Harris Hip Rating Research Articles

The 3—2-6-year results of a modular noncemented low-bending stiffness hip implant: A preliminary study

A review of the 3–6-year clinical and radiographic results of a modular noncemented stem has been carried out. This is a three-part stem consisting of a head, stem, and proximal sleeve. The stems are split distally like a clothespin in the coronal plane to reduce bending stiffness. No mechanical failures have occurred, including no bead separation from the single-layer porous-coated taper lock sleeves. Of the 48 cases, 13 had smooth stems distally while the rest were fluted. Five of the fluted stems were solid, that is, nonsplit. Clinical results are 93.7% excellent, 4.2% good, and 2.1% poor with the Harris hip rating. There have been no revisions. Thigh pain incidence with the distal split stem was 4.4%. Radiographic follow-up evaluations revealed nonprogressive radiolucency around one of the ingrowth sleeves. When inserted in varus the smooth stems developed some radiolucency around the distal end. Fluting of the stem appeared to prevent this.

Total Hip Arthroplasty in Juvenile Rheumatoid Arthritis

A series of 17 primary total hip arthroplasties in patients with juvenile rheumatoid arthritis (JRA) were performed at a mean age of 18 years with an average follow-up period of 9.3 years. There were 13 cemented prostheses and four noncemented. All patients were satisfied with their hip surgery and reported either slight or no hip pain according to the Harris hip rating system. Ambulation improved postoperatively and all but one patient was at least a limited community ambulator (able to ambulate short distances outside the home with crutches, walker, or cane). Roentgenogram evaluation showed five cemented hips that were believed to be definitely loose with impending failure. All were functioning well. One acetabular component has been revised to date. No femoral components have been revised. The four noncemented hips with an average follow-up period of five years were functioning well.

The porous-coated anatomic total hip prosthesis, inserted without cement. Results after five to seven years in a prospective study.

The results of 100 primary arthroplasties with a porous-coated anatomic total hip prosthesis that were performed consecutively in ninety-one patients were followed prospectively for five to seven years after the operation or until death. Clinical Harris hip ratings and anteroposterior and lateral radiographs were made preoperatively, several times in the first postoperative year, and at annual intervals thereafter. Average sequential hip ratings were maintained between 92 and 93 points during the follow-up interval. Pain in the thigh, which did not limit function, was recorded at the yearly examinations from the first to the fifth year. After one year, 18 per cent of the thighs were painful, and in succeeding years, 19 per cent, 23 per cent, 26 per cent, and 15 per cent were painful. Radiographs demonstrated that the fixation of the femoral component was by ingrowth of bone in 94 per cent of the hips, by stable fibrous fixation in 1 per cent, and by unstable fibrous fixation in 5 per cent, according to the criteria of Engh et al. By five years, 6 per cent of the acetabular components had migrated, and 5 per cent of the femoral components had subsided. Two acetabular components had been revised, and one revision of a femoral component was pending. The evaluated device was an early-generation prosthesis that was designed for insertion without the use of cement. Further study is necessary to determine the long-term durability of the prosthesis-bone interface.

A prospective study of 100 consecutive harris-galante porous total hip arthroplasties: 2–5—Year results

This is a prospective study of the authors' first 100 Harris-Galante porous total hip arthroplasties (THA) that were followed for 2–5 years. The mean age of the 83 patients was 43 years. Using the Harris hip rating system, 80% of the hips were rated as excellent, 13% as good, 5% as fair, and 2% as poor at final evaluation. Eighty percent of the hips had no pain, 11% had slight or occasional pain, 8% had activity-related pain, and 1% had moderate pain. Eighty-seven percent of the hips had no limp, 8% had a slight limp, and 5% had a moderate limp. One femoral component, placed as a conversion of a loose bipolar hemiarthroplasty, has been removed for loosening. Two other hips have been reoperated, one for lengthening the femoral neck and one for changing the acetabular liner. There were no problems with acetabular screw fixation and no component migrated. Only two hips had 1 mm nonprogressive radiolucent lines in all three zones. Femoral component subsidence of 3 or more mm was measured in 16 hips, but was progressive in only 1. Radiolucent and radiodense lines were frequently seen in the nonporous coated regions of the femoral stem. Loss of proximal medial femoral bone density was seen in 59% of hips, and calcar resorption was seen in 16% of hips. Although the clinical results of this uncemented implant system were good or excellent in 93% of hips, the high incidence of femoral component subsidence is worrisome.

