RESUMEN
Rehabilitation programs after total knee arthroplasty vary as much as do the surgical procedures employed. The postoperative range of motion of the knee is considered to be one of the primary indicators of the success of arthroplasty surgery. Protocols focusing on improving range of motion have been widely investigated: the end result does not seem to depend on using specific devices or exercises. There are no prospective randomized clinical trials evaluating the differences in outcome after total knee arthroplasty between patients following different rehabilitation programs. What are the needs of the patient after this surgery? Rehabilitation should focus on physical and functional limitations, and guidance of the patient during this process is important. The patient follows an individual program comprising a sensorimotor progression in weight-bearing positions to allow for improved functional knee stabilization. In knee osteoarthritis, and also after total knee arthroplasty, the neuromuscular system undergoes various adaptations during gait and other activities. Because of this, rehabilitation should not attempt to achieve hypothetical norms, but to help the patient in the motor learning process of acquiring improved motion patterns and stabilization strategies.
Asunto(s)
Artroplastia de Reemplazo de Rodilla/rehabilitación , Guías de Práctica Clínica como Asunto , Terapia por Ejercicio , Marcha , Humanos , Articulación de la Rodilla/fisiología , Movimiento , Modalidades de Fisioterapia , Rango del Movimiento Articular , Resultado del Tratamiento , Caminata , Soporte de PesoRESUMEN
Seven cases of total knee arthroplasty (TKA) after formal knee fusion were reviewed at a mean follow-up of 56 months (range, 12-161 months). The mean modified Hospital for Special Surgery score improved from 54 (range, 16-65) preoperatively to 68 (range, 57-80) at the latest follow-up. Mean range of motion was 74 degrees (range, 55-90 degrees ). Patient subjective rating was excellent or satisfied in 5 of 7 cases. Two patients underwent secondary refusion (1 for chronic infection, 1 for ligamentous instability). Six patients (86%) had to undergo reoperation for postoperative complications: 3 patients had open arthrolysis for adhesion and arthrofibrosis, 2 patients had a gastrocnemius flap for skin necrosis, and 1 patient had neurolysis of the peroneal nerve for painful paresis. Despite the presence of increased postoperative pain while walking, all 5 patients with the TKA still in place declared that they would undergo the same procedure again. The procedure of TKA in fused knees is technically demanding and has a considerable complication rate. Renewed mobility of the fused knee joint appears to correlate with increased pain on walking in this group of patients. Four types of postoperative problems were noted in the evaluation: skin necrosis, extensor mechanism contracture, insufficient collateral ligaments, and adhesion and arthrofibrosis. Takedown of a formal knee fusion with TKA should be performed only in carefully selected cases and in highly motivated patients with realistic expectations.
Asunto(s)
Artrodesis , Artroplastia de Reemplazo de Rodilla , Articulación de la Rodilla/cirugía , Complicaciones Posoperatorias/cirugía , Adulto , Anciano , Diagnóstico por Imagen , Femenino , Estudios de Seguimiento , Humanos , Articulación de la Rodilla/patología , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Complicaciones Posoperatorias/diagnóstico , Reoperación , Resultado del TratamientoRESUMEN
PURPOSE: This study was conducted to determine the importance of age as a limiting factor as well as to assess the role of age in combination with cartilage damage or osteoarthritis as predicting factors for the outcome after arthroscopic partial meniscectomy. TYPE OF STUDY: Case series. METHODS: We reviewed 97 patients over 70 years of age who underwent an arthroscopic partial meniscectomy between 1992 and 1996. At the time of evaluation, 5 patients had died and 1 patient was unavailable, leaving 91 patients (95 knees) suitable for assessment. There were 56 women and 35 men. The average age at time of surgery was 74 years (range, 70 to 84 years). The mean follow-up period was 4 years (range, 2 to 6 years). Assessment of the cases by 1 investigator included medical records and preoperative radiographs of the knee joint, with the main interest focused on evidence of osteoarthritis using the classification of Kellgren and Lawrence. Evaluation of cartilage