Retrieval analysis of porous-coated components for total knee arthroplasty: a report of two cases.
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Foreign Bodies↗
Biomedical subjects
D S Hungerford
Publications and source records attributed to D S Hungerford.
The rationale of cementless revision of cemented arthroplasty failures.
Patients with failed cemented total hip replacements develop minor to massive bone loss. In nearly all cases, the quality of the endosteal surface has been converted to a sclerotic tube. Because of the bone loss and the change in character of the remaining bone stock with which to form an interface with polymethylmethacrylate (PMMA), the microinterlock necessary for long-term interface stability cannot be achieved. Moreover, the first failure leads to the production of cement particles that incite a histiocytic osteolytic response. The difficulty in achieving interfacial stability in the revision setting is borne out in the published clinical results of cemented revision total hip arthroplasties showing failure rates ranging from 17% to 60.3%. Porous-surfaced prostheses have been introduced to permit biologic fixation as an alternative to cement fixation of each implant component. The good midterm clinical results and the lack of catastrophic bone loss when failure does occur have given impetus to the application of this technology to the revision situation. The preliminary clinical experience with cementless revision arthroplasty has yielded favorable results. The authors have fully developed the rationale against the use of PMMA in revision total hip replacements and for the cementless approach with porous-surfaced metal prostheses and bone grafts. The latter appear as a viable approach to a growing clinical problem.
Adult↗
Reflex sympathetic dystrophy affecting the knee.
Thirty-six patients with reflex sympathetic dystrophy primarily affecting the knee were reviewed. Injuries or operation about the patellofemoral joint triggered its onset in 64% of patients. Co-existent mechanical derangement of the knee was present in 64% of patients. Those patients who underwent sympathetic blockade or sympathectomy within one year of onset of symptoms had significantly better pain and function scores than those in whom intervention was later. Early diagnosis remains the key to successful management. Surgery for co-existent mechanical derangement in the affected knee should not be performed until the syndrome is controlled.
Adolescent↗
Two-year follow-up of the PCA noncemented total hip replacement.
The early results with the PCA total hip replacement have been most gratifying, especially the absence of complications related to the acetabular component. The radiographic evaluation was done critically, and the finding of no progressive acetabular radiolucencies was unexpected. Longer-term evaluation of these interfaces is necessary, but the short-term results have been encouraging. No components have migrated despite the absence of adjunct fixation mechanisms such as screws and flanges. The pressfit achieved with the roughened hemispherical surface has been adequate, and the fixation with the two outrigger pegs appears to have been sufficiently stable to preserve the prosthetic stability and has resulted in successful anchorage of all the components. The results with femoral components are obviously related to technique. In a few early cases when undersized prostheses were used, loosening occurred, and four of these components advanced to detectable loosening. One of these components was revised since this analysis. Attention to detail with maximal filling of the proximal femur apparently led to improved results, with successful anchorage in all subsequent implantations. The application of the dimensional analysis before surgery may indicate those cases in which a tight fitting metaphysis cannot be achieved. In elderly patients who have osteoporotic bone, a substantial mismatch exists between the size of the metaphysis and the diaphysis, and it may be advisable to continue with cement in these cases. By applying the dimensional analysis to preoperative templating, the surgeon may be sufficiently informed to know that a tight fit can be achieved at surgery. No catastrophic failures have occurred. If loosening does occur because of undersizing of the prosthesis, the process appears to be gradual and, although associated with pain, does not result in sudden failure. Despite the prosthesis not being anchored by cement or collar, no sudden subsidence of the components has resulted. Patients' clinical performance has been somewhat slower when compared to cemented series. Performance seems to accelerate once weight bearing occurs, however, and after 2 years no difference exists between this series and a corresponding cemented series. Noncemented total hip arthroplasty appears to offer as good if not better results than cemented total hip arthroplasty, if performed correctly and in the appropriate patient. Successful outcome depends greatly on technique, but when technically adequate implantation has been performed, the results have been gratifying.(ABSTRACT TRUNCATED AT 400 WORDS)
Activities of Daily Living↗
Cement disease.
