Showing papers in "Clinical Orthopaedics and Related Research in 2001"
TL;DR: The senior author (JRS) developed the microfracture technique to enhance chondral resurfacing by providing a suitable environment for new tissue formation and taking advantage of the body's own healing potential.
Abstract: Full-thickness articular cartilage defects rarely heal spontaneously. Some patients may not have clinically significant problems from chondral defects, but most eventually have degenerative changes. Techniques to treat chondral defects include abrasion, drilling, autografts, allografts, and cell tra
1,143 citations
TL;DR: Those comorbidities that were statistically significant in increasing the risk of infection were prior open surgical procedures, immunosuppressive therapy, poor nutrition, hypokalemia, diabetes mellitus, obesity, and a history of smoking.
Abstract: Six thousand four hundred eighty-nine knee replacements were done in 6120 patients at the authors' institution between 1993 and 1999 Operations were done in a theater with vertical laminar flow and with the surgical team using body exhaust suits Of these knee replacements, 116 knees became infected and 113 were available for followup One hundred of the infections occurred in patients undergoing primary knee replacement, whereas the remaining infections occurred in patients undergoing revision knee replacement Ninety-seven of these knees (86%) had deep periprosthetic infections and the remaining 16 knees had superficial wound infections One third of the deep infections occurred within the first 3 months after surgery and the remaining % occurred after 3 months The overall early deep infection rate for patients undergoing a primary knee replacement was 039%, whereas the rate for patients undergoing a revision knee replacement was 097% A cohort of noninfected knee replacements from patients matched for gender, age, and month of surgery was used as a control group Those comorbidities that were statistically significant in increasing the risk of infection were prior open surgical procedures, immunosuppressive therapy, poor nutrition, hypokalemia, diabetes mellitus, obesity, and a history of smoking Patients undergoing revision procedures had a statistically higher risk of infection than did patients undergoing primary surgeries If the surgery took longer than 25 hours, the risk of infection was increased significantly There was no change in the infection rate when the perioperative antibiotic prophylaxis was decreased from 48 to 24 hours after surgery The predominant infectious organisms were gram-positive (Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus Group B) Twenty percent of the knees that were infected clinically had no organisms that could be identified In each case, the patient had been treated empirically at another institution with antibiotics before a culture of the joint was obtained
761 citations
TL;DR: If all of the arthroplasties in the patients in this early failure group would have been cemented routinely and balanced carefully, the total number of early revisions would have decreased by approximately 40%, and the overall failures would have be reduced by 25%.
Abstract: Total knee arthroplasty is a predictable operation. Unfortunately, there is a subset of patients who do not do well and require revision surgery within the first 5 years. The purpose of the current study was to analyze the mechanisms of failure in patients who had revision surgery within 5 years of their index arthroplasty. Between 1986 and 1999, 440 patients with total knee arthroplasties were referred for revision surgery. An analysis of patients in whom the arthroplasties failed within 5 years of the index arthroplasty and the reasons for early failure were documented. Of the 440 patients who had revision surgery, 279 (63%) had revision surgery within 5 years of their index arthroplasty: 105 of the 279 patients with early failures (38%) had revision surgery because of infection; 74 (27%) had revision surgery because of instability; 37 (13%) had revision surgery because of failure of ingrowth of a porous-coated implant; 22 (8%) had revision surgery because of patellofemoral problems; and 21 (7%) had revision surgery because of wear or osteolysis. Only eight of the 279 patients with early failures (3%) had revision surgery because of aseptic loosening of a cemented implant. The remaining 12 patients had revision surgery because of miscellaneous problems. Host factors may prevent infection from ever being eradicated totally. The two other major patterns of failure in this series were failure of cementless fixation and instability. If all of the arthroplasties in the patients in this early failure group would have been cemented routinely and balanced carefully, the total number of early revisions would have decreased by approximately 40%, and the overall failures would have been reduced by 25%.
607 citations
TL;DR: The acetabular labrum tear appears to be an acquired condition that is highly prevalent in aging adult hips and may be one of the causes of degenerative hip disease.
Abstract: Acetabular labrum tears have been implicated as a cause of hip pain in adult patients. Few studies describe the anatomy, histologic features, and microvasculature of the acetabular labrum and labral tears. Fifty-five embalmed and 12 fresh-frozen adult hips with a mean age of 78 years (range, 61-98 years) were studied. Of these, 96 % (53 of 55) of the hips had labral tears, with 74% of the tears located in the anterosuperior quadrant. Histologically, the fibrocartilaginous labrum was contiguous with the acetabular articular cartilage through a 1- to 2-mm zone of transition. A consistent projection of bone extends from the bony acetabulum into the substance of the labrum that is attached via a zone of calcified cartilage with a well-defined tidemark. Two distinct types of tears of the labrum were identified histologically. The first consisted of a detachment of the fibrocartilaginous labrum from the articular hyaline cartilage at the transition zone. The second consisted of one or more cleavage planes of variable depth within the substance of the labrum. Both types of labral tears were associated with increased microvessel formation seen within the tear. The acetabular labrum tear appears to be an acquired condition that is highly prevalent in aging adult hips. Labral tears occur early in the arthritic process of the hip and may be one of the causes of degenerative hip disease.