damage was performed on surgical videotapes according to Outerbridge. All 91 patients were personally interviewed by telephone. The questionnaire included influence of the operation on knee pain, quality and duration of satisfaction, requirement of further surgery, and whether the patient would undergo the same operation again. RESULTS: According to the Kellgren and Lawrence classification, 80% of patients had radiographic evidence of osteoarthritis grade 0-2, and 20% had grade 3-4. According to Outerbridge, 43% of the patients had cartilage damage grade 0-2 and 57% had grade 3-4; 81% of the patients with osteoarthritis grade 0-2 and 83% of the patients with cartilage damage grade 0-2 had a satisfactory outcome when followed-up for more than 2 years. Among the patients with osteoarthritis grade 3-4 or cartilage damage grade 3-4, 55% and 69%, respectively, were satisfied when followed-up for more than 2 years; 45% and 37%, respectively, required a further surgery after 1 to 4 years. The grade of osteoarthritis had significant influence on satisfaction (P <.01), on whether the patients would have the operation done again (P =.01), and on whether they required further surgery (P =.04). The severity of cartilage damage only had a significant influence on whether the patients would undergo the operation again (P =.01). CONCLUSIONS: Pre-existing degenerative changes appeared to affect the outcome more than the patient's age. However, arthroscopic partial meniscectomy was followed by satisfactory results in more than two thirds of our cases even if performed in the presence of moderate degenerative changes. But two thirds does not correspond with the good results usually obtained in a younger population. Therefore, the indication for surgery and the expected outcome have to be evaluated carefully in elderly patients.
Asunto(s)
Artroscopía , Meniscos Tibiales/cirugía , Anciano , Anciano de 80 o más Años , Artroscopía/efectos adversos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Dolor/etiología , Satisfacción del Paciente , Complicaciones Posoperatorias/etiología , Resultado del TratamientoRESUMEN
The Zweymüller shaft for uncemented total hip arthroplasty was developed in the early 1970s. Encouraged by the clinical results with this stem, which was mainly used in primary arthroplasty, longer fitting stems were added to the line to accommodate bony defects and to allow for an optimal load transfer from proximal to distal. The principal of the design is to allow an optimal distal fixation while allowing the bone to remodel in the proximal part. This study reports on 89 patients who underwent revision surgery of the hip for mostly aseptic loosening. The results after a median follow-up of 36 months show an increase of the modified Harris hip score from 52 points pre- to 82 points postoperatively. Radiographic subsidence was found in nine cases, with eight having progressed for more then 3 mm. Postoperative complications occurred in 11.2%, with seven dislocations. Open revision became necessary in two cases. The stem reviewed here seems to achieve predictable results in cases where a proximal cone is still present to facilitate load transfer, while at the same time the quadrangular stem provides solid distal fixation and ensures rotary stability.
Asunto(s)
Prótesis de Cadera , Complicaciones Posoperatorias/cirugía , Falla de Prótesis , Anciano , Anciano de 80 o más Años , Femenino , Fémur/diagnóstico por imagen , Fémur/cirugía , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico por imagen , Diseño de Prótesis , Ajuste de Prótesis , Radiografía , Reoperación , Resultado del TratamientoRESUMEN
In a 67-year-old patient with severe valgus gonarthrosis and chronic occlusion of the superficial femoral artery on the same side, total knee replacement was performed without preceding angioplasty because the collateral circulation was intact. No tourniquet was used. To leave the peripatellar arterial ring intact on one side in this case of lateral patellar maltracking, a lateral approach was used. In this approach, a lateral release forms part of the approach itself. To achieve gentle eversion of the patella, the tibial tubercle was osteotomized. One year postoperatively, the patient was satisfied with the outcome and showed no clinical signs of any vascular deterioration. It is concluded that total knee replacement may be possible in the presence of chronic occlusion of the superficial femoral artery provided that the collateral circulation is intact.
