William H. Thomas

Long-term complications after total knee arthroplasty with or without resurfacing of the patella.

The long-term complications related to the patella were retrospectively evaluated for 891 knees (684 patients) that had had a total arthroplasty, with or without resurfacing of the patella, with use of an unconstrained, condylar, posterior-cruciate-preserving prosthesis. The study population comprised two groups of patients who were similar in size, age, sex distribution, and diagnosis. One group (396 knees [303 patients]) had had a total knee arthroplasty with patellar resurfacing and the other group (495 knees [381 patients]) had had the same procedure without resurfacing. The average duration of follow-up was six and one-half years (range, two to fifteen years). The decision to resurface the patella was based on subjective inspection of the articular surface and on assessment of patellar tracking at the time of the operation. Resurfacing was performed if there was loss of cartilage, exposed bone, gross surface irregularities, or tracking abnormalities. Complications occurred an average of three years (range, immediately postoperatively to nine years) after the operation in the group that had had resurfacing and an average of four years (range, immediately post-operatively to ten years) postoperatively in the group that had not had resurfacing. In the group that had had resurfacing, there was loosening of the patellar component in five knees, patellar subluxation in four knees, fracture of the patella in three knees, rupture of the patellar tendon in three knees, and chronic peripatellar pain in one knee. In the group that had not had resurfacing, the complications included patellar subluxation in five knees, rupture of the patellar tendon in two knees, and chronic peripatellar pain in fifty-one knees.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors influencing the incidence and outcome of infection following total joint arthroplasty.

During a ten-year period, 4240 total hip, knee, and elbow arthroplasties were performed. The overall infection rate was 1.25%. Certain groups were identified as being at higher risk of infection following total joint arthroplasty: rheumatoid arthritics were at 2.6 times greater risk than osteoarthritics; patients undergoing total hip arthroplasty as a revision of a previous operation were eight times more likely to have infection than those undergoing a primary operation; and patients with metal-to-metal hinged knee prostheses, when compared with patients with metal-to-plastic knee prostheses, were 20 times more likely to have infection. The majority of infections could be attributed either to perioperative problems or late bacterial seeding from a distant site. Although most infections occurred by two years after operation, late infections, particularly in rheumatoid patients via the hematogenous route, occurred as long as nine years after operation. There was no correlation between the Grams-staining characteristics of the pathogen and the outcome of the infected joint. Gram-negative organisms were frequent in the perioperative period and reflected either nosocomial infection or the ineffectiveness of the prophylactic antibiotic regimen used in inhibiting gram-negative pathogens. The major factors that influenced the outcome of the infected joint included the interval from the initial surgery to recognition of infection, the delay in institution of appropriate treatment, the particular joint that was infected, the integrity of the bone-cement interface, the type of prosthesis used, and the host susceptibility. Identification of high-risk groups and the recognition that patients with joint implants are at risk of infection at any time in the postoperative period may lead to a lowered infection rate in the future.

Total shoulder arthroplasty versus hemiarthroplasty. Indications for glenoid resurfacing.

Abstract The results of total shoulder arthroplasty and hemiarthroplasty in a similar patient population were compared in an effort to define more clearly the indications for resurfacing the glenoid. The results of 64 Neer hemiarthroplasties in 59 patients were compared with 146 Neer total shoulder arthroplasties in 134 patients in a retrospective review of the period between 1974 and 1986. The average follow-up period was 44 months (range, 24–124 months). Hemiarthroplasty and total shoulder arthroplasty produced similar results in terms of functional improvement. Pain relief, range of motion, and patient satisfaction were better with total shoulder arthroplasty than hemiarthroplasty in the rheumatoid population. Progressive glenoid loosening was found in 12% of total shoulder arthroplasties but no correlation with pain relief or range of motion was noted. Total shoulder arthroplasty is recommended for patients with inflammatory arthropathies, and hemiarthroplasty is recommended for patients with osteoarthritis, avascular necrosis, and four-part fractures with preservation of glenoid congruity and absent synovitis.

Total knee arthroplasty with the kinematic prosthesis. Results after five to nine years: a follow-up note.

