Correlation of age, acromial morphology, and rotator cuff tear pathology diagnosed by ultrasound in asymptomatic patients.

The importance of acromial morphology in the pathogenesis of rotator cuff tears remains controversial. Some surgeons place great emphasis on acromial morphology and others feel that acromial shape is a result of cuff tear pathology rather than the cause. The purpose of this study was to determine if there was an association between acromial morphology, age, and rotator cuff tears found by ultrasound in asymptomatic volunteer subjects with no past history of shoulder symptoms. One hundred eighteen outlet x-rays and ultrasound scans were performed in 59 asymptomatic patients in various age groups. Acromial morphology and the age of the patients were then correlated with the ultrasound findings. Older patients were noted to have a high incidence of type II and type III acromions (93% of those over 70). Full- and partial-thickness tears were more commonly seen in patients with type II or type III acromions compared with type I. Patients over 50 years had a high incidence of full-thickness tears (40%), but the incidence did not increase with increasing age past 50. These findings lend credence to the multifactorial etiology of rotator cuff tears. The patient's age (degeneration) and acromial morphology (impingement) are two of the factors involved in causing rotator cuff tears. The incidence of cuff tears and type III acromions was high in this group of entirely asymptomatic volunteer subjects. Surgeons should interpret radiologically hooked or curved acromions as well as rotator cuff tears diagnosed with ultrasound or other modalities with caution. It may well be that both of these findings should be regarded as part of the natural ageing process.

Patient demographics as a predictor of the ten-year survival rate in primary total knee replacement.

s the surgical indications for total knee replacement (TKR) expand to include younger, heavier and more active patients, knowledge of the effect of these demographic variables on the outcome and survival of the implant is increasingly important. Between November 1986 and September 1990, 402 patients underwent 562 primary cemented cruciate-retaining TKRs carried out by a single surgical team. The overall results showed a survival of 96.8% at 14 years with 1.44% lost to follow-up. Evaluating the demographics of these patients showed that certain groups fared significantly less well. The best results were seen in non-obese women with osteoarthritis who were over 60 years of age in whom there was ten-year survival of 99.4%. The worst results were in obese men with osteoarthritis who were less than 60 years of age in whom there was a ten-year survival of 35.7%. Caution should be exercised when considering TKR on a patient with this combination of poor risk factors. By identifying demographic factors at the time of consultation the surgeon is better able to predict the survival of the TKR. This information is important when considering the best options for treatment of a patient and in providing accurate information during preoperative counselling.

Bipolar shoulder arthroplasty in patients with osteoarthritis: short-term clinical results and evaluation of birotational head motion.

To determine the clinical outcome and evaluate the biomechanical properties (persisting birotational head motion) of the bipolar shoulder system in patients with primary osteoarthritis, a prospective study of 48 shoulders in 43 patients was undertaken. Patients were monitored for a mean of 3. 1 years (range 2 to 6 years). Pain relief was achieved in 92% of cases. Forty-one (96%) patients were satisfied with the result of the surgery, and satisfactory results were obtained in 92% of shoulders (with The University of California at Los Angeles rating system). Prosthetic birotational motion (head-shell and shell-glenoid motion) persisted in all shoulders. Bipolar shoulder arthroplasty is a low-friction device with persisting birotational head motion that offers excellent pain relief, eliminates glenoid component loosening concerns, and represents an adequate alternative to shoulder arthroplasty. Early results have been promising.

Repair of massive rotator cuff tears in patients older than 70 years.

