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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

[Clinical study of re-do surgery after Bentall-type operation].

Among patients who underwent reconstruction of the aortic root by Bentall-type procedure using a composite graft, we investigated patients who underwent reoperation for complications related to composite graft. We employed composite graft reconstruction of the aortic root in 155 patients for 16 years prior to December 1994. Annulo-aortic ectasia was observed in 112 patients, aortic dissection in 34, and aortitis without aneurysm formation in 9. The original Bentall procedure was performed in 36, the Cabrol method in 8, the interposition method in 26, and the Carrel patch method in 85 patients. Thirteen (8.4%) of these patients required reoperation for complications related to the composite graft. Three of 4 patients with graft infection early after surgery underwent reconstruction with composite graft, but died in the hospital. The remaining patient survived after combined treatment that included the graft washing with Iodine (Isozin) solution and omentopexy. Four patients developed pseudoaneurysm formation due to sutural insufficiency and 7 has prosthetic valve failure as late complications. Three of the 4 patients with pseudoaneurysm underwent reconstruction with a second composite graft by the interposition method, while one patient with aortitis required another reoperation. In the remaining one patient, the leak was directly close along with second aortic valve replacement. All prosthetic valves used in 7 patients with prosthetic valve failure were Ionescu-Shiley biological valves. Primary tissue failure was observed in 6 and prosthetic valve endocarditis in one patient. Second cardiac valve replacement using a mechanical valve was possible. All the patients who underwent late reoperation showed favorable results. Infection of the composite graft showed the poor prognosis, and prevention of infection is important. Sutural insufficiency at the anastomosed site can be prevented by appropriate surgical procedures such as reinforcing suture, but further countermeasures for sutural insufficiency were considered necessary for aortitis in conditions, such as Behcet's diseases.

Adult↗
PubMed2006

Endoprosthetic reconstruction in 250 patients with sarcoma.

UNLABELLED: We assessed the clinical results and complications associated with a new endoprosthetic replacement system (Mutars) used in 250 patients with a malignant bone or soft tissue tumor. The key features of the system are its cementless, hexagonal-shaped stem (titanium alloy), the possibility of torsion adjustments in 5 degrees -increments, and the Trevira tube for soft tissue attachment. The mean age of the patients was 30.7 years, and the mean followup was 45 months. Prosthetic survival at 5 years was 89.7% for the upper extremity and 68.5% for the lower extremity. Prosthetic survival without any reoperation was 73.4% at 3 years postoperatively and 60.4% at 5 years postoperatively. Prosthetic failure was caused by deep infection in 12% (30 patients) of patients and aseptic loosening in 8% (20 patients) of patients. Stem fracture occurred in only 1.6% (four patients) of patients. Dislocation rates were reduced by using the Trevira tube. Limb survival was achieved in 82.6% to 93.1% of patients depending on the endoprosthetic replacement site, and functional results ranged between 63% to 83% according to the Tumor Society score. Our results suggest limb salvage with the Mutars endoprosthesis is successful with good functional results. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series).

Adolescent↗
PubMed1997

Midterm results in metal-backed patella revisions for metallosis.

Nine patients underwent isolated patellar revisions and synovectomies for metallosis secondary to the mechanical failure of metal-backed patellar components. These patients were followed for an average of 5 years (range, 2 to 8 years). In all cases, the femoral and tibial components were left in place, and in one patient the patellar bone was deemed too thin to resurface. Two patients (22%) developed deep infection. One infection (enterococcal) required arthrodesis, and the other (staphylococcal) was successfully managed with a two-staged reimplantation. A third patient sustained an inferior patella pole fracture that was treated conservatively. The remaining six patients are functioning satisfactorily. Metallosis is a serious complication in knee arthroplasty, and these patients merit close follow-up.

Enterococcus↗
PubMed1995

Treatment of the failing implant: case reports.

