Bone remodelling around HA-coated acetabular cups : a DEXA study with a 3-year follow-up in a randomised trial

Hydroxyapatite-Coated Acetabular Cups in Primary Total Hip Arthroplasty: A Meta-Analysis

INTRODUCTION

Cementless fixation is the predominant method used in primary total hip arthroplasties (THAs) performed in the United States, with porous and hydroxyapatite-coated implants used most commonly. Preclinical studies have demonstrated that hydroxyapatite-coated implants achieve superior fixation and stability compared to those with porous surfaces alone, yet the adoption of hydroxyapatite (HA) coating in clinical practice has been inconsistent. There have been few previous meta-analyses comparing HA-coated versus non-HA-coated acetabular cups. We hypothesized that HA-coated acetabular cups would result in a reduced incidence of revisions compared to non-HA-coated cups with no difference in osteolysis, radiolucent lines, or patient-reported outcomes.

METHODS

Medline, Embase, and Cochrane libraries were searched through November 2024 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The studies included were randomized controlled trials comparing HA-coated acetabular cups to non-HA-coated cups in primary THA. Outcomes included Harris Hip Score (HHS), endosteal bone formation, radiolucent lines, linear wear rate, revision for aseptic loosening, and heterotopic ossification.

RESULTS

There were significantly fewer radiolucent lines (P < 0.00001) for patients who had HA-coated cups. There was no significant difference in HHS (P = 0.20), endosteal bone formation (P = 0.23), linear wear rate (P = 0.44), acetabular component revisions for aseptic loosening (P = 0.29), or heterotopic ossification (P = 0.71) between HA-coated and non-HA-coated cups.

DISCUSSION/CONCLUSION

The results of our meta-analysis demonstrated that HA-coated acetabular cups in primary THA led to significantly fewer radiolucent lines compared to non-HA-coated cups. They did not show any advantage of HA-coated cups over non-HA-coated cups in terms of HHS, endosteal bone formation, linear wear rate, acetabular component revisions, or heterotopic ossification. These results suggest that HA-coated acetabular cups should be preferred over non-HA-coated acetabular cups in primary THA.

Bone remodeling after revision total hip arthroplasty for large acetabular defects

Large acetabular bone defects are challenging in hip revision surgery. Clinical assessment is crucial to evaluate modern technologies in surgical reconstruction. We aimed to better understand the bone remodeling that occurs following acetabular reconstruction. Our objectives were: (1) To characterize changes in the shape of the pelvis by studying sequential computed tomography (CT) scans collected immediately and 1-year postoperatively and (2) to identify which part of the pelvis is most susceptible to remodeling. We used the CT scans taken at two timepoints, of 24 patients with acetabular bone defects classified as Paprosky IIIB, treated with three-dimensional (3D)-printed custom-made acetabular implants. Segmented 3D models of the bony pelvis were co-registered using three different techniques. A global co-registration of the full pelvis was conducted, followed by the co-registration of the innominate bone and then ilium only, on the ipsilateral reconstructed side. The relative movements of the ilium, ischium, and pubis were analyzed from visual inspection and using co-registration metrics (root mean square error and intersection over union). No bone remodeling was found in 14/24 patients (58%). The co-registration of the innominate bone indicated bone remodeling in five cases (21%), while the remaining five cases (21%) presented remodeling in the global co-registration but not the innominate bone co-registration, suggestive of changes occurring at the sacroiliac joint. Changes in the pelvic shape were greatest at the pubis and ischium. Bone remodeling may occur in complex cases of Paprosky type IIIB defects, after acetabular reconstruction (occurrence of 21%, 5/24 cases). Surgeons and engineers should consider this when monitoring implant migration.

The role of bone remodeling in measuring migration of custom implants for large acetabular defects

In revision total hip arthroplasty, achieving robust fixation is difficult and implant movement may occur over time. Bone may also rearrange around the implant as a result of mechanical loading, making the measurement of migration challenging. The study aimed to quantify changes in bone shape and implant position 1 year following acetabular reconstruction using custom three-dimensional-printed cups. This observational retrospective cohort study involved 23 patients with Paprosky type IIIB defects. Postop computed tomography scans taken within 1 week of surgery and at 1-year postsurgery were co-registered and analyzed. Three co-registration strategies were implemented including bone-to-bone and implant-to-implant. (1) Co-registration of the ipsilateral innominate bone (diseased anatomy) was used to measure changes in implant position. (2) Co-registration of the implant was carried out to quantify changes in the ipsilateral innominate bone shape. (3) Co-registration of the contralateral innominate bone (nondiseased anatomy) was performed to measure changes in the ipsilateral innominate bone shape and implant position. The median centroid distances (interquartile range [IQR]) were 2.3 mm (IQR: 3.7-1.7 mm) for changes in implant position, 2.4 mm (IQR: 3.6-1.6 mm) for changes in ipsilateral innominate bone shape, and 3.7 mm (IQR: 4.6-3.5 mm) for changes in ipsilateral innominate bone shape and implant position. Following acetabular reconstruction, implant movements and periprosthetic bone remodeling are physiological and of a similar extent. Surgeons and engineers should consider this when performing implant monitoring in these patients.

Mechanobiochemical bone remodelling around an uncemented acetabular component: influence of bone orthotropy

Mechanical loosening of an implant is often caused by bone resorption, owing to stress/strain shielding. Adaptive bone remodelling elucidates the response of bone tissue to alterations in mechanical and biochemical environments. This study aims to propose a novel framework of bone remodelling based on the combined effects of bone orthotropy and mechanobiochemical stimulus. The proposed remodelling framework was employed in the finite element model of an implanted hemipelvis to predict evolutionary changes in bone density and associated orthotropic bone material properties. In order to account for variations in load transfer during common daily activities, several musculoskeletal loading conditions of hip joint corresponding to sitting down/up, stairs ascend/descend and normal walking were considered. The bone remodelling predictions were compared with those of isotropic strain energy density (SED)-based, isotropic mechanobiochemical and orthotropic strain-based bone remodelling formulations. Although similar trends of bone resorption were predicted by orthotropic mechanobiochemical (MBC) and orthotropic strain-based models across implanted acetabulum, more volume (10-20%) of bone elements was subjected to bone resorption for the orthotropic MBC model. Higher bone resorption (75-85%) was predicted by the orthotropic strain-based and orthotropic MBC models compared to the isotropic MBC and SED-based models. Higher bone apposition (35-160%) across the implanted acetabulum was predicted by the isotropic MBC model, compared to the SED-based model. The remodelling predictions indicated that a reduction in estrogen level might lead to an increase in bone resorption. The study highlighted the importance of including mechanobiochemical stimulus and bone anisotropy to predict bone remodelling adequately.

