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PubMed2000

Subvastus and medial parapatellar approaches in total knee arthroplasty.

This retrospective study compared the outcome of two consecutive groups of patients having primary total knee arthroplasty. The arthroplasties were performed in the first group (169 arthroplasties in 143 patients) from 1988 to 1992 using a medial parapatellar approach, and in the second group (167 arthroplasties in 148 patients) from 1992 to 1996 using a subvastus approach. The patient outcomes were evaluated at 6 months, and were based on clinical and radiographic measures, occurrence of intraoperative lateral retinacular release, and incidence of postoperative patellar subluxation. There were no significant differences between the two groups for range of motion, Knee Society knee and function scores, and stair climbing ability. The patella tracked centrally in significantly more knees with the subvastus approach (139 of 167 knees, 83%) than with the parapatellar approach (107 of 169 knees, 63%). There were significantly fewer knees in the subvastus group requiring a lateral retinacular release (62 of 167 knees, 37%), compared with the parapatellar group (113 of 169 knees, 67%). The authors concluded that the subvastus approach led to improved patellar tracking and stability. Although the surgical and rehabilitative protocols were identical for both groups, the results may have been affected by changing circumstances during the 9-year period of the study.

Adult↗
PubMed2000

The early history of arthroplasty in the United States.

Arthroplasty is defined in the broadest sense as a reconstructive procedure that alters the structure or function of a joint. The first recorded procedures done in the United States in the early nineteenth century and the introduction of modern total joint replacement in the 1970s will be discussed. Although major surgical procedures occasionally were performed in the early 1800s, it was not until the introduction of general anesthesia and antiseptic techniques during the latter half of the nineteenth century that the field of surgery could be developed. Procedures involving the major joints of the upper and lower extremities are described. These procedures include resection and interposition arthroplasties, joint debridement, procedures done to correct complications of hip fractures and developmental dysplasia of the hip, cup arthroplasties, endoprosthetic replacement, hinge arthroplasties, resurfacing procedures, and early total joint replacement.

Anesthesia↗
PubMed2000

Articulating versus static spacers in revision total knee arthroplasty for sepsis. The Ranawat Award.

Antibiotic laden spacer blocks frequently are used to treat an infected total knee arthroplasty. Static spacer blocks make exposure at reimplantation difficult secondary to quadriceps shortening. Unexpected bone loss attributable to migration of the spacer block also has been reported. To avoid these problems, a temporary articulating molded implant made of antibiotic cement was used in a consecutive series. The authors sought to determine whether its use would affect the reinfection rate, improve functional results, or prevent bone loss compared with static spacers. Twenty-five patients were treated with static nonarticulating spacers. Since 1996, 30 patients have been treated with tobramycin-laden articulating spacers. The knee arthroplasties in three patients treated with a static spacer became reinfected (12%). The knee arthroplasty in one patient with an articulating spacer became reinfected (7%). Fifteen of the 25 patients with static spacers had unexpected bone loss between stages. No appreciable bone loss could be measured in the patients who received articulating spacers. The average Hospital for Special Surgery score was 83 points in the patients with static spacers and 84 points for the patients with articulating spacers. Range of motion at final followup averaged 98 degrees in the patients who received static spacers and 105 degrees in the patients who received articulating spacers. Articulating spacers seem to facilitate reimplantation of infected total knee arthroplasty without additional risk of infection. Unexpected bone loss is no longer a concern with this two-stage technique. Articulating spacers offered no functional advantage over static spacers in this study group.

Anti-Bacterial Agents↗
PubMed2000

The role of bladder catheterization in total knee arthroplasty.

