Replacement Arthroplasty: Lieberman JR

Lieberman JR. · No affiliation provided · J Am Acad Orthop Surg. · Pubmed #19202118 No free full text.

This publication has no abstract.

Petrigliano FA, Lieberman JR. · Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA. · Clin Orthop Relat Res. · Pubmed #17906590 No free full text.

Abstract: The treatment of osteonecrosis of the hip remains a dilemma. Contemporary basic science research focuses on establishing the molecular etiology of this disease with the hope of identifying targets for pharmacologic intervention. Researchers have identified specific genetic polymorphisms that may predispose its development and these may allow early diagnosis and treatment of at-risk patients. Refinements in magnetic resonance imaging aid in the staging of patients with osteonecrosis and findings appear to correlate with clinical outcome. Novel nonoperative and operative modalities for the treatment of osteonecrosis are also under investigation. The results of new pharmacologic and biophysical treatments appear beneficial in delaying, and possibly preventing, the progression of precollapse lesions. New bone grafting strategies may enhance the results of core decompression. Although the results of conventional total hip arthroplasty have improved, newer surface replacement systems provide satisfactory short-term outcomes and may preserve bone stock in younger patients. Further research is needed to clarify the roles of these emerging technologies in the treatment of osteonecrosis of the hip. Until there is convincing evidence of efficacy in randomized clinical trials, we recommend appropriate staging and core decompression with or without bone graft for precollapse lesions and total hip arthroplasty or surface replacement for advanced disease.

Conduah A, Lieberman JR. · Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA. · Clin Orthop Relat Res. · Pubmed #16331015 No free full text.

Abstract: Elective total hip arthroplasty is a common orthopaedic procedure that has been proven to relieve pain and reliably improves the quality of life of its patients. However, patients having a total hip arthroplasty are among those at greatest risk for venous thromboembolic disease. Therefore, most orthopaedic surgeons use routine prophylaxis. Although several agents have been shown to reduce the risk of thromboembolic disease, there is no clear preference for a particular agent in elective total hip arthroplasty. This evidence-based review focuses on the efficacy and safety of the agents that currently are used for prophylaxis against deep venous thrombosis. These agents include warfarin, low-molecular-weight heparin, fondaparinux, aspirin, and mechanical devices. Furthermore, the influence of shorter hospital stays on duration of prophylaxis and screening will be discussed. The most effective prophylactic agents for patients after total hip arthroplasty include low-molecular-weight heparin, warfarin, and fondaparinux. Pneumatic compression devices have been proven to reduce distal thromboembolic events but multi-center, randomized studies need to be done to determine the efficacy of mechanical prophylaxis with short hospital stays. The selection of a prophylaxis regimen is a balance between efficacy and safety, and individual patient factors can influence the prophylaxis regimen that is used.

Lieberman JR, Hsu WK. · Department of Orthopaedic Surgery, David Geffen School of Medicine at University of California at Los Angeles, Center for Health Sciences 76-134, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA. · J Bone Joint Surg Am. · Pubmed #16140827 No free full text.

Abstract: Patients undergoing total hip and knee arthroplasty are at increased risk for the development of venous thromboembolic disease, and there is general agreement that these patients require prophylaxis. The selection of a prophylactic agent involves a balance between efficacy and safety and often needs to be individualized for specific patients and institutions. Despite extensive research, the ideal agent for prophylaxis against deep venous thrombosis has not been identified. The results of randomized trials indicate that low-molecular-weight heparin, warfarin, and fondaparinux are the most effective prophylactic agents after total hip arthroplasty and that low-molecular-weight heparin, warfarin, fondaparinux, and pneumatic compression boots are the most effective agents after total knee arthroplasty. The duration of prophylaxis against deep venous thrombosis after total hip and knee arthroplasty remains controversial. Prophylaxis should be continued beyond hospital discharge. In the future, the determination of the duration of prophylaxis will be based on the risk stratification of individual patients. The practice of discharging patients from the hospital without prophylaxis, even when the decision is based on negative results of procedures that screen for the presence of deep venous thrombosis, is not cost-effective.

Vangsness CT, Kurzweil PR, Lieberman JR. · Keck School of Medicine at the University of Southern California in Los Angeles, USA. · Am J Orthop. · Pubmed #15005298 No free full text.

