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Background: The present study investigates the clinical and radiographic outcomes in patients with all 4 major lower extremity joints replaced., Methods: A retrospective review of our institution's database identified 125 patients in whom both hips and both knees were replaced. The mean time between the first and last arthroplasty was 6.6 years. Preoperative diagnoses included osteoarthritis in 80% and rheumatoid arthritis in 20%. The average age at the time of the first arthroplasty was 63.7 years. The mean follow-up for all arthroplasties was 10.5 years (range 2-31 years). Patients were then matched according to age, gender, diagnosis, prosthesis, and follow-up, to patients with single or bilateral total hip or total knee arthroplasty., Results: There were 11 aseptic hip revisions (4.4%) and 3 aseptic knee revisions (1.2%). At final follow-up, 86% of hips and 83% of knees were rated with no or mild pain, 68% of patients rated walking as unlimited, and 98% of patients were able to satisfactorily negotiate stairs. Aseptic survivorship for all joint arthroplasties was 93.8% at 15 years. No statistical differences were noted in pain, function, stair, and walking scores between the matched groups., Conclusion: This report demonstrated excellent clinical, functional, and radiographic outcomes in patients with all 4 major lower extremity joints replaced. Walking aids were needed in 15% of patients, however. At final follow-up, this selected group of patients appears to fare just as well as patients with single or bilateral hip or knee arthroplasty with respect to pain and function., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Dislocation after total hip arthroplasty (THA) is multifactorial and is dependent on surgical, implant, and patient factors. We hypothesized that high preoperative hip range of motion is an important variable contributing to instability after THA. We retrospectively reviewed 3379 THAs performed during a 21-year period. Average follow-up was 6.6 years. We examined the effect of surgical approach, femoral head size, and preoperative range of motion on dislocation rates. Patients with a posterior approach and 115 degrees or greater of combined preoperative flexion, adduction, and internal rotation dislocated at a significantly higher frequency than those with less than 115 degrees of combined motion (odds ratio, 1.9; P = .007). High preoperative motion in conjunction with a posterior approach and femoral head size less than 32 mm had the highest dislocation rate in our sample (5.9%). Preoperative range of motion is an important variable that should be taken into consideration during operative planning to help reduce the risk of dislocation., (Copyright 2010. Published by Elsevier Inc.)

Extended trochanteric osteotomy facilitates femoral reconstruction in revision total hip arthroplasty. This study examined the outcome of extended trochanteric osteotomy combined with a proximally porous-coated calcar replacement prosthesis during revision total hip arthroplasty. Forty-five cases were reviewed with an osteotomy union rate of 98%. No femoral component was loose radiographically, and none were revised for loosening. These findings indicate excellent short-term clinical and radiographic results can be achieved with an extended trochanteric osteotomy and proximally porous-coated calcar replacement prosthesis.

Background: The long-term results of total hip arthroplasty without cement have been reported only rarely. The purpose of the present study was to evaluate the minimum ten-year results of primary total hip arthroplasty performed with use of a proximally porous-coated, plasma-sprayed, straight-stemmed, titanium-alloy femoral component., Methods: The clinical and radiographic results of a consecutive series of 105 total hip replacements in ninety-five patients were reviewed ten to twelve years postoperatively. The diagnosis was osteoarthritis for seventy-seven hips (73%). The clinical result was evaluated on the basis of the Harris hip score, complications, and thigh pain. A detailed radiographic analysis was performed at each follow-up visit. Kaplan-Meier analysis was performed to evaluate the survival of the femoral component., Results: The average Harris hip score improved from 46 points preoperatively to 92 points postoperatively. The average pain score at the time of the most recent follow-up was 42 points, with eighty-three hips (79%) rated as pain-free. Thigh pain was identified in only two patients. All radiolucent lines were seen around the tip of the stem. All hips had some degree of femoral remodeling consistent with osseous ingrowth. No femoral component was revised, and no femoral component had evidence of loosening. Eight acetabular components were revised because of loosening and wear, and one was revised because of recurrent dislocation. One focal femoral osteolytic lesion was seen., Conclusions: This femoral component afforded durable fixation at ten to twelve years after primary total hip arthroplasty., Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

