Acrylic-fixed total hip and surface replacement arthroplasty have been very effective in affording immediate relief of pain and providing improved function. Complications have been reduced by improvements in design, materials, and especially technique. They are now very low in the elderly, and the stem type acrylic-fixed design remains the procedure of choice. The failure rates in youthful patients and those with bone-stock deficiencies have been high in both THR and surface types, although the latter had the advantage of preserving femoral stock. On the femoral side, the new "macro" femoral designs from Europe and "micro" femoral porous designs have shown promise, but thigh pain, incomplete and difficult to predict bone ingrowth patterns, coupled with removal problems have influenced design and technique changes. Both press-fit stem types and porous surface replacements have produced promising initial results with less potential downside risks. On the acetabular side, both the cementless hemispherical with screw-type adjuvant fixation, or the chamfered cylinder designs, used primarily with the UCLA porous surface replacements, but also with stem-type devices, appear to achieve best short-term results, while the entire variety of screw rings are disappointing. The future will bring further refinements in technique and specific indications for certain types of replacement stem in specific types of bone stock deficiencies. The all ceramic-ceramic and ceramic-polyethylene bearings show promise of reducing wear and, hence, should improve longevity of implant fixation.
Total knee arthroplasty (TKA) remains the preferred treatment for patients with invalidating osteoarthritis. It allows these patients to find once again a satisfactory quality of life. These results are reflected by the increasing number of interventions performed each year and in always younger patients. The objective of this review of the scientific literature was to determine the long-term quantitatively and qualitatively results of TKA and determine the parameters which could influence the long-term outcome. There does not seem to be any clear arguments in favor of one type of implant or surgical technique. One also notices that TKA in females and older patients seem to have longer lifespan, estimated to approximately 15 years. The most frequent complication remains aseptic loosening followed by infections.
Arthroplasty Today has published our first 2 Viewpoint manuscripts in the June 2019 [[1]Pean C.A. Lajam C. Zuckerman J. Bosco J. Policy and ethical considerations for widespread utilization of generic orthopedic implants.Arthroplasty Today. 2019; 5: 256Abstract Full Text Full Text PDF Scopus (3) Google Scholar] and September 2019 [[2]Hooper J. Israelski R.H. Schwarzkopf R. Total joint arthroplasty in the public hospitals of Port-au-Prince, Haiti: our experience.Arthroplasty Today. 2019; 5: 376Abstract Full Text Full Text PDF Scopus (2) Google Scholar] editions. A Viewpoint submission presents an opinion and critical analysis of a current issue of strong interest to the readership. It is expected to put forth an accurate and scholarly summary of the topic. A Viewpoint submission is a narrative that offers the opinion of a member or members of the arthroplasty community where intriguing, stimulating, controversial, or insightful ideas are presented. These discussions on healthcare policy, economics, ethics, decision-making, volunteerism, or the occupational challenges of surgical staff, for example, may not necessarily be endorsed by Arthroplasty Today or the American Association of Hip and Knee Surgeons. The authors should build a concise argument that tries to influence readership opinion, encourage critical thinking, and inspire readers to take action. This format has an introduction, body, and conclusion; objectively explains a timely issue; often references conflicting viewpoints; and takes a pro-active approach to better the problem presented (by giving constructive criticism). Each manuscript will be peer-reviewed and edited before publication. Viewpoint manuscripts are ideally 1000 words or fewer. The paper by Pean et al [[1]Pean C.A. Lajam C. Zuckerman J. Bosco J. Policy and ethical considerations for widespread utilization of generic orthopedic implants.Arthroplasty Today. 2019; 5: 256Abstract Full Text Full Text PDF Scopus (3) Google Scholar], in the June edition, “Policy and ethical considerations for the widespread utilization of generic orthopedic implants,” represents a “pro and con” manuscript reviewing the use of generic implants as a strategy to decrease implant expenditures in orthopedics. The authors present a detailed analysis of the economic, ethical, and regulatory factors that ought to be considered in a decision to introduce generic implants. The September Arthroplasty Today Viewpoint paper by Hooper et al [[2]Hooper J. Israelski R.H. Schwarzkopf R. Total joint arthroplasty in the public hospitals of Port-au-Prince, Haiti: our experience.Arthroplasty Today. 2019; 5: 376Abstract Full Text Full Text PDF Scopus (2) Google Scholar], “Total joint arthroplasty in the public hospitals of Port-au-Prince, Haiti: our experience,” is a “summary” type manuscript outlining one thoughtful approach to orthopedic volunteerism in a developing nation. The authors present their approach to introducing new orthopedic services while focusing on a sustainable program of teaching that supports, rather than displaces, practicing Haitian surgeons. They also review the practical and ethical arguments of introducing a technology like arthroplasty (which is susceptible to infection failures) in a developing country that currently lacks state-of-the-art infection minimization medications, technologies, and strategies. As Arthroplasty Today approaches the end of its 5th year of publication, we now have a comprehensive set of manuscript types to support and engage our readership. With the introduction of the Viewpoint option for submission, we have 10 different types of open-access papers that authors can submit through the “For Authors” section of our website arthroplastytoday.org. Please consider submitting your Viewpoint manuscript for publication in our journal. Download .docx (.02 MB) Help with docx files Conflict of Interest Statement for McGrory
