Entzündlicher Pseudotumor im M. ileopsoas mit Femoralisparese durch massiven Metallabrieb einer Hüftendoprothese

Case report of a 62-year-old patient with a presumed loosening of a hip endoprosthesis after 10 years and a planned replacement. In addition, the patient suffered pain in the thigh and had paresis of the femoral nerve. A CAT-Scan substantiated the diagnosis either of a suppurating or a neoplastic tumour in the left iliac foss. The wide excision revealed a rare inflammatory tumour in the left ileopsoas muscle due to the excessive abrasion of the metal hip endoprosthesis.     

Iliopsoas tendinitis--rare cause of pain following implantation of a total hip endoprosthesis

Pain following implantation of a total hip endoprosthesis is described in the literature with an incidence of 1-17.6%, depending on the type of prosthesis. The underlying causes are numerous; the primary reasons for such pain are septic and nonseptic loosening of the prosthesis, periarticular heterotopic ossifications, or trochanteric bursitis. Less common reasons are muscular hernia, squeezing of the joint capsule, distal nerve lesions, stress fractures, compartment syndromes, or neoplasia.One can find only a few reports about tendinitis of the iliopsoas muscle as a cause for pain following implantation of an endoprosthesis in total hip arthroplasty. We now report about a female patient with therapy-resistant pain after total hip replacement, caused by tendinitis of the iliopsoas muscle. We introduce the transpositioning of this tendon from the lesser trochanter to the proximal anterior femur and bony refixation with a PDS cord as a new operative treatment.     

Malignant fibrous histiocytoma at the site of a total hip arthroplasty

Malignant fibrous histiocytoma is the most frequent sarcoma in adults. Predisposing factors for malignant fibrous histiocytoma are Paget's disease, bone infarcts, malignant disorders of the hematopoetic system, or prolonged intake of corticosteroids. Malignant fibrous histiocytoma has been described as occurring with increasing frequency after endoprosthetic therapy and has been attributed to the implants or to their alloy constituents. Malignant fibrous histiocytoma at the site of an endoprosthesis of the hip constitutes a distinct rarity. To our knowledge, only 13 cases have been described to date. In this report, we present the case of a 66-year-old woman with rheumatoid joint disease. Eight years after primary endoprosthetic surgery, loosening of the implant with severe osteolysis of the surrounding bone required replacement surgery. Histopathologic evaluation of resected tissue revealed scar and granulation tissue and Grade 3 malignant fibrous histiocytoma. The patient died 1 year after revision arthroplasty because of diffuse pulmonary and cerebral metastases. In patients with loosening of a total hip endoprosthesis in combination with severe periprosthetic osteolysis an accompanying malignancy should be in the differential diagnosis. The histopathologic examination of the resected tissue should be obligatory.     

Endoprosthesis in paraplegics with periarticular ossification of the hip

STUDY DESIGN: Clinical study. OBJECTIVES: To evaluate indications of hip endoprosthesis in periarticular ossifications. SETTING: A Spinal Cord Injury Centre in Germany. METHODS: Clinical examination, X-ray control. RESULTS: Surgery of periarticular ossification (paraosteoarthropathy, POA) either involves simple resection of the ossification or removal of the hip. The latter has an impact on the sitting posture with concomitant increased pressure sore risk. Nevertheless the hip is biomechanically important in paraplegics. We are investigating the outcome of total hip replacement (THR) in patients with ankylosis due to periarticular ossification. Six hip replacement cases seen in follow-up of up to 24 months showed no loosening, with good mobility of the joint. We follow a strict perioperative POA prophylaxis, which resulted in each case reporting only a slight recurrence (Brooker 1-2) without any loss of functional mobility. CONCLUSION: In ankylotic hips with mobility/social/hygenic problems we favour a hip replacement in cases with osteoarthritis or high risk of osteoporotic fracture. A replacement of the joint should be preferred to a Girdlestone operation.     

Monitoring of IL-6 levels in patients after total hip joint replacement]

Total hip replacement became a method of choice in treatment of the severe osteoarthritis. Despite the progress in constructing the implants and also the surgical technique, the number of complications rises together with the number of arthroplasties performed. The periprosthetic osteolysis and its consequence--the loosening is the one of the greatest problems of today's joint replacement. It creates the main obstacle for the long-term efficiency of the total hip arthroplasty. It was proved by the numerous research, wear debris of the implant induce the chronic periprosthetic inflammatory process. Many studies emphasize the influence of the proinflammatory cytokines on the bone metabolism. The aim of the study was the evaluation of the inflammatory process in patients with the severe osteoarthritis before the surgery and in subsequent periods after total hip replacements and also in patients with the aseptic loosening of the endoprosthesis, by the monitoring the levels of IL-6 in serum of the peripheral blood. The results suggest, that in patients following THA with the elevated level of IL-6, the inflammatory process was present. This inflammation may lead in future to the aseptic loosening of the implant.     

