for dislocation, in cases of abductor insufficiency,
well-positioned components but poor abductor tension or or for idiopathic dislocation. These cases exhibit both a
abductor insufficiency with an intact tendon. Some small predilection for recurrent dislocation as well as extremely
series have reported reasonable outcomes. One study re- high bone-implant stress. One group reported on the
ported 81% success in 21 hips with chronic dislocation and placement of 755 consecutive constrained components
well-positioned components, but no large series appear in in 720 patients with minimum 10-year follow-up. Of
the literature.106 Given the risk of trochanteric nonunion these, 138 were cases of recurrent instability. Overall
Section 3: Hip
Kaplan-Meier survivorship for revision for the entire co-

hort was 68.5% at 5 years and 51.7% at 10 years. Of the
138 cases treated for recurrent instability, 28.9% failed
with recurrent dislocation.108 Short-term and midterm
results are somewhat more encouraging, but they also
suggest caution. A 2016 study reported on an average of
3.5 years’ follow-up in 58 hips revised with a constrained
liner. Eleven hips (19%) re-dislocated, and 14 hips (24%)
required revision for any reason.109 Another study re-
ported a re-dislocation rate of 16% (9 hips) at 2 years in
55 patients treated with constrained liners during THA
revision. Of the nine dislocations, eight occurred in pa-
tients who did not have acetabular component revision,
suggesting that position may not have been optimized.110
In general, it is ideal to place a constrained liner in
an already well-fixed acetabular component. When ap-
proaching the cup, all screws should be removed and
thorough testing performed for osseous ingrowth. If the
acetabular component has to be revised and constraint
used, two options exist: (1) placing the cup and allowing
ingrowth, then placing the constrained liner in a staged
fashion, or (2) using multiple screws for augmentation,
after which the patient’s weight bearing and activities are
limited for a prolonged period postoperatively. The first
Figure 6 AP radiograph of the left hip of a patient with
option may be preferable, as it theoretically has better multiple revisions demonstrating catastrophic
long-term outcomes because of lower loosening rates; failure of a constrained acetabular component.
however, this has yet to be shown in the literature. Failure
of a constrained liner can be catastrophic, and the patient
should be counseled on the risks of constraint and the like- occurs at the time of surgery can be either intentional or
lihood of a need for further revision surgery (Figure 6). inadvertent. Intentional lengthening may be used to cor-
rect a preoperative discrepancy or for increased soft-tissue
Resection Arthroplasty tension to achieve dynamic hip stability at the time of sur-
When dislocation continues to recur after all of the al- gery. Because soft-tissue tension is directly related to both
ready-discussed strategies have failed, then resection ar- length and offset, it is important to consider both when
throplasty (Girdlestone procedure) is the final salvage evaluating intraoperative soft-tissue tension. Inadvertent
operation. This has poor functional results and should be lengthening may occur when the acetabular or femoral
avoided if possible, but patients should be counseled that components do not restore the native center of rotation,
it may be a necessary option in the long term. leading to either lengthening or shortening. The multiple
radiographic and intraoperative measurement methods,
surgical techniques, and devices that have been developed
Limb-Length Discrepancy After THA speak to the difficulty of accurately assessing limb length
Peter K. Sculco, MD; Thomas K. Fehring, MD intraoperatively.
Limb-length discrepancy is one of the most common During the preoperative consultation, the challenges
complications and is also a major source of patient dis- associated with obtaining equal length should be dis-
3: Hip
satisfaction and the most common cause for litigation cussed with the patient. Additionally, any preoperative
after THA.111,112 In addition to patient dissatisfaction, a limb-length discrepancy must be identified and docu-
significant limb-length discrepancy can result in func- mented. Hip abduction and adduction motion should
tional disabilities, including limp, scoliosis, trochanteric be assessed for presence of contractures. The Thomas
bursitis, and low back pain.113 Although the definition of test, in which both hips are flexed to 90° and the surgi-
what constitutes a substantial limb-length discrepancy is cal leg is extended, helps to identify hip flexion contrac-
debated, lengthening or shortening the surgical limb as tures. If a pelvic obliquity is present, it is important to
little as possible should be the goal. Limb lengthening that determine whether it is flexible or fixed. A flexible pelvic
obliquity will correct in the seated position.114 Block test- as to the types of limb-length discrepancies that can be
ing, in which wedges of known widths are placed under reliably addressed at the time of surgery, those that will
the affected extremity until the patient perceives equal likely correct over time, and those that will persist and
leg lengths, best quantifies the functional limb-length require treatment with a shoe lift or alternative treatment
discrepancy. methods.
The assessment of limb-length discrepancy can be done Standing AP pelvic radiographs should be obtained for
radiographically or by measuring from the anterior su- all patients to assess standing pelvic tilt and to identify
perior iliac spine to the medial malleolus. However, the any pelvic obliquity that would affect limb length. Ideally,
most accurate method is the use of blocks, as the patient’s the femur should be internally rotated 15° when taking
perception of limb length is much more important than the radiograph to allow for an accurate assessment of
any measured value.115 Sources of limb-length discrepancy femoral offset. However, disease progression may limit
include cartilage and bone loss from disease processes, internal rotation and underestimate offset. If the opposite
previous surgery, or pediatric hip conditions (eg, slipped hip has normal motion, femoral offset can be estimated
capital femoral epiphysis, congenital hip dysplasia, or from the normal side.
Legg-Calvé-Perthes disease). Limb-length discrepancy Radiographic limb-length differences can be calculated
can also be extra-articular. A previous femoral or tib- on a standing AP pelvis radiograph by drawing a horizon-
ial fracture, infection, congenital deformity, or growth tal line between two symmetrical pelvic landmarks. The
plate arrest can all result in extra-articular limb length three most common anatomic pelvic landmarks include
inequalities. the base of the acetabular teardrop, the superior aspect
In addition to structural abnormalities, limb-length of the inferior obturator foramen, and the bottom of the
discrepancies can also arise from a functional difference ischial tuberosities.117 The vertical distance between these
in limb length from a pelvic tilt, scoliosis, or periarticular lines and a reproducible landmark on the femur, usually
soft-tissue contractures around the hip or knee.116 As the the apex or most medial aspect of the lesser trochanter,
hemipelvis elevates, the ipsilateral limb shortens, and the can then be calculated and the two limbs compared to
contralateral hemipelvis tilts inferiorly, creating func- determine intra-articular limb-length discrepancy.118 Note
tional shortening and contralateral lengthening. The ac- that this radiographic calculation may be influenced by
tual limb-length difference can represent a combination a hip flexion contracture. In a patient with a clinically
of both the structural difference in limb length and the significant hip flexion contracture, the lesser trochanter
apparent functional difference due to pelvic position or moves cephalad on the radiographs and will appear as
soft-tissue contracture. a shortened extremity. When the flexion contracture is
In routine cases with minimal limb-length discrep- corrected during surgery, inadvertent leg lengthening will
ancies, the center of rotation of the acetabular compo- ensue if this is not taken into account. Therefore, it is
nent should match that of the contralateral side, and the important to link the clinical and radiographic findings.
location of the femoral component should match the If a clinically significant flexion contracture is present,
center of rotation of the native femoral head. If this is it is best to create a template from the normal side to
achieved, the prosthetic components will have reproduced prevent inadvertent limb lengthening. Extra-articular
the prearthritic limb length postoperatively. Patients with sources of limb-length discrepancy will not be identified
functional limb-length discrepancy secondary to soft- on the AP pelvis radiograph; these will be identified on
tissue contracture may see it resolve over a few months. block measurements. A hip-knee-ankle radiograph, CT
Compensatory lumbar scoliosis or pelvic tilt secondary scanogram, or standing AP thoracolumbar radiograph
to a structural limb-length discrepancy should also cor- should be obtained to clarify the source of the length
rect once limb-length inequality is surgically corrected. discrepancy.
However, a fixed pelvic obliquity (from degenerative sco- Preoperative templating is critical to prevention of
liosis or lumbar fusion) will not correct unless specifically postoperative limb-length discrepancy. Preoperative
3: Hip
addressed with a separate procedure. templating should also include a measurement of limb-
Preoperatively, both patient and surgeon should agree length discrepancy. Templating provides not only a better
and understand that the ultimate goal of THA is to ac- understanding of acetabular and femoral component sizes
curately restore the intra-articular biomechanics of the but also the need for a standard or high offset femoral
joint. However, correct soft-tissue tension may occasion- stem and determines the level of the femoral neck resec-
ally have to take precedence over equal leg lengths to tion.117 The sequence of templating should begin with the
optimize abductor function and maintain dynamic hip acetabular component. The inferior aspect of the acetab-
stability. Patients should also be counseled preoperatively ular component is positioned slightly below the base of
Section 3: Hip
the acetabular teardrop, with the medial aspect of the fixation points.122 To determine intraoperative leg length
component adjacent to the medial wall. Superiorly, the in the lateral position, a pin is placed near the infracot-
acetabular component should have superolateral bony yloid fossa before neck resection and compared during
coverage, with the dome of the cup resting just above the component trial. The pin is temporarily placed outside
subchondral bone of the acetabular sourcil. the bone next to the ischium, at the junction with the
After the acetabular center of rotation has been estab- posterior aspect of the transverse acetabular ligament.
lished, the center of rotation of the native femoral head is A corresponding mark is made on the greater trochan-
marked on the preoperative AP radiograph. The differ- ter, with the patient’s knees and heels together. After a
ence between these two centers of rotation is measured trial, these steps are repeated and compared to the previ-
and compared to the preoperative limb-length discrepan- ous mark on the trochanter to determine changes in leg
cy calculated, as occasionally one can either shorten or length. The advantage of this technique is that it incor-
lengthen the limb through the acetabulum. The femoral porates length changes that occur with both acetabular
template is then dropped down to the appropriate level to and femoral components. This technique may reduce the
accurately restore both length and offset. If it is desired error associated with changes in leg position, as it is closer
to lengthen the limb by 1 cm, and the limb is length- to the center of rotation of the hip.
ened 0.5 cm with the location of the template acetabular A soft-tissue trial is another way to grossly assess
component, the femoral component would be templated soft-tissue tension that reflects a combination of leg length
0.5 cm above the acetabular center of rotation for a cu- and offset.123 Commonly used soft-tissue tests include the
mulative lengthening of 1 cm. A standard or high-offset shuck test, the drop-kick test, the Ober test, and direct
template is then selected to match the offset, and either heel-to-heel comparison. The shuck test involves direct
the distance from the femoral head center to the proposed axial traction on the surgical leg with the hip at 30° flex-
neck resection or the distance above the top of the lesser ion and detects axial laxity; the lateral shuck test detects
trochanter to the proposed neck resection is noted.119 If offset laxity. Less than 50% of the reduced femoral head
appropriate femoral offset is not restored, the leg is at should clear the acetabular rim with manual traction.
risk of excessive lengthening to achieve the appropriate The drop-kick test is performed with the hip extended
soft-tissue tension that should have been addressed with just past neutral and the knee flexed to 90°. The amount
increased offset. Conversely, if too much offset is placed of leg recoil is used to determine soft-tissue tension, as a
into the system, the patient may experience lateral hip leg with excessive kick-back may have been inadvertently
pain secondary to trochanteric bursitis. Another sequela lengthened.123 The Ober test assesses for lateral iliotibial
of increasing offset is a perceived limb-length discrepancy band tightness. A positive test occurs when the femur
whereby the increased offset leads to abductor tightness abducts with knee flexion and slight adduction. With
and tilting of the pelvis to the ipsilateral side. The patient any of these soft-tissue maneuvers, the patient’s intrinsic
will feel that the leg is long in this situation, even if the ligamentous laxity and the type of anesthesia must be
radiographic measurement is similar to the other side. In taken into consideration to avoid significant lengthening,
cases with a significant external rotational contracture as the use of paralytic agents will cause overestimation
or deformity, the contralateral hip can be used to assist of ligamentous laxity. The patella of the surgical and
with native hip geometry and preoperative templating. nonsurgical extremity can be compared side-by-side, both
Electronic templating systems are now available to help preoperatively and after placement of the trial compo-
with the process and provide accurate measurements of nents, allowing for gross assessment of any change in
length and offset. leg position. For the anterolateral or direct anterior ap-
Several methods, surgical techniques, and caliper proaches performed in the supine position, the medial
devices have been developed to help produce accurate malleoli can be directly compared. In addition, intra-
limb-length restoration intraoperatively. Several caliper operative fluoroscopy can be used to assess leg length,
devices have been developed that measure the distance offset, and component position. Computer navigation
3: Hip
between a fixed point on the ilium and the greater tro- and robotic THA have both been shown to accurately
chanter.120,121 This measurement is performed before and restore leg length, but the literature has yet to demonstrate
after placement of trial components to detect any intra- a significant difference in the accuracy of this technique
operative changes in leg length. The difficulty with this when compared to manual methods.124
technique is that the pelvic fixation point is usually away With accurate preoperative planning and a systematic
from the center of rotation of the femur. Small deviations approach to intraoperative execution, significant limb-
in leg position may result in significant errors in the calcu- length discrepancies can be avoided. Patient education
lated length between the pelvic and greater trochanteric is essential to avoid postoperative dissatisfaction from
residual limb-length discrepancies that cannot be ad- Male sex, cemented prostheses, bilateral THA, anky-
dressed with THA. Patients should be aware that small losing spondylitis, history of heterotopic ossification, and
increases in leg length and/or offset may be necessary to an ankylosed hip have been identified as risk factors after
optimize overall hip stability. Additionally, they should THA, whereas rheumatoid arthritis is negatively correlat-
be reassured that functional limb-length discrepancies ed with the development of heterotopic ossification.127,131
secondary to soft-tissue contractures and flexible pelvic
obliquity should correct gradually over time. Shoe lifts Physical and Radiographic Evaluation
should be discouraged if contracture resolution is antic- Occurrence of heterotopic ossification following THA
ipated. A careful preoperative plan is essential and will is usually asymptomatic and is often found incidental-
enhance the accuracy of surgical execution. ly on postoperative radiographs. Pain is rarely the chief
complaint, although it can be present. More often, de-
creased range of motion at the surgical hip is noted, which
Heterotopic Ossification may create limitations in postoperative rehabilitation
David M. Beck, MD; James J. Purtill, MD or functional deficits. Edema, erythema, and warmth
Heterotopic ossification, or bone formation in abnormal have also been reported in association with heterotopic
locations, can occur following soft-tissue trauma, frac- ossification.135
ture, head injury, burns, elective surgery (eg, hip or knee Standard AP and lateral radiographs are usually ade-
replacement), or as a result of genetic abnormalities (eg, quate to determine the existence and degree of heterotopic
fibrodysplasia ossificans progressiva, progressive osseous ossification.127 Both CT and MRI studies may be obtained
heteroplasia).125-129 The incidence of heterotopic ossifica- if it is necessary to more clearly define the extent and
tion following THA is between 5.2% and 87.0%, with location of heterotopic ossification.136 Radiographs and
0.5% to 12.3% of cases exhibiting some level of clinical CT may only define more mature heterotopic bone. Inves-
significance.130,131 tigations into radiologic techniques that identify hetero-
topic ossification at an earlier point in the postoperative
Basic Science period, including three-phase bone scintigraphy with or
One study has suggested that the following three condi- without single-photon emission computed tomography,
tions must be present for de novo formation of ectopic near-infrared optical imaging, and transcutaneous Ra-
bone: (1) an inducing agent, (2) an osteogenic precursor man spectroscopy, have been studied.126,127,136
cell, and (3) an environment permissive to osteogene-
sis.132 Bone morphogenetic proteins (BMPs) have been Classification
shown to govern chemotaxis, mitosis, and differentia- The Brooker classification of heterotopic ossification is
tion in bone formation and can be used to induce het- graded on a supine AP radiograph of the hip, with grades
erotopic ossification in vivo.133 An upregulation in the as follows: grade 1, islands of bone within the soft tissues
normal BMP pathway is now thought to be responsible about the hip; grade 2, bone spurs from the pelvis or
for conversion of progenitor cells to osteogenic precursor proximal end of the femur, leaving at least 1 cm between
cells. Mesenchymal stem cells are believed to play a major opposing bone surfaces; grade 3, bone spurs from the
role in the formation of heterotopic ossification.127 Lo- pelvis or proximal end of the femur, with less than 1 cm
cal oxygen tension, pH, micronutrients, and mechanical between opposing bone surfaces; grade 4, bony ankylosis
stimuli also may be substantial determinants in ectopic of the hip.137 One study found that intraobserver reliability
bone formation.127 In the genetic condition fibrodysplasia using the Brooker classification was poor and a modified
ossificans progressiva, a mutation of the gene ACVR1/ classification using three grades was proposed: grade A,
ALK2 has been found.125,127,129 The ACVR1/ALK2 gene is absence of heterotopic ossification or islands of bone less
a receptor for BMPs, which may lead to osteogenic differ- than 1 cm in length; grade B, 1 cm or more of islands of
entiation and widespread heterotopic bone formation.129 bone spurs with at least 1 cm between opposing surfaces;
3: Hip
grade C, bone spurs with less than 1 cm between opposing