600 citations
TL;DR: The authors review the structure and composition of articular cartilage, which is composed of an extensive extracellular matrix synthesized by chondrocytes and contains different zones with respect to depth from the articular surface.
Abstract: The authors review the structure and composition of articular cartilage. This tissue is composed of an extensive extracellular matrix synthesized by chondrocytes. It contains different zones with respect to depth from the articular surface and has a regional organization around the chondrocytes. Its composition varies regionally and zonally in its collagen and proteoglycan contents and those of other matrix molecules. There is a macrofibrillar collagen network and a microfilamentous network about which other noncollagenous molecules are organized. Its structure and composition are reflective of its special mechanical properties that primarily reflect its tensile strength (collagens) and compressive stiffness (proteoglycan aggrecan) and cell-matrix interactions (noncollagenous proteins).
597 citations
TL;DR: Arthroscopic and anatomic observations support the concept that labral disruption and degenerative joint disease are frequently part of a continuum of joint disease.
Abstract: The current authors examined the hypothesis that labral lesions contribute to early degenerative hip disease. Between 1993 and 1999, 436 consecutive hip arthroscopies were done by the senior author. In addition, 54 acetabula were harvested from human adult cadavers. Two hundred forty-one of the 436 (55.3%) patients who had arthroscopies had a 261 labral tears, all located at the articular, not capsular margin of the labrum. Stereomicroscopic examination of the 54 acetabula from cadavers revealed 52 labral lesions. Overall, there was no significant difference between the arthroscopic and cadaveric populations in terms of the incidence of labral tears. (Overall, 73% of patients with fraying or a tear of the labrum had chondral change. Arthroscopic and anatomic observations support the concept that labral disruption and degenerative joint disease are frequently part of a continuum of joint disease.
578 citations
TL;DR: All patients undergoing cruciate-retaining primary total knee arthroplasty for degenerative osteoarthritis at one center were studied prospectively and component malrotation is a significant factor in the development of anterior knee pain after total knee ligation.
Abstract: All patients undergoing cruciate-retaining primary total knee arthroplasty for degenerative osteoarthritis at one center were studied prospectively. Clinical and radiographic followup was obtained at a minimum 5 years in 102 knees in 73 patients. Patients were asked specifically about the presence of the pain in the anterior aspect of the knee in the vicinity of the patella and rated the severity of the pain on a visual analog scale. Significant anterior knee pain rating at least 3 of 10 on the visual analog scale was present in 16 knees (13 patients). Eleven patients with 14 symptomatic knees agreed to undergo computed tomography scanning to accurately determine the rotation of the tibial and femoral components. The epicondylar axis and tibial tubercle were used as references using a previously validated technique. A control group of 11 asymptomatic patients (14 knees), matched for age, gender, and length of followup also underwent computed tomography scanning. All patients in both groups had normal axial alignment. There was a highly significant difference in tibial component rotation between the two groups with the patients with anterior knee pain averaging 6.2 degrees internal rotation compared with 0.4 degrees external rotation in the control group. There also was a significant difference in combined component rotation with the patients with anterior knee pain averaging 4.7 degrees internal rotation compared with 2.6 degrees external rotation in the control group. There was no significant difference in the degree of radiographic patellar tilt or patellar subluxation between the two groups. Patients with combined component internal rotation were more than five times as likely to experience anterior knee pain after total knee arthroplasty compared with those with combined component external rotation. Component malrotation is a significant factor in the development of anterior knee pain after total knee arthroplasty.
546 citations
TL;DR: The Medical Outcomes Study 36-Item Short-Form Health Survey, Western Ontario and McMaster University Osteoarthritis Index, and the Harris hip score showed high validity and reliability.
