[Remote result of hip arthroplasty with an acrylic endoprosthesis of the femoral heat in a case of tuberculosis of the hip].
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Acrylates↗
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A structured education programme increased hip protector use and may reduce hip fractures in nursing homes.
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Comment↗
[Apropos of 13 cases of epiphysiolysis of the hip. Contribution to the study and treatment of epiphysiolysis of the hip].
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Accidents↗
[Adjustable bumper of the hip joint in a Canadian-type hip disarticulation prosthesis].
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Artificial Limbs↗
[Hip dislocations and hip fractures--acetabular fractures. Indication, technique and results of conservative treatment].
Despite the great number of publications during the last 10 years concerning the indication, technique and results of operative treatment of acetabular fractures, conservative treatment still has an important role when considering the therapeutic possibilities. Because of the modern techniques of radiological imaging and improvement of diagnostic facilities, a more defined indication for treatment becomes possible. Conventional X-rays, completed by special projections like the Ala and Obturator view, and a CT scan allow determination of the fracture type (the Letournel/Judet classification or the AO classification). The most suitable treatment can then be adapted to the individual circumstances of the patient, i.e., age, general condition and overall severity of traumatic impairment. Determination of the intact part of the weight-bearing dome is important in selecting the most adequate therapeutic procedure. The larger the intact roof arc, the better the prognosis. Together with the X-ray controls following axial and facultative lateral extensions, the indication for conservative treatment can be confirmed. Early active motion of the injured limb, followed by walking exercises with partial weight-bearing, are important aspects of nonoperative treatment. Conservative treatment is recommended in non-displaced fractures or in fractures with little displacement, transverse fractures of the lower region or severely comminuted acetabular fractures with no possibility of reconstruction. Our clinical and radiological follow-up of 97 patients with acetabular fractures from the years 1981-1990 showed that the majority were treated conservatively (approx. 70%). The functional result after an average observation period of more than 70 months was good or excellent (based on the Merle d'Aubigné score). We feel it is important to look at operative and conservative treatment of acetabular fractures as two complementary non-competitive therapeutic methods. The choice of treatment should be based on an exact diagnosis considering fracture type, the individual circumstances of the patient, and application of the necessary diagnostic facilities. Conservative treatment can lead to excellent long-term results.
Acetabulum↗
The prevalence of significant left-right differences in hip bone mineral density.
INTRODUCTION: We determined the prevalence of left-right differences in hip bone mineral density (BMD) by dual-energy x-ray absorptiometry (DXA) and the resultant consequence, namely: the frequency at which patients would be classified differently if lumbar spine and only one hip (rather than both hips) were measured. METHODS: This was a retrospective DXA scan reanalysis of 3012 white women >or=50 yrs who had scans of both hips using Hologic DXA systems. The difference between left and right hips was considered significant if it exceeded the least significant change (LSC) for any of three hip subregions (total hip, femoral neck, trochanter). The number of women with osteoporosis in both hips, the left hip only, or the right hip only was determined by lowest T-score from total hip, femoral neck, or trochanter. RESULTS: Despite high left-right correlations of subregion BMD, significant left-right differences in BMD were common: the difference exceeded the LSC for 47% of women at total hip, 31% at femoral neck, and 56% at trochanter. Left-right differences in BMD that exceeded the LSC affected the percent agreement of left-right hip classification: for all women irrespective of spine status, there was 77% classification (diagnostic) agreement in hip pairs in which the left-right hip BMD difference exceeded the LSC versus 87% agreement in which LSC was not exceeded (significant difference in proportions, P<0.0001). The greatest risk of different classification would occur in women with normal spines as the diagnosis might be determined by hip T-scores. Using L1-4 lumbar spine T-scores, 1229 women were normal at the spine. Twenty-four (2%) were osteoporotic at both hips. However, 12 women (1%) were osteoporotic only in the left hip (significantly different from zero, P<0.001) and 11 (1%) only in the right hip (P<0.001); of these 23 women, the difference in BMD between the osteoporotic hip and the contralateral hip exceeded the LSC in 16 (70% of those with osteoporosis in only one hip). Using L1-4 lumbar spine T-scores, 1159 women were osteopenic at the spine. Of these, 126 (11%) were osteoporotic at both hips, 54 (5%) only in the left hip (P<0.001), and 42 (4%) only in the right hip (P<0.001); of these 96 women, the difference in BMD between the osteoporotic hip and the contralateral hip exceeded the LSC in 56 (58% of those with osteoporosis in only one hip). CONCLUSIONS: A statistically significant number of women with osteoporosis are potentially classified differently when scanning only one hip as a result of the high prevalence of left-right differences in BMD. Although the percentages are low, the total number of women affected may be large. From a public health perspective, the practice of scanning both hips could potentially identify more women with osteoporosis and may help prevent future hip fractures.
