髋臼骨折的全髋关节置换术治疗

目的探讨全髋关节置换术（THA）治疗髋臼骨折的手术技术及近期疗效。方法1998年10月至2005年6月,本组采用THA治疗髋臼骨折合并创伤性髋关节骨关节炎患者27例28髋,其中13例初期采用切开复位内固定治疗,14例初期采用保守治疗。术前骨折分型（根据Letoumel—Judet分型系统）：后壁骨折（16例）,横行骨折（1例）,后柱＋后壁骨折（3例）,横行＋后壁骨折（4例）,T形骨折（1例）,双柱骨折（3例）。根据Harris髋关节评分系统分别对术前和术后疼痛程度、髋关节功能及活动度进行综合评分。结果随访资料完备者23例患者（24髋）,随访时间5—78个月,平均24．7个月。术前Harris髋关节评分21-76分,平均50．1分;术后评分56～100分,平均90．2分．较术前有显著性提高（P〈0．001）。其中18例优秀,4例良好,1例一般,1例较差。术前髋关节疼痛评分10—40分,平均24．6分;术后评分30—44分,平均41．1分。各有1例骨水泥型和非骨水泥型臼杯周围出现非连续性透亮带但未伴假体下沉或移位表现。术后未出现关节脱位、深部感染、严重异位骨化、医源性坐骨神经损伤或原有神经症状加重、下肢深静脉栓塞或肺栓塞等并发症。至最后一次随访尚无翻修患者。结论针对髋臼骨折合并创伤性髋关节骨关节炎患者施行THA,可有效缓解疼痛,改善髋关节功能及活动度且并发症少见。     

Total hip replacement with a cementless acetabular component and a cemented femoral component in patients younger than fifty years of age

BACKGROUND: We have been using hybrid total hip arthroplasty (a cementless acetabular component and a cemented stem) in young patients. The purpose of this study was to determine the prevalence of aseptic loosening, polyethylene wear, and osteolysis after the use of this technique. METHODS: We studied a prospective consecutive series of sixty-four primary hybrid total hip replacements in fifty-five patients younger than fifty years old. There were forty-three men and twelve women; the average age at the time of the index operation was 43.4 years. The average duration of follow-up was 9.4 years. We used a cementless acetabular component without screw-holes and a cemented femoral component with a 22-mm head in all hips. Clinical follow-up with use of Harris hip ratings and radiographic follow-up were performed at six weeks; at three, six, and twelve months; and yearly thereafter. The sequential annual linear and volumetric wear rates were measured, and bone-remodeling and osteolysis were assessed. RESULTS: The mean preoperative Harris hip score was 44 points, which increased to 95 points at the time of final follow-up. No hip had aseptic loosening. One hip (2%) was revised because of late infection. The average linear wear (and standard deviation) was 0.96 +/- 0.066 mm, with an average annual rate of 0.096 +/- 0.013 mm. The average volumetric wear was 364.7 +/- 25.2 mm (3), with an average annual rate of 43.4 +/- 3.5 mm (3). Six hips (9%) had an osteolytic lesion of <1 cm in diameter in the calcar femorale (zone 7). CONCLUSIONS: Our results show that a hybrid arthroplasty with a cementless acetabular component and a smooth cemented femoral component (Ra, 0.6 mm) is effective for primary total hip replacement in young patients. Although there was no aseptic loosening and a low prevalence of osteolysis at the latest follow-up evaluation, the high rates of linear and volumetric wear of the polyethylene liner in these young patients remain a concern.     

