Of the. 4 hips in Charnley category A, the diagnosis was avascular necrosis in 3 and developmental dysplasia of the hip in 1. In the 11 hips in Charnley category C, 9 were affected by juve- nile rheumatoid arthritis and 2 by multiple epiphyseal dyspl
before undergoing a total hip replacement, and counselled regarding the complications. ..... Deep infection: revised at 6 months - ended up as Girdlestone. 66. F.
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Radiological analysis assessing heterotopic ossification, femoral osteolysis and femoral stem ... following total joint replacement.12 A retrospec- tive study by ...
and the types of arthroplasty performed are shown in Tables. II and ... arthroplasties performed. Number of ..... in all 12 a Girdlestone arthroplasty was performed.
Gonzalez Della Valle A, Serota A, Go G, Sorriaux G, Sculco TP, Sharrock NE, et al. Venous thromboembolism .... Yu HT, Dylan ML, Lin J, Dubois RW. Hospitals' ...
Abstract: Instability after total hip arthroplasty (THA) is not a rare occurrence. Numerous factors have been associated with dislocation including surgical approach, implant design, failure to restore proper hip mechanics and soft tissue restraints,
V early osteointegration. On-growth of bone to porous coated prostheses is ... rich femoral component or with the ce- ... total hip arthroplasty in dogs (1, 2). Loo-.
Total hip replacement (THR) is a very common procedure undertaken in up to 285 000 .... diagnosis can include activity-related pain, aseptic loosening,.
an ideal total hip replacement with a large femoral head and a high head-neck ratio. B: Cam-type impingement in the native hip caused by a reduced femoral head-neck offset and similar impingement in a prosthetic hip with a small femoral head and a sk
Aug 13, 2017 - Parkinson's disease patients at 36 months after elective total hip ... Hoehn-Yahr scale, average. 2.30 ... on the assessment of risks and benefits of surgery. 2. .....  R. Skelly, F. Lindop, and C. Johnson, “Multidisciplinary care.
Total. 91. RESU. LTS. The 107 patients had 112 hip replacements; .... fixation versus hemiarthroplasty for the displaced subcapital fracture of the femur:.
Background Total hip replacement is increasingly used in active, ... femoral neck fracture (Garden III or IV) or a secondary total .... Type of total hip arthroplasty.
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The hip joint is commonly involved in multiple epiphyseal dysplasia and patients may require total hip replacement before the age of 30 years. We retrospectively reviewed nine patients (16 hips) from four families. The diagnosis of multiple epiphysea
The wait for total hip replacement in patients ... Objectives: We documented the following components of waiting time for total hip replacement. (THR): first .... time for people with hip OA who are ...... OA-rehab: designing a personalized exer-.
stable (greater than the control) when walking over barriers as was roll for the sit-to-stand task, indicative of ... after total hip replacement regarding the risk of a fall, especially in the elderly. Most patients ... metre cable to a computer whi
resulting in deformities, protrusio acetabuli and malalignment of the limbs. Ligamentous laxity is seen frequently. In the past few decades there has been an ...
Apr 29, 2013 - ing total hip replacement, and they were likely to change coital positions. The most common concern regarding sexual activity of patients was ...
This is an enhanced PDF from The Journal of Bone and Joint Surgery. 1979;61:15-23. ... ondary to congenital dislocation of the hip 1.4Ã¢â¬Â¢Charnley and Feagin ...
1 Health Services Research Unit, Institute of Applied Health Sciences, University of Aberdeen, UK. 2 Health Economics Research Unit, Institute ...... October 2006. Abstract A9-3. 79. Yoon TR, Moon E, Rowe SM, Jung ST, Seo HY,. Lee JY. ..... http://ww
STANMORE TOTAL HIP REPLACEMENT IN YOUNGER PATIENTS REVIEW OF A GROUP OF PATIENTS UNDER 50 YEARS OF AGE AT OPERATION D. F. G. EMERY,
H. J. CLARKE,
M. L. GROVER
From Queen Alexandra Hospital, Portsmouth, England
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. J Bone Joint Surg [Br] 1997;79-B:240-6. Received 15 August 1996; Accepted after revision 2 October 1996
Now that total hip replacement (THR) is widely used and accepted, more and more young patients are considered for operation (Figs 1 and 2). A number of studies have been made on the long-term results of Charnley arthroplasty in 1-3 young patients, but none concerning the Stanmore design, despite its use with the same stem geometry for
over 25 years (Fig. 3). We report the results of a series of Stanmore replacements implanted in patients under 50 years of age. PATIENTS AND METHODS Between 1973 and 1984, a total of 970 Stanmore THRs was implanted by or under the supervision of a single surgeon; of these 57 were in patients aged under 50 years. Most of the femoral prostheses were mark-9 stem; three were long-stem revision prostheses. The head size was 25 mm in all cases. The cups were all of high-density polyethylene, either standard Stanmore cups or the Portsmouth design (Fig. 3), which was a hybrid of the Charnley with a Stanmore bearing surface. A posterior approach was used in all. First-generation cementing techniques were used until November 1979, and second-generation methods thereafter. All patients had been followed up at regular intervals in specially organised clinics and the results recorded on a standardised ‘card index’ form. This contained demographic data and a written operative note with much information in numerical form on pain, movement, function and patient satisfaction. An overall indication of outcome was made at each attendance. An anteroposterior radiograph of the hip was taken and the cards and the radiographs were retained within the orthopaedic department. The information on the cards has now been transferred to a computer database. Patients were reviewed at six months and at one year and two-yearly intervals thereafter until the patient died, the prosthesis was revised, or until the patient became too decrepit or senile to attend. The clinics ended in April 1991. The notes of all patients whose prostheses were still in situ at the time when the clinics ceased were examined and if the implant had been revised, the reason for and time to revision were noted. If the patient had died after 1991 the notes were reviewed to assess whether the prosthesis had been revised or had been functioning satisfactorily until death. All remaining patients were then invited for review by the first author and all but two attended. They were asked to complete a questionnaire and examined to allow 4 the Merle D’Aubign´e score to be calculated. Using the scores from the original review and from the THE JOURNAL OF BONE AND JOINT SURGERY
STANMORE TOTAL HIP REPLACEMENT IN YOUNGER PATIENTS
Fig. 2 Figure 1 – Bilateral severe rheumatoid arthritis of the hip in a 17-year-old girl. Figure 2 – The same patient 19 years after bilateral Stanmore arthroplasties.
