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Biomedical subjects

R H Rothman

Publications and source records attributed to R H Rothman.

At least 37 records · Page 2Linked to original sources
PubMed1997

Simultaneous bilateral versus unilateral total knee arthroplasty. Outcomes analysis.

One hundred consecutive, primary simultaneous bilateral total knee arthroplasties were prospectively compared with 100 consecutive, primary unilateral total knee arthroplasties in reference to relative risk, complications, cost, and need for rehabilitation. All procedures were performed using identical preoperative, intraoperative, and postoperative protocols. Postoperative confusion was approximately four times greater in the simultaneous bilateral total knee arthroplasties group (29% versus 7%), which was thought to represent an increased incidence of fat embolism. Cardiopulmonary complications were approximately three times greater after simultaneous bilateral total knee arthroplasties (14% versus 5%), and most commonly involved arrhythmias. The increased stress on the cardiopulmonary system with simultaneous bilateral total knee arthroplasties may make this procedure contraindicated in certain patients with preexisting disease. There was an approximately 17 times greater need for banked blood in the simultaneous bilateral total knee arthroplasties group (17% versus 1%), which is alarming given the persistent concerns of transfusion related disease transmission. Although the length of hospitalization was similar (6.4 days simultaneous bilateral total knee arthroplasties versus 6 days unilateral total knee arthroplasty), 89% of the patients in the simultaneous bilateral total knee arthroplasties group required a rehabilitation stay versus 45% of the patients in the unilateral total knee arthroplasty group. Total hospital charges averaged $53,168 for simultaneous bilateral total knee arthroplasties versus $32,598 for unilateral total knee arthroplasty. Total rehabilitation charges were similar. The relative cost savings implicit by doing simultaneous bilateral total knee arthroplasties seem to be at least partially offset by the approximately two times greater need for rehabilitation in this group. The true safety, efficacy, relative risk, and total cost analysis of simultaneous bilateral total knee arthroplasties demands further critical evaluation.

Adult↗
PubMed1996

Head-neck modularity for total hip arthroplasty. Is it necessary?

Although modular head-neck combinations for femoral components are convenient and useful, theoretical concerns make them less attractive. In a consecutive series of 100 primary cementless total hip arthroplasties, the neck length chosen for the broach trial reduction was compared with the final neck length chosen after the actual femoral component had been impacted. In 19%, the neck length was changed after insertion of the femoral component. As a result, leg-length inequality or wastage of these femoral components would have resulted. For cementless femoral components, the ability to adjust neck length after component impaction remains important.

Biomechanical Phenomena↗
PubMed1996

Radiographic cost reduction strategy in total joint arthroplasty. A prospective analysis.

A consecutive series of 222 patients who underwent cemented total knee arthroplasty (124) and uncemented total hip arthroplasty (98) were evaluated prospectively. The purpose of this study was to determine if routine radiologic interpretation of postoperative total hip and total knee radiographs is cost effective. Also, the study was designed to determine if routine predischarge radiographs, in conjunction with recovery room radiographs, are worthwhile. There were no changes in postoperative patient management based on orthopaedic or radiologic review of either radiograph. No additional information was gained from review of the radiologic evaluations. Therefore, obtaining one series of routine inpatient postoperative total joint radiographs and eliminating postoperative radiologic consultation will significantly reduce costs without compromising patient care.

Cost Savings↗
PubMed1996

Incidence of thigh pain after uncemented total hip arthroplasty as a function of femoral stem size.

Two hundred seventy-one patients (297 primary total hip arthroplasties) were evaluated for thigh pain 2 years after surgery. All femoral components were identical in wedge-shaped geometry but differed in size. All components were radiographically stable. Regression analysis revealed the presence of thigh pain to be directly correlated to increasing stem size (P = .014, r = .857). An even more significant positive correlation to thigh pain was present for proximal and distal component moments of inertia for bending in the mediolateral plane. Femoral stem size has a significant effect on the incidence of thigh pain.

Aged↗
PubMed1996

Treatment of early symptomatic pulmonary embolism after total joint arthroplasty.

