RESUMO
AIMS: Despite declining frequency of blood transfusion and electrolyte supplementation following total joint arthroplasty, postoperative blood analyses are still routinely ordered for these patients. This study aimed to determine the rate of blood transfusion and electrolyte restoration in arthroplasty patients treated with a perioperative blood conservation protocol and to identify risk factors that would predict the need for transfusion and electrolyte supplementation. PATIENTS AND METHODS: Patients undergoing primary total joint arthroplasty of the hip or knee between July 2016 and February 2017 at a single institution were included in the study. Standard preoperative and postoperative laboratory data were collected and reviewed retrospectively. A uniform blood conservation programme was implemented for all patients. Need for blood transfusion or potassium supplementation was determined through a coordinated decision by the care team. Rates of transfusion and supplementation were observed, and patient risk factors were noted. RESULTS: The overall rate of blood transfusion was 1.06% in the study population of 1132 total joint arthroplasties performed in 1023 patients. Of the 12 patients requiring transfusion, 11 were female, ten occurred in patients undergoing total hip arthroplasty, and all 12 patients had a preoperative haemoglobin level less than 130 g/l. Operative duration and surgical blood loss were significantly greater in those patients requiring blood transfusion. Nearly all patients requiring transfusion had a history of, or risk factors for, cardiovascular disease. Potassium supplementation was required in 15.5% of the study cohort; 72% of these patients receiving potassium presented with a potassium level less than 4 mmol/l during preoperative testing, while the remaining 28% had a past medical history of either significant anaemia, cardiopulmonary, cardiovascular, or renal diseases that had required substantial medical management. CONCLUSION: A consistent blood-conserving perioperative strategy effectively minimized need for blood transfusion in total joint arthroplasty patients below previously reported rates in the literature. We suggest that postoperative full blood counts and basic metabolic panels should not routinely be ordered in these patients unless their preoperative haemoglobin and potassium is below 130 g/dl or 4 mmol/l respectively, and they have medical comorbidities.
Assuntos
Artroplastia de Quadril , Artroplastia do Joelho , Perda Sanguínea Cirúrgica/prevenção & controle , Hemoglobinas/análise , Potássio/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue/estatística & dados numéricos , Suplementos Nutricionais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/métodos , Potássio/uso terapêutico , Estudos Retrospectivos , Fatores de RiscoRESUMO
AIMS: Whether patient-reported pain differs among surgical approaches in total hip arthroplasty (THA) remains unclear. This study's purposes were to determine differences in pain based on surgical approach (direct anterior (DA) vs posterolateral (PL)) and PL approach incision length. PATIENTS AND METHODS: This was a retrospective investigation from two centres and seven surgeons (three DA, three PL, one both) of primary THAs. PL patients were categorized for incision length (6 cm to 8 cm, 8 cm to 12 cm, 12 cm to 15 cm). All patients had cementless femoral and acetabular fixation, at least one year's follow-up, and well-fixed components. Patients completed a pain-drawing questionnaire identifying the location and intensity of pain on an anatomical diagram. Power analysis indicated 800 patients in each cohort for adequate power to detect a 4% difference in pain (alpha = 0.05, beta = 0.80). RESULTS: A total of 1848 patients (982 DA, 866 PL) were included. PL patients were younger (59.4 years, sd 12.9 vs 62.7 years, sd 9.7; p < 0.001) and had shorter follow-up (3.3 years, sd 1.3 vs 3.7 years, sd 1.3; p < 0.001). DA patients reported decreased moderate to severe trochanteric (14% vs 21%; p < 0.001) and groin pain (19% vs 24%; p = 0.004) than PL patients. There were no differences in anterior, lateral, or posterior thigh, back, or buttock pain between cohorts (p = 0.05 to 0.7). PL approach incision length did not impact the incidence or severity of pain (p = 0.3 to 0.7). CONCLUSION: A significant proportion of patients perceive persistent pain following THA regardless of approach. DA patients reported less trochanteric and groin pain versus PL patients. PL incision length did not influence the incidence or severity of patient-reported pain. Cite this article: Bone Joint J 2019;101-B(6 Supple B):31-36.
