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PubMed2003

Postoperative fever after total knee arthroplasty: the role of cytokines.

Febrile temperatures commonly are seen after total knee arthroplasty, but their source and importance are unclear. The goal of the current study was to determine whether such fevers are part of the normal physiologic response to surgery mediated by inflammatory cytokines. In 20 patients who had total knee arthroplasty, serum and wound drain fluid samples were collected preoperatively and at 1, 6, 24, and 48 hours postoperatively; oral temperatures were measured postoperatively every 4 hours for 3 days. Concentrations of interleukin 1beta, interleukin 6, and tumor necrosis factor alpha in the samples were measured via enzyme-linked immunosorbent assays and compared in patients who did and did not have fevers develop (>or=38.5 degrees C). Gender, age, operative time, amount of blood loss or drain output, anesthesia type, drop in hematocrit, and transfusion administration were not associated with fever. Significant increases were seen postoperatively in drain fluid concentrations of interleukin 1beta and interleukin 6 and in serum concentrations of interleukin 6. Patients who were febrile had significantly higher drain and serum interleukin 6 concentrations than patients who were afebrile. These findings suggest that fevers seen after total knee arthroplasty are at least partly the result of surgical site inflammation and subsequent local and systemic release of the endogenous pyrogen interleukin 6.

Aged↗
PubMed2003

Demographic factors affecting long-term outcome of total hip arthroplasty.

We report the outcome of total hip arthroplasty (THA) in a cohort of patients with complete long-term radiographic and clinical followup information from our database of more than 48,000 primary hip replacements. The purpose of the study was to evaluate the influence of various demographic factors and patient comorbidity (Charnley classification) on the long-term outcome of THA. The cohort was comprised of 25,990 total hip replacements (THRs) in 10,243 (46.6%) men and 11,754 (53.4%) women with a median age of 66 years (range, 20-96 years) at the time of arthroplasty. Our study confirmed that THA has an impressive efficiency and reliability in alleviating pain and improving function for almost all of the patients. Furthermore, the results are enduring with more than 90% of patients being satisfied with the outcome at 15 years. Clinical outcome measures reach their maximum at 2 to 5 years after arthroplasty and thereafter they decline gradually. Furthermore, patient age, gender, body mass index, and main diagnosis all have an influence on specific functional parameters. The Charnley classification has the most profound effect on the overall functional status of patients.

Adult↗
PubMed2004

Dislocation after long-necked total hip arthroplasty.

Dislocation after total hip arthroplasty is problematic and not completely understood. Skirted long-necked implants have been used to reestablish soft tissue tension with the assumption that their use will reduce dislocation. It is unknown whether the dislocation rates with long-necked implants are different than those with standard neck length devices. The records of 250 consecutive total hip arthroplasties were reviewed, 125 primary and 125 revision, in which long-necked femoral prostheses were used. A matched control sample with standard neck length prostheses was defined. Dislocation rates and radiographic indices of leg length were calculated and compared with the control group. Dislocation rates in the long-necked groups were 10.6% and 18% for primary and revision surgeries, respectively. These rates were significantly higher than the rates seen in standard neck length controls (1.6% and 10%, respectively). There was no difference in leg-length discrepancy between long-necked prostheses and standard neck length matched controls. Long-necked prostheses are associated with higher rates of dislocation after total hip arthroplasty. The higher rates may be attributable to impingement of the neck, inadequate restoration of soft tissue tension, and/or other factors. Although this study cannot claim to have shown a cause and effect relationship between the skirted neck and dislocation, the association between the two variables is clearly shown.

Arthroplasty, Replacement, Hip↗
PubMed2004

Accurate measurement of ankle range of motion after total ankle arthroplasty.

