Abstract
Background: Revision of a total hip arthroplasty
in a patient who has had congenital hip dysplasia or dislocation
is often more difficult than a standard revision operation. The
purpose of this study was to assess the efficacy and complications
of use of a cementless hemispherical acetabular component for revision
of an acetabular component of a failed total hip replacement in
patients whose initial problem was arthritis secondary to congenital
dislocation or dysplasia. The mean duration of follow-up was approximately
eight years.
Methods: We reviewed a consecutive series of
sixty-one hips in fifty-three patients who underwent a cementless
acetabular revision with use of a hemispherical acetabular component,
with or without concurrent femoral revision. Data were collected prospectively.
The mean age of the patients at the time of the index operation
was fifty-six years. A mean of 1.9 ipsilateral hip operations had
been performed previously. Thirty-nine hips (64 percent) had a so-called
high hip center prior to the index revision. With one exception,
the uncemented acetabular component was fixed with screws. Fifty-one
acetabular components were placed with so-called line-to-line fit,
and ten were oversized by one to three millimeters. In thirty-eight
hips, the femoral component was revised as well. Twenty-nine femora
were reconstructed with use of a cemented device, and nine were
revised with an uncemented patch-porous-coated femoral stem (a stem
on which the porous coating appears in patches).
Results: Four patients (five hips) died prior
to the five-year minimum follow-up interval. With the exception of
one hip treated with resection arthroplasty because of deep infection,
none of the hips in these deceased patients had been revised or
had a loose component. One living patient (one hip) had a resection
arthroplasty, and one additional patient (two hips) had both stable
acetabular components rerevised at the time of femoral rerevision
at another institution because of loosening and osteolysis. One
patient refused to return for follow-up, but the components had
not been revised. The remaining fifty-two hips in forty-six patients
were followed for a mean of 8.6 years (range, 5.0 to 12.7 years).
The mean Harris hip score was 80 points (range, 56 to 100 points)
at the time of the latest follow-up. No acetabular component had
been revised, although two had migrated. No other acetabular component
was loose according to our radiographic criteria. Thus, the mechanical
failure rate on the acetabular side was 3 percent (two of sixty-one)
for the entire series and 4 percent (two of fifty-two) for the patients
who had been followed for a mean of 8.6 years. On the femoral side, the
mechanical failure rate was 3 percent (one of twenty-nine) for the
cemented stems and six of nine for the uncemented patch-porous-coated stems.
Conclusions: Of the approaches used in this
difficult series of patients requiring revision, the hybrid arthroplasty (a
cementless acetabular component and a cemented femoral component)
yielded overall good results after an intermediate duration of follow-up.
Primary total hip arthroplasty for the treatment of osteoarthritis
secondary to congenital hip dysplasia or dislocation is more difficult,
in general, than a standard total hip replacement. The acetabular reconstruction
can be challenging, and the femoral reconstruction may require miniature,
custom components. The abductor muscles are often deficient. Correction
of leg-length discrepancy may be complex and is associated with
the risk of sciatic nerve palsy.
These problems are compounded when a revision total hip arthroplasty
becomes necessary. The primary operation may have included shortening
of the femur and advancement of the greater trochanter. Acetabular
bone stock that was already deficient because of small initial pelvic
dimensions may have been limited further by the defects left by
prior surgery or osteolysis. On the other hand, previously placed
structural bone graft, if revascularized, may assist in the acetabular
reconstruction (Fig. 1-A, Fig. 1-B, and Fig. 1-C). A so-called high hip center (a
hip center located at least thirty-five millimeters proximal to
the interteardrop line) may be present or may be required for the
revision because of deficiency of the available bone (Fig. 2-A, Fig. 2-B, and Fig. 2-C). If a high
hip center is used, the femur may impinge on the innominate bone
at the extremes of motion, sometimes necessitating the removal of portions
of the anterior column, anterior superior iliac spine, ischium,
or greater trochanter. On the femoral side, the presence of a small
medullary canal increases the risk of perforation during cement removal.
If femoral osteolysis is present and superimposed on a small femur,
bone-grafting may be required.
We use uncemented acetabular components whenever possible because
the results of revision with cement on the acetabular side have
been unsatisfactory3,12,18,22,26,36 and
the results of cementless acetabular revision appear to be better11,19,33,38. Our intermediate-term
results of revision with use of an uncemented shell fixed with screws
have been excellent6,7,23. Because
of the high rate of late failure of bulk autografts and allografts
employed to augment acetabular bone stock in either primary or revision operations,
we try to avoid their use32.
