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Background: This follow-up study updates the results in a consecutive series of nineteen cemented total hip replacements with a swan-neck femoral component in patients with congenital dislocation or severe hip dysplasia. The series was previously reported on in 1993., Methods: The patients were petite, with an average height of 152 cm and an average weight of 50 kg, and the femoral canals could not accommodate an off-the-shelf femoral component. Sixteen of the nineteen hips were available for follow-up at an average of 13.3 years (range, eleven to twenty years). Fourteen hips had up-to-date clinical and radiographic examinations., Results: At the time of the latest follow-up, thirteen hips were rated as excellent; two, as good; and one, as a failure because of loosening of both components requiring revision eleven years after the index operation. Another hip required acetabular revision because of loosening fifteen years after the index operation. The rates of femoral and acetabular component revision were 6% and 12.5%, respectively. Radiographic analysis demonstrated that no femoral component was loose. One cup was definitely loose at 19.5 years, and three cups were possibly loose at an average of fourteen years. The radiographic rate of acetabular loosening was 33%. The total rate of cup failure (radiographic loosening and revision) was 43%., Conclusions: The excellent clinical and radiographic results associated with the swan-neck femoral component, and the 94% rate of survival, at an average of 13.3 years (range, eleven to twenty years) indicate that the biomechanical objectives of this custom-designed prosthesis for patients with congenital dislocation or severe hip dysplasia were met. On the basis of this favorable long-term experience, we still use this prosthesis when the anatomic abnormality cannot be adequately addressed by use of a commercially available prosthetic component.

Thirty-five consecutive total hip arthroplasties in twenty-eight patients were performed with use of cement and insertion of an autogenous graft from the femoral head. Five patients (six hips) subsequently died or were lost to follow-up. The results for the remaining twenty-three patients (twenty-nine hips) were reviewed retrospectively at a mean of eleven years (range, seven to seventeen years) after the operation. All of the grafts united. The mean estimated coverage of the acetabular component by the autogenous graft was 27 per cent (range, 15 to 45 per cent). Three sockets (10 per cent) were revised because of symptomatic loosening without infection at a mean of ten years (eight, ten, and twelve years) after the index procedure. All three hips were found to have viable, bleeding bone in the region of the remaining graft. An additional eight acetabular components had a nonprogressive, asymptomatic, continuous radiolucent line at the cement-bone interface. This finding was assumed to indicate loosening of the socket, so the total prevalence of loosening was 38 per cent (eleven of twenty-nine sockets). There was no significant difference between the loose and the well fixed components in terms of the amount of coverage by the graft (p > 0.2) or the method of fixation (p > 0.4). There was no collapse or resorption of the graft that was of mechanical consequence. Autogenous femoral-head bone-grafting is a useful technique with a good potential for long-term success when the amount of coverage by the graft is limited to less than 40 per cent of the surface of the acetabular component.

Aim: The assessment of hospital performance with reference to patients who receive Austin Moore hemiarthroplasty for neck of femur fractures and the assessment of patients at medium term follow up., Methods: A retrospective review of 103 Austin Moore hemiarthroplasties in 101 patients. This review spans an 11 year period at this institution. A clinical follow up of survivors including pain, x-ray and Harris hip score to evaluate their current position., Results: Mean hospital stay remained unchanged at 39.13 days. Also unchanged were the percentage of patients returning home at 44.6%. The time to surgery improved significantly over the review period being on average 2.8 days. Medium term follow up of surviving patients (16 patients) showed 14 patients with poor Harris hip scores. Radiographic analysis did not explain the clinical outcome., Conclusions: Whilst at this institution, total time to surgery improved total hospital stay and percentage discharged home remained unchanged. Medium term surviving Austin Moore patients should be followed as their hip function may deteriorate excessively with time. The predicted increase in patient load will further pressure the current resources making substantial improvements more difficult.

A retrospective review of in-hospital mortality after total hip and total knee arthroplasty was performed to determine whether extensive changes in anesthesia care, introduced in this institution in July 1986, were associated with changes in mortality rates. From 1981 to 1985, the mortality rate was 0.39% (23 of 5874 patients) and from 1987 to 1991, the mortality rate was 0.10% (10 of 9685 patients) (P = 0.0003). Significant reductions in mortality rate were observed for both total hip arthroplasty (from 0.36% to 0.10%) (P = 0.0277) and total knee arthroplasty (from 0.44% to 0.10%) (P = 0.0131). The mortality rate of 0.10% is significantly less than previously published rates. Marked changes in anesthesia management were associated with a significant reduction in mortality after total hip and knee arthroplasty.

