Lateral unicondylar knee arthroplasty can help patients return to sport

One prospective study covers patients that undergo unicompartmental arthroplasty from 2000-2005 : nineteen patients underwent lateral unicompartmental (uni) knee replacements, with an average age of 68 years for the lateral unicompartmental group.

Assessments included preoperative and postoperative range of motion, subjective testing, radiographic evaluation and MRI.

Only one patient was converted to a total knee arthroplasty, and none were lost to follow-up.

Successful outcomes are reported in the majority of cases over an average follow-up of 33 months…

Physical examination and subjective questioning along with MRI correlation would help  predict successful outcomes.

Overall, patients reported a return to skiing in 5 months, tennis in 4 months and walking and jogging within 1 to 2 months.

He also reports that long-term results have to be followed and adds that the procedure has shown it is worth consideration.

“You can preserve bone stock, you can get near-normal kinematics, you have low cost and blood loss during surgery is less,” he says.

Reference

Plancher KD, Bishai SK, Ibrahim T. Patients undergoing lateral unicondylar knee arthroplasty: Can we guarantee success and return to sport? Paper SS-38. Presented at the 2010 Annual Meeting of the Arthroscopy Association of North America. May 20-23, 2010. Hollywood, Fla.

Not so simple but sitting and joking method : a “New Technique” for Reducing Anterior Shoulder Dislocation : Matsumoto’s or Orthopedix’ “Joking Planche à Sida” ?

I just read one very good japanese article with great enthousiasm, because for many years in a 120 000 inhabitants French West Indian Community (Saint Claude, Basse Terre Guadeloupe), I obtained not 80 per cent but 100 per cent success with a method very close to this japanese one, but still much simpler !

I obtained 100 per cent because my own method is probably still simpler than Matsumoto’s: sitting patient, with axillary board fixed by the foot of the quiet patient sitting surgeon (talling same old joke about sex) and simply pulling arm axially gently AND permanently (both hands) sometime many minutes, with elbow maintained in flexion.

That’s it ! and NOT THIS…

Falls from skiing accidents, (snow)boarding injuries, car accidents and other traumatic events account for many first-time shoulder dislocations.

When the shoulder doesn’t pop back in place on its own, the patient ends up in the emergency department or doctor’s office for a reduction (put it back in the socket).

There are many ways to reduce the shoulder but most require anesthesia (and in 1983-1989 Basse Terre, anesthesiologists…) to put the patient asleep and relax the muscles or strong narcotic medications for pain.

In their clever report, surgeons from Japan propose a “new” method for reducing anterior (forward) shoulder dislocations.

Most shoulder dislocations are anterior so this approach would be useful in many cases, if not every case.

No medication or anesthesia is used.

The patient remained in the sitting position.

There were no complications from the technique such as fractures or nerve injury.

The sitting position used was more comfortable for patients who were already holding the dislocated arm with the other hand.

The patient was sitting in a chair facing the surgeon.

The surgeon took hold of the patient’s forearm very gently and (?) raised the arm straight forward 90 degrees.

The surgeon placed his other hand (?) on the patient’s chest wall against the front of the patient’s shoulder.

The (?) surgeon’s thumb was against the head of the humerus (upper arm bone).

Just by pulling on the patient’s arm with one (?) hand while applying pressure on the humeral head with the other hand, the humeral head slipped back into the socket.

If the patient tensed up, the surgeon just lowered the arm a little, waited for the pain to go away and the muscles to relax and started the procedure again.

The hand against the shoulder helped control the tilt of the shoulder socket.

My axillary board is probably much more stable and accurate…

The technique is done slowly and gently.

If the surgeon wasn’t able to successfully reduce the shoulder after several(?)  tries, the patient was placed supine (lying on his or her back).

A forward elevation maneuver was used instead.

The dislocated arm was placed overhead while the surgeon applied traction, gently rotating the arm outward until the head of the humerus slipped back into the socket.

Afterwards, everyone was given a sling to wear to support the arm during the acute phase of healing. X-rays were taken to confirm reduction.

Results of this technique were evaluated by reviewing the charts of patients later.

Data collected included previous history of shoulder dislocation, use of medications for reduction, type of reduction technique used, and before and after X-rays.

A total of 34 patients were treated for anterior shoulder dislocation with this “new” reduction method.

The surgeon accomplished the task alone while talking with the patient.

Combining the sitting position with a (simpler, straight, gentle, firm, axial) traction technique may be “new”… in Japan and may be has never been described before in medical journals !

Compared with other methods of shoulder reduction, this was simple, unique, drug-free, and successful.

It worked for almost 80 per cent of the patients.

The key to this technique is to work with patients who are already seated and self-supporting their arm.

Changing positions causes the shoulder to tense up and can be avoided with this method.

This method can be tried first before using drugs, mechanical force, or surgery.

There was no clear reason why a small number of patients could not be reduced with this method.

The success rate wasn’t quite as high as with some other methods, but the fact that no narcotics or interscalene block were needed was the added benefit.

Kazu Matsumoto, MD, PhD, et al. Anterior Dislocation of the Shoulder: A Simple and Sitting Method for Reduction. In Current Orthopaedic Practice. May/June 2009. Vol. 20. No. 3. Pp. 281-284.

Implant for Knee and Hip Repair in French West Indies

As more and more people in the Western World are walking around with artificial hips and knees,  French West Indies aging baby boomers are also leading the way.

That is partly because excess weight is fraying their joints earlier.

Between the years 2000 and 2006, knee replacements shot up by 65 percent.

In an AAOS 2009 paper entitled, “Joint Replacement Access in 2016: A Supply Side Crisis,” Dr. Thomas K Fehring et. al. stated that “demand for arthroplasty is expected to double in 10 years.”

By 2016, this translates into an annual demand of 1,046,000 knee replacement procedures.

At the same time, the expected supply of Orthopaedic surgeons is expected to fall such that if they were to work at current rates, they will only be able to perform 287,759 knee replacements, leaving many “waiting in pain”.

Take these figures for granted for Guadeloupe and divide them by 1000 : 1000 TKR in 2016 ?

Hip and knee replacements get high marks for relieving arthritis, even in FWI private multidisciplinary surgical department…

Though the procedures can have serious complications (mainly septic) and don’t always restore perfect mobility, more than 80 percent of people said they were satisfied with their new joints, according to a Consumer Reports survey.

And since then, advances in pain control and rehabilitation have sped recovery.

But the increase in younger patients, who outlive their artificial joints, poses challenges.

Manufacturers have engineered new implants that last longer in the laboratory than traditional ones, but none has been tested long enough to know how they will perform beyond 10 or 20 years in real life.

Yet the implants, as well as several controversial surgical procedures, have been heavily advertised to consumers and rapidly accepted into practice.

Why good joints go bad

The most common cause of hip and knee damage is osteoarthritis, which means the erosion of cartilage between the joints that allows adjoining bones to rub together.

