The outcome of trochanteric reattachment in revision total hip arthroplasty with a Cable Grip System: mean 6-year follow-up

We have reviewed 251 hips that were revised by the senior authors with subsequent reattachment using the Dall-Miles Cable Grip System. Of these patients, 223 were available for follow-up. A trochanteric slide osteotomy was used for most cases (n = 170), and the remainder had conventional trochanteric osteotomy to facilitate surgical exposure. Follow-up period was 1 to 8 years. Forty-eight percent (n = 108) of the hips had a previous trochanteric osteotomy. Thirteen percent (n = 30) had a prior trochanteric nonunion. Of the 223 hips, 91% (n = 204) of the trochanters remained attached to the trochanteric bed when reapproximated by the cable grip system. The 2 multifilament cables were passed medially through drill holes in the lesser trochanter in 67% (n = 149) of cases. Of the hips, 16% (n = 35) had 2 cables passed through bone lateral to the prosthesis, and 17% (n = 39) had cables passed 1 medial and 1 lateral to the prosthesis. Cable breakage was noted in 10% (n = 23) of cases. Of those 23, 70% (n = 16) were stainless steel. Unraveling of the cable occurred in 18% (n = 41) of cases. There were 19 nonunions (9%). Of the 19 nonunions, 74% (n = 14) were stainless steel. The trochanter was reattached to bone in 9 hips, to cement in 4 hips, and to a proximal femoral allograft in 6 hips (P = .0001). Eight of the 19 hips (42%) had the cables placed lateral to the prosthesis (P = .0002). When bone-to-bone apposition was achieved at surgery, the nonunion rate was 4%. In this difficult group of revision procedures, the Dall-Miles Cable Grip has provided reliable trochanteric fixation. Factors associated with successful trochanteric healing include use of vitallium cables, use of a trochanteric slide osteotomy, cables passed medially through the lesser trochanter, cerclage rather than intramedullary placement, and bone-to-bone apposition.

The incidence of venous thromboembolism after total hip arthroplasty: a specific hypotensive epidural anesthesia protocol

We retrospectively reviewed all consecutive unilateral primary total hip arthroplasty (THA) procedures performed by 3 attending surgeons on the Arthroplasty Service at our institution from January 1, 1990, to December 31, 1993. All surgery was performed under a specific hypotensive epidural anesthesia protocol. Hypotensive epidural anesthesia at our institution provides a lower level of hypotension (mean arterial pressure of 50-60 mmHg) as compared to hypotensive anesthesia used more generally around the world (mean arterial pressure >70 mmHg). For each patient, hospital and postdischarge office records for a minimum of 3 months after surgery were reviewed for the type of postoperative screening test, the incidence of deep venous thrombosis (DVT), and the incidence of symptomatic pulmonary embolism (PE). Overall, 2,592 primary unilateral THAs were performed with 78.6% (2,037 of 2,592) of patients receiving a venogram. Our protocol for thromboembolic disease prophylaxis in these patients included aspirin postoperatively as well as antithromboembolic disease stockings and early ambulation (24-48 hours postoperatively). The 555 patients who did not receive venography were managed with a different protocol that included warfarin postoperatively as well as antithromboembolic disease stockings and early ambulation. This high-risk group consisted of patients who received warfarin preoperatively (ie, cardiac valve) or patients with a history of DVT who were to receive warfarin postoperatively, regardless of venography result. Overall, DVT was diagnosed in 10.3% (210 of 2,037) of patients who had a venogram. Of these patients who had venography, 2.3% (46 of 2,037) had an isolated proximal DVT; 6.0% (123 of 2,037), a distal DVT; and 2.0% (41 of 2,037), both a proximal and a distal DVT. Of the 87 cases of proximal DVT identified, 60.9% (53 of 87) were femoral DVT; 18.4% (16 of 87), popliteal DVT; and 20.7% (18 of 87), both femoral and popliteal DVT. Of the 164 distal DVT, 68.3% (112 of 164) were major calf DVT and 31.7% (52 of 164) were minor calf DVT. The overall incidence of major venous thrombosis (sum of proximal and major calf thrombi) was 9.8% (199 of 2,037) in patients who had venography. Ventilation-perfusion scanning was used selectively in patients symptomatic for PE. Overall, symptomatic PE was diagnosed by ventilation-perfusion scan in 1.0% (26 of 2,592) of patients, with 0.58% (15 of 2,592) of patients having an in-hospital PE. Of the 15 patients who had an in-hospital PE, 11 patients had a venogram, and only 3 of 11 were positive. Late symptomatic PE was defined from discharge (mean, 7 +/- 2 days) to 3 months after discharge from the hospital and occurred in 0.42% (11 of 2,592) of patients. One of the 11 late symptomatic PEs was fatal. In the overall study, this represents 0.04% (1 of 2,592) fatal PE. Of the 11 patients with a late symptomatic PE, 10 had venograms in the hospital, and all 10 were negative for DVT. Overall, in the patients with a positive venogram, the incidence of symptomatic PE was 1.4% (3 of 210), whereas in the patients with a negative venogram, the incidence of symptomatic PE was 0.44% (8 of 1,827). At our institution, patients who undergo primary THA performed with hypotensive epidural anesthesia, postoperative aspirin, antithromboembolic disease stockings, and early ambulation have a low risk for thromboembolic disease.

