The Journal of arthroplasty

Published by Elsevier
Online ISSN: 0883-5403
Publications
Article
Blood management in the perioperative period of the total joint arthroplasty procedure has evolved over the last 3 decades. Strategies have changed and are changing based on a better understanding of blood loss and blood replacement options in this patient population. Patient-specific options based on preoperative hemoglobin levels and patient comorbidities as well as anticipated blood loss have been developed and studied. Patient-specific blood management programs have provided cost-efficient care with low morbidity.
 
Article
Polyethylene quality and production technique and monoblock versus modular design of tibial components affect the polyethylene wear of total knee arthroplasties (TKAs). We reviewed >1000 TKAs performed with the AGC prosthesis (Biomet, Warsaw, IN) using a uniform surgical technique with a 5- to 11-year follow-up. Of tibial components, 698 were of compression-molded monoblock design and 353 were of ram-extruded modular assembly design. The effect of the differences in tibial component design on the 5- to 11-year clinical and radiologic outcomes was studied. Higher rates of osteolysis, radiolucent lines, and revision were found with the ram-extruded modular design. This modular design is similar to most tibial component designs currently used in TKA, yet osteolysis in completely cemented components is described rarely. The TKAs done with a compression-molded monoblock design gave better clinical and radiologic results. The improved results may be due to polyethylene quality, assembly design, or a combination of these factors.
 
Article
A total of 893 patients with 1,000 Performance total knee prostheses were retrospectively studied. The mean follow-up was 5.2 years. In 584 cases, the femoral and tibial components were implanted using cementless techniques, and in 416 knees the femoral and tibial components were cemented. All patients received a cemented all polyethylene patellar replacement. Tibial bone density determined fixation type. The average age of patients with cementless fixation was 64.3 years versus 76.2 years for patients with cemented implants. The average subjective and functional Knee Society scores were 91.2 and 90.1 for patients with cementless knees and 89.6 and 83.5 for those with cemented replacements. A surprising absence of osteolysis around screw fixation was noted, and at 5 years, there was 99% implant survival.
 
Article
Survivorship analysis of 1,041 cemented Charnley total hip arthroplasties performed as a primary procedure revealed a probability of component survival at 10 years of 92%; the probability of acetabular cup survival was 99% and of femoral component survival was 96%. Three-zone acetabular demarcation was present in 16% of cases, as was migration of the cup greater than 5 mm. However, the acetabular revision rate was 1.65%, confirming the long-term clinical durability of the 22-mm internal diameter cup. Radiographic evidence of definite femoral component loosening was present in 9.6% and high-grade femoral bone-cement demarcation was present in 3.5%. The isolated femoral revision rate was 1.8%. Based on detailed survivorship analysis, a high-risk group of patients was identified for component failure and for femoral component loosening (radiographic). These patients were male, young (less than 50 years), heavy (greater than 170 pounds), and active (not Charnley class C). Given these findings, it is difficult to justify the widespread use of noncemented total hip systems, except in identifiable high-risk patients.
 
Article
A consecutive series of 1,390 primary total knee arthroplasty (TKA) procedures (1,201 patients, 1,600 arthroplasties) performed between January 1980 and July 1994 were reviewed to establish the incidence of death from pulmonary embolism (PE). Nine hundred twenty-three bi- or tricompartment TKAs and 467 unicompartment TKAs were performed as one-stage procedures. Chemical thromboprophylaxis was used only in high-risk cases in which there was a history of previous thromboembolism or obesity. There were no deaths from PE after unicompartment arthroplasty procedures. Autopsy confirmed PE as the cause of death in 2 patients following bi- and tricompartment TKAs (0.22%; 95% confidence interval [CI], 0.03-0.8%). The incidence was higher for one-stage bilateral TKA as 1 of the autopsy-confirmed deaths occurred in this group 0.7% (95% CI, 0.02-3.78%). Two other deaths were certified without postmortem examination (pneumonia and myocardial infarction in each case). As PE could not be ruled out as the cause of death in the latter 2 cases, these were considered as possible PE deaths to provide the maximum possible death rate that could result. Thus, the maximum possible incidence of fatal PE after TKA without routine use of chemical anticoagulation was 0.4% (95% CI 0.1-1.1%). It is concluded that the risk of fatal PE after unilateral TKA and unicompartment knee arthroplasty is low. The risk of clinical, nonfatal thromboembolic events, which might themselves warrant prophylaxis, was not quantified in this article.
 
Article
Hip resurfacing is currently the fastest growing hip procedure worldwide. We reviewed 1000 hips in 838 patients who received a Conserve Plus (Wright Medical Technology, Inc., Arlington, Tenn) resurfacing at a single institution. The mean age of the patients was 50.0 years with 74.7% male. The hips were resurfaced irrespective of femoral defect size or etiology. The mean follow-up was 5.6 years (range, 1.1-11.0 years). All clinical scores improved significantly (P < .05). There was no acetabular component loosening. Ten were converted to total hip arthroplasty for femoral neck fracture, 20 for femoral loosening, 2 for sepsis, and 1 for recurrent subluxations. The 5-year survivorship was 95.2% with no failures in hips implanted since 2002. Short-term failures can be prevented. First-generation surgical technique and a low body mass index were the most important risk factors for the procedure. Improvements in bone preparation significantly increased prosthetic survival in hips with risk factors for failure.
 
