NEW CHALLENGES IN INTERNAL MEDICINE
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TOTAL JOINT REPLACEMENT OF THE HIP AND KNEE Robert
J.
Quinet, MD, and Ellen C. Winters, MD
Total joint replacement (TJR) of the hip and knee are among the most successful orthopedic procedures and have revolutionized the management of arthritis, particularly osteoarthritis. We as internists must be knowledgeable about the benefits, risks, indications, and contraindications of these procedures so we can advise our patients and make appropriate and timely referrals to our orthopedic colleagues. We also must participate in the preoperative evaluation and be aware of the postoperative course and potential complications that might require our assistance. The following brief review of total hip and knee replacement from the internal medicine perspective does not deal with details of operative or surgical technique. INDICATIONS FOR T JR Pain
The most important indication is severe pain, particularly at rest, in a patient with advanced arthritis of the hip or knee. Severe pain must be persistent and refractory to conservative treatment including use of nonsteroidal anti-inflammatory drugs (NSAIDs), adequate rest, protected weight bearing with a cane or walker, therapeutic exercise performed daily, appropriate weight reduction, physical therapy, and analgesics. From the Section on Rheumatology, Department of Internal Medicine, Ochsner Clinic and Alton Ochsner Medical Foundation, New Orleans, Louisiana THE MEDICAL CLINICS OF NORTH AMERICA VOLUME 76· NUMBER 5· SEPTEMBER 1992
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Function
Major limitations of walking, climbing stairs, transfers, and putting on shoes and socks despite rigorous conservative management also enter into the decision. Functional status is improved by surgery in most patients, although not quite to the degree that pain relief occurs. Age
It is generally recommended that TJR be performed in patients older than age 60 because then the longevity of the prosthesis approaches the life expectancy of the patient, and the physical demands on the prosthesis are less. Elective total hip replacement (THR) may improve function even for octogenarians. 70 For rheumatoid arthritis, especially for juvenile rheumatoid arthritis, the procedure may have to be done at a younger age. For younger patients with osteoarthritis, one should consider alternative orthopedic procedures such as osteotomy, which can later be converted to a TJR if necessary. Physical Examination
Physical examination should document painful, significant limitation of joint range of motion and exclude other causes of the pain. Radiographs
Radiographs should demonstrate major loss of cartilaginous joint space with bony apposition. In summary, TJR is performed for severe pain and significant functional limitation, with physical examination findings of painful limitation of joint motion and radiographic evidence of severe joint space loss. EDUCATION OF PATIENT
It should be explained to the patient that the artificial joint is not a normal one and will have to be protected and used cautiously even if painless. Activities such as walking, climbing stairs, driving, swimming, bicycling, or golf are permitted; however, racquet sports, jogging, mountain climbing, jumping, and skiing are prohibited, and the patient must understand and accept this. As the chance of prosthetic loosening increases with body weight and age, an obese patient should demonstrate an effort at weight
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reduction preoperatively, and TJR should be delayed until age 60 to 65 if possible. The patient must be willing to participate in rehabilitation. This program involves protected weight bearing for 2 to 5 months and strengthening exercises. CONTRAINDICATIONS
Contraindications include poor general medical condition; significant peripheral vascular disease; neuropathy, particularly affecting the joint; and active infection. Total knee arthroplasty (TKA) was once contraindicated in patients with neuropathic joints; however, some success with TKA has been reported using newer unconstrained prostheses. 88 PREOPERATIVE EVALUATION
A thorough preoperative evaluation should be performed in an effort to minimize surgical risk. Most patients requiring TKA are elderly and may have significant medical problems. All patients should be evaluated for coronary and peripheral vascular disease, and peripheral pulses should be checked. Patients who are obese or who have venous varicosities, edema, prolonged preoperative immobilization, or a history of thromboembolism are at increased risk for thrombosis. All patients should have some form of thrombosis prophylaxis, but the optimal method is controversial. Early mobilization, active exercise, and compression stockings can be employed for all patients. Currently, warfarin begun the night before surgery and continued until the night of discharge seems most appropriate. 3 , 36, 39, 44 Aspirin provides some protection, predominantly in men, but is inferior to warfarin. 36, 37 Lowdose aspirin and intermittent pneumatic compression have been shown to be effective prophylaxis for TKA. 60 Dextran reduces the risk of thrombosis but is associated with a significant risk of bleeding and congestive heart failure. 36, 39 Experimentally, low molecular weight heparin (Enoxaparin) seems superior to standard heparin prophylaxis, but it is not yet available. 28 , 54 Adjusted-dose subcutaneous heparin is effective but may incur a high risk of bleeding. Epidural anesthesia significantly reduces thromboembolic risk. 22,44 All potential sources of infection should be evaluated. These include the urinary tract, dental caries or periodontal disease, sinuses, and skin. A preoperative chest radiograph and urine culture should be performed, and any infections should be treated before elective surgery. Prevention of perioperative infection includes the use of prophylactic antibiotics, usually a parenteral second-generation cephalosporin. 55, 58, 81 The use of antibiotic-impregnated cement, with or without systemic antibiotic prophylaxis, remains controversial and is still exper-
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imenta1. 46 , 58, 61 Ultra-clean air systems may reduce the incidence of joint sepsis by as much as one half, and the use of whole-body exhaustventilated suits worn by the surgeon may reduce infection to one quarter of that of conventional ventilation,55, 81, 84 Late infection may be avoided by preventing bacteremia,92 which involves prompt treatment of any infectious process to prevent hematogenous seeding and prophylaxis (as for endocarditis) at the time of dental work or any procedure associated with transient bacteremia. The latter recommendation must be weighed against the risk of antibiotic allergic reaction and lack of proven efficacy. Patients with diabetes mellitus should attain optimal control of serum glucose perioperatively because it may facilitate wound healing and reduce infection. 26 In patients with rheumatoid arthritis, lateral flexion views of the cervical spine should be obtained, and extra caution should be used during intubation if atlantoaxial subluxation is found. A thorough history regarding prior or current corticosteroid therapy must be obtained. If a patient has received corticosteroids within the year, a "steroid prep" should be used at the time of surgery. Patients with rheumatoid arthritis also appear to have a higher incidence of postoperative infections. There has been support for discontinuation of methotrexate 1 month before surgery in an effort to decrease potential complications. ll Recently, however, it was suggested that methotrexate use throughout the perioperative period may not increase the risk of infection and may be beneficial in preventing a postoperative flare that could potentially interfere with rehabilitation. 69 Although further studies are needed, for now it is probably prudent to withhold several doses of methotrexate. Aspirin should be discontinued 1 week before surgery, and other NSAIDs should be stopped five half-lives before surgery to reduce bleeding, especially if epidural anesthesia is used. This discontinuation will sacrifice their antithrombotic effect, however. Autologous blood donation of 2 to 3 units at weekly intervals in the month before elective surgery is recommended. POSTOPERATIVE REHABILITATION
The goal of rehabilitation is to obtain a maximal arc of comfortable joint motion with good muscle control and have the patient return to independent daily living as quickly as possible. Patients are at bedrest for the first several postoperative days. They should be encouraged to do exercises such as ankle plantar and dorsiflexion, straight leg raises, and quadriceps and hamstring isometrics. The use of continuous passive motion has been advocated in the early postoperative period following TKA.80 Range of motion was restored faster when continuous passive motion (CPM) was used. The need for postoperative manipulation is also reduced after CPM; how-
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ever, long-term range of motion appears not to be significantly improved with CPM. 76 On the third or fourth postoperative day, the patient should attempt to bear partial weight with a walker or crutch. Gentle, passive, range-of-motion exercises should be performed under the instruction of a physical therapist. Goals of the immediate postoperative rehabilitation are for the patient to bear full weight with a cane and to be independent in activities of daily living at hospital discharge. The average hospital stay is 10 days to 2 weeks, and physical therapy should be continued after discharge. The goal for knee motion is ?: 90°. If rehabilitation does not progress, gentle manipulation under anesthesia may be indicated. TOTAL HIP REPLACEMENT Definition
THR is an orthopedic surgical procedure involving excision of the native femoral head and part of the neck and enlargement of the native acetabulum. The metallic femoral prosthesis (stem and small diameter head) is inserted into the femoral medullary canal. The acetabular component, composed of a high-density polyethylene articulating surface usually surrounded by metallic backing, is inserted into the enlarged acetabular space. The components may be fixed either with methylmethacrylate (cement) or a porous coating designed to adhere directly to medullary bone (cementless). The procedure is performed mainly for severe osteoarthritis of the hip. Less commonly, it is performed in advanced rheumatoid arthritis, juvenile rheumatoid arthritis, ankylosing spondylitis, Paget's disease, or avascular necrosis of the hip. More than 100,000 THRs are performed annually in the United States. The large number of operations is because of the greater than 90% chance of complete pain relief and significant improvement in function in appropriately selected patients. Complications of THR
Heterotopic Ossification (HO). Heterotopic bone may form in up to 70% of patients undergoing THR, but it limits functional motion or produces pain in fewer than 4%.2,71,75,97 Patients at risk include those with previous HO, diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, or osteoarthritis (in men). Prophylaxis with NSAIDs29, 50, 83 or postoperative low-dose radiation therapy6, 41, 49 is quite effective for patients at risk. Diphosphonates are of no value. 92a If significant ossification develops, surgical excision is helpful, but it is typically delayed for 1 year to allow full maturity of the ectopic bone.
