Spinopelvic Alignment and Low Back Pain after Total Hip Replacement Arthroplasty in Patients with Severe Hip Osteoarthritis

STUDY DESIGN: Retrospective observational study. PURPOSE: We examined change in lumbrosacral spine alignment and low back pain (LBP) following total hip arthroplasty (THA) in patients with severe hip osteoarthritis (OA). OVERVIEW OF LITERATURE: Severe hip osteoarthritis has been reported to cause spine alignment abnormalities and low back pain, and it has been reported that low back pain is improved following THA. METHODS: Our target population included 30 patients (29 female, mean age 63.5 years) with hip OA who underwent direct anterior approach THA. There were 12 cases with bilateral hip disease and 18 cases with unilateral osteoarthritis. Visual analogue scale (VAS) scores for LBP and coxalgia, the Roland-Morris Disability Questionnaire (RDQ), and the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) were assessed before and after surgery. Spinal alignment metrics were measured before and after surgery. RESULTS: VAS for LBP change from preoperative to final postoperative observation was significantly improved (p < 0.05), as was VAS for hip pain (p < 0.001). RDQ improved significantly (p < 0.01). All five domains of JOABPEQ were significantly improved (p < 0.05). In terms of coronal alignment, lumbar scoliosis change from preoperative to last observation was significantly reduced (p < 0.05). There were no significant changes in the sagittal alignment metrics. In addition, there was a correlation between before and after RDQ difference and before and after lumbar scoliosis difference (p < 0.05). VAS for LBP (p < 0.05) as well as RDQ (p < 0.05) were significantly improved only in unilateral OA. Lumbar scoliosis was significantly improved in cases of unilateral OA (p < 0.05), but alignment did not improve in cases of bilateral OA (p=0.29). CONCLUSIONS: The present study demonstrates improvements in VAS for LBP, RDQ, and all domains of JOABPEQ. There were also significant reductions in lumbar scoliosis and an observed correlation of RDQ improvement with lumbar scoliosis improvement. We were able to observe improvements in lumbar scoliosis and low back pain only in cases of unilateral OA. It has been suggested that the mechanism of low back pain improvement following THA is related to compensatory lumbar scoliosis improvement.

Cementless Total Hip Arthroplasty Using a Ceramic on Ceramic Bearing Surface: The Clinical Results of a Minimum 10-year Follow-up for Patients with Short Term Follow-up / 대한고관절학회지

PURPOSE: The purpose of this study is to report on the clinical results of more than 10 years of follow-up after ceramic articulation total hip arthroplasty in patients younger than 50 years old who had reported a result of short-term follow-up. MATERIALS AND METHODS: We studied 25 patients who underwent cementless THA using ceramic on ceramic articulation between Jan 1998 and Dec 2001. They were followed up for 2-4 years, with good results, and could be followed up for more than 10 years. The evaluation of clinical results included Harris hip score (HHS) and occurrence of thigh pain. Radiologic evaluation was based on osteolysis and the stability of components. RESULTS: The mean HHS improved from 57.7 to 93.3 during the period of 2-4 years of follow-up and 91.0 at more than 10 years of follow-up. Two patients experienced thigh pain during the period of 2-4 years of follow-up and none of the patients had thigh pain at more than 10 years of follow-up. On the last radiographs, stable fixation was observed in all cases, except for one case of ceramic fracture. CONCLUSION: Clinical and radiologic observations of cementless ceramic on ceramic articulation THA in active patients younger than 50 years old who reported a favorable short-term result showed a satisfactory long-term result.

The Total Hip Replacement Arthroplasty for Femur Neck Fractures in the Elderly / 대한고관절학회지

PURPOSE: To analyze the clinical and radiological outcomes of total hip replacement arthroplasty (THRA) for the treatment of femur neck fractures in the elderly. MATERIALS AND METHODS: Femur neck fracture patients older than70 years of age, who showed good preoperative walking ability without dementia,and underwent THRA between February, 2008 and March, 2010 were reviewed retrospectively. Twelve patients(13 hips) were enrolled and the mean ages of the patients were 79.4(70-91). The mean follow-up period was 31(20-49) months. The modified Koval index was used to determine the clinical outcome. Inclination and anteversion of acetabular cup, loosening, osteolysis, periprosthetic fractures and dislocations were evaluated using the radiographs. RESULTS: The modified Koval index decreased from 4.92 to 4.84 at the final follow-up, but the decrease was not significant (P=0.339). Dislocations occurred in 2 cases postoperatively(2/13, 15.4%). No other complications were encountered. CONCLUSION: The THRA for the treatment of femur neck fractures in elderly patients over 70 years of age showed satisfactory clinical and radiological outcomes. Nevertheless, caution should be taken regarding the relatively high incidence of postoperative dislocations.

