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Sixty-one Total Condylar III (TC III) prostheses were implanted in 59 patients at the authors' institution between March 1977 and December 1987. Among the knees with adequate clinical and roentgenographic data, the average follow-up period was 6.1 years. There were six primary arthroplasties and 29 revisions in this group. The primary diagnosis was osteoarthrosis in 17 patients, rheumatoid arthritis in 16 patients, and juvenile rheumatoid arthritis in two patients. The knee score improved from 21.9 preoperatively to 73.7 at last follow-up evaluation. Based on the knee score, there were 71% good or excellent results. There were three failures (8.6%). Radiolucent lines were present in at least one component in 71% of patients, but few of these were considered significant. Although rarely needed, the TC III prosthesis has been shown to be a satisfactory and durable solution to complex knee reconstructive problems including severe deformity, ligamentous instability, and bone loss.

The purpose of this study was to compare unicompartmental knee arthroplasty (UKA) with total knee arthroplasty (TKA) and more specifically to evaluate the role of the patella in patient preference between UKA and TKA. A group of 23 patients were chosen, each with a UKA in one knee and a TKA in the opposite knee. As a subset of the group, 13 patients were compared who had not had patellar resurfacing on their TKA side (Group A) versus ten patients who had patellar resurfacing (Group B). Each patient had a UKA and TKA performed during the same hospitalization. Each patient's resurfacing was performed by the same surgical team. Moreover, inpatient care and physical therapy for each patient's respective UKA and TKA were the same. Patient evaluation consisted of chart review, joint registry data, and telephone interviews that focused on patient preference regarding pain, stability, "feel," and ability to climb stairs. The 23 patients studied had an average follow-up period of 81 months (range, 38-153 months). There were 14 men and ten women with an average age of 67 years. Preoperative diagnosis was osteoarthritis in 22 patients and rheumatoid arthritis in one patient. Range of motion (ROM) improved from a preoperative mean of 106 degrees to 123 degrees postoperatively on the UKA side. Mean ROM for the Group A TKAs improved from 104 degrees to 109 degrees, whereas the Group B TKAs remained unchanged at 113 degrees. For patients surveyed in Group A, 31% stated that their UKA knee was their better knee overall, 15% stated that their TKA knee was their better knee overall, and 54% could find no difference.(ABSTRACT TRUNCATED AT 250 WORDS)

We reviewed six capitellocondylar metal-to-plastic total elbow replacement prostheses with radial head components, implanted in patients with rheumatoid arthritis. At an average of 4.7 +/- 1.5 years, relief of pain, improvement of function, and a functional range of motion were preserved. Five of the six elbows (83%) were clinically rated good or excellent. Radiolucent lines were seen at the bone-cement interface in 50% of the humeral component stems and in all ulnar component boats within 2 years after surgery; none had progressed at subsequent examination. Most were less than or equal to 1 mm wide, and none were associated with clinical deterioration. Only one of the humeral components was radiographically loose. No radiolucent lines were seen along the stems of the ulnar or radial components. There were no postoperative dislocations when the radial component was used, presumably because the prosthetic radial head provided increased constraint. None of these elbows have required revision. Radial head replacement in capitellocondylar arthroplasty had been discontinued because radiolucent lines were observed at early review. However, the absence of clinical failure, dislocation, or progression of radiolucency at long-term follow-up examination favor radial head replacement in primary unconstrained total elbow arthroplasty.

Three cases of early recurrent synovitis of the rheumatoid elbow following silicone radial head implant arthroplasty are presented. All three patients underwent synovectomy with silicone radial head implant for pain and loss of function due to rheumatoid synovitis. All three implants failed within 4-9 months after surgery. This failure was associated with radiographic medial joint space widening. At reexploration, recurrent synovitis with hemosiderin pigmentation was noted. Patterns of prosthetic failure included fracture, fraying, and compressive deformation or rotary wear ("motar and pestle") of the silicone radial head; a prosthetic stem fracture was also present. Histologic examination of the synovium revealed evidence of silicone-induced synovitis; particulate, refractile silicone debris was associated with inflammatory and foreign body giant cells. The presence of rheumatoid destruction of the joint surface may have accelerated this process and may be a relative contraindication to silicone radial head implant arthroplasty.

