The Frank Stinchfield Award: Morphologic features of the acetabulum and femur: anteversion angle and implant positioning.

Morphologic features of the hips, in particular those features germane to determination of acetabular and femoral anteversion angles and femoral head offset, were studied in 50 male and 50 female human skeletons with bilateral normal joints. Four distinct configurations were identified relative to the anterior acetabular ridge. The majority (121, 60.5%) were curved; 51 (25.5%) were angular; 19 (9.5%) were irregular; and nine (4.5%) were straight. The acetabular anteversion angle measured 19.9 degrees +/- 6.6 degrees (range, 7 degrees-42 degrees) and was significantly larger in females (21.3 degrees +/- 7.1 degrees) versus males (18.5 degrees +/- 5.8 degrees). The notch acetabular angle, which can be identified easily intraoperatively, was defined as the angle created at the intersection of a line from the sciatic notch along the posterior acetabular ridge and a line from the posterior to the anterior acetabular wall. This angle is almost perpendicular (89.0 degrees +/- 3.5 degrees) and, therefore, may provide an accurate estimate of acetabular anteversion during cup placement. Awareness of the anatomic differences between genders for acetabular anteversion angle, anterolateral bowing of the femur, and neck shaft angle may help reduce the relatively higher incidence of dislocation in females and may lead to different implant designs for male and female patients.

Omnifit cementless total hip arthroplasty. A 10-year average followup.

Seventy-six hips in 67 patients were evaluated an average of 119 months (range, 61-150 months) after total hip arthroplasty with porous coated Omnifit femoral and acetabular components. The patients were young (average age, 45 years), and most were male (67%). Two stems and one cup were revised for aseptic loosening, for aseptic revision rates of 2.6% on the femoral side and 1.3% on the acetabular side. Thigh pain was present in three cases, one of which was activity limiting. Twenty-five (35.7%) hips had evidence of osteolysis confined to proximal Gruen Zone 1 or 7 or to the acetabulum (22 proximal femoral, three both). There were no cases of intramedullary osteolysis in surviving stems. Thirteen (17.1%) hips have undergone reoperation for bone grafting of progressive proximal osteolysis without component revision, at an average 93 months after the total hip arthroplasty. At an average 40 months after reoperation, all stems remain well fixed, and there has been no recurrence of osteolysis of grafted femoral lesions. These results suggest that a circumferentially proximally porous coated femoral component in cementless total hip arthroplasty can provide stable fixation for as long as 12 years after implantation and caseal the canal from distal osteolysis. Serious concerns remain about the incidence of proximal femoral osteolysis.

Nonunion of extended trochanteric osteotomies in impaction grafting femoral revisions.

Extended trochanteric osteotomies have been recommended to facilitate femoral component removal, femoral cement removal, and acetabular exposure in cases of difficult revision hip arthroplasty. Complications due to the osteotomy have been rare and no nonunions have been reported when this osteotomy has been used in conjunction with extensively porous-coated implants. It has been suggested that the osteotomy should also work well with impaction grafting revisions. This is a report of two cases of nonunion of extended trochanteric osteotomies in which the impaction grafting technique was used.

Hydroxyapatite in total hip arthroplasty. Clinical results and critical issues.

Surgeons who perform arthroplasties have posed some critical questions about hydroxyapatite. Does hydroxyapatite coating enhance bone ingrowth or ongrowth? Will hydroxyapatite lead to increased polyethylene wear or an increased incidence of osteolysis? Will the hydroxyapatite coating disappear, and if so, what will be left to maintain implant fixation? A multicenter study of 316 hips (282 patients) with a proximally hydroxyapatite coated stem and either a hydroxyapatite or porous coated cup were followed up 8.1 years (range, 5.6-9.9 years). The average patient age was 50 years (range, 16-81 years), and 61% of the patients were male. One (0.3%) stem, three (2.7%) porous coated cups, and 25 (11.9%) hydroxyapatite coated cups were revised for aseptic loosening. Disappointing results on the acetabular side indicate that substrate design is critical. There were no cases of intramedullary femoral osteolysis, and the incidence of acetabular and proximal femoral osteolysis- and polyethylene wear was no greater than that seen with other cementless or cemented components. Based on these clinical results and a critical review of the literature, it is concluded that hydroxyapatite coated hip components do enhance ingrowth or ongrowth with no increased incidence of osteolysis for as many as 10 years. Concern about the disappearance of the hydroxyapatite coating with time seems moot in light of the above clinical findings.

