The impact of familial environment on depression scores after genetic testing for cancer susceptibility.

The associations between characteristics of family relationships and family trends in cancer worry and the psychological adjustment of recipients of genetic testing for cancer susceptibility were investigated. Data provided by 178 individuals from 24 families with Lynch syndrome who participated in a cohort study investigating psychological and behavioral outcomes of genetic testing were used. Responses from multiple family members were aggregated to construct family trends representing norms and departure from norms in cancer worry. Lower perceived family cohesion at baseline and decrease in this variable at 6 months after receipt of test results were associated with higher depression scores at 12 months. More variability in cancer worry among family members at baseline was also associated with higher depression scores at 12 months. Increase in family conflict was associated with decrease in depression scores among individuals from families with higher levels of cancer worry on average and less variability among the members. Family relationships and family trends in levels of cancer worry may play important roles in the psychological adjustment of genetic test recipients. The findings highlight the complexity of familial environment surrounding individuals that undergo genetic testing and suggest the benefits of considering these factors when providing genetic services.

Single-stage, bilateral, cementless total hip arthroplasty.

Single-stage, bilateral, cementless total hip arthroplasties were performed in 92 patients (184 arthroplasties) between March 1984 and December 1989. The clinical and radiographic findings were retrospectively evaluated, and the effects of weight bearing on the clinical and radiographic outcomes of the patients' prostheses were assessed. With a follow-up period ranging from 24 to 77 months (average, 44 months), the postoperative Harris hip scores averaged 94.6. Radiographic assessment at the most recent follow-up examination showed that 70% of the femoral components were optimally fixed, 26% were stable, and 4% had failed. Ninety-six percent of the acetabular components were optimally fixed. There were six acetabular component failures. These results indicate that single-stage, bilateral, cementless total hip arthroplasty can be performed without compromise to either hip if initial fit is achieved in both the metaphyseal and diaphyseal portions of the femur. Moreover, weight bearing did not adversely affect the initial stability and possible bone ingrowth, further implicating initial rigid fixation as paramount among the factors influencing the amount of ingrowth into the prosthesis.

Dislocation following primary posterior-stabilized total knee arthroplasty.

From 1981 through 1991, 3,032 primary total knee arthroplasties were performed using the Insall-Burstein Posterior Stabilized Condylar Prosthesis (IB-I, IB-II, and IB-II modified) (Zimmer, Warsaw, IN). Fifteen posterior dislocations occurred: 4 with the IB-I system occurring 2 or more years after surgery, 10 with the IB-II system (8 occurring 6 months after surgery and 2 occurring 2-3 years after surgery), and 1 with the IB-II modified system occurring 9 months after surgery. Statistically significant differences for the rate of dislocation between both the IB-I and IB-II modified arthroplasties versus the IB-II arthroplasties were found (P < .001). In an attempt to identify a cause for these dislocations, the authors retrospectively assessed the 15 dislocated cases with respect to sex, age, weight, height, preoperative and postoperative Hospital for Special Surgery scores, preoperative and postoperative alignment, preoperative versus postoperative reconstruction dimensions, patellar thickness and height, and postoperative flexion and compared the results with those patients who did not experience dislocation. Possible etiologies and mechanisms of dislocation were sought. There were no significant differences between the control and study groups for any variable assessed, with the exception of postoperative flexion, which averaged 118 degrees for the study group and 105 degrees for the control group (P < .001). Conservative management was successful in 11 cases. In September 1988 the IB-II system was introduced; modification of the tibial insert was made in January 1990.(ABSTRACT TRUNCATED AT 250 WORDS)

Delayed wound healing and nutritional deficiencies after total hip arthroplasty.