Asunto(s)
Arteriopatías Oclusivas/complicaciones , Artroplastia de Reemplazo de Rodilla/métodos , Arteria Femoral , Osteoartritis de la Rodilla/complicaciones , Osteoartritis de la Rodilla/cirugía , Anciano , Angiografía , Arteriopatías Oclusivas/diagnóstico por imagen , Enfermedad Crónica , Femenino , Estudios de Seguimiento , Humanos , Osteoartritis de la Rodilla/diagnóstico por imagen , Dimensión del Dolor , Rango del Movimiento Articular , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
We report on three patients with a symptomatic inguinal mass as a late complication of repetitive arthroplastic hip surgery. In one case, there was a false aneurysm and in two cases a so-called "synovial cyst". A synovial cyst is usually an enlarged iliopsoas bursa in communication with the capsule of the hip joint. Hypersecretion in arthritic joints may cause expansion of this bursa. Compression of the common femoral and external iliac veins may lead to outflow obstruction and leg swelling. The most important diagnostic tools are plain films of the hip joint and ultrasound of the groin including colour-coded assessment of the femoral vessels. Symptomatic cysts usually need removing by an anterior approach. Loose arthroplastic components can be causative and should be replaced.
Asunto(s)
Aneurisma Falso/diagnóstico , Articulación de la Cadera/diagnóstico por imagen , Prótesis de Cadera/efectos adversos , Quiste Sinovial/diagnóstico , Adulto , Anciano , Aneurisma Falso/etiología , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Radiografía , Reoperación , Quiste Sinovial/etiología , UltrasonografíaRESUMEN
In a prospective study of 51 patients (61 cases) with primary total knee arthroplasty (valgus knees and/or knees that had undergone previous nonarthroplasty surgery), a lateral approach with osteotomy of the tibial tubercle was performed. In a lateral approach, lateral release techniques form part of the approach. In addition, the medial blood supply to the patella is preserved. An additional tibial osteotomy grants wide exposure with little tension on the extensor mechanism during eversion of the patella. The patients were followed up clinically (51 patients, 61 cases) and radiologically (44 patients, 52 cases) for 1 year. No postoperative tibial fractures, no delayed unions, and no nonunions at the site of the osteotomy were seen. No patellar necrosis occurred. The results after 1 year were good or excellent in 45 (88%) patients, fair in four (8%), and poor in two (4%). Complications related to technique were hematoma (four patients) and compartment syndrome (one patient). These complications occurred early in the series and were eliminated by technical modifications.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Osteotomía/métodos , Tibia/cirugía , Anciano , Artroplastia de Reemplazo de Rodilla/efectos adversos , Artroplastia de Reemplazo de Rodilla/métodos , Síndromes Compartimentales/etiología , Femenino , Estudios de Seguimiento , Hematoma/etiología , Humanos , Prótesis de la Rodilla , Masculino , Persona de Mediana Edad , Músculo Esquelético/cirugía , Osteotomía/efectos adversos , Osteotomía/instrumentación , Rótula/irrigación sanguínea , Rótula/cirugía , Estudios Prospectivos , Diseño de Prótesis , Rango del Movimiento Articular , Resultado del TratamientoRESUMEN
The functional behavior of two kinematically different knee arthroplasty systems within each subject was studied by gait analysis (three-dimensional kinematics, kinetics, dynamic electromyography) in five elderly patients, 2 to 5 years after bilateral surgery. Clinical results were good, yet gait velocity was reduced (range, 0.57-1.1 m/s), with a shortened stride length and a decreased duration of single-limb stance in all subjects. Force plate recordings revealed an undynamic gait with slow loading, reduced modulation of the vertical forces, and poor fore/aft shears. Sagittal plane knee motion during gait was reduced in all subjects, with trunk and pelvic compensation patterns for foot clearance. Muscle activity around the knee was prolonged bilaterally, with activity modulation related to the motion pattern. Although the stride parameters were quite symmetric, there was a marked asymmetry of the motion pattern, with a side-to-side difference of peak knee flexion during stance and swing phase of up to 15 degrees. This finding, however, was not clearly related to the type of prosthesis. Even within one subject, significant side-to-side variability may persist, which leads to asymmetry of the motion pattern, unrelated to the kinematic design of the implant. Other factors, such as the patella-extensor mechanism, ligament balancing, leg-length discrepancy, proprioception, continuation of a preoperative habit, or a contralateral influence, may explain part of the asymmetry seen in these subjects.
