P. E. Ochsner (Ed.) • Total Hip Replacement

Springer-Verlag Berl in Heidelberg G m b H

Peter E. Ochsner (Ed.)

Total Hip Replacement

Presentation based on the system according to M . E . Müller

with long-term follow-up

With Contributions by

M . Brunazzi • P. Ferrat • S. Häfliger • M . Kle in

G. Kohler • M . Lüem • T. Maurer • T. Münch • B. Nachbur

P. E. Ochsner • A.S. Pirwitz • U. Riede • M . Sarungi

M . Schafroth • A . Schweizer • R. Sommacal • H.R. Stöckli

Y. Thomann • D. Toia • J. Vaeckenstedt • W. Zimmerl i

Foreword by M . E. Müller

With 169 Figures in 361 Separate Illustrations, 84 in colour,

and 24 Tables

Implantation Technique

and Local Complications

||)f Springer

Professor Dr. med. P E T E R E M I L O C H S N E R

Chefarzt der Orthopädischen Klinik Kantonsspital

CH-4410 Liestal

Switzerland

Translator:

Robert Hinchliffe

2 The Gully

Winterbourne

Bristol BS36 l Q W United Kingdom

The German Edition appeared under the title Peter Ochsner (Hrsg.): Die Hüfttotalprothese

ISBN 978-3-642-62868-9 ISBN 978-3-642-55679-1 (eBook) DOI 10.1007/978-3-642-55679-1

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© Springer-Verlag Berlin Heidelberg 2003 Originally published by Springer-Verlag Berlin Heidelberg N e w Y o r k i n 2003

Softcover reprint of the hardcover i s t edi t ion 2003

The use of general descriptive names, registered names, trademarks, etc. in this publications does not imply, even in the absence of a specific statement, that such names are exempt from the relevant pro­tective laws and regulations and therefore free for general use.

Product liability: The publishers cannot guarantee the accuracy of any information about the appli­cation of operative techniques and medications contained in this book. In every individual case the user must check such information by consulting the relevant literature.

Medical illustrations: J. Kühn, Heidelberg Graphics: G. Hippmann, Nürnberg Cover design: deblik Berlin Typesetting and reproduction of the figures: AM-productions GmbH, Wiesloch

Printed on acid-free paper SPIN 10718477 24/3150PF 5 4 3 2 1 0

THIS BOOK IS DEDICATED

TO MAURICE E. MULLER

AND HANS WILLENEGGER tAND TO OUR PATIENTS

Foreword

"Total Hip Replacement" by Peter Ochsner and his colleagues is a unique, exem­plary, instructive and valuable addition to the world of surgery.

Shortly after taking charge of the newly established department fororthopaedic surgery in Liestal in June 1984, the new medical director, Peter E.Ochsner, decided to document all total hip replacement operations prospectivelyand then follow these up regularly over a minimum period of 10 years.

The former director of the surgical clinic, Professor Hans Willenegger, hadpreviously established a documentation secretariat. The documentation systemselected by Peter Ochsner was based on the code forms A (first hospital stay) B(revision procedure) and C (follow-up) which were developed in 1984 by theMEM Institute for Documentation in Berne, each form incorporating over 400

check boxes. The forms are supplemented by the radiograph card, with affixedcopies of the most important images, and the preoperative plans. New formsrevised by IDES ("International Documentation and Evaluation System") andaccepted by SICOT were used from 1991.

With the application of a little discipline, consistent completion of the A formdid not prove to be a problem, provided that every operator was prepared towrite the surgical report immediately after the procedure. This task took up lit­tle more than 5 minutes of the surgeon's time. Follow-up planning, however,proved rather more difficult according to Peter Ochsner, although it still provedpossible to invite and follow-up over 96 % of operated patients who were stillliv­ing.

Once the code forms have been correctly marked and imported into the data­base) either by the optical scanner or by hand, the surgeon then has at his disposalan incredibly valuable information resource. At the press of a button, the com­puter can provide not only the complete medical histories, but any desired sta­tistical compilation or lists with data summaries. By 2000, data were availablefrom over 1500 primary hip replacements and 478 revisions. In order to ensurethe inclusion of a sufficient follow-up period for patients with complications, itwas decided that the statistical analysis should only take into consideration thosepatients undergoing surgery prior to 1997. Excluding deceased patients, thisresulted in 1081 primary cases and 330 revision procedures. Each group of com­plications was analysed according to all possible criteria, which meant that notonly could number, cause, treatment and outcome, previous procedures, age andweight be determined, but also the precise diagnoses, per- or post-operativesources of error and complications of a local and general nature.