Abstract: Following damage or injury, as well as normal wear and tear, articular cartilage in adults has limited healing potential. Repair of cartilage is dependent on the extent and depth of the injury, its location, and the surviving chondrocytes and extracellular matrix. The ultimate goal of cartilage repair is to restore the normal composition and matrix of the cartilage, but for most patients this is not feasible. In these cases, filling the defect using interventions that provide adequate, albeit not optimal, functionality and pain relief is desirable. Therefore, a more realistic goal in these patients may be restoration of their respective activity levels and the delay or avoidance of prosthetic replacement. Depending on the age, activity level, and degree of cartilage damage, several methods to decrease pain and attempt cartilage repair are available; these include lavage and debridement, abrasion arthroplasty, and tissue and cell transplantation. Future strategies for cartilage repair may involve tissue engineering techniques, possibly coupled with specific growth factors. Randomized clinical trials must be established.

Gamradt SC, Lieberman JR. · Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, University of California-Los Angeles, Center for Health Sciences 76-134, Los Angeles, CA 90095, USA. · Clin Orthop Relat Res. · Pubmed #14646716 No free full text.

Abstract: Revision total hip arthroplasty often presents surgeons with difficult bone loss problems. The selection of an appropriate bone graft is influenced by the size of the bone defect, the location, the biology of the bone graft site, and whether the graft is required for structural support. Autogenous bone graft remains the gold standard bone graft material but there only is a limited amount available and there is morbidity associated with the harvesting of these grafts. The most frequently used bone graft materials include autogenous iliac crest bone graft, cancellous allograft chips, demineralized bone matrix, and bulk structural allografts (femoral head, distal or proximal femoral allograft, whole acetabuli, and femoral strut grafts). It often is difficult to determine on plain radiographs whether nonstructural grafts actually incorporate into the host bone. Recently, attention has focused on the use of new materials for bone grafting including: new demineralized bone matrices, ceramics, autologous platelet concentrates, recombinant proteins, and stem cells. The purpose of this review was to assess the biologic potential of these nonstructural grafts in revision hip arthroplasty and their limitations. Are these agents actually incorporating into host bone? Future bone graft options, including tissue engineering and gene therapy will be discussed briefly.

Lieberman JR, Berry DJ, Mont MA, Aaron RK, Callaghan JJ, Rajadhyaksha AD, Urbaniak JR. · Department of Orthopaedic Surgery, UCLA Medical Center, Los Angeles, California, USA. · Instr Course Lect. · Pubmed #12690862 No free full text.

Abstract: Osteonecrosis of the femoral head is a progressive condition that often leads to collapse of the femoral head. The ultimate goal in the treatment for osteonecrosis of the hip is preservation of the femoral head. However, the condition is difficult to treat because it is associated with a number of different diseases, and the etiology and natural history of the condition have not been definitively determined. The delineation of new information regarding the etiology, pathogenesis, and natural history of osteonecrosis is ongoing. Core decompression, vascularized and nonvascularized bone grafting procedures, and arthroplasty procedures play an important role in treatment.

Whang PG, Lieberman JR. · Department of Orthopaedic Surgery, University of California, Los Angeles Medical Center, USA. · Am J Orthop. · Pubmed #12349893 No free full text.

Abstract: Patients undergoing total joint arthroplasty are predisposed to the development of venous thromboembolic disease, including deep venous thrombosis and pulmonary embolism. Despite a standard course of postoperative prophylaxis, orthopedic patients remain at significant risk for late venous thromboembolic complications, resulting in considerable morbidity and mortality. Since routine screening for asymptomatic deep venous thrombosis with duplex ultrasound has not been found to be effective, the practice of extended out-of-hospital prophylaxis with low-molecular-weight heparin after total joint arthroplasty has been proposed in order to better protect these patients from delayed venous thromboembolic events. Multiple controlled, randomized clinical trials have shown that extended-duration low-molecular-weight heparin therapy significantly reduces the incidence of asymptomatic venous thromboembolic events following total hip arthroplasty, although no similar benefit has been observed in patients undergoing total knee arthroplasty. There are currently no comparative studies assessing the efficacy of long-term venous thromboembolic prophylaxis with oral anti-coagulant agents. Extending low-molecular-weight heparin therapy is not associated with any increase in major bleeding complications, but it may result in more frequent minor bleeding episodes. In addition, the cost-effectiveness of prolonging low-molecular-weight heparin treatment has not yet been firmly established. Although there is evidence supporting the use of extended out-of-hospital low-molecular-weight heparin prophylaxis after total hip arthroplasty, this strategy has not gained widespread acceptance in North America because of concerns regarding its adverse effects, cost-effectiveness, and uncertain patient compliance. There is general agreement that prophylaxis is needed after hospital discharge, and a minimum of 10 to 14 days of prophylaxis has been shown to be both safe and effective. However, further studies are necessary to determine the optimal duration of treatment.