This study examined the effect of the surgical approach used in total hip arthroplasty (THA) on gait mechanics six months following surgery. Quantitative gait analysis was performed on 29 subjects: 10 anterolateral (A-L) and 10 posterolateral (P-L) THA patients and nine able-bodied, velocity-matched subjects. Discriminant function analysis was used to determine the distinction of the groups with respect to sagittal plane hip range of motion, index of symmetry, trunk inclination, pelvic drop, hip abduction, and foot progression angles. The A-L group had the largest trunk inclination (3.0+/-2.4 degrees) and the smallest hip range of motion (34.0+/-7.4 degrees). Both THA groups demonstrated greater asymmetry as expressed by the smaller symmetry index (0.97+/-0.04 for A-L and 0.98+/-0.05 for the P-L) than the able-bodied group (0.99+/-0.01). The classification procedure correctly classified 89% of the control group cases, 90% of the A-L cases, and 50% of the P-L cases. These results support the conclusion that six months following surgery, the gait of the majority (85%) of THA patients has not returned to normal. The A-L patients displayed distinct gait patterns, while a small percentage (30%) of the P-L patients demonstrated normal gait. While these differences are statistically significant, the clinical significance is unknown and linked to the duration that they persist.

One-staged ipsilateral and contralateral total hip and total knee arthroplasties were compared. A total of 103 patients underwent a 1-staged total knee arthroplasty and total hip arthroplasty between January 1975 and July 1997 (67 contralateral and 36 ipsilateral patients). No prostheses were found to be loose or revised. The contralateral group had a 10.5% hip dislocation rate, and the ipsilateral group had an 8.3% hip dislocation rate. Most of the patients were discharged home (contralateral, 66%; ipsilateral, 56%). There was no significant difference in survival between the contralateral and ipsilateral groups. There was only 1 death within 3 months of the operation. The severity of these patients' deformity may necessitate these procedures be done at 1 operation with consideration of mortality and morbidity risks., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

A polyethylene-free, metal-on-metal acetabular system (M2a-taper [Biomet, Inc., Warsaw, IN]) was designed in an effort to improve total hip arthroplasty (THA) longevity. Minimum 2-year follow-up results involving 72 polyethylene liner THAs and 78 metal liner THAs from a multicenter, randomized, controlled, investigational device exemption study are reported. Mean Harris hip scores of 95.54 (polyethylene liner group) and 95.23 (metal liner group) were reported at mean follow-up intervals of 3.29 and 3.23 years. Radiographic evaluation revealed no evidence of early failure. No acetabular components have been revised or are pending revision. No statistically significant differences in the data were calculated between liner types except for the immediate postoperative (P=.0415) and minimum 2-year follow-up (P=.0341) angles of inclination. The M2a-taper metal-on-metal articulation may represent a viable alternative for THA in younger, higher demand patients.

Patients who had anterolateral and posterolateral approaches in total hip replacement surgery were compared clinically for limp, dislocation, hospital stay, and discharge disposition. The only statistical difference was that the posterior approach had a statistically higher dislocation rate. Although the number of patients with limp was higher in the anterolateral group, the difference was not statistically different.

The preoperative radiographs of 1015 patients undergoing 1163 total hip replacements for osteoarthritis were evaluated to determine if a relationship exists between the extent of osteoarthritis and the clinical results of a total hip replacement. Preoperative radiographs were graded with respect to the degree of cartilage space loss, direction of cartilage space loss (femoral head migration), and severity of osteophyte formation. Followup averaged 32.1 months (range, 6-93 months). Greater degrees of cartilage space loss correlated with lower hip scores preoperatively but were unrelated to preoperative pain. These patients had statistically less pain at 6 months and 1 year. Patients with superior cartilage space loss before surgery also had statistically less pain at 6 months. However, at 3 years and beyond, pain was independent of degree of preoperative cartilage space loss, osteophyte formation, or femoral head migration. In addition, hip scores at any followup were independent of the degree of osteoarthritis observed on the preoperative radiograph. These findings provide statistical support to the concept that greater degrees of joint space loss correlate with better relief of pain and less severe joint space loss correlates with less relief of pain within the first year after total hip replacement. At 3 years and beyond, hip and pain scores were independent of the degree of preoperative osteoarthritis.

