Showing papers in "Journal of Arthroplasty in 2011"

"Asymptomatic" pseudotumors after metal-on-metal hip resurfacing arthroplasty: prevalence and metal ion study.

Abstract: Symptomatic abnormal periprosthetic soft-tissue reactions ("pseudotumors") have been reported after metal-on-metal hip resurfacing arthroplasty (MoMHRA). The aims of this study were (1) to determine the prevalence of asymptomatic pseudotumors after MoMHRA and (2) to measure metal ion levels in these patients. A total of 201 hips in 158 patients were evaluated at a mean follow-up of 61 months (range, 36-88) using ultrasound/magnetic resonance imaging and serum/hip aspirate cobalt and chromium measurements. Pseudotumors found in 7 patients (4%) were associated with significantly higher cobalt and chromium levels and inferior functional scores. Elevated levels of cobalt and chromium ions suggest that pseudotumors are associated with increased wear generated from metal-on-metal articulations. Clinicians need to be aware of pseudotumors as a differential diagnosis during clinical evaluation of MoMHRA patients, and further imaging such as ultrasound or magnetic resonance imaging is recommended to confirm the diagnosis.

Measuring Functional Improvement after Total Knee Arthroplasty Requires both Performance-Based and Patient-Report Assessments: A Longitudinal Analysis of Outcomes

Abstract: The purpose was to explore the responsiveness of both patient-report and performance-based outcome measures to determine functional changes during the acute and long-term postoperative recovery after total knee arthroplasty (TKA) One hundred patients scheduled for unilateral TKA underwent testing preoperatively and at 1 and 12 months postoperatively using the Delaware Osteoarthritis Profile All physical performance measures decreased initially after surgery then increased in the long term; however, the perceived function did not follow the same trend, and some showed an increase immediately after surgery Patient-report measures were variable, with no to small response early, but had excellent long-term responsiveness that was twice as large as performance measures Patient perception fails to capture the acute functional declines after TKA and may overstate the long-term functional improvement with surgery

Predicting dissatisfaction after total hip arthroplasty: a study of 850 patients.

Abstract: We conducted a prospective cohort study investigating the rate and predictors of dissatisfaction among patients after primary total hip arthroplasty (THA). Eight hundred fifty patients were assessed preoperatively and 1 year postoperatively using Patient Reported Outcome Measures. There was a 7% rate of dissatisfaction after THA. After univariate analysis, depression, preoperative Short Form 12 mental component score, and symptomatic arthritis of another major joint predicted dissatisfaction at 1 year, but after multivariate analysis, only symptomatic arthritis in another major joint was significant. The development of a major complication did not predict dissatisfaction. Satisfaction also correlates strongly with postoperative functional scores, relief of pain, restoration of function, and success in meeting patient expectations. Pain relief and expectation management are critical in maximizing patient satisfaction after THA.

New definition for periprosthetic joint infection.

Abstract: Periprosthetic joint infection (PJI) is one of the most challenging and frequent complications after lowerextremity joint (hip and knee) arthroplasty. However, there is no single accepted set of diagnostic criteria for PJI. Various definitions have been proposed; however, none have been widely adopted. Furthermore, some of these definitions disagree with each other [14]. Therefore, a workgroup convened by the Musculoskeletal Infection Society (MSIS) analyzed the available evidence to propose a new definition for PJI. A summary of recommendations of those in attendance at a premeeting workshop of the 21st Annual Meeting of the MSIS on August 4, 2011, pertaining to the definition of PJI is outlined below. Existing published data on the definition of PJI was discussed by e-mail in the preceding 6 months by the executive members of the MSIS and a group of experts with known interest in this field. The intention of this proposal is to have a ‘‘gold standard’’ definition for PJI that can be universally adopted by all physicians, surveillance authorities (including the Centers for Disease Control, medical and surgical journals, the medicolegal community), and all involved in management of PJI. The panel acknowledged, in certain low-grade Each author certifies that he or she, or a member of their immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Differences of Knee Anthropometry Between Chinese and White Men and Women

Abstract: Whether there are differences in knee anthropometry between Asian and white knees remains unclear. Three-dimensional knee models were constructed using computed tomography or magnetic resonance imaging of healthy Chinese and white subjects. The morphologic measurements of the femur included mediolateral, anteroposterior dimensions, and aspect ratio. The tibial measurements included mediolateral, medial/lateral anteroposterior dimension, aspect ratio, and posterior slope of medial/lateral plateau. The results showed that Chinese knees were generally smaller than white knees. In addition, the femoral aspect ratio of Chinese females was significantly smaller than that of white females (1.24 ± 0.04 vs 1.28 ± 0.06). Tibial aspect ratio differences between Chinese and white males (1.82 ± 0.07 vs 1.75 ± 0.11), though significant, were likely a reflection of differences in knee size between races. These racial differences should be considered in the design of total knee arthroplasty prosthesis for Asian population.

