What Is the State of Total Joint Arthroplasty?

    Faculty at ICJR’s Pan Pacific Orthopaedic Congress addressed the key issues facing orthopaedic surgeons who perform hip and knee arthroplasty.

    Total hip arthroplasty (THA) is one of the most commonly performed surgical procedures in the United States, with more than 2.4 million Americans living with a hip implant today.

    At the International Congress for Joint Reconstruction’s recent Pan Pacific Orthopaedic Congress, Daniel Berry, MD, from Mayo Clinic, Rochester, Minnesota, discussed the state of THA in North America, offering his thoughts on trends and future issues.

    First, some facts about the procedure shared by Dr. Berry:

    • Uncemented implant fixation is done in approximately 90% of procedures.
    • More than 90% of bearing surfaces used in THA are cross-linked polyethylene. Metal-on-metal has all but disappeared
    • The use of ceramic femoral heads is increasing due to concerns about cobalt chromium.
    • The most common femoral head diameter is 36 mm, with 32 mm used in some women.
    • Fluted tapered modular stems are the most common femoral stem used in revision procedures.
    • In most revision procedures, an uncemented acetabular cup with screws is used. The cup often has a highly porous metal surface to increase friction and bone ingrowth.

    Dr. Berry said that optimizing perioperative management of the patient is one the strongest trends in THA today. This includes:

    • Improved multimodal pain management that incorporates peripheral nerve blocks and local wound infiltration)
    • Better blood management, such as the use of tranexamic acid to decrease transfusion rates
    • Rapid rehabilitation protocols that facilitate early hospital discharge

    Operative approaches have been the subject of much interest and controversy, Dr. Berry said. According to a survey done by the American Association of Hip and Knee Surgeons:

    • 60% of respondents use a posterior approach for THA
    • 20% using the anterolateral approach
    • 20% using the direct anterior approach

    Dr. Berry said the data showed an increase in the direct anterior approach and a decrease in the anterolateral approach.

    He cited one procedure and two implants that were formerly in vogue but have now fallen out of favor: hip resurfacing (although he admitted the procedure still has its advocates), dual-mobility femoral necks, and metal-on-metal implants.

    In the future, orthopaedic surgeons will need to address a number of issues with THA:

    • Trunion/taper corrosion with metal heads
    • Early femoral fracture with uncemented THA
    • Infection
    • Dislocation

    Dr. Berry’s presentation can be found here.

    More on the State of Hip and Knee Arthroplasty

    W. Norman Scott, MD, FACS, from the Insall Scott Kelly Institute for Orthopaedics and Sports Medicine in New York, addressed the state of total knee arthroplasty (TKA) in North America at the Pan Pacific Orthopaedic Congress.

    Like THA, TKA is a successful procedure, but it is also fraught with iatrogenic issues. By keeping in mind the mistakes of the past – and the lessons learned from those mistakes – orthopaedic surgeons can improve their technique and make better implant decisions today.

    His particular concerns include:

    • New implant designs and material properties
    • Implant fixation
    • Failure to resurface the patella
    • Overuse of unicondylar knee arthroplasty

    Dr. Scott’s presentation can be found here.

    S.K.S. Marya, MS, DNB, MCH, FRCS, FICS, from Max Healthcare Institute Limited and Max Super Specialty Hospital, New Dehli, India, discussed the state of THA in Asia. He noted that orthopaedic surgeons in the region are often faced with issues of size, shape, and structure of hip implants that challenge them to innovate and adapt to the needs of the Asian hip.

    Patient expectations can also be problematic, Dr. Marya said. Although they are counseled not to do so, many patients in Asia resume squatting and sitting cross-legged as soon as the pain of the procedure abates, stressing the new hip.

    Dr. Marya’s presentation can be found here.

    Shuichi Matsuda, MD, PhD, from Kyoto University, Kyoto, Tokyo, who spoke on the state of TKA in Asia, agrees that Asian patients have specific orthopaedic needs. He noted that because deep flexion is typically part of Asian cultures, orthopaedic surgeons primarily use posterior-stabilized knee implants, which allow more range of motion after surgeon.

    Original knee implants have been developed in Asia to accommodate deep flexion, Dr. Matsuda said. These include the Yoshino/Shoji knee and the Bisurface Knee (Japan), the Indus HiFlex Knee (India), and the Lospa Knee (South Korea).

    Dr. Matsuda’s presentation can be found here.