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It is reported that a 62-year-old man with total hip prosthesis developed a recurrent sterile fistula and loosening of his prosthesis due to allergy to the bone cement component benzoyl peroxide.
The authors have studied fifty-nine patients in whom a total hip prosthesis had been removed for various reasons. In forty-five cases the greater trochanter was inserted into the acetabulum and the position maintained by external fixation. In fourteen cases the prosthesis was simply removed and traction applied for several weeks. Forty-one patients were available for follow up study. The results were identical as regards pain. The residual stability was better in cases of trochantero-pelvic penetration but residual mobility was better after simple removal. The latter procedure should be performed in cases of acetabular destruction, in advanced age or in cases where the insertion of a new prosthesis can be anticipated later. Healing of draining sinuses is related to the extent of tissue excision and the removal of all cement.
We report a case of malignant epithelioid hemangioendothelioma in the acetabulum and ipsilateral femur 11 years after a total hip prosthesis.
Probabilistic analyses allow the effect of uncertainty in system parameters on predicted model performance measures to be determined. Furthermore, using performance functions to describe a failure event, the probability of failure can be quantified. The effect of three-dimensional prosthesis shape optimization on the probabilistic response and failure probability of a cemented hip prosthesis system is investigated. Random variables include joint and muscle loading, cortical and cancellous bone and PMMA bone cement elastic properties, and strength parameters describing failure of the bone cement and the prosthesis-bone cement interface. Several performance functions describing the bone cement and prosthesis-cement interface are used to compute the probability of failure. When evaluated deterministically, most performance functions indicated a safe design, with the exception of interface tensile failure. However, when evaluated probabilistically, finite probabilities of failure were computed, some significant. The most likely mode of failure before shape optimization was prosthesis-bone cement interface tensile failure with a predicted probability of failure of 97.9%. Deterministic prosthesis shape optimization reduced the probability of failure for all performance functions and reduced prosthesis-bone cement interface tensile failure by 31.7%. Probability sensitivity factors indicate that the uncertainty in the joint loading, cement strength, and implant-cement interface strength have the greatest effect on the computed probability of failure. Implant shape optimization results in a more robust implant design that is less sensitive to uncertainties in joint loading, which cannot be easily controlled, and more sensitive to cement and interface properties, which are easier to modify.
Radionuclide arthrography has been found to be valuable in the diagnosis of a loose hip prosthesis. The appearance of one normal case with no loosening and two abnormal cases with loosening of femoral and acetabular components are described. To diagnose this difficult problem, radionuclide arthrography should be used more frequently.
Three new methods to assess the degree of anteversion or retroversion of the femoral component of a total hip prosthesis are described. Compared with previously described methods, the new methods make few physical demands on the recently operated patient. The only requirement is that the affected femur be held in a neutral position parallel to the x-ray table. The methods are relatively easy to perform and are accurate and objective.
We report on six cases of metallosis which developed in bipolar hip prosthesis due to ceramic screws used for fixation of bone grafts. Two patients experienced severe metallosis due to abnormal abrasion of the femoral head. At the revision surgery, proliferated black synovia was found. Analyses of the retrieved prostheses revealed numerous small particles of alumina ceramic on the inner surface of the bearing insert of UHMWPE. These particles came from the broken ceramic screws, and scraped away the metallic femoral head resulting in severe metallosis. In four patients, the outer head came into direct contact with ceramic screws and mild metallosis was observed at revision surgery.
Aseptic loosening of prosthesis with consequential revision operations continues to be a major problem for both the patients concerned and the medical team. In the center of interest stands the magnitude of bone destruction caused by loosening effects. A concept designed to avoid uncontrolled progressive loss of bone stock is presented. Based on the experience of 248 cases of hip revision operations, advice to patients can be given. 2 septic (0.8%) and 6 aseptic (2.4%) cases with loosening and re-revision were documented. Statistical analysis of 5-year survivorship rate according to Kaplan-Meier shows 94.5%, and according to Armitage 92.5%. Clinical and radiologic 5-10-year findings in the first 72 consecutive cases are presented. Routine controls in patients with hip prostheses for early detection of bone destruction may help to perform simple and prognostically favourable revision operations.
