Indication For Total Hip Replacement Research Articles

Atypical Vancouver B1 periprosthetic fracture of the proximal femur in the United Kingdom: a case report challenged by myeloma, osteoporosis, infection, and recurrent implant failures

The indications for total hip replacement are increasing and not limited to osteoarthritis. Total hip replacement may also be done for trauma and pathological fractures in patients otherwise physiologically fit and active. This trend has led to an inevitable rise in complications such as periprosthetic femoral fracture. Periprosthetic femoral fracture can be challenging due to poor bone quality, osteoporosis, and stress fractures. We present a case of periprosthetic femoral fracture in a 71-year-old woman with some components of an atypical femoral fracture. The fracture was internally fixed but was subsequently complicated by infection, implant failure needing revision, and later stress fracture. She was on a bisphosphonate after her index total hip replacement surgery for an impending pathological left proximal femur fracture, and this may have caused the later stress fracture. Unfortunately, she then experienced implant breakage (nonunion), which was treated with a biplanar locking plate and bone grafting. The patient finally regained her premorbid mobility 13 months after the last surgery and progressed satisfactorily towards bony union.

SHORT- AND LONG-TERM MORTALITY RISK OF TOTAL HIP ARTHROPLASTY IN OBESE PATIENTS: DOES IT CONSTITUTE THA CONTRAINDICATION?

Osteoarthritis (OA) of the hip is the most common indication for total hip replacement (THR). Obesity is a risk factor for the development of OA and has recently resulted in patients requiring THRs at much younger ages to relieve pain at the joint capsule and restore mobility. However, the impact of obesity on THR mortality is not well understood.An updated systematic review was performed to identify whether an obese BMI should influence patient selection for surgery. Specifically, the impact of obesity on short-term mortality, long-term mortality, and peri- and post-operative complications was assessed with a particular focus on BMI classes.A comprehensive literature search of Ovid Medline and EMBASE in November 2022 identified relevant papers in accordance with PRISMA methodology. After removing duplicates, 2988 articles underwent strict inclusion and exclusion criteria, resulting in 12 papers for analysis.There was no statistically significant difference in mortality risk between obese and non-obese populations. Obesity was associated with a lower risk of short-term mortality than in the normal weight control group, however there was an increased mortality risk in obese patients long-term likely due to comorbidities. Obese patients were significantly younger than normal BMI and underweight patients. However, the paper found increased mortality risk in underweight and morbidly obese patients.Obese patients did not have an increased risk of mortality when compared to non-obese patients following THR. Obesity may have a protective effect on mortality up to a BMI of 40kg/m2, although this may be influenced by the obesity paradox which states only the healthiest obese individuals are selected for surgery, which could attribute to a lower mortality risk. The greatest risk of mortality and complication was associated with underweight patients. As a result, a BMI greater than 30kg/m2 may not necessitate a hip replacement contraindication. It is important surgeons apply careful consideration and comprehensive risk assessment on patients who require a THR, especially at the BMI extremes.

Aseptic necrosis of the femoral head as a complication of its traumatic dislocation

The work is based on the analysis of examination and treatment results in traumatic hip dislocation (52 patients). The development of aseptic femoral head necrosis was detected in 11 patients at follow-up from 2 to 5 years. Algorithm of complex examination and treatment in traumatic hip dislocation has been elaborated for early and long-term periods after trauma. The group of high risk for aseptic femoral head necrosis development includes the patients with concomitant trauma, with posterior, obturatory and central dislocation. Rehabilitation is requiered to all patients with traumatic hip dislocation in the period from 2 to 5 years taking into account the peculiarities of hip injury. If the signs of posttraumatic aseptic femoral head necrosis are detected at early stages, then conservative treatment is indicated. In advanced process the operative treatment is indicated. Localization of necrosis area within femoral head, necrosis extension and articular surface congruence are of importance for the choice of adequate operative treatment. Roentgenologic signs of irreversibility of articular tissues destruction are the indication for total hip replacement.

