The surgery of spinal stenosis.
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Humans↗
Biomedical subjects
R E Booth
Publications and source records attributed to R E Booth.
HIV risk-related sex behaviors among injection drug users, crack smokers, and injection drug users who smoke crack.
OBJECTIVES: This study was designed to assess and compare sex risk behaviors for human immunodeficiency virus (HIV) transmission of three drug user groups: injectors who do not smoke crack, crack smokers who do not inject, and injectors who also smoke crack. METHODS: Sexual risk behaviors for HIV were assessed among 246 drug users from Denver, Miami, and San Francisco. Respondents were classified into the three drug groups based on self-report and verified through urinalysis and physical inspection. RESULTS: An increased risk for HIV through sexual transmission was associated with crack cocaine use, particularly among those who also injected. Crack smoking injectors were more likely to report sex with an injector, exchanging sex for drugs and/or money, drug use before or during sex, and unprotected sexual intercourse. They also injected more than injectors only, smoked crack as often as smokers only, and reported higher overall frequencies of drug use. CONCLUSIONS: These findings, together with the higher rates of gonorrhea and syphilis reported by smokers and injectors/smokers, are indicators of the risk crack poses for the heterosexual transmission of HIV.
Adult↗
Techniques of bone grafting in total knee arthroplasty.
Bone grafting of osseous defects in primary or secondary total knee arthroplasty remains a popular and often indispensable solution to reconstructive problems. Solutions to contained, uncontained, and massive defects of both the tibia and femur are presented, as well as several options for reconstruction of deficient or ruptured extensor mechanisms.
Bone Transplantation↗
Incidence of pulmonary embolism after total knee arthroplasty with low-dose coumadin prophylaxis.
The incidence of pulmonary embolism (PE) in osteoarthritic patients prophylaxed with low-dose coumadin after cemented total knee arthroplasty (TKA) was investigated prospectively. Each patient had a preoperative perfusion scan and a ventilation-perfusion scan on the seventh postoperative day. Pulmonary embolism was diagnosed by a high probability ventilation-perfusion scan or positive arteriogram. Patients with a moderate probability scan had an arteriogram to rule out PE. Pulmonary embolus was identified in 48 (5.6%) of 852 TKAs in 755 patients. Of these, six (0.7%) were symptomatic, and no fatal PE was identified. Age, gender, and weight did not show statistical differences comparing the PE and non-PE groups, nor did the incidences of previous PE, contralateral phlebitis, malignancy, and diabetes. A history of ipsilateral phlebitis increased the risk of PE from 5.2% to 13%, and a history of cardiac disease decreased the risk from 7.8% to 4.2%. Type of anesthesia, blood loss, tourniquet time, and prosthesis type were not significant factors. With the exception of previous contralateral phlebitis, traditional risk factors for PE were not found to increase risk of PE with low-dose coumadin prophylaxis. Spinal anesthesia that has been shown to be protective in total hip surgery was not a significant factor in this study.
Aged↗
Complications of trochanteric osteotomy. Long-term implications.
Cemented total hip arthroplasties (THAs) were performed through a Charnley transtrochanteric approach in 1162 patients from 1970 through 1986. Trochanteric separations numbered 58 (5%). Rate of nonunion was related to gender, preoperative diagnosis, and prior THA or endoprosthesis. Nonunion patients had lower mean Charnley pain and function mean scores than union patients at the 45- and 49-month examinations, respectively. A Trendelenberg gait was noted in 17% of nonunions compared with 6% of united patients. Revision rates were nearly three times higher in nonunion patients. These results indicate there is a quantifiable risk for a surgeon who chooses to use a trochanteric osteotomy.
Aged↗
Cemented versus cementless total hip arthroplasty. A comparative study of equivalent patient populations.
Seventy-one cemented total hip arthroplasties (THAs) in 66 patients were compared with 70 cementless THAs in 61 patients. The cemented and cementless components were identical except for the presence of a porous proximal surface on the cementless component. The mean follow-up time was 4.3 years in the cemented group and 4.1 years in the cementless group, with a minimum follow-up of two years. Postoperative Charnley pain scores were identical for both groups, as was the incidence of limp. The final Charnley function score, however was significantly higher in the cementless group (5.6) than in the cemented group (5.1). One revision was performed in the cemented group, none in the cementless group. Complete demarcation of the bone-cement interface was presented in two cemented components and was associated with subsidence. Three cementless components had early subsidence, and two of these had complete radiopaque lines around the porous surface. None of these three patients, however, had unsatisfactory pain or function scores. The most important finding of this study is the equivalence of clinical results noted in both cemented and cementless THA as late as six years after operation.
Activities of Daily Living↗
A prospective randomized comparison of two surgical approaches to total hip arthroplasty.