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Dislocation. Dislocation of the prosthesis occurs in fewer than 1 % of patients and is a distant second to loosening as a cause of reoperation. 59 , 102 The major cause is malposition of the acetabular component, which occurs most commonly with revision arthroplasty. 59 Neurologic Complications. Nerve damage secondary to operative trauma can occur but is rarely clinically significant. The prognosis for recovery is good unless the nerve is severely damaged. Trauma usually involves the obdurator, gluteal, femoral, or sciatic nerves. 1,98 Fracture. The incidence of fracture has been much reduced with modern prostheses and contemporary surgical techniques. There is still a significant incidence in revision arthroplasties with cementless prostheses (6%). Infection. The rate of infection after primary THR is now less than 1%, and it is less than 3% with revision. 55,58,81,84 THR using perioperative antibiotics, laminar air-flow operating rooms, and body exhaust systems is associated with an overall incidence of sepsis of 0.38% (early and late).84 Sepsis necessitates 4 to 6 weeks of parenteral antibiotics and frequently removal of the prosthesis. In some cases, revision arthroplasty may be performed using antibiotic-impregnated cement. Detailed discussion of infected hip prostheses is beyond the scope of this article. Thromboembolism. In the absence of prophylaxis, deep vein thrombosis occurs in 50% of patients, asymptomatic pulmonary emboli with proximal (thigh) thrombosis in 20%, and fatal pulmonary emboli in 1% to 4%.37,44,94 With appropriate prophylaxis, the risk of deep vein and proximal thrombosis is reduced by one half, and the embolism rate falls to less than 1%. Because thromboembolism may occur despite prophylaxis, vigilance is necessary, and clinical suspicion should be evaluated with leg venography and nuclear medicine lung scanning. CEMENTED THR Clinical Outcome
THR usually leads to a dramatic improvement in the patient's quality of life and function. The Charnley cemented THR provides a good to excellent clinical result in 80% to 85% of patients for at least 15 to 20 yearsY, 99, 104 The clinical failure rate (i.e., symptomatic aseptic loosening or revision arthroplasty) is about 1% per year of follow-up.99 Radiographic loosening occurs at twice that rate, affecting one third of THR by 15 years. With contemporary prostheses and modern cementing techniques, the rate of femoral loosening seems to be dramatically reduced, based on 11 years' follow-up.66, 79 Aseptic loosening occurs more commonly in young, heavy, active men and with certain prosthetic designs, such as the older Muller curved-stem prosthesis or the McKee-Farrar prosthesis. Results in Other Arthropathies. Results are worse in patients with
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rheumatoid arthritis, with up to a 25% clinical failure rate at 12 years and an increased incidence of delayed wound healing and sepsis. 86 These patients tend to be younger and to have osteoporosis. Paget's disease is associated with a satisfactorv outcome,57 but avascular necrosis has an inferior outcome, in part as o a result of the generally younger age of the patients and the consequently increased demands placed on the hip.15 Ankylosing spondylitis THR may be associated with a high incidence of myositis ossificans, and pre-existing soft-tissue contractures may compromise motion. 95 Aggressive Granulomatous Reaction. A much less common cause of clinical failure and revision is re sorption and focal lysis of the femur secondary to an "aggressive granulomatous lesion,"32 a distinct entity that may cause loosening in up to 4% of THR, independent of mechanical or septic causes. This aggressive granulomatous reaction may account for up to 5% of hip revisions. 32, 38 Histologically, macrophages, multinucleated giant cells, cement particles, and a relative lack of fibroblasts are observed,38, 82 Radiographically, this results in focal lysis around the prosthetic stem that mayor may not cause pain, loosening, or both. A localized area of fracture in the cement surrounding an often well-fixed prosthetic stem results in fragmentation of the cement, which serves as a stimulus for an exuberant macrophage, histiocyte, giant cell reaction. 64 Mechanism of Loosening
The femoral component usually loosens because of failure at the cement mantle (prosthesis-cement interface) and much less commonly because of failure at the bone-cement interface. 89 Splitting of the cement mantle occurs secondary to circumferential stresses; failure at the bonecement interface results from injury to the bone trabeculae interdigitating with the cement secondary to overloading or trauma. Dimensional changes resulting from socket wear result in loosening of the acetabular component. 105 These mechanical factors, via their release of cement debris, metal ions, and high-density polyethylene, stimulate a cellular proliferative and infiltrative response. In a typical loosened prosthesis, a synovial-like membrane is found at the bone-cement interface that has demonstrably high levels of prostaglandin E2 (PGE 2 ) and enhanced bone-resorbing activity. 31 Histologically, there is heavy infiltration with particulate cement and a foreign body giant cell reaction. 31 ,82 Activated fibroblasts with dense connective tissue are also present. This fibrous tissue accounts for the radiolucent zone typically seen at the implant-bone or cement-bone interface. Studies of tissues obtained at revision arthroplasty reveal large amounts of metal and polyethylene debris and high metal ion levels in the capsule and fibrous membranes surrounding loose titanium and cobalt-chromium prostheses. 23 ,56 PGE z, interleukin-1 (IL-1), and especially collagenase elevations are found whether the implants are
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loose or fixed.23 Blood and synovial fluid metal ion levels are elevated in loose cemented (as well as uncemented) prostheses (titanium and chromium-cobalt). Blood ion levels are not elevated with well-fixed prostheses. The data suggest that mechanical failure occurs, with secondary release of debris and metal ions from the prosthesis. The clinical significance of systemic blood metal ion concentrations (chromium, cobalt, titanium, nickel) is unknown, although a few case reports of tumors associated with implants hypothesize a pathogenic relation with metal ions. 12 Stress Shielding
Marked stress shielding occurs with cemented femoral prostheses, usually in the proximal medial femoral cortex. Such shielding at the proximal femur results in persistent localized osteoporosis. 62 Revision Arthroplasty
Results of secondary (revision) cemented THR are vastly inferior to the results of primary THR, with a 30% clinical failure rate at only 8 years of follow-up and an even higher rate of radiographic loosening. 68 Pain relief and functional restoration occur less consistently with cemented revisions, and multiple revisions may become necessary.48 The results worsen with each successive operation. For these reasons, most surgeons have attempted uncemented THR in this situation. Early results seem to represent an improvement. 24,34 CEMENTLESS THR
Because cement debris seems to play a contributory role in bone lysis, fixation by biologic ingrowth has been used in an attempt to decrease the high rate of loosening of cemented prostheses. Data suggest that cementless THR has a relatively low revision rate and excellent prosthetic durability for up to 12 years. 25 An increased incidence (approximately 20%) of unexplained thigh pain or limp associated with uncemented femoral prostheses may diminish over several years. 16 Short-term results are somewhat less satisfactory compared with cemented THR, but after 5 to 10 years, the results improve. Long-term follow-up beyond 12 years is unavailable at present. Despite the absence of cement, femoral osteolysis may still occur in up to 5% of cases. 21 , 63 Prosthetic retrieval analyses have shown surprisingly low rates of ingrowth of bone, even in apparently wellfixed prostheses. 2o The osteolytic reaction may be related to metal ion release from the porous coating, causing a toxic or inflammatory reaction. 14, 67
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Some surgeons have found an increased rate of acetabular loosening relative to femoral loosening in cemented prostheses over time. 89 Thus, a "hybrid" hip has been used incorporating a cementless acetabulum and a cemented femoral prosthesis. Results at 2 to 4 years show that the hybrid hip performs as well as a contemporary, fully cemented device.35, 101 Cementless devices have a significant role in revisions, osteoporosis, and bone deficiency as well as in young, active patients in whom loosening rates with cement are particularly high; however, results using contemporary cement in older patients have been excellenes Custom Implants
This very expensive high-technology approach has not been proved to be safer or more efficacious than the use of standard "off-the-shelf" prostheses. 7 ,91 Customized implants may be helpful when the patient's anatomy is unusual, but cost and operating room time will limit widespread use of this alternative. 4, IS Ceramics
Ceramic prosthetic coatings such as hydroxyapatite, aluminum oxide, and tricalcium phosphate have been used to accelerate and stimulate bonding at the metal-bone interface. 8, 52, 53 They are also normal biologic substances that might serve as a barrier to elemental ion transfer from the prosthetic surface. Because the calcium-phosphate ceramics tend to have low shear and fatigue strengths, careful follow-up will be necessary. Early clinical experience suggests efficacy and good bony fixation. 30, 42 Growth Factors
Stimuli to new bone formation, such as transforming growth factor and bone morphogenetic protein (BMP) are also being evaluated with an eye toward enhancing bone-metal fixation. ~ (TGF-~)
TOTAL KNEE REPLACEMENT Surgical Technique
The primary principles of the surgical technique are restoring proper alignment and preparing the bone for placement of the prosthesis. Preoperative deformities are corrected by performing a soft-tissue
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release on the contracted or "tight" side. In the case of a severe flexion contracture, the posterior capsule must also be divided. The cruciate ligaments are often sacrificed because an intact posterior cruciate ligament can prevent correction of a severe flexion contracture. 45 Most surgeons try to retain the posterior cruciate ligament if possible, although the surgical technique may be made more difficult. Occasionally, the preoperative deformity is so severe that posterior cruciate retention is impossible and a cruciate-substituting design must be used. The bone ends are reshaped so they may be capped by prosthetic components. The femoral condyles are measured using templates, and a prosthesis is selected that approximates the size of the original femur. The diseased articular cartilage is then removed from the distal femur. Cartilage and approximately 5 mm of bone are removed from the tibia, providing a strong cancellous surface for anchoring the tibial component. 100 The tibial component must be of adequate size to cover the entire tibial surface. Failures have been reported when undersized components have gradually penetrated into the tibia. 96 The prosthetic components are placed onto the bony ends. After total knee replacement, large stresses are transmitted to the tibial junction of the implant and bone. Acrylic cement strengthens this junction. Cementless fixation has been advocated in young patients with good quality bone stock. The fixation is provided theoretically by bony ingrowth into the tibial component. It has been demonstrated, however, that ingrowth occurs infrequently.73 This type of fixation results in a higher rate of complications74 and more surgical revisions.13 A newer press-fit, cementless fixation device does not depend on bony ingrowth for its stabilization. Early studies 72 have shown that it provides results equal to those of cement fixation with regard to pain relief, corrected alignment, and unrestricted ambulation; however, these studies are preliminary and larger groups of patients should be evaluated. Currently, cement fixation appears to provide the most reliable long-term success and should be used in most cases. Another important part of the surgical technique is the decision to resurface the patella, which involves removal of the articular cartilage and replacement of the posterior surface of the patella with a domeshaped polyethylene component. The patella is routinely resurfaced in patients with rheumatoid arthritis or osteoarthritis if it is of adequate size and thickness. In patients with advanced patellofemoral disease, patellar resurfacing can provide a knee with superior pain relief and strengthY Complications
Patellofemoral Pain. The most frequent complications after TKA involve the patellofemoral joint. Anterior knee pain, often the primary symptom, can result from patellar subluxation or dislocation, a stress fracture, avascular necrosis, a ligament rupture, or loosening of the patellar prosthesis.