Measurement of Self-Supporting Ability among Patients with Hip Replacement

Total hip arthroplasty (THA) is an effective treatment for patients with end-stage arthritic hip condition. It provides pain relief, enhances mobility, and restores function (Liu, Zi, Xiang, & Wang, 2015). Arthroplasty, or joint replacement, comes from the Greek words ‘arthron’, that is meaning joint, and ‘plassein’, is meaning mould (Palareti et al., 2016).total hip replacement (THR) in patients with symptomatic osteoarthritis (OA) were succeed up to one-quarter of patients report suboptimal recovery. Osteoarthritis (OA) which cause pain and functional disability and most common form of arthritis and major structural changes of the joint and contains inflammation. Moderate to severe OA is the most common indication for total hip replacement (THR) (Brembo, Kapstad, Van Dulmen, & Eide, 2017).THR is a cost-effective treatment for hip OA and offers relief of pain and improved function and quality of life (Ethgen, Richy, & Reginster, 2004). In 2006, among 230,144 people who operated THR in USA, 86% of them had diagnosis of OA. According to the expectations in 2030, the number of surgeries for primary THR will reach to 572,000 per year in USA. Also, it was reported in Taiwan 6519 new cases in 2004 with increasing its number to 15,000 in 2008. It’s shows 2.1% growth per year in (of a total population of 23 million). The main task of rehabilitation is strengthening the muscles around the replaced hip joint to keep joint stability (Chang et al., 2017). For THR rehabilitation, hydrotherapy, stationary bike, motion’s range and walking programs are correlated (Nelson, Bourke, Crossley, & Russell, 2018). In the successful THR operation, gait alterations will stay in patients for 10 months after surgery. Also, immobilization after surgery will be remained due to the muscular weakness. To reduce immobilization effects and speed up discharging and increasing recovery, starting the rehabilitation of THR will be usually recommended on the day of operation. Furthermore, to improve balance, stability, safety and self-confidence using a crutch is proposed. Nevertheless, incorrect using of a crutch can effect on improving recovery time (Esposito, Freddolini, Marcucci, Latella, & Corvi, 2018). According to World Health Organization (WHO) almost 25% of the population will have bone and joint problems until 2050. With promoting the positive self-efficacy and instigating suitable medical treatment, the condition of patients can be highly improved. In the USA the number of patients with OA will be double in the population with aged >65 years old according to research conducted by the Centers for Disease Control and 4 Prevention (CDC) by 2030 (Wu, Lee, Chou, Chen, & Huang, 2018). Recently, the most common used treatment for hip disorders became the artificial hip replacement in old patients (Kutzner, Donner, Schneider, Pfeil, & Rehbein, 2017). The aim of the research: Our study was aimed at measuring the self-supporting ability including quality of life, walking distance, range of movement, muscle strengthening and balance among patients after operation of hip replacement. Hypothesis: We suppose the patient’s physical functioning will be improved after the physiotherapy program. After training, we assume the muscle strengthening will be also increased. We hypothesize the range of movement will be developed. Quality of life will be enhanced after three weeks of physiotherapy training, we presume. Furthermore, we believe during the physiotherapy program the walking distance will be extended. We assume standing balance will be improved after the above-mentioned training period.

Evaluation of stress-strain state of the femoral endoprosthesis component with a non-standard cone size and adapter for its standardization

This paper presents the results of biomechanical modelling of the "femur–implant" system under condition of non-standard cone size and addition of the developed hip replacement adapter. One of the most effective treatment methods for diseases and injuries of the hip joint is total hip replacement. Expansion of indications for total hip replacement led not only to an increase in the percentage of implants, but also to an increase in the number of recorded complications. The leading position among complications is occupied by aseptic instability of the endoprosthesis components. With isolated reimplantation of the endoprosthesis cup and the friction pair “head–liner”, orthopedists are faced with the problem of non-standard sizes of the neck cone of the stem. This leads to the need for extraction of stable femoral components and a significant decrease in the effectiveness of the technique. To solve this problem, we developed an adapter, which is shaped as a truncated cone. The inner diameter of the adapter corresponds to the outer diameter of the non-standard cone, and the outer diameter of the structure has standard size. Biomechanical modelling methods were used to introduce this development into practical medicine. This paper presents stages of creating biomechanical models of the "bone–implant" system. Biomechanical modelling is carried out in the Ansys Workbench software. The main attention is focused on the distribution of equivalent stress values. Stresses occur in the metal structure elements with application of physiological loads. The maximum values of equivalent stresses in the structure under study at the load of 800 N (133.3 MPa) are comparable to maximum equivalent stresses in standard endoprosthesis structures, ranging from 31 to195 MPa. The maximum values do not exceed yield strength of the material, which is 350 MPa. Thus, the results of biomechanical modelling showed high operational reliability of the developed adapter with a non-standard size of the femoral component’s neck.

Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty. POWER.2 Study: Study Protocol for a Prospective, Multicentre, Observational Cohort Study.

The number of indications for total hip replacement (THR) and total knee replacement (TKR) surgery is increasing. Enhanced recovery after surgery (ERAS) represents the next step in the evolution of standardised care. The primary aim of this study is to measure the in-hospital 30-day medical and surgical postoperative complications rate. The study's secondary aims are to determine the length of stay, 30-day mortality rate, 30-day reoperation and readmission rates, the ERAS overall compliance and predefined ERAS individual items compliance. This multicentre, prospective, observational study will include adult patients (aged >18 years) undergoing elective THR and TKR surgery. Consecutive patients undergoing surgery within the 2-month data collection period will be included. Centres that offer the THR and/or TKR surgery will be eligible to participate. The data collection will be done through an online data collection form via a secure, password-protected platform at each centre with predefined data fields. Ethical approval for this study has been obtained from the Comité de Ética de la Investigación de la Comunidad Autónoma de Aragón (C.P.-C.I. PI18/135; on 23 May 2018). It was prospectively registered on 27 June 2018, at www.clinicaltrials.gov with identification no. NCT03570944. The study will be disseminated through the SPARN-RedGERM, SEDAR, GERM and through social media. Peer-reviewed publications will be published under corporate authorship, including POWER.2 Study Group and SPARN-RedGERM.

Physical Therapy Following Total Hip Replacement and Assessment of the Effects on the Quality of Life

Introduction: Hip osteoarthritis (HOA) is a serious clinical and social problem and is considered a civilisation disease. HOA is a chronic condition that causes joint cartilage damage. Its symptoms increase slowly, resulting in considerable limitations in hip joint mobility and severe pain. Advanced degenerative changes constitute one of the main indications for total hip replacement. Aim: To assess the effects of physical therapy procedures on the quality of life in patients after total hip replacement. Material and Methods: The study group consisted of 25 patients aged 60 to 79 years, staying at the specialist St. Luke Hospital in Końskie. Patients were examined in two stages, namely before surgery and after physical therapy and rehabilitation, up to 6 months after hip replacement. Results: After total hip replacement, patients showed statistically significant improvements in the ranges of motion of the hip and reductions in pain, which contributed to better motor skills and improved patient independence in everyday life. Conclusions: Total hip replacement and comprehensive rehabilitation performed in the study patients improved the ranges of motion in the hip joint, which contributed to an improvement in gait, functioning, and physical fitness and a significantly better quality of life.

Enabling Cape Verde to Perform Total Hip Replacement: Cost-Benefit Study.

Cape Verde is a middle-income country benefiting from a health agreement with Portugal. The purpose of this study is to conduct a cost-benefit analysis on the enablement of Cape Verde to perform total hip replacement. We assessed records from the Orthopaedic Department of Baptista de Sousa Hospital and the Portuguese Directorate-General of Health regarding hip fracture with indication for total hip replacement and hip arthritis cases evacuated to Portugal. We also analysed the direct costs of the treatment, and hypothesised the costs of performing total hip replacement in Cape Verde. We then conducted a cost-benefit analysis. From 2011 to 2016, 126 patients (135 hips) would have indication for total hip replacement if it was possible to do it in Cape Verde. The performance of the procedure in Cape Verde would have resulted in a global benefit of €80 644.08, and a benefit of €597.36/per patient. Our analysis indicates that the enablement of Cape Verde to autonomously perform total hip replacement on patients with hip fracture and arthritis would have a positive financial return. Total costs were underestimated due to the impossibility to calculate indirect costs. Enabling Cape Verde to perform total hip replacement would provide the recommended treatment for patients and reduce the socio-psychological impact of evacuation. Enabling Cape Verde to perform total hip replacement would represent an expense reduction, and an improvement of the country's quality of healthcare and autonomy.