Lieberman JR. · Department of Orthopedic Surgery, UCLA Medical Center, Los Angeles, California 90024-3010, USA. · Am J Knee Surg. · Pubmed #10050694 No free full text.

Abstract: Low-dose warfarin prophylaxis has been found to provide safe and effective prophylaxis after TKA. The major advantage of warfarin prophylaxis is that it can be administered orally. However, monitoring of the INR level is required, and there are concerns that TKA patients may be relatively unprotected during the early perioperative period. In addition, further analysis of the impact of asymptomatic clot formation on venous stasis disease is required. Our protocol is to administer 2 weeks of DVT prophylaxis after TKA. Routine screening with ultrasonography is not recommended at this time.

Colwell CW, Berkowitz SD, Lieberman JR, Comp PC, Ginsberg JS, Paiement G, McElhattan J, Roth AW, Francis CW, Anonymous00317. · Orthopaedic Surgery, Scripps Clinic, 11025 North Torrey Pines Road, Suite 140, La Jolla, CA 92037, USA. · J Bone Joint Surg Am. · Pubmed #16203879 No free full text.

Abstract: BACKGROUND: Warfarin, which requires coagulation monitoring, is associated with relatively high rates of thromboembolism despite providing adequate prophylaxis. This study compared an oral direct thrombin inhibitor, ximelagatran, with warfarin in order to evaluate the safety and efficacy of the medication for the prevention of venous thromboembolism in patients undergoing total knee arthroplasty. METHODS: Following surgery, patients were randomly assigned to fixed-dose oral ximelagatran (36 mg twice daily) or warfarin (target international normalized ratio, 2.5), both administered for seven to twelve days in a double-blind, double-dummy design. Warfarin was initiated on the evening of the day of surgery, and ximelagatran, on the morning after surgery. The primary efficacy end point was the incidence of asymptomatic deep-vein thrombosis determined by bilateral venography, objectively confirmed symptomatic deep-vein thrombosis or pulmonary embolism, and death from all causes during treatment. RESULTS: Adequate venograms or confirmed symptomatic events (efficacy population) were obtained for 1949 patients. Venous thromboembolism and death from all causes occurred in 22.5% (221) of 982 ximelagatran-treated patients and in 31.9% (308) of 967 warfarin-treated patients (p < 0.001). Proximal deep-vein thrombosis and pulmonary embolism were observed in 3.1% (thirty) and 0.2%, respectively, of the patients in the ximelagatran group and in 3.4% (thirty-three) and 0.4%, respectively, of the patients in the warfarin group. The six deaths from all causes included 0.3% (four) of the ximelagatran-treated patients and 0.2% (two) of the warfarin-treated patients. Major bleeding was noted in 1% (twelve) of the ximelagatran-treated patients and in 0.4% (five) of the warfarin-treated patients (p = 0.09). CONCLUSIONS: Oral ximelagatran (36 mg twice daily), administered without coagulation monitoring or dose adjustment and started the day after total knee arthroplasty, demonstrates superior efficacy compared with warfarin prophylaxis, with no wound complications and no significant difference with respect to bleeding events, although the rate of major bleeding events was greater with ximelagatran than with warfarin. LEVEL OF EVIDENCE: Therapeutic Level I.

Francis CW, Berkowitz SD, Comp PC, Lieberman JR, Ginsberg JS, Paiement G, Peters GR, Roth AW, McElhattan J, Colwell CW, Anonymous00349. · Department of Medicine, University of Rochester, Rochester, NY, USA. · N Engl J Med. · Pubmed #14585938 links to  free full text

Abstract: BACKGROUND: In a previous study of the prevention of venous thromboembolism after total knee replacement, the efficacy of ximelagatran, an oral direct thrombin inhibitor that does not require monitoring of coagulation or dose adjustment, was found to be similar to that of warfarin at a dose of 24 mg of ximelagatran twice daily. The purpose of the present study was to determine whether a higher dose of ximelagatran is superior to warfarin. METHODS: This randomized, double-blind trial compared a regimen of 7 to 12 days of oral ximelagatran, at a dose of 24 or 36 mg twice daily, starting the morning after surgery, with warfarin therapy started the evening of the day of surgery. The composite end point of venous thromboembolism and death from all causes and the incidence of bleeding were the primary outcome measures. RESULTS: Among the 1851 patients in the efficacy analysis, oral ximelagatran at a dose of 36 mg twice daily was superior to warfarin with respect to the primary composite end point of venous thromboembolism and death from all causes (20.3 percent vs. 27.6 percent; P=0.003). There were no significant differences between these two groups with respect to major bleeding (incidence, 0.8 percent and 0.7 percent, respectively), perioperative indicators of bleeding, wound characteristics, or the composite secondary end point of proximal deep-vein thrombosis, pulmonary embolism, and death (2.7 percent vs. 4.1 percent; P=0.17). CONCLUSIONS: The efficacy of oral ximelagatran, administered starting the morning after total knee replacement, was superior to that of warfarin for prevention of venous thromboembolism. Rates of hemorrhagic complications with the two drugs were similar.

