DOI: 10.1148/rg.235035059
(Radiographics. 2003;23:1295-1314.)
© RSNA, 2003
Joint Arthroplasties and Prostheses1
Mihra S. Taljanovic, MD,
Marci D. Jones, MD,
Tim B. Hunter, MD,
James B. Benjamin, MD,
John T. Ruth, MD,
Andrew W. Brown, MD and
Joseph E. Sheppard, MD
1 From the Departments of Radiology (M.S.T., T.B.H.) and Orthopaedic Surgery (M.D.J., J.B.B., J.T.R., A.W.B., J.E.S.), University of Arizona College of Medicine, 1501 N Campbell Ave, PO Box 24506, Tucson, AZ 85724-5067. Received March 10, 2003; revision requested March 24 and received April 18; accepted April 23. Address correspondence to M.S.T. (e-mail: mihrat@radiology.arizona.edu).
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Abstract
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Joint arthroplasty is the most frequently performed orthopedic procedure after fracture fixation. The major indications for any joint replacement are degenerative joint disease, inflammatory arthropathy, avascular necrosis, and complicated fractures. The major contraindications for any joint arthroplasty are systemic and joint infection and a neuropathic joint. The interpretation of radiographs in cases of joint arthroplasty is a significant part of many radiology practices, and correct recognition of the prosthetic devices and their complications by the radiologist is important. The article reviews the most common types of joint arthroplasties and prostheses of the upper and lower extremities and discusses the most frequent complications associated with their placement.
© RSNA, 2003
Index Terms: Joints, surgery, 40.454 • Stents and prostheses, 40.454
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Introduction
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Numerous joint prostheses are used in orthopedic practice. Some of these are more commonly used than the others. The life of any joint prosthesis is related to complications of fixation, wear, or material failure (1–4). It is important for the radiologist to recognize the proper positioning of an implant as well as possible complications that can occur. The goal of this article is to present the most commonly used joint prostheses that are seen in everyday radiology practice and to address the most important points in the correct recognition and radiologic evaluation of these devices. Proper placement of these devices is discussed (1–5).
A review of a few basic terms that are frequently used in joint replacement surgery will help in the evaluation of these cases. The names of the numerous arthroplasty designs are less important and should not be mentioned in the radiology report, unless one is 100% sure about the name. Constraint is the resistance of an implant to a particular degree of motion (ie, anterior-posterior translation or axial rotation). An implant may be fully constrained (ie, have a very limited motion in a given direction), semiconstrained (ie, allow an intermediate amount of motion in a given direction), or nonconstrained (ie, allow full motion in a given direction). Conformity is the geometric measure of the articulation fit (fully conforming prostheses have full articular contact). With greater conformity, there is a larger contact area and less intrinsic stress wear. Modularity is the ability to add stems, augments, and wedges to standard implant components, so that the surgeon can make a custom prosthesis intraoperatively (6). A custom prosthesis is a preoperatively designed custom implant with features that accommodate the specific need of a patient (ie, long-stem tumor implant in a limb salvage procedure) (7). Fixation of the implant to the skeleton can occur with or without polymethylmethacrylate (PMMA) (cement).
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Arthroplasty of the Upper Extremities
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Arthroplasty of the Shoulder
The main indications for shoulder arthroplasty are degenerative and inflammatory arthritis, osteonecrosis, and proximal humerus fractures.
The humeral component of the shoulder implant is anchored in the proximal humerus. It consists of a metallic stem with a modular humeral head that articulates either with the native glenoid in a shoulder hemiarthroplasty (Fig 1) or with the polyethylene or metal glenoid component in a total shoulder arthroplasty (Fig 2). A hemiarthroplasty is used if the glenoid is relatively normal (usually in the treatment of proximal humeral fractures) or to repair severe rotator cuff tear. The humeral component can be cemented or interference-fit cementless. Humeral head resurfacing implants are used in Europe, but they are not currently approved for use in the United States.
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Figure 2. Anteroposterior radiograph of the left shoulder shows a polyethylene (keeled) glenoid component (Total Polyethylene glenoid; DePuy, Warsaw, Ind) used in a total shoulder arthroplasty.
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The glenoid component can be metal backed, which may be secured by screws, or made from polyethylene, which is typically cemented. Two general types of the glenoid components are used: keeled (polyethylene with an indwelling wire loop) and pegged (metal). The type of prosthesis depends on patient selection, the surgeon’s preference, and the surgeon’s experience. Shoulder prostheses are much less constrained than hip prostheses, and their functionality depends to a great degree on competency of the rotator cuff. Foreshortening of the humeral neck, which can commonly occur following proximal humeral fractures, should be avoided, since it compromises the function of the shoulder (1–4,8,9).
On the initial postoperative radiographs, radiolucent areas are frequently seen, particularly about the cemented glenoid component, and are most likely related to difficulty in achieving good cement penetration into the bone. On subsequent radiographs, the radiologist should look for progression of the radiolucent lines at the implant-bone interfaces, since they may indicate loosening. Loosening can occur about either component (1–4,8,9).
The main complications seen with shoulder arthroplasty are loosening and subluxation or dislocation. Periprosthetic humeral shaft fractures can occur intraoperatively or after surgery secondary to trauma (1–4,8,9).
