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Study design Patellar tendon reflexes were elicited among patients who had had a unilateral total knee replacement, those planned for unilateral total knee replacement, and a cohort of controlled patients. Patellar tendon reflex (PTR) response was measured with surface electromyography. Objective The aim of this study was to determine if total knee arthroplasty significantly alters the PTR. Summary of background data As part of the clinical evaluation of the spine, extremity reflexes are provoked. Reflex variation between right and left extremities can be a pathological finding in disease of the spine. It has been noted that in patients who have undergone total knee arthroplasty (TKA), the PTR is diminished on the operative side compared with the contralateral nonoperative side. PTR is part of the clinical exam when evaluating a patient for lumbar radiculopathy. Methods The right and left patellar tendon reflex intensities were measured by quadriceps surface electromyography in 3 groups of patients. Group 1 consisted of 21 patients with unilateral TKA who were at least 6 months postoperative. Group 2 consisted of 18 patients with unilateral severe knee arthritis indicated for TKA. Group 3, serving as the control group, included 20 patients with no evidence of knee arthritis in either knee. The average reflex response for each group was recorded and comparisons were then made between each group. Results Patients who have undergone unilateral TKA have a PTR on average of 55.1% of their contralateral uninvolved side. This is statistically significant when compared with reflexes in patients who are planned for unilateral total knee arthroplasty, 96.03% (P = 0.001) and when compared with patients without evidence for knee arthritis, 102.2% (P Conclusion The results of this case control study show that TKAs do significantly diminish PTRs when compared with a contralateral uninvolved knee in the same patient. Level of evidence 3.

Purpose. To evaluate early and mid-term risk factors and dislocation rates in the posterior surgical approach in three separate community private practices using a short curved neck-sparing total hip stem design.Material and Methods.The three senior authors performed 338 short curved neck-sparing stem designs since April 2010 to June 2014. Various cementless acetabular components were used for all three surgical centers based on preoperative and intraoperative risk factors. All cases were reviewed retrospectively for incidence of dislocation after surgery.Version and inclination of the acetabular component and version of the femoral component were assed intra-operatively prior to final implantation. Various risk factors were reviewed including surgical approach, cup position, combined cup and stem positioning, and femoral head size.There have been significant papers in the past ten years that have recommended large head diameters to reduce the chances of head/neck mechanical impingement. Since the neck-sparing designs have a potentially increased risk of mechanical impingement head diameters were restricted to 32 mm or larger. In the smaller patient profile if a 32 mm head size could not be reached a dual-mobility style implant was chosen or stem choice was changed to a conventional style design.Results.Historically the posterior approach has had higher reports of dislocations as compared to direct anterior, anterolateral or straight lateral approach in conventional cemented and cementless implant designs. Older neck-sparing designs of conventional stem length by Freeman, Townley and Whiteside have not reported any increased dislocation problems but these stems have been associated with modified acetabular component designs, including the short curved neck sparing design of Pipino back in the 1980s.Incidence of dislocation in our series utilizing a short curved neck-sparing stem with more traditional hemispherical cementless acetabular components was 3 or 0.88%.Conclusion.Neck sparing stem designs do save significantly more bone and require less soft tissue dissection as compared to conventional cementless stem designs. Mechanical risk factors are increased with the use of short curved neck-sparing stem designs. Careful pre-operative and intra-operative evaluation does reduce the risk factors resulting in low and in some cases lower than previous published rates with conventional style stems.Short curved neck sparing stems do provide safe and reliable reproduction of the joint mechanics in routine primary total hip arthroplasty in both short and mid term results.Key Words: hip, arthroplasty, posterior approach, dislocation, neck sparing, and risk factors

The influence of femoral component surface finish was investigated by comparing 2 finishes, precoat and satin finish, for 1 cemented total hip arthroplasty (THA) system using 1 acetabular cup design. All surgeries were performed by a single surgeon in 2 consecutive series. Minimum 2-year follow-up outcomes (36 precoat, 25 satin) were compared using Harris Hip Scores, radiographs, and survivorships. The precoat population experienced significantly more radiographic and debonding failures than the satin-finish population, and significantly more pain (P

Dislocation is the most common complication occurring after total hip arthroplasty.Several factors contribute todislocation, ie, surgical approach, inadequate restoration of soft tissue tension, prosthetic design, and orientation of the prosthetic components. Management includes closed reduction and hip cast brace, spica cast, revision of one or both components, acetabular augmentation, the use of bipolar or large unipolar heads, or a constrained system. If all causative factors are identified and corrected, stability can be achieved. Prevention is the best form of management.

