Biomedical subjects

J A Rand

Publications and source records attributed to J A Rand.

At least 73 records · Page 4Linked to original sources

PubMed1989

Diagnosis and management of the infected total knee arthroplasty.

The infected total knee arthroplasty presents challenges for diagnosis and management. Infection develops in patients with compromised host defense mechanisms and in those in whom there is compromised wound healing or intraoperative wound contamination. A high index of suspicion of infection is necessary to diagnose infection in the patient without implant loosening. Eradication of the infection is the most important objective of management. The treatment option that offers the best possible function for the patient should be selected. Prevention of infection by correct patient selection and proper surgical technique should remain the goal of the attending surgeon.

Humans↗

PubMed1989

Patellar tendon rupture after total knee arthroplasty.

Between 1973 and 1985, 18 knees in 17 patients were treated for rupture of the patellar tendon after total knee arthroplasty (TKA), accounting for 0.17% of the TKAs performed at the authors' institution during the same interval. Follow-up study was from two and one-half years to four years. Four ruptures occurred in patients who had had a distal patellar realignment procedure, and one occurred after knee manipulation. Only two xenograft reconstructions and two of four staple fixation procedures were successful. After treatment of the patellar tendon rupture, four knees developed deep infection. Avoidance of this complication seems paramount because the results of treatment are discouraging. Patients at high risk at the time of the initial TKA seem to be those with limited preoperative motion in whom surgical exposure is difficult.

Aged↗

PubMed1989

Subcapital fractures after open reduction and internal fixation of intertrochanteric fractures of the hip. Report of three cases.

Three cases of subcapital fractures were discovered after open reduction and internal fixation of intertrochanteric fractures of the hip. These fractures: (1) illustrate devices and methods that contribute to this complication; (2) occur typically in elderly patients with an osteoporotic type of bone; and (3) indicate measures necessary to avoid this complication.

Aged↗

PubMed1989

Long-term results of various treatment options for infected total knee arthroplasty.

Of 73 infected total knee arthroplasties treated from 1973 through 1984, the outcome of various management options revealed that solid arthrodesis was obtained in 70%. Fifteen percent of those with a solid fusion had residual pain or even recurrence of infection. Aggressive debridement was successful in eight of ten (80%). Long-term follow-up results show reimplantations were successful in eight of 15 (53%) but were functionally successful in only five of 15 (33%). A treatment plan based on functional considerations follows. For acute infections a very aggressive initial debridement followed by primary closure over an antibiotic-soaked pack is carried out. The prosthesis is left in place if at all possible and if the bone-cement interface has not demonstrated loosening. The knee is debrided every two or three days until negative cultures are obtained. Antibiotic beads are then inserted, with reexploration at three weeks with new cultures. Parenteral antibiotics are given for a three-week period initially. If two successive surgical debridements fail to reveal a positive culture, the knee is closed and rehabilitation is begun. For chronic infections, the recommendations of Wilde and Ruth are followed, employing antibiotic-impregnated beads and spacers with staged debridements similar to the method described above. Finally, an accurate definition of the true value of any of these options is predicated on long-term follow-up studies, since options that seemed promising as an initial procedure have proved disappointing as more experienced and longer follow-up study is obtained.

Anti-Bacterial Agents↗

PubMed1988

Old sepsis prior to total knee arthroplasty.

A retrospective study of 65 cemented total knee arthroplasties in previously infected knees was performed. Two subgroups were identified: in Group I there was prior infection of both the bone and joint (20 patients) and in Group II there was only joint involvement (45 patients). Following primary total knee arthroplasty, deep infection occurred in three of 20 (15%) in Group I and in two of 45 (4%) in Group II, or five of 65 (7.7%) overall. Subsequent revision arthroplasty was required in 18. Of these 18 knees, three (17%) developed deep infection. Old sepsis, especially with associated osteomyelitis, results in a high rate of infection following total knee arthroplasty.

Adult↗

PubMed1988

Unicompartmental porous coated anatomic total knee arthroplasty.

