Surface replacement of the hip in juvenile chronic arthritis

Seventeen resurfacing arthroplasties undertaken in 13 patients with severe hip arthritis are described. The youngest patient was 14 years and the mean age 23 years. The average follow-up time is 2 years. In one patient, pain-free for 7 months, the femoral cup slipped and revision into total hip replacement was easily performed. The remaining patients are pain-free, have increased motion, a better walking capacity and can enjoy sex life. The tremendous improvement in quality of life for these young patients justifies operation even if all may have to be converted into total hip replacement within a couple of years, although there is nothing to indicate that in this early follow-up.

A convenient distal plug for the femoral cavity in total hip arthroplasty

A new technique for plugging the femoral cavity prior to inserting methylmethacrylate during total hip arthroplasty is described. The plastic "Mexican hat" cement restrictor previously used in the acetabulum is trimmed and used conveniently as the femoral plug. This technique has been used satisfactorily and without complication in more than 50 cases.

Complications following osteotomy of the greater trochanter in total hip replacement arthroplasty using the lateral approach

In a consecutive series of 365 hip replacement arthroplasties ad modum Charnley in 309 patients migration of the trochanteric fragment was encountered in 4.9 per cent of the cases. The predisposing factors were wire-breakage, trochanteric fractures and excessive weight. Men were more apt than women to develop migration. Early mobilization with weight-bearing on the operated leg did not increase the risk of migration. The migration rarely gave rise to complaints, and if so only mild ones. Trochanteric union did not pose problems, and at the end of 2 years 98 per cent had united. After 5 years no case of non-union was detected.

Blood loss and operation time in the Charnley low friction arthroplasty

Review of 181 patients undergoing 194 Charnley low friction arthroplasties has shown that the average time taken for primary surgery was 65 minutes. The operative blood loss was 192 ml and postoperative drainage 437 ml. In conversion from failed hip surgery the blood loss was 260 ml at operation with an average drainage of 610 ml. The operative time was 87 minutes on average. Revision of failed hip replacement was carried out in an average time of 101 minutes. Average operative blood loss was 510 ml and postoperative drainage 680 ml. The findings show that criticism suggesting that detachment of the greater trochanter during total hip replacement increases operative time and blood loss is unfounded.

Pulmonary embolic syndrome caused by cementing of hip endoprosthesis

Previous studies have indicated that cementing of the femoral component in total hip replacement produces the features of the pulmonary embolic syndrome (P.E.S.). The present investigations have been carried out to ascertain if newer methods of insertion modify these features. There was no evidence to suggest that any of these approaches has any advantage over the others in relation to the various components of P.E.S.

Long term follow-up results of a femoral megaprosthesis. A review of thirteen patients

A total of 16 patients were treated with a femoral megaprosthesis at the University Hospital of Pellenberg. Their charts were reviewed and 13 patients were seen for a follow-up study. The indications for this procedure were revisions of a total hip arthroplasty and primary bone tumors. The aspects of the operative technique and postoperative management are discussed. A careful reconstruction of the abduction apparatus and a post-operative immobilisation for a period of 3 months seems to be important to prevent post-operative dislocation and to obtain an adequate functional result. The operation seems to be successful regarding the absence of pain and a restored function.

Function of fifty-seven septic, revised and healed total hip arthroplasties

An evaluation of hip function was made 2-5 years postoperatively in 57 patients reoperated using gentamicin-containing bone cement because of deep infection after total hip arthroplasty. Forty patients were completely free from pain and 17 had slight intermittent pain. Fifty-one had normal or nearly normal walking ability. Most patients managed dressing and getting in and out of a bath without help. It is concluded that revision in most case offers a satisfactory solution for the patient and gives a better functional result than simple removal of the prosthesis.

Total hip replacement ad modum ring

A 2-9 years (mean 5.4) follow-up of 295 Ring total hip replacements is presented. The pre- and postoperative conditions were evaluated according to Charnley. There were improvements as regards pain (1.4 to 5.4 points), mobility (2.5 to 5.0 points) and walking ability (2.2 to 4.0 points). The mortality rate was 0.3 per cent. Early deep infection occurred in 0.7 per cent and late deep infection in 0.3 per cent; 4.4 per cent needed revision for loosening (long femoral component 1.0 per cent; short femoral component 8.6 per cent). Radiological loosening indicated by a radiolucent zone of at least 3 mm wide surrounding the prosthesis was found to have no significant correlation with the clinical result. A significantly greater number of patients required reoperation when the short prosthesis was used. Even apart from those reoperated on the results were significantly poorer when the short prosthesis was used. It is concluded that the Ring prosthesis can still be recommended, but that the long prosthesis should be used whenever possible. When this is not possible, a cemented prosthesis should, perhaps, be used.

