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.

Wrist arthrodesis for failed wrist implant arthroplasty.

Thirteen wrist arthrodeses were performed for failed wrist implant arthroplasties between 1984 and 1992. Twelve patients were available for review, with an average follow-up period of 28 months. The original arthroplasties consisted of 8 silicone implants and 4 metal-plastic total wrist implants. The surgical method involved a tricortical iliac bone graft and an intramedullary Steinmann pin. There were 7 excellent results, 4 good results, and 1 poor result. All but 1 patient had markedly improved function with no or mild pain. Seven patients had solid fusions and 5 patients had pseudarthroses. Four pseudarthroses occurred at the graft-metacarpal junction and 1 occurred at the graft-radius junction. Each patient with a solid fusion had an excellent result. All graft-metacarpal pseudarthroses were painless and did not limit the patients' activities. There were 17 complications in 9 patients. Wrist arthrodesis can be a successful salvage procedure for failed wrist implant arthroplasty in patients with rheumatoid arthritis. However, the complication rate can be high. Owing to the high incidence of distal graft-metacarpal pseudarthrosis, we recommend using more rigid fixation techniques in patients with failed wrist arthroplasties.

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.

Wear debris from bipolar femoral neck-cup impingement. A cause of femoral stem loosening.

The source of wear debris in total hip arthroplasty may occur at various interfaces: metal-ultra-high molecular-weight polyethylene bearings, metal-cement micromotion, bone-cement interfaces, and implant coatings. Wear-induced osteolysis may result in a spectrum of radiographic changes from radiolucent lines to massive osteolysis. Subsequent loosening of the implant may occur and revision may be difficult because of bone deficiencies. Impingement of the femoral neck on the acetabular component may result in polyethylene and/or metal debris, leading to early femoral stem loosening. The five cases presented, involving six hips, illustrate how bipolar cup-stem impingement may result in significant wear-induced femoral osteolysis.

Wrist arthrodesis for treatment of rheumatoid arthritis.

Eighty-seven wrist fusions using the technique of Millender and Nalebuff were reviewed in 79 patients with rheumatoid arthritis. Follow-up averaged 6 years and 97% of all patients had an excellent or good result. Pain was absent or mild in all patients after operation, and 95% of this patient population had improved hand function after wrist fusion. Wrist position averaged neutral in the lateral plane and 6 degrees ulnar deviation. Time to clinical fusion averaged 10.8 weeks. Complications were present in 23% of all cases, with half of these a result of symptomatic hardware. Carpal tunnel syndrome was seen after operation in five patients, all of whom had significant palmar carpal dislocation before surgery. A neutral position of the wrist with slight ulnar deviation is very functional and cosmetically acceptable for the patient with rheumatoid arthritis, even in bilateral fusions. Wrist arthrodesis for the patient with rheumatoid arthritis is a dependable procedure with a high degree of success and patient satisfaction.

Blood conservation in major orthopedic surgery.

During an eight-year period, intraoperative autotransfusion was performed in 1922 operations. There were 476 primary hip arthroplasties, 1017 revision hip arthroplasties, 339 spinal procedures, and 90 vascular cases. There were no known complications related to autotransfusion in any of the cases. With proper technique, red cell salvage is approximately 58% effective, and intraoperative blood loss can be reduced by that amount. The first four years' experience with the preoperative autogeneic blood program is as follows. Using a combined program of predonation and primary hip arthroplasty, 72% of the revision hip arthroplasties and 81% of the spinal instrumentations required only autologous blood. A combined program of autologous donation and intraoperative autotransfusion is an excellent alternative to allogeneic blood replacement and a means of eliminating transfusion-related disease.

Patellofemoral problems following total knee arthroplasty.

We reviewed 350 knee arthroplasties performed between 1977 and 1984 for patellar problems. Seventeen knees with four types of patellofemoral complications were found. The diagnosis in both the group of 350 and the study group of 17 knees was evenly distributed between rheumatoid arthritis and osteoarthritis. The complication rate was 4.9%. Follow-up ranged from one to nine years post-complication. Two knees had two different complications, providing a total of 19 complications with five loosenings, three fractures of the patella, one fracture of the patellar component, and ten subluxations or dislocations. Sixteen revision surgical procedures were performed on 11 knees. Six knees were managed nonoperatively. In the four knees with multiple surgeries, one of the complications was patellar subluxation or dislocation. Only one patient was dissatisfied with his result; however, this included both knees. Patellar complications continue to be recognized as a frequent cause of problems after total knee arthroplasty. We recommend nonoperative management of patellar fractures, revision of implant with loosening or component fracture, and careful selection of realignment procedures.

Competitive enzyme-linked immunosorbent assay for Treponema pallidum antibodies.

A competitive enzyme-linked Treponema pallidum immunosorbent assay (CETPIA) was compared with the standard serological tests for syphilis. Of 3081 serum samples submitted, 2883 gave negative results in the CETPIA and the routine screening tests. Positive results were obtained in the CETPIA and in one or more of the specific treponemal tests with 115 samples. Discrepancies in the results of the CETPIA and standard serological tests were found with 83 serum samples, most of these were attributed to biological false positive reactions in the Venereal Disease Research Laboratory (VDRL) test. CETPIA may have a role in the serological diagnosis of syphilis.

Femoral revision total hip arthroplasty using a long-stem femoral component. Clinical and radiographic analysis.

