Automated seeded lesion segmentation on digital mammograms

The clinical results of eighty-four total hip arthroplasties performed through a transtrochanteric approach in sixty-seven patients who had a high dislocation of the hip (the femoral head completely out of the acetabulum), from 1976 to 1994, were reviewed. The acetabular component was placed in the true acetabulum and the femur was shortened at the level of the femoral neck, along with release of the psoas tendon and the small external rotators, in order to facilitate reduction of the components and to avoid neurovascular complications. Eleven hip prostheses (13 per cent) failed at a mean of 6.4 years (range, two months to sixteen years) postoperatively; the failure was due to aseptic loosening of both components in four hips, aseptic loosening of the stem only in three, late infection in three, and malpositioning of the acetabular component that caused recurrent dislocations in one. The other seventy-three hips were functioning well at the latest follow-up examination, two to twenty years (mean, 7.1 years) postoperatively. The overall cumulative rate of success was 92.4 per cent (95 per cent confidence interval, 89.5 to 95.3 per cent) at five years and 88.0 per cent (95 per cent confidence interval, 82.2 to 93.8 per cent) at ten years. We believe that this operative technique of total hip arthroplasty is effective for the treatment of the difficult condition of high dislocation of the hip.     

Long-term results of total hip replacement in young patients who had ankylosing spondylitis. Eighteen to thirty-year results with survivorship analysis

We determined the long-term results of total hip replacement in a series of young patients who had ankylosing spondylitis. Between 1966 and 1978, forty-three Charnley low-friction arthroplasties were performed in twenty-four patients who had an average age of 28.8 years (range, nineteen to thirty-nine years) at the time of the operation. There were seventeen men and seven women. The average duration of follow-up for the series was 22.7 years (range, one month [a perioperative death] to 30.3 years). Four patients (seven hips) had died an average of 12.6 years (range, one month to 18.7 years) after the operation. The twenty surviving patients had clinical and radiographic follow-up until the time of writing or until both of the original components had been revised. All patients had substantial relief of pain and improvement of function and the range of motion of the joint. Twenty-one patients (88 per cent; thirty-nine hips) were completely free of pain (6 points, according to the scale of Merle d'Aubigne and Postel), and the remainder had only slight discomfort (5 points). Ten acetabular components and one femoral component were revised because of aseptic loosening, and one patient had a revision of both components because of late deep infection. Three additional femoral components were revised during a revision operation for a loose acetabular component. Although the femoral components were not loose, they had been in place for more than ten years and it was thought likely that the bearing surface was damaged. The average time to revision was 13.3 years (range, 4.0 to 20.3 years). At an average of 22.7 years, thirty-eight (88 per cent) of the original femoral components and thirty-two (74 per cent) of the original acetabular components remained in situ. The average annual rate of acetabular wear was 0.12 millimeter for the entire series. Only six hips (14 per cent) had minor heterotopic ossification, and none of the hips had clinically important ossification (class III or IV according to the system of Brooker et al.). To our knowledge, the present report describes the largest series of total hip arthroplasties, with the longest duration of follow-up, in young patients who had ankylosing spondylitis. Survivorship analysis with use of the Kaplan-Meier method revealed that the probability of survival of the femoral component (with 95 per cent confidence intervals) was 91 per cent (83 to 99 per cent) at twenty years and 83 per cent (72 to 94 per cent) at thirty years. The probability of survival of the acetabular components was 73 per cent (61 to 84 per cent) at twenty years and 70 per cent (57 to 83 per cent) at thirty years. The probability that both components would survive was 91 per cent (82 to 100 per cent) at ten years, 73 per cent (61 to 84 per cent) at twenty years, and 70 per cent (57 to 83 per cent) at thirty years. The Charnley low-friction arthroplasty provided consistently good long-term results, with a low rate of complications and revisions, in this group of young patients.     

