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PubMed2001

The kinematic rotating hinge prosthesis for complex knee arthroplasty.

Fifty-eight patients (69 knees) treated with the Kinematic Rotating Hinged knee prosthesis for complex primary and salvage revision total knee arthroplasty were followed up for an average of 75.2 months (range, 24-199 months). The indications for use of the Kinematic Rotating Hinged knee prosthesis included severe bone loss combined with ligamentous instability (30 knees), nonunion of a periprosthetic fracture (10 knees), an acute periprosthetic fracture (nine knees), severe collateral ligamentous instability (five knees), reimplantation for infection (six knees), nonunion of a supracondylar femoral fracture (four knees), congenital dislocation of the knee (three knees), and treatment of a severely comminuted distal femur (two knees). At the time of surgery, the average patient age was 72 years (range, 46-92 years). Preoperatively, knee extension averaged 4.94 degrees (range, 0 degrees-40 degrees) and flexion averaged 81 degrees (range, 15 degrees-125 degrees). At final followup, knee extension averaged 1.25 degrees (range, -5 degrees-25 degrees) and flexion averaged 94.2 degrees (range, 5 degrees-125 degrees). The preoperative Knee Society Knee score averaged 40.3 points (range, 2-93 points) and improved to 77 points (range, 33-99 points) at final followup. Complications were numerous: 23 (32%) patients experienced at least one complication and 12 (17%) patients had two or more complications. Deep periprosthetic infection was the most common complication (14.5%), followed by patellar complications (13%), and prosthetic component breakage (10%). During the period of this study, there were 15,798 primary and 2673 revision total knee arthroplasties done at the authors' institution. The patients receiving a Kinematic Rotating Hinged knee prosthesis represent a highly complex and small subset (0.37%) of the overall population having knee arthroplasty. Although the use of the Kinematic Rotating Hinged knee prosthesis for these limited indications has been useful for the authors, the incidence of complications and the poor outcome of these complications is disconcerting. Hinged total knee arthroplasty should be reserved for the final salvage option of the treatment options available when doing complex primary and salvage revision knee arthroplasties.

Aged↗
PubMed2001

Prevention of dislocation after hip arthroplasty: lessons from long-term followup.

Regarding dislocation after total hip arthroplasty, prevention is worth an ounce of cure. The current authors evaluated dislocation after total hip arthroplasty during the 26-year practice of one surgeon to identify potential variables that can contribute to the prevention of dislocation. Between 1970 and 1996, dislocation after total hip replacement occurred after 7.2% of primary hip arthroplasty procedures (298 of 4164 primary hip replacements) and 11.2% of revision hip arthroplasty procedures (90 of 803 revision hip replacements). Significant findings included an increase in dislocation when 22-mm modular femoral heads were used and a decrease in dislocation after revision for dislocation when constrained liners were used. An additional finding was that 26% of first time dislocations occurred more than 2 years after surgery. Concerning prevention of dislocation, small head modular femoral components should be used cautiously, and constrained liners should be considered in complex revision cases. Patients should be counseled concerning the potential for dislocation many years after their arthroplasty.

Aged↗
PubMed2002

Complications of joint arthroplasty in patients with end-stage renal disease on hemodialysis.

The mortality and morbidity after hip and knee arthroplasty were reviewed retrospectively during a 3-year period in 14 patients who had chronic renal failure and who were receiving hemodialysis. The patients had a primary total hip or knee replacement, or a revision arthroplasty or resection arthroplasty. Four of the patients (29%) died in the hospital during the postoperative period. One of the seven patients (14%) having a primary joint replacement died, whereas three of the seven patients (86%) having a revision or resection died. Every patient had multiple medical comorbidities, and every patient had a complication. The results indicate that arthroplasty procedures, especially revisions and resections, in this patient population are associated with a high rate of complications and death, and that in-depth informed consent should be provided for all patients contemplating these procedures. Meticulous treatment of medical comorbidities is mandatory. Finally, data in the literature and in the current report question whether joint arthroplasty procedures should be done in patients with end-stage renal disease who are receiving hemodialysis.

