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PubMed2003

Preoperative use of recombinant human erythropoietin before total joint arthroplasty.

BACKGROUND: Previous reports have suggested that the use of recombinant human erythropoietin is effective for decreasing the need for perioperative allogeneic blood transfusion. The purpose of this study was to evaluate the efficacy of erythropoietin in combination with, and compared with, preoperative autologous donation for reducing allogeneic blood requirements for total joint arthroplasty. METHODS: Two hundred and forty patients undergoing primary and revision total hip or knee arthroplasty were enrolled into three groups with different treatment regimens: (1) erythropoietin and preoperative autologous donation (Group 1), (2) erythropoietin alone (Group 2), and (3) preoperative autologous donation alone (Group 3). Patients were evaluated with regard to requirements for allogeneic transfusion, change from the baseline to the lowest postoperative hemoglobin value, postoperative complications, and adverse reactions. RESULTS: The rate of allogeneic transfusion was 11% in Group 1 (erythropoietin and preoperative autologous donation) compared with 28% in Group 2 (erythropoietin alone) and 33% in Group 3 (preoperative autologous donation alone). Within Group 1, patients who had a unilateral primary arthroplasty had an allogeneic transfusion rate of 4% and those who had a bilateral or revision arthroplasty had an allogeneic transfusion rate of 17%. In Groups 2 and 3, the allogeneic transfusion rates were 14% and 15%, respectively, for the patients who had a unilateral primary arthroplasty and 35% and 47%, respectively, for those who had a bilateral or revision arthroplasty. CONCLUSIONS: Preoperative use of erythropoietin in conjunction with preoperative autologous donation reduces the need for allogeneic blood transfusion associated with total joint arthroplasty more effectively than does either erythropoietin or preoperative autologous donation alone.

Aged↗
PubMed2003

Endogenous cortisol production in response to knee arthroscopy and total knee arthroplasty.

BACKGROUND: There is controversy about whether patients who take exogenous glucocorticoids, such as prednisone, require supplemental (exogenous) glucocorticoids in order to meet the physiological demands of surgery. In this study, we sought to define the magnitude of the surgical stress response in normal patients undergoing major and minor elective orthopaedic surgery. METHODS: A prospective, observational study of thirty patients who had not taken exogenous glucocorticoids and who underwent either elective knee arthroscopy or elective unilateral total knee arthroplasty was performed. Regional anesthesia was used for all patients, and all patients treated with total knee arthroplasty had continuous epidural anesthesia for forty-eight hours after the surgery. The stress response was assessed on the basis of serum and twenty-four-hour urine cortisol levels; comparisons of the urine values were made after correcting for renal function by calculating the cortisol-to-creatinine clearance ratio. RESULTS: Preoperatively, patients undergoing arthroscopy and total knee arthroplasty had similar cortisol-to-creatinine clearance ratios. Patients treated with total knee arthroplasty had a significant (p < 0.001) surgical stress response on the day of the surgery, compared with baseline, whereas patients treated with arthroscopy did not. The mean cortisol-to-creatinine clearance ratio in patients treated with total knee arthroplasty was highest on the day of the surgery and decreased on the third postoperative day. However, on the third postoperative day, the cortisol-to-creatinine clearance ratio still was significantly higher than the baseline value (p < 0.001). Significant differences in the serum cortisol levels also were detected between the patients treated with arthroscopy and those treated with total knee replacement. CONCLUSIONS: Patients undergoing total knee arthroplasty had a significant surgical stress response (a seventeenfold increase in the cortisol-to-creatinine clearance ratio); patients treated with arthroscopy did not. Additional studies, including a prospective trial of patients taking exogenous glucocorticoids, are warranted. Until they are performed, the significantly increased cortisol production observed in non-steroid-dependent patients following total knee arthroplasty leaves open the possibility that steroid-dependent patients undergoing this procedure could benefit from perioperative glucocorticoid supplementation. Since the non-steroid-dependent patients in the present series did not mount a substantial stress response to knee arthroscopy, our results do not support the use of supplemental steroids for that less-invasive procedure.

Arthroplasty, Replacement, Knee↗
PubMed2004

The cumulative long-term risk of dislocation after primary Charnley total hip arthroplasty.