The various chapters, including those on surgical technique and planning,postoperative haematomas and dislocations, fractures and other perioperativecomplications, trochanteric problems, leg length discrepancies, limping, periar­ticular ossification, pain, revision rates, are objectively and comprehensively dis­cussed by various collaborators. In the difficult chapters on infections, nerve

VIII Foreword

lesions and vascular injuries, Peter Ochsner sought the assistance of well-knownspecialists. Special emphasis has been placed on preoperative patient briefing.Additionally, the literature, including the last five years of the principalorthopaedic journals, has been reviewed and compared with the authors' ownresults. The data were collated from all the patients undergoing surgery at theclinic, i.e. roughly one third were operated on by the medical director himself,one third by senior registrars and experienced assistants and the last third bymore junior registrars.

Over the course of the last five years, medical documentation technology hasadvanced in leaps and bounds. Electronic medical histories coupled with digitalarchiving of radiographs and integrated quality control, regardless of the spe­cialist field, have now become commonplace. All of the information that isimportant for the clinic director, surgeon, theatre nurse, patient, administration,clinical researcher, health insurance scheme, healthcare policy-maker, medicaltechnologist, not forgetting the lawyer, can be collated in one and the same data­base. At the same time, these systems represent a substantial saving on paper­work for the surgical assistant. The main question nowadays is whether the infor­mation should be saved via an Internet platform or via optical scanners.

While no-one can say how soon this trend will become a reality in Swiss hos­pitals, one thing is certain: systematic, prospective, seamless, patient-orienteddocumentation is here to stay, and should become a quality benchmark for pro­cedures performed by any conscientious orthopaedic surgeon.

To sum up: the work of Peter Ochsner and his colleagues is unique because alltotal hip replacements undertaken between 1984 and 1997 at the Liestal CantonalHospital have been documented almost seamlessly (> 96%). The book shows, inan exemplary manner, how to publish in book form data for a whole clinic thathave been prospectively collated and stored over many years.

The book is instructive in several respects, since it shows how the quality of asurgical team can be discerned through seamless documentation and providessenior surgeons and assistants with a wealth of data for presentations and scien­tific papers. These individuals can then draw on the experience thereby gainedthroughout their career.

The book is particularly valuable for those who seek to perform total hipreplacements correctly and avoid complications, yet manage them competentlywhen they occur. It will help the junior orthopaedic surgeon acquire a solidgrounding in these areas. But thanks to the wealth of detailed information, it alsoenables the experienced orthopaedic surgeon, in particular, to deal in depth withthe problems associated with complications and the options for systematic doc­umentation.

The book is recommended to all those who deal with problems relating to hipsurgery and statistics in medicine, and is also of particular interest to generalpractitioners.

MAURICE E. MULLER

Preface

Our aim in writing this book is to convey as much practical information as pos­sible on the surgical technique of total hip replacement and the prevention andtreatment of complications. Chapter 3, "Surgical Technique", deals with specialdesign features of the implants used, operation planning and the detailedsequence of surgical steps in primary and revision procedures. The uniformlystructured chapters on complications focus on definitions, frequency, prophy­laxis, treatment and literature references. Numerous examples and sketches,some described and illustrated in considerable detail, are intended to stimulate arational debate. Many cross-references are included for further enlightenment.Separate chapters are devoted to the subjects of documentation, patient popula­tion and preoperative briefing. The comprehensive survival curves for theimplants used constitute a key scientific element of the book and cover all theimplants developed by M.E. Muller and currently on the market, as well as theWagner SL revision stem. By way of a reminder, it was in 1977 - exactly 25 yearsago - that M.E. Muller introduced two of his most important implants, thestraight-stem prosthesis and the acetabular reinforcement ring.

The book aims to encourage both recently qualified and experienced or­thopaedic surgeons to compare their own experiences and problems with thoseof a hospital that has been monitoring its own patient population in a regular fol­low-up programme for 18 years. The idea of a standardised surgical techniqueand systematic documentation for total hip replacements was suggested to theeditor of this book on his arrival at Liestal in 1984 by Maurice E. Muller, who alsoprovided financial support to initiate the scientific research work at the newlyformed Orthopaedic Hospital. Since 1989, the editor has also regularly been in­vited by the company Protek to attend the meetings of its technical committee.This committee was made up of engineers, marketing specialists and or­thopaedic surgeons, including H.-B. Burch, R. Ganz, N. Gschwend, E. Morscher, R.Schneider, H. Vasey and H. Wagner. Working with this committee, M.E. Mullersuccessfully developed a number of hip and knee implants with specific features.Unfortunately, these activities were scaled down when the company was trans­ferred to Sulzer Orthopaedics. A similarly composed, albeit smaller, group re­mained for the sole purpose of managing the products developed by M.E. Muller,who transferred his chairmanship of this committee to the editor some time ago.The enthusiasm for his subject conveyed by M.E. Muller and the commitment ofour hospital to the scientific monitoring of these products were the driving forcesbehind this book.

