Decreasing mortality after femoral neck fracture treated with bipolar hemiarthroplasty during the last twenty years.

PURPOSE: The aim of our study was to investigate trends over time in the mortality of elderly patients after femoral neck fractures treated with bipolar hemiarthroplasty. METHODS: Altogether 487 cases of femoral neck fracture treated with bipolar hemiarthroplasty were observed during a 20-year period. Mortality rates were calculated for five years postoperatively. To account for the age distribution of the study population standardised mortality ratios (SMR) with respect to the age-specific mortality of the German population were determined and compared. Additional changes of the SMRs over time and the influence of the time delay before surgery on long-term mortality were evaluated. RESULTS: Femoral neck fractures treated with bipolar hemiendoprosthesis have a significant impact on mortality. Postoperative mortality is increased in patients of all age groups, but the effect diminishes in higher age groups. The influence on mortality was significantly greater for men than for women. The SMR has decreased from 3.52 before 1995 to 1.2 after 2006. Since 2006 there is no longer an increase in mortality after surgical treatment of a femoral neck fracture compared to general German population of the same age. CONCLUSION: Femoral neck fractures treated with bipolar hemiendoprosthesis result in a significantly increased mortality, however in our population this impact has significantly decreased over time. The effect on mortality is less in women and higher age groups than in men and younger patients. No influence of the time between accident and surgery on mortality could be detected.

Recovery after hip fractures: influence of bipolar hemiarthroplasty on physical disability and social dependency in the elderly.

Surgical treatment of femoral neck fractures is associated with a significant impact on quality of life. The aim of this study was to determine the long-term influence of displaced femoral neck fractures treated by bipolar hemiarthroplasty on the activities of daily living, quality of life and social dependency. We studied 487 geriatric patients treated in the years 1989 to 2003. At the beginning of follow-up in 2004, 166 patients were alive and evaluation was carried out on 145 patients (87.3%) at 91.3 (14 - 244) months postoperatively by a standardized questionnaire. All enrolled patients had been treated with cemented bipolar hemiarthroplasty for a displaced femoral neck fracture. Patients were evaluated concerning their average pre- and postoperative ability to walk, the need for assisting devices, type of residency and the SF-12® Score. Femoral neck fracture and hemiarthroplasty had a significant influence on all recorded aspects of quality of life. Even though almost two thirds of the patients needed assisting devices to walk after surgery, about two thirds returned to their original type of accommodation and the majority reached their original degree of mobility. Compared to a normal population no significant impact was observed on the quality of life measured by the SF-12® score. We consider bipolar hemiarthroplasty an effective treatment option for displaced femoral neck fractures in geriatric patients. Most patients returned to their original type of accommodation and level of mobility, even though the majority required a number of assisting devices to do so.

Is there a need of custom-made prostheses for total hip arthroplasty? Gait analysis, clinical and radiographic analysis of customized femoral components.

INTRODUCTION: Custom-made prosthesis in primary hip arthroplasty based on the concept of a better press-fitting to reach superior clinical results in comparison to conventional implants. Mid-term results provide a more complete picture with respect to gait and electromyographic analyses. MATERIALS AND METHODS: The custom-made femoral component (Adaptiva) was implanted in 24 hips and compared to 23 hips with a conventional implant (Alloclassic-SL). The mean retrospective follow-up times were 3.9 (3-4.9) years and 4.8 (3.1-5.1) years. Clinically, the Harris Hip Score (HHS) and the SF 36 were recorded. Motion analysis data (body kinematics, kinetics and muscle activities) were recorded with 3D gait analysis. RESULTS: Neither the HHS nor the SF-36 revealed any statistical differences between the two groups (P > 0.05). The radiographic parameters did not show the intended physiologic load transfer. Periprosthetic changes indicated a more distal load transfer of the customized stem. Gait analysis revealed in comparison to the controls (45.03 degrees ), a reduced mean hip range of motion in the sagittal plane by 11.4% (39.9 degrees ) in the customized stem group versus 17.4% (37.2 degrees ) in the conventional stem group. In keeping with the limited range of hip motion kinematic impairments of the ipsilateral knee and ankle joints were detected. The electromyographic amplitudes of the tensor fasciae latae and gluteus medius muscles both for stabilizing the hip joint in the stance phase were significantly higher in both groups. CONCLUSION: Compared to a conventional cementless hip prosthesis the custom-made device did not improve the mid-term clinical and radiographic outcome. Despite the individualized reconstruction of the biomechanical hip geometry objective gait analysis failed to show a benefit.

