Publications by authors named "William M Mihalko"

135 Publications

Risk Factors for Prolonged Time to Discharge in Total Hip Patients Performed in an Ambulatory Surgery Center due to Complaints of the Inability to Void.

J Arthroplasty 2021 Jun 24. Epub 2021 Jun 24.

Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis TN.

Background: Postoperative urinary retention (POUR) is among the reasons for delay in discharge after outpatient total hip arthroplasty (THA), occurring in 2%-46% of patients. We hypothesized that the frequency of POUR following outpatient THA in the ambulatory surgery center (ASC) is low compared to previously reported rates and that management can be effective in the perioperative period when it is encountered.

Methods: Three hundred seventy-seven THA patients (409 hips) who had arthroplasties in the ASC over a 5-year period were identified. Preoperatively, appropriate demographic information and medical comorbidities were collected from patient health history questionnaires completed during clinic visits. Intraoperatively, albumin volume administered and estimated blood loss were recorded. Postoperatively, post-anesthesia care unit medications, patients who reported an inability to urinate, and those who required urinary catheterization were recorded.

Results: POUR occurred in only 2 patients but complaints of the inability to void occurred in 38 others for an incidence of 9.8%. Factors associated with POUR and the inability to urinate included older age, time spent in the ASC, and intraoperatively albumin volume administered. No significant differences were found in body mass index, preoperative hematocrit, estimated blood loss, surgical time, or operating time.

Conclusion: POUR was infrequent but the reported inability to urinate was not (9.8%) and can be safely managed when it does occur and we found that increased age and albumin volume over 500 mL may increase the risk for a prolonged length of stay due to the inability to urinate.
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http://dx.doi.org/10.1016/j.arth.2021.06.010DOI Listing
June 2021

Anterior Supine Intermuscular Total Hip Arthroplasty at an Ambulatory Surgery Center Versus Hospitalization: Cost and Adverse Events.

Orthop Clin North Am 2021 Jul;52(3):209-214

Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA. Electronic address:

This study compares anterior supine intermuscular total hip arthroplasty performed at an ambulatory surgery center with the same procedure performed in a hospital setting in regard to complications and costs. The ambulatory surgery center had significantly shorter postoperative stays and superior visual analog pain scores at 3 months. No differences were noted in operative time, blood loss, or complications. Costs were significantly different between groups, with significant cost savings noted in the ambulatory surgery center group.
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http://dx.doi.org/10.1016/j.ocl.2021.03.011DOI Listing
July 2021

Blood Management in Outpatient Total Hip Arthroplasty.

Orthop Clin North Am 2021 Jul 6;52(3):201-208. Epub 2021 May 6.

Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN, USA.

Based on a series of 407 outpatient total hip arthroplasties performed by a single surgeon, a standardized protocol for blood loss management in outpatient arthroplasty was developed consisting of a presurgical hematocrit of greater than 36%, administration of tranexamic acid, prophylactic introduction of albumin, hypotensive epidural anesthesia, monopolar electrocautery, and bipolar sealer. This protocol uses techniques that alone are not novel but together create a standardized and reproducible pathway that when implemented can increase the safety of outpatient hip arthroplasty.
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http://dx.doi.org/10.1016/j.ocl.2021.03.004DOI Listing
July 2021

Response to Letter to the Editor on "Tibial implant Fixation Behavior in Total Knee Arthroplasty - A Study With Five Different Types of Bone Cements".

J Arthroplasty 2021 05;36(5):e32-e33

Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center, TN, USA.

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http://dx.doi.org/10.1016/j.arth.2020.11.022DOI Listing
May 2021

Opioid Use Patterns After Primary Total Knee Replacement.

Orthop Clin North Am 2021 Apr 10;52(2):103-110. Epub 2021 Feb 10.

Department of Orthopaedic Surgery and Biomedical Engineering, Joint Graduate Program in Biomedical Engineering, Campbell Clinic, University of Tennessee Health Science Center, E226 Coleman Building, 956 Court Avenue, Memphis, TN 38163, USA.

Orthopedic surgeries are associated with the prescription of more narcotics than any other surgical specialty, particularly for total knee replacement (TKR) surgery. The authors examined controlled substance prescriptions following TKR surgery in a sample of 560 TKR patients. Results indicated that of all the 5164 prescriptions documented on the controlled substance monitoring database, 64% were for opioid medications. More than half of the patients received controlled substances from both the surgery site provider and a nonsurgery site provider in the year following surgery. The authors recommend that providers consider the possibility of outside prescribing when prescribing opioid analgesic.
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http://dx.doi.org/10.1016/j.ocl.2020.12.003DOI Listing
April 2021

Cryoneurolysis before Total Knee Arthroplasty in Patients With Severe Osteoarthritis for Reduction of Postoperative Pain and Opioid Use in a Single-Center Randomized Controlled Trial.

J Arthroplasty 2021 05 14;36(5):1590-1598. Epub 2020 Nov 14.

