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PubMed2006

Revision total knee arthroplasty does not increase PACU utilization.

UNLABELLED: The hospital records of 232 consecutive cases of patients undergoing primary and revision total knee arthroplasty were analyzed to determine differences in operating room time, postanesthesia care unit time, operating room narcotic usage, and postanesthesia care unit narcotic usage between the two groups. The average operating room time for a surgeon performing revision total knee arthroplasty on a patient was greater than that for a primary total knee arthroplasty. However, there was no difference in average postanesthesia care unit time nor operating room and postanesthesia care unit narcotic usage. When stratified to anesthetic type and perioperative pain intervention, there was no difference in any of the measured parameters between the primary and revision groups. Thus, even with longer operating times, a patient undergoing revision total knee arthroplasty did not utilize more postanesthesia care unit time, nor more perioperative narcotics, than a patient undergoing primary total knee arthroplasty. LEVEL OF EVIDENCE: Therapeutic study, Level III (retrospective comparative study). See the Guidelines for Authors for a complete description of levels of evidence.

Aged↗
PubMed2006

Whole patellar allograft for total knee arthroplasty after previous patellectomy.

UNLABELLED: We treated seven consecutive patients (nine knees) with previous total knee arthroplasties and patellectomies with whole patellar allograft reconstructions of the extensor mechanism. The patients' extensor mechanism soft tissue sleeve was intact, but the patella was not present. Deficient patellae were reconstructed using patellar ligament (whole patella) quadriceps tendon allograft. Six knees had previous patellectomies and underwent primary total knee arthroplasties. Three knees had previous patellectomies and underwent revision total knee arthroplasties. Two patients who had primary total knee arthroplasties had failed results; one from infection and one from aseptic allograft resorption and fragmentation. One patient in the revision total knee arthroplasty group had failed results from infection. After an average followup of 44 months (range, 39-48 months), the six intact knees had an increase in quadriceps strength of one grade. The average Knee Society knee and function scores increased from 59 and 63 points, respectively, to 85 and 67 points, respectfully. The average patellar thickness was 24 mm 6 weeks postoperatively, and 15 mm (38% decrease) at the most recent followup. Patellar allografting improved quadriceps function by restoring patellar height. However, a high risk of allograft complications can occur with this procedure. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series).

Arthroplasty, Replacement, Knee↗
PubMed2006

Perioperative morbidity after single-stage bilateral total hip arthroplasty: a matched control study.

We asked whether the perioperative morbidity and mortality of patients having bilateral single-stage total hip arthroplasties would be increased. We retrospectively compared 400 patients who had bilateral total hip replacements with a matched group of 400 patients who had unilateral total hip replacements. Patients were matched according to age (+/- 1 year), gender, American Society of Anesthesiologists (ASA) classification, body mass index (+/- 4 kg/m), and diagnosis (osteoarthritis, 81.2%). There were no deaths in either group. The group of patients who had bilateral total hip arthroplasties had a greater number of minor complications per hip (0.34 +/- 0.6 versus 0.25 +/- 0.6) but only a trend toward an increased number of major complications per hip (0.037 +/- 0.2 versus 0.015 +/- 0.1). Patients who had bilateral total hip arthroplasties had a trend toward increased risk of dislocation (1.6%/hip versus 0.5%/hip). The patients in this group also had increased number of fat emboli syndrome per surgically treated hip (0.015 versus 0.0025). Based on a calculation per surgically treated hip, patients who had bilateral total hip arthroplasties had a similar percentage of blood transfusions (1.2 versus 0.9/hip), but more patients received allogeneic blood (23% versus 3.8%). The ASA classification was the only independent predictor for minor complications, major complications, and fat emboli syndrome. We think bilateral single-stage total hip arthroplasties have an acceptable perioperative risk for patients with ASA Class 1 or 2 physical status.

Adult↗
PubMed2006

The Mark Coventry Award: Prevention of readmission for venous thromboembolism after total knee arthroplasty.

