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PubMed1995

First metatarsophalangeal joint arthroplasties in the Commonwealth of Virginia.

This retrospective analysis of arthroplasty of the first metatarsophalangeal joint documents the incidence of surgery as well as the selection of the commercially available implants. During a 1-year period, 1994, arthroplasties were performed in 47 of the 1.7 million subscribers to Trigon Blue Cross Blue Shield of Virginia. Women received the majority of the arthroplasties (83%). Of the 47 cases, the silicone implant was predominantly used (83%). The most common indications for arthroplasty were hallux valgus (30%) and hallux rigidus (28%). Podiatrists performed 79% of the procedures, while orthopedic surgeons performed the remaining 21% of the cases. A prospective study is needed that will assess the long-term performance of the different implants.

Age Distribution↗
PubMed1996

Histologic analysis of the periprosthetic tissues of long-term surviving cemented total hip arthroplasties.

Qualitative and semiquantitative features of the interfacial membranes of five long-term (> 16 years) surviving cemented total hip arthroplasties (four revision cases and one autopsy case) were compared with those of thirty short-term surviving (< 15 years) cemented hip prostheses. Cement granulomas, micron-sized polyethylene particles-induced giant-celled granulomas, sheets of submicron-sized polyethylene particles-laden macrophages, and aggregated, metallic particles-laden macrophages were scattered in the fibrous tissue of all interfacial membranes. Quantitatively, characteristics of the interfacial membranes of the two groups differed from one another. The dominant species of prosthetic debris in the interfacial membranes of the short-term surviving joint replacements was derived from the polyethylene acetabular socket, and, correspondingly, giant-celled granulomas and macrophagic sheets predominated. Metallic particles and the macrophagic reaction thereto dominated in the interfacial membranes of the long-term surviving arthroplasties, and large cement and polyethylene chunks typically were incorporated in the fibrous tissue of the membranes without an accompanying macrophagic response. In long-term surviving hip arthroplasties, metallic particles may be at least as important as polymeric detritus in stimulating the formation of the bone-resorbing, granulomatous interfacial membrane, which is the hallmark of aseptically loosened arthroplasties. Differences in mechanical settings may account for unlike modes and rates of generation of prosthetic breakdown products, explaining the disparate survivorship of different patients' artificial joints.

Bone Cements↗
PubMed1995

Biomechanics of total shoulder arthroplasty: a preoperative and postoperative analysis.

To successfully perform a total shoulder arthroplasty, it is essential to understand the normal anatomy and biomechanics of the shoulder joint. Currently, nonconstrained prostheses offer the most consistent and durable long-term results, allowing for the restoration of normal anatomy and motion close to that of the normal shoulder joint. To determine the effects of the disease process, surgical technique, and postoperative rehabilitation on glenohumeral biomechanics after nonconstrained total shoulder arthroplasty, a prospective clinical trial was undertaken to evaluate preoperative and postoperative shoulder motion clinically and roentgenographically in nine patients with severe arthritis. Preoperatively, the ratio of glenohumeral to scapulothoracic motion was 1:2; for every degree of glenohumeral movement there were two degrees of scapulothoracic motion. This was associated with significant pain and decreased motion in the shoulder and represented the patient's attempt to immobilize the glenohumeral joint for pain relief and maximize shoulder movement with scapulothoracic motion. After total shoulder arthroplasty, significant improvements were observed in pain relief, motion, and function; however, the ratio of glenohumeral to scapulothoracic motion was not significantly different. The abnormal ratio indicates that less motion occurs between the prosthetic components compared with a normal joint, whereas scapulothoracic motion is unchanged. Abnormal shoulder biomechanics seem to be a function of the underlying disease process and were not restored after total shoulder arthroplasty. Despite the successes to date, improvements on the current state of the art are still needed, and will occur with better understanding of the complex biomechanics of the shoulder joint.

Biomechanical Phenomena↗
PubMed1995

Failure of total shoulder arthroplasty: why does it occur?