Although some authors have included small numbers of patients
with congenital hip disease in general reports of revision operations36, to our knowledge there have been
no specific studies of the results of revisions of total hip arthroplasties
in patients with congenital dysplasia or congenital dislocation
of the hip. We report the results of a consecutive series of sixty-one
revisions of total hip arthroplasties with use of an uncemented
acetabular component in fifty-three patients who had the underlying
diagnosis of congenital hip dysplasia or dislocation. If the femoral component
was revised at the same operation, it was either cemented or implanted
without cement.
Between September 1984 and April 1991, sixty-one total hip arthroplasties
were revised by the senior one of us (W. H. H.) in fifty-three patients with
a known underlying diagnosis of congenital hip dysplasia or dislocation.
Both the acetabular and the femoral component were revised in thirty-eight
hips, and only the acetabular component was revised in twenty-three.
There were forty-six women and seven men. The mean age at the time of
the index revision operation was fifty-six years (range, twenty-eight
to seventy-six years), and the patients weighed a mean of 61.4 kilograms
(range, 42.3 to 90.9 kilograms). The mean preoperative Harris hip
score was 54 points (range, 22 to 94 points).
A mean of 1.9 (range, one to eight) ipsilateral hip operations
had been performed previously. The index procedure was the second
acetabular revision in fourteen hips and the third in three hips.
In nine hips the acetabular component was implanted into a previously
placed bulk femoral head autograft, and in three the shell was placed
against a previously placed femoral head allograft. The index procedure
was the second femoral revision in five hips and the third in two
hips.
The indication for revision was aseptic loosening of the acetabular
component alone or of both components in fifty-eight hips. Of the
remaining three hips, one each was revised because of pelvic osteolysis,
recurrent dislocation, and a prior resection arthroplasty.
Trochanteric osteotomy was used in fifty-one index operations21. In thirty-five hips, the trochanteric
fragment was advanced and secured to the lateral femoral cortex. Trochanteric
mesh was used to supplement the trochanteric fixation in all but
three of the fifty-one hips. Wire fixation was achieved with use
of a combination of vertical and horizontal monofilament Vitallium
wires17. It was necessary to release
the iliopsoas tendon, in order to adequately mobilize the femur,
in forty-four hips.
Reconstruction with use of a hemispherical cementless acetabular
component required sufficient bone stock to resist load in the direction
of the resultant hip force and adequate support to prevent medial
or posterior displacement of the shell. In general, the largest
acetabular component that the acetabular recess could accommodate
was utilized. If the cavity was oblong and could not be shaped to
allow placement of a large hemisphere without destabilizing the
anterior or posterior column, a high-hip-center approach was used,
with a smaller component placed into the superior portion of the
recess31. The acetabulum was shaped
into a hemisphere, with the apex made more proximal than the lateral edge
of the acetabulum. Particulate autologous bone graft or allograft
was used in contained and segmental defects.
Twenty-nine Harris-Galante-I and thirty-two Harris-Galante-II
acetabular components (Zimmer, Warsaw, Indiana) were used. The mean
outer diameter of the acetabular components was fifty-one millimeters
(range, forty to sixty-six millimeters). In fifty-one hips the nominal
diameter of the shell matched that of the last reamer used (so-called line-to-line
fit), and in ten hips the shell was oversized by one to three millimeters.
Screws (a mean of 3.5 [range, two to nine]) were used in all but
one hip. The estimated contact of the shell with host bone averaged
81 percent (range, 50 to 95 percent).
The acetabular bone stock was classified, according to the severity
of the bone loss observed at the time of the revision, as stage
I in two hips, stage II in twenty, stage IIIA in twenty-five, stage
IIIB in thirteen, and stage IV (pelvic discontinuity) in one hip38. Particulate bone graft was used
in fifty-eight hips. The graft usually was obtained from the acetabular reaming,
but at times it was combined with particulate iliac crest graft
or morselized allograft. In two hips, autologous cancellous graft
was obtained from the contralateral femoral head, which had been
harvested at the time of a primary total hip arthroplasty and stored.
Three hips did not require bone-grafting. No structural allografts
were placed at the time of the index revision.
In thirty-eight hips, a new femoral component was placed as well.