Charnley total hip arthroplasty in patients less than fifty years old. A twenty to twenty-five-year follow-up note

We evaluated the results twenty to twenty-five years after ninety-three consecutive, nonselected Charnley total hip arthroplasties performed with cement by the senior one of us in sixty-nine patients who were less than fifty years old at the time of the procedure. Seventy of the seventy-two hips in the living patients were followed radiographically for at least twenty years. Twenty-seven hips (29 per cent) had a revision or a resection of the prosthesis during the follow-up period. The revision or the resection was performed because of aseptic loosening in twenty-one hips (23 per cent), infection in four (4 per cent), dislocation in one (1 per cent), and fracture of the femur in one. Eighteen acetabular components (19 per cent) and five femoral components (5 per cent) were revised because of aseptic loosening, and an additional fourteen acetabular components (15 per cent) and seven femoral components (8 per cent) demonstrated definite or probable radiographic loosening. The present study demonstrates the long-term durability of total hip arthroplasty performed with cement in an active population of patients. The fixation of the femoral component was found to perform better than that of the acetabular component at twenty to twenty-five years after the procedure.     

Neuroimaging in the high-risk infant: relationship to outcome

PURPOSE OF THE STUDY: Dislocation following total hip arthroplasty (THA) continues to be a problem. An innovative treatment is described with the intermediate Bousquet's prosthesis. This study reported 13 cases and demonstrates its high reliability despite the origins of the dislocation. Recurrent dislocation following initial dislocation, occurs in between 25 to 60 per cent of the cases reported in the literature. The main cause is a malpositioned prosthetic component and especially a retroverted acetabulum. The other reasons for dislocation were: trochanteric non-union, bone or cement impingement, previous surgery, age and neurologic disorder. In every case the instability of the hip may be caused or increased by muscular insufficiency. Various methods are described to control recurrent dislocation: repositioning the component, posterior acetabular wall component, trochanteric advancement, retentive acetabular component, bracing. When the cause is clear and isolated, the rate of success may be 70-80 per cent. This study examines the results of a revision procedure with the intermediate Bousquet's prosthesis. MATERIAL AND METHODS: 13 recurrent dislocations were treated with the intermediate Bousquet's prosthesis. There were 10 women and 3 men with an average age at operation of 73 years. The main cause in 7 cases was an abductor insufficiency including 4 trochanteric non unions. The other causes were 6 component malpositions, 7 previous surgery, 1 impingement. The average delay between the first dislocation and revision was one year. The Bousquet's acetabular component is an steel cup covered with alumina, impacted without cement. The polyethylene component is free in the cup and retentive on the femoral head. The femoral positioning was not modified. RESULTS: The revision did not correct all of the causes of luxation, however we noted only one case of dislocation and no recurrent dislocations. DISCUSSION: At last follow-up, all recurrent dislocations were controlled. Nevertheless, there remained 7 abductor insufficiencies and 4 femoral malpositionings. In the literature the rate of success depends on the cause. The main difficulty is the treatment of joint laxity. Some authors propose trochanteric advancement, a larger head, a posterior wall acetabular component, retentive acetabular component. Success is not uniform. The Bousquet's acetabular component supports joint laxity and femoral malpositioning. This allows to keep the same original femoral component when the risk is too high for a cemented prosthesis or impossible for a non cemented prosthesis. CONCLUSION: This treatment of the recurrent dislocation is reliable with a short and simple operation.     

Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury

The results were reviewed for 259 patients who had open reduction and internal fixation of 262 displaced acetabular fractures within twenty-one days after the injury. Two hundred and fifty-five hips were followed for a mean of six years (range, two to fourteen years) after the injury; the remaining seven, which clearly had a poor result, were followed for less than two years. According to the classification of Letournel and Judet, associated fracture types accounted for 208 (79 per cent) of the fractures, with both-column fractures being the most common type (ninety-two hips; 35 per cent). Two hundred and fifty-eight hips were operated on with a single operative approach (Kocher-Langenbeck, ilioinguinal, or extended iliofemoral). The four remaining hips were operated on with a Kocher-Langenbeck as well as an ilioinguinal approach. The reduction was graded as anatomical in 185 hips (71 per cent). The rate of anatomical reduction decreased with increases in the complexity of the fracture, the age of the patient, and the interval between the injury and the reduction. The over-all clinical result was excellent for 104 hips (40 per cent), good for ninety-five (36 per cent), fair for twenty-one (8 per cent), and poor for forty-two (16 per cent). The clinical result was related closely to the radiographic result. The clinical result was adversely affected by associated injuries of the femoral head, an older age of the patient, and operative complications. It was positively affected by an anatomical reduction and postoperative congruity between the femoral head and the acetabular roof. Osteonecrosis of the femoral head was noted in eight hips (3 per cent), and progressive wear of the femoral head was seen in thirteen (5 per cent). Subsequent operations included a total replacement of seventeen hips (6 per cent), an arthrodesis in four (2 per cent), and excision of ectopic bone in twelve (5 per cent). These findings indicate that in many patients who have a complex acetabular fracture the hip joint can be preserved and post-traumatic osteoarthrosis can be avoided if an anatomical reduction is achieved. An increase in the rate of anatomical reduction and a decrease in the rate of operative complications should be the goals of surgeons who treat these fractures.     

