Total intravenous general anaesthesia vs. spinal anaesthesia for total hip arthroplasty: a randomised, controlled trial.

BACKGROUND: The choice of anaesthetic technique for patients undergoing joint arthroplasty is debatable. The hypothesis of this study was that general anaesthesia would generate a more favourable recovery profile than spinal anaesthesia. METHODS: We randomly allocated 120 patients to either intrathecal bupivacaine or general anaesthesia with target-controlled infusion of remifentanil and propofol. Length of hospital stay assessed as meeting discharge criteria was the primary outcome parameter. Other outcome parameters were actual time of discharge, pain, use of rescue pain medication, blood loss, length of stay in the post-operative care unit, dizziness, post-operative nausea, need of urinary catheterisation and patient satisfaction. RESULTS: General anaesthesia resulted in slightly reduced length of hospital stay (26 vs. 30 h, P = 0.004), less nausea (P = 0.043) and dizziness (P < 0.001). General anaesthesia patients had higher pain scores during the first two post-operative hours (P < 0.001) but lower after 6 h compared with the spinal anaesthesia group (P < 0.01 and P < 0.05). General anaesthesia patients had better orthostatic function compared with spinal anaesthesia patients (P = 0.008). Patients in the spinal anaesthesia group fulfilled the discharge criteria from the post-operative care unit earlier compared with the general anaesthesia patients (P = 0.004). General anaesthesia patients requested a change in the method of anaesthesia for a subsequent operation less often than the spinal anaesthesia patients (5 vs. 13, P = 0.022). CONCLUSION: General anaesthesia resulted in a more favourable recovery profile compared with spinal anaesthesia.

Does a new knee design perform as well as the design it replaces?

OBJECTIVES: The objective of this study was to compare the early migration characteristics and functional outcome of the Triathlon cemented knee prosthesis with its predecessor, the Duracon cemented knee prosthesis (both Stryker). METHODS: A total 60 patients were prospectively randomised and tibial component migration was measured by radiostereometric analysis (RSA) at three months, one year and two years; clinical outcome was measured by the American Knee Society score and the Knee Osteoarthritis and Injury Outcome Score. RESULTS: There were no statistically significant differences in rotation or translation around or along the three coordinal axes, or in the maximum total point motion (MTPM) during the two-year follow-up. CONCLUSIONS: The Triathlon cemented knee prosthesis has similar early stability and is likely to perform at least as well as the Duracon cemented knee prosthesis over the longer term.

Interposition arthroplasty of the elbow with rheumatoid arthritis.

Radiographic bone loss and clinical outcome were evaluated at a median of 6 years after interposition arthroplasty was performed in 35 elbows with rheumatoid arthritis. Seven early postoperative complications, two major and five minor, occurred. Three elbows subsequently required total elbow replacement. Clinical results were good in terms of pain relief but only fair in terms of joint mobility and stability. Radiographic elbow destruction progressed to a higher Larsen stage in half of the elbows. Measurements revealed humeral bone loss in two thirds of the elbows and ulnar bone loss in one third. In comparison with total elbow replacement, the long-term results of interposition arthroplasty were found to be inferior, with a total elbow replacement being required in one tenth of the elbows in the long term. In addition, bone loss often became extensive, making reoperation difficult or impossible. The authors recommend total elbow replacement as the first choice in the surgical treatment of the painful elbow with rheumatoid arthritis and cartilage destruction.

Short-term complications of the lateral approach for non-constrained elbow replacement. Follow-up of 50 rheumatoid elbows.

We reviewed 50 capitellocondylar elbow replacements performed by the lateral approach in 42 rheumatoid patients, at a median follow-up of three years. There were two major and 17 minor complications; 18 were early and one was late. Eight elbows required reoperation: soft-tissue surgery was performed in seven and prosthesis removal in one because of a deep infection. There were few problems of instability, but one patient sustained a traumatic dislocation which was stabilised after ligament reconstruction. Wound healing was delayed in two of five elbows which had been immobilised postoperatively for only five days, but healing was rapid in 45 elbows immobilised for 12 days. There was transient ulnar-nerve palsy postoperatively in 11 patients, with permanent palsy in three. All elbows were painfree or only slightly painful at follow-up; 49 were stable and 43 had a range of motion sufficient for activities of daily living. Radiological loosening of the humeral component was suspected in one asymptomatic elbow. The lateral approach is recommended for use with the capitellocondylar type of prosthesis in rheumatoid elbows with reasonably well-preserved bone stock.

Intraoperative monitoring of ulnar nerve function during replacement of the rheumatoid elbow via the lateral approach.

Neurography of the ulnar nerve was performed pre-, intra- and postoperatively in 8 arms of 7 patients with rheumatoid arthritis operated on with total elbow replacement via the lateral approach. Ulnar nerve decompression was performed in 4 elbows before implantation. A reduction in the amplitude of compound muscle action potential (CMAP) recorded from the abductor digiti minimi on stimulation of the ulnar nerve in the axilla, was observed during elbow dislocation at surgery in all patients, in 5 cases transiently and in 3 cases until the end of surgery. The ulnar nerve had been decompressed in all patients with lasting amplitude reduction. One of them had a mild sensory ulnar nerve palsy, while the other 2 had normal nerve function at the postoperative clinical examination. All 3 had a reduction in the amplitude of compound sensory nerve action potential (SNAP) and 2 of them also in CMAP amplitude at the postoperative neurographic examination. In patients with transient reduction during surgery, the CMAP amplitude quickly normalized on relocation of the elbow and both the SNAP and the CMAP were preserved at the postoperative neurographic examination. The authors conclude that dislocation of the laterally approached elbow carries a risk of ulnar nerve injury, which is not prevented by decompression of the ulnar nerve, but frequent relocation of the elbow during surgery seems important. It is suggested that the ulnar nerve should not be decompressed routinely, and that the dislocated elbow should be frequently relocated.