Hydroxyapatite-coated total hip femoral components in patients less than fifty years old. Clinical and radiographic results after five to eight years of follow-up.

One hundred and thirty-three patients (152 hips) who were an average of thirty-nine years old (range, sixteen to forty-nine years old) received a proximally hydroxyapatite-coated femoral prosthesis as part of a total hip arthroplasty and were followed for a minimum of five years (average, 6.4 years; range, five to 8.3 years) or until revision. The average Harris hip score was 47 points (range, 22 to 77 points) preoperatively and 93 points (range, 49 to 100 points) at the time of the latest clinical evaluation. Two patients who had a well fixed femoral implant had activity-limiting pain in the thigh at the time of the most recent examination. Radiographic changes consistent with bone-remodeling (cortical hypertrophy and bone condensation) typically were seen around the mid-part of the shaft of the prosthesis. Forty-eight (32 per cent) of the 148 hips that were included in the radiographic analysis demonstrated a small amount of erosive scalloping in either zone 1 or zone 7 of Gruen et al., and intramedullary osteolysis was suspected in only one hip. All stems were radiographically osseointegrated according to a modification of the criteria described by Engh et al. Four stems were revised, but none of the revisions were performed because of mechanical failure (two stems were revised in conjunction with a revision of the cup because of pain; one, because of an infection; and one, after a traumatic femoral fracture that occurred six years postoperatively). Thus, the rates of aseptic and mechanical failure were both 0 per cent. The combined rate of failure, which included the two stems that were revised because of pain and the two stems that were associated with pain that limited activity, was 2.6 per cent (four of 152 stems). The over-all clinical results associated with hydroxyapatite-coated femoral components were excellent in this group of young patients after intermediate-term follow-up. A review of serial radiographs showed mechanically stable implants with osseous ingrowth, evidence of stress transmission at the middle part of the stem, and minimum endosteal osteolysis.

When is total hip arthroplasty a failure? The patients' perspective.

Total hip arthroplasty (THA) patients (186 primary, 92 revision) were surveyed regarding their satisfaction, their expectations regarding longevity, of the hip implant, and their perspective on the potential or actual need for revision surgery. The vast majority of patients were glad they had the original THA, would do it again if faced with a similar choice, and would recommend it to others. One-third of patients believed their current implants would last the rest of their life. The most common responses to either potential or actual failure were happiness it lasted as long as it did, accepting it as "one of those things," and disappointment. No primary THA patients and only 7% of revision of THA patients indicated that they would consider the primary THA a failure when revision surgery was indicated.

Primary cemented total hip arthroplasty: five to twelve year clinical and radiographic follow-up.

A retrospective clinical and roentgenographic study was completed on 131 primary cemented total hip arthroplasties with a minimum of five years follow-up (mean, seven years; range, five to twelve years). Second generation cement technique including plugging of the medullary canal, cement gun filling, and pressurization of the canal was used. Acetabular cement was also pressurized. The total mechanical failure rate of the acetabular components was 18.4% compared to that of the femoral components which was 3.1%. There was a significantly higher incidence of acetabular component failure in rheumatoid arthritis patients (38.9%) compared to a preoperative diagnosis of primary osteoarthritis (14.1%) (p = 0.013). Yet there were no rheumatoid arthritis patients in the femoral component revision group. There were no differences in revision rates for metal-backed versus nonmetal-backed cups (p = 0.113). The average thickness of the proximal medial cement mantle was 2.8 millimeters in the loosening group and 5.4 millimeters in the nonloosening group (p = 0.333). All failures occurred in those patients whose proximal medial cement mantle was less than five millimeters. The authors strongly endorse the use of hybrid total hip arthroplasty and emphasize the need for meticulous surgical technique especially in obtaining a cement mantle of sufficient thickness in the proximal medial aspect of the femur.

Total hip arthroplasty without cement in obese patients. A minimum two-year clinical and radiographic follow-up study.

