Five-year results of the uncemented RM pressfit cup clinical evaluation and migration measurements by EBRA.

This was a prospective consecutive, study of 50 patients (mean age 72 years, 56% males) treated unilaterally for primary osteoarthrosis using the uncemented, isoelastic, monoblock RM Pressfit Cup. Migration and wear were assessed using the EBRA (Ein-Bild-Röntgen-Analyse) software (201 radiographs from 36 patients). Mean migration was 0.82 mm after 2 years and 1.25 mm after 5 years. A decreasing migration rate over the period was observed. The mean annual wear rate was 0.09 mm/y. Five years after surgery, 84% of patients reached good or excellent Harris hip score values. No revisions related to the acetabular component were necessary. All cups appeared to have high primary stability.

Strategies for head and inlay exchange in revision hip arthroplasty.

Due to the increasing number of total hip arthroplasties performed during the last three decades and the limited long-term survival, mainly because of wear, the number of revisions has increased during the last two years. If the implant itself is still considered to be stable, only head and inlay exchange is necessary. This requires comprehensive knowledge of the characteristics of the articulating materials by the surgeon as the wrong choice of wear couple can lead to early failure for a second time. The aim of this paper is to present considerations and strategies for head and inlay exchange in case of failure, either due to wear of the articulation material or of other indications for revision hip arthroplasty.

Long-term results following Keller resection arthroplasty for hallux rigidus.

BACKGROUND: We assessed the long-term results following Keller resection arthroplasty for the treatment of hallux rigidus. We then compared them with alternative surgical methods like cheilectomy, arthrodesis and joint replacement. METHODS: Eighty-seven cases of Keller resection arthroplasty for hallux rigidus were reviewed with mean followup of 23 years. Their mean age at time of surgery was 50 years. Analysis included personal clinical evaluation with the AOFAS Hallux Score, quality-of-life assessment using the SF-36, radiographic assessment, pedobarographic evaluation and analysis of the patients' charts to detect any postoperative complications. RESULTS: At the time of followup only five (5%) feet had undergone revision surgery. For all other cases we calculated a mean AOFAS score of 83 points. Sixty-nine of 73 unrevised patients (94%) would opt for this operation again under the same circumstances. SF-36 parameters showed age related normal values. Pedobarographic assessment revealed only moderate weightbearing alterations. Our long-term results compare favorably with published results following arthrodesis, cheilectomy or joint replacement for the treatment of painful hallux rigidus. Clinical results and subjective assessments were very good and complication rates were low compared to competing methods. CONCLUSION: Keller resection arthroplasty remains a valuable surgical option for the treatment of advanced stages of hallux rigidus with high patient satisfaction, moderate weightbearing alterations and comparable low complication rate in our experience.

Early results with the cementless Variall hip system.

This study presents the early results of the Variall cementless hip system, a further development of the reliable Alloclassic Zweymüller system. In a prospective randomized study, 319 patients (333 hips) underwent the Variall cementless hip system with four different bearings and were scored using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Score and the Short Form-36 health survey form, with a follow-up period of 3 years. The patients were grouped according to age, with those in the age range 23-75 years as group one (n = 285) and those over 75 years of age as group two (n = 48). For both the Short Form-36 and WOMAC scoring, worse function was found in group two (i.e., patients >75 years). In this group, the function scores were worse in patients who received a conventional polyethylene bearing. The clinical and radiological results after 5 or more years will lead to a clearer prediction.

[Sporting activities following total hip and knee arthroplasty]. / Sport nach Hüft- und Knietotalendoprothese.

The expectations of total joint replacement are constantly increasing: Freedom of pain and mobility used to be the primary goal, while nowadays it is longevity despite heavy loading and intense sporting activity. A preoperative sportive patient expects to be able to perform his favorite sporting activities like hiking, swimming and cycling, but also the more demanding skiing, tennis and jogging, for example, after surgery. The aim of this article is to illustrate what level of sporting activities can be performed by patients with total joint replacement. Are there differences between the pre- and postoperative levels? What are the risks for, and negative influences on, the prosthesis during intense sporting activity? What is the role of the physician? Finally, recommendations for sporting activities after total hip and knee replacement are given.

Bone marrow edema syndrome of the femoral head: treatment with the prostacyclin analogue iloprost vs. core decompression: an MRI-controlled study.