Ninety-two patients (103 hips) treated with total hip arthroplasty (THA) were assessed before and after operation to determine nutritional status and any correlation with delayed wound healing. Parameters indicative of nutritional status (serum albumin and serum transferrin) were assessed, along with immunologic and anthropometric parameters. Delayed wound healing complicated 34 of the 103 (33%) THAs. The preoperative serum transferrin levels were significantly lower for patients who subsequently developed wound-healing complications. Patients treated with single-stage, bilateral procedures had substantially lower postoperative serum transferrin and serum albumin levels and significantly higher incidences of delayed wound healing (64%) than patients who had single joint procedures (25%). Only preoperative serum transferrin levels showed significant value in predicting which patients would have delayed wound healing. None of the other serologic variables, including serum albumin and total lymphocyte count, proved to be a predictor of delayed wound healing. The preoperative assessment of three variables--serum transferrin value, bilateral procedure, and patient age--resulted in the correct prediction of wound healing outcome in 79% of the patients. This preoperative information, in combination with postoperative monitoring of serum transferrin and albumin levels, should alert the physician to the approach of a malnourished state. The malnourishment is attributable to heightened demands on the body's basal energy requirements after major orthopaedic surgery and can increase morbidity and prolong the hospital stay.

Managing chronic dislocated total hip arthroplasty.

Dislocation is the most common complication occurring after total hip arthroplasty. Thus, managing the patient with chronic dislocation will continue to be a challenging problem facing joint replacement surgeons. It is believed that several factors contribute to chronic dislocation, ie, surgical approach, inadequate restoration of soft-tissue tension, prosthetic design, and orientation of the prosthetic components. Methods of constraint, both internal and external, are valuable adjuncts available to the joint replacement surgeon that, with certain limitations, result in successful reduction of repeated dislocation and lead to initial stability of the hip joint.

Clinical and radiographic experience with a hydroxyapatite-coated titanium plasma-sprayed porous implant.

Recent efforts to improve the interface between implant and bone have involved the use of bioactive materials, specifically hydroxyapatite (HA). HA coatings applied to implants have shown excellent clinical results at 2 years. There have been no radiolucent lines around the HA-coated implants. The long-term strength of the HA coating-substrate bone interface remains a concern as osseointegration of the HA appears to be a consistent phenomenon. This can lead potentially to an interruption between the substrate itself and the osseointegrated coating.

Clinical and radiographic experience with a hydroxyapatite-coated titanium plasma-sprayed porous implant.

The use of bioactive materials recently has given increased hope to achieving adequate fixation in cementless total hip arthroplasty. Hydroxyapatite, one of the most biocompatible materials known, interacts with surrounding bone and forms a chemical bond with the bone, rather than a mechanical microinterlock via bioingrowth. There is direct bonding of bone and the hydroxyapatite, as opposed to the development of an intervening fibrous tissue layer between the implant and the bone. Recent use of hydroxyapatite-coated implants has shown that very strong bonds with living bone occur within a relatively short period of time. In this article, 53 primary, cementless total hip arthroplasties, all performed by or under the direction of a codesigner of the prosthetic system, are reviewed. The average age of the patients at arthroplasty was 51 years; the follow-up period averaged 17 months. The preliminary results achieved in this group of patients were compared with those achieved in 50 patients who received the identical porous coated implant without hydroxyapatite. The preoperative diagnoses, Harris Hip Scores, and patient demographics were similar for both groups. A comparison of clinical results showed that patients with the hydroxyapatite-coated femoral implants experienced more rapid clinical improvement in the first 6 to 10 weeks after arthroplasty than the patients with the identical prosthesis without hydroxyapatite coating. Radiographically, in the hydroxyapatite group, there have been no femoral or acetabular component failures, and no instances of femoral component subsidence or acetabular component migration.

An evaluation of the efficacy of postoperative blood salvage after total joint arthroplasty. A prospective randomized trial.

The efficacy of a postoperative blood salvage system was assessed in 239 consecutive patients undergoing total knee or total hip arthroplasty. Patients were randomly allocated to either a control group using a standard drainage system or to the study group using the Solcotrans blood salvage canister. The median amount of homologous blood required after operation by the study group was reduced by 74% from the amount required by the control group (mean, 67 ml vs 256 ml, respectively; P less than .0001). Thirteen percent (13%) of the study group required postoperative homologous blood transfusions, as compared to 39% of the control group (P less than .0001). Additionally, patients in the study group had higher hemoglobin levels beginning on the first postoperative day. This study indicates that a postoperative blood salvage system safely and effectively reduces the amount of homologous blood required and sustains higher hemoglobin levels after operation.

