RESUMEN
Recognizing persistent infection after resection arthroplasty and implantation of cement spacers in the infected total knee arthroplasty is often difficult. The purpose of this study was to determine whether aspiration of the knee after resection arthroplasty is valuable for determining the presence of ongoing infection. Thirty-four previously infected knees that were aspirated and cultured after resection arthroplasty, implantation of cement spacers, and intravenous antibiotics for an average of 6.3 weeks were identified. There were 8 cases of persistent infection-none identified on preoperative aspiration. Two preoperative cultures were false positive for Staphylococcus epidermidis. Preoperative cultures were negative in 32 knees, with 8 false-negative results. The antibiotic-free interval among all cases averaged 20 days; the cases with false-negative results from aspiration had an antibiotic-free interval averaging 11.5 days, compared with an average of 26 days among all other cases. Aspiration of knees after resection arthroplasty had sensitivity of 0%, positive predictive value of 0%, and accuracy of 71%. Specificity was 92%, and negative predictive value was 75%. A negative result from joint aspiration after resection arthroplasty does not necessarily rule out the presence of ongoing infection. False-negative results may be observed if joint aspiration is not delayed more than 2 to 3 weeks.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Infecciones Relacionadas con Prótesis/diagnóstico , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Cuidados Preoperatorios , Infecciones Relacionadas con Prótesis/tratamiento farmacológico , Infecciones Relacionadas con Prótesis/cirugía , Recurrencia , Reoperación , Estudios Retrospectivos , Sensibilidad y Especificidad , SucciónRESUMEN
OBJECTIVES: To compare magnetic resonance imaging (MRI) with examination under anesthesia and with surgical findings in evaluating soft tissue injuries in acute traumatic knee dislocations in adults. DESIGN: Retrospective analysis. SETTING: Level I trauma center. PATIENTS: For a single surgeon, all patients who underwent MRI before surgical treatment for knee dislocations (ten individuals). INTERVENTION: Incompetent ligaments were repaired or reconstructed. MAIN OUTCOME MEASUREMENTS: MRI of knee dislocations was compared with clinical examination under anesthesia and with intraoperative findings at arthrotomy in ten cases. Pertinent positive and negative findings were recorded, and accuracy, sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: Two mid-grade sprains of the anterior cruciate ligament were erroneously read as complete tears. One rupture or avulsion of each the biceps tendon, the lateral collateral ligament, and the posterolateral and posteromedial corners were considered intact on MRI. The MRI studies erroneously identified tears of the lateral collateral ligament and medial meniscus in one case each. Otherwise, the study was highly accurate. CONCLUSIONS: MRI is useful for defining the presence of ligamentous injuries in knee dislocations; however, clinical examination under anesthesia is more accurate.
Asunto(s)
Artroscopía/métodos , Luxaciones Articulares/diagnóstico , Traumatismos de la Rodilla/diagnóstico , Imagen por Resonancia Magnética , Adulto , Femenino , Humanos , Luxaciones Articulares/cirugía , Traumatismos de la Rodilla/cirugía , Masculino , Persona de Mediana Edad , Examen Físico , Cuidados Preoperatorios , Estudios Retrospectivos , Sensibilidad y Especificidad , Centros Traumatológicos , Estados UnidosRESUMEN
BACKGROUND: In the presence of large extra-articular deformity, complex imbalance of the collateral ligaments may result if standard techniques of soft-tissue releases and intra-articular bone resection are used during total knee arthroplasty. The purpose of this paper is to review our experience with simultaneous corrective osteotomy and total knee arthroplasty for the treatment of severe extra-articular femoral deformity associated with ipsilateral osteoarthritis of the knee. METHODS: The results of simultaneous corrective osteotomy and total knee arthroplasty in eleven knees with osteoarthritis and associated extra-articular angular deformity of the femur were reviewed retrospectively. The femoral deformity resulted from fracture malunion in