Asunto(s)
Marcha , Prótesis de la Rodilla , Anciano , Anciano de 80 o más Años , Fenómenos Biomecánicos , Electromiografía , Femenino , Humanos , Articulación de la Rodilla/fisiología , Masculino , Persona de Mediana Edad , Rango del Movimiento ArticularRESUMEN
We report our experience with the treatment of infected total knee arthroplasties with a two-stage procedure during the period between 1992 and 1995. The two-stage procedure as a cure for infected total knee arthroplasty is a reliable and reproducible method of treatment. The infection healed in 86% of cases, and all patients with a follow-up of more than 1 year were satisfied with the result achieved. Also the objective values proved that the outcome of this severe complication of total knee arthroplasty was favorable. The two-stage exchange procedure is recommended as the treatment of choice for infected total knee arthroplasty wherever possible.
Asunto(s)
Prótesis de la Rodilla , Infecciones Relacionadas con Prótesis/cirugía , Anciano , Anciano de 80 o más Años , Femenino , Cocos Grampositivos/aislamiento & purificación , Humanos , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Diseño de Prótesis , Infecciones Relacionadas con Prótesis/microbiología , Reoperación/métodosRESUMEN
An increasing number of children and adolescents are complaining about knee pain. Because of unspecific patient history and the difficulty of clinical examination a correct diagnosis can be made in only half of the patients. The importance of the diagnostic and therapeutic knee arthroscopy has therefore increased. Indication, technique, complications and results are discussed.
Asunto(s)
Artroscopía , Traumatismos de la Rodilla/diagnóstico , Articulación de la Rodilla , Adolescente , Factores de Edad , Artroscopía/métodos , Niño , Femenino , Humanos , Artropatías/diagnóstico , MasculinoRESUMEN
The correct therapy of osteochondritis dissecans in patients under 16 years is very important to prevent the knee joint from secondary arthritis. We analysed clinical, radiological and with MRI the long term (10 years) results of a follow-up study on 36 patients under 16 years with 42 operatively treated osteochondritis dissecans of the knee joint. There were excellent and good results in 81% of the patients. After an average of 10 years there were no signs of arthritis which would necessitate any treatment.
Asunto(s)
Osteocondritis Disecante/cirugía , Complicaciones Posoperatorias/diagnóstico , Adolescente , Adulto , Tornillos Óseos , Femenino , Estudios de Seguimiento , Humanos , Cuerpos Libres Articulares/diagnóstico , Cuerpos Libres Articulares/cirugía , Articulación de la Rodilla/patología , Articulación de la Rodilla/cirugía , Masculino , Osteoartritis/prevención & control , Osteocondritis Disecante/diagnósticoRESUMEN
Our report is based on 47 infected knee arthroplasties that were revised and followed up in our hospital between 1984 and 1990. Various surgical and therapeutic management options are assessed. In our patient population our experience revealed that the two-stage reimplantation seemed to offer the best chances for management of infected knee arthroplasty. Infections with gram-negative bacteria tend to take a less favorable course than those caused be gram-positive organisms. A division into categories of infected knee joints is presented and the complexity of problems related to the diagnosis is discussed.