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Papers by Mark Figgie

Arthritis & rheumatology (Hoboken, N.J.), Jan 24, 2015

To provide evidence-based recommendations for the treatment of patients with ankylosing spondylit... more To provide evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). A core group led the development of the recommendations, starting with the treatment questions. A literature review group conducted systematic literature reviews of studies that addressed 57 specific treatment questions, based on searches conducted in OVID Medline (1946-2014), PubMed (1966-2014), and the Cochrane Library. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. A separate voting group reviewed the evidence and voted on recommendations for each question using the GRADE framework. In patients with active AS, the strong recommendations included use of nonsteroidal antiinflammatory drugs (NSAIDs), use of tumor necrosis factor inhibitors (TNFi) when activity persists despite NSAID treatment, not to use systemic glucocorticoids, use of physical the...

The Journal of the American Academy of Orthopaedic Surgeons

Psoriatic arthritis is a chronic inflammatory arthropathy that affects approximately 6% to 48% of... more Psoriatic arthritis is a chronic inflammatory arthropathy that affects approximately 6% to 48% of patients with psoriasis. Arthritis is not correlated with the extent of skin disease. Classic radiographic findings of the involved joint include erosion, ankylosis, and fluffy periostitis. Site-specific characteristic deformities such as pencil-in-cup deformity of the phalanges also may be present. The disease typically follows a moderate course, but up to 47% of cases develop into destructive arthritis in which the inflammatory process leads to bony erosion and loss of joint architecture. The mainstay of treatment is biologic therapy (eg, tumor necrosis factor-α inhibitors) in conjunction with disease-modifying antirheumatic drugs. Patients with end-stage joint destruction may require surgery to alleviate pain and restore function. Orthopaedic surgeons should be cognizant of the risk factors (eg, increased risk of cardiovascular disease) and potential complications (eg, poor wound hea...

The Journal of Arthroplasty, 2015

Little data exists comparing acute post-operative outcomes in patients with different types of in... more Little data exists comparing acute post-operative outcomes in patients with different types of inflammatory arthritis (IA) after undergoing a total knee arthroplasty (TKA). Our objectives were to compare perioperative complications and determine the most common complications between the different IA subtypes compared with patients with osteoarthritis undergoing primary TKA. We found significant differences when comparing complications within the different subtypes of IA. RA patients, despite having a greater number of comorbidities had a reduced rate of medical complications postoperatively compared to the OA cohort. All of the inflammatory subtypes had a higher rate of orthopedic complications postoperatively compared to the OA group except for patients with AS. However, ankylosing spondylitis had the highest mortality rate as well as medical complication rate among the subtypes.

Introduction: Despite recent improvements in the medical treatment of various inflammatory arthro... more Introduction: Despite recent improvements in the medical treatment of various inflammatory arthropathies, patients suffering from these conditions often go on to require a total knee replacement (TKR). Little information exists comparing the short-term surgical complications of the different inflammatory arthropathies and osteoarthritis (OA) after TKR. Our objectives were (1) to compare perioperative complications and (2) determine the most common complications between the different IA subtypes compared with patients with osteoarthritis (OA) undergoing primary TKA. Methods: The Nationwide Inpatient Sample was used to identify 6,894,641 patients undergoing elective unilateral TKR between 2002-2011. Of this number 278,844 (4%) had an inflammatory arthropathy (IA), including rheumatoid arthritis (RA), psoriatic arthritis (PA), juvenile idiopathic arthritis (JIA), ankylosing spondylitis (AS), systemic lupus erythematosus (SLE). The prevalence of inpatient medical and orthopaedic complic...

The Journal of rheumatology, 2015

More adverse events (AE) are reported after total knee arthroplasty (TKA) for patients with rheum... more More adverse events (AE) are reported after total knee arthroplasty (TKA) for patients with rheumatoid arthritis (RA) than for patients with osteoarthritis (OA). This study evaluates 6-month postoperative AE in a high-volume center in a contemporary RA cohort. Patients with RA in an institutional registry (2007-2010) were studied. AE were identified by self-report and review of office and hospital charts. Subjects with RA were matched to 2 with OA by age, sex, and procedure. RA-specific surgical volume was determined. Baseline characteristics and AE were compared and analyzed. There were 159 RA TKA and 318 OA. Of the patients with RA, 88.0% were women, 24.5% received corticosteroids, 41.5% received biologics, and 67% received nonbiologic disease-modifying antirheumatic drugs (DMARD). There was no difference in comorbidities. RA-specific surgical volume was high; 64% of cases were performed by surgeons with ≥ 20 RA cases during the study period. Patients with RA had worse baseline pa...