Prosthetic joint infection caused by gram-negative organisms.

Abstract: Traditionally, periprosthetic joint infections (PJIs) due to gram-negative organisms are considered more difficult to manage; however, little literature exists with regard to outcome of PJI caused by gram-negative organisms. We identified 277 patients with 282 culture-positive PJI receiving surgical treatment. Thirty-one joints were treated for gram-negative PJI. The gram-negative group was then compared with the gram-positive and polymicrobial PJI. A single debridement and retention of prosthesis were successful in 70% (7/10) of isolated gram negative compared with 33.3% (13/39) of methicillin-sensitive gram positive, 48.9% (23/47) of methicillin-resistant gram positive, and 57.1% (4/7) of polymicrobial. Of those patients undergoing a planned 2-stage exchange, a successful reimplantation was performed in 52% (12/23) of gram-negative, 51% (52/103) of methicillin-resistant gram-positive, 69% (65/94) of methicillin-sensitive gram-positive, and 0% (0/8) of polymicrobial PJI cases. These results indicate that PJI due to gram-negative pathogens, although less common, is difficult to treat and is associated with limited success.

Does Greater Knee Flexion Increase Patient Function and Satisfaction After Total Knee Arthroplasty

Abstract: The purpose of this study was to determine whether high flexion leads to improved benefits in patient satisfaction, perception, and function after total knee arthroplasty (TKA). Data were collected on 122 primary TKAs. Patients completed a Total Knee Function Questionnaire. Knees were classified as low (≤110°), mid (111°-130°), or high flexion (N130°). Correlation between knee flexion and satisfaction was not statistically significant. Increased knee flexion had a significant positive association with achievement of expectations, restoration of a "normal" knee, and functional improvement. In conclusion, although the degree of postoperative knee flexion did not affect patient satisfaction, it did influence fulfillment of expectations, functional ability, and knee perception. This suggests that increased knee flexion, particularly more than 130°, may lead to improved outcomes after TKA. Keywords: total knee arthroplasty, patient-derived outcomes, patient satisfaction, high flexion, function. © 2011 Elsevier Inc. All rights reserved.

Patients prefer a bicruciate-retaining or the medial pivot total knee prosthesis.

Abstract: Four-hundred forty patients underwent staged bilateral total knee arthroplasty using a different prosthesis on each side. Prostheses used were anterior-posterior cruciate-retaining (ACL-PCL), posterior cruciate-retaining (PCL), Medial Pivot (MP), posterior cruciate-substituting (PS), and mobile bearing (MB). At the 2-year evaluation, we asked "Which is your better knee overall?" Responses were as follows: 89.1% preferred the ACL-PCL to the PS and 76.2% preferred the MP to the PS. The ACL-PCL and the MP were preferred equally. The MP was preferred over the PCL by 76.0%, and 61.4% preferred the MP over the MB. The PS and PCL were preferred equally. Range of motion, pain relief, alignment, and stability did not vary significantly by prosthesis used. Patients with bilateral total knee arthroplasties preferred retention of both cruciates with use of the ACL-PCL prosthesis or substituting with an MP prosthesis.

Preoperative screening/decolonization for Staphylococcus aureus to prevent orthopedic surgical site infection: prospective cohort study with 2-year follow-up.

Abstract: We quantified surgical site infections (SSIs) after preoperative screening/selective decolonization before elective total joint arthroplasty (TJA) with 2-year follow-up and 2 controls. Concurrent controls (n = 2284) were patients of surgeons not participating in screening/decolonization. Preintervention controls (n = 741) were patients of participating surgeons who underwent TJA the previous year. Staphylococcus aureus nasal carriers (321/1285 [25%]) used intranasal mupirocin and chlorhexidine baths as outpatients. Staphylococcal SSIs occurred in no intervention patients (0/321) and 19 concurrent controls. If all SSIs occurred in carriers and 25% of controls were carriers, staphylococcal SSI rate would have been 3.3% in controls (19/571; P = .001). Overall SSI rate decreased from 2.7% (20/741) in preintervention controls to 1.2% (17/1440) in intervention patients (P = .009). Preoperative screening/selective decolonization was associated with fewer SSIs after elective TJA.