Total hip arthroplasty with cement in patients who have rheumatoid arthritis. A minimum ten-year follow-up study

One hundred and six consecutive total hip arthroplasties with cement were performed by one surgeon, at least ten years before the time of the present clinical and radiographic review, in seventy-five patients who had adult-onset rheumatoid arthritis. Two patients (three hips) were lost to follow-up. Seven (7 per cent) of the remaining 103 hips were revised. The revisions were performed because of infection (three hips), dislocation (two hips), or aseptic loosening (two hips). Of the ninety-eight hips that were not lost to follow-up or revised because of infection or dislocation, eight (8 per cent) had radiographic loosening of the acetabular component and two (2 per cent) had radiographic loosening of the femoral component. Although the prevalence of radiographic loosening of the acetabular component was four times greater than the prevalence of radiographic loosening of the femoral component, the prevalence of revision because of aseptic loosening of the acetabular component was identical to that for the femoral component (one component each). These results compared favorably with those of total hip arthroplasty with cement, performed by the same surgeon, for the treatment of other diagnoses. Loosening of the acetabular component was significantly associated with a younger age at the time of the index operation (p = 0.03) and with acetabular osteolysis (p = 0.0006). Of forty-eight hips in thirty-two patients who survived for at least ten years, 96 per cent (forty-six hips) were considered by the patients to have a satisfactory result. At the time of the latest follow-up, twenty-four (75 per cent) of the patients had no pain in the hip. Although eighteen patients (56 per cent) could walk without support at a minimum of ten years after the operation, we found that the functional results for patients who had rheumatoid arthritis were inferior to those observed for patients who had had a total hip arthroplasty with cement, performed by the same surgeon, for the treatment of other diagnoses.     

Combined procedure of open reduction and shortening of the femur in treatment of congenital dislocation of the hips in older children

A one-stage, combined operative procedure for reduction of congenitally dislocated hips in older children consists of shortening of the femur; open reduction by an inferior approach to the joint; reconstruction of the acetabular roof; correction of anteversion of both the femoral neck and the neck-shaft angle; anterior transposition of the iliopsoas muscle. On 60 hips operated in children, ages 5 to 15 with a follow-up period, ranging from 5 to 9 years, the results were found to be excellent in 3 per cent, good in 60 per cent, fair in 30 per cent, and poor in 7 per cent. The procedure is indicated in children up to the time of early puberty. The primary indication is high bilateral dislocation. In unilateral dislocations some residual leg-length discrepancy frequently occurs. This procedure should be done only by orthopedic surgeons who have special training and experience in the treatment of congenital dislocation of the hip.     

Impaired bile flow and disordered hepatic calcium homeostasis are early features of halothane-induced liver injury in guinea pigs

Although an acetabular component with an elevated rim is thought to improve the postoperative stability of a total hip prosthesis, the actual clinical value has not yet been demonstrated. To address this question, we reviewed the results of 5167 total hip arthroplasties that had been performed at our institution from April 1, 1985, through December 31, 1991. The prostheses included 2469 acetabular components with an elevated-rim liner (10 degrees of elevation) and 2698 with a standard liner. The cumulative probability of dislocation was estimated as a function of time since the operation with use of the Kaplan-Meier survivorship method. Forty-eight of the 2469 hips that had the elevated-rim acetabular liner dislocated within two years, compared with 101 of the 2698 hips that had the standard acetabular liner. The two-year probability of dislocation was 2.19 per cent for the hips with the elevated-rim liner and 3.85 per cent for those with the standard liner (p = 0.001). A similar trend was seen at five years; however, because of a smaller sample the difference was not significant. Increased stability at two years was also demonstrated for the hips with the elevated-rim liner when the hips were analyzed according to the operative approach, the mode of fixation, the sex of the patient, and the type of total hip arthroplasty (primary or revision). Although these data demonstrate improved stability after total hip arthroplasty when an elevated liner is used, particularly in hips that are at greater risk for dislocation of the prosthesis, the long-term effect of this elevated liner on wear and loosening remains unknown but is of considerable concern. The elevated liner deserves additional study to clarify its effect on wear and loosening.     

