Uncemented total hip arthroplasty in young patients with juvenile chronic arthritis.

The hip joint is commonly affected in juvenile chronic arthritis (JCA) and involvement is usually bilateral. It is well established that the involvement of the hip in JCA is the most important reason that the patient will lose independence and mobility. The positive gains, both in terms of hip function and the overall functional capability, of the patients of JCA after hip replacement have been shown by several studies. There have been many reports regarding cemented total hip replacement in young patients with JCA. The short-term results have been excellent, but failure rates were considerably higher with further follow-up. To our knowledge there have been no other reports to date of the results of cementless arthroplasty of the hip in this condition. We reviewed the results of 25 primary uncemented total hip replacements (THR) in 16 patients with JCA. The mean postoperative follow-up time was 4.5 years (range 1-19 years). The clinical results were evaluated using the modified Harris hip score. The functional outcome was assessed by a scoring system described by Witt et al. The most significant long-term problem was acetabular loosening (12%) in our series.     

Acute total hip arthroplasty for acetabular fractures in the elderly: 11 patients followed for 2 years

We describe the use of cable fixation and acute total hip replacement for acetabular fracture in the elderly. 12 patients with acetabular fractures, having a mean age of 79 (65-93) years, were treated with cable fixation and acute total hip arthroplasty. 8 were T-shaped fractures and 4 associated fractures of the posterior column and posterior wall. 1 patient died 5 months after surgery and the remaining 11 were followed for 2 years. All patients had a good clinical outcome. Radiographic assessment showed healing of the fracture and a satisfactory alignment of the cup without loosening. This surgical technique provides good primary fixation, stabilizes complex acetabular fractures in elderly patients with osteoporotic bone and permits early postoperative mobilization.     

Revision total hip arthroplasty in patients 80 years or older

We evaluated all revisions performed from March 1996 to December 2008 and compared complications, mortality, and clinical outcomes between patients 80 years and older and patients younger than 80 years. Data were collected prospectively. There were 325 revisions, 84 (25.8%) in patients 80 years and older and 241 in patients younger than 80 years (62% revision for aseptic loosening in both groups). The mean follow-up was 4.3 years. The results, 80 years and older vs younger than 80 years, revealed the following: mortality, 5% vs 0% 3 months postoperatively; medical complications in 23.8% vs 6.2%; postoperative fractures, 9.5% vs 2.5%; and improved Merle d'Aubigné scores from 9.6 to 13.0 vs 10.4 to 14.3. Revision total hip arthroplasty in patients 80 years and older was associated with substantial clinical improvement and patient satisfaction. However, medical complications and 90-day mortality were higher, and postoperative fractures occurred more frequently.     

The Charnley total hip arthroplasty in juvenile rheumatoid arthritis patients

A follow up of 27 consecutive total hip arthroplasties in 16 patients with juvenile rheumatoid arthritis was performed. The mean age at surgery was 18 years, and the average follow-up period was 64 months. No serious early complications were recorded, but three deep infections developed from 6 to 18 months after the arthroplasty, all requiring revision. The clinical results were good at follow up, as 20 hips were free of pain and 7 had only slight pain. Most of the patients had improved their walking ability and the range of motion in the hip as well. A poor correlation was, however, shown between the clinical and the roentgenographical results, as there was one femoral implant that was definitely loose and four more hips that had components which were probably loose. The frequency of infections might have been reduced by using antibiotic prophylaxis during surgery in all the cases; the frequency of aseptic loosening might also have been reduced by improved cementing techniques. Because of high loosening rate without clinical symptoms, it is recommended to follow the patients roentgenographically to make revision surgery possible while the bone stock still is sufficient.     

Hydroxyapatite-coated total hip replacement in Paget's disease: 20 patients followed for 4-8 years

20 patients, who had had total hip replacements for symptomatic osteoarthrosis secondary to Paget's disease, were followed for a mean of 6 (4-8) years. Proximal hydroxyapatite-coated stems were implanted in all patients. 12 patients received hydroxyapatite-coated, 2 cemented (Muller type) and 6 cementless cups (Morsher type). The mean Harris hip score was 31 (7-40) points preoperatively and 88 (74-100) postoperatively. The radiographic evaluation revealed good stability and fixation using Engh's criteria. One stem subsided early more than 5 mm and then seemed to stabilize. Our findings support the use of hydroxyapatite total hip implants for patients with this disease and osteoarthrosis.     