VenaFlow plus Lovenox vs VenaFlow plus aspirin for thromboembolic disease prophylaxis in total knee arthroplasty.

Two hundred seventy-five patients undergoing unilateral total knee arthroplasty were prospectively randomized to receive spinal epidural anesthesia (SEA), a VenaFlow calf compression device, and enoxaparin (group A) or SEA, VenaFlow, and aspirin (group B). Aspirin was started on the day of surgery, whereas enoxaparin was started 48 hours after surgery. Anticoagulants were continued for 4 weeks after surgery. All patients had an in-hospital ultrasound screening test on postoperative days 3 to 5 and a second follow-up ultrasound 4 to 6 weeks after surgery. The overall deep venous thrombosis rates in groups A and B were 14.1% and 17.8% (P = not significant), respectively. When used in combination with pneumatic compression devices and SEA, enoxaparin was not superior to aspirin in preventing deep venous thrombosis after total knee arthroplasty.

Minimally invasive total hip replacement: the posterolateral approach.

Our experience with the posterolateral mini-incision technique over the last 8 years has shown that total hip arthroplasty can be performed safely and effectively in properly selected patients through a much smaller incision than the one traditionally used. The main advantage of the posterolateral approach compared with other mini-incisions is its simplicity, with shortened operating time as a result. While the surgical time for a posterior approach is an average of 37 to 70 minutes throughout the literature, the 2-incision approach prolongs the surgery by a factor of 2 or 3. Compared with the anterior or 2-incision approach, the posterolateral and anterolateral approaches also have a much lower incidence of perioperative complications, with the rate being similar to rates seen with a standard incision. For the 2-incision technique and the anterior mini-incision approach, perioperative periprosthetic fracture rates of up to 8.7% and 8.4%, respectively, have been described. Surgeons who traditionally used an anterolateral standard approach might prefer an anterolateral mini-incision. The anterolateral mini-incision total hip arthroplasty has demonstrated excellent results; in the past it was suggested that the anterolateral approach has a higher incidence of heterotopic bone formation and impaired early abductor function, but more recent studies show no difference in abductor strength and limping between the anterolateral and posterior approaches. On the other hand, the posterior approach has been associated with an increased risk of postoperative dislocations. We did not encounter an increased incidence of postoperative dislocation at our institution. This might be related to the routine repair of the external rotators and the capsule in all patients. In summary, both the anterolateral and the posterior mini-incision approaches are reasonable alternatives, and surgeons should choose the approach that they feel most comfortable with. Statements in the press and by some members of the orthopedic community suggest that a smaller incision has revolutionized total hip replacement by accelerating the recovery and improving the functional outcome, but most articles in the peer-reviewed literature fail to confirm these hypotheses. Considering that mini-incision total hip replacement has no dramatic clinical benefits other than the cosmetic appeal, the use of mini-incision total hip replacement by the average orthopedic surgeon should be carefully monitored. In the meantime, the patient should be informed about the true merits of the technique, and any marketing that misleads patients' perception of the technique should be avoided. Because the mini-incision leads to results similar to those obtained with the standard approach, we will, encouraged by the enthusiasm of our patients, continue to use this approach.

Perioperative morbidity after single-stage bilateral total hip arthroplasty: a matched control study.

