The modern, hybrid total hip arthroplasty for primary osteoarthritis at the Hospital for Special Surgery.

We describe our technique and rationale using hybrid fixation for primary total hip arthroplasty (THA) at the Hospital for Special Surgery. Modern uncemented acetabular components have few screw holes, or no holes, polished inner surfaces, improved locking mechanisms, and maximised thickness and shell-liner conformity. Uncemented sockets can be combined with highly cross-linked polyethylene liners, which have demonstrated very low wear and osteolysis rates after ten to 15 years of implantation. The results of cement fixation with a smooth or polished surface finished stem have been excellent, virtually eliminating complications seen with cementless fixation like peri-operative femoral fractures and thigh pain. Although mid-term results of modern cementless stems are encouraging, the long-term data do not show reduced revision rates for cementless stems compared with cemented smooth stems. In this paper we review the conduct of a hybrid THA, with emphasis on pre-operative planning, surgical technique, hypotensive epidural anaesthesia, and intra-operative physiology.

[Cemented stems in hip arthroplasty: history and evolution]. / Vástagos cementados en la artroplastía de cadera: historia y evolución.

Despite the favorable results in cemented femoral fixation, there is a growing tendency to use uncemented stems. Due to the successful results of cementless acetabular fixation, the most versatile and easy implantation technique, to the misinformation about the "cement disease" and the poor performance of cemented stems with a rough surface. However, the advantages of cemented femoral fixation are numerous: it can be implemented successfully in femurs of diverse morphology and quality of bone, the surgeon can position the implant with the desired femoral anteversion, without it being determined by th natural femoral anteversion, very low incidence of intraoperative and postoperative fractures, allows the addition of antibiotics in patients with a history or predisposition to infection and minimal risk of postoperative leg pain during walking.

La planificación preoperatoria del reemplazo protésico en las fracturas de cadera del anciano / Preoperative planning of prosthetic replacement in hip fractures in the elderly

Existen numerosas publicaciones sobre la planificación preoperatoria en los reemplazos de cadera electivos con resultados satisfactorios. Sin embargo, ninguna de ellas se ha enfocado para el tratamiento de las fracturas de cadera. La planificación aumenta su importancia en estos pacientes debido a que la reconstrucción de la biomecánica de la cadera se ve dificultada por la ausencia de un fémur intacto.En este trabajo se describe un método de planificación preoperatoria basado en la reproducción de la biomecánica de la cadera contralateral no fracturada, siempre y cuando ésta sea anatómicamente normal. El plan registra medidas radiológicas que se reproducen durante la cirugía para lograr una reconstrucción de la biomecánica normal de la cadera fracturada (AU)

There are numerous reports on successful results for total hip replacement being achieved through preoperative planning. However, none of these reports have been focused on the treatment of hip fractures. Preoperative planning has increased importance in this group of patients as the correct biomechanical reconstruction of the hip is made more difficult by the absence of an intact femur.This report describes a method for preoperative planning based on the reproduction of the biomechanics of the intact contralateral hip, if and when it is anatomically normal. The plan is based on radiological measurements that are reproduced during surgery to achieve normal biomechanical reconstruction for the fractured hip (AU)

A new technique to improve cup inclination accuracy in primary total hip arthroplasty.

Accurate inclination and anteversion of the acetabular component is paramount to achieve a stable total hip arthroplasty, prevent prosthetic dislocation and minimize long- term wear. We present and evaluate a simple new technique to improve consistency in cup inclination during primary total hip arthroplasty, based on information available from the preoperative plan. The technique consists of assessing the distance and relationship between the inferomedial border of the acetabular cup and the inferomedial margin of the teardrop, with the use of a measuring probe. This simple surgical gesture improved consistency in cup inclination during total hip arthroplasty.;

Total hip replacement in identical twins with Scheie Mucopolysaccharidosis.