Incidence and Risk Factors surfaces or bony ankylosis.138
A meta-analysis of studies regarding heterotopic ossifica-
tion found the incidence after THA to be between 5% and Prophylaxis
90%, with an accumulated incidence of about 30%.131 Oc- Prophylaxis is the preferred method of management for
currence of heterotopic ossification is much more frequent patients at high risk of development of heterotopic ossi-
after THA than after knee arthroplasty, with rates be- fication following THA, with NSAIDs and radiation the
tween 5% and 40% after total knee arthroplasty.134 primary modalities used; the use of diphosphonates has
Section 3: Hip
been explored. Prostaglandins are known to be strong injuries are less common than nerve injuries, but they result
co-stimulating molecules with BMPs in the development in worse outcomes.144-146,149 These injuries are more com-
of heterotopic ossification.139 NSAIDs decrease prosta- mon in the left hip, with the external iliac, femoral, and
glandin production and may reduce heterotopic ossifica- obturator vessels the most frequently injured.144-146 Nerve
tion. Many studies have successfully demonstrated the injuries are more common in women and in those with
efficacy of NSAIDs in decreasing rates of heterotopic a preoperative diagnosis of posttraumatic arthritis or
ossification, although a single agent, dosage, and duration developmental dysplasia of the hip (DDH).145 The sciatic,
of treatment have not been agreed on.127,140,141 femoral, and superior gluteal nerves are most frequently
Perioperative radiation has also been shown to effec- at risk.145 Injury to the lateral femoral cutaneous nerve has
tively decrease rates of heterotopic ossification following also been reported, particularly with the recent increase
THA. Radiation stops the differentiation of osteogenic in the use of the anterior surgical approach. In revision
precursor cells that mature into osteoblasts.135 A single cases, a vascular ultrasound, magnetic resonance angio-
7- to 8-Gy fraction, which may be given during a period gram, or CT angiogram may be required preoperatively
of 4 hours preoperatively to 72 hours postoperatively, is or recommended postoperatively. These studies may have
recommended for prophylaxis.127 to be ordered emergently after surgery if internal bleeding
No studies have shown a significant difference in the is suspected.147,149 Knowledge of neurovascular anatomy,
effectiveness of NSAIDs versus radiation.127 For this rea- preoperative planning, appropriate intraoperative tech-
son, prophylaxis decisions should be made on an indi- niques, and management of postoperative complications
vidual basis with consideration given to cost, access, and is critical.
side effects. NSAIDs can lead to increased bleeding and
gastrointestinal issues, whereas radiation has a theoretical Vascular Injury
malignancy risk and can be accompanied by soft-tissue The incidence of vascular injury (requiring surgery, by-
contracture and delayed wound healing.127 pass grafting, or stenting) is 0.04% to 0.2% after primary
THA and increases to 5% in revision cases.145-147,150 Al-
Treatment though vascular injuries have a low prevalence in hip
After heterotopic ossification has developed following surgery, when they occur they are associated with a 7.3%
THA, treatment options are limited; no current phar- overall reported rate of death, a 1.6% rate of amputation,
macologic intervention is available to treat heterotopic and permanent disability.144-147 The external iliac, femoral,
ossification. Because heterotopic ossification frequently and obturator vessels are most frequently injured.145 In
presents as decreased range of motion, a trial period of revision cases, the external iliac artery and the femoral
physical therapy is reasonable to attempt to increase range artery and vein have been reported to be at an increased
of motion to acceptable limits. For heterotopic ossification risk for injury.147
that is painful, limits daily activities, or for which a trial Direct, immediate vascular injury can be caused by
of physical therapy has failed, surgical excision may be intraoperative laceration with a surgical instrument or
considered. Waiting for heterotopic bone to fully mature a sharp piece of bone. A sudden intraoperative drop in
before excision has been recommended; however, early blood pressure during reaming or after insertion of ace-
excision, while preserving tissue planes, has also been tabular screws should lead to suspicion of an intrapelvic
suggested.127 Studies have shown improvements in range vascular injury.147 Late damage can occur with chronic
of motion following resection; however, pain relief is erosion of a vessel by protruding screws, extruded cement,
less predictable.142,143 Resection is usually combined with or the migration of a loose component, leading to the
radiation or NSAIDs to prevent recurrence of heterotopic formation of a false aneurysm or thrombus.146 Indirect
ossification following the procedure. injuries can result from joint manipulation that stretches
atherosclerotic arteries, causing tears and detachment
of plaques as well as thrombus formation. Injuries can
3: Hip
Neurovascular Injuries also occur from thermal damage as a result of the po-
Jeffrey R. Engorn, DO; Carlos J. Lavernia, MD lymerization of cement.146 Approximately 25% of all
The incidence of neurovascular injuries in primary hip re- intraoperative vascular lesions are identified during the
placement has been reported to be 0.04% to 0.2% for vas- procedure and 50% within 24 hours of surgery; the re-
cular injuries and 0.09% to 3.7% for nerve injuries.144-147 In maining 25% present days or months later, and possibly
revision arthroplasty, however, these injuries are more up to 1 year or more postoperatively.146,147 If the patient
frequent and have been reported to be up to 5% for vas- begins to experience restriction of movement, pain, swell-
cular injuries and 7.6% for nerve injuries.145,147,148 Vascular ing of the ipsilateral limb, or a decrease in hemoglobin
level, diagnostic imaging should be considered to rule out Traditionally, vascular repair has been conducted with
bleeding.147 Duplex sonography, CT, CT angiogram, or open exploration, but more recently there has been a trend
magnetic resonance angiogram can be used; according to toward percutaneous endovascular repair with angioplas-
one author group, CT is the imaging modality of choice.147 ty, stenting, or grafting, when possible.146 Endovascular
The quadrant acetabular system is an established ap- repair is a quicker procedure that allows faster recovery,
proach to guiding safe transacetabular screw placement. lower rates of complication, and higher probability of
A study reported use of three-dimensional CT angio- success, and it may provide superior patient satisfac-
gram to visualize pelvic vessels in relation to the acetab- tion.144,146 For active arterial hemorrhage, open repair is
ulum.151 The external iliac vein was closer to the pelvis on still favored over endovascular treatment.144
the left side both in the elderly and in females. In 26% of
the 200 hips studied, the external iliac veins were direct- Neurologic Injury
ly on the osseous surface of the pelvis. Three anatomic Nerve injury is defined as a postoperative sensory or
variations of the iliac arteries were described (straight, motor neural deficit related to the index THA.150 The
curved, and tortuous). The mean distance from the pelvis incidence is 0.09% to 3.7% after primary THA, and
to the external iliac and femoral vessels in the curved and up to 7.6% after revision.145,148 Known causes of nerve
tortuous groups was shorter than in the straight group. injury are intraoperative direct nerve injury, limb leng-
The curved and tortuous types were more commonly thening, improper retractor placement, cement-related
identified in elderly patients (mean age, 67.9 years), where- thermal damage, patient positioning, manipulation, leg
as the straight type was more commonly identified in lengthening, and hematoma; risk factors include being
younger patients (mean age, 45.5 years). Because curved female, having DDH, having posttraumatic arthritis, and
and tortuous vessels tend to be closer to the pelvis, elderly undergoing revision.152
patients with curved or tortuous types had the greatest The sciatic nerve is the most commonly injured nerve
potential risk of injury. Obturator vessels were located during THA, but the femoral and superior gluteal nerves
just behind the acetabulum near the obturator foramen, (SGN) are also frequently injured.145,147 With the aid of CT
allowing the possibility of damage or avulsion during scans, the proximity of five commonly placed acetabular
preparation of the acetabulum. retractors to neurovascular structures in THA was iden-
A case report was presented of an uncommon vascu- tified.145 The anterior inferior iliac spine retractor had the
lar complication following a failed revision THA that farthest mean distance from the femoral nerve (2.65 cm),
led to injury of the superficial femoral artery, that in and the anteroinferior retractor distance was the closest
turn eventually led to a thromboembolism and trans- (mean distance, 0.95 cm). The superior retractor had a
metatarsal amputation.149 While the patient in the case 2.03-cm mean distance from the SGN. The posterior
report awaited a custom triflange prosthesis, intractable retractor had a 1.75-cm mean distance from the sciatic
foot pain with diminished pulses developed. A CT an- nerve. All five retractor positions had shorter distances
giographic study demonstrated a left superficial femoral to the structures in females.
artery thrombus adjacent to a migrated screw. If there is A cadaver and a CT angiographic study were per-
the slightest suspicion of vascular injury preoperatively in formed to analyze the relationships between the superior
patients presenting with a failed revision arthroplasty, a gluteal neurovascular pedicle and the greater trochanter
vascular surgery consultation and a vascular ultrasound to identify the site of incision with the lowest risk of
or CT angiogram should be routine during preoperative injury during THA with the Hardinge direct lateral ap-
planning to avoid catastrophic complications. proach.153 Results showed that during direct lateral access,
A study compared the distance of five common THA a very small safe zone exists, which is even smaller if the
acetabular retractor positions (three anterior, one pos- SGN presents in a branching pattern. The safe zone was
terior, and one superior) to the closest neurovascular identified as 4.7 cm from the greater trochanter to the
structures measured on hip CT.145 The inferior retractor SGN and 3.5 cm to its lower ramus. Proximal extension
3: Hip
position to the obturator neurovascular bundle was not of the incision should be restricted to 3.5 cm from the
measured, because it was not reliably identified on CT. trochanteric apex with an anterior cranial direction.
The anterior retractor at the level of the anterior inferior Lateral femoral cutaneous nerve (LFCN) injury during
iliac spine had the farthest mean distance (2.65 cm) from THA may occur with use of the anterior surgical ap-
the femoral artery, but as the anterior retractor moved proach.154 In a study of 132 patients who underwent
inferiorly along the anterior wall, the mean distance to the an anterior approach for THA and hip resurfacing, to
femoral artery decreased to 0.95 cm. All five retractor po- quantify the incidence and functional effect of lateral
sitions had shorter distances to the structures in females. femoral cutaneous nerve neurapraxia,155 an incidence of
Section 3: Hip
67% was reported for the THA group, which is higher is probable and independent of the nerve affected.158 Obe-
than the 2.0% and 31.9% incidences reported in other sity has been identified as a negative prognostic factor.159
studies; it is suspected that lateral femoral cutaneous Neurovascular injuries are rare complications of THA.
nerve neurapraxia is underreported.156,157 Although a Vascular injury is less common than nerve injury, but it has
low rate of complete resolution was noted, a decrease higher morbidity and increased mortality.144-146 Knowl-
in symptoms occurred over time, with no functional edge of neurovascular anatomy, preoperative planning,
limitations reported.155 appropriate intraoperative techniques, and manage-
A fivefold increased rate of nerve palsy is reported ment of postoperative complications is critical for every
when lengthening a limb in a patient with DDH as com- surgeon.
pared to the general population.152 A shortening subtro-
chanteric osteotomy or iliofemoral distraction of the hip
joint is often used to supplement THA to prevent nerve Summary
palsy after limb lengthening.152 These techniques have
good results but high complication rates.152 An unreported Although it is a very reliable surgical procedure, THA
technique was presented in a case report of three patients may be burdened by perioperative complications. The
with Crowe type IV DDH with an average 43 months’ surgeon and patient should be cognizant of the risks of the
follow-up.152 The technique involved inserting noncement- most common complications after THA. It is crucial that
ed total hip components through an anterior approach, the surgeon be familiar with the available evidence on pre-
leaving the components unreduced and applying traction vention, diagnosis, treatment, and prognosis of variable
until desired alignment of the components was reached, complications after THA. Periprosthetic joint infection
after which delayed closed reduction was performed.The remains a challenging problem, which has gained signif-
average hospital stay was 9 days. All three patients re- icant attention in recent years as the ability to define and
ported excellent pain relief and significant improvement diagnose infection has improved; nonetheless, treatment
of daily living without signs of neurologic deficit. At the options are numerous and require further exploration
last follow-up examinations, radiographs demonstrated into better surgical and medical management of these
all components to be well fixed in satisfactory position. patients to truly eradicate infection. Successful treatment
This technique is not indicated when significant limb- of periprosthetic fractures depends on appropriate clas-
length discrepancy is present. sification of the fracture. Instability after THA is also
Another report described use of intraoperative con- problematic; however, advances in management such as
tinuous multimodal monitoring (electromyography, the use of dual mobility components and constrained
motor-evoked potentials, and somatosensory evoked constructs may yield positive results. Limb-length discrep-
potentials) during revision and complex THA.148 A ret- ancy can be avoided with accurate preoperative planning
rospective review of the 69 procedures of complex hip and a systematic approach to intraoperative execution.
surgery with adjunctive multimodal intraoperative mon- Although prophylactic methods for heterotopic ossifica-
itoring showed that in 24 procedures (35%), the surgeon tion exist, there are limited treatment options available
was alerted by a neurophysiologist of a possible nerve after THA, including resection, which may lead to func-
lesion, which allowed the surgeon to adapt this intraop- tional improvement but variable pain relief. Knowledge
erative approach. Only one true positive nerve injury was of neurovascular anatomy, preoperative planning, ap-
reported postoperatively. propriate intraoperative techniques, and management of
Complete remission of nerve injury by 2 years occurs in postoperative complications is critical for avoiding nerve
50% of cases.158 According to another study, 91% of light and vascular injuries that are associated with significant
lesions reach full recovery, and 43% of severe lesions reach morbidity and mortality.
full recovery at 2 years; an improvement beyond 2 years
3: Hip
3. Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ:
Key Study Points
The epidemiology of revision total hip arthroplasty in the
United States. J Bone Joint Surg Am 2009;91(1):128-133.
• Periprosthetic joint infection remains a challeng- Medline DOI
ing complication, defined by recent published cri-
teria; various treatment modalities are based on 4. Jafari SM, Coyle C, Mortazavi SM, Sharkey PF, Parvizi J:
indications. Revision hip arthroplasty: Infection is the most common
cause of failure. Clin Orthop Relat Res 2010;468(8):2046-
• Periprosthetic fractures need to be diagnosed and
2051. Medline DOI
classified appropriately to guide treatment and eval-
uate prognosis. 5. Zmistowski B, Karam JA, Durinka JB, Casper DS, Parvizi
• There are both patient-specific and surgery-specific J: Periprosthetic joint infection increases the risk of one-
risk factors for dislocation; although many disloca- year mortality. J Bone Joint Surg Am 2013;95(24):2177-
2184. Medline DOI
tions can be managed with closed reduction alone,
revision for recurrent instability may be necessary in A retrospective study was performed. Compared to pa-
tients with aseptic revision arthroplasty, patients with
some cases, and its success requires an algorithmic periprosthetic joint infection are at increased risk of mor-
approach. tality at 90 days, 1 year, 2 years, and 5 years.
• Limb-length discrepancy is a major source of pa-
tient dissatisfaction and litigation after THA; with 6. Zmistowski B, Della Valle C, Bauer TW, et al: Diag-
nosis of periprosthetic joint infection. J Orthop Res
accurate preoperative planning and a systematic 2014;32(S1suppl 1):S98-S107. Medline DOI
approach to intraoperative execution, significant
limb-length discrepancies can be avoided. This is an article from the International Consensus Meet-
ing on periprosthetic joint infection. The definition of
• Although prophylaxis with NSAIDs and radiation PJI including diagnostic criteria for serum and synovial
may prevent occurrence of heterotopic ossification, parameters is discussed.
limited treatment options are available after THA.
Resection leads to improvements in range of motion; 7. Nodzo SR, Bauer T, Pottinger PS, et al: Convention-
al diagnostic challenges in periprosthetic joint infec-
however, pain relief is less predictable. tion. J Am Acad Orthop Surg 2015;23(suppl):S18-S25.
• Vascular injury is less common than nerve injury Medline DOI
but carries a higher risk of morbidity and mortality. The conventional diagnostic tools available to the surgeon
include testing synovial fluid and serum for inflammatory
markers, imaging, microbiological samples for culture,
and frozen section; however biomarkers and molecular
techniques such as PCR are gaining traction for making
Annotated References a more definitive diagnosis.
1. Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J: 8. Berbari E, Mabry T, Tsaras G, et al: Inflammatory blood
Economic burden of periprosthetic joint infection in the laboratory levels as markers of prosthetic joint infection:
United States. J Arthroplasty 2012;27(8suppl):61-5.e1. A systematic review and meta-analysis. J Bone Joint Surg
Medline DOI Am 2010;92(11):2102-2109. Medline DOI
The study examines the growing economic burden of 9. Cipriano CA, Brown NM, Michael AM, Moric M, Sporer
periprosthetic joint infection in the United States using SM, Della Valle CJ: Serum and synovial fluid analysis
the Nationwide Inpatient Sample from 2001-2009. The for diagnosing chronic periprosthetic infection in pa-
annual cost of infected revisions increased from $320 mil- tients with inflammatory arthritis. J Bone Joint Surg Am
lion to $566 million during this period and was projected 2012;94(7):594-600. Medline DOI
to be in excess of $1.62 billion by the year 2020 due to
increased demand. In this study, 871 total joint arthroplasties were prospec-
tively evaluated from 2002-2009. Synovial fluid white
2. Hackett DJ, Rothenberg AC, Chen AF, et al: The economic blood cell count and differential performed better than
3: Hip
significance of orthopaedic infections. J Am Acad Orthop serum erythrocyte sedimentation rate and C-reactive pro-
Surg 2015;23(suppl):S1-S7. Medline DOI tein level for diagnosis of PJI. For diagnosing chronic PJI,
the optimal cutoffs for these tests are similar in nonin-
Periprosthetic joint infection in total hip and knee arthro- flammatory and inflammatory arthritis.
plasty is a costly condition to treat and with the current
and future reimbursement models, risk-stratification will 10. Shahi A, Deirmengian C, Higuera C, et al: Premature ther-
be critical to maintain health equity for moderate to high- apeutic antimicrobial treatments can compromise the di-
risk patients. agnosis of late periprosthetic joint infection. Clin Orthop
Section 3: Hip
This was a retrospective study of 161 patients in whom This is a prospective study of which 156 aseptic and septic
late PJI developed after total knee arthroplasty; 53 of revision arthroplasties had tissue and swab cultures col-
these patients were on antibiotics. Premature antibiotic lected. Tissue cultures had a higher sensitivity, specificity,
administration can hinder or delay diagnosis of PJI. Pa- and positive and negative predictive value for diagnosing
tients with suspected late-PJI should not receive antibiotics PJI compared to swab cultures.
before diagnostic testing as it results in lower medians of
laboratory values for those parameters. 17. Parvizi J, Jacovides C, Antoci V, Ghanem E: Diagno-
sis of periprosthetic joint infection: The utility of a sim-
11. Tsaras G, Maduka-Ezeh A, Inwards CY, et al: Utility of ple yet unappreciated enzyme. J Bone Joint Surg Am
intraoperative frozen section histopathology in the diag- 2011;93(24):2242-2248. Medline DOI
nosis of periprosthetic joint infection: A systematic review
and meta-analysis. J Bone Joint Surg Am 2012;94(18): This prospective study examined 108 knees undergoing
1700-1711. Medline DOI revision arthroplasty (30 for PJI). A ++ reading on the
leukocyte esterase colorimetric test was determined to
This review and meta-analysis demonstrated that frozen be positive, and yielded a sensitivity of 80.6%, 100%
section is accurate in predicting a diagnosis of peripros- specificity, positive predictive value of 100%, and neg-
thetic joint infection; however, it has moderate accuracy ative predictive value of 93.3%. Advantages of this test
in ruling out the diagnosis. A diagnostic threshold of 5 or are that it provides real-time results, is simple to use, and
10 PMNs per high-power field can be used for diagnosis. is inexpensive.
12. Alijanipour P, Adeli B, Hansen EN, Chen AF, Parvizi J: 18. Aggarwal VK, Tischler E, Ghanem E, Parvizi J: Leukocyte
Intraoperative purulence is not reliable for diagnosing peri- esterase from synovial fluid aspirate: A technical note.
prosthetic joint infection. J Arthroplasty 2015;30(8):1403- J Arthroplasty 2013;28(1):193-195. Medline DOI
1406. Medline DOI
When using testing leukocyte esterase levels, a bloody
This was a retrospective study of 583 patients undergoing joint aspirate can hinder colorimetric strip testing. To
surgical treatment for PJI. It was determined that pu- circumvent this, a simple protocol was determined using
rulence cannot serve as an absolute diagnostic criterion centrifugation to spin down red blood cells and use the
for PJI due to the absence of an objective definition of supernatant for testing on colorimetric strips.
purulence and its accuracy in diagnosing PJI (sensitivity,
specificity, positive and negative predictive values of 0.82, 19. Deirmengian C, Kardos K, Kilmartin P, Gulati S, Citrano
0.32, 0.91, and 0.17, respectively). P, Booth RE Jr: The alpha-defensin test for periprosthetic
joint infection responds to a wide spectrum of organ-
13. Oethinger M, Warner DK, Schindler SA, Kobayashi H, isms. Clin Orthop Relat Res 2015;473(7):2229-2235.
Bauer TW: Diagnosing periprosthetic infection: False- Medline DOI
positive intraoperative Gram stains. Clin Orthop Relat
Res 2011;469(4):954-960. Medline DOI This was a retrospective analysis of 1,937 samples that
had alpha-defensin testing simultaneously with synovial
This was a retrospective review of 269 Gram stains from fluid cultures performed at the same laboratory. The alpha-
revision arthroplasties. Gram stains yielded a sensitivity defensin test for PJI was positive for a wide spectrum
of 9% and specificity of 99%. False-positive results were of organisms, with all comparisons between organisms
possibly due to stainable but nonviable bacteria used in showing no difference, but culture-positive samples were
commercial broth reagents. significantly different from negative controls.
14. Choi HR, Kwon YM, Freiberg AA, Nelson SB, Malchau 20. Shahi A, Parvizi J, Kazarian GS, et al: The Alpha-defensin
H: Periprosthetic joint infection with negative culture Test for Periprosthetic Joint infection is not affected by
results: Clinical characteristics and treatment outcome. prior antibiotic administration. Clin Orthop Relat Res
J Arthroplasty 2013;28(6):899-903. Medline DOI 2016;474(7):1610-1615. Medline DOI
This is a retrospective comparative study of 40 PJI pa- This retrospective study of 106 hip and knee arthroplasties
tients with negative cultures and 135 PJI patients with with PJI demonstrated that antibiotic administration did
positive cultures. The culture-negative group had a higher not affect alpha-defensin levels during diagnostic testing.
incidence of prior antibiotic use, higher incidence of prior
resection surgery, and lower ESR. The success rate of 21. Frangiamore SJ, Siqueira MB, Saleh A, Daly T, Higuera
infection control was higher in the culture-negative group. CA, Barsoum WK: Synovial cytokines and the MSIS
3: Hip
criteria are not useful for determining infection reso-