Nineteen total knee arthroplasties in 16 patients were performed using a new prosthesis designed specifically for uncemented, press-fit fixation without any provision for tissue ingrowth. This design may be suited for use in patients with juvenile rheumatoid arthritis, postseptic knees, failed total knee arthroplasties with large bone stock deficiencies, and young, active, overweight individuals. Preservation of bone stock is possible because the fixation stems are nails rather than larger cement pegs, removal for revision is easier without cement, sequestration of microbes within cement cannot occur, and bone graft may be continually loaded with this type of prosthesis. Pain relief, discarding crutch support, operative blood loss, and corrective alignment were equivalent to results obtained with cemented arthroplasty. Seventeen of the 18 knees available for review (average follow-up period, 3 years, 7 months; range of follow-up period, 2 years, 10 months to 4 years, 11 months) were pain-free. Range of motion averaged -2 degrees of extension to 101 degrees of flexion. Ambulation was unrestricted and unsupported in the majority of patients. Radiographic evaluation showed the development of increased bone density under the tibial plateau as well as a sclerotic line at the ends of the femoral and tibial stems. This observation gives support to the theory that multiple microtrabecular fractures with healing form a new supportive "subchondral bone plate." There was one incidence of tibial subsidence. Prosthesis migration and loosening were not observed.

Bone loss in the distal anterior femur in asymptomatic total knee arthroplasty (TKA) patients has been noted roentgenographically and during revision surgery. A retrospective roentgenographic review of 147 TKA cases was carried out to document bone loss. The influence that the mode of fixation (porous coated and cemented) and the implant design have on bone loss was examined. The time of onset and the progression of bone loss were studied. Bone loss occurred in the distal anterior femur in the majority of cases reviewed (68%). The prevalence of bone loss was independent of the mode of fixation and the implant design. By qualitative observation, roentgenographically detectable bone loss occurred within the first postoperative year and did not progress further. Previously three-dimensional finite element analysis demonstrated that the replacement of the bearing surface of the femur with a stiff metallic implant reduces the stress in the distal anterior femur by at least one order of magnitude. It is therefore speculated that the observed bone loss results from stress shielding. The apparent lack of progression may reflect the development of a new remodeling equilibrium under the altered stress conditions. The bone loss in the distal anterior femur described has not been implicated as a source of failure. However, since the bone strength in the femoral region is compromised as it becomes osteopenic, bone failure may occur with longer periods of cyclic loading. Furthermore, as a result of bone loss, revision arthroplasty may be more difficult.

A review of the results of 192 kinematic total knee replacements five to nine years after the operation showed that the results were still satisfactory. At the time of the review, the ages of the patients ranged from twenty-two to eighty-seven years. About half of the patients had rheumatoid arthritis and the other half, osteoarthrosis. About 90 per cent of the results were rated good or excellent, and the average range of flexion was 109 degrees. Radiolucency was present around 40 per cent of the tibial components, 30 per cent of the femoral components, and 60 per cent of the patellar components, but the lines were thin and not progressive. The complications included loosening of the patellar components in five knees, one fracture of the tibial tray with loosening of the patellar component, one fracture of the patellar component, and one dislocation of the patellar component.

Revision rates, complication rates, and the bone-cement interface reaction of 1,069 condylar total knee replacements were reviewed to help decide if conventional total knee replacement continues to be appropriate for the older low-demand patient. This knee replacement series was also compared with two published series of total hip replacements from the same institution. The conclusions are (1) in medium-term follow-up, total knee replacement is as good as or superior to total hip replacement and (2) based on bone-cement interface analysis, survival of total knee replacement is expected to be superior to conventional total hip replacement ten years postoperatively.

Total knee replacement has come of age, and long-term results are much better than those for total hip replacement. The designs of the late 1980s have addressed function, mobility, wear, and long-term survival for the young and active. Conventional, cemented knee arthroplasty is highly successful and well represented by the state of the art in the Kinemax total knee replacement prosthesis. This design also has the capability of treating the postseptic knee, the knee that requires extensive bone grafting, and, experimentally, the young, the active, or the overweight patient.

