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PubMed1998

Catastrophic failure of the acetabular component in a ceramic-polyethylene bearing total hip arthroplasty.

Recent research in total hip arthroplasty has focused on attempts to decrease wear at the femoral head-acetabulum articulation, to limit the production of debris that is believed to lead to osteolysis and prosthetic loosening. The use of ceramic-on-polyethylene bearing surfaces has been reported to produce lower wear rates and therefore may increase the life expectancy of the joint arthroplasty. Problems with this bearing have been reported to be due to ceramic femoral head fracture. Reported here are 2 cases of catastrophic failure of total hip arthroplasties, involving a ceramic femoral head, caused by failure of the polyethylene acetabular liner, with subsequent penetration of the femoral head through the acetabular shell.

Acetabulum↗
PubMed1998

Vascular injuries in total knee arthroplasty. A review of the problem with special reference to the possible effects of the tourniquet.

Considering the proximity of the major vascular structures to the back of the knee, vascular complications of total knee arthroplasty are relatively rare. A patient who developed acute vascular insufficiency immediately following a total knee arthroplasty is reported. This stimulated a survey of arterial complications encountered by members of the British Association for the Surgery of the Knee. The majority of surgeons still use a tourniquet but will modify their practice if there is anxiety about vascular status. The mechanism of injury to the vascular system is either direct trauma or thrombosis. The outcome following treatment after direct injury is extremely good. The outcome after thrombosis is extremely poor. There is no recorded case of thrombosis occurring when a tourniquet was not used. Whether all knee arthroplasties should be done without a tourniquet is discussed. Early intervention is vital if a vascular injury is suspected.

Aged↗
PubMed1998

Rotator cuff repair during shoulder arthroplasty in rheumatoid arthritis.

A prospective study of 40 shoulder arthroplasties in patients with rheumatoid arthritis was performed to evaluate the results of rotator cuff repair at the time of arthroplasty. A large cuff tear was present in 21 shoulders, and good repair of the cuff was performed in 9. In the other shoulders the repair was considered insufficient. All patients were clinically evaluated using the Hospital for Special Surgery 100-point scoring system. The minimum follow-up period for inclusion in this study was 2 years. The quality of the repair of the ruptured cuff at the time of surgery had a significant influence on the postoperative clinical score (linear regression model, P = .002). The clinical score of the shoulders with good repair of the rotator cuff improved considerably and continued to improve even after the first-year follow-up examination. Meticulous repair of the ruptured cuff at the time of arthroplasty is recommended.

Adult↗
PubMed1999

Total knee arthroplasty for post-traumatic arthrosis.

The outcomes of total knee arthroplasty for post-traumatic arthrosis were studied in 31 knees. The average age at arthroplasty was 60 years old (range, 36-78 years). The interval from fracture to total knee arthroplasty averaged 13 years. Simultaneous corrective osteotomy was necessary in 4 patients to correct axial alignment and preserve ligamentous integrity. Follow-up averaged 46 months. Mean arc of motion increased significantly, from 94 degrees to 100 degrees (P = .027). Average function score improved from 44 to 72 points. This change was statistically significant (P<.0001). Knee Society knee scores also improved significantly, from 36 to 78 points (P<.0001). At most recent follow-up, the functional scores were considered excellent or good in 58%; knee scores were considered excellent or good in 71% of cases. All periarticular osteotomies and tibial tubercle osteotomies healed uneventfully within 16 weeks. Complications occurred in 57% of cases, including aseptic failure (26%), septic failure (10%), patellar tendon rupture (3%), patellar subluxation (6%), thromboembolism (6%), and wound breakdown requiring debridement and muscle flap coverage (6%). Despite significant improvements in motion and function, patients with post-traumatic arthrosis are susceptible to high rates of complications. Adverse outcomes can be minimized by restoring limb alignment, soft tissue balance, and component alignment and by preserving vascularity of the skin and subcutaneous tissues.

Adult↗
PubMed1999

Economic evaluations in the hip arthroplasty literature: lessons to be learned.

