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PubMed2000

Simultaneous femoral osteotomy and total knee arthroplasty for treatment of osteoarthritis associated with severe extra-articular deformity.

BACKGROUND: In the presence of large extra-articular deformity, complex imbalance of the collateral ligaments may result if standard techniques of soft-tissue releases and intra-articular bone resection are used during total knee arthroplasty. The purpose of this paper is to review our experience with simultaneous corrective osteotomy and total knee arthroplasty for the treatment of severe extra-articular femoral deformity associated with ipsilateral osteoarthritis of the knee. METHODS: The results of simultaneous corrective osteotomy and total knee arthroplasty in eleven knees with osteoarthritis and associated extra-articular angular deformity of the femur were reviewed retrospectively. The femoral deformity resulted from fracture malunion in ten knees and from hypophosphatemic rickets in one. There were five primarily uniplanar deformities (four varus deformities and one antecurvatum deformity), five biplanar (varus and antecurvatum) deformities, and one triplanar (varus, antecurvatum, and internal rotation) deformity. Four knees were approached through a standard medial parapatellar arthrotomy and seven, through an anterolateral subvastus approach with an osteotomy of the tibial tubercle. The site of the femoral osteotomy was fixed with a blade-plate in seven patients, a press-fit long-stemmed femoral component in two, and a retrograde femoral nail in two. An extramedullary alignment system was utilized in eight patients, and intramedullary alignment was used in three. RESULTS: The duration of follow-up averaged forty-six months (range, twenty-six to eighty-eight months). According to the classification system of the Knee Society, the mean function score increased from 22 points preoperatively to 81 points at the time of follow-up and the mean knee score increased from 10 points preoperatively to 87 points at the time of follow-up. The mean flexion contracture decreased from 19 degrees preoperatively to 2 degrees at the time of follow-up. The arc of motion averaged 56 degrees (range, 30 to 75 degrees) preoperatively and 89 degrees (range, 65 to 115 degrees) at the time of follow-up. The mechanical alignment in the coronal plane was restored to within 2 degrees of normal in each patient. Ten femoral osteotomy sites healed, and one, in a patient treated with a press-fit long-stemmed femoral component, had not healed by the time of follow-up. All seven sites of the tibial tubercle osteotomies healed. There were no complete radiolucent lines at the prosthetic interfaces, and no total knee arthroplasty was revised. One patient had a nonfatal postoperative pulmonary embolism. As determined by clinical examination and the patients' assessment of function, no ligament imbalance was noted at the time of the most recent follow-up. CONCLUSIONS: Simultaneous femoral osteotomy and total knee arthroplasty is a technically difficult but effective treatment for patients with severe femoral deformity associated with ipsilateral osteoarthritis of the knee. We recommend that the femoral osteotomy site be secured with a plate or a locked intramedullary nail, depending on the location of the deformity and the subsequent osteotomy.

Adult↗
PubMed2001

Proximal femoral allografts for reconstruction of bone stock in revision arthroplasty of the hip. A nine to fifteen-year follow-up.

BACKGROUND: Revision of a femoral component in a patient who has severe bone loss is a complex problem that is likely to increase with the increasing numbers of patients who have multiple revision hip arthroplasties. A valuable option in such a situation is use of a long-stem prosthesis that is cemented to a proximal femoral allograft but not to the host bone. METHODS: Between April 1984 and December 1989, sixty-three total hip arthroplasties in sixty consecutive patients were revised with a proximal femoral allograft-prosthesis construct. The average length of the allograft was 15 cm. The average age of the patients at the time of the revision was 62.5 years. All patients had undergone at least one previous total hip arthroplasty, and an average of 3.8 previous total hip arthroplasties had been performed in the series. Each patient was assigned a modified Harris hip score. Radiographs were examined for trochanteric union, allograft-host union, endosteal and periosteal resorption, component loosening, and fracture. RESULTS: At an average of eleven years (range, nine years and four months to fifteen years) after the revision, forty-five patients were alive, fourteen patients had died, and one patient had been lost to follow-up. The patients who had died or had been lost to follow-up had had a total of fifteen allografts (24%) and had been followed for an average of five years and seven months (range, two years and four months to eight years). The average preoperative Harris hip score for the sixty-three hips was 30 points (range, 6 to 65 points). At the latest follow-up evaluation, the average score for the hips with the original graft in situ was 71 points (range, 47 to 95 points). Five hips failed because of infection, and four of them were successfully revised. Three hips failed because of aseptic loosening, at an average of ten years and three months; two were successfully revised, and the third was awaiting revision at the time of writing. An additional operation was performed in three hips with allograft-host nonunion and in two with dislocation. Success was defined as a postoperative increase in the Harris hip score of greater than 20 points, a stable implant, and no need for additional surgery related to the allograft at the time of the review. The success rate for all hips was 78% (forty-nine of sixty-three) after an average of nine years of follow-up. The success rate for the patients who were alive at the time of follow-up was 77% (thirty-seven of forty-eight hips) after an average of eleven years of follow-up. CONCLUSIONS: The clinical and radiographic results at an average of eleven years after revision hip arthroplasty with a proximal femoral allograft are encouraging. This report represents our early experience; improvements in the technique have been made. We believe that this technique provides a viable option for treatment of the difficult problem of severe femoral bone loss.

