Incidence and related factors for intraoperative failed spinal anaesthesia for lower limb arthroplasty.

BACKGROUND: Spinal anaesthesia is the preferred choice for total hip- and knee arthroplasty (THA/TKA), due to the claimed superior outcome profile, relative simple technique and without the need for advanced airway support. However, choosing and informing about spinal anaesthesia should also include the risk for intraoperative failed spinal anaesthesia with associated pain, discomfort and suboptimal settings for airway management. Small-scale studies suggest incidences from 1 to 17%; however, no multi-institutional large data exists on failed spinal incidence and related factors during THA/TKA, hindering evidence-based information and potential anaesthesia stratification. METHODS: In a sub-analysis, data from a prospective study on spinal anaesthesia for THA/TKA were examined for incidence of intraoperative conversion to general anaesthesia. Potential perioperative factors (age, gender, American Society of Anaesthesiologist (ASA) score, height, weight, BMI, procedure, bupivacaine dosage and duration of time from spinal administration until end of surgery) were analysed with logistic regression for relation to failed spinal anaesthesia. RESULTS: In all, 1451 patients were included for analysis, whereof 57 (3.9%) had failed spinal anaesthesia. Spinal failure patients were significantly younger (61 vs. 67 years, P = 0.003), and operation time longer in the failed spinal group vs no-failure, respectively (133 vs. 89 min, P < 0.001). No significant differences were found with regard to bupivacaine volume, gender, ASA-score, height, weight, BMI or THA vs. TKA. CONCLUSION: Failed spinal anaesthesia for THA and TKA is a relatively frequent occurrence and identification of risk patients is not feasible. These results should be considered when choosing anaesthesia and included in the information to patients.

Chronic pre-operative opioid use and acute pain after fast-track total knee arthroplasty.

BACKGROUND: Pre-operative opioid use has been suggested to increase post-operative pain and opioid consumption after total knee arthroplasty (TKA), but previous studies are either retrospective or inhomogeneous with regard to surgical procedures or control of analgesic regimes, or with few opioid-treated patients, hindering firm conclusions. METHODS: In a prospective observational study, we investigated the effect of > 4 weeks pre-operative opioid use [none vs. low dose (< 30 mg morphine equivalents (eq.)) vs. high dose (> 30 mg morphine eq.] in patients scheduled for primary, unilateral TKA. All patients had well-defined multimodal opioid-sparring perioperative analgesic therapy, and continued any pre-operative opioid medication. The primary outcome was differences between groups in pain at rest and during walk for the first 6 post-operative days. RESULTS: Among 123 patients included, 115 were available for final analysis (93% follow-up rate). Post-operative pain during walk was significantly increased in both opioid-treated groups vs. non-opioid-treated patients (P < 0.009). Secondary analysis of combining all pre-operatively opioid-treated patients vs. opioid-free patients, showed significantly increased pain at rest and walk and increased post-operative opioid requirement - excluding pre-operative dosage - during the first post-operative week in opioid-treated patients (P = 0.001 and P = 0.007, respectively). CONCLUSION: Pre-operative opioid use increases the risk for post-operative pain at rest and walk, and increased opioid consumption after TKA.

Re-admissions, re-operations and length of stay in hospital after aseptic revision knee replacement in Denmark: a two-year nationwide study.

We present detailed information about early morbidity after aseptic revision knee replacement from a nationwide study. All aseptic revision knee replacements undertaken between 1st October 2009 and 30th September 2011 were analysed using the Danish National Patient Registry with additional information from the Danish Knee Arthroplasty Registry. The 1218 revisions involving 1165 patients were subdivided into total revisions, large partial revisions, partial revisions and revisions of unicondylar replacements (UKR revisions). The mean age was 65.0 years (27 to 94) and the median length of hospital stay was four days (interquartile range: 3 to 5), with a 90 days re-admission rate of 9.9%, re-operation rate of 3.5% and mortality rate of 0.2%. The age ranges of 51 to 55 years (p = 0.018), 76 to 80 years (p < 0.001) and ≥ 81 years (p < 0.001) were related to an increased risk of re-admission. The age ranges of 76 to 80 years (p = 0.018) and the large partial revision subgroup (p = 0.073) were related to an increased risk of re-operation. The ages from 76 to 80 years (p < 0.001), age ≥ 81 years (p < 0.001) and surgical time > 120 min (p < 0.001) were related to increased length of hospital stay, whereas the use of a tourniquet (p = 0.008) and surgery in a low volume centre (p = 0.013) were related to shorter length of stay. In conclusion, we found a similar incidence of early post-operative morbidity after aseptic knee revisions as has been reported after primary procedures. This suggests that a length of hospital stay ≤ four days and discharge home at that time is safe following aseptic knee revision surgery in Denmark.