From a historical perspective, shoulder arthroplasty has evolved significantly from its inception. Much like arthroplasty of the lower extremities, shoulder implant design had its roots in a constrained device. Unfortunately, the inherently high loads that these devices generated across the implant articulation and the glenoid bone interface resulted in an unacceptably high failure rate. Beginning with Neer's original hemiarthroplasty of the 1950s and the more recent implant designs, there has been a strong trend toward less constraint and a greater emphasis on soft tissue preservation in shoulder replacement. In the ideal arthroplasty patient with an intact rotator cuff and a stable, yet degenerative, glenohumeral joint, arthroplasty invariably yields good-to-excellent results 90% of the time. However, owing to the enormous functional range of motion of the joint and its inherent dependence on soft tissues for both stability and motion, there are many areas for potential complications. This article addresses the etiology, recognition, and treatment of these problems.

Humans↗
PubMed2000

The Rotating Platform Mobile Bearing Total Knee Arthroplasty.

The recent evolution of total knee arthroplasty (TKA) has been substantial and unlike that of total hip arthroplasty (THA). The current THA technique is similar to that initially developed and perfected by Professor John Charnley in the mid 1960s. The ball-and-socket articulation of the hip is simple and reproducible biomechanically. The long term (20 years and longer) results with total hip arthroplasty have been very satisfactory. The THA prosthetic designs of today remain similar to those of years past. Improvements have been in biomaterials, methods of fixation and surgical technique. The total knee arthroplasty prostheses of today differ greatly from their predecessors.

Journal Article↗
PubMedDate not supplied

Arthroplasty of the knee--indications and contraindications.

Total knee arthroplasty has been showed to be a satisfactory procedure mainly in relation to designs evolution of condylar or surface prostheses. In this matter, the concepts of prostheses of Gunston Polycentric (2), Freeman-Swanson (1) and the Total Condylar (3) were particularly important. The present status of development of condylar or surface arthroplasties allows to establish that in the majority of cases, arthrodesis of the knee is a salvage procedure. The alternative procedures indicated must always be considered. The conservative treatments as anti-inflammatory drugs and physiotherapy as well as arthroscopy, arthrotomy, synovectomy and osteotomies can be performed. These procedures are indicated depending on age, joint condition and type of disease. The knee arthroplasty requires skill and training of the surgeon, particularly if we consider the deformities and instabilities to be corrected and joint function to be aimed. On the other hand, the major problem may be the selection of the patient who will be operated on for a given type of total knee arthroplasty.

Contraindications↗
PubMed1992

LD hip arthroplasty. Design concepts and first clinical trials of a new modular system.

The new LD modular hip arthroplasty is made of Ti6A14V. The acetabular component has a hemispheric expansive metallic ring and a polyethylene nucleus in the shape of a cone segment. Since June 1988, when the clinical trials began, 352 arthroplasties have been performed with 112 total hip arthroplasties among them. Only 60 noncemented total hip arthroplasties, with the longest follow-up evaluation reaching 24 months, were analyzed. Patients with revision operations were excluded. The results have been evaluated using the Merle D'Aubigne scoring scale. Good results were found in 86% of cases. Pain improved markedly at three months in the postoperative period. At six months, the Trendelenburg sign was negative in 76% and positive in 12%. The Duchenne sign was positive in 11%. Major complications included three dislocations, two acetabular component revisions caused by initial malposition, one external popliteal nerve palsy, one deep infection, and two periprosthetic fractures. No acetabular migrations have been found. There are six femoral sinkings of less than 1 cm. Heterotopic ossifications Grade II-III appear in 24% of cases. The results to date are evaluated clinically and radiologically. The acetabular design has proved efficient, and the femoral components show a low incidence of stress shielding.

Acetabulum↗
PubMed1992

Posterior dislocation of total knee arthroplasty.

Posterior dislocation of the prosthesis after total knee arthroplasty is an infrequent but serious complication. Seven patients with this complication were treated from January 1985 until October 1989. Five of the seven dislocations occurred in primary total knee arthroplasties and two occurred after revision arthroplasty. Limb alignment before arthroplasty, when it could be determined, was valgus in all patients, averaging 25 degrees. In each case there was an identifiable problem with the knee extensor mechanism: five had patellar dislocations, one a patellar tendon rupture, and one a patellar fracture. In three of the posterior dislocations, there was also an imbalance of the flexion and extension gaps with excessive laxity of the ligaments in flexion. Treatment was individualized. In two patients, the knee was reduced closed and the patella subsequently tracked so that no reoperation was necessary. One ruptured patellar tendon could not be repaired in a 94-year-old patient with cardiac disease. A cylinder cast was applied with poor results. Operative intervention was required in four patients, one of whom required only a patellar realignment procedure. The three other patients required component revision procedures, however, in addition to patellar realignment procedures. In these three patients, laxity of the knee in flexion was so severe that posterior instability could not be corrected merely by patellar relocation. At a follow-up examination (average, 21 months postoperatively), all six patients who were treated as recommended had good results with no further dislocations, with the exception of the one patient with a patellar tendon rupture.

