Surface Replacement Arthroplasty Research Articles

Surface replacement arthroplasty in the surgical treatment of hip osteoarthritis

Surface arthroplasty, also referred to as resurfacing, is a method of sparing hip arthroplasty, which is a surgical alternative usually reserved for younger, active patients. The introduction of successive generations of implants with metal-on-metal articulation resulted in increased interest in this method of treatment. Despite the unquestionable advantages and promising initial results, resurfacing has some limitations and disadvantages. One of them is the increase in the concentration of metal ions. Although they are necessary for the proper functioning of the human body, in large amounts they can lead to serious reactions of the soft tissues adjacent to the prosthesis, including metallosis, ALVAL (Aseptic Lyphocytic Vasculitis-Associated Lesion), or the formation of pseudotumours. Despite numerous studies and scientific reports, there is a need for further work on the relationship between the concentration levels of metal ions in people after resurfacing and the biological, causal mechanisms of the development of adverse reactions in the body.

Outcomes of Surface Replacement Arthroplasty in Metacarpophalangeal Joints Affected by Noninflammatory Arthritis.

The purpose of this study was to investigate the outcomes of surface replacement arthroplasty (SRA) for noninflammatory arthritis of the metacarpophalangeal (MCP) joint. Records from 20 SRAs performed between 1995 and 2017 in 17 patients with noninflammatory arthritis affecting the MCP joint were retrospectively reviewed. The mean follow up was 6.6 years. Three arthroplasties (15%) underwent 4 revision operations. The 2-, 5-, 10-, and 15-year rates of survival from surface replacement implant revision were 90%, 90%, 79%, and 79%, respectively. Major complications occurring in revised joints included arthrodesis (n = 1) and amputation (n = 1). The overall reoperation rate was 35%. The 2-, 5-, 10-, and 15-year rates of overall reoperation-free survival were 75%, 69%, 60%, and 60%, respectively. Pain ratings and MCP arc of motion significantly improved following arthroplasty. Metacarpophalangeal SRA for noninflammatory arthritis can improve arc of motion and pain. Revision is uncommon; however, 1 in 3 joints requires reoperation.

Long-term Outcomes of MCP Surface Replacement Arthroplasty in Patients With Rheumatoid Arthritis.

Background: Surface replacement arthroplasty (SRA) can be used in the treatment of rheumatoid arthritis (RA) affecting the metacarpophalangeal (MCP) joint. The authors of this study sought to investigate the outcomes of MCP SRA in patients with RA. Methods: Retrospective review of medical records and an institutional joint registry were used to gather data on 80 MCP SRAs performed in 27 patients with RA. Data collected included demographics, SRA revisions, reoperations, complications, pain, and MCP arc of motion. Results: The mean postoperative follow-up was 9.5 years (range, 2.1-20.5 years), with all SRAs achieving at least 2 years of follow-up. Thirteen digits (16%) underwent revision arthroplasty, and 29 (36%) required reoperation. The 5-, 10-, 15-, and 20-year rates of survival from implant revision were 95%, 85%, 80%, and 69%, respectively. The 5-, 10-, 15-, and 20-year rates of survival from overall reoperation were 80%, 65%, 55%, and 46%, respectively. Metacarpophalangeal joint arc of motion, grip strength, and pain levels significantly improved following surgery. Conclusions: Metacarpophalangeal SRA can offer benefit to patients with RA for improvement in function and pain. High overall reoperation rates remain concerning; however, most do not involve arthroplasty revision.

Lateral stability in healthy proximal interphalangeal joints versus surface replacement and silicone arthroplasty: Results of a three-dimensional motion analysis study

