Wrist arthrodesis for failed wrist implant arthroplasty

Thirteen wrist arthrodeses were performed for failed wrist implant arthroplasties between 1984 and 1992. Twelve patients were available for review, with an average follow-up period of 28 months. The original arthroplasties consisted of 8 silicone implants and 4 metal-plastic total wrist implants. The surgical method involved a tricortical iliac bone graft and an intramedullary Steinmann pin. There were 7 excellent results, 4 good results, and 1 poor result. All but 1 patient had markedly improved function with no or mild pain. Seven patients had solid fusions and 5 patients had pseudarthroses. Four pseudarthroses occurred at the graft-metacarpal junction and 1 occurred at the graft-radius junction. Each patient with a solid fusion had an excellent result. All graft-metacarpal pseudarthroses were painless and did not limit the patients' activities. There were 17 complications in 9 patients. Wrist arthrodesis can be a successful salvage procedure for failed wrist implant arthroplasty in patients with rheumatoid arthritis. However, the complication rate can be high. Owing to the high incidence of distal graft-metacarpal pseudarthrosis, we recommend using more rigid fixation techniques in patients with failed wrist arthroplasties.     

Total wrist arthroplasty

Although arthroplasty is a well-established procedure for many joints, its use in the wrist is less common, and the indications are less well defined. The standard procedure for the painful arthritic wrist remains radiocarpal arthrodesis. However, as technology and surgical procedures improve, wrist arthroplasty is being used more frequently. The authors provide a brief history of total wrist arthroplasty and review the arthroplasties most commonly used in the United States. Results with total wrist implants, the complications related to arthroplasty, technical aspects of the procedure, and salvage options are also discussed.     

Long-term evaluation of hip arthroplasty in patients with an ipsilateral knee arthrodesis

Hip arthroplasty with an ipsilateral knee arthrodesis occurs infrequently but does raise concern regarding surgical technical difficulties, dislocation, sepsis, and long-term loosening. Sixteen patients were evaluated 7.5 years (average period) after surgery. Technical difficulties were not prohibitive. No dislocation or revision was necessary in any of the cases. Two patients died as a result of unrelated sepsis from an infected knee. Loosening and protrusio of the acetabulum occurred in two patients. Hip arthroplasty in patients with a fused knee does not incur undue risk of loosening or instability and can provide long-term good function and pain relief. Patients with multiple joint arthroplasties, in whom concurrent sepsis occurs, can have devastating results.     

Vascularized fibular graft for reconstruction of the wrist after excision of giant cell tumor

Seven patients with a giant-cell tumor involving the distal end of the radius were treated with en bloc resection and reconstruction with a free vascularized fibular graft. Two patients with stage 2 disease of Enneking's surgical staging and grade 2 of Campanacci's radiographic grading system were reconstructed with an articular fibular head graft. Five patients with stage 3 and grade 3 disease underwent wrist arthrodesis using fibular shaft transfer. There was radiographic evidence of bone union at the host-graft junctions in all cases. No local recurrence was seen in any of the patients at the most recent follow-up examinations. There were six good and one excellent functional results. Wrist arthroplasty using a vascularized fibula head graft is the best procedure for a stage 2 or grade 2 giant-cell tumor of the distal end of the radius. In cases of stage 3 or grade 3 disease, wrist arthrodesis using a vascularized fibular shaft graft is indicated.     

Total wrist arthroplasty in rheumatoid arthritis. A long-term clinical review

Fourteen total wrist arthroplasties performed in 13 patients with rheumatoid arthritis between 1978 and 1982 were reviewed to evaluate long term outcome. Most patients had Stages III or IV rheumatoid arthritis at the time of surgery. Pain was the primary presenting complaint in 87%. Average followup was 6.5 years (range, 3.5-11.5 years). Pain relief was achieved in 86% of patients. Using objective data obtained from their wrist scores, 72% of the patients had a good result, 14% had a fair result, and 14% had a poor result. No patient had an excellent result. Twenty-seven percent suffered postoperative complications related to their surgical procedure. Although these results help confirm the usefulness of total wrist arthroplasty as an alternative to arthrodesis of the wrist, it is a technically demanding procedure, and should be reserved for the patient who has severely involved arthritis. Additional improvements are needed to decrease the currently high complication and failure rate.     