Colwell CW, Berkowitz SD, Davidson BL, Lotke PA, Ginsberg JS, Lieberman JR, Neubauer J, McElhattan JL, Peters GR, Francis CW. · Scripps Clinic Center for Orthopaedic Research and Education, 11025 North Torrey Pines Road, Suite 140, La Jolla, CA 92037-1030, USA. · J Thromb Haemost. · Pubmed #14521593 No free full text.

Abstract: BACKGROUND: Prophylaxis is recommended following total joint replacement because of the high risk of venous thromboembolism (VTE). Postoperative low-molecular-weight heparin (LMWH) reduces the incidence of venographically detected deep vein thrombosis (DVT) to about 10-15% in total hip replacement (THR) patients. Ximelagatran is a novel, oral direct thrombin inhibitor that selectively and competitively inhibits both free and clot-bound thrombin. We compared the efficacy and safety of ximelagatran with those of enoxaparin for the prevention of VTE in patients undergoing THR. METHODS: This was a prospective, randomized, multicenter, double-blind study conducted principally in the USA and Canada. Patients received fixed-dose oral ximelagatran 24 mg bid or subcutaneous enoxaparin 30 mg bid and matched placebo for 7-12 days; both regimens were initiated the morning after surgery. The incidence of VTE (by postoperative day 12) included thrombosis determined by mandatory venography of the leg on which surgery was performed and symptomatic, objectively proven DVT or pulmonary embolism (PE). VTE and bleeding events were interpreted by an independent central adjudication committee for primary analysis. RESULTS: Of the 1838 patients randomized, 1557 had either adequate venography or symptomatic, proven VTE (efficacy population). Overall rate of venography acceptable for evaluation was 85.4%. Overall rates of total VTE were 7.9% (62 of 782 patients) in the ximelagatran group and 4.6% (36 of 775 patients) in the enoxaparin group, with an absolute difference of 3.3% and a 95% confidence interval for the difference of 0.9% to 5.7%. Proximal DVT and/or PE occurred in 3.6% (28 of 782 patients) in the ximelagatran group and 1.2% (nine of 774 patients) in the enoxaparin group. Major bleeding events were observed in 0.8% (seven of 906) of the ximelagatran-treated patients and in 0.9% (eight of 910) of the enoxaparin-treated patients (P > 0.95). Non-inferiority of ximelagatran 24 mg bid based on a prespecified margin of 5% was not met, resulting in superiority of the enoxaparin regimen. CONCLUSIONS: Both ximelagatran and enoxaparin decreased the overall rate of VTE compared with that reported historically. However, in this study, enoxaparin 30 mg bid was more effective than ximelagatran 24 mg bid for prevention of VTE in THR. Oral ximelagatran was used without coagulation monitoring, was well tolerated, and had bleeding rates comparable to those of enoxaparin. Further refinement by testing a higher dose of ximelagatran in the patients undergoing THR is warranted.

Francis CW, Davidson BL, Berkowitz SD, Lotke PA, Ginsberg JS, Lieberman JR, Webster AK, Whipple JP, Peters GR, Colwell CW. · University of Rochester School of Medicine and Dentistry, Rochester, New York, USA. · Ann Intern Med. · Pubmed #12379064 links to  free full text

