Porosis around prosthesis.
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Absorptiometry, Photon↗
Biomedical subjects
B N Stulberg
Publications and source records attributed to B N Stulberg.
Preoperative nutritional status of total joint patients. Relationship to postoperative wound complications.
The records of 217 consecutive patients who underwent a primary total hip or total knee arthroplasty were reviewed for preoperative and postoperative nutritional status. Fifty-seven patients had a lymphocyte count of less than 1,500 cells/mm3, four patients had an albumin level of less than 3.5 g/dL, and two patients had both, giving a 27% incidence of indices indicative of preoperative nutritional depletion. Patients without wound complications had an average preoperative lymphocyte count of 1,995 (+/- 631), compared to 1,638 (+/- 491) for those with persistent serous drainage from their wounds, and 1,553 (+/- 419) for those patients with a major wound complication (P = .002). The average albumin levels were 4.30 (+/- 0.33), 4.22 (+/- 0.31), and 4.13 (+/- 0.54), respectively. Patients with rheumatoid arthritis were compared to those with osteoarthritis and were found to have significantly lower preoperative albumin levels. They were three times as likely to develop a major wound complication. Patients on immunosuppressive medications had significantly lower preoperative lymphocyte counts, lower albumin levels, and higher complication rates (P = .04). After operation, lymphocyte counts of all patients dropped to an average of 57% of their preoperative values, and albumin levels dropped to 72% of their preoperative values. No nutritional parameters had returned to their preoperative levels by 10 postoperative days. For all patients, a preoperative lymphocyte count of less than 1,500 cells/mm was associated with a five times greater frequency of developing a major wound complication, and an albumin level of less than 3.5 g/dL had a seven times greater frequency.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
A new model to assess tibial fixation in knee arthroplasty. I. Histologic and roentgenographic results.
A model to assess tibial fixation in knee arthroplasty is described. Eighteen mongrel dogs were implanted with a right tibial hemiarthroplasty. Implantation was of a press-fit, smooth implant (eight dogs) or a titanium alloy beaded device (ten dogs). Animals were studied at six, 12, 18, and 24 weeks. Roentgenographic and histologic analysis was performed for all implants. All animals were ambulatory. Roentgenographically, smooth implants showed progressive radiolucencies with increasing trabecular sclerosis under the implants. These changes were less prominent under the porous implants. Histologically, fibrous interfaces were identified focally under all implants but were thicker under smooth devices. Eighteen- and 24-week specimens showed substantial ingrowth into the porous pegs but minimal ingrowth into the porous plateau. Concurrent histologic and biochemical evaluation in dogs demonstrates the possible fate of implants in knee arthroplasty in human beings. As has been observed, histologic analyses suggest that clinically satisfactory results do not constitute evidence of stabilization by bone ingrowth.
Animals↗
A new model to assess tibial fixation. II. Concurrent histologic and biomechanical observations.
A tibial hemiarthroplasty model was designed to allow concurrent histologic and biomechanical analysis of the tibial implant-bone interface. In this study, micromotion was visually observed at the implant-bone interface of cemented and uncemented implants. Six dogs had staged bilateral implantation. Biomechanical analysis of three- and 12-month specimens was correlated with histologic analysis of the same specimen. Load transmission involved compression of trabecular bone and fibrous tissue at the interface. Failure of the interface occurred through cyclic fatigue and microfracture of trabeculae. Micromotion was seen at all interfaces, porous or smooth, cemented or uncemented. Displacement was greatest under an eccentrically loaded plateau. Micromotion at ingrown and cemented interfaces was because of trabecular compression. Uncemented smooth devices and uncemented porous devices with fibrous fixation of the plateau appeared unstable. The cemented implants and a single uncemented implant studied at 12 months showed no interface micromovement. The absence of micromovement in the uncemented implant was associated with subsidence and with ingrowth of 30% into the porous peg and porous plateau.
Animals↗
Osteonecrosis of the femoral head. A prospective randomized treatment protocol.