An Alternative Macrophage Activation Pathway Regulator, CHIT1, May Provide a Serum and Synovial Fluid Biomarker of Periprosthetic Osteolysis

BackgroundPeriprosthetic osteolysis (PPO) is a frequent indication for total hip replacement (THR) failure. Currently, PPO diagnosis occurs in advanced stages that often necessitate complex revisions due to bone loss. PPO biomarkers could facilitate earlier diagnosis. Alternative macrophage activation pathway regulators, chitotriosidase (CHIT1) and CC chemokine ligand 18 (CCL18), have increased periprosthetic expression in patients undergoing revision THR for osteolysis. We hypothesized that synovial fluid and serum levels of CHIT1 and CCL18 would be increased in patients undergoing revision THR for PPO versus controls without osteolysis.MethodsIn this prospective case-control study, 60 patients undergoing revision metal-on-polyethylene THR at Hospital for Special Surgery were screened preoperatively from January 2013 to December 2014. Twenty “osteolysis” patients who underwent revision for PPO (based on imaging and operative reports) and 10 “control” patients (with stable implants) who underwent revision for recurrent dislocation or a mechanical etiology were included. Among osteolysis and control patients, 11/20 and 4/10 were male; average age was 68 and 63 years, respectively; 9/20 and 3/10 had cemented femoral components; and average implant longevity was 15 and 5 years, respectively. Preoperative serum and intraoperative synovial fluid samples were collected. CHIT1 and CCL18 were quantified via enzyme-linked immunosorbent assay. Significance was assessed via nonparametric Mann-Whiney U test.ResultsCHIT1 was significantly increased in both synovial fluid (3727 versus 731 nanomoles [nM]) and serum (98 versus 39 nM) in the osteolysis versus control patients. CCL18 levels were also significantly increased in osteolysis versus control patients’ synovial fluid (425 versus 180 nM) but not their serum.ConclusionsIn this prospective case-control study, CHIT1 was identified as a novel synovial fluid and serum biomarker of PPO. CHIT1 expression is induced during macrophage activation in response to wear debris. CHIT1 monitoring may facilitate early diagnosis of THR PPO. Furthermore, CHIT1 may represent a novel therapeutic target for PPO.

An Evaluation of Intra- and Post-operative Blood Loss in Total Hip Arthroplasty at the National Orthopaedic Hospital, Lagos.

Background:Severe hip pain with associated significant functional limitation is the major indication for total hip replacement, a rewarding and gratifying procedure. However, significant blood loss can occur in the intra- and post-operative periods, posing a major challenge and necessitating prompt restoration of circulating blood volume to minimize morbidity and mortality. The aim of this study was to evaluate blood loss after primary total hip replacement, and to determine the effect of surgical time on blood loss.Patients and Methods:A prospective study of blood loss after total hip arthroplasty in 41 patients. All cases were primary total hip arthroplasty done by one surgeon. Intra- and post-operative blood losses were recorded in two groups of patients (surgical time <2 h and surgical time >2 h), and the effect of these on blood loss was evaluated.Results:The mean intra- and post-operative blood losses were 1222.7 ml and 574.3 ml, respectively. These showed a strong positive correlation with total blood loss (r = 0.790, P < 0.001 and r = 0.517, P < 0.001). Higher intra- and post-operative blood losses were recorded in patients with surgical time >2 h, with a significant difference on postoperative days 2 and 3 (P = 0.003 and P = 0.014, respectively).Conclusion:Blood loss in total hip replacement is an important factor and may be influenced by a shorter surgical time.

Developing a sustainable hip service in Cambodia.

