New concepts in orthopaedic thromboprophylaxis.
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Arthroplasty, Replacement↗
Biomedical subjects
P F Lachiewicz
Publications and source records attributed to P F Lachiewicz.
Two mechanical devices for prophylaxis of thromboembolism after total knee arthroplasty. A prospective, randomised study.
The optimal characteristics of pneumatic compression for mechanical prophylaxis of thromboembolism after total knee arthroplasty (TKA) are not known. Our study compared two methods of calf compression, with the hypothesis that the device which provided a larger increase in peak venous velocity would produce a lower rate of thromboembolism. We performed a prospective, randomised study on 423 patients (472 knees). Duplex ultrasonography was carried out by experienced technicians who were blinded to the device used. Overall, 206 patients (232 knees) used a rapid inflation, asymmetrical compression (RIAC) device and 217 (240 knees) a sequential circumferential compression device (SCD). The rate of venous thromboembolism was 6.9% with the RIAC device compared with 15% for the SCD device (p = 0.007). The incidence of thrombi with unilateral primary TKA was 8.4% for the RIAC compared with 16.8% for the SCD device (p = 0.03). In 47 patients with a bilateral TKA, the incidence of thrombi was 4% for the RIAC compared with 22.7% for the SCD device (p = 0.05 per knee). There was a low rate of mortality and pulmonary embolism when using mechanical prophylaxis for thromboembolism after TKA. Our findings show that the use of rapid inflation, asymmetrical calf compression gave a significantly lower rate of thromboembolism.
Adult↗
The influence of technique on fixation of primary total hip arthroplasty in patients with rheumatoid arthritis.
This is a prospective, consecutive study of 98 total hip arthroplasties implanted by 1 surgeon in 66 patients with rheumatoid arthritis. The mean follow-up time was 7.4 years (range, 2-13 years). All 98 acetabular components were uncemented titanium fiber metal-coated components fixed with multiple screws. Sixty-five hips had bulk or cancellous allograft for protrusio acetabuli. Following a prospective protocol based on patient age, 51 hips had an uncemented femoral component, and 47 hips had a cemented femoral component. Using the Harris Hip Score, 30 hips were rated as excellent; 44, good; 15, fair; and 9, poor. There were no early deep infections. One hybrid hip was removed for late metastatic infection at 7 years. Radiographic evaluation of 98 acetabular components showed 1 case of septic loosening, 2 cases of aseptic loosening (1 patient asymptomatic), and 1 case with severe wear and ischial osteolysis. None of the 47 cemented femoral components subsided, and osteolysis was seen in only 3 femora (7%). Of the 51 uncemented femoral components, subsidence occurred in 7 hips (14%), and osteolysis occurred in 15 hips (30%). Uncemented acetabular components have a high rate of success in patients with rheumatoid arthritis who have a total hip arthroplasty. There is a high rate of subsidence and osteolysis, however, with first-generation cementless femoral components.
Acetabulum↗
One-peg versus three-peg patella component fixation in total knee arthroplasty.
In many designs of total knee arthroplasty, the patella with one central peg has been replaced by a patella with three small pegs for cement fixation. There have been recent reports of failure of this design. This is a prospective, consecutive study of two types of patella component fixation in 228 posterior-stabilized knee arthroplasties done by one surgeon. A central peg all-polyethylene component was used for 84 consecutive knees in 63 patients (Group A) and a three-peg patella was used for the next 144 consecutive knees in 99 patients (Group B). The mean followup was 6.7 years (range, 2-10 years) for Group A and 3.5 years (range, 2-6 years) for Group B. Except for the patellar component fixation, all knees had the same posterior-stabilized prosthesis using a specific protocol for patellar resurfacing. No patient required reoperation for a patellofemoral complication. The prevalence of patella fracture was higher in Group A, 4.7% (four knees), compared with 2.1% (three knees) in Group B, but this difference was not statistically significant. The presence of anterior knee pain referable to the patella was 7.1% (five patients, six knees) in Group A (one patient with two knees had severe anterior knee pain) and 9% (13 knees in 13 patients) in Group B. There was no patella clunk syndrome, subluxation, or fracture of a fixation peg in either group. With this specific protocol for patella resurfacing, there was a higher rate of complications with the one central peg patella (4.7%) than with the three-peg patella (2.1%), but this did not reach statistical significance. The results do not support an increased risk of component failure with this three-peg patella design, but do not, at this length of followup, show any significant advantage of three-peg fixation.
