Two-stage exchange remains the gold standard
for treatment of peri-prosthetic joint infection after total hip replacement
(THR). In the first stage, all components and associated cement
if present are removed, an aggressive debridement is undertaken
including a complete
Increasingly, patients with bilateral hip arthritis wish to undergo staged total hip arthroplasty (THA). With the rise in demand for arthroplasty, perioperative risk assessment and counselling is crucial for shared decision making. However, it is unknown if complications that occur after a unilateral hip arthroplasty predict complications following surgery of the contralateral hip. We used nationwide linked discharge data from the Healthcare Cost and Utilization Project between 2005 and 2014 to analyze the incidence and recurrence of complications following the first- and second-stage operations in staged bilateral total hip arthroplasty (BTHAs). Complications included perioperative medical adverse events within 30 to 60 days, and infection and mechanical complications within one year. Conditional probabilities and odds ratios (ORs) were calculated to determine whether experiencing a complication after the first stage of surgery increased the risk of developing the same complication after the second stage.Aims
Patients and Methods
Arthroscopy of the native hip is an established diagnostic and therapeutic procedure. Its application in the symptomatic replaced hip is still being explored. We describe the use of arthroscopy of the hip in 24 symptomatic patients following total hip replacement, resurfacing arthroplasty of the hip and partial resurfacing (study group), and compared it with arthroscopy of the native hip in 24 patients (control group). A diagnosis was made or confirmed at arthroscopy in 23 of the study group and a therapeutic arthroscopic intervention resulted in relief of symptoms in ten of these. In a further seven patients it led to revision hip replacement. In contrast, arthroscopy in the control group was diagnostic in all 24 patients and the resulting arthroscopic therapeutic intervention provided symptomatic relief in 21. The mean operative time in the study group (59.7 minutes (35 to 93)) was less than in the control group (71 minutes (40 to 100), p = 0.04) but the arthroscopic approach was more difficult in the arthroplasty group. We suggest that arthroscopy has a role in the management of patients with a symptomatic arthroplasty when other investigations have failed to provide a diagnosis.
Fracture of a ceramic component in total hip
replacement is a rare but potentially catastrophic complication.
The incidence is likely to increase as the use of ceramics becomes
more widespread. We describe such a case, which illustrates how
inadequate initial management will lead to further morbidity and
require additional surgery. We present the case as a warning that
fracture of a ceramic component should be revised to another ceramic-on-ceramic
articulation in order to minimise the risk of further catastrophic
wear.
We present a case series of ten metal-on-polyethylene total hip
arthroplasties (MoP THAs) with delayed dislocation associated with
unrecognised adverse local tissue reaction due to corrosion at the
trunnion and pseudotumour formation. The diagnosis was not suspected in nine of the ten patients (six
female/four male; mean age 66 years), despite treatment in a specialist
unit (mean time from index surgery to revision was 58 months, 36
to 84). It was identified at revision surgery and subsequently confirmed
by histological examination of resected tissue. Pre-operative assessment
and culture results ruled out infection. A variety of treatment
strategies were used, including resection of the pseudotumour and
efforts to avoid recurrent dislocation. Aims
Methods
Symptomatic cobalt toxicity from a failed total
hip replacement is a rare but devastating complication. It has been reported
following revision of fractured ceramic components, as well as in
patients with failed metal-on-metal articulations. Potential clinical
findings include fatigue, weakness, hypothyroidism, cardiomyopathy,
polycythaemia, visual and hearing impairment, cognitive dysfunction,
and neuropathy. We report a case of an otherwise healthy 46-year-old
patient, who developed progressively worsening symptoms of cobalt
toxicity beginning approximately six months following synovectomy
and revision of a fractured ceramic-on-ceramic total hip replacement
to a metal-on-polyethylene bearing. The whole blood cobalt levels
peaked at 6521 µg/l. The patient died from cobalt-induced cardiomyopathy.
Implant retrieval analysis confirmed a loss of 28.3 g mass of the
cobalt–chromium femoral head as a result of severe abrasive wear
by ceramic particles embedded in the revision polyethylene liner.