Change in CT-measured acetabular bone density following total hip arthroplasty: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

Assessing peri-acetabular bone quality is valuable for optimizing the outcomes of primary total hip arthroplasty (THA) as preservation of good quality bone stock likely affects implant stability. The aim of this study was to perform a meta-analysis of peri-acetabular bone mineral density (BMD) changes over time measured using quantitative computer tomography (CT) and, second, to investigate the influence of age, sex, and fixation on the change in BMD over time.

METHODS

A systematic search of Embase, Scopus, Web of Science, and PubMed databases identified 19 studies that measured BMD using CT following THA. The regions of interest (ROI), reporting of BMD results, and scan protocols were extracted. A meta-analysis of BMD was performed on 12 studies that reported measurements immediately postoperatively and at follow-up.

RESULTS

The meta-analysis determined that periacetabular BMD around both cemented and uncemented components decreases over time. The amount of BMD loss increased relative to proximity of the acetabular component. There was a greater decrease in cortical BMD over time in females and cancellous BMD for young patients of any sex.

CONCLUSION

Peri-acetabular BMD decreases at different rates relative to its proximity to the acetabular component. Cancellous BMD decreases more in young patients and cortical bone decreases more in females. Standardized reporting parameters and suggested ROI to measure peri-acetabular BMD are proposed, to enable comparison between implant and patient variables in the future.

Radiographic quantification of the normal and near-normal coxofemoral conformation in Labrador Retrievers and German Shepherds: a comparative study

BACKGROUND

Canine hip dysplasia (CHD) is a multifactorial disease affecting large breed dogs with associated joint laxity and incongruity that predisposes them to osteoarthritis. The purpose of the study is to objectively compare the conformation of normal and near-normal coxofemoral joints (CFJS) in Labrador Retrievers versus German Shepherds on the extended ventrodorsal radiograph. Investigated groups were categorized as normal and near-normal CFJS according to the morphometric criteria established by the FCI scoring system. Center-edge (CE) angle, Norberg angle (NA), indices of dorsal AFH coverage width and area, acetabular slope (AS) angle, and inclination angle were determined for each group. CE angle and AS angle were modified from previously described human techniques. The width and area of dorsal AFH coverage were standardized by the corresponding femoral head diameter and area. Variables were compared between groups using an unpaired, two-tailed t-test. A Spearman correlation coefficient determined the relationship between selected variables.

RESULTS

In Labradors, CE angle (lateral coverage) and dorsal AFH coverage area index (dorsal coverage) were greater in normal versus near-normal CFJS. In German Shepherds, lateral AFH coverage (CE angle and NA) was greater in normal versus near-normal hip joints; whereas, dorsal AFH coverage did not differ between the two groups. Lateral AFH coverage was greater in normal versus near-normal CFJS of both breeds. In Labradors, the inclination angle was greater in near-normal versus normal CFJS. Normal CFJS of Labradors revealed greater lateral and dorsal AFH coverages compared to German Shepherds. Near-normal joints of Labradors showed greater lateral AFH coverage compared to those of German Shepherds; whereas, dorsal AFH coverage did not differ between the two breeds. A steeper acetabular slope angle was noted in normal and near-normal CFJS of German Shepherds compared to Labrador Retrievers. The inclination angle of near-normal joints was greater in Labrador Retrievers compared to German Shepherds.

CONCLUSIONS

Overall, normal and near-normal CFJS of German Shepherds had lesser AFH coverage and steeper acetabular slope angle compared to Labrador Retrievers. Labrador Retrievers and German Shepherds with CE-angles < 27° and < 21.8°, dorsal AFH coverage width indices < 51 and < 49%, and/or dorsal AFH coverage area indices < 53 and < 50%, respectively, may be consistent with CHD. Thus, the authors would recommend excluding subjects with lower values from breeding. Validating the reported measurements is still warranted.

Liner type has no impact on bone mineral density changes around a 3D printed trabecular titanium acetabular component

BACKGROUND

Three-dimensional printing of implants allows the ability to produce implants and interfaces which theoretically better mimic "normal" bone behaviour, leading to a possible reduction in stress shielding thus maintaining bone mineral density (BMD). This issue was not investigated in vivo using bone scan and different bearings; therefore, we did a prospective study aiming to answer: 1) is there a loss of BMD around the 3D printed trabecular titanium cup, when compared to the native hip?; 2) does liner type influence the BMD changes around the acetabulum when a 3D printed trabecular titanium cup is used?

HYPOTHESIS

BMD changes around the acetabulum are not influenced by the liner type, and the cup will be associated with a reduction in BMD when compared to the native hip.

MATERIAL AND METHODS

This is a prospective observational study of patients receiving a primary total hip arthroplasty. A 3D printed trabecular titanium uncemented acetabular component was used in all cases. All patients received a ceramic femoral head, with either a ceramic or polyethylene acetabular liner. BMD measurements using DXA were performed at 6 weeks, 6, 12 and 24 months after surgery to evaluate remodeling changes. The 3 acetabular regions of interest (ROI) of DeLee and Charnley were used for serial comparisons of peri-acetabular BMD. The study was powered as a non-inferiority study with the principle variables compared using a two-step repeated analysis of variance.

RESULTS

A total of 48 consecutive patients were included in the study, with all patients completing their 2 year follow-up. There were no failures, revisions or complications within this cohort. We found no statistically significant difference in the BMD change scores between the operated and the native hip in any of the 3 ROI zones. We found no differences in BMD scores when comparing ceramic to polyethylene acetabular liners, head sizes and BMI.

DISCUSSION

This study shows a similar pattern of BMD behaviour around a 3D printed cup when compared to the contralateral native hip. We were unable to show a clinical or radiological difference between the bearing material, head size, or BMI when used with this type of acetabular component.

LEVEL OF EVIDENCE

III; prospective comparative study.

Denosumab prevents acetabular bone loss around an uncemented cup: analysis of secondary outcomes in a randomized controlled trial

BACKGROUND AND PURPOSE

Uncemented total hip arthroplasty (THA) is associated with periprosthetic bone loss. In a secondary outcome analysis from a randomized controlled trial, we studied whether denosumab can prevent loss of acetabular periprosthetic bone mineral density (pBMD) in patients who received a trabecular metal cup during uncemented THA.

PATIENTS AND METHODS

64 patients (aged 35-65 years) with unilateral osteoarthritis of the hip were randomized to 2 subcutaneous injections with denosumab or placebo, given 1-3 days post-surgery and 6 months post-surgery. Acetabular pBMD was measured in 5 regions of interest (ROIs) by dual-energy X-ray absorptiometry. Serum markers for bone metabolism were analyzed. Periprosthetic osteoblastic activity, measured as standardized uptake values (SUVs) by [18F] positron emission tomography/computed tomography, was evaluated in 32 of the 64 study patients.

