The poor results obtained in young patients when using a conventional prosthesis led to the resurgence of hip resurfacing to find less invasive implants for the bone. Young patients present a demand for additional activity, which makes them a serious challenge for the survival of implants. In addition, new information technologies contribute decisively to the preference for non-cemented prostheses. Maintaining quality of life, preserving the bone and soft tissues, as well as achieving a very stable implant, are the goals of every hip orthopaedic surgeon for these patients. The results in research point to the use of smaller prostheses, which use the metaphyseal zone more and less the diaphyseal zone, and hence the large number of the abovementioned short stem prostheses. Both models are principally indicated in the young adult. Their revision should be a more simple operation, but this is only true for hip resurfacing, not for short stems.

Los malos resultados obtenidos en pacientes jóvenes cuando se utiliza una prótesis convencional fueron la causa que motivó el resurgir de las prótesis de superficie, en un intento de buscar implantes menos invasivos para el hueso. Los pacientes jóvenes presentan una demanda de actividad adicional, lo cual los convierte en un serio reto para la supervivencia de los implantes. Además, las nuevas tecnologías de la información contribuyen de forma determinante a la preferencia de prótesis no cementadas. Mantener la calidad de vida, preservar el hueso y las partes blandas, así como conseguir un implante muy estable, son los objetivos que todo cirujano ortopédico de cadera persigue para este tipo de pacientes. Los resultados en investigación apuntan hacia el uso de prótesis de menor tamaño, que utilicen más la zona metafisaria y menos la diafisaria, dando lugar al extenso capítulo de las mencionadas prótesis de vástago corto. Ambos modelos tienen su principal indicación en el adulto joven. Su revisión debería ser una cirugía más sencilla pero este hecho solo se cumple para las prótesis de superficie, no así para los vástagos cortos.

OBJECTIVE:To evaluate the short-term results of an ultra high molecular weight polyethylene retentive cup in patients at high risk of dislocation, either primary or revision surgery.MATERIAL AND METHOD:Retrospective review of 38 cases in order to determine the rate of survival and failure analysis of a constrained cemented cup, with a mean follow-up of 27 months. We studied demographic data, complications, especially re-dislocations of the prosthesis and, also the likely causes of system failure analyzed.RESULTS:In 21.05% (8 cases) were primary surgery and 78.95% were revision surgery (30 cases). The overall survival rate by Kaplan-Meier method was 70.7 months. During follow-up 3 patients died due to causes unrelated to surgery and 2 infections occurred. 12 hips had at least two previous surgeries done. It wasn't any case of aseptic loosening. Four patients presented dislocation, all with a 22 mm head (P=.008). Our statistical analysis didn't found relationship between the abduction cup angle and implant failure (P=.22).CONCLUSIONS:The ultra high molecular weight polyethylene retentive cup evaluated in this series has provided satisfactory short-term results in hip arthroplasty patients at high risk of dislocation.

To evaluate the short-term results of an ultra high molecular weight polyethylene retentive cup in patients at high risk of dislocation, either primary or revision surgery.Retrospective review of 38 cases in order to determine the rate of survival and failure analysis of a constrained cemented cup, with a mean follow-up of 27 months. We studied demographic data, complications, especially re-dislocations of the prosthesis and, also the likely causes of system failure analyzed.In 21.05% (8 cases) were primary surgery and 78.95% were revision surgery (30 cases). The overall survival rate by Kaplan-Meier method was 70.7 months. During follow-up 3 patients died due to causes unrelated to surgery and 2 infections occurred. 12 hips had at least two previous surgeries done. It wasn't any case of aseptic loosening. Four patients presented dislocation, all with a 22 mm head (P=.008). Our statistical analysis didn't found relationship between the abduction cup angle and implant failure (P=.22).The ultra high molecular weight polyethylene retentive cup evaluated in this series has provided satisfactory short-term results in hip arthroplasty patients at high risk of dislocation.