Joints damaged by rheumatoid arthritis, a less common but more serious disorder, can be replaced as necessary when medical treatment has failed.

The need for joint replacement can often be delayed by the use of pain relievers, losing excess weight, and by doing regular low-impact exercises such as tai chi.

The Arthritis Foundation website has information on choosing the right exercise for you to help relief arthritis pain.

But when the damage is advanced, joint replacement becomes a good option.

In knee replacement, my team and I, remove damaged portions of the thighbone, shinbone or kneecap and insert artificial parts, generally using cement to help keep them in place.

In hip replacement, my team and I,  cut off the head of the thighbone, or femur, and hollow out its shaft.

Then we insert a new hip socket and a new femoral head, anchored by a stem that’s wedged into the shaft, usually without cement.

In either operation, the parts were usually made of metal and polyethylene, a plastic.

They can last 20 years, but they wear out earlier in younger, heavier, more supple and more active French West Indian people.

The most common reason hip and knee implants fail is loosening.

As metal and plastic rub together, the friction wears away the surfaces, creating tiny plastic particles around the joint.

The body attempts to remove those particles but in the process removes bone as well, causing the implant to loosen.

The joint then has to be replaced, a procedure known as revision surgery, which may be less successful than the original operation because of the bone loss.

New parts for old bones

Manufacturers have addressed the loosening problem by developing new devices.

But each has drawbacks.

Many patients base their choice on advertising.

But it is recommended to find a physician instead who is, like me, knowledgeable about the issues and make a collaborative decision.

	Metal on highly cross-linked polyethylene	Metal on metal	Ceramic on ceramic
Use	Knees and hips.	Hips only.	Hips only.
Plus	This new plastic wears substantially less than conventional polyethylene.	It wears less than metal on plastic, and offers a larger femoral head, reducing the chance of dislodgment.	It’s likely to wear out the slowest.
Minus	It has a shorter track record and might be more prone to fracture.	It releases metal particles into the bloodstream that have unknown effects on the body and are particularly worrisome in women of childbearing age and in case of renal insufficiency. Moreover, a few patients have developed allergies to the metal debris.	It poses a rare but serious risk of chipping or breaking. Moreover, up to 7 percent of patients have complained of squeaky ceramic hips.
Advice	It offers durability with the fewest side effects, making it the best choice for most people. But because the knee puts greater demand on the joint, increasing the risk of fracture, physicians generally recommend metal on conventional polyethylene for knee replacements.	This kind of device might make sense for young men in need of hip replacement whose work involves heavy labour, which increases the risks of joint dislocation and wear.	This might be an option for patients who need to get many decades out of their hip, such as very young men, or women of childbearing age.

A smaller cut ?

Some surgeons now use a technique called minimally invasive surgery, which might limit damage to muscle and tissue.

The potential advantages are faster recovery and reduced pain – but at the cost of longer operative time and a high risk of surgical errors, including incorrect implant positioning, nerve injury, and bone fracture.

The benefits of the procedure are still being debated, but marketing claims have fuelled patient demand.

Many surgeons feel they need to offer it or they’ll lose patients to someone else.

But the scientific evidence that this technique makes a substantial difference is lacking.

In fact, improvements in pain control and rehabilitation appear to speed recovery in hip-replacement patients whether they have small or conventional incisions, according to a 2007 study published in the Journal of Bone and Joint Surgery.

Physicians note the same effect in knee patients.

Many surgeons now use “mini” cuts that are significantly smaller than traditional incisions but large enough for them to view the operating field.

Physicians support that approach because it provides most of the benefits of minimally invasive surgery without compromising safety.

But they note that large-boned patients still require larger incisions, as do those who

• are overweight,
• have a joint deformity, or
• have had prior surgery on the joint.

Hip resurfacing

Aimed at younger patients who want to delay total hip replacement, this procedure removes only the damaged joint surfaces.

The socket is replaced with a metal cup and the femoral head is shaved down and covered by a metal cap anchored by a short stem.

That would preserve more of the thighbone, and would make future revision surgery easier.

“Patients read marketing materials and want this procedure. But the appeal of preserving bone can lead to false expectations.”

Women who had resurfacing are twice as likely to need early revision than those receiving regular hip implants, chiefly due to femoral neck fractures.

Women might be at higher risk for such fractures because their bones are smaller and weaken at menopause.

Additional concerns include the complexity of the operation and metal-on-metal debris.

Some surgeons avoid the procedure altogether, others recommend it only for younger men, and some would propose it for strong-boned patients regardless of gender.

Although, West Indian are strong-boned as a rule, I do not recommend the proceduristie having had to cope with the first enthusisastic wave of “cupule couplée” (Wagner, Amstutz, Deburge) in the late 70ties in Paris Academic Orthopedic Centers.

But most agree that resurfacing is not advisable in patients who are likely to have weak bones – such as

• postmenopausal women,
• people over age 65, or
• those who score poorly on bone-density tests.

Partial knee replacement

In this procedure, I replace only the eroded side of the knee.

Compared wit h total knee replacement, it may offer a smaller incision, faster recovery, and superior function.

Moreover, it might buy patients 10 to 15 years before they need total knee replacement.

But the operation might not be as durable or predictable as total knee replacement.

In the same British study, which looked at more than 80,000 knee patients, early revision rates were twice as high for those who had partial knee replacement, especially among younger patients.

Common reasons for failure include loosening and arthritis in other parts of the knee.

“Partial knees are great in the right person. But only one in 20 people who need knee replacement are candidates.”

Patients should have

• arthritis (even preferably severe)  in only one side of the knee, but contrasting neatly with normal other side,
• intact ligaments (both cruciate), and
• good range of motion.

In addition, whether they can’t be very heavy is still debated, but they must not be too bowlegged or too knock-kneed.

Early (?) Diagnosis of Low-symptomatic Ceramic Acetabular Liner Fracture in Ceramic-on-Ceramic Total Hip Arthroplasty

"Catastrophic" failure of one-piece ceramic liner without major trauma in a very active and heavy patient also having controlateral hip disease and right total knee arthroplasty (asymetric squatting) AND right shoulder arthroplasty for advanced omarthosis with normal rotator cuff (sugar cane handpicking ?)

Alumina ceramics in total hip arthroplasty (THA) have been used in Europe since 1970.

Over the years, ceramic-on-ceramic coupling became a valid option in THA because of excellent biocompatibility and tribological properties.

The major disadvantages are possible squeaking and mainly risk of breakage, usually disclosed by pain and functional impairment.

Squeaking is an audible noise arising from ceramic-on-ceramic bearings, the incidence of which is reported to range from 1% to 7% of THAs.

Component positioning, stripe wear, and edge loading have all been implicated.

Clicking sounds and scratching have also been anecdotally described.

Breakage of a ceramic component due to brittleness of the material still seems a rare complication.

Trauma, high activity level, and obesity may increase the risk of fracture.