Autopsy findings were consistent with heavy metal-induced cardiomyopathy. We recommend using new ceramics at revision to minimise the risk
of wear-related cobalt toxicity following breakage of ceramic components. Cite this article:
Implantation of a large-diameter femoral head prosthesis with a metal-on-metal bearing surface reduces the risk of dislocation, increases the range of movement, minimises the risk of impingement and, in theory, results in little wear. Between February 2004 and March 2007 we implanted 100 consecutive total hip replacements with a metal-on-metal bearing and a large femoral head into 92 patients. There were 51 men and 41 women with a mean age of 50 years (18 to 70) at the time of surgery. Outcome was assessed using the Western Ontario McMaster University osteoarthritis index and the Harris hip score as well as the Devane activity score. These all improved significantly (p <
0.0001). At the last follow-up there were no cases of dislocation, no impingement, a good range of movement and no osteolysis, but seven revisions, two for infection and five for aseptic loosening. The probability of groin pain increased if the other acetabular component inclination exceeded 50° (p = 0.0007). At 4.8 years of follow-up, the projected survival of the Durom acetabular component, with revision for any reason, was 92.4% ( The design of the component made it difficult both to orientate and seat, which when combined with a poor porous coating, produced unpredictable fixation and a low survival at five years.
Based on the first implementation of mixing antibiotics
into bone cement in the 1970s, the Endo-Klinik has used one stage
exchange for prosthetic joint infection (PJI) in over 85% of cases.
Looking carefully at current literature and guidelines for PJI treatment,
there is no clear evidence that a two stage procedure has a higher
success rate than a one-stage approach. A cemented one-stage exchange
potentially offers certain advantages, mainly based on the need
for only one operative procedure, reduced antibiotics and hospitalisation time.
In order to fulfill a one-stage approach, there are obligatory pre-,
peri- and post-operative details that need to be meticulously respected,
and are described in detail. Essential pre-operative diagnostic
testing is based on the joint aspiration with an exact identification
of any bacteria. The presence of a positive bacterial culture and
respective antibiogram are essential, to specify the antibiotics
to be loaded to the bone cement, which allows a high local antibiotic
elution directly at the surgical side. A specific antibiotic treatment
plan is generated by a microbiologist. The surgical success relies
on the complete removal of all pre-existing hardware, including
cement and restrictors and an aggressive and complete debridement
of any infected soft tissues and bone material. Post-operative systemic
antibiotic administration is usually completed after only ten to
14 days. Cite this article:
Between 1985 and 2000, 120 patients underwent arthroscopic management for primary synovial chondromatosis of the hip. We report the outcome of 111 patients with a mean follow-up of 78.6 months (12 to 196). More than one arthroscopy was required in 23 patients (20.7%), and 42 patients (37.8%) went on to require open surgery. Outcomes were evaluated in greater detail in 69 patients (62.2%) treated with arthroscopy alone, of whom 51 (45.9%) required no further treatment and 18 (16.2%) required further arthroscopies. Of the 111 patients, 63 (56.7%) had excellent or good outcomes. At the most recent follow-up, 22 patients (19.8%) had undergone total hip replacement. Hip arthroscopy proved beneficial for patients diagnosed with primary synovial chondromatosis of the hip, providing good or excellent outcomes in more than half the cases.
We report a multicentre prospective consecutive
study assessing the long-term outcome of the proximally hydroxyapatite
(HA)-coated ABG II monobloc femoral component in a series of 1148
hips in 1053 patients with a mean age at surgery of 64.77 years
(22 to 80) at a mean follow-up of 10.84 years (10 to 15.25). At
latest follow-up, the mean total Harris hip score was 94.7 points
( Cite this article:
Hip arthroscopy is particularly attractive in
children as it confers advantages over arthrotomy or open surgery,
such as shorter recovery time and earlier return to activity. Developments
in surgical technique and arthroscopic instrumentation have enabled
extension of arthroscopy of the hip to this age group. Potential
challenges in paediatric and adolescent hip arthroscopy include
variability in size, normal developmental change from childhood to
adolescence, and conditions specific to children and adolescents
and their various consequences. Treatable disorders include the
sequelae of traumatic and sports-related hip joint injuries, Legg–Calve–Perthes’
disease and slipped capital femoral epiphysis, and the arthritic
and septic hip. Intra-articular abnormalities are rarely isolated and
are often associated with underlying morphological changes. This review presents the current concepts of hip arthroscopy
in the paediatric and adolescent patient, covering clinical assessment
and investigation, indications and results of the experience to
date, as well as technical challenges and future directions.
