Component Malposition Research Articles

Humeral and Glenoid Component Malposition in Revision Shoulder Arthroplasty: A Retrospective, Cross-sectional Study.

The purpose of this study was to assess the incidence of glenoid and humeral component malposition in failed primary shoulder arthroplasty requiring revision. We hypothesized that glenoid and humeral component malposition would be a prevalent feature in cases requiring revision arthroplasty for primary anatomic TSA, primary RSA, and primary hemiarthroplasty procedures. A retrospective cross-sectional study was performed focusing on identifying the incidence of malpositioned components in shoulder arthroplasty in quantitative and qualitative reviews. A total of 234 consecutive cases from three institutions were included in the study. Past surgical and radiographic data relative to the primary and revision surgeries were collected by each of the three investigative institutions, and radiographs were reviewed by an independent reviewer. Descriptive data are summarized as means ± standard deviations, or frequency (%). An Exact McNemar's test was used to compare frequencies between the independent reviewer and the institutions when appropriate, with significance set at p=0.05. Quantitative analysis demonstrated that the majority of glenoid components in these revision cases were malpositioned in both TSA (51%) and RSA (93%) when all measures were considered. Similarly, there was humeral component malposition in 57% of TSA cases, 62% of RSA cases, and 54% of hemiarthroplasty cases when all measures were considered. When asked if there was glenoid component malposition, the independent reviewer considered 17% of glenoid components to be malpositioned in TSA cases and 54% in RSA cases. The investigative institutions reported similar rates (p=0.585). For the humeral side, the independent reviewer felt that 71% of TSA cases, 24% of RSA cases, and 74% of hemiarthroplasty implants were malpositioned in some direction. The investigative institutions reported similar rates (p=0.087). The data from this study suggests that component malposition is frequently present among patients requiring revision arthroplasty. Component malposition was not just frequently present, but also occurred in consistent patterns. Moreover, while significant attention has been placed on the impact of glenoid malposition, this study highlights the previously underappreciated high incidence of humeral component malposition in revision cases.

Causes of revision hip arthroplasty after hemiarthroplasty for femoral neck fracture

Background. Hemiarthroplasty as a surgical choice for elderly patients with femoral neck fractures is still a matter of scientific controversy. The aim of the study is to analyse unsatisfactory outcomes of hemiarthroplasty and compare them with the similar outcomes of total hip arthroplasty in elderly patients with femoral neck fractures. Methods. We conducted a retrospective randomized study, which enrolled 36 patients who underwent revision endoprosthetics after various types of arthroplasty for a femoral neck fracture. The patients were divided into 3 groups. Group 1 included 10 patients who underwent arthroplasty with the use of hemiendoprostheses; Group 2 — 15 patients with cemented acetabular components; Group 3 — 11 patients who had cementless acetabular components. Results. The average age of patients in Group 1 at the time of revision arthroplasty was 79 years and was statistically significantly different from the age of patients in Groups 2 and 3 (74.4 and 74.9 years, respectively). The average time for revision interventions after hemiarthroplasty was 40.2 months and significantly differed from the time for the revisions after total cemented (82.7) as well as total cementless (86.6) arthroplasties. The average time for the onset of pain among patients in Group 2 was 68.2 months, and among patients in Group 3 — 71.2 months. The most common bone defects were types 2C and 3A (total of 41.6% in all groups). There were errors in choice of the size of the acetabular bipolar or monopolar component in all 100% of hemiarthroplasty cases. The use of a larger hemiendoprosthesis cup compared to the femoral head led to early erosion of cartilage tissue. Smaller hemiendoprosthesis cups were complicated by early protrusions of the acetabulum floor. The main errors in total arthroplasty were malposition of the acetabular component (33.3-54.5%) and inadequate cement mantle (20%). It should be noted that infections among patients from Groups 2 and 3 developed up to 24.7 months after primary arthroplasty. Conclusions. Errors associated with incorrect choice of the acetabular endoprosthesis component size during primary hemiarthroplasty lead to early complications: erosion and protrusion of the acetabulum. Severe pain syndrome due to incorrect selection of the acetabular hemiendoprosthesis component size develops on average after 13.9 months, and the time period for revision endoprosthetics is 40.2 months after the primary operation. With erosions of the acetabulum, there are no bone defects; with protrusions — bone defects of type 2C and 3A more often occur. In comparison with the outcomes of total hip arthroplasty, the use of hemiendoprostheses shows a low survival rate of 40.2 months.

Linear and Volumetric Polyethylene Wear Patterns after Primary Cruciate-Retaining Total Knee Arthroplasty Failure: An Analysis Using Optical Scanning and Computer-Aided Design Models.