RESULTS

After 12 months, patients treated with denosumab had higher pBMD compared with the placebo-treated patients in 4 of 5 ROIs and in sum of ROIs 1-5. After 24 months, the effect on pBMD for patients treated with denosumab declined. Serum markers declined pronouncedly up to 12 months in patients treated with denosumab, but rebounded above baseline levels after 24 months. Patients treated with denosumab had statistically significantly lower SUVs in all ROIs, except ROI 5, after 6 months.

INTERPRETATION

Based on this exploratory analysis of secondary endpoints the application of denosumab seems associated with preserved acetabular pBMD, reduced bone metabolism and attenuated periprosthetic osteoblastic activity. However, given the known rebound affects after discontinuation of denosumab treatment, these effects cannot be expected to persist. If prolonged treatment or shift to other regimes would be beneficial to reduce the risk of cup loosening is yet to be investigated.

Modified FCI (Fédération Cynologique Internationale) Scoring of the Coxofemoral Joint in Labrador Retrievers Without and With Hip Dysplasia

The objective is to propose a modified FCI scoring protocol of the canine hip joint via: (1) providing morphometric criteria of each score; (2) quantifying the extent of lateral and dorsal acetabular femoral head (AFH) coverage; (3) evaluating the steepness of cranial acetabular edge (acetabular index angle) and inclination angle (IA) in normal and dysplastic coxofemoral joints of Labrador Retrievers. The long-term goal is to achieve a selective breeding protocol using parental phenotypically healthy coxofemoral joints based on the standard extended-leg VD radiograph to help reduce the prevalence of CHD among offspring. Investigated populations were classified into normal (grade A) and dysplastic coxofemoral joints (grades B to E) based on the morphometric criteria previously established by the conventional FCI scoring system. Center-edge (CE) angle, Norberg angle (NA), indices of dorsal AFH coverage width and area, acetabular index angle, and inclination angle were determined for each group. Variables were compared between groups using ANOVA. Spearman correlation coefficient was used to determine the linear relationship between selected variables. Overall, all radiographic measurements differed significantly (P < 0.0001) among the five tested groups using ANOVA test. Dorsal AFH coverage area index was the only measure that differed significantly (P ≤ 0.007) between every two consecutive groups using Tukey's test. Significant correlations were identified between the Norberg and CE angles (r s = 0.95, P < 0.0001), the width and area of dorsal AFH coverage (r s = 0.96, P < 0.0001), and the radiographic techniques utilized to assess lateral vs. dorsal AFH coverage (r s ≥ 0.80, P < 0.0001). Evaluation of CE-angle, dorsal AFH coverage area index and acetabular index angle is recommended during selective breeding to include parents with radiographically healthy joints and reduce the incidence of hip dysplasia among offspring. Dogs with CE-angle <27°, dorsal AFH coverage area index <53%, and/or acetabular index angle >9° may be consistent with hip dysplasia and are recommended to be excluded from potential breeding groups. Re-evaluation of coxofemoral joints with borderline values located between near-normal and mildly dysplastic coxofemoral joints is strongly recommended to be performed after 6 months.

Does a Monoblock Acetabular Component With a Ceramic Liner Cause More Pelvic Bone Loss Than a Conventional Modular Cementless Acetabular Component? A 2-Year Randomized Clinical Trial

BACKGROUND

Ceramic-on-ceramic bearings permit the use of large femoral head size while maintaining a favorable effect on wear rates. However, because of increased device rigidity, periprosthetic bone quality could be negatively affected due to stress shielding. The purpose of this study is to assess pelvic periprosthetic bone remodeling around a monoblock ceramic-on-ceramic acetabular component compared to that around a conventional modular metal-on-polyethylene device.

METHODS

Participants were randomized to receive hip replacement using either a porous-coated, modular metal-on-polyethylene acetabular component (n = 46) or a hydroxyapatite and titanium-coated monoblock shell with an integrated ceramic-on-ceramic bearing (n = 40). Radiographic assessments were completed preoperatively and postoperatively, and measurements of bone mineral density (BMD) using dual-energy X-ray absorptiometry with region free analysis were performed postoperatively and over 2-years of follow-up.

RESULTS

There was no significant difference in BMD between the 2 groups at baseline or over the following 2 years. At follow-up, complete shell-to-bone contact without a radiolucent line was observed in 26 (67%) of the modular devices and in 37 (93%) of monoblock (P < .001). The modular device was an independent predictor of radiolucent lines (odds ratio 19.1, P = .007). No cases underwent revision surgery for acetabular loosening.

CONCLUSION

Both the porous-coated modular and hydroxyapatite-coated monoblock acetabular components showed successful clinical results at short-term follow-up with no difference in pixel-level BMD. Using a large head monoblock device does not appear to be associated with an adverse effect on the local bone environment when compared to a modular device. NCT: NCT01558752.

Bone mineralisation adjacent to cemented and uncemented acetabular cups: analysis by [18F]-fluoride-PET in a randomised clinical trial

PURPOSE

We present a randomised clinical trial using F-PET/CT to analyse new bone metabolic mineralisation adjacent to acetabular cups following total hip arthoplasty (THA).

PATIENTS AND METHODS

THA was performed on 26 patients (26 cases) with hip OA. Patients with hip osteoarthritis (OA) were randomly assigned to operations with cemented or uncemented acetabular components. The contralateral, healthy acetabulum was used as referent for normal bone metabolism. The patients were analysed with radiography, clinical scoring, and F-PET/CT preoperatively, and at 6 weeks and 6 months postoperatively.

RESULTS

No major complications were recorded, and clinical results were good in all patients. Radiography showed all cups to be stable. The bone-forming activity, as measured by F-PET/CT, was quantified as standardised uptake values (SUV). The mean SUV was 4.6 (6 weeks) and 3.5 (6 months) around the uncemented cups, and 4.8 and 4.0, respectively, for the cemented cups. Normal healthy bone metabolism in the referent was 2.8 and 2.7 SUV at 6 weeks and 6 months, respectively. P < 0.01 for the cemented group at 6 weeks and 6 months, for the uncemented group only at 6 weeks.

INTERPRETATION

An acetabulum affected by OA has elevated SUV activity. Both cemented and uncemented cups had elevated bone metabolic activity at 6 weeks. The raised activity was interpreted as an effect from bone mineralisation secondary to surgical trauma and healing, and to the OA. At 6 months, activity was more normalised for the uncemented group than for the cemented, suggesting healing may terminate faster in the uncemented group. Postoperative bone metabolic activity can be analysed in detail by F-PET/CT.ClinicalTrials.gov Identifier: NCT01623687.