The use of a urinary bladder catheter in the perioperative period for patients undergoing total knee arthroplasty is controversial. In the current study, two bladder management protocols were studied. One group of patients had an indwelling catheter inserted into the bladder before total knee arthroplasty. The other group of patients was observed and treated for urinary retention as necessary. From 1993 to 1998, 652 patients undergoing primary, unilateral total knee arthroplasty were randomized by surgeon into two groups: one group underwent preoperative insertion of an indwelling bladder catheter (306 patients), and one group (346 patients) had a catheter inserted postoperatively as necessary. Sixty-six percent (229 of 346) of these patients required catheterization (203 had indwelling catheters and 26 had intermittent straight catheters). A urinary tract infection developed in five patients (1.6%) in whom a catheter was inserted preoperatively. A urinary tract infection developed in six patients (1.7%) in whom a catheter was inserted if necessary. Five of these urinary tract infections developed in patients with delayed indwelling bladder catheters. A urinary tract infection did not develop in any patient in whom a straight catheter was inserted. There was no significant difference in the length of stay in the hospital between the two groups. The group in whom a catheter always was inserted generated $491 greater cost for total knee arthroplasty than patients in whom a catheter was inserted if necessary.

Adult↗
PubMed2001

Total knee arthroplasty in patients with isolated patellofemoral arthritis.

The current study evaluated the results of total knee arthroplasty for the treatment of isolated patellofemoral degenerative arthritis. Between 1980 and 1997, 31 total knee arthroplasties were done in 24 patients with advanced, isolated patellofemoral arthritis. The average followup was 5.2 years (range, 2-12 years). There was a significant improvement in the mean preoperative Knee Society pain and function scores. Twenty-one knees required a lateral retinacular release and three knees required additional formal proximal realignment at the time of the total knee arthroplasty. There were three reoperations in this series including, manipulation for poor motion in one patient; revision of a loose patellar component in one patient; and extensor mechanism realignment in the third patient. At midterm followup, total knee arthroplasty proved to be reliable and durable in alleviating pain and improving function in this group of patients with isolated, advanced patellofemoral arthritis. Surgeons should be made aware, however, that resurfacing of the patella and balancing the extensor mechanism for patients with isolated patellofemoral arthritis can be demanding technically as evidenced by the high rate of asymmetrically resurfaced patellas, the high rate of lateral retinacular release, and formal realignment procedures.

Aged↗
PubMed2001

Low molecular weight heparin prophylaxis in total knee arthroplasty: the answer.

Venous thrombosis continues to be a major risk after total knee arthroplasty. Without prophylaxis, the prevalence of deep vein thrombosis is as high as 84%, with proximal occurrence as high as 20%. Of more concern is the occurrence of pulmonary embolism as high as 7%, with fatal pulmonary embolism as high as 0.7%. This high prevalence mandates that prophylaxis for thromboembolic disease be used for patients undergoing total knee arthroplasty. Low molecular weight heparin has been studied extensively and is safe and effective prophylaxis after total knee arthroplasty. Low molecular weight heparins have a predictable dose response, offer high bioavailability at low doses, and produce linear pharmacokinetics. It has a half-life of approximately 4.5 hours providing effective dosing every 12 to 24 hours with rapid antithrombotic action. Routine pharmacologic prophylaxis with low molecular weight heparin seems to be effective in decreasing the occurrence of venous thromboembolism. However, venographic prevalence of deep vein thrombosis among patients undergoing total knee arthroplasty and receiving prophylaxis remains substantial at 30.6%. Prophylaxis with low molecular weight heparin beyond hospitalization may be indicated with decreased hospital stays, although studies have not been convincing that extended outpatient prophylaxis for more then 7 to 10 days is necessary.

Arthroplasty, Replacement, Knee↗
PubMed2001

Surveillance for venous thromboembolic disease after total knee arthroplasty.

The value of deep venous thrombosis screening after total knee arthroplasty is controversial. The purpose of the current study was to examine the value of routine surveillance for venous thrombosis after total knee arthroplasty done with modern operative and perioperative treatment. Computerized search engines were used to identify papers published between 1985 and July 2000 relevant to the purpose of the study. Papers that met the inclusion criteria for review were categorized as follows: the frequency of deep venous thrombosis; the natural history of deep venous thrombosis; the accuracy of screening methods for venous thrombosis; and efficacy of screening in reducing morbidity attributable to venous thromboembolism after total knee arthroplasty. Several studies have shown a low complication rate related to venous thromboembolic disease when compression ultrasound is used for screening as part of a clinical algorithm after knee arthroplasty. However, the only large prospective randomized trial evaluating ultrasound screening failed to show a reduction in morbidity with a surveillance protocol. The benefits of surveillance depend on factors specific to each surgeon's practice including the type and duration of venous prophylaxis, the rate of symptomatic and asymptomatic thromboembolic disease associated with that protocol, and the accuracy of screening tests used for surveillance.

