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Weekly News, Analysis, and Commentary

Orthopaedic Crossfire® Features & News

Gehrke Debates Haidukewych: Mega Prostheses

Image created by RRY Publications, LLC
Image created by RRY Publications, LLC

“Mega prostheses can work in elderly patients and osteopenic patients with poor bone stock who need a quick procedure,” says Thorsten Gehrke. George Haidukewych isn’t quite so sanguine. “I do a mega prosthesis as a last resort, with a very distal fracture, with severe osteolysis, etc.” and “ORIF remains the gold standard for periprosthetic fractures.”

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Su v. Lombardi: Yay or Nay to Metal-on-Metal Surface Replacement?

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Image created by RRY Publications, LLC

“Surface replacement trumps THR because it preserves bone, offers greater stability, and allows a higher activity level,” advocates Ed Su. “Keep in mind,” says Adolph Lombardi, “resurfacing is a more difficult operation with a high learning curve. Few patients meet the criteria…and there is concern over metal ion toxicity.”

Lee Debates Barrack: Ceramic-Ceramic THA

Image created by RRY Publications, LLC
Image created by RRY Publications, LLC

“Ceramic-ceramic hips have a place in young, active patients,” advocates Gwo-Chin Lee. “And they have the lowest wear rate.” Robert Barrack counters, “The new ceramics are better, but standard metal-crosslinked poly has improved more. And the 10-15 year results cannot be improved upon. Ceramic-ceramic isn’t ready for prime time.”

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Hofmann, Callaghan Debate the Posterior Stabilized Knee

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Image created by RRY Publications, LLC

“I haven’t saved a cruciate ligament in the last five years. It’s more difficult and less predictable. It’s more forgiving to take the PCL,” argues Aaron Hofmann. “A recent study found that ROM was better with the posterior stabilization,” counters John Callaghan. “And Chit Ranawat has had a 95% satisfaction rate with a PS knee…no revisions at 10 years.”

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Dunbar, Cameron Debate Modular Necks

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Image created by RRY Publications, LLC

“No modular necks for routine primary hip arthroplasty!” argues Michael Dunbar. “We have no proof of superiority and there is an increased risk of fracture and fretting, ion debris, etc.” Hugh Cameron counters, “Look, I’ve done more than 350 cases with no incidents of delayed metal hypersensitivity and no pseudotumors.”

Dunbar, Berend Debate the All Poly Tibia

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Image created by RRY Publications, LLC

“It’s undeniable that the all poly tibia is cheaper,” argues Mike Dunbar. “And there is no backside wear, more poly for the same tibial resection, better RSA data, and better survivorship.” “I agree that all poly components are equal to well-designed monoblock designs,” counters Mike Berend. “But caution…it’s design and technique sensitive.”

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McFarland, Gobezie Debate Treatment for Infected TSA

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Image created by RRY Publications, LLC

“This patient MAY be infected,” says Ed McFarland. “For patients who are even a bit ill, I would do a one-stage revision; those who are young and healthy get a two-stage revision. I don’t think debridement adds much.” Reuben Gobezie counters, “If you’re going to do anything to this patient, I think it would be reasonable to get an arthroscopic debridement at the most before you rip their arm out, Ed.”

Backstein v. Haidukewych Over the Mega Prosthesis

Image created by RRY Publications, LLC
Image created by RRY Publications, LLC

David Backstein has his favorite mega prosthesis system and he’s not giving it up any time soon. “You have shorter length of stay, and there is no chance of malunion or non-union.” George Haidukewych pulls the reins in, saying, “Mega prostheses have a limited role, namely, in situations where fixation is likely to fail. ORIF remains the gold standard for periprosthetic fractures.”

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Abdel v. Mullaji Over the Cementless Knee

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Image created by RRY Publications, LLC

Matt Abdel is all over cementless TKA. “It involves shorter operative times, preserves bone stock, means easier revision surgery, eliminates third body wear, etc.” Slow down, says Arun Mullaji. “With cementless TKA you’re paying more for a procedure for which the jury is still out. We don’t have good long term data and we don’t know what the optimum design is.”