The Journal of rheumatology, 2014

Total hip replacement (THR) outcomes have been worse for patients with rheumatoid arthritis (RA) ... more Total hip replacement (THR) outcomes have been worse for patients with rheumatoid arthritis (RA) compared with those who have osteoarthritis (OA). Whether this remains true in contemporary patients with RA with a high use of disease-modifying and biologic therapy is unknown. The purpose of our study is to assess pain, function, and quality of life 2 years after primary THR, comparing patients with RA and patients with OA. Baseline and 2-year data were compared between validated patients with RA and patients with OA who were enrolled in a single-center THR registry between May 1, 2007, and February 25, 2011. There were 5666 eligible primary THR identified, of which 193 were for RA. RA THR had worse baseline Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain (44.8 vs 53.2, p < 0.001) and function (38.7 vs 49.9, p < 0.001) compared with OA. These differences remained after surgery: pain (88.4 vs 94.0, p < 0.001) and function (82.9 vs 91.8, p < 0.001...

HSS journal : the musculoskeletal journal of Hospital for Special Surgery, 2014

Preoperative expectations of total knee arthroplasty (TKA) correlate with postsurgical satisfacti... more Preoperative expectations of total knee arthroplasty (TKA) correlate with postsurgical satisfaction, and are linked to outcomes. Rheumatoid arthritis (RA), and other chronic diseases, may lower expectations, although new biologic medications have greatly enhanced patients' quality of life. The purpose of this study is to compare preoperative expectations of RA to those of matched osteoarthritis (OA) patients undergoing TKA, and examine the subset of RA on biologic DMARD therapy. For a cross-sectional study, RA and OA identified from an institutional TKA registry were matched on age, sex, prior TKA, and preoperative function. Expectations were measured using the Hospital for Special Surgery (HSS) Knee Expectations Survey. Expectations and quality of life measures were assessed preoperatively and scores were compared between RA and OA. One hundred fourteen RA cases, 46.5% on biologics, were matched to 228 OA cases. The average expectations score was not significantly lower for RA ...

HSS journal : the musculoskeletal journal of Hospital for Special Surgery, 2006

Patients with rheumatoid arthritis (RA), an inflammatory arthritis that can destroy joint structu... more Patients with rheumatoid arthritis (RA), an inflammatory arthritis that can destroy joint structures, are often on multiple medications to control disease activity. These medications may have significant toxicities and side effects. Over the course of their lifetime, patients with this disease often require orthopedic procedures, including total joint arthroplasty, and the medications they are taking present management issues specific to the perioperative period. As many of these medications are immunosuppressive, the concern for postoperative infection and delayed wound healing are particularly worrisome. We conducted a review of the available literature pertaining to the perioperative use of the most commonly prescribed medications for RA. Although the existing data directly addressing perioperative complications in orthopedic surgery is sparse, information on relevant complications resulting from the general use of these drugs may be used as a basis for conservative recommendations.

The Journal of bone and joint surgery. American volume, 1989

The results in thirty-six knees that had a fracture of the patella after a total condylar arthrop... more The results in thirty-six knees that had a fracture of the patella after a total condylar arthroplasty were reviewed, and were analyzed according to the type of fracture and the alignment of the implant and the limb. Most of the fractures occurred two years or less after the initial operation. Fourteen knees were rated fair or poor and twenty-two, good or excellent. None of the thirty-six implants had been aligned in the neutral range. In sixteen knees, the alignment had a minor variation from the neutral range--that is, the knees were in minor malalignment. In general, these knees had the least severe fractures and the best over-all results. All had a good or excellent result except one, which was revised because of a loose patellar component. That knee was rated as fair at the latest follow-up. There was a major discrepancy in the alignment of twenty implants. These knees had more severe fractures and less satisfactory results than those in the other group. In two of these knees, ...

