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PubMed1991

Universal intramedullary instrumentation for unicompartmental total knee arthroplasty.

Certainly the advantages of unicompartmental total knee arthroplasty (TKA) are appealing as opposed to tricompartmental arthroplasty. Patients who have had unicompartmental arthroplasty have significant preservation of existing bone stock. They have an improved range of motion and they are definitely easier to revise. This reduces hospitalization time as well as costs with retention of more normal anatomy. In patients with unicompartmental disease with minimal patellofemoral changes, clinical results are certainly encouraging in terms of patient satisfaction with unicompartmental arthroplasty as opposed to tricompartmental arthroplasty. Restoration of function is unquestionably closer to normal than with tricompartmental arthroplasty. The advantages of an intramedullary instrumentation system for unicompartmental disease allows for a more standard method of placing unicompartmental prosthetic components so that less "eyeballing" occurs. Furthermore, utilization of a system that allows for more precise anatomical cuts should allow for better component fit as well as a return to a more normal femoral-tibial angle.

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PubMed1991

A comparison of quality of life before and after arthroplasty in patients who had arthrosis of the hip joint.

Quality of life before and one year after total hip arthroplasty was evaluated in fifty-six patients who had arthrosis of the hip joint. There were twenty-one men and thirty-five women, and the median age was sixty-five years (range, thirty to seventy-nine years). Before and after total hip arthroplasty, a functional assessment was done with the Charnley-Merle d'Aubigné scoring system. The patients assessed quality of life using the Nottingham Health Profile. In the comparison of quality of life before and after the arthroplasty, significant improvement was observed regarding pain (p less than 0.0001), energy (p less than 0.0001), sleep (p less than 0.0001), and social isolation (p = 0.001). Similarly, there was a significant reduction in the frequency of health-related problems pertaining to housework (p less than 0.0001), holidays (p less than 0.0001), hobbies (p = 0.0001), social life (p less than 0.0001), sexual function (p = 0.001), and family life (p = 0.0005), and among patients who were sixty-five years old or less and who worked at paid employment (p = 0.04). Quality of life after total hip arthroplasty was in close agreement with that of a healthy reference group of similar age and sex distribution. It was concluded that quality of life after total hip arthroplasty is improved considerably. The Nottingham Health Profile is a valuable tool in the evaluation of the result of, as well as the indicators for, total hip arthroplasty.

Activities of Daily Living↗
PubMed1987

Revision knee arthroplasty in rheumatoid arthritis.

Seventy-six revised total knee arthroplasties (TKAs) performed for mechanical, nonseptic failure of the primary arthroplasty in 62 rheumatoid arthritis patients were investigated. The revisions were performed with McIntosh, Marmor, Attenborough, Guepar, and various types of tricompartmental prostheses. Twenty-one of the 76 revisions subsequently failed. Fifteen were mechanical failures and six were deep infections. Thirteen of the 21 failures were treated with another arthroplasty, six with arthrodesis, and two with antibiotics only. After an average of 60 months, 48 of the surviving arthroplasties were examined clinically and roentgenographically. At follow-up examination, eight were clinical failures. One-half of the McIntosh and Marmor arthroplasties and one-third of the Attenborough and Guepar arthroplasties, altogether 17 cases, showed signs of potential roentgenographic failure. The majority of the revised TKAs classified as roentgenographic failures were clinically successful or acceptable. Revision of TKAs in noninfected rheumatoid patients can be performed with acceptable clinical results but with a significantly higher failure rate than after primary procedures.

Arthritis, Rheumatoid↗
PubMed1978

An evaluation of a method of trochanteric fixation using three wires in the Charnley low friction arthroplasty.

The crossed wire technique of trochanteric reattachment, with ambulation from the second day after the arthroplasty, resulted in 2.3% of complete detachments, and 2.7% of fibrous union at one year (total failure rate of 5%). Of 75 trochanters which had a fibrous union at 3 months, 2 later became completely detached, 27 remained as a fibrous union and 46 progressed to complete or partial bony union by one year. The incidence of defective trochanteric union was 2.3 times more frequent in arthroplasties performed by residents in training than it was in those performed by senior staff, (10.8% and 4.6% respectively at 3 months and 5.6% and 2.4% respectively at 12 months). The incidence of defective trochanteric union in bilateral arthroplasties was double the rate in unilateral operations, (14% and 7% respectively). Eighty-six and one half per cent of the arthroplasties which developed defective union of the trochanter showed follow-up radiographic evidence of defective fixation, though 13.5% were apparently satisfactory on discharge. Roughly 79% (79.2%) of the cases which developed defective union of the trochanter developed broken wires within one year of the arthroplasty. Relief from pain by total joint arthroplasty was not significantly influenced by defective trochanteric union (mean postoperative grade for pain 5.8).