There is no standardized method reported in the literature to measure ROM of the ankle after a total ankle arthroplasty, which limits the possibility to compare results from the various ankle designs. It seems that most of the measurements are a combination of ankle and midfoot motion, not the tibiotalar joint. A protocol was developed to accurately measure the true tibiotalar and midfoot motion before and after an ankle replacement. Lateral radiographs were taken of the ankle with the patient in a weightbearing position, and measurements were done along fixed landmarks. In this study, the tibiotalar, midfoot, and combined ROM were measured preoperative and 1 year postoperative in a standardized, reproducible fashion. The preoperative tibiotalar ROM was 18.5 degrees and combined ankle and midfoot motion 25.1 degrees. The true tibiotalar motion after an Agility total ankle arthroplasty was 23.4 degrees, and the combined ankle and midfoot motion was 31.3 degrees. The average improvement in ROM in the tibiotalar joint was approximately 5 degrees, and combined ROM was 6.1 degrees. Preoperative ROM proved to be the main factor determining the eventual postoperative ROM. It is possible to accurately measure the true ankle and the midfoot motion and those measurements should be used when reporting on the results of ankle replacements. Total ankle arthroplasty resulted in a statistically significant, but clinically less than expected, increase in ROM.

Adult↗
PubMed2004

Primary total knee arthroplasty for complex distal femur fractures in elderly patients.

Fractures of the distal femur in the geriatric population are associated with a high incidence of postoperative complications and poor results. Nonunion, loss of fixation, and malunion of these fractures occur with all types of treatment. The postoperative treatment of these patients demands a lengthy period of limited weightbearing that can increase the rate of medical complications. Our experience with these challenging fractures caused us to consider the use of a primary distal femur replacement total knee arthroplasty with the goals of elimination of fracture healing issues, early mobilization, and immediate weightbearing. Twenty-four distal femoral replacement knee arthroplasties were done from July 1998 to January 1999. Reviewed with a mean followup of 11 months, 17 patients (71%) resumed their preoperative level of ambulation. Knee range of motion averaged 1 degree - 103 degrees. No major surgical or significant medical complications were experienced by these patients. Our experiences with this small number of patients have shown that an immediate arthroplasty offers many advantages over open reduction and internal fixation for geriatric patients with poor bone quality, preexisting degenerative joint disease, and medical problems.

Aged↗
PubMed2004

Computer-assisted cup placement techniques in total hip arthroplasty improve accuracy of placement.

Malposition of the acetabular component during hip arthroplasty increases the occurrence of impingement, reduces range of motion, and increases the risk of dislocation and long-term wear. To prevent malpositioned hip implants, an increasing number of computer-assisted orthopaedic systems have been described, but their accuracy is not well established. The purpose of this study was to determine the reproducibility and accuracy of conventional versus computer-assisted techniques for positioning the acetabular component in total hip arthroplasty. Using a lateral approach, 150 cups were placed by 10 surgeons in 10 identical plastic pelvis models (freehand, with a mechanical guide, using computer assistance). Conditions for cup implantations were made to mimic the operating room situation. Preoperative planning was done from a computed tomography scan. The accuracy of cup abduction and anteversion was assessed with an electromagnetic system. Freehand placement revealed a mean accuracy of cup anteversion and abduction of 10 degrees and 3.5 degrees, respectively (maximum error, 35 degrees). With the cup positioner, these angles measured 8 degrees and 4 degrees (maximum error, 29.8 degrees), respectively, and using computer assistance, 1.5 degrees and 2.5 degrees degrees (maximum error, 8 degrees), respectively. Computer-assisted cup placement was an accurate and reproducible technique for total hip arthroplasty. It was more accurate than traditional methods of cup positioning.

Arthroplasty, Replacement, Knee↗
PubMed2004

Systemic safety of high-dose antibiotic-loaded cement spacers after resection of an infected total knee arthroplasty.

The purpose of this study was to assess the systemic safety and potential adverse effects of using a high-dose antibiotic-impregnated cement spacer after resection arthroplasty of an infected total knee replacement. Between October 2000 and December 2002, 36 knees (34 patients) had a resection arthroplasty of an infected total knee prosthesis with placement of a high-dose antibiotic impregnated cement spacer. There were 24 men and 10 women with a mean age of 66.5 years (range, 48-84 years). All spacers placed contained an average of 3.4 batches of cement with an average total dose of 10.5 g of vancomycin (range, 3-16 g) and 12.5 g of gentamicin (range, 3.6-19.2 g). All patients were followed up post-operatively until reimplantation for evidence of renal failure. The preoperative creatinine ranged from 0.7 to 1.8 mg/dL. All patients were concomitantly treated with 6 weeks of intravenous organism-specific antibiotics. One patient with normal preoperative renal function (Cr 0.7 mg/dL) had a perioperative 1-day transient rise in serum creatinine (1.7 mg/dL) postoperatively that subsequently normalized. No patients showed any clinical evidence of acute renal insufficiency, failure, or other systemic side effects of the antibiotics. Treatment of patients with an infected total knee arthroplasty with high-dose vancomycin and gentamicin antibiotic spacers seems to be clinically safe.

