Paul F. Lachiewicz

The Influence of Patient-related Factors and the Position of the Acetabular Component on the Rate of Dislocation after Total Hip Replacement*

The senior one of us performed 438 primary and 181 revision total hip arthroplasties with use of so-called modern prostheses between July 1983 and January 1994. Fifty-three patients, who had had forty-seven primary procedures and twelve revisions, either died or were lost to follow-up less than two years after the operation and were excluded from the study. The results for the remaining 446 patients (391 primary procedures and 169 revisions) were analyzed to determine the influence of patient-related and operative factors and the position of the acetabular component on the rate of dislocation. Dislocation occurred after thirty-two (6 per cent) of the 560 total hip arthroplasties: seventeen (4 per cent) of the 391 primary procedures and fifteen (9 per cent) of the 169 revisions (p = 0.046). There was no relationship between the variables of age, gender, obesity, or preoperative diagnosis and dislocation after either primary or revision arthroplasty. Seven (23 per cent) of the thirty arthroplasties in the patients who had a history of excessive intake of alcoholic beverages (more than 2.1 liters [seventy-two ounces] of beer or more than 0.2 liter [six ounces] of other alcoholic beverages a day) were followed by a dislocation compared with twenty-five (5 per cent) of the 530 arthroplasties in the patients who did not have such a history. This difference was significant for the patients who had had a revision arthroplasty (p = 0.00005), but with the numbers available we could not detect a difference for those who had had a primary arthroplasty (p = 0.264). Radiographic analysis was performed for thirty-two hips that had dislocated and thirty-two that had not (seventeen primary procedures and fifteen revisions in each group), matched exactly according to the type of prosthesis and the operative approach (but not age). We detected no association between either the version or the abduction angle of the acetabular component (within the range of 39 to 56 degrees for the primary prostheses and 38 to 57 degrees for the revision prostheses) and the risk of dislocation. Thirty of the thirty-two hips in each group had an abduction angle of the acetabular component that was in the so-called safe range of 30 to 50 degrees.

Aspiration of the Hip Joint before Revision Total Hip Arthroplasty. Clinical and Laboratory Factors Influencing Attainment of a Positive Culture

The value of routine aspiration of the hip joint before revision of a hip arthroplasty remains controversial. We reviewed the results of such aspirations in an attempt to determine clinical or laboratory factors that could help the surgeon to identify hips that are infected and that should be aspirated preoperatively. One hundred and fifty consecutive revision total hip arthroplasties were performed by one of us. Preoperative aspiration was not performed or data were excluded for eight hips; no fluid was obtained from one of these hips (0.7 per cent of the 150). Of the remaining 142 hips, 128 had preoperative aspiration once and fourteen, twice. Twenty-one (15 per cent) of the 142 hips were infected, as demonstrated by the intraoperative culture. The intraoperative culture for two of these hips, however, was considered to be false-positive. The initial aspiration was considered to be positive only if an organism grew on the solid medium or if grossly purulent fluid was obtained. The initial aspiration was positive for nineteen hips; on culture of specimens from one hip, Bacteroides thetaiotaomicron grew in the liquid medium only; and purulent fluid was obtained from one hip but no organisms grew on culture. Fourteen aspirations were repeated for various reasons, most commonly to confirm the presence of an unusual organism. The repeat aspiration did not change the diagnosis for these hips. When the two hips with a false-positive intraoperative culture were excluded, preoperative aspiration had a sensitivity of 92 per cent, a specificity of 97 per cent, and an accuracy of 96 per cent. Seventeen of the nineteen truly infected hips were associated with an abnormally elevated erythrocyte-sedimentation rate (mean, 80.8 millimeters per hour). However, fifty-eight (50 per cent) of the 116 hips that were not infected, and for which the results were available, also had an abnormally elevated erythrocyte-sedimentation rate (mean, 32.0 millimeters per hour). This difference was significant (p = 0.001, Fisher exact test). The peripheral leukocyte count was not helpful in predicting infection. Hips in which the implants had been in situ for more than five years were less likely to be infected (p = 0.008, Fisher exact test) than those in which the implants had been in situ for five years or less. None of the infected hips in which the implants had been in situ for more than five years were associated with a normal erythrocyte-sedimentation rate. In this study, preoperative aspiration of the hip joint had an excellent sensitivity and specificity with regard to the prediction of infection. On the basis of our findings, we now favor a selective approach to aspiration, as determined by the erythrocyte sedimentation rate and the amount of time that the implant has been in situ.

