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PubMed1990

Total-hip arthroplasty: periprosthetic indium-111-labeled leukocyte activity and complementary technetium-99m-sulfur colloid imaging in suspected infection.

Indium-111-labeled leukocyte images of 92 cemented total-hip arthroplasties were correlated with final diagnoses. Prostheses were divided into four zones: head (including acetabulum), trochanter, shaft, and tip. The presence (or absence) and intensity of activity in each zone was noted, and compared to the corresponding contralateral zone. Though present in all 23 infected arthroplasties, periprosthetic activity was also present in 77% of uninfected arthroplasties, and was greater than the contralateral zone 51% of the time. When analyzed by zone, head zone activity was the best criterion for infection (87% sensitivity, 94% specificity, 92% accuracy). Fifty of the arthroplasties were studied with combined labeled leukocyte/sulfur colloid imaging. Using incongruence of images as the criterion for infection, the sensitivity, specificity, and accuracy of the study were 100%, 97%, and 98%, respectively. While variable periprosthetic activity makes labeled leukocyte imaging alone unreliable for diagnosing hip arthroplasty infection, the addition of sulfur colloid imaging results in a highly accurate diagnostic procedure.

Adult↗
PubMed1990

Pneumatic sequential-compression boots compared with aspirin prophylaxis of deep-vein thrombosis after total knee arthroplasty.

This prospective, randomized study was undertaken to compare the effectiveness of pneumatic sequential-compression boots with that of aspirin in preventing deep-vein thrombosis after total knee arthroplasty. Patients were randomly assigned to one of two prophylactic regimens: compression boots or aspirin. One hundred and nineteen patients completed the study. Seventy-two patients had unilateral arthroplasty and forty-seven, one-stage bilateral arthroplasty. In the unilateral group, the incidence of deep-vein thrombosis was 22 per cent for the patients who used compression boots compared with 47 per cent for those who received aspirin (p less than 0.03). In the bilateral group, the incidence of deep-vein thrombosis was 48 per cent for the patients who used compression boots compared with 68 per cent for those who received aspirin (p less than 0.20). The results confirm the effectiveness of compression boots in the treatment of patients who have had unilateral total knee arthroplasty. Despite the use of compression boots, however, patients who had bilateral arthroplasty were at greater risk for the development of deep-vein thrombosis.

Aged↗
PubMed1989

[Preoperative autologous blood deposit and liquid storage for replacement arthroplasty].

Transfusion of homologous blood components is associated with immunological (incompatibility, alloimmunization, immunosuppression) and infectious risks (hepatitis, cytomegalovirus, HIV and other agents). Endoprosthetic surgery of the hip and knee frequently requires transfusion. Preoperative deposit of autologous blood can reduce homologous transfusion requirements. The simplest method is liquid storage of whole blood. In order to re-examine the efficiency of our present scheme of preoperative deposit, we studied patients scheduled for endoprosthetic surgery with respect to the amount of blood deposited, stimulation of erythropoiesis, and homologous blood requirements at the time of operation. PATIENTS AND METHODS. Sixty-seven consecutive patients (33 men, 34 women) scheduled for endoprosthetic replacement of hip or knee or for revision arthroplasty of the hip were studied. Patients with anemia, coagulopathies, coronary heart disease, severe obstructive or restrictive pulmonary disease, cerebral sclerosis, syncopes and seizures were excluded from preoperative deposit. Patients deposited 450 ml at weekly intervals, with occasionally slightly higher or lower volumes. A patient was temporarily deferred when the hemoglobin concentration prior to donation fell below 11 g/dl. Blood was collected in CPDA-1 buffer. The aim was a deposit of three units. In patients undergoing exchange reoperation of a total hip arthroplasty, intra- and postoperative autotransfusion with a cell separator was employed in addition to preoperative donation. RESULTS. The age of the patients ranged from 43 to 83 years (mean +/- SD: 61.2 +/- 9.1). The differences between men and women with respect to height (172.9 +/- 6.8 vs 160.6 +/- 7.4 cm; p less than or equal to 0.001), weight (75.7 +/- 11.2 vs 69.1 +/- 11.0 kg; p less than or equal to 0.05), calculated blood volume (p less than or equal to 0.001), and erythrocyte volume prior to donation (p less than or equal to 0.001) were significant. A total of 185 units was deposited. Men donated 1350 (450-1970) ml blood (median, range) and women 1260 (340-1450) ml (p less than or equal to 0.01). Hemoglobin concentrations decreased significantly from an average of 14.7 g/dl in men and 13.8 g/dl in women prior to donation to 13.4 g/dl and 12.3 g/dl preoperatively (p less than or equal to 0.0001 for both groups). The donation was not associated with serious complications. For 4 patients the scheduled operation was deferred for a longer term. Forty-six patients (23 men, 23 women) underwent total hip arthroplasty, 12 (4 men, 8 women) exchange of total hip arthroplasty, and 5 (3 men, 2 women) endoprosthetic knee surgery. In total hip arthroplasty men required 0 to 500 ml homologous packed red cells (median=0), women 0 to 1250 ml (median=0;p less than or equal to 0.05). Thirty-nine (69.6%) of the patients, 19 (82.6%) men and 13 (56.5%) women, did not require homologous transfusion.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1988