The first paper by M.E. Muller on arthroplasty of the hip appeared in 1950. Theobjective of the study was to analyse the results obtained by his host at that time,Comelis Pieter van Nes, in the Annaspital in Leiden following the implantationof Smith-Petersen shells and femoral head prostheses according to Judet [2]. Thetwo themes of surgical technique and management of complications appear like

X Preface

a central thread running through the principal works of Muller on total hip re­placement [3-5]. Three other publications dealing primarily with the manage­ment of complications deserve to be mentioned: a congress report by Postel in1970 [6] and two books, one edited by Ling in 1984 [1] and the other by Steinbergand Garino in 1999 [7].

In this book we have adopted the approach of M.E. Muller by combining sur­gical technique with the management of complications. In addition to a literatureanalysis, the scientific basis of the book is provided by a comprehensive evalua­tion of our own patient population. The data analysis was made possible by theMEM hip documentation system, which has been in operation since 1984. Thetradition of complete, seamless documentation was developed in Liestal by HansWillenegger, at that time the head of surgery, who, with M.E. Muller, was one ofthe four co-founders of the Arbeitsgemeinschaft fur Osteosynthesefragen (Asso­ciation for the Study of Internal Fixation). Hans Willenegger established a docu­mentation secretariat for organising the scrupulous follow-up of all internal fix­ations and for recording the resulting data. This facility remains at our disposalto this day. Willenegger's constant willingness to accept patients with complica­tions for treatment has resulted in a growing influx of such patients into our hos­pital. A considerable proportion of our wealth of practical experience in themanagement of complications derives from these patients.

All orthopaedic collaborators working on this book are indebted to our or­thopaedic department. They have written their chapters with considerable ener­gy and initiative and, together with the editor, have made many revisions. As re­gards the non-orthopaedic subjects, we have been able to count on the coopera­tion of a number of acknowledged experts in their field, specifically the vascularsurgeon Bernhard Nachbur, the neurologist Hansruedi Stockli, the infectiousdiseases specialist Werner Zimmerli and our own engineer Martin Wem. A prop­er statistical analysis of our patient population was made possible thanks only tothe collaboration with the Institute for Medical Biometrics and Medical Infor­matics in Freiburg in Breisgau, under the direction of Martin Schuhmacher. Doc­umentation played a key role in this study. As documentation secretary, SusanneHafliger ensured that patient data were meticulously recorded. We also receivedexcellent support in perfecting our database from our partnership with the M.E.Muller Institute in Berne, particularly from Mrs. Thomet and Mrs. Rosli. In thePathology Institute of the Canton of Basel-Land (Prof. Gieri Cathomas) we wereable to use the anatomical preparations as a basis for the corresponding draw­ings in Chaps. 11 and 13. The histological investigations were conducted by thelaboratory jointly operated by the Orthopaedic Department and Stratec AGOberdorf under the leadership of Peter Zimmermann. Ursula von Allmen pro­vided skilful photographic input, while Anna Berchtold helped with the litera­ture acquisition. The company Centerpulse has supported our scientific work fi­nancially, with the explicit proviso that this funding would not influence the re­sults. The company Stratec placed their laboratory, directed by Peter Zimmer­mann, at our disposal for the histological investigations. The two hospital direc­tors Hans Bider and Heinz Schneider have supported the scientific projects con­ducted at the Orthopaedic Hospital and generously provided us with the neces­sary facilities. I should like to offer my sincere thanks to all the aforementionedindividuals. But I should also particularly like to thank all those numerous col­leagues who, without being named, conducted thousands of follow-up evalua­tions and who gave the book's authors the time to produce this work.

I should like to thank Springer-Verlag for the helpful multi-coloured layout ofthe book, which I find very appealing. Mr. Kuhn has taken on the task of rework-

Preface XI

ing my original drawings and the anatomical photographs into printer's copy.Mrs. Schroder, Mr. Schmidt, Mrs. Hofmann and Mrs. Pfaff, together with manyothers, have worked on the book with considerable care and sensitivity. Theyhave repeatedly surprised me with impressive design details.

We should like to dedicate this book to our patients, to Maurice E. Muller andto the late Hans Willenegger. Our hope for our patients is that they should nothave to endure avoidable suffering. We are grateful to M.E. MUller for his con­tinuing and generous support for our work. We thank Hans Willenegger for en­couraging us to work for the benefit of those patients who suffer complications,and for the portrayal of our hospital as a contributor to scientific research.