15. Schäfer P, Fink B, Sandow D, Margull A, Berger I, From- lution after periprosthetic joint infection explantation
melt L: Prolonged bacterial culture to identify late peri- [published correction appears in Clin Orthop Relat
prosthetic joint infection: A promising strategy. Clin Infect Res 2016;474(7):1740-1741]. Clin Orthop Relat Res
Dis 2008;47(11):1403-1409. Medline DOI 2016;474(7):1630-1639. Medline DOI
This prospective study determined that cytokines and Mus-
16. Aggarwal VK, Higuera C, Deirmengian G, Parvizi J, Aus- culoskeletal Infection Society criteria had low sensitivity
tin MS: Swab cultures are not as effective as tissue cultures to rule out infection after explantation. I nterleukins-6 and
for diagnosis of periprosthetic joint infection. Clin Orthop -1β yielded high sensitivities for diagnosing PJI and also
demonstrated the greatest decrease between both stages Association with complications in men undergoing total
of surgery. joint arthroplasty. J Bone Joint Surg Am 2011;93(4):321-
327. Medline DOI
22. Jacovides CL, Kreft R, Adeli B, Hozack B, Ehrlich GD, This was a retrospective cohort study of 185 patients
Parvizi J: Successful identification of pathogens by poly- who reported drinking alcohol in the year before their
merase chain reaction (PCR)-based electron spray ion- total joint arthroplasty. The authors found that alcohol
ization time-of-flight mass spectrometry (ESI-TOF-MS) screening scores were significantly related to the number
in culture-negative periprosthetic joint infection. J Bone of complications after TJA.
In this prospective study of 80 revision arthroplasty pro- 28. Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert
cedures, Ibis technology detected organisms in 4 of 5 cul- JO: Smoking cessation reduces postoperative complica-
ture-negative cases of suspected PJI and in 88% (50 of tions: A systematic review and meta-analysis. Am J Med
57) in which revision arthroplasty was performed for a 2011;124(2):144-154.e8. Medline DOI
presumed noninfectious etiology.
In this review of 6 randomized trials and 15 observational
studies, the authors found that longer periods of smoking
23. Palestro CJ: FDG-PET in musculoskeletal infections. cessation decreased total postoperative complications.
Semin Nucl Med 2013;43(5):367-376. Medline DOI
FDG-PET has several uses for workup of a musculoskeletal 29. Bombardier C, Hazlewood GS, Akhavan P, et al; Cana-
infection, including anatomic localization, semiquantita- dian Rheumatology Association recommendations for
tive analysis, detecting acute and subacute musculoskeletal the pharmacological management of rheumatoid arthri-
infections, diagnosing chronic and low-grade infection tis with traditional and biologic disease-modifying anti-
because FDG accumulates in macrophages, and it is partic- rheumatic drugs: Part II. Safety. J Rheumatol 2012;39(8):
ularly useful in detecting spinal osteomyelitis. For diagnos- 1583-1602. Medline DOI
ing PJI, it has a sensitivity of 87% and specificity of 82%.
Recommendations set forth by the Canadian Rheuma-
tology Association are presented for perioperative care
24. Diaz-Ledezma C, Lamberton C, Lichstein P, Parvizi J: of patients with rheumatoid arthritis.
Diagnosis of periprosthetic joint infection: The role of
nuclear medicine may be overestimated. J Arthroplasty
2015;30(6):1044-1049. Medline DOI 30. Tokarski AT, Blaha D, Mont MA, et al: Perioperative skin
preparation. J Orthop Res 2014;32(S1suppl 1):S26-S30.
A systematic review of studies published between 2004 and Medline DOI
2012 demonstrated a high risk of bias and concern for
clinical use. The authors recommend that nuclear imaging This article from the International Consensus Meeting on
for PJI should be limited to select cases. periprosthetic joint infection discusses current evidence
on perioperative skin preparation for patients undergoing
total joint arthroplasty.
25. Umpierrez GE, Hellman R, Korytkowski MT, et al; En-
docrine Society: Management of hyperglycemia in hospi-
talized patients in non-critical care setting: An endocrine 31. Stocks GW, Self SD, Thompson B, Adame XA, O’Connor
society clinical practice guideline. J Clin Endocrinol DP: Predicting bacterial populations based on airborne
Metab 2012;97(1):16-38. Medline DOI particulates: A study performed in nonlaminar flow oper-
ating rooms during joint arthroplasty surgery. Am J Infect
This is an evidence-based guideline that showed that im- Control 2010;38(3):199-204. Medline DOI
provement in glycemic control results in lower rates of
complications. Patients with hyperglycemia, particularly 32. Panahi P, Stroh M, Casper DS, Parvizi J, Austin MS: Op-
those with diabetes, can have impaired wound healing erating room traffic is a major concern during total joint
and suboptimal defenses against bacteria. This guideline arthroplasty. Clin Orthop Relat Res 2012;470(10):2690-
provides recommendations for glycemic targets and pro- 2694. Medline DOI
vides protocols to facilitate this.
This is an observational study of 80 primary and 36 revi-
26. Iorio R, Williams KM, Marcantonio AJ, Specht LM, Til- sion total joint arthroplasties. Revision cases demonstrated
zey JF, Healy WL: Diabetes mellitus, hemoglobin A1c, a high rate of traffic, which may increase particulate count,
and the incidence of total joint arthroplasty infection. including bacteria, in the operating room and may lead to
J Arthroplasty 2012;27(5):726-9.e1. Medline DOI an increased risk for infection. 3: Hip
This was a retrospective study of 4,241 primary or revi- 33. Namba RS, Inacio MC, Paxton EW: Risk factors associ-
sion total joint arthroplasties (hips and knees). The au- ated with deep surgical site infections after primary total
thors demonstrated that patients with diabetes were at knee arthroplasty: An analysis of 56,216 knees. J Bone
a significantly higher risk for infection after total joint Joint Surg Am 2013;95(9):775-782. Medline DOI
arthroplasty compared to patients without diabetes, and
they did not find hemoglobin A1c levels to be reliable in This was a retrospective review of a registry containing
predicting PJI risk. 56,216 total knee arthroplasties, and identifies patient
and surgical factors associated with deep surgical site
27. Harris AH, Reeder R, Ellerbe L, Bradley KA, Rubin- infections.
sky AD, Giori NJ: Preoperative alcohol screening scores:
Section 3: Hip
34. Spahn DR: Anemia and patient blood management in hip 41. O’Toole P, Osmon D, Soriano A, et al: Oral antibiot-
and knee surgery: A systematic review of the literature. ic therapy. J Arthroplasty 2014;29(2suppl):115-118.
Anesthesiology 2010;113(2):482-495. Medline DOI Medline DOI
This article from the International Consensus Meeting
35. Alshryda S, Sarda P, Sukeik M, Nargol A, Blenkinsopp J, discusses PJI and the role of antibiotic therapy in PJI.
Mason JM: Tranexamic acid in total knee replacement:
A systematic review and meta-analysis. J Bone Joint Surg
Br 2011;93(12):1577-1585. Medline DOI 42. Jiranek WA, Waligora AC, Hess SR, Golladay GL: Surgical
treatment of prosthetic joint infections of the hip and knee:
This was a systematic review and meta-analysis of 19 ran- Changing paradigms? J Arthroplasty 2015;30(6):912-918.
domized controlled trials evaluating effects of tranexamic Medline DOI
acid in total knee arthroplasty. The evidence demonstrates
that tranexamic acid resulted in significantly lower use of Recent changes to the indications and techniques for treat-
blood transfusion and does not demonstrate an increased ment and management of periprosthetic joint infection
risk of venous thromboembolic events. are reviewed.
36. Brown NM, Cipriano CA, Moric M, Sporer SM, Della 43. Azzam KA, Seeley M, Ghanem E, Austin MS, Purtill JJ,
Valle CJ: Dilute betadine lavage before closure for the pre- Parvizi J: Irrigation and debridement in the management of
vention of acute postoperative deep periprosthetic joint in- prosthetic joint infection: Traditional indications revisited.
fection. J Arthroplasty 2012;27(1):27-30. Medline DOI J Arthroplasty 2010;25(7):1022-1027. Medline DOI
This was a retrospective study of 1,862 total joint arthro- 44. Haasper C, Buttaro M, Hozack W, et al: Irrigation and
plasties without dilute povidone-iodine lavage compared debridement. J Orthop Res 2014;32(suppl 1):S130-S135.
to 688 consecutive cases with dilute povidone-iodine la- Medline DOI
vage. It was determined that povidone-iodine lavage before
wound closure significantly reduced acute postoperative This article from the International Consensus Meeting on
infections (90 days postoperatively). PJI discusses the role of irrigation and débridement in PJI.
37. Springer BD, Beaver WB, Griffin WL, Mason JB, Odum 45. Lora-Tamayo J, Murillo O, Iribarren JA, et al; REIPI
SM: Role of surgical dressings in total joint arthroplasty: Group for the Study of Prosthetic Infection: A large
A randomized controlled trial. Am J Orthop (Belle Mead multicenter study of methicillin-susceptible and meth-
NJ) 2015;44(9):415-420. Medline icillin-resistant Staphylococcus aureus prosthetic joint
infections managed with implant retention. Clin Infect
This was a randomized controlled trial of 262 patients Dis 2013;56(2):182-194. Medline DOI
comparing the efficacy of two surgical dressings: occlusive
antimicrobial barrier dressing versus traditional dress- This is a multi-institutional, retrospective case series of
ing. The occlusive dressing had less wound complications PJI caused by S. aureus managed with DAIR. The suc-
and fewer dressing changes, and patient satisfaction was cess rate was 55% with no overall prognostic differences
higher. between methicillin-susceptible and methicillin-resistant
Staphylococcus aureus–PJI.
38. Zmistowski B, Tetreault MW, Alijanipour P, Chen AF,
Della Valle CJ, Parvizi J: Recurrent periprosthetic joint 46. Koyonos L, Zmistowski B, Della Valle CJ, Parvizi J:
infection: Persistent or new infection? J Arthroplasty Infection control rate of irrigation and débridement for
2013;28(9):1486-1489. Medline DOI periprosthetic joint infection. Clin Orthop Relat Res
2011;469(11):3043-3048. Medline DOI
This was a multi-institutional, retrospective study that
identified 92 patients in whom two-stage exchange arthro- This is a retrospective study of 138 total joint arthroplas-
plasty failed. Twenty-nine of these patients (31.5%) had ties that were treated with irrigation and débridement from
identical organisms at treatment failure. Positive cultures two institutions. Sixty-five percent of joints did not have
at reimplantation and a higher comorbidity index were infection adequately controlled, and thus it was recom-
associated with higher rates of recurrent infection due to mended that irrigation and débridement be reserved for
new organisms. specific indications.
39. Tande AJ, Patel R: Prosthetic joint infection. Clin Micro- 47. Kordelle J, Frommelt L, Klüber D, Seemann K: [Results
biol Rev 2014;27(2):302-345. Medline DOI of one-stage endoprosthesis revision in periprosthetic
3: Hip
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48. Gehrke T, Kendoff D: Peri-prosthetic hip infections: In
40. Azzam K, Parvizi J, Jungkind D, et al: Microbiological, favour of one-stage. Hip Int 2012;22(suppl 8):S40-S45.
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Am 2009;91(Suppl 6suppl 6):142-149. Medline DOI The one-stage exchange arthroplasty for treatment of
PJI is reviewed. Advantages include a reduced number of
surgical interventions, decreased hospital stay, and quicker This was a retrospective study of 27 hip-joint empyemas
mobilization. Surgical considerations are discussed. that underwent Girdlestone arthroplasty. The infection
control rate was 96%, with significant pain relief despite
49. Lie SA, Havelin LI, Furnes ON, Engesaeter LB, Vollset SE: poor functional results overall.
Failure rates for 4762 revision total hip arthroplasties in
the Norwegian Arthroplasty Register. J Bone Joint Surg 59. Meek RM, Norwood T, Smith R, Brenkel IJ, Howie CR:
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50. Yoo JJ, Kwon YS, Koo KH, Yoon KS, Kim YM, Kim HJ: Br 2011;93(1):96-101. Medline DOI
One-stage cementless revision arthroplasty for infected This longitudinal study evaluates the incidence of PPFs
hip replacements. Int Orthop 2009;33(5):1195-1201. in a cohort of 52,136 primary total hip replacements,
Medline DOI 8,726 revision total hip replacements, 44,511 primary
total knee replacements (TKRs), and 3,222 revision TKRs
51. Winkler H, Kaudela K, Stoiber A, Menschik F: Bone grafts that were performed over an 11-year period. Five years
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Cell Tissue Bank 2006;7(4):319-323. Medline DOI replacement, 0.6% after primary TKR, and 1.7% after
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52. Gehrke T, Zahar A, Kendoff D: One-stage exchange: It
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63. Haidukewych GJ, Jacofsky DJ, Hanssen AD, Lewallen
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56. Shukla SK, Ward JP, Jacofsky MC, Sporer SM, Pa- The authors present a retrospective review of 2,423 consec-
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persistent sepsis following resection arthroplasty of the rate was 4.4% when using two different primary cement-
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65. Meek RM, Garbuz DS, Masri BA, Greidanus NV, Duncan
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66. Masri BA, Meek RM, Duncan CP: Periprosthetic frac-

