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PubMed2002

Bone anatomy and rotational alignment in total knee arthroplasty.

The purpose of the current study was to investigate the bone anatomy in determining the rotational alignment in total knee arthroplasty using computed tomography. Axial images of 109 knees in 83 patients with varus osteoarthritis who had total knee arthroplasty were analyzed. On the images of the distal femur and the proximal tibia, a baseline for the anteroposterior axis of each component was drawn based on the epicondylar axis for the femur and the medial (1/3) of the tibial tuberosity for the tibia. The angle between these two lines was analyzed as the rotational mismatch between the components when they were aligned to the anatomic landmarks of each bone. Fifty-four knees (49.5%) had an angle of 5 degrees or greater and 13 knees (11.9%) had an angle of 10 degrees or greater. There was a tendency to align the tibial component in external rotation relative to the femoral component. The results indicated that the landmarks of each bone were the intrinsic cause of the rotational mismatch in knees with varus osteoarthritis. Surgeons doing total knee arthroplasties should be aware of this and check the rotational mismatch between the components. When it is present, the tibial component should be realigned to match the femoral component rotation to minimize problems caused by the mismatch.

Aged↗
PubMed2002

Haemophilus influenza infection complicating a total knee arthroplasty.

Haemophilus influenza is rarely a cause of septic arthritis in adults. It has not been reported as a cause of infection in total knee arthroplasties. Haemophilus influenza septic arthritis is a late stage, hematogenous infection. A 43-year-old woman with a history of rheumatoid arthritis was found to have Haemophilus influenza infection 3 years after the index total knee arthroplasty. The patient was treated with debridement and systemic antibiotics. At the 5-year followup, the patient was comfortable and free of clinical signs of infection. This approach was successful at eradicating infection and salvaging the total knee arthroplasty.

Adult↗
PubMed2002

Outcome of uncemented hip arthroplasty components in patients with Paget's disease.

The outcome of uncemented hip arthroplasty in patients with Paget's disease is unknown. The clinical and radiographic records of patients with Paget's disease affecting the hip who had total hip arthroplasty using uncemented components against pagetic bone were reviewed. There were 18 patients (19 hips) with an average age of 71.3 years (range, 54-85 years). Followup averaged 7 years (range, 2-15 years). Surgery often was reported to be demanding technically because of hard sclerotic bone and excessive bleeding in some patients. Estimated blood loss averaged 996 mL (range, 200-2500 mL). Harris hip scores improved significantly. There was clinical and radiographic evidence of bone ingrowth in all patients. Six of 19 hips had heterotopic bone. One hip had severe Brooker Grade IV heterotopic ossification and the patient required excision of the ossification at 5 years. One hip was unstable (subluxating) at the latest followup. There was no revision for component loosening and no recognized cases of clinical or radiographic loosening of any uncemented implants. Results of total hip arthroplasty using uncemented components in patients with Paget's disease are excellent overall, with an extremely low risk of component loosening during the first decade after implantation. These patients may be at higher risk for heterotopic bone formation and increased perioperative blood loss because of hypervascularity of the bone.

Aged↗
PubMed2002

Insall Award paper. Why are total knee arthroplasties failing today?

The incidence of failure after knee replacement is low, yet it has been reported that more than 22,000 knee replacements are revised yearly. The purpose of the current study was to determine current mechanisms of failure of total knee arthroplasties. A retrospective review was done on all patients who had revision total knee arthroplasty during a 3-year period (September 1997-October 2000) at one institution. The preoperative evaluation in conjunction with radiographs, laboratory data, and intraoperative findings were used to determine causes of failure. Two hundred twelve surgeries were done on 203 patients (nine patients had bilateral surgeries). The reasons for failure listed in order of prevalence among the patients in this study include polyethylene wear, aseptic loosening, instability, infection, arthrofibrosis, malalignment or malposition, deficient extensor mechanism, avascular necrosis in the patella, periprosthetic fracture, and isolated patellar resurfacing. The cases reviewed included patients who had revision surgery within 9 days to 28 years (average, 3.7 years) after the previous surgery. More than half of the revisions in this group of patients were done less than 2 years after the index operation. Fifty percent of early revision total knee arthroplasties in this series were related to instability, malalignment or malposition, and failure of fixation.

