Roderick H. Turner

Femoral fractures in conjunction with total hip replacement

We reviewed thirty-eight cases, in thirty-six patients, of fracture of the femur distal to the base of the neck incurred in conjunction with total hip replacement. There were thirteen preoperative, eighteen intraoperative, and seven postoperative fractures. The cases were contributed by thirteen surgeons. We found that the preoperative fractures with pre-existing disease in the hip joint were effectively treated by primary total hip replacement using custom-made femoral components with long necks or long stems, or both. The intraoperative femoral fractures usually occurred while the surgeon was reaming the canal, seating the femoral component, or manipulating the femur in patients who were predisposed to fracture. Theoretically these lesions can be treated like preoperative fractures, but this demands immediate access to custom-made femoral components with long necks or long stems, or both, along with an appreciation of the extent and significance of the fracture. Inadequate fixation was found to lead to painful non-union or late loosening of the femoral component in four of eighteen patients. Postoperative fractures occurred too rarely for us to draw any definite conclusions about management, except to say that surgical treatment can be hazardous and traction has been successful in this series and in other reports. Prophylactic measures, however, may help to prevent postoperative femoral fractures. Most of these fractures occur through a cortical defect near the tip of the femoral component. A long-stem femoral component may help to prevent postoperative fractures whenever a proximal cortical defect of the femur is present preoperatively or is created at surgery.

Femoral revision total hip arthroplasty using a long-stem femoral component. Clinical and radiographic analysis.

Proximal femoral bone stock deficiencies exist during many femoral revision arthroplasties, thus providing inadequate support and fixation for conventional-length cemented femoral components. The authors analyzed the long-term clinical and roentgenographic results of 165 hips requiring femoral revision arthroplasty with a long-stem femoral prosthesis. Intraoperative complications occurred in 23% of hips, with femoral perforations in 16% and femoral fractures in 5%. Of 110 hips with at least 5 years of follow-up study (average, 6.7 years), functional ratings were graded excellent in 34%, good in 36%, fair in 17%, and poor in 13%. Failures occurred in 17 hips (12%) and were attributed to aseptic loosening (11 hips), femoral component fracture (2), femoral shaft fracture (1), and sepsis (3). Symptomatic trochanteric separations occurred in 16% of hips. Rerevision or resection arthroplasty was required in 7 hips (5%) and recommended for another 10 hips (7%). Cemented long-stem femoral components (versus cemented conventional-length stems) decrease the extent and progression of femoral lucencies, thereby lowering the incidence of mechanical failures and improving long-term functional results in cemented femoral revision arthroplasty.

Medical and surgical treatment of the septic hip with one-stage revision arthroplasty.

Sepsis of the hip, particularly associated with total hip arthroplasty, can be treated successfully by an aggressive antimicrobial and surgical approach to accomplish a one-stage revision. Although this is a very acceptable alternative to Girdlestone arthroplasty, 13% (6 hips) of the septic total hip revisions failed. The possibility of hematogenous seeding of the total hip should be recognized by all health care professionals. Aggressive treatment of infections or potential infections is mandatory.

The Outcome of Trochanteric Reattachment in Revision Total Hip Arthroplasty With a Cable Grip System Mean 6-Year Follow-up

We have reviewed 251 hips that were revised by the senior authors with subsequent reattachment using the Dall-Miles Cable Grip System. Of these patients, 223 were available for follow-up. A trochanteric slide osteotomy was used for most cases (n = 170), and the remainder had conventional trochanteric osteotomy to facilitate surgical exposure. Follow-up period was 1 to 8 years. Forty-eight percent (n = 108) of the hips had a previous trochanteric osteotomy. Thirteen percent (n = 30) had a prior trochanteric nonunion. Of the 223 hips, 91% (n = 204) of the trochanters remained attached to the trochanteric bed when reapproximated by the cable grip system. The 2 multifilament cables were passed medially through drill holes in the lesser trochanter in 67% (n = 149) of cases. Of the hips, 16% (n = 35) had 2 cables passed through bone lateral to the prosthesis, and 17% (n = 39) had cables passed 1 medial and 1 lateral to the prosthesis. Cable breakage was noted in 10% (n = 23) of cases. Of those 23, 70% (n = 16) were stainless steel. Unraveling of the cable occurred in 18% (n = 41) of cases. There were 19 nonunions (9%). Of the 19 nonunions, 74% (n = 14) were stainless steel. The trochanter was reattached to bone in 9 hips, to cement in 4 hips, and to a proximal femoral allograft in 6 hips (P = .0001). Eight of the 19 hips (42%) had the cables placed lateral to the prosthesis (P = .0002). When bone-to-bone apposition was achieved at surgery, the nonunion rate was 4%. In this difficult group of revision procedures, the Dall-Miles Cable Grip has provided reliable trochanteric fixation. Factors associated with successful trochanteric healing include use of vitallium cables, use of a trochanteric slide osteotomy, cables passed medially through the lesser trochanter, cerclage rather than intramedullary placement, and bone-to-bone apposition.

