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PubMed2002

Anconeus arthroplasty: a new technique for reconstruction of the radiocapitellar and/or proximal radioulnar joint.

BACKGROUND: Management of posttraumatic radiocapitellar and/or proximal radioulnar joint dysfunction and pain is a challenging problem, often with more than one pathological feature, and to date there are no consistently reliable solutions. The unreliability of prosthetic replacement prompted us to develop an anconeus arthroplasty wherein the anconeus muscle is rotated into the radiocapitellar and/or proximal radioulnar joint. METHODS: Three interposition options were assessed in our laboratory and were employed clinically: interposition at the radiocapitellar joint (Type I), interposition at the radiocapitellar and proximal radioulnar joints (Type II), and proximal radioulnar interposition (wrap) (Type III). The clinical outcomes in fourteen patients who had been treated with one of the three types of anconeus interposition arthroplasty were reviewed at least two years (mean, 6.1 years) postoperatively. RESULTS: Anatomic dissection of twenty-five specimens revealed that all three applications were possible. Of the fourteen patients, twelve (all six with a Type-I interposition, three of the five with a Type-II interposition, and all three with a Type-III interposition) had a satisfactory overall subjective result. The Mayo Elbow Performance Score averaged 63 points before the surgery and 89 points after it. CONCLUSIONS: Anconeus interpositional arthroplasty offers a reasonable likelihood of improved subjective and objective function in patients with the challenging problem of radiocapitellar and/or proximal radioulnar joint dysfunction and pain after trauma, even when there is Essex-Lopresti axial instability.

Adult↗
PubMed2002

Modern unicompartmental knee arthroplasty with cement: a three to ten-year follow-up study.

BACKGROUND: Unicompartmental arthroplasty is a treatment alternative when only one compartment of the knee is affected with arthritis, but the reported results of this procedure have been variable. The purpose of the present study was to evaluate the results of a modern unicompartmental knee arthroplasty performed with use of a cemented metal-backed prosthesis and surgical instrumentation comparable with that used for total knee replacement. METHODS: The indications for the procedure were osteonecrosis or osteoarthritis associated with full-thickness loss of cartilage that was limited to one tibiofemoral compartment as evaluated on standing and stress radiographs. One hundred and sixty consecutive cemented metal-backed Miller-Galante prostheses in 147 patients were evaluated after a mean duration of follow-up of sixty-six months (range, thirty-six to 112 months). The mean age of the patients at the time of the index procedure was sixty-six years. RESULTS: Three knees were revised because of progression of osteoarthritis in the patellofemoral joint (two knees) or the lateral tibiofemoral compartment (one knee). Two knees had revision of the polyethylene liner. The average Hospital for Special Surgery knee score improved from 59 points preoperatively to 96 points at the time of the review. According to Kaplan-Meier analysis, the ten-year survival rate (with twenty-nine knees at risk) was 94% +/- 3% with revision for any reason or radiographic loosening as the end point. CONCLUSIONS: A modern unicompartmental knee arthroplasty is a valid alternative for patients with unicompartmental tibiofemoral noninflammatory disease. The patient selection must be strict with regard to the status of the patellofemoral joint. The preoperative planning includes stress radiographs to assess the correction of the deformity and the status of the uninvolved compartment. Continued long-term follow-up is necessary to evaluate long-term polyethylene wear.

Adult↗
PubMed2002

[Transfusion of recuperated blood in total knee arthroplasty].

