St. Francis Hospital

The purpose of this study was to examine the failure mechanisms and factors associated with failure of a nonmodular metal backed cemented tibial component. Out of 3152 total knee replacements done for osteoarthritis, 41 tibial components had been revised (1.3%). Four distinct failure mechanisms were identified: 20 knees were revised for medial bone collapse, 13 for ligamentous imbalance, 6 for progressive radiolucencies, and 2 for pain. Factors associated with medial bone collapse were varus tibial component alignment more than 3.0 degrees , Body Mass Index higher than 33.7, and overall postoperative varus limb alignment. Ligamentous imbalance was more prevalent in knees with preoperative valgus deformity. There were no knees revised for tibial component polyethylene wear or osteolysis. We conclude that the dominant failure mechanisms for this component design are related to preoperative deformity, technical factors of component alignment, overall limb alignment, and ligamentous imbalance.

BACKGROUND: The purpose of this study was to determine the effect of tibiofemoral alignment, femoral and tibial component alignment, and body-mass index (BMI) on implant survival following total knee replacement. METHODS: We retrospectively reviewed 6070 knees in 3992 patients with a minimum of two years of follow-up. Each knee was classified on the basis of postoperative alignment (overall tibiofemoral alignment and alignment of the tibial and the femoral component in the coronal plane). Failures (defined as revision for any reason other than infection) were analyzed with use of Cox regression; patient covariates included overall alignment, component alignments, and preoperative BMI. RESULTS: Failure was most likely to occur if the orientation of the tibial component was <90° relative to the tibial axis and the orientation of the femoral component was ≥8° of valgus (failure rate, 8.7%; p < 0.0001). In contrast, failure was least likely to occur if both the tibial and the femoral component were in a neutral orientation (≥90° and <8° of valgus, respectively) (failure rate, 0.2% [nine of 4633]; p < 0.0001). "Correction" of varus or valgus malalignment of the first implanted component by placement of the second component to attain neutral tibiofemoral alignment was associated with a failure rate of 3.2% (p = 0.4922) for varus tibial malalignment and 7.8% (p = 0.0082) for valgus femoral malalignment. A higher BMI was associated with an increased failure rate. Compared with patients with a BMI of 23 to 26 kg/m2, the failure rate in patients with a BMI of ≥41 kg/m2 increased from 0.7% to 2.6% (p = 0.0046) in well-aligned knees, from 1.6% to 2.9% (p = 0.0180) in varus knees, and from 1.0% to 7.1% (p = 0.0260) in valgus knees. CONCLUSIONS: Attaining neutrality in all three alignments is important in maximizing total knee implant survival. Substantial "correction" of the alignment of one component in order to compensate for malalignment of the other component and thus produce a neutrally aligned total knee replacement can increase the risk of failure (p = 0.0082). The use of conventional guides to align a total knee replacement provides acceptable alignment; however, the surgeon should be aware that the patient's size, as determined by the BMI, is also a major factor in total knee replacement failure.

BACKGROUND: Range of motion is a crucial measure of the outcome of total knee arthroplasty. The purpose of this study was to determine which factors are predictive of the postoperative range of motion. METHODS: We retrospectively studied 3066 patients (4727 knees) who had a primary total knee arthroplasty with the same type of implant at the same center between 1983 and 1998. Statistical clustering analysis paired with log-linear regression was used to determine groupings along continuous variables. Regression tree analysis was used to characterize the combinations of variables influencing the postoperative range of motion. The variables considered were preoperative and intraoperative flexion and extension, preoperative alignment, age, gender, and soft-tissue releases. RESULTS: Preoperative flexion was the strongest predictor of the postoperative flexion regardless of preoperative alignment. Other factors that were significantly related to reduced flexion were intraoperative flexion (p < 0.0001), gender (p < 0.0001), preoperative tibiofemoral alignment (p = 0.0005), age (p < 0.0001), and posterior capsular release (p < 0.0001). The removal of posterior osteophytes was related to the greatest increase in postoperative flexion in the group of patients with a varus tibiofemoral alignment preoperatively. CONCLUSIONS: The principal predictive factor of the postoperative range of motion was the preoperative range of motion. Removal of posterior osteophytes and release of the deep medial collateral ligament, the semimembranosus tendon, and the pes anserinus tendon in patients with large preoperative varus alignment and the attainment of a good intraoperative range of motion improved the likelihood that a good postoperative range of motion would be achieved.