Liestal, April 2002

References

PETER E. OCHSNER

1. Ling RSM (Hrsg) (1984) Complications of total hip replacement. Churchill Livingstone,Edinburgh

2. Muller M, Sibay R (1950) Zur Arthroplastik des Hiiftgelenkes. Z Orthop 80: 8-163. Muller ME (1966) Proceedings, SICOT Congress Paris, pp 323-3334. Muller ME (1970) Total hip prosthesis. Clin Orthop 72: 46-685. MUller ME, Jaberg H (1990)Total hip reconstruction. In: McCollister E (ed) Surgery of

the musculoskeletal system, 2nd edn. Churchill Livingstone, New York, pp 2979-30176. Postel M (1970) Les complications des protheses totales de hanche. Revue Chir Orthop

56:27-1207. Steinberg ME, Garino JP (eds) (1999) Revision total hip arthroplasty. Lippincott

Williams &Wilkins, Philadelphia

Table of Contents

1 Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

SUSANNA HAFLIGER, PETER E. OCHSNER

1.1 Prospectively Recorded Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.2 Retrospectively Integrated Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

1.3 Data Entry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

1.4 Data Correction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.5 Data Basis for this Book. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

2 Patient Population . . .. . .. . . .. . . . . . . .. . . . .. . . .. . . .. . .. . .. . . . . . 5MARTIN LUEM

2.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52.2 General Analysis of the Patient Population. . . . . . . . . . . . . . . . . . . . . . . . 5

2.2.1 Recorded Cases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

2.2.2 Characteristics of the Patient Population . . . . . . . . . . . . . . . . . . . 62.3 Prostheses Used. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

2.3.1 Primary Operations on the Acetabulum . . . . . . . . . . . . . . . . . . . . 72.3.2 Revision Operations on the Acetabulum. . . . . . . . . . . . . . . . . . . . 92.3.3 Primary Operations on the Femoral Shaft 92.3.4 Revision Operations on the Femoral Shaft. . . . . . . . . . . . . . . . . . 12

2.4 Frequency of Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

3 Surgical Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

PETER E. OCHSNER, ANDREAS SCHWEIZER

3.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

3.2 Concept of Total Hip Replacement According to M.E. Muller. . . . . . . . 16

3.3 Implants and Corresponding Indications . . . . . . . . . . . . . . . . . . . . . . . .. 16

3.3.1 Acetabular Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17General Information on Implantation. . . . . . . . . . . . . . . . . . . . . . 17Primary Stability and Preventionof Migration Through Screw Fixation. . . . . . . . . . . . . . . . . . . . . . 17Checking the Migration of Acetabular Implants (EBRA) . . . . .. 20

Acetabular Implants Used. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

- Cemented Polyethylene Cup. . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

- Uncemented SL Cup. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

XIV Table of Contents

- Acetabular Reinforcement Ring. . . . . . . . . . . . . . . . . . . . . . . . . 21- Burch-Schneider Antiprotrusio Cage. . . . . . . . . . . . . . . . . . .. 22

3.3.2 Selection of Femoral Implants 22Femoral Implants Used 22- Cemented Straight-Stem Systems 22- Uncemented Femoral Components. . . . . . . . . . . . . . . . . . . . .. 26

3.4 Operation Planning 263-4.1 Planning Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 263-4.2 Objectives of Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 263-4.3 Standard Planning for a Primary Total Hip Replacement 283.4.4 Planning Example for a Complex Primary Prosthesis 363.4.5 Planning Revision Operations 36

3.5 Preparing for the Operation 443.5.1 Preoperative Patient Examination . . . . . . . . . . . . . . . . . . . . . . . .. 443.5.2 Anaesthetic Preparation 443.5.3 Implant and Instrument Preparation 443.5.4 Positioning the Patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 44

3.6 Operation Procedure for Primary Prostheses 463.6.1 Approach.......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 463.6.2 Cup Implantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 473.6.3 Stem Implantation 503.6.4 Wound Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

3.7 Surgical Procedure During Revision Operations. . . . . . . . . . . . . . . . . .. 543.7·1 Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 543.7.2 Prosthesis Retrieval 543.7.3 Reimplantation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 56

3.8 Postoperative Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 56References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 57

4 Postoperative Haematomas 59MATHIAS KLEIN, DAMIEN TOIA

4.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 594.2 Frequency................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 59

4.2.1 Frequency in Our Own Patients " 594.2.2 Frequency in the Literature " 60

4.3 Preventive Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 604.].1 Haematoma Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 604.3.2 Thromboprophylaxis.................................... 61

4.4 Treatment for Haematomas 614.4.1 Aspiration............................................. 614.4.2 Revision............................................... 614-4.3 Embolisation of Bleeding Vessels . . . . . . . . . . . . . . . . . . . . . . . . .. 624.4.4 Infected Haematomas 634-4.5 Duration of Hospitalisation 63