The purpose of this study was to evaluate the risk of intravenous heparin therapy or the use of Greenfield filters (Meditech, Watertown, MA) in the early postoperative period in patients who have documented symptomatic pulmonary embolism. Symptomatic pulmonary embolism in the first weeks was identified in 52 patients. Twenty-four patients were treated with Greenfield filter insertion and 28 patients with intravenous heparin therapy. One complication associated with insertion of the Greenfield filter-premature opening in the internal jugular vein-resulted in no adverse consequences. Three complications were associated with intravenous heparin therapy: one transient thrombocytopenia, one recurrent symptomatic pulmonary embolism, and one knee hematoma, which did not require surgical evacuation. It appears that Greenfield filter insertion is a viable option for treatment of symptomatic pulmonary embolism in the early postoperative period after total joint arthroplasty. In contrast to other published data, this study suggests that intravenous heparin therapy may also be a reasonable alternative, but is a treatment regimen that requires careful monitoring of platelets, wound complications, and bleeding parameters.

Adult↗
PubMed1996

Heterotopic ossification. Incidence in cemented versus cementless total hip arthroplasty.

To resolve the debate whether cementless total hip arthroplasty (THA) carries an increased risk of heterotopic ossification (HO) as compared with cemented THA, 100 patients undergoing primary cemented THA (both acetabulum and femur) were individually matched to 100 patients undergoing primary cementless THA. Preoperative, 6-week postoperative, and 2-year postoperative radiographs were reviewed for the presence of HO using the Brooker classification. No subject in either group received any postoperative prophylaxis for HO. The matching parameters were age ( +/- 10 years), sex, weight ( +/- 10 lb.), diagnosis (all were osteoarthritis), Charnley class (A/B), and surgical approach (trochanteric osteotomy or modified Hardinge). The overall incidence of HO was 68% in the cemented group and 65% in the cementless group. The extent of HO (grade III) was significant in 9% of the cemented group and 5% of the cementless group. There was no grade IV HO (bone ankylosis) in either group. Neither the overall incidence nor the incidence of grade III HO was statistically different between the two groups. Patient sex and surgical approach had no interactive effect with type of component fixation on the incidence of HO. Fear of HO should not be a factor in the choice of fixation for THA.

Aged↗
PubMed1996

Relationship between polyethylene wear, pelvic osteolysis, and clinical symptomatology in patients with cementless acetabular components. A framework for decision making.

The purpose of this study is to assess the relationship between acetabular component polyethylene wear, pelvic osteolysis, and clinical symptoms to determine when operative intervention should occur and to predict the degree of difficulty of the revision. Fifty-four revisions of failed cementless acetabular components were performed in 52 patients. All cases demonstrated polyethylene wear radiographically, and in 43 cases (80%), osteolysis of the pelvis was seen. Symptoms of groin or buttock pain were seen in 45 of 54 cases (83%). Preoperative staging of the disease process included one patient with wear radiographically but neither symptoms nor lysis (stage I), 10 patients with wear and pain (stage IIA), 8 patients with wear and lysis but no pain (stage IIB), and 35 patients with wear, lysis, and pain (stage III). Patients in stages I and IIA could be revised with cementless components without structural allograft. Patients in stages IIB and III required structural allograft in 79% and cemented components in 53%. Cemented components were used when there was less than 50% contact between host-bone and prosthesis. Polyethylene wear alone (stage I) is an indication of impending failure, and when symptoms develop (stage IIA), revision should be undertaken. The development of radiographic lysis is a critical event, and as soon as osteolysis develops (stage IIB or III), revision should be undertaken immediately. From the perspective of the revision surgeon, there is great value in the early intervention for polyethylene wear and pelvic osteolysis.

Acetabulum↗
PubMed1996

Hydroxyapatite-coated femoral stems. A matched-pair analysis of coated and uncoated implants.

Fifty-two pairs of patients who had had a total hip arthroplasty with a porous-coated femoral implant were studied in a retrospective, matched-pair analysis. Half of the patients had received a femoral component coated with hydroxyapatite and the other half (the controls), an identical component but without hydroxyapatite. The patients were matched for age, sex, weight, diagnosis, Charnley class, operative approach, and duration of follow-up. Identical uncoated hemispherical acetabular implants were used in both groups. At the time of follow-up, at a mean of 2.2 years (range, two to 3.4 years) after the operation, the mean Charnley scores for pain, function, and motion were 5.6, 5.5, and 5.6 points, respectively, in the group that had received a hydroxyapatite-coated femoral component and 5.6, 5.6, and 5.6 points, respectively, in the group that had received a non-coated component; none of these differences were significant (p = 0.86, 0.89,, and 0.80, respectively). There were no revisions in either group. Radiographs indicated stable fixation in both groups and no differences in the radiographic parameters of loosening between the two groups. Within the relatively short time-frame of this study, there appeared to be no clinical or radiographic advantage to the use of hydroxyapatite in primary total hip arthroplasties. However, these results should be considered as preliminary. Longer follow-up may reveal unrecognized advantages or disadvantages.

