Transient subluxation of the femoral head after total hip replacement.

Dislocation is a common and well-studied complication after total hip replacement. However, subluxation, which we define as a clinically recognised episode of incomplete movement of the femoral head outside the acetabulum with spontaneous reduction, has not been studied previously. Out of a total of 2521 hip replacements performed over 12 years by one surgeon, 30 patients experienced subluxations which occurred in 31 arthroplasties. Data were collected prospectively with a minimum follow-up of two years. Subluxation occurred significantly more frequently after revision than after primary hip replacement, and resolved in 19 of 31 cases (61.3%). In six of the 31 hips (19.4%) the patient subsequently dislocated the affected hip, and in six hips (19.4%) intermittent subluxation continued. Four patients had a revision operation for instability, three for recurrent dislocation and one for recurrent subluxation. Clinical and radiological comparisons with a matched group of stable total hips showed no correlation with demographic or radiological parameters. Patients with subluxing hips reported significantly more concern that their hip would dislocate, more often changed their behaviour to prevent instability and had lower postoperative Harris hip scores than patients with stable replacements.

Fixation of Vancouver B1 peri-prosthetic fractures by broad metal plates without the application of strut allografts.

The use of allograft struts and cerclage wire, possibly augmented by plate fixation, for the treatment of Vancouver type-B1 peri-prosthetic fractures around a total hip replacement has been strongly advocated. We examined our results using plate fixation without allograft struts and compared them with the results of the use of struts alone or when combined with plate fixation. Of 20 consecutive patients with type-B1 fractures treated by open reduction and plate fixation, 19 were available for follow-up. The fractures healed in 18 patients with a mean time to weight-bearing of ten weeks (4 to 19). There were no cases of infection or malunion. Nonunion occurred in one patient and required a second plate fixation to achieve union. Safe, cost-effective treatment of Vancouver type-B1 fractures can be performed by plate fixation without the addition of cortical struts. This procedure may allow earlier weight-bearing than allograft strut fixation alone.

The Harris hip score: comparison of patient self-report with surgeon assessment.

Outcome evaluations are of primary concern in contemporary medical practice. Questionnaires are being used increasingly to provide input data for such outcomes evaluation. This study comprised 50 primary total hip arthroplasties in 36 patients who had undergone the procedure at least 12 months before enrollment. Each patient completed a self-report Harris Hip Score (HHS) 30 days before a formal evaluation by an independent orthopaedic surgeon that included a HHS. Comparison was made between the completed responses to the individual items on the self-report HHS and surgeon-assessed HHS. Concordance of item response and kappa statistic were calculated. Overall the self-report and surgeon-assessed HHS showed excellent concordance. The results of this study support the use of the HHS as a self-report instrument.

A simple and useful method of follow-up after diagnostic and therapeutic injections.

Accurate follow-up after diagnostic and therapeutic injections is extremely important in orthopedic surgery. We describe a simple, inexpensive, and convenient method of obtaining such follow-up in a precise and easy-to-interpret way. A case example is given in which this information was useful to the physician and patient.

Adhesive capsulitis of the hip after bilateral adhesive capsulitis of the shoulder.

Adhesive capsulitis of the hip is a not a common clinical presentation. We report a case of adhesive capsulitis of the hip in a patient with hypothyroidism and previous adhesive capsulitis of the shoulder who was receiving thyroid-hormone replacement. The adhesive capsulitis of both hip and shoulder were treated successfully with physical therapy. Orthopedic surgeons should be aware of this diagnosis and its association with shoulder adhesive capsulitis and thyroid dysfunction, to allow them to recognize it and intervene early.

Hepatitis C virus infection: review and implications for the orthopedic surgeon.

Hepatitis C virus (HCV), a single-stranded ribonucleic acid virus identified in 1989, is estimated to have infected 1%-2% of the United States population. The incidence of HCV in patients requiring orthopedic surgery may be as high as 5%. Surgeons and operating room personnel are at risk for blood-borne diseases transmitted during surgery. The orthopedic surgeon must be aware of viral infection with this pathogen for the safety of the entire operating room team. Further, screening for HCV is routinely done when a patient donates autologous blood prior to elective surgery, and the orthopedic surgeon is often the first or only physician informed of a positive result. The surgeon should know how to interpret the result, advise the patient, and incorporate the diagnosis of HCV into the plan for the proposed surgery. We will review the natural history, transmission, evaluation of, and current treatment for infection with this blood-borne virus.

