There has been a renewed interest in
The classic Hill-Sachs lesion is a compression or impression fracture of the humeral head in occurrence with anterior glenohumeral instability. The true incidence is unknown but clearly increases with recurrent instability episodes. Recent peer-reviewed literature has highlighted the importance of addressing “significant” humeral and glenoid bone defects in the management of glenohumeral instability. Quantification of the “significance” of a Hill-Sachs lesion with regard to location, size, and depth in relation to the glenoid has helped guide indications for surgical management. Options for managing Hill-Sachs lesions include both humeral-sided techniques (soft tissue, bone, and/or prosthetic techniques) and also glenoid-sided techniques (bone transfers to increase glenoid width). The majority of significant acute or chronic Hill-Sachs lesions can be effectively managed without prosthetic replacement. Is a prosthetic
Total hip arthroplasty (THA) is among the most successful interventions in all of medicine and has recently been termed “The Operation of the Century”. Charnley originally stated that “Objectives must be reasonable. Neither surgeons nor engineers will ever make an artificial hip joint that will last 30 years and at some time in this period enable the patient to play football.” and he defined an appropriate patient as generally being over 65 years of age. Hip rating scales developed during this time were consistent with this approach and only required relief of pain and return to normal activities of daily living to achieve a perfect score. Since this time, however, hip arthroplasty has been applied to high numbers of younger, more active individuals and patient expectations have increased. One recent study showed that in spite of a good hip score, only 43% of patients had all of their expectations completely fulfilled following THA. The current generation metal-metal hip
Total hip arthroplasty is among the most successful interventions in all of medicine and has recently been termed “The Operation of the Century”. Charnley originally stated that “Objectives must be reasonable. Neither surgeons nor engineers will ever make an artificial hip joint that will last 30 years and at some time in this period enable the patient to play football.” and he defined appropriate patient as generally being over 65 years of age. Hip rating scales developed during this time were consistent with this approach and only required relief of pain and return to normal activities of daily living to achieve a perfect score. Since this time, however, hip arthroplasty has been applied to high numbers of younger, more active individuals and patient expectations have increased. One recent study showed that in spite of a good hip score, only 43% of patients had all of their expectations completely fulfilled following THA. The current generation metal-metal hip
Hill-Sachs and reverse Hill-Sachs lesions come in different shapes and sizes, and their effect on “glenoid track” can vary. Small Hill-Sachs lesions that do not engage can be successfully treated with a Bankart repair alone done arthroscopically or open. Moderate, engaging, Hill-Sachs lesions can be treated either with the addition of remplissage to an arthroscopic Bankart or by adding the triple blocking effect of the Bristow-Latarjet procedure.
Metal-metal
The Hill-Sachs lesion is a bony defect of the humeral head that occurs in association with anterior instability of the glenohumeral joint. Hill-Sachs lesions are common, with an incidence approaching nearly 100% in the setting of recurrent anterior glenohumeral instability. However, the indications for surgical management are very limited, with less than 10% of anterior instability patients considered for treatment of the Hill-Sachs lesion. Of utmost importance is addressing bone loss on the anterior-inferior glenoid, which is highly successful at preventing recurrence of instability even with humeral bone loss. In the rare situation where the Hill-Sachs lesion may continue to engage the glenoid, surgical management is indicated. Surgical strategies are variable, including debridement, arthroscopic remplissage, allograft transplantation,
It has been proposed that a major advantage of
Introduction. Studies of metal-on-metal (MoM) hip resurfacing arthroplasty (HRA) have reported high complication and failure rates due to elevated metal ion levels. These rates were shown to be especially high for the Articular
Cementless
The Hill-Sachs lesion is a bony defect of the humeral head that occurs in association with anterior instability of the glenohumeral joint. Hill-Sachs lesions are common, with an incidence approaching nearly 100% in the setting of recurrent anterior glenohumeral instability. However, the indications for surgical management are very limited, with less than 10% of anterior instability patients considered for treatment of the Hill-Sachs lesion. Of utmost importance is addressing bone loss on the anterior-inferior glenoid, which is highly successful at preventing recurrence of instability even with humeral bone loss. In the rare situation where the Hill-Sachs lesion may continue to engage the glenoid, surgical management is indicated. Surgical strategies are variable, including debridement, arthroscopic remplissage, allograft transplantation,