Major ruptures of the rotator cuff are common in elderly patients, and their management has been a challenge for orthopaedic surgeons. This study was undertaken to evaluate the results obtained in patients older than 70 years who were treated with open surgical repair for massive ruptures of the rotator cuff tendons and to correlate the functional outcomes with the quality of the repairs. Between January 1991 and November 1994, 69 patients older than 70 years of age underwent rotator cuff repairs of massive tears with a minimum follow-up of 2 years (mean of 3 years). These patients were evaluated before and after surgery with the University of California at Los Angeles score. The mean age was 75 years (range 70 to 90 years), and female sex and right shoulder were predominant. A good bone-tendon repair was achieved in 55 patients, a fair bone-tendon repair in 5 patients, a poor bone tendon-repair in 8 patients, and 1 patient had no repair. The mean University of California at Los Angeles rating score before surgery was 9.4 points, and the mean postoperative score at final follow-up was 30.9 points, with an average improvement of 21.5 points (P = .0001). Satisfactory results were achieved in 78.2% of the patients (University of California at Los Angeles score equal or over 28). The patients' clinical results and postoperative arthrograms are evaluated with regard to the quality of cuff repair. Painful massive rotator cuff tears can be repaired in patients older than 70 years with satisfactory results.

Non-Hodgkin's lymphoma as an unexpected diagnosis in a shoulder arthroplasty.

Shoulder arthroplasty (SA) is commonly performed in patients with rheumatoid arthritis (RA) who have been treated with long-term immunosuppressive medication. RA is associated with an increased risk of neoplasms of the immune system. A case of non-Hodgkin's lymphoma as an unexpected diagnosis after the routine pathologic examination of the soft tissues after SA was detected in a 54-year-old woman with long-standing RA and prolonged immunosuppressive therapy. Although this case does not support the cost-effectiveness of routine specimen evaluation during SA, we suggest that histological analysis of the surgical tissues is appropriate and should be performed in all patients who have been treated with prolonged immunosuppressive medication, especially RA patients as well as patients who have suspicious surgical findings.

Periprosthetic humeral fractures: management and classification.

Six patients (67 to 94 years of age) sustained a periprosthetic humeral fracture at an average of 43 months after shoulder arthroplasty (range 13 to 85 months). These fractures were classified depending on fracture anatomy and implant stability. Type A fractures occur about the tuberosities. Type B fractures occur about the stem and are subclassified by fracture anatomy and implant stability: B1 fractures are spiral fractures with a stable implant, B2 fractures are transverse or short oblique fractures about the tip of the stem with a stable implant, and B3 fractures are those fractures about the stem with an unstable implant. Type C fractures occur well distal to the tip of the stem. Five of the 6 fractures required surgery, 4 with revision to a long-stemmed component. All fractures united with restoration of range of motion and function. Satisfactory results may be anticipated if these fractures are managed in an appropriate fashion.

Home continuous passive motion machine versus professional physical therapy following total knee replacement.

A vigorous rehabilitation program following discharge from the hospital is necessary for patients having a total knee arthroplasty to maintain and improve range of motion and function. To compare the effectiveness of the continuous passive motion (CPM) machine as a home therapy program versus professional physical therapy, a prospective, comparative, randomized clinical study of 103 consecutive primary total knee arthroplasties in 80 patients (23 bilateral) was performed. The CPM group consisted of 37 patients (49 knees), and the physical therapy group consisted of 43 patients (54 knees). At 2 weeks, knee flexion was similar in the two groups, but a flexion contracture was noted in the CPM group (4.2 degrees). This difference is felt by the authors to be clinically insignificant. At 6 months, there were no differences in knee scores, knee flexion, presence of flexion contracture, or extensor lag between the two groups. The cost for the CPM machine group was $10,582 ($286 per patient), and the cost for professional therapy was $23,994 ($558 per patient). We conclude that the CPM machine after the hospital discharge of patients having total knee replacement is an adequate rehabilitation alternative with lower cost and with no difference in results compared with professional therapy.

Bipolar shoulder arthroplasty for painful conditions of the shoulder.

