Efecto del ejercicio físico sobre las prótesis articulares / Effect of physical exercise on articular prostheses

El individuo adulto que tiene una artrosis grave de rodilla o cadera presenta dolor e incapacidad para la actividad física, lo que puede interferir con las actividades de la vida diaria. En ocasiones el tratamiento conservador no es suficiente para mejorar esta patología, por lo que la cirugía puede proporcionar mejoras sustanciales en estos pacientes. La sustitución protésica de rodilla y cadera son los procedimientos quirúrgicos que se practican de forma más habitual en los hospitales de Cirugía Ortopédica y Traumatología en España. Representan una clara mejoría en la sintomatología y calidad de vida de estos pacientes. En general el éxito del resultado depende de la selección del paciente y de sus expectativas, de la técnica, del diseño de los componentes, de la rehabilitación y de la prevención de las complicaciones. Los resultados de las artroplastias de sustitución se han estudiado utilizando parámetros o escalas que analizan el dolor, la función, los hallazgos radiológicos, la calidad de vida e incluso su coste-efectividad. Muy poco se ha analizado sobre el ejercicio y la actividad física tras una artroplastia de sustitución. El objetivo de este trabajo es realizar una revisión de las recomendaciones de ejercicio físico tras una prótesis total de cadera o rodilla y cuáles son esos conocimientos científicos y biomecánicos que justifican dichas recomendaciones (AU)

Use of grommets for flexible implant resection arthroplasty of the metacarpophalangeal joint.

In 1987, after 11 years of research, press fit titanium circumferential grommets were introduced for arthroplasty of the metacarpophalangeal joint to protect the flexible hinge implant midsection from sharp bony edges and shearing forces that can initiate implant abrasions and tears leading to implant fracture and formation of silicone wear particles. The effectiveness of the titanium circumferential grommets was assessed by comparing the results of 170 metacarpophalangeal joint implant (high performance) arthroplasties performed with (139 joints) and without (31 joints) grommets in 38 patients presenting an average 5.8 years followup. Both groups obtained pain relief, functional motion, stability, and correction of deformity. There was no evidence of particulate synovitis or infection. There were four implant fractures (12.9%) in the nongrommet group, and one (0.7%), because of implant rotation, in the grommet group. Although favorable bone remodeling was observed in both groups, the grommet group showed greater bone preservation at the metaphyseal and midshaft levels and increased intramedullary bone production around the implant stems. The results depend on appropriate surgical staging, meticulous operative and postoperative techniques, severity and progression of disease, and implant durability. The circumferential grommets safely and effectively protect the implant to bone interface to further the durability of implant arthroplasty of the metacarpophalangeal joint.

Surgical treatment of osteoarthritis.

Surgical treatment of OA is appropriate when conservative therapy fails or is inadequate. The veterinary orthopedist's goals in treatment should be to alleviate pain, maintain function, and prevent or remove the potential for further degeneration of the joint. Currently, in veterinary surgery, THR and femoral head and neck excision are the primary treatments for OA of the coxofemoral joint. Other joints are treated primarily by arthrodesis or excision arthroplasty. Arthroscopy is proving to be a valuable tool in the diagnosis and treatment of OA, and total stifle and elbow replacement and cartilage resurfacing through chondrocyte grafting are on the horizon as potential treatment options.

The Norway elbow replacement. Design, technique and results after nine years.

The Norway elbow prosthesis is a non-constrained cemented total replacement. It depends on intact collateral ligaments for stability, and allows a full range of movement. The system includes several sizes of components, all freely interchangeable, and semi-constraint can be provided by a locking ring if damaged collateral ligaments make dislocation possible. The prosthesis has been used in more than 350 elbows in Norway and the detailed results for 118 elbows studied prospectively since 1987 are reported. It is inserted through a posterolateral triceps-splitting incision with minimal muscle disruption and bone resection, preserving the collateral ligaments. The results as regards pain relief and range of movement were comparable with those of other elbow prostheses, but there were fewer serious complications. At a mean follow-up of 4.3 years, the failure rate was 3.4%.

Arthroplasty for arthritis and rotator cuff deficiency.

Massive and irreparable loss of rotator cuff tendon integrity can be associated with the development of glenohumeral and acromiohumeral arthritis. Loss of glenohumeral instability provided by the rotator cuff may initiate and perpetuate this unique condition of the shoulder. Proximal humeral replacement arthroplasty is the preferred surgical treatment; special techniques of this procedure are presented. Patients are gratified by the durable restoration of comfort and, to a lesser extent, function.

