Of 142 Chiari pelvic osteotomies for osteoarthritis in dysplastic hips, most performed by Chiari himself, we were able to review 82 and obtain information about 18 by questionnaire. All patients were over 30 years of age at operation; follow-up averaged 15.5 years. Twenty hips had undergone secondary total hip replacement. The outcome was good in 75%, fair in 9% and poor in 16%. High osteotomies all gave good results, and the result also depended on adequate medialisation. Statistics were worse for patients over 44 years of age at the time of operation. For osteoarthritis secondary to hip dysplasia, the Chiari pelvic osteotomy is an alternative procedure to early hip replacement. In contrast to intertrochanteric osteotomy, it has the advantage of facilitating the implantation of an acetabular prosthesis should arthroplasty become necessary at a later stage

Valgus extension osteotomy (VGEO) is a salvage procedure for ‘hinge abduction’ in Perthes’ disease. The indications for its use are pain and fixed deformity. Our study shows the clinical results at maturity of VGEO carried out in 48 children (51 hips) and the factors which influence subsequent remodelling of the hip. After a mean follow-up of ten years, total hip replacement has been carried out in four patients and arthrodesis in one. The average Iowa Hip Score in the remainder was 86 (54 to 100). Favourable remodelling of the femoral head was seen in 12 hips. This was associated with three factors at surgery; younger age (p = 0.009), the phase of reossification (p = 0.05) and an open triradiate cartilage (p = 0.0007). Our study has shown that, in the short term, VGEO relieves pain and corrects deformity; as growth proceeds it may produce useful remodelling in this worst affected subgroup of children with Perthes’ disease

Total hip replacement was performed in 27 hips of patients who had sickle cell anaemia with avascular necrosis of the femoral head. The disease was bilateral in 11 patients. Considerable medical problems were encountered although most of the patients had exchange transfusion before surgery (86%), which prevented postoperative sickle cell crises in all but two cases. At the primary operation hard sclerotic bone was seen in nine femora with complete obliteration of the femoral canal. There were four femoral fractures, three following perforation of the shaft due to this hard bone. There was a very high morbidity due to loosening in both cemented and uncemented prostheses. With a rate of 59% over a cumulative 5.5 year period, revision was being performed at an average of only 43 months. Surgeons should be aware of these problems

The newer techniques of cementing aim to improve interlock between cement and bone around a femoral stem by combining high pressure and reduced viscosity. This may produce increased embolisation of fat and marrow leading to hypotension, impaired pulmonary gas exchange and death. For this reason the use of high pressures has been questioned. We compared finger-packing with the use of a cement gun by measuring intramedullary pressures during the cementing of 31 total hip replacements and measuring physiological changes in 19 patients. We also measured pressure in more detail in a laboratory model. In the clinical series the higher pressures were produced by using a gun, but this caused less physiological disturbance than finger-packing. The laboratory studies showed more consistent results with the gun technique, but for both methods of cementing the highest pressures were generated during the insertion of the stem of the prosthesis

The radiological features of the cement mantle around total hip replacements (THRs) have been used to assess aseptic loosening. In this case-control study we investigated the risk of failure of THR as predictable by a range of such features using data from patients recruited to the Trent Regional Arthroplasty Study (TRAS). An independent radiological assessment was undertaken on Charnley THRs with aseptic loosening within five years of surgery and on a control group from the TRAS database. Chi-squared tests were used to test the probability of obtaining the observed data by chance, and odds ratios were calculated to estimate the strength of association for different features. Several features were associated with a clinically important increase (> twofold) in the risk of loosening, which was statistically significant for four features (p < 0.01). Inadequate cementation (Barrack C and D grades) was the most significant feature, with an estimated odds ratio of 9.5 (95% confidence interval 3.2 to 28.4, p < 0.0001) for failure

We reviewed the long-term results of the treatment of slipped upper femoral epiphysis (SUFE) using realignment procedures in 36 patients (37 hips) at an average follow-up of 33.8 years (26 to 42). There were serious short-term complications in seven of the 22 hips treated by subcapital osteotomy, three of the 11 hips treated by intertrochanteric osteotomy and three of the four hips treated by manipulative reduction. At re-examination, the clinical and radiological results were excellent or good in 41% of the hips treated by subcapital osteotomy, in 36% treated by intertrochanteric osteotomy and in none treated by manipulative reduction. In all, seven hips (19%) had had arthrodesis or total hip replacement. The natural history of SUFE was probably not improved by any of the treatments used in our study. We therefore discourage the use of subcapital and intertrochanteric osteotomy as well as manipulative reduction in the primary treatment of chronic SUFE