(1) Background: Analyses of retrieved inserts allow for a better understanding of TKA failure mechanisms and the detection of factors that cause increased wear. The purpose of this implant retrieval study was to identify whether insert volumetric wear significantly differs among groups of common causes of total knee arthroplasty failure, whether there is a characteristic wear distribution pattern for a common cause of failure, and whether nominal insert size and component size ratio (femur-to-insert) influence linear and volumetric wear rates. (2) Methods: We digitally reconstructed 59 retrieved single-model cruciate-retaining inserts and computed their articular load-bearing surface wear utilizing an optical scanner and computer-aided design models as references. After comprehensively reviewing all cases, each was categorized into one or more of the following groups: prosthetic joint infection, osteolysis, clinical loosening of the component, joint malalignment or component malposition, instability, and other isolated causes. The associations between volumetric wear and causes of failure were estimated using a multiple linear regression model adjusted for time in situ. Insert linear penetration wear maps from the respective groups of failure were further processed and merged to create a single average binary image, highlighting a potential wear distribution pattern. The differences in wear rates according to nominal insert size (small vs. medium vs. large) and component size ratio (≤1 vs. >1) were tested using the Kruskal-Wallis test and the Mann-Whitney test, respectively. (3) Results: Patients with identified osteolysis alone and those also with clinical loosening of the component had significantly higher volumetric wear when compared to those without both causes (p = 0.016 and p = 0.009, respectively). All other causes were not significantly associated with volumetric wear. The instability group differentiated from the others with a combined peripheral antero-posterior wear distribution. Linear and volumetric wear rates showed no significant differences when compared by nominal insert size (small vs. medium vs. large, p = 0.563 and p = 0.747, respectively) or by component (femoral-to-insert) size ratio (≤1 vs. >1, p = 0.885 and p = 0.055, respectively). (4) Conclusions: The study found increased volumetric wear in cases of osteolysis alone, with greater wear when combined with clinical loosening compared to other groups. The instability group demonstrated a characteristic peripheral anterior and posterior wear pattern. Insert size and component size ratio seem not to influence wear rates.

Outcomes related to penile prosthesis reservoir removal: a 7-year multi-institutional experience.

The 3-piece inflatable penile prosthesis (IPP) is the most widely used device for erectile dysfunction refractory to medications, containing a reservoir inserted into the retropubic space (RPS) or an alternative/ectopic space (AES). Indications for removal of the reservoir include malfunction, malposition, or infection. In revision cases without infection, reservoir removal is sometimes optional. We reviewed outcomes and complications related to reservoir removal from a large multi-institutional series. We retrospectively reviewed databases at 6 institutions over 7years. Patients with artificial urethral sphincter, urethral sling, or mini-jupette were excluded. Outcomes and complications related to IPP reservoir removal were analyzed. Data were collected, but only reservoir-related complications at surgery were included. Data were compared between the RPS and AES cohorts to evaluate differences with a χ2 test, with significance at P < .05. Of 215 cases, there were 172 RPS and 43 AES reservoirs. The mean patient age was 65.3years. An overall 131 procedures were due to malfunction and 49 to malposition of an IPP component; 35 were secondary to infection. Among those retained (n = 44), reasons included reuse, avoiding surrounding structure damage, and difficult dissection. Among those removed (n = 171), 15 required a counterincision. To determine the statistical difference between those removed from the RPS and an AES, the χ2 test result was P = .00059, indicating a significant difference in the need for a counterincision between the groups. Complications included bladder perforation (n = 1) in the RPS group and an avulsion of the epigastric vessels requiring abdominal exploration (n = 1) in the AES group. To determine the statistical difference between RPS and AES complications, the χ2 test result was P = .365, indicating no significant difference between the groups. Strengths include being a multi-institutional study with high-volume skilled implanters. Limitations include being a retrospective review, with implanters exclusively performing penoscrotal incisions and not utilizing an infrapubic approach. Last, there was a lack of long-term follow-up with these patients. Removal of an IPP reservoir remains safe, with few intraoperative complications. Surgeons should be aware of the inferior epigastric vessels during removal in an AES or be willing to perform a counterincision to avoid injury to surrounding structures. Surgeons should also obtain preoperative imaging to identify the specific location of the reservoir and adjacent anatomy. This is the first multi-institutional study reviewing outcomes related to reservoir removal during IPP revision or removal surgery.

