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At least 1,531 records · Page 85Linked to original sources
PubMed1999

Uncemented total hip arthroplasty in patients with rheumatoid arthritis.

Total hip arthroplasty has become a successful way of treating the painful and destroyed hip joint in the patient with rheumatoid arthritis. Because of the underlying disease, it still is controversial whether the implants selected should be used with bone cement, or whether uncemented devices will give equally good results in this population. Fifteen patients suffering from rheumatoid arthritis underwent 21 hip arthroplasties. The followup period averaged 3.3 years (range, 2.5-6.8 years). All but one patient were taking medication at the time of surgery for their underlying disease. Clinical evaluation was based on a modified Harris hip score that showed significant improvement in pain and function preoperatively compared with pain and function at the most recent followup. Radiographic analysis revealed five cases of minor migration of the acetabular components, and three cases of distal migration of 2 mm or less in the femoral components. Complications consisted of heterotopic ossifications in one patient, and an intraoperative femoral fracture in one patient. There were no infections, and there were no deep vein thromboses. The results in these patients suggest that cementless total hip arthroplasty might become a successful way of treating the destroyed hip joint in the patient with rheumatoid arthritis.

Acetabulum↗
PubMed1999

Interleukin-6 in the blood of patients with total hip arthroplasty without loosening.

Patients with total hip arthroplasty were screened for the presence of proinflammatory cytokines in the systemic circulation. Only increased levels of interleukin-6 were detected in patients having had total hip arthroplasty more than 10 years ago. These increased levels of interleukin-6 were associated with a decrease in bone mineral density associated with polyethylene wear and with radiologic osteolysis in some patients. These abnormalities were not found in control subjects without total hip arthroplasty or in patients who had a prosthesis in place for less than 6 years. The elevation in interleukin-6 levels found in patients with the oldest prostheses could constitute a marker for periprosthetic osteolysis.

Aged↗
PubMed1999

Effect of rotational alignment on patellar tracking in total knee arthroplasty.

Forty-four consecutive patients (65 knees) who underwent identical condylar type total knee arthroplasty were evaluated retrospectively. In 22 of the patients (32 knees), the femoral component was set parallel to the posterior condylar axis (neutrally aligned group). In the remaining 22 patients (33 knees), it was set in an external rotation position of 3 degrees to 5 degrees relative to the axis (externally aligned group). Of the total knee arthroplasties in the neutrally aligned group, 34% required lateral release, compared with only 6% in the externally aligned group; patellar tracking in the externally aligned group was significantly better than that in the neutrally aligned group. Postoperative measurements performed using computed tomography scans showed that the mean angle between the prosthetic posterior condylar axis and the transepicondylar axis was 7.9 degrees in the neutrally aligned group and 3.2 degrees in the externally aligned group. The external rotation setting of the femoral component diminished the need for lateral retinacular release and may decrease the rate of patellofemoral complications that occur after total knee arthroplasty.

Adult↗
PubMed1999

Hip arthroplasty in patients with Paget's disease.

In individuals with Paget's disease, the pelvis and upper femur are the areas of the skeleton most frequently involved. Associated deformities and alterations in bone quality can complicate total hip arthroplasty when required for degenerative joint changes, and can compromise outcome. A review of reported series shows that patients with Paget's disease may present unique problems during the preoperative assessment, intraoperative treatment, and postoperative followup. Preoperative determination of disease activity and assessment of the cause of hip symptoms is important. Intraoperatively, deformity such as coxa vara, femoral bowing, acetabular protrusio, and bony enlargement may cause alterations in implant choice or fixation method used and the patient may even require corrective osteotomy. Excessive bleeding and bone quality changes may complicate these efforts additionally. Postoperative problems include heterotopic bone formation, and in those patients in whom the underlying disease is highly active or poorly controlled, rapid postoperative bone resorption is possible. Results of cemented arthroplasty in patients with Paget's disease have been reported as comparable with but slightly worse than the results reported for unselected patients who underwent hip arthroplasty. The long-term results of uncemented implants in patients with Paget's disease remains to be established.

Arthroplasty, Replacement, Hip↗
PubMed1999

Total hip arthroplasty in patients with proximal femoral deformity.