Knee manipulation following total knee arthroplasty. Analysis of prognostic variables.

In an effort to identify prognostic indicators for knee manipulation, the authors retrospectively reviewed the records of 60 osteoarthritic patients with posterior stabilized knee implants who required manipulation (94 knees) between January 1984 and December 1986. They also studied the records of 28 consecutive osteoarthritic patients who were implanted with 41 posterior stabilized knees between January 1985 and September 1985 whose knees did not require manipulation (control group). In both patient groups the following parameters were assessed and compared: overall knee alignment, joint line elevation, anterior to posterior (AP) dimension of the knee, AP placement of the tibial component, patellar height, obesity, age, preoperative flexion, time of manipulation, single vs bilateral knee implants, final flexion, final Hospital for Special Surgery (HSS) score, and the development of heterotopic ossification. The findings of this study showed that an increase in the AP knee dimension by 12% or greater was a critically independent variable that significantly predisposed patients to manipulation. They also show that quadriceps adhesions were another major factor leading to manipulation, and that rupturing of these adhesions led to an increase in heterotopic ossification. This review also indicated that 3 months after knee arthroplasty was a significant time for evaluation because knee flexion and HSS score at this point in the patient's recovery positively correlated with the final HSS score.

The efficacy of suction drains after routine total joint arthroplasty.

A prospective study of thirty-eight patients (seventy-six knees) who had had a primary bilateral total knee replacement and twelve patients (twenty-four hips) who had had a primary bilateral total hip replacement was conducted to assess the effect of postoperative suction drainage on wound-healing. A suction drain was placed on each patient's right operative wound, while no drains were used on the left. Otherwise, the same operative technique and method of closure were used in all wounds. Statistical analysis of the results showed no difference between the two sides with regard to the incidences of swelling or persistent drainage. Return of active function of the quadriceps and of range of motion of the knee in patients who had had a total knee replacement was also unaffected by the use of suction drains. We concluded that the routine use of suction drains for wounds is unnecessary after uncomplicated total joint arthroplasty.

Preliminary report on the S-ROM constraining acetabular insert: a retrospective clinical experience.

The incidence of dislocation after total hip arthroplasty is significantly higher after revision and in patients with neuromuscular or other complications. To prevent dislocation, 55 patients with multiply revised total hip arthroplasties, unstable hips, and neuromuscular and/or neurologic conditions associated with total hip arthroplasty received implants with the S-ROM constraining acetabular insert. With an average follow up of 30.2 months, 50 patients have not experienced redislocation after insertion. Before S-ROM, our dislocation rate in 176 revision total hip arthroplasties was 19%, but is now 4.5% (P less than .001).

A comparison of intramedullary and extramedullary alignment systems for tibial component placement in total knee arthroplasty.

Fifty-two primary total knee arthroplasties (TKAs) using an intramedullary tibial jigging system to obtain ideal tibial alignment (90 degrees +/- 2 degrees) were compared with 62 TKAs using an extramedullary tibial jigging system. The Insall-Burstein total knee system was used in all cases, and all femoral components were positioned with extramedullary jigs. Postoperative evaluation consisted of a standing, hip-to-ankle anteroposterior roentgenogram and measurement of the following angles: (1) femorotibial, (2) tibial component, (3) femoral component, and (4) mechanical axis. Ideal tibial component alignment using the intramedullary system was statistically superior to alignment achieved with the extramedullary system. All other angle comparisons showed no statistical significance.

Impedance plethysmography for surveillance of deep venous thrombosis following early discharge of total joint replacement patients.