INTRODUCTION:Mechanical failure of femoral stems of revision hip arthroplasty has been rarely reported. In the current study, the cause of two stem fractures, which occurred in vivo, was analysed with use of clinical and radiological data, and the functional result after revision is presented.CASE REPORT:Two patients, A 70-year-old male and a 73-year-old female, both of Mediterranean ethnic, and both patients underwent a revision total hip replacement to an uncemmented extensively porous coated stem. Both stems suffered an implant fatigue in vivo at three years and at two years follow-up respectively.CONCLUSION:Revision total hip arthroplasty is a procedure that will be performed more often the following years due to aging of population. Any orthopaedic surgeon performing hip surgery should be aware of the risk factors that can lead to total hip arthroplasty failure. In the analysed cases we can learn that the main factors related to this failure included the use of a small size stem (inferior to 14mm), an inadequate proximal osseous support because of trochanteric osteotomy, and a reduced preoperative bone stock. Although the use of cables has not been stated as a predisposing factor, we consider that they could also play a role in the development of this rare complication.

Intraoperative periprosthetic femoral fractures (IPFF) have been studied extensively for total hip arthroplasties, but not for hemiarthroplasties. Recent series in the literature show an IPFF rate for hemiarthroplasties ranging from 0% to 14%. The present study was designed to determine the prevalence and outcome after IPFF during non-cemented hemiarthroplasty. In addition, the surgical step at higher risk to produce these fractures was evaluated in an attempt to identify strategies that could minimize the prevalence of this complication. We performed an observational study of 365 consecutive patients undergoing and Austin-Moore hemiarthroplasty from 2005 to 2006 at our institution. The institutional IPFF rate was 6.8% (twenty-five out of 365). The moment at which the fracture was detected was collected: 1) intraoperatively and 2) in the postoperative radiological control. The surgical step in which the fracture occurred was collected: 1) neck osteotomy, 2) broaching, 3) prosthesis introduction, and 4) reduction. Results were compared to a control group according to blood transfusion rate, mortality rate and revision surgery rate. The fractures were detected during the surgery in twenty cases (80%); for the five remaining cases the fracture was only detected in the postoperative radiology. For those detected during the surgery, the two most common manouvers in which the fracture occurred was hip reduction (10 cases) and prosthesis introduction (7 cases). The blood transfusion rate, first-month mortality rate and revision surgery rate showed no statistical difference between the two groups (p = 0.3). In the present series, most of IPFF during Austin-Moore hemiarthroplasty implantation, occurred during arthroplasty reduction. Difficulties during this step should lead the surgeon to reconsider if technical mistakes are present and can be solved. However, if fracture occurs, adequate treatment of IPFF should provide satisfactory results without increasing blood transfusion needs, mortality or revision surgery.

Background Although HIV-infected patients are at greater risk of presenting with ischaemic necrosis of the femoral head, there have been concerns about whether total hip arthroplasty (THA) may have worse outcomes than expected. Methods From the Orthopedic and Trauma Surgery database we identified all patients who had undergone THA because of ischaemic necrosis of the femoral head from January 2001 until March 2010. Patient's diagnosis of HIV infection was confirmed at the time of arthroplasty by cross-matching with the HIV unit database. For every THA in HIV-infected patients, two THAs in patients not known to be HIV-infected, with the same diagnosis of ischaemic necrosis of the femoral head and having undergone surgery over the same period, were randomly selected. THAs were compared in HIV- and non-HIV-infected patients for surgical procedure, in-patient stay and long-term prognosis. Results There were 18 THAs in 13 HIV-infected patients and 36 THAs in 27 non-HIV-infected patients. No significant differences were observed in the mean time spent in surgery (106 vs. 109 minutes, respectively; P?=?0.66), the need for red cell transfusion (1 vs. 4, respectively; P?=?0.48) or the mean duration of hospitalization (7.8 vs. 9.4 days, respectively; P?=?0.48). The two groups showed similar postoperative functional results, which were maintained until the end of the follow-up period (median 3.3 years in the HIV-positive group and 5.8 years in the HIV-negative group). Conclusion Our study suggests that the outcome of THA in HIV-positive patients is not worse than that of HIV-negative patients, although future research on larger numbers of patients is required to confirm this.

