Calvin S. Oishi

The femoral component in total hip arthroplasty. Six to eight-year follow-up of one hundred consecutive patients after use of a third-generation cementing technique.

One hundred consecutive patients had a primary unilateral total hip arthroplasty with use of a single design of the femoral component (Harris Precoat), inserted with a so-called third-generation cementing technique, between July 1985 and June 1987. There were seventy-four women and twenty-six men. The mean age at the time of the operation was seventy-one years (range, forty-one to ninety-two years) and the mean weight was seventy kilograms (range, forty-eight to 105 kilograms). Eleven of the 100 patients died during the follow-up period, all with the implant in place. Of the eighty-nine surviving patients, one had a revision arthroplasty for aseptic loosening. The mean duration of clinical follow-up for the remaining eighty-eight patients was seven years (range, six to eight years). The mean Harris hip score at the latest follow-up evaluation was 91 points (range, 68 to 97 points). Of the eighty-eight patients, eighty-five (97 percent) had a good or excellent result. Radiographic follow-up was performed for eighty-one patients; none had evidence of loosening of the stem, and five (6 percent) had endosteal cavitation but were asymptomatic. The rate of failure (loosening or revision) of the femoral component in the entire series was 1 per cent (one hip). The low rate of failure and the maintenance of good and excellent clinical and radiographic results during this period of follow-up are consistent with reports from other institutions. This strengthens the argument to retain or widen the existing indications for the insertion of a femoral stem with cement in primary total hip arthroplasty.

Postoperative surveillance for deep venous thrombosis with duplex ultrasonography after total knee arthroplasty.

Duplex ultrasonography of the lower extremity was used for routine non-invasive screening for asymptomatic proximal and distal deep venous thrombosis, for monitoring of potential propagation of deep venous thrombosis from distal to proximal, and for confirmation of the resolution of proximal deep venous thrombosis after treatment. In the first part of the study, to substantiate the accuracy of duplex ultrasonography, 130 lower limbs (seventy-nine patients) were studied with that modality as well as with venography after a total hip or total knee arthroplasty. Compared with venography, duplex ultrasonography demonstrated 100 per cent sensitivity, specificity, and accuracy for the detection of proximal deep venous thrombosis and 88 per cent sensitivity, 98 per cent specificity, and 98 per cent accuracy for the detection of distal deep venous thrombosis. In the second part of the study, 100 patients who had had a total knee arthroplasty and had been managed with pneumatic stockings and aspirin for prophylaxis against deep venous thrombosis had screening of both lower extremities with duplex ultrasonography on the fourth postoperative day. Duplex ultrasonography demonstrated proximal deep venous thrombosis in seven patients and distal deep venous thrombosis in twenty-two patients; all twenty-nine patients were asymptomatic. The patients who had distal deep venous thrombosis had surveillance with serial duplex ultrasonography on the seventh and fourteenth postoperative days; five of these patients were found to have had propagation of the thrombosis to the proximal deep veins.(ABSTRACT TRUNCATED AT 250 WORDS)

The clinical course of distal deep venous thrombosis after total hip and total knee arthroplasty, as determined with duplex ultrasonography

Duplex ultrasonography was used to screen 273 consecutive patients, on the fourth day after a total hip or total knee arthroplasty, for the presence of a distal deep venous thrombosis. Patients who had a history of thromboembolic disease or who had an active neoplasm were excluded from the study. Of the 273 patients, twenty-four (9 per cent) were found to have a proximal deep venous thrombosis (a thrombosis involving the femoral or popliteal veins) and forty-one (15 per cent), a distal deep venous thrombosis (a thrombosis involving the veins of the calf). All of the thromboses were asymptomatic. The forty-one patients in whom a distal deep venous thrombosis had been detected with duplex screening subsequently had serial duplex examinations, on the seventh and fourteenth postoperative days. If a proximal deep venous thrombosis was detected, anticoagulation was begun immediately. If no proximal thrombosis was observed, the distal thrombosis was considered stable, the serial duplex examinations were terminated, and clinical observation was continued. Of the forty-one patients who had serial examinations, seven (17 per cent) had a proximal deep venous thrombosis in the ipsilateral limb by the fourteenth postoperative day; all seven were asymptomatic, and all were managed with anticoagulation. Thirty-four patients (83 per cent) were determined to have a stable distal deep venous thrombosis on the fourteenth postoperative day, and no additional duplex examinations were performed. Thirty-three (97 per cent) of these thirty-four patients remained asymptomatic for deep venous thrombosis thereafter; the remaining patient (3 per cent) had a proximal deep venous thrombosis in the ipsilateral limb eleven months postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of parenteral prophylactic antibiotics in clean orthopaedic surgery. A review of the literature.