Venous thromboembolism is the most common reason for readmission after total knee arthroplasty. Prospective contrast venography was conducted from 1984 to 2003 in 1321 patients undergoing total knee arthroplasty. Patients with deep venous thrombosis or pulmonary embolism were treated with warfarin; those with negative venograms received no further anticoagulation. From 1984 to 1992, patients not completing venography were discharged without warfarin; since 1993 patients without venography received warfarin for 6 weeks. Readmission for deep venous thrombosis, pulmonary embolism, or bleeding was tracked for 6 months. Venography was completed in 810 patients; 343 (42.3%) had deep venous thrombosis. Readmission for venous thromboembolism occurred in 0.6% of patients after total knee compared with 1.62% after total hip arthroplasty. Following total knee arthroplasty, patients discharged on warfarin (target INR 2.0) had a 0.21% readmission rate compared with 1.05% for patients with negative venograms discharged without further anticoagulation. One patient suffered a fatal pulmonary embolism after negative venography and no outpatient prophylaxis. Secondary prophylaxis with extended warfarin therapy reduced venous thromboembolism-related readmission. Surveillance venograms were a poor predictor of ultimate thromboembolism risk and need for extended anticoagulation therapy. We therefore recommend extended warfarin prophylaxis for all patients after hospital discharge following total knee arthroplasty.

Arthroplasty, Replacement, Knee↗
PubMed2006

Factors affecting survival of uncemented total hip arthroplasty in patients 50 years or younger.

Providing a long-lasting total hip arthroplasty for patients younger than 50 years remains one of the greatest challenges for modern arthroplasty surgery. We retrospectively reviewed 221 patients younger than 50 years who underwent 299 uncemented total hip arthroplasties from 1983 to 2000. We assessed 5- to 15-year survival with revision as the endpoint. Femoral stem survival was 99.3% (range, 98.4-100%), 98.9% (range, 97.7-100%), and 96.8% (92.5-100%) at 5, 10, and 15 years, respectively. Including all component designs acetabular survival was 98.7% (range, 97.4-100%), 84.6% (78.8-90.4%), and 52.5% (40.7-64.3%) at 5, 10, and 15 years, respectively. Overall survival was 46.8% (33.5-58.1%) at 15 years. Total hip arthroplasties performed for hip dysplasia had lower 10-year and 15-year survival. Zirconium-on-polyethylene articulations had lower acetabular revision rates compared with cobalt-chrome-on-polyethylene. Sixty-nine revisions were performed, most commonly for polyethylene wear. Uncemented femoral stems resulted in 90% survival at 15 years followup in patients younger than 50 years at index operation. Contemporary bearing surfaces in association with such stems may provide long-lasting total hip arthroplasties, even in young, active patients.

Adolescent↗
PubMed2005

Treatment of the painful motion segment: cervical arthroplasty.

STUDY DESIGN: A retrospective review of the literature. OBJECTIVE: This work serves as a comprehensive update of cervical arthroplasty. SUMMARY OF BACKGROUND DATA: Cervical arthroplasty has developed as a means to preserve normal spinal motion after an anterior cervical discectomy. Preserving motion may lead to an acute improvement in patient outcome and may decrease the incidence of symptomatic adjacent segment disease in the long-term. METHODS: The literature concerning the outcomes following anterior cervical decompression and fusion, the indications for cervical arthroplasty, the indications and contraindications for arthroplasty, the surgical technique, and early outcome studies for those devices currently in U.S. FDA IDE trials are reviewed. RESULTS: The most data are available for the Prestige, Bryan, and ProDisc-C devices. While these devices all preserve normal segmental motion, the articulations vary (metal on metal, metal on polyurethane, and metal on ultra-high molecular weight polyethylene). Wear testing indicates that these devices will have a long life once implanted. Preliminary outcomes compare very favorably to anterior decompression and arthrodesis. CONCLUSIONS: Cervical arthroplasty is a promising new technology that may improve patient outcome following anterior cervical decompression.