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PubMed1997

Failed total wrist arthroplasty. Analysis of failures and results of operative management.

Nine metal on polyethylene total wrist arthroplasties were revised for failure, including eight trispherical devices and one Volz implant. Causes of failure include sepsis in one patient, progressive wrist flexion contracture in two patients, and mechanical failure in six patients. The most common mode of mechanical failure was metacarpal loosening with dorsal perforation of the stem. This was associated with an intact articulation between the third metacarpal and the capitate, with a proximal position of the metacarpal component in the shaft, and with poor cement fill of the metacarpal shaft. The one infected wrist was managed with resection arthroplasty. Five patients had conversion to a wrist arthrodesis and three patients underwent revision total wrist arthroplasty with custom trispherical components. Followup averaged 3.3 years. All patients undergoing arthrodesis attained a solid painless fusion after a single operation at an average of 4.8 months. The three patients treated with revision arthroplasty had wrists that were pain free, functional, and had no evidence of loosening at latest followup. Failed total wrist arthroplasties can be salvaged successfully to either a fusion or a revision arthroplasty in most patients.

Adult↗
PubMed1997

Total knee arthroplasty infections associated with dental procedures.

Total knee arthroplasties are at risk for hematogenous seeding secondary to procedures that create a transient bacteremia. To define the risk of infection associated with dental surgery, a retrospective review of the records of 3490 patients treated with total knee arthroplasty by the authors between 1982 and 1993 was performed. Sixty-two total knee arthroplasties with late infections (greater than 6 months after their procedure) were identified, and of these, seven infections were associated strongly with a dental procedure temporally and bacteriologically. These seven cases represented 11% of the identified infections or 0.2% of the total knee arthroplasty procedures performed during this period. In addition, among 12 patients referred for infected total knee arthroplasties from outside institutions, two infections were associated with a dental procedure. Five of the nine (56%) patients had systemic risk factors that predisposed them to infection, including diabetes and rheumatoid arthritis. All dental procedures were extensive in nature (average, 115 minutes; range, 75-205 minutes). Eight of the patients received no antibiotic prophylaxis. One patient had only one preoperative dose. Infections associated with dental procedures may be more common than previously suspected. Eight of these patients had no prophylactic antibiotics, and one had inadequate coverage. The authors think that patients with a total knee arthroplasty who have systemic disease that compromises host defense mechanisms against infections and who undergo extensive dental procedures should receive prophylactic antibiotics. A first generation cephalosporin, given 1 hour preoperatively and 8 hours postoperatively would provide the best prophylaxis against the organisms identified in this study.

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PubMed1997

Opportunities for control of hospital cost for total knee arthroplasty.

The hospital financial records of 120 consecutive patients who underwent unilateral knee replacement surgery at one hospital during 1995 were reviewed to determine opportunities for control of hospital cost for total knee arthroplasty. The average hospital length of stay for these patients was 4.27 days (range, 3-10 days). The average hospital cost was $10,231. All 120 patients were classified under Diagnosis Related Group 209, principle procedure 81.54 primary total knee arthroplasty. Medicare paid for 70% of the patients. All payers were profitable except Medicaid and one managed care organization. When hospital cost for total knee arthroplasty was allocated to hospital service centers, 78% of the cost was attributed to the operating room, nursing units, recovery room, and pharmacy. When hospital cost for total knee arthroplasty was allocated to hospital days, 80% of the hospital cost occurred during the first 48 hours of hospitalization. Hospital reimbursement for total knee arthroplasty is primarily a prospective case price payment system. After initial cost containment efforts reduce the hospital length of stay for total knee arthroplasty to 4 to 6 days, additional control of hospital cost should focus on these areas of opportunity.

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PubMed1998

Heterotopic ossification after total hip arthroplasty: risk factors and prevention.