Peripheral defects in the proximal tibia can be difficult to treat during total knee arthroplasty. Attempts can be made to solve the problem with cement, cement with screws, bone grafts, metal wedges, and custom components. In vitro testing has shown that a custom-augmented prosthesis with a built-up metal wedge is mechanically superior in resisting deflections when loaded. Using modular metal wedges, the tibial tray can be customized at the time of surgery. In vitro testing has also shown the wedge to be superior to the use of cement alone or cement reinforced by screws. The authors report on modular metal wedges to augment tibial bone stock deficiency. Twenty-two knees (20 patients) were followed for a minimum of two years with an average follow-up time of 37 months. The average age of the patients at the time of surgery was 70 years. There have been no failures of this technique and no loosening of tibial components. The incidence of nonprogressive radiolucent lines was 27%. All but one patient was pain-free, and this patient's discomfort was not related to the tibial component fixation. No patient has had subsequent revision surgery. This technique should be considered in the treatment of severe peripheral tibial deficiencies in the elderly, low-demand patient.

Calcium ions have been shown to be involved in smooth muscle contraction and various secretory processes. Nifedipine, a calcium channel blocking drug, does not have any intrinsic bronchodilatory effect, but it has been suggested to possibly inhibit bronchial reactivity. Eight patients, with normal baseline pulmonary function studies and methacholine-induced bronchial reactivity, had a repeat metacholine challenge after nifedipine. Spirometry was obtained at baseline and three minutes after successive inhalations of normal saline and five, 15, 30, 50, 100 and 200 inhalation units of 0.5% methacholine. Plethysmographic lung volumes and airways resistance were measured at the start of the test and after the last inhalation of methacholine. The FEV1, FVC, MMEF and PEFR were reduced by an average of 35.6%, 20.6%, 54.4% and 30.6%, respectively, on the initial study, and by 35.4%, 20.5%, 54.8% and 34.5% after nifedipine. Airways resistance was increased by 249.3% in the initial study and by 265.7% after nifedipine. There was no statistical difference in baseline spirometry, spirometry obtained at any level of methacholine inhalation, or in airways resistance between the two studies. Despite comparable decreases in lung function, all patients were less symptomatic after receiving nifedipine. Nifedipine does not alter methacholine-induced bronchial reactivity. Until the role of nifedipine in asthma is better defined, caution should be used in prescribing nifedipine to asthmatic patients with heart disease, because their perception of airways resistance may be altered.

A theoretically attractive approach to femoral head arthroplasty would be the preservation of a"biologic" bearing surface composed of autogenous articular cartilage and subchondral bone, supported by a prosthetic material with mechanical properties similar to those of trabecular bone. The substitution of such a material for bone would preclude incomplete revascularization of the femoral head and eventual bony collapse. The advantages of preserving the patient's hip joint, even in the face of a fracture that has caused the loss of vascular supply to the femoral head, are self-evident. To test this hypothesis, seven dogs underwent hip arthroplasty, whereby the trabecular bone of the femoral head was replaced with polymethylmethacrylate. When killed 2 1/2 years after operation all of the dogs demonstrated injury or loss of articular cartilage in the superior aspect of the femoral head. The lesions are consistent with advanced osteoarthritis by gross and histologic examination. These lesions apparently were produced by changing either the geometry or stiffness, or both, of the material supporting the articular cartilage. Supporting human articular cartilage with methacrylate for joint arthroplasty is not recommended.

A roentgenographic knee evaluation system endorsed by The Knee Society is included in this year's proceedings to encourage uniform reporting of the results of total knee arthroplasty. No rating system is ideal, but if many surgeons and centers use the same reporting system, then relative comparisons will at least become possible. Agreement on a new system by many experienced surgeons and institutions with a large clinical volume represents a sacrifice because old rating system data will have to be discarded.

