Mortality following primary total knee arthroplasty.

BACKGROUND: Total joint arthroplasty is one of the most successful orthopaedic surgical procedures. However, it carries a risk of perioperative mortality. The purpose of this study was to determine the mortality rate for patients undergoing primary total knee arthroplasty in a private-practice setting involving one surgeon in a nonteaching institution. METHODS: We analyzed 3048 consecutive primary total knee arthroplasties, performed between July 1976 and December 1996, with respect to mortality data (deaths that occurred intraoperatively, during hospitalization, and within ninety days after surgery) and comorbidities (major cardiovascular disease). RESULTS: The mortality rate was 0.46% (fourteen patients; one death per 217 procedures) within ninety days after primary total knee arthroplasty. CONCLUSIONS: Increasing patient age and the presence of associated cardiovascular comorbidities were identified as risk factors for mortality. This information, we believe, is useful to patients, their families, physicians, and health-care planners in deciding when a total knee arthroplasty is appropriate. LEVEL OF EVIDENCE: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

Conversion of a fused hip to total hip arthroplasty.

BACKGROUND: Arthrodesis of the hip remains a viable treatment for severe unilateral arthritis after traumatic injury or infection in a young but otherwise healthy individual. The goal of the present study was to review the long-term clinical and radiographic results after conversion of a fused hip to a total hip arthroplasty and to identify the risk factors that would lead to a higher rate of failure. METHODS: We performed a retrospective review of the charts and radiographs of 187 patients (208 hips) who had conversion of a fused hip to a total hip arthroplasty. The mean duration of follow-up after the conversion to total hip arthroplasty was 9.2 years (range, two to twenty-six years). RESULTS: The mean age at time of the arthroplasty was fifty-one years. The mean time-interval between the arthrodesis and the conversion to a total hip arthroplasty was twenty-seven years. According to the information in the charts, at a mean duration of follow-up of 9.2 years after the total hip arthroplasty, 79% of hips were either pain-free or had minimal pain, 83% had good-to-excellent function, and 79% had good-to-excellent range of motion. Complications, which included fifteen nerve palsies, occurred in twenty-four hips. Twenty-eight hips had heterotopic ossification, but it was not associated with a recurrence of ankylosis or a marked reduction of motion. Revision arthroplasty was performed in twelve hips. The probability of survival of the implant was 96.1% (95% confidence interval, 91.5% to 98.2%) at ten years, 89.9% (95% confidence interval, 85.3% to 96.1%) at fifteen years, and 72.8% (95% confidence interval, 36% to 90.6%) at twenty-six years. CONCLUSIONS: Conversion of a fused hip to a total hip arthroplasty has a favorable outcome. However, the technically demanding nature of the procedure should not be underestimated. Patients should be cautioned with regard to the possibility of a higher rate of complications than that seen with primary total hip arthroplasty.

Total knee arthroplasty in nonagenarians.

Between 1976 and 1999, 3714 consecutive primary total knee arthroplasties (TKAs) were done at our institution. Of these, 20 (0.54%) TKAs were done in 18 patients who were > or =90 years old. The average follow-up period was 62.2 months. There was 1 postoperative death among the nonagenarians within 90 days of surgery. All patients had complete pain relief and excellent knee scores using the Knee Society clinical assessment scale. None had an excellent function score at final follow-up examination, however. Only 1 patient experienced any surgical complications; the patient had wound dehiscence. Five (26.3%) of the surviving 19 patients had medical complications. The average length of hospital stay was 10.1 days. Although TKA produced only moderate improvement in knee function for the nonagenarians, it produced excellent clinical improvement. TKA improved the patients' ability to manage the activities of daily living and their quality of life.

Outcome in patients lost to follow-up.

Long-term outcome studies are valuable for providing information on the results of joint arthroplasty. However, a progressively increasing rate of attrition correlates with the length of study. The attrition rate of patients "lost to follow-up" ("non-attenders") may have a significant effect on the reported outcome. The goal of this study was to analyze the effect of the outcome in patients lost to follow-up on analysis in the setting of total knee arthroplasty. We found a lower rate of failure for revision surgery and higher satisfactory results in "non-attenders" compared with patients completing follow-up. No statistical effect of loss to follow-up care was noted on survivorship analysis when revision surgery or revision plus severe pain were considered as end points. Therefore, the patients who do not attend follow-up visits do not necessarily have poor results.

Results for a custom acetabular component for acetabular deficiency.

We report our experience with a triflanged titanium cementless custom-made acetabular implant in the management of complex major acetabular deficiency for revision total hip arthroplasty in 27 patients. The mean follow-up period was 58 months (range, 48-72 months). There were 9 men and 18 women. Clinical assessment was performed using Charnley's modification of the Merle d'Aubigne and Postel scoring system. Radiographic assessment was carried out using the DeLee and Charnley grading system. All patients had improved hip scores at latest examination. Six patients (22%) had complications. Two patients (7.4%) required further revision surgery. This procedure is technically demanding and has a high complication rate. Until better long-term results are shown, this procedure should be restricted to patients for whom a Girdlestone pseudarthrosis is the only surgical alternative.

Total hip arthroplasty in ankylosing spondylitis: an analysis of 181 hips.

The results of cemented total hip arthroplasty (THA) in patients with ankylosing spondylitis were studied to determine the utility of THA for these patients. A total of 103 patients with ankylosing spondylitis underwent 181 THAs; 72 patients (69.9%) had bilateral surgery. The mean follow-up was 10.3 years. The mean age of patients at surgery was 47 years. Before surgery, 42 hips (23.2%) were ankylosed. Revision surgery was carried out in 25 hips (13.8%). Heterotopic ossification was present in 21 hips (11.6%); however, no patients had functional impairment or reankylosis. At final follow-up examination, 173 hips (96%) had an excellent (low) pain score, and 53 hips had a normal or near-normal function score (29.2%). The probability of survival of the implant was 71% at 27 years. THA provides long-term improvement in hip function for patients with ankylosing spondylitis.