Scott S. Kelley

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 Influence of Patient-related Factors and the Position of the Acetabular Component on the Rate of Dislocation after Total Hip Replacement*

The senior one of us performed 438 primary and 181 revision total hip arthroplasties with use of so-called modern prostheses between July 1983 and January 1994. Fifty-three patients, who had had forty-seven primary procedures and twelve revisions, either died or were lost to follow-up less than two years after the operation and were excluded from the study. The results for the remaining 446 patients (391 primary procedures and 169 revisions) were analyzed to determine the influence of patient-related and operative factors and the position of the acetabular component on the rate of dislocation. Dislocation occurred after thirty-two (6 per cent) of the 560 total hip arthroplasties: seventeen (4 per cent) of the 391 primary procedures and fifteen (9 per cent) of the 169 revisions (p = 0.046). There was no relationship between the variables of age, gender, obesity, or preoperative diagnosis and dislocation after either primary or revision arthroplasty. Seven (23 per cent) of the thirty arthroplasties in the patients who had a history of excessive intake of alcoholic beverages (more than 2.1 liters [seventy-two ounces] of beer or more than 0.2 liter [six ounces] of other alcoholic beverages a day) were followed by a dislocation compared with twenty-five (5 per cent) of the 530 arthroplasties in the patients who did not have such a history. This difference was significant for the patients who had had a revision arthroplasty (p = 0.00005), but with the numbers available we could not detect a difference for those who had had a primary arthroplasty (p = 0.264). Radiographic analysis was performed for thirty-two hips that had dislocated and thirty-two that had not (seventeen primary procedures and fifteen revisions in each group), matched exactly according to the type of prosthesis and the operative approach (but not age). We detected no association between either the version or the abduction angle of the acetabular component (within the range of 39 to 56 degrees for the primary prostheses and 38 to 57 degrees for the revision prostheses) and the risk of dislocation. Thirty of the thirty-two hips in each group had an abduction angle of the acetabular component that was in the so-called safe range of 30 to 50 degrees.

Relationship of femoral head and acetabular size to the prevalence of dislocation.

Two clinical studies, one prospective randomized and one retrospective, were performed to evaluate the relationship of femoral head size and acetabular component outer diameter to the prevalence of dislocation of the modular total hip replacement. Between October 1995 and April 1996, 31 primary total hip arthroplasties in 30 patients were randomized to a femoral head diameter of 22 mm or 28 mm, for two groups of acetabular components of outer diameters of 56 mm or larger and 54 mm or smaller. Head size (22 mm) and acetabular component outer diameter (≥ 56 mm) were found to increase the risk of dislocation. From December 1984 to January 1994, 308 primary total hip arthroplasties were performed through a posterior approach by one surgeon using a modular 28 mm femoral head and one type of uncemented acetabular component. The rate of dislocation for acetabular components with an outer diameter of 62 mm or larger was increased significantly (five of 36 hips, 14%) compared with those with an outer diameter of 60 mm or smaller (11 of 272 hips, 4%).

Aspiration of the knee joint before revision arthroplasty.

Sixty-four operative procedures were performed on 55 patients with knee arthroplasties for pain, loosening, instability, or suspicion of infection. Forty-three knees had a preoperative aspiration. In 19 knees, the aspiration showed growth on solid media, and in 18 of these knees the diagnosis of infection was confirmed by the intraoperative cultures. In 1 knee with an infected total knee replacement, the patient was receiving an intravenous antibiotic at the time of arthroscopic irrigation and debridement and the cultures showed no growth. In 23 of 24 knees with a negative preoperative aspiration, the intraoperative cultures showed no growth on solid media. In 1 knee with a preoperative aspiration that had negative results, a single intraoperative culture grew Staphylococcus epidermidis. However, the presenting symptoms, examination, preoperative radiographs, and intraoperative evaluation were consistent with aseptic loosening of a cemented total knee arthroplasty. Thus, the preoperative aspiration of the prosthetic knee joint had a sensitivity of 100%, specificity of 100%, and accuracy of 100%. The Westergren erythrocyte sedimentation rate, peripheral leukocyte count, and presenting symptoms correlated poorly with infection. Radiographs were also not helpful in the diagnosis of infection, with loosening of components, periostitis, focal osteolysis, and radiolucent lines frequently seen in infected and noninfected knees. Preoperative aspiration of the knee is the most helpful study for the diagnosis or exclusion of infection in a prosthetic knee joint.