Twenty-nine cemented femoral components were utilized; these included
eighteen Harris Precoat (Zimmer), five Precoat Plus (Zimmer), one
CDH Precoat (Zimmer), one Harris Design-II (HD-II; Howmedica, Rutherford,
New Jersey), and four calcar-replacing stems (Zimmer). Twenty-four
of the twenty-nine cemented components were precoated. The components
were cemented with so-called second-generation techniques24, which included lavage of the canal,
porosity reduction by means of centrifugation, use of a medullary
plug and cement gun, and pressurization of the cement. No distal
or proximal centralizers were used.
Nine femoral components were placed without cement. These included
seven BIAS and two Harris-Galante porous-coated (HGP) femoral components
(both Zimmer).
Bone-grafting was performed on the femoral side in twenty-five
hips. In fourteen of these hips, the calcar was the primary zone
of deficiency and particulate bone graft was placed in contained
deficits. In five hips, femoral perforation occurred during cement
removal, requiring particulate graft or a strut graft, or both.
Three femora had major, circumferential proximal deficiency and
were reconstructed with use of a proximal femoral allograft.
Resection of portions of the ischium, anterior column, or greater
trochanter was necessary in twenty-six hips in order to avoid impingement
between the femur, greater trochanter, or femoral component and
the pelvis at the extremes of motion. These hips generally had a
relatively high center of rotation. In thirteen of these hips, the
location of the reconstruction necessitated excision of the anterior
inferior iliac spine and release of the direct head of the rectus
femoris.
No patient was lost to follow-up. Of the four patients (five
hips) who died prior to the minimum follow-up interval of five years,
one, who had severe liver disease, required a resection arthroplasty because
of deep infection and died three days later of hepatic failure.
None of the four other hips in the deceased patients had a loose
component or had been revised at a mean of 3.3 years (range, 1.1 to
4.9 years) after the index revision. One hip was chronically dislocated.
Of the patients who were alive at the time of follow-up, one
(one hip) had had a resection arthroplasty for what appeared to
be an extensive deep infection at 4.7 years, but all cultures were
negative. Another patient (two hips) had bilateral femoral osteolysis
with fractures at the metaphyseal-diaphyseal junctions, requiring
revision with proximal femoral allografts at another institution
at 4.1 and 4.5 years. Although the acetabular components were stable,
both were revised at the time of the femoral revisions. One other
patient (one hip) refused to return for follow-up, but the components
had not been revised.
The remaining forty-six living patients (fifty-two hips) with
retained implants constitute the follow-up group. Thirty-three of
these hips were assessed clinically by us, three were examined by
other orthopaedic surgeons, and sixteen were evaluated by means
of a questionnaire. Current radiographs, including an anteroposterior
radiograph of the hip and pelvis, a true lateral radiograph of the
hip, and a frog-leg lateral radiograph of the femur, were available
for fifty of the fifty-two hips. Right and left 45-degree oblique
views of the pelvis were included in the assessment of thirty-eight
hips. All preoperative, postoperative, and current radiographs were
evaluated by an orthopaedic surgeon other than the senior one of
us.
Gaps were defined as sharp radiolucent lines between the shell
and the pelvis, as seen on the initial postoperative radiograph,
and were believed to represent incomplete seating of the implant
or defects remaining from the prior reconstruction28. Radiolucent lines were defined
as lucencies at the bone-shell interface that had not been seen
on the initial postoperative radiographs or as gaps that had increased
in size after the two-year radiograph was made28.
Any radiolucent line greater than three millimeters in width was
classified arbitrarily as osteolysis. Periacetabular lucencies were
grouped according to their location with use of the method of DeLee
and Charnley8. Preoperatively,
thirty-nine hips had acetabular osteolysis in at least one zone.
The position of the hip center was determined in reference to
a line drawn between the inferior margins of the teardrops13,27. A change in position of the
acetabular component of four millimeters or more was defined as
component migration. Preoperatively, the previously placed acetabular
component had migrated four to eighteen millimeters in nineteen
hips. The mean location (and standard deviation) of the hip center preoperatively
was 40 15 millimeters (range, zero to seventy-seven millimeters)
proximal to the interteardrop line and 34 9 millimeters (range, eighteen
to fifty-eight millimeters) lateral to the inferior margin of the
ipsilateral teardrop. Thirty-nine hips (64 percent) were classified
as having a high hip center (at least thirty-five millimeters proximal
to the interteardrop line) prior to the index revision.