Aged↗
PubMed1992

Intraoperative femoral fractures in cementless total hip arthroplasty.

Ten patients with intraoperative femoral fractures during primary cementless total hip arthroplasty were matched by age, sex, weight, diagnosis, and length of follow-up to 20 patients who had primary cementless total hip arthroplasty without this complication. All fractures were identified in the operating room, and treatment was individualized for each case. Initial stability of the implant was felt to be satisfactory for all cases despite this complication. The mean follow-up was 2.3 years. In this series, no difference was found in clinical or roentgenographic results after cementless total hip arthroplasty between patients who had an intraoperative femoral fracture and patients who did not have this complication. If initial stability of the implant is satisfactory, despite intraoperative fracture, good clinical results can be expected with cementless total hip arthroplasty.

Adult↗
PubMed1991

Patellar tendon bone grafting for patellectomized patients having total knee arthroplasty.

A technique for restoring the moment arm to improve quadriceps leverage after patellectomy has been developed and used in patients treated with total knee arthroplasty. Essentials of the technique involve use of a 2.5-cm diameter by 1-cm thick bone graft sewn into the previous anatomical position of the patella, using a subsynovial pouch for stabilization. Clinically, seven knees in six patients were treated with patellar tendon bone grafting during total knee arthroplasty. The final outcome of these patients was evaluated from 24 to 125 months (mean, 75.4 months). Good to excellent results were demonstrated in six of seven knees (85.7%) with sufficient extension power for normal gait in most cases. Failure to achieve painless, active extension was seen in one patient following revision knee arthroplasty complicated by chronic reflex sympathetic dystrophy of the knee. Patellar tendon bone grafting improves quadriceps leverage in previously patellectomized knees and is useful in restoring extensor function in such patients having primary or revision knee arthroplasty.

Adult↗
PubMed1991

Effects of epidural anesthesia on the incidence of deep-vein thrombosis after total knee arthroplasty.

Epidural anesthesia has been reported to reduce the prevalence of deep-vein thrombosis after total hip arthroplasty compared with the prevalence after general anesthesia. However, the effect of epidural anesthesia on the rate of thrombosis after total knee arthroplasty has not been reported previously, to our knowledge. A review was conducted of 705 total knee arthroplasties (541 patients) that had been performed by a single surgeon between September 1984 and December 1988. During this period, the operative technique, the protocol for rehabilitation, and the regimen for prophylaxis against thromboembolism did not change meaningfully. The patients received either epidural or general anesthesia. Preoperative and postoperative perfusion scans of the lungs and a venogram of the lower limb or limbs that had been operated on were done for all patients. For the 227 patients who had received epidural anesthesia, the over-all rate of deep-vein thrombosis was 48 per cent, which was significantly lower than the 64 per cent incidence in the 264 patients who had received general anesthesia (p less than 0.0001). The greatest reduction was in the occurrence of proximal thrombosis, which was identified in 9 per cent of the patients who had had general anesthesia but in only 4 per cent of those who had had epidural anesthesia (p less than 0.05). The use of epidural anesthesia reduced the incidence of proximal thrombosis after both unilateral and one-stage bilateral arthroplasty.

Adult↗
PubMed1991

Dislocations following arthroplasties of the hip. Incidence, prevention, and treatment.

