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PubMedDate not supplied

Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus.

The purpose of this multicenter study was to analyze the results of shoulder arthroplasty for the treatment of the sequelae of proximal humerus fractures and establish an updated classification system and treatment guidelines for these complex situations. Seventy-one sequelae of proximal humerus fractures were treated with shoulder replacement with the use of the same nonconstrained, modular, and adaptable prosthesis: the Aequalis prosthesis (Tornier Inc, St Ismier, France). The average time between initial fracture and shoulder arthroplasty was 5 years and 5 months. On the basis of anatomic classification schemes, sequelae were divided into 4 types: type 1, humeral head collapse or necrosis with minimal tuberosity malunion (40 cases); type 2, locked dislocations or fracture-dislocations (9 cases); type 3, nonunions of the surgical neck (6 cases); and type 4, severe malunions of the tuberosities (16 cases). The mean postoperative follow-up was 19 months (range, 12 to 48 months). Overall, the postoperative Constant score was excellent in 11 cases (16%), good in 19 cases (26%), fair in 18 cases (25%), and poor in 23 cases (33%). There were 18 complications (27%). Fifty-nine of 70 patients (81%) stated that they were satisfied with the result. The most significant factor affecting functional outcome was greater tuberosity osteotomy (P <.005). Regarding both surgical treatment and postoperative prognosis, we identify 2 categories of proximal humerus fracture sequelae: category 1, intracapsular/impacted fractures sequelae (associated with both cephalic collapse or necrosis [type 1] and chronic dislocation or fracture-dislocation [type 2]), in which an articulating joint can be reconstructed without a greater tuberosity osteotomy; and category 2, extracapsular/disimpacted fractures sequelae (associated with both surgical neck nonunions [type 3] and severe tuberosity malunions [type 4]) where the proximal humerus cannot be reconstructed without a greater tuberosity osteotomy. All of the excellent and good postoperative Constant scores were obtained in type 1 and 2, in which osteotomy of the greater tuberosity was not required. All patients in type 3 and 4, who underwent a greater tuberosity osteotomy, had either fair or poor results and did not regain active elevation above 90 degrees. We conclude that a greater tuberosity osteotomy is the most likely reason for poor and unpredictable results after shoulder replacement arthroplasty for the treatment of the complex sequelae of proximal humerus fractures. Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus should be performed without an osteotomy of the greater tuberosity when possible. If prosthetic replacement is possible without an osteotomy, surgeons should accept the distorted anatomy of the proximal humerus and adapt the prosthesis and their technique to the modified anatomy. A modular and adaptable prosthesis with both adjustable offsets and inclination may allow surgeons to adapt to a large number of malunions and may help to avoid the troublesome greater tuberosity osteotomy in a higher proportion of cases.

Adult↗
PubMedDate not supplied

Shoulder arthroplasty for advanced glenohumeral arthritis after anterior instability repair.

We retrospectively reviewed 19 patients (19 shoulders) in whom advanced glenohumeral arthritis developed after anterior instability repair. The anterior instability repairs included 4 Bristow, 4 Putti-Platt (2 in combination with other procedures), 4 Magnuson-Stack, 2 Bankart, and 5 other anterior capsulorrhaphies. Seventeen of the shoulders were treated with arthroplasty: 15 with total shoulder replacement and 2 with humeral head replacement, at a mean age of 45 years (range, 32-69 years). Two patients did not have surgical treatment. The mean internal rotation contracture was 58 degrees (15 degrees -125 degrees ). Eleven patients (65%) required subscapularis lengthening and anterior capsular release to correct a severe internal rotation contracture. Three (18%) had glenoid bone grafting, and one had glenoidplasty to correct severe posterior glenoid wear. The results were evaluated after a mean follow-up of 62 months (range, 24-167 months). Arthroplasty reduced the level of pain in 16 cases (94%). Active forward elevation increased 21 degrees to 120 degrees, active external rotation increased 38 degrees to 41 degrees, and passive internal rotation increased a mean of 3 vertebral levels to T12. There was improvement in functional use of the upper extremity in all cases except one. Subjectively, 12 shoulders were rated as much better, 4 as better, and 1 as worse than preoperatively. Three underwent revision arthroplasty procedures. Advanced glenohumeral arthritis is a rarely reported late sequela of anterior instability surgery. It is more common after nonanatomic repairs, presents in patients at younger ages than typical glenohumeral osteoarthritis, and is characterized by severe internal rotation contracture and posterior glenoid wear. Prosthetic arthroplasty, although technically challenging, effectively reduced pain and improved function in our series.