Adult↗
Pregnancy after total hip arthroplasty.
BACKGROUND: Younger patients are having total hip arthroplasty now, and a woman who has had such a procedure may want to become pregnant. The purposes of this study were to report on a series of women who had completed a pregnancy after a total hip arthroplasty and to determine if pregnancy affects the function and longevity of the prosthesis. METHODS: Five women, with a total of seven uncemented total hip replacements, had six successful pregnancies. The mean age at the arthroplasty was twenty-nine years (range, twenty-two to thirty-eight years), and the mean time from the hip arthroplasty to the pregnancy was 2.5 years (range, one to seven years). These patients (Group A) were compared with a matched group of five women with a total of eight uncemented total hip prostheses (Group B) who had not completed a pregnancy. The mean follow-up time was eight years (range, two to thirteen years) for Group A and seven years (range, two to twelve years) for Group B. Patients were clinically evaluated with the Harris hip score. Radiographs were evaluated for component fixation and osteolysis. RESULTS: The five women completed a total of six successful pregnancies. One patient, with a bilateral total hip arthroplasty, had two successful pregnancies, 2.5 years apart. Three children were delivered vaginally (with the mother in the lithotomy position) and three, by cesarean section. There were no complications related to the total hip arthroplasty after delivery. The mean weight gain during the pregnancy was 13 kg (range, 8 to 14.2 kg). In Group A, the mean Harris hip score was 94 points prior to the pregnancy and 97 points at the time of the most recent follow-up. In group B, the mean Harris hip score was 91 points at one to two years after the arthroplasty and it was unchanged at the time of the most recent follow-up. There were six excellent results and one good result of the hip arthroplasty in Group A and five excellent and three good results in Group B. The mean total arc of hip motion was 217 degrees in Group A before the pregnancy and 241 degrees at the time of the most recent follow-up. The mean total arc of hip motion was 193 degrees in Group B at one to two years postoperatively and 190 degrees at the time of the most recent follow-up. The difference in the total arc of hip motion between the two groups at the latest follow-up evaluation was significant (p = 0.025). There were no reoperations in either group. Radiographs showed osteolysis of the femur in three hips in Group A and three hips in Group B. CONCLUSIONS: It appears that successful pregnancy and normal vaginal delivery can occur safely after total hip arthroplasty. The overall result, function, and radiographic appearance after the total hip arthroplasty was not adversely affected by pregnancy in this small group of patients.
Adult↗
Thromboembolism after total knee arthroplasty: intermittent pneumatic compression and aspirin prophylaxis.
This is a study of two consecutive antithromboembolism regimens after total knee arthroplasty. In group 1, 131 patients were given aspirin prophylaxis alone (650 mg by mouth twice a day). In group 2, 123 patients were treated with aspirin, knee-high compression stockings, and intermittent knee-high pneumatic compression devices, which were started intraoperatively. The prevalence of deep vein thrombosis in group 1 was 15.9% (21 of 131 patients). One patient had a possible symptomatic nonfatal pulmonary embolism, and one patient had a symptomatic calf thrombus. Asymptomatic thrombi were detected in calf veins in 9 patients, popliteal vein in 6 patients, and femoral vein in 5 patients. In Group 2, the prevalence was 7.4% (9 of 123 patients). Asymptomatic thrombi were located in calf veins in 6 patients, popliteal vein in 1 patient, and femoral vein in 2 patients. There was a significant difference in the prevalence of deep vein thrombosis between the two groups. A history of previous thromboembolism was a significant risk factor for a new thrombus. The prevalence after bilateral one-stage knee arthroplasty was 24.3% for group 1 and 12.5% for group 2. Aspirin and knee-high intermittent pneumatic compression together are more effective than aspirin alone for prevention of deep vein thrombosis after primary and revision knee arthroplasty.
