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PubMed2006

Periprosthetic malignancy as a mode of failure in total hip arthroplasty.

The presence of periprosthetic malignancy in proximity to arthroplasty implants has been infrequently reported. We present the clinical, radiographic, and pathological features of three patients in whom loosening and failure of total hip arthroplasties occurred secondary to malignant infiltration. They consisted of a 66-year-old man with the first presentation of metastatic gastric carcinoma as a periacetabular lytic lesion, a 64-year-old man presenting with femoral metastases from a previously undiagnosed lung carcinoma, and a 75-year-old woman presenting with a painless discharging thigh sinus around a total hip arthroplasty subsequently diagnosed as immunoblastic lymphoma. Malignant infiltration should be considered part of the differential diagnosis in aseptic and septic loosening of prosthetic implants. Joint aspiration and isotope bone scanning provide useful additional information before surgical intervention.

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PubMed2006

Revision total hip arthroplasty in a centenarian: a case report and review of the literature.

The clinical success of primary total hip arthroplasty in elderly patients is well established. Because of the rapid growth rate of the population aged 85 years and older and the increasing life expectancy of this group of patients, the number of patients in their 8th, 9th, and even 10th decades of life requiring revision total hip arthroplasty will increase. We present the only documented case of revision total hip arthroplasty in a centenarian and a review of the relevant literature.

Age Factors↗
PubMed2006

Comparative flexion after rotating-platform vs fixed-bearing total knee arthroplasty.

A retrospective review of rotating-platform (n = 113) and fixed-bearing (n = 100) total knee arthroplasties at a minimum 2-year follow-up was performed. All patients in both groups in this study had osteoarthritis and underwent surgery by 1 of the 2 senior authors at 1 of 2 institutions. A cruciate-retaining total knee arthroplasty was implanted with patellar resurfacing in all cases. The only difference between the 2 groups was the design of the tibial bearing and its tibial tray. Through minimization of confounding variables relating to pathology, surgeon, institution, soft-tissue balancing, and type of prosthesis, this study isolates articular design as a variable. We could not demonstrate any significant difference in knee flexion after either fixed-bearing or rotating-platform cruciate-retaining total knee arthroplasty.

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PubMed2006

Total hip arthroplasty for acute femoral neck fractures using a cementless tapered femoral stem.

The purpose of this study was to evaluate the osseointegration potential and implant-related complications of cementless total hip arthroplasty with a titanium alloy collarless, tapered, wedge-shaped femoral stem with a proximal circumferential plasma-spray coating in patients with acute hip fractures. The cohort consists of 85 patients with a mean age of 78.1 years. The mean duration of follow-up was 3.8 years. Total hip arthroplasty conferred significant improvement in function for all patients. All femoral components were stable with evidence of bone ingrowth (84 hips) or fibrous fixation (1 hip). Mild thigh pain was present in 3 patients. The complications included dislocation (3 cases), intraoperative femoral fracture (2 cases), and periprosthetic femoral fracture in the postoperative period (1 case). There was one reoperation for revision of the femoral component in the patient with a periprosthetic fracture. There were 25 (29%) deaths. Cementless total hip arthroplasty using a tapered proximally coated femoral stem is a viable option for the treatment of a displaced hip fracture and preexistent arthritis.

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PubMed2007

In vivo sagittal plane kinematics of the Avon patellofemoral arthroplasty.

Isolated patellofemoral osteoarthritis can be treated with patellofemoral arthroplasty (PFA). In contrast to total knee arthroplasty, the effect of PFA on knee joint kinematics is not known. A study was performed to identify the kinematic changes after PFA. The sagittal plane kinematics was examined in 12 patients who had undergone Avon PFA. An established fluoroscopic method was used to examine the patellar tendon angle (PTA)/knee flexion relationship during functional activities. No significant difference existed between the kinematics of PFA knees compared with normal, except for a uniform elevation in PTA throughout the range. This increase in PTA in the PFA joint represents a 1.6-mm anterior displacement of the patella. The kinematic profile after PFA is close to normal and suggests that the knee is exhibiting more normal loading characteristics than those of the total knee arthroplasty joint.

