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TRANSCRIPT
Editor
P Maxwell Courtney MD
Assistant Professor
Department of Orthopedic Surgery
Thomas Jefferson University
Rothman Institute
Philadelphia, Pennsylvania, USA
Orthopedics-2
Recent Advances in
The Health Sciences PublisherNew Delhi | London | Panama
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Jaypee Brothers Medical Publishers (P) Ltd
Website: www.jaypeebrothers.comWebsite: www.jaypeedigital.com© 2018, Jaypee Brothers Medical PublishersThe views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book.All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photo copying, recording or otherwise, without the prior permission in writing of the publishers.All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contra indications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to ��������������� ��������������������������������� ������CD/DVD-ROM (if any) provided in the sealed envelope with this book is complimentary and free of cost. Not meant for sale.Inquiries for bulk sales may be solicited at: [email protected]
Recent Advances in Orthopedics-2
First Edition: 2018ISBN: 978-93-5270-287-9Printed at
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Dedicated toMy wife, Courtney
for her patience, love and unending support
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Contributors
Lucas A Anderson MDDepartment of Orthopedic Surgery and
Sports Medicine
Coeur d’Alene, Idaho, USA
D Greg Anderson MDProfessor
Departments of Orthopedic and
Neurological Surgery
Thomas Jefferson University
Rothman Institute
Philadelphia, Pennsylvania, USA
Bradley M AndersonDepartment of Orthopedic Surgery
Thomas Jefferson University
Rothman Institute
Philadelphia, Pennsylvania, USA
Blair Ashley MD
Department of Orthopedic Surgery
University of Pennsylvania
Philadelphia, Pennsylvania, USA
Philip Ashley MD
Assistant Professor
Department of Orthopedic Surgery
University of Alabama-Birmingham
Children’s of Alabama
Birmingham, Alabama, USA
Frank R Avilucea MD
Assistant Professor
Department of Orthopedic Surgery
University of Cincinnati College of Medicine
Cincinnati, Ohio, USA
Pedro Beredjiklian MD
Assistant Professor
Department of Orthopedic Surgery
Thomas Jefferson University Hospital
Rothman Institute
Philadelphia, Pennsylvania, USA
Daniel Bouton MD
Shriner’s Hospital for Children
Portland, Oregon, USA
James Carey MD MPH
Director
Penn Center for Cartilage Repair and
Osteochondritis Dissecans Treatment
Assistant Professor
Department of Orthopedic Surgery
University of Pennsylvania
Philadelphia, Pennsylvania, USA
Gerard Chang MD
Department of Orthopedic Surgery
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania, USA
Ryan S Charette MD
Department of Orthopedic Surgery
University of Pennsylvania
Philadelphia, Pennsylvania, USA
Daniel E Davis MD
Assistant Professor
Department of Orthopedic Surgery
Thomas Jefferson University
Rothman Institute
Philadelphia, Pennsylvania, USA
Carl A Deirmengian MD
Associate Professor
Department of Orthopedic Surgery
Thomas Jefferson University
Rothman Institute
Philadelphia, Pennsylvania, USA
Claudio Diaz-Ledezma MD
Adult Reconstruction Surgeon
Clínica Bicentenario
Santiago, Chile
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Recent advances in orthopedics-2viii
Jill A Erickson PA-C
Department of Orthopedic Surgery
University of Utah
Salt Lake City, Utah, USA
David Figueroa MD
Professor
Department of Orthopedic Surgery
Facultad de Medicina Clinica Alemana
Universidad del Desarrollo
Santiago, Chile
Francisco Figueroa MD
Facultad de Medicina Clinica Alemana
Universidad del Desarrollo
Santiago, Chile
Yale A Fillingham MD
Adult Reconstruction Fellow
Thomas Jefferson University
Rothman Institute
Philadelphia, Pennsylvania, USA
Charles L Getz MD
Associate Professor
Department of Orthopedic Surgery
Thomas Jefferson University
Rothman Institute
Philadelphia, Pennsylvania, USA
J Gabriel Horneff MD
Assistant Professor
Department of Orthopedic Surgery
Thomas Jefferson University
Rothman Institute
Philadelphia, Pennsylvania, USA
Asif Ilyas MD
Associate Professor
Department of Orthopedic Surgery
Thomas Jefferson University Hospital
Rothman Institute
Philadelphia, Pennsylvania, USA
Tetsuya Jinno MD PhD
Associate Professor
Department of Rehabilitation Medicine/
Orthopedic Surgery
Tokyo Medical and Dental University
Bunkyo, Tokyo, Japan
Gregg R Klein MD
Vice Chairman
Department of Orthopedic Surgery
Hackensack University Medical Center
Hartzband Center for Hip and
Knee Replacement
Paramus, New Jersey, USA
James Krieg MD
Professor
Department of Orthopedic Surgery
Thomas Jefferson University
Rothman Institute
