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PubMed1997

Metal-on-metal articulation in total hip arthroplasty: preliminary results in 57 cases.

BACKGROUND: Aseptic loosening of hip prostheses may lead to implant failure and necessitate revision surgery. Metal-on-metal hip articulation has characteristics that may minimize prosthesis loosening when compared with other forms of hip articulation. The purpose of the present prospective study was to identify early problems that may contraindicate the use of the 'prosthesis femorale modulaire' (PFM) metal-on-metal prosthesis. METHODS: The preliminary results of 57 metal-on-metal total hip arthroplasties performed by one surgeon (RR) from 1994 to 1996 in Lismore, New South Wales, are presented here. Data were obtained using patient questionnaires, physical examination and by examination of radiographs. RESULTS: A total of 87.6% of patients had an excellent or good outcome, according to the Harris rating system, at the latest review. The two patients with poor results had obvious alternative causes for their continuing symptoms. There was no radiological evidence of bone or prosthesis failure during the period of follow-up. CONCLUSIONS: The preliminary results are comparable with those of other authors who have examined the early results of metal-on-metal total hip arthroplasty.

Activities of Daily Living↗
PubMed1992

Lymphocytes in pseudomembranes of late prosthetic joint failure.

The pseudomembrane formed in association with late aseptic prosthesis failure contains a mixed giant cell and histiocytic infiltrate with variable numbers of lymphocytes. Immunolabelling with a panel of antibodies on paraffin sections was undertaken to define the nature of the lymphoid infiltrate in 19 cases. In all cases, the predominant lymphoid cell was a memory (CD45RO+, CD45RA-) T-cell. B-cells were rare. Tissue from patients with rheumatoid arthritis (RA) contained greater numbers of T-cells when compared with patients with osteoarthritis (OA), suggesting that the intensity of the lymphoid infiltrates reflects the underlying joint disease rather than necessarily being part of a hypersensitivity response to wear debris.

Aged↗
PubMed1996

The total cost of hip-joint replacement; a model for purchasers.

A computer-based model is used to investigate the total cost of primary total hip-joint replacement. The model takes into account the probability of prosthesis failure, death and re-revision. The results emphasize the importance of age at insertion, demonstrating that the expected life-span of the patient has a major influence on the total cost for a given prosthesis. The discussion considers the idea of a 'lifetime care package' to encapsulate the concept of quality when considering the purchasing of total hip replacements. If it is assumed that a primary replacement episode costs 3500 pounds and revision surgery costs twice as much, then the additional premium on the best implant currently available would be 630 pounds. The premium payable on the same patient using the worst design would be 3080 pounds. This difference reflects the importance of quality in total hip replacement surgery.

Adult↗
PubMed1992

[Metal or plastic endoprostheses in malignant obstructive jaundice. A randomized and prospective comparison].

In a prospective randomized trial 58 patients (24 men, 34 women, mean age 67 +/- 13 [42-89] years) with inoperable malignant jaundice were treated with synthetic (S; n = 29) or expanding metal endoprostheses (M; n = 29). After endoscopic retrograde cholangiopancreatography patients were divided into a group with hilar (K: n = 7; M: n = 6) or distal involvement (K: n = 22, M: n = 23). In two cases with hilar involvement (28%) a synthetic endoprosthesis could not be implanted, while early prosthesis occlusion (after 2 days) was observed in one case. But in this group it was possible to implant all metal stents. In the group with distal involvement both synthetic and metal endoprostheses were successfully implanted. In the M group the proportion of patients with prosthesis failure (13.6%) was significantly higher than in the S subgroup (40.9%). The cholangitis incidence was 9% in the M group, significantly less (P less than 0.05) than in the K group (40.9%). Duration of hospital stay to treat prosthesis-related complications was significantly less in the M group (average 2.9 days) than the K group (12.9 days). It would be a great advance in palliative tumour treatment if it were possible significantly to reduce, by means of metal stents, the incidence of late cholangitis and the duration of hospital stay necessary to treat late complications. But improvement in the technique of implanting metal stents would be essential before their general use in distal lesions can be recommended.

Adult↗
PubMed1996

Porous pad separation and loosening of Harris-Galante femoral hip components.

Failure of the bond between the metal beads and the solid substrate of porous-coated chrome-cobalt femoral components, or so-called "bead shedding," has been reported previously and may indicate motion of the component within the femur or mechanical loosening of the prosthesis. Failure of the bond between a sintered titanium fibermesh pad and a titanium alloy femoral stem has not been documented in the literature to date. The separation of fibermesh pads from three Harris-Galante femoral prostheses (Zimmer, Warsaw, IN) is reported.