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PubMed2006

Assuring a painless total hip arthroplasty: a multimodal approach emphasizing peripheral nerve blocks.

A highly effective comprehensive multimodal pain protocol has evolved at our institution for both primary and revision hip and knee arthroplasty. At the center of this protocol are peripheral nerve blocks to deliver postoperative pain relief. Total hip arthroplasty patients receive a lumbar plexus block with an indwelling catheter. Total knee arthroplasty patients receive a femoral nerve block with an indwelling catheter and also get a single-shot sciatic nerve block. Before surgery, patients are given a long-acting oral narcotic medication and a nonsteroidal anti-inflammatory. After surgery, oral medications are given on a set schedule and include acetaminophen, a nonsteroidal anti-inflammatory, and a long-acting oral narcotic. Outstanding pain control is achieved without parenteral narcotics and allows early physical therapy, early return to self-care, and improved patient satisfaction.

Analgesics↗
PubMed2006

Incidence and reasons for reoperation after minimally invasive unicompartmental knee arthroplasty.

The goal of this report is to review reoperations undertaken on the initial 221 unicompartmental arthroplasties performed using a minimally invasive technique. A comparison was then performed between these cases and the previous 514 open medial unicompartmental arthroplasties performed at our institution. In the minimally invasive group, 9 (4.1%) of 221 knees were revised (8 for component loosening, 1 for deep infection). Of 212 unrevised knees, 16 have required a total of 18 nonrevision reoperations. Overall, 25 of 221 knees required at least 1 reoperation (total reoperation rate, 11.3%). Despite an accelerated recovery and decreased hospital stay in our minimally invasive unicompartmental arthroplasties, the rate of revision due to aseptic loosening (3.7% vs 1.0%) and the overall reoperation rate (11.3% vs 8.6%) compare unfavorably with those performed with an open technique.

Adult↗
PubMed2006

Effect of retaining a patellar prosthesis on pain, functional, and satisfaction outcomes after revision total knee arthroplasty.

It remains controversial whether patients' pain, function, and satisfaction are affected in revision total knee arthroplasty by patellar prosthetic resurfacing. This is a retrospective, comparative cohort study to evaluate this. One hundred twenty-six patients who underwent total knee arthroplasty revision were identified. After revision, the presence or absence of a patellar prosthesis was ascertained. At a minimum of 2 years' follow-up, pain and function were assessed by Western Ontario and McMaster Universities Osteoarthritis Index, Oxford-12, Short-Form 12, and patient satisfaction questionnaires in 110 patients (58 with patellar component, 52 bony shell). Univariate and multivariate analyses demonstrated no significant difference between the 2 cohorts for Western Ontario and McMaster Universities Osteoarthritis Index pain, function, Oxford-12, and satisfaction outcomes. The absence of a patellar prosthesis does not appear to significantly affect pain, function, or satisfaction outcomes after revision total knee arthroplasty.

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PubMed2007

Clinical experience using a minimally invasive surgical approach for total knee arthroplasty: early results of a prospective randomized study compared to a standard approach.

There has been recent attention concerning minimally invasive techniques for knee arthroplasty. It is not clear whether these complicated techniques can be reproduced across multiple centers and for all surgeons. This prospective, randomized, multicenter study was carried out to assess safety and efficacy of a minimally invasive total knee arthroplasty. The study consisted of 80 knees. There were no differences in blood loss, operative time for completion of surgery, infection, and ultimate wound healing. There were 4 knees with delayed wound healing in the minimally invasive surgical technique group versus 1 in the standard group, which did not affect outcome. Early clinical and radiographic results were also indistinguishable. At 12 weeks follow-up, there was no difference in mean Knee Society objective and functional scores. In summary, in this study, minimal incision total knee arthroplasty demonstrated no improvement over a standard approach.

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PubMed2006

Clinical and biomechanical assessment of patella resurfacing in total knee arthroplasty.