Department of Orthopedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN.

Background: We hypothesized that preoperative cryoneurolysis of the superficial genicular nerves in patients with osteoarthritis would decrease postoperative opioid use relative to standard of care (SOC) treatment in patients undergoing total knee arthroplasty (TKA).

Methods: Patients received either cryoneurolysis (intent-to-treat [ITT]: n = 62) or SOC (ITT: n = 62). The cryoneurolysis group received cryoneurolysis of the superficial genicular nerves 3-7 days before surgery plus a similar preoperative, intraoperative, and postoperative pain management protocol as the SOC group. The primary end point was cumulative opioid consumption in total daily morphine equivalents from discharge to the 6-week study follow-up assessment. Secondary end points included changes in pain and functional scores. Primary and secondary end points were assessed using ITT and per-protocol (PP) analyses.

Results: The primary end point was not met in the ITT analysis (4.8 [cryoneurolysis] vs 6.1 [SOC] mg; P = .0841) but was met in the PP analysis (4.2 vs 5.9 mg; P = .0186) after excluding patients with medication deviations or missing follow-up data. Compared with the SOC group, the cryoneurolysis group had improved functional scores and numerical improvements in pain scores across all follow-up assessments, with significant improvements observed in current pain from baseline to the 72-hour and 2-week follow-up assessments and pain in the past week from baseline to the 12-week follow-up assessment.

Conclusion: Findings from the PP analysis suggest that preoperative cryoneurolysis in patients with knee osteoarthritis can reduce opioid consumption and improve functional outcomes after TKA.
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http://dx.doi.org/10.1016/j.arth.2020.11.013DOI Listing
May 2021

Electrocautery Induced Damage of Total Knee Implants.

J Arthroplasty 2021 03 28;36(3):1126-1132. Epub 2020 Sep 28.

Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, Memphis, Tennessee; Department of Bioscience Research, College of Dentistry, University of Tennessee Health Science Center, Memphis, Tennessee.

Background: Pitting damage on implants has been reported and attributed to the use of electrocautery. This study aimed to determine how different total knee arthroplasty bearing surfaces are susceptible to this type of damage and whether surgeons are aware that this damage can occur.

Methods: A survey was sent to Hip and Knee Society members to determine what percentage of adult reconstructive surgeons use electrocautery after implantation of components. Three bearing surfaces for total knee arthroplasty were selected: cobalt chromium, Oxinium, and zirconium nitride to be damaged by electrocautery with a monopolar (MP) and bipolar (BP) electrocautery with 3 different energy settings. A comparison of surface damage using scanning electron microscopy and elemental differences using energy dispersion spectroscopy was performed. Average roughness (R), maximal peak-to-valley height (R), kurtosis (R), and skewness (R) were recorded for comparison using a profilometer was performed.

Results: Median R and R measurements were larger for BP damaged areas compared to MP for all bearing surfaces. The Oxinium surface had the greatest increase in roughness parameters. Survey results indicate that a significant percentage of adult reconstructive surgeons use the electrocautery after implants are in place and are not aware of this type of damage. Backscatter scanning electron microscopy analysis found significant changes for BP damage compared to MP.

Conclusion: Surface damage caused by electrocautery can have significant effects on the bearing surfaces of implants but further study needs to be performed to determine if this is a clinical issue. Our survey determined that many arthroplasty experts are unaware that this damage can occur.
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http://dx.doi.org/10.1016/j.arth.2020.09.044DOI Listing
March 2021

Optimal designs and surgical technique for hip and knee joint replacement: The best is yet to come!

J Orthop Res 2021 Sep 13;39(9):1851-1859. Epub 2020 Oct 13.

Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.

Over the last three decades, there have been significant advancements in knee and hip replacement technology. The implants and the surgical technology we now have to aid in their implantation are advancing and improving functional outcomes and survivorship. Despite these advancements, there are still issues with patient satisfaction, functional limitations, and early revisions due to instability and aseptic loosening. This article reviews the state of current technology in hip and knee replacement implant design and surgical technique, and reviews some of the current implant designs and surgical technologies that may be able to solve some of the most common issues in the knee and hip replacement surgery.
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http://dx.doi.org/10.1002/jor.24873DOI Listing
September 2021

Defining Outpatient Hip and Knee Arthroplasties: A Systematic Review.

J Am Acad Orthop Surg 2021 Apr;29(8):e410-e415

From the Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN.

Introduction: The term "outpatient" has a variety of meanings regarding the location of arthroplasty and the duration of stay postoperatively. The purpose of this systematic review was to evaluate the literature and more accurately define the term "outpatient."

Methods: A PubMed search (2014 to 2019) using the terms "outpatient AND arthroplasty" identified 76 studies; 35 studies that met the inclusion criteria were assessed to determine the definition of "outpatient." The level of evidence, type of arthroplasty, location of surgery (hospital or ambulatory surgery center [ASC]), approach used for hip arthroplasty, number of patients, number of surgeons, and length of time the patients were kept at the location after surgery were evaluated.