Aged↗
PubMed2002

Preoperative hip to ankle radiographs in total knee arthroplasty.

Whether a preoperative long leg radiograph taken with the patient standing helps the surgeon reproduce a normal mechanical axis after total knee arthroplasty is unknown. The purpose of the current study was to evaluate whether a preoperative long leg radiograph helps to restore normal limb alignment after total knee arthroplasty. Ninety-four patients (124 primary total knee arthroplasties) were randomized to either receive or not receive a preoperative long leg standing radiograph. Patients with previous hip or ankle surgery, femoral or tibial fracture, deformity of 15 degrees or greater, or those who were obese (body weight index > 40 kg/m2) were excluded. All arthroplasties were done by one surgeon. The angle of distal femoral resection varied between 5 degrees and 8 degrees (mean, 6.2 degrees) among patients with long leg radiographs. In patients without long leg radiographs, the distal femur was cut at 5 degrees. Long leg radiographs were obtained postoperatively in all patients and the mechanical axis was assessed, first by whether the mechanical axis fell within the central third of the knee, and second by the distance in millimeters that the mechanical axis fell from the knee center. No significant difference in the postoperative mechanical axis was detected between the two groups. Eighty-six percent of the patients with long leg preoperative radiographs and 92% of the patients without long leg preoperative radiographs had the mechanical axis pass through the central (1/3) of the knee. Preoperative hip to ankle long leg radiographs taken with the patient standing did not significantly help to obtain a neutral mechanical axis during routine total knee arthroplasty.

Adult↗
PubMed2002

Biomechanics of posterior-substituting total knee arthroplasty: an in vitro study.

The cam-spine system in posterior-substituting total knee arthroplasty was designed to improve posterior stability and to increase posterior femoral translation (rollback). Little is known on its effectiveness in the restoration of femoral rollback under functional loads. In the current study, the effect of cam-spine engagement on knee motion under simulated muscle loads was investigated using knees from cadavers. The translations of the lateral and medial femoral condyles of the knee before and after total knee arthroplasty were compared from 0 degrees to 120 degrees flexion. Cam-spine contact forces were measured under the same muscle loads. The posterior translations of both femoral condyles in the total knee arthroplasty were significantly lower than that of the native knee beyond full extension. Cam-spine engagement occurred between 60 degrees and 90 degrees flexion followed by an increase in posterior translation of both femoral condyles. However, the resultant femoral translation of the total knee arthroplasty was still lower than that of the native knee from 90 degrees to 120 degrees flexion. Knee motion after cam-spine engagement was independent of muscle loads, indicating the importance of the cam-spine mechanism at high flexion angles. Decreased posterior translation of both femoral condyles after total knee arthroplasty may be a limiting factor at high flexion.

Aged↗
PubMed2002

Total knee arthroplasty after prior bone or joint sepsis about the knee.

The current study was done to determine the effect of current methods to diagnose and treat infection on the incidence of deep prosthetic infection after total knee arthroplasty for patients with previous sepsis or osteomyelitis about the knee. Between 1989 and 1999, one surgeon did 20 consecutive primary total knee arthroplasties in 19 patients with a previous history of either septic arthritis or osteomyelitis about the knee. Antibiotic-impregnated cement was used in all patients. One patient was lost to followup and two patients died before 2 years from the arthroplasty. The remaining 16 patients were followed up for an average of 5 years (range, 2-11 years). There was one (5%) recurrent deep periprosthetic infection for which the patient required resection arthroplasty at 3.5 years. No patients required chronic antibiotic suppression. With careful preoperative and intraoperative evaluation and the routine use of antibiotic bone cement for fixation, total knee arthroplasty, in patients with prior bone or joint sepsis about the knee can provide good pain relief, functional improvement, and an acceptably low rate of deep prosthetic infection.

Aged↗
PubMed2002

Surgical approach, abductor function, and total hip arthroplasty dislocation.

