Results of revision total hip replacement.
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Adult↗
Biomedical subjects
C B Sledge
Publications and source records attributed to C B Sledge.
Intravenous methylmethacrylate after total hip replacement.
In eight patients, radiographs made after total hip replacement revealed methylmethacrylate in the soft tissues of the thigh. In one of them the configuration of the density was that of a vein. In the other seven patients similar but less extensive soft-tissue densities were seen postoperatively. One patient had postoperative hypotension which was thought to be due to a myocardial infarction. In another patient, with a prior history of congestive heart failure, congestive heart failure developed again after total hip replacement. The relationship of these complications to the radiographic observations was not clear.
Aged↗
Hip fracture mortality. Relation to age, treatment, preoperative illness, time of surgery, and complications.
This retrospective analysis of 406 patients with proximal femoral fractures was designed to identify both the significant and nonsignificant risk factors that influence patient mortality. The 399 patients treated by open reduction and internal fixation or femoral head prostheses routinely received prophylactic antibiotics and anticoagulants. Of 406 patients followed until death or for at least one year, the overall mortality rate at one year was 14% (58/406). For patients with subcapital fractures the rate was 13% (25/187) and with intertrochanteric fractures 15% (33/219). The expected mortality rate for the normal population of similar age was about 9%. Sex, treatment of subcapital fracture by either internal fixation or arthroplasty, and the level of postoperative ambulation did not influence mortality. The number of preexisting medical conditions and the time of surgery following admission were highly significant factors (p less than or equal to 0.001 for both). The number of postoperative medical complications was also significant. The recommendation is for serious medical conditions to be maximally stabilized for at least 24 hours and pulmonary and physical therapy instituted before scheduling open surgical procedures.
Age Factors↗
Breakdown of cartilage proteoglycan in a tissue culture model of rheumatoid arthritis.
Proteoglycan breakdown was studied in a coculture model which mimics the confrontation between synovium and cartilage that occurs in rheumatoid arthritis. Bovine nasal-septum cartilage discs radioactively labeled (35SO2-4 with or without [3H]glucosamine) and 'chased' in non-radioactive medium were cultured in contact with minced rheumatoid synovial membranes for intervals up to 8 days. Synovium-stimulated (2-3-fold) cartilage breakdown was unaffected by ascorbate supplementation. Labeled products (small molecules plus proteoglycan complexes) in culture media were characterized by chromatographic, sedimentation and enzymic digestion methods. Breakdown was dominated by the release of a range of proteoglycan products, fully disaggregated and incapable of reaggregation with added hyaluronate. Because constituent glycosaminoglycans were of uniform size, proteoglycan polydispersity was attributed to differences in core protein length. Hydrocortisone inhibited degradation and partially prevented the shift of proteoglycans to lower average molecular weight. An additional breakdown pattern occasionally noted during the initial 48 h of coculture was characterized by release of a subpopulation of low charge-density proteoglycan bearing shortened glycosaminoglycan chains, consistent with glycosidase action. We conclude that rheumatoid synovia exhibit two distinct cartilage degradative potencies in vitro that may be important in vivo: (a) A variable hyaluronidase-like activity at early culture times, and (b) a dominant proteolytic activity generating an array of disaggregated proteoglycan products that differ largely on the basis of their core lengths. The response to hydrocortisone is consistent with inhibition of proteolysis through the stabilization of cellular membranes.
Animals↗
Synovial factors and chondrocyte-mediated breakdown of cartilage: inhibition by hydrocortisone.