Most proximal femoral deformities encountered during hip arthroplasty are secondary to developmental processes, previous osteotomy, or fracture. A classification method is proposed in which deformities are categorized anatomically by level. Anatomic deformity levels include: greater trochanteric deformities, femoral neck deformities, metaphyseal level deformities, and diaphyseal level deformities. Deformities at each level may be angular, rotational or translational, abnormal bone size, or a combination thereof. Treatment is individualized according to patient needs and the anatomy of the deformity. Careful preoperative planning helps predict prosthesis requirements and technical challenges. If cemented implants are used, care must be taken to obtain reasonable alignment and a continuous cement mantle. For uncemented implants, obtaining a good fit is challenging and there is a risk of intraoperative fracture. Access to a wide range of implants helps the surgeon treat unique femoral geometries. Implants fixed in the diaphysis allow some proximal femoral deformities to be bypassed. Modular or custom implants simplify treatment of certain deformities. For patients with severe deformities, femoral osteotomy may be required. Successful osteotomy requires correcting the deformity, maintaining vascular supply of fragments, obtaining fixation of osteotomy fragments (with the implant or adjunctive fixation), and obtaining implant stability. Although most deformities can be treated during hip arthroplasty, occasionally there is a role for two-stage treatment: deformity correction followed later by arthroplasty.

Arthroplasty, Replacement, Hip↗
PubMed2000

Cost analyses of extended prophylaxis with enoxaparin after hip arthroplasty.

Venous thromboembolic complications occur in 50% to 70% of patients undergoing total hip arthroplasty if no prophylactic regimen is used. Because enoxaparin and warfarin are useful for extended outpatient prophylaxis, the objective of this study was to determine which of these agents is most cost effective in preventing venous thromboembolic complications. A decision tree analysis was developed to simulate a hypothetical cohort of patients with total hip arthroplasty. The analysis considered home health care services to perform monitoring and compliance verification. Accounting for prophylactic failures and treatment complications, results showed that enoxaparin maintained a cost effective advantage over warfarin for extended prophylaxis in the time after discharge and total hip arthroplasty ranging from 19 to 31 days after the patient was discharged from the hospital. The duration of cost effectiveness of enoxaparin was reduced to 14 to 17 days when home care services were excluded. These results indicated that approximately 3 weeks of outpatient therapy with enoxaparin is cost effective. With the cornerstone of managed care being cost efficiency in the provision of quality care, this conclusion warrants the development of integrated care strategies for the patient having orthopaedic surgery to achieve cost effective patient management.

Anticoagulants↗
PubMed2000

Total hip arthroplasty in patients receiving Workers' Compensation.

Numerous studies have reported on the adverse outcome of patients who sustain job-related injuries. In addition, studies have reported poor outcomes in patients receiving Workers' Compensation who undergo elective surgery. This study sought to determine the influence of Workers' Compensation on the outcome of patients who had undergone primary total hip arthroplasty. Between January 1984 and December 1996, 44 patients (48 hips) were studied. Of these, 17 were men and five were women with a mean age of 45 years (range, 27-76 years) at the time of surgery. These patients were receiving compensation benefits and were matched directly with a group of 22 patients who had 24 arthroplasties and were not receiving compensation. After a mean final followup of 77 months (range, 25-125 months), the compensation group had a mean Harris hip score of 86 points (range, 54-95 points). The matched control group had a mean Harris hip score of 92 points (range, 79-100 points) at a mean final duration of followup of 80 months. Two patients (9%) had undergone revision surgery for aseptic loosening at 28 and 67 months. The percentage of patients with good or excellent results did not differ significantly between the two groups. Based on these findings, the authors think that Workers' Compensation does not negatively influence the outcome of total hip arthroplasty.

Adult↗
PubMed2000

Athletic activity after total knee arthroplasty.

Americans are aging, elderly Americans are more active, and the prevalence of total knee arthroplasty is increasing. Indications for knee replacement include pain, deformity, and a desire to improve function. When patients have knee replacement operations, frequently they increase their activities. It is important for patients with knee replacements to understand the impact of athletic activity on the outcome of knee replacements. Orthopaedic surgeons should educate patients regarding athletic activity after total knee arthroplasty. Considerations and risk factors for athletic activity after knee replacements include athletic activity before surgery, preoperative rehabilitation, surgical reconstruction, implant failure or fracture, implant fixation or loosening, and joint bearing surface wear. Anatomic reconstruction and compulsive postoperative rehabilitation with restoration of muscular control are important for optimum function after total knee arthroplasty. In general, patients with knee replacements are encouraged to participate in low-impact, low-demand sports, and to avoid high-impact, high-demand sports.

Arthroplasty, Replacement, Knee↗
PubMed2000

The role of continuous passive motion after total knee arthroplasty.