The objective of this study was to quantify the lateral stability of healthy proximal interphalangeal (PIP) joints using a three-dimensional motion capture system and compare it to affected joints after surface replacement or silicone arthroplasty. Three study groups comprised healthy participants, patients with PIP joint osteoarthritis treated with a surface replacing implant (CapFlex-PIP) and those with a silicone arthroplasty. All participants were matched on gender and finger, and the two patient groups were also matched on length of follow-up. An optical tracking system was used to measure lateral stability. Radial and ulnar stability of the PIP joint was measured as the maximal lateral deviation angle of the middle phalanx under loads of 40 g, 90 g and 170g at 0°, 20° and 45° PIP joint flexion. Measurement reliability was evaluated with a test-retest trial [intraclass correlation coefficient (ICC)]. A total of 30 joints were assessed with 5 index and 5 middle fingers per test group. Lateral deviation increased proportionally with applied weight. Silicone arthroplasty joints had a higher median lateral deviation angle of 5.1° (range 0.7–7.9) than healthy [3.0° (0.5–11.0)] and surface replacement joints [3.3° (0.3–7.4)] at 45° flexion and under 170g load. Test-retest reliability was high with an ICC of 0.93. Lateral PIP joint stability is highly variable in both healthy participants and patients after PIP joint arthroplasty. PIP joint surface replacement arthroplasty tends to achieve better anatomical stability compared to flexible silicone implants.

Glenohumeral Dislocation Arthropathy: Etiology, Diagnosis, and Management.

Dislocation arthropathy describes the development of progressive degenerative changes of the glenohumeral joint in the setting of instability. Although the specific etiology remains unclear, the trauma of a single dislocation, repetitive injury associated with recurrent dislocations, changes in shoulder biomechanics, and complications associated with instability surgery have all been implicated in its development. Pain and restricted range of motion are the most common patient complaints. Conservative management, consisting of pain control, activity modification, and physical therapy, is the first-line treatment after the development of arthropathy. If conservative management fails, multiple surgical options exist. Arthroscopic débridement can be attempted in young, active patients and in those patients with mild-to-moderate arthropathy. Open subscapularis lengthening and capsular release can be done in patients with prior instability repairs that are overly tight. In young patients with minimal bone loss and glenoid wear, surface replacement arthroplasty and hemiarthroplasty are surgical options. In older patients with moderate-to-severe arthropathy, total shoulder or reverse shoulder arthroplasty is the preferred treatment option. Further study is needed to better predict which patients will develop dislocation arthropathy and will thus benefit from early surgical intervention.

Analysis of cobalt deposition in periprosthetic bone specimens by high-resolution synchroton XRF in undecalcified histological thin sections

Increasing numbers of implant revisions are a current clinical issue. Interactions of the endoprosthesis biomaterial with the body affect implantation time by wear processes, i.e. corrosion and abrasion. Previously, cobalt-chrome implants were shown to cause high levels of cobalt ions being deposited in the bone matrix. To determine a potential functional role of these ions on bone homeostasis, we have developed a non-destructive dual analysis of highly sensitive elemental analysis by synchrotron XRF directly in undecalcified histological bone thin sections (4 µm). In this study, samples from 28 bone samples from hip endoprosthesis carriers (Surface Replacement Arthroplasty, metal-on-metal bearing) with an implant lifetime of 17–1750 days were used. Results were compared to age-matched control specimens. The histological analysis identified areas of bone cell activity and assigned them for XRF measurements. Co-Cr wear particles were identified in the bone marrow. In addition, Co ions were highly enriched in the mineralized bone matrix. The cobalt deposits were not homogeneously distributed, and areas of high signal intensity were identified. Co was distinctly deposited in the newly formed osteoid layer, but also within deeper layers of the bone matrix, whereby the Co concentration increased with higher degrees of bone matrix mineralization. In the current study, we determined cobalt accumulations in the bone matrix and showed for the first time via synchrotron XRF with a high spatial resolution direct on histological slides, that cobalt deposits in the mineralized bone matrix in a mineral-specific way that is dependent upon the implant lifetime.

Is there evidence to support an indication for surface replacement arthroplasty?: a systematic review.