TOTAL HIP ARTHROPLASTY FOR PROTRUSIO ACETABULI: A 3- TO 9-YEAR FOLLOW UP OF THE HEYWOOD TECHNIQUE

Thirty-five total joint arthroplasties (34 patients) were performed in patients who had protrusio acetabuli. Twenty-nine percent of the patients had acetabular protrusio of grade I, while 71% had grade II and grade III protrusio. The mean follow up was 4 years (range: 3 to 9). Cemented acetabular components were used in 11 hips; 24 hips received an uncemented porous coated acetabular component. The patient evaluations included preoperative and postoperative Harris Hip Ratings and standard radiographs. In all cases, the medial wall defect was reconstructed with the solid autogenous femoral head as described by Heywood. The mean preoperative Harris Hip Rating was 45 (range: 30 to 60 points), and the postoperative mean was 85 (range: 70 to 100 points). Radiographically, the preoperative protrusio measured a mean of 8.8 mm (range: 6 to 18 mm), and the mean postoperative placement of the femoral head was 10 mm lateral to Kohler's line (range: 6 to 13 mm). There were no acetabular component failures and no acetabular bone graft resorptions. All autogenous grafts were incorporated to the host radiographically by 1 year post-surgery. This study corroborates previous work which suggests that medial-placed bone grafting is not resorbed and consolidates with the host bone. We find this technique extremely useful in dealing with this technical problem.

A relationship between stem orientation and function following total hip arthroplasty

A retrospective gait analysis of patients with cemented Charnley-Mueller total hip arthroplasties was conducted to determine if functional differences exist between patients with femoral stems placed in varus and valgus orientations. Twenty patients and ten normals were studied using gait analysis to quantify joint motion and moments during level walking. In addition, a radiographic analysis of stem placement and mechanics of the reconstructed hip was performed on the total hip patients. All patients selected for the study had excellent clinical results on the basis of a score of 95 or better on the Harris hip rating form. The patients were divided into two subgroupings on the basis of stem orientation. A valgus group was defined as having a valgus stem orientation relative to the femoral shaft, with the femoral head-shaft offset shortened by 5 mm or greater compared to the contralateral unoperated hip, while the varus group was defined on the basis of having a varus stem orientation relative to the femoral shaft, with the femoral head-shaft offset restored to normal or greater than normal. A difference in gait was found between the varus and valgus patient groupings. The varus group had abnormal gait characteristics in the range of hip motion, the flexion-extension moments at the hip, and stride length. The patients in the valgus group had statistically normal gait. The differences in the gait characteristics were interpreted as an attempt to alter the forces on the hip joint for patients in the varus group. These alterations were possibly an early indication of a subtle adaptation in patients with varus-placed femoral stems since, historically, a greater percentage of the patients in this configuration, retrospectively, go on to mechanical failure. The results of this study suggest the potential use of gait analysis as a method of screening procedural or implant design changes in total joint arthroplasties. Retrospective clinical studies take a considerable amount of time before differences among design criteria or surgical procedures can be identified. Most design changes work well for the short term, and thus, a method of quantitatively separating designs, such as quantitative gait analysis, would be extremely useful in the evaluation of new procedures and designs.

Total hip replacement with cemented, uncemented, and hybrid prostheses. A comparison of clinical and radiographic results at two to four years.

One hundred and thirty-one patients who had 144 cemented or uncemented hip prostheses were followed prospectively for two to four years. A cemented or a hybrid prosthesis (consisting of a cemented femoral component and an uncemented acetabular component) was used in men older than seventy years, in women older than sixty years, and in younger patients in whom adequate initial fixation could not be obtained without cement. Uncemented, porous-surfaced implants were used in all other patients. The over-all clinical results were similar for the three groups. For the fifty-two hips that had a cemented prosthesis, the mean total Harris hip rating was 91 points and the score for pain, 42 points; for the twenty-seven hips that had a hybrid prosthesis, 90 and 43 points; and for the sixty-five hips that had an implant allowing ingrowth of bone in both the acetabulum and the femur, 95 and 43 points. Two prosthetic stems that were designed to allow ingrowth of bone had aseptic loosening; one was revised. Pain in the thigh, usually slight and not disabling, occurred at one year in 24 per cent of the patients in whom a femoral component allowing ingrowth had been used; the prevalence of pain then declined. The incidences of migration of the components and of radiolucent lines were greater in the acetabula that had a cemented component than in those that had a cup allowing ingrowth of bone.

