Robert D. Beckenbaugh

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.

Proximal radioulnar synostosis after repair of distal biceps brachii rupture by the two-incision technique : report of four cases

In four cases, proximal radioulnar synostosis developed as a complication of distal biceps tendon reattachment through a two-incision technique. The synostosis was excised in all four cases but recurred in two. In each case, the initial reattachment exposed the bicipital tuberosity of the radius anteriorly and exposed the ulna extraperiosteally through a second incision along its subcutaneous border. This two-incision approach may place the patient at risk for synostosis. If two incisions are to be used for distal biceps tendon reattachment, then a limited muscle-splitting approach through the extensor muscle mass, which avoids exposure of the ulna, may be preferable.

Long-Term Follow-up of Pyrolytic Carbon Metacarpophalangeal Implants*

BACKGROUND The metacarpophalangeal joint is the most commonly involved joint when rheumatoid arthritis affects the hand. Many prosthetic implants have been designed for the replacement of this joint. Although studies of these implants have shown relief of pain, they have generally demonstrated a poor range of motion, progression of ulnar drift, and bone loss, as well as failure, fracture, and dislocation of the implant. METHODS From December 1979 to February 1987, 151 pyrolytic carbon metacarpophalangeal implants were inserted in fifty-three patients. The implants had an articulating, unconstrained design with a hemispherical head and grooved, offset stems. Forty-four patients had rheumatoid arthritis; five, posttraumatic arthritis; three, osteoarthritis; and one, systemic lupus erythematosus. Three patients (eleven implants) were lost to long-term follow-up, and twenty patients (fifty-one functioning implants) died after the implant had been in situ for an average of 7.2 years. Eighteen implants (12 percent) in eleven patients were revised. Fourteen of the eighteen implants were replaced with a silicone-elastomer or another type of implant, and the remaining four were removed and a pyrolytic carbon implant was reinserted with the addition of bone cement or bone graft, or both. Twenty-six patients (seventy-one implants) were available for long-term review at an average of 11.7 years (range, 10.1 to 16.0 years) after implantation. RESULTS The implants improved the arc of motion of the fingers by an average of 13 degrees and elevated the arc by an average of 16 degrees. As a result, fingers were in a more functional, extended position. A complete set of preoperative, postoperative, and follow-up radiographs was available for fifty-three of the seventy-one implants that were followed long term. There was a high prevalence of joint stability: fifty (94 percent) of the fifty-three implants were in a reduced position postoperatively, and forty-one (82 percent) of those fifty implants were still in the postoperative reduced position at the time of long-term follow-up. Ulnar deviation averaged 20 degrees preoperatively and 19 degrees at the time of follow-up, with only the long finger having an increase in deviation. No adverse remodeling or resorption of bone was seen. Fifty (94 percent) of the fifty-three implants had evidence of osseointegration, with sclerosis around the end and shaft of the prosthetic stems. Radiolucent changes were seen adjacent to twelve implants. There was minimum-to-moderate subsidence (four millimeters or less) of thirty-four implants; most of the subsidence occurred immediately postoperatively. Survivorship analysis demonstrated an average annual failure rate of 2.1 percent and a sixteen-year survival rate of 70.3 percent. The five and ten-year survival rates were 82.3 percent (95 percent confidence interval, 74.6 to 88.2 percent) and 81.4 percent (95 percent confidence interval, 73.0 to 87.8 percent), respectively. None of the revised implants had any visible changes of wear or deformity of the surfaces or stems. Four instances of chronic inflammatory tissue and three instances of proliferative synovitis were noted histologically. Focal pigment deposits were seen in three fingers, one of which had removal of the implant two months after a fracture. No evidence of intracellular particles or particulate synovitis was found. CONCLUSIONS The results of this study demonstrate that pyrolytic carbon is a biologically and biomechanically compatible, wear-resistant, and durable material for arthroplasty of the metacarpophalangeal joint.

Delayed Prophylactic Anticoagulation: A Study of Results and Complications in 2,012 Total Hip Arthroplasties

Prophylactic anticoagulation with sodium warfarin was used after 1,950 of 2,012 consecutive total hip arthroplasties, beginning on the fifth postoperative day. No anticoagulative was used after the remaining procedures. The rate of fatal pulmonary embolism in the group treated with anticoagulants was 0.05 per cent, and in the group not treated with anticoagulants, 3.4 per cent. There were nineteen serious bleeding problems in the anticoagulated group, six of which necessitated surgery. There were also two deep infections associated with wound hematomas which resolved satisfactorily with treatment. There were no fatal complications resulting from anticoagulation.

Kienböck's disease: the natural history of Kienböck's disease and consideration of lunate fractures.