Arthroplasty of the Elbow
Elbow arthroplasty remains one of the biggest challenges in joint arthroplasty because of the forces transmitted across the elbow (owing to the long lever arm of the forearm and its limited bone stock). The main indications for elbow arthroplasty are advanced inflammatory or degenerative arthritis refractory to medical therapy and complex fractures or nonunion of the distal humerus. The absolute contraindications for elbow arthroplasty, as with all arthroplasties, are systemic or joint infections, and a relative contraindication is a neuropathic joint (1–4,10,11).
Hemiarthroplasties of the proximal ulna and distal humerus were attempted in the past, but they are not performed in current orthopedic practice because of poor results (10). Occasionally, a radial head hemiarthroplasty (Fig 3) is performed to treat complex radial head and neck fractures that resulted in instability (1). Arthrodesis of the elbow is a rarely performed procedure and is usually used for rheumatoid arthritis patients or patients with failed elbow arthroplasties who do not have adequate bone stock for revision surgery (1,10).
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Figure 3a. Anteroposterior (a) and lateral (b) radiographs of the right elbow show a stainless steel radial head prosthesis (Evolve; Wright Medical, Arlington, Tenn). An overlying brace is seen in the frontal view. The patient underwent arthroplasty for a severely comminuted radial head fracture.
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Figure 3b. Anteroposterior (a) and lateral (b) radiographs of the right elbow show a stainless steel radial head prosthesis (Evolve; Wright Medical, Arlington, Tenn). An overlying brace is seen in the frontal view. The patient underwent arthroplasty for a severely comminuted radial head fracture.
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Three basic types of elbow arthroplasty are currently used in orthopedic surgery: (a) unconstrained or resurfacing elbow arthroplasty, (b) semiconstrained elbow arthroplasty, and (c) constrained elbow arthroplasty. There are a few different prosthetic designs for all three types (2).
The unconstrained elbow prosthesis consists of two separate humeral and ulnar metal components that articulate by a high-density polyethylene component. This design relies on the overlying soft tissues, rather than a bushing-axle linkage, to maintain the articulation. The major complication associated with this implant is subluxation or dislocation. Constrained elbow prostheses consist of rigid hinges. They are constructed with either metal-on-metal or metal–to–high-density polyethylene parts connected through a bushing, or a separate polyethylene piece, that links the humeral and ulnar components. In placement of a constrained prosthesis, the radial head is resected proximal to the annular ligament. The most common complication associated with a constrained prosthesis is increased stress, which results in osteolysis and loosening. The semiconstrained elbow (sloppy hinge) prostheses (Fig 4) are designed to help alleviate some of the loosening problems found with the constrained hinges. They link the humeral and ulnar components together with an axle and bushing arrangement. They are less constrained in the varus-valgus (coronal) plane than are the constrained elbow prostheses (1,2).
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Figure 4a. Anteroposterior (a) and lateral (b) radiographs of the left elbow show a cemented semiconstrained total elbow arthroplasty prosthesis (Discovery elbow; Biomet). A bone graft (arrow in b) taken from the resected trochlea is usually placed between the humeral shaft and the flange to enhance fixation and the stability of the implant. A cerclage wire is also placed about the fractured proximal ulna. The proximal portion of the radial intramedullary rod is seen on the anteroposterior view.
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Figure 4b. Anteroposterior (a) and lateral (b) radiographs of the left elbow show a cemented semiconstrained total elbow arthroplasty prosthesis (Discovery elbow; Biomet). A bone graft (arrow in b) taken from the resected trochlea is usually placed between the humeral shaft and the flange to enhance fixation and the stability of the implant. A cerclage wire is also placed about the fractured proximal ulna. The proximal portion of the radial intramedullary rod is seen on the anteroposterior view.
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The humeral component of elbow prostheses is more prone to failure (ie, loosening) than the ulnar component. Thus, in the postoperative radiologic evaluation, special attention should be given to anterior migration of the proximal end of the humeral stem. This location is also a common place for bone remodeling (Fig 5) (1,2,4).
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Figure 5a. Anteroposterior (a) and lateral (b) radiographs of the right elbow show a failed cemented semiconstrained total elbow arthroplasty (Coonrad Morey; Zimmer, Warsaw, Ind). There is loosening of both components (note extensive osteolysis about the cemented humeral stem), bone remodeling along the anterior distal humeral shaft, and a periprosthetic ulnar shaft fracture about the distal component.
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Figure 5b. Anteroposterior (a) and lateral (b) radiographs of the right elbow show a failed cemented semiconstrained total elbow arthroplasty (Coonrad Morey; Zimmer, Warsaw, Ind). There is loosening of both components (note extensive osteolysis about the cemented humeral stem), bone remodeling along the anterior distal humeral shaft, and a periprosthetic ulnar shaft fracture about the distal component.
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Arthroplasty of the Wrist and Hand
Partial (Fig 6) or total (Fig 7) wrist arthrodesis is still standard surgical treatment for a painful arthritic wrist. However, with improvements in technology and surgical technique, wrist arthroplasty is being used more frequently (1–4,12).
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Figure 6. Anteroposterior radiograph of the left wrist shows a four-bone partial carpal fusion with a spider plate and screw device (KMI; San Diego, Calif). The patient underwent scaphoid resection because of previous fracture nonunion and proximal scaphoid pole avascular necrosis. Note the lucent area in the distal radius secondary to previous bone graft donor site.
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Figure 7a. Anteroposterior (a) and lateral (b) radiographs of the right wrist show a Steinman rod wrist arthrodesis in a patient with advanced rheumatoid arthritis. Fixation of the third PIP joint with a Kirshner wire tension band fixation is also evident.