Arthroplasty↗
PubMed2004

Effect of total hip arthroplasty on recreational and sporting activity.

BACKGROUND: Common concerns of patients undergoing total hip arthroplasty are whether they can continue with certain recreational and sporting activities or even commence new ones after the procedure. The present paper describes preoperative and postoperative activities, the numbers participating and the time to resume these activities. METHODS: Between 1 and 2 years after total hip arthroplasty, 216 patients, who had undergone a total of 235 arthroplasties, were surveyed by postal questionnaire to ascertain how the arthroplasty had affected their recreational and sporting ability. Their preoperative and postoperative activity along with the time to resume was recorded. A general hip score and estimate of physical activity was also collected. RESULTS: The number of patients participating in sport increased from 188 preoperatively to 196 postoperatively. Patients stated that the surgery had a beneficial effect on their performance of sporting activities although the number of sporting events decreased. By multiplying individuals by the number of sports they participated in, there were 434 occurrences of sport preoperatively giving a mean for the group of 1.9 sports per patient. Postoperatively this had reduced to 382, giving a mean of 1.7. Five sports showed a significant change for individual patients from pre to postoperation. Those which showed an increase were exercise walking, where 38 patients (16.8%) who did not walk before surgery took up walking afterwards (P < 0.0001) and aqua aerobics, where 15 took up this activity postoperatively for the first time (P = 0.002). There were three sports which decreased significantly from pre to postoperation. They were, golf where 13 out of 39 (P = 0.005), tennis 13 out of 14 (P = 0.01) and jogging where six out of seven (P = 0.01) patients stopped participating. CONCLUSION: This study has shown that patients are adopting lower impact activities to participate in after total hip arthroplasty. The total number of patients performing a sport increases postoperatively but the total amount of sport played decreases. These data will help to counsel patients.

Aged↗
PubMedDate not supplied

Tennis after total hip arthroplasty.

The purpose of this study was to characterize patients who play tennis after undergoing hip arthroplasty in terms of their functional abilities and degree of satisfaction. A questionnaire was sent to all United States Tennis Association member associations in a tri-state area to identify players who had undergone a hip arthroplasty. The study group had 50 men and 8 women with a mean age of 70 years (range, 47 to 89). Only 14% of the patients' surgeons approved this tennis activity, with 34% of the surgeons recommending only doubles. Three patients required revision surgery after a mean of 8 years. One year after arthroplasty, players played both singles and doubles approximately three times per week. All tennis players were extremely satisfied with their hip arthroplasties and their increased ability to participate in their favorite sport. Because this study was confined to association members, further studies are needed to assess the general effect of tennis on total hip arthroplasty. Until future studies are performed, the authors would recommend that physicians advise caution in tennis activities and to carefully follow their patients yearly to see if osteolysis is occurring prematurely.

Aged↗
PubMed2000

Kinematics of a total arthroplasty of the ankle: comparison to normal ankle motion.

Although the concept of a total ankle arthroplasty has been advanced as a method for treating severe ankle arthritis, the clinical experience with all of the models developed has been discouraging. Both the constrained designs, which maximize joint contact area by restricting the available motion, and the unconstrained designs, which allow more normal motion at the expense of higher contact stresses, uniformly result in implant loosening, pain, and clinical failure in 2 to 7 years. This has led to the recommendation against the use of a total ankle arthroplasty except in very low-demand patients. Failure of ankle implants can be ascribed to either anatomic considerations (e.g.--the talus is too small to accommodate the stress transfers of a prosthesis), or mechanical etiologies. Abnormal 3-dimensional motion of the ankle following arthroplasty would fall into the latter category. This study examined the motion that occurs after implantation of an unconstrained-type total ankle arthroplasty. Using previously validated methodology, axially loaded ankle specimens were cycled through an arc of plantarflex/dorsiflexion while measuring the resulting coupled internal/external and varus/valgus rotations. The average coupled motions in prosthetic ankles were not significantly different than their intact controls. There was, however, a significantly increased amount of hysteresis (defined as the difference between the upper and lower pathways of coupled motion at any given sagittal position) that occurred as the ankle was dorsiflexed and plantar flexed. The increased hysteresis was seen in both the axial and coronal planes. This indicates that there was a greater permitted envelop of motion in the prosthetic ankles compared to normal ankles. It is hypothesized that this subtle change in ankle kinematics caused by the arthroplasty leads to abnormal stress transfer at the prosthesis-bone interface, thereby promoting early implant failure.

