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Whats New in Orthopaedic Surgery

John E McDermott,MD, FACS

Ask any orthopaedic surgeon whats new, and the answerwill usually be orthopaedic practice. How we prac-tice has changed more than what. The change is how

we are serving our patients. How can we provide evermore costly modern surgical care to the increasing num-ber of minimally or uninsured in our population? In-creasingly, our patients are facing care denial and carerestriction from insurance, government, and healthmaintenance agencies.

Although great strides in scientific advancement andsurgical innovation continue, a great vexation has cometo orthopaedics, and probably to all of surgery: thechange in health care delivery and associated distractingsocioeconomic issues.

Orthopaedic practice

Unheard of just a few years ago, portions of national,local, and even subspecialty meetings are devoted to cod-ing, marketing, and reimbursement issues. New surgicaltexts not only focus on diagnosis, operative techniques,and patient management, but now also on how to codefor care and operations.1

Although these efforts seem to be focused on increas-

ing our ability to maintain the business of surgical andmedical care provision, there is, at the same time, a crisisin the availability of care to a large portion of our pop-ulation. The problem extends from university and teach-ing institutions to private practice, and affects even solocommunity practices. All feel the challenge of providingadvanced technical management for disadvantaged pa-tients without resources for reimbursement. Increas-ingly, patients lacking insurance or other financial re-sources turn to the emergency department for care,creating increasing demands on these facilities and on

the specialists who cover them, particularly the sur-geons.2 Urgent and nonurgent referrals from the emer-gency departments are shunted to primary providers andcommunity clinics where, again, referral for surgical care

is a challenge. With the high percentage of musculoskel-etal problems seen among patients in emergency depart-ments, orthopaedic care then becomes the major chal-lenge. Additionally complicating the problem is thenationwide trend of trauma center closures: 30 so far,

with 20% more expected in the next few years.

Trauma call

It is now becoming common for hospitals to contractwith orthopaedic surgeons or their groups to cover theemergency departments.3 But again, this does not really

address the lack of available insurance for the poorlycovered or, more unfortunately, the working poor. In atleast one area, the challenge to find resources for theseneedy musculoskeletal patients has resulted in creationof a special volunteer clinic, financed by the medicalcenter with support from orthopaedic groups.

Orthopaedic advertisement

The irony of this problem is that although teaching insti-tutions and private physicians are now being asked to vol-unteer, every area of the country has been inundated with

medical advertisingon television, radio, andin print, muchof it devoted to solicitationof patientswithmusculoskeletalproblems. Now competition for patients results in teachinginstitutions, large clinics, and even individual orthopaedicpractitioners emulating other specialties in advertisingschemes, both directly and through the use of Website in-formational marketing.

Increased use of computer searches for informationand the use of this information for marketing are nowcommon. Concern over what patients actually under-stand has also caused the Council on Communication of

the American Academy of Orthopaedic Surgeons to cau-tion that it is difficult for patients to differentiate be-tween false, misleading, self-serving, and objective infor-mation. The Council expressed concern about theorthopaedic equipment industrys use of Web lists ofsurgeons performing certain operative procedures. Theynoted that such marketing puts undue pressure on thesurgeon with respect to procedure selection and othersurgical decisions.

Perhaps an even greater problem is the direct con-

Received August 27, 2004; Accepted August 30, 2004.From the Department of Surgery, Swedish-Providence Medical Center,Seattle, WA.Correspondence address: John E McDermott, MD, FACS, Suite 400, 1600East Jefferson, Seattle, WA 98122.

924 2004 by the American College of Surgeons ISSN 1072-7515/04/$30.00

Published by Elsevier Inc. doi:10.1016/j.jamcollsurg.2004.08.026


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sumer advertising by major orthopaedic products sup-pliers. One major supplier of orthopaedic hip replace-ments features a famous golfer in TV and otheradvertising. These ads encourage patients to discuss

with their orthopaedic surgeon the use of this particular

implant device.4

Although the development of lists ofphysicians using products is not new to medicine and isfrequently used by the pharmaceutical industry, it now isplacing added stress on surgical practice.

