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PubMed2005

Current trends in blood conservation in total knee arthroplasty.

There is a lack of consensus with regard to ways to minimize blood transfusions after total knee arthroplasty. We surveyed 434 members of the American Association of Hip and Knee Surgeons, each of whom averaged 18 years in practice and performed an average of between 100 and 150 knee replacements a year, about their preferences and practices regarding blood conservation during total knee arthroplasty. Of those surveyed, only 24% reported that there was a blood conservation program in place at their institutions. Fifty-nine percent of those surveyed routinely asked their patients to donate blood before unilateral and bilateral knee replacements. The amount of blood collected averaged 1.32 units (range, 1-4 units) and 2.04 units (range, 1-4 units) before unilateral and bilateral knee arthroplasty, respectively. Nearly half (47.5%) reported they rarely ever prescribed epoetin alfa because of a combination of cost, time, and labor issues. Furthermore, the majority (84%) has not had any experience with the use of antifibrinolytics. Overall, the mean transfusion rate after unilateral knee replacement was estimated to be less than 5% (range, 0%-20%) whereas the rate after bilateral knee replacement was estimated to be between 10% and 20% (range, 5%-20%).

Arthroplasty, Replacement, Knee↗
PubMed2005

Polyethylene in knee arthroplasty: what is the future?

Ultra-high molecular weight polyethylene remains the gold standard as a bearing surface for total knee arthroplasty. But problems of oxidative degradation and wear have prompted new sterilization techniques and new forms of more highly cross-linked polyethylene. The value of these solutions can be shown initially from laboratory data, but in the end their usefulness will be confirmed through clinical performance. The significance of new polyethylenes cannot be established on the basis of a single type of test or even on a single goal such as improved wear resistance. Rather, a range of requirements dictated by design goals (function, fixation, and wear) must be considered. The requirements can be competing, so that matching one compromises matching another that, if not taken into account, can lead to failure in clinical use. Previous improvements to polyethylene ultimately failed because not all the requirements were met. The same concern exists with highly cross-linked polyethylenes; improvements in wear resistance are tempered by a decrease in toughness. A case can be made for and against these polyethylenes, but early clinical results in hip arthroplasty show significantly improved wear, raising the possibility of also improving wear performance in knee arthroplasties.

Arthroplasty, Replacement, Knee↗
PubMed2006

Complications of cemented long-stem hip arthroplasties in metastatic bone disease.

UNLABELLED: It is controversial whether a cemented long-stem femoral arthroplasty is a safe surgical option for patients with meta-static bone disease of the hip. Cemented long stems increase the risk of embolic cascades and may cause subsequent cardiopulmonary complications, particularly in patients with metastatic disease. We retrospectively reviewed results of 29 long-stem cemented femoral arthroplasties in 27 patients in which surgical techniques that minimized intramedullary debris and canal pressurization were used. The surgical techniques minimized intraoperative cement-related emboli with aggressive medullary lavage, intraoperative canal suctioning during cementation, use of early low-viscosity polymethylmethacrylate, and slow, controlled insertion of the long-stem prosthesis. Cement-associated hypotension occurred in four (14%) patients, sympathomimetics were administered in nine (31%) patients, and a worsening mental status occurred postoperatively in one (3%) patient. There were no cement-associated desaturation events, cardiac arrests, or intraoperative deaths. No patients required prolonged intubation, and there were no postoperative cardiopulmonary events. Cemented long-stem femoral arthroplasty is a safe procedure for patients with high-risk metastatic disease. Increased awareness of cement-related cardiopulmonary pathophysiology, and modifying conventional surgical techniques can minimize cement-associated complications. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Adult↗
PubMed2006

Case reports: Shoulder arthroplasty in transplant recipients: a report of five cases.

The fate of shoulder arthroplasties in transplant recipients is unknown but potential concerns include the immunocompromised state and inferior bone quality of these patients. We retrospectively reviewed five shoulder arthroplasties performed from January 1, 1985 to December 31, 2001 in four patients who previously had transplant surgery. All patients were followed up for a minimum of 2 years (mean, 5.4 years). The results were graded according to a modified Neer result rating system. There were four excellent results and one satisfactory result. There were no intraoperative complications, infections, or revisions. In this limited group of patients the results of shoulder arthroplasty after transplantation were satisfactory.

Adult↗
PubMed2005

The John Charnley Award: heritable thrombophilia and development of thromboembolic disease after total hip arthroplasty.