We asked whether the perioperative morbidity and mortality of patients having bilateral single-stage total hip arthroplasties would be increased. We retrospectively compared 400 patients who had bilateral total hip replacements with a matched group of 400 patients who had unilateral total hip replacements. Patients were matched according to age (+/- 1 year), gender, American Society of Anesthesiologists (ASA) classification, body mass index (+/- 4 kg/m), and diagnosis (osteoarthritis, 81.2%). There were no deaths in either group. The group of patients who had bilateral total hip arthroplasties had a greater number of minor complications per hip (0.34 +/- 0.6 versus 0.25 +/- 0.6) but only a trend toward an increased number of major complications per hip (0.037 +/- 0.2 versus 0.015 +/- 0.1). Patients who had bilateral total hip arthroplasties had a trend toward increased risk of dislocation (1.6%/hip versus 0.5%/hip). The patients in this group also had increased number of fat emboli syndrome per surgically treated hip (0.015 versus 0.0025). Based on a calculation per surgically treated hip, patients who had bilateral total hip arthroplasties had a similar percentage of blood transfusions (1.2 versus 0.9/hip), but more patients received allogeneic blood (23% versus 3.8%). The ASA classification was the only independent predictor for minor complications, major complications, and fat emboli syndrome. We think bilateral single-stage total hip arthroplasties have an acceptable perioperative risk for patients with ASA Class 1 or 2 physical status.

Hybrid component fixation in revision total knee arthroplasty.

UNLABELLED: We retrospectively analyzed the midterm survivor rate of revision total knee arthroplasty using hybrid stem fixation. We included 33 patients, 21 women and 12 men with an average age of 68 years (range, 57-80 years). Revision was performed for aseptic loosening in 16 patients, aseptic loosening and knee instability in five patients, instability in seven patients, infection in three patients, and postoperative stiffness and pain in two patients. The average follow-up was 38 months. Three knees (9%) were revised during the follow-up period. Two patients (6%) underwent revision for aseptic loosening and one patient (3%) for deep implant infection. The average knee score improved from 42 points (range, 10 to 60) to 83 points (range, 60 to 100). The average functional score improved from 48 points (range, 15-65 points) to 76 points (range, 46-99 points). All patients had no pain (13%) or moderate/occasional pain (87%) during walking. The average ROM improved from 94 degrees (range, 45 degrees-125 degrees) to 105 degrees (range, 70 degrees-125 degrees). Hybrid component fixation is a useful treatment option in revision total knee arthroplasty. The revision rate for aseptic loosening within a three year follow-up is 6%. LEVEL OF EVIDENCE: Therapeutic study, level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

The effects of femoral nerve blockade in conjunction with epidural analgesia after total knee arthroplasty.

Either epidural analgesia or femoral nerve blockade improves analgesia and rehabilitation after total knee arthroplasty. No study has evaluated the combination of femoral nerve blockade and epidural analgesia. In this prospective, randomized, blinded study we investigated combining femoral nerve blockade with epidural analgesia. Forty-one patients received a single-injection femoral nerve block with 0.375% bupivacaine and 5 microg/mL epinephrine; 39 patients served as controls. All patients received combined spinal-epidural anesthesia and patient-controlled epidural analgesia with 0.06% bupivacaine and 10 microg/mL hydromorphone. Average duration of epidural analgesia was 2 days. All patients received the same standardized physical therapy intervention. Median visual analog scale (VAS) scores with physical therapy were significantly lower for 2 days among patients who received a femoral nerve block versus controls: 3 versus 4 (day 1), 2.5 versus 4 (day 2); P < 0.05. Median VAS pain scores at rest were 0 in both groups on days 1 and 2. Flexion range of motion was improved on postoperative day 2 (70 degrees versus 63 degrees ; P < 0.05). No peripheral neuropathies occurred. We conclude that the addition of femoral nerve blockade to epidural analgesia significantly improved analgesia for the first 2 days after total knee arthroplasty.

CT-based accuracy of implanting custom-made endoprostheses.

