Post-operative blood salvage with autologous retransfusion in primary total hip replacement.

Clinical, haematological or economic benefits of post-operative blood salvage with autologous blood re-transfusion have yet to be clearly demonstrated for primary total hip replacement. We performed a prospective randomised study to analyse differences in postoperative haemoglobin levels and homologous blood requirements in two groups of patients undergoing primary total hip replacement. A series of 158 patients was studied. In one group two vacuum drains were used and in the other the ABTrans autologous retransfusion system. A total of 58 patients (76%) in the re-transfusion group received autologous blood. There was no significant difference in the mean post-operative haemoglobin levels in the two groups. There were, however, significantly fewer patients with post-operative haemoglobin values less than 9.0 g/dl and significantly fewer patients who required transfusion of homologous blood in the re-transfusion group. There was also a small overall cost saving in this group.

C reactive protein and skin temperature post total knee replacement.

We prospectively assessed 20 patients following uncomplicated total knee replacement (TKR). Clinical status, skin temperature and C-reactive protein (CRP) were measured preoperatively and at intervals up to 18 weeks. The CRP rose postoperatively up to 5-7 days but returned to normal values by 6 weeks. The skin temperature remained elevated up to 18 weeks. We concluded that in uncomplicated cases, the CRP should be within normal limits by 6 weeks after operation, but skin temperature may remain elevated up to 18 weeks. A sustained rise in these values may indicate the development of a complication such as infection and the patient must be closely monitored.

Spontaneous recurrent haemarthrosis following unicompartmental knee arthroplasty and its successful treatment by coil embolisation.

A case of spontaneous recurrent haemarthrosis of the knee presenting 3 months after the unicondylar knee replacement is described. Femoral arteriography demonstrated hypertrophy of the saphenous branch of descending genicular artery with a prominent vascular blush in the region of posteromedial aspect of the popliteal fossa thought to represent a hypertrophic vascular mass of synovium. Therapeutic embolisation of the saphenous branch of descending genicular artery was performed using three fibred platinum coils with satisfactory clinical results. Since the embolisation, the haemarthrosis has not recurred. To our knowledge, this therapeutic procedure used to treat recurrent haemarthrosis following unicondylar knee arthroplasty has not been previously described in the literature.

Local vascular complications after knee replacement: a review with illustrative case reports.

The incidence of vascular complications after knee replacement is between 0.03% and 0.2%. These complications include acute ischaemia, thrombosis, haemorrhage, fistula and aneurysm formation. Vascular complications can be avoided by careful pre-operative selection. If doubt exists, a vascular opinion should be obtained before knee replacement. In the event of a vascular complication occurring, serious morbidity can be avoided by prompt diagnosis, investigation and specialist treatment.

Recurrent dislocation of a posterior-stabilized prosthesis: a series of three cases.

We report three cases of recurrent posterior dislocation of primary posterior-stabilized total knee replacements. In all of the cases, reduction was not possible under sedation alone, and general anaesthesia was needed to allow disengagement of the components and reduction of the dislocation. In addition, it was noted in all cases that the ability of the patients to flex their knee replacement excessively contributed to the instability. The design of the prosthesis, and issues of operative technique are discussed with reference to this serious complication.

Therapeutic embolization of the genicular arteries for recurrent hemarthrosis after total knee arthroplasty.

The case of a recurrent hemarthrosis initially presenting 30 months after a total knee arthroplasty in a patient on lifelong warfarin is described. Angiography was used to aid in the diagnosis, and therapeutic selective embolization of the superior genicular arteries was performed with satisfactory clinical results.

Changes in the proportions of peripheral blood lymphocytes in patients with worn implants.

