Andrew H. Glassman

Results of cementless revision for failed cemented total hip arthroplasty.

The goals of revision total hip arthroplasty (THA) are to reestablish and maintain stable implant fixation. Based upon promising early results in primary THA, porous-surfaced implants designed for bone ingrowth fixation are being increasingly used in hopes of more successfully achieving these goals than has been the case using cement. One hundred and sixty such revisions were followed for a mean of 4.4 years, with specific reference to implant fixation. Roentgenographic evaluation of implant fixation suggested four categories of femoral and acetabular components: (1) bone ingrown, (2) stable fibrous encapsulation, (3) questionable, with signs of impending instability, or (4) definitely unstable implant migration, indicative of the need for rerevision. Not surprisingly, success in achieving and maintaining stable implant fixation following revision THA is dependent upon component design, surgical technique, and preexistent bone stock damage. This classification according to bone stock damage should be borne in mind when critically evaluating the results from various revision series.

The case for porous-coated hip implants. The femoral side.

A series of 1163 total hip arthroplasties (THAs) using porous-coated femoral components were roentgenographically assessed for implant fixation. For 959 primary THAs followed from two to 12 years, the femoral revision rate was 1% and the ten-year survivorship rate was 96.4%; 150 young patients had a fixation failure incidence of only 1.3% at a mean follow-up period of 6.4 years; in 204 revision THAs, the femoral re-revision rate was 4% at a mean follow-up period of 53.4 months. Failures were largely related to inadequate femoral canal filling. Because of refinements in implant design and surgical techniques, a press fit of the implant is currently achieved in 94% of cases compared to 36% during the first five years. Porous-coated femoral components have yielded results equivalent to those with cement in primary THAs. Excellent results were observed in relatively young patients and patients with revisions.

A technique of extensile exposure for total hip arthroplasty

A technique of trochanteric osteotomy that allows extensile exposure of the hip and wide exposure of the proximal femoral diaphysis for total joint replacement is described. Pathologic conditions of the shaft encountered during arthroplasty can therefore be addressed. The approach is based on the preservation of an intact musculoosseous-muscular sleeve comprised of the gluteus medius, greater trochanter, and vastus lateralis and allows physiologic reconstruction of the hips soft tissue envelope. This versatile approach is particularly useful in revision surgery and in difficult primary interventions where leg length is adjusted. The surgical technique, indications, and advantages are described. Early clinical results of 90 cases are presented.

Recurrent Dislocation After Revision Total Hip Replacement with a Large Prosthetic Femoral Head

Surgical treatment choices for recurrent dislocation of the hip include isolated soft-tissue tightening1 or revision of prosthetic components with use of an array of options, including standard components implanted in satisfactory position1,2, constrained acetabular devices1,3, elevated-rim polyethylene components3,4, and the use of larger prosthetic femoral heads3,5. The last treatment option is facilitated by the recent availability of larger prosthetic heads and cups that use highly cross-linked polyethylene6,7. We report the case of a patient who had recurrent dislocation after a total hip replacement, in which the orientation of the acetabular component was suboptimal and had been unsuccessfully treated initially with a large femoral head. The patient was informed that data concerning her case would be submitted for publication. A sixty-five-year-old woman was referred to one of us (D.H.) because of a dislocated hip prosthesis approximately six months after a primary total arthroplasty of the left hip. Since the arthroplasty, she had had multiple dislocations of the hip and was treated each time with closed reduction. The medical history included breast cancer with mastectomy, hypertension, hyperlipidemia, and postoperative deep-vein thrombosis of the left lower extremity with a pulmonary embolus that had developed two months after the total hip replacement and was treated with Coumadin (warfarin). The patient had had Coumadin one week prior to presentation. She was 5 ft 6 in (168 cm) tall and weighed 222 lb (101 kg). The findings on the physical examination were consistent with her age, gender, and large body mass. An anteroposterior pelvic radiograph (Fig. 1) revealed no evidence of prosthetic component loosening. The acetabular component was oriented in approximately 70° of abduction. The elliptical appearance of the acetabular component on …

A low stiffness composite biologically fixed prosthesis.

The current authors addressed the question whether stress-induced adaptive bone remodeling of the proximal femur is a necessary consequence after total hip reconstruction with extensively biologically-fixed femoral components. A novel total hip femoral component was designed to simultaneously achieve stable skeletal fixation, structural durability, and reduced femoral stress shielding. This implant allowed for proximal and distal canal filling, yet was significantly less rigid than all-metallic femoral stems crafted of either cobalt chromium or titanium alloy. A cohort of 366 patients (386 hips) treated at 21 institutions worldwide now have been followed up a mean of 2.4 years postoperatively (range, 3 months–6 years). Two hundred sixty-eight patients have 2 years minimum followup. To date, no femoral implants have failed to achieve bone ingrowth and none have required revision. The implants appear radiographically well-fixed with no progressive radiolucencies or osteolysis. Radiostereometric analysis studies on one subset of patients showed stable initial fixation and minimal stem micromotion. Dual energy xray absorptiometry analysis on another subset of patients revealed excellent periprosthetic bone mineral density retention. Compared with more rigid metal implants, this design shows reduced proximal femoral bone loss secondary to stress-mediated bone resorption.