Three methods of avoiding postoperative prosthetic dislocation following total or bipolar hip arthroplasty are described; each approach is recommended for a specific population. The anterior surgical approach was utilized for bipolar hip endoprosthetic arthroplasty in 62 minimal or bed-to-chair ambulators with established flexion contractures about the hip. Two of these patients subsequently experienced a prosthetic dislocation, one of which was secondary to infection. An additional 98 patients who underwent arthroplasty using the posterior approach wore a knee immobilizer postoperatively, without incidence of prosthetic dislocation. A modification of Wilke boot casting was utilized for four patients following reduction of a dislocated hip prosthesis. The cast consisted of a short cylinder cast on the affected extremity connected by a cross bar to a short leg cast on the contralateral leg. The casts controlled rotation, were well tolerated, and resulted in no redislocations. We therefore recommend the anterior approach in minimal ambulatory patients who are to undergo total bipolar hip arthroplasty. When the posterior approach is used in hip replacement procedures, we have found that postoperative use of a knee immobilizer helps prevent dislocation. Following reduction of a dislocated hip prosthesis, a modification of the Wilke boot cast that does not immobilize the affected ankle can be used.

Aged↗
PubMed1990

Total shoulder arthroplasty: complications and revision surgery.

Fortunately, revision surgery after prosthetic shoulder arthroplasty is rarely required. However, various complications or combinations of complications can lead to the need for revision surgery. For many of these, several treatment options are possible. Recognizing all the problems that contributed to failure in an individual patient may be difficult before revision surgery. Understanding the abnormality present at the time of surgery requires considerable experience. For example, glenoid loosening, in addition to being accompanied by scapular bone loss, may be associated with rotator-cuff tearing, instability, or joint contracture. In addition to the component loosening, all of these must also be treated if the revision procedure is to be successful. When addressing glenoid loosening, it seems to be best to revise the component, if possible. If there is extreme bone loss, one may have to bone graft the deficiencies and not replace the glenoid component. Fortunately, clinically significant humeral loosening is rare. When it occurs, revision of the component is justified and almost always possible. In hemiarthroplasties with pain, conversion to a total shoulder arthroplasty by placing a glenoid component is highly effective. In instability after shoulder arthroplasty, soft-tissue repair does not always create stability. Unfortunately, for most patients, component revision is a necessary part of the revision surgery. When rotator-cuff tearing is acute, repair is indicated; for chronic rotator-cuff tearing, repair depends on the severity of the symptoms. When infection develops after shoulder arthroplasty, implant removal is almost always necessary, but occasionally, in low-grade infections, a primary or secondary exchange procedure may be possible.

Humans↗
PubMed1990

Treatment of infection after total knee arthroplasty by débridement with retention of the components.

Thirty-one total knee arthroplasties were followed by infection in twenty-seven patients who were subsequently treated with débridement, retention of the components, and intravenous administration of antibiotics. The results were reviewed retrospectively in an effort to evaluate the function of the prostheses that had been salvaged successfully and to identify the causes of failure of those around which an infection had recurred. At the most recent follow-up (average duration, 8.8 years), infection had recurred around twenty-four (77 per cent) of the thirty-one arthroplasties. Seven knees (23 per cent) remained free of infection. Function remained satisfactory, although revision was subsequently needed in two knees for reasons other than infection. One cause of failure was the duration of the infection before débridement. This averaged twenty-one days for the seven knees in which the prosthetic arthroplasty had been salvaged and thirty-six days for the twenty-four knees in which treatment had failed. Another cause of failure was the type of organism: Staphylococcus aureus had caused the infection in fourteen (58 per cent) of the twenty-four knees in which the treatment failed but in only two of the seven knees in which the prosthetic arthroplasty was salvaged. In addition, eight infections in the first group were resistant to penicillin, whereas both infections in the second group were sensitive to penicillin. The four infections with gram-negative organisms in the series were all in knees in which the treatment failed. All six hinged prostheses that were used failed.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1990

Failure of acetabular autogenous grafts in total hip arthroplasty. Increasing incidence: a follow-up note.