We compared the peripheral blood and periprosthetic tissues of 53 patients at revision arthroplasty with those of 30 patients at primary arthroplasty to determine whether there is a systemic difference in lymphocytes in patients with worn hip implants. The absolute number and relative proportion of lymphocytes bearing CD2, CD3, CD4, CD8, CD16, CD19, HLA-DR, kappa and lambda antigens were compared with the levels of IL-1beta, IL-6 and PGE2 in the pseudosynovial membrane as well as with a semiquantitative estimate of metal and polyethylene particles, necrosis and chronic inflammation and the total concentration of metals within the periprosthetic tissues. There was a significant increase in the relative proportion of CD2-positive T-cells and CD16-positive natural killer cells in the peripheral blood at revision arthroplasty compared with primary arthroplasty and an increased proportion of CD8-positive T-cells and a decreased ratio of CD4 to CD8 (helper inducer/suppressor cytotoxic cells). Three control patients, who went on to have revision surgery, had values at primary arthroplasty which were similar to those of patients at the time of revision surgery. These differences did not correlate with the local concentration of metal, plastic or cement or inflammatory response or the type of prosthesis. An inverse correlation was noted between the necrosis in the periprosthetic tissue and both the local production of IL-6 and the absolute numbers of T-cells in peripheral blood. We conclude that there may be several cell-mediated systemic immune responses to aseptic loosening, at least one of which may be directly related to events in the periprosthetic tissues. We cannot exclude the possibility that the changes in the proportion of CD8-positive cells reflected a predisposition, rather than a reaction, to loosening of the implant.

Pitfalls and delay in the diagnosis of Pancoast tumour presenting in orthopaedic units.

Pancoast tumours present a difficult and peculiar problem. Their clinical manifestations may be extrapulmonary. The underlying lesion may be missed in patients presenting with predominantly orthopaedic symptoms. We present four consecutive cases, which were referred to our clinic and the diagnosis was made with mean delay of 18.5 months from the beginning of symptoms.

Tumors around implants.

In 1989, A. G. Apley recommended cautious surveillance of malignant tumors that developed in association with orthopaedic implants. This retrospective review of the Bristol Bone Tumour Register between 1980 and 1992 reports on 240 malignant soft tissue sarcomas. Eighteen developed in the thigh region of patients more than 50 years old, and 4 of these developed in the soft tissues around a hip arthroplasty.

Bone-membrane interface in aseptic loosening of total joint arthroplasties.

In 19 patients who underwent revision arthroplasty for aseptic loosening of total joint arthroplasty, specimens were taken at the time of operation to include the bone-membrane interface. In 16 (84%) of the specimens, sufficient visualization of the interface was possible to allow histologic interpretation. In 13 of these cases, there was prominent evidence of classic bone remodeling with osteoclast-mediated resorption and active new bone formation. These results suggest that the osteolysis in aseptic loosening is mediated through osteoclastic bone resorption and that the bone found in such areas is extremely active. The findings help to explain the efficacy of impacted morselized bone-graft in the treatment of bone lysis in aseptic loosening.

Preliminary observations on possible premalignant changes in bone marrow adjacent to worn total hip arthroplasty implants.

Previous epidemiologic studies have suggested that there may be a risk of malignancy, especially lymphoma and leukemia, after joint replacement, but the followup has been relatively short. This is a preliminary study to see if there is any biologic basis for such a risk. Blood and bone marrow samples from 71 patients at revision arthroplasty of a loose or worn prosthesis and 30 control patients at primary arthroplasty were analyzed with cytogenetic techniques and molecular biology. There was a higher chromosomal aberration rate in cells adjacent to the prosthesis at revision surgery compared with iliac crest marrow from the same patients or with femoral bone marrow at primary arthroplasty. Clonal expansion of lymphocytes without a serum paraprotein was seen in 2 of 21 patients at revision arthroplasty performed more than 10 years after primary arthroplasty. The results of this preliminary study suggest that future epidemiologic studies should concentrate on patients with longer postoperative intervals to see if there is any risk that would be pertinent to a young patient at primary arthroplasty.

The dynamic condylar screw in the management of subtrochanteric fractures of the femur.

We reviewed 43 patients with subtrochanteric fractures treated with the AO dynamic condylar screw (DCS) to determine the medical and technical complication rate. Seven patients died before union and nine sustained major medical complications. Thirty fractures united without event. There were six technical failures, three related to failure of the medial buttress. The DCS can be used successfully in most subtrochanteric fractures, although there is a considerable complication rate, which reflects the general condition of the patient and the biomechanics of the proximal femur.

Widespread dissemination of metal debris from implants.

In a post-mortem study, we compared subjects with metal implants with and without visible wear with an age-matched control group to determine the extent and effects of dissemination of wear debris. In subjects with stainless-steel and cobalt-chrome prostheses metal was found in local and distant lymph nodes, bone marrow, liver and spleen. The levels were highest in subjects with loose, worn joint prostheses and the main source of the debris was the matt coating. Metal levels were also raised in subjects with implants without visible wear and, to a less extent, in those with dynamic hip screws. Necrosis of lymph nodes was seen in those cases with the most wear, and potential damage to more distant organs such as the bone marrow, liver and spleen in the long term cannot be discounted. The consequences for the immune system and the role of metal dissemination in the possible induction of neoplasia are discussed.

