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PubMedDate not supplied

Continuous versus single-injection lumbar plexus blocks: comparison of the effects on morphine use and early recovery after total knee arthroplasty.

BACKGROUND AND OBJECTIVES: Continuous lumbar plexus infusion of local anesthetic after total knee arthroplasty has been shown to improve analgesia and early recovery as compared with patient-controlled analgesia (PCA) morphine. Any benefit of an infusion over a single-injection lumbar plexus block has not been directly shown however. METHODS: In a double-blind, randomized, controlled trial, 32 patients undergoing total knee arthroplasty were randomly allocated to 1 of 2 groups: 0.1% levobupivacaine infusion or saline infusion. Preoperatively, all patients received a lumbar plexus block with 25 mL 0.5% levobupivacaine using a posterior approach with a catheter left in situ, a sciatic nerve block with 15 mL 0.5% levobupivacaine, and a spinal anesthetic. At the end of surgery, 0.1% levobupivacaine or saline was infused into the catheter at 10 mL/h for 48 hours. All patients also received PCA morphine. The primary endpoint was morphine use from the PCA machine. Secondary endpoints included pain scores, day of first postoperative mobilization, and nausea. RESULTS: Patients receiving the levobupivacaine infusion used significantly less morphine than those receiving saline (19 mg [interquartile range (IQR) 8.5-29.5] vs 32 mg [IQR 23.5-53.0], P = .04) and also mobilized earlier postoperatively (day 1 or 2 [levobupivacaine] vs day 2 or 3 [saline], P = .001). Pain scores were similar. CONCLUSION: Postoperative infusion of local anesthetic around the lumbar plexus reduces morphine requirement and improves early recovery after total knee arthroplasty as compared with a single-injection block.

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PubMed2004

Minimally invasive total hip arthroplasty.

Total hip arthroplasty procedures relieve patients' arthritic hip pain. Since the first procedure was performed in the 1960s, surgeons and implant companies have worked to improve prosthesis design, composition of implants, and the mechanisms for holding the implants in place. Recently, surgeons have focused on minimizing the surgical incision. Smaller incisions have resulted in smaller scars and faster recoveries. This article presents a brief historical overview of, as well as current trends in, minimally invasive total hip arthroplasty. All aspects of care for a patient undergoing total hip arthroplasty are discussed.

Aged↗
PubMed2000

Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients.

Distal humeral fractures are difficult to treat. In the elderly population, the problems are compounded by osteoporosis and gross comminution. Open reduction and internal fixation for such fractures is sometimes difficult and may be associated with poor results. Total elbow arthroplasty has been suggested as a last-ditch effort to salvage functional use for such difficult fractures in the elderly. We followed seven patients (seven elbows) with a mean age of 81.7 years at the time of injury. Open reduction and internal fixation was considered a difficult option for these fractures. They were treated with a total elbow arthroplasty using the semi-constrained Coonrad-Morrey elbow replacement prosthesis. The duration of follow up at present is between 2 and 4 years. At the latest follow up the mean arc of flexion is 20-130 degrees. Six patients have no pain while one complains of mild pain. All elbows are stable. The Mayo elbow performance score for five elbows is excellent and two scored good. All but one patient are satisfied with the result. One patient developed superficial wound infection which resolved after antibiotic therapy. One patient has developed post-operative triceps weakness. There have been no cases of deep infection, ulnar nerve neuritis or component failure. The rarity of this procedure suggests its very narrow spectrum of indication. We feel that the short-term results do suggest an important role for semi-constrained total elbow arthroplasty in managing carefully selected comminuted distal humeral fractures in the elderly, especially those that cannot be treated by conventional open reduction and internal fixation.

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PubMed2004

Posterior-lateral approach to minimal incision total hip arthroplasty.