BACKGROUND: The purpose of this study was to assess the efficacy of the vasoactive drug iloprost in Bone Marrow Edema Syndrome (BMES) and to compare it to the results of a control group treated by core decompression. PATIENTS AND METHODS: 38 hips (36 patients) with BMES in the femoral head were investigated. In group A, 18 hips (17 patients; mean age 49 years) were treated with iloprost, a vasoactive drug that dilates arterioles and venules, reduces capillary permeability and suppresses platelet aggregation. The therapy comprised a series of five infusions with 20 microg iloprost over 6 hours on 5 consecutive days. Weight bearing was reduced for up to 3 weeks, depending on the severity of symptoms. In group B, 20 hips (19 patients; mean age 41 years) underwent surgical core decompression of the femoral head followed by 6 weeks of partial weight bearing. Both groups were evaluated clinically, radiographically and by MRI. RESULTS: In group A, one patient had to discontinue therapy on the first day because of severe headache. In the remaining patients the Harris Hip Score (HHS) improved from a mean of 64.7 points (range 44-89) before therapy to 97.0 points (83-100) after 3 months. MRI controls showed complete remission in all hips. In group B, the preoperative HHS improved from 53.7 points (31-82) to 95.1 points (39-100) after 3 months. MRI controls showed complete remission of BMES in 14 hips, residual focal bone marrow edema in four hips and a small osteonecrotic area in two hips. In both groups the high level of clinical recovery was maintained at the last examination after a mean follow up of 11 months in group A and 12 months in group B. CONCLUSION: The parenteral application of iloprost can achieve equal or better results in the treatment of bone marrow edema syndrome of the hip compared to core decompression.

Poor agreement between prospective and retrospective assessment of hallux surgery using the AOFAS Hallux Scale.

BACKGROUND: Retrospective assessment of preoperative status is common in nonprospective study designs. The aim of this study was to test the hypothesis that prospective and retrospective evaluations of the preoperative patient condition in hallux surgery gives equal results and therefore can be used interchangeably. METHODS: One hundred and fifty-nine consecutive feet with hallux surgery were analyzed prospectively. Parallel to routine evaluation of the preoperative status, the AOFAS Hallux Scale was recorded prospectively. Two years after surgery, the medical records were re-evaluated for retrospective reconstruction of the AOFAS score. Simultaneously all patients were asked to assess their preoperative status retrospectively. RESULTS: Using the medical charts for retrospective assessments, the preoperative status was estimated too low compared to prospective evaluation. This effect was even more pronounced with the patients' own retrospective assessment of their preoperative status. Linear regression coefficient for prospective and retrospective data showed moderate correlation with r = 0.59 for the AOFAS Score using the medical charts and poor correlation of r = 0.24 using the patients' own retrospective assessments. Spearman's rank correlation index was p = 0.57 and p = 0.23, respectively. The coefficient of repeatability according to Bland and Altman was 25.7 and 48.7 points, respectively, for the AOFAS score. The difference between the mean values of prospective and retrospective assessment was 5.6 (13.0) points. This means that a retrospectively evaluated AOFAS Score may be 31.3 points below or 20.1 points above prospective assessments (61.6 points below or 35.7 points above compared to the patients' own retrospective self-assessments). Agreement between individual items using Kappa statistics showed poor results except for metatarsophalangeal joint motion. CONCLUSIONS: Prospectively and retrospectively evaluated AOFAS scores cannot be used interchangeably for clinical outcome evaluations. Retrospective scoring gives worse results even when evaluated using conscientiously recorded medical charts and therefore leads to overestimation of the effect of surgery. These data support prospective study designs to ensure the best outcome analysis for clinical evaluation of hallux surgery.

Total hip replacement in younger patients: survival rate after avascular necrosis of the femoral head.

BACKGROUND: A high risk of loosening has been reported in replacements performed because of avascular necrosis. PATIENTS AND METHODS: To study cementless total hip replacement (THR) in younger patients with avascular necrosis (AVN), we analyzed retrospectively the outcome in 129 cases: 46 Mittelmeier monobloc ceramic hips (22 cases with AVN), and 83 Zweymüller total hip systems (35 cases with AVN) clinically and radiographically. RESULTS: At follow-up, 17 Mittelmeier prostheses (10 AVN) and 4 Zweymüller prostheses (none with AVN) had been revised. The diagnosis did not affect the implant survival, but the Zweymüller THR fared better than the Mittelmeier system. The main reason for revision of Mittelmeier implants was aseptic loosening, 3 of 4 Zweymüller revisions were necessary due to polyethylene wear. This difference was confirmed by the radiographic evaluation of the still intact implants: Zweymüller THR showed better values for signs of osseointegration, radiolucent lines around the implants and migration, but more acetabular wear. None of these differences was affected by the AVN diagnosis. INTERPRETATION: We could not confirm that AVN is a risk factor in total hip replacement.

Reproducibility of the radiographic metatarsophalangeal angle in hallux surgery.