Absorptiometry, Photon↗
Minimum ten-year follow-up of cemented total hip replacement in patients with osteonecrosis of the femoral head.
Between November 1970 and September 1984 the senior author performed fifty-three consecutive total hip arthroplasties with cement in forty-one patients with the diagnosis of osteonecrosis of the femoral head. Five hips in three patients with failed renal transplants requiring chronic hemodialysis were excluded. At the time of final review, a minimum of ten years after the procedure, twenty-one patients (twenty-eight hips) were living, fifteen patients (eighteen hips) had died, and two patients (two hips) were lost to follow-up. A minimum ten-year follow-up radiograph was obtained on twenty-two (79%) of the hips in surviving patients. During the follow-up period 17.4% of hips (eight hips) required revision: 13.0% (six hips) for aseptic loosening, 2.2% (one hip) for sepsis, and 2.2% (one hip) for recurrent dislocation. All eight revisions occurred in patients living at time of final review, giving a revision prevalence of 22.9% (17.1% for aseptic loosening, 2.9% for sepsis, and 2.9% for recurrent dislocation) in patients surviving ten years. The prevalence of revision of the femoral component for aseptic loosening was 6.5% (three hips) for all hips and 9.1% (three hips) in patients surviving at least ten years. The prevalence of femoral aseptic loosening, defined as those components revised for aseptic loosening and those that demonstrated definite or probable radiographic loosening, was 13.0% (six hips) for all hips and 28.6% (six hips) for hips with at least ten-year radiographic follow-up. The prevalence of revision of the acetabular component for aseptic loosening was 13.0% (six hips) for all hips and 18.2% (six hips) in patients surviving at least ten years. The prevalence of acetabular aseptic loosening was 15.2% (seven hips) for all hips and 29.2% (seven hips) for hips with at least ten-year radiographic follow-up. In patients with osteonecrosis of the femoral head survivorship was significantly inferior to that in the senior author's overall patient population with regard to revision for aseptic loosening (p=0.019), revision for acetabular loosening (p=0.01), revision for femoral loosening (p=0.008), and aseptic femoral loosening (p=0.004). Survivorship to aseptic acetabular loosening was not significantly different (p=0.32). Young age at the time of surgery significantly increased the risk of subsequent component loosening (p<0.008) and revision due to aseptic loosening (p<0.002). These findings demonstrate the relatively poor durability of cemented total hip arthroplasty in patients with osteonecrosis of the femoral head as compared to patients with other diagnoses and suggest that the younger age in this patient population compromises results.
Adolescent↗
[Neonatal screening for congenital hip dislocation. Indication of ultrasonography from a systematic study correlating clinical findings and ultrasonography].
