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PubMed1981

Comminuted fractures of the radial head. The role of silicone-implant replacement arthroplasty.

Radial head resection is the accepted treatment of comminuted radial-head fractures in adults, but the results are not always satisfactory. This study examines the results of silicone replacement arthroplasty of the radial head in acute fractures and as a salvage procedure after failed resections of the radial head. The first group of patients was evaluated both before and after silicone replacement arthroplasty had been done as a salvage procedure following a previous radial head fracture. This group comprised twelve patients with an average follow-up of 3.8 years. Improvement was found in a number of parameters, including supination and grip strength. The second group of patients had had a primary silicone replacement arthroplasty following a comminuted radial-head fracture. This group was composed of six patients with an average follow-up of 3.6 years. The radial head implant was found to provide a spacer effect that maintained good radiocapitellar contact and prevented radial shortening. Silicone replacement arthroplasty has a role as a useful, safe, and reliable alternative in the treatment of comminuted radial-head fractures in adults and as a salvage procedure in patients with failed radial-head resections. This is especially true in young, active individuals, who were found to be at the greatest risk of failure after radial head resection alone. This was attributed to greater demands being placed on the involved extremity.

Adolescent↗
PubMed1995

Economic considerations in total hip arthroplasty and implant standardization.

During the 1980s, the hospital cost for total hip arthroplasty was controlled, but the implant cost for total hip arthroplasty was not controlled. With the introduction and acceptance of case price payment systems, hip implant cost consumed a greater portion of the hospital payment each year during the 1980s. Cost control for total hip arthroplasty during the 1990s will require control of implant costs. One objective method for controlling implant costs in total hip arthroplasty is implant standardization.

Adult↗
PubMed1994

Routine postoperative duplex ultrasonography screening and monitoring for the detection of deep vein thrombosis. A survey of 110 total hip arthroplasties.

The use of duplex ultrasonography for routine noninvasive screening, monitoring, and management of deep venous thrombosis after total hip arthroplasty was evaluated. The reliability of duplex ultrasonography for detection of deep vein thrombosis was confirmed in an initial cohort of 51 total hip arthroplasty patients (102 lower extremities), demonstrating 91% sensitivity, 98% specificity, and 97% accuracy when compared with venography. A second cohort of 110 total hip arthroplasty patients using pneumatic compression stockings and aspirin as deep vein thrombosis prophylaxis underwent screening duplex ultrasonography of both lower extremities on postoperative Day 4. Duplex ultrasonography screening showed 10 (9.1%) patients with proximal deep vein thrombosis and 10 (9.1%) with distal deep vein thrombosis, all of whom were asymptomatic. The 10 patients with proximal deep vein thrombosis on duplex ultrasonography were prescribed therapeutic anticoagulation. Duplex ultrasonography subsequently confirmed resolution of proximal deep vein thrombosis in these patients before discontinuation of anticoagulation; none developed symptomatic pulmonary embolism through 12-month clinical followup. The 10 patients with distal deep vein thrombosis diagnosed by duplex ultrasonography were not treated with anticoagulation, but were monitored by serial duplex ultrasonography through postoperative Day 14 for propagation of distal to proximal deep vein thrombosis; none manifested symptomatic deep vein thrombosis or pulmonary embolism through 12-month clinical followup. The 90 patients with negative duplex ultrasonography results were followed clinically; 3 developed late symptomatic proximal deep vein thrombosis (1 of these later manifested pulmonary embolism). Therefore, duplex ultrasonography was used after total hip arthroplasty for the following: (1) to screen routinely in the hospital for asymptomatic proximal and distal deep vein thrombosis; (2) to monitor for potential propagation of distal to proximal deep vein thrombosis; (3) to minimize exposure to therapeutic anticoagulation by confirming the absence of proximal deep vein thrombosis in 97 of 110 patients; and (4) to demonstrate the effectiveness of mechanical and systemic deep vein thrombosis management by confirming the absence or resolution of deep vein thrombosis in all 110 patients.