The purpose of the current study was to evaluate the authors' 15-year experience with the Anatomic Graduated Components total knee replacement. This is a report of the survivorship of 4583 Anatomic Graduated Component total knee arthroplasties. Kaplan-Meier survival analyses were performed with the end point defined as radiographic loosening, revision, or both. This end point was subdivided into the best case scenario in which it was assumed that all the patients lost to followup were doing well throughout the study and a worst case scenario in which it was assumed that all patients lost to followup had failed results at their last clinic visit. There were six (0.18%) femoral, 21 (0.46%) tibial, and 180 (4.2%) all-polyethylene patellar component failures secondary to aseptic loosening. All femoral components and 90% of the tibial components were revised; however, only 15 patellar components were revised. The clinical survival rate with revision of one or more of the components was 98.86% at 15 years. Despite having nearly flat-on-flat geometry and retaining the posterior cruciate ligament, which should increase the stresses in the polyethylene and at the bone-cement interface, this total knee replacement has proved to have minimal wear and excellent longevity with time. The authors think this is a result of the direct compression molded polyethylene articulation and the nonmodular configuration that incorporates metal backing on the tibial component and eliminates back-sided tibial component polyethylene wear.

The use of epidural morphine for postoperative analgesia outside of intensive care units remains controversial. In this report our anesthesiology-based acute pain service documents experience with 1,106 consecutive postoperative patients treated with epidural morphine on regular surgical wards. This experience involved 4,343 total patient days of care and 11,089 individual epidural morphine injections. On a 0-10 verbal analog scale, patient-reported median pain scores at rest and with coughing or ambulation were 1 (inter-quartile range 3) and 4 (interquartile range 4), respectively. The incidence of side effects requiring medication were as follows: pruritus 24%, nausea 29%, and respiratory depression 0.2%. There were no deaths, neurologic injuries, or infections associated with the technique. Migration of epidural catheters into the subarachnoid space and into epidural veins each occurred twice. Overall, 1,051 of the 1,106 patients (95%) experienced none of the following problems: catheter obstruction, premature dislodgement, painful injections, catheter migration, infection, or respiratory depression. We conclude that postoperative pain can be safely and effectively treated with epidural morphine on surgical wards.

Impaction bone-grafting was performed before insertion of a collarless, polished, tapered femoral stem with cement in thirty-four revision total hip arthroplasties (thirty-four patients) that were done because of aseptic loosening. The average duration of follow-up was thirty months (range, twenty-four to forty-two months). The operation was the initial revision in twenty-eight patients (82 per cent). Twenty-two patients (65 per cent) also had revision of the acetabular component. Complications included four intraoperative and two postoperative fractures of the femur as well as one dislocation (at one month). Two patients (6 per cent) needed a repeat revision of the femoral stem because of aseptic loosening at twenty-six and thirty-six months postoperatively. Both of these patients had an associated fracture of the femur (one was intraoperative, and the other was postoperative). Subsidence was common (thirteen patients; 38 per cent) and averaged 10.1 millimeters (range, four to thirty-one millimeters). Although the study group was relatively small, with the numbers available subsidence was not found to be associated with the preoperative or postoperative hip score, segmental or cavitary femoral defects, femoral ectasia, intraoperative fracture of the femur, strut-grafting, trochanteric osteotomy, or varus position of the femoral component. Incorporation of the allograft into the trabecular bone and secondary remodeling were noted radiographically in thirty-two (94 per cent) and fourteen (41 per cent) of the patients, respectively, often within one year. Although the duration of follow-up was relatively short, no localized resorption of the allograft occurred and cortical repair was noted in one patient at three years. At the most recent follow-up evaluation, the Harris hip scores had improved from a preoperative average of 51 points (range, 32 to 90 points) to an average of 87 points (range, 65 to 100 points) and twenty-eight patients (82 per cent) had no or only slight pain. Despite the satisfactory early clinical results, we remain concerned about the high rate of fracture of the femur and the rate and extent of subsidence of the femoral component. On the basis of the worrisome findings after this two-year period, we recommend that impaction bone-grafting be used only when proximal femoral osteopenia is so severe that stability cannot be obtained with insertion of a long-stemmed femoral component without cement. In that setting, impaction bone-grafting may be considered instead of implantation of a massive proximal femoral allograft in combination with insertion of a femoral component with cement.