Philadelphia, Pennsylvania, USA
Harlan Levine MD
Hackensack University Medical Center
Hartzband Center for Hip and
Knee Replacement
Paramus, New Jersey, USA
Daniel Lim MD
Department of Orthopedic Surgery
University of Pennsylvania
Philadelphia, Pennsylvania, USA
Jess H Lonner MD
Associate Professor
Department of Orthopedic Surgery
Thomas Jefferson University
Rothman Institute
Philadelphia, Pennsylvania, USA
Kevin Lutsky MD
Assistant Professor
Department of Orthopedic Surgery
Thomas Jefferson University Hospital
Rothman Institute
Philadelphia, Pennsylvania, USA
Rafael Martínez MD
Orthopedics Department
Universidad Finis Terrae
Santiago, Chile
Jonas Matzon MD
Associate Professor
Department of Orthopedic Surgery
Thomas Jefferson University Hospital
Rothman Institute
Philadelphia, Pennsylvania, USA
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Contributors ix
Christopher M Melnic MD
Instructor of Orthopedic Surgery
Harvard Medical School
Massachusetts General Hospital
Boston, Massachusetts, USA
Liane Miller MD
Department of Orthopedic Surgery
University of Pennsylvania
Philadelphia, Pennsylvania, USA
Wayne G Paprosky MD
Professor
Department of Orthopedic Surgery
Rush University Medical Center
Chicago, Illinois, USA
Christopher E Pelt MD
Associate Professor
Department of Orthopedic Surgery
University of Utah
Salt Lake City, Utah, USA
Christopher L Peters MD
Professor
Department of Orthopedic Surgery
University of Utah
Salt Lake City, Utah, USA
David A Podeszwa MD
Associate Professor
Department of Orthopedic Surgery
Texas Scottish Rite Hospital for Children
Dallas, Texas, USA
Ivan Radovic MD
Hip Surgeon
Clínica Bicentenario
Santiago, Chile
Andrew Tice MD
Texas Scottish Rite Hospital for Children
Dallas, Texas, USA
Maria Jesus Tuca MD
Facultad de Medicina Clinica Alemana
Universidad del Desarrollo
Santiago, Chile
John S Vorhies MD
Department of Orthopedic Surgery
Stanford University School of Medicine
Lucile Packard Children’s Hospital
Stanford, California, USA
Toshifumi Watanabe MD PhD
Associate Professor
Adult Reconstruction Division
Department of Rehabilitation Medicine/
Orthopedic Surgery
Tokyo Medical and Dental University
Bunkyo, Tokyo, Japan
Kazuyoshi Yagishita MD PhD
Department of Rehabilitation Medicine/
Orthopedic Surgery
Tokyo Medical and Dental University
Bunkyo, Tokyo, Japan
Stephan Zmugg MD
Texas Scottish Rite Hospital for Children
Dallas, Texas, USA
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Thank you for your interest in Recent Advances in Orthopedics-2.
This series is intended to serve as a practical source for the general
orthopedic surgeon, both in practice and still in training. Surgeons
with a subspecialty focus will also find this book of value. Our goal was
to provide the reader with a broad understanding on the “hot topics”
in each orthopedic subspecialty with a special emphasis on current
debates in the field of adult reconstruction.
Like the first volume, we have sought to provide the reader with an
informed perspective on the most important subjects in orthopedics, written by renowned
thought leaders in their specialty. This new edition highlights topics including minimally
invasive approaches to the spine, new developments in cartilage basic science, implant
selection in revision arthroplasty and surgical techniques in joint preservation. We are
both honored and excited to have contributions from internationally recognized surgeons
in South America and Asia. We hope these chapters can give the reader new insight on
challenges faced by orthopedic surgeons all over the world.
It is our sincerest hope that this edition of Recent Advances in Orthopedics-2 will serve as
a compendium of the newest advances in orthopedic surgery. We hope that you will find
this to be a unique, practical source for the latest information as you care for your patients.
P Maxwell Courtney MD
Preface
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Acknowledgments
I would like to express my sincere appreciation to the talented contributors to Recent Advances in Orthopedics-2, without whom this wonderful work would not be possible. I
would also like to thank, the editors of the first volume of this book, who helped build the
foundation for a successful series.
I especially appreciate the constant support and encouragement of Mr Jitendar P Vij
(Group Chairman) and Mr Ankit Vij (Group President), Jaypee Brothers Medical Publishers
(P) Ltd, New Delhi, India in publishing this textbook and also their associates particularly
Ms Chetna Malhotra Vohra (Associate Director—Content Strategy) and Ms Angima Shree
(Senior Development Editor) who have been prompt, efficient and most helpful.