UNLABELLED: We retrospectively assessed whether heritable thrombophilia-hypofibrinolysis was more common in patients developing venous thromboembolism after total hip replacement than among control patients who did not develop venous thromboembolism, as an approach to better identify causes of venous thromboembolism after total hip arthroplasty. Twenty patients with proximal deep venous thrombosis after THA and 23 patients with symptomatic pulmonary embolism were compared with 43 control patients who did not have postoperative venous thromboembolism. Five of 42 patients with venous thromboembolism (12%) and 0 of 43 control patients (0%) had antithrombin III deficiency (< 75%). Nine of 42 patients with venous thromboembolism (21%) and 2 of 43 control patients (4.7%) had protein C deficiency (< 70%). Ten of 43 patients with venous thromboembolism (9 heterozygous, 1 homozygous; 23%) and 1 of 43 control patients (heterozygous; 2%) had the prothrombin gene mutation. Patients who had venous thromboembolism after total hip arthroplasty were more likely than matched control patients to have heritable thrombophilia with antithrombin III or protein C deficiency, or homo-heterozygosity for the prothrombin gene mutation. Screening for these three tests of heritable thrombophilia before total hip arthroplasty should improve the identification of patients with a reduced risk of venous thromboembolism who may need only mild thromboprophylaxis, and of those patients with heritable thrombophilia in whom prophylaxis should be more aggressive. LEVEL OF EVIDENCE: Prognostic study, Level II-1 (lesser-quality RCT). See the Guidelines for Authors for a complete description of levels of evidence.

Adult↗
PubMed2005

Operative and patient care techniques for posterior mini-incision total hip arthroplasty.

UNLABELLED: Technical and patient care improvements have occurred with the posterior mini-incision total hip arthroplasty. We hypothesized that these changes would provide better results for patients. The clinical and radiographic results of 100 total hip arthroplasties done with the posterior mini incision between January 2004 and October 2004 were compared with 100 mini-incision total hip arthroplasties done between December 2001 and September 2002. There were no differences in diagnosis, age, and body mass index of the patients in each group. Component positions were not compromised in either group. There were improvements in the 2004 group with decreased hospital stay, reduction of postoperative pain and opioid analgesic use, reduced use of assistive devices, and earlier muscle recovery. In the 2004 group there were no complications of infection, dislocation, or sciatic palsy. The posterior mini-incision operation has shown improved results with experience and changes in technique and patient care treatment. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Aged↗
PubMed2005

The mini-incision direct lateral approach in primary total hip arthroplasty.

UNLABELLED: Patients are inquiring about mini-incision primary total hip arthroplasty with increasing frequency. There are no published randomized controlled trials to substantiate claims that the mini-incision direct lateral approach is better than a standard approach. The purpose of our study was to review our initial experience with the mini-incision technique through the direct lateral approach, with the intent of implementing a randomized controlled trial if the approach could be shown as safe and effective. Of importance was determining if there is any difference in component positioning and if there is any difference in intraoperative or postoperative complications between the two groups. We retrospectively compared a consecutive series of 87 primary total hip arthroplasties. Thirty-four total hip arthroplasties were done using a mini-incision direct lateral approach. The mean abduction angle was 45 degrees for both groups. The femoral stem alignment was within five degrees of neutral in 97% of the mini group and 94% of the standard group. There were no dislocations, infections, neurologic or wound complications. There were no differences in medical complications or blood transfusions. A significant decrease was found regarding body mass index, which reflects the bias in patient selection and lack of randomization. We conclude that it is safe to continue further study with this approach because as there was no increase in complications or component malpositioning. LEVEL OF EVIDENCE: Therapeutic study, Level III (retrospective comparative study). See the Guidelines for Authors for a complete description of levels of evidence.

Aged↗
PubMed2005

The John Charnley Award: prevention of readmission for venous thromboembolic disease after total hip arthroplasty.