Wound healing after total elbow replacement in rheumatoid arthritis. Wound complications in 50 cases and laser-Doppler imaging of skin microcirculation.

Wound healing complications, predisposing to deep infection, are common following prosthetic surgery of the elbow. 50 capitellocondylar elbow prostheses were inserted, using a lateral approach, in 42 patients with rheumatoid arthritis. The first 5 elbows were immobilized postoperatively for 5 days and the following 45 elbows for 12 days, because of delayed wound healing in 2 of the first 5 elbows. No wound healing complications were recorded in elbows immobilized for 12 days and elbow motion was not compromised. 5 elbows were investigated with laser-Doppler imaging (LDI) technique, both pre- and postoperatively. Postoperative LDI values were considerably higher than preoperative ones, indicating no impairment of local skin microcirculation. The authors conclude that the lateral approach is safe to use in prosthetic surgery on the elbow. Early mobilization can delay wound healing, but this can be prevented by 2 weeks of postoperative immobilization.

Comparison of talonavicular dowel arthrodesis utilizing autogenous bone versus defatted bank bone.

A simple dowel arthrodesis of the talonavicular joint in an early stage of destruction can reduce pain and prevent the development of valgus deformity in the rheumatoid hindfoot. Previously, we used autogenous dowels made from the iliac crest. In order to facilitate the operation and to get a better fitting dowel, we tried defatted cancellous allograft dowels from which marrow tissue had been removed. The dowels were prepared from femoral heads in our surgical bone bank. At operation, the dowels were embedded in fresh marrow aspirate from the iliac crest and the arthrodeses were stabilized with a staple. Results were evaluated by clinical examination and radiography. The results of four patients were compared with an earlier study of eight patients using autogenous dowels taken from the iliac crest. With both techniques, the patients were relieved of pain in the talonavicular joint, but some had pain from other hindfoot joints. With autogenous dowels, all eight patients healed with radiographic bony union, but with allogenous dowels, the four patients developed fibrotic nonunion. The results indicate that talonavicular arthrodesis should be made using only autologous dowels.

Talonavicular arthrodesis in the rheumatoid foot.

Arthrodesis of the talonavicular joint with a cylindrical dowel was performed in 19 feet in 17 rheumatoid patients with arthritic destruction of the talonavicular joint, but without fixed hindfoot deformity. Osseous union was achieved in 12 feet, but all patients experienced pain relief and no foot showed progressive valgus deformity of the hindfoot during follow-up. Staple fixation seemed to promote osseous union. The procedure, easy to perform and requiring only 6 weeks of immobilization, may, in the absence of fixed hindfoot deformity, supersede triple arthrodesis in rheumatoid patients with hindfoot arthritis.

Fracture of the tibial tray of the PCA knee. A case report of early failure caused by improper design.

Knee prostheses with metal backing of the polyethylene tibial component are nowadays used almost universally. Eight cases of fracture of the metal tray are reported in the literature. We present a case in which the failure could be expected because of improper design of the tibial tray.

Failure of the Wadsworth elbow. Nineteen cases of rheumatoid arthritis followed for 5 years.

Nineteen Wadsworth elbow prostheses were inserted in 15 patients with rheumatoid arthritis during the 4 years 1979-1982. The patients were followed prospectively for an average of 5.7 years. Five elbows were revised because of mechanical loosening and one because of deep infection. Of the remaining 13 prostheses, there were radiographic signs of loosening in 8 cases.

Hip socket wear due to component mismatch. A case report.

A total hip replacement with loosening of the femoral component was revised. The original femoral component with a 35-mm head was exchanged for one with a 32-mm head. The mismatch caused extensive wear of the acetabular component. The importance of preoperative planning in revision surgery is stressed.

Nerve lesions after total hip replacement.

In a prospective study 50 extremities in 46 patients with total hip replacement (THR) were examined clinically and with EMG preoperatively and 4 weeks postoperatively. Four patients with normal preoperative findings had electromyographical evidence of nerve lesions postoperatively and three of these had clinical symptoms; one patient had no clinical symptoms. Ten patients with normal pre- and postoperative findings were re-examined 1 year after the operation and still found to be normal. In 150 records of patients with THR reviewed retrospectively, only one doubtful case of nerve lesions was found.

Pre-operative and postoperative scintimetry after femoral neck fracture.

In 22 patients with femoral neck fractures 99mTc-MDP scintimetry was performed before operation and again shortly after operation; in 17 of these patients the investigation was repeated after four months. Six patients with increased uptake in the femoral head before operation and eight with decreased uptake had similar results at the first postoperative investigation. Of eight patients with an intermediate uptake before operation, two showed increased and six decreased femoral head uptake after operation. It is concluded that for the patients in the group with intermediate femoral head uptake before operation, the operative procedure probably influenced the postoperative blood supply of the femoral head.

Meniscectomy. A comparison of two series treated as outpatients and inpatients.

A total of 129 patients were operated on for meniscus lesion in the knee joint. Of these, 64 were operated as outpatients and 65 as inpatients. The outpatients reported to the operation department in the morning and left the hospital in the evening of the same day, after the operations. The inpatients were admitted to the hospital the day before the operation and were discharged 1--3 days after the operation. Objective postoperative findings, sick-leave periods and the number of visits to the outpatient clinic show no differences between the groups. The end result in the two groups is the same. This investigation also shows that it is possible to operate on patients with meniscus injury as outpatients without increased discomfort for the individual and without medical risks. Thus expensive nursing resources are released for other groups requiring more nursing care.