4.5 Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 63

Table of Contents XV

5 Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 65MATHIAS SCHAFROTH, WERNER ZIMMERLI, MARCO BRUNAZZI,

PETER E. OCHSNER

5.1 Classification, Definitions 655.1.1 Exogenous vs. Haematogenous Infection. . . . . . . . . . . . . . . . . .. 655.1.2 Implant-Associated Infection. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 665.1.3 Time of Manifestation of the Infection . . . . . . . . . . . . . . . . . . . .. 665.1.4 Pathogenicity and Virulence of the Pathogens 675.1.5 Soft Tissue Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 685.1.6 Probability ofInfection . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . .. .. 68

5.2 Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 69502.1 History and Clinical Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 695.2.2 Laboratory Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 695.2.3 Imaging Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 69502.4 Intraoperative Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 70502.5 Microbiological Investigations. . . . . . . . . . . . . . . . . . . . . . . . . . .. 70502.6 Histological Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 72502.7 (Missed) Infection in Old Age 72

5·3 Frequency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 745.3.1 Frequency in Our Own Patients. . . . . . . . . . . . . . . . . . . . . . . . . .. 745.3.2 Frequency in the Literature 74

5.4 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 745.4.1 Patient-Specific Risk Factors 745.4.2 General Risk Factors 75

5.5 Preventive Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 755.5.1 Proven Effective Measures 755.5.2 Presumed Effective Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 75

5.6 Treatment of Infected Total Hip Prostheses 765.6.1 Surgical Management 765.6.2 Therapeutic Elements 82

Debridement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 82Irrigation-Suction Drainage. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 82Spacer Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 83Reimplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 84Revision in Fluid Retention 84Reimplantation Long After a Girdlestone Hip 84

5.6.3 Antibiotic Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 845.6.4 Our Own Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 855.6.5 Comparison with Published Data 88

5.7 Concluding Remarks 88References 89

6 Dislocations After Total Hip Replacement. . . . . . . . . . . . . . . . . . . . . . 91GREGOR KOHLER

6.1 Definitions, Impingement 916.1.1 Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 916.1.2 Impingement and Dislocation 97

6.2 Frequency...................... . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 996.2.1 Frequency in Our Patient Population 996.2.2 Frequency in the Literature 101

XVI Table of Contents

6.3 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 102

6.4 Preventive Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 102

6.5 Management of Dislocations 103

6.5.1 Our Own Measures 103

6.5.2 Dislocation Management in the Literature. . . . . . . . . . . . . . . . .. 104

6.5.3 Overview of the Therapeutic Options for Dislocations 104

6.6 Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 105

6.6.1 Early Dislocations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 105

6.6.2 Late Dislocations 105

References 106

7 Periprosthetic Fissures, Fractures and Perforationsof the Proximal Femoral Shaft 107

THIERRY MUNCH

7.1 Introduction, Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 107

7.1.1 Fracture Types 107

7.1.2 Site. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 109

7.1.3 Time of Onset/Time Identified. . . . . . . . . . . . . . . . . . . . . . . . . . .. 109

7.1.4 Stability of the Prosthesis 111

7.2 Frequency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 111

7-2.1 Frequency in Our Own Patients . . . . . . . . . . . . . . . . . . . . . . . . . .. 111