Three case reports of treatment of the failing implant are presented. The implants were immobile but had lost a significant amount of osseous support. The cause of failure was determined to be a combination of bacterial and occlusal traumatogenic insult. The defects were debrided and the implant surface was detoxified with tetracycline. Decalcified freeze-dried bone allograft was implanted in the osseous defects and covered with expanded polytetrafluoroethylene material in accordance with principles of guided tissue regeneration. The barrier membrane was removed 6 to 8 weeks after placement. Eight months to 1 year posttreatment, all sites demonstrated a substantial reduction in probing depth, a gain in clinical attachment, and bone fill of the defects adjacent to the implant.

Aged↗
PubMed2001

Tibial post wear in posterior stabilized total knee arthroplasty. An unrecognized source of polyethylene debris.

BACKGROUND: With extensive use of posterior stabilized total knee arthroplasty implants, it is increasingly important to assess the mechanical performance of this design alternative. The purpose of this study was to examine the wear patterns at the femoral cam-tibial post interface in a series of posterior stabilized prostheses retrieved at revision arthroplasty. METHODS: Qualitative and quantitative wear analysis was performed over the surface of the stabilizing posts from twenty-three retrieved total knee components that had been implanted for a mean of 35.6 months (range, 2.3 to 107.2 months). The implants were designs from four different manufacturers. Digital images of the anterior, posterior, medial, and lateral surfaces of the tibial post were made for quantitative analysis and determination of a post wear score. Wear was characterized with a grading system that isolates adhesive, abrasive, and fatigue wear, inferring a weighted score from an estimation of generated polyethylene debris. RESULTS: Evidence of wear or damage was observed on all twenty-three of the stabilizing posts, including those revised because of infection. On the average, 39.9% (range, 18.5% to 60%) of the post surface demonstrated some form of deformation, with adhesive wear, or burnishing, being the predominant wear mechanism. Seven posts (30%) exhibited severe damage with gross loss of polyethylene. The wear caused premature failure and early revision of two components: one of these failures was related to isolated post wear and the other, to severe post wear and subsequent fracture. Overall, wear was primarily posterior, but wear over the anterior, medial, and lateral surfaces was also notable. CONCLUSIONS: The cam-post articulation in posterior stabilized implants can be an additional source of polyethylene wear debris. The variability in wear patterns observed among designs may be due to differences in cam-post mechanics, post location, and post geometry. The surgeon should be aware that the cam-post interface is not an innocuous articulation, and manufacturers should be motivated to produce implants that maintain the function of the post while limiting wear and surface damage.

Humans↗
PubMed1997

Long-term in vivo alterations of polyester vascular grafts in humans.

OBJECTIVES: To examine the influence of in vivo hydrolysis on the physical properties of polyester grafts and their correlation to the period of implantation in the human body. MATERIALS AND METHODS: Sixty-five explanted vascular grafts were obtained after 0-23 years of implantation due to suture aneurysms (18), occlusion (12), graft infection (12), failure of graft material (7) and post-mortem (16). The surface was examined by scanning electron microscopy, the molecular integrity by infra-red spectroscopy and physical strength by probe puncture. RESULTS: Scission of macromolecular chains and loss of strength were shown. It was demonstrated that hydrolytic degradation of polyester takes place with increasing time of implantation in humans. Analysis by linear regression showed that polyester grafts lose 31.4% of their bursting strength in 10 years and 100% in 25-39 years after implantation. CONCLUSIONS: Regular follow-ups of patients with aged vascular grafts and the precise documentation of implanted materials are necessary to estimate graft degradation.

Blood Vessel Prosthesis↗
PubMed2003

Cardiac valve replacement in human immunodeficiency virus-infected patients.