Unicompartmental arthroplasty has been advocated for management of the older patient with unicompartmental arthritis. Implant breakage and loosening has led to modifications of implant design to metal backing and porous coating for potential bone ingrowth. A review of 28 cementless porous coated anatomic total knee arthroplasties two years after the operation revealed good to excellent results in 20 knees (71%). Six knees in five patients required revision for persistent pain. Only fibrous tissue ingrowth was observed. Five knees were considered potential failures based upon persistent pain and roentgenographic evidence of component loosening. This implant design is not acceptable with cementless fixation.

Aged↗

PubMed1988

Patellar instability after total knee arthroplasty.

Twenty-five knees with symptomatic lateral patellar instability after total knee arthroplasty (TKA) were treated by operative realignment. Causes of instability include errors in surgical technique, quadriceps imbalance, and trauma. Fourteen knees had proximal realignment, nine had combined proximal and distal realignment, and two had component revision. At an average follow-up period of 50 months, 20 knees had normal patellar tracking and five had recurrent instability. Two patellar tendon ruptures occurred after combined realignment. Proximal realignment alone, in the absence of component malposition, is recommended for the management of patellar instability. Component malposition should be corrected by component revision. Combined proximal and distal realignment procedures are recommended only with great caution because of the predisposition to serious complications such as patellar tendon rupture.

Aged↗

PubMed1988

The role of continuous passive motion following total knee arthroplasty.

A retrospective study of 94 knees with postoperative continuous passive motion (CPM) therapy was compared with a control group of 116 knees with no postoperative CPM following kinematic condylar total knee arthroplasty (TKA) performed in 1983. The diagnoses were similar in both groups, with osteoarthritis in 167 knees, rheumatoid arthritis in 34 knees, osteonecrosis in four knees, traumatic arthritis in four knees, and psoriatic arthritis in one knee. Average flexion at hospital discharge was 87.7 degrees in the control group and 90.2 degrees in the CPM group (p less than 0.02). Seventy-four percent of the CPM group and 60% of the control group had achieved 90 degrees of flexion by the time of hospital discharge. The number of days to achieve 90 degrees averaged 10.3 in the control group and 7.7 in the CPM group (p less than 0.001). There was no significant difference in flexion at two or three months or at one year after operation between the two groups. Five knees in the control group and one in the CPM group required manipulation. The duration of hospitalization was not significantly different between the two groups. Hemoglobin levels, operative blood loss, and transfusion requirements were not significantly different. Patients with CPM following TKA achieve motion earlier than those without CPM, but ultimate motion and complications are not affected.

Aged↗

PubMed1988

Total knee arthroplasty in young adults who have rheumatoid arthritis.

At the Mayo Clinic, between 1978 and 1982, forty-four total knee arthroplasties were performed with cement in twenty-six adults who had rheumatoid arthritis. The age at operation ranged from nineteen to thirty-nine years old. The twenty-six patients were followed for two to eight years (average, five years). At the time of final follow-up, thirty-nine knees were free of pain and five were mildly painful during weight-bearing. The Hospital for Special Surgery knee score improved from a mean of 52 points preoperatively to 84 points postoperatively. There were twenty-four excellent, fourteen good, six fair, and no poor results. Radiographic analysis revealed an incomplete radiolucent line that was more than one millimeter in width adjacent to five tibial and four femoral components in eight knees (18 per cent). The positions of the components had not changed. Postoperatively, there was one transient peroneal palsy and two knees required patellar resurfacing. No revisions were performed for loosening of a prosthesis. We concluded that use of a cemented total knee prosthesis in a patient who has rheumatoid arthritis and is less than forty years old provides a satisfactory result and that the component will not loosen after an average of five years.

Adult↗

PubMed1988

A comparison of primary and revision total knee arthroplasty using the kinematic stabilizer prosthesis.

The first 121 arthroplasties (in 105 patients) in which the cemented kinematic-stabilizer total knee prosthesis was used for primary arthroplasty or surgical revision at the Mayo Clinic were reviewed. Sixty-six patients (seventy-nine arthroplasties) were followed for a mean of thirty-seven months. There were fifty-three revision and twenty-six primary arthroplasties. The average range of motion in both groups increased from 95 to 101 degrees. Although none of these patients could ascend stairs without support before the operation, thirty-two (51 per cent) could do so at the time of the final follow-up. The incidence of moderate or severe pain was reduced from 86 to 6 per cent. Moderate or severe ligamentous instability had been present in thirty-three knees (42 per cent) preoperatively, but only five knees had significant medial, lateral, anterior, or posterior instability at final follow-up. The Hospital for Special Surgery knee score increased from an average of 56 points to 83 points in all of the knees. At follow-up, the patients who had had primary arthroplasty had 92 per cent good or excellent results and the patients who had had surgical revision had 81 per cent good or excellent results (p less than 0.05). There was no significant difference in the results between the patients who had osteoarthritis and those who had rheumatoid arthritis. Over-all, 85 per cent of the results were good or excellent at final follow-up. Tibial radiolucent lines of one to two millimeters were observed in 29 per cent of the knees at follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1988