On both the prerevision and the postrevision radiographs, the
orientation of the femoral component was recorded and the quality
of the cementing was graded with use of a previously published scheme29. The locations of cement deficiencies
and radiolucent lines were recorded in reference to established
femoral zones14. Femoral loosening
was assessed radiographically according to previously published
criteria24.
Of the thirty-six cemented femoral components that were revised,
none showed grade-A cementing on the prerevision radiograph; eight
showed grade-B; three, grade-C1; twenty, grade-C2; and five, grade-D.
One additional revised femur had been previously treated with an
uncemented femoral component, and one had had a resection arthroplasty.
Twenty-seven of the femoral components that were revised had been
associated with femoral osteolysis preoperatively.
Polyethylene wear was measured with use of previously described
techniques5,20.
We utilized the Student t test to compare the mean polyethylene
wear rates between various patient groups. A probability level of
p < 0.05 was used to determine significance.
The results in the forty-six patients (fifty-two hips) in the
follow-up group were reviewed at a mean of 8.6 years (range, 5.0
to 12.7 years) following the index revision operation. The mean
final Harris hip score15, which
was calculated for fifty hips, was 80 points (range, 56 to 100 points).
Thirteen hips (26 percent) were considered to have an excellent
result (a hip score of 90 points or better); twelve (24 percent),
a good result (80 to 89 points); sixteen (32 percent), a fair result
(70 to 79 points); and nine (18 percent), a poor result (less than
70 points). Seventeen hips (34 percent) were not painful, sixteen
(32 percent) occasionally caused slight pain, fifteen (30 percent)
caused mild pain, and two (4 percent) caused moderate pain. No patient
had severe hip pain.
Of the nine poor results, two were attributed to a loose acetabular
component and two, to a femoral component that had been retained
from a prior operation and had become loose. Among the five hips
with a poor result associated with stable components, one had a
complete femoral nerve palsy in addition to weak abductor muscles
secondary to a prior, long-standing hip fusion. Another patient had
severe bilateral lower-extremity poliomyelitis with a contralateral
hip fusion and required two crutches for walking. One patient had
had a revision of a cementless femoral component placed prior to
the index operation and had persistent thigh pain. The two final
poor hip scores were in patients with mild hip pain but debilitating
knee arthritis.
Of the fifty-two hips in the follow-up group, two had migration
of the acetabular component. One of these two hips was scheduled
for revision at the time of the latest follow-up. This hip was in
a forty-eight-year-old woman who had had a loose cemented acetabular
component that had been placed at a high hip center. The other patient
with a migrated acetabular component was a sixty-one-year-old woman
who had previously had a cup arthroplasty followed by a total hip
replacement with cement. At the index operation, eighteen years
after the primary total hip arthroplasty, severe osteolysis and
a transverse acetabular fracture in combination with a large medial
wall defect were found. Adequate stability could not be achieved
at the operation, and the acetabular component migrated into an
inverted position. Despite this, the patient preferred to remain
functional by using two crutches, had a hip score of 65 points, and
had not had a revision as of the latest follow-up evaluation.
No other acetabular component was loose according to our radiographic
criteria, and none had been revised. Thus, the rate of mechanical
acetabular loosening was 4 percent (two of fifty-two). Eleven hips
(21 percent) had radiolucency at the acetabular interface in all
three zones on at least one of the three pelvic radiographs. In
two of these hips, the line appeared to be continuous; one hip had
a 0.5 to one-millimeter line, and one had a one-millimeter line
that widened to three millimeters in zone III. Neither component
had migrated, and therefore neither was considered loose. There
was no association between the presence and width of radiolucent
lines and the clinical status of the hip or the appearance of gaps
on the initial postoperative radiographs.
Of the twelve hips (23 percent) in which the acetabular component
was placed against a prior bulk graft in zone I, nine were available
for follow-up, one was in a patient who had died, one had had a resection
arthroplasty because of suspected infection, and one was stable
but had been revised elsewhere at the time of a concurrent femoral
revision. Only one of the nine hips had a continuous acetabular
radiolucent line of 0.5 to one millimeter in width. Three hips had
radiolucency of 0.5 to one millimeter in width in zone I on the
anteroposterior radiograph and both Judet radiographs. The remaining
five hips had either no zone-I radiolucency or a line on only one
or two radiographic views. Two (4 percent) of the fifty-two hips
had evidence of pelvic osteolysis. These were the two hips with a
loose, migrated acetabular component. In both, the lysis was present
primarily around screws that had pulled loose.