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Figure 7b. Anteroposterior (a) and lateral (b) radiographs of the right wrist show a Steinman rod wrist arthrodesis in a patient with advanced rheumatoid arthritis. Fixation of the third PIP joint with a Kirshner wire tension band fixation is also evident.
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The indications for total wrist arthroplasty are not clearly defined. It is usually performed in patients with rheumatoid arthritis or osteoarthritis that affects the other joints in the same extremity. The contraindications for total wrist arthroplasty are lack of sensory or motor function, infection, poor bone stock, chronic severe volar and ulnar subluxation, and the need for weight bearing through the wrist joint (use of a cane or walker). Relative contraindications for total wrist arthroplasty are flail nonfunctional digits with swan-neck deformity, failed arthroplasties of the metacarpophalangeal (MCP) or interphalangeal joints, and lupus arthropathy (1,13–15).
The integrity of the extensor carpi radialis brevis and longus tendons is imperative for total wrist arthroplasty. Regardless of the arthroplasty type, reconstruction of the carpal height and alignment is essential and should be noted on the follow-up radiographs. The third metacarpal is often used as a center of rotation in the coronal plane, and stemmed distal prosthetic components are usually inserted into this bone. In the lateral projection, the carpal alignment should be restored to the neutral position in relationship with the radius, but palmar and dorsal flexion is acceptable. Many authors believe that the most important motion of the wrist is extension with ulnar deviation for power grip. New designs of total wrist arthroplasty prostheses allow 60° of extension, 40° of flexion, and 20° of radial and ulnar deviation (1,13,14).
With total wrist arthroplasty, the distal ulna is always resected to avoid ulnar abutment that will occur after resecting the distal radius. The proximal radial component of the prosthesis does not require cement except in cases of previous medullary canal surgical hardware or extensive osteoporosis. The distal component is almost always cemented.
In 1967, Swanson developed a double-stemmed, flexible-hinge silicone wrist prosthesis (Fig 8). This prosthesis represents a spacer around which scar tissue conforms, giving soft tissue stability to the joint. The complication rate with this prosthesis is high, and the indications for its use at the present time are limited. In the 1970s, Muely and Volz simultaneously invented metal and plastic wrist devices for cement fixation. Both original designs had metal components for insertion in the second and third metacarpals as well as in the distal radius. It was believed initially that ball-and-socket type arthroplasty would be preferable for the wrist as a less constrained prosthesis with total degrees of freedom. However, this type of prosthesis was actually functionally constrained. In addition to other complications, loosening of the distal component occurred in over 50% of these prostheses. In 1973, Volz developed an articulated nonhinged prosthesis that functioned as a dorsopalmar tracking device, with no rotational motion allowed. There were fewer complications with this design (Fig 9) than with the previous ones, but the complications were not eliminated. Tendon balance and dislocations continued to be a problem (1,13,14).
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Figure 8a. Anteroposterior (a) and lateral (b) radiographs of the left wrist in a patient with advanced rheumatoid arthritis show silicone prostheses and associated titanium grommets (Swanson finger joint implant; Wright Medical) in both the wrist and first MCP joints, as well as a Herbert screw (Zimmer) across the fused first interphalangeal joint. The wrist prosthesis is subluxed.
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Figure 8b. Anteroposterior (a) and lateral (b) radiographs of the left wrist in a patient with advanced rheumatoid arthritis show silicone prostheses and associated titanium grommets (Swanson finger joint implant; Wright Medical) in both the wrist and first MCP joints, as well as a Herbert screw (Zimmer) across the fused first interphalangeal joint. The wrist prosthesis is subluxed.
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Figure 9a. Anteroposterior (a) and lateral (b) radiographs of the right wrist demonstrate a Volz II total wrist prosthesis (DePuy). Note failure of the distal component, which is protruding through the dorsal aspect of the third metacarpal bone.
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Figure 9b. Anteroposterior (a) and lateral (b) radiographs of the right wrist demonstrate a Volz II total wrist prosthesis (DePuy). Note failure of the distal component, which is protruding through the dorsal aspect of the third metacarpal bone.
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Because of significant problems with ball-and-socket type arthroplasty, a new semiconstrained, transversely oriented, ellipsoid wrist prosthesis design that could nearly duplicate natural wrist motion was invented. This technique was introduced by Beckenbaugh in 1982, and it is known as the biaxial total wrist arthroplasty. In this design, the prosthetic stems are coated with porous material to enhance cement fixation or even eliminate the need for it. The loosening of the distal component remained problematic. In an attempt to minimize distal component loosening, a modified distal component of the prosthesis is under evaluation. It is not cemented and has a short stem that requires less resection of the capitate. The tip of the distal stem of the prosthesis is just distal to the third carpometacarpal joint (1,13,14).
Numerous additional models of total wrist arthroplasty prostheses were designed in an attempt to solve the complications with previous designs. In 1990, Menon introduced the universal total wrist arthroplasty prosthesis composed of a flat distal component with a prong, which is cemented into the capitate, and with radial and ulnar screws, which are placed through the prosthesis into the peripheral carpal bones. A polyethylene insert is placed between the cemented titanium components. The distal radial component has an inclination of 20°, similar to that of the natural radius (Fig 10) (13–15).