Survivorship analysis of 215 medial displacement pelvic osteotomies undertaken for symptomatic, incongruent dysplasia of the hip since 1966 showed that four of every five hips had not required conversion to a total hip arthroplasty. The radiological characteristics of 86 osteotomies were evaluated at a mean of 18 years (5 to 30) after surgery which was performed at the age of 15.9 ± 9.5 years. Revision was significantly (p < 0.05) more likely in those patients operated on after the age of 25 years. The centre-edge (CE) angle increased from 2.5 ± 13.9° before to 41.8 ± 15.0° immediately after operation. The increase in CE angle was maintained at later review (38.5 ± 16.5°). Even with severe dysplasia with a CE angle less than zero a substantial improvement in the cover of the femoral head was achieved, usually by medial shift of the lower pelvic fragment. However, the head was not invariably medialised by the osteotomy and lateral movement of the ilium was noted when the position of the joint was relatively medial before operation or when the hip was arthritic. In the longer term pelvic remodelling did not reverse the medialisation produced by the osteotomy, and the cover of the femoral head was maintained

Postoperative deep-vein thrombosis (DVT) is believed to be rare in Asians. We studied 88 consecutive patients in Malaysia who had operations for fracture of the proximal femur or for total hip or knee replacement. No patient had prophylaxis against DVT; bilateral ascending venography was performed between six and ten days after operation. A total of 55 patients (62.5%) showed venographic evidence of DVT. The prevalence was greatest after total knee replacement (76.5%), less after total hip replacement (64.3%) and smallest in the fracture group (50%). One patient developed symptomatic pulmonary embolism. In contrast to other reports from Asia, we found an incidence of postoperative DVT which is similar to that reported in Western populations. This suggests that the present practice of withholding routine prophylaxis against thromboembolism in Asian patients undergoing high-risk orthopaedic procedures should be reconsidered

We report 11 patients having revision of total hip arthroplasty using massive structural allografts for failure due to sepsis and associated bone loss. All patients had a two-stage reconstruction and the mean follow-up was 47.8 months (24 to 72). Positive cultures were obtained at the first stage in nine of the 11 patients, with Staphylococcus epidermidis being the most common organism. The other two patients had draining sinuses with negative cultures. There was no recurrence of infection in any patient. The mean increase in the modified Harris hip score was 45 and all the grafts appeared to have united to host bone. Two patients required additional procedures, but only one was related to the allograft. Complications included an incomplete sciatic nerve palsy and one case of graft resorption. Our results support the use of massive allografts in failed septic hip arthroplasty in which there is associated bone loss

In previous randomised clinical trials of thromboprophylaxis after total hip replacement, low-molecular-weight heparin has been given for an arbitrary 7 to 14 days. The risk factors are mainly perioperative and it is possible that a shorter course may be adequate. We assessed the safety and effectiveness of a three-day course. We assessed 156 primary THR patients after randomisation to either a control group or to receive enoxaparin at 12 hours preoperatively and 12 and 36 hours postoperatively. Thrombosis was diagnosed by routine venography. Haemorrhagic side-effects were assessed by measurement of blood loss, and soft-tissue side-effects by descriptive scores for wound discharge and bruising of the leg. The prevalence of calf thrombosis was 15.4% in the enoxaparin group and 32.1% in the control group (p = 0.01); the prevalence of proximal thrombosis was 15.4% and 17.9% respectively (not significant). There was no difference in haemorrhagic side-effects or wound discharge, but there was more bruising in the enoxaparin group