HSS journal : the musculoskeletal journal of Hospital for Special Surgery, 2013

Rhabdomyolysis (RML) can complicate prolonged surgery and may lead to renal failure and death. Ob... more Rhabdomyolysis (RML) can complicate prolonged surgery and may lead to renal failure and death. Obese patients are at high risk for this complication. This complication has been recently described in bariatric surgery and prolonged spine surgery, but it is not well recognized in patients undergoing THA. We present an obese patient (BMI = 50) who developed RML and acute kidney injury after a total hip arthroplasty.

HSS journal : the musculoskeletal journal of Hospital for Special Surgery, 2013

Prevention, early identification, and effective management of periprosthetic joint infection (PJI... more Prevention, early identification, and effective management of periprosthetic joint infection (PJI) in patients with inflammatory joint disease (IJD) present unique challenges for physicians. Discontinuing disease-modifying anti-rheumatoid drugs (DMARDs) perioperatively may reduce immunosuppression and infection risk at the expense of increasing disease flares. Interpreting traditional diagnostic markers of PJI can be difficult due to disease-related inflammation. This review is designed to answer how to (1) manage immunosuppressive/DMARD therapy perioperatively, (2) diagnose PJI in patients with IJD, and (3) treat PJI in this population. The PubMed database was searched for relevant articles with subsequent review by independent authors. While there is evidence to support the use of methotrexate perioperatively in RA patients, it remains unclear whether using anti-tumor necrosis factor medications perioperatively increases the risk of surgical site infections. Serum erythrocyte sedi...

Current Rheumatology Reports, 2008

HSS Journal, 2009

Osteonecrosis of the femoral head is a condition that affects upwards of 10,000 individuals in th... more Osteonecrosis of the femoral head is a condition that affects upwards of 10,000 individuals in the USA each year. The peak incidence is in the fourth decade of life, and overall, there is a male preponderance. The condition accounts for up to 12% of total hip arthroplasties performed in developed countries. The etiology can be traumatic or non-traumatic, with 90% of atraumatic cases attributed to corticosteroid therapy or excess alcohol consumption. Osteonecrosis of the femoral head reflects the final common pathway of a range of insults to the blood supply and ultimately results in femoral head collapse, acetabular involvement, and secondary osteoarthritis. Currently, conservative treatment options, which aim to correct pathophysiologic features allowing revascularization and new bone formation, appear to be able to delay but not halt the progression of this condition. As a consequence of femoral head osteonecrosis, many individuals undergo surgical treatments including: core decompression, osteotomy, non-vascularized bone matrix grafting, free vascularized fibular grafts, limited femoral resurfacing, total hip resurfacing, and total hip arthroplasty.

HSS Journal, 2010

Diseases of the connective tissue are a varied group of disorders with major musculoskeletal mani... more Diseases of the connective tissue are a varied group of disorders with major musculoskeletal manifestations such as joint pain and loss of function. As a consequence of the accompanying inflammatory joint disease, such patients often require surgery. Due to the protean organ-related consequences of these conditions, patients who suffer from chronic connective tissue disease are a highly challenging population in the perioperative context. This paper reviews the management of such patients in this clinical setting.

The Journal of Arthroplasty, 2014

Juvenile Idiopathic Arthritis (JIA) is a common rheumatologic disease that frequently involves th... more Juvenile Idiopathic Arthritis (JIA) is a common rheumatologic disease that frequently involves the hip joint and requires treatment with total hip arthroplasty (THA). A retrospective study with prospective follow-up was conducted to determine implant survival and patient-reported outcomes in JIA patients aged 35 or younger treated with THA. This study included 56 patients, and the mean time to follow-up was 12years. The 10-year implant survival was 85%, and implant survival was significantly longer in older patients (P value=0.04). Hip disability and osteoarthritis outcome (HOOS) scores were favorable at follow-up, but significantly worse in women and patients with custom implants or history of revision THA. Overall, patient factors and implant characteristics predict implant survival and outcomes after THA in young patients with JIA.