1995/96 clinics, a graph of the progression of the Merle D’Aubign´e scores was then prepared. A standard AP radiograph was taken, reviewed according to the methods of 5 6 Gruen, McNeice and Amstutz and DeLee and Charnley, and compared with the last available radiograph to assess whether there had been appreciable change or migration of either component; the amount of osteolysis was noted. A survivorship life table was then calculated according 7 8 to the method of Dobbs and Murray et al, and confidence 9 intervals calculated according to the Peto equation. We were able to assess the eventual outcome clinically, radiologically and in terms of survivorship for all but four of the original 57 hips. RESULTS Fifty-seven prostheses were implanted in 46 patients, of whom 31 were female and 15 male, with 38 hips in women VOL. 79-B, NO. 2, MARCH 1997
and 19 in men. The average age was 41 years (17 to 49). Most of the procedures were for primary osteoarthritis, with 21% for rheumatoid arthritis and 21% after hip disease in childhood. Previous operations had been carried out on the hip in 15% (Table I). The average time to follow-up was 13 years (3 months to 21 years). One patient had not attended from the time of his six-month follow-up, but attendance in the review clinics was otherwise extremely good. Of the original 57 prostheses, 24 (40%) remain in situ in patients who are still living. All these were reviewed in 1995/96 by the first author. Seven prostheses (12%) were in patients who had died, 22 (39%) have been revised or have failed, and four (9%) have been lost to follow-up. First-generation cementing techniques were used in 37 hips and 20 were implanted by more modern methods. The average follow-up period and the original diagnoses did not vary significantly between the two groups.
D. F. G. EMERY,
H. J. CLARKE,
M. L. GROVER
Table I. Diagnosis and previous operations in 57 patients under 50 years at THR Number Diagnosis Primary osteoarthritis (OA) Rheumatoid arthritis (RA) CDH Secondary osteoarthritis Birth injury SUFE Ankylosing spondylitis Revision of Girdlestone Revision THR Previous operations Pin and plate for trauma Crawford Adams pins Macmurray osteotomy Stanmore THR Girdlestone
Fig. 3 Stanmore hip replacement stems. Stanmore and Portsmouth cups.
23 12 10 5 2 2 1 1 1 3 2 1 1 1
Merle d’Aubign´e scores. Merle D’Aubign´e scores were calculated from the cards and from the recent clinic visits. The preoperative scores were 1.5 for pain, 3.4 for movement and 3.6 for function. This gives an overall poor assessment, which improved to excellent soon after operation and was maintained for 14 years; after 16 years, the numbers were too small give reliable results. The changes in each of the three scores are shown in Fig. 4. The average patient satisfaction on a scale of 0 to 5 remained greater than 4 until 16 years. Radiographs. A review of the radiographs of the surviving prostheses showed that six (28%) of the acetabula had progressive radiolucency in all three zones. Only two sockets (8%) had migrated (Fig. 5) and there was one osteolytic lesion of 1 cm in diameter. The average wear was 1.5 mm with a range of 0 to 4 mm. On the femoral side there was no evidence of radiological loosening. There were four isolated lytic lesions in the calcar and one within the medullary canal. Revision. Twenty-two of the 57 prostheses have been
Fig. 4 Graph showing the progression of the Merle D’Aubign´e scores. THE JOURNAL OF BONE AND JOINT SURGERY
STANMORE TOTAL HIP REPLACEMENT IN YOUNGER PATIENTS
Fig. 5 Radiograph 14 years after operation showing migration of the cup on the right side. At revision, the stem was found to be solidly fixed and was left in situ.