Parenteral prophylactic antibiotics are now a routine part of most clean orthopaedic procedures since so many animal and clinical studies have shown a reduced infection rate with their use. First-generation cephalosporins are theoretically the preferred agents, and the pharmacokinetics of Cefazolin make it the drug of choice. It is imperative that an antibiotic be given on the induction of anesthesia or at least ten minutes before inflation of a tourniquet. Based on evidence in the current literature, 24 hours of postoperative coverage appears to be adequate.

Recurrent hemarthrosis following a total knee arthroplasty

The case of a recurrent hemarthrosis of a total knee arthroplasty after the sixth postoperative month is described. Because of disabling pain, the patient underwent an explorative arthrotomy 18 months after implantation of the total knee arthroplasty. A hypertrophied vascular mass of synovium was discovered in the lateral gutter and excised with an associated synovectomy. Since the arthrotomy, the hemarthrosis has not recurred. Therefore, in cases of recurrent hemarthrosis of a total knee arthroplasty that becomes disabling, exploration by arthrotomy should be considered.

Perioperative bladder management after primary total hip arthroplasty

A retrospective review of 95 consecutive primary total hip arthroplasty patients was performed to assess the clinical outcome of two postoperative bladder management protocols. The first 49 patients (group 1) were treated with a pro re nata straight catheterization protocol. The next 46 patients (group 2) were treated with an indwelling catheterization protocol. There were no differences between the groups with respect to sex or age. The patients in group 2 had significantly lower incidences of urinary retention (P < .0005) and bladder distention (P < .0005) than those in group 1. Preoperative systemic diseases and urologic symptoms did not correlate with the occurrence of postoperative urinary retention or bladder distention. There were no infections in group 1. In group 2, one patient (2%) had bacteriuria and one patient (2%) had a urinary tract infection (P > .1). This trend of increased contamination in the catheterization group may be related to a mean catheterization duration of 72 hours.

Hemodilution with other blood reinfusion techniques in total hip arthroplasty

Acute normovolemic hemodilution has been reported to result in blood savings varying from 18% to 90%. Very few of these are randomized prospective studies. This study attempts to determine the blood transfusion savings if acute normovolemic hemodilution is used in combination with autologous predonated blood and cell saver. Thirty-three patients undergoing total hip arthroplasty were assigned randomly to one of two groups (control, n = 16; hemodilution, n = 17). Patients in both groups entered an autologous predonation program if cleared medically and were placed on Cell Saver intraoperatively and in the postanesthesia care unit. In addition, the hemodilution group underwent acute normovolemic hemodilution preoperatively. Only 41% of the patients in the hemodilution group required any autologous blood transfusion as compared with 75% of the control group. In addition, the hemodilution group required a mean lower quantity of autologous blood transfusion (41% of the estimated blood loss) as compared with the control group (71%). The net anesthesia time increased by an average of 11.4 minutes in the hemodilution group. Acute normovolemic hemodilution is a safe procedure even in an older patient population. Hemodilution resulted in fewer patients needing autologous predonated blood transfusions. The major benefit of hemodilution was seen when predonation was not possible.

100 Cemented Versus 100 Noncemented Stems With Comparison of 25 Matched Pairs

Two series of 100 consecutive primary total hip arthroplasties, each using a single design of noncemented or cemented femoral component (all 28 mm heads), were compared. One cemented and two noncemented stems underwent revision for aseptic loosening. Of unrevised hips, outcome data statistically favored cemented, rather than noncemented, stems. The data for cemented and noncemented stems, respectively, were: An excellent to good result in 97% versus 88%; thigh pain in 3% versus 40%; subsidence in 0% versus 22%; and endosteal cavitation in 6% versus 12%. For patients with 25 unrevised matched pairs, selected by gender, age, diagnosis, and weight, outcome data also statistically favored cemented over noncemented stems, respectively: an excellent or good result in 25 versus 20 hips; thigh pain in two versus eight hips; and subsidence in none versus six hips. Midterm followup data for these concurrent total hip arthroplasty series of a mid1980s design revealed prevalence of mechanical failure of 1% for cemented stems and 4% for noncemented stems. Corroborating matched pair comparison neutralized selection bias as a causative factor for these differences. These data indicate contemporary cemented femoral stem fixation is superior to second generation noncemented femoral stem fixation. Controlled comparative studies at midterm to long term followup, such as in this report, are needed to define outcome and indications for current third generation noncemented stem fixation.