Patellofemoral complications following total knee arthroplasty. Correlation with implant design and patient risk factors.

Results of 211 total knee arthroplasty operations were retrospectively evaluated to identify patients with knees at greatest risk for the development of patellofemoral complications and to determine the incidence and type of patellofemoral complications associated with different patellar implants. Patellofemoral complications occurred in 27 knees (12.8%). Osteoarthritis and obesity were associated with an increased incidence of patellofemoral problems. Significantly higher rates of patellofemoral complications were noted with metal-backed patellar implants and with patellar components implanted without cement. The loosening rate with cementless fixation was 13.5%. The lowest rate of patellofemoral complications following total knee arthroplasty was obtained with all-polyethylene domed patellar components implanted with cement.

Effect of surgical timing on recovery and associated injuries after anterior cruciate ligament reconstruction.

This study was undertaken to determine the optimal time after injury for arthroscopically assisted anterior cruciate ligament reconstruction using a double semitendinosus graft. We analyzed 87 patients. Time from injury to surgery was established as acute, subacute, or chronic; the three groups were matched. Meniscal damage and treatment were categorized. Chondral lesions were graded, postoperative parameters of motion, strength recovery, and stability were tabulated at 3, 6, 12, and 18 months. Complications were compared. Six percent of the patients with chronic knee injuries had two normal menisci at surgery, compared with 29% of the acute and subacute groups. Reparable tears were found in 37.8% of the knees. Chondral lesions were found in the tibiofemoral joint in 17% of acute, 7% of subacute, and 44% of the chronic knees. Postoperative motion recovery was significantly less at all time intervals for the acute group. Quadriceps strength recovery was slower in the acute knees. Stability was similar in all groups. Arthrofibrosis was found in 22% of acute, 0 subacute, and 12.5% of the chronic knees. Patellofemoral pain was noted in 17% of the acute, 0 of the subacute, and 9.3% of the chronic knees. This study showed that surgery done within 6 months of injury does not jeopardize the knee. Recovery after acute anterior cruciate ligament reconstruction is significantly slower than after subacute or chronic reconstruction.

Methylmethacrylate monomer and fat content in shed blood after total joint arthroplasty.

Twenty-five patients were prospectively evaluated to quantify levels of methylmethacrylate monomer and fat in systemic blood and in shed blood after total joint arthroplasty. Levels of methylmethacrylate monomer in systemic blood were measured at intervals after insertion of the prosthesis. Levels of methylmethacrylate monomer in shed blood were measured at intervals after insertion of the drain. Levels of fat in systemic blood were measured preoperatively and 30 minutes after insertion of the prosthesis. Levels of fat in shed blood were measured 60 minutes after insertion of the drain. No significant fat or methylmethacrylate monomer was noted in systemic blood. Levels of methylmethacrylate monomer in shed blood were highest five minutes after insertion of the drain. Levels of methylmethacrylate monomer in shed blood collected from the hip were significantly lower than levels in shed blood from the knee. Levels of shed blood from the hip and knee were undetectable six hours after insertion of the drain. Shed blood from the hips and knees contained fat particles of three diameters: fat particles less than 9 microns, 9-40 microns, and greater than 40 microns. The diameter of most of the fat particles in the shed blood was less than 9 microns. Fat particles less than 40 microns in diameter will not be removed by microaggregate screen filters 40 microns in diameter.

Ankle arthrodesis: a long-term study.

Few studies of ankle arthrodesis have assessed tarsal mobility. This study was performed to evaluate radiographically the effect of ankle arthrodesis on tarsal motion. Thirty patients (31 ankles) returned for clinical and radiographic examination, review of charts, and completion of questionnaire forms. Radiographs were evaluated for success of fusion, position of fusion, tarsal motion, hindfoot position, and subtalar and midtarsal arthritis. The median follow-up time was 7.0 years (range 2-20 years). Results showed that fusion was achieved in 22 patients (71%). The evaluation score based on the grading system of Mazur et al. correlated with success of fusion and patient satisfaction. However, no correlation existed between evaluation score and tarsal motion or position of fusion in the sagittal or coronal planes. Radiographic evaluation showed no significant difference between tarsal motion of the fused side and the unfused side. Tarsal mobility was not affected by ankle arthrodesis or by the techniques performed to achieve fusion.

Roentgenographic changes after arthroscopic meniscectomy: five-year follow-up in patients more than 45 years old.