Conservative treatment versus core decompression for cases of osteonecrosis (ON) of the femoral head was prospectively reviewed in 36 patients. A preoperative evaluation of the patients' history, physical examination, Harris Hip Score, roentgenograms, computed tomography, bone scan, magnetic resonance imaging, and measurement of the intraosseous pressure was used to grade the level of ON according to a rating system developed by Ficat. Hips were randomized to core decompression or conservative treatment groups. Fifty-five hips in 36 patients were randomized (29 surgical and 26 conservative). When success was gauged by Harris Hip Scores for Stage I hips, treatment was successful for seven of ten (70%) operatively treated hips and one of five (20%) non-operatively treated hips. Among Stage II hips, treatment was successful for five of seven (71%) decompressed hips and none of seven conservatively treated hips. Successful treatment was accomplished in eight of 11 hips (73%) and one of ten hips (10%) in decompression and conservative groups, respectively, for Stage III hips. Stages 0 and IV had groups too small for comparison. Less successful results were seen if roentgenographic criteria of success were used. Survival analysis showed more favorable results with surgical treatment. Core decompression produced better results than conservative treatment in the early stages of ON.
Adolescent↗
Expandable breast implant reconstruction of Tikhoff-Linberg shoulder deformity.
Expanding breast implants were used in two patients to reconstruct shoulder contour following a Tikhoff-Linberg resection for cancer. In the first patient, one implant alone was used, and in the second patient, two implants in separate but adjacent pockets. The resulting double contour is more pleasing than that after a single implant, and there also appears to be more flexibility with shoulder motion. This method is suggested as an excellent means of reconstructing the contour of the shoulder area following resection for cancer.
Breast↗
Prevention of venous thrombosis after total knee arthroplasty. Comparison of antithrombin III and low-dose heparin with dextran.
In a prospective, randomized trial, we compared the efficacy of a combination of antithrombin III and heparin with that of dextran 40 as prophylaxis against venous thrombosis after total knee arthroplasty. Ascending venography identified thrombosis in about one-third of the patients who received the combination of antithrombin III and heparin, compared with about four-fifths of those who received dextran (p less than 0.001). In both groups, the patients who had venous thrombosis had a significantly lower concentration of antithrombin III postoperatively than those who did not have thrombosis. Venous thrombosis occurred in all patients in whom the concentration of antithrombin III was less than 65 per cent postoperatively. These findings demonstrated that, after total knee replacement, the combination of antithrombin III and heparin effectively reduces the incidence of postoperative venous thrombosis and is significantly better than dextran. Furthermore, the findings suggested a relationship between postoperative deficiency of antithrombin III and the occurrence of thrombotic complications.
Adult↗
Making core decompression work.
Meaningful assessment of a treatment modality for osteonecrosis (ON) must take into account a number of factors: (1) an accurate diagnosis, (2) consistent staging of the disease process, (3) understanding of the variability of the disease, (4) consistent application of the treatment modality (or the surgical technique), and (5) a clear understanding of the goal of the treatment used. This article reviews the important steps of a diagnostic algorithm that has been used to accurately diagnose and stage the disease process of ON. A consistent surgical technique with clearly defined goals is also outlined. The results of two clinical studies that were based on these diagnostic and therapeutic philosophies and that assess the role of core decompression in the treatment of ON are reviewed. The first study compared core decompression to conservative management in a prospective randomized study of 55 hips. Decompression provided more predictable pain relief and changed the indications for further surgical intervention more consistently than did conservative management. The second study represents a preliminary review of a ten-year study of the decompression procedure; it showed that core decompression was particularly useful in Stage I and Stage II ON. Roentgenographic stabilization was most predictable for Stage I hips. Core decompression can be a safe, effective, and predictable procedure in the treatment of Stage I and Stage II ON.
Adult↗
The incorporation of tibial allografts in total knee arthroplasty.
Twelve knees in ten patients had revision total knee replacement with insertion of an allograft for a large tibial defect. The knees were retrospectively evaluated at an average of thirty-two months (range, twenty-five to fifty-one months) by clinical examination, radiography, planar bone scintigraphy, and single-photon-emission computed tomography. The average age of the patients was sixty-two years (range, fifty-four to seventy-nine years). A constrained total-condylar prosthesis was used for all revisions. A contained tibial defect was present in five knees, and seven knees had an uncontained defect that was treated with a massive composite structural allograft, five of which were secured with internal fixation. The knee scores improved from an average of 51 points before operation to an average of 87 points post-operatively. Seven knees had a score of 85 points or more and were considered to have an excellent clinical result. Two knees had a good result, with scores of 77 and 72 points. One knee had another revision because of painful non-union of a medial structural graft, and the result in that knee was considered a failure. The average range of motion improved from 84 degrees to 105 degrees. There were no deep infections, and no graft showed evidence of fracture or collapse. Radiographs demonstrated complete incorporation of the graft in eleven of the twelve knees at an average of twenty-three months after operation. Single-photon-emission computed-tomography scans showed uniform activity in the area of the graft in four of the five knees that were studied.
