Biomedical subjects
Publications and source records attributed to R E Booth.
The techniques and principles of revisional total knee surgery are reviewed, including soft tissue management, component excision, ligament and bone augmentation, and extensor mechanism supplementation.
Femoral neuropathy is an uncommon yet debilitating complication of total hip arthroplasty (THA). Over a 1-year period, in 440 consecutive THAs performed at Pennsylvania Hospital, 10 (2.3%) femoral neuropathies occurred. Among primary arthroplasties, all neuropathies were associated with the Hardinge anterolateral approach. A retrospective case review as well as a detailed anatomic cadaveric study highlighted the characteristics of the femoral nerve that make it susceptible to injury. In addition, a review of the existing literature on this subject was performed. Placement and management of acetabular retractors were the factors most commonly associated with injury of the femoral nerve. All affected patients had significant initial disability. However, full femoral nerve. All affected patients had significant initial disability. However, full functional recovery occurred within 1 postoperative year. Clear understanding and awareness of the anatomy of the femoral triangle as well as accurate placement of anterior acetabular retractors can minimize the incidence of this complication.
Survivorship analysis of 1,041 cemented Charnley total hip arthroplasties performed as a primary procedure revealed a probability of component survival at 10 years of 92%; the probability of acetabular cup survival was 99% and of femoral component survival was 96%. Three-zone acetabular demarcation was present in 16% of cases, as was migration of the cup greater than 5 mm. However, the acetabular revision rate was 1.65%, confirming the long-term clinical durability of the 22-mm internal diameter cup. Radiographic evidence of definite femoral component loosening was present in 9.6% and high-grade femoral bone-cement demarcation was present in 3.5%. The isolated femoral revision rate was 1.8%. Based on detailed survivorship analysis, a high-risk group of patients was identified for component failure and for femoral component loosening (radiographic). These patients were male, young (less than 50 years), heavy (greater than 170 pounds), and active (not Charnley class C). Given these findings, it is difficult to justify the widespread use of noncemented total hip systems, except in identifiable high-risk patients.
Between 1983 and 1988, 182 total hip arthroplasties were inserted using modern cement techniques including metal-backed acetabular components. Femoral head size was 32 mm in 84, 22 mm in 98. Radiographic analysis revealed three-zone demarcation of acetabular bone-cement interface in 56% of the 32 mm group as compared to 5% of the 22 mm group at 19 and 24 months mean follow-up period, respectively. When a subgroup of women under 60 years of age was created to control variables, the high-grade demarcation rates were 67% and 18%, respectively. Although Charnley hip scores remain similar between the two groups, these results emphasize the adverse effects of large femoral head prostheses on cement-bone interface and underline the need for alternative methods of fixation.
Eighty-one cementless Trilock (Depuy, Warsaw, IN) femoral components were observed for 2 to 6 years. The following end points were examined: revision (none), pain score less than 5 (six patients), and radiographic settling greater than 5 mm (three patients). Four patients (5%) had thigh pain at follow-up. No complete radiopaque lines could be identified around the porous surface of the femoral components. By any standard, the wedge-fit tapered cementless femoral design is successful. As the follow-up period lengthens, a survivorship analysis can be done to assess the long-term potential of the Trilock design.
The efficacy of low-dose warfarin therapy for prophylaxis of venous thromboembolic disease was studied prospectively in a group of 1,392 patients undergoing cemented total hip arthroplasty between 1978 and 1985. The incidence of both symptomatic and asymptomatic pulmonary emboli was determined after surgery in all patients using ventilation-perfusion lung scanning as the diagnostic endpoint. The total incidence of postoperative pulmonary embolus was 3.2%, with two-thirds asymptomatic and one-third symptomatic pulmonary emboli. There were no fatalities due to pulmonary embolism in the entire patient population. Bleeding complications requiring surgical intervention developed in 2.4% of patients. The authors conclude that low-dose warfarin therapy is a safe and easily administered form of inpatient treatment for prophylaxis of venous thromboembolic disease in all total hip arthroplasty patients and has demonstrated complete protection against fatal pulmonary embolism in this population.
The patellofemoral articulation in total knee arthroplasty can give rise to postoperative complications, such as patellar fracture, subluxation, or dislocation. The accumulation of hypertrophic fibrous tissue at the superior margin of the patellar button can give rise to catching or "clunking" of the extensor mechanism. Open surgical excision of this mass is successful in alleviating symptoms but runs the risk of infection and wound complications and delays postoperative mobilization. Arthroscopic resection with motorized instrumentation is highly successful, offers less risk of infection, and allows rapid postoperative mobilization.
Unintended incidental durotomy is not an infrequent complication of spinal surgery (incidence, 0.3-13% reported). Although prompt repair is advocated, little has been written regarding any consequences of primarily repaired durotomies on long-term patient outcome. A retrospective review of 450 patients undergoing lumbar spine surgery revealed 17 cases (4%) of incidental durotomy, recognized intraoperatively and repaired primarily. These patients were evaluated at long-term follow-up (mean, 25.1 months); and their results were compared with controls matched for age, diagnosis, procedure, and length of follow-up. No differences of statistical significance could be identified in comparing the outcomes of the two groups. Incidental durotomy, when recognized and repaired intraoperatively, does not increase perioperative morbidity or compromise final result.
Autogenous bone grafts from the ilium are frequently harvested for purposes of bone union and/or stability. Although some donor site complications may be unavoidable, awareness of the anatomy and complications may aid in planning the approach and minimizing the risks. Documented donor site complications include pain, nerve and arterial injury, peritoneal perforation, sacroiliac joint instability, and herniation of abdominal contents through defects in the ilium. Strict observation of relevant anatomic considerations will help in avoiding these complications.