BACKGROUND: A widely variable prevalence of dislocation after total hip arthroplasty has been reported, partly because of varying durations of follow-up for this specific end-point. The effect of demographic factors on the long-term risk of dislocation as a function of time after total hip arthroplasty is not well understood. The purpose of the present study was to determine the risk of dislocation as a function of time after Charnley total hip arthroplasty and to investigate the demographic factors that influence the cumulative risk of dislocation. METHODS: Six thousand six hundred and twenty-three consecutive primary Charnley total hip arthroplasties were performed in 5459 patients at one institution between 1969 and 1984. The patients included 2869 female patients and 2590 male patients with a mean age of sixty-three years. All procedures were performed with a 22-mm femoral head, and all femoral and acetabular components were fixed with cement. The patients were followed at routine intervals and were specifically queried about dislocation. The cumulative risk of dislocation was calculated with use of the Kaplan-Meier method. RESULTS: Three hundred and twenty hips (4.8%) dislocated. The cumulative risk of a first-time dislocation was 1% at one month and 1.9% at one year and then rose at a constant rate of approximately 1% every five years to 7% at twenty-five years for patients who were alive and had not had a revision by that time. Multivariate analysis revealed that the relative risk of dislocation for female patients (as compared with male patients) was 2.1 and that the relative risk for patients who were seventy years old or more (as compared with those who were less than seventy years old) was 1.3. Three underlying diagnoses-osteonecrosis of the femoral head, acute fracture or nonunion of the proximal part of the femur, and inflammatory arthritis-were associated with a significantly greater risk of dislocation than osteoarthritis was. CONCLUSIONS: The cumulative long-term risk of dislocation after total hip arthroplasty is considerably greater than has been reported in short-term studies. The incidence of dislocation is highest in the first year after arthroplasty and then continues at a relatively constant rate for the life of the arthroplasty. Patients at highest risk are female patients and those with a diagnosis of osteonecrosis of the femoral head or an acute fracture or nonunion of the proximal part of the femur. LEVEL OF EVIDENCE: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

Adolescent↗
PubMed2004

Posterior slope of the tibial implant and the outcome of unicompartmental knee arthroplasty.

BACKGROUND: Laboratory studies have suggested that the sagittal displacements permitted by a knee replacement are influenced by the posterior slope of the tibial implant. The effect of the posterior slope of the tibial implant on the outcome of unicompartmental arthroplasty is not well known. The purpose of the present study was to assess the effect of the posterior slope on the long-term outcome of unicompartmental arthroplasty in knees with intact and deficient anterior cruciate ligaments. METHODS: We retrospectively reviewed the results of ninety-nine unicompartmental arthroplasties after a mean duration of follow-up of sixteen years. At the time of the arthroplasty, the anterior cruciate ligament was considered to be normal in fifty knees, damaged in thirty-one, and absent in eighteen. At the most recent follow-up, we measured the posterior tibial slope and the anterior tibial translation on standing lateral radiographs. The anteroposterior stability of seventy-seven knees that had not been revised by the time of the most recent follow-up was evaluated clinically. RESULTS: In the group of seventy-seven knees that had not been revised by the time of the most recent follow-up, there was a significant linear relationship between anterior tibial translation (mean, 3.7 mm) and posterior tibial slope (mean, 4.3 degrees ) (p < 0.01). The mean posterior slope of the tibial implant was significantly less in the group of seventy-seven knees without loosening of the implant than it was in the group of seventeen knees with loosening of the implant (p < 0.05). Five ruptures of the anterior cruciate ligament occurred in knees in which the ligament had been considered to be normal at the time of implantation; the posterior tibial slope in these five knees was > or = 13 degrees. Clinical evaluation revealed normal or nearly normal anteroposterior stability at the time of the most recent follow-up in all sixty-six unrevised knees in which the anterior cruciate ligament had been present at the time of implantation. Of the eighteen knees in which the anterior cruciate ligament had been absent at the time of the arthroplasty, eleven still had the implant in situ at the time of the most recent follow-up; the mean posterior tibial slope in these eleven knees was <5 degrees. Seven knees in which the anterior cruciate ligament had been absent at the time of the arthroplasty were revised. In these knees, the tibial prosthesis was implanted with a posterior slope of >8 degrees. CONCLUSIONS: These findings suggest that >7 degrees of posterior slope of the tibial implant should be avoided, particularly if the anterior cruciate ligament is absent at the time of implantation. An intact anterior cruciate ligament, even when partly degenerated, was associated with the maintenance of normal anteroposterior stability of the knee for an average of sixteen years following unicompartmental knee arthroplasty. LEVEL OF EVIDENCE: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

Adult↗
PubMed2004

Complications and failure after total ankle arthroplasty.

