John J. Callaghan

Results of revision for mechanical failure after cemented total hip replacement, 1979 to 1982. A two to five-year follow-up.

From January 1979 to February 1982, 143 patients (seventy-nine women and sixty-four men) with 146 uninfected cemented total hip arthroplasties had revision cemented hip arthroplasty at The Hospital for Special Surgery for what was considered to be mechanical failure. The average age of the patients at primary arthroplasty was 56.1 years and at revision, 62.1 years. Loosening of the femoral component before revision correlated with varus positioning in 50 per cent of the hips, inadequate cement in 34 per cent, and a relatively young age in 16 per cent. The average age of the patients (fifteen hips) with a loose femoral component that had been placed in a neutral or valgus position with good cementing technique was 48.2 years at the time of primary arthroplasty. Loosening of the acetabular component was attributed to high placement of the cup in 41 per cent, inadequate bone in 18 per cent, a vertical orientation of the opening of the cup in 7 per cent, and poor cementing technique in 3 per cent. Complications associated with revision included perforation of the femoral cortex in 13 per cent, postoperative deep infection in 3.4 per cent, postoperative dislocation in 8.2 per cent, trochanteric complications in 6.2 per cent, and sciatic palsy in 0.7 per cent. Of the 139 hips that were followed for an average of 3.6 years (range, two to five years) after revision, the results were excellent in 59 per cent, good in 7 per cent, fair in 16 per cent, and poor in 18 per cent. After revision of the 139 hips, 29 per cent showed progressive radiolucencies; 18 per cent, femoral subsidence; and 9 per cent, acetabular migration. Definite mechanical failure after revision was identified in 15.8 per cent of the hips. These failures were due to loosening in 12.2 per cent of the hips, femoral fracture in 2.2 per cent, and disabling dislocation in 1.4 per cent. At the time of follow-up, twelve hips (8.6 per cent) had been revised a second time: six (4.3 per cent) for loosening of one or both components, three (2.2 per cent) for femoral fracture, and three (2.2 per cent) for infection. Mechanical failure and progressive radiolucencies were associated with poor quality of bone (p less than 0.001) and inadequate anatomical reconstruction (p less than 0.03).

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 patients 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)

The agility total ankle arthroplasty seven to sixteen-year follow-up

BACKGROUND We previously reported the intermediate-term results with the early version of the Agility total ankle replacement, a unique design that takes advantage of arthrodesis of the tibiofibular syndesmosis for tibial component support. The purpose of this study was to report longer-term results of this procedure in the treatment of disabling ankle arthritis. METHODS We conducted an independent review of all Agility total ankle replacements performed by a single surgeon between 1984 and 1994. Follow-up evaluation consisted of completion of a validated ankle osteoarthritis scale and a short questionnaire and a review of the radiographs. All radiographs were evaluated for evidence of the development of progressive hindfoot arthritis, nonunion of the tibiofibular syndesmosis, progressive radiolucent lines, osteolysis, and component subsidence. RESULTS One hundred and thirty-two arthroplasties were performed in 126 patients. After a mean follow-up period of nine years, thirty-three patients (thirty-six implants) had died, fourteen patients (11%) had a revision of the implant or an ankle arthrodesis, and one had the leg amputated because of an unrelated cause. Of the remaining seventy-eight patients (eighty-one ankles), sixty-seven (sixty-nine ankles) were followed clinically. More than 90% of them reported that they had decreased pain and were satisfied with the outcome of the surgery. We found modest differences in a comparison of the pain and disability scores with those of age-matched controls. Of the 117 ankles that had been followed radiographically for a minimum of two years, twenty-two (19%) had progressive subtalar arthritis, seventeen (15%) had progressive talonavicular arthritis, and nine (8%) had a syndesmosis nonunion. Eighty-nine (76%) of the 117 ankles had some evidence of peri-implant radiolucency. CONCLUSIONS Arthrodesis of the tibiofibular syndesmosis impacts the radiographic and clinical outcomes with the Agility total ankle replacement. The relatively low rates of radiographic hindfoot arthritis and revision procedures at an average of nine years after the arthroplasty are encouraging. Agility total ankle replacement is a viable and durable option for the treatment of ankle arthritis in selected patients.

