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PubMed2003

The use of bone cement induces an increase in serum astroglial S-100B protein in patients undergoing total knee arthroplasty.

UNLABELLED: Cerebral microemboli can occur during arthroplasty with the use of bone cement. Astroglial S-100B protein is a sensitive marker of cerebral damage. Therefore, we designed this study to determine the effect of bone cement on the brain by investigating serum levels of S-100B protein in patients undergoing bone surgery with or without bone cement. Fourteen patients undergoing knee arthroplasty (n = 7) or reamed intramedullary nailing for tibial fracture (n = 7) requiring a pneumatic tourniquet were enrolled in this study. Bone cement containing polymethyl methacrylate and methyl methacrylate was used for every patient undergoing knee arthroplasty. Serum samples were obtained from venous blood before the induction of general anesthesia, 15 min after deflation of a pneumatic tourniquet, and 3 days after the operation. The serum level of S-100B protein was significantly increased 15 min after a pneumatic tourniquet deflation in the knee arthroplasty group compared with the tibial fracture group (0.41 and 0.08 ng/mL, respectively; P < 0.05). In all patients studied, no neurological abnormalities were noted in the postoperative period. These results suggest that, in patients undergoing knee arthroplasty, bone cement may transiently induce astroglial injury, although it does not alter neurological outcome. IMPLICATIONS: Serum S-100B protein was significantly increased 15 min after a pneumatic tourniquet deflation in patients undergoing knee arthroplasty with bone cement, but not in those undergoing reamed intramedullary nailing for tibial fracture without bone cement. These results suggest that bone cement may transiently induce astroglial injury.

Aged↗
PubMed2005

One-stage exchange shoulder arthroplasty for peri-prosthetic infection.

There are few reports in the literature of the diagnosis and treatment of the infected shoulder arthroplasty. Most deal with resection arthroplasty and two-stage exchange surgery. We present our results of one-stage exchange operation as treatment for the infected shoulder arthroplasty. Our group comprised 16 patients (ten men, six women) with 16 infected arthroplasties. By the time of follow-up, two patients had died (mean 5.8 years), two could not be located and three had already undergone revision surgery. Nine patients were thus available for clinical examination and assessment. The infections were largely caused by staphylococci, Propionibacterium species and streptococci. Two were early infections (within three months of surgery) and 14 were late infections. The mean follow-up was 5.8 years (13 months to 13.25 years) when the mean Constant-Murley score was 33.6 points and the mean University College of Los Angeles score 18.3 points. Further revision was performed in three patients. One sustained a peri-prosthetic humeral fracture, another developed an acromial pseudarthrosis after transacromial surgery and the third suffered recurrent dislocations. No patient had a recurrence of infection. A one-stage exchange procedure using antibiotic-loaded bone cement eradicated infection in all our patients and we suggest that such a procedure is at least as successful as either a resection arthroplasty or a two-stage exchange in the management of the infected shoulder arthroplasty.

Aged↗
PubMed2006

Combined anterior cruciate reconstruction and Oxford unicompartmental knee arthroplasty.

The options for treatment of the young active patient with isolated symptomatic osteoarthritis of the medial compartment and pre-existing deficiency of the anterior cruciate ligament are limited. The potential longevity of the implant and levels of activity of the patient may preclude total knee replacement, and tibial osteotomy and unicompartmental knee arthroplasty are unreliable because of the ligamentous instability. Unicompartmental knee arthroplasties tend to fail because of wear or tibial loosening resulting from eccentric loading. Therefore, we combined reconstruction of the anterior cruciate ligament with unicompartmental arthroplasty of the knee in 15 patients (ACLR group), and matched them with 15 patients who had undergone Oxford unicompartmental knee arthroplasty with an intact anterior cruciate ligament (ACLI group). The clinical and radiological data at a minimum of 2.5 years were compared for both groups. The groups were well matched for age, gender and length of follow-up and had no significant differences in their pre-operative scores. At the last follow-up, the mean outcome scores for both the ACLR and ACLI groups were high (Oxford knee scores of 46 (37 to 48) and 43 (38 to 46), respectively, objective Knee Society scores of 99 (95 to 100) and 94 (82 to 100), and functional Knee Society scores of 96 and 96 (both 85 to 100). One patient in the ACLR group needed revision to a total knee replacement because of infection. No patient in either group had radiological evidence of component loosening. The radiological study showed no difference in the pattern of tibial loading between the groups. The short-term clinical results of combined anterior cruciate ligament reconstruction and unicompartmental knee arthroplasty are excellent. The previous shortcomings of unicompartmental knee arthroplasty in the presence of deficiency of the anterior cruciate ligament appear to have been addressed with the combined procedure. This operation seems to be a viable treatment option for young active patients with symptomatic arthritis of the medial compartment, in whom the anterior cruciate ligament has been ruptured.

