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PubMedDate not supplied

Complications of total shoulder arthroplasty: are they fewer or different?

There has been significant evolution of total shoulder arthroplasty design and improvement in technique over the past 25 years, but there is no information available as to whether this has translated into lower complication rates or different sorts of complications. The purpose of this study was to determine the contemporary complications and their frequency. Between 1990 and 2000, 431 total shoulder arthroplasties were performed with a cemented all-polyethylene glenoid component. Follow-up averaged 4.2 years. Complications were categorized by type as early or late and as minor, major, or major requiring reoperation. In total, 53 surgical complications occurred in 53 patients (12%). Of these, 32 were major complications (7.4%), with 17 of these requiring reoperation. Index complications in order of frequency included rotator cuff tearing, postoperative glenohumeral instability, and periprosthetic humeral fracture. Notably, glenoid and humeral component loosening requiring reoperation occurred in only 1 shoulder. Developing a complication was unrelated to diagnosis, previous surgery, age, sex, humeral head size, or cementing or not cementing the humeral component. Data from the contemporary patient group suggest that there are fewer complications of shoulder arthroplasty and less need for reoperation. Especially striking is the near absence of component revision because of loosening or other mechanical factors. Periprosthetic humeral fractures are more common; the explanation for this warrants further study.

Adult↗
PubMed2006

Ultrasound evaluation and clinical correlation of subscapularis repair after total shoulder arthroplasty.

The purpose of this study was to document the subscapularis healing rate by use of postoperative ultrasound and correlate healing to physical examination findings. We included 23 patients (30 shoulders), who underwent total shoulder arthroplasty in the study. The evaluation included a standard history and physical examination, ultrasound evaluation, and outcome questionnaires. The postoperative examination included careful documentation of an abdominal-compression test to evaluate subscapularis function. All patients had an improvement in functional outcome scores and shoulder range of motion. Of 30 shoulders, 26 (87%) had an intact subscapularis as determined by ultrasound. By use of ultrasound as the gold standard, the abdominal-compression test had 7 false-positive results, 3 false-negative results, 19 true-negative results, and 1 true-positive result. The sensitivity of the abdominal-compression test was 25%, and the specificity was 73%. The negative predictive value was 86%, and the positive predictive value was 13%. The abdominal-compression test demonstrated a low sensitivity, specificity, and positive predictive value in this study for the assessment of subscapularis function after total shoulder arthroplasty. If a subscapularis tear is suspected in a patient after total shoulder arthroplasty, the abdominal-compression test is unreliable in predicting a subscapularis defect.

Activities of Daily Living↗
PubMedDate not supplied

Revision shoulder arthroplasty with positive intraoperative cultures: the value of preoperative studies and intraoperative histology.

Currently, there are no reported results of patients without overt infection who had a positive intraoperative culture during revision shoulder arthroplasty. We therefore reviewed the intraoperative and preoperative investigations as well as the postoperative course of these patients who had positive intraoperative cultures. We reviewed the results of 75 shoulders without overt infection that underwent revision shoulder arthroplasty at our institution between January 1, 1974 and December 31, 2002 who had positive intraoperative cultures. Preoperatively, the results of 67 (93%) of 72 white-blood-cell counts were negative, 64 (91%) of 70 polymorphonuclear percentage distributions were negative, and 36 (86%) of 42 samples of erythrocyte sedimentation rate were negative. C-reactive protein concentration was measured in 16 patients, of which 12 (75%) had negative results. Results of intraoperative histologic evaluations were negative in 67 (92%) of 73 patients. The most common pathogen cultured was Propionibacterium acnes in 45 of 75, followed by Staphylococcus epidermidis in 10 of 75. Another operation was necessary in 10 (13%) of 75 shoulders to decrease pain or improve function. The mean time to re-revision was 2.5 years. The data from this study suggest that there are no good preoperative or intraoperative investigations to detect who will have a positive intraoperative culture at the time of revision shoulder arthroplasty.

Adult↗
PubMedDate not supplied

Fracture and nonunion of the olecranon in total elbow arthroplasty.

