Orthopaedic outcome measures are used to evaluate the effect of operative interventions. They are used for audit and research. Knowledge of these measures is becoming increasingly important with league tables comparing surgeons and hospitals being made accessible to the profession and the general public. Several types of tool are available to describe outcome after hip surgery such as generic quality-of-life questionnaires, disease-specific quality-of-life questionnaires, hip-specific outcome measures and general short-term clinical measures. We provide an overview of the outcome measures commonly used to evaluate hip interventions.
Evaluation of patients with painful total knee replacement requires a thorough clinical examination and relevant investigations in order to reach a diagnosis. Awareness of the common and uncommon problems leading to painful total knee replacement is useful in the diagnostic approach. This review article aims to act as a guide to the evaluation of patients with painful total knee replacement.
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.
We carried out metal artefact-reduction MRI, three-dimensional CT measurement of the position of the component and inductively-coupled plasma mass spectrometry analysis of cobalt and chromium levels in whole blood on 26 patients with unexplained pain following metal-on-metal resurfacing arthroplasty. MRI showed periprosthetic lesions around 16 hips, with 14 collections of fluid and two soft-tissue masses. The lesions were seen in both men and women and in symptomatic and asymptomatic hips. Using three-dimensional CT, the median inclination of the acetabular component was found to be 55° and its positioning was outside the Lewinnek safe zone in 13 of 16 cases. Using inductively-coupled plasma mass spectrometry, the levels of blood metal ions tended to be higher in painful compared with well-functioning metal-on-metal hips. These three clinically useful investigations can help to determine the cause of failure of the implant, predict the need for future revision and aid the choice of revision prostheses.
This is a longitudinal study of the daily urinary output and the concentrations in whole blood of cobalt and chromium in patients with metal-on-metal resurfacings over a period of four years. Twelve-hour urine collections and whole blood specimens were collected before and periodically after a Birmingham hip resurfacing in 26 patients. All ion analyses were carried out using a high-resolution inductively-coupled plasma mass spectrometer. Clinical and radiological assessment, hip function scoring and activity level assessment revealed excellent hip function. There was a significant early increase in urinary metal output, reaching a peak at six months for cobalt and one year for chromium post-operatively. There was thereafter a steady decrease in the median urinary output of cobalt over the following three years, although the differences are not statistically significant. The mean whole blood levels of cobalt and chromium also showed a significant increase between the pre-operative and one-year post-operative periods. The blood levels then decreased to a lower level at four years, compared with the one-year levels. This late reduction was statistically significant for chromium but not for cobalt. The effects of systemic metal ion exposure in patients with metal-on-metal resurfacing arthroplasties continue to be a matter of concern. The levels in this study provide a baseline against which the
We describe the survivorship of the Exeter femoral component in a District General Hospital. Between 1994 and 1996, 230 Exeter Universal cemented femoral components were implanted in 215 patients who were reviewed at a mean of 11.2 years (10 to 13). We used one acetabular implant, the Elite Ogee component, in 218 of the 230 hips. During the period of this study 76 patients (79 hips) died. Of the remaining 139 patients (151 hips), 121 were able to attend for radiological analysis at a minimum of ten years. One patient was lost to follow-up. No femoral component was revised for aseptic loosening. Three hips were revised for deep infection and six acetabular components required revision, four for loosening and two for recurrent dislocation. Taking the ‘worst-case scenario’ including the one patient lost to follow-up, the overall survival rate was 94.4% at 13 years. Our results confirm excellent medium-term results for the Exeter Universal femoral component, implanted in a general setting. The excellent survival of this femoral component, when used in combination with the Ogee acetabular component, suggests that this is a successful pairing.
Arthritis of the hip in the young adult can be a disabling condition. Recent years have witnessed extensive research related to the management of this condition. This article reviews the current status with regard to aetiology, diagnosis and treatment of arthritis of the hip in the young adult.
We report a case of osteonecrosis of the femoral head in a young man who is a carrier of the prothrombin gene mutation. We suggest that an electrical injury to his lower limb may have triggered intravascular thrombosis as a result of this mutation with subsequent osteonecrosis of the femoral head. No case of osteonecrosis of the femoral head secondary to a distant electrical injury has previously been reported.