Cartilage-synovium interactions were explored in a model culture system. Bovine nasal-cartilage discs were cocultured with minced rheumatoid synovium or synovium-conditioned media (SCM) in the presence or absence of hydrocortisone. Cartilage breakdown was assessed by the release of proteoglycan (PG) and hydroxyproline, and matrix biosynthesis by [35S]sulfate incorporation during pulse labeling. Chondrocyte-dependent breakdown in response to synovial factors (i.e., "catabolin" activity) was assessed by the difference in PG release between living and dead cartilages. Short-term contact with minced synovial membrane or exposure to its products released at a distance was sufficient to induce cartilage degradation in coculture; continued exposure was not required for breakdown to persist. Conditioned media from short-term synovial culture were similarly potent, and the induced breakdown was chondrocyte dependent. Matrix biosynthesis was inhibited in exposed cartilage but could be rapidly restored to normal on synovium removal despite the persistence of cartilage breakdown. Early hydrocortisone treatment suppressed the initiation of cartilage breakdown in cocultures and largely abolished the appearance of inductive factors in SCM. Later applications had little effect either in cocultures or in catabolin assays. We conclude that synovium-induced breakdown is an early event and that chondrocyte catabolic mechanisms once they have been activated are sufficient to maintain breakdown at a high level. Hydrocortisone, as well as limiting proteolysis, inhibits early tissue interactions at the level of synovial catabolin production or release.
Animals↗
Inhibition of cartilage breakdown by hydrocortisone in a tissue culture model of rheumatoid arthritis.
Bovine nasal cartilage discs cocultured with human rheumatoid synovial membrane or synovial-membrane-conditioned media release proteoglycan largely as a result of cartilage breakdown. We assessed the effects of hydrocortisone on proteoglycan distribution between cartilage and culture medium, and on cartilage breakdown expressed as the release of either proteoglycan or 35S-products from prelabelled discs. The presence of synovial membrane inhibited the capacity for net proteoglycan synthesis, preventing its accumulation in cartilage; this was little affected by hydrocortisone. The major response to pharmacological concentrations of hydrocortisone was suppression of both spontaneous and synovial-membrane-induced cartilage breakdown. The autolysis of synovial protein that normally occurred during culture was similarly prevented by comparable doses of corticosteroid. Changes in chromatographic distribution of the 35S-labelled degradation products released from cartilage conformed with a corticosteroid-induced inhibition of endogenous lysosomal or related proteinase activity. Additionally, inhibition of the early events in synovial membrane that are responsible for chondrocyte-mediated breakdown of cartilage may contribute significantly to the overall corticosteroid effect.
Animals↗
Total knee arthroplasty in juvenile rheumatoid arthritis.
From 1971 to 1981, total knee arthroplasty was performed on forty-eight knees in twenty-eight patients with juvenile rheumatoid arthritis at the Robert Breck Brigham (now Brigham and Women's) Hospital. Seventeen of these patients, with twenty-nine knee-replacement arthroplasties, were followed for from two to eleven years (average, five years) and are the basis for this study. The patients' ages at operation ranged from thirteen to thirty-nine years (average, twenty-three years). Six patients had undergone total hip arthroplasty prior to admission for total knee replacement, and five patients had a total hip replacement performed while they were hospitalized for the knee arthroplasty. Thirteen patients (twenty-one knees) had significant preoperative pain but only three (five knees) had severe discomfort. Four patients were unable to walk, three were household walkers, and ten were limited community walkers. Preoperative deformities of the knees ranged from 20 degrees of varus angulation to 35 degrees of valgus angulation. The average preoperative flexion deformity was 23 degrees and the arc of motion averaged 45 degrees. At follow-up, twenty of the twenty-one knees that had been significantly painful preoperatively were completely relieved of discomfort. The average arc of motion increased by 34 degrees, while in all but one knee the angular deformity had been corrected to zero to 10 degrees of valgus angulation. All but one patient became a limited or full community walker. Complications included one late deep infection and one posterior tibial subluxation. Four knees required subsequent resurfacing of the patella for treatment of pain. We now routinely resurface the patella in all patients with juvenile rheumatoid arthritis who have a total knee replacement. To date no prosthesis has required revision for loosening. Radiolucency of one millimeter or less about the prosthesis was noted at follow-up in eight (30 per cent) of the knees. As custom-made components were required in twelve of the twenty-nine knees, it is obvious that preoperative planning is crucial in the treatment of these patients. Our recent experience has shown that the use of preoperative and postoperative serial casts aids greatly in the correction of severe flexion deformity of the knee. Postoperative manipulation was required for twenty-one of the twenty-nine knees. Skeletal immaturity was not an absolute contraindication to surgery. We think that our results, which showed a marked improvement in both knee function and in quality of life, make the short and long-term risks of knee-implant surgery well worth taking in this patient population.
