We report the outcome of total hip arthroplasty (THA) in a cohort of patients with complete long-term radiographic and clinical followup information from our database of more than 48,000 primary hip replacements. The purpose of the study was to evaluate the influence of various demographic factors and patient comorbidity (Charnley classification) on the long-term outcome of THA. The cohort was comprised of 25,990 total hip replacements (THRs) in 10,243 (46.6%) men and 11,754 (53.4%) women with a median age of 66 years (range, 20-96 years) at the time of arthroplasty. Our study confirmed that THA has an impressive efficiency and reliability in alleviating pain and improving function for almost all of the patients. Furthermore, the results are enduring with more than 90% of patients being satisfied with the outcome at 15 years. Clinical outcome measures reach their maximum at 2 to 5 years after arthroplasty and thereafter they decline gradually. Furthermore, patient age, gender, body mass index, and main diagnosis all have an influence on specific functional parameters. The Charnley classification has the most profound effect on the overall functional status of patients.

We reviewed 508 consecutive total hip replacements in 370 patients with old developmental dysplasia of the hip, to relate the amount of leg lengthening to the incidence of nerve palsies after operation. There were eight nerve palsies (two femoral, six sciatic), two complete and six incomplete,We found no statistical correlation between the amount of lengthening and the incidence of nerve damage (p = 0.47), but in seven of the eight hips, the surgeon had rated the intervention as difficult because of previous surgery, severe deformity, a defect of the acetabular roof, or considerable flexion deformity. The correlation between difficulty and nerve palsy was significant (p = 0.041), We conclude that nerve injury is most commonly caused by direct or indirect mechanical trauma and not by limb lengthening on its own.

Patients who had a revision total hip arthroplasty using the Bürch-Schneider anti-protrusio cage (APC) by a single surgeon have been reviewed after a minimum of five years. There were 63 operations in 58 patients with an average age of 63 years (41 to 83) at the time of revision. At an average follow-up of 8.5 years (5 to 18), 15 patients (25.9%) rated their results as excellent, 38 (65.5%) as good, and five (8.6%) as fair. Five further revisions of the acetabular prosthesis were required, three due to aseptic loosening, one for recurrent dislocation and one due to sepsis. Of the remainder, one was definitely loose, two probably loose, and 12 possibly so. Impressive augmentation of bone stock can be achieved with the anti-protrusio cage, while enabling the hip to be centred in its anatomical position.

The purpose of our study was to examine the clinical and technical problems associated with reconstruction of the hip in patients who had congenital dysplasia and to offer recommendations for their solution.We reviewed the records on 123 consecutive total hip arthroplasties that had been performed by one of us (M. E. M.), between 1981 and 1986, for the treatment of coxarthrosis due to congenital dysplasia of the hip. A minimum of five years of follow-up was required for inclusion in the study. The study group consisted of seventy patients who had had a total of eighty-seven reconstructions. According to the classification of Crowe et al., eleven hips had type-IV acetabular dysplasia; sixty-five, type-III; and eleven, type-II. Acetabular reconstruction was performed with use of the Müller acetabular roof-reinforcement ring and a polyethylene cup, which was inserted with cement. Autologous graft from the femoral head was used in forty-two hips. Femoral reconstruction was performed with use of the Müller straight-stem component for congenital dysplasia of the hip in eighty hips and with use of a standard Müller straight-stem component in seven hips.At an average of 9.4 years (range, five to fifteen years) postoperatively, the result was described as excellent for sixty hips (69 per cent), as good for twenty-three (26 per cent), as fair for two (2 per cent), and as poor for two. Nine (10 per cent) of the hips had been revised. One revision had been performed because of aseptic loosening of the acetabular component; one, because of aseptic loosening of the femoral component; one, because of aseptic loosening of both components; and six, because of infection. Of the unrevised hips, three had had superior migration of the acetabular component of less than five millimeters, and mild protrusio had developed in one. Two hips had a continuous radiolucent line around the acetabular construct. Two hips had had subsidence of the femoral stem of less than three millimeters; one had a complete, non-progressive radiolucent line at the bone-cement interface; and four had a radiolucent line at the proximal part of the bone-cement interface. Six hips had evidence of endosteal osteolysis. Six hips had grade-III or IV heterotopic ossification according to the system of Brooker et al.These results compare favorably with others in the literature. We recommend restoration of the anatomical hip center with the use of an acetabular roof-reinforcement ring and a polyethylene cup inserted with cement for the reconstruction of a deficient acetabulum. The acetabular reinforcement ring prevents resorption of bone graft and migration of the cup, which are major causes of failure of the cup in patients who have had a reconstruction of a deficient acetabulum. Bone graft should be used medially and superiorly as needed to augment bone stock notably. Cement should not be used to fill acetabular defects as we believe that it contributes to aseptic loosening.

To analyse the value and accuracy of preoperative planning for total hip replacement (THR) we digitised electronically and compared the hand-sketched preoperative plans with the pre- and postoperative radiographs of 100 consecutive primary THRs. The correct type of prosthesis was planned in 98%; the agreement between planned and actually used components was 92% on the femoral side and 90% on the acetabular side. The mean (+/- SD) absolute difference between the planned and actual position of the centre of rotation of the hip was 2.5 +/- 1.1 mm vertically and 4.4 +/- 2.1 mm horizontally. On average, the inclination of the acetabular component differed by 7 +/- 2 degrees and anteversion by 9 +/- 3 degrees from the preoperative plans. The mean postoperative leg-length difference was 0.3 +/- 0.1 cm clinically and 0.2 +/- 0.1 cm radiologically. More than 80% of intraoperative difficulties were anticipated. Preoperative planning is of significant value for the successful performance of THR.