One hundred patients had total hip arthroplasty (THA) with either a modified Hardinge approach or transtrochanteric lateral approach. Perioperative data showed that osteotomies resulted in significantly more blood loss but required shorter operative time. Postoperative pain, using a visual analog scale, showed no statistical difference between the two groups. Postoperative hip scores for pain, function, and range of motion (ROM), presence of limp, and abductor muscle strength scores showed no significant difference between groups at six months and one year. Roentgenographic follow-up evaluation showed a mean acetabular cup angle of 40 degrees and a neutral-to-valgus femoral stem position in all patients. Trochanteric union was present in 92%. Heterotopic ossification occurred predominantly in the Hardinge patients but was not functionally significant. Therefore, the ability to achieve adequate pain relief and function with THA is not affected by the type of approach.
Adult↗
Arterial and ischemic aspects of total knee arthroplasty.
Prospective and retrospective analyses of 1,182 consecutive patients undergoing primary total knee arthroplasty (TKA) were performed to determine (1) the incidence of chronic lower extremity ischemia (CLEI); (2) the effect of tourniquet occlusion; and (3) guidelines that will allow TKA to be performed safely. Despite the appropriately advanced age of our patients, the incidence of CLEI was only 2%. All ischemic complications occurred in six patients with CLEI (25%), but none resulted in death or amputation. The ischemic complications consisted of pressure-induced necrosis of toes, heel, or foot, atheroembolism, femoral-popliteal graft occlusion, and asymptomatic popliteal occlusion. Tourniquet compression in the 1,158 patients without CLEI produced no untoward effects. Patients with mild CLEI can have a TKA performed safely with a tourniquet if there is no femoropopliteal calcification. When the ischemia is severe or there is a femoropopliteal aneurysm, arterial reconstruction should precede the TKA. In patients with patent femoral-popliteal bypasses or calcification without ischemia, TKA should be performed without a tourniquet. Ischemic pressure necrosis is an additional mechanism of injury.
Adult↗
Pulmonary embolism. Incidence in primary cemented and uncemented total hip arthroplasty using low-dose sodium warfarin prophylaxis.
During a 5 1/2-year period from January 1984 to July 1989, 736 patients between the ages of 50 and 75 with a diagnosis of osteoarthritis had either cemented or uncemented primary total hip arthroplasty. Patients were treated with low-dose sodium warfarin for prophylaxis against pulmonary embolism and had preoperative and postoperative serial lung scanning. The overall incidence of pulmonary embolism was not statistically different between the cemented and uncemented groups (3.87% and 6.19%, respectively; P > .05). Eighty-one percent of the pulmonary emboli were asymptomatic. The incidence of pulmonary embolism was higher in men than in women (7.3% and 2.93%, respectively; P < .05) but did not differ within each individual sex for the cemented and uncemented groups. Of greater significance, when the two initial groups were matched to control for sex and weight differences (564 patients), the incidence of pulmonary embolism narrowed to 4.3% and 5.3% in the cemented and uncemented groups, respectively (P > .55). These data indicate that the use of uncemented total hip arthroplasty does not offer any additional protective value against pulmonary embolism when using low-dose sodium warfarin prophylaxis.
Aged↗
Pulmonary embolism in total hip and knee arthroplasty. Risk factors in patients on warfarin prophylaxis and analysis of the prothrombin time as an indicator of warfarin's prophylactic effect.
This study was designed to identify those total arthroplasty patients at high risk for embolism even while on a proven warfarin prophylactic regimen and to identify the measure of anticoagulation that would be most efficacious in the prevention of pulmonary embolism (PE). A series of 2348 total arthroplasty patients had a preoperative perfusion scan and a postoperative ventilation/perfusion scan. All patients were placed on a low-dose warfarin protocol. Eighty-one patients were identified as having a PE by pulmonary arteriography (incidence of 3.4%). Of these, 89% were asymptomatic and no case was fatal. A control group of 159 patients without PE was used for comparison. Patients older than 65 years of age with a history of genitourinary infection were identified as being at higher risk of PE while on a proven warfarin prophylactic program. These patients may need additional prophylactic measures to reduce the risk of PE. In contrast, patients with a history of phlebitis, PE, obesity, or varicosities were not at excess risk for PE while on warfarin prophylaxis; therefore, no additional prophylactic measures are required. All prothrombin time profiles were within the prophylactic range. Therefore, the actual prothrombin time may not be the critical determinant of the level of anticoagulation or prophylaxis achieved.
Analysis of Variance↗
Primary total knee arthroplasty for displaced, acute intraarticular knee fractures. A report of four cases.
Primary total knee arthroplasty was performed in four patients with acute intraarticular fractures. All four were at high risk of failure for standard operative and nonoperative treatment because of severe osteopenia, preexisting intraarticular pathology, or a limited life expectancy. All benefited by early pain relief, functional range of motion, and early ambulation, with no early perioperative morbidity.
Acute Disease↗
Posterior dislocation of total knee arthroplasty.
