Daniel J. Berry

Twenty-five-year survivorship of two thousand consecutive primary Charnley total hip replacements: factors affecting survivorship of acetabular and femoral components.

Background: Charnley total hip arthroplasty has been demonstrated to provide good clinical results and a high rate of implant survivorship for twenty years and longer. Most long-term series are not large enough to stratify the many demographic factors that influence implant survivorship. The purpose of this study was to analyze the effects of demographic factors and diagnoses on the long-term survivorship of the acetabular and femoral components used in Charnley total hip arthroplasty.Methods: Two thousand primary Charnley total hip arthroplasties (1689 patients) were performed at one institution from 1969 to 1971. Patients were contacted at five-year intervals after the arthroplasty. Twenty-five years after the surgery, 1228 patients had died and 461 patients were living. Hips that had not had a reoperation, revision or removal of a component for any reason, or revision or removal for aseptic loosening were considered to have survived. Survivorship data were calculated with use of the method of Kaplan and Meier. Patients were stratified by age, gender, and underlying diagnosis to determine the influence of these factors on implant survivorship.Results: The twenty-five year rates of survivorship free of reoperation, free of revision or removal of the implant for any reason, and free of revision or removal for aseptic loosening were 77.5%, 80.9% and 86.5%, respectively. The twenty-five-year survivorship free of revision for aseptic loosening was poorer for each decade earlier in life at which the procedure was performed; this survivorship ranged from 68.7% for patients who were less than forty years of age to 100% for patients who were eighty years of age or older. Men had a twofold higher rate of revision for aseptic loosening than did women.Conclusions: Age, gender, and underlying diagnosis all affected the likelihood of long-term survivorship of the acetabular and femoral components used in Charnley total hip arthroplasty.

Reverse Obliquity Fractures of the Intertrochanteric Region of the Femur

Background: The reverse obliquity fracture of the proximal part of the femur is a distinct fracture pattern that is mechanically different from most intertrochanteric fractures. The purpose of this retrospective study was to determine the prevalence of these fractures and the results and complications of different types of internal fixation used in their treatment. Methods: Between 1988 and 1998, 2472 consecutive patients with a hip fracture were treated at our Level-One Trauma Center; 1035 of the fractures were classified as intertrochanteric or subtrochanteric. Clinical and radiographic records were retrospectively reviewed, and fifty‐five fractures with a reverse obliquity pattern were identified. Forty‐nine patients were followed until the fracture united or a revision operation was performed. The duration of clinical follow-up averaged eighteen months (range, three to sixty‐seven months), and the duration of radiographic follow-up averaged fifteen months (range, three to sixty months). Fractures were classified with the Orthopaedic Trauma Association scheme. Results were analyzed according to the fracture pattern, type of implant, quality of the reduction, position of the implant, and use of bone graft at the index operation. Function was assessed on the basis of pain, living situation, need for walking aids, need for analgesics, and walking capacity. Results: Thirty‐two (68%) of forty‐seven hips treated with internal fixation healed without an additional operation. Fifteen (32%) of the forty‐seven failed to heal or had a failure of fixation. The failure rate was nine of sixteen for the sliding hip screws, two of fifteen for the blade-plates, three of ten for the dynamic condylar screws, one of three for the cephalomedullary nails, and zero of three for the intramedullary hip screws. Use of the fixed-angle devices (the blade-plate and the dynamic condylar screw) resulted in fewer failures than did use of the sliding hip screw (p = 0.023). Eleven (46%) of twenty‐four nonanatomically reduced fractures and four (17%) of twenty‐three anatomically reduced fractures had a failure of treatment (p = 0.060). Eleven (26%) of forty‐two fractures with an ideally placed implant and four (80%) of five fractures with a non-ideally placed implant had a failure of treatment (p = 0.023). Of the fifteen fractures that failed to heal or had a failure of fixation, five were treated with revision to a calcar-replacement prosthesis, seven were treated with revision open reduction and internal fixation with bone-grafting, and one was treated with bone-grafting without revision of the fixation. Two patients refused additional surgery because they had limited functional demands. The two-year mortality rate was 33%. Functional results were poor, with many patients requiring walking aids and losing the capacity for independent walking and self-care. Conclusions: In this series, reverse obliquity fractures accounted for 2% of all hip fractures and 5% of all intertrochanteric and subtrochanteric fractures. Ninety‐five-degree fixed-angle internal fixation devices performed significantly better than did sliding hip screws. Results were also worse for fractures with poor reduction and those with a poorly placed implant.

