Arthroscopic debridement for osteoarthritis of the knee: predictors of patient satisfaction.

A retrospective review of 204 knees with osteoarthritis debrided arthroscopically was carried out to determine possible predictors of patient satisfaction with the outcome of their procedure. Knees were divided into three groups based upon the alignment on a standing anteroposterior radiograph in extension: group I, 0 degrees; group II, <5 degrees ; and group III, >5 degrees. Each group was further subdivided as to whether the patients were better (satisfied), unchanged, or worse (unsatisfied) with their operation at the time of review. There were 81 men (42.6%) and 109 women (57.4%) ranging in age from 30 to 88 years (mean, 62.1 years). Follow-up ranged from 2 to 15 years (mean, 7.4 years). Overall, 63.2% (129 knees) were better, 21.1% (43 knees) were unchanged, and 15.7% (32 knees) were worse after surgery. Further surgery was needed in 54 knees (26.5%). Regarding satisfactory results, group I (n = 57) had 84.2%, group II (n = 102) had 67.6%, and group III (n = 45) had 26.7%. Based on statistical analysis, it is concluded that patients with less deviated axes do better than those with large angulations, prior surgery predisposes to poorer results, and while the age was lower in the better and unchanged groups, it seems to be secondary in importance to angular deformity. Arthroscopic debridement is a successful palliative, temporizing treatment for the osteoarthritic knee.

Patellofemoral complications in symmetrical total knee arthroplasty.

A review of 356 Kinemax (Howmedica, Inc, Rutherford, NJ) cemented posterior cruciate ligament-retaining condylar total knee arthroplasties employing a symmetrical femoral component articulating with a medially offset symmetrical dome patella component was carried out to examine the results and determine the incidence and nature of the patellofemoral complications. Follow-up was from 3 to 8 years, with a mean of 5.1 years. A review of patellofemoral complications in previously reported homogeneous series of symmetrical and asymmetrical implants is presented. Mean postoperative Knee Society scores improved to 91, function scores to 86, and Hospital of Special Surgery scores to 90 yielding 95% good and excellent results. Mean postoperative range of motion was -1.5 degrees extension to 113 degrees flexion. There were five patellofemoral complications (1.4%), including two symptomatic subluxations, two distal pole avulsion fractures, and one lateral facet fracture. There were two reoperations necessary for patellofemoral problems (0.56%), one to correct subluxation and one for excision of the fractured lateral facet. These rates are lower than those previously reported for asymmetrical implants as well as current and phased-out symmetrical designs of total knee arthroplasty in the intermediate term. This review suggests that cemented total knee arthroplasty with symmetrical patellofemoral resurfacing with an offset patella dome and posterior cruciate ligament retention yields low patellofemoral complications and reoperations. The symmetrical femoral component appears to be a satisfactory compromise of "normal" femoral anatomy, which decreases inventory and cost without adversely affecting patellofemoral function and complications.

Influence of intramedullary versus extramedullary alignment guides on final total knee arthroplasty component position: a radiographic analysis.

A prospective study of 116 consecutive Kinemax cemented posterior cruciate ligament-retaining total knee arthroplasties was carried out. Similar surgical technique was used with a single variable: 61 were implanted using intramedullary guides on the tibia and 55 were implanted using extramedullary guides on the tibia. A radiographic study was performed after at least 1 year of follow-up to evaluate postoperative component position and compare the difference in the accuracy of positioning of the femoral and tibial components. Radiographic analysis showed that satisfactory position was achieved using both types of instrumentation. No statistically significant difference was observed in either the coronal or sagittal plane of the femoral component and the sagittal plane positioning of the tibial component. However, the coronal plane positioning of the tibial component revealed a statistically significant difference (P < .01), with intramedullary guides being superior to extramedullary guides. Also observed, was that using either technique, patients with less accurate postoperative positioning tended to be obese, with wide intramedullary canals. Patients with significant extraarticular deformities, marked bowing, and those with prior surgery or fractures may not be suitable for intramedullary guides, and they may require the use of extramedullary guides and intraoperative radiographic control. The ideal indication for the use of intramedullary instrumentation is in the patient who is not obese, with no extraarticular deformity, and with a well-defined, but not excessively wide, tibial medullary canal. Since tibial component malalignment in general, and coronal plane malalignment in particular, may adversely affect the long-term survival of total knee arthroplasties, the use of intramedullary alignment instrumentation is recommended when possible.

Immunohistochemical analysis of mechanoreceptors in the human posterior cruciate ligament: a demonstration of its proprioceptive role and clinical relevance.