ten knees and from hypophosphatemic rickets in one. There were five primarily uniplanar deformities (four varus deformities and one antecurvatum deformity), five biplanar (varus and antecurvatum) deformities, and one triplanar (varus, antecurvatum, and internal rotation) deformity. Four knees were approached through a standard medial parapatellar arthrotomy and seven, through an anterolateral subvastus approach with an osteotomy of the tibial tubercle. The site of the femoral osteotomy was fixed with a blade-plate in seven patients, a press-fit long-stemmed femoral component in two, and a retrograde femoral nail in two. An extramedullary alignment system was utilized in eight patients, and intramedullary alignment was used in three. RESULTS: The duration of follow-up averaged forty-six months (range, twenty-six to eighty-eight months). According to the classification system of the Knee Society, the mean function score increased from 22 points preoperatively to 81 points at the time of follow-up and the mean knee score increased from 10 points preoperatively to 87 points at the time of follow-up. The mean flexion contracture decreased from 19 degrees preoperatively to 2 degrees at the time of follow-up. The arc of motion averaged 56 degrees (range, 30 to 75 degrees) preoperatively and 89 degrees (range, 65 to 115 degrees) at the time of follow-up. The mechanical alignment in the coronal plane was restored to within 2 degrees of normal in each patient. Ten femoral osteotomy sites healed, and one, in a patient treated with a press-fit long-stemmed femoral component, had not healed by the time of follow-up. All seven sites of the tibial tubercle osteotomies healed. There were no complete radiolucent lines at the prosthetic interfaces, and no total knee arthroplasty was revised. One patient had a nonfatal postoperative pulmonary embolism. As determined by clinical examination and the patients' assessment of function, no ligament imbalance was noted at the time of the most recent follow-up. CONCLUSIONS: Simultaneous femoral osteotomy and total knee arthroplasty is a technically difficult but effective treatment for patients with severe femoral deformity associated with ipsilateral osteoarthritis of the knee. We recommend that the femoral osteotomy site be secured with a plate or a locked intramedullary nail, depending on the location of the deformity and the subsequent osteotomy.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Fémur/cirugía , Deformidades Adquiridas de la Articulación/cirugía , Osteoartritis de la Rodilla/cirugía , Osteotomía , Adulto , Anciano , Femenino , Humanos , Deformidades Adquiridas de la Articulación/diagnóstico por imagen , Deformidades Adquiridas de la Articulación/etiología , Masculino , Persona de Mediana Edad , Osteoartritis de la Rodilla/diagnóstico por imagen , RadiografíaRESUMEN
The outcomes of total knee arthroplasty for post-traumatic arthrosis were studied in 31 knees. The average age at arthroplasty was 60 years old (range, 36-78 years). The interval from fracture to total knee arthroplasty averaged 13 years. Simultaneous corrective osteotomy was necessary in 4 patients to correct axial alignment and preserve ligamentous integrity. Follow-up averaged 46 months. Mean arc of motion increased significantly, from 94 degrees to 100 degrees (P = .027). Average function score improved from 44 to 72 points. This change was statistically significant (P<.0001). Knee Society knee scores also improved significantly, from 36 to 78 points (P<.0001). At most recent follow-up, the functional scores were considered excellent or good in 58%; knee scores were considered excellent or good in 71% of cases. All periarticular osteotomies and tibial tubercle osteotomies healed uneventfully within 16 weeks. Complications occurred in 57% of cases, including aseptic failure (26%), septic failure (10%), patellar tendon rupture (3%), patellar subluxation (6%), thromboembolism (6%), and wound breakdown requiring debridement and muscle flap coverage (6%). Despite significant improvements in motion and function, patients with post-traumatic arthrosis are susceptible to high rates of complications. Adverse outcomes can be minimized by restoring limb alignment, soft tissue balance, and component alignment and by preserving vascularity of the skin and subcutaneous tissues.