Conversion of ankylosed hips to total hip arthroplasty

Between 1970 and 1979, 17 patients underwent conversion of ankylosed hip to total hip arthroplasty. The patients' ages ranged from 38 to 82 years and the duration of fusion prior to conversion ranged from five to 60 years. The primary indication for conversion to total hip replacement in all patients was disabling pain in the low back, the ipsilateral knee, and the contralateral hip. The reason for ankylosis varied: five patients had previously undergone fusion for posttraumatic arthritis, two patients for tuberculous arthritis, six patients for osteoarthritis, one for a previous old slipped capital femoral epiphysis which had undergone spontaneous fusion after internal fixation, and two patients for ankylosing spondylitis. Relief of preoperative pain in the lower back was seen in 12 of 13 patients, knee pain was relieved in four out of four patients, and contralateral hip pain was relieved in seven out of 10 patients. Complications included heterotopic ossification, infection, perforation of the posterior shaft of the femur, and failure of trochanteric fixation with subsequent dislocation. Predictable pain relief from pain in the contralateral hip was less predictable and directly related to the degree of osteoarthritis in the contralateral hip. In these patients it is suggested that conversion of the fused hip to total hip arthroplasty be staged with total hip replacement in the contralateral hip as well. The end results were least satisfactory in patients with ankylosing spondylitis.

Total hip replacement in congenital dislocation of the hip

Twenty cases of congenital dislocation of the hip were treated with total hip replacement. The hips were completely dislocated with the femoral head supported by a nearthrosis proximal to the original acetabulum. The concept was to reconstruct the hip with an acetabular cup at the site of the original acetabulum even if a portion of the proximal end of the femur had to be sacrificed in the process. The Harris prosthesis appears, in most instances, to be the most suitable type of prosthesis but it was concluded that the surgeon needs a selection or prostheses for this procedure. Nine-tenths of the patients were improved by the procedure and the complications could mostly be successfully dealt with. This type of surgery is justified in cases with special indications.

Clinical experience with Mueller total hip endoprostheses of different design and material

Patients of the Orthopaedic University Hospital in Frankfurt operated between 1970 and 1977 were examined to control the success of implantations of total hip endoprostheses. Ninety-three percent of totally 1497 implanted hip prostheses are Müller standard type, additionally there have been implanted 44 Weber-Huggler prostheses and 54 special long stem prostheses. During the follow-up period of 10 years 7.4% of the primarily implanted prostheses had to be revised. The reasons for revision were loosening of the stem and/or socket in 56% of the cases, 20% infections, 14% technical errors and in 11% of the cases fractures of the stem occured. Fifty-two percent of the implanted Weber-Huggler prostheses with rotational ball heads made of polyester had to be revised in the meantime, 78% of the cases because of loosening of the prosthetic components. It could be shown that the number of infected cases could be diminished after introduction of an ultraclean air operating box. The change of the cross section of the Müller-type-stem from a round medial wedge to a flat one and the introduction of CoNiCrMo wrought alloy Protasul-10 instead of CoCrMo cast alloy Protasul-2 as stem material in 1973 resulted in a much smaller rate of loosened prostheses without fractures of the forged Protasul-10 stems. During the 6 examined years there has been no fracture of a prosthetic stem made of Protasul-10.

[Airborne contamination and post-operative infection (author's transl)]

The authors have studied the rate of infection after 14000 orthopaedic interventions performed in the same hospital during the period between 1971 and 1978. 1020 of these were performed in a vertical air flow enclosure with a clearance of air at a rate of 425 times per hour. The others were performed in the conventional operating theatre with an air clearance of 22 times per hour. The density of particles was found to be 50 to 100 times lower at the level of the incision in cases operated on under vertical flow. Depsite this, the rate of infection was 0.7p. 100 in the conventional theatre and 1.4p. 100 in the vertical flow theatre. However, if the study was limited to hip prostheses (1382 cases), the rate of infection was about the same: 2,9p. 100 in conventional theatres and 3,2p. 100 in vertical flow enclosures. It is concluded that the role of a vertical air flow enclosure in decreasing the rate of post-operative infection in doubtful. The authors recall the effects of previous operations on liability to infection and consider that the use of cement may increase the incidence of infection. They advocate the use of cementless, self-locking total prostheses.