Aged↗
PubMed2004

Debate: bilateral simultaneous total knee arthroplasty.

Controversy persists regarding the value of doing bilateral simultaneous total knee arthroplasty. Advocates of this procedure focus on economic costs, patient satisfaction, and quicker return to function as compared with bilateral staged total knee arthroplasty. Those in opposition focus on increased complication rates that question the overall safety of this operative procedure. The purpose of this discussion is to review the orthopaedic literature, concentrating on the reported advantages and disadvantages of bilateral simultaneous total knee arthroplasty in hopes of providing the surgeon with information valuable in determining the safety and efficacy of this procedure.

Arthroplasty, Replacement, Knee↗
PubMed2004

Surgical approaches in mini-incision total knee arthroplasty.

Mini-incision total knee arthroplasty can be accomplished through versions of exposures used in standard total knee arthroplasty. Modifications of the medial parapatellar, subvastus, and midvastus approaches are presented, and potential advantages and disadvantages of each approach are reviewed. When making the transition to smaller incisions and arthrotomies, the medial parapatellar seems to be the most versatile. The ability to do a total knee arthroplasty through a mini incision, and ultimately the success of the procedure, will depend on appropriate patient selection.

Arthroplasty, Replacement, Knee↗
PubMed2005

Real in vivo kinematic differences between mobile-bearing and fixed-bearing total knee arthroplasties.

We did an in vivo fluoroscopic study comparing the sagittal plane kinematics of mobile-bearing and fixed-bearing total knee arthroplasties in a unique group of patients. These patients were part of a larger bilateral randomized controlled outcome trial with each patient having received both types of total knee arthroplasties. Invited patients did three exercises with each of their different knee replacements; extension against gravity, flexion against gravity, and a step-up. These exercises were recorded using video fluoroscopy, and a series of still digital images over the flexion range were retrieved. The relationship of patella tendon angle to knee flexion angle for each patient was derived. The patella tendon angle to knee flexion angle of the mobile-bearing knee behaved in a linear manner more closely replicating the normal knee, whereas the fixed-bearing knee behaved in a nonlinear, more variable manner. This pattern of results was similar for all three exercises with each patient having one knee replacement that behaved differently in the sagittal plane when compared with their other knee replacement. These kinematic differences may explain the clinical differences observed in the randomized controlled trials that compared these two total knee arthroplasties.

Adult↗
PubMed2005

Cemented total knee arthroplasty in patients with juvenile rheumatoid arthritis.

UNLABELLED: The optimal techniques and implants for total knee arthroplasty in patients with juvenile rheumatoid arthritis are controversial. We report the functional outcomes and complications of a series of 17 cemented total knee arthroplasties done by one surgeon during a 10-year period in which off-the-shelf implants were used, the posterior cruciate ligament was excised, and a lateral retinacular release was done. Preoperatively, all knees had severe loss of normal joint space and osteopenia on 3-foot, standing AP radiographs, lateral radiographs, and patellofemoral views. The patients were evaluated after a mean followup of 74 months (range, 36-116 months). The Knee Society scores improved from a mean of 38.9 +/- 23.9 points (range, 10-81 points) preoperatively to 81.9 +/- 16.6 points (range, 39-99 points) postoperatively. Range of motion showed significant improvement in all patients at the most recent followup. Ambulation scores improved significantly; nine of 10 patients (15 knees) were ambulatory after surgery. Complications included two transient regional pain syndromes and one patellofemoral subluxation requiring realignment. Cemented total knee arthroplasty with off-the-shelf implants, excision of the posterior cruciate ligament, and lateral retinacular release in patients with juvenile rheumatoid arthritis can provide substantial improvement in pain, deformity, ambulation, and function. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Adolescent↗
PubMed2005

The 20-year outcome of the charnley arthroplasty in younger and older patients.