Fifty knees with a mean follow-up time of greater than 5 years after arthroscopic meniscectomy were evaluated clinically and roentgenographically. Clinically, patients did well, with 98% patient satisfaction and 90% good or excellent results based on a modified Lysholm score. Although postoperative roentgenography showed some progression of Fairbank's changes in 61% with significant progression in 15% of knees, when changes in the nonoperative knee were considered, only 40% of operative knees showed progression, with only 4% of these knees showing significant progression. Normal results on preoperative anteroposterior roentgenography with the patient weight bearing and an anatomic tibiofemoral axis of greater than or equal to 4 degrees of valgus correlated with better long-term roentgenographic results.

Rotator cuff pathology. Arthroscopic assessment and treatment.

The results of 50 operative arthroscopies for impingement syndrome were reviewed. Preoperative arthrography was correlated with arthroscopic findings, which were pathologically graded. Results of arthroscopic surgery were assessed. Preoperative arthrography predicted 78% of the complete tears of the rotator cuff and only 25% of the partial tears. Of 40 shoulders followed for at least one year postoperatively, 87.5% had satisfactory results. Arthrography was not as reliable as arthroscopy in predicting partial tears of the rotator cuff. Arthroscopy permitted detailed intraarticular and subacromial visualization and classification of partial and complete tears of the rotator cuff. The early results of arthroscopic acromioplasty and debridement are comparable to those obtained with open operations.

Single-dose radiation therapy for prevention of heterotopic ossification after total hip arthroplasty.

Single-dose radiation therapy was prospectively evaluated for its efficacy in prevention of heterotopic ossification in patients at high risk after total hip arthroplasty. Thirty-one patients (34 hips) were treated between 1981 and 1988. Risk factors for inclusion in the protocol included prior evidence of heterotopic ossification, ankylosing spondylitis, and diffuse idiopathic skeletal hyperostosis. Patients with hypertrophic osteoarthritis or traumatic arthritis with osteophytes were not included. Operations on 34 hips included 19 primary total and 11 revision total hip arthroplasties and 4 excisions of heterotopic ossification. All patients received radiotherapy to the hip after operation with a single dose of 700 centigray. Radiotherapy is recommended on the first postoperative day. After this single-dose radiation treatment, no patient had clinically significant heterotopic ossification. Recurrent disease developed in two hips (6%), as seen on radiography (grades 2 and 3). This series documents a 100% clinical success rate and a 94% radiographic success rate in preventing heterotopic ossification in patients at high risk after total hip arthroplasty. Single-dose radiotherapy is as effective as other radiation protocols in preventing heterotopic ossification after total hip arthroplasty. It is less expensive and easier to administer than multidose radiotherapy.

Value of continuous passive motion in total knee arthroplasty.

Two methods of rehabilitation after 91 total knee arthroplasties in 74 patients were reviewed. Patients in each group were well matched for age, sex, and diagnosis. Forty-four knees in 39 patients were treated with conventional physiotherapy, consisting of 3 days of immobilization followed by a program of active assisted range-of-motion exercises. Forty-seven knees in 41 patients were placed in a continuous passive motion machine immediately after operation. Other aspects of preoperative, intraoperative, and postoperative care were identical in both groups. Patients in the continuous passive motion group were found to have a lower incidence of complications, especially of wound healing problems and thromboembolic disease. Analgesic use in patients in the continuous passive motion group was reduced. Straight leg raising was achieved slightly earlier in patients in the continuous passive motion group (4.9 days) compared with patients not treated with continuous passive motion (5.2 days). Although the range of motion of the knee at discharge from the hospital in patients in the continuous passive motion group was greater (91 degrees) compared with patients not treated with continuous passive motion (81 degrees), the range of motion in both groups at ultimate follow up was equivalent. However, when knee-rating scores were considered, patients treated with continuous passive motion averaged 9 points higher on a 100-point scale than patients not treated with continuous passive motion. In addition, the length of hospital stay for patients in the continuous passive motion group was 2.1 days shorter. We concluded that continuous passive motion was an effective adjunct to physiotherapy in the postoperative care of patients undergoing total knee arthroplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Arthroscopic synovectomy.

This study was undertaken to evaluate the efficacy of knee synovectomy with arthroscopic technique. Nineteen patients with 25 operated knees were studied. All 25 knees had 6-month follow-up, 21 knees had 2-year follow-up, and 14 knees were evaluated at least 4 years after operation. After operation, patients were evaluated using clinical data including pain relief, functional capacity, range of motion, recurrent synovitis, and presence of effusion. Preoperative as well as follow-up weight-bearing radiographs were also studied to assess the results of this procedure. At 6 months' postoperative clinical evaluation, 96% of patients showed good results. At 2 years, 90% of patients were considered to have good results, and at 4 years, 57% of patients continued to do well. Of those knees studied radiographically, 81% showed no progressive radiographic changes at 2 years and 61.5% showed no deterioration at 4 years. Clinical results correlated well with radiographic results. Arthroscopic synovectomy yielded results similar to those previously published for open synovectomy, with less operative and postoperative morbidity.