This was a retrospective study of 504 cases of PJI that were tures evaluation and treatment. Clin Orthop Relat Res
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Section 3: Hip
This latest knowledge on periprosthetic fractures is pre- screws and cables proximally around the stem provided
sented, along with a new comprehensive Unified Classi- the best fixation. Level of evidence IV.
fication System on periprosthetic fractures, combining
the original Vancouver classification with the AO/Or- 74. Dehghan N, McKee MD, Nauth A, Ristevski B, Schemitsch
thopaedic Trauma Association Fracture and Dislocation EH: Surgical fixation of Vancouver type B1 periprosthetic
Classification. femur fractures: A systematic review. J Orthop Trauma
2014;28(12):721-727. DOI Medline
68. Duncan CP, Haddad FS: The Unified Classification Sys-
tem (UCS): Improving our understanding of peripros- The authors present a systematic review of articles evalu-
thetic fractures. Bone Joint J 2014;96-B(6):713-716. ating union rates in patients with B1 PPFs. Locking plates
Medline DOI had a significantly higher rate of nonunion (3% vs. 9% P =
0.02) and a trend toward a higher rate of hardware failure
An overview of the Unified Classification System is pre- (2% vs. 7%, P = 0.07). Level of evidence: I.
sented, along with a description of the types of peripros-
thetic fractures and approach to treatment. 75. Moore RE, Baldwin K, Austin MS, Mehta S: A sys-
tematic review of open reduction and internal fixation
69. Vioreanu MH, Parry MC, Haddad FS, Duncan CP: Field of periprosthetic femur fractures with or without al-
testing the Unified Classification System for peri-pros- lograft strut, cerclage, and locked plates. J Arthroplasty
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replacement: An international collaboration. Bone Joint
J 2014;96-B(11):1472-1477. Medline DOI The authors present a systematic review of studies eval-
uating union rates in type B1 and C PPFs. Percent union
The authors present the interobserver and intraobserver was similar for B1 fractures treated with or without an
agreement for the Unified Classification System as applied allograft strut (90.7% vs. 91.5%). Time to union (4.4 vs.
to the pelvis and femur using 20 examples of PPF in 17 pa- 6.6 months) and deep infection (3.8% vs. 8.3%) were
tients. The results varied from 0.728 to 0.92 depending on increased with use of allograft struts. Level of evidence: I.
level of training and anatomic region evaluated.
76. Munro JT, Masri BA, Garbuz DS, Duncan CP: Tapered
70. Wang JW, Chen LK, Chen CE: Surgical treatment of fluted modular titanium stems in the management of Van-
fractures of the greater trochanter associated with osteo- couver B2 and B3 peri-prosthetic fractures. Bone Joint
lytic lesions: Surgical technique. J Bone Joint Surg Am J 2013;95-B(11suppl A):17-20. Medline DOI
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The authors present a retrospective case series of 55 pa-
tients who received a tapered fluted modular titanium stem
71. Zeh A, Radetzki F, Diers V, Bach D, Röllinghoff M, Delank for management of a type B2 or B3 PPF. Stem survival
KS: Is there an increased stem migration or compromised at a mean of 54 months was 96%. Level of evidence: IV.
osteointegration of the Mayo short-stemmed prosthesis
following cerclage wiring of an intrasurgical periprosthetic
fracture? Arch Orthop Trauma Surg 2011;131(12):1717- 77. Munro JT, Garbuz DS, Masri BA, Duncan CP: Tapered
1722. Medline DOI fluted titanium stems in the management of Vancouver
B2 and B3 periprosthetic femoral fractures. Clin Orthop
The authors present a retrospective review of 38 patients Relat Res 2014;472(2):590-598. Medline DOI
who sustained an intraoperative B2 calcar fracture treated
with cerclage wiring. No difference could be found with The authors present a retrospective review of 55 type B2 or
regard to osseointegration or implant loosening when B3 PPFs treated with a tapered fluted titanium stem. Two
compared to a no-fracture cohort. Level of evidence: IV. stems required revision, one for loosening and subsidence
greater than 10 mm and one for infection. Maintenance
or improvement of bone stock was seen in 89% and subsi-
72. Demos HA, Briones MS, White PH, Hogan KA, Barfield dence was noted in 24% of cases, but only two patients
WR: A biomechanical comparison of periprosthetic femo- had subsidence greater than 10 mm. Level of evidence: IV.
ral fracture fixation in normal and osteoporotic cadaveric
bone. J Arthroplasty 2012;27(5):783-788. Medline DOI
78. Al-Taki MM, Masri BA, Duncan CP, Garbuz DS: Quality
The authors present a biomechanical study of cadaver of life following proximal femoral replacement using a
femurs with simulated PPFs. Four different proximal con- modular system in revision THA. Clin Orthop Relat Res
structs were tested in axial load to failure. A combination 2011;469(2):470-475. Medline DOI
of screws and cables proximally around the stem provided
3: Hip
the strongest fixation. Level of evidence: IV. The authors present a retrospective review of 63 patients
who received a proximal femoral replacement in treatment
of their PPF. At a mean follow-up of 3.2 years, patients
73. Chen DW, Lin CL, Hu CC, Wu JW, Lee MS: Finite ele- showed modest improvements in Western Ontario and
ment analysis of different repair methods of Vancouver McMaster Universities Arthritis Index, Oxford, and Medi-
B1 periprosthetic fractures after total hip arthroplasty. cal Outcomes Study 12-Item Short Form scores. High rates
Injury 2012;43(7):1061-1065. Medline DOI of hip instability led the authors to suggest a constrained
The authors used finite element analysis to evaluate dif- liner in all cases with good acetabular fixation. Level of
ferent fixation constructs for B1 PPFs. A combination of evidence: IV.
79. Froberg L, Troelsen A, Brix M: Periprosthetic Vancouver dislocation after total hip arthroplasty. Bone Joint
type B1 and C fractures treated by locking-plate osteo- J 2015;97-B(8):1046-1049. Medline DOI
synthesis: Fracture union and reoperations in 60 con-
secutive fractures. Acta Orthop 2012;83(6):648-652. A retrospective study of the functional outcomes and costs
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is presented.
The authors present a retrospective review of 58 consec-
utive patients with either a B1 or C PPF treated using a 87. Joshi A, Lee CM, Markovic L, Vlatis G, Murphy JC:
locking plate. Evaluation of patients requiring reoperation Prognosis of dislocation after total hip arthroplasty. J Ar-
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avoid stress-rising areas is important for successful treat-
ment. Level of evidence: IV. 88. Wera GD, Ting NT, Moric M, Paprosky WG, Sporer
SM, Della Valle CJ: Classification and management
80. Ehlinger M, Adam P, Di Marco A, Arlettaz Y, Moor B-K, of the unstable total hip arthroplasty. J Arthroplasty
Bonnomet F: Periprosthetic femoral fractures treated by 2012;27(5):710-715. Medline DOI
locked plating: Feasibility assessment of the mini-in-
vasive surgical option: A prospective series of 36 frac- This review paper proposes a classification system of hip
tures. Orthop Traumatol Surg Res 2011;97(6):622-628. dislocation by etiology.
Medline DOI
89. Carter AH, Sheehan EC, Mortazavi SM, Purtill JJ, Shar-
The authors present a prospective series of 36 patients key PF, Parvizi J: Revision for recurrent instability: What
treated with minimally invasive plate osteosynthesis us- are the predictors of failure? J Arthroplasty 2011;26
ing locking plate technology. They reported high rates (6suppl):46-52. Medline DOI
of union (35 of 36 cases) and low rates of malalignment.
Level of evidence: IV. A retrospective review of hip dislocations treated surgi-
cally, identifying predictors of recurrent dislocation, is
81. Malkani AL, Ong KL, Lau E, Kurtz SM, Justice BJ, presented.
Manley MT: Early- and late-term dislocation risk after
primary hip arthroplasty in the Medicare population. 90. Woo RY, Morrey BF: Dislocations after total hip arthro-
J Arthroplasty 2010;25(6suppl):21-25. Medline DOI plasty. J Bone Joint Surg Am 1982;64(9):1295-1306.
Medline
This study of the Medicare National Sample from 1998 to
2007 compared dislocation rates over time.
91. Sanchez-Sotelo J, Berry DJ: Epidemiology of instabili-
ty after total hip replacement. Orthop Clin North Am
82. Haynes JA, Stambough JB, Sassoon AA, Johnson SR, 2001;32(4):543-552. Medline DOI
Clohisy JC, Nunley RM: Contemporary surgical indica-
tions and referral trends in revision total hip arthroplasty:
A 10-year review. J Arthroplasty 2016;31(3):622-625. 92. Masonis JL, Bourne RB: Surgical approach, abductor
Medline DOI function, and total hip arthroplasty dislocation. Clin
Orthop Relat Res 2002;405:46-53. Medline DOI
A study of referrals to a single large volume center is
presented. 93. Hummel MT, Malkani AL, Yakkanti MR, Baker DL: De-
creased dislocation after revision total hip arthroplasty us-
83. Jo S, Jimenez Almonte JH, Sierra RJ: The cumulative risk ing larger femoral head size and posterior capsular repair.
of re-dislocation after revision THA performed for insta- J Arthroplasty 2009;24(6suppl):73-76. Medline DOI
bility increases close to 35% at 15 years. J Arthroplasty
2015;30(7):1177-1182. Medline DOI 94. Abdel MP, von Roth P, Jennings MT, Hanssen AD, Pag-
A retrospective analysis of 539 hips undergoing revision nano MW: What safe zone? The vast majority of dis-
for dislocation with long-term follow-up. located THAs are within the Lewinnek safe zone for
acetabular component position. Clin Orthop Relat Res
2016;474(2):386-391. Medline DOI
84. Sanchez-Sotelo J, Haidukewych GJ, Boberg CJ: Hos-
pital cost of dislocation after primary total hip arthro- In a retrospective review of hip dislocations, cup position
plasty. J Bone Joint Surg Am 2006;88(2):290-294. compared to classically described safe zones is examined.
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95. Ranawac C, Maynard M: Modern technique of cemented
3: Hip
85. de Palma L, Procaccini R, Soccetti A, Marinelli M: Hos- total hip arthroplasty. Tech Orthop 1991;6(3):17-25. DOI
pital cost of treating early dislocation following hip ar-
throplasty. Hip Int 2012;22(1):62-67. Medline DOI 96. Pulos N, Tiberi Iii JV III, Schmalzried TP: Measuring
A study of the direct hospital costs of early dislocation acetabular component position on lateral radiographs -
is presented. ischio-lateral method. Bull NYU Hosp Jt Dis 2011;69
(suppl 1):S84-S89. Medline
86. Abdel MP, Cross MB, Yasen AT, Haddad FS: The func- This study describes a technique of more accurately mea-
tional and financial impact of isolated and recurrent suring acetabular cup position on lateral radiographs
compared to prior techniques.
Section 3: Hip
97. Kung PL, Ries MD: Effect of femoral head size and ab- In this technique paper and case series, gluetus maximus
ductors on dislocation after revision THA. Clin Orthop transfer for abductor deficiency is described.
Relat Res 2007;465(465):170-174. Medline
108. Berend KR, Lombardi AV Jr, Mallory TH, Adams JB,
98. Hailer NP, Weiss RJ, Stark A, Kärrholm J: Dual-mobility Russell JH, Groseth KL: The long-term outcome of
cups for revision due to instability are associated with a 755 consecutive constrained acetabular components in to-
low rate of re-revisions due to dislocation: 228 patients tal hip arthroplasty: Examining the successes and failures.
from the Swedish Hip Arthroplasty Register. Acta Orthop J Arthroplasty 2005;20(7suppl 3):93-102. Medline DOI
2012;83(6):566-571. Medline DOI
Dual-mobility cups used in revision surgery secondary to 109. Chalmers BP, Arsoy D, Sierra RJ, Lewallen DG, Trous-
instability are retrospectively reviewed. dale RT: High failure rate of modular exchange with a
specific design of a constrained liner in high-risk patients
undergoing revision total hip arthroplasty. J Arthroplasty
99. Langlais FL, Ropars M, Gaucher F, Musset T, Chaix O: 2016; Feb 17 [Epub ahead of print]. Medline DOI
Dual mobility cemented cups have low dislocation rates in
THA revisions. Clin Orthop Relat Res 2008;466(2):389- A retrospective review of patients undergoing hip revisions
395. Medline DOI with a specific constrained liner is presented.
100. Philippot R, Adam P, Reckhaus M, et al: Prevention of dis- 110. Della Valle CJ, Chang D, Sporer S, Berger RA, Rosenberg
location in total hip revision surgery using a dual mobility AG, Paprosky WG: High failure rate of a constrained
design. Orthop Traumatol Surg Res 2009;95(6):407-413. acetabular liner in revision total hip arthroplasty.
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101. Mohammed R, Hayward K, Mulay S, Bindi F, Wallace M: 111. Xue E, Su Z, Chen C, Wong PK, Wen H, Zhang Y: An in-
Outcomes of dual-mobility acetabular cup for instability traoperative device to restore femoral offset in total hip ar-
in primary and revision total hip arthroplasty. J Orthop throplasty. J Orthop Surg Res 2014;9:58. Medline DOI
Traumatol 2015;16(1):9-13. Medline DOI
The authors describe the use of an intraoperative device
A retrospective review of patients with primary and revi- (length-offset lever) in 51 patients undergoing primary
sion hip arthroplasty using dual mobility liners at a single THA to minimize limb-length discrepancy. It was found
center is presented. to be a useful tool to restore anatomic femoral offset and
height of femoral head, with no complications associated
102. Matsen Ko LJ, Pollag KE, Yoo JY, Sharkey PF: Serum met- with the use of the device.
al ion levels following total hip arthroplasty with modular
dual mobility components. J Arthroplasty 2016;31(1):186- 112. Woolson ST, Hartford JM, Sawyer A: Results of a method
189. Medline DOI of leg-length equalization for patients undergoing primary
total hip replacement. J Arthroplasty 1999;14(2):159-164.
A prospective study of metal ion levels and possible adverse Medline DOI
soft-tissue reactions in 100 consecutive patients with dual
mobility liners is presented.
113. Whitehouse MR, Stefanovich-Lawbuary NS, Brunton
LR, Blom AW: The impact of leg length discrepancy on
103. Parvizi J, Morrey BF: Bipolar hip arthroplasty as a salvage patient satisfaction and functional outcome following total
treatment for instability of the hip. J Bone Joint Surg Am hip arthroplasty. J Arthroplasty 2013;28(8):1408-1414.
2000;82-A(8):1132-1139. Medline Medline DOI
104. Ries MD, Wiedel JD: Bipolar hip arthroplasty for recur- 114. Sarin VK, Pratt WR, Bradley GW: Accurate femur re-
rent dislocation after total hip arthroplasty. A report of positioning is critical during intraoperative total hip ar-
three cases. Clin Orthop Relat Res 1992;278:121-127. throplasty length and offset assessment. J Arthroplasty
Medline 2005;20(7):887-891. Medline DOI
105. Grigoris P, Grecula MJ, Amstutz HC: Tripolar hip replace- 115. Röder C, Vogel R, Burri L, Dietrich D, Staub LP: Total
ment for recurrent prosthetic dislocation. Clin Orthop hip arthroplasty: Leg length inequality impairs functional
Relat Res 1994;304:148-155. Medline outcomes and patient satisfaction. BMC Musculoskelet
Disord 2012;13:95. Medline DOI
3: Hip
106. Kaplan SJ, Thomas WH, Poss R: Trochanteric advance-