We aimed to assess whether the immunological abnormalities which have been observed in patients with loose total hip replacements (THRs) are present in patients with a well-fixed prosthesis. We examined blood samples from 39 healthy donors, 22 patients before THR and 41 with well-fixed THRs of different types (15 metal-on-metal, 13 metal-on-polyethylene, 13 ceramic-on-ceramic). Before THR, the patients showed a decrease in leukocytes and myeloid cells in comparison with healthy donors, and a prevalence of type-1 T lymphocytes, which was confirmed by the increase in ratio of interferon-γ to interleukin 4. Moreover, patients with metal-on-metal or metal-on-polyethylene implants showed a significant decrease in the number of T lymphocytes and a significant increase in the serum level of chromium and cobalt, although no significant correlation was observed with the immunological changes. In the ceramic-on-ceramic group, leukocytes and lymphocyte subsets were not significantly changed, but a significant increase in type-2 cytokines restored the ratio of interferon-γ to interleukin 4 to normal values. We conclude that abnormalities of the cell-mediated immune response may be present in patients with a well-fixed THR, and that the immunological changes are more evident in those who have at least one metal component in the articular coupling

Socket migration and rotation in the Charnley total hip replacement were evaluated by roentgen stereophotogrammetric analysis in 23 patients with rheumatoid arthritis and 23 patients with osteoarthritis. The two groups were matched with regard to age and sex. The follow-up time was two years. In the rheumatoid patients socket migration was most prominent in the proximal direction and averaged 0.6 mm at 24 months as compared with 0.1 mm in the osteoarthritic group (p = 0.0003). Within the rheumatoid group a preoperative acetabular protrusion in five patients was associated with increased migration and rotation in all directions. The increased proximal migration in rheumatoid arthritis was consistent (p = 0.0009) even after the exclusion of the five protrusion cases. In the rheumatoid patients there was a correlation between low body-weight and proximal migration, but there was no such correlation in the osteoarthritic group. Our results suggest that socket fixation is less secure in patients with advanced inflammatory arthritis

Our aim was to determine if the detection rate of infection of total hip replacements could be improved by examining the removed prostheses. Immediate transfer of prostheses to an anaerobic atmosphere, followed by mild ultrasonication to dislodge adherent bacteria, resulted in the culture of quantifiable numbers of bacteria, from 26 of the 120 implants examined. The same bacterial species were cultured by routine microbiological techniques from only five corresponding tissue samples. Tissue removed from 18 of the culture-positive implants was suitable for quantitative tissue pathology and inflammatory cells were present in all samples. Furthermore, inflammatory cells were present in 87% of tissue samples taken from patients whose implants were culture-negative. This suggests that these implants may have been infected by bacteria which were not isolated by the techniques of culture used. The increased detection of bacteria from prostheses by culture has improved postoperative antibiotic therapy and should reduce the need for further revision

We have prospectively studied the wear of enhanced ultra-high molecular-weight polyethylene (Hylamer) in combination with a zirconia femoral head of 22.225 mm diameter on a cemented, triple-tapered, collarless, polished stem, the C Stem. The 71 patients who underwent total hip arthroplasty had a mean follow-up of six years (3 to 8). No patient died or was lost to follow-up. The clinical results were excellent with 96% of patients satisfied. There were no revisions. Two cups were considered to be loose radiologically. One was avulsed from the cement in a skiing accident, with a periprosthetic fracture of the femur, but has remained stable for more than seven years. One femur shows radiological appearances which are compatible with a healing infection. One femoral component is at risk of loosening. The mean rate of penetration of the cup was 0.22 mm/year (0.06 to 0.55). Our results appear to be within the guidelines set by the National Institute of Clinical Excellence. We have discontinued the use of Hylamer despite excellent clinical results and no revisions to date because the high initial rates of penetration did not settle to the expected low levels within the anticipated time

Instruments used in surgery which rotate or vibrate at a high frequency can produce potentially contaminated aerosols. Such tools are in use in cemented hip revision arthroplasties. We aimed to measure the extent of the environmental and body contamination caused by an ultrasound device and a high-speed cutter. On a human cadaver we carried out a complete surgical procedure including draping and simulated blood flow contaminated with Staphylococcus aureus (ATCC 12600). After cemented total hip arthroplasty, we undertook repeated extractions of cement using either an ultrasound device or a high-speed cutter. Surveillance cultures detected any environmental and body contamination of the surgical team. Environmental contamination was present in an area of 6 x 8 m for both devices. The concentration of contamination was lower for the ultrasound device. Both the ultrasound and the high-speed cutter contaminated all members of the surgical team. The devices tested produced aerosols which covered the whole operating theatre and all personnel present during the procedure. In contaminated and infected patients, infectious agents may be present in these aerosols. We therefore recommend the introduction of effective measures to control infection and thorough disinfection of the operating theatre after such procedures