BACKGROUND: Currently there is a limited understanding of the factors influencing range of motion by comparing patellar resurfacing vs non-resurfacing in total knee arthroplasty during activities of daily living. A recent meta-analysis of patellar replacement confirms better outcome with patella resurfacing; however, the result can be influenced by many other factors, such as: component design, surgeon experience, and technical aspects of the surgery. This study compares the biomechanics of the knee in patients after total knee arthroplasty with and without patellar resurfacing during stair climbing. METHODS: Forty-seven patients with total knee arthroplasty were assessed at the mean follow-up of 24 months. In all of them a posterior stabilised fixed bearing prosthesis (Optetrak PS, Exactech) was implanted. Twenty-six patients were treated without patellar resurfacing and 21 with patellar resurfacing. Clinical evaluations were performed using the International Knee Society and the Hospital for Special Surgery scores. Ten patients with patellar resurfacing and 10 patients without patellar resurfacing were also studied with motion analysis during stair climbing; 10 healthy subjects were studied for statistical comparison. FINDINGS: Clinical passive knee flexion, International Knee Society Function and Hospital for Special Surgery scores were significantly higher in the patellar resurfacing group. During stair climbing, active knee joint range of motion during the stance phase was greater in patients with patellar resurfacing. The maximum adduction moment was significantly higher in the group without patellar resurfacing. INTERPRETATION: Patients with patellar resurfacing demonstrated better clinical scores, and kinematic and kinetic data while ascending stairs.

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PubMed2006

Localization of SP- and CGRP-immunopositive nerve fibers in the hip joint of patients with painful osteoarthritis and of patients with painless failed total hip arthroplasties.

Using immunohistochemical methods we determined the presence of SP- and CGRP-immunopositive nerve fibers in the hip joint of patients with femoral neck fracture (controls, group 1), painful osteoarthritis (group 2), and painless failed total hip arthroplasties (group 3). Immunoreactive nerve fibers were found in the soft tissue of the fossa acetabuli as well as in the subintimal part of the synovial layer in the hip joint capsule of groups 1 and 2. In the capsule of controls the innervation density had a median of 5.7fibers/cm(2) for CGRP-ir and 3.2fibers/cm(2) for SP-ir afferents. In the osteoarthritic group, the density significantly increased to a median of 15.6fibers/cm(2) for CGRP-ir and 8.2fibers/cm(2) for SP-ir neurons (p=0.05). Patients with failed hip arthroplasties completely lacked these neuropeptide containing afferents. Innervation density in the fossa acetabuli of osteoarthritc patients showed a median of 14.1fibers/cm(2) for CGRP-ir and 5.9fibers/cm(2) for SP-ir afferents. From these data we assume that the hip joint capsule and the soft tissue of the fossa acetabuli are important triggers of nociception. This is supported by the fact, that patients with loosened total hip arthroplasties, where we failed to detect SP- and CGRP-immunoreactive fibers, did not feel pain. The upregulation of SP- and CGRP-positive neurons in response to arthritic stages suggests a mechanism involving neuropeptides in the maintenance of a painful degenerative joint disease and in mediating noxious stimuli from the periphery. Furthermore, these findings help to explain clinical observations, such as effectiveness of local therapy to control hip pain with intraarticular injection, synovectomy and denervation procedures.

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PubMed2006

Rheumatoid arthritis: silicone metacarpophalangeal joint arthroplasty indications, technique, and outcomes.

Silicone implant arthroplasty has been used for more than 40 years for severe rheumatoid disease at the metacarpophalangeal (MCP) joint. Multiple investigations have shown that silicone arthroplasty places the MCP joint in a more extended posture, with some improvement in the total arc of motion. Ulnar drift is also improved, but strength and other objective measures have not demonstrated marked changes postoperatively. The lack of prospective data and more complete outcome assessment has been, at least in part, responsible for the marked difference in opinions between rheumatologists and hand surgeons on the effectiveness of MCP arthroplasty. Recent reports using patient-centered outcome measures have shown that early outcome is favorable, with improvements in appearance, pain, and function.

Arthritis, Rheumatoid↗
PubMed2006

Retention of the patella in total knee arthroplasty for rheumatoid arthritis.