Cement versus cementless fixation in total knee arthroplasty

A prospectively studied group of 55 uncemented Press Fit Condylar total knee arthroplasties was compared retrospectively with a matched group of 51 cemented Press Fit Condylar total knee arthroplasties at a mean of 10 years after operation. For the cemented group, the pain and function scores improved from 32 and 45 preoperatively to 95 and 77, respectively. For the uncemented group the scores improved from 33 and 50 preoperatively to 93 and 60, respectively. There were 10 revisions in the uncemented group for femoral or tibial aseptic loosening or osteolysis compared with two revisions in the cemented group. Exclusive of problems related to patellar metal backing, survival to revision for aseptic failure or radiographic loosening was 72% in the uncemented group and 94% in the cemented group at 10 years. A significantly higher revision rate was found in the uncemented compared with cemented total knee arthroplasty of the Press Fit Condylar design.     

Total hip arthroplasty with cement in patients who have rheumatoid arthritis. A minimum ten-year follow-up study

One hundred and six consecutive total hip arthroplasties with cement were performed by one surgeon, at least ten years before the time of the present clinical and radiographic review, in seventy-five patients who had adult-onset rheumatoid arthritis. Two patients (three hips) were lost to follow-up. Seven (7 per cent) of the remaining 103 hips were revised. The revisions were performed because of infection (three hips), dislocation (two hips), or aseptic loosening (two hips). Of the ninety-eight hips that were not lost to follow-up or revised because of infection or dislocation, eight (8 per cent) had radiographic loosening of the acetabular component and two (2 per cent) had radiographic loosening of the femoral component. Although the prevalence of radiographic loosening of the acetabular component was four times greater than the prevalence of radiographic loosening of the femoral component, the prevalence of revision because of aseptic loosening of the acetabular component was identical to that for the femoral component (one component each). These results compared favorably with those of total hip arthroplasty with cement, performed by the same surgeon, for the treatment of other diagnoses. Loosening of the acetabular component was significantly associated with a younger age at the time of the index operation (p = 0.03) and with acetabular osteolysis (p = 0.0006). Of forty-eight hips in thirty-two patients who survived for at least ten years, 96 per cent (forty-six hips) were considered by the patients to have a satisfactory result. At the time of the latest follow-up, twenty-four (75 per cent) of the patients had no pain in the hip. Although eighteen patients (56 per cent) could walk without support at a minimum of ten years after the operation, we found that the functional results for patients who had rheumatoid arthritis were inferior to those observed for patients who had had a total hip arthroplasty with cement, performed by the same surgeon, for the treatment of other diagnoses.     

Hinged total knee arthroplasty

Analysis of an on-going prospective study of seventy-seven hinged total knee arthroplasties in sixty-seven patients revealed that most patients had improvement in function, although major complications occurred in eighteen knees (23.4 per cent. These complications included sepsis, loosening, patellar tendon rupture, peroneal palsy, and patellar subluxation. Eight of nine knees with deep sepsis required removal of the prosthesis, and three of sixteen knees with patellar pain required realignment of the quadriceps. When prosthetic failure occurred, salvage of a functional extremity was difficult. Hinged total arthroplasty is not without its problems, and a cautious approach to its use is indicated. Whenever possible, a moderately constrained replacement arthroplasty should be considered.     

Charnley total hip arthroplasty in patients less than fifty years old. A twenty to twenty-five-year follow-up note

We evaluated the results twenty to twenty-five years after ninety-three consecutive, nonselected Charnley total hip arthroplasties performed with cement by the senior one of us in sixty-nine patients who were less than fifty years old at the time of the procedure. Seventy of the seventy-two hips in the living patients were followed radiographically for at least twenty years. Twenty-seven hips (29 per cent) had a revision or a resection of the prosthesis during the follow-up period. The revision or the resection was performed because of aseptic loosening in twenty-one hips (23 per cent), infection in four (4 per cent), dislocation in one (1 per cent), and fracture of the femur in one. Eighteen acetabular components (19 per cent) and five femoral components (5 per cent) were revised because of aseptic loosening, and an additional fourteen acetabular components (15 per cent) and seven femoral components (8 per cent) demonstrated definite or probable radiographic loosening. The present study demonstrates the long-term durability of total hip arthroplasty performed with cement in an active population of patients. The fixation of the femoral component was found to perform better than that of the acetabular component at twenty to twenty-five years after the procedure.     

