Revision total hip arthroplasty (THA) is challenging
when there is severe loss of bone in the proximal femur. The purpose
of this study was to evaluate the clinical and radiographic outcomes
of revision THA in patients with severe proximal femoral bone loss
treated with a fluted, tapered, modular femoral component. Between
January 1998 and December 2004, 92 revision THAs were performed
in 92 patients using a single fluted, tapered, modular femoral stem
design. Pre-operative diagnoses included aseptic loosening, infection
and peri-prosthetic fracture. Bone loss was categorised pre-operatively
as Paprosky types III-IV, or Vancouver B3 in patients with a peri-prosthetic
fracture. The mean clinical follow-up was 6.4 years (2 to 12). A
total of 47 patients had peri-operative complications, 27 of whom
required further surgery. However, most of these further operations
involved retention of a well-fixed femoral stem, and 88/92 femoral
components (97%) remained Revision THA in patients with extensive proximal femoral bone
loss using the Link MP fluted, tapered, modular stem led to a high
rate of osseointegration of the stem at mid-term follow-up. Cite this article:
We reviewed 123 second-generation uncemented total hip replacements performed on 115 patients by a single surgeon between 1993 and 1994. The acetabular component used in all cases was a fully porous-coated threaded hemispheric titanium shell (T-Tap ST) with a calcium ion stearate-free, isostatically compression-moulded polyethylene liner. The titanium femoral component used was a Taperloc with a reduced distal stem. No patient was lost to follow-up. Complete clinical and radiological follow-up was obtained for all 123 hips at a mean of 14 years (12 to 16). One femoral component was revised after a fracture, and three acetabular components for aseptic loosening. No additional femoral or acetabular components were judged loose by radiological criteria. Mild proximal femoral osteolysis was identified in two hips and minor acetabular osteolysis was present in four. The mean rate of penetration of the femoral head was 0.036 mm/year (0.000 to 0.227). These findings suggest that refinements in component design may be associated with excellent long-term fixation in cementless primary total hip replacement.
We conducted a multicentre cohort study of 228 patients with osteoarthritis followed up after total hip or knee replacement. Quality of life and patient satisfaction were assessed by self-administered questionnaires. Patient satisfaction was the dependent variable in a multivariate linear regression model. Independent variables included sociodemographic factors, pre- and post-operative clinical characteristics and the pre-operative and post-discharge health-related quality of life. The mean age of the patients was 69 years ( The pre-operative health-related quality of life and patient characteristics have little effect on inpatient satisfaction with care. This suggests that the impact of the care process on satisfaction may be independent of observed and perceived initial patient-related characteristics.
The December 2014 Hip &
Pelvis Roundup360 looks at: Sports and total hips; topical tranexamic acid and blood conservation in hip replacement; blind spots and biases in hip research; no recurrence in cam lesions at two years; to drain or not to drain?; sonication and diagnosis of implant associated infection; and biomarkers and periprosthetic infection
The common recommended treatment for infected
total hip replacement is two-staged exchange including removal of
all components. However, removal of well-fixed femoral stems can
result in structural bone damage. We recently reported on an alternative
treatment of partial two-stage exchange used in selected cases,
in which a well-fixed femoral stem was left and only the acetabular
component removed, the joint space was debrided thoroughly, an antibiotic-laden
polymethylmethacrylate spacer was moulded using a bulb-type syringe
and placed in the acetabulum, intravenous antibiotics were administered
during the interval, and delayed re-implantation was performed.
