Re-attachment of the un-united trochanter in Charnley low friction arthroplasty

In a prospective study, a double crossover wire with a compression spring was used to re-attach 52 un-united trochanters at revision operations on total hip arthroplasties. Bony union was achieved in 42 (81%) and was not influenced by the duration of the nonunion or the separation gap. The new method compared favourably with earlier revisions at which other methods of trochanteric re-attachment had been used.     

Salvage of failed trochanteric fracture fixation using the Revitan curved cementless modular hip arthroplasty

Failed internal fixation of an intertrochanteric or subtrochanteric fracture often leads to persistent pain and diminished function. This study evaluated 16 patients treated with Revitan curved cementless modular stem (Zimmer GmbH, Winterthur, Switzerland). At a mean follow-up period of 60 months, all patients demonstrated clinically significant pain relief and return to ambulation after salvage total hip arthroplasty. Mean Harris Hip Score improved from 17.8 to 87.7 points postoperatively. Radiographic follow-up demonstrated stable stem and bony ingrowth in 16 patients without evidence of subsidence. Eight patients had slight awareness of lateral trochanteric pain with no compromise of activities, and 1 patient had nonunion of the greater trochanter. Revitan curved cementless modular stem represents a useful treatment option in salvage total hip arthroplasty of failed pertrochanteric fixation.     

Hip arthroplasty after failed fixation of trochanteric and subtrochanteric fractures

Background and purpose Hip arthroplasty is an option for elderly patients with osteoporosis for the treatment of failure after fixation of trochanteric and subtrochanteric fractures, either as a total hip arthroplasty (THA) or as a hemiarthroplasty (HA). We analyzed the reoperation rate and risk factors for reoperation in a consecutive series of patients.

Methods All patients (n = 88) operated from 1999 to 2006 with a THA (n = 63) or an HA (n = 25) due to failure of fixation of a trochanteric fracture (n = 63) or subtrochanteric fracture (n = 25) were included. Background data were collected from the patient records. A search was performed in the national registry of the Swedish National Board of Health and Welfare in order to find information on all reoperations. The follow-up time was 5–11 years.

Results The reoperation rate was 16% (14/88 hips). A periprosthetic fracture occurred in 6 patients, a deep prosthetic infection in 5 patients, and a dislocation of the prosthesis in 3 patients. Standard-length femoral stems had an increased risk of reoperation (11/47) compared to long stems (3/41) (HR = 4, 95% CI: 1.0–13; p = 0.06).

Interpretation The high reoperation rate reflects the complexity of the surgery. Using long femoral stems that bridge previous holes and defects may be one way to reduce the risk for reoperation.     

Replacement arthroplasty using the Charnley prosthesis in old tuberculosis of the hip

Summary This report is based upon a retrospective study of a consecutive series of twenty patients who had tuberculosis of the hip in quiescent state. Two patients had only a short history but were included in this study. An interesting feature at the time of operation was that in many cases the bone showed old features of tuberculous disease despite the long history of quiescence.A modification of the Charnley technique is discussed. In addition, details of radiographic assessment before operation, antituberculous drug therapy and the use of Kanamycin in bone cement are given. The complications and results are recorded.

---

Résumé Etude rétrospective de 20 malades ayant présenté une tuberculose de la hanche et apparemment guéris. Deux malades qui avaient une histoire clinique plus courte ont été inclus dans cette série. Il est intéressant de noter que l'examen anatomo-pathologique des prélèvements osseux pratiqués lors de l'arthroplastie a montré la présence de lésions tuberculeuses bien que la maladie soit cliniquement quiescente depuis de nombreuses années.Il a paru nécessaire de modifier la technique originale de Charnley. Il convient en outre de pratiquer avant l'opération un bilan radiologique particulier, de mettre en route une chimiothérapie antituberculeuse et d'ajouter de la Kanamycine au ciment. Les complications et les résultats sont rapportés.