Arthroscopic Iliopsoas Fractional Lengthening After Total Hip Arthroplasty: Utilization of the Iliopsoas Air Bursogram Technique for Safe and Efficient Access

Background: Patients with persistent symptomatic iliopsoas tendonitis following total hip arthroplasty may benefit from iliopsoas fractional lengthening. We present an arthroscopic approach utilizing an air bursogram that provides safe and predictable access to the iliopsoas tendon for efficient tendon lengthening without violating the capsule or unintentional instrumentation of the nearby medial neurovascular bundle. Indications: Arthroscopic iliopsoas fractional lengthening is indicated for patients with clinical evidence of symptomatic iliopsoas tendonitis following total hip arthroplasty and have no radiographic evidence of frank acetabular malpositioning. A diagnosis of iliopsoas tendinitis amenable to surgical management can be established with substantial but nondurable relief following image-guided anesthetic injection to the iliopsoas bursa. Technique Description: Under fluoroscopic guidance, an air bursogram is employed in the anatomic plane of the iliopsoas tendon to accurately identify its course. This allows for hip portal placement with precise subsequent instrumentation. This technique is preferred in the setting of postarthroplasty anatomy because it avoids capsular violation and the challenge of working in an altered anatomic space with a nearby, medially based neurovascular bundle. Results: Arthroscopic and endoscopic approaches to iliopsoas release have been shown to provide excellent functional and patient-reported outcomes in &gt;85% of patients, and several studies have shown that an arthroscopic approach not only provides a less invasive technique but also results in comparable or improved clinical outcomes with lower revision rates compared to open release or acetabular cup revision. Our technique for arthroscopic iliopsoas fractional lengthening using the air bursogram is both safe and reproducible and offers distinct advantages, including maintenance of an intact capsule, visual confirmation of the correct anatomic structure to be released, and percutaneous access with standard arthroscopic access cannulas without the need for hip distraction. Conclusions: Arthroscopic fractional iliopsoas lengthening is a minimally invasive and successful treatment option for patients with persistent groin pain after total hip arthroplasty, especially without substantial acetabular component malpositioning. This technique includes using an air bursogram to safely identify and navigate to the iliopsoas tendon without violating the hip capsule, thereby reducing the risk of inadvertent instrumentation of adjacent critical neurovascular structures. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Magnum metal-on-metal uncemented total hip replacement: 8- to 18-year outcomes of 211 cases

BackgroundReports of adverse reactions to metal debris contributed in part to a decline in use of large-bearing metal-on-metal total hip devices. We hypothesize an optimal trunnion design may reduce risk of this failure mode in large-bearing total hip arthroplasty systems. The purpose of this study is to report mid- to long-term outcomes for a single-surgeon series of 211 total hip arthroplasties using the large-bearing Biomet Magnum metal-on-metal system.Materials and methodsBetween December 2004 and January 2016, the primary surgeon performed 211 uncemented Magnum total hip arthroplasties in 181 patients. The average length of follow-up was 10.1 ± 3.5 years (range 8–18 years).ResultsUsing failure of any component as the endpoint, the overall survivorship rate was 98.1% at 10 years and 97.4% at 18 years. These eight failures (3.8% of cohort) included one case of adverse wear-related failure (0.5%), two cases of acetabular ingrowth failure (0.9%), three cases of trunnion corrosion (1.4%), one failure of late infection (0.5%), and one inappropriate revision of components for trochanteric nonunion without instability (0.5%). Excluding failed cases, all components were radiographically stable with no radiolucencies. Except for the one wear failure, ion testing revealed that 97.2% of cases were within optimal whole blood metal ion levels with the remaining ion test results within acceptable levels.ConclusionsWith the uncemented Magnum metal-on-metal total hip, we achieved 97.4% 18-year implant survivorship, exceeding the NICE criteria and registry benchmarks for implant survivorship. We observed a trunnion corrosion rate of 1.4% and no cases of instability. The single case of adverse wear-related failure was caused by acetabular component malposition.

Robotic-assisted Total Hip Arthroplasty and Spinopelvic Parameters: A Review.

Total hip arthroplasty (THA) is an effective treatment for osteoarthritis, and the popularity of the direct anterior approach has increased due to more rapid recovery and increased stability. Instability, commonly caused by component malposition, remains a significant concern. The dynamic relationship between the pelvis and lumbar spine, deemed spinopelvic motion, is considered an important factor in stability. Various parameters are used in evaluating spinopelvic motion. Understanding spinopelvic motion is critical, and executing a precise plan for positioning the implant can be difficult with manual instrumentation. Robotic and/or navigation systems have been developed in the effort to enhance THA outcomes and for implementing spinopelvic parameters. These systems can be classified into three categories: X-ray/fluoroscopy-based, imageless, and computed tomography (CT)-based. Each system has advantages and limitations. When using CT-based systems, preoperative CT scans are used to assist with preoperative planning and intraoperative execution, providing feedback on implant position and restoration of hip biomechanics within a functional safe zone developed according to each patient's specific spinopelvic parameters. Several studies have demonstrated the accuracy and reproducibility of robotic systems with regard to implant positioning and leg length discrepancy. Some studies have reported better radiographic and clinical outcomes with use of robotic-assisted THA. However, clinical outcomes comparable to those for manual THA have also been reported. Robotic systems offer advantages in terms of accuracy, precision, and potentially reduced rates of dislocation. Additional research, including conduct of randomized controlled trials, will be required in order to evaluate the long-term outcomes and cost-effectiveness of robotic-assisted THA.

