Tibial osteotomy for varus gonarthrosis. A 10- to 21-year followup study.

From 1975 to 1986, 102 high tibial osteotomies for varus gonarthrosis were performed in 99 patients. Fifty-eight patients (60 knees) were reviewed at an average followup of 15 years (range, 10-21 years); of the remaining 41 patients, seven had a knee replacement, 18 had died, and 16 were lost to followup. The results, assessed according to the scoring system of the Hospital for Special Surgery and including the seven patients who underwent a knee replacement, were excellent or good in 37 (55%) knees and fair or poor in 30 (45%). Twenty-six patients of the current study previously were reviewed in 1986, with an average followup of 8 years, using the same clinical and radiographic criteria. In this group of 26 patients, excellent and good results decreased from 73% in 1986 to 46% in 1996. The knees in these 26 patients with a followup greater than 15 years had a statistically significant higher percentage of fair and poor results. No statistically significant differences in the results were found according to the amount of correction. Radiographic controls at followup were available for 45 of the 60 knees; a loss of correction greater than 5 degrees was observed in 11 knees. The results of this long-term followup study show that high tibial osteotomy for gonarthrosis allows a long period (range, 10-15 years) of relief of pain, good range of motion, and function in a large number of patients. Results tend to deteriorate with time, particularly after 15 years.

Clinical outcome of orthopaedic patients with negative lower limb venography at discharge.

Pharmacological prophylaxis for postoperative venous thromboembolism is generally restricted to the hospital stay. A high incidence of deep vein thrombosis (DVT) and pulmonary embolism presenting after hospital discharge has been reported and thus it has been claimed that pharmacological prophylaxis should be continued after discharge. The aim of this study was to perform a prospective survey to assess the prevalence of clinically overt thromboembolic events in hip surgery patients discharged with a negative venography without further pharmacological prophylaxis. We followed-up 213 patients with negative venography at discharge (105 elective hip replacement and 108 hip fracture patients). 186 patients (87.3%) were re-examined as outpatients one to two months after discharge. Five patients reported symptoms of DVT but the diagnosis was not confirmed by objective testing. The remaining 27 patients (12.7%) were followed up through their family doctor or by telephone call; in these patients the follow-up period ranged from 60 days to 2 years. Twenty-two patients (10.3%) were still alive and reported no signs or symptoms of venous thromboembolism. Three patients (1.4%) died for reasons not correlated with venous thromboembolism. Two patients could not be traced due to geographical inaccessibility; they were still alive after 1 year according to the records of their health care district. The results of our study suggest that in hip surgery patients with negative venography the prevalence of clinically overt thromboembolic events after hospital discharge ranges from 0 to 2.2% (95% C.I.). It is conceivable that the majority of late presenting postoperative DVT actually develop during the hospital stay and become symptomatic after hospital discharge.

[Arthroplasty of the knee using total condylar prosthesis. Long term results (10 to 17 years) and survival analysis]. / Arthroplastie du genou par prothèse Total Condylar. Résultats à long terme (10 à 17 ans) et analyse de survie.

INTRODUCTION: This study refers to the first 76 Total Condylar knee prostheses that were implanted in 66 patients, with a minimum follow-up of 10 years. MATERIALS AND METHODS: There were 54 women and 12 men with an average age of 65 years (range 45-81). The diagnosis was osteoarthrosis in 63 knees and rheumatoid arthritis in 13. We were able to review 54 prostheses with an average follow-up of 13 years (10-17) using the rating system of the Hospital for Special Surgery and the Survivorship analysis. RESULTS: The results were excellent and good in 72.5 per cent knees and fair and poor in 22 per cent, 3 knees (5.5 per cent) had been revised for deep infection in 2 cases and for aseptic loosening in 1. Pain at rest was absent or mild in all but one patient; walking pain was absent in 32 knees (63 per cent), mild in 12 (23 per cent), moderate in 5 (10 per cent) and severe in 2 (4 per cent). Average range of motion was 89 degrees, ranging from 40 degrees to 120 degrees. A flexion contracture greater 5 degrees was seen in 8 knees (16 per cent). Instability in the frontal plane tested in full extension was more than 5 degrees in 10 patients (19.5 per cent). A significant deterioration of the results occurred in the last 4-5 years, since in 1988 excellent and good results were still 82 per cent. A loss of postoperative alignment of 5 degrees or more was observed in 11 knees: aseptic loosening was identified in 2 of these cases and deformation of the tibial component was seen in 1 knee. In the remaining 8 knees we observed increased lateral instability, compared to the postoperative evaluation. In this group of 8 knees we measured in the AP view the thickness of the tibial component on the lateral and medial side. We found polyethylene wear on the medial side in 4 cases. Ten of the 11 knees with loss of alignment had an early postoperative femoro-tibial axis less than 5 degrees. We observed radiolucent lines in 18 patellar and 27 tibial components. A width greater than 2 mm, correlated to an extension to 5 or more zones, was seen in 3 tibial components with aseptic loosening. Survivorship analysis using aseptic loosening, mechanical failure of the polyethylene and deep infections as end point gave a cumulative success rate at 10 years of 92 per cent% with 95 per cent confidence interval ranging from 85.1 to 98. DISCUSSION: Our study reports a lower percentage of excellent and good results if compared to other series of Total Condylar prosthesis with a comparable follow-up. A significant deterioration of the results occurred in the last years, but this was often not related to the knee itself but to poor general conditions in some patients. In this series there is a relevant number of knees with a post-operative alignment that today we don't consider correct and all the aseptic loosenings occurred in knees with a tibial component positioned in varus. CONCLUSION: Survivorship analysis gave a cumulative success rate comparable with those reported in other studies and confirmed the durability and longevity of this model of prosthesis.