Early migration of stemless and stemmed humeral components after total shoulder arthroplasty for osteoarthritis-study protocol for a randomized controlled trial

BACKGROUND

Glenohumeral osteoarthritis can, in the most severe cases, require surgery with insertion of a shoulder arthroplasty. A design with a stem in the humeral bone canal is currently regarded as the standard treatment option in patients who have an intact rotator cuff function, but complications related to the stem including humeral fractures can have devastating consequences. By using a stemless humeral component, stem-related complications can be reduced. The aim of this study is to compare the Comprehensive Nano stemless total shoulder arthroplasty (intervention group) with the Comprehensive stemmed total shoulder arthroplasty (control group).

MATERIALS AND METHODS

This is a randomized controlled trial comparing the stemless and the stemmed total shoulder arthroplasty. All Danish citizens with glenohumeral osteoarthritis indicating a total shoulder arthroplasty referred to the orthopedic department at Copenhagen University Hospital in Herlev/Gentofte will be offered participation. The following exclude from participation: below 18 years of age, cognitive or linguistic impairment, insufficient function of the rotator cuff, poor bone quality, and ASA groups 4-5. A total of 122 patients will be included of which 56 will be part of a radiostereometric analysis (RSA) study of humeral component migration. The primary outcomes are magnitude of migration of the humeral component assessed by RSA and patient-reported outcome by Western Ontario Osteoarthritis of the Shoulder index (WOOS). The secondary outcomes are additional patient-reported outcomes, functional outcome, readmission, complications, revisions, and changes in bone mineral density (BMD) of the proximal humerus assessed by duel energy x-ray absorptiometry (DXA) and economy (cost-utility analysis). The patients are examined before the operation and 3, 6, 12, and 24 months postoperative.

DISCUSSION

To our knowledge, RSA has never been used to access migration of a stemmed or a stemless humeral component nor has the stemmed and the stemless humeral component been compared with regard to pain relief and shoulder function in a randomized clinical trial. Today, the two designs are considered equal in the treatment of osteoarthritis. The study will provide surgeons and patients with information about shoulder arthroplasty for osteoarthritis and assist them in decision-making.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04105478 . Registered on 25 September 2019.

Peri-acetabular bone remodelling after uncemented total hip arthroplasty with monoblock press-fit cups: an observational study

Background

Bone stock preservation in total hip replacement is essential to allow for later revisions in an increasingly younger and fitter index patient population. While contemporary modular press-fit acetabular cups lead to rigid fixation with equatorial stress and central osteolysis, more elastic fixation may cause different peri-acetabular bone remodelling. The purpose of this study was to investigate changes in peri-acetabular bone mineral density (BMD) in uncemented elastic fixation with monoblock press-fit cups.

Methods

This prospective observational study included 45 patients with monoblock cups. We evaluated peri-acetabular BMD using dual-energy X-ray absorptiometry and reported functional outcomes and complications.

Results

At a mean follow-up of 24.2 ± 2.2 months, we found that BMD stabilised in DeLee and Charnley zones I and III and recovered to baseline value in zone II. The mean Harris Hip Scores improved significantly from 56.9 ± 20.0 to 97.2 ± 4.0 (p <  0001). Other than one peri-operative dislocation, we saw no post-operative complications.

Conclusions

We found favourable adaptive bone changes with BMD stabilisation in the equatorial zones and recovery to pre-operative values in the central zone. Additionally, excellent clinical outcomes and few prosthesis-related complications strengthened the favourable results of monoblock acetabular cups.

Trial registration

Registration number DRKS00017076.

Influence of Hydroxyapatite Coating for the Prevention of Bone Mineral Density Loss and Bone Metabolism after Total Hip Arthroplasty: Assessment Using 18F-Fluoride Positron Emission Tomography and Dual-Energy X-Ray Absorptiometry by Randomized Controlled Trial

Background

Hydroxyapatite- (HA-) coated implants tend to achieve good osteoinductivity and stable clinical results; however, the influence of the coating on the prevention of bone mineral density (BMD) loss around the implant is unclear. The purpose of this randomized controlled trial was to evaluate the effectiveness of HA-coated implants for preventing BMD loss and to determine the status of bone remodeling after total hip arthroplasty (THA), making comparisons with non-HA-coated implants.

Methods

A total of 52 patients who underwent primary THA were randomly allocated to HA and non-HA groups. BMD was measured by dual-energy X-ray absorptiometry (DEXA) at 1 week postoperation to form a baseline measurement, and then 24 weeks and 48 weeks after surgery. The relative change in BMD was evaluated for regions of interest (ROIs) based on the Gruen zone classifications. ¹⁸F-fluoride positron emission tomography (PET) was performed at 24 weeks postsurgery, and the maximum standardized uptake values (SUV_max) were evaluated in the proximal (HA-coated) and distal (non-HA-coated) areas in both groups.

Results

There were significant differences in BMD loss in ROIs 3 and 6 (p = 0.03), while no significant difference was observed in ROI 7 at either 24 or 48 weeks postsurgery. There was no significant correlation between PET uptake and BMD (24 or 48 weeks) in either group.

Conclusion

The influence of a HA coating in terms of BMD preservation is limited. No significant correlation was found between BMD and SUV_max measured by PET, either with or without the use of a HA coating.

Changes in periacetabular bone mineral density five years after resurfacing hip arthroplasty versus conventional total hip arthroplasty

INTRODUCTION:

We studied whether acetabular bone mineral density (BMD) is better preserved after resurfacing hip arthroplasty (RHA) versus small diameter metal-on-metal total hip arthroplasty (THA).

METHODS:

This randomised controlled trial included 82 patients. BMD was measured in 5 periprosthetic regions of interest (ROI) with dual-energy absorptiometry (DEXA) preoperatively, at 3 and 6 months, 1, 2, 3 and 5 years postoperative. 34 RHA and 26 THA had a complete 5 years follow-up. 1 RHA and 1 THA were revised due to pseudotumour formation, 2 THA were revised because of recurrent dislocations and 1 RHA for avascular necrosis.

RESULTS:

Overall an initial decrease in BMD was observed for both implants, stabilising after 2 years. 5 years after RHA a BMD change of +1% in upper cranial, -4% ( p < 0.01) in cranial, -8% ( p < 0.01) in craniomedial, -7% ( p < 0.01) in medial and +4% in caudal ROI compared to baseline values was seen. 5 years after THA a BMD change of -3% ( p = 0.01), -13% ( p < 0.01), -21% ( p < 0.01), -11% ( p < 0.01) and -2% for each respective ROI. The observed BMD decrease in different regions was structurally favouring the RHA-cup, with significantly higher levels in the cranial and craniomedial ROI.