Surface replacement arthroplasty (SRA), compared with traditional total hip arthroplasty (THA), is more expensive and carries unique concern related to metal ions production and hypersensitivity. Additionally, SRA is a more demanding procedure with a decreased margin for error compared with THA. To justify its use, SRA must demonstrate comparable component survival and some clinical advantages. We therefore performed a systematic literature review to investigate the differences in complication rates, patient-reported outcomes, stress shielding, and hip biomechanics between SRA and THA. A systematic review of the literature was completed using MEDLINE and EMBASE search engines. Inclusion criteria were level I to level III articles that reported clinical outcomes following primary SRA compared with THA. An initial search yielded 2503 potential articles for inclusion. Exclusion criteria included review articles, level IV or level V evidence, less than one year's follow-up, and previously reported data. In total, 27 articles with 4182 patients were available to analyze. Fracture and infection rates were similar between SRA and THA, while dislocation rates were lower in SRA compared with THA. SRA demonstrated equivalent patient-reported outcome scores with greater activity scores and a return to high-level activities compared with THA. SRA more reliably restored native hip joint biomechanics and decreased stress shielding of the proximal femur compared with THA. In young active men with osteoarthritis, there is evidence that SRA offers some potential advantages over THA, including: improved return to high level activities and sport, restoration of native hip biomechanics, and decreased proximal femoral stress shielding. Continued long-term follow up is required to assess ultimate survivorship of SRA.

Higher blood loss and transfusion requirement in surface arthroplasty versus conventional total hip replacement.

Background and aim of the work: Surface replacement arthroplasty (SRA) is an alternative to stemmed total hip arthroplasty (THA) providing a femoral bone preserving procedure. Because of the wider surgical dissection, an increased blood loss could be expected. This retrospective study evaluates the transfusion requirement in two homogeneous groups of patients who underwent primary hip replacement electively. Methods: Perioperative haematological data of 42 hip resurfacing procedures and 41 conventional cementless THAs were compared. The pre- and post-operative haemoglobin (Hb) levels and the amount of blood transfusions were registered. The median values were compared with use of the non-parametric Wilcoxon signed-rank test. Results: In the SRA group, a significantly increased (p<0.02) preoperative Hb concentration (13.1 g/dL, range 10.9 to 15.6) was detected in comparison with the THA group (12.5 g/dL, range 10.4 to 15.2). In the resurfacing procedures a median of 900 mL (range 600 to 1500) were transfused vs. 600 (range 300 to 1500) in the conventional THAs, demonstrating a significantly higher transfusion requirement (p<0.04). Conclusions: Whereas hip resurfacing is a femoral bone preserving alternative to conventional THA with comparable clinical and radiographic outcomes, higher blood loss and transfusion requirement may occur. (www.actabiomedica.it)

Is There a Role for Surface Replacement Arthroplasty in Today's Orthopaedic Practice?: Commentary on an article by Marcus C. Ford, MD, et al.: "Five to Ten-Year Results of the Birmingham Hip Resurfacing Implant in the U.S. A Single Institution's Experience".

Is There a Role for Surface Replacement Arthroplasty in Today's Orthopaedic Practice?: Commentary on an article by Marcus C. Ford, MD, et al.: "Five to Ten-Year Results of the Birmingham Hip Resurfacing Implant in the U.S. A Single Institution's Experience".

Five to Ten-Year Results of the Birmingham Hip Resurfacing Implant in the U.S.: A Single Institution's Experience.

International surgeon series and registry data have demonstrated positive outcomes and long-term survival of the Birmingham Hip Resurfacing (BHR) implant. We report the 5 to 10-year results from a single center in the U.S. Three hundred and fourteen patients (360 hips) underwent surface replacement arthroplasty with use of the BHR implant and consented to study participation. Patient-reported outcomes and complication and revision data were collected at a minimum of 5 years of follow-up for 93% (324 of 350) of the hips in surviving patients. A matched-cohort analysis was used to compare clinical outcomes between use of the BHR and total hip arthroplasty. Mean modified Harris hip score (mHHS) and University of California, Los Angeles (UCLA) scores significantly improved postoperatively, to 89.9 and 8.0, respectively (p < 0.001). The Kaplan-Meier estimated rate of survival for all-cause revision was 97.2% (95% confidence interval [CI], 94.7% to 98.5%) and 93.8% (95% CI, 88.8% to 96.7%) at 5 and 10 years, respectively. In a subgroup analysis of patients fitting our current BHR inclusion criteria (males <60 years of age with a diagnosis of osteoarthritis and anatomy conducive to a femoral head component of ≥48 mm), survival free of aseptic revision was 99.5% (95% CI, 96.6% to 99.9%) at 5 years and 98.2% (95% CI, 94.4% to 99.4%) at 10 years. Fourteen patients (4.3% of all hips) required revision. Postoperative UCLA scores were significantly greater for BHR compared with total hip arthroplasty (mean score of 8.0 ± 2.0 versus 7.6 ± 1.8; p = 0.040) in a matched-cohort analysis, with patients matched according to preoperative UCLA score, diagnosis, age, sex, and body mass index. Among matched patients who were highly active preoperatively (UCLA score of 9 to 10), BHR provided a smaller median decrease in the postoperative UCLA score (0.0 versus 1.0; p < 0.001), which was clinically important according to the minimal clinically important difference (MCID, 0.92). Furthermore, BHR provided a greater likelihood of remaining highly active compared with total hip arthroplasty (61% compared with 20%; p < 0.001). BHR demonstrated excellent survivorship and clinical outcomes at 5 to 10 years in selected patients. As compared with total hip arthroplasty, the use of the BHR may provide highly active patients with clinically important advantages in postoperative activity as well as a greater likelihood of remaining highly active. Continued follow-up is necessary to validate long-term BHR outcomes. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes Following Acute Metacarpophalangeal Joint Arthroplasty Dislocation: An Analysis of 37 Cases.