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Chapter 1 What’s new in spinal surgery? 1
Bradley M Anderson, D Greg Anderson
Chapter 2 What’s new in hip joint preservation surgery? 8
Lucas A Anderson, Frank R Avilucea, Christopher E Pelt,
Jill A Erickson, Christopher L Peters
Chapter 3 What’s new in total hip arthroplasty? 37
Harlan Levine, Gregg R Klein
Chapter 4 What’s new in knee arthroplasty? 49
Yale A Fillingham, Carl A Deirmengian, Jess H Lonner
Chapter 5 What’s new in revision arthroplasty? 63
Christopher M Melnic, Ryan S Charette, Wayne G Paprosky
Chapter 6 What’s new in sports medicine? 81
Daniel Lim, James Carey
Chapter 7 What’s new in shoulder and elbow surgery? 89
Charles L Getz, Daniel E Davis, J Gabriel Horneff
Chapter 8 What’s new in orthopedic trauma? 96
Gerard Chang, James Krieg
Chapter 9 What’s new in hand surgery? 113
Kevin Lutsky, Asif Ilyas, Jonas Matzon, Pedro Beredjiklian
Chapter 10 What’s new in orthopedics: Asian perspective—hip? 130
Tetsuya Jinno, Toshifumi Watanabe, Kazuyoshi Yagishita
Chapter 11 What’s new in orthopedics: Asian perspective—knee? 143
Toshifumi Watanabe, Kazuyoshi Yagishita, Tetsuya Jinno
Chapter 12 What’s new in knee arthroplasty: South American
perspective? 150
David Figueroa, Rafael Martínez, Maria Jesus Tuca,
Francisco Figueroa
Chapter 13 What’s new in hip arthroplasty: South American
perspective? 162
Claudio Diaz-Ledezma, Ivan Radovic
Contents
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Recent advances in orthopedics-2xvi
Chapter 14 What’s new in basic orthopedic science? 169
Blair Ashley, Liane Miller
Chapter 15 What’s new in pediatric orthopedics? 191
Philip Ashley, Daniel Bouton, Andrew Tice, John S Vorhies,
Stephan Zmugg, David A Podeszwa
Index 201
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Harlan Levine, Gregg R Klein
What’s new in total hip arthroplasty?
Chapter 3
INTRODUCTIONThis installment of “What is new in total hip arthroplasty?” reviews several topics relevant to
the total hip arthroplasty surgeon including the use of tapered stems in the revision setting,
consensus statements regarding the perioperative use of antirheumatic medications, and
the use of antibiotics prior to dental work for total hip arthroplasty (THA) patients and the
utility of hip precautions following posterolateral THA and outpatient THA.
TAPERED STEMS IN REVISION TOTAL HIP ARTHROPLASTY It has been projected that by 2020 the need for revision total hip arthroplasty will increase a
factor of 2.1 Reliable instruments systems and implants that can be used to manage a wide
range of bone defects encountered at the time of revision that are easy to use and predictable
in outcome will continue to be important tools in the orthopedic surgeon’s armamentarium.
Titanium tapered, splined stems, originally popularized by Wagner in the 1980s2 have
tremendous utility, particularly in the setting of proximal bone loss and poor bone quality,
and are now commonly used in revision total hip arthroplasty.3-5
The original stem design was a monolithic, tapered splined stem made of titanium with
a grit blasted surface texture. Early concerns with the use of this stem design involved stem
subsidence resulting from suboptimal femoral preparation and undersizing of the implant,
as well as instability resulting from inadequate neck length and femoral offset restoration.6
To overcome these shortcomings of earlier generation monolithic stems, modular implants
were developed that allow for the independent placement of the stem and proximal body
and give the surgeon the ability to independently control anteversion, length, and offset.
However, concerns with the use of modular stems exist including fatigue failure and
corrosion at the body/stem interface.7,8 Several recent articles extolling the benefits of both
monolithic as well as modular tapered revision implants have been published.
Hellman et al. recently reported on a single surgeon, minimum 2 year (range 24–89
month, mean 41.8 month) revision experience using a monolithic splined tapered grit
blasted titanium stem (Wagner SL, Zimmer-Biomet, Warsaw Indiana) in revision total hip
arthroplasty.9 The authors believe that there is a place in revision total hip arthroplasty for
a monolithic stem as it provides economic benefits compared to modular stems, simplicity
in inventory management, and eliminates the risk of corrosion and fatigue failure of the
body/stem junction versus a modular stem. The authors followed 67 patients (68 cases) for a
minimum of 2 years. Femoral defect classification was Paprosky grade IIIa or greater in 85%
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What’s new in total hip arthroplasty?38
of the cases. At 4-year follow-up, the Kaplan-Meier estimated survivorship was 95.5% for
aseptic femoral revision. In this series, fixation by bone ingrowth was observed in 94.1% of
patients. One patient developed stable fibrous fixation and three patients required revision
for failure of osseointegration. Mean stem subsidence in this series was 2.03 ± 3.64 mm, and
two patients had greater than 1 cm of stem subsidence both of whom required revision. The
authors advocate accurate preoperative templating, considering the use of intraoperative
X-rays to assess canal fill, and protected weight-bearing for 6 weeks postoperatively to
minimize the risk of stem subsidence. The average limb length discrepancy following revision
was 1.43 ± 11.9 mm and 86.4% of patients had limb lengths within 1 cm of the contralateral
side. The authors stress that most patients in this series with large limb length discrepancy
postoperatively had severe limb length discrepancy preoperatively as well. They report
a dislocation rate of 7.4%. They note that this dislocation rate is lower than the European
experience which ranges from 2.5% to 21%; the authors attribute the lower rate of dislocation
to a design modification in North America giving the stem a neck shaft angle of the 135°
versus the European model which has a neck shaft angle of 145°. The authors report that this
improvement in implant offset as well as the use of large femoral heads (85.3% had a head
size of 36 mm or greater in this series), and appropriate femoral canal preparation to limit
stem subsidence are the factors responsible for the improvement in dislocation rate.