Hidden Blood Loss After Total Hip Arthroplasty

Abstract: A prospective study was carried out to analyze the characteristics of hidden blood loss after total hip arthroplasty (THA) in a series of 1232 patients. The method of deducting the observed perioperative blood loss from the calculated total blood loss based on hematocrit changes was used to calculate the hidden blood loss of each patient. The reinfused and transfused bloods were also considered. We found that the amount of hidden blood loss after THA was much larger than we observed perioperatively and significantly different between differently diagnosed patients. We concluded that THA can cause a large amount of hidden blood loss, which should be monitored carefully. Retaining and repairing the articular capsule is recommended during the operation, which can significantly decrease hidden blood loss.

The Effect of Total Knee Arthroplasty on Knee Joint Kinematics and Kinetics During Gait

Abstract: This study determined how total knee arthroplasty (TKA) altered knee motion and loading during gait. Three-dimensional kinematic and kinetic gait patterns of 42 patients with severe knee osteoarthritis were collected 1 week prior and 1-year post-TKA. Principal component analysis extracted major patterns of variability in the gait waveforms. Overall and midstance knee adduction moment magnitude decreased. Overall knee flexion angle magnitude increased due to an increase during swing. Increases in the early stance knee flexion moment and late stance knee extension moment were found, indicating improved impact attenuation and function. A decrease in the early stance knee external rotation moment indicated alteration in the typical rotation mechanism. Most changes moved toward an asymptomatic pattern and would be considered improvements in motion, function, and loading.

Cementing the Tibial Component in Total Knee Arthroplasty: Which Technique is the Best?

Abstract: Aseptic loosening of the tibial component remains a major cause of failure in total knee arthroplasty and may be related, directly or indirectly, to micromotion. Therefore, good fixation of the tibial component is a prerequisite to achieve long-term success of the implant. Cementing technique is one of the factors that play a role in this respect. We investigated the effect of different cementing techniques on the cement penetration in the proximal tibia. We compared 5 different cementing techniques in an anatomical open pore sawbone model (n = 25), using a contemporary total knee arthroplasty design and standard polymethylmetacrylate cement. We demonstrated that applying cement to both the undersurface of the tibial baseplate and as well as onto the tibial bone, either by a spatula or fingerpacking technique, leads to an optimal cement penetration of 3 to 5 mm. When cement is applied only onto the tibial component, penetration is insufficient. When a cement gun is used, cement penetration is too excessive.

Irrigation and debridement for periprosthetic infections: does the organism matter?

Abstract: Irrigation and debridement (I&D) is an attractive treatment alternative for periprosthetic joint infection (PJI). Irrigation and debridement failure rates average 64% (range, 10.5%-84%) and may be associated with causative organism type and virulence. The study objective was to compare revision rates for PJI caused by streptococcal organisms to other organisms treated with I&D. A multicenter retrospective cohort study of 200 consecutive PJIs treated with I&D was performed. Failure was defined as reoperation for PJI. Failure rate for streptococcal infections was 65% (20/31) compared with 71% (84/119) for other organisms. Failure rate for sensitive Staphylococcus was 72% (48/67) compared with a 76% (22/29) failure rate for resistant Staphylococcus. These results indicate that eradication rates of I&D for a streptococcal PJI are comparable with other causative organisms. Irrigation and debridement should play a limited role in the PJI treatment algorithm regardless of organism type.

Total hip arthroplasty modular neck failure.

Abstract: The use of modular components in total hip arthroplasty has increased in popularity. The advantages of modularity in hip arthroplasty include improved visualization during acetabular revision and restoration of proper hip biomechanics. Disadvantages include disassociation of components, failure at modular junctions, corrosion, and the generation of metal ions and debris. We present 2 cases that demonstrate the potential for modular neck fracture, requiring subsequent revision of well-fixed components.

Molecular markers for diagnosis of periprosthetic joint infection.

Abstract: Despite a battery of tests available for diagnosing periprosthetic joint infection, as yet, no gold standard has been identified. Our purpose was to measure inflammatory proteins in synovial fluid from patients undergoing revision arthroplasty for septic or aseptic failure. We analyzed 74 synovial fluid samples: 31 infected and 43 uninfected, based on clinical and laboratory criteria. Proteomics analysis and receiver operating characteristic curve analyses were conducted on 46 inflammatory proteins for each sample. Of 46 proteins, 5 (interleukin 6, interleukin 8, α 2 -macroglobulin, C-reactive protein, and vascular endothelial growth factor) had an area under the curve greater than 0.90. This prospective study has demonstrated promising results for the use of molecular markers in diagnosis of periprosthetic joint infection. Future studies will focus on designing assays with these proteins in mind.