Asunto(s)
Traumatismos de la Rodilla/complicaciones , Prótesis de la Rodilla , Osteoartritis/etiología , Adulto , Anciano , Artroplastia de Reemplazo de Rodilla/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Osteoartritis/cirugía , Falla de Prótesis , Rango del Movimiento Articular , Factores de Riesgo , Heridas y LesionesRESUMEN
Eighteen patients with nonunions of the proximal tibial metaphysis were treated at one institution. Nine patients had a history of osteomyelitis. There was an average of 4 prior surgical procedures to achieve fracture union, obtain soft-tissue coverage, or eradicate infection. Stable internal fixation with bone grafting was performed in 13 patients, with a fixed angle blade plate in 10 and standard compression plate in 3. Three patients were treated with hybrid circular external fixators, and one patient was placed in a cast. An additional patient underwent long-stem total knee arthroplasty with structural allografting. Follow-up averaged 45 months. Osseous union was achieved in 100% of patients. Alignment was within 5 degrees of neutral in 94% of patients. Forty-four percent of patients continue to require the assistance of a cane for ambulation. Twelve patients have some pain with activity, primarily related to ipsilateral knee arthrosis. No infections have recurred. Knee motion improved an average of 28 degrees. Healing of nonunions of the proximal tibial metaphysis may be achieved with meticulous soft-tissue care and appropriate stabilization of small, osteoporotic, periarticular fragments.
Asunto(s)
Fracturas no Consolidadas , Fracturas de la Tibia/cirugía , Adulto , Anciano , Artritis/complicaciones , Artroplastia de Reemplazo de Rodilla , Placas Óseas , Sustitutos de Huesos , Fijadores Externos , Femenino , Fijación Interna de Fracturas/rehabilitación , Fracturas no Consolidadas/complicaciones , Fracturas no Consolidadas/cirugía , Humanos , Masculino , Persona de Mediana Edad , Osteomielitis/complicaciones , Reoperación , Estudios Retrospectivos , Infecciones de los Tejidos Blandos/complicaciones , Insuficiencia del TratamientoRESUMEN
A total of 102 revision total knee arthroplasties (TKAs) were reviewed to determine the prodromal symptoms and radiographic findings associated with failure. Presenting symptoms included pain (84%); swelling (76%); progressive varus or valgus deformity (19%); instability (17%); stiffness (17%); clicking or grinding (7%); catching (4%); and patellar pain, subluxation, or clicking (4%). Radiographs were diagnostic in 91% of cases, demonstrating complete radiolucencies (80%), polyethylene wear (43%), component breakage (5%), metallic debris (3%), patellar subluxation or dislocation (4%), and osteolysis (4%). Gross intraoperative findings included polyethylene wear (72%), osteolysis (22%), metal-wear synovitis (9%), component breakage (6%), patellar wear and dissociation (4%), and occult sepsis (5%). The average duration of symptoms was 13 months; the interval between orthopedic evaluations averaged 23 months. Based on this information, we recommend that an annual questionnaire and weight-bearing radiographs be used to ensure adequate surveillance of TKA patients and avoid complications associated with delay in diagnosis of polyethylene wear or implant loosening.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Prótesis de la Rodilla , Falla de Prótesis , Anciano , Femenino , Humanos , Articulación de la Rodilla/diagnóstico por imagen , Masculino , Radiografía , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Encuestas y Cuestionarios , Soporte de PesoRESUMEN
OBJECTIVE: To assess the efficacy of treatment and develop an algorithm for management of nonunions of the femoral diaphysis. STUDY DESIGN: Retrospective. SETTING: University hospital. METHODS: Forty-four patients treated at one institution for nonunion of the femoral diaphysis were studied. Thirteen of these patients had a history of infection. After debridement (where appropriate) and repair of the femoral nonunion, follow-up averaged twenty-eight months (range, 24 to 108 months). All patients were examined at final follow-up. RESULTS: Thirty-three patients achieved union after one procedure, and eight patients achieved union after additional procedures. One patient underwent above-knee amputation, and two patients remained ununited at the time of their final follow-up. Time to union averaged 11.8 months. Seventeen patients healed with more than two centimeters of shortening, and ten patients lost more than 30 degrees of knee flexion. CONCLUSION: Established femoral diaphyseal nonunions can be treated effectively, even in the presence of chronic sepsis. Selective use of a vascularized fibula transfer has proven beneficial in addressing intercalary defects. Plate fixation, with or without a vascularized fibula transfer, has been the predominant mode of skeletal stabilization in more complex reconstructions.