Adult↗
PubMed2004

Survivorship analysis of 141 modular metallic endoprostheses at early followup.

Although our institution historically has been known for its use of osteoarticular allografts in limb salvage surgery for tumors, during the last 8 years there has been an increase in the use of metallic modular endoprostheses. A retrospective review of 141 patients in whom a modular endoprosthesis was implanted in the past 8 years was done, and survival data were compiled using Kaplan-Meier survival analysis, clinical score was determined using a previously described system, and a multivariate regression analysis was done to identify independent risk factors. There were 13 failures (defined as need for revision of the majority of the prosthetic components, excluding cases of local recurrence) yielding an overall implant survival of 91%. Based on Kaplan-Meier estimates, the endoprosthetic survival rate was 88% at 3 years and 76% at 5 years; per location, it was 100% for the proximal humerus, 100% for the proximal femur, 87% for modular knees, and 53% for total femoral implants at 3 years. The clinical scores were good to excellent in 74% of the patients. Multivariate analysis showed that only location and infection were independent risk factors for prosthesis failure. Loosening, infection, and dislocation were independently predictive of a fair or poor clinical score. Age, gender, diagnosis, length of implant, dislocation, nor failed prior allograft had an independent effect on implant survival or clinical outcome. The proximal humeral and proximal femoral implants had greater survival rates than modular knee and total femoral implants. Conversion of failed allografts to modular endoprostheses had a trend for a higher failure rate, but after a multivariate analysis, did not prove to be an independent risk factor for failure. We think that our experience is similar to other endoprosthesis survivorship reports in the literature with short-term followup.

Adolescent↗
PubMed1994

Nonsteroidal antiinflammatory drug modulation of prosthesis pseudomembrane induced bone resorption.

OBJECTIVE: To study the in vitro effect of therapeutic levels of select nonsteroidal antiinflammatory drugs (NSAID) on prosthesis associated pseudomembrane induced bone resorption and cytokine and prostanoid synthesis using tissue obtained from osteoarthritic patients undergoing revision of cemented implants. METHODS: Pseudomembranes were cultured in the presence and absence of therapeutic levels of select NSAID: Processed conditioned media were evaluated for bone resorbing capacity by assessing murine neonatal limb rudiment release of 45Ca. Interleukin 1 (IL-1) and tumor necrosis factor (TNF) were analyzed by bioassay and prostaglandin E2 (PGE2) by radioimmunoassay. RESULTS: Piroxicam, in contrast to indomethacin and sodium salicylate, significantly decreased membrane associated bone resorption. The NSAID effect correlated more consistently with piroxicam downregulation of TNF synthesis than that of IL-1. Consistent drug associated suppression of PGE2 synthesis did not enable differentiation of NSAID effectiveness in suppressing pseudomembrane induced bone resorption. CONCLUSION: Results provide a rational basis for design of animal models and/or further human studies to test the hypothesis that the prophylactic administration of an NSAID can potentially retard the pseudomembrane effected bone resorptive process associated with aseptic cemented prosthesis failure.

Adult↗
PubMed1995

[Dynamic obstruction of the left ventricular outflow tract by prosthesis dysfunction].

We report on a case of dynamic left ventricular (LV) outflow tract obstruction combined with a prosthetic valve dysfunction 13 years following mitral valve replacement with a Hancock bioprosthesis in a 46-year-old patient. Previously, repeated echocardiographic controls had been performed at regular intervals and the prosthesis had been found to be oversized and seated in abnormal position, with projection of the struts into the LV outflow tract. Moreover, a mild chronic LV outflow tract obstruction had been diagnosed upon intermittent findings of relatively high velocity in the outflow tract. Clinically, however, the patient had been stable and the function of the prosthesis had been good. With the onset of the mitral regurgitation due to prosthesis failure, a dynamic obstruction to LV outflow occurred, with severe narrowing of the LV outflow tract by a strut of the bioprosthesis during systole. Subsequently, a low cardiac output syndrome developed. The patient was referred for a mitral valve reoperation. The valve was replaced with a Sorin Bileaflet Carbon prosthesis. On the setting of a mild chronic LV outflow obstruction due to the oversized prosthesis and its abnormal position, hypercontractile cardiac function as a result of mitral regurgitation may have caused the dynamic and symptomatic LV outflow tract obstruction.

Bioprosthesis↗
PubMed1997

[Arthroplasty of the knee. Postoperative radiologic followup].