Adult↗
PubMed1996

Comparative risk of early postoperative pulmonary embolism after cemented total knee versus total hip arthroplasty with low-dose warfarin prophylaxis.

Four hundred thirteen cemented total hip arthroplasties and 852 cemented total knee arthroplasties were evaluated prospectively for postoperative pulmonary embolism. Inclusion criteria were a diagnosis of osteoarthritis, age 50 to 75 years old, cemented primary arthroplasty, and prophylaxis with low-dose warfarin (Coumadin, DuPont Pharma, Wilmington, Delaware). All patients underwent a preoperative perfusion scan and postoperative ventilation perfusion scan with all moderate probability scans evaluated with arteriogram. The overall incidence of pulmonary embolism was 3.8% after cemented total hip arthroplasty and 5.6% after cemented total knee arthroplasty. Because of a weight bias, patient age, weight, and gender-matched comparison was performed. Two hundred eighty-two patients from each group were matched with identical age, weight, and gender. The incidence of postoperative pulmonary embolism was 4.3% for total hip arthroplasty and 4.6% for total knee arthroplasty. These results do not support the contention that pulmonary embolism is higher after total hip arthroplasty than after total knee arthroplasty.

Aged↗
PubMed1996

Primary cementless hip arthroplasty with a titanium plasma sprayed prosthesis.

One hundred two patients underwent 105 primary uncemented total hip arthroplasties and were reviewed at a minimum of 5 years after operation (mean, 6.1 years). The components were titanium alloy with a titanium plasma spray coating. The acetabular revision rate was 11.4%. Acetabular cavitary lytic lesions were identified in 25.5% at 5 years. All acetabular revisions were performed for a combination of wear and osteolysis. One femoral revision was performed to facilitate an acetabular revision, but the femoral revision rate for aseptic loosening was 0%. In addition, no femoral components had subsided or were thought to be loose radiographically. Thigh pain was present in 4% at 5 years. Despite the 25.5% incidence of acetabular osteolysis, distal femoral lysis was not seen and only 5% showed focal osteolysis in the trochanteric region proximal to the circumferential porous coating of the femoral component. Component design features were thought to be critical to the excellent performance of the femoral component and to the poor performance of the acetabular component.

Adult↗
PubMed1995

Predicting quality-of-life outcomes following total joint arthroplasty. Limitations of the SF-36 Health Status Questionnaire.

A group of 114 patients undergoing total hip and knee arthroplasty were evaluated to assess the effect of total joint arthroplasty on quality of life, as measured by the SF-36 Health Status Questionnaire, and to determine the predictive relationship between preoperative and postoperative scores. A highly significant improvement was seen comparing preoperative with postoperative scores at 2 years for physical function, social function, physical role function, emotional role function, mental health, energy, and pain. Despite a significant change in health status (P < or = .001), no change was seen in the patient's health perception (P = .61). Regression analysis failed to indicate a predictive relationship between preoperative and postoperative scores for any scale. Total joint arthroplasty dramatically improves the quality of life and function of patients afflicted with arthritis; however, because of the poor ability of the SF-36 to predict postoperative improvement on an individual basis, it cannot be used alone to determine treatment selection.

Activities of Daily Living↗
PubMed1995

Postoperative blood salvage in total knee arthroplasty using the Solcotrans autotransfusion system.

One hundred forty-four patients who underwent primary total knee arthroplasty were examined in a prospective controlled study to determine the efficacy and safety of a postoperative wound drainage autotransfusion system (Solcotrans, Smith & Nephew Richards, Memphis, TN). The patients were divided into two groups: control group 1 comprised 88 (61%) patients who either received a Hemovac disposable drainage system (63 patients) or the Solcotrans system and had inadequate drainage for autotransfusion (25 patients). Experimental group 2 comprised 56 (39%) patients who received a Solcotrans drainage system and were autotransfused. The Solcotrans proved itself safe. No sepsis, transfusion reactions, or coagulopathies were associated with autotransfusion, which averaged 524 mL. There were no significant differences between groups 1 and 2 when comparing preoperative and postoperative hemoglobins and hematocrits. The Solcotrans system did not lower homologous blood requirements. Only 1.6% (2 patients) of all patients who autodonated at least 2 units of autologous blood (122 patients) were in need of a homologous blood transfusion in the postoperative period. Thus, although safe, the Solcotrans system was not proven effective in the management of primary total knee arthroplasty patients.