Readers are increasingly encountering articles dealing with health economic evaluations that compare various surgical strategies, leaving orthopaedists with the challenge of determining which program is cost-efficient and truly pertains to their setting. This study carries out a systematic review of the literature to appraise the quality, quantity, and type of economic evaluation as it pertains to the hip arthroplasty literature. To identify all relevant articles, we conducted a comprehensive computerized bibliographic search of Medline from 1966 to 1996. This search produced 1,611 abstracts that were screened. Studies that were incorporated met the following inclusion criteria: i) formal economic analysis, ii) an intervention specific to hip arthroplasty, and iii) the perspective of the study was evident (ie, patient, provider, society). These studies were appraised with regards to methodologic soundness based on 8 established economic principles. Only 68 articles from the 138 retrieved met the study criteria. Only 2 of the 68 articles met all 8 criteria of a comprehensive economic evaluation. The hip arthroplasty literature is deficient in methodologically sound economic evaluations. Several guidelines are introduced to aid orthopaedists in appraising the various economic studies, and recommendations are made to improve the quality of these studies in the orthopaedic literature. We suggest that the generation of such information should rank high on the priority list of the orthopaedic profession, granting agencies, and governments.

Arthroplasty, Replacement, Hip↗
PubMed1999

Analysis of lower extremity embolic material after total knee arthroplasty in a canine model.

Emboli assumed to consist of fat, marrow, cement, and bone are generated during total knee arthroplasty. This study collected and identified the constituents of the embolic debris and assessed the effects of intramedullary cutting guides in a canine model. During cemented knee arthroplasties with or without the use of intramedullary guides, all embolic debris was collected in a single lobe of lung. In dogs using intramedullary guides, transesophageal echocardiography revealed a sustained embolic shower, and histologically marked amounts of emboli obstructed the pulmonary vasculature. The emboli were composed of fat cells and hematopoietic cells (marrow elements) interspersed with free fat globules. Marrow elements are the primary constituents of the emboli generated during total knee arthroplasty. Intramedullary guides increased debris generation.

Animals↗
PubMed1999

Total hip arthroplasty for osteonecrosis: matched-pair analysis of 188 hips with long-term follow-up.

A matched comparison was made between total hip arthroplasties done for osteonecrosis and those done for osteoarthritis. Patients were matched for age, sex, surgical approach, prosthesis, and surgeon. All received cemented Charnley replacements and had minimal follow-up of 10 years. There were 118 women and 70 men with a mean age of 58 years. Thirty-five patients were younger than 50. The mean follow-up was 17.8 years (range, 10 to 25.4 years). Revision rates for osteonecrosis and osteoarthritis were 18% and 19% (not significant). The mechanical failure rate (revision for loosening plus radiographic loosening) was greater, but not significantly so, in the osteonecrosis group. In patients younger than 50 years, the revision rate in osteonecrosis (50%) was significantly higher than that in any other group. Similarly, the mechanical failure rate in osteonecrosis was significantly greater in the patients younger than 50. Radiographic femoral loosening was greater in osteonecrosis at all follow-up intervals, and dislocations occurred more frequently in the osteonecrosis group than in the osteoarthritis group. Results of arthroplasty in both groups were comparable in patients over 50 years of age, although patients with osteonecrosis had an increased rate of dislocation. Patients with osteonecrosis who are younger than 50 years have a significantly higher rate of mechanical failure than those with osteoarthritis who are younger than 50 years. Cemented total hip arthroplasty should be recommended in this group with caution if at all.

Arthroplasty, Replacement, Hip↗
PubMed1999

Perioperative X-rays in arthroplasty surgery: outcome and cost.

Numerous legislative proposals to cut reimbursement to surgeons and hospitals are presently included in U.S. congressional and senate agendas. Perioperative x-ray films in arthroplasty surgery are standard operating procedure. Our objective was to assess the effects of the radiologist reading on the clinical and economic outcome of arthroplasty procedures. One hundred consecutive cases were prospectively studied. The radiologist reading, clinical management, and outcome of each case were carefully reviewed. The amount billed for the radiologist interpretation was noted for each examination. A total of 398 studies in 100 patients were done. Ninety-six preoperative, 110 intraoperative, and 192 postoperative radiographic studies were reviewed. These reports took an average of 1.71 days to be recorded on the chart (SD +/- 2.45). The total radiologic professional fees billed to Medicare in these cases was $11,054. (The radiologist's interpretation was not useful in the clinical management and did not affect the outcome in any case.) Assuming that each surgeon takes 1 x-ray film on every arthroplasty case, the total actual savings to Medicare of not having a radiologist reading these studies could reach $536,000 per year; if 2 intrahospital x-ray studies are performed per procedure (preoperative, intraoperative, or postoperative), the savings are $1.1 million per year. These cost reductions are achieved at no sacrifice to quality of care or outcome. Numerous areas of excessive spending with no improvement in outcome exist in the treatment of Medicare patients. There areas should be identified and eliminated before surgical fees are lowered even further.