Results: Arthroplasties analyzed were total hip (11), total knee (seven), unicompartmental knee (five), and hip and knee (12). Only 16.8% of surgeries defined as outpatient hip or knee arthroplasty were done in a freestanding ASC, and 44.2% of patients defined as outpatients were kept overnight for the 23-hour observation.

Discussion: We propose "DASH" (Discharge from ASC to Home) as a new term to define arthroplasties done in an outpatient setting with the patient discharged home the same day.
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http://dx.doi.org/10.5435/JAAOS-D-19-00636DOI Listing
April 2021

New materials for hip and knee joint replacement: What's hip and what's in kneed?

J Orthop Res 2020 07 28;38(7):1436-1444. Epub 2020 May 28.

Department of Orthopaedic Surgery, Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania.

Over the last three decades there have been significant advancements in the knee and hip replacement technology that has been driven by an issue in the past concerning adverse local tissue reactions, aseptic and septic loosening. The implants and the materials we utilize have improved over the last two decades and in knee and hip replacement there has been a decrease in the failures attributed to wear and osteolysis. Despite these advancements there are still issues with patient satisfaction and early revisions due to septic and aseptic loosening in knee replacement patients. This article reviews the state of current implant material technology in hip and knee replacement surgery, discusses some of the unmet needs we have in biomaterials, and reviews some of the current biomaterials and technology that may be able to solve the most common issues in the knee and hip replacement surgery.
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http://dx.doi.org/10.1002/jor.24750DOI Listing
July 2020

Racial/Ethnic Disparities in Physical Function Before and After Total Knee Arthroplasty Among Women in the United States.

JAMA Netw Open 2020 05 1;3(5):e204937. Epub 2020 May 1.

Department of Family Medicine and Public Health, University of California, San Diego, La Jolla.

Importance: Although racial/ethnic differences in functional outcomes after total knee arthroplasty (TKA) exist, whether such differences are associated with differences in presurgical physical function (PF) has not been thoroughly investigated.

Objective: To examine trajectories of PF by race/ethnicity before and after TKA among older women.

Design, Setting, And Participants: This cohort study was conducted among the prospective Women's Health Initiative with linked Medicare claims data. A total of 10 325 community-dwelling women throughout the United States with Medicare fee-for-service underwent primary TKA between October 1, 1993, and December 31, 2014, and were followed up through March 31, 2017.

Exposures: Race/ethnicity comparisons between Hispanic or Latina women, non-Hispanic black or African American women, and non-Hispanic white women (hereafter referred to as Hispanic, black, and white women, respectively).

Main Outcomes And Measures: Physical functioning scale scores and self-reported activity limitations with walking 1 block, walking several blocks, and climbing 1 flight of stairs were measured by the RAND 36-Item Health Survey during the decade before and after TKA, with a median of 9 PF measurements collected per participant over time.

Results: In total, 9528 white women (mean [SD] age at surgery, 74.6 [5.5] years), 622 black women (mean [SD] age at surgery, 73.1 [5.3] years), and 175 Hispanic women (mean [SD] age at surgery, 73.1 [5.2] years) underwent TKA. During the decade prior to TKA, black women had lower PF scores than white women (mean difference, -5.8 [95% CI, -8.0 to -3.6]) and higher odds of experiencing difficulty walking a single block (5 years before TKA: odds ratio, 1.86 [95% CI, 1.57-2.21]), walking multiple blocks (odds ratio, 2.14 [95% CI, 1.83-2.50]), and climbing 1 flight of stairs (odds ratio, 1.81 [95% CI, 1.55-2.12]). After TKA, black women continued to have lower PF scores throughout the decade (mean difference 1 year after TKA, -7.8 [95% CI, -10.8 to -4.9]). After adjusting for preoperative PF scores, PF scores after TKA were attenuated (mean difference 1 year after TKA, -3.0 [95% CI, -5.3 to -0.7]), with no statistically significant differences in long-term follow-up. Hispanic women had similar PF scores to white women during the pre-TKA and post-TKA periods.

Conclusions And Relevance: This study suggests that black women had significantly poorer PF than white women during the decades before and after TKA. Poorer PF after surgery was associated with poorer preoperative PF. Reducing disparities in post-TKA functional outcomes should target maintenance of function preoperatively in the early stages of arthritic disease and/or reduction of delays to receiving TKA once need arises.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.4937DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7229524PMC
May 2020

Retrieval Analysis of Cruciate-Retaining and Posterior-Stabilized Total Knee Arthroplasty and Correlations to Laxity and Wear.

J Arthroplasty 2020 08 21;35(8):2249-2253. Epub 2020 Mar 21.

Campbell Clinic Orthopaedics, Germantown, TN; Department of Biomedical Engineering and Orthopedic Surgery, University of Tennessee Health Science Center, Memphis, TN.

