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The occurrence of pain following a technically satisfactory cemented total hip arthroplasty is of concern for both the orthopedic surgeon and the patient. In order that the source of the pain be accurately located, a scientific approach is required. We present an algorithm for the evaluation of pain following an apparently satisfactory hip arthroplasty which, if followed, results in the correct diagnosis.
Orgaran (danaparoid sodium injection) is a novel antithrombotic agent. Early studies suggest that this compound may be beneficial in preventing deep vein thrombosis in predisposed patients. This multicenter, randomized, assessor blinded, clinical trial compared subcutaneous danaparoid with warfarin for the prevention of deep vein thrombosis in patients undergoing hip replacement surgery. Bilateral venography was used to detect thrombi. Patients also underwent follow-up examinations 1, 2, and 3 months after discontinuation of the study to determine the after effects of treatment. Nearly 27% of patients who received warfarin and 14.6% of patients who received danaparoid developed deep vein thrombosis, a risk reduction of 46%. The absolute difference in the incidence of deep vein thrombosis was 12.3% in favor of danaparoid. The incidence of venographically documented proximal deep vein thrombosis was 1.5% for danaparoid and 4.1% for warfarin. These results demonstrate that danaparoid is more effective than warfarin in preventing deep vein thrombosis following hip replacement surgery. The preoperative administration of danaparoid does not increase surgical blood loss compared with warfarin.
The acetabulum-head index (AHI), which is used to assess femoral head coverage on plain radiographs, was measured in 77 children (154 hips) with normal hips aged 2 to 14 years. The mean AHI value was 94 (range, 79-114). Both the intraobserver and the interobserver reproducibility of the measurements was high. The AHI values tended to decrease with increasing age. The mean AHI minus 2 standard deviations, which was used to define the border value for subluxation of the femoral head, was 80. The authors propose that an AHI < or = 80 can be used as a guideline to reveal abnormal lateral displacement of the femoral head in children.
Total hip arthroplasty was performed in a patient who had tuberculous hip, quiescent for the last 15 years, without pre or postoperative anti-tuberculous chemotherapy. At a 27 month follow up, there has been no evidence of reactivation. A brief review of relevant literature is also presented.
The results of 40 acetabuloplasties of the hip for osteoarthritis have been studied over a follow-up period of 6 months to 7 years. 12 patients have been treated by shelf arthroplasty alone and 26 by the same operation combined with intertrochanteric osteotomy. These operations, which are suitable for use in patients too young for a total hip prosthesis, give very satisfactory results in 80% of the cases, but the patients must be carefully selected. The clinical and radiological criteria on which this choice is based, and the technical peculiarities of the operation, are described.
The aim of this paper was to determine the differences in hip remodeling and final outcomes of hip dysplasia treatment by fixing a certain amount of varus during varus-detorsion osteotomy of the proximal femur. The analysis included 33 children who underwent 48 osteotomies. During final follow-up at skeletal maturity it was found that the amount of varus fixed during the osteotomy influenced significantly femur remodeling and some containment measurements. However it played only slight part in acetabular remodeling. The outcomes at final follow-up proved significantly better in the group in whom a greater amount of varus was fixed.
Retrieved ceramic femoral heads and acetabular cups were investigated. On the basis of the case studies, the reasons for revision are discussed. Wear patterns and wear rates were found to differ from those observed in hip simulating testing. Monolithic ceramic cups showed a high wear rate. Owing to their limited range of motion, ceramic "mushroom heads" are associated with impingement that leads to a high risk of cup loosening, high wear rates and in vivo fractures. The combination of ceramic "mushroom heads" and cups is not recommended. An evaluation of complications shows that some can be explained by patient behaviour--e.g. Japanese sitting position, horse riding. Designers need to develop new concepts offering a larger range of motion, for example, with head diameters of 32 and 36 mm that reduce the risk of impingement, subluxation and dislocation, while increasing the range of motion. The potential of ceramic/ceramic coupling has been known since the 70s, and ceramic concepts for total hip replacement are currently experiencing a renaissance, although further developments are still possible.
The paper presents a series of 51 hips (5 boys, 33 girls) that underwent reconstructive surgery because of congenital hip dislocation. Surgical treatment involved a one-stage procedure, consisting of correction of the proximal femur position and acetabuloplasty. Acetabulum reconstruction was achieved by using one of three methods: Pemberton osteotomy, Salter osteotomy and a "shelf-type" acetabuloplasty. Excellent and good results were found in 84% of the cases under 4 years of age, irrespective of the acetabuloplasty implemented.
The Norwegian national register for total hip replacements collects data on the total hip arthroplasties performed in Norway. 17,444 operations were registered from the start i September 1987 and through 1990. The age of the patients ranged from 12 til 97 years. The median was 69 years. 69% of the patients were females. The operating-time ranged from 25 to 420 minutes, with a median of 100 minutes. Cemented prostheses constituted 83% and uncemented prostheses 17% of the market. The Charnley prosthesis dominated, and was used in 49% of all implants. 13% of all operations were revisions. During these three and a half years, 0.9% of the cemented prostheses and 2.9% of the noncemented prostheses were revised (P less than 0.001).
The results obtained in 167 extracapsular fractures of the hip are presented. Ender's pins were used in 82 cases and the dynamic hip screw (DHS) in 85. Comparison of different aspects (handling, postoperative mobility, complication rate, mortality) shows that the second operating procedure named DHS is highly suitable for the treatment of fractures A1-A3 and B2 (Müller classification) and superior to the procedure with Ender's pins.
