Mitchell B. Sheinkop

Results of Unicompartmental Knee Arthroplasty at a Minimum of Ten Years of Follow-up

BACKGROUND There is a renewed interest in unicompartmental knee arthroplasty. The present report describes the minimum ten-year results associated with a unicompartmental knee arthroplasty design that is in current use. METHODS Sixty-two consecutive unicompartmental knee arthroplasties that were performed with cemented modular Miller-Galante implants in fifty-one patients were studied prospectively both clinically and radiographically. All patients had isolated unicompartmental disease without patellofemoral symptoms. No patient was lost to follow-up. Thirteen patients (thirteen knees) died after less than ten years of follow-up, leaving thirty-eight patients (forty-nine knees) with a minimum of ten years of follow-up. The average duration of follow-up was twelve years. RESULTS The mean Hospital for Special Surgery knee score improved from 55 points preoperatively to 92 points at the time of the final follow-up. Thirty-nine knees (80%) had an excellent result, six (12%) had a good result, and four (8%) had a fair result. At the time of the final follow-up, thirty-nine knees (80%) had flexion to at least 120 degrees . Two patients (two knees) with well-fixed components underwent revision to total knee arthroplasty, at seven and eleven years, because of progression of patellofemoral arthritis. At the time of the final follow-up, no component was loose radiographically and there was no evidence of periprosthetic osteolysis. Radiographic evidence of progressive loss of joint space was observed in the opposite compartment of nine knees (18%) and in the patellofemoral space of seven knees (14%). Kaplan-Meier analysis revealed a survival rate of 98.0% +/- 2.0% at ten years and of 95.7% +/- 4.3% at thirteen years, with revision or radiographic loosening as the end point. The survival rate was 100% at thirteen years with aseptic loosening as the end point. CONCLUSIONS After a minimum duration of follow-up of ten years, this cemented modular unicompartmental knee design was associated with excellent clinical and radiographic results. Although the ten-year survival rate was excellent, radiographic signs of progression of osteoarthritis in the other compartments continued at a slow rate. With appropriate indications and technique, this unicompartmental knee design can yield excellent results into the beginning of the second decade of use.

Long-term followup of the Miller-Galante total knee replacement

One hundred seventy-two consecutive cemented Miller-Galante-I total knee arthroplasties in 155 patients were compared with 109 consecutive cemented Miller-Galante-II total knee arthroplasties in 92 patients. The average followup was 11 years (range, 8–15 years) and 9 years (range, 8–10 years), respectively. Of the 172 Miller-Galante-I arthroplasties, there have been 21 revisions; 15 patellar revisions; two included femoral revisions attributable to abrasion. Six additional well-fixed femoral and tibial components were revised: two for early instability, one for pain, one for periprosthetic fracture, and two for infection. No component had aseptic loosening or osteolysis. Using revision or loosening of any components as the end point, the Kaplan-Meier 10-year survivorship was 84.1% ± 4.1%. Of the 109 Miller-Galante-II arthroplasties, there have been no component revisions, no aseptic loosening, and no osteolysis. Using revision or loosening of any components as the end point, the Kaplan-Meier 10-year survivorship was 100%. The Miller-Galante knee systems showed excellent fixation with no loosening and no osteolysis at as many as 15 years. Additionally, there have been no component revisions for late instability at as many as 15 years. Finally, the high prevalence of patellofemoral complications with the Miller-Galante-I design has been obviated with the Miller-Galante-II design.