人工全髋关节置换术中髋臼骨缺损的重建

目的 探讨人工全髋关节置换术中各种髋臼骨缺损的特点与重建方法.方法 1998年5月至2008年8月对获得随访的行初次全髋关节置换或翻修的37例(37髋)髋臼缺损患者的临床资料进行回顾性分析,依据AAOS分型采取颗粒性或结构性植骨、生物或骨水泥髋臼假体以及钛网或加强环置入等方法对骨缺损进行重建.术前Harris评分(42±8)分.术后采用Harris评分判断髋关节的功能改善情况,复查X线片了解移植骨愈合及假体在位情况.结果 AAOS Ⅰ型9例,Ⅱ型13例,Ⅲ型15例.颗粒性植骨24例,结构性植骨6例,混合性植骨7例;生物型假体21例,骨水泥型假体16例.平均随访时间53.7个月.术后Harris评分(87±5)分,与术前比较,差异具有统计学意义(P<0.05).移植骨在最后一次复查时均已愈合或基本愈合.结论 对于AAOS Ⅰ型、Ⅱ型等简单的髋臼骨缺损,颗粒性或结构性植骨结合生物型髋臼假体就可以获得很好的初始稳定性,而对于AAOSⅢ型等较严重的缺损,则应行结构性植骨或附加钛网及加强环等重建髋臼.其短、中期疗效是令人满意的.     

颗粒打压植骨结合骨水泥型髋臼杯在髋关节发育不良髋臼重建中的应用

目的探讨颗粒打压植骨结合骨水泥型髋臼杯在CroweⅡ、Ⅲ型髋关节发育不良（DDH）中应用的早期疗效。方法2005年3月至2008年3月,采用颗粒打压植骨重建髋臼结合骨水泥型髋臼杯治疗11例DDH继发骨性关节炎的患者。女10例,男1例,年龄43～58岁,平均49．4岁;CroweⅡ型9例,Crowem型2例,疼痛病史5～30年,术前Harris评分28～55分,平均45．3分。术后定期随访进行影像学评价和Harris评分。结果本组患者临床随访4～36个月,平均18个月,全部患者髋关节功能恢复良好,无感染、神经损伤、脱位等并发症。术后Harris评分90～98分,平均94．1分,术后随访影像学上显示植骨均与宿主骨愈合,最后一次随访无植骨吸收髋臼假体松动、移位。结论颗粒打压植骨结合骨水泥型髋臼杯治疗CroweⅡ、Ⅲ型DDH患者早期效果可靠。     

全髋关节置换术治疗髋臼骨折后创伤性关节炎的疗效观察

目的探讨人工全髋关节置换术治疗髋臼骨折后髋关节创伤性骨关节炎的疗效。方法本组共随访髋臼骨折后髋关节创伤性骨关节炎患者32例32髋,男20例,女12例,平均年龄45.3岁。本组患者全部行人工全髋关节置换术治疗。所有假体均采用生物型假体。采用Harris、UCLA评分对患者术前术后的髋关节功能进行评分,拍摄标准双髋正位片对假体状态进行影像学评估。结果本组患者平均随访26个月,Harris评分由术前42.5分增加到术后93.6分,UCLA评分由术前3.2分增加到术后8.1分,改变有统计学差异。影像学评估显示假体位置良好,无假体松动、关节脱位、感染及明显假体周围骨溶解等并发症。结论全髋关节置换是治疗髋臼骨折后创伤性关节炎的有效治疗手段,术中尽量采用生物型假体,近期随访结果令人满意。     

Hybrid total hip arthroplasty with a precoated offset stem. Four to nine-year results