Hepatitis C virus infection: knowledge in the orthopedic community.

A survey with 14 questions pertaining to the natural history, infectiveness, and diagnosis and treatment of hepatitis C viral infection was given to all practicing orthopedic surgeons in Portland, Maine. Possible responses were "true," "false," or "don't know" to the 14 statements. A question regarding any interest in learning more about the hepatitis C virus was also posed. Most (82%, 23/28) surgeons completed the questionnaire. A total of 72% of the responses were either wrong or marked "don't know"; most (83%) of the respondents wanted to know more about the infection about hepatitis C viral infection. Not only are orthopedic surgeons at risk for exposure to this virus, but also they are often the first to notify a patient of a positive result after routine hepatitis C testing of autologous predonated blood. Education programs and journal reviews should be directed toward this goal.

Acute periprosthetic fracture of the acetabulum associated with osteolytic pelvic lesions: a report of 3 cases.

Three cases of acute acetabular fracture around uncemented porous-coated acetabular components associated with osteolytic lesions of the pelvis are reported. In each case, the fracture occurred through an area of severe osteolysis that contributed to the structural failure of the pelvis. None of the fractures were associated with significant trauma, and none of the implants demonstrated evidence of loosening before the fracture. When marked pelvic osteolysis develops around the acetabular component of a total hip arthroplasty, the possibility of pelvic fracture must be considered. Total hip arthroplasty patients with osteolysis should be followed with radiographs at regular and frequent intervals. When osteolysis progresses, early intervention should be strongly considered because appropriate treatment may prevent fracture occurrence.

Periprosthetic fracture of the acetabulum during total hip arthroplasty in a patient with Paget's disease.

The case of a patient with Paget's disease of the pelvis (acetabulum) who had an intraoperative posterior wall fracture during the insertion of a noncemented acetabular component into an under-reamed acetabular bed of sclerotic Pagetoid bone is reported. This unusual complication has not, to my knowledge, been previously reported. Patients with sclerotic bone, like those with osteoporotic bone, may also be at risk for periprosthetic acetabular fractures when an under-reaming technique is used.

Patients' concerns prior to undergoing total hip and total knee arthroplasty.

OBJECTIVE: To document and examine the concerns patients have prior to undergoing primary total hip or total knee arthroplasty in a tertiary care center or an orthopedic private practice group. PATIENTS AND METHODS: In this prospective survey, 136 patients from a tertiary care center and 130 from an orthopedic private practice group completed a questionnaire covering 54 items regarding their concerns prior to undergoing primary total hip or total knee arthroplasty. Patients responded on a visual analog scale, and concern was ranked by mean responses (1, not concerned at all; 2, somewhat concerned; 3, very concerned; or 4, extremely concerned). RESULTS: Responses to only 6 items averaged scores higher than 1.9: pain immediately after the surgery (2.07), length of recovery (2.07), ability to walk as much as you wish (2.03), ability to return to recreational activities (1.97), ability to go up and down stairs (1.94), and risk of getting acquired immunodeficiency syndrome from a transfusion (1.92). Older patients (> or = 65 years) were less concerned than younger patients (< 65 years) in 34 of the 54 questions asked. Women were more concerned than men in 19 of the 54 questions asked. CONCLUSION: These data provide information that will be helpful in preoperative patient discussions and in development of educational materials for patients undergoing total hip or total knee arthroplasty.

Follow-up of intertrochanteric osteotomy of the hip during a 25-year period.

In 1984, in reporting follow-up on 67 hips in 61 patients who underwent intertrochanteric osteotomies for osteoarthritis of the hip, we found that between 12 and 15 years after osteotomy, 34% (23) of the 67 hips remained functional and the remainder had been converted to an arthroplasty. We now report on the fate of those osteotomies over a 25-year period. Ten patients with 10 osteotomies did not require an arthroplasty, having died without requiring conversion to total hip arthroplasty at an average of 18.3 years after osteotomy (range: 11 to 24.1 years). Two others were living at an average of 25.2 years after osteotomy without requiring conversion. Thus, for 18% of the hips, no further hip surgery was performed. For the remaining 55 hips in 49 patients, the osteotomy had served for an average of 9.8 years (range: 1.3 to 26.1 years) before requiring arthroplasty. The cumulative probability of osteotomy survival was 57.8% (standard error: 6.0%) at 10 years, 20.0% (standard error: 4.9%) at 20 years, and 5.7% (standard error: 2.9%) at 25 years by Kaplan-Meier survivorship analysis.