The purpose of this study is to present the 20-year outcome of 206 Charnley low-friction arthroplasties done by the same surgeon on 181 patients who were separated into two age groups (younger and older). In Group A (76 patients, 92 hips) the mean age at surgery was 44 years (range, 24-55 years), and in Group B (105 patients, 114 hips) the mean age at surgery was 65 years (range, 56-82 years). All patients were evaluated clinically and radiographically. At final followup, 71 patients (87 hips) in Group A and 90 patients (99 hips) in Group B were available for study. The overall failure rate for the hips of Group A was 37.9%, and the overall failure rate for the hips of Group B was 20%. The main cause of failure in Group A was aseptic loosening of the components and breakage of the femoral stem, whereas in Group B the main cause of failure was deep infection. We concluded that by eliminating the above factors, and using new cementing techniques and improved implants, the 20-year results of this arthroplasty would be better. Our results show that the Charnley arthroplasty is a reliable procedure for hip replacement, even in younger patients.

Adult↗
PubMed2005

Minimally invasive outpatient total hip arthroplasty: a financial analysis.

UNLABELLED: Costs of outpatient total hip arthroplasties were compared with costs of a matched group of patients having inpatient total hip arthroplasties. Ten patients were in each group and had surgery by the same surgeon in the same hospital. The average hospital bill for the outpatients was $4000 less than for the inpatients. The total average charge including prehospital, intrahospital, and posthospital care for the outpatients was approximately $2500 less than for the inpatients. The total average reimbursement was $1155 less for the outpatients. Results of this pilot study show that outpatient total hip arthroplasty is financially advantageous. LEVEL OF EVIDENCE: Economic and decision analyses, Level IV (no sensitivity analyses). See the Guidelines for Authors for a complete description of levels of evidence.

Aged↗
PubMed2005

Thromboembolic disease prophylaxis in total hip arthroplasty.

UNLABELLED: We sought to determine if using aspirin and exercise as prophylaxis against thromboembolic disease in patients having total hip arthroplasties would provide results as effective as or better than those reported in the literature using other chemical agents. One thousand eight hundred thirty-five total hip arthroplasties were done in 1585 patients using a posterior approach. Surgery was done with the patient under general anesthesia in 459 instances and regional anesthesia in 1376 instances. Graduated elastic stockings were used in 1117 instances and intermittent compression stockings were used in 718 instances. Passive exercises of the major joints of the operated extremity were done intraoperatively, and active exercises were done postoperatively. Patients received a suppository containing 10 grains of aspirin immediately after surgery and 325 mg twice a day for the length of their hospitalization. Fatal pulmonary embolism developed after two (0.10%) surgical procedures. Nonfatal pulmonary embolisms were diagnosed in 17 (0.9%) patients, and deep venous thrombosis was diagnosed in 17 (0.9%) patients. The low incidence of thromboembolic complications recorded in this series suggests that our postoperative protocol, including 325 mg of aspirin twice a day during hospitalization and exercise, is an effective and inexpensive method of prophylaxis after total hip arthroplasty. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Arthroplasty, Replacement, Hip↗
PubMed2005

Outcome instruments for patellofemoral arthroplasty.

Although there are numerous patient outcome instruments available, the most reliable and valid instruments for evaluating patient outcomes after patellofemoral arthroplasty have not been identified. In this article, we review and evaluate the psychometric properties and practical considerations of administering general health instruments (Medical Outcomes Study (MOS) Short Form-36 and Short Form-12), knee scales (Knee Society Clinical Rating System, Knee Outcome Survey, International Knee Documentation Committee form, Knee Injury and Osteoarthritis Outcome Score) and a disease specific scale (Western Ontario and McMaster Universities Osteoarthritis Index) for patellofemoral arthroplasty outcome assessment. Based on our review of the literature, we recommend the Short Form-36 and Knee Injury and Osteoarthritis Outcome Score for evaluation of patellofemoral arthroplasty outcomes and provide recommendations for implementation of these instruments in a clinical setting.