Patellofemoral arthroplasty. A three- to nine-year follow-up study.

Twenty-two patients with 25 patellofemoral arthroplasties (resurfacing of the patella and femoral groove) were evaluated to assess long-term results. A past history of patellofemoral malalignment or instability was obtained from 14 patients. Preoperative roentgenograms demonstrated patellofemoral osteoarthritis in all 25 knees; five patients had both tibiofemoral and patellofemoral osteoarthritis. The average age at the time of surgery was 62 years and follow-up time averaged 5.3 years. Results were determined using a modified Hungerford knee rating scale. Follow-up roentgenograms were evaluated for mechanical failure and progressive deterioration of the tibiofemoral joint. Eighteen of 25 (72%) patellofemoral arthroplasties were rated excellent or good. However, 15 of 17 patellofemoral arthroplasties (88%), all performed on women, had satisfactory results. There were seven failures. The presence of tibiofemoral osteoarthritis adversely affected the outcome; excluding the five patients with tibiofemoral osteoarthritis, 17 of 20 patellofemoral arthroplasties (85%) had satisfactory results. Other reasons for failure were malposition of the components and persistent patellofemoral malalignment. Mechanical failure was not observed. Patellofemoral arthroplasty may be indicated for patients with osteoarthritis limited to the patellofemoral compartment.

Aged↗
PubMed1988

A comparison of primary and revision total knee arthroplasty using the kinematic stabilizer prosthesis.

The first 121 arthroplasties (in 105 patients) in which the cemented kinematic-stabilizer total knee prosthesis was used for primary arthroplasty or surgical revision at the Mayo Clinic were reviewed. Sixty-six patients (seventy-nine arthroplasties) were followed for a mean of thirty-seven months. There were fifty-three revision and twenty-six primary arthroplasties. The average range of motion in both groups increased from 95 to 101 degrees. Although none of these patients could ascend stairs without support before the operation, thirty-two (51 per cent) could do so at the time of the final follow-up. The incidence of moderate or severe pain was reduced from 86 to 6 per cent. Moderate or severe ligamentous instability had been present in thirty-three knees (42 per cent) preoperatively, but only five knees had significant medial, lateral, anterior, or posterior instability at final follow-up. The Hospital for Special Surgery knee score increased from an average of 56 points to 83 points in all of the knees. At follow-up, the patients who had had primary arthroplasty had 92 per cent good or excellent results and the patients who had had surgical revision had 81 per cent good or excellent results (p less than 0.05). There was no significant difference in the results between the patients who had osteoarthritis and those who had rheumatoid arthritis. Over-all, 85 per cent of the results were good or excellent at final follow-up. Tibial radiolucent lines of one to two millimeters were observed in 29 per cent of the knees at follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1988

Technical considerations of total knee arthroplasty after proximal tibial osteotomy.