A review of the results of 192 kinematic total knee replacements five to nine years after the operation showed that the results were still satisfactory. At the time of the review, the ages of the patients ranged from twenty-two to eighty-seven years. About half of the patients had rheumatoid arthritis and the other half, osteoarthrosis. About 90 per cent of the results were rated good or excellent, and the average range of flexion was 109 degrees. Radiolucency was present around 40 per cent of the tibial components, 30 per cent of the femoral components, and 60 per cent of the patellar components, but the lines were thin and not progressive. The complications included loosening of the patellar components in five knees, one fracture of the tibial tray with loosening of the patellar component, one fracture of the patellar component, and one dislocation of the patellar component.

Capitellocondylar total elbow replacement in rheumatoid arthritis. Long-term results.

We evaluated the long-term results of 202 capitellocondylar total elbow replacements that had been performed, from July 1974 through June 1987, in 172 patients. The duration of follow-up averaged sixty-nine months (range, twenty-four to 178 months). At the most recent follow-up examination, use of a 100-point rating score demonstrated an improvement from an average preoperative score of 26 points (range, 2 to 50 points) to an average postoperative score of 91 points (range, 45 to 100 points). The most improvement occurred in the categories of relief of pain, functional status, and range of motion in all planes except extension. The improvements in these categories and in the roentgenographic appearance that were seen in the early postoperative period did not deteriorate with time. The average preoperative arc of motion at the elbow ranged from -37 degrees of extension to 118 degrees of flexion. The average postoperative arc of motion at the elbow ranged from -30 degrees of extension to 135 degrees of flexion. Supination improved from 45 degrees preoperatively to 64 degrees postoperatively; pronation improved from 56 degrees preoperatively to 72 degrees postoperatively. The roentgenograms showed a radiolucent line adjacent to eight humeral and nineteen ulnar components; most of the lines were incomplete and one millimeter wide or less. Revision of the prosthesis was necessary in three elbows (1.5 per cent) because of loosening without infection, and in three additional elbows because of dislocation of the prosthesis. Complications included deep infection in three elbows (1.5 per cent); problems related to the wound in fifteen (7 per cent); permanent, partial sensory ulnar-nerve palsy in five (2.5 per cent); permanent, partial motor ulnar-nerve palsy in one (0.5 per cent); and dislocation in seven (3.5 per cent).

Nonconstrained total shoulder arthroplasty in patients with polyarticular rheumatoid arthritis.

A retrospective review of 114 patients with polyarticular rheumatoid arthritis who had 140 total shoulder arthroplasties revealed that 93% of the patients had excellent pain relief; however, improvement in active forward elevation averaged 34 degrees. Nearly one-half of the patients had significant rotator cuff pathology. Three-fourths of the patients had a press-fit type of humeral component, and 5% of these have had variable amounts of subsidence. None have been sufficiently painful to require a revision. Eighty-two percent of the glenoid components developed radiolucent lines during the follow-up period. One percent of these were definitely loose and 9% were probably loose. To date, none have been revised. Complications occurred in 7% of the shoulders, but no deep or superficial wound infections were noted.

Total Hip Arthroplasty with Cement for Juvenile Rheumatoid Arthritis. Results at a Minimum of Ten Years in Patients Less Than Thirty Years Old

We retrospectively reviewed the clinical and radiographic results of total hip arthroplasty with cement in patients with juvenile rheumatoid arthritis who were less than thirty years old at the time of the index procedure. Thirty-nine patients (sixty-six hips) were managed with this procedure at our institution between 1971 and 1983. Six patients (eleven hips) died before a minimum of ten years of follow-up; the remaining thirty-three patients (fifty-five hips) were followed for at least eleven years. Twenty-eight patients (forty-six hips) had at least one original component in situ after an average duration of clinical follow-up of 15.1 years, and twenty-three of these patients (thirty-eight hips) were followed radiographically for an average of 14.7 years. At the time of the latest follow-up examination, all twenty-eight patients were able to walk outside the home; twenty of these patients (thirty-five hips; 76 per cent) had no pain with activity, and eight patients (eleven hips; 24 per cent) had mild-to-moderate pain with activity. Over-all, twelve (18 per cent) of the sixty-six femoral components and twenty-three (35 per cent) of the sixty-six acetabular components were revised after an average of 12.8 and 11.8 years, respectively. The fifteen-year survival rate for the femoral components was 85 per cent with revision or radiographic loosening as the end point. The fifteen-year survival rate for the acetabular components was 70 per cent with revision as the end point and 61 per cent with revision or radiographic loosening as the end point. The benefits of total hip arthroplasty were maintained over the long term in most of our patients who had juvenile rheumatoid arthritis. However, the durability of the components in these young patients remains a concern.