Sandiford et al. also recently reported their institution’s experience with the same
monolithic, tapered, splined, titanium, grit blasted femoral stem (Wagner SL, Zimmer-
Biomet, Warsaw Indiana) as reported above.10 Citing concerns regarding stress shielding on
femoral bone stock with the use of nonmodular, cylindrical stems as well as apprehension
resulting from failures at the body/stem interface with tapered splined stems, the authors
advocate the use of nonmodular, tapered stems for all but the most complex revision cases
were a modular stem or proximal femoral replacement may be more appropriate. They report
on 104 cases performed over a 20 month period with a median follow-up of 32 months (24–
46 months). Femoral defects were classified as follows: Paprosky type I—10 hips, Paprosky
II—26 hips, Paprosky IIIA—52 hips, Paprosky IIIB—9 hips, and Paprosky IV—2 hips. In this
series, the mean Oxford Hip Scores improved from 39 ± 15 preoperatively to 87 ± 19 (p <
0.001) at latest follow-up. Similarly, WOMAC scores improved from 44 ± 15 to 87 ± 20 (p
< 0.001). Six patients exhibited stem subsidence of between 10 mm and 15 mm while the
remaining 98 patients had a mean subsidence of 2 mm (0–9 mm). There was one revision for
septic loosening. The authors advocate that this monoblock stem is a reasonable option to
treat Paprosky II and III femoral defects while avoiding potential complications at a modular
interface. They also indicate that the stem may be used for selected type IV defects.
There are many reports in the literature regarding the use of modular, tapered, splined
stems showing favorable results in the setting of femoral bone loss,11,12 periprosthetic
fracture13,14 and infection (Figures 3.1A and B).15 However, many of these studies are limited
by short-term follow-up and small patient numbers. Abdel et al. reviewed their institution’s
experience of 519 aseptic hip revisions using a modular, tapered, splined stem. Follow-up
ranged from 2 years to 14 years with a mean of 4.5 years. Harris hip scores improved from
51 points preoperatively to 76 points postoperatively. In this series, there were 16 femoral
failures requiring full femoral revisions (removal of both the body and tapered stem)
performed for the following reasons: aseptic loosening—6, infection—4, instability—3,
periprosthetic fracture—2, implant fracture—1. There were 12 other operations to address
instability where the tapered stem was retained and the proximal modular body was revised.
Ten-year survivorship was 98% with revision of the tapered, splined component for aseptic
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Consensus statements
loosening as the endpoint, was 96% with revision of the tapered splined component for any
reason as the endpoint, and was 90% for any reoperation on the hip. The authors did not note
any difference in revision rates between different modular systems. Additionally, bone loss
had no appreciable effect on risk of revision. Twelve-stems were noted to have subsidence
of greater than 5 mm on radiographic evaluation. Eleven of these had no further subsidence
after 1 year and showed no radiographic evidence for loosening. One implant continued
to subside but was not revised secondary to medical comorbidities. The authors could not
demonstrate a relationship between increased BMI, stem diameter, or stem length as risk
factors for subsidence. Importantly, the authors did not find a significant increased risk for
stem subsidence when comparing degrees of bone loss. The authors note this finding is
advantage over fully coated, cylindrical stems. In this series 68 intraoperative fractures (13%)
and 20 hip dislocations were noted.
Few studies have looked at potential differences in utility and outcomes comparing
monolithic versus modular tapered splined stems. Huang et al. retrospectively compared
160 revision hips with a modular stem to 129 hips revised with a nonmodular stem.16 No
differences with respect to postoperative Harris Hip Scores, patient satisfaction, 8 year
survival rates, rates of dislocation, infection or periprosthetic fractures were noted between
the two groups. The modular group had significantly more fractures (16.9%) compared to
the nonmodular group (7%) (p = 0.011). The nonmodular group had significantly more stem
subsidence at 1.93 mm compared to the modular group at 0.95 mm (p = 0.001).
CONSENSUS STATEMENTSTwo consensus statements have recently been released that are particularly germane to
the practicing total hip arthroplasty surgeon. The first is a collaborative guideline from
the American College of Rheumatology and the American Association of Hip and Knee
39
Figures 3.1A and B A tapered, flu-ted, monoblock titanium stem (A) and a modular tapered stem (B) used in revision hip arthroplasty.
A B
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What’s new in total hip arthroplasty?40
Surgeons regarding the perioperative management of antirheumatic medication for patients
undergoing elective total joint arthroplasty. The second is an appropriate use criteria (AUC)
guideline from the American Academy of Orthopaedic Surgeons and the American Dental
Association regarding the use of antibiotics in patients that have total joint implants who are
undergoing dental procedures.