BACKGROUND: Valve replacement in human immunodeficiency virus (HIV)-infected patients is being performed with increasing frequency, but the early and late results in these immunocompromised patients are not known. METHODS: A 10-year retrospective clinical review was undertaken; patients and their physicians were contacted for follow-up clinical status. RESULTS: Twenty-two HIV-infected patients underwent valve replacement between 1990 and 1999, with no operative or hospital deaths. Mean patient age was 37.6 years; 15 were men. Indications for operation were heart failure in 59% (13/22) and sepsis in 91% (20/22). There were 12 aortic valve replacements, seven mitral valve replacements, and three double valve replacements. Mechanical valves were used in 11, bioprostheses in seven, and homografts in four. Follow-up information was available in 20 of 22 patients (84%). At mean follow-up of 5 years, there were 10 late deaths, due to: intracerebral hemorrhage (2), heart failure (2), unknown cause (2), renal failure (1), AIDS (1), sepsis (1) and endocarditis (1). Of the 20 patients with active preoperative endocarditis, 4 (20%) developed recurrent endocarditis; freedom from recurrent endocarditis was 83% at 1 year. Intravenous drug abuse was reported in 16 patients; survival among these patients was 94% at 1 month and 50% at 5 years. Recurrent endocarditis was only seen in patients with continued intravenous drug abuse. CONCLUSIONS: Valve replacement in HIV-infected patients has low operative risk, but late results are poor when HIV infection is associated with intravenous drug abuse, probably due to immunocompromise and continued high-risk behavior.

Adult↗
PubMed2004

Aspergillus infection of implantable cardioverter-defibrillator.

The use of pacemakers and implantable cardioverter-defibrillators continues to increase for the management of cardiac dysrhythmias and, more recently, heart failure. Long-term complications associated with their use include infection, lead failure, and spurious shocks. Although the risk of infection with intracardiac devices is well known, the clinical presentation of this complication can be insidious, delayed in onset, and difficult to diagnose. We report a case of Aspergillus fumigatus infection of an implantable cardioverter-defibrillator with right-sided endocarditis in a 55-year-old man. The infection presented as persistent pulmonary infiltrates (due to recurrent septic pulmonary embolism) and anemia more than 2 years after implantation of the device. Clinicians should be aware of the variable manifestations resulting from infection of intracardiac devices.

Amphotericin B↗
PubMed2000

[Review of infected total arthroplasties of the hip and knee--apropos of 28 cases].

This study is a long-term analysis of a group of patients with infected arthroplasties of the hip or the knee. We identified 28 patients with an infected arthroplasty (22 hips, 6 knees) documented by bacterial culture or on direct examination. At the time of diagnosis and on follow-up (a mean of 46 months after treatment) we evaluated the clinical picture, the radiological appearances of the articulation and the biological parameters. 19/28 patients showed a typical clinical picture, whereas in 9 others the picture was more doubtful. The treatments were 14 two-stage replacements of the arthroplasties, 7 simple resections, 5 conservative treatments and 2 one-stage replacements. On follow-up, 25 patients were considered as cured of their infection and 3 as failures. From a functional viewpoint, 9 patients showed no limitation, whereas 19 were limited in the daily activity. Half of the patients had no pain. Radiology showed that 20/26 evaluated patients had no signs of recurrence. Paraclinical examinations are important in the diagnosis of persistent low grade infections, particularly the demonstration of bacteria by pre-surgical sampling (fine needle aspiration, culture from draining sinuses). In spite of the cure of infection, the functional and painful sequellae are often considerable. As a result of our experience, we recommend a two-stage surgical procedure. Only when the general condition of the patient is poor, or when the infection is not under control, would we envisage an alternative procedure (arthrodesis, girdelstone, conservative).

Aged↗
PubMed2003

Total joint arthroplasty in human immunodeficiency virus-positive patients: an alarming rate of early failure.