BACKGROUND: Telavancin, a novel lipoglycopeptide, exerts concentration-dependent, rapid bactericidal activity on account of its multiple mechanisms of action. Telavancin is highly active against gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-intermediate, and vancomycin-resistant strains. METHODS: We conducted a randomized, double-blind, controlled, phase-2 clinical trial. Patients > or = 18 years of age with a diagnosis of complicated skin and soft-tissue infection caused by suspected or confirmed gram-positive organisms were randomized to receive either intravenously administered telavancin once daily or standard therapy (antistaphylococcal penicillin 4 times daily or vancomycin twice daily). RESULTS: For the study, 167 patients were randomized and received at least 1 dose of study medication. Success rates were similar in all analysis populations at the test-of-cure evaluation. Of patients with S. aureus infection at baseline (n = 102), 80% of the telavancin group were cured and 77% of the standard therapy group were cured. For patients with MRSA infection at baseline (n = 48), cure rates were 82% for the telavancin group and 69% for the standard therapy group. Microbiologic eradication in patients with MRSA infection was 84% for the telavancin group versus 74% for the standard therapy group. MIC90 values were lower for telavancin in all tested strains of S. aureus (< or = 0.25 ug/mL) compared with the MIC90 values for vancomycin and oxacillin. Similar proportions of patients discontinued therapy for adverse events in both treatment groups (approximately 5%). Fewer serious adverse events were reported in the telavancin group (4 events) than were for the standard therapy group (9). CONCLUSION: Clinical and microbiological results of this study support the further development of telavancin, especially for treatment of infection due to MRSA.

Despite literature showing safety, accuracy, and therapeutic capability of emergency colonoscopy for acute lower gastrointestinal (LGI) bleeding, surgical literature suggests that this examination is difficult to perform in the acute setting. In contrast to currently accepted protocols, we believe that unprepared colonoscopy within 24 hours of presentation can be performed safely with a high rate of success in localizing and often treating the specific cause of LGI bleeding. We report results over a 7-year period in our institution using early colonoscopy as the primary investigative method for the diagnosis and treatment of LGI bleeding. We analyzed 85 consecutive patients suspected of LGI bleeding referred to the surgical service between 1989 and 1996. LGI bleeding was defined as the passage of blood per rectum, distal to the ligament if Trietz. We excluded patients who were only hemoccult positive or had an upper gastrointestinal source by nasogastric aspirate or upper gastrointestinal endoscopy. All patients underwent urgent unprepped colonoscopy by surgical endoscopists relying on the cathartic effect of blood and liberal suction/irrigation to cleanse the colon. Therapeutic maneuvers included Nd:YAG laser or BICAP coagulation. Studies in which active bleeding was found or lesions with endoscopic evidence of recent hemorrhage were considered positive. A total of 126 colonoscopies were performed in 85 patients, 44 males and 41 females, with a median age of 75 years (range, 12-91 years). Fifty-three patients (62%) had hematocrit drops of greater than 5 per cent. Thirty-four patients were transfused an average of 4.5 units of blood per patient. The source of bleeding was correctly identified in 82 of 85 (97%) patients. Ninety-one per cent of sources were colonic, and 9 per cent were small bowel. Fecal residue prevented initial adequate examination in only two patients. Diverticulosis (20%), ischemic colitis (18%), hemorrhoids (14%), and arteriovenous malformations (11%) were the predominant sources of bleeding. Spontaneous cessation of bleeding occurred in 58 (68%) patients. Control of active hemorrhage was achieved endoscopically in 17 of 27 acutely bleeding patients. Significant therapeutic interventions were performed in 26 additional patients, including fulgration, polypectomy, relief of obstruction, and removal of foreign body. One patient with asymptomatic free air was observed nonoperatively, for a complication rate of 0.8 per cent. In-hospital mortality was 3.5 per cent (three patients), all secondary to multisystem organ failure and underlying disease. In-hospital rebleeding rate was 3.5 per cent (three). We conclude that, using colonoscopy, it is possible to identify the source of acute LGI bleeding in more than 95 per cent of cases. Diagnostic and therapeutic capability with colonoscopic intervention to control active hemorrhage is especially appealing. Additionally, the pattern, amount, and location of blood in the unprepared colon all give clues as to source and rate of bleeding. In experienced hands, morbidity and mortality of emergent colonoscopy is very low. High accuracy, safety, and therapeutic capability makes colonoscopy the initial diagnostic test of choice for acute LGI hemorrhage.

