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PubMed1989

Distraction resection arthroplasty of the wrist.

Proximal row carpectomy should not be done if wrist degeneration includes cartilage destruction of the capitate or lunate fossa of the radius; yet total wrist arthroplasty has been disappointing for treatment of osteoarthritis. We have used a technique we call distraction resection wrist arthroplasty in such cases. We retrospectively reviewed distraction resection wrist arthroplasty in 14 wrists and compared them to nine patients who had PRC; average follow-up was 32 months. Three patients had spastic contractures and 20 had operation for painful osteoarthritis. Patient satisfaction was high but there were four failures requiring arthrodesis (1 PRC, 3 DRA). Average postoperative wrist motion was 41 degrees of extension, 38 degrees of flexion, 11 degrees of radial deviation, and 13 degrees of ulnar deviation. Static strength averaged almost two thirds of the uninvolved side and dynamic power more than half. Differences between the DRA and PRC patients were not statistically significant in single or aggregate analysis. We believe that distraction technique extends the indications for biologic arthroplasty to patients whose only prior option was wrist arthrodesis.

Adult↗

PubMed1996

Basal joint arthritis: trapeziectomy with ligament reconstruction and tendon interposition arthroplasty.

This article provides a qualitative and quantitative outcomes assessment of a consecutive series of 27 patients (30 thumbs) with basal joint arthritis of the thumb undergoing ligament reconstruction and tendon interposition arthroplasty. Outcome analysis revealed that 24 (89%) patients were satisfied with the relief of pain provided by the arthroplasty and 23 (87%) would undergo surgery again. Eighteen (67%) thumbs were noted to have improvement in the ability to perform activities of daily living. Significant improvements were noted in web space measurements and in grip and pinch strength determination. X-ray film assessment using the trapezial space ratio averaged 0.33 +/- 0.08 in preoperative x-ray films of thumbs with stage III and IV degenerative arthritis and 0.23 +/- 0.07 in thumbs following basal joint arthroplasty. This represents a total decrease of 51% in the trapezial space ratio following arthroplasty compared to the normal values obtained in previous studies and 33% compared to the preoperative values obtained in this study. Outcomes assessment at a mean of 42 months after surgery showed that there was no significant correlation between maintenance of trapezial height and both objective and subjective clinical outcomes. Although ligament reconstruction consistently failed to restore trapezial height, primary and secondary clinical outcomes following basal joint arthritis were almost uniformly satisfactory.

Activities of Daily Living↗

PubMed1996

A comparison of abrasion burr arthroplasty and subchondral drilling in the treatment of full-thickness cartilage lesions in the rabbit.

The purpose of this study was to observe the difference in healing of full-thickness articular cartilage defects treated with burr arthroplasty versus subchondral drilling. Cartilage was shaved off the medial femoral condyles of 39 rabbits without penetrating the subchondral plate. In left knees, two 2.0-mm holes were drilled into the condyle until bleeding was obtained. Right knees underwent a burr arthroplasty until punctate bleeding was observed. Animals were sacrificed at 6, 12, and 24 weeks postoperatively. Joint resurfacing and degenerative changes were evaluated grossly and histologically. Degenerative changes in the cartilage surface were observed with both treatments. Rabbits undergoing subchondral drilling had increased fibrocartilaginous healing with time, with a slight increase in degenerative changes. With burr arthroplasty, there was significant decrease in cartilaginous coverage of the exposed surface as well as progressive increase in degenerative changes. Although both techniques were suboptimal, histological evidence at 6 months suggests that subchondral drilling may result in a longer-lived repair than abrasion arthroplasty in the treatment of full-thickness lesions.

Animals↗

PubMed2003

Primary total knee arthroplasty for periarticular fractures.

We present a series of 6 patients with periarticular fractures of the knee that were treated by primary total joint arthroplasty. These fractures around in 6 elderly women, three in the proximal tibia and three in the distal femoral. All the patients had osteoarthritis and osteopenia. In five patients, a hinged total knee arthroplasty was performed, and in one case an unconstrained prosthesis was performed. Cementing techniques were used in all. Postoperatively, immediate mobilization with full weight bearing was initiated. No radiographic or clinical evidence of loosening was seen, and the functional outcome was satisfying. The results suggest that another treatment option for intra-articular distal femoral or intra-articular proximal tibial fractures in elderly patients with severe osteopenia and osteoarthritis is primary total knee arthroplasty. Furthermore, this primary total knee arthroplasty may require some degree of constraint.

Accidental Falls↗

PubMed2003

A two-stage approach to primary knee arthroplasty in the infected arthritic knee.

