Gordon A. Hunter

Failure in total knee arthroplasty: mechanisms, revisions, and results.

Of 700 prosthetic knees inserted during the period from 1969 to 1978, 94 failed; 19 of the failures occurred due to infection. Other obvious mechanisms of failure were wear debris sy novitis, ligament rupture, and patellar dislocation. The majority of prosthetic loosenings occurred on the tibial side. There were five mechanical factors of such loosening: tilt and sink; compression; torsion; toggle; and a combination of these factors. Excluding those who died or were lost to follow-up, the results of revision were 37% good or excellent; 60% fair or poor; and 3% failure. To some extent the results were prosthesis dependent; the semiconstrained prosthesis had a good result in 48%, unlinked hinges a good result in 24%, and a true hinge a good result in 21%. The results in infected cases were poor; of five prosthetic revisions, only one was good. Fusion was found difficult to achieve; of 11 attempts, only six obtained solid fusion. Four amputations were performed, all for infection in hinged knee replacements.

The results of prosthetic replacement in fracture-dislocations of the upper end of the humerus

Eleven patients with fracture-dislocation of the upper end of the humerus treated by a Neer prosthesis are reviewed. The results of treatment are very disappointing. The complication rate is high. From these results in a small series, it would appear that prosthetic replacement of the humeral head does not offer the patient any significant advantage when compared with other reported methods. The possible cause of these poor results are discussed.

Should we abandon primary prosthetic replacement for fresh displaced fractures of the neck of the femur

The complications and results of 100 patients with a displaced femoral neck fracture, treated by primary prosthetic arthroplasty between 1972 and 1977, demonstrate a high morbidity from the surgical procedure. The six-month mortality was 20%. Good results were obtained in only 28% of the patients. In view of the reported incidence of deep-wound infection, dislocation and high mortality at six months, arguments are presented for and against the routine use of cemented hemiarthroplasty. Further consideration should now be given to alternative procedures, such as the muscle-pedicle graft. Total hip replacement may be indicated in some patients in whom accurate reduction of a displaced femoral neck fracture is impossible.

Analysis of the Analgesic Efficacy of Acetaminophen 1000 mg, Codeine Phosphate 60 mg, and the Combination of Acetaminophen 1000 mg and Codeine Phosphate 60 mg in the Relief of Postoperative Pain

Patients who experienced pain after surgery were administered a single dose of 1 of 3 treatments: acetaminophen 1000 mg, codeine phosphate 60 mg, or a combination of these. Patients rated their pain intensity on ordinal and visual analog scales just prior to medication and at intervals thereafter for up to 5 hours. They also rated pain relief, pain half gone, and any adverse effects. Sum of pain intensity difference and total pain relief scores were analyzed using Dunnetts procedure. The drug combination was statistically superior to codeine as measured by SPID, TOTPAR, pain half gone, and time to remedication. The combination achieved better mean scores than acetaminophen on all efficacy measures, but was (margnally) statistically superior only in pain half gone. No appreciable differences in adverse effects were noted among the treatments. The difficulty of showing the analgesic efficacy of codeine in a single dose trial is discussed.

Total Hip Revision Arthroplasty: Does Sepsis Influence the Results?

The results of revision total hip arthroplasty, with or without sepsis, are compared in a review of the recent literature. In 661 total hip revisions without sepsis, there is an overall 54% excellent/good/satisfactory rate and a 12% infection rate. Of 1063 total hip revisions in the presence of or after sepsis, there is an overall success rate of 73% and a 17% reinfection rate. Comparison of the two groups is difficult due to the different criteria used to diagnose infection, the variable use of parenteral antibiotics and cement impregnated with antibiotics, the frequently short follow-up periods, and the definition of success by different rating s stems. Aside from infection, before advising revision surgery or excision arthroplasty, consideration should be given to the individual patient, the hip to be revised, and the technical skills available. Follow-up should be monitored yearly by an independent examination of the patient, not by chart review or telephone questionnaire. Standardized rating methods should be used, together with strict criteria for the diagnosis of infection. Only in this way will results from different centers be comparable.

The results of medial displacement osteotomy for unstable intertrochanteric fractures of the femur.

The results of medial displacement osteotomy for unstable intertrochanteric fractures demonstrate that instability exists whenever there is lack of continuity of bone cortex on opposing surfaces of the 2 main fragments after reduction of the fracture. In 88 patients, 5 were lost to follow-up; 83 were reviewed personally by the authors at an average follow-up period of 27 months; the complication rate (both local and general) was high. Eight per cent showed non-union of the fracture; 13% developed deep infection (2 suffered from septicemia). Fifteen of 83 patients required a second operation. The mortality rate at 6 months was 13%, owing to heart failure, bronchopneumonia or thromboembolism. Of the 56 living, only 24 (43%) demonstrated a good functional result. Medial displacement osteotomy should be combined with a sliding screw-plate device. Without a sliding screw plate, medial displacement osteotomy for unstable intertrochanteric fractures of the femur may not be as successful as would appear from reports in the literature.

Dislocation requiring revision in total hip arthroplasty.

SummaryIn a study of 141 hip revisions seventeen were found to be due to recurrent dislocation. Thirteen cases occurred immediately postoperatively and four more than two years following surgery. In the early cases component malposition was found to be the commonest cause of dislocation. Revision resulted in only 40% acceptable results.

The treatment of intertrochanteric fractures--a review article.

INTRODUCTION INTERTROCHANTERIC fractures of the femur, essentially a disorder of the aged, set surgeons considerable problems in combining union in good position with minima1 mortality and maximal comfort to the patient and the greatest economy of hospital beds. Over the last 20 years, the evolution of newer materials, devices and techniques for fixation of fractures, and the application of biomechanical principles to fixation has led to improvements and a reduction in the complication rate. These improvements, combined with advances in anaesthesia and the techniques of resuscitation have not yet succeeded in reducing the hazards of operation and its consequences to an acceptable level. The surgeon faced with the treatment of these fractures must be able to make a critical appraisal of methods of treatment and of the results. The purpose of this review is to analyse the subject from the standpoints of epidemiology, classification, treatment and results, and to draw some conclusions as to how different fractures may best be treated.

The management of injuries of the midfoot and forefoot in the patient with multiple injuries

Injuries to the midfoot and forefoot in patients with multiple injuries can be a major source of long-term functional disability. Careful clinical and radiologic assessment is necessary to define the precise injury pattern, which is frequently complex. Treatment of the soft tissues is the immediate priority to preserve a viable foot with normally innervated plantar skin. Dislocations and subluxations in the midtarsal area must be reduced congruously. Reduction must be maintained by external fixation or percutaneous Kirschner wires until ligaments have healed. Fractures should be treated using accepted principles of management. Displaced intraarticular fractures should be treated by open reduction and internal fixation, if technically possible, to allow functional rehabilitation. The length and alignment of metatarsal shaft fractures must be restored and maintained, by internal fixation if necessary. In severe injuries, an early decision should be made regarding useful viability of the foot. If necessary, amputation should be performed early at a definitive level.

The results of operative treatment of trochanteric fractures of the femur

One hundred and seventy trochanteric fractures of the femur treated by operative fixation are reviewed. The results of treatment are disappointing. The complication rate is high. The mortality rate should be assessed at 6 months after the fracture. From these results, it would appear that operative treatment does not offer the patient with a trochanteric fracture of the femur less morbidity, a lowered mortality rate or even a better result, when compared with operative treatment 25 years ago, or when compared with a recent review of conservative treatment from Inverness.