BACKGROUND: Second-generation total ankle arthroplasty has been reported to have good intermediate-term results. The purpose of the present study was to report on the cause and frequency of reoperation and failure after total ankle arthroplasty and to determine demographic and clinical predictors of reoperation and failure. METHODS: Three hundred and six consecutive primary total ankle arthroplasties were performed with use of the DePuy Agility Total Ankle System between 1995 and 2001. At a mean of thirty-three months after the arthroplasty, we retrospectively reviewed the records with regard to patient age, gender, the indications for the index procedure, adjuvant procedures, the timing and frequency of reoperation, and the indications for and the type of reoperations performed. Kaplan-Meier analysis was performed to determine the rate of prosthetic survival, and Cox regression analysis was performed to determine predictors of reoperation and failure. RESULTS: Eighty-five patients (28%) underwent 127 reoperations (involving 168 procedures) after primary total ankle arthroplasty. The most common procedures at the time of reoperation were débridement of heterotopic bone (fifty-eight), correction of axial malalignment (forty), and component replacement (thirty-one). Eight patients underwent below-the-knee amputation. Age was found to be the only significant predictor of reoperation and failure after total ankle arthroplasty. The five-year survival rate with reoperation as the end point was 54%. The five-year survival rate with failure as the end point was 80% for all patients and 89% for patients who were more than fifty-four years of age. The prosthesis could not be salvaged in nine ankles (2.9%); the inability to salvage the prosthesis was most often due to loosening or infection. CONCLUSIONS: We noted a relatively high rate of reoperation after total ankle arthroplasty with this second-generation device. Younger age was found to have a negative effect on the rates of reoperation and failure. Most prostheses could be salvaged; however, the functional outcome of this procedure is uncertain.

Age Factors↗
PubMed2004

Patient survival after hip arthroplasty for metastatic disease of the hip.

BACKGROUND: The hip joint is a common location for metastatic disease. Actual as well as impending fractures at this site are frequently due to mechanical instability after tumor invasion and are usually treated surgically with hip arthroplasty. The objective of this study was to analyze survival and influences on survival after hip arthroplasty for metastatic hip disease. METHODS: Two hundred and ninety-nine patients who had undergone a total of 306 hemiarthroplasty or total hip arthroplasty procedures for treatment of a pathologic or an impending pathologic hip fracture between 1969 and 1996 at our institution were included in this study. Data that had been acquired prospectively within the total joint registry of our institution were reviewed retrospectively. RESULTS: The median duration of survival after the arthroplasty was 8.6 months. The duration of survival was significantly associated with the site of the fracture, location of the primary tumor, and time from the diagnosis of the primary tumor to the surgery for the fracture (p < or = 0.05). The time from the diagnosis to the arthroplasty was a significant independent predictor of survival. CONCLUSIONS: Patients undergoing hip arthroplasty for metastatic disease have a limited life expectancy, with only 40% (120) of the 299 patients in our series still alive at one year after the surgery. By identifying prognostic factors regarding life expectancy, this study provides surgeons and oncologists with information with which to weigh risks and benefits of hip arthroplasty for individual patients preoperatively.

Adult↗
PubMed2006

Patient expectations regarding total knee arthroplasty: differences among the United States, United Kingdom, and Australia.

BACKGROUND: Total knee arthroplasty is an effective treatment for severe osteoarthritis of the knee. Our aim was to determine whether patients from the United Kingdom, United States, and Australia have different preoperative expectations regarding total knee arthroplasty and whether these expectations have an impact on outcomes and patient satisfaction. METHODS: Patients from the United Kingdom, the United States, and Australia were recruited into a prospective observational study of primary total knee arthroplasty for the treatment of osteoarthritis. Preoperative expectations, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Short Form-36 (SF-36) scores, and demographic, socioeconomic, and follow-up data, including satisfaction with outcome, were obtained from self-administered patient questionnaires. RESULTS: A total of 598 patients with a mean age of sixty-nine years at the time of the index arthroplasty were recruited; 58% were women. The majority of patients expected to have no pain at twelve months after the surgery, and with the numbers available there was no significant difference among the countries with regard to pain expectations. Australian patients were more likely than patients in the United Kingdom or the United States to expect better function at twelve months after the surgery. With the numbers available, satisfaction scores at twelve months did not differ significantly among the countries and were not influenced by preoperative expectations. Australian patients were more likely than patients in the United Kingdom or the United States to be unwilling to undergo total knee arthroplasty again at twelve months under similar circumstances. CONCLUSIONS: Patients from different countries have different expectations regarding total knee arthroplasty, which are not fully explained by differences in sociodemographic factors, clinical characteristics, and pain and functional status. Australian patients had the highest expectations but, despite reporting similar outcomes and satisfaction following total knee arthroplasty, they were more likely not to want to have the surgery again under similar circumstances.