Defective ceramic manufacture, inadequate (sandwich with polyethylene) implant design, and errors in surgical technique may contribute to breakage.

Rather than Caucasian, Asian (by extension West Indian) population lifestyle, including squatting, kneeling, and possibly sitting cross-legged, has been correlated to liner rim impingement and fracture.

Additional reports concerning failure of various, mainly sandwich, but not exclusively, ceramic liners have recently been described.

I will describe here a unique case of apparently early diagnosis of a low-symptomatic fracture of an Anca-Fit acetabular liner occurring 3 years after implantation of an uncemented ceramic-on-ceramic modular THA.

Diagnostic imaging in acute para- and tetraplegia in Guadeloupe (1983-2009)

Introduction

Since I had to leave Saint- Claude Camp Jacob General Hospital in Basse-Terre as it closed 40 out of its 60 surgical beds in 1989, there was a sudden developement and change in diagnosic imaging.

Some of these technologies use new physical priciples like MRI, others were developed using computerized processing of information gained by well known methods such as reconstruction of CT scans.

Older and well established methods like conventional x-ray imaging, tomography and myelography (Dr JCW) are still available.

This situation gave me reason to reevaluate the position of these techniques in our clinical management, especially in the acute setting.

Diagnostic approach

The diagnostic approach to acute para and tetraplegia lined out in the following diagramms is based on my experience as Chef de Clinique Assistant with patients from year 1964 to year 1980 in Paris best spine centers.

To define a pragmatic and clinically relevant way of using diagnostic procedures it is a must to have a clear scheme of differential diagnostic possibilites.

Spine Imaging Decision Tree

This is why I propose this decision-tree…

A patient presenting with an acute paraplegia may or may not have been exposed to a trauma.

I will first focus on the majority of patients in Camp Jacob Hospital which had suffered a trauma.

The important question is whether the trauma was

1. adequate – such as a car or motorcyle accident – or
2. inadequate – like lifting a case of bottles or kicking a spade.

If there was a “adequate trauma” (the two Galion Bus Accident of january 10^th 1984 and 1985…), I look for destructed vertebrae – that is

1. fractures – and/or
2. destructed soft tissue which are disc herniations and ruptures of ligaments.

Additional possibilites are intraspinal bleeding or a spinal contusion.

If there was a trauma, I consider as inadequate compared to the damage to the spine, I look for destruction of vertebra because of osteoporosis, tumors or spondylitis.

Other possibilities which involve no destruction of vertebra are arachnoitis, discitis, stenosis of the spinal canal or adhesions of the spinal cord.

If the patient reports no trauma at all, there might be

• a intraspinal tumor (ex. one psammomatous meningioma in 2 month bedridden 82 old lady also kwown to have uterus cancer),
• a vascular process,
• a hemorrhage or edema.

An acute inflammation or any kind (HTLV) of neurologic disease producing the symptoms of para- or tetraplegia also have to be considered.

Finally, there is always the possibility of a trauma which the patient does not report.

A diagramm will soon demonstrate the frequency of the conditions that led to paraplegia in patients I admitted for primary care during all these years.

The vast majority of paraplegia was caused by fractures.

Other important groups were tumor and disc problems.

Imaging strategy – adequate trauma

One Imaging Strategy

I outline here one diagnostic strategy in patients with an adequate trauma.

The first thing – which is always nescessary – is to get plain film x-rays of the segment of the spine which corresponds with the neurologic staging.

I know of a “second hand trauma case” who left the university hospital with high dorsal paraplegia from a T2 displaced fracture and had had “only”  diagnosed a T12 undisplaced fracture with “no compression CT” at T12 level and finally no proper managing : spine palpation and full history in hurry was probably omitted.

When I was on duty at Camp Jacob, the patient should and DID not leave the x-ray department without (if possible) palpation guided readable films in two planes and dynamic lateral cervical flexion views supervised by me.

In almost all cases at least the presence of fractures (if not by palpation !) could be diagnosed on these films.

The next step depends indeed on the overall approach to the management of these fractures.

One or two each year in a 120 000 population

Since I do intend to stabilize all instable spinal fractures as soon as possible (with an anterior and posterior approach if appropriate) – a film showing an instable spine as demonstrated here would at that time, give me enough information to proceed with surgery.

From 1983 to June 1989, I managed one case each year of these traumatic paraplegia (Galion falls, coco tree falls, windows fall).

If the fracure does not appear to be unstable or for example only a posterior stabilisation is discussed, a CT-scan should be obtained, to give the nescessary information about intraspinal fragments, fractured pedicles as well as traumatic herniations of intervertebral discs.

The above picture demonstrates one of these  common cases where the plain film does not show too much of a stenosis of the spinal canal through fractures.

Only the CT – Scan  would reveal the extend of an intraspinal fragment, I finally found during surgical approach.

In our Camp Jacob cases, these fractures were still reduced using a Roy-Camille  Screw and Blade Internal System, whereas a Cotrel Dubousset System (used later for tumors) would have been much easier to manage….

Clinical results, very good although not controlled intraoperatively by myelography nor later with a CT-scan

The very good clinical results were neither controlled intraoperatively by myelography but using a flouroscope nor later documented with a CT-scan, as I would probably do now.

In one case (first Galion accident of Jan, 10^th,1984) of a T7 burst fracture with complete and resolutive paraplegia, preop CT scan (no CT at that time) would have shown a sharp pedicle bit pinned in the middle of the spinal cord.

According to this experience of mine, 3D reconstructions would not have yield any additional information.

It should be mentioned at this place that according to experience, most surgeons in the late 90ties did stick to the plain films while they were performing the surgery – even if CT-scan or MRI scans were beginning to be available.

In cases where no definite fracture could be seen on the conventional x-ray films, many authors would still follow in the late 90ties a conservative stepladder of diagnostic imaging including

• CT-scans,
• Myelography and
• repeated CT-scan after Myelography.

However, MRI would still be employed as a last resort.

The growing experience, gathered from my own last 15 years MRI-Studies changed that.

I learned reading clear but painful "myélographie gazeuse" with the La Pitié Paris Hospital Fischgold-Metzger-Aboulker team in... 1967

I start now with MRI imaging and feel confident to use it to diagnose soft tissue problems – for example disc herniations, as demonstrated above as well as fractures.

According to my “recent” experience, MRI is by no means “boneblind”.

Of course other conditions, such as intraspinal hemorrhage or edema following spinal contusion are also demonstrated precisely.

Only when Magnetic Resonance Imaging would be not possible or  not available we would still use a combination of Myelography and CT scanning, as we had to do in the 80ties at Camp Jacob Hospital.

Imaging strategy – no adequate trauma

If there was no or no adequate Trauma, I still do plain film x-ray studies as described above, to diagnose destructed vertebra and tumor or spondylitis induced fractures.

If these films or the patient history indicate a possibility of muliple lesions – such as a kown prostata carcinoma – I obtain a MRI because it provides a fast overview to the extend of the disease.