Abstract: BACKGROUND: Warfarin is used for prophylaxis of venous thromboembolism in patients undergoing total knee arthroplasty. However, it is associated with rates of deep venous thrombosis (DVT) of approximately 38% to 55% and requires routine coagulation monitoring and frequent dose adjustment. Ximelagatran, an oral direct thrombin inhibitor, has shown promising efficacy and tolerability in patients undergoing total hip or knee arthroplasty. OBJECTIVE: To compare the efficacy and safety of ximelagatran and warfarin for prophylaxis of venous thromboembolism after total knee arthroplasty. DESIGN: Randomized, double-blind, parallel-group trial. SETTING: 74 North American hospitals. PATIENTS: 680 patients who had undergone total knee arthroplasty. INTERVENTION: 7 to 12 days of treatment with oral ximelagatran, 24 mg twice daily, starting on the morning after surgery, or warfarin (target international normalized ratio, 2.5 [range, 1.8 to 3.0]), starting on the evening of the day of surgery. MEASUREMENTS: Principal end points were asymptomatic DVT on mandatory venography; symptomatic DVT confirmed by ultrasonography or venography; symptomatic, objectively proven pulmonary embolism; and bleeding. All were assessed by blinded adjudication locally and at a central study laboratory. RESULTS: On central adjudication, incidence of venous thromboembolism was 19.2% (53 of 276 patients) in the ximelagatran group and 25.7% (67 of 261 patients) in the warfarin group (difference, -6.5 percentage points [95% CI, -13.5 to 0.6 percentage points]; P = 0.070). On local assessment, incidence was 25.4% in the ximelagatran group and 33.5% in the warfarin group (P = 0.043). In the ximelagatran and warfarin groups, respectively, major bleeding occurred in 1.7% and 0.9% of patients and minor bleeding occurred in 7.8% and 6.4% of patients. No variables related to bleeding differed significantly between the two groups. CONCLUSIONS: For prophylaxis of venous thromboembolism, fixed-dose ximelagatran started the morning after total knee arthroplasty is well tolerated and at least as effective as warfarin, but it does not require coagulation monitoring or dose adjustment.

Johanson NA, Lachiewicz PF, Lieberman JR, Lotke PA, Parvizi J, Pellegrini V, Stringer TA, Tornetta P, Haralson RH, Watters WC. · Department of Orthopaedic Surgery, Drexel University College of Medicinbne, Philadelphia, PA, USA. · J Am Acad Orthop Surg. · Pubmed #19264711 No free full text.

Abstract: This clinical practice guideline is based on a systematic review of published studies on the management of adult patients undergoing total hip replacement (THR) or total knee replacement (TKR) aimed specifically at preventing symptomatic pulmonary embolism (PE). The guideline emphasizes the need to assess the patient's risk for both PE and postoperative bleeding. Mechanical prophylaxis and early mobilization are recommended for all patients. Chemoprophylactic agents were evaluated using a systematic literature review. Forty-two studies met eligibility criteria, of which 23 included patients who had TKR and 25 included patients who had THR. The following statements summarize the recommendations for chemoprophylaxis: Patients at standard risk of both PE and major bleeding should be considered for aspirin, low-molecular-weight heparin (LMWH), synthetic pentasaccharides, or warfarin with an international normalized ratio (INR) goal of < or =2.0. Patients at elevated (above standard) risk of PE and at standard risk of major bleeding should be considered for LMWH, synthetic pentasaccharides, or warfarin with an INR goal of < or =2.0. Patients at standard risk of PE and at elevated (above standard) risk of major bleeding should be considered for aspirin, warfarin with an INR goal of < or =2.0, or none. Patients at elevated (above standard) risk of both PE and major bleeding should be considered for aspirin, warfarin with an INR goal of < or =2.0, or none.

Pianta TJ, Lieberman JR. · Department of Orthopedic Surgery, New England Musculoskeletal Institute, University of Connecticut Health Center, 263 Farmington Ave-MC 5456, Farmington, CT 06030-5456. USA. · Orthopedics. · Pubmed #18814610 No free full text.

This publication has no abstract.

Lassen MR, Ageno W, Borris LC, Lieberman JR, Rosencher N, Bandel TJ, Misselwitz F, Turpie AG, Anonymous00013. · Nordsjaellands Hospital, Hørsholm, Denmark. · N Engl J Med. · Pubmed #18579812 links to  free full text