HSS Journal, 2007

Infection is a devastating complication following total knee replacement (TKR). In the majority o... more Infection is a devastating complication following total knee replacement (TKR). In the majority of cases, single-or two-stage revision has excellent results in eradicating infection and restoring function. Rarely, recurrent infection requires alternative treatments such as resection, amputation, or arthrodesis. A review of infections following TKR treated at two joint replacement centers identified 29 cases of resistant knee sepsis treated with a long intramedullary fusion nail. Clinical outcome and radiographs were reviewed at an average follow-up of 48 months (13-114). After the initial intramedullary arthrodesis union occurred in 24 of 29 patients (83%). The average time to fusion was 6 months (3-18 months). Failures included two cases of nail breakage, one of which subsequently achieved fusion following revision nailing, and three cases of recurrent infection requiring nail removal and permanent resection. At a minimum 2-year follow-up, 28% of the patients that achieved fusion complained of pain in the fused knee, 28% complained of ipsilateral hip pain, and two patients complained of contralateral knee pain. Four of the 25 fused patients (16%) remained nonambulatory after fusion, 17 required walking aids (68%) and only four ambulated unassisted. There was no association between age, number of previous procedures, the use of two-stage versus single stage technique, or infecting organism and failure of arthrodesis. Intramedullary arthrodesis is a viable treatment for refractory infection after TKR. Patients undergoing fusion should be informed of the potential for nonunion, recurrence of infection, pain in the ipsilateral extremity, and the longterm need for walking aids.

HSS Journal, 2010

Glenoid component loosening is one of the most common causes of failed total shoulder arthroplast... more Glenoid component loosening is one of the most common causes of failed total shoulder arthroplasty. Previous reports indicate that it is desirable to reimplant the glenoid component during revision shoulder arthroplasty. The purpose of our study was to retrospectively evaluate the satisfaction of patients undergoing glenoid revision (reimplantation or resection) following total shoulder replacement specifically for symptomatic glenoid loosening. Twenty-eight shoulders that developed symptomatic glenoid loosening following primary total shoulder arthroplasty were included in the study. Patients were retrospectively evaluated at a minimum of 2 years postoperatively. Patients either underwent resection followed by reimplantation of the glenoid component (13) or resection of the component with or without bone grafting (15). Each patient was evaluated with the UCLA Shoulder Scale and the Constant-Murley Shoulder Assessment. There were seven excellent, 13 good, five fair and three poor results on the UCLA score. Functional outcome scores trended higher in the reimplantation group but were not statistically significant. Both groups reported equal pain relief and satisfaction. Five out of 15 patients underwent arthroscopic resection of the glenoid, and these patients scored as well on the UCLA and Constant scores as the reimplantation group. When symptomatic glenoid loosening is the indication for revision total shoulder replacement, patients tend to achieve good to excellent results. Though functional scores were slightly higher in the reimplantation group, satisfaction was equally high in both groups. Resection, when indicated, should be performed arthroscopically as this improved functional outcome in our series.

Techniques in Knee Surgery, 2009

ABSTRACT Intramedullary arthrodesis for the treatment of the failed septic total knee arthroplast... more ABSTRACT Intramedullary arthrodesis for the treatment of the failed septic total knee arthroplasty results in a high rate of union but should be reserved as a salvage procedure in the management of failed septic total knee arthroplasty. If selected, it should be performed as a 2-staged procedure after the 2-stage protocol for joint reimplantation. It is a technically demanding procedure with high complication rate, and severe functional limitation resulting from a shortened limb requiring a high-energy gait pattern. The indication for fusion of the failed aseptic total knee is becoming increasingly rare as revision reconstructive options become more widespread.

Orthopedic Clinics of North America, 1998

Osteoarthritis is a slowly progressive disease of one or more joints that appears to primarily af... more Osteoarthritis is a slowly progressive disease of one or more joints that appears to primarily affect articular cartilage. A joint affected by osteoarthritis develops cartilage thinning and, ultimately, patches of complete cartilage loss. The main symptom of osteoarthritis in the glenohumeral joint is diffuse, achy, and insidiously progressive pain. Total shoulder arthroplasty has become the standard treatment for advanced osteoarthritis of the glenohumeral joint.