The purpose of the current study was to review the results of total knee replacement (TKR) in patients with diabetes mellitus and to test the hypothesis that patients with diabetes achieve inferior results after TKR. From a consecutive series of 5220 primary cemented TKRs, 363 were done in 291 patients with diabetes mellitus. Cefuoxime-impregnated cement was used routinely. The results in the study group were compared with the results in the patients without diabetes who had TKR during the same period. The followup averaged 52 months. Knee scores were higher in patients with diabetes preoperatively (47 versus 38) and postoperatively up to 7 years (80 versus 75). The average preoperative and postoperative pain scores also were higher in patients with diabetes. Four deep infections (1.2%) occurred in patients with diabetes versus 35 deep infections (0.7%) in patients without diabetes. The revision rate (including infections) was greater in patients with diabetes (3.6% versus 0.4 %). Knee and pain scores were similar in patients with insulin-dependent and noninsulin-dependent diabetes. Postoperative function scores, however, were lower in patients with insulin-dependent diabetes. In the study group, all deep infections occurred in patients with insulin-dependent diabetes.

BACKGROUND: The treatment of a supracondylar femoral fracture following total knee arthroplasty is complicated by the presence of the prosthetic components. Anterior femoral notching during arthroplasty has been implicated as a contributing risk factor for femoral fracture. We retrospectively reviewed the effect of anterior femoral notching on the subsequent occurrence of a periprosthetic supracondylar fracture of the distal aspect of the femur and the outcomes of primary total knee arthroplasty in such patients. METHODS: The prevalence and depth of femoral notching were determined on a review of the lateral radiographs by observers blinded to the clinical results of 1089 consecutive total knee replacements performed in 1997 and 1998. Linear and logistic regression modeling was used to analyze the relationship between femoral notching and the prevalence of supracondylar femoral fracture, postoperative range of motion, the Knee Society score, and the Knee Society functional and pain scores. RESULTS: Femoral notching was performed in 325 (29.8%) of the 1089 knees in our series. During an average follow-up period of 5.1 years, only two supracondylar femoral fractures occurred, both in femora treated without notching. Femoral notching was not associated with an increased rate of fracture (p = 1.000) or with significant differences in the measures of outcome (range of motion [p = 0.117], knee score [p = 0.967], functional score [p = 0.861], need for a lateral release [p = 0.234], or postoperative pain [p = 0.948]). CONCLUSIONS: This study demonstrated no difference in knees managed with or without notching of the anterior distal aspect of the femur with respect to the occurrence of a supracondylar fracture, range of motion, Knee Society score, Knee Society function, or pain.

Patients who had anterolateral and posterolateral approaches in total hip replacement surgery were compared clinically for limp, dislocation, hospital stay, and discharge disposition. The only statistical difference was that the posterior approach had a statistically higher dislocation rate. Although the number of patients with limp was higher in the anterolateral group, the difference was not statistically different.

The long-term success of total knee replacement is multifactorial, including factors relating to the patient, the operation and the implant. The purpose of this study was to examine the 20-year survival of the cemented Anatomical Graduated Component (AGC) total knee replacement. Between 1983 and 2004, 7760 of these were carried out at our institution. Of these, 6726 knees which received the non-modular metal-backed tibial component with compression-moulded polyethylene and had a minimum two-year follow-up were available for study. In all, 36 knees were followed over 20 years with a survival of the tibial and femoral components together of 97.8% (95% confidence interval (CI) 0.9851 to 0.9677), with no implants being revised for polyethylene wear or osteolysis. Age > 70 was associated with increased survival (99.6%, 95% CI 99.0 to 99.8) (p < 0.0001) but pre-operative valgus alignment reduced survival (95.1%, 95% CI 90.0 to 97.6) (p = 0.0056). Age < 55 (p = 0.129), pre-operative varus alignment (p = 0.707), osteonecrosis (p = 0.06), rheumatoid arthritis (p = 0.247), and gender (p = 0.666) were not statistically associated with failure. We attribute the success of the AGC implant to its relatively unconstrained articular geometry and the durability of a non-modular metal-backed tibial component with compression moulded polyethylene.