Of the thirty-eight femoral components that were placed at the
time of the index acetabular revisions, three (8 percent) were revised
because of aseptic loosening. Two, in one patient (described above),
were noncircumferentially porous-coated (BIAS) stems that subsided
in association with femoral osteolysis. The third was a cemented
CDH Precoat stem that had been placed in varus, resulting in a defect
in the cement mantle.
Four additional femoral components were loose but had not been
revised as of the latest follow-up evaluation. Three were BIAS components,
and one was an HGP component. All four subsided, but the symptoms
have not warranted revision to date. The overall rate of loosening
of uncemented femoral components was six of nine. The rate of revision
of femoral stems because of aseptic loosening was one (3 percent)
of twenty-nine. No other femoral components were loose, so the rate
of mechanical failure of cemented femoral components was also 3
percent.
Three subsequent femoral revisions were required because of loosening
of a femoral component placed at the time of a prior operation.
Dislocation occurred in seven hips. Four of them had recurrent
dislocations, and one of the four required a reoperation at 5.7
years because of the recurrent dislocations.
Nine (18 percent) of the fifty-one trochanteric osteotomy sites
failed to unite, and seven of the trochanteric fragments migrated
proximally. In seven of the nine hips, a prior trochanteric osteotomy
had been performed, and two had had a previous nonunion. None of
these hips required a reoperation because of the nonunion, although
one of the nonunions was repaired successfully at the time of a
reoperation for dislocation.
Additional complications included eight nerve palsies, six of
which resolved; one femoral artery laceration; one nonfatal postoperative
myocardial infarction; three deep-vein thromboses; and one nonfatal
pulmonary embolism.
Three additional hips (5 percent) required reoperations. One
hip became infected ten months following the index revision. Because
the organism (a nutritive-variant streptococcus) was of low virulence,
the hip was debrided and a strut graft was removed. The femur subsequently
fractured through the previously grafted area at 4.2 years, requiring
open reduction and plate fixation. There was no evidence of infection
at that time. One other femur sustained a periprosthetic fracture
and was treated with a revision to a long stem at another institution.
The third hip had removal of heterotopic bone, which was causing
subluxation. The greater trochanter was advanced during that procedure
as well. No subsequent subluxations occurred.
Polyethylene wear was measurable on the final anteroposterior
radiographs of forty-seven of the fifty hips with updated radiographs
at a mean of 8.4 years. The mean linear wear rate was calculated
to be 0.13 millimeter per year (range, 0.01 to 0.47 millimeter per
year). There was no significant difference between the mean wear
rate in patients with a retained femoral component and that in patients
with a revised femoral component (0.16 ±0.11
compared with 0.13 ±0.09 millimeter per
year). However, the mean rate was significantly greater in patients
who were younger than fifty years of age than in those who were
fifty years and older (0.24 ±0.12 compared
with 0.10 ±0.06 millimeter per year, p < 0.001).
Polyethylene wear was not associated with body weight in this series.
The location of the hip center changed as a result of the revision
in most patients, although the mean value for the whole group did
not. The hip center was elevated a mean of 5.5 millimeters (range,
one to sixteen millimeters) at the index revision in thirty-nine
hips (64 percent), and it was lowered a mean of 8.4 millimeters
(range, one to forty-one millimeters) at the index revision in nineteen
hips (31 percent). Of the thirty-nine hips with a high hip center
preoperatively, thirty-five still had a high hip center after the
index revision. Forty-two hips were classified as having a high
hip center postoperatively.
This series of revisions of total hip replacements is unique
in that all patients had congenital hip disease as the primary etiology
of the arthritis requiring arthroplasty. Although many authors have reported
results following primary arthroplasty in this patient group, the
literature concerning revision operations is sparse. Stromberg et
al. reported mechanical failure in 36 percent (twenty-four) of sixty-seven
hips at four years following a revision operation with cement in
patients younger than fifty-five years of age36.
Nearly half of the patients in their series had underlying congenital
dysplasia or dislocation. The data, however, were not stratified
by the initial diagnosis.
In our series of fifty-two acetabular revisions followed for
a mean of 8.6 years (range, 5.0 to 12.7 years), one component became
loose and could not be repaired. Another was loose and was scheduled for
revision at the time of writing. No other component was loose. In
both of the hips in which the acetabular component loosened, no
inferomedial support could be obtained from the pubis at the time
of the index revision, and one of the patients had pelvic discontinuity.