Aged↗
Fat embolism associated with cementing of femoral stems designed for press-fit application.
The authors report four cases of fat embolism syndrome following total hip arthroplasty using cementless acetabular press-fit components and cemented press-fit femoral components. Factors implicated in the production of this syndrome following "hybrid" total hip arthroplasty include increased canal pressure during femoral reaming and prosthetic insertion, retained marrow elements and reaming debris, and the use of lumbar epidural anesthesia. This potentially fatal syndrome must be a recognized complication following the use of cemented press-fit femoral stems. Specific recommendations for decreasing the incidence of this complication are reviewed.
Aged↗
Management of orthopedic complications of metabolic bone disease.
Orthopedic manifestations of metabolic bone disease are usually related to structural compromise of the skeleton. Fractures due to osteoporosis are the most often encountered problem. In this overview, the authors focus on the commonly encountered fractures related to osteoporosis and discuss concerns and complications related to their management. In addition, they point out the subtle ways in which less commonly encountered metabolic bone diseases, such as osteomalacia, hyperparathyroidism, and Paget's disease, might come to the attention of the orthopedist. Appropriate criteria for medical and surgical management are suggested.
Bone Diseases, Metabolic↗
Antithrombin III/low-dose heparin in the prevention of deep-vein thrombosis after total knee arthroplasty. A preliminary report.
This preliminary report outlines the rationale for a new approach to deep-vein thrombosis (DVT) prophylaxis in total knee arthroplasty (TKA) patients and describes preliminary hematologic and venographic findings. A protocol was employed to (1) document a series of hematologic events surrounding cemented TKA and the alterations of these events by the study drugs and (2) compare the safety and efficacy of a regimen of antithrombin III/low-dose heparin (ATIII/LDH) to that of low-molecular-weight dextran (LMWD) in the prevention of DVT after TKA. Using a dosage regimen of 3000 units of ATIII as a loading dose followed postoperatively by 2000 units daily combined with 5000 units of LDH twice daily, a prospective randomized study of patients treated by cemented TKA was performed. The ATIII/LDH regimen was compared with LMWD (10 ml/kg x 12 hours loading dose followed by 7 ml/kg x 24 hours maintenance dose). The rate of DVT after TKA in 42 patients was 25% (5/20) for the ATIII/LDH group versus 82% (18/22) for the LMWD group (p less than 0.001). Bleeding complications were minimal and comparable for each group. Hematologic studies demonstrated that quantitative and functional ATIII levels decreased after TKA and that preoperative loading with ATIII prevented levels from falling below 100%. Studies of clot formation (fibrinopeptide A) and plasmin activity (fibrinopeptides B beta 15-42 and 1-42) in 34 patients suggest some reduction in procoagulant activity in patients in the ATIII/LDH group. These findings indicate that the combination of ATIII and LDH may offer superior protection from DVT than does LMWD.
Antithrombin III↗
Bone quality. Roentgenographic versus histologic assessment of hip bone structure.
Bone quality is an accepted criterion for determining fixation options for total hip arthroplasty (THA). Eighty patients with 95 uncemented THAs were evaluated by comparing preoperative roentgenographic assessment with histologic evaluation of bone biopsy specimens obtained from the ipsilateral iliac crest. Roentgenographic analysis of bone quality was performed using the Singh and Engh indices. Histologic evaluation employed a quantitative analysis of static and dynamic parameters of bone turnover on undecalcified sections. Extensive statistical analysis comparing roentgenographic with histologic parameters of bone quality showed: (1) no relationship of the two roentgenographic indices to trabecular bone volume and most other histologic parameters and (2) a high incidence of bone abnormalities. Bone quality is an imprecise term and is inadequately measured by these roentgenographic indices. Histologic measurement offers a more precise means of analyzing the relationship of the bone environment to the performance of the THA.
Biopsy↗
A diagnostic algorithm for osteonecrosis of the femoral head.