Does "cement disease" exist? The bony environment surrounding a loosened cemented prosthesis is an abnormal pathologic condition which, if left unattended, will progress to a total failure of the joint including an inhibition of function and immobilizing pain. That biomaterial properties of the cement used for fixation also contribute to the pathologic state separates this disease from other modes of loosening. This leads inevitably to the conclusion that "cement disease" does exist. Methyl methacrylate has revolutionized the treatment of severe joint dysfunction. There can be no doubt that improving surgical technique, cement handling, and the cement itself will continue to improve the results and reduce the incidence of failure due to loosening. Cement is undoubtedly satisfactory for elderly patients with low activity levels and relatively short life expectancies. However, because of the inherent biologic and biomechanical properties of methyl methacrylate, it is unlikely that it can be rendered satisfactory in the long run for the young, the active, or the overweight patient, for whom alternatives are currently being sought. In such cases, the elimination of "cement disease" can only occur with the elimination of cement. Alternatives include the search for other grouting materials and the development of prostheses with satisfactory surfaces for either press-fit or biologic ingrowth.
Age Factors↗
The effect of sympathectomy on blood flow in bone. Regional distribution and effect over time.
Considerable interest has developed in the role of the autonomic nervous system and its effect on blood flow in bone. Theories pertaining to the long-term physiological effect of sympathectomy on blood flow in bone have been controversial. This study employed the radioactive tracer-microsphere technique to investigate the influence of sympathectomy on regional blood flow in bone over time in dogs. Blood flow was measured in fifteen adult dogs, weighing eighteen to twenty kilograms, at one hour, one day, and one, two, three, four, and six weeks after a transperitoneal sympathectomy from the first to the sixth lumbar level. Absolute control flow values were consistent with those that have been reported previously and had lower standard errors. Blood flow in bone in the femoral regions increased by 24.0 to 41.0 per cent. Greater elevations, of 37.0 to 59.0 per cent, were noted in the tibial sections. The largest increases (58.0 to 67.0 per cent) were seen in the metatarsals and proximal phalanges. All elevated values for blood flow returned to control values by six weeks. The data support the hypothesis that surgical sympathectomy exerts a significant yet transient effect on blood flow in bone. Furthermore, the greater increase distally is the first physiological evidence to support previous anatomical work that concluded that the major site of sympathetic tone lies distally in the lower extremity of the dog.
Animals↗
Achondroplasia: effectiveness of an orthosis in reducing deformity of the spine.
Deformity of the spine and its complications have long been accepted as characteristics of achondroplasia. We have sought to prevent these with a spinal orthosis. This report includes a description of the orthosis and an analysis of its use in achondroplastic children and adults. Nineteen dwarfs between 11 and 52 months of age were fitted with a light truncal polyform orthosis. The effect on the thoracolumbar (TL) and lumbosacral curves (LS) in the seated and standing child were compared by measurements made from lateral roentgenograms with and without the orthosis. The group mean reduction in TL curve of the seated dwarfs was 23 degrees (range 2 degrees to 73 degrees) and the reduction in the LS curve in the standing position was 15 degrees (range 1 degree to 44 degrees). Seventeen older children aged 4-1/2 to 11-2/3 years were equipped with an aluminum version of the orthosis. Their TL curve sitting was reduced by a mean of 31 degrees (range 6 degrees to 45 degrees) and their LS curve standing was decreased by 16 degrees (range 6 degrees to 30 degrees). Thirty-one achondroplastic children and adults were braced for back pain and/or neurologic deficits. Most were relieved of their symptoms to some degree. These and other data lead us to conclude that this form of treatment reduces deformity and alleviates symptoms.
Achondroplasia↗
[Current knowledge and future perspectives of cementless endoprosthetics].
The current problems facing the clinician, regarding young patients whose hips and knees have completely deteriorated, involve a return to function, as well as a longer life for the prosthesis than that rendered by cement fixation. The alternatives to cemented primary fixation devices have not yet with stood the test of time. In addition, when aseptic loosening of cemented prostheses occurs, cemented revisions have already demonstrated a high failure rate after a short-term follow-up, particularly in the hip. A follow-up period of up to 6 years for a cementless total knee and a short-term follow-up for a cementless hip (up to 3 years), using a porous metal bone contact surface, have shown very satisfactory clinical results in primary total hip and knee prostheses and revision of the total hip without the use of bone cement. These early results justify continuation of this clinical trial.
Bone Cements↗
Total knee arthroplasty following patellectomy.