Adult↗
PubMed1998

Infection after total elbow arthroplasty.

The purpose of this study was to review our experience with the treatment of twenty-five infections (in twenty-five patients) after total elbow arthroplasty and to examine indications for salvage of the prosthesis compared with those for resection arthroplasty. The patients were divided into three groups on the basis of treatment. Group I comprised fourteen patients who were managed with multiple, extensive irrigation and debridement procedures with retention of the original components. The primary indication for retention of the prosthesis was evidence that it was well fixed as determined both radiographically and intraoperatively. Group II comprised six patients who had removal of the prosthesis and debridement followed by immediate or staged reimplantation. Group III comprised five patients who were managed with resection arthroplasty. The infection was successfully eradicated in seven of the fourteen elbows that had salvage of the prosthesis with irrigation and debridement. The results were strongly dependent on the causative organism; attempts at debridement failed in the four elbows that were infected with Staphylococcus epidermidis compared with three of the ten that were infected with another organism. Four of the six patients in Group II had successful reimplantation of a prosthesis; in three, the infection had been caused by an organism other than Staphylococcus epidermidis. Only one of the three patients who had a Staphylococcus epidermidis infection had a successful reimplantation. None of the five patients who had a resection arthroplasty had signs of infection at the latest follow-up examination. We concluded that salvage of the prosthesis with extensive irrigation and debridement in the presence of an infection about the elbow can be reasonably successful if the infecting organism is not Staphylococcus epidermidis and if the components are well fixed. When removal of the components is warranted, staged reimplantation can also be highly successful when the infecting organism is not Staphylococcus epidermidis. However, the repeated operations necessary to retain a prosthesis and the high rates of complications seen with this approach--and the relatively good rates of satisfaction obtained with resection arthroplasty--suggest that resection arthroplasty remains the procedure of choice in medically frail patients or in patients for whom function of the elbow is less of a concern.

Adult↗
PubMed1998

Total hip arthroplasty after operative treatment of an acetabular fracture.

Sixty-six primary total hip arthroplasties were performed to treat post-traumatic osteoarthrosis that had developed following an acetabular fracture and subsequent open reduction and internal fixation. The mean age of the patients at the time of the total hip arthroplasty was fifty-two years (range, nineteen to eighty years). The arthroplasty was performed with cement in forty-four hips and without cement in twenty hips; in the remaining two hips, the acetabular component was inserted without cement and the femoral component was inserted with cement (a so-called hybrid procedure). Scarring from a previous procedure, retained hardware, heterotopic bone, and residual osseous deformity and deficiency made the procedure more complex than routine total hip arthroplasty in most patients. However, only one of the sixty-six procedures was associated with an operative complication. Three patients were lost to follow-up. The remaining sixty-three patients were followed for a mean of 9.6 years (range, two to twenty years). The mean duration of follow-up was 14.9 years for the acetabular components inserted with cement, 11.6 years for the femoral components inserted with cement, 4.6 years for the femoral components inserted without cement, and 3.9 years for the acetabular components inserted without cement. The mean Harris hip score improved from 49 points preoperatively to 93 points at the latest follow-up evaluation for the forty-six patients who did not have a revision procedure after the index arthroplasty. Seventeen patients had a revision; sixteen revisions were performed because of aseptic loosening of one or both components (nine acetabular and eleven femoral components). Mechanical failure (radiographic loosening or revision due to aseptic loosening) occurred in twenty-five hips. As determined with use of the Kaplan-Meier method, the ten-year survival rate, with revision due to aseptic loosening as the end point, was 78 per cent (95 per cent confidence interval, 66 to 92 per cent) for the prosthesis as a whole (that is, no revision of either component), 87 per cent (95 per cent confidence interval, 76 to 99 per cent) for the acetabular component, and 84 per cent (95 per cent confidence interval, 72 to 97 per cent) for the femoral component. An age of less than fifty years (p = 0.02), a weight of eighty kilograms or more (p = 0.047), and large residual combined segmental and cavitary deficiencies in the acetabular bone (p < 0.0001) were significant risk factors for revision because of aseptic loosening. At the ten-year follow-up, none of the twenty-two acetabular components that had been inserted without cement had been revised or demonstrated radiographic loosening. The ten-year rate of failure due to aseptic loosening was higher than that in many reported series of total hip arthroplasties performed for other indications; this was probably partly because of the young mean age of the patients, the high number of patients who had Charnley class-A involvement, and the predominantly male cohort.

