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`Clinical Orthopaedics
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`MARSHALL R. URIST
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`Number Two Hundred Sixty-Nine
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`Mexico City, Mexico
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`c:
`a]
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`i
`t
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`
`-.
`
`Page iii
`
`

`
`CLINICAL ORTHOPAEDICS
`AND RELATED RESEARCH
`
`Number Two Hundred Sixty-Nine
`
`Sponsored by
`
`THE ASSOCIATION OF BONE AND JOINT SURGEONS
`
`A Publication of The Hip Society (USA)
`
`A Publication of The Knee Society (USA)
`
`Board of Trustees
`
`Herbert J. Louis, M.D., Chairman
`Justus C. Pickett, M.D., Chairman Emeritus
`Joseph A. Kopta, M.D.
`Clifford W. Colwell, Jr., M.D.
`John F. Connolly, M.D.
`Dempsey Springfield, M.D.
`Franklin Hoaglund, M.D.
`Marshall R. Urist, M.D.
`Herbert Kaufer, M.D.
`Guy T. Vise, Jr., M.D.
`
`Page IV
`
`

`
`,·
`
`Contents
`SECTION I: SYMPOSIUM
`
`TOTAL ARTHROPLASTY AND THE
`VETERANS ADMINISTRATION
`
`WILLIAMG. WINTER, M.D.
`DONALD G. ECKHOFF, M.D.
`Guest Editors
`
`Editorial Comment
`William G. Winter, M.D., and Donald G. Eckhoff: M.D.
`The Classic
`Recurrent Dislocation of the Shoulder
`Paul B. Magnuson, M.D., and James K. Stack, M.D.
`
`Total Hip Arthroplasty
`
`Infections at the Site of a Hip Implant: Successful and Unsuccessful
`Management
`David N. Collins, M.D., and James M. McKenzie, M.D.
`Noncemented Porous-Coated Anatomic Total Hip Arthroplasty
`Ben M. Dodge, M.D., Richard Fitzrandolph, M.D.,
`and David N. Collins, M.D.
`Patient Activity, Sports Participation, and Impact Loading on the
`Durability of Cemented Total Hip Replacements
`Douglas J. Kilgus, M.D., Frederick J. Dorey, Ph.D.,
`Gerald A. M. Finerman, M.D., and Harlan C. Amstutz, M.D.
`Total Hip Arthroplasty Followng Failed Internal Fixation of Hip
`Fractures
`Thomas Mehlhaff, M.D., Glenn C. Landon, M.D., and Hugh S. Tullos, M.D .
`Triphasic Bone Scanning Following Porous-Coated Hip Arthroplasty
`Robert M. Lifeso, M.D., F.R.C.S.C., F.A.C.S., M. Abdel-Nabi, M.D.,
`and Craig Meinking, R.P.A.
`Uncemented Total Hip Arthroplasty: Prospective Analysis of the Tri-
`Lock Femoral Component
`Samuel E. Smith, M.D., Kevin L. Garvin, M.D., 0. Max Jardon, M.D.,
`and Phoebe A. Kaplan, M.D.
`
`2
`
`4
`
`9
`
`16
`
`25
`
`32
`
`38
`
`43
`
`Total Knee Arthroplasty
`
`Total Knee Arthroplasty at a Veterans Administration Medical Center
`Ronald R. Bowman, M.D., William D. Guyer, M.D., and Gary D. Bos, M.D.
`
`51
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`
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`by J.B.
`
`3030; in
`, Bangla-
`
`$275.00
`1: 8 1,800
`ys of the
`
`Hospital
`
`

`
`vi
`
`Clinical Orthopaedics
`and Related Research
`
`Num
`Auge
`
`Results of Total Knee Arthroplasty Using the Posterior Stabilized
`Condylar Prosthesis: A Report of 137 Consecutive Cases
`Gordon I. Groh, M.D., Jeffrey Parker, M.D., Jim Elliot, B.S.,
`and Arthur J. Pearl, M .D.
`
`Effect of the Tibial Cut on Subsidence Following Total Knee
`Arthroplasty
`·
`Aaron A. Hofmann, M .D., Kent N. Bachus,.Ph.D.,
`and Ronald W . B. Wyatt, M.D.
`Subvastus (Southern) Approach for Primary Total Knee Arthroplasty
`Aaron A. Hofmann, M.D., Rodney L. Plaster, M.D.,
`and Louis E. Murdock, M.D.
`Total Knee A1ihroplasty: Two- to Four-Year Experience Using an
`Asymmetric Tibial Tray and a Deep Trochlear-Grooved Femoral
`Component
`Aaron A. Hofmann, M.D., Louis E. Murdock, M.D.,
`Ronald W. B. Wyatt, M.D., and Jeffrey P. Alpert, M.D.