Fourteen patients with either septic knee arthritis or osteomyelitis of the knee with marked joint destruction were treated by resection arthroplasty with the introduction of an antibiotic cement spacer block, appropriate antibiotic therapy, and subsequent primary total knee arthroplasty. Most patients with septic arthritis had chronic infection. Eight patients had positive cultures preoperatively; the remaining patients had either a culture negative purulent aspiration or diagnostic radiographic studies. All patients underwent reconstruction with primary total knee arthroplasty on an average of 3.1 months after the initial stage procedure. Knee Society scores progressed from 46 preoperatively to 89 postoperatively, with an average range of motion from 3 degrees to 105 degrees. At latest clinical follow-up (average, 4.5 years), no patients had recurrence of infection. These data suggest that this method is successful in treating chronically infected knees with a 2-staged arthroplasty.

Aged↗

PubMed1989

Abrasion arthroplasty as a salvage for failed upper tibial osteotomy.

Eight patients with persistent pain after upper tibial osteotomy and correction of malalignment were treated with abrasion arthroplasty of the affected compartment. At 34-month follow-up examination, only one patient had significant lasting benefit. Five of the patients required subsequent total knee arthroplasty for relief of their pain. One patient was symptomatically unchanged, and one was awaiting total knee arthroplasty. The authors conclude that abrasion arthroplasty is not a satisfactory salvage for a failed upper tibial osteotomy.

Aged↗

PubMed1989

Nonresurfaced patella in total knee arthroplasty.

Problems attributable to the patellofemoral joint are still the major cause of disability in contemporary knee arthroplasty. Patellar resurfacing does lead to further complications, such as loosening, wear, and malalignment. Two studies have been performed specifically to review experience with the nonresurfaced patella in total knee arthroplasty. The first study determined that patellofemoral symptoms occurred in 8% of the total group and the majority of these were due to patellar malalignment. The postoperative skyline views at 60 degrees and 90 degrees of flexion obtained routinely identified dynamic patellar maltracking responsible for anterior knee pain. The second study addressed long-term durability of the nonresurfaced patella. The tracking of the patella was maintained with only small shifts of patella position and the tendency to stabilize with time. Stress-induced bone remodelling, particularly of the lateral facet, occurred in 85% of patellae. No preoperative or postoperative radiologic variable was associated with anterior knee pain. The authors strongly recommend that accurate patellofemoral tracking be obtained at the time of knee arthroplasty by staged procedures, with removal of peripheral osteophytes, then proximal iliotibial tract release followed by lateral debulking to a marked degree to obtain neutral tracking. Only then will intracapsular lateral release be performed. The results presented support the use of the nonresurfaced patella, and patellar malalignment remains a major source of disability attributable to the patellofemoral joint following total knee arthroplasty.

Arthroplasty↗

PubMed1997

Incidence of fatal pulmonary embolism after 1,390 knee arthroplasties without routine prophylactic anticoagulation, except in high-risk cases.

A consecutive series of 1,390 primary total knee arthroplasty (TKA) procedures (1,201 patients, 1,600 arthroplasties) performed between January 1980 and July 1994 were reviewed to establish the incidence of death from pulmonary embolism (PE). Nine hundred twenty-three bi- or tricompartment TKAs and 467 unicompartment TKAs were performed as one-stage procedures. Chemical thromboprophylaxis was used only in high-risk cases in which there was a history of previous thromboembolism or obesity. There were no deaths from PE after unicompartment arthroplasty procedures. Autopsy confirmed PE as the cause of death in 2 patients following bi- and tricompartment TKAs (0.22%; 95% confidence interval [CI], 0.03-0.8%). The incidence was higher for one-stage bilateral TKA as 1 of the autopsy-confirmed deaths occurred in this group 0.7% (95% CI, 0.02-3.78%). Two other deaths were certified without postmortem examination (pneumonia and myocardial infarction in each case). As PE could not be ruled out as the cause of death in the latter 2 cases, these were considered as possible PE deaths to provide the maximum possible death rate that could result. Thus, the maximum possible incidence of fatal PE after TKA without routine use of chemical anticoagulation was 0.4% (95% CI 0.1-1.1%). It is concluded that the risk of fatal PE after unilateral TKA and unicompartment knee arthroplasty is low. The risk of clinical, nonfatal thromboembolic events, which might themselves warrant prophylaxis, was not quantified in this article.

Adult↗

PubMed1997

Subtrochanteric femoral shortening osteotomy in total hip arthroplasty for high-riding developmental dislocation of the hip.