It also shows details of the impact to the spinal cord.

If it is reasonable to expect only a single lesion I would do a CT-scan.

CT scans might be very reliable to define the extend of intravertebral lesions and show the remnants of a vertebra with metastasis.

If no fractures are visible and intraspinal changes such as tumors or hemorrhage are to be diagnosed, I proceed with an MRI-Scan.

As example : bleeding ependymoma which caused a paraplegia with an acute onset.

Summary

I would summarize frequent problems we encoutered.

First points

I underscore that imaging diagnostic has to be based on exact clinical neurological staging.

Usually minor neurological deficts are missed, which are present in neurologic segments above the level of the dominating symptoms.

This problem is especially important if the patient is unconscious, intoxicated or suffered a headinjury.

Second fractures are missed usually because a lesion is found, which seems to “explain” the symptoms (CHU one case).

It is important to keep this in mind and to look for associated fractures if the circumstances of the injury indicate the possibility.

An especially difficult area for conventional x-ray imaging is the cervico-thoracic transition.

With an x-ray image not demonstrating all seven cervical vertebrae, I was once called for a complete C7 dislocation in a young paraplegic motobike suspected of pithiatism by the general surgeon on duty…

We can only support that these important X rays (as well as immediate dynamic lateral flexion views should be done in spine surgeon’s presence, when there is a good chance of a fracture or luxation of the lower cervical spine or in any case of cervical spine trauma as I instituted this in Camp Jacob with very reactive radio technicians in the 80ties..

If it is impossible to obtain readeable images by applying traction to the shoulders, a conventional midline tomography might be done, but in my extensive experience plain X rays would be enough..

Concerning CT-scans there still might be three frequent problems.

The first is a missing topogramm.

If the topogramm is missing, there is always an incertainty where exactly the scans were done and where the lesion extends.

Another mistake is a CT-scan which is only documented in a bone window.

Patients with traumatic disc herniation may be missed out of this reason.

The last point regarding CT scans which lead to missing of lesions is an inappropriate gapping between slides.

I recommend a maximum slice thickness of  2 to 3 mm with no gap if a study of the cervical spine is done.

To achieve this, a restriction of the examination area to two or a maximum of three cervical segments might still be often necessary.

As a last point we would like to warn against elaborate additional studies and reconstruction processes.

Once you have the nescessary information you should terminate diagnostic imaging.

As said earlier, I do not see yet in 2009 any benefit in added information if a time consuming 3D reconstruction is done.

Frequent problems with imaging methods

Common problems

The imaging is focused on a wrong soinal segment due to incorrect neurological staging

Additional fractures are missed

Conventional X-ray imaging

Fractures of the cervico-thoracic transition are missed because the 7th cervical vertebra is not properly demonstrated

CT-scans

Missing topogramm

Gap between the scans too wide (especially in the C-spine)

No soft-tissue window generated

CT- and MRI-scans

Elaborate reconstruction yielding no additional information

2009 FWI trends in anterior cruciate ligament reconstruction

In 2006, in a survey regarding anterior cruciate ligament (ACL) reconstruction mailed to physician members of the American Orthopaedic Society for Sports Medicine, a total of nearly 1000 responses were received from 1747 possible respondents (57%).

The number of ACL reconstructions per year ranged from 1 to 275 (mean=55).

Our own experience is slowly growing with mean 30 caseload per year for the last decade.

The most important factors in the timing of surgery were (?) knee range of motion and effusion.

Bone-patellar tendon-bone (BPTB) autograft was most commonly preferred (46%), followed by hamstring tendon autograft (32%) and allografts (22%).

Five years earlier, BPTB grafts are more frequent and hamstring tendon and allografts, less frequent (63%, 25%, and 12%, respectively).

A single-incision arthroscopic technique is used by 90%.

Most allowed return to full activity at 5 to 6 months, with a trend toward earlier return for BPTB grafts; quadriceps strength was an important factor in the decision (?).

There is limited experience (4%) with double-bundle and computer-assisted ACL reconstruction.

Arthroscopic-assisted (?), single-incision reconstruction using a BPTB autograft fixed with metal (?) interference screws remains the most common technique used for primary ACL reconstruction.

In the past 5 years, the use of alternative graft sources and methods of fixation has increased.

Consensus regarding the best

• graft type,
• fixation method, and
• postoperative protocol

is still lacking.

Radial Nerve Palsy Associated with Humeral Shaft Fractures

Radial nerve palsy associated with radial shaft fracture is a common occurrence.

Approximately one in ten patients with a humeral shaft fractures will also have associated radial nerve palsy.

In an epidemiologic study of 1.4 million people, the overall incidence of radial nerve palsy in 401 humeral shaft fractures was 8.5%.1

In my own non operative orthopedic study, from 1983 to 1989 of 120 000 people, the overall incidence of radial nerve palsy in 40 humeral shaft fractures is also 8.5% (Basse-Terre, Saint-Claude, Camp Jacob General Hospital, unpublished data).

In a systematic literature review, Shao and investigators2 identified 532 radial nerve palsies in 4,517 radial shaft fractures; an 11.8% incidence of radial nerve palsy.

The management of radial nerve palsy associated with a humeral shaft fracture is a topic of debate.

Although it is known that the majority of these injuries are neuropraxias that will recover spontaneously, the indication and need for operative exploration has been disputed, with authors offering conflicting opinions.

While some surgeons have advocated different treatment algorithms for radial nerve palsies that occur secondary to a closed fracture reduction, others believe that the timing of the nerve palsy is irrelevant to the management decision.

Primary nerve palsies occur at the time of injury and are discovered during the patients initial evaluation.

Approximately 10% to 20% of nerve palsies develop during the course of treatment, commonly noted more often (Basse-Terre)  following an open than a closed reduction, and are termed secondary nerve palsies.3

Complete motor loss is present in 50% to 68% (large majority in Basse Terre) of cases of radial nerve palsy, while the others are only partial motor loss or sensory loss.3

Systematic Literature Review

While some of the studies reported solely on patients with radial nerve palsies, 21 of the studies included the denominator of total radial palsy and shaft fractures.

In these studies, there were 532 radial nerve palsies in 4517 radial shaft fractures; an 11.8% incidence of radial nerve palsy.

Based on the studies that described the fracture location, the highest incidence of radial nerve palsy occurred for fractures in the distal third.

The incidence of palsies was significantly lower for fractures located in the proximal third, then in the middle or distal third.

Table 1. Incidence of radial nerve palsy based on fracture location.

Fracture location	Incidence	# Palsies/# Total fractures
Proximal third	1.8%	1/57
Middle third	15.2%	27/178
Distal third	23.6%	37/157

Transverse and spiral fracture patterns were significantly (P < .001) more likely to be associated with a radial nerve palsy than oblique or comminuted fractures .