`
`58
`
`63 ·
`
`70
`
`78
`
`Associated Phenomena
`Intermittent Pneumatic Compression Versus Coumadin: Prevention
`of Deep Vein Thrombosis in Lower-Extremity Total Joint
`Arthroplasty
`Frederick A. Kaernptfe, M.D., Robert M. Lifeso, M.D.,
`and Craig Meinking, R.P.A.
`Blood Loss in Total Knee Arthroplasty
`Fred D. Cushner, M.D., and Richard J. Friedman, M.D., F.R.C.S.C.
`PostoperativeUrinary Retention Associated with Total Hip and Total
`Kne~ Arthroplasties
`MichaeLS. Petersen, M.D., David N. Collins, M.D.,
`Walter G. Selakovich, M.D., and Alex E. Finkbeiner, M.D.
`
`Prevention of Thromboembolic Disease Following Total Knee
`Arthroplasty: Epidural Versus General Anesthesia
`David Mitchell, M.D., Richard J. Friedman, M.D., F.R.C.S.C.,
`J. David Baker III, M.D., James E. Cooke, M.D.,
`Michael D. Darcy, M.D., and M. Clinton Miller III, M.D.
`
`Research and Total Joint Arthroplasty
`The Use of Periosteally Vascularized Autografts to Augment the
`Fixation of Large Segmental Allografts
`Keith S. Albertson, M.D., Robert J. Medoff, M.D.,
`and Morris M. Mitsunaga, M.D.
`Investigation of Eady Surface Delamination Observed in Retrieved
`Heat-P:ress¢dTibial Inserts
`Roy .D. Bloebaum, Ph.D., Keith Nelson, M .D., Lawrence D. Dorr, M.D.,
`Ati.ronA Hofmann, M.D., and Donald J. Lyman, Ph.D.
`
`SECTION II: GENERAL ORTHOPAEDICS
`Spine
`Fuller Albright: His Concept of Postmenopausal Osteoporosis and
`What Came of it
`Anne P. Forbes, M .D.
`
`89
`
`98
`
`102
`
`109
`
`113
`
`120
`
`1°28
`
`';.;...,_ ____ _
`
`1
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`t
`1
`
`. I
`
`

`
`1aedics
`sea rch
`
`Number 269
`August, 1991
`
`Pyogenic Vertebral Osteomyelitis With Paralysis: Prognosis and
`Treatment
`Meir Liebergall, M.D., Gershon Chaimsky, M.D., Joseph Lowe, M.D.,
`Gordon C. Robin, M.D., and Yizhar Floman, M .P.
`Chemonucleolysis in the Herniated L3-L4 Disk
`Leonard Hofstra, M.D., Henk H. van Woerden, M.D.,
`and Robert Deutman, M.D., Ph.D.
`Sublaminar Fixation in Lumbosacral Fusions
`James W. Ogilvie, M.D., and David S. Bradford, M.D.
`
`Shoulder
`.
`Shoulder Impingement Syndrome: A Critical Review
`Freddie H. Fu, M.D., Christopher D. Harner, M.D., and Alan H. Klein, M.D.
`Scapular Fractures: Analysis of 113 Cases
`Jesse R. Ada, M.D., and Michael E. Miller, M.D.
`Differences in Shoulder Muscle Activity Between Patients With
`Generalized J0int Laxity and ]'~formal Controls
`Margar~ta Kronberg, M.D., Lars-Ake Brostrom, M.D.,
`and .Gunnar Nemeth, M.D.
`
`Elbow
`The Failed Ulnar Nerve Transposition: Etiology and Treatment
`Mark R. Rogers, M.D., Thomas G. Bergfield, M.D.,
`and Pat L. Aulicino, M.D.
`Posterior Dislocation of the Elbow
`Stephen G. Royle, M.B., Ch.B., F.R.C.S.
`
`142
`
`151
`
`157
`
`162
`
`17 4
`
`181
`
`193
`
`201
`
`209
`
`Hip
`Prospective Study of PorQus-Coated Anatomic Total Hip Arthroplasty 205
`Mi.clutelM. Ale:dades1 M.D., Michael R. Clain, M.D.,
`and Micha~! J. Bronson, M.D.
`The Non cemented Porous-Coated Hip Prosthesis: A Three-Year
`Clinical Follow-Up Study and Roentgenographic Analysis
`Roy Bands, M.D., Richard R. Pelker, M.D., Ph.D., John Shine, M.D.,
`Hubert Bradburn, M.D., Robert Margolis, M.D., and John Leach, P.A.