Some authors believe that use of a silicone elastomere implant (Fig 11) together with rerouting of the extensor carpi ulnaris tendon can improve both cosmesis and stabilization of the distal ulna once it has been resected. This prosthesis is sometimes used with radiocarpal arthroplasty. Occasionally, a limited arthroplasty is performed in the carpus of the scaphoid and lunate bones. These procedures have poor outcome because of the difficulty in maintaining the intricate balance of the wrist, which relies on both the bones and the functional complex system of intrinsic and extrinsic wrist ligaments. Silastic and metal arthroplasties of the first carpometacarpal joint after the trapezium is resected (Fig 12) have been performed with variable results (14,16).
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Figure 11a. (a, b) Anteroposterior (a) and oblique (b) radiographs of the right hand in a patient with rheumatoid arthritis show multiple devices implanted for wrist and first MCP joint fusion: Swanson silicone devices for the MCP joints with circumferential titanium grommets (note abnormal orientation of the distal grommet of the second MCP joint), silicone elastomere capping of the distal ulna (Swanson), fusion of the third through fifth PIP joints with Acutrak screws (Acutrak screw system; Acumed, Hillsboro, Ore), and an additional Kirshner wire through the fourth PIP joint. (c) Anteroposterior radiograph of the same hand after removal of the failed distal grommet from the second MCP joint and the Kirshner wire.
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Figure 11b. (a, b) Anteroposterior (a) and oblique (b) radiographs of the right hand in a patient with rheumatoid arthritis show multiple devices implanted for wrist and first MCP joint fusion: Swanson silicone devices for the MCP joints with circumferential titanium grommets (note abnormal orientation of the distal grommet of the second MCP joint), silicone elastomere capping of the distal ulna (Swanson), fusion of the third through fifth PIP joints with Acutrak screws (Acutrak screw system; Acumed, Hillsboro, Ore), and an additional Kirshner wire through the fourth PIP joint. (c) Anteroposterior radiograph of the same hand after removal of the failed distal grommet from the second MCP joint and the Kirshner wire.
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Figure 11c. (a, b) Anteroposterior (a) and oblique (b) radiographs of the right hand in a patient with rheumatoid arthritis show multiple devices implanted for wrist and first MCP joint fusion: Swanson silicone devices for the MCP joints with circumferential titanium grommets (note abnormal orientation of the distal grommet of the second MCP joint), silicone elastomere capping of the distal ulna (Swanson), fusion of the third through fifth PIP joints with Acutrak screws (Acutrak screw system; Acumed, Hillsboro, Ore), and an additional Kirshner wire through the fourth PIP joint. (c) Anteroposterior radiograph of the same hand after removal of the failed distal grommet from the second MCP joint and the Kirshner wire.
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Figure 12. Posteroanterior radiograph shows the trapezial part of a wrist implant (Titanium; Wright Medical) that is fractured at the radial site. The patient had undergone trapeziometacarpal arthroplasty.
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The terms elastomere, silicone, and silastic are commonly confused. Elastomere is a type of synthetic rubber, and silicone and silastic are types of polymers (17). We do not think that radiologists can distinguish these materials with certainty on radiographs. Silastic material is used more than elastomere and silicone in current orthopedic practice and can be found in repair of almost any deformity.
Arthroplasties of the MCP and proximal interphalangeal joints (PIP) are occasionally performed. The most common indication for MCP joint arthroplasty is rheumatoid arthritis. Both silicone and metal prostheses are used. An arthroplasty is occasionally indicated for the isolated PIP joints affected by osteoarthritis, but in cases of rheumatoid arthritis, arthroplasty of the PIP joints is rarely indicated. Numerous designs exist for MCP and PIP joint arthroplasty. Resection arthroplasty with silicone elastomere spacer placement is sometimes performed in the MCP or PIP joints. Arthrodesis is much more commonly performed than arthroplasty for pain relief in the distal interphalangeal joints. Fusion of the MCP joints is rarely performed. The Swanson MCP implant (Fig 13) remains standard. This silicone prosthesis can be used with circumferential titanium grommets (Fig 11) if there is adequate bone stock. Numerous other types of MCP joint arthroplasties, including total MCP joint arthroplasty, have been designed with more or less successful outcomes.
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Figure 13. Posteroanterior radiograph shows Swanson silicone implants in the second through fifth MCP joints in a patient with rheumatoid arthritis who underwent wrist arthroplasty.
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Surface arthroplasty is under clinical trial for use in the MCP joints. Surface arthroplasty consists of replacing the articular cartilage of a joint with a prosthetic cap that is placed over its surface in its stead. Surface arthroplasty has been used with varying success in the hip with removal of the cartilage of the femoral head and a cap placed over the head (there is no change to the acetabulum) (1,2,14,18).
Small joint (proximal, middle, and distal interphalangeal joint) arthroplasties of the hand are associated with frequent complications including fractures, subluxation or dislocation, loosening, small particle disease, and infection (1,2,14,18).
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Arthroplasty of the Lower Extremities
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Arthroplasty of the Hip
Development of modern total hip arthroplasty in the 1960s by John Charnley, a British surgeon, represents a milestone in orthopedic surgery.
The main indication for total hip arthroplasty is disabling pain secondary to severe osteoarthritis, inflammatory arthropathy, avascular necrosis, ankylosis secondary to prior infection or surgery, benign and malignant tumors around the hip joint, and hip fractures. The absolute contraindication for hip arthroplasty is an active local or systemic infection. The relative contraindications are morbid obesity, neurologic dysfunction, and remote infection. Given the appropriate conditions, total hip arthroplasty can be considered for patients of any age group after skeletal maturity. In patients older than 65 years with intracapsular hip (femoral neck) fractures, treatment with hip arthroplasty is sometimes performed instead of open reduction and internal fixation of the fracture (3,4,19–21).