Abstract: Although the Harris hip score frequently is used to assess the outcome of total hip replacement, only a few minor validity tests have been presented. The aim of this study was to perform a validity test of the Harris hip score and to test its reliability. Two cohorts were studied. First, 58 patients who had undergone total hip replacement 2 to 10 years earlier were evaluated by an orthopaedic surgeon and an experienced physiotherapist using the Harris hip score. The patients also answered the Western Ontario and McMaster University Osteoarthritis Index and the Medical Outcomes Study 36-Item Short-Form Health Survey. Second, 1,056 patients answered the Western Ontario and McMaster University Osteoarthritis Index and the Medical Outcomes Study 36-Item Short-Form Health Survey questionnaires. The results were compared with those of a subcohort of 344 patients who were evaluated using the Harris hip score. The following items were tested: content validity, convergent and divergent construct validity, criterion validity, test and retest reliability, internal consistency reliability, and interobserver reliability. The Medical Outcomes Study 36-Item Short-Form Health Survey, Western Ontario and McMaster University Osteoarthritis Index, and the Harris hip score showed high validity and reliability. The Harris hip score can be used by a physician or a physiotherapist to study the clinical outcome of hip replacement.
465 citations
TL;DR: Several of the key features of this unique disease are presented focusing on the importance of periprosthetic osteolysis, understanding of the diverse radiographic evidence of this disease, and the consequences that can occur from the disease.
Abstract: The dominant long-term problem in total hip replacement surgery, and an important problem in total knee replacement surgery, is wear of the polyethylene and its resulting periprosthetic osteolysis. Several of the key features of this unique disease are presented focusing on the importance of periprosthetic osteolysis, comprehension of the general progressive nature of periprosthetic osteolysis, understanding of the diverse radiographic evidence of this disease, and the consequences that can occur from the disease.
422 citations
TL;DR: Encouraging results from an increasingly large series and similar results from other centers seem that autologous osteochondral mosaicplasty may be a viable alternative treatment of localized full-thickness cartilage damage of the weightbearing surfaces of the knee and other weightbearing synovial joints.
Abstract: Efficacious treatment of full-thickness cartilage defects of the weightbearing surfaces is a multifaceted challenge for the orthopaedic surgeon. Autologous osteochondral transplantation represents one solution: to bring about a hyaline or hyalinelike repair of the defected area. The current authors
420 citations
TL;DR: The basic physics of shock waves and the physical parameters involved in assessing the amount of energy delivered to the target tissue and in comparing the various high- and low-energy devices being evaluated clinically for musculoskeletal applications are summarized.
Abstract: A shock wave is a transient pressure disturbance that propagates rapidly in three-dimensional space. It is associated with a sudden rise from ambient pressure to its maximum pressure. A significant tissue effect is cavitation consequent to the negative phase of the wave propagation. The current authors summarize the basic physics of shock waves and the physical parameters involved in assessing the amount of energy delivered to the target tissue and in comparing the various high- and low-energy devices being evaluated clinically for musculoskeletal applications.
TL;DR: At final followup, patients with a prosthesis in situ had better pain relief and shoulder function than patients treated with resection arthroplasty and delayed reimplantation may offer the best hope for pain relief, eradication of infection, and maintenance of shoulder function.
Abstract: Between 1972 and 1994, 2279 patients underwent primary shoulder arthroplasty (2512 shoulders) and 194 patients underwent revision shoulder arthroplasty (222 shoulders) at the authors' institution. Of these, 18 patients with primary shoulder arthroplasties (19 shoulders) and seven patients with revision shoulder arthroplasties (seven shoulders) were diagnosed with deep periprosthetic infection. Additionally, during this period, seven patients (seven shoulders) with primary shoulder arthroplasties and one patient (one shoulder) with a previously revised shoulder arthroplasty were referred to the authors' institution for treatment of deep periprosthetic infection. Two patients (two shoulders) were excluded because of incomplete medical records and with component removal performed elsewhere. The average time from arthroplasty to the diagnosis of infection was 3.5 years (range, 0-14.8 years). The patients were divided into four groups on the basis of treatment. Group I comprised 20 patients (21 shoulders) who underwent resection arthroplasty. Six of the 21 shoulders had additional episodes of infection. Group II comprised six patients (six shoulders) who underwent debridement and prosthetic retention. Three of the six shoulders failed this treatment with subsequent reinfection and underwent a resection arthroplasty. Group III comprised two patients (two shoulders) who had removal of the prosthesis, debridement, and immediate reimplantation. One patient underwent resection arthroplasty 9 months after direct exchange because of reinfection. Group IV comprised three patients (three shoulders) who had removal of the prosthesis, debridement, and delayed reimplantation. Reinfection has not occurred in any of these patients. At final followup, patients with a prosthesis in situ had better pain relief and shoulder function than patients treated with resection arthroplasty. Delayed reimplantation may offer the best hope for pain relief, eradication of infection, and maintenance of shoulder function.
TL;DR: Although initial animal studies are promising for possible pharmacologic treatment and prevention of osteolysis, well-controlled human trials are required before agents such as bisphosphonates can be recommended for general clinical use.