Anticoagulants↗
PubMed1994

Imaging techniques for glenohumeral arthritis and glenohumeral arthroplasty.

A thorough history and physical examination can usually determine the cause of a painful shoulder. In most cases, the diagnosis and cause of glenohumeral arthritis are fairly obvious. Imaging studies such as radiographs, computed tomography (CT), arthrography, ultrasonography, and magnetic resonance (MR) imaging are used to confirm and further define the pathologic process. Early in the development of glenohumeral arthrosis, subtle radiographic findings may suggest the diagnosis when the symptoms are mild. Later in the progression of joint destruction, imaging studies are crucial to the planning of prosthetic arthroplasty. Subsequent to arthroplasty, imaging studies can identify existing or potential problems that might correlate with the clinical course. Recent advances in musculoskeletal imaging, such as CT, ultrasound, and MR imaging, enable the physician to confirm or document anatomic pathology that was previously only inferred. There has been a corresponding increase in the use of imaging modalities. Concurrently, cost has become a major concern, and its limitation or reduction a priority of current and future medical care. Consequently, the knowledge gained from further research, education, and clinical experience must promote appropriate use and enable doctors to avoid sophisticated imaging when the results will not influence the course of treatment. The radiographic evaluation of glenohumeral arthrosis the use of imaging techniques in planning prosthetic glenohumeral arthroplasty, and the role of imaging in followup evaluations of prosthetic arthroplasty are discussed. The preferred approaches to these subjects are presented and clinical cases are used to highlight the important and interesting principles.

Arthritis, Rheumatoid↗
PubMed1994

Cemented long-stem revision total knee arthroplasty.

Theoretical concerns about the use of cemented long-stemmed revision total knee arthroplasty include inducing stress shielding with adverse effects on prosthesis fixation. This study details the clinical outcome of 35 patients with 40 cemented long-stemmed kinematic stabilizer revision total knee arthroplasties at followup evaluation averaging 58.2 months (range, 24-111 months). Of these 40 revision arthroplasties, there were 25 long-stemmed tibial components and 38 long-stemmed femoral components. The Knee Society pain score improved from a preoperative value of 38 points (range, 4-80 points) to 83 points (range, 33-100 points) at last evaluation. The Knee Society function score improved from a preoperative value of 46 points (range, 5-100 points) to 64 points (range, 0-100 points) at last evaluation. Initial postoperative radiographs showed tibial bone-cement radiolucencies in 5 knees, but at final followup none of these radiolucencies had progressed. Radiolucencies developed in 5 additional tibial components by the time of final followup, but these were all incomplete and < 1 mm in width. Two femoral components had initial postoperative radiolucencies. These radiolucencies remained stable in 1 knee, whereas the other knee had asymptomatic radiographic loosening. Incomplete radiolucencies of < 1 mm developed in 3 additional femoral components at final followup. The incidence of tibial radiolucencies of 32% in the present study is similar to the incidence of radiolucencies with a nonstemmed revision cemented total knee arthroplasty, with the same prosthetic design, previously reported from the authors' institution.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1994

Posterior cruciate ligament strain biomechanics in total knee arthroplasty.

To evaluate the role of the posterior cruciate ligament in total knee arthroplasty, 8 normal whole-leg cadaveric legs were studied. Strain patterns of the posterior cruciate ligament were measured during active and passive knee flexion extension. Total knee arthroplasty was performed, and posterior cruciate ligament strain was measured again. The standard tibial insert was removed, and 3 additional tibial trays were used: flat, 10 degrees sloped, and 15 degrees sloped. The posterior cruciate ligament strain was recorded for each tibial insert. Total knee arthroplasty with a standard insert produced a large range of posterior cruciate ligament strain values (+/- 6%). Of the 8 specimens, 3 produced excessively taut posterior cruciate ligament strain, 3 were slack, and 2 returned strain to the baseline strain value. Changing the surface contour and slope of the tibial inserts did not produce any consistent change in the posterior cruciate ligament strain pattern. The ability of total knee arthroplasty to reproduce normal posterior cruciate ligament strain behavior has not been demonstrated.

