Allan E. Inglis

Total hip arthroplasty in protrusio acetabuli of rheumatoid arthritis.

Thirty-five total hip arthroplasties done in twenty-five patients with protrusio acetabuli secondary to rheumatoid arthritis were reviewed. There was an average follow-up of 4.3 years, with a range of three to seven years. The results were rated as excellent or good in 66 per cent, fair in 26 per cent, and poor in 8 per cent. Although 100 per cent demonstrated cementbone interface demarcation around the acetabular component, only 10 per cent showed progression of the line of demarcation to two millimeters and one had acetabular loosening with migration. Eight per cent showed femoral loosening or subsidence; 8 per cent, calcar resorption; and 6 per cent, a receding cortex with cystic changes. Twenty-three per cent had nonunion of the greater torchanter after trochanteric osteotomy. Type-III cement-bone interface demarcation was present around the acetabular component was positioned one centimeter superiorly or medially beyond the anatomical position, as estimated by the method described. In thirteen hips in which the acetabular component was positioned within five millimeters of the anatomical position, no Type-III demarcation was present. Better fixation and position of the acetabular component is achieved by the use of a bone graft or a special titanium perforated-sheet mesh, or both, or by an acetabular shell. The use of three wires improved trochanteric fixation.

The effect of alignment of the implant on fractures of the patella after condylar total knee arthroplasty.

The results in thirty-six knees that had a fracture of the patella after a total condylar arthroplasty were reviewed, and were analyzed according to the type of fracture and the alignment of the implant and the limb. Most of the fractures occurred two years or less after the initial operation. Fourteen knees were rated fair or poor and twenty-two, good or excellent. None of the thirty-six implants had been aligned in the neutral range. In sixteen knees, the alignment had a minor variation from the neutral range--that is, the knees were in minor malalignment. In general, these knees had the least severe fractures and the best over-all results. All had a good or excellent result except one, which was revised because of a loose patellar component. That knee was rated as fair at the latest follow-up. There was a major discrepancy in the alignment of twenty implants. These knees had more severe fractures and less satisfactory results than those in the other group. In two of these knees, the fracture was treated non-operatively; one had a good and the other, a poor result. Twelve of the remaining knees, which were treated surgically, were rated as fair or worse. Two knees that had revision of three components and restoration of alignment to the neutral range had an excellent result. The results of this study indicate that the alignment and fit of a component are important in determining the severity of a fracture of the patella after condylar total knee replacement and the long-term results after treatment of the fracture.

Total elbow replacement.

Thirty-one patients who underwent thirty-six total elbow replacements between 1974 and 1977 were followed for a minimum of two years with an average of 3.7 years. A scoring system was used to quantitate results. Patients with rheumatoid arthritis and functional disability primarily related to pain benefited most from the operation. Patients with post-traumatic arthritis and disability secondary to loss of motion benefited least. The over-all complication rate was 53 per cent and the reoperation rate was 22 percent. However, only one-fourth of the complications adversely affected the final outcome. Total elbow replacement can give good results in carefully selected patients.

The coracoid impingement syndrome

Coracoid impingement results from encroachment on the coracohumeral space, presenting as anterior shoulder pain and clicking, particularly in forward flexion, medial rotation, and adduction. In eight shoulders in seven patients, coracohumeral decompression by excision of the lateral 1.5 cm of the coracoid with re-attachment of the conjoined tendon gave pain relief in all, and complete relief in six. This procedure is described and recommended.

GUEPAR knee arthroplasty results and late complications.

One hundred eight GUEPAR knee arthroplasties have been studied with a follow-up of one year on 41; 2 years on 22 and 3 years on 45 knees. Overall results were 17% excellent, 44% good, 10% fair and 29% poor. Excellent results were comparatively fewer in rheumatoid arthritis. There was a deterioration in the quality of results of arthroplasty with longer follow-up. The incidence of deep infection was 11%. There was a significant correlation between early wound drainage and deep infection. More than half of the infected knees have not required intervenition as yet. One knee was revised and 3 had attempted arthrodesis with one successful fusion. Two patients died with septicemia. Axle migration occurred in 8 knees and femoral stem breakage in 2 knees. Loosening was found in 27% of the knees with progressive reduction in quality of the arthroplasty. Incomplete cementing predisposed to loosening. Patellar symptoms were present in 28% of the knees. Patellar subluxation and dislocation occurred in 49% of the knees. More than half of these were symptomatic. With normal patellofemoral alignment, pain was more common in the osteoarthritic knee. Use of a patellar implant with GUEPAR knee prostesis should be restricted to severely disabled patients with major fixed deformities. Mechanical failure can be minimized by proper positioning of the implant, correct alignment of the extensor mechanism and adequate cement around the entire stem.

Salvage of non-union of supracondylar fracture of the humerus by total elbow arthroplasty.

Fourteen patients in whom open reduction and internal fixation could not be achieved satisfactorily had a total elbow arthroplasty for non-union of a supracondylar humeral fracture. All patients had an established non-union, and ten had had from one to four previous attempts at internal fixation. The average age at the time of operation was sixty-five years. The average duration of follow-up was five years, with a minimum of two years. The average preoperative elbow score was 17 points, with both pain and functional disability present. The average postoperative score was 84 points; there were eight good or excellent results and three failures. The latter three patients had an additional operation: one each for dislocation, loosening of the humeral component, and deep infection. Salvage of supracondylar non-union by means of a total elbow arthroplasty is a technically demanding procedure. Strict indications for selection of patients must be followed. A semiconstrained implant is recommended, with preservation of the epicondyles and their muscular attachments in order to achieve balance of the soft tissues.