Periprosthetic Femoral Fractures Around Well-Fixed Implants:Use of Cortical Onlay Allografts with or without a Plate

Background: Periprosthetic femoral fractures around hip replacements are increasingly common. When the femoral component is stable, open reduction and internal fixation is recommended in all but exceptional cases. The purpose of this study was to evaluate the outcome of treatment of fractures around stable implants with cortical onlay strut allografts with or without a plate. Methods: A survey of our four centers identified forty patients with a fracture around a well-fixed femoral stem treated with cortical onlay strut allografts without revision of the femoral component. There were fourteen men and twenty-six women, with an average age of sixty-nine years. Nineteen patients were treated with cortical onlay strut allografts alone, and twenty-one were managed with a plate and one or two cortical struts. All of the patients were followed until fracture union or until a reoperation was done. The mean duration of follow-up was twenty-eight months for thirty-nine patients. One patient, who was noncompliant with treatment recommendations, had a failure at two months because of a fracture of the plate and graft. The primary end point of the evaluation was fracture union; secondary end points included strut-to-host bone union, the amount of final bone stock, and postoperative function. Results: Thirty-nine (98%) of the forty fractures united, and strut-to-host bone union was typically seen within the first year. There were four malunions, all of which had <10° of malalignment, and one deep infection. There was no evidence of femoral loosening in any patient. All but one of the surviving patients returned to their preoperative functional level within one year. Conclusions: Cortical onlay strut allografts act as biological bone plates, serving both a mechanical and a biological function. The use of cortical struts, either alone or in conjunction with a plate, led to a very high rate of fracture union, satisfactory alignment, and an increase in femoral bone stock at the time of short-term follow-up. Although this study did not address the potential for later allograft remodeling, our findings suggest that cortical strut grafts should be used routinely to augment fixation and healing of a periprosthetic femoral fracture.

The Chitranjan Ranawat Award: Long-term Survivorship and Failure Modes of 1000 Cemented Condylar Total Knee Arthroplasties

We examined factors affecting survivorship, and reasons for reoperation and revision of a cemented modular condylar total knee arthroplasty (TKA). One thousand and eight consecutive primary cemented cruciate-retaining TKAs performed at one institution were studied. At the time of review, 411 patients (562 knees) had died, 43 patients (45 knees) had their knee components revised or removed, and 47 patients (62 knees) were lost to followup. Mean followup of living patients with their TKA components in situ (244 patients, 331 knees) was 15.7 years. Survivorship at 15 years for revision for any reason, revision for mechanical failure, and revision for aseptic loosening were 95.9%, 97.0%, and 98.8% respectively. Survivorship was poorer among patients aged less than 60. Forty-five knees had components removed or revised; approximately one-third were removed for infection, one-third for aseptic loosening or tibial polyethylene wear, and one-third for other causes. Mechanical implant failures accounted for less than one-half of the reoperations and revisions, while infection and periprosthetic fractures accounted for a substantial portion of revisions and reoperations. Because mechanical arthroplasty failures have become less common, other complications related to arthroplasty have become proportionately more frequent. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Late dislocation after total hip arthroplasty.