Arthritis & rheumatology (Hoboken, N.J.), Jan 24, 2015

To provide evidence-based recommendations for the treatment of patients with ankylosing spondylit... more To provide evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). A core group led the development of the recommendations, starting with the treatment questions. A literature review group conducted systematic literature reviews of studies that addressed 57 specific treatment questions, based on searches conducted in OVID Medline (1946-2014), PubMed (1966-2014), and the Cochrane Library. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. A separate voting group reviewed the evidence and voted on recommendations for each question using the GRADE framework. In patients with active AS, the strong recommendations included use of nonsteroidal antiinflammatory drugs (NSAIDs), use of tumor necrosis factor inhibitors (TNFi) when activity persists despite NSAID treatment, not to use systemic glucocorticoids, use of physical the...

The Journal of the American Academy of Orthopaedic Surgeons

Psoriatic arthritis is a chronic inflammatory arthropathy that affects approximately 6% to 48% of... more Psoriatic arthritis is a chronic inflammatory arthropathy that affects approximately 6% to 48% of patients with psoriasis. Arthritis is not correlated with the extent of skin disease. Classic radiographic findings of the involved joint include erosion, ankylosis, and fluffy periostitis. Site-specific characteristic deformities such as pencil-in-cup deformity of the phalanges also may be present. The disease typically follows a moderate course, but up to 47% of cases develop into destructive arthritis in which the inflammatory process leads to bony erosion and loss of joint architecture. The mainstay of treatment is biologic therapy (eg, tumor necrosis factor-α inhibitors) in conjunction with disease-modifying antirheumatic drugs. Patients with end-stage joint destruction may require surgery to alleviate pain and restore function. Orthopaedic surgeons should be cognizant of the risk factors (eg, increased risk of cardiovascular disease) and potential complications (eg, poor wound hea...

The Journal of Arthroplasty, 2015

Little data exists comparing acute post-operative outcomes in patients with different types of in... more Little data exists comparing acute post-operative outcomes in patients with different types of inflammatory arthritis (IA) after undergoing a total knee arthroplasty (TKA). Our objectives were to compare perioperative complications and determine the most common complications between the different IA subtypes compared with patients with osteoarthritis undergoing primary TKA. We found significant differences when comparing complications within the different subtypes of IA. RA patients, despite having a greater number of comorbidities had a reduced rate of medical complications postoperatively compared to the OA cohort. All of the inflammatory subtypes had a higher rate of orthopedic complications postoperatively compared to the OA group except for patients with AS. However, ankylosing spondylitis had the highest mortality rate as well as medical complication rate among the subtypes.

Introduction: Despite recent improvements in the medical treatment of various inflammatory arthro... more Introduction: Despite recent improvements in the medical treatment of various inflammatory arthropathies, patients suffering from these conditions often go on to require a total knee replacement (TKR). Little information exists comparing the short-term surgical complications of the different inflammatory arthropathies and osteoarthritis (OA) after TKR. Our objectives were (1) to compare perioperative complications and (2) determine the most common complications between the different IA subtypes compared with patients with osteoarthritis (OA) undergoing primary TKA. Methods: The Nationwide Inpatient Sample was used to identify 6,894,641 patients undergoing elective unilateral TKR between 2002-2011. Of this number 278,844 (4%) had an inflammatory arthropathy (IA), including rheumatoid arthritis (RA), psoriatic arthritis (PA), juvenile idiopathic arthritis (JIA), ankylosing spondylitis (AS), systemic lupus erythematosus (SLE). The prevalence of inpatient medical and orthopaedic complic...

The Journal of rheumatology, 2015

More adverse events (AE) are reported after total knee arthroplasty (TKA) for patients with rheum... more More adverse events (AE) are reported after total knee arthroplasty (TKA) for patients with rheumatoid arthritis (RA) than for patients with osteoarthritis (OA). This study evaluates 6-month postoperative AE in a high-volume center in a contemporary RA cohort. Patients with RA in an institutional registry (2007-2010) were studied. AE were identified by self-report and review of office and hospital charts. Subjects with RA were matched to 2 with OA by age, sex, and procedure. RA-specific surgical volume was determined. Baseline characteristics and AE were compared and analyzed. There were 159 RA TKA and 318 OA. Of the patients with RA, 88.0% were women, 24.5% received corticosteroids, 41.5% received biologics, and 67% received nonbiologic disease-modifying antirheumatic drugs (DMARD). There was no difference in comorbidities. RA-specific surgical volume was high; 64% of cases were performed by surgeons with ≥ 20 RA cases during the study period. Patients with RA had worse baseline pa...