Abstract: BACKGROUND: We investigated the efficacy of rivaroxaban, an orally active direct factor Xa inhibitor, in preventing venous thrombosis after total knee arthroplasty. METHODS: In this randomized, double-blind trial, 2531 patients who were to undergo total knee arthroplasty received either oral rivaroxaban, 10 mg once daily, beginning 6 to 8 hours after surgery, or subcutaneous enoxaparin, 40 mg once daily, beginning 12 hours before surgery. The primary efficacy outcome was the composite of any deep-vein thrombosis, nonfatal pulmonary embolism, or death from any cause within 13 to 17 days after surgery. Secondary efficacy outcomes included major venous thromboembolism (i.e., proximal deep-vein thrombosis, nonfatal pulmonary embolism, or death related to venous thromboembolism) and symptomatic venous thromboembolism. The primary safety outcome was major bleeding. RESULTS: The primary efficacy outcome occurred in 79 of 824 patients (9.6%) who received rivaroxaban and in 166 of 878 (18.9%) who received enoxaparin (absolute risk reduction, 9.2%; 95% confidence interval [CI], 5.9 to 12.4; P<0.001). Major venous thromboembolism occurred in 9 of 908 patients (1.0%) given rivaroxaban and 24 of 925 (2.6%) given enoxaparin (absolute risk reduction, 1.6%; 95% CI, 0.4 to 2.8; P=0.01). Symptomatic events occurred less frequently with rivaroxaban than with enoxaparin (P=0.005). Major bleeding occurred in 0.6% of patients in the rivaroxaban group and 0.5% of patients in the enoxaparin group. The incidence of drug-related adverse events, mainly gastrointestinal, was 12.0% in the rivaroxaban group and 13.0% in the enoxaparin group. CONCLUSIONS: Rivaroxaban was superior to enoxaparin for thromboprophylaxis after total knee arthroplasty, with similar rates of bleeding. (ClinicalTrials.gov number, NCT00361894.)

Anonymous00019, Ginsberg JS, Davidson BL, Comp PC, Francis CW, Friedman RJ, Huo MH, Lieberman JR, Muntz JE, Raskob GE, Clements ML, Hantel S, Schnee JM, Caprini JA. · McMaster University Medical Centre, Ontario, Canada. · J Arthroplasty. · Pubmed #18534438 No free full text.

Abstract: Dabigatran, an oral once-daily unmonitored thrombin inhibitor, has been tested elsewhere using enoxaparin 40 mg once daily. We used the North American enoxaparin 30 mg BID regimen as the comparator. This was a double-blind, centrally randomized trial. Unilateral total knee arthroplasty patients were randomized to receive oral dabigatran etexilate 220 or 150 mg once daily, or enoxaparin 30 mg SC BID after surgery, blinded. Dosing stopped at contrast venography, 12 to 15 days after surgery. Among 1896 patients, dabigatran 220 and 110 mg showed inferior efficacy to enoxaparin (venous thromboembolism rates of 31% [P = .02 vs enoxaparin], 34% [P < .001 vs enoxaparin], and 25%, respectively). Bleeding rates were similar, and no drug-related hepatic illness was recognized. Dabigatran, effective compared to once-daily enoxaparin, showed inferior efficacy to the twice-daily North American enoxaparin regimen, probably because of the latter's more intense and prolonged dosing.

Soohoo NF, Vyas RM, Samimi DB, Molina R, Lieberman JR. · Department of Orthopaedic Surgery, UCLA School of Medicine, Los Angeles, California 90095, USA. · J Arthroplasty. · Pubmed #18078886 No free full text.

Abstract: This study examines the responsiveness of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Short Form-36 (SF-36) in patients undergoing total hip arthroplasty. Eighty-nine patients completed the WOMAC and SF-36 preoperatively and postoperatively. Standardized response means (SRMs) and effect sizes (ES) were used to measure responsiveness. Mean follow-up was 17 months. The SRMs for the WOMAC ranged from -0.93 to -1.49, and the ES ranged from -1.02 to -1.53. The SRMs for the SF-36 ranged from 0.22 to 1.64, and the ES ranged from 0.20 to 1.97. The highest values occurred with the physical functioning, bodily pain, and Physical Component Summary Scales. This study demonstrates a similar level of responsiveness of the WOMAC and several components of the SF-36. This suggests that the isolated use of the SF-36 may be adequate to monitor outcomes after total hip arthroplasty. There may still be a role for the WOMAC when comparing outcomes of specific designs or techniques of total hip arthroplasty.

Soohoo NF, Sharifi H, Kominski G, Lieberman JR. · Department of Orthopaedic Surgery, University of California at Los Angeles, 10945 Le Conte Avenue, Los Angeles, CA 90095, USA. · J Bone Joint Surg Am. · Pubmed #16951114 No free full text.