Total hip and total knee arthroplasties (n = 951) were retrospectively reviewed to determine the cost-effectiveness of routine pathologic examination of surgical specimens in primary total hip and total knee replacements. Discrepancies between the postoperative diagnosis and the final pathologic diagnoses were recorded. Of the 951 cases reviewed, 27 (2.8%) noted conflicting postoperative and pathologic diagnosis. In all cases, the discrepancy was between a postoperative diagnosis of osteoarthritis and pathologic diagnosis of avascular necrosis. No new cases of neoplasia or inflammatory arthropathy were noted based on the pathologic interpretation. Sixteen of these discrepancies (5.1%) and were noted in total hip arthroplasties, and 11 (1.7%) were noted in total knee arthroplasties. In no case was postoperative medical or surgical treatment altered. Based on this review, strong consideration should be given to the elimination of routine pathologic evaluation of surgical specimens during primary joint arthroplasty, leaving this pathologic evaluation optional, at the discretion of the orthopaedic surgeon, rather than mandatory.

All patients who underwent primary total knee arthroplasty (TKA), revision TKA, primary total hip arthroplasty (THA), and revision THA between January 1, 1990, and December 31, 1996, were retrospectively reviewed to determine the incidence of fatal pulmonary emboli. All TKA patients received 1,000 U of intravenous heparin sodium before the tourniquet was inflated and an additional 500 U of intravenous heparin sodium before the inflation of the second tourniquet during bilateral TKA. All THA patients received 1,000 U of intravenous heparin sodium at the time of the skin incision and 500 U of intravenous heparin sodium before preparation of the femoral canal. The overall incidence of fatal pulmonary emboli was extremely low (TKA, 0.096%; THA, 0.16%). With this regimen of intravenous intraoperative heparin, postoperative aspirin, thromboembolic disease hose, and early ambulation, there is no risk of postoperative bleeding, it is inexpensive, and there is no concern on how long to keep the patients on this regimen postoperatively. We recommend this regimen for the prevention of fatal pulmonary emboli after total joint arthroplasty.

We have made a retrospective review of 185 cemented Charnley total hip arthroplasties performed between 1970 and 1974 to determine the relationships between radiological variables and failure of the femoral and acetabular components. We measured the acetabular wear, the orientation of the cup, the thickness and consistency of acetabular and femoral cement mantles, radiolucency and femoral alignment. The mean follow-up was for 11.7 years. Femoral loosening was demonstrable radiologically in 15 hips (8.1%), ten (5.4%) of which were revised during the period of follow-up. Only when the first postoperative radiograph showed a thin cement mantle in Gruen zone 5 was there a significant association with failure of the femoral component. There were 12 loose acetabular components (6.5%), nine (4.8%) of which were revised. When the initial radiograph after operation showed radiolucency in DeLee and Charnley zone 1, the incidence of acetabular loosening was 28.21%. If such radiolucency was not present, the incidence of acetabular loosening was only 0.69%. Our findings emphasise the importance of careful cementing.

Between July 1986 and November 1989, 437 consecutive primary cemented total hip arthroplasties were performed using a straight-stemmed titanium alloy femoral component. Collared and collarless versions of this identical stem were randomly chosen by computer allowing a comparison between 213 collared stems (198 patients) and 224 collarless stems (209 patients). Diagnosis, sex, weight, and average age (72.8 years, collared; 72.0 years, collarless) were similar. Follow-up averaged 76 months (collared) and 72 months (collarless) with 49 patients followed for at least 10 years. Calcar-collar contact was noted in 205 hips (96%) on the initial postoperative radiograph. Early complications, including dislocations (5% each group), were similar. Late complications included 3 deep infections (2 collared, 1 collarless) and 2 postoperative femur fractures (1 each). Hip scores at the most recent follow-up averaged 91.2 and 90.1 in the collared and collarless groups. No or slight pain was noted in 93% of collared and 91.5% of collarless hips. Although no radiographic differences were noted in distal cortical hypertrophy, stem subsidence, and osteolysis, collarless hips lost significantly more medial femoral neck cortical bone (average 0.90 mm vs 0.63 mm). A higher incidence of radiolucent lines in femoral zone VI (20.7% vs 9.4%) was also noted in collarless hips.

