Total Hip Replacement

Total

Hip

Replacement

FRANK E. STINCHFIELD,* M.D., ERIc S. WmTE,** M.D.

From the New York Orthopaedic Hospital, Columbia-Presbyterian Medical Center,

New York City

OURclinical experience with total hip re-placement is based upon the work of

Charnley.2'

6 In 1958, he departed from the anatomic approach to arthroplasty of the hip and designed a mechanical hip joint based uponbiomechanical and engineering principles.

The essential features ofthe low friction arthroplasty are: (1) A metal-to-plastic rather than metal-to-metal joint surface is used with a small diameter femoral head. The surface friction between metal and plastic is considerably less than metal-to-metal and the small diameterhead reduces the contact area between the articulating surfaces.3 (2) Atthe time of operation, the acetabulum is deepened in order to medi-allydisplace the center of rotation and the weight-bearing axis. This reduces the moment of force onthe

prosthetic

compon-ents. In addition, the hip abductor muscles are transplanted laterally and distally to

allow them to work at a more effective lever arm. (3) A self-curing cement,

methylmethacrylate,

is used to bond both the acetabular and femoral components to

endosteal bone.

Methymethacrylate

has no

adhesive properties, but acts as a filler or

mechanical bond which allows a more

uni--'orm distribution of stress over a

large

surface area. These three features are de-signed to minimize wear and to prevent loosening of the

prosthesis (Fig.

1).

*161 Fort Washington Avenue, New York,

NewYork 10032.

**622 West 168th Street, New York, New

York 10032.

Presentedat theAnnualMeeting of the

Ameri-canSurgicalAssociation, March 24-26, 1971, Boca Raton, Florida.

Methylmethacrylate

The unanswered question about the use of cement, which has led to conservatism in the United

States,

is thelong-term tissue tolerance of this material in the human body.

Charnley's

monograph, Acrylic Ce-ment inOrthopaedicSurgery, discussesthis question in

depth.4

Laboratory investigation has shown that the initial host response to methylmethacrylate in bone is a narrow margin of

cell

death, presumably caused

by

the heat of polymerization followed by a fibroblasticresponse with interspersedgiant

cells.

After the passage of time, normal re-modeling and bone marrow function take place adjacentto cementseparated only by a thin layer of fibrous

tissue."'5'

21 At The New York Orthopaedic Hospital, we have done in vivo studies utilizing the canine femur to try and separate the various fac-tors which elicit the histological changes toward

methylmethacrylate.13

Under

condi-tions of a minimum shearing-load, histo-logic sections 6 months after implant show normal bone function directly adjacent, to cementwithno residual fibrous lining. Fur-ther studies are being performed to study the relationship between increased shear-ing-loads, i.e., motion, and the amount of fibrous tissue lining between bone and cement.

Operative Technic

A shortdescription of the operative tech-nic would seem indicated. A lateral ap-proach to the hip joint is used. Osteotomy of the greater trochanter is recommended to minimize muscle dissection to allow easier dislocation andto facilitate adequate acetabular exposure. This also permits

656

STINCHFIELD AND WHITE

FIG. 1. Low Friction Arthroplasty of Charnley.

Barium sulfate is added to the cement to make it

radiopaque. A wire outlines the outer surface of

the plastic socket. Fixation holes are drilled into the acetabulum to produce maximum stability at

the cement-bone interface.

eral and distal displacement of the abduc-tor muscle.

Astraight8to 10inch incision is centered

over or just posterior to the greater tro-chanter and extends along the femoral shaft towards the iliac crest. The fascia lata is incised and the tensor fascia femoris muscle is retracted anteriorly. The junction between the origin of the vastus lateralis and the insertion of the gluteus minimus

and medius is identified. The fatty tissue

and investing fibers of the vastus lateralis are then reflected from the joint capsule. The anterior capsuleis incisedin the

direc-tion ofthe femoral neck and a largs chole-cystectomy clamp is introduced intracapsu-larly, superior to the femoral neck and just medial to the greater trochanter (Fig.

2).