Turning to the scientific aspects of orthopaedic sur-gery, 2004 seemed to be a time of renewed interest inalternatives to some of the more common orthopaedicprocedures: arthroplasty, fusion, and reconstruction, thehallmarks of orthopaedic care. The greatest generationis facing the challenge of joint replacements worn outearlier, arthroplasty, and the baby boomers, with their

more active weekend-warrior lifestyles need joint re-placement at an even earlier age.5

Hip arthroplasty

Hip replacement arthroplastic procedures continue toevolve and, as noted in last years Whats New in Or-thopaedic Surgery, are being performed through mini-mum incisions with new and improved materials. They,as noted, are also increasingly performed on a repeatbasis. The continued publication of outcomes studiesand the challenges of failed procedures have focused at-tention on alternatives to joint replacement.

The use of MRI to evaluate other pathology of thepelvis, colon, rectum, uterus, and prostate, often leads toearly detection of that hip pathology. This has createdinterest in femoral head revascularization surgery andother preventive efforts,6 notably for avascular necrosisof the femoral head, a common cause of destructive ar-thritis of the hip.

For morethan 30 years, hiparthroplasty hasbeen a com-mon procedure. Now increasing numbers of revision ar-

throplasty procedures are being done. A study of 4,762 hiprevisions wasdoneby the Norwegian Arthroplasty Register.They found a 10-year failure rate on these revisions of 26%and noted failure was less for femoral and acetabular com-ponents that were uncemented.7

Similarly, another study of longterm success of unce-mented acetabular revisions found a 95% 12-year sur-vival rate.8 In primary total hip arthroplasties, however,the use of methylmethacrylate-type glue still achievesexcellent results. In a 30-year study, 88% of the implants

were functional, with a 7.3% revision rate at death orstudy.9

Analysis of these failures and their associated prob-lems has led to modification of surgical techniques topreserve muscular attachment and to changes in the im-

plants themselves. Protection of the bone attachmentand bone surface interface has led to more judicious useof cement, preservation of bone stock, and efforts toenhance bone implant surface attachment. There is evi-dence that particle debris from implants increases wearlevels, provides more debris, and ultimately results inpathologic failure of the implants. The age of polyethyl-ene knee replacements has been studied, and it appearseven that shelf life before implantation has a consider-able effect on survival. Implants, if stored for less than1.7 years, have a 96% survival, versus 71% survival for

older, longer-stored similar units.10

Also affecting the durability of the polyethylene-bearing surfaces is the way they are sterilized. The use ofgamma radiation does better, but with the resultanthighly crystalline-type implants, this process must becarried out with a vacuum barrier because there is earlierdegradation if oxygenation of the plastic occurs.

The problem of plastic wear has led to increased in-terest in nonpolyethylene-bearing surfaces. Attentionhas returned to implants with metal-to-metal articulat-ing surfaces. These newer devices have improved pol-

ished surfaces to reduce friction and increase longevity.Similarly, ceramic implants are again becoming popularwith newer materials of increased strength and smoothersurfaces.11 But these alternatives also have challenges.There are reports of elevated metal ion levels and onereport of malignant change secondary to metal deterio-ration.12 Although concern continues to exist over theuse of metal and other materials in manufacture of im-plants, the concern, at least with respect to malignancy,may be less than previously thought.13

A new concept is metal-to-metal as a modified

surface-only replacement arthroplasty of the hip. Theearly results of this look promising, with a 94% 4-yearsurvival in highly active younger patients. Three percentof implants did require revision to conventional total hipreplacement.14

Knee arthroplasty

These same concepts in technical development and al-ternatives to replacement are being reported for theknee: improvements in the mechanical design of the

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knee prosthesis, new concepts in the preservation of softtissue and implant control, and alternatives to total re-placement.15 To control medial knee stability, there aremodifications in design of the implant restraint, reduc-ing friction and wear. The medial pivot shift design sta-

bilizes anterior and posterior motion of the component.In comparing the performance of knees of different de-sign, as yet there seems to be minimal difference. In astudy of bilateral different implants, the anterior-posterior glide type resulted in a 89.4 good result versusthe rotated platform type giving an 88.6 good result.16

This study also reported three failures in each group. Itwould appear that implant fixation and bone reaction tothe implant itself are still the prominent causes of im-plant failure; 16% show some radiolucency at 5 to 15years.