Acetabulum↗
PubMed2000

Osteonecrosis of the femoral head treated with cementless total hip arthroplasty.

BACKGROUND: The treatment of young patients who have osteonecrosis of the femoral head associated with collapse or substantial secondary degeneration remains a therapeutic challenge, with total hip arthroplasty being a treatment of choice. However, concerns about the durability of the results of hip arthroplasty in this population necessitate long-term evaluation of this treatment option. To determine its advantages and limitations, we evaluated the results of cementless total hip arthroplasty in a consecutive series of young patients with advanced osteonecrosis. METHODS: We reviewed the results of fifty-five consecutive primary total hip arthroplasties, after an average of 117 months of follow-up, in forty-five patients with a preoperative diagnosis of advanced osteonecrosis of the femoral head (Ficat and Arlet stage III or IV). The average age was thirty-one years (range, twenty-one to forty years) at the time of the operation. We collected data prospectively with the use of patient questionnaires and radiographs. RESULTS: Five patients died and one patient was lost to follow-up before the time of the minimum five-year follow-up; this left forty-eight hips in thirty-nine patients for inclusion in the study. Ten (21 percent) of the forty-eight hips required revision. No revisions were due to aseptic failure of the femoral component. Of the remaining twenty-nine patients (thirty-eight hips), twenty-seven (93 percent) reported few or no functional limitations and twenty-three (79 percent) could walk an unlimited distance at the time of the latest follow-up. Pain was absent or mild in twenty-five patients (86 percent). Twenty-three patients (79 percent) were employed full-time. Radiographically, thirty-seven femoral components (97 percent) were bone-ingrown and the remaining component was judged to be fibrous stable. All thirty-eight acetabular components were bone-ingrown. CONCLUSIONS: Cementless total hip arthroplasty remains a reasonable treatment option for advanced osteonecrosis of the femoral head. Wear of the bearing surface continues to limit the long-term success rate, but we are encouraged by the predictable long-term stability of the bone-implant interface achieved with cementless fixation. These results compare favorably with those of published reports of total hip arthroplasty with cement in younger patients with osteonecrosis.

Adult↗
PubMed2002

Total knee arthroplasty for arthritis of the knee with extra-articular deformity.

BACKGROUND: Simultaneous corrective osteotomy of angular deformity and total knee arthroplasty has been considered the treatment of choice for patients with arthritis of the knee associated with ipsilateral extra-articular deformity. However, this procedure is technically demanding, and the functional outcome of the total knee arthroplasty may be jeopardized if the osteotomy fails. This retrospective study was performed to evaluate the clinical results of total knee arthroplasty combined with intra-articular bone resection, without osteotomy, in patients with extra-articular deformity and arthritis of the knee. METHODS: Fifteen patients with arthritis of the knee and extra-articular deformity underwent total knee arthroplasty with bone resection and soft-tissue balancing. All deformities had resulted from fracture malunion. There were ten uniplanar, three biplanar, and two triplanar deformities. The deformity was in the tibia in eight patients and in the femur in seven. The average angle of the femoral deformities was 15.1 degrees in the coronal plane and 8.1 degrees in the sagittal plane. Two femora had a rotational deformity, consisting of 20 degrees of internal rotation in one and 10 degrees of external rotation in the other. The average angle of the tibial deformities was 19 degrees in the coronal plane. RESULTS: The duration of follow-up averaged thirty-eight months. The average Knee Society knee score improved from 22.3 points preoperatively to 91.7 points at the time of the last follow-up, and the average Knee Society function score improved from 28.0 points preoperatively to 87.3 points at the time of the last follow-up. The average arc of knee motion improved from 77.7 degrees preoperatively to 103.7 degrees postoperatively. The average mechanical axis of the knee improved from 22.7 degrees of varus preoperatively to 0.3 degrees of varus at the time of the last follow-up. Two patients had an unsatisfactory clinical result, which was not related to the total knee arthroplasty. There were no complications such as infection, ligament instability, or component loosening. CONCLUSIONS: Total knee arthroplasty in conjunction with intra-articular bone resection is an effective procedure for patients with arthritis of the knee and extra-articular varus deformity of <20 degrees in the femur or 30 degrees in the tibia in the coronal plane.