Total hip replacement for coxarthrosis secondary to congenital dysplasia and dislocation of the hip : long-term results

Between 1970 and 1982, sixty-six total hip replacements were performed with cement, without bone-grafting, in fifty-three patients who had congenital dysplasia and dislocation of the hip. Preoperatively, the patients had had Crowe type-II, III, or IV subluxation. Current information was available for fifty-nine hips in forty-six patients after an average duration of follow-up of sixteen years (range, ten to twenty-one years). The average age of the patients at the time of the operation was fifty-three years (range, twenty-three to seventy-three years). The average Harris hip score at the most recent examination was 92 points (range, 61 to 100 points). Eight hips were revised. The reason for the revision was infection in two hips, fracture of the femoral stem in two, and loosening of the acetabular component in four. The rate of revision for aseptic loosening, therefore, was 10 per cent (six hips). In the unrevised hips for which radiographs were available, the rate of radiographic loosening of the femoral component was 5 per cent (two hips) and that of the acetabular component was 32 per cent (twelve hips). We did not find a relationship between the amount of horizontal or vertical displacement of the center of the femoral head and the rate of loosening. Kaplan-Meier survivorship analysis with revision as the end point predicted a rate of survival of 85 per cent (95 per cent confidence interval, 75 to 95 per cent) at fifteen years. With radiographic loosening as the end point, the predicted rate of survival was 68 per cent (95 per cent confidence interval, 54 to 81 per cent) at fifteen years. We concluded that, for patients who have Crowe type-II, III, or IV congenital dysplasia of the hip, good long-term results can be obtained with insertion of a femoral stem with cement. The high rate of loosening of cemented acetabular components is a concern.

High hip center in revision arthroplasty.

What is the effect of superior placement of the acetabulum in complex hip reconstruction? Twenty-two patients (23 cases) had revision hip arthroplasty with superiorly placed porous-coated components without bone-grafts. Cemented femoral components were used in 21 cases and ingrowth components in 2. The average vertical height (corrected for magnification) was 36.8 mm from the interteardrop line, compared to a contralateral normal height of 12.1 mm. Three patients were deceased. The remaining 19 patients (20 hips) had a minimum 2-year follow-up period (average, 35 months). Fourteen hips had two or more previous surgeries. Seven acetabular components had thin (< 1 mm), nonprogressive, incomplete radiolucent lines. One acetabulum had a complete 1 mm radiolucent line in an asymptomatic patient. The remaining 12 acetabular components had no evidence of radiolucent lines and none of the acetabular components migrated. One hip with a cemented femoral component had evidence of possible loosening. Two cemented femoral components had evidence of definite loosening, one with minimal clinical symptoms and the other was revised to a long stem at 14 months after revision. Of the two ingrown femoral components, one had initial subsidence of 1.5 cm and both had thigh pain. All other patients had improved from their preoperative status; however, 4 of 20 hips had moderate to severe pain. Superior cup position did not result in concomitant lateral position. With a short-term follow-up period however, vertical displacement alone resulted in high loosening rates, with 25% for the femur and 5% for the acetabulum.

Periprosthetic Femoral Fractures.

&NA; Fracture of the femoral shaft around a hip prosthesis presents the simultaneous problems of prosthetic stability and femoral‐ fracture management. Treatment options include nonoperative stabilization (traction) and operative stabilization by means of intramedullary fixation, extramedullary fixation, or proximal femoral prosthetic replacement.

Isolated chondrons: a viable alternative for studies of chondrocyte metabolism in vitro

OBJECTIVE To develop and test a simple enzymatic procedure for isolating chondrons, which consist of the chondrocytes and their surrounding pericellular microenvironment. DESIGN Chondrons were obtained by digesting adult human articular cartilage with a mixture of dispase and collagenase. Chondrons and chondrocytes were cultured in alginate beads, immunofluorescence labeled and examined by confocal microscopy. RESULTS Comparison of freshly isolated chondrons with cryostat sections of cartilage revealed that type VI collagen, type II collagen and aggrecan were retained, but fibronectin and a unique chondroitin sulfate epitope recognized by the antibody, 7D4, were lost. Comparison of enzymatic and mechanical homogenization methods revealed subtle changes in chondron morphology and retention of fibronectin in mechanically isolated chondrons. Average yield of enzyme-isolated chondrons was slightly lower than that of chondrocytes isolated by pronase and collagenase digestion, but was much greater than that reported for mechanically isolated chondrons. Enzyme-isolated chondron viability was greater than 80% 1 day after isolation, and continued to be above 80% through 7 weeks of alginate bead culture. Viability of isolated chondrocytes was initially greater than 80% but fell to 60-80% with time in culture. Chondrons and isolated chondrocytes had a similar division rate except osteoarthritic chondrons were significantly slower after 2 weeks in culture. Cell division was more rapid for nonosteoarthritic chondrons than for osteoarthritic ones. CONCLUSIONS Enzymatic isolation of chondrons is relatively simple, gives better yield and viability than mechanical isolation, but comparable yield and viability of traditional chondrocyte isolation. Enzymatic chondron isolation allows the effect of the in vivo-formed pericellular matrix on chondrocyte metabolism to be studied in vitro.