As Arthroplasty Today enters its 5th year, the Editorial Board remains mindful of its duty to ensure the integrity of peer review, a foundational element of our publication. Research is critical to advancing our specialty, and peer review is essential toward improving, validating, and corroborating that research, and communicating results to our readers. We address here the subject of human research trials, with a brief historical overview, and discussion of current practices in medical research using human subjects. In clinical trials, patient benefit and safety must come first. The orthopaedic device industry may sponsor clinical trials, raising the question of investigator bias. As such, the peer review process must be rigorous and transparent. Arthroplasty Today has instituted policies and protocols that ensure patient protections and research integrity during review of submitted manuscripts. Human subject research is necessary to determine the efficacy of innovative interventions, such as new devices and operations in orthopaedic surgery. The protection of human research subjects was codified by the Nuremberg Code of 1947, in the Helsinki Declaration of 1964, and most recently in the Belmont Report [[1]The Belmont report: ethical principles and guidelines for the protection of human subjects of research. 1979http://ohsr.od.nih.gov/guidelinesbelmont.htmlDate accessed: November 14, 2018Google Scholar]. The latter captures the findings of the 1974 National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. This commission, formed in the aftermath of the Tuskegee experiment scandal, was charged with shaping bioethics policy. Toward that end, the commission was asked to identify the boundary between research and accepted medical standards, assess the risk-benefit ratio of research, determine the appropriate guidelines for human subject selection, and define the nature and definition of informed consent. The guiding principles issued by the commission are still helpful in minimizing patient risk, while ensuring the maximum potential benefit in human trials. Human trials today require oversight, with patient protections monitored and enforced by a local or external Institutional Review Board (IRB). On occasion, it is necessary to stop a human trial prematurely, in the interest of patient safety. For example, in 2002 MacDonald et al [[2]MacDonald S.J. McCalden R.W. Chess D.G. et al.Metal-on-metal versus polyethylene in hip arthroplasty: a randomized clinical trial.Clin Orthop Relat Res. 2003; 406: 282Crossref PubMed Scopus (224) Google Scholar] stopped an approved, randomized controlled trial comparing metal-on-metal to metal-on-polyethylene total hip bearings, when early data showed a concerning rise in serum cobalt and chromium ions. One of this editorial’s authors (T.J.B.) has written about the first recalled orthopaedic product in the United States [[3]Blumenfeld T.J. Bargar W.L. Early aseptic loosening of a modern acetabular component secondary to a change in manufacturing.J Arthroplasty. 2006; 21: 689Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar]. Well-known arthroplasty surgeon Lawrence Dorr openly cautioned his colleagues in 2008 about premature failures of a specific hip implant, and urged discontinuation of the device; those concerns were subsequently validated [[4]Long W.T. Dastane M. Harris M.J. Wan Z. Dorr L.D. Failure of the Durom Metasul acetabular component.Clin Orthop Relat Res. 2010; 486: 400Google Scholar]. In each of these instances, orthopaedic investigators took proactive steps to mitigate risk, and protect patients, exemplifying the concept of beneficence. Industry-supported research may be important, but it raises concerns related to investigator bias. This bias can manifest in favorable patient selection, interpretation, presentation, and publication of data. Investigators may have financial incentives toward publishing only positive findings for favored products, and negative findings for competing products. Externally funded research must acknowledge the funding source, and strive to maintain objectivity with regard to data analysis and conclusions. As an example, at the 2018 American Association of Hip and Knee Surgeons Annual Meeting, a researcher acknowledged that a product did not show the expected benefit, even though he was a paid consultant for the manufacturer [[5]Westrich G.H. IV vs. oral acetaminophen as a component of multimodal analgesia after total hip arthroplasty: a randomized, double-blinded, controlled trial.2018Google Scholar]. Peer review is essential in scholarly publication, in ensuring relevance of the research question, appropriateness of the methodology, and validity of the conclusions. The reviewer is tasked with judging the merits and quality of the submission, relying on the IRB and other regulatory mechanisms to ensure that human subjects were properly counseled, gave informed consent, and were sufficiently protected throughout the trial. Arthroplasty Today has measures in place that require affirmation from the corresponding author that proper IRB approval is in place. Human subjects research may be prospective or retrospective, and may involve a single center or multiple centers. Subjects can be enrolled in an observational study, or in prospective randomized trials. In some cases, trial participants and/or the investigators