A retrospective review of 168 consecutive total hip arthroplasty procedures done in 1983 at the Cochin Teaching Hospital, Paris, France, was conducted to determine the rate of occurrence of heterotopic paraarticular ossification and to look for risk factors for this complication. None of the patients received preventive therapy for heterotopic ossification. Mean age was 66.2 years. The reason for arthroplasty was hip osteoarthritis in every case. The index operation was the first arthroplasty procedure. Heterotopic ossification was noted in 61.3% of patients and was high-grade in 8.3%. The rate of occurrence of heterotopic ossification was not influenced by age, gender, joint destruction, preoperative osteophytosis, duration of the arthroplasty or the occurrence of complications during or after the arthroplasty. However, severe ossification was more common in men that in women (12.7% men versus 5.7% women had grade III ossification) and in patients operated on by relatively inexperienced surgeons (28/8% grade II and III ossifications, versus 14.7% in patients operated on by experienced surgeons). The rate of occurrence of heterotopic ossification in the patients who had no risk factors (60.9%) was not significantly different from that in the overall study population. These data suggest that preventive strategies targeted to specific patient subgroups would probably be ineffective, and that routine preventive therapy of all total hip arthroplasty patients is warranted.

Adult↗
PubMed1976

Complications of polycentric knee arthroplasty.

Results of 89 polycentric knee arthroplasties are assessed from 2 years to 7 1/2 years after operation. Seventy-two arthroplasties (81%) are considered to improve the mobility of the patient, with 17 arthroplasties producing no improvement. Infection after operation in 6 arthroplasties (7%) required arthrodesis of 3 arthroplasties. Loosening of prosthetic components occurred in 9 arthroplasties (10%).

Arthroplasty↗
PubMed2000

Replacement arthroplasty versus internal fixation for extracapsular hip fractures.

BACKGROUND: Internal fixation, commonly used for extracapsular hip fractures, may fail particularly in unstable fractures. Replacement of the hip using arthroplasty, often used for intracapsular fractures, has been used as an alternative. OBJECTIVES: To compare replacement arthroplasty with internal fixation for the treatment of extracapsular hip fractures in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group's trials register and bibliographies of published papers, and contacted colleagues. Date of the most recent search: August 1999. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing replacement arthroplasty with an internal fixation implant for skeletally mature patients with an extracapsular hip fracture. DATA COLLECTION AND ANALYSIS: Both reviewers independently assessed trial quality, using a ten item scale, and extracted data. Additional information was sought from trialists. Odds ratios and 99% confidence intervals were calculated for relevant dichotomous outcomes and presented graphically. MAIN RESULTS: Only one randomised trial of 90 patients with unstable extracapsular hip femoral fractures in the trochanteric region was identified and included in this review. This compared arthroplasty with a sliding hip screw and was of poor methodological quality. From the limited data available for this trial, there were no significant differences between the two methods of treatment for operating time, local wound complications, mortality rate or mobility of previously independent patients. There was however a reportedly higher blood transfusion need in the arthroplasty group. REVIEWER'S CONCLUSIONS: There is insufficient evidence from randomised trials to determine whether replacement arthroplasty has any advantage over the sliding hip screw for extracapsular hip fractures. Further well designed randomised trials for the treatment of these fractures for this comparison are required.

Fracture Fixation, Internal↗
PubMed1987

Revision arthroplasty of the hip joint. A retrospective analysis.

During the period 1974-1983, 768 total hip arthroplasties were performed at the Surgical Hospital, University Central Hospital in Helsinki. Brunswik prostheses were used until 1980, and after this the operations were routinely performed with Lubinus prostheses. Additionally, from 1977 to 1981 Wagner and Freeman resurfacing prostheses were used in 107 cases. Of all these patients, 44 (5.7%) needed revision arthroplasty. The average interval between the primary operation and revision arthroplasty was 3.7 years and the follow-up period after the second operation averaged 2.9 years. The patients who underwent revision arthroplasty were compared with a matched control group. In the revision group, radiographs revealed that the medial cement packing was complete in 28% of the hips, this being the case in 78% of the controls (P less than 0.001). Also, the cement tip packing was more often incomplete in the revision hips than in the controls (P less than 0.01). Regarding the lateral cement packing there was no statistical difference between the two groups. The revision rate of the resurfacing prostheses was 14.9%, compared with 7.8% of the Brunswik prostheses which were inserted at the same time. At the follow-up, the patients with revised hips had less pain than before the primary operation (P less than 0.001) and their mobility was similarly improved. We conclude that adequate medial and tip cement packing must be emphasized in the primary arthroplasty. Resurfacing prostheses have a relatively high loosening tendency. Revision arthroplasty is the treatment of aseptic loosening after total hip replacement and it gives good clinical results. Aseptic loosening is the most common long-term complication after total hip replacement surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

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PubMed1987

Pulmonary marrow embolism: a dog model simulating dual component cemented arthroplasty.