We reported previously on the application of an autogenous femoral-head graft to the acetabulum during total hip arthroplasty for compensation of marked osseous deficiency in patients who had arthritis secondary to severe congenital dysplasia or dislocation of the hip. An average of seven years postoperatively, the graft seemed to have been a successful adjunct to the arthroplasty. Five years later, to assess our long-term results, we reviewed the findings in the same forty-six hips (thirty-seven patients) that we had studied previously. An average of 11.8 years after the total replacement and use of the autogenous femoral-head graft, nine hips (20 per cent) needed a second operation because the acetabular fixation had failed. Two had had a resection arthroplasty and seven, a complex revision. In one additional hip, a resection arthroplasty was done for infection that had developed after operative reattachment of the greater trochanter. In twelve of the remaining thirty-six hips, there was definite radiographic evidence of acetabular loosening. Thus, the total incidence of loosening of the acetabular component was 46 per cent (twenty-one hips). The average time from the index operation to the first definite radiographic evidence that the fixation had failed was 6.4 years (range, 2.9 to 12.7 years). While we recognize that application of a bulk autogenous graft to the acetabulum is useful when the acetabular bone stock is extremely deficient, we no longer recommend the use of bulk corticocancellous autogenous grafts in other situations.

Acetabulum↗
PubMed1989

Multicenter clinical trials and their value in assessing total joint arthroplasty.

Multicenter clinical trials (MCT) have an important role in the assessment of total joint arthroplasty. The primary reason for such MCT is the need to have access to a large number of patients. In Sweden, failure after total hip arthroplasty has been recorded prospectively since 1979. Medical records from every reoperation are documented and computer analyzed. This MCT has shown that patient-related, surgical, and implant-related parameters are of importance to rates of failure. There were an increasing number of revisions after total hip arthroplasty in Sweden between 1979 and 1986. Male gender and young age increase the risk of revision. The primary diagnosis is very important for type of failure. The risk of deep infection is small but increases with the number of previous operations. Aseptic loosening has emerged as the main problem and is the cause for 74% of all revisions. Prosthetic design is of utmost importance for the rate of failure, and significant differences exist among different prosthesis types with respect to long-term survival. Finally, this MCT has shown that revisions for total hip arthroplasty in patients younger than 70 years of age eventually have failed in Sweden whenever the cemented technique has been used.

Aged↗
PubMedDate not supplied

Advances in implant arthroplasty in the upper extremity, circa 1988.

Artificial joint replacement has paralleled that in the lower extremity during the past 15 years. The ability to replace the shoulder, elbow, and the wrist joint has relieved pain and restored function to the upper extremities of patients with rheumatoid arthritis. Engineering developments have led to improved design, sufficient enough that the implant durability appears to exceed that of the patients' themselves. The kinematics and design of these implants has been under intensive and continuing study since the inception of these procedures. The exact anatomical restoration of the centers of motion and alignment for movement are essential for the success of these arthroplasties. We report here our long-term experience with shoulder replacement arthroplasties in which the success rate in terms of good and excellent results has been 90%. Similar results have been achieved with elbow replacement arthroplasties during a 14 year follow-up. Wrist replacement arthroplasties have also shown high good to excellent results during a nine-year follow-up period. Experience has demonstrated that if infection and wound complications are minimized, the long-term results are excellent in terms of pain relief, movement, and restoration of function.

Elbow Joint↗
PubMed1989

High-volume, high-pressure pulsatile lavage during cemented arthroplasty.

To determine the efficacy of high-volume, high-pressure pulsatile lavage in the prevention of cardiopulmonary dysfunction and fat embolism during cemented arthroplasty, we studied twenty-eight mongrel dogs that had had a bilateral cemented arthroplasty. Significant increases in pulmonary-artery pressure and pulmonary vascular resistance, accompanied by decreases in arterial oxygen tension and increases in intrapulmonary shunt fraction (Qs/Qt), characterized cardiopulmonary dysfunction after bilateral cemented arthroplasty when no lavage was used. Low-volume, low-pressure manual lavage did not significantly alter these physiological changes, but there was a significant reduction in the number of fat emboli that were demonstrated in the lungs as compared with the no-lavage group. High-volume, high-pressure pulsatile lavage of the intramedullary cavity after reaming significantly reduced the changes in pulmonary-artery pressure, pulmonary vascular resistance, arterial oxygen tension, and intrapulmonary shunt fraction (Qs/Qt). In the pulsatile-lavage group, the number of fat microemboli that were found in the lungs was reduced to 25.7 per cent of those found in the no-lavage group. We concluded that meticulous high-volume, high-pressure pulsatile lavage reduces both pulmonary physiological derangements and fat emboli during bilateral cemented arthroplasty in dogs.

Animals↗