This allows placement ofaGiglisawwhich

is used to osteotomized the greater

tro-Ann. Surg. * Oct. 1971 Vol. 174 No. 4

chanter. A limited capsular excision is usually necessary to allow anterior disloca-tion of the femoral head which is accomp-lished by flexion, adduction, and external rotation of the patient's leg. The Gigli saw

is used again to resect the femoral head at

the mid-neck level. Self-retaining retractors

are used to expose the acetabulum which is deepened and widened with special reamers (Fig. 3). The high density poly-ethylene acetabular socket is cemented in

the deepened acetabulum at a 45-degree angle from the horizontal and in neutral rotation. After the cement holding the

ace-tabular component has hardened, attention

is directed toward the femoral shaft. The medullary canal is then reamed for recep-tion of the metal prosthesis. A trial pros-thesis is introduced into the prepared shaft. The hip joint is relocated and a range of

motion is carried out. Anyosteophytes that impinge upon the prosthesis or restrict hip

motion are removed. After placing hori-zontal and vertical trochanteric fixation wires, the permanentprosthesisiscemented

inplace. The hip isrelocated asecond time

and the greater trochanter is secured in its

newposition withthetwo#18 gaugewires.

FIG. A cholecystectomy clamp is used to route the Gigli saw intracapsularly, medial to the hip abductors prior to osteotomy of the greater

TOTAL HIP REPLACEMENT Patient Selection

Newness of the operative technic and the use of methylmethacrylate cement prompted us to restrict our indications for

total hipreplacement.9 Sixty years of age is

the approximate lower limit for patients

withunilateral hip disease. A slightly lower

age limit is allowed forthose patients with

bilateral hip disease since disability is so

much greater when both hips are involved.

Many of the candidates for low friction arthroplasty have had previous attempts

at conventional arthroplasty which have

failed. The ideal candidate for the

proce-dure is one in whom the only alternative

is a Girdlestone resection. In all of the

above situations pain is the primary

indi-cation for surgical treatment while limited

range of motion and gait disturbance are

only secondary considerations.

An absolute contraindication to the

pro-cedure is a history of infection in the

ipsi-lateral hip joint. Patients who have had

multiple hip surgery in the past must

un-dergo careful tests to rule out late, low-grade infection. The surgeon must be

pre-pared to abandon the procedure if during

the operation a positive bacterial smear is

obtained from the operative wound, or if

suspiciousgranulationtissue ispresent.

Rel-ative contraindi@ations are patients having

littledisabilityorwho arestill able towork

when their pain is relieved by analgesics.

Table 1 lists the frequency ofvarious hip

disorders referred to our institution which

warranted total hip replacement.

Hip Assessment

A prospective study has been established

on all patients for low friction arthroplasty

(LFA) at The New York Orthopaedic Hospital. The 6-6-6 numerical grading

system of D'Aubigne and Postel has been

adopted to measure the degree of pain,

function, and mobility in each hip.8 Grade

1 denotes the most severe condition while

Grade 6 indicates the normal. Each

pa-tient is then placed in one of three groups

657

FIG. 3. The acetabulum is exposed laterally.

After deepening it with reamers, fixation holes are

drilled in the acetabulum to increase the contract

area ofcement and bone.

accordingtothetypeof involvement.Group

A indicates unilateral hip disease; Group

B bilateral hip disease and Group C

in-cludes patients with either unilateral or

bilateral hip disease who have some

addi-tional medical or orthopaedic condition

which restricts function. Results of Surgery

Thefirstone hundredlow friction

arthro-plasties were performed at The New York

Orthopaedic Hospital between April 1969 and May 1970. This study group consisted of 93 patients, sevenof whom hadbilateral

arthroplasties. Two died from unrelated causes before their follow-up visit.

Eighty-four patients actually returned for

exami-nation. The shortest interval between

sur-gery and the time of hip assessment was

six months and the longest period was

eighteen months. The average follow-up time was ten months. The actual time

elapsed between surgery and the reading

of this paper ranged from ten to

twenty-three months. This additional follow-up

time is important when considering the incidence ofposssible late wound infection. Pain. Every patientinterviewed had sig-nificant and many times dramatic relief of

pain. Table 2 shows that all but seven

pa-tientswere graded5 and6, postoperatively.

Ann. Surg. Oct. 1971 Vol. 174 * No. 4

STINCHFIELD AND WHITE

Mobility. Table 3. The majority of

pa-tients had a striking increase in range of motion. Afewpatients havinghadmultiple procedures and who formed heterotopic bone, did not have any increase in range

ofmotion. No one, however, had less than

his preoperative range of motion.

Function.Table 4. Our analysis of

func-tion has been divided into the three

pre-viously mentioned categories, A, B, and C. It should be emphasized that function

re-lates to gait pattern and overall activity.

The patients inGroup Adiduniformly well. ThoseinGroup B didnotfarequiteaswell.

Our interpretation of this finding is that

Ann. Surg. * Oct. 1971 Vol. 174 * No. 4

FIG. 4A. J. B., is a

56-year-old man with

osteoarthritis secondary

tocongenitallysubluxated

hips. Five years ago he

underwent bilateral osteo-tomies but didnotobtain permanent relief from pain. At the time of evaluation for LFA, he had Grade 3painandwas unable to work.