Adult↗
PubMed2006

Primary unconstrained shoulder arthroplasty in patients with a fixed anterior glenohumeral dislocation.

BACKGROUND: Reports of shoulder arthroplasty for the treatment of fixed glenohumeral dislocation are rare. The purpose of this study was to analyze the results following shoulder arthroplasty in patients with a fixed anterior shoulder dislocation. METHODS: Eleven patients were evaluated at a minimum of twenty-four months after they underwent an arthroplasty for the treatment of a fixed anterior shoulder dislocation. Four patients underwent a total shoulder arthroplasty, and the remainder were treated with a hemiarthroplasty. Four shoulders had osseous reconstruction of the anterior aspect of the glenoid. The patients were evaluated with use of the Constant score, measurement of active anterior elevation and external rotation, the patient's subjective grading of the result, and a radiographic examination. RESULTS: The mean Constant score improved from 21.1 points preoperatively to 46.0 points following the arthroplasty, and the mean active anterior elevation improved from 48.6 degrees to 90.0 degrees . The pain component of the Constant score was the most reliably improved parameter, increasing from a mean of 4.8 points preoperatively to a mean of 11.0 points postoperatively. Eight patients reported that the result was excellent or good, and the remaining three considered it to be fair. We observed seven complications in five patients, including four cases of anterior instability of the shoulder. Two of the four patients treated with a total shoulder replacement were seen to have definite loosening of the glenoid component on follow-up radiographs. CONCLUSIONS: Shoulder arthroplasty in patients with a fixed anterior shoulder dislocation is fraught with difficulties and complications. Although arthroplasty reliably relieved shoulder pain in this population, limited functional results should be expected.

Aged↗
PubMed2006

Analysis of transfusion predictors in shoulder arthroplasty.

BACKGROUND: We are not aware of any previous study that has examined predictive factors for blood transfusion after shoulder arthroplasty. We analyzed the association between clinical factors and the need for postoperative blood transfusion and documented the use and waste of predonated blood in a group of patients managed with shoulder arthroplasty. METHODS: A retrospective study of 119 patients who underwent 124 shoulder arthroplasties (including eighty-seven primary uncomplicated total shoulder arthroplasties, twenty-seven revision or complicated primary total shoulder arthroplasties, and ten hemiarthroplasties) from 2001 to 2004 was performed. Logistic regression analysis was conducted to determine which clinical variables were predictive of transfusion. RESULTS: A postoperative transfusion was received after thirty-one arthroplasties (25%). The strongest predictor of blood transfusion after shoulder arthroplasty was the preoperative hemoglobin level (likelihood ratio test = 37.8, p < 0.0001). Patients with a preoperative hemoglobin level of between 110 and 130 g/L had a five times greater estimated risk of transfusion than those with a level of >130 g/L (p < 0.001). Gender, body mass index, preoperative diagnosis, comorbid conditions, use of anticoagulants or aspirin, autologous predonation status, type of anesthesia, operative time, and decrease in hemoglobin or hematocrit were not predictors of blood transfusion. One hundred and two (78%) of the 131 predonated autologous units were discarded. Patients with a preoperative hemoglobin level of >130 g/L had the highest percentage of wasted units (90%; fifty-five of sixty-one). Preoperative autologous blood donation did not eliminate the risk of allogeneic blood transfusion in autologous donors. CONCLUSIONS: The preoperative hemoglobin level is the strongest predictor of blood transfusion after shoulder surgery, and individuals with a preoperative hemoglobin level of <110 g/L have the highest risk of transfusion. On the basis of these findings, we do not recommend autologous predonation for individuals with a preoperative hemoglobin level of >130 g/L, to avoid unnecessary expense and waste.

Adult↗
PubMed2006

Osteonecrosis of the knee after laser or radiofrequency-assisted arthroscopy: treatment with minimally invasive knee arthroplasty.