Adult↗
PubMed2001

Pitfalls of using patient recall to derive preoperative status in outcome studies of total knee arthroplasty.

BACKGROUND: It is essential to adjust for the level of preoperative pain and functional status when measuring the outcome of total knee arthroplasty. Some study designs rely on postoperative patient recall to derive preoperative status. In this study, we compared prospectively collected preoperative data with data derived from patient recall of preoperative status three months after total knee arthroplasty. METHODS: Patients were recruited as part of a prospective observational study of the outcome of primary total knee arthroplasty for osteoarthritis at four centers in the United States, six centers in the United Kingdom, and two centers in Australia. Independent research assistants recruited patients and collected data with use of a uniform documentation system preoperatively and three months postoperatively. Preoperative data included the findings of a clinical history and physical examination, demographic information, socioeconomic status, and scores from two health-status instruments: the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and the Medical Outcomes Study Short Form-36 Health Survey (SF-36). Postoperative data included the WOMAC and SF-36 scores and patient recall of preoperative status on selected items from these health-status measures. RESULTS: A total of 862 patients were recruited, and recall data were available for 770 patients (89%). The mean age was seventy years (range, thirty-eight to ninety years), and 59% of the patients were women. Comparisons of prospective and recall data on individual pain and function items showed poor-to-fair agreement (weighted kappa, 0.20 to 0.41). Patients recalled significantly more pain than they had reported preoperatively (p < 0.001), but there were random recollection errors for the function items. There was only moderate correlation between the prospective and recalled summary scores for pain (Spearman r = 0.53) and function (Spearman r = 0.48). In addition, 61% of the recalled pain scores and 50% of the recalled function scores differed from the prospective scores by more than 10 points (10% of the total range). CONCLUSIONS: Patients' recall of preoperative pain and functional status three months after total knee arthroplasty demonstrated only moderate agreement with what the patients had reported prospectively. Researchers who use recall data to derive preoperative status must recognize these limitations when drawing conclusions about the effectiveness of total knee arthroplasty.

Activities of Daily Living↗
PubMed2001

Total knee arthroplasty in patients with ankylosing spondylitis.

BACKGROUND: Ankylosing spondylitis is a seronegative spondyloarthropathy that primarily affects the sacroiliac joints, spine, hips, and, less commonly, the knee joints. The purpose of this study was to evaluate the results in a consecutive group of patients with ankylosing spondylitis who underwent total knee arthroplasty. METHODS: The results of thirty total knee arthroplasties in twenty patients with ankylosing spondylitis were reviewed. There were seventeen men and three women, with an average age of fifty-five years (range, twenty-eight to sixty-seven years) at the time of the arthroplasty. The diagnosis of ankylosing spondylitis was established preoperatively with use of the New York criteria. All patients received a cemented condylar-type implant. The average duration of follow-up was 11.2 years (range, three to sixteen years). RESULTS: The average Knee Society pain score improved from 14 points preoperatively to 76.3 points at the time of the latest follow-up. The improvement in the average Knee Society function score was less impressive, with an increase from 16.3 points preoperatively to 58.7 points at the time of the latest follow-up. The average arc of motion was 84.8 degrees prior to the arthroplasty and 86.7 degrees at the time of the final follow-up. Six knees (20%) had heterotopic bone formation. Three knees required manipulation under anesthesia because of poor motion postoperatively. There was one revision, due to loosening of a patellar component. All other components were radiographically stable at the time of the latest follow-up. CONCLUSIONS: Total knee arthroplasty with cement in patients with ankylosing spondylitis provided excellent pain relief and durable fixation at an average of 11.2 years postoperatively. However, patients with ankylosing spondylitis are at increased risk for the development of stiffness and heterotopic bone formation.

Adult↗
PubMed2001

Second-generation cementless total hip arthroplasty. Eight to eleven-year results.