Two-Year Results of Ceramic-on-Ceramic Hip Resurfacing in an International Multicenter Cohort

BackgroundHip resurfacing arthroplasty (HRA) is a bone-conserving alternative to total hip arthroplasty. We present the 2-year clinical and radiographic follow-up of a novel ceramic-on-ceramic HRA in an international multicenter cohort. MethodsPatients undergoing HRA between September 2018 and January 2021 were prospectively included. Patient-reported outcome measures (PROMs) in the form of the Forgotten Joint Score, Hip Disability and Osteoarthritis Outcome Score Jr., Western Ontario and McMaster Universities Arthritis Index, Oxford Hip Score, and University of California, Los Angeles, Activity Score were collected preoperatively, and at 1 and 2 years postoperation. Serial radiographs were assessed for migration, component alignment, evidence of osteolysis or loosening, and heterotopic ossification formation. ResultsThe study identified 200 patients who reached a minimum 2-year follow-up (mean 3.5 years). Of these, 185 completed PROMs follow-up at 2 years. There was a significant improvement in Hip Disability and Osteoarthritis Outcome Score (P < .001) and Oxford Hip Score (P < .001) between the preoperative, 1-year, and 2-year outcomes. Patients had improved activity scores on the University of California, Los Angeles, Active Score (P < .001), with 45% reporting a return to high-impact activity at 2 years. At 1 and 2 years, the Forgotten Joint Score was not significantly different (P = .38). There was no migration, osteolysis, or loosening of any of the implants. No fractures were reported over the 2-year follow-up, with only 1 patient reporting a sciatic nerve palsy. There were 2 revisions, 1 for unexplained pain at 3 months due to acetabular component malposition and 1 at 33.5 months for acetabular implant failure. ConclusionsThe ceramic-on-ceramic resurfacing at 2 years postoperation demonstrates promising results with satisfactory outcomes in all recorded PROMs. Further long-term data are needed to support the widespread adoption of this prosthesis as an alternative to other HRA bearings.

Excellent 10-Year survivorship of robotic-arm-assisted unicompartmental knee arthroplasty

IntroductionRobotic-arm-assisted unicompartmental knee arthroplasty (UKA) is an excellent solution for patients suffering from single-compartment knee arthritis. While outcomes tend to be favorable for UKAs, revision operations, commonly due to component malpositioning and malalignment resulting in accelerated wear, are a major concern. Intraoperative technologies, such as robotic assistance, can help better ensure that implants are positioned based on a patient's specific anatomy and mechanical physiology. However, long-term survivorship and patient-reported satisfaction with robotic-assisted UKAs are limited. Therefore, the purpose of this study was to assess the 10-year outcomes of patients who underwent robotic-arm-assisted unicompartmental knee arthroplasty. Specifically, we evaluated: 1) 10-year survivorships; 2) patient satisfaction scores; and 3) re-operations. MethodsFrom a single surgeon and single institution, 185 patients who had a mean age of 65 years (range, 39 to 92) and a mean body mass index of 31.6 (range, 22.4 to 39) at a mean of 10 years follow-up were evaluated (range, 9 to 11). For all patients, the same robotic-assistive device was utilized intraoperatively, and all patients underwent standardized physical therapy and received standardized pain control management. Then 10-year survivorships with Kaplan-Meir curves, patient satisfaction evaluations with a 5-point Likert scale, and re-operations were assessed as primary outcomes. ResultsOverall implant survivorship was 99%, with only two patients requiring revision surgery. There was one patient who was converted to a total knee arthroplasty, while the other patient underwent polyethylene exchange at 5 weeks for an acute infection with successful implant retention. Overall, 97% of the patients were satisfied with their postoperative outcomes, with 81% of patients reporting being very satisfied. There were two other patients who required arthroscopic intervention: one to remove a cement loose body, the other to remove adhered scar from the fat pad and the anterior cruciate ligament. ConclusionThis study is one of the first to provide longer-term (mean 10-year) survivorship and patient-reported satisfaction outcomes for robotic-assisted UKA patients. These data show strong support for utilizing this surgical technique, as nearly all patients maintained their original prostheses and reported being satisfied after a mean of 10 years. Therefore, based on these results, we recommend the use of robotic assistance when performing UKAs.

Distal femur morphology and the suitability of standard guides for knee arthroplasty in the Turkish population.