Hip Arthroplasty Using Collarless Polished Tapered Stem: Minimum 2 Years Follow-up Results

PURPOSE: This study evaluated the clinical and radiologic results of total hip arthroplasty and bipolar hemiarthroplasty using collarless polished tapered femoral stem. MATERIALS AND METHODS: We retrospectively reviewed the results of 33 patients who underwent THA and BHA using cemented CPT femoral stem from November 2006 to April 2009. The mean follow-up period was 33 months. The clinical results were evaluated with a Harris Hip Score (HSS), and radiographic results were assessed with cement grade, osteolysis, loosening, stress shielding and subsidence methods. RESULTS: Mean HSS improved with 91 points. Postoperative cement grade was A in 14 cases, B in 14 cases, C1 in 5 cases and D in none. Aseptic loosening was not found, while focal radiolucency in zone 8 was found. 70% of stems showed grade 1 and 2 stress shielding according to Engh's criteria. Subsidence of the femoral stem was less than 1 mm in 32 cases, and was 1.47 mm in another case. Ectopic ossification was observed in 13 cases, class I in 11 cases, and class II in 2 cases, using Brooker's classification. CONCLUSION: This study showed the good clinical and radiographic results of THA and BHA with a cemented CPT femoral stem at the mid-term follow-up. However, a long-term follow-up study will be needed to evaluate the more precise clinical and radiographic outcomes.

Do You Need CAOS (Computer Assisted Orthopedic Surgery) in THA?: From a Negative Perspective

CAOS (Computer Assisted Orthopedic Surgery) has been introduced into the field of artificial joint replacement to increase the accuracy of implant placement. The advocates of CAOS insist that total hip replacement arthroplasty using CAOS will decrease dislocation, the wear rate, impingement and limb length discrepancy by increasing the accuracy and consistency of implant placement. However, we have to maximize the good results of total hip replacement arthroplasty by developing CAOS with understanding its disadvantages and limits, so we have reviewed CAOS using a critical eye for its negative aspects.

A pitfall for short external rotator preserving THA : A Case Report

The posterior and posterolateral surgical approach has been frequently used for total hip replacement arthroplasty (THA). But there is a risk of dislocation with this method and so several other methods for preventing dislocation have been presented. The short external rotator preserving technique is currently under the limelight and the reported clinical outcomes have been good. But we report here on one case of disruption of the piriformis muscle from the origin site due to excessive tension during total hip arthroplasty with using the short external rotator preserving technique. We think the conventional approach is safer than the short external preserving approach if excessive tension has to be loaded on the short external rotator for obtaining an appropriate intraoperative field for the patient with a large skeletal structure or the obese patient.

Primary Total Hip Arthroplasty in Systemic Lupus Erythromatosus / 대한류마티스학회지

OBJECTIVE: The purpose of this study is to evaluate the short term results of total hip arthroplasty (THA) for avascular necrosis in patients with systemic lupus erythematosus (SLE). METHODS: This is a retrospective case control, matched pair study. Ten patients (15 hips) with SLE and avascular necrosis of the femoral head (AVNFH) underwent THA. Eight patients (12hips) with a minimum follow up of 2 years were reviewed. To determine whether these patients had results similar to those of patients with other diagnosis, we formed a control group of 12 patients who had 12 THA. They were matched for age, sex, BMI, activity, follow-up period, and type of implant with SLE group. The clinical and radiographic results were evaluated by Harris hip score (HSS) and serial radiographic findings, respectively. RESULTS: There was no complication during the perioperative period. In the SLE group, HHS was from 67.3 preoperatively to 97.7 at last follow-up. In the control group, HHS was from 70.1 preoperatively to 97.8 at last follow-up. On the last roentgenograms, none of acetabular components demonstrated any evidence of migration, tilt, rotation or shedding of metal particles in both groups. All femoral components demonstrated no evidence of subsidence, pedestal, or shedding of metal particles in both groups. CONCLUSION: Patients with SLE and AVNFH had excellent results after THA. Results were not different from that of patients who had hip replacement for other diagnoses. Therefore, it is considered that uncemented THA was useful treatment method for the patient who had SLE and AVNFH.