Although long-term studies report successful results with total knee arthroplasty (TKA), performed with or without posterior cruciate ligament (PCL) retention, controversy exists as to which is preferable in regard to patient outcome and satisfaction. The possible proprioceptive role of the PCL may account for a more normal feeling of the arthroplasty. Although the PCL has been examined using various histological techniques, immunohistochemical techniques are the most sensitive for neural elements. Therefore an immunohistochemical study was designed to determine the patterns of innervation, the morphological types of the proprioceptors, and their immunohistochemical profile. During TKA, samples were obtained from 22 osteoarthritic PCLs and subjected to immunohistochemical analysis with mouse monoclonal antibodies against neurofilament protein (NFP), S100 protein (S100P), epithelial membrane antigen (EMA), and vimentin (all present in neuromechanoreceptors). Three normal PCLs from cadaveric specimens were also obtained and analyzed for comparison. Five types of sensory corpuscles were observed in both the normal and the arthritic PCLs: simple lamellar, Pacini-like, Ruffini, Krause-like, and morphologically unclassified. Their structure included a central axon, inner core, and capsule in lamellar and Pacini corpuscles and variable intracorpuscular axons and periaxonal cells in the Ruffini and Krause-like corpuscles. The immunohistochemical profile showed the central axon to have NFP immunoreactivity, periaxonal cells to have S100P and vimentin immunoreactivity, and the capsule to have EMA and vimentin immunoreactivity. Nerve fibers and free nerve endings displayed NFP and S100P immunoreactivity. The immunohistochemical profile of the PCL sensory corpuscles is almost identical to that of cutaneous sensory corpuscles. Some prior histological studies of the PCL reported Golgi-like mechanoreceptors, and others found encapsulated corpuscles but no Golgi-like structures. This report determined the innervation of the PCL by the more sensitive immunohistochemical means, revealing four major types of encapsulated mechanoreceptors. The plentiful and varied types of encapsulated mechanoreceptors found in even the arthritic PCL suggests a rich proprioceptive role. It is controversial as to whether preservation of the PCL at TKA improves postoperative proprioception. Our findings tend to support those clinical reports of improved proprioception after PCL-retaining versus PCL-substituting TKAs. The presence of many and varied types of mechanoreceptors may account for the improved stair climbing reported in patients with PCL-retaining TKA and may contribute to patient satisfaction and a more normal feeling after TKA.

Is the routine examination of surgical specimens worthwhile in primary total knee arthroplasty?

Two thousand two hundred eighty-nine consecutive primary total knee arthroplasties performed between 1993 and 1996 were reviewed retrospectively to assess the utility and cost effectiveness of the routine examination of surgical specimens. In those cases where a discrepancy was seen between the clinical and pathologic diagnoses, the records were reviewed carefully and those patients were contacted to determine whether their subsequent treatment was altered as a result of the pathologic findings. In 10 cases there was a potentially important discrepancy between the clinical and pathologic diagnoses. In none of those 10 cases was the subsequent treatment of the patient altered as a result of the pathologic findings. This study suggests a reexamination of regulations that mandate the routine pathologic review of surgical specimens from primary total knee arthroplasties.

Patellofemoral resurfacing at total knee arthroplasty.

A retrospective review of 268 primary total knee arthroplasties (TKAs) with a mean follow-up of four years is presented. The patellae were resurfaced in all cases. There were six complications (2.2%) referable to the patellofemoral articulation: three subluxations, one patellar fracture, one loosening of a metal-backed patellar component, and one patellar tendon avulsion. Successful patellofemoral resurfacing (PFR) can be accomplished with minimal complications if the following technical considerations are met: 5-7 degrees of valgus alignment; medial placement of the patellar component; taking care not to increase either the AP diameter of the knee or the thickness of the patella; avoiding internal rotation of either the tibial or femoral components and proper soft tissue balancing. A thorough review of patellofemoral complications after TKA is presented, and technical considerations relevant to the successful performance of PFR are discussed.

Heterotopic ossification following primary total knee arthroplasty.

Heterotopic ossification is a rare complication following primary total knee arthroplasty and may be symptomatic if massive enough. The authors retrospectively reviewed 158 primary total knee arthroplasties from 1985 to 1989 and found 6 cases (3.8%) of heterotopic ossification. Patients were graded before and after surgery according to the Hospital for Special Surgery total knee arthroplasty score and their histories were reviewed for the presence of recognized risk factors for heterotopic ossification and whether a manipulation under anesthesia was performed. This report describes the incidence of, appearance of, and clinical risk factors for heterotopic ossification following primary total knee arthroplasty in this series. A radiographic grading system is proposed.

Works in progress #7. Clinical experience with the Accu-Path threaded acetabular cup. A preliminary report.

