Introduction and Aims: Periprosthetic femur fractures, severe bone loss with loosening, infection and debridements, and non-union can all result in loss of bone stock following total hip (THA) and/or total knee arthroplasty (TKA). In the multiply-operated or osteopenic patient, few options exist when bone is severely compromised. We report results of a total femoral construct to salvage the severely compromised femur.

Method: We retrospectively reviewed 59 consecutive total femurs. Revision THA and/or TKA was performed utilising a custom total femoral construct: a constrained acetabular component, proximal femoral replacement, diaphyseal segment, and rotating hinge knee. Return to ambulation, pain, functional capacity, and subsequent surgery outcomes were measured. All cases involved severe bone loss: 13 aseptic loosening of revision THA and TKA, 24 periprosthetic fractures, five failed non-unions around implants, and 17 cases of multiple debridements for sepsis.

Results: Mean age was 74 years, mean follow-up was 38 months. One peri-operative death occurred. Pain scores improved by 18 points. Average post-operative hip flexion was 90 and knee flexion 93. All but one patient achieved ambulatory capability. Four of 17 septic cases recurred, three successfully treated and one disarticulation. Three other infections occurred in the aseptic and periprosthetic groups, all treated successfully. There were five dislocations, one acetabular revision, and two knee revisions for aseptic loosening.

Conclusion: Total femoral replacement represents a viable salvage procedure for the compromised femur associated with THA and/or TKA. Rapid return to ambulating, relief of pain and improved function can be expected from this, the ultimate revision surgery.

Introduction and Aims: Successful cementless total hip arthroplasty (THA) is well documented, with increasing reports in elderly patients. Concerns exist with respect to the ability to achieve and maintain long-term cementless femoral fixation in this patient population. This study reviews the clinical and radiographic outcomes of a tapered porous femoral component in cementless THA in elderly patients.

Method: Forty-nine hips in 47 patients over 74 years of age underwent primary cementless THA with a tapered stem between April 1996 and April 2000. All femoral heads were sent to pathology. Radiographs, Harris hip scores and clinical data were evaluated. Revision status was known for all hips.

Results: Average age: 79 years, mean follow-up was 46 months. Six patients died during the study (mean 40 months) all THA unrelated. Twenty-two peri-operative variances occurred. There were no dislocations. Three irrigation and drainage procedures were performed, and no revisions. Mean post-operative HHS improved by 33, with 87 percent of patients having no or minimal pain. We identified two cases of stem subsidence to a stable position with no progressive radiolucencies. Mean length of stay was 4.5 days. One patient required intensive care, 52 percent were discharged to home. Metastatic cancer was identified in one femoral head.

Conclusion: Using revision status as an end-point, the success rate was 100 percent. No peri-operative deaths or significant orthopaedic complications were identified. Advanced age and Dorr C anatomy is not a contraindication for tapered cementless THA. The femoral head should routinely be sent to pathology.

Introduction and Aims: With interest in minimally invasive surgery, and smaller incisions for total hip arthroplasty (THA), ways to ensure appropriate alignment are critical. Femoral stem varus has been associated with poorer results. We report the incidence of varus placement of a tapered, proximally plasma-sprayed, titanium femoral component and describe the outcomes of varus at minimum five-year follow-up.

Method: Between 1986 and 1997, 1080 tapered, proximally plasma-sprayed femoral components were implanted in primary cementless THA at one institution. Twenty-six components in 25 patients were placed in five degrees or more of varus. Two patients were lost to follow-up. The need for further surgery was assessed and Harris hip scores evaluated.

Results: Harris hip scores improved an average of 44 points. All femoral components were judged to be osteo-integrated. There was no displacement or progression into further varus, or impending failures. One well-fixed stem was revised at an outside institution for unexplained pain at 2.5 years. Survival with aseptic loosening as an end-point is 100 percent. Overall survival of the femoral component is 96 percent at 10 years average follow-up.

Conclusion: As visualisation decreases with decreasing incision length, a component that is reliably placed into appropriate position is required. Implant position with this component is forgiving. It may be an excellent choice for less-invasive techniques with compromised visualisation. In varus, the stem performs well, with no revisions for aseptic loosening and a 96 percent survival at up to 16 years.

Introduction and Aims: Adequacy of post-operative pain control can effect total knee arthroplasty (TKA) outcomes. We examine the effectiveness of a simple and inexpensive method using long-acting local anesthetic (bupivacaine) with epinephrine and morphine injection on controlling pain, blood loss, and motion in primary TKA.

Method: We retrospectively reviewed 170 patients who underwent 208 primary TKA, by a single surgeon between October 2001 and December 2002. The control group of 75 patients (99 knees) had received no intra-operative injections. The study group of 95 patients (109 knees) had received intra-operative injection of 0.25 percent bupivacane with epinephrine and morphine divided two-thirds soft-tissue injection and one-third intra-articular injection. Bilateral simultaneous TKA in the study group received a divided anaesthetic dose.

Results: The control group required significantly more breakthrough narcotic (85 percent vs 67 percent; p=0.004); and required more narcotic reversal for over-sedation. The study group had significantly higher ROM at discharge 63 degrees vs 52 degrees. Lower ROM at discharge was associated with manipulation (p equals 0.001). The study group required less transfused blood (mean 0.03 vs 0.1 units), and had significantly lower bleeding indices 2.7 vs 3.5.