Ten-year evaluation of geometric total knee arthroplasty.

One hundred ninety-three geometric total knee arthroplasties (TKA) were performed between 1972 and 1975 in 129 patients (66 women, 63 men; mean age, 69 years) with osteoarthritis. Of these, 102 knees were followed for a mean of 11 years. Eighty-three percent of the patients had mild or no pain. The revision rate was 20%, and the surgical complication rate was 12%. By actuarial analysis, the probability of retaining a geometric prosthesis at 10 years was 78%. With revision or moderate to severe pain as the end point, the predicted implant survival was 69% at 10 years. Lucent lines greater than 1 mm were present in 38% of the knees and progressed in 34%; they were more frequent in knees with greater than or equal to 3 degrees of varus axial alignment (p less than 0.05) or greater than or equal to 4 degrees of varus placement of the tibial component (p less than 0.05). The geometric prosthesis has provided a functional result in 69% of knees at 10 years, despite being the first two-part component knee replacement retaining the cruciate ligaments and using early surgical instrumentation and implant design.

Aged↗

PubMed1988

Results of revision total knee arthroplasties using condylar prostheses. A review of fifty knees.

Revisions of total knee arthroplasties for aseptic failure have provided varied results. In this review of fifty revisions in which a condylar prosthesis was used in carefully selected knees, the results were rated good or excellent in 76 per cent after an average length of follow-up of 4.8 years. At the follow-up examination, radiolucent lines were seen in 17 per cent of the knees. The complications included loosening of one or both prosthetic components in three knees (of which two were revised again); a hematoma in one knee; and a piece of loose cement, which had to be removed, in one knee. There were no deep infections. On the basis of these results, we concluded that revision total knee arthroplasty using a condylar prosthesis will have infrequent complications and will provide a satisfactory result in properly selected patients.

Adult↗

PubMed1988

Posterior cruciate condylar total knee arthroplasty. Five-year results.

A series of 189 consecutive posterior cruciate condylar total knee arthroplasties (TKAs) in 151 patients was reviewed. Of these, 18 patients died (22 knees), and two patients (three knees) were lost to follow-up study, leaving 164 knees in 131 patients for evaluation at 5.3 +/- 0.8 years (mean +/- SD). Before surgery 91% of the patients experienced moderate to severe pain with weight bearing, whereas 6% had such pain at five years. The average motion was -5 degrees -107 degrees before surgery and -1 degrees -101 degrees at last examination. The percentage of patients who could walk more than six blocks (600 m) increased from 9% preoperatively to 61% at last examination. The percentage of patients who could independently climb stairs increased from 37% preoperatively to 69% at last examination. Hospital for Special Surgery (HSS) scores improved an average of 29 points, from 57 preoperatively (poor) to 86 (excellent) at last examination. Complications included an overall reoperation rate of 3.7% (seven knees), with a revision rate of 1.6% (three knees). Lucent lines greater than or equal to 1 mm at five years were present in 6% of knees and progressed in 3%. Overall, the results after posterior cruciate-sparing TKAs were excellent, with few complications.

Adult↗

PubMed1987

Vascular complications of total knee arthroplasty. Report of three cases.

A review of the Mayo Clinic experience between 1971 and 1986 revealed an incidence of acute arterial insufficiency following total knee arthroplasty of 0.03%. Preexisting arteriosclerotic disease and correction of extensive flexion contractures appear to predispose to this complication. Early diagnosis and treatment are essential for satisfactory results.

Aged↗

PubMed1987

Arthrographic study of painful total hip arthroplasty: refined criteria.

