The use of plate-and-cable constructs to treat periprosthetic fractures around a well-fixed femoral component in total hip replacements has been reported to have high rates of failure. Our aim was to evaluate the results of a surgical treatment algorithm to use these lateral constructs reliably in Vancouver type-B1 and type-C fractures. The joint was dislocated and the stability of the femoral component was meticulously evaluated in 45 type-B1 fractures. This led to the identification of nine (20%) unstable components. The fracture was considered to be suitable for single plate-and-cable fixation by a direct reduction technique if the integrity of the medial cortex could be restored. Union was achieved in 29 of 30 fractures (97%) at a mean of 6.4 months (3 to 30) in 29 type-B1 and five type-C fractures. Three patients developed an infection and one construct failed. Using this algorithm plate-and-cable constructs can be used safely, but indirect reduction with minimal soft-tissue damage could lead to shorter times to union and lower rates of complications.
A reduced femoral offset in total hip replacement has been thought to be disadvantageous. We reviewed the results of 54 consecutive primary total hip replacements in 49 patients (mean age of 68 years) performed between August 1990 and December 1994, with a mean follow-up of 8.8 years ( At their latest follow-up, surviving patients had a significant improvement in the performance of their hip. Three had undergone revision, one each for deep infection, recurrent dislocation and late pain with subluxation. No hips had been revised, or were at risk of revision, for aseptic loosening. The mean annual linear rate of wear was 0.2 mm (
We inserted an electrode up the femoral neck into the femoral head of ten patients undergoing a metal-on-metal hip resurfacing arthroplasty through a posterior surgical approach and measured the oxygen concentration during the operation. In every patient the blood flow was compromised during surgery, but the extent varied. In three patients, the oxygen concentration was zero at the end of the procedure. The surgical approach caused a mean 60% drop (p <
0.005) in oxygen concentration while component insertion led to a further 20% drop (p <
0.04). The oxygen concentration did not improve significantly on wound closure. This study demonstrates that during hip resurfacing arthroplasty, patients experience some compromise to their femoral head blood supply and some have complete disruption.
The Birmingham hip resurfacing metal-on-metal arthroplasty was introduced in 1997 and has shown promising short- to mid-term results. We used radiostereophotogrammetric analysis (RSA) to study the stability of 20 resurfacing arthroplasties over a follow-up period of 24 months. Radiological examinations for RSA were performed immediately after surgery and at two, six, 12 and 24 months after operation. Precision and detection of migration thresholds (non-zero movement) were calculated. All the results corresponded well to those found in similar experimental arrangements with standard hip prostheses. Migration of the cup and vertical and mediolateral migration of the head were calculated. The values were low at two years compared with those of earlier studies of cemented femoral components in conventional total hip replacements indicating that there was no evidence of excessive early migration or loosening of the components.
We describe the clinical and radiological results of 120 consecutive revision hip replacements in 107 patients, using the JRI Furlong hydroxyapatite-ceramic-coated femoral component. The mean age of the patients at operation was 71 years (36 to 92) and the mean length of follow-up 8.0 years (5.0 to 12.4). We included patients on whom previous revision hip surgery had taken place. The patients were independently reviewed and scored using the Harris hip score, the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) and the Charnley modification of the Merle d’Aubigné and Postel score. Radiographs were assessed by three reviewers for the formation of new bone, osteolysis, osseointegration and radiolucent lines in each Gruen zone. The mean Harris hip score was 85.8 (42 to 100) at the latest post-operative review. The mean WOMAC and Merle d’Aubigné and Postel scores were 34.5 and 14.8, respectively. The mean visual analogue score for pain (possible range 0 to 10) was 1.2 overall, but 0.5 specifically for mid-thigh pain. There were no revisions of the femoral component for aseptic loosening. There were four re-revisions, three for infection and one for recurrent dislocation. Radiological review of all the femoral components, including the four re-revisions showed stable bony ingrowth and no new radiolucent lines in any zone. Using revision or impending revision for aseptic loosening as an end-point, the cumulative survival of the femoral component at ten years was 100% (95% confidence interval 94 to 100). We present excellent medium- to long-term clinical, radiological and survivorship results with the fully hydroxyapatite-ceramic-coated femoral component in revision hip surgery.
Metal meshes are used in revision surgery of the hip to contain impacted bone grafts in cases with cortical or calcar defects in order to provide rotational stability to the stem. However, the viability of bone allografts under these metal meshes has been uncertain. We describe the histological appearances of biopsies obtained from impacted bone allografts to the calcar contained by a metal mesh in two femoral reconstructions which needed further surgery at 24 and 33 months after the revision procedure. A line of osteoid and viable new bone was observed on the surface of necrotic trabeculae. Active bone marrow between these trabeculae showed necrotic areas in some medullary spaces with reparative fibrous tissue and isolated reactive lymphocytes. This is interpreted as reparative changes after revascularisation of the cancellous allografts. These pathological findings are similar to those reported in allografts contained by cortical host bone and support the hypothesis that incorporation of morcellised bone under metal meshes is not affected by these devices.