INTRODUCTION: The aim of our study was to verify the correlation between clinical and sonographic screening for CDH. MATERIALS AND METHODS: Clinical and sonographic screening was carried out in 1000 newborns (2000 hips) during the first week of life. Anamnestic risk factors were evaluated and clinical examination was performed using the BARLOW, Le DAMANY and ORTOLANI maneuvers. We also took into account a possible limitation of abduction due to adductor hypertonia and the presence of a hip crepitation. All hips were evaluated by ultrasound examination using Graf's morphologic method. We considered as clinically pathological the positive BARLOW, Le DAMANY and ORTOLANI hips and "doubtful" the stable hips having "crepitation" or "hypertonia of the adductors". The hips considered pathological with the ultrasound were the hips 2c, 3a and 3b according to GRAF. RESULTS: 1) Hips clinically pathological (BARLOW, Le DAMANY and ORTOLANI): 150 (7.5 per cent). 2) The clinically stable hips but "doubtful":--crepitation: 105 (5.25 per cent); adductor hypertonia: 86 (4.3 per cent), total 191 (9.55 per cent). 3) Hips clinically normal but with at least anamnestic risk factor: 198 (9.9 per cent); 4) Hips clinically normal but without anamnestic risk factor: 1461 (73.05 per cent). 5) Hips echographically pathological, that is 2c, 3a and 3b according to Graf: 124 (6.2%) and particularly 2c: 61 (3.05 per cent), 3a: 61 (3.05 per cent) and 3b: 2 (0.1 per cent). DISCUSSION: 1) In the clinically pathological hips (BARLOW positive) 36 were echographically pathological with a clinical-sonographic correlation of 28.3 per cent (36 out of 127); all the ORTOLANI positive hips, were echographically pathological (100 per cent (23 out of 23)). In doubtful hips, sonograms were pathological in 17 of 105 hips with "crepitation" (0.85 per cent) and in 13 of 86 hips with "adductor hypertonia" (0.65 per cent). 2) The clinically and echographically pathological hips at birth, that is 2c, 3a and 3b, must be followed for months. At follow up they showed in almost all the cases an evolution towards normality. It is, therefore, indicated to repeat the clinical and sonographic examination in the first month, before undertaking any kind of treatment. 3) Finally, 12 hips, 0.6 per cent, presenting pathological sonographic type 2c and 3a, were found clinically normal. Nevertheless, almost all of these hips evolved normally. From this study only 0.05 per cent of clinically normal hips presented, later, a dysplasia of the acetabulum. Analysis of the results clearly showed that ultrasound examination may be an excellent help to clinical examination which, if well performed, has top priority for early diagnosis of C.D.H. CONCLUSION: The clinical examination, carefully performed in the first days of life, has priority because it allows discovering a pathological hip or a hip at risk. The sonographic examination is a useful image complementing the clinical examination because it allows confirmation of the diagnosis and follow up of the morphologic evolution of the hip with an inoffensive method and it can give indications for possible treatment. From our study we may conclude that at birth a clinical screening is preferable and that the ultrasound study is to be reserved for pathological, doubtful or at risk hips.
Data Interpretation, Statistical↗
High placement of an acetabular component inserted without cement in a revision total hip arthroplasty. Results after a mean of ten years.
BACKGROUND: Revision of an acetabular component in a patient who has severe periacetabular bone loss is a complex problem, particularly when there is not enough bone stock to allow placement of an acetabular component near the normal anatomical hip center. A valuable option for revision in such a situation is placement of a hemispherical shell, fixed with screws and without cement, against the superior margin of the acetabular defect. The resulting hip center is more proximal than that seen following a typical primary total hip replacement. METHODS: Forty-six hips in forty-four patients were treated consecutively, between July 1984 and February 1988, with a revision in which a hemispherical acetabular component was fixed with screws and without cement. All shells but one were placed with a so-called line-to-line fit. The procedures resulted in a so-called high hip center--that is, the center of rotation of the revised hip was located at least thirty-five millimeters proximal to the interteardrop line. The mean age of the patients at the time of the index procedure was fifty-two years (range, twenty-five to eighty-one years). The most common diagnosis for which the original arthroplasty was performed was osteoarthritis secondary to congenital hip