BACKGROUND: While fracture and nonunion of the olecranon have been reported in patients undergoing total elbow arthroplasty, little information exists about the management and outcome of these cases. METHODS: Twenty-four patients (twenty-five elbows) were studied; fifteen (sixteen elbows) with rheumatoid arthritis and nine with post-traumatic elbow disorders. Twenty-three of the twenty-five elbows presented with an olecranon fracture or nonunion prior to the reported arthroplasty. During arthroplasty the olecranon fragment was initially treated by tension band in sixteen elbows, excision in four, suture fixation in two and three with stable fibrous union were left alone. RESULTS: At an average follow-up of 66 months (range, 18 to 242), there were twelve excellent, nine good, three fair and one poor results. The mean pre-operative Mayo Elbow Performance Score improved from 42 (range, 20 to 62) points pre-operatively to 86 (range, 50 to 100) points post-operatively (p < 0.001). Of the eighteen patients undergoing an attempt at union, nine (50%) obtained osseous union, eight (45%) developed a stable fibrous union and one patient underwent subsequent excision of the fragment due a superficial infection (5%). Fifteen of twenty-one could extend the hand above the head against gravity. CONCLUSION: A functional arc of motion and satisfactory clinical outcome can be achieved with osseous or a stable fibrous nonunion.

Adult↗
PubMed2006

Osseous anatomy of the distal humerus and proximal ulna: implications for total elbow arthroplasty.

Cortical thickness and multiple intramedullary canal diameters were measured in sequential axial sections from 27 human cadavers. No age or side differences were identified. The intramedullary humeral canal shape changed along the length of the bone in both male specimens and female specimens. Anteroposterior and male minimal humeral canal diameters increased proximally from the elbow. Male and female medial-lateral humeral diameters decreased proximally from the elbow. All ulnar canal diameters decreased distally in a uniform fashion. The minimal ulnar and humeral canal diameters did not occur in either the sagittal or coronal plane. Humeral and ulnar cortical thickness did not vary within axial sections. Only ulnar cortical thickness changed between sections, decreasing distally. On the basis of these data, a cylindrical humeral stem and an ulnar stem tapering in all planes may be optimal for total elbow arthroplasty stems. The relatively thin cortices of both the humerus and the ulna predispose patients to perforation, periarticular fracture, and complications during revision arthroplasty surgery. Finally, routine frontal and lateral radiographs may overestimate minimal canal size for total elbow arthroplasty components. However, the lateral view appears to approximate the true minimal canal diameter more closely.

Aged↗
PubMed2006

Long-term results of uncemented humeral components in shoulder arthroplasty.

The purpose of this study was to determine the long-term results of uncemented humeral components in shoulder arthroplasty. We reviewed 37 shoulder arthroplasties with press-fit humeral components with a mean follow-up of 9.2 years (range, 5.8-13.6 years). The mean Constant score was 57 points (range, 16-95 points), and the results in 70% of the patients remained satisfactory. No complications or revisions occurred related to the uncemented humeral component. On radiographic analysis, none of the humeral components showed subsidence. Of the components, 22 (59%) showed radiolucency, 12 (32%) had endosteal erosion, and 5 (14%) had tilted. Of the humeral components, 7 (19%) were judged to be at risk for loosening. The prevalence of an at-risk humeral component was not associated with increasing pain or deteriorating function. This study shows favorable results with the use of uncemented humeral components in shoulder arthroplasty, with a low prevalence of clinical loosening at long-term follow-up.

Adult↗
PubMed2006

Determinants of patient satisfaction with outcome after shoulder arthroplasty.

The purpose of this investigation was to identify the determinants of patient satisfaction with outcome after hemiarthroplasty and total shoulder arthroplasty. Seventy patients who underwent shoulder arthroplasty were studied to determine predictors of patient satisfaction. Patient satisfaction was graded on an ordinal scale from 1 to 10. There was a significant association between patient satisfaction and age (P = .010) and between patient satisfaction and worker's compensation status (P = .018). There was no significant decrease in patient satisfaction for patients with rotator cuff tears. Patient satisfaction was significantly associated with all pain and function variables at follow-up (P < .05). The American Shoulder and Elbow Surgeons score was significantly correlated with patient satisfaction (P = 0.680, P < .05). Independent predictors of satisfaction included pain with activities of daily living, painless use of the arm above the shoulder, and difficulty with toileting (R(2) = 0.555). Subjective variables associated with pain were independent predictors of patient satisfaction. Thus, in assessing patient satisfaction after shoulder arthroplasty, we emphasize the importance of patient-derived subjective assessment of symptoms and function.

Adult↗
PubMed2006

Shoulder arthroplasty in cases with avascular necrosis of the humeral head.