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Routine patellar resurfacing provides pain relief in most patients but also has complications. The blood supply may be disrupted during surgery, which can result in osteonecrosis, stress fractures, and loosening. lO • 17, 19 It has been suggested that patellar malalignment and maltracking are the primary causes of pain and disability.9 Nonresurfaced patellae may be durable and painless if proper alignment is achieved at surgery. 87 Component Loosening. Another potential complication is component loosening, usually seen in the tibial component and heralded by development of radiolucent lines at the bone-cement interface. Loosening usually occurs within the first 2 years. With newer prostheses, the incidence of component loosening has dramatically declined. Infection. Superficial wound infection, which occurs in 20% of patients after TKA, can progress to major wound necrosis and dehiscence. Another potential concern is progression to a deep infection involving the prosthetic components. Treatment of early wound healing problems should include obtaining cultures, local wound care, debridement, and intravenous antibiotics. One of the most serious potential problems after TKA is deep infection. The incidence is less than 1% with the newer surface replacements.33, 81 Deep infections are divided into early or late, depending on whether they occur 3 months before or after TKA. Late infections are most commonly hematogenous in origin. Thrombosis. The incidence of deep vein thrombosis after TKA can reach 85% without prophylaxis. Pulmonary emboli occur in 7% to 17% of patients after TKA without prophylaxis. 90 Often these lesions are asymptomatic, and the diagnosis is unreliable even with careful physical examination. Therefore, venography, colorflow Doppler ultrasound examination of the lower extremities, or ventilation perfusion scanning of the lungs may be required to accurately identify deep vein thromboses or pulmonary emboli. Neurologic. Peroneal nerve palsy is relatively uncommon but can be a very disturbing occurrence. Most patients who develop this complication have valgus deformities and flexion contractures preoperatively.77 Injury to the peroneal nerve may occur during surgical correction of these deformities. If the initial palsy is incomplete, the chance for full recovery of function reaches 85%.5 The most useful initial therapeutic measure for this problem is loosening a constrictive compressive dressing and putting the knee in a flexed position, which may result in immediate improvement in some patients. Vascular. Vascular complications also occur uncommonly. These may include arterial thromboses, lacerations, aneurysms, and arteriovenous fistulae and may be the result of tourniquet use or arterial damage created by knee manipulation during surgery.43 Fat embolism syndrome has been reported only rarely after TKA but has resulted in death in a few patients. 65
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Clinical Outcome
Most studies report good or excellent results in nearly 90% of patients with regard to function and pain relief. ~5, 1113 The most common cause of revision is component loosening. Scott and associates 85 evaluated 119 TKAs using a posterior cruciate-substituting design over 2 to 8 years. Of all the knees, 83% were rated as excellent, and 15% were rated as good with regard to function and pain relief. Radiolucencies of 1 mm or smaller were seen in 76% of patients, and radiolucencies of larger than 2 mm were seen in 10% of patients. Only one knee required revision for aseptic loosening. Wright et aP03 recently reviewed 192 TKAs using a posterior cruciate-sparing prosthesis. Approximately 90% of patients had good or excellent pain relief and function. Radiolucencies were present in 40% of tibial, 30% of femoral, and 60% of patellar components but were not progressive, and only six knees required revision. Radiolucent lines seen on plain radiographs do not necessarily indicate a loose component unless they surround the entire component or are larger than or equal to 2 mm in width. A 6-year follow-up of more than 8000 TKA of differing types S ] found that 87% were functioning satisfactorily. The most common reason for failure was component loosening followed by infection. Results in rheumatoid arthritis are worse than results in osteoarthritis. Of 192 TKAs followed for 6 years,4U 95% of patients with osteoarthritis had an excellent result, compared with only 83% of patients with rheumatoid arthritis. A recent study Y3 of 209 TKAs in patients with rheumatoid arthritis showed that at 2 years, use of the total condylar prosthesis provided results superior to those of polycentric prosthetic designs. The largest study regarding the survival of TKA followed 9200 TKAs for 15 years. 74a There were 8069 primary arthroplasties and 1131 revision arthroplasties. The study population was composed of patients with severe osteoarthritis (68%), rheumatoid arthritis (31 %), and traumatic arthritis « 1 %). The study showed four favorable variables regarding the success of TKA. These were primary TKA, rheumatoid arthritis, age greater than 60 years, and use of a condylar prosthesis with a metal-backed tibial component. The survival of TKA, as judged by prosthesis in situ, was 97% at 5 and 10 years if all of these variables were present. TKA has proved to be a very successful treatment for severely arthritic knees. With vigorous pre- and postoperative medical management, risks of this procedure can be significantly minimized. TKA may provide patients with years of painless ambulation and a better quality of life. ACKNOWLEDGMENTS We thank J, Lockwood Ochsner, Jr, MD, for his orthopedic advice and Ms. Susan Barker for her excellent editorial assistance,
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References 1. Abitbol JJ, Gendron 0, Laurin CA, et al: Gluteal nerve damage following total hip arthroplasty: A prospective analysis. J Arthroplasty 5:319, 1990 2. Ahrengart L: Periarticular heterotopic ossification after total hip arthroplasty: Risk factors and consequences. Clin Orthop 263:49, 1991 3. Amstutz He, Friscia DA, Dorey F, et al: Warfarin prophylaxis to prevent mortality from pulmonary embolism after total hip replacement. J Bone Joint Surg 71A:321, 1989 4. Amstutz He, Nasser S, Kabo JM: Preliminary results of an off-the-shelf press-fit stem: The anthropometric total hip femoral component using exact-fit principles. Clin Orthop 249:60, 1989 5. Asp JPL, Rand JA: Peroneal nerve palsy after total knee arthroplasty. Clin Orthop 261:233, 1990 6. Ayers De, Pellegrini VD, Evarts CE, et al: Prevention of heterotopic ossification in high risk patients by radiation therapy. Clin Orthop 263:87, 1991 7. Bargar WL: Shape the implant to the patient: A rationale for the use of custom-fit cementless total hip implants. Clin Orthop 249:73, 1989 8. Bloebaum RD, Merrell M, Gustke K, et al: Retrieval analysis of a hydroxyapatitecoated hip prosthesis. Clin Orthop 267:97, 1991 9. Briard J-L, Hungerford OS: Patellofemoral instability in total knee arthroplasty. J Arthroplasty (Suppl):S87, 1989 10. Brick GW, Scott RD: Blood supply to the patella: Significance in total knee arthroplasty. J Arthroplasty (Suppl):S75, 1989 11. Bridges SL Jr, Lopez-Mendez A, Han KH, et al: Should methotrexate (MTX) be discontinued before elective orthopedic surgery in patients with RA? [abstract). J Rheum 18:984, 1991 12. Brien WW, Salvati EA, Healey JH, et al: Osteogenic sarcoma arising in the area of a total hip replacement: A case report. J Bone Joint Surg 72A:1097, 1990 13. Bryan RS: Total knee arthroplasty revisited [abstract). Orthopedic Transactions 10:171, 1986 14. Buchert PK, Vaughn BK, Mallory TH, et al: Excessive metal release due to loosening and fretting of sintered particles on porous-coated hip prostheses: Report of two cases. J Bone Joint Surg 68A:606, 1986 15. Cabanela ME: Bipolar versus total hip arthroplasty for avascular necrosis of the femoral head: A comparison. Clin Orthop 261:59, 1990 16. Callaghan JJ, Dysart SH, Savory CG: The uncemented porous-coated anatomic total hip prosthesis: Two-year results of a prospective consecutive series. J Bone Joint Surg 70A:337, 1988 17. Cameron NU, Fedorkow OM: The patella in total knee arthroplasty. Clin Orthop 165:197, 1982 18. Capello WN: Fit the patient to the prosthesis: An argument against the routine use of custom hip implants. Clin Orthop 249:56, 1989 19. Clayton ML, Thirupathi R: Patellar complications after total condylar arthroplasty. Clin Orthop 170:152, 1982 20. Collier JP, Mayor MB, Chae JC, et al: Macroscopic and microscopic evidence of prosthetic fixation with porous-coated materials. Clin Orthop 235:173, 1988 21. Cook SO, McCluskey Le, Martin pe, et al: Inflammatory response in retrieved noncemented porous-coated implants. Clin Orthop 264:209, 1991 22. Davis FM, Laurenson VG, Gillespie WJ, et al: Deep vein thrombosis after total hip replacement. A comparison between spinal and general anesthesia. J Bone Joint Surg 7lB:181, 1989 23. Dorr LD, Bloebaum R, Emmanual J, et al: Histologic, biochemical, and ion analysis of tissue and fluids retrieved during total hip arthroplasty. Clin Orthop 261:82, 1990 24. Emerson RH Jr, Head We, Berklacich FM, et al: Noncemented acetabular revision arthroplasty using allograft bone. Clin Orthop 249:30, 1989 25. Engh CA, Glassman AH, Suthers KE: The case for porous-coated hip implants: The femoral side. Clin Orthop 261:63, 1990 26. England SP, Stern SH, Insall IN, et al: Total knee arthroplasty in diabetes mellitus. Clin Orthop 260:130, 1990