Adult↗
Failure of a cemented all-polyethylene patellar component of a Press-Fit Condylar Total Knee arthroplasty.
A 65-year-old woman had a posterior cruciate-retaining cemented Press-Fit Condylar (PFC; Johnson & Johnson Professional, Inc., Raynham, MA) knee replacement with resurfacing of the patella using a cemented all-polyethylene, 3-peg component. Five years postoperatively, the patient developed anterior knee pain. The patella tracked normally, but radiographs showed a shift of the patellar component. At revision, there was shear failure of all 3 fixation pegs and loosening of the component. Revision with a cemented Press-Fit Condylar Sigma patellar 3-peg component (Johnson & Johnson Professional, Inc., Raynham, MA) was performed.
Aged↗
Early failure of revision total hip arthroplasty with cemented precoated femoral components: comparison with uncemented components at 2 to 8 years.
This is a retrospective analysis of 2 methods of fixation of the femoral component in 86 consecutive revision arthroplasties, for which all clinical and radiographic data were recorded prospectively. There were 56 cemented revisions using precoated femoral components followed for 2 to 8 years (mean, 4 years) and 30 uncemented, proximally porous-coated femoral revisions followed for 2 to 6 years (mean, 4 years). Of the 56 cemented hips, 31 (55%) had a good or excellent clinical result. Rerevision has been performed in 10 hips, and revision of 3 loose femoral components is pending (23%). Radiographic review of 56 femoral components showed that 16 (29%) had probable or definite loosening. Of 30 cementless hips, 24 (80%) had a good or excellent clinical result. There was radiographic bone ingrowth in 22 of 30 hips (73%). Seven hips (23%) had nonprogressive subsidence, and 3 hips (10%) had progressive subsidence or loosening. Rerevision has been performed in only 2 hips (7%). The high rate of loosening (29%) and rerevision (23%) at a mean follow-up of only 4 years suggests that a precoated femoral component may place increased stress at the already damaged bone-cement interface.
Adult↗
The role of continuous passive motion after total knee arthroplasty.
The usefulness of continuous passive motion after total knee arthroplasty remains controversial. The reported benefits include decreased rates of knee manipulation, deep vein thrombosis, and postoperative use of analgesics, and a greater range of motion. Other studies have reported increased wound complications, bleeding, and pain. Lack of consensus on the use of continuous passive motion exists because reported studies include many confounding variables. Several studies have shown that continuous passive motion in the hospital decreased the rate of knee manipulation from as high as 21% to as low as 0%. Although many studies show that range of motion may improve more rapidly with continuous passive motion, the ultimate range of motion at followup is unchanged. At the author's institution, continuous passive motion is used three times per day (1 hour sessions), beginning on the first postoperative day, within a 4 to 5 day inpatient hospital pathway. Of 132 knees that had a primary posterior-stabilized total knee arthroplasty, seven knees (5%) had a manipulation for failure to obtain greater than 70 degrees flexion. No patients had major wound complications that required reoperation. There is no specific charge to the patient for the continuous passive motion because it is included in the hospital per diem charge. The literature and the author's data support the use of continuous passive motion to decrease the rate of manipulation (and its costs) for poor range of motion after total knee arthroplasty. If patients follow fixed inpatient hospital pathways, the length (and possibly cost) of hospital stay is not changed by use of continuous passive motion. The data on the effect of continuous passive motion on overall analgesic use and prevalence of deep vein thrombosis are not clear.
Arthroplasty, Replacement, Knee↗
Patellofemoral complications with the Insall-Burstein II posterior-stabilized total knee arthroplasty.