Total hip arthroplasty in patients who have chronic lymphocytic leukemia

Twenty patients who had chronic lymphocytic leukemia underwent 25 elective primary total hip arthroplasties at the Mayo Clinic. No patient had a postoperative prosthetic infection. No patient had an intraoperative or postoperative hemorrhagic complication. One patient had a revision for aseptic loosening. After an average follow-up period of 4.6 years, there were 84% good and excellent results. It is concluded that patients who have early-stage chronic lymphocytic leukemia may not be at increased risk for major perioperative or postoperative complications in total hip arthroplasty. The surgeon must remain vigilant for postoperative complications, but satisfactory clinical results can be obtained in this patient population.     

Total hip arthroplasty with porous-coated prostheses fixed without cement in patients who are sixty-five years of age or older

We reviewed the results of 212 total hip arthroplasties performed without cement in 203 unselected, consecutive patients who were sixty-five years of age or older. The outcome was known for 196 hips, thirty-seven of which had been followed until the death of the patient and 159 of which had been followed for a minimum of five years. A reoperation was done in 4 percent (seven) of the 196 hips. These reoperations included one revision because of loosening of the stem and five revisions of the cup. Three of the acetabular revisions were done because of fracture due to polyethylene wear; one, because of recurrent dislocation; and one, because of polyethylene wear and a fracture due to lysis. In the seventh reoperation, a cup and stem were exchanged because of infection. The probability that a hip prosthesis would survive twelve years without a reoperation was 0.92 (95 percent confidence interval, 0.85 to 0.99). We evaluated the clinical results for 152 patients who had not had a reoperation and had been followed for at least five years (mean, 8.5 years; range, five to fourteen years). Of these patients, thirteen (9 percent) had pain that limited activity: five (3 percent) had pain in the thigh (four patients) or groin (one patient), and eight (5 percent) had trochanteric pain and tenderness. One hundred and forty-four (95 percent) of the patients noted an improvement in overall function, and 149 (98 percent) reported satisfaction with the outcome. One hundred and thirty-five hips that were not revised were followed radiographically for at least five years (mean, 8.2 years; range, five to fourteen years). In this group, osteolysis was observed in three hips (2 percent); loosening of the cup, in three (2 percent); and loosening of the stem, in one (1 percent). Stress-shielding was seen on the two-year postoperative radiographs of forty-five (26 percent) of the 174 hips that were followed for at least that duration. The prevalence of osteolysis, loosening of a component, and reoperations was no greater in this subgroup than in the overall group. These results indicate that total hip arthroplasty without cement can be successful in older patients. This study also provides a reference for comparison with the results of total hip arthroplasty performed with cement and those of so-called hybrid total hip arthroplasty (an acetabular component fixed without cement and a femoral component fixed with cement) in patients who are sixty-five years of age or older.     

Characteristics of impaired awareness after traumatic brain injury

The condylar constrained total knee arthroplasty was performed on 29 patients undergoing 33 procedures and were reviewed clinically and radiographically at an average follow-up of 5 years (range, 2-10 years). There were 21 women and 8 men. The average age at the time of surgery was 70 years (range, 32-84). Of the 16 knees that were revision total knee arthroplasties, 8 had a previous infected total knee arthroplasty, and 17 knees had severe deformities requiring the use of the condylar constrained prosthesis. The patients were rated according to the Knee Society clinical and radiological evaluation protocol. Measurements of femoral and tibial component position were obtained as well as femoral tibial angle, patella position, and cement bone radiolucencies. All clinical measurements were made by an independent physical therapist. Clinical results revealed an improvement from an average preoperative knee score of 38 points to an average postoperative score of 86 points. The clinical results for 19 (58%) knees were excellent, 8 (24%) had a good result, 1 (3%) was fair, 2 (6%) were poor, and 3 (9%) were failures. The patients' average functional levels increased from 24 to 58. The final average flexion was 96 degrees. Three knees have been revised (9%). One was revised for recurrent infection, one for periprosthetic fracture, and one for mechanical loosening of the tibial component. There were no other knees with evidence of radiologic loosening. We conclude that the condylar constrained total knee prosthesis provides an acceptable solution for revision and complex primary total knee replacements at an intermediate follow-up term of 5 years.     