AIM: To determine whether retention of the native patella during total knee arthroplasty is appropriate in patients with rheumatoid arthritis. METHODS: All patients undergoing total knee arthroplasty with a diagnosis of rheumatoid arthritis were identified between January 1997 and December 2000. Subsequently, each individual underwent both radiological and clinical assessments at a designated follow-up clinic. RESULTS: A total of 30 total knee arthroplasties were studied in 28 patients. Twenty-six patients (93%) were female with a mean age of 74.7 years (range 60-83 years). The average post-operative interval was 59.4 months (range 46-82 months). All individuals were noted to have satisfactory patellar tracking and bone stock at the time of surgery. No patient subsequently underwent revision surgery during follow-up and no episodes of implant sepsis were identified. The mean Patellar Score at final follow-up was 26.2 (range 22-30) with an average anterior knee pain score of 14.2 (range 10-15). The mean Oxford Knee Score was 18.7 (range 16-23) with a mean pain score component of 5.9. Patients were finally assessed with respect to the Knee Society Score. The mean Knee Score was 83.8 (range 71-96) with a mean Function Score of 79.7 (range 40-90). CONCLUSION: By retaining the native patella we were still able to obtain highly satisfactory medium-term results in terms of pain relief and function. In addition, the potential complications associated with prosthetic replacement of the patella were avoided.

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PubMed2004

Long-term assessment of Swanson implant arthroplasty in the proximal interphalangeal joint of the hand.

PURPOSE: The purpose of this study was to evaluate the clinical results of Swanson silicone implant arthroplasty of the proximal interphalangeal (PIP) joint, specifically evaluating clinical results with long-term assessment. METHODS: A retrospective review of 70 silicone implants of the PIP joint in 48 patients was performed with an average follow-up period of 6.5 years (range, 3-20 y). Clinical assessment included motion, stability, and alignment. Radiographic assessment included implant fracture, deformity, and cystic bone resorption. The pathology consisted of degenerative joint disease in 14, posttraumatic arthritis (TA) in 11, rheumatoid arthritis (RA) in 13, and idiopathic arthritis (IA) associated with collagen disease in 12 patients. Swan neck and boutonniere deformities were assessed separately. Statistical analysis of preoperative risk factors was compared with the postoperative assessment of pain, motion, and function (return to work). RESULTS: There was no significant change in the active range of motion (ROM) before and after PIP arthroplasty (26 degrees vs 30 degrees ). Correction of swan neck and boutonniere deformities was difficult, usually leading to poor results. There was improvement in maximum active extension before surgery lacking 32 degrees to after surgery lacking 18 degrees . From a statistical standpoint rheumatoid joint involvement with PIP arthroplasty had poorer results than degenerative or posttraumatic arthritis with respect to pain relief and ROM. Pain relief was present in 70% of replaced PIP joints with residual pain and loss of strength in 30%. Radiographic analysis showed abnormal bone formation (cystic changes) in 45%. There were 11 implant fractures and 9 joints that required revision surgery. CONCLUSIONS: Silicone replacement of the PIP joint is effective in providing relief of pain from arthritis but does not provide improvement in motion or correction of deformity. It provided a poorer outcome in rheumatoid disease in comparison with degenerative, posttraumatic, or idiopathic arthritis.

Arthritis↗
PubMedDate not supplied

Total elbow arthroplasty with massive composite allografts.

Total elbow arthroplasty is challenging when there is extensive bone loss. We studied retrospectively the long-term (mean, 6.5 years) clinical and radiographic results of 10 patients in whom 14 massive allograft-prosthetic composites were used in such clinical situations. The mean arc of active flexion/extension was 92 degrees. The Bryan-Morrey and Hospital for Special Surgery elbow scoring systems were used and revealed a modest improvement in pain and stability but a disappointing return of function, with independent self-care possible in only 3 patients, household and employment activities in 2, and recreational pursuits in 2. Three patients claimed that they were unable to use the elbow. Multiple procedures (mean, 2.2) were sometimes required to optimize the result. The 79% rate of allograft-host union is similar to that of hip and knee arthroplasty. The use of massive allografts is a reasonable alternative in salvage situations involving total elbow arthroplasty with massive bone loss.