BACKGROUND: Second-generation cementless femoral components were designed to provide more reliable ingrowth and to limit distal osteolysis by incorporating circumferential proximal ingrowth surfaces. We examined the eight to eleven-year results of total hip arthroplasty with a cementless, anatomically designed femoral component and a cementless hemispheric acetabular component. METHODS: Ninety-two consecutive primary total hip arthroplasties with implantation of a femoral component with a circumferential proximal porous coating (Anatomic Hip) and a cementless hemispheric porous-coated acetabular component (Harris-Galante II) were performed in eighty-five patients. These patients were prospectively followed clinically and radiographically. Six patients (seven hips) died and five patients (seven hips) were lost to follow-up, leaving seventy-four patients (seventy-eight hips) who had been followed for a mean of ten years (range, eight to eleven years). The mean age at the time of the arthroplasty was fifty-two years. RESULTS: The mean preoperative Harris hip score of 51 points improved to 94 points at the time of final follow-up; 86% of the hips had a good or excellent result. Thigh pain was reported as mild to severe after seven hip arthroplasties. No femoral component was revised for any reason, and none were loose radiographically at the time of the last follow-up. Two hips underwent acetabular revision (one because of dislocation and one because of loosening). Kaplan-Meier survivorship analysis was performed with revision or loosening of any component as the end point. The ten-year survival rate was 96.4% +/- 2.1% for the total hip prosthesis, 100% for the femoral component, and 96.4% +/- 2.1% for the acetabular component. Radiolucencies adjacent to the nonporous portion of the femoral component were seen in sixty-eight (93%) of the -seventy-three hips with complete radiographic follow-up. Femoral osteolysis proximal to the lesser trochanter was noted in four hips (5%). No osteolysis was identified distal to the lesser trochanter. Periacetabular osteolysis was identified in twelve hips (16%). Five patients underwent exchange of the acetabular liner because of polyethylene wear. CONCLUSIONS: This second-generation cementless, anatomically designed femoral component provided excellent clinical and radiographic results with a 100% survival rate at ten years. The circumferential porous coating of this implant improved ingrowth and prevented distal osteolysis at a mean of ten years after the arthroplasty.

Acetabulum↗
PubMed2002

Comparison of patient and doctor responses to a total hip arthroplasty clinical evaluation questionnaire.

BACKGROUND: Surgeons traditionally undertake a prospective evaluation of patients undergoing total hip arthroplasty in order to determine outcomes. The validity of doctor-derived data is questionable because of the potential for interobserver error, reporting bias, and differences between the perceptions of doctors and patients. Also, the use of doctor-derived data necessitates the use of costly outpatient services. Consequently, there are likely to be benefits associated with the use of patient-derived clinical evaluation data. However, few studies have focused on whether data obtained from the patient and doctor differ. METHODS: The agreement between patient and doctor responses on a sixteen-item total hip arthroplasty clinical evaluation questionnaire completed at more than 2900 clinical assessments was determined. Data from repeated assessments performed preoperatively and postoperatively enabled stratified analyses that were used to examine reasons for disagreement and factors influencing agreement. Agreement was measured with use of the kappa coefficient. RESULTS: For twelve of the sixteen items, the patient responses had acceptable agreement with the doctor responses. Some important differences between patient-derived and doctor-derived data were found. If the patient had other joint or health problems, had a revision total hip arthroplasty, or reported mild or moderate pain, there was a greater chance of reduced agreement on the pain items. Younger patients demonstrated better agreement with doctors than older patients did. CONCLUSIONS: Patients' perceptions of symptoms and outcomes after total hip arthroplasty are relatively similar to those of their doctor. There is minimum risk of misinterpreting outcomes data by replacing doctor-completed questionnaires with patient-completed questionnaires in uncomplicated total hip arthroplasty cases. For patients with comorbid joint problems or other health problems, and for those reporting substantial pain, direct physician involvement in the evaluation of pain is recommended. The selective use of patient-completed questionnaires has the potential to substantially reduce the costs of outcomes evaluation programs by minimizing doctor input. Pending revision of some of the items, the use of this patient-completed questionnaire is advocated.

Age Distribution↗
PubMed2002

Late dislocation after total hip arthroplasty.