Three basic types of hip arthroplasty are currently used in orthopedic practice: unipolar hip hemiarthroplasty (endoprosthesis), bipolar hip hemiarthroplasty, and total hip arthroplasty (1–4). Unipolar hemiarthroplasty (Fig 14) is used in elderly patients with lower life expectancy for treatment of intracapsular hip fractures. The unipolar prosthesis consists of a press-fit or cemented component with a head diameter that matches that of the acetabulum and articulates directly with the acetabular articular cartilage (1,3,4).
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Figure 14a. Anteroposterior (a) and lateral (b) radiographs of the right hip show a cemented unipolar hip hemiarthroplasty (endoprosthesis) (Zimmer). Note the collar abutting the calcar (arrow).
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Figure 14b. Anteroposterior (a) and lateral (b) radiographs of the right hip show a cemented unipolar hip hemiarthroplasty (endoprosthesis) (Zimmer). Note the collar abutting the calcar (arrow).
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Bipolar hip hemiarthroplasty (Figs 15, 16) uses two components: a femoral stem with a small diameter head and a separate acetabular component made of metal shell lined with polyethylene. Two components of the bipolar hip prosthesis snap together as an articular unit. The external diameter of the acetabular cap matches the acetabular size, and the internal surface of the acetabular cap articulates with the smaller femoral head component. Motion can occur at two places: between the femoral head and acetabular components and at the interface between the external surface of the acetabular component and the native acetabulum. Because of the motion at both interfaces, bipolar hip hemiarthroplasty tends to be less prone to dislocation and theoretically results in less wear of the acetabular articular cartilage that would lead to pain and acetabular protrusio (1,3,4).
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Figure 16. Anteroposterior radiograph of the right hip shows a bipolar revision arthroplasty (Solution fully porous coated; DePuy) with a long femoral stem, onlay allograft, and cerclage wires. The revision arthroplasty was performed after periprosthetic fracture of the femoral shaft.
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Total hip arthroplasty, the most commonly used type of hip replacement (Fig 17), also uses two components: a stemmed femoral component with a prosthetic femoral head and an acetabular component. More than 100,000 total hip arthroplasties are performed annually in the United States. Both components can be cemented or noncemented. Most modern hip arthroplasty systems are modular, with the femoral stem, head, acetabular shell, and acetabular liner being separate pieces. This modularity allows for greater flexibility in "customizing" prosthesis sizing and fit, but it can create problems at the interfaces, such as disengagement and fretting. The classic articulating surface for a total hip prosthesis is metal against polyethylene. In an effort to reduce the problem of polyethylene wear, alternative bearing surfaces, such as metal on metal and ceramics, are being explored (1,3,4,6,20,22).
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Figure 17a. Anteroposterior (a) and lateral (b) radiographs of the right hip show a hybrid total hip prosthesis with cementless acetabular and cemented femoral components (CPCS; Smith & Nephew, Memphis, Tenn).
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Figure 17b. Anteroposterior (a) and lateral (b) radiographs of the right hip show a hybrid total hip prosthesis with cementless acetabular and cemented femoral components (CPCS; Smith & Nephew, Memphis, Tenn).
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The most commonly used size of femoral head components varies from 22 to 32 mm in diameter, although metal-on-metal systems use larger diameters (up to 38 mm). The preferred position of the acetabular cup is 40°–50° of abduction from the horizontal plane and 20° anteversion from the coronal plane. The orientation of the acetabular component can vary depending on surgical approach, bone stock, and surgeon preference. Cup position can best be evaluated on an anteroposterior pelvic radiograph by using the inferior aspect of the teardrop figure. A horizontal line drawn tangentially to the inferior aspect of the teardrop figure and a second line drawn perpendicular to the first at the apex of the teardrop figure serve as reliable references for acetabular position. The version of the acetabular component can best be determined by obtaining a cross-table lateral radiograph of the hip. Normal anteversion is 15° ± 10. On the true lateral radiograph, the anteversion can be only qualitatively assessed, since the apparent degree of angulation is affected by pelvic or thigh rotation. If the true measurement of anteversion is required, it can be assessed with computed tomography. The preferred position of the femoral component, regardless of fixation, is the stem centered in the femoral canal on the anteroposterior view, with the center of rotation of the prosthetic femoral head at the level of the greater trochanter. The position of the stem can also vary depending on the patient’s preexisting anatomy (1,3,4,20,23).
Although cement fixation of prosthetic components is still commonly used, cementless fixation, which proliferated in the 1970s and early 1980s, has overtaken cement fixation in much of North America. Cementless fixation is based on the use of a rough or porous surface on the prosthetic materials that allows bone ingrowth. Bioactive coatings (hydroxyapatite) can also be used with or without a roughened surface to stimulate bone ingrowth or ongrowth to the prosthesis. Acetabular components usually have porous coating over the entire surface of the cup, whereas femoral components can be either partially coated proximally or fully coated. Use of certain cemented and noncemented designs depends on proper patient selection and the surgeon’s preference. Cementless acetabular components are sometimes additionally fixed with screws, which can be used in patients with significant bone loss or because of surgeon preference. Cemented acetabular components are indicated in patients who require acetabular bone grafting or who have previously received a high dose of radiation. Cementless stems are preferred in younger patients (<65 years old) with normal life expectancy and adequate bone mass, because it is possible that a well-ingrown stem will not require revision. Both the cemented and cementless femoral components, with or without a collar at the medial aspect of the prosthesis that is abutting the calcar, are used depending on the surgeon’s preference. Currently, the most commonly used types of total hip prostheses in North America are hybrids, with cementless acetabular and cemented femoral components. However, these hybrids are considered a regional preference, and it is not necessarily true worldwide. If revision is necessary, removal of a noncemented prosthetic component is technically simpler and often does not entail as much bone loss during surgery (1–4,20).