Aged↗
PubMed2003

Comparison of general and spinal anesthesia and their influence on hemostatic markers in patients undergoing total hip arthroplasty.

STUDY OBJECTIVE: To evaluate the profile of molecular hemostatic markers in patients receiving either spinal or balanced general anesthesia for total hip arthroplasty. DESIGN: Open, randomized, observational study. SETTING: Orthopedic unit and central laboratory of a university hospital. PATIENTS: 26 consenting ASA physical status II and III inpatients undergoing total hip arthroplasty with general balanced anesthesia (n = 10) or spinal (regional) anesthesia (n = 16). INTERVENTIONS: The time course of seven procoagulatory and fibrinolytic parameters was examined during and after surgery in both groups of patients (general and regional). Blood samples were drawn on the day before surgery, directly before induction of general anesthesia or regional anesthesia, respectively, intraoperatively (before bone manipulation), at the end of surgery, and on the mornings of postoperative days 1 and 5. MEASUREMENTS AND MAIN RESULTS: The coagulation samples were centrifuged within 1 hour of collection at 2,300 g for 15 minutes at 4 degrees C. Hemoglobin, hematocrit, platelets, fibrinogen, prothrombin time, thrombin time, activated partial thromboplastin time, antithrombin, and protein C were measured immediately on arrival at the laboratory. Specimens were then aliquoted and stored at -70 degrees C. Within 2 weeks, samples were thawed and prepared for the following assays: thrombin-antithrombin complexes (TAT complexes), D-dimers, plasminogen activator inhibitor type 1 (PAI-1), and plasminogen and plasmin inhibitor. Maximum activation of coagulation was not reached until 2 hours postoperatively and then slowly decreased until normal values were reached around the fifth postoperative day. Parameters displaying the greatest changes were antithrombin and D-dimers. No statistically significant differences were found between the two groups at the individual time points. CONCLUSION: Our initial hypothesis that the lesser risk of postoperative DVT in patients undergoing total hip arthroplasty in regional anesthesia is reflected in the course of the plasmatic molecular markers of hemostasis could not be verified. There were no significant differences in the timely course of the markers at any given time point.

Aged↗
PubMed2002

Knee joint functional range of movement prior to and following total knee arthroplasty measured using flexible electrogoniometry.

The functional ranges of movement of the knee were investigated in a group of patients with knee osteoarthritis (n = 42, mean age 70 years) before, 4 months and at 18-24 months after total knee arthroplasty and then compared with age matched normal subjects (n = 20, mean age 67 years). Flexible electrogoniometry was used to record the maximum flexion-extension angle, the minimum flexion-extension angle and flexion-extension excursions of both knees during eleven functional activities along with the active and passive knee joint range of motion measured using a manual goniometer. Over the eleven functional activities the patients pre-operatively exhibited 28% less knee joint excursion than normal age matched subjects. By 18-24 months following total knee arthroplasty only 2% of this deficit was recovered. Statistically this recovery was only significant in level walking, slope ascent and slope descent. A greater range of movement was measured in a non-weight bearing position than was used in weight bearing functional activity. It is concluded that total knee arthroplasty gives rise to little improvement in knee motion during functional activities and that functional range of movement of the knee remains limited when compared to normal knee function for a minimum of 18 months following operation.

Activities of Daily Living↗
PubMed2002

Reconstruction of soft tissue defects following total knee arthroplasty.

Soft tissue defects following total knee arthroplasty can represent serious problems for the patient and the surgeon. Perioperative soft tissue complications can result in loss of the prosthesis or limb. In this study, we present 17 cases with complex wounds following total knee arthroplasty who had surgery between May-1994 and July-2001. Patient-related factors, wound factors, surgical operation, secondary procedures, and duration of follow-up have been analysed for each patient. After local wound care and debridement, soft tissue defects have been covered with either a fasciocutaneous or gastrocnemius myocutaneous flap. All the knees (100%) have been salvaged although in 1 patient (6%) replacement of the prosthesis was necessary. In 5 patients (30%) secondary surgical procedures have been performed. Even though there is no consensus in the management of soft tissue defects following total knee arthroplasty, adequate wound care, including identification of infection, debridement, and early appropriate defect coverage should be the main points to consider.