Dislocation is a leading early complication of total hip arthroplasty. The effect of surgical approach on instability and abductor function is a controversial topic. A comprehensive literature review was done to evaluate the correlation of surgical approach and primary total hip arthroplasty dislocation. Two hundred sixty clinical studies were identified between 1970 and 2001. Four prospective studies were identified but individually they contained insufficient power or control groups to reach statistical significance regarding surgical approach and dislocation. Fourteen studies involving 13,203 primary total hip arthroplasties met the inclusion criteria based on variables previously shown to affect stability. These studies were evaluated with respect to surgical approach and dislocation. The combined dislocation rate for these studies was 1.27% for the transtrochanteric approach, 3.23% for the posterior approach (3.95% without posterior repair and 2.03% with posterior repair), 2.18% for the anterolateral approach, and 0.55% for the direct lateral approach. Eight studies involving 2455 primary total hip arthroplasties evaluated postoperative limp. The incidence of postoperative limp was 4% to 20% for patients who had the lateral approach and 0% to 16% for patients who had the posterior approach. The quality of the literature regarding surgical approach, dislocation rates, and abductor function is limited. Larger controlled prospective studies are needed to investigate the potential benefits of the posterior approach in lieu of a dislocation rate six times higher than the direct lateral approach for primary total hip arthroplasty.

Arthroplasty, Replacement, Hip↗
PubMedDate not supplied

Unicompartmental knee arthroplasty (alias uni-knee). An overview with nursing implications.

During the past 30 years, the unicompartmental knee arthroplasty has undergone growing pains with various implant designs, refining indications, and improving surgical techniques and instrumentation. Today, studies show survivorship results comparable to the tricompartmental total knee arthroplasty and a renewed interest has emerged. Even though the unicompartmental knee arthroplasty is recommended for only a select 10-15% who have osteoarthritis of the knee, it has many advantages over the total knee arthroplasty. Although the nursing care and rehabilitation are similar to the total knee arthroplasty, including wound care, prophylactic antibiotics, and venous thromboembolism prophylaxis, the patient frequently has less pain, increased range of motion, shorter hospitalization, and fewer complications, resulting in a quicker rehabilitation.

Arthroplasty, Replacement, Knee↗
PubMed2003

Knee motions during maximum flexion in fixed and mobile-bearing arthroplasties.

Full flexion is a critical performance requirement for patients in Asia and the Middle East, and increasingly for patients in Europe and North America who have total knee arthroplasty. There has been considerable work characterizing maximum flexion in terms of clinical, surgical, and preoperative factors, but less in vivo experimental work after rehabilitation. The purpose of the current investigation was to determine whether anteroposterior tibiofemoral translation influenced maximum weightbearing knee flexion in patients with good or excellent clinical and functional outcomes. One hundred twenty-one knees in 93 subjects, including 16 different articular surface designs, were studied using fluoroscopy and shape matching to determine knee kinematics in a weightbearing deep flexion activity. A relatively posterior position of the femur on the tibia was significantly correlated with greater maximum knee flexion. Posterior-stabilized arthroplasties had significantly more posterior femoral position and maximum flexion than posterior cruciate-retaining fixed-bearing arthroplasties, which had more posterior femoral position and greater maximum flexion than mobile-bearing arthroplasties. Posterior bone-implant impingement was observed in 28% of knees. Tibiofemoral motions influence the mechanics of weightbearing deep flexion in well-functioning knee arthroplasties.

Aged↗
PubMed2003

Economics of one-stage versus two-stage bilateral total knee arthroplasties.