The aim of this study was to evaluate the posterior condylar angle (PCA) and condylar twist angle (CTA) of the distal femur in the Turkish population and its concordance with the current standard prosthesis guides used in total knee arthroplasty (TKA). Two hundred and forty knees of 120 Turkish subjects (60 male and 60 female) were included in this study. PCA, CTA, femoral mediolateral lengths (fML), medial femoral anteroposterior lengths (fMAP), lateral femoral anteroposterior lengths (fLAP), distances between the trochlear groove and fMAP (DBTG-fMAP), distances between the trochlear groove and fLAP (DBTG-fLAP), medial posterior condylar cartilage thickness (MPCCT) and lateral posterior condylar cartilage thicknesses (LPCCT) were measured on magnetic resonance imaging (MRI). The median CTA was 7° (range: 0°-13.0°) and the median PCA was 4° (range 0°-11.0°) (P < .0001). The median fML was 79.5 mm (range: 65.7-98.9). The median length of the fMAP was 58.2 mm (range: 46.8-69.0) and the median length of fLAP was 58.2 mm (range: 48.4-73.0). The DBTG-fMAP was 15.2 mm (range: 5.2-23.2), and DBTG-fLAP length was 21.9mm (range: 16.4-29.4). The median MPCCT and LPCCT were 2.4 mm (range: 1.6-3.6) and 2.3 mm (range: 1.2-2.8), respectively. The intraclass correlation coefficient for quantifying interobserver and intraobserver reliability showed excellent agreement regarding the PCA and CTA. This study has shown us that PCA and CTA may be higher in the Turkish population. Although it is not known whether these results have any clinical utility, it may be useful for surgeons to keep this in mind to prevent femoral component malposition. Level IV, Diagnostic Study.

"Pain without loosening"-revisions of knee arthroplasties in the Danish Knee Arthroplasty Register.

We aimed to investigate "pain without loosening" as an indication for knee arthroplasty revisions and to screen for other indications potentially hidden in this category to improve future registration and enhance data quality in the Danish Knee Arthroplasty Register. We included 104 patients undergoing revision knee arthroplasty for the indication "pain without loosening" from 1 January 2016 to 31 December 2018 at five Danish centres. Medical records, radiographs and computed tomographies were reviewed. In 103 of 104 cases, we confirmed "pain without loosening" as an indication for revision. We found hidden indications in 44 cases; malposition of components (n = 19), stiffness (n = 13), progression of arthrosis (n = 6), instability (n = 3), liner dislocation (n = 1), residual cement (n = 1) and aseptic loosening (n = 1). The Kellgren-Lawrence arthrosis grades prior to primary knee arthroplasty were 1-2 (31%) and 3-4 (69%). The indication "pain without loosening" covered patients revised due to pain, but other hidden indications were also present. Stiffness and malposition of components were hidden indications and these are not provided as indication options in the DKR and other registers. The relatively high frequency of arthrosis grade 1-2 prior to primary knee arthroplasty is concerning and may explain the occurrence of knee pain without any other pathology present. The Danish Rheumatism Association, the Region of Southern Denmark, the Research Fund of Region Zeeland and Region of Southern Denmark, and the University of Southern Denmark. Not relevant.

Arthroscopic Iliopsoas Fractional Lengthening After Total Hip Arthroplasty: Using the Iliopsoas Air Bursogram Technique to Hit the Target

Iliopsoas tendinitis following total hip arthroplasty has been linked to retroverted acetabular cup position with associated anterior overhang. For severely malpositioned components, preferred treatment is in the form of revision arthroplasty. However, for a substantial number of cases, iliopsoas tendinitis as well as associated pain and disability are observed in the presence of modest acetabular overhang. In such cases, patients may benefit substantially from arthroscopic iliopsoas fractional lengthening. Given altered postarthroplasty anatomy, we present an arthroscopic approach employing an iliopsoas air bursogram. In such a way, safe and predictable access can be provided for efficient tendon lengthening without capsular violation or inadvertent instrumentation of the nearby medial neurovascular bundle.

Patient Reported Outcomes Before and After Revision Total Ankle Arthroplasty Done In the First Two Years of a Single Surgeons Practice