Failure of the Mecring screw-ring acetabular component in total hip arthroplasty. A three to seven-year follow-up study

We prospectively studied the results of 411 consecutive total hip arthroplasties with a Mecring screw-ring acetabular component inserted without cement combined with a Stanmore femoral stem inserted with cement. The duration of follow-up ranged from three to seven years (mean, four years and six months). Three hundred and thirty-one patients (378 hips) were available for physical examination and had a complete set of radiographs. The clinical result was good or excellent for 82 per cent (309) of the 378 hips. However, the rate of radiographic loosening of the acetabular component, as evidenced by migration at the most recent follow-up examination, was alarmingly high: 25 per cent (ninety-five) of the 378 hips. In general, these patients did not have serious clinical symptoms. The cups in women migrated significantly more often (p = 0.003) than those in men. Migration was also more frequent in patients who were less than fifty-one years old and in patients in whom the index procedure was a revision arthroplasty, but these differences were not significant. Twenty-one (6 per cent) of the acetabular cups were revised for aseptic loosening. The high rate of radiographic loosening has led us to abandon the use of the Mecring screw-ring acetabular component.     

Radiotherapy for elderly patients

Fifty-seven revision total hip arthroplasties in fifty-six patients were performed with a Harris-Galante porous-coated acetabular component by one surgeon, and the patients were followed prospectively for a mean of seven years (range, five to twelve years). A trochanteric osteotomy was performed in forty hips, and a posterior approach with an extended anterior capsulectomy was used in the other seventeen. The acetabular defect was classified as segmental in seven hips, cavitary in twenty-three, and combined in twenty-one; six hips had no notable defect. A bulk allograft was used in eleven hips, and morseled cancellous-bone allograft or autogenous graft was used in thirty-four hips; twelve hips did not have bone-grafting. Both the femoral and the acetabular component were revised in forty-five hips, and only the acetabular component was revised in twelve. Thirty-nine hips (68 per cent) had a good or excellent clinical result according to the Harris hip score. The acetabular component was well fixed in the fourteen hips that had a fair result and the four hips that had a poor result. The acetabular component was considered to have migrated if there was a change in the angle of the cup of 5 degrees or more or a change in the horizontal or vertical position of the cup of more than three millimeters. Despite varying degrees of bone loss, no acetabular component had radiographic evidence of loosening at the latest follow-up examination. No component was revised and no revisions were scheduled. One hip was debrided for a late metastatic infection, but the component was well fixed and was not revised. There were no complications related to the use of screws for fixation. These mid-term results confirm the early success of acetabular revisions performed with fixation of a titanium fiber-metal-coated hemispherical component with multiple screws and no cement.     

Salvage of a recurrently dislocating total hip prosthesis with use of a constrained acetabular component. A retrospective analysis of fifty-six cases

Fifty-six constrained acetabular components were placed, between April 1988 and February 1993, in fifty-five patients who had had recurrent dislocations (average, six dislocations; range, two to twenty dislocations) of the femoral component after a previous total hip arthroplasty. All patients had additional factors contributing to the instability of the implant, including absence or disruption of the abductor mechanism, poor health, mental retardation, confusion, and Alzheimer disease. One patient was lost to follow-up. The remaining patients were followed clinically for a minimum of three years (average, sixty-four months; range, thirty-seven to ninety-seven months) or until the time of death. During the follow-up interval, only two (4 per cent) of the fifty-five patients had a subsequent dislocation. The use of this type of component should be considered for patients who have recurrent dislocation if other treatment modalities are unlikely to be effective.     

