Function after revision of failed total hip arthroplasty

Cemented revision total hip arthroplasties in patients younger than 55 years old. A multicenter evaluation of second-generation cementing technique

The results of all cemented first-time revisions in Sweden performed in patients younger than 55 years of age, during the period 1984-1986, are reported. The revisions were performed by the average orthopaedic surgeon in 25 hospitals distributed throughout Sweden. Second-generation femoral cementing technique was used. One third of the acetabular revisions were performed with pressurized cement. The reason for revision was aseptic loosening. Seventy hips in 68 patients were reviewed at an average follow-up period of 7 years (range, 4-10 years). The average age of the patients at the time of revision surgery was 47 years. Forty-eight cups and 57 stems were revised using cement. Survival analysis, with revision for aseptic loosening as the endpoint, suggests an overall 76% survival rate after 8 years. The survival rate for the cup was 80%, and for the stem, 85%. The radiographic evaluation revealed that the cement mantle was inadequate in many revisions. Localized osteolysis was rare. Clinical data were reported for 55 (53 patients) non-revised hips. Thirty-five hips were without pain or slightly painful. Forty patients limped when walking. Forty-three patients were satisfied with the revised hip. These results using second-generation femoral cementing technique are better than those reported with first-generation technique, but the failure rate in this young patient population is too high. The search for a more durable fixation in revision total hip athroplasty for young patients with long life expectancy is ongoing. These results emphasize that there is a need for centralization to gain experience in extended clinical research and to further improve surgical and cementing techniques.

Revision total hip replacement without trochanteric osteotomy

Revision total hip replacement has traditionally required a trochanteric osteotomy for successful cement removal and component reinsertion. In this study the authors have concluded that in most instances the revision total hip replacement procedure can be successfully performed without trochanteric osteotomy. The advantages are underscored by the high percentage of trochanteric complications with trochanteric osteotomy for revision total hip replacement and the ease of rehabilitation without trochanteric osteotomy. Also, improved functional results without trochanteric osteotomy were noted. The specific indications for the procedure included revision total hip replacement with ununited prior trochanteric osteotomy, revision total hip replacement with femoral shaft fractures, and revision total hip replacement with stem fractures requiring only acetabular revision. The contraindications to the procedure are fibrous union or ununited trochanteric osteotomy from prior total hip replacement, severe acetabular protrusion of the acetabular component, advanced myositis ossificans, ankylosis of the hip, and advanced proximal femoral osteoporosis. The operating room records, x-rays, and outpatient records of 63 total hip revisions in 52 patients were reviewed. There was a minimum 2-year follow up with a range from two years to seven years. The patients were divided into two groups, comparing 21 trochanteric osteotomized revisions to 44 with trochanteric sparing techniques. Both groups were analyzed for age, type of implant, intraoperative perforation of femur, intraoperative femoral shaft fractures, intraoperative cortical window, component malpositioning extraneous cement, intraoperative blood loss, operating time, postoperative leg length inequality, persistent abductor weakness, average first day of ambulation, wound infection, dislocation, nonunion of the trochanter, and postoperative pain. In the nonosteotomized group, there was a 21% decreased blood loss, a 14% decrease in persistent abductor weakness, a 14% decrease in subluxation and dislocation, a 30% decrease operating time and a 50% reduction in intraoperative femoral perforation. In the osteotomized group there were six cases of fibrous union of the greater trochanter, two cases requiring removal of broken wires for trochanteric bursitis. A detailed surgical technique and representative cases are presented. In carefully selected cases, revision total hip replacement is optimally performed without trochanteric osteotomy. Postoperative trochanteric problems of nonunion, broken wires, bursitis, and abductor weakness can effectively be eliminated by avoiding trochanteric osteotomy.(ABSTRACT TRUNCATED AT 400 WORDS)

The influence of total hip replacement on hip pain and the use of analgesics

The influence of total hip replacement (THR) on pain and use of analgesics was evaluated in 511 patients with McKee-Farrar and Brunswik prostheses. The mean age of the patients was 63.8 years and the mean follow-up time 4.2 years. The average grade of pain decreased from 1.8 to 4.9 as evaluated according to Charnley. The proportion of regular users of all analgesics decreased from 75% to 17% (P less than 0.001). Indomethacin was the most common preoperative drug and the proportion of its regular use decreased from 47 to 12% (P less than 0.001). The preoperative association which existed between the grade of pain and the regular drug users in each pain grade decreased more than expected by the preoperative figures. Postoperatively those with previous hip operations, McKee-Farrar prosthesis, one hip replaced, reapplications and removal of the prosthesis gave inferior results with respect to pain than those without previous surgery, with Brunswik prosthesis, both hips replaced and with the original prosthesis in situ. In addition to previous THR operations, type of the hip prosthesis, bilateral or unilateral surgery, primary or secondary coxarthrosis and reapplication of the prosthesis influenced the use of drugs. THR, however, brought a marked drop in the use of analgesics and this effect should be taken into account when assessing the costs and benefits of THR.