Table II. Reason for revision related to diagnosis
Reason for revision
OA (n = 12)
RA (n = 3)
Childhood diseases Total (n = 7) (n = 22)
Mean time to failure (yr)
Cup loosening Stem loosening Cup and stem loosening Recurrent dislocation Infection Stem fracture
5 1 4 0 1 1
0 1 2 0 0 0
2 3 1 1 0 0
12.2 8.8 12.3 1.8 1.8 1.8
13.3 8.9 14.9 2.1 0.25 18.8
7 5 7 1 1 1
* of whole series
Table III. Reason for revision related to cementing technique Reason for revision
Cup loosening Stem loosening Cup and stem loosening Recurrent dislocation Infection Stem fracture Total
5 4 6 1 1 1 18
2 1 1 0 0 0 4
revised or have failed, mainly for aseptic loosening. Most had been implanted originally for osteoarthritis after disease in childhood. Only 25% of replacements performed for rheumatoid arthritis have been revised compared with 43% of those for osteoarthritis and 50% of those secondary to childhood disease (Table II). The average time to revision was 12 years (3 months to 21 years). The average time to aseptic loosening was 13 years. Revision for loosening of the stem only was carried out on average 4.4 years earlier than for loosening of the cup only, and six years before operation for loosening of both cup and stem. Radiographs taken immediately before revision showed osteolysis of the femur in seven prostheses. Most had failed due to Gruen type-1A failure (i.e. VOL. 79-B, NO. 2, MARCH 1997
subsidence of the stem within the cement mantle). Of the 22 hips requiring revision, 18 had been implanted using first-generation cementing techniques (Table III). Survivorship. A survivorship table was prepared according 7 to the method of Dobbs (Table IV) and is shown graphically in Figure 6. The column on the survivorship table normally titled ‘withdrawal’ has been clarified by division into ‘Died’ and ‘Lost to follow-up’ as suggested by a 10,11 number of authors. The confidence intervals and number at risk are shown on the graph. There was a survivorship of 90% at 10 years and 68% at 15 years. After 18 years the numbers were less than 10 and are too small to give a reliable estimate. DISCUSSION Our study used information collected by a single surgeon on his series of Stanmore hip replacements. This series has 12-14 We reviewed the cases been the source of other papers. of all patients under 50 years of age at the time of operation. All but three have remained under regular review with a loss to follow-up of only 9%. The use of confidence intervals in survivorship analysis 8,11,15-17 of joint replacement is recommended. but Murray
Fig. 6 Survivorship. The 95% confidence intervals and number at risk are shown on the graph.
et al state that calculations of standard errors are of dubious value in series of less than 200 patients. Few papers on hip replacement in young patients can achieve this number, and we have therefore provided confidence intervals, with the recommendation that they should be interpreted with some caution. Sir John Charnley originally advised that THR should be reserved for elderly patients, but the dramatic success of the operation led to operations on younger patients with 18,19 and survivorship figures from 69% encouraging results, 20 at five years to 98% at ten years (Table V). Barrack et al using second-generation cementing techniques, report no loosening of stems but significant problems with the cup at 21 ten years, and Ballard et al had similar results. There have been three recent series from single surgeons in specialist units giving a survivorship of between 69% and 88% at 20 1-3 years for the Charnley arthroplasty, with loosening of the acetabulum the main reason for revision. Our findings of a
survivorship of 90% at 10 years and 68% at 15 years are comparable with all the other series except those from specialist units or when ceramic-on-ceramic prostheses 22 have been used. The clinical scores remained excellent up to 14 years and the average time to revision of 12 years appears to have improved after the introduction of secondgeneration techniques of cementing. Joint replacements implanted in patients with rheumatoid disease tend to last longer in young patients, probably because of reduced activity. In our series revision rates for loosening of the stem and the cup were roughly equivalent, but radiographic review has shown that appearances about the acetabulum continue to deteriorate. Isolated loosening of the stem presented earlier as a clinical problem than that of the acetabulum alone or of both combined, perhaps because it produces pain earlier. Second-generation techniques of cementing have sigTHE JOURNAL OF BONE AND JOINT SURGERY
STANMORE TOTAL HIP REPLACEMENT IN YOUNGER PATIENTS
Table V. Comparison of published literature on THR in young patients
Various unspecified Charnley/Muller T28/Mckee Farrar Charnley
<50 (18 to 50) <45
Cementing method †
Year Survival (%) 10 15 10 20 10 10 20 10 20 10
90 68 95 88 88 90 69 93 75 88
<55 (mean 50) <30 (14 to 30) <30 (12.30)
21% revised at 5 years No revisions at 7 years
<30 (mean 25)
1 Revision at 8 years
* not known † 1 = first-generation cementing techniques, 2 = second-generation cementing techniques
nificantly decreased the incidence of loosening of the stem. Problems on the acetabular site remain, but pressurisation of the socket and better bearing surfaces may bring 23-27 improvement. The Stanmore hip has been shown to give long-term results which are comparable with those of other cemented prostheses. The results of Charnley THR by a single surgeon in a specialist unit are only marginally better. We
consider that THR in a young patient should be undertaken only by an experienced surgeon, using a prosthesis which has given reliable results after long-term follow-up. The authors would like to thank Mr R. A. Denham for permission to review his series of patients, and acknowledge his foresight in organising the original clinics in which the data were collected. One or more of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article.
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