The Journal of rheumatology, 2014

Total hip replacement (THR) outcomes have been worse for patients with rheumatoid arthritis (RA) ... more Total hip replacement (THR) outcomes have been worse for patients with rheumatoid arthritis (RA) compared with those who have osteoarthritis (OA). Whether this remains true in contemporary patients with RA with a high use of disease-modifying and biologic therapy is unknown. The purpose of our study is to assess pain, function, and quality of life 2 years after primary THR, comparing patients with RA and patients with OA. Baseline and 2-year data were compared between validated patients with RA and patients with OA who were enrolled in a single-center THR registry between May 1, 2007, and February 25, 2011. There were 5666 eligible primary THR identified, of which 193 were for RA. RA THR had worse baseline Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain (44.8 vs 53.2, p < 0.001) and function (38.7 vs 49.9, p < 0.001) compared with OA. These differences remained after surgery: pain (88.4 vs 94.0, p < 0.001) and function (82.9 vs 91.8, p < 0.001...

HSS journal : the musculoskeletal journal of Hospital for Special Surgery, 2014

Preoperative expectations of total knee arthroplasty (TKA) correlate with postsurgical satisfacti... more Preoperative expectations of total knee arthroplasty (TKA) correlate with postsurgical satisfaction, and are linked to outcomes. Rheumatoid arthritis (RA), and other chronic diseases, may lower expectations, although new biologic medications have greatly enhanced patients' quality of life. The purpose of this study is to compare preoperative expectations of RA to those of matched osteoarthritis (OA) patients undergoing TKA, and examine the subset of RA on biologic DMARD therapy. For a cross-sectional study, RA and OA identified from an institutional TKA registry were matched on age, sex, prior TKA, and preoperative function. Expectations were measured using the Hospital for Special Surgery (HSS) Knee Expectations Survey. Expectations and quality of life measures were assessed preoperatively and scores were compared between RA and OA. One hundred fourteen RA cases, 46.5% on biologics, were matched to 228 OA cases. The average expectations score was not significantly lower for RA ...

HSS journal : the musculoskeletal journal of Hospital for Special Surgery, 2006

Patients with rheumatoid arthritis (RA), an inflammatory arthritis that can destroy joint structu... more Patients with rheumatoid arthritis (RA), an inflammatory arthritis that can destroy joint structures, are often on multiple medications to control disease activity. These medications may have significant toxicities and side effects. Over the course of their lifetime, patients with this disease often require orthopedic procedures, including total joint arthroplasty, and the medications they are taking present management issues specific to the perioperative period. As many of these medications are immunosuppressive, the concern for postoperative infection and delayed wound healing are particularly worrisome. We conducted a review of the available literature pertaining to the perioperative use of the most commonly prescribed medications for RA. Although the existing data directly addressing perioperative complications in orthopedic surgery is sparse, information on relevant complications resulting from the general use of these drugs may be used as a basis for conservative recommendations.

The Journal of bone and joint surgery. American volume, 1989

The results in thirty-six knees that had a fracture of the patella after a total condylar arthrop... more The results in thirty-six knees that had a fracture of the patella after a total condylar arthroplasty were reviewed, and were analyzed according to the type of fracture and the alignment of the implant and the limb. Most of the fractures occurred two years or less after the initial operation. Fourteen knees were rated fair or poor and twenty-two, good or excellent. None of the thirty-six implants had been aligned in the neutral range. In sixteen knees, the alignment had a minor variation from the neutral range--that is, the knees were in minor malalignment. In general, these knees had the least severe fractures and the best over-all results. All had a good or excellent result except one, which was revised because of a loose patellar component. That knee was rated as fair at the latest follow-up. There was a major discrepancy in the alignment of twenty implants. These knees had more severe fractures and less satisfactory results than those in the other group. In two of these knees, ...