BACKGROUND: Use of modern cementing techniques for fixation of femoral components in total hip arthroplasty has had excellent clinical and radiographic results in most patients. However, several authors have described early loosening of femoral components with roughened and precoated finishes. The purpose of this study was to examine the performance of the precoated Iowa stem, which has increased offset, and to compare the results with those of another cemented precoated femoral component with standard offset used at our institution. METHODS: We carried out a prospective analysis of 102 primary hybrid total hip arthroplasties (a cementless acetabular component and a cemented femoral component) performed with use of the Iowa femoral component in ninety-five patients at our institution. The Iowa stem was used in hips that required greater offset than is available with standard stems as determined by preoperative templating. The average age of the patients at the time of the index procedure was sixty-nine years. Sixteen patients (seventeen hips) died before the forty-eight-month minimum follow-up period had elapsed. Two patients were lost to follow-up, and radiographic follow-up was incomplete for one. The mean duration of clinical and radiographic follow-up of the remaining eighty-two hips in the seventy-six surviving patients was sixty-five months (range, forty-eight to 104 months). RESULTS: The average preoperative Harris hip score of 47 points (range, 16 to 69 points) improved to an average of 87 points (range, 24 to 100 points) at the time of the review. Two hips underwent femoral component revision. Four femoral stems were radiographically loose at an average of thirty-four months. Femoral osteolysis was seen in five hips (6 percent) at an average of fifty-four months postoperatively. No acetabular component was revised because of aseptic loosening. According to Kaplan-Meier analysis, the seven-year survival rate, with an end point of femoral revision, osteolysis, or stem debonding, was 90.6 percent (95 percent confidence interval, 0.87 to 0.94). CONCLUSIONS: The prevalence of revision, osteolysis, and loosening after total hip arthroplasty with the Iowa femoral component at our institution was higher than that seen in our series of Harris Precoat stems, which had a survival rate of 98.4 percent (95 percent confidence interval, 0.97 to 1.00) at ten years with the same end points. The design of the Iowa stem may make it difficult to achieve a good cement mantle, and, in combination with the geometry and increased offset of the stem, may compromise the long-term survival of this cemented femoral component.     

Acetabular revision using acetabular roof reinforcement ring with a hook

This study evaluated the clinical and radiographic results of 37 acetabular revisions using an acetabular roof reinforcement ring with a hook (ARRRH). The average age of the patients was 52.4 years, and the mean follow-up period was 4.5 years. The mean Harris hip score had improved from 49 points preoperatively to 87 points at the final follow-up. The bone graft was radiographically incorporated in all cases. The postoperative complications were a hip dislocation in 3 cases, nonunion of the greater trochanter in 1, infection in 1, discomfort at the autograft donor site in 3, and 2 cases of hook failure. An ARRRH combined with a morsellized bone graft is a useful treatment particularly in moderate-to-severe acetabular bone deficiencies.     

Avascular necrosis of the hip treated by hemiarthroplasty: Results in renal transplant recipients

Osteonecrosis of the femoral head is a common complication in renal transplant recipients. Despite the young age of these patients, replacement arthroplasty is often used in treating symptomatic individuals. Between 1983 and 1990, 22 cemented biarticular hemiarthroplasties were performed in 16 consecutive patients with advanced osteonecrosis of the hip. The average interval from initial transplant to arthroplasty was 28 months (range, 11–63 months). The mean age at the time of arthroplasty was 40 years (range, 21–66 years), and all patients were treated with steroids and immunosuppressants at the time of surgery. The average preoperative Harris hip score was 27 points (range, 4–46 points). The mean follow-up period was 40 months (range, 24–71 months). All patients had improvement in pain. Eighty percent of the patients reported a slight or mild limp, although only 25% demonstrated a positive Trendelenburg sign. The average postoperative Harris hip score was 88 points (range, 71–96 points), with 9 hips rated excellent, 12 good, and 1 fair. One patient fractured her acetabulum 26 months after arthroplasty, which resulted in progressive subluxation of the prosthesis. It was revised to a total hip arthroplasty. Another patient developed symptomatic aseptic loosening after 30 months. Apart from this patient there was no other radiologic evidence of loosening in the remainder of the series. Only one patient had demonstrable acetabular protrusion. Twenty percent of the hips had asymptomatic heterotopic ossification. The early results of using a cemented, biarticular hemiarthroplasty in this young group of renal transplant recipients appear encouraging. There was no evidence that this prosthesis causes accelerated acetabular erosion or early loosening. It also has the advantage of preserving acetabular bone stock, which facilitates future revision.     