Abstract: Since the recognition of aseptic loosening by Charnley in the early 1960s, much information has been gained on the basic science of periprosthetic bone loss. Initially termed cement disease, it now generally is accepted that, in most instances, osteolysis is a manifestation of an adverse cellular response to phagocytosable particulate wear and corrosion debris, possibly facilitated by local hydrodynamic effects. Tissue explant, animal, and cell culture studies have allowed us to compile an appreciation of the complexity of cellular interactions and chemical mediators involved in osteolysis. Cellular participants have been shown to include the macrophage, osteoblast, fibroblast, and osteoclast. The plethora of chemical mediators that are responsible for the cellular responses and effects on bone include prostaglandin E 2 , tumor necrosis factor-alpha, interleukin-1, and interleukin 6. However, an increasing number of other proinflammatory and antiinflammatory cytokines, prostenoids, and enzymes have been shown to play important roles in this process. The ultimate goal of basic research is to develop novel strategies for evaluation and treatment of patients with osteolysis. Although initial animal studies are promising for possible pharmacologic treatment and prevention of osteolysis, well-controlled human trials are required before agents such as bisphosphonates can be recommended for general clinical use.
TL;DR: Surgical grade calcium sulfate pellets are considered a convenient, safe, and readily available bone graft substitute that yield consistent successful results in patients with bone defects.
Abstract: In a prospective, nonrandomized, multicenter study, 109 patients with bone defects were treated with a surgical grade calcium sulfate preparation as a bone graft substitute. The calcium sulfate pellets were used in place of morselized cancellous bone graft for the treatment of patients with bone defects who usually would require grafting secondary to trauma, periprosthetic bone loss, tumor, or fusion. The calcium sulfate was used alone or mixed with other materials such as bone marrow aspirate, demineralized bone matrix, or autograft. The defects that were treated were contained and were not necessary for the stability of the bony structure. Radiographic and clinical data were collected at predetermined intervals for 12 months. At 6 months postoperatively, radiographic results for all patients showed that 99% of the calcium sulfate had been resorbed and 88% of the defect was filled with trabeculated bone. There were 13 complications; however, only four (3.6%) were attributable to the product. The results of a subgroup of 46 patients with benign bone lesions treated in the same manner are identical to the results of the overall study population. Surgical grade calcium sulfate pellets are considered a convenient, safe, and readily available bone graft substitute that yield consistent successful results.
TL;DR: The Total Condylar Knee replacement maintains excellent durability at 20-years followup.
Abstract: Between 1976 and 1979, 220 total knee replacements were done on 164 patients using the Total Condylar Knee replacement. The diagnosis was rheumatoid arthritis in 111 knees and osteoarthritis in 109 knees. Patients with 157 knees are known to have died as of December 1998, leaving 63 knees in patients who are still alive. Twelve patients with 18 knees were lost to followup. The average 20-year followup data (range, 18-22 years) are presented for 45 knees in 30 patients using Knee Society evaluations. The average Knee Society clinical score for the surviving patients was 88 points, and the average functional score was 58 points. The radiographic followup averaged 19 years. The average overall alignment was 3 degrees valgus. Femoral lucencies were present in 17 of 40 adequate lateral views, most commonly about the anterior and posterior surfaces. Two femoral components were loose. Twenty-two tibial components had radiolucencies; four radiolucencies were circumferential. The remaining 41 knees retained a well-fixed cemented central peg despite proximal interface lucencies. From the group of 220 knees, 14 revisions have been done at an average of 11.4 years postoperative. Two knee replacements were revised for isolated tibial loosening, whereas one knee replacement had isolated femoral loosening. Three knee replacements were revised for loosening of both components, and one was revised for isolated patellar loosening. Four patients had sepsis develop; three of these four patients were treated with two-stage revision, and one underwent fusion. Three patients were treated for supracondylar fractures. The Total Condylar Knee replacement maintains excellent durability at 20-years followup.
TL;DR: Autologous chondrocyte implantation has been used since March 1995 in a prospective cohort evaluation and there were 22 failures in 169 patients treated, which was defined as no clinical improvement or graft failure.