We investigated whether simultaneous bilateral sequential total hip replacement (THR) would increase the rate of mortality and complications compared with unilateral THR in both low- and high-risk groups of patients. We enrolled 978 patients with bilateral and 1666 with unilateral THR in the study. There were no significant pre-operative differences between the groups in regard to age, gender, body mass index, diagnosis, comorbidity as assessed by the grading of the American Society of Anesthesiologists (ASA), the type of prosthesis and the duration of follow-up. The mean follow-up was for 10.5 years (5 to 13) in the bilateral THR group and 9.8 years (5 to 14) in the unilateral group. The peri-operative mortality rate of patients who had simultaneous bilateral THR (0.31%, three of 978 patients) was similar to that of patients with unilateral THR (0.18%, three of 1666 patients). The peri-operative mortality rate of patients in the bilateral group was similar in high risk and low risk patients (0.70%, two of 285 patients vs 0.14%, one of 693 patients) and this was also true in the unilateral THR group (0.40%, two of 500 patients vs 0.09%, one of 1166 patients). Patients with bilateral THR required more blood transfusions and a longer hospital stay than those in the unilateral THR group. There was no significant difference (p = 0.32) in the overall number of complications between the groups. This was also true for the low-risk (p = 0.81) vs high-risk (p = 0.631) patients. Our findings confirm that simultaneous sequential bilateral THR is a safe option for patients who are considered to be either high or low risk according to the ASA classification.
We review the treatment of pelvic Ewing’s sarcoma by the implantation of extracorporeally-irradiated (ECI) autografts and compare the outcome with that of other reported methods. We treated 13 patients with ECI autografts between 1994 and 2004. There were seven males and six females with a median age of 15.7 years (interquartile range (IQR) 12.2 to 21.7). At a median follow-up of five years (IQR 1.8 to 7.4), the disease-free survival was 69% overall, and 75% if one patient with local recurrence after initial treatment elsewhere was excluded. Four patients died from distant metastases at a mean of 17 months (13 to 23). There were three complications which required operative intervention; one was a deep infection which required removal of the graft. The functional results gave a mean Musculoskeletal Tumor Society score of 85% (60% to 97%), a mean Toronto extremity salvage score of 86% (69% to 100%) and a mean Harris hip score of 92 (67 to 100). We conclude that ECI grafting is a suitable form of treatment for localised and resectable pelvic Ewing’s sarcoma.
The aim of this prospective single-centre study
was to assess the difference in clinical outcome between total knee replacement
(TKR) using computerised navigation and that of conventional TKR.
We hypothesised that navigation would give a better result at every
stage within the first five years. A total of 195 patients (195
knees) with a mean age of 70.0 years (39 to 89) were allocated alternately
into two treatment groups, which used either conventional instrumentation
(group A, 97 knees) or a navigation system (group B, 98 knees).
After five years, complete clinical scores were available for 121
patients (62%). A total of 18 patients were lost to follow-up. Compared
with conventional surgery, navigated TKR resulted in a better mean
Knee Society score (p = 0.008). The difference in mean Knee Society
scores over time between the two groups was not constant (p = 0.006),
which suggests that these groups differed in their response to surgery
with time. No significant difference in the frequency of malalignment
was seen between the two groups. In summary, computerised navigation resulted in a better functional
outcome at five years than conventional techniques. Given the similarity
in mechanical alignment between the two groups, rotational alignment
may prove to be a better method of identifying differences in clinical
outcome after navigated surgery.
In skeletally immature patients, resection of
bone tumours and reconstruction of the lower limb often results
in leg-length discrepancy. The Stanmore non-invasive extendible
endoprosthesis, which uses electromagnetic induction, allows post-operative
lengthening without anaesthesia. Between 2002 and 2009, 55 children
with a mean age of 11.4 years (5 to 16) underwent reconstruction
with this prosthesis; ten patients (18.2%) died of disseminated
disease and one child underwent amputation due to infection. We
reviewed 44 patients after a mean follow-up of 41.2 months (22 to
104). The mean Musculoskeletal Tumor Society score was 24.7 (8 to
30) and the Toronto Extremity Salvage score was 92.3% (55.2% to
99.0%). There was no local recurrence of tumour. Complications developed
in 16 patients (29.1%) and ten (18.2%) underwent revision. The mean length gained per patient was 38.6 mm (3.5 to 161.5),
requiring a mean of 11.3 extensions (1 to 40), and ten component
exchanges were performed in nine patients (16.4%) after attaining
the maximum lengthening capacity of the implant. There were 11 patients
(20%) who were skeletally mature at follow-up, ten of whom had equal
leg lengths and nine had a full range of movement of the hip and
knee. This is the largest reported series using non-invasive extendible
endoprostheses after excision of primary bone tumours in skeletally
immature patients. The technique produces a good functional outcome,
with prevention of limb-length discrepancy at skeletal maturity.
