Biomedical subjects
Publications and source records attributed to F S Haddad.
As the need for hip and knee replacement continues to increase, technical and material changes have allowed a dramatic evolution in the way that degenerative, inflammatory and traumatic arthritis are managed. Advances include new bearing surfaces which should have greater longevity, minimal incision joint replacement, computer guidance and partial joint resurfacing for younger patients. These advances and their implications are discussed.
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The Kent hip is a distally-locked femoral stem which was developed to address severe proximal bone loss, severe bony deformity and peri-prosthetic fracture. We reviewed the results of 145 consecutive Kent hips implanted into 141 patients between 1987 and 2000. The indications for implantation were aseptic loosening (75 hips), septic loosening (two), peri-prosthetic and prosthetic fracture (37), severe bony deformity (24), and fracture through a proximal femoral metastasis (seven). The median time to full weight-bearing after surgery was two days and the mean length of follow-up was 5.1 years (2 to 15). Further revisions were required for 13 femoral stems. With removal of the stem for any reason as an end-point, the cumulative survival at five, ten and 15 years was 93%, 89% and 77%, respectively. In patients aged>or=70 years, the cumulative survival at 15 years was 92%, compared with 68% in those aged<70 years. Because of these findings, we recommend the use of interlocking stems in patients aged>or=70 years, particularly in those with a peri-prosthetic fracture, for whom alternative methods are limited. Outcome scores and survival data, compared with other systems, indicate that the Kent hip should be used with caution in younger patients.
Compartment syndrome occurs when pressure within a closed muscle compartment exceeds the perfusion pressure and results in muscle and nerve ischaemia. Two distinct conditions are recognized: acute and chronic (exertional) compartment syndromes. Differences in aetiology, pathophysiology and management are elaborated on in this article.
Pelvic fractures are associated with a high mortality and morbidity and their presence should be considered in all high energy traumas. Early management is directed towards basic advanced trauma life support (ATLS) principles but it is essential to be aware of the diagnosis and management of these complex injuries.
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We reviewed retrospectively the outcome of the treatment by impaction grafting of periprosthetic femoral fractures around loose stems in 106 patients with Vancouver type-B2 and type-B3 fractures. Eighty-nine patients had a cemented revision with impaction grafting and a long or short stem. The remaining 17 had cemented revision without impaction grafting. Fractures treated by impaction grafting and a long stem were more than five times likely to unite than those treated by impaction grafting and a short stem (odds ratio = 5.5, 95% confidence interval (CI) 1.54 to 19.6; p = 0.009). Furthermore, those with impaction grafting and a long stem were significantly more likely to unite than those with a long stem without impaction grafting (odds ratio = 4.07, 95% CI 1.10 to 15.0; p = 0.035). There was also a trend towards a higher rate of union in those treated by impaction grafting than in those without (odds ratio = 2.69, 95% CI 0.86 to 8.45; p = 0.090). Impaction grafting is being increasingly widely used for the restoration of femoral bone stock. It can be successfully applied to periprosthetic femoral fractures but a long stem should be used to bypass the distal fracture line.
Bony deficiency, particularly loss of bone stock associated with failed joint replacements or tumours, is a challenging problem in orthopaedic surgery. Bone transplantation techniques provide solutions that can be tailored to the clinical problem. However, the risks of bone transplantation are well documented and the biology of allograft incorporation remains unpredictable and poorly understood.
We compared 28 total hip arthroplasties done in dysplastic hips after previous Chiari osteotomy (group I) with a well-matched control group of 50 primary procedures (group II) done during the same period at an average follow-up of 5 years (range, 25-199 months). Group I required significantly less acetabular augmentation, had significantly shorter operative times, had less intraoperative blood loss, and had fewer complications than group II. There was no significant difference between the 2 groups in terms of clinical or radiographic outcome. Total hip arthroplasty after a successful Chiari osteotomy leads to medium-term results similar to those of other dysplastic hips. In our experience, less bone grafting was required, better coverage of the cup by host-bone was obtained, and the center of motion of the hip was more anatomic. Chiari osteotomy may delay the need for total hip arthroplasty, may facilitate acetabular reconstruction, and does not seem to compromise the medium-term clinical or radiographic outcome.
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Sixty patients were prospectively assessed using the Western Ontario and McMaster Osteoarthritis Index (WOMAC) scale for osteoarthritis of the hip and the Short Form 36 (SF-36) general health status scale as well as the expectation WOMAC, which asked patients to estimate how they expected to feel 6 months after revision hip arthroplasty. There was a wide range of expectations, but we were unable to find any significant correlation between the patients' preoperative pain and stiffness levels and their expectations for pain and stiffness after revision hip arthroplasty. There was no significant correlation between the SF-36 scores and the patients' expectations. Our findings suggest that the expectations of patients awaiting revision hip arthroplasties are high and are not related closely to the level of preoperative disability.
The differences between the pneumatic compression thromboprophylaxis delivered after elective total hip arthroplasties and that was expected were quantified before (49 patients) and after a concerted nursing education program (30 patients) that was designed to ensure maximum compliance and to verify the correct application of the devices. The expected therapy was not delivered to any of the patients monitored. Therapy was delivered only an average of 77.8% of the time during the expected treatment periods. During 99.9% of the expected therapy times, values of key outcomes-related parameters of the therapy delivered to the patients varied by >10% from expected values. These variations were not reduced significantly by medical and nursing education. This variation may be a significant confounding factor in comparatively evaluating thromboembolic disease outcome reports.
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The management of the dysplastic hip represents a clinical and a technical challenge. There is a great deal of variation in the degree and direction of acetabular dysplasia, and the accurate determination of femoral head coverage is difficult. It is, therefore, important to measure and plan any osteotomy based on each patient's unique acetabular anatomy. A clear understanding of the underlying anatomic abnormalities is vital so that reconstruction can be appropriately planned. This understanding is facilitated by an appreciation of the imaging techniques available and their correct application. The initial imaging of the dysplastic hip is based on plain radiographs. These determine the diagnosis of dysplasia and give a good indication of its severity and of the degree of congruency, instability, and degenerative change. A number of indices have been defined on these radiographs to facilitate surgical planning and to evaluate surgical outcomes. Moreover, plain radiographs or fluoroscopy are usually the only modalities accessible during surgery. More complex imaging is necessary to define any associated lesions and to quantify the acetabular deficiency more accurately. Multiplanar imaging using CT scans and computer reconstructions reduces the need for complex spatial interpretation, facilitates preoperative planning, and allows preoperative simulation. The availability of more powerful computers has extended the use of these techniques to intraoperative surgical navigation. Continued progress and development of imaging techniques will further determine the type and degree of correction required for each hip and will help to stratify dysplastic hips for outcomes assessment. Ultimately, it will help orthopaedic surgeons to evaluate whether the success or failure of osteotomies around the hip are intrinsic to the techniques used or to the primary disease process or are related to the surgeon's failure to create a more normal biomechanical environment for the hip.
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