BACKGROUND: The outcome of total knee replacement after high tibial osteotomy remains uncertain. We hypothesized that the results of total knee replacement with or without a previous high tibial osteotomy are similar. METHODS: The results of a consecutive series of thirty-nine bilateral total knee arthroplasties performed with cement at an average of 8.7 years after unilateral high tibial osteotomy were reviewed. There were twenty-seven men and twelve women. Preoperatively, the knee scores according to the system of the Knee Society were similar for all of the knees; however, valgus alignment and patella infera were more common in the knees with a previous high tibial osteotomy. Bilateral total knee replacement was staged in seven patients and was simultaneous in thirty-two patients. The results of the total knee arthroplasties were retrospectively reviewed with respect to the knee and function scores according to the system of the Knee Society, the radiographic findings, and the complications. RESULTS: Intraoperatively, no notable differences were identified in the number of medial, lateral, or lateral patellar releases required. However, less lateral tibial bone was resected in the group with a previous high tibial osteotomy (average, 3.3 millimeters) than in the group without a high tibial osteotomy (average, 7.5 millimeters). The average duration of follow-up was 7.5 years (range, three to sixteen years) in the group with a previous high tibial osteotomy and 6.8 years (range, two to ten years) in the group without a high tibial osteotomy. At the time of the final follow-up, the knee and function scores were similar for the two groups (89.0 and 81.0 points, respectively, for the group with a previous high tibial osteotomy, and 89.6 and 83.9 points, respectively, for the group without a high tibial osteotomy). Although more knees were free of pain in the group without a previous high tibial osteotomy (thirty-six) than in the group with a previous osteotomy (thirty-three), this difference was not found to be significant with the numbers available (p = 0.4810). Knee alignment and stability, femoral and tibial component alignment, and range of motion also were similar in both groups postoperatively. One allpolyethylene tibial component was revised in the high tibial osteotomy group. Two knees in each group required manipulation. There were no deep infections. CONCLUSIONS: While patients with a previous high tibial osteotomy may have important differences preoperatively, including valgus alignment, patella infera, and decreased bone stock in the proximal part of the tibia, the present study suggests that the clinical and radiographic results of primary total knee arthroplasty in knees with and without a previous high tibial osteotomy are not substantially different. In our relatively small group of patients, the previous high tibial osteotomy had no adverse effect on the outcome of the subsequent total knee replacement.

BACKGROUND: Implant survival after total knee arthroplasty has historically been dependent on postoperative knee alignment, although failure may occur when alignment is correct. Preoperative knee alignment has not been thoroughly evaluated as a possible risk factor for implant failure after arthroplasty. The purpose of this study was to analyze the effect of preoperative knee alignment on implant survival after total knee arthroplasty. METHODS: We performed a retrospective review of 5342 total knee arthroplasties performed with use of cemented Anatomic Graduated Component implants from 1983 to 2006. Each knee was independently measured preoperatively and postoperatively for overall coronal alignment. Neutral ranges for preoperative and postoperative alignment were defined by means of Cox proportional hazards regression. RESULTS: The overall failure rate was 1.0% (fifty-four of 5342 prostheses); failure was defined as aseptic loosening of the femoral and/or tibial component. The average preoperative anatomical alignment (and standard deviation) was 0.1° ± 7.7° of varus (range, 25° of varus to 35° of valgus), and the average postoperative anatomical alignment (and standard deviation) was 4.7° ± 2.5° of valgus (range, 12° of varus to 20° of valgus). The failure rate in knees in >8° of varus preoperatively (2.2%; p = 0.0005) or >11° of valgus preoperatively (2.4%; p = 0.0081) was elevated when compared with knees in neutral preoperatively (0.71%). Knees with preoperative deformities corrected to postoperative neutral alignment (2.5° through 7.4°) had a lower failure rate (1.9%) than undercorrected or overcorrected knees (3.0%) (p = 0.0103). Knees with postoperative neutral alignment, regardless of preoperative alignment, had a lower failure rate (0.74%) than knees with postoperative alignment of <2.5° or >7.4° of anatomic valgus (1.7%) (p < 0.0001). CONCLUSIONS: Patients with excessive preoperative alignment (>8° of varus or >11° of valgus) have a greater risk of failure (2.3%). Neutral postoperative alignment (2.5° through 7.4° of valgus) improves (1.9% for preoperatively deformed knees) but does not completely eliminate the risk of failure (0.5% for knees that were neutral both preoperatively and postoperatively). Careful attention should be paid to knee alignment during total knee arthroplasty, especially for patients with severe preoperative deformities.