PURPOSE OF THE STUDY: Autologous blood transfusion is not a routine procedure in knee replacement surgery. Several authors have proposed recovering blood shed during the procedure to limit the need for homologous transfusions. The purpose of this retrospective study was to analyze the amount of blood recovered and reinfused with a blood conservation system (MI, USA) and its effect on hemoglobin level five days after surgery in 405 consecutive patients undergoing total knee arthroplasty. MATERIAL AND METHODS: Preoperative intravascular blood volume and hemoglobin level were used to calculate the quantity of hemoglobin transfused expressed in g/dl at time t 0 of transfusion then at day 1 and day 5 postop. Autologous blood transfusion was not programmed for any of these patients. Twenty patients were given homologous blood transfusions and were excluded from the analysis of data on recovered shed blood but were included in the analysis of risk of homologous transfusion. The analysis thus included 385 patients who did not require homologous blood transfusion. Shed blood was reinfused in 337 patients; no transfusion was performed for 48 patients whose drainage produced an insufficient volume. The same analysis was performed for three sub-groups of patients: 205 patients whose transfusion volume was less than 10% of their intravascular volume, 132 patients whose transfusion volume was greater than 10% of their intravascular volume, and 50 transfused patients who weighed less than 70 kg. RESULTS: Mean transfusion volume was 516 ml (range 100-1440 ml), accounting for 59% of the drainage volume over 24 hours and 32% of total estimated blood loss. On the average, the whole blood shed and reinfused contained 60.60 g hemoglobin and increased serum hemoglobin by 0.97 g/dl at day 5 postop (with a wide range: 0.18-2.74 g/dl). Mean transfusion volume, based on hemoglobin equivalent packed cell units, corresponding to 10% of the mean intravascular volume was taken as the threshold of transfusion efficacy. Among the 132 patients whose transfusion volume was greater than 10% of the intra-vascular volume, hemoglobin level at day 5 postop increased 1.32 g/dl on the average. Among the 205 patients whose transfusion volume was less than 10% of the intravascular volume, hemoglobin level on day 5 postop increased 0.74 g/dl on the average. In patients weighing less than 70 kg, transfusion increased hemoglobin level on day 5 postop 1.23 g/dl on the average. The probability of transfusion of more than 10% of the intravascular volume was 0.66 +/- 0.1 in patients weighing less than 70 kg and 0.33 +/- 0.05 for the entire population (p<0.001). The fall in mean hemoglobin level from day 0 to day 5 was 3.46 g/dl in transfused patients and 4.16 g/dl in non-transfused patients (p<0.0001). Reinfusion of shed blood allowed 80 more patients (20% of the 405 patients in this series) to maintain their hemoglobin level above 9 g/dl on day 5 postop. The probability of homologous blood transfusion for serum hemoglobin<8 g/dl was 0.5 +/- 0.08. Applying this probability in a situation without recovery of shed blood, the total number of homologous blood transfusions would have increased from 4.9% to 10.7% (p<0.01). DISCUSSION: Patient follow-up confirmed the absence of specific problems. Mean transfusion volume was 516 ml with a 59% (mean) reinfusion/drainage ratio, in line with data reported in the literature. The efficacy of the blood conservation system was unpredictable due to the wide range of blood volume transfused, and consequently of hemoglobin transfused, related to wide interindividual variability for total blood loss and drainage volume. Since the mean volume of reinfused blood contained the same quantity of hemoglobin as one packed red cell units, it would appear reasonable to take 10% of theoretical intravascular volume as a threshold above which the transfusion method becomes efficacious. CONCLUSION: Considerable interindividual variability in total blood loss and total drainage volume compromises the overall efficacy of blood conservation systems. Increase in hemoglobin level on day 5 postop was vary variable in this series of reinfused knee arthroplasty patients (range 0.18 - 2.74 g/dl) with a mean of 0.97 g/dl which corresponds to one packed red cell unit. The probability that the transfused volume would be greater than 10% of the theoretical intravascular volume was 0.66 +/- 0.1 in patients weighing less than 70 kg versus 0.33 +/- 0.05 for the entire population (p<0.001). This finding would suggest that a blood conservation system should be used routinely in patients weighing less than 70 kg. Conversely, the use of the system as a routine measure for all knee arthroplasty patients with the aim of limiting the risk of homologous blood transfusion to a minimum would divide the risk by two and also avoid the risk of viral contamination and identification errors.

Aged↗
PubMed2002

Functional restoration by excision arthroplasty in temporomandibular joint ankylosis--a report of 35 cases.