One hundred consecutive primary total hip arthroplasties performed with use of a porous-coated anatomic total hip prosthesis, fixed without cement, in ninety-one patients were followed prospectively for a minimum of ten years. At the time of the most recent follow-up, twenty patients (twenty-three hips) had died and seventy-one patients (seventy-seven hips) were living. The average age of the living patients was sixty-six years (range, thirty-two to ninety-two years), and their average Harris hip score was 84 points (range, 33 to 100 points). Twelve percent (nine) of the seventy-seven hips were found to be associated with pain in the thigh when the patients were specifically questioned by the examiner. Eleven hips were revised during the follow-up period. Only the acetabular component was revised in six hips, only the femoral component was revised in one hip, and both the femoral and the acetabular components were revised in four hips. Of the ten acetabular revisions, one was performed because of acute dissociation of the component and eight, because of a combination of polyethylene wear, osteolysis, and loosening; the tenth acetabular revision consisted of exchange of the liner and curettage and bone-grafting of the osteolytic area. Of the five femoral revisions, two were performed because of loosening and three, because of extensive osteolysis of the proximal aspect of the femur. Including the revised components, twelve acetabular components and five femoral components had radiographic evidence of aseptic loosening. Acetabular osteolysis occurred in seventeen hips. Femoral osteolysis occurred in thirty-nine hips: in the proximal aspect of thirty-one hips, in the distal aspect of four, and in both the proximal and the distal aspect of four. The durability of the femoral fixation documented in this study is especially encouraging in view of the fact that this was our initial experience with devices fixed without cement and that a so-called first-generation femoral component was used. However, the study also demonstrated that not all acetabular components fixed without cement function well over the long term and that specific design considerations (adequate initial fixation, congruency between the liner and the shell, an optimum shell-liner capturing mechanism, and a smaller femoral head) are warranted.
Since the introduction of cementless total hip arthroplasty in the early 1980s, concern has shifted from component loosening toward polyethylene wear and osteolysis. The current review of 223 consecutive unselected Anatomic Medullary Locking femoral and acetabular components extends the followup on a series of patients previously reported on at 5 and 10 years. The purposes are to describe the reasons for revisions and to assess the onset and size of osteolytic lesions, with the hypothesis that osteolysis represents an important cause of loosening. The population included 204 patients (211 hips) with mean followup of 13.9 years (range, 2-18 years). Among them, 122 patients (129 hips) had a minimum 15-year followup. Minimum 2-year radiographs with a mean radiographic followup of 12.2 years (range, 2-18 years) were available for 204 hips (197 patients). Of the entire study group, 39 hips (38 patients) had 44 component revisions, increasing the number of revisions by 24 since this series was reported previously. Twenty-six patients (27 hips) had their first revision surgery more than 10 years after the primary surgery. The most common reason for revision of original components was wear or osteolysis occurring in 22 of the 39 hips (21 of 38 patients). The overall loosening rate was 3.4% (seven of 204) for femoral components and 5.4% (11 of 204) for acetabular components. Twenty-four percent of hips (48 of 204) had evidence of femoral or pelvic osteolytic lesions larger than 1.5 cm2. Femoral osteolysis was not associated with any case of femoral loosening, whereas seven of the 11 loose acetabular components were associated with pelvic lesions larger than 1.5 cm2.
By CT scan, the author analyzed morphologically the proximal medullary canal of the femur in 52 cases of osteoarthritis of the hip. The purpose is to determine the stem shape of an artificial hip joint suitable for Japanese patients. The results were as follows: 1) The femoral head diameter indicated positive correlation with the height, the femoral length, the femoral shaft transverse diameter, and the medullary canal diameter. The proportionality of the femur was found in Japanese patients with osteoarthritis. 2) The femoral head offset indicated no correlation with any results obtained by various measurement. 3) The medullary canal diameter of the diaphysial portion as well as the ratio of the medullary canal to the femur increased with age. 4) The taper angle*, 3.8 degree on the average was positively correlated only with the medullary canal diameter. *"Taper angle" indicates the degree of tapering of the medullary canal.
Interface tissue between the bone and loosening total hip implant is acidic and highly osteolytic. It is characterized by the formation of cathepsin K positive foreign body giant cells. Similar structures to those found in the normal joint surround the artificial hip joint. Cells in synovial membrane of the artificial hip generate synovial fluid that is called pseudosynovial fluid. Interface tissue fibroblasts are able to produce receptor activator of NF-kappaB ligand (RANKL), which can induce osteoclastogenesis during the loosening process. Western blot analysis indicated that RANKL is present in the pseudosynovial fluid. Pseudosynovial fluid induced cultured peripheral blood mononuclear cells to form multinuclear TRAP positive giant cells. In the presence of osteoprotegerin, the soluble RANKL decoy receptor, the number of TRAP positive multinuclear cells was reduced to half (p < 0.05). The multinuclear cells induced with pseudosynovial fluid contained active cathepsin K protein and were capable of bone matrix resorption in vitro. The cells were shown to express osteoclast phenotype markers, such as mRNA for cathepsin K, TRAP, and calcitonin receptor. It is therefore apparent that pseudosynovial fluid from patients with aseptic loosening of total hip prosthesis contains a potent osteoclastogenic factor RANKL that further suggests a favorable environment for osteoclast formation in the peri-implant tissues. It is thus concluded that suppression of RANKL activity may be beneficial in terms of increasing the lifetime of total hip prostheses.
This communication describes the use of a total hip prosthesis to successfully alleviate the symptoms of severe coxofemoral osteoarthrosis in a seven-year-old Samoyed dog. Prior to implantation of the prosthesis, the dog had been treated with analgesic and anti-inflammatory drugs and a bilateral pectineal myectomy had been performed. These measures had achieved only limited control of the symptoms. After total hip replacement there was a rapid improvement in the dog;s demeanour and use of the leg which had been operated on. This improvement was maintained during the twelve-month follow-up period.