Biomechanical Phenomena↗
PubMed1994

Hematologic and circulatory changes associated with total knee arthroplasty surgical instrumentation.

This study evaluated the effects of intramedullary instrumentation when used on the femur and tibia. Twenty-six patients (52 knees) undergoing bilateral index cemented total knee arthroplasty were analyzed. Bilateral knee arthroplasties were chosen because the increased surgery would theoretically maximize any perioperative hemodynamic or hematologic changes. Patients were randomized into one of two groups depending on the exact form of surgical instrumentation used. Group I (intramedullary) knees were implanted with standard intramedullary fluted instruments. No special measures to vent the entrance holes were made. Group II (extramedullary) knees were implanted with an extramedullary tibial guide, in conjunction with an intramedullary femoral guide placed through a vented femoral hole. All patients manifested significant changes in their hematologic and hemodynamic values after arthroplasty. Leukocytes increased 85% on average, whereas fibrinogen (106%) and erythrocyte sedimentation rates (145%) also showed significant increases. Conversely, patients exhibited a relative thrombocytopenia (63%) nadiring on the second postoperative day. However, there was no significant differences seen between the two instrumentation groups. Hemodynamically, all patients exhibited rises in cardiac index (52%) and pulmonary artery pressures (64%). Analysis of the hemodynamic results in this study does demonstrate subtle evidence of increased pulmonary vascular resistance in the intramedullary group. Specifically, the intramedullary group had lower cardiac indexes, in association with higher pulmonary pressures. This increase in pulmonary vascular resistance with the use of intramedullary instrumentation may represent subtle evidence of increased lung injury in this group. Results point to the continued use of fluted intramedullary rods and vented entrance holes as a reasonable surgical technique in patients undergoing knee arthroplasty.

Aged↗
PubMed1994

Preoperative autologous blood donation in total-hip arthroplasty. A cost-effectiveness analysis.

Preoperative autologous blood donation is employed with increasing frequency, particularly in patients undergoing elective orthopedic procedures. While autologous transfusion decreases the incidence of postoperative infections and other complications, the cost-effectiveness of this therapy has not been fully investigated. We constructed a decision analytic model to study the cost-effectiveness of preoperative autologous blood donation of packed red blood cells compared with allogeneic packed red blood cells in primary hip arthroplasty. We used data from 73 patients presenting at our blood center with a prescription for 2 U of autologous red blood cells prior to hip arthroplasty to establish probabilities for the number of units that would be donated. Patients were able to donate an average of 1.9 U (range, 0 to 2 U) of autologous blood. We also reviewed the charts of 56 patients who underwent primary hip arthroplasty to model the number of units given during hospitalization (1.5 U given; range, 0 to 5 U). We applied the model to a 65-year-old patient undergoing primary hip arthroplasty. Estimates for the incidence of posttransfusion hepatitis, chronic active hepatitis, human immunodeficiency virus infection, postoperative bacterial infection, and fatal hemolytic transfusion reaction were derived from the literature. Patient utility was measured in life-years. Costs included the cost of preoperative autologous blood donation, blood administration, and medical care costs associated with the complications of transfusion. Costs were derived from local data and the literature. Future earnings lost were not modeled. In the baseline analysis, autologous transfusion results in a net cost savings compared with allogeneic blood over a wide range of complication rates, patient ages, and transfusion requirements. The dominant factor in the analysis is the effect of postoperative bacterial infection on length of hospital stay and the resultant increase in costs. The effect of viral infections on the results of the analysis is minimal.

Adult↗
PubMed1994

Lumbar decompression to treat foot drop after hip arthroplasty.