Asunto(s)
Algoritmos , Fracturas del Fémur/cirugía , Fijación de Fractura/métodos , Fracturas no Consolidadas/cirugía , Traumatismos de la Rodilla/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Antibacterianos/uso terapéutico , Artroplastia de Reemplazo , Infecciones Bacterianas/tratamiento farmacológico , Infecciones Bacterianas/microbiología , Placas Óseas , Trasplante Óseo , Niño , Desbridamiento , Diáfisis/lesiones , Diáfisis/microbiología , Fijadores Externos , Femenino , Fracturas del Fémur/complicaciones , Fracturas del Fémur/diagnóstico por imagen , Fijación de Fractura/instrumentación , Curación de Fractura , Fracturas no Consolidadas/complicaciones , Fracturas no Consolidadas/diagnóstico por imagen , Humanos , Traumatismos de la Rodilla/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Aparatos Ortopédicos , Pronóstico , Radiografía , Rango del Movimiento Articular , Estudios Retrospectivos , Infección de la Herida Quirúrgica/tratamiento farmacológico , Infección de la Herida Quirúrgica/microbiologíaAsunto(s)
Lesiones del Ligamento Cruzado Anterior , Ligamento Cruzado Anterior/cirugía , Fracturas del Fémur/etiología , Traumatismos de la Rodilla/cirugía , Complicaciones Posoperatorias , Adulto , Artroscopía , Fracturas del Fémur/diagnóstico por imagen , Fracturas del Fémur/cirugía , Fijación Interna de Fracturas , Humanos , Masculino , Radiografía , ReoperaciónRESUMEN
Heterotopic ossification has been reported to occur in less than 10% of total knee arthroplasties. When this condition has occurred, it has previously been reported either to be asymptomatic or to cause discomfort that resolves with the passage of time. This case report is the first to note persistent pain and snapping due to heterotopic ossification adherent to the distal femoral cortex that required surgical excision to relieve symptoms after total knee arthroplasty.
Asunto(s)
Prótesis de la Rodilla/efectos adversos , Osificación Heterotópica/etiología , Humanos , Articulación de la Rodilla/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Osificación Heterotópica/diagnóstico por imagen , Osificación Heterotópica/cirugía , Dolor/etiología , RadiografíaRESUMEN
Twenty fractures of the distal part of the femur proximal to a total knee replacement were treated operatively by members of the New England Trauma Study Group. Notching of the anterior aspect of the femoral cortex was associated with only two of these fractures, and none of the knee prostheses was loose at the time of the fracture. All twenty fractures were treated with open reduction and stable internal fixation, and the operation on fifteen fractures was supplemented with bone grafts. Every fracture healed, and eighteen healed after a mean of sixteen weeks (range, six to forty weeks). Union of the other two fractures was delayed, but repeat open reduction and internal fixation combined with autogenous bone-grafting resulted in union. After operative treatment, the patients returned to the level of activity that they had had before the fracture. The pre-existing tibiofemoral alignment and range of motion of the knee were also restored. At the time of follow-up, the average clinical rating of the Knee Society for all twenty knees had not decreased compared with the score before the fracture.