Abstract: Autologous chondrocyte implantation has been used since March 1995 in a prospective cohort evaluation. One hundred sixty-nine patients, 13 to 58 years, have been treated as of December 1999. One hundred seven patients have greater than 12 months followup, and 56 have greater than 24 months followup. Overall 87% of patients improved. Patient assessment instruments include the modified Cincinnati knee rating scale, Short Form-36, Knee Society score, Western Ontario McMaster Universities Osteoarthritis Index score, and patient satisfaction survey. Treatment cases included the following categories: Simple (N = 12) isolated femoral condyles; Complex (N = 86) nonarthritic knees with multiple defects on the femur, or isolated lesions to the patella or tibia; and Salvage (N = 71) knees with early arthritic changes. The areas treated were large: Simple, 4.3 cm2 (one defect); Complex, 6.75 cm2 (4.5 cm2 per defect x 1.5 defects per case), and Salvage, 11.66 cm2 (5.3 cm2 per defect x 2.2 defects per case). Patients who had complex and salvage treatments (N = 107) with greater than 1 year followup frequently had adjuvant treatments including valgus tibial (N = 24) or tibial tubercle (N = 15) osteotomies or ligament reconstruction (N = 5). At the 2-year followup, statistically significant functional improvements occurred in the patients in the Simple and Complex categories (Cincinnati score; Simple, baseline 3.57, 24 months = 5.38; Complex, baseline 3.40, 24 months = 6.06). Patients in the Salvage category had statistically significant improvement in Short Form-36 quality of life scores (Physical summary, 24 months) and an increase in the Cincinnati rating scale when the patellofemoral joint was not involved. Patient satisfaction at 24 months for Simple, Complex, and Salvage categories was 60%, 70%, and 90%, respectively. There were 22 failures in 169 patients treated (13%), which was defined as no clinical improvement or graft failure.
TL;DR: A retrospective review was performed of 163 nonunions in 945 patients who underwent allograft transplantation for various benign and malignant tumors at the authors’ institution between 1974 and 1997, finding infection and fracture rates were higher in the patients with nonunion as compared with the patients withoutnonunions.
Abstract: Nonunion of allograft-host junction after bone transplantation is not uncommon, and its treatment frequently is problematic. To improve the understanding of these nonunions, a retrospective review was performed of 163 nonunions in 945 patients who underwent allograft transplantation (17.3%) for various benign and malignant tumors at the authors' institution between 1974 and 1997. Of these 945 patients, 558 did not receive adjuvant therapy. Chemotherapy was administered to 354 patients and only 33 patients received radiation therapy alone. Seventy-one patients had radiation treatment and chemotherapy. Of the 163 patients who had nonunion develop at the allograft-host junction, there were 269 reoperations performed on the involved extremity. In 108 patients, treatment was successful resulting in union of the allograft-host junction. Forty-nine patients did not respond to multiple surgical treatment attempts. The greater the number of surgical procedures, the worse the outcome. The rate of nonunions increased to 27% for the patients who received chemotherapy as compared with 11% for the patients who did not receive chemotherapy. The order of allografts from highest rate of nonunion to lowest was as follows: alloarthrodesis, intercalary, osteoarticular, and alloprosthesis. Infection and fracture rates were higher in the patients with nonunions as compared with the patients without nonunions.
TL;DR: Femoral component rotation parallel to the epicondylar axis resulted in the most normal patellar tracking and minimized patellofemoral shear forces early in flexion, which minimized tibiofemoral wear motions.
Abstract: Femoral component rotation is important in total knee arthroplasty to optimize patellofemoral and tibiofemoral kinematics. More recently, the epicondylar axis has been cited as the definitive landmark for femoral component rotation. However, there are few studies to support the validity of this rotational landmark and its effect on the patellofemoral and tibiofemoral articulations. In the current study, a total knee arthroplasty was done in 11 knees from cadavers. The knees were tested with various femoral component rotations from 5 degrees internal rotation to 5 degrees external rotation referenced to the epicondylar axis and to the posterior femoral condyles. Each knee acted as its own internal control. The knees were actively ranged from 0 degrees to 100 degrees by a force on the quadriceps tendon in an Oxford knee simulator. Three-dimensional kinematics of all three components were measured whereas a multiaxial transducer imbedded in the patella measured patellofemoral forces. Femoral component rotation parallel to the epicondylar axis resulted in the most normal patellar tracking and minimized patellofemoral shear forces early in flexion. This optimal rotation also minimized tibiofemoral wear motions. These beneficial effects of femoral rotation were less reproducibly related to the posterior condyles. Rotating the femoral component either internal or external to the epicondylar axis worsened knee function by increasing tibiofemoral wear motion and significantly worsening patellar tracking with increased shear forces early in flexion. Based on the current study, the femoral component should be rotationally aligned parallel to the epicondylar axis to avoid patellofemoral and tibiofemoral complications.
TL;DR: Lateralization of the femoral component in this series more closely restored preoperative hip biomechanics and significantly decreased polyethylene wear.