Initial report on establishment of a hip service in Phnom Penh, Cambodia at Children's Surgical Centre. We describe indications for total hip replacement (THR) and initial results. A database was established to collect data and track patients for follow up. Initial data collected included; diagnosis, implant used, post-operative complications. As the service developed, pre- and postoperative Harris hip scores were included. High rate of avascular necrosis (AVN) as the initial diagnosis. Five years post initiation of the hip service, 95 patients have received 116 THRs; including 10 revisions, 12 bilateral procedures. Complications/failures requiring revision involved four prosthetic femoral neck fractures, two aseptic acetabular component, two late infections, one instability. One failure, a periprosthetic acetabular fracture, required removal of all prosthetics. Complications not requiring revision, included three post-op foot drops, three superficial wound infections, one Vancouver B1 periprosthetic femur fracture. Average age was 41. Overall implant survival is 85% at three years. AVN was the most common indication for THR: many patients had a history of hip trauma, and/or prolonged steroids from traditional healers for pain. Problems with specific implants were addressed by the company. A different stem is now routinely used, no further fractures have been reported. Acetabular loosening, thought to be due to poor technique, has been addressed by focused training. Infection rate is monitored, and microbiology resources are improving. Developing an affordable hip arthroplasty service in a country like Cambodia is challenging. Developing a local registry has helped to identify complications and modify techniques.

Five-year results of a cementless short-hip-stem prosthesis

Hip prosthesis stems with a short stem length and proximal fixation geometry support a bone-preserving and muscle-sparing implantation and should also allow for revision surgery with a standard hip stem. We present 250 prospectively documented clinical and radiological results from the Metha Short Hip Stem prosthesis (B. Braun-Aesculap, Tuttlingen, Germany) after an average follow-up of 4.9 years. The average patient age at surgery was 60 years. Indication for total hip replacement was primary osteoarthrosis (OA) (78% of patients), OA based on developmental dysplasia of the hip (16%), and other indications (6%). At the last follow-up, the average Harris Hip Score was 97 points. 85% of patients were very satisfied and 14% were satisfied after surgery, whereas 1% were dissatisfied. Pain according to the Visual Analogue Scale improved from 7.4 (min 1.6, max 9.5) pre-operatively to 0.23 (min 0, max 6.6). No joint dislocations occurred when predominantly using 28 mm and 32 mm prosthesis heads. Nine short-stems were revised: three after bacterial infections, two after primary via valsa with penetration of the femoral cortex two and three months after surgery, and three after early aseptic cases of loosening within the first year. A further nine osseously consolidated short-stems had to be replaced due to breakage of the modular titanium cone adapter after an average of 3.1 years (min 1.9, max 4.4). All surgical revisions were performed using primary standard stems. Without taking the material-related adapter failures into account, a five year Kaplan-Meier survival rate of 96.7% (95% confidence interval 93.4–98.3) was determined for the short-stem prostheses. There were no radiological signs of loosening in any of the short-stem prostheses at the last examination. Fine sclerotic lines were detected in Gruen's AP zones 1 (19%) and 2 (10.5%), individual hypertrophies in zone 3 (3.5%), fine seams in zones 4 (5.5%) and 5 (4%), without pedestal formations in zone 4, clear cancellous bone compressions in zone 6 (97.5%), as well as single fine scleroses (1.5%) and atrophies (2.5%) in zone 7. The mid-term clinical results with periprosthetic bone remodeling and without radiological signs of loosening confirm this metaphyseal short-stem treatment and fixation concept and the possibility of revision surgery using standard hip stems. Long-term results must be further observed on a prospective basis as part of this collective study.

Complications and Owner Assessment of Canine Total Hip Replacement: A Multicenter Internet Based Survey

To assess the variables associated with the complications of total hip replacement (THR) and report owner-assessed outcomes, through surgeon-based registration of cases via an online database, informed owner consent, and prospective outcomes assessment using a client-administered clinical metrology instrument. Prospective case series Dogs (n = 170) Entries into the British Veterinary Orthopaedic Association-Canine Hip Registry (BVOA-CHR) between January 2010 and August 2011 were reviewed. Variables evaluated included dog age, body weight, breed, and indication for THR and prosthesis. Associations between each variable and the incidence of complications were assessed using logistic regression. Additionally, an on-line, owner-administered outcomes assessment questionnaire (modified from the Liverpool Osteoarthritis in Dogs (LOAD) questionnaire) was used to collect data from owners. One hundred and seventy cases met the inclusion criteria. Surgical indications included hip dysplasia and coxofemoral osteoarthritis (n = 150), Legg-Calves-Perthes disease (7), coxofemoral luxation (6), fracture (4), slipped capital physis (2), and femoral head and neck ostectomy revision (1). Surgical implants were from 4 systems. The incidence of surgeon-reported complication was 9.4%. No significant association was identified between weight, age, sex, breed, indication for THR, surgical technique and prosthesis, and the incidence of complications. In 82% of the cases, owners described their satisfaction with the outcome of THR as "very good" and a total of 20% complication rate was reported. There was a statistically significant improvement in owner-assessed questionnaire score before and after THR (P < .001). The BVOA-CHR offers a novel framework for the prospective studies on THR and on a national/international scale. Initial complication rates from the BVOA-CHR are similar to previous studies.