FIG. 4B. The failed osteotomies were

con-verted to low friction

arthroplasties. At one-yearfollowup, hehas

re-turned to work as a traveling salesman and walks with no pain and noaids.

many of the Group B patients are limited

by arthritic involvement of their opposite hip. When those patients with

sympto-matic disease in the opposite hip come to

surgery, the results in Group B should

ap-proach that of Group A. Improvement in

Group C after surgery was quite variable.

We believe that this reflects the degree of

limitations imposed bysystemic medical or

orthopaedic conditions rather than hip function, per se.

Complications

Tables 5 and 6. The data on our

com-plications have been updated to include

-ourfirst200 procedures. Althoughthe most

TOTAL HIP REPLACEMENT

frequent postoperative complication was

urinary retention requiring a Foley

cathe-ter, two more important problems warrant discussion.

Thromboembolism. Because ofthe

dan-ger of deep wound hematoma and the risk

of subsequent wound infection,7 we have

been selectively rather than routinely,

anti-coagulating our patients with coumadin.

After analyzing the results of our first 100

procedures, the incidence of thromboembo-lic complications was alarmingly high, 15

per cent. This prompted us to take very

stringent measures duringthepostoperative

periodtopreventthrombophlebitis. In

addi-tion, we have instituted a controlled study to evaluate the use of Dextran-40 as a

prophylactic anticoagulant. Although re-cent reports in the surgical literature have appeared favoring the use of Dextran," 10

our preliminary results based upon 60

treated and60 controlledpatients showjust

as manypulmonary emboli and episodes of

thrombophlebitis in the treated groups as

the control group.14 Further studies are nowbeing carried out inrespect to the use

of Dextran 70.

Infection. The most important and

dan-gerous complication of LFA is postopera-tive deepwound infection. Fortunately, we

have had little experience in this regard. Although we have had three superficial

wound hematomas whichdrained and grew

out an organism, there have been no early

and no late deep wound infections.

Charmley's wound infection rate in a large

series of patients was unacceptable priorto the institution of stringent measures to

pre-vent intraoperative contamination. These

included the use ofsterile laminar air flow system and the complete isolation of the

surgeons'florafrom the operative field.5We

currently do not have a laminar air flow

operatingroom for implant surgery.

Never-theless,everyeffort ismadeto carryoutthe strictestaseptic technic inordertoeliminate

any potential source of intraoperative

wound inoculation.

Another factor to be considered in the

659

TABLE 1.Diagnostic Categories Primaryosteoarthritis 120

Failed previous surgery 36 Secondaryosteoarthritis 16 Rheumatoidarthritis 15 Avascularnecrosispostfracture 7

Mixed arthritis 6

TABLE 2. Pre-andPostoperative Pain (90Hips)

Grade 1 2 3 4 5 6

Preop. - 20 49 18 3

Postop. - - 1 6 21 62

TABLE3.Pre-andPostoperativeMobility (90Hips)

Grade 1 2 3 4 5 6

Preop. 12 22 33 19 3 1

Postop. - - 3 18 37 32

TABLE 4.Pre-andPostoperativeFunction (84Patients)

Grade 1 2 3 4 5 6 A Preop. - 5 12 2 Postop. - - 1 3 3 12 B Preop. 2 20 23 3 1 Postop. - 2 9 14 10 14 C Preop. 4 8 4 - -Postop. 1 1 3 7 2 2

TABLE5.GeneralComplications (200 Hips)

Urinaryretention 83 Urinarytractinfection 36 Pulmonary embolus 15

Atelectasis 6

Paralytic ileus 5

Gastrointestinal bleed 3

TABLE 6.LocalComplications (200flips)

Thrombophlebitis 12

Deepwound hematoma 10

Peroneal palsy (transient) 4

Subluxation 2

Dislocation 1

Deepwound infection 0

Ann. Surg. * Oct. 1971 Vol. 174 No. 4

STINCHFIELD AND WHITE Ann. 8urg. * Oct. 1971

Vol. 174 No. 4

FIG. 5A. L. J.,is a70

year-old woman with a

congenital dislocation of

her left hip. In recent

years, her hip had be-come painful and limited her activity.

prevention of wound infection is the use

ofprophylactic antibiotics. Our department

published a paperinJanuary 1970

advocat-ing the use of prophylactic antibiotics in

major hip and backsurgery." This was

re-commended on the basis of a controlled

comparison of postoperative wound

infec-tions utilizing Penicillin-G as the

prophy-lactic antibiotic choice. Whenever

select-ing a prophylactic antibiotic, one must be

familiar with his own hospital's infecting

organisms and their sensitivities. All of the

patients undergoing LFA received

Peni-cillin-G or an alternate antibiotic before,

during, and after operation.