BACKGROUND: Some patients have a dislocation for the first time many years after a total hip arthroplasty, but little is known about the risk factors and outcomes associated with late dislocation. The purposes of this study were (1) to determine the prevalence of late dislocation after total hip arthroplasty, (2) to characterize demographic and other factors associated with such late dislocations, and (3) to report the outcomes of such late dislocations. METHODS: Between 1969 and 1995, 19,680 primary total hip arthroplasties were performed in 15,964 patients at our institution. According to a prospective surveillance protocol, the patients were followed routinely at regular intervals and were specifically queried at each time-point about whether (and, if so, when) the hip had dislocated. First dislocations that occurred five years or more after the operation were defined as late dislocations. RESULTS: Five hundred and thirteen (2.6%) of the 19,680 hips dislocated. Of the 513 hips, 165 (0.8% of the entire cohort; 32% of the dislocated hips) first dislocated five or more years after the primary arthroplasty. The median time until the occurrence of these late dislocations was 11.3 years (range, five to 24.9 years) after the operation. Late dislocation was more frequent than early dislocation in women (p = 0.03), and late dislocation was associated with a younger age at the time of the primary total hip arthroplasty (median, sixty-three years) than was early dislocation (median, sixty-seven years) (p = 0.02). Clinical factors associated with late dislocation included previous subluxations without dislocation in twenty patients, a substantial episode of trauma in eleven patients, and onset of marked cognitive or motor neurologic impairment in eleven patients. Radiographically, the late dislocation occurred in association with polyethylene wear of >2 mm in eighteen hips, with implant loosening with migration or a change in position in eight, and with initial malposition of the acetabular implant (anteversion of <0 degrees or >30 degrees or abduction of >55 degrees) in thirty. Late dislocation recurred in ninety (55%) of the 165 hips and was treated with a reoperation in fifty-five hips (33% of the hips with late dislocation; 61% of the hips with recurrent dislocation). CONCLUSIONS: Late dislocation is more common than was previously thought. Several separate processes, some distinct from those associated with early dislocation, can lead to late dislocation. Late dislocation can occur in association with a long-standing problem with the prosthesis that manifests late (such as malposition of the implant or recurrent subluxation), it can occur in association with a new problem (such as neurologic decline, an episode of trauma, or polyethylene wear), or it can occur in association with any combination of these factors. The likelihood of the first late dislocation recurring is high.

Adolescent↗
PubMed2003

Total knee arthroplasty in patients with a prior fracture of the tibial plateau.

BACKGROUND: A fracture of the tibial plateau may predispose the knee to the development of posttraumatic arthritis. Malunion, intra-articular chondro-osseous defects, limb malalignment, retained internal fixation devices, and poor surrounding soft tissues may in turn compromise the outcome of total knee arthroplasty. The aim of our study was to evaluate the results of total knee arthroplasty in patients with a previous fracture of the tibial plateau. METHODS: The results of sixty-two condylar total knee arthroplasties performed with cement, from 1988 to 1999, in sixty-two patients with a previous fracture of the tibial plateau were reviewed. The fracture of the tibial plateau had been treated by open reduction and internal fixation in thirty-eight knees, external fixation in one knee, and nonoperatively in twenty-three knees. There were forty women and twenty-two men with an average age of sixty-three years at the time of the arthroplasty. Knee Society scores were recorded preoperatively and at the time of follow-up, at an average of 4.7 years, and complications were noted. No patient was lost to follow-up. RESULTS: The mean Knee Society scores improved significantly (p < 0.0001), from 43.9 points for pain and 52 points for function preoperatively to 82.9 and 84 points, respectively, at the time of the latest follow-up. There were thirteen reoperations, which included manipulation with the patient under anesthesia (five knees), wound revision (three knees), and component revision (five knees). There were six intraoperative complications (10%). A postoperative complication occurred in sixteen knees (26%). CONCLUSIONS: The vast majority of patients treated with total knee arthroplasty after a previous fracture of the tibial plateau have substantial improvement in function and relief of pain. However, these patients are at increased risk for perioperative complications, as evidenced by the high reoperation rate of 21% in this study.

Adult↗
PubMed2003

Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis.

