The Journal of arthroplasty
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Comparative Study
Total shoulder arthroplasty versus hemiarthroplasty. Indications for glenoid resurfacing.
The results of total shoulder arthroplasty and hemiarthroplasty in a similar patient population were compared in an effort to define more clearly the indications for resurfacing the glenoid. The results of 64 Neer hemiarthroplasties in 59 patients were compared with 146 Neer total shoulder arthroplasties in 134 patients in a retrospective review of the period between 1974 and 1986. The average follow-up period was 44 months (range, 24-124 months). ⋯ Pain relief, range of motion, and patient satisfaction were better with total shoulder arthroplasty than hemiarthroplasty in the rheumatoid population. Progressive glenoid loosening was found in 12% of total should arthroplasties but no correlation with pain relief or range of motion was noted. Total shoulder arthroplasty is recommended for patients with inflammatory arthropathies, and hemiarthroplasty is recommended for patients with osteoarthritis, avascular necrosis, and four-part fractures with preservation of glenoid congruity and absent synovitis.
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Both the Harris and the Charnley hip evaluation forms were applied to 191 ingrowth-type total hip arthroplasties in an attempt to determine the effectiveness of the hip score as an indicator of success following arthroplasty. The Harris form demonstrated significantly lower pain scores than the Charnley form and, consequently, failed patients more often due to pain. However, it is important to note that 32% of the hips that failed due to pain on the Harris form did not fail due to total score. This inconsistency prompts the authors to state that when using a hip form to evaluate the performance of a prosthesis, especially one of the ingrowth type, it is important to consider not only the average total score but also the percentage of patients still experiencing significant pain.
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Comparative Study
Treatment of infected total knee arthroplasty. Irrigation and debridement versus two-stage reimplantation.
The results of 24 cases of deep wound infection after total knee arthroplasty were reviewed. Twenty-one knees were initially treated with irrigation and debridement. Infection recurred in 15 knees. ⋯ The average Hospital for Special Surgery knee rating was 41 in patients without a prosthesis and 75 in patients with a prosthesis (P less than .001). The authors conclude that irrigation and debridement is not likely to be successful for treatment of infections when used more than 2 weeks after the initial arthroplasty. Also, two-stage reimplantation for the treatment of infected total knee arthroplasties gives a reliably low recurrence rate and provides a superior clinical result, compared to arthrodesis or resection arthroplasty.
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Sixty-six patients undergoing total knee arthroplasty were offered epidural morphine as a method of postoperative analgesia. Of the 66 patients, 50 completed the minimum protocol of 3 days in a special epidural monitoring unit and were thus available for study. In this study group, 86% stated that they obtained 75-100% relief of pain with each epidural injection. ⋯ Epidural morphine provided excellent but inconsistent postoperative pain relief. When relief was present, aggressive in-house rehabilitation could be instituted, and a shorter overall hospital stay was achieved when compared with conventional analgesia. Nonetheless, the related adverse effects and inconsistent pain relief on many patients may preclude the use of epidural morphine as a single postoperative analgesic agent.
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Warfarin provides effective prophylaxis against postoperative venous thromboembolic complications in adults undergoing elective hip surgery, but at the risk of increased bleeding complications. Although patients on this drug are routinely monitored by prothrombin time (PT), mild elevations of the partial thromboplastin time (PTT) have been reported with warfarin therapy. In a prospective study of 194 patients undergoing elective hip surgery, the authors assessed the incidence of elevation of the PTT above 50 seconds while the patient was receiving warfarin prophylaxis and the effect of this elevation on bleeding complications. ⋯ Major postoperative bleeding complications occurred in 26.3% of group 1 patients, versus 4.5% of group 2 (P less than .01). This subset of patients with an abnormal PTT elevation despite appropriate control of the PT is at a significantly increased risk of major postoperative bleeding. This observation may also prove valuable in reducing bleeding complications from warfarin use in nonsurgical patients.