Total hip replacement arthroplasty in the Netherlands

The total hip arthroplasty (THA) is an effective treatment of osteoarthritis of the hip joint. Each year, more than 16,000 THAs are performed in the Netherlands. The incidence of THA had doubled between 1980 and 1994. The medical indication has extended to younger and older patients. Due to the success of the THA the number of alternative treatments, such as arthrodesis and osteotomy decreased. The number of revision surgeries increased more than four folds, to 1,400 in 1994. Based on these data the increase of primary and revision hip arthroplasties is expected to continue, but it is unknown how much the exact increase will be. In view of the increased demand it is important to gain more insight into the numbers of primary and revision surgical procedures to be expected, so that a better estimation can be made of the health care capacity and financial resources required in the future.     

Radiohumeral arthrodesis for salvage of failed total elbow arthroplasty

Ulnohumeral arthrodesis is the standard technique for elbow fusion. The geometry and surface area of the distal humerus and proximal ulna enhance the chances of fusion while maintaining some wrist motion. A case of a patient with multiple failed elbow procedures in which the standard ulnohumeral fusion was not possible is presented. A radiohumeral arthrodesis was performed in an attempt to obtain a stable, nonpainful elbow. After complete healing of the fusion, the patient was able to use the arm for most functions. This technique is presented as an option for salvage failed elbow arthroplasty in the face of significant bone loss.     

Revision of failed cementless total knee implants with cement

Between 1986 and 1996, 268 revision total knee replacements were performed. Revisions for aseptic loosening were reviewed prospectively. Sixty-three patients had implants revised for aseptic loosening. Thirty-six of the patients had revisions of cemented constructs, whereas 27 of the patients had revisions of cementless constructs. The average time before revision for the cemented group was 86 months. The average time to revision for the cementless group was only 43 months. Fifty-two percent of the patients in the cementless group had revision of their implants within 2 years of their index arthroplasty. The average pain free interval for the cementless group was only 11 months with 63% of the patients having no pain relief after their index arthroplasty. The average postoperative score for the cementless group was 88, whereas the average postoperative score for the cemented group was 82. Revision of failed cementless total knee implants with cement is a reliable procedure. Results are similar to those of cemented knees revised with cement.     

Ibutilide: an antiarrhythmic agent for the treatment of atrial fibrillation or flutter

The results of nineteen semiconstrained modified Coonrad-Morrey total elbow arthroplasties performed in nineteen patients to treat instability were evaluated at an average of seventy-two months (range, twenty-five to 128 months) postoperatively. Preoperatively, all patients had either a flail elbow or gross instability of the elbow that prevented useful function of the extremity. The instability of sixteen elbows was the result of a traumatic injury or of the treatment of such an injury. The most recent result was satisfactory for sixteen elbows and unsatisfactory for three. The average overall Mayo elbow performance score increased from 44 points preoperatively to 86 points postoperatively. At the most recent follow-up examination, no elbow was unstable. The average arc of flexion was from 25 degrees (range, 0 to 60 degrees) to 128 degrees (range, 30 to 142 degrees), which represented a 58-degree increase from the preoperative average arc. Sixteen patients had little or no pain after the arthroplasty. There were four complications in four patients. Three complications (loosening of the humeral component in one patient and a fracture of the ulnar component in two) occurred postoperatively; all three were treated with a revision procedure. The other complication (a fracture of the olecranon) occurred intraoperatively and was treated with tension-band fixation; the most recent outcome was not affected. Radiographically, one patient had complete (type-V) radiolucency about the humeral component. None of the nine patients for whom true anteroposterior radiographs were available had evidence of wear of the bushings. The bone graft behind the anterior flange of the humeral prosthesis was mature in fourteen elbows, incomplete in two, and resorbed in two. One patient was excluded from this analysis because radiographs were not available. Instability of the elbow resulting in the inability to use the extremity is a challenging clinical situation. However, in patients who are more than sixty years old and in selected patients who are less than sixty years old but who have extensive loss of bone as a result of severe injury, have had multiple operations, or have rheumatoid arthritis, total elbow arthroplasty with a linked, semiconstrained prosthesis reestablishes a mobile, stable joint without premature loosening or failure of the components. In our experience, the use of customized implants, maintenance of the muscular attachments to the epicondyles, and reconstruction of the epicondyles to the implant were unnecessary.     