Periprothetische Frakturen bei Hüftendoprothese

The number of periprosthetic fractures following hip replacement is increasing due to longer life expectancy and the rising number of joint replacements. The main causes of periprosthetic fractures include trauma, implant specific factors or loosening of the endoprosthesis. When planning therapy, surgeons should consider specific and general implant- and patient-related risk factors to ensure the best possible treatment. Established classification systems can facilitate preoperative planning. At present, the Vancouver classification system probably comes closest to the ideal, as it considers fracture configuration, stability of the implant and quality of the bone stock. Depending on these factors, therapeutic options include conservative treatment, fracture stabilisation or replacement of the endoprosthesis. The problems associated with periprosthetic fractures of varying etiology and the available treatment options are discussed against the background of the established classification systems.     

Haematogenous tuberculous infection following revision of a loosened total hip replacement

A case of tuberculous arthritis complicating revision of a total hip replacement (THR) is reported. Primary THR was performed for arthrosis of the hip and the patient underwent revision because of aseptic loosening. After this surgical procedure, secondary infection with Mycobacterium tuberculosis occurred. Bacterial contamination due to haematogenous spread probably from a reactivated old quiescent tuberculous pleural focus is proposed as the most likely source of infection in this patient. Tuberculous infections in THR are rare but prophylactic use of antituberculous drugs in patients with a history of tuberculosis may reduce the risk of reactivation of old foci and serve to eliminate contamination of prosthetic replacements. Received: 15 May 1997     

An analysis of selected risk factors of aseptic loosening of hip endoprosthesis]

An analysis of selected risk factors of aseptic loosening of hip endoprosthesis has been attempted on the ground of retrospective evaluation of 57 hips in 54 patients (41 females, 13 males) who underwent revision of the hip replacement. Age of the patients at primary surgery ranged from 18 to 73 years (mean 55.6 years). Follow-up ranged from 8 to 212 months (mean 83 months). Originally, in 45 cases cemented hip replacement was done and in 12 cementless endoprosthesis was implanted. In 34 cases both components were replaced, in 14 cases acetabular component, in 9 cases stem only and in 1 case the endoprosthesis was removed. Clinical evaluation was done according to Merle-d'Aubignea criteria, radiologic assessment was done according to DeLee and Charnley classification and the one of Gruen. Within 10 years after primary surgery all cementless hips were revised (all Parhofer-M?nch type within 5 years). Among Weller cemented replacements both components were replaced in 18 cases, acetabulum in 8, the stem in 5 and 1 endoprosthesis was removed. McKee-Farrar implants were replaced completely in all but 2 cases. Most of revisions among cemented hip replacements took place 10 years after primary operation. Angular migration of the acetabular component was found in 40 cases; in 8 cases no migration was observed. Forty-three hips with loosened stem have been analyzed: to small size of the stem was found in 6 cases, varus deviation was found in 14 cases and valgus deviation in 6. Special attention has been paid to the technical errors that are essential for long-term result of hip replacement.     

Demonstration of the loosening of hip endoprostheses by computerized tomography

A pilotstudy was undertaken to evaluate the utilisation of modified computed tomography as an early diagnostic means to confirm the loosening of the total hip endoprosthesis. In nine of the twelve cases the CT investigation clearly indicated the loosening of the endoprosthesis. With respect to the remaining three patients, no conclusions could be drawn because of the presence of artifacts. It is of further interest to note pertaining to these three, that two had been supplied with an endoprosthesis of the hip on both sides and the third with an irregular surfaced shaft endoprosthesis. In conclusions one can say, despite the problems associated with the modified CT, that it is a suitable additional method for the early diagnosis of the loosening of total hip endoprosthesis.     

全髋关节置换术治疗人工股骨头置换术后并发症的临床分析

目的：探讨人工股骨头置换术后全髋翻修及效果。方法：于2005年4月-2007年10月对43例股骨头置换术后并发疼痛、松动、中心型脱位患者行全髋关节翻修术。结果：随诊8月～2年,术后髅关节功能依据Harris评分法,优31例,良9例,可3例,优良率93．02％。结论：全髋关节翻修术是治疗人工股骨头置换术后并发疼痛、松动、脱位的有效方法,效果可靠。     

Replacement of the Femoral Head by Ceramic Endoprosthesis: An Experimental Study on Rabbits

In 31 rabbits the femoral head was replaced by a ceramic endoprosthesis. For 11 of the experimental animals the endoprostheses were made by the Arabia China Factory in Helsinki, and for 20 by Staatliche Porzellan Manufaktur in Berlin. The operation was performed under fully sterile conditions and the follow-up time was between 6 and 34 weeks. The hip joint was examined clinically, roentgenologically, macroscopically and histologically.

