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Bone defects of the acetabulum caused by loosening of the socket of a total hip prosthesis can be filled in with autoclaved homologous cancellous bone grafts. Five months after surgery a radiological change in the bony structure is visible. Histological examination shows that new bone is formed around the autoclaved bone.
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The performance of a total hip prosthesis is considered in terms of reliability. The causes requiring removal of the prosthesis are considered and methods of avoiding these difficulties are outlined. It is pointed out that most attention must be focused on the areas of low reliability. The goal of increasing prosthesis lifetime must be shared between the surgeon and manufacturer.
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A retrospective study was done on a consecutive series of patients who had revision of a femoral hip prosthesis using a titanium-alloy implant with proximal fibermesh pads. Of 28 patients who had revision using a Harris-Galante (Zimmer, Warsaw, IN) femoral prosthesis between 1985 and 1989, 25 of them (25 hip arthroplasties) were followed for an average of 5.5 years (range, 4-8 years); the other 3 had died. There were 12 men and 13 women whose age averaged 55 years. Thirty-two percent of the patients had moderate or severe femoral bone stock deficiency before surgery and 72% had intramedullary femoral bone-grafting. All of the patients had revision of the acetabular component using a cementless Harris-Galante prosthesis. Five (20%) of the 25 patients have undergone repeat femoral revision, 4 for aseptic loosening and 1 for persistent thigh pain. Of the 20 hips that have not been revised, 9 (45%) of the femoral prostheses have subsided 5 mm or more. Femoral endosteal lysis was present in 36% of all the hips. Only 8 (32%) of the 25 patients had radiologic signs of bone ingrowth fixation of the femoral component. The average Harris hip score rose from 46 before surgery for all 25 patients to 82 (range, 55-100) at last follow-up examination for the 20 patients not rerevised. Because of the poor clinical results (36% of patients with a poor Harris hip score [4 patients] or rerevised [5 patients]) and radiologic results (48% subsidence) of femoral reconstruction with this proximally porous-coated femoral prosthesis, its use for revision hip surgery is not recommended.
In a series of 48 cases of infected hip prosthesis the different therapeutic possibilities are being discussed. In 30 instances a one stage exchange operation with the use of antibiotic bone cement as described by BUCHHOLZ was performed. Provided good stability of the new prosthesis is obtained, the signs of infection as well as most pathologic X-ray aspects will disappear, in spite of the introduction of additional implant material. After an observation time of up to 5 years more than half of the cases appeared clinically healed. The poor results generally manifest themselves within the first postoperative year. As palliation against infection a good general condition of the patient, the absence of infectious foci as well as a good operative technique and discipline to us seem more important than the number of germs in the operation theater.
UNLABELLED: During 1978 to 1987 361 patients (312 female, 49 male) were treated with Variokopf-prosthesis (a bipolar hip prosthesis with a variable head) after femoral neck fracture, per- or subtrochanteric fracture. The mean age was 83 years. During postoperative treatment 73 patients (20.2%) died. 288 could be discharged. 98 of these died before the follow-up examination. The follow-up was possible in 103 cases. A good to satisfactory result was found in 91 cases (88%). A poor result in twelve cases (12%) (Score by Merle d'Aubigne et al.). CONCLUSIONS: 1. The Variokopf-prosthesis is a favourable alternative to a normal hip prosthesis (e.g. Moore), 2. The implantation of a Variokopf-prosthesis was found to be indicated as well in the treatment of medial femoral neck fractures as in special cases in the treatment of per- or subtrochanteric fractures. 3. The operation should be performed soon after the trauma--after a two to three days treatment. 4. The dorsal approach is superior to the lateral in the treatment of hip fractures because of short operating time and the possible early mobilisation of the patients.
The postoperative x-rays of 34 patients with rheumatoid arthritis or spondylitis who had received a cement-free fixed total hip endoprosthesis were examined. The postoperative period ranged from 3 months to four years. In the region of the acetabular component an increasing rate of osseous integration in relation to the postoperative time was observed. Adaptive modeling changes in the area of the femoral stem were found as radiolucent lines parallel to the implant. Also a densification of cancellous bone and cortical hypertrophy as well as cortical rarefaction was noticeable. The bone in rheumatoid arthritis or spondylitis reacts to the implantation of a cementless fixed total hip prosthesis similar as the bone in osteoarthritis.
A majority of hip disarticulations are performed in young people, with malignancy being the most common cause. The exoskeletal Canadian Hip Disarticulation prosthesis had been widely used as a standard total hip disarticulation prosthesis until recently when an endoskeletal modular version became the prosthesis of choice. However, the "basket-shaped" socket provided by the standard total hip disarticulation prostheses has been a source of discomfort and a reason for prosthetic rejection by many patients. This report concerns two patients with true lower limb disarticulation at the hip joint. Both of the patients failed to adapt to the standard total hip disarticulation prosthesis but successfully used a new total contact suction socket design. This new prosthesis provided improved suspension, better patient compliance, and enhanced prosthetic acceptance and mobility.