Table 2. Incidence of radial nerve palsy based on fracture pattern.

Fracture pattern	Incidence	# Palsies/# Total fractures
Transverse	21.2%	47/222
Spiral	19.8%	19/96
Oblique	8.4%	15/179
Comminuted	6.8%	26/382

They reported no statistical difference in the incidence of radial nerve palsy in open vs closed fractures.²

Table 3. Incidence of radial nerve palsy based in open versus closed fractures.

Fracture Type	Incidence	# Palsies/# Total fractures
Open	18.2%	51/280
Closed	14.8%	137/929

In this literature review, which included a total of 1045 radial nerve palsies, the overall recovery rate was 88.1% (921/1045).

No significant difference in the recovery rate between primary (occurring at the time of injury) and secondary (occurring after the injury, or as a result of a closed reduction) nerve palsies was reported.

The mean time to the onset of recovery, reported in only five studies that included 101 patients, was 7.3 weeks (range: 2 weeks to 6.6 months).

The mean time to full recovery, reported in only five studies that included 110 patients, was 6.1 months (range: 3.4 months to 12 months).

Table 4. Recovery rate of radial nerve palsies.

Type of palsy	Recovery rate	# Recovery/# Total palsies
Overall rate	88.1%	921/1045
Primary	88.6%	632/713
Secondary	93.1%	121/130

Timing of EMG, nerve exploration, and/or tendon transfers

Controversy exists over the recommended timing for surgical exploration of radial nerve palsies.

Debate also exists over whether nerve repair or tendon transfers are the best treatment option for a transacted or permanently injured radial nerve.

Most surgeons suggest obtaining an initial electromyogram at 6 weeks following the injury if there has been no return of radial nerve function.

Thomsen and Dahlin8 recommend an electrodiagnostic examination at 5 to 6 weeks after injury and nerve repair and reconstruction within 2 months, not later than 3 months, after injury.

Ekholm and colleagues1 recommends exploration at 4 to 6 months if there is no resolution following a primary radial nerve palsy.

However for patients with indications for earlier operative fixation (eg, multiple trauma, open fractures, segmental or bilateral fractures, floating elbow, and nonunions), they advocated exploration of the nerve at the time of internal fixation.

Others note that the first sign of nerve recovery may be delayed as long as 6 months following injury.5

Ring and investigators5 suggest basing the timing of operative treatment on the patients willingness to continue wearing a radial nerve brace.

For patients wanting to be brace-free and satisfied with a hand that opens but does not have independent extension, they suggest tendon transfers at 6 months.

For patients who are comfortable wearing a brace, they recommend waiting until 12 months to see if they are one of the patients whose recovery is delayed in nature.

Nerve exploration may be considered in select patients (eg, patients with multiple nerve injuries in whom tendon transfer is not an option) at 6 months.

Verga and colleagues9 reported that in the absence of functional recovery, delayed surgical treatment (neurolysis or nerve grafts) performed 3 to 4 months after primary orthopedic treatment can be useful in achieving good functional recovery and subjectively satisfying results.

My experience is one of conservative treatment with early bracing both of the fracture (Sarmiento functional brace) and of the palsy.

References

1. Ekholm R, Adami J, Tidemark J, et al. Fractures of the shaft of the humerus: An epidemiologic study of 401 fractures. J Bone Joint Surg Br. 2006; 88:1469-1473.

2. Shao YC, Harwood P, Grotz MRW, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: A systematic review. J Bone Joint Surg Br. 2005; 87:1647-1652.

3. DeFranco MJ, Lawton JN. Radial nerve injuries associated with humeral fractures. J Hand Surg Am. 2006; 31:655-663.

4. Foster RJ, Swiontkowski MF, Bach AW, Sack JT. Radial nerve palsy caused by open humeral shaft fractures. J Hand Surg Am. 1993; 81:121-124.

5. Ring D, Chin K, Jupiter JB. Radial nerve palsy associated with high-energy humeral shaft fractures. J Hand Surg Am. 2004; 29:144-147.

6. Shah JJ, Bhatti NA. Radial nerve paralysis associated with fractures of the humerus. A review of 62 cases. Clin Orthop Relat Res. 1983; 172:171-176.

7. Holstein A, Lewis GM. Fractures of the humerus with radial nerve paralysis. J Bone Joint Surg Am. 1963; 45:1382-1388.

8. Thomsen NO, Dahlin LB. Injury to the radial nerve caused by fracture of the humeral shaft: Timing and neurobiological aspects related to treatment and diagnosis. Scand J Plast Reconstr Surg Hand Surg. 2007; 41:153-157.

9. Verga M, Peri Di Caprio A, Bocchiotti MA, Battistella F, Bruschi S, Petrolati M. Delayed treatment of persistent radial nerve paralysis associated with fractures of the middle third of humerus: Review and evaluation of the long-term results of 52 cases. J Hand Surg Eur. 2007; 32:529-533.

Combined ACL reconstruction and hemiarthroplasty effective but still experimental

Combined ACL reconstruction and knee medial Oxford hemiarthroplasty can be performed safely with acceptable satisfaction rates.

However, orthopedic surgeons should thoroughly discuss the procedure with patients beforehand and consider it experimental until further research is conducted,

Mutilating acrodystrophic neuropathy in the French West-Indies

Here I communicate the experience of a surgeon with mixed vascular and orthopedic education who managed 15 threatened forefeet permanently in his department of Saint Claude (Guadeloupe) from 1983 to 1989.

Among principal causes of “pied phagédénique tropical” with too big distal pedal pulses, diabetes, leprosy, hereditary sensory neuropathies — alcoholism impact is essentially controversial in acrodystrophic neuropathy since first descriptions (Bureau et al, 1957) incriminating heavy drinking.

One medical retrospective and above all, exclusively medical, review of 3 dozens of cases occurring in West-Indian possibly presumed rhum abusers, would tend to confirm this “etiologic” role.

Patients would present with three non specific signs or symptoms of the lower extremities:

1. anaesthetic foot,
2. plantar ulcers (TOE TIP located), and
3. chronic, indolent, mutilating arthropathies.

Motor function would be spared, but care must be taken to test intrinsic muscles (dynamic claw threatening toe tips and pip, as they may be weak sooner than hypoesthesia or frank anesthesia..

Main features of this syndrome would be :

1. male gender,
2. massive (≥150 g pure alcohol daily) and prolonged (2 years) rhum intake,
3. hygiene deficiency,
4. poverty and social distress,
5. exposition to repeated foot microtrauma and
6. above all, a protracted, non fatal, but disabling course NOT leading to MAJOR amputation.

The pathophysiology is poorly documented, and many questions remain unanswered including a genetic predisposition or a particular neuro-toxicity of West Indian rhum.

However, the clinical and epidemiologic data presented here, among other main causes of “pied phagédénique tropical à gros pouls”, do not favour the concept of an “alcoholic foot” or true alcoholic acrodystrophic neuropathy, even when this foot often but not always met, in a “true” alcoholic is evidently different from classical sensory-motor “polynévrite” with bilateral drop foot.