Preoperative Risk Stratification and Risk Reduction for Total Joint Reconstruction: AAOS Exhibit Selection.

Demand for primary total hip arthroplasty and demand for total knee arthroplasty in the United States are anticipated to grow by 174% and 673%, respectively, over the next twenty years1. Satisfaction rates are good to excellent in most patients2-4. Modern techniques and perioperative care have reduced systemic and local complications5-7. Nevertheless, the risks of major adverse outcomes (2.2% to 7.4%)8-10 and death (0.1% to 0.8%)5,7-9,11-19 remain real. Careful preoperative clearance and targeted therapeutic interventions are necessary to minimize complications. Studies have demonstrated total joint arthroplasty to be a highly cost-effective procedure. Nevertheless, many payers, especially the U.S. Centers for Medicare & Medicaid Services (CMS), have targeted total joint arthroplasty for cost control20. Adoption of a pay-for-performance program by CMS21 has created a zero-sum game to reward overachievers and penalize underachievers. The current literature lacks a detailed, comprehensive approach for risk-stratifying total joint arthroplasty patients and a systematic method for preoperatively allaying these risks. Popular tools such as the American Society of Anesthesiologists (ASA) classification system may be effective in predicting the overall outcome of surgery, but they cannot predict specific complications22 and they do not facilitate further preparatory action23-25. Although medical evaluation should be performed in collaboration with the internist, evidence-based guidelines provide standardization and comprehensiveness. Conditions necessitating postponement or cancellation of total joint arthroplasty are present in approximately 4% of patients26. Complications related to the cardiovascular system represent 42% to 75% of major systemic adverse events and deaths following total joint arthroplasty7,13,27,28, and cardiovascular comorbidities are a significant risk factor for these events14,29. Intramedullary instrumentation …

Exposure for revision: total hip replacement.

The author uses four basic approaches for the majority of revision total hip replacements (THRS). The posterior approach is used for most simple revisions of loose endoprostheses, short, loose, cemented stems, and straightforward cup revisions. The key technical maneuvers are the soft tissue releases necessary to adequately displace the proximal femur anteriorly. The sliding trochanteric osteotomy is used when greater exposure of the femoral shaft is necessary to remove implant materials, to treat deformities or fractures, when abductor tension must be adjusted, or when enhanced acetabular exposure is required. Proper orientation of the osteotomy and excision of anterior pseudocapsule are necessary to mobilize the muscular osseous sleeve created by this approach. The extended trochanteric osteotomy is recommended for the most difficult femoral revisions, including the removal of well-fixed cementless and cemented components. The lateral 1/3 of the femoral shaft is removed as far distally as necessary. Careful attention to the creation, elevation, mobilization, and fixation of the osteotomized fragment is important in avoiding fracture or nonunion. The combined AP extensile approach is used for the most difficult acetabular reconstructions, including total acetabular allografting. Cadaveric training and possibly general, vascular, or urologic surgical assistance is recommended for this difficult approach.

Twenty- to twenty-six-year radiographic review in patients 50 years of age or younger with cemented Charnley low-friction arthroplasty

This is a retrospective radiographic study at 20 to 26 years of follow-up of a single surgeons consecutive series of patients operated on at 50 years of age or younger with Charnley low-friction arthroplasty. Loosening, osteolysis, and wear were evaluated. Fifty-four patients underwent 68 low-friction arthroplasties. Fifty percent were 40 years of age or younger at surgery. The average rate of wear was 0.08 mm/yr. Osteolysis was infrequent. Twenty-two-year survival estimates and corresponding confidence levels were 76% for the cup (all causes) and 78.8% for the stem. For aseptic loosening, the figure was 80.5% for the cup and 85.2% for the stem. Successful radiographic results can be achieved in younger patients undergoing Charnley low-friction arthroplasty with more than 20 years of follow-up.

The removal of porous-coated femoral hip stems.

During a ten-year period, 70 porous-coated femoral hip components of several designs were removed for various reasons. Based on this experience, techniques for the removal of porous-coated stems have evolved and are described, including a newer method for the safe removal of extensively coated bone-ingrown stems. Preoperative roentgenograms were highly predictive of fixation mode as corroborated by intraoperative mechanical testing, gross inspection, and histologic examination. Stable implants (17 bone-ingrown and 11 fibrous tissue-encapsulated) required interface access and division before their removal. Minimal bone damage was incurred, and in no case was reconstruction precluded by stem removal. There were no unplanned cortical perforations. Two minor femoral fractures occurred. The authors present an overall approach and specific surgical techniques that facilitate the safe removal of porous-coated femoral stems on a consistent basis.

Limb-length discrepancy after hip arthroplasty.

➤ Limb-length discrepancy is a common condition found in the general population and elderly individuals with osteoarthritis. ➤ All aspects of total hip arthroplasty are interconnected, and making adjustments in one can affect several others. ➤ Intraoperative imaging with trial or final components in place is helpful to rule out excessive limb-length discrepancy and to confirm proper component sizing and position in difficult primary total hip arthroplasty or revision situations.