Abstract: BACKGROUND: The purpose of this study was to compare the cost-effectiveness of unicompartmental knee arthroplasty as an alternative to total knee arthroplasty in patients with degenerative arthritis limited to either the medial or lateral compartment. METHODS: A decision model was created for the treatment of end-stage unicompartmental knee arthritis. A literature review was used to identify possible outcomes and their probabilities following treatment with either unicompartmental or total knee arthroplasty. Each outcome was weighted for quality of life with use of a utility factor, and effectiveness was expressed in units of quality-adjusted life years. Gross costs were estimated from Medicare reimbursement data for the relevant Current Procedural Terminology and Diagnosis-Related Group codes. RESULTS: Sensitivity analysis demonstrated that the cost-effectiveness of unicompartmental knee arthroplasty is dependent on the assumption that its durability and functional outcomes approach those of total knee arthroplasty. Specifically, it is necessary for the survival of unicompartmental implants to be within three to four years of the assumed survival of total knee implants for unicompartmental arthroplasty to remain a cost-effective alternative. Under these assumptions, the use of unicompartmental arthroplasty is a cost-effective choice as it results in incremental gains in effectiveness at a cost of less than US dollars 50,000 (in 1998 United States dollars) per quality-adjusted life year gained. CONCLUSIONS: This study supports unicompartmental knee arthroplasty as a cost-effective alternative for the treatment of unicompartmental arthritis when the durability and function of a unicompartmental replacement are assumed to be similar to those of a primary total knee replacement. This suggests that, with appropriate patient selection, the currently available literature supports unicompartmental arthroplasty as a cost-effective alternative to total knee arthroplasty. LEVEL OF EVIDENCE: Economic and decision analysis, Level II.

Soohoo NF, Zingmond DS, Lieberman JR, Ko CY. · Department of Orthopaedic Surgery, UCLA School of Medicine, Los Angeles, CA 90095, USA. · J Arthroplasty. · Pubmed #16877157 No free full text.

Abstract: This study attempts to identify the optimal follow-up period to report short-term complication rates after primary total knee arthroplasty. Discharge data from 1991 through 2001 was obtained from California and linked to state death records. Rates of mortality, infection, and pulmonary embolism were determined at 30-day intervals for up to 1 year postoperatively. An analysis of 222,684 primary total knee arthroplasties was performed. The peak rate and a large proportion of the complications that occurred during the first year after surgery were seen within the initial 30-day postoperative period. Regression analyses demonstrated that the patient and hospital characteristics predictive of outcome differed when comparing the results at 1 year postoperatively to shorter-term follow-up periods. The findings of this study indicate that 30- and 60-day follow-up periods provide an adequate accounting for adverse events related to mortality, infection, and pulmonary embolism. However, the regression results highlight the continued importance of reporting long-term outcomes.

Soohoo NF, Vyas S, Manunga J, Sharifi H, Kominski G, Lieberman JR. · UCLA School of Medicine, Department of Orthopaedic Surgery, Los Angeles, California 90095, USA. · J Arthroplasty. · Pubmed #16877152 No free full text.

Abstract: Core decompression is widely used to treat the early stages of osteonecrosis of the hip. The purpose of this analysis is to assist orthopedic surgeons in judging whether currently available data support the use of core decompression as cost-effective. A decision model was created for the treatment of osteonecrosis of the femoral head. Literature review was used to identify possible outcomes and their probability after initial treatment with either observation or core decompression. This model demonstrates core decompression must delay the need for total hip arthroplasty for a minimum of 5 years to maintain an incremental cost-effectiveness ratio lower than 50,000 dollars per quality-adjusted life year gained. Treatment options with ratios higher than 50,000 dollars per quality-adjusted life year are generally considered to have limited cost-effectiveness. This study demonstrates that core decompression has the potential to be a highly cost-effective alternative if it is leads to a delay in the need for total hip arthroplasty of 5 years or longer.

Soohoo NF, Zingmond DS, Lieberman JR, Ko CY. · Department of Orthopaedic Surgery, UCLA School of Medicine, Los Angeles, California 90095-6902, USA. · J Arthroplasty. · Pubmed #16520207 No free full text.

Abstract: This study reports the relationship between hospital surgical volume and outcomes after total knee arthroplasty. Discharge data from 1991 to 2001 were obtained from California's Office of Statewide Health Planning and Development and linked to California death records. Multivariate logistic regression models were performed to examine the association between hospital volume and complications. The models were adjusted for patient age, sex, race/ethnicity, insurance type, Charlson comorbidity index, hospital type and size, year of surgery, and whether patients underwent bilateral procedures. A total of 222684 primary total knee arthroplasties were identified during the study period. Patients treated at low volume hospitals had a higher likelihood in the 90 days after discharge of death (rate 0.55% vs 0.49%, odds ratio [OR] 1.50, 95% confidence interval [CI] 1.14-1.98, P = .004), and readmission for infection (1.13% vs 0.65%, OR 1.60, 95% CI 1.21-2.12, P = .001), pulmonary embolism (0.48% vs 0.39%, OR 1.45, 95% CI 1.07-1.97, P = .016), and thrombophlebitis (0.49% vs 0.28%, OR 2.12, 95% CI 1.47-3.05, P </= .001). This study confirms the relationship of lower hospital volumes to a higher OR for complications after total knee arthroplasty.

