Biomedical subjects
Publications and source records attributed to Daniel J Berry.
Long-term follow-up studies of cemented total hip arthroplasty (THA) are restricted to a few successful designs. The most studied design, the Charnley THA, has demonstrated excellent, though not perfect, survivorship at long-term follow-up in most studies. Patient-related factors including age, gender, and patient diagnosis, affect implant survivorship.
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This case discussion features knee arthroplasty cases presented to a panel of surgeons. The cases were chosen to represent common clinical problems encountered in everyday practice.
Since Charnley hip arthroplasty was introduced to North America over 30 years ago, the popularity of cemented femoral components has waxed and waned. During this time, much has been learned about factors that contribute to cemented stem success and failure. The most important factors that influence arthroplasty success with a cemented femoral stem are patient selection, intramedullary implant geometry, implant surface finish, implant design above the femoral neck resection level, and surgical technique.
This case-control study was performed to investigate the hypothesis that metal-on-metal (M-M) bearings reduce the risk of aseptic component loosening when compared with metal-on-polyethylene (M-PE) bearings. Cases were identified from a computerized joint database as patients who had received a primary total hip arthroplasty using an M-M or M-PE bearing and had documented revision or radiographic loosening of the stem or cup. Multiple controls were matched to each case for gender, age, diagnosis, hospital, operation date, follow-up, stem type, and cup design. Odds ratios were determined to identify the risk of component loosening for either bearing surface. In all, 505 cases and 1,605 controls were identified. M-M bearings demonstrated a lower risk of aseptic stem and/or cup loosening than M-PE bearings; however, this was not statistically significant.
Bearing surface wear and periprosthetic osteolysis due to wear particles are among the most common reasons for joint replacement failure. A murine calvarial model of wear particle-induced osteolysis has been used to identify different biologic factors associated with this problem and to test nonsurgical methods of modulating the host response to particulate debris. This model has utilized titanium particles, however, in clinical practice the most common source of particulate debris is polyethylene particles from bearing surface wear. We now report a calvarial model of wear particle-induced osteolysis based on commercially available polyethylene particles. We found that compared to sham surgery osteoclast recruitment and bone resorption can be induced by introduction of the titanium particles or polyethylene particles. However, bone resorption was significantly higher with polyethylene particles compared to titanium particles (p=0.02). We consider the polyethylene based murine calvarial model of wear particle-induced osteolysis a reliable and clinically relevant tool to understand the host factors and potential pharmacologic interventions that can influence wear debris generated osteolysis. This model might serve as an extension of the well-established titanium based bone resorption model.
There are no large clinical series to guide the clinician treating a subtrochanteric nonunion. Deformity, bone loss from previous hardware, and the high stresses in the subtrochanteric region all pose challenges to achieving successful bony union with reoperation. The purpose of this study was to retrospectively review a consecutive series of patients treated with reoperation using contemporary techniques for subtrochanteric nonunion. Between 1992 and 2002, 23 patients with a mean age of 55 years (range, 16-88 years) with 23 subtrochanteric nonunions were treated with additional attempts to achieve union. Two patients were lost to followup. The remaining 21 patients were followed up for a mean of 12 months (range, 6-39 months). Implants used for revision internal fixation were as follows: eight patients were treated with a cephalomedullary nail, seven patients were treated with a standard antegrade femoral nail, five patients were treated with a 95 degree angled blade plate, one patient was treated with a sliding hip screw, one patient was treated with a 95 degree dynamic condylar screw, and one patient was treated with dual large fragment plates. Eighteen of 23 patients had bone grafting: eight had autograft, six had allograft, and both were used in three patients. One patient had free vascularized fibular transfer. Twenty of 21 nonunions healed (95%). At last followup, all patients with healed fractures had no or minimal pain. All were ambulatory. There were no intraoperative complications. There was one postoperative complication (4%), an adynamic ileus that was treated medically. Revision internal fixation and selected bone grafting for subtrochanteric nonunion led to a high rate of fracture union and functional improvement. Intramedullary devices with fixation into the femoral head and neck and fixed angled devices were effective in achieving stable fixation of the proximal bony fragment.