Avascular necrosis (AVN) is a relatively uncommon cause of glenohumeral arthritis. Previous retrospective reviews of shoulder arthroplasty for AVN have shown very good results in small numbers of patients. This study prospectively evaluated a consecutive series of 21 shoulders in 19 patients treated with the same modular prosthesis at a single institution. Of the shoulders, 8 developed AVN after a proximal humeral fracture, 1 was associated with a massive rotator cuff tear, 10 developed after corticosteroid therapy, and 2 were idiopathic. The patients, 14 women and 5 men, with a mean age of 54 years, were followed up for a mean of 4.7 years (range, 2 to 8 years). Hemiarthroplasty was performed in 15 shoulders, whereas 6 required total shoulder arthroplasty. Assessment included visual analog scales, the Simple Shoulder Test, and the American Shoulder and Elbow Surgeons Shoulder Score Index (SSI). Physical examination was performed, and radiographs were obtained. The visual analog scale scores for pain and function improved significantly after surgery (P < .01). The mean SSI score rose from 36 to 81 (where 0 indicates the worst outcome and 100 indicates the best outcome). The mean number of positive responses on the Simple Shoulder Test increased from 3 to 10. Mean active elevation increased from 88 degrees to 123 degrees . External rotation improved from 7 degrees to 34 degrees , and internal rotation improved from L4 to T12. No difference in outcome was noted based on age or sex. Patients with steroid-related or idiopathic AVN had greater pain and functional impairment preoperatively (mean SSI score, 26) than those with prior fracture or rotator cuff tear (mean SSI score, 49) (P < .01). Postoperatively, however, these groups fared equally well (mean SSI score, 78 vs 82). Shoulder arthroplasty for AVN produces good pain relief and function, although a concurrent series with osteoarthritis yielded better results. Forward elevation did not approach normal as had been previously reported.

Adult↗
PubMed2005

The effect of aprotinin on blood loss in bilateral total knee arthroplasty.

Twenty-five patients undergoing bilateral total knee arthroplasty were given aprotinin (1-2 million units) in doses adjusted for weight, infused at the end of the first arthroplasty. Blood management was compared with our previous series of 68 patients who were not treated with aprotinin. Blood drained and re-transfused in the first 6 h was significantly less in the aprotinin group (323 ml, S.D. 320) than the untreated group (1033 ml, S.D. 539, p<0.0005). The total blood drained was also less in the aprotinin group (713 ml compared to 1613 ml, p<0.0005) but this was accounted for soley by the difference in early blood loss. The use of other blood products was less in the aprotinin group (360 ml, S.D. 357 compared to 827 ml, S.D. 434, p<0.0005). The mean postoperative haemoglobin on the day following surgery was similar at around 10 g. There were no complications or adverse reactions to the use of aprotinin. We conclude that aprotinin significantly reduces early blood loss after bilateral knee arthroplasty. In our hands, we have found it to be safe. Further work is required to determine whether postoperative use may further reduce the need for blood transfusion.

Aged↗
PubMed2004

The precision and accuracy of templating the size of unicondylar knee arthroplasty.

In trauma and joint arthroplasty, preoperative templating is an important step that can help in the selection of implant size, position and alignment. Although the precision (reproducibility) of templating in unicondylar knee arthroplasty has been assessed previously, the accuracy has never been studied. Our aim is to assess the precision and accuracy of using the templating system for one commonly used unicondylar knee arthroplasty, ALPHANORM design (Alphanorm Medizintechnik, Germany). Eight observers used the templating system to estimate the size of the unicondylar knee prosthesis ALPHANORM in 29 randomly selected patients with osteoarthritis. The observers, who all were orthopaedic surgeons with two different levels of experience, worked independently and repeated their measurements 2 weeks later. All the patients subsequently underwent unicondylar knee replacements, and the actual size of the femur and tibia was assessed intra-operatively without any knowledge of the template sizes. Our results revealed a high level of intra-observer reproducibility. However, the inter-observer reproducibility and the accuracy all were poor.

Arthroplasty, Replacement, Knee↗
PubMed2006

Stiffness after total knee arthroplasty: prevalence, management and outcomes.