Aged↗
PubMed2002

Correlation of thrombophilia and hypofibrinolysis with pulmonary embolism following total hip arthroplasty: an analysis of genetic factors.

BACKGROUND: The increased thromboembolic risk associated with total hip arthroplasty is multifactorial. We assessed whether the prevalence of abnormalities shown by newer genetic screening tests for thrombophilia and hypofibrinolysis was higher in patients in whom pulmonary embolism had developed after total hip arthroplasty than it was in matched control patients. METHODS: Fourteen patients with documented pulmonary embolism after total hip arthroplasty and fourteen matched control patients who had undergone total hip arthroplasty without any clinical indication of thromboembolism were evaluated for risks of thrombophilia and hypofibrinolysis. Functional tests of hemostasis included evaluations of prothrombin time; activated partial thromboplastin time; levels of fibrinogen, serum homocysteine, protein C and S, and antithrombin III; activated protein-C resistance; and dilute Russell viper venom time. Molecular genetic testing was performed for factor-V Leiden, prothrombin promoter G20210A, methylenetetrahydrofolate reductase C677T, plasminogen activator inhibitor-1 4G/4G, and platelet glycoprotein IIb/IIIa A1/A2 or A2/A2 mutations. RESULTS: The total number of genetic thrombophilic abnormalities identified was higher in the pulmonary embolism group (twenty-four abnormalities) than in the control group (fifteen abnormalities). Only patients with pulmonary embolism were found to have heterozygosity or homozygosity for the prothrombin G20210A mutation (four of fourteen patients; p = 0.05 compared with the control group) and a decreased antithrombin-III level (three of thirteen patients; p = 0.10 compared with the control group). Patients with pulmonary embolism were much more likely than control patients to have at least one thrombophilic abnormality: seven of fourteen patients with pulmonary embolism had a low antithrombin-III level or the prothrombin G20210A gene mutation compared with none of the fourteen in the control group (Fisher exact test, p < 0.01). The presence of the prothrombin G20210A gene mutation was significantly correlated with pulmonary embolism (r = 0.41, p = 0.03), as was the presence of least one abnormality (a low antithrombin-III level or the presence of the prothrombin G20210A gene mutation) (r = 0.58, p = 0.001). CONCLUSIONS: Genetic thrombophilia and hypofibrinolysis were more frequent in patients who had had pulmonary embolism after total hip arthroplasty than in those who had not. The presence of multiple genetic thrombophilic polymorphisms, particularly prothrombin G20210A and antithrombin III, rather than any single genetic prothrombotic abnormality, appears to signal an increased thromboembolic risk in patients undergoing total hip arthroplasty. Future refinements and availability of these tests will likely allow preoperative identification of patients with an increased genetic predisposition for thromboembolism.

Arthroplasty, Replacement, Hip↗
PubMed2003

Results of treatment of infection in both knees after bilateral total knee arthroplasty.