The Insall-Burstein and Insall-Burstein II posterior-stabilized (I-B II PS) prostheses have been reported to have a high prevalence of patellar complications. This is a prospective, consecutive study of 118 primary total knee arthroplasties in 82 patients with the I-B II PS prosthesis implanted by 1 surgeon, using a specific technique for patellar resurfacing. The mean follow-up time was 4.0 years (range, 2-8 years). Clinical evaluation was performed using a standard knee score system with specific additional evaluation of the patellofemoral joint. Radiographs were evaluated for fracture, loosening, and subluxation. Ninety-four knees (80%) were rated excellent, 21 knees (17%) good, and 3 knees (3%) fair. The mean flexion was 112 degrees postoperative. No knee required reoperation for the patellofemoral joint. There were 2 nondisplaced and 1 minimally displaced patellar fractures treated nonoperatively, no patellar clunk syndrome, and no subluxations. Using the patellar evaluation system, 109 knees had no anterior knee pain, 7 knees had mild pain, and 2 knees (1 patient) had moderate-to-severe pain only with rising from a chair. Patellofemoral crepitus with active flexion-extension in the seated position was noted in 16 knees (14%) but was painful in only 2 knees (1 patient). With this technique for patellar resurfacing with this prosthesis, patellofemoral complications were only 4.2%, and no knee required reoperation for the patella or for loosening. With attention to operative technique, patellofemoral resurfacing with this posterior-stabilized total knee arthroplasty can be highly successful.
Aged↗
Knee arthroplasty in hemophilic arthropathy.
Twenty-three total knee arthroplasties in 15 patients with severe hemophilia were performed between February 1974 and September 1988. Thirteen patients had Factor VIII deficiency and two had Factor IX deficiency. The mean followup period was 7.5 years, with a minimum of 4 years for patients who were alive (eight) at the time of this review. Seven patients had died before this report, and all were seropositive for the human immunodeficiency virus. Using the Hospital for Special Surgery knee scoring system, the result was excellent in one knee, good in three, fair in two, and poor in 17. One patient was seropositive for the human immunodeficiency virus at the time of the index procedure, and 12 were seropositive at the most recent followup; the human immunodeficiency status of three patients was unknown. There were two early and two late deep infections, all in patients who were seropositive for the human immunodeficiency virus. The most recent postoperative radiographs for all knees were reviewed using the Knee Society radiographic scoring system. Ten femoral components were well fixed, 11 were possibly loose, and two were probably loose. Eight tibial components were well fixed, 10 possibly loose, three probably loose, and two definitely loose. One knee had been revised for aseptic loosening. There are few published studies of the long term results of total knee arthroplasties in patients with hemophilia. In this series of 23 knees, there was a high rate of loosening and infection. Total knee arthroplasty may be a useful treatment for the relief of pain attributable to end stage hemophilic arthropathy, but there is a high rate of complications, especially in patients who are seropositive for the human immunodeficiency virus.
Adolescent↗
Precoated femoral component in total hip arthroplasty. Results of 5- to 9-year followup.
One hundred nineteen consecutive primary hybrid total hip arthroplasties with a precoated femoral component were performed by one surgeon in 100 patients and followed up prospectively. Ninety-eight hips in 82 patients (mean age, 67 years) were evaluated clinically and radiographically at a mean of 6.5 years (range, 5-9 years). The hips were evaluated clinically using the Harris hip score, and radiographs were evaluated for femoral cement grade, loosening, and osteolysis. Ninety-five hips remained in place at the most recent followup. Two femoral components were revised for definite loosening, and one well fixed femoral component was removed because of late hematogenous infection. Excluding the three hips that were revised, the clinical result was excellent or good in 79 hips (83%), fair in 12 hips (13%), and poor in four hips (4%). All other femoral components were well fixed. There were defects of the cement mantles (C1 and C2) in 90 hips. No femoral component had a stem and cement radiolucent line. Focal femoral osteolysis was seen in only two hips. One acetabular component was removed at 5 years because of late hematogenous infection. One acetabular component had asymptomatic migration. The remaining 96 acetabular components were well fixed. Focal acetabular osteolysis was present in four hips. The mean linear polyethylene wear rate was 0.06 (+/- 0.05) mm per year. In contrast to other reports of early failure and osteolysis, the use of a precoated femoral component in this study did not adversely affect the fixation of hybrid total hip arthroplasty, with definite failure of only 2% (two of 98) of the femoral components.
Adult↗
Efficacy of prophylaxis against thromboembolism with intermittent pneumatic compression after primary and revision total hip arthroplasty.