Custom and modular components in primary total hip replacement

Cementless custom implants attempted to enhance fit and fill of variable hip geometry. Fabrication of custom implants in referenced from a computed tomography scan, thus allowing three dimensional specifications of femoral anatomy. However, the aggregate charge of manufacturing the implant and obtaining the computed tomography scan is prohibitive in today's healthcare climate. Clinical studies have not shown that customized implants incrementally improve clinical success or implant longevity. Modular prostheses allow the surgeon intraoperative versatility, allowing adjustment of leg length, offset, neck length, anteversion, and fixation. This is particularly helpful in developmental dysplasia of the hip and posttraumatic arthritis. Other advantages of modularity include decreased implant inventory and the ability to remove the femoral head at revision surgery to improve exposure or change head size without component removal. Subsequent clinical experience has witnessed significant drawbacks associated with modularity. These include corrosion, especially with mixed metals, fretting, dissociation, implant fracture below the head and neck taper joint, and reduced range of motion. In addition, thin acetabular polyethylene contributes to higher were rates, earlier failure, local or distal debris particles, and osteolysis. Finally, the cost of modular implants is generally higher than a comparable monolithic prosthesis. In primary hip arthroplasty, use of custom or modular implants should be judicious. Modularity beyond the head and neck junction should be reserved for those cases where a comparable monolithic implant would not suffice.

Occupational knee injuries

This article focuses on occupational knee injuries. After an overview of work-related injuries, sections on the following are presented: (1) occupational knee injuries (patient history, physical examination, laboratory tests, radiographic tests, and treatment); (2) patellar and quadriceps tendinitis; (3) occupational osteoarthritis (overview and treatment); and failed knee surgery.

Minimum four-year radiographic and clinical evaluation of results following femoral revision surgery with the S-ROM modular hip system

Thirty-four patients were reviewed following revision modular cementless reconstruction for proximal femoral deficiency. One patient underwent a Girdlestone conversion for sepsis at 3 years postoperatively, leaving 33 patients with an average follow-up of 51 months (range 48 to 62 months). The average age at surgery was 60 years, and there were 17 right and 16 left hips. Patients were assessed clinically using the Merle d'Aubigné and Postel hip rating system. Radiographic assessment was performed on preoperative and postoperative films. Femoral assessment was performed using the Engh fixation stability score, Gruen zonal system for radiolucencies and observing for the presence or absence of osteolysis. The average pain score was 5.4/6 with 88% having slight or no pain. Only one patient (3%) had thigh pain. Radiographically, the average fixation stability score was 21.7 with features of bony ingrowth present in 97%, and one case with features of stable fibrous ingrowth. There was no evidence of osteolysis.

Methyl methacrylate levels in the breast milk of a patient after total hip arthroplasty

Blood levels of methyl methacrylate (MMA) are known to be transiently elevated in patients having undergone total hip arthroplasty using cement fixation. However, it is not known whether MMA is present in the breast milk of lactating women after this procedure. The authors studied an otherwise healthy lactating 29-year-old mother 5 months postpartum who had undergone total hip arthroplasty because of walking limitations due to congenital hip dysplasia. Less than 0.0005 micrograms/mL of MMA was found in her breast milk 36 hours after the procedure. If the negative findings in this case can be confirmed in a larger trial, the current practice of discontinuing breast-feeding after arthroplasty may be reconsidered.

Orthopaedic manifestations of Lyme disease

Lyme disease is caused by the spirochete Borrelia burgdorferi and is transmitted by the Ixodes tick. Early diagnosis is difficult because the tick bite may go unnoticed and the distinguishing rash, erythema chronicum migrans, often does not occur. Serologic tests are both sensitive and specific in the later stages of the disease but not in stage 1. Thus diagnosis of Lyme disease remains clinical. Knowledge of the orthopaedic manifestations of Lyme disease may aid in early diagnosis and help differentiate from possible cases of juvenile rheumatoid arthritis and septic arthritis. If septic arthritis is suspected, appropriate antibiotic therapy should be initiated while awaiting serology for Lyme disease. Recurrence of Lyme arthritis following antibiotic treatment is rare. Lyme disease should be considered in any patient with arthritis and a history of rash, fever, or neurologic or cardiac abnormality.