OBJECTIVE: To evaluate the long term functional results of excision arthroplasty in treatment of temporomandibular joint (TMJ) ankylosis. MATERIAL AND METHODS: This retrospective study includes 35 patients of TMJ ankylosis who were treated by excision arthroplasty and followed for a maximum period of eight years after surgery. Past trauma was documented as a major etiological factor in 63% cases. Fibrous ankylosis & unilateral involvement was found to be more common. Peroperatively a gap of 1 1/2 to 2 cm was created. The results were assessed according to a criteria based on inter-incial month opening, deviation of jaw and complications. They were satisfactory in 29 cases and there were 3 recurrences. CONCLUSION: Childhood trauma is a major cause of TMJ ankylosis in India. Long term results of excision arthroplasty are satisfactory & comparable to other surgical modalities that are in vogue, provided the patients are operated when young, the ankylosis is in early stage, gap created is adequate and post operative exercise regimen is followed diligently.

Adolescent↗
PubMed2002

[Total hip arthroplasty and problems encountered in patients with high-riding developmental dysplasia of the hip].

OBJECTIVES: We evaluated total hip arthroplasty in patients with high-riding developmental dysplasia of the hip with regard to surgical method and modifications, problems encountered during surgery, and follow-up results. METHODS: A total of 42 hips (22 Crowe type III, 20 type IV) of 31 patients (29 women, 2 men; mean age 45.7 years; range 26-70 years) who underwent total hip arthroplasty were clinically and radiologically evaluated. In all cases, cementless acetabular components were placed in the true acetabulum. Fifteen acetabula required structural autografts. Cementless stems were used on the femoral side. Proximal metaphyseal step-cut osteotomy was performed in patients with high-riding hips of more than 4 cm. The mean follow-up period was 54.7 months (range 11 to 127 months). RESULTS: The mean Harris hip score increased from 37.6 preoperatively to 91.02 at the end of follow-up. No acetabular autograft resorption or non-union were observed. Non-union and delayed union in the femoral osteotomy site were encountered in two patients, respectively. Two components (1 acetabular, 1 femoral) were revised during the follow-up period. Two sciatic and two femoral temporary nerve palsies occurred. One patient developed superficial infection and was treated by debridement and antibiotics. Brooker type I heterotopic ossification was observed in seven patients. CONCLUSION: Total hip arthroplasty proved successful in high-riding developmental dysplasia of the hip.

Acetabulum↗
PubMed2002

[Cemented total hip arthroplasty for severe dysplasia or congenital dislocation of the hip].

OBJECTIVES: We evaluated total hip arthroplasty and short-term results in the treatment of coxarthrosis due to neglected congenital dislocation or severe dysplasia of the hip. METHODS: Cemented total hip arthroplasty was performed in 23 hips of 22 patients (2 men, 20 women; mean age 48.6 years; range 28 to 65 years) with osteoarthrosis due to congenital dislocation or severe dysplasia of the hip. The acetabular component was placed at the level of the true acetabulum; four patients required augmentation with autogenous bone grafts due to severe acetabular deficiency. Femoral shortening osteotomy using a subtrochanteric step-cut osteotomy was performed in seven patients with high-riding hips. Five patients underwent proximal femoral shortening after the trochanter major was osteotomized and distally advanced. All patients were evaluated with the use of the Merle d'Aubigne and Postel hip scores. Radiologic evaluations were made by preoperative and follow-up radiographs. The mean follow-up was 52.8 months (range 30 to 108 months). RESULTS: According to the Merle d'Aubigne and Postel hip scores, the results were excellent in 17 hips (74%), good in four hips (18%), fair in one hip (4%), and poor in one hip (4%). One hip required revision because of nonunion of the acetabular graft. The femoral stem was fractured in one patient. Complications included temporary sciatic nerve palsy in one patient, deep venous thrombosis in one patient, early dislocation in one patient, and nonunion of the femur in one patient who underwent subtrochanteric step-cut osteotomy. CONCLUSION: Total hip arthroplasty for congenitally dislocated or severely dysplastic hips is more effective than other treatment methods. Long-term results can be improved by the use of contemporary cementing techniques.