     

Revision total hip arthroplasty using a fluted and tapered modular distal fixation stem with and without extended trochanteric osteotomy

We reviewed 62 revision total hip arthroplasties performed using a fluted and tapered modular distal fixation stem after a mean follow-up of 4.2 years. An extended trochanteric osteotomy (ETO) was used in 32 of the 62 hips (52%), whereas no osteotomy was used in the remaining 30 hips. The mean postoperative Harris hip score among the patients was 87.3 points. The mean stem subsidence was 1.1 mm. With the exception of one reoperation for a deep infection, no femoral revision was performed because of mechanical failure. Complications included intraoperative diaphyseal split fractures (6%), cortical perforations (6%), and dislocations (5%). Postoperative Harris hip scores, femoral component stability, and overall complication rates did not differ between the group treated with an ETO and that treated without it. However, the rates of cortical perforation and marked stem subsidence (>5 mm) were significantly higher in the group treated without an ETO than those in the group treated with an ETO, but these were not significantly different when stratified by femoral bone defect. The potential advantages of this implant design could be highlighted in a clinical setting when inserted using an ETO.     

Charnley low-friction arthroplasty in the young patient.

One thousand three hundred forty-two Charnley low-friction arthroplasties (LFAs) were reviewed at an average of ten years four months after surgery. Patients' average age at surgery was 41 years. The clinical results at follow-up review remained excellent: 79% were pain free and 11% had no more than occasional discomfort. One hundred forty-one (10.5%) LFAs have been revised so far. Stem fracture has been completely eliminated. Revision for stem loosening has been reduced to below 1% and revision for socket loosening has also been reduced. The long-term problem remains socket wear--and with it--an increasing incidence of socket migration. Failure of component fixation is a short- and medium-term problem that has been improved by better component design and surgical technique.     

股骨转子间骨折人工关节置换术中转子部骨折固定技术的应用

目的探讨股骨转子间骨折人工关节置换术中转子部骨折固定的理想方式及选择依据。方法采用人工关节置换术治疗86例老年股骨转子间骨折患者。骨折按照Evans-Jenson分型,Ⅱ型2例,Ⅲ型22例,Ⅳ型45例,Ⅴ型17例。双极人工股骨头置换50例,全髋关节置换术36例。转子部骨折块采用金属线缆双交叉法捆绑固定46例,采用连接钛缆GTR接骨板固定技术28例,其他方法 12例。结果手术成功78例,术后发生转子部骨折移位5例(合并假体柄松动下沉2例),关节脱位1例,假体深部感染1例,中毒性肠麻痹死亡1例。住院期间发生坠积性肺炎2例,无坐骨神经损伤和严重的血栓栓塞并发症发生。2例出院后失访,76例均获随访,时间3~79个月。1例于术后2年死于急性心肌梗死,1例术后5个月死于脑溢血。末次随访时根据Harris髋关节功能判定标准,优52例,良13例,中9例,优良率为87.8%。转子部骨折愈合时间3~8个月。结论老年人股骨转子间骨折采用人工关节置换治疗中,转子部骨折块的可靠固定对于术后开始进行康复训练的时间、行走步态和假体的使用寿命具有重要影响。     

Periprosthetic femoral fractures around well fixed implants: a simple method of fixation using LC-DCP with trochanteric purchase

Periprosthetic fractures of the femur are among the most serious complications in hip surgery. Various classifications have been suggested. At present the Vancouver classification system probably comes closest to the ideal. Most authors recommend internal fixation of the fractures in well-fixed implants (Vancouver type B1). However as the fixation to the proximal fragment has always been a problem, many types of fixation devices have been used. This retrospective study was done to evaluate the efficacy of an LC-DCP with trochanteric purchase, in the fixation of Vancouver type B1 periprosthetic femoral fractures. Our study included 12 patients, 7 male and 5 female with a mean age of 73 years (range: 57 to 91). One patient died due to complications not related to surgery and in another patient the plate was found broken with a loose implant, which was revised. All cases were primary arthroplasties. A long broad LC-DCP was used for the fixation. Purchase in the proximal fragment was obtained with screws in the greater trochanter. Ten fractures united in an average period of 7 months. The mean duration of follow-up was 6.5 years. The final results were evaluated using the Harris hip score. The mean Harris hip score was 85 with a range of 75 to 94.     