Forty-five total knee replacements in forty-one patients who had continued to have progressive osteoarthritis after a proximal tibial osteotomy were evaluated prospectively. There were 51 per cent excellent, 29 per cent good, 4 per cent fair, and 16 per cent poor results after a minimum follow-up of two years. The resection of tibial bone that was produced by the osteotomy could not be related causally to the fair or poor clinical results that were found after arthroplasty. Radiographic study, however, showed that 80 per cent of the knees had patella infera before the arthroplasty, which may contribute to altered biomechanics of the patellofemoral joint of the arthroplasty. The procedure for total knee replacement is made more difficult by the previous osteotomy, and a custom-made prosthesis may be required. The clinical results that were obtained in this series are similar to those for the revision total knee arthroplasties that have been done at this institution, but they were not as satisfactory as those that were obtained after primary total knee replacement. Our results should be considered when a surgeon compares the advantages and disadvantages of proximal tibial osteotomy with those of total knee arthroplasty for an older patient who has unicompartmental osteoarthritis of the knee.

Adult↗
PubMed1988

A fifteen-year follow-up study of one hundred Charnley low-friction arthroplasties.

This two-part study concerns the fate of 100 Charnley low-friction arthroplasties performed in 92 patients at The Hospital for Special Surgery. The first part of the study is a clinical and radiographic evaluation of the 40 hips that were available for follow-up at an average of 15.3 years after surgery. The second part is a survival analysis of the arthroplasty, the individual components, and the patients, using data from all 100 arthroplasties. The authors conclude that the vast majority of older patients who undergo cemented total hip arthroplasty will not require a subsequent arthroplasty, and will have satisfactory pain relief for the remainder of their lives.

Activities of Daily Living↗
PubMed1988

Blood loss with total knee arthroplasty.

A substantial drop in blood volume occurs in patients being treated by total knee arthroplasty (TKA). Of 140 TKAs (108 patients) studied to analyze this blood loss, 70 required transfusion and 70 did not. The average transfusion was 2.6 units per arthroplasty. Blood loss in the nontransfused group was 1.8 units per arthroplasty. The overall mean blood loss was 2.2 units per TKA. Insertion of a constrained TKA resulted in a statistically significant increase in blood loss. Preoperative diagnosis, anesthetic technique, revision arthroplasty, patellofemoral arthroplasty, and tourniquet technique did not statistically affect the blood loss. The bulk of the blood loss is collected postoperatively in the suction drainage system.

Adult↗
PubMed1987

Treatment of the septic hip with total hip arthroplasty.

Forty-three patients, 23 with definite infection and 20 with probable infections before total hip arthroplasty (THA), were compared to 41 matched uninfected patients. The 43 infected patients were treated by 45 operative procedures: eight Girdlestone resections, 12 revisions of total hips, and 25 conversions from infected nontotal hip surgery to total hip arthroplasties. (Two revision THAs were converted to Girdlestones). The average follow-up period was 38.8 months, with a range of six-118 months. The statistically significant negative prognosticators were gross sepsis at surgery, number of previous operations, and elevated erythrocyte sedimentation rate (ESR). The type of infecting organism did not affect the outcome. The prosthesis survival rate for total hip arthroplasties revised for sepsis was 83%. The prosthesis survival rate for other infected hips treated by total hip arthroplasty was 100%. All groups except Girdlestone resections improved postoperatively. While Girdlestone resection offered acceptable pain relief, total hip arthroplasty provided unequivocally superior function (p = 0.0001).

Adult↗
PubMed1986

Failures and reoperations following low-friction arthroplasty of the hip. A five- to fifteen-year follow-up study.

One thousand nine Charnley low-friction arthroplasties performed by one surgeon were investigated for occurrence of failure from five to 15 years after operation. Six hundred ninety-six of the arthroplasties, 499 operations for primary and 197 for secondary surgery, qualified for study. Eleven hips of the 499 primary arthroplasties (2.2%) and five hips of 197 secondary surgery (2.5%) required reoperation. Six hips (of five patients) in primary and four hips in secondary surgery were identified as "pending failure," for which further surgical correction may be imminent. There were six deep infections (1%), one in primary and five in secondary surgery. Five patients (0.7%) required reoperations other than revision of arthroplasty. Combining the actual and pending failures resulting from mechanical failures and deep infection, there were 31 failures in 696 arthroplasties (4.5%).