Hydroxyapatite-coated total hip replacement in Paget's disease: 20 patients followed for 4-8 years

20 patients, who had had total hip replacements for symptomatic osteoarthrosis secondary to Paget's disease, were followed for a mean of 6 (4-8) years. Proximal hydroxyapatite-coated stems were implanted in all patients. 12 patients received hydroxyapatite-coated, 2 cemented (Muller type) and 6 cementless cups (Morsher type). The mean Harris hip score was 31 (7-40) points preoperatively and 88 (74-100) postoperatively. The radiographic evaluation revealed good stability and fixation using Engh's criteria. One stem subsided early more than 5 mm and then seemed to stabilize. Our findings support the use of hydroxyapatite total hip implants for patients with this disease and osteoarthrosis.     

Hydroxyapatite-coated total hip replacement in Paget's disease: 20 patients followed for 4-8 years

20 patients, who had had total hip replacements for symptomatic osteoarthrosis secondary to Paget's disease, were followed for a mean of 6 (4-8) years. Proximal hydroxyapatite-coated stems were implanted in all patients. 12 patients received hydroxyapatite-coated, 2 cemented (Muller type) and 6 cementless cups (Morsher type). The mean Harris hip score was 31 (7-40) points preoperatively and 88 (74-100) postoperatively. The radiographic evaluation revealed good stability and fixation using Engh's criteria. One stem subsided early more than 5 mm and then seemed to stabilize. Our findings support the use of hydroxyapatite total hip implants for patients with this disease and osteoarthrosis.     

Charnley total hip arthroplasty in ankylosing spondylitis: survivorship analysis of 76 patients followed for 8-28 years

76 consecutive Charnley low friction hip arthroplasties were performed in 54 (37 men) patients with ankylosing spondylitis from 1971 to 1991 in the Rheumatism Foundation Hospital. Their mean age was 40 (16-67) years. They were followed until the end of 1999. The overall prosthesis survival was 80% at 10 years, 66% at 15 years and 62% at 20 years. The survival of the acetabular component was 91%, 77% and 73% at 10, 15 and 20 years and that of the femoral component 82%, 79% and 77%, respectively. We found no significant risk factor that predicted prosthesis survival.     

Charnley total hip arthroplasty in ankylosing spondylitis: Survivorship analysis of 76 patients followed for 8-28 years

76 consecutive Charnley low friction hip arthroplasties were performed in 54 (37 men) patients with ankylosing spondylitis from 1971 to 1991 in the Rheumatism Foundation Hospital. Their mean age was 40 (16-67) years. They were followed until the end of 1999. The overall prosthesis survival was 80% at 10 years, 66% at 15 years and 62% at 20 years. The survival of the acetabular component was 91%, 77% and 73% at 10, 15 and 20 years and that of the femoral component 82%, 79% and 77%, respectively. We found no significant risk factor that predicted prosthesis survival.     

Charnley total hip arthroplasty in ankylosing spondylitis: Survivorship analysis of 76 patients followed for 8-28 years

76 consecutive Charnley low friction hip arthroplasties were performed in 54 (37 men) patients with ankylosing spondylitis from 1971 to 1991 in the Rheumatism Foundation Hospital. Their mean age was 40 (16-67) years. They were followed until the end of 1999. The overall prosthesis survival was 80% at 10 years, 66% at 15 years and 62% at 20 years. The survival of the acetabular component was 91%, 77% and 73% at 10, 15 and 20 years and that of the femoral component 82%, 79% and 77%, respectively. We found no significant risk factor that predicted prosthesis survival.     

髋关节置换术后感染的手术治疗

目的探讨髋关节置换术后感染手术治疗的临床疗效。方法共11例髋关节置换术后感染患者,男6例,女5例,平均63岁(54～71岁)。术前Harris评分25～40分,平均33分。术前血沉均有升高,平均61mm/h(34～80mm/h)。所有患者术前、术中均进行细菌培养和药敏试验。11例中一期翻修6例,二期翻修5例,术后均置引流管引流并根据药敏试验应用抗生素。11例患者早期感染2例,晚期感染9例。术前穿刺及窦道脓液培养阳性8例,其中5例为表皮葡萄球菌,2例为大肠埃希氏菌,1例为金黄色葡萄球菌。结果术后11例患者随访12～31个月,平均17个月,感染均未复发,血沉、血常规检查正常,术后Harris评分为79～92分,平均84.2分,较术前平均提高51.2分(P<0.05)。结论髋关节置换术后感染,只要诊断明确,合理使用抗生素和抗生素骨水泥,一期翻修同样可以取得满意的临床疗效。     

Arthroplasty for ochronotic arthritis: no failure of 11 replacements in 3 patients followed 6-12 years