Category: Ankle Arthritis; Ankle Introduction/Purpose: As Total Ankle Arthroplasty (TAA) volume continues to grow nationally, so is the need for revision TAA surgery. A foot and ankle surgeon fresh out of fellowship is likely to encounter these challenging cases soon after beginning practice. The learning curve for ankle replacement has been demonstrated in multiple studies but no such study exists for revision TAA due to the relative infrequency of this procedure. The experience of one high volume revision TAA surgeon in the first two years after fellowship is reviewed in this study. Radiographic, clinical, and patient reported outcomes are analyzed in this study. Methods: In this IRB approved study, we retrospectively reviewed prospectively collected data on 18 patients who underwent Revision Total Ankle Arthroplasty Surgery from January 1, 2018, to January 1, 2021. Patient-reported outcome (PRO) measures including PROMIS depression, physical function and pain interference CATs taken preoperatively and then at specific post- operative intervals were collected on all patients. Radiographic and clinical results were also reviewed. Patients being revised, whether single stage or two-stage, for infection were excluded. Patients converted from ankle arthrodesis to ankle replacement were omitted. Student t tests, chi-square test, and nonparametric alternatives (p &lt;.05) we used. Results: Eighteen patients ( Average age 65.5, 50% male) underwent revision TAA average follow up 25 months. Aseptic loosening (50%) was the most common cause for revision followed by component malpositioning (28.8%). The Scandanavian Total Ankle Replacement was the most commonly revised implant in this study 83.3%. Radiographic parameters (Tibiotalar angle Tibial component positioning) improved after revision TAA. Average Promis physical function improved from 41.18 pre-op to 47.77 (p.078), depression improved from 57.64 pre-op to 49.67(p .025*), and pain interference improved from 61.3 preop to 50.55 (p .045*) after revision TAA. No differences were seen in any outcome measure with regards to time from fellowship, when assessing for a learning curve. See attached table for complete list of results. Conclusion: Revision TAA is a technically challenging procedure. One which will continue to be more and more common as ankle replacement continues to replace arthrodesis as the preferred treatment for ankle arthritis. This study did not identify a learning curve for revision total ankle arthroplasty. Outcomes were similar independent of time after fellowship the cases occurred. Patient reported outcomes, clinical outcomes, and radiographic outcomes all improved in this cohort after revision TAA.

The ceramic coated implant (CCI). Evolution total ankle replacements: a retrospective analysis of 40 ankles with 8 years follow-up.

Diminutive data is available on the outcome of several previously used total ankle replacement implants. The purpose of this study was to investigate the medium-term functional and radiological outcome and implant survival of the CCI Evolution implant. Consecutive series of 40 ankles operated in our hospital with primary TAR using the CCI Evolution implant in 2010-2013 were available for follow-up. The prospective clinical and radiographic data including the Kofoed score, subjective satisfaction and standard radiographs were collected preoperatively and at fixed time-points postoperatively. A CT was obtained in cases where osteolysis or loosening were suspected. The improvement of the Kofoed score and subjective satisfaction were statistically significant (p<0.0001). The implant survival was 97% (95% confidence interval (CI) 81%-100 %) at 5 years, and 81 % (95% confidence interval (CI) 60 %-92%) at 8 years. There were altogether 25 (64%) complications. Overall revision rate was 28% and failure rate 13%. The CCI implant outcome was not acceptable. The malposition of prosthetic components, subsidence, and peri-implant osteolysis were recorded often. Although the patient reported outcome measures improved, mostly due to positive changes in pain severity, overall revision and failure rates were high and comparable with previous findings of the CCI implant.

1244 Wound Dehiscence and Infection of a Total Knee Replacement Secondary to Postoperative ‘Dorsal Fin’ Intra-Articular Vertical Patella Dislocation

Abstract A 75-year-old man presented to our emergency department with a bleeding wound 19 days following a primary hinged left total knee replacement, performed elsewhere, for lateral tibiofemoral osteoarthritis. Examination revealed a knee held in fixed flexion of 30°, with partial dehiscence of the wound, implant exposure and a visible patella. Radiographs revealed an abnormally raised joint line with a vertical appearance of the patella on the lateral image. The decision was made to proceed with a two-stage revision. At operation, the patella was confirmed to be vertically positioned in the trochlea groove of the femoral component and identified as the likely cause for the wound dehiscence. There was evidence of a large lateral release having been performed during the primary surgery. A joint orthoplastic wound debridement was performed, together with implant removal, and static cement spacer insertion. Following an eight-week interval of IV antibiotics, the second stage was performed. A new hinged implant was implanted, with metaphyseal sleeves and stems. A tibial tubercle osteotomy was required to address the lateral tracking patella and a gastrocnemius flap was necessary to address a distal soft tissue defect. This case study highlights an unusual cause for wound dehiscence following total knee arthroplasty. Patella dislocation with vertical axis rotation has been described in the native knee1, but to our knowledge, this is the first report of this phenomenon following arthroplasty. This was almost certainly secondary to component malpositioning and emphasizes the significance of restoring the native joint line and correct implant rotation during knee replacement surgery.

Anterior Knee Pain After Total Knee Arthroplasty: A Critical Review of Peripatellar Variables.

» Despite the widespread success of total knee arthroplasty (TKA), postoperative anterior knee pain (AKP) remains a common occurrence and source of dissatisfaction with several readily discernible and diagnosable causes of AKP after TKA, including component malpositioning, infection, wear and osteolysis, instability, and loosening, among others.» In the setting of the well-appearing but painful TKA, potential intraoperative contributors to AKP have been extensively investigated, but remain controversial and include patellar resurfacing, patellar denervation, and patellofemoral joint overstuffing or understuffing.» Intraoperative management of peripatellar soft tissues has comparatively attained substantially less attention recently, and persistent controversy exists in the literature to make informed decisions on soft-tissue management and identify potential contributors to AKP.» Further investigations and research is needed, including exploration of multifactorial or alternative etiologies, specifically ones related to less obvious soft-tissue-related factors, needed to better understand and ultimately avoid AKP after TKA.