Patients with cerebral palsy frequently develop coxarthrosis after acquired hip dislocation or dysplasia. Nineteen total hip arthroplasties (THA) were performed in 18 patients with cerebral palsy and end-stage hip degeneration. The average age at arthroplasty was 30 years (range, 16-52 years). All components were cemented, and four hips required bone graft augmentation of the deficient acetabulum. Spica casts were used in 16 of 18 patients to minimize the incidence of dislocation and trochanteric nonunion. The average follow-up time was ten years (range, three to 17 years). Seventeen of 18 patients (94%) had pain relief and improved function after arthroplasty. One stem loosened at three years, and one acetabular component loosened at 15 years. One stem and one acetabular component were revised for malposition. Survivorship analysis was 95% at ten years for loosening and 86% with removal for any reason. Total hip arthroplasty can provide long-term relief and improved function in cerebral palsy patients with severe coxarthrosis.

A custom-designed femoral prosthesis was implanted with cement and a standard acetabular component was used to treat nineteen severely dysplastic hips in fourteen consecutively managed patients. Components that had been custom-designed with the use of plain radiography were used because the anatomical reconstructive goals could not be achieved with commercially available implants. These goals were to match the offset of the femoral head and the length of the lower limb with those on the normal side for patients who had unilateral involvement and to provide an average (thirty to forty-millimeter) offset with equal limb lengths for patients who had bilateral involvement. A retrospective clinical and radiographic analysis was performed. The diagnoses included coxa vara (one hip), congenital dislocation (twelve hips), achondroplasia (three hips), and spondyloepiphyseal dysplasia (three hips). The mean age at the time of the reconstruction was forty-nine years (range, twenty-two to seventy-three years), and the mean duration of follow-up was fifty-seven months (range, twenty-seven to 108 months). In five hips, bone-grafting of the acetabulum was needed to obtain superolateral coverage. The clinical result was excellent in eighteen hips and good in one. No revisions have been performed to date. Two femoral components were possibly loose radiographically. One was associated with a definite loosening of the acetabular cup. In addition, one other cup was possibly loose. There was a 100 per cent rate of survival if only a revision procedure was considered as a failure.(ABSTRACT TRUNCATED AT 250 WORDS)

The results of eighteen acetabular reconstructions in which a bipolar prosthesis and morseled bone grafts were used for a major acetabular defect were evaluated. Thirteen Type-II (cavitary) and five Type-III (combined) acetabular deficits were treated. All of the patients were followed for at least two years. The procedure failed in eleven patients: six had radiographic evidence of complete resorption of the bone grafts and migration of the acetabular component; three, deep infection; one, recurrent dislocation; and one, pain of undetermined cause despite a satisfactory radiographic appearance of the hip. The remaining seven patients had a satisfactory clinical outcome. However, an improved acetabular bone structure, as judged by radiographic evidence of incorporation of the bone grafts, was maintained in only four patients. In our experience, acetabular reconstruction with morseled bone grafts and a bipolar prosthesis was associated with a high rate of failure, and we do not recommend that it be performed routinely. It should be considered only as a salvage procedure in elderly or infirm patients, as a possible alternative to more extensive procedures.

We performed seven total hip replacements in six patients with the adult form of Gaucher's disease. Excessive perioperative hemorrhage was a common complication, and three patients have required revision of loosened components. Two of these were young patients with a more severe form of the disease. Total hip replacement is feasible and likely to be successful in the older patient with Gaucher's disease and osteonecrosis or failed prior hip surgery.