UNLABELLED: Venous thromboembolic disease remains the most common reason for readmission after total hip arthroplasty. Prospective analysis of screening contrast venography was done from 1984 to 2003 in 1972 patients having elective total hip arthroplasty. Patients with deep venous thrombosis or pulmonary embolism received warfarin therapy; those with negative venograms received no further anticoagulation. From 1984 to 1992, patients not completing venography were discharged without warfarin; since 1993, patients without venography received warfarin for 6 weeks. Readmission for deep venous thrombosis, pulmonary embolism, or bleeding was tracked for 6 months. Venograms were completed in 1032 patients; 175 (16.9%) had deep venous thrombosis. Deep venous thrombosis was reduced by a clinical pathway that included continuous epidural anesthesia (14.2% versus 22.5%). The overall readmission rate for venous thromboembolic disease was 1.62%, including 14 pulmonary emboli (three fatal) and 18 femoral deep venous thrombosis. Readmission occurred in 0.27% (1 of 360) patients on continued warfarin, compared with 2.2% (19 of 880) with negative venograms discharged without further anticoagulation. Three patients (0.15%) suffered fatal pulmonary emboli; all had negative venograms and received no outpatient prophylaxis. Extended outpatient warfarin therapy provided effective protection against venous thromboembolic disease readmission. Surveillance venography was a poor predictor of need for continued prophylaxis; all patients should have extended anticoagulation after total hip arthroplasty. LEVEL OF EVIDENCE: Therapeutic study, Level I-1 (high-quality randomized trial with statistically significant difference or no statistically significant difference but narrow confidence intervals). See the Guidelines for Authors for a complete description of levels of evidence.

Anticoagulants↗
PubMed2006

Acetabular component orientation in 834 total hip arthroplasties using a manual technique.

UNLABELLED: Acetabular component orientation during total hip arthroplasty affects dislocation, range of motion, polyethylene wear, pelvic osteolysis, and component migration. New total hip arthroplasty navigation systems have been introduced to avoid the errors reported after acetabular component orientation using a manual technique. We investigated acetabular component orientation in 834 consecutive primary total hip arthroplasties performed by one surgeon using a manual technique. We examined the relationship between dislocation and a defined safe range. Vertical tilt and planar anteversion were 44.4 +/- 6.5 and 17.9 +/- 6.3 (mean +/- standard deviation), respectively. The error of vertical tilt and planar anteversion were 5.2 +/- 3.9 and 5.3 +/- 4 (mean +/- standard deviation), respectively. Two hundred thirty-three of 834 hips (27.8 %) were outside the safe range. Logistic regression analysis showed that patients with Group IV class according to the classification system of Crowe et al and right hips had a greater risk of being outside the safe range. Navigation systems should be considered, especially in patients with highly dislocated hips. We found no relationship between risk of dislocation and the safe range. Factors other than acetabular component orientation also might affect dislocation. LEVEL OF EVIDENCE: Prognostic Study, Level IV (case series).

Acetabulum↗
PubMed2006

Outcomes after interposition arthroplasty for treatment of hallux rigidus.

UNLABELLED: Interposition arthroplasty reportedly improves outcomes after traditional salvage procedures for advanced hallux rigidus. We hypothesized this procedure can provide pain relief and satisfactory function with few complications. We examined 18 patients with severe articular cartilage loss who received 21 interposition arthroplasties. The patients a mean age was 56 years. They had a mean followup of 38 months. All patients had substantial loss of articular cartilage when examined intraoperatively. Patients were evaluated using the American Orthopaedic Foot and Ankle Society and Short Form-36 scores. All 18 patients had pain relief, and 17 of 18 patients said they would have the procedure again. The mean postoperative increase in range of motion of the first meta-tarsophalangeal joint was 37 degrees . The mean American Orthopaedic Foot and Ankle Society and Short Form-36 scores were 78.4 and 96.3, respectively. The complication rate was 6%. Results of our study indicate that interposition arthroplasty relieves pain and restores motion in patients with advanced hallux rigidus and may offer a reliable option to fusing the joint. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series).

Adult↗
PubMed2006

Favorable midterm results of total hip arthroplasties with a lateral flare uncemented stem.

UNLABELLED: Uncemented stems have been advocated for primary total hip arthroplasties in the young active population. We evaluated the clinical and radiographic results of total hip arthroplasties with a customized lateral flare cementless femoral stem in a prospective, consecutive series of 35 patients (40 hips) younger than 55 years at the time of surgery and who were followed up for an average of 9.2 years (range, 5.7-12.2 years). The study group comprised 20 men and 15 women with an average age of 45.2 years (range, 30-55 years). One patient had aseptic loosening of the stem and one patient had a deep infection. The mean preoperative Harris hip score was 47 and at the latest followup it was 97. The mean axial migration was 0.51 mm. Femoral osteolysis was found to be circumscribed to the proximal femur in Gruen Zones 1 (15%) and 7 (8%) in patients with accelerated polyethylene wear. Radiographic changes consistent with new bone apposition under the lateral flare of the stem in Zones 2, 6, and 7 were found in 73% of the cases. Our data suggest a custom lateral flare stem for primary arthroplasties in the younger patient population achieves excellent clinical results with a low rate of aseptic loosening. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series).