Adult↗
PubMed2002

Impaction grafting and wire mesh for uncontained defects in revision knee arthroplasty.

The current authors review the results of 17 revision total knee arthroplasties in 14 patients in whom large uncontained defects were treated with impaction allografting and molded wire mesh for containment. Knee Society clinical scores increased from an average of 47 points to 95 points and function scores increased from 48 points to 73 points at the most recent followup. No patients required revision surgery, although, nonprogressive tibial radiolucency has been observed in three patients. One patient required open reduction and internal fixation of a periprosthetic supracondylar femur fracture. One patient with an acute postoperative infection with Staphylococcus epidermidis was treated successfully with irrigation and debridement with retention of the implant. Impaction grafting with wire mesh containment for large uncontained defects in revision total knee arthroplasty is an effective method of treating massive uncontained bone loss in revision total knee arthroplasty.

Aged↗
PubMed2002

Blood management in revision total knee arthroplasty.

Much attention has been focused on blood management issues in orthopaedic surgery in recent years, but blood management in patients having revision total knee arthroplasty is not well-established. Hematologic values and transfusion records of 100 patients (52 women, 48 men; mean age, 65 years) who had aseptic revision total knee arthroplasty at the authors' institution were evaluated retrospectively. Two- or three-component revisions comprised 66% of the procedures, and 58 patients participated in a preoperative autologous donation program. The mean preoperative hemoglobin level was 12.1 g/dL in the women and 14.1 g/dL in the men, but the men experienced a greater decrease in hemoglobin level (mean largest decrease, 4.2 g/dL versus 3.1 g/dL), possibly caused by the higher allogeneic transfusion rate in women (19.2%) versus men (4.2%). Patient age did not influence hemoglobin level or transfusion rates. Patients who participated in a preoperative autologous donation program had significantly higher hemoglobin levels before donation (14.4 g/dL versus 13.3 g/dL for patients who did not participate in a program) but comparable hemoglobin levels after predonation (12.9 g/dL). Patients with preoperative hemoglobin levels less than 13 g/dL were significantly more likely to have a transfusion. Symptom-based transfusion strategies and blood management approaches such as epoetin alfa that elevate preoperative hemoglobin level therefore may be beneficial in patients having revision total knee arthroplasty.

Adult↗
PubMed2002

Ceramic-on-ceramic bearings in total hip arthroplasty.

The ideal bearing surface for total hip arthroplasty still is being sought. This bearing would be durable, cost-effective, easy to implant, inert, and produce minimal wear debris. Ceramic-on-ceramic bearings have continued to evolve and have enjoyed success in many European centers throughout the past 3 decades. A limited number of early reports from the United States discouraged widespread acceptance and use of ceramic-on-ceramic total hip arthroplasty. Once critically analyzed most of the failures from the early reports are attributable to design and material specific flaws. Vast improvements have been made in ceramic manufacturing leading to even more superior wear characteristics and higher burst strengths. The case for alumina-on-alumina ceramic bearings is becoming stronger as data accumulate clinically and in vitro. In a multicenter, prospective and randomized study, an alumina-on-alumina ceramic bearing is compared with a cobalt chrome-on-polyethylene bearing. After as many as 48 months there has been no significant difference in clinical performance between the two study groups. No ceramic head fracture or ceramic bearing failure has occurred. Therefore, this new alumina-on-alumina ceramic bearing is a safe option for total hip arthroplasty and may provide a more durable prosthesis especially in young and active patients.

Aluminum Oxide↗
PubMed2004

A posterior approach to primary total hip arthroplasty with soft tissue repair.

To determine whether repair of the posterior soft tissue structures affects dislocation rate, a comparison of the posterolateral approach with and without a posterior soft tissue repair in primary total hip arthroplasty was done. Between January 1993 and December 1998, 250 consecutive primary total hip arthroplasties (220 patients) without a posterior soft tissue repair followed by 96 consecutive primary total hip arthroplasties (83 patients) with a posterior soft tissue repair in the posterolateral approach were done. With the exception of a posterior soft tissue repair, all surgical procedures were done in the same manner. A dislocation rate of 6.4% in 250 hips without a posterior soft tissue repair in the posterolateral approach was reduced to 1% in 96 hips with a posterior soft tissue repair. The results were statistically significant. The current results indicate that the posterior structures should be preserved as much as possible and repaired to reduce dislocation in the posterolateral approach.