The results of 21 total joint arthroplasties (13 knees, 8 hips) in 15 patients were reviewed. There were 13 men and 2 women with an average age of 38 years (range, 28 to 69 years). The mean follow-up period was 10.2 years (range, 2 to 23 years). Six patients died within an average of 10.6 years (range, 3 to 18 years) of joint arthroplasty. All patients died of AIDS. Deep infection developed in 6 joints. Knee Society scores improved significantly, but 13 repeat surgeries were required. An alarmingly high rate of complications was found after total knee and total hip arthroplasty in these patients with human immunodeficiency virus (HIV). Physicians and surgeons should be made aware of this high rate of complications after joint arthroplasty in patients with HIV and include a frank discussion of this information with their patients who are contemplating total joint arthroplasty.

Adult↗
PubMed2002

Technical details with the use of cryopreserved arterial allografts for aortic infection: influence on early and midterm mortality.

PURPOSE: In situ repair with cryopreserved vascular allografts improves the results in the surgical treatment of aortic infection. This study evaluated the technical pitfalls with the use of allografts that influence early and midterm mortality. METHODS: Between 1990 and 1999, 49 patients, 21 (43%) with a mycotic aneurysm and 28 (57%) with a prosthetic graft infection of the thoracic and abdominal aorta including pelvic and groin vessels, underwent in situ repair with cryopreserved arterial allografts. Seventeen patients (35%) had aortobronchial, aortoesophageal, or aortoenteric fistulas. RESULTS: Allograft-related technical problems occurred in eight patients (16%) in this series, and they included: intraoperative rupture caused by allograft friability; allograftenteric fistula from ligated allograft side branches rupturing 8, 18, and 48 months after implantation; anastomotic failure caused by inappropriate mechanical stress; anastomotic stricture after partial replacement of infected prosthetic grafts; allograft failure caused by inappropriate wound drainage; and recurrence of infection after inappropriate duration of antifungal treatment. Seven of the eight technical problems (87%) occurred in the first 10 patients (80%) in this series. There was one technical failure in the remaining 39 patients (2.6%; P =.0002) because of various technical adaptations, such as critical selection of allografts, use of allograft strips supporting large anastomoses, sealing with antibiotic-impregnated fibrin glue, and change in technique of allograft side-branch ligature. The 30-day mortality rate was 6% for the whole series; however, it was 2.6% for last 39 patients, with no recurrence of infection or allograft-related late death. CONCLUSIONS: In situ repair with cryopreserved arterial allografts achieves excellent early and late results in the treatment of aortic infection. However, distinct allograft-related technical problems had to be overcome to improve the outcome of patients with major vascular infections.

Adult↗
PubMed2005

Late surgical conversion after thoracic endograft failure due to fracture of the longitudinal support wire.

PURPOSE: To report complications from a thoracic endograft wire fracture and early experience with elective conversion after thoracic endografting. CASE REPORT: A 43-year-old man underwent urgent endovascular repair of a symptomatic post-traumatic thoracic aneurysm in 1999. The patient had been involved in a car accident 14 years before. He developed clinical and radiological signs of graft infection 46 months after stent-graft implantation. Multidetector computed tomography confirmed a fracture of the longitudinal support wire in the Excluder thoracic stent-graft. Additionally, radiological signs of suspected endograft infection were described. Due to concerns over a potential chronic infection, the stent-graft was successfully excised, and a polyester graft was implanted 50 months after primary endovascular repair. CONCLUSIONS: Recognition or strong suspicion of endograft infection requires conversion with removal of the device. Long-term follow-up after endografting is necessary to assess material fatigue that undermines the durability of these implants.

Adult↗
PubMed1990

Artificial heart valves.

This overview of heart valve prostheses is based on a current review of clinical reports and focuses on the major complications that characterize long-term valve performance: thromboembolism, thrombosis, anti-coagulant-related bleeding, and structural failure.

Bioprosthesis↗
PubMed1988

Results of revision total knee arthroplasties using condylar prostheses. A review of fifty knees.