Adult↗
PubMed2006

Removing well-fixed total knee arthroplasty implants.

UNLABELLED: Revision total knee arthroplasty requires the removal of one or all of the prior knee components. Thoughtful and careful removal of well-fixed total knee components can preserve host bone stock and facilitate subsequent reconstructive efforts. The tools and techniques for knee component removal include simple osteotomes, saws, extraction devices, ultrasonic devices, and frequently a combination of some or all of the above. It is the unique nature of each revision arthroplasty, which presents the surgeon with such challenge. Each of the techniques discussed in this review reflects the anecdotal experience acquired in over 800 revision total knee arthroplasties performed at our center. We review our empiric bias regarding the individual applicability of these techniques. LEVEL OF EVIDENCE: Therapeutic studies, Level V (expert opinion). See Guidelines for Authors for a complete description of Levels of Evidence.

Arthroplasty, Replacement, Knee↗
PubMed2006

Surgical treatment and customized rehabilitation for stiff knee arthroplasties.

UNLABELLED: Treating patients who have arthrofibrotic or stiff knees after total knee arthroplasty can be difficult. Treatment with arthroscopic débridement, arthrolysis of adhesions with polyethylene spacer exchange, or complete revision arthroplasty often has led to less than optimal range of motion and functional outcomes. We used a combination of surgical arthrolysis and an intensive postoperative rehabilitation protocol, including functional bracing, to treat this condition. We then retrospectively reviewed 18 knees in 17 patients who had stiff knees after total knee arthroplasty with no other detectable clinical or radiographic abnormalities, at a mean followup of 30 months. Seventeen knees (94%) had gains in knee range of motion with a mean increased range of motion of 31 degrees. Although 16 of 17 patients had clinical improvement and were satisfied with the procedure, only (2/3) of the patients (12 of 18 patients) had excellent or good Knee Society objective scores. This combined surgical and rehabilitation method can lead to an increased range of motion. All patients improved clinically, but good functional results were less predictable. The authors think treatment of these difficult knees should be aimed at soft tissue operative releases supplemented by an intensive rehabilitation protocol. LEVEL OF EVIDENCE: Therapeutic study, level IV (prospective study). See Guidelines for Authors for a complete description of levels of evidence.

Adult↗
PubMed2006

A new tool for measuring cup orientation in total hip arthroplasties from plain radiographs.

Orientation of the hip cup is important in total hip arthroplasties. Orientation includes abduction (inclination) and anteversion. Anteversion can be considered as true (anatomic) and planar (radiographic) anteversion. Some measurement methods either are too complicated or are less precise. We developed a new protractor to measure cup orientation using postoperative anteroposterior radiographs centered at the hip. The new protractor measures true and planar anteversion and abduction easily and precisely. We verified its accuracy using a software simulator and simulated 45 radio- graphs of total hip arthroplasties with 15 different anteversions ranging from 15 degrees -29 degrees and 45 actual radiographs of total hip arthroplasties. We then measured the planar ante- version with our method and the method of Lewinnek et al. Maximal errors were 3 degrees and 2.61 degrees , respectively, and mean errors were 0.96 degrees and 1.2 degrees , respectively. The standard deviations were 0.74 degrees with our method and 0.57 degrees with the method of Lewinnek et al. For the real radiographs, the mean of absolute difference between the two methods was 1.34 degrees , and the standard deviation was 1.13 degrees . We found no difference between the two methods and no difference in our findings compared with those of Pradhan.

Acetabulum↗
PubMed2006

Comparison of total knee arthroplasty in stiff and ankylosed knees.