Single-stage, bilateral, cementless total hip arthroplasties were performed in 92 patients (184 arthroplasties) between March 1984 and December 1989. The clinical and radiographic findings were retrospectively evaluated, and the effects of weight bearing on the clinical and radiographic outcomes of the patients' prostheses were assessed. With a follow-up period ranging from 24 to 77 months (average, 44 months), the postoperative Harris hip scores averaged 94.6. Radiographic assessment at the most recent follow-up examination showed that 70% of the femoral components were optimally fixed, 26% were stable, and 4% had failed. Ninety-six percent of the acetabular components were optimally fixed. There were six acetabular component failures. These results indicate that single-stage, bilateral, cementless total hip arthroplasty can be performed without compromise to either hip if initial fit is achieved in both the metaphyseal and diaphyseal portions of the femur. Moreover, weight bearing did not adversely affect the initial stability and possible bone ingrowth, further implicating initial rigid fixation as paramount among the factors influencing the amount of ingrowth into the prosthesis.

From 1981 through 1991, 3,032 primary total knee arthroplasties were performed using the Insall-Burstein Posterior Stabilized Condylar Prosthesis (IB-I, IB-II, and IB-II modified) (Zimmer, Warsaw, IN). Fifteen posterior dislocations occurred: 4 with the IB-I system occurring 2 or more years after surgery, 10 with the IB-II system (8 occurring 6 months after surgery and 2 occurring 2-3 years after surgery), and 1 with the IB-II modified system occurring 9 months after surgery. Statistically significant differences for the rate of dislocation between both the IB-I and IB-II modified arthroplasties versus the IB-II arthroplasties were found (P.001). In an attempt to identify a cause for these dislocations, the authors retrospectively assessed the 15 dislocated cases with respect to sex, age, weight, height, preoperative and postoperative Hospital for Special Surgery scores, preoperative and postoperative alignment, preoperative versus postoperative reconstruction dimensions, patellar thickness and height, and postoperative flexion and compared the results with those patients who did not experience dislocation. Possible etiologies and mechanisms of dislocation were sought. There were no significant differences between the control and study groups for any variable assessed, with the exception of postoperative flexion, which averaged 118 degrees for the study group and 105 degrees for the control group (P.001). Conservative management was successful in 11 cases. In September 1988 the IB-II system was introduced; modification of the tibial insert was made in January 1990.(ABSTRACT TRUNCATED AT 250 WORDS)

In an effort to identify prognostic indicators for knee manipulation, the authors retrospectively reviewed the records of 60 osteoarthritic patients with posterior stabilized knee implants who required manipulation (94 knees) between January 1984 and December 1986. They also studied the records of 28 consecutive osteoarthritic patients who were implanted with 41 posterior stabilized knees between January 1985 and September 1985 whose knees did not require manipulation (control group). In both patient groups the following parameters were assessed and compared: overall knee alignment, joint line elevation, anterior to posterior (AP) dimension of the knee, AP placement of the tibial component, patellar height, obesity, age, preoperative flexion, time of manipulation, single vs bilateral knee implants, final flexion, final Hospital for Special Surgery (HSS) score, and the development of heterotopic ossification. The findings of this study showed that an increase in the AP knee dimension by 12% or greater was a critically independent variable that significantly pre- disposed patients to manipulation. They also show that quadriceps adhesions were another major factor leading to manipulation, and that rupturing of these adhesions led to an increase in heterotopic ossification. This review also indicated that 3 months after knee arthroplasty was a significant time for evaluation because knee flexion and HSS score at this point in the patient's recovery positively correlated with the final HSS score.

The efficacy of a postoperative blood salvage system was assessed in 239 consecutive patients undergoing total knee or total hip arthroplasty. Patients were randomly allocated to either a control group using a standard drainage system or to the study group using the Solcotrans blood salvage canister. The median amount of homologous blood required after operation by the study group was reduced by 74% from the amount required by the control group (mean, 67 ml vs 256 ml, respectively; P P

A prospective study of thirty-eight patients (seventy-six knees) who had had a primary bilateral total knee replacement and twelve patients (twenty-four hips) who had had a primary bilateral total hip replacement was conducted to assess the effect of postoperative suction drainage on wound-healing. A suction drain was placed on each patient's right operative wound, while no drains were used on the left. Otherwise, the same operative technique and method of closure were used in all wounds. Statistical analysis of the results showed no difference between the two sides with regard to the incidences of swelling or persistent drainage. Return of active function of the quadriceps and of range of motion of the knee in patients who had had a total knee replacement was also unaffected by the use of suction drains. We concluded that the routine use of suction drains for wounds is unnecessary after uncomplicated total joint arthroplasty.

