Use of recombinant human erythropoietin in two-stage total knee arthroplasty for infection.

A multicenter prospective study was conducted to determine whether epoetin alfa could be used to lower transfusion requirements after two-stage exchange arthroplasty for infection. Forty-one consecutive patients undergoing successful two-stage exchange arthroplasty for an infected total knee arthroplasty were enrolled in a prospective study. Epoetin alfa (40,000 units) was administered subcutaneously after prosthesis resection and antibiotic spacer placement. Although there was no difference in the hemoglobin levels before resection arthroplasty or on postoperative Day 3 between the study group and the control group, hemoglobin levels before reimplantation were higher in the patients who received epoetin alfa (12.4 mg/dL; range, 9.3-15.1 mg/dL) compared with the control group (11.3 mg/dL; range, 8.1-14.4 mg/dL). Average increase in hemoglobin level in the interval between stages was higher in the treatment group (3.2 mg/dL; range, -0.7-6.8 mg/dL) than the control group (1.7 mg/dL; range, -1.9-6 mg/dL). The transfusion rate decreased from 83% of patients in the control group to 34% in the study group during reimplantation. In addition, overall incidence of transfusion for either stage improved from 89% in the control group to 44% in the patients treated with epoetin alfa. Perioperative epoetin alfa statistically increased the hemoglobin levels and decreased transfusion rates for patients undergoing two-stage revision for infected total knee arthroplasty.

Long-term results of total knee arthroplasty after the use of soft tissue expanders.

The success of total knee arthroplasty can be jeopardized by poor wound healing. In the current study, the results of knee arthroplasty after soft tissue expansion were reviewed retrospectively in 27 patients (29 knees) at risk for problematic healing. The incidence of wound complications was recorded for all patients after the expansion procedure and the arthroplasty. A Knee Society score also was calculated at the latest evaluation. Minor wound complications occurred after 21% (six of 29) of the tissue expansion procedures and after 18% (five of 28) of the subsequent arthroplasties. One major wound complication occurred during tissue expansion necessitating abandonment of the planned arthroplasty. No major wound complications occurred in those patients who underwent knee arthroplasty. At an average followup of 34.4 months, the average Knee Society score was 83.7 points. The results of the current study show that the technique of soft tissue expansion before total knee arthroplasty in patients at high risk for wound healing problems can successfully prevent catastrophic wound complications after the arthroplasty procedure and can avoid the need for disfiguring soft tissue reconstructions.

Debridement arthroscopy. 10-year followup.

The treatment of osteoarthritis of the knee is a difficult problem. In the senior author's opinion, nonaggressive arthroscopic debridement of the knee is an effective procedure to relieve pain and restore function in patients with osteoarthritis of the knee. A subjective telephone interview of patients done 10 or more years after arthroscopic debridement evaluated the long term results of this treatment in patients with osteoarthritis of the knee. The patients all were candidates for total knee replacement who selected arthroscopy as a temporizing procedure. Of the 191 knees in patients undergoing arthroscopic debridement, 77 patients (91 knees) were contacted for followup. Sixty-seven percent of the 91 knees did not have total knee arthroplasty at an average of 13.2 years followup. The Tegner activity score averaged 3.5 and patient satisfaction averaged 8.6 on a 0 to 10 scale. Twenty-one patients (30 knees) or (33%) had total knee arthroplasty at an average of 6.7 years. Seven of these had total knee arthroplasty within 2 years of arthroscopic debridement. Six of these seven knees had Outerbridge Grade 4 articular cartilage changes and clinically significant meniscus tears. Seven of the 19 knees (37%) with Outerbridge Grade 4 changes in 80% of one knee compartment did not require total knee arthroplasty after greater than 10 year followup. The difficulties in long term followup in this patient population is evident, yet the number of patients who had a functional lifestyle after arthroscopic debridement was notable.

Blood management in two-stage revision knee arthroplasty for deep prosthetic infection.

Treatment of infected total knee arthroplasty requires aggressive management to treat the infection and restore joint function. For patients with infected knee arthroplasties, a two-stage procedure is used that involves resection of the joint and placement of an antibiotic impregnated cement spacer followed by implantation of a new prosthetic 6 weeks later. Patients undergoing the two-stage procedure typically endure high allogeneic blood transfusion rates (82% to 88%) and progressive anemia because the two surgeries are spaced closely and because the infection precludes the use of alternatives to allogeneic blood. Records were reviewed of 75 patients who underwent two-stage total knee arthroplasty to characterize perioperative hemoglobin levels and blood transfusion needs in this patient group. Although transfusions were administered only when warranted by clinical symptoms and were not based on predetermined hematologic values, 62 (82%) patients received a mean of 2.3 units of blood at first-stage surgery, and 60 (80%) patients received a mean of 2.1 units of blood at the second stage. Overall, only 12% of patients did not have allogeneic blood transfusion. At the first stage before resection, mean hemoglobin concentration was 11.6 g/dL and reached a mean nadir of 8.6 g/dL 3 days after surgery. At the second stage before reimplantation, hemoglobin concentration averaged 11.1 g/dL and reached a mean nadir of 8.2 g/dL 3 days after surgery. After the first stage, allogeneic blood transfusion failed to improve postoperative hemoglobin levels enough to prevent transfusions associated with the second-stage. Patients undergoing two-stage total knee arthroplasty have anemia, and a substantial proportion of these patients require allogeneic blood transfusion at both stages. Thus, novel blood management practices are required to improve hemoglobin levels and reduce allogeneic transfusion rates in this patient population.