[Follow-up of Souter elbow prostheses]. / Etterundersøkelse av Souters albueproteser.

27 patients (30 elbows) treated with Souter elbow prosthesis replacement were examined at a follow-up study. 26 patients had rheumatic arthritis. The mean observation time was five years (2-10 years). The indication for surgery was severe pain and reduced elbow function. Preoperative radiological examination revealed considerable pathological changes in all the elbows. Six of the elbows underwent revision with new prosthesis replacement. The indications for the re-operations were fractures, loosening of the prosthesis and luxations. 19 elbows (26%) had deteriorated and three patients had no definite opinion. Four of the six elbows replaced by a new prosthesis, became worse than before the first operation. Follow-up radiological examination showed that 80% of the humerus components showed varying degrees of radiological loosening and more than half of the humerus components showed cranial migration. All patients who suffered fractures during the operation have been, or will be, re-operated. Radiological loosening of the prosthesis makes the prognosis uncertain for the majority of the patients. Re-operation with a new prosthesis is unsatisfactory. As a consequence of the poor results, this prosthesis is no longer used at our hospital.

Advanced cement technique improves fixation in elbow arthroplasty.

An in vitro study was conducted to assess the efficacy of advanced cementing techniques in the fixation of the humeral stem in elbow arthroplasty. Sixteen fresh frozen cadaveric distal humeri were prepared to accept an acrylic sham humeral stem. Conventional cementing technique using doughy cement manually inserted and packed was performed in 8 specimens. The advanced cementing technique, consisting of canal irrigation, brushing and drying with gauze, canal plugging, and low viscosity cement pressurization with a delivery system was performed in the other specimens. All humeri subsequently were sectioned into 10 mm thick sections, photographed, and digitized to quantify the perimeter and area of the stem, cement mantle, corticocancellous junction, and cement voids. The degree of cement filling, determined from the area fraction of cement to the total available area within the corticocancellous junction, was significantly greater in the advanced group compared with the conventional group. Mechanical assessment of the specimens consisted of a push out load to failure test of the cement mantle from bone. For all locations in the distal humerus, the failure load and failure stress in the advanced group was significantly greater than the conventional group. It is concluded that development of an effective cement restrictor and application of advanced cement techniques in vivo should improve the initial fixation of the humeral component and may decrease the incidence of aseptic loosening associated with elbow arthroplasty.

Hemiarthroplasty of the shoulder for rotator cuff arthropathy.

Sixteen patients underwent hemiarthroplasty for rotator cuff arthropathy between June 1989 and March 1992, and evaluations obtained before and after surgery in all patients were compared. A modular head large enough to articulate with the coracoacromial arch but not so large as to prevent approximately 50% of humeral head translation on the glenoid was used in these cases. Each patient was evaluated with Neer's limited goals rating scale after an average follow-up of 33 months (24 to 55 months). Ten patients were rated as successful and six as unsuccessful. Four of the six unsuccessful patients had undergone at least one attempt at rotator cuff repair with acromioplasty before the index procedure, and two of these four patients had deficient deltoid function after this rotator cuff surgery as a result of postoperative deltoid detachment. Also, three of these four patients who had previously undergone acromioplasty subsequently had anterosuperior subluxation after hemiarthroplasty. Hemiarthroplasty did not provide for a successful outcome in all patients with rotator cuff arthropathy. However, 10 of the 12 patients in this series with good deltoid function and an adequate coracoacromial arch were rated as successful by Neer's limited goals criteria. In addition, this study illustrates that formal acromioplasty carried out during attempts at rotator cuff repair in such patients may jeopardize the subsequent success of hemiarthroplasty.

An acrylic Judet hip prosthesis in a shoulder hemiarthroplasty for thirty-nine years--a case report.

We describe a hemiarthroplasty of the shoulder with an acrylic Judet hip prosthesis, inserted after the excision of a giant cell tumour of the head of the humerus, which functioned well for 39 years.

Spontaneous resolution of soft-tissue interposition after closed reduction of hip endoprosthesis dislocation.