dysplasia or dislocation (twenty-two hips). Thirty-four hips had had a high hip center before the index revision, and most patients had had a substantial limb-length discrepancy, with a mean of 1.6 centimeters of shortening on the side of the operation. In thirty-three hips, the femoral component was replaced as well, with a long-neck or calcar-replacement stem used when necessary to maintain or increase the length of the limb. RESULTS: Six patients (six hips) died before the minimum eight-year follow-up interval; none had had another revision or loosening of the revised acetabular component. Of the remaining patients, four (four hips) had the implant removed. One of them had a resection arthroplasty and one of them had a hip disarticulation because of infection after a subsequent femoral reoperation. Another had a hip disarticulation because of late infection. The fourth implant was removed because it had displaced into the pelvis at approximately six years; this was the only reoperation for aseptic loosening in the series. The remaining thirty-six hips (thirty-four patients) were followed for a mean of 10.4 years (range, 8.5 to 12.7 years). One acetabular component migrated medially and was scheduled for revision. No other acetabular component was loose or had been revised. The mean Harris hip score was 81 points (range, 56 to 100 points) at the time of the most recent follow-up. Despite the use of a high hip center, the prevalence of a positive Trendelenburg sign was reduced from 98 percent (forty-five of forty-six hips) preoperatively to 44 percent (sixteen of thirty-six hips) at the time of the most recent follow-up. The short limbs were lengthened a mean of seven millimeters (range, five millimeters of shortening to forty millimeters of lengthening). CONCLUSIONS: In this study of acetabular revisions with use of a high hip center in patients who had major periacetabular bone loss, mechanical failure occurred in 4 percent (two) of the forty-six hips in the entire series and in 6 percent (two) of the thirty-six hips in patients who were alive and still had the implant in place after a mean of 10.4 years of follow-up. The use of a high hip center did not adversely affect function of the abductor muscles, and the mean limb-length discrepancy was reduced by the femoral reconstruction.
Acetabulum↗
Effect of subtle positioning flaws on measured bone mineral density of the hip.
Careful hip positioning is necessary for accurate and precise measurement of bone mineral density (BMD) by dualenergy X-ray absorptiometry (DXA). Large, intentional rotational deviations from best hip position reportedly increase measured BMD at the femoral neck. The aim of this study is to determine the effect of unintentional, subtle deviations from best hip position ("flaws") on expected and measured BMD of the hip and its subregions. Two hundred DXA scans (GE/Lunar Prodigy) performed in the dual-femur mode were randomly selected and scrutinized for hip-positioning flaws. Hips were sorted by side (right/left), positioning quality (flawless/flawed), and specific positioning flaw (under/over-rotation and adduction/abduction). Individual hip pairs in which at least one hip was flawlessly positioned were further sorted as flawless/flawless, flawless/vertically flawed, flawless/rotationally flaw, and flawless/dually flawed. Differences and direction of difference in BMD between sorted groups and within individual hip pairs were analyzed by univariate analysis (t-test for equal samples). Two hundred hip pairs (400 individual hip scans) were analyzed. Overall, there was no significant difference in BMD between all right and all left hips or between all flawlessly positioned and all flawed hips. In hip pairs in which one hip was flawlessly positioned and the contralateral hip position was flawed (vertically, rotationally, or both), the measured BMD of the latter hip was not predictably greater than the former. Average absolute intrapair BMD difference between hip subregions was 0.038+/-0.001 g/cm2 and was unaffected by the presence or type of positioning flaw. Net intrapair difference between sorted hip groups and within hip pairs was negligible, indicating that the direction of the variance was equally positive and negative. In the practice of clinical densitometry, subtle positioning flaws do not generate predictable changes in measured BMD at any hip region of interest. The current teaching that rotational deviations from best hip position results in a greater measured BMD needs to be reconsidered when comparing a rotationally flawed hip with a contralateral flawlessly positioned hip.
Absorptiometry, Photon↗
The bone-vacuum cementing technique for the fixation of the stem in total hip arthroplasty.
