Postoperative management of total joint replacements

Total joint replacement has been one of the major breakthroughs in the field of orthopedics during the past 25 years. Performance of these procedures has enabled many severely disabled individuals to resume a virtually normal way of life. Unlike many other operative procedures, however, the ultimate success of total joint replacement depends not only on the surgery itself, but on appropriate preoperative planning and postoperative management. This does not end when the patient leaves the hospital but should be made a part of the patient's way of life forever. With an appropriate postoperative routine, the average patient can expect many years of satisfactory use of his or her total joint. A realistic approach must be adopted and certain simple restrictions and limitations must be clearly borne in mind. The patient must be conscious of the fact that although the artificial joint causes little or no pain and functions extremely well, it is, in fact, an artificial joint and not a normal joint. In simple terms he or she must be instructed to use it, not abuse it.     

Urinary tract sequelae: possible influence on joint infections following total joint replacement

A total of 277 patients receiving 364 total joint replacements in a period of 2 years were analyzed to determine whether urinary tract sequelae (infections, catheterization, and genitourinary instrumentation) encountered preoperatively or perioperatively had any significant influence on the development of postoperative joint infections. Three of these patients developed joint injections, none as a result of urinary tract infection. None of these infected patients required any catheterizations or instrumentation of the genitourinary system postoperatively. To enhance the previous data, all joint infections encountered in a period of 16 years were analyzed using the same criteria. Only one infection spread hematogenously from a urinary tract infection, and this occurred 20 months after surgery. The results of this study show no correlation between preoperative or perioperative urinary tract sequelae and postoperative joint infections. Bacteriuria should not be considered a contraindication for total joint replacement.     

Use of bisphosphonates to improve the durability of total joint replacements

Total joint arthroplasty is very effective for improving the quality of life of patients with end-stage arthritis. Despite advances in materials, surgical technique, and rehabilitation regimens, joint replacements are still fraught with complications leading to their premature failure. Aseptic loosening and osteolysis are the primary causes of implant failure. Other reasons include early migration of components leading to instability, lack of ingrowth into implant porosities, and bone loss caused by stress shielding. Pharmaceutical agents used for preventing and managing postmenopausal osteoporosis (eg, bisphosphonates) may in the future play an important role in improving the long-term duration of joint arthroplasties. Early findings indicate that bisphosphonates upregulate bone morphogenetic protein-2 production and stimulate new bone formation. Because of their anabolic effect on osteoblasts, bisphosphonates have the potential to enhance bone ingrowth into implant porosities, prevent bone resorption under adverse conditions, and dramatically extend the long-term durability of joint arthroplasties. The long-term effects of bisphosphonate use on the mechanical properties of bone have not been adequately investigated. Along with improvements in implant design and material properties, bisphosphonates and other pharmaceutical agents may, in the near future, be part of the growing armamentarium that provides more durable joint arthroplasties.     

Advance pre-operative chlorhexidine preparation reduces periprosthetic infections following total joint arthroplasty

The purpose of this study was to evaluate the efficacy of an advance pre-operative chlorhexidine gluconate preparation protocol on the incidence of surgical site infections following total joint arthroplasty. In our review of 4671 patients at our institution, between 2007 and 2011, we found a significantly lower incidence of periprosthetic infections in the advance preparation group (0.5% and 0.6%) when compared to patients receiving in-hospital perioperative skin preparation only (1.7% and 2.2%) following total hip and knee arthroplasty, respectively. Chlorhexidine cloths may be more efficacious than other antiseptic methods at reducing surgical site infections following lower extremity total joint arthroplasty.     

Secondarily infected total joint replacements by hematogenous spread.

Three fatal cases of infections that followed total joint replacement are repoarted, in each of which a hematogenous source of infection was identified. There also were five non-fatal cases presumable arising hematogenously which were reported in the literature. It is emphasized that concomitant disease, including active rheumatoid arthritis, may predispose to this complication.     

The changing pattern of pyogenic infections of the hand

Four hundred cases of pyogenic hand infection treated in 1947 are compared with a similar number of cases treated in 1974.     

Conversion of bilateral hip and knee ankylosis to total joint replacements

We present a 25-year-old patient with juvenile rheumatoid arthritis and ankylosis of both hips and both knees treated by staged bilateral hip and knee arthroplasty. She was followed up for 18 months. We discuss the pre-operative planning, surgical details and post-operative rehabilitation.     

Borderline indications for use of cement in total joint replacements.