The cardiopulmonary changes resulting from cemented arthroplasty procedures were monitored in 11 dogs with a single prosthesis implanted and nine dogs with a dual arthroplasty procedure. These changes were characterized by decreased BP, elevated PPA, and elevated PVR, associated with decreases in PaO2, cardiac output and mixed venous oxygen tension. All changes were more pronounced and prolonged in the dual component arthroplasty group. Histologic lung examination and morphometry demonstrated significant degrees of marrow (fat) microembolism in the dual arthroplasty model. Cardiopulmonary collapse has been associated with Guepar dual component arthroplasties clinically and these patients are at increased risk and should be monitored continuously. Prophylactic measures include meticulous lavage of the intramedullary cavity, increased FIO2, and maintenance of intravascular volume and cardiac output. The bilateral arthroplasty model is useful in investigating therapeutic interventions which may detect and prevent the marrow microembolism syndrome intraoperatively.

Animals↗
PubMed1993

Total knee arthroplasty: evaluation of an acute care rehabilitation program.

This retrospective research was performed to evaluate the acute care rehabilitation program provided for patients receiving total knee arthroplasties in one institution. Included were 146 patients with unilateral arthroplasties and 40 patients with bilateral arthroplasties. Care and charge data, functional scores, and discharge disposition were documented for all subjects. The mean hospital days and associated charges were, respectively, 9.9 and $16,149 for unilateral arthroplasties and 11.9 and $23,594 for bilateral arthroplasties. Significant improvements in function (bed mobility, transfers, locomotion, and stairs) occurred during the course of rehabilitation. Over 96% of the patients were discharged home (either with or without services). Predictive of both discharge disposition and hospital charges were arthroplasty type, initial bed mobility score, and discharge transfer score. The results demonstrate differences associated with unilateral and bilateral surgeries, verify that functional changes accompany rehabilitation, and show that functional capacity has implications for charges and discharge disposition.

Activities of Daily Living↗
PubMed1992

Total knee arthroplasty in patients with prior ipsilateral hip fusion.

Sixteen total knee arthroplasties performed between 1977 and 1985 in 13 patients with prior ipsilateral hip arthrodesis or ankylosis were studied to determine the preferred sequence and long-term follow-up of procedures in this clinical setting. Twelve of 16 underwent fusion takedown and total hip arthroplasty prior to knee replacement. The average age at total knee arthroplasty was 52.7 years and the average time from hip fusion to total knee arthroplasty was 36.3 years. Mean follow-up after total knee arthroplasty was 5.5 years (range, 2.3 to 10 years). The Hospital for Special Surgery knee score increased from a mean of 31.8 preoperatively to 72.2 after surgery. In patients who had conversion of the hip fusion prior to knee replacement, knee scores were 28 before and 72.5 after both procedures. Patients who retained their hip fusion had mean scores of 43.5 and 72.1, respectively. None of the knees has been removed and 14 of 16 had no pain at last follow-up. One had mild pain and one had moderate pain attributed to pes anserine bursitis. Although the numbers are small, this experience reveals that takedown of the fusion with total hip arthroplasty is an effective technique before performing the knee replacement. Though successful in some instances, the experience is too small to show that if hip fusion is in good position, knee replacement without fusion takedown is acceptable.

Adolescent↗
PubMed1988

Proposed digital arthroplasty critical study of the preliminary results.

In view of the results of Swanson implants, particularly the long-term course of silicone implants, the authors studied and developed semi-constrained sliding arthroplasty designed for metacarpo-phalangeal and proximal interphalangeal joints. The preliminary study on bones and then on cadaver hands and finally on the knee of the rabbit allowed the design and experimentation of a prototype which led to the creation of a semi-constrained arthroplasty for which the elastic diaphyseal anchoring is ensured without cement and which possesses sliding surfaces composed of a metallic (proximal piece)--polyethylene (distal piece) interface. We therefore describe the principles of functioning of this arthroplasty, its technique of insertion, dorsal trans-tendon incision, its accessory (drill for diaphyseal preparations), its anatomical requirements (preservation of the palmar plate and lateral ligaments, bone section) and the postoperative course. To date, 52 arthroplasties have been inserted and we present the results of the first 36 cases for which the follow-up is equal to or a greater than one year (20 MP-16 PIP), indicating the technical modalities according to the various aetiologies (21 cases of rheumatoid arthritis--15 post-traumatic cases) and the complications. The average gain in mobility is 40 degrees with a mean range of movement of 64 degrees. In terms of pain, none of the arthroplasties were associated with pain apart from pain on cold in certain post-traumatic cases. The global and thumb-finger prehensile forces were evaluated to be an average of 90% in relation to the healthy side. Radiological assessment demonstrated fixation of the pieces in every case. Lastly, we discuss the outcome of this arthroplasty and its current indications in relation to the problems of instability essentially occurring in dislocated MP joints of rheumatoid arthritis.