Thirty specimens were removed from the bone-cement interface in 25 hips revised for aseptic loosening of total hip arthroplasty. Histologic examination of the membranous tissues revealed that histiocytosis, fibrosis, and necrosis were present in every specimen. Other prominent features included particles of acrylic cement, polyethylene debris, and fragments of necrotic bone. Mechanical failure was characterized by cement fractures, and microfracture of bone. The presence of cement debris and bone detritus in the membranes, and smooth appearance of the removed cement mantles substantiated the presence of mechanical failure. The process of loosening was characterized by the recruitment of histiocytes into the interface and the subsequent resorption of bone around the prosthesis. This may be a manifestation of the rate of cement wear and tear, particle size, and the immunologic predispositions of the host. These observations on interfaces of loosened prostheses are reexamined and reinterpreted in the light of radiologic observations on interface radiolucent zones and well-functioning prostheses.

Although fracture of the femoral component is an uncommon mode of mechanical failure, when it does occur, symptoms may be dramatic. In addition, it presents the surgeon with one of the more challenging problems in revision total hip arthroplasty surgery. This study reviews the problem of femoral stem fracture and evaluates the stem failures and long-term follow-up of the revision for femoral component fractures performed at The Hospital for Special Surgery.

Six patients who had a total hip replacement, as well as a trochanteric osteotomy, while they were in the lateral decubitus position had complications involving the contralateral side. The complications included transient paresthesias, massive swelling of the thigh with myonecrosis, acute renal failure secondary to myoglobinuria, and arterial insufficiency that resulted in a below-the-knee amputation. In order to elucidate the causes of the complications, the external pressure of the contralateral femoral triangle and the blood flow to the contralateral foot were monitored intraoperatively in seventeen patients. The results supported the postulate that pressure at the groin is increased intraoperatively and that this can cause vascular compromise. Other proposed causes of the complications were pre-existing vascular disease, obesity, the lateral decubitus position of the patient on the operating table, and the use of hypotensive anesthesia. We found several techniques that may minimize complications in the contralateral limb during operations on the hip.

In 29 consecutive failed total hip arthroplasties revised during a 15-month period, cement fixation was used in 14 and cementless fixation in 11. A combination of the two techniques was used in four patients. Analysis of the indications for one or the other fixation type showed that the quality of bone stock and the location of bone deficiency were the most important criteria. The use of a fixation technique that suited the method of bone repair, i.e., autografts, allografts, or a combination of the two, was all-important. Cement technique alone was generally used when bone stock was intact and healthy. Cement was also used in combination with protrusio screens and allografts for gross acetabular deficiencies. Cementless, porous ingrowth technique, together with autografts, was preferred for femoral deficiencies or minor acetabular deficiencies. Bipolar prostheses with compressed, fragmented allografts were used as salvage procedures in gross acetabular deficiencies in older patients, especially when the femoral component did not need to be exchanged.

Total hip replacement fixed with acrylic cement can be successful despite past or present hip infection. Recovery of the infecting organism must be vigorously pursued, either by repeated aspirations or open biopsies. Staging the reconstruction is determined by the pathogenicity of the infecting organism, gram stain, frozen section, and above all the surgeon's observations of the condition of the wound. If in doubt, treatment of infection must take precedence over the reconstruction. Adequate antibiotic coverage should begin as soon as the diagnosis is certain and the organism identified. Antibiotics should be continued postoperatively for one month intravenously, followed by 4--8 months oral therapy, though the length of oral antibiotics could be debated. A number of authors have based their diagnosis of hip infection on clinical, roentgenographic, laboratory and bacteriologic studies. However, they have not given specific guidelines for the determination of deep hip infection. The application of the criteria outlined in this paper can distinguish superficial from deep hip infection as illustrated in 40 cases with no evidence of recurrence of infection. For the present only relative guidelines may be drawn for the treatment of subacute or recently arrested sepsis of the hip. Considering some 80,000 total hip replacements done in the U.S. in the past year, a significant number of patients will require treatment of this type and appropriate programs should be established for the welfare of the patients.

In this review, 110 hips in 107 patients underwent revision total hip arthroplasty at The Hospital for Special Surgery and the Robert B. Brigham Hospital. The minimum follow-up period was two years (average, 3.4 years). Failures of the original total hip arthroplasties were due to loosening of the femoral component (44 hips), loosening of both components (23 hips), loosening of the acetabular component (17 hips), fracture of the femoral component (14 hips), recurrent dislocation due to prosthetic malposition (7 hips), acetabular protrusion (3 hips), and fracture of the femoral shaft (2 hips). Sixty-six hips were categorized as good or excellent, and 25 hips were rated as fair. Nineteen poor results were due to: (a) deep infection (2 hips); (b) mechanical failure (15 hips); and (c) recurrent dislocation (2 hips). Complications included infection (3.6%), trochanteric problems (13%), mechanical failure (14%), and progressive radiolucent zones (26%). The quality of the result of a revision total hip arthroplasty is potentially as good as that of the original arthroplasty. However, the higher incidence of infection and mechanical failure reduces the frequency of such good results in the long-term. The extremely high incidence of progressive radiolucent zones at the bone-cement interface makes predictions for even longer term results guarded.