ANTIRHEUMATIC MEDICATIONThe American College of Rheumatology and the American Association of Hip and Knee
Surgeons together have released guidelines regarding the usage and stoppage of antirheumatic
medications in the perioperative period for patients undergoing elective total hip and total
knee arthroplasty.17,18 The concern is to minimize the effect these medications can have on
the immune system while mitigating the risk of a rheumatic flare-up. The panel consisted
of orthopedic surgeons, rheumatologists, methodologists and patients who, through a
consensus process, made their evaluations and recommendations. Rheumatic conditions
considered in this consensus statement include rheumatoid arthritis, spondyloarthritis,
juvenile idiopathic arthritis, and systemic lupus erythematous. Patients with these diseases
show tremendous improvement in pain and function after elective total joint arthroplasty,
however, these patients are also inherently susceptible to increased risk of complications
including infection.19-21 Many patients with rheumatologic disorders are now being treated
with biologic agents, disease modifying antirheumatic drugs, and glucocorticoids all of
which may influence the immune system to further increase susceptibility to infection.
The purpose of this guideline is to provide recommendations for the optimal perioperative
management of antirheumatic medications to lessen the risk of infection. At the time that
this committee was formulating these guidelines, no randomized controlled studies had
been performed examining the withholding and subsequent restarting of these medications.
The relevant outcomes that the committee considered for these recommendations were the
potential increased risk of infection caused by the continued use of these medications versus
the risk of disease exacerbation, if these medications were stopped. These guidelines are only
to be used for the perioperative management of adult patients undergoing total hip or total
knee arthroplasty with an underlying diagnosis of rheumatoid arthritis, spondyloarthritis,
juvenile idiopathic arthritis, or systemic lupus erythematosus. Please see Table 3.1 for the
committee’s recommendations.
DENTAL PROPHYLAXISMuch confusion remains regarding appropriate use of antibiotics for patients who
have total hip and total knee arthroplasties and are undergoing dental procedures.
The American Academy of Orthopedic Surgeons and the American Dental Association
Council on Scientific Affairs developed an Appropriate Use Criteria (AUC) “to identify the
appropriateness of the use of prophylactic antibiotics in the management of patients who
have had orthopedic implants, undergoing dental procedures.”22-24 Recommendations
of the committee were formulated from the best available evidence in the literature
combined with the clinical recommendations of experts in the medical, surgical, and
dental specialties. Several assumptions were made by the committee to create their
recommendations. Assumptions regarding the planned dental procedures include the
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Dental prophylaxis
Contd...
41
DMARDs: Continue these medications through surgery Dosing Interval Continue/Withhold
Methotrexate Weekly Continue
Sulfasalazine Once or twice daily Continue
Hydroxychloroquine Once or twice daily Continue
Leflunomide (Arava) Daily Continue
Doxycycline Daily Continue
BIOLOGIC AGENTS: STOP these medications prior to surgery and at the end of the dosing cycle. RESUME medications at minimum 14 days after surgery in the absence of wound healing problems, surgical site infection, or systemic infection. Dosing Interval
Schedule Surgery (relative to last biologic agent dose administered) during
Adalimumab (Humira) Weekly or every 2 weeks Week 2 or 3
Etanercept (Enbrel) Weekly or twice weekly Week 2
Golimumab (Simponi) Every 4 weeks (SQ) or
every 8 weeks (IV)
Week 5
Week 9
Infliximab (Remicade) Every 4, 6, or 8 weeks Week 5, 7, or 9
Abatacept (Orencia) Monthly (IV) or
weekly (SQ)
Week 5
Week 2
Certolizumab (Cimzia) Every 2 or 4 weeks Week 3 or 5
Rituximab (Rituxan) 2 doses 2 weeks apart every
4–6 months
Month 7
Tocilizumab (Actemra) Every week (SQ) or
every 4 weeks IV)
Week 2
Week 5
Anakinra (Kineret) Daily Day 2
Secukinumab (Cosentyx) Every 4 weeks Week 5
Ustekinumab (Stelara) Every 12 weeks Week 13
Belimumab (Benlysta) Every 4 weeks Week 5
Tofacitinib (Xeljanz): STOP this
medication 7 days prior to surgery.
Daily or twice daily 7 days after last dose
SEVERE SLE-SPECIFIC MEDICATIONS: CONTINUE these medications in the perioperative period. Dosing Interval Continue/Withhold
Mycophenolate mofetil Twice daily Continue
Azathioprine Daily or twice daily Continue
Cyclosporine Twice daily Continue
Tacrolimus Twice daily (N and PO) Continue
Table 3.1: Medications included in the 2017 American College of Rheumatology/ American Association of Hip and Knee Surgeons Guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. Dosing intervals were obtained from prescribing information provided online by pharmaceutical companies.
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What’s new in total hip arthroplasty?42
following statements: (1) The chance of oral bacteremia being related to joint infections
is extremely low, with no evidence for association, (2) oral bacteremia frequently occurs
secondary to activities of daily living, such as tooth brushing and eating, and (3) virtually
all dental office procedures have the potential to create bacteremia. Assumptions
regarding the definition of the severely immunocompromised state include: (1) patients
with stage III AIDS, (2) cancer patients undergoing immunosuppressive therapy
with febrile (>39°C) neutropenia (ANC < 2,000) or severe neutropenia (ANC < 500),
(3) rheumatoid arthritis with the use of biologic agents including tumor necrosis factor alpha
or prednisone > 10 mg per day, (4 ) solid organ transplant on immunosuppressants, (5)
inherited diseases of immunodeficiency, and (6) active bone marrow transplant recipient.