Aged↗
PubMed2005

Review of proximal interphalangeal joint excisional arthroplasty for the correction of second hammer toe deformity in 100 cases.

BACKGROUND: The main bony procedures used in the treatment of second hammertoe are excisional arthroplasty and arthrodesis of the proximal interphalangeal (PIP) joint. While a number of studies have reported the outcomes after PIP joint arthrodesis, there are few reports of the outcome of excisional arthroplasty of the PIP joint for the correction of second hammertoes. The purpose of this study was to evaluate the long-term outcome of PIP joint excisional arthroplasty. METHODS: Seventy-five patients (100 toes) who had excisional arthroplasty of the PIP joint for the correction of second hammertoe were reviewed at an average followup of 44 months. All patients were seen in clinic and were physically examined to assess the alignment and function of each digit. The radiographs were evaluated preoperatively. The AOFAS clinical rating scale was used preoperatively and at final followup. Patients were asked to rate their satisfaction on a scale of 0 to 10 and were asked if they would be happy to have the surgery under similar circumstances again. RESULTS: The mean preoperative AOFAS clinical rating scale was 46. At final followup this increased to 94, showing an average improvement of 48 points (p < 0.0001). The mean satisfaction on a scale of 0 to 10 (with 0 equaling complete dissatisfaction and 10 complete satisfaction) was 9.3 (SD 1.3). One patient would not have been happy to undergo outpatient surgery again, because of a change in her social circumstances. CONCLUSION: In a group of 75 patients who had PIP joint arthroplasty for the correction of second hammertoe, high levels of satisfaction were achieved. No serious complications were encountered, and revision surgery was required in just two cases. Floating toe was the most common complication encountered, and although this did decrease the level of patient satisfaction in seven patients it was not a cause of footwear irritation or pain in any patient.

Arthroplasty↗
PubMed2006

Total ankle arthroplasty with the Agility prosthesis: clinical and radiographic evaluation.

BACKGROUND: Although ankle arthrodesis remains a standard operative procedure for disabling ankle arthritis, it has potential long-term problems. Total ankle arthroplasty offers preserved joint motion and may be a more favorable option in select patients. The purpose of this study was to report the intermediate-term clinical and radiographic results of total ankle arthroplasty using the Agility prosthesis. METHODS: We retrospectively reviewed the results of total ankle arthroplasty in 41 consecutive patients (43 ankles). Evaluation included preoperative and postoperative questionnaires, physical examination, and radiographs. RESULTS: At the time of followup, 38 patients (40 ankles) were available for review. The most common preoperative diagnoses included posttraumatic arthritis (24 of 40 ankles, 60%) and rheumatoid arthritis (eight of 40 ankles, 20%). Average age at surgery was 63 (range 32 to 85) years. Average followup was 44.5 (range 26 to 64) months. Preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scores averaged 33.6 and 83.3, respectively, demonstrating significance (p < 0.001). Postoperative Medical Outcomes Study Short Form-36 (SF-36) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores averaged 49.5 and 56.1, respectively. Although 34 of 40 ankles demonstrated radiographic lucency or lysis, the degree of involvement varied. Migration or subsidence of components was noted in 18 ankles. Overall, 37 of 38 patients were satisfied with the outcome of their surgery and would have the same procedure under similar circumstances. CONCLUSIONS: Agility total ankle arthroplasty results in a favorable clinical outcome and patient satisfaction in most patients at intermediate-term followup. However, total ankle arthroplasty is associated with potential complications and the need for subsequent operative intervention. Radiographic followup commonly reveals periprosthetic lucency, lysis, and component migration or subsidence, but this does not appear to adversely affect the intermediate-term clinical outcome. The long-term consequences of such radiographic findings are of concern, and surgeons and patients choosing this procedure need to be cautious.