Arthroplasty, Replacement, Knee↗
PubMed2001

Revision of failed unicompartmental knee arthroplasty.

Little information has been published on the salvage of failed unicompartmental knee arthroplasty. The current authors examined the failure mechanisms, complexity of surgery, and complications in such revisions. Of 39 consecutive unicompartmental knee revisions, two patients died within 2 years of surgery, four had inadequate followup, and one was excluded because of infection before revision. Therefore, 30 patients (32 knees) were followed up a mean 53 months. The patients were a mean age of 59 years at the time of unicompartmental knee arthroplasty and were predominantly male (60%). Revisions were done 9 to 204 months after the unicompartmental knee arthroplasty. The predominant failure mechanism was polyethylene wear; however, nine failed because of loosening. The mean polyethylene thickness of the failed arthroplasties was 7.3 mm. Revision procedures were straightforward. Ten patients required local autograft but no allografts were used. Primary femoral components were used in all patients; 25 were cruciate-retaining. Fourteen patients had stemmed tibial components; eight had wedge augments. The mean range of motion after revision was 111 degrees. Six patients had complications not requiring intervention. Three patients had rerevision surgery for polyethylene wear at 76, 77, and 102 months, respectively, two of whom required polyethylene insert and patellar component revision. The third patient also required tibial component revision for osteolysis. Although this is a small series, the simplicity of the procedure and the complications encountered compare favorably with those of total knee revision.

Adult↗
PubMed2001

Component removal in revision total hip arthroplasty.

One of the primary steps in revision hip arthroplasty is the extraction of retained components before surgical reconstruction. In revision arthroplasty, the removal of well-fixed components and cement can be extremely demanding, time consuming, and damaging to the remaining host bone. The aims of the current study were to examine the numerous operative techniques used during extraction of acetabular and femoral components and review the results of revision hip arthroplasty after cementless component removal. A review of 157 acetabular components and 113 femoral components removed from 219 patients during hip revision arthroplasty between 1985 and 2000 was done. The average age of the patients was 64.3 years. The average followup was 5 years (range, 0.7-12.5 years). An extended proximal femoral osteotomy was done in 37 (33%) of the femoral revisions. There were 14 (5%) acetabular failures for which the patients required reoperation. There were no femoral rerevisions. Complications included dislocation (6% after acetabular revision and 9% after femoral revision), infection (6%), femoral fracture (6%), hematoma (3.5%), acetabular fixation failure (2.5%), and femoral osteolysis (1%). The removal of cemented and well-fixed porous-coated implants can be done with adequate preoperative planning and a thorough knowledge of numerous implant removal techniques.

Acetabulum↗
PubMed2002

Adverse clinical events during cemented long-stem femoral arthroplasty.

The occurrence and risk factors for adverse clinical events associated with cemented long-stem femoral arthroplasty were studied. The hypothesis was that patients with femoral metastatic disease and previously uninstrumented canals were at higher risk for such adverse events. Fifty-five consecutive patients requiring long-stem femoral arthroplasty at two institutions were retrospectively reviewed. Adverse clinical events including hypotension, sympathomimetic administration, and O 2 desaturation were subclassified according to the timing of their occurrence. Adverse events occurred in 34 of 55 patients (62%), including coma in two patients and death in a third patient. The three catastrophic events occurred in patients with metastatic disease involving previously uninstrumented femoral canals. Desaturation was more frequent in patients with metastatic disease and previously uninstrumented canals compared with patients who had revision arthroplasty and patients with previously instrumented femoral canals. Preexisting medical illness was a significant risk factor in total adverse clinical events that included cement-associated adverse clinical events and cement-associated and postoperative hypotension. In long-stem cemented femoral components risk factors for adverse clinical events included metastatic disease, uninstrumented femoral canals, and preexisting medical conditions. These findings underscore the importance of appropriate patient selection, patient and family education, and anesthesia preparation before long-stem cemented femoral arthroplasty.