The first generation of total knee arthroplasties (TKA) had an unacceptably high failure rate due to prosthetic design problems. The current generation closely duplicates the normal anatomy of the knee. This essay describes the normal imaging appearance. First, evaluation of TKA alignment is important. The center of the knee should lie on the mechanical axis of the leg. The width and location of lucent lines (standard system by the "Knee Society") and the height of the prosthetic joint space must be noted (wear of the polyethylene). On the AP view, the tibial component should be perpendicular in relation to the tibial or up to 2 degrees of varus alignment. On the lateral view, the tibial plateau should be horizontal or should slope downward posteriorly no more than 10 degrees. Many complications of TKA can be detected radiographically (wear, descellement, complications of the patella) and corrected to prevent prosthesis failure.

Arthroplasty, Replacement, Knee↗
PubMed1999

Morphologic findings in explanted Hancock II porcine bioprostheses.

BACKGROUND AND AIM OF THE STUDY: Heart valve substitutes have been in use for over 30 years. Bioprosthetic heart valves have many advantages, but unfortunately suffer tissue degeneration and calcification. Many approaches, such as antimineralization treatment to prevent or delay these changes, have been tried. We present the morphologic findings from a series of Hancock II (antimineralization-treated) porcine bioprostheses. METHODS: Forty-five Hancock II porcine valve bioprostheses (16 mitral, 29 aortic) surgically explanted between March 1991 and December 1995 at the Toronto Hospital were analyzed for morphologic findings and causes of failure. The prostheses were implanted in 36 adults (mean age 55+/-14.7 years, range: 27 to 75 years) and had been in place between one month and 11 years (mean 5.1+/-3.3 years). RESULTS: Structural valve deterioration (SVD) characterized by tissue degeneration, calcification, cusp tears and increased stiffness, was the single most significant finding and cause of failure, affecting 56% of valves. Some degree of calcification was seen in 55% of prostheses, with severe calcification (grade 3 or 4) in 18%. Aortic bioprostheses showed more severe and earlier calcification than mitral ones (p = 0.03). Compared with the standard Hancock valve, the low incidence of significant calcification suggests a beneficial protective effect of antimineralization treatment. Severe pannus (grade 3 or 4) was seen in 60% of these prostheses. The pattern of pannus growth differs between mitral and aortic sites; mitral prostheses showed pannus on the flow and non-flow surfaces, often associated with cusp tears, mitral regurgitation and mitral leaflet preservation. A similar degree of pannus on aortic prostheses was invariably present on the flow surface and extended onto the valve cusps, leading to changes in the orifice which may cause clinical aortic stenosis. Infective endocarditis was seen in 15 prostheses (five mitral, 10 aortic) from 11 patients, and comprised the second most important cause of prosthesis failure. The risk of recurrent endocarditis was particularly high in patients who had infective endocarditis before valve replacement, even at five and six years post implantation. CONCLUSIONS: SVD is the major finding in explanted Hancock II bioprostheses and is associated with cusp tears and calcification. The incidence of tissue calcification appears lower at the mitral site. These findings suggest that the antimineralization treatment had some beneficial effect. Pannus associated with prosthesis dysfunction at the mitral sites is a prominent finding and on the non-flow surface may be related to the native mitral valve-conserving procedure.

Adult↗
PubMed1999

A survey of function in children with lower limb deficiencies.

Function and prosthesis technical problems were surveyed in 258 experienced paediatric lower-limb prosthesis wearers. The two-part survey form consisted of the modified Prosthesis Evaluation Scale and the core module of the American Academy of Orthopaedic Surgeons/Council of Musculoskeletal Specialty Societies (AAOS/COMSS) Lower Limb Outcomes instrument. Eighty-eight percent (88%) of these paediatric subjects were able to wear their prosthesis more than 9 hours/day; only 3 subjects (1%) were not able to wear their limb at all. The average distance walked per day was reported to be 5.24 kilometres. Sixteen percent (16%) reported pain as "moderate" or worse. A majority reported not having a problem with perspiration, however, 20% had problems serious enough to limit prosthesis wearing time significantly. The most common reasons for temporary loss of limb use were pain (62 responses) and prosthesis failure (59 responses), followed by tissue breakdown (42 responses) and perspiration (30 responses). In general, the paediatric population achieves full use at a high rate, is much more active than the adult population, and experiences less limb pain.

Adolescent↗
PubMed2000

[Shape optimization of the femoral component of hip prosthesis using the finite element method].