Arthroplasty, Replacement, Hip↗
PubMed2004

Total knee arthroplasty for patients 90 years of age and older.

This study was done to review the reliability, durability, and safety of primary and revision total knee arthroplasty for patients 90 years of age and older. Because little data exist about the safety or efficacy of total knee replacement in this elderly population some physicians may be hesitant to recommend elective surgery to patients of this age. Fifty-one total knee replacements were done for 41 patients age 90 to 102 years (mean, 92 years). Forty-four primary total knee replacements and seven revision total knee replacements were done. Each patient was followed up until death or for a minimum of 2 years (mean, 4.0 years). The Knee Society pain scores improved significantly for the primary and revision groups from preoperative mean scores of 30 and 29 points to latest followup scores of 86 and 87 points, respectively. One patient died in the early postoperative period of causes related to the operation. The remaining patients have lived an average of 4.4 +/- 2.2 years after the primary knee arthroplasties and 5.7 +/- 2.8 years after the revision knee arthroplasties. No knees have required revision subsequently. Total knee replacement was reliable, durable, and safe in this group of patients older than 90 years. Primary care physicians and surgeons should be aware that primary and revision total knee replacement can be done safely and effectively for patients 90 years and older and result in years of marked pain relief for those patients.

Age Factors↗
PubMed2005

Patient-perceived outcomes in thigh pain after primary arthroplasty of the hip.

UNLABELLED: Thigh pain after arthroplasty first was identified in the joint replacement literature in 1988; little information has been published about the functional status of patients who develop this complication. Eleven patients who reported thigh pain at 2 years after cementless primary total hip arthroplasty were matched with patients who did not report thigh pain on the following characteristics: age, gender, diagnosis, bone type, and surgical procedure (ie, unilateral or bilateral). Preoperative WOMAC function scores were different in these two groups (53.5 versus 39.7). There were no differences in SF-36 and Quality of Well Being scores in the two patient groups. There were also no differences in the WOMAC, SF-36, and Quality of Well Being scores at the 2-year followup. However, item analysis of the WOMAC indicated that patients with thigh pain were more likely to report at least some functional deficit relative to patients without thigh pain at the 2-year followup. Thigh pain does not seem to affect 2-year postoperative quality of life severely in patients who have had cementless hip arthroplasties with a tapered stem design. Selected functional activities will be impacted by the presence of thigh pain. LEVEL OF EVIDENCE: Prognostic study, Level III (case-control study). See the Guidelines for Authors for a complete description of levels of evidence.

Activities of Daily Living↗
PubMedDate not supplied

Finding patients after 40 years: a very long term follow-up study of the Colonna arthroplasty.

Between 1952 and 1965, surgeons at the Los Angeles Shriners Hospital managed 23 hips with the Colonna two-stage capsular arthroplasty, a procedure originally described in 1936 with very stringent indications for the treatment of childhood hip dysplasia. By using chart review, credit traces, telephone listings software, and the Internet, we found 17 (90%) of 19 patients known to be alive 40 years after surgery. Only four of 16 patients questioned have not undergone total hip arthroplasty, and these patients were no better candidates for the Colonna arthroplasty than were the 12 patients who have required hip-replacement surgery. We do not support revival of this now obscure procedure. However, we do attest that the average clinical investigator currently has access to tools that allow reliable location of patients for very long term follow-up. This technology will improve the accuracy and statistical power of outcomes research.

Adolescent↗
PubMedDate not supplied

Total hip arthroplasty after childhood septic hip in patients younger than 25 years of age.