The bending tolerance of the ceramic endoprosthesis was not adequate. Mechanical loosening of the proximal part of the prosthesis occurred in 68 per cent and was combined with fracture of the prosthetic stem. This created a pseudarthrosis-like reaction in the acetabular area and limited the movement of the hip joint. The distal fragment of the stem was always surrounded by a thin layer of dense bone. In the nonfractured cases (32 per cent), however, the reaction was only moderate and the movement of the hip joint was well preserved. The tissue reactions to the ceramic material were slight, but the great number of secondary reactions following stem fractures make the use of the ceramic endoprosthesis questionable in experiments with rabbits.     

Tuberculosis as a late complication of total hip replacement

A case of tuberculosis developing in a hip joint which had undergone total prosthetic replacement arthroplasty 7 years previously is described. The patient had no manifestation of active systemic tuberculosis although calcified mesenteric nodes were noted on abdominal X-ray. It is assumed that hip joint infection occurred during a bacteraemia following activation of a latent tuberculous focus in the mesenteric lymph nodes.     

脑血管意外患者髋关节置换术临床体会(附12例分析)

目的：探讨脑血管意外患者行人工髋关节置换术的适应证围手术期、术后的综合治疗。方法：分析了从１９９２～１９９８年６月共收治脑血管意外患者行人工髋关节置换术１２例，其中男８例，女４例，过往有脑出血５例，脑梗塞７例，脑血管意外病程最短１年，最长５年，伴肢体偏瘫９例，全部病者伤前可独步或扶拐行走。手术原因是摔倒致股骨颈骨折１０例，股骨头缺血性坏死１例，骨关节炎１例。施行全髋关节置换术８例，人工股骨头置换术４例。结果：复查随访平均时间２年３个月，总满意率为７８４％，术后发生并发症５例，关节脱位４例，髋痛２例，异位骨化和假体松动各１例。结论：（１）脑血管意外患者只要机体情况好，肢体肌力４级或以上，因髋部疾病致功能障碍者应尽早手术治疗。（２）术前术后要注意治疗并存病，改善全身状况。术后关节脱位在脑血管意外患者中发生率较高，值得注意。（３）应选用骨水泥型假体，采用后外侧入路切口，术中避免广泛组织剥离，术后不宜过早负重下地活动，加强康复训练是手术成功的重要因素之一。     

Joint preserving procedures and endoprostheses in hemophiliacs – indications and long term results

Hemophilic arthropathy is the result of recurrent joint bleedings in patients with severe haemophilia A or B and von Willebrand Syndrome. Conservative orthopaedic treatment is preferred in every stage of the arthropathy. Synovectomy is indicated only after failure of the conservative regimen after 3 to 6 months in order to control synovitis and recurrent bleeding. This paper presents the indications, methods, and results of different joint preserving operations. Especially synovectomy of the elbow joint with or without radial head resection shows very good long term results. Radiosynoviorthesis is an alternative in certain cases. The end stages of hemophilic arthropathy are characterised by pronounced joint contractures. We achieved very good long term results by implanting total hip joints (n = 13) and total knee joints (n = 20) with a median follow up of 102 respectively 53 months. No perioperative complications like bleeding or infection were registrated. Only one aseptic loosening of a cemented cup occurred 14 years postoperatively as well as one septic loosening 14 months postoperatively in an HIV positive haemophilic. Another HIV positive patient developed a hematogenic abscess on both operated on hips without loosening of the endoprosthesis. Bicondylar prosthesis (n = 14) showed 6 very good, 6 good and 2 fair results in the HSS-score. Only one subsidence of an uncemented tibia plateau without definitive loosening occurred 55 months later. The functional results of constrained knee endoprostheses (n = 6) were not as good (2 good, 2 fair, 2 poor). However, these patients suffered preoperatively from severe contractures and malalignments. Aseptic loosening or late infections did not occur even in case of HIV infections.     

Tuberculosis as a Late Complication of Total Hip Replacement

A case of tuberculosis developing in a hip joint which had undergone total prosthetic replacement arthroplasty 7 years previously is described. The patient had no manifestation of active systemic tuberculosis although calcified mesenteric nodes were noted on abdominal X-ray. It is assumed that hip joint infection occurred during a bacteraemia following activation of a latent tuberculous focus in the mesenteric lymph nodes.     

A total hip replacement infected with mycobacterium bovis after intravesicular treatment with Bacille-Calmette-Guérin for bladder cancer

An 86-year-old male presented with a loose total hip replacement (THR) ten years after implantation. At revision for anticipated aseptic loosening, watery pus was found in the joint and Bacille-Calmette-Guérin (BCG) was seen on culture. The bacterial strain was identified and was identical to the BCG used in the intravesicular treatment of superficial bladder carcinoma in this patient ten months earlier. After revision he received a full course of antituberculous treatment. The clinical and radiological results were excellent after follow-up for 30 months with his uncemented THR showing satisfactory incorporation. His inflammatory markers were normal and his Harris hip score was 95 points. The diagnosis of a tuberculous infection can be easily missed, but must be considered, especially if sterile pus is encountered.     