Adult↗
PubMed2003

Optimizing the dose of intrathecal morphine in older patients undergoing hip arthroplasty.

UNLABELLED: Intrathecal (IT) morphine provides excellent postoperative analgesia but may result in many side effects, including postoperative nausea and vomiting, pruritus, and respiratory depression, particularly at larger doses. Older patients may be at particular risk. The optimal dose of spinal morphine in older patients undergoing hip arthroplasty is not known. We designed this prospective, randomized, controlled, double-blinded study to evaluate the analgesic efficacy and side effect profile of 50-200 microg of IT morphine in older patients undergoing elective hip arthroplasty. Sixty patients older than 65 years undergoing elective hip arthroplasty were enrolled. Patients were randomized to receive spinal anesthesia with 15 mg of bupivacaine and IT morphine in four groups: 1). 0 microg, 2). 50 microg, 3). 100 microg, and 4). 200 microg. IT morphine 100 and 200 microg produced effective pain relief and decreased the postoperative requirement for morphine compared with control. IT morphine 50 microg did not provide effective pain relief. Both 100 and 200 microg of IT morphine provided comparable levels of postoperative analgesia. There were no between-group differences in postoperative nausea and vomiting, sedation, respiratory depression, or urinary retention. Pruritus was significantly more frequent with 200 microg of IT morphine. In conclusion, 100 microg of IT morphine provided the best balance between analgesic efficacy and side effect profile in older patients undergoing hip arthroplasty. IMPLICATIONS: The dosage of intrathecal morphine that provides the best balance between analgesic efficacy and side effect profile in the older patient undergoing hip arthroplasty is not known. This prospective, randomized, controlled, double-blinded clinical trial demonstrates that a dose of 100 microg of intrathecal morphine provides the best balance between efficacy and side effects, compared with doses of 0, 50, and 200 microg of morphine, in this patient population.

Aged↗
PubMed2000

The Roper-Tuke total elbow arthroplasty. 4- to 10-year results of an unconstrained prosthesis.

We report the results of a series of 59 unconstrained total arthroplasties of the elbow after a mean follow-up of 6.5 years (4 to 10). All the patients had rheumatoid arthritis. The indication for surgery was pain in all but one. Outcome was assessed by the Mayo Elbow Performance Index (MEPI). Of the 59 arthroplasties, two were lost to follow-up. Ten patients died, but as two of their arthroplasties were failures we included them in the results. The outcome in the remaining 49 was excellent in 26 (53%), good in 15 (31%), fair in one (2%) and poor or a failure in seven (14%). There was an improvement in the pain score (p < 0.001), movement (p < 0.001) and function (p < 0.001). Two patients developed instability, but neither required further surgery. There was a mean increase of 21 degrees in flexion and of 7 degrees in extension. The overall rate of complications was 33.9%. Lesions of the ulnar nerve, one of which did not recover, occurred in four patients, deep infection in two and stiffness in five. The rates of complications were similar to those in recent reports of other elbow arthroplasties. We carried out a radiological analysis of 39 arthroplasties which showed radiolucent lines around the humeral component in 22 and the ulnar component in 15. There were lower scores on the MEPI for those with radiolucent lines around the humeral component.

Arthroplasty, Replacement↗
PubMed2002

A prospective randomised trial of internal fixation versus arthroplasty for displaced fractures of the neck of the femur. Functional outcome for 450 patients at two years.