In 19 patients treated with this technique from January 2000 to
January 2011, 89% were free of infection at a mean follow-up of
four years (2 to 11). Since then, disposable silicone moulds have
become available to fabricate spacers in separate femoral and head
units. The head spacer mould, which incorporates various neck taper adapter
options, greatly facilitates the technique of partial two-stage
exchange. We report our early experience using disposable silicone
head spacer moulds for partial two-stage exchange in seven patients
with infected primary hip replacements. Cite this article:
The June 2012 Hip &
Pelvis Roundup360 looks at: whether metal-on-metal is really such a disaster; resurfacings with unexplained pain; large heads and high ion levels; hip arthroscopy for FAI; the inaccuracy of clinical tests for impingement; arthroscopic lengthening of iliopsoas; the OA hip; the injured hamstring – football’s most common injury; an algorithm for hip fracture surgery; and sparing piriformis at THR.
Non-modular tapered fluted, titanium stems are
available for use in femoral revision. The combination of taper
and flutes on the stem provides axial and rotational stability,
respectively. The material and surface properties of the stem promotes
bone on-growth. If the surgeon is confident and reasonably experienced
in the surgical use of this sort of design and the case is relatively
straightforward, a non-modular design is effective. It also potentially reduces
implant inventory, and circumvents the potential problems of taper
junction corrosion and fatigue fracture. There are reports of excellent
survival, good clinical and functional results and evidence of subsequent
increase in proximal bone stock. Cite this article: Bo
We investigated the incidence of soft-tissue
lesions after small head metal-on-metal total hip replacement (MoM THR).
Between December 1993 and May 1999, 149 patients (195 hips) underwent
primary cementless MoM THR. During the follow-up period, three patients (five THRs) died
and eight patients (14 THRs) were lost to follow-up. We requested
that all patients undergo CT evaluation. After exclusion of five
patients (six THRs) who had undergone a revision procedure, and
22 (28 THRs) who were unwilling to take part in this study, 111
patients (142 THRs) were evaluated. There were 63 men (88 THRs)
and 48 women (54 THRs) with a mean age of 45.7 years (37 to 56)
at the time of surgery. The mean follow-up was 15.4 years (13 to
19). A soft-tissue lesion was defined as an abnormal peri-prosthetic
collection of fluid, solid lesion or asymmetrical soft-tissue mass. At final follow-up, soft-tissue lesions were found in relation
to 28 THRs (19.7%), including 25 solid and three cystic lesions.
They were found in 20 men and eight women; 26 lesions were asymptomatic
and two were symptomatic. The mean maximal diameter of the soft-tissue
lesion was 42.3 mm (17 to 135). The relatively high rate of soft-tissue lesions
observed with small head MoM THR remains a concern. Cite this article:
Intertrochanteric osteotomy may postpone the need for total hip replacement (THR). In young patients with an acquired deformity of the femoral head and secondary osteoarthritis, a valgus intertrochanteric osteotomy may allow better congruency but the acetabular cover may become insufficient because of subluxation of the femoral head. In patients with a spherical femoral head and acetabular dysplasia, cover can still remain insufficient after varus displacement osteotomy. We present the long-term results of intertrochanteric osteotomy combined with an acetabular shelfplasty in both these circumstances. Sixteen hips (15 patients) with a deformed femoral head, and ten (seven patients) with a spherical femoral head, underwent an intertrochanteric osteotomy and acetabular shelfplasty. The mean age at the time of surgery was 30 and 37 years and the mean final follow-up was 15 and 19 years, respectively. Six patients in the deformed group, but only one in the spherical group, had required a THR by the time of their final follow-up. In both groups, those who had not undergone a THR had a good result. Acetabular shelfplasty is an excellent addition to an intertrochanteric osteotomy and gives full cover of the femoral head in patients with a deformity of the head and secondary osteoarthritis.