Adult↗
PubMed2003

Do we practice evidence based medicine with regard to drain usage in knee arthroplasty? Results of a questionnaire of BASK members.

Clinical governance requires our clinical practice to be evidence based. We wished to see if British Orthopaedic surgeons are using the current evidence with regards to the use of drains in knee arthroplasty. A questionnaire was faxed to all UK members of BASK to ascertain their current practice regarding the use of drains in knee arthroplasty and the rationale for their drain policy. The study suggests that the majority of practising members of BASK do not practice evidence based medicine with regard to the use of drains in knee arthroplasty.

Arthroplasty, Replacement, Knee↗
PubMedDate not supplied

Neurologic complications after total shoulder arthroplasty.

Three hundred sixty-eight patients underwent 417 total shoulder arthroplasties between 1975 and 1989. Seventeen patients with 18 operated shoulders had a neurologic deficit after surgery. Osteoarthritis and rheumatoid arthritis were the most common diagnoses. Twelve patients (13 shoulders) had neurologic deficits localized to the brachial plexus; the upper and middle trunks were most commonly affected. Three patients had idiopathic brachial plexopathy. One patient had an exacerbation of preexisting dysesthesias in the lower trunk/medial cord distribution. Another patient had a median neuropathy at the wrist. Four patients had lesions that interfered significantly with shoulder rehabilitation and general activity; six had lesions that temporarily interfered with their scheduled rehabilitation program. All but two of these patients were monitored to a point of maximum improvement. Neurologic recovery at 1 year was graded as good in 11 shoulders and fair in five shoulders. The long deltopectoral approach leaving the deltoid attached to the clavicle and acromion was found to be significant in the development of a postoperative neurologic complication (p = 0.003). Use of methotrexate was also significant (p < 0.0001). A correlation was found between operative time and postarthroplasty neurologic complication (p = 0.02), with shorter operative times being associated with more neurologic complications. No other statistically significant risk factors were identified. In most cases the presumed mechanism of injury was traction on the plexus occurring during the operation. In most cases the prognosis for neurologic recovery was good. In this series neurologic injury after total shoulder arthroplasty did not interfere with the long-term outcome of the arthroplasty itself.

Adolescent↗
PubMedDate not supplied

Joint stability after total shoulder arthroplasty in a cadaver model.

A cadaver model was used to test the hypothesis that glenohumeral joint stability is independent of articular surface conformity after total shoulder arthroplasty. For the purposes of this study joint stability was defined as the minimum force required for joint dislocation. After arthroplasty components were implanted into fresh-frozen glenohumeral joints, specimens were mounted on a load frame and tested for joint stability. For each specimen the amount of conformity between the articular surfaces was varied from 0 to 5 mm by changing the humeral head radius of curvature. Because the glenoid component was not charged, the wall height, or joint constraint, was maintained constant for a given specimen. Variations in joint conformity changed dislocation forces by an average of only 3%. These small differences are not believed to be clinically relevant, indicating that design changes affecting the joint conformity of a total shoulder arthroplasty system will not significantly affect glenohumeral joint stability, assuming that all other factors remain constant.

Aged↗
PubMedDate not supplied

A comparison between the Regnauld arthroplasty and osteotomies of the first ray for the treatment of hallux valgus.