In an effort to improve the surface and wear characteristics of ultra-high molecular weight polyethylene, an enhanced ultra-high molecular weight polyethylene (Hylamer; DePuy-DuPont Orthopaedics, Wilmington, Delaware)6 was introduced in 1991. It was anticipated that the wear characteristics of a Hylamer acetabular surface in combination with a ceramic modular femoral head would improve the long-term performance of prostheses in young, active patients4,25. Several recent reports, however, have described wear and early osteolysis in association with Hylamer acetabular liners coupled with cobalt-chromium modular femoral heads manufactured by various companies3,15. The purpose of the current report is to describe rapid wear and early osteolysis following use of a Hylamer acetabular liner in combination with a ceramic femoral head made by the same manufacturer. In April 1994, a total hip arthroplasty was performed on a thirty-three-year-old woman (height, 167 centimeters; weight, fifty-two kilograms) who had arthritis due to congenital dysplasia of the left hip. The patient's preoperative work activities as an accountant had required frequent climbing and descending of multiple sets of stairs, which had greatly aggravated the problems with the hip. The work environment subsequently was modified to better accommodate the patient. The arthroplasty was performed with use of components from the same manufacturer. These included a femoral component (Stability; DePuy Orthopaedics, Warsaw, Indiana) measuring twelve by 150 millimeters, which was inserted without cement; an acetabular shell (Duraloc; DePuy Orthopaedics) with a diameter of fifty-two millimeters, also inserted without cement; a Ti-6Al-4V bone-screw (Low Profile; DePuy Orthopaedics) with a diameter of 6.5 millimeters and a length of thirty millimeters, for augmentation of the cup; and a neutral Hylamer liner measuring fifty-two by twenty-eight millimeters with a thickness of eight millimeters. Because of the patient's young age, activity level, and life expectancy, an aluminum-oxide-ceramic modular …

Between April 1988 and February 1989, 877 patients undergoing total hip (394 patients) and total knee (483 patients) replacement surgeries were given warfarin prophylaxis perioperatively and were tested with impedance plethysmography (IPG) approximately 17 days postoperatively (10 days post-discharge) in the outpatient office. There were 69 positive IPG tests (7.8%). Further assessment of patients with positive IPG results using duplex scanning or venography confirmed DVT in 25 of the 69 patients (3.6%) in the popliteal or thigh areas, and ruled out venous disease in 44 patients. All 25 patients were readmitted for anticoagulation therapy with intravenous (IV) heparin and warfarin. There were no cases of pulmonary embolus. This study indicates that IPG testing is a safe and effective method of screening patients for DVT and its potentially fatal sequela of pulmonary embolus. Furthermore, IPG testing has proven to be cost effective, as it is a relatively simple procedure which can be administered by non-professional personnel in the outpatient office setting.

Ninety-two patients (103 hips) treated with total hip arthroplasty (THA) were assessed before and after operation to determine nutritional status and any correlation with delayed wound healing. Parameters indicative of nutritional status (serum albumin and serum transferrin) were assessed, along with immunologic and anthropometric parameters. Delayed wound healing complicated 34 of the 103 (33%) THAs. The preoperative serum transferrin levels were significantly lower for patients who subsequently developed wound-healing complications. Patients treated with single-stage, bilateral procedures had substantially lower postoperative serum transferrin and serum albumin levels and significantly higher incidences of delayed wound healing (64%) than patients who had single joint procedures (25%). Only preoperative serum transferrin levels showed significant value in predicting which patients would have delayed wound healing. None of the other serologic variables, including serum albumin and total lymphocyte count, proved to be a predictor of delayed wound healing. The preoperative assessment of three variables--serum transferrin value, bilateral procedure, and patient age--resulted in the correct prediction of wound healing outcome in 79% of the patients. This preoperative information, in combination with postoperative monitoring of serum transferrin and albumin levels, should alert the physician to the approach of a malnourished state. The malnourishment is attributable to heightened demands on the body's basal energy requirements after major orthopaedic surgery and can increase morbidity and prolong the hospital stay.

We inserted a Greenfield filter prophylactically in forty-two of approximately 4,000 patients who were about to have a total hip or knee replacement, or both, and who were at high risk for pulmonary embolism (Group I). The filter was implanted postoperatively in twenty-four additional patients who had thromboembolic complications or in whom anticoagulation was contraindicated (Group II). None of the patients in Group I and only one in Group II had a fatal pulmonary embolism. Use of the Greenfield filter is a safe, easy, and effective method of preventing fatal pulmonary embolism in selected patients: those who are at exceptionally high risk for thromboembolism, as a method of preoperative prophylaxis; those who have had a thromboembolism and in whom therapeutic anticoagulation is contraindicated; and those who have complications secondary to therapeutic anticoagulation.

Between 1982 and 1986, 56 femoral fractures associated with cementless total hip arthroplasty (THA) were evaluated and compared to a randomly selected cementless THA control group without fractures. Depending upon the femoral shaft location, these fractures were classified as Types I, II, or III. There were 45 (80%) Type I, 9 (16%) Type II, and 2 (4%) Type III fractures. Patient evaluations were quantified using a modified d'Aubigne-Harris scoring system. Nonparametric statistical methodology was used tor fracture and control group comparisons. Treatment protocols were divided into various modalities, depending upon fracture classification. Type I and Type II fractures have no long-term prognostic hazards associated with them (P > 0.1), while Type III fractures appear to have analogous clinical results (sample size was too small for statistical analysis).