There is a high risk of the development of avascular
necrosis of the femoral head and nonunion after the treatment of
displaced subcapital fractures of the femoral neck in patients aged
<
50 years. We retrospectively analysed the results following
fixation with two cannulated compression screws and a vascularised
iliac bone graft. We treated 18 women and 16 men with a mean age
of 38.5 years (20 to 50) whose treatment included the use of an
iliac bone graft based on the ascending branch of lateral femoral
circumflex artery. There were 20 Garden grade III and 14 grade IV
fractures. Clinical and radiological outcomes were evaluated. The
mean follow-up was 5.4 years (2 to 10). In 30 hips (88%) union was
achieved at a mean of 4.4 months (4 to 6). Nonunion occurred in
four hips (12%) and these patients had a mean age of 46.5 years
(42 to 50) and underwent revision to a hip replacement six months
after operation. The time to union was dependent on age with younger
patients achieving earlier union (p <
0.001). According to the
Harris hip score which was available for 27 of the 30 hips with
satisfactory union, excellent results were obtained in 15 (score ≥ 90
points), fair in ten (score 80 to 90 points), and poor in two hips
(≤ 80 points). One patient aged 48 years developed avascular necrosis
of femoral head six years after operation and underwent total hip
replacement. The management of displaced subcapital fractures of the femoral
neck, in patients aged <
50 years, with two cannulated compression
screws and an iliac bone graft based on the ascending branch of
lateral femoral circumflex artery, gives satisfactory results with
a low rate of complication including avascular necrosis and nonunion. Cite this article:
Peri-prosthetic bone loss caused by stress shielding may be associated with aseptic loosening of femoral components. In order to increase primary stability and to reduce stress shielding, a three-dimensional, cementless individual femoral (Evolution K) component was manufactured using pre-operative CT scans. Using dual energy x-ray absorptiometry, peri-prosthetic bone density was measured in 43 patients, three months, six months, 3.6 and 4.6 years after surgery. At final follow-up there was a significant reduction in mean bone density in the proximal Gruen zones of −30.3% (zone 7) and −22.8% (zone 1). The density in the other zones declined by a mean of between −4% and −16%. We conclude that the manufacture of a three-dimensional, custom-made femoral component could not prevent a reduction in peri-prosthetic bone density.
The technical advances in arthroscopic surgery
of the hip, including the improved ability to manage the capsule
and gain extensile exposure, have been paralleled by a growth in
the number of conditions that can be addressed. This expanding list
includes symptomatic labral tears, chondral lesions, injuries of
the ligamentum teres, femoroacetabular impingement (FAI), capsular
laxity and instability, and various extra-articular disorders, including snapping
hip syndromes. With a careful diagnostic evaluation and technical
execution of well-indicated procedures, arthroscopic surgery of
the hip can achieve successful clinical outcomes, with predictable
improvements in function and pre-injury levels of physical activity
for many patients. This paper reviews the current position in relation to the use
of arthroscopy in the treatment of disorders of the hip. Cite this article:
The August 2014 Hip &
Pelvis Roundup360 looks at: Serial MRIs best for pseudotumour surveillance; Is ultrasound good enough for MOM follow-up?; Does weight loss in obese patients help?; Measuring acetabular anteversion on plain films; Two-stage one-stage too many in fungal hip revisions? and 35 is the magic number in arthroplasty.
The treatment of substantial proximal femoral
bone loss in young patients with developmental dysplasia of the
hip (DDH) is challenging. We retrospectively analysed the outcome
of 28 patients (30 hips) with DDH who underwent revision total hip
replacement (THR) in the presence of a deficient proximal femur,
which was reconstructed with an allograft prosthetic composite.
The mean follow-up was 15 years (8.5 to 25.5). The mean number of
previous THRs was three (1 to 8). The mean age at primary THR and
at the index reconstruction was 41 years (18 to 61) and 58.1 years
(32 to 72), respectively. The indication for revision included mechanical
loosening in 24 hips, infection in three and peri-prosthetic fracture
in three. Six patients required removal and replacement of the allograft
prosthetic composite, five for mechanical loosening and one for
infection. The survivorship at ten, 15 and 20 years was 93% (95%
confidence interval (CI) 91 to 100), 75.5% (95% CI 60 to 95) and
75.5% (95% CI 60 to 95), respectively, with 25, eight, and four
patients at risk, respectively. Additionally, two junctional nonunions
between the allograft and host femur required bone grafting and
plating. An allograft prosthetic composite affords a good long-term outcome
in the management of proximal femoral bone loss in revision THR
in patients with DDH, while preserving distal host bone.