How to Do a Revision Total Hip Arthroplasty: Revision of the Acetabulum

The need for revision total hip arthroplasty continues to increase as the indications for total hip replacement broaden and the average life expectancy of patients and their demands for activity increase. To achieve a successful long-term outcome after revision acetabular surgery, the surgical reconstruction must provide a mechanically stable construct that will minimize micromotion, allow bone ingrowth, and restore appropriate hip biomechanics. Achieving these goals during revision acetabular surgery can be challenging because of periacetabular bone loss and a compromised biologic environment. Acetabular classifications can help to preoperatively predict areas of bone loss to guide treatment options. Most acetabular defects can be managed with a hemispheric or elliptic porous acetabular component; however, large areas of segmental or cavitary bone loss may require alternative treatments such as custom implants, metal/allograft augmentation, or an acetabular cage reconstruction.

Commentary on an article by Stephen S. Tower, MD: “Arthroprosthetic Cobaltism: Neurological and Cardiac Manifestations in Two Patients with Metal-on-Metal Arthroplasty. A Case Report”

This issue of The Journal of Bone and Joint Surgery includes a report on two patients with metal-on-metal total hip replacements who developed systemic neurological and cardiac complications associated with an elevation in serum cobalt levels. Causality is suggested by the fact that the systemic symptoms improved in at least one of the two patients following revision surgery. The report is unusual because of the rarity of the occurrence of metal-induced systemic complications in patients with total hip replacement and the fact that the author was one of the patients. As millions of patients worldwide have undergone total hip replacement, these cases represent rare events indeed. Metal-on-metal bearing surfaces in total hip arthroplasty have been in use for over fifty years. The earliest iterations of these devices lost favor in the 1970s and were replaced by metal-on-ultrahigh molecular weight polyethylene implants. As the indications for total hip replacement were extended to younger, more active patient populations with higher activity demands, clinically important problems such as osteolysis and aseptic loosening related to bearing surface performance were reported with increasing frequency. So-called alternative bearing materials were developed with the goal of reducing wear debris and decreasing osteolysis, aseptic loosening, and other wear-related failures. Metal-on-metal bearings generally demonstrated reduced volumetric wear in comparison with metal-on-polyethylene bearings in hip simulator and implant-retrieval studies. Metal-on-metal bearings allow the use of thinner acetabular components and larger femoral heads, which have been associated with a lower rate of postoperative hip dislocation. Thinner acetabular components also facilitate hip resurfacing. As is the case with metal-on-polyethylene bearings, ceramic-on-polyethylene bearings, and ceramic-on-ceramic bearings, there are potential risks associated with metal-on-metal bearings that accompany the potential clinical benefits. One such risk associated with metal-on-metal bearings is the potential for adverse biological responses to elevated levels of cobalt and chromium in local and remote tissues. This risk is not unique to metal-on-metal bearings as other metal devices with accelerated damage due to wear or corrosion can lead to elevated levels of metal in local and remote tissues. In fact, four of the six reported cases to date that have demonstrated chromium and cobalt-associated neurological and/or cardiac complications had bearing couples other than metal-on-metal. In orthopaedic surgery, metal devices are used for joint replacements, fracture fixation, spine fusion, and tumor reconstruction and therefore are essential for the orthopaedic surgeon. However, if metal release is extensive as a result of wear or corrosion, adverse local and systemic biological responses can ensue. At the present time, there is no generally accepted threshold beyond which serum or blood concentrations of cobalt and chromium are known to be toxic in patients with a metal implant. As there are known risks of revision surgery, undertaking such a procedure on the basis of the blood or serum metal level alone and in the absence of symptoms is problematic. The value of these case reports would have been enhanced if there had been additional clinical, histological, and radiographic detail demonstrating implant orientation (particularly in Case 2, in which this information is quite limited) and if there had been additional detail regarding the methodology of the metal measurement in serum. The latter is particularly critical given the known variability in these measurements, which makes comparison of the metal concentrations in different published series difficult. Nonetheless, there are important lessons that can be learned from these two cases: (1) routine periodic surveillance by an orthopaedic surgeon is recommended for patients with total joint replacements to identify and treat, in a timely fashion, any prosthetic-related complications; (2) surveillance should include both an evaluation of the replaced joint and a discussion of the overall health of the patient; (3) determination of concentrations of metal in the blood or serum may be helpful for the evaluation of patients with local pain and/or otherwise unexplained systemic symptoms and should be used in concert with other clinical and radiographic information; (4) the orthopaedic surgeon should be cognizant of these rare systemic complications of metal devices undergoing accelerated wear and corrosion; and (5) expeditious revision surgery should be considered for a symptomatic patient with evidence of accelerated wear or corrosion who demonstrates local and/or systemic complications associated with the device.