BACKGROUND: The purpose of this study was to review the results and complications of treatment of simultaneous infection of both knees after bilateral total knee arthroplasty. METHODS: Between 1976 and 1999, twenty-one patients with a mean age of seventy-one years were treated for simultaneous infection of both knees after bilateral total knee arthroplasty. Two patients died within two years, and one patient was lost to follow-up after one year. The remaining eighteen patients were followed for a mean of five years. At the time of presentation, all twenty-one patients had had symptoms for less than three weeks. Eleven patients (twenty-two knees) were treated with attempts at prosthetic salvage with surgical débridement and administration of suppressive antibiotics. Resection arthroplasty was performed as the initial treatment in ten patients (twenty knees). RESULTS: Of the ten patients treated with initial resection, seven patients (fourteen knees) underwent subsequent reimplantation. All fourteen knees were functioning well at the time of the latest follow-up, and none had been revised at a mean of two years after reimplantation. Of the eleven patients (twenty-two knees) who had been initially treated with prosthetic salvage, nine patients (eighteen knees) had a recurrence of the infection that required a reoperation (bilateral resection arthroplasty in seven patients, bilateral above-the-knee amputation in one patient, and repeat débridement of both knees in one patient). Two of the seven patients who had resection underwent reimplantation six weeks postoperatively, and the other five patients (ten knees) did not have reimplantation because of low functional demands and prohibitive medical comorbidity. CONCLUSION: We believe that treatment of simultaneous infection of both knees after bilateral total knee arthroplasty should consist of bilateral resection arthroplasty and delayed reimplantation after a period of intravenous administration of organism-specific antibiotics.

Aged↗
PubMed2003

Surgeon experience and clinical and economic outcomes for shoulder arthroplasty.

BACKGROUND: Previous studies have demonstrated that a high surgical volume for certain surgical procedures reduces morbidity and improves economic outcome; however, to our knowledge, no study has demonstrated a similar relationship between volume and outcome for total shoulder arthroplasty and hemiarthroplasty. The objective of this study was to determine whether increased surgeon experience was associated with improved clinical and economic outcomes for patients undergoing total shoulder arthroplasty or hemiarthroplasty. METHODS: We analyzed discharge data on patients treated between 1994 and 2000 from the Maryland Health Services Cost Review Commission, which has a statewide hospital discharge database of all patients in the state of Maryland. The database included all patients undergoing total shoulder arthroplasty and hemiarthroplasty. We assessed the relationship between surgeon volume (low, medium, and high) and the risk of complications, length of stay, and total charges. The statistics were adjusted for procedure, age, gender, race, marital status, comorbidity, diagnosis, insurance type, income, and hospital volume. RESULTS: For the 1868 discrete total shoulder arthroplasties and hemiarthroplasties done in the state of Maryland, the risk of at least one complication associated with the procedures done by the high-volume surgeon group was nearly half that associated with the procedures done by the low-volume surgeon group (adjusted odds ratio, 0.6; 95% confidence interval, 0.4 to 0.9). High-volume surgeons were three times more likely than were low-volume surgeons to have patients with a hospital stay of less than six days (odds ratio, 0.3; 95% confidence interval, 0.2 to 0.6). Although the average cost of hospitalization was $1000 less in the high-volume surgeon group compared with the low-volume surgeon group, this reduction did not reach significance after adjustment for multiple variables (odds ratio, 0.8; 95% confidence interval, 0.5 to 1.4). CONCLUSIONS: This study indicates that the patients of surgeons with higher average annual caseloads of total shoulder arthroplasties and hemiarthroplasties have decreased complication rates and hospital lengths of stay compared with the patients of surgeons who perform fewer of these procedures. These analyses of hospital discharge data are limited because of a lack of prospective data, operative details, and patient outcomes data. However, this study emphasizes the importance of continued education for orthopaedic surgeons who perform shoulder arthroplasty.

Adult↗
PubMed2004

Proprioception, kinesthesia, and balance after total knee arthroplasty with cruciate-retaining and posterior stabilized prostheses.