Acetabulum↗
PubMed2002

Total knee arthroplasty after failed dome osteotomy.

A retrospective, clinical and radiographic analysis was done between a study group of 15 patients with 17 total knee arthroplasties done following failed, proximal-tibial dome osteotomies and a control group of 14 patients with 17 primary arthroplasties. The groups were matched according to age of patients, type of prosthesis, primary disease and length of follow-up. The average length of follow-up was 59.4 months (range, 25-146 mo) in the study group and 62.3 months (range, 43-140 mo) in the control group. On the basis of the knee rating scale of the American Knee Society, 94% of the patients had either an excellent or a good result in the study group. There were no significant differences in knee scores, function scores, or range of motion of the knee between the two groups during the follow-up period. Although two overcorrected valgus knees and one severe varus knee necessitated an autogeneic bone graft for tibial defects at the time of implantation of the secondary prosthesis, dome osteotomy does not appear to compromise a subsequent arthroplasty.

Aged↗
PubMed2002

Total hip arthroplasty for a patient with angel-shaped phalango-epiphyseal dysplasia (ASPED). A case report.

Angel-shaped phalango-epiphyseal dysplasia is characterized by the angel shape of the middle phalanx and severe coxarthrosis in adult life. This osteochondrodysplasia shows a further variety of heterogeneous multiple epiphyseal dysplasias. It also shows a late and dysplastic development of the femoral head that leads to osteoarthrotic changes with severe hip pain and gait disturbance. In this report, we show a 35-year-old female with Angel-shaped phalango-epiphyseal dysplasia that was treated by bilateral total hip arthroplasty. She has suffered from her coxalgia since she was 27 and since the age of 30 has been able to walk with the aid of crutches. The radiographs of her bilateral hip showed severe osteochondrotic changes with a progressive disappearance of the joint space. Total hip arthroplasties were performed to treat the osteoarthrosis on the bilateral hip joint due to Angel-shaped phalango-epiphyseal dysplasia. One year after surgery, she is pain-free, and able to walk with a cane. Based on this case, we propose that total hip arthroplasty should be considered one of the treatments for the coxopathy in patients with Angel-shaped phalangoepiphyseal dysplasia.

Adult↗
PubMed2003

Metacarpophalangeal joint arthroplasty in rheumatoid arthritis.

In patients with rheumatoid arthritis, metacarpophalangeal joint deformities can significantly affect hand function. Flexible hinge implant arthroplasty, designed in the 1960s, remains the most accepted and widely performed technique for treatment of severely involved metacarpophalangeal joints in rheumatoid arthritis. An arc of motion of 40 degrees to 60 degrees can be expected after arthroplasty, with improvement of finger extension and ulnar deviation. Silicone implant arthroplasty, although technically challenging, is the standard surgical procedure for improving hand function in these patients. Complications include recurrent ulnar deviation, extensor lag, implant fracture, infection, and silicone-induced particulate synovitis. Despite these limitations, patient satisfaction is high with enhancement of hand appearance and function and relief of pain.

Arthritis, Rheumatoid↗
PubMed2003

Cementless revision for infection following total hip arthroplasty.

Eradication of chronic infection complicating total hip arthroplasty requires removal of all infected, devitalized and foreign tissue, including the arthroplasty components. Reimplantation into a sterile bed is the goal of treatment in most patients and successful reimplantation yields better functional results than excision arthroplasty. Reimplantation may be performed at the same stage as débridement as part of a single-stage procedure, using cemented components with antibiotic-loaded cement. Alternatively, a two-stage procedure may be performed so that the débridement and reimplantation are separated by a period of antibiotic delivery, both locally and systemically. The results of these treatment regimens and the rationale for cementless reconstruction at the second stage of a two-stage treatment protocol are important considerations in the treatment of periprosthetic infection.

Anti-Bacterial Agents↗
PubMed2002

Radiographic evaluation of periprosthetic metallosis after total knee arthroplasty.

