Philip D. Wilson

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).

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.

Total Hip Replacement with Fixation by Acrylic Cement: A Preliminary Study Of 100 Consecutive Mckee-farrar Prosthetic Replacements

Total hip replacement utilizing the McKee-Farrar prosthesis and acrylic cement relieved pain in seventy-nine of 100 diseased hips and improved the stance, walking function, and mobility of these same hips for periods of follow-up ranging from two to four years. The results have been so-satisfactory to the patients that continued use and further development of this type of operation is certainly warranted. Basic long-term questions, however, remain to be answered in connection with the use of an all-metal bearing with skeletal fixation by acrylic cement. A cautious attitude toward the use of this technique of total hip replacement should be continued. The patients selected for this procedure should be the elderly and infirm, or patients with desperate and difficult clinical problems which cannot be solved adequately in any other way. The operation should be performed only after the patient has been informed of the unknowns involved. The incidence of wound complications in this series was high. However, only the tendency to subclinical or latent deep infection seemed significantly higher with this type of procedure than with interpositional or femoral replacement arthroplasty without acrylic cement. To avoid infection, standards of surgical asepsis more stringent than those hitherto accepted seem indicated. Prosthetic loosening even in the absence of infection was also a problem. Patient selection, operative technique, and postoperative management probably contributed importantly to this complication. Appropriate changes in methodology have been made, but it is too early to evaluate their efficacy.

Long-term Results of Femoral-head Replacement

A study of 436 replacements of the femoral head by Austin Moore, Thompson, Valls, and Judet prostheses, done from 1950 to 1965, revealed best results with the Austin Moore prosthesis. Only 195 patients could be followed for five years or more. The Austin Moore prosthesis gave 31 per cent excellent, 36 per cent good, 25 per cent fair, and 8 per cent poor results; relatively few patients showed much change in the results obtained—roughly as many showed long-term improvement as showed deterioration.

Reimplantation in Infection: A 12-year Experience

Three groups of patients underwent reimplantation for infected hip prostheses during the period from 1968 to 1979. The first group (N = 19) was diagnosed mainly by hip aspiration and treated with antibiotics selected by disc sensitivity and one-stage reimplantation in 14 hips. The second group (N = 26) was diagnosed by strict hip infection criteria and treated with a similar antibiotic regimen. Reimplantation was performed in one stage in 13 patients and in two stages in the remaining 13. The third group (N = 16) was diagnosed by the same criteria but treated with standardized bactericidal antibiotics evaluated by the tube dilution method. There were five one-stage reimplantations, ten two-stage, and one radical debridement without removal of components. The follow-up period ranged from two to 12 years. The present guidelines for reimplantation include subacute hip sepsis caused by susceptible bacteria, according to tube dilution methods in immunocompetent patients with adequate soft tissue and bone stock to allow a satisfactory biomechanical reconstruction. Patients should be aware of the risk of recurrence of infection, persistent pain, limited durability, and further surgical treatment.

Total Hip Replacement Failures: A Histological Evaluation

The first twenty failed total hip replacements in one hospital population showed infection in twelve (two Charnley and ten McKee-Farrar) and loosening in eight (McKee-Farrar). Acute inflammation was present in all of the infections and ranged from mild to severe. Chronic inflammation was universally seen, more severe in the presence of infection. Intracellular and extracellular metallic debris was seen in all but two cases. Acrylic debris was found extracellularly in all cases and intracellularly in small amounts in three. Debris resembling polyethylene was seen in two patients. It was not possible to determine what part the debris played in inflammation versus infection.

Revision Total Hip Arthroplasty

In this review, 110 hips in 107 patients underwent revision total hip arthroplasty at The Hospital for Special Surgery and the Robert B. Brigham Hospital. The minimum follow-up period was two years (average, 3.4 years). Failures of the original total hip arthroplasties were due to loosening of the femoral component (44 hips), loosening of both components (23 hips), loosening of the acetabular component (17 hips), fracture of the femoral component (14 hips), recurrent dislocation due to prosthetic malposition (7 hips), acetabular protrusion (3 hips), and fracture of the femoral shaft (2 hips). Sixty-six hips were categorized as good or excellent, and 25 hips were rated as fair. Nineteen poor results were due to: (a) deep infection (2 hips); (b) mechanical failure (15 hips); and (c) recurrent dislocation (2 hips). Complications included infection (3.6%), trochanteric problems (13%), mechanical failure (14%), and progressive radiolucent zones (26%). The quality of the result of a revision total hip arthroplasty is potentially as good as that of the original arthroplasty. However, the higher incidence of infection and mechanical failure reduces the frequency of such good results in the long-term. The extremely high incidence of progressive radiolucent zones at the bone-cement interface makes predictions for even longer term results guarded.

Conventional total hip arthroplasty for degenerative joint disease in patients between the ages of forty and sixty years.

We analyzed the records of 103 conventional hip arthroplasties in seventy-five active patients who were between the ages of forty and sixty years. After five to ten years of follow-up, an excellent or good clinical result was evident in 90 per cent. The radiographic appearance of the cement-bone interface of the acetabular component was stable in those hips, and no progressive acetabular radiolucency was found in 80 per cent of the hips. Of twenty hips with a complete acetabular radiolucency (Grade III or IV), only three had a secondary revision operation, two in conjunction with a fracture of the stem of the prosthesis and one for migration (Grade IV). Eight additional hips showed migration. Seventy per cent of the femoral components were well fixed, without radiographic evidence of loosening. A fracture of the femoral stem occurred in eight hips, all of which had a revision operation. One revision operation was done for loosening of the femoral stem. Seven femoral stems showed either shift or subsidence. An isolated radiolucency in the superolateral zone was present in four hips and an isolated lucency in other zones, measuring one millimeter or less, was present in ten hips. Thus, radiographic evidence of loosening, including the hips with a fractured stem, was present in 29.9 per cent. One additional revision, making ten in all, was done for symptomatic acetabular loosening. Based on this study, we concluded that conventional hip arthroplasty is a highly successful treatment in active patients between forty and sixty years old who have osteoarthritis of the hip.

Neonatal diagnosis, treatment and related factors of congenital dislocation of the hip.

The unstable hip can be diagnosed in newborns with acceptable accuracy. The following factors are associated with the newborn unstable hip: female preponderance, breech presentations, cesarean section deliveries, first borns, left hip involvement, the Caucasian race, and increased birth weight. These findings suggest that the newborn unstable hip is determined prior to delivery, possibly within the last 4 weeks of intrauterine life. Diagnosed at birth, treatment in the average case is relatively short-term, effective, and without complication.

The microscopic anatomy of the bone-cement interface in failed total hip arthroplasties.

Thirty specimens were removed from the bone-cement interface in 25 hips revised for aseptic loosening of total hip arthroplasty. Histologic examination of the membranous tissues revealed that histiocytosis, fibrosis, and necrosis were present in every specimen. Other prominent features included particles of acrylic cement, polyethylene debris, and fragments of necrotic bone. Mechanical failure was characterized by cement fractures, and microfracture of bone. The presence of cement debris and bone detritus in the membranes, and smooth appearance of the removed cement mantles substantiated the presence of mechanical failure. The process of loosening was characterized by the recruitment of histiocytes into the interface and the subsequent resorption of bone around the prosthesis. This may be a manifestation of the rate of cement wear and tear, particle size, and the immunologic predispositions of the host. These observations on interfaces of loosened prostheses are reexamined and reinterpreted in the light of radiologic observations on interface radiolucent zones and well-functioning prostheses.