Arthroscopy update #5. Rehabilitation after arthroscopic lateral retinacular release.

This study compares postoperative quadriceps strength with functional results in a homogeneous population with isolated anterior knee pain and patellofemoral instability. Although several factors may interfere with the success of lateral retinacular release, this study suggests that poor quadriceps rehabilitation is the single factor preventing total return to athletic participation in patients with lateral subluxation. Many patients seem to adopt changes in life-style in order to accommodate weakened quadriceps and remain symptom free.

Arthroscopy of the painful dysfunctional total knee replacement.

Arthroscopy of the painful failed total knee arthroplasty has rarely been reported. The indications and results in terms of diagnosis and treatment of pathologic conditions in 13 knees after total knee arthroplasty are reviewed. Arthroscopy established the diagnosis for pain in 12 of 13 knees. Several problems were commonly encountered, including arthrofibrosis and fracture of the polyethylene button. Arthroscopic surgery for arthrofibrosis was successful in improving range of motion and knee-rating score.

Fracture of polyethylene of patellar component in total knee arthroplasty, diagnosed by arthroscopy.

Three reports of fracture of the polyethylene of the patellar component in total knee arthroplasty are presented. The value of arthroscopy in providing the correct diagnosis of this unusual complication of total knee arthroplasty is emphasized.

Heterotopic bone formation after hip surgery: prevention with single-dose postoperative hip irradiation.

From 1981 to 1986, 23 patients (24 hips) were treated with single-dose irradiation after hip surgery in an attempt to prevent heterotopic bone formation. All patients were at high risk for the development of heterotopic ossification because of the presence of heterotopic bone in either hip secondary to trauma or previous surgery, ankylosing spondylitis, or hypertrophic osteoarthritis. Thirteen patients (14 hips) underwent primary total-hip arthroplasty, and ten patients underwent revision total-hip arthroplasty or excision of heterotopic bone. The minimum follow-up period was 6 months. All patients were treated by means of a linear accelerator with a single dose of 700 cGy, calculated at midplane. Almost all treatments were given within 72 hours after surgery. Recurrent disease of Brooker grade II type developed in only one (4%) patient. This result is comparable with outcomes reported after fractionated courses of postoperative radiation therapy delivered over a period of 1 or 2 weeks. Postoperative hip irradiation with a single 700-cGy dose appears to be as effective as fractionated courses of radiation in the prevention of heterotopic bone formation in patients at high risk for the development of this complication.

Distal femoral varus osteotomy.

The results of twenty-three distal femoral varus osteotomies (in twenty-one patients) that were performed between 1977 and 1984 were evaluated. Fifteen osteotomies were done for osteoarthritis; three, for post-traumatic arthritis or deformity; three, for rheumatoid arthritis; and two, for renal osteodystrophy. The median age of the patients was fifty-six years (range, nineteen to seventy years). The length of follow-up averaged four years (range, two to nine years). The average tibiofemoral angle preoperatively was 18 degrees of valgus, which was corrected postoperatively to an average of 2 degrees of valgus. At follow-up, nineteen (83 per cent) of the twenty-three knees were rated as good or excellent according to The Hospital for Special Surgery knee score, which had improved from an average of 65 points preoperatively to 86 points post-operatively. Of the fifteen patients who had osteoarthritis (93 per cent), all but one had a good or excellent result. Most patients had no substantial improvement in the range of motion of the knee as a result of the operation. Eighty-six per cent of the patients expressed satisfaction with the outcome. We concluded that varus osteotomy of the distal part of the femur is a reliable and effective surgical procedure for the treatment of gonarthrosis associated with valgus deformity due to osteoarthritis or trauma. We do not recommend its use in patients who have rheumatoid arthritis or in those who have inadequate motion of the knee before the operation.

Cartilaginous Avulsion of the Tibial Eminence and Anterior Cruciate Ligament in a Six-Year-Old Child.

In brief: This case report describes an avulsion fracture of the anterior cruciate ligament in a child. Because it was not initially completely reduced, it resulted in limitation of motion. The authors emphasize that even if initial x-rays appear normal, further investigation with examination under anesthesia, stress x-ray, arthrography, and arthroscopy should be considered to prevent permanent knee dysfunction.