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PubMed2001

[Prevention of thrombosis in hip prosthesis implantation].

Deep venous thrombosis is one of the most common perioperative complications after total hip arthroplasty. Systemic anticoagulation has been the gold standard for prophylaxis of postoperative deep venous thrombosis. There is no doubt that early mobilization and the use of pneumatic compression devices decrease the overall deep venous thrombosis rate. Single postoperative prophylaxis may decrease the overall deep venous thrombosis rate to 15-20% and the proximal deep venous thrombosis rate to approximately 7%. However,the activation of thrombogenesis is mainly an intraoperative event. The position of the extremity during the implantation of the femoral component leads to obstruction of the venous outflow. At the same time, the coagulation cascade is activated and markers of thrombogenesis in the blood are increased. By combining intraoperative (hypotensive epidural anesthesia and intraoperative heparin) and postoperative (pneumatic compression devices and aspirin) prophylaxis of deep venous thrombosis, the total deep venous thrombosis rate is reduced to less than 10% and the proximal deep venous thrombosis rate is reduced to 2%. Patients with increased risk for deep venous thrombosis should receive Coumadin or low-molecular weight heparin. In addition, hypotensive epidural anesthesia reduces the intraoperative blood loss and the need for postoperative blood transfusion.

Anesthesia, Epidural↗
PubMedDate not supplied

[Mycobacterium fortuitum infection after total hip prosthesis. A report of 3 cases (author's transl)].

The authors have observed three instances of sepsis due to Mycobacterium fortuitum complicating total hip replacement for osteoarthritis. The case histories are fully described. The requirements are given for recognition of the organism which grows on special culture media and which may be mistaken for Mycobacterium tuberculosis. This feature explains why, in some cases, the organism may not be discovered. Antibiotics were ineffective but the general condition of the patient was not greatly affected.

Aged↗
PubMed1998

[Cementless hip prosthesis in patients with rheumatoid arthritis].

From 1986 to 1996, we implanted a total of 92 hip arthroplasties (86 cementless, 4 hybrid and 2 cemented) in 65 patients with rheumatoid arthritis. Of the 89 uncemented cups, 59 were threaded cups (Hofer-Imhof n = 45, Zweymüller n = 7, Mecring n = 5, PM n = 2) and 30 were hemispherical cups of the Harris Galante type I and II. 87 stems were implanted without cement (Zweymüller SL n = 58, Uni n = 16, Schenker n = 9, Zweymüller I n = 4) and 5 with cement. One patient died postoperatively and three (4 implants) within the first year. To date, one cup of each threaded type had to be revised because of loosening (revision rate approx. 6.8%); Up to now, three of 87 (approx. 3.4%) stem revisions (1 x Zweymüller I, 1 x Schenker, 1 x Zweymüller SL) have been undertaken. Ten patients with twelve hip arthroplasties did not return for follow-up; some of them had a poor general health status. The clinical and radiological results of the arthroplasties of 52 patients showed a Harris Hip Score averaging 72 after an average of 54 months (min. 12-max. 132). Ten patients had minor complaints in the hip region. 79% of the uncemented implants (70 out of 89 cups, 69 out of 87 stems) were assessed radiologically. Two threaded cups showed slight migration after cancellous bone grafting in the presence of acetabular protrusion that was present in a total of 13 hip joints. This subsided markedly after filling with cancellous bone and recentering of the hip joint. Homogeneous incorporation of the bone grafting und thus remodelling of the medial wall was achieved, with the bone graft exhibiting marked reduction. At final follow-up, approx. 75% of the cementless cups had complete bone ingrowth without any evidence of radiolucency (type I), approx. 19% had near-complete bone ingrowth with minimal radiolucencies in one zone or in a maximum of 50% of the bone contact area (type III) and approx. 6% had radiolucencies in more than 50% of the bone contact area (type II). The radiographic evaluation of the most frequently used stem (Zweymüller SL) showed approx. 47% with only slight remodelling of the calcar (type I), approx. 33% with moderate loss of femoral density (type II) and approx. 20% with severe bone loss and thinning of cortical bone (type III).

Arthritis, Rheumatoid↗
PubMed2002

[Clinical and radiological results of surgical removal of periarticular ossifications after hip prosthesis implantation].

The occurrence of heterotopic ossification (HO) is a well-recognized problem after total hip replacement. In a retrospective study, we investigated 32 patients who had undergone surgical excision of symptomatic HO followed by radiation with 7 Gy and nonsteroidal anti-inflammatory drug therapy between 1994 and 1999. The mean follow-up was 20 months (range: 12-60). Clinical and radiographic follow-up examinations included Harris hip score and classification according to Brooker. The preoperative Brooker class was III in 16 cases and IV in 16 patients. Comparison of the Brooker classification at follow-up revealed a statistically significant improvement (p < 0.0001; class 0:3, class I: 14, class II: 8, class III: 7 patients). In one case with symptomatic Brooker class III ossification, surgical reexcision of HO was necessary. A statistically significant increase (p < 0.05) in mean range of motion (ROM) was observed in flexion [preoperative: 57 degrees (+/- 26), follow-up: 83 degrees (+/- 21)], in abduction [preoperative: 17 degrees (+/- 12), follow-up: 24 degrees (+/- 9)], and in rotation (preoperative: 16 degrees (+/- 17), follow-up: 31 degrees (+/- 18)]. Comparison of preoperative Harris hip score (60 +/- 11) and Harris hip score at the time of follow-up examination (73 +/- 17) revealed a statistically significant increase (p < 0.0001) after treatment. At the time of follow-up examination, 18 patients (56%) assessed their pain symptoms as low but 6 patients (19%) reported strong pain symptoms. Nevertheless, the score at the time of examination (35 +/- 10) was statistically improved (p < 0.02) when compared to the preoperative score (30 +/- 8). Surgical excision of Brooker class III or IV heterotopic ossification with limited ROM followed by irradiation and anti-inflammatory prophylaxis results in significant improvement in flexion, abduction, and rotation arc and significant reduction of HO in radiographic examination at follow-up, but pain relief was only satisfactory.