As surgeons learn to perform minimally invasive hip arthroplasty procedures, the various techniques will evolve and one or two approaches may eventually become the standard. Currently, most of these procedures are reserved for the nonmorbidly obese patients; however, as techniques are perfected and surgeons gain experience, this patient population may eventually be served. Surgeons must present information to patients in a responsible manner and clarify the actual versus perceived advantages of the MITH. It is unfortunate that some patients may abandon an experienced surgeon (who will likely give an excellent long-term clinical outcome) for an inexperienced surgeon who can provide a smaller incision (with long-term benefits thus far unknown). Surgeons must also address the same comorbidities and complications for MITH arthroplasty as with the conventional approaches such as DVT, fat embolism, pain control, and wound healing. Routines for postoperative care and screening for complications must remain within the plan of care for the standard incision and MITH patient.information to patients in a responsible manner and clarify the actual versus perceived advantages of the MITH. It is unfortunate that some patients may abandon an experienced surgeon (who will likely give an excellent long-term clinical outcome) for an inexperienced surgeon who can provide a smaller incision (with long-term benefits thus far unknown). Surgeons must also address the same comorbidities and complications for MITH arthroplasty as with the conventional approaches such as DVT, fat embolism, pain control, and wound healing. Routines for postoperative care and screening for complications must remain within the plan of care for the standard incision and MITH patient.

Acetabulum↗
PubMed2004

[Long-term results of alumina-on-alumina total hip arthroplasty].

PURPOSE OF THE STUDY: Mechanical failure in total hip arthroplasty is usually related to aseptic loosening itself related to wear particles as seen with polyethylene bearings. Alumina has bee proposed to avoid wear problems. In vitro and mid-term clinical studies have shown tribological advantages but early acetabular fixation remains an issue. Since alumina-on-alumina bearings are currently used with new fixation techniques, updated evaluations of older series are informative regarding the long-term tolerance of alumina in vivo. MATERIAL AND METHODS: We investigated 104 consecutive alumin-on-alumina cemented total hip arthroplasties (Cervaer-Osteal, Roissy, France) implanted 20 years ago in 81 patients (from 1979 to 1983). A32-mm alumina femoral head was used. The alumina acetabular socket and the titanium femoral stem were cemented. The Postel-Merle-d'Aubigne score was used for clinical evaluation. Radiological wear and development of osteolysis or loosening were noted for establishing actuarial curves. When accessible, histological samples from revision procedures were analyze. RESULTS: Six infected cases were not taken into account for data analysis. The average follow-up was 11 years, reaching 18 years in 38 cases. Twenty-three hips were revised for changing 23 acetabular sockets, 12 femoral heads, and one femoral stem. We noted one femoral head fracture, 24 definite acetabular loosenings, 12 probable acetabular loosenings, and 3 definite femoral loosenings. Radiological acetabular osteolysis was present in 4 cases, always limited to De Lee zone 1, and associated with loosening. Radiological wear was below eye detection. Periprosthetic tissue showed non-specific histological reactions to cement particles. Survival rate at 20 years was 62.8% [49.3-76.2%], in terms of revision 57.1% [42.5-71.7%] and 95.2% [89.9-100%] in terms of definite acetabular and femoral loosening. DISCUSSION: Besides the high rate of cemented fixation failure of the socket, loosened and non-loosened cases showed an excellent long-term tolerance of the alumina-on-alumina bearing with normal wear and osteolysis. This may also have protected the femoral component from complications. This study confirms in vivo the long-term tribological benefit of the alumina-on-alumina bearing in total hip arthroplasty and suggests that acetabular fixation should be improved to achieve full benefit.

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PubMed2005

[Early femoral osteolysis following Charnley-Kerboull total hip arthroplasty combining a 22-mm zirconia head on polyethylene].