BACKGROUND: Osteonecrosis of the knee after various arthroscopic procedures associated with the use of laser or radiofrequency devices has been described in a few case reports. The purpose of this study was to report on a series of nineteen patients with osteonecrosis of the knee after arthroscopic procedures. A literature search was done to compare this series of patients to previously reported cases. In addition, we analyzed the outcome after treatment with minimally invasive knee arthroplasty. METHODS: We studied patients who had development of osteonecrosis of the knee after a routine arthroscopic procedure. Preoperative and postoperative clinical notes, radiographs, and magnetic resonance images of patients were analyzed. Only those patients with no evidence of osteonecrosis on preoperative magnetic resonance imaging who later had development of osteonecrosis and subsequently required a knee arthroplasty were included. We conducted a search of the current literature to compare the results seen in our patient population with those seen in other patients with this entity. Patients were followed both clinically and radiographically for a mean of sixty-two months. RESULTS: A total of nineteen patients met the inclusion criteria. There were fourteen women and five men with a mean age of sixty-nine years. Six patients underwent an arthroscopy with associated holmium or yttrium-aluminum-garnet laser treatment, ten patients had associated radiofrequency treatment, and three patients had microfracture surgery. Subsequent arthroplasty procedures included four unicompartmental knee arthroplasties and fifteen tricompartmental knee arthroplasties. At the time of final follow-up, the mean Knee Society objective score was 95 points. CONCLUSIONS: Arthroscopic procedures may play a role in the development of osteonecrosis of the knee. To our knowledge, this is the largest series of patients to have development of this condition after arthroscopy with associated laser, radiofrequency, or microfracture surgery. The midterm results of knee arthroplasty in this unique patient population are comparable with those of patients undergoing knee arthroplasty for osteoarthritis of the knee. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.

Aged↗
PubMed2005

Displaced intracapsular hip fractures in fit, older people: a randomised comparison of reduction and fixation, bipolar hemiarthroplasty and total hip arthroplasty.

OBJECTIVES: To compare internal fixation, bipolar hemiarthroplasty and total hip arthroplasty for the management of displaced subcapital fracture of the hip in previously fit patients of 60 years or older. DESIGN: A prospective randomised clinical trial. SETTING: This multicentre trial was carried out in 11 Scottish hospitals with acute orthopaedic trauma units. PARTICIPANTS: The participants were 298 previously fit patients of 60 years or older with displaced subcapital hip fractures. INTERVENTIONS: The three surgical interventions for comparison were reduction and fixation, bipolar hemiarthroplasty and total arthroplasty (total hip replacement). Participating surgeons elected to randomise patients either among all three types of operation (three-way randomisation) or just between fixation and hemiarthroplasty (two-way randomisation). MAIN OUTCOME MEASURES: Clinical outcomes were mortality rates, reoperation rates and the complication rates associated with each procedure. Functional outcome was measured using a hip specific questionnaire [Johanson Hip Rating Questionnaire (HRQ)] and a general health status questionnaire [EuroQol 5 Dimensions (EQ-5D)]. Economic analysis compared the costs in the randomised groups of hospital treatment for the initial and subsequent admissions for up to 2 years. RESULTS: Altogether, 207 patients were randomised among all three trial operations, and 91 between just fixation and bipolar hemiarthroplasty. There were no statistically significant differences in clinical outcomes, but confidence intervals (CIs) were wide. At 2 years fixation failure reached 37% among those allocated fixation and 39% had undergone further surgery. Further surgery rates after hemiarthroplasty and total hip replacement were 5% and 9%, respectively. The group allocated fixation had significantly worse HRQ and EQ-5D scores than both arthroplasty groups at 4 and 12 months. At 24 months the results still favoured arthroplasty, but the overall HRQ and EQ-5D scores were no longer statistically significant. Total hip replacement had the best patient-assessed outcome scores. At 24 months the overall HRQ and EQ-5D scores for total hip replacement were significantly better than for hemiarthroplasty. The mean costs for the initial episode ranged from 6384 pounds Sterling for fixation to 7633 pounds Sterling for total hip replacement. The cost differences were largely due to differences in theatre costs and the cost of prostheses and hardware. The cumulative cost over 2 years of hemiarthroplasty was around 3000 pounds Sterling lower than for fixation (95% CI 1227 pounds Sterling to 7192 pounds Sterling). Compared with total hip replacement, both fixation and hemiarthroplasty were characterised by increased costs arising from hip-replacement admissions. When total (initial episode and subsequent hip-related admissions) hip-related costs are compared, total hip replacement conferred a cost advantage of around 3000 pounds Sterling per patient (versus hemiarthroplasty, 95% CI -pounds Sterling 1400 to 7420 pounds Sterling). CONCLUSIONS: In fit, older patients the results of the study show a clear advantage for arthroplasty over fixation; arthroplasty was more clinically effective and probably less costly over a 2-year period postsurgery. The results suggest that total hip replacement has long-term advantages over bipolar hemiarthroplasty, but these findings are less definite. This study provided support for the use of total hip replacement to treat displaced intracapsular hip fractures in fit, older patients. A larger trial comparing total versus hemiarthroplasty for these fractures could help to verify these findings. It would also be useful to know whether the findings of this study apply to patients aged 60 years or less who are usually treated with reduction and fixation. A clinical trial comparing arthroplasty versus fixation in patients older than 40 years would be a logical extension of the current study.