Starting with these assumptions, the committee evaluated and made recommendations on
64 different clinical situations as to whether or not antibiotic prophylaxis prior to dental
procedure was appropriate for the patient with a total hip or knee arthroplasty. Indication
profiles for specific patient scenarios include whether or not the planned dental procedure
involves the manipulation of the gingival or periapical tissues or the perforation of the oral
mucosa; whether or not a patient is severely immunocompromised; the presence of diabetes
and extent of glycemic control; the history of periprosthetic or deep prosthetic joint infection
requiring surgery; and the timing since joint replacement surgery of less than or greater than
1 year. The AUC is available online at http://www.orthoguidelines.org/auc as an interactive
webtool that makes recommendations regarding the appropriateness of antibiotic usage
in different clinical scenarios. In most clinical situations, antibiotic prophylaxis is not
deemed appropriate. In clinical scenarios where antibiotic prophylaxis is considered to
be appropriate, the AUC guidelines make further recommendations regarding antibiotic
selection. Clindamycin is no longer recommended for dental prophylaxis. Recommended
antibiotics include 2 g of amoxicillin for patients without penicillin allergies, or either 2 g of
cephalexin or 500 mg of either azithromycin or clarithromycin for patients with a penicillin
allergy. The authors of the AUC emphasize that there is only a 5% cross-reactivity with first-
generation cephalosporins and only 1% cross reactivity for three generation cephalosporins
for patients with a penicillin allergy, and recommend that cephalosporins be used unless
there is a history of anaphylaxis from a penicillin exposure. They recommend referral to an
allergist, if there is any concern regarding antibiotic administration.
NOT-SEVERE SLE: DISCONTINUE these medications 1 week prior to surgery Dosing Interval Continue/Withhold
Mycophenolate mofetil Twice daily Withhold
Azathioprine Daily or twice daily Withhold
Cyclosporine Twice daily Withhold
Tacrolimus Twice daily (N and PO) Withhold
(DMARDs: Disease-modifying antirheumatic drugs; SQ: Subcutaneous; IV: Intravenous; SLE: Systemic lupus
erythematosus; PO: Oral).
Source: Goodman SM, Springer B, Guyatt G, et al. 2017 American College of Rheumatology/American Association of
Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients with
Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. Arthritis Rheumatol. 2017;69(8):
1538-51.
Contd...
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Are hip precautions necessary when utilizing a posterior lateral approach to the hip?
ARE HIP PRECAUTIONS NECESSARY WHEN UTILIZING A POSTERIOR LATERAL APPROACH TO THE HIP?Hip precautions immediately following total hip arthroplasty have long been a tradition in
orthopedic surgery to minimize the risk of a postoperative dislocation which can corrupt
a patient’s confidence in their hip replacement, cause them to lose faith in their surgeon,
and can lead to further hospitalizations and revision surgery which adds economic burden
to these procedures. The contention has been that, in the postoperative period, patients
need to be protected while their tissues heal and their strength returns to minimize risk of
dislocation. However, hip precautions can be restrictive, influence patient satisfaction, and
slow down or impede recovery.25-27 In the anterolateral approach, it is been shown that hip
precautions can be removed without increasing rates of instability.28,29
The posterolateral approach remains a widely used approach to the hip as it is easy to
use, provides excellent visualization of both the acetabular and femoral anatomy, is reliable
for both primary and revision arthroplasty, is extensile, and has a low complication rate
as compared to other approaches. However, concerns for increased rate of dislocation
compared to other approaches has been a concern.30 Soft tissue repair of the posterior capsule
and short external rotators, however, have dramatically reduced the rates of dislocation to
approximately 0.5%.31-35 Some authors have shown that 4 weeks of precautions does not
increase the rate of dislocation compared to 6 weeks.36 Several recent studies (retrospective,
meta-analysis, and prospective) have examined whether or not standard hip precautions are
necessary at all following posterolateral THA.
