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Total knee arthroplasty with cemented all-polyethylene tibial components in patients seventy-five and over
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The Journal of Arthroplasty Vol. 13 No. 2 February 1998 POSTER #5
TOTAL KNEE ARTHROPLASTY WITH CEMENTED ALL-POLYETHYLENE TIBIAL COMPONENTS IN PATIENTS SEVENTY-FIVE AND OVER Mark W. Pagnano, MD, Jacksonville, FL, Bruce A. Levy, MD, Daniel J. Berry, MD Introduction: So-cailed demand matching protocols often dictate the use of all-polyethylene tibial components In older, low-demand patients. The clinical and scientific basis for this use of cemented all-polyethylene tibial components is poorly defined as no authors have carefully cited the survivorship of cemented all-polyethylene tibial components in an exclusively older patient population. Our aim was to define the survivorship free of revision or pain when cemented all-polyethylene tibial components are utilized in an exclusively elderly population of primary condylar knee replacemants.
Discussion: This study demonstrated that the baseline hemoglobin is a powerful predictor of transfusion risk. Patients with a preoperative hemoglobin over 14 g m / d l have a very small chance of requiring a blood transfusion following primary unilateral THA or TKA and therefore do not require preoperative autologous donation. This will result in the increased efficiency of blood-ordering practices and aid the surgeon in more costeffective transfusion planning. Costs can be reduced without significantly increasing the risk of exposing patients to alloganeic blood transfusions.
POSTER #7 *RESULTS OF REVISION TOTAL KNEE WITH PATELLAR REPLACEMENT VERSUS PATELLAR BONY SHELL Robert L. Barrack, MD, New Orleans, LA, Robert Ingraham, MD, Elizabeth Matzkin, MS, Cecil H. Rorabeck, MD, Gerard A. Engh, MD
Methods: Between 1976 and 1980, 83 knees in patients 75 years of age or older, underwent primary TKA utilizing a condylar femoral component and a cemented, moderately conforming, all-polyethylene tibial component. The mean age at arthroplasty was 78.5 (range 75 to 88). Preoperative diagnosis was osteoarthritis in 72 and rheumatoid arthritis in 11. Results were calculated using the Knee Society ScorIng systems.
After removing the patellar component during revision TKA, the surgeon may be left With a cortical shell that may be judged as inadequate to support another patellar component. In such cases, the bony shell may be left unresurfaced. A study was undertaken to assess the clinical results of revision TKA with such an unresurfaced bony shell compared to those cases in which a patellar component was implanted.
Results: 2 pts (3 knees) were lost to follow-up. The remaining patients were followed until death, revision, or for a m i n i m u m of 10 yrs (mean 14.0 yrs). At final follow-up: one knee had required revision (for medial instability), and one knee had marked pain but no radiographic evidence of loosening. No knees required revision for aseptic loosening and no knees had symptomatic aseptic loosening.
A prospective study of all revision total knees performed at three university affiliated hospitals by three surgeons was undertaken. The same implant was used In all cases. Attempt was made to implant a patellar component whenever possible. Assessment included a Knee Society Clinical Score (KSCS), SF36, satisfaction survey, and radiographs preoperatively, 6 and 12 months postoperatively and annually thereafter. Minimum followup of 2 years (range 24 - 48 mos., mean 30) was obtained in 123 of 130 consecutive knees (94%). Thirty-one knees were left with a bony shell while 92 had a patellar component.
Conclusion: Cemented all-polyethylene tibial components of a moderately conforming design implanted in patients older than 75 demonstrated a high rate of survivorship free of revision, and free of symptomatic loosening. This study suggests a role for cemented all-polyethylene tibial components with a moderately conforming femoro-tibial articulation in elderly, low demand patients.
POSTER #6 PREOPERATIVE HEMOGLOBIN AS A PREDICTOR OF TRANSFUSION RISK IN TOTAL HIP AND KNEE ARTHROPLASTY Richard J. Friedman, MD, FRCS(C), Charleston, SC, Jennifer E. Buffer, BS, Richard H. Zimlich, MD, H. Del Schutte, Jr., MD Introduction: Idantification of a universal "transfusion trigger" has eluded orthopaedic surgeons for years. Similarly, little data exists on establishing baseline hemoglobin levels as a predictor of transfusion risk and the need for preoperative autologous donation, since the majority of autologous blood is never transfused and gets wasted. The purpose of this study was to assess transfusion requirements in patients who underwent primary unilateral total hip arthroplasty (THA) or total knee arthroplasty (TKA) based on their preoperative hemoglobin level and to develop efficient cost effective blood ordering practices for total joint patients. Methods: To ascertain the predictors of blood transfusions, the charts of 200 THA and 200 TKA patients were reviewed. Stepwise regression analysis was used to determine which patient and case related variables (such as preoperative hemoglobin concentration, sex, age, co-morbidities, medications, procedure, anesthesia) should be considered in predicting transfusion risk. Results: Patients with a preoperative hemoglobin level <10.5 g m / d l had greater than a 95% chance of requiring a blood transfusion in the intra or postoperative period. As the preoperative hemoglobin level rose, the risk of transfusion dropped In a linear fashion, and was negligible over 14 g m / dl. Other factors studied were not found to be reliable predictors of blood transfusion.