Early morbidity after aseptic revision hip arthroplasty in Denmark: a two-year nationwide study.

Data on early morbidity and complications after revision total hip replacement (THR) are limited. The aim of this nationwide study was to describe and quantify early morbidity after aseptic revision THR and relate the morbidity to the extent of the revision surgical procedure. We analysed all aseptic revision THRs from 1st October 2009 to 30th September 2011 using the Danish National Patient Registry, with additional information from the Danish Hip Arthroplasty Registry. There were 1553 procedures (1490 patients) performed in 40 centres and we divided them into total revisions, acetabular component revisions, femoral stem revisions and partial revisions. The mean age of the patients was 70.4 years (25 to 98) and the median hospital stay was five days (interquartile range 3 to 7). Within 90 days of surgery, the readmission rate was 18.3%, mortality rate 1.4%, re-operation rate 6.1%, dislocation rate 7.0% and infection rate 3.0%. There were no differences in these outcomes between high- and low-volume centres. Of all readmissions, 255 (63.9%) were due to 'surgical' complications versus 144 (36.1%) 'medical' complications. Importantly, we found no differences in early morbidity across the surgical subgroups, despite major differences in the extent and complexity of operations. However, dislocations and the resulting morbidity represent the major challenge for improvement in aseptic revision THR.

Orthostatic intolerance during early mobilization after fast-track hip arthroplasty.

BACKGROUND: Early postoperative mobilization is a cornerstone in fast-track total hip arthroplasty (THA), but postoperative orthostatic intolerance (OI) may delay early recovery or lead to fainting, falls, and prosthesis dislocation or fracture. However, the prevalence and pathophysiology of OI has not been established after THA. This study evaluated the cardiovascular response and tissue oxygenation to mobilization before and after surgery in relation to OI in fast-track THA patients. METHODS: OI and the cardiovascular response to standing were evaluated with a standardized mobilization protocol, before, 6, and 24 h after surgery in 26 patients undergoing THA with spinal anaesthesia and an opioid-sparing analgesic regime. Haemoglobin, fluid balance, and opioid use were recorded. Systolic (SAP) and diastolic (DAP) arterial pressure, heart rate (HR), stroke volume (SV), cardiac output (CO), and systemic vascular resistance were measured non-invasively (Nexfin(®)) and cerebral ( ) and muscle tissue oxygenation by non-infrared spectroscopy. RESULTS: No patients demonstrated OI before surgery, whereas 11 (42%) and five (19%) patients experienced OI 6 and 24 h after surgery, respectively. OI was associated with decreased orthostatic responses in SAP, DAP, SV, CO, and compared with orthostatic tolerant patients (P<0.05). There was no difference in postoperative haemoglobin concentrations or opioid use between orthostatic intolerant and tolerant patients. CONCLUSIONS: Early postoperative OI is common in patients undergoing THA and is associated with an impaired cardiovascular orthostatic response and decreased cerebral oxygenation.

Femoral revision with impaction allografting and an uncemented femoral component.

A technique for uncemented revision of the femoral component which combines impaction allografting and the use of a long-stemmed proximally coated titanium prostheses (Bimetric, Biomet Inc.) is described. The results after a mean follow-up of 112 months are reported. From 1991 to 1995 femoral component revision for aseptic loosening was performed on 100 hips. In 14 cases (14%) an intraoperative fracture occurred and 7 patients (7%) had other postoperative complications. Seventeen patients (17%) required further revision, 10 because of aseptic loosening. Of 50 surviving patients with retained implants 88% had no pain, 10% had slight pain and only 2% had severe pain. Thirty-eight patients had radiographic signs of remodelling of the graft and/or cortical repair. In cases with a successful outcome, the results have been encouraging in relation to clinical performance, regeneration of bone and implant survival.

Cementless porous-coated total knee arthroplasty: 10-year results in a consecutive series.