Adult↗
PubMed2002

Evaluation of a staging system for infected hip arthroplasty.

A previously reported staging system for prosthetic joint infection was evaluated in 26 consecutive patients with an infected hip arthroplasty. Six patients were treated by a definitive resection arthroplasty whereas the remaining 20 patients received delayed insertion of another hip arthroplasty. Four of the 20 patients (20%) receiving a new prosthesis had reinfection develop. The only variable in common among the patients who had reinfection was the use of a massive femoral structural allograft at reconstruction. Because of the small number of patients in this study, the power of statistical analysis did not allow definitive determination of the effect of the staging system score with respect to recurrent infection. Based on this study, recommendations can be suggested for addition and deletion of certain variables within the existing staging system. Although the concept of a staging system for treatment of an infected hip arthroplasty is promising, the number of patients required to evaluate the use of a staging system will require a multicenter collaborative study.

Adult↗
PubMed2002

Unicompartmental knee arthroplasty for younger patients: an alternative view.

Unicompartmental knee arthroplasty has been a controversial operation for the past 3 decades. Many surgeons in the 1980s and 1990s found little or no indication for the procedure. Others were enthusiastic for its use in selected patients with osteoarthritis who had unicompartmental disease. Initially, unicompartmental knee arthroplasty was thought to be appropriate for the elderly patient who was sedentary. With the advent of minimally invasive techniques, indications have expanded to include its use in younger patients (especially females) as an alternative to osteotomy or tricompartmental knee arthroplasty. Advantages over osteotomy include higher initial success, greater longevity, and fewer early complications. If done conservatively, salvage is not difficult. The extent of safe postoperative activity levels has yet to be established. Failure rates seem to be higher in heavy active males. A metallic interposition hemiarthroplasty in the form of a McKeever or Macintosh prosthesis has been available for 50 years as a unicompartmental arthroplasty, but with limited use. It still may have a role in selected patients as a conservative temporizing procedure.

Adult↗
PubMed2002

Long-term results of tendon shortening trapeziometacarpal arthroplasty.

Multiple soft tissue arthroplasties have been described for reconstruction of trapeziometacarpal arthritis. Trapeziectomy with abductor pollicis longus tendon shortening has been reported to have favorable short-term results, with 95% to 100% good or excellent pain relief at an average of 18 to 31 months. No long-term results of this reconstruction have been published. In the current study, 29 abductor pollicis longus shortening arthroplasties were reviewed at an average of 5.1 years. Although 83% of patients experienced good or excellent pain relief, pinch weakness, a small arthroplasty space, and first metacarpal instability were present in numerous patients. Because of these problems observed at long-term followup, the authors now use ligament reconstruction tendon interposition as the primary trapeziometacarpal arthroplasty.

Adult↗
PubMed2003

Complications associated with reimplantation after girdlestone arthroplasty.

Complications associated with reimplantation of a total hip arthroplasty after resection or Girdlestone arthroplasty for treatment of an infected hip are not well-documented. Forty-four hips in 44 patients with a minimum 2-year followup (range, 2-9 years) from the time of reimplantation total hip arthroplasty were evaluated retrospectively. The average Harris hip score changed from 40 preoperatively to 78 at the latest followup. One patient had persistent infection requiring rerevision surgery, and another patient had rerevision surgery for recurrent dislocation. Complications related to the prosthesis consisted of dislocations in five patients (11.4%), recurrent infection in one patient (2.3%), trochanteric nonunion in four patients (9.1%), hematoma in one patient, heterotopic ossification in one patient, and postoperative wound drainage in one patient. Resection arthroplasty of the hip is highly effective in eradicating infection. In the current series, 97.7% of patients were free of infection at the latest followup. However, with an 11.4% dislocation rate and 39% of patients having a persistent limp, alternative approaches need to be evaluated which might reduce these complications.