may be blinded to the treatment arm. Some studies simply involve analysis of data acquired to test a research hypothesis. In multicenter studies, enrollment of patients requires IRB approval at each participating institution. A distinct kind of clinical trial is the seeding trial, which does not require informed consent. Some patients who have participated in a trial of a device or drug prior to 510K-market approval may be added to the data set of the seeding trial; only these specific patients will have undergone informed consent. In the medical arena, these trials usually involve approved drugs [[6]Krumholz S.D. Egilman D.S. Ross J.S. Study of neurontin: titrate to effect, profile of safety (STEPS) trial: a narrative account of a gabapentin seeding trial.Arch Intern Med. 2011; 171: 1100Crossref PubMed Scopus (36) Google Scholar]. A 2-decade old article in the New England Journal of Medicine reported that seeding trials were relevant to product marketing, rather than product evaluation; significant funding to the investigators was involved [[7]Kessler D.A. Rose J.L. Temple R.J. Schapiro R. Griffin J.P. Therapeutic-class wars—drug promotion in a competitive marketplace.N Engl J Med. 1994; 331: 1350Crossref PubMed Scopus (110) Google Scholar]. In seeding trials in arthroplasty surgery, the trial sponsor may pay surgeons to enroll patients and collect data on an approved device, sometimes in order to establish the surgeon as a key opinion leader. The trial sponsor typically does not provide the product for free, and in fact may charge more for the technology being investigated, while claiming equivalence to an existing product. In such instances, informed consent may not be required. Arthroplasty Today requires confirmation of IRB approval and informed consent for all manuscripts involving human subjects. Informed consent must include relevant financial disclosures, and the relationship of the surgeon to the manufacturer. In addition, conflict of interest forms are completed by all authors for disclosure of external funding so that readers are aware of potential bias. These standards help ensure the integrity of the collected data, and its subsequent analysis. Reviewers are asked to focus on the importance of the research question, the novelty of the hypothesis tested, and the absence of ethical concerns with the submission. Next, the reviewers assess the scientific merit of the investigation, the ability of the data to prove or disprove the hypothesis, and the validity of the results shown. Finally, the discussion must represent valid conclusions based on the data presented, without overstating the implications of the results or editorializing in favor of a product. Once the peer reviewers are done with the above tasks, the Editor-in-Chief or Deputy Editor assesses and scores the quality of the reviews, makes additional comments or suggestions for potential changes to the manuscript, then submits an initial decision. For most submissions that are successfully published, one or more revisions to the submission are required. These revisions are often necessary to clarify the methods and the conclusions, and ensure adherence to the publication standards outlined above. The Editorial Board of Arthroplasty Today is committed to the ethical evaluation and publication of relevant and timely submissions that relate to the science and practice of hip and knee arthroplasty. We understand the need for human subject research, and value the peer review process toward a quality control tool in communicating research findings to our readers. We are grateful to, and proud of our outstanding peer reviewers, and will continue to support their generous volunteer work for the advancement of our specialty and association. 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The orthopaedic joint replacement team is very different today than even a decade ago. Although the surgeon is still the leader, excellent outcomes depend on the help and interactions of physician assistants; nurse practitioners; office, floor, and operating room nurses; surgical technicians; physical and occupational therapists; and medical assistants—to name but a few. Medical student and resident support may be part of the team if the practice is affiliated with an academic program. One of the most important elements of a successful joint replacement team is “buy-in” from each member that they make a substantial contribution to the ultimate result. A keystone in that accountability is specialty education. Depending on their particular area of expertise, joint replacement education of these team members can be complex, expensive, and subsequently lacking. The American Association of Hip and Knee Surgeons (AAHKS) has recognized the need for educating joint replacement team members in specialty content and offers ongoing educational opportunities that make a career in joint reconstruction rewarding and successful. The 26th AAHKS Annual Meeting in November 2016 will mark the sixth year of the Orthopaedic Team Member Course. This course was specifically created for nonphysician team members and offers continuing medical education credit. Having the shared venue with the Annual Meeting further allows for team-building opportunities. In addition to this didactic offering, physician assistants, nurse practitioners, and surgical technologists have general specialty journals that they may subscribe to; some offer continuing medical education credit. The Journal of Orthopaedics for Physician Assistants, Orthopaedic Nursing, and the AST Journal may have joint replacement content, but this information is sporadic, and subscriptions may be expensive. AAHKS has a recommendation to overcome these challenges. The AAHKS journal Arthroplasty Today is a tool to foster discussion of joint replacement issues and act as