There remains a paucity of information regarding the treatment outcomes of dislocation after metacarpophalangeal (MCP) joint arthroplasty. The purpose of this study was to assess the outcomes of surgical and nonsurgical treatment modalities of MCP arthroplasty dislocations. Of 816 MCP joint arthroplasties over a 14-year period, there were 37 (4%) acute MCP joint dislocations that required intervention by a health care professional. Implants involved included 28 nonconstrained implants including pyrocarbon (n= 17) and surface replacement arthroplasty (n= 11), and 9 silicone implants. The analysis included the treatment of dislocations after primary (n= 30) and revision (n= 7) MCP joint arthroplasty. Dislocation was defined as clinical and radiographic evidence of MCP joint prosthetic acute dislocation diagnosed and treated by a fellowship trained hand surgeon. Etiologies underlying the dislocations included implant fracture (n= 6), component loosening (n= 2), and soft tissue deficiency (n= 29). Of the 37 dislocations, treatments included 14 nonsurgical (closed reduction, orthosis fabrication) all of which ultimately failed. Surgically, including some of the failed prior procedures, 18 soft tissue stabilization procedures and 21 revision arthroplasties were performed, with 6 that had failed soft tissue stabilization. The soft tissue stabilization procedures had a 28% success rate in achieving a stable MCP joint. Revision arthroplasty had a 71% success rate. Subgroup analysis showed an 86% success rate for silicone revisions and a 43% success rate with nonconstrained revisions, with 80% and 36% 5-year survival free of instability, for the 2 types of implants, respectively. The treatment of MCP joint arthroplasty dislocation with revision to silicone implant appears to hold the most promise in achieving a stable MCP joint after an acute prosthetic dislocation. Therapeutic IV.

Study of functional and radiological outcome of total knee arthroplasty using the knee society score

The common causes of arthritis of the knee include Osteoarthritis (OA), Rheumatoid Arthritis (RA), Juvenile Rheumatoid Arthritis, Post traumatic Arthritis or secondary Osteoarthritis and other types of inflammatory arthritis. Osteoarthritis is thought to be the most prevalent chronic joint disease. The surgical techniques have varied from soft tissue interposition arthroplasty to resection arthroplasty to surface replacement arthroplasty. In surface replacement arthroplasty different types of prosthesis were developed to address the complex knee kinematics. Total Knee Arthroplasty (TKA) is now a reliable treatment for severe arthritis. Various systems are available with specific features regarding the geometry of the components, the degree of conformity of the articulating surface and the anchoring technique. Aim: To study the clinical, functional and radiological outcome in a consecutive series of Total Knee Arthroplasty using Knee Society Score. Materials and Methods: This study was done to analyse the clinical, functional and radiological outcome of Total Knee Arthroplasty using Knee Society score using a Posterior Cruciate substituting (Indus Knee Prosthesis). A Prospective study consisting of 30 patients who consented and underwent Total Knee Arthroplasty. The follow up period was at 3 months, 6 months and 1 year. Results and Discussion: According to the Knee Society Functional Scoring system, 30 patients were assessed in this study. 16 patients (53%) had Excellent, 11 patients (37%) had Good, 2 patients (7%) had Fair and 1 patient (3%) poor results. The results were found to be comparable with other studies. Conclusion: Total Knee Arthroplasty improves the functional ability of the patient and the ability of the patient to get back to pre-disease state, which is to have a pain free mobile joint, as reflected by the improvement in the post-op Knee Clinical Score and Knee Functional Score.