Over a 5-year period at a single institution, 164 endoprostheses were used for the treatment of displaced femoral neck fractures. Soft-tissue restraint preservation and repair (hip capsule and labrum) is recommended to enhance stability after endoprosthesis placement. When dislocation does occur, however, this soft tissue may become interposed after closed reduction. This occurred in 2 of the dislocations reported here. In these 2 dislocations, despite the widened joint space, the range of motion was stable. Neither of these cases had a subsequent dislocation, and after 1 month, both had spontaneously narrowed their joint space back to the immediate postoperative state.

Modern cement technique and the survivorship of total shoulder arthroplasty.

Thirty-eight consecutive Neer II total shoulder arthroplasties were performed in 35 patients by one surgeon using the so called modem cement technique and followed for a mean of 5 years (range, 2-9.5 years). The preoperative diagnosis was osteoarthritis or avascular necrosis in 22 shoulders, rheumatoid arthritis in 10 shoulders, and posttraumatic arthritis in 6 shoulders. The components were implanted using specific improved techniques for cement fixation initially described for total hip arthroplasty. Twenty-six metal-backed and 12 polyethylene glenoid components were used. The humeral component was implanted with cement in 32 shoulders. There were no intraoperative fractures or postoperative neurapraxias. At most recent followup, 36 shoulders had no or slight pain with activity. The mean increase in active forward elevation was 38 degrees and in active external rotation was 29 degrees. There have been no revisions, and all components remain in place. With failure defined as definite radiographic loosening of the components, there was 97% survivorship at 5 years, and 93% at 8 years. Radiolucent lines around more than 50% of the bone cement interface of the humeral component were present in only 3 shoulders. Radiolucent lines around more than 50% of the bone cement interface of the glenoid component were seen in only 2 shoulders. Both components in 1 severely osteopenic shoulder had a complete radiolucent line and a change in position. Meticulous attention to cement technique may improve the long term survival of cemented total shoulder arthroplasty components.

A floating prosthesis for radial-head fractures.

We report our experience over seven years with a floating radial-head prosthesis for acute fractures of the radial head and the complications which may result from such injury. The prosthesis has an integrated articulation which allows change of position during movement of the elbow. We present the results in 12 patients with a minimum follow-up of two years. Five prostheses had been implanted shortly after injury with an average follow-up of 49 months and seven for the treatment of sequelae with an average follow-up of 43 months. All prostheses have performed well with an improved functional score (modified from Broberg and Morrey 1986). We have not experienced any of the complications previously reported with silicone radial-head replacement. Our initial results suggest that the prosthesis may be suitable for the early or delayed treatment of Mason type-III fractures and more complex injuries involving the radial head.

Total replacement of the metatarsophalangeal joint in the horse. A single pilot study.

In this paper the successful replacement of an equine metatarsophalangeal joint by a human total condylar knee prosthesis is reported. In the period of observation following implantation of the endoprosthesis the experimental animal showed almost no lameness when exercised at walk, bearing weight on the operated limb. Flexion and extension of the joint were markedly reduced. The clinical and histological observations clearly support further investigation into the equine metatarsophalangeal joint replacement by an endoprosthesis.

[Guépar's total radio-carpal prosthesis in the surgery of the rheumatoid wrist. Apropos of 72 cases reviewed]. / La prothèse totale radio-carpienne Guépar dans la chirurgie du poignet rhumatoïde. A propos de 72 cas revus.

PURPOSE OF THE STUDY: Total wrist arthroplasty is an alternative to arthrodesis in the treatment of the rheumatoid wrist. MATERIAL AND METHODS: Seventy-two GUEPAR total wrist arthroplasties in sixty-four patients with rheumatoid arthritis were reviewed 1 to 10 years after the operation (average follow-up of 4 years). GUEPAR total wrist arthroplasty is a bicondylar prosthesis. The radial component made of polyethylene is cemented in the radius. The carpal component made of metal is fixed by two screws in the second and the third metacarpal. This component is constitued by two pieces: a perforated lower part permitting the passage of the screws and its metacarpal fixation and a biconvex cover fixed on the lower part by a micro-screw. RESULTS: In preoperative evaluation, all patients had severe pain and loss of function. Post-operatively, 89 per cent had no pain or mild pain and 96 per cent had better function. The average arc of flexion-extension was 47 degrees preoperatively and 39 degrees postoperatively. There were no deep infections or dislocations. Seventy percent of the patients were satisfied but eleven wrists (15 per cent) required revision: 5 cases for prosthesis revision and 6 cases for implant removal and arthrodesis. Prosthesis revisions were justified by the unscrewing of the carpal component micro-screw: they gived good results. Arthrodesis was required for 4 radial component loosening and for 2 important bone resorptions under the carpal component. Radial component loosening was associated in 3 cases with unscrewing of the micro-screw. Radiographical analysis showed in nearly all cases of this serie a bone resorption under the carpal component. This resorption was 2 mm wide at an average of to 2 years and 4 mm wide at 4 years. DISCUSSION: Clinical results of this study are good but eleven wrists required revision. Nine of these revisions were due to anomalies of first prosthesis: the unscrewing of the carpal component micro-screw was accountable to abnormal use of polyethylene with reaction of the wear products and loosening of the radial component. This problem is now resolved. More disquieting is the bone resorption under the carpal component. In fact, this resorption was constant and evolutive. It was very likely due to micro-movements between the metacarpal screws and the carpal lower part. Also, the conception of the metacarpal-fixation of this prosthesis must be revised. CONCLUSION: In rheumatoid arthritis, wrist arthrodesis gives good results if nothings affects the fingers, elbow or shoulder. If they are affected, total wrist arthroplasty is an alternative. Long term loosening of total wrist arthroplasty is a significant problem so its indication must be reserved for old patients.