Assuntos
Artroplastia de Quadril/métodos , Percepção da Dor/fisiologia , Dor Pós-Operatória/fisiopatologia , Artroplastia de Quadril/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor Musculoesquelética/etiologia , Dor Musculoesquelética/fisiopatologia , Medição da Dor , Dor Pós-Operatória/etiologia , Estudos Retrospectivos , AutorrelatoRESUMO
AIMS: Few reconstructive techniques are available for patients requiring complex acetabular revisions such as those involving Paprosky type 2C, 3A and 3B deficiencies and pelvic discontinuity. Our aim was to describe the development of the patient specific Triflange acetabular component for use in these patients, the surgical technique and mid-term results. We include a description of the pre-operative CT scanning, the construction of a model, operative planning, and surgical technique. All implants were coated with porous plasma spray and hydroxyapatite if desired. PATIENTS AND METHODS: A multicentre, retrospective review of 95 complex acetabular reconstructions in 94 patients was performed. A total of 61 (64.2%) were female. The mean age of the patients was 66 (38 to 85). The mean body mass index was 29 kg/m2 (18 to 51). Outcome was reported using the Harris Hip Score (HHS), complications, failures and survival. RESULTS: The mean follow-up was 3.5 years (1 to 11). The mean HHS improved from 46 (15 to 90) pre-operatively to 75 (14 to 100). A total of 21 hips (22%) had at least one complication with some having more than one; including dislocation (6%), infection (6%), and femoral complications (2%). The implant was subsequently removed in five hips (5%), only one for suspected aseptic loosening. CONCLUSION: The Triflange patient specific acetabular component provides predictable fixation with complication rates which are similar to those of other techniques. Cite this article: Bone Joint J 2018;100-B(1 Supple A):50-4.
Assuntos
Acetábulo/cirurgia , Artroplastia de Quadril/instrumentação , Prótese de Quadril , Desenho de Prótese , Reoperação/instrumentação , Acetábulo/diagnóstico por imagem , Acetábulo/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/métodos , Feminino , Seguimentos , Humanos , Imageamento Tridimensional , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/epidemiologia , Cuidados Pré-Operatórios , Falha de Prótese , Reoperação/métodos , Estudos Retrospectivos , Tomografia Computadorizada por Raios XRESUMO
AIMS: To examine incidence of complications associated with outpatient total hip arthroplasty (THA), and to see if medical comorbidities are associated with complications or extended length of stay. PATIENTS AND METHODS: From June 2013 to December 2016, 1279 patients underwent 1472 outpatient THAs at our free-standing ambulatory surgery centre. Records were reviewed to determine frequency of pre-operative medical comorbidities and post-operative need for overnight stay and complications which arose. RESULTS: In 87 procedures, the patient stayed overnight for 23-hour observation, with 39 for convenience reasons and 48 (3.3%) for medical observation, most frequently urinary retention (13), obstructive sleep apnoea (nine), emesis (four), hypoxia (four), and pain management (six). Five patients (0.3%) experienced major complications within 48 hours, including three transferred to an acute facility; there was one death. Overall complication rate requiring unplanned care was 2.2% (32/1472). One or more major comorbidities were present in 647 patients (44%), including previous coronary artery disease (CAD; 50), valvular disease (nine), arrhythmia (219), thromboembolism history (28), obstructive sleep apnoea (171), chronic obstructive pulmonary disease (COPD; 124), asthma (118), frequent urination or benign prostatic hypertrophy (BPH; 217), or mild chronic renal insufficiency (11). CONCLUSION: The presence of these comorbidities was not associated with medical or surgical complications. However, presence of one or more major comorbidity was associated with an increased risk of overnight observation. Specific comorbidities associated with increased risk were CAD, COPD, and frequent urination/BPH. Outpatient THA is safe for a large proportion of patients without the need for a standardised risk assessment score. Risk of complications is not associated with presence of medical comorbidities. Cite this article: Bone Joint J 2018;100-B(1 Supple A):31-5.
