Examining pain before and after primary total knee replacement (TKR): A retrospective chart review.

OBJECTIVE: The goal of total knee replacement is to improve function and reduce knee pain. The aim of this retrospective chart review was to assess the change in pain intensity from prior to TKR to after TKR at time of discharge from hospital. METHOD: Consecutive charts of 595 patients who were discharged from the orthopaedic inpatient setting between January 2014 and July 2014 were reviewed. RESULTS: The mean pre-operative pain intensity score was 7/10 (n = 473), and the mean pain intensity score prior to discharge from hospital was 3/10 (n = 548). Four hundred and fifty-six patients had both a pre-operative and pre-discharge pain intensity score documented; for those patients there was a significant change in pain intensity scores from prior to surgery to prior to discharge (p < 0.001). CONCLUSION: Pain after TKR can be a limiting factor in rehabilitation activities. This retrospective chart review examined the pain intensity scores before and after primary TKR for patients in our facility. We found a significant difference in the pain intensity from before surgery to after surgery. However, further research needs to be conducted to examine the intensity and quality of pain as well as which analgesics patients are consuming after discharge from hospital at 6 weeks and 3 months.

What would you do?: challenges in hip surgery.

A moderator and panel of five experts led an interactive session in discussing five challenging and interesting patient case presentations involving surgery of the hip. The hip pathologies reviewed included failed open reduction internal fixation of subcapital femoral neck fracture, bilateral hip disease, evaluation of pain after metal-on-metal hip arthroplasty, avascular necrosis, aseptic loosening secondary to osteolysis and polyethylene wear, and management of ceramic femoral head fracture.

Cementless fixation in total knee arthroplasty: down the boulevard of broken dreams - opposes.

In this study we present our experience with four generations of uncemented total knee arthroplasty (TKA) from Smith & Nephew: Tricon M, Tricon LS, Tricon II and Profix, focusing on the failure rates correlating with each design change. Beginning in 1984, 380 Tricon M, 435 Tricon LS, 305 Tricon 2 and 588 Profix were implanted by the senior author. The rate of revision for loosening was 1.1% for the Tricon M, 1.1% for the Tricon LS, 0.5% for the Tricon 2 with a HA coated tibial component, and 1.3% for the Profix TKA. No loosening of the femoral component was seen with the Tricon M, Tricon LS or Tricon 2, with no loosening seen of the tibial component with the Profix TKA. Regarding revision for wear, the incidence was 13.1% for the Tricon M, 6.6% for the Tricon LS, 2.3% for the Tricon 2, and 0% for the Profix. These results demonstrate that improvements in the design of uncemented components, including increased polyethylene thickness, improved polyethylene quality, and the introduction of hydroxyapatite coating, has improved the outcomes of uncemented TKA over time.

Total knee replacement with rotational proximal tibial osteotomy for osteoarthritis with severe external tibial torsion and patellar instability.

The management of osteoarthritis of the knee associated with patellar instability secondary to external tibial torsion > 45 degrees is challenging. Patellofemoral biomechanics in these patients cannot be achieved by intra-articular correction using standard techniques of total knee replacement. We reviewed seven patients (eight knees) with recurrent patellar dislocation and one with bilateral irreducible lateral dislocation who had undergone simultaneous total knee replacement and internal tibial derotational osteotomy. All had osteoarthritis and severe external tibial torsion. The mean follow-up was for 47.2 months (24 to 120). The mean objective and functional Knee Society scores improved significantly (p = 0.0001) from 29.7 and 41.5 pre-operatively to 71.4 and 73.5 post-operatively, respectively. In all patients the osteotomies healed and patellar stability was restored. Excessive external tibial torsion should be identified and corrected in patients with osteoarthritis and patellar instability. Simultaneous internal rotation osteotomy of the tibia and total knee replacement is a technically demanding but effective treatment for such patients.

Total hip arthroplasty in patients with deficient bone stock and small femoral canals.

Total hip arthroplasty in patients requiring very small femoral stems is a challenge because frequently deformity and inadequate bone stock, especially of the acetabulum, are also present. An analysis of 34 consecutive cases managed with a 9-mm distal diameter noncemented stem was performed. The mean patient age was 42.6 years and mean follow-up time was 7.8 years. Two patients were lost to follow-up at 4 and 6 years, and 1 patient had a fracture below the stem immediately after surgery, necessitating revision. These patients were excluded from analysis. Of the remaining 31 patients, 1 underwent revision for distal osteolysis leading to fracture. The Harris hip ratings for these patients were 58.1% excellent, 22.6% good, 16.1% fair, and 3.2% poor. Complications experienced included 1 femoral component that fractured but remains asymptomatic. Polyethylene wear of the very small acetabular components in 31% of cases is a cause for concern; 2 of these patients have required revision for this reason. The acetabular component was subsequently modified to allow thicker polyethylene.

[Modular shafts in hip prosthesis revision surgery]. / Modulare Schäfte in der Hüftprothesenrevisionschirurgie.