PURPOSE OF THE STUDY: New bearings have been developed to reduce polyethylene wear. Zirconia ceramic is one proposal with attractive tribologic properties. The purpose of this prospective study was to evaluate the clinical and radiological results at least two years after implantation in a continuous series of total hip arthroplasties combining a zirconia head with polyethylene socket. MATERIAL AND METHODS: The series included 56total hip arthroplasties performed in 51 patients (30 females and 21 males), mean age 52.2 +/- 12 years (25-76 years). Prostheses were implanted for primary degenerative disease (43%) and dysplasia (27%). The femoral component was a stainless steel stem with a Morse cone measuring 11degrees 25' for 27 hips and 5 degrees 40' for 28 hips. A 22-mm stabilized yttrium tetragonal polycrystalline zirconia head (Y-TZP) was used. The transtrochanteric approach was used for all arthroplaties with implantation of a cemented Charnley-Kerboull prosthesis. Clinical outcome was assessed with the Postel-Merle-d'Aubligné (PMA) score. Acetabular cup wear and periprosthetic osteolysis were measured on successive AP x-rays of the pelvis. RESULTS: Mean follow-up was 32 months (24-48). None of the patients were lost to follow-up. Mean function score at last follow-up was 17.8 +/- 0.2 (16-18) versus 12.2 +/- 2.6 preoperatively (Wilcoxon, p < 0.0001). There were no cases of implant migration (femoral or acetabular). An endosteal defect by femoral osteolysis in the calcar femoral was observed in 19 of 55 cases. It appeared early between first and second post-operative year and did not progress later. Its surface remained less than 1 cm2 in all cases. We were unable to identify any factor predictive of these osteolytic lesions. DISCUSSION: The short-term clinical results with this type of arthroplasty was comparable with earlier results described with classical Charnely-Kerboull implants using a metal-polyethylene bearing. The Merkel osteolysis observed in this series occurred early for one-third of the hips with no measurable polyethylene wear. We suggest surgeons should be cautious about using the zirconia head. We are continuing our surveillance of these patients.

Adult↗
PubMed2006

[Metal-metal-backed polyethylene cemented hip arthroplasty: mid-term results].

PURPOSE OF THE STUDY: Metal-on-metal bearings in total hip arthroplasty may, in theory, provide an effective answer to osteolysis in active patients. The purpose of this retrospective study was to evaluate the results of a consecutive series of Metasul total hip arthroplasties with a cemented socket. MATERIAL AND METHODS: The series was composed of 28 total hip arthroplasties in 23 patients (13 women and 10 men). The mean age at operation was 44 +/- 8.3 years (range 22-59 years). The initial diagnosis was osteoarthritis (14 hips), osteonecrosis of the femoral head (11 hips) and rheumatoid arthritis (3 hips). Cemented cups with a metal articulation surface molded into the polyethylene were used. The cup was articulated with a 28-mm metallic head. Cemented stems were used in 27 hips, whereas a hydroxyapatite coated stem was implanted in one hip. RESULTS: One hip required revision for deep infection five months postoperatively. One patient (one hip) was lost to follow-up. Twenty-six hips were evaluated at an average 31-month follow-up (range 12-47 months). All hips were rated excellent or very good. Radiographically, seven hips (27%) had a progressive acetabular radiolucent line, including three complete radiolucent lines. The latter always were located at the bone-cement interface. No implant migration was noted. In these cases, the mean socket diameter was lower than for the rest of the cohort (p < 0.001). DISCUSSION AND CONCLUSION: Progression of acetabular radiolucent lines remains of concern in this series of Metasul artificial hips. It is hypothesized that the diminution of polyethylene thickness has led to an increased rigidity of the socket, resulting in a higher rate of constraints at the bone-cement interface. Special attention must be given to these hips.

Adult↗
PubMed1997

Total joint arthroplasty and the immune response.