Results in Patients with Craniocerebral Trauma and an Operatively Managed Acetabular Fracture

Results in 23 patients with significant craniocerebral trauma (Glasgow Coma Scale less than or equal to 10) and displaced acetabular fracture requiring surgery were reviewed after a minimum follow-up of 1 year. Despite a postoperative anatomic reduction in all but one case, clinical outcome for these hips was poor, with an average Harris hip rating of 59. Patients older than 40 years had a significantly poorer outcome than did younger patients (p = 0.004). Postoperative problems occurred in 70% of patients (n = 16); the largest portion of these represented symptomatic heterotopic bone, which occurred in 61%. None of the four patients who had an anterior ilioinguinal surgical approach had symptomatic heterotopic ossification. The average Glasgow outcome score was 3.9 out of 5, and 20 of the 23 patients, despite a prolonged convalescence, were able to return to independence and self-care. The authors conclude that patients with combined significant craniocerebral trauma and an operatively managed displaced acetabular fracture are likely to have compromised hip function despite a well-executed osteosynthesis. This was especially true for those patients over age 40 in this series. The authors suggest that if the fracture pattern permits it, the operative management of the acetabular fracture in these patients be by an anterior ilioinguinal approach, so as to minimize the formation of heterotopic bone.

Femoral Head Autografting With Total Hip Arthroplasty for Lateral Acetabular Dysplasia

The use of a lateral femoral head autograft with total hip arthroplasty is an effective method to treat moderate to severe acetabular dysplasia with an excellent chance of satisfactory results. The operation was performed on 42 hips in 37 patients over a 12-year period. The average follow-up period was 5.7 years, with none shorter than two years. A posterior approach was used with no trochanteric osteotomy in 38 hips. Average operative time was 133 minutes and average blood replacement was 435 ml. All grafts united. Average Harris hip ratings increased from a preoperative 39.1 points to a postoperative 89.8 points. Complications included three loose femoral components (one definite, one probable, and one possible), two loose acetabular components (one definite and one possible), one Class IV heterotopic ossification, and two cases of thrombophlebitis. Two patients required revision surgery for loosening. To date, there are no infections, dislocations, pulmonary emboli, nerve palsies, or deaths.

A porous polyethylene-coated femoral component of a total hip arthroplasty

The authors report their clinical experience with a femoral titanium stem with 3 mm of polyethylene (the outer 1.5 mm being porous) that was developed to function as a low-modulus type of prosthesis in an attempt to match the modulus of the prosthesis to the bone. The authors analyzed 223 of these stems of two different cross-sectional geometries: square (129) and round (94). Of these, 14 square and 5 round stems were subsequently replaced and all revealed only a fibrous ingrowth. Despite an average 82.4 Harris hip rating, 20% of the recipients still reported pain. For this reason the authors do not believe that the current design is adequate for the femoral component of a total hip arthroplasty.

Salvage total hip reconstruction in patients with major acetabular bone deficiency using structural femoral head allografts

We evaluated 38 hip reconstructions in 36 patients at a mean follow-up of 5.9 years (range 4 to 9.1) after femoral head allografts had been used to augment severely deficient acetabular bone stock. The patients were all relatively young and had many previous operations. Their pre-operative Harris hip rating averaged 46 points (range 18 to 73). All the allografts united and there were no infections. However, 12 acetabular components (32%) became loose; six of these had needed revision using the healed allograft, and two hips had required resection arthroplasty. The 30 surviving hips had a mean Harris hip score of 82 points. Some radiographic evidence of graft resorption was seen in 23 hips, though this was mild in 17. The extent of cover provided by the allograft and the severity of graft resorption both correlated with acetabular loosening. Although structural allografts had allowed successful hip reconstructions in many of these patients with major bone loss, the failure rate had increased from zero at four years to 32% at six years; clearly they provide only a short-term solution.

Results of Total Hip Reconstruction Using Acetabular Mesh in Patients With Central Acetabular Deficiency

Fifty-three patients (54 hips) treated with cemented total hip reconstruction with the aid of an acetabular mesh made of Vitallium (Howmedica Inc., Rutherford, New Jersey), a cobalt-chrome molybdenum alloy, to reinforce the medial cement for deficient bone stock in the central acetabular region, were evaluated at an average follow-up period of 6.8 years (range, five to ten years). Thirty of these patients (30 hips) were treated with revision operations for either failed cup arthroplasty (ten hips), failed endoprosthesis (six hips), or failed total hip arthroplasty (14 hips) and presented difficult problems for acetabular reconstructions. Although none of the hips required reoperations for acetabular loosening, three patients showed roentgenographic evidence of acetabular component migration, and three others showed signs of impending failure of fixation of the acetabular component. The overall mean Harris hip rating improved from a mean of 43 points preoperatively to 87 points at follow-up evaluations. The extent of bone loss in the central acetabular region had the greatest influence on the results of acetabular fixation at the follow-up evaluation. None of the hips with intact medial acetabular cortex had roentgenographic evidence of failure of fixation, while 14% of the hips with medial cortical defects measuring less than 1 cm, and 75% of the hips with larger defects developed acetabular component loosening. The results of total hip reconstruction using acetabular mesh were unsatisfactory in patients with moderate or severe central acetabular bone loss and defects through the medial wall.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of a bipolar prosthesis with bone grafting in revision surgery