Bulk grafts placed prior to the index revision improved the available
bone stock and were well vascularized at the time of the revision.
Placement of uncemented shells against these grafts was successful,
and none of the shells became loose.
Two hips in our series had a continuous radiolucent line. In
an analysis of 200 revised hips, Hodgkinson et al. found that the
probability of a cemented acetabular component being loose in the presence
of a continuous radiolucent line was 94 percent16.
However, the meaning of a continuous radiolucent line at the mesh-bone
interface of an uncemented component is unclear at this time. Sumner et
al. showed, in retrieval specimens, that radiolucent lines are associated
with areas of the interface that have a greater proportion of fibrous ingrowth37. Because localized areas of bone
ingrowth (so-called spot welds) may be invisible on radiographs,
such focal bone ingrowth may stabilize the acetabular component
despite extensive radiolucency. We therefore use implant migration
as the primary indicator of loosening of cementless acetabular components.
The rate of femoral component loosening was high (18 percent
[seven] of thirty-eight), primarily because of the use of nine uncemented
femoral components that were not circumferentially coated. The rate
of failure of the uncemented femoral components was six of nine.
In contrast, only one (3 percent) of twenty-nine cemented femoral
components became loose, and this CDH Precoat stem had been placed
in varus, which produced a defect in the cement mantle. More than
half of the femoral components were placed with grade-C2 cement technique,
usually because of varus or valgus positioning relative to the prepared
canal. While deficiencies in the cement mantle are associated with an
increased risk of early loosening and osteolysis34,
obviously many deficient cement mantles continue to function well.
Current centralization techniques should reduce the prevalence of
cement mantle deficiency.
The overall complication rate in this series of complex cases
was high. Trochanteric nonunion was the most common problem and
occurred in nine (18 percent) of the fifty-one hips in which a trochanteric
osteotomy had been done. The performance of a trochanteric osteotomy
before the index revision was a substantial risk factor for nonunion.
This finding is contrary to previously published findings from our
institution in an era when patients with trochanteric osteotomy
were mobilized more slowly1,30.
In the present series, six patients had transient femoral or sciatic
nerve palsy postoperatively and two had femoral nerve palsy that
did not resolve. We attribute the high rate of nerve palsy to the amount
of dissection and retraction necessary in some of the hips.
If the best contact of the acetabular component with host bone
required the use of an elevated hip center6,
this approach was selected. Biomechanically, simple elevation of
the hip center by two centimeters increases the hip joint force
by 5 percent or less2,10,39. The
risk of impingement associated with use of a high hip center can
be reduced by techniques and implants that produce an increased
offset.
In conclusion, revisions of total hip arthroplasties in patients
who had had congenital hip dysplasia or dislocation had good intermediate-term
results when an uncemented acetabular component fixed with screws
had been utilized in combination with a cemented femoral component.
The maintenance or creation of a high hip center produced good results.
The frequency of varus or valgus alignment of the stem within the
relatively small femoral canals was worrisome. Because of the increased
risk of a deficient cement mantle, as shown in other series24, we recommend centralization of
all cemented femoral components.
Bal, B. S.; Maurer, B. T.; and Harris, W. H.: Trochanteric union following revision total hip arthroplasty. J. Arthroplasty,13: 29-33, 1998.1329
1998
[PubMed]
Brand, R. A., and Pedersen, D.: Hip
forces resulting from altered hip joint location revisited. Read
at the Annual Meeting of the Hip Society, Scottsdale, Arizona, Sept.
20, 1990.