Investigation performed at the Hospital for Special Surgery, New York, USA Scheie Syndrome is an autosomal recessive metabolic storage disease with distinct skeletal findings known as "dysostosis multiplex". This paper reports on identical twins with Scheie Syndrome who required total hip arthroplasty for early osteoarthritis of the hip. The surgical approach and exposure was particularly demanding due to the stiffness imposed by the soft tissues arising from infiltration of glycosaminoglycans. The small femoral head and acetabulum limited the diameter of the acetabular component and subsequently the prosthetic head diameter that could be safely utilized without compromising the thickness of the polyethylene liner. Twenty-two millimeter heads with a standard polyethylene insert were therefore utilized in the two arthroplasties performed in 1998 in the first twin, and a 28 mm head with a highly cross linked polyethylene liner, in the arthroplasty performed on the second twin in 2003. This is a relevant issue considering that these patients required an arthroplasty at a young age. Hip arthroplasty relieved pain, improved ambulation and provided a better range of motion in our two patients. There were no peri-operative complications. Long-term survivorship of total hip replacement in this population is not yet known. (Hip International 2005; 15: 55-8).

Age affects the perception of limb length discrepancy in patients with and without a total hip arthroplasty.

The amount of lengthening or shortening that can be detected by patients before and after total hip arthroplasty has not been yet quantified. We studied the ability to detect limb length inequality in 194 patients with and without a total hip arthroplasty, match-paired for age and sex. None of the participants had clinical signs of lumbosacral pathology, spinal deformity, or fixed pelvic obliquity; and all had equal functional and actual limb length. The participants walked with shoes, with and without the addition of fixed insoles, to simulate 2.5, 5, 10 and 15 millimeters of shortening and lengthening of the tested limb. Lengthening and shortening were similarly detected. Younger individuals detected the differences better than older ones (p=0.001), and there was a significant correlation between the decade of life and the ability to detect a limb length discrepancy (r=-0.22; p=0.002). This study demonstrates that perception of limb length is affected by the age, with older individuals having less awareness of changes in limb length than younger ones. (Hip International 2004; 14: 249-53).

Inflatable pillows as axillary support devices during surgery performed in the lateral decubitus position under epidural anesthesia.

UNLABELLED: The lateral decubitus position can cause dependent shoulder discomfort or result in traction on the brachial plexus. We measured pressure beneath the dependent shoulder and lateral angulation of the cervical spine in patients positioned in the lateral decubitus position for total hip replacement under epidural anesthesia. Inflatable pillows (Shoulder-Float) beneath the chest wall and head reduced pressure beneath the dependent shoulder from 66 to 12 mm Hg (P < 0.001) and lateral angulation of the cervical spine from 14 degrees to 4 degrees (P < 0.001). In a randomized crossover study of a further 15 patients, the use of inflatable pillows resulted in significantly less pressure beneath the dependent shoulder and chest wall than either a gel-pad or a 1000-mL lactated Ringer's bag. Inflatable pillows placed beneath the chest wall and head in the lateral decubitus position provided lower pressure beneath the dependent shoulder than other support devices and facilitated alignment of the cervical spine. IMPLICATIONS: When patients lie on their side, this results in pressure beneath the shoulder and tilting of the head and neck to one side. These problems were effectively corrected with an inflatable pillow (Shoulder-Float).

Effective bactericidal activity of tobramycin and vancomycin eluted from acrylic bone cement.