Arthroplasty, Replacement, Knee↗
PubMed2005

Bone strength influences periprosthetic bone loss after hip arthroplasty.

UNLABELLED: Our primary question was whether bone strength at the time of surgery, reflected by the lumbar spine T-score and femoral cortical thickness, influences periprosthetic bone loss after a total hip arthroplasty. Using dual energy xray absorptiometry we preoperatively and postoperatively examined 38 consecutive patients having cementless total hip arthroplasties for their bone density. Bone strength was estimated using lumbar spine bone mineral density and the ipsilateral diaphyseal cortical thickness of the femur measured on radiographs. Periprosthetic femoral bone mineral density was measured with dual energy xray absorptiometry within 1 week postoperatively and at 2, 4, 6, 9, 12, and 24 months thereafter. Periprosthetic bone loss was influenced by the patient's bone strength at the time of surgery. Bone loss in the calcar femoris (as much as 54% after 2 years) was greater in patients with a low lumbar spine T-score or low femoral cortical thickness. Preoperative assessment of bone strength (ie, lumbar spine bone mineral density and femoral cortical thickness on radiographs) served as a reliable indicator in predicting the extent of periprosthetic bone loss after total hip arthroplasty. LEVEL OF EVIDENCE: Prognostic Study, Level I (high quality prospective study-all patients were enrolled at the same point in their disease with > or = 80% followup of enrolled patients). See the Guidelines for Authors for a complete description of levels of evidence.

Adult↗
PubMed2005

Minimal-incision total knee arthroplasty: the early clinical experience.

UNLABELLED: Minimal-incision total knee arthroplasty can be considered part of the continuum from traditional extensile exposures to the quadriceps-sparing approach. We did this study to identify preoperative variables that predict which patients are amenable to a mini-incision and mini-arthrotomy technique, and to compare early outcomes in these patients versus patients in whom a standard approach was required. A consecutive series of 118 primary total knee arthroplasties were evaluated. In each case, the incision and arthrotomy were kept as small as possible, while still allowing proper implantation of the prosthesis. Group 1 consisted of 69 patients (58%) with skin incisions smaller than 14 cm and limited medial parapatellar arthrotomies. Group 2 consisted of 49 patients (42%) with incisions greater than or equal to 14 cm and standard medial parapatellar arthrotomies. Patients in Group 1 averaged one size smaller femoral and tibial components, had narrower femurs, required fewer transfusions and had better postoperative flexion. There were no differences between the groups in length of hospital stay, ambulatory ability, stair-climbing, tourniquet time, radiographic alignment, or complications. Based on these results, the ideal patient for a minimal incision total knee arthroplasty and limited arthrotomy seems to be a thin woman with a low body mass index, a narrow femur, and good preoperative range of motion. LEVEL OF EVIDENCE: Prognostic study, Level III-1 (retrospective cohort study). See the Guidelines for Authors for a complete description of levels of evidence.

Aged↗
PubMed2005

Patellofemoral arthroplasty: an update.

UNLABELLED: The rationale for presenting this updated study is to report long-term clinical and survival results of patellofemoral arthroplasty and to ascertain whether the preoperative diagnosis influenced outcomes and therefore indications. We retrospectively updated a previous evaluation of 66 patients who had unilateral patellofemoral arthroplasty between 1972 and 1990. The mean age of the patients at the initial surgery was 57 years (range, 21-82 years). The patients had an average followup of 16.2 years (range, 12-20 years). Preoperative diagnosis included instability, fracture, and primary arthritis. Revision surgery was done in 14 patients for femorotibial osteoarthritis, in 11 for loosening, and in four for stiffness. Survivorship was 58% at 16 years. The knee function score improved from 40 points preoperatively to 81 points at last followup. The best results were in patients with preoperative instability and corrected alignment of the extensor mechanism. Stiffness occurred only in those patients with osteoarthritis from previous fracture. Progressive degeneration of the tibiofemoral joint was noted mainly in the primary osteoarthritis etiologic group. This long-term evaluation of patellofemoral arthroplasty showed the importance of patient selection while excluding knees with significant frontal tibiofemoral malalignment. LEVEL OF EVIDENCE: Therapeutic study, Level IV-1 (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Adult↗