Patellofemoral complications with the Insall-Burstein II posterior-stabilized total knee arthroplasty

The Insall-Burstein and Insall-Burstein II posterior-stabilized (I-B II PS) prostheses have been reported to have a high prevalence of patellar complications. This is a prospective, consecutive study of 118 primary total knee arthroplasties in 82 patients with the I-B II PS prosthesis implanted by 1 surgeon, using a specific technique for patellar resurfacing. The mean follow-up time was 4.0 years (range, 2-8 years). Clinical evaluation was performed using a standard knee score system with specific additional evaluation of the patellofemoral joint. Radiographs were evaluated for fracture, loosening, and subluxation. Ninety-four knees (80%) were rated excellent, 21 knees (17%) good, and 3 knees (3%) fair. The mean flexion was 112 degrees postoperative. No knee required reoperation for the patellofemoral joint. There were 2 nondisplaced and 1 minimally displaced patellar fractures treated nonoperatively, no patellar clunk syndrome, and no subluxations. Using the patellar evaluation system, 109 knees had no anterior knee pain, 7 knees had mild pain, and 2 knees (1 patient) had moderate-to-severe pain only with rising from a chair. Patellofemoral crepitus with active flexion-extension in the seated position was noted in 16 knees (14%) but was painful in only 2 knees (1 patient). With this technique for patellar resurfacing with this prosthesis, patellofemoral complications were only 4.2%, and no knee required reoperation for the patella or for loosening. With attention to operative technique, patellofemoral resurfacing with this posterior-stabilized total knee arthroplasty can be highly successful.

Efficacy of Prophylaxis Against Thromboembolism with Intermittent Pneumatic Compression After Primary and Revision Total Hip Arthroplasty

BACKGROUND Thromboembolism is a common and important complication after total hip arthroplasty. A variety of pharmacological and mechanical measures have been proposed for prophylaxis. The purpose of the present study was to evaluate the efficacy of intermittent pneumatic compression as prophylaxis against thromboembolism following total hip arthroplasty. METHODS The prospective study involved a consecutive series of 425 patients in whom a total of 502 (324 primary and 178 revision) total hip arthroplasties had been performed by two surgeons. The patients were managed intraoperatively and postoperatively with use of thigh-high elastic compression stockings and thigh-high intermittent pneumatic compression sleeves. Experienced vascular technologists performed venous duplex ultrasonography on both lower extremities of all patients at a mean of six days (range, two to fifteen days) postoperatively. All patients were followed for at least one year in order to detect late thromboembolism. RESULTS An asymptomatic deep-vein thrombosis was noted on the scans made after twenty-three (4.6 percent) of the 502 procedures. Nineteen (3.8 percent) of the arthroplasties were followed by the development of a proximal thrombosis and four (0.8 percent), a distal thrombosis. Nineteen of the thromboses were ipsilateral (eighteen were proximal and one, distal), and four were contralateral (one was proximal and three, distal). No symptomatic deep-vein thrombosis developed in the hospital. In addition, three (two proximal and one distal) symptomatic ipsilateral deep-vein thromboses (a prevalence of 0.6 percent) developed three to twenty-three weeks after postoperative scans revealed negative findings and the patients were discharged from the hospital. Three symptomatic pulmonary embolisms (a prevalence of 0.6 percent) were confirmed by ventilation-perfusion scanning while the patients were in the hospital. There were no symptomatic pulmonary embolisms after discharge, and there were no fatal pulmonary embolisms. With the numbers available, we were unable to detect an association between deep-vein thrombosis and age (p = 0.76), gender (p = 0.13), body-mass index (p = 0.12), type of arthroplasty (primary or revision) (p = 0.12), operative approach (p = 0.37), duration of the operation (p = 0.21), type of anesthesia (general or regional) (p = 0.51), units of blood transfused (autologous, p = 0.79; homologous, p = 0.57), blood type (p = 0.18), or the presence of a so-called classic risk factor for the development of thrombosis (p = 0.22). Five arthroplasties (1.0 percent) were followed by the development of a wound hematoma, but only one hematoma necessitated operative drainage. CONCLUSIONS The use of intraoperative and postoperative thigh-high intermittent pneumatic compression, combined with duplex ultrasonography performed by experienced vascular technologists, is effective for prophylaxis against thromboembolism after both primary and revision total hip arthroplasties. The low prevalence of deep-vein thrombosis (4.6 percent) and symptomatic pulmonary embolism (0.6 percent) is comparable with that associated with pharmacological prophylaxis.

Revision of a total hip arthroplasty with a Harris-Galante porous-coated acetabular component inserted without cement. A follow-up note on the results at five to twelve years.