Preoperative hemoglobin concentration may be an important predictor of transfusion risk in surgical procedures with significant expected blood loss. Contemporary studies investigating transfusion risk with regard to the relationship between perioperative administration of Epoetin alfa and baseline hemoglobin provide data to test this hypothesis. The predictive power of seven preoperative variables (hemoglobin concentration, age, erythropoietin level, ferritin concentration, serum iron, total iron-binding capacity, and predicted blood volume) on transfusion risk was examined via retrospective logistic regression analysis of 276 orthopedic surgical patients. In the two studies used to perform the regression analysis, patients were treated daily with either Epoetin alfa or placebo. Based on the retrospective analyses, a prospective study was conducted to validate the hypothesis. Of the seven variables evaluated, baseline hemoglobin concentration and predicted blood volume were significantly predictive of transfusion risk in both Epoetin alfa- and placebo-treated patients. Further, an inverse correlation between hemoglobin concentration and transfusion risk was demonstrated in placebo-treated patients. Placebo-treated patients with hemoglobin > 10 to < or = 13 g/dL had an approximately twofold greater risk of transfusion than patients with hemoglobin > 13 g/dL. In contrast to placebo treatment, Epoetin alfa significantly reduced transfusion risk in patients with hemoglobin > 10 to < or = 13 g/dL. Baseline hemoglobin concentration is an excellent predictor of transfusion risk in orthopedic surgical patients. As a result, hemoglobin testing should be considered a part of routine preoperative testing for orthopedic surgical patients.

A total of 3,807 patients undergoing total hip arthroplasty (THA) between the years 1970 to 1995 were evaluated for mortality. Patient age groups were designated in 10-year intervals as follows: age <40; 41-50; 51-60; 61-70; 71-80; age >80. The life expectancy estimate of the patients with THA was calculated by the Kaplan-Meier method, and that of the normal population was obtained from standard life-tables. Statistical significance was evaluated using 95% confidence limits. A significant difference in life expectancy was found in patient age groups >60 (61-70, 71-80, >80) demonstrating significantly higher survival rates among THA patients when compared with the normal population.

Between July 1989 and June 1994, a consecutive series of 651 cemented total hip arthroplasties were performed in 577 patients using relatively inexpensive implants and standardized surgical and postoperative protocols. We set out to determine what effect these cost-saving measures have on the overall success and complication rate after total hip replacement surgery. Surgical results remained excellent, and perioperative, early, and late complications, including infection, loosening, and revision hip surgery, remained minimal, indeed, below usual complication rates. We concluded that cost-effective measures can be implemented while maintaining the overall excellent results of hip replacement surgery without the risk of increasing complication rates.

Impaction bone-grafting was performed before insertion of a collarless, polished, tapered femoral stem with cement in thirty-four revision total hip arthroplasties (thirty-four patients) that were done because of aseptic loosening. The average duration of follow-up was thirty months (range, twenty-four to forty-two months). The operation was the initial revision in twenty-eight patients (82 per cent). Twenty-two patients (65 per cent) also had revision of the acetabular component. Complications included four intraoperative and two postoperative fractures of the femur as well as one dislocation (at one month). Two patients (6 per cent) needed a repeat revision of the femoral stem because of aseptic loosening at twenty-six and thirty-six months postoperatively. Both of these patients had an associated fracture of the femur (one was intraoperative, and the other was postoperative). Subsidence was common (thirteen patients; 38 per cent) and averaged 10.1 millimeters (range, four to thirty-one millimeters). Although the study group was relatively small, with the numbers available subsidence was not found to be associated with the preoperative or postoperative hip score, segmental or cavitary femoral defects, femoral ectasia, intraoperative fracture of the femur, strut-grafting, trochanteric osteotomy, or varus position of the femoral component. Incorporation of the allograft into the trabecular bone and secondary remodeling were noted radiographically in thirty-two (94 per cent) and fourteen (41 per cent) of the patients, respectively, often within one year. Although the duration of follow-up was relatively short, no localized resorption of the allograft occurred and cortical repair was noted in one patient at three years. At the most recent follow-up evaluation, the Harris hip scores had improved from a preoperative average of 51 points (range, 32 to 90 points) to an average of 87 points (range, 65 to 100 points) and twenty-eight patients (82 per cent) had no or only slight pain. Despite the satisfactory early clinical results, we remain concerned about the high rate of fracture of the femur and the rate and extent of subsidence of the femoral component. On the basis of the worrisome findings after this two-year period, we recommend that impaction bone-grafting be used only when proximal femoral osteopenia is so severe that stability cannot be obtained with insertion of a long-stemmed femoral component without cement. In that setting, impaction bone-grafting may be considered instead of implantation of a massive proximal femoral allograft in combination with insertion of a femoral component with cement.