[Early complication of the hip joint surface replacement according to Wagner (author's transl)]

Apart from infection and loosening of the implants, spontaneous fracture of the femoral neck is a specific early complication of the hip joint surface replacement according to Wagner. Based on our case material we demonstrate the problems involved, investigating not only the deficient operation technique but also the reasons for its deficiency which, in our opinion, are to be found in the method itself.

Device and method for controlling cement thickness

The ideal thickness of cement between the prosthesis and bone has not been accurately determined, but there is general agreement that the surgeon should be able to provide and accurately produce a certain thickness of cement between the prosthesis and the bone. Conventional cementing technique could allow the surgeon to ovepush the cup into direct contact with the bone producing a very thin cement coat or a void. We have developed a simple method of achieving a predictable thickness. We insert small spacers made of methylmethacrylate, which can be placed between the bone of the acetabulum and the acetabular component, preventing voids or thin areas in the cement coat. The device has been used in over 50 patients and has proven to be a simple and reliable method of allowing the surgeon to produce a predictable thickness of cement surrounding a joint replacement component. An additional benefit obtained from the use of these spacers is the ability to rigidly hold the acetabular component during polymerization of the acrylic without fear of overpushing. This allows better packing of the bone cement and prevents imperfections caused by the cup contacting the bone.

A new approach towards hip-prosthesis design

A new femoral prosthesis with a stemless design, different from conventional types, has been conceived in an effort to preserve the physiological stress distribution in magnitude and direction within the living bone as far as possible. The most important feature is that the hip joint forces are transmitted directly to the cortical bone of the resected femoral neck by means of a thrust plate, which maintains the physiological stress an the proximal end of the femur. The prosthesis, the instruments required for its implantation and the surgical technique are described in detail. Up to now, 3 patients have received this new prosthesis.

Arthroplasty with a solid bone graft for protrusio acetabuli

A high percentage of hips in patients with rheumatoid arthritis presenting for total joint replacement have protrusio deformity with extremely thin medial acetabular walls. Biomechanical principles suggest that, to prevent inward migration of the acetabular component, the prosthesis should be positioned laterally near the acetabular rim. To reinforce the medial wall, the femoral head is fashioned into a solid graft which is anchored against the medial wall as a plug, minimising the amount of cement used and making the use of wire mesh and restraining rings about the acetabulum unnecessary. A series of nine operations on seven patients is presented. Serial radiographs, tomograms and scintigrams taken after operation suggest satisfactory incorporation of the grafts, and no complications have been encountered in a follow-up period ranging from three months to two years.

[Alloarthroplastic experience with the Wagner double-cup (author's transl)]

Today, alloarthroplasty is one of the many standard therapeutical procedures in osteoarthrosis of the hip, or coxarthrosis. With this operation, many patients can be completely relieved from pain and regain their ability to walk to an excellent degree. However, long-term observations have shown that the stability of the prostheses does not always correlate with the life expectation of the operated patient. Dislocations and states of irritation, over and above infections, may necessitate repeat surgery. It must be borne in mind that such repeated operations are by no means certain to produce safe results. Hence, it is recommended to employ for the first implantation a prosthesis model which offers a better chance of interchangeability. This possibility is supplied by the double-cup prosthesis of the type described by Wagner and other authors. Certain limitations are imposed by the prosthetic form and by the surgical approach; these limitations should be taken into account when choosing the double-cup prosthesis.

Hip replacement with the McKee-Farrar prosthesis in rheumatoid arthritis

A follow-up investigation was made of 74 patients suffering from rheumatoid arthritis (RA) who underwent total hip replacement (THR) according to McKee-Farrar during the years 1969-1975. There were 27 bilateral cases. The mean observation time was 47 months (range 9-85 months). The results were graded according to the method of d'Aubigné & Postel. As regards pain relief and increase in hip mobility after THR the results were good, but walking ability was not greatly improved, partly because many other factors besides the state of the hips influence walking ability. In addition to the THRs, 332 other orthopaedic operations were performed on the 78 patients. No correlation was shown between the results and RA serology, age at THR, preoperative classification of hip radiographs, or observation times. A high frequency of migration of the prosthetic components was found.