Trochanteric osteotomy in Charnley low-friction arthroplasty of the hip

The use of trochanteric osteotomy in lateral approach to the hip joint is a fundamental part of Charnley's low-friction arthroplasty. Its use allows adequate exposure and easy orientation of the hip. Reattachment using a single transverse and double vertical wires was evaluated in 500 consecutive hip arthroplasties. Of 500 patients, 466 (93.2%) showed complete bony union of their trochanteric osteotomy at three months. A further 20 (4%) patients united by 12 months, giving a union rate of 97.2%; 34 (6.8%) patients who showed incomplete or defective union at three months. There were five dislocations. Only one patient required removal of the wires, for bursitis. The patients with defective bony union had a relatively high rate of wire breakage at three months. Despite a 1.8% complete detachment and 1% fibrous union, the transtrochanteric approach allows easy access without fear of shaft fracture in very difficult cases, with surprisingly little ill effect or loss of function even in those failing to reunite.     

Stability of osteosynthesis in trochanteric fractures: Comparison of three fixation devices in cadavers

Stable trochanteric fractures were produced in 12 pairs of human cadaver femora, which were fixed by either a 135° Jewett nail plate, a 135° NoLok™ sliding screw/plate, or a 140° Hansson pin/plate. The bone-implant preparations were then subjected to 20,000 load cycles simulating full weight bearing, measuring the elastic and permanent fracture displacement. In each case, elastic displacement occurred during loading. for the Jewett-stabilized fractures, a steady increased elastic displacement, as well as permanent displacement, was seen throughout the test, causing 2/8 failures when the implant penetrated the femoral head. In the NoLok™-and Hansson-stabilized fractures, there were no failures, both giving better overall stability than the Jewett device with sufficient fracture stability throughout the test.     

Cementless modular hip arthroplasty as a salvage operation for failed internal fixation of trochanteric fractures in elderly patients

Failure of internal fixation of trochanteric fractures requires repeat surgery in order to avoid the risks of complications affecting bedridden patients. This study was conducted to assess the results of hemi- or total hip arthroplasty with a cementless modular femoral stem, as a salvage operation following early mechanical failure of internal fixation. Twenty nine patients with a mean age of 81.1 years (70-91) were included in the study. Fractures extending into the diaphysis and pathological fractures were excluded, as well as patients who presented late complications. A cementless modular stem designed for metaphyso-diaphyseal anchorage was used in all cases. Twenty-two patients underwent hemiarthroplasty and seven total hip arthroplasty. Four patients died within one year and two were lost to follow-up. The remaining 23 patients were followed for a mean of 20 months (range: 6-89). At the time of last follow-up, 20 were ambulatory with (11 cases) or without support (9 cases) and three were bedridden. There were no intra- or postoperative femoral fractures. Two patients presented an early dislocation after bipolar hemiarthroplasty. One was successfully treated by closed reduction; the other underwent revision with a dual mobility acetabular component because of recurrent dislocation. All the patients reported significant pain relief and functional improvement. Subsidence of the stem greater than 5 mm was noted in three cases, without clinical consequences. The cementless modular femoral stem used in this study appeared as a reliable implant. Primary arthroplasty with such an implant could be considered in selected cases such as markedly unstable fractures and in osteoporotic elderly patients.     

Greater trochanteric blood flow during total hip arthroplasty using a posterior approach.

The authors investigated the effect of a posterior surgical approach on the local femoral blood supply during primary total hip arthroplasty. Greater trochanteric blood flow measurements were made with a laser Doppler flowmeter at intervals during the performance of eight uncemented and nine cemented total hip arthroplasties. Complete detachment of the quadratus femoris was associated with a significant decrease in trochanteric blood flow in the uncemented and cemented groups. The lowest perfusion levels during the procedure were seen transiently with posterior dislocation of the femoral head, after which trochanteric perfusion was decreased by 66% in the uncemented group, and 61% in the cemented group compared with baseline values. Blood flow remained approximately half of baseline values after insertion of the femoral prosthesis in the uncemented and cemented groups. These changes in greater trochanteric blood flow may serve as a marker for reduction in proximal femoral blood flow during total hip arthroplasty, and subsequently relate to the extent of bony ingrowth, periprosthetic bone loss, and ultimately the incidence of implant failure caused by aseptic loosening.     