Clinical experience with the Accu-Path threaded titanium hemispheric cup is presented. A series of 62 cases was followed for an average of 28.1 months (range, 6 to 48). Primary surgery was performed in 50 cases and revision surgery in 12. The surgical technique is described in detail. Preoperative Harris scores improved from 28 to 93 in primary cases and from 24 to 84 in revision cases. Complications included 3.2% dislocation, 3.2% loss of cup position, and 1.6% recurrent subluxation. The overall reoperation rate was 8% (8% in primary surgery and 8.3% in revision surgery). Roentgenographic analysis is discussed. The importance of preservation of the subchondral plate and a rim fit in the use of this implant is stressed. It is not indicated in those with loss of the plate due either to prior surgery (as in revision) or in aggressive over-reaming in primary cases. Although the overall results were encouraging, caution was recommended--especially in revision surgery or in the patient with severe osteopenia.

Management of ipsilateral femoral shaft fractures following hip arthroplasty.

Femoral shaft fractures following hip arthroplasty can be difficult to manage, particularly in elderly patients. Nine patients were treated with open reduction and rigid internal fixation using cement augmentation for screw fixation in the distal shaft. The stability achieved allowed all patients to be mobilized in the immediate postoperative period. No incidences of reduction loss or implant failure occurred, and all fractures had healed by the time of review. The results obtained support this method of treatment for ipsilateral femoral shaft fractures when prosthetic stability has not been compromised.

Primary Bateman-Leinbach bipolar prosthetic replacement of the hip in the treatment of unstable intertrochanteric fractures in the elderly.

The results of primary Bateman-Leinbach bipolar prosthetic replacement for comminuted intertrochanteric fractures of the hip in the elderly are examined. In an effort to avoid the postoperative complications seen in open reduction and internal fixation of severely comminuted fractures with osteoporotic bone, and to avoid postoperative restrictions when fixation is suboptimal, a group of 58 patients were treated with a bipolar Bateman-Leinbach prosthesis. They were followed for an average of 28 months. Surgery was performed using an anterolateral approach, which is recommended. A detailed description of the surgical approach and operative technique are provided. Eighty-eight percent of patients were able to ambulate within the first week, weight bearing as tolerated with no postoperative restrictions, except for a simple abduction pillow for 2 weeks while in bed. Ninety-one percent of patients ambulated prior to discharge. Morbidity and mortality was no greater in this group than in groups treated by open reduction and internal fixation for these types of fractures. Complications were few. Primary Bateman-Leinbach bipolar prosthetic replacement is recommended as the preferred treatment of selected unstable comminuted intertrochanteric fractures in the elderly.

Infected uncemented hip arthroplasty. Preserving the femoral stem with a two-stage revision procedure.

Revision of an infected uncemented hip arthroplasty can be significantly complicated by the presence of extensive bony ingrowth. Although removal of the prosthesis is desirable, technical difficulties in extracting a well anchored prosthesis can be extreme. Femoral windowing or splitting may be necessary. In these cases, treatment alternatives that avoid destruction of the femoral cortex are desirable. A 47-year-old man presented with a deep infection of a virtually fully coated porous implant two years postoperatively. Radiographs revealed extensive bony ingrowth and an arthrogram revealed no dye tracking down the femoral canal. The infecting organism was Staphylococcus epidermis. In order to avoid the possible complications of extraction of this fully coated stem, treatment was carried out initially with removal of the bipolar head, joint debridement, and placement of antibiotic impregnated beads. After seven weeks of intravenous antibiotic therapy with the patient in tibial pin traction, a revision was undertaken and the acetabulum was revised with a threaded uncemented acetabular component. The patient recovered and at 18 month follow-up is without evidence of infection and back to full function. Revision with a two-stage femoral stem preserving procedure is presented as an alternative in the management of infected uncemented hip arthroplasty.

Subcutaneous lateral retinacular release for chondromalacia patellae: a preliminary report.

When chondromalacia patellae is caused by lateral capsular and retinacular tightness, subcutaneous lateral release affords relief of pain. The operation, performed at the time of arthroscopy, causes minimal morbidity, and it is advantageous when cosmetics are of concern. Range-of-motion exercises are begun on the second postoperative day to keep the retinaculum open. In the postoperative examination of 25 knees at 24 to 45 months in 15 patients, there were 20 excellent and five good results; none was made worse. There were two postoperative hemarthroses. The procedure is most effective in the carefully selected patient with demonstrable tightness of the lateral capsule and retinaculum. Abnormal attachments of the iliotibial band and synovial plicae are also significant in the etiology of this syndrome.

Spontaneous and simultaneous rupture of both quadriceps tendons.

The seventh case known to be reported in the literature on simultaneous rupture of both quadriceps tendons occurred in a 60-year-old man with diabetes mellitus. The patient was treated by surgical repair of both tendon ruptures with a satisfactory return of function. Diabetes mellitus may be a predisposing condition for the bilateral rupture, but does not prevent either the tendon or wound from healing.