髋关节翻修术中髋臼骨缺损的处理与重建

目的探讨髋关节翻修术中髋臼骨质缺损的处理和重建方法。方法对28例髋关节置换术后髋臼骨缺损的患者进行翻修,观察术后随访X线片上的髋臼假体及周围骨质变化情况,并对髋关节行Harris功能评定。结果 28例均获随访,随访时间12～184个月,平均61.6个月。1例术后出现脱位,2例术后出现骨溶解并伴患髋疼痛。7例术后随访的X线片上出现髋臼的骨溶解,但髋臼假体无松动表现,患髋无疼痛,患髋功能不受影响。至末次随访为止,25例髋（89%）获得良好的稳定性。术前Harris评分平均31.8分（14～57分）,末次随访时平均85.2分（46～99分）。两组数据具有显著性差异。结论充分的术前准备是手术顺利进行并获得良好效果的一个重要前提,植骨的方式和翻修假体的选择还需结合术中对骨缺损的评价。髋臼假体表面被自体骨覆盖超过50%,可考虑行植骨加非骨水泥型髋臼假体置换;自体骨覆盖不足50%,宜行骨水泥型髋臼假体置换。如骨缺损面积较大,可行加强环等翻修。从随访中可见,颗粒骨打压植骨是治疗髋臼骨缺损可靠的方法。     

Acetabular revision with impacted morselized cancellous bone graft and a cemented cup in patients with rheumatoid arthritis: three to fourteen-year follow-up

BACKGROUND: Acetabular revision in patients with rheumatoid arthritis is often difficult because of the poor quality and quantity of the acetabular bone stock. The purpose of this study was to evaluate the midterm clinical and radiographic outcomes of acetabular revision with use of an impaction bone-grafting technique and a cemented polyethylene cup. METHODS: Thirty-five consecutive acetabular revisions were performed with impaction bone-grafting and use of a cemented cup in twenty-eight patients with rheumatoid arthritis. The average age at the revision was fifty-seven years. The minimum duration of follow-up of all reconstructions that were still functioning or that were followed until the time of death was three years (mean, 7.5 years; range, three to fourteen years). No patient was lost to follow-up, but five patients (six hips) died before the time of the review. The acetabular bone defects were classified as cavitary in twelve hips and as combined segmental-cavitary in twenty-three. RESULTS: The five patients (six hips) who died had been doing well at the time of their latest follow-up. Of the remaining patients, six (six hips) had a repeat revision. The average Harris hip score of the living patients with a surviving implant at the time of follow-up was 82 points, and there was no or only mild pain in twenty-one of the twenty-three hips. Radiographic analysis of all twenty-nine hips that had not been revised showed loosening in one hip and a nonprogressive radiolucent line in one zone in two others. Kaplan-Meier analysis demonstrated a prosthetic survival rate, with aseptic loosening as the end point, of 90% at eight years. CONCLUSION: Acetabular revision with impaction bone-grafting and a cemented cup in patients with rheumatoid arthritis had acceptable results at an average of 7.5 years postoperatively.     