In a prospective, comparative, safety study, Kornuijt et al.37 looked at two groups of patients
undergoing total hip arthroplasty. No differences between the two groups were noted with
respect to patient demographics or risk factors for dislocation. There were 109 patients in the
more restricted group and 108 patients in the less restricted group. For 6 weeks, the more
restricted group was managed with traditional hip precautions and the less restricted group
was managed with a modified restriction protocol. Both groups were instructed to avoid
cross legged sitting and to bend forward with the operative leg moving backwards. The less
restrictive group was given no sleeping restrictions, utilized an abduction pillow only until
they were first mobilized, used a standard pillow at home only for comfort, were instructed
to avoid the combined position of full hip flexion with internal rotation and adduction, were
allowed to drive when they were able to walk without crutches, were allowed to use a normal
toilet seat and normal chair and were instructed to use crutches only as needed. All surgeries
were performed by five experienced total hip arthroplasty surgeons using a posterior lateral
approach with posterior capsule and short external rotator soft tissue repair. Patients in the
less restricted group were given a choice of a short acting spinal or general anesthetic and
were mobilized within 4 hours of surgery whereas the patients in the more restrictive group
were offered a long acting spinal or general anesthetic and were mobilized greater than 4
hours after surgery. Femoral head sizes range from 28 mm to 36 mm. In the 3 month follow-
up period, there were no dislocations in the less restricted group and there was one anterior
dislocation in the more restrictive group. No significant difference was noted for the risk for
dislocation between the two groups (p = 0.32). The authors note that this was a safety study
undertaken to make sure that no harm would come to either study group. They called for
larger studies to be performed to reach further statistical significance. In their discussion,
the authors note that hip precautions were originally derived in the earliest stages of total
hip arthroplasty before soft tissue repair was standard and when patients were not mobilized
43
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for many days following surgery. They note that most early dislocations occur secondary to
either a fall or an unexpected twisting motion, and that neither of these mechanisms would
be avoided with a more restricted protocol.
Gromov et al. performed a retrospective, noninferiority study to investigate the rate of
dislocation within 90 days of posterolateral THA in unselected patients with and without
postoperative mobilization precautions. All patients underwent posterolateral THA with soft
tissue repair. 946 patients who underwent THA with postoperative mobilization restriction
were compared to 1,329 patients who underwent THA with unrestricted mobilization.
Postoperative mobilization restrictions included avoidance of hip adduction across the
midline, hip flexion greater than 90°, and internal rotation. Patients were instructed to only
use a pillow between the legs well in bed lying on the nonoperative side. Patients were
instructed to use elevated chairs and toilet seats. Precautions were followed for 3 months
postoperatively. Patients in the unrestricted group received the same physical therapy
but were mobilized without restrictions and allowed free range of motion. There were 32
dislocations in the restricted group (3.4%) and 37 (2.8%) in the unrestricted group. The
authors found that there was no increased risk for early dislocation in the group treated with
unrestricted postoperative mobilization. The results of the study also found a trend toward
a lower 30 day and 90 day risk of dislocation as well as a trend for a lower risk of recurrent
dislocation in the unrestricted mobilization group although statistical significance was not
achieved. The authors found that almost half of all dislocations in each group were the result
of either a fall or a twisting motion, neither of which would be avoided with mobilization
restrictions, and conclude that it is safe to use minimal precautions in the postoperative
period following posterolateral THA.
van der Weegen et al.38 performed a meta-analysis to determine the utility of postoperative
hip precautions in patients undergoing THA. Six articles were used and 1,122 procedures
were identified and included for analysis. There were 528 patients in the restricted group
and 594 in the unrestricted group. Both the standard posterior and anterolateral approaches
were used in these studies. In the restricted group there were eight dislocations (1.5%) and
six dislocations (1%) in the unrestricted group. Isolating procedures performed with mini-
posterior approaches there was a dislocation rate of 2.1% in the restricted group versus 1.8%
in the unrestricted group. The authors noted that patients in the unrestricted group were
generally more satisfied with their recovery, and returned to activities including independent
walking and driving faster then those patients in the restricted group. Based on the pooled
evidence in their study, the authors conclude that a postoperative protocol that uses either
less or no hip precautions does not lead to an increase in postoperative dislocations, and may
actually improve dislocations rates. Additionally, such protocols can lead to better and more
rapid return to activities of daily living, earlier return to work, shorter hospital admissions,
and greater patient overall satisfaction with their THA.
The posterior approach has been compared to other approaches including the
anterior approach. One promoted benefit of the anterior approach is the lack of need for
traditional hip precautions; surgeons, the lay press, and the general public have toted this
as an advantage for patients in the recovery period. The studies mentioned above serve as a
reference for surgeons who prefer the posterior approach who wish to consider reevaluating
their perioperative protocols. Additionally, several studies have failed to show benefit of the
anterior approach compared to posterior THA. Reininga et al.39 in a randomized controlled
study comparing computer-navigated direct anterior THA to conventional posterolateral
THA, found no difference in the return of gait metrics including walking speed, stride
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length, cadence or frontal plane angular movements at 6 weeks, 3 months, and 6 months
postoperatively. In a single institutional experience comparing 126 direct anterior hips to 96
miniposterior hips, Poehling-Monaghan et al. found better return to work and faster return
to driving with the mini-posterior approach.40 The authors conclude that there is no inherent
advantage of direct anterior THA versus mini-posterior THA and state that factors other than
surgical approach (rapid rehabilitation protocols, patient selection, surgical volume, etc.)
may be more important for early recovery following THA. Meneghini found a higher rate of
femoral failure in direct anterior hips compared to posterior THA and are concerned that a
higher rate of complications may be associated with this approach.41
OUTPATIENT TOTAL JOINT ARTHROPLASTYTotal hip and knee arthroplasty has demonstrated excellent short- and long-term clinical
results. There has been an historic trend toward shorter length of stays and more recently
outpatient total joint arthroplasty has gained increasing popularity and success.