We conducted extensive histological examination of the tissues that were adjacent to the prosthesis in nine hips that had a failed total arthroplasty. The prostheses were composed of titanium alloy (Ti-6Al-4V) and ultra-high molecular weight polyethylene. The average time that the prosthesis had been in place in the tissue was 33.5 months (range, eleven to fifty-seven months). Seven arthroplasties were revised because of aseptic loosening and two, for infection. In eight hips cement had been used and in one (that had a porous-coated implant for fifty-two months) no cement had been utilized. Intense histiocytic and plasma-cell reaction was noted in the pseudocapsular tissue. There was copious metallic staining of the lining cells. Polyethylene debris and particles of cement with concomitant giant-cell reaction were present in five hips. Atomic absorption spectrophotometry revealed values for titanium of fifty-sic to 3700 micrograms per gram of dry tissue (average, 1047 micrograms per gram; normal, zero microgram per gram), for aluminum of 2.1 to 396 micrograms per gram (average, 115 micrograms per gram; normal, zero micrograms per gram), and for vanadium of 2.9 to 220 micrograms per gram (average, sixty-seven micrograms per gram; normal, 1.2 micrograms per gram). The highest values were found in the hip in which surgical revision was performed at fifty-seven months. The concentrations of the three elements in the soft tissues were similar to those in the metal of the prostheses. The factors to which failure was attributed were: vertical orientation of the acetabular component (five hips), poor cementing technique on the femoral side (three hips), infection (two hips), and separation of a sintered pad made of pure titanium (one hip). A femoral component that is made of titanium alloy can undergo severe wear of the surface and on the stem, where it is loose, with liberation of potentially toxic local concentrations of metal debris into the surrounding tissues. It may contribute to infection and loosening.

The results of 110 revision total hip replacements performed for aseptic failure, with an average follow-up of 3.4 years, were reported in 1982. We were able to continue to follow ninety-nine of these patients for an average of 8.1 years (range, five to 12.5 years). With this longer follow-up, we found that twenty-nine (29 per cent) of these revised arthroplasties have since failed. Most of the failures after 1982 occurred in the hips that were known to have a progressive radiolucency at the time of the first evaluation. We concluded that there is an increased failure rate with longer follow-up of revision total hip replacement, and that progressive radiolucency at an interface indicates a poor prognosis for the arthroplasty.

This two-part study concerns the fate of 100 Charnley low-friction arthroplasties performed in 92 patients at The Hospital for Special Surgery. The first part of the study is a clinical and radiographic evaluation of the 40 hips that were available for follow-up at an average of 15.3 years after surgery. The second part is a survival analysis of the arthroplasty, the individual components, and the patients, using data from all 100 arthroplasties. The authors conclude that the vast majority of older patients who undergo cemented total hip arthroplasty will not require a subsequent arthroplasty, and will have satisfactory pain relief for the remainder of their lives.

It is the purpose of this article to evaluate the authors' results of cemented acetabular reconstructions in revision surgery for massive osseous deficiencies with the previously stated techniques. In addition, the authors will examine the results with respect to bone allografting and bone autografting and their compatibility with methyl methacrylate.

