WHAT'S NEW |
| SEE PREVIOUS NEWS | |
| Information on how to use the References |
| SUBMIT YOUR QUESTION / OPINION |
CONTENTS:
June 2009
28/06 - What is your top priority – the best surgeon or the best total joint model?
12/06 Labrum tear – a new disease of young people with hip pain
10/06 – How long will a total knee joint last? – 20 years at least
April 2009
25/04 – What the total joint patents wish to know –the role of websites
14/04 – Total hip dislocation – how is life after that?
10/04 – Does TKR fulfill patients’ preoperative expectations?
March 2009
30/03 – Computer navigated surface hip replacement improves position of the replacement device
28/03 - THR operations – both hips in one séance?
13/03 – Labral tear – a new disease causing hip pain in young adults
10/03 – Do we need “high-flexion” total knees?
February 2009
20/02 - Bad results of revision operations of THR apparent after 20 years after surgery
06/02 – Catastrophic failure of total knee – surgeons’ responsibility this time
January 2009
26/01 - Supersterile OR (Operation Rooms) not so sterile
20/01/ - the failure rates of surface hip replacements – the reality
15/01 – Surface hip replacements – good or bad?
June 2009
WHAT IS YOUR TOP PRIORITY – THE BEST SURGEON OR THE BEST TOTAL HIP MODEL?
The independent Internet network (www.hipandkneenetwork.co.uk) organization has an information site for patients.
The prospective patients can participate in the network by registering their opinions, wishes, and expectations from a possible hip or knee total replacement surgery. They will do it by filling a self completed questionnaire.
Recently the network published a survey of these questionnaires for the period from September 2008 through to February 2009. Some interesting results emerged.
The length of pain symptoms in hip and knee symptoms is surprising: 22% of patients stated that they suffered joint pain for 8 years or longer. From the survey date it is not obvious if all these patients were candidates for total joint surgery. It is, however, plausible that at least a part of them were candidates; it would be then interesting to know, why they were waiting so long with their decision.
Another interesting question what was the top priority of possible candidates for total hip or knee replacement surgery. For 42% of candidates it was the freedom from pain during and after surgery, for 31% it was access to the best medical technology, for 24% it was the short recovery time. Curiously enough, with respect to the number of published articles, only 2% of all candidates were concerned about the length of the operative wound,
In considering the most important factors for replacement surgery itself, the vast majority of candidates (78% ) considered the reputation of their future surgeon to be the most important, whereas only 14 % considered the reputation of the total joint model most important, and only 8% considered the reputation of the hospital most important.
These data re interesting. The majority of the prospective patients considers the surgeon’s reputation closely related to the results of the replacement surgery. It is, however, difficult to differentiate what is this “reputation”. Where can the patient find any scale on which to measure “reputation” of his/her chosen surgeon.
Whereas most politicians proclaim that “free choice of a doctor” is one of the basic human rights, there is as yet no established system how the patient can proceed to find the surgeon with the “best reputation”.
Information for you: This is a report published by an “independent network organization”, financed partly by European Union, but it is unclear which surgeons participate. Yet, the opinions of the candidates for total joint replacement, especially the concern about the “reputation” (experience) of their future surgeon are very interesting and confirm the claims made in other reports: patients wish to know the reputation of the surgeons before they make their choice.
Any comments / recommendations?
_____________________
References :
Orthopaedic Product News (European Edition) February/March 2009, pp 20
LABRUM TEAR – A NEW DISEASE OF YOUNG PEOPLE WITH HIP PAIN
During the last ten years our knowledge of the young people hip joints developed tremendously. This has been the result of the introduction of two new diagnostic methods: magnetic resonance arthrography and hip arthroscopy.
In the early 80’ s the surgeons were referred to the x-ray arthrography pictures when examining soft tissues of the hip joint; this examination method, however, provided unclear fuzzy pictures. With this raw method the surgeons could see sometimes ruptures through the labrum in young people with Perthes hip disease or congenital hip dysplasia who had pain in their hips. But these examinations were difficult and done only seldom so that the general opinion was that labrum tear is a rarity
The magnetic resonance hip arthrography on the other hand was providing excitedly detailed pictures of the whole hip joint, both the bony structures and the soft tissues.