This retrospective study examined the clinical significance of a radiographic sign associated with periprosthetic metallosis after total knee arthroplasty. Of 71 knees undergoing revision arthroplasty over an 8-year period, 11 had gross evidence of metal debris identified intraoperatively. Histologic preparations confirmed the presence of particulate metal debris in all cases. Radiographs in 7 of 11 cases were positive for metallosis. The radiographic sign identified on lateral radiographs was divided into 3 types based on the size of the mass. The magnitude of soft tissue pathology and the extent of osteolysis correlated with the size of the mass on preoperative radiographs. Replacement of all components was necessary in 71% of cases with radiographs positive for metallosis and 47% of cases with negative radiographs. Only 1 of the 11 knees with metallosis had a late postoperative infection, for which 2-stage revision arthroplasty was required. All cases with positive radiographs had gross and histologic confirmation of metal and polyethylene debris. These data suggest that careful assessment of radiographs can facilitate preoperative planning.

Aged↗
PubMed2003

[Acute normovolemic hemodilution combined with inhibition of fibrinolysis and use of cell saver in total hip arthroplasty].

INTRODUCTION: Transfusion with homologous blood is not without costs for the recipient: An increased risk of postoperative infections must be anticipated, and the risk of transfusion-transmitted viral infections is of growing concern. This has increased the interest for methods which can reduce the need for intraoperative blood transfusion. The goal of this study was to determine if acute normovolemic hemodilution combined with fibrinolytic inhibition and the use of cell saver can reduce the need for homologous blood transfusion in total hip arthroplasty compared to the cellsaver technique alone. MATERIAL AND METHODS: 145 patients undergoing total hip arthroplasty in spinal anesthesia were included in the study. They were all operated by the same surgeon. In group A (N = 64) only the cell saver was used, whereas in group B (N = 81) it was combined with acute normovolemic hemodilution and use of the fibrinolytic inhibitor tranexamic acid. RESULTS: The total blood loss and the need for homologous blood transfusion were significantly smaller in group B than in group A. DISCUSSION: Although the cell saving technique is effective in total hip arthroplasty, this study demonstrates that a further reduction of blood loss and homologous blood transfusion can be achieved by combining the method with acute normovolemic hemodilution and pharmacological inhibition of fibrinolysis.

Antifibrinolytic Agents↗
PubMed2003

Reactive pelvic cyst following total hip arthroplasty. A case report.

A 77-year-old woman presented with an intrapelvic cyst which had developed secondary to polyethylene wear of the socket after total hip arthroplasty. This reactive cyst surrounded polymethylmethacrylate cement fragments due to excessive penetration in the pelvis during the initial procedure 20 years previously. This pelvic mass was responsible for gynaecologic symptoms. The cyst was resected in a first stage. Revision hip arthroplasty is scheduled because of cup wear and progressive femoral osteolysis. Cement extrusion must be avoided during total hip arthroplasty to prevent pelvic complications, since these problems can present even several years later. Cement intrusion into the pelvis possibly opens up a pathway for polyethylene wear particles to migrate into the pelvis.

Aged↗
PubMed2003

Hybrid total hip arthroplasty: state-of-the-art in the new millennium?

Clinical results from the past 30 years have proven total hip arthroplasty (THA) to be an effective technique for treating arthritic and degenerative conditions of the hip. Though there is little question concerning the effectiveness THA in general, significant debate exists concerning the best technique for performing the procedure. Sir John Chamley's concept of low-friction arthroplasty (LFA), considered to be the gold standard for THA, employs a cemented fixation technique for both the femoral and acetabular components. Over time, the merits of cemented fixation have been called into question as significant percentages of LFA implants failed and required revision surgery. Hybrid total hip arthroplasty is a variation of LFA that employs cemented fixation of the femoral component with cementless fixation of the acetabular component. Intermediate-term clinical results of hybrid THA have shown it to be a promising technique, with revision rates of both the femoral and acetabular components superior to Chanley LFA studies at similar lengths of follow-up. Though these results are encouraging, long-term data from the hybrid THA studies are required before a conclusion can be made as to whether the hybrid method is in fact superior to the LFA technique for performing THA.