Total Ankle Arthroplasty: a Unique Design. Two to Twelve-Year Follow-up*

We evaluated the intermediate-term results of a novel total ankle arthroplasty that includes insertion of the components without cement and arthrodesis of the tibiofibular syndesmosis as part of the operative procedure. One hundred consecutive Agility ankle replacements were performed in ninety-five patients between 1984 and 1993. At the time of follow-up, eighty-three patients (eighty-six ankles) were alive and twelve patients (fourteen ankles) had died. Five (6 per cent) of the eighty-six ankles in the living patients had been revised. Including the components that had been revised for loosening, twenty-one (twelve tibial and nine talar) components had migrated. Delayed union of the syndesmosis (twenty-eight ankles) and non-union of the syndesmosis (nine ankles) were associated with the development of lysis around the tibial component. Non-union of the syndesmosis was also associated with migration of the tibial component and circumferential radiolucency around that component. In addition to the patients who died, one patient had a resection of the implant with subsequent arthrodesis. The remaining eighty-two patients (eighty-five ankles) were the basis for the clinical evaluation in the study. The average age at the time of the procedure was sixty-three years (range, twenty-seven to eighty-one years). At the time of the most recent follow-up (range, 2.8 to 12.3 years; average, 4.8 years), forty-seven (55 per cent) of the remaining eighty-five ankles were not painful and twenty-four (28 per cent) were only mildly painful. The range of motion of the fifty-six ankles that were examined at the time of follow-up averaged 36 degrees (range, 10 to 64 degrees), and the results for seventy-nine (93 per cent) of the eighty-five ankles were satisfactory to the patients.

Current Concepts Review - Wear in Total Hip and Knee Replacements*

Before the advent of total joint replacement, patients who had end-stage arthritis of the lower extremities had unremitting pain and a greatly decreased functional capacity. In addition, they often were confined to a wheelchair and were dependent on the care of others. Today, the outcomes of primary total hip and knee replacement are predictable and usually excellent35,45,57,64,212,221. Prosthetic joint replacement has dramatically improved the lives of millions of people worldwide. As the fixation of total joint implants has become more reliable and durable and as the technology of total joint replacement has been applied to younger and more active patients, the current limitations of total joint arthroplasty are related to the wear of the components248. Wear is the removal of material, with the generation of wear particles, that occurs as a result of the relative motion between two opposing surfaces under load. In complex mechanical-biological systems such as total hip and knee replacements, there can be many types of wear. Although the mechanical consequences of wear, such as progressive thinning of polyethylene components, can limit the functional life of a joint replacement, the clinical problems from wear more frequently are due to the release of an excessive number of wear particles into a biological environment. When particles within a certain size-range are phagocytized in sufficient amounts, the macrophages enter into an activated state of metabolism, releasing substances that can result in periprosthetic bone resorption. Progressive loss of periprosthetic bone can necessitate a reoperation, which is the definitive measure of clinical failure of a joint arthroplasty. It is important to distinguish among the fundamental mechanisms of wear (adhesion, abrasion, and fatigue); the changes in the appearance (the morphological characteristics) of the bearing surfaces, which are referred to …

Minimally invasive total hip arthroplasty development, early results, and a critical analysis

Hip replacement with use of small incisions has been practiced selectively by a few practitioners for many years, but only in the last several years has so-called minimally invasive hip replacement been widely introduced to the majority of orthopaedic surgeons. Minimally invasive hip replacement, in fact, is not a single type of surgery but rather is a family of operations designed to allow total hip replacement to be done through smaller incisions, potentially with less soft-tissue disruption. The three main methods involve a combination of a small incision and a posterior approach to the hip, a combination of a small incision and an anterior approach to the hip, or two small incisions performed with use of the Smith-Peterson interval for acetabular placement and the approach usually used for femoral intramedullary nailing for femoral component insertion. Minimally invasive total hip arthroplasty has created much controversy among orthopaedic surgeons and a great deal of publicity in the popular press. Advocates emphasize the potential for these methods to reduce soft-tissue trauma and thereby reduce operative blood loss, postoperative pain, and hospitalization time; speed the postoperative recovery; and improve the cosmetic appearance of the surgical scar. Advocates view minimally invasive total hip arthroplasty as a logical extension of less invasive methods that have revolutionized other fields, such as arthroscopy, laparoscopic cholecystectomy, and cardiac surgery, just to name a few. Those with reservations about minimally invasive total hip replacement point out that conventional hip replacement already provides excellent pain relief, functional improvement, and durability with a low complication rate. Skeptics are concerned that minimally invasive procedures introduce new potential problems related to reduced visualization at the time of the operation, such as implant malposition, neurovascular injury, poor implant fixation, or compromised long-term results. Advocates of minimally invasive methods believe that minimally invasive hip arthroplasty holds …