Metal Ion release with large-diameter metal-on-metal hip arthroplasty.

Abstract: Preoperative and postoperative ion concentrations were measured in 29 metal-on-metal, large-diameter head total hip arthroplasty (LDH-THA) patients. Mean chromium, cobalt (Co), and titanium levels from LDH-THA were 1.3, 2.2, and 2.7 μg/L at 12 months. The open femoral head design showed significantly higher Co concentrations than the closed design (3.0 vs 1.8 μg/L, P = .037). Compared with previously published ion levels from a hip resurfacing system presenting the same bearing characteristics, Co levels were significantly higher in LDH-THA (2.2 vs 0.7 μg/L, P < .001). This study has demonstrated that the addition of a sleeve with modular junctions and an open femoral head design of LDH-THA causes more Co release than bearing surface wear (157% and 67%, respectively). Even if no pathologic metal ion threshold level has been determined, efforts should be made to minimize its release. We recommend modification or abandonment of the modular junction and femoral head open design for this specific LDH-THA system.

Tranexamic acid to reduce blood loss after bilateral total knee arthroplasty: a prospective, randomized double blind study.

Abstract: The effects of 2-dosage regimens of tranexamic acid (10 mg/kg and 15 mg/kg) on blood loss and transfusion requirement were compared to saline placebo in 60 patients undergoing concurrent bilateral total knee arthroplasty, with additional reinfusion autotransfusion from intraarticular drains. Mean blood loss was 462 mL in 15 mL/kg group, 678 mL in 10 mg/kg group, and 918 mL in controls (P < .01 vs 15 mg/kg). Blood available for autotransfusion was greatest in controls and least in 15 mg/kg group. Combined autologous and allogenic transfusion volumes were similar in the treatment groups and significantly less than controls (P < .01). With use of an autologous reinfusion strategy, the lower dose is sufficient to lead to a lesser allogenic transfusion requirement.

Revision for Recurrent Instability: What are the Predictors of Failure?

Abstract: Dislocation is a common complication following total hip arthroplasty (THA). In this study, we evaluated treatment strategies in patients undergoing revision THA for instability. A total of 156 hips in 154 patients underwent revision THA for instability between 2000 and 2007 at our institution. Demographic data and surgical treatment used were analyzed to determine risk factors for failure. Revision treatments included acetabular components in 100 hips, liner exchange in 56 hips, and femoral and acetabular components in 13 hips. Thirty-three (21.2%) had further dislocation. Isolated liner revision (P = .004), previous revision arthroplasty (P < .05), and the use of a 28-mm femoral head were associated with higher failure rates. A total of 20.3% (12/59) of constrained liners failed. Isolated liner exchange, history of revision, and use of a 28-mm head were associated with failure in revision THA for instability.

Quality of Life Outcomes in Revision Versus Primary Total Knee Arthroplasty

Abstract: The purpose of this study was to evaluate and compare the quality of life and satisfaction outcomes of patients undergoing primary and revision total knee arthroplasty (TKA). Sixty revision and 199 primary TKA patients were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford-12 Knee Score, Short Form-12, and patient-reported satisfaction. Baseline preoperative scores demonstrate that revision TKA patients have inferior quality of life across all measures (WOMAC, Oxford-12, and Short Form-12) in comparison with primary TKA patients (P < .05). At follow-up revision, TKA patients continue to have inferior outcomes (P < .05) in comparison with primary TKA patients. When adjusting for confounding factors in regression analyses, revisions are inferior to primary TKA by 8.6 (95% confidence interval, 2.7-14.6) normalized WOMAC units.

Readmission and length of stay after total hip arthroplasty in a national Medicare sample.