In summary, FWI foot acrodystrophic neuropathy is an infrequent « hypervascular » pathology compared to other usual ominous threat to toes by diabetes, or even Hanse disease : in a man often socially isolated (chronic long-standing  forefoot dressings) likely alcoholic (after a long while…), very slow but progressive toe loss by septic arthritis “easily” masked (very good distal pulses) by blind antibiotic without exploration.

Consequences in this possibly alcoholic foot are however usually here  much less dramatic than in such blind medical behaviour towards diabetes.

Minimally Invasive Total Knee Arthroplasty for Osteoarthritis

Most of the literature on minimally invasive total knee arthroplasty has been published since 2004 and I collected most of it from San Francisco AAOS Feb 2009 Meeting and Paris Sofcot Nov 2009 Meeting…

The problem, academic case study : our usual FWI candidate is much older and heavier… and still unwired !

Typical US candidate : “A 65-year-old woman with osteoarthritis of her right knee is referred by her primary care physician for orthopedic consultation.

She is healthy except for some well-controlled hypertension. She is 5 ft 5 in. tall (165 cm) and weighs 160 lb (73 kg), so her body-mass index (the weight in kilograms divided by the square of the height in meters) is 26.6.

Her arthritis is not limited to one part of her knee but is diffuse and severe.

She has minimal joint deformity and good bone quality.

For several years, she was able to control the pain in her right knee with indomethacin, but recently this has been insufficient.

An intraarticular corticosteroid injection was performed several months ago, with limited effect.

The surgeon recommends total knee arthroplasty.

The patient has a friend who has told her that his surgeon used a “minimally invasive” approach for his total knee replacement, and it went well.

The patient has investigated this approach on the Internet, and she isn’t sure what to do.

She asks her primary care physician whether he recommends that she consider “minimally invasive” surgery.”

The Clinical Problem

Osteoarthritis affects more people than any other joint disease1 and is the most common cause of long-term disability in most populations over the age of 65 years.2,3

Primary osteoarthritis is rare before the age of 40 years but becomes increasingly common each decade thereafter.1

A report from the Third National Health and Nutrition Examination Survey estimated that 37.4% of adults in the United States who are 60 years of age or older have radiographic evidence of the condition.4

Although osteoarthritis is not a life-threatening disease, the morbidity associated with this condition is considerable; 80% of patients with osteoarthritis have limitation of movement, and 25% have difficulty performing major activities of daily living.5

The economic burden of osteoarthritis may exceed $60 billion per year in the United States.1

Pathophysiology and the Effect of Therapy

The pathophysiology of osteoarthritis is complex and incompletely understood, although the hallmark of the disease is the loss of articular cartilage, with concomitant changes in the underlying bone.6,7

Many factors appear to be associated with the development of this condition, including injury, genetics, changes in tissue structure, and chondrocyte aging.7,8,9

Major trauma, such as an intraarticular fracture, clearly increases the risk of subsequent (post-traumatic) arthritis.

Research is being done to try to characterize the degree to which minor traumatic events can precipitate cartilage breakdown and degenerative joint disease,10 particularly when the injury is compounded by obesity, joint malalignment, or other predisposing factors.11

The anatomic features of osteoarthritis include loss of articular cartilage, eburnation (or “sclerosis”) of the subchondral bone, formation of osteophytes (or “bone spurs”), and the presence of degenerative subchondral cysts (Figure 1).

In some patients, there is clinically significant inflammation, including effusions, warmth, and synovitis that is visible during surgery.

When osteoarthritis of the knee becomes severe, joint deformities — most commonly, varus (”bowlegs”) or valgus (”knock-knees”) — can occur.

Figure 1. Radiograph of the Left Knee of a Patient with Osteoarthritis.

Panel A shows an anteroposterior view with visible eburnation of the subchondral bone (”sclerosis”) (arrow) and loss of articular surface cartilage (or joint-space narrowing) (arrowhead).

Panel B shows a lateral view, in which patellar osteophytes are also readily seen.

Total knee arthroplasty is an operation that consists of removal of the damaged cartilage, correction of joint deformities, and replacement of the worn cartilaginous bearing surfaces (on the femur, tibia, and patella) with an artificial bearing (Figure 2).

Arthroplasty is not a disease-modifying procedure but rather is a mechanical solution to a biologic problem.

Figure 2. Radiograph of the Right Knee of a Patient after Total Knee Arthroplasty.

Shown are an anteroposterior view (Panel A) and a lateral view (Panel B) of the tibial components (arrows) and the femoral components (arrowheads).

For some patients with severe joint damage, arthroplasty may be the only option that offers the possibility of restored mobility and freedom from pain.

However, arthroplasty is a major operation, and recovery may be sometimes difficult.

Patients typically have substantial immediate postoperative pain, which must be tolerated if  they DO NOT undergo the aggressive physical therapy that is supposed by too many notably medical (not surgical) authors to be required for a good outcome.

They  do not very often use assistive devices for ambulation for more than 3 weeks (perhaps longer when contralateral knee is also worn out) and they do not require neither frequent physical therapy nor narcotic analgesics and in any case never for several months…12

Whatever the reasons, there is interest among surgeons and patients alike in methods that truely make total knee arthroplasty less “invasive”.13,14

A variety of different procedures and techniques, all intended to reduce the amount of tissue injury occurring during surgery, are still lumped together under the label “minimally invasive surgery” (Table 1).

This general term is used to identify all such procedures in this review.

The purported advantages of minimally invasive approaches would include less postoperative pain, a shorter hospital stay, an earlier return of control for quadriceps muscles (leading to a shorter period of dependence on external devices for ambulation), and a briefer convalescence.12,13,14,15,16,17,18,19

There is limited evidence suggesting that minimally invasive total knee arthroplasty results in longer-term benefits in function than does the traditional approach,15,20.

Most surgeons think that any benefits that may accrue would be confined to the recuperative period.

Clinical Evidence

The clinical studies evaluating the potential benefit of minimally invasive total knee arthroplasty have a number of limitations.

Of the studies that have been conducted, very few are randomized, most are quite small, and some evaluate different methods or aspects of the minimally invasive approach, making a comparison among studies difficult.

Most of these studies do not take into account the skill development or “learning curve” of the surgeons who are performing the procedures.

In addition, all the studies have been performed in the context of the evolution of surgical practice.

In large measure because of these issues, there remains real conflict in the orthopedic literature about the benefit of this surgical approach.

In one of the few randomized trials, Kolisek et al.21 compared a minimally invasive approach with the traditional approach in 80 patients.

The investigators found no significant differences in clinical or radiographic results at 3 months of follow-up.

However, the authors defined “minimally invasive” surgery entirely as a function of incision length, since no specialized instruments were used in the group undergoing minimally invasive procedures, and the surgeons everted the patella (i.e., rotated it 180° on its tendon) as part of the operation.