The bone-vacuum cementing technique is a promising method developed to obtain reliable fixation of the femoral component. Previous studies showed that intraoperative embolic complications, cardiopulmonary impairment, and deep venous thrombosis can be prevented when this technique is used. The specific aims of the present investigation were to provide additional treatment outcome information, to identify risk factors for poor results, and to define the need of surgical technique improvement by risk factor analysis. The first 118 consecutive patients (121 hips) who had primary total hip arthroplasty using the bone-vacuum cementing technique and an anatomical stem were followed-up for a mean of 2.5 years (1 to 4 years). The mean age of patients at index operation was 73 years. Current criteria were used for clinical and radiological assessment. At the time of the latest follow-up, 3 patients (3 hips, 2.5%) had been lost, and 9 patients (9 hips, 7.5%) had died. However, the status of the hip joint at the time of death could be verified in all patients. Thus, the clinical outcome of 115 patients (118 hips, 97.5%) was known. Radiographs were available for 102 patients (104 hips) who were alive for the entire follow-up period. The mean preoperative Harris Hip Score was rated 51, and it had improved to 92 at the time of follow-up. The score was good for 70 hips and excellent for 42 hips, so the rate of clinical success was 95%. Six patients (6 hips, 5%) had a fair result. Two of them had a fracture of the greater trochanter after the index operation, requiring internal fixation. Four hips with severe acetabular dysplasia had persistent limp and limited motion. The quality of the cement mantle was rated good (grade A and B) in 108 of 121 hips (89.5%). Nineteen of the 108 hips presented at least one small void in the cement mantle (grade C1). Insufficient thickness of the cement mantle (grade C2) was present in 10 hips (8%). Failure of cement to extend below the tip of the stem (grade D) was observed in the remaining 3 hips (2.5%). In the present series no femoral component required revision because of aseptic loosening, and there was no radiographic evidence of aseptic loosening at follow-up. Radiolucencies without progression were found in Gruen zone 1 in 11 of 104 hips (10.6%), and in zone 7 in 7 hips (6.7%). In one hip (0.9%) ballooning osteolysis was observed in zone 7. Seventy-five hips (72%) had either no change in femoral bone density or only patchy loss of bone density isolated to Gruen zones 1 and 7. Twenty-nine hips (28%) had some reduction of bone density isolated to zones 1 and 7. A slight cortical hypertrophy was seen in 4 hips (3.8%). Of the whole series, one hip required revision surgery because of septic loosening 2 years after the index operation. At an average of 2.5 years postoperatively, the femoral component inserted using the bone-vacuum technique functioned well overall, and patient satisfaction was high. Clinical and radiological results do not contrast with those achieved using contemporary cementing techniques.
Age Factors↗
Charnley total hip arthroplasty with cement. Minimum twenty-five-year follow-up.
BACKGROUND: This report presents the results of the senior author's initial twenty-five-year experience with the use of Charnley total hip arthroplasty with cement. The purpose of this paper was to evaluate the long-term results of total hip arthroplasty. METHODS: Between July 1970 and April 1972, the senior author (R. C. J.) performed 330 Charnley total hip replacements with cement using a hand-packing cement technique in 262 patients. Fifty-one patients (sixty-two hips) who were alive at least twenty-five years post-operatively were evaluated from a clinical standpoint with use of a standard-terminology questionnaire. The average age of this group at the time of surgery was fifty-six years (range, thirty-five to seventy-one years) compared with sixty-five years (range, twenty-one to eighty-nine years) for the entire group. All patients were evaluated for radiographic changes at the time of their most recent follow-up. Of the fifty-one patients (sixty-two hips) who were alive at least twenty-five years postoperatively, thirty-one (thirty-six hips) had a follow-up radiograph made at a minimum of twenty-five years after the surgery. The average duration of radiographic follow-up for the fifty-one patients was 22.7 years (range, two to twenty-seven years). RESULTS: Of the sixty-two hips in the fifty-one patients who were alive at least twenty-five years postoperatively, fourteen (23 percent) had been revised. Three (5 percent) had the revision because of loosening with infection; eleven (18 percent), because of aseptic loosening; and none, because of dislocation. The prevalence of revision due to aseptic loosening of the acetabular component in all 316 hips (excluding those that were lost to follow-up or that were revised for infection or dislocation) was 6 percent (eighteen hips), whereas the prevalence in the fifty-nine hips (excluding the three revised for infection) in the patients who were alive at least twenty-five years after the arthroplasty was 15 percent (nine hips). The prevalence of revision because of aseptic loosening of the femoral component in all 316 hips was 3 percent (nine hips), and the prevalence in the fifty-nine hips in the living patients was 7 percent (four hips). In the group of living patients, osteolysis occurred in Gruen zone 1 or 7 in thirty-three hips and in Gruen zones 2 through 6 in two hips. Ballooning acetabular osteolysis occurred in five hips. Of the 327 hips for which the outcome was known after a minimum of twenty-five years, 295 (90 percent) had retained the original implants until the patient died or until the most recent follow-up examination. Of the sixty-two hips in patients who lived for at least twenty-five years after the surgery, forty-eight (77 percent) had retained the original prosthesis. CONCLUSIONS: Our follow-up study at twenty-five years following Charnley total hip arthroplasty with cement demonstrates the durability of the results of the procedure. These results should provide a means for comparison with the results of newer cementing techniques as well as those associated with newer cemented and cementless hip designs.