Background: Total knee arthroplasty (TKA) with posterior-stabilized (PS) or posterior cruciate-retaining (CR) implants has high success rates and survivorship. However, it is uncertain how laxity and constraint are associated with long-term polyethylene wear under physiological conditions.

Methods: To answer this question, we measured the laxity patterns of 47 harvested cadaver specimens with primary TKAs in a custom knee-testing machine at full extension and at 30°, 60°, and 90° of flexion. The wear patterns of the tibial inserts were assessed using a semiquantitative method which is a modified approach of that proposed by Hood et al in 1983.

Results: Statistical analysis found that the PS TKA cohort had a statistically significant increase in varus laxity at 60° and 90° of flexion, as well as total coronal laxity at 60° of flexion when compared to the CR cohort. Furthermore, analysis demonstrated a significant correlation between increased PS coronal laxity and increased tibial wear, a trend that was not seen in the CR specimens.

Conclusion: Our findings suggest that greater laxity in flexion after primary TKA may increase the wear realized over time and that PS TKAs may be more susceptible due to the loss of support the PCL affords to the flexion space. Whether a CR or PS TKA is used, surgeons need to avoid the pitfalls that may create greater flexion laxity during the procedure to optimize long-term polyethylene wear.
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http://dx.doi.org/10.1016/j.arth.2020.03.027DOI Listing
August 2020

Association of the Intensive Lifestyle Intervention With Total Knee Replacement in the Look AHEAD (Action for Health in Diabetes) Clinical Trial.

J Arthroplasty 2020 06 19;35(6):1576-1582. Epub 2020 Feb 19.

Department of Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN.

Background: Evidence has established obesity as a risk factor for total knee replacement (TKR) due to osteoarthritis. Obesity is a risk factor for TKR. Randomized trials such as Look AHEAD (Action for Health in Diabetes) have shown long-term successful weight loss with an intensive lifestyle intervention (ILI). It is unknown, however, if intentional weight loss can reduce the risk of TKR.

Methods: Look AHEAD randomized persons aged 45-76 with type 2 diabetes who had overweight or obesity to either an ILI to achieve/maintain 7% weight loss or to standard diabetes support and education (DSE). Reported knee pain was assessed using the Visual Analog Scale and Western Ontario McMaster University Osteoarthritis Index questionnaire in 5125 participants without previous TKR. Cox proportional hazard regression was used to model differences in risk of TKR in relation to randomization group assignment (ILI vs DSE) along with baseline body mass index category and baseline knee pain as potential confounders from baseline through Look AHEAD-Extension.

Results: Baseline mean ± SD Western Ontario McMaster University Osteoarthritis Index knee pain scores did not differ by treatment assignment (ILI: 3.6 ± 2.9, DSE: 3.9 ± 3.0, P = .08); as expected due to randomization. During follow up, the 631 (12%) participants who reported having a TKR were more likely to have been heavier (P < .001) and older (P < .001) at enrollment, but risk of TKR did not differ by treatment group assignment (hazard ratio [HR] 1.07, 95% confidence interval [CI] 0.91-1.25, P = .43). Heterogeneity of treatment effect was observed according to baseline knee pain (interaction P = .02). In persons without knee pain at baseline, there was a 29% reduced risk of TKR in ILI compared to DSE (HR 0.71, 95% CI 0.52-0.96). However, in persons with knee pain at baseline, there was no statistically significant association of treatment assignment with respect to subsequent TKR incidence (HR 1.11, 95% CI 0.92-1.33).

Conclusion: Findings suggest that intensive lifestyle change including physical activity, dietary restriction and behavioral changes to achieve weight loss for prevention of TKR may be most effective in preventing TKR prior to the development of knee pain.
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http://dx.doi.org/10.1016/j.arth.2020.01.057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7247950PMC
June 2020

Topical Tranexamic Acid Is Effective in Cementless Total Knee Arthroplasty.

Orthop Clin North Am 2020 Jan 17;51(1):7-11. Epub 2019 Oct 17.

Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA. Electronic address:

Surgical techniques used to decrease the amount of blood lost during the procedure range from tourniquets to electrocautery and, more recently, the use of antifibrinolytics. Currently, tranexamic acid is the most commonly used antifibrinolytic in arthroplasty procedures. It was previously thought that intravenous tranexamic acid was more effective than topical tranexamic acid, but had an increased risk of thrombosis and cardiac events; however, this study showed that topical tranexamic acid is as effective in decreasing blood loss and the need for a blood transfusion after hybrid fixation total knee arthroplasty as with cemented total knee arthroplasty.
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http://dx.doi.org/10.1016/j.ocl.2019.08.002DOI Listing
January 2020

Safety and Cost-Effectiveness of Outpatient Unicompartmental Knee Arthroplasty in the Ambulatory Surgery Center: A Matched Cohort Study.

Orthop Clin North Am 2020 Jan 21;51(1):1-5. Epub 2019 Oct 21.

Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.