`In Vivo Measurements of Relative Motion Between an Uncerrtented
`Femoral Total Hip Component and the Femur by Roentgen
`Stereophotogrammetric Analysis
`Lars Nistor, M.D., J. David Blaha, M.D., UlfKjellstrom, M.D.,
`and Goran Selvik, M.D.
`Sexual Function After Total Hip Arthroplasty
`Steven H. Stern, M.D., Marc D. Fuchs, M.D., Sandy B. Ganz, R.P.T.,
`Patti Classi, R.P.T., Thomas P. Sculco, M.D.,
`and Eduardo A. Salvati, M.D.
`
`220
`
`228
`
`Foot
`Sesamoid Disorders and Treatment: An Update
`Edward 0. Leventen, M.D.
`
`236
`
`

`
`viii
`
`Clinical Orthopaedics
`and Related Research
`
`Compartment Syndrome of the Foot After Intraarticular Calcaneal
`Fracture
`Thomas Mittlmeier, M.D., Gudrun Machler, Gi.inther Lob, M.D.,
`Wolf Mutschler, M.D., Gerhard Bauer, M.D., and Thomas Vogl, M.D.
`Symptomatic Talocalcaneal Coalition: Its Clinical Significance and
`Tre~me~
`Yoshinori Takakura, M.D., Kazuya Sugimoto, M.D.,
`Yasuhito Tanaka, M.D., and Susumu Tamai, M.D.
`
`241
`
`M9
`
`SECTION III: BASIC SCIENCE AND PATHOLOGY
`
`Ultrastructure, T'ltttate-Resista.n.t Acid Phosphatase Activity and
`Calcitonin Responsivene$s ofQsteocla.sts at Sites of
`Demineralized ·Bone Matrix Implant-Induced Osteogenesis
`Cedo M. Bagi, M.D., Ph.D., and Scott C. Miller, Ph.D.
`Effect of Immunosuppression on Rejection of Cartilage Formed by
`Transplanted Allogeneic Rib Chondrocytes in Mice
`Jacek Malejczyk, Ph.D., Anna Osiecka, M.Sc., Anna Hye, M.Sc.,
`and Stanislaw Moskalewski, Ph.D.
`The ()rigiu of Bone Forrned in Con1posite Grafts of Porous Ca lei um
`Phosphate Ceramic Loaded With Marrow Cells
`JunGoshbna, M.D,, Victor M. Goldberg,M.o,, and Arnold I. Caplan, Ph.D.
`Bone Induction in Nonhuman Primates: An Experimental Study on
`the Baboon
`Ugo Ripamonti, M.D.
`Anterior Cruciate Ligament Allograft Transplantation in Dogs
`Philip B. Vasseur, D.V.M., Sharon Stevenson, D.V .M., Ph.D.,
`Clare R. Gregory, D.V.M., Juan J. Rodrigo, M.D., M.S., Steve Pauli,
`Dave Heitter, B.S., and Neil Sharkey
`Hurler Syndrome With Special Reference to Histologic Abnormalities
`of the Growth Plate
`Christopher P. Silveri, M.D., Frederick S. Kaplan, M.D.,
`Michael D. Fallon, M.D., Eliel Bayever, M.D., and Charles S. August, M.D.
`
`257
`
`266
`
`2 7 4
`
`284
`
`295
`
`305
`
`\
`
`NOTICE TO COPIERS
`
`Al.lthodzationto photocopy items for internal or personal use, or the internal or
`personal use of srrecifi.c clients, is granted by J. B. Lippincott for libraries and other
`users registered wlih the Copyright Clearance Center (CCC) provided that the base
`fee -of $J;OO: per copy is paid directly to CCC, 21 Congress St., Salem, MA 01970.
`0009-921 X/91 $3.00.
`
`

`
`Effect of the Tibial Cut on Subsidence Following
`Total Knee Arthroplasty
`
`AARON A. HOFMANN, M.D., KENT N. BACHUS, Ptt.D., AND RONALD W . B. WYATT, M.D.
