THE
LONG-TERM
RESULTS
HIP
PERFORMED
OF
THE
JOHN
Froni
This
paper
tue
for
the
Hip
hip
INTERVENTION*
ENGLAND
iYrigiltingtoFl
of total
ARTHROPLASTY
A PRIMARY
WRIGHTINGTON,
Surgery,
results
LOW-FRICTION
AS
CHARNLEY,
Centre
reports
OF
Hospital,
Wigan,
replacement
Lancashire
by the
‘low-friction”
technique
in 379 primary
interventions
with a follow-up
of four to seven years.
The early
of a much larger group
of 582 operations,
including
these cases, are also reported.
material
relates
to the
replaced
Teflon
Osteoarthritis
255 per
fractured
for
cent.
neck
hips
operated
TABLE
November
Total
the
hips
in
I
of Teflon
previous
Failed
period
LENGTH
1965
cases
.
under
when
high-density
study
Less
140
.
379
5 years
.
256
6 years
.
the
4 years
203
7 years
total
number
of
FOLLOW-uI’
4 years
773
.
arthritis
1962 to 1965)
582
51
than
rheumatoid
II
OF CLINIC-AL
(All cases
and
polyethylene
such
as complications
of bone.
TABLE
surgery
.
1962,
comprised
conditions
and Paget’s
disease
ARTHROPLASTIES
interventions
Revision
During
per cent
spondylitis
1962 to December
Primary
November
component,
to December
1965.
in 70 per cent ofthe
whole series
The residue
of 45
of femur,
ankylosing
Low-FRICTION
Operations
arthroplasty)
of another
arthroplasties
on from
the acetabular
was the diagnosis
complications
The clinical
.
84
.
14
of low-friction
arthroplasties
was
773.
for
failure
of previous
operations
(osteotomy,
femoral
hip replacement
or cup
numbering
fifty-one
have been excluded
but form
part of the clinical
material
report
(see page
77 of this issue).
Operations
for revision
of failed
Teflon
numbering
140 have also been excluded
(Table
I). This leaves
a total
of 582
which
a low-friction
arthroplasty
using
high-density
polyethylene
was
the
primary
intervention.
The hips followed
up by clinical
examination
hips are included
in the study of early complications
Table
II indicates
the number
of hips examined
periods.
In
addition,
thirty-seven
hips
followed
for
less than four years
number
203; these
but excluded
from the long-term
results.
clinically
every
year in various
follow-up
for
between
five
questionnaire
and radiographs
sent by post are reported
on separately.
The statistics
in this review
relate
to hips rather
than patients,
recording
of bilateral
operations.
METHOD
before
The
study
operation
of the
data
*
VOL.
to a punch
Based
54 B,
was a prospective
and at annual
NO.
on a paper
1, FEBRUARY
card
read
OF
ill
and
eight
order
to
years
simplify
by
the
STUDY
one with special
documentation.
review
were recorded
on standard
The physical
cards
allowing
examinations
the transfer
system.
to the British
1972
Orthopaedic
Association
in London,
September
23,
1970.
61
62
i.
Because
per
of the
week),
it soon
attendances
those
hips
and
five
the
at
number
on
of these
of arthroplasties
obvious
hospital.
operated
ten
large
became
The
from
that
it would
policy
was
November
earlier
CHARNLEY
therefore
1962
patients
is now
to the
by
the
our
classification-Any
use
of
numbers
satisfaction
(Table
has
with
an
III).
The definitions
described
Pain-The
4 and
category
above
two
3.
of the
and
encountered.
for surgical
the
and
2.
on
Severe
Prevents
state
method
OF
THE
l . 0-30
to walk.
some
after
41L.
5. Slight
-
-
limited
or
activity
activity.
quickly
Pain with
on
less
V
with
is Grade
three
columns
increased
Postel
of six
be helpful.
for arthroplasty
STATE
OF
AFFECTED
HIP
I . ew
(1954)
digits
are
as
Grades
and
is not
Grade
a
6 is
JOINTS
rees
100
4
160 de rees
Yard1s or bedriden.
2. Time
and distance
without
sticks
degrees
Limited
with
one
very
stick
limited
(less
with
than
one
or
hour).
Difficult
without
a stick.
Able to stand long periods
4. Long
Limited
g
distances
without
with
one
a stick
to walk
activity
but
getting
digit
indicates
factor”
this
the
such
corresponds
5.
210
degrees
5. No
6.
260
degrees
6.
sum
of
as a Gade
to
the
the
ranges
Index
common
stick
but
stick.
a limp
Normal
of
movement
has been
state
in
used.
of
aIi
“B”
denotes
a patient
with
both
hips
involved
but
the
A useful
to the
been
three
digit
arthritic
prefixes
“A”,
“B” and “C” to facilitate
assessment
of the function
“A” denotes
a patient
with only one hip involved
in whom
n
and therefore
some
factor
of rheumatoid
operation
has
Walking
3.
.
No “loading
3 because
walking.
after
d’Aubign#{233} and
degrees
of flexion
but little other
movement.
Walking-This
digit
indicates
the function
of the hip with
regard
Alphabetical
prefixes-An
important
extension
of the code
has
with
and
experience
intermittent.
starting
normal
Movement-This
directions.
clinic.
III
g
rest
pain
6. No
weekly
before
long
to the
3.
Disappears
of a hip
of Merle
degrees
-.
