Charnley low-friction arthroplasty of the hip. Long-term results

Charnley low-friction arthroplasty (LFA) has become the method of choice for patients with destroyed arthritic hip joints; the authors' 18-26-year observation suggests that LFA could be considered the gold standard for total hip arthroplasty (THA). The continuity of concept, design, and the surgical technique extends beyond 29 years and offers predictability of outcome. Fatal postoperative pulmonary embolism, initially at 0.7% within one year of surgery, shows significant seasonal variation and as yet unexplained declining incidence. Incidence of dislocation is 0.63%, with a 0.11% chance of revision. The incidence of deep infection is 0.3%-1.5% in primary surgery and varies with the underlying hip pathology. Introduction of the intramedullary bone block has reduced the revision rate for stem loosening to less than 1% at 14 years and completely eliminated stem fracture. There has not been a fracture of a recently manufactured stem (Ortron). Revision for socket loosening has been reduced to 3% by the introduction of the ogee-flanged socket. The outcome of the socket survivorship is determined by the depth of socket penetration, the relationship between the two being exponential. Because the socket demarcation and migration are usually asymptomatic, the timing of revision would be determined by the surgeon's awareness of the problem. Repeated revisions produce conditions almost comparable to a locally malignant condition: dwindling bone stock, increasing implant size, local recurrence of the problem. Accumulation of the experience with the Charnley LFA has been shown to benefit both old and young patients.     

Isolated traumatic dorsal dislocation of the distal radio-ulnar joint. Report of seven cases

The authors report seven cases of isolated dorsal dislocations of the distal radio-ulnar joint. Four were recent dislocations and three were old, chronic dislocations. Acute dislocations were treated surgically. An anatomic study on human cadavers enabled us to define the injuries responsible for radio-ulnar dislocations. An electromyographic study of the extensor carpi ulnaris confirmed its role as a dynamic stabilizer of the ulnar head. Two of the three old dislocations were revised after an attempt at ligamentous reconstruction. These patients benefitted from a resection of the ulnar head. The third patient one underwent a Sauve-Kapandji procedure. Cadaver studies underline the fact that ligamentous reconstruction procedures are actually tenodeses.     

Bilateral traumatic hip dislocation with bilateral sciatic nerve injury

Bilateral traumatic dislocation of the hip is a rare injury. In fact, only about 50 cases have been reported previously. We report a case of traumatic bilateral posterior hip dislocation with bilateral sciatic nerve damage suffered in a traffic accident by a 65-year-old woman.     

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.     

Rotationplasty in skeletally immature patients. Long-term followup results

Twenty-one skeletally immature patients with a Grade IIB osteosarcoma about the knee were treated with a modified Van Nes rotationplasty. Fourteen patients were followed up for 4 to 10.5 years (mean followup, 8 years). Functional assessment using Enneking's method showed all had good or excellent results. No patient thought that the reconstruction affected their ability to achieve recreational, sporting, or career goals. The reconstruction is durable and is not associated with an increase in late complications.     

Topical metronidazole application in recall patients. Long-term results

The aim of this randomised study in split-mouth design, in which 24 patients from the recall programme of Marburg University Department of Periodontology were enrolled, was to compare topical application of a metronidazole 25% dental gel with subgingival scaling. The clinical parameters used were pocket probing depth (PPD) and bleeding on probing (BOP); these were recorded at baseline and 1, 3, 6, 14, 18 and 24 months after completion of treatment. In addition, plaque samples were taken from all mesial pockets for evaluation by dark-field microscopy. All patients had at least one tooth in each quadrant with a PPD of 5 mm or more showing BOP when they entered the study. The treatment consisted of 2 applications of dental gel in 2 randomly selected quadrants (on days 0 and 7) as well as subgingival scaling of the remaining quadrants. Statistical evaluation of all sites with a baseline PPD of 5 mm or more showed that both methods led to a significant reduction in PPD and BOP in the first 6 months. The average reduction in PPD was 1.3 mm in the gel group and 1.5 mm in the scaling group, with the tendency to bleeding being reduced by ca. 50% in both groups. After 24 months, improvements of 0.6 mm and 0.5 mm respectively were observed in PPD. The tendency to bleeding had undergone a slight increase but was still below baseline values. No statistically significant differences were observed between the two methods, although the results recorded with subgingival scaling were slightly better. Dark-field microscopy revealed a shift in the composition of the bacterial flora, suggesting a more physiological situation, which was maintained for 6 months before reverting consistently after 18 months to the baseline values of the plaque composition. Overall, application of a metronidazole 25% dental gel led in recall patients to an improvement in the investigated clinical and microbiological parameters comparable with subgingival scaling. After 24 months, the clinical parameters still displayed a very slight improvement over baseline values; after 18 months the microflora had reverted to its baseline composition.     

Long-term clinical and radiological results of the Lord total hip prosthesis. A prospective study

We enrolled 98 patients (107 hips) with a mean age of 47 years (SD 8.6) into a prospective study of the Madreporic Lord THR; 34 hips had primary and 73 secondary osteoarthritis. After ten years, the survival rate using revision as the endpoint for failure was 70% (+/-9) for the cup and 98% (+/-0.3) for the stem. The combined clinical and radiological survival rates were 46% (+/-11) and 81% (+/-10), respectively. Osteoporosis due to stress-shielding was observed in the proximal femur. Hips with radiologically dense bone postoperatively showed the most pronounced bone loss. We recommend continued radiological follow-up of patients with this type of implant to allow revision to be performed before there is severe bony destruction of the pelvis.     

Long-term results of late non-operative reduction of developmental dysplasia of the hip

Alcohol-related crime is an ongoing problem in the court system of England and Wales. The Magistrates' Association believes that the system could be improved by: (1) the introduction of a new Licensing Act; (2) better control over licensed premises; (3) increased training for licensees; (4) more informative training for magistrates on the availability and role of alcohol programmes; (5) improved enforcement of licensing laws by the police.     

