Impaction bone-grafting before insertion of a femoral stem with cement in revision total hip arthroplasty. A minimum two-year follow-up study.

Impaction bone-grafting was performed before insertion of a collarless, polished, tapered femoral stem with cement in thirty-four revision total hip arthroplasties (thirty-four patients) that were done because of aseptic loosening. The average duration of follow-up was thirty months (range, twenty-four to forty-two months). The operation was the initial revision in twenty-eight patients (82 per cent). Twenty-two patients (65 per cent) also had revision of the acetabular component. Complications included four intraoperative and two postoperative fractures of the femur as well as one dislocation (at one month). Two patients (6 per cent) needed a repeat revision of the femoral stem because of aseptic loosening at twenty-six and thirty-six months postoperatively. Both of these patients had an associated fracture of the femur (one was intraoperative, and the other was postoperative). Subsidence was common (thirteen patients; 38 per cent) and averaged 10.1 millimeters (range, four to thirty-one millimeters). Although the study group was relatively small, with the numbers available subsidence was not found to be associated with the preoperative or postoperative hip score, segmental or cavitary femoral defects, femoral ectasia, intraoperative fracture of the femur, strut-grafting, trochanteric osteotomy, or varus position of the femoral component. Incorporation of the allograft into the trabecular bone and secondary remodeling were noted radiographically in thirty-two (94 per cent) and fourteen (41 per cent) of the patients, respectively, often within one year. Although the duration of follow-up was relatively short, no localized resorption of the allograft occurred and cortical repair was noted in one patient at three years. At the most recent follow-up evaluation, the Harris hip scores had improved from a preoperative average of 51 points (range, 32 to 90 points) to an average of 87 points (range, 65 to 100 points) and twenty-eight patients (82 per cent) had no or only slight pain. Despite the satisfactory early clinical results, we remain concerned about the high rate of fracture of the femur and the rate and extent of subsidence of the femoral component. On the basis of the worrisome findings after this two-year period, we recommend that impaction bone-grafting be used only when proximal femoral osteopenia is so severe that stability cannot be obtained with insertion of a long-stemmed femoral component without cement. In that setting, impaction bone-grafting may be considered instead of implantation of a massive proximal femoral allograft in combination with insertion of a femoral component with cement.

Total knee arthroplasty after high tibial osteotomy. A comparison study in patients who had bilateral total knee replacement.

BACKGROUND: The outcome of total knee replacement after high tibial osteotomy remains uncertain. We hypothesized that the results of total knee replacement with or without a previous high tibial osteotomy are similar. METHODS: The results of a consecutive series of thirty-nine bilateral total knee arthroplasties performed with cement at an average of 8.7 years after unilateral high tibial osteotomy were reviewed. There were twenty-seven men and twelve women. Preoperatively, the knee scores according to the system of the Knee Society were similar for all of the knees; however, valgus alignment and patella infera were more common in the knees with a previous high tibial osteotomy. Bilateral total knee replacement was staged in seven patients and was simultaneous in thirty-two patients. The results of the total knee arthroplasties were retrospectively reviewed with respect to the knee and function scores according to the system of the Knee Society, the radiographic findings, and the complications. RESULTS: Intraoperatively, no notable differences were identified in the number of medial, lateral, or lateral patellar releases required. However, less lateral tibial bone was resected in the group with a previous high tibial osteotomy (average, 3.3 millimeters) than in the group without a high tibial osteotomy (average, 7.5 millimeters). The average duration of follow-up was 7.5 years (range, three to sixteen years) in the group with a previous high tibial osteotomy and 6.8 years (range, two to ten years) in the group without a high tibial osteotomy. At the time of the final follow-up, the knee and function scores were similar for the two groups (89.0 and 81.0 points, respectively, for the group with a previous high tibial osteotomy, and 89.6 and 83.9 points, respectively, for the group without a high tibial osteotomy). Although more knees were free of pain in the group without a previous high tibial osteotomy (thirty-six) than in the group with a previous osteotomy (thirty-three), this difference was not found to be significant with the numbers available (p = 0.4810). Knee alignment and stability, femoral and tibial component alignment, and range of motion also were similar in both groups postoperatively. One allpolyethylene tibial component was revised in the high tibial osteotomy group. Two knees in each group required manipulation. There were no deep infections. CONCLUSIONS: While patients with a previous high tibial osteotomy may have important differences preoperatively, including valgus alignment, patella infera, and decreased bone stock in the proximal part of the tibia, the present study suggests that the clinical and radiographic results of primary total knee arthroplasty in knees with and without a previous high tibial osteotomy are not substantially different. In our relatively small group of patients, the previous high tibial osteotomy had no adverse effect on the outcome of the subsequent total knee replacement.

