Mark B. Coventry

Proximal tibial osteotomy. A critical long-term study of eighty-seven cases.

Eighty-seven valgus osteotomies of the tibia were performed in seventy-three patients for osteoarthrosis of the medial compartment of the knee; the median follow-up was ten years (range, three to fourteen years). The data were subjected to univariate and multivariate statistical analysis and to survivorship analysis. For these calculations, the end-point of failure was defined as an arthroplasty of the knee, and additional calculations were performed with the end-point defined as the performance of an arthroplasty or moderate or severe pain in patients who had declined an arthroplasty. None of the many risk factors that were evaluated could be found to be associated with the duration of survival, except for relative weight and angular correction. The median loss of correction after the osteotomy was 1 degree. If, at one year after the operation, the valgus angulation was 8 degrees or more, or if the patients weight was 1.32 times the ideal weight or less, the probability of survival five years thereafter was at least 90 per cent and the probability ten years thereafter was at least 65 per cent. However, when valgus angulation at one year was less than 8 degrees in a patient whose weight was more than 1.32 times the ideal weight, the rate of survival decreased to 38 per cent five years thereafter and to 19 per cent ten years thereafter. There is a considerable risk of failure of a proximal tibial osteotomy if the alignment is not overcorrected to at least 8 degrees of valgus angulation and if the patient is substantially overweight.

Normal axial alignment of the lower extremity and load-bearing distribution at the knee.

Based on a series of 120 normal subjects of different gender and age, the geometry of the knee joint was analyzed using a full-length weight-bearing roentgenogram of the lower extremity. A special computer program based on the theory of a rigid body spring model was applied to calculate the important anatomic and biomechanical factors of the knee joint. The tibiofemoral mechanical angle was 1.2 degrees varus. Hence, it is difficult to rationalize the 3 degree varus placement of the tibial component in total knee arthroplasty suggested by some authors. The distal femoral anatomic valgus (measured from the lower one-half of the femur) was 4.2 degrees in reference to its mechanical axis. This angle became 4.9 degrees when the full-length femoral anatomic axis was used. When simulating a one-legged weight-bearing stance by shifting the upper-body gravity closer to the knee joint, 75% of the knee joint load passed through the medial tibial plateau. The knee joint-line obliquity was more varus in male subjects. The female subjects had a higher peak joint pressure and a greater patello-tibial Q angle. Age had little effect on the factors relating to axial alignment of the lower extremity and load transmission through the knee joint.

Osteogenic Sarcoma: A Study Of Six Hundred Cases

Of 600 patients with pathologically verified osteogenic sarcoma (exclusive of tumors of the jaws and parosteal osteogenic sarcoma), 410 were eligible for five-year follow-up and 408 were traced. Of the 408 patients, eighty-three (20.3 per cent) survived more than five years. The survival rate (17.1 per cent) for patients whose tumors were predominantly osteoblastic was lower, but not to a statistically significant degree, than the rate for those with chondroblastic or fibroblastic tumors. More than 25 per cent of those with tumors in the more readily treatable sites, namely distal to the proximal end of the humerus or femur, survived five years. Sex had little bearing on prognosis. The more anaplastic sarcomata were associated with a poorer prognosis than the average, but again the difference was not statistically significant. Two patients survived long intervals after resection for pulmonary metastasis. Twenty of the 600 patients had osteogenic sarcoma that developed in lesions of Pagets disease, and three of these became long-term survivors. Sixteen had osteogenic sarcoma that arose in bones that had been irradiated previously; none of these survived more than three years. The possibility of multicentric origin of osteogenic sarcoma arose in sixteen patients. It is concluded that vigorous, prompt treatment should be employed for osteogenic sarcoma and a gratifying number of survivors obtained.

Deep wound sepsis following total hip arthroplasty

After follow-ups ranging from two to five years on all but four (five hips) of 2,694 patients who had 3,215 total hip arthroplasties, deep wound infection had been demonstrated in forty-two hips (1.3 per cent). The infections among the 3,210 hips appeared during the immediate postoperative period or as long as five years after surgery. All operations were performed in conventional operating rooms. Previous operations, prolonged operating time, positive culture at operation, and unrecognized preoperative sepsis were related to the development of deep infection. In only eight of the forty-one patients (forty-two hips) was salvage of the prosthetic arthroplasty possible. The deaths of tree patients were directly attributable to the infection or its treatment.

Osteotomy about the knee for degenerative and rheumatoid arthritis.

In seventy-one patients with degenerative arthritis and sixteen with quiescent rheumatoid arthritis, proximal tibial or femoral osteotomy was performed for varus or valgus deformity. The correction needed was gauged in standing roentgenograms. After one to nine years, the patients with either form of arthritis had good or fair results in all but three cases in each group, gauged mostly by relief of pain, since the range of motion did not change. The results tended to be better in patients with lesser degrees of arthrosis.