Mid-term changes in blood metal ion levels after Articular Surface Replacement arthroplasty of the hip

Our first aim was to determine whether there are significant changes in the level of metal ions in the blood at mid-term follow-up, in patients with an Articular Surface Replacement (ASR) arthroplasty. Secondly, we sought to identify risk factors for any increases. The study involved 435 patients who underwent unilateral, metal-on-metal (MoM) hip resurfacing (HRA) or total hip arthroplasty (THA). These patients all had one measurement of the level of metal ions in the blood before seven years had passed post-operatively (early evaluation) and one after seven years had passed post-operatively (mid-term evaluation). Changes in ion levels were tested using a Wilcoxon signed-rank test. We identified subgroups at the highest risk of increase using a multivariable linear logistic regression model. There were significant increases in the levels of metal ions for patients who underwent both MoM HRA (Chromium (Cr): 0.5 parts per billion (ppb); Cobalt (Co): 1.1 ppb) and MoM THA (Cr: 0.5 ppb; Co: 0.7 ppb). In a multivariable model considering MoM HRAs, the change in the levels of metal ions was influenced by female gender (Co: Odds Ratio (OR) 1.42; p = 0.002 and Cr: OR 1.08; p=0.006). The change was found to be irrespective of the initial level for the MoM HRAs, whereas there was a negative relationship between the initial level and the change in the level for those with a MoM THA (Co: OR -0.43; p<0.001 and Cr: OR -0.14; p = 0.033). The levels of metal ions in the blood increase significantly over the period until mid-term follow-up in patients with both a MoM HRA and those with a MoM THA. We recommend that the levels of metal ions be measured most frequently for women with a MoM HRA. While those with a MoM THA appear to stabilise at a certain level, the accuracy of this trend is not yet clear. Vigilant follow-up is still recommended. Cite this article: Bone Joint J 2017;99-B(4 Supple B):33-40.

Post-Operative Contracture of the Proximal Interphalangeal Joint after Surface Replacement Arthroplasty Using a Volar Approach.

Postoperative contracture as a major complication of surface replacement arthroplasty (SRA) remains an unresolved problem. Contracture after SRA can occur early in the postoperative period due to mechanical dysfunction, and tardy contracture where ROM declines with time postoperatively is also reported. 13 fingers with degenerative osteoarthritis and two fingers with post-traumatic arthritis where SRA was performed using volar approach were involved. Contracture was defined as limited ROM of less than 35 degrees. Cases were then categorized into two groups according to time of onset of contracture; early contracture and tardy contracture. Characteristic findings of postoperative X-rays in each contracture group were examined. Required procedures and efficacy of any further surgery was also reviewed. Early contracture was observed in three cases, all of which suffered intra-operative fracture or fragility of the central slip insertion on the dorsal rim of the middle phalanx. This was observed in a further two cases, both of which deteriorated to tardy contracture. Tardy contracture was observed in five cases, and the average ROM was 63 degrees preoperatively, 48 degrees one year postoperatively and 21 degrees at the most recent follow-up, or at the time of the second surgery. In the three cases, development of osteophyte formation on the volar aspect of the proximal head component was observed on the follow-up X-rays. Required further surgeries were resection of the volar plate in two cases, resection of ossification in one and resection of the osteophyte in two. The results of further surgeries were mediocre in all but one case. This study showed that intra-operative fracture or fragility of the central slip insertion was a risk factor for postoperative contracture after SRA, and that development of osteophyte formation can be a cause of deterioration in ROM of the PIP joint.

MatOrtho proximal interphalangeal joint arthroplasty: minimum 2-year follow-up.