`
`In 33 total knee arthroplasties (TKAs) using in(cid:173)
`strumentation designed to cut the tibia with 0 ° pos(cid:173)
`terior slope, ten tibial components demonstrated at
`least 2 mm of tibial component subsidence. These
`subsided components were implanted onto tibiae
`with an average of 8° ± 2° difference between the
`preoperative, anatomic posterior slope and their
`postoperative posterior slope. The remaining 23
`components, without subsidence, were implanted
`onto tibiae cut within 2° ± 2° of their anatomic
`slope. To help understand these clinical observa(cid:173)
`tions, a laboratory study was performed to com(cid:173)
`pare the load carrying capacity and the stiffness of
`tibial subchondral bone following two types of tib(cid:173)
`ial cuts: one made perpendicular to the long axis of
`the tibia and the other made parallel to the articu(cid:173)
`lar surface of the tibia. Mock tibial baseplates
`mounted on paired cadaver tibiae were loaded in
`compression and force displacement curves were
`recorded. Tibiae cut parallel to the surface exhib(cid:173)
`ited 40% greater load carrying capacity and 70%
`greater stiffness than the paired tibiae cut perpen(cid:173)
`dicular to the long axis. The biomechanical data of
`this study indicated that cutting the tibia perpen(cid:173)
`dicular to the long axis results in weaker bone that
`may be inadequate to support a tibial component.
`This may explain the higher incidence of clinical
`subsidence if the tibial cut is not made approxi(cid:173)
`mately parallel to the anatomic slope.
`
`Tibial component loosening continues to
`be a common mode of failure following
`TKA. Possible causes of loosening include
`
`From the Bone and Joint Research Labs, VA Medical
`Center, Salt Lake City, Utah.
`Reprint requests to Aaron A. Hofmann, M.D., Bone
`and Joint Research Labs ( 151 F), VA Medical Center.
`500 Foothill Blvd., Salt Lake City, Utah 84148.
`Received: June 11 , 1990.
`
`mechanical failure, 4 malalignment of the
`15 inadequate fixa(cid:173)
`prosthetic component, 3
`•
`tion techniques, 17 and inadequate support of
`the existing cortical and cancellous bone
`stock. 10
`Human knees have an anatomic posterior
`slope of the tibial condyles. Some knee sys(cid:173)
`tems have been designed to cut the proximal
`tibia with a specific posterior slope, whereas
`others have been designed to be cut perpen(cid:173)
`dicular to the long axis of the tibia. The poste(cid:173)
`rior angle of the cut may influence the load(cid:173)
`carrying capacity of the cancellous bone and
`be related to the anterior subsidence of the
`tibial component.
`In the human knee, tibial subchondral
`bone strength is greatest in the center of the
`condyles, directly beneath the major load
`bearing areas, with anterior bone being rela(cid:173)
`7
`tively weaker. 2
`13 Maximum strength of the
`8
`•
`•
`•
`proximal tibia has been reported in the cen(cid:173)
`tral portion of the medial condyle, with de(cid:173)
`creased subchondral bone strength of the lat(cid:173)
`eral condyle and at the periphery. 7 Goldstein
`et al.2 and Volz et a/. 16 have shown that the
`strength of tibial subchondral bone decreases
`with the distance from the articular surface.
`Johnson et al. 8 mapped the compressive
`strength of the cancellous bone of the proxi(cid:173)
`mal tibia and found that there was a dramatic
`drop in cancellous bone stiffness adjacent to
`the anterior margin of the upper tibia. There(cid:173)
`fore, the depth and orientation of the tibial
`cut can significantly effect the quality and
`strength of the underlying subchondral bone.
`
`63
`
`Page 63
`
`

`
`64
`
`Hofmann et al.
`
`The purpose of this study was to under(cid:173)
`stand the effect of orientation of the tibial cut
`during TKA using a retrospective clinical se(cid:173)
`ries of TKAs. The laboratory study was de(cid:173)
`signed to quantify the effect of the orienta(cid:173)
`tion of the tibial cut on the stiffness of the
`cancellous bone bed and its ability to carry a
`compressive load.
`
`CLINICAL REVIEW
`
`MATERIALS AND METHODS
`
`Of the patients treated with TKA between 1982
`and 1984 at the authors' institutions, 31 patients
`(33 knees) had adequate roentgenographic and
`clinical follow-up evaluation for inclusion in this
`study. There were 27 males and 4 females with an
`average age of 64 years (range, 56 to 74 years).
`Twenty-three patients had preoperative diagnosis
`of osteoarthritis: eight patients had rheumatoid ar(cid:173)
`thritis. All surgeries were performed by the senior
`author or by an orthopedic resident under the se(cid:173)
`nior author's direct supervision. The mean follow(cid:173)
`up period was 40 months (range, 20 to 59
`months).
`Preoperative roentgenograms were obtained,
`including standard weight-bearing anteroposterior
`and lateral views. The preoperative posterior slope
`of the tibial plateau was measured from the lateral
`views using a standard hand held goniometer and
`recorded.