Porous-coated acetabular components with screw fixation. Five to ten-year results

The results of 136 consecutive primary total hip arthroplasties performed by one surgeon with the Harris-Galante-I porous-coated acetabular component were reviewed at a mean of seven years (range, five to ten years). In all hips, the outer diameter of the acetabular component was the same as the diameter of the final reamer used in the preparation of the acetabulum. However, this reamer was used only briefly at the rim of the acetabulum, and therefore the components had so-called press-fit stability. A mean of four screws (range, three to six screws) were used for additional fixation of the component. The clinical evaluation was performed with use of the Harris hip score. Standardized anteroposterior radiographs of the pelvis were assessed for migration of the component, radiolucent and radiodense lines, linear wear of the polyethylene, and osteolysis. No acetabular component had been revised for loosening and none were radiographically loose at the time of the most recent follow-up evaluation. There were no complications related to the use of the screws, and no screw had bent or broken. A non-progressive radiolucent line was seen in one acetabular zone in thirty-four hips (25 per cent) and in two acetabular zones in six hips (4 per cent). No hip had a radiolucent line in all three acetabular zones. The mean rate of linear wear of the polyethylene was 0.1 millimeter per year. There was no dissociation of the acetabular liner from the metal shell. Two hips (1 per cent) had asymptomatic osteolysis in the ischium and adjacent to the rim of the acetabular component; this was treated with grafting at the site of the lesion and exchange of the femoral head and the worn polyethylene liner. Five femoral components inserted without cement and one inserted with cement were revised because of loosening. The data suggest that, at a mean of seven years, fixation of this porous-coated component was uniformly excellent. The low prevalence of radiolucent lines and the absence of loosening are probably related, in part, to the technique of implantation. The low prevalence of polyethylene wear and pelvic osteolysis is a notable improvement compared with the results of arthroplasty with other porous-coated acetabular components. Although the results of the present study are encouraging, longer follow-up is necessary to determine the prevalence of late loosening and osteolysis.     

A femoral component inserted without cement in total hip arthroplasty. A study of the Tri-Lock component with an average ten-year duration of follow-up

Seventy-four total hip arthroplasties in sixty-six patients were performed, between 1983 and 1986, with use of a Tri-Lock femoral component inserted without cement. This tapered cobalt-chromium component has a fixed head and a circumferential proximal porous coating. Follow-up was conducted with use of a questionnaire, physical examination, and radiographic analysis. At the time of the latest follow-up, fifteen patients (eighteen hips) had died, three patients (four hips) had been lost to follow-up, and one patient (one hip) had refused to participate in the follow-up study; however, the status of fifteen hips at the time of death could be verified. Thus, clinical follow-up data were available for sixty-six of the original seventy-four hips. The average age at the time of the operation was sixty-two years (range, seventeen to eighty-four years), and the average interval between the operation and the latest follow-up evaluation was 10.0 years (range, 8.3 to 11.6 years). The Harris hip score was determined for forty-three hips (forty-one patients) in which the prosthesis was in situ at the time of the latest follow-up. The score was good for thirteen hips and excellent for twenty-eight, so the rate of clinical success was 95 per cent. Two patients had a fair result. One of them had persistent pain and the other had limited motion, but neither had radiographic evidence of loosening of the femoral or acetabular component. All forty-one patients were satisfied with the result. The probability (with standard error) of survival of the femoral component at ten years, with revision as the end point, was 0.95 +/- 0.03. The rate of revision of the femoral component because of aseptic loosening was one (2 per cent) of sixty-six. The overall rate of aseptic loosening of the femoral component in the hips that were followed radiographically was two (4 per cent) of forty-seven. Only one (2 per cent) of the forty-seven acetabular cups had evidence of aseptic loosening. There was no radiographic evidence of distal osteolysis around the prostheses that were well fixed. Proximal osteolysis was present in five (11 per cent) of forty-seven hips, but none of the lesions compromised the stability of the prosthesis or the bone and there were no associated fractures. At an average of ten years postoperatively, the Tri-Lock femoral component functioned well overall and patient satisfaction was high.     

Salvage of total hip instability with a constrained acetabular component

Between April 1988 and February 1993, 101 constraining acetabular components were implanted into 98 patients. One patient was lost to followup at 8 months. Otherwise, all patients were observed until death or for at least 2 years minimum followup. The average clinical followup for the living patients was 61 months (range, 24-97 months). Indications for the use of the constrained acetabular components were recurrent dislocation (an average of six dislocations, range 2-20) in 56 cases, intraoperative instability in 38 cases, and neurologic impairment in seven cases. For the entire group there were four cases of recurrent dislocation or failure of the component (4%). For the cases where this component was used for recurrent dislocation, 96% (54 of 56 cases) had no additional dislocations. Radiographically, at this short term followup, there was no evidence of an increased incidence of femoral or acetabular component loosening. The authors recommend judicious use of this component as a salvage measure for desperate cases of hip instability during or after total hip arthroplasty.     