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27. Enis JE, Gardner R, Robledo MA, et al: Comparison of patellar resurfacing versus nonresurfacing in bilateral total knee arthroplasty. Clin Orthop 260:38, 1990 28. Eriksson BI, Kalebo P, Anthmyr BA, et al: Prevention of deep-vein thrombosis and pulmonary embolism after total hip replacement. Comparison of low-molecularweight heparin and unfractionated heparin. J Bone Joint Surg 73A:484, 1991 29. Freiberg AA, Cantor R, Freiberg RA: The use of aspirin to prevent heterotopic ossification after total hip arthroplasty: A preliminary report. Clin Orthop 267:93, 1991 30. Geesink RGT: Hydroxyapatite-coated total hip prosthesis. Two-year clinical and roentgenographic results of 100 cases. Clin Orthop 261:39, 1990 31. Goldring SR, Jasty M, Roelke MS, et al: Formation of a synovial-like membrane at the bone-cement interface: Its role in bone resorption and implant loosening after total hip replacement. Arthritis Rheum 29:836, 1986 32. Granulomatous reaction in total hip arthroplasty [editorial]. Lancet 335:203, 1990 33. Grogan TJ, Dorey F, Rollins J, et al: Deep sepsis following knee arthroplasty: Tenyear experience at the University of California at Los Angeles Medical Center. J Bone Joint Surg 68A:226, 1986 34. Harris WH, Krushell RJ, Galante JO: Results of cementless revisions of total hip arthroplasties using the Harris-Galante prosthesis. Clin Orthop 235:120, 1988 35. Harris WH, Maloney WJ: Hybrid total hip arthroplasty. Clin Orthop 249:21, 1989 36. Harris WH, Salzman EW, Athanasoulis C, et al: Comparison of warfarin, lowmolecular-weight dextran, aspirin, and subcutaneous heparin in prevention of venous thromboembolism following total hip replacement. J Bone Joint Surg 56A:1552, 1974 37. Harris WH, Salzman EW, Athanasoulis CA, et al: Aspirin prophylaxis of venous thromboembolism after total hip replacement. N Engl J Med 297:1246, 1977 38. Harris WH, Schiller AL, Scholler J-M, et al: Extensive localized bone resorption in the femur following total hip replacement. J Bone Joint Surg 58A:612, 1976 39. Harris WH, Sledge CB: Total hip and total knee replacement (first of two parts). N Engl J Med 323:725, 1990 40. Harris WH, Sledge CB: Total hip and total knee replacement (second of two parts). N Engl J Med 323:801, 1990 41. Healy WL, Lo TCM, Cavall DJ, et al: Single-dose radiation therapy for prevention of heterotopic ossification after total hip arthroplasty. J Arthroplasty 5:369, 1990 42. Hoffinger SA, Keggi KJ, Zatorski LE: Primary ceramic hip replacement: A prospective study of 119 hips. Orthopedics 14:523, 1991 43. Hozack WJ, Cole PA, Gardner R, et al: Popliteal aneurysm after total knee arthroplasty: Case reports and review of the literature. J Arthroplasty 5:301, 1990 44. Huo HM, Salvati EA: Thromboembolic disease in total hip arthroplasty: Pathophysiology, diagnosis, and prophylaxis. Contemporary Orthopedics 22:407, 1991 45. Insall IN, Binazzi R, Soudry M, et al: Total knee arthroplasty. Clin Orthop 192:13, 1985 46. Josefsson G, Gudmundsson G, Kolmert L, et al: Prophylaxis with systemic antibiotics versus gentamicin bone cement in total hip arthroplasty: A five-year survey of 1688 hips. Clin Orthop 253:173, 1990 47. Kavanagh BF, Dewitz MA, Iistrup DM, et al: Charnley total hip arthroplasty with cement. J Bone Joint Surg 71A:1496, 1989 48. Kavanagh BF, Ilstrup DM, Fitzgerald RH: Revision total hip arthroplasty. J Bone Joint Surg 67 A:517, 1985 49. Kennedy WF, Gruen TA, Chessin H, et al: Radiation therapy to prevent heterotopic ossification after cementless total hip arthroplasty. Clin Orthop 262:185, 1991 50. Kjaersaard-Anderson P, Schmidt SA: Total hip arthroplasty-the role of antiinflammatory medications in the prevention of heterotopic ossification. Clin Orthop 263:78, 1991 51. Knutson K, Lindstrand A, Lidgren L: Survival of knee arthroplasties: A nation-wide multicentre investigation of 8000 cases. J Bone Joint Surg 68B:795, 1986 52. Lemons JE: Bioceramics: Is there a difference? Clin Orthop 261:153, 1990 53. Lemons JE: Hydroxyapatite coatings. Clin Orthop 235:220, 1988 54. Levine MN, Hirsh J, Gent M, et al: Prevention of deep vein thrombosis after elective hip surgery: A randomized trial comparing low molecular weight heparin with standard unfractionated heparin. Ann Intern Med 114:545, 1991
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55. Lidwell OM, Lowbury EJL, Whyte W, et al: Effect of ultraclean air in operating rooms on deep sepsis in the joint after total hip or knee replacement: A randomised study. Br Med J 285:10, 1982 56. Lombardi AV Jr, Mallory TH, Vaughn BK, et al: Aseptic loosening in total hip arthroplasty secondary to osteolysis induced by wear debris from titanium-alloy modular femoral heads. J Bone Joint Surg 71A:1337, 1989 57. Ludkowski P, Wilson-MacDonald J: Total arthroplasty in Paget's disease of the hip: A clinical review and review of the literature. Clin Orthop 255:160, 1990 58. Maguire JH: Advances in the control of perioperative sepsis in total joint replacement. Rheum Dis Clin North Am 14:519, 1988 59. McCollum DE, Gray WJ: Dislocation after total hip arthroplasty: Causes and prevention. Clin Orthop 261:159, 1990 60. McKenna R, Galante J, Bachmann F, et al: Prevention of venous thromboembolism after total knee replacement by high-dose aspirin or intermittent calf and thigh compression. Br Med J 280:514, 1980 61. McQueen MM, Hughes SPF, May P, et al: Cefuroxime in total joint arthroplasty: Intravenous or in bone cement. J Arthroplasty 5:169, 1990 62. Moloney WJ, Jasty M, Burke DW, et al: Biomechanical and histologic investigation of cemented total hip arthroplasties: A study of autopsy-retrieved femurs after in vivo cycling. Clin Orthop 249:129, 1989 63. Moloney WJ, Jasty M, Harris WH, et al: Endosteal erosion in association with stable uncemented femoral components. J Bone Joint Surg 72A:1025, 1990 64. Moloney WJ, Jasty M, Rosenberg A, et al: Bone lysis in well-fixed cemented femoral components. J Bone Joint Surg 72B:966, 1990 65. Monto RR, Garcia J, Callaghan J: Fatal fat embolism following total condylar knee arthroplasty. J Arthroplasty 5:291, 1990 66. Mulroy RD, Harris WH: The effect of improved cementing techniques on component loosening in total hip replacement: An ll-year radiographic review. J Bone Joint Surg 72B:757, 1990 67. Nasser S, Campbell PA, Kilgus 0, et al: Cementless total joint arthroplasty prostheses with titanium-alloy articular surfaces: A human retrieval analysis. Clin Orthop 261:171, 1990 68. Pellicci PM, Wilson PD Jr, Sledge CB, et al: Long-term results of revision total hip replacement: A follow-up report. J Bone Joint Surg 67A:513, 1985 69. Perhala RS, Wilke WS, Clough JD, et al: Local infectious complications following large joint replacement in rheumatoid arthritis patients treated with methotrexate versus those not treated with methotrexate. Arthritis Rheum 34:146, 1991 70. Pettine KA, Aamlid BC, Cabanela ME: Elective total hip arthroplasty in patients older than 80 years of age. Clin Orthop 266:127, 1991 71. Pittenger DE: Heterotopic ossification. Orthop Rev 20:33, 1991 72. Rackemann S, Mintzer CM, Walker PS, et al: Uncemented press-fit total knee arthroplasty. J Arthroplasty 5:307, 1990 73. Ranawat CS, Johanson NA, Rimnac CM, et al: Retrieval analysis of porous-coated components for total knee arthroplasty: A report of two cases. Clin Orthop 209:244, 1986 74. Rand JA, Bryan RS, Chao EYS: Porous coated anatomic total knee arthroplasty [abstract]. Orthopedic Transactions 10:169, 1986 74a. Rand JA, Ilstrup OM: Survivors hip analysis of total knee arthroplasty: Cumulative rates of survival of 9200 total knee arthroplasties. J Bone Joint Surg 73A:397, 1991 75. Rockwood PR, Home JG: Heterotopic ossification following uncemented total hip arthroplasty. J Arthroplasty 5(Suppl):S43, 1990 76. Romness DW, Rand JA: The role of continuous passive motion following total knee arthroplasty. Clin Orthop 226:34, 1988 77. Rose HA, Hood RW, Otis JC, et al: Peroneal-nerve palsy following TKA: A review of the Hospital for Special Surgery experience. J Bone Joint Surg 64:347, 1982 78. Rothman RH, Cohn JC: Cemented versus cementless total hip arthroplasty: A critical review. Clin Orthop 254:153, 1990 79. Russotti GM, Coventry MB, Stauffer RN: Cemented total hip arthroplasty with contemporary techniques. A five-year minimum follow-up study. Clin Orthop 235:141, 1988
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80. Salter RB: The biologic concept of continuous passive motion of synovial joints: The first 18 years of basic research and its clinical application. Clin Orthop 242:12, 1989 81. Salvati EA, Robinson RP, Zeno SM, et al: Infection rates after 3175 total hip and total knee replacements performed with and without a horizontal unidirectional filtered air-flow system. J Bone Joint Surg 64A:525, 1982 82. Santavirta 5, Konttinen YT, Bergroth V, et al: Aggressive granulomatous lesions associated with hip arthroplasty: Immunopathological studies. J Bone Joint Surg 72A:252, 1990 83. Schmidt SA, Kjaersgaard-Andersen P, Pedersen NW, et al: The use of indomethacin to prevent the formation of heterotopic bone after total hip replacement: A randomized, double-blind clinical trial. J Bone Joint Surg 70A:834, 1988 84. Schutzer SF, Harris WH: Deep-wound infection after total hip replacement under contemporary aseptic conditions. J Bone Joint Surg 70A:724, 1988 85. Scott WN, Rubenstein M, Scuderi G, et al: Results after knee replacement with a posterior cruciate substituting prosthesis. J Bone Joint Surg 70A:1163, 1988 86. Se vert R, Wood R, Cracchiolo A Ill, et al: Long-term follow-up of cemented total hip arthroplasty in rheumatoid arthritis. Clin Orthop 265:137, 1991 87. Smith SR, Stuart P, Pinder IM: Nonresurfaced patella in total knee arthroplasty. J Arthroplasty (Suppl):S81, 1989 88. Soudry M, Binazzi R, Johanson NA, et al: Total knee arthroplasty in Charcot and Charcot-like joints. Clin Orthop 208:199, 1986 89. Stauffer RN: Ten-year follow-up study of total hip replacement: With particular reference to roentgenographic loosening of the components. J Bone Joint Surg 64A:983, 1982 90. Stulberg BN, Insall IN, Williams GW, et al: Deep-vein thrombosis following total knee replacement: An analysis of six hundred and thirty-eight arthroplasties. J Bone Joint Surg 66:194, 1984 91. Stulberg SO, Stulberg BN, Wixson RL: The rationale, design characteristics, and preliminary results of primary custom total hip prosthesis. Clin Orthop 249:79, 1989 92. Sullivan PM, Johnston RC, Kelley SS: Late infection after total hip replacement, caused by an oral organism after dental manipulation: A case report. J Bone Joint Surg 72A:121, 1990 92a. Thomas B, Amstutz H: Results of the administration of diphosphonates for the prevention of heterotopic ossification after total hip arthroplasty. J Bone Joint Surg 67 A:400, 1985 93. Thomas BJ, Cracchiolo A Ill, Lee YF, et al: Total knee arthroplasty in rheumatoid arthritis: A comparison of the polycentric and total condylar prostheses. Clin Orthop 265:129, 1991 94. Turpie AGG, Levine MN, Hirsh J, et al: A randomized controlled trial of a low molecular weight heparin (enoxaparin) to prevent deep-vein thrombosis in patients undergoing elective hip surgery. N Engl J Med 315:925, 1986 95. Walker PS, Greene 0, Reilly 0, et al: Fixation of tibial components of knee prostheses. J Bone Joint Surg 63A:258, 1981 96. Walker LG, Sledge CB: Total hip arthroplasty in ankylosing spondylitis. Clin Orthop 262:198, 1991 97. Warren SB: Heterotopic ossification after total hip replacement. Orthop Rev 19:603, 1990 98. Weber ER, Daube JR, Coventry MB: Peripheral neuropathies associated with total hip arthroplasty. J Bone Joint Surg 58A:66, 1976 99. Welch RB, McGann WA, Picetti GO Ill: Charnley low-friction arthroplasty: a fifteento seventeen-year follow-up study. Orthop Clin North Am 19:551, 1988 100. Windsor RE, Insall IN: The knee. In Harris K, Sledge R (eds): Texbook of Rheumatology. Reconstructive Surgery in Rheumatic Diseases, ed 3. Philadelphia, W.B. Saunders, 1989, p 2041 101. Wixson RL, Stulberg SO, Mehlhoff M: Total hip replacement with cemented, uncemented, and hybrid prostheses: A comparison of clinical and radiographic results at two to four years. J Bone Joint Surg 73A:257, 1991 102. Woo RYG, Morrey BF: Dislocations after total hip arthroplasty. J Bone Joint Surg 64A:1295, 1982