Internal Rotation, Varus, and Anterior Femoral Component Malalignments Adversely Affect Patellofemoral Joint Kinematics in Patellofemoral Arthroplasty.

Patellofemoral arthroplasty (PFA) is reported to provide nearly normal PF joint kinematics but only with adequate surgical techniques. This study evaluated the effects of various femoral component settings on patellar component biomechanics. A dynamic musculoskeletal computer simulation analyzed normal knee and standard PFA models, as well as 8 femoral component malposition models: 5° internal or external rotation, 5° valgus or varus, 5° extension or flexion, and 3-mm or 5-mm anterior positioning. Mediolateral patellar translation, lateral patellar tilt, and contact force and stress at the PF joint were measured in each model during gait. The patella in the standard PFA model was shifted up to 5.0 mm laterally near heel off and was tilted up to 3.0° laterally at heel strike compared to the normal knee model. The patella in the external rotation model translated more laterally in the direction of the femoral component setting than in the standard model. However, in the internal rotation and varus alignment models, the patellar lateral shift occurred largely in the opposite direction of the femoral component setting. The patella in most models was tilted in the same direction as the femoral component setting. The PF contact force was increased, especially in the anterior femoral position models, by up to 30 MPa compared with 20 MPa in the standard model. Internal rotation, varus, and anterior femoral component settings during PFA should be avoided to reduce postoperative complications, whereas external rotation might be appropriate only for cases with lateral patellar instability.

Is the Direct Anterior Approach for Total Hip Arthroplasty Effective in Obese Patients? Early Clinical and Radiographic Results from a Retrospective Comparative Study.

Background and objectives: Total hip arthroplasty (THA) in obese patients (BMI > 30) is considered technically demanding, and it is associated with higher rates of general and specific complications including infections, component malpositioning, dislocation, and periprosthetic fractures. Classically, the Direct Anterior Approach (DAA) has been considered less suitable for performing THA surgery in the obese patient, but recent evidence produced by high-volume DAA THA surgeons suggests that DAA is suitable and effective in obese patients. At the authors' institution, DAA is currently the preferred approach for primary and revision THA surgery, accounting for over 90% of hip surgeries without specific patient selection. Therefore, the aim of the current study is to evaluate any difference in early clinical outcomes, perioperative complications, and implant positioning after primary THAs performed via DAA in patients who were divided according to BMI. Material and methods: This study is a retrospective review of 293 THA implants in 277 patients that were performed via DAA from 1 January 2016 to 20 May 2020. Patients were further divided according to BMI: 96 patients were normal weight (NW), 115 were overweight (OW), and 82 were obese (OB). All the procedures were performed by three expert surgeons. The mean follow-up was 6 months. Patients' data, American Society of Anesthesiologists (ASA) score, surgical time, days in rehab unit, pain at the second post-operative day recorded by using a Numerical Rating Scale (NRS), and number of blood transfusions were recorded from clinical charts and compared. Radiological evaluation of cup inclination and stem alignment was conducted on post-operative radiographs; intra- and post-operative complications at latest follow-up were recorded. Results: The average age at surgery of OB patients was significantly lower compared to NW and OW patients. The ASA score was significantly higher in OB patients compared to NW patients. Surgical time was slightly but significantly higher in OB patients (85 ± 21 min) compared to NW (79 ± 20 min, p = 0.05) and OW patients (79 ± 20 min, p = 0.029). Rehab unit discharge occurred significantly later for OB patients, averaging 8 ± 2 days compared to NW patients (7 ± 2 days, p = 0.012) and OW patients (7 ± 2 days; p = 0.032). No differences in the rate of early infections, number of blood transfusions, NRS pain at the second post-operative day, and day of post-operative stair climbing were found among the three groups. Acetabular cup inclination and stem alignment were similar among the three groups. The perioperative complication rate was 2.3%; that is, perioperative complication occurred in 7 out of 293 patients, with a significantly higher incidence of surgical revisions required in obese patients compared to the others. In fact, OB patients showed a higher revision rate (4.87%) compared to other groups, with 1.04% for NW and 0% for OW (p = 0.028, Chi-square test). Causes for revision in obese patients were aseptic loosening (2), dislocation (1), and clinically significant post-operative leg length discrepancy (1), with a revision rate of 4/82 (4.87%) during follow-up. Conclusions: THA performed via DAA in obese patients could be a solid choice of treatment, given the relatively low rate of complications and the satisfying clinical outcomes. However, surgical expertise on DAA and adequate instrumentation for this approach are required to optimise the outcomes.

