June 2009
28/06/2009
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
12/06/2009
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
10/06/2009
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
25/04/2009
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?
14/04/2009
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
10/04/2009
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
30/03/2009
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
28/03/2009
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
13/03/2009
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
10/03/2009
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
20/02/2009
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.
09/02/2009
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.
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References:
Mabilleau G et al.: Metal-on-metal hip resurfacing arthroplasty. A review of periprosthetic biological reactions. Acta Orthopaedica 2008; 79: 734 -47.
06/02/2009
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).
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References:
Kempshall P.J. et al: Review of Kinemax knee arthroplasty…. J Bone Joint Surg-Br 2009; 91-B: 229 – 233.