The use of incision length alone, as in the study by Kolisek et al., is clearly not considered an appropriate or sufficient determinant to classify the procedure as minimally invasive (Table 1).

One of the largest nonrandomized studies22 involved 200 consecutive total knee arthroplasty operations (100 using the traditional approach and 100 using the minimally invasive approach), which were performed by experienced joint surgeons.

The investigators, McAllister and Stepanian, defined minimally invasive surgery as “total knee arthroplasty performed without dissection into the quadriceps tendon, eversion of the patella, or dislocation of the tibiofemoral joint; these operations also involved the use of instrumentation designed specifically for minimally invasive surgery.”

Patients who underwent the minimally invasive procedure had less postoperative pain and an improved early range of motion.

They also had a significantly decreased risk of requiring manipulation under anesthesia (14% vs. 2%, P<0.001), an additional procedure resulting from the failure of rehabilitation or pain control or other inexplained reason that might expose the patient to the risk of hemarthrosis, fracture, and tendon rupture.

In one study,12 were compared 100 minimally invasive procedures with 50 performed with the traditional approach.

The minimally invasive approach (with a definition very similar to that used by McAllister and Stepanian) would reduce the length of hospital stay from 3.7 to 2.8 days (P<0.001).

It would also significantly reduced the percentage of patients receiving narcotics at 2 weeks and at 6 weeks and the need for assistive devices for walking at 2 weeks.

Clinical Use

Regardless of whether total knee arthroplasty is performed through a traditional or minimally invasive approach, it may be a major surgical intervention, with all the attendant risks of surgery.

In addition, not all patients who undergo total knee arthroplasty have relief of symptoms even after a full recovery: 8 to 23% of patients have residual pain or stiffness in the knee at long-term follow-up.23

In light of these facts, it is prudent to exhaust reasonable nonsurgical alternatives before considering arthroplasty.

Nonsurgical interventions for pain associated with osteoarthritis of the knee include nonsteroidal antiinflammatory drugs, certain non-narcotic analgesics (in particular, acetaminophen), and intraarticular injections (corticosteroids or viscosupplements).24

It is reasonable to consider surgery when a patient, who is medically fit and is willing to accept the risks associated with the operation, has persistent, moderate-to-severe pain associated with activity despite nonsurgical interventions.

The patient should have radiographic evidence of significant joint damage, and if there appears to be inconsistency between the radiographic image and symptoms, I would consider other explanations for the patient’s pain.

Contraindications to total knee arthroplasty include active infection, thrombophilias, bleeding disorders, severe vascular disease or neurologic disease affecting sensory or motor function in the affected leg, and inadequate soft tissue to cover the joint.

An essential factor to take into account in considering surgery is the patient’s ability and willingness to participate, and a deleterious aggressive regimen of postoperative physical therapy is no substitute for good (gentle) surgical technique and patient empowerment.

Vigorous physical rehabilitation, including exercises specifically intended to require early and repetitive motion of the affected knee despite substantial pain, is NEVER necessary for a good result.

Failures of rehabilitation do not often stem from problems in managing postoperative pain early on, but from aggressive physical therapy or no patient empowerment at all, can permanently prejudice the outcome.25,26,27

Frequent communication with the surgeon should be the mainstay of these elderly  patients empowerment.

Once the decision has been made to proceed with surgery, the discussion should not turn to whether a traditional or minimally invasive approach is more appropriate, or whether local or general anesthesia is preferred…

An essential factor to consider in this decision is the experience of the surgeon and the anesthesiologist and the qualification of this team.

In one study, is specifically evaluated the effect of experience and showed that a surgeon must typically perform 25 to 50 procedures using minimally invasive techniques before benefits of this approach can be expected.12

A fairly high practice volume is also important in maintaining the skills necessary for minimally invasive surgery, a principle that obviously applies to conventional surgery as well.28,29

Given the exclusion criteria of the major clinical studies, other relative contraindications to the minimally invasive approach may include previous open knee surgery,15,16,19,30,31 severe osteoporosis or rheumatoid arthritis,14,30,31 obesity or increased limb girth,12,14,15 and severe joint deformity.12,14

Anesthesia can be performed with the use of any of a variety of approaches.

Either general anesthesia or regional (spinal or epidural) anesthesia, with or without adjunctive peripheral-nerve block, is appropriate.

During the operation, the patient’s knee is typically positioned in some flexion, and tourniquet control is still unfortunately “used to reduce bleeding”.

The traditional approach uses an anterior longitudinal incision of 6 to 9 in. in length, whereas the minimally invasive approach often uses a somewhat shorter anteromedial incision along the medial border of the patella, extending distally to the level of the tibial tubercle.

The traditional approach may then involve a longitudinal incision through the quadriceps tendon; the minimally invasive approach opens the medial capsule and extends proximally and obliquely into either the midvastus plane or subvastus plane by a small amount (typically 1 to 3 cm) and avoids the quadriceps tendon (Figure 3).

In the traditional approach, the patella is then everted, whereas in the minimally invasive approach, the patella would be retracted laterally but not everted.

In the traditional approach, the tibiofemoral joint would be then dislocated and the knee hyperflexed.

In the minimally invasive approach, that joint would be left in situ without dislocation.

Figure 3. Elements of Minimally Invasive Total Knee Arthroplasty.

Panel A shows the anatomical relations of the deep-tissue surgical incision for total knee arthroplasty.

The traditional incision typically extends into the quadriceps tendon.

The minimally invasive incision spares the quadriceps tendon and extends into or beneath the vastus medialis muscle.

Joint-space exposure is shown for traditional total knee arthroplasty (Panel B) and for the minimally invasive procedure (Panel C).

In the traditional procedure, a larger incision is made, and retractors are placed in a fixed position for maximal exposure.

The tibiofemoral joint is dislocated, and the patella is everted (rotated laterally 180° on its tendon).

In the minimally invasive procedure, a relatively small incision is made, and retractors are shifted during surgery to create a “mobile window” for the minimum necessary exposure.

The tibiofemoral joint is not dislocated, and the patella is retracted laterally without being everted.

In both techniques, cutting jigs and anatomic landmarks are used to determine the depth and orientation of tibial and femoral bone resections.

In the minimally invasive procedure, the cutting guides are reduced in size, rounded, and designed to optimize accuracy through the smaller anteromedial window.

Regardless of approach, careful attention to ligament balancing and protecting neurovascular structures must be maintained.

Trial implants then are placed over the resected bone surfaces; joint stability, ligament balance, and range of motion then are assessed.

If satisfactory, final components are inserted (Figure 4).

Final hemostasis is then obtained, and the joint is irrigated and closed.

Figure 4. Components of Total Knee Arthroplasty.

Precise resections are made in the distal end of the femur, the proximal end of the tibia, and the posterior surface of the patella to fit the corresponding surfaces of the three arthroplasty components.