a teaching and education tool for your entire orthopaedic unit. Because it is an open-access journal, Arthroplasty Today is free. Team members can create a new account and sign up for quarterly e-mail issues at www.ArthroplastyToday.org by selecting “New Content Alerts” in the “Journal Info” menu. Arthroplasty Today is an ideal springboard for the whole orthopaedic team because it is a quarterly journal, is primarily case based, and also has office tips and surgical techniques that are relevant for all members of the joint replacement staff. The “Arthroplasty in Patients with Rare Conditions” feature is very helpful for preoperative evaluation, surgical care, and follow-up of patients with uncommon but relevant conditions that lead to joint replacement. The journal’s fast publication time guarantees that content is timely and up to date. Arthroplasty Today, published by AAHKS, is the official journal of the American Joint Replacement Registry, and research and commentary directly relating to data from the American Joint Replacement Registry is presented. Team members are often from hospitals that contribute data to this registry. Our new reality in joint replacement care is one of a high level of accountability for excellent outcomes. More than ever before, outcomes depend on a dedicated, specialized, and engaged team from multiple disciplines in the care model. AAHKS has anticipated this need, and through educational opportunities such as our annual Orthopaedic Team Member Course and Arthroplasty Today open-access journal, we feel that a joint reconstruction team can be created and supported. Excellent outcomes will follow—as will enhancement of rewarding and successful careers of the professionals involved. Download .pdf (.05 MB) Help with pdf files Conflict of Interest Statement for McGrory Download .pdf (.21 MB) Help with pdf files Conflict of Interest Statement for Della Valle
Joint replacement registries have been in place in Europe and Australia for decades. This registry data have given researchers robust information to evaluate joint replacement volume, utilization patterns, and outcomes. In many instances, registries can also serve as a mechanism for implant surveillance and an early warning system for underperforming implants. As the US health care system evolves from a volume-based system to a value-based system, the role of registry data will become increasingly more important. The true value of a registry in this type of health care environment will allow for an evaluation of value, cost, comparative effectiveness, and patient reported outcomes. The American Joint Replacement Registry (AJRR) is a multistakeholder, independent nonprofit organization established by the American Academy of Orthopaedic Surgeons in 2009. AJRR has experienced wide support across the orthopaedic community and as such as seen a rapid expansion in the number of participating hospitals and procedural volume reported. On concluding a pilot study in 2011, AJRR had 8 hospitals enrolled and approximately 13,000 procedures. In the latest annual report for 2014, these numbers had increased dramatically to 417 enrolled hospitals and over 225, 000 procedures in the registry. In addition, AJRR has been recognized for 2 years by the Centers for Medicare and Medicaid Services as a Qualified Clinical Data Registry that satisfies Physician Quality Reporting System requirements for eligible professionals. In addition, the American Association of Hip and Knee Surgeons recognizes AJRR as its official registry. To date, most of the data collected and reported in AJRR have been descriptive procedural (level I) data such as surgical volume, diagnoses, component metrics, and reasons for early failure of implants. AJRR has embarked on an ambitious plan to substantially increase collection of subsequent levels of data submitted to the registry. Level II data include patient risk factors, comorbidities, and operative and postoperative complications. The collection of this data will allow for the development of a risk adjustment model to accurately and fairly evaluate hospital and surgeon level data. In addition, AJRR is currently collecting and accepting Patient Reported Outcome Measures. Disease-specific outcome measures, consistent with those recommended by Centers for Medicare and Medicaid Services for the Comprehensive Care for Joint Replacement initiative, such as the Hip disability and Osteoarthritis Outcome Score Junior and Knee disability and Osteoarthritis Outcomes Score Junior forms, and general health measures, such as Veterans RAND 12 and Patient Reported Outcome Measure Information System 10 Global, will help providers and payors better assess the value and improvements in quality of life that patients receive after joint replacement surgery. AJRR has partnered with Arthroplasty Today to provide the readership with in-depth information regarding registry data in the United States. Given the changing health care environment, registry data provided at the national level will greatly impact health care and lead to improvements in our clinical practice. Each year Arthroplasty Today will publish the Executive Summary of the AJRR Annual Report in its December issue. Subsequently, in the June issues, Arthroplasty Today will publish important research and information from AJRR. In this issue, McGrory, Etkin, and Lewallen look at the definitions of revision and revision burden across international registries. With the rapid expansion in the amount of quality data being reported, registry data will become the mainstay to evaluate outcomes and value. The collaborative efforts of AJRR and Arthroplasty Today will bring the most relevant information to readers and hopefully encourage all surgeons and hospitals to participate in AJRR as we work toward our goal of a truly comprehensive national total joint registry. Download .pdf (.4 MB) Help with pdf files Conflict of Interest Statement for Bryan D. Springer