This study concerns our first 100 Charnley low friction arthroplasties. The follow-up of the surviving forty hips ranged from 14.4 to 16.2 years (average 15.3 years). Thirty-nine of the original 100 hips were lost to follow-up due to death. Twenty-one could not be traced. There had been six known failures (defined as removal or revision of the prosthesis), two of which occurred in the surviving forty hips. Femoral component failure had occurred twice as often as acetabular failure. Survival analysis was performed using the last follow-up from all 100 hips. This depicted 91% survival of the arthroplasty (both components), 91% survival of the femoral component, and 96% survival of the acetabular component at fifteen years. Clinical evaluation of the surviving forty hips revealed 87.5% good and excellent results. This represented a small decline from 95% good and excellent results in the same hips at the ten year follow-up. Radiographic evaluation of thirty-two of forty hips demonstrated 6% migration of acetabular components, and 7% loose femoral components, while 31% of the acetabular components and 50% of the femoral components showed no sign of loosening. Femoral loosening was positively correlated with femoral shaft diameter. Measurable polyethylene wear was present in twenty-seven of thirty-two hips. The wear ranged from 0.2 to 8.5 millimeters (average 1.85 millimeters). Wear was associated with male sex and with calcar resorption.

We analyzed the records of 103 conventional hip arthroplasties in seventy-five active patients who were between the ages of forty and sixty years. After five to ten years of follow-up, an excellent or good clinical result was evident in 90 per cent. The radiographic appearance of the cement-bone interface of the acetabular component was stable in those hips, and no progressive acetabular radiolucency was found in 80 per cent of the hips. Of twenty hips with a complete acetabular radiolucency (Grade III or IV), only three had a secondary revision operation, two in conjunction with a fracture of the stem of the prosthesis and one for migration (Grade IV). Eight additional hips showed migration. Seventy per cent of the femoral components were well fixed, without radiographic evidence of loosening. A fracture of the femoral stem occurred in eight hips, all of which had a revision operation. One revision operation was done for loosening of the femoral stem. Seven femoral stems showed either shift or subsidence. An isolated radiolucency in the superolateral zone was present in four hips and an isolated lucency in other zones, measuring one millimeter or less, was present in ten hips. Thus, radiographic evidence of loosening, including the hips with a fractured stem, was present in 29.9 per cent. One additional revision, making ten in all, was done for symptomatic acetabular loosening. Based on this study, we concluded that conventional hip arthroplasty is a highly successful treatment in active patients between forty and sixty years old who have osteoarthritis of the hip.

This study concerns the fate of the first 100 Charnley total hip replacements done in ninety ninety patients at The Hospital for Special Surgery. At the time of this study, the follow-up of the surviving sixty-seven patients ranged from nine and one-half to eleven and one-half year (average, ten years). When studied at an average of ten years after the initial operation, twenty-six of the original 100 hips that had been operated on had been lost to follow-up due to death, and seven could not be traced. Of the remaining sixty-seven hips that were available for clinical evaluation, thirty-seven were rated as excellent; twenty-two, as good; four, as fair; and four, as poor, according to The Hospital for Special Surgery scoring system. The radiographs of fifty-four of the sixty-seven hips were available for this evaluation. Twenty-three of these hips showed radiographic signs of problems that appeared to have no significant bearing on the quality of their clinical results. There was loosening of the femoral component in five hips which occurred within the first three years after operation and then apparently stabilized. One required reoperation eight years after the original surgery. There was one fracture of the femoral stem eight years after the original operation, requiring reoperation. Six hips demonstrated so-called calcar resorption, the greatest measuring fourteen and thirty millimeters. Ten acetabular components showed wear of more than one millimeter, the maximum being five millimeters in both components of a patient with bilateral hip replacement. Two acetabular components migrated, one requiring reoperation due to progressive bone loss nine and one-half years after the original procedure. All three reoperations have been successful to date.

Careful selection and preoperative evaluation of patients with bilateral hip disease for one-stage bilateral total hip arthroplasty can yield satisfactory results consistent with those published for unilateral hip disease. These patients are generally younger and more active than patients undergoing unilateral total hip arthroplasty and require meticulous attention to both technique and prosthetic design. The authors found that the Charnley design remains the gold standard against which other prostheses must be measured in the long-term follow-up.

Clinical, pathologic, radiographic, and biomechanical factors of 10 severely worn retrieved Charnley acetabular cups were examined to determine whether these factors influenced cup wear. Change in cup thickness was found to be linear with time. It was found that the actual change in cup thickness was not significantly different from the radiographic change in cup thickness. No correlation was found with the other clinical or radiographic factors.