4. Only
detail
of between
5 is slight
and
intermittent,
For post-operative
results
CLINICAL
60 de
-,
all activity
permitting
special
examination
Movement
spontaneous
3. Tolerable,
by annual
in
or satisfactory.
CLASSIFICATION
attempting
twenty-four
patients
following
of a special
following
points
may
which
qualify
a patient
Grade
treatment.
Pain
I . Severe
all
The
Nevertheless,
TABLE
NUMERICAL
of
1965.
part
corresponding
accepted.
The
grades
of pain
5 good
Grade
states
of
(currently
to follow
RESULTS
the simple
of
clinical
1 is rarely
a need
OF
limitations.
adaptation
end
to compare
obvious
have been
commonest
Grade
indicating
excellent
attempt
performed
adopted
a standard
GRADING
Numerical
being
be impossible
standard
to recognise
hip which
ability
the
to
has
90
walk.
addition
of three
of walking.
other
the
rest
condition
of
the
interferes
body
normal
not responsible
for any defect
in ability
to walk.
“C” denotes
a patient
with
contributing
to failure
to achieve
normal
locomotion,
such as the polyarthritis
arthritis,
senility,
hemiplegia,
and cardiovascular
or respiratory
disability.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
LONG-TERM
RESULTS
To
assess
the
prefixes,
we must
category
who
B”
“
OF
quality
of
walking
our
study
had
bilateral
without
study
of pain
the contribution
and
Comparison
the
using
series
the
not
average
so good
figure
in
quality
cases
the
in the
decimal
on
“C”
the
an
indicates
the
quite
in the
“B”
example,
be used for
can
system
for
makes
the
the
studying
it possible
the quality
as a whole
were 5 I for example,
,
This
way
the distribution
comprises
only
in the
of 47
fractions
alphabetical
unsuitable
of 59.
indicating
If a series
these
to those
for
category,
average
percentage
of
and
remainder,
are
63
INTERVENTION
aid
of cases by expressing
for pain in a series
with
only 4’s and S’s an average
greatest
value
of decimal
the
category
of the three-digit
of different
series
If the average
as one
PRIMARY
The
and
extension
A
with
“A”
and after operation,
but
to the quality
of walking.
be as good
point
AS
arthroplasties.
operated
fractions-An
not
HIP
arthroplasty
can be amplified
by a statement
contributing
to the final number.
containing
5. The
Grade
hip
qualities
fraction.
clearly
an
replacement
second
decimal
would
after
a group
after
OF
to patients
movement
before
of the arthroplasty
to compare
the average
number
plus a decimal
this
ARTHROPLASTY
restrict
have
category
LOW-FRICTION
higher
group;
indicates
that 70 per
is with regard
to
of expressing
of good
two grades
for
and
the
example,
with
cent of cases come
the total
range
of
movement.
SURGICAL
The
size
essential
of femoral
mechanical
head,
the
details
shape
both
socket
and neck-were
the three
years
preceding
reattachment
of the greater
The present
low-friction
with
are
a metal
fixed
The
socket
head
in their
greater
beds
trochanter
is orientated
downwards
anteversion
is
neutral.
and
size
with
of the
employed
femoral
in diameter.
Both
self-curing
acrylic
is elevated
with
technique
neck,
the
in this
series-notably
avoidance
the
of anteversion
of
all established
from
experience
with sockets
made
of Teflon
in
the start
of this series.
Except
for changes
in the method
of
trochanter,
these technical
details
are the same today.
arthroplasty
employs
a socket
of high-density
polyethylene
mated
22 millimetres
bony
TECHNIQUE
of the
the axis
at the
inclined
start
the acetabular
of the
at 45 degrees
and laterally.
Neutral
anteversion
permitted
in order
to avoid
any
and
the femoral
components
cement.
operation
; the plane
is advised,
retroversion.
and
later
reattached.
of the mouth
faces
The
outwards,
with a maximum
of 5 degrees
of
The axis of the femoral
prosthesis
Emphasis
is laid on deepening
the acetabulum
until no more than two or three millimetres
of bone are left in the floor,
the pelvic
surface
of which
can be palpated
by a gloved
finger
introduced
through
a pilot hole half an inch in diameter
and then directed
caudally.
Post-operative
care-Over
the years 1963 to 1965 post-operative
rehabilitation
was conducted
more
slowly
than
at present,
patients
being
confined
to bed for three
weeks
with the legs
separated
and were
(Dindevan)
Press-fit
study
by a pillow.
Most
patients
mobilised
quickly
after this rather
usually
fit to return
home
walking
after a further
week.
At that
were used routinely
; they have now been abandoned.
sockets
of the
without
use
encased
spigot
in a shell
to prevent
operation
the
Press-fit
cement-An
analysis
socket
could
sockets
were
rotate
VOL.
54 B,
late
NO.
on
abandoned
indistinguishable
of
feature
cemented
its
rest
of this three-year
period
was a parallel
into the acetabulum.
This socket
was
of stainless
steel similar
to a Smith-Petersen
cup
tilting
(Figs.
1 to 4). Though
rigidly
hammered
plane
of the mouth
to become
tilt gave good
results.
During
for over four years)
compared
Excluding
the press-fit
sockets
practically
interesting
socket
not
of a polyethylene
prolonged
bed
time anticoagulants
but with a projecting
into position
at the
central
time of
axis.
during
1965
because
of a tendency
to tilt,
causing
the
vertical
and permit
dislocation.