On these pictures the surgeons could for the first time see the soft tissue structure called labrum clearly. And they could for the first time see clearly the tears going through this structure in some people. And when looking through the arthroscope into such a hip joint, the surgeons could see the tear crossing through the labrum by a “naked eye”.
At once the surgeons had explanation for pain in the hip of the young people who had an apparently normal hip joint at conventional examination. Only successively the surgeon learned to know the “hip impingement sign” and to find skeletal change also on conventional x-ray pictures that previously would be declared as “normal”. (See also the chapter: Hip joint diseases / Impingement of the hip joint)
So today we know that the pain in the hip of the young people with seemingly “normal” hip joint is often caused by damage to the structure named “labrum”.
Today we can take “conventional” x-ray pictures of the hip joint of good quality in specific projection. We can discover skeletal changes on these special projection pictures indicating that soft tissues in the hip are suffering impingement by these small skeletal changes. The surgeons learned that the repeated impingement of the soft tissues, especially of the labrum, causes lasting damages of the labrum and pain in the hip area.
Obviously, when the surgeons know the cause of the hip pain they should remove it to make the patient pain free. So what about the treatment? There is the progress less distinct. The surgeons are unanimous whether only to excise (remove) the torn portion or suture it back.
They are unanimous in which cases to remove the changes in the hip skeleton that produce the impingement by a “small” arthroscopic operation and when to do a large open operation such as an osteotomy.
The surgeons are also unanimous when it is too late to do some of these smaller operations (arthroscopic removal of labral tear, or an osteotomy) because the damage of the hip joint cartilage has gone too deep.
Information to you:
This is an exciting development and all patients with unclear pain in the hip should know of it and seek a doctor for examination with the question: Do I have a labral tear that causes my hip problems? Do I suffer of impingement of my hip joint although the “conventional” x-ray pictures of my hip joint see “normal? Despite the exciting development many doctors are still not aware of the importance of hip impongment and of the resulting labral damage.
Studies showed that an “average” patient visited three doctors who misdiagnosed his hip condition before finding the fourth doctor that made the right diagnosis. So, be insistent and don’t accept a no!
References :
Beaule PE et al.: Acetabular Labral Tears. Current Concept Reviews. J Bone Joint Surg-Am 2009; 91-A: 701-10
HOW LONG WILL A TOTAL KNEE JOINT LAST? – 20 years at least
Patients often ask how long will their total knee device last. They get different answers, depending on the surgeon. A lot of these answers is unnecessarily pessimistic.
Recent report from the known American surgeon M.A.Ritter shows that a good total knee device may last 20 years and more. This surgeon had implanted since 1983 over 7 700 (7760) total knee devices named Anatomical Graduated Component (AGC total knee model, Biomet).
This report is about the model with the metal backed and cemented tibial polyethylene component. 98% of these total knee devices lasted 20 years.
With such very high general success rate, it was difficult to find factors that would improve the chances of success. The only such factor was patient’s age > 70 years.
The author attributes the success of this model to its relatively simple construction; all components are non modular, produced at the manufacturing plant. The other important factor is the metal-backing of the polyethylene tibial component.
Actually there is a proof how important this metal backing is for the survival of the whole total knee device.
Originally, there were two models on the market:
The "old" model had an all polyethylene tibial component. The polyethylene component was cemented directly to the raw surface of the trimmed tibia. The results of this model were catastrophic: 32 % of these devices failed during the first ten postoperative years. This model is not longer on the market
Then there is the present model; the only difference is that the present model has its polyethylene tibial component metal backed and the metal dish has a beam for anchoring in the tibial shaft. (See picture)
Picture: The upper picture shows the old AGC model, Note that the polyethylene tibiaal component has no metal backing
The lower picture shows the present AGC model. Note the metal backing dish with a beam for anchoring in the tibia (shinbone).
Information for you: These total knee results are better than any results of a total hip. Total knee replacement is really a successful surgery, although many doctors still do not believe it. So be not fright of any tales about the "not so successful total knee surgery" that some doctors still tell their patients.
_______________________________________
References:
Ritter M.A.: The Anatomical Graduated Componet total knee replacement. J Bone Jopint Surg . Br 2009; 91-B: 745 - 9
April 2009
WHAT THE TOTAL JOINT PATIENTS WISH TO KNOW – THE ROLE OF WEBSITES
Recent study showed that the role of patient support websites is multiple.