HSS journal : the musculoskeletal journal of Hospital for Special Surgery, 2013

Rhabdomyolysis (RML) can complicate prolonged surgery and may lead to renal failure and death. Ob... more Rhabdomyolysis (RML) can complicate prolonged surgery and may lead to renal failure and death. Obese patients are at high risk for this complication. This complication has been recently described in bariatric surgery and prolonged spine surgery, but it is not well recognized in patients undergoing THA. We present an obese patient (BMI = 50) who developed RML and acute kidney injury after a total hip arthroplasty.

HSS journal : the musculoskeletal journal of Hospital for Special Surgery, 2013

Prevention, early identification, and effective management of periprosthetic joint infection (PJI... more Prevention, early identification, and effective management of periprosthetic joint infection (PJI) in patients with inflammatory joint disease (IJD) present unique challenges for physicians. Discontinuing disease-modifying anti-rheumatoid drugs (DMARDs) perioperatively may reduce immunosuppression and infection risk at the expense of increasing disease flares. Interpreting traditional diagnostic markers of PJI can be difficult due to disease-related inflammation. This review is designed to answer how to (1) manage immunosuppressive/DMARD therapy perioperatively, (2) diagnose PJI in patients with IJD, and (3) treat PJI in this population. The PubMed database was searched for relevant articles with subsequent review by independent authors. While there is evidence to support the use of methotrexate perioperatively in RA patients, it remains unclear whether using anti-tumor necrosis factor medications perioperatively increases the risk of surgical site infections. Serum erythrocyte sedi...

Current Rheumatology Reports, 2008

HSS Journal, 2009

Osteonecrosis of the femoral head is a condition that affects upwards of 10,000 individuals in th... more Osteonecrosis of the femoral head is a condition that affects upwards of 10,000 individuals in the USA each year. The peak incidence is in the fourth decade of life, and overall, there is a male preponderance. The condition accounts for up to 12% of total hip arthroplasties performed in developed countries. The etiology can be traumatic or non-traumatic, with 90% of atraumatic cases attributed to corticosteroid therapy or excess alcohol consumption. Osteonecrosis of the femoral head reflects the final common pathway of a range of insults to the blood supply and ultimately results in femoral head collapse, acetabular involvement, and secondary osteoarthritis. Currently, conservative treatment options, which aim to correct pathophysiologic features allowing revascularization and new bone formation, appear to be able to delay but not halt the progression of this condition. As a consequence of femoral head osteonecrosis, many individuals undergo surgical treatments including: core decompression, osteotomy, non-vascularized bone matrix grafting, free vascularized fibular grafts, limited femoral resurfacing, total hip resurfacing, and total hip arthroplasty.

HSS Journal, 2010

Diseases of the connective tissue are a varied group of disorders with major musculoskeletal mani... more Diseases of the connective tissue are a varied group of disorders with major musculoskeletal manifestations such as joint pain and loss of function. As a consequence of the accompanying inflammatory joint disease, such patients often require surgery. Due to the protean organ-related consequences of these conditions, patients who suffer from chronic connective tissue disease are a highly challenging population in the perioperative context. This paper reviews the management of such patients in this clinical setting.

The Journal of Arthroplasty, 2014

Juvenile Idiopathic Arthritis (JIA) is a common rheumatologic disease that frequently involves th... more Juvenile Idiopathic Arthritis (JIA) is a common rheumatologic disease that frequently involves the hip joint and requires treatment with total hip arthroplasty (THA). A retrospective study with prospective follow-up was conducted to determine implant survival and patient-reported outcomes in JIA patients aged 35 or younger treated with THA. This study included 56 patients, and the mean time to follow-up was 12years. The 10-year implant survival was 85%, and implant survival was significantly longer in older patients (P value=0.04). Hip disability and osteoarthritis outcome (HOOS) scores were favorable at follow-up, but significantly worse in women and patients with custom implants or history of revision THA. Overall, patient factors and implant characteristics predict implant survival and outcomes after THA in young patients with JIA.