Technical Complications. Technical complications of LFA also can lead to a

poorresult. Most patients undergoing LFA

as their initial surgical treatment for pri-mary osteoarthritis present no difficulty for thoseproperly trained inthe technic.

How-ever, revisionsurgeryforapreviouslyfailed

arthroplasty is considerably more difficult.

Dislocation of the hip joint, resection of heterotopic bone, preparation of the

aceta-bulum andaligmentof theprosthesis areall

technical barriers with whichonemust

con-tend. The followingtwo examples illustrate difficulties imposed by a deficient

aceta-bulum. The first patient (Fig. 4) represents

failed bilateral osteotomies which

pre-viously had been performed for

congeni-tally subluxated hips. Although hardware

removal, dislocation, and acetabular

pre-paration were difficult, a good end result was achieved. The secondexample (Fig. 5)

is that of an elderly lady with a congenital

Fic. 5B. An LFA was performed but the acet-abular component was not well seated because of

an inadequate bony roof.

Ann. Surg. Oct. 1971 TOTAL HIP REPLACEMENT 661

Vol. 174 No. 4

r_r

FiG,. 5G. Two months after operation, fixation of the acetabular socket waslostand theprosthesis

dislocated.

dislocation. No acetabulum is present. At-tempts to create an acetabulum failed

be-cause of lack of

bony

support over the acetabular socket. Two months after

opera-tion and after a limited amount of

weight-bearing,

this

prosthesis

loosened and dis-located. The entire

prosthesis, including

cement, had to be removed. The

patient

was in no way

helped by

her

original

operation.

Summary

The

early

results of our low friction

arthroplasty

series are very encouraging. We believe that total

hip

replacement

is here to

stay,

but we know that this

proce-dure carries with it the potential of many

and

major complications.

Inherent in this method of low friction

arthroplasty

is the

possibility

of

catastrophic

results unless the

principles

laid down are

carefully

followed. We believe that

thoughtful

selection of

pa-tients and strict attention to

operative

FIG. 5D. The entire prosthesis had to be

re-moved leaving the patient with her preoperative

deformity, after two major surgical procedures.

asepsis are the two most important factors in this procedure.

Acknowledgment

The authors wish to acknowledge the con-tribution of Nasseroddin S. Eftekhar, M. D. and

Kenneth M. Kurokawa, M. D., in the initiation and continuation of this prospective study.

References

1. Atik, M., Harkness, J. W. and Wichman, H.

W.: Prevention Fatal Pulmonary Embolism. Surg. Gynec. Obstet., 130:403, 1970. 2. Charnley, J.: Arthroplasty of the Hip. A New

Operation. Lancet. 1:1129, 1961.

3. Charnley, J., Kamangar, A. and Longfield,

M. D.: The Optimum Size of Prosthetic

Heads in Relation to the Wear of Plastic Sockets in Total Replacement of the Hip. Med. Biol. Engin., 7:31, 1969.

4. Charnley, J.: Acrylic Cement in Orthopaedic

Surgery. Balitmore, Maryland, Williams and

Wllins Co., 1970.

5. Charnley, J.andEftekhar, N.S.: Postoperative Infection in Total Prosthetic Replacement Arthroplasty of the Hip Joint. Brit. J. Surg., 56:641, 1969.

6. Charnley, J.: Total Hip Replacement by Low Friction Arthroplasty. Clin. Orthop., 72:7, 1970.

STINCHFIELD AND WHITE Ann. Surg. Oct. 1971

662

Vol. 174 No. 4

7. Crawford, W. J., Hillman, F. and Charnley, J.: A Clinical Trial of Prophylactic

Anticoagu-lant Therapy in Elective Hip Surgery, Cen-ter for Hip Surgery, Wrightington. Hospital

Internal Publication, No. 14, May 1968.

8. D'Aubigne, R. M. and Postel, M.: Functional Results of Hip Arthroplasty with Acrylic Prosthesis. J. Bone Joint Surg., 36A:451, 1954.

9. Eftekhar, N. S.: Low Friction Arthroplasty: Indications, Contraindications, and

Com-plications. Presented at The Section on

Orthopaedic Surgery, 119 Annual Meeting, American Medical Association, Chicago,

Illinois, June1970.