Cementless Acetabular Reconstruction After Acetabular Fracture

Background: Total hip arthroplasty in patients with posttraumatic arthritis has produced results inferior to those in patients with nontraumatic arthritis. The use of cementless acetabular reconstruction, however, has not been extensively studied in this clinical context. Our purpose was to compare the intermediate‐term results of total hip arthroplasty with a cementless acetabular component in patients with posttraumatic arthritis with those of the same procedure in patients with nontraumatic arthritis. We also compared the results of arthroplasty in patients who had had prior operative treatment of their acetabular fracture with those in patients who had had prior closed treatment of their acetabular fracture. Methods: Thirty total hip arthroplasties were performed with use of a cementless hemispheric, fiber‐metal-mesh-coated acetabular component for the treatment of posttraumatic osteoarthritis after acetabular fracture. The median interval between the fracture and the arthroplasty was thirty‐seven months (range, eight to 444 months). The average age at the time of the arthroplasty was fifty‐one years (range, twenty‐six to eighty‐six years), and the average duration of follow‐up was sixty‐three months (range, twenty‐four to 140 months). Fifteen patients had had prior open reduction and internal fixation of their acetabular fracture (open-reduction group), and fifteen patients had had closed treatment of the acetabular fracture (closed-treatment group). The results of these thirty hip reconstructions were compared with the intermediate‐term results of 204 consecutive primary total hip arthroplasties with cementless acetabular reconstruction in patients with nontraumatic arthritis. Results: Operative time (p < 0.001), blood loss (p < 0.001), and perioperative transfusion requirements (p < 0.001) were greater in the patients with posttraumatic arthritis than they were in the patients with nontraumatic arthritis. Of the patients with posttraumatic arthritis, those who had had open reduction and internal fixation of their acetabular fracture had a significantly longer index procedure (p = 0.01), greater blood loss (p = 0.008), and a higher transfusion requirement (p = 0.049) than those in whom the fracture had been treated by closed methods. Eight of the fifteen patients with a previous open reduction and internal fixation required an elevated acetabular liner compared with one of the fifteen patients who had been treated by closed means (p = 0.005). Two of the fifteen patients with a previous open reduction and internal fixation required bone-grafting of acetabular defects compared with seven of the fifteen patients treated by closed means (p = 0.04).The thirty patients treated for posttraumatic arthritis had an average preoperative Harris hip score of 41 points, which increased to 88 points at the time of follow-up; there was no significant difference between the open-reduction and closed-treatment groups (p = 0.39). Twenty‐seven patients (90%) had a good or excellent result. There were no dislocations or deep infections. The Kaplan‐Meier ten‐year survival rate, with revision or radiographic loosening as the end point, was 97%. These results were similar to those of the patients who underwent primary total hip arthroplasty for nontraumatic arthritis. Conclusions: The intermediate‐term clinical results of total hip arthroplasty with cementless acetabular reconstruction for posttraumatic osteoarthritis after acetabular fracture were similar to those after the same procedure for nontraumatic arthritis, regardless of whether the acetabular fracture had been internally fixed initially. However, total hip arthroplasty after acetabular fracture was a longer procedure with greater blood loss, especially in patients with previous open reduction and internal fixation. Previous open reduction and internal fixation predisposed the hip to more intraoperative instability but less bone deficiency.

Affective and sensory dimensions of back pain.

&NA; Pain words used to communicate suffering were analyzed to identify specific dimensions of back pain. The words were obtained from a group of 131 patients suffering from back pain who described their discomfort on a standardized 87‐item pain questionnaire. The results indicate that words descriptive of back pain are not associated in completely random ways. When patients complain of back pain, their report falls into 7 distinguishable patterns. The major pattern accounts for 38% of the variance and refers almost entirely to emotional discomfort. The second pattern accounts for 9% of the variance and is a mixed emotional and sensory factor. The remaining 5 patterns account for 29% of the variance and constitute an entirely sensory class of factors.

Revision of the Acetabular Component without Cement after Total Hip Arthroplasty. A Follow-up Note Regarding Results at Seven to Eleven Years*

The results of revision of the acetabular component without cement, performed for aseptic loosening, were reported previously after a mean of forty-four months for 138 hips (132 patients). After an additional mean duration of follow-up of almost five years, twelve patients (twelve hips) had died before they could be followed long enough for the later study and nine patients (eleven hips) had been lost to follow-up; thus, a total of 111 patients (115 hips) were available for follow-up at a mean of 100 months (range, seventy-eight to 135 months). Between the earlier and later times of follow-up, six additional acetabuli had had a repeat revision: one, for recurrent dislocation; two, for infection; and three (which were stable), at the time of a revision of the femoral stem. No revision of the acetabular cup was performed because of aseptic loosening, and no cup was noted to have migrated. Radiographs were available for 105 patients (109 hips) at a mean of ninety-eight months (range, seventy-eight to 135 months). Five (5 per cent) of the 109 cups were surrounded by a complete radiolucent line and three (3 per cent), by a partial progressive radiolucent line. A radiolucent line adjacent to a screw was seen in association with two cups (2 per cent), and osteolysis was noted at the margin of four cups (4 per cent). Revision of the acetabular component with a porous-coated, nearly hemispherical fiber-metal component inserted without cement was associated with a high rate of excellent results at the seven to eleven-year follow-up examination.

Problems with cementless total knee arthroplasty at 11 years followup.

One hundred two patients with 131 consecutive cementless total knee arthroplasties that retained the posterior cruciate ligament were followed up prospectively. The average age of the patients was 58 years (range, 32–75 years). The mean followup on the surviving knee arthroplasties was 11 years (range, 7–16 years). The patellar component was metal-backed in the first 112 (85%) knees, cementless all-polyethylene in the last 17 (13%) knees, and two knees had a prior patellectomy. Forty-four metal-backed patellar components (48%) were revised; nine were loose, and 35 had polyethylene wear through. Thirteen femoral components (12%) were revised because of femoral abrasion from a failed metal-backed patellar component. No other femoral component was revised, loose, or had osteolysis develop. Nine (8%) tibial components had failure of ingrowth; eight have been revised. Partial radiolucencies occurred in 53% of the tibias. Thirteen (12%) small osteolytic lesions developed, all around screws or screw holes in the tibial components. At an average of 11 years followup, cementless fixation yielded mixed results: cementless femoral fixation was excellent and metal-backed patellar components had a 48% patellar revision rate. Cementless tibial components had an 8% aseptic loosening rate and a 12% incidence of small osteolytic lesions. Based on these results, the authors have abandoned cementless fixation in total knee arthroplasty.

