Failures in orthopaedic implants.
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[Salvage surgery in chronic infection following total hip prosthesis].
Thirteen patients were analyzed who suffered from chronic infection after total hip replacement. Some of them had had severe soft tissue defects or multiple fistulae for years. Some showed acute, sometimes life-threatening infection after long-standing loosening of the prosthesis. Therapy consisted of radical debridement, installation of a closed suction-irrigation drainage system and if another total hip prosthesis was implanted of a specific antibiotic management, including rifampin. In one case treatment was limited to the achievement of a permanent fistula. The average follow-up time was 4.3 years. With or without total hip reimplantation infections were healed as a rule and the decrease in pain was marked. There was only a partial increase in walking ability. In these severely damaged patients treatment can result in marked amelioration of the quality of life but only exceptionally in normalization.
Aged↗
Microflora associated with percutaneous craniofacial implants used for the retention of facial prostheses: a pilot study.
Craniofacial implants have been used successfully for the retention of facial prostheses. However, complications occur that can lead to the loss of implant integration. One such complication is infection possibly resulting from crevicular microflora activity. As part of an ongoing study, samples from crevicular sites surrounding 17 craniofacial implants were collected and submitted for microbiological assay. The results demonstrated the presence of opportunistic pathogens in many sites regardless of subjects' hygiene efforts. The significance of the findings is reviewed.
Colony Count, Microbial↗
Diagnostic protocol in prosthetic loosening.
The authors report the results they obtained in 35 cases studied based on a protocol to identify prosthetic loosening and to preoperatively establish its possible septic etiology. After clinical and radiographic assessment, the protocol called for a total body bone scan with Tc 99 m which, in positive cases, were associated laboratory tests and further instrumental testing (CT, bone scan and needle aspiration). Thanks above all to bone scan with labelled granulocytes the protocol provided high accuracy (91.4%) in preoperatively identifying the causes of infection.
Clinical Protocols↗
Hip revision surgery in septic loosening.
62 patients with infected hip joints whose treatment was started between January 1980 and December 1986 were analysed retrospectively in December 1992 with a mean observation period of 7.2 years (range 1-13). The treatments employed were debridement with lavage drainage in 6 cases, one-stage replacement of the prosthesis on 47 occasions and two-stage replacement in 27 cases. On 5 occasions the prosthesis was removed and a Girdlestone procedure was undertaken. In the 47 one-stage replacements primary intervention was successful in 57% (n = 27), in the two-stage replacements in 74% (n = 20). In 42 cemented shafts there was primary healing in 34, i.e. 81%, compared with 13 (65%) in the 20 non-cemented shafts. Successful healing was finally achieved in all 62 infected hips.
Adult↗
Reimplantation or resection arthroplasty for septic loosening.
Resection arthroplasty should nowadays be considered as obsolete for the following reasons: the removal of the implant and adequate antibiotic therapy can clear the infection. From this point of view the reimplantation of an endoprosthesis is possible. "Deficient bone stock" is not a contraindication to the reimplantation since there are surgical means available to replace bone stock. The results of revision arthroplasty (reimplantation) are incomparably better today that they were years ago (cement-free technique, bone replacement, supports of the acetabulum, special revision prostheses etc.
Hip Prosthesis↗
Reimplantation or explantation in the treatment of septic prosthetic loosening.
Indications for the surgical treatment of septic loosening of hip arthroplasty vary depending on different parameters. Explantation is indicated when patients are elderly, in generally poor condition, when there are veterate infections, particularly if these were caused by gram negative bacteria, and when there is severe skeletal injury. Reimplantation is instead indicated in patients whose general conditions are good, and who are young and motivated.
Age Factors↗
[Valve prostheses and transesophageal echocardiography].
The aim of this paper is to inform about the experience of the Echocardiography Department of the National Institute of Cardiology Ignacio Chávez, in the assessment of prosthetic valves dysfunction by transesophageal echocardiography. Sixty patients with a total of 75 prosthetic valves: 19 bioprostheses and 56 mechanical valves were studied. Forty four were in mitral position, 27 in aortic position and 4 in tricuspid position. All patients were evaluated using 5 MHz monoplane or biplane transesophageal transducers. The 52% (39) of the studied prosthetic valves were found normally functioning. However, 48% (36) of these showed signs of dysfunction. The causes of dysfunction in the mechanical valves were: obstruction, pannus, infectious endocarditis and periprosthetic leak, and in relation with bioprostheses rupture of the leaflets, stenosis and calcification, partial dehiscence, infectious endocarditis and periprosthetic leak were identified. The obtained percentage and type of prosthetic valves dysfunction in our results agree with those reported in the literature and confirm the great utility of transesophageal research in the detection of the valvular prosthetic dysfunction.