Article
One thousand consecutive cementless total hip arthroplasties performed in 759 patients using a posterior, single-incision, minimally invasive surgical approach were followed prospectively for a minimum of 2 years. All surgeries were performed using a tapered, titanium, cementless femoral component and a press-fit, ingrowth acetabular component. Mean patient age was 62.3 years. Mean incision length was 8.8 cm. Harris hip scores improved from 34 preoperatively to 92 postoperatively. Component position was considered acceptable in 95.3% of patients. Six acetabular components failed to osseointegrate, whereas no femoral component was loose. Radiolucencies were limited to the upper femur and were nonprogressive. Complications and component malpositioning were within accepted standards. This consecutive series of minimally invasive total hip arthroplasties shows that satisfactory results can be consistently achieved using this surgical technique.
 
Article
Unicompartmental knee arthroplasty (UKA) is a less invasive treatment for medial gonarthrosis. However, registry data have demonstrated higher revision and early failure rates. The purpose of this study is to report the early survivorship and failure modes in a series of 1000 consecutive medial mobile bearing UKA. UKA patients with a minimum of 2year follow-up or those meeting the study endpoint (UKA failure or death) were included. Demographic variables, pre and post-operative clinical variables, and mode of failure were analyzed. Eight hundred and thirty-nine knees were included in the analysis. Forty revisions were performed at an average of 23.1months (range, 2.3-74.2) following UKA for a survivorship of 95.2%. Indications for revision were aseptic loosening (15), tibial collapse (7), mobile bearing dislocation (2), persistent pain (12), progression of disease (2), infection (1), and tibiofemoral instability (1). These results are from a single center and may not be comparable to those of larger reports such as national registries.
 
Article
We report the radiological and clinical outcome of 102 consecutive femoral hip arthroplasty we prospectively followed up in 84 patients using the third generation of the thrust-plate prosthesis with a mean period of follow-up of 58 (range, 26-100) months. Four implants were revised: 2 because of an infection and 2 because of aseptic loosening. The thrust-plate prosthesis, which allows preservation of part of the femoral neck, was used in younger patients, 80% were younger than 60 years. In 95 implants, contact was maintained between thrust plate and underlying bone, and in only 3 instances, without any clinical manifestation, did the bone retract from the thrust plate to the extent that a gap appeared. The extent of radiologically evident bone contact with the flat surface of the thrust plate, as a consequence of the bone remodeling behavior, is described and retrospectively classified. The average Harris hip score increased from 51 points preoperatively to 96 points postoperatively at the last follow-up. Survivorship analysis according to Kaplan-Meier showed a survival rate of 98% after 6 years, with no further losses up to the end of the 8-year follow-up period.
 
Article
The authors reviewed 103 cementless AGC 2000 total knee arthroplasties in unselected cases of osteoarthritis and rheumatoid arthritis with a follow-up period of 3 years. Excellent or good clinical results were obtained in 96%. The median maximal flexion was 110 degrees. Two aseptic loosenings of the tibial components had been revised prior to this evaluation. Two other patients showed radiographic signs of tibial loosening but were asymptomatic. Undersizing of the tibial component predisposes to subsidence and loosening. One had septic tibial loosening planned for revision. Four had nonprogressive lucent lines beneath the tibial tray but were asymptomatic. No patellar or femoral component loosening was revealed. Undercorrection of preoperative varus deformity did not dispose to tibial loosening or radiolucency, nor influence the clinical result. In terms of survival of the prosthesis the cumulative success rate was 97.1%. When pain and radiographic loosening was also considered, the success rate was 90.7%. These results encourage uncemented use of this prosthesis, but emphasize the importance of good primary prosthetic fit at the tibial side.
 
Article
Functional results of resection arthroplasty are currently considered poor. In 104 hip prosthesis removals after either septic or aseptic loosening, pain, walking, joint motility, life style, and patient's opinion were evaluated. A satisfactory result was recorded in 72% of cases. Prognosis is poorer in patients who are young, have septic loosening, and have poor residual mobility. Resection arthroplasty should be considered a salvage procedure in cases of septic loosening and/or bone stock deficiency after a failed total hip arthroplasty.
 
Article
Postoperative femoral periprosthetic fracture is an uncommon complication of total hip arthroplasty surgery, but several centers worldwide have recently reported an increase in total numbers of such fractures. This severe complication is costly for society and results in high morbidity. Our analysis of 1049 periprosthetic fractures occurring in Sweden between 1979 and 2000 and recorded in the Swedish National Hip Arthroplasty Register focuses on patient- and implant-related factors, fracture classification, and fracture frequency. These were our 3 major findings: (1) a majority of the patients who sustained a late periprosthetic femoral fracture had a loose stem. (2) Implant-related factors are significantly associated with occurrence of a periprosthetic fracture. (3) Since the 1980s in Sweden, treatment results for periprosthetic fractures have been poor, with low long-term survivorship and a high frequency of complications. We have initiated further studies of this important problem.
 