The majority of patients (73 %) seek these websites for advice. The patients are seeking the websites both before and after the surgery.
Before the surgery the patients are interested mainly of experience of patients who already were “through it”. Obviously, no surgeon can tell as much as the “live” experience of a colleague-patient. Another often asked issue is “the best surgeon”. Personal recommendation of a surgeon weights very much, no professional websites flaunting with supersterile operation rooms and like can replace it.
After the operation then there come problems: the major problem for the patient is pain. The pain has many forms and always makes the patients dissatisfied. The worst scenario is this: the surgeon looks on the x-ray pictures and dismiss the patient with the painful new hip with the words: “The x-ray picture shows that all is normal”. Obviously, there are surgeons who do not believe that soft tissue changes may cause pain.
On the other hand, questions pointing to a litigation are extremely rare on patient support sites.
There is another kind of patient communication on websites (18 %). These patients wish to share their experience ; the majority of this communications tells a good experience, a luckily patient who is now pain free. But some patient seek also a direct support, they wish to know that they are nor alone, that there is this thin but important Internet line of empathy and spiritual support.
Obviously no professional website can replace this function of patient support website.
There are only a few patients who will inform others about an interesting article, TV program, new development. These few communication cause only scant response.
Information for you:
What issue is interesting you when you visit a patient support website?
TOTAL HIP DISLOCATION – HOW IS LIFE AFTER THAT?
Uncertain, at least.
Although the repeated dislocations of a total hip joint are one of the most frequent causes of revision operations of TH, not much is known about how often the once dislocated total hip develops repeated episodes of instability.
Surgeons of The University of Wales in Cardiff followed 101 total hips (operated on 99 patients) that dislocated at least once. During a relatively short follow up period, 60 % these total hips dislocated furthermore, at least twice (26%) or more times.
Under the six years period of the study, these 99 patients had totally 236 episodes of total hip dislocation. After a mean follow up of 4.6 years, 50 % of the dislocating total hips were revision operated. The two most often observed causes of recurrent dislocation that led to revision operation were: first, bad position of the cup component, and second, weak musculature around the hip.
Revision operations were successful in 84 % of cases. This percentage of healed instable total hips, curiously enough, is considered as success. Even if these revision operated patients were satisfied with the results, the function of their repeatedly operated on total hip was worse than in patients who did not have any revision operation.
Information for you:
Dislocation of a total hip joint is a serious complication that may left lasting consequences. Although the surgeon usually succeeds to replace the dislocated hip, there is considerable risk that the hip remains instable with further dislocations to follow.
This article demonstrates that the majority of these repeated dislocations is avoidable, because it is caused by bad position of the cup component. Exceptions to this rule are total hip replacements done on patients with acute fractures of the hip joint. These fractures make the following total hips more unstable and these patients must count with greater risk of instability of their total hip.
_______________________________________
References:
Kotwal R.S. et al: Outcome of treatment for dislocation after primary total hip replacement. J Bone Joint Surg – Br 2009; 91-B: 321 - 6
DOES TKR FULFILL PATIENTS’ PREOPERATIVE EXPECTATIONS?
Do patients expect too much from their total knee replacement operation? Seems to be so, at least according to the last study conducted jointly by Swedish and Danish orthopaedic surgeons (Nilsdotter 2009). In spite of not fulfilled expectations, the majority of the operated on patients are, however, satisfied with the results of the arthroplasty.
The Swedish and Danish surgeons followed 102 patients operated on with total knee replacement for osteoarthritis of their knees for totally five years. It appeared that the absolute majority of patients (98%) expected relief of knee pain. Their expectations were fulfilled. One year after surgery, 93 % of patients experienced full or substantial pain relief; this relief, however, did not last but diminished with time. Five years after surgery only 63 % of all patients noted still substantial pain relief, but this did not influence their general satisfaction: 93 % of all patients were “generally” still satisfied with their total knee surgery five years after surgery.
Fulfillment of other expectations was more meager. Before the surgery, 39 % of patients expected unlimited walking capacity, but only 21 % of them could do so five years after surgery. Even worse was it with expectations of improvement of sports and leisure activities. 41 % of patients expected to be able to go dancing and playing golf after surgery. Yet, only 24 % of them were able to do so five years after surgery.