In Sweden in 1976, nine orthopedic departments organized a prospective, randomized, and controlled study in which the prophylactic effect of systemic antibiotics (SA) was compared to gentamicin bone cement (GBC) in 1688 consecutive total hip arthroplasties (THAs). After a follow-up period of one to two years, there was a statistically significant difference in the infection rate between the two groups in favor of the gentamicin cement. After five years or more, the difference was unaltered. Altogether, 16 deep infections had occurred in the SA group (1.9%) and seven (0.8%) in the GBC group. Roentgenographically, aseptic loosening had occurred in 29% and 24% of the hips in the SA and GBC groups, respectively, which suggests that admixture of the antibiotic did not weaken the cement. The results of this five-year review clearly showed the prophylactic value of gentamicin cement against deep infection after THA but did not support the hypothesis that this effect was prolonged over one year.
All 441 cases of hip fracture admitted to Sahlgrenska sjukhuset, Göteborg, during a one-year period were followed in accordance with a form developed by the Swedish Medical Research Council. Osteosynthesis was the method used in over 97 per cent of the cases. There were 336 women, mean age 80.0 (+/- 9.9) years, and 105 men, mean age 77.1 (+/- 11.8). A rehabilitation programme for non-institutionalised patients (68 per cent of the total of 441) reduced the length of stay at the orthopaedic department from 22 days to an average of 15 days in 1986, and the proportion of patients able to return home was increased from 81 per cent in 1982 to 90 per cent in 1987-88. Thus, the use of rehabilitation or nursing home facilities was reduced, and the length of stay there was reduced. The findings of the study also showed the rehabilitation to be time-consuming, and that few hip fracture patients ever regain complete pre-fracture function. Therefore it is suggested that the follow-up should be extended to cover a longer period than four months. Otherwise, the form is well designed, and its use improves the comparability of different studies.
Well established procedures exist for treatment of congenital dislocation of hip, whereas unanimity is lacking with respect to management of a hip at risk during the neonatal period. Based on a homogeneous series of 720 case-reports of neonates at risk a decision tree has been developed to determine essential risk factors and to demonstrate preferential pathways when evaluating appropriate therapy.
Sixty-seven hip-arthroplasty and fifty-two hip-fracture patients participated in a placebo-controlled randomized double-blind study on the effects of low-dose heparin prophylaxis in the prevention of venous thromboembolism. In this study, a positive thromboembolic event meant a positive test by: (1) daily 125I-fibrinogen scanning, (2) contrast venography on the tenth postoperative day, or (3) radionuclide perfusion lung scan in confirmation of suspected clinical pulmonary emboli. Nineteen (59.4 per cent) of thirty-two placebo-treated arthroplasty patients showed evidence of a thromboembolic event in contrast with eight (22.9 per cent) of thirty-five heparin-treated patients (p less than 0.003). Heparin-treated arthroplasty patients required mean blood transfusions of 4.7 units, contrasted with a mean 3.2-unit transfusion requirement for placebo-treated patients (p less than 0.05). The incidence of observed bleeding complications was higher among the heparin-treated patients. Of the twenty-three placebo-treated patients with fracturs, 39.1 per cent had a thromboembolic event, while 41.4 per cent of the twenty-nine who received heparin showed evidence of thromboembolism, demonstrating that low-dose heparin afforded no protection, nor did it affect the incidence of bleeding complications or transfusion requirements in fracture patients.
Seventy-five patients were treated for intertrochanteric hip fractures with the hip compression screw. There were 4 cases in which the lag screw was inserted twice into the femoral head. Three of these patients had a poor result due to superolateral migration and extrusion of the lag screw. The fact that the lag screw is large in comparison to the femoral head makes double placement dangerous. Satisfactory guide wire placement is essential for a one time, precise insertion of the lag screw into the femoral head. The use of a threaded tip guide wire minimizes the chance of it falling out when withdrawing the reamer or tap. If the position of a lag screw is unacceptable, it seems better to insert a flanged nail rather than a second screw in a second track.
The authors have analysed the results of treatment of 112 congenitally dislocated hips at the end of growth. They had been treated at walking age by progressive reduction and femoral osteotomy. Any hips that required open reduction were excluded from the study. Over the years, the principles of treatment remain the same but the technique was improved. Most of the poor results were related to trophic or vascular complications. Satisfactory results were obtained in 84 p. 100 of cases. Improvements in technique suggest to the authors that better results may be expected in the future.
The occurrence of amyloid in capsular tissue and cartilage from human hip joints were studied by the macroscopic iodine/sulphuric acid test, by light and polarization microscopy, and finally by electron microscopy. It is concluded that the congophilic substance with green dichroism, which in an earlier light and polarization microscopic study was found in a large percentage of hip joints of elderly persons, is amyloid.
The authors report the results of a statistical study undertaken for the screening of congenital dislocation of the hip. 961 children born between September 24, 1977 and June 30, 1978 were examined. Congenital dislocation of the hip was diagnosed in 9 (0.9 % of the cases). Out of these, 4 had no clinical sign of dislocatability at birth. The only determination of acetabular angles cannot be relied upon and qualitative criteria such as ilium thickness must be added.