Article
This prospective study analyzed data from 105 primary total knee arthroplasties performed in 90 patients using the Genesis Total Knee Arthroplasty System. The 34 men and 56 women with a mean age of 68.7 years (range, 41-86 years) were evaluated at a mean follow-up period of 4.25 years (range, 3-6 years). Fifty-five procedures (52%) used cemented femoral and tibial components, 49 (47%) used cementless femoral and cemented tibial components, and 1 (1%) used cementless femoral and tibial components. The preoperative mean pain and function scores were 50 (range, 12-79) and 41 (range, 5-80), respectively. At the most recent follow-up evaluation, the mean pain score increased to 97 (range, 67-100), and the mean function score increased to 88 (range, 40-100). Mean preoperative range of motion was 104 degrees (range, 50 degrees-130 degrees) and increased to 116 degrees (range, 80 degrees-130 degrees) at most recent follow-up evaluation. Clinically, there were 100 excellent results (95%). 4 good results (4%), and 1 poor result (1%).
 
Article
Two-stage revision is widely used for the treatment of prosthetic joint infections. However, the duration of antibiotic treatment between stages and role of reimplantation microbiology are controversial. The purpose of this study was to evaluate the outcome and influence of the reimplantation microbiology of two-staged revisions with 6weeks of antibiotic treatment. We retrospectively reviewed 107 patients treated with two-stage revision between 2001 and 2009. The overall treatment success rate was 94.4%. The reimplantation cultures were positive in 5/97 (5.2%) cases, and only one of them failed. Therefore, we achieved excellent results with a 6-week course of antibiotics between stages in two-stage revision. Positive reimplantation cultures do not seem to be associated with worse outcomes.
 
Article
One hundred eight ICLH knee arthroplasties with cementless tibial component fixation were performed from 1978 through 1982 in Gothenburg, Sweden. The patients were followed for 2-8 years (mean, 4 years) with clinical and radiographic examinations at regular intervals, and the data were computer-analyzed. Patellar subluxation-dislocation, often accompanied by pain, occurred in 50% of the knees. Eleven arthroplasties failed due to aseptic loosening. Survival rate analysis performed using three different definitions of failure resulted in cumulative success rates after 8 years of 86%, 78%, and 72%. Most failures occurred between 2 and 5 years after surgery. Patients with bilateral arthritis were overrepresented among the failures. There was a significant correlation between failure and poor bone sclerosis around the polyethylene pegs. Most patients can be treated with cementless fixation, but other types of fixation should be considered for elderly patients and patients with severe bilateral disease.
 
Article
The outcome of 109 consecutive total knee arthroplasties in 86 diabetic patients was studied. There were 73 women and 13 men, with a mean age of 69 years (range, 56-84 years). All the patients were followed for at least 36 months. The mean follow-up period was 42 months (range, 36-60 months). In the early postoperative period (< or =1 month), the overall wound infection rate was 7.3% (8 knees). The risk of deep joint infection was 5.5% (6 knees). Of the patients, 15% (17 knees) developed a urinary tract infection after the operation. The superficial and deep infection rates were higher when compared with a similar study in the general population. Maximum precautions should be taken for diabetic patients undergoing total knee arthroplasties.
 
Article
This is a retrospective, non-comparative study of 212 consecutive patients who underwent Total Hip Arthroplasty with an uncemented hydroxyapatite (HA) coated stem system from November 1997 to March 2000. The objective of the study was to analyze the performance of the implant at a minimum of 10years in older patients (mean age 79.6years). The Kaplan-Meier survivorship of the femoral stem at 10years was 100%, and 97.5% for the whole prosthesis. The mean Merle d'Aubigné clinical score improved from 4.4±2.1 points pre-operatively to 13.39±3.77 points at final follow-up (p<0.05), and the mean VAS score for thigh pain was 1.25. The radiographic analysis showed that there were no significant radiolucent lines or osteolysis compromising the fixation of the implant.
 
Article
Between 1984 and 1989, 188 consecutive femoral revision surgeries were performed. Eighteen patients died or were lost to follow-up, and the remaining 170 patients were followed for 11 to 16 years (mean, 14.2 years). Radiographic evidence of a bone ingrown stem was present in 82% of the hips, stable fibrous fixation was present in 14% of the hips, and 4% of the hips were unstable. Six stems were revised to a larger, fully coated cementless implant. Proximal femoral osteolysis was seen in 23% of femora but was limited to Gruen zones 1 and 7. No diaphyseal osteolysis was seen. The overall mechanical failure rate in this series was 4.1%. Failure of fixation correlated highly with extent of bone loss present at the time of surgery. On the basis of the radiographic and clinical results at a mean follow-up of 14.2 years, we recommend the use of extensively coated femoral stems in revision hip arthroplasty.
 