Between April 1988 and February 1989, 877 patients undergoing total hip (394 patients) and total knee (483 patients) replacement surgeries were given warfarin prophylaxis perioperatively and were tested with impedance plethysmography (IPG) approximately 17 days postoperatively (10 days post-discharge) in the outpatient office. There were 69 positive IPG tests (7.8%). Further assessment of patients with positive IPG results using duplex scanning or venography confirmed DVT in 25 of the 69 patients (3.6%) in the popliteal or thigh areas, and ruled out venous disease in 44 patients. All 25 patients were readmitted for anticoagulation therapy with intravenous (IV) heparin and warfarin. There were no cases of pulmonary embolus. This study indicates that IPG testing is a safe and effective method of screening patients for DVT and its potentially fatal sequela of pulmonary embolus. Furthermore, IPG testing has proven to be cost effective, as it is a relatively simple procedure which can be administered by non-professional personnel in the outpatient office setting.

Malignant fibrous histiocytoma after total hip arthroplasty. A case report.

Technical advancements in total joint arthroplasty have led to components of varied design and substance and to increased longevity of the implanted components. Along with increased longevity of the implants comes concern about how these synthetic materials affect the tissues of the host. Experimentally, several materials currently used in implantable components have been shown to be potentially carcinogenic. Clinically, 12 cases of malignancy have been reported previously in association with orthopedic implants; of these, four were malignant fibrous histiocytomas (MFH). This report describes an additional case of MFH occurring in a patient who had multiple hip arthroplasties over a period of 15 years. While 13 malignancies associated with orthopedic implants could certainly be coincidental in view of the vast number of implanted orthopedic devices, each incidence of malignancy associated with an implant should be considered significant in determining any meaningful trends and relationships.

Use of the Greenfield filter to prevent fatal pulmonary embolism associated with total hip and knee arthroplasty.

We inserted a Greenfield filter prophylactically in forty-two of approximately 4,000 patients who were about to have a total hip or knee replacement, or both, and who were at high risk for pulmonary embolism (Group I). The filter was implanted postoperatively in twenty-four additional patients who had thromboembolic complications or in whom anticoagulation was contraindicated (Group II). None of the patients in Group I and only one in Group II had a fatal pulmonary embolism. Use of the Greenfield filter is a safe, easy, and effective method of preventing fatal pulmonary embolism in selected patients: those who are at exceptionally high risk for thromboembolism, as a method of preoperative prophylaxis; those who have had a thromboembolism and in whom therapeutic anticoagulation is contraindicated; and those who have complications secondary to therapeutic anticoagulation.

Aseptic loosening in total hip arthroplasty secondary to osteolysis induced by wear debris from titanium-alloy modular femoral heads.

Since 1984, we have used components made of titanium alloy for total joint arthroplasty. Recently, two patients needed revision hip arthroplasty, approximately three years after the initial procedure, because of aseptic loosening secondary to severe osteolysis that had been induced by metallic debris. Although implants made of titanium alloy have many favorable qualities--most importantly, superb biocompatibility--the alloy is more susceptible to wear by particles of acrylic cement and tends to generate more polyethylene wear than do components made of stainless steel or chromium-cobalt. A new process of implanting ions has reportedly improved resistance to wear as well as fatigue properties and has enhanced the resistance to corrosion of the implants. Although, to our knowledge, only in vitro studies of this process have been reported to date, we recommend avoiding the use of components made of titanium alloy in which ions have not been implanted. We suggest considering the possibility of osteolysis secondary to appreciable metallic debris in patients who have aseptic loosening of titanium-alloy components that were not implanted with ions.

Intraoperative femoral fractures associated with cementless total hip arthroplasty.

Between 1982 and 1986, 56 femoral fractures associated with cementless total hip arthroplasty (THA) were evaluated and compared to a randomly selected cementless THA control group without fractures. Depending upon the femoral shaft location, these fractures were classified as Types I, II or III. There were 45 (80%) Type I, 9 (16%) Type II, and 2 (4%) Type III fractures. Patient evaluations were quantified using a modified d'Aubigne-Harris scoring system. Nonparametric statistical methodology was used for fracture and control group comparisons. Treatment protocols were divided into various modalities, depending upon fracture classification. Type I and Type II fractures have no long-term prognostic hazards associated with them (P greater than 0.1), while Type III fractures appear to have analogous clinical results (sample size was too small for statistical analysis).