Adult↗
PubMed2001

The Swedish Knee Arthroplasty Register 1975-1997: an update with special emphasis on 41,223 knees operated on in 1988-1997.

From 1975, when the Swedish Knee Arthroplasty Register (SKAR) started, until the end of 1997, 57,533 primary arthroplasties and revisions have been registered. Recently, the register underwent a comprehensive validation and update regarding revisions. We now report on general demographic and epidemiological data for the whole period and on the survivorship of arthroplasties performed in Sweden during 1988-1997. During this 10-year period, 41,223 primary knee arthroplasties were performed on 34,877 patients. We found, as in our earlier reports, that survivorship was affected by patient-, time-, implant- and method-related factors but, apart from an overall higher cumulative revision rate, general conclusions reported from the register in recent years appeared to be unaffected.

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PubMed2004

Quality of life after hip revision with impaction bone grafting on a par with that 4 years after primary cemented arthroplasty.

BACKGROUND: There have been few studies evaluating patient-reported quality of life outcomes after hip revision with impaction bone grafting. PATIENTS AND METHODS: The inclusion criteria were aseptic loosening after primary arthroplasty performed for osteoarthrosis, and first-time revision with impacted morselized allograft bone and cemented Exeter stem. During a 4-year period, 35 patients were eligible and all were included. The Nottingham Health Profile (NHP) was completed by the patients and the Charnley hip scores recorded by the examining surgeon preoperatively, after 6 months and yearly up to 4 years (28 patients) postoperatively. For comparison, 35 osteoarthrotic patients completed the NHP 4 years after cemented Exeter primary arthroplasty. RESULTS: At 4 years, the NHP scores for the revision patients did not differ significantly from those recorded in the primary arthroplasty group. Among the revision patients, mixed model analysis showed improvement in NHP pain (p < 0.001) and physical mobility scores (p = 0.002). The effect size at 4 years was large for pain (1.2) and moderate for physical mobility (0.6). The major improvement was recorded at 6 months, with no further substantial change observed. The correlations between the NHP and Charnley scores were weak or moderate (r, -0.15 to -0.67). INTERPRETATION: Hip revision with impaction bone grafting leads to substantially improved quality of life, similar to that 4 years after primary arthroplasty.

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PubMed2002

Reorganization of equilibrium and movement control strategies after total knee arthroplasty.

This work was aimed at identifying changes in posturomotor control strategies in patients with unilateral total knee arthroplasty. Using kinetic and kinematic data, a previous study had revealed that, during a side step, patients with unilateral knee arthritis showed a shortened monopodal phase and a lengthened postural phase when the affected leg was the supporting one. It was expected that these strategies would be modified after undergoing total knee arthroplasty. Postoperatively the durations of the monopodal phase and of the postural phase became similar when the operated limb was supporting and when the sound limb was supporting. Concerning the upper body movements, the same asymmetrical results as before surgery were observed. Hence, patients with total knee arthroplasty exhibit posturomotor strategies which, although they become close to normal, remain asymmetrical. The durations of the monopodal and of the postural phases could be considered to assess the results of total knee arthroplasty.

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PubMed2005

Tranexamic acid reduces blood loss in cemented hip arthroplasty: a randomized, double-blind study of 39 patients with osteoarthritis.

BACKGROUND: Tranexamic acid has been found to reduce blood loss and the need for blood transfusions in knee arthroplasty. In hip arthroplasty, the benefit of tranexamic acid is not as clear. PATIENTS AND METHODS: In a randomized, double-blind study, 39 patients with primary cemented hip arthroplasty for osteoarthritis were divided into two groups; one receiving tranexamic acid and the other not receiving it. Tranexamic acid was given in a dose of 10 mg/kg before the operation and twice thereafter, at 8-hour intervals. RESULTS AND INTERPRETATION: Total blood loss was smaller in the tranexamic acid group than in the control group. No thromboembolic complications were noticed. Tranexamic acid appears to be an effective and economic drug for reduction of blood loss in cemented primary hip arthroplasty for osteoarthritis.