Proximal femoral bone stock deficiencies exist during many femoral revision arthroplasties, thus providing inadequate support and fixation for conventional-length cemented femoral components. The authors analyzed the long-term clinical and roentgenographic results of 165 hips requiring femoral revision arthroplasty with a long-stem femoral prosthesis. Intraoperative complications occurred in 23% of hips, with femoral perforations in 16% and femoral fractures in 5%. Of 110 hips with at least 5 years of follow-up study (average, 6.7 years), functional ratings were graded excellent in 34%, good in 36%, fair in 17%, and poor in 13%. Failures occurred in 17 hips (12%) and were attributed to aseptic loosening (11 hips), femoral component fracture (2), femoral shaft fracture (1), and sepsis (3). Symptomatic trochanteric separations occurred in 16% of hips. Rerevision or resection arthroplasty was required in 7 hips (5%) and recommended for another 10 hips (7%). Cemented long-stem femoral components (versus cemented conventional-length stems) decrease the extent and progression of femoral lucencies, thereby lowering the incidence of mechanical failures and improving long-term functional results in cemented femoral revision arthroplasty.

Pressure-heat treatment of meat: Changes in myofibrillar proteins and ultrastructure.

The effects on muscle of a combined pressure-heat (P-H) treatment that overcomes myofibrillar toughness have been investigated using SDS gel electrophoresis and electron microscopy. Densitometer scans of polyacrylamide gels of muscle extracts revealed that P-H treatment caused greater degradation of connectin than did heat treatment alone. Breakdown of connection by P-H treatment was reduced in muscle that had been injected with the protease inhibitor pepstatin. However, pepstatin treatment did not reduce the effectiveness of P-H treatment for tenderizing meat, as would be expected if connectin was responsible for myofibrillar toughness. P-H treatment resulted in an increase in the intensity of a peak with M(r) ∼ 150 000, but this peak was also produced by non-tenderizing pressure treatments. The ultrastructural studies revealed that P-H treatment disrupted the thick and the thin filaments, leaving voids at the M-line region. It is suggested that P-H treatment achieves most of its effect by an irreversible disaggregation of the myosin of thick filaments.

Nonconstrained total elbow arthroplasty.

Twenty-eight nonconstrained capitellocondylar elbow offhroplasties were performed in 23 patients. The clinical criteria were intractable pain in a joint with radiologic destruction from rheumatoid arthritis. Patients were examined at an average of 35 months postsurgery with the Ewald scoring system. Results were satisfactory in 24 elbows (86%) and unsatisfactory in four (14%). Pain relief and functional improvement were dramatic. The average arc of motion increased from 88 degrees preoperation to 101 degrees postoperation. There was an average 33 degrees residual flexion contracture. There was one failure from loosening, but no radiographic or clinical loosening was detected in the remaining patients. Postoperative dislocation was the most frequent complication, occurring in four cases. One dislocation required revision while three stabilized following four weeks of immobilization. There were two remote infections occurring two and five years postoperation. Although complications are frequent, this is a predictably successful procedure in properly selected patients.

Revisions with cemented long-stem prostheses.

The purpose of this paper was to describe the surgical techniques for removing and replacing failed femoral prosthetic components. We have also tried to develop a rationale for the use of long-stem femoral components to maximize femoral fixation and to protect the femur from future stresses. It is our recommendation that the revision femoral implant should be anchored into at least 100 mm of healthy bone distal to any previous metal, cement, perforation, or fracture. The surgical techniques described are demanding and require careful practice and preparation on the part of the surgical team. Distal intermedullary plugging and precise biphased cementing techniques are advocated to achieve microinterlock in the distal femur and to provide bulk filling of the proximal femur.

Binding of comminuted meat: Effect of high pressure.

Patties prepared from comminuted meat were pressure-treated at up to 150 MPa at 0-3°C and the cohesion between meat particles in the cooked patty investigated from tensile strength measurements. Pressure treatment increased tensile strength, the magnitude of the increase depending upon the intensity and duration of pressure treatment, the concentration of salt in the patty and pH value. The effect was most pronounced in patties of pH 5 to 6 and with 1% salt in the aqueous phase. Under these conditions cooking losses were reduced. When compared with the effect of addition of 0·5% tetrasodium pyrophosphate in a patty with 1% salt, pressure treatment retained its effect at lower pH values.

Selective hindfoot arthrodesis in rheumatoid arthritis.

Rheumatoid arthritis that involves the hindfoot is disabling because it affects the patient's ability to walk. Fifteen patients with ankle pain who demonstrated isolated hindfoot arthritis clinically and radiographically underwent 19 selective hindfoot arthrodeses. At followup averaging 3 ½ years, results were rated good in 16, fair in four, and none were rated poor. Selective hindfoot fusion is effective in relieving pain and restoring the foot to ambulatory status.

Medical and surgical treatment of the septic hip with one-stage revision arthroplasty.

Sepsis of the hip, particularly associated with total hip arthroplasty, can be treated successfully by an aggressive antimicrobial and surgical approach to accomplish a one-stage revision. Although this is a very acceptable alternative to Girdlestone arthroplasty, 13% (6 hips) of the septic total hip revisions failed. The possibility of hematogenous seeding of the total hip should be recognized by all health care professionals. Aggressive treatment of infections or potential infections is mandatory.

Evaluation of the role of the Treponema pallidum immobilisation test in Britain.

After specimens of sera from 100000 patients had been screened by a reagin and Treponema pallidum haemagglutination assay (TPHA) 2.7% required further examination. The fluorescent treponemal antibody-absorption (FTA-ABS) test confirmed either a negative or positive TPHA result in 95% of the samples, so that no further investigations were required. This accounted for 99% of the specimens submitted to the laboratory. Repeat tests on a further sample resolved many of the remaining discrepancies. Only 0.05% of patients, in whom repeat tests confirmed a positive TPHA but a negative FTA-ABS result, benefited from a TPI test.