The purpose of this review was to explore the results of antiprotrusio cages and present indications for these devices. The role of antiprotrusio cages has had several reassessments in North America during the past decade. Currently, the primary indication for antiprotrusio cages are: (1) circumstances in which a stable, uncemented hemispheric acetabular component cannot be gained; and (2) circumstances in which there is so little remaining host bone that biologic fixation of a porous implant is very unlikely. Antiprotrusio cages have been reported to have a mechanical failure rate between 0% and 15% at midterm followup but most series do not report selective results of using cages only for the most severe bone defects. Key technical points when using antiprotrusio cages include: (1) wide exposure of the acetabular bone while protecting surrounding neurovascular structures; (2) positioning the antiprotrusio cage so as to span from host bone to host bone, thereby bridging acetabular defects; (3) appropriate bone grafting of acetabular bone deficiencies; and (4) secure fixation of the cage with good dome and posterior column support.
Seventy-three patients (84 hips) 50 years or younger were treated with primary total hip arthroplasty using the Harris-Galante uncemented acetabular component. At a median followup of 10 years, there were seven acetabular metal shell revisions: five for osteolysis and one each for aseptic loosening and dislocation. There were 10 polyethylene exchanges without metal acetabular shell removal. None of the unrevised acetabular components was radiographically loose, but eight had pelvic osteolysis. The rate of 10-year survival without revision of the acetabular metal shell was 87.9% (95% confidence interval, 80.1%-95.7%). The same rate of survival without revision for aseptic acetabular component loosening was 97.3% (95% confidence interval, 92.9%-100%). Revision for aseptic acetabular loosening or polyethylene liner exchange or both was 84.5% (95% confidence interval, 75.8%-93.4%).
Between January 1989 and December 1994, 94 patients (96 knees) had a two-stage reimplantation for treatment of an infected total knee arthroplasty. All patients were treated with an interval antibiotic-loaded static cement spacer and had antibiotic-loaded bone cement for prosthesis fixation at the time of reimplantation. The purpose of this study was to assess the long-term risk of reinfection and the mechanical durability of these reimplantation arthroplasties. Patients were followed up for a median of 7.2 years (range, 2.5-13.2 years). At final followup, 15 knees (16%) had required reoperation. Nine knees (9%) had component removal for reinfection and six knees (6%) were revised for aseptic loosening. The median time to reoperation for reinfection was 1 year (range, 0.1-9.8 years). The risk of recurrent infection was not correlated with the type of organism, patient demographics, or method of prosthesis fixation at reimplantation. The survivorship free of implant removal for any reason was 90% (confidence intervals, 83.9-96.4%) at 5 years and 77.3% (confidence intervals, 65.5-89.6%) at 10 years. The survivorship free of implant removal for reinfection was 93.5% (confidence intervals, 88.5-98.7%) at 5 years and 85% (confidence intervals, 73.8-96.3%) at 10 years. Survival free of revision for mechanical failure (aseptic loosening or radiographic loosening) was 96.2% (confidence intervals, 92-100%) at 5 years and 91% (confidence intervals, 80.8-98.3%) at 10 years. These results suggest that the high likelihood of early success after two-stage reimplantation of an infected TKA is well maintained throughout long-term followup, with a modest rate of late recurrent infection or mechanical implant failure.
BACKGROUND: A widely variable prevalence of dislocation after total hip arthroplasty has been reported, partly because of varying durations of follow-up for this specific end-point. The effect of demographic factors on the long-term risk of dislocation as a function of time after total hip arthroplasty is not well understood. The purpose of the present study was to determine the risk of dislocation as a function of time after Charnley total hip arthroplasty and to investigate the demographic factors that influence the cumulative risk of dislocation. METHODS: Six thousand six hundred and twenty-three consecutive primary Charnley total hip arthroplasties were performed in 5459 patients at one institution between 1969 and 1984. The patients included 2869 female patients and 2590 male patients with a mean age of sixty-three years. All procedures were performed with a 22-mm femoral head, and all femoral and acetabular components were fixed with cement. The patients were followed at routine intervals and were specifically queried about dislocation. The cumulative risk of dislocation was calculated with use of the Kaplan-Meier method. RESULTS: Three hundred and twenty hips (4.8%) dislocated. The cumulative risk of a first-time dislocation was 1% at one month and 1.9% at one year and then rose at a constant rate of approximately 1% every five years to 7% at twenty-five years for patients who were alive and had not had a revision by that time. Multivariate analysis revealed that the relative risk of dislocation for female patients (as compared with male patients) was 2.1 and that the relative risk for patients who were seventy years old or more (as compared with those who were less than seventy years old) was 1.3. Three underlying diagnoses-osteonecrosis of the femoral head, acute fracture or nonunion of the proximal part of the femur, and inflammatory arthritis-were associated with a significantly greater risk of dislocation than osteoarthritis was. CONCLUSIONS: The cumulative long-term risk of dislocation after total hip arthroplasty is considerably greater than has been reported in short-term studies. The incidence of dislocation is highest in the first year after arthroplasty and then continues at a relatively constant rate for the life of the arthroplasty. Patients at highest risk are female patients and those with a diagnosis of osteonecrosis of the femoral head or an acute fracture or nonunion of the proximal part of the femur. LEVEL OF EVIDENCE: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.