Within the publishing industry, article numbering has emerged as an easy and efficient way to cite journal articles. Article numbering has already been successfully rolled out to Elsevier’s multidisciplinary open access journal Heliyon, as well as thousands of other journals, and has been well received by the academic community. Based on that positive feedback, we are now pleased to introduce article numbering to Arthroplasty Today from November 2022. A unique article number is an abbreviated form of an article’s DOI - digital object identifier. Citing an article with an article number is very simple: the article number is used instead of the page range in the citation. Style 3–Vancouver:[2]Van der Geer J, Hanraads JAJ, Lupton RA. The art of writing a scientific article. Heliyon. 2018;19:100205. https://doi.org/10.1016/j.heliyon.2018.100205. While journal volumes and issue numbers will remain in place, article numbering will now play the key role in identifying specific articles. The introduction of article numbers brings several benefits for the journal and its readers and authors. •More flexible reading: Article content can be optimized based on the device used to access it, supporting reading on-the-move, without needing to know how many traditional print pages the article takes up.•Increased options for grouping related content: In online collections and Special Issues, articles can now be placed in any order, helping readers to identify papers relevant to their research interests faster.•Faster publication: With article numbers, the version of record of the article is online and citable as soon as the proof corrections have been incorporated, ensuring readers have access to the latest research faster. We are delighted that Arthroplasty Today’s readers and authors will now enjoy these benefits.
The most effective continuing medical education (CME) is that which is highly relevant to your work life, and achieves the goal of maintaining competence and improving your practice. As arthroplasty specialists, American Association of Hip and Knee Surgeons (AAHKS) members have some unique opportunities for CME compared with our other orthopedic colleagues. Our annual fall and spring meetings are engaging and present compelling, practice-based content that keeps members up-to-date with arthroplasty topics. AAHKS offers webinars that review topics like "Coding and billing: tips and tricks to enhance your practice," a recent offering from our association. In addition to AAHKS opportunities, the American Academy of Orthopedic Surgeons offers specialty tests like "Adult Reconstructive Surgery of the Hip and Knee Scored and Recorded Self-Assessment Examination 2019," edited by AAHKS fellow Michael J. Taunton, MD. CME is a mandatory component of recertification for the American Board of Orthopedic Surgeons, the American Osteopathic Board of Orthopedic Surgery, as well as the credentialing process of our advanced practice provider colleagues. For example, the American Board of Orthopedic Surgeons requires 240 CME credits in its 10-year maintenance of certification cycle, of which 40 credits must be from self-assessment examinations. This year Arthroplasty Today started a program to offer CME credits for reading an "Original research" or "Systematic review" manuscript (picked by our CME committee) and taking a brief test on our website. One hour of CME credit is earned for reading a selected paper and scoring 80% or better on test responses. Our CME software program keeps track of credits and allows members to print a CME transcript. Deputy editor Gregory Golladay, MD and Associate editor Thomas Blumenfield, MD worked with Sigita Wolfe, AAHKS Director of Education and Research, as well as Denise Smith Rodd, AAHKS Manager of Communications and Web Content, to make this member request a reality and to offer educational benefits to our readers. Our plan is to continue to offer this opportunity to our readership, and perhaps even expand the program in the future. Stay tuned, and please try out our CME program on the ArthroplastyToday.org website under the "CME" tab. Download .docx (.02 MB) Help with docx files Conflict of Interest Statement for McGrory
Modern total hip arthroplasty has been performed using femoral stems manufactured from stainless steel, cobalt-chrome molybdenum alloy (CoCrMb), titanium aluminum vanadium alloy (TiAlV), and, on a limited basis, low-elastic modulus composites. Today, only CoCrMb and TiAlV are used in significant numbers. There is ample theoretical, experimental, and clinical evidence to support Ti-AlV as the material of choice for cementless femoral stems, based on superior mechanical compatibility and biocompatibility. The primary advantage of TiAlV over CoCrMb is a lower modulus of elasticity. This results in decreased stress shielding and subsequent favorable femoral remodeling. This effect is more significant with the smaller stem sizes used in primary surgery but persists even with larger stem sizes used in revision surgery. The second advantage of TiAlV is its biocompatibility. Titanium aluminum vanadium alloy is of relatively low toxicity in concentrations found clinically, and TiAlV is inert in the physiologic environment. With regard to fixation in cementless total hip arthroplasty, TiAlV has been shown to achieve excellent bone ingrowth into porous surfaces. In addition, there is evidence of superior bony ingrowth into TiAlV as compared with CoCrMb. Titanium aluminum vanadium alloy is presently the material of choice to be used in conjunction with hydroxyapatite coating. Prosthetic design, stem diameter, and porous-coating applications play significant roles in bony response regardless of metal composition.