Features of thrombi and diagnostic accuracy of impedance plethysmography in symptomatic and asymptomatic deep vein thrombosis.

Impedance plethysmography (IPG) has high sensitivity and specificity in patients with symptomatic deep vein thrombosis (DVT) while it fails to detect asymptomatic DVT. The aim of this study was to determine whether the features of thrombi such as location, size and occlusiveness could explain the different accuracy of IPG in symptomatic and asymptomatic DVT patients. One-hundred and seventeen consecutive outpatients with a clinical suspicion of DVT and 246 consecutive patients undergoing hip surgery were admitted to the study. In symptomatic patients IPG was performed on the day of referral, followed by venography, while in asymptomatic patients IPG was performed as a surveillance programme, followed by bilateral venography. A venography proved DVT was observed in 37% of the symptomatic patients and 34% of the asymptomatic limbs. A significantly higher proportion of proximal DVTs was found in symptomatic patients than in asymptomatic patients (78% vs 46%; p = 0.001). The mean Marder score, taken as an index of thrombus size, was significantly higher in symptomatic patients than in asymptomatic patients (19.0 vs 9.6; p = 0.0001). A significantly higher proportion of occlusive DVTs was observed in symptomatic than in asymptomatic patients (69% vs 36%; p = 0.001). We conclude that the unsatisfactory diagnostic accuracy of IPG in asymptomatic DVT is due to the high prevalence of distal, small and non occlusive thrombi. Such thrombi are unlikely to cause a critical obstruction of the venous outflow and therefore to produce a positive IPG.

Long-term results and survivorship analysis of 89 total condylar knee prostheses.

The results of 89 total condylar I prostheses were assessed using both the Hospital for Special Surgery rating system and survivorship analysis. At an average follow-up period of 9.5 years (range, 5-15) 61 patients (72 knees) were available for clinical and radiographic evaluation. Thirty (41.5%) knees were rated as excellent, 29 (40.5%) good, 4 (5.5%) fair, and 6 (8.5%) poor. Three (4%) cases were considered failures because they needed a second operation. Loss of the postoperative alignment often associated with lateral instability was observed in 23 knees. Loosening of the tibial plateau occurred in two knees; in one of these a successful revision was performed. Survivorship analysis, using deep infection and aseptic loosening as end-point criteria, gave a 15-year probability of survival of 95%. These results confirm the validity of the total condylar prosthesis and the reliability of cementation in knee arthroplasty.

Halo-cast treatment of fractures and dislocations of the cervical spine.

Twenty-eight consecutive patients with dislocated, and often unstable, injuries of the cervical spine were treated by halo-cast stabilisation. One died and 27 were followed up. Twenty had no symptoms and 17 had full movement of the neck. There were only a very few minor complications. Seven patients had initial neurological impairment. They included the single death, but the remaining 6 regained useful muscle function. The halo-cast allows complete reduction in many types of fractures and dislocations, and good immobilisation is maintained.

Impedance plethysmography in the diagnosis of asymptomatic deep vein thrombosis in hip surgery. A venography-controlled study.

We prospectively evaluated the accuracy of computerized impedance plethysmography (CIP) in the diagnosis of asymptomatic deep vein thrombosis (DVT) in 246 consecutive high-risk patients scheduled for hip surgery, with bilateral venography used for comparison. The CIP was performed as a surveillance program every third day. If the CIP remained negative, bilateral venography was performed on postoperative day 10 +/- 1 or on day of treatment 14 +/- 1 in nonoperated-on patients. If the CIP became positive, venography was performed within 24 hours. The sensitivity and specificity of CIP for proximal and distal DVT were 19% (confidence interval [CI], 13% to 24%) and 91% (CI, 87% to 94%), respectively. The positive and negative predictive values were 52% (CI, 38% to 65%) and 70% (CI, 65% to 74%), respectively. The sensitivity and specificity of CIP for proximal DVT were 24% (CI, 13% to 34%) and 90% (CI, 87% to 94%), respectively; the positive and negative predictive values were 31% (CI, 20% to 51%) and 87% (CI, 83% to 90%), respectively. We conclude that, because of its low sensitivity, CIP cannot be used in the surveillance of DVT in high-risk patients or for outcome measurements in clinical trials on DVT prophylaxis.