Assuntos
Procedimentos Cirúrgicos Ambulatórios , Artroplastia de Quadril/métodos , Tempo de Internação , Complicações Pós-Operatórias/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/epidemiologia , Fatores de RiscoRESUMO
AIMS: An evidence-based radiographic Decision Aid for meniscal-bearing unicompartmental knee arthroplasty (UKA) has been developed and this study investigates its performance at an independent centre. PATIENTS AND METHODS: Pre-operative radiographs, including stress views, from a consecutive cohort of 550 knees undergoing arthroplasty (UKA or total knee arthroplasty; TKA) by a single-surgeon were assessed. Suitability for UKA was determined using the Decision Aid, with the assessor blinded to treatment received, and compared with actual treatment received, which was determined by an experienced UKA surgeon based on history, examination, radiographic assessment including stress radiographs, and intra-operative assessment in line with the recommended indications as described in the literature. RESULTS: The sensitivity and specificity of the Decision Aid was 92% and 88%, respectively. Excluding knees where a clear pre-operative plan was made to perform TKA, i.e. patient request, the sensitivity was 93% and specificity 96%. The false-positive rate was low (2.4%) with all affected patients readily identifiable during joint inspection at surgery. In patients meeting Decision Aid criteria and receiving UKA, the five-year survival was 99% (95% confidence intervals (CI) 97 to 100). The false negatives (3.5%), who received UKA but did not meet the criteria, had significantly worse functional outcomes (flexion p < 0.001, American Knee Society Score - Functional p < 0.001, University of California Los Angeles score p = 0.04), and lower implant survival of 93.1% (95% CI 77.6 to 100). CONCLUSION: The radiographic Decision Aid safely and reliably identifies appropriate patients for meniscal-bearing UKA and achieves good results in this population. The widespread use of the Decision Aid should improve the results of UKA. Cite this article: Bone Joint J 2016;98-B(10 Suppl B):3-10.
Assuntos
Artroplastia do Joelho/métodos , Técnicas de Apoio para a Decisão , Hemiartroplastia/métodos , Osteoartrite do Joelho/diagnóstico por imagem , Osteoartrite do Joelho/cirurgia , Seleção de Pacientes , Idoso , Artrografia/métodos , Artroplastia do Joelho/reabilitação , Medicina Baseada em Evidências/métodos , Feminino , Hemiartroplastia/reabilitação , Humanos , Articulação do Joelho/diagnóstico por imagem , Articulação do Joelho/fisiopatologia , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/fisiopatologia , Recuperação de Função Fisiológica , Sensibilidade e Especificidade , Resultado do TratamentoRESUMO
AIMS: Since redesign of the Oxford phase III mobile-bearing unicompartmental knee arthroplasty (UKA) femoral component to a twin-peg design, there has not been a direct comparison to total knee arthroplasty (TKA). Thus, we explored differences between the two cohorts. PATIENTS AND METHODS: A total of 168 patients (201 knees) underwent medial UKA with the Oxford Partial Knee Twin-Peg. These patients were compared with a randomly selected group of 177 patients (189 knees) with primary Vanguard TKA. Patient demographics, Knee Society (KS) scores and range of movement (ROM) were compared between the two cohorts. Additionally, revision, re-operation and manipulation under anaesthesia rates were analysed. RESULTS: The mean follow-up for UKA and TKA groups was 5.4 and 5.5 years, respectively. Six TKA (3.2%) versus three UKAs (1.5%) were revised which was not significant (p = 0.269). Manipulation was more frequent after TKA (16; 8.5%) versus none in the UKA group (p < 0.001). UKA patients had higher post-operative KS function scores versus TKA patients (78 versus 66, p < 0.001) with a trend toward greater improvement, but there was no difference in ROM and KS clinical improvement (p = 0.382 and 0.420, respectively). CONCLUSION: We found fewer manipulations, and higher functional outcomes for patients treated with medial mobile-bearing UKA compared with TKA. TKA had twice the revision rate as UKA although this did not reach statistical significance with the numbers available. Cite this article: Bone Joint J 2016;98-B(10 Suppl B):28-33.
Assuntos
Artroplastia do Joelho/instrumentação , Prótese do Joelho , Osteoartrite do Joelho/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia do Joelho/métodos , Artroplastia do Joelho/reabilitação , Feminino , Humanos , Articulação do Joelho/fisiopatologia , Masculino , Pessoa de Meia-Idade , Medição da Dor/métodos , Desenho de Prótese , Falha de Prótese , Amplitude de Movimento Articular , Sistema de Registros , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Immunocompromised organ transplant recipients have a high incidence of B cell lymphomas (BCL). Severe combined immunodeficient (SCID) mice develop human BCL when engrafted with Epstein-Barr virus (EBV) transformed and immortalized B lymphoblastoid cell lines (BLCL). Because a lack of effective EBV-specific cytotoxic T lymphocytes (EBV-CTL) is thought to lead to lymphoma development, the SCID mouse model was used to determine the relationship between EBV-infected B cells and EBV-specific CTL in BCL development in vivo. METHODS: EBV-CTL were generated by in vitro stimulation of peripheral blood leukocytes with autologous BLCL. CD8+ CTL were isolated from CTL populations by depletion of CD4+ cells. SCID mice were engrafted with BLCL, EBV-CTL were adoptively transferred into engrafted SCID mice either immediately or 7 days after engraftment, and the animals were monitored for the development of BCL. Statistical significance was determined by the log rank test. RESULTS: SCID mice engrafted with BLCL rapidly developed BCL (mean, 20 days). SCID mice engrafted with BLCL and human leukocyte antigen-identical EBV-CTL or CD8+ EBV-CTL had a significant delay in BCL development (p < 0.05), whereas some mice did not develop BCL. In contrast, human leukocyte antigen-nonidentical EBV-CTL did not significantly delay BCL development. CONCLUSIONS: This study showed the role of EBV-CTL in inhibiting the development of BCL. A greater understanding of the cellular and viral interactions leading to B-cell transformation and malignancy may allow the development of specific interventional therapies in patients who have received immunosuppressants.