HSS Journal, 2007

Infection is a devastating complication following total knee replacement (TKR). In the majority o... more Infection is a devastating complication following total knee replacement (TKR). In the majority of cases, single-or two-stage revision has excellent results in eradicating infection and restoring function. Rarely, recurrent infection requires alternative treatments such as resection, amputation, or arthrodesis. A review of infections following TKR treated at two joint replacement centers identified 29 cases of resistant knee sepsis treated with a long intramedullary fusion nail. Clinical outcome and radiographs were reviewed at an average follow-up of 48 months (13-114). After the initial intramedullary arthrodesis union occurred in 24 of 29 patients (83%). The average time to fusion was 6 months (3-18 months). Failures included two cases of nail breakage, one of which subsequently achieved fusion following revision nailing, and three cases of recurrent infection requiring nail removal and permanent resection. At a minimum 2-year follow-up, 28% of the patients that achieved fusion complained of pain in the fused knee, 28% complained of ipsilateral hip pain, and two patients complained of contralateral knee pain. Four of the 25 fused patients (16%) remained nonambulatory after fusion, 17 required walking aids (68%) and only four ambulated unassisted. There was no association between age, number of previous procedures, the use of two-stage versus single stage technique, or infecting organism and failure of arthrodesis. Intramedullary arthrodesis is a viable treatment for refractory infection after TKR. Patients undergoing fusion should be informed of the potential for nonunion, recurrence of infection, pain in the ipsilateral extremity, and the longterm need for walking aids.

HSS Journal, 2010

Glenoid component loosening is one of the most common causes of failed total shoulder arthroplast... more Glenoid component loosening is one of the most common causes of failed total shoulder arthroplasty. Previous reports indicate that it is desirable to reimplant the glenoid component during revision shoulder arthroplasty. The purpose of our study was to retrospectively evaluate the satisfaction of patients undergoing glenoid revision (reimplantation or resection) following total shoulder replacement specifically for symptomatic glenoid loosening. Twenty-eight shoulders that developed symptomatic glenoid loosening following primary total shoulder arthroplasty were included in the study. Patients were retrospectively evaluated at a minimum of 2 years postoperatively. Patients either underwent resection followed by reimplantation of the glenoid component (13) or resection of the component with or without bone grafting (15). Each patient was evaluated with the UCLA Shoulder Scale and the Constant-Murley Shoulder Assessment. There were seven excellent, 13 good, five fair and three poor results on the UCLA score. Functional outcome scores trended higher in the reimplantation group but were not statistically significant. Both groups reported equal pain relief and satisfaction. Five out of 15 patients underwent arthroscopic resection of the glenoid, and these patients scored as well on the UCLA and Constant scores as the reimplantation group. When symptomatic glenoid loosening is the indication for revision total shoulder replacement, patients tend to achieve good to excellent results. Though functional scores were slightly higher in the reimplantation group, satisfaction was equally high in both groups. Resection, when indicated, should be performed arthroscopically as this improved functional outcome in our series.

Techniques in Knee Surgery, 2009

ABSTRACT Intramedullary arthrodesis for the treatment of the failed septic total knee arthroplast... more ABSTRACT Intramedullary arthrodesis for the treatment of the failed septic total knee arthroplasty results in a high rate of union but should be reserved as a salvage procedure in the management of failed septic total knee arthroplasty. If selected, it should be performed as a 2-staged procedure after the 2-stage protocol for joint reimplantation. It is a technically demanding procedure with high complication rate, and severe functional limitation resulting from a shortened limb requiring a high-energy gait pattern. The indication for fusion of the failed aseptic total knee is becoming increasingly rare as revision reconstructive options become more widespread.

Orthopedic Clinics of North America, 1998

Osteoarthritis is a slowly progressive disease of one or more joints that appears to primarily af... more Osteoarthritis is a slowly progressive disease of one or more joints that appears to primarily affect articular cartilage. A joint affected by osteoarthritis develops cartilage thinning and, ultimately, patches of complete cartilage loss. The main symptom of osteoarthritis in the glenohumeral joint is diffuse, achy, and insidiously progressive pain. Total shoulder arthroplasty has become the standard treatment for advanced osteoarthritis of the glenohumeral joint.