Results of the total bi-metric cementless hip arthroplasty

A 2.9-year follow up of 50 primary Bi-Metric System cementless, porous-coated hip arthroplasties (Biomet) is presented. Four patients were operated bilaterally. In two patients, revision arthroplasty was carried out, in one because of infection, in the other because of loosening of the stem. The average Harris hip score was 96 points. The pain level according to d'Aubigné was 5.87. All patients belonged to Jensen's social function group 1. According to Engh's x-ray score, the femoral component achieved an average total of 19 points. Twenty-three patients with heterotopic ossification were graded according to Brooker et al; 18 patients belonged to group I-II, and 5 patients to group III. Discrepancy of leg length was measured in 20 patients, and averaged 0.52 cm (range: 0 cm to 2.5 cm). Four patients complained of thigh pain, but they had no radiographic evidence of loosening of components. The mean age was 63.4 years for women and 58.1 for men. Acceptably high Harris Hip Scores were obtained for the Bi-Metric hip prosthesis at 2-year follow up.     

Molecular cloning in Arabidopsis thaliana of a new protein phosphatase 2C (PP2C) with homology to ABI1 and ABI2

Trapeziectomy, ligament reconstruction and tendon interposition arthroplasty is one of the most commonly performed procedures to address pain and instability due to osteoarthritis at the basal joint of the thumb. To determine the effect of stress on first metacarpal subsidence, 15 ligament reconstruction and tendon interposition basal joint arthroplasties were evaluated after a mean follow-up of 32 months. Radiographs were obtained of the arthroplasty at rest and then with maximal effort key pinch stress, which is known to subject the first carpometacarpal joint to considerable axial compression stress. Compared with the preoperative x-rays, the first metacarpal had subsided 21% of the arthroplasty space at rest. Under stress, the first metacarpal was found to subside another 10.5% in height. No subluxation of the metacarpal base could be detected. Key pinch strength improved 17% from the preoperative strength. Tip-to-tip pinch strength improved 17% from the preoperative measurement. Grip strength improved 17% from the preoperative measurement. Grip strength was 9% greater than the preoperative grip strength. There was no statistical association between the amount of first metacarpal subsidence and follow-up key pinch, tip pinch, or grip strength. With axial compressive loading of the arthroplasty, such as in lateral pinch, there is some further proximal migration of the first metacarpal, but this is minimal and does not correlate with functional outcome.     

Extensor mechanism reconstruction with an allograft after total knee arthroplasty

The authors report on a series of 15 knees in which an extensor mechanism allograft was used to treat a rupture of the patellar tendon associated with a total knee arthroplasty. Nine of the knees have greater than two-year follow-up evaluation (average, 4.1 years; range, 2.3-7 years). Postoperatively, the average flexion was 106 degrees. All but three patients achieved full passive extension. Six of the nine knees had no extensor lag. The average post-operative clinical score for the follow-up group was 78 points. Graft complications include one early graft rupture, one early quadriceps junction failure, and one patellar component loosening. One graft fractured after revision of a metal-backed patella.     

Protection from carcinogenic agents in work environments: considerations on Title VII of Legislative Decree 626/94

A variety of techniques are available for reconstruction of the wrist. The efficacy of wrist arthroplasty, however, is met with narrowed indications and does not enjoy the success that total joint replacement in other joints, such as the hip and knee, has enjoyed. With design improvements during the last decade, good short-term results from total wrist arthroplasty can be expected in the low-demand patient with rheumatoid arthritis. Wrist arthrodesis, either pancarpal or limited, is considered the primary surgical alternative in patients with most arthritic conditions of the wrist. The pancarpal arthrodesis is a predictable, durable alternative to a variety of post-traumatic, degenerative, or neoplastic conditions of the wrist; however, some authors report that complications may be prevalent. This procedure also may be modified and applied to the destroyed rheumatoid wrist. Overall, selection of fixation mode depends on bone quality. In an attempt to preserve motion, various limited arthrodeses of the carpus have been described. Although technically demanding, successful results may be expected, especially in conditions of carpal instability. With the current wide array of surgical alternatives, the surgeon must consider each case carefully and select the procedure that best applies to each particular situation. Furthermore, it is extremely important that the surgeon educate the patient on the limitations of each procedure.