Total hip arthroplasty is among the most successful interventions in all of medicine and has recently been termed “The Operation of the Century”. Charnley originally stated that “Objectives must be reasonable. Neither surgeons nor engineers will ever make an artificial hip joint that will last 30 years and at some time in this period enable the patient to play football.” and he defined the appropriate patient as generally being over 65 years of age. Hip rating scales developed during this time were consistent with this approach and only required relief of pain and return to normal activities of daily living to achieve a perfect score. Since this time, however, hip arthroplasty has been applied to high numbers of younger, more active individuals and patient expectations have increased. One recent study showed that in spite of a good hip score, only 43% of patients had all of their expectations completely fulfilled following THA. The current generation of metal-metal hip
Introduction. A metal ion study was undertaken in patients who had received an articular
Introduction. While fixation on the acetabular side in resurfacing implants has been uncemented, the femoral component is usually cemented. The most common causes for early revision in hip resurfacing are femoral head and or neck fractures and aseptic loosening of the femoral component. Later failures appear to be more related to adverse soft-tissue reactions due to metal wear. Little is known about the effect of cementing techniques on the clinical outcome in hip resurfacing, since retrieval analysis of failed hip resurfacing show large variations. Two cementing techniques have dominated. The indirect low viscosity (LV) technique as for the Birmingham Hip resurfacing (BHR) system and the direct high viscosity (HV) technique as for the Articular
Hip resurfacing presents advantages and disadvantages compared to total hip arthroplasty. Dislocation and leg length discrepancy, common complaints with total hips, are unusual following resurfacing. Bone stock in the proximal femur is retained, and revision options on the femoral side of a resurfacing are much better. Concerns persist regarding adverse tissue reactions to metal debris. Conflicting data abounds regarding ultimate hip function, patient satisfaction, durability, etc. Yet all of these would be rendered irrelevant if resurfacing carried with it greater life expectancy. We would not speak of survivorship of the implant, but survival of the patient. Instead of quality of life, let us preserve life itself. Beginning in 2010, the UK Registry reported improved mortality rates at 90 days and five years after hip resurfacing compared with total hip replacement. This persisted after multivariate analysis for several covariables, including age, gender, health status, type of device, provider, and country. Recently, the 2016 Australian Registry Mortality Supplement showed similar results, corrected for age and gender. Analysis of UK data by the designing surgeons of the Birmingham device, and an independent group of Oxford statisticians confirmed the lower mortality rate in patients treated with resurfacing vs. total hip replacement. Possible reasons for these differences include greater post-operative activity, longer stride length, less fat and marrow embolism, or perhaps more internet-savvy, health-conscious patients seeking out a resurfacing procedure. Mid-term data from the US is now starting to come in, and mortality benefits are being confirmed in a series of patients from a large, academic center. Should there be a confirmed mortality advantage of resurfacing over total hip replacement, more surgeons and patients would be interested in this procedure, and new materials and techniques may follow.
Hip resurfacing using metal-on-metal bearings has a number of purported advantages over traditional total hip replacement in the young, active patient. Males in particular can benefit from the bone preservation, stability, and higher activity levels seen with this procedure. As more is learned about the factors affecting long-term outcome of hip resurfacing, component position has emerged as one major predictor of success. Given a well-selected patient, and a well-designed device, acetabular positioning is perhaps the most important determinant of long-term survivorship in hip resurfacing. One feature of resurfacing socket design which has not been widely disseminated is the sub-hemispheric arc of the bearing surface. While the outer circumference of the socket represents a complete hemisphere, and radiographic evaluation may assume that the apparent socket angle is satisfactory, the actual bearing is less than a hemisphere, so that the true abduction of the bearing is considerably more vertical. This important fact leads to excessive bearing inclination, edge loading, and all that follows, including runaway wear, metallosis, ALVAL, and pseudotumors. Inadequate socket anteversion can expose the psoas tendon to abrasion and tendonitis. Too much acetabular anteversion, especially when combined with increased femoral neck anteversion, can result in an overall decrease in bearing contact area, and excessive wear. Femoral component positioning is critical in the prevention of femoral neck fractures, which are a chief cause of early failure. Varus placement increases the tensile stresses on the superior femoral neck. Excessive valgus threatens notching. Both increase femoral neck fractures. Sufficient malposition will ultimately result in edge loading. Edge wear is incompatible with fluid film lubrication, the key to longevity of these bearings.