The radiographic and histological features of radiolucent areas at the cement-bone interface were correlated in 15 specimens retrieved at post-mortem from patients who had undergone cemented total hip arthroplasty, two weeks to 15 years prior to death. All but one of the components were securely fixed, as demonstrated by direct measurements of micromotion. Extensive radiolucencies were present in all but one case. In 11 of the 14 specimens with radiolucencies, histological examination showed that the radiolucent areas represented regions of osteoporosis and bone remodelling. The remodelling changes were characterised by osteoporosis, cancellisation and thinning of the endosteal cortex, and osteopenia of the trabecular bone. In two specimens the appearance of radiolucency was found to be due to fibrous tissue at the cement-bone interface and in one specimen there was a mixed picture of osteolysis and fibrosis. The study demonstrates that radiolucent lines can occur with well-fixed components and that they may commonly represent osteoporosis rather than the presence of a fibrous membrane at the cement-bone interface

We followed the first 354 consecutive implantations of a cementless, double-tapered straight femoral stem in 326 patients. Follow-up was at a mean of 12 years (10 to 15). The mean age of the patients was 57 years (13 to 81). At follow-up, 56 patients (59 hips) had died, and eight (eight hips) had been lost to follow-up. Twenty-five hips underwent femoral revision, eight for infection, three for periprosthetic fracture and 14 for aseptic loosening. The overall survival was 92% at 12 years (95% CI 88 to 95). Survival with femoral revision for aseptic loosening as an endpoint was 95% (95% CI 92 to 98). The median Harris hip score at follow-up was 84 points (23 to 100). Radiolucent lines (< 2 mm) in Gruen zones 1 and 7 were present in 38 (16%) and 34 hips (14%), respectively. Radiolucencies in zones 2 to 6 were found in five hips (2%). The results for mid- to long-term survival with this femoral component are encouraging and compare with those achieved in primary cemented total hip arthroplasty. The high rate of loosening of the cup and the high rate of pain are, however, a source of concern

Total hip arthroplasty was performed in 45 hips of 44 patients who had pyogenic arthritis of the hip during childhood. The average age of the patients was 36.4 years (range 19 to 50). The interval between active infection and arthroplasty ranged from 11 to 40 years, and average follow-up was 65.4 months (range 58 to 80). Specimens of tissue taken before and during operation gave negative cultures in all hips, and no patient had reactivation of infection. The mean functional rating of the hips was 58 points before operation and 90 at the final review. Complications were seen in 11 cases (24%), loosening of components occurred in six (13%) and one hip had to be revised for acetabular component migration. Acetabular allografts were required in 27 hips (60%). All allografts united but there was partial resorption of the graft in the non-weight-bearing area in all

We treated 50 consecutive patients with infected total hip arthroplasties according to a standard protocol. Previous surgery to eradicate the infection had been attempted in 13 patients and discharging sinuses were present in 20. Aspiration arthrography was routinely carried out before our interventions. The first stage was a meticulous removal of all foreign and potentially infected material. Samples were taken for culture and a thorough lavage carried out. Antibiotic-loaded beads were placed in the femoral shaft and an antibiotic-loaded cement ball in the acetabulum. At the second stage an uncemented arthroplasty was introduced. Bone allograft was used in 18 patients. The interval between procedures was usually three weeks, but this was extended if the wound was slow to heal or there was extensive bony destruction. Appropriate antibiotics were given for three months. At a mean follow-up of 5.8 years the rate of reinfection was 8% (4 patients). Two of these patients have had another, successful, two-stage revision. At this medium-term review, a satisfactory clinical and radiological outcome was obtained in all except two patients

The number of arthroplasties of the hip and knee is predicted to increase rapidly during the next 20 years. Accompanying this is the dilemma of how to follow-up these patients appropriately. Current guidelines recommend long-term follow-up to identify patients with aseptic loosening, which can occur more than a decade postoperatively. The current guidelines and practices of orthopaedic surgeons vary widely. Existing models take up much clinical time and are expensive. Pilot studies using ‘virtual’ clinics and advanced-practice physiotherapists have shown promise in decreasing the time and costs for orthopaedic surgeons and patients.

This review discusses current practices and future trends in the follow-up of patients who have an arthroplasty.

Cite this article: Bone Joint J 2018;100-B:6–10.