Patients requiring bilateral total knee arthroplasties may have both joints replaced simultaneously during one hospitalization (one-stage) or during two separate hospitalizations (two-stage). The goals of the current study were to retrospectively analyze discharge patterns for 91 patients who had one-stage bilateral total knee arthroplasties and 32 patients who had two-stage surgeries, and to quantify their in-hospital costs and their costs if the patients were discharged from the hospital to an inpatient unit. Patients having one-stage and two-stage surgery were similar in age, gender, severity of illness (as measured by the American Society of Anesthesiologists Physical Status score), principal diagnosis, and ethnicity. Using a microcosting approach, the authors found that the average in-hospital costs for one-stage total knee arthroplasty (27,468 US dollars) were significantly lower (by 24%) than for two-stage total knee arthroplasty. However, 38% of patients who had the one-stage bilateral total knee arthroplasties were admitted to an acute rehabilitation unit, which had a mean cost of 6469 US dollars and length of stay of 9 days. In contrast, none of the patients who had the two-stage procedure required acute rehabilitation. Patients who had the two-stage procedure were discharged directly home (or with home health services) 42% of the time, versus 21% for patients who had the one-stage procedure. Patients from both groups were discharged to a skilled nursing facility approximately (1/2) of the time, accruing similar costs. Economic analyses of the one-stage procedure need to consider that these patients will require increased use of acute inpatient rehabilitation after hospital discharge.

Aftercare↗
PubMed2003

Total knee arthroplasty for neuropathic (Charcot) joints.

The clinical and radiographic results of 40 modern design condylar total knee arthroplasties (TKAs) in 29 patients with a confirmed diagnosis of Charcot joint were reviewed. The followup averaged 7.9 years (range, 2-15 years) for clinical and 6.4 years (range, 2-15) for radiographic surveillance. There was a significant improvement in Knee Society pain and function scores and ROM after knee arthroplasty. Extensive bone fragmentation and bone defect was present in 38 knees (95%). Metal wedge augments (10 knees, eight patient), autologous bone grafting (17 knees, 13 patients), and bone allografts (two knees, two patients) were used to reinforce the bony defects. Ligamentous instability necessitated the use of long stem components in 27 knees and rotating hinge prostheses in five knees. There were six reoperations for periprosthetic fracture (two knees, two patients), aseptic loosening (two knees, two patients), instability (one knee, one patient), and deep infection (one knee, one patient). Total knee arthroplasty may be offered to a select group of patients with end-stage neuropathic arthropathy. The basic principles of knee arthroplasty in restoring limb alignment, reinforcing bony defects by bone grafting or augmented prostheses, careful ligamentous balancing, and appropriate selection of constrained prostheses particularly are important in these patients. The technical challenges encountered during TKA in patients with neuropathic arthropathy, particularly in those with significant deformities, can require skills, implant systems, and methods usually reserved for complex revision arthroplasty.

Adult↗
PubMed2005

Implant survivorship and complication rates after total knee arthroplasty with a third-generation cemented system: 5 to 8 years followup.

UNLABELLED: We evaluated implant survivorship, reoperation rates, and complication rates of a group of patients who had total knee arthroplasty with a third-generation cemented prosthetic device using cruciate-retaining and posterior-stabilized designs at 5 to 8 years followup. Three hundred thirty-four consecutive primary total knee arthroplasties (186 cruciate retaining and 148 posterior stabilized) were done in 287 patients at our institution during a 2-year period. Kaplan Meier survivorship using revision for any reason and revision for aseptic loosening as endpoints were 95.9% and 99.5% respectively at 8 years. Nine patients (four with cruciate-retaining total knee arthroplasties, five with posterior-stabilized total knee arthroplasties; 3.1%) had reoperations for any reason. No patients had reoperation for problems related to the patellofemoral joint. Thirty-two patients (11.1%) had intraoperative or postoperative complications. There were no differences in any of the outcomes analyzed between patients who had cruciate-retaining or posterior-stabilized total knee replacements. Our results show that with appropriate patient selection and meticulous attention to surgical technique, excellent clinical and radiographic results can be achieved with a third-generation total knee arthroplasty system at intermediate followup. LEVEL OF EVIDENCE: Therapeutic study, Level III-2 (retrospective cohort study).

Aged↗
PubMed2004

Extended medial gastrocnemius rotational flap for treatment of chronic knee extensor mechanism deficiency in patients with and without total knee arthroplasty.