Aged↗
PubMed2002

[Technical principles for removal of femoral bone cements in hip prosthesis implant revision].

As the removal of femoral bone cement is one of the most challenging tasks in cemented total Hip Revision, a lot of different technical devices have been developed to aid the surgeon. All of their pros and cons are partly consequences of the specific system-design but mainly arise from the basic physical principles used. The known methods and devices as well as their data-handling have therefore been analysed, reduced to their principles according to the criteria of systematic engineering design and systematized in order to provide a better comparability and starting point for the development of new devices.

Arthroplasty, Replacement, Hip↗
PubMed2003

[Bone grafts in hip prosthesis revisions].

PURPOSE OF THE STUDY: We describe the collection, storage and examination of allogenic bone grafts and their use in revision hip arthroplasty, indicated because of acetabular loosening, that involved either an uncemented cup or an augmentation device with a cemented cup according to the extent and nature of acetabular defects. MATERIAL: Allogenic bone grafts, usually long bones, were collected from deceased humans within 12 hours of death. They were processed according to the standards of US tissue banks. Using ELISA, the blood of each donor was serologically examined for antibodies against selected antigens (HIV I, HIV II, syphilis, HbsAg, HCV, and p24HIV I, HTLV I and II, and HbcAg, if required). Microbiological examination of each bone sample was also included. The samples were kept in a quarantine box until the examination results were known. When these were negative, the bones were cut, under aseptic conditions, to obtain parts (condyle, metaphysis, diaphysis, patella, etc.) weighing from 80 to 150 gr. Subsequently, another quality check, involving microbiological and histological examination, was performed. The allografts were stored at -80 degrees C. METHODS: Between October 1999 and October 2000, 67 revision total hip replacements were performed. Of these, allogenic bone grafting was used for acetabular reconstruction in 30 cases (45%). The average amount of graft tissue per operation was 107 gr (range, 43 to 163 gr). Eleven grafts had been harvested from the tibial condyle, nine from the trochanters, eight from the femoral condyle and two from the patella. The graft bone, ground into coarse chips, was washed with an antibiotic solution. Two techniques were used in graft implantation. 1) Impaction grafting, under pressure, of the acetabulum whose surface was free from any granulation tissue and scratched to make the bone bleed, and implantation of a cemented cup (LOR or Spotorno CLS). 2) Filling of large defects with a bulk of allograft bone chips, using an augmentation ring, mesh or Burch-Schneider cage, and implantation of a cemented polyethylene acetabular component. Uncemented implants were used in 17 and cemented cups with an augmentation device in 13 cases. The hips were checked by X-ray at 3, 6 and 12 months and then at yearly intervals. RESULTS: In the postoperative period of 26 to 38 months, an early recurrent infection led to temporary removal of the implant in one case, one hip showed superficial infection that responded to therapy and there was one case of aseptic acetabular loosening. A recurrent dislocation led to femoral stem exchange for a modular component with a longer neck in one case. The remaining 28 cases showed good incorporation of the graft without any signs of implant migration. DISCUSSION: Segmental defects of the acetabulum can be treated by implantation of specific types of acetabular cups or by massive bone grafting. Cavitary defects can be filled with cancellous allograft bone or bioactive, artificial materials. We prefer morselized allograft bone from the tissue bank and this was used in 45% of repeat surgeries for failure of the acetabular component. An uncemented cup is more convenient, supposing sufficient primary stability can be ensured. When defects are extensive, augmentation devices and filling with graft bone are necessary. Cadaver allografts offer advantages over autologous bone because they are available at any amount and thus enable us to avoid extensive damage to the iliac crest by autologous tissue harvesting. Cadaver grafts are bones of good quality, free from degenerative or dystrophic changes because they are usually taken from young subjects. The size of 7 to 10 mm is optimal because it permits the grafts to maintain both structure and strength. The strict procedure of sample collection and examination minimizes the risk of infection transfer. The progress of graft bone ingrowth was evaluated on radiographs that showed incorporation of allograft into the surrounding bone during 3 to 6 months and no radiolucent areas at host bone-implant contact. CONCLUSIONS: Our patients showed good allogenic bone ingrowth in relation to the acetabular bed and good bone restructuring and incorporation in relation to the implant. Neither mechanical failure of implants nor graft rejection were recorded. The risk of infection transfer was low and comparable with routine blood transfusion. The necessary prerequisite for revision hip arthroplasty is a well-operating bone tissue bank.

Acetabulum↗