Information for you:
This is an interesting study that demonstrates that if you expect pain relief by total knee surgery your expectations are realistic and would very probably be fulfilled. But if you expect that you would be able to return to more demanding sport activities after this surgery you should look more realistic on these expectations.
This study shows again that total knee replacement is basically a surgery for pain relief and that it fulfills this promise very well. But it is not an operation that can restore the knee function to normal, in spite of manufacturers’ advertising campaigns in press and TV. Be realistic there.
_______________________________________
References:
Nilsdotter AK et al: Knee arthroplasty: are patients’ expectations fulfilled? Acta Orthopaedica 2009;80: 55 -61.
March 2009
COMPUTER NAVIGATED SURFACE REPLACEMENT IMPROVES POSITION OF THE REPLACED DEVICE
Surface hip replacement is a technically demanding operation. The much talked about “surgeon’s learning curve” showed that surgeons usually needed to carry up about 60 surface replacements done under guiding before they gained the ability to carry out this operation flawlessly. A long time, for some surgeons perhaps lasting a year.
A new study demonstrated that use of computer navigation would shorten this learning period to > 20 operations (Olsen 2009)
In the resurfacing hip arthroplasty the placement of the femoral component is very important. Especially important is to achieve the “right” incline angle of the shaft component.
When the position of this shaft deviates more than 5 degrees from the ideal there is a risk that the femoral neck will break. Femoral neck fracture is indeed the major cause of failure of resurfacing hip arthroplasty.
Olsen and his colleagues showed that in resurfacing operations done with help of computer navigation 86% of all operations had the position of the shaft within the stipulated 5 % degrees of ideal position. In the resting 14 % operations the deviation from the ideal position was never larger than 8 degrees. I think this is an excellent position.
All studied operations were done by an experienced surgeon. Moreover, the authors do not tell the precision of the surgeon before he began to use the navigation device. So there is no question to compare both operation methods: precision of surface replacement with the use of computer navigation compared with the surface replacement done without the computer navigation help.
Information for you: The computer navigation produces very precise placement of the femoral component of the surface replacement device. If your surgeon has such a device (there are several models of it) and if he is experienced with its use than it is a plus. But from this report you cannot decide whether another surgeon working without such instrumentation can achieve equally good precision. Sorry.
_______________________________________
References:
Olsen M et al: Imageless computer navigation for placement of the femoral component in resurfacing arthroplasty of the hip. J Bone Joint Surg-Br 2009; 91-B: 310 - 20
THR OPERATIONS – BOTH HIPS IN ONE SÉANCE?
Hip joints are par organs – when both hip joints need replacement the question arises whether to carry out the surgery of both hips in one séance or do the operation on one side first and after a waiting time, which may be all between 6 weeks to six months, to carry out the operation on the other side.
There are many advantages with to have both hips operated on at once, not the least of them is that the patient needs not to experience the preoperative psychical anguish twice. On the negative side is the fact that simultaneous operation on both hips is a much more traumatic event than operation on one hip, with real possibility to more complications.
The published studies, however, give no definite answer: some of them claiming higher incidence of complications after bilateral surgery, whereas other studies demonstrating “acceptable safety” for bilateral simultaneous THR.
Recently had South Korean surgeons published yet another such study, claiming that simultaneous bilateral THR “is a safe operation” (Kim 2009). The study has some interesting details worth closer attention.
The authors studied totally 2644 patients, their death rates and complication after THR. 978 patients had simultaneous operation of both hips whereas 1666 patients had only one hip operated on.
It appeared that the death rate (within 3 months?) after THR was almost twice as high in patients with si,ultaneous TH operation (0.31%) as that in patients operated on only one side (0.18%). Statistical tests, however, said that the difference very probably arose by chance. Similarly, the rates of major complications after THR, such as deep wound infection, cerebrovascular accident, or heart failure were trice as high in simultaneously operated on patients (2.2%) compared to patients operated on only one side (0.7%). Also this threefold difference very probably arose by chance alone, according to the statistical tests.
The patients with cardiovascular disease and other preoperative risks had five times higher risk of a major postoperative complication if operated simultaneously on both hips than the patients with the same risks who were operated on only one hip joint. Also this fivefold difference was statistically insignificant.