Severe polyethylene wear in total hip arthroplasty. Observations from retrieved AML PLUS hip implants with an ACS polyethylene liner

A retrospective review was performed of 94 consecutive Anatomic Medullary Locking Plus (AML+, DePuy, Warsaw, IN) cementless acetabular components implanted between January 1988 and January 1990. All acetabular cups utilized the Acetabular Cup System (ACS) polyethylene liner (Depuy). Of these hips, 72 had been followed for more than 2 years (average, 43 months). There have been 15 (21%) clinical failures, all due to catastrophic wear of the acetabular polyethylene component surfaces. Of the 15 failures, clinical symptoms were absent in 7, an audible squeak was present in 3, and 5 patients reported having pain. All clinical failures had accelerated acetabular wear necessitating revision. Patients in the failure population were younger (56 years vs 62 years) than the remainder of the patients, and had greater cup abduction angles (55 degrees vs 49 degrees). All of the failed ACS polyethylene components had a 32 mm inner diameter articulating surface. The AML + acetabular component outer diameter averaged 56 mm (range, 50-64 mm). Six of 15 failures occurred in cups 58 mm or larger. Acetabular wear in the failure group was 0.77 mm/y (average). The incidence of acetabular (78%) and femoral (71%) osteolysis in the failure population is alarming. The rate of failure (21%) at 46 months of the AML + acetabular component with the ACS polyethylene liner appears to be related to design. The ACS design is flawed by a lack of hemispherical geometry, leading to failure at the superior rim with penetration of the femoral head through the polyethylene and against the metal shell.(ABSTRACT TRUNCATED AT 250 WORDS)

Stabilization procedures of the hindfoot

Images

Surgical arthrodesis of the neuropathic foot. A salvage procedure

Reconstructive foot and ankle surgery is a salvage procedure in the deformed neuropathic foot, despite condemnation by some authors. Clinical union and stability was achieved in 91% of the patients, and soft-tissue coverage without skin breakdown was achieved in 100% of the cases. Although one patient had moderate to severe pain in her ankle after operation and was able to do only bed-to-wheelchair transfers, she had good clinical stability, no skin ulceration, and was satisfied overall with the procedure. In addition, a significant component of her pain was believed to be from diabetic neuropathy and not pain that was directly attributable to her reconstructive surgery. All other patients were able to ambulate to some degree. More than half had unlimited use of the affected lower extremity. More than half of the patients had mild or no pain, and all patients had a functional limb. Surgical arthrodesis of the deformed neuropathic foot as a salvage procedure can preserve the limb as a stable functional unit, and create an acceptable alignment of the ankle-foot complex that will promote viability of the overlying soft-tissue structures.

Methohexital for orthopaedic procedures in the emergency department

The past two decades have seen more and more orthopaedic procedures performed in the emergency department. Methohexital would seem to be a useful adjunct drug for the performance of these procedures because of its well-known attributes (eg, rapid induction and recovery, brief duration, and minimal hemodynamic changes). A search of the literature revealed no previous studies on the use of methohexital in the emergency department. Therefore, the authors undertook a 1-year prospective study of all patients in their emergency department who received methohexital for orthopaedic procedures. The study's hypothesis was that methohexital is a safe drug for use in orthopaedic procedures in the emergency department. Additionally, the authors sought to determine the drug's indications for use, patterns of usage, and effects on the respiratory and cardiovascular systems. The data presented here are a subset of data previously presented and published.

Triple arthrodesis through a single lateral approach: a cadaveric experiment

Using a single lateral approach, triple arthrodesis was performed on six cadaveric feet. An attempt was made to obliterate the talocalcaneal, talonavicular, and calcaneocuboid joints. The limbs were subsequently disarticulated to allow for an inspection of the talonavicular, talocalcaneal, and calcaneocuboid joints. An estimate of cartilage and subchondral bone removed from each articular surface was made by a single observer (J.V.B.) by direct visual inspection. Results were as follows: calcaneocuboid joint, 90% of cartilage removed; talocalcaneal joint, 80% of cartilage removed; talonavicular joint, 38% of cartilage removed. Failures at the talonavicular joint were attributed to a poor appreciation of the anatomy of the talar head and poor observation. Complications involved in obliteration of the talonavicular joint from a single lateral approach included: inadvertent division of the talar neck; inadvertent division of the talar head; removal of excessive bone stock; medial skin punctures; and creation of an iatrogenic cut through the talar dome. Therefore, a triple arthrodesis through a single lateral approach, as described by Ryerson, Hoke, and Campbell, cannot be recommended. The talonavicular joint should be approached through an auxiliary medial incision, as recommended by Cracchiolo. This paper documents the experience of a beginner with this operation, and demonstrates the value of using the anatomy laboratory.