BACKGROUND: The results of shoulder arthroplasty for osteoarthritis have been reported to be excellent or good for the majority of patients, but the value of using a glenoid component and the anatomic factors that affect outcome are still debated. The purpose of this study was to evaluate the influence of an operatively confirmed full-thickness tear of the rotator cuff, the severity of preoperative erosion of glenoid bone, preoperative radiographic evidence of subluxation of the humeral head, and the severity of preoperative loss of the passive range of motion on the outcome of total shoulder arthroplasty and hemiarthroplasty. METHODS: In a multicenter clinical outcome study, we evaluated 128 shoulders in 118 patients with primary osteoarthritis who had been followed for a mean of forty-six months (range, twenty-four to eighty-seven months). RESULTS: Patients with <10 degrees of passive external rotation preoperatively had significantly less improvement in external rotation after hemiarthroplasty (p = 0.006). Thirteen (10%) of the 128 shoulders had a repairable full-thickness tear of the supraspinatus tendon, but these tears did not affect the overall American Shoulder and Elbow Surgeons score, the decrease in pain, or patient satisfaction. Severe or moderate eccentric glenoid erosion was seen in twenty-nine (23%) of the 128 shoulders, and total shoulder arthroplasty resulted in significantly better passive total elevation and active external rotation as well as a trend toward significantly better active forward flexion than did hemiarthroplasty in these shoulders. The humeral head was subluxated posteriorly in twenty-three shoulders (18%), and when they were compared with the other shoulders in the study, these shoulders were found to have lower final American Shoulder and Elbow Surgeons scores, more pain, and decreased active external rotation following either total shoulder arthroplasty or hemiarthroplasty. CONCLUSIONS: On the basis of our data, we recommend the use of a glenoid component in shoulders with glenoid erosion. Humeral head subluxation was associated with a less favorable result regardless of the type of shoulder arthroplasty and must be considered in preoperative planning and counseling. Severe loss of the passive range of motion preoperatively was associated with a decreased passive range of motion postoperatively. A repairable tear of the supraspinatus tendon is not a contraindication to the use of a glenoid component. .

Adult↗
PubMed2003

Mortality following primary total knee arthroplasty.

BACKGROUND: Total joint arthroplasty is one of the most successful orthopaedic surgical procedures. However, it carries a risk of perioperative mortality. The purpose of this study was to determine the mortality rate for patients undergoing primary total knee arthroplasty in a private-practice setting involving one surgeon in a nonteaching institution. METHODS: We analyzed 3048 consecutive primary total knee arthroplasties, performed between July 1976 and December 1996, with respect to mortality data (deaths that occurred intraoperatively, during hospitalization, and within ninety days after surgery) and comorbidities (major cardiovascular disease). RESULTS: The mortality rate was 0.46% (fourteen patients; one death per 217 procedures) within ninety days after primary total knee arthroplasty. CONCLUSIONS: Increasing patient age and the presence of associated cardiovascular comorbidities were identified as risk factors for mortality. This information, we believe, is useful to patients, their families, physicians, and health-care planners in deciding when a total knee arthroplasty is appropriate. LEVEL OF EVIDENCE: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

Age Factors↗
PubMed2003

Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures.

BACKGROUND: Failed treatment of an intertrochanteric fracture typically leads to profound functional disability and pain. Treatment with repeated attempts to gain union and to preserve the host femoral head usually is preferred for young patients, but salvage treatment with hip arthroplasty may be considered for selected older patients with poor bone quality, bone loss, or articular cartilage damage. The purpose of the present study was to evaluate the results and complications of hip arthroplasty performed as a salvage procedure after the failed treatment of an intertrochanteric hip fracture. METHODS: Between 1985 and 1997, sixty patients (forty-nine women and eleven men) with a mean age of seventy-eight years were treated at our institution with hip arthroplasty after the failed treatment of an intertrochanteric fracture. Thirty-two patients had a total hip arthroplasty with a cemented cup (twenty-four patients) or an uncemented cup (eight patients), twenty-seven had a bipolar hemiarthroplasty, and one had a unipolar hemiarthroplasty. A calcar-replacement design, extended-neck stem, or long-stem implant was used in fifty-one of the sixty hips. RESULTS: Ten patients died within two years (all with the implant intact), and six were lost to follow-up. The remaining forty-four patients were followed for a mean of five years (range, two to fifteen years). At the time of the last follow-up, thirty-nine patients had no or mild pain and five had moderate or severe pain; in all of these patients, the pain was in the region of the greater trochanter. Forty patients were able to walk, twenty-six with one-arm support or less. Twelve patients had a total of thirteen medical complications postoperatively. A total of five reoperations were performed: two patients had a revision, one had a rewiring procedure because of trochanteric avulsion, one had late removal of trochanteric hardware, and one had débridement of fat necrosis. One patient had two dislocations, both of which were treated with closed reduction. Kaplan-Meier survivorship analysis with revision of the implant for any reason as the end point revealed a survival rate of 100% at seven years and 87.5% (95% confidence interval, 67.3% to 100%) at ten years. CONCLUSIONS: Hip arthroplasty is an effective salvage procedure after the failed treatment of an intertrochanteric fracture in an older patient. Most patients have good pain relief and functional improvement. Calcar-replacement and long-stem implants often are required. Despite the operative challenges, surprisingly few serious orthopaedic complications were associated with this procedure in the present study.

Aged↗
PubMed2003

Total knee arthroplasty in young patients with juvenile rheumatoid arthritis.