Assuntos
Imunoterapia Adotiva , Linfoma de Células B/terapia , Transplante de Órgãos/efeitos adversos , Linfócitos T Citotóxicos/imunologia , Adulto , Animais , Linfócitos B/imunologia , Células-Tronco Hematopoéticas/imunologia , Herpesvirus Humano 4/genética , Herpesvirus Humano 4/imunologia , Humanos , Ativação Linfocitária , Camundongos , Camundongos SCIDRESUMO
BACKGROUND: B-cell lymphomas (BCL) occur with increased frequency in immunosuppressed patients. BCL develop in severe combined immunodeficient (SCID) mice after engraftment with human peripheral blood leukocytes (PBL; hu-PBL-SCID mice) and infection with Epstein-Barr virus (EBV). The contributions of latent and active EBV infection to BCL development, the potential enhancing effects of immunosuppressive therapy, and inhibitory effects of antiviral therapy on the development of BCL in this model were studied. METHODS: SCID mice were engrafted with PBL from EBV-seropositive donors (latent infection), PBL from EBV-seronegative donors followed by infection with EBV (active infection), PBL from EBV-seropositive donors followed by infection with EBV (latent plus active infection), or EBV-transformed B-lymphoblastoid cells and monitored for the development of BCL. Hu-PBL-SCID mice were treated with the immunosuppressive agents cyclosporine or methylprednisolone or the antiviral agents acyclovir or ganciclovir. RESULTS: Tumors developing in hu-PBL-SCID mice were high-grade lymphomas of human B-cell origin and contained EBV-DNA. BCL developed in 70% of mice 11 to 14 weeks after latent infection. BCL developed after 4 to 7 weeks in all hu-PBL-SCID mice after active infection. Treatment with cyclosporine or methylprednisolone had no effect on BCL development after active infection, but inhibited rather than enhanced the development of BCL in latently infected mice. Ganciclovir, but not acyclovir, inhibited BCL development after active infection. CONCLUSIONS: The hu-PBL-SCID mouse provides an in vivo model of BCL associated with immunosuppression. Active EBV infection results in the rapid development of BCL in this model even when latently infected B cells are present. Inhibition of BCL development in latently infected hu-PBL-SCID mice by immunosuppressive therapy may reflect inhibition of a T-cell/B-cell interaction necessary for B-cell activation. Inhibition of BCL development by granciclovir suggests a possible role for this agent in the management of BCL associated with immunosuppression.