CONCLUSION:

Acetabular BMD is better preserved behind a rigid press-fit convex cup in RHA compared to a titanium threaded cup in conventional THA in the cranial and craniomedial ROI. Despite of a theoretical higher stress-shielding behind the stiff acetabular component in RHA, compared to the more elastic threaded titanium THA-cup, bone depletion behind the RHA component does not seem to be of major concern.

REGISTRATION:

EudraCT (2006-005610-12).

Radiolucency around highly porous sockets and hydroxyapatite-coated porous sockets in total hip arthroplasty for hip dysplasia

Studies over the past decade have reported that the use of highly porous sockets in total hip arthroplasty (THA) results in osseointegration and long-term implant stability. However, some reports have raised concerns regarding radiographic evidence of poor osseointegration with features of fibrous tissue ingrowth. The purpose of this study was to compare clinical and radiographic assessments of highly porous sockets with those of hydroxyapatite (HA)-coated porous sockets in THA for hip dysplasia (DDH) at least 1 year after surgery. A total of 127 patients (136 hips) were recruited for the study. Of these, 94 patients (101 hips) received highly porous sockets with clustered screws, while 33 patients (35 hips) received HA-coated porous sockets with clustered screws. There was no difference in clinical outcomes between the two types of sockets. All HA-coated porous sockets were radiographically stable, without radiolucent lines. Fifteen hips had radiolucent lines in two or three DeLee and Charnley zones, accompanied by sclerotic lines along the circumferences of the highly porous sockets. A significant difference in the height of the preoperative osteophyte of the anterior acetabular wall was observed between 86 hips with one or no radiolucent lines and 15 hips with two or three radiolucent lines. In cases of DDH with atrophic bone remodeling pattern, highly porous sockets with multiple screws may be used, while HA-coated porous sockets with clustered screws result in better sealing of the bone–component interface.

Bone remodelling of the proximal femur after total hip arthroplasty with 2 different hip implant designs: 15 years follow-up of the thrust plate prosthesis and the Bi-Metric stem

INTRODUCTION

The thrust plate prosthesis (TPP) was introduced to preserve bone in patients undergoing total hip arthroplasty. We assessed the long-term results of hip arthroplasty in patients who received the TPP compared to a traditional intramedullary stem (Bi-Metric).

METHODS

In this prospective observational cohort study, we evaluated bone mineral density (BMD) using dual-energy X-ray absorptiometry (DXA), radiological imaging and clinical outcome using Harris Hip Score (HHS). Twenty patients received the TPP (group A) and 18 patients received the Bi-Metric stem (group B). Baseline was the 1st postoperative day, and subsequent follow-up was performed at 6 months, 1, 2, 8, 12 and 15 years after surgery. A four regions of interest (ROI) protocol was developed to assess BMD.

RESULTS

In ROI1, bone resorption was significantly higher for group A at 6 months with a mean difference of 10% (95% confidence interval [CI], 4-16; p = 0.003) and 8% (95% CI, 1-15; p = 0.03) at 8 years. Regarding ROI4, group A had a lesser decrease in general compared to group B. The radiological findings did not reveal any subsidence or detectable implant migration. HHS improved from 53 (23-69) to 93 (55-100) in group A and from 51 (24-72) to 94 (78-100) in group B.

CONCLUSION

The TPP was not found to be inferior to the Bi-Metric stem regarding bone preservation. The decrease in BMD in ROI4 was greater in group B. Clinical and radiological results also revealed that the TPP was not inferior to the Bi-Metric stem.

Periacetabular bone densitometry after total hip arthroplasty with highly porous titanium cups: a 2-year follow-up prospective study

INTRODUCTION

Trabecular Titanium is an advanced cellular solid structure, composed of regular multiplanar hexagonal interconnected cells that mimic the morphology of the trabecular bone. This biomaterial demonstrated improved mechanical properties and enhanced osteoinduction and osteoconduction in several in vitro and in vivo studies. The aim of this study was to assess Trabecular Titanium osseointegration by measuring periacetabular changes in bone mineral density (BMD) with dual-emission X-ray absorptiometry (DEXA).

METHODS

89 patients (91 hips) underwent primary total hip arthroplasty (THA) with acetabular Trabecular Titanium cups. Clinical (Harris Hip Score (HHS), SF-36) and radiographic assessment were performed preoperatively, and postoperatively at 7 days and at 3, 6, 12 and 24 months. DEXA analysis was performed only postoperatively, using the BMD values measured at 7 days as baselines.

RESULTS

After an initial decrease from baseline to 6 months, BMD increased and progressively stabilised in all 3 regions of interest (ROIs). Median (IQR) HHS and SF-36 increased from 48 (39-62) and 49 (37-62) preoperatively to 99 (96-100) and 86 (79-92) at 24 months, indicating a considerable improvement in terms of pain relief, functional recovery and quality of life. BMD patterns and radiographic evaluation showed evident signs of periacetabular bone remodelling and osseointegration; all cups were stable at the final follow-up without radiolucent lines, loosening or osteolysis. No revisions were performed.

CONCLUSIONS

After an initial reduction in periacetabular BMD, all 3 ROIs exhibited stabilisation or slight recovery. Although clinical outcomes and functional recovery proved satisfactory, longer follow-ups are necessary to assess this cup long-term survivorship.

Combined Bone Ingrowth and Remodeling Around Uncemented Acetabular Component: A Multiscale Mechanobiology-Based Finite Element Analysis

Bone ingrowth and remodeling are two different evolutionary processes which might occur simultaneously. Both these processes are influenced by local mechanical stimulus. However, a combined study on bone ingrowth and remodeling has rarely been performed. This study is aimed at understanding the relationship between bone ingrowth and adaptation and their combined influence on fixation of the acetabular component. Based on three-dimensional (3D) macroscale finite element (FE) model of implanted pelvis and microscale FE model of implant–bone interface, a multiscale framework has been developed. The numerical prediction of peri-acetabular bone adaptation was based on a strain-energy density-based formulation. Bone ingrowth in the microscale models was simulated using the mechanoregulatory algorithm. An increase in bone strains near the acetabular rim was observed in the implanted pelvis model, whereas the central part of the acetabulum was observed to be stress shielded. Consequently, progressive bone apposition near the acetabular rim and resorption near the central region were observed. Bone remodeling caused a gradual increase in the implant–bone relative displacements. Evolutionary bone ingrowth was observed around the entire acetabular component. Poor bone ingrowth of 3–5% was predicted around the centro-inferio and inferio-posterio-superio-peripheral regions owing to higher implant–bone relative displacements, whereas the anterio-inferior and centro-superior regions exhibited improved bone ingrowth of 35–55% due to moderate implant–bone relative displacement. For an uncemented acetabular CoCrMo component, bone ingrowth had hardly any effect on bone remodeling; however, bone remodeling had considerable influence on bone ingrowth.