The introduction of a proximally modular hip stem has greatly simplified difficult hip surgery. The long-term results of revision surgery indicate that the majority of revision cases can be handled with a proximal ingrowth implant, which helps speed bone recovery and simplifies re-revision if it is required. To date no particular downside has been noted as a result of the use of a modular stem.

Fracture of the patella following total knee arthroplasty.

The charts of 21 patients (22 knees) with significant radiographic changes of the patella after total knee arthroplasty were reviewed. The average patient age was 73 years, and average follow-up after arthroplasty was 7.3 years. Lateral release, fat pad excision, quadriceps tendon release, and previous surgery were implicated in the etiology of fracture of the patella. Five cases had type 1 pattern (sclerosis, fragmentation, and no fracture), 5 cases had type 2 pattern (undisplaced fracture and fragmentation), and 12 cases had type 3 pattern (displaced fracture and fragmentation). Type 1 and 2 patterns required no surgical treatment and were rated good to excellent according to the Hospital for Special Surgery Disability Score Sheet. Patients with a type 3 pattern who did not undergo surgery were rated poor to fair, while patients with a type 3 pattern who underwent surgical treatment (patellectomy, removal of the patellar component, or excision arthroplasty for infection) were rated good. Patellectomy is the treatment of choice for patients with displaced fractures of the patella. A classification system for the pattern of patellar changes is proposed.

Use of oblong socket in hip revision surgery.

A 2 to 8 year follow up has been conducted in the use of an ingrowth noncemented oblong acetabular component used in hip revision surgery. To date no loosening and no significant migration has occurred. These intermediate results are promising and warrant further study of this implant. Key words: S-ROM, THR, revision surgery, oblong cup.

Review of constrained acetabular component in total hip replacement.

Recurrent dislocation following total hip replacement remains a very significant problem with indifferent results when treated conventionally. A constrained acetabular component has been developed. A cohort of 40 cases has been followed from 1-10 years (mean 3.5 years). One redislocation occurred and 2 metal shells loosened and were revised. These results demonstrate that when indicated this cup is very useful. The teoretical increase in wear debris generation caused by neck/cup impingement has not proved clinically significant, but the potential for this occurrence should limit the use of this cup to situation where it is clearly indicated. Key words: THR dislocation, constrained acetabular component.

Total joint replacement in multiplex congenita contractures: a case report.

A 34-year-old man with multiplex congenita contractures underwent replacement of 2 hips and 1 knee. Even though a good range of movement was achieved at surgery and intensive physiotherapy, his joints returned to their preoperative status within 2 years. This outcome suggests that total joint replacement has little to offer the patient with multiplex congenita contractures who has immobile joints.

Modified cups.

Late results of structural allografting of the acetabulum are quite variable. In order to reduce or avoid the necessity for bone grafting, some modified cups have been developed. The deep cup with or without a lateralized polyethylene liner reduces the problem of the protrusio socket. Oblong or bilobed ingrowth cups significantly reduce the need for grafting of the roof-deficient acetabulum. Constrained or capture polyethylene liners are useful in the unstable hip.

Hinge total knee replacement revisited.

OBJECTIVE: To determine if aseptic loosening is a major problem in hinge total knee replacement. DESIGN: A cohort study. SETTING: A university-affiliated institute, specializing in elective orthopedic surgery. PATIENTS: Fifty-eight patients, mainly those requiring revision, in whom the conditions were such that it was felt only a totally constrained implant was appropriate. In 7 patients the implant was press-fitted; in the remainder it was cemented. Five patients required fusion or revision, and 8 died less than 2 years after implantation, leaving 45 for review. Follow-up was 2 to 13 years. INTERVENTION: Total knee replacement with a Guepar II prosthesis. MAIN OUTCOME MEASURES: Radiolucency determined by the Cameron system and clinical scoring using the Hospital for Special Surgery system. RESULTS: Of the cemented components, 91% of femoral stems were type IA (no lucency), 9% were type IB (partial lucency), with no type II or III lucency. Tibial lucency was 87% type IA and 13% type IB, with no type II or III lucency. Of the noncemented components, 58% of femoral components were type IA and 42% type IB. Tibial lucency was 71% type IA and 29% type IB. Lucency was mainly present in zones 1 and 2 adjacent to the knee. Clinical rating was 18% excellent, 20% good, 20% fair and 42% poor. Postoperative complications included infection (13%), aseptic loosening (7%), quadriceps lag (16%) and extensor mechanism problems (16%). CONCLUSIONS: Aseptic loosening is an uncommon problem in hinge total knee replacement. The complication rate in cases of sufficient severity as to require a hinge replacement remains high. Current indications for a hinge prosthesis are anteroposterior instability with a very large flexion gap, complete absence of the collateral ligaments and complete absence of a functioning extensor mechanism.

Total knee replacement after supracondylar femoral osteotomy.

Surgically produced deformities around the knee may influence the outcome of total knee replacement (TKR). This article reviews eight cases of TKR following supracondylar varus femoral osteotomy. While in each case, the distal femur was offset medially on the femoral diaphysis, the outcome as measured by the clinical result and the alignment was uniformly excellent. It is concluded, therefore, that supracondylar varus femoral osteotomy does not affect the subsequent TKR.