Those
sockets
which
did not
this period
244 press sockets
were inserted
(169 being followed
with 338 cemented
sockets
(210 followed
for over four years).
which
tilted,
the difference
in quality
of the late results
was
and
results.
A slight
1, FEBRUARY
1972
the
two
inferiority
operations
are
of the
press-fit
therefore
socket
considered
was
sometimes
together
detected,
in the
but
64
less
J. (IIARNLLY
than
could
Occasionally
cemented
Though
stances,
be expressed
patients
socket
now
slight
by
with
on
the
a whole
bilateral
other:
arthroplasties
these
abandoned,
the
movement
between
of difference
unit
patients
press-fit
had
almost
technique
and
socket
highest
distribution-The
Sex
therefore
disorder
In the
thstrthutio,z-
Proportion
of
“A”,
age
lIlcideIlce
is misleadingly
“B”
be seen that
in fIt patients
whole
and
was
high
series
“C”
ratIo
over this period
for replacement:
of
1963
osteotomv
for
on
one
the
cemented
side
pain.
and
side.
that,
in certain
circuman excellent
result.
with
were used in this case of rheumaFigure 2-After
operation.
in
the seventh
the
was
to
decade
majority
25
1965
was
to
I III
selected
incidence
patients
cases
employed
JOt
The
10, 4S and
as
seldom
generally
IV).
younger
were
1 male.
each
of
we
(Table
of these
females
percentage
cases-The
fact
“6”
DETAILS
because
the
the
is compatible
and
2
FIG.
in the sixth decade
just under
sixty.
socket
preferred
established
Press-flt’
sockets
of high-density
polyethylene
toid arthritis. Figure 1-Before
operation.
Age
“5”
a press-fit
invariably
bone
GENERAL
between
RN
\I
(
)I
for
BONI
42.
of
such
\\I)
It will
unilateral
“A”
JOINT
cases.
SI IRGERY
a
LONG-TERM
RESULTS
LOW-FRICTION
OF
Bilateral
replacement-No
arthroplasties
eventually
comprise
eighty-nine
ARTHROPLASTY
“B”
same
cases
previously
case.
Figure
3-Late
Figure
4-After
“revision”
satisfactory
up to the present
reported
V indicates
the
bilateral
arthroplasties
rate is 10 per cent.
Assessment
of patients
and
movement
regard
as
is about
54 B,
VOL.
E
23.
qualifying
intervals
(4 per
cent)
before
PRIMARY
for
hip
replacement.
1, FEBRUARY
1972
operation
average
The
65
INTERVENTION
series of 582
148 patients
cases.
clinical
current
recurrent
subluxation.
clinical
(patient
State is very
inactive
from
knees).
performed
denote
“C”
fifty-nine
the
of both
between
were
gradings
35.
NO.
A
4
of
operation-The
These
and
sockets
with
to cemented
sockets.
The
despite
marked
osteoporosis
tilting
stiffness
Table
AS
less than
148 patients
(25 per cent)
out of the total
had the second
hip made
into an arthroplasty.
These
FIG.
The
OF HIP
on
at one
the
grading
states
average
first
session
and
in this
of pain
considerably
grade
second
series;
was
25,
worse
for pain
sides.
Six
currently
the
walking
than
before
we
27,
now
operation
66
.
CHARNLEY
EARLY
This
section
hospital
tions
is
is concerned
; infection
and
calculated
from
with
thrombo-embolism
dislocation
582
COMPLICATIONS
are
and
discussed
arthroplasties
causes
separately.
performed
of death
The
during
incidence
as primary
the
of early
stay
in
complica-
interventions.
Deep venous
thrombosis-Thirty-two
cases
(S’S per cent) were recorded.
Pulmonary
embolism-Nineteen
patients
(32 per cent)
recovered.
Eight
patients
( 1 4 per cent)
died ; all eight came
to post-mortem.
Post-operative
deaths
excluding
embolism-Four
patients
(07 per cent)
died following
operation;
all
were
examined
at
twenty-four
hours;
undiagnosed
sepsis
autopsy.
one
of
One
died
the
patient
at fifteen
hip;
and
died
days
two
deaths
ASSESSMENT
Relief
of pain-The
excellent
and
assessment
good
of
results
pain
(Grade
itself
5).
30
Interval
Less
.
examining
4 before
TABLE
1 -5
the
associated
first
with
conditions.
into
Grade
BILATERAL
Percentage
31-40
cardiac
IV
Years
in
haemorrhage
RESULTS
resolves
Grade
haemorrhage
gastric
from
OF LATE
DISTRIBUTION
Under
subarachnoid
acute
were
relief
6 and
TABLE
AGE
from
from
the
operation
incidence
was
of
the
least
V
REPLACEMENTS
between
than
operations
I year
.
51
.
Between
I and
2 years
44
Between
2 and
3 years
17
l00
41-50
.
51-60
.
21-0
Between
3 and
4 years
16
61-70
.
400
Between
4 and
5 years
13
71-80
.
27-0
Between
5 and
6 years
7
80
Over
for
which
failure,
was
surgery
even
was
though
3 or 2.
This
0-5
.
considered
it could
justifiable;
be
is therefore
148
an
therefore
improvement
an exacting
Grade
for
standard
4 after
a patient
for
whose
operation
is taken
pre-operative
as
category
success.
The series
of 379 hips showed
an average
post-operative
grading
for pain
of 59.
This
figure remained
constant
at five years after operation
(256 hips),
at six years
(eighty-four
hips)
and at seven years (fourteen
hips).