The following article on total hip arthroplasty was published in the Bulletin over 40 years ago. Even today it is a frequently cited paper because of its review of the contemporary prosthesis designs of the time as well as the new materials the author advocates and the methods he employed for the analysis of weight-bearing stresses on the prosthetics. Certainly a great deal of progress has been made in total hip arthroplasty since this paper was originally published. However, the article is reprinted here exactly as it first appeared in the hope that you will find it valuable as both a reminder of our surgical heritage as well as its insights into the direction in which we are heading.
In large studies, the failure modes of lateral unicompartmental knee arthroplasty (UKA) are usually presented in combination with medial UKA, which is mainly due to low surgical frequency of lateral UKA. Because lateral UKA differs from medial UKA in anatomic and kinematic characteristics, failure modes of lateral UKA should not be presented in combination with medial UKA. Therefore, we performed a systematic review to assess failure modes in lateral UKA and compared failure modes in cohort studies with those found in registry-based studies. A search performed in PubMed, Embase, and Cochrane identified 25 studies (23 cohort studies and 2 registry-based studies) that were eligible in presenting failure modes in lateral UKA. Most common failure modes in lateral UKA were progression of osteoarthritis (OA; 29%), aseptic loosening (23%), and bearing dislocation (10%). In cohort studies, progression of OA was more common (36%) than bearing dislocation (17%) and aseptic loosening (16%), while in the registry-based studies, aseptic loosening (28%) was more common than progression of OA (24%) and bearing dislocation (5%). In conclusion, progression of OA is the most common failure mode in lateral UKA. In the future, both cohort studies and registry-based studies should report the failure modes of medial and lateral UKA separately.
BACKGROUND: Management of the cuff-deficient arthritic shoulder has long been challenging. Early unconstrained shoulder arthroplasty systems were associated with high complication and implant failure rates. The evolution toward the modern reverse shoulder arthroplasty includes many variables of constrained shoulder arthroplasty designs. QUESTIONS/PURPOSES: This review explores the development of reverse shoulder arthroplasty, specifically describing (1) the evolution of reverse shoulder arthroplasty designs, (2) the biomechanical variations in the evolution of this arthroplasty, and (3) the current issues relevant to reverse shoulder arthroplasty today. METHODS: Using a PubMed search, the literature was explored for articles addressing reverse shoulder arthroplasty, focusing on those papers with historical context. RESULTS: Results of the early designs were apparently poor, although they were not subjected to rigorous clinical research and usually reported only in secondary literature. We identified a trend of glenoid component failure in the early reverse designs. This trend was recognized and reported by authors as the reverse shoulder evolved. Authors reported greater pain relief and better function in reverse shoulder arthroplasty with the fundamental change of Grammont's design (moving the center of rotation medially and distally). However, current reports suggest lingering concerns and challenges with today's designs. CONCLUSIONS: The history of reverse shoulder arthroplasty involves the designs of many forward-thinking surgeons. Many of these highly constrained systems failed, although more recent designs have demonstrated improved longevity and implant performance. Reverse shoulder arthroplasty requires ongoing study, with challenges and controversies remaining around present-day designs.