BACKGROUND: Patterns of care for prostate cancer patients in the United States have changed as early detection has improved. The National Cancer Data Base of the American College of Surgeons Commission on Cancer provides information about the treatment of patients in all age, race, and regional groups from institutions that represent cancer care at the community level as well as in medical centers. METHODS: Data on 251,416 prostate cancer patients diagnosed between 1992 and 1994 were studied. Patient and disease characteristics, including age, race, the geographic region from which a case was reported, American Joint Committee on Cancer stage, and tumor grade were related to the primary pattern of treatment. Stage-standardized comparisons were made among different age groups, race groups, and regional groups. RESULTS: Stage and tumor grade varied little across age, race, and regional classifications. African American patients were more likely than white patients to have Stage IV prostate cancer at the time of diagnosis. Men older than 75 years had greater proportions than younger men of both the earliest and the most advanced stages of cancer. Overall, 24.6% of patients received no cancer-directed therapy, 11.6% were treated with hormones or endocrine surgery, 28.6% received radiation therapy, 28.3% underwent radical prostatectomy, and 6.9% were treated by other modalities or combinations of modalities. Treatment patterns varied markedly by age. The selection of radical prostatectomy relative to no treatment and radiation therapy varied by race and region. CONCLUSIONS: The results of this study showed that prostate cancer treatment varies by patient age, race, and geographic region. The reasons for some of these variations are not well understood and deserve further investigation.

Among 300 fractures of the elbow in children, the most frequent type was the supracondylar fracture (177 cases, with marked displacement in 72 of these). The authors recommend skeletal traction as the primary treatment for this fracture if there is severe displacement; three weeks of traction are generally followed by two weeks of immobilization in a cast. Fractures of the lateral condyle (34 cases) require careful diagnosis because even a slight displacement of the capitellar epiphysis can result in deformity. Open reduction was necessary in 14 of these cases. Fractures of the medial epicondyle (27 cases) were accompanied by dislocation in 14 cases and by incarceration of a fragment of bone in the joint in 4 cases. Such incarceration must be watched for, since it calls for either excision or reattachment of the fragment. Fracture of the head of the radius (22 cases) was successfully treated by immobilization (15 cases) without severe displacement; others required either manipulation or open operation. The foregoing types of fracture are illustrated by four case histories. Gentleness in dealing with soft tissues is essential. Evidence of circulatory trouble demands prompt action. Restoration of function to injured nerves occurred in all cases but one. The expense and inconvenience of a few weeks of hospital care should not influence the choice of treatment, which largely decides whether the elbow is ever to regain normal form and function.

BACKGROUND: Following total knee arthroplasty, some patients who fail to achieve >90 degrees of flexion in the early perioperative period may be considered candidates for manipulation of the knee under anesthesia. The purpose of this study was to assess the outcomes of manipulation following total knee arthroplasty. METHODS: One hundred and thirteen knees in ninety patients underwent manipulation for postoperative flexion of < or =90 degrees at a mean of ten weeks after surgery. Flexion was measured with a goniometer prior to total knee arthroplasty, at the conclusion of the operative procedure, before manipulation, immediately after manipulation, at six months, and at one, three, and five years postoperatively. RESULTS: Eighty-one (90%) of the ninety patients achieved improvement of ultimate knee flexion following manipulation. The average flexion was 102 degrees prior to total knee arthroplasty, 111 degrees following skin closure, and 70 degrees before manipulation. The average improvement in flexion from the measurement made before manipulation to that recorded at the five-year follow-up was 35 degrees (p < 0.0001, paired t test). There was no significant difference in the mean improvement in flexion when patients who had manipulation within twelve weeks postoperatively were compared with those who had manipulation more than twelve weeks postoperatively. Patients who eventually underwent manipulation had significantly lower preoperative Knee Society pain scores (more pain) than those who had not had manipulation (p = 0.0027). CONCLUSIONS: Manipulation generally increases ultimate flexion following total knee arthroplasty. Patients with severe preoperative pain are more likely to require manipulation.