Posterior instability of the hip in an adult. A case report.

Dislocation of the hip except as a congenital or developmental lesion is not common, and the onset of symptoms because of posterior instability of the hip in an adult has not been reported previously. An adult patient who had benign congenital hypotonia as an infant and who presented with generalized ligamentous laxity and hip pain associated with recurring posterior subluxation of the hip is the subject of this report.

Enhancement of the value of hip questionnaires by telephone follow-up evaluation.

Errors, omissions, false understanding, and contradictory answers can compromise the use of questionnaires to generate follow-up data. To assess the utility of and effort involved in adding routinely a telephone interview to clarify the questionnaire, a study of total hip arthroplasty patients was carried out. Thirty-six patients with 37 primary and 13 revision total hip arthroplasties filled out a standardized questionnaire (which asks a number of demographic questions as well as questions that allow calculation of the Medical Outcome Studies [MOS] 36-Item Short-form Health Survey [SF-36], Western Ontario MacMaster Arthritis Center [WOMAC] osteoarthritis index, and Harris hip score) prior to returning for routine follow-up evaluation a minimum of 1 year after surgery. Two hundred thirty-two of a possible 4,350 responses (5.3%) were missing, contradictory, or answered with two or more answers on the questionnaire. Only eight such defects occurred following the telephone interview by a skilled orthopaedic surgeon, representing a significant reduction in these defects (P < .005). The average time of the telephone call was 2.8 minutes (range, 1-12 minutes), and the average number of attempts to contact the patient was 1.4 (range, 1-6). All questionnaire data and questionnaire data plus telephone data were compared with data obtained from a subsequent face-to-face interview by a different skilled orthopaedic surgeon who was blinded to the data from both the questionnaire and the telephone interview. It is demonstrated that a telephone call to follow up a standardized, self-administered questionnaire is a very effective way to augment the quality and quantity of questionnaire responses.

Wear of retrieved cemented polyethylene acetabula with alumina femoral heads.

Four yttrium-stabilized alumina ceramic-on-polyethylene articulations obtained from patients who were undergoing revision surgery for sepsis (3) or recurrent dislocation (I) between 34 and 73 months were evaluated to assess their in vivo wear performance. The annual volumetric wear of the acetabular components determined directly by a fluid displacement method ranged from 58 to 140 mm3/y. Scanning electron microscope examination of these four ceramic heads revealed similar surface damage in all cases from a variety of causes. These included differential granular wear (alumina grains and yttrium-stabilized alumina grains at different depths), multidirectional scratches with heaped up boundaries, and incompletely sintered grains, as well as the formation of craters and separation of grain boundaries. The femoral heads in this small series of revision cases show that yttrium-stabilized alumina ceramic heads may develop surface irregularities from either manufacturing processes or in vivo use. The wear rates of this type of alumina-on-polyethylene articulation up to the time of revision were not substantially different from those found in other metal-on-polyethylene articulations retrieved at revision surgery.

Can the western Ontario and McMaster Universities (WOMAC) osteoarthritis index be used to evaluate different hip joints in the same patient?

The Western Ontario and McMaster Universities (WOMAC) osteoarthritis index was originally designed for disease-specific evaluation of patients with lower extremity osteoarthritis (1988), but has not been validated for evaluation of more than one joint at the same time in the same patient. Thirty-three patients with bilateral total hip arthroplasties answered a questionnaire containing both the WOMAC osteoarthritis index and the Harris hip score (HHS) (1969), a joint-specific health status measure that was designed to include evaluation of bilateral hip arthroplasty. Differences in scores between hips were highly correlated for HSS and WOMAC total score (P = .0001), HHS pain and WOMAC pain subscores (P = .0001), and HHS function and WOMAC physical function subscores (P = .0001). WOMAC stiffness and HHS range of motion were not significantly correlated (P = .1308). In 23 patients (70%), both scores graded the hips with the same comparative outcome. When comparative outcomes were different, the average difference was less than 3 points (of 100 possible points). These results demonstrate that patients with bilateral hip arthroplasty can apply the WOMAC osteoarthritis index questions to individual hips at the same time as effectively as the joint-specific HHS questions.