Intra-articular fractures of the calcaneum. Part II: Open reduction and internal fixation by the extended lateral transcalcaneal approach.

The classification of intra-articular fractures of the calcaneum described in part I is related to an operative approach which allows accurate reduction and stable fixation of the fracture fragments. An extended lateral incision is used to avoid sural nerve damage and problems of soft-tissue healing. In type 3 fractures, access to the lateral joint fragment requires an osteotomy of the lateral wall, but after this the lateral joint fragment can be rotated out of the subtalar joint to allow transcalcaneal reduction of the medial wall. Reduction of the body fragment and lateral joint fragment on to the sustentacular fragment allows the three fragments to be stabilised by a 3.5 mm Y-shaped reconstruction plate. Our early results have been successful in terms of fracture reduction and the restoration of heel shape and joint congruity, but extended follow-up will be necessary to define the indications for this difficult procedure.

An image processing technique for the identification of contact pixels applied to x-ray CT images of implanted hip prostheses.

Uncemented prosthetic joint implants used in orthopaedic surgery are usually coated with a porous surface to encourage bone ingrowth. Better contact between the endosteal bone and the porous surface improves ingrowth, and such contact may be increased if the joint further subsides into position in the first weeks following implantation. An image processing technique has been developed as part of a study undertaken to determine the effect of early subsidence on endosteal contact. The method provides a measure of the degree of contact between the surfaces from transverse x-ray CT images, but is suitable for application to any image with a similar intensity distribution.

Systemic distribution of wear debris after hip replacement. A cause for concern?

The production of particulate wear debris is a recognised complication of joint arthroplasty, but interest has concentrated on local tissue reactions and a possible association with implant loosening. The fate of wear products in the body remains unknown, although some of the metals used in the construction of orthopaedic implants are known to have toxic and oncogenic properties. We report histological and electron-microscopic evidence from two cases which shows that metallic debris can be identified in the lymphoreticular tissues of the body distant from the hip some years after joint replacement. The increase in the use of total arthroplasty in younger patients, the development of new alloys and the use of porous coatings must raise concern for the long-term effects of the accumulation of wear debris in the body.

Complications of splintage in congenital dislocation of the hip.

The use of abduction splintage in the treatment of congenital dislocation of the hip has an important morbidity. Six children who developed complications are presented in this paper. Sustained splintage of an unreduced hip, overcorrection of the femoral head displacement, avascular necrosis of the femoral head, full thickness pressure sores, and excessive tibial torsion may occur as a consequence of treatment. Expert supervision of abduction splintage, correct case selection, and regular review are necessary to reduce the incidence of such complications.

Internal fixation of forearm fractures in the 1980s: lessons to be learnt.

A series of 156 diaphyseal forearm fractures in 108 patients were treated by internal fixation between 1980 and 1985. These cases have been critically reviewed in the light of the present knowledge and expertise of internal fixation. A total of 122 fractures were fixed with ASIF compression plates. An analysis of results shows that 17 patients (15.7 per cent) had a poor clinical symptom result, 29 patients (26.9 per cent) had a poor functional score, 14 (13 per cent) had a poor subjective and employment score, and 40 fractures (32 per cent) united after 18 weeks. Non-union rate was 10.3 per cent, the infection rate was 5.5 per cent and there were three cases (2.7 per cent) of synostosis. Only six patients had primary cancellous bone grafting. A statistical analysis of the variables which may affect the result shows that the most important factors are accurate reduction of the fracture, correct use of interfragmentary screw fixation and rigid fixation. Failure to observe these rules will produce a poor result. Fracture complexity and comminution, especially if combined with a butterfly fragment, predispose to a poor result.

Removal of forearm plates. A review of the complications.

We studied 55 patients who had undergone elective removal of forearm plates between 1980 and 1986; 44 plates were removed from the radius and 37 from the ulna. Before removal only 20 patients (36%) had definite symptoms attributable to the plates, but 44 patients (80%) were advised by the surgeon to have the plates removed. In 22 cases (40%) the operation was followed by a significant complication. The complication rate was higher with junior surgeons and was permanent in 50% of cases. It is recommended that forearm plates should be removed only if they are causing significant symptoms, and that the operation should not be delegated to the most junior surgeon.