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The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 6 | Pages 896 - 899
1 Nov 1997
Fender D Harper WM Thompson JR Gregg PJ

We calculated the rates for perioperative mortality and fatal pulmonary embolism (PE) after primary total hip replacement in a single UK health region, using a regional arthroplasty register and the tracing service of the Office of National Statistics. During 1990, there were 2111 consecutive primary replacements in 2090 separate procedures. Within 42 days of operation a total of 19 patients had died (0.91%, 95% CI 0.55 to 1.42). Postmortem examination showed that four deaths (0.19%, 95% CI 0.05 to 0.49) were definitely due to PE.

The overall perioperative mortality and fatal PE rates are low and in our study did not appear to be altered by the use of chemical thromboprophylaxis (perioperative mortality rate: one-tailed Fisher’s exact test, p = 0.39; fatal PE rate: one-tailed Fisher’s exact test, p = 0.56).

The routine use of chemical thromboprophylaxis for primary THR is still controversial. The issue should be addressed by an appropriate randomised, prospective study using overall mortality and fatal PE rate as the main outcome measures, but the feasibility of such a study is questioned.


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 6 | Pages 914 - 917
1 Nov 1997
Pope RO Corcoran S McCaul K Howie DW

We report a prospective randomly controlled trial to examine the effectiveness of continuous passive motion (CPM) in improving postoperative function and range of movement after total knee arthroplasty (TKA).

We allocated 53 patients (57 knees) to one of three postoperative regimes: no CPM (n = 19); CPM at 0 to 40° (0 to 40 CPM; n = 18); and CPM at 0 to 70° (0 to 70 CPM; n = 20). Those in the CPM groups had CPM for 48 hours and all patients had an identical regime of physiotherapy. There was an even distribution of various cemented and cementless TKAs in each group. Patients were assessed preoperatively and at one week and at one year postoperatively.

At one week, there was a statistically significant increase in the range of flexion and total range of movement in the 0 to 70 CPM group compared with the no-CPM group. At one year we found no significant differences in mean flexion, overall range of movement, fixed flexion deformity or functional results in the three groups. Those who had CPM had a significant increase in analgesic requirement (p = 0.04). There was an increased mean blood drainage postoperatively in those who had 0 to 70 CPM (1558 ml) compared with those with no CPM (956 ml) (t = 2.96, p = 0.005) and with 0 to 40 CPM (1017 ml) (t = 2.62, p = 0.01).

Our findings show that CPM had no significant advantage in terms of improving function or range of movement, and that its use increased blood loss and analgesic requirements.


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 6 | Pages 900 - 907
1 Nov 1997
McLaughlin JR Lee KR

We followed 138 patients (145 hips) who had had uncemented total hip arthroplasty using the Taperloc femoral component for a mean of ten years (8 to 12.5). No patient was lost to follow-up; 31 (31 hips) died before the minimum time of eight years for inclusion in the study, and 30 of these still had their femoral component in place. One well-fixed prosthesis had been exchanged at the time of acetabular revision. Of the remaining 114 hips, one femoral component required revision for aseptic loosening and one for sepsis. Three other well-fixed femoral components were removed during acetabular revision.

Complete clinical and radiological follow-up was obtained in the 109 hips which had not had revision. Clinically, 94 (87%) were rated good or excellent, eight (7%) fair and seven (6%) poor. The average Harris hip score increased from 48 before operation to 88 at the time of the last follow-up. Radiologically, 103 hips (94%) had fixation by bone ingrowth, three (3%) showed stable fibrous ingrowth and three (3%) were unstable. Osteolysis of the femoral cortex was seen in seven hips (6%), with major lysis in only one.

At a mean follow-up of ten years, the results of the Taperloc femoral component are comparable with those of modern techniques of cementing in primary total hip arthroplasty.