Aseptic loosening of implants in bone is the main reason of prosthesis failure. Stress distribution around the implant surface plays a major role in this process, which can be minimized by implant shape optimization. Numerical methods, particularly the finite element method, are an important tool in the analysis of stress distribution and design optimization. The paper presents the problem formulation for this method, illustrated by computational examples.

Arthroplasty, Replacement, Hip↗
PubMed1994

Clinical evaluation of resin-bonded prostheses: Rochette technique.

Ninety patients, with a total of 90 resin-bonded prostheses placed in a private dental office from 1981 to 1991, were recalled for clinical evaluation of their restorations. Tissue condition, patient satisfaction, prosthesis failures by location and by sex of patient were assessed. Debondings occurred in both the mandibular and maxillary arches. In the present study, there were no gender-based differences in the rate of debonding and prostheses with more than two retainers were more likely to have problems.

Adult↗
PubMed2000

Intraurethral application of alprostadil in patients with failed inflatable penile prosthesis.

PURPOSE: Many men who underwent penile prosthesis implantation before the advent of oral and injection therapy present for replacement of a malfunctioning prosthesis but choose not to undergo revision surgery because of personal, medical or reimbursement issues. Others with normally functioning prostheses report significant difficulties with "cold glans," and they and their partners observe decreased engorgement and temperature of the glans penis with the inflated penile prosthesis, despite adequate stimulation. Intracorporal injection therapy is contraindicated in any patient with a penile prosthesis and use of a vacuum erection device may result in prosthesis cylinder rupture. In these patients intraurethral application of alprostadil may restore prosthesis function and permit satisfactory intercourse. We evaluate the efficacy of a medicated urethral system for erection (MUSE) using alprostadil to restore function for men with a failed prosthesis, and improve glans penis temperature sensation and engorgement for those with a functioning prosthesis. MATERIALS AND METHODS: From February 1997 to February 1998, 28 men 47 to 81 years old (mean age 61.2) with a penile prosthesis were treated with alprostadil. Of the patients 11 had penile prosthesis failure (group 1) and 17 reported decreased glans penis engorgement (group 2). In 18 cases erections were observed at the clinic. Doses of alprostadil varied from 250 to 1,000 microgm. (mean 566). RESULTS: Of the 28 patients 23 had a response to alprostadil. Erections were sufficient for intercourse in 7 of 11 group 1 patients, and 10 of 17 group 2 were satisfied with treatment. There was no device specific morbidity but 12 men discontinued use of alprostadil because of penile pain. A significant or excellent response was noted in 10 of 18 men observed at the clinic. CONCLUSIONS: Intraurethral alprostadil may be used to restore or improve function of a penile prosthesis in patients with a malfunctioning device or lack of glans penis engorgement, with low expected morbidity.

Aged↗
PubMed2005

Interleukin-1 modulates periprosthetic tissue formation in an intramedullary model of particle-induced inflammation.

UNLABELLED: Interleukin-1 (IL-1) is a proinflammatory cytokine that has been implicated in wear-debris associated total joint replacement failure. We hypothesized that the absence of the IL-1 type-1 receptor would mitigate the inflammatory response to titanium particles and decrease periprosthetic inflammatory tissue in a murine intramedullary rod model. METHODS: An intramedullary rod with and without commercially pure titanium particles was placed in the femora of 24 wild type mice (WT) and 24 mice lacking a functional type-1 receptor to IL-1. Femora were analyzed histologically and by ELISA of organ culture explant supernatants. RESULTS: The presence of titanium particles in WT mice stimulated increased expression of interleukin-6 (IL-6) and macrophage chemoattractant protein-1 (MCP-1) relative to rod only controls. In contrast, IL-6 and MCP-1 expression were diminished in IL-1r1-KO mice exposed to titanium particles. Additionally, the formation of a periprosthetic fibro-inflammatory membrane in IL-1r1-KO mice was blunted at 2 weeks when compared to that in wild-type mice. Inflammatory changes and the quality of periprosthetic bone of IL-1r1-KO mice was similar to WT mice in response to titanium particles. CONCLUSIONS: These results implicate IL-1 as an important modulator in the local inflammatory response to intramedullary titanium particles. MCP-1 appears to be significantly modulated in IL-1r1-KO mice in response to titanium particles. This may be responsible, in part, for the diminished periprosthetic membrane observed in IL-1r1-KO mice at 2 weeks. Expansion of this murine model of intramedullary particle-induced inflammation to other gene targets may contribute to a more mechanistic understanding of wear-debris associated prosthesis failure.

Animals↗
PubMedDate not supplied

Grammont reverse prosthesis: design, rationale, and biomechanics.