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PubMedDate not supplied

Treatment options for infected knee arthroplasties.

Twenty-four total knee arthroplasty infections in 23 patients treated over a 9-year period at the University of Texas Medical Branch at Galveston were retrospectively reviewed. Staphylococcus epidermidis was isolated from 11 of 24 and Staphylococcus aureus from eight of 24 knees, respectively. Eleven infections were polymicrobic. Control of infection was obtained in 13 of 13 patients treated initially with resection arthroplasty, and 11 of these were ambulatory at follow-up. Infection was controlled in three of 10 knees treated initially with debridement, and six of these nine patients were ambulatory at follow-up. One patient was initially treated with amputation. Four of four patients treated by resection arthroplasty and then by reimplantation were ambulatory without signs of infection at follow-up. Resection arthroplasty reliably controls infection but produces a painful unstable joint that requires brace support or subsequent surgery for pain-free ambulation. Reimplantation in selected patients offers the best chance for pain-free ambulation.

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PubMed2003

Elective primary total hip arthroplasty in octogenarians.

BACKGROUND: Total hip arthroplasty (THA) has resulted in decreased pain and increased function in people with end-stage hip arthritis for several decades. In elderly people, THA has been used most often following femoral neck fracture. However, with life spans increasing and people remaining healthy and active well into their eighties, arthroplasty surgeons are now performing primary THA as an elective procedure in octogenarians. The aim of this study was to demonstrate the efficacy of elective total hip arthroplasty in patients aged 80 years or older with end-stage hip arthritis. METHODS: Forty patients (46 THAs), aged 80 or older at the time of surgery, were identified for this study. Clinical assessment included amount of hip pain, limp, and use of assistive devices for ambulation at most recent follow-up. Radiographic assessment included implant stability, heterotopic bone formation, and osteolysis. Medical and hip-related complications, reoperations, and revisions were recorded from medical records. RESULTS: Eleven patients (27.5%) suffered a medical complication and six patients (15%) had a hip-related complication, all of which were treated and were not life threatening. Clinically, 80% were pain free and 70% walked without assistance at an average 4-year follow-up. Radiographically, all implants were stable without osteolysis. No components had been revised; however, four patients had undergone a reoperation, three for recurrent dislocation. CONCLUSIONS: Elective total hip arthroplasty is a safe and effective treatment for end-stage osteoarthritis of the hip in the elderly patient. However, the procedure is not without risk. Complications, often related to preexisting comorbidities, do occur, but mortality rates are low.

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PubMed2001

Physical exercise and risk of severe knee osteoarthritis requiring arthroplasty.

OBJECTIVES: To examine the association between physical exercise and the risk of severe knee osteoarthritis requiring arthroplasty. SUBJECTS AND METHODS: A case-control study was carried out in which the cases were men (n=55) and women aged 55-75 yr (n=226) receiving knee arthroplasty for primary osteoarthritis at the Kuopio University Hospital. Controls (n=524) were selected randomly from the population of Kuopio province. Lifetime physical exercise was assessed retrospectively. Cumulative exercise hours were calculated and divided into two classes by mean (low/high). RESULTS: The risk of knee osteoarthritis requiring arthroplasty decreased with increasing cumulative hours of recreational physical exercise. After adjustment for age, body mass index, physical work stress, knee injury and smoking, the odds ratios (with 95% confidence intervals) of knee arthroplasty were 0.91 (0.31-2.63) in men with a low number of cumulative exercise hours and 0.35 (0.12-0.95) in those with a high number of cumulative exercise hours, with a history of no regular physical exercise as the reference. For the women, the corresponding odds ratios were 0.56 (0.3-0.93) and 0.56 (0.32-0.98). CONCLUSION: Moderate recreational physical exercise is associated with a decrease in the risk of knee osteoarthritis.

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PubMed1998

The incidence of large venous emboli during total knee arthroplasty without pneumatic tourniquet use.