Because
we are concerned
only with Grades
5 and 6 in assessing
the
quality
of pain
relief,
59 for pain relief indicates
90 per cent of results
in Grade
6 and only 10 per cent in
Grade
5.
Assessment
of the function
of walking-The
criteria
in patients
thirty
or forty
or distance
than in the age groups
category
Using
obscured
“A”
the
was
sixty-nine
“A”,
“B”
by conditions
In the group
of forty-six
This
final
figure
represents
years,
and
“A”
with
“C”
unrelated
ability
years
of age
in this study.
only
prefixes,
to the
cases
forty-two
the
four
cases
under
average
patients
walk
is obviously
fifty-five
whom
observation
ability
walking
related
to
be more
exacting
in terms
average
age of the forty-six
between
all
hip
to
would
The
in
JOURNAL
the
fifty-nine.
the function
are excluded
to walk
normally
THE
and
age;
of stamina
patients
in
of walking
was
from the study.
was raised
from
(Grade
6) and
OF BONE
AND
27
JOINT
only
to
59.
four
SURGERY
LONG-TERM
RESULTS
patients
OF
in Grade
5.
LOW-FRICTION
In the
ARTHROPLASTY
subsequent
five,
OF
six and
HIP
AS
seven
A PRIMARY
year
67
INTERVENTION
periods
this
grading
remained
constant.
There
were eighty-nine
hips
at least four years from operation.
after
Thus
1965. The
eighty-one
eight
were
Walking
it has
use
only
In
assessing
to walk
with
classification
the
a limp
proportion
the
has
need
been
to
less
using
one
the
achieved
anteversion
socket
range
The
no “click”
In
studying
element,
and
two
grade
always
23
and
the
results
(256
hips)
seven-year
loss
of movement
selected
had
an
those
in Grade
that
the
On
movement
with
series
stiffest
about
Grade
after
with
VOL.
the
is a sensitive
out
59.
only
index,
of doors,
with
of
of a limp
59
and
range
after
this
with
material,
type
code,
If the
figure
for
means
that
patients
of 100
can be
without
any
the rim of the
with
the
hip
joint
inaccuracies
total
The
metal
neck
bond.
of the
introduces
5
a
hip
comment.
though
with
cement
movement
of the digital
of total
a range
of flexion
of flexion
range
contact
to the
6 or
indicates
range in a patient
this of course
is
here
regard
degrees
apparent
defect,
must be in contact
of plastic
of passive
of motion
We
120
any
neck
Grades
therefore
of the results.
movement
requires
is transferred
range
range
the
observer
not encountered
of movement
may
that
lies
decide,
a change
close
for example,
of only one
mobile
70
of 5 1 ; the
figures
where
These
studied
degrees
six-year
figures
clinically
and
220
results
for
four
degrees).
indicate
years
The
(eighty-four
therefore
for movement
do not indicate
the starting
range is very limited.
for
of 27;
with
the
before
hip
cases
was
five-year
hips)
52 ; and
no trend
towards
of time.
started
other
hand,
after
operation.
379
ranges
5 I.
examined
grade
4 also
grade
hips)
average
in cases
the
(total
passage
and
of
52
average
the
an average
more
grade
features
6 for normal
made
range
(fourteen
at random
with
being
range
results
started
after,
and
significant.
These
decimalised
expected
after operation
was
stick
only
grades,
a variation
of only 5 degrees
as Grade
4 or Grade
3. This means
pre-operative
post-operative
the
absence
without
femoral
parameters.
separating
two
result
is recorded
average
or
use
is incompatible
average
A “normal”
arthroplasty
prosthetic
the rigidity
other
indoors
An
The
person.
in the
with
the
is not
was 3, and
of walking
in this study has been taken as the average
to anything
over a total of 260 degrees;
socket
to a division
whether
the
The
a cane
with
impressive
no shock-loading
variations
combined
recording
use
even with slight
difficulty.
maximum.
Quite
often
the
at 120 degrees.
a cane
for Grade
in a young
after
low-friction
of the socket
produces
in
full
to
patient,
cane.
most
criteria
their own toe nails,
as the most
desirable
use
no aid.
of the
of movement-The
than
need
of the
the
“normal”
total range ofhip movement
sixty years
of age and corresponds
can cut
degrees
the
age
without
of patients
replacement
eighty-nine
hips before
operation
were Grade
6 for the function
confidence.
it implies
Range
ability
to be correlated
our
where
the first hip was
not operated
on until
was
5.
Grade
to give
because
high
average
grade for these
hips of the eighty-nine
aids-In
but
in patients
with bilateral
arthroplasty
The second
hip in many
cases
this
those
what
range
is to be
A group
of 1 12 hips
purpose.
Those
achieving
Grade
achieving
Grade
5 started
with
grade
of 1 8.
an average
operation
the
greater
This
the
6 after
illustrates
final
operation
an average
the
of 1 8;
generalisation
range.
there
were
many
instances
of stiff hips achieving
a full
This is demonstrated
in Table
VI, based
on a randomly
range
of
selected
174 hips. Here it will be seen that approximately
25 per cent of hips starting
in the
grade
(Grade
1) achieved
a full range
of movement.
On the other
hand,
there
was
a 50 per cent chance
of a hip which
started
in one of the restricted
categories
achieving
of
5.