Childhood septic hip should usually be treated immediately by arthrotomy and antibiotic. Even if treated correctly, the affected hip may become osteoarthritic and functionally disabling. Usually the literature is not in favor of total hip arthroplasty in young patients, and the reports are on patients older than 32 years of age. We present here a unique group of very young patients with early coxarthrosis caused by septic hip in childhood, with an average age of 19.14 years (range, 14-25) at the time of the arthroplasty. The Harris hip score improved from a preoperative mean of 58.43 to a postoperative mean of 94.14. The follow-up period ranged between 2 and 24 years, with an average of 8.14 years. We conclude that total hip arthroplasty in young people with early coxarthrosis caused by septic hip in childhood provides good functional results.

Adolescent↗
PubMed2003

Internal fixation versus arthroplasty of comminuted fractures of the distal humerus.

BACKGROUND: A comminuted distal humerus fracture in an older patient is a difficult clinical problem. Open reduction internal fixation (ORIF) carries the risks of nonunion, loss of fixation, infection, and stiffness. Arthroplasty carries the risks of loosening, infection, and periprosthetic fracture. Both procedures are technically challenging, and complications following these procedures are frequent. OBJECTIVE: To evaluate best available evidence to assist in guiding clinical decision making for ORIF versus arthroplasty of intraarticular distal humeral fractures in elderly patients. HIGHEST AVAILABLE EVIDENCE: 1. Case series of internal fixation or arthroplasty of acute interarticular distal humerus fractures in the elderly (level IV). 2. Review of expert opinion without explicit critical appraisal or controlled research (level V). STUDY IDENTIFICATION: 1. Computerized data search 1969-2003, Cochrane Database, OVID Search Engine. 2. Reviews of bibliographies of selected articles.

Aged↗
PubMed2002

Ethnic differences in the perception of prayer and consideration of joint arthroplasty.

CONTEXT: Ethnic differences in utilization of arthroplasty may reflect differences in health-related attitudes and beliefs. OBJECTIVE: To examine ethnic differences in the perception and use of prayer in the treatment of arthritis and its role in patients' decision making toward surgery. DESIGN: A cross-sectional survey. SETTING: VA Primary Care Clinics. PATIENTS: Patients older than 50 years with chronic moderate-to-severe knee pain, hip pain, or both. MEASURES: The "helpfulness of prayer" in the treatment of arthritis and patients' attitude toward joint arthroplasty. RESULTS: Five hundred ninety-six veterans; 44% black patients, 56% white patients. Groups were comparable with respect to age (65 +/- 9.5 vs. 66 +/- 9), disease severity as assessed by WOMAC (47 +/- 17 vs. 45 +/- 17). Black patients scored higher than white patients on the religiosity scale (77 +/- 17 vs. 70 +/- 21). In multivariate analysis, black patients were more likely than white patients to perceive prayer as helpful in the management of their arthritis (OR, 2.1; 95% CI, 1.19, 3.72). Black patients were also less likely than white patients to consider surgery for severe hip/knee pain (OR, 0.58; 95% CI 0.34, 0.99); this relationship between ethnicity and consideration of surgery is mediated by perceptions of "helpfulness of prayer." The odds ratio for this relationship changes to 0.70 (P = 0.215). CONCLUSION: In this sample, black patients were more likely than white patients to perceive prayer as helpful and to have actually used prayer for their arthritis. Perception of helpfulness of prayer may be an important explanatory variable in the relationship between ethnicity and patients' decision in considering arthroplasty.

Black or African American↗
PubMedDate not supplied

Valdecoxib, a COX-2-specific inhibitor, is an efficacious, opioid-sparing analgesic in patients undergoing hip arthroplasty.

Opioid agents are highly effective analgesics after orthopedic surgery but are associated with several adverse effects. Valdecoxib is a new, highly selective cyclooxygenase (COX)-2-specific inhibitor with a rapid onset of action and significant analgesic properties that is being developed for the management of acute pain. The objective of this study was to demonstrate the opioid-sparing efficacy of valdecoxib as part of a multimodal treatment of pain associated with hip arthroplasty. This multicenter, multiple-dose, double-blind, parallel-group study compared the opioid-sparing effects, analgesic efficacy, and safety of 20- and 40-mg doses of valdecoxib twice daily with placebo in patients receiving morphine by patient-controlled analgesia after hip arthroplasty. Study medication was first administered 1 to 3 hours preoperatively. The total amount of morphine administered, pain intensity, and patient's global evaluation of study medication were assessed over a period of 48 hours. Patients receiving 20 or 40 mg valdecoxib twice daily required on average 40% less morphine than those receiving placebo after hip arthroplasty. Pain intensity levels and patient satisfaction were significantly improved in both valdecoxib groups compared with placebo. Valdecoxib and placebo were equally well tolerated. Pre- and postoperative administration of valdecoxib reduces the amount of morphine required for postoperative pain relief and provides greater analgesic efficacy compared with morphine alone. Thus, valdecoxib has significant clinical utility for acute pain management in orthopedic surgery patients.