The statistical tests thus said that the different rates of complications and deaths between patients operated on both hips simultaneously and patients operated on on only one hip may be explained by the action of pure chance.
We may accept the results of the statistical tests although there is no proof that it is so. There is a possibility that the difference is real. Statisticians speak about Type I and Type II errors. All depends on the size of the studied patient population.
The authors of this study also point out that with greater numbers of studied patients, the same difference in percentages of complications and deaths between the two studied patient groups may become “statistically significant”. But it would be very difficult to enroll so many more patients for the study.
Information for you: It seems from this article that simultaneous operations of both hips in one séance carries out higher risks of early postoperative death and major complications. It depend on you whether you accept the doom of the statistical tests that say that this difference is not statistically significant.
I think, however, that the simultaneous operation of THR would be preferable for otherwise healthy patients only.
_______________________________________
References:
Kim Y.H et al.: Is one-stage bilateral sequential total hip replacement as safe as unilateral total hip replacement? J Bone Joint Surg Br 2009;91-B: 316- 20
LABRAL TEAR – A NEW DISEASE CAUSING HIP PAIN IN YOUNG ADULTS.
The doctors may have difficulty to find the right cause of groin pain in young adults. There is more and more clear that there is a new, previously unknown cause to this specific pain syndrome: tear of the cartilage-like part of the capsule of the hip joint called labrum (See also the chapter Hip diseases / Impingement of the hip joint).
In the majority of these patients, the damage of this structure is caused by minor skeletal abnormalities of the hip joint, not always rightly discovered on plain x-ray pictures. Tear of this labrum causes usually insidiously starting pain in the groin, the majority of patients cannot remember any traumatic event related to the start of the pain.
Three Canadian surgeons (Beaule et al. 2009) published recently a summary of present day results of diagnostic methods and treatment results of this disease.
It appears that the doctors still have problem to find out the right diagnosis: in some reports about one third of patients with labral tear were receiving initially wrong diagnosis, and it was necessary to visit three different doctors before the last of them arrived at the right diagnosis.
Plain x-ray pictures require special projection (views) to discover the skeletal abnormalities that cause the impingement of hip joint.
The magnetic resonance imaging (MRI arthrography) is the preferred examination, as it provides the surgeon with a direct image of the tear in the labrum structure on the MRI pictures. (Again see the chapter Hip diseases / Impingement of the hip joint)
The torn labrum structure leads to successive degeneration of the hip joint cartilage. The treatment depends on how well the hip joint cartilage is preserved.
In patients with still well preserved joint cartilage, arthroscopic operation (either suture of the tear or extirpation of the torn part of the cartilage) is usually all what is needed. Such treatment resulted in 50 to 94% satisfied patients 3 years after the surgery. There is still risk, however, that the damage of joint cartilage will continue in spite of arthroscopic operation, producing painful osteoarthritis. In some series thus between 10 to 25 % of all arthroscopically operated on patients ended up with a total hip replacement.
The biggest problem is with patients who are developing greater damage of their hip joint cartilage because of hip joint impingement and labral tear.The question is just how much osteoarthritis of the hip joint is still allowable for a good result of arthroscopic surgery.
Information for you:
Labrum tear is a newly discovered disease of the hip joint, actually it is rather congenital change of the skeleton of the hip joint, which untreated may cause total degeneration of the hip joint cartilage. If you have pain in the groin lasting several months your doctor should be suspicious of this cause. Especially if your doctor excluded other possible causes of the groin pain.
________________________________
References:
Beaule PE and al.: Acetabular labral tears. J Bone Joint Surg-Am, 2009; 91-A: 701 - 9
DO WE NEED “HIGH-FLEXION” TOTAL KNEES?
The flexion of a healthy knee joint in normal weight European adults is from 0 (full extension) to a mean of 134 degrees.
In patients with total knee replacement the flexion in replaced knee joints differs, depending among other factors on the race. In the Europeans and USA patients the mean knee flexion is to 105 -110 in most statistics. Until recently, most surgeons believed that this range of motion was sufficient for the majority of daily activities and most patients were also satisfied with this range of motion.
On the other hand in statistics from East Asia, the flexion is usually more than 120 degrees in most patients; The flexion range over 120 degrees is also called “deep flexion”. This greater range of flexion in Asian patients’ total knees was explained by two facts: 1. these patients needed deep flexion for the every day activities and thus trained their replaced knee joints harder; 2. these patients were usually smaller, with lean legs, without much soft tissues in their calves and legs.