A remarkable
feature
of this
operation
than before.
series
It is to be noted
VI that
a range
54 B,
NO.
from
of movement
1, FEBRUARY
Table
before
1972
is that
operation
not
there
a single
hip has
were
no cases
as good
as Grade
finished
in this
4.
with
randomly
This
gives
less movement
selected
some
series
indication
68
J. CHARNLEY
the
of
general
grade
level
of
Dislocation-The
582
hip
in
incidence
of the
of
arthroplasties.
by
easily
for
disability
patients
before
surgery,
corresponding
to
an
average
of 23.
immediate
twenty-four
abduction
early
There
traction
hours.
by pillows:
post-operative
were
nine
under
cases
(15
anaesthesia,
dislocation
relates
cent).
Reduction
per
but
in two
cases
Reduction
was followed
by three weeks
in no case was a plaster
spica used.
the
to
only
total
was
usually
after
skeletal
of bed-rest
Recurrent
series
of
achieved
with the
subluxation
traction
limb held
did not
occur.
One
occurred
late
dislocation,
where
in the
section
on
one
had
there
or
been
mechanical
two
no
years
after
immediate
TABLE
OF
THE
HIP
IN
IN 174
Before
Grade
I
Grade
2
Grade
3
Grade
48
Grade6
39
25
32
0
96
Grade
15
8
7
0
30
Grade4
WHOLE
SERIES
MECHANICAL
sockets
Tilted
press-fit
sockets
Loose
femoral
prosthesis.
(over
(over
pain
4 years)
In calculating
complications.
of
mechanical
Thus
failure
the
l-0#{176}
,,
11
.
.
582
0
0
.
.
.
582
1
0-l7,,
.
.
.
.
582
1
0-17
.
.
.
.
582
2
034#{176}
.
.
.
.
as to shorten
as a success
2
169
evident
that despite
the small
to post-operative
dislocation
incidence
210
.
dislocation
dislocation
5
4 years)
LATE
is recorded
recorded
VII
FAILURE:
use of large diameter
heads,
or indeed
simple
This
is attributed
to avoidance
of anteversion
The
4
0
Total
case
dislocation
are
After
operation
22
cemented
a way
These
END-RESULT
15
Loose
in such
THE
11
Unexplained
trochanter
TO
operation
TABLE
it is therefore
more prone
recurrent
CASES
-
LATE
is not
one
VI
RELATION
UNSELECTED
-
Late
and
instability.
failures.
STIFFNESS
Recurrent
operation,
post-operative
17
diameter
of the femoral
head, this arthroplasty
than other types of total replacement,
with
femoral
head replacement
of the socket,
and to
capsular
structures
MECHANICAL
failure
if it had
the
for
to be
rates
different
rate of 65 per
6-5
sizes
cent
reduction
type.
of the
of the femoral
head.
FAILURE
whole
revised
after
the
of the Moore
reattachment
and
of sample
for tilting
series
then
JOURNAL
Vii.
No
successful.
have
had to
of the press-fit
THE
in Table
is indicated
became
OF
be
used
socket
BONE
AND
for different
is calculated
JOINT
SURGERY
LONG-TERM
RESULTS
the
against
1 per
OF
LOW-FRICTION
169 examples
cent
for
of this
loosening
type
of the
cemented
sockets
followed
whole
series
of 582 hips,
the long-term
followed
for
ARTHROPLASTY
OF
of operation
cemented
HIP
followed
socket
AS A PRIMARY
for
is calculated
for four years.
Recurrent
because
this complication
period
under
study.
four years (including
THE
four
years,
while
210
arthroplasties
against
subluxation
made
itself
69
INTERVENTION
the
is calculated
evident
before
rate
of
with
against
the
the start
of
The total number
of mechanical
failures
in the whole
series
the press-fit
sockets)
is thus seventeen
cases in 379 (44 per
cent).
TABLE
LATE
MECHANICAL
Loose
socket
Loose
femoral
(over
4 years)
pain
Total
The
total
failure
rate
from
sockets
because
in association
one of the
with press-fit
sockets
cent)
cent)
(1 per
I -0%
.
582
0
0
.
.
582
1
0-17%
.
.
582
1
017%
.
.
4
134%
mechanical
in which
SOCKETS
2
causes
cases of unexplained
sockets.
There
as opposed
(Table
VIII).
The two instances
CEMENTED
210
prosthesis
Late dislocation
Unexplained
VIII
FAILURE:
was
lower
for
cemented
than
for
pain and one recurrent
dislocation
were only two loose
sockets
in 210
to eleven
mechanical
cemented
sockets
failures
became
in 169 press-fit
loose
deserve
press-fit
occurred
cemented
sockets
special
(65
per
comment.
Case 1-A
was
side
woman
aged forty years suffered
from rheumatoid
arthritis.
The pre-operative
grading
C=2-l-l.
Bilateral
arthroplasty
was performed
in 1964 with an interval
of six months.
The right
has remained
perfect
for six years.
The left cemented
socket
slowly
subsided
into the cavity
of
the pelvis and eventually
pain supervened
(Figs. 5 to 8). There was no doubt
that excessive
use of
the reamer
in soft rheumatoid
bone had destroyed
the floor of the acetabulum.
That this was a
technical
failure is indicated
by the maintenance
of an excellent
result on the other side.
Case
2-A
woman
aged
fifty-seven
years
suffered
from
a bilateral
destructive
arthrosis
of steroid
type,
causing
a scissors
performed
in 1963
as an outstanding
showed
a zone of
gait (Fig. 9). The pre-operative
grading
was B=3-2-3.