Wear debris from bipolar femoral neck-cup impingement: A cause of femoral stem loosening

The source of wear debris in total hip arthroplasty may occur at various interfaces: metal-ultra-high molecular-weight polyethylene bearings, metal-cement micromotion, bone-cement interfaces, and implant coatings. Wear-induced osteolysis may result in a spectrum of radiographic changes from radiolucent lines to massive osteolysis. Subsequent loosening of the implant may occur and revision may be difficult because of bone deficiencies. Impingement of the femoral neck on the acetabular component may result in polyethylene and/or metal debris, leading to early femoral stem loosening. The five cases presented, involving six hips, illustrate how bipolar cup-stem impingement may result in significant wear-induced femoral osteolysis.

Revision total hip arthroplasty

Failure Mechanisms in THA Loosening, Wear, Osteolysis, Dislocation, Fracture, Evaluation of the Painful Hip History and the Physical Exam, Radiographic Studies, Pain Syndromes, Pre-Operative Planning Bone Stock Loss - Acetabulum, Bone Stock Loss - Femur, Bone Stock - Trochanter, Blood Conversation, Anesthesia, Surgical Planning - Templating, Surgical Planning - Biomechanics, Equipment: Overview, Cup-Out Hand Tools, Ultrasonic Cement Removal, Drill and Excavate, Bone Bank/Bone Graft, Surgical Techniques, Part 1: Femur Reconstruction of Cavitary Defects, Impact Grafting, Cement within Cement, Segmental Defects: Onlay Allografting, Segmental Defects: Structural Allograft, Cemented Implants, Cemented Long Stem Implants, Cementless Proximally Ingrown Stems, Cementless Distally Fixed Stem, Modular Stems, Impact Modular Stems, Part II: Surgical Approaches Posterolateral Approach, Direct Lateral Approach, Modified Dall Approach, Trochanteric Osteotomy, Anterolateral Approach, Trochanteric Slide Approach, Extended Trochanteric Osteotomy, Extended Lateral Femoral Osteotomy, Extended Anterior Femoral Osteotomy, Retroperitoneal Approach, Part III: Acetabulum Management of Cavitary Deficiencies, Bipolar Components, Management of Segmental Deficiencies, Determination of the Hip Center, Use of Oblong or Modular Cups, Posterior Deficiencies, Medial Deficiencies, Use of Cages, Pelvic Discontinuity and Fusion Take Down, Post-operative Complications Neurologic Injury, Post-operative Infection, Dislocation, Deep Venous Thrombosis, Anesthetic Complication, Cardiac Complication, Femoral Stem Breakage, Abdominal Complications, Genitourinary Complications, Plastic Surgical Complications, Heterotopic Ossification, Special Considerations Prior Surgery, Leg Length Descrepancy, Metastatic Disease, Girdlestone Conversion, Fusion Take-Down, Motor Defects, Fracture, Making Revision Surgery Work in the Current Health Care Environment Maximizing Efficiency in Revision THR, Physical Rehabilitation, Outcome Studies, Looking Forward: Implant Research, Robotically Assisted Cement Removal, Malpractice Malpractice. Index.

Total Replacement of the Arthritic Hip

Total hip replacement may provide dramatic relief for patients crippled and severely discomforted by osteoarthritis, as in the case described and documented here, as well as by rheumatoid arthritis, congenital malformation, and various degenerative diseases. A number of common attributes that suggest which patients are most likely to benefit from this surgical procedure are discussed.