Adolescent↗
Leakage of radioactive particle systems from a synovial joint studied with a gamma camera. Its application to radiation synovectomy.
UNLABELLED: We have determined rates of leakage of radioactivity from a rabbit synovial pouch in vivo for a number of particle systems of varying sizes and differing resistance to degradation. The estimates were made using a gamma scintillation camera and without killing the test animals. The lowest leakage at twenty-four hours was seen with inert carbonized microspheres and the highest rates were seen with surface-labeled particles of biodegradable denatured human serum albumin and with erythrocytes. The carbonized microspheres had no adverse long-term effects on the health of the animals' articular cartilage. CLINICAL RELEVANCE: Results obtained with inert particles indicate that reducing the biodegradability of the particle or increasing its diameter, or both, reduces radioactivity losses from the knee joint. Large (twenty-five-micrometer-diameter) microspheres of human serum albumin incorporating the radioactivity and carbonized microspheres are suggested as potential carriers of isotopes for human radiation synovectomy.
Animals↗
Quantitative gait analysis after total knee arthroplasty for monarticular degenerative arthritis.
By quantitative gait analysis, we characterized the functional results of total knee arthroplasty in a group of twelve elderly patients with isolated degenerative arthritis of one knee. All patients had had a standard replacement arthroplasty performed at least two years before the study. In the gait analysis we used high-speed movie cameras synchronized with force platforms and electromyograms to provide kinetic and kinematic data. The data were compared with those obtained from an age-matched control group. In the patients most of the measurements of gait had been restored to normal levels. These measurements included: velocity; stride length; arcs of motion of the hip, knee, and ankle bilaterally; phasic muscle activity; and the amount of mechanical work performed. There were three patterns of external torque across the implants and in the control knee which were comparable in magnitude but varied in relative frequency between the two groups. As compared with the controls, the patients spent approximately 30 per cent more time in double-limb stance and had prolonged cycle times. These findings may have been the result of muscle weakness, neural impairment, or habit, but the cause could not be determined by this study.
Aged↗
Breaking force of the rabbit growth plate and its application to epiphyseal distraction.
The in vitro breaking forces of the distal femoral growth plates of young rabbits were measured as a background to the design of a bone lengthening method, using epiphyseal distraction. The mean breaking force in 16 femora was 12.98 +/- 3.48 kg and the mean strain was 0.91 +/- 0.33 mm. The mean stress in 10 femora was 14.51 +/- 3.88 kg/cm2. The procedure was repeated, after applying a 1.0 kg dead weight to 6 femora for 24 hours and the breaking force was then 15.01 +/- 4.70 kg, with a mean strain of 0.85 +/- 0.62 mm. A further 8 rabbits then underwent epiphyseal distraction for 2 days in vivo, with 1 or 2 kg forces delivered to two parallel K wires by a pair of spring devices, whereupon the femora were removed and tested as before. The breaking force on the distracted side was now only 8.91 +/- 3.71 kg, compared with 13.99 +/- 3.40 kg on the control side. Although not fractured, these plates had obviously been weakened. The clinical implication of this is discussed.
Animals↗
Alternatives to arthrodesis for the failed total knee arthroplasty.
Surgical options for the failed total knee arthroplasty include resection arthroplasty, arthrodesis, and total knee revision. Resection arthroplasty has not been a satisfactory alternative for revision of the failed total knee in a rheumatoid patient population. The arthrodesis experience has been associated with a high incidence of pseudarthrosis (30%), significant shortening, a high complication rate, and poor functional results. Sixty-five failed noninfected total knee arthroplasties were revised to metal-to-plastic total knee arthroplasty. The most common mechanism of failure was loosening (57%). The average follow-up period following revision was 33 months (range, 24-60 months). Fifty-three of the knees were improved at last follow-up examination, compared with the prerevision score. The average postoperative score in the revision series was 80 points. Eight knees have required further surgery. Total knee revision of the failed noninfected total knee arthroplasty is a successful and preferable alternative to knee arthrodesis. Knee revision surgery is technically demanding and requires the availability of multiple components of varying constraint, including custom-made components.
Adult↗
Revision total hip arthroplasty.