A series of 100 consecutive patients with total hip replacements in whom trochanteric osteotomy was performed was compared with 100 patients in whom the greater trochanter was left in place. The groups were comparable with respect to age and incidence of osteoarthritis and connective tissue disorders. Although no statistically significant difference was noted among trochanterectomy groups or disease subgroups in terms of preoperative impairment as indicated by preoperative Harris score, 16 patients presented exposure problems necessitating trochanteric osteotomy despite preoperative plans to leave the trochanter in place. Salvage operations after unsuccessful previous operations were performed in 18 patients in the osteotomy group and 11 in the nonosteotomy group. Mean operating time was 3 hours for patients in the osteotomy group and 2 hours for those in the nonosteotomy group. Considerably more intraoperative and postoperative blood replacement was required in the patients having osteotomy. Patients sat, stood, walked, and left the hospital sooner in the nonosteotomy group than in the osteotomy group. Trochanteric bursitis requiring treatment 3 or more months after operation occurred in 17 patients having osteotomy and in 3 patients not having osteotomy. Hematomas developed in 15 patients in the osteotomy group and in 4 in the nonosteotomy group. Ectopic bone formation was observed in 12 of the osteotomy group, 8 with limitation of function, and 5 of the nonosteotomy group; non had symptoms. Six osteotomized patients had troublesome abductor weakness secondary to wire breakage and proximal migration of the trochanter. The rates of infection and thrombophlebitis were low in both groups. When exposure was not difficult, leaving the trochanter intact had many advantages.

Ninety-three total hip arthroplasties were examined radiographically and clinically to investigate the best method of correction in protrusio acetabuli. Fifty-three percent were treated with cement alone, 36% with mesh or protrusio shell, and 11% with bone graft. Long-term follow-up study revealed a high percentage of immediate and late radiolucent lines. The highest rate of loosening, 50%, occurred in the cement alone group, which had not been corrected to within 10 mm of anatomic position. Sex, cause of protrusio, age at operation, and degree of osteopenia were not significantly different between the groups. The follow-up period was longer in the cement alone group, but this did not account for the excessively high rate of loosening. Correction of the anatomic position in protrusio deformity is vital, whether accomplished with cement, mesh, protrusio shell, or bone graft. Late radiolucent lines are common and do not reliably indicate loosening.

During a ten-year period, 4240 total hip, knee, and elbow arthroplasties were performed. The overall infection rate was 1.25%. Certain groups were identified as being at higher risk of infection following total joint arthroplasty: rheumatoid arthritics were at 2.6 times greater risk than osteoarthritics; patients undergoing total hip arthroplasty as a revision of a previous operation were eight times more likely to have infection than those undergoing a primary operation; and patients with metal-to-metal hinged knee prostheses, when compared with patients with metal-to-plastic knee prostheses, were 20 times more likely to have infection. The majority of infections could be attributed either to perioperative problems or late bacterial seeding from a distant site. Although most infections occurred by two years after operation, late infections, particularly in rheumatoid patients via the hematogenous route, occurred as long as nine years after operation. There was no correlation between the Gram's-staining characteristics of the pathogen and the outcome of the infected joint. Gram-negative organisms were frequent in the perioperative period and reflected either nosocomial infection or the ineffectiveness of the prophylactic antibiotic regimen used in inhibiting gram-negative pathogens. The major factors that influenced the outcome of the infected joint included the interval from the initial surgery to recognition of infection, the delay in institution of appropriate treatment, the particular joint that was infected, the integrity of the bone-cement interface, the type of prosthesis used, and the host susceptibility. Identification of high-risk groups and the recognition that patients with joint implants are at risk of infection at any time in the postoperative period may lead to a lowered infection rate in the future.

Between 1973 and 1978, 1,474 metal-to-plastic knee arthroplasties were evaluated to determine the typical modes of failure and improved design concepts (Table 2). Although the concepts are still evolving, and longer follow-up is necessary, recent experience with nearly 1,000 semiconstrained devices allowing cruciate retention strongly suggests that duopatella and kinematic design concepts are correct. Soft tissue reconstruction is critical with these designs, since they rely heavily on soft tissue integrity and balance. If the concepts of soft tissue balance, prosthetic design, and physical rehabilitation are applied, total knee replacement is as reliable in relieving pain and restoring function as total hip replacement. The low incidence of radiolucency at the bone-cement interface (although the length of follow-up is relatively short), coupled with the results of in vitro bench testing, suggest that the longevity of this generation of knee implants should be adequate.