OBJECTIVE:Check the agreement of a preoperative digital templating, compared with the final result in the postoperative radiograph.MATERIAL AND METHOD:The study was carried out on a 55 total hip prosthesis. A templating-software Neteous (Socincer, Gijón, Spain) was used. Agreement was measured using the Kappa Index for the stem offset or Lin Index for others variables: stem size, cup size, femoral neck length, and the distance from the center of rotation of the femoral head to the lesser trochanter. The percentage of accurate hits was also described.RESULTS:Stem size: The exact success or error of only one size was of 61.6%. Quantitatively the Lin Index was 0.64 (substantial). Horizontal offset: satisfactory agreement was obtained (Kappa index of 0.75). In 6 cases (10.90%) was changed to lateralized during surgery, for more joint stability. Size of the cup: the agreement obtained was 0.67 (substantial) with a hit grade of 43.6%. Prosthetic neck length: the exact hit or error of only one size were found in 50.9%, moderate level of agreement. Distance from the center of rotation to the lesser trochanter: was observed for almost perfect agreement with Lin Index of 0.95. The exact percentage of hits or gap error less than 5mm was 74.5%.DISCUSSION AND CONCLUSION:In ours hands, the preoperative templating software analyzed, has provided acceptable agreement rates, when compared with the postoperative result. But it takes more works verified by independent observers.

The aim of our study was to compare the effectiveness of high-pressure pulsatile lavage and low-pressure lavage in patients with an orthopaedic implant infection treated with open débridement followed by antibiotic treatment.

Currently there is limited information on the indications for the use of cortical allograft for the treatment of periprosthetic fractures on a stable stem. The purpose of this study was to retrospectively evaluate the treatment and the results obtained in this type of fractures and propose a series of criteria for the use of cortical allograft. Between 2003 and 2008 a total of 31 periprosthetic femur fractures were treated at our institution. Twelve of them were classified as B1: 6 were treated with a Dall-Miles (Stryker) system plate and 6 with the same plate supplemented with a structural cortical allograft over the medial cortex of the femur (DM and DM-Allo groups, respectively). An evaluation of the clinical and radiologic results was performed in the latest follow-up available. A patient in the DM-Allo group had rupture of a screw and 10 degrees varization; the fracture healed despite this and the patient had a satisfactory clinical course. The Oxford Hip Score was 9 points lower in the DM group compared with the DM-Allo group, and the EQ-5D health scale was 0.10 better for the DM group. The DM-Allo group had a longer hospital stay and more transfusion-related requirements. We think that the patients with clinical or radiologic criteria of osteoporotic bone may benefit from the use of a cortical allograft to favor healing and increase the bone stock. However, those advantages should be weighed considering the higher risk of surgical-related morbidity associated with the surgical insult.

Osteoarticular complications are common in patients with chronic renal failure and they often require implantation of a hip arthroplasty (total or partial) due to osteoarthritis, femoral neck fracture or ischemic necrosis of multifactor aetiology. Between 1992 and 2005 we operated on eighteen patients (23 hips) with chronic renal failure who were receiving renal replacement therapy (ten haemodialysis and eight renal transplants), and in each case either a total or partial hip arthroplasty was implanted. This group comprised nine women and nine men, with a mean age of 56 years (range: 30-83). Five cases were bilateral. The clinical diagnoses were necrosis (fourteen cases), femoral neck fracture (five cases) and osteoarthritis (three cases). The main early complications were haemorrhage in seventeen cases (74%) and infection in six cases (33%) (two urinary infections and four of the surgical wound). The late complications involved eight cases (35%) of prosthetic loosening (five aseptic and three septic). The surgery-related mortality rate was 17% (three cases). Prosthetic hip surgery in patients receiving renal replacement therapy is associated with high morbidity and mortality, thus highlighting the importance of careful patient selection.