ment for recurrent dislocation after total hip arthroplasty. This study examined 478 cases with postoperative leng-
J Arthroplasty 1987;2(2):119-124. Medline DOI thening and 275 with shortening and matched the groups
with 3 controls each. Walking capacity, limping, and pa-
107. Whiteside LA: Surgical technique: Transfer of the ante- tient satisfaction were significantly associated with limb
rior portion of the gluteus maximus muscle for abductor lengthening, whereas pain alleviation was not. Limping,
deficiency of the hip. Clin Orthop Relat Res 2012;470(2): patient satisfaction, and hip pain were significantly associ-
503-510. Medline DOI ated with shortening, whereas walking capacity was not.
116. Ranawat CS, Rodriguez JA: Functional leg-length in- 124. Maloney WJ, Keeney JA: Leg length discrepancy after
equality following total hip arthroplasty. J Arthroplasty total hip arthroplasty. J Arthroplasty 2004;19(4suppl 1):
1997;12(4):359-364. Medline DOI 108-110. Medline DOI
117. Ranawat CS: The pants too short, the leg too long! 125. Kaplan FS, Chakkalakal SA, Shore EM: Fibrodysplasia
Orthopedics 1999;22(9):845-846. Medline ossificans progressiva: Mechanisms and models of skele-
tal metamorphosis. Dis Model Mech 2012;5(6):756-762.
118. Parvizi J, Sharkey PF, Bissett GA, Rothman RH, Hozack DOI Medline
WJ: Surgical treatment of limb-length discrepancy follow- A review of the role of ACVR1 mutation in fibrodysplasia
ing total hip arthroplasty. J Bone Joint Surg Am 2003; ossificans progressiva with regard to progressive hetero-
85-A(12):2310-2317. Medline topic endochondral ossification is presented. A knock-in
mouse model for fibrodysplasia ossificans progressiva may
119. Ogawa K, Kabata T, Maeda T, Kajino Y, Tsuchiya H: help the understanding of human development of hetero-
Accurate leg length measurement in total hip arthroplasty: topic ossification and its treatment.
A comparison of computer navigation and a simple manual
measurement device. Clin Orthop Surg 2014;6(2):153- 126. Peterson JR, Okagbare PI, De La Rosa S, et al: Early
158. Medline DOI detection of burn induced heterotopic ossification using
This was a retrospective study comparing 30 computer- transcutaneous Raman spectroscopy. Bone 2013;54(1):
assisted THAs with 40 THAs using a manual measure- 28-34. Medline DOI
ment device; there was no significant difference in the A mouse model of heterotopic ossification was used to
postoperative limb-length discrepancy between both demonstrate that transcutaneous Raman spectroscopy can
groups. be used to identify formation of heterotopic ossification as
early as 5 days following an injury. The earliest point at
120. Nam D, Sculco PK, Abdel MP, Alexiades MM, Figgie MP, which heterotopic ossification was identified using micro-
Mayman DJ: Leg-length inequalities following THA based CT was 3 weeks.
on surgical technique. Orthopedics 2013;36(4):e395-e400.
Medline DOI 127. Ranganathan K, Loder S, Agarwal S, et al: Heterotop-
Three surgical approaches were compared for accura- ic ossification: Basic-science principles and clinical cor-
cy of limb length restoration: anterior with fluoroscopy, relates. J Bone Joint Surg Am 2015;97(13):1101-1111.
conventional posterior, and computer-assisted posteri- Medline DOI
or THA. Measurements were performed on standing A review of the epidemiology, presentation, risk factors,
anterior-posterior radiographs. Mean ±SD absolute limb- management, and current research related to heterotopic
length inequality were 3.8±3.9, 3.9±3.0, and 3.9±2.7 mm, ossification is presented.
respectively, demonstrating that all methods provided
reliable limb-length equalization.
128. Sakellariou VI, Grigoriou E, Mavrogenis AF, Soucacos
PN, Papagelopoulos PJ: Heterotopic ossification follow-
121. Meermans G, Malik A, Witt J, Haddad F: Preopera- ing traumatic brain injury and spinal cord injury: Insight
tive radiographic assessment of limb-length discrep- into the etiology and pathophysiology. J Musculoskelet
ancy in total hip arthroplasty. Clin Orthop Relat Res Neuronal Interact 2012;12(4):230-240. Medline
2011;469(6):1677-1682. Medline DOI
This article analyzes the complex pathophysiology of
This study validated different methods for preoperative neurogenic heterotopic ossification along with its current
radiographic measurements of limb- length discrepancy management and prognosis.
and evaluated their reliability. The interteardrop line
was found to be a more accurate pelvic reference than the
bi-ischial line. There was substantial agreement when the 129. Shore EM, Kaplan FS: Role of altered signal transduction
lesser trochanter was used as a femoral reference. in heterotopic ossification and fibrodysplasia ossificans
progressiva. Curr Osteoporos Rep 2011;9(2):83-88.
Medline DOI
122. Della Valle AG, Padgett DE, Salvati EA: Preoperative
planning for primary total hip arthroplasty. J Am Acad This study reviews the discovery of the activating muta-
Orthop Surg 2005;13(7):455-462. Medline DOI tion of ACVR1/ALK2, a BMP receptor, in fibrodysplasia
ossificans progressiva and the roles of the BMP signaling
123. Lambers A, Jennings R, Bucknill A: Does computer navi- pathway in regulating normal and pathologic events lead-
3: Hip
gation help the surgeon to achieve pre-operative leg length ing to new bone formation.
and offset targets in total hip arthroplasty? Bone Joint
J 2013;95-B(suppl 15):110. 130. Aubut J-A, Mehta S, Cullen N, Teasell RW; ERABI Group;
Scire Research Team: A comparison of heterotopic ossi-
This was a study of 61 patients (24 prospective cases un- fication treatment within the traumatic brain and spinal
dergoing navigated THA, and a retrospective series of cord injured population: An evidence based systematic re-
37 patients who underwent THA without navigation). view. NeuroRehabilitation 2011;28(2):151-160. Medline
Femoral offset targets were better achieved in the navi-
gated cohort, but no difference was found in limb-length This systematic review of the literature on interventions to
management between both groups. prevent or treat heterotopic ossification in populations that
Section 3: Hip
had sustained spinal cord injury or traumatic brain injury 139. Kaplan FS, Glaser DL, Hebela N, Shore EM: Heterotopic
found that NSAIDs showed the greatest efficacy in the ossification. J Am Acad Orthop Surg 2004;12(2):116-125.
prevention of heterotopic ossification when administered Medline DOI
early. Diphosphonates were the most effective treatment
strategy in spinal cord injury, whereas surgical excision 140. Kan S-L, Yang B, Ning G-Z, et al: Nonsteroidal anti-
was the most effective treatment strategy in the traumatic inflammatory drugs as prophylaxis for heterotopic ossifi-
brain injury population. cation after total hip arthroplasty: A systematic review and
meta-analysis. Medicine (Baltimore) 2015;94(18):e828.
131. Zhu Y, Zhang F, Chen W, Zhang Q, Liu S, Zhang Y: Medline DOI
Incidence and risk factors for heterotopic ossification af-
ter total hip arthroplasty: A meta-analysis. Arch Orthop This meta-analysis indicated that NSAIDs significantly
Trauma Surg 2015;135(9):1307-1314. Medline DOI decreased the incidence of heterotopic ossification after
THA. There was no statistical difference in prevention of
A meta-analysis of 14 studies involving 6,468 cases of heterotopic ossification between selective and nonselective
THA found a 30% overall rate of heterotopic ossification NSAIDs, though discontinuation secondary to gastroin-
and identified risk factors, including male sex, cemented testinal side effects was higher with nonselective NSAIDs.
implant, bilateral procedures, ankylosing spondylitis, and
ankylosed hip, for the development of heterotopic ossifica- 141. Vasileiadis GI, Sakellariou VI, Kelekis A, et al: Prevention
tion postoperatively. Rheumatoid arthritis was protective of heterotopic ossification in cases of hypertrophic osteo-
against heterotopic ossification. arthritis submitted to total hip arthroplasty. Etidronate
or indomethacin? J Musculoskelet Neuronal Interact
132. Chalmers J, Gray DH, Rush J: Observations on the 2010;10(2):159-165. Medline
induction of bone in soft tissues. J Bone Joint Surg Br
1975;57(1):36-45. Medline This study compares two groups receiving either eti-
dronate or indomethacin following THA for the preven-
tion of heterotopic ossification with a mean follow-up of
133. Balboni TA, Gobezie R, Mamon HJ: Heterotopic ossi- 36 months. There was no statistical difference between
fication: Pathophysiology, clinical features, and the role clinical and radiographic outcomes regarding development
of radiotherapy for prophylaxis. Int J Radiat Oncol Biol of heterotopic ossification, though etidronate was six times
Phys 2006;65(5):1289-1299. Medline DOI more expensive.
134. Dalury DF, Jiranek WA: The incidence of heterotopic 142. Cobb TK, Berry DJ, Wallrichs SL, Ilstrup DM, Morrey
ossification after total knee arthroplasty. J Arthroplasty BF: Functional outcome of excision of heterotopic ossifi-
2004;19(4):447-452. Medline DOI cation after total hip arthroplasty. Clin Orthop Relat Res
1999;361:131-139. Medline DOI
135. Board TN, Karva A, Board RE, Gambhir AK, Porter ML:
The prophylaxis and treatment of heterotopic ossification 143. Wick M, Müller EJ, Hahn MP, Muhr G: Surgical excision
following lower limb arthroplasty. J Bone Joint Surg Br of heterotopic bone after hip surgery followed by oral
2007;89(4):434-440. Medline DOI indomethacin application: Is there a clinical benefit for
the patient? Arch Orthop Trauma Surg 1999;119(3-4):
136. Perosky JE, Peterson JR, Eboda ON, et al: Early detection 151-155. Medline DOI
of heterotopic ossification using near-infrared optical im-
aging reveals dynamic turnover and progression of min- 144. Troutman DA, Dougherty MJ, Spivack AI, Calligaro KD:
eralization following Achilles tenotomy and burn injury. Updated strategies to treat acute arterial complications
J Orthop Res 2014;32(11):1416-1423. Medline DOI associated with total knee and hip arthroplasty. J Vasc
A mouse model of heterotopic ossification was used to Surg 2013;58(4):1037-1042. Medline DOI
demonstrate that near-infrared optical imaging could be Endovascular treatment for acute arterial complications
used to identify heterotopic ossification at a much earlier of TKA and THA provides faster vascular restoration,
point (as early as 5 days) compared to micro-CT (5 weeks). with less morbidity than open repair, and equivalent sat-
isfactory outcomes.
137. Brooker AF, Bowerman JW, Robinson RA, Riley LH Jr:
Ectopic ossification following total hip replacement. In- 145. Shubert D, Madoff S, Milillo R, Nandi S: Neurovascu-
cidence and a method of classification. J Bone Joint Surg lar structure proximity to acetabular retractors in total
Am 1973;55(8):1629-1632. Medline
3: Hip
hip arthroplasty. J Arthroplasty 2015;30(1):145-148.