Ectopic bone formation following Charnley hip arthroplasty

In a consecutive series of 309 patients the degree of ectopic bone formation was assessed 3 months, 2 years, and 5 years after total hip arthroplasty. At the three follow-up examinations ectopic bone formation was found in 49 per cent, 61 per cent, and 71 per cent. In men ectopic bone formation was more common and more pronounced than in women. It was demonstrated that walking ability and range of hip movement may be reduced in the presence of ectopic bone formation. A past history of hip surgery, preoperative exostoses, and postoperative elevation of the erythrocyte sedimentation rate did not appear to influence the formation of ectopic bone. There was no correlation between the degree of ectopic bone formation in the two hips of patients who had undergone bilateral operation. In the present study it was not possible to demonstrate preoperatively which groups of patients are most liable to develop ectopic bone postoperatively.

Modification of the anterior iliofemoral approach to the hip

This paper describes a modified iliofemoral surgical approach to the hip joint performed on 282 patients over a 26-year period. The surgical technique follows the anterior iliofemoral approach except that the lateral "bone overhang" of the iliac crest is osteotomized and dissected distally with the fascia lata to expose the hip capsule. The "six muscle glove" is sharply dissected off the greater trochanter, the hip capsule is opened and surgery is carried out, upon completion of which the operated leg is abducted. The osteotomized iliac crest bone-graft with the attached muscles is reapproximated to its anatomical position and fixed with permanent sutures through five holes drilled through the replaced bone graft and the intact ilium. The closure is rapidly performed, strong, and allows early functional return. Blood loss is relatively slight.

Fashioning a new greater trochanter for unusual Charnley low friction arthroplasties

In cases of conversion of hips with bony ankylosis to the Charnley low friction arthroplasty where the greater trochanter is nonexistent, the new trochanteric fragment, with the attached abductors, can be fashioned from the outer aspect of the femoral shaft and neck.

A new socket design for the dysplastic acetabulum in total hip replacement

A special socket was designed by holography for total hip replacement for the treatment of the dysplastic acetabulum and correction of the deformation pattern. Excellent clinical results of 12 cases demonstrate that the special socket design provides good stability as well as favorable redistribution of mechanical forces about the hip joint.

Bilateral total hip arthroplasty: a single procedure

A total of 196 patients with bilateral hip disease underwent the simultaneous bilateral total hip arthroplasty procedure (392 hips), compared with 427 patients with unilateral disease and one hip replaced. A multiple regression analysis showed no difference between the 2 groups in regard to age, sex, and preoperative diagnosis. The mean length of operation was 3 hours for the bilateral group and one hour and 15 minutes for the unilateral group, with a mean blood loss of 3 units and 0.5 units respectively (the majority of the patients were given hypotensive anesthesia. Post-operative complications revealed no differences in the phlebitis (1% for each group), clinical pulmonary emboli (1% for each group), dislocation (1% for unilateral and none for the bilateral group), and non-union of the greater trochanter (11% for the unilateral group and 12% for the bilateral group). The unilateral group revealed 25% ectopic ossification vs. 36% for the bilateral group (p < 0.008). The mean hospital stay was 14 days for the unilateral group and 16 days for the bilateral group, at respective costs of $4,137 and $5,780. There were signs of clinical loosening in 1% of both groups. The infection rate was 1% for both. An analysis of covariance revealed no follow-up differences between the 2 groups in regard to pain, abduction status, or functional capabilities, although the range of motion was better in the unilateral group (p < 0.001), as may be expected, with less initial range of motion, there was also more postoperative ectopic ossification. Replacement of both hips under one anesthetic benefits patients in that the postoperative complications are the same as for the procedure for one hip; the length of hospitalization and convalescence are only slightly longer; the postoperative follow-up shows no differences except for a slight restriction in range of motion for the bilateral group; and the cost represents a 30% savings over that of a unilateral hip performed twice.

[Antibiotic concentration in postoperative wound secretions and in serum of patients after implantation of hip endoprostheses having used neomycin-bacitracin loaded bone cement (author's transl)]

Antibiotic concentrations in postoperative wound secretions and in serum give some indication of the local and general effects of an antibiotic additive to bone cement. Ten patients received hip endoprostheses using a prepacked mixture of the bone cement Sulfix 6 with neomycin + bacitracin (Sulfix 6 A). After operation secretions from Redon drains were collected over the next 48 hours as well as venous blood over 14 days in order to measure neomycin and bacitracin levels. Neomycin was found in sera of some patients up to the eighth postoperative day, whereby concentrations did not exceed 0.75 mcg/ml. Bacitracin was not detected in any serum samples. In secretions from Redon drains neomycin as well as bacitracin reached effective levels during the first 48 hours. The results indicate that the addition of neomycin and bacitracin to the bone cement Sulfix 6 for local antibiotic prophylaxis is justified since effective antibiotic concentrations are thereby obtained in the wound without the danger of general toxicity arising when neomycin and bacitracin are administered by the usual method of topical application.