Article
Seventy-four revisions of the femoral component featuring placement of a Wagner stem in 74 patients operated upon between 1995 and 2003 were reviewed. Clinical evaluation, radiological assessment, and survival analysis of revision stems were conducted. The mean follow-up duration was 14.4years (range, 11 to 19years). When failure was defined as stem removal for any reason, 4 of 64 stems had to be further revised during the follow-up period, yielding a cumulative stem survival rate of 93.8% (95% CI: 87.7% to 98.2%) at 18years. The Wagner revision stem is an effective implant for revision hip surgery when bone stock is lacking. Use of the stem affords mechanical stability even when bone loss is massive. Copyright © 2015 Elsevier Inc. All rights reserved.
 
Article
Acetabular dysplasia causes difficulty in achieving adequate coverage of the acetabular component during total hip arthroplasty (THA). Bulk femoral-head autografting is one technique that has been used to achieve better coverage of the acetabular component. Long-term follow-up studies have shown a significant failure rate when this technique has been used in conjunction with a cemented acetabular component; however, with uncemented components, early results have been encouraging. In our study, 15 patients with acetabular dysplasia underwent uncemented THA, during which bulk femoral-head autografts were used. At an average follow-up of 10 years, no cases required revision, and radiologically, the bone graft had united. Our results support the use of bulk femoral-head autografting in patients with acetabular dysplasia requiring hip arthroplasty.
 
Article
A retrospective study of a series of 126 consecutive primary cemented total knee replacements using the AGC prosthesis is reported. Sixty-two knees were available for long-term review with an average clinical follow-up of 11.4 years (range, 8.4-13.6 years). The survivorship was 95%, defining the endpoint as revision of all components for any reason except sepsis. The average knee flexion was 110.9 degrees. The average Knee Society score was 91, and the average Knee Society Functional score was 67. There was no finding of tibial polyethylene failure, wear debris-generated osteolysis, or tibial or femoral loosening. Seven metal-backed patellae developed wear-through at an average of 80.4 months (7 of 126 for a 5.5% failure rate), with 3 (2.3%) resulting in complete revision. The authors continue to use the AGC prosthesis with an all-polyethylene patella. Compared with historical controls, the AGC has comparable survivorship.
 
Article
This report extends the follow-up for the largest center of the first multicenter US Food and Drug Administration investigational device exemption study on metal-on-metal hip resurfacing arthroplasty up to 11 years. A single surgeon performed 373 hip resurfacing arthroplasties using the hybrid Corin Cormet 2000 system. The Kaplan-Meier survivorship at 11 years was 93% when revision for any reason was used as an end point and 91% if radiographic failures were included. The clinical results demonstrate an acceptable failure rate with use of this system. Loosening of the cemented femoral components was the most common source of failure and occurred at all follow-up intervals. A learning curve that persisted for at least 200 cases was confirmed. All femoral neck fractures occurred before 6 months postoperatively.
 
Article
There are few modern reports that document the results of all-polyethylene (all-poly) tibial components in younger, active patients. The potential benefits of this design are the elimination of backside wear and lower implant cost than modular, metal-backed components. Nonetheless, since the mid 1980s, modular, metal-backed tibial trays have dominated the total knee arthroplasty market based on finite-element analysis studies that demonstrated superior force distribution compared with conventional all-poly components. As a result, backside wear has become an emerging problem and refocused design efforts on unitized components. Our clinical experience indicates that an all-poly tibial component fixed with cement can provide excellent performance and survivorship even in younger, active patients at intermediate follow-up.
 
Article
This is a report on 11 years (1990-2000) of total hip arthroplasty cases and days of discharge from one large city hospital. In 1990, patients stayed an average of 9.7 days after surgery. By 2000, patients stayed only 5.3 days. In general, women stayed longer than men, but this gap had nearly disappeared by 2000. The patients discharged in 2000 achieved fewer functional milestones during their hospital stay than those discharged in 1990.
 
Article
The performance of an anatomically designed femoral implant with porous titanium mesh coating was assessed in patients undergoing total hip arthroplasty. The stem, with built-in 12 degrees anteversion, was implanted in neutral position relative to the long axis of the femur through a cementless press-fit application. The only requirement was the presence of sufficient thickness within the cortical bone of the femoral metaphysis to support the stem. Ninety-one evaluable patients were followed up for a minimum of 10 years. Patients tolerated weight-bearing activity within 24 hours after surgery. Only 1 femoral component required revision because of loosening. Most patients showed uniform bony ingrowth. Quality of life was markedly improved. The anatomically designed, porous-coated implant provides robust performance which has general utility in a wide range of patients.
 
Article
This is a clinical and radiographic review of 87 hips in 79 patients 9 (7-11) years after acetabular revision with extensive use of morselized allograft firmly impacted into localized defects as well as the entire acetabular cavity, followed by insertion of an uncemented hydroxyapatite-coated cup with supplementary screw fixation. The 9-year survival rate for the acetabular implant was 90.5% (95% CI, 83.4%-97.6%) with revision for any reason as end point and 94% (95% CI, 89%-99.1%) with revision for aseptic loosening as end point. Acetabular revision with massive allograft impaction and hydroxyapatite-coated implants show very promising results. The limited contact between implant and host bone does not seem to compromise implant survival in the 7- to 11-year perspective.
 