Medline DOI
138. Della Valle AG, Ruzo PS, Pavone V, Tolo E, Mintz DN,
Salvati EA: Heterotopic ossification after total hip ar- The anterior inferior iliac spine is the safest anterior ace-
throplasty: A critical analysis of the Brooker classification tabular retractor position during THA. Posterior retrac-
and proposal of a simplified rating system. J Arthroplasty tor position should be monitored closely due to the close
2002;17(7):870-875. DOI Medline proximity of the sciatic nerve, particularly in women.
146. Alshameeri Z, Bajekal R, Varty K, Khanduja V: Iatrogenic

vascular injuries during arthroplasty of the hip. Bone Joint
J 2015;97-B(11):1447-1455. Medline DOI
The rate of vascular injuries and mortality during THA reduction for Crowe IV developmental dysplasia of the hip.
over the past 22 years has been similar, but rates of ampu- J Arthroplasty 2013;28(6):1052-1054. Medline DOI
tation and permanent disability have become lower, espe-
cially in patients managed by percutaneous endovascular The goal of this THA technique, involving an anterior
strategies rather than by open exploration. approach followed by postoperative limb traction and
delayed reduction, is to minimize the risk of postoperative
femoral and/or sciatic nerve palsy following reconstruction
147. Dietze S, Perka C, Baecker H: Blood vessel and nerve of the severely dysplastic hip.
damage in total hip arthroplasty [German]. Orthopade
2014;43(1):64-69. Medline DOI
153. Stecco C, Macchi V, Baggio L, et al: Anatomical and
This review article discusses vascular and neural complica- CT angiographic study of superior gluteal neurovascular
tions after THA and the options for diagnosis, treatment, pedicle: Implications for hip surgery. Surg Radiol Anat
and prevention. 2013;35(2):107-113. Medline DOI
This study identified the incision site with the lowest risk
148. Sutter M, Hersche O, Leunig M, Guggi T, Dvorak J, Egg- of injury to the superior gluteal neurovascular bundle
spuehler A: Use of multimodal intra-operative monitoring when using the Hardinge direct lateral approach in THA.
in averting nerve injury during complex hip surgery. J Bone
Joint Surg Br 2012;94(2):179-184. Medline DOI
154. Bhargava T, Goytia RN, Jones LC, Hungerford MW:
Use of multimodal intraoperative monitoring during com- Lateral femoral cutaneous nerve impairment after direct
plex hip surgery is appropriate and effective for alerting anterior approach for total hip arthroplasty. Orthopedics
the surgeon to the possibility of nerve injury. 2010;33(7):472. Medline
149. Hussain WM, Hussain HM, Hussain MS, Manning DW: 155. Goulding K, Beaulé PE, Kim PR, Fazekas A: Incidence
A late vascular complication due to component migra- of lateral femoral cutaneous nerve neuropraxia after an-
tion after revision total hip arthroplasty. J Arthroplasty terior approach hip arthroplasty. Clin Orthop Relat Res
2011;26(6):976.e7-976.e10. Medline DOI 2010;468(9):2397-2404. Medline DOI
The authors recommend early, preoperative ultrasound or
CT angiogram in patients presenting with failed and mi- 156. Restrepo C, Parvizi J, Pour AE, Hozack WJ: Prospective
grated acetabular reconstructions with screws, in addition randomized study of two surgical approaches for total
to vascular surgery consultation, as a screw could lead to hip arthroplasty. J Arthroplasty 2010;25(5):671-9.e1.
compression of the superficial femoral artery. Medline DOI
150. Healy WL, Iorio R, Clair AJ, Pellegrini VD, Della Valle CJ, 157. Homma Y, Baba T, Sano K, et al: Lateral femoral cuta-
Berend KR: Complications of total hip arthroplasty: Stan- neous nerve injury with the direct anterior approach for
dardized list, definitions, and stratification developed by total hip arthroplasty. Int Orthop 2015. Medline
The Hip Society. Clin Orthop Relat Res 2016;474(2):357- Lateral femoral cutaneous nerve injury after direct ante-
364. Medline DOI rior approach for THA decreased quality of life but did
Acceptance of the list of standardized, stratified, and val- not affect hip function.
idated THA complications and adverse events, proposed
by The Hip Society THA Complications Work Group, 158. Zappe B, Glauser PM, Majewski M, Stöckli HR, Ochsner
could advance reporting of outcomes of THA and improve PE: Long-term prognosis of nerve palsy after total hip ar-
assessment of THA by clinical investigators. throplasty: Results of two-year-follow-ups and long-term
results after a mean time of 8 years. Arch Orthop Trauma
151. Kawasaki Y, Egawa H, Hamada D, Takao S, Nakano Surg 2014;134(10):1477-1482. Medline DOI
S, Yasui N: Location of intrapelvic vessels around the Improvement of neurologic deficits associated with THA
acetabulum assessed by three-dimensional computed after 2 years is probable and independent of the nerve
tomographic angiography: Prevention of vascular-relat- affected.
ed complications in total hip arthroplasty. J Orthop Sci
2012;17(4):397-406. Medline DOI 159. Park JH, Hozack B, Kim P, et al: Common peroneal nerve
Three-dimensional CT angiogram can be helpful as a pre- palsy following total hip arthroplasty: Prognostic fac-
operative measure to understand the anatomic orientation tors for recovery. J Bone Joint Surg Am 2013;95(9):e55.
of the pelvic vessels around the acetabulum to prevent vas- Medline DOI
3: Hip
cular injury during THA, especially in high-risk patients. One-half of the patients in whom common peroneal nerve
palsy developed after THA recovered fully. The mean time
152. Flanagin BA, Dushey CH, Rubin LE, Keggi KJ: To- to recovery was approximately one year for partial palsies
tal hip arthroplasty followed by traction and delayed and 1.5 years for complete palsies.
Index
Page numbers with f indicate figures. Institute (AORI) classification system, and bipolar sealer, 31
Page numbers with t indicate tables. 187, 187f and CAS, 178–179
Anemia, 246, 476 hidden, 27, 32
and complications, 28 and hypotensive anesthesia, 30
A and erythropoietin, 29 and retroperitoneal approach, 352
Accelerometer-based CAS systems, 178t
and iron supplementation, 29 and THA, 27, 33
Accelerometer-based navigation, 179
and nutritional supplementation, 29 and TKA, 27, 33
Acetabuloplasty, 406
and THA, 27–28 and topical hemostatic agents, 31
Acetabulum, 332f
and TKA, 27–28 and TXA, 32
components, wear, 382
Anesthesia, 19, 30, 226, 440 and wound drains, 32
and CT, 8
Anterior cruciate ligament (ACL), Blood management, 246, 441, 442
and DDH, 393–394
86–87, 96, 114, 120–122, 121f, 124, salvage and reinfusion, 32–33
defects, 457
143–147, 149–151, 153, 163, 169 transfusions, 17, 28, 476
fractures, 408–409, 410f
and iatrogenic injury, 146 allogeneic, 28, 29, 33
and dysplasia, 4, 330
retention, and PCL retention, 121–122 and bilateral THA/TKA, 34
osteotomies, 341
Anterior Total Hip Arthroplasty and BMI, 28
and pelvic tilt, 5
Collaborative, 348 and revision THA/TKA, 34
reaming, 429f
Antibiotic spacers, 248–249 Blount disease, 198
reconstruction, 394
Antibiotic suppression, 248 Body mass index (BMI), 16, 88, 133t,
revisions, 453
Antibiotic-resistant bacteria, 478 133–134, 476
Achondroplasia, 403–404, 405f
Anticoagulants and TKA, 188 and blood transfusions, 28
ACL. See Anterior cruciate ligament
Antioxidant-stabilized polyethylene, and infections, 271
Acute normovolemic hemodilution, 30
123 and readmissions, 69
Adductor canal blocks, 20, 226
Antiplatelet agents/antiplatelet therapy, and TKA, 188–189
Adult-onset cerebrovascular accident,
16, 17, 29 Bone grafting, 50
408
Antiprotrusio cage and ring techniques, Bone impaction grafting, 56
Adverse local tissue reactions, 381
457 Bone loss, 187, 187f, 253f, 268, 269,
Age, 15, 16
Appropriate Use Criteria, 317, 318t 455, 464
and aseptic loosening, 132, 271
Arthrotomy iatrogenic, 480
and infection, 132, 271
lateral, 100, 100f and osteolysis, 5–6
and readmissions, 69
medial parapatellar, 97f Bone morphing, 175f
and revision surgery, 208f
Aseptic loosening, 10, 51, 251, 268 Bone morphogenetic protein, 491
and TKA, 208f
and age, 271 Bundled Payment for Care
young patients, 131–132
and ceramics, 123 Improvement, 67, 67t
Alendronate, 53, 56, 57
and obesity, 251–252 Bundled payment programs, 15
All Patients-Refined–Diagnosis-Related
and young patients, 132 Bursectomy, 327
Group (APR-DRG) system, 68
Aspirin, 16, 17, 29
Allergies. See also Hypersensitivity,
Atlantoaxial subluxation, 190
metal
Autologous chondrocyte implantation
allogeneic blood transfusions, 33
(ACI), 302, 303–304
C
cephalosporin, 476 Calcium hydroxyapatite, 53
Autologous matrix-induced
metal, 358, 359 Cam-post interactions, 108
chondrogenesis, 326
TXA, 31 Cams, 107f, 108f
Autologous stromal vascular fraction,
Allogeneic blood transfusions Cardiac stents, 16
340
complications, 33t Cardiovascular history and TKA, 188
costs, 33 Cartilage lesions, 302
Allograft-composite reconstruction, Cemented all-polyethylene acetabular
463–464 B components, 385
Allograft-prosthetic composites, 464 Bariatric surgery, and arthroplasty, 16 Cemented stems, femoral components,
Alternative payment models, 68 Bearing materials, 356, 367 382
American Association of Hip and Knee Bearings Centers for Medicare & Medicaid
Surgeons Bundled Payment Task large-diameter, 357–358 Services (CMS), 15, 63, 215
Force, 67 metal-on-metal, 359 Ceramicized metal, 123–124, 358
American Joint Replacement Registry, Bernese periacetabular osteotomy, 330, Ceramic particles, 368–369
75–76 331t Ceramic-on-ceramic bearing surfaces,
American Knee Society Clinical Rating Bicompartmental arthritis, 156 370f
System, 215–216 Bicompartmental knee arthroplasty, Ceramic-on-ceramic bearings, 355–357,
American Society of Anesthesiologists 150, 156 362, 382
Task Force on Perioperative Blood Biohazard management, 292 Ceramic-on-polyethylene bearings, 367
Transfusion and Adjuvant Therapies, Bipolar hemiarthroplasty, 487 Ceramics, in implants, 123
33 Block testing, 489 fractures, 123, 356, 357
Analgesia, 439, 442 Blood loss, 17, 28, 226, 441, 476 Charcot arthropathy and TKA,
Anderson Orthopaedic Research and bilateral THA/TKA, 34 191–192
©2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5 507
Index
Charcot joints, 406 patellofemoral arthroplasty, 154 Dual-mobility bearings, 386, 386f
Charcot-Marie-Tooth disease, 406 subvastus approach, 98 Dual mobility liners, 486–487
Charlson Comorbidity Index, 271, 317 TXA, 31
Chondral injury, 323 Core decompression, 49–50, 50–51, 53,
classification systems, 324f, 325t 56, 57
treatment of, 325 Cost savings and rapid recovery
E
Economic issues and robotics, 169
Chondroplasty, 302–303 programs, 443
Electromagnetic tracking, 424
Clinical Practice Guideline on the Cross-linked polyethylene (XLPE), 354,
Empyema, 480
Management of Hip Fractures in the 358
End-stage disease, 4
Elderly, 318 C-sign, 328
hip, 4
Clopidogrel, and TKA, 188 CT-based navigation, 425, 426f
renal, 17
Comorbidities, 15, 16t, 68 CT-guided nerve blockade, 340
Erythropoietin, 29, 29t, 34
congestive heart failure, 132 Cup-cage constructs, 457–458
Exchange arthroplasty, 248, 479–480
diabetes, 132 Cup-cage reconstruction, 456, 457,
Exercise, 299, 300
and infection, 132 458–459, 459f
Excision arthroplasty, 480
obesity, 132 Cup-cage technique, 457
Extended trochanteric osteotomy, 6,
psychosis, 132 Cup-in-cup stacking, 456
352
Complications
Extra-articular deformities, 197–198,
and allogeneic blood transfusions, 33t
199, 199f
and anesthesia, 19
and blood salvage and reinfusion,