The usefulness of continuous passive motion after total knee arthroplasty remains controversial. The reported benefits include decreased rates of knee manipulation, deep vein thrombosis, and postoperative use of analgesics, and a greater range of motion. Other studies have reported increased wound complications, bleeding, and pain. Lack of consensus on the use of continuous passive motion exists because reported studies include many confounding variables. Several studies have shown that continuous passive motion in the hospital decreased the rate of knee manipulation from as high as 21% to as low as 0%. Although many studies show that range of motion may improve more rapidly with continuous passive motion, the ultimate range of motion at followup is unchanged. At the author's institution, continuous passive motion is used three times per day (1 hour sessions), beginning on the first postoperative day, within a 4 to 5 day inpatient hospital pathway. Of 132 knees that had a primary posterior-stabilized total knee arthroplasty, seven knees (5%) had a manipulation for failure to obtain greater than 70 degrees flexion. No patients had major wound complications that required reoperation. There is no specific charge to the patient for the continuous passive motion because it is included in the hospital per diem charge. The literature and the author's data support the use of continuous passive motion to decrease the rate of manipulation (and its costs) for poor range of motion after total knee arthroplasty. If patients follow fixed inpatient hospital pathways, the length (and possibly cost) of hospital stay is not changed by use of continuous passive motion. The data on the effect of continuous passive motion on overall analgesic use and prevalence of deep vein thrombosis are not clear.

Arthroplasty, Replacement, Knee↗
PubMed2000

Arthrofibrosis after total knee arthroplasty.

Six total knee arthroplasties in five patients were revised because of persistent limited motion after the primary arthroplasty. All of the revised implants were of an appropriate size and not malpositioned. No cause of stiffness was identified other than soft tissue contracture. Four of the components were posterior cruciate retaining and two were posterior cruciate substituting. Heterotopic bone formation was observed in two knees before the revision surgery and five knees after the revision surgery. Arc of motion was increased from 36 degrees (range, 20 degrees-70 degrees) before revision surgery to 86 degrees (range, 70 degrees-110 degrees) after revision surgery. What triggers the proliferation of extensive scar tissue formation in patients with arthrofibrosis is not clear. Some patients may be predisposed to this condition or may have it develop as a response to the surgical trauma and postoperative rehabilitation. However, when arthrofibrosis does develop after total knee arthroplasty, some improvement in motion and pain can be achieved with revision surgery.

Aged↗
PubMed2001

Radiographic assessment in total knee arthroplasty.

Sixty-five total knee arthroplasties were evaluated by the Knee Society Radiological Evaluation System which was developed to encourage uniform reporting of the results of total knee arthroplasty. All patients were examined by three independent experienced radiologists 8.9 years after surgery (range, 3-16 years) to analyze the interobserver variability. For measurement of angles, high interobserver correlation was calculated for the prosthetic component angles and the femorotibial shaft angle. The comparison of the means indicated no significant differences except for the femorotibial shaft angle. For measurement of radiolucent lines, interobserver correlation was low for all components. The differences of the means were significantly different for all components. The results of interobserver variability of the patellar evaluation revealed high interobserver correlation for the patellar angle and for patellar subluxation and dislocation evaluation. For assessment of patellar mediolateral and superoinferior displacement, a low interobserver correlation was found. For radiographic assessment of total knee arthroplasty, the measurement of angles, including alpha, beta, femorotibial shaft angle, sagittal femoral and tibial component angle, patellar angle, and patellar subluxation and dislocation evaluation are recommended. The method of assessing radiolucent lines should be reconsidered.

Aged↗
PubMed2001

Cementless hip arthroplasty in the treatment of patients with femoral head necrosis.

Treatment of patients with osteonecrosis of the femoral head focuses on pain relief and improved function of the hip. Total hip arthroplasty remains an effective tool for the treatment of patients with end-stage osteonecrosis with collapse of the femoral head, although there is a greater risk for failure. The aim of the current study was to assess the long-term survival of cementless total hip arthroplasties in 28 patients (36 hips) with osteonecrosis of the femoral head (Steinberg Stage V and Stage VI) with an average followup of 11.2 years (range, 10-15 years). There were 19 women and nine men with an average age of 51.4 years (range, 28-65 years). A threaded titanium cup CST (Conical Screwed Titanium) was used in all patients and different cementless femoral components were used depending on the optimal fit in the femoral canal as assessed during preoperative templating. No serious complications were encountered postoperatively. The patients were evaluated preoperatively and postoperatively with the Merle d'Aubigné and Postel scale. After cementless total hip arthroplasty, the average pain score improved 3.6 points, walking ability improved 1.6 points, and range of motion improved 1 point. Two patients had thigh pain. Radiographic evaluation on anteroposterior and lateral radiographs of the proximal femur was excellent in 10 hips postoperatively. No heterotropic ossification was observed, although proximal femoral atrophy was seen in 15 hips. Clinical and radiologic findings did not correlate. There were two revisions of the acetabular implants in one patient with bilateral idiopathic osteonecroses and total hip replacement. Overall, survival of the prostheses was 93.4% at the average followup of 11.2 years.