Article
The purpose of this study was to identify the factors that affect polyethylene wear of 55 porous-coated anatomic total hip arthroplasties after 9 to 14 years selected from a study population of 311 implants. The average three-dimensional linear, two-dimensional linear, and volumetric wear rates were 0.096 mm/y, 0.052 mm/y, and 34 mm3/y. Negative wear was noted in 7 patients using two-dimensional techniques. Significantly higher volumetric wear rate was observed for men (48 mm3/y) compared with women (24 mm3/y; P<.01), for patients <60 years old (45 mm3/y) compared with patients >60 years old (25 mm3/y; P<.01), and for 32-mm femoral heads (54 mm3/y) compared with 26-mm femoral heads (29 mm3/y; P<.01). Volumetric wear rate for patients having small (39 mm3/y) and large (65 mm3/y) areas of osteolysis were 2 and 3 times greater than for patients having no osteolysis (21 mm3/y) (P<.01).
 
Article
The original Oxford and Low Contact Stress mobile-bearing unicompartmental knee designs have been used successfully since the mid-1970s, but have had limited exposure. Our study reviews 177 LCS unicompartment replacements (156 medial) with 5-19 years follow-up. Mean age was 68 years, 70% were female, with osteoarthritis (OA) diagnosis in 96%. Fixation was cementless in 72% and cemented in 28%. Results were good/excellent [modified Hospital for Special Surgery (HSS)] in 82%. Scores improved from 60 to 86, mean range of motion 123 degrees. Complications requiring reoperation were 32 of 177 knees (18%). Early failures were technique-related and late failures (3+ years) related to bearing wear/fracture; 15 cases required bearing exchange alone. Low contact stress mobile-bearing unicompartmental knee arthroplasties with 82% prosthetic survivorship at 11 years is encouraging, especially in a more active population and with the success of bearing exchange.
 
Article
A radiation sterilization dose (RSD) of 25 kGy is deleterious to bone allografts. This study aimed to establish a lower RSD for bone allografts using method 1 of International Standard Organisation 11137.2:2006. This provides a database to select an RSD corresponding to an allograft's bioburden, given that the bioburden's gamma resistance is equal to or less than the standard. This can be verified by irradiating 100 allografts at a dose selected to provide a sterility assurance level of 10(-2). The bioburden of our allografts was 0, which prescribed a verification dose of 1.3 kGy. After irradiating 100 allografts, sterility tests returned no positive cultures. We therefore validated an RSD of 11 kGy for allografts with that bioburden. According to the standard, this RSD provides a sterility assurance level of 10(-6) for bone allografts.
 
Article
Between 1986 and 1991, 65 cementless hemispherical acetabular cups were implanted in 60 patients in revision surgery. Different designs were used, including PCA (29 cups), Duraloc (14 cups), Harris-Galante (12 cups), and Omnifit (10 cups). The mean age of patients was 54.7 years. The Paprosky types of the acetabular tone defects were type 1, 2 hips; type 2, 38 hips; type 3A, 15 hips; and type 3B, 10 hips. For unrevised hips, the mean follow-up was 8.3 years (range, 6-11 years). Bone allografts were used in 56 hips: Morcellized cancellous graft was used in 42 hips, structural graft for contained defects was used in 7 hips, and structural graft for uncontained defects was used in 7 hips. There were poor clinical results in 14 hips (22%). Re-revision was necessary in 7 hips (10.8%). There was definite radiographic loosening in 18 hips and possible loosening in 4 hips. Screw failure occurred in 6 hips, and a radiolucency in 1 or more DeLee-Charnley zones was apparent in 45 hips (69.2%). Moderate or severe graft resorption were found in 4 of the 42 morcellized grafts, in 6 of the 7 structural grafts for uncontained defects, and in all 7 of the 7 structural grafts for contained defects. The best results were obtained in hips with a bone defect of less than 30%. The use of a cementless acetabular cup supplemented with screws is contraindicated in hips with a bone defect greater than 50%. Hip reconstruction using structural bone-graft to stabilize the prosthesis gives the worst results.
 
Article
We present a retrospective evaluation of 1369 hip arthroplasties performed using the Bicon-Plus cups and SL-Plus stems, differing only in the bearing combination. Four bearing combination groups were used: metal-on-polyethylene (MoP) group with 587 hips, ceramic-on-polyethylene (CoP) group with 161 hips, metal-on-metal (MoM) group with 322 hips and ceramic-on-ceramic (CoC) group with 299 hips. The mean follow-up was 11.5years (4.1 to 15.0). Radiological evaluation was performed on implants failed due to aseptic loosening. The survival for prosthesis with revision for any reason at ten years was 96.1% (95% confidence interval (CI) 94.3 to 97.9) for MoP, 98.1% (CI 95.9 to 100) for CoP, 90.2% (CI 86.8 to 93.6) for MoM, and 95.6% (CI 93.0 to 98.2) for CoC. Survival for aseptic loosening was also determined.
 