It remains a matter of debate whether displaced fractures of the neck of the femur should be treated by internal fixation or arthroplasty. We have compared the two methods with regard to complications, mortality and functional outcome. We studied 409 patients, aged 70 years and over, with subcapital fractures graded as Garden 3 or 4, in a two-year prospective multicentre study from 12 Swedish hospitals. They were randomised to internal fixation or arthroplasty. Patients who were mentally confused, bedridden or in a nursing-home were excluded from the survey. After two years the rate of failure was 43% in the internal fixation (IF) and 6% in the arthroplasty group (p < 0.001). In the IF group 36% had impaired walking and 6% had severe pain compared with 25% and 1.5%, respectively, in the arthroplasty group (both p < 0.05). There was no difference in mortality. With a high rate of failure and poor functional outcome after IF, we recommend primary arthroplasty for displaced fractures of the neck of the femur in patients over 70 years of age.

Aged↗
PubMed2004

Utilisation of shoulder arthroplasty in the UK.

AIMS: To estimate the per capita utilisation of shoulder prostheses in the UK and to compare UK figures to those from the US. METHODS: A postal and telephone survey was undertaken of all hospitals in the UK carrying out orthopaedic operations. The relative usage of total shoulder replacement and hemi-arthroplasty for both elective and trauma indications were analysed and UK figures compared to those from the US. RESULTS: There were 281 replies from 314 questionnaires, a response rate of 90%. The per capita rate of shoulder replacement is approximately one-tenth for total replacement and one-fifth for hemiarthroplasty compared to the US, suggesting that there is an unmet demand in the UK. In the US, the proportion of total replacements to hemi-arthroplasties for elective indications is approximately equal whereas in the UK there are twice as many hemi-arthroplasties, which raises the question as to whether hemi-arthroplasties are being used when a total replacement might be preferable. The numbers of shoulder arthroplasties implanted by individual surgeons and units is, except for a few large centres, small. Consequently, it is much more difficult for the surgeon to evaluate the various prosthetic designs and surgical techniques. CONCLUSION: There is a need for a national register to increase the knowledge about such designs and techniques and to analyse risk factors.

Arthroplasty, Replacement↗
PubMedDate not supplied

Urinary retention and the role of indwelling catheterization following total knee arthroplasty.

INTRODUCTION: We aimed to investigate the rate of urinary retention after knee arthroplasty, the various factors involved in predicting those at risk for retention and to assess the impact of retention and catheterization on joint sepsis. MATERIALS AND METHODS: A retrospective review was conducted of all available case notes of patients undergoing total knee arthroplasty in a consecutive 2-year period (2000-2002). Adequate data was available for 142 patients. RESULTS: 142 patients underwent total knee arthroplasty. 19 patients were catheterized preoperatively for monitoring urine output. 123 patients were not catheterized. Urinary retention occurred in 19.7% (28/142). The mean day of catheterization for retention was 0.66. The mean duration of catheterization in patients developing retention was 3.58 days and was 3 days in the patients catheterized pre- or perioperatively. Deep joint sepsis occurred in 2.1% (3/142)--only one had been catheterized and that was preoperatively. No case of infection had urinary retention or had a symptomatic urinary tract infection. The only factors predicting those at significant risk of retention following knee arthroplasty was a past medical history of urinary retention (p = 0.049) and postoperative morphine requirement (p = 0.035). No patients required urological surgical intervention at mean follow up of 1.97 years. CONCLUSIONS: This study supports the use of indwelling urinary catheterization for patients developing urinary retention after total knee arthroplasty.

Aged↗
PubMed1999

Total knee arthroplasty with retention of both cruciate ligaments. A nine to eleven-year follow-up study.