The criteria for a diagnosis of loosening or infection of hip arthroplasties on arthrographic study were further refined by a retrospective review of 178 arthrograms representing 170 patients. The 97 arthroplasties that were surgically evaluated form the basis of this report. With the refined criteria, subtraction arthrography had a sensitivity of 96% and specificity of 92% for demonstrating loosening of the femoral component and a sensitivity of 97% and a specificity of 68% for demonstrating loosening of the acetabular component. Pseudocapsule size and the presence of bursae were important factors influencing arthrographic interpretation. Arthrographic findings of pseudocapsule irregularity and the presence of nonbursal cavities were suggestive of infection but were not sensitive or specific. Laboratory evaluation of aspirated material was a more reliable predictor of infection, although its sensitivity was only 71%.

Adolescent↗

PubMed1987

Pseudobursae: a useful finding in patients with painful hip arthroplasty.

A retrospective review of 178 consecutive subtraction hip arthrograms (175 patients) was performed to evaluate the significance of cavities or bursal communications (or both) with the pseudocapsule in patients with painful hip arthroplasty. Bursae and/or communicating cavities were shown in 75 (43%) of the 175 patients. Communicating irregular cavities were noted in 12 patients (nine infected), and smooth bursae or bursalike structures were noted in 63 patients. The most frequent bursal locations were the greater trochanteric region (32/63), supraacetabular region (18/63), and iliopsoas (12/63). Three patients had multiple bursae. Six of the 18 acetabular bursae were associated with previous dislocations. Twenty-seven patients with bursae had no radiographic findings of loosening or infection. Of these 27, 12 (44%) responded to local injection of anesthetic into the bursa and were judged clinically to have bursitis. Arthrography, with aspiration from the bursae or cavities and injection of anesthetic, provides additional information regarding painful hip arthroplasty and may prevent unnecessary surgery.

Adult↗

PubMed1987

Failed total knee arthroplasty treated by arthrodesis of the knee using the Ace-Fischer apparatus.

Twenty-eight patients were treated for a failed total knee arthroplasty by arthrodesis with a new type of biplane external fixator. The reasons for failure of the total knee arthroplasty were sepsis in twenty-five patients, loosening in one, pain of unknown etiology in one, and fibrous ankylosis in one. The mean duration of fixation with pins was 112 days. In twenty knees, arthrodesis occurred without further treatment. One knee fused after the application of dual plates, and one united after treatment with electrical stimulation. Of the remaining six patients, one had an above-the-knee amputation for persistent non-union and five had a persistent pseudarthrosis. The extent of loss of bone appeared to be the most important factor influencing union of the primary arthrodesis. One patient who had a solid union of the arthrodesis had a persistent non-union after a fracture at the site of a femoral pin. The rate of success of 68 per cent that was achieved with the device that we used is similar to the rates obtained with the use of older external fixators.

Adult↗

PubMed1987

Nonunion of intertrochanteric fractures of the femur following open reduction and internal fixation. Results of second attempts to gain union.

A retrospective review was performed on 20 patients treated at the authors' hospital between 1961 and 1981 with noninfected nonunions following primary open reduction and internal fixation (ORIF) of intertrochanteric femoral fractures. All patients were available for follow-up examination. Each patient was interviewed at an average follow-up period of 6.6 (0.8-11.9) years. The group consisted of 15 women and five men with an average age at the time of fracture of 63 (36-86) years. Only one fracture was "stable" while 19 were "unstable" with loss of medial support. The initial fixation device was a sliding nail or screw in four patients, fixed nail plate in 11, Smith-Petersen in two, Deyerle pins in one, and was unrecorded in two. Of the 20 cases, it was possible to obtain the original postoperative roentgenograms in 12. Anatomic reduction had been achieved in four, medial displacement osteotomy had been used in two, varus positioning in one, and valgus positioning in five. Subsequent operative treatment for the nonunions consisted of three endoprostheses, six total hip arthroplasties, and 11 repeated attempts at ORIF. Of those treated with repeat ORIF, nine (82%) achieved radiographic union at an average time of six months. Of the remaining two who did not achieve union with the second ORIF, one achieved union following removal of internal fixation and bone grafting (five months) and one required a total hip arthroplasty. The postoperative functional results, as determined by a modified Harris hip score, were improved over the preoperative functional results for each treatment mode. Functional results were best in those patients who achieved union with a second surgical attempt.

Adult↗