Short Term Results of Cementless Total Hip Arthroplasty with Using a Accolade TMZF Femoral Stem

PURPOSE: We wanted to evaluate the short term clinical and radiological results and the complications of primary total hip arthroplasty with using a Accolade TMZF femoral stem. MATERIALS AND METHODS: 66 cases among 80 cases underwent total hip arthroplasty by one surgeon with using an Accolade TMZF femur stem from January 2002 to August 2006. The minimum follow-up was 30 months and we retrospectively analyzed these 66 patients. RESULTS: The mean Harris Hip Score improved from 54 to 92 at the last follow up. On the last follow-up X-ray, all the femoral stems (100%) showed stable fixation and there was no osteolysis or loosening, but there were 34 cases of stress shields and 20 cases of cortical hypertrophy. The acetabular component revealed stable fixation in 65 cases (98.5%) and loosening in one case (1.5%). There was no acetabular osteolysis, but 22 cases of radiolucency were observed in the Dee Lee and Charnley zone II. As complications, there were 5 cases of heterotrophic ossification, 1 case of greater trochanteric bursitis, 2 cases of thigh pain and 1 case with a squeaking sound. CONCLUSION: Primary total hip arthroplasty using a cementless Accolade TMZF femoral stem showed good results in the short term, but long term follow up is needed.

Cerebral Infarction following Total Hip Replacement Arthroplasty in Geriatric Patient : A case report / 대한마취과학회지

Perioperative cerebral infarction is uncommon and its mechanism is often uncertain. This is a report of an unusual case of acute cerebral infarction following general anesthesia. The patient was a 83-year-old female admitted for total hip replacement arthroplasty (THRA). There were no previous cerebro- and cardio-vascular symptoms and history. During introduced general anesthesia with sevoflurane, there was a persistent low systolic BP of 80-100 mmHg (preoperative BP was 140/85 mmHg). On emerging from anesthesia, confusion and dense right hemiparesis were observed. Emergency CT brain scan showed early cerebral infarction in the middle cerebral artery (MCA) territory. Even though prompt supportive neurosurgical intensive care was initiated, the patient died at postoperative 4 days.

Intraoperative Imaging to Monitor the Alignment of Acetabular Cup for Total Hip Replacement Arthroplasty

PURPOSE: This study examined intraoperative imaging to monitor the alignment of the acetabular cup for total hip replacement arthroplasty (THRA) using C-arm fluoroscopy and to increase the accuracy of THRA prosthetic fixation. MATERIALS AND METHODS: From March 2004 to April 2007, 54 patients underwent THRA monitored by the imaging. 40degreesinclination and a 15degreesanteversion angle was considered to be ideal. The items compared included the alignment of the acetabular cup and the follow up rates of the hip dislocation. RESULTS: There was one case of hip dislocation. The mean inclination angle of the acetabular component was 39.9degreeswith a standard deviation of 3.038. The mean anteversion angle of the acetabular component was 14.9degreeswith a standard deviation of 1.398. The mean difference examination and variance in the anteversion angle showed a significant result.(P<0.05) CONCLUSION: Intraoperative imaging increases the alignment accuracy of the acetabular cup and helps stabilize the prosthesis.

Treatment of Acute Arterial Thrombosis after Total Hip Replacement Arthroplasty Using Urokinase: A Report of Two Cases

Arterial thrombosis of the lower extremity following total hip replacement is a rare but serious complication that threatens the lower limb and sometimes the life of the patient. We report two cases of an arterial occlusion after total hip arthroplasty. The cause of the occlusion is believed to be a thromboembolism in elderly patients due to underlying artherosclerosis. In the case of multifocal artherosclerosis, a vein graft is not feasible and an infusion of a thrombolytic drug is the optimal treatment. However, the result of this method varies.