Using an age- and comorbidity-matched cohort, we compared patients who underwent unicompartmental knee arthroplasty in an ambulatory surgery center with those who underwent the procedure in a traditional hospital inpatient setting. Postoperatively, the ambulatory surgery center cohort had fewer major complications than the inpatient cohort. No ambulatory surgery center patients required acute hospital admission and none had major complications. Four major complications occurred in the inpatient cohort. There was no difference in complication rates. Our results suggest that outpatient unicompartmental knee arthroplasty in a freestanding ambulatory surgery center is a safe and reasonable alternative to the traditional inpatient hospital setting.
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http://dx.doi.org/10.1016/j.ocl.2019.08.001DOI Listing
January 2020

Postmortem Retrieval Analysis of Metallosis and Periprosthetic Tissue Metal Concentrations in Total Knee Arthroplasty.

J Arthroplasty 2020 02 19;35(2):569-578. Epub 2019 Aug 19.

Implant Research Center, School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA; Exponent Inc, Philadelphia, PA.

Background: The purpose of this study is to determine the preferred sampling location for tissue analysis in total knee arthroplasty (TKA) and to evaluate metal concentrations, inflammatory cytokines, component damage, and tissue metallosis.

Methods: Twenty TKA systems were collected at necropsy along with tissue samples from 5 distinct locations. Inductively coupled plasma mass spectrometry (ICP-MS) analysis was performed to determine cobalt (Co), chromium (Cr), and titanium (Ti) concentrations. Synovial fluid cytokine analysis was preformed using a Magnetic Luminex Screening Assay. Femoral components were assesed for damage and tissues were visually scored for metallosis.

Results: The median metal concentrations were 16 ppb for Co, 46 ppb for Cr, and 9.8 ppb for Ti. There was no association between the tissue collection site and the metal concentration for Co (P = .979), Cr (P = .712), or Ti (P = .854). Twelve of 20 of the necropsy-retrieved TKAs had metallosis, but there was no correlation between Co (P = .48), Cr (P = .89), or Ti (P = .60) concentration and metallosis. Increased Co was associated with decreased tumor necrosis factor alpha (ρ = -0.56, P = .01) and interleukin 1 beta (ρ = -0.48, P = .03). Increased Cr was associated with decreased tumor necrosis factor alpha (ρ= -0.47, P = .03), interleukin 6 (ρ= -0.43, P = .04), and macrophage inflammatory protein 3 alpha (ρ= -0.47, P = .03).

Conclusion: We observed elevated Co, Cr, and Ti concentrations in tissue from necropsy-retrieved TKA. Our findings did not support the hypothesis that tissue metal concentrations were associated with inflammatory cytokines. The results of this research will be useful for the design of future prospective studies.
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http://dx.doi.org/10.1016/j.arth.2019.08.038DOI Listing
February 2020

Tibial Implant Fixation Behavior in Total Knee Arthroplasty: A Study With Five Different Bone Cements.

J Arthroplasty 2020 02 18;35(2):579-587. Epub 2019 Sep 18.

Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN.

Background: The objectives of this study are to (1) evaluate if there is a potential difference in cemented implant fixation strength between tibial components made out of cobalt-chromium (CrCoMo) and of a ceramic zirconium nitride (ZrN) multilayer coating and to (2) test their behavior with 5 different bone cements in a standardized in vitro model for testing of the implant-cement-bone interface conditions. We also analyzed (3) whether initial fixation strength is a function of timing of the cement apposition and component implantation by an early, mid-term, and late usage within the cement-specific processing window.

Methods: An in vitro study using a synthetic polyurethane foam model was performed to investigate the implant fixation strength after cementation of tibial components by a push-out test. A total of 20 groups (n = 5 each) was used: Vega PS CrCoMo tibia and Vega PS ZrN tibia with the bone cements BonOs R, SmartSet HV, Cobalt HV, Palacos R, and Surgical Simplex P, respectively, using mid-term cement apposition. Three different cement apposition times-early, mid-term, and late usage-were tested with a total of 12 groups (n = 5 each) with the bone cements BonOs R and SmartSet HV.

Results: There was no significant difference in implant-cement-bone fixation strength between CrCoMo and ZrN multilayer-coated Vega tibial trays tested with 5 different commonly used bone cements.

Conclusion: Apposition of bone cements and tibial tray implantation in the early to mid of the cement-specific processing window is beneficial in regard to interface fixation in TKA.
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http://dx.doi.org/10.1016/j.arth.2019.09.019DOI Listing
February 2020

Trunnion Corrosion in Total Hip Arthroplasty-Basic Concepts.

Orthop Clin North Am 2019 Jul 16;50(3):281-288. Epub 2019 Apr 16.

Department of Orthopaedic Surgery, Rush University, 1653 West Congress Parkway, Chicago, IL 60612, USA.