Revisions of total knee arthroplasties for aseptic failure have provided varied results. In this review of fifty revisions in which a condylar prosthesis was used in carefully selected knees, the results were rated good or excellent in 76 per cent after an average length of follow-up of 4.8 years. At the follow-up examination, radiolucent lines were seen in 17 per cent of the knees. The complications included loosening of one or both prosthetic components in three knees (of which two were revised again); a hematoma in one knee; and a piece of loose cement, which had to be removed, in one knee. There were no deep infections. On the basis of these results, we concluded that revision total knee arthroplasty using a condylar prosthesis will have infrequent complications and will provide a satisfactory result in properly selected patients.

Adult↗
PubMed1986

[Possibilities of endoprosthetic joint replacement].

Nowadays arthroplastic operations determine the everyday work in the orthopaedic clinic. The good primary results show a distinct change of indications in favour of the artificial joint replacement. After a longer duration of implantation is to be reckoned with a failure quote of 10% and more. Here the problems of the durable anchoring of the prosthesis, the late infection and the exhaustion of the material are in the foreground. In the development of endoprosthesis in the GDR as carriers of the power the nickel-free cobalt-basis alloy Prothecast and as sliding partner the highly pure Hermsdorf aluminum oxide ceramic material were used as implant materials. These biomaterials best stood the test.

Biocompatible Materials↗
PubMed1998

Arthrodesis with a short Huckstep nail as a salvage procedure for failed total knee arthroplasty.

Arthrodesis of the knee with use of a short Huckstep nail was performed in thirty-three patients (thirty-three knees) after failure of a non-constrained total knee arthroplasty. The indication for the arthrodesis was an infection in thirty-one knees and a Charcot joint in two. Three knees had had a failed attempt at arthrodesis with use of external fixation. The Huckstep nail was inserted through the knee, retrograde into the femur, and then antegrade into the tibia. The duration of the operation averaged 104 minutes (range, sixty-five to 155 minutes). Local bone graft was used in all knees. At the time of follow-up, at an average of forty-seven months (range, eighteen to ninety-four months), thirty knees (91 per cent) had radiographic evidence of union. The average time to union was 5.2 months (range, two to ten months) after the arthrodesis. Eight knees that had a grossly purulent infection were treated with debridement, which was followed by the arthrodesis as a second-stage procedure; the other knees had a one-stage arthrodesis. Only one of the thirty-one knees that had had an infection before the arthrodesis had a recurrence after it. Arthrodesis with a short Huckstep nail provides immediate axial and rotational stability and allows weight-bearing without use of external support as well as placement of the knee in a slightly flexed and valgus position. In addition, the nail does not migrate and it may be used even when there is a standard-size prosthesis in the ipsilateral hip.

Aged↗
PubMed2004

Factors regulating osteoclast formation in human tissues adjacent to peri-implant bone loss: expression of receptor activator NFkappaB, RANK ligand and osteoprotegerin.

Aseptic bone loss adjacent to orthopedic joint implants is a common cause of joint implant failure in humans. This study investigates the expression of key regulators of osteoclast formation, receptor activator NFkappaB (RANK), Receptor activator of NFkappaB ligand (RANKL) and osteoprotegerin (OPG), in the peri-implant tissues of patients with osteolysis compared with levels in synovial tissues from osteoarthritic and healthy subjects. Immunohistochemical studies demonstrated that significantly higher levels of RANKL protein (p<0.05) were found in the peri-implant tissues of patients with implant failure than in similar tissues from osteoarthritic and healthy subjects. In contrast, OPG protein levels were similar in all tissues. RANKL, expressed as mRNA and protein, was predominantly associated with cells containing wear particles. Dual labeling studies showed that the cells expressing RANKL protein were macrophages. In situ hybridization studies confirmed that mRNA encoding for these proteins is also expressed by cells in the peri-implant tissues. In addition, RANK mRNA was expressed in cells that contained wear particles. These findings show that abnormally high levels of RANKL are expressed in peri-implant tissues of patients with prosthetic loosening and that these abnormal levels of RANKL may significantly contribute to aseptic implant loosening.

Adult↗