Aged↗
PubMed1998

Functional outcome of arthrodesis for failed total knee arthroplasty.

To establish the ability of a salvage procedure to restore an independent lifestyle, the SF-36 functional outcome instrument and the pain, mobility, and physical activity subscales of the Arthritis Impact Measurement Scale (AIMS) was used to assess patient function. Nine patients (10 knees) who had undergone arthrodesis for failed total knee arthroplasty were compared with a control group of successful primary total knee arthroplasty patients. Average clinical follow-up was 42 months (minimum: 24 months). For six of the eight SF-36 categories, the average scores for the arthrodesis and arthroplasty groups were similar. The average global scores for the two groups were nearly identical. The arthroplasty patients scored better on the AIMS physical activity and mobility subscales than the arthrodesis group, although the latter group fared better on the pain subscale. Overall, global scores favored the arthroplasty patients. The only subscales to show a statistically significant difference between the arthrodesis and arthroplasty groups were the SF-36 physical functioning and the AIMS physical activity subscales. This pilot study demonstrated the ability of a salvage procedure to allow for an independent lifestyle with minimal complications. Furthermore, despite its popularity, the SF-36 does not appear as sensitive as the AIMS to differences in functional status or health outcomes between total knee arthroplasty and arthrodesis patients.

Activities of Daily Living↗
PubMed2003

Arthroplasty in the treatment of subcapital hip fracture.

After reviewing recent literature on the treatment of displaced intracapsular fractures of the femoral neck (Garden types III and IV) and from personal experience, a number of conclusions can be made. Orthopedic surgeons and hospitals face the challenge of providing the treatment most beneficial to patients with intracapsular, subcapital hip fractures in the most cost-effective way. The numbers of patients will increase annually and exceed the 125,000 per year at present in the United States. Most authors agree that fractures with the least displacement and younger, more demanding patients will do well with a precise fracture reduction without delay and an accurately placed internal fixation system. However, an overall median risk for reoperation 2 years after internal fixation is 35%. A patient with a displaced intracapsular fracture will need to consider monopolar, bipolar, or THA as the treatment of choice. Monopolar and bipolar arthroplasty have a reduced survivorship compared to THA and are not as suitable for the younger, more active patient. A large femoral head implant leads to decreased motion from increased friction and an undersized head implant leads to reduced contact area with increased erosion and pain. Bipolar arthroplasties, while allowing early mobilization, may develop some of the characteristics of monopolar implants if motion is not mainly at the internal joint. The increased cost may not justify their use over monopolar arthroplasty. Should dislocation occur, monopolar implants are easier to reduce (closed) than bipolar. Ceramic heads on monopolar or bipolar arthroplasties offer reduced wear and less erosion of the acetabulum. Total hip arthroplasty provides early mobilization, long-term pain relief, and little additional morbidity at surgery. The increased rate of early dislocation may be related to surgeon skill rather than an inherent failure of the system. If the early dislocators are removed from consideration, the complication rate drops to equal that of monopolar and bipolar implants. Total hip arthroplasty also is cost effective. Total hip arthroplasty may be the only option if pre-existing arthritis, significant osteoporosis, or Paget's disease of the pelvis is present.

Arthroplasty, Replacement, Hip↗
PubMed1999

[Replacement arthroplasty of paralytic hip. Apropos of 18 cases].