Aseptic loosening of prosthetic components is still the most common cause for revision surgery. The mechanism of loosening can be secondary to mechanical (stress) or biologic factors (degradation of the cement-bone or cementless interface resulting from the migration of wear particles). In both situations, the failure can occur at the prosthesis-bone interface, prosthesis-cement interface, or cement-bone interface. Progressive radiolucent areas greater than 1 mm at these interfaces are worrisome for prosthesis loosening. A radiolucent area greater than 2 mm in any of the three of acetabular zones (1 = superolateral, 2 = central, 3 = medial aspect of the bone–acetabular component interface), superior or medial migration of the cup, or change in inclination of the cup is indicative of loosening. The femoral component–bone interface is divided into zones 1–7 on the anteroposterior view (zones 1–3 at the lateral side proximal to distal, zone 4 at the tip of the femoral stem, zones 5–7 at the medial side distal to proximal) and into zones 1–7 on the lateral view (zones 1–3 at the anterior side proximal to distal, zone 4 at the tip of the femoral stem, and zones 5–7 at the posterior side distal to proximal) (Fig 18). The same rules regarding potential prosthesis loosening are used for both the prosthesis-bone interfaces of the femoral stem and those of the acetabular component (1–4,20,23,24).
Periprosthetic bone remodeling can occur after total hip arthroplasty because of stress alterations in the proximal femur and pelvis after prosthesis implantation. Proximal medial cortical bone loss and distal cortical thickening are commonly seen in the femur. Bone remodeling changes seen around cementless acetabular components are most commonly due to resorption of the subchondral plate and relative osteoporosis in zone 2 (1–4,20,23).
Focal osteolysis about the prosthesis was first recognized by Charney in the 1960s and was thought to be related to the cement used to anchor the prostheses. It has subsequently been recognized that any small particles (metal, cement, or polyethylene) can play a role in initiating osteolysis. With the increased prevalence of cementless fixation, polyethylene wear debris is the most common cause for initiating osteolysis. Eccentric position of the femoral head component within the acetabular component leads to polyethylene wear (1–4,20,23,24). Small particle disease can take place with any joint arthroplasty.
Femoral stem fracture was seen more commonly in the past when alloys with relatively low fatigue strength (stainless steel) were used for prosthesis manufacturing. Prosthesis breakage has become rare with the introduction of high-strength metal alloys (forged cobalt-chromium alloy, titanium-6–aluminum-4–vanadium, and high-strength stainless steel) (20). Dislocation is a relatively uncommon complication (0.4%–0.8% of cases) in primary total hip arthroplasty; it is more common in revision hip arthroplasty (up to 16% of cases) (23).
In the patients with aseptic loosening of the acetabular component and significant bone loss, several types of reconstruction rings are available for management of the acetabular bone loss during revision hip surgery (Fig 19) (25). Custom endoprostheses are used as needed for limb salvage surgery and occasionally after failed primary joint replacement and chronic fracture nonunion (Fig 20) (7).
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Figure 19. Anteroposterior radiograph of the left hip shows an acetabular reconstruction ring placed during total hip revision arthroplasty (Smith & Nephew). Note postoperative overlying drain.
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Figure 20. Anteroposterior radiograph of the left hip shows a custom tumor prosthesis (saddle) (Waldemar link; Hamburg, Germany) in a patient with extensive multiple myeloma lesions involving the left acetabulum and other pelvic bones.
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Arthroplasty of the Knee
Total knee arthroplasty was introduced in the 1970s. The indications for knee replacement are advanced degenerative and inflammatory arthritis. With proper patient selection, good to excellent results can be expected in 95% of patients, and the survival rate of the implant is expected to be 95% at 15 years, which is similar to that for hip prostheses (26).
Unicompartmental arthroplasty is being used more frequently for isolated unicompartmental arthritis, usually in the medial compartment. In this setting, a single femoral condyle and its corresponding tibial articulation are resurfaced (Fig 21). However, the unicompartmental patellofemoral arthroplasty (Fig 22) did not show promising results, and therefore is not routinely used (1,2,4,27).
Total knee arthroplasty involves resurfacing the femoral, tibial, and patellar articular surfaces by using metal and polyethylene bearing surfaces. Numerous total knee arthroplasty designs were used in the past. Both femoral and tibial components can be stemmed, cemented, noncemented, or anchored with screws. The Gunston polycentric prosthesis was the first cemented surface implant for the knee joint, but later work by Freeman and colleagues has had a greater influence on the direction of the prosthetic designs and surgical technique (1–4,26,28,29).
Modern tricompartmental knee arthroplasty uses a multiradius metal femoral component, which resurfaces both condyles and the trochlear notch, and a tibial component, which consists of a metal-backed polyethylene tray that articulates with the femoral component. The tibial component can also be all polyethylene. The patella is often resurfaced with high-density polyethylene, which may be metal backed.