PD42-07 OUTCOMES RELATED TO INFLATABLE PENILE PROSTHESIS (IPP) RESERVOIR REMOVAL: A 7-YEAR MULTI-CENTER EXPERIENCE

You have accessJournal of UrologyCME1 Apr 2023PD42-07 OUTCOMES RELATED TO INFLATABLE PENILE PROSTHESIS (IPP) RESERVOIR REMOVAL: A 7-YEAR MULTI-CENTER EXPERIENCE Javier Piraino, Ian Madison, Matthew Ziegelmann, Run Wang, Tobias Kohler, Aram Loeb, Gerard Henry, Robert Cornell, Dylan Supak, Landon Trost, and Jonathan Clavell Javier PirainoJavier Piraino More articles by this author , Ian MadisonIan Madison More articles by this author , Matthew ZiegelmannMatthew Ziegelmann More articles by this author , Run WangRun Wang More articles by this author , Tobias KohlerTobias Kohler More articles by this author , Aram LoebAram Loeb More articles by this author , Gerard HenryGerard Henry More articles by this author , Robert CornellRobert Cornell More articles by this author , Dylan SupakDylan Supak More articles by this author , Landon TrostLandon Trost More articles by this author , and Jonathan ClavellJonathan Clavell More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003352.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The 3-piece IPP is the most widely used device for erectile dysfunction refractory to medications, containing a reservoir inserted into the Space of Retzius (SOR) or an alternative/ectopic space (AES). Indications for removal of the reservoir include malfunction, malposition or infection. In revision cases without infection, reservoir removal is sometimes optional. We review outcomes and complications specifically related to reservoir removal from a large multi-institutional series. METHODS: We retrospectively reviewed databases at 6 institutions over 7 years. Patients with artificial urethral sphincter, urethral sling or Mini-jupette were excluded. Outcomes and complications related to IPP reservoir removal were analyzed. Data were collected but only reservoir-related complications at surgery were included. Data were compared between SOR and AES cohorts to evaluate differences with χ2, with significance at p<0.05. RESULTS: Of 215 cases, there were 172 SOR (80%) and 43 AES (20%) reservoirs. Mean patient age was 65.3 years old. 131 (60.9%) procedures were due to malfunction, 49 (22.8%) were due to malposition of an IPP component, and 35 (16.3%) were secondary to infection. Among those retained (N=44, 20.5%), reasons included reuse, avoiding surrounding structure damage, unspecified, and difficult dissection. Among those removed (N=171), 15 (8.8%) required a counter-incision (6 in SOR and 9 in AES). χ2 to determine statistical difference between those removed from SOR and AES found a p=0.00059, indicating significant difference in the need for a counter-incision those groups. Complications included bladder perforation (N=1) in the SOR group, and an avulsion of the epigastric vessels requiring abdominal exploration (N=1) in the AES group. χ2 to determine statistical difference when comparing SOR and AES complications was p=0.365, indicating no significant difference between groups. CONCLUSIONS: Removal of an IPP reservoir remains safe with few complications. Surgeons should be aware of the inferior epigastric vessels during removal in an AES or be willing to perform a counter incision to avoid injury to surrounding structures. Surgeons should obtain preoperative imaging to identify the specific location of the reservoir and adjacent anatomy. This is the first and largest multi-institutional study reviewing outcomes related to reservoir removal during IPP revision or removal surgery. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1113 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Javier Piraino More articles by this author Ian Madison More articles by this author Matthew Ziegelmann More articles by this author Run Wang More articles by this author Tobias Kohler More articles by this author Aram Loeb More articles by this author Gerard Henry More articles by this author Robert Cornell More articles by this author Dylan Supak More articles by this author Landon Trost More articles by this author Jonathan Clavell More articles by this author Expand All Advertisement PDF downloadLoading ...

Complications in cervical total disc arthroplasty

Cervical total disc arthroplasty (CTDA) is an alternative to cervical fusion when addressing single level cervical disc disease and attempts to restore normal disc height and preserve motion, theoretically decreasing rates of adjacent segment disease (ASD) and symptomatic pseudoarthrosis. Although safe and effective, CTDA has a unique complication profile particularly in regard to long-term complications. Approach related complications are similar to anterior cervical discectomy and fusion (ACDF) and include injury to surrounding vascular, digestive, and neurologic structures. To achieve anatomic positioning, CTDA requires vertebral endplate cartilage removal and osseous preparation which can lead to endplate fracture, salvage fusion, or component malpositioning. Long term complications include heterotopic ossification (HO), implant subsidence, ASD requiring surgical intervention, and implant migration or translation. Although HO reduces motion at the prosthesis site, it does not appear to worsen clinical outcomes in most cases. Evidence is still conflicting regarding ASD when comparing ACDF to CTDA, however, the most recent evidence suggests a lower rate of development with CTDA.