BACKGROUND: The effect of total knee arthroplasty on proprioception, kinesthesia, and postural control remains controversial. It is argued that retaining the posterior cruciate ligament may help to preserve these sensorimotor functions and improve the longevity of the prosthesis and the functional outcome. We performed a prospective, randomized study to assess proprioception, kinesthesia, and balance following total knee arthroplasty with cruciate-retaining and posterior stabilized prostheses. METHODS: Twenty patients scheduled to undergo total knee arthroplasty were randomly assigned to receive either a cruciate-retaining or a posterior stabilized prosthesis. Joint-position sense, the threshold to detect joint motion, and the subject's ability to balance on an unstable platform were assessed prior to and at least six months after the operation. Paired two-tailed t tests (with a level of significance of p < 0.05) were used to assess the effect of the arthroplasty on the preoperative measures for all subjects. Analysis of covariance was performed to identify the effects of prosthetic design. RESULTS: Following total knee arthroplasty, patients detected motion significantly faster and reproduced joint position with less error. The balance index also improved significantly from the preoperative to the postoperative evaluation. The group treated with the posterior stabilized prosthesis more accurately reproduced joint position when the knee was extended from a flexed position. CONCLUSIONS: Total knee arthroplasty results in mild improvements in proprioception, kinesthesia, and balance. These changes may result from the retensioned capsuloligamentous structures and reduced pain and inflammation. Retention of the posterior cruciate ligament does not appear to significantly improve proprioception and balance compared with those functions in patients with a posterior stabilized total knee design.

Aged↗
PubMed2004

Allograft-prosthesis composite for revision of catastrophic failure of total elbow arthroplasty.

BACKGROUND: Revision of a failed total elbow arthroplasty is a challenging procedure, often associated with bone deficiency. The purpose of this investigation was to review our experience with a composite allograft-implant reconstruction for patients with a failed total elbow arthroplasty. METHODS: Thirteen patients (thirteen elbows) in whom a total elbow arthroplasty had failed, primarily as a result of loosening of the humeral or ulnar component, were operated on with use of an allograft-prosthesis composite; the composite was placed on the humeral side in four of these patients and on the ulnar side in nine. The delay between the last total elbow arthroplasty and the allograft-prosthesis-composite procedure averaged eight years. RESULTS: At an average of forty-two months after the revision, the Mayo Elbow Performance Score was excellent for four elbows, good for three, fair for one, and poor for five. Nine of the thirteen patients had no or only slight pain in the elbow. The mean arc of flexion was 97 degrees, with an average of 28 degrees (range, 0 degrees to 60 degrees ) of extension to 125 degrees (range, 100 degrees to 140 degrees ) of flexion. There were seven complications affecting seven elbows, and five of the seven required a revision procedure. Deep infection developed in four elbows, and the allograft-prosthesis composite had to be removed from three. Two nonunions occurred at the allograft-humeral junction. CONCLUSIONS: An allograft-prosthesis composite can be a valuable option in selected patients with a failed total elbow arthroplasty with massive bone loss. The union and implant survival rates are high. Deep infection remains the main complication. Hence, we recommend the pursuit of other revision options, such as strut graft reconstruction, whenever possible before resorting to the use of an allograft-prosthesis composite in the surgical treatment of a failed total elbow arthroplasty with massive bone loss.

Adult↗
PubMed2004

Long-term changes of the nonresurfaced patella after total knee arthroplasty.

BACKGROUND: The most common complications of total knee arthroplasty involve the patellofemoral joint. However, the long-term fate of the nonresurfaced patella after total knee arthroplasty has seldom been reported. The purpose of this study was to evaluate the long-term changes of the nonresurfaced patella after total knee arthroplasty. METHODS: We retrospectively evaluated the nonresurfaced patella in 227 knees (181 patients) at an average of 8.5 years after total knee arthroplasty. Functional results were correlated with radiographic changes, and risk factors leading to abnormal changes of the patella were analyzed. RESULTS: Preoperatively, 186 (82%) of the patellae tracked centrally, thirty-nine (17%) displaced or tilted laterally, and two (1%) subluxated laterally. At the time of the latest follow-up, 133 (59%) of the patellae still tracked centrally with preservation of the cartilage thickness, fifteen (7%) showed early lateral tilt, sixty-eight (30%) had progressive loss of lateral cartilage thickness with lateral tilt and/or displacement, seven (3%) had progressed to lateral subluxation, and four (2%) tilted medially. An abnormal patellofemoral joint did not affect the knee and functional scores (p = 0.90 and 0.89, respectively). However, symptoms such as difficulty rising from a chair or reluctance to use the involved lower limb while climbing stairs were noted. Preoperative patellar maltracking was identified as the only risk factor leading to postoperative patellar abnormalities (relative risk, 2.7; 95% confidence interval, 2.21 to 3.30; p = 0.003). CONCLUSIONS: At the time of follow-up, at an average of 8.5 years, patellar tracking and the patellofemoral joint remained normal after approximately 60% of the total knee arthroplasties performed without resurfacing of the patella. Progressive degenerative changes of the nonresurfaced patella (mainly on the lateral facet) and patellar maltracking were the most common abnormal radiographic changes. Patients with preoperative patellar maltracking were at risk for the development of these changes and clinical symptoms. Resurfacing of the patella during total knee arthroplasty may benefit such patients.