Article
This study regards the total articulating cementless knee. This is a mobile-bearing knee, the tibial component of which consists of 2 parts: a highly conforming polyethylene insert freely rotating on a metal tray. Our case study relating to the implant of the first 110 knees operated on consecutively from 1991 to 1995 is reported, with an average follow-up of 6.3 years (range, 5-9 years). The average preoperative Knee Society Score was 78 points, and the average postoperative score was 156 points. The complications specifically related to the prosthetic components and which required revision surgery were 4: 2 cases of instability, 1 aseptic loosening of the tibial tray, and 1 traumatic dislocation of the tibial insert. A further 3 patients underwent reoperation for causes not strictly related to the implant: 2 because of intractable patellar pain and 1 because of periprosthetic ossifications that limited flexion. All of the complications were observed in patients operated on during the first 3 years of our experience, thus suggesting a definite learning curve with this prosthesis. No evidence of progressive radiographic periprosthetic osteolysis was recorded, and no relevant polyethylene wear was observed over time. Kaplan-Meier survival curves show the probability of survival to be 93.7% with revision surgery for any reason as an endpoint, and 96.3% with revision surgery for a mechanical reason as an endpoint. Certainty that mobile-bearing total knees are able to assure a longer life of the implant than the conventional models would require an evaluation of results over 15 to 20 years. However, in the meantime, these good preliminary results at least justify continuing the use of this type of prosthesis, which still awaits confirmation of the, as-yet-theoretical, advantage compared with fixed-bearing total knees.
 
(A) Indium and (B) sulfur colloid scan from a 64-year-old woman with a painful total hip arthroplasty. The scan showed a congruent pattern of activity (matched scan) and was interpreted as negative for infection. Final histologic and culture data confirmed the absence of infection. 
Blood pooling/flow phase imaging in a 52-year-old woman with a painful total knee arthroplasty. This scan, showing activity surrounding the prosthesis, was performed after a matched indium/colloid scan indicated the lack of infection. Final histologic and culture data revealed Staphylococcus aureus as the infecting agent. 
Article
The reliability of combined indium-111 leukocyte/technetium-99m sulfur colloid scans, with and without the addition of blood pooling and blood flow studies, in the diagnosis of infected total joint arthroplasty was investigated. Both scans were performed on 58 patients before reoperation of total hip or knee arthroplasty in the period 1996-1999. Results for imaging alone included 100% specificity, 46% sensitivity, 100% positive predictive value, 84% negative predictive value, and 88% accuracy. Inclusion of blood pooling and flow phase data improved results to 66% sensitivity, 89% negative predictive value, and 90% accuracy, with reductions in specificity (98%) and positive predictive value (91%). Routine use of these radionuclide scans is not supported by these data.
 
Article
We aimed to compare the accuracy of fluorodeoxyglucose positron emission tomography (FDG-PET) with technetium-99m sulfur colloid (111)indium-labeled white blood cell scintigraphy (TcSC-Ind BM/WBC) in diagnosis of periprosthetic infection. Eighty-nine patients with 92 painful hip prostheses were recruited prospectively and given the option of undergoing either combined FDG-PET and TcSC-Ind BM/WBC or FDG-PET only. FDG-PET correctly diagnosed 20 of the 21 infected cases (sensitivity, 95.2%) and ruled out infection in 66 of the 71 aseptic hips (specificity, 93%) corresponding to a positive predictive value of 80% (20/25) and a negative predictive value of 98.5% (66/67). TcSC-Ind BM/WBC correctly identified 5 of the 10 infected cases (sensitivity, 50%) and 39 of 41 aseptic cases (specificity, 95.1%) corresponding to a positive and negative predictive values of 41.7% (5/12 cases) and 88.6% (39/44 cases), respectively. Based on these preliminary results, FDG-PET appears to be a promising diagnostic tool for distinguishing septic from aseptic painful hip prostheses.
 
Article
We prospectively enrolled 118 patients (133 knees) whose arthroplasties were performed using posterior-stabilized rotating-platform knee implants. Introduced in year 2000, this implant's performance beyond 5 years is not reported on, to date. We present 5- to 8-year (average, 6.5 years) results of 118 posterior-stabilized rotating-platform knee arthroplasties. Kaplan-Meier survival rate was 100%, considering revision or the need for it as the end point. Mean Knee Society Score improved from 27 (range, 1-54) to 96 (range, 54-100). Mean function score improved from 51 (range, 5-81) to 83 (range, 0-100). No patient had spin-out of rotating bearing or osteolysis. Postoperatively, knee flexion averaged 120° (range, 80°-155°), 34% patients achieved more than 130° flexion, and 67% patients could sit cross legged. Only 5% patients presented with patellofemoral symptoms.
 