Polyethylene wear in uncemented acetabular components.

We measured polyethylene wear in 231 porous-coated uncemented acetabular cups. We divided the hips into two groups according to the fixation of the femoral component, by cementing (n = 97) or press-fit (n = 134). Follow-up was from three to five years. The patients in two sub-groups were matched for weight, diagnosis, sex, age and length of follow-up. The linear wear rate of cups articulated with uncemented femoral components (0.22 mm/year) was significantly higher than the wear rate (0.15 mm/year) of cups articulated within cemented femoral components (p < 0.05). These results can be compared with previously reported wear rates of 0.08 mm/year for cemented all-polyethylene cups and 0.11 mm/year for cemented metal-backed cups. The higher wear rates of uncemented arthroplasties could jeopardize the long-term results of this type of hip replacement.

Intra-articular morphine and/or bupivacaine after total knee replacement.

The postoperative analgesic effects of intra-articular injections of bupivacaine and/or morphine were examined prospectively in 437 patients who had total knee replacement for osteoarthritis. They were divided randomly into four groups. Group I received 10 mg of morphine (1 ml) and 9 ml of saline, group II received 10 ml of bupivacaine (2.5 mg/ml), group III received 10 ml of saline, and group IV received 10 mg of morphine (1 ml) and 9 ml of bupivacaine (2.5 mg/ml). All analgesics administered in the first 24 hours after operation were recorded. The patients rated their pain on the McGill-Melzack scale at 1, 6, 12 and 24 hours. No significant differences were found between any of the groups in the use of Demoral and/or Toradol in 24 hours, the length of stay in hospital or the pain rating at 1, 6, 12 or 24 hours. Patients in groups I and IV, whose injections included morphine, used significantly more morphine in the first 24 postoperative hours than did groups II or III.

Intra-operative findings in varus osteoarthritis of the knee. An analysis of pre-operative alignment in potential candidates for unicompartmental arthroplasty.

Interest in unicompartmental knee arthroplasty (UKA) for the treatment of medial compartment osteoarthritis has increased in recent years with apparent improvement in the long-term results. This is a result of improved surgical technique, patient selection, and implant design. In an effort further to improve patient selection we analysed the relationship between the pre-operative alignment of the knee and the anatomical findings at the time of surgery. We compared these findings with the indications for UKA. From 4021 total knee arthroplasties we compared intra-operative observations with the pre-operative clinical data in order to identify knees with isolated, medial, compartment changes, which would have been ideal candidates for UKA. We found that only 247 of the knees (6.1%) met anatomical qualifications for isolated, medial, unicompartmental osteoarthritis, and of these, only 168 (4.3%) met clinical standards ideal for UKA. Preoperative alignment showed a significant relationship with patterns of disease. Logistic regression revealed a relationship between pre-operative alignment and intraoperative findings resembling a Gaussian distribution. Patients with a pre-operative varus alignment of 7 degrees were slightly more likely to be selected for UKA. But the further the anatomical alignment in either direction varies from 7 degrees of varus, the more unlikely it is for the knee to exhibit a disease pattern of isolated, medial, unicompartmental osteoarthritis.

Long-term deterioration of joint evaluation scores.

