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Biomedical subjects

R H Rothman

Publications and source records attributed to R H Rothman.

At least 19 recordsLinked to original sources
PubMed1992

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↗
PubMed1992

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↗
PubMed1992

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↗
PubMed1992

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↗
PubMed1992

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↗
PubMed1992

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↗
PubMed1991

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↗
PubMed1991

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↗
PubMed1991

Rotation affects apparent radiographic positioning of femoral components in total hip arthroplasty.

The authors have noted a change in the varus/valgus positioning of femoral components on anteroposterior (AP) radiographs that is dependent on limb rotation after total hip arthroplasty (THA). This effect, called pseudoposition, was demonstrated in six cadaver femurs implanted with an uncemented prosthesis that is noncanal-filling in the AP dimension. The distal tip of the prosthesis was positioned posteriorly in all specimens due to the bow of the femur. External rotation causes pseudovalgus positioning, and internal rotation causes pseudovarus positioning. Awareness of this phenomenon is important in the longitudinal analysis of femoral components after THA and emphasizes the need for standardized radiographic technique.

Femur↗
PubMed1991

Femoral neuropathy following total hip arthroplasty. Anatomic study, case reports, and literature review.

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.

Female↗
PubMed1991

The treatment of lumbar disc herniation: simple fragment excision versus disc space curettage.

The purpose of this study was to determine whether there was any difference in the clinical outcome between groups of patients treated with lumbar discectomy and vertebral endplate curettage as compared with disc fragment excision without endplate curettage. Eighty-three patients requiring lumbar disc excision for herniated nucleus pulposus were evaluated retrospectively at minimum 2-year follow-up. Forty-three patients had undergone fragment excision and disc space curettage at one center, whereas 40 patients underwent fragment excision without curettage at two other centers. There was no increased rate of reherniation or reoperation in the excision-only group. Vertebral endplate curettage carries a risk of annular penetration and damage to the great vessels. This study shows that this potentially dangerous step of the operation is unwarranted. In addition, patients who underwent endplate curettage had a higher incidence of low-back pain on follow-up.

Adult↗
PubMed1990

Survivorship analysis of 1,041 Charnley total hip arthroplasties.

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.

Age Factors↗
PubMed1990

Radiographic demarcation of the acetabular bone-cement interface. The effect of femoral head size.

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.

Aged↗
PubMed1990

Cemented versus cementless total hip arthroplasty. A critical review.

One of the major issues confronting the contemporary hip surgeon is the choice of fixation. The correct decision as to the use or abandonment of cement is as yet unclear. The aim of this essay is to view those elements of the scientific process that would allow the surgeon to reach the correct conclusions during the next decade. General considerations are discussed that will help the reader analyze clinical series focused on this problem. Theoretical advantages and disadvantages of both cemented and cementless fixation are also discussed along with supporting data. The major reports of large series of cases pertinent to this issue suggest that results of cemented primary total hip arthroplasty (THA) are excellent in the short run but deteriorate with time. This is in contrast to the results of uncemented primary THAs, which are not only satisfactory in the short run but tend to improve with the passage of time. Uncemented primary THAs are a rational treatment in the young, active male. In revision surgery, cemented techniques are unsatisfactory. Uncemented techniques show promise but as yet remain unproven.

Bone Cements↗
PubMed1990

A rare intradural tumor simulating spondylolisthetic radiculopathy.

Intradural tumors can produce nerve root symptoms similar to those caused by extradural compressive processes. In a 48-year-old man, the preoperative evaluation was spondylolisthetic radiculopathy; however, a lumbar myelogram prior to surgery revealed an unsuspected intradural tumor. The patient's symptoms resolved after removal of the tumor without treatment of the spondylolisthesis. When planning surgical treatment for any extradural process, intradural abnormalities must be ruled out by appropriate preoperative studies. Myelography and magnetic resonance imaging are now standard methods of evaluating the dural contents.

Diagnosis, Differential↗
PubMed1989

The prevention of pulmonary embolism in total hip arthroplasty. Evaluation of low-dose warfarin therapy.

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.

Aged↗
PubMed1989

Arthroscopic management of the patellar clunk syndrome following posterior stabilized total knee arthroplasty.

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.

Aged↗