The removal of all prosthetic material and a
two-stage revision procedure is the established standard management of
an infected total hip replacement (THR). However, the removal of
well-fixed femoral cement is time-consuming and can result in significant
loss of bone stock and femoral shaft perforation or fracture. We
report our results of two-stage revision THR for treating infection,
with retention of the original well-fixed femoral cement mantle
in 15 patients, who were treated between 1989 and 2002. Following
partial excision arthroplasty, patients received local and systemic
antibiotics and underwent reconstruction and re-implantation at
a second-stage procedure, when the infection had resolved. The mean follow-up of these 15 patients was 82 months (60 to
192). Two patients had positive microbiology at the second stage
and were treated with six weeks of appropriate antibiotics; one
of these developed recurrent infection requiring further revision.
Successful eradication of infection was achieved in the remaining
14 patients. We conclude that when two-stage revision is used for the treatment
of peri-prosthetic infection involving a THR, a well-fixed femoral
cement mantle can be safely left
A 70-year-old man with an uncemented metal-on-polyethylene
total hip prosthesis underwent revision arthroplasty 33 months later
because of pain, swelling and recurrent dislocation. There appeared
to be corrosion and metal release from the prosthetic head, resulting
in pseudotumour formation and severe local soft-tissue destruction.
The corrosion occurred at the junction between the titanium-molybdenum-zirconium-iron
taper and the cobalt-chrome-molybdenum head, but the mechanism was unproven.
We report the long-term results of revision total
hip replacement using femoral impaction allografting with both uncemented
and cemented Freeman femoral components. A standard design of component
was used in both groups, with additional proximal hydroxyapatite
coating in the uncemented group. A total of 33 hips in 30 patients received
an uncemented component and 31 hips in 30 patients a cemented component.
The mean follow-up was 9.8 years (2 to 17) in the uncemented group
and 6.2 years (1 to 11) in the cemented group. Revision procedures
(for all causes) were required in four patients (four hips) in the
uncemented group and in five patients (five hips) in the cemented
group. Harris hip scores improved significantly in both groups and
were maintained independently of the extent of any migration of
the femoral component within the graft or graft–cement mantle.
Bleeding is a major complication of revision total hip replacement. We report a case where the inflated balloon of a urinary catheter was used to temporarily control intrapelvic bleeding from the superior gluteal artery, while definitive measures for endovascular embolisation were made.
This editorial considers the shortcomings of assessing outcome after joint replacement only by the survival of the implant.
Peripheral nerve injury is an uncommon but serious
complication of hip surgery that can adversely affect the outcome.
Several studies have described the use of electromyography and intra-operative
sensory evoked potentials for early warning of nerve injury. We
assessed the results of multimodal intra-operative monitoring during
complex hip surgery. We retrospectively analysed data collected
between 2001 and 2010 from 69 patients who underwent complex hip
surgery by a single surgeon using multimodal intra-operative monitoring
from a total pool of 7894 patients who underwent hip surgery during
this period. In 24 (35%) procedures the surgeon was alerted to a
possible lesion to the sciatic and/or femoral nerve. Alerts were
observed most frequently during peri-acetabular osteotomy. The surgeon
adapted his approach based on interpretation of the neurophysiological changes.
From 69 monitored surgical procedures, there was only one true positive
case of post-operative nerve injury. There were no false positives
or false negatives, and the remaining 68 cases were all true negative.
The sensitivity for predicting post-operative nerve injury was 100%
and the specificity 100%. We conclude that it is possible and appropriate
to use this method during complex hip surgery and it is effective
for alerting the surgeon to the possibility of nerve injury.
We report a case of spontaneous physeal growth arrest of the distal femur in a nine-year-old child with Ewing’s sarcoma of the proximal femur treated with chemotherapy and endoprosthetic replacement. Owing to the extent of disuse osteoporosis at the time of surgery, the entire intramedullary canal up to the distal femoral physis was filled with cement. Three years later, the femur remained at its pre-operative length of 19 cm. Pre-operative calculations of further growth failed to account for the growth arrest, and the initial expandable growing prosthesis inserted has been revised to a longer one in order to address the leg-length discrepancy. To our knowledge, this is the only reported case of distal femoral physeal growth arrest following cemented endoprosthetic replacement of the proximal femur.