Clinical study of total ankle replacement with gait analysis. A preliminary report.

Twenty-one ankle replacements in nineteen patients after an average follow-up of 14.7 months were analyzed with respect to their history, physical and roentgenographic findings, and gait analysis. The relief of pain and functional improvement after operation were disappointing compared with the results of prosthetic replacement in other joints and were not related to early complications, age, diagnosis, or the prosthesis used. Muscle weakness about the ankle, especially of the plantar flexors, was a prominent finding and appeared to cause abnormal patterns of gait and of ankle motion. The frequency of progressively increasing radiolucent lines was 88 per cent and of late loosening, 10 per cent. These results suggest a need for more emphasis on postoperative rehabilitation and on the uncertainty of this procedure at its present stage of development.

Eight-Year Results of a Minimally Constrained Total Ankle Arthroplasty

Background: Few studies have reported the intermediate to long-term results of minimally constrained total ankle replacements. The purpose of this study was to investigate the efficacy and safety of a minimally constrained total ankle prosthesis in a select low-demand patient population. Methods: We reviewed a consecutive series of patients with rheumatoid arthritis who underwent a Buechel-Pappas total ankle replacement (BP TAR) between 1990 to 1997. Thirty-one ankle arthroplasties were performed in 23 patients with rheumatoid arthritis. One patient was lost to followup (deceased) and two ankles that failed resulted in fusion (overall survivorship − 93%). This left 28 ankles (21 patients) that were re-evaluated clinically and radiographically with an average followup of 8.3 (range 5.0 to 12.2) years. Preoperative and postoperative ranges of motion were measured and AOFAS hindfoot scores were calculated. Recent weightbearing radiographs were reviewed for evidence of component subsidence, radiolucent lines, and osteolysis. Results: In 25 of 28 ankles (89%), patients were completely satisfied with the result of their ankle replacement and rated their pain as only mild to none; three (11%) patients were dissatisfied. Radiographic analysis revealed stable, well-positioned implants with evidence of biologic ingrowth in 23 ankles (82%), while five implants were interpreted as being at risk for impending failure because of marked tibial or talar component subsidence (18%). Component subsidence did not correlate with the presence or absence of radiolucent lines. Only one ankle demonstrated clear evidence of osteolysis. Ten intraoperative medial malleolar fractures occurred (32% of ankles) during implantation of the prosthesis, though in only one did this adversely affect patient outcome. Nine postoperative complications (29%) occurred; four wound dehiscences, four stress fractures, and one medial malleolar nonunion. Conclusions: Improvements in prosthetic design such as cementless fixation and decreased constraint appear to make total ankle arthroplasty a more predictable procedure over this period of followup. Despite a variety of complications, we are encouraged by the intermediate-term results in a select low-demand arthritic population.

Capitellocondylar total elbow arthroplasty.

Sixty-nine non-constrained capitellocondylar metal-to-plastic total elbow-replacement prostheses were implanted in sixty-four patients with rheumatoid arthritis. These patients were followed for an average of 3.5 years. Postoperative flexion and pronation were significantly improved, but no significant increase in postoperative extension or supination could be demonstrated. Based on a rating system evaluating pain and function, there were 87 per cent good or excellent results. The complication rate based on the total number of prostheses implanted was 39 per cent. Eight patients required revision of the arthroplasty: four for dislocation of the prosthesis, two for sepsis, one for loosening, and one for a fracture. Eight other asymptomatic patients showed minimum radiolucent lines adjacent to the ulnar component. No patient demonstrated radiolucent lines adjacent to the humeral component.