Biphasic calcium phosphate ceramics for bone reconstruction: A review of biological response

Autologous bone graft is considered as the gold standard in bone reconstructive surgery. However, the quantity of bone available is limited and the harvesting procedure requires a second surgical site resulting in severe complications. Due to these limits, scientists and clinicians have considered alternatives to autologous bone graft. Calcium phosphates (CaPs) biomaterials including biphasic calcium phosphate (BCP) ceramics have proven efficacy in numerous clinical indications. Their specific physico-chemical properties (HA/TCP ratio, dual porosity and subsequent interconnected architecture) control (regulate/condition) the progressive resorption and the bone substitution process. By describing the most significant biological responses reported in the last 30years, we review the main events that made their clinical success. We also discuss about their exciting future applications as osteoconductive scaffold for delivering various bioactive molecules or bone cells in bone tissue engineering and regenerative medicine.

STATEMENT OF SIGNIFICANCE

Nowadays, BCPs are definitely considered as the gold standard of bone substitutes in bone reconstructive surgery. Among the numerous clinical studies in literature demonstrating the performance of BCP, Passuti et al. and Randsford et al. studies largely contributed to the emergence of the BCPs. It could be interesting to come back to the main events that made their success and could explain their large adhesion from scientists to clinicians. This paper aims to review the most significant biological responses reported in the last 30years, of these BCP-based materials. We also discuss about their exciting future applications as osteoconductive scaffold for delivering various bioactive molecules or bone cells in bone tissue engineering and regenerative medicine.

All dual mobility cups are not the same

PURPOSE

Although the natural history of dual mobility has been exclusively borne for 20 years by a single company (due to industrial ownership), the concept has undeniably been very widely popularised with nearly 40 cups on the French market which should be regarded as a weight bearing surface, both broadly and in their own right. However, within the same original idea, these implants are not all identical (design, material, fixation ect.).The aim of this work is to propose a classification of different dual mobility cups by distinguishing between thegeneral characteristics of a conventional cup and those particular to this type of implant.

METHODS

By comparison with a standard metal-back cup, dual mobility is based on at least one additional interface corresponding to the mobility of the polyethylene insert in the concavity of the acetabular cup called the outersurface. Design, constitutive material, fixation of the cup and characteristics of the retentive insert are analysed through the published results.

RESULTS

The complications associated, in particular, the intraprosthetic dislocation and to a lesser extent fixation failures undoubtedly condemned the dissemination of the dual mobility concept, as witnessed by the fact that despite the precedence of this 40-year old concept, the overriding majority of publications (more than 95%) have only appeared in the last ten years.

CONCLUSION

The latest generation of dual mobility cups combines: 1) a cast chrome-cobalt alloy cup covered with a bilayer coating of porous titanium and hydroxyapatite for long-term press-fit fixation to 2) an insert designed to eliminate all of the risks of intraprosthetic dislocation, whilst keeping all of the elasticity properties of the polyethylene, which has demonstrated its medium and long term effectiveness on preventing instability by overcoming other complications.

Radiographic evaluation of early periprosthetic acetabular bone contrast and prosthetic head acetabular coverage after uncemented and cemented total hip prosthesis in dogs

BACKGROUND

Coxofemoral osteoarthritis is a chronic, disabling condition affecting people and dogs, with THA providing an excellent return to function in severely affected joints. The principal role of THA is to restore an adequate range of motion to the hip joint while transferring load from the acetabulum in order to improve the survival of the implant and enhance the limb function in the short and long terms. The objectives of the study reported here were, therefore, to radiographically evaluate periprosthetic acetabular bone GV and to assess prosthetic head acetabular coverage after 4 months of uncemented and cemented THA in dogs. Means periprosthetic acetabular GV for each and combined 3 regions of interest (zones 1, 2 and 3) were calculated immediately and 4 months after THA. Prosthetic head Norberg (PHN) angle was also measured to assess the degree of prosthetic head acetabular coverage after 4 months of surgery.

RESULTS

Zones 2 and 3 showed a significant increase in the mean bone GV after 4 months of uncemented THA. No differences in zones 1-3 after 4 months of cemented THA. Combined zones showed a significant increase in overall mean bone GV 4 months after uncemented THA; whereas, no changes were identified after 4 months of cemented THA. The PHN angles did not change after 4 months of uncemented and cemented THA and did not differ significantly between the 2 designs of hip arthroplasty.

CONCLUSIONS

Regional periprosthetic acetabular bone GV varies with the design of THA. None of the designs showed periprosthetic acetabular bone lucency. No differences identified in the degree of prosthetic head acetabular coverage in both designs, indicating proper implant stability after 4 months of surgery. Further longer-term investigation on larger population is however still warranted.

The effects of musculoskeletal loading regimes on numerical evaluations of acetabular component

The importance of clinical studies notwithstanding, the failure assessment of implant–bone structure has alternatively been carried out using finite element analysis. However, the accuracy of the finite element predicted results is dependent on the applied loading and boundary conditions. Nevertheless, most finite element–based evaluations on acetabular component used a few selective load cases instead of the eight load cases representing the entire gait cycle. These in silico evaluations often suffer from limitations regarding the use of simplified musculoskeletal loading regimes. This study attempts to analyse the influence of three different loading regimes representing a gait cycle, on numerical evaluations of acetabular component. Patient-specific computer tomography scan-based models of intact and resurfaced pelvises were used. One such loading regime consisted of the second load case that corresponded to peak hip joint reaction force. Whereas the other loading regime consisted of the second and fifth load cases, which corresponded to peak hip joint reaction force and peak muscle forces, respectively. The third loading regime included all the eight load cases. Considerable deviations in peri-acetabular strains, standard error ranging between 115 and 400 µε, were observed for different loading regimes. The predicted bone strains were lower when selective loading regimes were used. Despite minor quantitative variations in bone density changes (less than 0.15 g cm−3), the final bone density pattern after bone remodelling was found to be similar for all the loading regimes. Underestimations in implant–bone micromotions (40–50 µm) were observed for selective loading regimes after bone remodelling. However, at immediate post-operative condition, such underestimations were found to be less (less than 5 µm). The predicted results highlight the importance of inclusion of eight load cases representing the gait cycle for in silico evaluations of resurfaced pelvis.

Total hip replacement and surface replacement for the treatment of pain and disability resulting from end-stage arthritis of the hip (review of technology appraisal guidance 2 and 44): systematic review and economic evaluation

BACKGROUND

Total hip replacement (THR) involves the replacement of a damaged hip joint with an artificial hip prosthesis. Resurfacing arthroplasty (RS) involves replacement of the joint surface of the femoral head with a metal surface covering.