There is also a concern with the observations over thedesign of the polyethylene-to-metal attachment portionof the implant, noting some implant failure results fromdisruption of this attachment.17 The micromotion of themodular components leads to minimal problems.Ninety percent of the removed implants showed pitting,77% burnishing (worse with cobalt chromium implantsthan titanium), and a 61% protrusion rate of the poly-ethylene into the metal support was documented.18An-other article suggested that this problem is not reallynotable and that the modular components are no differ-ent than the single design type.19

Surgical preservation of the posterior cruciate liga-ment is also believed to affect implant stability, and pres-ervation of this ligament, along with flexion and exten-sion balance, is critical for stable replacement.20 There isalso renewed interest in preserving patellar integrityrather than using surface replacement to eliminate fail-ure associated with this component. The recommenda-tion is that in patellar-friendly implants, the patellasurface not be replaced.21

For the knee, as with the hip, there is continued in-terest in alternatives to knee replacement. To avoid thechallenges of revision, one approach is the use of menis-cal replacement for younger and more active individuals.Meniscal transplantation is reported to allow 76% ofyoung adults to return to sports activity, 68% with nopain and 33% with mild pain, in a mean 40-monthshort-term study.22 Interest remains in an implantablespacer for isolated medial compartment disease. In aninterview, Hallock23 reported up to 100% relief of pain

for 3 to 6 months. But, the longest followup of thesepatients was 3 years.

Another alternative is hemiarthroplasty, to replaceonly the medial compartment of the knee in patients

with minimal pathology in the lateral and patellar area,

to forestall the need for full knee replacement. There isan acknowledged additional need for surgery becauseunicompartmental arthroplasties often will need to berevised to full knee arthroplasty.

Alternatives to forestall knee replacement are increas-ingly attractive.24 Interest in less invasive management andconcern over outcomes has stimulated more efforts in ar-throscopic management, both in simple debridement andin efforts to resurface the cartilaginous articular surface.Two types of articular cartilage replacement for localizedareas of loss are in common use. Mosaicplasty uses autolo-

gous bonecartilage cylinders.These bonecartilage plugs areharvested from the intercondylar notch or lateral aspects ofthe joint, off the weight-bearing area, and then transferredto the damaged, weight-bearingsurface defect.25 This os-teochondral grafting is an alternative to the earlier tech-niques of abrasion through drilling procedures that are alsoreported to be successful, with 77% improvement in kneefunction.26Themicrofracture technique, in whichan awl isused to create an osteal defect to allow chondral site in-growth, is reported at 75% in a 3-to-5-year followup.27 Inlooking at osteochondral plug treatment for osteoarthritis

versus acute chondral defects as a separate entity, the out-comes may not be as encouraging. In the single lesion type,there was 88% improvement; less than one-half of patients

with combined reported improvement, as did those need-ing associated realignment procedures.28

An alternative technique of transplantation of in vitroculture of harvested chondrocytes has been proved suc-cessful. Defects in articular cartilage cover of minimumdepth of bone loss can be resurfaced with the patientsown cultured chondrocytes. Outcomes appear promis-ing because this technique compares favorably with the

microfracture technique of stimulation of cartilage cellregrowth.29

Ankle arthroplasty

Ankle replacement is becoming more commonplace.But challenges remain, even among the innovators. Fail-ure rates are higher than those in the hip and knee.30 Ina study of the only FDA-approved ankle implant thatincluded the originators patients, an 11% revision rate

was noted. Although 90% of the results were good, there

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was one amputation, and 19 patients required subtalararthrodesis. Seventy percent of patients showed implantradiolucency on x-ray, most frequently involving the ta-lus. Fusion of the distal tibial fibular syndesmosis hasimproved outcomes over earlier designs, reducing tibial

component problems. The more common failure now iswith subsidence of the talar component.