Three groups of patients underwent reimplantation for infected hip prostheses during the period from 1968 to 1979. The first group (N = 19) was diagnosed mainly by hip aspiration and treated with antibiotics selected by disc sensitivity and one-stage reimplantation in 14 hips. The second group (N = 26) was diagnosed by strict hip infection criteria and treated with a similar antibiotic regimen. Reimplantation was performed in one stage in 13 patients and in two stages in the remaining 13. The third group (N = 16) was diagnosed by the same criteria but treated with standardized bactericidal antibiotics evaluated by the tube dilution method. There were five one-stage reimplantations, ten two-stage, and one radical debridement without removal of components. The follow-up period ranged from two to 12 years. The present guidelines for reimplantation include subacute hip sepsis caused by susceptible bacteria, according to tube dilution methods in immunocompetent patients with adequate soft tissue and bone stock to allow a satisfactory biomechanical reconstruction. Patients should be aware of the risk of recurrence of infection, persistent pain, limited durability, and further surgical treatment.

To determine the effect of the ventilation system on infection rates after total hip and total knee arthroplasties performed in operating rooms with and without a horizontal unidirectional filtered air-flow system, using modern antiseptic conditions and antibiotic prophylaxis, all of the single-stage procedures (3175 of a total of 4769) were subjected to statistical analysis and fifty-seven matched pairs for controls were established. A reduced infection rate after total hip replacement (from 1.4 to 0.9 per cent) and an increased infection rate after total knee replacement (from 1.4 to 3.9 per cent) were found when patients operated on in the filtered laminar air-flow operating room were compared with those whose operations were done in two conventional rooms. This pattern was statistically significant and was believed to be due to the positions of the operating team and of the wound with respect to the air flow. Prospectively accumulated factors (such as the experience of the surgeon, the duration of surgery, the diagnosis, and the patient's age) as well as retrospectively accumulated factors (such as predisposing conditions of the patient) did not explain the observed patterns of infection.

From January 1979 to February 1982, 143 patients (seventy-nine women and sixty-four men) with 146 uninfected cemented total hip arthroplasties had revision cemented hip arthroplasty at The Hospital for Special Surgery for what was considered to be mechanical failure. The average age of the patients at primary arthroplasty was 56.1 years and at revision, 62.1 years. Loosening of the femoral component before revision correlated with varus positioning in 50 per cent of the hips, inadequate cement in 34 per cent, and a relatively young age in 16 per cent. The average age of the patients (fifteen hips) with a loose femoral component that had been placed in a neutral or valgus position with good cementing technique was 48.2 years at the time of primary arthroplasty. Loosening of the acetabular component was attributed to high placement of the cup in 41 per cent, inadequate bone in 18 per cent, a vertical orientation of the opening of the cup in 7 per cent, and poor cementing technique in 3 per cent. Complications associated with revision included perforation of the femoral cortex in 13 per cent, postoperative deep infection in 3.4 per cent, postoperative dislocation in 8.2 per cent, trochanteric complications in 6.2 per cent, and sciatic palsy in 0.7 per cent. Of the 139 hips that were followed for an average of 3.6 years (range, two to five years) after revision, the results were excellent in 59 per cent, good in 7 per cent, fair in 16 per cent, and poor in 18 per cent. After revision of the 139 hips, 29 per cent showed progressive radiolucencies; 18 per cent, femoral subsidence; and 9 per cent, acetabular migration. Definite mechanical failure after revision was identified in 15.8 per cent of the hips. These failures were due to loosening in 12.2 per cent of the hips, femoral fracture in 2.2 per cent, and disabling dislocation in 1.4 per cent. At the time of follow-up, twelve hips (8.6 per cent) had been revised a second time: six (4.3 per cent) for loosening of one or both components, three (2.2 per cent) for femoral fracture, and three (2.2 per cent) for infection. Mechanical failure and progressive radiolucencies were associated with poor quality of bone (p less than 0.001) and inadequate anatomical reconstruction (p less than 0.03).

Controversy exists over the safety of performing one-stage bilateral total hip arthroplasty. A prospective protocol was established in 35 patients to evaluate the perioperative morbidity of one-stage bilateral arthroplasty as compared with unilateral controls. Although there was no increase in the frequency of respiratory morbidity in bilateral procedures, respiratory depression is common with both procedures. The authors believe this is consistent with varying degrees of the adult respiratory distress syndrome and that the term fat embolism syndrome is misleading and should be abandoned.