A. Gonzalez Della Valle

Reconstruction of non-contained acetabular defects with impaction grafting, a reinforcement mesh and a cemented polyethylene acetabular component

This review summarises the technique of impaction grafting with mesh augmentation for the treatment of uncontained acetabular defects in revision hip arthroplasty. The ideal acetabular revision should restore bone stock, use a small socket in the nearanatomic position, and provide durable fixation. Impaction bone grafting, which has been in use for over 40 years, offers the ability to achieve these goals in uncontained defects. The precepts of modern, revision impaction grafting are that the segmental or cavitary defects must be supported with a mesh; the contained cavity is filled with vigorously impacted morselised fresh‐frozen allograft; and finally, acrylic cement is used to stabilise the graft and provide rigid, long‐lasting fixation of the revised acetabular component. Favourable results have been published with this technique. While having its limitations, it is a viable option to address large acetabular defects in revision arthroplasty.

The modern, hybrid total hip arthroplasty for primary osteoarthritis at the Hospital for Special Surgery

We describe our technique and rationale using hybrid fixation for primary total hip arthroplasty (THA) at the Hospital for Special Surgery. Modern uncemented acetabular components have few screw holes, or no holes, polished inner surfaces, improved locking mechanisms, and maximised thickness and shell-liner conformity. Uncemented sockets can be combined with highly cross-linked polyethylene liners, which have demonstrated very low wear and osteolysis rates after ten to 15 years of implantation. The results of cement fixation with a smooth or polished surface finished stem have been excellent, virtually eliminating complications seen with cementless fixation like peri-operative femoral fractures and thigh pain. Although mid-term results of modern cementless stems are encouraging, the long-term data do not show reduced revision rates for cementless stems compared with cemented smooth stems. In this paper we review the conduct of a hybrid THA, with emphasis on pre-operative planning, surgical technique, hypotensive epidural anaesthesia, and intra-operative physiology.

Age affects the perception of limb length discrepancy in patients with and without a total hip arthroplasty

The amount of lengthening or shortening that can be detected by patients before and after total hip arthroplasty has not been yet quantified. We studied the ability to detect limb length inequality in 194 patients with and without a total hip arthroplasty, match-paired for age and sex. None of the participants had clinical signs of lumbosacral pathology, spinal deformity, or fixed pelvic obliquity; and all had equal functional and actual limb length. The participants walked with shoes, with and without the addition of fixed insoles, to simulate 2.5, 5, 10 and 15 millimeters of shortening and lengthening of the tested limb. Lengthening and shortening were similarly detected. Younger individuals detected the differences better than older ones (p=0.001), and there was a significant correlation between the decade of life and the ability to detect a limb length discrepancy (r=-0.22; p=0.002). This study demonstrates that perception of limb length is affected by the age, with older individuals having less awareness of changes in limb length than younger ones. (Hip International 2004; 14: 249-53).

Bilateral total hip arthroplasty in siblings with Stickler Syndrome.

Stickler Syndrome is an infrequent autosomal dominant connective tissue disorder. The most prevalent mutation affects type II collagen gene and results in abnormalities in cartilage, vitreous and nucleus pulposus. Orthopaedic manifestations include joint hyper- mobility and pain with early development of secondary osteoarthritis. The condition has a predilection for the femoral head and patients usually present in their third to fourth decade with secondary hip arthritis. We report on two siblings with Stickler Syndrome who presented with hip osteoarthritis in their third decade of life and underwent staged bilateral total hip arthroplasties (THA). The patients experienced pain relief and improved quality of life after surgery.

A new technique to improve cup inclination accuracy in primary total hip arthroplasty

Accurate inclination and anteversion of the acetabular component is paramount to achieve a stable total hip arthroplasty, prevent prosthetic dislocation and minimize long- term wear. We present and evaluate a simple new technique to improve consistency in cup inclination during primary total hip arthroplasty, based on information available from the preoperative plan. The technique consists of assessing the distance and relationship between the inferomedial border of the acetabular cup and the inferomedial margin of the teardrop, with the use of a measuring probe. This simple surgical gesture improved consistency in cup inclination during total hip arthroplasty.;

Subsidence Pattern of Charnley Cemented Femoral Revisions with Impacted Morcelised Bone After a Follow-up of Two to Twelve Years

We quantified the subsidence in 56 of 59 consecutive Charnley femoral revisions with impacted morcelised bone, after 57 months of follow-up (range 48–144). Subsidence was measured on AP radiographs obtained at regular intervals. Subsidence was analysed together with the development of radiographic loosening or need for re-revision subsidence. During the first two years it was compared with that of 50 Charnley primary arthroplasties. In forty-five revisions no subsidence was detected, and 11 had subsided an average of 6 millimeters (range 2–20). Among 52 successful revisions, 45 had no subsidence detected and 7 subsided less than 5 millimeters (average 2.42; range 2–4). All 4 failed revisions subsided (average: 12 millimeters; range 2–20). The difference between successful and failed revisions was significant (p=0.009). At 2 years of follow-up, 9 revisions and 2 primary arthroplasties had subsidence detected (p=0.14). Subsidence detected after the second year was observed in all failed revisions and in only one successful. Subsidence in successful Charnley revisions is restricted to less than 5 millimeters and occurs during the first two postoperative years. The different subsidence pattern between revision and primary arthroplasties suggests that limited subsidence of the grafts occurs, predominantly during the first two years.

Polymethylmethacrylate Venogram after Cemented Arthroplasty of the Hip. A Report of Seven Cases and Review of the Literature

We present seven patients with polymethylmethacrylate (PMMA) filling the veins accompanying the second perforating branch of the profunda femoris artery detected after primary cemented hip arthroplasty. All implants were cemented utilizing retrograde canal filling with a cement pistol and pressurization. No haemodynamic changes were observed throughout any of the procedures and all patients had an uneventful recovery and evolution. The presence of a PMMA venogram is an infrequent finding after cemented hip arthroplasty. In our seven cases it was not associated with higher peri-operative morbidity. Differential diagnoses must be made with cement extruded through incomplete fractures or through femoral screw holes, as treatment and weightbearing status may differ.

Early detection of occult fractures around the hip with magnetic resonance imaging

Hip fractures may not be evident on initial radiographs but can be demonstrated with special imaging studies. These “occult fractures” can displace if not promptly treated. In a four-year period, 3...