* Denotes that somethingof value was received Presenters are boldface
Patients in which a bony shell was left had a lower KSCS preoperatively (77 vs 91, p < .05) as well as postoperatively (121 vs. 135, p < .05). Compared to those with a patellar component, knees left with a bony shell had a significantly higher percentage of patients who had difficulty with stairs (47% vs 24%, p < .05), were not satisfied with their surgery (21% vs 2%, p < .01), and rated their surgery as unsuccessful in returning them to normal daily activities (21% vs 12%, p < .05). The clinical outcome following revision TKA was better in patients in which a patellar component was implanted compared to those left with a bony shell. This is, in part, attributable to the lower preoperative clinical score and function in patients subsequently left with a bony shell. There was a lower incidence of pateilofemoral symptoms, a higher degree of satisfaction, pain relief, and return to activities in patients in which a patellar component was successfully implanted. When a patellar component is not able to be implanted in revision TKA, a lower quality result can be expected.
POSTER #8 HIGH PLACEMENT OF THE UNCEMENTED ACETABULAR COMPONENT IN REVISION SURGERY: RESULTS AFTER AN AVERAGE OF 10.2 YEARS John T. Dearborn, MD, Boston, MA, William H. Harris, MD, Daniel M. Estok, II, MD Purpose: We report our near 10.2 year results of uncemented acetabular revision in which the available bone stock necessitated creation Of a high hip canter. Methods: Between July, 1984 and February, 1988, 46 acetabular revisions in 45 patients were performed in which the hip center was placed at least 35 m m craniad to the interteardrop line~ The mean age was 52 years. The most frequent original diagnosis was congenital hip dysplasia or dislocation. In each case, acetabular reconstruction with conventional techniques at the normal hip center w~is not possible. The acetabulu_m was shaped into a hemisphere, grafts were added as needed, and an uncemented acetabular shell was fixed with screws. The estimated contact with host bone averaged 79°.
The Journal of Arthroplasty Vol. 13 No. 2 February 1998 POSTER #5
TOTAL KNEE ARTHROPLASTY WITH CEMENTED ALL-POLYETHYLENE TIBIAL COMPONENTS IN PATIENTS SEVENTY-FIVE AND OVER Mark W. Pagnano, MD, Jacksonville, FL, Bruce A. Levy, MD, Daniel J. Berry, MD Introduction: So-cailed demand matching protocols often dictate the use of all-polyethylene tibial components In older, low-demand patients. The clinical and scientific basis for this use of cemented all-polyethylene tibial components is poorly defined as no authors have carefully cited the survivorship of cemented all-polyethylene tibial components in an exclusively older patient population. Our aim was to define the survivorship free of revision or pain when cemented all-polyethylene tibial components are utilized in an exclusively elderly population of primary condylar knee replacemants.
Discussion: This study demonstrated that the baseline hemoglobin is a powerful predictor of transfusion risk. Patients with a preoperative hemoglobin over 14 g m / d l have a very small chance of requiring a blood transfusion following primary unilateral THA or TKA and therefore do not require preoperative autologous donation. This will result in the increased efficiency of blood-ordering practices and aid the surgeon in more costeffective transfusion planning. Costs can be reduced without significantly increasing the risk of exposing patients to alloganeic blood transfusions.
POSTER #7 *RESULTS OF REVISION TOTAL KNEE WITH PATELLAR REPLACEMENT VERSUS PATELLAR BONY SHELL Robert L. Barrack, MD, New Orleans, LA, Robert Ingraham, MD, Elizabeth Matzkin, MS, Cecil H. Rorabeck, MD, Gerard A. Engh, MD
Methods: Between 1976 and 1980, 83 knees in patients 75 years of age or older, underwent primary TKA utilizing a condylar femoral component and a cemented, moderately conforming, all-polyethylene tibial component. The mean age at arthroplasty was 78.5 (range 75 to 88). Preoperative diagnosis was osteoarthritis in 72 and rheumatoid arthritis in 11. Results were calculated using the Knee Society ScorIng systems.
After removing the patellar component during revision TKA, the surgeon may be left With a cortical shell that may be judged as inadequate to support another patellar component. In such cases, the bony shell may be left unresurfaced. A study was undertaken to assess the clinical results of revision TKA with such an unresurfaced bony shell compared to those cases in which a patellar component was implanted.