A surgical technique, which uses a transverse osteotomy, for subtrochanteric femoral shortening and derotation in total hip arthroplasty for high-riding developmental dislocation of the hip is described. Anteversion is set by rotating the osteotomy fragments, and torsional stability is augmented with allograft struts and cables when indicated. Eight patients with 9 total hip arthroplasties were followed for an average of 43 months (range, 24-84 months). Good to excellent results were obtained in 87% of patients (7 of 8). Eight of 9 osteotomies (89%) demonstrated radiographic evidence of healing at an average of 5 months. One patient had an asymptomatic nonunion of the osteotomy site but still had a good overall clinical result. Another patient suffered fatigue failure of a distally ingrown porous device, which necessitated revision total hip arthroplasty 18 months after surgery. Subtrochanteric osteotomy in total hip arthroplasty for developmental dislocation of the hip allows for acetabular exposure and diaphyseal shortening while facilitating femoral derotation. Furthermore, proximal femoral bone stock is maintained and some of the potential complications of greater trochanteric osteotomy may be avoided.

Adult↗

PubMed1998

Drainage versus nondrainage in simultaneous bilateral total hip arthroplasties.

A prospective study of 48 patients (96 hips) who had undergone primary simultaneous bilateral total hip arthroplasty was conducted to assess the effect of postoperative suction drainage on wound healing and infection. A suction drain was placed by randomization of the drained versus undrained side. The same surgical technique was used in all total hip arthroplasty wounds. Statistical analysis of the results showed significant differences with respect to drainage from the wound, soaked dressings requiring reinforcements, ecchymosis, and erythema about the wound in the group without drainage. There was no specific correlation between the incidence of wound complications and infection after total hip arthroplasty and the use or nonuse of closed-suction drainage. The hip score and range of motion of the hip were unaffected by the use or nonuse of the drains. The cost of 1 set of hemovac drains is $135 and the cost for 4-5 dressings and bed sheet changes is about $50. Although the hemovac is more expensive, the authors recommend the routine use of suction drains for wounds after primary total hip arthroplasty to reduce drainage, soaked dressings requiring reinforcement, ecchymosis and erythema around the wound, and psychological impact on the patient's fear of bleeding.

Adult↗

PubMed1998

Particulate debris presenting as radiographic dense masses following total knee arthroplasty.

Two cases of failed total knee arthroplasty associated with significant titanium debris that created massive radiographic densities are reported. The similarities of the failed total knee arthroplasties are that both involve titanium femoral components with failed metal-backed patellar components. At the time of surgical intervention, patellar polyethylene dissociation from metal-backed patellar components was noted with excessive burnishing and wear of the remaining metal-backed patellar component and of the titanium femoral component. Wear of the tibial polyethylene was noted in both cases. The titanium-on-titanium wear couple produced significant debris, resulting in large mass formation about the total knee arthroplasty. Additionally, there were loculated, fluid-filled sacks of titanium debris. Histologic sections performed for both cases revealed significant deposits of titanium in combination with polyethylene. In both cases, radiographs revealed the presence of large, radiodense masses. These cases illustrate that when considering etiologies for radiodense masses about total joint arthroplasty, particulate titanium debris resulting in mass formation must be added to the differential diagnosis.

Aged↗

PubMed1998

10-year survivorship of metal-backed, unicompartmental arthroplasty.

Between January 1985 and December 1987, 100 consecutive metal-backed, unicompartmental arthroplasties (MBUKAs) were performed and retrospectively reviewed; 5 patients died, and the surviving 95 patients were reviewed. Of these arthroplasties, 10 were uncemented and 85 were cemented. There were 2 failures in the uncemented arthroplasties and 10 failures in those that were cemented, resulting in an 87.4% survivorship at a mean follow-up of 10 years. After 5 years, 10 of these cases were revised because of progressive lateral compartment disease and lateral compartment pain. Despite improved function compared with tricompartmental arthroplasty, MBUKA is beneficial only in highly selective cases. In this series, after 5 years, survivorship declined because of progression of arthrosis in the nonreplaced compartment.

Arthroplasty, Replacement, Knee↗

PubMed1999

Total knee arthroplasty for steroid-induced osteonecrosis.

There have been only a few reports that evaluate the outcome of total knee arthroplasty in patients with steroid-induced osteonecrosis of the knee. We retrospectively reviewed 31 total knee arthroplasties in 24 patients with confirmed steroid-induced osteonecrosis of the knee. The average follow-up was 64 months. Of surviving knees, 92% had significant improvement in knee scores. Five knees (16%) required a revision procedure. Reasons for revision were aseptic loosening in 3 knees and sepsis in 2 knees. Complications not requiring revision occurred in 6 of 31 knees (19%). Survivorship of total knee arthroplasty to revision in patients with steroid-induced avascular necrosis of the knee was 84% at 5 years. Although there was a slightly higher complication rate, this may, in part, be due to the severity of the patients' underlying disease processes. Total knee arthroplasty can be a successful procedure for chronically ill patients with steroid-induced osteonecrosis.