The MatOrtho proximal interphalangeal replacement is a cementless cobalt-chromium metal-on-polyethylene mobile-bearing surface replacement arthroplasty. The aim of this study is to report the outcome and complications of this implant at a minimum of 2 years follow-up from a single institution. A retrospective case review was performed on all MatOrtho proximal interphalangeal joint replacements performed with a minimum of 2 years follow-up. Patient demographics, diagnosis, implant revision and other surgical interventions were recorded. Subjective and objective outcomes were evaluated at latest follow-up, including pain scores, range of motion, function and radiographic assessment. A total of 109 implants were inserted in 56 patients. Nine implants (six patients) were lost to follow-up. Of the remaining 100 implants, 75 had been undertaken in females. The mean age at time of surgery was 64 years and the principal diagnosis was osteoarthritis in 74%. The mean follow-up was 47 months (range 24-77). Within the group there was a statistically significant diminution in pain. There was also an improvement in functional scores post-operatively. Improvement in range of motion was seen in those joints with a pre-operative range of motion greater than 20°. Radiologically there was no evidence of loosening or of implant subsidence at final follow-up. The revision rate was 13%. Nine joints were revised to the NeuFlex (silicone rubber) prosthesis, three were converted to an arthrodesis and one had exchange of the MatOrtho prosthesis. The survival of the MatOrtho proximal interphalangeal joint arthroplasty was 85% at a minimum of 2-years follow-up. Patients can be advised that the procedure achieves good pain relief, improvement in functional scores and may improve range of motion. We would, however, caution against this implant's use in joints that are either stiff or have significant deformity and/or instability pre-operatively.

Proximal Femur Bone Density Decreases up to 5 Years After Total Hip Arthroplasty in Young, Active Patients

BackgroundThe number of young, active patients undergoing hip arthroplasty continues to increase. The purpose of this study was to evaluate femoral bone density over a 5-year period after hip arthroplasty in young, active patients. MethodsA total of 96 patients (103 hips) with a presymptomatic University of California at Los Angeles (UCLA) score ≥6 who had a total hip arthroplasty (THA; 45 hips) or surface replacement arthroplasty (SRA; 58 hips) were prospectively enrolled. UCLA and Harris Hip Scores were collected preoperatively and postoperatively, and dual energy X-ray absorptiometry scans were performed at 6 weeks, 6 months, 1 year, 2 years, and 5 years postoperatively. Bone density was analyzed for 7 traditional Gruen zones in both groups and 6 femoral neck zones in the SRA group. Bone density ratios were calculated for change in bone density compared with baseline. ResultsNo differences were present in the preoperative or postoperative UCLA or Harris Hip Scores between the SRA and THA cohorts (P = .07-.7). In the THA group, bone density never returned to baseline during the 5-year period in Gruen zones 1 (91.2% of baseline), 2 (94.8%), 6 (97.3%), and 7 (89.2%). There were no decreases in bone mineral density ratio for the femoral Gruen zones in the SRA group at any interval. Femoral neck bone density after SRA increased on the lateral, tension side up to 5 years postoperatively (P < .0001). ConclusionYoung, active patients undergoing THA with cementless femoral fixation demonstrate reductions in bone density in the proximal femur in Gruen zones 1, 2, and 7 over time.

Residual Symptoms and Function in Young, Active Hip Arthroplasty Patients: Comparable to Normative Controls?

BackgroundWhether patient-reported symptoms and function after total hip and surface replacement arthroplasty in young, active patients compare favorably to those without known hip pathology has not been investigated. MethodsA retrospective, multicenter study was designed in which 5 centers contributed patients aged <60 years with a presymptomatic University of California at Los Angeles score ≥6 undergoing hip arthroplasty. Data were collected by an independent, third-party survey center that administered a questionnaire assessing patient satisfaction and function. A “control” population with no prior hip interventions or hip pathology limiting their activity, that met the age and activity criteria, was identified for comparison using multivariate regression analyses. ResultsEight-hundred six hip arthroplasties (682 total hip arthroplasty, 124 surface replacement arthroplasty) and 158 controls were included. A greater percentage of hip arthroplasty patients were male and aged >50 years which was controlled during multivariate regression analyses. Control patients reported the presence of a limp (15%), stiffness (11%), and pain in the hip (8%), but to a lesser degree than hip arthroplasty patients. Control patients were less likely to report pain in the hip (odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.2-0.7, P = .006), stiffness in the hip (OR = 0.5, 95% CI = 0.3-0.8, P = .02), and a limp (OR = 0.5, 95% CI = 0.3-0.8, P < .001) vs patients undergoing hip arthroplasty. ConclusionWhen interviewed by an independent third party, a substantial portion of control patients did note the presence of hip symptoms, but to a lesser degree than young, active patients undergoing hip arthroplasty.