Bilateral
arthroplasty
was
with an interval of three months
(Fig. 10). The patient was frequently
demonstrated
example
of athletic
function.
Despite
the excellent
result the serial radiographs
demarcation
between
the cement
and the bone of the acetabulum
on both sides
as early
as three
years
after
the operation,
but without
symptoms
(Fig. 1 1). Intermittent
pain started
in the right hip after five years.
In 1970, seven years after the operation,
it was decided
to revise the
right hip because
of progressive
sinking
of the socket
even though
symptoms
were few (Fig. 12).
The
socket
was
found
to be quite
loose
on
a bed
of soft
tissue.
The
sedimentation
rate
was
normal
throughout
and the histology
and bacteriology
of the material
obtained
at operation
revealed
no
infection.
This patient
is unique
in the series.
Further
trouble
may yet arise on the left side.
No
explanation
can be offered for the loosening
of both these sockets,
unless it be a combination
of high
pain
threshold,
very destructive
disease and spectacular
athletic
performance.
We
failure
because
therefore
see
that
of the
two
from bad technique.
The
no satisfactory
explanation
cemented
FAILURE
A remarkable
two
cases
had
feature
of the
to be recorded
be found.
VOL.
54B,
NO.
1, FEBRUARY
1972
sockets
other,
though
not
can be offered.
whole
as failures
FROM
series
which
became
loose,
a clinical
failure,
in a way
UNEXPLAINED
of 582
by reason
one
was
a clinical
is more
serious
PAIN
low-friction
of pain
for
arthroplasties
which
no
is that
explanation
only
could
70
J. CHARNLEY
One
patient
this
she could
above
the
had
walk
a press-fit
indoors
couch.
socket
without
Radiologically
years.
The
hip
was
of the
pain
and
then
it was
and
a limp
the
explored
changed
complained
and
bones
on
for
the
raise
remained
a cemented
1-Subsidence
arthritis
caused
right
hip remains
still
This
to be cemented
patient
died
firmly
been
operation
and
by
6
into
in the
femur.
laparotomy
of pain was
of unexplained
a cemented
persists
socket
excessive
reaming
intact
after
six years.
Immediately
following
operation.
The cause
The second
case
on six years ago using
the
of a cemented
in
saying
for
the
The
the pelvis
the floor
of the
Figure
5-Before
after
operation.
the
acute
revision
pain
now
is worse
the
first
knee
femoral
month.
straight
a period
press-fit
Despite
to 80 degrees
of two
socket
was
prosthesis
and
a half
the
cause
was
found
in a case of rheumatoid
left acetabulum.
operation.
Figure
pain
cholecystitis
never discovered.
pain is in a man
socket.
He complained
that
the
of
After
the
over
that
socket.
after
with
normal
supposition
FIG.
Case
of pain
the leg
The
6-
of the
same
type
seven
years
after
persisted.
the
first
eighty-two
years of age operated
of pain as early as six months
after
than
before.
No cause
has so far
discovered.
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
LONG-TERM
RESULTS
OF
All
enclosure
the operations
but without
LOW-FRICTION
ARTHROPLASTY
OF
POST-OPERATIVE
this
series
thirteen
of
582
(22
per
in this series
the more elaborate
hips
(38
cent)
did
per
Early
Figure
infections-Two
fractured
neck
Late infections-Of
and because
determined.
one
1.
were
of femur.
these
of secondary
Five cases
staphylococcus
VOL.
at biopsy
54 B,
NO.
in
These
thirteen
under
1, FEBRUARY
same
two
blood,
stringent
1972
FIG.
8
two years
revision.
case
arthritis,
no further
per cent)
the bacteriology
without
a sinus.
coagulase
it was
and
per
until
rheumatoid
because
negative
proved
by being
conditions
A
PRIMARY
71
INTERVENTION
in a prototype
clean-air
There
were twenty-two
cent)
were
months
recognised
or years
operation
infections
in
hospital
in
but
later.
-.
cases need
cases (22
infection
presented
aureus,
latter
is of special
interest
antibody
in the patient’s
taken
7-The
(I6
themselves
p
-
Case
Nine
reveal
AS
INFECTION
were
performed
current
regime.
cent).
not
HIP
later.
six
Figure
8-One
in
osteoarthrosis
comment.
eight presented
grown
of asepsis.
with
of the original
Organisms
were
staphylococcus
not
year
and
to be a contaminant
in pure culture
from
after
and
one
discharging
abscess
grown
one
could
in four
B. Cereus.
after
sinuses,
not be
cases:
This
by the presence
of
four of six specimens
72
J. CHARNLEY
Four
patients
manifested
infection
more
than
four
years
after
operation.
These
were
discovered
since the preparation
of our monograph,
published
in 1970, in which
we stated
that the chances
of infection
manifesting
more than three years after operation
were negligible.
Some general
features
about
these four very late cases are of interest:
a) Three
out of the four
had press-fit
sockets,
and therefore
much
less cement
than usual.
h) Three
of the four cases
were
never
completely
successful,
but
the
idea
of infection
Case
itself.
was
e) The
single
clinically
Re-operation
was
taking
after
years
place.
prior
This experience
to operation
seven
Infection
the
was
by
hips
before
FIG.