2,012 Total Hip Arthroplasties: A Study of Postoperative Course and Early Complications

The postoperative course and early complications after total hip arthroplasty were evaluated by reviewing the records of 1,684 patients who underwent 2,012 arthroplasties. Arthroplasty-related complications (after 6 per cent of the operations) included dislocation, spontaneous subluxation, loosening of acetabular or femoral components, sciatic and femoral-nerve palsy, and superficial and deep wound infections. Medical complications (in 25 per cent of the patients) included urinary-tract infections, acute renal failre, myocardial infarction, cardiac failure, pneumonitis and atelectasis, thrombophlebitis, hemorrhage, and gastrointestinal disturbances. The intrahospital mortality was 0.4 per cent (nine patients). Based on these findings, it was concluded that certain technical considerations are important, including correct use of methylmethacrylate, positioning of prosthetic components, trochanteric wiring, and the configuration of the tissues and cement adjacent to the joint.

OSTEOTOMY OF THE UPPER PORTION OF THE TIBIA FOR DEGENERATIVE ARTHRITIS OF THE KNEE. A PRELIMINARY REPORT.

Thirty knees of twenty-two patients have been operated on in the past four years (1960-1964) to correct the varus or valgus deformity resulting from degenerative changes. Six knees in four other patients suffering from rheumatoid arthritis had similar procedures. An upper tibial wedge osteotomy was used in the general region of the closed epiphysis. The thrust of weight-bearing and other stresses was thus lessened on the degenerated tibial condyle and transferred to the more normal condyle. The results at from one to four years after operation have been encouraging. It Is hoped that by this procedure the pain of degenerative arthritis of the knee can be relieved or reduced and the usefulness of the knee prolonged.

Ten-Year Evaluation of Geometric Total Knee Arthroplasty

One hundred ninety-three geometric total knee arthroplasties (TKA) were performed between 1972 and 1975 in 129 patients (66 women, 63 men; mean age, 69 years) with osteoarthritis. Of these, 102 knees were followed for a mean of 11 years. Eighty-three percent of the patients had mild or no pain. The revision rate was 20%, and the surgical complication rate was 12%. By actuarial analysis, the probability of retaining a geometric prosthesis at 10 years was 78%. With revision or moderate to severe pain as the end point, the predicted implant survival was 69% at 10 years. Lucent lines greater than 1 mm were present in 38% of the knees and progressed in 34%; they were more frequent in knees with greater than or equal to 3 degrees of varus axial alignment (p less than 0.05) or greater than or equal to 4 degrees of varus placement of the tibial component (p less than 0.05). The geometric prosthesis has provided a functional result in 69% of knees at 10 years, despite being the first two-part component knee replacement retaining the cruciate ligaments and using early surgical instrumentation and implant design.

Anterior Interbody Lumbar Spine Fusion: Analysis Of Mayo Clinic Series

A consecutive series of eighty-three patients treated with anterior interbody disc excision and bone-grafting has been presented. A good clinical result was achieved by only 36 per cent of the patients and roentgenographic evidence of fusion at all levels grafted occurred in only 56 per cent. A one-level grafting procedure gave a better chance of fusion (68 per cent) and the lumbosacral interspace became solid slightly more frequently than more cephalad interspaces. Postoperative cast immobilization significantly improved the fusion rate. We concluded that the reported differences in success with this technique are attributable chiefly to the interpretation of clinical and roentgenographic factors by different authors and to the type of patients selected for this procedure. We believe that this technique should be utilized as a salvage procedure only in those infrequent cases in which posterolateral grafting is inadvisable because of infection or unusally extensive scarring.

Posterolateral Lumbar-spine Fusion: Analysis Of Mayo Clinic Series

A series of 177 patients who had posterolateral lumbar-spine bone-grafting has been presented. The clinical result was based on reliefof pain, the need for analgesic medication, the restriction of physical activities, and the return to employment. Sixty per cent achieved good results, and 81 per cent satisfactory results (good and fair). A solid fusion based on roentgenographic evaluation was achieved in 80 per cent. There was high correlation between the clinical result and the presence or absence of a solid fusion in all diagnostic categories except spondylolisthesis. For spondylolisthesis, a one-level posterolateral grafting procedure seemed to be more reliable than a two-level procedure. Compensation considerations and a diagnosed psychoneurosis were factors that were identified as predisposing to a poor clinical result. Postoperative immobilization with a plaster body cast did not improve the fusion rate. Our experience indicates that posterolateral lumbar-spine bone-grafting resulted in a better fusion rate and a greater percentage of good clinical results than those reported for either anterior interbody or strictly posterior bone-grafting techniques.