Nine patients with chronic extensor mechanism disruption were treated with an extended medial gastrocnemius rotational flap reconstruction of the extensor mechanism. Seven patients previously had total knee arthroplasty and two patients had chronic infection of nonreplaced, native knees. Four patients previously had failed Achilles' tendon allograft reconstruction after total knee arthroplasty and two were complicated by infection. Infected arthroplasty patients had a staged procedure with placement of an antibiotic spacer after debridement and extended medial gastrocnemius rotational flap, followed by total knee arthroplasty replant 8 weeks later. The four infected arthroplasty patients had medical comorbidities that included a patient with HIV and hemophilia, and two with diabetes mellitus. Another patient with rheumatoid arthritis was severely malnourished as a result of dumping syndrome. Of the four patients treated by this two-stage procedure, one died in the early postoperative period from chronic medical issues after the second stage and another patient elected to have above-knee amputation after the first stage because of severe reflex sympathetic dystrophy. The final group of seven patients was studied at a mean followup of 21 months (range, 7-31 months), the average extensor lag was 13.5 degrees (range, 0-50 degrees ), and the average range of motion was 2 degrees to 93 degrees . The two patients with nonreplaced, native knees had extensor lags of 30 degrees and 10 degrees . All patients were able to regain sufficient extensor mechanism strength to return to independent ambulation, and all infections resolved after treatment. Two patients were able to ascend stairs foot over foot without support. In addition to the patient who had amputation, the other complication involved a wound breakdown that required a free flap at 13 months in a patient who had a failed Achilles' tendon allograft reconstruction after takedown of a knee fusion. Medial gastrocnemius flap reconstruction can provide successful salvage of a failed extensor mechanism allograft or an alternative to allograft reconstruction in patients with poor soft tissue coverage, previous infection, or a compromised immune system.

Achilles Tendon↗
PubMed2004

A multicenter analysis of axial femorotibial rotation after total knee arthroplasty.

A multicenter analysis was done to determine in vivo femorotibial axial rotation magnitudes and patterns in 1,027 knees (normal knees, nonimplanted ACL-deficient knees, and multiple designs of total knee arthroplasty). All knees were analyzed using fluoroscopy and a three-dimensional computer model-fitting technique during a deep knee bend and/or gait. Normal knees showed 16.5 degrees and 5.7 degrees of internal tibial rotation during a deep knee bend and gait, respectively. Rotation magnitudes and the percent having normal axial rotation patterns decreased in all total knee arthroplasty groups during a deep knee bend. During gait, all knee arthroplasty groups had similar rotational patterns (limited magnitudes). Average axial rotational magnitudes in gait and a deep knee bend were similar among major implant categories (ie, fixed-bearing versus mobile-bearing, etc). Average values in normal knees and ACL-retaining total knee arthroplasty patients (16.5 degrees and 8.1 degrees , respectively) were higher than in groups in which the ACL was absent (< 4.0 degrees ). All total knee arthroplasty groups had at least 19% of patients have a reverse axial rotational pattern during a deep knee bend and at least 31% during gait. Normal axial rotation patterns are essential for good patellar tracking, reduction of patellofemoral shear forces, and maximization of knee flexion.

Analysis of Variance↗
PubMed2005

Failure to resurface the patella during total knee arthroplasty may result in more knee pain and secondary surgery.

UNLABELLED: Resurfacing the patella during primary total knee arthroplasty is controversial. The objective of this meta-analysis was to evaluate the outcome of total knee arthroplasty with or without resurfacing of the patella with particular attention to patient satisfaction, incidence of anterior knee pain, patellar complications, and the need for secondary operations. Computerized databases were searched for citations and published randomized clinical trials relevant to patellar resurfacing from 1966-2003. Of 158 citations identified as related to patellar resurfacing during total knee arthroplasty, 14 articles met all inclusion criteria for this study. The incidence of anterior knee pain was greater in knees with nonresurfaced patellas. Secondary resurfacings for anterior knee pain was needed in 8.7% of nonresurfaced knees. No difference in reported complications existed. Total knee arthroplasty resulted in improvement of functional outcome regardless of whether the patella was resurfaced. Based on the results of this meta-analysis, nonresurfacing of the patella during primary total knee arthroplasty is likely to result in a greater incidence of anterior knee pain, the need for secondary resurfacing in almost one in 10 patients, and possibly less patient satisfaction. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Aged↗
PubMed2005

A modular prosthesis for patellofemoral arthroplasty: design and initial results.