UNLABELLED: Echogenic venous emboli accompany tourniquet deflation during total knee arthroplasty. Two types of echogenic emboli appear in the central circulation: small venous emboli (miliary emboli) and large venous emboli (masses of echogenic material superimposed on miliary emboli). Presumably, medullary cavity trespass releases small and large echogenic emboli. However, patients undergoing lower extremity procedures with a tourniquet have large echogenic emboli regardless of medullary cavity invasion. Avoiding tourniquet inflation may decrease the release of large venous emboli. Thirteen patients undergoing total knee arthroplasty without pneumatic tourniquet received intramedullary guides and 11 patients received tibial extramedullary guides. Recordings of hemodynamic variables, mixed venous oximetry, end-tidal CO2, and echocardiographic images were made after the induction of anesthesia and for 15 min after femoral prosthesis cementing. Mean arterial pressure did not change during the study, and mean pulmonary arterial pressure increased minimally. Large venous emboli appeared in eight patients, small venous emboli appeared in 12 patients, and no emboli appeared in four patients. Compared with previous investigations of large venous emboli during total knee arthroplasty with a pneumatic tourniquet, multiple logistic regression analysis discloses a 5.33-fold greater risk of large venous embolism accompanied the use of a tourniquet during total knee arthroplasty. IMPLICATIONS: One third of knee replacements performed without a tourniquet demonstrated large emboli. Reducing marrow cavity invasion did not decrease the release of large emboli. Compared with knee replacement without tourniquet, tourniquet use places patients at a 5.33-fold greater risk of having a large emboli.

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PubMed2001

The clinical relevance of embolic events detected by transesophageal echocardiography during cemented total hip arthroplasty: a randomized clinical trial.

UNLABELLED: The first aim of this prospective clinical study was to characterize the relationship between embolic events observed during cemented total hip arthroplasty using transesophageal echocardiography (TEE), and changes in cardiopulmonary function. The second aim was to assess the efficiency of a modified cementing technique that was developed to reduce the risk of embolism. The modification consists in a vacuum drainage placed in the proximal femur to reduce the increase of intramedullary pressure during insertion of the prosthesis. One hundred twenty patients were randomized into two groups. Group 1 received a total hip arthroplasty cemented conventionally, whereas Group 2 was cemented with the modified technique. Continuous TEE, hemodynamic monitoring, and blood gas analysis were done during the perioperative period. Severe embolic events were imaged during the insertion of the femoral component and the reduction of the hip joint. Embolism occurred in 93.3% of patients operated on with the conventional cementing technique, compared with 13.3% of patients operated on with the modified technique (P < 0.05). Intraoperative shunt values during insertion of the femoral component increased from 8.2% to 10.3% (P < 0.05) in Group 1 patients, whereas there was no significant change in Group 2 patients. We observed no clinical signs of fat embolism syndrome in any study patient. The results of the study indicate that embolic events observed using TEE can cause increased pulmonary shunt values during hip arthroplasty, especially in patients with systemic disease (ASA physical status III). The modified surgical technique effectively reduced the incidence of embolization during cemented hip arthroplasty. IMPLICATIONS: Use of conventional cementing techniques is associated with echocardiographic evidence of embolism in 93% of patients and with a significant increase in pulmonary shunting. The incidence of embolism and change in shunting are reduced with a modified cementing technique that limits increases in intramedullary pressure.

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PubMed2000

Intraoperative cerebral arterial embolization during total hip arthroplasty.

BACKGROUND: Fat embolism to the pulmonary circulation is known to occur during total hip arthroplasty, especially during insertion of a cemented femoral component. Fat and air bubbles may enter the systemic circulation via a patent foramen ovale or through pulmonary circulation. METHODS: To determine whether microemboli to the brain were occurring during total hip arthroplasty, 23 patients underwent transcranial Doppler assessment of emboli to the middle cerebral artery during total hip arthroplasty. Surgery was performed with the patient in the lateral decubitus position so that the probe recorded from the nondependent side. RESULTS: Successful recordings were made in 20 patients, in 8 of 20 patients there were embolic signals, which ranging from 1 to 200. In all eight patients, signals were recorded during impaction of a cemented component or after relocation of the hip. Only one patient showed evidence of emboli with impaction of the acetabulum component. In two patients there were 150 and 200 embolic signals: in both mild respiratory symptoms developed. One patient became overtly agitated during a flurry of emboli. CONCLUSION: Cerebral microemboli can occur during total hip arthroplasty. Whether this contributes to changes in postoperative cognitive function is unknown.