Article
Wear of orthopaedic implants generates particles capable of inducing bone resorption and aseptic loosening of the implant. The present study shows the combined effect of particles and cell activation on macrophage (THP-1) and osteoclast (HD-11EM) release of reactive oxygen and nitrogen species, providing insight into mechanisms that can lead to osteolysis. In the absence of cell activation, exposure of either cell type to submicron zirconia or latex particles did not elicit an increase in reactive oxygen and nitrogen species production. Suboptimal stimulation with 4 beta-phorbol-12-myristate-13-acetate (PMA) plus particles resulted in a synergistic release of superoxide (O2-), however, and a low-level production of nitric oxide small middle dot by THP-1 macrophages. Similarly, particle stimulation of tumor necrosis factor-alpha-activated THP-1 cells increased O2- release. Our findings show the synergistic effect of cell activation and wear particles on O2- production by activated macrophages and osteoclasts, suggesting O2- involvement in mediating osteolysis.
 
Article
Successful medial unicompartmental knee arthroplasty is becoming standard; however, the "screw-home" mechanism, internal femoral rotation on a fixed tibia as the knee is fully extended, should be taken into account with lateral compartment arthroplasty. Twenty-nine consecutive lateral unicompartmental arthroplasties were performed with our unique tibial component positioning in 10 degrees to 15 degrees of internal rotation to compensate for the "screw-home" mechanism. The Hospital for Special Surgery knee score and serial radiographs were used in the evaluation of each patient. The mean duration of follow-up was 12.4 years with no revisions. The HSS score was excellent or good in all knees. The average postoperative femoral-tibial alignment was 5 degrees of valgus, and the average posterior tibial slope was 6 degrees . Lateral unicompartmental arthroplasty can provide excellent long-term results with modified positioning of the tibial component.
 
Article
We conducted the prospective randomized controlled trial to test that continuous femoral nerve block (CFNB) improves attainment of 120° knee flexion compared to continuous epidural analgesia (CEA). Sixty-six patients scheduled for unilateral total knee arthroplasty were randomized into two groups; infusion of ropivacaine 0.15% into CEA or CFNB to third postoperative days. We studied the time required to attain 120° knee flexion, variations in thigh and calf circumferences around the treated knee, pain scores, rehabilitation milestones, the need for adjuvant analgesics, and side effects. CFNB patients attained earlier knee flexion to 120°, lower variations in thigh and calf circumferences, less pain during rehabilitation, and less need for adjuvant analgesics. CFNB is a better pain management strategy that accelerates knee flexion rehabilitation.
 
Article
Periprosthetic femoral fractures are associated with high failure rates and mortality, particularly within one postoperative year. However, mid-term results related to this issue are lacking. Thus, we performed a retrospective follow-up evaluation. Between 2007 and 2012, we treated a total of 121 consecutive patients for periprosthetic femoral fractures. After a mean of 57.2 postoperative months, we documented a total surgical revision rate of 16.5% within the first year, and the one-year mortality rate was 13.2%. Between one year and up to 7.3 postoperative years, only one surgical revision was necessary, and the mortality rate also decreased. No significant factors related to surgical revisions were detected. However, the initial hip fracture, older age, higher ASA score and dementia were associated with a higher mortality rate. Copyright © 2014 Elsevier Inc. All rights reserved.
 
Article
This study reports the minimum 5-year follow-up of our experience with the Duracon Total Knee Arthroplasty System. A total of 121 consecutive total knee replacements using the Duracon system (Howmedica, Rutherford, NJ) were performed in 104 patients. Three patients died before the 5-year follow-up and were excluded from the final evaluation. The remaining 118 knees (101 patients) were assessed at a mean follow-up of 65 months (range, 60-80 months). The knee diagnoses were osteoarthritis in 97 patients, rheumatoid arthritis in 2 patients, osteonecrosis in 1 patient, and pigmented villonodular synovitis in 1 patient. The mean age was 70 years (range, 28-85 years). There were no reoperations for aseptic loosening, and there have been no reoperations for patellofemoral problems. At final follow-up evaluation, 112 knees (96%) had good or excellent results, and 6 knees (4%) had poor clinical results or went on to revision. For the surviving knees, the preoperative Knee Society objective score improved from a mean of 52 points (range, 20-72 points) to a final follow-up mean of 94 points (range, 66-100 points). Five knees needed reoperations: 2 knees in 1 patient because of acute hematogenous infection at 12 months, 1 knee because of a supracondylar femur fracture, 1 because of a patellar tendon rupture, and 1 to increase polyethylene thickness because of instability. The lack of aseptic loosening at the minimum 5-year follow-up compares favorably with any cemented or cementless series of knee replacement. The almost complete absence of patellofemoral complications in this series also indicates that the design changes, with particular attention to the trochlea design and patellofemoral contact throughout full flexion, have achieved their intended purpose. The results are encouraging at midterm, awaiting true long-term (15-20 years) follow-up.
 
Article
After 2 to 7 years we reviewed 125 prosthetic hip arthroplasty stem revisions using a modular tapered stem with distal fixation. Median age of these patients was 68 (33-92) years. Baseline and follow-up data were registered prospectively according to the Danish Hip Arthroplasty Registry. Survival, free of any rerevision, was 94%. Harris Hip Score improved from average 44 to 85. Bony regeneration was an early and significant finding in most cases. Complications included 4 (3%) fractures intraoperatively and 8 (6%) dislocations, 4 (3%) deep infections, and 1 (1%) stem fracture. This modular taper system is very versatile, can be used in most femoral revision cases, and allows rapid bone remodeling. We did not find an increased number of complications compared to the literature. Further long-term follow-up, however, is essential.
 