Due to its advantages, ceramic-on-ceramic bearings have been widely used in young patients for almost 30 years. Long-term survivorship, low wear, and low biological reactivity to particles are some of its characteristics. Even though this material has had a lot of improvements, the risk of fracture is one of the concerns. There have been reports of fracture of ceramic in the acetabular liner and head but no fractures of both in the same patient. We report a case of a fracture in a sandwich type acetabular liner and the ceramic head in a patient involving ankylosing spondylitis. It occurred three years after the operation and with no history of direct trauma. We decided to change the bearing surfaces to metal polyethylene without removing the metal back. The patient is satisfied by the clinical results after a 5-year followup.

INTRODUCTION:At present a wide spectrum of cement types are available for cemented total hip arthroplasty (CTHA). All types have the same objective, i.e. to prolong the life of the implant for as long as possible. The purpose of this study was to compare the radiologic cement mantle of CTHA using cement with fast or standard setting characteristics.METHOD:A prospective comparative study of patients who underwent CTHA was performed: the first group received fast setting cement (Cemex System Fast), the second group received standard setting cement (Cemex System). A radiologic evaluation of the cement mantle was done using Barrack's classification. In order to give the study clinical relevance we assembled Barrack's classification in two groups: 1) Low risk group (Types A and B); 2) High risk group (Types C and D). According to ISO 5833:2002, the international standard was used to perform physico-chemical (polymerization temperature, setting time) and mechanical testing (compression strength, bending strength and bending modulus).RESULTS:The fast setting cement showed a shorter setting time and a higher polymerization temperature. The mechanical performances of both cements met the ISO limits. At a mean follow-up of 23 months (11-37 months) no statistically significant radiological difference was found in the radiologic cement mantle between the two groups either in the post-operative X-ray evaluation (p=0.32) or in the last follow-up (p=0.72). Statistical evaluation was done comparing the two sub-groups, i.e. low risk and high risk.CONCLUSIONS:The use of fast or standard setting cement does not produce any difference in the quality of the radiologic cement mantle in the short-term. Both cements comply with ISO 5833 requirements.

The sliding hip screw, sometimes called the dynamic hip screw (DHS) has been a successful method for treating hip fractures. Nevertheless, mechanical complications of this system have been reported from time to time. They are mainly the result of instability of the fracture, bone quality and technical errors occurring during surgery. We report a case of an intrapelvic protrusion of a sliding screw after a basicervical fracture was treated with a DHS and a 6.5 mm cannulated screw, and its surgical solution using a hybrid total hip arthroplasty. In our case we think the mechanical failure was due mainly to technical errors during surgery. Despite that, we believe the sliding hip screw is the implant of choice for basicervical fractures. Using an additional K-wire during the technique is sufficient to avoid rotation of the proximal fragment and no additional fixation is necessary.;

Exponer dos técnicas quirúrgicas de refuerzo de una osteosíntesis convencional en situaciones especiales de debilidad ósea del fémur, como son las fracturas periprotésicas, las fracturas patológicas y los fracasos de osteosíntesis previas en pacientes de edad avanzada. La debilidad del hueso puede llegar a dificultar la realización de osteosíntesis estables en fracturas de fémur porque impide el correcto anclaje del material, ya sean agujas, cerclajes o especialmente tornillos. Se evaluaron 13 pacientes (media de edad de 78,3 años), 9 de los cuales sufrieron fracturas periprotésicas de fémur, dos fracasos de osteosíntesis previas, un caso de pseudoartrosis tras una fractura periprotésica y una fractura diafisaria en un fémur muy osteoporótico, en los cuales se han utilizado dos técnicas de refuerzo del hueso: el cementado endomedular y el implante de contraplacas atornilladas de aloinjerto óseo congelado. Se realizó un seguimiento de estos pacientes en un período que oscila entre 12 y 72 meses (media de 26,2 meses). En un caso se produjo una pseudoartrosis de la fractura por ocupación accidental del foco de fractura por el cemento acrílico. En los 12 casos restantes se consiguió la consolidación. El cementado endomedular y la utilización de contraplacas atornilladas de aloinjerto óseo son dos recursos técnicos útiles en situaciones especiales en las que es necesario realizar una osteosíntesis estable sobre un hueso muy débil. To describe two surgical techniques for reinforcing conventional bone fixation in special situations of femoral bone weakness, such as periprosthetic fracture, pathologic fracture, and failure of previous bone fixation in patients of advanced age. Bone weakness can make it difficult to achieve stable osteosynthesis of femoral fractures because it impedes correct fixation of materials, whether pins, tension bands or, especially, screws. Thirteen patients (mean age 78.3 years) were evaluated, 9 with periprosthetic fracture of the femur, 2 osteosynthesis failures, 1 nonunion after periprosthetic fracture, and 1 diaphyseal fracture in an osteoporotic femur. Two techniques were used to reinforce the bone: intramedullary cementing and the implantation of screw-on counterplates of frozen bone allograft. Patients were followed up for 12 to 72 months (mean 26.2 months). In one patient, nonunion occurred due to accidental occupation of the fracture site by acrylic cement. The remaining 12 patients achieved bone healing. Intramedullary cementing and the use of screw-on counterplates of bone allograft are two useful technical resources for special situations requiring stable bone fixation of very weak bone.