Arthritis, Rheumatoid↗
PubMed1995

Patient outcomes following unicompartmental or bicompartmental knee arthroplasty. A meta-analysis.

The purpose of this study was to summarize the literature describing patient outcomes following unicompartmental and bicompartmental knee arthroplasty. Original studies were included in this meta-analysis if they enrolled 10 or more patients at the time of an initial knee arthroplasty and measured patient outcomes using a global knee rating scale. Forty-six studies on unicompartmental prostheses and 18 studies on bicompartmental prostheses met these criteria. For unicompartmental studies, the total number of enrolled patients was 2,391, with a mean enrollment of 47 patients and a mean follow-up period of 4.6 years. The mean patient age was 66 years; 67% were women, 75% had osteoarthritis, and 16% underwent bilateral knee arthroplasty. The mean postoperative global rating scale score was 80.9. The overall complication rate was 18.5% and the revision rate was 9.2%. Studies published after 1987 reported better outcomes, but also tended to enroll older patients and patients with osteoarthritis and higher preoperative knee rating scores. For bicompartmental studies, the total number of enrolled patients was 884, with a mean enrollment of 44 patients and a mean follow-up period of 3.6 years. The mean patient age was 61 years; 79% were women, 31% had osteoarthritis, and 29% underwent a bilateral arthroplasty. The mean postoperative global rating scale score was 78.3. The overall complication rate was 30% and the revision rate was 7.2%. Although bicompartmental studies reported lower mean postoperative global rating scale scores, these studies tended to enroll patients with worse preoperative knee rating scores. Recent improvements in patient outcomes following unicompartmental knee arthroplasty appear to be due, at least partially, to changes in patient selection criteria. Patient outcomes appear to be worse for bicompartmental arthroplasties than for other prosthetic designs; however, patients enrolled in these studies had more poorly functioning knees before surgery and actually had greater absolute improvements in global knee rating scores.

Aged↗
PubMed1990

Total shoulder arthroplasty versus hemiarthroplasty. Indications for glenoid resurfacing.

The results of total shoulder arthroplasty and hemiarthroplasty in a similar patient population were compared in an effort to define more clearly the indications for resurfacing the glenoid. The results of 64 Neer hemiarthroplasties in 59 patients were compared with 146 Neer total shoulder arthroplasties in 134 patients in a retrospective review of the period between 1974 and 1986. The average follow-up period was 44 months (range, 24-124 months). Hemiarthroplasty and total shoulder arthroplasty produced similar results in terms of functional improvement. Pain relief, range of motion, and patient satisfaction were better with total shoulder arthroplasty than hemiarthroplasty in the rheumatoid population. Progressive glenoid loosening was found in 12% of total should arthroplasties but no correlation with pain relief or range of motion was noted. Total shoulder arthroplasty is recommended for patients with inflammatory arthropathies, and hemiarthroplasty is recommended for patients with osteoarthritis, avascular necrosis, and four-part fractures with preservation of glenoid congruity and absent synovitis.

Adult↗
PubMed1989

Total knee arthroplasty following high tibial osteotomy for osteoarthritis.

The authors assessed the effect of proximal tibial osteotomy on the results of a subsequent total knee arthroplasty. A retrospective, clinical and radiographic analysis was carried out between a study group of 39 patients with 42 total knee arthroplasties following osteotomy and a control group of 39 patients with 41 primary arthroplasties. Outcome was assessed using the Hospital for Special Surgery (HSS) knee score, pain, function, range of motion, and radiographic evaluation. The follow-up period averaged 37 months (range, 24-50 months). The study group had 88% good or excellent results using the HSS score, compared to 90% in the control group. Function and pain improved equally in both groups. The control group had, on average, 14 degrees greater range of motion (115 degrees v. 101 degrees) after arthroplasty. The control group had, on average, posterior inclination of the tibial plateau of 7 degrees before operation and 3 degrees after operation; the corresponding values in the study group were 2 degrees and 1 degree. Using the HSS score and pain and function as parameters, previous osteotomy does not seem to affect the outcome of total knee arthroplasty. Conversely, range of motion following arthroplasty appears to be less in those with prior osteotomy. In addition, a high tibial osteotomy may alter the inclination of the tibial plateau.

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