Abstract: Evaluation of hospital readmissions after total hip arthroplasty may help improve patient safety and cost reduction. This study investigates the rates and reasons for readmission as well as length of hospital stay (LOS) for 1802 total hip arthroplasty patients from 2002 to 2007. Data were abstracted from the Medicare Patient Safety Monitoring System. The overall 30-day rate of readmission was 6.8%. There was no difference in readmission rate from 2002 to 2004 (7.1%) to 2005 to 2007 (6.3%) (odds ratio, 0.90; 95% confidence interval, 0.63-1.30; P = .58). The overall mean LOS was 4.2 ± 2.2 days. There was a significant reduction in LOS from 2002 to 2004 (4.4 ± 2.5 days) to 2005 to 2007 (3.8 ± 1.7 days) (odds ratio, 1.28; 95% confidence interval, 1.25-1.31; P < .0001). The most common causes for readmission were cardiac related. A reduction in LOS was not associated with an increase in the rate of readmission in this sample. Efforts to optimize cardiac status before discharge may lead to lower rates of readmission in the future.

Mobile-Bearing Total Knee Arthroplasty: A Meta-Analysis

Abstract: An extensive database search was completed to perform a meta-analysis of outcomes of mobile-bearing total knee arthroplasty. Nineteen manuscripts encompassing 3506 total knee arthroplasty met criteria for analysis (average follow-up, 8.6 years). Data were subdivided based on design type and included rotating platform, meniscal bearing, and anterior-posterior glide-rotation subgroups. Fifteen-year survivorship of rotating platform designs (96.4%) was greater than meniscal bearing implants (86.5%). Mean component loosening (0.33%) and bearing instability (<1%) for all subgroups were uncommon. Implants placed prior to 1995 exhibited higher rates of bearing complications (1.6% vs 0.1%). Excellent results were obtained with mobile-bearing TKA over 2 decades. Loosening and bearing instability were uncommon. Bearing complications lessened after 1995, possibly secondary to improved surgical technique.

Dermatitis Associated With Chromium Following Total Knee Arthroplasty

Abstract: All metal implants release metal ions because of corrosion. Although 20% to 25% of patients develop metal sensitivity after total joint arthroplasty, which is 10% higher than that in the general population, only very few highly susceptible patients exhibit symptoms. Even patients with known metal allergy often do not react to their metal prosthesis. Systemic allergic contact dermatitis is particularly uncommon with total knee arthroplasty because there is no metal-on-metal contact between the femoral and tibial components. We present a case report of 62-year-old man with dermatitis most likely caused by chromium after total knee arthroplasty and review the relevant literature. Although this complication is very rare, it sometimes can be painful enough for the patient to undergo revision surgery.

Meta-Analysis and Systematic Review of Clinical Outcomes Comparing Mobile Bearing and Fixed Bearing Total Knee Arthroplasty

Abstract: Mobile bearing (MB) knee replacements were designed with the goal of increased conformity and decreased bearing wear. We conducted a meta-analysis and systematic review of randomized controlled trials comparing outcomes of MB and fixed bearing (FB) total knee arthroplasty (TKA). We identified 14 studies reporting our primary outcome of Knee Society Scores (KSS). We also pooled data for post-operative range of motion (ROM) and Hospital for Special Surgery scores (HSS). The standard difference in mean outcome scores for KSS and HSS demonstrated no difference between groups (P = .902, and P = .426 respectively). Similarly, the pooled data for ROM showed no difference between groups (P = .265). The results of this study found no significant differences between clinical outcomes of MB and FB TKA.

Higher body mass index is not associated with worse pain outcomes after primary or revision total knee arthroplasty.

Abstract: We assessed whether higher body mass index (BMI) is associated with higher risk of moderate-severe knee pain 2 and 5 years after primary or revision total knee arthroplasty (TKA).We adjusted for sex, age, comorbidity, operative diagnosis, and implant fixation in multivariable logistic regression. Body mass index (reference, b 25 kg/m2) was not associated with moderate severe knee pain at 2 years post primary TKA (odds ratio [95% confidence interval], 25-29.9, 1.02[0.75-1.39], P = .90; 30-34.9, 0.93 [0.65-1.34], P = .71; 35-39.9, 1.16 [0.77-1.74], P = .47; ≥ 40,1.09 [0.69-1.73], [all P values ≥ .47]). Similarly, BMI was not associated with moderate-severe pain at 5-year primary TKA and at 2-year and 5-year revision TKA follow-up. Lack of association of higher BMI with poor pain outcomes post-TKA implies that TKA should not be denied to obese patients for fear of suboptimal outcomes.

Minimum 5-year follow-up of a cementless, modular, tapered stem in hip revision arthroplasty.