Relationship between total hip replacement appropriateness and surgical priority instruments

Variability in indications for total hip replacement (THR) and unequal waiting times may limit health care access. To analyse the relationship between appropriateness and previously developed surgical priority instruments. Multicentre cross-validation study of patients placed on the waiting list for THR. Information on surgical priority, surgeons' evaluation of priority through a visual analogue scale (VAS) and health-related quality of life (HRQOL) (Health Utilities Index mark 3, EQ-5D, Western Ontario McMaster Osteoarthritic Index) was collected. THR indications were considered appropriate, uncertain or inappropriate according to appropriateness criteria. Statistical differences and clinically important differences in surgical priority, VAS and HRQOL between appropriateness categories were analysed with the Mann-Whitney U-test and effect size (ES), respectively. Surgical priority score's ability to discriminate appropriate and inappropriate indications was evaluated through the area under the receiver-operating characteristic curve (AUC) and its 95% confidence interval (95% CI). 49.4% (87) of the THR indications were deemed appropriate, 39.8% (70) uncertain and 10.8% (19) inappropriate. Differences in surgical priority score, VAS and HRQOL between appropriateness categories were statistically significant. Clinically important differences were generally small (ES, 0.2-0.5) between inappropriate and uncertain, moderate (ES, 0.5-0.8) between uncertain and appropriate, and large (ES > 0.8) between inappropriate and appropriate categories. The AUC to discriminate appropriate and inappropriate indications was 0.97 (95% CI: 0.96-0.99) and 0.90 (95% CI: 0.83-0.97), respectively. The relationship between the surgical priority and appropriateness instruments reinforces their validity and could improve waiting list management by establishing maximum waiting periods based on patients' characteristics.

Relative importance of gait vs. joint positioning on hip contact forces after total hip replacement

Implant loosening is a common indication for total hip replacement (THR) revision. High contact forces and implant twisting moments are thought to be associated with implant loosening. Relationships between joint positioning and hip forces, or outcomes, have been investigated through in vivo and in vitro modalities. Relationships between hip forces and gait are less understood, despite repeated findings that gait following a THR does not fully return to normal. We tested the hypothesis that gait parameters would be better predictors of implant force (peak contact forces and peak twisting moment during walking) than joint positioning parameters. Subjects underwent gait analysis, hip force modeling, and measurement of clinical radiographs 1 year after successful THR surgery. Gait parameters were consistently more influential in determining hip forces. Alone, gait explained as much as 67% of the variation in force, compared to a maximum of 33% by joint geometry. Combinations of gait and joint positioning parameters together explained up to 86% of the variation in hip force parameters. Results suggest that gait may provide a valuable postoperatively modifiable target to improve hip loads and potentially reduce the risk for implant loosening.