Total joint replacement arthroplasty has proved highly successful in the management of osteoarthritis and rheumatoid arthritis. The cause of aseptic loosening of prosthetic joint replacement components is unclear. Early experience with total joint arthroplasty was plagued by a number of problems that no longer exist as major impediments to long-term success. Improvement in the operating room environment and the use of prophylactic antibiotics have substantially reduced the high incidence of infection to less than 1%. Implant materials have long been considered biologically inert, but recent studies indicate that inflammatory reactions directed against the implanted materials may contribute to aseptic loosening. Currently, particulate debris from cement or polyethylene causing loosening of the prosthesis is the major problem in total joint arthroplasty. Significant data suggest a progression from a simple inflammatory reaction to complex immune responses against the biomaterials. The cellular responses to particles of polymethylmethacrylate, ultra-high-molecular-weight polyethylene, and alloys of cobalt-chromium and titanium have been assayed in vitro in patients with osteoarthritis, rheumatoid arthritis, and avascular necrosis who had total joint replacement. Elevated immunologic cell proliferation responses to both acrylic and cobalt chromium were observed in patients with aseptically loosened prostheses. These findings suggest that the development of a cellular response to particulate debris may be significant in the pathogenesis of aseptic loosening.

Arthritis, Rheumatoid↗
PubMed2003

Glass ionomer as an expander of allograft in revision arthroplasty of the hip.

The use of glass ionomer as a bone graft expander was investigated in an in vivo model of revision hip arthroplasty. Bone grafts of pure allograft and allograft + glass ionomer particles in a 50:50 by weight mixture were implanted in an ovine hemi-arthroplasty model. Post-operative assessments of locomotor function, radiographic appearance and quantitative changes in mineralisation around the graft were made at 2, 4 and 6 months. Post-mortem assessments of radiographic and histologic appearance of the grafts were made at 6 months. No significant differences were noted in any of the measured or assessed parameters between the two graft types. The glass ionomer particles seemed to be well tolerated within the matrix of new bone, smaller sized particles appearing to be better incorporated than larger ones. The use of particles of glass ionomer as a bone graft expander, in this in vivo model of revision hip arthroplasty, would therefore appear to offer no detriment in performance over pure allograft in the short to medium term.

Acrylic Resins↗
PubMed1996

Radiographic assessment of the trapezial space before and after ligament reconstruction and tendon interposition arthroplasty.

A radiographic method was developed, the trapezial space ratio, for assessing the space occupied by the trapezium (a space defined by the distal scaphoid and thumb metacarpal base divided by the thumb proximal phalanx). This method was applied to 100 normal thumb radiographs and to the radiographs of 15 patients with symptomatic degenerative arthrosis of the thumb basal joint before and after operative treatment with ligamentous reconstruction and tendon interposition arthroplasty. The trapezial space ratio averaged 0.476 +/- 0.033 for radiographs of normal thumbs, 0.372 +/- 0.084 for the pre-operative radiographs of thumbs with symptomatic basal joint arthrosis, and 0.270 +/- 0.078 for the radiographs of thumbs following basal joint arthroplasty. A significant reduction in the trapezial space ratio was noted when values from arthritic thumbs were compared to those of normal thumbs (22%; P < 0.0001). A further reduction in the trapezial space ratio was noted when post-operative values were compared to pre-operative ones (27%; P < 0.0002). Comparing post-operative trapezial space ratio values to values obtained in normal thumbs, a reduction of 43% was found in those thumbs treated operatively. These finding indicate that the trapezial space is reduced significantly in thumbs with severe degenerative arthrosis compared to normal thumbs and that ligament construction tendon interposition arthroplasty is not entirely successful in either restoring or maintaining the length of the thumb ray.

Adult↗
PubMed2002

Bilateral lower limb strategies used during a step-up task in individuals who have undergone unilateral total knee arthroplasty.