Primary Total Hip Arthroplasty with Cementless VerSys Femoral Stem: a Minimum 5-years follow-up

PURPOSE: This study evaluated the clinical and radiographic results of primary total hip arthroplasty with a noncemented VerSys Fiber Metal Midcoat stem. MATERIALS AND METHODS: Thirty nine hips in thirty three patients were followed up for a minimum of five years. The clinical results were evaluated based on the Harris hip scores. Radiographic analysis of the femoral component was performed by evaluating the radiolucent lines, cortical hypertrophy, stress shielding, osteolysis and fixation stability. Radiographic analysis of the acetabular component was performed by evaluating the osteolysis and fixation stability. RESULTS: The average Harris hip score improved from 54.3 points preoperatively to 95.4 points at the last followup. In the results of radiographic analysis of the femoral component, stable bony ingrowth was noted in thirty-eight cases and stable fibrous ingrowth was observed in one. Non-progressive radiolucency<2 mm in width was observed in eight cases. There were three cases of osteolysis, thirty-six cases of stress shielding, and one case of cortical hypertrophy. Radiographic analysis of the acetabular component revealed stable bony ingrowth in thirty-eight cases and unstable fixation in one case. There were two cases of osteolysis. CONCLUSION: The results of primary total hip arthroplasty using cementless VerSys femoral stem after a minimum of five-year follow up revealed that the rate of femoral osteolysis had decreased and the rate of bone resorption by stress shielding was relatively high. However, a longer-term follow up will be needed.

Primary Total Hip Arthroplasty Using Non-cemented Multilock Proximal Porous Coated Femoral Stem: Ten to Twelve Years Follow Up Study / 대한정형외과학회잡지

PURPOSE: This study evaluated the minimum ten-year result of primary total hip arthroplasty with a non-cemented Multilock femoral stem. MATERIALS AND METHODS: Fifty five total hip replacements in forty-four patients using a non-cemented Multilock femoral stem and Harris-Galante 2 acetabular component were performed between January 1992 and December 1994. Forty-four hips in thirty-six patients were available for follow up for an average of eleven years (range, ten to twelve years). The clinical results were evaluated based on the Harris hip scores. A detailed radiography analysis was performed by an evaluation of the radiolucent lines, femoral osteolysis, and fixation stability by Engh Method. RESULTS: The average Harris hip score improved from 54.3 points preoperatively to 93.6 points postoperatively. Non-progressive radiolucencies < 2 mm in width were observed in nine (20.5%), and femoral osteolysis was observed in thirteen cases (29.5%). For the fixation stability, osseous ingrowth was noted in thirty nine cases (88.6%) and fibrous ingrowth was observed in two (4.5%). There were three (6.8%) cases with unstable fixation. Two hips underwent revision. The survival rate of the femoral component was 93.2% (forty one cases) after a minimum ten-year follow up. CONCLUSION: The non-cemented Multilock femoral component provided excellent clinical and radiographic results. However, the rate of femoral osteolysis was relatively high (mostly restricted to zone 1 and 7).

Blood Loss and Transfusion In Primary Total Hip Arthroplasty

Introduction: This study examined the factors related to the amount of blood loss and transfusion after primary total hip arthroplasty. Materials and methods: Sixty THRA patients, who had records of perioperative complete blood counts and transfusion, were enrolled in this study. Age, gender, diagnosis, use of cement, size of an incision, operative time, intraoperative crack, estimated blood loss, use of suction drain and the amount drained were used as possible variables. Results: The decrease in the serum hemoglobin level immediately after and 1 day after surgery was 3.18 and 3.90g/dL respectively. An average of 2.30 units were transfused in 78.3% of cases. The preoperative serum hemoglobin level, the use of a suction drain and the amount drained was related to the total amount of transfusion. Adverse transfusion reactions were found to be associated with the amount of transfusion Discussion: The reduction in the hemoglobin level and total amount of blood transfused showed no relationship with the variances associated with the surgical techniques. The total amount of blood transfused was significantly lower in the groups that had no suction drain. Therefore, a reduction in the volume of intraoperative transfusion and avoiding use of a suction drain can reduce the total amount of blood needed and reduce the adverse reactions of the transfusion.