BACKGROUND: Juvenile rheumatoid arthritis is a disabling and destructive condition that commonly affects the knee during childhood. Total knee arthroplasty occasionally may be necessary for the treatment of end-stage disabling arthritis of the knee in young patients. There is a paucity of available data on the results of total knee arthroplasty in adolescents. We report our experience with total knee arthroplasty in patients under the age of twenty years who had juvenile rheumatoid arthritis. MATERIALS AND METHODS: We reviewed the results of twenty-five consecutive total knee arthroplasties that had been performed at our institution between 1982 to 1997 in thirteen patients (mean age, seventeen years) with juvenile rheumatoid arthritis. The average duration of clinical follow-up was 10.7 years, and the average duration of radiographic follow-up was 6.5 years. RESULTS: The mean Knee Society pain score improved markedly from 27.6 to 88.3 points, and the mean Knee Society function score improved modestly from 14.8 to 39.2 points. There was a slight improvement in the range of motion. Symptomatic and progressive radiolucent lines were noted in two knees, one of which was revised. Two knees (one patient) required exchange of the polyethylene liner at thirteen years. There were four additional reoperations, including manipulation under general anesthesia (two knees in one patient), lysis of adhesions (one knee), and extensor mechanism realignment (one knee). CONCLUSIONS: Despite a substantial number of postoperative complications, total knee arthroplasty provided excellent relief of pain and improvement in function in this group of adolescent patients with juvenile rheumatoid arthritis.

Adolescent↗
PubMed2003

Provider Volume of Total Knee Arthroplasties and Patient Outcomes in the HCUP-Nationwide Inpatient Sample.

BACKGROUND: The relationship between volume and outcome of total knee arthroplasties has never been evaluated in a nationally representative sample, to our knowledge. We hypothesized that surgeons and hospitals with higher patient volumes would have better outcomes, as defined by lower mortality rates, shorter hospital stays, and lower postoperative complication rates. METHODS: The 1997 Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample, Release 6, provided discharge abstracts of patients undergoing total knee arthroplasty from a national stratified probability sample. Logistic and multiple regression models were used to estimate the adjusted association of surgeon or hospital volume with rates of in-hospital mortality, pulmonary thromboembolism, deep venous thrombosis in the lower extremity, and postoperative wound infection as well as length of hospital stay. Estimates were calculated for a target population of 277,550 patients. Models were adjusted for comorbidity, age, gender, race, household income, and procedure (primary or revision arthroplasty). RESULTS: The patients were mostly white (70.2%) and female (62.7%), with a mean age of 68.9 years. The overall in-hospital mortality rate for the target population was 0.2%, and the average length of stay was 4.6 days for the primary total knee arthroplasties and 4.9 days for the revision procedures. Surgeon volumes of at least fifteen procedures per year and hospital volumes of at least eighty-five per year were significantly and linearly associated with lower mortality rates (odds ratio = 0.56 [0.24 to 1.31] for surgeon volume of > or = 60). No other association demonstrated a significant and directionally consistent linear trend for improved outcomes. CONCLUSION: Patients treated by providers with lower caseload volumes had higher rates of mortality following total knee arthroplasty in 1997. Proposing volume standards could decrease patient mortality following this procedure.

Aged↗
PubMed2003

Metacarpophalangeal joint arthroplasty in rheumatoid arthritis. A long-term assessment.

BACKGROUND: The long-term results of silicone metacarpophalangeal arthroplasty in patients with rheumatoid arthritis are uncertain. The purpose of this investigation was to evaluate the subjective, objective, and radiographic outcomes at the time of long-term follow-up. METHODS: Patients with rheumatoid arthritis who underwent simultaneous silicone metacarpophalangeal joint arthroplasties of all four fingers by one surgeon were eligible for inclusion in the study. The results of a total of 208 arthroplasties in fifty-two hands of thirty-six patients were evaluated at an average of fourteen years postoperatively. Active metacarpophalangeal joint motion, ulnar drift, and radiographs were assessed. The radiographs were reviewed for changes in bone length, erosions, and implant fractures. The Michigan Hand Outcomes Questionnaire (MHQ) was administered to the patients. RESULTS: The mean arc of motion of the metacarpophalangeal joints improved from 30 degrees preoperatively to 46 degrees immediately after the surgery but decreased to 36 degrees at the time of final follow-up. The mean extension deficit of the metacarpophalangeal joints improved from 57 degrees preoperatively to 11 degrees immediately after the surgery but worsened to 23 degrees at the time of final follow-up. The mean ulnar drift improved from 26 degrees preoperatively to <5 degrees in the immediate postoperative period and then recurred to an average of 16 degrees at the time of final follow-up. Implant fractures were associated with increased ulnar drift (p < 0.001). Bone reaction adjacent to the implant was demonstrated by bone-shortening in most patients and by erosions in 29% of the patients. One hundred and thirty implants (63%) were broken and forty-five (22%) more were deformed at the time of final follow-up. The MHQ score averaged 48 of 100 points. The patients expressed satisfaction with the function of only 38% of the hands, and only 27% of the hands were pain-free at the time of final follow-up. A greater degree of ulnar drift was associated with decreased patient satisfaction and a decreased score for the cosmetic appearance (p </= 0.01). CONCLUSIONS: The outcome after silicone metacarpophalangeal joint arthroplasty in patients with rheumatoid arthritis worsens with long-term follow-up. Given these findings, the indications for and long-term expectations of silicone metacarpophalangeal arthroplasty must be carefully examined in light of the improvements in the medical management of rheumatoid disease.