Combined destruction of the rotator cuff and the glenohumeral joint may lead to a painful and pseudo-paralyzed shoulder. In this situation a nonconstrained shoulder prosthesis yields a limited functional result or may even be contraindicated. Previous constrained prostheses (ball-and-socket or reverse ball-and-socket designs) have failed because their center of rotation remained lateral to the scapula, which limited motion and produced excessive torque on the glenoid component, leading to early loosening. The reverse prosthesis designed by Paul Grammont, unlike any previous reverse ball-and-socket design, has introduced 2 major innovations that have led to its success: (1) a large glenoid hemisphere with no neck and (2) a small humeral cup almost horizontally oriented with a nonanatomic inclination of 155 degrees, covering less than half of the glenosphere. This design medializes and stabilizes the center of rotation, minimizes torque on the glenoid component, and helps in recruiting more fibers of the anterior and posterior deltoid to act as abductors. Furthermore, the humerus is lowered relative to the acromion, restoring and even increasing deltoid tension. The Grammont reverse prosthesis imposes a new biomechanical environment for the deltoid muscle to act, thus allowing it to compensate for the deficient rotator cuff muscles. The clinical experience does live up to the biomechanical concept: the reverse prosthesis restores active elevation above 90 degrees in patients with a cuff-deficient shoulder. However, external rotation often remains limited, particularly in patients with an absent or fat-infiltrated teres minor. Internal rotation is also rarely restored after a reverse prosthesis. Failure to restore sufficient tension in the deltoid may result in prosthetic instability. The design does appear to protect against early loosening of the glenoid component, but impingement of the humeral cup on the scapular neck can lead to scapular notching and polyethylene wear. This is a cause for concern, especially as the notch is often more extensive than can be explained by impingement alone. Bony lysis of the scapula may also be related to a polyethylene granuloma. Further follow-up is required to ensure that loosening does not become a problem in the long term, and it has been recommended to limit its use to elderly patients, arguably those aged over 70 years. Despite these concerns, the reverse prosthesis, based on the biomechanical Grammont concept, offers a true surgical option in several situations where only limited possibilities were previously available: cuff tear arthrosis, persistent shoulder pseudo-paralysis due to a massive and irreparable cuff tear, severe fracture sequelae, prosthetic revision in a cuff-deficient shoulder, and tumor surgery. Finally, surgeons must be aware that results are less predictable and complication/revision rates are higher in revision surgery.

Biomechanical Phenomena↗
PubMed2006

[Rotational malalignment causing patellofemoral complications after total knee replacement].

OBJECTIVE: To study the rotation of femoral component and tibial component with CT and evaluate the relationship between patellofemoral complications and rotational alignment of the components. METHODS: Thirty patients with isolated patellofemoral complications after total knee arthroplasty were compared with 20 patients with well functioning total knee replacements free of patellofemoral complications. The epicondylar axis and tibial tubercle were used as references on CT scans to quantify the rotational alignment of the femoral and tibial components. RESULTS: Patients with patellofemoral complications had excessive combined (tibial plus femoral) internal component rotation, which was directly proportional to the severity of the patellofemoral complications. Mild combined internal rotation (1 degree-4 degrees) was correlated with patellar and lateral tracking tilting, moderate rotation (3 degrees-8 degrees) with patellar subluxation, and severe rotation (7 degrees-17 degrees) with early patellar dislocation or late patellar prosthesis failure. The control group had combined external rotation of 10 degrees-0 degree. CONCLUSIONS: The direct correlation of combined internal component rotation to the severity of the patellofemoral complication suggests that internal component rotation may be the predominant cause of patellofemoral complications in patients with normal axis alignment. CT scans can be used intraoperatively and postoperatively to determine whether the rotational malalignment is present to require revision of one or both components.

Adult↗
PubMed1992

Durability of glutaraldehyde-fixed pericardial valve prostheses: clinical and animal experimental studies.

Bovine pericardium has been widely employed as a xenograft tissue for the manufacture of bioprosthetic valve substitutes. Early three-leaflet valve models showed poor tissue preservation and shortcomings in valve design, which accounted for tissue wear and prosthesis failure due to cuspal tear. Reducing the number of cusps in the unicusp pericardial valve has proved unsuccessful due to stretching of the single pericardial leaflet with consequent valvular incompetence. The new generation of pericardial xenografts present basic changes in valve design and optimal tissue preservation after industrial processing, with no evidence of leaflet tear at medium term follow up. However, clinical experience is limited and, similarly to porcine xenografts, dystrophic calcification still appears to be a major problem.

Adult↗