Adult↗
PubMed1987

Condylar total knee arthroplasty after failed proximal tibial osteotomy.

Data were collected retrospectively on thirty-five patients who had a failed osteotomy of the proximal part of the tibia for unicompartmental osteoarthrosis of the knee that was treated with a cruciate condylar, total condylar, kinematic condylar, or cemented porous-coated anatomical total knee prosthesis. The patients were evaluated clinically and roentgenographically before and after the arthroplasty. The minimum period of follow-up was twenty-nine months (mean, forty-four months). On the basis of the knee-rating scale of The Hospital for Special Surgery, 89 per cent of the patients had either an excellent or a good result after the arthroplasty. No result was a failure. One patient had loosening of the patellar component, but no other loosening was identified. The results of total knee arthroplasty after osteotomy of the proximal part of the tibia were found to be comparable with the results after arthroplasty in knees that had not had a prior osteotomy. The intraoperative and postoperative rates of complications were not higher, and no untoward technical difficulties were encountered at surgery. These data support the clinical impression that an osteotomy of the proximal part of the tibia does not "burn any bridges" insofar as a future successful arthroplasty is concerned.

Adult↗
PubMedDate not supplied

Essay on total knee arthroplasty.

Patient selection in total knee arthroplasty can be a difficult problem for the surgeon. It appears that more young patients are appearing with advanced arthritis of the knee than in the past. Many patients have had previous knee injuries resulting in premature development of degenerative arthritis. The authors believe that in selected cases total knee arthroplasty may be offered to younger patients. Young patients incapacitated by rheumatoid or inflammatory arthritis should not be denied reconstruction by total knee arthroplasty. The problem arises in the more active patient in his forties or fifties who has advanced arthritis of the knee not suitable for treatment by other means. The authors believe that these patients should not be treated by conventional total knee arthroplasty. On an experimental basis, the authors have been performing cementless total knee arthroplasty in younger, more active patients with disabling arthritis. Precision of surgical technique is critical with the newer cementless type of knee replacement.

Adult↗
PubMed1983

A posterior ascending popliteal cyst mimicking thrombophlebitis following total knee arthroplasty (TKA).

Pain and swelling of the lower extremity following total knee arthroplasty are not infrequent. The most frequent conditions responsible for these symptoms include thrombophlebitis, prosthetic loosening, infection, and fracture of either the prosthesis or the bones. In addition to these conditions, a dissecting or ruptured popliteal cyst should be considered in the differential diagnosis of acute calf pain and swelling following total knee arthroplasty. Two patients with symptoms of phlebothrombosis were evaluated retrospectively two to three years following total knee arthroplasty. In both patients the popliteal cysts dissected proximally into the thigh. A dissecting popliteal cyst is diagnosed by arthrography. The usual arthrographic films evaluated for a Baker's or popliteal cyst are anteroposterior and lateral views of the calf. These films are inadequate in patients who have undergone total knee arthroplasty; the dissecting cysts observed in the patients of the present report dissected proximally above the knee and were diagnosed on anteroposterior and lateral views of the distal femur. The more common symptoms noted after total knee arthroplasty should not be excluded due to the presence of a dissecting or ruptured cyst, as one of the patients of the present report also had a superimposed infection. Clinical considerations of a dissecting popliteal cyst are emphasized so that arthrography can be performed early in the course of the symptoms and proper treatment initiated.

Aged↗
PubMed1984

Advances in total hip arthroplasty. The metal-backed acetabular component.

Detailed, long-term studies of cemented total hip arthroplasties clearly show that failure of fixation of the acetabular component is a major problem, with a rising incidence and an unusual complexity. By finite element analysis the stress distribution in the human acetabulum before and after total hip arthroplasty was analyzed by three different groups of investigators. Data from all three studies are in agreement that the introduction of cemented acetabular components of high-density polyethylene results in major disturbances of stress distribution, with peak stresses after total hip arthroplasty occurring in the cement, trabecular bone, and medial wall of the acetabulum. The most effective way to reduce these peak stresses in these three critical areas is to use an acetabular component with a metal backing. Long-term follow-up studies of 51 patients who underwent total hip arthroplasty performed by the author during the period from 1971 to 1975 using metal-backed acetabular components confirm the improved fixation that results from use of this design. Both the analytic data of stress distribution and clinical follow-up studies strongly support the use of metal-backed acetabular components in cemented total hip arthroplasty.