Adult↗
PubMed2003

Unicompartmental knee arthroplasty in patients sixty years of age or younger.

BACKGROUND: Unicompartmental knee arthroplasty has been used to treat elderly, low-demand patients, but the literature is sparse regarding the use of this procedure for younger, active patients. The purpose of the present retrospective study was to evaluate the results of unicompartmental knee arthroplasty in younger, more active patients. METHODS: Forty-one patients underwent forty-six consecutive unicompartmental knee arthroplasties with use of the Miller-Galante system between 1988 and 1996. All of the patients were sixty years of age or younger and all were physically active. The Hospital for Special Surgery knee score and the University of California at Los Angeles activity assessment were used to rate the function and to determine the activity level of each patient, respectively. Serial radiographs were used to evaluate the status of prosthetic fixation, femorotibial alignment, and the progression of arthrosis in the unreplaced compartment. Long-term survivorship was calculated with use of Kaplan-Meier analysis. RESULTS: The mean duration of follow-up was eleven years. Of the forty-five knees that were available for follow-up, three had been revised. The Hospital for Special Surgery score was excellent for thirty-nine (93%) of the remaining forty-two knees and good for three. The University of California at Los Angeles activity assessment score was 6.6 +/- 1.4 for the knees in which the original prosthesis had been retained and 7.3 +/- 1.5 for those in which it had been revised. Two asymptomatic patients had revision of a modular tibial component because of substantial radiographic evidence of polyethylene wear; one of these patients had exchange of the polyethylene insert and the tibial tray, and the other had exchange of the polyethylene insert only. A third patient underwent revision total knee arthroplasty because of continuing knee pain and a progressive tibial radiolucent line that was >2 mm in width. The average postoperative femorotibial alignment was 5 degrees of valgus. Nine knees had progression of arthritis in the unresurfaced compartment; none of these knees were revised, and none of the patients had deterioration in the Hospital for Special Surgery score. Kaplan-Meier analysis demonstrated an eleven-year survivorship of 92%. CONCLUSIONS: At an average duration of follow-up of eleven years, unicompartmental knee arthroplasty was associated with pain relief and excellent function in a cohort of patients who had been sixty years of age or younger and active at the time of surgery.

Adult↗
PubMed2003

The effect of alendronate on bone mineral density in the distal part of the femur and proximal part of the tibia after total knee arthroplasty.

BACKGROUND: Bone mineral density around the knee is related to the mechanical properties of bone. Alendronate has been shown to be effective for the treatment of osteoporosis and for reducing the rate of osteoporotic fractures. The purpose of the present study was to investigate the effect of alendronate on bone mineral density in the distal part of the femur and proximal part of the tibia after total knee arthroplasty in women. METHODS: Ninety-six women with an average age of seventy years who were undergoing total knee arthroplasty were randomly divided into two groups. Patients in the study group received oral alendronate at a dose of 10 mg/day for six months, whereas patients in the control group did not. The bone mineral density in the distal part of the femur and proximal part of the tibia was determined preoperatively and at six and twelve months postoperatively. RESULTS: In the control group, the bone mineral density showed significant decreases of 13.8% (p < 0.001) and 7.8% (p = 0.003) in the distal part of the femur and of 6.5% (p = 0.002) and 3.6% (p = 0.141) in the proximal part of the tibia at six and twelve months, respectively. In the study group, however, the bone mineral density showed significant increases of 10.0% (p = 0.010) and 1.9% (p = 0.049) in the distal part of the femur and of 9.4% (p < 0.001) and 5.4% (p = 0.032) in the proximal part of the tibia at six and twelve months, respectively. The overall differences in bone mineral density between the study and control groups were significant (p = 0.011 for the proximal part of the tibia, and p = 0.033 for the distal part of the femur). CONCLUSIONS: We found significant postoperative decreases in bone mineral density in the distal part of the femur and proximal part of the tibia in women who had undergone total knee arthroplasty. Oral administration of alendronate for six months postoperatively significantly improved the bone mineral density. While the clinical benefits of alendronate after total knee arthroplasty remain unproven and the duration of follow-up in the present study was quite short, the improvement in bone mineral density may have a clinically important effect on prosthetic fixation and the rate of periprosthetic fractures after total knee arthroplasty.