We report the results of 114 AGC 2000 porous-coated, cementless total knee arthroplasties (TKA) performed consecutively in 102 patients during the period 1984-1986. After 10 years, 58 TKAs in 52 patients were evaluated with patient assessment, Hospital for Special Surgery knee score, weight-bearing radiographs done under fluoroscopic control, and survivorship analysis. All dropouts within the first 9 years were patients dying with a functioning TKA except 1 revision secondary to a supracondylar fracture after 8.5 years. Of the patients, 53 (92%) were satisfied or very satisfied with their TKA, and 55 (95%) of the knees were rated good or excellent. There was no pain in 53 knees, and the median knee flexion was 110 degrees. Six radiolucencies >1 mm were found beneath parts of the tibial component, and 5 radiolucencies were seen beneath the femoral component. None had progressed compared with the 5-year follow-up, and in all cases trabeculae could be seen reaching the prosthetic component. No migrations had occurred since the 5-year follow-up. No obvious joint space reduction was seen. Osteolysis presenting as an isolated cyst was found in 1 knee in the lateral tibial condyle and was not progressive. Two tibial components had been revised because of aseptic loosening and 1 because of septic loosening, all within the first 3 years. No femoral or patellar components were revised. The cumulative prosthesis survival rate after 10 to 11 years was 97%. When pain and radiographic loosening also were considered, the success rate was 87%. Cementless insertion of a nonmodular, porous-coated TKA resulted in a long-term durable bone-prosthesis interface. The flat-on-flat articulation did not result in catastrophic polyethylene wear or osteolysis within the first 10 years.

The hemispherical Harris-Galante acetabular cup, inserted without cement. The results of an eight to eleven-year follow-up of one hundred and sixty-eight hips.

We studied the results for 168 available hips from a series of 324 consecutive primary total hip arthroplasties that had been performed with insertion of a Harris-Galante-I acetabular component without cement. The acetabulum had been reamed in a so-called line-to-line manner, and the cup had been fixed with one to four screws. A femoral component with a modular alumina-ceramic head had been inserted with cement in all hips. The median duration of follow-up was 112 months (range, 101 to 131 months). Of the original 324 hips, 109 could not be included in the clinical and radiographic follow-up because the patients had died and thirty could not be included because the patients were not available for examination. Seventeen hips had had a revision of the acetabular cup: five, because of infection; five, because of dislocation; three, because of aseptic loosening; and four, because of technical failure. This left 168 hips for clinical and radiographic follow-up; of these, fifteen had had a revision of the femoral component only. Of the remaining 153 hips, which had not had a revision, 147 (96 percent) were considered by the patient to have a satisfactory, good, or excellent result. One hip was found to have a loose cup on radiographic evaluation and was therefore considered to have failed, but the clinical function was good. We concluded that, with an overall rate of aseptic loosening of 1 percent (four of 324) after an intermediate (ten-year) duration of follow-up, use of this cup has good results.

[Increasing incidence of clubfoot in the county of Frederiksborg]. / Stigende incidens af klumpfod i Frederiksborg Amt.

The incidence of congenital clubfoot in Frederiksborg County, Denmark, was studied over a period of 16 years (1979-1994). Altogether 60, 186 live infants were born, and of these 72 had a congenital clubfoot. Twenty-five children (35%) had bilateral clubfoot and 54 (75%) were boys. The overall incidence was 1.20 per thousand children. The incidence increased significantly during the observation period and was 2.41 per thousand in 1994. We cannot explain the rise in incidence.

[Non-cemented acetabular cup in hip arthroplasty. Prosthesis survival and clinical results after 1-8 years]. / Ucementeret acetabulaer cup ved total hoftealloplastik. Proteseoverlevelse og klinisk resultat efter 1-8 år.

This is a retrospective clinical evaluation of 1028 primary hip arthroplasties performed with the non-cemented Harris-Galante I acetabulaer cup. Hospital records regarding all hips operated from July 1985 through March 1992 were evaluated after a median of 48 (12-93) months. Furthermore, questionnaires were sent out to all patients still alive in order to establish the actual function of the hips. At time of evaluation, 43 of the 1028 primary acetabular cups (4.2%) had been or were due to be revised. (20 because of one or more episodes of dislocation or displacement of the cup, 10 due to deep infection, eight following aseptic loosening of the cup, two because of implant failure and three due to other reasons). Four hundred and twenty-six hips were without pain, 274 had only mild or slight pain, whereas 84 experienced moderate or worse pain. We conclude, that the results after non-cemented hemispheric acetabular arthroplasties in this study are satisfying with a low rate of aseptic loosening.