The Validity of the Radiographic Measurement of Acetabular Anteversion after Total Hip Replacement Arthroplasty / 대한정형외과학회잡지

PURPOSE: This study was performed to evaluate the efficacies and the reliabilities of methods used to measure acetabular anteversion in plain radiographs. MATERIALS AND METHODS: Three orthopedic surgeons measured prosthetic acetabular anteversions in three plain AP and three translateral radiographs of ten patients who underwent total hip arthroplasty. In each film, we measured anteversions three times using three methods in AP and a direct method in translateral radiographs. Data were collected and analyzed statistically with CT axial and planar anteversion measured by a radiologist. RESULTS: All methods with plain AP film showed very low inter and intraobserver variances and correlated well with CT planar and axial anteversions. Although the data obtained from translateral radiographs were showed low variances, they did not correlate with those of the other methods. CONCLUSION: Simple estimation alone or mathematical methods can be reliably and reproducibly used to assess planar anteversion in a clinical setting. Data from translateral radiographs were unreliable and did not correlated well with the other methods, and they are not recommended for clinical use.

A Comparative Study of the in vivo Wear of Zirconia and Metal Heads Articulating with Polyethylene Liners in Total Hip Arthroplasty / 대한정형외과학회잡지

PURPOSE: The purposes of this paper was to determine the wear rates and volumetric wears of ceramic (Zirconia) and metal (Cobalt-chrome) femoral heads, and to differentiate creep from true wear. Another purpose was to determine the extent of wear and volumetric wear per annum. MATERIALS AND METHODS: We examined 86 patients (111 hips) who were continuously followed up from 180 patients (225 hips) who received THRA with AVN of stage III or above at our hospital. Patients were followed until December 1999 for more than a minimum of 3 years from June for 1996. The hip joint AP radiographs that had been taken immediately after the operations, six weeks postoperatively and annually thereafter were compared. We used the computer assisted vector wear analysis program of Martell to measure the wear rate, volumetric wear and vector wear. RESULTS: The wear rate and the volumetric wear in the zirconia ceramic head group (1.443 mm/year, 665.433 mm3/year) and metal head group (2.161 mm/year, 1271.831 mm3/year) were high immediately after operation and six weeks postoperatively, and this was significantly more than during all for other periods, giving a wear rate and volumetric wear in the ceramic head group of 0.180 mm/year and 81.101 mm3/year, and in the metal head group of 0.219 mm/year and 124.149 mm3/year. Moreover, the average wear rates and volumetric wear rates of these two groups were significantly different, and annual wear and volumetric wears showed a trend to decrease with time. CONCLUSION: Wear rate and volumetric wear six weeks after operation were remarkably high compared with the other periods. This is interpreted as the result of a creep phenomenon, which occurred mainly during the six weeks following the operation. The Zirconia ceramic head group showed little wear, which confirms the theoretical advantage of the zirconia ceramic head in vivo.

Polyethylene Liner Wear in Harris-Galante Acetabular Cup: Two Dimensional versus Three Dimensional Method / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to compare the two-dimensional with three-dimensional radiographic measurements of polyethylene liner wear in the Harris-Galante II acetabular cup. MATERIALS AND METHODS: We measured the polyethylene liner wear amount and the wear rate of 64 hips with Harris-Galante II acetabular cup by two methods: Livermore's method and modified Devane's method. We evaluated the relationships between the two methods. RESULTS: The average total amount of wear and the average wear rate are 0.86+/-1.01 mm and 0.18+/-0.20 mm/year using the two-dimensional method and 0.99+/-1.01 mm and 0.21+/-0.2 mm/year using three-dimensional method respectively. The amount of wear and the wear rate by the three-dimensional method was larger than those by the two dimensional method. CONCLUSION: The amount of polyethylene liner wear can be measured by the two-dimensional method because it is highly correlated with the amount that is measured by the three-dimensional method, since there was no differences between the two methods.