Adult↗

PubMed2002

Total knee arthroplasty following prior distal femoral fracture.

BACKGROUND: Femoral fracture may predispose the knee to the development of post-traumatic arthritis by either a direct intra-articular injury or residual limb malalignment. Malunion, intra-articular osseous defects, limb malalignment, retained internal fixation devices, and compromised surrounding soft tissues may in turn affect the outcome of total knee arthroplasty (TKA) in these patients. The aim of our study was to evaluate the result of TKA in patients with previous distal femoral fracture. METHODS: The results of 48 cemented condylar total knee arthroplasties, performed between 1980 to 1998, in 47 patients with a previous distal femoral fracture were reviewed. There were 37 females and 10 males with an average age of 65 years (range, 19-84 years). Follow-up averaged 6.2 years (range, 2-16 years). No patients were lost to follow-up. RESULTS: At the time of arthroplasty a femoral fracture non-union was present in three knees, all of which were treated with a long stem cemented femoral component and bone grafting. Malunion, defined as angulation greater than 10 degrees in the coronal plain or greater than 15 degrees in the sagittal plain, was present in 21 knees. Of these, six underwent distal femoral osteotomy during TKA. In the remaining 15 patients, with a malunion, the deformity was addressed by alterations in the orientation and location of bone resection. Other procedures were commonly needed at the time of arthroplasty and included: lateral retinacular release (22 knees), extensor mechanism realignment (eight knees), and collateral ligament reconstruction (two knees). The mean pre-operative Knee Society Scores were 40 (range, 0-80) for pain and 48 (range, 0-100) for function and improved significantly to a mean of 84 (range, 37-99) and 66 (range, 0-100) points, respectively, at the latest follow-up (P<0.001). The knee arc of motion improved from a pre-operative mean of 83-99 degrees at the latest follow-up (P<0.004). Post-operative manipulation under anesthesia for poor motion was carried out in four knees. Two knees had aseptic loosening that required subsequent revisions. Three knees developed deep infection which was treated with debridement and retention of components in one knee, arthrodesis in another, and eventual amputation in one knee. CONCLUSIONS: Significant improvement in function and relief of pain is seen in the vast majority of patients with previous distal femoral fractures undergoing subsequent TKA. However, these patients are at increased risk for restricted motion and perioperative complications following TKA. Special efforts to preserve the vascularity of the skin and subcutaneous tissues, restore limb alignment, ensure correct component positioning, and achieve soft tissue balance may help minimize the problems identified in this study.

Adult↗

PubMed2006

Evaluation of the pharmacokinetic profile and analgesic efficacy of oral morphine after total hip arthroplasty.

BACKGROUND AND OBJECTIVE: Oral morphine may be useful for postoperative pain relief, but few studies have tested its use after in-hospital surgery. METHODS: We evaluated clinical efficacy and the pharmacokinetic parameters of oral morphine after total hip arthroplasty. We recruited 60 patients who had total hip arthroplasty under general anaesthesia. The patients were randomized to receive placebo, 10 mg morphine sulphate or 20 mg morphine sulphate orally every 4 h for 24 h. The oral administration was started 3 h after the morphine-loading dose in the Post Anaesthesia Care Unit and then patients used intravenous morphine patient-controlled analgesia for 24 h. Pain score at rest (scored by patients on a visual analogue scale), sedation, nausea, vomiting and urinary retention were monitored. In 11 additional total hip arthroplasty patients, we determined the pharmacokinetics of morphine and its metabolites after oral administration of 20 mg morphine sulphate every 4 h for 16 h. RESULTS: The amount of morphine administered via patient-controlled analgesia over 24 h was reduced in the 20-mg group compared with that in the placebo group (19.0 +/- 2.7 mg vs. 33.0 +/- 5.5 mg; P = 0.03). No significant morphine-sparing effect was observed in the 10-mg group. Pain scores and side-effects were similar in all groups. The pharmacokinetic study revealed a limited and slow absorption of morphine. CONCLUSION: Despite a limited absorption of oral morphine postoperatively, high doses of oral morphine have a significant analgesic effect after total hip arthroplasty.

Administration, Oral↗

PubMed1998

Beta 2-microglobulin amyloid deposition in hip revision arthroplasty tissues.