BACKGROUND: To optimize physiological load transfer and mechanical stability a close geometric fit between cementless stems and the bone stock is essential. To solve the problem of a geometric mismatch between the anatomic shape of the femoral canal and conventional stems custom-made implants were developed. This study determined the accuracy of implanting custom-made press-fit straight femoral stems compared to conventional cementless stems. METHODS: Nine pairs of human cadaveric femurs were used to determine the extent of the endocortical area in contact with the stem. The bone-femoral component interface was measured in vitro using CT-data analysis. A software program was developed to describe the periprosthetic inner cortical bone structure, the stem surface and the proportionate implant-endosteal bone contact. FINDINGS: The mean endosteal bone contact of both prostheses was 21.6%. The proportionate implant-endosteal bone contact for straight custom-made femoral prostheses averaged 20.98%. For the conventional cementless stems the mean proportionate contact was 22.15%. Especially in the proximal femur the desirable contact of customized implants was not achieved by closed distal press-fit. INTERPRETATION: Compared to conventional straight cementless stems custom-made stems did not extend the endocortical contact area. The desirable "fit and fill" of the proximal femur was not achieved with straight custom-made femoral components in femurs of regular geometry.

Implant migration after early weightbearing in cementless hip replacement.

UNLABELLED: Twenty-nine patients (five women and 24 men) with an average age of 47 years (range, 24-59 years) had 37 total hip arthroplasties using a hydroxyapatite-coated double-wedge press-fit femoral component. All patients had a Type A bone quality. Patients were either mobilized with weightbearing as tolerated or toe-touch weightbearing for 6 weeks postoperatively. After 6 weeks all patients were advanced to weightbearing as tolerated. Radiostereometric analysis radiographs were taken at 3 days, 6 weeks, and 6 months postoperatively to measure migration of the femoral component. Radiostereometric analysis revealed no difference in stem migration between the two groups as defined by maximal total point migration. There was a difference in the vertical (proximal-distal) migration within the first 6 weeks between groups (0.81 mm versus 0.13 mm), but not afterwards (0.17 mm versus 0.18 mm). Continuous migration after 6 weeks was observed in three patients from each group. There was no loosening in either group within a 2-year followup. Weightbearing as tolerated is recommended for young patients with excellent bone quality after cementless total hip arthroplasty with a double-wedge press-fit femoral component. LEVEL OF EVIDENCE: Diagnostic study, Level I (testing of previously developed diagnostic criteria in series of consecutive patients--with previously applied reference gold standard). See the Guidelines for Authors for a complete description of levels of evidence.

Acetabular augmentation ring for recurrent dislocations in revision arthroplasty.

UNLABELLED: We retrospectively reviewed 18 patients with recurrent dislocations after revision total hip arthroplasty with no identifiable specific cause. All patients were treated with an acetabular component augmentation ring to evaluate whether the acetabular augmentation ring effectively decreases the redislocation rate compared with other treatment options. The acetabular augmentation ring was implanted after an average of 4.9 dislocations and failed nonoperative or surgical treatment. Seven patients had postoperative complications, including four patients with persistent neurologic deficits. The average followup was 35.1 months (range, 24-52 months). During followup six patients experienced a dislocation. Four patients and three patients presented with implant loosening and deep infection, respectively. Overall, 10 patients had surgical revision and removal of the acetabular augmentation ring during followup. The remaining eight patients, who did not require additional surgical intervention, had an average Harris hip score of 42.5 (range, 9.5-61.7). The use of an acetabular augmentation ring is not supported by results of our study. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Perioperative morbidity in bilateral one-stage total knee replacements.

A retrospective review was done on 501 patients who had bilateral sequential one-stage total knee replacements from September 1995 to April 2000 to evaluate perioperative (inhospital) morbidity. One thousand two knee replacements were done with the patients receiving regional anesthesia, on 286 women and 215 men with an average age of 66 years. The average transfusion requirement was 2.8 units of blood per patient. There were no deaths, myocardial infarctions, or cerebrovascular accidents. The mean length of hospital stay was 7.2 days. One hundred forty-four perioperative complications were observed in 109 patients (21.8%). These complications included 27 arrhythmias (5%), one congestive heart failure (0.2%), 65 lower extremity deep venous thromboses (13%), 14 fat emboli (3%), and two pulmonary emboli (0.4%). Other major complications were pneumonia (1%), acute renal failure (0.4%), ileus (2%), and mental status changes (2%). Wound complications included two deep infections (0.4%), three hematomas (0.6%), and five delayed wound healings (0.9%). According to the current study the perioperative morbidity and mortality is acceptable if the procedure is used for selected patients. Patients with significant comorbidities should have a staged bilateral total knee replacement.