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103. Wright L Ewald Fe, Walker PS, et al: Total knee arthroplasty with the kinematic prosthesis: Results after five to nine years: A follow-up note. J Bone Joint Surg 72A:1003, 1990 104. Wroblewski BM: 15-21-year results of the Charnley low-friction arthroplasty. Clin Orthop 211:30, 1986 105. Wroblewski BM: Wear and loosening of the socket in the Charnley low-friction arthroplasty. Orthop Clin North Am 19:627, 1988
Address reprint requests to Robert J. Quinet, MD Ochsner Clinic 1514 Jefferson Highway New Orleans, LA 70121
0025-7125/92 $0.00 + .20
TOTAL JOINT REPLACEMENT OF THE HIP AND KNEE Robert
J.
Quinet, MD, and Ellen C. Winters, MD
Total joint replacement (TJR) of the hip and knee are among the most successful orthopedic procedures and have revolutionized the management of arthritis, particularly osteoarthritis. We as internists must be knowledgeable about the benefits, risks, indications, and contraindications of these procedures so we can advise our patients and make appropriate and timely referrals to our orthopedic colleagues. We also must participate in the preoperative evaluation and be aware of the postoperative course and potential complications that might require our assistance. The following brief review of total hip and knee replacement from the internal medicine perspective does not deal with details of operative or surgical technique. INDICATIONS FOR T JR Pain
The most important indication is severe pain, particularly at rest, in a patient with advanced arthritis of the hip or knee. Severe pain must be persistent and refractory to conservative treatment including use of nonsteroidal anti-inflammatory drugs (NSAIDs), adequate rest, protected weight bearing with a cane or walker, therapeutic exercise performed daily, appropriate weight reduction, physical therapy, and analgesics. From the Section on Rheumatology, Department of Internal Medicine, Ochsner Clinic and Alton Ochsner Medical Foundation, New Orleans, Louisiana THE MEDICAL CLINICS OF NORTH AMERICA VOLUME 76· NUMBER 5· SEPTEMBER 1992
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Function
Major limitations of walking, climbing stairs, transfers, and putting on shoes and socks despite rigorous conservative management also enter into the decision. Functional status is improved by surgery in most patients, although not quite to the degree that pain relief occurs. Age
It is generally recommended that TJR be performed in patients older than age 60 because then the longevity of the prosthesis approaches the life expectancy of the patient, and the physical demands on the prosthesis are less. Elective total hip replacement (THR) may improve function even for octogenarians. 70 For rheumatoid arthritis, especially for juvenile rheumatoid arthritis, the procedure may have to be done at a younger age. For younger patients with osteoarthritis, one should consider alternative orthopedic procedures such as osteotomy, which can later be converted to a TJR if necessary. Physical Examination
Physical examination should document painful, significant limitation of joint range of motion and exclude other causes of the pain. Radiographs
Radiographs should demonstrate major loss of cartilaginous joint space with bony apposition. In summary, TJR is performed for severe pain and significant functional limitation, with physical examination findings of painful limitation of joint motion and radiographic evidence of severe joint space loss. EDUCATION OF PATIENT
It should be explained to the patient that the artificial joint is not a normal one and will have to be protected and used cautiously even if painless. Activities such as walking, climbing stairs, driving, swimming, bicycling, or golf are permitted; however, racquet sports, jogging, mountain climbing, jumping, and skiing are prohibited, and the patient must understand and accept this. As the chance of prosthetic loosening increases with body weight and age, an obese patient should demonstrate an effort at weight
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reduction preoperatively, and TJR should be delayed until age 60 to 65 if possible. The patient must be willing to participate in rehabilitation. This program involves protected weight bearing for 2 to 5 months and strengthening exercises. CONTRAINDICATIONS
Contraindications include poor general medical condition; significant peripheral vascular disease; neuropathy, particularly affecting the joint; and active infection. Total knee arthroplasty (TKA) was once contraindicated in patients with neuropathic joints; however, some success with TKA has been reported using newer unconstrained prostheses. 88 PREOPERATIVE EVALUATION
A thorough preoperative evaluation should be performed in an effort to minimize surgical risk. Most patients requiring TKA are elderly and may have significant medical problems. All patients should be evaluated for coronary and peripheral vascular disease, and peripheral pulses should be checked. Patients who are obese or who have venous varicosities, edema, prolonged preoperative immobilization, or a history of thromboembolism are at increased risk for thrombosis. All patients should have some form of thrombosis prophylaxis, but the optimal method is controversial. Early mobilization, active exercise, and compression stockings can be employed for all patients. Currently, warfarin begun the night before surgery and continued until the night of discharge seems most appropriate. 3 , 36, 39, 44 Aspirin provides some protection, predominantly in men, but is inferior to warfarin. 36, 37 Lowdose aspirin and intermittent pneumatic compression have been shown to be effective prophylaxis for TKA. 60 Dextran reduces the risk of thrombosis but is associated with a significant risk of bleeding and congestive heart failure. 36, 39 Experimentally, low molecular weight heparin (Enoxaparin) seems superior to standard heparin prophylaxis, but it is not yet available. 28 , 54 Adjusted-dose subcutaneous heparin is effective but may incur a high risk of bleeding. Epidural anesthesia significantly reduces thromboembolic risk. 22,44 All potential sources of infection should be evaluated. These include the urinary tract, dental caries or periodontal disease, sinuses, and skin. A preoperative chest radiograph and urine culture should be performed, and any infections should be treated before elective surgery. Prevention of perioperative infection includes the use of prophylactic antibiotics, usually a parenteral second-generation cephalosporin. 55, 58, 81 The use of antibiotic-impregnated cement, with or without systemic antibiotic prophylaxis, remains controversial and is still exper-
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imenta1. 46 , 58, 61 Ultra-clean air systems may reduce the incidence of joint sepsis by as much as one half, and the use of whole-body exhaustventilated suits worn by the surgeon may reduce infection to one quarter of that of conventional ventilation,55, 81, 84 Late infection may be avoided by preventing bacteremia,92 which involves prompt treatment of any infectious process to prevent hematogenous seeding and prophylaxis (as for endocarditis) at the time of dental work or any procedure associated with transient bacteremia. The latter recommendation must be weighed against the risk of antibiotic allergic reaction and lack of proven efficacy. Patients with diabetes mellitus should attain optimal control of serum glucose perioperatively because it may facilitate wound healing and reduce infection. 26 In patients with rheumatoid arthritis, lateral flexion views of the cervical spine should be obtained, and extra caution should be used during intubation if atlantoaxial subluxation is found. A thorough history regarding prior or current corticosteroid therapy must be obtained. If a patient has received corticosteroids within the year, a "steroid prep" should be used at the time of surgery. Patients with rheumatoid arthritis also appear to have a higher incidence of postoperative infections. There has been support for discontinuation of methotrexate 1 month before surgery in an effort to decrease potential complications. ll Recently, however, it was suggested that methotrexate use throughout the perioperative period may not increase the risk of infection and may be beneficial in preventing a postoperative flare that could potentially interfere with rehabilitation. 69 Although further studies are needed, for now it is probably prudent to withhold several doses of methotrexate. Aspirin should be discontinued 1 week before surgery, and other NSAIDs should be stopped five half-lives before surgery to reduce bleeding, especially if epidural anesthesia is used. This discontinuation will sacrifice their antithrombotic effect, however. Autologous blood donation of 2 to 3 units at weekly intervals in the month before elective surgery is recommended. POSTOPERATIVE REHABILITATION