Acetabular growth potential in congenital dislocation of the hip and some factors upon which it may depend

The factors which determine the rate and amount of acetabular growth in congenital dislocation of the hip are ill-understood. A prospective radiological study has been devised in order to assess the influence of the age of congruity, femoral anteversion and neck/shaft angles on acetabular growth. To be included, the children must have reached at least 8 years of age. Those with associated congenital abnormalities and subluxation were excluded, as were those who had operations for acetabular reconstruction. Seventy-four hips were suitable for analysis, and the age range at follow-up was from 8 to 17 years. The acetabular angle was used as an index of acetabular growth. Measurement of this angle, and the anteversion and neck/shaft angles were made before, and each year after reduction of the hip. Congruity was assessed from a radiograph with the legs in the functional position. A satisfactory acetabulum was obtained in 44 hips and the mean age of congruity was 33 months; the acetabulum was unsatisfactory in 30 hips, with a mean age of congruity of 48 months. Four years is the critical age, for if congruity is obtained later, the risk of producing a moderate or severely dysplastic acetabulum is more than doubled. If congruity is obtained under four years of age, growth of the acetabulum with continue in most patients up to 8 and in some to 11 YEARS OF age; the resulting acetabulum was normal or mildly dysplastic. Fifty-nine per cent of the satisfactory hips at follow-up had a normal anteversion angle, and 6 per cent a normal neck/shaft angle. Correction of these angles by themselves, seems not to be a major importance for promoting acetabular growth.     

Guepar hinge prosthesis: complications and results with two years' follow-up

Experience with the GUEPAR prosthesis in 292 cases of which 103 have been followed for more than 2 years, suggests that: implanting a hinge prosthesis is major surgery on elderly patients in whom severe complications have occurred and for this reason, the operations should be reserved for extremely damaged and unstable knees; the most important local complications have been deep sepsis for which we have noted a rate of 6.6 per cent; in the treatment of sepsis, everything must be done to preserve the prosthesis because arthrodesis is difficult to obtain; pain relief has been significant as a result of the operation. The prosthetic design allows flexion of more than 90 degrees in 85 per cent of the cases and 120 degrees in 26 per cent; after two years, the results seem relatively stable. We have not observed aseptic loosening after this period but a longer observation period is necessary to be reassured on this point; patellar pain remains a major concern because this arthroplasty has not solved the problem, and other solutions will have to be found.     

Voluntary school screening for scoliosis in Minnesota

School screening for scoliosis is a well accepted technique for the early detection of spinal deformities. We reviewed the experience in Minnesota over the past eight years, with an average of one-quarter of a million children being screened yearly. Of the children screened, 3.4 per cent were referred for evaluation and scoliosis was found in 1.2 per cent. The number of children requiring operations for adolescent idiopathic scoliosis has diminished since 1970. The average curve for which a surgical procedure was done has also diminished from 60 to 42 degrees. The cost of the program is low, averaging 6.6 cents per student screened. This compares with a so-called time cost averaging thirty-five cents. Voluntary scoliosis screening in Minnesota is an efficient and cost-effective program.     

A patient-initiated system for preventive health care. A randomized trial in community-based primary care practices