Acetabulum↗
PubMed1984

The significance of asymptomatic bacteriuria in patients undergoing hip/knee arthroplasty.

The urinary tract has received a great deal of attention as a possible source of infection following arthroplasty. The incidence and significance of asymptomatic bacteriuria in patients admitted for arthroplasty is obscure. The occurrence of bacteriuria was therefore analyzed retrospectively in 299 patients admitted for hip/knee arthroplasty to determine its incidence and relation to the age of the patient and the result of the operation. There was a high incidence of bacteriuria in patients 65 years of age or older and an abnormally high incidence of asymptomatic bacteriuria in younger patients of both sexes who were to undergo hip/knee arthroplasty. However, there was no correlation between bacteriuria and surgical infection in these patients. Bacteriuria is common in patients admitted to the hospital for arthroplasty and should not be considered a cause for postponement of surgical treatment in the absence of other signs of cystitis or pyelonephritis.

Age Factors↗
PubMed1984

Management of infected total knee arthroplasties.

In a prospective study of 14 consecutive infected total knee arthroplasties ( TKAs ) treated through 1979, the management consisted of: (1) 11 delayed exchange arthroplasties, with 2 failures requiring above-knee amputation; (2) 2 in situ debridements; and (3) 1 arthrodesis. The final outcome of the delayed exchange arthroplasty group regarding joint pain, patient function, and joint performance was (a) inferior to that of primary TKA (before infection), (b) better than that of resection arthroplasty, and (c) worse than that of a control group of non-infected TKAs respectively. Debridement without prosthesis resection was successful only in cases of immediate postoperative infection (2 successes in 4 TKAs ) and uniformly unsuccessful in infections occurring beyond the perioperative period (4 failures in 4 TKAs ). The study indicates that delayed exchange total knee arthroplasty is a reasonable alternative to arthrodesis following resection of an infected TKA and can be performed without undue risk of recurrent infection.

Aged↗
PubMed1983

Total hip arthroplasties in patients less than forty-five years old.

We studied the cases of eighty-one patients (108 total hip arthroplasties), ranging in age from fourteen to forty-five years, at an average of 4.5 years after the index operation and evaluated them with regard to six major factors: age, disease, Charnley category, prior operations, length of time since arthroplasty, and quality of the arthroplasty with regard to cementing technique and component position. After two to five years 78 per cent were satisfactory, but after five years or more only 72 per cent were satisfactory. Patients who were less than thirty years old had poorer results. Good technique yielded 93 per cent satisfactory clinical results. The patients in this study with the worst prognosis for success following total hip arthroplasty were less than thirty years old, had osteonecrosis or osteoarthritis as the primary disease, and had a less than optimum reconstruction. Patients who were alcohol-abusers or who had had a prior hip infection or a prior acetabular cup or femoral hemiarthroplasty also had a poor prognosis. Patients who had the arthroplasty for collagen disease or were thirty years old or older, or both, and had a good technical reconstruction had the best prognosis.

Adolescent↗
PubMed1982

Revision surgery following a failed total elbow arthroplasty.

The need for revision surgery following total elbow arthroplasty can be minimized if certain principles are observed. These include careful preoperative assessment for diaphyseal bone size, the presence of anatomic resources for arthroplasty, the possible need for future adjacent joint arthroplasties, meticulous surgical detail during the arthroplasty, and prompt diagnosis and correction of postoperative problems. Many of the problems following total elbow arthroplasty can be surgically corrected by replacing the high-density polyethylene bearing. Other problems are amenable to arthrodesis of the joint. Although the complication rate and need for revision surgery have diminished with improved implant design and improved surgical technology, it is helpful both to the patient and to the surgeon to discuss the potential problems and the risk versus gain ratio with the patient so that a clear understanding of the reconstruction is understood by everyone.

Elbow Joint↗