We studied the bioactivity of vancomycin and tobramycin eluted from methylmethacrylate bone cement. Aliquots of the drainage were obtained at 1, 6, 12 and 24 hours following total hip prosthetic implantation with vancomycin-tobramycin-loaded cement in 3 patients. The samples were analyzed with fluorescence polarization immunoassay and bioassay, using group B streptococcus for vancomycin and Escherichia coli for tobramycin. These bacteria were selected due to the effectiveness of vancomycin and poor effectiveness of tobramycin against group B streptococcus and conversely with E. coli. The immunodetection of vancomycin averaged 14 (1 hour), 9 (6 hours), 10 (12 hours) and 11 microg/mL (24 hours). The bioassay averaged 47, 36, 79 and 41 microg/mL (p = 0.03). The immunodetection of tobramycin averaged 43, 21, 18 and 14 microg/mL; and bioassay 30, 15, 15 and 12 microg/mL (p = 0.1). Both antibiotics eluted with a highly effective bactericidal activity. Our findings indicate that the presence of tobramycin has a synergistic-like effect on the bactericidal activity of vancomycin, which has not been previously reported. We recommend a combination of vancomycin and tobramycin with cement for the treatment of orthopedic infections caused by gram-positive organisms.

The effect of preoperative donation of autologous blood on deep-vein thrombosis after total hip arthroplasty.

We have assessed the effect of the donation of autologous blood and the preoperative level of haemoglobin on the prevalence of postoperative thromboembolism in 2043 patients who had a total hip arthroplasty. The level of haemoglobin was determined seven to ten days before surgery and all patients had venography of the operated leg on the fifth postoperative day. The number of patients who had donated autologous blood (1037) was similar to that who had not (1006). A significant decrease in the incidence of deep-vein thrombosis (DVT) was noted in those who had donated blood preoperatively (9.0%) compared with those who had not (13.5%) (p = 0.003). For all patients, the lower the preoperative level of haemoglobin the less likely it was that a postoperative DVT would develop. Of those who had donated blood, 0.3% developed a postoperative pulmonary embolism compared with 0.7% in those who had not, but this difference was not statistically significant. No significant difference was found in the requirements for transfusion between the two groups.

Pigmented villonodular synovitis of the hip: 2- to 23-year followup study.

Pigmented villonodular synovitis affecting the hip is rare. Seven new patients are presented and 117 cases from the literature are reviewed. Among the new patients, two refused treatment; in one patient, severe bone loss was observed after a radiographic followup of 21 years; the second patient showed no radiographic changes 2 years after diagnosis. One patient underwent a synovectomy and had a recurrence 9 years later, requiring a total hip replacement. The remaining four patients underwent synovectomy and primary total hip replacement with no recurrences detected after an average followup of 13 years (range, 2-23 years). Among 117 cases published, 62 patients (53%) did not have enough information for analysis. A metaanalysis using the remaining 55 patients was done. In nine patients (16%; nine of 55) the diagnosis was made with a preoperative biopsy. Treatment consisted of synovectomy in 26 patients (47%; 26 of 55), arthroplasty in 24 (43%; 24 of 55), arthrodesis in two (4%; two of 55), and hindquarter amputation in a patient misdiagnosed as having synovial sarcoma (2%; one of 55). Two patients (4%; two of 55) were not treated. Ten patients had a recurrence (19%; 10 of 53); nine in the synovectomy group (35 %; nine of 26) and one in the joint replacement group (4%; one of 24). Synovectomy is recommended for patients with preserved articular cartilage and total hip replacement is recommended for patients with secondary osteoarthritis. Removal of all macroscopic tumors including careful curetting of the osteolytic lesions should be done as they may constitute a source of recurrence.

Dislodgment of polyethylene liners in first and second-generation Harris-Galante acetabular components. A report of eighteen cases.