For patients considered at risk for osteonecrosis (ON) of the femoral head, an algorithm for the efficient and appropriate use of diagnostic tests can be developed. Such an algorithm requires a clear idea of the evolution of the disease process and an understanding of the limitations of each of the modalities by which the disease process can be identified. The role of each of the diagnostic tests available for the diagnosis of ON and the results of prospective evaluations to assess their sensitivity, specificity, and predictive values are reviewed. No single diagnostic test is 100% accurate in the diagnosis of the disease. Thus, one must consider an algorithm that accounts for the variable nature of the disease presentation. The goal of such an algorithm is the accurate identification and staging of the disease. For disease not roentgenographically apparent, an approach using magnetic resonance imaging and bone scanning is recommended. For disease that is apparent roentgenographically, tomography is used to define the extent of the disease and the presence or absence of subchondral fracture. The accuracy of diagnosis is critical to understanding the role of the various treatment modalities prescribed for ON. For this purpose, it is necessary to reach a consensus as to what constitutes a successful outcome of treatment. Once diagnosis of the disease is accepted, clinical success of treatment outcomes should be reported in three ways: by a standard hip rating system, by ability to prevent roentgenographic deterioration, and by survival of the femoral head (the absence of further treatment intervention).(ABSTRACT TRUNCATED AT 250 WORDS)
Algorithms↗
The rationale, design characteristics, and preliminary results of a primary custom total hip prosthesis.
Seventy-three primary custom-made uncemented hip implants have been inserted since July 1987. The initial clinical results are equivalent to those of conventionally made components, but there has been less residual and recurrent thigh pain with the custom devices. The custom implants have achieved 20% greater canal fill with much less variation than conventionally made devices. Custom components have been particularly useful in patients with significant anatomic deformity and associated arthritis.
Bone Cements↗
Multimodality approach to osteonecrosis of the femoral head.
Treatment of osteonecrosis of the femoral head appears to be effective when the disease is identified and treated early. Forty-one patients were evaluated with prospective laboratory assessment, anteroposterior and frog-lateral roentgenograms of both hips, intraosseous pressure measurements (IOP), magnetic resonance imaging (MRI), and 99mTc methylene diphosphonate planar and single-photon emission computerized tomographic (SPECT) bone imaging. Pathologic specimens were obtained in most patients. Preradiographic disease was identified in 26 hips and 11 of these were asymptomatic. Fifteen clinically symptomatic hips had normal plain roentgenograms, but abnormal protocol studies. Evaluation of sensitivity, specificity, and predictive value (positive and negative), respectively, in diagnosing osteonecrosis of the femoral head revealed the following percentages: 83%, 83%, 96%, and 48% for planar bone scanning; 91%, 78%, 94%, and 70% for SPECT; 87%, 83%, 96%, and 55% for MRI; 80%, 60%, 95%, and 25% for IOP; and 88%, 100%, 100%, and 25% for core biopsy. (There were few true negatives, thus specificity values are approximations.) The identification of preradiographic stages is possible, but difficult. MRI appears appealing at present, particularly in identifying disease in asymptomatic hips. However, there is no definitive method for noninvasive diagnosis. Pathologic confirmation in early stages is difficult.
Adolescent↗
Failure mechanisms of metal-backed patellar components.
A specific type of failure of a metal-backed patella occurred, consisting of a separation of the polyethylene from the metal backing. This dissociation is followed by wearing of the metal backing against the femoral component. This produces clinical signs and symptoms that usually require revision. This failure occurred in 16 knees of 14 patients. Average time to failure was 14 months. Failure was associated with patellar implant design, surgical technique, patient characteristics, and femoral component design. The plastic of the metal-backed patellae was thin at the periphery. The metal plate did not extend to the edge of the plastic and acted like a sharp edge that cut the thin plastic. The plastic dome was not bonded to the plate and became separated from the plate once the plastic tore. The plate became deformed. Failure was more likely with a subluxated, tilted, or excessively thick patella or flexed femoral component. The typical patient was a large, active male who had achieved more than 115 degrees of flexion. A prominent edge on the lateral intercondylar ridge of the femoral component resulted in a concentrated load being applied to the plastic dome and favored rapid wear of the patella. Until a greater understanding of patello-femoral loading is acquired, caution in the use of metal-backed patellae is recommended.
Aged↗
In vivo measurement of platelet activity in postoperative patients.
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Aspirin↗