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PubMed2002

Abnormal echogenic findings detected by transesophageal echocardiography and cardiorespiratory impairment during total knee arthroplasty with tourniquet.

BACKGROUND: In patients undergoing total knee arthroplasty, intraoperative pulmonary embolic events are rare, and most occur following tourniquet deflation. This embolization can be observed using transesophageal echocardiography. However, the authors have encountered sudden decreases in arterial oxygen partial pressure while a tourniquet is still inflated. Therefore, the current investigation was designed to detect emboli during the tourniquet inflation phase and to identify the composition of the echogenic material. METHODS: Forty-six patients were randomly assigned to undergo total knee arthroplasty without (control, n = 24) or with a tourniquet (n = 22). Hemodynamic monitoring, blood gas analysis, and continuous transesophageal echocardiography were performed during the total knee arthroplasty procedure. Right jugular blood specimens were collected whenever echogenic material was seen in the atrium. RESULTS: In the tourniquet group, embolic events occurred in 27% of patients during femoral reaming and in 100% after tourniquet deflation. In the control group, emboli were detected in 54% of patients during femoral reaming. Most of the patients exhibited cardiopulmonary impairment after severe echogenic embolism, even while the tourniquet was inflated (two patients). None of the blood samples aspirated from the central catheters contained detectable material. CONCLUSIONS: This prospective study showed that embolic events occurred during total knee arthroplasty, even while a tourniquet was inflated. An inflated tourniquet does not completely prevent pulmonary emboli.

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PubMed1997

Arthroplasty of rheumatoid metatarsophalangeal joints. An outcome study.

Deformity of the forefoot is a common disabling problem in chronic rheumatoid arthritis. The most common deformifies are hallux valgus, cockup toes, and depressed metatarsal heads. Resection arthroplasty has been improved by adding reconstructive procedures, for example, medial capsular arthroplasty in the great toe and plantar plate arthroplasty of the lesser toes with longitudinal pinning of all toes for 4 weeks. Results were compared with a series of silicone double hinge implants without grommets in the great toe and resection of lesser metatarsal heads and pinning. Patients were evaluated by questionnaire to evaluate outcome. There was no significant difference in the two series of patients. Overall good results were 85% to 95% and slightly favored the group without implants. These results were equal to those reported in the literature for patients who underwent fusion of the great toe and resection arthroplasty of lesser toes.

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PubMed1998

Femoral component failure in hybrid total knee arthroplasty.

From 1986 to 1991, 74 consecutive hybrid total knee arthroplasties (in 65 patients) of a single design were performed at the authors' institution. Seven patients (eight knees) died with well functioning replacements during the surveillance period. One patient refused to participate in any followup efforts because of billing disputes. This left 65 total knee arthroplasties (57 patients) for review. There were 35 men and 22 women with an average age of 60 years (range, 27-83 years) at the time of arthroplasty. The underlying diagnosis was osteoarthritis in 46 knees, rheumatoid arthritis in six knees, and other in four knees. The average length of followup was 7.4 years (range, 5-10 years), and no patients were lost to followup. The Knee Society scores improved from an average of 37 preoperatively to 84 at latest followup. The functional score improved from 49 to 69 at latest followup. Ten (13.8%) knees required revision surgery. Eight of the nine knees that were revised had femoral component problems, including a loose component in six and a fractured component in two. One knee was revised for polyethylene wear with secondary osteolysis and one was revised elsewhere in which the operative details are unknown. The implant survival to revision at 5 years was 89% and 85% at final followup. Femoral component fixation in hybrid total knee arthroplasty in unreliable with this component design. In light of the excellent 10- to 15-year results of cemented condylar knee designs it is thought that hybrid fixation should be abandoned.

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PubMed1999

In vivo femoral intramedullary pressure during uncemented hip arthroplasty.