BACKGROUND: Dislodgment of the polyethylene liner is an increasingly common complication following total hip arthroplasty. The purposes of this study are to present the results in a series of patients with this complication and to analyze the mode of failure. METHODS: Between November 1995 and January 2001, eighteen patients who had had a total hip arthroplasty presented with dislodgment of the polyethylene liner from a Harris-Galante metal acetabular shell. The medical records, radiographs, operative notes, and retrieved components were reviewed. In addition, scanning electron microscopy was used to study the fractured surfaces in a shell that had four broken tines. RESULTS: The components had been in situ for an average of seven years (range, three to eleven years). Seventeen components were second generation, and one was first generation. Symptoms developed spontaneously in sixteen patients, during sexual intercourse in one, and following a fall on the hip in one. Radiographs showed eccentric positioning of the head in all of the hips and broken tines in six. All of the shells were well fixed. Treatment consisted of revision of the shell in four patients, exchange of the liner in four, cementation of a new liner into the shell in seven, and cementation of an all-polyethylene cup in three. The liners had severe damage of the rim. Scanning-electron microscopy of the fractured surfaces of four tines revealed a fatigue pattern. CONCLUSIONS: We believe that, as the liner wears and becomes loose because of an inadequate locking mechanism, progressive micromotion occurs and the load increases on the polyethylene rim until it deforms and/or fractures. Subsequently, nothing prevents the liner from rotating out of the shell. As this mechanism of failure appears to include fatigue failure of the locking tines and wear of the liner, this complication is likely to increase as the components age in situ.

Bone density adjacent to press-fit acetabular components. A prospective analysis with quantitative computed tomography.

BACKGROUND: The status of periprosthetic bone stock is an important concern when revision total hip arthroplasty is undertaken. Remodeling of periprosthetic femoral bone after total hip arthroplasty has been studied extensively, and the phenomenon of femoral stress-shielding has been well characterized. Finite element analysis and computer-simulated remodeling theory have predicted that retroacetabular bone-mineral density decreases after total hip arthroplasty; however, remodeling of periprosthetic pelvic bone in this setting has yet to be well defined. This study was conducted to evaluate the short-term natural history of periacetabular bone-mineral density following primary total hip arthroplasty. METHODS: Periacetabular bone-mineral density was studied prospectively in a group of twenty-six patients who underwent primary hybrid total hip arthroplasty for the treatment of advanced osteoarthritis. Density within the central part of the ilium (directly cephalad to a press-fit acetabular component) was assessed with serial quantitative computed tomography. Baseline density was measured within the first five days following the total hip arthroplasty. Ipsilateral density measurements were repeated at an average of 1.28 years postoperatively. Density values at corresponding levels of the contralateral ilium were obtained at both time-points in all patients to serve as internal controls. RESULTS: Bone-mineral density decreased significantly (p< or =0.001) between the two time-points on the side of the operation. The mean absolute magnitude of the interval density reduction (75 mg/cc) was greatest immediately adjacent to the implant (p<0.001), but it was also significantly reduced (by 35 mg/cc) at a distance of 10 mm cephalad to the implant (p = 0.001). Relative declines in mean density ranged from 33% to 20% of the baseline values. No focal bone resorption (osteolysis) was detected at the time of this short-term follow-up study. With the numbers available, no significant interval alteration in bone-mineral density was found on the untreated (internal control) side (p> or =0.07). CONCLUSIONS: We suggest that the observed decline in bone-mineral density represents a remodeling response to an altered stress pattern within the pelvis that was induced by the presence of the acetabular implant. This finding corroborates the predictions of finite element analysis and computer-simulated remodeling theory. It remains to be seen whether this trend of atrophy of retroacetabular bone stock will continue with longer follow-up or will ultimately affect the long-term stability of press-fit acetabular components.

The safety and efficacy of intraoperative heparin in total hip arthroplasty.

A single dose of unfractionated heparin (15 U/kg), administered intravenously before surgery on the femur suppresses thrombogenesis during total hip replacement. Nine hundred eighty-nine patients (1021 hips) who received one dose of intraoperative heparin with hypotensive epidural anesthesia were followed up prospectively for 3 months. Asymptomatic deep vein thrombosis assessed by ultrasound in the first 198 consecutive patients showed an incidence of 7.1% (14 of 198). The incidence of clinical deep vein thrombosis in the subsequent 791 patients was 0.88% (seven of 791). Symptomatic pulmonary embolism occurred in 0.5% (five of 989). No patients died and there was one major bleeding episode. Based on this favorable experience, intraoperative heparin appears safe and efficacious as thromboembolic prophylaxis.