In order to delineate the borderline indications for the cemented and uncemented total hip replacements, we need to evaluate the existing success rates with these procedures. The long term success rates with cemented total hip replacements done using an intramedullary methylmethacrylate plug, doughy Simplex bone cement introduced in a retrograde fashion via a cement gun, and collared cobalt-chrome femoral components with rounded corners were reviewed at eleven year follow-up. The patients ranged in ages from 20 to 84 years (mean 57 years). Among the 105 patients in the group followed up at a minimum of 10 years 97% of the femoral components remained rigidly fixed. These results suggest that the cemented femoral components give satisfactory results to the vast majority of patients over eleven years. Further improvements in the use of cement for prosthetic fixation were made since then. The strength of the cement-prosthesis interface is now considerably enhanced by precoating the prosthesis industrially with a thin layer of methacrylate and or by using texture prosthesis. The strength of cement is considerably improved by techniques such as centrifuging the cement after mixing, or mixing the cement in vacuum. These techniques appear promising and may further enhance the fixation of the prostheses to the skeleton.     

Outpatient total joint arthroplasty: Is the paradigm changing?

Total joint arthroplasty (TJA) is generally considered an inpatient operation. Yet, the actual length of stay (LOS) has diminished over time. With the adaptation of improved anesthesia and pain management protocols, minimally invasive surgery techniques, rapid recovery protocols, and proper patient selection, outpatient TJA may be the next step in maximizing perioperative efficiency. Patient education, home health care utilization, and proper patient selection are key factors in keeping emergency room visits and hospital admission rates to a minimum. The potential benefits of outpatient TJA include improved patient care and control, better patient and surgeon satisfaction, and a lower overall cost.     

Pathomechanics of the femoropatellar joint following total knee arthroplasty

Persistent discomfort in the femoropatellar joint is still one of the most disappointing aspects following total knee arthroplasty (TKA). Especially, TKA without patellofemoral replacement has a significant incidence of patellofemoral problems with a frequency between 5% and 45%. Pathomechanical factors in the development of retropatellar problems are loss of patellar thickness and retropatellar erosions. In 157 TKAs using Gschwend, Scheier, B?hler (GSB) joints without patellar resurfacing, pathomechanically postoperative vertical patellar malposition appeared to be the main cause of dysfunction. In many cases, the implantation technique leads to an artificial form of patella alta. This altered knee anatomy results in pathologic biomechanics, thus leading to reduced function. The combination of altered anatomy and reduced function leads to extensive patellar destruction and ultimately to intractable retropatellar pain.     

Prophylactic antibiotics against early and late deep infections after total hip replacements.

A review with a longer observation period is performed of a previously published double-blind investigation of the prophylatic value of cloxacillin against late infections after total hip replacements; In addition, a retrospective patient material is examined. The total material consisted of 1065 total hips. 15.4 per cent deep, late infections were found in the group without prophylaxis and 20 per cent in the one with prophylaxis. The frequency of haematogenous deep infection was estimated to be less than 1 per cent.     

Tuberculosis joint infection following total knee arthroplasty

Delayed onset tuberculosis infection appeared in a total knee implant in a 61-year-old former coal miner. After a five-day interval the knee was salvaged by removal, aggressive debridement, suction-irrigation, and reinsertion. Antituberculosis drugs were administered immediately following surgery on the basis of the characteristic exudate and stat histologic sections showing granulomata formation. At one year follow-up examination the result was excellent. Retention of the total knee implant is a viable alternative to arthrodesis or fibrous ankylosis of the knee in such a case. Tuberculosis should be included in the differential diagnosis in patients with knee joint degenerative disease.     

DVT prophylaxis strategies following total joint arthroplasty

Routine prophylaxis against venous thromboembolism is indicated following total joint arthroplasty. Prophylactic strategies differ in efficacy and safety, and variable risk exists among patients. Many strategies have been successfully used for chemoprophylaxis as well as mechanical prophylaxis with the use of pneumatic compression. Advances in battery technology and pump miniaturization have expanded the use of pneumatic compression in the post-discharge setting with mobile devices. Pneumatic compression is contraindicated in certain patients, and not all patients tolerate the devices. Mobile pneumatic compression is a valuable adjunct to venous thromboembolic risk mitigation strategies, but does not eliminate the need for pharmacologic agents.     

Clinical studies and postoperative results of 51 nonambulatory rheumatoid patients with total joint replacements

Between October 1971 and June 1984, total joint replacement was performed on 51 nonambulatory patients with rheumatoid arthritis (RA). These nonambulatory patients showed high RA activity, and many presented with extra-articular symptoms with reference to the heart, lung, etc. During follow-up, 13 patients died of diseases unrelated to the operation, and the whereabouts of other 3 patients were unknown. Thus, the total joint replacement was evaluated in the remaining 35 patients. The walking ability was improved in 27 patients. However, the hoped-for results were not attained in relation to various aspects of the activities of daily life. Complications developed in 6 joints of 6 patients. The factors responsible for poor results were loss of motivation, muscle weakness, reduced function of the upper extremities, osteoporosis, cervical spinal cord injury, etc. From these results, it is emphasized that properly-timed surgery at the right level can prevent RA patient from becoming nonambulatory.