7.2.2 Frequency in the Literature 113

7.3 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 113

7-4 Preventive Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 114

7.5 Management of Complications 114

7.5.1 Fissures and Fractures Associated with Primary Prostheses. .. 114

Intraoperatively Detected Fissures/Fractures 114

Postoperatively Detected Fractures and Perforations. . . . . . . .. 117

Fractures Associated with Loose Prosthesis. . . . . . . . . . . . . . . .. 119

7.5.2 Fissures and Fractures Associated with Revision Prostheses .. 119

7.5.3 Postoperative Managementand Complications After Osteosyntheses . . . . . . . . . . . . . . . . . .. 120

7.5.4 Results After Internal Fixation of Fissures and Fractures 120

7.5.5 Literature on the Management of Fissures and Fractures 120

7.6 Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 121

References 122

8 Trochanteric Problems 123MARTIN SARUNGI

8.1. Introduction, Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 123

8.1.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 123

8.1.2 Definitions........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 123

8.2 Frequency of Trochanteric Fractures and Osteotomies 126

8.2.1 Frequency in Our Own Patients . . . . . . . . . . . . . . . . . . . . . . . . . .. 126

8.2.2 Frequency in the Literature 1278.3 Risk Factors for Trochanteric Fractures 127

8.4 Indications for Trochanteric Osteotomies -Prevention of Trochanteric Fractures 128

Table of Contents XVII

8.4.1 Indications for Osteotomies of the Greater Trochanter 128

8.4.2 Prevention of Trochanteric Fractures 128

8.5 Techniques for Osteotomy and Fracture Osteosynthesis 129

8.5.1 Methods Used in Our Patients 129

8.5.2 Osteosynthesis of Trochanteric Osteotomies . . . . . . . . . . . . . . .. 129

8.5.3 Osteosynthesis of Trochanteric Fractures and Nonunions .... 130

8.6. Outcome for Trochanteric Fractures and Osteotomies. . . . . . . . . . . . .. 133

8.6.1 Nonunion Rate 133

8.6.2 Clinical Outcome 134

References 135

9 Leg Length Discrepancies 137

ANJA S. PIRWITZ

9.1. Definitions, Classification 137

9.1.1 True Leg Length Discrepancy. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 137

9.1.2 Functional Leg Length Discrepancy 140

9.1.3 Mixed Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 140

9.2 Frequency in Our Own Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 140

9.2.1 Material and Methods 140

9.2.2 Analysis of the Patient Population. . . . . . . . . . . . . . . . . . . . . . . .. 140

9.3 Frequency in the Literature. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 142

9.4 Preventive Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 144

9.4.1 Clinical and Radiological Recording. . . . . . . . . . . . . . . . . . . . . .. 144

9.4.2 Preoperative Planning in Cases of Leg Length Discrepancy ... 144

9.4.3 Intraoperative Reference Points. . . . . . . . . . . . . . . . . . . . . . . . . .. 145

9.5 Management of Postoperative Leg Length Discrepancy. . . . . . . . . . . .. 145

9.5.1 Leg Length Discrepancyin the Immediate Postoperative Period. . . . . . . . . . . . . . . . . . . .. 145

9.5-2 Leg Length Discrepancy of Gradual Onset Postoperatively. . .. 145

9.5.3 Management of Leg Length Discrepancy in the Literature .... 146

9.6 Conclusions.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 146

References 146

10 Limping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 147PIA FERRAT

10.1 Definitions................................................... 147

10.1.1 General................................................ 14710.1.2 Normal Gait. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 14710.1.3 Limping 148