In later years, however, some surgeons and manufacturers promoted a hypothesis that even European and North American total knee patients need more flexion in their total knees for their greater satisfaction. Manufacturers quickly presented special “high flexion” total knees (NexGen for example).
The normal flexion and “high flexion” total knee models are difficult to distinguish from each other; the only difference between a normal flexion and a “high flexion” total knee model is 5 mm thicker posterior (back) part of the femoral component.
Do these “high flexion” total knees really provide the patient with better flexion (beyond 120 degrees) when compared with flexion in patients operated on with normal flexion total knee models?
Two recently published studies say clearly: No. Otherwise similar patients with similar knee disease (osteoarthritis) have similar range of movement either they are operated on with normal flexion or “high flexion” total knee models (Seon 2009; Nutton 2008).
Seon et al. study was done on South Korean patients who were thin and who needed to squat and to sit with cross-legged legs. The patients were thus highly motivated to acquire “deep flexion” in their replaced knees. Both patient groups (normal flexion TK model and “high flexion” TK) had one year after operation almost identical mean maximal flexion, 135 and 134 degrees, respectively, in their total knees. Also almost identical percentage 38 % and 36 % of all operated on patients in respective groups were able to sit cross-legged.
Nuttonn et al. study was done on English patients operated on with the same total knee models as the South Korean patients (NexGen, Zimmer). More massively built, one year after surgery these English patients achieved (mean) 106 degrees knee flexion in the normal TK group and 110 in the “high flexion” total knee group.
The English surgeons measured also the flexion needed for daily activities in English people. The only daily activities in England that needed “deep flexion” (> 120 degrees) of the knee joint in healthy people were: stepping into a bath and out of a bath. Somehow, the total knee patients in both groups managed these activities with only 90 degrees of flexion.
Information for you: The manufacturers discovered that it is possible to offer different total prosthesis models according to the patient’s gender and race. The argument goes that these specially adapted total joint models produce better results.
Experience with “high flexion” total knee models as yet did not demonstrate any benefit of a specialized “high flexion” total knee models. I guess that a future cost-benefit analysis will also discover that these special (and specially extensive) total knee models are not so cost effective
Postoperative range of motion in a total knee patient depends on many factors, the two probably most important are: the preoperative range of motion and the soft tissue development in patient’s calf and thigh.
Patient with so much calf – thigh soft tissues development as the patient on this picture will never achieve “deep flexion” (> 120 degrees) in his/ her totally replaced knee even with a very special total knee model. _______________________________
References:
Nutton R.W et al: A prospective randomized….study of functional outcome and range of flexion….J Bone Joint Surg-Br 2008; 90-B: 37 – 42
Seon JK et al.: Range of motion in total lnee arthroplasty. J Bone Joint Surg-Am, 2009; 91-A: 672 - 9
February 2009
BAD RESULTS OF REOPERATIONS OF THR APPARENT 20 YEARS AFTER SURGERY.
The surgery of total hip and knees has big handicap. Whereas there are many early results (5 to ten years) of total hip (and knee) replacements published, long term results (20 years and more after surgery) are sparse.
Especially results of revision operations suffer of this handicap. And yet, the published early results of revision operations of failed total hips are probably too optimistic. One comes to this conclusion after reading the report of American surgeons from Rush’s orthopaedic clinic in Chicago (Daniel 2009).
They followed young patients who had revision operation of their failed total hip done for more than 20 years ago. In this report they studied only the failures of the cup component.
The first report on these patients was published 1993. At that time the patients were followed for between 3 and 7 years (mean 5 years). In that report only 5 % of all revised total hips failed, and within further five years after surgery further 9 % of these components failed, the failures accelerated, however, after that period so that between eleven to 24 years after revision surgery further 29% cup components failed.
This report, as many similar, reported failures of only one component (the cup). One of the authors (J.Galante) is also a developer of the studied cup component.
The failures of the femoral component were, however, equally many, although not studied closer. Authors only note that 42% of all revision operation had also a failed femoral component!
Information for you: These were very young patients, mean age 50 years. This is a very open report and the authors acknowledge that long term results of this cup are a worry. The main causes of failure were instability and infection.