Arthroplasty, Replacement, Hip↗
PubMed2003

Cemented total hip arthroplasty: still relevant in the new millennium?

Total hip arthroplasty can be performed successfully using cement or cementless technology. Cemented femoral stems can achieve enduring long-term suvivorship as long as meticulous surgical technique is utilized and patient selection is appropriate. Cemented acetabular components should only be utilized in patients with less than 10 years of remaining life expectancy. Critical risk factors for cemented total hip arthroplasty include atrophic osteoarthrtis on the acetabular side and unfavorable femoral geometry for the femoral stem such as "the stove-pipe" canal. Rapid polyethylene wear and osteolysis are rarely seen in contemporary cemented total hip arthroplasty performed with a smooth, tapered, collarless femoral stem with a highly polished head and a well-designed acetabular component.

Arthroplasty, Replacement, Hip↗
PubMed2000

[Follow-up study of total condylar knee arthroplasty with three types of Chinese knee prosthetics].

OBJECTIVE: To clinical evaluate the results of total condylar knee arthroplasty using three types of Chinese knee prosthesis. METHODS: Hundred and two knees (in 92 patients) arthroplasty were performed in our department during the 14 years (April 1981-November 1995) were analyzed. The follow-up period averaged 64.4 months. Eight cases had died and 14 cases were lost of follow-up, leaving 80 knees in 70 patients for clinical evaluation. The clinical results were evaluated according to Hospital for Special Surgery Rating System. RESULTS: The average preoperative score was 47.65 and the postoperative score was 90.23. Almost all patients achieved significant pain relief after operation. Sixty-one of the 70 patients (87%) reported that they satisfied or very satisfied with the results of surgery. There were 6 failures. One was due to deep infection, one with loose patellar component, and four directly related to either improper selection or technical reasons. CONCLUSIONS: Total condylar knee arthroplasty with Chinese knee prosthetics gives a satisfactory grade of pain relief and movement of the operated knee. Chinese knee prosthetics is safety and durable.

Adult↗
PubMed2003

Revision total knee arthroplasty.

BACKGROUND: Revision total knee arthroplasties are performed with increasing frequency due to the increasing numbers of primary arthroplasties. OBJECTIVES: To retrospectively analyze 71 patients who underwent 78 revision total knee arthroplasties during the years 1991 to 1999 METHODS: We evaluated the revised knees using the Knee Society Clinical Rating System after an average follow-up period of 3 years and 9 months (2-10 years). The indications for revision included pain and instability, deep infection of the joint, complaints linked to the patella, or post-trauma to the operated knee. RESULTS: The average knee score (evaluation of the knee joint itself) calculated after the revision was 74.5. The results on the knee score were excellent (> 85) in 48% of patients and poor (< 60) in 22%. The functional results (patient's ability to walk and climb stairs) were only 48.3. CONCLUSION: Although the revision of total knee replacements is known to be problematic, most patients show good results on knee examination, and reasonable functional results given the factors involved.

Aged↗
PubMed2003

Mini-invasive knee unicompartmental arthroplasty: bone-sparing technique.

Total knee replacement (TKR) has been well accepted as the definitive knee- salvage procedure. Existence of a predictable, reproducible, salvage procedure has allowed for re-evaluation of other surgical techniques, such as unicompartmental arthroplasty, to prolong or preserve knee function. Knee osteoarthritis has been described as highly segmental, primarily medial, and slowly progressive. Loss of articular cartilage is compensated by development of sclerotic bone, which although it supports weight, it deforms with weight-bearing and produces pain. Ligament imbalance is not compensated. A mini-invasive knee arthroplasty has been developed that features the following three criteria: (1) minimizes physiologic damage, (2) minimizes interference in life style, and (3) avoids interference with future treatment options. Unicompartmental knee arthroplasty can, therefore, be performed as a low-morbidity outpatient procedure while preserving bone for future TKR--in essence, a pre-TKR procedure. Techniques include limited surgical exposure, internal landmarks for prosthetic insertion, and pain management to facilitate out-patient status.

Adult↗