Adult↗
PubMed2001

Long-term followup of cementless versus hybrid fixation for total knee arthroplasty.

In a prospective trial, 99 patients (100 knees) with osteoarthritis were randomized to either cementless or hybrid fixation of cruciate-retaining Miller-Galante-I total knee arthroplasties between January 1987 and December 1988. Thirty-one patients died during the study period and two additional patients were lost to followup, leaving 67 total knee arthroplasties for analysis. Thirty-nine patients underwent revision surgery at an average of 6.9 years postoperatively. The main reason for revision surgery was failure of metal-backed patellas with 25 knees revised at an average of 7.4 years, and the second most common reason was tibial polyethylene failure. Survival curves showed 60% survival at 14 years for all knees, and 85% survival at 14 years when failures for metal-backed patellas and infection were excluded, with no significant difference between the two groups. Failure of metal-backed patellas was significantly higher in the cementless group. Tibial polyethylene failure occurred in five of the hybrid group and none of the cementless group, but this was not a significant difference. Surviving prostheses were assessed at an average of 12.8 years (range, 11.5-13.5 years). Average clinical scores were 94.8 points preoperatively, and 143 points at the latest followup, with significantly higher scores in the hybrid group. Differences in outcome between the two groups were not sufficiently significant to recommend one method of fixation over another. With elimination of poor design features related to the patellofemoral articulation and thin tibial polyethylene, cruciate-retaining total knee arthroplasties can yield good durable results, whether cementless or hybrid fixation is used.

Aged↗
PubMed2001

Component rotation and anterior knee pain after total knee arthroplasty.

All patients undergoing cruciate-retaining primary total knee arthroplasty for degenerative osteoarthritis at one center were studied prospectively. Clinical and radiographic followup was obtained at a minimum 5 years in 102 knees in 73 patients. Patients were asked specifically about the presence of the pain in the anterior aspect of the knee in the vicinity of the patella and rated the severity of the pain on a visual analog scale. Significant anterior knee pain rating at least 3 of 10 on the visual analog scale was present in 16 knees (13 patients). Eleven patients with 14 symptomatic knees agreed to undergo computed tomography scanning to accurately determine the rotation of the tibial and femoral components. The epicondylar axis and tibial tubercle were used as references using a previously validated technique. A control group of 11 asymptomatic patients (14 knees), matched for age, gender, and length of followup also underwent computed tomography scanning. All patients in both groups had normal axial alignment. There was a highly significant difference in tibial component rotation between the two groups with the patients with anterior knee pain averaging 6.2 degrees internal rotation compared with 0.4 degrees external rotation in the control group. There also was a significant difference in combined component rotation with the patients with anterior knee pain averaging 4.7 degrees internal rotation compared with 2.6 degrees external rotation in the control group. There was no significant difference in the degree of radiographic patellar tilt or patellar subluxation between the two groups. Patients with combined component internal rotation were more than five times as likely to experience anterior knee pain after total knee arthroplasty compared with those with combined component external rotation. Component malrotation is a significant factor in the development of anterior knee pain after total knee arthroplasty.

Aged↗
PubMed2001

The Knee Society Index of Severity for failed total knee arthroplasty: development and validation.