Aged↗
Heterotopic ossification after primary cemented and noncemented total hip arthroplasty in patients with osteoarthritis and rheumatoid arthritis.
OBJECTIVE: To compare the frequency and severity of heterotopic ossification (HO) in patients with osteoarthritis or rheumatoid arthritis who undergo cemented or noncemented total hip arthroplasty. DESIGN: A prospective case study. SETTING: A university referral centre. PATIENTS: One hundred and sixty one patients underwent 184 total hip arthroplasties. The 184 hips were categorized as follows: cemented total hip arthroplasty--60 osteoarthritis hips, 26 hips affected by rheumatoid arthritis; noncemented total hip arthroplasty--67 osteoarthritic hips, 31 hips affected by rheumatoid arthritis. INTERVENTIONS: Total hip arthroplasty. A standard approach was used to implant either a cemented or noncemented prosthesis. Radiographs were obtained of each hip preoperatively, immediately postoperatively and 6 weeks, 3 months, 6 months and 1 year postoperatively. MAIN OUTCOME MEASURES: Radiographs were graded in blind fashion for HO, according to the criteria of Brooker. Modified Harris hip scores were calculated at 1 and 2 years postoperatively. RESULTS: HO (incidence of Brooker grades 2, 3 and 4) was greater after cemented (22%) than noncemented (9%) total hip arthroplasty in osteoarthritic hips (p < 0.05), but there was no significant difference between the two types of prosthesis in hips affected by rheumatoid arthritis. When both types of prosthesis were considered together there was no significant difference in the incidence of HO between osteoarthritic hips (15%) and hips affected by rheumatoid arthritis (12%). With respect to Harris hip score, the presence of grade 4 HO was associated with a significantly (p < 0.05) lower score (50.6) than grade 3 (89.4) and grade 2 (91) HO. CONCLUSIONS: Cemented total hip arthroplasty increases the frequency of HO only in osteoarthritic hips. Compared with Brooker's grades 2 and 3 HO, grade 4 HO significantly lowers the Harris hip score after total hip arthroplasty.
Adult↗
The outcome of Charnley total hip arthroplasty with cement after a minimum twenty-year follow-up. The results of one surgeon.
We evaluated the results of 330 total hip arthroplasties that were performed with use of the Charnley prosthesis and cement in 262 patients by the senior one of us between July 1970 and April 1972. All hips had been thoroughly assessed preoperatively to document the patient's functional level. All patients had been disabled because of pain in the hip or a fracture of the hip, and 212 patients (81 per cent) had used walking aids. At a minimum of twenty years after the index operation, eighty-three patients (ninety-eight hips) were still living, 174 patients (224 hips) had died, and five patients (eight hips) had been lost to follow-up. The outcome of the arthroplasty was determined for all except the five latter patients. Thus, the outcome of 322 (98 per cent) of the 330 arthroplasties was known at the latest follow-up evaluation. Radiographs were available for sixty-three of the eighty-three patients (seventy-six [78 per cent] of the ninety-eight hips) who were alive for the entire follow-up period. Of the ninety-eight hips in the living patients, eighty-three (85 per cent) caused no pain, fourteen (14 per cent) caused mild pain, and one (1 per cent) caused moderate pain. Fifty-two hips (53 per cent) were in patients who did not use walking aids, and only seven (7 per cent) were in patients who used support for walking because of the hip. At the minimum twenty-year follow-up, thirty-two (10 per cent) of the 322 hips that had been followed had been revised: eight (2 per cent), because of loosening with infection; twenty-one (7 per cent), because of aseptic loosening; and three (1 per cent), because of dislocation. Of the ninety-eight hips of the patients who were still alive, fifteen (15 per cent) had been revised: three (3 per cent), because of loosening with infection; eleven (11 per cent), because of aseptic loosening; and one (1 per cent), because of dislocation. The rate of revision due to aseptic loosening of the acetabular component in all 322 hips was 6 per cent (eighteen hips), while in the ninety-eight hips of the patients who were alive at least twenty years after the arthroplasty, it was 10 per cent (ten hips). The rate of revision because of aseptic loosening of the femoral component in all 322 hips was 2 per cent (eight hips), while in the ninety-eight hips of the living patients, it was 3 per cent (three hips).(ABSTRACT TRUNCATED AT 400 WORDS)
Acetabulum↗
Charnley total hip arthroplasty with use of improved techniques of cementing. The results after a minimum of fifteen years of follow-up.