Long-term results of revision total hip replacement. A follow-up report.

The results of 110 revision total hip replacements performed for aseptic failure, with an average follow-up of 3.4 years, were reported in 1982. We were able to continue to follow ninety-nine of these patients for an average of 8.1 years (range, five to 12.5 years). With this longer follow-up, we found that twenty-nine (29 per cent) of these revised arthroplasties have since failed. Most of the failures after 1982 occurred in the hips that were known to have a progressive radiolucency at the time of the first evaluation. We concluded that there is an increased failure rate with longer follow-up of revision total hip replacement, and that progressive radiolucency at an interface indicates a poor prognosis for the arthroplasty.

Charnley total hip arthroplasty with cement : Minimum twenty-five-year follow-up

Background: This report presents the results of the senior authors 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 postoperatively 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.

Wear in total hip and knee replacements.

Before the advent of total joint replacement, patients who had end-stage arthritis of the lower extremities had unremitting pain and a greatly decreased functional capacity. In addition, they often were confined to a wheelchair and were dependent on the care of others. Today, the outcomes of primary total hip and knee replacement are predictable and usually excellent. Prosthetic joint replacement has dramatically improved the lives of millions of people worldwide. As the fixation of total joint implants has become more reliable and durable and as the technology of total joint replacement has been applied to younger and more active patients, the current limitations of total joint arthroplasty are related to the wear of the components. Wear is the removal of material, with the generation of wear particles, that occurs as a result of the relative motion between two opposing surfaces under load. In complex mechanical-biological systems such as total hip and knee replacements, there can be many types of wear. Although the mechanical consequences of wear, such as progressive thinning of polyethylene components, can limit the functional life of a joint replacement, the clinical problems from wear more frequently are due to the release of an excessive number of wear particles into a biological environment. When particles within a certain size-range are phagocytized in sufficient amounts, the macrophages enter into an activated state of metabolism, releasing substances that can result in periprosthetic bone resorption. Progressive loss of periprosthetic bone can necessitate a reoperation, which is the definitive measure of clinical failure of a joint arthroplasty.

Unicompartmental knee replacement. A minimum 15 year followup study.

One hundred forty Marmor cemented unicompartmental knee replacements were inserted in 103 patients between 1975 and 1982. Fifty-two patients were women and 51 were men. One hundred twenty-five were medial compartment knee replacements and 15 were lateral knee replacements. At minimum 15 year followup 34 patients with 48 knee replacements were living; only four patients with four knee replacements were lost to followup. Average preoperative and final followup Hospital for Special Surgery knee scores were 57 and 82 points, respectively for the knees of living patients. Average preoperative and final followup Knee Society clinical and Knee Society functional scores were 31 and 42, and 85 and 71 points, respectively. For all knees, 10.2% (14 knees) were revised [4.4% (six knees) for tibial loosening, 5.1% (seven knees) for disease progression, and .7% (one knee) for pain]. For patients living 15 years, 12.5% (six knees) were revised [2.1% (one knee) for tibial loosening, and 10.4% (five knees) for disease progression]. Revision for failure of fixation of these unicompartmental replacements was comparable with that reported for fixed bearing total knee replacement. Disease progression (46%; 62 of 136 knees) and tibial subsidence with wear (10.4%; 15 of 136 knees, five of which required revision) were the major long term problems in this group of patients.