BACKGROUND: Five different methods have been described to define the longitudinal axis of the first metatarsal for radiographic measurements of the first metatarsophalangeal angle. None of these methods has been validated for both preoperative and postoperative assessment of patients undergoing hallux valgus surgery. Previous studies have demonstrated conflicting results regarding the measurement accuracy of these methods. METHODS: To evaluate the measurement accuracy of these five methods, we calculated the intraobserver and interobserver coefficients of repeatability for all five methods with use of twenty preoperative and twenty postoperative standardized plain dorsoplantar weight-bearing radiographs of patients undergoing chevron distal osteotomy. RESULTS: The preoperative assessment of the metatarsophalangeal angle revealed small differences among the five methods. The intraobserver coefficient of repeatability ranged from 2.10 degrees to 3.34 degrees, and the interobserver coefficient ranged from 2.17 degrees to 3.44 degrees. The postoperative assessment demonstrated substantial differences between methods in which the diaphysis of the first metatarsal is used as a reference (intraobserver coefficient, 5.06 degrees to 7.23 degrees; interobserver coefficient, 5.29 degrees to 8.19 degrees) and methods in which there is one reference point in the metatarsal head and one reference point in the base of the first metatarsal (intraobserver coefficient, 1.88 degrees to 2.67 degrees; interobserver coefficient, 1.86 degrees to 2.34 degrees). CONCLUSIONS: For the assessment of patients undergoing a distal metatarsal osteotomy, we cannot recommend methods in which the metatarsal shaft is used as a reference for the axis of the first metatarsal. Such methods had poor measurement accuracy, especially postoperatively. Methods with reference points distal and proximal to any possible osteotomy site had much better measurement reproducibility. We recommend the method described by Miller in 1974, in which a line is drawn from the center of the first metatarsal head through the center of the base of the first metatarsal, as it was the most precise method and was least biased by postoperative effects.

Keller procedure and chevron osteotomy in hallux valgus: five-year results of different surgical philosophies in comparable collectives.

We evaluated 97 Keller procedures and 64 chevron osteotomies, both combined with the "Cerclage fibreux" distal soft-tissue procedure, with a minimum follow-up period of five years to assess the limits of indications of these two different operations. We then formed two subgroups providing a statistical midrange of the metatarsophalangeal angle, intermetatarsal angle I-II and degree of arthrosis of the first metatarsophalangeal joint to obtain comparable collectives of 40 Keller and 36 chevron procedures. The postoperative AOFAS score averaged 85.4 for the Keller procedure and 83.0 for chevron patients. The metatarsophalangeal angle was improved to an average of 11.0 degress and 13.9 degrees, the intermetatarsal angle to values of 8.8 degrees and 9.4 degrees, respectively. The patient's overall satisfaction rated "very satisfied" and "satisfied" in 92.5% and 94.4%, respectively. The main reason for dissatisfaction was pain. Compared to the literature, the good long-term results in this series following resection arthroplasty are attributed to the routine use of the "Cerclage fibreux" technique. This contemporary type of the Keller procedure is still a valuable surgical procedure for older patients with minor functional expectations. Excellent outcome after chevron osteotomy was not only seen in younger patients with minor deformities, but also in an older population. The chevron osteotomy should not be restricted to younger patients. The combination of the chevron distal metatarsal osteotomy with a distal soft-tissue procedure does not increase the risk of clinically manifest avascular necrosis of the metatarsal head and helps to correct higher metatarsophalangeal and intermetatarsal angles.

Intra- and interobserver repeatability of radiographic measurements in hallux surgery: improvement and validation of a method.

To test the hypothesis that the reproducibility of radiographic measurements of the first metatarsophalangeal angle and the intermetatarsal angle I-II can be increased by exact guidelines, we calculated the intra- and interobserver reliability of both methods. 4 independent observers (2 senior residents and 2 orthopedic trainees) evaluated 50 pre- and 50 postoperative plain dorsoplantar radiographs with their method of preference and then with Mitchell et al.'s method (1958). The mean intraobserver coefficient of repeatability for the metatarsophalangeal angle improved from 5.9 degrees to 4.2 degrees and for the intermetatarsal angle I-II, from 4.4 degrees to 2.8 degrees. The interobserver coefficient of repeatability improved from 6.5 degrees to 5.0 degrees for the metatarsophalangeal angle, and from 4.9 degrees to 3.6 degrees for the intermetatarsal angle I-II. This improvement in measurement accuracy was more marked for postoperative measurements, due to deformation of the metatarsal after the osteotomy which made it more difficult to find the longitudinal axis of the metatarsal. The improvements in the accuracy of measurements were also greater in the two inexperienced observers, since their measurements differed more when they had no exact guidelines for their drawings.