PURPOSE OF THE STUDY: From 1983 to 1986, 156 alumina/polyethylene combination hip arthroplasties (131 patients) were performed at the Henri Mondor Hospital. Before 1983, the stainless-steel/polyethylene combination was performed. In this follow-up study, the outcome of the first 156 consecutive alumine-polyethylene combination hip arthroplasties were analyzed with clinical and radiological features. The comparison of the two combinations was analyzed. A survival analysis was performed over a ten years interval. MATERIAL AND METHODS: The femoral component of the prosthesis was made of Titanium alloy (TiA16V4). The femoral head was made of dense alumina (A1203). The head diameter was 32 mm. The socket was made of ultra-high-molecular-weight polyethylene (UHMWPE). Fixation of head to stem was obtained through conical sleeving. We used a posterolateral approach, and a cemented THA without pressurization. At last follow-up evaluation, 90 patients were reviewed, 9 patients were interviewed by phone. Three patients were dead and 20 patients were lost for follow-up evaluation, in the first year. Nine failures were reoperated. The major cause of failure was septic complication of the THA (8). The average age of patients at arthroplasty was 58.1 year. The clinical evaluation was performed with the Merle d'Aubigné, Postel scoring system. The radiographs of 117 hips out of the 156 were available for this evaluation. Radiolucents, failures and wear were analyzed. RESULTS: There was a 5 per cent rate (8 hips) of deep infection due for two hips to the underlying pathology. Ten (6.5 per cent) of the 156 hips had had an episode of dislocation at last follow-up. Eighty-nine per cent of the hips were rated excellent, very good, and good; 9.3 per cent were rated fair: and 1.7 per cent were rated poor. The radiographs of the socket revealed 54 per cent of bone-cement radiolucent and three failures at last follow-up. The radiographs of the stem revealed 29 per cent of bone-cement radiolucent and one failure at last follow-up. There was no revision of the femoral stem. Survival analysis (aseptic failures) depicted 93.45 per cent durability of the arthroplasty at 10 years. The survival analysis for the socket alone, using the same criteria for failure, demonstrated 94.53 per cent survival success at 10 years, and 98.91 per cent for the stem component. The comparison of the two combinations gave us a survival analysis for the socket alone, using aseptic failure as criteria, 79.84 per cent for stainless-steel/polyethylene combination at 8 years, and 97.63 per cent for alumina/polyethylene at the same time. CONCLUSION: The alumina/polyethylene combination with a 32 mm head diameter gave better results than the stainless-steel/polyethylene combinations. The improvement was noted on the acetabular component.     

Heart valve replacement with the Ionescu-Shiley pericardial xenograft

Between March, 1971, and September, 1975, glutaraldehyde-stabilized pericardial xenografts were used for single valve replacement in.212 patients (142 aortic, 67 mitral, and three tricuspid). The 195 operative survivors were observed for a total of 5,926 months over a period 6 to 61 months (mean 30). actuarial analysis of late results indicates an expected survival rate at 5 years of 92.3 per cent for patients with aortic and 91.1 per cent for patients with valve replacement. The rate of systemic embolism has been 0.62 episodes per 100 patient years for the aortic and 2.48 episodes per 100 patient years for the mitral group in the absence of anticoagulant treatment. All six emboli occurred early postoperatively, were trivial or mild, and left no sequelae. Symptomatically, 96.7 per cent of patients are now in Class I and 3.3 per cent in Class II (N.Y.H.A.). Maintenance of structural and functional integrity of the glutaraldehyde-stabilized pericardial zenograft was demonstrated by histologic and hemodynamic investigations. Catheterization showed substantial circulatory improvement in both patients with aortic and those with mitral replacement. The transaortic gradients were negligible (8 mm. Hg at rest and 17.5 mm. Hg during exercise). The available indicates that results of valve replacement withpericardial xenografts. Over this period of follow-up, compare very favorably with those obtained with other available prostheses and tissue valves.     

The natural history of hereditary multiple exostoses

We established a database of hereditary multiple exostoses for the state of Washington, on the basis of a retrospective review of the medical records and a clinical evaluation of family members, to determine the prevalence, clinical range of expression, and rate of malignant degeneration. The database comprised forty-six kindreds with 113 affected members; all kindreds had at least one member living in the state of Washington. The over-all prevalence was at least one in 50,000. Approximately 10 per cent of the subjects had no family history of multiple exostoses. With the use of twenty-three pedigrees that demonstrated an adequate multigenerational history for determination of penetrance of the gene, we identified one unaffected individual among twenty-six obligate heterozygotes, a rate of penetrance of 96 per cent. There was no evidence for a substantial reduction of penetrance in female subjects. The median age at the time of the diagnosis in the 113 affected individuals was three years (range, birth to twelve years). In a cohort of eighty-four subjects for whom we had complete information, the clinical range of expression was wide: thirty-three (39 per cent) had an obvious deformity of the forearm, eight (10 per cent) had an inequality in the lengths of the limbs, seven (8 per cent) had an angular deformity of the knee, and two (2 per cent) had a deformity of the ankle. The average number of operations for the patients for whom the operative history was known was two.(ABSTRACT TRUNCATED AT 250 WORDS)