Conclusion: Preemptive analgesia with intra-articular and soft-tissue injection of long-acting local anesthetic with epinephrine and morphine appears to decrease need for rescue narcotics and reversal agents. The use of the injection also increases ROM at discharge, which reduces the need for manipulation. Lastly, the bleeding index and transfusion requirements are significantly reduced. This inexpensive method is effective in improving the post-operative course of primary TKA.

The overall success or failure of total knee arthroplasty (TKA) is predicated upon the successful combination of appropriate patient selection, proper meticulous surgical technique, and correct prosthetic design. The majority of discussions regarding the outcome of TKA seem to be focused on the hardware utilised and the surgical technique employed. Little attention is given to choosing the correct patient for this operative intervention. Consider some intuitive examples: 1.) patients with a diagnosis of osteoarthritis are less prone to perioperative complications than patients with rheumatoid arthritis; 2.) the greater the degree of preoperative combined varus/valgus deformity and flexion contracture, the more difficult the operative intervention and subsequent postoperative physical therapy and rehabilitation; 3.) it has been well documented that preoperative range of motion, as well as pre-existing flexion contractures, are the best determinant of postoperative range of motion; 4.) the presence or absence of secondary gain via manipulation of loved one or the status of a worker’s compensation claim will have a direct effect on the patient’s ability to recover successfully from the operative intervention; and 5.) the ability of the patient to participate in the postoperative physical therapy and rehabilitation program, as determined by either motivational status, postoperative depression, or cognitive ability will directly impact the result of the TKA. These examples are illustrative of the importance of optimising the doctor-patient relationship and of providing additional resources to the patient, especially a well-organised team.

The patient must be informed that the ultimate outcome of TKA is multi-factorial and that he/she plays a significant role in determination of that outcome. The ideal candidate for TKA is the patient who presents with incapacitating pain resulting in alteration of lifestyle in spite of the utilisation of conservative modalities. Clinical evaluation documents the presence of effusion with a painful range of motion and antalgic gait pattern. In addition, roentgenographs reveal advanced arthrosis. Complete preoperative medical evaluation is mandatory to delineate co-morbidities and to optimise the patient’s preoperative status for the surgical intervention. Careful assessment of the preoperative norvascular status of the extremities may serve to prevent postoperative complications. Preoperative evaluation and discussion should focus not only on the actual operative intervention and perioperative complications, but should also include a thorough discussion of postoperative pain management, as well as the expectations that will be placed upon the patient. The importance of motivation to participate in the postoperative physical therapy and rehabilitation program and to follow the directives of the physician, nurses, and physical therapist must also be stressed. Patients should also be cognizant of the fact that there is a delicate balance between over activity and under activity in the postoperative period. The patient’s experience may only be fully appreciated when the physician becomes a patient and experiences the consequences of TKA firsthand. This offers the surgeon a greater insight into patients’ expectations, the importance of preoperative counselling, the severity of perioperative pain, as well as the difficulty in dealing with postoperative swelling, mobilisation, range of motion, and the struggle to the return to activities of daily living. In summary, the quality of the outcome of TKA is dependent on the harmony that exists between the patient’s perioperative status and expectations, the physician’s diagnostic, surgical, and motivational skills, and the characteristics of the prosthesis.

Perioperative pain involves both neurogenic and inflammatory mediators. The neurogenic component is produced by the intense stimulation of the surgical procedure itself. However, inflammatory mediators resulting from tissue damage and the release of certain cytokines provoke the inflammatory response. Both the neurogenic and inflammatory elements create central nervous system (CNS) excitability. While conventional pain management responds to pain as it occurs, rather than anticipating it, a more appropriate protocol may involve pre-emptive administration of analgesic medication. By beginning this administration prior to surgery and continuing it throughout the rehabilitation process, CNS pharmacological agents are utilised to achieve the following goals: 1.) decrease the neurogenic component at the wound site; 2.) depress afferent pathways; and 3.) decrease central sensitisation in the spinal column.

Our experience with such pre-emptive analgesic clinical trials have included implementation of three different protocols in three groups of patients, Groups A-C. In Group A, a continuous epidural for 72-hours was utilised. A short-term epidural for 2–3 hours, followed by the use of scheduled opioid drugs and the use of anti-inflammatory medications, was used in Group B. Finally, Group C included spinal analgesia with shortacting morphine and the continued use of patient-controlled analgesia (PCA) pumps. In all groups, patients were monitored for the return of motor function, respiratory depression, ileus, pain relief, efficacy in analgesia maintenance, and cost. The following trends were observed among the variances: 1.) approximately equal length of stay in all three groups; 2.) decreased motor function in the continuous epidural group (Group A); 3.) increased ileus in the spinal group (Group C); 4.) equal pain relief in all three groups; 5.) high maintenance in the continuous epidural group (Group A); and 6.) decreased cost when continuous epidurals (Group B) were utilised.

In conclusion, of the three methodologies implemented, the continuous epidural had a high failure rate (26%). While spinal analgesia is technically easier and less expensive to perform, it has a poorly defined dose response curve and is associated with an increased incidence of ileus. The scheduled opioid medications proved effective. Pre-emptive analgesia not only significantly suppresses pain, it also provides protective sensation. Our recommendation for pre-emptive pain management consists of the use of multi-modal analgesics attacking various sites along the pain pathway, including regional blocks, oral and parental opioids, topical anaesthetics, and ice. However, ongoing study is required to further delineate appropriate protocol, thorough assessment of consequences, and complications associated with all methodologies. Future protocols to be evaluated at this practice include the local injection of bupivacaine hydrochloride prior to wound closure, in addition to assessing the postoperative integration of rofecoxib into the pain management regime.