Adolescent↗
Cementless femoral components should be made from cobalt chrome.
Before 1982, the authors performed 177 primary total hip arthroplasties using a single-sized, extensively porous-coated cobalt-chrome femoral prosthesis. The current status of 122 of these arthroplasties is known. Two femoral prostheses have been revised for late symptomatic loosening, 2 for stem fracture, and 1 for infection. From 1982 to 1984, 227 primary arthroplasties were performed using the same stem in multiple sizes. Of these cases, 171 are available for followup. One stem (0.6%) has been revised for symptomatic loosening. Large osteolytic femoral lesions (average size, 8.1 cm2) developed in 3 patients, associated with an unusually large amount of polyethylene wear of their acetabular components. These patients have been treated by exchange of the polyethylene liner within the porous-coated acetabular component and allografting of the osteolytic lesions. The femoral components were not exchanged because osteolysis had not eroded the integrity of the supporting bone-implant interface to a point where loosening occurred. Before 1987, 193 patients with loose femoral components were treated with revision total hip arthroplasty, also using an extensively porous-coated cobalt-chrome femoral stem of similar design. Ten (5.7%) patients have required rerevision of the femoral prosthesis. Six of these 10 rerevisions were performed because of symptomatic loosening. Ninety-three percent of the patients in the primary series had relief of their preoperative pain and have improved functional ability; 94.2% are satisfied with their results. In the revision series, 89.1% of the patients are free of pain and function better than preoperatively, and 89.6% are fully satisfied with their results.(ABSTRACT TRUNCATED AT 250 WORDS)
Chromium Alloys↗
The spacer block technique in revision of total knee arthroplasty with septic loosening.
Five cases of septic loosening of total knee arthroplasty were treated by two-stage revision using a cement mixed with antibiotic. The spacer block was responsible for greater mechanical stability of the joint in the interval between the two stages of the operation, and the association of the antibiotic favored resolution of septic complications, allowing at the same time for systemic antibiotic treatment at doses lower than usual. In all of the cases treated reimplantation was performed in conditions of apparent sterility. The minimum amount of time between the first operation and reimplantation was 3 months, maximum was 5 months. Four to 18 months after reimplantation there was no recurrence of infection. Despite the short follow-up, the technique used appears to constitute a valid solution for septic complications in total knee arthroplasty.
Aged↗
Follow-up with Mentor two-piece inflatable penile prosthesis.
Between October, 1987 and June, 1993, we implanted 50 Mentor two-piece inflatable penile prostheses with a mean follow-up of 52.18 months (6-72 months). In 7 pts (14%), the implants were removed for various reasons. One pt (2%) had total fluid leak due to breakage of the tube at its junction with the cylinder. One implant (2%) was replaced due to loss of rigidity. Two implants (4%) were removed due to infection and later replaced with semirigid prostheses. Three pts (6%) had pump erosion. There was loss of rigidity in seven implants (14%), which appears to be due to stretching of the tunica albuginea from repeated use. The limited amount of fluid in the resipump precludes compensation for the stretching, leading to loss of rigidity. The overall complication rate of 28% in this long-term series appears to be much higher than that in other reported short-term follow ups. Thirty-six pts (72%) are fully satisfied with the device and 7 pts (14%) are partially satisfied, with an overall satisfaction rate of 86%. In our series, 46/50 (92%) pts have functioning prostheses at the time of review.
Adult↗
Maxillary sinus complications related to endosseous implants.
There have been many expanded applications for the use of endosseous implants in the reconstruction of partially and totally edentulous patients. The posterior maxilla, which frequently has inadequate quality and quantity of bone, and the contiguous maxillary sinus often provide poor recipient sites for endosseous implants. However, innovative procedures using autogenous, allogeneic, and alloplastic graft materials have enabled clinicians to place implants in the reconstructed resorbed maxilla. These techniques often violate the anatomic integrity and interfere with the physiologic mechanisms of the maxillary sinus, creating potential complications. Eight patients with complications following maxillary sinus augmentation and reconstruction with endosseous implants are reported.
Adult↗
Total hip replacement in renal transplant patients.