The goal of rehabilitation is to obtain a maximal arc of comfortable joint motion with good muscle control and have the patient return to independent daily living as quickly as possible. Patients are at bedrest for the first several postoperative days. They should be encouraged to do exercises such as ankle plantar and dorsiflexion, straight leg raises, and quadriceps and hamstring isometrics. The use of continuous passive motion has been advocated in the early postoperative period following TKA.80 Range of motion was restored faster when continuous passive motion (CPM) was used. The need for postoperative manipulation is also reduced after CPM; how-
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ever, long-term range of motion appears not to be significantly improved with CPM. 76 On the third or fourth postoperative day, the patient should attempt to bear partial weight with a walker or crutch. Gentle, passive, range-of-motion exercises should be performed under the instruction of a physical therapist. Goals of the immediate postoperative rehabilitation are for the patient to bear full weight with a cane and to be independent in activities of daily living at hospital discharge. The average hospital stay is 10 days to 2 weeks, and physical therapy should be continued after discharge. The goal for knee motion is ?: 90°. If rehabilitation does not progress, gentle manipulation under anesthesia may be indicated. TOTAL HIP REPLACEMENT Definition
THR is an orthopedic surgical procedure involving excision of the native femoral head and part of the neck and enlargement of the native acetabulum. The metallic femoral prosthesis (stem and small diameter head) is inserted into the femoral medullary canal. The acetabular component, composed of a high-density polyethylene articulating surface usually surrounded by metallic backing, is inserted into the enlarged acetabular space. The components may be fixed either with methylmethacrylate (cement) or a porous coating designed to adhere directly to medullary bone (cementless). The procedure is performed mainly for severe osteoarthritis of the hip. Less commonly, it is performed in advanced rheumatoid arthritis, juvenile rheumatoid arthritis, ankylosing spondylitis, Paget's disease, or avascular necrosis of the hip. More than 100,000 THRs are performed annually in the United States. The large number of operations is because of the greater than 90% chance of complete pain relief and significant improvement in function in appropriately selected patients. Complications of THR
Heterotopic Ossification (HO). Heterotopic bone may form in up to 70% of patients undergoing THR, but it limits functional motion or produces pain in fewer than 4%.2,71,75,97 Patients at risk include those with previous HO, diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, or osteoarthritis (in men). Prophylaxis with NSAIDs29, 50, 83 or postoperative low-dose radiation therapy6, 41, 49 is quite effective for patients at risk. Diphosphonates are of no value. 92a If significant ossification develops, surgical excision is helpful, but it is typically delayed for 1 year to allow full maturity of the ectopic bone.
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Dislocation. Dislocation of the prosthesis occurs in fewer than 1 % of patients and is a distant second to loosening as a cause of reoperation. 59 , 102 The major cause is malposition of the acetabular component, which occurs most commonly with revision arthroplasty. 59 Neurologic Complications. Nerve damage secondary to operative trauma can occur but is rarely clinically significant. The prognosis for recovery is good unless the nerve is severely damaged. Trauma usually involves the obdurator, gluteal, femoral, or sciatic nerves. 1,98 Fracture. The incidence of fracture has been much reduced with modern prostheses and contemporary surgical techniques. There is still a significant incidence in revision arthroplasties with cementless prostheses (6%). Infection. The rate of infection after primary THR is now less than 1%, and it is less than 3% with revision. 55,58,81,84 THR using perioperative antibiotics, laminar air-flow operating rooms, and body exhaust systems is associated with an overall incidence of sepsis of 0.38% (early and late).84 Sepsis necessitates 4 to 6 weeks of parenteral antibiotics and frequently removal of the prosthesis. In some cases, revision arthroplasty may be performed using antibiotic-impregnated cement. Detailed discussion of infected hip prostheses is beyond the scope of this article. Thromboembolism. In the absence of prophylaxis, deep vein thrombosis occurs in 50% of patients, asymptomatic pulmonary emboli with proximal (thigh) thrombosis in 20%, and fatal pulmonary emboli in 1% to 4%.37,44,94 With appropriate prophylaxis, the risk of deep vein and proximal thrombosis is reduced by one half, and the embolism rate falls to less than 1%. Because thromboembolism may occur despite prophylaxis, vigilance is necessary, and clinical suspicion should be evaluated with leg venography and nuclear medicine lung scanning. CEMENTED THR Clinical Outcome
THR usually leads to a dramatic improvement in the patient's quality of life and function. The Charnley cemented THR provides a good to excellent clinical result in 80% to 85% of patients for at least 15 to 20 yearsY, 99, 104 The clinical failure rate (i.e., symptomatic aseptic loosening or revision arthroplasty) is about 1% per year of follow-up.99 Radiographic loosening occurs at twice that rate, affecting one third of THR by 15 years. With contemporary prostheses and modern cementing techniques, the rate of femoral loosening seems to be dramatically reduced, based on 11 years' follow-up.66, 79 Aseptic loosening occurs more commonly in young, heavy, active men and with certain prosthetic designs, such as the older Muller curved-stem prosthesis or the McKee-Farrar prosthesis. Results in Other Arthropathies. Results are worse in patients with
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rheumatoid arthritis, with up to a 25% clinical failure rate at 12 years and an increased incidence of delayed wound healing and sepsis. 86 These patients tend to be younger and to have osteoporosis. Paget's disease is associated with a satisfactorv outcome,57 but avascular necrosis has an inferior outcome, in part as o a result of the generally younger age of the patients and the consequently increased demands placed on the hip.15 Ankylosing spondylitis THR may be associated with a high incidence of myositis ossificans, and pre-existing soft-tissue contractures may compromise motion. 95 Aggressive Granulomatous Reaction. A much less common cause of clinical failure and revision is re sorption and focal lysis of the femur secondary to an "aggressive granulomatous lesion,"32 a distinct entity that may cause loosening in up to 4% of THR, independent of mechanical or septic causes. This aggressive granulomatous reaction may account for up to 5% of hip revisions. 32, 38 Histologically, macrophages, multinucleated giant cells, cement particles, and a relative lack of fibroblasts are observed,38, 82 Radiographically, this results in focal lysis around the prosthetic stem that mayor may not cause pain, loosening, or both. A localized area of fracture in the cement surrounding an often well-fixed prosthetic stem results in fragmentation of the cement, which serves as a stimulus for an exuberant macrophage, histiocyte, giant cell reaction. 64 Mechanism of Loosening
The femoral component usually loosens because of failure at the cement mantle (prosthesis-cement interface) and much less commonly because of failure at the bone-cement interface. 89 Splitting of the cement mantle occurs secondary to circumferential stresses; failure at the bonecement interface results from injury to the bone trabeculae interdigitating with the cement secondary to overloading or trauma. Dimensional changes resulting from socket wear result in loosening of the acetabular component. 105 These mechanical factors, via their release of cement debris, metal ions, and high-density polyethylene, stimulate a cellular proliferative and infiltrative response. In a typical loosened prosthesis, a synovial-like membrane is found at the bone-cement interface that has demonstrably high levels of prostaglandin E2 (PGE 2 ) and enhanced bone-resorbing activity. 31 Histologically, there is heavy infiltration with particulate cement and a foreign body giant cell reaction. 31 ,82 Activated fibroblasts with dense connective tissue are also present. This fibrous tissue accounts for the radiolucent zone typically seen at the implant-bone or cement-bone interface. Studies of tissues obtained at revision arthroplasty reveal large amounts of metal and polyethylene debris and high metal ion levels in the capsule and fibrous membranes surrounding loose titanium and cobalt-chromium prostheses. 23 ,56 PGE z, interleukin-1 (IL-1), and especially collagenase elevations are found whether the implants are
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loose or fixed.23 Blood and synovial fluid metal ion levels are elevated in loose cemented (as well as uncemented) prostheses (titanium and chromium-cobalt). Blood ion levels are not elevated with well-fixed prostheses. The data suggest that mechanical failure occurs, with secondary release of debris and metal ions from the prosthesis. The clinical significance of systemic blood metal ion concentrations (chromium, cobalt, titanium, nickel) is unknown, although a few case reports of tumors associated with implants hypothesize a pathogenic relation with metal ions. 12 Stress Shielding
Marked stress shielding occurs with cemented femoral prostheses, usually in the proximal medial femoral cortex. Such shielding at the proximal femur results in persistent localized osteoporosis. 62 Revision Arthroplasty