Callaghan, J. J.; Salvati, E. A.; Pellicci, P. M.; Wilson, P. D., Jr.; and Ranawat, C. S.: Results of revision for mechanical failure after cemented
total hip replacement, 1979 to 1982. A two to five-year follow-up. J. Bone and Joint Surg.,67-A: 1074-1085, Sept 1985.67-A1074
1985
Davey, J. R., and Harris, W. H.: Reverse skeletal traction for instability following revision
total hip arthroplasty. A report of two cases. Clin. Orthop.,234: 110-114, 1988.234110
1988
[PubMed]
Dearborn, J. T., and Murray, W. R.: Arthopor 2 acetabular component with screw fixation in
primary hip arthroplasty: a 7- to 9-year follow-up study. J. Arthroplasty,13: 299-310, 1998.13299
1998
[PubMed]
Dearborn, J. T., and Harris, W. H.: High placement of an acetabular component inserted without
cement in a revision total hip arthroplasty. Results after a mean
of ten years. J. Bone and Joint Surg.,81-A: 469-480, April 1999.81-A469
1999
Dearborn, J. T., and Harris, W. H.: Acetabular revision arthroplasty using so-called jumbo
cementless components: an average 7-year follow-up study. J. Arthroplasty,15: 8-15, 2000.158
2000
[PubMed]
DeLee, J. G., and Charnley, J.: Radiological demarcation of cemented sockets in total
hip replacement. Clin. Orthop.,121: 20-32, 1976.12120
1976
[PubMed]
Delp, S. L., and Maloney, W.: Effects of hip center location on the moment-generating
capacity of the muscles. J. Biomech.,26: 485-499, 1993.26485
1993
[PubMed]
Doehring, T. C.; Rubash, H. E.; Shelley, F. J.; Schwendeman, L. J.; Donaldson, T. K.; and Navalgund, Y. A.: Effect of superior and superolateral relocations of the
hip center on hip joint forces. An experimental and analytical analysis. J. Arthroplasty,11: 693-703, 1996.11693
1996
[PubMed]
Dorr, L. D., and Wan, Z.: Ten years of experience with porous acetabular components
for revision surgery. Clin. Orthop.,319: 191-200, 1995.319191
1995
[PubMed]
Fuchs, M. D.; Salvati, E. A.; Wilson, P. D., Jr.; Sculco, T. P.; and Pellicci, P. M.: Results of acetabular revisions with newer cement techniques. Orthop. Clin. North America,19: 649-655, 1988.19649
1988
Goodman, S. B.; Adler, S. J.; Fyhrie, D. P.; and Schurman, D. J.: The acetabular teardrop and its relevance to acetabular
migration. Clin. Orthop.,236: 199-204, 1988.236199
1988
[PubMed]
Gruen, T. A.; McNeice, G. M.; and Amstutz, H. C.: "Modes of failure" of cemented stem-type femoral components.
A radiographic analysis of loosening. Clin. Orthop.,141: 17-27, 1979.14117
1979
[PubMed]
Harris, W. H.: Traumatic arthritis of the hip after dislocation and acetabular
fractures: treatment by mold arthroplasty. J. Bone and Joint Surg.,51-A: 737-755, June 1969.51-A737
1969
Hodgkinson, J. P.; Shelley, P.; and Wroblewski, B. M.: The correlation between the roentgenographic appearance
and operative findings at the bone-cement junction of the socket
in Charnley low friction arthroplasties. Clin. Orthop.,228: 105-109, 1988.228105
1988
[PubMed]
Jensen, N. F., and Harris, W. H.: A system for trochanteric osteotomy and reattachment for
total hip arthroplasty with a ninety-nine percent union rate. Clin. Orthop.,208: 174-181, 1986.208174
1986
[PubMed]
Kavanagh, B. F.; Ilstrup, D. M.; and Fitzgerald, R. H., Jr.: Revision total hip arthroplasty. J. Bone and Joint Surg.,67-A: 517-526, April 1985.67-A517
1985
Lachiewicz, P. F., and Hussamy, O. D.: Revision of the acetabulum without cement with use of
the Harris-Galante porous-coated implant. Two to eight-year results. J. Bone and Joint Surg.,,76-A: 1834-1839, Dec 1994.76-A1834
1994
Livermore, J,; Ilstrup, D.; and Morrey, B.: Effect of femoral head size on wear of the polyethylene
acetabular component. J. Bone and Joint Surg.,72-A: 518-528, April 1990.72-A518
1990
McGrory, B. J.; Bal, B. S.; and Harris, W. H.: Trochanteric osteotomy for total hip arthroplasty: six
variations and indications for their use. J. Am. Acad. Orthop. Surgeons,4: 258-267, 1996.4258
1996
Marti, R. K.; Schuller, H. M.; Besselaar, P. P.; and Vanfrank Haasnoot, E. L.: Results of revision arthroplasty with cement: a five to
fourteen-year follow-up study. J. Bone and Joint Surg.,72-A: 346-354, March 1990.72-A346
1990
Meldrum, R. M. Personal communication.