颗粒松质骨压紧植骨全髋关节置换术治疗创伤性髋关节炎的疗效

目的探讨颗粒松质骨压紧植骨全髋关节置换术(THA)治疗髋臼骨折继发创伤性髋关节炎的疗效。方法1998年12月-2005年5月,对15例髋臼骨折继发创伤性髋关节炎患者行颗粒松质骨压紧植骨THA,所有患者髋臼假体均采用骨水泥固定,颗粒骨均取自体骨,术后24h后开始被动活动,3个月后开始全负重锻炼。临床随访采用Harris髋关节评分(HSS)系统评分,对任何原因引起髋臼假体翻修均视为临床失败。根据Conn等影像学评价法观察颗粒骨长人情况,根据DeLee的三区法测量臼杯、骨水泥与移植骨间的界面宽度,臼杯的移位程度则依据其相对于泪点间线的距离而定。结果14例患者获得平均4．3年(1．0-7．5年)随访,HHS评分由术前平均42分(10-62分)提高到随访结束时平均84分(58-98分)。1例髋部有轻度疼痛,无患者行翻修手术。大部分髋部恢复了其正常的旋转中心,仅有2例高出对侧0．8 mm。大多数患者影像学表现稳定,2例在Ⅰ区和Ⅲ区出现进行性增宽的透亮带,1例在Ⅲ区出现非进行性增宽的透亮带。1例臼杯假体在术后7年出现明显移位(6 mm),但并没有行翻修手术。结论颗粒骨压紧植骨技术作为一种生物学髋臼重建方法,其联合THA治疗髋臼骨折后继发创伤性关节炎伴髋臼缺损的疗效令人满意,能够恢复髋关节的正常解剖和功能活动。     

Hydroxyapatite-coated total hip arthroplasty in osteoporotic patients

A prospective review was performed on 22 osteoporotic patients (rated from 1 to 3 on the Singh Index) with hydroxyapatite-coated total hip replacements. These results were compared with a control group (Singh Index 4 to 6) of 45 patients (48 hips) with respect to clinical and radiographic data. Surgery was performed over a six-year period (1991 to 1996) and the time to follow-up evaluation averaged 5 years (range: 2 to 7 years). All patients, in both groups, were over 65 years old with an average age of 71 and 73 years, respectively. The pre-operative diagnoses and Harris hip scores were also similar for both groups. Clinical evaluation was based on the Harris Hip score and radiographic evaluations using Engh's criteria. There was no significant difference between the final average Harris hip score in the osteoporotic bone group, which was 87 points, and that for the control group, which was 91 points (p > 0.05). Radiographic evaluation demonstrated confirmed bone ingrowth in most patients in each group; one patient in each group had suspected bone ingrowth. No stems were revised for aseptic loosening and no endosteal lysis was found. Progressive bone formation was seen around the femoral stem proximally. The acetabular components demonstrated no sign of mechanical loosening or osteolysis. Bone formation was found in most patients in zone I, and in a few patients also in zone III. On the basis of the results of this study, it is believed that osteoporotic bone as a factor by itself should not compromise the early results of hydroxyapatite total hip arthroplasty and should provide good results in the long term.     

Total Hip Arthroplasty in Down Syndrome Patients: An Improvement in Quality of Life : Replacement Arthroplasty in Down Syndrome (RADS) Study Group

The purpose this study was to assess survival rates, clinical outcomes, and radiographic outcomes of total hip arthroplasty in Down syndrome patients. We reviewed 26 total hip arthroplasties (21 patients) performed by four experienced hip surgeons. These patients had a mean age of 35 years and a mean follow-up of 106 months. Clinical outcomes were assessed using Harris Hip scores, and radiographic evaluation for component fixation and migration was performed. The overall survival with aseptic failure as an endpoint was 85%. The mean Harris Hip score improved to 84 points at final follow-up. While these patients can be challenging to treat, excellent surgical technique and selective use of acetabular constraint can reliably provide patients with excellent pain-relief and improved function.     

Clinical and radiographic outcomes of total hip arthroplasty with insertion of an anatomically designed femoral component without cement for the treatment of primary osteoarthritis. A study with a minimum of six years of follow-up