Evaluation of 100 Müller curved-stem and 276 Müller long-stem total hip arthroplasties after 10 to 15 years of follow-up.

This study evaluates 376 total hip arthroplasties performed between 1978 and 1983 using 276 Müller long-stem and 100 Müller curved-stem prostheses. Demographic and clinical data were obtained from patient records. All patients still alive who did not undergo revision arthroplasty were sent a detailed questionnaire. Results indicated that long-term survival of the femoral component of the arthroplasty was significantly better when the Müller long-stem was used. Furthermore, there was no difference in the clinical out-come between patients who underwent revision and those who did not. To eliminate demographic differences between the two groups, 77 patients from each group were paired. There was no difference in clinical results of the hips between the paired groups, and long-term survival of the Müller long-stem was still significantly better using Kaplan-Meier analysis.

Survival of autotransfused red cells. 51Cr studies in 10 knee arthroplasty patients.

We determined the long-term survival of red blood cells collected postoperatively from the surgical drains, filtered and autotransfused with the Constavac Blood Conservation System. 10 patients with knee arthrosis were treated with cementless total knee arthroplasty and postoperatively connected to the autotransfusion system. Shed blood was collected for 6 hours postoperatively and then reinfused. Before reinfusion, a fraction of the blood shed was radiolabeled with chromium-51 (51Cr). For a postoperative minimum period of 40 days the activity of 51Cr was measured in frequent venous blood samples. The time from 100% to 50% activity of the isotope (T50Cr) was 21 days, equal to that reported for banked autologous blood.

Late disassembly of modular acetabular components. A report of two cases.

We report two cases of late disassembly of modular acetabular components, 4 and 5 years after implantation. One was revised immediately after the disassembly and one after 4 months, the latter demonstrating excessive wear of metal and polyethylene. Radiographs showing eccentric displacement of the femoral head in the cup associated with a dark, curved shadow representing the displaced polyethylene insert identify this type of implant failure.

Older's classification of Colles' fractures. Good intraobserver and interobserver reproducibility in 185 cases.

To evaluate the reliability of the Older classification, 4 observers classified 185 distal radius fractures twice with 1 month's interval. Both the intraobserver agreement and the interobserver agreement were high, with kappa values of 0.75 (0.69-0.79) and 0.69 (0.60-0.77), respectively. The agreement was especially high for type 1 and type 4 fractures. Older's method of classifying distal radius fractures can thus be recommended for clinical use.

Displaced distal radius fractures. A comparative study of early results following external fixation, functional bracing in supination, or dorsal plaster immobilization.

A comparison of the radiographical and functional results after displaced distal radius fractures in 41 patients treated by external fixation (EF), 36 patients treated by functional bracing in supination (FUSU), and 49 patients treated by dorsal plaster immobilization (DPI) was performed. The rate of initial complications after EF was 53%, compared with 22% after FUSU and 14% after DPI. The radiographical result after EF was significantly better than after nonoperative treatment, but the functional result after 3 and 6 months demonstrated no significant difference between the three series. Consequently, EF and FUSU do not restore wrist function faster than conventional plaster treatment (DPI), but EF improves the radiographical result, though the rate of complications is higher.

Displaced diaphyseal forearm fractures in children: classification and evaluation of the early radiographic prognosis.

In a retrospective study of 70 children with 73 diaphyseal forearm fractures, we measured the radiographic angulation and sideways displacement initially, after reduction, at 1 week and at union. Statistical analysis was performed with a multivariate log linear regression model to evaluate the correlation between variables. We showed that the initial displacement of the fracture and the age of the patient had only a minor influence on the position at union. We constructed a classification system using the measurements initially, after reduction, and at 1 week and showed that the prognostic value of the classification system could be improved during the period of treatment. We recommend that all displaced diaphyseal forearm fractures in children should be radiographed after 1 week and after 2 weeks.

External fixation or a cast for Colles' fracture.

Function and radiographic position were evaluated 2.5 years after a displaced distal radial fracture had been reduced and treated by external fixation in 40 patients as compared with immobilization in a below-the-elbow cast in 91 patients. Wrist function was better after external fixation associated with less residual displacement. The frequency of arthrosis was the same in both series. The rate of complications after external fixation was higher than after immobilization in a plaster cast, notably sensory disturbances in the thumb. This complication can probably be eliminated by modifying the surgical technique.