Twenty-one patients with spinal stenosis who developed foot drop after total hip arthroplasty were reviewed. Patients with other risk factors for nerve injury, such as dislocation, hematoma, intraoperative limb lengthening, revision surgery, and direct operative trauma, were excluded. Also excluded were patients without symptoms of spinal stenosis. Patients in this series had back and leg pain without weakness before their hip arthroplasty. When foot drop developed and persisted four months after hip arthroplasty, patients were examined with magnetic resonance imaging or myelography and computed tomography. High-grade spinal stenosis was found in each patient. Sixteen patients were treated by lumbar decompression. Twelve patients improved; six had complete recovery of foot drop. None of the five patients who did not have surgery significantly recovered. One patient developed a foot drop in the other leg after undergoing lumbar decompression. Coexisting spinal stenosis may be a risk factor for symptomatic nerve injury during hip arthroplasty. Selected patients may benefit from lumbar decompression surgery.

Aged↗
PubMed1994

Wound infection in total joint arthroplasty: effect of extended wound surveillance on wound infection rates.

OBJECTIVE: To determine the effects of a wound monitoring program on infection rates after total joint arthroplasty. DESIGN: Case series, comparing postoperative wound infection rates before and after hospital discharge. SETTING: A university-affiliated tertiary-care hospital. PATIENTS: A group of 865 patients who underwent primary or revision total hip or knee arthroplasty between September 1989 and September 1991 followed by in-hospital and post-discharge wound monitoring was compared with a baseline group of 204 patients who had undergone an arthroplasty procedure and in-hospital wound monitoring between March and September 1988; only 38 of these patients were selected for post-discharge monitoring. INTERVENTIONS: In the study group, wounds were monitored every 48 to 72 hours to the time of patient discharge and at 30 days post-discharge. Monthly reports of surgeon-specific and overall infection rates were sent to each surgeon during both baseline and study periods. MAIN OUTCOME MEASURES: Presence or absence of surgical wound infection. RESULTS: The initial overall wound infection rate was 9.9%. This decreased to 3.8% in the study group, after the wound monitoring program had been in place for at least 18 months. Post-discharge monitoring accounted for the majority of wound infections diagnosed. CONCLUSIONS: A wound monitoring program may be an important tool in lowering wound infection rates associated with total joint arthroplasty. Post-discharge monitoring is important in determining true wound infection rates.

Alberta↗
PubMed1993

Total hip arthroplasty in cerebral palsy. Long-term follow-up results.

Patients with cerebral palsy frequently develop coxarthrosis after acquired hip dislocation or dysplasia. Nineteen total hip arthroplasties (THA) were performed in 18 patients with cerebral palsy and end-stage hip degeneration. The average age at arthroplasty was 30 years (range, 16-52 years). All components were cemented, and four hips required bone graft augmentation of the deficient acetabulum. Spica casts were used in 16 of 18 patients to minimize the incidence of dislocation and trochanteric nonunion. The average follow-up time was ten years (range, three to 17 years). Seventeen of 18 patients (94%) had pain relief and improved function after arthroplasty. One stem loosened at three years, and one acetabular component loosened at 15 years. One stem and one acetabular component were revised for malposition. Survivorship analysis was 95% at ten years for loosening and 86% with removal for any reason. Total hip arthroplasty can provide long-term relief and improved function in cerebral palsy patients with severe coxarthrosis.

Activities of Daily Living↗
PubMed1993

Total hip arthroplasty in sickle cell hemoglobinopathy.

Twenty-two arthroplasties were performed in 14 patients with sickle cell hemoglobinopathy (SCH). There were 15 primary and seven revision procedures; none were lost to follow-up evaluation. In the primary arthroplasty group, there were two deaths in patients whose implants were functioning well. The remaining 13 hips had a mean follow-up period of 4.8 years. Failure occurred in five of these 13 hips (38%), four due to aseptic acetabular loosening and one due to sepsis. In the revision arthroplasty group, at a mean follow-up period of 5.3 years, failure occurred in three hips (43%), one due to acetabular loosening, one due to femoral loosening, and one due to sepsis. Perioperative complication rates were high in both groups. Femoral intramedullary sclerosis and bone altered by marrow hyperplasia were associated with intraoperative technical difficulties as well as problems with achieving long-term component fixation. Though total hip arthroplasty provides the most reliable measure of effective treatment in SCH, it carries a high risk of complications and failure.