We evaluated the clinical and radiographic outcomes of 100 consecutive primary total hip arthroplasties in which a proximally coated anatomically designed femoral component was fixed without cement for the treatment of primary osteoarthritis. The minimum duration of follow-up was six years (average, 7.1 years). The eighty-eight patients who had the arthroplasties were followed prospectively with a standard clinical evaluation that involved use of the Harris hip score and a radiographic evaluation based on the criteria of the Hip Society. Bone ingrowth was evaluated with the method of Engh et al. The average age of the patients at the time of the operation was 62.6 years (range, thirty-nine to eighty-four years). Fifty-one patients were men and thirty-seven were women. The average preoperative Harris hip score was 48 points, with an average pain score of 15 points and an average function score of 26 points. Nonmechanical complications that necessitated a revision operation included one deep hematogenous infection, one late periprosthetic fracture, and a 0.5-inch (1.27-centimeter) limb-length discrepancy. At the time of the most recent follow-up, the average Harris hip score was 96 points, with an average pain score of 42 points and an average function score of 45 points. The prevalence of pain in the anterior part of the thigh was 5 percent (five hips). One patient had a revision of the femoral component because of aseptic loosening, and one had a revision of the acetabular component because of recurrent dislocations. Radiographic assessment revealed consistent evidence of proximal bone ingrowth. No complete radiolucent line was identified, except around the stem that had loosened. Twenty-seven femoral components were associated with slight pedestal formation. No osteolytic lesion of the femur was identified. Nonprogressive pelvic osteolysis was identified in four hips, but none of the lesions were more than two millimeters in diameter. None of the acetabular components migrated, and no radiolucent line of more than two millimeters in thickness was seen around any acetabular cup. The data from this study, in which the minimum duration of follow-up was six years, indicate that the anatomically designed prosthesis can provide good results, with low prevalences of pain in the thigh and loosening of the component, in younger, active patients.     

Surgical treatment of fractures of the greater trochanter associated with osteolytic lesions

BACKGROUND: A fracture of the greater trochanter through an osteolytic lesion may occur as a late complication after total hip arthroplasty. The optimal treatment for this difficult complication remains controversial. We have treated this problem with internal fixation and allogeneic bone-grafting at the time of revision of a loose acetabular component. METHODS: We retrospectively reviewed the results of treatment of a fracture through an osteolytic lesion of the greater trochanter in nineteen patients seen from 1996 to 2002. All fractures were treated with morselized allogeneic bone grafts and wire fixation at the time of revision of a failed acetabular component. Postoperative care included the use of an abduction orthosis and protected weight-bearing for at least three months. Follow-up of all patients consisted of radiographic examinations and clinical evaluation with use of the Harris hip score. RESULTS: At an average duration of 3.8 years after the revision, eighteen of the nineteen fractures had healed. The average time to healing was five months. The one treatment failure occurred in a patient who did not comply with the use of an abduction orthosis. The average Harris hip score for all patients improved from 32.5 points preoperatively to 91.2 points at the time of the latest follow-up. Polyethylene wear and recurrent osteolysis of the greater trochanter was noted in one hip at the eight-year follow-up examination. CONCLUSIONS: Fractures of the greater trochanter associated with osteolytic lesions can be effectively treated with open reduction, internal fixation with wire, and allogeneic bone-grafting.     

Intermediate-term results after hybrid total hip arthroplasty for the treatment of dysplastic hips

BACKGROUND: In recent studies, good intermediate-term results have been reported after primary hybrid total hip arthroplasty (a cementless acetabular component with a cemented femoral stem) for the treatment of primary osteoarthritis. However, few studies have described the results of this technique in patients with developmental dysplasia of the hip. METHODS: One hundred primary hybrid total hip replacements were performed in ninety patients to treat degenerative arthritis of the hip secondary to developmental dysplasia. Seventy-one patients (eighty-one hips) were available for clinical and radiographic evaluation. The average duration of follow-up was 10.6 years. There were ten men and sixty-one women. Seventy hips were classified as type 1 (dysplasia); seven, as type 2 (low dislocation); and four, as type 3 (high dislocation), according to the classification system of Hartofilakidis et al. RESULTS: At the time of the final follow-up, the average Harris hip score was 86 points. Structural autograft was used in fifteen hips to supplement acetabular coverage. Within five years postoperatively, the acetabular component in six of the fifteen hips had an average of 4.5 mm of vertical migration and an average increase in vertical rotation of 3 degrees, but the position appeared to stabilize thereafter. Revisions were performed in two hips because of recurrent dislocation. No acetabular or femoral component was revised because of aseptic loosening. Osteolysis was identified around two acetabular components and two femoral components. The average rate of polyethylene wear was 0.09 mm per year. CONCLUSIONS: Hybrid total hip arthroplasty for the treatment of symptomatic degenerative arthritis secondary to developmental dysplasia provides favorable results at intermediate-term follow-up. With lower grades of dysplasia, the majority of patients can be treated effectively without a structural bone graft by placement of the cementless acetabular component at a medial or high position.     