Absorptiometry, Photon↗
PubMed2003

Extended trochanteric osteotomy in complex primary total hip arthroplasty. A brief note.

BACKGROUND: The extended trochanteric osteotomy has been a useful approach for patients undergoing revision total hip arthroplasty; however, it has not been well described as an approach for those undergoing complex primary total hip arthroplasty. The purpose of the present report is to describe our experience with the use of an extended trochanteric osteotomy for patients undergoing complex primary total hip arthroplasty. METHODS: Six patients underwent primary total hip arthroplasty with use of an extended trochanteric osteotomy. The reasons for the use of this technique included severe femoral deformity, removal of intraosseous hardware, and high-riding developmental hip dysplasia. A fully porous-coated femoral component with diaphyseal fixation was used for all reconstructions. The mean age of the patients at the time of surgery was fifty-six years. Clinical and radiographic evaluation was performed at a minimum of two years. RESULTS: After a mean duration of follow-up of fifty months, all patients had an osseointegrated, stable femoral component. The site of the extended trochanteric osteotomy healed in five of the six patients. One patient had nonunion at the osteotomy site and a fracture at the base of the greater trochanter, with a subsequent fracture of the femoral component. The mean Merle D'Aubigné and Postel pain and walking scores improved from 2.2 and 2.3 preoperatively to 5.3 and 4.7 at the time of the final follow-up (p < 0.001). CONCLUSIONS: The extended trochanteric osteotomy is useful for the correction of femoral deformity and facilitates the removal of intraosseous hardware in carefully selected patients undergoing complex primary total hip arthroplasty.

Adult↗
PubMed2004

Copeland surface replacement arthroplasty of the shoulder in rheumatoid arthritis.

BACKGROUND: Shoulder arthroplasty with a stemmed prosthesis is a recognized treatment for rheumatoid arthritis of the shoulder. The humeral component of the Copeland cementless surface replacement arthroplasty consists of a cup for surface replacement with a short central peg for primary fixation to the bone. We hypothesized that surface replacement may offer some advantages over stemmed prostheses. METHODS: Between 1986 and 1998, seventy-five shoulders underwent surface replacement arthroplasty (thirty-three hemiarthroplasties and forty-two total shoulder arthroplasties) for the treatment of rheumatoid arthritis. The results of these procedures were reviewed after an average duration of follow-up of 6.5 years. Patients were assessed with use of the Constant score, a patient satisfaction score, and radiographs. RESULTS: The average Constant score was 47.9 points (age and sex-adjusted score, 71%) in the hemiarthroplasty group and 53.4 points (age and sex-adjusted score, 76%) in the total shoulder replacement group. The mean range of active flexion improved from 50 degrees in the hemiarthroplasty group and 47 degrees in the total shoulder replacement group to 101 degrees and 104 degrees, respectively. Seventy-two of the seventy-five shoulders were considered by the patients to be much better or better at the time of the review. Of the sixty-eight humeral implants that were evaluated radiographically, fifty-six (82%) showed no lucencies, eleven (16%) showed localized lucencies of <1 mm in width, and one was definitely loose. Of the thirty-nine glenoid implants that were evaluated radiographically, nineteen (49%) showed no lucencies, nineteen showed localized lucencies of <1 mm, and one was definitely loose. No lucencies were observed adjacent to the hydroxyapatite-coated implants. Thirty-nine (57%) of the sixty-eight shoulders showed some degree of superior subluxation. Three patients required a major reoperation: two required a revision because of loosening of both components, and one patient with pain at the site of a hemiarthroplasty had a revision to a total shoulder arthroplasty to provide relief. CONCLUSIONS: The indications for this surface replacement are the same as those for the conventional stemmed prostheses, but the surface replacement has the advantage of bone preservation as well as avoidance of the potential complications associated with a long humeral stem in rheumatoid bone. This procedure is not suitable for severely damaged joints in which the humeral head is insufficient or too soft. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Activities of Daily Living↗