Primary replacement arthroplasty of the hip in femoral neck fractures: a study of 145 cases

A series of 145 patients (77 males and 68 females) with fracture of the neck of the femur treated by primary replacement arthroplasty (prosthesis) is presented. The indications, complications and results of operation are discussed. Prosthetic replacement has yielded satisfactory results in 91.7 per cent of cases and is a particularly suitable procedure for Indians.

[Insertion of Judet's prosthesis in high-region dislocation of the hip (author's transl)]

Osteoarthrosis of the hip (also known as coxarthrosis) as a result of a high-region dislocation of the hip, presents a difficult task for the orthopaedic surgeon, the solution of which is still under frequent and intense discussion. Total hip replacemnt (hip endoprosthesis) involves technical difficulties which result on the one hand, from the underdeveloped anatomic conditions (underdeveloped primary acetabulum with soft spongiosa on valgus position of the highly sclerosed secondary acetabulum associated with underdeveloped shaft of the femur); on the other hand, a repositioning is difficult if anchoring of the prosthesis is effected at the level of the primary acetabulum. For this reason, we developed an original operation method requiring two sessions: in a first operation, an extended arthrolysis is performed via an anterior access, whereas at the same time an extension is carried out by means of the distraction apparatus according to Wagner. After this first session, distraction is performed during 3 to 4 weeks until the head of the femur has attained the level of the primary acetabulum. The prosthesis is inserted in a second session, where anchoring at the level of the primary acetabulum becomes possible and repositioning can be affected without undue difficulties. An example of such total hip replacement by endoprosthesis, requiring 2 sessions, is demonstrated.

[Technique of total hip replacement in acetabular protrusion (author's transl)]

The authors describe the technique used in total hip replacement associated with acetabular protrusion. Use is maded of the femoral head which is placed in the acetabulum after reaming of its cartilage as a free graft filling part of the cavity. The remainder of the surgical procedure is conducted in the usual way. 10 cases have been operated on. 2 had to be operated on a second time for loosening. In all cases, the grafted femoral head was well incorporated.

[The review of 4300 Charnley total hip replacements inserted between 1968 and 1979 (author's transl)]

4 300 Charnley total hip replacements have been performed since 1968 using either a lateral or a posterior approach. The operative and post operative complications are analysed. 10 p. 100 of the cases had venous complications. There were 125 early dislocations which were easily reduced, and 38 dislocations occurring 6 to 8 years after the operation which were reduced under general anesthesia. There were 5 fractures of the stem of the femoral prosthesis. Instances of wear of the acetabular component were rare. 1.5 p. 100 of severe sepsis occurred leading to the need for the removal of the prosthesis in 23 cases. The percentage of septic complications was much higher in hip that had previously been operated on (5 p. 100) compared with when there had been no previous operation (1. p. 100). Functional results were rated excellent in 85 p 100, good and failure in 2 p. 100. In their conclusions, the authors state that the assessment of the results is difficult because of the age of the patients, the variability in methods of assessment and the presence of associated diseases. They emphasize that the results were consistent even after long periods of time and that wear in the prosthesis is not a hazard, any particles being produced by wear being well tolerated.

Replacement with the Christiansen endoprosthesis in acute femoral neck fractures. A 5 year follow-up study

Patients with acute femoral neck fractures, treated with prosthetic replacement (Christiansen's trunnion bearing endoprosthesis), were followed up at 15 months and again at 67 months postoperatively, and the results of the two examinations have been compared. The patients' personal opinion of the results of the operation did not change between the time of the first and second follow-up examinations. However, the objective results showed a deterioration in function (according to Stinchfield's hip assessment scheme) with increasing follow-up time. This deterioration in rating was mostly caused by reduced walking ability. X-ray study of the hips showed an increasing frequency of acetabular protrusion, and settling and loosening of the prosthetic stem. No clear correlation between X-ray findings and clinical results could be found. We conclude that the serviceability of the prosthetic operation is apparently good despite the objective evidence of progressive deterioration both in the grading of the results and in the X-ray findings.

Late results of intertrochanteric osteotomy for advanced osteoarthritis of the hip

The results are presented of 50 intertrochanteric osteotomies after a minimum observation time of 9.3 years. This method of treatment was found to be of lasting benefit in 86 per cent of the patients. The results encourage us to consider osteotomy also in younger patients with osteoarthritis.