The progression of patellofemoral arthrosis after medial unicompartmental replacement: results at 11 to 15 years.

This study reports the 11-year to 15-year results of unicompartmental knee arthroplasty with an emphasis on failure mechanisms and progression of patellofemoral arthrosis. In a prospective study of 513 consecutive potential knee replacement candidates, 59 patients (12%) had medial unicompartmental arthroplasty of the knee. All 59 patients had isolated unicompartmental disease without clinical symptoms or radiographic evidence of patellofemoral arthritis. No patient was lost to followup. The average followup was 13 years (range, 11–15 years). The mean preoperative Hospital for Special Surgery knee score of 55 points (range, 30–79 points) improved to a mean of 90 points (range, 60–100 points) at final followup. Patellofemoral symptoms were present in 1.6% of patients at 10 years; this increased markedly to 10% of patients at 15 years (p < 0.01). Four patients (10%) had moderate or severe patellofemoral symptoms at final followup; two were revised to a primary total knee replacement at 7 and 11 years for progressive patellofemoral degeneration. No component was radiographically loose and no osteolysis was seen. The Kaplan-Meier survival with loosening or revision for any reason was 98.0% ± 2.0% at 10 years and 95.7% ± 4.3% at 15 years. At up to 15 years, unicompartmental knee arthroplasty yielded good clinical results; however, progressive patellofemoral arthritis was the primary mode of failure.

Idiopathic hip instability. An unrecognized cause of coxa saltans in the adult.

The painful, snapping hip often presents a diagnostic dilemma having many potential etiologies. An understanding of the precise cause increases the potential for successful treatment. Five patients with no prior history of significant trauma were evaluated, all of whom had longstanding painful snapping in the groin and consistent symptoms of gait disturbance and increased pain in the provocative position of hip flexion, adduction, and internal rotation. Multiple prior tests and procedures had been nondiagnostic. Simple manual longitudinal traction under fluoroscopy showed subluxation with appearance of a vacuum sign in the symptomatic hip, whereas no such finding was observed on the asymptomatic side. This strongly suggests atraumatic hip instability as a previously unrecognized cause of the painful, snapping hip. The easily obtainable diagnostic traction radiograph is described.

Arthroplasty with a composite of an allograft and a prosthesis for knees with severe deficiency of bone.

We reviewed the clinical and radiographic results of fourteen patients who had a severe deficiency of bone and were managed with a massive allograft in conjunction with a standard total knee prosthesis between 1987 and 1990. The etiology of the bone loss included the failure of a previous total knee prosthesis, a supracondylar fracture of the femur or a fracture of the proximal part of the tibia, and débridement during the first stage of a reconstruction for the treatment of an infection. Thirteen patients had satisfactory clinical and radiographic results after the index procedure. The knee score of The Hospital for Special Surgery improved from an average of 24 points (range, 0 to 54 points) preoperatively to 82 points (range, 37 to 98 points) at the time of the most recent follow-up examination. The average duration of follow-up was forty-three months (range, twenty-nine to sixty-three months). The radiographic and functional results compare favorably with those that have been reported in most studies of otherwise comparable patients who had less deficiency of bone. While considerable risks are associated with the use of allograft bone and the true longevity of reconstructions with such bone is not yet known, the initial and short-term follow-up results support the use of allograft for the restoration of a functional knee joint in a patient who has a severe deficiency of bone.

Posterior cruciate ligament-retaining total knee arthroplasty in patients with rheumatoid arthritis.

7We previously reported the minimum eight-year follow-up results of cruciate-retaining total knee arthroplasty in a consecutive series of seventy-two knees in patients with rheumatoid arthritis. In the present study, we evaluated the longer-term outcomes after twenty to twenty-five years of follow-up. Since the publication of our original study, ten knees have been revised: three because of periprosthetic fracture, three because of infection, two because of patellofemoral failure, and two because of posterior instability. The rate of implant survival at twenty years after surgery was 69% (95% confidence interval [CI], 56% to 79%) with revision for any reason as the end point, 81% (95% CI, 69% to 89%) with femoral or tibial component revision for any reason as the end point, and 93% (95% CI, 83% to 97%) with posterior instability as the end point. These long-term results demonstrate that posterior cruciate ligament insufficiency with instability was rarely the cause of failure following cruciate-retaining total knee arthroplasty in patients with rheumatoid arthritis.