Survivorship of the Total Condylar I prosthesis: Results of a series of 100 total knee arthroplasties.

The Total Condylar knee prosthesis was employed at our institution from April 1975 to October 1986; currently the posterior stabilized type is in use. The results of 100 knee arthroplasties using the Total Condylar I prosthesis, 83 of which were reviewed after an average of 7 1/2 years (maximum 14), were rated good or excellent in 82% of the subjects. Three cases were considered failures due to infection or aseptic loosening. According to the survivorship analysis, there is a 14-year success rate of 93%.

Introduction to orthopaedic surgery in rheumatoid arthritis.

Surgical treatment of rheumatoid arthritis dates back some fifty years to when rheumatology developed into a separate branch of medicine. An interdisciplinary approach to rheumatoid arthritis was then introduced at a few specialized centres. By refining the surgical techniques, increasing the number of surgical options to be more precisely defined, this fifty years' experience in the surgery of rheumatoid arthritis has led to the good results that can be achieved today. The goals of the surgical treatment of rheumatoid arthritis are pain relief, improvement of joint motion or stability and correction of deformities. In addition, progression of the disease is likely to be halted in the operated joint. Operations may be classified as either preventive or reconstructive; sometimes they are both. Surgery is indicated when medical treatment fails to adequately check progression of the disease. Absolute indications include tendon ruptures, nerve compression, instability of the cervical spine associated with neurological symptoms, and severe deformities.

High tibial osteotomy in the treatment of arthritic varus knee. A medium term (small) review of 61 cases.

Sixty-one valgizing high tibial osteotomies performed according to the Insall method between 1975 and 1982 were reviewed; follow-up ranged from a minimum of 4 years to a maximum of 11, with an average of 7.5 years. The stage of preoperative osteoarthritis, evaluated according to Ahlbacks's classification, never exceeded Grade 3 (obliteration of the joint space and slight bone erosion). Preoperative varus never exceeded 10 degrees. The clinical results, evaluated on the score-form used at the Hospital for Special Surgery, were satisfactory in 48 cases (79% of the total) and unsatisfactory in 13 (21%). The success rate decreased to 65% in cases with a follow-up exceeding 10 years. There was frequently some loss of radiographic correction between the postoperative and follow-up values, but this was significant in only 9 cases where it exceeded 5 degrees. The arthritis was radiographically progressive in 22 cases, 18 of which were from the satisfactory group (excellent and good) and 4 from the unsatisfactory group (fair and poor). This positive evaluation of the results, even if they tended to deteriorate over a period of time, show that high valgizing tibial osteotomy is an effective operation, particularly when performed in knees without severe deformity.

Congenital hip dysplasia treated by the Salter osteotomy. Long-term review of 18 patients.

Between 1965 and 1974 at the Orthopaedic Clinic of the University of Perugia, 20 osteotomies of the innominate bone were performed on 18 patients aged between 18 months and 10 years. All the patients were followed up for 10 to 19 years (average 15 years) after operation. The results were evaluated both clinically and radiographically (according to the Severin and MacFarland methods). The data were later submitted to computer analysis, using a semiautomatic aquisition programme which allowed for evaluation of the geometry of the hip. The most important parameters for evaluation of the results were the Wiberg CE angle, the acetabular angle, the minimum joint space, and the horizontal component of the resultant force. Clinically and radiographically there was an 80% success rate according to Severin's method of evaluation. There was also good correlation with the computerized analysis. Biomechanically, there was almost normal recovery of the load distribution. The clinical, radiographic and biomechanical parameters worsened slightly with age, particularly during puberty.

Total condylar knee arthroplasty. A five-year follow-up study of 33 knees.

The authors report the results of a consecutive series of 37 total condylar prostheses inserted between 1975 and 1977 in 31 osteoarthritic and six rheumatoid arthritic knees. Prostheses were inserted in 33 usually low-activity patients with an average age of 65 years. There was a five-year minimum follow-up period for 33 knees. The clinical results, according to the Hospital for Special Surgery's knee rating system, were 21 excellent (64%), 7 good (21%), 3 fair (9%), and 2 poor (6%). The two poor results were due to tibial component aseptic loosening. The comparison between the tibial radiolucencies at two and five years showed only minor variations. At five years 75% of the knees had an absent or less than 30% lucency. Most of the mechanical problems occurred after a technically incorrect operation. Varus alignment was not well tolerated with the passage of time. There were no problems caused by the routine use of a patellar component.