One thousand sixty-nine consecutive cemented Kinematic Condylar total knee arthroplasties performed by one group of orthopaedists were studied. The maximum follow-up period was 7 years. Most patients had rheumatoid arthritis or osteoarthritis, and the average patient age was 67 years (range, 12-90 years). Aseptic revisions for loosening were required for only one tibial component and six patella components. Average postoperative flexion was 2.5-107 degrees. The preoperative to postoperative change in range of flexion was not affected by the tilt angle of the tibial component in the sagittal plane. With the use of external alignment guides, the average postoperative alignment was ideal but the standard deviation was high; the standard deviation and the extremes were lower when intramedullary guides were used. There was a 14% incidence of femoral radiolucency and a 30% incidence of tibial radiolucency, which increased only slightly with time. Most radiolucencies on the tibial side were small and restricted to the extreme edges; rarely did radiolucency occur around the central peg. More than one half of the thicker radiolucencies occurred adjacent to wedge-shaped bone defects that were filled with cement.

The results of 138 total hip arthroplasties in 98 rheumatoid arthritic patients were reviewed six to 11 years (mean, 7.0 years) after operation. While 96% of the patients were clinically improved as a result of surgery, radiographic analysis suggests that, despite their low functional requirements, this group of patients experiences mechanical loosening and failure with time. Improvements in prosthetic design and cementing technique should contribute to a lowered incidence of mechanical failure in the future. In addition to improvements in technology, the failure rate can be further diminished by recognition of the systemic problems associated with rheumatoid arthritis, e.g., high incidence of infection, osteopenia, and sequelae of multiple joint involvement. In reconstruction of the acetabulum, especially in the presence of protrusio, failure to restore the anatomic position and orientation of the acetabulum predisposes to loosening and migration.

Stress fracture of the patella can occur with significant frequency following patellar replacement with the duopatellar knee prosthesis. In the first 372 knees with patellar resurfacing, the incidence was 0.7% in rheumatoid arthritis (2 fractures in 286 knees) and 3.5% in osteoarthritis (3 fractures in 86 knees). The incidence may be greater in osteoarthritic patients because they have more function and are generating greater force across the patellofemoral joint. There was an association with osteonecrosis of the patella in at least three cases in which a lateral retinacular release had been performed and the lateral superior genicular artery sacrificed. This vessel should be preserved during a lateral release to save its contribution to the blood supply of both the patella and the lateral skin flap. Initial treatment of the stress fractures can be nonoperative, with surgery necessary only if the patellar prosthesis has become dislodged, or if pain or inadequate active extension persists. If the fracture can not be repaired, patellectomy can yield a good result. To avoid stress fracture, a minimal amount of patellar articular surface should be resected and the peripheral cortex of both the medial and lateral facets preserved. Fewer stress fractures may occur if a smaller fixation lug is used, thereby preserving more patellar bone stock.

In the eight-year experience at the authors' institution (1974-1981) with an unlinked resurfacing elbow prosthesis, one failure occurred due to loosening of an ulnar component (1 of 153; 0.6%). The authors concluded that loosening of the prosthetic components in bone is not a serious problem, but other problems remain. Postoperative dislocation continued after a lateral approach was adopted but improved with the use of components of variable sizes. Ulnar nerve palsies are an unsolved problem and require special investigation in the rheumatoid patient. Other soft tissue problems have been relieved by the more physiologic lateral approach. Indications have been expanded to include posttraumatic or osteoarthritic conditions in relatively inactive elderly patients.

To determine ideal alignment and component placement of total knee prostheses, Kinematic (K) and total condylar (TC) devices were physiologically loaded and interface forces were measured. Laboratory observations were correlated with clinical (roentgenographic) findings. Asymmetric loading of the tibial component has been proposed as causing loosening and radiolucent lines. Misalignment of components is one factor that affects load sharing by bone under the medial and lateral regions of the tibial plateau. Tibial components of K and TC prostheses were inserted without cement into the cut surfaces of artificial tibiae. The mating femoral condylar components were mounted. The tibial and femoral components were individually positioned at 0 degrees (horizontal) and at certain angles of varus and valgus. Pressure-sensitive film was placed between the tibial component and the artificial tibia. A vertical load of 1500 N was used. The experiment was replicated twice. The percentages of the load on the medial and lateral regions of the tibial plateau were calculated from quantitative image analysis of the pressure patterns on the film. Roentgenograms from 532 K and 21 TC patients were examined to determine the orientations of the condylar and tibial components and the presence of radiolucent lines around the tibial component. An even distribution (ideal alignment) of load on the medial and lateral regions of the K tibial component occurred at 9 degrees of valgus tilt of the femoral component and 2 degrees of varus tilt of the tibial component and for the TC at 7 degrees valgus and 0 degrees varus. Misalignment by 5 degrees yielded a 7% change in the load distribution under the K plateau and a 40% change for the TC prosthesis; a 10 degrees misalignment produced changes of 34% and 62% for the K and TC, respectively. Small variations in clinical knee alignment produced the same percentage of radiolucent lines for each alignment group. The location of radiolucent lines was distributed among the medial, lateral, and both tibial plateaus regardless of knee alignment, although there were more medial reactions overall. The smallest incidence (8%) of radiolucent lines occurred with the K prosthesis at 7 degrees of knee valgus, the femoral component placed at 9 degrees valgus, and the tibial component at 2 degrees varus. This correlated with the ideal bench-test findings for the K device.