PURPOSE: There is a lack of long-term data evaluating the impact of synovectomy versus no synovectomy during total knee arthroplasty (TKA) in patients with rheumatoid arthritis (RA). This study aimed to assess and compare bilateral TKA outcomes with and without synovectomy in the same patients over a similar follow-up period. METHODS: A retrospective review was conducted on 65 bilateral staged posterior-stabilized (PS) fixed-bearing TKAs (28 men, 37 women) performed by a single surgeon on RA-affected knees, with an average follow-up of 17 years (range: 15-24 years). In the first knee, synovectomy was performed during TKA, while no synovectomy for the contralateral TKA. Outcomes assessed included Knee Society scores for knee and function, radiographic findings, complications, and patellar position using the Insall-Salvati ratio. RESULTS: The synovectomy group had a higher rate of blood transfusion (23.3% vs. 16.6%; P < 0.01) and longer hospital stays (mean 9.60 days [95% CI: 6.56-13.63] vs. 6.51 days [95% CI: 5.50-9.52]; P < 0.001). The group without synovectomy demonstrated significantly better Knee Society Scores (89.1 vs. 80.2 points; P = 0.02) and greater range of motion (ROM) for flexion (130° vs. 102°; P = 0.01). Both groups had similar knee alignment, stability, and femoral and tibial component alignment. Patella baja was observed in six patients in the synovectomy group. Severe haematoma (n = 6) and deep infections (n = 4) were noted exclusively in the synovectomy group. Kaplan-Meier survivorship at 15 years was 81% (95% CI: 78-95) for TKA with synovectomy and 95% (95% CI: 90-100) for TKA without synovectomy. CONCLUSION: Knees undergoing synovectomy during primary TKA exhibited reduced knee flexion, inferior Knee Society pain scores, and higher complication rates compared to contralateral knees without synovectomy. Omitting synovectomy in RA patients did not increase the risk of implant loosening.
Achieving optimal alignment in total knee arthroplasty (TKA) is a critical factor in ensuring optimal outcomes and long-term implant survival. Traditionally, mechanical alignment has been favored to achieve neutral post-operative joint alignment. However, contemporary approaches, such as kinematic alignments and hybrid techniques including adjusted mechanical, restricted kinematic, inverse kinematic, and functional alignments, are gaining attention for their ability to restore native joint kinematics and anatomical alignment, potentially leading to enhanced functional outcomes and greater patient satisfaction. The ongoing debate on optimal alignment strategies considers the following factors: long-term implant durability, functional improvement, and resolution of individual anatomical variations. Furthermore, advancements of computer-navigated and robotic-assisted surgery have augmented the precision in implant positioning and objective measurements of soft tissue balance. Despite ongoing debates on balancing implant longevity and functional outcomes, there is an increasing advocacy for personalized alignment strategies that are tailored to individual anatomical variations. This review evaluates the spectrum of various alignment techniques in TKA, including mechanical alignment, patient-specific kinematic approaches, and emerging hybrid methods. Each technique is scrutinized based on its fundamental principles, procedural techniques, inherent advantages, and potential limitations, while identifying significant clinical gaps that underscore the need for further investigation.
Osteoarthritis is a process largely associated with aging, and Americans today are living longer than ever before, with the most recent data from the Centers for Disease Control and Prevention showing an average life expectancy of 78.2 years. With an increasingly older society, there will be an increased need for medical and surgical treatment of osteoarthritis. At the same time, a decline in the number of surgeons performing total joint arthroplasty is anticipated, by as much as 30% in some studies. Due to this anticipated shortage, nonoperative physicians will play a more prominent role in patient care and should become better educated in maximizing nonoperative care, recognizing appropriate surgical indications, and educating their patients on surgical outcomes. Total joint arthroplasty offers pain relief and potential functional improvement. Unfortunately, the outcomes for joint replacement differ significantly by the joint being replaced. The best examples of positive outcome for both pain relief and functional improvement are total hip arthroplasty and total knee arthroplasty. Shoulder arthroplasty has demonstrated encouraging outcomes but the outcome data is not yet as robust as the data for hip and knee arthroplasty. Elbow arthroplasty provides good pain relief but functional outcomes are not nearly as good, and significant potential complications exist. Lastly, ankle arthroplasty has not demonstrated outcomes that are as positive as the other major joints, and the criterion standard treatment continues to be ankle fusion. In this article, surgical options for arthroplasty will be reviewed for each of the major joints, including the joint-specific indications and outcomes for each procedure.