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 5 | Pages 796 - 800
1 Sep 1997
Crawford RW Ellis AM Gie GA Ling RSM

We investigated 15 patients with painful hip arthroplasties using intra-articular injection of bupivicaine. Fourteen had pain relief and 13 of them were subsequently found to have loosening of one or both components. The relief of pain after total hip arthroplasty by intra-articular injection of bupivicaine indicates that a satisfactory result is probable after revision surgery with refixation of the components.


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 5 | Pages 787 - 791
1 Sep 1997
Clarke MT Green JS Harper WM Gregg PJ

We performed routine venography after operation in a consecutive series of 252 patients with total joint arthroplasties in whom no form of routine chemical or mechanical prophylaxis had been used.

The prevalence of deep-vein thrombosis (DVT) was 32% (16% distal, 16% proximal) after total hip replacement and 66% (50% distal, 16% proximal) after total knee replacement (p < 0.001). We did not treat distal DVT. There were only two readmissions within three months of surgery because of thromboembolic disease. There were two deaths within this period, neither of which was due to pulmonary embolism.


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 5 | Pages 780 - 786
1 Sep 1997
Warwick DJ Whitehouse S

Chemical prophylaxis is known to reduce the venographic prevalence of deep-vein thrombosis (DVT) after total knee replacement (TKR), but it is uncertain whether this affects the incidence of symptoms. Further analysis depends on the basic epidemiology of thromboembolic symptoms. We therefore studied the pattern of such symptoms in a consecutive series of 1000 patients with primary TKR, with particular reference to risk factors and prophylaxis.

We reviewed all the clinical records and contacted all the patients individually, noting risk factors, prophylaxis, symptomatic pulmonary embolus (PE) or DVT and its timing, death and its causes, and all complications. All the patients wore antiembolism stockings, 83% had regional anaesthesia and 33.9% had chemical prophylaxis.

One patient died from PE on the day of surgery, having had no prophylaxis giving a rate of 0.1% (95% CI 0.003% to 0.56%). Symptomatic, radiologically confirmed thromboembolism (VTE) was common with a rate of 10.6% (95% CI 8.7% to 12.5%). There was a similar incidence of VTE in those with and without chemical prophylaxis (10.1% v 10.5%, RR 0.96, NS). VTE was more common in patients with risk factors (15.1% v 9.5%, RR 1.59, p = 0.02) and tended to occur earlier in this group (median day of onset 5 v 7, p = 0.01). Chemical prophylaxis did not reduce the frequency of symptomatic thromboembolism in either those with risk factors (RR 0.81, p = 0.5) or those without them (RR 0.94, p = 0.8). Haematoma or wound dehiscence was more common in those having chemical prophylaxis (11.9% v 6.9%; RR 1.73 95% CI 1.16 to 2.60). Readmission for symptomatic, radio-logically confirmed thromboembolism involved 1.1% of patients (95% CI 0.55% to 2.1%). Four patients were readmitted with proven non-fatal PE and six with proven DVT (the latest on day 40).

Our results show that the main risk factor for thromboembolism was TKR itself; chemical prophylaxis did not reduce the incidence of symptomatic thromboembolism but gave an increased perception of side-effects. New prophylactic methods or combinations of methods are needed, with their efficacy compared by randomised controlled studies of both the clinical and the radiological effect.


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 5 | Pages 792 - 795
1 Sep 1997
Lehtimäki MY Lehto MUK Kautiainen H Savolainen HA Hämäläinen MMJ

Between 1971 and 1991 we performed Charnley low-friction arthroplasty (LFA) on 116 patients (186 hips) with juvenile chronic arthritis (JCA). We have now carried out a survival study, taking endpoints as revision, death or the end of the year 1993.

Overall survival was 91.9% at ten years and 83.0% at 15 years. That of the femoral component was 95.6% at ten years and 91.9% at 15 years and of the acetabulum 95.0% and 87.8%, respectively. Only the use of steroids significantly impaired the survival.

We therefore recommend the use of Charnley LFA for young patients with JCA requiring total hip replacement.