The stress levels in the femoral component of a total hip prosthesis (Corin Taper Fit, Corin Medical Ltd, Cirencester, Gloucestershire, UK) were calculated by finite element (FE) analysis. This prosthesis has two holes drilled in the shoulder to engage a stem introducer. There were no unacceptable stress levels around these holes. Instead the maximum stresses were around the periphery of the shaft of the stem, as has been observed for FE analyses of conventional designs. Three prostheses were also subjected to cyclic mechanical testing (peak load 2.3 kN) according to the appropriate British Standard. The holes were examined for cracks, before and after testing, by stereomicroscopy. All three specimens were able to withstand 5 million loading cycles with no evidence of damage. Thus it is possible to design a femoral component with holes in the shoulder, to accommodate a stem introducer, without creating unacceptable stress concentrations.
The Müller acetabular reinforcement ring has proven very useful, especially in total hip revision when the bone of the acetabulum is of poor quality or deficient. However, the acetabular reinforcement ring may also be indicated in primary total hip replacement, especially in the case of poor quality bone in the acetabular bone stock, e.g. in chronic polyarthritis or protrusio acetabuli, or of deficient morphology of the acetabulum, e.g. in hip dysplasia. We analysed the results recorded in 145 patients operated on between 1977 and April 1983. Each of these patients had received a total hip prosthesis for the first time, with the polyethylene cup supplemented by an acetabular reinforcement ring. This patient group cannot be compared with the usual patient populations reported on in connection with primary hip replacement, since most of our 145 patients had several risk factors and had undergone previous surgery on up to seven occasions on the hip ultimately replaced by a prosthesis. Radiological analysis did not show a significant correlation between malposition of the acetabular reinforcement ring and signs of loosening, except when the acetabular component had been implanted in a most atypical manner. The infection rate was 4.8%, but it must be borne in mind that from 1977 to 1983 there was no routine prophylaxis with antibiotics. The incidence of aseptic loosening of the acetabular reinforcement ring necessitating revision was 0.7% after a mean follow-up of 7.7 years (range 5.5-11 years).(ABSTRACT TRUNCATED AT 250 WORDS)
Osteolysis and loosening of artificial joints caused by polyethylene wear debris has prompted renewed interest in alternative bearing materials for hip prosthesis designs. Lower wearing metal-on-metal (MOM) and ceramic-on-ceramic prostheses are being used more extensively, and there is considerable interest in further improving on their performance. This study investigated the wear properties and debris morphology of a novel differential hardness ceramic-on-metal (COM) prosthesis, in comparison with MOM articulations in a physiological anatomical hip joint simulator. The COM pairings were found to have wear rates approximately 100-fold lower than the MOM pairings. The MOM pairings showed a higher "bedding in" wear rate (3.09+/-0.46mm(3)/10(6) cycles) in the first million cycles, which then reduced to a steady state wear rate of 1.23+/-0.5mm(3)/10(6) cycles. The wear rate of the COM pairings over the duration of the test was approximately 0.01mm(3)/10(6) cycles with very little wear detected on the surface of the prosthesis components. The wear particles from both articulations were oval to round in shape and in the nanometer size range. After one million cycles the mean maximum diameter of the MOM and COM wear particles were 30+/-2.25 and 17.57+/-1.37nm, respectively. After five million cycles the wear particles were statistically significantly smaller than at one million cycles, 13.9+/-0.72nm for the MOM pairings and 6.11+/-0.40nm for the COM pairings. The wear rates of the MOM prostheses were representative of clinical values. The use of differential hardness COM pairings dramatically reduced the wear rate compared to MOM hip prostheses. The wear particles from the MOM articulation were similar to particles found in retrieved tissues from around MOM prostheses. The extremely low wearing differential hardness COM bearings presented in this study produced far smaller volumetric particle loads compared to MOM prostheses currently used clinically.
OBJECTIVE: The highly osteolytic interface tissue between the bone and loosening total hip prosthesis is characterized by low pH, formation of foreign body giant cells, osteoclasts, and production of receptor activator of nuclear factor-kappaB (RANKL) and cathepsin K. We hypothesized that fibroblasts in the interface tissue may form a source for RANKL production. METHODS: Primary interface tissue fibroblasts, fibrous joint capsule fibroblasts, and trabecular bone osteoblasts were stimulated with tumor necrosis factor-alpha (TNF-alpha), interleukin 1beta (IL-1beta), IL-6, IL-11, or 1alpha,25-(OH)2 vitamin D3. Cellular RANKL and released cathepsin K were detected by Western blotting. RANKL in cell lysates and osteoprotegerin (OPG) in cell culture medium were measured by ELISA. RANKL, OPG, and cathepsin K mRNA were measured with quantitative reverse transcriptase polymerase chain reaction. RESULTS: Interface tissue fibroblasts were found to produce RANKL. 1alpha,25-(OH)2 vitamin D3 stimulation increased RANKL mRNA expression. TNF-alpha was found to be the most potent OPG inducer in interface tissue fibroblasts. Cathepsin K mRNA production in fibroblasts was upregulated roughly 3-fold (p < 0.01) after 1alpha,25-(OH)2D3 stimulation, and both pro- and active cathepsin K protein was released to fibroblast culture media. CONCLUSION: Interface tissue fibroblasts are able to produce RANKL, OPG, and cathepsin K and may contribute indirectly and directly to pathologic periprosthetic collagenolysis and bone destruction.