There has been increased interest in the role of corrosion in early implant failures and adverse local tissue reaction in total hip arthroplasty. We review the relationship between the different types of corrosion in orthopaedic surgery including uniform, pitting, crevice, and fretting or mechanically assisted crevice corrosion (MACC). Passive layer dynamics serves a critical role in each of these processes. The femoral head-neck trunnion creates an optimal environment for corrosion to occur because of the limited fluid diffusion, acidic environment, and increased bending moment.
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http://dx.doi.org/10.1016/j.ocl.2019.02.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521866PMC
July 2019

Arthroscopic Treatment of a Low-Velocity Gunshot Injury to a Primary Total Hip Arthroplasty: A Case Report.

JBJS Case Connect 2019 Jan-Mar;9(1):e18

Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, Tennessee.

Case: An immunosuppressed 51-year-old man sustained a ballistic injury about the site of a primary total hip arthroplasty, which had been performed for osteonecrosis of the femoral head 2 years earlier. He was treated with arthroscopic debridement and irrigation, inspection of the implants, and removal of foreign bodies.

Conclusion: Ballistic injury to a hip arthroplasty site with retained foreign bodies is an unusual injury. Hip arthroscopy may represent a minimally invasive treatment option for implant inspection, joint debridement, and removal of intra-articular fragments while minimizing the risk of soft-tissue complications.
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http://dx.doi.org/10.2106/JBJS.CC.18.00204DOI Listing
July 2020

Comparison of Inflammatory Cell-Induced Corrosion and Electrocautery-Induced Damage of Total Knee Implants.

J Long Term Eff Med Implants 2019 ;29(3):231-238

Department of Orthopaedic Surgery and Biomedical Engineering, School of Medicine, University of Tennessee Health Science Center, Memphis TN; Campbell Clinic Orthopedics, Germantown, TN.

Recently, inflammatory cell-induced corrosion (ICIC), a unique type of damage, has been reported in cobalt-chromium (CoCr) implants, but the mechanism remains poorly understood and controversial because electrocautery damage has also been shown to produce similar findings. This study aimed to distinguish between these two damage mechanisms. Forty-one CoCr primary total knee arthroplasty specimens were collected at time of necropsy. After removal and cleaning, light microscopy was used to identify areas of ICIC-like damage scars. A CoCr knee implant was intentionally damaged by electrocautery from both Bovie and Aquamantys sources using a 3-second hover method with 3 different energy settings for comparison to necropsy findings. Average roughness (Ra), max peak-to-valley height (Rmax), kurtosis (Rk), and skewness (Rsk) measurements were collected to represent the topography on the damaged areas for the CoCr implants. Necropsy implants showed signs of ICIC in 7 of 41 implants (17%) examined. Fe/C ratios of the Bovie electrocautery-damaged knee implant were shown to be statistically higher than those of necropsy-retrieved implants. Median Ra measurements were statistically less (P = 0.008) for Bovie-damaged areas compared to ICIC-dam-aged areas on CoCr. Median Rmax and Ra measurements were statistically less (P = 0.012, P < 0.001, respectively) for Aquamantys-damaged areas compared to ICIC-damaged areas on CoCr. While the visual patterns seen in necropsy-retrieved implants appeared similar to those with the intentionally damaged CoCrMo implant, the contents of the corroded regions are unique. The difference in roughness found on ICIC-damaged and electrocautery-damaged regions also indicates examination of surface topography as another distinguishing feature between the two mechanisms.
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http://dx.doi.org/10.1615/JLongTermEffMedImplants.2020033871DOI Listing
November 2020

A Randomized Study of Exercise and Fitness Trackers in Obese Patients After Total Knee Arthroplasty.

Orthop Clin North Am 2019 Jan;50(1):35-45

Division of Epidemiology, Biostatistics and Environmental Health, School of Public Health, University of Memphis, 228 Robison Hall, Memphis, TN 38152, USA.

Functional limitations persist in obese patients after total knee arthroplasty (TKA). This study assessed the effect of an exercise program (EP) and fitness trackers (FT) in obese patients with TKA. Sixty patients 1 year after orthopedic surgery were recruited and received a 16-week tailored EP; half were randomized to receive an FT. FT had no measurable effect compared with EP alone. EP improved knee range of motion, strength, and quality-of-life scores. This study provides preliminary evidence that a 16-week EP in obese individuals 1 year post TKA is feasible and effective in improving function and quality of life.
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http://dx.doi.org/10.1016/j.ocl.2018.08.002DOI Listing
January 2019

Is Soft Tissue Laxity Associated with Tissue Metal Concentrations after Total Knee Arthroplasty?

J Long Term Eff Med Implants 2018 ;28(2):79-85

Department of Orthopedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN; Campbell Clinic Orthopedics, Germantown, TN.