Background: Some patients have a dislocation for the first time many years after a total hip arthroplasty, but little is known about the risk factors and outcomes associated with late dislocation. The purposes of this study were (1) to determine the prevalence of late dislocation after total hip arthroplasty, (2) to characterize demographic and other factors associated with such late dislocations, and (3) to report the outcomes of such late dislocations.Methods: Between 1969 and 1995, 19,680 primary total hip arthroplasties were performed in 15,964 patients at our institution. According to a prospective surveillance protocol, the patients were followed routinely at regular intervals and were specifically queried at each time-point about whether (and, if so, when) the hip had dislocated. First dislocations that occurred five years or more after the operation were defined as late dislocations.Results: Five hundred and thirteen (2.6%) of the 19,680 hips dislocated. Of the 513 hips, 165 (0.8% of the entire cohort; 32% of the dislocated hips) first dislocated five or more years after the primary arthroplasty. The median time until the occurrence of these late dislocations was 11.3 years (range, five to 24.9 years) after the operation. Late dislocation was more frequent than early dislocation in women (p = 0.03), and late dislocation was associated with a younger age at the time of the primary total hip arthroplasty (median, sixty-three years) than was early dislocation (median, sixty-seven years) (p = 0.02). Clinical factors associated with late dislocation included previous subluxations without dislocation in twenty patients, a substantial episode of trauma in eleven patients, and onset of marked cognitive or motor neurologic impairment in eleven patients. Radiographically, the late dislocation occurred in association with polyethylene wear of >2 mm in eighteen hips, with implant loosening with migration or a change in position in eight, and with initial malposition of the acetabular implant (anteversion of <0&degree; or >30&degree; or abduction of >55&degree;) in thirty. Late dislocation recurred in ninety (55%) of the 165 hips and was treated with a reoperation in fifty-five hips (33% of the hips with late dislocation; 61% of the hips with recurrent dislocation).Conclusions: Late dislocation is more common than was previously thought. Several separate processes, some distinct from those associated with early dislocation, can lead to late dislocation. Late dislocation can occur in association with a long-standing problem with the prosthesis that manifests late (such as malposition of the implant or recurrent subluxation), it can occur in association with a new problem (such as neurologic decline, an episode of trauma, or polyethylene wear), or it can occur in association with any combination of these factors. The likelihood of the first late dislocation recurring is high.

Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures.

Background: Failed treatment of an intertrochanteric fracture typically leads to profound functional disability and pain. Treatment with repeated attempts to gain union and to preserve the host femoral head usually is preferred for young patients, but salvage treatment with hip arthroplasty may be considered for selected older patients with poor bone quality, bone loss, or articular cartilage damage. The purpose of the present study was to evaluate the results and complications of hip arthroplasty performed as a salvage procedure after the failed treatment of an intertrochanteric hip fracture. Methods: Between 1985 and 1997, sixty patients (forty-nine women and eleven men) with a mean age of seventy-eight years were treated at our institution with hip arthroplasty after the failed treatment of an intertrochanteric fracture. Thirty-two patients had a total hip arthroplasty with a cemented cup (twenty-four patients) or an uncemented cup (eight patients), twenty-seven had a bipolar hemiarthroplasty, and one had a unipolar hemiarthroplasty. A calcar-replacement design, extended-neck stem, or long-stem implant was used in fifty-one of the sixty hips. Results: Ten patients died within two years (all with the implant intact), and six were lost to follow-up. The remaining forty-four patients were followed for a mean of five years (range, two to fifteen years). At the time of the last follow-up, thirty-nine patients had no or mild pain and five had moderate or severe pain; in all of these patients, the pain was in the region of the greater trochanter. Forty patients were able to walk, twenty-six with one-arm support or less. Twelve patients had a total of thirteen medical complications postoperatively. A total of five reoperations were performed: two patients had a revision, one had a rewiring procedure because of trochanteric avulsion, one had late removal of trochanteric hardware, and one had débridement of fat necrosis. One patient had two dislocations, both of which were treated with closed reduction. Kaplan-Meier survivorship analysis with revision of the implant for any reason as the end point revealed a survival rate of 100% at seven years and 87.5% (95% confidence interval, 67.3% to 100%) at ten years. Conclusions: Hip arthroplasty is an effective salvage procedure after the failed treatment of an intertrochanteric fracture in an older patient. Most patients have good pain relief and functional improvement. Calcar-replacement and long-stem implants often are required. Despite the operative challenges, surprisingly few serious orthopaedic complications were associated with this procedure in the present study. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Surgical Treatment of Developmental Dysplasia of the Hip in Adults: II. Arthroplasty Options

