Surya Bhan

A Comparison of Fixed-Bearing and Mobile-Bearing Total Knee Arthroplasty at a Minimum Follow-up of 4.5 Years

BACKGROUND Durable long-term independent results with the Low Contact Stress rotating-platform (mobile-bearing) and the Insall Burstein-II (fixed-bearing) total knee prostheses have been reported, but no studies describing either the mid-term or long-term results and comparing the two prostheses are available, to our knowledge. METHODS Thirty-two patients who had bilateral arthritis of the knee with similar deformity and preoperative range of motion on both sides and who agreed to have one knee replaced with a mobile-bearing total knee design and the other with a fixed-bearing design were prospectively evaluated. Comparative analysis of both designs was done at a mean follow-up period of six years, minimizing patient, surgeon, and observer-related bias. Clinical and radiographic outcome, survival, and complication rates were compared. RESULTS Patients with osteoarthritis had better function scores and range of motion compared with patients with rheumatoid arthritis. However, with the numbers available, no benefit of mobile-bearing over fixed-bearing designs could be demonstrated with respect to Knee Society scores, range of flexion, subject preference, or patellofemoral complication rates. Radiographs showed no difference in prosthetic alignment. Two knees with a mobile-bearing prosthesis required a reoperation: one had an early revision because of bearing dislocation and another required conversion to an arthrodesis to treat a deep infection. CONCLUSIONS We found no advantage of the mobile-bearing arthroplasty over the fixed-bearing arthroplasty with regard to the clinical results at mid-term follow-up. The risk of bearing subluxation and dislocation in knees with the mobile-bearing prosthesis is a cause for concern and may necessitate early revision. LEVEL OF EVIDENCE Therapeutic Level II.

Balance and Gait in Total Hip Replacement: A Pilot Study

Nallegowda M, Singh U, Bhan S, Wadhwa S, Handa G, Dwivedi SN: Balance and gait in total hip replacement: A pilot study. Am J Phys Med Rehabil 2003;82:669–677. Objective Evaluation of balance, gait changes, sexual functions, and activities of daily living in patients with total hip replacement in comparison with healthy subjects. Design A total of 30 patients were included in the study after total hip replacement. Balance was examined using dynamic posturography, and gait evaluation was done clinically. Sexual functions and activities of daily living were also assessed. A total of 30 healthy subjects of comparable age and sex served as a control group. Results Dynamic balance and gait differed significantly in both the groups. Despite capsulectomy, no significant difference was observed on testing proprioception. In the sensory organization tests with difficult tasks, patients needed more sensory input from vision and vestibular sense, despite normal proprioceptive sense. Significant difference was observed for limits of stability, rhythmic weight shifts, and for gait variables other than walking base. Some of the patients had major difficulties with sexual functions and activities of daily living. Conclusions Compared with the healthy age- and sex-matched controls, patients with total hip replacement did not have any proprioceptive deficit. Patients required extrasensory input, and there was a delayed motor response. Gait and dynamic balance results also indicated the motor deficit and required a compensatory strategy. Restoration of the postural control in these patients is thus essential. Necessary training is required for balance, gait, and activities of daily living, and proper sexual counseling is necessary in postoperative care.

One- or two-stage bilateral total hip arthroplasty: a prospective, randomised, controlled study in an Asian population.

We compared the safety and outcome of one-stage bilateral total hip arthroplasty with those of a two-stage procedure during different admissions in a prospective, randomised controlled trial in an Asian population. Of 168 patients included in the study, 83 had a single- and 85 a two-stage procedure. Most of the patients (59.9%) suffered from inflammatory arthritis. The intra-operative complications, early systemic complications, the operating time, positioning of the components, the functional score, restoration of limb length and survival rates at 96 months were similar in the two groups. The total estimated blood loss was significantly lower in patients undergoing a one-stage procedure than in patients who had a two-stage procedure, but the transfusion requirements were significantly higher in the former group (p=0.001). The hospital stay was significantly shorter in the one-stage group, 7.25 days (sd 1.30; 5 to 20) compared with 10 days (sd 1.65; 8 to 24) in the two-stage group (p=0.023). We believe that a one-stage procedure is safe and appropriate in our population.

Primary cementless total hip arthroplasty for bony ankylosis in patients with ankylosing spondylitis.

We retrospectively reviewed 54 patients (92 hips) who underwent cementless total hip arthroplasty for bony ankylosis in ankylosing spondylitis between September 1988 and 2002. The mean age of the patients was 25.5 years. The mean duration of follow-up was 8.5 years. The average preoperative Harris Hip Score of 49.5 improved to 82.6 postoperatively. Postoperatively, 10 hips had mild to moderate pain. Anterior dislocation occurred in 4 (4.3%) hips, and sciatic nerve palsy in 1 (1.1%) hip. Heterotopic ossification was seen in 12 patients; reankylosis rate was 0%. Thirteen (14%) arthroplasties were revised because of aseptic loosening. Kaplan-Meier survivorship analysis with revision as end point revealed 98.8% survival at 5 years and 85.8% survival at 8.5 years follow-up.

Dome osteotomy for posttraumatic cubitus varus: a surgical technique to avoid lateral condylar prominence.