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 3 | Pages 388 - 389
1 May 1997
Basu P Packer CJ Himstedt J

We have assessed the effect of a variety of implants commonly used in fracture fixation and joint replacement on the activation of metal detectors at airport security gates. A volunteer with metal implants strapped on and patients with implants in situ walked through the device. Implants used in fixation do not activate it, except for Richards cannulated screws. An Austin-Moore prosthesis does set off the detector, but a single joint replacement does not. Three or four joint replacements activate the alarm and patients with these implants should be warned of this possibility.


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 3 | Pages 385 - 387
1 May 1997
Grohs JG Gottsauner-Wolf F

We studied the detection of joint replacements at airport security checks in relation to their weight, using two types of detector arch. A single-source, unilateral detector showed different sensitivities for implants on different sides of a test subject.

All implants weighing more than 145 g were detected by one of the arches. The degree of detection was directly related to the logarithm of the weight of the prosthesis in patients, with a linear correlation (r2 = 0.61). A bilateral arch detected all prostheses weighing over 195 g.

With their usual sensitivity settings many joint replacements were detectable; an identification pass containing the site and weight of such prostheses would help to avoid the need for body-search procedures.


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 3 | Pages 371 - 373
1 May 1997
Nicolai P Aldam CH Allen PW

An intact barrier between the hands of the surgeon and the patient remains the single most important factor in protection against infection for both. Increasing the awareness of possible glove perforation without skin penetration will decrease the risk of contamination.

We performed a prospective, randomised trial comparing the incidence of glove perforation using a new type of glove (Regent Biogel Reveal) and standard double-gloves in total hip and knee replacement. One or more perforations was detected in 14.6% of all gloves. The new gloves increased significantly the awareness of perforation. Multiple perforations at the base of the ring finger were found in surgeons who wore wedding rings during the operation and we recommend that rings be removed before undertaking surgery.


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 3 | Pages 351 - 360
1 May 1997
Donnelly WJ Kobayashi A Freeman MAR Chin TW Yeo H West M Scott G

We compared the radiological appearances and survival of four methods of fixation of a femoral stem in 538 hips after follow-up for five or ten years. The fixation groups were: 1) press-fit shot-blasted smooth Ti-Al-V stem; 2) press-fit shot-blasted proximally ridged stem; 3) proximal hydroxyapatite (HA) coating; and 4) cementing.

Survival analysis at five to ten years showed better results in the HA-coated (100% at five to six years) and cemented stems (100% at 5 to 6 years) than in the two press-fit groups. There was a higher mean rate of migration in the smooth and ridged Ti-Al-V shot-blasted press-fit groups (0.8 mm/year and 0.6 mm/year, respectively) when compared with the HA-coated and cemented prostheses (both 0.3 mm/year). More radiolucent lines and osteolytic lesions were seen in the press-fit groups than in either the HA-coated or cemented implants, with a trend for a lower incidence of both in the HA compared with the cemented group. Proximal osteopenia increased in the press-fit and cemented prostheses with time, but did not do so in the HA group. There was a higher incidence of resorption of the femoral neck with time in the cemented group than in the other three.

We conclude that the HA and the cemented interfaces both provide secure fixation with a trend in favour of HA. The cemented prosthesis meets the suggested National Institutes of Health definition of ‘efficacious’ at ten years.


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 3 | Pages 366 - 370
1 May 1997
Simank H Brocai DRC Reiser D Thomsen M Sabo D Lukoschek M

We report our results using three different threaded acetabular components (Mecring A, Mecring B and Weill) in 715 hips with a follow-up of between one and ten years (median: 99.1, 56.5, 38.3 months, respectively). All cups were implanted with one type of cementless stem.

The clinical results were good or acceptable in about 70% of the hips, but signs of loosening with radiolucency and/or migration were found in 10.1%. Radiological evidence of loosening did not correlate significantly with the clinical outcome. Pain was not a reliable indicator of loosening and its absence sometimes allowed severe osteolysis to develop. Twenty-five hips were revised (3.5%) for aseptic loosening of the acetabular component. Kaplan-Meier estimates of the cumulative rate of failure showed a rapid increase five years after the initial operation, but no significant correlation with gender, age or weight.