10.2. Frequency 148

10.2.1 Frequency in Our Own Patients. . . . . . . . . . . . . . . . . . . . . . . . . .. 148

Primary Operations 148

Revisions 149

10.2.2 Frequency in the Literature 151

10.3 Risk Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 152

10.4 Preventive Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 152

10.5 Treatment.................................................... 152

10.6 Discussion 153References 153

XVIII Table of Contents

11 Neurological Complications 155

YVES THOMANN, HANS RUDOLF STOCKLI

11.1 Definitions................................................... 156

11.1.1 The Injury Mechanisms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 156

11.1.2 Severity of the Nerve Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 156

11.1.3 Severity of Paralysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 156

11.1.4 Pain and Nerve Lesions 157

11.2 Clinical Pictures and Their Clinical Diagnosis 157

11.2.1 Sciatic Nerve 157

11.2.2 Femoral Nerve 159

11.2.3 Superior Gluteal Nerve 161

11.2.4 Obturator Nerve. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 163

11.2.5 Lateral Femoral Cutaneous Nerve 163

11.3 Neurological Examination 163

11.3.1 Clinical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 163

11.3.2 Electrophysiological Diagnosis and Methods 164

Electrophysiological Methods 164

Timetable and Objectivesin Electrophysiological Investigations 164

11.4. Frequency and Course of Neurological Complications 165

11.4.1 Incidence and Course in Our Patients. . . . . . . . . . . . . . . . . . . . .. 165

11.4.2 Frequency in the Literature 167

11.5 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 169

11.6 Preventive Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 171

11.7 Treatment of Nerve Injuries 171

11.7.1 Principles of Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 171

11.7.2 Therapeutic Components 171

Positioning 171

Physiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 171

Pain Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 172

Orthoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 172

Surgical Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 172

Electrostimulation 173

11.7.3 Accompanying Spinal Problems 173

References 173

12 Periarticular Ossification 175

JOACHIM VAECKENSTEDT

12.1 Introduction 175

12.2 Definitions................................................... 176

12·3 Classification................................................. 176

12·4 Aetiology.................................................... 177

12.5 Clinical and Radiological Presentation . . . . . . . . . . . . . . . . . . . . . . . . . .. 177

12.6 Frequency 179

12.6.1 Frequency in Our Own Patients. . . . . . . . . . . . . . . . . . . . . . . . . .. 179

12.6.2 Frequency in the Literature 180

12.7 Risk Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 181

12.8 Preventive Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 181

12.8.1 Overview of Possible Measures 181

12.8.2 Literature on Prophylactic Measures . . . . . . . . . . . . . . . . . . . . . .. 181

Table of Contents XIX

12.9 Management of Ossification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 182

12.9.1. Procedure in Our Hospital 182

12.9.2 Literature on the Management of Ossification. . . . . . . . . . . . . .. 183

12.10 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 183

References 184

13 Vascular Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 185

PETER E. OCHSNER, BERNHARD NACHBUR

13.1 Introduction, Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 185

13.1.1 Time of Clinical Manifestation. . . . . . . . . . . . . . . . . . . . . . . . . . .. 186

13.1.2 Type ofVascular Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 186

13.1.3 Causes of Injury 187

13.1.4 Affected ArterieslVeins 187

1).2 Frequency 188

13.2.1 Frequency in Our Own Patients . . . . . . . . . . . . . . . . . . . . . . . . . .. 188

13.2.2 Frequency in the Literature 188

13.3. Known Causes ofVascularrnjuries 188

13.3.1 Our Own Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 188

13.).2 Supplied Case Studies with Fatal Outcome 189

13.3.3 Case Studies from the Literature 191

13.4. Preventive Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 194

13.4.1 Measures to Reduce the Frequency of Injury. . . . . . . . . . . . . . .. 194

1342 Prevention of Injuries During Screw Fixationof Acetabular Implants 194

Uncemented SL Cup. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 194

Acetabular Reinforcement Ring. . . . . . . . . . . . . . . . . . . . . . . . . .. 198

Burch-Schneider Antiprotrusio Cage 198

13.4.3 General Precautionary Measures . . . . . . . . . . . . . . . . . . . . . . . . .. 198

13.5 Management of Vascular Injuries 198

13.5.1 Intraoperative Massive Bleeding 198

Timely Detection 198

Intraoperative Emergency Procedure:Lower, Anterior Lumbotomy 199

13.5.2 Detection of Postoperative Bleeding or Ischaemia 200

References 201

14 Pain 203

PETER E. OCHSNER

14.1 Exploratory Options - Investigations 203

14.2. Pain Associated with Common Organic Complications. . . . . . . . . . . .. 205

14.3. Foreign Body Sensation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 205

14.4. Rare Pain Phenomena 205

14.4.1 Groin Pain 205

14.4.2 Buttock Pain 208

14.4.3 Trochanteric Pain 208

14.4.4 Thigh Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 210

14.4.5 Scar Pain 211

xx Table of Contents

14-4.6 Pain After Vascular and Nerve Injuries. . . . . . . . . . . . . . . . . . . .. 211

14.4.7 Back Problems 213

14-4.8 Polymyalgia rheumatica 213

14.5. Complex Clinical Pictures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 213

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 215

15 Revision Rates Due to Aseptic LooseningAfter Primary and Revision Procedures . . . . . . . . . . . . . . . . . . . . . . .. 217

PETER E. OCHSNER, ULF RIEDE, MARTIN LUEM,

THOMAS MAURER, RENATO SOMMACAL

15.1 Definitions................................................... 217

15.2 Plotting of Curves. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 218

15.3 Analysis of Revisions After Primary Operations . . . . . . . . . . . . . . . . . .. 219

15.3.1 Overview.............................................. 219

15.3.2 Femoral Components 219

Straight-stem Prosthesis 220

SL Prosthesis with a Rough-blasted Proximal Section 220

Virtec Prosthesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 221

CDH Prosthesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 221

15.3.3 Acetabular Components 221

Polyethylene Cups 222

Acetabular Reinforcement Ring According to M.E. Muller 222

SL Cup, Uncemented, Types 1 and 2 . . . . . . . . . . . . . . . . . . . . . . .. 223

Burch-Schneider Antiprotrusio Cage 224

15.4. Analysis of the Re-revisions After Revision Operations 224

15-4.1 Overview 224

1542 Femoral Components 224

15.4.3 Acetabular Components 225

15.5 Conclusions.................................................. 225

15.5.1 Confirmed Implants 226

15.5.2 Abandoned Implants 226

15.5.3 Re-introduced Implants 226

15.5.4 Decisions Still Outstanding 226

15.5.5 Difficulty of Evaluating a Single Componentas a Counterpart to a Poorer Component. . . . . . . . . . . . . . . . . .. 226

15.5.6 Comparative Evaluation of the Kaplan-Meierand Competing-Risk Curves 226

15.5.7 Assessment of the Generous Revision Policy. . . . . . . . . . . . . . .. 227

References 227

16 Preoperative Briefing 229

PETER E. OCHSNER

16.1 Purpose and Content of the Briefing . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 229

16.1.1 Benefit to Be Expected for the Patient. . . . . . . . . . . . . . . . . . . . .. 229

16.1.2 Alternatives 230

16.1.3 Treatment Schedule 230

Table of Contents XXI

16.1.4 Risks.................................................. 23016.1.5 Costs.................................................. 230

16.2 General Conditions of the Briefing Discussion 23116.2.1 Clarification of the Patient's Environment by the Doctor 23116.2.2 Time of Briefing 23116.2.3 The Briefing Doctor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 231