A retrospective study of patients who had had a primary total hip arthroplasty without cement between 1983 and 1990 was done to examine differences in clinical and radiographic results between obese and normal-weight individuals. Patients were considered to be of normal weight if the body-mass index (calculated as weight in kilograms divided by height in meters squared) was between twenty and less than thirty, and they were considered to be obese if the body-mass index was thirty or more. There were 127 normal-weight patients (142 hips) and fifty-five obese patients (sixty hips) in the analysis. Eight obese patients (eight hips) who had a body-mass index of forty or more were considered to be morbidly obese and were examined separately as a subset of the obese group. The duration of follow-up averaged forty-eight months (range, twenty-four to ninety-two months). There were no differences between the groups with regard to age, diagnosis, the type of stem or cup, the type of bone, the postoperative level of activity, or the duration of follow-up. The obese patients had a significantly greater loss of blood during the operation than the patients in the normal-weight group. There were no significant differences between groups with regard to the prevalence of perioperative complications, the number of units of blood transfused, the operative duration, or the duration of hospitalization. Of the 202 hips, 184 (91 percent) were pain-free or only mildly painful at the latest follow-up examination.(ABSTRACT TRUNCATED AT 250 WORDS)

Omniflex modular femoral component. Two- to five-year results.

A prospective study was completed on 106 consecutive cementless arthroplasties (94 patients) to determine the clinical and radiographic outcome. Ninety-two hips (81 patients) had complete follow-up data. The average age was 46 years, and the average follow-up period was 41 months (24-63 months). Clinically 94% had no or slight pain. Two patients had activity-limiting thigh pain. Most patients had no or slight limp and walked without support. Patients had similar outcomes regardless of their bone type. Ninety-three percent of hips were radiographically stable. Six were loose; three of those had major intraoperative fractures. Stable stems were characterized by middle and distal zone endosteal condensation and cortical hypertrophy; these occurred primarily in the distal zones for unstable implants. Calcar resorption was noted in 38% of hips with collars and in 68% without collars (p = 0.015). Endosteal erosions were seen in six hips (6.5%) and were related only to the patient's activity level (p = 0.021). Seven hips were revised, two for delayed sepsis, one for loosening after trauma, one for intraoperative fracture, and three for aseptic loosening. The Omniflex implant system provides acceptable but not outstanding results in a wide array of femoral geometries. The early difficulty with femoral fractures has been significantly reduced by using a prophylactic cerclage cable.

WAIS-R intrasubtest scatter in a chronic schizophrenic population: is it an attentional problem?

This study investigated the hypothesis that intrasubtest scatter on the WAIS-R is a measure of fluctuations in attention/concentration. Thirty-two chronic schizophrenic inpatients were administered the WAIS-R, the Mini-Mental State Examination, an attention task battery, and the Psychotic Inpatient Profile. Intrasubtest scatter correlated significantly with some attention measures. However, scatter was correlated more highly with cognitive aspects of mental status, Freedom from Distractibility, and observed psychotic behavior. Thus, intrasubtest scatter in this population appears to reflect a broader measure of the integrity of "cognitive state" and not merely a clinical indication of attention/concentration problems.

Allied health team management of rheumatoid arthritis patients.

The use of a coordinated team of allied health professionals (AHPs) to treat patients with rheumatoid arthritis assigned to experimental groups (EG) and comparison groups (CG) was assessed. The EG patients were evaluated regularly by each AHP team member, whereas CG patients were seen by AHPs only upon referral. Of the 10 EG and 13 CG patients who remained in the study for 2 years, the EG patients initially exhibited somewhat greater disease activity than CG (as reflected by erythrocyte sedimentation rate and duration of morning stiffness). After 2 years, EG patients demonstrated less disease activity than at the outset, whereas CG patients either showed little change in these parameters or deteriorated during the study. Grip strength, which was initially similar in the two groups, improved in EG patients but decreased in CG patients, so that after 2 years a significant difference was noted between the two groups (p less than .05). Tendency to lose hand range of motion was also greater in CG than in EG patients. Some EG patients showed improvement in finger flexion deformities during the study. Furthermore, EG patients showed a greater tendency to acquire positive attitudes regarding themselves and family relationships. These results suggest that ongoing "team care" may be more efficacious than episodic use of AHPs in management of patients with mild rheumatoid arthritis.