Warfarin-associated intracapsular hemorrhage causing an acutely painful total hip arthroplasty: a rare complication of prolonged anticoagulant therapy.

Hemorrhage is the most prevalent adverse effect of oral anticoagulant therapy. The incidence of bleeding complications is related to the duration and range of therapy. A patient on long-term warfarin anticoagulation developed a spontaneous intracapsular bleed into a total hip arthroplasty that had been implanted 11 years before. Joint aspiration allowed early recognition with immediate resolution of symptoms. Diagnosis and treatment of this rare complication are discussed with a review of the literature.

Pneumatic compression hemodynamics in total hip arthroplasty.

A crossover study was performed to evaluate the effect of several pneumatic compression devices and active dorsoplantar flexion in 10 patients who underwent total hip arthroplasty. Using the Acuson 128XP/10 duplex ultrasound unit with a 5-MHz linear array probe, peak venous velocity and venous volume were assessed above and below the greater saphenous vein and common femoral vein junction. A computer generated randomization table was used to determine the order of the test conditions. The pneumatic compression devices evaluated included two foot pumps, one foot and calf pump, one calf pump, and three calf and thigh pumps. Statistical analyses included analysis of variance and analysis of variance with covariance between devices and patients. The covariates tested were the baseline measurements and the order in which the devices were tested. Differences between devices relate in part to the frequency and rate of inflation and the location and type of compression. Pulsatile calf and foot and calf pneumatic compression with a rapid inflation time produced the greatest increase in peak venous velocity, whereas compression of the calf and thigh showed the greatest increase in venous volume. Because patient and nursing compliance is essential to the success of mechanical prophylaxis for thromboembolic disease, the more simple, yet efficacious, devices that are easier to apply and less cumbersome appear to have a greater likelihood of success. In the active and alert patient, active dorsoplantar flexion should be encouraged.

The arthroscopic drainage, irrigation, and débridement of late, acute total hip arthroplasty infections: average 6-year follow-up.

We present our experience with arthroscopy for the treatment of late, acute periprosthetic hip infections in 8 consecutive patients, treated from 1989 to 1994. After a hip aspiration confirmed the presence of bacterial infection, all patients underwent prompt arthroscopic treatment, which consisted of drainage, lavage, and debridement. Postoperatively, patients were given 2 to 6 weeks of intravenous antibiotics, followed by long-term oral antibiotic suppression. At a mean follow-up of 70 months (range, 29-104 months), no recurrence of infection occurred. No progressive radiographic loosening was noted. Based on this initial study, we believe that arthroscopic irrigation and debridement can benefit well-selected patients who suffer late, acute hip periprosthetic infections. Effective treatment requires early diagnosis, prompt arthroscopic debridement, well-fixed components, a sensitive microorganism, and patient tolerance to and compliance with the antibiotic therapy.

The incidence of venous thromboembolism after total hip arthroplasty: a specific hypotensive epidural anesthesia protocol.