Adult↗
PubMedDate not supplied

Getting back to the future: a grounded theory study of the patient perspective of total knee joint arthroplasty.

PURPOSE: The purpose of this study was to describe the experience of adults with osteoarthritis who had undergone a total knee joint arthroplasty. METHOD: Grounded theory qualitative methodology was applied. SAMPLE: Purposive and theoretical sample of nine participants. FINDINGS: In managing the experience of total knee joint arthroplasty, participants expressed the basic psychosocial process, "Getting back to the future." There were three main categories identified within this process, "enduring," "thinking twice," and "keeping faith." "Enduring" conceptualized the way the participants lived their daily lives. "Thinking twice" captured the participants' processes of adaptation and problem solving. "Keeping faith" was the combination of determination, trust, and optimism that sustained participants as they progressed through the total knee joint arthroplasty experience to rehabilitation. CONCLUSION: The study provides a grounded theory of the participants' perspectives of undergoing total knee joint arthroplasty, making the process more visible for those involved in their care. Prehabilitation, postoperative care, and discharge planning can facilitate the patients' optimism and motivation to self-help. Further research to explore the process from the perspective of patients with rheumatoid arthritis and patients who have complications is recommended.

Activities of Daily Living↗
PubMed2002

A new knee arthroplasty versus Brown procedure in congenital total absence of the tibia: a preliminary report.

The rates of successful knee arthroplasties according, for example, to Brown in patients with congenital total absence of the tibia are disappointing. A new form of knee arthroplasty is demonstrated in a 15-month-old infant with a congenital total absence of the tibia. With the help of two crossed capsular flaps and a Z-plasty of the quadriceps tendon, the patella is transposed under the femoral condyles to function as a tibial plateau. The proximal fibula is fused centrally to the external, cortical surface of the patella. A mini-ringfixator construction is used to stabilize the components, although permitting mobilization of the knee arthroplasty in the immediate postoperative period. This new type of knee arthroplasty offers distinct advantages compared with the previously published procedures.

Arthroplasty, Replacement, Knee↗
PubMed2003

Improvement in driving reaction time after total hip arthroplasty.

Decisions made regarding resumption of driving after total hip arthroplasty may be determined by a combination of factors including driving reaction time and when postsurgical precautions need no longer be adhered to. Ninety patients, ranging in age from 34 to 85 years old were recruited after total hip arthroplasty to measure driving reaction time preoperatively and from 1 to 52 weeks postoperatively. Driving reaction time worsened 1 week postoperatively for patients who had a right hip arthroplasty. The driving reaction time then improved up to 1 year postoperatively. Patients who had a left arthroplasty improved from 1 week postoperative. In general, patients reach their preoperative driving reaction time 4 to 6 weeks postoperatively and continue to improve.

Adult↗
PubMed2003

Validity of index of suspicion for pulmonary embolism after hip arthroplasty.

Pulmonary embolism after total hip arthroplasty is problematic, and intravenous heparin treatment in the absence of pulmonary embolism carries risk. Algorithms for treating pulmonary embolism often cite clinical index of suspicion as a basis for initiating intravenous heparin, but most information regarding variables to predict pulmonary embolism originate from studies of patients rather than only from patients who had arthroplasty. We studied the hypothesis that a more homogenous subpopulation, patients who had total hip arthroplasty, may have findings more accurately predictive of pulmonary embolism. One hundred fifty records of patients who had total hip arthroplasty who were suspected of having pulmonary embolism and who were evaluated for pulmonary embolism were assessed. Complaints, physical findings, heparinization status, and test results were analyzed with univariate and multivariate assessments to determine predictors of pulmonary embolism. No significant differences were found between patients with or without pulmonary embolism regarding subjective complaints, physical examination, blood gas results, electrocardiogram findings, radiographs of the chest, and imaging of the veins of the legs. All attempts to model these variables into an index of suspicion that accurately predicted pulmonary embolism were unsuccessful. We advise adherence to established treatment algorithms rather than clinical suspicion when deciding whether to initiate heparin therapy.

Aged↗