AIMS: Hip joint disease associated with progressive amyloid deposition in uraemic patients receiving chronic haemodialysis treatment often requires treatment by joint arthroplasty. The aim of this study was to determine whether beta 2-microglobulin amyloid deposition occurred in the periprosthetic tissues of arthroplasties that had undergone aseptic loosening and required a revision procedure. METHODS AND RESULTS: Sections of the pseudocapsule, acetabular and femoral pseudomembrane surrounding failed total hip replacements of five uraemic patients known to have beta 2-microglobulin amyloid deposits at the time of primary joint replacement were examined for the presence of beta 2-microglobulin amyloid deposition by Congo red staining and immunohistochemical staining for beta 2-microglobulin and other amyloid proteins. Clinical and radiological features of each case, including postoperative history and extent of osteolysis, were also noted. In all cases evidence of beta 2-microglobulin amyloid deposits were found in one or more of the above periprosthetic tissues. In three of these cases amyloid deposition was extensive. CONCLUSIONS: This study shows that beta 2-microglobulin amyloid deposition occurs in revision arthroplasty tissues. Accelerated loosening of the prosthesis is known to occur in uraemic patients and it is possible that beta 2-microglobulin amyloid deposition may contribute to early arthroplasty failure in uraemic patients who remain on haemodialysis treatment.

Adult↗

PubMed2002

Angiotensin-converting enzyme gene polymorphism may influence blood loss in a geriatric population undergoing total hip arthroplasty.

OBJECTIVES: To evaluate how angiotensin-converting enzyme (ACE) gene polymorphism is associated with perioperative blood loss in hip arthroplasty in a geriatric population. DESIGN: A case-control study of subjects consecutively undergoing total hip arthroplasty. SETTING: A department of orthopedic surgery in Italy. PARTICIPANTS: One hundred five patients, mean age +/- standard deviation 68.6 +/- 10.4, undergoing total hip arthroplasty. MEASUREMENTS: ACE gene polymorphism was analyzed using polymerase chain reaction. Decrement of hemoglobin (Hb) and hematocrit (Ht) was calculated as the difference between the preoperative and the lowest postoperative value, measured 1, 2, and 3 days after surgery. Total blood loss was calculated as the sum of intra- and postoperative blood loss. RESULTS: Patients carrying the deletion homozygous and insertion/deletion heterozygous genotypes of the ACE gene show a higher decrement of Hb (P <.01) and Ht (P <.01) and higher total blood loss (P <.007) after hip surgery than subjects carrying the insertion (II) homozygous. The role of ACE gene polymorphism seems hypertension independent. Logistic regression analysis showed that II genotype reduces total blood loss. CONCLUSIONS: This is the largest study evaluating the distribution of ACE gene genotypes in patients undergoing hip arthroplasty and the first investigating the association between bleeding and ACE gene polymorphism. Our data suggest that II genotype is associated with lower total blood loss.

Aged↗

PubMed2000

Arthroscopy for failed shoulder arthroplasty.

PURPOSE: It was the purpose of this study to describe the specifics of technique and results of arthroscopic evaluation and treatment of failed shoulder arthroplasties in 10 patients with early and late complications of shoulder arthroplasty. TYPE OF STUDY: Case series. MATERIALS AND METHODS: Ten patients (2 bilateral) underwent 13 arthroscopies after poor results following shoulder arthroplasty. The arthroscopic diagnoses ranged from rotator cuff tears in 5 shoulders, fibrosis and scarring of the long head of the biceps in 5 shoulders, impingement and biceps tendinitis in 1 shoulder, and capsular contracture in 1 shoulder. We performed 4 mini-open rotator cuff repairs, 1 open rotator cuff repair with revision of the humeral component, 5 arthroscopic debridements of the long head of the biceps, 2 arthroscopic decompressions with biceps tenodesis, and 1 arthroscopic capsular release. RESULTS: Before arthroscopy, the preoperative Hospital for Special Surgery (HSS) scores were 6 fair and 6 poor. At latest follow-up, there were 3 excellent, 4 good, and 5 fair results. There was a statistically significant improvement in HSS scores and range of motion for all patients in this study. All patients were satisfied with the results of the procedure. There were no infections or wound problems and neurovascular status was unaltered after arthroscopy. There was 1 intraoperative complication, a periprosthetic humerus fracture after manipulation in an osteoporotic woman with rheumatoid arthritis. CONCLUSION: Arthroscopy proved to be a reliable diagnostic and therapeutic tool in dealing with some of the postoperative complications encountered both early and late after shoulder arthroplasty. Careful attention to surgical technique, including use of blunt trocars, traction, and intraoperative prophylactic antibiotics, can minimize complications of arthroscopy in this setting.

Adult↗