We retrospectively reviewed all consecutive unilateral primary total hip arthroplasty (THA) procedures performed by 3 attending surgeons on the Arthroplasty Service at our institution from January 1, 1990, to December 31, 1993. All surgery was performed under a specific hypotensive epidural anesthesia protocol. Hypotensive epidural anesthesia at our institution provides a lower level of hypotension (mean arterial pressure of 50-60 mmHg) as compared to hypotensive anesthesia used more generally around the world (mean arterial pressure >70 mmHg). For each patient, hospital and postdischarge office records for a minimum of 3 months after surgery were reviewed for the type of postoperative screening test, the incidence of deep venous thrombosis (DVT), and the incidence of symptomatic pulmonary embolism (PE). Overall, 2,592 primary unilateral THAs were performed with 78.6% (2,037 of 2,592) of patients receiving a venogram. Our protocol for thromboembolic disease prophylaxis in these patients included aspirin postoperatively as well as antithromboembolic disease stockings and early ambulation (24-48 hours postoperatively). The 555 patients who did not receive venography were managed with a different protocol that included warfarin postoperatively as well as antithromboembolic disease stockings and early ambulation. This high-risk group consisted of patients who received warfarin preoperatively (ie, cardiac valve) or patients with a history of DVT who were to receive warfarin postoperatively, regardless of venography result. Overall, DVT was diagnosed in 10.3% (210 of 2,037) of patients who had a venogram. Of these patients who had venography, 2.3% (46 of 2,037) had an isolated proximal DVT; 6.0% (123 of 2,037), a distal DVT; and 2.0% (41 of 2,037), both a proximal and a distal DVT. Of the 87 cases of proximal DVT identified, 60.9% (53 of 87) were femoral DVT; 18.4% (16 of 87), popliteal DVT; and 20.7% (18 of 87), both femoral and popliteal DVT. Of the 164 distal DVT, 68.3% (112 of 164) were major calf DVT and 31.7% (52 of 164) were minor calf DVT. The overall incidence of major venous thrombosis (sum of proximal and major calf thrombi) was 9.8% (199 of 2,037) in patients who had venography. Ventilation-perfusion scanning was used selectively in patients symptomatic for PE. Overall, symptomatic PE was diagnosed by ventilation-perfusion scan in 1.0% (26 of 2,592) of patients, with 0.58% (15 of 2,592) of patients having an in-hospital PE. Of the 15 patients who had an in-hospital PE, 11 patients had a venogram, and only 3 of 11 were positive. Late symptomatic PE was defined from discharge (mean, 7 +/- 2 days) to 3 months after discharge from the hospital and occurred in 0.42% (11 of 2,592) of patients. One of the 11 late symptomatic PEs was fatal. In the overall study, this represents 0.04% (1 of 2,592) fatal PE. Of the 11 patients with a late symptomatic PE, 10 had venograms in the hospital, and all 10 were negative for DVT. Overall, in the patients with a positive venogram, the incidence of symptomatic PE was 1.4% (3 of 210), whereas in the patients with a negative venogram, the incidence of symptomatic PE was 0.44% (8 of 1,827). At our institution, patients who undergo primary THA performed with hypotensive epidural anesthesia, postoperative aspirin, antithromboembolic disease stockings, and early ambulation have a low risk for thromboembolic disease.

Dose response of intravenous heparin on markers of thrombosis during primary total hip replacement.

BACKGROUND: Thrombogenesis in total hip replacement (THR) begins during surgery on the femur. This study assesses the effect of two doses of unfractionated intravenous heparin administered before femoral preparation during THR on circulating markers of thrombosis. METHODS: Seventy-five patients undergoing hybrid primary THR were randomly assigned to receive blinded intravenous injection of either saline or 10 or 20 U/kg of unfractionated heparin after insertion of the acetabular component. Central venous blood samples were assayed for prothrombin F1+2 (F1+2), thrombin-antithrombin complexes (TAT), fibrinopeptide A (FPA), and D-dimer. RESULTS: No changes in the markers of thrombosis were noted after insertion of the acetabular component. During surgery on the femur, significant increases in all markers were noted in the saline group (P < 0.0001). Heparin did not affect D-dimer or TAT. Twenty units per kilogram of heparin significantly reduced the increase of F1+2 after relocation of the hip joint (P < 0.001). Administration of both 10 and 20 U/kg significantly reduced the increase in FPA during implantation of the femoral component (P < 0.0001). A fourfold increase in FPA was noted in 6 of 25 patients receiving 10 U/kg of heparin but in none receiving 20 U/kg (P = 0.03). Intraoperative heparin did not affect intra- or postoperative blood loss, postoperative hematocrit, or surgeon's subjective assessments of bleeding. No bleeding complications were noted. CONCLUSIONS: This study demonstrates that 20 U/kg of heparin administered before surgery on the femur suppresses fibrin formation during primary THR. This finding provides the pathophysiologic basis for the clinical use of intraoperative heparin during THR.