Results of CFV total wrist arthroplasty: review and early report.

Articulated total wrist arthroplasties have been used in the United States since 1974. In the 1980s the CFV wrist was developed in an attempt to reduce the incidence of imbalance, loosening, and bone resorption that has been seen in the early implants, and also to eliminate the use of bone cement. Since 1988, we have implanted 15 of these wrists. To date, nine patients are satisfied because of pain relief and motion; however, there have been 6 failures: 2 for infection, 3 because of a loose distal component, and 1 because of balance. Other problems that have been observed are flexor tenosynovitis, carpal tunnel syndrome, and a balancing problem.

Tratamento das complicaçöes de endopróteses näo convencionais utilizadas em tumores ósseos / Treatment of the complications of the custom-made prosthesis in the treatment of bone tumors

Os autores apresentam os resultados das complicaçoes de 79 endopróteses nao convencionais realizadas em 75 pacientes para o tratamento de tumores ósseos e de lesoes pseudotumorais que acometeram o ombro, o quadril e o joelho. Entre as complicaçoes mais freqüentes, encontraram a recidiva local em oito (10,13 por cento) pacientes, a luxaçao em seis (7,59 por cento), a infecçao em cinco (6,33 por cento) e a liberaçao de partículas em cinco (6, 33 por cento), entre outras. Na avaliaçao final, 22 (29,33 por cento) pacientes estavam livres de doença e três (4,00 por cento) sem evidência dela, enquanto 11 (14, 67 por cento) estavam vivos com doença em atividade e 36 (48 por cento) evoluíram para óbito devido à doença. Na avaliaçao final, encontraram 29,11 por cento de resultados excelentes, 36,71 por cento de bons, 25,32 por cento de regulares e 8,86 por cento de maus. Concluem que as endopróteses nao convencionais utilizadas foram, a despeito das complicaçoes, método satisfatório no tratamento dos tumores ósseos em 52 (65,82 por cento) entre as 79 cirurgias realizadas.

Total shoulder arthoplasty: pearls and pitfalls in surgical technique.

Total should arthroplasty is recommended for the treatment of shoulder arthritis that causes severe pain and loss of function. Successful shoulder arthroplasty is a technically demanding procedure because of lack of intrinsic stability of the glenohumeral joint. The tension of the rotator cuff and glenohumeral capsule must be balanced for mobility and stability. Attention to important anatomic landmarks and glenohumeral relationships ("pearls") minimizes the risk of complications ("pitfalls").

Rotator cuff insufficiency in the arthritic shoulder: treatment alternatives.

Shoulder arthroplasty can relieve the pain and improve the functional status of an arthritic shoulder. Because of the unique anatomic characteristics of the glenohumeral joint, the rotator cuff provides stability and control of shoulder motion. Thus, an intact, functioning rotator cuff is necessary for successful shoulder arthroplasty. There are clinical situations where the rotator cuff is torn, absent, or incompetent and an arthritic condition affects the shoulder. The patient must understand that, when confronted with rotator cuff insufficiency and shoulder arthritis, the goal of surgical treatment is limited to pain relief, with shoulder function often limited by the condition of the rotator cuff. We will discuss the incidence of rotator cuff disease associated with differing arthritic conditions, the treatment options available, and expected outcomes in these difficult and challenging clinical situations.