Total shoulder arthroplasty in rheumatoid arthritis

Twenty-nine Neer-type total shoulder arthroplasties were performed in 26 patients with rheumatoid arthritis. The average age was 55.5 years and the average follow-up period was 37 months. On a 100-point scoring system, the average preoperative score of 25 improved to 71 after surgery. The most significant improvement was noted in pain relief. Radiographs demonstrated nonprogressive radiolucent lines in 86% of the glenoid components and 31% of the humeral components. Surgical problems included bone loss of the glenoid, acromioclavicular joint arthritis, and rotator cuff tears, in 7 of 29 shoulders. Follow-up study demonstrated poorer results for patients with rotator cuff tears. However, significant pain relief was achieved in 93% of our patients, despite limited functional improvements.

An analysis of factors affecting the long-term results of total shoulder arthroplasty in inflammatory arthritis

The authors studied 36 patients undergoing 50 total shoulder arthroplasties for inflammatory arthritis with an average follow-up period of 5 years (range, 2-9 years). There were 7 men and 29 women. Twenty-nine patients (38 shoulders) had rheumatoid arthritis, 6 patients (11 shoulders) had systemic lupus erythematosus, and 1 patient (1 shoulder) had psoriatic arthritis. Twenty-four of the procedures were performed on the dominant hand. Twenty-one patients (32 shoulders) were receiving steroids, chemotherapeutic agents, or Gold therapy at the time of arthroplasty. Using the Hospital for Special Surgery scoring system, 22 shoulders had excellent, 18 good, 1 fair, and 9 poor results. Forty-eight of 50 shoulders had satisfactory pain relief. The average shoulder score was 85 points (range, 50-100 points). There were no reoperations, infections, or persistent nerve palsies and no symptomatically loose prostheses, although there were three cases of glenoid component shift. Eighteen glenoid components and 4 humeral components had radiolucent lines and in two cases metaphyseal bone atrophy was noted about the proximal humerus with firm cement fixation and bone hypertrophy about the stem tip. Total shoulder arthroplasty provides a predictable reconstructive alternative for patients with inflammatory arthritis. Overall functional results are related to the biologic condition and motivation of the patient, the status of the rotator cuff, and prosthesis alignment.

Patellar fracture type and prognosis in condylar total knee arthroplasty.

Fractures of the patella occurred following implantation of 36 condylar total knee arthroplasties in 35 patients. The end results were evaluated in relation to fracture type after an average 4.5-year follow-up period. The follow-up observations included a physical examination, quantitative knee score, and roentgenographic evaluations of extremity alignment and implant position. Twenty-two of the 36 knees had a good or excellent knee score and 14 had a fair or worse score at the time of the latest follow-up evaluation. The satisfactory knees had an average arc of motion of 100 degrees, while the unsatisfactory knees had an average arc of motion of 80 degrees. Fourteen fractures through the mid-body or superior pole of the patella not involving the implant, cement, or quadriceps mechanism (Type I) and two nondisplaced fractures through the inferior pole of the patella (Type IIIB) were managed nonoperatively, with all knees rating either a good or excellent score. Fractures of the patella disrupting the quadriceps mechanism or implant/bone/cement composite (Type II) were managed operatively in the six knees. Fractures of the inferior pole of the patella with disruption of the patellar ligament (Type IIIA) were managed operatively in seven of eight knees (one patient refused surgery). Lateral fracture-dislocations were managed operatively in all six knees. Six of the knees operated upon had a good or better score, and nine knees were rated as poor or failed. Those fractures alignment and implant position were seen had the more severe patellar fractures and poorest outcomes.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary semiconstrained total elbow arthroplasty. Survival analysis of 113 consecutive cases

We used survival analysis to evaluate 113 consecutive semiconstrained total elbow arthroplasties (TEAs) in 95 patients at a maximum follow-up of 99 months. Our criteria for failure were mechanical malfunction, revision for any reason, and deep infection. The primary diagnosis was inflammatory arthritis in 86 elbows, post-traumatic arthritis in 6, supracondylar nonunion or fracture in 12, osteoarthritis in 2 and other causes in 3. Seven failures were due to deep infection, and five of these had a primary diagnosis of inflammatory arthritis. Eight failures were revised or had revision recommended for aseptic loosening, and six of these were in patients with post-traumatic arthritis or supracondylar nonunion. The cumulative survival for TEAs performed for post-traumatic arthritis, fractures or supracondylar nonunion was 73% at three years and 53% at five years, significantly worse than the cumulative three- and five-year survivals of 92% and 90%, respectively, for patients with inflammatory arthritis. TEA with a semiconstrained prosthesis appears to have a satisfactory survival in selected patients with arthritic disorders. The incidence of deep infection was reduced by improvements in surgical technique and postoperative management, and the routine use of antibiotic-impregnated cement. The incidence of aseptic loosening was low, except in patients with supracondylar nonunion or post-traumatic arthritis.