Stability of osteosynthesis in trochanteric fractures: Comparison of three fixation devices in cadavers

Stable trochanteric fractures were produced in 12 pairs of human cadaver femora, which were fixed by either a 135° Jewett nail plate, a 135° NoLok? sliding screw/plate, or a 140° Hansson pin/plate. The bone-implant preparations were then subjected to 20,000 load cycles simulating full weight bearing, measuring the elastic and permanent fracture displacement. In each case, elastic displacement occurred during loading. for the Jewett-stabilized fractures, a steady increased elastic displacement, as well as permanent displacement, was seen throughout the test, causing 2/8 failures when the implant penetrated the femoral head. In the NoLok?-and Hansson-stabilized fractures, there were no failures, both giving better overall stability than the Jewett device with sufficient fracture stability throughout the test.     

Stability of osteosynthesis in trochanteric fractures. Comparison of three fixation devices in cadavers

Stable trochanteric fractures were produced in 12 pairs of human cadaver femora, which were fixed by either a 135 degree Jewett nail plate, a 135 degree NoLok sliding screw/plate, or a 140 degree Hansson pin/plate. The bone-implant preparations were then subjected to 20,000 load cycles simulating full weight bearing, measuring the elastic and permanent fracture displacement. In each case, elastic displacement occurred during loading. For the Jewett-stabilized fractures, a steady increased elastic displacement, as well as permanent displacement, was seen throughout the test, causing 2/8 failures when the implant penetrated the femoral head. In the NoLok- and Hansson-stabilized fractures, there were no failures, both giving better overall stability than the Jewett device with sufficient fracture stability throughout the test.     

Hip arthroplasty after failed internal fixation of the trochanteric fractures in aged patients with co-existent osteoporosis]

The authors present the results of hip arthroplasty of 67 patients treated after failed internal fixation of the osteoporotic, trochanteric fractures of the femur, which were primary stabilised with angular plate AO in 39 patients and with dynamic hip screw (DHS) in 28 patients. In the discussed material 16 persons were male and 51 female, in the age between 51 and 83 years old. According to the Evans classification in 4 cases we diagnosed type I of fracture, in 10--type II, 31--type III and in 22--type IV. Hip arthroplasty was made from the 3rd to the 39th week after primary fixation of the fracture. In 42 patients we made total hip arthroplasty, in 14 cases Austin-Moore hemiarthroplasty, and in 11 patients bipolar arthroplasty. According to the Postel and Merle d'Aubigne classification there were obtained 29 very good, 21 good and 17 satisfactory results.     

Activity and socket wear in the Charnley low-friction arthroplasty

A clinical study was undertaken to assess the influence of patient-related factors on wear of the socket in Charnley low-friction arthroplasty. One hundred nine arthroplasties in 79 patients were reviewed at an average of 10.3 years. A new method of activity assessment was designed and used to estimate the distance walked by each patient. This method was validated by a pedometer that recorded the time taken by each patient to walk 20 m. Activity level was related to the amount of movement at the level of the prosthetic articulation by calculating the sliding distance of a point at the center of the surface of the head of the femoral component. Wear was found to correlate with patient activity, but not with the physical characteristics of the patient or the time since operation.     

Structural changes in the socket of a charnley low friction arthroplasty associated with recurrent subluxation

Summary Damage to the rim of the aperture of the socket in a Charnley low friction arthroplasty may be associated with recurrent subluxation or persistent dislocation of the femoral component. Impingement of the neck of the prosthesis against the socket or cement is the cause of this complication. The damage to the socket may require a full revision operation.

---

Résumé Une détérioration portant sur le rebord de la cavité centrale d'une cupule de Charnley peut s'observer dans certains cas de subluxation récidivante ou de luxation vraie de la pièce fémorale. Le contact entre le col de la prothèse et la cupule ou son ciment est la cause de ces complications. L'usure de la cupule peut justifier une intervention de reprise.

     

Long-term follow-up of Charnley arthroplasty of the hip.

A review of 11.5 year (average interval) follow-up examination of 409 low friction arthroplasties performed included only 3 late failures. The excellent results of the successes have been fully maintained for as long as 14 years. This was true with regard to pain, function of walking and mobility. Resorption of the calcar femorale was rare and no correlation was found with the wear of the socket. The average wear of 1.5 mm was less than predicted by Professor Sir John Charnley. Although 10 patients (7.8%) had excessive wear no patient is at present near the stage of requiring replacement of the socket for this reason. No adverse reaction was found to the implant or the cement.