Increased joint laxity is associated with excessive polyethylene wear, but the correlation between laxity and metal wear has not been established. Fifteen necropsy-retrieved primary total knee replacements were mounted into a custom knee-testing machine that measured anterior-posterior, varus-valgus, and internal-external rotational laxity at 0°, 30°, 60°, and 90° of flexion. Inductively coupled plasma-mass spectrometry analysis was performed to measure the cobalt (Co), chromium (Cr), and titanium (Ti) concentrations in periprosthetic tissue samples. Spearman's rank correlations were performed to determine whether a significant correlation (p < 0.05) existed between soft tissue laxity and tissue metal concentrations. At 0° flexion, decreased posterior displacement was negatively correlated with elevated Co and Cr concentrations. At 30° flexion, decreased external rotation and varus deflection was negatively correlated with elevated Ti concentrations. At 60° flexion, decreased anterior displacement was negatively correlated with elevated Cr concentrations and decreased varus deflection was negatively correlated with increased Ti concentrations. At 90° flexion, decreased anterior displacement was negatively correlated with elevated Co and Cr concentrations. To our knowledge, this is the first study to investigate the correlation between tissue metal concentration and laxity. Decreased laxity was associated with elevated metal concentrations in periprosthetic tissue.
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http://dx.doi.org/10.1615/JLongTermEffMedImplants.2018025386DOI Listing
November 2019

Three-Dimensional Printing and Tissue Engineering in Orthopaedics.

Instr Course Lect 2018 Feb;67:595-602

Hartwell Postdoctoral Fellow, Department of Materials Science and Engineering, Simpson Querrey Institute for BioNanotechnology, Northwestern University, Chicago, Illinois.

Additive manufacturing and three-dimensional printing technology may revolutionize tissue-engineering strategies. Many clinical needs, including multitissue regeneration, remain unmet among patients with orthopaedic conditions. Ongoing research efforts in three-dimensional printing, including cell-containing bioinks for bioprinting, have resulted in acellular and cellular biomaterials that may help regenerate or replace damaged or missing biologic tissues. Recent advances in additive manufacturing aid in the preservation of biologic activity, such as the retention of growth factors, which may affect the delivery of safe, cost-effective, and efficacious bone graft substitutes for orthopaedic patients.
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February 2018

Applications of Three-Dimensional Printing in Orthopaedic Surgery.

Instr Course Lect 2018 Feb;67:587-594

Professor of Orthopedic Surgery, Department of Orthopedic Surgery and Rehabilitation, University of Wisconsin, Madison, Wisconsin.

Orthopaedic surgeons should be aware of the variety of applications of three-dimensional printing, which range from rough-and-ready applications, such as rapid prototyping of implant designs with the use of polymers to the fabrication of patient-specific implants and custom implants with the use of the principles of metallurgy. The local manufacture of low-cost prosthetic devices in third-world nations is the best example of the potential application of three-dimensional printing. Orthopaedic surgeons should understand the multiple applications of three-dimensional printing, including prototyping of anatomy, implants, orthotics, patient-specific instrumentation, and implants that incorporate porous structures and accommodate complex anatomy, as well as the future of biologically active three-dimensional printing. It is helpful to be aware of the types of three-dimensional printing that are currently used in the clinical setting, those that are commercially available, and those under development.
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February 2018

Introduction to Additive Manufacturing and Three-Dimensional Printing in Orthopaedics.

Instr Course Lect 2018 Feb;67:579-586

Hartwell Postdoctoral Fellow, Department of Materials Science and Engineering, Simpson Querrey Institute for BioNanotechnology, Northwestern University, Chicago, Illinois.

Additive manufacturing involves the construction of devices via the layer-by-layer deposition of materials. Additive manufacturing, which also is referred to as three-dimensional printing, is different from traditional machining, which involves the subtraction of material from a workpiece. Although traditional machining methods have been used in the field of manufacturing for decades, a recent rise in the commercial use of additive manufacturing has occurred in the field of orthopaedic surgery. Orthopaedic surgeons should understand the pertinent history of three-dimensional printing with regard to the field of manufacturing technology and the manner in which recent advances in additive manufacturing have allowed for new product designs with musculoskeletal applications. In addition, it is helpful to be aware of the regulatory aspects of additive manufacturing to ensure the safe and effective use of orthopaedic surgical devices created via three-dimensional printing.
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February 2018

Low Rates of Adverse Events Following Ambulatory Outpatient Total Hip Arthroplasty at a Free-Standing Surgery Center.

J Arthroplasty 2018 01 26;33(1):46-50. Epub 2017 Aug 26.

Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, Tennessee.

Background: We proposed to determine the complication and hospital admission rates for patients with total hip arthroplasty (THA) done by a single surgeon in a stand-alone ambulatory surgical center with same-day discharge. Given the recent emphasis on bundled payments for a 90-day episode of care, this same time frame after surgery was chosen to determine patient outcomes.

Methods: The records of patients with THAs done through a direct anterior approach by a single surgeon at 2 separate ambulatory surgery centers were reviewed. To analyze the learning curve for outpatient THA, the procedures were arbitrarily divided into 2 groups depending on when they were done: early in our experience or later. Complications were recorded, as were hospital admissions and surgical interventions, length of surgery and blood loss, and time spent at the outpatient facility.