We investigated the long-term changes in the Harris Hip and Knee Society scores (HSS and KSS) to determine whether they result from overall functional decline rather than actual changes in the condition of the prosthesis. The HHS for 106 total hip arthroplasties with a minimum follow-up of ten years, no medical complications after operation and no evidence of radiological loosening, and the KSS for 264 total knee arthroplasties with a minimum follow-up of 12 years and no medical complications after operation or signs of radiographical loosening were evaluated. There were statistically significant drops in the functional scoring components of the joint evaluation systems despite no loosening of the prostheses or other significant medical complications. The HHS declined at an average of 0.67 points per year from between three and ten years after operation (p < 0.0001). Contributing to this were deterioration in gait and limp (p < 0.0004), the use of support aids (p < 0.0001), the distance walked (p < 0.0001) and the ability to climb stairs (p < 0.0455). The functional component of the KSS declined significantly at an average 0.88 points per year betwen the third and 12th years (p < 0.0001). There were significant declines in every component of the functional score including the distance walked (p < 0.0001), the ability to climb stairs (p < 0.0001) and the use of support aids (p < 0.0001). The knee score component of the KSS did not decline significantly (p < 0.9750). The combination of functional and pain scores within the HHS system leads to an inaccurate decline in the entire score. The decline of HHS and Knee Society functional scores in total joint arthroplasties, in the absence of implant-related problems, suggests that deterioration in the functional capacity of ageing patients is an important factor in longitudinal studies using these scoring systems.

Radiological factors influencing femoral and acetabular failure in cemented Charnley total hip arthroplasties.

We have made a retrospective review of 185 cemented Charnley total hip arthroplasties performed between 1970 and 1974 to determine the relationships between radiological variables and failure of the femoral and acetabular components. We measured the acetabular wear, the orientation of the cup, the thickness and consistency of acetabular and femoral cement mantles, radiolucency and femoral alignment. The mean follow-up was for 11.7 years. Femoral loosening was demonstrable radiologically in 15 hips (8.1%), ten (5.4%) of which were revised during the period of follow-up. Only when the first postoperative radiograph showed a thin cement mantle in Gruen zone 5 was there a significant association with failure of the femoral component. There were 12 loose acetabular components (6.5%), nine (4.8%) of which were revised. When the initial radiograph after operation showed radiolucency in DeLee and Charnley zone 1, the incidence of acetabular loosening was 28.21%. If such radiolucency was not present, the incidence of acetabular loosening was only 0.69%. Our findings emphasise the importance of careful cementing.

Maximizing cost-effectiveness while minimizing complications in total hip replacement.

Between July 1989 and June 1994, a consecutive series of 651 cemented total hip arthroplasties were performed in 577 patients using relatively inexpensive implants and standardized surgical and postoperative protocols. We set out to determine what effect these cost-saving measures have on the overall success and complication rate after total hip replacement surgery. Surgical results remained excellent, and perioperative, early, and late complications, including infection, loosening, and revision hip surgery, remained minimal, indeed, below usual complication rates. We concluded that cost-effective measures can be implemented while maintaining the overall excellent results of hip replacement surgery without the risk of increasing complication rates.

Intraarticular trochanteric wire migration following bilateral total hip arthroplasty. A case report.

A 64-year-old man underwent bilateral simultaneous total hip replacement and experienced articular interposition of a wire fragment in the right hip joint 3 years postoperatively. Because of destructive wear of the acetabulum, this eventually required revision total hip arthroplasty 12 years after the original surgery.

Total hip arthroplasty. Can the patient play sports again?

To analyze the effect of athletic involvement on total hip replacements, a questionnaire was sent to all of our total hip patients with at least a 3-year follow up. Patients were asked to list the type, degree, and frequency of sports participation before and after surgery, along with any problems they encountered upon returning to active sports. The patients who responded were then placed in one of two groups, participant or non-participant, for each sport we encountered, and were statistically compared with respect to clinical analysis. The population showed a significant decrease in all forms of activity after surgery, except bicycling; yet more returned to an active sport than did not. No correlation existed between involvement in a sport and the variables we tested. We concluded that intelligent participation in activities such as walking, golf, or bowling where no excess load was placed on the total hip, had no influence on the outcome of a total hip replacement.

Femoral head size: variation among manufacturers.