We present the medium-term results of hybrid total hip arthroplasties using pre-coated stems with a second-generation cementing technique. The 128 hips in 111 patients (18 men and 93 women) were followed up at a mean of 11 years after surgery. The mean age at the time of surgery was 61 years. Both components of one hip were removed at ten months after surgery for infection. None of the other 127 femoral components showed possible, probable, or definite loosening at the most recent follow-up. Five acetabular components were revised for aseptic loosening, recurrent dislocation, or displacement of the polyethylene liner from the metal shell. The mean Harris hip score at follow-up was 84 points. A pre-coated femoral component with a second-generation cementing technique provides good clinical function and survival in the medium term.
Sacral insufficiency fractures are traditionally treated with bed rest and analgesia. The importance of early rehabilitation is generally appreciated; but pain frequently delays this, resulting in prolonged hospital stay and the risk of complications related to immobility. We describe three women with sacral insufficiency fractures who were treated with percutaneous sacroiliac screws and followed up for a mean of 18 months (12 to 24). They had immediate pain relief, uncomplicated rehabilitation and uneventful healing.
The practice of regular radiological follow-up of infants with a positive family history of developmental dysplasia of the hip is based on the widespread belief that primary acetabular dysplasia is a genetic disorder which can occur in the absence of frank subluxation or dislocation. We reviewed all infants who were involved in our screening programme for developmental dysplasia of the hip, between November 2002 and January 2004, and who had a normal clinical and ultrasound examination of the hip at six to eight weeks of age, but who, because of a family history of developmental dysplasia of the hip, had undergone further radiography after an interval of 6 to 12 months. The radiographs of 89 infants were analysed for signs of late dysplasia of the hip and assessed independently by three observers to allow for variability of measurement. There were 11 infants (11%) lost to follow-up. All the patients had normal radiographs at the final follow-up and none required any intervention. We therefore question the need for routine radiological follow-up of infants with a positive family history of developmental dysplasia of the hip, but who are normal on clinical examination and assessment by ultrasound screening when six to eight weeks old.
This study validates the short-form WOMAC function scale for assessment of conservative treatment of osteoarthritis of the knee. Data were collected before treatment and six and nine months later, from 100 patients with osteoarthritis of the knee to determine the validity, internal consistency, test-retest reliability, floor and ceiling effects, and responsiveness of the short-form WOMAC function scale. The scale showed high correlation with the traditional WOMAC and other measures. The internal consistency was good (Cronbach α: 0.88 to 0.95) and an excellent test-retest reliability was found (Lin’s concordance correlation coefficient (ρc): 0.85 to 0.94). The responsiveness was adequate and comparable to that of the traditional WOMAC (standardised response mean 0.56 to 0.44 and effect size 0.64 to 0.57) and appeared not to be significantly affected by floor or ceiling effects (0% and 7%, respectively). The short-form WOMAC function scale is a valid, reliable and responsive alternative to the traditional WOMAC in the evaluation of patients with osteoarthritis of the knee managed conservatively. It is simple to use in daily practice and is therefore less of a burden for patients in clinical trials.
This is a retrospective case review of 237 patients with displaced fractures of the acetabulum presenting over a ten-year period, with a minimum follow-up of two years, who were studied to test the hypothesis that the time to surgery was predictive of radiological and functional outcome and varied with the pattern of fracture. Patients were divided into two groups based on the fracture pattern: elementary or associated. The time to surgery was analysed as both a continuous and a categorical variable. The primary outcome measures were the quality of reduction and functional outcome. Logistic regression analysis was used to test our hypothesis, while controlling for potential confounding variables. For elementary fractures, an increase in the time to surgery of one day reduced the odds of an excellent/good functional result by 15% (p = 0.001) and of an anatomical reduction by 18% (p = 0.0001). For associated fractures, the odds of obtaining an excellent/good result were reduced by 19% (p = 0.0001) and an anatomical reduction by 18% (p = 0.0001) per day. When time was measured as a categorical variable, an anatomical reduction was more likely if surgery was performed within 15 days (elementary) and five days (associated). An excellent/good functional outcome was more likely when surgery was performed within 15 days (elementary) and ten days (associated). The time to surgery is a significant predictor of radiological and functional outcome for both elementary and associated displaced fractures of the acetabulum. The organisation of regional trauma services must be capable of satisfying these time-dependent requirements to achieve optimal patient outcomes.