In this review, 110 hips in 107 patients underwent revision total hip arthroplasty at The Hospital for Special Surgery and the Robert B. Brigham Hospital. The minimum follow-up period was two years (average, 3.4 years). Failures of the original total hip arthroplasties were due to loosening of the femoral component (44 hips), loosening of both components (23 hips), loosening of the acetabular component (17 hips), fracture of the femoral component (14 hips), recurrent dislocation due to prosthetic malposition (7 hips), acetabular protrusion (3 hips), and fracture of the femoral shaft (2 hips). Sixty-six hips were categorized as good or excellent, and 25 hips were rated as fair. Nineteen poor results were due to: (a) deep infection (2 hips); (b) mechanical failure (15 hips); and (c) recurrent dislocation (2 hips). Complications included infection (3.6%), trochanteric problems (13%), mechanical failure (14%), and progressive radiolucent zones (26%). The quality of the result of a revision total hip arthroplasty is potentially as good as that of the original arthroplasty. However, the higher incidence of infection and mechanical failure reduces the frequency of such good results in the long-term. The extremely high incidence of progressive radiolucent zones at the bone-cement interface makes predictions for even longer term results guarded.
Adult↗
Parameters of longitudinal growth rate in rabbit epiphyseal growth plates.
UNLABELLED: Three parameters have been identified that provide useful indices of longitudinal growth rate in rabbit epiphyseal plates. Specifically, we have examined the relationship between longitudinal growth rate and (1) growth-plate thickness; (2) the rate of cell division by proliferating chondrocytes; and (3) 35SO4 incorporation associated with matrix synthesis. There were statistically significant correlations between growth rate and each of the three experimentally determined parameters. Growth rate increased in direct proportion to growth-plate thickness, rate of chondrocyte proliferation, or 35SO4 incorporation associated with matrix synthesis. Of the three parameters, the rate of cell division of proliferative chondrocytes, as determined by counts of 3H thymidine-labeled cells following autoradiography, appeared to provide the most sensitive index of growth rate. However, used in combination, determination of the three parameters should make it possible to assess the relative contributions of changes in the numbers of cells, in the rate of chondrocyte proliferation, and in extracellular matrix synthesis to over-all growth rate. CLINICAL RELEVANCE: Methods are described and data are presented that should make it possible to design studies of the factors that regulate and control the longitudinal growth rate of epiphyseal cartilage growth plates. The experimental design of this work is applicable to the study of hormonal regulation of over-all growth rates and to determination of whether the effects of certain hormones are due to their effect on cell proliferation or matrix synthesis. Such studies should contribute to a better understanding of the control of growth in normal individuals and in patients with disease.
Animals↗
Total hip replacement in rheumatoid arthritis.
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Arthritis, Rheumatoid↗
Results of revision total hip replacement.
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Adult↗
Dextran sulphate induced arthritis in rabbits.
Persistent effects of a short course of intra-articular dextran sulphate, dextrans, or chondroitin sulphate were examined in rabbit knees. Only dextran sulphate produced gross arthritis, associated with high synovial acid phosphatase and beta-glucuronidase activities. Synovial degradative capacity in synovium-cartilage cocultures was increased 2-fold by dextran sulphate and 1.5-fold by chondroitin sulphate treatments. Stimulation of cartilage breakdown in vitro paralleled the content of synovial marker enzyme at death of the animal, but the 2 responses could be dissociated.
Animals↗
[Replacement arthroplasty of the shoulder].
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Humans↗
Capitellocondylar total elbow arthroplasty.
Sixty-nine non-constrained capitellocondylar metal-to-plastic total elbow-replacement prostheses were implanted in sixty-four patients with rheumatoid arthritis. These patients were followed for an average of 3.5 years. Postoperative flexion and pronation were significantly improved, but no significant increase in postoperative extension or supination could be demonstrated. Based on a rating system evaluating pain and function, there were 87 per cent good or excellent results. The complication rate based on the total number of prostheses implanted was 39 per cent. Eight patients required revision of the arthroplasty: four for dislocation of the prosthesis, two for sepsis, one for loosening, and one for a fracture. Eight other asymptomatic patients showed minimum radiolucent lines adjacent to the ulnar component. No patient demonstrated radiolucent lines adjacent to the humeral component.
Adolescent↗