OBJECTIVES

To undertake clinical effectiveness and cost-effectiveness analysis of different types of THR and RS for the treatment of pain and disability in people with end-stage arthritis of the hip, in particular to compare the clinical effectiveness and cost-effectiveness of (1) different types of primary THR and RS for people in whom both procedures are suitable and (2) different types of primary THR for people who are not suitable for hip RS.

DATA SOURCES

Electronic databases including MEDLINE, EMBASE, The Cochrane Library, Current Controlled Trials and UK Clinical Research Network (UKCRN) Portfolio Database were searched in December 2012, with searches limited to publications from 2008 and sample sizes of ≥ 100 participants. Reference lists and websites of manufacturers and professional organisations were also screened.

REVIEW METHODS

Systematic reviews of the literature were undertaken to appraise the clinical effectiveness and cost-effectiveness of different types of THR and RS for people with end-stage arthritis of the hip. Included randomised controlled trials (RCTs) and systematic reviews were data extracted and risk of bias and methodological quality were independently assessed by two reviewers using the Cochrane Collaboration risk of bias tool and the Assessment of Multiple Systematic Reviews (AMSTAR) tool. A Markov multistate model was developed for the economic evaluation of the technologies. Sensitivity analyses stratified by sex and controlled for age were carried out to assess the robustness of the results.

RESULTS

A total of 2469 records were screened of which 37 were included, representing 16 RCTs and eight systematic reviews. The mean post-THR Harris Hip Score measured at different follow-up times (from 6 months to 10 years) did not differ between THR groups, including between cross-linked polyethylene and traditional polyethylene cup liners (pooled mean difference 2.29, 95% confidence interval -0.88 to 5.45). Five systematic reviews reported evidence on different types of THR (cemented vs. cementless cup fixation and implant articulation materials) but these reviews were inconclusive. Eleven cost-effectiveness studies were included; four provided relevant cost and utility data for the model. Thirty registry studies were included, with no studies reporting better implant survival for RS than for all types of THR. For all analyses, mean costs for RS were higher than those for THR and mean quality-adjusted life-years (QALYs) were lower. The incremental cost-effectiveness ratio for RS was dominated by THR, that is, THR was cheaper and more effective than RS (for a lifetime horizon in the base-case analysis, the incremental cost of RS was £11,284 and the incremental QALYs were -0.0879). For all age and sex groups RS remained clearly dominated by THR. Cost-effectiveness acceptability curves showed that, for all patients, THR was almost 100% cost-effective at any willingness-to-pay level. There were age and sex differences in the populations with different types of THR and variations in revision rates (from 1.6% to 3.5% at 9 years). For the base-case analysis, for all age and sex groups and a lifetime horizon, mean costs for category E (cemented components with a polyethylene-on-ceramic articulation) were slightly lower and mean QALYs for category E were slightly higher than those for all other THR categories in both deterministic and probabilistic analyses. Hence, category E dominated the other four categories. Sensitivity analysis using an age- and sex-adjusted log-normal model demonstrated that, over a lifetime horizon and at a willingness-to-pay threshold of £20,000 per QALY, categories A and E were equally likely (50%) to be cost-effective.

LIMITATIONS

A large proportion of the included studies were inconclusive because of poor reporting, missing data, inconsistent results and/or great uncertainty in the treatment effect estimates. This warrants cautious interpretation of the findings. The evidence on complications was scarce, which may be because of the absence or rarity of these events or because of under-reporting. The poor reporting meant that it was not possible to explore contextual factors that might have influenced study results and also reduced the applicability of the findings to routine clinical practice in the UK. The scope of the review was limited to evidence published in English in 2008 or later, which could be interpreted as a weakness; however, systematic reviews would provide summary evidence for studies published before 2008.

CONCLUSIONS

Compared with THR, revision rates for RS were higher, mean costs for RS were higher and mean QALYs gained were lower; RS was dominated by THR. Similar results were obtained in the deterministic and probabilistic analyses and for all age and sex groups THR was almost 100% cost-effective at any willingness-to-pay level. Revision rates for all types of THR were low. Category A THR (cemented components with a polyethylene-on-metal articulation) was more cost-effective for older age groups. However, across all age-sex groups combined, the mean cost for category E THR (cemented components with a polyethylene-on-ceramic articulation) was slightly lower and the mean QALYs gained were slightly higher. Category E therefore dominated the other four categories. Certain types of THR appeared to confer some benefit, including larger femoral head sizes, use of a cemented cup, use of a cross-linked polyethylene cup liner and a ceramic-on-ceramic as opposed to a metal-on-polyethylene articulation. Further RCTs with long-term follow-up are needed.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003924.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Use of internal references for assessing CT density measurements of the pelvis as replacement for use of an external phantom

PURPOSE

The purpose of this research is to study the use of an internal reference standard for fat- and muscle as a replacement for an external reference standard with a phantom. By using a phantomless internal reference standard, Hounsfield unit (HU) measurements of various tissues can potentially be assessed in patients with a CT scan of the pelvis without an added phantom at time of CT acquisition. This paves the way for development of a tool for quantification of the change in tissue density in one patient over time and between patients. This could make every CT scan made without contrast available for research purposes.

MATERIALS AND METHODS

Fifty patients with unilateral metal-on-metal total hip replacements, scanned together with a calibration reference phantom used in bone mineral density measurements, were included in this study. On computed tomography scans of the pelvis without the use of intravenous iodine contrast, reference values for fat and muscle were measured in the phantom as well as within the patient's body. The conformity between the references was examined with the intra-class correlation coefficient.

RESULTS

The mean HU (± SD) of reference values for fat for the internal- and phantom references were -91.5 (±7.0) and -90.9 (±7.8), respectively. For muscle, the mean HU (± SD) for the internal- and phantom references were 59.2 (±6.2) and 60.0 (±7.2), respectively. The intra-class correlation coefficients for fat and muscle were 0.90 and 0.84 respectively and show excellent agreement between the phantom and internal references.

CONCLUSION

Internal references can be used with similar accuracy as references from an external phantom. There is no need to use an external phantom to asses CT density measurements of body tissue.