BACKGROUND: Thromboembolism is a common and important complication after total hip arthroplasty. A variety of pharmacological and mechanical measures have been proposed for prophylaxis. The purpose of the present study was to evaluate the efficacy of intermittent pneumatic compression as prophylaxis against thromboembolism following total hip arthroplasty. METHODS: The prospective study involved a consecutive series of 425 patients in whom a total of 502 (324 primary and 178 revision) total hip arthroplasties had been performed by two surgeons. The patients were managed intraoperatively and postoperatively with use of thigh-high elastic compression stockings and thigh-high intermittent pneumatic compression sleeves. Experienced vascular technologists performed venous duplex ultrasonography on both lower extremities of all patients at a mean of six days (range, two to fifteen days) postoperatively. All patients were followed for at least one year in order to detect late thromboembolism. RESULTS: An asymptomatic deep-vein thrombosis was noted on the scans made after twenty-three (4.6 percent) of the 502 procedures. Nineteen (3.8 percent) of the arthroplasties were followed by the development of a proximal thrombosis and four (0.8 percent), a distal thrombosis. Nineteen of the thromboses were ipsilateral (eighteen were proximal and one, distal), and four were contralateral (one was proximal and three, distal). No symptomatic deep-vein thrombosis developed in the hospital. In addition, three (two proximal and one distal) symptomatic ipsilateral deep-vein thromboses (a prevalence of 0.6 percent) developed three to twenty-three weeks after postoperative scans revealed negative findings and the patients were discharged from the hospital. Three symptomatic pulmonary embolisms (a prevalence of 0.6 percent) were confirmed by ventilation-perfusion scanning while the patients were in the hospital. There were no symptomatic pulmonary embolisms after discharge, and there were no fatal pulmonary embolisms. With the numbers available, we were unable to detect an association between deep-vein thrombosis and age (p = 0.76), gender (p = 0.13), body-mass index (p = 0.12), type of arthroplasty (primary or revision) (p = 0.12), operative approach (p = 0.37), duration of the operation (p = 0.21), type of anesthesia (general or regional) (p = 0.51), units of blood transfused (autologous, p = 0.79; homologous, p = 0.57), blood type (p = 0.18), or the presence of a so-called classic risk factor for the development of thrombosis (p = 0.22). Five arthroplasties (1.0 percent) were followed by the development of a wound hematoma, but only one hematoma necessitated operative drainage. CONCLUSIONS: The use of intraoperative and postoperative thigh-high intermittent pneumatic compression, combined with duplex ultrasonography performed by experienced vascular technologists, is effective for prophylaxis against thromboembolism after both primary and revision total hip arthroplasties. The low prevalence of deep-vein thrombosis (4.6 percent) and symptomatic pulmonary embolism (0.6 percent) is comparable with that associated with pharmacological prophylaxis.
Arthroplasty, Replacement, Hip↗
Surgical management of inflammatory arthritis of the adult hip and knee.
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Adult↗
Cortical strut allografts for the treatment of femoral fractures and deficiencies in revision total hip arthroplasty.
Thirty-three hips had revision total hip arthroplasty, using an average of three cortical strut allografts fixed to the femur with cables and followed-up for a mean of 4 years. The indications for strut allografts were ectatic femurs or segmental defects of the femoral diaphysis (22 hips), femoral fractures (10 hips), and severe proximal femoral osteolysis (1 hip). Twenty-one hips had an excellent or good clinical result, 6 had a fair clinical result, and 6 had a poor clinical result. Reoperation was done in six hips, but in only two hips was reoperation related to failure of the allograft. Nine of the 10 femoral fractures repaired with allograft struts healed by 3 to 6 months. Radiographs showed partial or complete bridging of the allograft to host bone with peripheral remodeling and minimal resorption in 30 of 33 hips. Strut allografts, fixed with multiple cables, are an important adjunct to femoral component revision for the restoration of deficient femoral bone stock and in the treatment of periprosthetic femur fractures.
Adult↗
Results of isolated acetabular revisions: the fate of the unrevised femoral component.