Compared with primary knee replacement, total knee arthroplasty revision surgery is a more complex procedure and accounts for greater expenditures of healthcare resources at each clinical stage. Overall, patients having revision procedures have poorer functional outcomes and higher complication rates than patients having primary arthroplasty. Despite the expanded scope of revision problems and the rapidly emerging technology in revision surgery, the long-term success of any method remains in question. Because there is little consensus on the timing of revision surgery, optimal surgical reconstruction, and the type of prosthesis to be implanted, the Knee Society began development of an Index of Severity for Failed Total Knee Arthroplasty. Fifty-four percent of Knee Society members completed an 82-item questionnaire that determined their clinical impression about potential risk factors for the outcomes of revision surgery for failed total knee replacements. Using these results, a consensus group developed the final version of the index. The result of the nominal group process was the Knee Society Index of Severity, which was based on eight distinct domains. Each domain was divided into attributes and weights based on the questionnaire responses and consensus meeting. Actual case scenarios from five institutions were used to test interrater reliability and validity. The interrater reliability of the average score of all ratings was 0.95; the correlation of the criterion rating with the mean rating was 0.77. When three outliers were not included, the Pearson product correlation increased to 0.92. These data support the application of the Knee Society Index of Severity as a critical component of risk factor studies, effectiveness research, and cost-effectiveness analysis involving revisions of total knee replacements.

Arthroplasty, Replacement, Knee↗
PubMed2001

Problems with cementless total knee arthroplasty at 11 years followup.

One hundred two patients with 131 consecutive cementless total knee arthroplasties that retained the posterior cruciate ligament were followed up prospectively. The average age of the patients was 58 years (range, 32-75 years). The mean followup on the surviving knee arthroplasties was 11 years (range, 7-16 years). The patellar component was metal-backed in the first 112 (85%) knees, cementless all-polyethylene in the last 17 (13%) knees, and two knees had a prior patellectomy. Forty-four metal-backed patellar components (48%) were revised; nine were loose, and 35 had polyethylene wear through. Thirteen femoral components (12%) were revised because of femoral abrasion from a failed metal-backed patellar component. No other femoral component was revised, loose, or had osteolysis develop. Nine (8%) tibial components had failure of ingrowth; eight have been revised. Partial radiolucencies occurred in 53% of the tibias. Thirteen (12%) small osteolytic lesions developed, all around screws or screw holes in the tibial components. At an average of 11 years followup, cementless fixation yielded mixed results: cementless femoral fixation was excellent and metal-backed patellar components had a 48% patellar revision rate. Cementless tibial components had an 8% aseptic loosening rate and a 12% incidence of small osteolytic lesions. Based on these results, the authors have abandoned cementless fixation in total knee arthroplasty.

Adult↗
PubMed2001

Modular, mobile-bearing hinge total knee arthroplasty.

Early reports of hinge total knee arthroplasty showed high rates of complications and implant failure. Third-generation modular, mobile-bearing, hinge knee arthroplasty systems have evolved to decrease the deleterious stresses that contributed to the failures of earlier designs. The combined series of Barrack et al and Jones et al documents midterm results using the S-ROM Hinge Knee System for patients with significant soft and hard tissue deficiencies not suitable for standard, less constrained, revision knee systems. The combined series included 30 knees with a mean followup of 49 months. Knee Society clinical scores improved from 52 to 134 points. There were no mechanical failures of the implants. The knee system used provides press-fit diaphyseal stems and metaphyseal filling and loading sleeves, all of which showed apposition and positive remodeling of bone at followup radiographic analysis. The excellent midterm results of this modular, mobile-bearing, linked knee system suggest the orthopaedic surgeon can display increasing confidence in the selection of such a knee system when confronted with catastrophic, salvage knee arthroplasty.

Arthroplasty, Replacement, Knee↗
PubMed2002

Muscle torques in total knee arthroplasty with subvastus and parapatellar approaches.

The current study was designed to compare muscle torques when using the subvastus and parapatellar approaches for unilateral total knee arthroplasty. Twelve female patients had unilateral total knee arthroplasty with the subvastus approach from January 1997 to June 1998. The historic control group consisted of 16 female patients who had unilateral total knee arthroplasty with the parapatellar approach from July 1994 to January 1997. Six and 12 months after surgery, a Cybex dynamometer was used to measure isometric and isokinetic muscle strength. Two parameters were used to compare the two approaches, the first parameter was the difference in peak torque between the surgically treated knee and the baseline value for the healthy knee, and the second parameter was the hamstring to quadriceps peak-torque ratio, again using the value for the healthy knee as baseline. The subvastus approach resulted in an initial higher peak torque in the quadriceps 6 months after surgery, but this difference became insignificant 12 months postoperative. Using the subvastus approach, the hamstring to quadriceps peak-torque ratio reached the normal range (0.50-0.80) sooner than was the case using the parapatellar approach. There is a phenomenon of cross adaptation of the untreated knee to the surgically treated knee, and knees operated on by the subvastus approach showed functional recovery at an earlier date than those operated on by the parapatellar approach.

Adult↗