Asunto(s)
Fracturas del Fémur/cirugía , Prótesis de la Rodilla , Anciano , Anciano de 80 o más Años , Femenino , Fracturas del Fémur/diagnóstico por imagen , Fijación Interna de Fracturas/métodos , Humanos , Articulación de la Rodilla/diagnóstico por imagen , Masculino , Persona de Mediana Edad , RadiografíaRESUMEN
The use of an intramedullary alignment rod in the distal part of the femur is an important step in performing total knee-replacement arthroplasty. On the basis of our observation of a sudden decrease in oxygen saturation in some patients after insertion of the rod, a prospective study was done of the circulatory and blood-gas changes that were associated with insertion in thirty-five patients. We examined the effects of the use of an eight-millimeter solid alignment rod, with and without venting; an eight-millimeter fluted alignment rod, with venting; and an eight-millimeter fluted or solid alignment rod, inserted through a 12.7-millimeter drill-hole, but without other venting. A statistically significant reduction in oxygen saturation, arterial oxygen tension (PaO2), and end-tidal carbon-dioxide tension (PETCO2) occurred after insertion of both solid and fluted eight-millimeter alignment rods through an eight-millimeter hold in both vented and unvented femoral canals, in association with a significant increase (p less than 0.01) in intramedullary pressure. Bone-marrow contents and fat were retrieved from samples of blood from the right atrium, indicating that embolization of marrow contents had occurred during insertion of the alignment rod. A small decrease in systemic blood pressure and heart rate also occurred. These changes were completely eliminated by the use of a 12.7-millimeter drill-hole as the entry site of the eight-millimeter fluted rod. We concluded that insertion of an intramedullary alignment rod in the femur causes embolization of marrow contents, which decreases arterial oxygen tension, oxygen saturation, end-tidal carbon-dioxide tension, arterial blood pressure, and heart rate.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Dióxido de Carbono/sangre , Hemodinámica , Prótesis de la Rodilla , Oxígeno/sangre , Anciano , Anciano de 80 o más Años , Función Atrial , Presión Sanguínea , Médula Ósea/fisiología , Femenino , Frecuencia Cardíaca , Humanos , Articulación de la Rodilla/cirugía , Masculino , Persona de Mediana Edad , PresiónRESUMEN
The records on fifty-two supracondylar-intercondylar fractures of the femur were reviewed twenty to 120 months after injury. More than one-third of the fractures had been open. All of the fractures were treated in a single trauma center, using: (1) a single lateral incision, (2) internal fixation with ASIF interfragmentary screws and plates, (3) bone-grafting of comminuted metaphyseal segments, (4) impaction of comminuted metaphyseal segments in osteoporotic elderly patients, and (5) repair of any associated torn ligaments and patellar fractures. Postoperatively, early active motion of the knee was encouraged, and for selected patients a brace was used only to protect the repair of associated disruptions of ligaments or of the extensor mechanism. The fractures were classified by the ASIF system, with C1 being a simple Y pattern, C2 having additional supracondylar comminution, and C3 having intra-articular comminution. The final results were rated using the system that was described by Neer et al. for fractures of the distal end of the femur. The average time between the operation and full weight-bearing (healing) was 13.6 weeks and ranged from 12.3 weeks for C1 fractures (as graded using the ASIF classification) to 15.4 weeks for C3 fractures. The average final arc of motion of the knee was 107 degrees, ranging from 113 degrees for C1 fractures to 99 degrees for C3 fractures. C1 fractures had a better outcome (92 per cent excellent and good results) than did C2 and C3 fractures (77 per cent excellent and good results). Two amputations and one arthrodesis were done to treat infection, and infection accounted for three of the four poor results. Age did not influence the final results, although elderly patients had a longer period of hospitalization. Supracondylar-intercondylar fractures of the femur should be analyzed separately from other fractures of the distal end of the femur because of their intra-articular involvement and associated ligamentous injuries and patellar fractures. Rigid internal fixation permits early functional rehabilitation of the patient and decreases the incidence of malunion, non-union, and loss of fixation.