Abstract: Seventeen staged, bilateral total hip arthroplasties performed in 17 patients were reviewed to compare side-to-side polyethylene wear. Implants used on both sides were similar except for implant offset: one hip in each patient was replaced using a femoral component having a standard implant offset, whereas the other side had a lateral offset implant. The mean followup was 5.70 years (range, 2-10.2 years) on the side with a standard femoral implant and 5.67 years (range, 2-9.7 years) on the side with a lateralized femoral component. The only statistically different parameter between the sides was the femoral component offset. All other parameters affecting polyethylene wear, such as period of followup, head size, head type, cup size, cup inclination, medialization of cup, and patient-related factors were similar on both sides. On the side with a standard femoral component, the mean actual prosthetic offset (determined by manufacturer's specifications) was 35.2 mm and the radiologic offset was 31.5 mm. On the side with a lateralized femoral component, the actual prosthetic offset was 42.5 mm and the radiologic offset was 40.1 mm. The difference in offsets between the sides was statistically significant. The mean preoperative offset of the femur was 38.8 mm. Regression analysis revealed that only femoral component offset and cup size correlated significantly with linear wear rate. On the side with a standard femoral component, the linear wear rate was 0.21 mm per year, whereas on the side with a lateralized femoral component, the linear wear rate was 0.10 mm per year. The differences in the linear wear rates were significant. Lateralization of the femoral component in this series more closely restored preoperative hip biomechanics and significantly decreased polyethylene wear.
TL;DR: Radiographic evaluation at minimum 10-year followup showed stable fixation of all components, no gross migration but significant osteolysis requiring bearing exchange and bone grafting in three cementless rotating platform knee replacements in three patients who underwent previous surgeries at an average of 10.2 years from the index surgery.
Abstract: Clinical results of the initial cemented and cementless series of 373 New Jersey Low Contact Stress total knee replacements in 282 patients surviving at least 10 years were analyzed using a strict knee scoring scale. The study showed excellent, good, fair, or poor results in 68.1%, 29.8%, 2.1%, or 0% of primary posterior cruciate-retaining meniscal bearing knee replacements, 46.7%, 53.3%, 0%, or 0% results in primary cemented rotating platform knee replacements, and 68.1%, 29.8%, 2.1%, or 0% results in primary cementless rotating platform knee replacements, respectively. Radiographic evaluation at minimum 10-year followup showed stable fixation of all components, no gross migration but significant osteolysis requiring bearing exchange and bone grafting in three cementless rotating platform knee replacements (1.8%) in three patients who underwent previous surgeries at an average of 10.2 years from the index surgery. Survivorship of the patients who underwent primary cementless posterior cruciate-retaining meniscal bearing knee replacements with an end point of revision for any mechanical reason was 97.4% at 10 years and 83% at 16 years; using an end point of a poor clinical knee score the survivorship was 98.9% at 10 years and at 16 years. Survivorship of the patients who underwent primary cemented rotating platform knee replacements with end points of revision for any mechanical reason or a poor clinical knee score was 97.7% at 10 years and at 20 years. Survivorship of the patients who underwent cementless rotating platform knee replacements with end points of revision for any mechanical reason or a poor clinical knee score was 98.3% at 10 years and at 18 years.
TL;DR: The experience with autologous chondrocyte transplantation during the past 13 years with in vitro chondROcyte expansion, cartilage harvest, and postoperative biopsy technique is discussed, and the latest followup of 213 consecutive patients in different subgroups with 2 to 10 years followup is presented.
Abstract: Articular cartilage in adults has a poor ability to self-repair after a substantial injury; however, it is not known whether there is a cartilage resurfacing technique superior to the existing techniques. It is not satisfactory that at the beginning of the new millennium, there still is a lack of randomized studies comparing different cartilage repair techniques and there still is little knowledge of the natural course of a cartilaginous lesion. To date, various articular cartilage resurfacing techniques have the potential to improve the repair of cartilage defects and reduce the patient's disability. One such cartilage repair technique is autologous chondrocyte transplantation combined with a periosteal graft. Since the first patient was operated on in 1987, much interest in cartilage repair and cell engineering has emerged. The experience with autologous chondrocyte transplantation during the past 13 years with in vitro chondrocyte expansion, cartilage harvest, and postoperative biopsy technique is discussed, and the latest followup of 213 consecutive patients in different subgroups with 2 to 10 years followup is presented. The technique gives stable long-term results with a high percentage of good to excellent results (84%-90%) in patients with different types of single femoral condyle lesions, whereas patients with other types of lesions have a lower degree of success (mean, 74%).
TL;DR: An instrument was devised according to the particular requirements of the author's research, and began work in March 1930 in the Anatomy Laboratory of the New York UniverArthroscopy.