Three hundred and fifty-seven consecutive Charnley total hip arthroplasties were performed in 320 patients with use of a so-called second-generation technique of cementing between July 1976 and June 1978. This technique includes use of a distal femoral intramedullary cement plug, hand-mixing of the cement, and use of a cement gun to deliver the cement into the femoral canal in a retrograde fashion. At the time of the latest follow-up evaluation, a minimum of fifteen years after the arthroplasty, 130 patients (142 hips) were still alive, 189 patients (214 hips) had died, and one patient (one hip) had been lost to follow-up. A radiograph was made for 116 (82 per cent) of the 142 hips in the 130 surviving patients. Of the 356 hips that had not been lost to follow-up, thirty-three (9 per cent) had had a revision and two (1 per cent), a Girdlestone resection arthroplasty during the follow-up period. Nineteen hips (5 per cent) were revised because of aseptic loosening of the femoral or acetabular component, or both (two hips); seven (2 per cent), because of loosening with infection; and seven (2 per cent), because of dislocation. The two resection arthroplasties were performed because of loosening with infection; both were done in patients who died before the time of the latest follow-up evaluation. Of the 142 hips in the 130 patients who were alive at a minimum of fifteen years, twenty-two (15 per cent) had been revised: fifteen (11 per cent), because of aseptic loosening; three (2 per cent), because of loosening with infection; and four (3 per cent), because of dislocation. Revision of the femoral component because of aseptic loosening (excluding components that were revised because of dislocation or infection) was performed in four (1 per cent) of the entire series of 356 hips and in three (2 per cent) of the 142 hips in the 130 patients who survived for at least fifteen years. Two of the 356 hips and two of the 142 hips had aseptic loosening of the acetabular as well as the femoral component at the time of the revision. Loosening of the femoral component, defined as aseptic loosening leading to revision or as definite or probable radiographic loosening, occurred in ten (3 per cent) of the 356 hips and in six (5 per cent) of the 116 hips for which radiographs were made at a minimum of fifteen years. The acetabular component was revised because of aseptic loosening in seventeen (5 per cent) of the entire series of 356 hips and in fourteen (10 per cent) of the 142 hips in the 130 patients who survived for at least fifteen years. The acetabular component loosened without infection in forty-one (12 per cent) of the 356 hips and in twenty-six (22 per cent) of the 116 hips for which radiographs were made at a minimum of fifteen years. In two of these patients, the femoral component was also revised. Thus, of the entire series of 356 hips, two had a revision of the femoral component alone because of aseptic loosening; fifteen, a revision of the acetabular component alone; and two, a revision of both components. Of the 142 hips in the 130 patients who survived for at least fifteen years, one was revised for loosening of the femoral component alone; twelve, for loosening of the acetabular component alone; and two, for loosening of both components. These findings demonstrate long-term durability of fixation of the femoral component but less reliable fixation of the acetabular component, even when the surgeon is experienced and improved techniques of cementing are used.