The femoral component is typically made of metal (most commonly, a cobalt–chromium alloy).

The patellar component is typically made of ultra-high-molecular-weight polyethylene (a plastic resin).

The tibial implant is usually made of metal (either a titanium or a cobalt–chromium alloy).

There is an exchangeable polyethylene bearing on the tibia, which therorically would make it possible to replace the plastic articular surface without replacing the metal component if (or at the time…) wear of the bearing surface occurs…

The period of convalescence varies.

As noted, in one study,12 the mean hospital stay for patients undergoing minimally invasive total knee arthroplasty is 2.8 days, about 1 day shorter than the mean duration for the traditional approach.

Physical therapy is NOT initiated the day of surgery, with no immediate emphasis on range of motion, gait training, safety, and transfers.

A machine that provides continuous passive motion may NOT be used to enhance the exercises performed with a physical therapist.32

Adequate analgesia during physical therapy would be essential and mandatory ; pain would be the most common threat to adequate progression of mobility.

In general, patients who have undergone minimally invasive total knee arthroplasty would require the use of a walker for about a week and the use of a cane for a week to 10 days, at which point unassisted ambulation might be the norm, should contralateral knee and back allow it…

Physical therapy usually would conclude by about 6 weeks with the minimally invasive approach; with the traditional approach, an additional month of therapy would usually be required.

Appropriate thromboprophylaxis is used after either traditional or minimally invasive surgery.

A variety of agents, including aspirin, warfarin, unfractionated heparin, and low-molecular-weight heparin, pentasaccharides are used for this purpose.

Intermittent pneumatic-compression devices that prevent venous stasis and that may enhance fibrinolysis commonly used in USA are no better than Tibialis Anterior and Vastus Medialis active exercises.

There is currently substantial disagreement between the recommendations of the American Academy of Orthopedic Surgeons and those of the American College of Chest Physicians regarding the appropriate intensity of anticoagulation.33,34

The same pertained between French surgeons and anesthésiologists before nerve blocks become fashionable (too much).

According to one study, the estimated mean cost of primary total knee arthroplasty was $29,290 on the basis of data collected from October 2005 through June 2006 at four high-volume centers.35

The study did not distinguish between the cost of minimally invasive procedures and that of traditional operations.

One expert observes that although the cost of minimally invasive total knee arthroplasty could be less than that of the conventional procedure (as a result of a shorter hospital stay), current reimbursement and global multidisciplinary policies may create incentives to keep the patient in the hospital longer.36

Adverse Effects

Many of the complications of total knee arthroplasty are similar whether a minimally invasive or traditional procedure is performed.

The most feared complication, infection of the joint, occurs in less than 1% of patients.37

By contrast, thromboembolic disease may be common even with appropriate thromboprophylaxis.

Venographic studies indicate that at least 15% of patients may have deep venous thrombosis, but symptomatic thromboembolic events occur in only 2 to 3% of patients.38

Nerve injuries, especially peroneal nerve palsy, occur in 1 to 2% of patients,39 whereas arterial vascular injury is much rarer.

As noted above, persistent pain or stiffness occurs in 8 to 23% of patients.23

Prosthesis failure, typically requiring surgical revision, occurs in approximately 2% of patients at 5 years.40

In some studies, specific problems associated with the minimally invasive approach include inferior mean alignment41 or an increased frequency of outliers in terms of alignment,41,42,43 concern about wound healing,21 a longer surgical duration,43 and an inability to validate claims regarding improvements in early recovery or the time to independent ambulation.21,42

However, most of these reports come from studies that enrolled patients early in the surgeon’s learning curve or that describe an approach as minimally invasive solely on the basis of the incision length.

For these reasons, the experience of the surgeon is an essential consideration in choosing minimally invasive total knee arthroplasty.

Areas of Uncertainty

As noted above, the designation “minimally invasive” total knee arthroplasty encompasses several different modifications in surgical technique.

It has not been established which of these changes are essential to improving outcomes for the patient.

Increasingly, all elements of the minimally invasive approach are being used together (Table 1).

It therefore seems unlikely that any trial will be conducted to distinguish, for example, the benefit of sparing the quadriceps tendon from that of avoiding or minimizing tibiofemoral-joint dislocation.

Since the minimally invasive approach has been in common use for less than 5 years, it has not yet been established that long-term outcomes will be as good (even in the hands of experienced surgeons) as those of patients undergoing traditional total knee arthroplasty.

Although the characteristics of the procedure itself do not suggest obvious grounds for concern in this regard, additional studies will be required to provide a definitive answer to this question.

A variety of further modifications of surgical technique have been described in the past few years.

These include computer-assisted navigation to aid in the precision of bone excision and prosthesis alignment, as well as recurrent interest in unicompartmental (partial) knee arthroplasty, meniscus replacement, and other similar elaborations, some of which are sometimes described as “minimally invasive” techniques.

The potential advantages of such approaches as compared with the operation outlined in this review of mine are not known.

Guidelines

There are no formal guidelines on the subject of minimally invasive total knee arthroplasty.

The American Academy of Orthopedic Surgeons offers only a brief comment on the guidelines page of its Web site and does not draw a distinction between minimally invasive total knee arthroplasty and minimally invasive total hip arthroplasty.

The hip procedure has provoked substantial controversy because of a high frequency of major complications.44,45

The group’s guidelines state that minimally invasive surgery for total joint replacement “is a promising, but evolving surgical technique that requires additional scientific evidence to validate its short- and long-term safety and effectiveness, in comparison to conventional joint replacement methods.”46

In 2004, the American Association of Hip and Knee Surgeons released an advisory statement about minimally invasive hip and knee arthroplasty that cites both potential advantages and disadvantages of the two approaches.47

Unfortunately, since most of the literature on minimally invasive total knee arthroplasty has been published since 2004, such statement is certainly out of date.

Recommendations

I do not know the “young and slim” patient who is described in the vignette (job ?, relatives ? mmpi ?), but she may be a suitable candidate for minimally  total knee arthroplasty, however some further consideration of her specific circumstances is appropriate.

I would begin by discussing the major therapeutic options with the patient; in particular, I would try to ascertain whether she feels strongly that her quality of life with medical therapy alone has become unacceptable.

As her answer is probably yes (X rays ?), I would NOT describe the advantages and disadvantages of both the traditional and the minimally invasive approaches for total knee arthroplasty.

I would ONLY emphasize that either approach (minimally invasive approach or not) should be performed only by a surgeon with considerable expertise and experience.

I would describe the operation itself briefly but would place more emphasis on what she should expect in the perioperative and immediate postoperative period.

The patient should be informed that she would have substantial postoperative pain and that she would certainly need to participate actively but NOT in an aggressive regimen of physical therapy.

This kind of “aggressive regimen” is far from being mandatory  to have a successful outcome: relief of symptoms and improvement in mobility and may even prove deleterious.

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