Infection of a total hip prosthesis by Mycobacterium tuberculosis (MT) is an uncommon complication. We report a patient with septic loosening of a total hip prosthesis with a presumptive diagnosis of MT infection. His previous history was negative to any form of tuberculosis, and there was no evidence of a primary focus on the radiological study of the chest. He was diagnosed initially as presenting aseptic loosening and revision surgery was performed. Six months after surgery, septic loosening was diagnosed. The prosthesis was then removed. The histological study showed caseum granulomas and acid-fast bacilli, and routine cultures of the synovial fluid were negative. Since only a positive Löwenstein culture would have confirmed the diagnosis with certainty, a presumptive diagnosis of MR infection was made based on the findings in the histological study. Tuberculostatic treatment was administered for 9 months. At six years follow-up no signs of infection are present, neither by clinical or radiological criteria.

The implant of a proximal femoral structural allograft is one of the possibilities to restore circumferential defects of multiply revised total hip arthroplasties. A review of 7 patients who underwent proximal femoral reconstruction with an allograft-prosthesis composite to restore bone loss in revision hip replacements is presented. The average follow-up period was 50.2 months. Two patients developed an infection and in one case an instability of the prosthesis appeared. Incorporation in the remaining 5 cases was/achieved in an average period of 8.2 months. Neither fractures nor high rate of resorption appeared in our series. The majority of patients have improved in the functional assessment. Despite the rate of complications, structural femoral allografts can be used with success in this difficult challenge of reconstructing major segmental bone loss of the proximal femur in revision hip surgery.

We are reporting the cases of five patients in whom a pathological fracture of the femoral neck developed secondary to massive deposition of amyloid while they were receiving maintenance hemodialysis. The immunohistochemical studies demonstrated the presence of beta-2-microglobulin as the major constituent protein of the amyloid deposits.

Three hundred patients were included in a prospective randomized double-blind trial comparing the efficacy of cefamandole with that of a placebo for prophylaxis of sepsis in operations using Ender or Küntscher nails, bone plates, or other internal fixation devices. Patients with an open fracture, total joint replacement, or direct operation on the hip were not included in the study. Sixteen patients were excluded because the trial protocol was not followed exactly, so a total of 284 patients participated, 134 of whom were given cefamandole and 150, a placebo. The two groups were similar in terms of mean age, sex ratio, duration of preoperative hospital stay, underlying risk factors, and type of surgical procedure. A superficial wound infection developed in none of the 134 patients who were given cefamandole and in seven of those in the control group (p less than 0.05). Two deep-wound infections developed in the cefamandole-treated group and four, in the control group (p greater than 0.05). Staphylococcus aureus, Staphylococcus epidermidis, and gram-negative bacilli were the most common infecting organisms. The rates of infection-related mortality and abscopal infection were similar in both groups. No adverse side effects of the drug were encountered.