This report is a useful reminder that results of revision operation are worse (much worse) that the results of the first operation. Try to get successful surgery the first time!
___________________________________________________
References:
Daniel K. Park et al : Revision of the Acetabular Component without Cement. A Concise Follow-up, at Twenty to Twenty-four Years, of a Previous Report. J Bone Joint Surg Am. 2009;91:350-355.
BIOLOGICAL REACTIONS ON HIGH BLOOD LEVELS OF METALS IN PATIENTS WITH METAL ON METAL HIP REPLACEMENTS
Patients with surface hip replacements (and total hips) have high blood levels of metals, especially cobalt and chrome. Even very rare cases of acute poisoning by these metals were already described in patients with such hip replacements.
Yet little is known about the effects of these metals that accumulate as wear products in the patient’s body. This appears from a review published by British surgeons (Mabilleau 2008).
Compared with the metal-on-polyethylene total hips, the metal-on-metal hip arthroplasty produces very small metallic wear particles. Whereas the polyethylene wear particle is about the size of a bacterium (micrometer size), the majority of metallic wear particles is about thousand times smaller (nanometer size). This difference is important: polyethylene wear particles are too big to produce allergic reaction whereas metallic wear particles are small enough to produce delayed allergic reaction. The bone dissolving disease (osteolysis) and the soft tissue masses, found in some patients with metal-on-metal surface replacements may be caused by such reaction.
There is, however, one as yet insurmountable problem: there are no tests to decide which patients may become allergic to metallic wear particles, and there are no reliable tests to prove that osteolysis or soft tissue masses found in a patient are caused by patient’s metal allergy.
There is one silver lining to all this lack of knowledge: High metal blood levels even after ten year do not damage the patient’s kidney as one recent report demonstrated.
Information for you: there are as yet no really long term reports of the results of surface hip replacement. But the 5 years results of surface replacements in carefully selected patients are comparable with results of total hip replacements. There are just these important words “carefully selected”. Even these patients must, however, know that there is the risk of delayed allergic reaction. As yet the magnitude of this risk is still unknown; according to some scientists about 1 % of all patients seeking total hip replacement are in the risk zone.
___________________________________________________
References:
Mabilleau G et al.: Metal-on-metal hip resurfacing arthroplasty. A review of periprosthetic biological reactions. Acta Orthopaedica 2008; 79: 734 -47.
CATASTROPHIC FAILURE OF TOTAL KNEE – SURGEONS RESPONSIBILITY THIS TIME
Whereas there is an easy criterion how to gauge the surgeon’s experience (by the number of operation carried out annually), there is no easy criterion how to assess the surgeon’s carefulness.
This may be the problem with surgeons rented from outside to do only the total joint operation. These surgeons come, do the operation, and leave; without taking care of the possible complications of their surgery that may occur later.
Recent number of the renowned Journal of Bone and Joint Surgery describes the disastrous experience with rented Swedish orthopaedic surgeons, flown to England to carry out total knee replacement surgery. From the article it appears (although not stated explicitly) that the surgeons did not stay long enough to see the patients leaving the hospital after their surgery.
The results of the Swedish surgeons’ operative activity were catastrophic. From 258 total knee replacements with Kinemax total knee performed between 2004 and 2006, 39 % of operations failed within three years and 20 % of the patients were already re-operated while the rest are awaiting revision operation, Further 37 % of the patients had severe pain or other complaints in the operated on total knee that made the operation result a failure.
According to the Swedish national statistics, the Kinemax total knee model has only 3 % of failures within the first 3 postoperative years.
This article is a disastrous reading. It demonstrates that all faults that one can do with total knee replacement were done on these poor patients.
From the article it does not appear what caused such catastrophic failure rate of operations carried out by Swedish rented surgeons? Was it lack of surgeons’ experience, their carelessness, or both?
Information for you: Choose carefully the surgeon for the total knee operation if you contemplate one. Ask directly about the number of operations he / she had done annually; ask him if he / she is only rented (in that case he / she probably will leave the hospital before you and it will be difficult to demand of him /her to take care of the possible complications).
___________________________________________________
References:
Kempshall P.J. et al: Review of Kinemax knee arthroplasty…. J Bone Joint Surg-Br 2009; 91-B: 229 – 233.