Adolescent↗
PubMed1996

[Total hip arthroplasty after femoral neck fractures. Results from the national registry on joint prostheses].

From September 1987 to January 1994, data on 3,876 total hip arthroplasties performed because of previous hip fracture were collected in the Norwegian arthroplasty register. During the same period, 19,654 patients received total hip arthroplasties because of osteoarthrosis. The results of total hip arthroplasties after an earlier hip fracture were compared with prostheses in patients who were operated on because of primary osteoarthrosis. After five years the cumulative percentage failure was 4.1 in the fracture group and 3.7 in the arthrosis group (p = 0.19). After adjustment for differences in sex and age distribution in the Cox model, the fracture patients were shown to have 1.35 times higher risk of revision when compared with the osteoarthrosis patients (p = 0.008). The reasons for reoperation differed, however, in the two groups. More of the fracture patients than of the osteoarthrosis patients had to be reoperated because of dislocation or femoral shaft fracture, while fewer needed reoperation because the acetabular component had loosened.

Adult↗
PubMed1996

Early motion after arthroplasty.

Early controlled motion after arthroplasty in the MP and PIP joints allows for collagen remodeling during the encapsulation process that creates a stable joint. Motion generally is begun within the first few days after surgery and must be supervised carefully. Dynamic splinting is an important component in achieving early motion in the MP joints and often is a useful adjunct in the PIP joints. Early motion after total wrist arthroplasty depends on surgical fit of the prosthesis. Only a tight fit allows early motion. The potential for complications resulting from early motion in the wrist is greater than in the MP or PIP joints and may involve increased wear, fracture, or component loosening. The benefits of early motion after arthroplasty, therefore, must be weighed against potential risks. Although generally necessary in the MP and PIP joints to achieve satisfactory results, early motion after total wrist arthroplasty has limited applications and significant risks.

Arthritis↗
PubMed1996

Evaluation of shelf arthroplasty as a treatment for hip dysplasia in dogs.

OBJECTIVE: To evaluate effects of shelf arthroplasty on coxofemoral joint laxity and progression of degenerative joint disease in young dogs with hip dysplasia. DESIGN: Prospective, controlled study. ANIMALS: 10 dogs between 10 and 24 months old and weighing between 20 and 27 kg. All dogs had bilateral coxofemoral joint laxity (i.e., an Ortolani's sign). PROCEDURE: In all dogs, shelf arthroplasty was performed on the right coxofemoral joints, and a sham procedure was performed on the left. Dogs were evaluated before and after surgery by means of lameness assessment, coxofemoral joint palpation and goniometry, thigh circumference measurement, and radiography. RESULTS: There were no significant changes in coxofemoral joint mobility, range of motion, joint laxity, degree of degenerative joint disease, or thigh circumference during the study. A greater amount of periacetabular bone formed on the right side than on the left side; however, dogs did not develop large bony shelves, and the amount of periarticular bone decreased over time. The polymer implants remained in their original position and were encapsulated by fibrous tissue. There was no histologic evidence of osteoconduction by the implants. CLINICAL IMPLICATIONS: The polymer implants used in this procedure do not appear to be osteoconductive. Shelf arthroplasty was associated with minimal morbidity and was not associated with serious adverse sequelae in this study, but the procedure did not alter the progression of hip dysplasia in these dogs. We cannot advocate shelf arthroplasty using this polymer as a treatment for dogs with hip dysplasia.

Animals↗
PubMed1996

Pharmacokinetic model for cefazolin distribution during total hip arthroplasty in dogs.