Forty-six patients with Kienböcks disease were evaluated over a 2- to 27-year period; 72% had a history of wrist injury prior to diagnosis; 67% had evidence of fracture or fragmentation of the lunate. Documented fractures of the lunate were identified followed by both the presence and absence of subsequent Kienböcks disease and this may be explained by the variable blood supply of the lunate. Ten patients were not treated; 36 patients were treated surgically. Patients were relieved of pain and had functional wrists whether they were treated or not and regardless of the type of surgical treatment.

Failed distal ulna resections.

Twenty patients with complaints of pain and limitation of activities for more than 1 year after ulnar head resection (Darrach) were studied. Their ages ranged from 18 to 60 years (mean, 38 years). The initial indications for operation were posttraumatic derangement in 18 patients, radial growth anomaly in 1, and a lesion of the ulna in 1. Follow-up ranged from 29 to 135 months (mean, 61 months). The patients had an average of 2.2 additional operations, with up to seven procedures per patient. Radiographs were compared with those from an equal number of successful Darrach resections chosen randomly, and no significant differences were noted. All 20 patients continue to have difficulties despite several years of treatment. The Darrach resection can result in serious disability, especially in the younger patient and the patient with lax ligaments. Reoperation on these patients is rarely successful.

Fracture of the hamate hook

Twenty-one cases of hamulus fracture are presented. Diagnosis depends on clinical acuity. The most common symptom is pain in the palm that is aggravated by grasp. Weakness of grasp and dorsal wrist pain are also common. Ulnar nerve paresthesia or weakness and mild carpal tunnel syndrome are frequently present. Tenderness directly over the hamulus is always present, and grip strength typically is diminished. Tenosynovitis, tendon fraying, or tendon rupture may be demonstrated in 25% of the cases and is not related to the use of steroids. Lateral trispiral tomography is clearly superior to the other diagnostic methods. Excision produced generally excellent results, particularly in patients with an athletic injury or with no associated additional injury. A nonathletic injury or the presence of associated trauma adversely affected results. Immediate immobilization of acute fractures may result in fracture healing and obviate operative intervention. Open reduction and internal fixation is feasible but offers little advantage over excision.

Review and analysis of silicone-rubber metacarpophalangeal implants

A series of 530 consecutive arthroplasties using silicone-rubber implants in 119 patients was reviewed. Clinical and roentgenographic evaluations were completed on sixty patients and 254 implants, with an average follow-up of two and a half years; the remaining fifty-nine patients were evaluated by questionnaire. All but three patients had rheumatoid disease, usually with severe deformity, and many of the patients underwent other procedures on the upper extremity; these procedures often precluded early motion after the arthroplasties. Three prostheses (0.6 per cent) were removed because of infection, and reoperation was required in 2.4 per cent of the joints. Detailed clinical follow-up of 254 prostheses revealed the following: for Swanson prosthesis-average motion 38 degrees, fracture rate 26.2 per cent, and recurrence of clinical deformity 11.3 per cent; for Neibauer prostheses-average motion 35 degrees, fracture rate 38.2 per cent, and recurrence of clinical deformity 44.1 per cent. It should be noted that use of early implant types and some variations from the designers recommended rehabilitation protocols were features of this series.

Ulnar lengthening in the treatment of Kienböck's disease.

Twenty patients with Kienböcks disease were treated with a modification of the Persson ulnar-lengthening procedure to remove compressive stress from the damaged lunate. After an average follow-up of thirty-seven months, relief of pain was satisfactory in eighteen patients who had returned to work (nine of whom had strenuous occupations), and two patients were dissatisfied because they had persistent pain and were not able to return to their previous occupations. Non-union at the site of the ulnar osteotomy occurred in three patients who were treated early in the series and was the result of inadequate internal fixation or insufficient duration of protective splinting. All three of the patients had satisfactory results after replating and bone-grafting. The procedure appears to help to maintain carpal height, prevent further collapse of the lunate, encourage consolidation of the fragmented lunate, and increase grip strength. Except for ulnar deviation, which the procedure may further diminish, the postoperative motions of the wrist were moderately improved.

Entrapment of the ulnar nerve by the deep flexorpronator aponeurosis

A study of eight patients and 20 cadaveric limbs identified the deep aponeurosis of the flexor carpi ulnaris as a potential site for constriction of the ulnar nerve. The ulnar nerve passes through this aponeurosis approximately 5 cm distal to the medial epicondyle and 2 to 3 cm distal to the cubital tunnel. In two cases of isolated compression at this level, local decompression was successful in relieving the symptoms of ulnar nerve compression. Submuscular transposition is also effective because it places the ulnar nerve deep to this aponeurosis throughout its entire course.