UNLABELLED: This study was designed to determine if a new and modular prosthesis for patellofemoral arthroplasty would produce results at least as good as those reported for other designs, while simultaneously eliminating the risks of patellar revision should total knee arthroplasty be needed in the future. Another issue was its suitability for the older patient with isolated patellofemoral arthritis in order to avoid destruction of the normal femoro-tibial compartments involved in total knee arthroplasty. Finally, I sought information about the safety and longevity of this prosthesis when used for patellofemoral arthroplasty in severely disabled patients too young to be considered for total knee replacement. From a cohort of 16 patients (8 studied retrospectively and 8 prospectively), aged 26 to 81 years, and followed up for 2.75-6.25 years, 15 (94%) rated their results excellent or good using the Activities of Daily Living Scale. These results are better than previously reported for other prosthetic designs. To date, no patient in this study group has required conversion to a total knee arthroplasty. The design has proven safe for use in both the older and younger patient, but longer followup will be needed to assess greater longevity. LEVEL OF EVIDENCE: Therapeutic Study, Level IV-8 (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Activities of Daily Living↗
PubMed2006

Impaction grafting for bone defects in revision total knee arthroplasty.

UNLABELLED: Bone loss in revision total knee arthroplasty is a complex and challenging problem. Frequently, the defects encountered are irregular in size and shape. Since 1998, we have been using impaction bone allografting for constrained and unconstrained defects in revision total knee arthroplasty. We prospectively studied the mid-term results of 48 consecutive revision total knee arthroplasties with substantial bone loss treated with impaction allograft. Average followup was 3.8 years. Knee Society scores improved from a preoperative average of 57.0 to a postoperative average of 89.8 points (p < 0.001). Knee Society functional scores improved from a pre-operative average of 52.3 to a postoperative average of 80.3 points (p < 0.001). There have been no mechanical failures of the revisions and all radiographs have shown incorporation and remodeling of the bone graft. There were six complications out of the 42 revisions available for followup (14%); two periprosthetic fractures, one early infection salvaged with irrigation and antibiotics, one late infection resulting in fusion, and two patellar clunk syndromes. Though time consuming and technically demanding, impaction grafting for bone loss in revision total knee arthroplasty has excellent durability and versatility. It has become our preferred technique for the management of substantial bone loss in revision total knee arthroplasty. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series).

Adult↗
PubMed2006

Current etiologies and modes of failure in total knee arthroplasty revision.

UNLABELLED: Although total knee arthroplasty is a very effective intervention and increasing in prevalence, failures do occur. We studied patients presenting for total knee arthroplasty revision to determine any modifiable causes of failure, both short and long term, and where future efforts should be directed to reduce the incidence of failure. A multicenter prospective observational cohort study of 318 consecutive patients, with minimum 1 year follow-up, undergoing total knee arthroplasty revision was performed. Associations between modes of failure were also assessed. The mean time from primary procedure to total knee arthroplasty revision was 7.9 years. Many patients (64.4%) had more than one cause of failure. Thirty-one percent of patients were early (< 2 years) failures at a mean of 11 months. These had a higher prevalence of infection, perioperative factors and comorbidities. Late failures occurred at a mean of 119.2 months. Other major causes of failure included instability (28.9%), wear (24.5%) and component loosening suggesting the importance of modifications in technique, implants and other areas. Application of these findings will ultimately reduce revision numbers through continued refinement of total knee arthroplasty practice and through further specific investigation of these modes of failure. LEVEL OF EVIDENCE: Therapeutic study, level II-2 (prospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Adult↗