Between April 1991 and March 1997, 182 bipolar shoulder replacements were implanted in 174 patients (8 bilateral) for painful conditions of the shoulder. The study group comprises 108 patients who were followed for an average of 2.9 years (range, 2-6 years). Diagnoses included osteoarthritis (51), rotator cuff arthropathy (27), avascular necrosis (3), revisions (8), rheumatoid arthritis (2), and fractures--both old and recent (17). A satisfactory rating (University of California at Los Angeles shoulder rating score greater than or equal to 28 points of 35) was achieved by 72% of the patients (including rotator cuff arthropathy patients). Patients with osteoarthritis obtained 90.2% of satisfactory results (46 of 51). The overall pain score after surgery was 8.8 points (of 10), meaning that none or occasional pain was present. Five patients required prosthetic revision, and 102 (94.4%) were satisfied with the surgical procedure.

Scintigraphic evaluation in total knee failure secondary to severe metallosis.

The scintigraphic findings are described for a patient with severe metallosis in a failed noninfected total knee arthroplasty secondary to metal-metal friction between the femoral and tibial components as a result of polyethylene wear. Technetium-99m phosphate and gallium-67 citrate scans were positive in incongruent uptake areas. This uptake is classically associated with septic loosening. The recommendation is made that metallosis be suspected before surgery as a possible cause of a false positive scan where sequential technetium-gallium scans are employed.

Nonunion after a tibial shaft fracture complicating tibial tubercule osteotomy.

Tibial shaft fracture after tibial tubercle osteotomy in total knee replacement is a rare complication. We report on a 67-year-old man who had a knee revision arthroplasty in which a long tubercle osteotomy was performed to facilitate exposure. Three weeks after surgery, he presented with a transverse shaft fracture, which became a nonunion requiring surgical management. This shaft nonunion and its solution after tibial tubercle osteotomy is discussed as well as relevant literature.

Midterm results in metal-backed patella revisions for metallosis.

Nine patients underwent isolated patellar revisions and synovectomies for metallosis secondary to the mechanical failure of metal-backed patellar components. These patients were followed for an average of 5 years (range, 2 to 8 years). In all cases, the femoral and tibial components were left in place, and in one patient the patellar bone was deemed too thin to resurface. Two patients (22%) developed deep infection. One infection (enterococcal) required arthrodesis, and the other (staphylococcal) was successfully managed with a two-staged reimplantation. A third patient sustained an inferior patella pole fracture that was treated conservatively. The remaining six patients are functioning satisfactorily. Metallosis is a serious complication in knee arthroplasty, and these patients merit close follow-up.

Restoration of limb alignment in total knee arthroplasty: evaluation and methods.

Obtaining adequate alignment is critical in the proper performance of total knee arthroplasty (TKA). This study prospectively evaluates 350 patients who had previous TKA. Its goals are to establish the best method of measuring limb alignment as well as the best method of restoring ideal alignment. Intramedullary alignment techniques were compared with extramedullary, and alignment of each limb was evaluated by both long (scanogram) and short films (14 inches x 17 inches). Conclusions reached were (1) that only data obtained from full limb radiographs are accurate for determining and reporting limb alignment in TKA, (2) that alignment values should be reported relative to the mechanical axis of the limb because of the variability of the femoral anatomic angle, (3) that intramedullary femoral guides are required to make accurate femoral bone cuts, (4) that extramedullary tibial guides permit accurate cuts of the proximal end of the tibia, and (5) that tibial intramedullary guides are not only unnecessary but also potentially misleading.

Posterior cruciate recession in total knee arthroplasty.

Incremental recession of the posterior cruciate ligament (PCL), as a part of ligamentous balancing in total knee arthroplasty, is critical if the PCL is too tight. This study was undertaken to evaluate any possible untoward effects of PCL recession. Twenty-one patients who underwent simultaneous bilateral total knee arthroplasty between 1988 and 1992 with a PCL recession performed only on one side (necessary to balance the knee) served as the study group. The average follow-up period was 4 years. The patients were evaluated subjectively, by manual physical testing, by radiography, and by KT-1000 arthrometry (Medmetric, San Diego, CA). There were no significant differences between the recessed and nonrecessed knees. The conclusion is that PCL recession is appropriate and safe long-term for the patient in whom the PCL is found to be too tight at the time of knee arthroplasty.