Abstract: Hip revision surgery with a cementless tapered femoral component can provide axial and rotational stability in patients with compromised proximal bone stock. This study includes 90 cases revised with the Link MP (Waldemar Link, Hamburg, Germany) prosthesis. The median age at surgery was 72 (38-89) years. Aseptic loosening (70%) and periprosthetic fracture (22%) were common indications for surgery. Sixty-three patients (70%) were followed clinically with a median of 6 (5-11) years of follow-up. All other patients were followed through the Swedish Hip Register. The 5-year survival rate was 98% with stem removal and 90% with any reoperation as the end point. Complications included hip dislocation in 17 (19%) patients. The median Harris hip score was 78 (16-100) points, and the median radiographic stem migration was 2.7 mm at follow-up.

Acetabular component positioning in total hip arthroplasty: an evidence-based analysis.

Abstract: Advocates for navigated (NAV) total hip arthroplasty (THA) emphasize the potential for improved component placement. We reviewed published literature to investigate the claim of increased precision of acetabular component placement in navigated THA compared to conventional (N-NAV) THA. Major medical and publishers' databases were searched, making no restrictions for study type, yet restricting results to English-language sources. Nine studies of varying methodological quality involving 1479 THA with a mean age of 59.10 years were included. There was no statistically significant difference in mean acetabular component abduction and anteversion angles between the NAV and N-NAV groups. There was a statistically significant difference in the incidence of acetabular component placement in the "safe zone," with NAV having significantly more "safe placements" than N-NAV, regardless of the chosen safe zone. In addition, NAV had significantly fewer dislocations than N-NAV. These outcomes demonstrate the possible patient benefit from navigation and resulting tighter control of component position.

Patient vs Provider Characteristics Impacting Hospital Lengths of Stay After Total Knee or Hip Arthroplasty

Abstract: This study aims to identify whether patient-level or provider-level characteristics are most influential on a patient's length of stay in the acute care hospital. A data set containing a nationally representative sample of inpatient discharge abstracts was used. Multilevel linear regression models were used to evaluate the associations between patient-level and provider-level characteristics on patients' lengths of stay. The target population included 322 894 discharges with a primary procedure code for primary total knee arthroplasty and 193 553 discharges for total hip arthroplasty. The variables associated with the greatest increases in length of stay were a higher comorbidity level among patient level attributes (+17.4%) and low surgeon volume among provider-level characteristics (+18.8%). Provider-level characteristics, particularly provider volume, had a greater impact on length of stay.

Surgical repair of the gluteal tendons: a report of 72 cases.

Abstract: Lateral hip pain is a common problem in middle-aged women. This pain is usually attributed to trochanteric bursitis and treated as such. This study reports the results of investigation, the findings at surgery, the operative technique, the histopathologic findings, and the results of gluteal tendon repair in 72 patients with long-standing trochanteric pain and reports a classification of the operative findings. Six patients (7%) in the original study cohort of 89 patients were lost to follow-up, but of the remaining patients, 65 of 72, or 90%, were pain-free or had minimal pain (P < .00001). Surgical reconstruction of detached gluteal tendons causing chronic lateral hip pain addresses the problem directly and reliably relieves the symptoms of so-called "trochanteric bursitis."

Comparison Between Closed Suction Drainage and Nondrainage in Total Knee Arthroplasty: A Meta-Analysis

Abstract: From individual randomized studies, it is not clear whether a closed suction drainage should be used after total knee arthroplasty. Our meta-analysis compares the clinical outcomes of closed suction drainage with nondrainage after total knee arthroplasty in randomized controlled trials reported between January 1966 and May 2010. Fifteen eligible trials involving 1361 knee incisions (686 knees with closed suction drainage and 675 knees without drainage) satisfied the inclusion criteria for our meta-analysis. The result of the meta-analysis indicates that closed suction drainage reduces the incidence of soft tissue ecchymosis and requirement for dressing reinforcement, but increases the rate of homologous blood transfusion. No significant difference between drainage and nondrainage was observed in the incidence of infection, deep venous thrombosis, or postoperative range of motion.

The Stepwise Introduction of Innovation into Orthopedic Surgery: The Next Level of Dilemmas

Abstract: The optimum method for the appropriate introduction of innovative technologies into orthopedics is a vital but vexing issue. Compromises in the introduction process are driven by (a) the magnitude of the problem addressed (incidence and severity), (b) the advantages and risks of the proposed solution, and (c) the "universal dilemma," meaning the inherent "gap" between all the nonhuman supporting data and the unknowns of both efficacy and long-term safety in large human usage over many years. Drawing on the data generated and the actual decision tree used in the introduction of a new highly cross-linked polyethylene as a case study, this article illustrates these "subsequent dilemmas."