Role of the posterior cruciate ligament in total knee arthroplasty.

Since the introduction of condylar knee designs, total knee arthroplasty has become a remarkably successful and durable procedure. Improvements in instrumentation systems, fixation, and patellar resurfacing have been widely applied and have made total knee arthroplasty a reproducible procedure. The appropriate role for the posterior cruciate ligament in total knee arthroplasty, however, continues to be debated. Proponents of both cruciate substitution and cruciate retention can point to excellent clinical and radiographic results in the literature with knee designs of both types. Recent research findings in the areas of biomechanics, histology, and gait analysis, combined with refinements in intraoperative technique, have further sharpened the focus of the posterior cruciate ligament debate.

Natural history of uncorrected flexion contractures following total knee arthroplasty.

Over a 2-year period, 29 patients were identified that had preoperative flexion contractures less than 30 degrees and were not fully corrected to neutral following total knee arthroplasty. They were followed after surgery at 3, 6, and 12 months, and yearly thereafter with complete clinical and roentgenographic examinations to determine the natural history of the flexion contracture and its effect on the clinical outcome. The mean age of the 10 women and 19 men was 66 years (range, 47-80 years). The mean preoperative flexion contracture was 11 degrees (range, 5 degrees-30 degrees). The mean follow-up period was 33 months (range, 24-60 months). The mean values of the flexion contractures at each follow-up period were; immediately after surgery, 10.5 degrees; at 3 months, 5 degrees; at 6 months, 2 degrees; at 12 months, 1 degree; and at 24 months, 1 degree (P < .0001). Resolution of the flexion contracture did not vary between patients under and over the age of 65 years. There was no statistically significant difference in the residual flexion contracture when knees with preoperative contractures from 0 degrees to 14 degrees and 15 degrees to 30 degrees were compared. The clinical outcome was not affected by the residual flexion contracture after 6 months of follow-up evaluations. Significant improvements can occur after surgery with rehabilitation, and it appears that complete intraoperative correction is not necessary. There appears to be no difference in the natural history of flexion contractures with regard to age or severity up to 30 degrees.

Myositis ossificans traumatica.

Myositis ossificans is a benign condition of heterotopic bone formation. It is a generalized term for four separate clinical entities. Although not a rare disease process, diagnosis often remains difficult. This article reviews the various forms of myositis ossificans, as well as the pathology, diagnostic tests, and treatment options.

Blood loss in total knee arthroplasty.

Over a two-year period, 112 consecutive primary total knee arthroplasties (TKA) were performed according to a standard protocol and were evaluated to determine the effects of intraoperative tourniquet deflation, suction drainage, and immediate continuous passive motion (CPM) on blood loss and the need for blood transfusions. It has been reported that these measures lead to increased morbidity following TKA. The tourniquet was deflated before closure, hemostasis was obtained, and two suction drains were placed for 24 to 48 hours. CPM was started immediately, and continued for a mean of seven days. Serial hematocrits (Hct) were obtained. Mean age of the 64 males and 48 females was 65 years. The diagnosis was osteoarthritis in 86% and rheumatoid arthritis in 14%. Seventy-three percent of the prostheses were cemented and 27% were uncemented. The mean tourniquet time was 104 minutes and the mean length of surgery was 140 minutes. Blood loss measured at surgery averaged 222 ml. Total calculated blood loss averaged 794 ml, but was higher for patients with a cemented versus uncemented prosthesis (p less than .05), and males versus females (p less than .005). It was not related to diagnosis, tourniquet time, or length of surgery. Of the 38% of patients requiring a transfusion (mean, 2.2 units), there was not a significantly greater drop in Hct (from 36.6 to 26.5; change, 10.1) when compared to patients not receiving a transfusion (from 43.1 to 32.5; change, 10.6). Therefore, the need for transfusion was related to preoperative Hct and not the intraoperative or postoperative blood loss.(ABSTRACT TRUNCATED AT 250 WORDS)