This article is a retrospective study comparing the efficacy of Regnauld arthroplasty to first ray osteotomies for the treatment of hallux valgus. One hundred consecutive cases of Regnauld arthroplasties were compared with 100 consecutive first ray osteotomies. One hundred fourty-one patients were available for follow-up, and based on clinical/radiographic examinations, 72 were treated with the osteotomy protocol (group A) and 69 with Regnauld arthroplasty (group B). Age at surgery, clinical symptoms, and preoperative radiologic findings were similar for the 2 groups; there was a preponderance of female patients (90%). The average follow-up was 49 months in group A and 51 months in group B. Clinical evaluation showed in the osteotomy group a more stable correction (79% v 49%), greater pain reduction (measured in a visual analog scale from 0 = pain free to 10 = deep intolerable pain), increased residual articular excursion of the first metatarsophalangeal joint (27 degrees of active dorsiflexion from neutral position v 8 degrees ), and less presence of central metatarsalgia (15% v 34%) (P <.05). The radiographic evaluation expressed more stable correction values in group A for the following parameters: joint preservation, sesamoid position, intermetatarsal angle (7 degrees v 12 degrees ), abduction angle of the hallux (14 degrees v 20 degrees ), and proximal articular set angle (8 degrees v 18 degrees ) (P <.05).

Adult↗
PubMed1999

Functional restoration by gap arthroplasty in temporomandibular joint ankylosis: a report of 50 cases.

OBJECTIVE: The purpose of this study was to determine the cause of temporomandibular ankylosis and the long-term results of gap arthroplasty with coronoidectomy followed by immediate postoperative jaw exercises as a treatment of the condition. STUDY DESIGN: This retrospective study evaluated the cause of temporomandibular joint ankylosis and the 36-month postoperative results of gap arthroplasty in 50 patients (62 joints). The patients were divided into 2 groups; group I (aged 0-12 years) consisted of 29 cases (24 unilateral and 5 bilateral; 34 joints); group II (aged 13-30 years) consisted of 21 cases (14 unilateral and 7 bilateral; 28 joints). A postoperative jaw opening exercise regimen was followed. Descriptive statistics, the Wilcoxon signed rank test, and rank sum 2-sample (Mann-Whitney) tests were applied. RESULT: Trauma to the temporomandibular joint was documented as a major etiologic factor in 86% of cases. The 36-month postoperative mean maximal incisal opening was 30.62 mm (+/- 6.25 mm) for group I and 30.14 mm (+/- 3.9 mm) for group II. The P value in each group was highly significant for the Wilcoxon signed rank test; the Mann-Whitney test showed no difference between the groups, indicating that both groups had done well. The recurrence rate was 2%. CONCLUSION: Trauma is the major cause of temporomandibular joint ankylosis in India. The long-term functional results of gap arthroplasty are satisfactory and comparable to those obtained through use of other treatments. Postoperative exercises play a crucial role in lasting success.

Adolescent↗
PubMedDate not supplied

Complete brachial plexus palsy after total shoulder arthroplasty done with interscalene block anesthesia.

BACKGROUND AND OBJECTIVES: This report illustrates that brachial plexus palsy can result from either interscalene block or total shoulder arthroplasty. It is often impossible to determine which procedure caused the deficit; therefore, we believe the focus should be placed on treatment of the neurologic deficit. This report provides a suggested algorithm for diagnosis and treatment of postprocedure brachial plexus palsy. METHODS: Interscalene block was used as the operative anesthetic for our patient's total shoulder arthroplasty. Complete brachial plexus palsy was diagnosed postoperatively. RESULTS: The patient's postoperative treatment and recovery are described. CONCLUSIONS: Proper diagnosis and treatment of postprocedure brachial plexus palsy may improve recovery of function. Several precautions may reduce the likelihood of brachial plexus palsy following interscalene block for total shoulder arthroplasty.

Adult↗
PubMed2004

The benefit of arthroscopy for symptomatic total knee arthroplasty.

Thirty-one knees with symptomatic total knee arthroplasty were diagnosed and treated arthroscopically. There were 18 knees with soft tissue impingement and 13 knees without. There were 16 knees with painful arthroplasty and range of motion (ROM) greater than 90 degrees. Hypertrophied synovitis with or without impingement was more easily found by arthroscopy in this group than in the other 15 knees with the chief complaint of limited ROM, where more remarkable fibrotic tissue with intra-articular adhesion was found. Overall, the average improvement in ROM was 43.1 degrees immediately after arthroscopy, and 20 degrees at the final follow-up. Symptoms improved in 90.3% of patients, and 58.1% were satisfied with the outcome of their surgery. Arthroscopy is helpful for intra-articular diagnosis, obtaining a specimen for histopathologic analysis, culture for subclinical infection, and better improvement in ROM. In our experience, arthroscopy for symptomatic knee arthroplasty is reliable, safe and effective.

Adolescent↗