Fifty-seven revision total hip arthroplasties in fifty-six patients were performed with a Harris-Galante porous-coated acetabular component by one surgeon, and the patients were followed prospectively for a mean of seven years (range, five to twelve years). A trochanteric osteotomy was performed in forty hips, and a posterior approach with an extended anterior capsulectomy was used in the other seventeen. The acetabular defect was classified as segmental in seven hips, cavitary in twenty-three, and combined in twenty-one; six hips had no notable defect. A bulk allograft was used in eleven hips, and morseled cancellous-bone allograft or autogenous graft was used in thirty-four hips; twelve hips did not have bone-grafting. Both the femoral and the acetabular component were revised in forty-five hips, and only the acetabular component was revised in twelve. Thirty-nine hips (68 per cent) had a good or excellent clinical result according to the Harris hip score. The acetabular component was well fixed in the fourteen hips that had a fair result and the four hips that had a poor result. The acetabular component was considered to have migrated if there was a change in the angle of the cup of 5 degrees or more or a change in the horizontal or vertical position of the cup of more than three millimeters. Despite varying degrees of bone loss, no acetabular component had radiographic evidence of loosening at the latest follow-up examination. No component was revised and no revisions were scheduled. One hip was debrided for a late metastatic infection, but the component was well fixed and was not revised. There were no complications related to the use of screws for fixation. These mid-term results confirm the early success of acetabular revisions performed with fixation of a titanium fiber-metal-coated hemispherical component with multiple screws and no cement.

Clinical and Radiographic Results of the Total Condylar III and Constrained Condylar Total Knee Arthroplasty

The Total Condylar III (Johnson and Johnson, Braintree, MA) and Constrained Condylar (Zimmer, Warsaw, IN) knee prostheses are nonlinked, semi-constrained prosthetic alternatives to rigid or rotating hinge prostheses for use in complex knee reconstructions. Forty-six Total Condylar III or Constrained Condylar prostheses were implanted with cement in 36 patients and followed for a mean of 5 years (range, 2-9 years). There were 25 primary total knee arthroplasties and 21 revision total knee arthroplasties. The knees were evaluated using The Hospital for Special Surgery 100-point knee rating system. Overall, 40 knees (87%) had a good or excellent clinical result, 2 knees (4%) had a fair result, and 4 knees (9%) had a poor result. There was one revision for loosening of a cemented, nonmodular Constrained Condylar prosthesis, and one knee had a debridement for a late, metastatic infection, but the components were retained. There were no mechanical failures in those knees that were primary arthroplasties, but two mechanical failures occurred in those knees that were revision arthroplasties. Radiographic review showed one asymptomatic loosening of a Constrained Condylar tibial component with an uncemented press-fit stem, and only 8 knees had scattered nonprogressive tibial bone-cement radiolucent lines. The Total Condylar III and Constrained Condylar semiconstrained prostheses are successful when used in complex knee reconstructions.

Factors Influencing the Longer-Term Survival of Uncemented Acetabular Components Used in Total Hip Revisions

BACKGROUND There are few longer-term follow-up reports of the results and complications of the use of cementless acetabular components in revision hip arthroplasty. In this study, we analyzed the clinical and radiographic results to determine the factors that affect longer-term survival of titanium-fiber-metal-coated acetabular components. METHODS During a fourteen-year period, one surgeon performed 211 consecutive unselected cementless acetabular revisions in 194 patients with a mean age of sixty-two years. The same technique was used for all revisions: the component was impacted and was fixed with multiple screws, and bone deficiencies were augmented with supplemental bone graft. Both the acetabular and the femoral components were revised in 142 hips, whereas an isolated acetabular revision was performed in sixty-nine hips. All 211 revisions were included in a survivorship analysis to twelve years. Prospectively determined clinical results in 135 hips and radiographic results in 131 hips were available at a minimum of five years postoperatively. RESULTS Seven acetabular components were removed: three, because of infection; one, because of recurrent dislocation; and three, because of mechanical loosening. There was asymptomatic radiographic loosening of one additional acetabular component, for a total rate of aseptic loosening of 2%. The twelve-year prosthetic survival rate was 95% (95% confidence interval, 91% to 99%), with failure defined as component removal for any reason. There was no significant difference in the rate of survival of the cup or femoral component between the sixty-nine hips treated with isolated acetabular revision and the 142 hips in which both components were revised. There was a significant difference in the rate of dislocation between the hips treated with isolated acetabular revision (dislocation in fourteen hips, 20%) and those in which both components had been revised (dislocation in eleven hips, 8%; p = 0.03), but there was no difference in component survival if a dislocation occurred. There was a significant association between a patient weight of >82 kg and acetabular failure (p = 0.04). CONCLUSIONS This titanium-fiber-metal-coated hemispheric component fixed with multiple screws had a twelve-year survival rate of 95% when used in an unselected, consecutive series of acetabular revisions. The rate of dislocation was significantly higher in the patients treated with isolated acetabular revision, and routine postoperative bracing is now recommended for that group.