Assuntos
Herpesvirus Humano 4 , Tolerância Imunológica , Linfoma de Células B/etiologia , Infecções Tumorais por Vírus/complicações , Doença Aguda , Aciclovir/uso terapêutico , Animais , Antivirais/uso terapêutico , Ganciclovir/uso terapêutico , Humanos , Imunossupressores/farmacologia , Linfoma de Células B/patologia , Linfoma de Células B/prevenção & controle , Camundongos , Camundongos SCID , Infecções Tumorais por Vírus/tratamento farmacológicoRESUMO
Chondrosarcoma, a malignant cartilage-forming mesenchymal tumor, displays a wide range of clinical behavior that can be difficult to predict with histological analysis. Matrix metalloproteinases contribute to the processes of local invasion and metastasis by controlling the ability of a tumor to transverse tissue boundaries. The specificity of matrix metalloproteinase-1 (interstitial collagenase) for fibrillar collagen may be central to those processes. Matrix metalloproteinase-2 facilitates invasion by degradation of such basement-membrane structures as type-IV collagen. The balance between the activity of tissue inhibitors of metalloproteinase and the activity of matrix metalloproteinase determines the proteolytic activity and may, in part, determine the overall invasiveness and potential for metastasis. The measurement of the ratio of matrix metalloproteinase to tissue inhibitor of metalloproteinase may have prognostic value for determining whether individual chondrosarcomas are locally invasive or will metastasize. Furthermore, there may be a specific pattern of expression of matrix metalloproteinase and tissue inhibitor of metalloproteinase in chondrosarcomas that is related to local invasion and probability of metastasis. Sixteen paraffin-embedded archival specimens of tumors were examined. Six twenty-micrometer-thick sections were cut from each tumor, and the amounts of cDNA formed from the mRNA were determined with reverse transcription-polymerase chain reaction with use of novel primers for matrix metalloproteinase-1, matrix metalloproteinase-2, tissue inhibitor of metalloproteinase-1, and tissue inhibitor of metalloproteinase-2. The amounts of cDNA for the matrix metalloproteinases and their inhibitors were determined by chemiluminescence and band densitometry. The ratio of the amount of cDNA for matrix metalloproteinase-1 to that for its tissue inhibitor and the ratio of the amount of cDNA for matrix metalloproteinase-2 to that for its tissue inhibitor were calculated, and the results were compared with use of the Student t test, enabling log-rank analysis of Kaplan-Meier survival curves. These ratios as well as the age and gender of the patient; the grade, size, and location of the tumor; the type of adjuvant therapy; and the operative margins were examined for significance with use of stepwise logistic-regression analysis. The patients who had recurrent disease had a significantly higher (p < 0.003) ratio of matrix metalloproteinase-1 to tissue inhibitor of metalloproteinase-1 (mean, 0.939; range, 0.647 to 1.101) than the patients who were free of disease (mean, 0.703; range, 0.629 to 0.772). Moreover, there was a striking difference between the Kaplan-Meier survival curve associated with a high ratio (more than 0.8) and that associated with a low ratio (p = 0.0015). The mean ratio of matrix metalloproteinase-2 to tissue inhibitor of metalloproteinase-2 was 1.814 (range, 1.206 to 3.77) in the patients who had recurrent disease compared with 1.473 (range, 1.073 to 2.390) in those who were free of disease; this difference was not found to be significant, with the numbers available. Analysis of the survival curves indicated that a worse prognosis was associated with a high ratio, but again this relationship was not found to be significant. Regression analysis revealed that a high ratio of matrix metalloproteinase-1 to its tissue inhibitor was a moderately significant independent predictor of a poor outcome (alpha = 0.07).
Assuntos
Neoplasias Ósseas/enzimologia , Neoplasias Ósseas/patologia , Condrossarcoma/enzimologia , Condrossarcoma/patologia , Colagenases/metabolismo , Inibidor Tecidual de Metaloproteinase-1/metabolismo , Adulto , Idoso , Neoplasias Ósseas/mortalidade , Condrossarcoma/mortalidade , DNA de Neoplasias/análise , Feminino , Humanos , Modelos Logísticos , Masculino , Metaloproteinase 1 da Matriz , Pessoa de Meia-Idade , Invasividade Neoplásica , Metástase Neoplásica , Recidiva Local de Neoplasia , Reação em Cadeia da Polimerase , Prognóstico , RNA Mensageiro/análise , RNA Neoplásico/análise , Especificidade por Substrato , Análise de SobrevidaRESUMO
The treatment of some mesenchymal malignancies has made significant gains over the past few decades with the development of effective systemic therapies. In contrast, the treatment of chondrosarcoma has been limited to surgical resection, with the most significant prognostic indicators being surgical margins and histologic grade. We have reported that MMP-1/TIMP-1 gene expression serves to prognosticate for tumor recurrence in this group of patients. This led to the hypothesis that collagenase activity facilitates cell egression from the cartilaginous matrix. In the current study we examine the specificity of collagenase gene expression in archival human chondrosarcoma samples using semi-quantitative PCR. Messenger RNA was affinity extracted and subject to reverse transcription. The subsequent cDNA was amplified using novel primers and quantitated by densitometry. Ratios of gene expression were constructed and compared to disease-free survival. The data demonstrate that the significance of the MMP-1/TIMP-1 ratio as a predictor of recurrence is confirmed with a larger number of patients. Neutrophil collagenase or MMP-8 was observed in only 5 of 29 samples. Collagenase-3 or MMP-13 was observed in all samples but the level did not correlate with disease-free survival. Since the collagenases have similar activity for fibrillar collagens and cleave the peptide in the same location, post-transcriptional regulatory mechanisms may account for the observed specificity. The determination of the MMP-1/TIMP-1 gene expression ratio not only serves to identify those patients at risk for recurrence but may also serve as a novel therapeutic avenue as an adjunct to surgical resection.