Even at a medical center where hip arthroplasty is performed routinely without trochanteric osteotomy, selected arthroplasties still require greater trochanteric osteotomy. A technique of greater trochanteric biplane osteotomy and reattachment with one wire is described. The technique provides maximum stability with a minimum of internal fixation and it can be performed quickly. The postoperative rehabilitation protocol is the same as that used in hip arthroplasty patients without trochanteric osteotomy. Results with a minimum two-year follow-up period disclosed osseous union in 98% of 53 primary arthroplasties and 97% of 74 revision hip arthroplasties. Problems related to the greater trochanter necessitated reoperation in only two patients: one for reattachment of a migrated trochanter and one for trochanteric wire removal.

Revision hip arthroplasty in patients with massive acetabular bone deficiency has generally given poor long-term results. We report the use of an 'anti-protrusio cage', secured to the ischium and ilium, which bridges areas of acetabular bone loss, provides support for the acetabular socket, and allows pelvic bone grafting in an environment protected from excessive stress. Forty-two failed hip arthroplasties with massive acetabular bone loss were revised with the Burch-Schneider anti-protrusio cage and evaluated after two to 11 years (mean five years). There was failure due to sepsis in five hips (12%) and aseptic loosening in five (12%); the remaining 32 hips (76%) showed no evidence of acetabular component failure or loosening.

A comprehensive system has been developed for analyzing and reporting the results of total hip arthroplasty. The personal-computer-based system links patient demographic data with digital storage, retrieval, and analysis of roentgenographs. The system consists of a roentgenograph scanner for converting sheet film to digital data, an optical mark reader for patient data input, an archiving system with optical storage, and a physician display station for preoperative planning and postoperative evaluation. Once a roentgenograph has been digitized and stored, the image can be retrieved and manipulated in a manner not possible with the original sheet film. A selected roentgenograph can be brought to full or enlarged scale, enhanced, and overlaid with templates for preoperative planning or for postoperative measurement of changes. In addition, an intelligent database system has been developed for linking patient demographic information with the roentgenographic data. The database system employs uniform criteria and terminology and allows the retrospective study and statistical analysis of comparable cases. Three machine-readable code sheets are used: Form A, Replacement of the Hip; Form B, Hip Prosthesis Reoperation; and Form C, Follow-up. Forms A and B contain information concerning anamnesis, diagnosis, treatment, postoperative course, recovery, and discharge of the patient from the hospital. Form C provides information on physical examination, pain, mobility of the hip, walking ability, and evaluation of the results by the surgeon as well as the patient.

The following are lessons of 30 years of total hip arthroplasty (THA): Prosthetic components should allow for easy preoperative graphic planning with one or two templates only. Polyethylene is the weak link in THA and ought to be replaced by perfectly concentric metallic sockets and femoral heads of casted Cr/Co/Mo alloys. The operating technique should guarantee large exposure, suitable orientation of both components, and adequate fixation. Loosening is correlated with loss of bone stock and changes of the position of the implants. In case of progressive bone loss, one should reoperate already in presence of slight clinical symptoms to prevent more difficult and dangerous revisions. To evaluate objectively the outcome of THA, a combined data and roentgenographic documentation system with standardized terms and scales is necessary.

Johnston, R C; Fitzgerald, R H Jr; Harris, W H; Poss, R; Müller, M E; Sledge, C B Author Information

Presented at the 53rd Annual Meeting of the American Academy of Orthopaedic Surgeons, New Orleans, Louisiana, February 21, 1986. Reprint requests to Maurice E. MüUr, M.D., Dr.h.c, Hon. F.R.C.S.(Eng.), Emeritus Professor of Orthopaedic Surgery, Maurice E. MüUFoundation for Continuing Education and Research in Orthopaedic Surgery, Mur-tenstrasse 35 (P.O. Box 2016), CH-3001 Berne, Switzerland. Received: September 28, 1987.

Non-union of a long bone presents a formidable prospect to the patient. Eight months or more have, by d e f i n i t i ~ n , ~ elapsed since his injury and he is faced with a further period of prolonged treatment before he can return to a normal way of life. This series of 113 patients (one with 2 nonunions) was treated by rigid stabilization, where possible using compression by means of internal fixation. The principle of compression of a non-union to secure healing was described by Dank' in 1949. A series of 100 uninfected non-unions treated by rigid internal fixation was reported in 1966.4 The present series combines the further experience of one of the authors (Muller) with that of the resident staff of the Inselspital, Berne. It is the practice of Swiss Study Group Clinics to consider surgical intervention if a fracture shows evidence of delayed healing at 3-4 months and many cases of potential non-union are thus aborted. These cases are not included in this series, which is confined to long bones excluding non-unions of the femoral neck. The recorded results are

Während bei der reaktiven, „elefantenfußartigen” Form eine stabile Osteosynthese die Heilung zur Folge hat, sind beim reaktionslosen „atrophischen” Poeudarthrosetyp zusätzlich zur stabilen Osteosynthese eine Dekortikation und eine Spongiosaplastik notwendig.

Der alloplastische Ersatz des erkrankten Hüftgelenkes ist eine orthopädische Standardoperation geworden. Neben einer peinlichen Asepsis bleibt aber die Operationstechnik von ausschlaggebender Bedeutung. In zwei zusammenhängenden Filmen werden Richtlinien und Ablauf dieses Eingriffes, wie sie an der Orthopädischen Universitätsklinik in Bern anhand von über 3000 Fällen ausgearbeitet wurden, aufgezeigt. Die Filme sind so abgefaßt, daß sie auch einzeln in sich abgeschlossen und verständlich sind.