BACKGROUND: There is a paucity of data on the treatment of femoral neck fractures in young patients. The purpose of the present study was to review the results and complications associated with the treatment of femoral neck fractures with internal fixation in a large consecutive series of young patients. METHODS: Between 1975 and 2000, eighty-three femoral neck fractures in eighty-two consecutive patients who were between fifteen and fifty years old were treated with internal fixation at our institution. Two patients died, and eight were lost to follow-up. Seventy-three fractures were followed until union, until conversion to hip arthroplasty, or for a minimum of two years; the mean duration of follow-up was 6.6 years. Fifty-one of the seventy-three fractures were displaced, and twenty-two were nondisplaced. The results and complications of treatment were retrospectively reviewed, and the effects of fracture displacement, reduction quality, and capsular decompression on outcome were evaluated. Function was assessed by evaluating pain, walking capacity, and the need for gait aids. The mean duration of follow-up for the fifty-seven patients (fifty-eight fractures) who had not undergone early conversion to arthroplasty was 8.1 years. RESULTS: Fifty-three (73%) of the seventy-three fractures healed after one operation and were associated with no evidence of osteonecrosis of the femoral head. Osteonecrosis developed in association with seventeen fractures (23%), and a nonunion developed in association with six (8%). Four of the six nonunions later healed after a secondary procedure. At the time of the final follow-up, thirteen patients had had a conversion to a total hip arthroplasty because of osteonecrosis (eleven), nonunion (one), or both (one). Five (9.8%) of the fifty-one displaced fractures were associated with the development of nonunion, and fourteen (27%) were associated with the development of osteonecrosis. Three (14%) of the twenty-two nondisplaced fractures were associated with the development of osteonecrosis, and one (4.5%) was associated with the development of nonunion. Eleven (24%) of the forty-six displaced fractures with a good to excellent reduction were associated with the development of osteonecrosis, and two (4%) were associated with the development of nonunion. Four of the five displaced fractures with a fair or poor reduction were associated with the development of osteonecrosis, nonunion, or both. CONCLUSIONS: The ten-year survival rate of the native femoral head free of conversion to total hip arthroplasty was 85%. Osteonecrosis was the main reason for conversion to total hip arthroplasty, but not all patients with osteonecrosis required further surgery. The results of treatment were influenced by fracture displacement and the quality of reduction.
BACKGROUND: Hip arthroplasty for the treatment of nonunion at the site of a femoral neck fracture has provided good short-term results. The purpose of the present study was to evaluate the long-term results and complications of total hip arthroplasty for the treatment of femoral neck nonunion. METHODS: The records of ninety-nine patients who had been managed with total hip arthroplasty with use of a cemented Charnley acetabular component and a cemented Charnley monoblock femoral component for the treatment of a femoral neck nonunion were retrospectively reviewed. The average age at the time of the arthroplasty was sixty-eight years. Eighty-four patients (85%) were followed until death, revision, or component removal or for at least two years (mean, 12.2 years) postoperatively. RESULTS: Twelve patients were treated with revision (eleven) or resection arthroplasty (one), eleven were lost to follow-up, and four died less than two years postoperatively. Of the remaining seventy-two unrevised hips that were followed for at least two years, sixty-nine (96%) had no or mild hip pain at the time of the last follow-up. The rate of component survival free of revision or removal for any reason was 93% at ten years and 76% at twenty years. The risk factors that were significantly associated with revision for aseptic loosening included an age of less than sixty-five years at the time of the arthroplasty (p = 0.045), a body-mass index of >/=30 (p < 0.01), and male gender (p = 0.02). The second most common complication after loosening was dislocation, which occurred in nine patients (9%). CONCLUSIONS: Total hip arthroplasty is an effective method for the treatment of nonunion of the femoral neck and provides satisfactory long-term results. However, the rate of implant survival is poorer than that reported in most other studies of Charnley total hip arthroplasty in the general population.