To assess the causes of failure in a blood saving program and the consequent need for homologous transfusions during major orthopedic surgery, data were collected from six orthopedic centers where an autotransfusion program was carried out from 1992-1994. The 1,576 (1,016 female and 560 male) patients studied (average age 63.6 +/- 10 years) were treated either for total hip prosthesis (1,144 pts) total knee prosthesis (212 pts), plate and screw removal plus hip prosthesis (8 pts), hip revision (cup 48 pts, stem 10 pts, cup plus stem 146 pts) and total knee revision (8 pts). Ninety percent of patients did not undergo homologous transfusions, which was significantly connected to: male sex (8% versus 11.7% p = 0.02), younger age (63.2 vs 66.9 years, p = 0.0001), higher weight (male 76 vs 70.7 Kg. p = 0.003, female 65.6 vs 61.9 Kg. p = 0.0003); higher baseline Hb (13.9 vs 12.8 g/dl, p = 0.0041), shorter operation time (110 vs 128 minutes, p = 0.0001); use of indobufen for antithromboembolic prophylaxis (indobufen 4.6% vs heparin calcium 15.2% vs low molecular weight heparin 9% p = 0.0001). On the contrary, the factors favoring homologous transfusions were: peripheral anesthesia (spinal and epidural 15.3% vs general 9.3% vs integrated 9.8% p = 0.016), total hip or knee revision, fixation device removal before hip prosthesis, systemic hypertension and coronary heart disease.
Medical and/or distal migration of the prosthetic stem was found in 63 out of 337 patients (19 per cent) treated surgically with a Christiansen hemiprosthesis, a Christiansen total hip prosthesis or a Charnley total hip prosthesis. Fractured bone cement, radiolucent zones at the cement/bone interface, resorption of the femoral calcar and cortical sclerosis were all associated with migration. Varus position of the Christiansen total hip prosthesis was significantly associated with medical migration, and a short stem was significantly associated with distal migration. The other structural variables could not be linked with migration. Distal migration was pain-inducing and was significantly associated with late infection. Medical migration had a less distinct association with pain, and was not correlated with infection. Both medical and distal migration were time-dependent, and 4 or more years after operation about 2.5 per cent of the prosthetic stems had migrated.
The results of 45 revisions performed for fracture of the femoral stem in patients with total hip replacements were reviewed after an average follow-up time of 5 (3-7) years. We were able to examine 38 of the patients. Surgery was performed in a standardized way through a posterior approach and with a dorsal proximal window in the femur. In 7 cases the femoral stem only was changed, while in 31 both components had to be replaced. The femoral components implanted were of the revision type, and were cemented and individually selected in each case. To stabilize large acetabular defects a combination of an acetabular support ring and a homologous bone graft was used in 21 cases; bank bone was used in a total of 28 hips. During surgery 1 fracture and 4 defects of the femur occurred. Good intraoperative stability of the femoral component was attained in every case, allowing full weight-bearing during mobilization unless acetabular instability was present. There were no deep infections. One dislocation had to be treated by closed reduction. Clinical evaluation was performed according to Merle d'Aubigné. Radiological loosening was classified according to Gruen, DeLee and Charnley. Clinical results were good in 33 (87%) and were rated as poor in 5. In the latter group a good correlation between subjective and objective parameters was noted in 4 of the 5 patients. Two acetabular and two femoral components in 3 patients were classified as radiologically loose; in 1 of these the cup was not changed at revision.(ABSTRACT TRUNCATED AT 250 WORDS)
Vascular injuries during or after total hip replacements have often been reported. In 2257 artificial hip joint replacements, we observed 8 cases of vascular injuries requiring reconstruction (3 cases), suturing (2 cases), end-to-end anastomosis (1 case), or ligature (2 cases) performed by a vascular surgeon. A separate skin incision for vascular repair was necessary in all patients. Most of the injuries occurred as a result of technical errors through lack of caution when using bone hooks or rough handling, resulting in dislocation of the hip joint. The latter occurs mainly in revision procedures. Six patients recovered fully, but two died, one of hemorrhagic shock and the other of cardiac decompensation.
Hip arthroplasty using a bipolar prosthesis was performed in 73 patients (75 hips) with femoral neck fracture, osteoarthritis, rheumatoid arthritis, or degenerative arthritis. Bipolar hip arthroplasty is more conservative than conventional total hip arthroplasty, because methyl methacrylate usually is not needed to fix the bipolar prosthesis to bone. Overall results were 67.1% good to excellent, 20.5% fair, and 12.3% poor; among the arthritic patients, the results were 72.9% good to excellent, 19.1% fair, and 8.5% poor. Complications included one deep wound infection and one arterial embolus; no dislocations occurred.