Activities of Daily Living↗
Medial protrusio technique for placement of a porous-coated, hemispherical acetabular component without cement in a total hip arthroplasty in patients who have acetabular dysplasia.
Twenty-four hip replacements were performed with use of a medial protrusio technique to stabilize the fit of a hemispherical metal shell in the acetabulum in nineteen patients who had dysplasia of the hip. All of the hips were followed for a minimum of five years (average, seven years; range, five to thirteen years). Six of the hips were type I, seven were type II, eight were type III, and three were type IV according to the criteria of Crowe et al. The acetabular cup was implanted with the medial aspect of its dome beyond the Kohler line (drawn from the ischium along the ilioischial line) in all hips. An autogenous graft sculpted from the femoral head was used to cover 15 to 30 percent of the superolateral portion of the cup in one type-I hip, four type-III hips, and one type-IV hip. The need for these six bone grafts could have been avoided by reaming two to three millimeters more medially or by allowing 20 percent of the superolateral portion of the cup to be uncovered. Sixty to 84 percent of each bone graft was resorbed, effectively leaving the superolateral portion of the cup uncovered. The amount of the surface of the cup that was beyond the Kohler line averaged 41 percent for the six type-I hips, 43 percent for the seven type-II hips, 41 percent for six of the type-III hips, and 44 percent for one of the type-IV hips. Crossing of the ilioischial and iliopubic lines was noted on the radiographs of two type-III and two type-IV hips. Radiographs of two type-I hips and one type-II hip showed 7 to 17 percent of the surface of the dome of the cup through the internal pelvic wall (beyond the iliopubic line). None of the twenty-four metal shells were revised. A reoperation was performed on two hips to exchange a worn polyethylene insert, and three femoral components that had been fixed without cement were revised because of mechanical loosening. Wear averaged 0.26 millimeter per year in the fourteen hips that had a titanium femoral head and 0.09 millimeter per year in the nine hips that had a cobalt-chromium femoral head. The remaining hip had a ceramic femoral head, and the wear rate was 0.09 millimeter per year. The medial protrusio technique is a predictable, reproducible method for obtaining fixation of a porous-coated, hemispherical acetabular component in a dysplastic acetabulum. The technique permits the use of a porous-coated (bone-ingrowth) component; avoids the use of support bone graft and thereby reduces the operative time; facilitates rehabilitation by permitting earlier weight-bearing of the hip; and permits the use of a modular bearing surface, which may allow future exchange of only this surface rather than revision of the entire acetabular component because of excessive wear.
Acetabulum↗
Hip fractures: incidence, risk factors, energy absorption, and prevention.
The present review summarizes the pathogenic mechanisms leading to hip fracture based on epidemiological, experimental, and controlled clinical studies. The estimated lifetime risk of hip fracture is about 14% in postmenopausal women and 6% in men. The incidence of hip fractures increases exponentially with aging, but the time trend in increasing age-specific incidence may finally reach a plateau. Postmenopausal women suffering earlier non-hip fractures have an increased risk of later hip fracture. The relative risk is highest within the first years following the fracture. Nursing home residents have a high risk of hip fracture (annual rate of 5-6%), and their incidence of falls is about 1.5 falls/person per year. Most hip fractures are a result of a direct trauma against the hip. The incidence of falls on the hip among nursing home residents is about 0.29 falls/person per year and about 20% of these traumas lead to hip fracture. Women with hip fractures have a lower body weight compared with controls, and they may also have less soft tissue covering the hip, even when adjusted for body mass index, indicating a more android body habitus. Experimental studies show that the passive energy absorption in soft tissue covering the hip may influence the risk of hip fracture and be an important determinant for the development of hip fracture, perhaps even more important than bone strength. External hip protectors were developed and tested in an open randomized nursing home study. The rate of hip fracture was reduced by 50%, corresponding to 9 of 247 residents saved from sustaining a hip fracture. This review points to the essentials in the development of hip fracture: risk of fall; type of fall; type of impact; energy absorption; and last, bone strength, which is the final permissive factor leading to hip fracture. Risk estimation and prevention of hip fracture may prove realistic when these issues are taken into consideration.
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