Bone cement--porous coated or hydroxylapatite coated prosthesis in total knee arthroplasty--state of the art--future trends.

1. Cementation in total knees is here to stay. 2. Future improvements will lie in the area of implant interfaces--in the near term by improving our polyethylene. 3. Cementless knees, with or without HA, may be indicated in the young, more active patient and where economic concerns have no impact on prosthetic selection.

Thigh pain following tourniquet application in simultaneous bilateral total knee replacement arthroplasty.

Thigh pain following tourniquet application is a common patient complaint in the early postoperative period following total knee arthroplasty. Postoperative thigh pain was evaluated in 28 consecutive simultaneous bilateral total knee arthroplasty patients between April 1996 and October 1996. A prospective, double-blind, randomized clinical trial was performed. Tourniquet pressure of 350 mmHg was used on 1 thigh (thigh 1) and 100 mmHg plus systolic blood pressure on the other (thigh 2). A scale of pain (no pain, mild, moderate, or severe) was applied on the first, second, and third days, as well as 2 and 6 weeks after surgery. There were 16 men and 12 women with a mean age of 72 years (range, 55-85 years). The mean tourniquet time was similar in both groups (thigh 1 = 23 minutes, thigh 2 = 22 minutes). The mean tourniquet pressure in thigh 2 was 230 mmHg (range, 212-260 mmHg). There was a statistically significant difference in thigh pain on the first (P = .01), second (P = .01), and third (P = .001) postoperative days between both groups, with more thigh pain on the 350 mmHg side. At 6 weeks after surgery, the difference in thigh pain was gone. For total knee arthroplasty, using the tourniquet at a pressure of 100 mmHg above the systolic blood pressure is recommended. This is adequate to provide a bloodless field and will result in a less unpleasant postoperative period.

Bipolar shoulder arthroplasty for rotator cuff arthropathy.

Between July 1991 and February 1995, 33 patients underwent bipolar shoulder arthroplasty for painful rotator cuff arthropathy of the shoulder. Twenty-two of these patients have been followed for an average of 28 months (range 24 to 48 months) and comprised the study group. All patients had massive, irreparable rotator cuff tears and presented with preserved passive motion, good deltoid function, and obliterated glenohumeral joint surfaces. Function and comfort were dramatically improved in all patients, with an average increase in active forward elevation of 29 degrees and a gain in active external rotation of 39 degrees. There was one complication requiring reoperation at 4 years. Utilizing the UCLA and Swanson scoring systems, all patients were rated fair or better.

Recurrent hemarthrosis after total knee arthroplasty.

Seven patients developed recurrent hemarthroses following total knee arthroplasty. The average interval between arthroplasty and the first bleed was more than 20 months (range, 1-30 months). All seven required open synovectomy an average of 21 months (6-31 months) after arthroplasty. Follow-up evaluation averaged 44 months (19-60 months) and all had an excellent result without further bleeds. A prolific synovitis was seen in all cases, with histologic features revealing a chronic synovitis with fibrosis and hemosiderin staining. Entrapment of the proliferative synovial tissue between the components is postulated to be the etiology for these recurrent bleeds which averaged four per patient prior to synovectomy.

Preoperative medical evaluation in patients having joint replacement surgery: added benefits.

Elderly patients having elective total joint replacement surgery are at increased perioperative risk because of comorbid conditions. To show the importance of the preoperative medical evaluation for total joint replacement, we reviewed the records of 238 patients who had screening for total joint replacement surgery in 1994. Of these 238 patients, 76 (32%) benefited from findings on the preoperative medical evaluation. Four percent of these patients were found to have a condition that warranted the postponement or cancellation of surgery, and others were found to have a condition that was immediately treatable. Some patients required referral to their primary care provider or to a specialist. This study emphasizes the importance and added benefits of the preoperative medical evaluation for elderly patients having elective total joint replacement surgery.