Assuntos
Neoplasias Ósseas/enzimologia , Neoplasias Ósseas/secundário , Condrossarcoma/enzimologia , Condrossarcoma/secundário , Colagenases/metabolismo , Regulação Enzimológica da Expressão Gênica , Colagenases/análise , Colagenases/genética , Intervalo Livre de Doença , Humanos , Prognóstico , Especificidade por Substrato/genéticaRESUMO
The current literature offers only sparse reports of the use of hip arthroscopy in the pediatric patient injured during athletics. In contrast, the role of this technique in the diagnosis and treatment of multiple childhood hip conditions including pyarthrosis, Legg-Calvé-Perthes disease, slipped capital femoral epiphysis, coxa vara, juvenile chronic arthritis, chondrolysis, and avascular necrosis is well described. The application of this relatively uncommon technique to the young athlete has only recently become more attractive. The ability to examine and treat traumatic intra-articular pathology with minimal morbidity and prompt recovery is mandated by the young age of these patients and their demanding activity levels. Hip arthroscopists are now beginning to correlate preoperative physical exam findings and history with diagnosis and expectations for outcome. As our combined experience with this technique grows, the specific indications for its use in the young athlete become increasingly better defined. In pediatric and adolescent patients, the new onset of hip pain should warrant a high level of suspicion for the more common causes of pain such as infection, Legg-Calvé-Perthes disease, slipped capital femoral epiphysis, or developmental dysplasia. When these have been evaluated, further differential diagnosis should include labral tears, loose bodies, synovitis, and chondral lesions. As this review begins to elucidate, these conditions are amenable to arthroscopic evaluation and treatment. At this time, the presence of reproducible mechanical symptoms after a twisting or axial loading injury during athletics should prompt the orthopaedic surgeon to consider arthroscopic examination of the hip if conservative therapy fails. Satisfying and reproducible results have been achieved when using hip arthroscopy within these parameters.
Assuntos
Artroscopia/métodos , Traumatismos em Atletas/cirurgia , Lesões do Quadril/cirurgia , Articulação do Quadril/cirurgia , Adolescente , Artralgia/etiologia , Traumatismos em Atletas/complicações , Traumatismos em Atletas/diagnóstico , Criança , Feminino , Lesões do Quadril/complicações , Lesões do Quadril/diagnóstico , Humanos , Doença de Legg-Calve-Perthes/complicações , Doença de Legg-Calve-Perthes/diagnóstico , MasculinoRESUMO
Over the past 30 years there have been many improvements in implant fixation, correction of deformity, improved polyethylene wear, and survival after knee replacement. The work over the last decade has focused on less invasive surgical techniques, multimodal pain management protocols, more rapid functional recovery and reduced length of stay, aiming to minimise the side effects of treatment while maintaining function and implant durability. When combined and standardised these pre-, intra- and post-operative factors have now facilitated outpatient knee replacement procedures for unicompartmental replacement, patella femoral arthroplasty and total knee replacement (TKR). We have found liposomal bupivacaine, with potential for longer therapeutic action, to be a helpful adjunct and describe our current pain management program. The next step in our multimodal program is to improve the duration of patient satisfaction and reduce cost and length of stay after TKR.
Assuntos
Gerenciamento Clínico , Dor Pós-Operatória/terapia , Artroplastia do Joelho , Humanos , Medição da DorRESUMO
The common recommended treatment for infected total hip replacement is two-staged exchange including removal of all components. However, removal of well-fixed femoral stems can result in structural bone damage. We recently reported on an alternative treatment of partial two-stage exchange used in selected cases, in which a well-fixed femoral stem was left and only the acetabular component removed, the joint space was debrided thoroughly, an antibiotic-laden polymethylmethacrylate spacer was moulded using a bulb-type syringe and placed in the acetabulum, intravenous antibiotics were administered during the interval, and delayed re-implantation was performed. In 19 patients treated with this technique from January 2000 to January 2011, 89% were free of infection at a mean follow-up of four years (2 to 11). Since then, disposable silicone moulds have become available to fabricate spacers in separate femoral and head units. The head spacer mould, which incorporates various neck taper adapter options, greatly facilitates the technique of partial two-stage exchange. We report our early experience using disposable silicone head spacer moulds for partial two-stage exchange in seven patients with infected primary hip replacements.