Nine manufacturers were contacted for their specific femoral head diameters of the 22 mm, 28 mm, and 32 mm femoral components. The 22 mm heads averaged .869 in. (+/- .005) and 100% were within 1 standard deviation; however, the standard deviation was large. The 28 mm heads averaged 1.101 in. (+/- .002), and 89% were within 1 standard deviation. The 32 mm heads averaged 1.258 in. (+/- .002), and 78% were within 1 standard deviation. It seems that when a 28 mm or 32 mm femoral head is used, different femoral and acetabular components by different manufacturers can be intermixed. However, when changing a 22 mm femoral head, the manufacturer should possibly be notified and an attempt to use the same manufacturer is preferable.

Meeting increased demand for total knee replacement and follow-up: determining optimal follow-up.

The strain on clinic and surgeon resources resulting from a rise in demand for total knee replacement (TKR) requires reconsideration of when and how often patients need to be seen for follow-up. Surgeons will otherwise require increased paramedical staff or need to limit the number of TKRs they undertake. We reviewed the outcome data of 16 414 primary TKRs undertaken at our centre to determine the time to re-operation for any reason and for specific failure mechanisms. Peak risk years for failure were determined by comparing the conditional probability of failure, the number of failures divided by the total number of TKRs cases, for each year. The median times to failure for the most common failure mechanisms were 4.9 years (interquartile range (IQR) 1.7 to 10.7) for femoral and tibial loosening, 1.9 years (IQR 0.8 to 3.9) for infection, 3.1 years (IQR 1.6 to 5.5) for tibial collapse and 5.6 years (IQR 3.4 to 9.3) for instability. The median time to failure for all revisions was 3.3 years (IQR 1.2 to 8.5), with an overall revision rate of 1.7% (n = 282). Results from our patient population suggest that patients be seen for follow-up at six months, one year, three years, eight years, 12 years, and every five years thereafter. Patients with higher pain in the early post-operative period or high body mass index (≥ 41 kg/m(2)) should be monitored more closely.

The role of the posterior cruciate ligament in total knee replacement.

OBJECTIVES: The purpose of this study was to examine the effect of posterior cruciate ligament (PCL) retention, PCL recession, and PCL excision during cruciate-retaining total knee replacement. METHODS: A total of 3018 anatomic graduated component total knee replacements were examined; 1846 of these retained the PCL, 455 PCLs were partially recessed, and in 717 the PCL was completely excised from the back of the tibia. RESULTS: Clinical scores between PCL groups favored excision for flexion (p < 0.0001), and recession and retention for stairs (p < 0.0001). There was a mild difference in long-term all-cause aseptic survivorship between PCL-retained (96.4% at 15 years) combined with PCL-recessed groups (96.6% at 15 years) when compared with the PCL-excised group (95.0% at 15 years) (p = 0.0411, Wilcoxon; p = 0.0042, log-rank), as well as tibial or femoral loosening, which reported prosthesis survival of 97.8% at 15 years for PCL-retained knees, 98.2% for recessed knees, and 96.4% for excised knees (p = 0.0934, Wilcoxon; p = 0.0202, log-rank). CONCLUSIONS: Despite some trade off in clinical performance, if the PCL is detached at the time of operation, conversion to a posterior-stabilised prosthesis may not be necessarily required as long as stability in the anteroposterior and coronal planes is achieved.

Bilateral simultaneous total knee arthroplasty.

One hundred thirty-two patients (264 knees) who had simultaneous bilateral total knee arthroplasty and 77 patients who had unilateral procedures were reviewed for statistical comparison of the two procedures with respect to pain, tibial and femoral radiolucency, and all other complications as well as average hospital stay and hospital costs. Both groups had posterior cruciate condylar total knee prostheses. There were no significant differences except for tibial radiolucency, which was significantly higher in the unilateral group. Bilateral total knee arthroplasty as a single procedure does not increase the risk of postoperative or follow-up complications and decreases the probability of complications such as phlebitis and pulmonary emboli, because only one operation is necessary. The average hospital cost and length of stay were lower in the simultaneous group (decreased by 20% and 46%, respectively), compared with twice that of the unilateral group.

A comparison of osteonecrosis and osteoarthritis patients following total hip arthroplasty. A long-term follow-up study.