Tibial osteotomy for the varus osteoarthritic knee.

High tibial osteotomy is a reliable method for relieving pain in the varus osteoarthritic knee. In a review of 139 osteotomies, excellent and good results were noted in 64% of the knees after a follow-up period of at least ten years. The ideal candidate for this operation has Grade I or II osteoarthritis; less than 10 degrees of varus deformity, as measured by a single leg standing roentgenogram; no lateral subluxation; and no instability. The lateral closed wedge osteotomy without internal fixation is the preferred technique, and correction beyond the normal anatomic position, to 5 degrees of valgus, is advised. Protected weight-bearing after the second postoperative day is allowed. Complications have been infrequent and minor. Forty-seven knees were managed in this manner, and 88% had an excellent or good result at a four-year follow-up evaluation. In the majority of the well corrected knees, the alignment did not change with time, and the osteoarthritis did not progress. No failures in this series were attributable to the associated patellofemoral osteoarthritis; the reaction of the patellofemoral joint to osteotomy is obscure.

A radiographic study of Charnley total hip prostheses.

This paper presents a radiographic study of Charnley hip prostheses, 100 fitted by the transtrochanteric route and controlled at a minimum distance of a 2 years and 40 by the posterolateral approach without osteotomy of the trochanter, controlled on the postoperative radiographs. For the first group, the behaviour was studied of the components, bone and cement. For the second, a comparison was made with cases operated on by the transtrochanteric route on the basis of several biochemical parameters.

Results of the total-condylar knee prosthesis.

The Total-Condylar knee prosthesis is a non-hinged, semi-restricted prosthesis with partial intrinsic stability, incorporating a prosthetic surface covering the patella. The surgical technique involved includes release of the contracted soft tissues, so as to obtain symmetry and balance of the ligaments before the bone is cut. These bone cuts are made at a right angle to one another and are standardised. The cases presented comprise forty-eight knees (in forty-one patients), of whom thirty-eight were affected by arthrosis and ten by rheumatoid arthritis. The mean age of the patients was sixty-five years. They were examined not less than twenty-four months nor more than seventy months after operation. This was a prospective survey and the cases were consecutive. Excellent or good results were obtained in 89.5 per cent of cases. Only one case had to undergo re-operation, due to loosening of the tibial component, not to deep infection. The results were permanent over the review period, and the quality was as good as in prostheses of the hip.

Results of 100 arthroprostheses of the hip of Charnley's method. (Prospective study, consecutive series).

This is a prospective survey of 100 consecutive cases of arthroprosthesis of the hip by Charnley's method, operated on in a conventional operating theatre under similar environmental conditions to those of the great majority of Italian hospitals. Ninety-four cases were available for review at an average follow up period of three and a half years (with a range of two to seven years). The incidence of infection was very high (9.6 per cent). In two cases there was aseptic loosening of the femoral component, demonstrated at re-operation (2.1 per cent) and in three cases it is suspected but not yet confirmed by re-operation (3.2 per cent). In eighty-three cases (88.2 per cent) the result was considered to be successful.

Methods of combining the correction of deformities of the knee with the use of the total condylar prosthesis. Study of post-operative stability.

(1) Our Total Condylar knee prosthesis can be adapted to cases of severe deformity, either varus or valgus, and to flexion contracture. (2) The technique of mobilization and sliding of the capsulo-ligamentous structures on the contracted side is necessary in cases with severe deformity. (3) After mobilization of the contracted structures it is necessary, before sectioning the bone, to distract the joint in flexion as well as extension in order to achieve stability both in the sagittal and frontal planes. (4) Despite the removal of the cruciate ligaments and capsulo-ligamentous slide, no significant residual instability was found in either plane.

A new total knee prosthesis: the "total-condylar".

We have described the instrumentation and surgical technique of a new total knee prosthesis, the Total-Condylar, designed at the Hospital for Special Surgery (New York) and which we are the first to use in Italy. This prosthesis has evolved from the "sliding" prosthesis and seems to us to constitute a real step forward. The femoro-patellar compartment is completely substituted. The cruciate ligaments are removed, which markedly increases the possibility of correcting even severe deformities. The fixation of the tibial component is improved by the adoption of a short stem. The prosthesis has a certain intrinsic stability on weightbearing. The surgical technique is characterised by bone sections perpendicular to each other by the use of aligning instruments which simplify the operation. Our experience is just beginning (five cases) but our results so far are very encouraging and correspond to those reported in a very much larger series in the United States.