There is evidence in several animal and human studies that high intramedullary pressure in the femur is of causal significance for bone marrow release into the circulation, causing pulmonary fatty marrow embolization. A previous clinical study provided evidence that in uncemented hip arthroplasty, high intramedullary pressure and subsequent fat embolism with cardiorespiratory deterioration can occur. In this prospective clinical trial, the effect of five surgical techniques on the femoral intramedullary pressure was recorded intraoperatively in 36 patients during uncemented press fit hip arthroplasty. In Group A, the conventional surgical technique (slide hammer and femoral rasps) showed intramedullary hypertension during opening of the femoral canal, femur preparation, and prosthesis insertion. In Group B, a mechanical high frequency vibration rasp was used, instead of the slide hammer, and provided reduction of the intramedullary pressure peaks during opening of the femoral canal but could not prevent intramedullary hypertension during rasping and prosthesis insertion. In Group C, a modified surgical technique to prevent high intramedullary pressure reduced pressure peaks during opening of the femoral canal and resulted in a significant reduction of intramedullary pressure during femur preparation and prosthesis insertion compared with the conventional surgical technique used with Group A. In Group D the results of the modified surgical technique could be improved additionally by using the high frequency vibration rasp, instead of the slide hammer. In Group E conventional surgical technique in combination with a distal venting hole has not proven to be efficient in uncemented hip arthroplasty. Based on the results of this in vivo study, the proposed modified surgical technique in cementless hip arthroplasty can be recommended to avoid high intramedullary pressure peaks, which should minimize the risk of significant bone marrow release into the circulation and the risk for cardiorespiratory deterioration caused by fat embolism.

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PubMed1999

Venous thromboembolic disease after hybrid hip arthroplasty with negative duplex screening.

Postoperative duplex ultrasonography screening after total hip arthroplasty has been shown to identify patients who may require treatment or additional monitoring for venous thromboembolic disease. The potential for manifestation of venous thromboembolic disease subsequent to screening remains a concern. The objective of this study was to determine the prevalence of symptomatic venous thromboembolic disease after total hip arthroplasty and after inhospital prophylaxis, inhospital screening with negative results for proximal deep venous thrombosis, and no posthospitalization venous thromboembolic disease prophylaxis. One hundred fifty patients undergoing primary hybrid total hip arthroplasty and using pneumatic compression stockings and aspirin as prophylaxis against venous thromboembolic disease were screened for deep venous thrombosis with duplex ultrasonography on the fourth day after surgery. Duplex ultrasonography screening revealed 17 (11.3%) patients with asymptomatic proximal deep venous thrombosis. In response to duplex ultrasonography screening, these patients with proximal deep venous thrombosis received therapeutic anticoagulation. Of 133 patients with a duplex screen with negative results for proximal deep venous thrombosis, 131 (98.5%) continued to have no symptoms of venous thromboembolic disease and two (1.5%) began to have symptoms for venous thromboembolic disease (one with proximal deep venous thrombosis, one with nonfatal pulmonary embolism) during 12 months of clinical followup after total hip arthroplasty. The overall prevalence of venous thromboembolic disease requiring anticoagulation was 19 of 150 (12.6%) patients. The remaining 131 (87.4%) were not exposed to the risks of postoperative anticoagulation and did not have subsequent symptomatic venous thromboembolic disease.

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PubMed2000

Revision total knee arthroplasty by impaction bone grafting.

The presence of bone loss in a failed total knee arthroplasty can present a significant reconstructive challenge. Experience with the technique of using impacted morselized allograft with revision components having fixed stems is presented. Nineteen knees (21 patients) were reconstructed using impacted bone graft alone in 14 knees, bone graft plus methylmethacrylate in five knees (including one knee in which the replacement failed), and in three knees morselized bone graft was used in conjunction with structural bone allograft. Minimum followup ranged from 6 months to 62 months for the patients in the current series. These patients represent a relatively small, but growing portion of this surgeon's population of patients undergoing revision knee arthroplasty. Patients with large defects were selected for the study. Histologic specimens from the one failed knee arthroplasty revealed viable, incorporated bone graft. Excluding the replacement that failed, the average improvement in Knee Society combined knee and function scores was 87 points. The principles of revision and primary total joint arthroplasty are applied for achieving a stable implant. Specific to this technique, solid support of the implant-graft interface, graft-host bone interface, and the use of a tight, supportive stem is imperative. The author's experience provides additional support for the use of bone grafting techniques in patients with large bone defects who are undergoing revision total knee replacement.

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