10. Evarts, C. M. and Feil, E. I.:

Thrombo-embolism after Elective Surgery of the Hip. Orthop. Clin. N. Amer.,2:167, 1971.

11. Fogelberg, E. V., Zitzmann, E. K. and

Stinchfield, F. E.: Prophylactic Penicillin in

Orthopaedic Surgery. J. Bone Joint Surg., 52A:95, 1970.

12. Henrichsen,E., Jansen, K.andKrough-Poulson,

W.: Experimental Investigationof the Tissue Reaction to Acrylic Plastics. Acta Orthop. Scand., 22:141, 1952.

13. Kurokawa, K. M. and Pawluk, R.: Response

of Canine Bone to Self-Curing Methyl-methacrylate. In preparation.

14. Rothermel, J. E.: Personal communication. 15. Wiltse, L. L., Hall, R. H. and Stenejem, J. C.:

Experimental Studies Regarding the Possible

Use of Self-Curing Cement in Orthopaedic Surgery. J. Bone Joint Surg., 39A:961, 1957.

DIscusSION PRESIDENT-ELECr MooRE:

I would like to ask Dr. Stinchfield acouple of questions.

What about Paget's disease? Is that a con-traindication? How do you choose this, versus a cupor aprosthesis, or do you pretty much just go overthis?

Finally, our group, has been concerned over this late sepsis, and we wonder if the plastic sets up a reaction intheacetabulum which favors later

localization of organisms from the bloodstream. In

other words, could it be blood-borne to the site, rather than true, surgical infection?

DR. KENNETH W. WARREN (Boston).Charnley gives considerable credit to the "greenhouse" in

reducing the incidence of infection in total hip

replacement. Do you feel that the "greenhouse" or someformoflaminar airflow is asignificantfactor

in controlling infection in this procedure? Do you use local antibiotic spray or irrigation during the

operation?

DR. EDWIN W. SALZMAN (Boston): We have recently completed a study of 169 patients with

Vitallium mold arthroplasty, in whom we

com-pared the efficacy of agents affecting platelet

function with warfarin for the prophylaxis of

venous thromboembolism. In that study dextran

and aspirin were each as effective as warfarin,

which was significantly more effective than the

control.

Ina companion study of totalhip arthroplasty

whichisstillinprogress, theincidence of thrombo-embolism appears higher than following the cups;

perhaps Dr. Stinchfield would comment on this difference.

The preliminary results of this second study appear to show that dextran is not as effective as

warfarin in these high risk patients.

DR. FRANK E. STINCHFDELD (Closing): We have operated upon five patients with Paget's

Disease. However, this type of patient is not the ideal one on whom to operate-if one expects to obtainanexcellentresult. Paget's, per se,produces

painandonecannoteliminate thediseasebydoing

a total hip replacement. In the five patients

operatedupon, two results were disappointing and three patients said they received relief from pain -butstill had their Paget's pain.

The question was asked-"When do you use

cups?"Iwant to saythat I still consider the mold

operation to be an excellent one and continue to

use itonpatients inthe younger age group-those

between the ages of 20 to 55 years. Also, we use

the cup arthroplasty in those patients where there has been previous infection. One should never attempt a total hip replacement where there has been priorinfection.

Late sepsis is something thatIcannotcomment

onbecause we have been doing this procedure for but the past2 years. We may experience this

com-plication in another 1 to 3 years but to date we havehadnone. Ithink that when infection occurs it probably is introduced at the time of operation

andisnot bloodborne. Actually, there is

consider-able evidence to prove that methylmethacrylate

does not really give very much soft tissue reaction. The question by Dr. Warren relative to the 'greenhouse,' the laminar air flow, and the space suit, is very appropriate- as all of these

contrib-ute todiscipline. There is no doubt ofthat. How-ever, inour series, we have not foundthe

'green-house' tobeessential.

Relative to the use of antibiotics we have re-ported our findings in a previous study. In that

study we reported on 236 patients who had had

mold arthroplasties. The infection rate was

re-duced from 5.4 to 1.2 by the use of appropriate prophylactic antibiotics.

Regarding the use of anticoagulants, I agree that anticoagulation is helpful. We anticoagulate

all of our patients who have had a mold

arthro-plasty, in an effort to prevent thrombophlebitis.

However, inthe totalhip replacement patient, we fearhematomamorethanthromboembolism.

Anti-coagulation may cause bleeding and hematoma more thanthromboembolism. Anticoagulationmay cause bleeding and hematoma-which could lead to infection. Therefore, we do not routinely anti-coagulatethe totalhippatient.