Clinical experience with a proximally porous-coated second-generation cementless total hip prosthesis: minimum 5-year follow-up

This study reports the minimum 5-year follow-up of our experience with the Porous-Coated Anatomic E (PCA-E) series femoral stem and the modular acetabular cup. A total of 115 consecutive total hip replacements using PCA-E series (Howmedica, Rutherford, NJ) were performed in 108 patients. Six patients whose hips were performing well clinically died before 5-year follow-up and were excluded from the final evaluation. The remaining 109 hips (102 patients) were assessed at a mean follow-up of 72 months (range, 60-84 months). The hip diagnoses were osteoarthritis in 73, osteonecrosis in 31, rheumatoid arthritis in 2, and hip dysplasia in 3. The mean age was 56 years (range, 24-83 years). Three hips were revised: 1 because of late hematogenous infection, 1 because of aseptic loosening of the femoral component, and 1 because of postoperative loosening of an acetabular component. The Harris hip scores improved from a mean of 50 points (range, 20-66 points) preoperatively to a mean of 92 points (range, 64-100 points) at final follow-up. The score differed in each Charnley functional class, with a mean of 93 points (range, 72-100 points) in 57 hips of class A (no other joint involvement); 90 points (range, 58-100 points) in 26 hips of class B (opposite hip involvement); and 85 points (range, 37-100 points) in 26 hips of class C (multiple joint involvement or severe systemic disease). Out of 106 hips that had a full radiographic evaluation performed, 103 femoral components revealed stable bony ingrowth, 2 revealed stable fibrous ingrowth, and 1 showed migration with progressive loosening. This patient with radiographic loosening has minimal symptoms and has not required or been offered further surgery (Harris hip score of 86 points). The low aseptic loosening rate (2%) at minimum 5-year follow-up compares favorably with any cemented or cementless series. The osteolysis that was seen was focal and localized. The short follow-up does not allow determination of progression. There were no cases of distal osteolysis. We attribute the improved results from reported first-generation experience to multiple factors, including increased number of sizes (9 vs 6), increased proportional metaphyseal size, improved polyethylene manufacture (ram extruded vs machined), improved acetabular locking mechanism, and change to 26-mm from 32-mm femoral heads.     

Acetabular reconstruction with impacted morcellized cancellous bone autograft and cemented primary total hip arthroplasty: a 10- to 17-year follow-up study

During the period 1979 through 1986, 69 acetabular reconstructions in 63 patients were performed with the use of autologous morcellized bone-grafts because of acetabular bone stock loss. Nine cases (10 hips) were lost to follow-up. Eleven patients (12 hips) died <10 years after surgery; none had a revision. The results for the remaining 43 patients (47 hips) were reviewed at an average interval of 12.3 years (range, 10-17 years). No preoperative Harris hip score was available. The average Harris hip score at follow-up was 88 (range, 60-100). Radiographically, all grafts united. One hip developed a deep infection. Three other hips (6%) were revised because of aseptic loosening of the acetabular component. An additional 3 acetabular components were considered radiographic failures. Excluding the infected case, the overall survival rate of these acetabular reconstructions with a revision as endpoint was 94% at an average follow-up of 12.3 years. Reconstruction of acetabular bone stock loss with autologous morcellized bone-grafts is an attractive technique with a good potential for long-term success.     