Total elbow replacement utilizing the G.S.B. hinge prosthesis will improve function in patients with ankylosed or painful, unstable elbows in the early postoperative period. However, painful loosening has been the primary long-term problem and has led to the abandonment of this concept even for salvage of the destroyed rheumatoid elbow joint.

A 78-year-old woman presented with a painful total hip arthroplasty five years postoperation. Plain radiographs revealed air in the hip joint. Aspiration of the hip indicated hip sepsis, and arthrogram showed communication of the hip joint with the sigmoid colon. Cultures grew Bacteroides fragilis. Abdominal exploration showed a ruptured diverticulum that decompressed through the sciatic notch into the total hip arthroplasty. A colostomy was performed, and the hip joint was drained and debrided laterally at the same operation. The prosthesis was later removed with all cement, and the hip was converted to a Girdlestone resection. The authors conclude that air or gas shadows in a painful total hip arthroplasty are an ominous finding and mean either joint sepsis with a gas-forming bacteria or communication of the joint with a hollow viscus and sepsis.

A study was undertaken to compare the cardiac and ventilatory responses to different types of exercise between 12 patients with COPD and ten normal age-matched control subjects. Both groups attained comparable heart rates and the percentage of their maximum predicted heart rate. Patients had a higher heart rate and VE with a lower O2P at every level of work load. Patients had a mean VT which approximated their FEV1 and increased their VE predominantly by increasing their respiratory frequency. During the low intensity test, despite the differences in work load, the patients had comparable heart rates and VE. No resting spirometric value accurately predicted work load, VE, or maximal VO2. We conclude that patients have a reduced work tolerance that is not adequately explained by their reduced lung function. Thus, cardiac factors, deconditioning, and the dyspneic sensation may be determinants of exercise limitation in some patients.

Twenty-four nonconstrained total elbow arthroplasties (TEAs) in 20 patients with severe disabling functional class IV rheumatoid arthritis were reviewed retrospectively to determine the effects of their disease on the end result. The mean follow-up period was 6 years (range, 2-11 years). All planes of elbow motion improved after surgery (P less than .005), there was a highly significant reduction in pain and improvement in function (both P less than .005) and patient satisfaction was high. The severity of the disease does not appear to affect the end result when a nonconstrained TEA is used, and the results compare favorably with those of other series reported.

During the period 1969 through 1974, 716 total hip-replacement arthorplasties were performed. The results of the surgery in 275 cases of rheumatoid arthritis as regards complications were compared with those in 382 procedures in cases of osteoarthritis. In contrast to the reports of others,the incidence of deep would infection in the two groups was found to be equal. Patients undergoing total hip-replacement arthroplasty as a revision of a previous operation had a substantially increased risk of infection. Patients with rheumatoid arthritis, however, were more subject to certain other complication (intraoperative fracture, difficulties with anesthesia, and malposition of prosthetic components), in addition to the complications that were predictable because of the involvement of multiple joints and the systemic disease process.

Destroyed patellar articular surfaces were replaced with a high molecular weight polyethylene prosthesis in two patients. The patellofemoral articulation of the femur consisted of eburnated bone in one case and degenerative cartilage in the other. Both operations failed within one year because of a giant cell synovitis caused by a high volume (0.2 cc) of fine polyethylene (1-100 mu) wear particles. Ultra high molecular weight polyethylene should not be used as a prosthetic bearing surface to articulate against cortical, cancellous or eburnated bone or against degenerative articular cartilage in a major joint.