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PubMedDate not supplied

Shoulder arthroplasty for atraumatic avascular necrosis of the humeral head: nineteen shoulders followed up for a mean of seven years.

Nineteen shoulder arthroplasties for the treatment of nontraumatic avascular necrosis of the humeral head were evaluated. The osteonecrosis was idiopathic in 6 shoulders, was a result of corticotherapy in 10, occurred after radiation in 2, and occurred after Gaucher's disease in 1. A total shoulder arthroplasty was performed in 5 cases and a hemiarthroplasty in 14. At 7 years' follow-up (range, 2 to 12 years), there were 7 excellent, 9 satisfactory, and 3 unsatisfactory results. The Constant score averaged 58 points, for an adjusted score of 78%. Radiolucent lines were present around 2 glenoid components, and 1 was radiographically loose. In 2 cases with humeral head replacement, there was painful glenoid wear. Shoulder arthroplasty for nontraumatic avascular necrosis yields satisfactory results with a pain-free shoulder in more than 80% of cases. However, limitation of motion often persists. Better results can be expected with shorter preoperative delay, when preoperative pain is moderate and range of motion preserved and when the etiology is not postradiation avascular necrosis, which in our series yielded the worst results.

Adult↗
PubMedDate not supplied

Humeral windows in revision shoulder arthroplasty.

Currently, there are no published results of patients in whom a window in the humeral cortex had been created to facilitate revision of a failed shoulder arthroplasty. Therefore, we reviewed the results of patients who underwent creation of a humeral window in the course of a revision shoulder arthroplasty to determine the complications and rate of healing. Twenty patients underwent humeral osteotomy to remove a well-fixed humeral component during the course of revision shoulder arthroplasty at our institution between January 1, 1987, and December 31, 2002. There were 17 cemented humeral components and 3 fully textured, press-fitted components. Of the shoulders, 16 had an anterior window, 3 had a medial window, and 1 had combined anterior and medial windows. There were 4 intraoperative fractures: 3 in the humeral shaft and 1 in the greater tuberosity. At the most recent radiographic follow-up at a mean of 3.3 years (range, 3-176 months), 17 of 20 windows had healed. Among 3 patients with limited radiographic follow-up (1, 3, and 4 months), 2 were healing and 1 did not demonstrate radiographic signs of healing. There were no cases of window malunion. No humeral components have developed clinical loosening. The data from this study suggest that humeral windows may facilitate controlled removal of well-fixed humeral components with a high rate of union. Further evolution of this technique may result in a lower fracture rate.

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PubMedDate not supplied

Total arthroplasty versus hemiarthroplasty for glenohumeral osteoarthritis: role of provider volume.

The selection between total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) for the treatment of glenohumeral osteoarthritis is largely a matter of the surgeon's preference. We evaluated practice patterns among surgeons and hospitals in using shoulder arthroplasty procedures for osteoarthritis. Patients undergoing TSA (8,743 cases) and HA (4,998 cases) for osteoarthritis were extracted from the Nationwide Inpatient Sample databases. Surgeon volume and hospital volume were divided into low-, intermediate-, and high-volume categories. Multivariate logistic regression models were used to estimate the risk-adjusted association between provider volume and selection of TSA. High-volume surgeons (TSA rate, 77.2%) and intermediate-volume surgeons (TSA rate, 65.2%) were significantly more likely to perform a TSA compared with low-volume surgeons (TSA rate, 60.1%) after adjustment for confounders (P < .005). Similarly, patients admitted to high-volume hospitals were significantly more likely to undergo TSA compared with those admitted to low-volume hospitals (TSA rate, 69.9% compared with 59.5%; P < .001). In addition, procedure volume of the hospital in which the surgery was performed independently influenced a surgeon's decision to choose TSA over HA. Our study showed that high-volume providers, shown to have better outcomes after shoulder arthroplasty in previous studies, use TSA more frequently for osteoarthritis. Possible explanations may include better patient outcomes with TSA and a low-volume surgeon's comfort level in performing the more technically complex TSA procedure. Definitive treatment guidelines for glenohumeral osteoarthritis are needed.

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