The indication for surgery in most children with posttraumatic cubitus varus is the presence of an unsightly deformity. The function of the limb is generally not impaired. Lateral closing-wedge supracondylar osteotomy, although a widely used corrective procedure, tends to produce lateral condylar prominence, thus jeopardizing the cosmetic outcome. The authors used the dome supracondylar osteotomy, as described by Tien et al, as the corrective procedure for cubitus varus in 12 consecutive children. The average follow-up was 2.3 (range 1-4) years. The objective evaluation was done by one of the authors by measuring the pre- and postoperative lateral condylar prominence index, carrying angle, and the range of movement at the elbow. The patients and parents were also asked to self-assess the cosmetic outcome. There were seven excellent and five good results. None of the children showed a prominent lateral humeral condyle. Hypertrophic scar formation and ulnar neurapraxia were seen in one patient each. These results were comparable to the published results of lateral closing-wedge osteotomy in terms of correction of carrying angle and preservation of elbow motion and were superior to those of the lateral closing-wedge osteotomy in terms of the prominence of lateral humeral condyle, acceptability of the scar, and cosmesis. The authors offer independent verification of the observation that the technique of dome osteotomy as described by Tien et al for the correction of the posttraumatic cubitus varus is a simple, safe, and technically sound procedure that prevents the lateral condyle from becoming prominent and yields an excellent cosmetic outcome.

Bilateral anterior dislocation of the shoulders with proximal humeral fractures: a case report

Bilateral simultaneous anterior dislocation of the shoulders with bilateral 3-part fracture of the proximal humeri is unusual. A 42-year-old man presented with pain and restriction of movement on both shoulders. He was injured by a heavy object falling over his back while he was leaning forward holding an overhead bar. His arms were abducted and externally rotated. The injury was not correctly diagnosed, and the patient was treated with repeated manipulations and splintage for 2 weeks. Radiological examination revealed bilateral anterior dislocation of the shoulders with displaced 3-part fractures of the proximal humeri involving the shaft, greater tuberosity, and head. The patient was treated with open reduction and internal fixation through a deltopectoral approach using multiple Kirschner wires. The shoulders were kept immobilised for 3 weeks until the removal of the wires. The patient was able to resume work 3 months after surgery. He had an excellent and comfortable range of motion in both shoulders at one-year follow-up.

The External Rotation Method for Reduction of Acute Anterior Dislocations and Fracture-Dislocations of the Shoulder

BACKGROUND Several methods of reducing an acute anterior dislocation of the shoulder have been described. The aim of this study was to assess the effectiveness of the external rotation method in the reduction of acute anterior shoulder dislocations with and without fractures of the greater tuberosity and to evaluate the causes of failure. METHODS Senior and junior orthopaedic residents attending in the Emergency Department were instructed in the external rotation method for the reduction of a shoulder dislocation in a classroom setting. Forty patients with an acute anterior dislocation of the shoulder, with or without an associated fracture of the greater tuberosity, who were treated with this method were evaluated prospectively. Data sheets completed by the orthopaedic residents when this method was used were evaluated with regard to the type of dislocation, the effectiveness of the procedure in achieving reduction, the need for premedication, the ease of performing the reduction, and complications, if any. RESULTS Of the forty patients, thirty-six had a successful reduction. No premedication was required in twenty-nine patients who had a successful reduction, and the average time required for reduction in twenty patients was less than two minutes. Only four patients reported severe pain during the process of reduction. The method was not successful in four patients, two of whom had a displaced fracture of the greater tuberosity. CONCLUSIONS The external rotation method for the reduction of an acute anterior dislocation of the shoulder is a safe and reliable method that can be performed relatively painlessly for both subcoracoid and subglenoid dislocations provided that a displaced fracture of the greater tuberosity is not present.

Management of Extensor Mechanism Deficit as a Consequence of Patellar Tendon Loss in Total Knee Arthroplasty A New Surgical Technique

Extensor mechanism disruption is an uncommon but devastating complication of total knee arthroplasty. A new technique of extensor mechanism reconstruction for patellar tendon loss, after total knee arthroplasty, with the help of extensor mechanism composite allograft is described. Four patients with chronic extensor mechanism-deficient total knee arthroplasty were undertaken for revision surgery along with reconstruction of extensor mechanism with an innovative technique using an extensor mechanism composite allograft consisting of a patella-patellar tendon-tibial tubercle. On final follow-up, none of the patients had extensor lag but for 10 degrees of extensor lag in 1 patient only. Providing an environment for bone-to-bone healing both proximally as well as distally and supervised postoperative rehabilitation led to encouraging results in the management of a failed extensor mechanism after total knee arthroplasty.

Morphological Variations of the Ulnar Styloid Process

P.A. radiographs of both wrists were taken in 400 normal individuals to study the configuration of the styloid process of the ulna. Five different morphological variations were noticed, the commonest being an elongated process (102 wrists). Medially deviated (41 wrists), parrot beaked (27 wrists) and hypertrophic (16 wrists) patterns were less common. One person had bilateral unfused separate ossification centres for the ulnar styloid. There was no correlation between the length of the styloid process and ulnar variance.

Comparison of total knee arthroplasty in stiff and ankylosed knees.

We compared the results of total knee arthroplasties in patients with stiff or ankylosed knees. We retrospectively reviewed 90 total knee arthroplasties in 52 patients with minimum 2 years followup who had less than a 50° arc of flexion preoperatively. Preoperative and intraoperative data were retrieved from a computerized database. Patients were followed for an average of 6.5 years at an outpatient department. Knee Society knee scores improved from 34.6 points preoperatively to 89.5 points postoperatively in the stiff knees and from 47 points preoperatively to 75 points postoperatively in the ankylosed knees. The arc of flexion improved from 35°-69° preoperatively to 1°-94° postoperatively in the stiff knees and from 0° to 3°-77° in the ankylosed knees. There were major complications in four of the 26 ankylosed knees and in two of the 64 stiff knees. The data suggest results of total knee arthroplasty are better in patients with stiff knees than in patients with ankylosed knees.Level of Evidence: Therapeutic study, Level III-2 (retrospective comparative study).