Tranexamic acid: optimal blood loss management in surface replacement arthroplasty.

This study investigated whether the use of tranexamic acid (TXA) decreased blood loss and transfusion related cost following surface replacement arthroplasty (SRA). A retrospective review of patients treated with TXA during a SRA, who did not receive autologous blood (TXA group) was performed. Two comparison groups were established; the first group comprised of patients who donated their own blood pre-operatively (auto group) and the second of patients who did not donate blood pre-operatively (control). Outcomes included transfusions, post-operative haemoglobin (Hgb), complications, and length of post-operative stay. Between 2009 and 2013, 150 patients undergoing SRA were identified for inclusion: 51 in the auto, 49 in the control, and 50 in the TXA group. There were no differences in the pre-operative Hgb concentrations between groups. The mean post-operative Hgb was 11.3 g/dL (9.1 to 13.6) in the auto and TXA groups, and 10.6 g/dL (8.1 to 12.1)in the control group (p = 0.001). Accounting for cost of transfusions, administration of TXA, and length of stay, the cost per patient was $1731, $339, and $185 for the auto, control and TXA groups, respectively. TXA use demonstrated higher post-operative Hgb concentrations when compared with controls and decreased peri-operative costs. Tranexamic acid safely limits allogeneic transfusion, maintains post-operative haemoglobin, and decreases direct and indirect transfusion related costs in surface replacement arthroplasty.

Revision shoulder arthroplasty: does the stem really matter?

The management of a failed shoulder arthroplasty represents a complex and difficult problem for the treating surgeon, with potential difficulties and complications that are related to the need to remove a well-fixed stem. The aim of this study is to compare the intraoperative complications, postoperative complications, and outcome of revisions from stemmed arthroplasties (STAs) with those from surface replacement arthroplasties (SRAs). From 2005 to 2012, 40 consecutive revision shoulder arthroplasties were performed at our institute: 17 from STAs and 23 from SRAs. Perioperative events, operation time, blood loss, intraoperative fractures, and use of structural allograft were recorded. Clinical and radiologic outcomes were analyzed. Operation time, need for humeral osteotomy, need for structural allograft, and number of intraoperative fractures were significantly higher in the STA group. Blood loss, drop in hemoglobin level, need for blood transfusion, and hospitalization time were also higher in the STA group, but these differences were not statistically significant. Reoperation was performed in 3 patients in the SRA group. A significant clinical improvement was observed in both groups. The Constant score was higher in the SRA group. Revision of STAs is a more demanding procedure. The postoperative complication rate was slightly higher in the SRA group. The group with revision of SRAs showed slightly better clinical and radiographic results, but there was no statistically significant difference between the groups.

Conversion of a failed hip resurfacing arthroplasty to total hip arthroplasty: pearls and pitfalls.

Surface replacement arthroplasty (SRA) remains a viable alternative to total hip arthroplasty (THA) in appropriately selected, active adults with degenerative hip disease. However, orthopedic surgeons are facing a number of scenarios where revision of one or both components of an SRA is indicated. Indications for revision vary and impact the potential outcomes of conversion of a SRA to THA. While clinical outcomes are generally favorable, a growing body of data illustrates patients who undergo conversion of a SRA to THA to be at increased risk of requiring a repeat revision surgery and experiencing functional outcomes inferior to that of a primary THA. The results of patients undergoing conversion of a SRA to THA highlight the need for careful patient selection, thorough preoperative counseling, and technical precision when performing a SRA. Furthermore, a systematic approach to the failed SRA is necessary to ensure optimal clinical results.