Between November 1969 and December 1983, 105 total hip arthroplasties were performed on 82 patients with a diagnosis of idiopathic osteonecrosis (ON). During the same period, 891 total hip surgeries were performed on 706 osteoarthritis (OA) patients. In order to statistically compare these two diseases, the records of each patient were examined for possible differences in bilaterality, sex, age, and acute postoperative complications including infections, pain, nonunions, and heterotopic bone (HB). Sixty-four ON hips and 615 OA hips (all with at least three years of follow-up data) were then evaluated for acetabular and femoral radiolucency, acetabular and femoral loosening, and pain. The same long-term complications were evaluated in some of these patients at five-, seven-, and ten-year follow-up periods. The ON patients were significantly younger than the OA patients (p less than .001). Bilateral involvement and male/female distributions were found to be similar. Except for HB, acute postoperative complications (zero to six months) were similar. Early HB surrounding one-third or more of the hip joint was statistically less in the ON patient population (p less than .001). No significant differences in long-term complications were found. However, a much higher death rate was found in ON patients (24%) as compared to OA patients (15%) (significant at p less than .07). This difference was not due to any postoperative complication or the hip arthroplasty itself, because both were the same in the two populations.

Anterior displacement. Its effects on instability and radiolucency in total knee replacements.

One hundred sixty-nine posterior cruciate condylar knee arthroplasties were evaluated for investigation of the effect of anterior displacement on instability and interface radiolucency in total knee arthroplasty. All knees were followed for at least one year, and 37 knees were followed for at least three years. The status of the anterior cruciate ligament at surgery was first compared to the postoperative, six-month, one-year, and three-year anterior drawer sign. A correlation coefficient was computed to test for the existence of a relation between these two variables. A chi-square test for statistical significance was used to compare the overall anterior drawer results with time and the anterior drawer sign at each follow-up evaluation with pain and radiolucent zones between cement and bone. For further evaluation of the effect of anterior stability on radiolucent zones, the authors analyzed the records of all their posterior cruciate condylar total knee arthroplasties over a seven-year period (average follow-up period, 2.5 years). Anterior stability over time was independent of the status of the anterior cruciate at surgery, and the presence or absence of an anterior cruciate ligament at surgery did not affect anterior stability over time. Furthermore, cutting of the anterior cruciate did not change anterior stability over time. Anterior instability proved to be statistically less at six months than at surgery and did not become worse with time. Neither anterior instability nor the preoperative state of the anterior cruciate ligament affects pain and interface radiolucency between cement and bone.

Overview: long-term followup: predicting the success of a total knee arthroplasty.

As the number of total knee arthroplasties performed each year in the United States continues to increase, knowledge of long-term prosthetic performance and implant durability is paramount. A selection of the best total knee replacement system for a given patient should be based on long-term followup studies reviewing, among other parameters, survivorship and complications. The importance of such long-term data should not be underestimated.

Critical analysis of strut grafts in anterior spinal fusions.

Fifty patients undergoing anterior spinal decompression with partial or complete corpectomy and fusion with strut grafting were reviewed. The etiology of the spinal lesions included pathologic fracture (9 patients), trauma (22 patients), congenital/developmental lesions (6 patients), failed fusion (6 patients), and degenerative lesions (7 patients). Vertebral body reconstruction of the cervical, thoracic, or lumbar spine used iliac crest (20 cases), rib (12 cases), and fibular autografts (9 cases). Additionally, in 10 cases fibular allografts were used. There were four deaths, all secondary to systemic disease. Of the remaining 46 patients, 2 required revisions and all subsequently progressed to a solid anterior arthrodesis with an average follow-up of 30.4 months (range 12-62 months). Posterior spinal fusion was staged in 38 patients. Twenty of 29 patients with neurologic lesions improved after corpectomy. Eleven cases treated for a progressive, painful kyphosis averaged correction of 11.4 degrees (26%), which was maintained on long-term follow-up. Complications were primarily pulmonary and/or genitourinary. Others included a pseudarthrosis, an early fractured strut, and a late allograft infection. On the basis of this review, it appears that spinal arthrodesis with anterior decompression and strut grafting is an effective method of treating anterior compressive syndromes of the spine and painful progressive kyphoses.