Eleven patients with a previous patellectomy and primary total knee arthroplasty (TKA) had chart reviews, recent clinical examinations, evaluation of roentgenograms, rating of knee arthroplasty on a standard scale, and quantitation of quadriceps and hamstring torque using an isokinetic dynamometer. Good to excellent results were present in only five of the 11 knees studied, compared with 11 of 11 patients in a control group with intact patellae. Quadriceps and hamstring torque and strength were diminished relative to the control groups. Factors that correlated with a success or failure of TKA in patients with previous patellectomy included: number of previous knee operations, three or less; presence of severe arthritic changes roentgenographically; and quadriceps performance of greater than 40 ft-lb at 30 degrees/second testing speed. Patients without patellae who lack these favorable prognostic factors for a successful TKA should be strongly considered for bracing or primary arthrodesis, rather than knee arthroplasty.
Adult↗
Results of total knee arthroplasty after failed proximal tibial osteotomy for osteoarthritis.
The cases of twenty-one consecutive patients who had a minimally constrained total knee arthroplasty (six of whom had a cemented and fifteen, an uncemented prosthesis) after a failed proximal tibial osteotomy for osteoarthritis were compared with those of a non-consecutive group of twenty-one patients who had had a primary total knee arthroplasty for osteoarthritis. The groups were matched according to age and sex of the patient, type of prosthesis and fixation, and length of follow-up. At an average length of follow-up of 2.9 years, a good or excellent result was obtained in 81 per cent of the patients who had had a previous osteotomy. At an average length of follow-up of 2.8 years, a good or excellent result was obtained in 100 per cent of the patients who had had a primary arthroplasty. Two patients in the osteotomy group and none in the primary arthroplasty group required additional surgery. At the time of arthroplasty, technical difficulties in exposing the proximal part of the tibia were noted in three patients in the group that had undergone an osteotomy. The results of total knee arthroplasty after failed proximal tibial osteotomy approached but did not equal the results after primary total knee arthroplasty.
Adult↗
The early diagnosis of ischemic necrosis of bone.
One hundred sixty-nine patients with radiographic or histologic evidence of ischemic necrosis of bone (INB) were evaluated. Ninety-nine (59%) of the 169 patients had multiple sites of INB, with 310 bones affected. Two hundred sixty-three (85%) of the 310 ischemic bones were symptomatic. Routine radiography produced negative findings in 58 (20%) of the bones with histologically confirmed INB. Results of hemodynamic studies, including baseline bone marrow pressure, saline stress test, and/or intraosseous venography, were abnormal in 243 (94%) of 259 ischemic bones so evaluated. Most importantly, hemodynamic studies detected 51 (93%) of the 55 bones that were radiographically normal but had histologically confirmed INB.
Adolescent↗
Reflex sympathetic dystrophy as a cause of poor results after total knee arthroplasty.
In a series of 662 primary total knee arthroplasties, reflex sympathetic dystrophy (RSD) was diagnosed in five patients (0.8%), four of whom demonstrated marked limitation of flexion requiring manipulation during the early postoperative period. Limitation of flexion, along with excessive pain and cutaneous hypersensitivity, should alert the surgeon to the possibility of RSD. Classic posttraumatic RSD findings of objective vasomotor changes and radiographic osteopenia may be difficult to interpret in patients after total knee arthroplasty. Sympathetic blockade is the key diagnostic and therapeutic measure in the management of RSD. RSD should be considered in a differential diagnosis of early poor results after total knee arthroplasty.
Aged↗
Hyaluronic acid and its effect on postoperative adhesions in the rabbit flexor tendon. A preliminary look.
The effect of hyaluronic acid in preventing adhesion formation in a surgically prepared rabbit flexor tendon model has been evaluated. Nineteen rabbits had partial tenotomy of the middle digit flexor profundus tendon, eight being treated with hyaluronic acid and eleven with saline. The quality of tendon repair and the quantity of adhesion tissue were graded. Though both the treated and control groups showed significant adhesions, the hyaluronic acid treated tendons showed less adhesion tissue and better sliding properties as compared to the controls. No significant difference was noted in the quality of tendon repair and no adverse effects of hyaluronic acid were seen. It is proposed that additional investigation into the development of a better model of postoperative tendon adhesions and an improved characterization of this model are needed. This preliminary study suggests that hyaluronic acid is effective in reducing the quantity of adhesions after tendon surgery but warrants further evaluation.
Animals↗
Corticosteroid therapy associated with ischemic necrosis of bone in systemic lupus erythematosus.