Aged↗
PubMed2005

Quadriceps tendon rupture after total knee arthroplasty. Prevalence, complications, and outcomes.

BACKGROUND: There is relatively little information about quadriceps tendon tears after total knee arthroplasty. The purpose of this study was to determine the prevalence of this condition and the outcomes of patients who had a tear of the quadriceps tendon after a total knee arthroplasty. METHODS: From a cohort of 23,800 primary total knee arthroplasties, we identified twenty-four patients who had a rupture of the quadriceps tendon postoperatively. Ten additional patients had the total knee arthroplasty done elsewhere and were referred for care after sustaining a tear of the quadriceps tendon. Thus, the study group consisted of thirty-four patients, and all had at least two years of follow-up. Eleven patients had a complete tear, and twenty-three had a partial tear. RESULTS: The prevalence of a quadriceps tendon tear after total knee arthroplasty was 0.1% (twenty-four of 23,800). Seven patients with a partial tear were treated nonoperatively, and all had a satisfactory outcome. One patient with a complete tear was treated nonoperatively and had an unsatisfactory result. Of the ten patients treated operatively after a complete tear, four subsequently had rerupture of the repaired tendon and four had a satisfactory outcome. Of the sixteen patients with a partial tear treated operatively, only one had rerupture and twelve had a satisfactory outcome. Complications occurred in eleven of the twenty-six patients managed operatively. CONCLUSIONS: The prevalence of complications was high, and the outcomes were poor for seven of the eleven patients who had a complete quadriceps tendon tear after total knee arthroplasty. Patients who sustained a partial tear and were treated nonoperatively had no complications and had uniformly good outcomes.

Adult↗
PubMed2005

The functional outcomes of total knee arthroplasty.

BACKGROUND: As an elective procedure, total knee arthroplasty is under scrutiny to evaluate its cost-effectiveness. In this review, we examined the available literature on total knee arthroplasty to assess the evidence regarding factors associated with better functional outcomes. METHODS: A structured literature search of English-language databases was performed to identify studies of the functional outcomes of total knee arthroplasty that had been published between 1995 and April 2003. Inclusion criteria were a study of primary total knee arthroplasty, more than 100 knees in the study, provision of baseline data and rating of postoperative outcomes with a standardized symptom scale, and an experimental or quasi-experimental study design. The abstracting form included a list of potential prognostic factors, including comorbidities, radiographic evidence of joint destruction, bone loss, integrity of the extensor mechanism, range of motion, alignment, tibiofemoral angle, and ligament integrity, as well as the characteristics of the operating surgeon, such as procedure volume and experience. RESULTS: Sixty-two studies met the criteria and were reviewed. Total knee arthroplasty was found to be associated with substantial functional improvement, with the effect sizes varying with the measure that was used. Physician-derived measures showed effect sizes of 2.35 and 3.91, whereas patient-derived measures showed smaller effect sizes (1.27 and 1.62). Few investigators used multivariate models to identify associations between outcomes and patient characteristics. CONCLUSIONS: Total knee arthroplasty is a generally effective procedure, but the current English-language literature does not support specific recommendations about which patients are most likely to benefit from it.

Aged↗
PubMed2006

Three-year changes in bone mineral density around the knee after a six-month course of oral alendronate following total knee arthroplasty. A prospective, randomized study.