There are numerous designs of total knee arthroplasty that can be broadly grouped into several categories. Cruciate-retaining designs (Fig 23) preserve the posterior cruciate ligament and are still the most commonly performed knee arthroplasty in North America. Cruciate-substituting designs (Fig 24) involve resection of the posterior cruciate ligament and provide posterior stability by incorporating a post in the center of the polyethylene insert that articulates in a "box" in the central portion of the femoral component. The radiologist frequently can differentiate cruciate-substituting from cruciate-retaining knee arthroplasty on lateral views because of the larger "box" or thicker femoral component. Mobile-bearing knee designs allow for motion not only between the femoral component and the tibial polyethylene but also between the tibial polyethylene and the metal tibial tray. Hinged knee designs provide a mechanical linkage between the femoral and tibial components and are used in revision and tumor surgery when the bone and soft-tissue envelope is severely compromised. Regardless of actual implant design, both the femoral and tibial components can include stems that extend varying distances into the metaphysis and diaphysis to augment prosthesis fixation (1–4,26).
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Figure 24a. Anteroposterior (a) and lateral (b) radiographs of the left knee show a cemented cruciate-substituting total knee prosthesis and resurfacing of the patella (Genesis II; Smith & Nephew). Note the large "box" of the femoral component (arrow).
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Figure 24b. Anteroposterior (a) and lateral (b) radiographs of the left knee show a cemented cruciate-substituting total knee prosthesis and resurfacing of the patella (Genesis II; Smith & Nephew). Note the large "box" of the femoral component (arrow).
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The alignment of the prosthesis can vary depending on design, but, in general, the femoral component is oriented in 4°–7° of valgus on the anteroposterior projection and neutral to minimal flexion on the lateral radiograph. The femoral component should duplicate the original anteroposterior dimensions of the femur, but it often appears "undersized" on the anteroposterior radiograph. The anterior flange of the femoral component in an ideal setting should be flush with the anterior cortex of the femur. Tibial components routinely are placed perpendicular to the long axis of the tibia on the anteroposterior projection and perpendicular to slight flexion (3°–6°) on the lateral projection. As with hip arthroplasty, the orientation of various knee designs can vary. Some total knee arthroplasty designs are placed in 1°–2° varus, but more than 5° of varus or valgus of the tibial component is considered abnormal. The goal with tibial sizing is to maximize coverage of the proximal tibial surface and to avoid overhanging the bony surface more than 1–2 mm (1,2,4,26).
As with total hip arthroplasty, the complications seen with knee arthroplasty include aseptic loosening (polyethylene wear, small particle disease, osteolysis) (Fig 25), periprosthetic fractures, and infection. Osseous changes that may be observed following total knee arthroplasty include radiolucent lines, polyethylene wear, osteolysis, and change in prosthesis position. Radiolucent lines are seen commonly under the tibial component but can be obscured by the metal tray if the view is not perfectly tangential to the component surface. Focal radiolucent areas less than 2 mm in size that are nonprogressive are often viewed as benign; however, progressive, circumferential, radiolucent areas larger than 2 mm are often viewed as indicative of prosthesis loosening. Our orthopedic surgeons believe that polyethylene wear, which is often asymmetric, can best be appreciated on weight-bearing views. Others think that osteolysis is seen long before there is enough wear to decrease the joint space. Osteolytic lesions can be seen in both the tibia and femur. A system similar to that used for the proximal femoral stem components is used to divide and evaluate the tibial component–bone interface into zones 1–7. Tibial component failure is more common than femoral component failure. Femoral lesions are often underestimated because the femoral component makes visualization of the lesions difficult. Change in position of components on serial images is indicative of prosthesis loosening (1,2,4,26).
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Figure 25a. (a, b) Anteroposterior (a) and lateral (b) radiographs of the left knee show a cruciate-retaining total knee prosthesis with resurfacing of the patella (AMK; DePuy). Lytic lesions are seen in the medial femoral condyle and in the patella, as well as asymmetric appearance of tibial tray polyethylene (arrow), findings consistent with small particle disease. Note a moderate-size dense joint effusion on the lateral view. (c, d) Anteroposterior (c) and lateral (d) radiographs of the same knee demonstrate bone grafting of the medial femoral condyle and the patella and revision of the polyethylene liner. Note the polyethylene locking mechanism clip, which locks the tibial polyethylene into the tibial base plate (arrow).
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Figure 25b. (a, b) Anteroposterior (a) and lateral (b) radiographs of the left knee show a cruciate-retaining total knee prosthesis with resurfacing of the patella (AMK; DePuy). Lytic lesions are seen in the medial femoral condyle and in the patella, as well as asymmetric appearance of tibial tray polyethylene (arrow), findings consistent with small particle disease. Note a moderate-size dense joint effusion on the lateral view. (c, d) Anteroposterior (c) and lateral (d) radiographs of the same knee demonstrate bone grafting of the medial femoral condyle and the patella and revision of the polyethylene liner. Note the polyethylene locking mechanism clip, which locks the tibial polyethylene into the tibial base plate (arrow).
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Figure 25c. (a, b) Anteroposterior (a) and lateral (b) radiographs of the left knee show a cruciate-retaining total knee prosthesis with resurfacing of the patella (AMK; DePuy). Lytic lesions are seen in the medial femoral condyle and in the patella, as well as asymmetric appearance of tibial tray polyethylene (arrow), findings consistent with small particle disease. Note a moderate-size dense joint effusion on the lateral view. (c, d) Anteroposterior (c) and lateral (d) radiographs of the same knee demonstrate bone grafting of the medial femoral condyle and the patella and revision of the polyethylene liner. Note the polyethylene locking mechanism clip, which locks the tibial polyethylene into the tibial base plate (arrow).