Long-term results of intertrochanteric varus osteotomy for arthrosis of the dysplastic hip (over 10 years' follow-up)

We performed a retrospective clinical and radiographic review of the long-term results of 64 hips in 53 patients who underwent intertrochanteric varus osteotomy for arthrosis of the hip at the pre- or early stage with acetabular dysplasia. Their average age at operation was 26 years. The average duration of follow-up was 18 years and 10 months. The mean Harris hip score was 77 ± 9 points pre-operatively, and improved significantly to 84 ±13 points at the final follow-up. The acetabular coverage influenced the final outcome, and the postoperative prognosis was predictable from the acetabular head index (AHI) on a pre-operatively done hip maximum abduction radiograph (abd XP). We conclude that varus osteotomy for a dysplastic hip should be considered when the acetabular coverage is sufficient, and that a good prognosis can be expected when AHI on abd XP is greater than 60%.     

Total hip arthroplasty with use of the Metasul metal-on-metal articulation. Four to seven-year results

BACKGROUND: Total hip replacements with a metal-on-metal articulation were commonly used until the mid-1970s; most were then abandoned in favor of hip replacement with a metal-on-polyethylene articulation. The reason for this change was primarily early cup loosening, which was more prevalent with these metal-on-metal designs than it was with metal-on-polyethylene designs. In the late 1980s, a metal-on-metal design with improved clearance (adequate space between the femoral head and the acetabular articulation surface to allow fluid film lubrication and clearance of any debris from within this joint), metal hardness, and reproducible surfaces was introduced by Sulzer Orthopedics in Switzerland. Orthopaedic surgeons were interested in this Metasul articulation because the contribution of polyethylene wear particles to the failure of total hip replacements had become evident. This study was undertaken to review the clinical performance of this implant and to determine if early acetabular loosening or revision and wear and osteolysis were prevalent. METHODS: Between 1991 and 1994, seventy patients (seventy hips) had a total hip replacement with the Metasul metal-on-metal articulation and a cemented Weber cup. Nine patients died less than four years after the replacement; none of these deaths were related to the operation. Five patients were not available for radiographic evaluation, but they were contacted and it was known that the hip was not painful and had not been revised. Fifty-six patients (fifty-six hips) had complete clinical and radiographic data four to 6.8 years after the operation, and they made up the study group. The patients were evaluated with use of the Harris hip score, a patient-self-assessment form, and radiographs. RESULTS: At an average of 5.2 years (range, four to 6.8 years) after the operation, the average total Harris hip score for the fifty-three patients who did not have a revision was 89.6 points (range, 62 to 100 points). The average Harris pain score was 41.0 points (range, 30 to 44 points), and the average Harris limp score was 9.4 points (range, 5 to 11 points). One patient had revision of a loose cup, but there were no other loose acetabular components in the series. Two patients had revision of the acetabular component because of dislocation. No patient had a loose or revised femoral component. Therefore, the mechanical failure rate was one (2 percent) of fifty-six patients. Thirty-six of forty-seven patients who completed the patient-self-assessment form rated their result as excellent; seven, as very good; two, as good; one, as fair; and one, as poor. Wear could not be measured on radiographs because of the metal-on-metal articulation. No hip had radiographic evidence of acetabular osteolysis and two hips had calcar resorption, but there was no other radiographic evidence of focal osteolysis. CONCLUSIONS: Our four to seven-year experience with this articulation surface indicates that the clinical results are similar to those of total hip replacements with a metal-on-polyethylene articulation. We believe that the Metasul articulation may have a role in reducing the wear that occurs with total hip replacement. The Metasul articulation appears to be particularly indicated for more active patients. A historical comparison with the reports in the literature of which we are aware indicated that the hips in our study had a lower rate of acetabular revision and loosening than did those with previous metal-on-metal designs and that they had no more acetabular loosening or osteolysis than did those with metal-on-polyethylene articulations followed for an average of five years.