Results: 2 pts (3 knees) were lost to follow-up. The remaining patients were followed until death, revision, or for a m i n i m u m of 10 yrs (mean 14.0 yrs). At final follow-up: one knee had required revision (for medial instability), and one knee had marked pain but no radiographic evidence of loosening. No knees required revision for aseptic loosening and no knees had symptomatic aseptic loosening.
A prospective study of all revision total knees performed at three university affiliated hospitals by three surgeons was undertaken. The same implant was used In all cases. Attempt was made to implant a patellar component whenever possible. Assessment included a Knee Society Clinical Score (KSCS), SF36, satisfaction survey, and radiographs preoperatively, 6 and 12 months postoperatively and annually thereafter. Minimum followup of 2 years (range 24 - 48 mos., mean 30) was obtained in 123 of 130 consecutive knees (94%). Thirty-one knees were left with a bony shell while 92 had a patellar component.
Conclusion: Cemented all-polyethylene tibial components of a moderately conforming design implanted in patients older than 75 demonstrated a high rate of survivorship free of revision, and free of symptomatic loosening. This study suggests a role for cemented all-polyethylene tibial components with a moderately conforming femoro-tibial articulation in elderly, low demand patients.
POSTER #6 PREOPERATIVE HEMOGLOBIN AS A PREDICTOR OF TRANSFUSION RISK IN TOTAL HIP AND KNEE ARTHROPLASTY Richard J. Friedman, MD, FRCS(C), Charleston, SC, Jennifer E. Buffer, BS, Richard H. Zimlich, MD, H. Del Schutte, Jr., MD Introduction: Idantification of a universal "transfusion trigger" has eluded orthopaedic surgeons for years. Similarly, little data exists on establishing baseline hemoglobin levels as a predictor of transfusion risk and the need for preoperative autologous donation, since the majority of autologous blood is never transfused and gets wasted. The purpose of this study was to assess transfusion requirements in patients who underwent primary unilateral total hip arthroplasty (THA) or total knee arthroplasty (TKA) based on their preoperative hemoglobin level and to develop efficient cost effective blood ordering practices for total joint patients. Methods: To ascertain the predictors of blood transfusions, the charts of 200 THA and 200 TKA patients were reviewed. Stepwise regression analysis was used to determine which patient and case related variables (such as preoperative hemoglobin concentration, sex, age, co-morbidities, medications, procedure, anesthesia) should be considered in predicting transfusion risk. Results: Patients with a preoperative hemoglobin level <10.5 g m / d l had greater than a 95% chance of requiring a blood transfusion in the intra or postoperative period. As the preoperative hemoglobin level rose, the risk of transfusion dropped In a linear fashion, and was negligible over 14 g m / dl. Other factors studied were not found to be reliable predictors of blood transfusion.
* Denotes that somethingof value was received Presenters are boldface
Patients in which a bony shell was left had a lower KSCS preoperatively (77 vs 91, p < .05) as well as postoperatively (121 vs. 135, p < .05). Compared to those with a patellar component, knees left with a bony shell had a significantly higher percentage of patients who had difficulty with stairs (47% vs 24%, p < .05), were not satisfied with their surgery (21% vs 2%, p < .01), and rated their surgery as unsuccessful in returning them to normal daily activities (21% vs 12%, p < .05). The clinical outcome following revision TKA was better in patients in which a patellar component was implanted compared to those left with a bony shell. This is, in part, attributable to the lower preoperative clinical score and function in patients subsequently left with a bony shell. There was a lower incidence of pateilofemoral symptoms, a higher degree of satisfaction, pain relief, and return to activities in patients in which a patellar component was successfully implanted. When a patellar component is not able to be implanted in revision TKA, a lower quality result can be expected.
POSTER #8 HIGH PLACEMENT OF THE UNCEMENTED ACETABULAR COMPONENT IN REVISION SURGERY: RESULTS AFTER AN AVERAGE OF 10.2 YEARS John T. Dearborn, MD, Boston, MA, William H. Harris, MD, Daniel M. Estok, II, MD Purpose: We report our near 10.2 year results of uncemented acetabular revision in which the available bone stock necessitated creation Of a high hip canter. Methods: Between July, 1984 and February, 1988, 46 acetabular revisions in 45 patients were performed in which the hip center was placed at least 35 m m craniad to the interteardrop line~ The mean age was 52 years. The most frequent original diagnosis was congenital hip dysplasia or dislocation. In each case, acetabular reconstruction with conventional techniques at the normal hip center w~is not possible. The acetabulu_m was shaped into a hemisphere, grafts were added as needed, and an uncemented acetabular shell was fixed with screws. The estimated contact with host bone averaged 79°.