Abstract: Scholar of the Henry W. Frauenthal Travel Scholarship, Hospital for Joint Diseases Introduction The idea first occurred to us in the latter part of the year 1929 that it might be possible to see the interior of joints directly through a proper instrument introduced into the joint. In February 1930, we consulted with Mr. Reinhold Wappler concerning the construction of an instrument for this purpose. An instrument was devised according to our particular requirements. At that time, Mr. Wappler told us that he had not heard of any instrument for such a purpose, nor had he ever made any similar instrument. We first began work in March 1930 in the Anatomy Laboratory of the New York UniverArthroscopy or the Direct Visualization of Joints: An Experimental Cadaver Study
TL;DR: In this paper, the femoral anteversion angles and femoral head offset were investigated in 50 male and 50 female human skeletons with bilateral normal joints and four distinct configurations were identified relative to t
Abstract: Morphologic features of the hips, in particular those features germane to determination of acetabular and femoral anteversion angles and femoral head offset, were studied in 50 male and 50 female human skeletons with bilateral normal joints. Four distinct configurations were identified relative to t
TL;DR: Between 1982 and 1989, 100 primary lower limb reconstructions were done using the Kotz Modular Femur Tibia Reconstruction System after resection of a malignant tumor, resulting in a statistically significant reduction of implant failure.
Abstract: Between 1982 and 1989, 100 primary lower limb reconstructions were done using the Kotz Modular Femur Tibia Reconstruction System after resection of a malignant tumor. In 32 patients a proximal femur prosthesis was implanted, in 40 patients a distal femur prosthesis was implanted, in 19 patients a proximal tibia component was implanted, in four patients a total femur prosthesis was implanted, and in five patients a total knee prosthesis was implanted. The Kaplan-Meier estimate of the overall survival rate of the prostheses was 85% after 3 years, 79% after 5 years, and 71% after 10 years. The most common reason for implant failure was aseptic loosening in 27% of patients (11 patients; range, 10-121 months) after the initial operation. The other reasons for revision surgery were implant fracture (n 54) and infection (n 54). Early repair of prostheses-related minor complications, such as worn polyethylene bushings, resulted in a statistically significant reduction of implant failure. After a median followup of 127.5 months after the initial surgery, 51 patients had died and eight patients were lost to followup. Forty-one patients were evaluated clinically and radiologically using the Musculoskeletal Tumor Society score and the radiologic implant evaluation system of the International Symposium on Limb Salvage; these 41 patients had a mean of 80% (range, 40%-100%) of the normal functional capability.
TL;DR: The purpose of the current study was to compare the incidence of early posterior dislocation within the first 6 months after surgery using a complete posterior capsulectomy versus a formal posterior capsular repair.
Abstract: Formal repair of the posterior capsule and short external rotator tendons has been described as a surgical approach to reduce the incidence of posterior dislocation after posterolateral surgical approach to primary total hip replacement. The purpose of the current study was to compare the incidence of early posterior dislocation (within the first 6 months after surgery) using a complete posterior capsulectomy versus a formal posterior capsular repair. In patients with a complete posterior capsulectomy, 52 of 1078 primary total hip replacements (4.8%) had an early posterior dislocation. In patients with posterior capsular repair, three of 437 primary total hip replacements (0.7%) had an early posterior dislocation. This difference was statistically significant. The only complication in the capsular repair group was an avulsion fracture of the greater trochanter in four of 437 total hip replacements (0.9%).
TL;DR: The application of extracorporeal shock wave therapy should be the first choice of treatment for patients with nonunions and delayed bone fracture healing and resulted in bony consolidation with a simultaneous decrease in symptoms.
Abstract: One hundred fifteen patients with nonunions or delayed fracture healing were treated with high-energy shock waves. After shock wave treatment, immobilization of the fracture also was done. The followup was at least 3 months and as long as 4 years. In 87 patients (75.7%), one treatment with shock waves resulted in bony consolidation with a simultaneous decrease in symptoms. Besides negligible local reactions (swelling, hematomas, petechial hemorrhages), no complications were observed. The treatment was noninvasive, and personnel and technical requirements were not problematic. The authors concluded that the application of extracorporeal shock wave therapy should be the first choice of treatment for patients with nonunions and delayed bone fracture healing.
TL;DR: The author analyzes each factor, anatomic and mechanical, that influences the quality of the repair, and explains how to optimize the overall repair by optimizing each step in the repair.
Abstract: In the past 10 years, arthroscopic surgeons have gone from being unable to repair any rotator cuff tears arthroscopically to being able to repair virtually all rotator cuff tears, even complex massive tears, arthroscopically. The factors responsible for this rapid evolution have been: (1) recognition of the mechanical principles responsible for a secure repair (margin convergence, knot security, loop security); (2) recognition of major tear patterns that require different techniques of repair; and (3) development of instrumentation and arthroscopic portals that predictably accomplish secure repair of the rotator cuff and direct access to the pathologic areas. In the current study, the author analyzes each factor, anatomic and mechanical, that influences the quality of the repair, and explains how to optimize the overall repair by optimizing each step in the repair. In the author's series of arthroscopic repair of rotator cuff tears, the results have been gratifying, with massive tears achieving final results equivalent to those of smaller tears.