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Osteolysis around total knee arthroplasty can be difficult to identify because it typically occurs in cancellous bone of the distal femur and proximal tibia, which has a low radiodensity, and because it is often obscured on radiographs by the metallic prosthesis. Careful evaluation is warranted in circumstances where osteolysis is likely: radiographically evident polyethylene wear, high-activity young patients with a prosthesis in place for a long time period, or implant designs associated with osteolysis. Osteolysis of the distal femur is best seen on lateral radiographs and often involves the posterior condyles; on anteroposterior radiographs it may be seen as radiolucency extending proximally into either condyle. Osteolysis of the tibia often occurs along access tracks such as screws or around the periphery of well-fixed implants. Three-dimensional imaging modalities with new metal suppression technology hold the promise of improving accuracy of osteolysis detection in the near future.
Sixty-three failed total knee arthroplasties in 60 patients (27 females, 33 males; average age, 66 years) were treated consecutively with revision using cemented component fixation and an uncemented stem. Patients were followed for a mean of 5.75 years (range, 2-10 years); none were lost to follow-up. There were 12 (19%) re-revisions: 6 (10%) were revised for aseptic loosening, 4 (6%) for recurrent infection, and 2 (3%) for instability. Knee Society Pain Scores improved from 56 to 81, and function scores improved from 49 to 62 points. Latest radiographs in retained knees showed none with definite femoral loosening but 4 with tibial component loosening. Combining those revised for aseptic loosening and radiographic aseptic loosening, mechanical failure occurred in 10 patients (16%).
Periprosthetic fractures caused by osteolysis can occur in the pelvis, peritrochanteric area, or femoral diaphysis after hip arthroplasty. Most, but not all, hips are ultimately treated surgically to manage the osteolysis or to stabilize the fracture. Some stable, minimally displaced fractures of the pelvis and greater trochanter can be allowed to heal before revision is considered, which simplifies the operation. Unstable fractures, especially of the femoral diaphysis, are usually treated with early repeat surgery following the established principles of periprosthetic fracture management.
BACKGROUND: Prevention of thromboembolic complications after elective lower extremity arthroplasty has increasingly relied on routine thromboprophylaxis in all patients. Not all patients are at equal risk, however, and prophylaxis is not devoid of complications. The aim of this study was to examine the risk factors for clinically relevant pulmonary embolism and deep venous thrombosis after elective primary hip or knee arthroplasty in a large patient population. METHODS: During the 10-yr study period, 116 of 9,791 patients undergoing primary hip or knee arthroplasty at the authors' institution who experienced pulmonary embolism or deep venous thrombosis within 30 days of surgery were matched at a 1:1 ratio with patients undergoing the same surgery with the same surgeon who did not experience an adverse event. Medical records were reviewed, with data abstracted using a standardized data collection form. RESULTS: Increased body mass index (P = 0.031; odds ratio = 1.5 for each 5-kg/m2 increase) and American Society of Anesthesiologists physical status classification of 3 or greater (P = 0.005; odds ratio = 2.6) were found to independently increase the likelihood of pulmonary embolism or deep venous thrombosis. In addition, use of antithrombotic prophylaxis was found to decrease the likelihood of these thromboembolic events (P = 0.050; odds ratio = 0.2 for aspirin or subcutaneous heparin, and odds ratio = 0.4 for warfarin or low-molecular-weight heparin). CONCLUSIONS: In patients undergoing primary elective lower extremity arthroplasty, obesity, poor American Society of Anesthesiologists physical status classification, and lack of thromboprophylaxis are independent risk factors for clinically relevant thromboembolic events.