`The surgical technique was standardized, and
`all patients received the same type of implant in(cid:173)
`cluding a resurfacing tibial tray with two porous(cid:173)
`coated pegs (PCA, Howmedica, New Jersey). This
`implant system was designed for a tibial cut per(cid:173)
`pendicular to the long axis of the tibia (no poste(cid:173)
`rior slope). A standard parapatellar approach was
`used, and a lateral release performed when re(cid:173)
`quired for adequate patellar tracking. The tibial
`components were sized to obtained maximal pe(cid:173)
`ripheral cortical coverage. Cementless fixation,
`augmented with an anterior screw. was used in 21
`knees. and cemented tibial components were fixed
`with low viscosity cement in 12 knees. Cement
`was pressurized 2 to 3 mm into the cancellous
`bone using a cement delivery system (Zimmer,
`Warsaw, Indiana). 11
`Postoperatively, the patients were started on im(cid:173)
`mediate continuous passive motion. Progressive
`weight-bearing was instituted immediately postop(cid:173)
`eratively with 50% weight bearing. All patients
`were allowed full weight bearing at six weeks. All
`patients were seen at regular follow-up intervals,
`and weight-bearing anteroposterior and lateral
`roentograms were obtained. The alignment of the
`
`Clinical Orthopaedics
`and Related Research
`
`tibial tray relative to the shaft axis was measured
`using a hand-held goniometer on both roentgeno(cid:173)
`grams. In addition, fluoroscopic views exactly par(cid:173)
`allel to the tibial cuts in the anteroposterior and
`lateral planes were obtained. This provided full vi(cid:173)
`sualization of the prosthesis-tibial interface. and
`allowed accurate measurements of lucency and
`subsidence. 9
`12 Tibial tray subsidence was mea(cid:173)
`·
`sured in millimeters. All roentgenogram measure(cid:173)
`ments were corrected for magnification.
`Subsidence was defined roentgenographically as
`at least 2 mm sinking of the prosthesis into cancel(cid:173)
`lous bone associated with any secondary sclerosis
`of the cancellous bone only when combined with
`lift-off of the prosthesis on the opposite side. If
`these criteria were not met, the knee was catego(cid:173)
`rized as having no subsidence (Fig. l ). This was
`done to avoid any confusion with hypertrophy of
`bone around a prosthesis. A propensity for subsi(cid:173)
`dence was evaluated based on diagnosis, fixation,
`age. and alignment of the tibial tray relative to the
`preoperative articular surface.
`
`RESULTS
`The mean preoperative slope of all the tib(cid:173)
`ial condyles used in this study was 7° ± 3°
`(range, 2° to 12°). Although the intention
`was to cut the tibiae with no posterior slope,
`the mean postoperative slope was 3° ± 3°
`(range, 0° to J0°) (Table 1 ). Subsidence of
`the tibial component occurred in ten of 33
`knees; four of which required revision for tib(cid:173)
`ial loosening. Of the ten knees with subsi(cid:173)
`dence, three were implanted with cement and
`nine were implanted without cement; three
`were inpatients with rheumatoid arthritis,
`whereas seven were inpatients with osteo(cid:173)
`arthritis. Patients with subsidence had a
`mean preoperative tibial slope of 9° ± 2°
`(range, 4° to 12°) and a mean postoperative
`slope of 2° ± 3° (range, 0° to J0°), for a dif(cid:173)
`ference ofS 0 ± 2° (range, 6° to 11°). Patients
`without subsidence had a mean preoperative
`tibial slope of6° ± 3° (range, 2°-12°) and a
`mean postoperative tibial slope of 4 ° ± 2 °
`), a difference of 2° ± 2°
`(range, 0° to S0
`(range, 0° to S0
`). Although some tibial com(cid:173)
`ponent subsidence was noted both posteri(cid:173)
`orly (0 to 2 mm) and medially (0 to 3 mm),
`the most pronounced subsidence occurred an(cid:173)
`teriorly (0 to JO mm). No component subsi(cid:173)
`dence was noted laterally.
`
`Page 64
`
`

`
`Number 269
`August, 1991
`
`Tibial Cut and Subsidence Following TKA
`
`65
`
`F1os. I A AND I B. (A) Lateral view of a cemented total knee demonstrating anterior subsidence. (B)
`Lateral view of a cementless total knee demonstrating anterior subsidence.
`
`Multifactor analysis of variance was per(cid:173)
`formed on the patients based on age (before
`and after age 65), clinical diagnosis (rheuma(cid:173)
`toid arthritis versus osteoarthritis), and type
`offixation (cemented versus cementless pros(cid:173)
`theses). There were no statistically significant
`dif