D Extracorporeal shock wave therapy, 49
DDH. See Developmental dysplasia of Extrinsic neuromuscular disorders, 406
32–33
the hip
cardiovascular, 16
Débridement, 302–303
and hypotensive anesthesia, 30
and antibiotics with implant retention
infections, 16, 17
(DAIR), 478
F
and JRA, 191 FDG-PET. See Imaging
of the labrum, 322
kidney failure, 16 Femoral deficiency, 399t
Decolonization, 17, 476
and obesity, 133 Femoral head
Deep vein thromboembolism
quadriceps-sparing approach, 99 ceramic, 75–76, 76f
prophylaxis, 438
and rapid recovery programs, 443 collapse, 47f
Deep vein thrombosis (DVT)
sepsis, 17 size, 386–387
prophylaxis, 227, 443
and TKA, 122–123 Femoral impaction grafting,
and diabetes mellitus, 189
VTE, 17 contraindications, 462
Degenerative scoliosis, 4
wound, 16, 32 Femoral neck fractures, 313, 314f, 315f
Developmental dysplasia of the hip
Components treatment, 316, 318t
(DDH), 393, 395f, 398f, 399
TKA, 136f Femoral nerve blocks, 226
and prior surgical procedures,
damage, 295 and TKA, 20
396–397
positioning, 134, 135 Femoroacetabular impingement (FAI),
Diabetes mellitus, 15, 16, 476
damage scoring scale, 295t 4, 7, 9, 10f, 321, 323, 327–328
and deep vein thrombosis, 189
inspection, 292 acetabuloplasty, 329
and infection, 132, 189
positioning, 134, 135 arthroscopic surgery, 329
and readmissions, 69
THA, corrosion, 354, 356, 381, 387 categories, 328
and TKA, 189
Comprehensive optical navigation open/arthroscopic surgery, 329
Diphosphonates, 57, 412
systems, 176–177, 177f, 178t Femorotibial contact patterns, 109,
and secondary osteonecrosis of the
Computer adaptive technology, 188 Femoral retroversion, 398f
knee, 53, 56
Computer-assisted imaging, 429f Fibrodysplasia ossificans progressiva,
Disease-specific outcome measures, 212,
Computer-assisted navigation, 178 491
214
and blood loss, 178–179 Fibrous dysplasia, 404
Knee Injury and Osteoarthritis
and TKA, 202–203 Flexion instability and revision TKA,
Outcome Score (KOOS), 212, 214
Computer-assisted surgery (CAS), 173 268
12-Item Oxford Knee Score
accelerometer-based, 175–176 Fluoroscopically based navigation, 424,
(Oxford-12), 212
CASPAR (Computer Assisted Surgical 425f
Western Ontario and McMaster
Planning and Robotics System), 428 Force platform, 144
Universities Arthritis Index
Congestive heart failure and infection, Foreign body inflammatory response,
(WOMAC), 212
132 368
Dislocation, hip, 316, 482, 486f
Contraindications Fractures, 197–198
management, 485–486
ACL deficiency, 146 acetabular, 408, 409, 410f, 481
risk factors, 482–484
bicruciate-retaining TKA, 146 ceramics, 123
Distal femoral fractures, 238f, 239f,
deformity parameters, 146 femur, 6f, 482
240f
incompetent extensor mechanism, 146 hip, 399
treatment of, 237–238
lateral UKA, 153 periprosthetic, 480–482
Distal femoral osteotomy, 198
mobile-bearing UKA, 96 Fretting, 296, 356, 359, 381, 384
Drop-kick test, 490
508 ©2017 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Hip and Knee Reconstruction 5
Index
Frozen sections, 474 low-dose radiation, 3, 7, 8f and congestive heart failure, 132
Fully porous-coated cylindrical stems, metal artifact reduction sequence MRI, and diabetes mellitus, 132, 189
459–460 9–10, 10f fungal, 480
Functional rating systems, pain-reported MRI, 3, 8, 9 and inflammatory arthritis, 132
outcomes measures, 212–214 multidetector CT, 7 latent, 400
nuclear medicine, 3, 10 and obesity, 132, 133–134
and osteonecrosis, 47 and psychosis, 132
and postarthroscopic osteonecrosis, 56 and readmissions, 69
G radiographs, 3 risk factors, 245–246
Gait, 328
radiostereometric analysis, 7 and young patients, 132, 134
Girdlestone arthroplasty, 480, 488
and secondary osteonecrosis of the Inflammatory arthritis and infection,
Global Knee Rating Systems, 215–216
knee, 55 132
single-photon emission computed Inflammatory arthropathies and TKA,
tomography (SPECT)/CT, 10 190
H technetium scan, 155 Instability, following TKA, 483
Half cup-cage construct, 458 and THA, 3 Intensive Diet and Exercise for Arthritis
Heterotopic bone formation, 409 ultrasonography, 3, 8, 10–11, 20 trial, 299–300
Heterotopic ossification, 408, 409, Immune system, 371–372, 373t Interprosthetic fractures, 243–244, 244f
491–492 Immunosuppression, 17, 28, 33 Intra-articular analgesia, 329
and robotic-assisted surgery, 429 Impaction grafting, 459, 462 Intra-articular lidocaine injection, 268
High tibial osteotomy (HTO), 53, 54, Implants, 122, 143–145, 144f Intraoperative fractures
198 acetabular, 5, 9f acetabular, 481
Highly cross-linked polyethylene ACL-substituting and PCL-retaining, femur, 481–482
(XLPE), 123, 250, 352, 382 122 Intrinsic neuromuscular disorders, 406
Highly porous surfaces, 384, 385f ball-in-socket medial pivot, 119 Iron supplementation and anemia, 29
Hip bicruciate TKA, 144 Irrigation and débridement, 248, 248t,
disarticulation, 480 bicruciate-substituting, 120–121, 120f, 478–479, 480
dysplasia, 4, 5f, 7, 8f, 9 122–123
fractures, 317 biomimetic bicruciate-retaining, 121f,
joint contractures, 408 145
microfracture, 325–326 biomimetic cruciate-retaining, 119f
J
Jehovah’s Witnesses, 30, 34
septic arthritis, 326 biunicompartmental, 121f
Joint aspiration, 474
surgical approaches, 345, 347–353, cobalt-chromium-molybdenum
Jump distance, 387, 485f
347t (CoCrMo), 123
Jumped-post dislocation, 106
synovectomy, 326 constraint, 201–202
Juvenile rheumatoid arthritis (JRA)
resurfacing, 341 contemporary bicruciate-retaining,
and TKA, 190–191
Hospital for Special Surgery knee 121f
scores, 30, 215 contemporary cruciate-retaining, 119,
Hydroxyapatite coatings, 457 121f
Hypersensitivity, metal, 123. See also cruciate-retaining, 107–108, 109 K
Allergies dual cam design, 109 Kartogenin conjugated with chitosan
Hypervascularity, 412–413 femoral, 5 nanoparticles, 341
Hypotensive anesthesia, 441, 476 knee, 170f Kinematic alignment, 115, 117
materials, 123–124 Kinematic registration, 174–175, 174f
mobile-bearing, 108 Kinematic tracking, 167f
modular, 157, 380
I monolithic, 156 Knee
Iatrogenic bone loss, 480
multiradius femoral, 114–115 articular mechanics, 87–88
Iatrogenic patella baja, 98
oxidized zirconium, 123 adduction moment, 88, 300
Iatrogenic soft-tissue injury, 348
posterior stabilized, 106–107, 109 biomechanics, 88
Imageless navigation, 165, 168, 424,
press-fit unicompartmental, 169 fusion, 249
425
single-radius femoral, 114–115, 114f kinematics, 87f, 89–90, 105, 117, 120,
Imaging
titanium, 123 122–123, 144
bone scintigraphy, 10
TKA, 113–114, 210–211 microfracture, 325–326
CT, 3, 8
ultracongruent, 118–119 osteoarthritis, 88
delayed gadolinium-enhanced MRI of
UHMWPE, 123 soft-tissue mechanics, 86–87
cartilage, 9
Indium 111-labeled leukocyte scanning, stiffness, 185–186
EOS, 7, 8f
477 Knee Injury and Osteoarthritis Outcome
F-18 fluorodeoxyglucose–positron
Infection, 6f, 17 Score (KOOS), 212, 214
emission tomography (FDG-PET),
and age, 132, 271
10, 477
and BMI, 271
fluoroscopy, 7
and comorbidities, 132
labeled leukocyte scans, 10
Index
L Microfracture, 325–326
Minimally invasive surgery, 96, 100,
Open reduction and internal fixation,
408–409
Labrum, 332f
437, 440, 441 complications, 409
débridement of, 322
Mobile compression devices, 17, 19 Opioids
function of, 322
Modified sliding trochanteric osteotomy, adverse effects, 19
reconstruction of, 322–323, 324f
extended version, 351–352 and osteoarthritis, 301
refixation of, 322–323, 323f, 324f
Modular stems, 380, 381, 396 Optical localization, 176
repair of, 322
Mosaicplasty, 304, 326 Optical motion capture technology, 168
Lachman test, 146, 151
MRI. See Imaging Optical navigation systems, 176, 178t
Lateral condyle rollback, 119
Multimodal pain management, 66 Optical tracking, 424, 424f
Lateral decubitus position, 348
Multimodal preemptive analgesics, 66 OrthAlign, 432–433
Lateral heel wedges, 300
OrthAlign Plus, 433f
Lateral overresection, 201f
ORTHODOC, 427
Legg-Calvé-Perthes disease, 323, 328,
Osteitis deformans, 412
330, 489 N Osteoarthritis
Limb-length discrepancy and DDH, Narcotics, 66, 226
and corrective knee braces, 300
396, 488–491, 494 adverse effects, 442
and corticosteroid injections, 301–302
Liners, 485f National Joint Registry (NJR), 74, 76,
and flexible knee sleeves, 300
constrained, 487–488 78
and hyaluronan products, 302
dual mobility, 486–487 Nerve injuries, 493–494
knee, 92
Local infiltration anesthesia, 440 Neuromuscular diseases, 405
and lateral heel wedges, 300
Lumbar plexus blocks, 20 Neuromuscular hip disorders
lifestyle changes, 299–300
Lumbopelvic kyphosis, 5 and THA, 404–405
and mesenchymal stem cell therapy,
Lumbopelvic lordosis, 5 Neuropathic arthropathy
340
Lymphocytic proliferative response, 370 and TKA, 191–192
nonsurgical treatment of, 340t
New Zealand National Joint Registry,
and obesity, 340
179
and oral and topical medications, 301
M Nicotine screening tests, 16
Noise, 145
and platelet-rich plasma (PRP), 302,
Macrophages, 368, 371 339–340
and ceramic-on-ceramic bearings, 356
Marrow stimulation, 302, 303. See also and selective cyclooxygenase-2
Noncemented hemispherical acetabular
Microfracture inhibitors, 301
cup, 453
Mass spectrometry, 475 Osteoblasts, 369
contraindications, 454
McMurray test, 151 Osteochondral allograft transplantation
Noncemented hemispherical
Mechanical alignment, 115–116 (OCA), 302
components, 453–455
Mechanical axis, 175, 175f Osteochondral autograft transfer
Non-cross-linked UHMWPE, 123
Mechanical loosening, 67 (OAT), 302, 304
Nonvascularized bone grafting, 50
Mechanical therapy, 300 Osteochondral lesions, 303t
NSAIDs, 19, 28–29, 190, 226, 301
Medial collateral ligament (MCL), 87, Osteogenesis imperfecta, 198
and heterotopic ossification, 491
184, 186 Osteolysis, 198, 249–250, 253f, 254f,
and osteoarthritis, 301
Medial condyle motion, 119 296, 381, 383, 384, 387
and SONK, 53
Medial overresection, 200f, 201f and bone loss, 5
Nutritional supplementation
Medial patellofemoral ligament, 87 and ceramics, 123
and anemia, 29
Medial pivot rotation, 119 diagnosis, 252
Medial UKA, 150, 151, 151f periacetabular, 7, 8
Medial unicondylar arthroplasty, 96f periprosthetic, 368
Medical Outcomes Study 36-Item Short O polyethylene-induced, 368
Form (SF-36), 212, 273, 347 Ober test, 490 treatment of, 252
Medicare guidelines and TKA, 225 Obesity, 15, 16, 88. See also Body mass Osteolysis-targeted therapies, 251
Medicare Physician Fee Schedule, 64 index Osteonecrosis, 323, 402f
Meniscal tears, 303 and aseptic loosening, 251–252 and alcohol abuse, 46
Meralgia paresthetica, 348 and Blount disease, 198 and antalgic gait, 47
Mesenchymal stem cells, 50, 340, 368 complications, 133 atraumatic, 51
Metabolic bone disease and THA, 410 and component positioning, 134 and autoimmune diseases, 47
Metabolic syndrome, 189 and imageless systems, 424 and Behçet disease, 47
Metal augmentation, 187–188 and infection, 132, 133–134, 139 classification, Koshino, 51
Metal-on-metal, 355–356, 359, 372f, and osteoarthritis, 340 and coagulation disorders, 46–47
382 and subvastus approach, 98 and corticosteroids, 46, 47, 56
articulations, 370 and THA, 431 and Gaucher disease, 51
hip resurfacing, 359 and TKA, 133, 188–189 and heart transplantation, 51
Metal-on-polyethylene bearing surfaces, Open femoral head-neck hip, 45, 47, 48f, 49f, 51
367, 369f osteochondroplasty, 331 and hypofibrinolysis, 46
Metaphyseal sleeves, 136 idiopathic, 51
Index
and imaging, 47 Patient-reported outcomes measures Portable navigation. See Accelerometer-