PURPOSE: Frequency of hip impairment, with sub-luxation or dislocation, during evolution of neuromuscular diseases depends on intensity and spreading of palsy. At the end of growth or at the beginning of adult life, secondary arthritis can induce pain and lack of mobility. The importance of the chondropathy and irreducible lack of congruence may doom to failure a conservative articular or periarticular surgery. Total hip arthroplasty is an alternative, but the risks of dislocation, ectopic ossifications and infection make often refute this indication. We report our experience of total arthroplasty for paralytic hip, about 18 cases. MATERIALS AND METHODS: We reviewed retrospectively 14 consecutive patients with neuromuscular disease, who had 18 total arthroplasties of paralytic hips. The origin of neuromuscular disease was cerebral for 7 patients (6 cerebral palsy: 4 spastic or athetosic tetraplegias, 1 spastic diplegia, 1 hemiplegia; 1 head trauma), 6 medullar disorders (1 Friedreich disease, 2 acute anterior poliomyelitis, 1 vascular injury, 1 malformative spine with sacral agenesis and 1 cervical spine trauma) and 1 muscular affection (Steinert disease). Mean age of the patient was 40 year old (19 to 64). Mean follow up was 5 years. Intensity and diffusion of weakness were variables, compatible with gait with or without help for 11 patients, and for 3 patients with sitting posture and transfer. The coxopathy, with pain stiffness and vicious attitudes, induced the loss of gait or sitting posture and transfer. The goal of the arthroplasty was the restitution of the initial function. 11 hip had previous surgery, with infection in 2 cases. Arthritis was secondary to hip palsy in 14 cases (4 dislocations, 6 subdislocations, 3 complications of surgery of paralytic hip dislocation in childhood, 1 nervous arthropathy), and independent of palsy in 4 cases (1 femoral head avascular necrosis ans 3 primary arthritis). The prosthesis were LFA Charnley Kerboull in all cases except 1. We used transtrochanteric approach. RESULTS: Mean follow-up is 5.6 years. Functional initial goal has been obtain in all cases. Ectopic ossifications occurred in 3 cases, without functional consequence. One acetabular loosening occurred after 13 years and has been reoperated on. There was no polyethylene wear. We noticed 1 mechanical and 2 chemical femoral loosening. Prosthetic dislocation occurred in 4 cases, always during the 4 post-operative months, without recurrence after this critical period. There were no infection. DISCUSSION: If gait is possible, there is no satisfactory alternative to total hip arthroplasty. In absence of gait, total hip arthroplasty gives also the best functional results. Girdlestone procedure is not indicated because it will induce the loss of transfer and side effects as ascension of proximal femur with recurrence of adduction bringing out pain and sometimes scabs. CONCLUSION: Total arthroplasty of paralytic hip induced restitution of initial function for all patients and an acceptable rate of complication after strict selection of patients and indications, specific operative technique and rehabilitation for each patient. This results encourage us to carry on with this therapeutic orientation.

Adult↗
PubMed2004

Total hip arthroplasty: optimal treatment for displaced femoral neck fractures in elderly patients.

Although internal fixation is recommended for most nondisplaced fractures of the femoral neck, the optimal treatment for displaced fractures of the femoral neck is controversial. Options for operative treatment of displaced fractures of the femoral neck include: reduction and internal fixation; unipolar hemiarthroplasty; bipolar hemiarthroplasty; and total hip arthroplasty. One hundred eighty-six displaced fractures of the femoral neck in elderly patients were treated surgically with internal fixation (in 120 patients), hemiarthroplasty (in 43 patients), and total hip arthroplasty (in 23 patients). One hundred twenty patients with displaced fractures treated with internal fixation were compared with 66 patients with displaced fractures treated with arthroplasty. Criteria for comparison were reoperation, mortality, hospital discharge disposition, functional outcome, living status, and cost effectiveness. There was no difference in rates of reoperation or mortality, but arthroplasty produced a longer interval to reoperation or death. Arthroplasty was associated with more independent living, and arthroplasty was more cost-effective than internal fixation. Total hip arthroplasty was the best treatment for displaced fractures of the femoral neck in elderly patients in this series.

Age Factors↗
PubMed2005

[Resection hip arthroplasty--mid- and long-term results].