The October 2014 Hip &
Pelvis Roundup360 looks at: functional acetabular orientation; predicting re-admission following THR; metal ions and resurfacing; lipped liners increase stability; all anaesthetics equal in hip fracture surgery; revision hip surgery in very young patients; and uncemented hips.
This review examines the future of total hip arthroplasty, aiming to avoid past mistakes
We describe the clinical and radiological results
of cementless primary total hip replacement (THR) in 25 patients
(18 women and seven men; 30 THRs) with severe developmental dysplasia
of the hip (DDH). Their mean age at surgery was 47 years (23 to
89). In all, 21 hips had Crowe type III dysplasia and nine had Crowe
type IV. Cementless acetabular components with standard polyethylene
liners were introduced as close to the level of the true acetabulum
as possible. The modular cementless S-ROM femoral component was
used with a low resection of the femoral neck. A total of 21 patients (25 THRs) were available for review at
a mean follow-up of 18.7 years (15.8 to 21.8). The mean modified
Harris hip score improved from 46 points pre-operatively to 90 at
final follow up (p <
0.001). A total of 15 patients (17 THRs; 57%) underwent revision of the
acetabular component at a mean of 14.6 years (7 to 20.8), all for
osteolysis. Two patients (two THRs) had symptomatic loosening. No
patient underwent femoral revision. Survival with revision of either
component for any indication was 81% at 15 years (95% CI 60.1 to
92.3), with 21 patients at risk. This technique may reduce the need for femoral osteotomy in severe
DDH, while providing a good long-term functional result. Cite this article:
We report the clinical and radiological outcome of 86 revisions of cemented hip arthroplasties using JRI-Furlong hydroxyapatite-ceramic-coated acetabular and femoral components. The acetabular component was revised in 62 hips and the femoral component in all hips. The mean follow-up was 12.6 years and no patient was lost to follow-up. The mean age of the patients was 71.2 years. The mean Harris hip and Oxford scores were 82 (59 to 96) and 23.4 (14 to 40), respectively. The mean Charnley modification of the Merle d’Aubigné and Postel score was 5 (3 to 6) for pain, 4.9 (3 to 6) for movement and 4.4 (3 to 6) for mobility. Migration of the acetabular component was seen in two hips and the mean acetabular inclination was 42.6°. The mean linear polyethylene wear was 0.05 mm/year. The mean subsidence of the femoral component was 1.9 mm and stress shielding was seen in 23 (28%) with bony ingrowth in 76 (94%). Heterotopic ossification was seen in 12 hips (15%). There were three re-revisions, two for deep sepsis and one for recurrent dislocation and there were no re-revisions for aseptic loosening. The mean EuroQol EQ-5D description scores and health thermometer scores were 0.69 (0.51 to 0.89) and 79 (54 to 95), respectively. With an end-point of definite or probable loosening, the probability of survival at 12 years was 93.9% and 95.6% for the acetabular and femoral components, respectively. Overall survival at 12 years, with removal or further revision of either component for any reason as the end-point, was 92.3%. Our study supports the continued use of this arthroplasty and documents the durability of hydroxyapatite-ceramic-coated components.
Obesity is a global epidemic of 2.1 billion people and a well known cause of osteoarthritis. Joint replacement in the obese attracts more complications, poorer outcomes and higher revision rates. It is a reversible condition and the fundamental principles of dealing with reversible medical conditions prior to elective total joint replacement should apply to obesity. The dilemma for orthopaedic surgeons is when to offer surgery in the face of a reversible condition, which if treated may obviate joint replacement and reduce the risk and severity of obesity related disease in both the medical arena and the field of orthopaedics.
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.