16.3 Legal Aspects of Briefing 23216.3.1 Rightto Briefing . . .. . .. . .. . .. . .. . . . . . . .. . . . . . .. . . . . . .. .. 23216.3.2 Scope 23216.3.3 Record Keeping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 232

16.4 Specific Briefing Before a Total Hip Replacement 23516.4.1 Complications of a General Nature 23516.4.2 Local Complications 23516.4.3 Specific Problems in Revision Operations 23616.4.4 Effect of Complications on Quality of Life 236

References 236

Subject Index 237

List of Contributors

BRUNAZZI, MARCO, Dr. med.ChefarztOrthopadie/Traumatologiedes BewegungsapparatesThurgauisches KantonsspitalCH-8soo FrauenfeldSwitzerlande-mail: marco.brunazzi@kttg.ch

FERRAT, PIA, Dr. med.OberarztinUniversitatskinderklinik beider BaselKantonsspitalCH-4101 BruderholzSwitzerlande-mail: pia.ferrat@ksli.ch

HAFLIGER, SUSANNADokumentationsmitarbeiterinWissenschaftliche Abteilungder Orthopadischen KlinikKantonsspitalCH-44IO LiestalSwitzerlande-mail: susanna.haefliger@ksli.ch

KLEIN, MATTHIAS, Dr. med.OberarztOrthopadische KlinikKantonsspitalCH-4101 BruderholzSwitzerlande-mail: matthias.klein@ksbh.ch

KOHLER, GREGOR, Dr. med.Leitender ArztOrthopadie/Traumatologiedes BewegungsapparatesThurgauisches KantonsspitalCH-8soo FrauenfeldSwitzerlande-mail: gregor.kohler.@kttg.ch

LOEM, MARTIN, Dip!. lng. HTLWissenschaftliche Abteilungder Orthopadischen KlinikKantonsspitalCH-4410 LiestalSwitzerlande-mail: martin.lueem@ksli.ch

MAURER, THOMAS, Dr. med.OberarztOrthopadische KlinikCH-4410 LiestalSwitzerlande-mail: thomas.maurer@ksli.ch

MUNCH, THIERRY, Dr. med.Praxis im KurzentrumRoberstenstr. 31CH-431O RheinfeldenSwitzerlande-mail: twhmuench@bluewin.ch

NACHBUR, BERNHARD, Prof. Dr. med.Talmoosstr. 48CH-3063 lttigenSwitzerlande-mail: nachbur@bluewin.ch

OCHSNER, PETER EMIL, Prof. Dr. med.ChefarztOrthopadische KlinikKantonsspitalCH-4410 LiestalSwitzerlande-mail: peter.ochsner@ksli.ch

PIRWITZ,ANJA-S., Dr. med.H6pitaux de la villeCH-2000 NeuchatelSwitzerlande-mail: pir-bie@bluewin.ch

XXIV List of Contributors

RIEDE ULF, Dr. med.Orthopadische KlinikKantonsspitalCH-4410 LiestalSwitzerlande-mail: ulf.riede@ksli.ch

SARUNGI, MARTIN, MDDepartment of Orthopaedicand Trauma SurgeryMAV HospitalH-1062 BudapestHungarye-mail: sarungi@dpg.hu

SCHAFROTH, MATHIAS, Dr. med.OberarztAcademisch Medisch CentrumNL-HOl WR AmsterdamThe Netherlandse-mail:m.u.schafroth@amc.uva.nl

SWITZERLANDER, ANDREAS, Dr. med.Orthopadische KlinikKantonsspitalCH-4410 LiestalSwitzerlande-mail: andreas.Switzerlander@ksli.ch

SOMMACAL, RENATO, Dr. med.Werner Kiilin-Str. 16CH-8840 EinsiedelnSwitzerlande-mail:orthopaedie.einsiedeln@bluewin.ch

STOCKLI, HANS RUDOLF, Dr. med.Konsiliararzt fur NeurologieKantonsspitalCH-4410 LiestalSwitzerlande-mail: hrstoeckli@datacomm.ch

THOMANN, YVES, Dr. med.Praxis im KurzentrumRoberstenstr. 31CH-43IO RheinfeldenSwitzerlande-mail: yrthomann@bluewin.ch

TOIA, DAMIEN, Dr. med.Chefarzt RadiologieInstitut fUr RadiologieKantonsspitalCH-4410 LiestalSwitzerlande-mail: damien.toia@ksli.ch

VAECKENSTEDT, JOACHIM, Dr. med.SUVA BaselSt. Jakobsstr. 24CH-4002 BaselSwitzerlande-mail: vaeckenstedt@web.de

ZIMMERLI, WERNER, Prof. Dr. med.Ordinarius fUr Innere MedizinMedizinische UniversitatsklinikKantonsspitalCH-4410 LiestalSwitzerlande-mail: werner.zimmerli@ksli.ch