Das Kallmann-Syndrom – eine Form des hypogonadotropen Hypogonadismus

Two men (aged 44 and 47 years) were admitted with the diagnosis of Kallmann's syndrome, but they had widely different symptoms. The first patient (A) suffered from significant secondary symptoms, i.e. weight gain and skeletal pain, which had caused him to seek medical assistance. The second patient (B) had been admitted because of symptoms of depression, caused by separation from his female partner.Patient A showed major somatic symptoms characteristic of the syndrome: eunuchoidism (physique, boyish voice, gynecomastia, micropenis and absent secondary sex characteristics). Further diagnostic tests revealed low testosterone concentrations (0.958 ng/ml; reference range 1.8 - 7.58 ng/ml) and low luteinizing hormone (LH) concentrations (<0.7 IU/l; reference range 0.8 - 7.6 IU/l), as well as infertility. Radiology showed marked osteoporosis, providing the indication for total hip replacement. Magnetic resonance imaging (MRI) of the skull and chromosomal analysis gave normal results. The physical development of patient B had progressed ever since hormone substitution after a suspected diagnosis of mumps orchitis in early childhood. However infertility was still present. Abnormal laboratory findings at admission: LH 0.10 IU/l (reference range 0.8 - 7.6 IU/l), follicle stimulating hormone 0.10 IU/l (reference range 1.2 - 10.1 IU/l), testosterone 10.0 ng/ml (reference range 1.8 - 7.58 ng/ml). A hypoplastic olfactory sulcus was shown by MRI, but no olfactory bulb. Mineral density of the femur was slightly diminished. Combined stimulation test of the pituitary gland revealed hypogonadotropic hypogonadism and anosmia in both patients.In patient A administration of testosterone, calcium, colecalciferol and biphosphonates improved virilization and reduced skeletal pain. Continuation of testosterone, calcium and colecalciferol treatment, psychotherapy and antidepressive medication with paroxetine were initiated in patient B. His symptoms of depression were treated successfully, but personal and sexual relationships remained difficult and had many problems.Early diagnosis of Kallmann's syndrome and symptomatic treatment with hormone replacement prevent patients from developing pernicious sequelae. However, sexual identity will be difficult even for patients treated after early diagnosis.

Elective palliative total hip replacement in a patient with lymphoma and advanced lung cancer

Total hip replacement is among the most effective procedures in medicine, providing sustained relief of hip pain in more than 90% of recipients, with perioperative mortality rates less than 1% (1–3). The procedure is highly cost-effective and may even be cost-saving (4). Originally introduced in the 1960s, total hip replacement is presently performed on more than 260,000 persons annually in the US (5). The indications for elective total hip replacement have traditionally included advanced joint destruction and severe pain-related functional loss in otherwise healthy older adults. Data have emerged in the last decade showing that patients operated on later in the course of disease experience worse functional outcome (6). Consequently, the indications for total hip replacement are broadening to include patients with less severe functional loss. Although the indications for total joint replacement are expanding, the procedure is typically reserved for patients who are generally healthy. Texts suggest that medical conditions that might influence the outcome of total joint replacement should be recognized and stabilized prior to surgery (7). We report the case of an 82-year-old woman with advanced metastatic lung cancer (not involving the hip) and severely symptomatic hip osteoarthritis (OA) who underwent elective left total hip replacement in order to provide pain relief in her last year or two of life. We discuss the limited literature on the use of elective total hip replacement and similar procedures as palliative care for patients with terminal conditions not involving the index joint. We suggest that total joint replacement be considered as a therapy for patients with symptomatic, advanced OA who are receiving palliative care for terminal medical conditions. More generally, we suggest that a wide range of elective procedures traditionally contraindicated in patients with terminal illness may in fact be entirely appropriate when viewed in a palliative care context.

Follow-up analysis of total hip endoprosthesis after femoral neck fracture with and without previous operation

Damage occurring after joint-preserving surgical treatment of femoral neck--mostly femoral head necrosis of pseudoarthrosis-necessitates endoprosthetic joint replacement. In the case of inferior bone quality and unfavorable fracture forms as well as after failed conservative therapy, surgical treatment consists of implanting a total hip endoprosthesis. Between 1971 and 1989, 120 patients received total hip replacement after suffering fractures of the femoral neck: 61 patients did not have previous surgery, 59 patients had had joint-preserving surgery. Statistical analysis of the results showed that the primary stabilizing operation to preserve the joint did not have a negative influence on the survival probability of the total hip replacement in comparison with primary implantation. If the joint-preserving primary intervention fails, total hip replacement is a good choice for secondary surgery. In the case of complications such as femoral head necrosis or pseudoarthrosis the indication for total hip replacement should therefore be made early on.