10
socket
a coagulase
one
known
was
requested
when
the
of
it declared
until
operation.
appearance
socket
entertained
later.
to be loose
seen
for
year
the
negative
to
be
sole
two
years
migrating
reason
at
that
staphylococcus
after
each
the
recurrent
was
operation
annual
review.
subluxation
discovered.
this infection
had not been suspected.
emphasises
the importance
of having
at least two sedimentation
order
to establish
a base-line.
A reading
over 40 is strong
rate
in
2-The
a cemented
though
a sedimentation
infection
with
successful,
from
chronic
case
2-The
not
9
FIG.
Case
was
Apart
50,
pre-operative
level
has
been
readings
evidence
of
normal.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
LONG-TERM
RESULTS
OF
Late
infection
in bilateral
with
one
becoming
years.
side
In
remained
one
perfect
infection.
cause
case
An
arthroplasties-ln
infected
the
for
and
infected
seven
important
of appearances
ARTHROPLASTY
LOW-FRICTION
hip
aspect
five patients
the
other
was
years.
So
to
masquerading
far
the
on
we
have
findings
at three
radiograph
at seven
function
The final
outcome
died seventeen
not suspected
all eventually
Of
still
VOL. 54 B,
thirteen
for
after
the
encountered
they
Perfect
function
was
first
a case
tend
to
performed
a minimum
side,
of
exonerate
of four
which
has
bilateral
late
cement
as
11
and
no pain.
12
Pain
with
no
on
the
nine
pain
early
on the
the
left
right
side:
still
perfect
side.
infections,
of a severe
at necropsy.
one patient
haematemesis;
The remaining
already
mentioned
the infection
eight
hips
was
were
to pseudarthroses.
late
a discharging
NO.
cases-Of
years
not
years.
days after operation
as a result
clinically,
being
discovered
only
changed
the
have
of infected
two
is that
years.
FIG.
2-The
arthroplasty
trouble-free
73
INTERVENTION
infection.
FIG.
Case
AS A PRIMARY
bilateral
remaining
operated
as late
Case 2-Appearance
OF HIP
1, FEBRUARY
infections,
sinus.
1972
ten
were
eventually
changed
into
pseudarthroses,
but
three
a
74
J. CHARNLEY
NON.UNION
wire
During
the years
(18 s.w.g.)
using
and
the
area
reattached
union
(42
of contact
with
when
In
broke
loops
the
with
cent).
the
surface
leg in 10 degrees
In only
GREATER
TROCHANTER
cases
were
cases after
through
was reattached
The cut surface
of the
or more
is encouraged.
for four years
four
in twenty-eight
of wire
passing
THE
1965 the trochanter
now abandoned.
early rehabilitation
379 hips followed
the
per
1963 to
techniques
OF
the
femur
was
small.
The
of abduction.
These
or more
were
there
ununited
with heavy
stainless
steel
of the trochanter
was flat
trochanter
features
sixteen
fragments
was
prejudice
cases
widely
of non-union
separated.
union
of the trochanter,
a phenomenon
soft tissues
and
becoming
fatigued
often
osseous
The
wire
which
results
from
by repeated
bending
movements.
Fibrous
union
therefore
does
instances
of
of the
not
trochanter
appear
complete
as
had
of
A
problem
with
adjacent
to
radiological
self-curing
the
(85
per
on
the
quality
to
the
remaining
in
None
cement
cases
of the
cent).
artificially
cases
are
cortical
bone
patients
the
is
which
of these
the
stiffened
were
or healed
osteitis.
change
of this type
1970),
most
examples
of
important
379 cases
The
ectopic
a notable
average
point
same
significance
clinically
of the
result
and
even
in the
four
were
symptoms
(Charnley,
that
infrequency
of
almost
of ectopic
of movement
it has
and
been
seen
area.
sense
from
with
of pain
on full
of
1968).
The
a non-suppurative
radiological
(Charnley
in cases
after
of
academic
was
replacement
total
of
bilateral
replacement
makes
the
In the total
series
of
in nineteen
cases (5 per cent).
encountered
was
hip
interest.
23
(the
same
as for the
and the average
post-operative
range
was 43 (less
than
the general
average
This corresponds
to a loss of 50 degrees
from a total range of about
220 degrees
ossification
therefore
was associated
with a trend
towards
reduced
mobility.
an average
grade
of 43 indicates
an adequate
total range
of movement
when
absence
Some
of hypertrophy
normal
tubular
for believing
that
of acrylic
material
unilaterally
the
in thirty-three
this
Hammond
compatible
results
matter
ossification
before
to
in
in
sides.
poor
a
encountered
in the
transition
reasons
rejection
changes
Abnormalities
related
Follacci
texture
given
in detail
of sterile
tissue
on both
of radiological
successful.
femur
had
in bone
being
cement
ossification
degree
range
section
of changes
We have elsewhere
cannot
be a sign
arthroplasty
using the
Ectopic
ossification-The
incidence
clinical
VII),
APPEARANCES
these radiological
changes
were considered
to be “physiological”
of bone
in response
to raised
stress
produced
by the abrupt
bone
of the
(Table
failure
RADIOLOGICAL
acrylic
cement
appearance
instances
effect
mechanical
separation.
ABNORMAL
bone
little
a source
whole
series)
of 5#{149}1
or 52).
(5 1). Ectopic
Nevertheless,
combined
with
weight-bearing.
WEAR
A radiographic
marker
enable
wear to be estimated
from a maximum
of rather
has
from
more
OF
THE
PLASTIC
been incorporated
annual
radiographs.
than
1 millimetre
SOCKET
in the plastic
Considerable
in five
years
socket
since early
variations
occur,
to nil at seven
years.