We compared the results of total knee arthroplasties in patients with stiff or ankylosed knees. We retrospectively reviewed 90 total knee arthroplasties in 52 patients with minimum 2 years followup who had less than a 50 degrees arc of flexion preoperatively. Preoperative and intraoperative data were retrieved from a computerized database. Patients were followed for an average of 6.5 years at an outpatient department. Knee Society knee scores improved from 34.6 points preoperatively to 89.5 points postoperatively in the stiff knees and from 47 points preoperatively to 75 points postoperatively in the ankylosed knees. The arc of flexion improved from 35 degrees -69 degrees preoperatively to 1 degrees -94 degrees postoperatively in the stiff knees and from 0 degrees to 3 degrees -77 degrees in the ankylosed knees. There were major complications in four of the 26 ankylosed knees and in two of the 64 stiff knees. The data suggest results of total knee arthroplasty are better in patients with stiff knees than in patients with ankylosed knees.

Adult↗
PubMed2006

The Chitranjan Ranawat Award: Long-term survivorship and failure modes of 1000 cemented condylar total knee arthroplasties.

We examined factors affecting survivorship, and reasons for reoperation and revision of a cemented modular condylar total knee arthroplasty (TKA). One thousand and eight consecutive primary cemented cruciate-retaining TKAs performed at one institution were studied. At the time of review, 411 patients (562 knees) had died, 43 patients (45 knees) had their knee components revised or removed, and 47 patients (62 knees) were lost to followup. Mean followup of living patients with their TKA components in situ (244 patients, 331 knees) was 15.7 years. Survivorship at 15 years for revision for any reason, revision for mechanical failure, and revision for aseptic loosening were 95.9%, 97.0%, and 98.8% respectively. Survivorship was poorer among patients aged less than 60. Forty-five knees had components removed or revised; approximately one-third were removed for infection, one-third for aseptic loosening or tibial polyethylene wear, and one-third for other causes. Mechanical implant failures accounted for less than one-half of the reoperations and revisions, while infection and periprosthetic fractures accounted for a substantial portion of revisions and reoperations. Because mechanical arthroplasty failures have become less common, other complications related to arthroplasty have become proportionately more frequent.

Adolescent↗
PubMed2006

Thromboembolic disease after total hip arthroplasty: who is at risk?

The strong activation of the clotting cascade that occurs during total hip arthroplasty places patients at increased risk for venous thromboembolism. The risk is higher in those patients with the following predisposing factors, listed in approximate order of importance: hip fracture; malignancy, particularly if associated with chemotherapy; antiphospholipid syndrome; immobility; history of venous thromboemholism; administration of tamoxifen; raloxifene; oral contraceptives or estrogen; morbid obesity; stroke; atherosclerosis; and an American Society of Anesthesiologists physical status classification of 3 or greater. The following risk factors are weak or controversial: advanced age; diabetes mellitus; congestive heart disease; atrial fibrillation; varicose veins; and smoking. However, 50% of patients who develop thromboembolism after total hip arthroplasty have no clinical predisposing factors. In a matched, controlled study, we defined the major genetic predispositions that increase the risk of venous thromboembolism after total hip arthroplasty: deficiency of antithrombin III (< 75%) and protein C (< 70%), and prothrombin gene mutation. Preoperative genetic screening in conjunction with the recognized clinical risk factors can help categorize postoperative venous thromboembolism risk and differentiate patients who can be protected with milder and safer prophylaxis (eg, aspirin, intermittent pneumatic compression) compared with those at higher risk who need to be anticoagulated.

Arthroplasty, Replacement, Hip↗
PubMed2006

Dislocation of primary total hip arthroplasty with 36 and 40-mm femoral heads.

Some authors suggest the use of larger (36 and 40 mm) femoral heads against highly cross-linked polyethylene acetabular liners will reduce the prevalence of early dislocation after primary total hip arthroplasty (THA). We prospectively followed 61 consecutive patients at high risk for dislocation to determine the prevalence of early dislocation after primary THA with 36 and 40 mm femoral heads. We established specific indications for the use of these larger heads in primary arthroplasty. There were 65 hips in 61 patients with a minimum followup of 1 year (mean 2 years, range 1-4 years). There were 55 36 mm heads and 10 40 mm heads. All arthroplasties were performed by the posterior approach with capsular repair. The prevalence of early dislocation was 4.6% (3 of 65). There was one patient with an anterior dislocation and two with posterior dislocation. No patient underwent reoperation for dislocation. There was no dislocation in the 10 hips that had a 40 mm head. We identified no complications related to the larger femoral heads. The use of larger femoral heads did not notably reduce the prevalence of early dislocation after primary THA in high risk patients compared to historical controls.

Aged↗