BACKGROUND: Alkaptonuria is a rare single-gene disorder characterized by black pigmentation of cartilage and other connective tissues. Premature degenerative arthritis affects the large joints in many of these of patients. Medical treatment is limited to a protein-restricted diet (phenylalanine and tyrosine) with surgery reserved for end-stage joint disease. As in other metabolic bone diseases, there are concerns about the quality and strength of affected bones and therefore the suitability and longevity of replacement arthroplasty. The histopathology and outcome of joint replacement for alkaptonuric arthritis is unknown and limited to sporadic case reports. PATIENTS AND RESULTS: We describe 11 joint replacements in 3 patients with alkaptonuric polyarthropathy, including shoulder and elbow replacements not previously reported. No prosthetic failures occurred in up to 12 years of follow-up. INTERPRETATION: Total joint replacement is an acceptable treatment for degenerative joint disease in alkaptonuric patients, with implant survival comparable to that found in patients with osteoarthritis.     

Revision total hip arthroplasty in patients younger than 55 years old. Clinical and radiologic results after 4 years

Since 1979, all revision total hip arthroplasties performed in Sweden have been entered into a prospective multicenter study. Between 1979 and 1982, 65 patients (67 hips) younger than 55 years old required revision arthroplasty because of aseptic loosening. These patients were followed clinically and radiographically for 2-6 years (mean, 4 years). Thirteen patients requiring a second revision because of a recurrent aseptic loosening and one because of subluxations were classified as failures and were not included in the final follow-up study. In the remaining 52 hips (50 patients), the results, rated by the Harris hip score, were good or excellent in 15 hips (29%), fair in 9 hips (17%), and poor in 28 hips (54%). Early complications were rare. Ten hips in 10 patients had radiographic signs of gross loosening of the acetabular or femoral component. mechanical failure, defined as gross loosening or a second revision, was identified in 36% of hips included in the study (n = 67). Revision hip arthroplasty using cement in young and middle-aged patients with cemented primary arthroplasty gave a high rate of failure, because of aseptic loosening. The use of alternative methods and techniques must be explored for revision surgery in younger patients.     

Total hip and total knee arthroplasty in juvenile rheumatoid arthritis

Total hip arthroplasty (THA) or total knee arthroplasty (TKA) is indicated for patients with juvenile rheumatoid arthritis (JRA) when marked joint destruction is present and pain or deformity compromises function despite optimal medical therapy. Relief of pain, reduction of the deformity, and dramatic improvement in functional status and quality of life can be achieved in most patients. Functional impairment and deformity rather than pain are usually the primary indications for THA or TKA. When there is both hip and knee involvement, hip arthroplasty should probably be done first. Regional anesthetic appears to be the anesthetic of choice. Careful preoperative planning and the availability of custom and minisized components are essential. Small bone size, osteoporosis, and severe soft tissue disease make the surgery technically demanding. Skeletal immaturity may not contraindicate surgery if the patient is otherwise bedridden with progressive deformity. In the hip trochanteric osteotomy is often necessary for adequate exposure, with the possible exception being a patient with juvenile ankylosing spondylitis who is subject to heterotopic bone formation. Although complete capsulectomy and psoas tenotomy may be necessary to relieve a hip flexion contracture, a soft tissue release that produces leg lengthening may lead to nerve palsy. In the hip component loosening has been less common in patients with JRA than in other young patients who have undergone THA, but it is still the most frequent cause of failure. In the knee preoperative and postoperative serial casts can aid in the correction of severe flexion contracture. Secondary patellar pain has been the most common cause of late failure. Patellar resurfacing should probably be performed at the time of the original knee arthroplasty in all patients with JRA.     

Revision total hip arthroplasty for metal-on-metal failure

Metal-on-metal (MoM) arthroplasty systems became popular in the early-2000s due to presumed advantages of improved wear characteristics and superior stability. However, subsequent reports of abnormal soft-tissue reactions to MoM implants and national registry data reporting high failure rates raised concerns. Early outcomes of revision total hip arthroplasty (THA) for adverse reaction to metal debris (ARMD) were poor, leading to development of surveillance programs and a trend towards early revision surgery. Patients with MoM arthroplasties require surveillance, comprehensive history and physical examination, imaging with ultrasound or magnetic resonance imaging (MRI), and laboratory evaluation including metal ion levels. Operative strategies for revision THA vary from exchange of modular components to extensive debridement and reconstruction with revision components. Surgeons should be aware of the increased risks of dislocation and infection following revision THA for ARMD. However, there is growing evidence that early revision surgery prior to extensive soft tissue destruction results in improved outcomes and decreased re-operation rates. It is estimated that >1 million MoM articulations have been implanted, with a large proportion still in situ. It is imperative to understand the aetiology, presentation, and management strategies for these patients to optimise their clinical outcomes.