Aged↗
PubMed2003

Magnetic resonance imaging of total knee arthroplasty.

Evaluation of painful total knee arthroplasty can be clinically difficult, and traditional imaging techniques such as conventional radiographs, arthrography, and bone scintigraphy are limited by poor contrast resolution and specificity. Traditional magnetic resonance imaging techniques often are nondiagnostic because of significant metal artifact. Forty-one patients (46 knees) had magnetic resonance imaging, tailored to reduce metallic susceptibility artifact, after total knee arthroplasty, and the findings and clinical and surgical followup were reviewed. All studies consistently showed the integrity of the periprosthetic soft tissues. Magnetic resonance imaging findings led to surgical or other therapeutic interventional procedures in 20 patients, and influenced clinical treatment in all patients. Optimized magnetic resonance imaging, in which the metallic artifact is diminished, is a clinically useful adjunct to traditional imaging techniques in evaluation of patients with painful total knee arthroplasty.

Adult↗
PubMed2003

Revision total hip arthroplasty: hospital cost and reimbursement analysis.

Revision total hip arthroplasty is a complex surgical procedure that frequently requires high levels of hospital resources. The purpose of the current study was to report the actual costs and reimbursement to the hospital for a stratified group of patients having revision total hip arthroplasty based on a severity index. The clinical and financial records of 49 patients (51 hips) stratified by complexity of revision were reviewed. Clinical variable included age, length of stay, operating time, estimated blood loss, number of transfusions, implant type, metallic augmentation, use of bone graft, and time spent in the postanesthesia care unit. Financial review included the actual fixed and variable costs associated with each procedure. Hospital costs associated with revision total hip arthroplasty were significantly greater in the most complex revisions and in older patients. The use of bone grafting techniques on the femur resulted in significantly greater costs. The average loss to the hospital was $5402 US dollars per procedure with a range of $5657 (US dollars) profit to $28,780 (US dollars) loss. Procedures in patients younger than 65 years has an average loss of $1133 US dollars. All procedures in patients who were 65 years or older resulted in a loss to the hospital, with the average loss being $8617 US dollars. Despite improvements in length of stay, use of clinical pathways, and negotiated discounts on implants, the hospital loss on each hip revision procedure averaged $5402 US dollars.

Adult↗
PubMed2003

Minimal incision total knee arthroplasty: early experience.

Total knee arthroplasty (TKA) has evolved during the past 30 years to a well-defined technical surgery with excellent results for as many as 20 years of followup. The concepts of exposure, ligament balancing, and joint alignment have been established clearly by Insall and others. In the early 1990s, Repicci introduced minimally invasive surgery for unicondylar knee arthroplasty. This approach suggested that less invasive surgery could accomplish similar results to those of standard unicondylar knee arthroplasty. Early reports in the literature support these conclusions. It only was logical that the minimally invasive surgery approach eventually would be applied to TKA. It is extremely important to establish a clear definition of the minimally invasive surgery and, then, to follow the results. We have completed 70 minimally-invasive TKAs during the past 9 months with early results that indicate less intraoperative blood loss, shorter length of stay, increased range of motion (ROM), with similar implant accuracy to standard TKA. These new procedures will require thorough evaluation as with any new clinical endeavor. It also is of paramount importance to remember that the main goal of any new technology is to advance the science of medicine without compromising the ultimate result for the patient. The early findings are encouraging for the future of minimally invasive TKA and we hope to improve the technology during the next few years.

Aged↗