Posterior dislocation of the prosthesis after total knee arthroplasty is an infrequent but serious complication. Seven patients with this complication were treated from January 1985 until October 1989. Five of the seven dislocations occurred in primary total knee arthroplasties and two occurred after revision arthroplasty. Limb alignment before arthroplasty, when it could be determined, was valgus in all patients, averaging 25 degrees. In each case there was an identifiable problem with the knee extensor mechanism: five had patellar dislocations, one a patellar tendon rupture, and one a patellar fracture. In three of the posterior dislocations, there was also an imbalance of the flexion and extension gaps with excessive laxity of the ligaments in flexion. Treatment was individualized. In two patients, the knee was reduced closed and the patella subsequently tracked so that no reoperation was necessary. One ruptured patellar tendon could not be repaired in a 94-year-old patient with cardiac disease. A cylinder cast was applied with poor results. Operative intervention was required in four patients, one of whom required only a patellar realignment procedure. The three other patients required component revision procedures, however, in addition to patellar realignment procedures. In these three patients, laxity of the knee in flexion was so severe that posterior instability could not be corrected merely by patellar relocation. At a follow-up examination (average, 21 months postoperatively), all six patients who were treated as recommended had good results with no further dislocations, with the exception of the one patient with a patellar tendon rupture.
Aged↗
Intraoperative femoral fractures in cementless total hip arthroplasty.
Ten patients with intraoperative femoral fractures during primary cementless total hip arthroplasty were matched by age, sex, weight, diagnosis, and length of follow-up to 20 patients who had primary cementless total hip arthroplasty without this complication. All fractures were identified in the operating room, and treatment was individualized for each case. Initial stability of the implant was felt to be satisfactory for all cases despite this complication. The mean follow-up was 2.3 years. In this series, no difference was found in clinical or roentgenographic results after cementless total hip arthroplasty between patients who had an intraoperative femoral fracture and patients who did not have this complication. If initial stability of the implant is satisfactory, despite intraoperative fracture, good clinical results can be expected with cementless total hip arthroplasty.
Adult↗
Evaluation of the painful prosthetic joint. Relative value of bone scan, sedimentation rate, and joint aspiration.
Seventy-two joint arthroplasties undergoing total hip or total knee surgery were studied prospectively with plain radiographs, three-phase bone imaging (3PBI), erythrocyte sedimentation rate (ESR), aspiration of the joint for culture, and multiple intraoperative cultures at the time of revision. Intraoperative cultures and the operative appearance were used to form a diagnosis of definite infection (unequivocal microbiology and gross sepsis), possible infection (positive microbiology or gross sepsis), or no infection (neither positive microbiology nor gross sepsis). For the preoperative diagnosis of infection, as opposed to aseptic loosening, 3PBI alone had a sensitivity of 33% and a specificity of 86%. In conjunction with plain radiographs, minimal improvement in accuracy was seen. A preoperative ESR greater than 30 had low sensitivity (60%) and a specificity of (65%). However, the ESR was statistically significantly higher in the joints with definite infection as compared to those joints without infection. The preoperative joint aspiration had a sensitivity of 67% and a specificity of 96% and, therefore, appears to be the most useful single test in the workup of a painful total joint arthroplasty.
Aged↗
Patient-controlled analgesia in a postoperative total joint arthroplasty population.
The present study prospectively evaluated patient-controlled analgesia (PCA) in 94 postoperative primary total joint patients. Total knee arthroplasty patients had significantly higher pain scores than those undergoing total hip arthroplasty. Trochanteric osteotomy patients used less morphine (mean, 37.6 mg) than those undergoing a muscle-splitting (Hardinge) approach. Eighty-eight percent of patients would use PCA again. The authors recommend PCA as a potentially superior form of postoperative pain control in joint arthroplasty patients, but recommend antiemetic usage, generous additional intravenous administration of bolus doses on the floor, trials of higher set doses, and earlier administration of PCA in the recovery room.
Aged↗
Isolated intradural metastasis simulating lumbar disc disease.
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Adenocarcinoma↗
Total hip arthroplasty for osteonecrosis.
The success of Charnley cemented total hip arthroplasty for osteonecrosis of the femoral head was assessed using survival analysis. Eighty-seven total hip arthroplasties were followed up for an average of 5.7 years (range, 1.4-13.0 years). There were 59 women and 28 men. The average age was 60 years (range, 30-84 years). Using Charnley hip scores, all patients showed significant progress. The survival analysis showed that using femoral loosening, revision, and pain scores less than 5 as end points, survival was 0.61, 0.94, and 0.81, respectively. With revision as an end point, there were no differences between patients in groups less than 50 and greater than or equal to 50 years of age, weighing less than 185 and greater than =185 lb, and men versus women. There was an 11.5% overall revision rate. Charnley cemented total hip arthroplasty is a viable alternative for patients with painful osteonecrosis.
Adult↗
The use of an antibiotic-impregnated spacer block for revision of the septic total knee arthroplasty.
Through the use of an antibiotic-impregnated polymethylmethacrylate spacer block in two-stage exchange arthroplasty, the chronically infected total knee arthroplasty can, in most cases, be effectively salvaged. In a review of 28 such consecutive cases by a single surgeon, all revised implants were retained except one which required arthrodesis. In the remaining cases, mean Hospital for Special Surgery knee scores were 86, with mean total range of motion of 90 degrees . All wounds healed eventually, and seven patients were thereafter able to undergo other total joint arthroplasties. Advantages of this technique included maintenance of ligamentous balance as well as bone stock with weight bearing, local antibiotic delivery, and facilitation of reimplantation.
Aged↗