Results: Over a 3-year period, 145 outpatient THAs were done in 125 patients; 73 were considered to be initial procedures, and 72 were considered to be later procedures. Only one of the 145 procedures (0.7%) required transfer from the outpatient facility to the hospital for a blood transfusion. No other direct admissions to the hospital or transfers to the emergency department from the surgery center were necessary. Surgical interventions were required after 3 (2%) of the 145 arthroplasties in the global period (90 days).

Conclusion: This study demonstrated that same-day discharge to home following THA can be safely done without increased complications, readmissions, reoperations, or emergency room visits.
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http://dx.doi.org/10.1016/j.arth.2017.08.026DOI Listing
January 2018

Primary stability of tibial plateaus under dynamic compression-shear loading in human tibiae - Influence of keel length, cementation area and tibial stem.

J Biomech 2017 07 22;59:9-22. Epub 2017 May 22.

Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee, TN, USA.

The objective of our study was to evaluate the impact of the tibial keel & stem length in surface cementation, of a full cemented keel and of an additional tibial stem on the primary stability of a posterior stabilised tibial plateau (VEGA® System Aesculap Tuttlingen, Germany) under dynamic compression-shear loading conditions in human tibiae. We performed the cemented tibial plateau implantations on 24 fresh-frozen human tibiae of a mean donor age of 70.7years (range 47-97). The tibiae were divided into four groups of matched pairs based on comparable trabecular bone mineral density. To assess the primary stability under dynamic compression shear conditions, a 3D migration analysis of the tibial component relative to the bone based on displacements and deformations and an evaluation of the cement layer including penetration was performed by CT-based 3D segmentation. Within the tested implant fixation principles the mean load to failure of a 28mm keel and a 12mm stem (40mm) was 4700±1149N and of a 28mm keel length was 4560±1429N (p=0.996), whereas the mean load to failure was 4920±691N in full cementation (p=0.986) and 5580±502N with additional stem (p=0.537), with no significant differences regarding the dynamic primary stability under dynamic compression-shear test conditions. From our observations, we conclude that there is no significant difference between a 40mm and a 28mm tibial keel & stem length and also between a surface and a full cementation in the effect on the primary stability of a posterior stabilised tibial plateau, in terms of failure load, migration characteristics and cement layer thickness including the penetration into the trabecular bone.
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http://dx.doi.org/10.1016/j.jbiomech.2017.04.031DOI Listing
July 2017

Two-Stage Revision Total Knee Arthroplasty in the Setting of Periprosthetic Knee Infection.

Instr Course Lect 2017 Feb;66:249-262

Researcher, Chicago Medical School, North Chicago, Illinois.

Two-stage revision total knee arthroplasty (TKA) is the standard of care for patients who require a revision procedure for the mangement of a late or chronic periprosthetic knee infection. A careful examination of two-stage revision TKA is warranted as the number of patients who require revision TKA in the United States continues to rise. Surgeons should understand the intricacies involved in two-stage revision TKA, including the indications, procedural variations, and current deliberations on two-stage revision TKA in the literature. Surgeons also should understand the alternative treatments for periprosthetic knee infections.
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February 2017

Single-Stage Revision Total Knee Arthroplasty in the Setting of Periprosthetic Knee Infection: Indications, Contraindications, and Postoperative Outcomes.

Instr Course Lect 2017 Feb;66:235-247

Clinical Research Fellow, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York.

Single-stage revision total knee arthroplasty has become an increasingly common treatment option for patients with failed knee prostheses. Periprosthetic knee infection is the leading and most devastating cause of revision total knee arthroplasty. Although periprosthetic knee infection has been extensively studied in the orthopaedic literature, the role of single-stage revision total knee arthroplasty for the treatment of periprosthetic knee infection warrants further research. As healthcare reform shifts from a volume-based to a value-based system, it is imperative that orthopaedic surgeons understand the procedural indications, risks, and benefits of single-stage revision total knee arthroplasty.
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February 2017

Prevention and Diagnosis of Periprosthetic Knee Infection.

Instr Course Lect 2017 Feb;66:223-233

Orthopaedic Surgery Resident, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.

Total knee arthroplasty (TKA) has become an increasingly common treatment option for patients who have debilitating knee arthritis. TKA is a relatively safe and efficient procedure that results in promising outcomes and has a positive effect on a patient's quality of life. More TKAs are being performed annually because the procedure substantially reduces pain and improves functionality; however, as the number of TKAs continues to rise, there is concern for potential complications that may result in prosthetic joint failure. Primary TKA failure may result in revision procedures that have high costs and an increased risk for additional complications. Infection is the second most common cause of primary TKA failure and the single most common cause of revision TKA failure. Surgeons who have a better understanding of the epidemiology, risk factors, and diagnostic modalities associated with periprosthetic knee infection will be able to implement preventive measures and treat patients in whom such a complication occurs.
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February 2017
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