Special problems of cementless fixation of total hip-joint endoprostheses with reference to the PM type

The success of cement-free hip endoprosthetics is largely dependent on precise surgical techniques and primary stability of the anchorage, in which favorable biomechanical conditions as well as the quality of the stabilizing bone are of considerable importance. Information gathered from more than 1500 cementless hip-joint endoprosthesis implantations is presented with biomechanical solutions and indications regarding operating techniques, and a correlation between clinical symptoms and radiological signs of complications is discussed. In close coordination with material-specific factors, design and surface characteristics are decisive in the function and quality of anchorage of the endoprosthetic replacement. In the case of the PM total hip endoprosthesis, these widely variable values were governed strictly by biomechanical considerations, with particular reference to the resulting bone reactions. Results so far, including those relating to stable integration of the implant, must be regarded as absolutely positive and confirm the design characteristics on which this model was based. Avoiding the disadvantages of bone cement, cementless hip-joint replacement, particularly in operations for the exchange of cemented prostheses after loosening, can be regarded as a step forward in hip-joint surgery.     

Special problems of cementless fixation of total hip-joint endoprostheses with reference to the PM type

Summary The success of cement-free hip endoprosthetics is largely dependent on precise surgical techniques and primary stability of the anchorage, in which favorable biomechanical conditions as well as the quality of the stabilizing bone are of considerable importance. Information gathered from more than 1500 cementless hip-joint endoprosthesis implantations is presented with biomechanical solutions and indications regarding operating techniques, and a correlation between clinical symptoms and radiological signs of complications is discussed. In close coordination with material-specific factors, design and surface characteristics are decisive in the function and quality of anchorage of the endoprosthetic replacement. In the case of the PM total hip endoprosthesis, these widely variable values were governed strictly by biomechanical considerations, with particular reference to the resulting bone reactions. Results so far, including those relating to stable integration of the implant, must be regarded as absolutely positive and confirm the design characteristics on which this model was based. Avoiding the disadvantages of bone cement, cementless hip-joint replacement, particularly in operations for the exchange of cemented prostheses after loosening, can be regarded as a step forward in hip-joint surgery.     

感染后关节的初次人工关节置换术

目的：探讨关节感染后骨关节炎患者行初次人工关节置换术的特点及治疗原则。方法：回顾性研究既往有关节感染史的8例初次全髋和全膝关节置换术病例，其中化脓性感染6例，结核性感染2例。全髋关节置换6例，手术时平均年龄38．1岁(24—51岁)，感染平均静止22．0年(6—30年)。全膝关节置换2例。行关节置换术前，常规进行白细胞计数、血沉、C反应蛋白等检查以除外活动性感染。术后随访2-11年。结果：既往有髋关节感染者患肢均有明显短缩畸形．股骨上段发育异常，并伴有屈曲挛缩畸形。所有患者术前均无活动性感染。化脓性感染的6例，5例感染静止20年以上者均无感染复发：1例感染静止6个月后行全膝关节置换者，术后9个月感染复发，结核感染的2例术后均无感染复发。1例全髋关节置换患者在术后1年出现假体柄无菌性松动，其余患者功能良好，结论：关节感染后骨关节炎患者年龄相对较轻．关节置换手术难度较大，易出现并发症，术前应先排除活动性感染．在感染静止相当一段时间后进行一期置换．可以取得较好的临床效果。     

Septische Lockerung eines Wagner-Revisionsschaftes durch Mycobacterium tuberculosis.

Only a few cases of specific tuberculous infections of total hip arthroplasties have been published. We report the case of a 66-year-old male patient who received a cementless total hip arthroplasty due to osteoarthritis of the left hip in 1990. Four years later, revision arthroplasty with a Wagner revision stem was performed because of aseptic loosening. In 1995 revision of a loosened acetabular cup was necessary. In 1996 we saw the patient for the first time in our outpatient unit. He complained of increasing pain in the region of the left hip. X-rays showed loosening of the Wagner stem. Aspiration of the synovial fluid of the left hip revealed an infection with mycobacterium tuberculosis (radioimmunoassay). There were no signs of tuberculous infection in the patient's history. Treatment consisted of removal of the prosthesis followed by antituberculosis chemotherapy for 12 months with rifampicin, ethambutol, isoniazid, and pyrazinamide. In April 2001 revision of the left hip joint and implantation of a MRP titanium revision stem and reconstruction of the acetabulum with an acetabular reconstruction ring was done. Until today the patient exhibits no signs of recurrence of the tuberculous infection.