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Figure 25d. (a, b) Anteroposterior (a) and lateral (b) radiographs of the left knee show a cruciate-retaining total knee prosthesis with resurfacing of the patella (AMK; DePuy). Lytic lesions are seen in the medial femoral condyle and in the patella, as well as asymmetric appearance of tibial tray polyethylene (arrow), findings consistent with small particle disease. Note a moderate-size dense joint effusion on the lateral view. (c, d) Anteroposterior (c) and lateral (d) radiographs of the same knee demonstrate bone grafting of the medial femoral condyle and the patella and revision of the polyethylene liner. Note the polyethylene locking mechanism clip, which locks the tibial polyethylene into the tibial base plate (arrow).
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Arthroplasty of the Ankle
The ankle is a complex hinge joint that allows both rotation and translation, with a changing center of rotation. It has three articulations: tibia and superior talar trochlea, fibula and lateral talus, and medial malleolus and talus. Ankle arthroplasty is rarely performed, since excellent results are achieved with arthrodesis (30).
The first generation of total ankle prostheses was introduced in the 1970s, with unacceptably high complication rates compared with those for ankle arthrodesis. More recently, second-generation designs demonstrated a significantly better outcome (1,2,30–34).
The indications for total ankle arthroplasty are osteoarthritis and inflammatory arthropathy. Absolute contraindications are active infection, peripheral vascular disease, deficient soft tissues, and Charcot neuroarthropathy. The relative contraindications for total ankle arthroplasty are young age, active patients, prior infection, severe malalignment of the lower extremity, marked ankle instability, osteoporosis, avascular necrosis of the talus, and morbid obesity (30).
Four second-generation ankle prostheses with promising results are used currently. The cementless designs are the Scandinavian total ankle replacement (STAR), the Buechel-Pappas total ankle arthroplasty (Endotec, South Orange, NJ), and the TNK ankle (Nara, Japan). The Agility total ankle system (DePuy, Warsaw, Ind) is a cemented design (30–34).
Each of the four designs has advantages and shortcomings. The fixed-bearing designs are fully conforming joints, which create high axial constraint and which can result in excessive axial loosening. The mobile-bearing designs have two articulations, which increase risk for dislocation and small particle disease.
The following concerns must be addressed with total ankle arthroplasty: (a) the amount of resection of the tibial and talar components (it should not be excessive), (b) the thickness of the ultra-high-molecular-weight polyethylene (UHMWPE) that articulates with the tibial and talar components (it should be 6–10 mm thick), and (c) the type of metal used (cobalt-chromium is preferred over titanium). Some designs are implanted with surface hydroxyapatite coatings, and others are porous for bone ingrowth. Implantation of the Agility prosthesis (which is porous coated, fixed bearing, with partially conforming articulation) includes syndesmotic fusion to prevent tibial component subsidence and resurfacing of the medial and lateral ankle recesses to enhance fixation and alignment (Figs 26, 27). A somewhat eccentric position of the talar component within the tibial component on the radiographs is normal, since there is a normal space between the talar component and the polyethylene that allows more mobility of the total ankle arthroplasty prosthesis. The tibial component should have its articulating surface perpendicular to the long axis of the tibia (30–34). Despite these considerations, the optimal total ankle arthroplasty configuration has not yet been established (30).
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Figure 26a. Anteroposterior (a), mortise (b), and lateral (c) radiographs of the right ankle show a fixed-bearing porous-coated total ankle prosthesis (early postoperative phase), with a partially conforming articulation (Agility; DePuy).
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Figure 26b. Anteroposterior (a), mortise (b), and lateral (c) radiographs of the right ankle show a fixed-bearing porous-coated total ankle prosthesis (early postoperative phase), with a partially conforming articulation (Agility; DePuy).
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Figure 26c. Anteroposterior (a), mortise (b), and lateral (c) radiographs of the right ankle show a fixed-bearing porous-coated total ankle prosthesis (early postoperative phase), with a partially conforming articulation (Agility; DePuy).
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Figure 27a. Anteroposterior (a) and lateral (b) radiographs of the left ankle show a fixed-bearing porous-coated total ankle prosthesis, with a partially conforming articulation (Agility; DePuy). Note fused tibiofibular syndesmosis (late postoperative phase).
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Figure 27b. Anteroposterior (a) and lateral (b) radiographs of the left ankle show a fixed-bearing porous-coated total ankle prosthesis, with a partially conforming articulation (Agility; DePuy). Note fused tibiofibular syndesmosis (late postoperative phase).
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Arthroplasty of the Small Joints of the Foot
Arthroplasty of the small joints of the foot is performed mainly in rheumatoid arthritis patients. Metatarsophalangeal joints are replaced with silastic and polyethylene spacers, most commonly in the great toe (Fig 28). However, because of a high rate of complications including breakage and fragmentation, which leads to synovitis and bone resorption secondary to small particle disease, these procedures are losing their popularity. Therefore, arthrodesis and resection arthroplasties are the more commonly performed procedures in the foot (1,2,4,35).
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Footnotes
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Abbreviations: MCP = metacarpophalangeal,
PIP = proximal interphalangeal joints
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References
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Abstract
Introduction