Controversy exists over whether to remove a well-fixed femoral component at the time of revision of a failed acetabular component, and it has been suggested that the femoral component be removed and recemented. The hypothesis presented in this article is that only the acetabular component should be revised in these situations. Thirty-eight isolated, uncemented acetabular revisions were performed by 1 surgeon and prospectively followed for a mean of 4 years (range, 2-10 years). The femoral component was well fixed at the time of revision and left in situ. There were 30 cemented and 8 uncemented femoral components, which had been in place for a mean of 10.7 years. The hips were evaluated clinically using the Harris hip score rating system. Radiographic evaluation of both components was performed using well-established criteria. Morselized cancellous allograft was used to fill acetabular defects in 30 hips, and a bulk allograft was used in 1 hip. There was a good or excellent clinical result in 32 hips (84%). Two cemented femoral components required revision for aseptic loosening at 2.5 and 4 years. No acetabular component migrated or was revised, and no revisions of either component are pending. Thirty-six (95%) of the unrevised femoral components remain well fixed at the most recent follow-up examination. Compared with a similar population of hips in which both the acetabular and femoral components were revised, the mean blood loss for these revisions was 52% less and the mean surgical time was 35% shorter. Revision of only the acetabular component is recommended for isolated acetabular aseptic loosening. Because the femoral component is not removed, surgical time and blood loss are decreased and serious potential complications related to removing a well-fixed femoral component can be avoided.
Acetabulum↗
Relationship of femoral head and acetabular size to the prevalence of dislocation.
Two clinical studies, one prospective randomized and one retrospective, were performed to evaluate the relationship of femoral head size and acetabular component outer diameter to the prevalence of dislocation of the modular total hip replacement. Between October 1995 and April 1996, 31 primary total hip arthroplasties in 30 patients were randomized to a femoral head diameter of 22 mm or 28 mm, for two groups of acetabular components of outer diameters of 56 mm or larger and 54 mm or smaller. Head size (22 mm) and acetabular component outer diameter (> or = 56 mm) were found to increase the risk of dislocation. From December 1984 to January 1994, 308 primary total hip arthroplasties were performed through a posterior approach by one surgeon using a modular 28 mm femoral head and one type of uncemented acetabular component. The rate of dislocation for acetabular components with an outer diameter of 62 mm or larger was increased significantly (five of 36 hips, 14%) compared with those with an outer diameter of 60 mm or smaller (11 of 272 hips, 4%).
Acetabulum↗
Revision of a total hip arthroplasty with a Harris-Galante porous-coated acetabular component inserted without cement. A follow-up note on the results at five to twelve years.
Fifty-seven revision total hip arthroplasties in fifty-six patients were performed with a Harris-Galante porous-coated acetabular component by one surgeon, and the patients were followed prospectively for a mean of seven years (range, five to twelve years). A trochanteric osteotomy was performed in forty hips, and a posterior approach with an extended anterior capsulectomy was used in the other seventeen. The acetabular defect was classified as segmental in seven hips, cavitary in twenty-three, and combined in twenty-one; six hips had no notable defect. A bulk allograft was used in eleven hips, and morseled cancellous-bone allograft or autogenous graft was used in thirty-four hips; twelve hips did not have bone-grafting. Both the femoral and the acetabular component were revised in forty-five hips, and only the acetabular component was revised in twelve. Thirty-nine hips (68 per cent) had a good or excellent clinical result according to the Harris hip score. The acetabular component was well fixed in the fourteen hips that had a fair result and the four hips that had a poor result. The acetabular component was considered to have migrated if there was a change in the angle of the cup of 5 degrees or more or a change in the horizontal or vertical position of the cup of more than three millimeters. Despite varying degrees of bone loss, no acetabular component had radiographic evidence of loosening at the latest follow-up examination. No component was revised and no revisions were scheduled. One hip was debrided for a late metastatic infection, but the component was well fixed and was not revised. There were no complications related to the use of screws for fixation. These mid-term results confirm the early success of acetabular revisions performed with fixation of a titanium fiber-metal-coated hemispherical component with multiple screws and no cement.
Adult↗