and inherited thrombophilia, 46 (PROM), 212, 214 based navigation
ischemic, 51 Patient-specific instrumentation, 203 Post and cam interaction, 106f
knee, 51, 52t, 55f Patient-specific intraoperative Post and cam positioning, 106–107
postarthroscopic, 56, 57 protractor, 431f Postarthroscopic osteonecrosis, 56, 57
secondary, 51, 54f, 55–56 Pelvic discontinuity, 7, 454, 456, 457, Posterior cruciate ligament (PCL), 87,
SONK, 51–55, 54f 458, 481 118–119
management, 49, 49f Pelvic dissociation, 481 Posterior femoral rollback, 122
and renal transplantation, 51 Pelvic obliquity, 4–5, 488–489 Posterior-transmuscular approach,
and rheumatoid arthritis, 47 Pelvic tilt, 5 346–347
risk factors, 46t, 47 Pentaerythritol tetrakis (3-[3,5-di Postinjection synovitis, 302
and sickle cell anemia/disease, 46, 51 tertiary butyl-4-hydroxyphenyl] Postoperative acetabular fractures, 481
staging, 47 propionate) (PBHP), 354, 355 Posts, positioning, 107f
and systemic lupus erythematosus, Peptostreptococcus, 475 Posttraumatic arthritis, 187–188, 203f,
47, 51 Performance-based tools, 215 409
and THA, 51 Periacetabular osteotomy Pregabalin, 19, 226
and trauma, 46 contrandications, 330 Preoperative autologous blood
treatment, 45, 48 indications, 330, 331t donation, 29–30
and Trendelenburg sign, 47 outcomes, 331 Preoperative education, 225
Osteopetrosis, 410–411, 414f Periacetabular osteotomy anteversion, Preoperative imaging, 425
Osteoporosis, 383, 413f 329 Preoperative planning, 462
and THA, 410–411 Periarticular injections, 6, 20 and robotic-assisted surgery, haptic,
Osteoprotegerin, 251 Peripheral blocks, 20, 226 428
Osteotomy, 199–200 Peripheral nerve blockade, 66 THA, 400, 409
acetabular, 341 Periprosthetic inflammation, 368 Preoperative rehabilitation, 439
femoral, 50, 341 Periprosthetic joint infection (PJI), 67, Press-fit modular components, 383, 384
Outliers, 77, 167, 426, 427, 443 244–245, 246–247, 246t, 247t, 473– Progressive osseous heteroplasia, 491
Oxford knee rig, 109 474, 475f, 476f, 478 Prooxidants, 355
Oxidation, 355 and antibiotic spacers, 248–249 Propionibacterium acnes, 247, 474, 475
Oxidized zirconium, 123, 124, 358, 359 and antibiotic suppression, 248 Proprioception, 88, 144, 300, 405
and antibiotic therapy, 249 Proprioception acuity, 88
and irrigation/débridement, 248 Prostaglandins, 56
and primary exchange arthroplasty, and heterotopic ossification, 491
P 248 Proximal femur deformity, 398, 399,
Paget disease, 198, 399, 403, 415f
treatment of, 247–248 399t
Paget sarcoma, 412
and two-stage exchange arthroplasty, Proximal femur fracture, 398, 399
Pain management, 19, 66, 225–226,
248 Proximal tibial periprosthetic fractures,
442
Periprosthetic knee fractures, 233, 234t 241f
nerve blocks, 20
classification systems, 235, 237 Pseudotumors, 8, 10, 10f, 11, 360, 371
oral medications, 19
outcomes of, 238–239 Psoas compartment blocks, 20
periarticular injections, 20
treatment of, 237, 479–480 Psychosis
Pamidronate, 56, 57
Unified Classification System, 236t and infection, 132
Paprosky classification system, 399t
Periprosthetic patellar fractures Psychosomatic issues
Paradoxical anterior sliding, 119
management of, 243f and TKA, 268
Paralysis, 405, 406
Periprosthetic tibial fractures Pulmonary Embolism Prevention (PEP)
Parkinson disease, 406
management of, 241–242f trial, 17
Patellar fractures, 242–243
Pes anserinus bursitis, 268 Pulsed electromagnetic field therapy, 53
Patellar resurfacing, 134
Phagocytosis, 368, 372 Purulence, 475
Patellofemoral arthroplasty, 149, 154,
Phagocytosis index, 369
156, 156f
Pharmaco-Epidemiology of
Patellofemoral articulation and
Gonarthrosas (PEGASus) study, 301
kinematics, 86
Physician Quality Reporting System,
Q
Patient education, 438–439 Q angle, 88, 154, 156
215
Patient Protection and Affordable Care Quadriceps-sparing approach, 99f
Platelet-rich plasma (PRP), 31, 302
Act (PPACA), 63
and osteoarthritis, 339–340
Patient satisfaction
Platelets, 302
primary TKA, 272
revision TKA, 272
Polyethylene, science and manufacturing R
of, 250 Radiation
TKA, 216–217, 271–272
Polyethylene wear, 249–252 and cross-linked UHMWPE, 354
Patient selection, 223, 225, 438
Polykaryons, 368 and heterotopic ossification, 491
Patient-controlled analgesia, 66
Porous metal metaphyseal cones, 269 and necrosis, 383
Patient-controlled analgesic pumps, 442
Porous tantalum, 191, 269 Radiofrequency ablation, 340
Index
Radionuclide scanning tests, 477

Range of motion (ROM), 19, 113
S Surgical techniques, 30, 401–403
acetabular reconstruction, 394
Safe zones, 384, 426, 427, 431–433,
Rapid recovery care programs BCA, 156–157
484
and complications, 443 Bernese periacetabular osteotomy,
Safety systems, 168
cost savings, 443 330–331
Sciatic nerve blocks, 226
and risk factors, 444–445, 444t bipolar sealer, 30–31
and THA, 20
and THA, 443 bone impaction grafting, 56
Scoliosis, 403
Readmissions, 68–69 bulk autogenous grafting, 394–395
Scopolamine, 226
Reconstruction cages, 456 Cloutier bicruciate TKA, 144
Scoring systems, 212
Regional anesthesia, 440 computer-assisted, 173
Screw-home mechanism, 86f
Registration points, 424f computer-assisted UKA, 151
Screws, 187, 383
Registries, 73–74 computer-navigated UKA, 151
Selection bias, 78
challenges/problems/risks, 77–78 core decompression, 53, 54, 57
Selective cyclooxygenase-2 inhibitors,
data, 270 costs, 31
301
end point of, 74, 78 electrocautery, 30–31
Semiactive robotic approach
international, 76 Insall, 97
image-based navigation, 165
limitations of, 74 inside-out, 184
Imageless navigation, 165–166
national, 75 lateral approach, 96, 99–100
Sensory nerve blockade, 340
and revision bias, 78 lightbulb, 50
Sepsis, 17
and revision burden, 76 medial approach, 96
Septic arthritis, 326
and revision surgery, 74, 78 medial parapetellar approach, 97
Septicemia, 17
and risk stratification, 74 midvastus approach, 98–99
Serum biomarkers, 475
and TKA, 208–209 minimally invasive, 95, 345, 482
Serum metal ion assessment, 360
Renal disease, 17 modified Smith-Petersen approach,
Severity of illness, 68, 69
Renal osteodystrophy, 416 330
Shear forces, 117
and THA, 414–415 “no hands,” 134–135, 135f
Short noncemented stems, 379–380
Renal transplantation, 17 noncemented hemispherical acetabular
Shuck test, 490
Resection arthroplasty, 488 cup, 454
Sickle cell anemia, 34
Retrieval analyses, 292 osteochondral allografting, 53
Sick-patient model, 350, 437
Retroperitoneal approach, 352 and osteopetrosis, 411–412
Slipped capital femoral epiphysis, 328
Reverse periacetabular osteotomy, 329 patellofemoral arthroplasty, 155
Smoking/tobacco use, 16
Revision bias, 78 Phemister, 50
Sodium hyaluronate
Revision burden, 76 pie-crusting, 184, 185
and osteoarthritis, 302
Revision surgery, 149 progressive resection of the lesser
Soft-tissue augmentation, 487
and obese patients, 134 trochanter, 396
Soft-tissue impingement, 268
and periprosthetic knee fractures, 233 quadriceps snip, 186, 186f
Soft-tissue tests, 490
and registries, 74, 78 quadriceps-sparing approach, 99f
Spacers, 480
and robotic-assisted UKA, 163 and revision, 347
Spastic hip, 407f
TKA, 208f, 211f robotic-arm assistance, 158
Spasticity, 406
and TKA, 208 robotic-assisted UKA, 151–152
Spinal cord injury, 408
and UKA, 152 subvastus approach, 97
Spinal injections, 226
and young patients, 134 tibial tubercle osteotomy (TTO), 186
Squalene, 355
Revision total hip arthroplasty (THA), transverse subtrochanteric osteotomy,
Squeaking, 355, 356, 358
5, 34, 67 396
S-ROM stems, 380–381, 396
Revision total joint arthroplasty (TJA), trapdoor, 50
Staging systems, 47, 48t
67 unicompartmental knee arthroplasty
Stem augmentation/supplementation,
Revision total knee arthroplasty (TKA), (UKA), 54–55, 151, 153
269
6, 347, 67, 268, 271 von Langenbeck, 97
Strength training, 300
Rheumatoid arthritis, 190, 476 V-Y quadriceps turndown, 186–187,
Stress shielding, 460
Rifampin, 478, 479 187f
Stroke, 408
Risk stratification, 68, 74 Symmetric tibial trays, 117, 117f
Structural allograft, 269
Rivaroxaban, 17, 29 Synovectomy, 326
Subarachnoid hemorrhage, 31
ROBODOC, 427–428, 428f, 430 Systemic lupus erythematosus, 191
Suppressive antibiotic therapy, 478
Robotic technologies, 165, 169
Surface damage, 295t
Robotic-assisted cup insertion, 430f
Surface damage analysis, 292, 293, 294
Robotic-assisted knee arthroplasty,
151–156, 163–165, 163f, 164f
Surface registration, 174, 175 T
Surgical approaches to the hip, 330, Tantalum beads, 253
Robotic-assisted surgery, 427–429
345–347, 347t, 493 Tapered fluted titanium stems, 460–461
Rotational axes, 177f
Surgical instruments, 96 Templating, 4–6, 4f, 202, 489–490
Surgical site infections, 244 Thomas test, 488
Three-phase bone scan, 477
Thrombin, 31
Index
Tibial articular surface, 119–121 122–123, 122f Total Knee Function Questionnaire,
Tibial components, 118 and ACL function, 121 214–215
Tibial fixation, 135–136, 136f and age, 208f Tourniquets, 30
Tibial periprosthetic fractures, 241–242 and anesthesia, 19 Tramadol, 301
Tibial tray design, 117, 117f and anticoagulants, 188 Tranexamic acid (TXA), 17, 30, 31, 32,
Tibiofemoral articulation, 85–86 bicruciate-retaining, 89, 123, 144f, 34, 226, 246, 441, 442, 448, 476
Tibiofemoral joint forces, 87–88 145 Transfemoral amputation, 249
Tibiofemoral kinematics, 85–86 contraindications, 146 Transfusion protocols, 442
Titanium alloy, 354 bilateral, 33–34, 191 Transfusion triggers, 33, 442
Titanium modular necks, 381–382 and blood loss, 27, 33 Transgluteal approach, 346
Titanium niobium nitride, 123 and BMI, 188–189 Transmuscular approach, 346
Titanium nitride, 123 cam-post interactions, 108 Trendelenburg sign, 330
Titanium sleeves, 269–270 and cardiovascular history, 188 and DDH, 395
TJA and readmissions, 68–69 and Charcot arthropathy, 191–192 Trendelenburg status, 400
Tobramycin, 480 and clopidogrel, 188 Trial reduction, 349
Toll-like receptors, 368 Cloutier bicruciate, 144 Triamcinolone acetate, 301
Tönnis angle, 328 comorbidities, 15, 16t Triamcinolone acetonide in poly (lactic-
Tönnis grade, 331, 341 complications, 122–123 co-glycolic acid) microspheres, 341
Topical hemostatic agents, 31 contemporary cruciate-retaining, 89, Triamcinolone hexacetonide, 301
Total hip arthroplasty (THA), 313 122f, 209–210 Trochanteric advancement, 487
anesthesia, 19 demographics, 143 Trochanteric bursitis, 327
bilateral, 33–34 and diabetes mellitus, 189 Trochanteric osteotomy, 351–352
and blood loss, 27, 33 and digital templating, 3 Trochanteric slide, 351
cemented/hybrid, 377 fluorokinematic studies, 108–109 Trunnion, 354, 356–359
and comorbidities, 15, 16t, 315f imaging, 3 Tumors, 198
complications, 397, 409, 416, 473, implant design, 114–116, 115f, 116f 12-Item Oxford Knee Score, 212, 214
482, 494 and inflammatory arthropathies, 190 12-Item Short Form (SF-12), 212
contraindications, 399t and juvenile rheumatoid arthritis, Two-incision approach, 347
and digital templating, 3 190–191 Two-stage exchange arthroplasty, 248
direct anterior approach, 347–349, kinematics, 108–109
440–441 lateral approach, 99–100, 101n5
Hardinge direct lateral approach, 493 medial parapatellar approach, 97
and imaging, 3, 9f and Medicare guidelines, 225
U
UHMWPE. See Ultra-high–molecular-
and limb-length discrepancy, 488–491 midvastus approach, 98–99, 98f
weight polyethylene
litigation, 488 minimally invasive, 95
Ultra-high-molecular-weight
and metabolic bone disease, 410, 412t navigation technologies, 178t
polyethylene (UHMWPE), 292, 295,
minimally invasive, 350 and neuropathic arthropathy, 191–192
354, 356
miniposterior approach, 441 outcomes, 272
Ultrasonography, 10, 11f, 20, 424–425
neuromuscular disorders, 404–405 outpatient, 223, 224t
Underreaming, 383–384
noncemented, 377 and pain management, 66
Unicompartmental (unicondylar) knee
and obesity, 431 and patient satisfaction, 216–217,
arthroplasty (UKA), 54–55, 95, 149,
and osteonecrosis, 51 271–272
166
and osteoporosis, 410–411 patient-specific positioning guides, 203
all-polyethylene, 152
outcomes, 317 and PCL, 105
cemented, 166f
and Paget disease, 412 and periprosthetic knee fractures, 233
failure, 270
pain management, 66 posterior-stabilized, 89, 106,
fixed-bearing, 151, 152
postoperative care, 442 postoperative care, 227
kinematics, 167f
preoperative planning, 400–401 and psychosomatic issues, 268
lateral, 152, 153, 153f, 154
rapid recovery care programs, 438, quadriceps-sparing approach, 99f
metal-backed, 152
443 and registries, 208–209
mobile-bearing, 151, 152
risk factors, 16, 17, 438, 483–484 revision, 211f
surgical techniques, 151–152
surgical techniques, 381f, 383f, 385– revision rates, 208f
Unified Classification System, 235,
386, 398f, 402f risk factors, 133, 234–235, 235t, 241,
236t, 481
technical considerations, 409 272
unstable, 487f and robotics, 163, 167–168, 168f
Total joint arthroplasty (TJA), 63–65, simultaneous bilateral, 191
68–69 single-radius femoral component, 114f V
cost variations, 64 subvastus approach, 97–98, 98f Valgus/varus deformity, 183–184
implant costs, 64–65 survivorship rates, 207–210, 209f femoral, 200f
inpatient costs, 64 and systemic lupus erythematosus tibial, 201f
Total knee arthroplasty (TKA), 27 (SLE), 191 and TKA, 184–185
ACL and PCL substitution, retention, systems, 89 Value-based purchasing movement, 65
Index
Vancomycin, 476, 480

Vancouver Classification System (VCS),
Watson-Jones approach, 345
Wear, 295, 296, 382
Y
Yttria-stabilized tetragonal zirconia,
481, 481t ceramic-on-ceramic bearings, 357
123
Vascular injuries, 492–493 Wear assessment, 292
Vascularized bone grafting, 50 Weight loss, 299, 300
Venous thromboembolism (VTE), 17 Well-patient model, 350, 437
Viscosupplementation, 302 Western Ontario and McMaster Z
Visualization Toolkit libraries, 433 Universities Arthritis Index Zimmer modular revision hip system,
Vitamin E, 354, 355 (WOMAC), 212 462
Vitamin E-infused polyethylene (VEPE), Wettability, 358 Zirconium nitride, 123
250 Whole-body skin cleansing, 476 Zirconium-niobium, 123
Vitamin K antagonists, 17 Wound drainage, 478
Volume depletion, 442 Wound drains, 32
W X
Wagner self-locking stem, 461 XLPE. See Cross-linked polyethylene
Warfarin, 17, 29

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Imaging of the Hip and Knee for

1: Hip and Knee

Preoperative Planning and Digital Templating

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knee anatomic and mechanical axes. These images also

Extended Trochanteric Osteotomy Implant Position

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1: Hip and Knee

prosthetic joint infections can all have positive bone scans.

Summary Annotated References

Digital radiographs are the main diagnostic test in the

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position based on weight-bearing preoperative imaging Medline DOI

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tumors and muscle atrophy but superior in detecting joint

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associated with total joint arthroplasty. J Am Acad Orthop Surg Smoking

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Table 3 more favorable recovery profiles associated with general

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and easier to perform.

This review article emphasizes the need to minimize peri-

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2014;29(10):1889-1898. Medline DOI

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hip or knee arthroplasty and received mobile compression

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gle-injection nerve blocks. Level of evidence: I.

Abstract Keywords: blood conservation has been

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and prolong bleeding time by acting on cyclo-oxygenase Table 1

known side effects on coagulation should be stopped

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Intraoperative Strategies Surgical Technique

1: Hip and Knee