Results of secondary (revision) cemented THR are vastly inferior to the results of primary THR, with a 30% clinical failure rate at only 8 years of follow-up and an even higher rate of radiographic loosening. 68 Pain relief and functional restoration occur less consistently with cemented revisions, and multiple revisions may become necessary.48 The results worsen with each successive operation. For these reasons, most surgeons have attempted uncemented THR in this situation. Early results seem to represent an improvement. 24,34 CEMENTLESS THR
Because cement debris seems to play a contributory role in bone lysis, fixation by biologic ingrowth has been used in an attempt to decrease the high rate of loosening of cemented prostheses. Data suggest that cementless THR has a relatively low revision rate and excellent prosthetic durability for up to 12 years. 25 An increased incidence (approximately 20%) of unexplained thigh pain or limp associated with uncemented femoral prostheses may diminish over several years. 16 Short-term results are somewhat less satisfactory compared with cemented THR, but after 5 to 10 years, the results improve. Long-term follow-up beyond 12 years is unavailable at present. Despite the absence of cement, femoral osteolysis may still occur in up to 5% of cases. 21 , 63 Prosthetic retrieval analyses have shown surprisingly low rates of ingrowth of bone, even in apparently wellfixed prostheses. 2o The osteolytic reaction may be related to metal ion release from the porous coating, causing a toxic or inflammatory reaction. 14, 67
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Some surgeons have found an increased rate of acetabular loosening relative to femoral loosening in cemented prostheses over time. 89 Thus, a "hybrid" hip has been used incorporating a cementless acetabulum and a cemented femoral prosthesis. Results at 2 to 4 years show that the hybrid hip performs as well as a contemporary, fully cemented device.35, 101 Cementless devices have a significant role in revisions, osteoporosis, and bone deficiency as well as in young, active patients in whom loosening rates with cement are particularly high; however, results using contemporary cement in older patients have been excellenes Custom Implants
This very expensive high-technology approach has not been proved to be safer or more efficacious than the use of standard "off-the-shelf" prostheses. 7 ,91 Customized implants may be helpful when the patient's anatomy is unusual, but cost and operating room time will limit widespread use of this alternative. 4, IS Ceramics
Ceramic prosthetic coatings such as hydroxyapatite, aluminum oxide, and tricalcium phosphate have been used to accelerate and stimulate bonding at the metal-bone interface. 8, 52, 53 They are also normal biologic substances that might serve as a barrier to elemental ion transfer from the prosthetic surface. Because the calcium-phosphate ceramics tend to have low shear and fatigue strengths, careful follow-up will be necessary. Early clinical experience suggests efficacy and good bony fixation. 30, 42 Growth Factors
Stimuli to new bone formation, such as transforming growth factor and bone morphogenetic protein (BMP) are also being evaluated with an eye toward enhancing bone-metal fixation. ~ (TGF-~)
TOTAL KNEE REPLACEMENT Surgical Technique
The primary principles of the surgical technique are restoring proper alignment and preparing the bone for placement of the prosthesis. Preoperative deformities are corrected by performing a soft-tissue
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release on the contracted or "tight" side. In the case of a severe flexion contracture, the posterior capsule must also be divided. The cruciate ligaments are often sacrificed because an intact posterior cruciate ligament can prevent correction of a severe flexion contracture. 45 Most surgeons try to retain the posterior cruciate ligament if possible, although the surgical technique may be made more difficult. Occasionally, the preoperative deformity is so severe that posterior cruciate retention is impossible and a cruciate-substituting design must be used. The bone ends are reshaped so they may be capped by prosthetic components. The femoral condyles are measured using templates, and a prosthesis is selected that approximates the size of the original femur. The diseased articular cartilage is then removed from the distal femur. Cartilage and approximately 5 mm of bone are removed from the tibia, providing a strong cancellous surface for anchoring the tibial component. 100 The tibial component must be of adequate size to cover the entire tibial surface. Failures have been reported when undersized components have gradually penetrated into the tibia. 96 The prosthetic components are placed onto the bony ends. After total knee replacement, large stresses are transmitted to the tibial junction of the implant and bone. Acrylic cement strengthens this junction. Cementless fixation has been advocated in young patients with good quality bone stock. The fixation is provided theoretically by bony ingrowth into the tibial component. It has been demonstrated, however, that ingrowth occurs infrequently.73 This type of fixation results in a higher rate of complications74 and more surgical revisions.13 A newer press-fit, cementless fixation device does not depend on bony ingrowth for its stabilization. Early studies 72 have shown that it provides results equal to those of cement fixation with regard to pain relief, corrected alignment, and unrestricted ambulation; however, these studies are preliminary and larger groups of patients should be evaluated. Currently, cement fixation appears to provide the most reliable long-term success and should be used in most cases. Another important part of the surgical technique is the decision to resurface the patella, which involves removal of the articular cartilage and replacement of the posterior surface of the patella with a domeshaped polyethylene component. The patella is routinely resurfaced in patients with rheumatoid arthritis or osteoarthritis if it is of adequate size and thickness. In patients with advanced patellofemoral disease, patellar resurfacing can provide a knee with superior pain relief and strengthY Complications
Patellofemoral Pain. The most frequent complications after TKA involve the patellofemoral joint. Anterior knee pain, often the primary symptom, can result from patellar subluxation or dislocation, a stress fracture, avascular necrosis, a ligament rupture, or loosening of the patellar prosthesis.
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Routine patellar resurfacing provides pain relief in most patients but also has complications. The blood supply may be disrupted during surgery, which can result in osteonecrosis, stress fractures, and loosening. lO • 17, 19 It has been suggested that patellar malalignment and maltracking are the primary causes of pain and disability.9 Nonresurfaced patellae may be durable and painless if proper alignment is achieved at surgery. 87 Component Loosening. Another potential complication is component loosening, usually seen in the tibial component and heralded by development of radiolucent lines at the bone-cement interface. Loosening usually occurs within the first 2 years. With newer prostheses, the incidence of component loosening has dramatically declined. Infection. Superficial wound infection, which occurs in 20% of patients after TKA, can progress to major wound necrosis and dehiscence. Another potential concern is progression to a deep infection involving the prosthetic components. Treatment of early wound healing problems should include obtaining cultures, local wound care, debridement, and intravenous antibiotics. One of the most serious potential problems after TKA is deep infection. The incidence is less than 1% with the newer surface replacements.33, 81 Deep infections are divided into early or late, depending on whether they occur 3 months before or after TKA. Late infections are most commonly hematogenous in origin. Thrombosis. The incidence of deep vein thrombosis after TKA can reach 85% without prophylaxis. Pulmonary emboli occur in 7% to 17% of patients after TKA without prophylaxis. 90 Often these lesions are asymptomatic, and the diagnosis is unreliable even with careful physical examination. Therefore, venography, colorflow Doppler ultrasound examination of the lower extremities, or ventilation perfusion scanning of the lungs may be required to accurately identify deep vein thromboses or pulmonary emboli. Neurologic. Peroneal nerve palsy is relatively uncommon but can be a very disturbing occurrence. Most patients who develop this complication have valgus deformities and flexion contractures preoperatively.77 Injury to the peroneal nerve may occur during surgical correction of these deformities. If the initial palsy is incomplete, the chance for full recovery of function reaches 85%.5 The most useful initial therapeutic measure for this problem is loosening a constrictive compressive dressing and putting the knee in a flexed position, which may result in immediate improvement in some patients. Vascular. Vascular complications also occur uncommonly. These may include arterial thromboses, lacerations, aneurysms, and arteriovenous fistulae and may be the result of tourniquet use or arterial damage created by knee manipulation during surgery.43 Fat embolism syndrome has been reported only rarely after TKA but has resulted in death in a few patients. 65
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Clinical Outcome