BACKGROUND: Although many early designs of total knee arthroplasty allowed the retention of both cruciate ligaments, in most current designs of knee replacement systems, either both cruciate ligaments are removed or the posterior cruciate ligament alone is retained. This report is a review of a series of total knee arthroplasties in which both cruciate ligaments were retained. METHODS: The results of 163 total knee arthroplasties (130 patients) in which both cruciate ligaments were retained were assessed prospectively. One hundred and seven knees (eighty-nine patients) were followed for an average of ten years. There were thirty-four men and ninety-six women, and the average age at the time of the index arthroplasty was sixty-seven years (range, forty-two to eighty-four years). The diagnosis was osteoarthritis in 122 (75 percent) of the knees and rheumatoid arthritis in forty-one (25 percent). Twenty-six knees had a valgus deformity, 109 had a varus deformity, and twenty-eight had a normal alignment of 5 to 10 degrees of valgus. The anterior cruciate ligament was relatively normal in ninety-six knees and was partly degenerated in sixty-seven knees. With use of the rating system of the Knee Society, all 163 knees were prospectively evaluated at yearly intervals; fifty-six of these knees (in forty-one patients) were followed in this manner until the patient died or was lost to follow-up. RESULTS: One hundred and four (97 percent) of the 107 knees available for study at an average of ten years had an excellent or good result. At the time of the latest follow-up, pain was adequately relieved in ninety-seven knees (91 percent) and the average range of flexion was 107+/-12.6 degrees (range, 65 to 135 degrees). Ninety-five knees (89 percent) had normal anteroposterior stability (less than five millimeters of movement in this plane), and twelve knees (11 percent) had five to ten millimeters of movement as demonstrated by the drawer sign. Ninety-six knees (90 percent) had normal mediolateral stability, and eleven (10 percent) had 5 to 10 degrees of laxity. Ninety-four knees (88 percent) had valgus alignment of 5 to 10 degrees. The average knee score was 91+/-8.4 points (range, 54 to 100 points), and the average functional score was 82+/-21 (range, 10 to 100 points). The survival rate at ten years, with revision as the end point, was 95+/-2.0 percent. Seven (4 percent) of the 163 knees in this series were revised. There were no revisions for patellar problems or aseptic loosening of the tibial component. CONCLUSIONS: The good anteroposterior stability in this series after an average follow-up period of ten years indicates that both the anterior and the posterior cruciate ligaments, even when partly degenerated, remain functional when they are preserved in a total knee arthroplasty.

Aged↗
PubMed1999

The use of heparin in patients in whom a pulmonary embolism is suspected after total hip arthroplasty.

BACKGROUND: The morbidity and mortality associated with pulmonary embolism are well known, as is the benefit of the use of heparin in patients who have a pulmonary embolism. However, the patterns of heparin use as well as its undesirable effects, especially in patients who have recently had a total hip arthroplasty, have been less well studied. Thus, concern arises regarding the use of heparin in patients who have no firm evidence of a pulmonary embolism. The purpose of the current study was to track the use of heparin and associated orthopaedic complications in patients in whom a pulmonary embolism was suspected after a total hip arthroplasty. METHODS: The records of 150 patients in whom a pulmonary embolism had been suspected after a total hip arthroplasty were reviewed retrospectively. The rates of individual complications (such as stroke, infection, and hematoma) and those of groups of complications (such as medical complications, orthopaedic complications, and all complications combined) were recorded and then were stratified according to the treatment (with or without heparin), the presence or absence of pulmonary embolism, and other variables. RESULTS: Thirty-two (47 percent) of sixty-eight patients who were managed with heparin had complications compared with sixteen (20 percent) of eighty-two patients who were not thus managed (p = 0.0006). Specifically, patients who were managed with heparin were more likely to have gastrointestinal bleeding, hematological complications, a loose prosthesis, a hematoma, or an early revision arthroplasty (p<0.05 for all). With the numbers available, the use of heparin was not found to be significantly associated with an increased risk of death, stroke, or infection at the site of the prosthesis. Interestingly, thirty-one (31 percent) of ninety-nine patients who had ventilation-perfusion scans that demonstrated normal findings or findings indicating a low probability of pulmonary embolism were given heparin before the diagnosis of a pulmonary embolism was excluded, and sixteen (52 percent) of these thirty-one had complications. CONCLUSIONS: Given this risk profile, we advise against the use of heparin before the diagnosis of pulmonary embolism is established in patients who have had a total hip arthroplasty. This recommendation is supported by algorithms, in widely read medical texts, pertaining to the use of heparin in patients in whom a pulmonary embolism is suspected.

Adult↗