Parvizi, Sculco Debate Simultaneous Bilateral TKA

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Image created by RRY Publications, LLC

A bilateral TKA procedure triggers higher rates of post-operative complications, says Javad Parvizi, M.D., F.R.C.S. and specifically cites rates of cardiac complications and pulmonary embolus. Actually, these procedures are safe, says Thomas Sculco, M.D. particularly as “We move towards improved patient selection, better anesthetic techniques, better perioperative care, and faster surgery.” Who wins this debate? Read on.

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Jones, MacDonald Debate Tourniquetless TKA

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Image created by RRY Publications, LLC

“OK, so you have a bloodless field using a tourniquet in TKA,” says Dickey Jones. “But there are many downsides, such as nerve damage and a delay in the recovery of muscle function.” Hold on says Steven MacDonald, There is no clinical evidence of nerve damage or delays in muscle function recovery when employing a tourniquet.”

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Rodriguez, Penenberg Debate Mini Anterior Approach

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Image created by RRY Publications, LLC

It’s Penenberg vs. Rodriquez. “The direct anterior approach is quicker and people recover sooner…”, says Dr. Brad Penenberg. Hold on a minute, says Dr. Jose Rodriquez. Success using the direct anterior approach depends on “…by whom, which outcomes, and compared to what.” It’s a lively and extremely informative debate.

Hofmann, Ranawat Debate Post in Posterior Knee

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Image created by RRY Publications, LLC

“I think that the ultracongruent insert provides excellent posterior stability, it’s bone sparing and technically easy, there are fewer complications, and it’s certainly time saving,” says Aaron Hofmann. “Wait,” says Chit Ranawat. “RP-PS has better survivorship and improved ROM compared to fixed bearing posterior stabilized.”

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All-Poly Tibia: Cheaper, Better?

David G. Lewallen, M.D., Thomas S. Thornhill, M.D.
David G. Lewallen, M.D., Thomas S. Thornhill, M.D.

“Saying that modular metal backed tibial trays are somehow the ‘gold standard’ for modern TKA just isn’t true,” says David Lewallen. “Wait,” says Tom Thornhill. “Most all-poly tibia results are in low demand patients. And, backside wear is now substantially better than it was during the period of time that David showed us.”

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Patient Specific Instruments: Overpromised, Under Delivered

Paul Lachiewicz, M.D. and Michael E. Berend, M.D.
Paul Lachiewicz, M.D. and Michael E. Berend, M.D.

“Is patient specific instrumentation (PSI) less expensive? Is it easier for you? The answer is definitely ‘no,’” argues Paul Lachiewicz. “PSI provides a way to position the implants specific to that patient’s anatomy (preop valgus, patient height, hip pathology, etc.),” says Mike Berend. And you can do it before you enter the OR…with templating this means it is time neutral.”

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Implant Registries Flawed? Murray v. Lewallen

David Murray, M.D., F.R.C.S. and David G. Lewallen, M.D.
David Murray, M.D., F.R.C.S. and David G. Lewallen, M.D.

“The data proves that registries cannot compare implant designs!” says David Murray. “Going to single surgeon or institutional efforts allow large numbers of patients to be studied very quickly,” says David Lewallen. “What registry studies really do is allow us to ask interesting questions and perhaps direct the next studies.”

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All Poly Tibia: Dunbar Debates Thornhill

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Image created by RRY Publications, LLC

“We shouldn’t be afraid of the all polyethylene construct. There’s been good evidence since 1984 that it’s a safe construct,” says Michael Dunbar. Tom Thornhill counters, “Cost is increasingly going to be an issue…and this is going to be a zero sum game. In my practice I use a modular tibial component that is cemented.”

Short Stems in Primary Hip: Lombardi v. Whiteside

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Image created by RRY Publications, LLC

“My message is that the short tapered titanium porous plasma sprayed femoral component is efficacious, with less than 1% stem revisions if we look at revisions related to the stem,” says Adolph Lombardi. Leo Whiteside counters, “Despite the literature we must be careful here. I know a lot of good guys who have tried and failed with fractures, migration, and loosening. Let’s avoid the learning curve.”

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