Bone reactions were studied around a titanium, hydroxyapatite (HA)-coated Osteonics (Allendale, NJ) bipolar hip prosthesis, which was revised for severe midthigh pain 4 years after implantation. Inspection of the retrieved prosthesis using a dissecting microscope revealed scarce remnants of a coating-like material on the surface of the prosthesis; however, histology of this layer and histology of the bony side of the bone--HA interface failed to reveal any remnants of an HA coating. The interface was covered predominantly by trabecular bone, which closely followed the contour of the prosthesis, and was partly woven nonmineralized bone. At locations where mineralized bone faced the prosthesis, many small dark titanium wear particles were found. Similar particles were found in macrophages in the intertrabecular medullary space. Polyethylene wear particles were specifically located in macrophages in a soft tissue interface at more distal levels along the stem of the prosthesis. Although the observations presented in this case cannot be generalized, it clearly shows that the HA coating layer had completely disappeared after 4 years. More detailed retrieval studies and longer clinical follow-up studies are needed before a final evaluation of the behavior of HA coatings and long-term fixation of HA-coated prostheses can be made.
For the anchorage of femoral prosthesis stems in total hip arthroplasty, various cement application techniques are used. Experimental comparison of these techniques requires a set-up in which only the cementing technique itself is tested. We used a computer-controlled implantation device based on a milling machine and standardized artificial femur models. The stems are reproducibly positioned by the machine and any influence of manual positioning during the implantation is excluded. The results can be evaluated macroscopically and radiologically with no interference by disturbing bone--with sufficient sensitivity to objectify differences in cement quality. The increase in pressure in the peripheral medullary cavity, which is responsible for the embolisation, can be determined experimentally for the individual cementing technique. The experimental implantation device described enables a standardized comparison of various cementing techniques.
BACKGROUND: Assessment of total hip replacement has been performed without careful attention to the patients' perceived health. The objective of this study is to assess, in a standardized way, the benefit of hip replacement in terms of hip pain, mobility, and function and as an increase in general perceived health. And to quantify clinical complications of the procedure. PATIENTS AND METHODS: Observational study of a series of 131 consecutive patients of a tertiary hospital to whom two health questionnaires (one specific and the other generic) were administered before and one year after total hip replacement. The specific instrument, the Hip Pain and Function (HPF) scale, measures the functional capacity of the hip gathering information on pain, function and mobility. Scores for the HPF range from 0 (maximal limitation of functional capacity) to 85 (no limitation). The generic instrument used, the Nottingham Health Profile (NHP) measures perceived health and scores range from 0 (best health status) to 100 (worse). RESULTS: Mean age of patients was 63 years; ostheo-arthritis was the most frequent diagnosis (78%), with 42% of the patients with associated pathology. An improvement in both hip functional capacity and perceived general health was observed after one year. HPF scores increased from 26.6 at baseline to 69.9 (p < 0.001). Improvements was important and statistically significant in each of the three dimensions of the specific instrument: Pain, Function and Mobility. Overall score for the NHP changed from 50.9 (at baseline) to 18.1 (p < 0.001). Regression analysis showed only two variables associated with improvement: a higher improvement hip function for patients with no other joints affected; and a higher improvement of perceived health in patients over 70 years with cemented prosthesis, that had a worse initial perceived health status. CONCLUSION: Total hip replacement decreases pain and significantly improves hip mobility and function, as well as the general perceived health. The improvement of perceived health was higher in patients over 70 years.
The authors present a method of semiquantitative analysis of bone scintigraphy in the study of the evolution of total hip prosthesis and analyse the course of remodelling processes in a group of patients who showed no post surgical complication after total isoelastic hip arthroplasty without cement. The authors will use data worked out as terms of comparison in the study of those patients who present, after surgery, a symptomatology difficult to be evaluated in order to discriminate the cases where the symptoms indicate the beginning of a pathologic process (loosening and/or infection).
OBJECTIVE: To describe the radiographic and computed tomography (CT) scan features of iliopsoas impingement on the acetabular component (IPI) in total hip arthroplasty. METHOD: Eight cases of iliopsoas impingement were diagnosed and confirmed by surgical revision. The plain film radiograph findings and CT scan findings were compared with those of two control populations (8 patients with painless total hip prosthesis and 16 patients with other complications confirmed by surgical revision). RESULTS: An oversized cup was found in four hips with IPI (50%) and in one hip with another complication (6%). Coronal inclination of the acetabular cup was normal in the IPI group and in the two control groups, with a similar mean cup size. All patients with IPI had an acetabular cup overhang of more than 12 mm. Conversely, in the two control groups, the overhang, present in three and two cases, respectively, was always less than 8 mm. Iliopsoas bursal effusion was present in four hips with IPI and three hips with other complications and was never present in normal prostheses. CONCLUSION: More than a 12-mm overhang of the acetabular cup is a sensitive and specific parameter for diagnosing IPI.