Of 1197 renal transplant recipients on the Oxford Transplant Programme, 25 (2%) needed arthroplasties for painful osteonecrosis of the hip. Nine of them had bilateral operations, giving a total of 34 primary total hip replacements (THR). The mean time from onset of symptoms to THR was 2.4 years and from transplantation to THR 5.1 years. The mean follow-up was 5.1 (1 to 14) years. THR relieved the pain in all the patients, but survival analysis indicated a lower survival rate than is usual for primary THR. There were eight major complications. One graft-related problem, early acute tubular necrosis, resolved rapidly after immediate treatment. One patient developed deep infection at 3.5 years after THR which settled with conservative treatment. Five hips developed aseptic loosening requiring revision arthroplasty at a mean of 8.8 years' follow-up. One patient had a non-fatal pulmonary embolism. THR is the treatment of choice for patients with painful osteonecrosis of the hip after renal transplant, but has higher rates of both early and late complications. Surgery should be performed in close association with a renal transplant unit.
Adult↗
[Voice rehabilitation after laryngectomy with the Provox voice prosthesis. Surgical and technical aspects. II].
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Aged↗
Transesophageal echocardiography in the evaluation of prosthetic valves.
Biplane and multiplane TEE, with its relatively low risk, has become an invaluable complement to a comprehensive transthoracic two-dimensional Doppler and color flow examination. It should be undertaken in all instances when the transthoracic information is not adequate or if there is suspicion of abnormality that is not detected by TTE. One can advocate the use of TEE in the operating room in all instances wherein a patient is going to be implanted with a prosthetic valve because it will permit one to obtain baseline information that may be valuable in the management of patients seen subsequently with questionable findings when comparison is valuable. The role of cardiac catheterization is limited. Hemodynamic cardiac catheterization should only be used in instances in which there is discrepancy between echocardiographic findings and clinical presentation. Visualization of coronary arteries may be indicated in some situations, and a limited coronary arteriogram could be performed, the procedure being less morbid if separated from hemodynamic right and left heart catheterization. Echocardiography represents the state of the art in evaluation of patients with valvular prosthesis. Biplane TEE and multiplane TEE are valuable complementary technology to be used in conjunction with TTE, when the situation dictates its use, because it provides useful information that alters management of the patient.
Aortic Valve↗
[Descending thoracic aorta: an excellent inflow source for recurrent revascularization of the lower limbs].
Although severe complications after anatomic reconstruction of the abdominal aorta are unusual, when they occur, a different strategy is required to treat the patient with success and a distinct operation is generally required for a durable favourable long term outcome. Late complications after abdominal aortic grafting include prosthetic infection, enteric erosion and graft thrombosis. Treatment by resection of the infected graft and extra-anatomic reconstruction with axillary-femoral or axillary-popliteal bypass leaves the patient with an unreliable arterial inflow for his lower extremities; in those patients who survive graft removal and extra-anatomic bypass, an alternative source of major arterial inflow should at least be discussed to effect a permanent repair. The descending thoracic aorta has been described as an ideal inflow source for definitive intracavitary conversion of extra-anatomic subcutaneous bypasses and as an occasional alternative to avoid a densely scarred abdomen or retroperitoneum. Our experience with 8 patients includes 7 in whom the aorta had been overseen below the renal arteries in a previous operation [after removal of infected graft (n = 4) and after repair of aorto-enteric fistula (n = 3)]. Our technique of primary extra-anatomic reconstruction consists of a right-sided axillo-femoral (-popliteal) bypass with femoro-femoral crossing graft. This method avoids tunneling an extra-anatomic graft in the left thoraco-abdominal region, thus facilitating the definitive repair. Preoperative radiographic evaluation of inflow and outflow details is essential in these complex cases.(ABSTRACT TRUNCATED AT 250 WORDS)
Aorta, Thoracic↗
Diagnosis of infection by frozen section during revision arthroplasty.
We assessed the efficacy of intraoperative frozen-section histology in detecting infection in failed arthroplasties in 106 hips and knees. We found inflammatory changes consistent with infection (an average of one or more neutrophil polymorphs or plasma cells per high-power field in several samples) in 18 cases; there was a significant growth on bacterial culture in 20 cases. Compared with the bacterial cultures, the frozen sections provided two false-negative results and three false-positive results (sensitivity, 90%; specificity, 96%; and accuracy, 95%). The positive predictive value was 88%, the negative value, 98%. These results support the inclusion of intra-operative frozen-section histology in any protocol for revision arthroplasty for loose components.
Adult↗
[Management of the infected total knee arthroplasty].
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