Blood Transfusion, Autologous↗
PubMed1995

Prospective randomized evaluation of blood salvage techniques for primary total hip arthroplasty.

A controlled, randomized, prospective study was performed evaluating the need for perioperative blood salvage for primary total hip arthroplasty patients who had donated autologous blood before surgery. One hundred fifty-three patients able to donate at least 2 units of autologous blood were divided into four groups. In group 1 (35 patients), intraoperative and postoperative Cell-Saver (Haemonetics, Braintree, MA) was employed. In group 2 (40 patients), a postoperative Solcotrans (Smith & Nephew Richards, Memphis, TN) reinfusion protocol was followed. In group 3 (40 patients), a closed-suction Hemovac drain (Zimmer, Warsaw, IN) was placed. In group 4, (38 patients), no drain was used. Decisions for transfusion were based on clinical and laboratory parameters and made in conjunction with medical consultation. All autologous blood was routinely reinfused. There was no statistically significant difference in transfusion requirements or wound complications among the four groups. Hemoglobin and hematocrit changes between groups also were not statistically significant, but a power test suggested insufficient patient numbers for absolute reliability of this observation. Only five patients (3.3%) in this study received homologous blood. Four of these patients were in the Solcotrans group and one was in the Cell-Saver group. Two reoperations were performed: one for hematoma (Solcotrans group) and one for a sewn-in drain. It is concluded that expensive perioperative blood salvage techniques are usually not needed in patients who have a primary total hip arthroplasty without cement and who have donated 2 units of blood before operation.

Adult↗
PubMed1995

Comparison of cemented and cementless total hip arthroplasty in patients with bilateral hip arthroplasties.

A consecutive series of 36 patients underwent primary cemented total hip arthroplasty followed by primary cementless total hip arthroplasty of the contralateral hip. Clinical pain scores between the cementless and cemented hips were not different. Subjectively, patients either had no preference or preferred the cementless side. Comparison of results in the same patient eliminates variability introduced by differences in sex, weight, comorbidities, bone quality, and activity level. Control of these factors permits more meaningful comparison of the type of fixation.

Adult↗
PubMed1994

Acute arterial thrombosis associated with total knee arthroplasty.

PURPOSE: Acute arterial thrombosis associated with total knee arthroplasty (TKA) is a rare but limb-threatening complication. The purpose of this report was to determine the incidence and optimal management of these complications by reviewing our extensive orthopedic experience and the English-language literature. METHODS: Between April 1989 and March 1994 seven (0.17%) patients had development of acute limb-threatening ischemia after 4097 TKAs that were performed at our hospital. Management of these complications included (1) emergency arteriography to define inflow and outflow arteries, (2) use of autologous vein from the contralateral leg when arterial bypasses were necessary (because TKAs are associated with a high incidence of deep vein thrombosis), and (3) early, aggressive revascularization that often required difficult distal bypasses to achieve limb salvage. Management of our cases are compared with treatment of 13 patients described in the literature. RESULTS: Ten patients treated at other hospitals by arterial thrombectomy alone (six cases), sympathectomy alone (two cases), fasciotomy alone (one case) or delayed arterial bypass resulted in seven major amputations and one death. All seven of our patients and three patients treated elsewhere underwent emergency femorodistal bypasses (six tibial, three below-knee popliteal, one pedal). All 10 patients had limb salvage after long-term follow-up (average 18 months; range 1 to 58). CONCLUSION: Thrombectomy alone for acute arterial thrombosis associated with TKA generally is unsuccessful and associated with unacceptably high amputation rates. Dismal results without emergency bypass is due to underlying chronic occlusive atherosclerotic disease found in these patients and intimal plaque disruption that can occur with knee manipulation or tourniquet compression. Acute arterial occlusion after TKA is best managed by emergency arteriography and a femoroinfrageniculate bypass.

Acute Disease↗
PubMed1994

Radiographic assessment of cementless femoral components. Correlation with intraoperative mechanical stability.

The correlation between preoperative radiographic findings and intraoperative testing for stability was evaluated for 75 cementless femoral components. Fourteen of 45 porous-coated prostheses were unstable. The following radiographic signs were correlated with instability in order of significance: radiolucent lines at the bone-prosthesis interface covering greater than 50% of the porous interface, a distal pedestal, calcar hypertrophy, poor implant-cortical contact, and varus component alignment. Signs consistent with implant stability were good implant-cortical contact, spot welds, and calcar atrophy. Preoperative radiographs have predictive value in assessing the mechanical stability of the cementless femoral component at the time of surgery.

Hip↗