Quality of life and clinical outcome in salvage revision total knee replacement: hinged vs total condylar design.

This study compared the overall outcome after salvage revision total knee arthroplasty using hinged and nonhinged designs. We followed 26 total knee arthroplasties for an average of 20.4 months. The average age was 68.5 years. All patients had a salvage situation secondary to excessive bone loss, enlarged flexion gap, collateral ligament insufficiency, or extensor mechanism insufficiency. Ten patients received a hinged implant after an average of 2.8 prior total knee replacements. Sixteen patients received nonhinged constrained implants after an average of 3.4 prior total knee replacements. The outcome was evaluated using the Hospital for Special Surgery Score (HSS), the Knee Society Score (KSS), the Visual Analogue Scale for pain (VAS), the Tegner Activity Score, the Patella Score, and the Short Form-36 Health Survey (SF-36). There was a statistically significant difference in flexion range of motion between hinged and nonhinged designs (96.5 degrees vs. 107.5 degrees ) but not in HSS, KSS, VAS, Tegner Activity Score, or Patella Score. Patients with hinged and nonhinged prostheses had significantly lower scores than an age-matched normal population in physical functioning, role limitations, and bodily pain on the SF-36 survey. However, patients with a hinged implant had no statistically significant difference compared to controls in the mental component summary. In salvage total knee arthroplasty the implant design does not significantly affect the overall functional outcome. However, patients with a hinged implant had significant better scores in the mental components of the SF36 quality-of-life assessment.

Blood management after bilateral total knee arthroplasty.

Four hundred sixty-one patients who had bilateral one-stage total knee replacements were reviewed to evaluate their blood management. Overall, patients received an average of 2.1 units of autologous blood and 0.9 units of allogenic blood. Seventy-six percent of the patients who preoperatively donated one unit of autologous blood required allogenic blood transfusions compared with 51% of patients who donated two units, 29% of patients who donated three units, and 27% of patients who donated four units of autologous blood. Ninety-eight percent of the patients who did not donate autologous blood required allogenic blood. Donating two units of autologous blood in combination with a perioperative cell saver reduced the incidence of allogenic blood transfusions to 8% but increased the amount of unused autologous blood to 54%. If the indication for wound drainage recovery is guided by the preoperative hematocrit (< or = 40%) or postoperative hemoglobin (> or = 11 mg/dL) the incidence of allogenic blood transfusions decreased to 17% and 13%, respectively and the amount of unused autologous blood decreased to 39% and 30%. There is no statistical difference among the three protocols regarding the need for allogenic blood transfusions and associated costs. Based on this retrospective evaluation the combination of preoperative donation of two units autologous blood and use of a postoperative cell salvage system in all patients is recommended.

Cytokine levels after transfusion of washed wound drainage in total knee arthroplasty: a randomized trial comparing autologous blood and washed wound drainage.

Forty patients undergoing total knee arthroplasty (TKA) were prospectively randomized to autologous blood transfusion or retransfusion of washed wound drainage. The wound drainage was washed using a dynamic disk separation chamber. Interleukin (IL)-1 beta, IL-6, IL-8, and tumor necrosis factor (TNF) alpha blood levels were measured prior to epidural anesthesia and at 0, 30, 60, and 120 minutes after initiation of the transfusion. Washed wound drainage contained significantly higher amounts of IL-6 (P < .05) and IL-8 (P < .05) than predonated autologous blood. No significant difference was found for IL-1 beta (P = .28) and TNF-alpha (P = .14). The patients' IL-6 and IL-8 blood levels increased in both groups within 2 hours after the transfusion. This increase was correlated to the time interval between surgery and transfusion (P < .05) and was not significantly different between both groups. No correlation was found between the increase in patients' cytokine levels and the amount of washed wound drainage transfused. According to these results, the increase in IL-6 and IL-8 after transfusion is related to the surgical trauma response and not the transfusion protocol.