Most studies report good or excellent results in nearly 90% of patients with regard to function and pain relief. ~5, 1113 The most common cause of revision is component loosening. Scott and associates 85 evaluated 119 TKAs using a posterior cruciate-substituting design over 2 to 8 years. Of all the knees, 83% were rated as excellent, and 15% were rated as good with regard to function and pain relief. Radiolucencies of 1 mm or smaller were seen in 76% of patients, and radiolucencies of larger than 2 mm were seen in 10% of patients. Only one knee required revision for aseptic loosening. Wright et aP03 recently reviewed 192 TKAs using a posterior cruciate-sparing prosthesis. Approximately 90% of patients had good or excellent pain relief and function. Radiolucencies were present in 40% of tibial, 30% of femoral, and 60% of patellar components but were not progressive, and only six knees required revision. Radiolucent lines seen on plain radiographs do not necessarily indicate a loose component unless they surround the entire component or are larger than or equal to 2 mm in width. A 6-year follow-up of more than 8000 TKA of differing types S ] found that 87% were functioning satisfactorily. The most common reason for failure was component loosening followed by infection. Results in rheumatoid arthritis are worse than results in osteoarthritis. Of 192 TKAs followed for 6 years,4U 95% of patients with osteoarthritis had an excellent result, compared with only 83% of patients with rheumatoid arthritis. A recent study Y3 of 209 TKAs in patients with rheumatoid arthritis showed that at 2 years, use of the total condylar prosthesis provided results superior to those of polycentric prosthetic designs. The largest study regarding the survival of TKA followed 9200 TKAs for 15 years. 74a There were 8069 primary arthroplasties and 1131 revision arthroplasties. The study population was composed of patients with severe osteoarthritis (68%), rheumatoid arthritis (31 %), and traumatic arthritis « 1 %). The study showed four favorable variables regarding the success of TKA. These were primary TKA, rheumatoid arthritis, age greater than 60 years, and use of a condylar prosthesis with a metal-backed tibial component. The survival of TKA, as judged by prosthesis in situ, was 97% at 5 and 10 years if all of these variables were present. TKA has proved to be a very successful treatment for severely arthritic knees. With vigorous pre- and postoperative medical management, risks of this procedure can be significantly minimized. TKA may provide patients with years of painless ambulation and a better quality of life. ACKNOWLEDGMENTS We thank J, Lockwood Ochsner, Jr, MD, for his orthopedic advice and Ms. Susan Barker for her excellent editorial assistance,
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27. Enis JE, Gardner R, Robledo MA, et al: Comparison of patellar resurfacing versus nonresurfacing in bilateral total knee arthroplasty. Clin Orthop 260:38, 1990 28. Eriksson BI, Kalebo P, Anthmyr BA, et al: Prevention of deep-vein thrombosis and pulmonary embolism after total hip replacement. Comparison of low-molecularweight heparin and unfractionated heparin. J Bone Joint Surg 73A:484, 1991 29. Freiberg AA, Cantor R, Freiberg RA: The use of aspirin to prevent heterotopic ossification after total hip arthroplasty: A preliminary report. Clin Orthop 267:93, 1991 30. Geesink RGT: Hydroxyapatite-coated total hip prosthesis. Two-year clinical and roentgenographic results of 100 cases. Clin Orthop 261:39, 1990 31. Goldring SR, Jasty M, Roelke MS, et al: Formation of a synovial-like membrane at the bone-cement interface: Its role in bone resorption and implant loosening after total hip replacement. Arthritis Rheum 29:836, 1986 32. Granulomatous reaction in total hip arthroplasty [editorial]. Lancet 335:203, 1990 33. Grogan TJ, Dorey F, Rollins J, et al: Deep sepsis following knee arthroplasty: Tenyear experience at the University of California at Los Angeles Medical Center. J Bone Joint Surg 68A:226, 1986 34. Harris WH, Krushell RJ, Galante JO: Results of cementless revisions of total hip arthroplasties using the Harris-Galante prosthesis. Clin Orthop 235:120, 1988 35. Harris WH, Maloney WJ: Hybrid total hip arthroplasty. Clin Orthop 249:21, 1989 36. Harris WH, Salzman EW, Athanasoulis C, et al: Comparison of warfarin, lowmolecular-weight dextran, aspirin, and subcutaneous heparin in prevention of venous thromboembolism following total hip replacement. J Bone Joint Surg 56A:1552, 1974 37. Harris WH, Salzman EW, Athanasoulis CA, et al: Aspirin prophylaxis of venous thromboembolism after total hip replacement. N Engl J Med 297:1246, 1977 38. Harris WH, Schiller AL, Scholler J-M, et al: Extensive localized bone resorption in the femur following total hip replacement. J Bone Joint Surg 58A:612, 1976 39. Harris WH, Sledge CB: Total hip and total knee replacement (first of two parts). N Engl J Med 323:725, 1990 40. Harris WH, Sledge CB: Total hip and total knee replacement (second of two parts). N Engl J Med 323:801, 1990 41. Healy WL, Lo TCM, Cavall DJ, et al: Single-dose radiation therapy for prevention of heterotopic ossification after total hip arthroplasty. J Arthroplasty 5:369, 1990 42. Hoffinger SA, Keggi KJ, Zatorski LE: Primary ceramic hip replacement: A prospective study of 119 hips. Orthopedics 14:523, 1991 43. Hozack WJ, Cole PA, Gardner R, et al: Popliteal aneurysm after total knee arthroplasty: Case reports and review of the literature. J Arthroplasty 5:301, 1990 44. Huo HM, Salvati EA: Thromboembolic disease in total hip arthroplasty: Pathophysiology, diagnosis, and prophylaxis. Contemporary Orthopedics 22:407, 1991 45. Insall IN, Binazzi R, Soudry M, et al: Total knee arthroplasty. Clin Orthop 192:13, 1985 46. Josefsson G, Gudmundsson G, Kolmert L, et al: Prophylaxis with systemic antibiotics versus gentamicin bone cement in total hip arthroplasty: A five-year survey of 1688 hips. Clin Orthop 253:173, 1990 47. Kavanagh BF, Dewitz MA, Iistrup DM, et al: Charnley total hip arthroplasty with cement. J Bone Joint Surg 71A:1496, 1989 48. Kavanagh BF, Ilstrup DM, Fitzgerald RH: Revision total hip arthroplasty. J Bone Joint Surg 67 A:517, 1985 49. Kennedy WF, Gruen TA, Chessin H, et al: Radiation therapy to prevent heterotopic ossification after cementless total hip arthroplasty. Clin Orthop 262:185, 1991 50. Kjaersaard-Anderson P, Schmidt SA: Total hip arthroplasty-the role of antiinflammatory medications in the prevention of heterotopic ossification. Clin Orthop 263:78, 1991 51. Knutson K, Lindstrand A, Lidgren L: Survival of knee arthroplasties: A nation-wide multicentre investigation of 8000 cases. J Bone Joint Surg 68B:795, 1986 52. Lemons JE: Bioceramics: Is there a difference? Clin Orthop 261:153, 1990 53. Lemons JE: Hydroxyapatite coatings. Clin Orthop 235:220, 1988 54. Levine MN, Hirsh J, Gent M, et al: Prevention of deep vein thrombosis after elective hip surgery: A randomized trial comparing low molecular weight heparin with standard unfractionated heparin. Ann Intern Med 114:545, 1991
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80. Salter RB: The biologic concept of continuous passive motion of synovial joints: The first 18 years of basic research and its clinical application. Clin Orthop 242:12, 1989 81. Salvati EA, Robinson RP, Zeno SM, et al: Infection rates after 3175 total hip and total knee replacements performed with and without a horizontal unidirectional filtered air-flow system. J Bone Joint Surg 64A:525, 1982 82. Santavirta 5, Konttinen YT, Bergroth V, et al: Aggressive granulomatous lesions associated with hip arthroplasty: Immunopathological studies. J Bone Joint Surg 72A:252, 1990 83. Schmidt SA, Kjaersgaard-Andersen P, Pedersen NW, et al: The use of indomethacin to prevent the formation of heterotopic bone after total hip replacement: A randomized, double-blind clinical trial. J Bone Joint Surg 70A:834, 1988 84. Schutzer SF, Harris WH: Deep-wound infection after total hip replacement under contemporary aseptic conditions. J Bone Joint Surg 70A:724, 1988 85. Scott WN, Rubenstein M, Scuderi G, et al: Results after knee replacement with a posterior cruciate substituting prosthesis. J Bone Joint Surg 70A:1163, 1988 86. Se vert R, Wood R, Cracchiolo A Ill, et al: Long-term follow-up of cemented total hip arthroplasty in rheumatoid arthritis. Clin Orthop 265:137, 1991 87. Smith SR, Stuart P, Pinder IM: Nonresurfaced patella in total knee arthroplasty. J Arthroplasty (Suppl):S81, 1989 88. Soudry M, Binazzi R, Johanson NA, et al: Total knee arthroplasty in Charcot and Charcot-like joints. Clin Orthop 208:199, 1986 89. Stauffer RN: Ten-year follow-up study of total hip replacement: With particular reference to roentgenographic loosening of the components. J Bone Joint Surg 64A:983, 1982 90. Stulberg BN, Insall IN, Williams GW, et al: Deep-vein thrombosis following total knee replacement: An analysis of six hundred and thirty-eight arthroplasties. J Bone Joint Surg 66:194, 1984 91. Stulberg SO, Stulberg BN, Wixson RL: The rationale, design characteristics, and preliminary results of primary custom total hip prosthesis. Clin Orthop 249:79, 1989 92. Sullivan PM, Johnston RC, Kelley SS: Late infection after total hip replacement, caused by an oral organism after dental manipulation: A case report. J Bone Joint Surg 72A:121, 1990 92a. Thomas B, Amstutz H: Results of the administration of diphosphonates for the prevention of heterotopic ossification after total hip arthroplasty. J Bone Joint Surg 67 A:400, 1985 93. Thomas BJ, Cracchiolo A Ill, Lee YF, et al: Total knee arthroplasty in rheumatoid arthritis: A comparison of the polycentric and total condylar prostheses. Clin Orthop 265:129, 1991 94. Turpie AGG, Levine MN, Hirsh J, et al: A randomized controlled trial of a low molecular weight heparin (enoxaparin) to prevent deep-vein thrombosis in patients undergoing elective hip surgery. N Engl J Med 315:925, 1986 95. Walker PS, Greene 0, Reilly 0, et al: Fixation of tibial components of knee prostheses. J Bone Joint Surg 63A:258, 1981 96. Walker LG, Sledge CB: Total hip arthroplasty in ankylosing spondylitis. Clin Orthop 262:198, 1991 97. Warren SB: Heterotopic ossification after total hip replacement. Orthop Rev 19:603, 1990 98. Weber ER, Daube JR, Coventry MB: Peripheral neuropathies associated with total hip arthroplasty. J Bone Joint Surg 58A:66, 1976 99. Welch RB, McGann WA, Picetti GO Ill: Charnley low-friction arthroplasty: a fifteento seventeen-year follow-up study. Orthop Clin North Am 19:551, 1988 100. Windsor RE, Insall IN: The knee. In Harris K, Sledge R (eds): Texbook of Rheumatology. Reconstructive Surgery in Rheumatic Diseases, ed 3. Philadelphia, W.B. Saunders, 1989, p 2041 101. Wixson RL, Stulberg SO, Mehlhoff M: Total hip replacement with cemented, uncemented, and hybrid prostheses: A comparison of clinical and radiographic results at two to four years. J Bone Joint Surg 73A:257, 1991 102. Woo RYG, Morrey BF: Dislocations after total hip arthroplasty. J Bone Joint Surg 64A:1295, 1982
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