Isolated dislocation of the carpal scaphoid

A case of isolated dislocation of the carpal scaphoid is presented and the literature on the subject reviewed. An analysis has been made of the cases reported and attention is drawn to certain features which are common to most of the cases.     

Gait analysis of adult patients with complete congenital dislocation of the hip

Comprehensive gait analysis is valuable in understanding the performance of patients with lower limb disorders. The gait pattern of adult patients with untreated congenital dislocation of the hip (CDH) has not yet been reported. We studied the gait pattern in nine women (mean age 31.4 years) with Crows group IV CDH. Six had unilateral and three had bilateral involvement. They were not treated during childhood and had no pain at the time of study. A control group comprised 15 normal female subjects of the same age group. Gait was studied using a motion-analysis system, force plateforms, and computer calculation during level walking. Common abnormal gait patterns seen in patients with both unilateral and bilateral CDH were slower walking velocity, which was due to a shorter stride length, less forward tilting of the pelvis, insufficient flexion, and excessive internal rotation of the hips. The patients with unilateral CDH had a shorter step length, lower pelvis, a lateral shift of the ground reaction force, decreased maximum adduction moments of the hip and knee on the diseased side, and increased maximum adduction moments of the hip and knee on the unaffected side. This asymmetry may have been due to leg length inequality. Thus, correlation of the leg length discrepancy may be important for unilateral CDH patients in improving their gait.     

A study of the factors in hip replacement dislocation. Part 2

Dislocation is a dramatic and distressing common complication following total hip replacement. The first article describing this study, published last week, considered some of the factors thought to predispose to dislocation. The authors emphasised the multifactorial nature of hip replacement dislocation and in this second article they examine the factors relating to acetabular position and orientation, and femoral component placement.     

Surgical treatment of bronchogenic carcinoma. Long-term results in 496 surgical patients

BACKGROUND: The operability of lung cancer and the period of survival after resection of the lungs in our country does not yet attain the standard recorded in some advanced countries. The objective of the present work is to analyze factors which influence the survival period after resection therapy of lung cancer. METHODS AND RESULTS: In 1985-90 in our department 496 patients were operated on account of lung cancer. This number comprised 31 patients subjected to explorative thoracototomy and three patients with pulmonary resection on account of a stage IIIb (pTNM) tumour who were excluded from the statistical analysis. The retrospective study proper analyzes the results of 462 patients (403 men and 59 women) operated in stages I, II and IIIa. Their mean age was 57 years (range 30-74 years, SD 7.5 years). The most frequent histological type was epidermoid carcinoma (68.8%), adenocarcinoma 18.2%, small-cell tumours 5.4% (25 patients). In 262 patients operated on account of lung cancer in stage I (pTNM) the probability of five-year survival was 49.2%, in patients in stage II 42.1%, in 158 patients in stage IIIa 20.9% (for all histological types combined). In 437 patients after resection of the lungs on account of non-small-cellular carcinoma the probability of five-year survival was as follows: stage I 50.0%, stage II 45.0%, stage IIIa 21.2%. CONCLUSIONS: The probability of five-year survival for the whole group of 462 patients in stages I, II and IIIa was 38.8%. The most important factor which influenced the probability of five-year survival was the stage of the disease. Neither age nor sex of the patients nor the histological type of the tumour had a statistically significant effect on the probability of five-year survival.     

Magnetic resonance tomography in diagnosis and therapy follow-up of patients with congenital hip dysplasia and hip dislocation

PROBLEM: Human chrionic gonadotropin (hCG) is a placental glycoprotein hormone, a heterodimeric molecule, consisting of alpha and beta chains. It induces the synthesis of progesterone, which is essential for the maintenance of the fertilized egg. Antibodies directed against hCG can, therefore, prevent pregnancy and serve as a vaccine. hCG belongs to the glycoprotein hormone family and shares the alpha chain with the other members. The beta chain is a hormone-specific subunit that is unique to hCG, but still possesses 85% amino acid homology with the beta chain of luteinizing hormone (LH), which means that prolonged immunization with hCG produces antibodies that cross-react with LH. METHOD OF STUDY: We have taken an approach involving the mutation of beta hCG to eliminate cross-reactive epitopes without affecting the natural folding of the polypeptide chain and thus the unique beta hCG-specific epitopes. RESULTS: Several mutants have been constructed that have maintained the binding to hCG-specific monoclonal antibodies (mAbs) but have lost the ability to bind to a panel of LH cross-reactive mAbs. To investigate the immunogenicity of selected mutants, mice were immunized with expression plasmid DNA, containing the gene for wild-type beta hCG and two mutants: mutant 3, with four amino acid substitutions (68 Arg-->Glu; 74 Arg-->Ser; 75 Gly-->His; 79 Val-->His), and mutant 7, with a single amino acid substitution (68 Arg-->Glu). CONCLUSIONS: Although both mutants were able to elicit antibody responses in at least some animals, the levels were less than those seen with the wild-type beta hCG DNA, and there seems still to be a residual cross-reactivity with LH. Attempts to improve the immunogenicity of the mutants and to further modify the sequence to remove the cross-reactivity are currently underway.     

Isolated volar carpometacarpal dislocation of the fifth digit

McWharter first described volar carpometacarpal dislocations of the fifth digit in 1918. Since then, 14 cases have been reported in the medical literature. Berg and Murphy were first to report a case of ulnopalmar dislocation that was successfully treated with closed reduction and immobilization. Previously reported cases required internal fixation with or without open reduction. We report a fifth carpometacarpal ulnopalmar dislocation, treated with closed reduction and casting.