&NA; Total hip arthroplasty is the procedure of choice for most patients with symptomatic end‐stage coxarthrosis secondary to hip dysplasia. The anatomic abnormalities associated with the dysplastic hip increase the complexity of hip arthroplasty. When pelvic bone stock allows, it is desirable to reconstruct the socket at or near the normal anatomic acetabular location. To obtain sufficient bony coverage of the acetabular component, the socket can be medialized or elevated, or a lateral bone graft can be applied. Uncemented acetabular components allow biologic fixation with potentially improved results compared with cemented cups, especially in young patients. The location of the acetabular reconstruction and the desired leg length influence the type of femoral reconstruction. Cemented and uncemented implants can be used in femoral reconstruction, depending on the clinical situation. Femoral shortening is required in some cases and can be performed by metaphyseal resection with a greater trochanteric osteotomy and advancement or by a shortening subtrochanteric osteotomy. The results of total hip arthroplasty demonstrate a high rate of pain relief and functional improvement. The long‐term durability of cemented total hip arthroplasty reconstruction in these patients is inferior to that in the general population. The results of uncemented implants are promising, but only limited early and midterm data are available.

Bilobed oblong porous coated acetabular components in revision total hip arthroplasty.

Thirty-eight oblong bilobed noncustom uncemented, porous-coated titanium acetabular components were used to reconstruct failed hip arthroplasties with large superior segmental acetabular bone deficiencies. No structural bone grafts were used. All patients were followed up for 2 to 5 years (mean, 3 years) after the operation. One patient (whose socket rested primarily on a structural bone graft from a previous procedure) had revision surgery for acetabular loosening. No other patients have had revision surgery or had another ipsilateral hip operation. At latest followup, 35 patients had no or mild pain and two patients had moderate pain. Two implants migrated more than 2 mm in the first year, then stabilized. On the latest radiographs, two implants had bead shedding, but there was no measurable migration or change in position. For selected patients with large superolateral acetabular bone deficiencies, this implant facilitated a complex reconstruction, provided good clinical results, and showed satisfactory stability at early to midterm followup in most patients.

Long-term survivorship of cemented bipolar hemiarthroplasty for fracture of the femoral neck.

Cemented bipolar hemiarthroplasty commonly is used to treat displaced fractures of the femoral neck in elderly patients. The purpose of the current study was to review the results and survivorship of 212 bipolar hemiarthroplasties done in 205 patients for acute femoral neck fracture between 1976 and 1985. The mean age of the patients at the time of surgery was 79 years (range, 61–100 years). The mean followup for the patients who were alive was 11.7 years (range, 5.3–16.8 years) and 5.8 years (range, 51 days–19.4 years) for the entire group. Ten hips (4.7%) were revised or removed: five for aseptic femoral component loosening, one for acetabular erosion, one for chronic dislocation, and three for infection. In living patients with surviving implants, 96.2% had no or slight pain. Ten-year survivorship free of reoperation for any reason was 93.6%, free of revision surgery for aseptic femoral loosening or acetabular cartilage wear was 95.9%, free of revision surgery for aseptic femoral loosening was 96.5%, and free of revision surgery for acetabular cartilage wear was 99.4%. Cemented bipolar hemiarthroplasty for acute femoral neck fracture is associated with excellent component survivorship in elderly patients. The rate of complications was low, and the arthroplasty provided satisfactory pain relief for the lifetime of the majority of elderly patients.

“minimally Invasive” Total Hip Arthroplasty

“Minimally invasive” hip replacement was widely introduced to the orthopaedic community and public several years ago and has been greeted variably with enthusiasm, concern, and skepticism1. Enthusiasm has centered around the potential for quicker recovery, a better cosmetic result, and less perceived invasion of the body. Concern has focused on the potential for more complications, related to poorer operative visualization and the learning curve for new methods. Remarkably, despite widespread marketing of minimally invasive methods by companies and orthopaedic surgeons and much dissemination of information of varying accuracy by the lay press, little objective data quantifying the risks and benefits of these methods compared with traditional methods have been available. Early short-term follow-up studies suggested possible benefits of the techniques, but those investigations mostly involved selected patient populations and often were performed with modified pain management and rehabilitation protocols1. In this issue of The Journal, Ogonda et al. report on the first large, prospective, randomized blinded trial of a minimally invasive total hip arthroplasty technique, and the results call into question many assumptions that have been made about minimally invasive total hip arthroplasty. In an extremely carefully performed and comprehensive trial, the authors demonstrated that the procedure, as performed through a posterior approach, provided no objective short-term benefit with respect to postoperative pain level, …