SooHoo NF, Lieberman JR, Ko CY, Zingmond DS. · Department of Orthopaedic Surgery, University of California at Los Angeles, 10945 Le Conte Avenue, PVUB #3355, Los Angeles, CA 90095, USA. · J Bone Joint Surg Am. · Pubmed #16510811 No free full text.

Abstract: BACKGROUND: The purpose of this investigation was to expand on previous studies by more fully examining the role of a variety of patient and hospital characteristics in determining adverse outcomes following total knee replacement. METHODS: With use of data from all hospital admissions in California from 1991 through 2001, multiple logistic regression was performed on the information regarding patients treated with total knee replacement. Rates of mortality and readmission due to infection and pulmonary embolism during the first ninety days after discharge were regressed against a variety of independent variables, including demographic factors (age, gender, race, ethnicity, and insurance type), burden of comorbid disease (Charlson comorbidity index), and provider variables (hospital size, teaching status, and surgical volume). A separate baseline probability analysis was then performed to compare the relative importance of all predictor variables. RESULTS: The sample size for this analysis was 222,684. A total of 1176 deaths (rate, 0.53%), 1586 infections (0.71%), and 914 pulmonary emboli (0.41%) occurred within the first ninety days after discharge. The average age of the patients at the time of surgery was sixty-nine years. Sixty-two percent of the patients were women, and 32% had a Charlson comorbidity index of >0. The significant predictors for complications (p < 0.05) included age, gender, race/ethnicity, Charlson comorbidity index, insurance type, and hospital volume. A baseline probability analysis was performed with the base case considered to be a white woman who was over the age of sixty-five years, had a Charlson comorbidity index of 0, had Medicare insurance, and was treated at a high-volume, non-teaching hospital. For a patient with the baseline case characteristics, the probability of death was 31/10,000, the probability of infection was 59/10,000, and the probability of pulmonary embolism was 41/10,000 in the first ninety days after discharge. Altering the base case by assuming that care was received at a low-volume hospital increased the expected mortality rate by a factor of 26%. Increasing the Charlson comorbidity index to 1 increased the mortality rate by 170%, whereas decreasing the age to younger than sixty-five years lowered the mortality rate by 73%. Hospital volume, comorbidity, and age had similar effects on the expected rates of readmission due to infection and pulmonary embolism. CONCLUSIONS: The effects of age and the Charlson comorbidity index on the baseline probability of adverse outcomes following total knee replacement were shown to be similar to or greater than the effect of hospital volume. This study elucidates and compares the relative importance of the effects of several different factors on outcome. This information is important when considering the conclusions and implications of this type of policy-relevant outcomes research.

Lieberman JR, Romano PS, Mahendra G, Keyzer J, Chilcott M. · Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA. · Clin Orthop Relat Res. · Pubmed #16394767 No free full text.

Abstract: The purpose of this descriptive study was to identify the ranges of operative treatment, perioperative management, and mortality rate of elderly patients with hip fractures. We retrospectively identified 1001 elderly patients who had operative treatment for a fractured hip in 49 medium- and high-volume California hospitals using a two-stage stratified cluster sample of hospitalizations for hip fractures. This sampling method allowed for generation of weighted estimates that described the overall care of all patients with hip fractures in California from 1995 to 1996. The in-hospital, 30-day, and 6-month mortality rates were 1.7%, 5%, and 12% respectively. Bipolar hemiarthroplasties were used more often than unipolar implants (73% versus 26%). There were some deviations from generally accepted guidelines for care of patients with hip fractures particularly related to administration of antibiotic and deep vein thrombosis prophylaxis. Fourteen percent of patients did not receive any antibiotic prophylaxis before and during surgery, and 24% did not receive prophylaxis within 4 hours of the beginning of the surgical procedure. Twenty-four percent of patients received no prophylaxis for deep vein thrombosis, and 81% of patients did not receive prophylaxis after hospital discharge. Surgeons need to continually evaluate the treatment regimens for patients with hip fractures to optimize care. Level of Evidence: Descriptive Study, Level II (retrospective cohort study). See the Guidelines for Authors for a complete description of levels of evidence.

Lieberman JR. · Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA. · J Arthroplasty. · Pubmed #15991136 No free full text.

Abstract: Cemented femoral revisions can provide durable fixation when used for specific indications. These indications include elderly patients with minimal bone loss or large femoral canals and the cement-within-cement technique where a new femoral component is cemented into an intact cement mantle.