OBJECTIVE: The purpose of this study was to determine how bilateral lower limb joint function is altered by the combined effects of osteoarthritis and its treatment by total knee arthroplasty. DESIGN: Lower limb joint work of age-matched healthy, control participants was compared to surgical and non-surgical limb work in individuals who had undergone total knee arthroplasty. BACKGROUND: Research investigating outcomes following total knee arthroplasty has focussed primarily on the surgical knee, identifying deficits in surgical knee function. The existence of additional lower limb deficits and adjustments made by unaffected joints to complement these deficits, has yet to be examined. METHODS: Joint moments, power and work were calculated using bilateral lower limb force and kinematic data collected during a step-up to heights of 11.25 and 20 cm. RESULTS: Fifty percent of patients were unable to step onto the 20 cm step. At both step heights, when the surgical limb led the step-up, surgical knee work was less than controls. When the non-surgical limb led, deficits in non-surgical lead knee work were observed. In both cases, lead hip work increased. CONCLUSIONS: Work done by both surgical and non-surgical knees in a step-up task was lower than that done by healthy controls. This deficit was balanced by increased lead hip extensor work. RELEVANCE: These findings highlight the importance of including exercises that optimize bilateral knee and hip function in rehabilitation programs used following knee replacement. Clinicians working with this population can use this information to assist in the design of evidenced based treatment programs.

Aged↗
PubMed1998

Arthroscopic management of temporomandibular joint disc perforations and associated advanced chondromalacia by discoplasty and abrasion arthroplasty: a supplemental report.

PURPOSE: This article describes the results of treating temporomandibular joint (TMJ) articular disc perforation and advanced chondromalacia arthroscopically by the use of discoplasty and abrasion arthroplasty. PATIENTS AND METHODS: Forty-four joints were treated in 25 patients (23 females and 2 males). Twenty-nine disc perforations were present, 24 joints had grade III chondromalacia (fibrillated cartilage), and 14 joints had grade IV chondromalacia (exposed bone). Surgical procedures included 14 abrasion arthroplasties and 24 motorized shavings or holmium laser vaporizations. Holmium laser discoplasty with mobilization was used in 29 joints. Patients were followed-up for an average of 40.8 months (11 to 74 months). RESULTS: Preoperative pain on the visual analog scale (VAS) (1 to 10 cm) ranged from 5 to 10 cm, with an average of 7.4 cm. Postoperatively, nine patients had no pain and 16 patients had an average VAS of 2.7 cm (range, 1 to 5 cm). Preoperatively, 30 joints had clicking, and 14 joints had crepitation. Postoperatively, 25 joints had no noise, 12 joints had slight intermittent clicking, and seven joints had crepitation. The preoperative range of motion averaged 29.7 mm. Postoperatively, the range of motion averaged 37.7 mm (range, 33 to 42 mm). All patients could masticate a regular diet except hard food after an average of 40.8 months (11 to 74 months). CONCLUSIONS: These findings seem to justify the arthroscopic surgical procedures of discoplasty for disc perforations, motorized shaving, or holmium laser vaporization of grade III chondromalacia, and abrasion arthroplasty for bone exposure. The results also question the need for discectomy in the treatment of disc perforation.

Adult↗
PubMed1987

Late rupture of the flexor tendons as a complication of replacement arthroplasty.

A case of attritional rupture of the flexor tendons secondary to metacarpophalangeal (MP) replacement arthroplasty for treatment of rheumatoid arthritis is reported. This complication is thought to be the result of resection of the palmar plate during the arthroplasty that was performed 5 1/4 years previously. Although not previously reported, it could be an expected late result if the palmar plate is excised during arthroplasty.

Adult↗
PubMed1998

Wrist arthrodesis after failed wrist implant arthroplasty.

Wrist arthroplasty has not achieved large success to date, and there are patients with failures in their procedures who will need arthrodesis. We review our experience in revising a wrist implant arthroplasty to an arthrodesis with a block graft of fresh-frozen allograft femoral head or iliac crest bone graft. Fixation was achieved with an intramedullary Steinmann pin. Ten patients with 12 failed wrist implants required wrist arthrodesis; 7 had wrist arthrodesis with a bulk allograft femoral head, 4 with an iliac crest bone autograft, and 1 without a bone graft. After an average follow-up period of 5 years, all patients were pain free and fusion had been achieved. Complications included 1 patient with acute carpal tunnel syndrome, 2 patients with nonunions requiring secondary bone grafting procedures, and 2 patients requiring revisions of their intramedullar pins. In both nonunions, iliac crest bone graft was used for the initial arthrodesis. All the patients were satisfied. Arthrodesis after failed wrist implant arthroplasty is a satisfactory procedure, and a fresh-frozen allograft can be used effectively in wrist fusion.