Complication and revision rates have shown to be high for all metal-on-metal (MoM) bearings, especially for the ASR Hip System (ASR hip resurfacing arthroplasty (HRA) and ASR XL total hip arthroplasty (THA)). This prompted the global recall of the ASR Hip System in 2010. Many studies have previously explored the association between female gender and revision surgery MoM HRA implants; yet less research has been dedicated to exploring this relationship in MoM THA. The first purpose of this study was to assess the associations between gender and implant survival, as well as adverse local tissue reaction (ALTR), in patients with MoM THA. Secondly, we sought to report the differences between genders in metal ion levels and patient reported outcome measures (PROMs) in patients with MoM THA. The study population consisted of 729 ASR XL THA patients (820 hips) enrolled from September 2012 to June 2015 in a multicenter follow-up study at a mean of 6.4 (3–11) years from index surgery. The mean age at the time of index surgery was 60 (22–95) years and 338 were women (46%). All patients enrolled had complete patient and surgical demographic information, blood metal ion levels and PROMs obtained within 6 months, and a valid AP pelvis radiograph dating a maximum of 2 years prior to consent. Blood metal ion levels and PROMs were then obtained annually after enrollment. A sub-set of patients from a single center had annual metal artifact reduction sequence (MARS) MRI performed and were analyzed for the presence of moderate-to-severe ALTR.Introduction
Methods
Resurfacing arthroplasty of the hip enjoyed a resurgence of enthusiasm. A recent article has documented that the media played a significant role in its popularity, making claims that were not substantiated in scientific literature. Proponents of resurfacing arthroplasty state that it is bone conserving, provides greater stability, enhances range of motion, leads to a more normal gait, facilitates increased activity levels, decreases risk of dislocation, decreases the risk of leg length discrepancy and find that it is easier to insert in the face of deformity or retained hardware. The naysayers state that it is a more difficult operative procedure associated with a higher learning curve. They note that there are few patients who meet the selection criteria and there is an increased risk of fracture of the femoral neck. Finally, there is concern over metal ion toxicity and adverse tissue reaction. Furthermore, as we explore the literature, several studies have observed that resurfacing requires a bigger cup and results in a significantly higher volume of normal bone reamed from the acetabulum. Other studies note decreased range of motion with resurfacing compared with total hip arthroplasty (THA) secondary to an unfavourable head to neck ratio resulting in increased impingement. While resurfacing is purported to enhance functional outcomes, one randomized trial of 48 patients, 24 each resurfacing and large head THA, compared with 14 healthy control subjects found no difference in gait speed and postural balance evaluations, functional test, and clinical data at 3, 6 and 12 months post-operative. In another study comparing 337 resurfacings with 266 ceramic-on-ceramic THA, at 24 months there was no difference in Harris hip score, pain score or function score, but a statistically greater improved Harris hip range of motion score in THA. In a large meta-analysis study comparing 3269 hip resurfacings (3002 patients) with average follow-up of 3.9 years to 5907 cementless THA (5907 patients) with average follow-up of 8.4 years, the observed rate of femoral revision due to mechanical failure was 2.6% for resurfacing versus 1.3% for THA, yielding annualized rates of 0.67% and 0.15% respectively. An analysis of hip resurfacing data from national joint registries found that hip resurfacing demonstrates an overall increased failure rate compared with THA, except in males younger than 65 years old having a diagnosis of primary osteoarthritis and except with head diameters larger than 50 mm, which may be especially relevant as a contraindication for use of the procedure in female patients.