We wished to establish whether delivery by Caesarean section influenced the incidence of developmental dysplasia of the hip in term breech infants compared with those delivered vaginally. We used maternal charts, singleton term breech presentation, mode of delivery and incidence of developmental dysplasia of the hip for births between January 1997 and October 2002. During the study period 46 089 infants were born. We analysed a total of 941 breech infants of whom 756 were delivered by Caesarean section (515 pre-labour, 241 intrapartum) and 185 vaginally. The incidence of developmental dysplasia of the hip according to the mode of delivery was 19 of 515 (3.69%) following pre-labour Caesarean section, 16 of 241 (6.64%) for intrapartum Caesarean section and 15 of 185 (8.11%) after vaginal delivery. There was a lower incidence of developmental dysplasia of the hip among those infants delivered by elective Caesarean section compared with those delivered vaginally (p <
0.02). These results demonstrate a significantly lower incidence of developmental dysplasia of the hip in term singleton breech births delivered by elective, pre-labour Caesarean section and suggest that labour and delivery influence hip stability in predisposed infants.
We compared the five- to seven-year clinical and radiological results of the metal-on-metal Birmingham hip resurfacing with a hybrid total hip arthroplasty in two groups of 54 hips, matched for gender, age, body mass index and activity level. Function was excellent in both groups, as measured by the Oxford hip score, but the Birmingham hip resurfacings had higher University of California at Los Angeles activity scores and better EuroQol quality of life scores. The total hip arthroplasties had a revision or intention-to-revise rate of 8%, and the Birmingham hip resurfacings of 6%. Both groups demonstrated impending failure on surrogate end-points. Of the total hip arthroplasties, 12% had polyethylene wear and osteolysis under observation, and 8% of Birmingham hip resurfacings showed migration of the femoral component. Polyethylene wear was present in 48% of the hybrid hips without osteolysis. Of the femoral components in the Birmingham hip resurfacing group which had not migrated, 66% had radiological changes of unknown significance.
We report the survival at five years of 144 consecutive metal-on-metal resurfacings of the hip implanted between August 1997 and May 1998. Failure was defined as revision of either the acetabular or femoral component for any reason during the study period. The survival at the end of five years was 98% overall and 99% for aseptic revisions only. The mean age of the patients at implantation was 52.1 years. Three femoral components failed during the first two years, two were infected and one fractured. A single stage revision was carried out in each case. No other revisions were performed or are impending. No patients were lost to follow-up. Four died from unrelated causes during the study period. This study confirms that hip resurfacing using a metal-on-metal bearing of known provenance can provide a solution in the medium term for the younger more active adult who requires surgical intervention for hip disease.
There remains uncertainty about the most effective surgical approach in the treatment of complex fractures of the acetabulum. We have reviewed the experience of a single surgeon using the extended iliofemoral approach, as described by Letournel. A review of the database of such fractures identified 106 patients operated on using this approach with a minimum follow-up of two years. All data were collected prospectively. The fractures involved both columns in 64 (60%). Operation was undertaken in less than 21 days after injury in 71 patients (67%) and in 35 (33%) the procedure was carried out later than this. The reduction of the fracture was measured on plain radiographs taken after operation and defined as anatomical (0 to 1 mm of displacement); imperfect (2 to 3 mm) or poor (>
3 mm). The functional outcome was measured by the modified Merle d’Aubigné and Postel score. The mean follow-up was for 6.3 years (2 to 17). All patients achieved union of the fractures. The reduction was graded as anatomical in 76 (72%) of the patients, imperfect in 23 (22%), and poor in six (6%). The mean Merle d’Aubigné and Postel score was 15 (5 to 18) with 68 patients (64%) showing good or excellent and 38 (36%) fair or poor results. Function correlated significantly with the accuracy of the reduction (p <
0.009). Significant heterotopic ossification developed in 32 patients (30%) and was associated with a worse mean Merle d’Aubigné and Postel score of 13.7. The extended iliofemoral approach can be performed safely in selected complex acetabular fractures with an acceptable clinical outcome and rate of complications. Effective prophylaxis against heterotopic ossification should be strongly considered.
The outcome of displaced hips treated by Somerville and Scott’s method was assessed after more than 25 years. A total of 147 patients (191 displaced hips) was reviewed which represented an overall follow-up of 65.6%. The median age at the index operation was two years. During the first five years, 25 (13%) hips showed signs of avascular change. The late development of valgus angulation of the neck, after ten years, was seen in 69 (36%) hips. Further operations were frequently necessary. Moderate to severe osteoarthritis developed at a young age in 40% of the hips. Total hip replacement or arthrodesis was necessary in 27 (14%) hips at a mean age of 36.5 years. Risk factors identified were high dislocation, open reduction, and age at the original operation. Two groups of patients were compared according to outcome. All the radiographic indices were different between the two groups after ten years, but most were similar before. It takes a generation to establish the prognosis, although some early indicators may help to predict outcome.