Adult↗
PubMed2000

Heterotopic ossification after total shoulder arthroplasty.

Fifty-eight primary ingrowth total shoulder arthroplasties, performed between 1989 and 1992, with a minimum of 2 years' radiographic and clinical follow-up (mean, 4.7 years), were reviewed to determine the frequency and clinical significance of heterotopic ossification after total shoulder arthroplasty. Fourteen of the 58 shoulders had radiographic evidence of heterotopic ossification: grade I (12 shoulders) and grade II (2 shoulders). Heterotopic ossification was present on the early postoperative radiographs (1-2 months) in 12 of the 14 shoulders. Among these 12 shoulders, there was no increase in the grade of ossification comparing the early postoperative radiographs with those obtained at a minimum of 2 years. There were no identifiable preoperative patient characteristics associated with the development of heterotopic ossification (P > .05). Range of motion, pain, and result rating were not statistically different comparing patients with and without heterotopic ossification (P > .05). The data from this study suggest that when heterotopic ossification develops after elective total shoulder arthroplasty, it is usually low grade, is present in the early postoperative period, is nonprogressive, and does not adversely affect the clinical results.

Arthroplasty, Replacement↗
PubMed2000

White blood cell counts and differential in synovial fluid of aseptically failed total knee arthroplasty.

A cell count and differential was obtained on synovial fluid samples from 79 total knee arthroplasties undergoing revision for aseptic failure over a 5-year period. The mean white blood cell count (WBC) was 782/mL (range, 11-7,200/mL). The mean percentage of monocyte cells was 87%, and the mean polymorphonuclear leukocyte (PML) cell count was 13%. Eight patients (10.4%) had leukocyte cell counts >2,000. Five knees in 4 patients with rheumatoid arthritis had PML counts >50%. There was a single postoperative infection. In patients with osteoarthritis as a primary diagnosis, a synovial WBC of <2,000 and a differential with <50% PMLs had a 98% negative predictive value for the absence of infection. Key words: synovial fluid, cell count and differential, failed total knee arthroplasty, revision total knee arthroplasty.

Adult↗
PubMed2000

Primary total hip arthroplasty in patients with ankylosing spondylitis.

The results of total hip arthroplasty in a group of patients with ankylosing spondylitis are described. Ninety-five arthroplasties were performed in 56 men and 2 women whose average age at operation was 38.9 years (standard deviation [SD], 11.6; range, 19.2-78.8). They were followed for an average of 135.4 months (SD, 81.6; range, 24.4-331.2). We encountered 4 deep infections necessitating the removal of prostheses. Two of 3 dislocations were anterior dislocations. Nineteen arthroplasties were revised at an average of 162.0 months (SD, 49.6; range, 55.1-250.5) after the primary surgery; 9 of them had only the acetabular component revised because of aseptic loosening. Hyperextension of the hips is a common phenomenon that can lead to surgical error and predispose the prosthesis to anterior dislocation.

Adult↗
PubMed2003

Mid-term results of an AGC total knee arthroplasty system survival and function analysis: 2- to 8-year follow-up results.

Between 1993 and 1999, 148 total knee arthroplasties were performed in Dipreca Hospital; 94 were anatomically graduated components (AGC) cam-and-groove posterior-stabilized total knee arthroplasties. All patients underwent implantation with a cemented posterior cruciate-substituting design, with resurfacing of 3 components. Mean age at surgery was 69 years, and patients were followed up for a minimum of 2 years (range, 2-8). The survival analysis at 8 years was 96.6%. Revision for any reason was considered to be the endpoint. Of patients, 3.2% were lost to follow-up. The mean knee pain and function scores were 89 and 64 of 100, respectively. The scores were also analyzed by categories. This knee arthroplasty follow-up analysis shows excellent midterm results.

Aged↗