Assuntos
Artroplastia de Quadril/efeitos adversos , Equipamentos Descartáveis , Infecções Relacionadas à Prótese/cirurgia , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Desbridamento/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/tratamento farmacológico , Reoperação , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
Previous studies of failure mechanisms leading to revision total knee replacement (TKR) performed between 1986 and 2000 determined that many failed early, with a disproportionate amount accounted for by infection and implant-associated factors including wear, loosening and instability. Since then, efforts have been made to improve implant performance and instruct surgeons in best practice. Recently our centre participated in a multi-centre evaluation of 844 revision TKRs from 2010 to 2011. The purpose was to report a detailed analysis of failure mechanisms over time and to see if failure modes have changed over the past 10 to 15 years. Aseptic loosening was the predominant mechanism of failure (31.2%), followed by instability (18.7%), infection (16.2%), polyethylene wear (10.0%), arthrofibrosis (6.9%) and malalignment (6.6%). The mean time to failure was 5.9 years (ten days to 31 years), 35.3% of all revisions occurred at less than two years, and 60.2% in the first five years. With improvements in implant and polyethylene manufacture, polyethylene wear is no longer a leading cause of failure. Early mechanisms of failure are primarily technical errors. In addition to improving implant longevity, industry and surgeons must work together to decrease these technical errors. All reports on failure of TKR contain patients with unexplained pain who not infrequently have unmet expectations. Surgeons must work to achieve realistic patient expectations pre-operatively, and therefore, improve patient satisfaction post-operatively.
Assuntos
Artroplastia do Joelho , Tomada de Decisões , Prótese do Joelho , Falha de Prótese/tendências , Humanos , Desenho de Prótese , Fatores de RiscoRESUMO
Direct anterior approaches to the hip have gained popularity as a minimally invasive method when performing primary total hip replacement (THR). A retrospective review of a single institution joint registry was performed in order to compare patient outcomes after THR using the Anterior Supine Intermuscular (ASI) approach versus a more conventional direct lateral approach. An electronic database identified 1511 patients treated with 1690 primary THRs between January 2006 and December 2010. Our results represent a summary of findings from our previously published work. We found that patients that underwent an ASI approach had faster functional recovery and higher Harris hip scores in the early post-operative period when compared with patients who had a direct lateral approach The overall complication rate in our ASI group was relatively low (1.7%) compared with other series using the same approach. The most frequent complication was early periprosthetic femoral fractures (0.9%). The dislocation rate in our series was 0.4% and the prosthetic joint infection rate was 0.1%. We suggest that the ASI approach is acceptable and safe when performing THR and encourages early functional recovery of our patients.
Assuntos
Artroplastia de Quadril/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Osteoartrite do Quadril/cirurgia , Complicações Pós-Operatórias/epidemiologia , Adulto , Feminino , Seguimentos , Articulação do Quadril/fisiopatologia , Articulação do Quadril/cirurgia , Humanos , Incidência , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Amplitude de Movimento Articular , Recuperação de Função Fisiológica , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
Debate has raged over whether a cruciate retaining (CR) or a posterior stabilised (PS) total knee replacement (TKR) provides a better range of movement (ROM) for patients. Various sub-sets of CR design are frequently lumped together when comparing outcomes. Additionally, multiple factors have been proven to influence the rate of manipulation under anaesthetic (MUA) following TKR. The purpose of this study was to determine whether different CR bearing insert designs provide better ROM or different MUA rates. All primary TKRs performed by two surgeons between March 2006 and March 2009 were reviewed and 2449 CR-TKRs were identified. The same CR femoral component, instrumentation, and tibial base plate were consistently used. In 1334 TKRs a CR tibial insert with 3° posterior slope and no posterior lip was used (CR-S). In 803 there was an insert with no slope and a small posterior lip (CR-L) and in 312 knees the posterior cruciate ligament (PCL) was either resected or lax and a deep-dish, anterior stabilised insert was used (CR-AS). More CR-AS inserts were used in patients with less pre-operative ROM and greater pre-operative tibiofemoral deformity and flexion contracture (p < 0.05). The mean improvement in ROM was highest for the CR-AS inserts (5.9° (-40° to 55°) vs CR-S 3.1° (-45° to 70°) vs CR-L 3.0° (-45° to 65°); p = 0.004). There was a significantly higher MUA rate with the CR-S and CR-L inserts than CR-AS (Pearson rank 6.51; p = 0.04). Despite sacrificing or not substituting for the PCL, ROM improvement was highest, and the MUA rate was lowest in TKRs with a deep-dish, anterior-stabilised insert. Substitution for the posterior cruciate ligament (PCL) in the form of a PS design may not be necessary even when the PCL is deficient.