The high rate of failure indicates that further use of these acetabular components cannot be recommended. Annual radiographs are required to assess osteolysis even if the patients are free from pain.


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 3 | Pages 379 - 384
1 May 1997
McCaskie AW Barnes MR Lin E Harper WM Gregg PJ

The newer techniques of cementing aim to improve interlock between cement and bone around a femoral stem by combining high pressure and reduced viscosity. This may produce increased embolisation of fat and marrow leading to hypotension, impaired pulmonary gas exchange and death. For this reason the use of high pressures has been questioned.

We compared finger-packing with the use of a cement gun by measuring intramedullary pressures during the cementing of 31 total hip replacements and measuring physiological changes in 19 patients. We also measured pressure in more detail in a laboratory model.

In the clinical series the higher pressures were produced by using a gun, but this caused less physiological disturbance than finger-packing. The laboratory studies showed more consistent results with the gun technique, but for both methods of cementing the highest pressures were generated during the insertion of the stem of the prosthesis.


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 3 | Pages 374 - 378
1 May 1997
Hedlundh U Sanzén L Fredin H

We studied the risk of recurrent dislocation in 121 primary and 39 revision Charnley or Charnley hybrid total hip arthroplasties which had been treated for a primary dislocation between 1979 and 1995. Only 35% of these hips had no further dislocation or a revision for instability within one year. The rates of survival gradually declined with time or if a second, third or fourth dislocation occurred. The risk of recurrence was greater in men, but was not related to age, diagnosis, time of the first dislocation or whether the index operation had been a primary or a revision procedure.

Operative treatment included 15 reoperations leaving intact components, 50 revisions, and permanent removal of the femoral stem in seven patients. The operation was successful in four patients with reoperations and in 36 who had an exchange procedure within two years. Treatment was successful in 35 of 49 hips in which it was possible to correct a technical error compared with 5 out of 16 hips in which malposition of the components was not seen (p = 0.007).


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 3 | Pages 361 - 365
1 May 1997
Shih C Lee P Chen J Tai C Chen L Wu JS Chang WH

We made a clinical study of polyethylene wear in 240 hips of 187 patients having primary total hip arthroplasties from 1989 to 1990, using uncemented Osteonics components, with a head size of 26 mm. We excluded cups with anteversion of over 20° and measured linear wear by a new method using a digitiser and special software of our design. Follow-up was from two to five years (mean 4.3).

The mean age at operation was 50.3 years, with more men than women (1.4:1). The mean linear wear per year was 0.15 mm; this did not increase with the longevity of the prosthesis (p = 0.54). In 59 hips showing evidence of osteolysis, the mean linear wear rate was significantly higher at 0.23 mm/year (p < 0.001). The mean linear wear rate also correlated significantly with age at the time of operation (p = 0.008), but we found no significant correlations with body-weight, gender, aetiology of the disease, thickness of polyethylene, or cup position.

Our new method of measurement is time-saving and reproducible. The results confirm the greater rate of linear wear of polyethylene in patients showing osteolysis and in those who are younger.


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 2 | Pages 247 - 253
1 Mar 1997
Boos N Krushell R Ganz R Müller ME

We compared 74 total hip arthroplasties (THAs) carried out after previous proximal femoral osteotomy with a diagnosis-matched control group of 74 primary procedures performed during the same period. We report the perioperative results and the clinical and radiological outcome at five to ten years.

We anticipated a higher rate of complications in the group with previous osteotomy, but found no significant difference in the rate of perioperative complications (11% each) or in the septic (8% v 3%) and aseptic (4% each) revision rates. There was a trend towards improved survival in the group without previous osteotomy (90% v 82%), but this difference was not statistically significant. The only significant differences were a higher rate of trochanteric osteotomy (88% v 14%) and a longer operating time in the osteotomy group.

Our study indicates that THA after previous osteotomy is technically more demanding but not necessarily associated with a higher rate of complications. Furthermore, proximal femoral osteotomy does not jeopardise the clinical and radiological outcome of future THA enough to exclude the use of osteotomy as a therapeutic alternative in younger patients.