TL;DR: Statin drugs may offer some protection against having osteonecrosis develop when steroid treatment is necessary, and this 1% incidence is much less than the 3% to 20% incidence usually reported for patients receiving high-dose steroids.
Abstract: Osteonecrosis is a devastating complication of systemic steroid use. Prolonged steroid use produces a hyperlipidemic state in most patients and puts them at risk for osteoporosis and osteonecrosis. The fat content within the femoral head increases, resulting in increased intracortical pressure that may lead to sinusoidal collapse and osteonecrosis. Statins are lipid-clearing agents that dramatically reduce lipid levels in blood and tissues. Statins are widely used to prevent cardiovascular disease and have been shown to reduce the adverse effects of steroids on lipid metabolism. The purpose of this study was to determine whether the use of statin drugs affects later development of osteonecrosis in patients receiving steroids. The records of 284 patients who were taking statin drugs at the time they were started on high dose steroids were examined to determine whether osteonecrosis had developed. The patients remained on statin drugs during the entire time of steroid exposure. Magnetic resonance imaging scans were used to verify the osteonecrosis unless it was visible by radiograph. After an average of 7.5 years (minimum followup, 5 years), only three patients (1%) from the group had osteonecrosis develop. This 1% incidence is much less than the 3% to 20% incidence usually reported for patients receiving high-dose steroids. Statins may offer some protection against having osteonecrosis develop when steroid treatment is necessary.
TL;DR: The ulnocarpal ligaments attach to the palmar radioulnar ligament rather than directly to the ulna, allowing increased independence between wrist and forearm motion.
Abstract: The ligaments of the wrist are responsible for guiding and constraining the complex motion of the carpal bones relative to the forearm bones, the metacarpals, and contiguous carpal bones. The majority of wrist ligaments are found within the joint capsule as organized thickenings composed of parallel collagen fascicles, small caliber nerves and blood vessels, and lined on their deep surfaces by synoviocytes. The palmar radiocarpal ligament complex is composed of the radioscaphocapitate, long radiolunate, radioscapholunate and short radiolunate ligaments. The ulnocarpal ligaments include the ulnolunate, ulnotriquetral and ulnocapitate ligaments. Dorsally, the radiocarpal joint is spanned by the dorsal radiocarpal ligament. Palmar ligaments connecting the proximal and distal carpal rows include the scaphotrapeziotrapezoid, scaphocapitate, triquetrocapitate and triquetrohamate ligaments. Within each row are interosseous ligaments connecting adjacent carpal bones, each divisible into dorsal and palmar components. There are unique regions within some of the ligaments, such as a zone of fibrocartilage in the proximal regions of the scapholunate and lunotriquetral interosseous ligaments, and strong deep regions connecting the trapezoid, capitate, and hamate. The distal radioulnar joint is connected by the triangular fibrocartilage complex, composed of a fibrocartilaginous disc and the palmar and dorsal radioulnar ligaments. The ulnocarpal ligaments attach to the palmar radioulnar ligament rather than directly to the ulna, allowing increased independence between wrist and forearm motion.
TL;DR: The current study showed that the directed application of electrohydraulic-generated shock waves to the insertion of the plantar fascia onto the calcaneus is a safe and effective nonsurgical method for treating chronic, recalcitrant heel pain syndrome.
Abstract: Three hundred two patients with chronic heel pain caused by proximal plantar fasciitis were enrolled in a study to assess the treatment effects consequent to administration of electrohydraulicall-generated extracorporeal shock waves. Symptoms had been present from 6 months to 18 years. Each treated patient satisfied numerous inclusion and exclusion criteria before he or she was accepted into this study, which was approved by the Food and Drug Administration as a randomized, double-blind evaluation of the efficacy of shock wave therapy for this disorder. Overall, at the predetermined evaluation period 3 months after one treatment, 56% more of the treated patients had a successful result by all four of the evaluation criteria when compared with the patients treated with a placebo. This difference was significant and corroborated the fact that this difference in the results was specifically attributable to the shock wave treatment, rather than any natural improvement caused by the natural history of the condition. The current study showed that the directed application of electrohydraulic-generated shock waves to the insertion of the plantar fascia onto the calcaneus is a safe and effective nonsurgical method for treating chronic, recalcitrant heel pain syndrome that has been present for at least 6 months and has been refractory to other commonly used nonoperative therapies. This technology, when delivered using the OssaTron (High Medical Technology, Kreuz-lingen, Switzerland), has been approved by the Food and Drug Administration specifically for the treatment of chronic proximal plantar fasciitis. The results suggest that this therapeutic modality should be considered before any surgical options, and even may be preferable to cortisone injection, which has a recognized risk of rupture of the plantar fascia and recurrence of symptoms.