We investigated the prevalence of stiffness after total knee arthroplasty, and the results of the treatment options in our practice. Between 1987 and 2003, we performed 1188 posterior-stabilized total knee arthroplasties. The prevalence of stiffness was 5.3%, at a mean follow-up 31 months postoperatively. The average age was 71 years (range, 54-88). The patients with painful stiffness were treated by two modalities: manipulation and secondary surgery. In the manipulation group (n:46), the mean range of motion improved from 67 degrees before manipulation to 117 degrees afterward. This improvement was maintained at final follow-up as 114 degrees. There was no significant difference between the motion, immediately after manipulation and at final follow-up. However, motion at final follow-up was better for those manipulated early to those done later (p=0.021). In the secondary surgery group (n:10), the mean gain in motion was 49 degrees at final follow-up and average pain score was found 43. Patellar problems--component loosening and clunk syndromes--were found in 4 patients (40%). Early manipulation gives better gain of motion than done later and our patients had not lost flexion during follow-up. The patella should always be evaluated in every stiff arthroplasty. In our opinion, patellar problems are a good prognostic factor for the success of revision surgery and open arthrolysis does not correct a limited flexion arc, but it does relieve pain. Arthroscopic release is not reliable for severely stiff knees and we prefer to perform it in less painful and moderately stiff knees within 3 to 6 months after operation.

Aged↗
PubMed2006

Tranexamic acid reduces early post-operative blood loss after total knee arthroplasty: a prospective randomised controlled trial of 29 patients.

INTRODUCTION: Extensive blood loss related to knee arthroplasty is quite normal and many patients require blood transfusions. Surgery and the use of pneumatic tourniquets lead to an increase in the activity of the fibrinolytic system, which in turn may accentuate the blood loss. Drugs that inhibit the fibrinolytic system may thus be used to reduce blood loss. Tranexamic acid (TA) acts by binding to one of the enzymes at the start of the coagulation cascade, so inhibiting the fibrinolytic system. A concern is that this inhibition may have the side effect of increasing thromboembolic disease, a common complication of joint replacement surgery. We aimed to confirm the reductions in blood loss and to assess the impact of TA usage on clinical and sub-clinical DVT. METHOD: We performed a prospective, randomised, double blind, controlled trial, using patients due to undergo primary unilateral total knee arthroplasty. Patients were randomised to receive either 15 mg/kg of tranexamic acid or a similar volume of normal saline at the time of cementing of the prosthesis. Perioperative blood loss was recorded and patients were screened for DVT with duplex ultrasound assessment of both legs on the fifth post-operative day. RESULTS: A statistically significant (p=0.006) decrease in blood loss in the early post-operative period was noted in the group receiving tranexamic acid. This was not associated with a significant difference in total blood loss (p=0.55) or in transfusion requirements. There was no of evidence in DVT in either group on duplex ultrasound screening of the lower limbs. INTERPRETATION: One injection of 15 mg/kg of tranexamic given at the time of cementing the prosthesis in total knee arthroplasty, before deflation of the tourniquet, significantly decreases the amount of blood loss in the early post-operative period. The treatment was not associated with an increase in thromboembolic complications.

Aged↗
PubMed2006

Successful total knee arthroplasty in the presence of sporotrichal arthritis.

Articular sporotrichosis, a chronic granulomatous fungal infection, is a rare entity but when present may lead to significant joint destruction. Severe knee arthrosis due to sporotrichal arthritis has traditionally been treated with arthrodesis. Total knee arthroplasty in the presence of sporotrichal arthritis has been treated with long-term suppressive antifungal agents or 1-stage exchange total knee arthroplasty. We present a case in which primary total knee arthroplasty in the presence of sporotrichal arthritis resulted in good functional outcome at 2.5 years of follow-up.

Aged↗
PubMed2005

General considerations for cervical arthroplasty with technique for ProDisc-C.

Motion-preserving spinal arthroplasty is a triumph of modern biomechanics, material sciences, and surgical technique. The ability to remove entire intervertebral discs and re-place them with prostheses that preserve height and alignment as well as motion and stability, all the while alleviating the pain and spinal cord compression, is the result of nearly 50 years of progress in joint arthroplasty. Although the clear benefit or danger of artificial cervical discs is still unknown, they are already fundamentally changing the field of cervical spine surgery and are undoubtedly going to establish their place in the armamentarium for spinal surgeons. Short-term follow-up studies indicate that cervical arthroplasty is as safe and effective as traditional fusion surgery, but follow-up studies are no longer needed.

Arthroplasty, Replacement↗
PubMed2005

Cervical disc arthroplasty: general introduction.