A bipolar prosthesis can be used in revision hip surgery, permitting the use of bone-grafting techniques to restore bone stock. This procedure can relieve pain on the acetabular side of the joint and can enhance bone stock for another conversion if necessary. A review of 19 hips operated on in this manner revealed that after two years, the average postoperative Harris Hip Rating was 84, compared with 44 preoperatively. At follow-up, there were no pending revisions, and bone graft incorporation was seen in all cases.

Total Joint Arthroplasty for Steroid-induced Osteonecrosis in Cardiac Transplant Patients

Ten cardiac transplant patients have had bilateral total hip or knee surgery for treatment of osteonecrosis secondary to corticosteroid immunosuppression. Nine had bilateral total hip arthroplasty and one had bilateral total knee arthroplasty for osteonecrosis of the tibial plateaus. The only immediate postoperative complication was in a single hip patient who had a nonfatal pulmonary embolism. Two patients died from cardiovascular causes; the remaining eight had excellent results from arthroplasty, with an average Harris hip rating of 95 at a mean follow-up period of 34 months. No patient had required revision surgery and radiographic follow-up examination has revealed no evidence of loosening of any of these cemented arthroplasties. One patient developed a late hematogeneous sepsis of one hip seven years after replacement from atypical mycobacterium three months following renal transplantation, which was done 11 years after cardiac transplantation. Total joint arthroplasty has resulted in excellent clinical and radiologic results in this patient population. Despite the increased risks of major surgery in these immunocompromised transplant recipients, total joint arthroplasty appears to be a safe and effective method of treatment of osteonecrosis of the hip.

Femoral head autografting to augment acetabular deficiency in patients requiring total hip replacement. A minimum five-year and an average seven-year follow-up study.

Adults who have osteoarthritis that is secondary to mild congenital dysplasia can be treated with total hip replacement using customary techniques. Those who have severe acetabular dysplasia or total congenital dislocation usually require augmentation of acetabular bone stock in order to carry out the total hip replacement. We reviewed the results of forty-seven total hip replacements in thirty-eight patients (age range, sixteen to sixty-eight years; average age, forty-seven years) who required autogenous grafting with bone from the femoral head for severe acetabular deficiency. The average length of follow-up was 7.1 years (minimum, five years). All grafts united. The average preoperative Harris hip rating was 46 points and the average postoperative rating was 74 points. Five hips (approximately 10 per cent) had a failure that required reoperation; four hipshad aseptic loosening of the acetabular component and in the fifth sepsis developed after a reoperation to reattach the greater trochanter. For the remaining forty-two hips, the average postoperative Harris hip rating was 78 points. Six additional sockets (approximately 15 per cent) were definitely loose by radiographic criteria, making a total of ten hips (approximately 20 per cent) with definite aseptic loosening of the acetabular component. The major factors that contributed to this aseptic loosening were complexity of the surgical procedure, necessity for a graft, lack of a small-sized metal-backed acetabular component, young age, obesity, lack of posterior support, and resorption of the graft. Dislocation was common, occurring in five (approximately 10 per cent) of the hips.(ABSTRACT TRUNCATED AT 250 WORDS)

Allograft reconstruction of the acetabulum during revision total hip arthroplasty. Clinical, radiographic, and scintigraphic assessment of the results.

In twenty-one hips of twenty-one patients, the acetabulum was reconstructed using allografts during revision of a total hip arthroplasty. The patients' average age at the time of revision was 64.3 years (range, nineteen to eighty-six years). At an average follow-up of 3.5 years (range, two to five years), three patients had died of causes unrelated to the hip reconstruction, and one had been lost to follow-up. In the other seventeen, the average Harris hip rating was 89 points (range, seventy to 100 points) at follow-up. In one patient the allograft collapsed, so that revision was required. Two patients had asymptomatic progressive radiolucencies at the cement-bone interface of the reconstructed acetabulum, and another had a 1.5-millimeter-wide lucency at the interface of the donor and recipient bone but was asymptomatic, and there had been no change in the position of the cemented acetabular component since operation. The remaining grafts appeared to be incorporated securely, as determined by radiographic examination. Three-dimensional computerized tomographic radioisotopic bone scans showed uniform uptake, consistent with revascularization and new-bone formation, in all grafts. There was no radiographic evidence of focal avascularity and there were no infections. Femoral-head bone allografts appear to provide a useful technique for the reconstruction of a severely deficient acetabulum during revision total hip arthroplasty.