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 2 | Pages 265 - 268
1 Mar 1997
Barwell J Anderson G Hassan A Rawlings I

We studied the effects of the timing of tourniquet release in 88 patients randomly allocated for release after wound closure and bandaging (group A), or before the quadriceps layer had been closed allowing control of bleeding before suture (group B). The groups were similar in mean age, weight, gender, preoperative knee score, radiographic grading, and prosthesis implanted.

Patients in group B had less postoperative pain, achieved earlier straight-leg raising, and had fewer wound complications. Five patients in group A had to return to theatre, three for manipulation under anaesthesia, one for secondary closure of wound dehiscence, and one for drainage of a haematoma. The last patient later developed a deep infection, which was treated by a two-stage revision. There were no significant differences between the two groups in operating time, or the decrease in haemoglobin concentration at 48 hours postoperatively.

Some of the adverse effects of the use of a tourniquet for knee surgery can be significantly reduced by early tourniquet release, with haemostasis before the quadriceps mechanism and the wound are closed.


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 2 | Pages 235 - 239
1 Mar 1997
Takahashi T Wada Y Yamamoto H

We measured the pressure distribution across the tibiofemoral and patellofemoral joints during total knee arthroplasty (TKA) using Fuji pressure-sensitive film (Prescale) in 51 patients (63 joints) comparing the results with those in 21 patients in whom Prescale was not used.

We classified the stress-distribution patterns in the tibiofemoral joints into four types: normal, varus-valgus instability, rotational malalignment, and a combination of instability and malrotation. The medial ligaments were then released according to the information obtained from these patterns. The conformity ratio of the contact area between repeated trials was 87.0%. Pressure distribution across the patellofemoral joints was also considered.

There was a significant decrease in the mean valgus stress angle in the Prescale group compared with the control group (p < 0.01). Release of the lateral retinaculum according to the results showed no significant differences in subluxation of the patella between the released group and the group which did not appear to need this procedure.


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 2 | Pages 254 - 257
1 Mar 1997
Murray DW Britton AR Bulstrode CJK

Survival analysis of joint replacement relies on the assumption that surgical procedures in patients lost to follow-up have the same chance of failing as those in patients who continue to be assessed. Our study questions that assumption.

During the 16-year follow-up of 2268 patients who had received total hip replacements 142 (6%) were lost to follow-up. The cumulative loss at 15 years was 20%. At their last assessment, patients who subsequently failed to attend for follow-up had significantly worse pain, range of movement and opinion of their progress (p < 0.001) and significantly worse radiological features than a matched control group (p < 0.01).

Patients lost to follow-up have a worse outcome than those who continue to be assessed. Consequently, a survival analysis that does not take into account such patients is likely to give falsely optimistic results. It is therefore essential that vigorous attempts are made to minimise loss to follow-up, and that the rate of such loss is quoted. The overall loss to follow-up disguises the magnitude of the problem, which is best quantified by a cumulative rate of follow-up.

The reliability of a study can be assessed by a loss-to-follow-up quotient, calculated by the number of failures: the lower the quotient the more reliable the data. Ideally, the quotient should be less than 1.


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 2 | Pages 240 - 246
1 Mar 1997
Emery DFG Clarke HJ Grover ML

Fifty-seven Stanmore Total Hip replacements were implanted between 1974 and 1986 in patients under the age of 50 years. We have reviewed the results in terms of survivorship and function, and assessed the reasons for revision.

Of the original 57, 22 (39%) have been revised at an average of 12 years from implantation, usually for aseptic loosening. Most of them had originally been implanted for osteoarthritis. Prostheses cemented with second-generation techniques have lasted significantly longer, and acetabular loosening emerged as a continuing problem. The overall survivorship was 90% at 10 years and 68% at 15 years.

Cemented hip replacement appears to be a viable option in younger patients and the Stanmore implant is comparable with other cemented prostheses in this age group.