BACKGROUND: Bone mineral density decreases after total knee arthroplasty and is believed to affect prosthetic fixation. Treatment with alendronate has been shown to improve short-term bone mineral density after total knee arthroplasty; however, the long-term effects of this therapy are unknown. The purpose of this study was to evaluate the long-term effects of a six-month course of alendronate on bone mineral density after total knee arthroplasty. METHODS: Sixty patients were randomly assigned to receive either oral alendronate at a dosage of 10 mg/day for six months or no alendronate. The bone mineral density in the distal aspect of the femur and the proximal aspect of the tibia was measured preoperatively and at six, twelve, and thirty-six months after total knee arthroplasty. RESULTS: Fifty-four patients (twenty-nine in the alendronate group and twenty-five in the control group) completed the study. The alendronate group showed significant increases in bone mineral density in the distal aspect of the femur compared with the controls at six months (+4.8% and -14.2%, respectively; p < 0.01) and twelve months (+1.6% and -11.5%, respectively; p < 0.01). No significant difference in bone mineral density was detected between the groups at thirty-six months (-3.9% and -12.2%, respectively; p = 0.08). Similar trends in bone mineral density changes were also observed in the proximal aspect of the tibia. CONCLUSIONS: A six-month course of alendronate initially increased bone mineral density at six and twelve months after total knee arthroplasty, but no difference was noted after thirty-six months. The effect of alendronate on bone mineral density after total knee arthroplasty may be limited after discontinuation of therapy.

Administration, Oral↗
PubMed2006

Metal-on-metal hybrid surface arthroplasty. Surgical Technique.

BACKGROUND: Following the reintroduction of metal-on-metal articulating surfaces for total hip arthroplasty in Europe in 1988, we developed a surface arthroplasty prosthetic system using a metal-on-metal articulation. The present study describes the clinical and radiographic results of the first 400 hips treated with metal-on-metal hybrid surface arthroplasties at an average follow-up of three and a half years. METHODS: Between November 1996 and November 2000, 400 metal-on-metal hybrid surface arthroplasties were performed in 355 patients. All femoral head components were cemented, but only fifty-nine of the short metaphyseal stems were cemented. The patients had an average age of forty-eight years, 73% were men, and 66% had a diagnosis of osteoarthritis. Clinical and radiographic follow-up was performed at three months postoperatively and yearly thereafter. RESULTS: The majority of the patients returned to a high level of activity, including sports, and 54% had activity scores of >7 on the University of California at Los Angeles activity assessment system. Kaplan-Meier survivorship curves demonstrated that the rate of survival of the components at four years was 94.4%. For patients with a surface arthroplasty risk index score of >3, the rate of survival of the components at four years was 89% compared with a rate of 97% for those with a score of <or=3. The patients with a higher risk index were 4.2 times more likely to undergo revision to a total hip replacement at four years. Twelve hips (3%) had a revision to a total hip replacement. Seven of the twelve hips were revised because of loosening of the femoral component, and three were revised because of a femoral neck fracture. Substantial radiolucencies were seen around sixteen uncemented metaphyseal femoral stems. No femoral radiolucencies were observed among the hips in which the metaphyseal stem was cemented. The most important risk factors for femoral component loosening and substantial stem radiolucencies were large femoral head cysts (p = 0.029), patient height (p = 0.032), female gender (p = 0.005), and smaller component size in male patients (p = 0.005). CONCLUSIONS: The preliminary experience with this hybrid metal-on-metal bearing is encouraging. Optimal femoral bone preparation and component fixation are critical to improving durability. The metal-on-metal hybrid surface arthroplasty is easily revised to a standard femoral component if necessary.

Adolescent↗
PubMed1988

Femoral shaft fracture after hip arthroplasty.

Femoral shaft fractures after hip arthroplasties were treated in 74 noncemented hemiarthroplasties and 65 cemented arthroplasties. In loose prostheses the best clinical results and the least number of operations were achieved with revision arthroplasty with a long-stem prosthesis, combined with simple internal fixation methods when applicable. In firmly fixed prostheses the results of revision arthroplasty and traction treatment were similar. Cemented revision arthroplasty did not interfere with fracture union. Internal fixation with the prosthesis in situ cannot be recommended because of a large number of secondary revision arthroplasties and nonunions. Removal of the femoral stem prosthesis and internal fixation nearly always require a secondary revision and cannot be recommended.

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