Mulroy, W. F.; Estok, D. M.; and Harris, W. H.:: Total hip arthroplasty with use of so-called second-generation
cementing techniques. A fifteen-year-average follow-up study. J. Bone and Joint Surg.,77-A: 1845-1852, Dec 1995.77-A1845
1995
Pagnano, M. W.; Hanssen, A. D.; Lewallen, D. G.; and Shaughnessy, W. J.: The effect of superior placement of the acetabular component
on the rate of loosening after total hip arthroplasty. Long-term
results in patients who have Crowe type-II congenital dysplasia
of the hip. J. Bone and Joint Surg.,78-A: 1004-1014, July 1996.78-A1004
1996
Raut, V. V.; Siney, P. D.; and Wroblewski, B. M.: Revision of the acetabular component of a total hip arthroplasty
with cement in young patients without rheumatoid arthritis. J. Bone and Joint Surg.,78-A: 1853-1856, Dec 1996.78-A1853
1996
Russotti, G. M., and Harris, W. H.: Proximal placement of the acetabular component in total
hip arthroplasty. A long-term follow-up study. J. Bone and Joint Surg.,73-A: 587-592, April 1991.73-A587
1991
Schmalzried, T. P., and Harris, W. H.: The Harris-Galante porous-coated acetabular component
with screw fixation: radiographic analysis of eighty-three primary
hip replacements at a minimum of five years. J. Bone and Joint Surg.,74-A: 1130-1139, Sept 1992.74-A1130
1992
Schmalzried, T. P., and Harris, W. H.: Hybrid total hip replacement. A 6.5-year follow-up study. J. Bone and Joint Surg.,75-B(4): 608-615, 1993.75-B(4)608
1993
Schutzer, S. F., and Harris, W. H.: Trochanteric osteotomy for revision total hip arthroplasty.
97% union rate using a comprehensive approach. Clin. Orthop.,227: 172-183, 1988.227172
1988
[PubMed]
Schutzer, S. F., and Harris, W. H.: High placement of porous-coated acetabular components
in complex total hip arthroplasty. J. Arthroplasty,9: 359-367, 1994.9359
1994
[PubMed]
Shinar, A. A., and Harris, W. H.: Bulk structural autogenous grafts and allografts for reconstruction
of the acetabulum in total hip arthroplasty. Sixteen-year-average
follow-up. J. Bone and Joint Surg.,79-A: 159-168, Feb 1997.79-A159
1997
Silverton, C. D.; Rosenberg, A. G.; Sheinkop, M. B.; Kull, L. R.; and Galante, J. O.: Revision of the acetabular component without cement after
total hip arthroplasty. A follow-up note regarding results at seven
to eleven years. J. Bone and Joint Surg.,78-A: 1366-1370, Sept 1996.78-A1366
1996
Smith, S. W.; Estok, D. M.; and Harris, W. H.: Total hip arthroplasty with use of second-generation cementing
techniques. An eighteen-year-average follow-up study. J. Bone and Joint Surg.,80-A: 1632-1640, Nov . 1998.80-A1632
. 1998
Stock, J. R.; Athanasoulis, C. A.; Harris, W. H.; Waltman, A. C.; Novelline, R. A.; and Greenfield, A. J.: Transcatheter embolization for the control of wound hemorrhage
following hip surgery. J. Bone and Joint Surg.,62-A: 1000-1003, Sept 1980.62-A1000
1980
Stromberg, C. N.; Herberts, P.; and Ahnfelt, L.: Revision total hip arthroplasty in patients younger than
55 years old. Clinical and radiologic results after 4 years. J. Arthroplasty,3: 47-59, 1988.347
1988
[PubMed]
Sumner, D. R.; Jasty, M.; Jacobs, J. J.; Urban, R. M.; Bragdon, C. R.; Harris, W. H.; and Galante, J. O.: Histology of porous-coated acetabular components. 25 cementless
cups retrieved after arthroplasty. Acta Orthop. Scandinavica,64: 619-626, 1993.64619
1993
Tanzer, M.; Drucker, D.; Jasty, M.; McDonald, M.; and Harris, W. H.: Revision of the acetabular component with an uncemented
Harris-Galante porous-coated prosthesis. J. Bone and Joint Surg.,74-A: 987-994, Aug 1992.74-A987
1992
Vasavada, A. N.; Delp, S. L.; Maloney, W. J.; Schurman, D. J.; and Zajac, F. E.: Compensating for changes in muscle length in total hip
arthroplasty. Effects on the moment generating capacity of the muscles. Clin. Orthop.,302: 121-133, 1994.302121
1994
[PubMed]