A six-year follow-up of infected total hip replacements managed by Girdlestone's arthroplasty.

Thirty-three Girdlestone's arthroplasties used to salvage infected total hip replacements were followed for a mean of 6.2 years to assess the efficacy of this procedure. Subjective and objective assessment was obtained at the time of review. Gram-negative organisms, retained cement, bony sequestra and secondary healing were common features of the five patients (15%) whose wounds discharged for more than four weeks after operation. Girdlestone's arthroplasty provided satisfactory pain relief in 91% of patients, and control of infection in 97%. Although leg-length discrepancy (mean 4 cm) and a Trendelenburg gait made walking difficult and tiring , 42% were satisfied with their functional ability; 85% needed walking aids, and 3 patients could not walk at all and were confined to bed or a chair. Overall, 79% were satisfied. Objectively, the mean Harris hip rating was 60; however, if patients with multiple joint problems were excluded, this score increased to 77. Girdlestone's arthroplasty seems a reasonable salvage procedure in the management of an infected total hip replacement and the results seem to improve with time.

Hip Arthroplasty with a Moore Prosthesis with Porous Coating

The five-year clinical experience with Moore hip prostheses with a porous coating has been encouraging. The results have been equivalent to those of a simultaneous experience using cemented prostheses. The patient population chosen for hip arthroplasty using prostheses with a porous coating was a group at high risk for failure with cemented prostheses. The mean Harris hip ratings for the 26 patients have improved rather than deteriorated with time. Based on current knowledge, it is the author's opinion that the implants in these 26 patients were firmly fixed by a combination of fibrous and bony tissue ingrowth. The presence of radiopaque lines in one-third of the patients at a two-year follow-up examination indicates that micromotion often was present. Close inspection of the three- and four-year follow-up roentgenograms reveals that the tissue ingrowth seems to have provided implant fixation sufficiently uniform to prevent the roentgenographic signs of localized high-stress concentration so frequently seen with smooth-stem Moore prostheses of the same design. The tissue ingrowth also has produced stress transfers sufficiently uniform to provide roentgenographic signs of healthy bone modeling. With four-year follow-up roentgenograms now available in ten patients, there has been no roentgenographic evidence of bone resorption due to femoral stress shielding by the relatively high-modulus implant with a porous surface.

Hemiarthroplasty of the Hip Using a Low-friction Bipolar Endoprosthesis

A low-friction bipolar endoprosthesis was implanted in 200 patients. The primary indications for the procedure were acute fractures or failed internal fixation of the hip. The prosthesis was also implanted in a smaller series of patients who presented with pathologic lesions of the femoral head and minimal involvement of the acetabulum. Intrahospital results proved the morbidity and mortality rates to be well within acceptable limits for arthroplasty of the hip. Seventy-five patients were followed up during periods of one to eight years (average, 3 years). Sixty-nine patients (92%) with satisfactory results had a mean Harris hip rating score of 87 points. Six patients (8%) scored below 70, indicating a poor result. The biomechanical advantage of the bipolar endoprosthesis is reflected in the low incidence of failures.

A Radiographic Analysis of 166 Charnley-M$uUller Total Hip Arthroplasties

A review of 166 total hip arthroplasties, with follow-up from six months to 11 years, showed a 73% incidence of femoral "looseness," 22% incidence of progressive femoral "loosening" and 95% incidence of acetabular "looseness" for all radiolucent line sizes. Part of the reason for the high incidence of femoral "looseness" may be explained by the rigorous criteria in the authors' definition of "looseness." However, femoral "looseness" remains high at 47% and 36% incidences at the cement-bone and cement-stem interfaces, respectively, for radiolucent lines greater than 1 mm. Only one trochanteric osteotomy was performed and it is suggested that omission of trochanteric osteotomy results in inadequate cement filling of the femoral stem, as well as a lack of proper placement of the stem, contributing to the high incidence of femoral "looseness." Larger and more tapered stems, with routine trochanteric osteotomy, together with the use of low viscosity cement under pressure, should be investigated to reduce the incidence of femoral "loosening" and necessity for revision. The Harris Hip rating was found to have good correlation with the radiologic findings of loose and nonloose femoral stems.