It is probable that both genetic and environmental
factors play some part in the aetiology of most cases of degenerative
hip disease. Geneticists have identified some single gene disorders
of the hip, but have had difficulty in identifying the genetics
of many of the common causes of degenerative hip disease. The heterogeneity
of the phenotypes studied is part of the problem. A detailed classification
of phenotypes is proposed. This study is based on careful documentation
of 2003 consecutive total hip replacements performed by a single
surgeon between 1972 and 2000. The concept that developmental problems
may initiate degenerative hip disease is supported. The influences
of gender, age and body mass index are outlined. Biomechanical explanations
for some of the radiological appearances encountered are suggested.
The body weight lever, which is larger than the abductor lever, causes
the abductor power to be more important than body weight. The possibility
that a deficiency in joint lubrication is a cause of degenerative
hip disease is discussed. Identifying the phenotypes may help geneticists
to identify genes responsible for degenerative hip disease, and
eventually lead to a definitive classification.
Cementless acetabular fixation has demonstrated superior long-term durability in total hip replacement, but most series have studied implants with porous metal surfaces. We retrospectively evaluated the results of 100 consecutive patients undergoing total hip replacement where a non-porous Allofit component was used for primary press-fit fixation. This implant is titanium alloy, grit-blasted, with a macrostructure of forged teeth and has a biradial shape. A total of 81 patients (82 hips) were evaluated at final follow-up at a mean of 10.1 years (8.9 to 11.9). The Harris Hip Score improved from a mean 53 points (23 to 73) pre-operatively to a mean of 96 points (78 to 100) at final review. The osseointegration of all acetabular components was radiologically evaluated with no evidence of loosening. The survival rate with revision of the component as the endpoint was 97.5% (95% confidence interval 94 to 100) after 11.9 years. Radiolucency was found in one DeLee-Charnley zone in four acetabular components. None of the implants required revision for aseptic loosening. Two patients were treated for infection, one requiring a two-stage revision of the implant. One femoral stem was revised for osteolysis due to the production of metal wear debris, but the acetabular shell did not require revision. This study demonstrates that a non-porous titanium acetabular component with adjunct surface fixation offers an alternative to standard porous-coated implants.
Between June 1991 and January 1995, 42 hydroxyapatite-coated CAD-CAM femoral components were inserted in 25 patients with inflammatory polyarthropathy, 21 of whom had juvenile idiopathic arthritis. Their mean age was 21 years (11 to 35). All the patients were reviewed clinically and radiologically at one, three and five years. At the final review at a mean of 11.2 years (8 to 13) 37 hips in 23 patients were available for assessment. A total of four femoral components (9.5%) had failed, of which two were radiologically loose and two were revised. The four failed components were in patients aged 16 years or less at the time of surgery. Hydroxyapatite-coated customised femoral components give excellent medium- to long-term results in skeletally-mature young adults with inflammatory polyarthropathy. Patients aged less than 16 years at the time of surgery have a risk of 28.5% of failure of the femoral component at approximately ten years.
A modular layered acetabular component (metal-polyethylene-ceramic) was developed in Japan for use in alumina ceramic-on-ceramic total hip replacement. Between May 1999 and July 2000, we performed 35 alumina ceramic-on-ceramic total hip replacements in 30 consecutive patients, using this layered component and evaluated the clinical and radiological results over a mean follow-up of 5.8 years (5 to 6.5). A total of six hips underwent revision, one for infection, two for dislocation with loosening of the acetabular component, two for alumina liner fractures and one for component dissociation with pelvic osteolysis. There were no fractures of the ceramic heads, and no loosening of the femoral or acetabular component in the unrevised hips was seen at final follow-up. Osteolysis was not observed in any of the unrevised hips. The survivorship analysis at six years after surgery was 83%. The layered acetabular component in our experience, has poor durability because of unexpected mechanical failures including alumina liner fracture and component dissociation.