Deep in a dried-up riverbed in Brazil, scientists uncovered a bizarre prehistoric mystery—twisted jawbones from a strange, long-lost animal unlike anything seen before。 Dating back 275 million years, this creature, named Tanyka amnicola, belonged to an ancient lineage that should have already faded away, making it a kind of “living fossil” of its t
National projections of future joint arthroplasties are useful for understanding the changing burden of surgery and related outcomes on the health system. The aim of this study is to update the literature by producing Medicare projections for primary total joint arthroplasty (TJA) procedures until 2040 and 2060. Methods: The present study used data from the Centers for Medicare & Medicaid Services (CMS) Medicare/Medicaid Part B National Summary and combined procedure counts with use of Current Procedural Terminology (CPT) codes to identify whether the procedure was a primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) procedure. In 2019, the annual volume of primary TKA was 480,958 and that of primary THA was 262,369. These values formed a baseline from which we generated point forecasts for 2020-2060 and 95% forecast intervals (FIs). Results: Between 2000 and 2019, the estimated annual volume of THA increased by 177% and that of TKA increased by 156% on average. Regression analysis projected an annual growth rate of 5.2% for THA and 4.44% for TKA. Based on these yearly projected increases, an estimated increase of 28.84% and 24.28% is expected for each 5-year period after 2020 for THA and TKA, respectively. By 2040, the number of THAs is projected to be 719,364 (95% FI, 624,766 to 828,286) and the number of TKA is projected to be 1,222,988 (95% FI, 988,714 to 1,512,772). By 2060, the number of THAs is projected to be 1,982,099 (95% FI, 1,624,215 to 2,418,839) and the number of TKAs is projected to be 2,917,959 (95% FI, 2,160,951 to 3,940,156). In 2019, Medicare data showed that THA constituted approximately 35% of TJA procedures performed. Conclusions: Based on 2019 total volume counts, our model forecasts an increase in THA procedures of 176% by 2040 and 659% by 2060. The estimated increase for TKA is projected to be 139% by 2040 and 469% by 2060. An accurate projection of future primary TJA procedure demands is important in order to understand future health-care utilization and surgeon demand. This finding is only applicable to a Medicare population and demands further analysis to see if this extends to other population groups. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
PURPOSE: Patellofemoral arthroplasty remains controversial, primarily due to the high failure rates reported with early implants. Numerous case series have been published over the years detailing results of various first- and second-generation implants. The purpose of this work is to summarize results published to date and identify common themes regarding implants, surgical techniques, and indications in order to maximize results of future procedures. METHODS: A comprehensive review of the MEDLINE database was carried out to identify all clinical studies related to patellofemoral arthroplasty. RESULTS: First-generation resurfacing implants were associated with relatively high failure rates in the medium term. Second-generation implants, with femoral cuts based on TKA designs have yielded more promising medium-term results. Surgical indications are specific and must be carefully followed to minimize poor results. Short-term complications are generally related to patellar maltracking, while long-term complications are generally related to progression of osteoarthritis in the tibiofemoral joint. Implant loosening and polyethylene wear are rarely reported. Short-term results are favourable for new technology including custom implants and computer navigated surgery. CONCLUSIONS: Overall, recent improvements in implant design and surgical techniques have resulted in improvements in short- and medium-term results. More work is required to assess the long-term outcomes of modern implant designs. LEVEL OF EVIDENCE: IV.
BACKGROUND: Little is known about the persistence of health disparities in joint arthroplasty. The objective of this study was to update our knowledge on the state of racial and ethnic disparities in total hip arthroplasty (THA). METHODS: Patients undergoing primary, elective THA using the 2011-2017 American College of Surgeons National Surgical Quality Improvement Program were retrospectively reviewed. Five minority groups (non-Hispanic black or African American, Hispanic or Latino, Asian, American Indian or Alaska Native, and Native Hawaiian or Pacific Islander) were compared with non-Hispanic whites. The primary outcomes were in the differences in demographic characteristics, comorbidities, perioperative characteristics, THA utilization, length of stay (LOS), and 30-day adverse events (mortality, readmission, reoperation, and complications). RESULTS: < .001). There were higher rates of nonprimary osteoarthritis, procedure length exceeding 100 minutes, and comorbidities among all minority groups. All minority groups, except Asian and Hawaiians or Pacific Islanders, were more likely to require an LOS >2 days. Blacks were more likely to develop surgical or medical complications (odds ratio [OR]: 1.21 and 1.2, respectively), whereas Hispanics or Latinos were more likely to develop surgical complications (OR: 1.28). American Indians or Alaska Natives were more likely to undergo reoperations (OR: 1.91). CONCLUSIONS: Health disparities persist among minority groups with respect to comorbidities, THA utilization, LOS, and complications. Blacks and Hispanics or Latinos appear to be the most impacted by these disparities.