Asunto(s)
Fracturas del Fémur/cirugía , Fijación Interna de Fracturas , Adulto , Anciano , Placas Óseas , Tornillos Óseos , Femenino , Fracturas del Fémur/complicaciones , Fracturas del Fémur/diagnóstico por imagen , Estudios de Seguimiento , Fracturas Óseas/cirugía , Fracturas Abiertas/cirugía , Humanos , Ligamentos Articulares/lesiones , Ligamentos Articulares/cirugía , Masculino , Persona de Mediana Edad , Osteítis/etiología , Rótula/lesiones , Radiografía , Factores de TiempoRESUMEN
Obturator neuropathy is an infrequently identified complication of total hip replacement that may cause debilitating pain. There have been isolated reports of this complication in the literature, but only one case has been published in which intrapelvic cement was the causative agent. We are describing the cases of four patients with obturator neuropathy after total hip replacement, documented by electromyography and attributed to intrapelvic extension of cement. In each patient the source of the symptoms was not initially apparent. In three of the patients the extruded cement and obturator nerve were explored surgically. One of the three patients was improved by obturator neurectomy. Of the other two patients, both treated by excision of cement, only one was improved. The fourth patient was not treated. Persistent pain in the groin and thigh, intrapelvic cement visible on plain roentgenograms, and adductor weakness after total hip replacement suggest that this complication has occurred. Electromyography can confirm the presence of obturator neuropathy. Based on this limited series, excision of the extruded cement and preservation of the nerve should be attempted only when the nerve is grossly normal and functional as determined by electrical stimulation at the time of surgical exploration; otherwise, obturator neurectomy should be considered.
Asunto(s)
Cementos para Huesos/efectos adversos , Prótesis de Cadera/efectos adversos , Síndromes de Compresión Nerviosa/etiología , Nervio Obturador , Parálisis/etiología , Electromiografía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Síndromes de Compresión Nerviosa/diagnóstico , Síndromes de Compresión Nerviosa/cirugía , Nervio Obturador/cirugíaRESUMEN
A modified V-Y quadricepsplasty technique is described that facilitates exposure for prosthetic replacement in the knee with limited preoperative motion. The technique allows increased postoperative flexion without increasing the final postoperative extension lag. Seven patients have undergone knee arthroplasty using this method. The average increase in flexion was 49 degrees. The average ultimate extension lag was 8 degrees.
Asunto(s)
Anquilosis/fisiopatología , Articulación de la Rodilla , Prótesis de la Rodilla , Músculos/cirugía , Anquilosis/etiología , Humanos , Articulación de la Rodilla/fisiopatología , Métodos , Movimiento , Cuidados PosoperatoriosRESUMEN
To develop the surgical model, whole knee joints including the distal femur, proximal tibia, and joint capsule, were raised on a vascular pedicle and then replanted at the same site. Rigid fixation of the bones was achieved using two mini-plates on the tibia and femur. Revascularization of the knee was accomplished by end-to-end anastomosis of the popliteal vessels using standard microvascular techniques, and the vascular and neural supplies to the lower leg and foot were preserved. A total of 21 vascularized whole knee allografts were then similarly performed on a microvascular pedicle between two incompatible strains of rabbit. In a control group of six adult animals, no immunosuppression was administered. Two of these joints were harvested at 1 week and had patent popliteal arteries. The remaining four joints were harvested at 2-3 weeks when they were deteriorating and were found to have occluded popliteal vessels by arteriography. Eight adult allograft recipients were immunosuppressed with cyclosporin A (CyA) at 15 mg/kg per day. One allograft failed at 10 days due to femoral fracture. None of the remaining seven were rejected acutely, and three of them had patent vessels by arteriography and live bone and cartilage by light microscopy when harvested 100 days after transplantation. In another group, seven knee joints were allografted into immature rabbits immunosuppressed with CyA. Again, none rejected acutely, and 90 days later two of the seven allografts had patent vessels by arteriography, growth by serial radiographs, and live bone and cartilage by histological examination. This pilot study suggests that CyA will be useful as an immunosuppressive agent in the study of vascularized bone and cartilage transplantation, and that experimental epiphyseal plate allografting is possible in rabbits.