M. P. Figgie

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.

The results of revision total knee arthroplasty

The results of 65 consecutive revision total knee arthroplasties performed for mechanical failure were reviewed. Fifty-nine of the knees were followed for an average of five years (range, 2-10 years). The types of implants used included: total condylar, posterior stabilized, total condylar III, and the kinematic rotating hinge prostheses. Only 46% of the knees were considered excellent or good; 42% either had poor results or failed. The infection rate was 4.5%. Poor results were generally caused by patellofemoral problems and kinematic abnormalities. Revision total knee arthroplasty is a technically demanding procedure that can improve function when anatomic relationships of the knee are restored.

Use of a total condylar knee prosthesis for treatment of osteoarthritis and rheumatoid arthritis. Long-term results.

Between May 1975 and December 1979, 113 patients had 153 arthroplasties using a total condylar knee prosthesis. Thirty patients (forty-two knees) died, and one (two knees) was lost to follow-up. Thirty-eight of these forty-four knees had been followed for more than two years, and none had had a revision. The remaining eighty-two patients (109 knees) were followed for an average of nine years (range, seven to 11.5 years). At the time of the latest examination, ten had had a revision for various reasons. For the ninety-nine knees that had the original prosthesis, the findings were compared with those of an evaluation that had been done four years postoperatively. The average over-all knee score was found to have decreased between the four-year and the latest follow-up evaluation, primarily because of a 7-point decrease in the score for function. The rate of infection was 0.6 per cent. The knees that had had patellar resurfacing had better over-all scores and better scores for pain than those that had not. This was particularly true in the patients who had osteoarthritis. The results of arthroplasty using a total condylar prosthesis appeared to be consistent and durable. Although there was a decrease in the quality of the functional result with increasing age, the patients reported consistent relief of pain.

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)

Sagittal measurements of the cervical spine in subaxial fractures and dislocations. An analysis of two hundred and eighty-eight patients with and without neurological deficits.

We analyzed three factors involved in fractures and dislocations of the cervical spine and their relation to the degree of injury of the spinal cord. The three factors were the space available for the spinal cord at the level of the injury, the sagittal diameter of the spinal canal at the uninjured levels, and the Pavlov ratio at the uninjured levels. Of the 288 patients analyzed, eighty-three had a complete injury of the spinal cord, ninety-two had an incomplete injury of the spinal cord, thirty had an isolated nerve-root injury, and eighty-three had no neurological deficit. The mean space available for the spinal cord at the level of the injury was 10.5 millimeters for the patients who had a complete injury of the spinal cord, 13.1 millimeters for those who had an incomplete injury of the spinal cord, 15.9 millimeters for those who had an isolated nerve-root injury, and 16.7 millimeters for those who had no neurological deficit. The difference between the groups was significant (p < 0.001) except for the difference between the patients who had an isolated nerve-root injury and those who had no neurological deficit. The mean sagittal diameter of the canal at the uninjured levels was 16.1 millimeters for the patients who had a complete injury of the spinal cord, 16.1 millimeters for those who had an incomplete injury of the spinal cord, 17.9 millimeters for those who had an isolated nerve-root injury, and 18.1 millimeters for those who had no neurological deficit. The difference between the patients who had a complete injury of the spinal cord and those who had an incomplete injury of the spinal cord and that between the patients who had an isolated nerve-root injury and those who had no neurological deficit were not significant (p > 0.05). However, the patients who had a complete injury of the spinal cord and those who had an incomplete injury of the spinal cord were significantly different from the patients who had an isolated nerve-root injury and those who had no neurological deficit (p < 0.001). The mean Pavlov ratio at the uninjured levels was 0.82 for the patients who had a complete injury of the spinal cord, 0.84 for those who had an incomplete injury of the spinal cord, 0.96 for those who had an isolated nerve-root injury, and 0.96 for those who had no neurological deficit.(ABSTRACT TRUNCATED AT 400 WORDS)

Triple arthrodesis in rheumatoid arthritis.

Fifty-five patients with rheumatoid arthritis were treated with 65 triple arthrodeses of the hindfoot from March 1975 through July 1985. Twelve patients (12 procedures) have died, and follow-up evaluation could not be completed on three patients (four procedures), leaving 40 patients (49 procedures) available for clinical and roentgenographic evaluation. There were 32 women and eight men, with an average age at the time of surgery of 50 years. The follow-up period averaged five years. Standard operative technique involved medial and lateral incisions with staple fixation and local bone grafting. Correction of deformity was performed with closing wedge osteotomies. All patients had moderate to severe pain preoperatively and difficulty with ambulation. Postoperatively, 94% of the patients had significant pain relief and 83% had complete pain relief. Ambulatory status was improved in 80% of the patients. Ninety percent were at least community ambulators at the time of review, whereas more than half the patients were limited to household ambulation preoperatively. Complications included four superficial wound infections, all of which responded to local care. One patient required revision surgery for pseudarthrosis, and three patients had progression of ankle disease and required pantalar arthrodeses. There was no significant progression of fore-foot or knee symptoms, however, and there was no progression of ankle symptoms in patients whose hindfeet were corrected to 0 degrees-10 degrees valgus. Triple arthrodesis in the rheumatoid population has a high union rate. Pain relief and ambulation improvement can be expected.

Knee arthrodesis following total knee arthroplasty in rheumatoid arthritis.

Twenty-seven knees in 23 patients, all with seropositive rheumatoid arthritis and failed total knee arthroplasty, were treated by arthrodesis. Twenty of the 27 knees were solidly fused. A fusion aligned in 7 degrees +/- 5 degrees of valgus and knee flexion from zero to 30 degrees was associated with the highest rate of arthrodesis, the lowest rate of progression of disease in other joints, and the highest functional scores. Stable fixation using either internal or external fixation gave the most predictable rate of arthrodesis. Persistent sepsis and bone stock losses were associated with failure of arthrodesis, even under the best circumstances. All of the 20 successfully arthrodesed knees were completely functional.