There is no consensus regarding the definition of outpatient total joint arthroplasties.
Many procedures designated as outpatient may not truly have a length of stay of zero nights. In
fact, some patients may be “observed” in the hospital for a day or two but still be classified as
having undergone an outpatient procedure. Bovonratwet et al. reviewed the National Surgical
Quality Improvement Program. National Surgical Quality Improvement Program (NSQIP)
database from 2004 to 2015 evaluates the effect of definitional differences on outcomes.
72,651 THAs were reviewed. 529 of these were identified as outpatient but only 61 (12%) had a
LOS of zero. Similarly, 117,454 TKAs were reviewed and 890 (11%) of these had a length of stay
of zero days. After controlling for confounding factors the authors found that the inpatient
groups had an increased risk for adverse events or readmission.42
Klein et al.43 reviewed 549 consecutive mini-posterior THA performed at a free standing
independent ambulatory surgical center. The average age was 54 (27–73) years old, with 68%
males and an average BMI of 29 (18–45). 546/549 (99.5%) of patients were discharged to home
the same day and there were no overnight stays or transfers to a rehab or skilled nursing
facility (SNF). Three patients required a hospital admission; one patient for pain control
after failing to disclose his long-term narcotic dependence, one for acetabular component
position change identified on postoperative X-ray and one for postoperative hypotension,
bradycardia, and polyarthralgia exacerbation.
There has been emphasis in the recent literature regarding patient selection and suitability
for outpatient joint replacement. Sher et al.44 reviewed NSQIP data on 120,847 patients and
found that 7,474 of these primary total joint arthroplasties were discharged within 24 hours.
The authors found that these patients were more likely to be less than 50 years of age, male,
and ASA class 1 or 2. In addition, these patients were less likely to be obese or taking steroids
and less likely to have comorbidities. Adverse events were more likely to be associated with
age over 80 years, ASA class 3 or 4, smoking and having bleeding causing disorders.
Courtney et al.45 retrospectively reviewed 1,012 patients undergoing total joint arthroplasty
to identify risk factors associated with postoperative complications. Seventy (6.9%)
complications requiring physician intervention were required. Independent multivariate
risk factors for developing a complication greater than 24 hours from the index surgery
included: chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD),
congestive heart failure (CHF), and cirrhosis.
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What’s new in total hip arthroplasty?46
Courtney and Boniello46 queried the American College of Surgeons NSQIP database
from 2011 to 2014 and identified 169,406 total joint replacements. 1,220 (0.7%) of these were
outpatient procedures. They identified a complication rate of 8% in the outpatient group
and 16% in the inpatient group. Risk factors for complications or readmissions included:
age greater than 70, malnutrition, cardiac history, smoking history, and diabetes mellitus.
Outpatient surgery did not increase the risk for readmission and was a negative independent
risk factor for complications.
Rozell et al.46 prospectively evaluated a series of 802 patients who had a primary
joint arthroplasty. There were 382 postoperative complications and 152 required active
management for the complications. Multiple logistic regression analysis identified cirrhosis,
CHF, and chronic kidney disease as risk factors for a late complication.
Goyal et al.47 received the Otto Aufranc Award for a multicentered randomized study of
220 patients who were randomized to outpatient or inpatient direct anterior THA. Inclusion
criteria included age less than 75, BMI less than 40, the ability to ambulate without a walker,
and the absence of chronic opioid usage. One hundred twelve patients were randomized
to outpatient and 108 patients to inpatient surgery. Eighty-five (76%) of the outpatient
group were discharged on the day of surgery as planned and the remaining patients were
discharged after one night except for one patient that was discharged after two nights. In the
inpatient group 18 (17%) patients met discharge criteria and were discharged on the day of
surgery, 81 (75%) were discharged as planned on postoperative day one, and nine patients
(8%) stayed two or more nights. There were no differences in reoperations, readmissions,
emergency department visits, or acute office visits between the two groups. On the day of
surgery, the visual analog scale for pain was the same between the groups. It was higher on
postoperative day one for the patients who were discharged home.
While outpatient total joint arthroplasty is being performed with greater frequency
the general public and potential patients are generally not aware of this surgical option.
Meneghini and Ziemba-Davis48 surveyed 110 consecutive patients scheduled for primary
TJA in an academic suburban hospital regarding their perceptions of outpatient joint
replacement. Only three patients expected same-day discharge and 17 expected a one night
stay in the hospital. Over half (54%) expected to stay in the hospital two or more nights. Only
54.5% of patients were aware that outpatient TJA is an option.
Nelson et al.49 has reported on the “safety” of outpatient total hip arthroplasty. They
retrospectively reviewed prospectively collected NSQIP data regarding length of stay. Out
of 63,844 THA patients 420 (0.665) underwent outpatient surgery and had a length of stay
of zero days. The patients who were considered outpatients tended to be male, younger,
and had fewer comorbidities. Eighteen different adverse events were evaluated. Of these
18 different adverse events the only difference between the two groups was the need for
perioperative blood transfusions, which was less in the outpatient group (3.69% vs 9.06%,
p < 0.001).
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