1963 to
ranging
These
variations
are probably
related
to the quality
of the plastic,
because
they do not
always
correspond
to specially
heavy conditions
of service;
little
or no wear
has been
observed
in vigorous
patients
and vice versa.
A number
of post-mortem
specimens
have been
recovered
after
periods
of one and a
half
In
to seven
no
case
years
has
there
from
been
operation,
any
caseation
and
direct
or
measurement
sterile
pus
of wear
inside
the
THE
JOURNAL
has
joint,
thus
as
OF BONE
was
AND
been
frequent
JOINT
possible.
with
SURGERY
LONG-TERM
RESULTS
Teflon.
There
white,
was
tended
any
change
Direct
half
years
(Table
OF
LOW-FRICTION
no metallic
to take
on
07
discoloration
a slightly
in the physical
measurements
to
ARTHROPLASTY
millimetre
in
colour,
sockets
three
HIP
of synovial
cream
condition.
of seven
OF
A
tissue.
but
showed
years,
AS
The
otherwise
polyethylene,
did
of wear
average
being
75
INTERVENTION
there
variations
the
PRIMARY
originally
not
from
appear
to be
nil in six
0 13 millimetre
POSTAL
to the
we have kept
sent radiographs
379
patients
studied
in contact
by questionnaire
of their hips annually
TABLE
WEAR
examination
for
with thirty-seven
patients
for inspection.
The postal
Years
FAILURE
Millimetres
AND
SUCCESS
Death
more
than
four
living far away
group
comprises
TABLE
SOCKETS
____________
-----
FOLLOW-UP
by clinical
IX
OF SEVEN
Patient
X
RATES
FOR
Pulmonary
CEMENTED
embolism
SOCKETS
I -4%
-
.
7-5
1-4
P.
.
7-0
0-8
Mechanical
.
5-0
0-1
Sepsis
.
6-5
0-0
.
3-0
0-7
J_S.
2-I
-
Bo.
Othercauses
07%
failure
l4#{176}
Early
14%
I 6%
3-8%
-
LS.
W.
2-2%
Late
0/
7-3/’O
Total
Bu.
3.5
.
Average
followed
patients
years.
In
pain
0-5
0- 1 3 millimetre
no
for
case
five
or intermittent
_________________________________________________
per year
has
Success
years,
there
twelve
been
for
results
Apart
have
from
been
failures
failures
When
failure
3. As regards
were
so good
reported
4.
As regards
5.
The
by the
VOL.
cent
relief
59
average
54 B,
for
NO.
of total
to infection,
of the
that
it
success
of pain
both,
in Grade
for
seven
; only
%
years
three
and
two
patients
for
eight
report
slight
hip
CONCLUSIONS
replacement
by
a low-friction
technique
using
component
in 379 primary
interventions,
1965 and followed
for between
four and
performed
seven years.
the
was
rate
of which
in the era
under
review
results
was
and
and
ability
indicating
and
their
unnecessary
maintenance
to
over
distinguish
an
the
years,
38
per
by this
the late
the
intermediate
results
class
of
failure.
to walk,
90 per
cent
the
average
of patients
final
rating,
in Grade
on a scale
6 (excellent)
numbered
and
only
5 (good).
recovery
pre-operative
six
927
mechanical
causes
were unusual
after total
hip replacement
socket
was cemented
in position,
which
is now
routine,
all causes
was only l3 per cent in 210 cases.
between
1 to 6, was
10 per
due
from
the
from
AND
for the acetabular
and December
the quality
(Table
X)
“improvement”
years,
deterioration
rate
discomfort.
high-density
polyethylene
between
November
1962
cent,
late
technique.
mechanical
six
significant
SUMMARY
The
years,
who have
seventeen
-
2.
a
year
IX).
In addition
I.
and
per
range,
1, FEBRUARY
of movement
but
1972
was
in all cases
not
that
as spectacular
range
was
and
improved
was
influenced
considerably
on.
starting
Even
with
76
J. CHARNLEY
the stiffest
was
6.
tend
no
of hips
about
As regards
late
7.
The
Teflon
cement
mechanical
era,
trochanter,
they
CHARNLEY,
J. (1970):
patient
with
are
with
(22
per
regained
the
cent
passage
out
a right
angle
of flexion
movement.
There
of time.
of a total
of 38
per
cent),
the
various
findings
as a cause.
details
and
in four
movement
infection
to exonerate
the
one
to lose
tendency
of the
the
identical
technique
exception
with
became
of
our
improved
current
practice
stabilised
methods
in the
of
period
1959
to
1962
of
the
greater
and
London:
reattachment
in
in 1971.
REFERENCES
The
Use
of
,4crvlic
cement
in
Orthopaedic
Surgery,
p. 112.
Edinburgh
E. & S. Livingstone.
CHARNLEY,
Acrylic
J.,
FOLLACCI,
Cement.
MERLE D’AUBIGNf,
Jourzzal
of
Boize
M.,
and
HAMMOND,
Jourizal of Bone
R., and
and
B. T. (1968):
azd Joiizt Surgery,
POSTEL, M. (1954):
Functional
Surgery,
36-A, 45 1.
The Long-term
Reaction
50-B, 822.
Results
of Hip Arthroplasty
of Bone
with
to Self-curing
Acrylic
Prosthesis.
Joint
THE JOURNAL
OF BONE AND JOINT SURGERY