Article
The authors describe a new approach to the hip joint arthroplasty performed in 127 cases of total hip arthroplasty without major complication. A small anterior fragment of greater trochanter, maintaining the insertions of the gluteus minimus and vastus lateralis muscles, is detached. The whole insertion of the gluteus medius is preserved intact, providing good prosthetic stability and rapid recovery of abductor power and gait. Three months after surgery, 74% of patients had recovered good abductor strength with a Merle d'Aubigné and Postel score of 17 points. This surgical approach is technically easy to perform and provides good exposure of the hip. The osteotomized fragment is easily reattached using 2 cerclage wires, and upward displacement after operation was rarely seen.
 
Article
Between 1995 and 2003, 129 cemented primary THAs were performed using full acetabular impaction grafting to reconstruct acetabular deficiencies. These were classified as cavitary in 74 and segmental in 55 hips. Eighty-one patients were reviewed at mean 9.1 (6.2-14.3) years post-operatively. There were seven acetabular component revisions due to aseptic loosening, and a further 11 cases that had migrated >5mm or tilted >5° on radiological review - ten of which reported no symptoms. Kaplan-Meier analysis of revisions for aseptic loosening demonstrates 100% survival at nine years for cavitary defects compared to 82.6% for segmental defects. Our results suggest that the medium-term survival of this technique is excellent when used for purely cavitary defects but less predictable when used with large rim meshes in segmental defects.
 
Article
From January 1987 through December 2000, 1,179 cementless calcar prostheses were implanted at the Texas Center for Joint Replacement. The prosthesis is titanium, has proximal circumferential plasma-spray coating, and is designed for proximal bone loading. The average follow-up for the entire series was 6.2 years, and the projected stem survivorship at 13 years is 95.2%. There have been 9 stem revisions for loosening. When mechanical loosening alone is evaluated, the projected stem survivorship is 99%. There have been 56 revisions in the entire series. Prosthetic survivorship for the entire patient population is projected at 93.6% at 13 years. There have been no cases of distal lysis or late loosening. None of the prostheses are classified as loose at this time, and none are classified as stable fibrous fixation.
 
Article
Acetabular fracture during insertion of a cementless acetabular component occurred in 13 patients. The preoperative diagnosis was osteoarthritis in 6 patients, rheumatoid arthritis in 2 patients, avascular necrosis in 3 patients, hip fracture nonunion in 1 patient, and developmental dysplasia of the hip in 1 patient. Several different components were used; however, the acetabulum was underreamed by 1 to 3 mm in all cases. The acetabular fracture was identified in 9 of 13 cases intraoperatively. The fracture was identified on postoperative radiographs for the other 4 cases. Fractures were treated by a variety of means, including the addition of augmentation screws in or around the cup, use of autograft bone at the fracture site, modified postoperative weight-bearing status, and immobilization. In 2 cases, the socket needed to be revised after it progressively migrated and failed. One patient had cup migration, and another had a radiolucent line about the cup but was not symptomatic enough to require revision. In 3 of these 4 cases, the fracture was not identified intraoperatively. Underreaming of the acetabulum and use of an oversized acetabular component has been recommended to improve the initial stability of the acetabular component during total hip arthroplasty. Impaction of an oversized component requires bone to undergo plastic deformation if the cup is to be fully seated. Theoretically, this technique provides improved component stability with enhanced osseous ingrowth into the cup. The 13 cases reported in this study demonstrate that acetabular fracture is a complication that may occur in association with uncemented hip arthroplasty, particularly if oversized components are used. The importance of recognizing acetabular fractures intraoperatively and the need to institute appropriate treatment to ensure a stable acetabular component is emphasized. In patients with osteoporotic bone, line-to-line reaming with use of a cementless acetabular component or insertion of a cemented socket may be considered to avoid this significant complication.
 
Article
The 5- to 13-year follow-up data on 297 cementless revision arthroplasties with extensively coated components (Anatomic Medullary Locking femoral component, DePuy, Warsaw, IN) are reported. A basic classification of the femoral defects was developed. All patients were evaluated clinically and radiographically at a minimum of 60 months. Clinically, the average Postel-d'Aubigné score improved from 4.8 before to a 10.2 after surgery. Definite radiographic instability was noted in seven hips. Five patients were symptomatic and were revised. The mechanical failure rate was 2.4%. The overall complication rate was 5.7%, with a 2.6% dislocation rate. In the presence of bone loss in the proximal metaphyseal region of the femur, fixation of the femoral component is best achieved in the diaphyseal region of the femur using an extensively coated femoral component.
 
Top-cited authors
Javad Parvizi
  • Rothman Orthopaedic Institute
Michael A Mont
  • Lenox Hill Hospital
Bill Hozack
  • Rothman Orthopaedic Institute
Peter Sculco
  • Hospital for Special Surgery
Lawrence Dorr
  • Dorr Institute for Arthritis Education and Research