Total Hip Arthroplasty in Bony Fused Hip / 대한정형외과학회잡지

PURPOSE: This study was to evaluate results after conversion of fused hip to total hip replacement arthroplasty and to correlate factors that affect the results. MATERIALS AND METHODS: Twenty-five hips in twenty-three patients who underwent THRA for bony ankylosis of hip from January 1983 to July 1996 were reviewed. RESULTS: Of 19 cases who had adjacent joint pain, 13 cases improved clinically. The average Harris Hip Score improved from 74 points preoperatively to 86 points postoperatively, and HSS seemed to have no relationship with the causes and duration of ankylosis or presence of previous operation. Radiologically, three of femoral components that had been inserted without cement were loose. The socket was loose in all 6 cases using PM type prosthesis. Within 19 cases that porous coated hemispheric prosthesis were inserted, the socket was loose in 2 cases. The acetabular socket of PM type showed much higher incidence of aseptic loosening ( p< 0.01 ) . CONCLUSION: THRA in fused hip improved the quality of life by restoring joint motion and relieving pain in adjacent joint affected secondarily to fused hip. However, threaded type cup showed high rate of failure due to lack of biologic fixation.

Changes of Thrombelastography in Acute Isovolemic Hemodilution Undergoing Total Hip Replacement Arthroplasty / 대한마취과학회지

BACKGROUND: Acute isovolemic hemodilution is one of the autologous transfusion which diminishes intraoperative blood loss and avoids homologous transfusion. A method of assessment of hemostatic function by whole blood is thrombelastography, which is a sensitive indicator of platelet interreaction with protein coagulation cascade. We investigated the effect of intraoperative isovolemic hemodilution on blood coagulation as measured by thrombelastography. METHODS: We studied in twenty-one patients undergoing elective total hip replacement arthroplasty. Hemodilution was done with Hartmann's solution and pentastarch and prothrombin time, activated partial thromboplastin time and native whole blood thrombelastography were performed preoperatively, immediate postoperative and days 2 postoperatively. RESULTS: The Hb, Hct and platelet count decreased significantly after hemodilution. The thrombelastographic changes included decreases in r and k with concurrent increases in alpha angle and MA in immediate postoperative time. On days 2, there were further increase in alpha angle and MA. These changes indicate enhanced procoagulant activity and progressive increase in maximum clot strength. Conclusion: Acute isovolemic hemodilution with Hartmann's solution and pentastarch induced hypercoagulable state without any serious complication in total hip replacement arthroplastic surgery.

Total Hip Replacement Arthroplasty in Ankylosing Spondylitis / 대한정형외과학회잡지

Total hip replacement arthroplasties(THRA) have been done in 19 patients(31 hips), who were diagnosed ad ankylosing spondylitis from January, 1984 till July, 1993 at Seoul National University Hospital. All patients were male; 12 patients were affected bilaterally. Modified New York criteria was used as diagnostic criteria. HLA B27 antigen was positive in 18 cases(95%). The thoracolumbar spine and sacroiliac joint were affected in all cases and cervical spine was affected in five patients, among them, fiberoptic laryngoscopic intubation was needed in four cases. The trastrochanteric approach was used in 19 cases, which have severe limitation of motion and deformity of the acetabulum. For the prevention of postoperative heterotopic ossification, low dose radiation therapies were done in 10 cases of the risk group. The average follow-up period was three year and eleven months(two year-seven year and 10 months). Harris hip score and radiographs were obtained at each follow-up. The mean preoperative Harris hip score was 50(19–90), and finally, the mean Harris hip score was 87(68–96). Loosening of endoprothesis was noted in 3 cases and heterotopic ossification in 5 hips. Ischial enthesopathy was observed in 13 cases. Among the hips which had heterotopic ossification, four were class Ι by Brooker's classification and only one was class Ⅲ. No nonunion was observed in the cases which had trochanteric osteotomy expect breakage of wire in 4 cases. In THRA of ankylosing spendylitis, we obtained good result clinically and radiologically. In severely affected cases, we had used transtrochanteric approach and obtained good result due to better operative field. The incidence of heterotopic ossification was not significant and the prophylactic low dose radiation therapy seems to be effective in risk group.