Grafting, as in the knee, for localized areas of boneloss and arthritis is an attractive alternative to total ar-throplasty. The technique of autologous chondrocytetransplantation as described previously has also been ap-plied to the ankle. Results in 10 patients with lesions 16to 20 mm in size with a depth of up to 7 cm weresatisfactory and encouraging.31

In the knee, osteochondral bone plugs harvestedfrom silent areas in the knee such as the intracon-

dylar notch or lateral femoral articular surface areused to repair osteochondral lesions of the talus. Al-though bone plugs can usually be harvested arthro-scopically from the knee, the ankle anatomy usuallyrequires open surgical technique. Combined arthro-scopic and arthroscopically assisted procedures are in-creasingly common.32

Computer-assisted surgery

Options for approaching the articular surface of the ta-lus, other than through an open technique, often require

a medial malleolar osteotomy (Fig. 1). With biplane im-aging, it is difficult but possible to guide the small boreplugs into the dome of the talus with accuracy from theplantar aspect of the talus. To assist in this challenge,Christian Fink,33 from Innsbruck, presented a techniqueusing a computer to assist MRI and to facilitate guidanceof the osteochondral bone graft plugs retrogradethrough the talus to the ankle articular surface.

Computer-assisted procedures are also being studiedto aid in implant placement for knee arthroplasty. Thecomputer can be a considerable help in aligning femoral

and tibial implants. It has been able to better place them,with respect to both alignment and rotation. The down-side is longer operative time, as with other computer-assisted surgery at this point.34 Computer assistance hasalso been found advantageous in the revision of totalknee replacements complicated by large bone defects.Sikrski35 reported on 14 patients with large tibial bonedefects; he used the computer to align the revision im-plants in grafted cortical cancellus allographs made fromfemoral head sources.

The computer is also being used to assist in ligamen-tous repair in the knee. A problem in anterior cruciateligament (AC) reconstruction is critical alignment of thegraft. A group at the University of Geneva Hospital inSwitzerland has noted that the 10% to 20% incident ofsuboptimal graft tunnel placement in anterior cruciateligament reconstruction can be markedly improved us-ing a computer program. By using virtual knee naviga-tion from landmarks placed in the tibia and femur atoperation, range of motion can then be carried out todetermine the true virtual graft placement, identifyingoptimal position for the tunnels.36 The computer systemallows a virtual graft placement to be tested in flexionand extension before actual placement during the surgi-cal procedure.

Stabilization of the knee

Instability of the knee from anterior cruciate disruptionis a common injury that often requires ligament graft-ing, usually either the use of the patellar tendon, or oneconstructed from the patients medial hamstrings.37 In-growth revascularization is now accepted to be bestachieved with such autologous grafting38 (Fig. 2). Eachof the patellar tendon or hamstring graft donor sites havetheir advocates and are associated with concern, al-though outcomes are quite similar. Recently the use ofthe quadriceps tendon has been proposed.39

Figure 1. Bone Plug autografts inserted into medial articular car-

tilage defect of the talus (Note: medial malleolar osteotomy).

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Perioperative surgical management

Blood replacement continues to be a challenge for largejoint replacement of the hip and knee and in spinalprocedures, particularly those using a combinedanterior/posterior approach. Most patients having elec-tive arthroplasty are asked to donate autologous blood,but frequently the surgical loss requires additional effort.Concern over blood replacement has led to the commonuse of reinfusion systems and to presurgical enhance-

ment by erythropoietin.40

Studies have suggested that itis possible to predict hidden blood loss not detected atoperation, and to preoperatively plan for its manage-ment. This occult blood loss is projected to be 26% intotal hip replacements and up to 49% in total kneereplacements.41 It has been shown that, using a conser-vation algorithm, it may be possible to reduce even theneed for autologous transfusion. When compared tononalgorithm patients, this algorithm resulted in only a2% transfusion incidence versus 16% in the nonalgo-rithm group.42

Deep vein thrombosis and pulmonary embolism con-tinue to be the most frequent postoperative complica-tions from hip replacement, knee replacement, and ma-

jor orthopaedic trauma. The American College of ChestPhysicians Guidelines have led to increased awarenessand more uniform protection efforts.43 The high-riskpatients need prophylaxis with either low molecular

weight heparin or warfarin, in combination with elasticstockings, intermittent pneumatic compression devices,or both. The use of fondaparinux, while showing a two-

fold improvement in deep-vein thrombosis rates (6%versus 13%), in comparison with enoxaparin, is associ-ated however, with an increased incidence of majorbleeding.44 A new warfarin-like drug, Ximelagatran, anoral direct thrombin inhibitor, shows promise and does

not seem to be associated with increased bleeding.45

Trauma management

Among the noteworthy orthopaedic advances in traumamanagement is the use of a flexible titanium nail forfixation of childrens femur fractures. These devices al-low for less traumatic insertion and, because of flexibil-ity, they offer the additional advantage over commontraction treatment of shorter hospitalization and earlierambulation.46