PURPOSE OF THE STUDY: The study deals with resection hip arthroplasty, which is currently one of the principal orthopedic surgery procedures.The aim of the study was to evaluate the mid- and long-term results of resection arthroplasty carried out for different indications and to ascertain effects of the extent of proximal femur resection on the functional outcome. MATERIAL: In the period from 1979 to 2000, we carried out 159 resection hip arthroplasties for septic and aseptic loosening of total hip arthroplasty (THA), septic arthritis or osteomyelitis. Of these only the patients who underwent no THA implantation or reimplantation within 2 years of the operation were evaluated. We assessed 102 patients (71 women and 31 men) with 105 resection arthroplasties for the following indications: 14 cases of aseptic loosening of the THA, 72 cases of septic loosening and 19 cases of hip inflammation. The average follow-up was 70.8 months (range, 26 months to 20 years). The average age of the patients at the time of surgery was 62.5 years (29 to 86 years). METHODS: We recorded the patient's subjective evaluation of the surgery outcome, shortening of the extremity, and the range of hip motion. Harris hip scores were used to assess the functional outcome. We also evaluated, and statistically analysed, the extent of resection of the proximal femur on X-ray images and its effect on the eventual shortening of the extremity; this was done on the basis of the Grauer classification system. RESULTS: The average Harris hip score was 63.2 points (range, 47 to 88). None of the joints achieved excellent outcomes; 8.5 % were good, 22 % were satisfactory and 73 % were poor. On pain evaluation, 35 % of the patients were completely free from pain, 18 % reported mild pain not interfering with daily activities, 27 % experienced moderate pain responding to common analgetics and 11 % had severe pain necessary to be treated with strong analgetics. Persistent rest pain not responding to analgetics was in 9 % of the patients. The average shortening of the extremity for the whole group was 4.1 cm (range, 3.5- 7 cm): the average values for shortening in type I, type II and type II resections were 3.25 cm (3-5 cm), 4.1 cm (3-6 cm) and 5.3 cm (4.5/7 cm), respectively. The range of passive flexion was on average 81 degrees (range, 45-105 degrees ). Limping and a positive Trendelenburg's test were recorded in all patients and all also had to use walking aids. The outcome of surgery was evaluated as satisfactory by 35 % and as partially satisfactory by 43 % of the patients. DISCUSSION: Resection arthroplasty is a reliable technique for pain reduction, but it results in a considerable alteration of hip function. Pain in the hip after surgery is bearable, as 80 % of our patients reported only mild or moderate pain alleviated by common analgetics, or complete absence of pain. This is in agreement with the results of Stoklasa (84 %) and Stedrý (79 %). However, the subjective evaluation of surgery by patients is different; Petty has reported 14 % of satisfied patients, while Ahlgren and Böhler described 100 % of satisfied patients. Hip stability and less shortening of the extremity are more important for patients' satisfaction than a certain mild degree of pain. The best subjective evaluation was reported by the patients who had resection at the femoral neck level and who also had the lowest average shortening of the extremity. But only 55 % of the satisfied or partially satisfied patients reported mild or no pain. CONCLUSIONS: Resection arthroplasty is, in indicated cases, a reliable method which, in spite of certain drawbacks, produces good functional outcomes and makes the patients satisfied. It is, without doubt, an integral part of the current orthopedic surgery repertoire. We recommend a cautious approach to repeated attempts at THA reimplantation or to reconstruction procedures.

Adult↗
PubMed2005

Acute hip arthroplasty for the treatment of intertrochanteric fractures in the elderly.

Arthroplasty for intertrochanteric fractures in elderly patients may allow early weightbearing and avoid fixation failure. Clinical results are reviewed in a consecutive group of acute arthroplasties (5 hemiarthroplasties and 29 total hip arthroplasties) performed via the anterolateral approach for intertrochanteric fractures. Age averaged 80.2 years. Follow-up averaged 35 months for living patients. Twenty-six patients died during follow-up. Time to death averaged 3.5 years. Five hips, all total hip arthroplasties, required subsequent surgeries: four for dislocation and one revised for sepsis. Acute intertrochanteric fractures are associated with high early mortality. In this series, a 15% complication rate and high mortality rate at 12 years was associated with acute arthroplasty. Dislocation is higher than in primary total hip arthroplasty utilizing the same surgical approach. The results do not support routine use of arthroplasty in treatment of intertrochanteric hip fractures in the elderly.

Aged↗
PubMedDate not supplied

[Assessment of supply and demand for hip arthroplasty in Puglia (Italy) in the years 1996-2003].

Hip arthroplasty is one of the major achievements of orthopaedic surgery. In the Puglia region the demand for this procedure is moderately met. This study evaluates the regional distribution of hip arthroplasty procedures in Puglia in the years 1996-2003. Demand and supply was estimated through analysis of discharge abstract forms. Between 1996 and 203, 21,392 hip arthroplasty procedures were performed. of these, 12,491 (58,4%) were total hip arthroplasties, 7,742 (36,2%) were hip endoprostheses and 1,159 (5,4%) wee revisions. The median age of patients undergoing any of these procedures was 70 years and the proportion of females was almost double that of males (64%). The main indication was primary osteoarthrosis and 52,1% of all procedures were performed in the province of Bari. The average annual crude hospitalisation rate for hip arthroplasty procedures was 75,9 cases/100.000 inhabitants; this rate places the Puglia region in an intermediate position with respect to other Italian regions and is lower than that found in the literature. Discharge abstract forms are currently the sole source of data regarding hip arthroplasty procedures and this presents several limits. This factor, in addition to the complexity and high costs of these procedures and to the increasing average life expectancy of the general population all point to the need for a regional Hip arthroplasty Register, which would allow better planning for patients.

Adolescent↗