BACKGROUND: Cigarette smoking is an important environmental factor affecting inflammatory bowel disease. The role of smoking has not been rigorously studied in microscopic colitis (MC). The aim of this study was to compare the association of cigarette smoking in individuals with MC compared to a control population without MC. METHODS: We reviewed the records of patients with a clinical and histologic diagnosis of collagenous colitis (CC) or lymphocytic colitis (LC). Clinical history, including alcohol and smoking status at the time of diagnosis of MC, were reviewed. In this case-control study, age- and gender-matched patients without diarrhea presenting for outpatient colonoscopy served as the control population. RESULTS: We analyzed a total of 340 patients with MC: 124 with CC and 216 with LC. Overall, any smoking status (former or current) was associated with MC (odds ratio [OR] 2.12, 95% confidence interval [CI]: 1.56-2.88). This risk was more prominent in current smokers (adjusted OR 5.36, 3.81, and 4.37 for CC, LC, and all MC, respectively, 95% CI all greater than 1). The association of smoking was not significantly affected by gender or average alcohol consumption. CONCLUSIONS: In our study population, cigarette smoking is a risk factor for the development of both forms of microscopic colitis. There were no significant differences between LC and CC, and current smoking and the development of microscopic colitis affected men and women similarly. We feel that these data are sufficient to discuss the potential risks of tobacco use in patients with microscopic colitis.

BACKGROUND: The long-term results of total hip arthroplasty without cement have been reported only rarely. The purpose of the present study was to evaluate the minimum ten-year results of primary total hip arthroplasty performed with use of a proximally porous-coated, plasma-sprayed, straight-stemmed, titanium-alloy femoral component. METHODS: The clinical and radiographic results of a consecutive series of 105 total hip replacements in ninety-five patients were reviewed ten to twelve years postoperatively. The diagnosis was osteoarthritis for seventy-seven hips (73%). The clinical result was evaluated on the basis of the Harris hip score, complications, and thigh pain. A detailed radiographic analysis was performed at each follow-up visit. Kaplan-Meier analysis was performed to evaluate the survival of the femoral component. RESULTS: The average Harris hip score improved from 46 points preoperatively to 92 points postoperatively. The average pain score at the time of the most recent follow-up was 42 points, with eighty-three hips (79%) rated as pain-free. Thigh pain was identified in only two patients. All radiolucent lines were seen around the tip of the stem. All hips had some degree of femoral remodeling consistent with osseous ingrowth. No femoral component was revised, and no femoral component had evidence of loosening. Eight acetabular components were revised because of loosening and wear, and one was revised because of recurrent dislocation. One focal femoral osteolytic lesion was seen. CONCLUSIONS: This femoral component afforded durable fixation at ten to twelve years after primary total hip arthroplasty. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

UNLABELLED: We identified patient and surgeon factors associated with patellar component failure in a series of 8530 TKAs performed in 5640 patients using the same posterior cruciate ligament-retaining TKA with all-polyethylene patellar components between January 1983 and December 2003. Patellar failure was defined as loosening, fracture, or patellar revision. All infections were excluded. Statistical analysis using Kaplan-Meier and Cox regression was used to determine the risk of patellar failure. Followup averaged 7.0 years (range, 2-22 years). Patellar component loosening occurred in 4.8% of TKAs (409 knees). Patellar fracture was identified in 5.2% of TKA (444 knees). Twenty-five patellae were revised (0.3%). TKA performed with a lateral release and patients with a body mass index of greater than 30 kg/m(2) were at the greatest risk of patellar loosening and fracture, respectively. Male gender, preoperative varus alignment of greater than 5 degrees , and large patellar component size also predicted a higher risk of patellar fracture. Medial patellar component position, tibial component thickness of greater than 12 mm, preoperative valgus alignment of 10 degrees or more, and preoperative flexion of 100 degrees or more predicted patellar loosening. An awareness of these factors that predict patellar failure after TKA may help determine the relative indications for TKA and influence surgical technique, especially when using this prosthesis. LEVEL OF EVIDENCE: Level IV, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.