Cervical disc arthroplasty is a relatively new motion-preserving technique for the treatment of symptomatic degenerative disc disease of the cervical spine. Unlike anterior discectomy and fusion, cervical disc replacement restores normal motion and a physiologic biomechanical environment to adjacent disc levels, thereby decreasing the incidence of adjacent segment disease. To date, cervical disc arthroplasty has been at least as effective as cervical fusion in providing symptomatic relief while reducing perioperative morbidity, eliminating the need for postoperative external immobilization, and allowing for earlier return to normal function. No significant complications have been associated with this procedure so far. Further study in the form of large, randomized, prospective studies is needed to make conclusions about the long-term efficacy of this procedure as well as to determine the patient populations that may benefit most from cervical disc arthroplasty.

Arthroplasty, Replacement↗
PubMed2005

Clinical correlation of femoral component migration in hip resurfacing arthroplasty analyzed by Einzel-Bild-Röntgen-analyze-femoral component analysis.

Hip resurfacing arthroplasty using metal-on-metal bearings has become increasingly popular. Wear of these bearings has been imperceptible on plain radiographs. Migration analysis studies may represent the opportunity to detect early failures and evaluate long-term prosthetic survival. The authors retrospectively reviewed 29 hips in a consecutive series of metal-on-metal hip resurfacing arthroplasties with a long-term clinical follow-up (average 8.7 years) to analyze the femoral component migration pattern by means of Einzel-Bild-Röntgen-Analyze-femoral component analysis (EBRA-FCA). Femoral component migrations at 2 years and latest follow-up were compared with the known clinical outcomes. The authors' findings add validity to EBRA-FCA as a means to monitor femoral component migration and the clinical outcome of metal-on-metal hip resurfacing arthroplasty.

Arthroplasty, Replacement, Hip↗
PubMed2005

Sagittal bowing of the distal femur in Chinese patients who require total knee arthroplasty.

PURPOSES: The importance of the femoral sagittal bowing on total knee arthroplasty is under-recognized. The bowing could lead to potential errors in positioning of the femoral component if it is ignored. We aimed to document the femoral sagittal bowing at different segments of the Chinese femur and to discuss the implications of this sagittal bowing on total knee arthroplasty. METHODS: One hundred lateral radiographs of the entire lower limbs of 85 Chinese patients admitted for total knee arthroplasty were digitized. The radii of curvature of the intramedullary canal of the proximal, middle and distal one-third of the femora were measured. RESULTS: The average age of the patients was 67.3 years. The radii of curvature of the proximal, middle and distal one-third of the femora were 1081.6, 926.2 and 715.1 mm, respectively. The distal one-third of the femora was significantly more bowed than the other parts of the femora (p<0.001). The distal femoral bowing was more profound in rheumatoid patients and in those with a short femur. CONCLUSIONS: The lateral contour of the Chinese femur is like a hockey stick. This exaggerated sagittal bowing in the Chinese femur can affect the final sagittal position of the femoral component and has implications for the choice of implant design. In revision setting, a long and straight press-fit stem might either endanger the anterior cortex or deflect the femoral component to an abnormally extended position.

Adult↗
PubMed2005

The role of hereditary hemochromatosis in aseptic loosening following primary total hip arthroplasty.

Hereditary hemochromatosis (HH) results in increased iron absorption and subsequent deposition in tissue. This condition occurs predominantly in individuals of Northern European and Celtic origin with Ireland having one of the highest allele frequencies in the world. This study examines the hypothesis that homozygosity for either the C282Y or H63D mutations in the HFE gene may be associated with aseptic loosening following total hip arthroplasty (THA). Two groups of individuals were screened for the C282Y and H63D mutations associated with HH. Group 1 were individuals who had undergone primary hip arthroplasty and group 2 were individuals who had undergone revision hip arthroplasty for aseptic loosening. Exclusion criteria included rheumatoid or other inflammatory arthropathies and revision due to causes other than aseptic loosening. Significantly more patients in the revision THA group were homozygous for the C282Y genotype (P = 0.014). Aseptic loosening occurred earlier in these patients (P = 0.009), in particular in the patients who had clinical signs of hemochromatosis. No association was seen with the H63D mutation and revision THA. The incidence of HH in the group of primary THA patients was no higher than the background incidence. Patients who require primary THA and who are homozygous for the C282Y mutation have an increased risk of developing aseptic loosening, leading to revision THA. Moreover C282Y homozygosity appears to be associated with earlier aseptic loosening than in individuals without the C282Y mutation.

Adult↗