There is also continued interest in the use of the lli-

zarov technique of external cages with multiple pin fix-ation. The functional recovery of 40 patients with non-union treated with this technique was analyzed. Afterremoval of the device, functional recovery was slowest inthe first 6 months and greatest in the second 6 months,but did not progress after the 2-year mark.47

Timing of operation was addressed in an article study-ing proximal femur hip fractures in 182 patients. Thosehaving operation within the first 6 hours after fracturehad a lower mortality rate, 10%, compared with a mor-tality rate up to 33% for patients delayed 24 hours. But

outcomes in both groups was otherwise similar.48

Delayof operation also constituted cost factor to the institu-tion; spending for resources was markedly increased ifoperation was delayed beyond 48 hours.49

A similar outcomes-related study of amputations fo-cused on ultimate patient outcomes. Noted was a dete-rioration in sickness impact profile between those oper-ated on within the first 24 hours and those whoseamputation was delayed for 3 months or more. Loss ofsuccess in walking, increase in number of operations,and a reduction in return to work from 57% to 14% was

found in the delayed amputation category.50

The effect of telemedicine on initial trauma manage-ment was studied. Ninety percent of respondents to thetelemedicine trauma case presentations found the effortuseful. They were found to disagree with the radiologyreport 49% of the time, change their minds with respectto admission need 17% of the time, and surgical indica-tions 22% of the time.51

This year saw attention drawn to two types of com-partment syndromes. The chronic exertional type, usu-

Figure 2. Knee arthroscopic view of anterior cruciate reconstructed

tendon emerging from intercondylar notch of femur. (Note: complete

tissue ingrowth of quadruple hamstring autograft, 5 years post-

surgery). Photo courtesy of Pierce Scranton, MD.



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ally secondary to sports overuse, is a syndrome charac-terized by severe muscle compartment pain aftervigorous exercises; as with other compartment-type syn-dromes, these usually require surgical management.52 Ofequal challenge in diagnosis is acute compartment syn-

drome in the absence of fractures. Thirty-eight patientswith 164 acute compartment syndromes had no frac-ture; a high level of clinical suspicion is needed, becauseearly decompression results in statistically significantoutcomes.53

Gas gangrene and its management was studied byPerry and colleagues,54who noted that despite pharma-ceutical advances, the prevalence of this devastatingproblem continues, and surgical management remainschallenging. Hemostasis in these complicated woundscan be aided by application of fibrin sealants to muscletissue surfaces. Adequate drainage, systemic manage-ment, and antimicrobial efforts are necessary in theselife-threatening infections. Assisting in the general man-agement of wounds has been the development ofvacuum-assisted wound closure. This has also proved tobe an adjunct to difficult extremity wound coveragechallenges and particularly helpful in open fracturemanagement of the lower extremity. These devices arealso used in wound care centers for chronic diabetic andnondiabetic wounds.55

Prevention

The sprained ankle represents one of the most commonsports and work injuries. Although admitting special inter-est, my colleagues and I have determined that the anatomicposition of the fibula influences the frequency of anklesprain, ankle injury, and resulting disability. Two-thirds ofankle sprains occur in patients with a posterior fibula.

When the fibula is 15 degrees or more posterior to thetransverse axis, protection by bracing, taping, and so forth,

would most likely benefit this group (Fig. 3).56

Another study found that the frequency of anteriorcruciate ligament injuries could be markedly reduced.

A 1-year study of 61 Division I National CollegiateAthletic Association female soccer teams found thaton-field warm-up exercise effort reduced the numberof these injuries by 45% and the noncontact anteriorcruciate ligament injuries by 72%, with a decrease of58% of noncruciate ligament injuries duringgames.5,7

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57. Rapp SM. Early results: Soccer warm-ups reduced some ACLinjuries. Orthopedics Today. May 2004:20

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F. Buna Noutati in Chirurgia Ortopedica