In this prospective study, 28 (52 percent) of 54 patients with systemic lupus erythematosus (SLE) had ischemic necrosis of bone in 93 sites. All but two of the patients had multiple sites of involvement, with hips, knees, and shoulders affected in decreasing order of frequency. Demographic, clinical, and laboratory features were comparable in patients with and without ischemic necrosis of bone except for cushingoid changes in 24 (86 percent) of the 28 patients with ischemic necrosis of bone versus four (15 percent) of the 26 patients without ischemic necrosis of bone (p less than 0.0001). The duration of steroid therapy, total cumulative steroid dose, and the mean daily prednisone dose for the first one, three, six, and 12 months of therapy were not significantly different between the two groups. Mean daily prednisone dose for the highest single month as well as the highest consecutive three, six, and 12 months of therapy was significantly higher in patients with ischemic necrosis of bone. The mean daily dose of prednisone for the highest month of therapy was greater than 40 mg per day in 93 percent and greater than 20 mg per day in all patients with ischemic necrosis of bone. In patients with ischemic necrosis of bone, there was a statistically significant correlation between higher mean prednisone dose at all time intervals and increased number of bony sites involved. A lower mean dose of prednisone was required to produce ischemic necrosis of bone in patients with Raynaud's phenomenon.
Adolescent↗
Clinical experience with an acetabular cup for cementless use.
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Adult↗
The importance of increased intraosseous pressure in the development of osteonecrosis of the femoral head: implications for treatment.
Early diagnosis of osteonecrosis by radiograph, bone scan, CT scan, magnetic resonance imaging (MRI), intraosseous pressure measurement, or intraosseous venogram can lead to early successful treatment. For early (Ficat stages I and II) osteonecrosis of the hip, core decompression can provide diagnostic confirmation and pain relief and may prevent progression of disease. For more advanced disease (Ficat stages II and IV), osteotomy, endoprosthetic or bipolar prosthetic replacement, total hip arthroplasty, and arthrodesis are surgical options.
Alcoholism↗
Comparison of bone scan and radiograph sensitivity in the detection of steroid-induced ischemic necrosis of bone.
A prospective study of bone scanning for detection of ischemic necrosis of bone (INB) was performed in 36 patients (97% female, age range 16-36 yrs.) with systemic lupus erythematosis (SLE). Since the hips, knees, and shoulders are usually affected by INB in patients with SLE, 300 K converging collimator images of these joints were obtained on film and in digital format 2 to 3 hours after the injection of 20 mCi (740 MBq) of Tc-99m methylene diphosphonate. All patients underwent radiography of the joints, and 10 had intraosseous pressure determinations in the marrow space of affected joints (n = 31) for independent assessment of INB. Scans showed abnormally increased joint activity in 28 of the 36 patients. A total of 97 joints showed abnormalities, 19% in the hips, 34% in the knees, and 47% in the shoulders. Twenty-four of 27 joints with elevated bone marrow pressure (BMP) had abnormal scans (sensitivity = 89%), and scans were abnormal in 2 of 4 joints with normal pressures (specificity = 50%). The positive predictive value of the scans compared with BMP measurements was 92% (24/26). Eleven of 27 joints with abnormal BMP had abnormal radiographs, a sensitivity of 41%.
Adolescent↗
Pathogenesis of ischemic necrosis of the femoral head.
The findings of elevated BMP in the preradiologic stages of INFH and the histologic findings of extensive bone marrow ischemia and necrosis preceding trabecular death support the pathogenetic concept that INFH represents a compartment syndrome similar to the anterior tibial compartment syndrome following tibial fracture and increased intracranial pressure following closed head injury. The documentation by multiple authors that decompression instituted in the preradiologic stage leads to a high percentage of success both in relief of symptoms and lack of radiographic progression further supports this hypothesis. The compartment syndrome can be viewed as the final common path down which multiple etiologic entities proceed to a clinical syndrome that has a remarkably uniform clinical and radiographic expression. Acceptance of this pathogenetic concept leads to an aggressive approach to early diagnosis and treatment. Even in these circumstances, the majority of patients with INFH will seek help for the first side only after collapse has begun, at which time a decompression offers only a temporary relief of symptoms but does not appear to significantly alter the course of the disease over the long term. However, since the majority of patients with nontraumatic INFH will develop the disease on the second side and since only a small percentage have bilaterally collapsed femoral heads, an opportunity frequently exists to salvage the second side.
Adult↗