Biomedical subjects
Publications and source records attributed to A H Wilde.
A 64-year-old man with total knee arthroplasty for tricompartmental osteoarthritis had a postoperative course complicated by an attack of acute cholecystitis and was treated with cholecystectomy. The TKA was hematogenously seeded with Clostridium perfringens, which necessitated emergency removal of the implants, debridement, and ultimately arthrodesis.
Twenty-one infected total knee arthroplasties (TKA) in 21 patients were treated from September 1980 through October 1987. Of these, 15 were followed for more than one year. Treatment of these patients consisted of thorough debridement of all infected tissue and components; a cement spacer was used in ten patients. The cement was impregnated with antibiotics. This procedure was followed for an average of 4.2 weeks with intravenous antibiotics and TKA utilizing antibiotic-impregnated cement. Five patients had rheumatoid arthritis and ten had osteoarthritis. The organisms included Staphylococcus coagulase negative (seven patients), Streptococcus group B (two patients), Streptococcus bovis (one patient), Enterococcus (one patient), Staphylococcus coagulase positive and Bacillus circulans (one patient), Staphylococcus coagulase negative and Enterococcus (one patient), Staphylococcus coagulase negative and Pseudomonas aeuriginosa (one patient), and Clostridium perfringens (one patient). Of the 15 patients, 12 appeared to be free of infection, two were obvious failures and required knee fusion, and one was suspected of having continued infection at five years and was treated elsewhere. Eleven patients with revision TKA were available for follow-up examinations at an average of 2.9 years (range, one to six years). One patient died five years after reimplantation but had been functioning well. One patient functioning at three years postreimplantation did not return for a later follow-up examination. The average knee score (modification of the Hospital for Special Surgery Knee Score) was 75.5 points (range, 48-94); average flexion was 81 degrees (range, 52 degrees-120 degrees), and average extension was +6 degrees (range, 0 degrees-30 degrees).(ABSTRACT TRUNCATED AT 250 WORDS)
Infection with Candida albicans of a total knee arthroplasty developed in an immunosuppressed 52-year-old woman with rheumatoid arthritis who initially presented with clear drainage from the incision, which cultured negative initially. Successful treatment consisted initially of debridement and a course of intravenous antibiotics, followed by staged arthrodesis with an intramedullary rod.
This article describes the current indications, contraindications, and results of shoulder fusion. The preferred position, AO technique, and complications are described.
A series of 35 capitellocondylar total elbow arthroplasties was performed on 29 patients. The average patient age at the time of surgery was 58 years (range, 28-71 years). Follow-up study averaged 5.6 years (range, 2-8 years). The complication rate was 57%. There were three infections, three dislocations, and two intraoperative fractures. Transient ulnar nerve palsy occurred in nine patients, postoperative hematomas in two patients, and intraoperative perforation of the ulna cortex in one patient. Aseptic loosening occurred around the humeral component of one elbow. No ulnar components developed aseptic loosening. Range of motion increased in all planes, except extension. Pain relief was achieved in all but one patient. There were no unstable elbows.
In twenty-one hips of twenty-one patients, the acetabulum was reconstructed using allografts during revision of a total hip arthroplasty. The patients' average age at the time of revision was 64.3 years (range, nineteen to eighty-six years). At an average follow-up of 3.5 years (range, two to five years), three patients had died of causes unrelated to the hip reconstruction, and one had been lost to follow-up. In the other seventeen, the average Harris hip rating was 89 points (range, seventy to 100 points) at follow-up. In one patient the allograft collapsed, so that revision was required. Two patients had asymptomatic progressive radiolucencies at the cement-bone interface of the reconstructed acetabulum, and another had a 1.5-millimeter-wide lucency at the interface of the donor and recipient bone but was asymptomatic, and there had been no change in the position of the cemented acetabular component since operation. The remaining grafts appeared to be incorporated securely, as determined by radiographic examination. Three-dimensional computerized tomographic radioisotopic bone scans showed uniform uptake, consistent with revascularization and new-bone formation, in all grafts. There was no radiographic evidence of focal avascularity and there were no infections. Femoral-head bone allografts appear to provide a useful technique for the reconstruction of a severely deficient acetabulum during revision total hip arthroplasty.
One hundred consecutive Müller curved-stem total hip replacements were reviewed ten years after operation. Twenty patients with twenty-two arthroplasties had died within the ten-year period without having a revision, and twenty-five arthroplasties had been revised for various reasons. Of the remaining fifty-three arthroplasties, thirty-five were classified as good or excellent, with Harris hip scores of 80 points or higher, and eighteen were classified as poor or fair, with scores lower than 80 points. Follow-up radiographs, made for all but six of the fifty-three hips at ten years, showed a 23 per cent incidence of migration of the acetabular component and a 28 per cent incidence of migration of the femoral component. In addition, there was a 15 per cent incidence of bone resorption in the proximal end of the femur without migration of the femoral component and a 4 per cent incidence of osteolytic defects about the femoral component, also without migration. Combining the radiographically loose replacement (migration) with the clinically loose ones (revised), the over-all incidence of aseptic loosening was 29 per cent for the acetabular component and 40 per cent for the femoral component. There was a positive correlation between the incidence of loosening of the femoral component and younger age, heavier weight, male sex, unilateral hip disease, a wide femoral canal, and varus position of the femoral component, whereas the incidence of loosening of the acetabular component was increased only in association with older age. The rate of loosening of the femoral component appeared to be higher during the early follow-up period and to decrease with time, while the rate of loosening of the acetabular component appeared to be lower during the early follow-up period but to increase with time.
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When aseptic failure of the bond between the cement and the prosthesis of a total joint replacement occurs, complete removal of the cement has been advocated before the insertion of a new prosthesis. The present study questions this practice. Both laboratory tests on variously prepared specimens of cement and clinical experiences demonstrate that recementing over old cement is a practical alternative if the technique employed includes the removal of blood from the old cement surface, rasping of this surface and the early application of fresh cement.
We tested the Herbert knee prosthesis, which was designed to restore intrinsic stability with limited degrees of freedom for rotation to severely damaged or deformed knees, in a knee simulator. These tests indicated a tendency for the prosthesis to fracture through the medial femoral housing after cycling for the equivalent of one to three years of normal use. In a clinical series of thirty-five knees treated with the prosthesis, there were five failures similar to those produced by laboratory testing. On the basis of this combined study, the Herbert prosthesis appears to have design characteristics that seriously limit its usefulness for long-term knee replacement. Testing in a knee simulator in this case appeared to be a valid predictor of clinical failure.
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The Ruiz-Mora procedure has been advocated for the correction of hammertoe deformities and congenital overlapping of the fifth toe, primarily on empirical grounds. This is a review of forty-one such procedures in which the operation was used for correction of a hammertoe deformity of the fifth toe with a painful corn overlying the proximal interphalangeal joint. Twenty-two patients with thirty-one procedures were followed for an average of 3.5 years. All of the patients had complete relief of symptoms and correction of deformity. However, in 23 per cent of the patients a painful prominent head of the fifth metartarsal or a bunionette developed, and in 32 per cent a hammertoe deformity of the adjacent fourth toe developed with a painful corn either over the proximal interphalangeal joint or on the tip of the fourth toe. These problems seem to be related to excessive shortening of the the fifth toe. Less bone resection (resection of only the head and neck of the proximal phalanx) might be preferable and might not lead to these complications.
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