OBJECTIVES: To compare cefazolin pharmacokinetics in serum and concentrations in tissues during total hip arthroplasty in dogs with and without hip dysplasia, and to calculate the optimal dosage of cefazolin for prophylactic use during total hip arthroplasty. ANIMALS: 10 dogs with hip dysplasia and 3 clinically normal dogs. PROCEDURE: Blood samples and tissue specimens from the coxofemoral joint capsule, acetabulum, and femur were obtained during unilateral total hip arthroplasty. Cefazolin concentrations in serum and tissue specimen supernatant were determined, using high-performance liquid chromatography, for use in pharmacokinetic analysis. Mathematical simulation of serum cefazolin concentration was used to to predict the optimal dose. RESULTS: Mean pharmacokinetic constants (SEM) were 0.146 (0.013) min-1 for alpha, 4.47 min for t1/2 alpha 0.015 (0.004) min-1 for beta, 46.83 min for t1/2 beta. Significant different was not detected for cefazolin distribution and elimination between dogs with and without hip dysplasia. Additional, significant difference was not observed in pharmacokinetic parameters describing distribution and elimination between the first and second doses of cefazolin. The predicted optimal dosage regimen was 8 mg/kg of body weight, i.v. every hour or mg/kg, i.v. every 2 hours. CLINICAL RELEVANCE: For prophylactic i.v. treatment during total hip arthroplasty, use of cefazolin at a dosage of 8 mg/kg every hour or 22 mg/kg every 2 hours should maintain serum cefazolin concentrations at least 10x the minimum inhibitory concentration for 3 to 4 hours.

Acetabulum↗
PubMed1996

Noncemented femoral components in total hip arthroplasty for patients with rheumatoid arthritis.

Twenty-seven patients with rheumatoid arthritis underwent cementless total hip arthroplasty from 1982 through 1989. We performed all operations through a posterior approach. Postoperatively, patient convalescence consisted of ambulation with crutches, followed by weight bearing as tolerated until pain and discomfort subsided. We contacted 25 (92.5%) patients for follow-up. Combined, these patients received 34 total hip arthroplasties. The patients ranged in age from 14 to 69 years old with a mean age of 42.9 years. The follow-up period ranged from two to eight years with a mean of five and one-half years. The mean preoperative total Harris hip score was 48 (range 31-68). The mean total Harris hip score at latest follow-up was 80 (range 44-95). Hip pain status and functional ability were important indicators of treatment efficacy. The lower incidence of pain, as well as the increase in functional abilities experienced by the patients, suggests that cementless total hip arthroplasty is a preferable alternative to fixed arthroplasty in patients with rheumatoid arthritis.

Adolescent↗
PubMed1996

Proprioception after arthroplasty: role of the posterior cruciate ligament.

To test the hypothesis that retaining the posterior cruciate ligament during total knee arthroplasty helps preserve the threshold of proprioceptive sensation, a machine was designed that permitted direct measurement of passive angular deflection from a resting point to the threshold of patient perception. Sixty patients with unilateral primary total knee arthroplasties were evaluated; 30 with posterior cruciate ligament retaining prostheses and 30 with posterior cruciate ligament substituting prostheses. All patients had a minimum postoperative followup of 1 year, a good or excellent result as defined by the Hospital for Special Surgery Knee Score, and no evidence of peripheral neuropathy. The gender and age distributions were equivalent between groups. The average threshold of perception for the posterior cruciate ligament retention group was 2.4 degrees. The average threshold of perception for the posterior cruciate ligament substitution group was also 2.4 degrees. Substitution or retention of the posterior cruciate ligament makes no clinical difference in proprioception as measured by threshold testing. This study provides new information for surgeons performing total knee arthroplasty to aid in the decision to retain or substitute the posterior cruciate ligament. Previous proprioception evaluation in patients with posterior cruciate ligament retaining versus posterior cruciate ligament substituting arthroplasties, using different testing methods, has revealed different results.

Adult↗