Serial pulmonary imaging has proved to be effective in the evaluation of patients undergoing total joint arthroplasty. A clinical dilemma arises in asymptomatic patients whose postoperative pulmonary images differ from the preoperative images. The authors prospectively evaluated 403 patients with serial imaging to determine the significance of changed postoperative images in asymptomatic patients undergoing total hip or knee arthroplasty. Twenty-two (5.5%) patients had significant changes on postoperative images. Seventeen were asymptomatic; all but one underwent pulmonary angiography. Documented pulmonary emboli were demonstrated in 100% of patients whose postoperative images changed to indicate a high probability of pulmonary embolism, 71% whose images changed to a moderate probability, and 0% whose images changed to indeterminate probability. Overall, pulmonary emboli occurred in 76% of all asymptomatic patients with significantly change postoperative images. Asymptomatic pulmonary embolism is a significant occurrence after total hip or knee repair, and a changed lung scan with appropriate clinical evaluation is an accurate indicator of pulmonary emboli in asymptomatic postarthroplasty patients.
An antibiotic-impregnated polymethylmethacrylate spacer block functions in the delayed exchange approach to chronic deep infection of total knee arthroplasty. It provides antibiotic delivery, greater patient comfort and mobility, temporized reimplantation or other surgical options, and improved soft-tissue healing and tension. Bone quality is enhanced, the opportunity to prepare for custom implants or special situations is preserved, and a more facile reimplantation can be anticipated.
Patellofemoral pain due to an unusual suprapatellar fibrous nodule developed in three patients after posterior stabilized total knee arthroplasty. Each patient had a "catch" or "clunk" associated with pain on extension of the knee. At revision, a prominent fibrous nodule was found at the junction of the proximal patellar pole and the quadriceps tendon. The pathogenesis of this proximal fibrous nodule may involve impingement of the anterosuperior edge of the intercondylar notch area of the femoral component into the proximal quadriceps tendon or may involve impingement of the patellar prosthesis itself on the quadriceps tendon. Roentgenographic examination revealed an abnormally proximal placement of the patellar prosthesis on the patella. Surgical removal of the fibrous nodule resolved the symptoms. Revision of the patellar prosthesis may be necessary.
This brief report details the previously unreported complication of dislocation of the posterior stabilized total knee arthroplasty. Both patients had valgus deformities requiring extensive release of the contracted lateral soft tissues. The mechanism of dislocation was one of slight flexion and external rotation. The prosthetic tibial spine became locked posterior to the femoral cam. Reduction was accomplished by applying traction and anterior translation on the tibia with the knee slightly flexed. No redislocations have occurred. A literature review is presented and the authors discuss technique modifications that may prevent this complication.
The management of an infected total knee implant is a major challenge to the orthopaedic surgeon. This article reviews the use of antibiotic-PMMA spacer block in two-stage reimplanation of septic total knee arthroplasties. In addition to serving as an antibiotic delivery system between the time of component removal and reimplantation, the antibiotic-impregnated spacer block imparts mechanical stability to the joint and decreases the morbidity during the period before reimplantation. This temporary "interposition arthroplasty" facilitates the patient's ambulation and also simplifies dissection at the time of reimplantation. Furthermore, osteoporotic bone at the time of resection becomes firm, good-quality bone by the time of reimplantation.
Twenty patients with sciatica associated with anomalous lumbar nerve roots were reviewed with an average follow-up of 26.3 months. All patients had predominantly leg pain and their nerve root anomaly was known preoperatively. Overall success rate was 65% but was increased to 80% in patients with concurrent disk herniation. Improved results of surgical decompression were most consistently associated with concurrent disk herniation whereas other factors such as more extensive decompression were less strongly correlated. Surgery should only be offered with these results in mind.
A major concern with the use of sublaminar wires for segmental spinal instrumentation is the risk of neurologic compromise associated with repeated passage of wires through the epidural space. Because of the inability to visualize the wire tip during its sublaminar passage, the surgeon is unable to appreciate the depth of wire penetration (DOWP). The purpose of this investigation was to determine, through direct measurement, the depth of intraspinal penetration during the passage of sublaminar wires. Using their model, the authors have been able to define the optimal parameters for safe wire passage. Careful attention to maintaining contact between the wire tip and the under-surface of the lamina, using a wire of optimal configuration, will result in minimal DOWP and reduce the possibility of neurologic compromise.
Two hundred seventy-four patients were reviewed 1-5 years after laminectomy for spinal stenosis or herniated disks. All patients were treated according to the Pennsylvania Plan Algorithm for Degenerative Disk Disease. Ninety to ninety-five percent of the patients noted good to excellent relief of their leg pain, whereas only 80% noted low-back pain relief. The majority returned to work within 4 months. This review demonstrates that by following an algorithm for the treatment of back and leg pain from degenerative disk disease, the surgical results can be extremely gratifying, assuming the goals are relief of leg pain, the operative findings are definite, and the preoperative surgical indications and patient selection are well developed.
Based on 21 patellar fractures after total knee arthroplasty, the authors found that nondisplaced fractures of the patella following total knee arthroplasty are best treated nonoperatively, that displaced fractures with no extensor lag can adequately be treated nonoperatively, and that displaced fractures with an extensor lag present have poor results with operative treatment. Fragment excision should be considered for displaced distal pole fractures with patellar tendon disruption, and patellectomy should be considered for failures of all other treatments.