Hip arthroplasty in hemophilic arthropathy.

As hemophilic arthropathy infrequently affects the hip joint, we performed a multicenter retrospective study to determine the results of hip arthroplasty in hemophilic patients. Thirty-four hip arthroplasties were performed in twenty-seven male patients at four major hemophilia centers from October 1972 through September 1990. Twenty-six patients had classic hemophilia and one had factor-IX deficiency. The mean age of the patients at the time of the operation was thirty-eight years (range, fifteen to seventy-three years). The mean duration of follow-up was eight years, with a minimum of two years for all patients who were still alive at the time of this review. Four patients were seropositive for the human immunodeficiency virus at the time of the operation, and sixteen patients were seropositive at the time of the most recent follow-up examination. Nine patients (33 per cent) died before the time of this review; seven had been seropositive for the human immunodeficiency virus. There were twenty-six total hip arthroplasties performed with cement, six total hip arthroplasties performed without cement, one total hip arthroplasty in which the femoral component was inserted with cement and the acetabular component was inserted without it (so-called hybrid arthroplasty), and one bipolar arthroplasty performed with cement. There were no early infections after these thirty-four primary arthroplasties. There were three late infections around prostheses inserted with cement, and all led to a resection arthroplasty. Six (21 per cent) of the twenty-eight cemented femoral components and six (23 per cent) of the twenty-six cemented acetabular components were revised because of aseptic loosening.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy of Prophylaxis Against Thromboembolism with Intermittent Pneumatic Compression After Primary and Revision Total Hip Arthroplasty

BACKGROUND Thromboembolism is a common and important complication after total hip arthroplasty. A variety of pharmacological and mechanical measures have been proposed for prophylaxis. The purpose of the present study was to evaluate the efficacy of intermittent pneumatic compression as prophylaxis against thromboembolism following total hip arthroplasty. METHODS The prospective study involved a consecutive series of 425 patients in whom a total of 502 (324 primary and 178 revision) total hip arthroplasties had been performed by two surgeons. The patients were managed intraoperatively and postoperatively with use of thigh-high elastic compression stockings and thigh-high intermittent pneumatic compression sleeves. Experienced vascular technologists performed venous duplex ultrasonography on both lower extremities of all patients at a mean of six days (range, two to fifteen days) postoperatively. All patients were followed for at least one year in order to detect late thromboembolism. RESULTS An asymptomatic deep-vein thrombosis was noted on the scans made after twenty-three (4.6 percent) of the 502 procedures. Nineteen (3.8 percent) of the arthroplasties were followed by the development of a proximal thrombosis and four (0.8 percent), a distal thrombosis. Nineteen of the thromboses were ipsilateral (eighteen were proximal and one, distal), and four were contralateral (one was proximal and three, distal). No symptomatic deep-vein thrombosis developed in the hospital. In addition, three (two proximal and one distal) symptomatic ipsilateral deep-vein thromboses (a prevalence of 0.6 percent) developed three to twenty-three weeks after postoperative scans revealed negative findings and the patients were discharged from the hospital. Three symptomatic pulmonary embolisms (a prevalence of 0.6 percent) were confirmed by ventilation-perfusion scanning while the patients were in the hospital. There were no symptomatic pulmonary embolisms after discharge, and there were no fatal pulmonary embolisms. With the numbers available, we were unable to detect an association between deep-vein thrombosis and age (p = 0.76), gender (p = 0.13), body-mass index (p = 0.12), type of arthroplasty (primary or revision) (p = 0.12), operative approach (p = 0.37), duration of the operation (p = 0.21), type of anesthesia (general or regional) (p = 0.51), units of blood transfused (autologous, p = 0.79; homologous, p = 0.57), blood type (p = 0.18), or the presence of a so-called classic risk factor for the development of thrombosis (p = 0.22). Five arthroplasties (1.0 percent) were followed by the development of a wound hematoma, but only one hematoma necessitated operative drainage. CONCLUSIONS The use of intraoperative and postoperative thigh-high intermittent pneumatic compression, combined with duplex ultrasonography performed by experienced vascular technologists, is effective for prophylaxis against thromboembolism after both primary and revision total hip arthroplasties. The low prevalence of deep-vein thrombosis (4.6 percent) and symptomatic pulmonary embolism (0.6 percent) is comparable with that associated with pharmacological prophylaxis.