Assuntos
Artroplastia do Joelho/instrumentação , Tomada de Decisões , Prótese do Joelho , Desenho de Prótese , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Amplitude de Movimento Articular , Resultado do TratamentoRESUMO
BACKGROUND: Obesity is considered to be a contraindication for unicompartmental knee replacement (UKR). The aim was to study the impact of BMI on failure rate and clinical outcome of the Oxford mobile bearing UKR. METHOD: Two thousand four hundred and thirty-eight medial Oxford UKRs were studied prospectively and divided into groups: BMI<25 (n=378), BMI 25 to <30 (n=856), BMI 30 to <35 (n=712), BMI 35 to <40 (n=286), and BMI 40 to <45 (n=126) and BMI≥45 (n=80). RESULTS: There was no significant difference in survival rate between groups. At a mean follow-up of 5years (range 1-12years) there was no significant difference in the Objective American Knee Society Score between groups. There was a significant (p<0.01) trend with the Oxford Knee Score (OKS) and Functional American Knee Society Scores decreasing with increasing BMI. As there was an opposite trend (p<0.01) in pre-operative OKS, the change in OKS increased with increasing BMI (p=0.048). The mean age at surgery was significantly (p<0.01) lower in patients with higher BMI. CONCLUSIONS: Increasing BMI was not associated with an increasing failure rate. It was also not associated with a decreasing benefit from the operation. Therefore, a high BMI should not be considered a contra-indication to mobile bearing UKR. LEVEL OF EVIDENCE: IV.
Assuntos
Artroplastia do Joelho/métodos , Índice de Massa Corporal , Obesidade/diagnóstico , Falha de Prótese/tendências , Adulto , Idoso , Artroplastia do Joelho/efeitos adversos , Estudos de Coortes , Bases de Dados Factuais , Feminino , Seguimentos , Humanos , Prótese do Joelho , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Obesidade/epidemiologia , Desenho de Prótese , Recuperação de Função Fisiológica , Estudos Retrospectivos , Medição de Risco , Resultado do TratamentoRESUMO
Metal-on-metal hip arthroplasty gained significant favor in the first decade of the millennium. However, the past several years have seen increasing reports of failure, pseudotumor and other adverse reactions. This study presents the results of a single center's 15-year experience with metal-on-metal total hip arthroplasty as strong evidence that metal-on-metal is going, going, gone.
Assuntos
Artroplastia de Quadril/instrumentação , Prótese de Quadril/efeitos adversos , Próteses Articulares Metal-Metal/efeitos adversos , Falha de Prótese/etiologia , Feminino , Seguimentos , Humanos , Masculino , Desenho de Prótese , Falha de Prótese/efeitos adversos , Estudos RetrospectivosRESUMO
Since 1996 more than one million metal-on-metal articulations have been implanted worldwide. Adverse reactions to metal debris are escalating. Here we present an algorithmic approach to patient management. The general approach to all arthroplasty patients returning for follow-up begins with a detailed history, querying for pain, discomfort or compromise of function. Symptomatic patients should be evaluated for intra-articular and extra-articular causes of pain. In large head MoM arthroplasty, aseptic loosening may be the source of pain and is frequently difficult to diagnose. Sepsis should be ruled out as a source of pain. Plain radiographs are evaluated to rule out loosening and osteolysis, and assess component position. Laboratory evaluation commences with erythrocyte sedimentation rate and C-reactive protein, which may be elevated. Serum metal ions should be assessed by an approved facility. Aspiration, with manual cell count and culture/sensitivity should be performed, with cloudy to creamy fluid with predominance of monocytes often indicative of failure. Imaging should include ultrasound or metal artifact reduction sequence MRI, specifically evaluating for fluid collections and/or masses about the hip. If adverse reaction to metal debris is suspected then revision to metal or ceramic-on-polyethylene is indicated and can be successful. Delay may be associated with extensive soft-tissue damage and hence poor clinical outcome.