Two mechanical devices for prophylaxis of thromboembolism after total knee arthroplasty: A PROSPECTIVE, RANDOMISED STUDY

The optimal characteristics of pneumatic compression for mechanical prophylaxis of thromboembolism after total knee arthroplasty (TKA) are not known. Our study compared two methods of calf compression, with the hypothesis that the device which provided a larger increase in peak venous velocity would produce a lower rate of thromboembolism. We performed a prospective, randomised study on 423 patients (472 knees). Duplex ultrasonography was carried out by experienced technicians who were blinded to the device used. Overall, 206 patients (232 knees) used a rapid inflation, asymmetrical compression (RIAC) device and 217 (240 knees) a sequential circumferential compression device (SCD). The rate of venous thromboembolism was 6.9% with the RIAC device compared with 15% for the SCD device (p = 0.007). The incidence of thrombi with unilateral primary TKA was 8.4% for the RIAC compared with 16.8% for the SCD device (p = 0.03). In 47 patients with a bilateral TKA, the incidence of thrombi was 4% for the RIAC compared with 22.7% for the SCD device (p = 0.05 per knee). There was a low rate of mortality and pulmonary embolism when using mechanical prophylaxis for thromboembolism after TKA. Our findings show that the use of rapid inflation, asymmetrical calf compression gave a significantly lower rate of thromboembolism.

The Rates of Osteolysis and Loosening Associated with a Modular Posterior Stabilized Knee Replacement: Results at Five to Fourteen Years

BACKGROUND Osteolysis and increased polyethylene wear have been reported in association with several designs of modular total knee prostheses. The purpose of the present study was to evaluate a modular posterior stabilized prosthesis to determine its clinical performance as well as the rates of component loosening and osteolysis. METHODS We performed a prospective, consecutive study of 193 knees in 131 patients who were managed with the modular Insall-Burstein II posterior stabilized total knee prosthesis by one surgeon. The mean age of the patients at the time of surgery was sixty-eight years, and the mean duration of follow-up was seven years (range, five to fourteen years). Clinical evaluation was performed with use of standard knee-scoring systems. Radiographs were evaluated for the presence of radiolucent lines, osteolysis, and loosening. RESULTS The overall result (as determined with the Hospital for Special Surgery scoring system) was rated as excellent for 112 knees, good for sixty, fair for fifteen, and poor for six. The mean postoperative flexion was 112 degrees. No clinical or radiographic loosening of the tibial component was noted. Eight knees had osteolytic lesions of the tibia. Thin, incomplete, nonprogressive radiolucent lines were noted around thirty tibial components (16%). There were three reoperations. CONCLUSIONS Despite previous reports of osteolysis, polyethylene wear, and loosening in association with some modular total knee implant designs, there was no loosening in this series of posterior stabilized total knee replacements and only eight knees had tibial osteolysis after a mean duration of follow-up of seven years. We believe that total knee arthroplasties that are performed with use of cemented modular posterior stabilized components can have a high rate of intermediate-term success. LEVEL OF EVIDENCE Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Knee arthroplasty in hemophilic arthropathy

Twenty-three total knee arthroplasties in 15 patients with severe hemophilia were performed between February 1974 and September 1988. Thirteen patients had Factor VIII deficiency and two had Factor IX deficiency. The mean followup period was 7.5 years, with a minimum of 4 years for patients who were alive (eight) at the time of this review. Seven patients had died before this report, and all were seropositive for the human immunodeficiency virus. Using the Hospital for Special Surgery knee scoring system, the result was excellent in one knee, good in three, fair in two, and poor in 17. One patient was seropositive for the human immunodeficiency virus at the time of the index procedure, and 12 were seropositive at the most recent followup; the human immunodeficiency status of three patients was unknown. There were two early and two late deep infections, all in patients who were seropositive for the human immunodeficiency virus. The most recent postoperative radiographs for all knees were reviewed using the Knee Society radiographic scoring system. Ten femoral components were well fixed, 11 were possibly loose, and two were probably loose. Eight tibial components were well fixed, 10 possibly loose, three probably loose, and two definitely loose. One knee had been revised for aseptic loosening. There are few published studies of the long term results of total knee arthroplasties in patients with hemophilia. In this series of 23 knees, there was a high rate of loosening and infection. Total knee arthroplasty may be a useful treatment for the relief of pain attributable to end stage hemophilic arthropathy, but there is a high rate of complications, especially in patients who are seropositive for the human immunodeficiency virus.