Acetabular bone density and metal ions after metal-on-metal versus metal-on-polyethylene total hip arthroplasty; short-term results

Information on periprosthetic acetabular bone density is lacking for metal-on-metal total hip arthroplasties. These bearings use cobalt-chromium instead of titanium acetabular components, which could lead to stress shielding and hence periprosthetic bone loss. Cobalt and chromium ions have detrimental effects on bone. It is unknown whether serum metal ion levels affect bone density clinically. We compared cementless large femoral head (mean 48 mm) metal-on-metal total hip arthroplasties (M2a-Magnum, Biomet) to cementless 28 mm metal-on-polyethylene total hip arthroplasties (Mallory-Head, Biomet) in a randomised clinical trial. We evaluated periprosthetic acetabular bone density and serum metal ion levels at 1 year postoperatively. Acetabular bone density was analyzed with dual energy x-ray absorptiometry in four horizontal regions of interest in 70 patients. After one year, acetabular bone density decreased (-3.5% to -7.8%) in three of four regions of interest in metal-on-polyethylene patients, but was retained in metal-on-metal patients. Bone density preservation was most pronounced superior to the metal-on-metal cup (+1% versus -3.7%). Serum cobalt, chromium and titanium ion levels were not related to bone density, nor to acetabular inclination or femoral head size. Oxford and Harris hip scores were similar in both groups. Contrary to our hypothesis, acetabular bone density was retained with metal-on-metal total hip arthroplasty, compared to metal-on-polyethylene arthroplasty. Bone preservation was most pronounced in the area superior to the cup. This could be a benefit during future revision surgery.

Porous titanium construct cup compared to porous coated titanium cup in total hip arthroplasty. A randomised controlled trial

PURPOSE

The purpose of this study was to determine if a new titanium cup with increased porosity resulted in different periacetabular bone loss and migration compared to a porous coated cup.

METHODS

Fifty-one patients with primary hip osteoarthritis were randomized to either a cup with porous titanium construct backside (porous titanium group, n = 25) or a conventional porous coated titanium cup (control group, n = 26). The primary outcome variable was change in periacetabular bone mineral density two years after surgery measured with dual energy X-ray absorptiometry (DXA). Secondary outcomes were implant fixation measured with radiostereometry (RSA) and clinical outcome scores.

RESULTS

The pattern of bone remodelling was similar in the two groups with almost complete restoration to baseline values. BMD diminished in the two proximal zones and increased in the two distal zones. After minimal migration up to six months all implants in both groups became stable. We found no difference between the two groups in clinical outcome scores.

CONCLUSIONS

In this prospective, randomized, controlled trial on a new porous titanium cup we found, compared to the control group, no clinically relevant differences regarding periacetabular bone preservation, implant fixation or clinical outcome up to two years postoperatively.

No superior performance of hydroxyapatite-coated acetabular cups over porous-coated cups

BACKGROUND AND PURPOSE

Hydroxyapatite (HA) coating is believed to improve bone-implant ingrowth and long-term survival of prostheses. Recent studies, however, have challenged this view. Furthermore, HA particles may produce third-body wear and initiate aseptic loosening of implants. We report the performance of HA- and porous-coated acetabular cups in a prospective randomized trial.

METHODS

This was an 8-year follow-up study of our previously published prospective randomized study to compare clinical outcomes, survival, periprosthetic bone mineral density, migration, and wear rates of HA- and porous-coated acetabular cups. Dual X-ray absorptiometry (DXA) and Ein Bild Roentgen Analyse (EBRA) measurements were used. 100 patients who underwent unilateral cementless total hip arthroplasty were randomized to either porous-coated cups or HA-coated cups. Patients were examined preoperatively and at 3, 6, and 9 months, and also 1, 3, and 8 years after surgery. 81 patients were available for 8-year follow-up, 40 with porous-coated cups and 41 with HA-coated cups.

RESULTS

Age, sex, bone mineral density, and clinical results (Harris hip score) were similar in the 2 groups. The survival, wear, and migration patterns of the cups were also similar in both groups. The results of periprosthetic bone mineral density scans in region of interest 2 was in favor of the porous-coated cups, but there were no differences between the 2 groups in all the remaining regions of interest.

INTERPRETATION

HA coating had no statistically significant effect on clinical results, survival, wear, or migration at the 8-year follow-up.

Periacetabular bone mineral density changes after resurfacing hip arthroplasty versus conventional total hip arthroplasty. A randomized controlled DEXA study

A randomized controlled trial was performed to evaluate acetabular bone mineral density (BMD) changes after hip resurfacing (RHA) versus an established conventional total hip arthroplasty (THA). A total of 71 patients were allocated randomly to receive either an RHA press-fit cobalt-chromium cup (n=38) or a THA with a threaded titanium cup and polyethylene-metal-inlay insert (n=33). The BMD in five separate periacetabular regions of interest (ROI) was prospectively quantified preoperative until 24 months. We conclude that, in contrast to our hypothesis, periacetabular BMD was better preserved after RHA than after placement of a conventional THA. Long term follow-up studies are necessary to see whether this benefit in bone preservation sustains over longer time periods and whether it is turned into clinical benefits at future revision surgery.

Bone remodelling around uncemented metallic and ceramic acetabular components

Stress shielding–induced bone resorption around cementless acetabular components has been indicated as a potential failure mechanism that may threaten long-term fixation. Using a bone remodelling algorithm in combination with three-dimensional finite element models of intact and implanted pelvises and musculoskeletal loading during normal walking, the objectives of the study were to investigate the deviations in load transfer due to implantation and bone adaptation around cementless metallic and ceramic acetabular components. Variations in implant–bone interfacial condition affected strain shielding and bone remodelling; strain shielding was higher for the bonded condition as compared to the debonded condition. For bonded interfacial condition, severe bone resorption, 20%–50% bone density reduction, was observed within the acetabulum. Considering debonded implant–bone interface, bone density increase of 50%–60% was observed around the supero-posterior part of acetabulum, whereas bone density reductions were low (2%–15%) in other locations. The implant–bone interface appeared less likely to fail, post-operatively and after bone remodelling. Moreover, the implant–bone micromotion was found to be low, less than 100 µm. Strain shielding and bone remodelling were almost similar for the metallic and ceramic components. Based on the results of this study, the ceramic acetabular component appeared to be a viable alternative to metal.

Experimental validation of numerically predicted strain and micromotion in intact and implanted composite hemi-pelvises

The failure mechanisms of acetabular prostheses may be investigated by understanding the changes in load transfer due to implantation and using the analysis of the implant–bone micromotion. Computational finite element (FE) models allow detailed mechanical analysis of the implant–bone structure, but their validity must be assessed as a first step, before they can be employed in preclinical investigations. In this study, FE models of composite hemi-pelvises, intact and implanted with an acetabular cup, were experimentally validated. Strains and implant–bone micromotions in the hemi-pelvises were compared with those predicted by the equivalent FE models. Regression analysis indicated close agreement between the measured and FE strains, with a high correlation coefficient (0.95–0.98), a low standard error (SE) (36–53 µε) and a low error in regression slope (7%–11%). Measured micromotions along three orthogonal directions were small, less than 30 µm, whereas the FE-predicted values were found to be less than 85 µm. Although the trends were similar, the deviations are due to artefacts in experimental measurement and additional imperfections in recreating experimental loading and boundary conditions in the FE model. This supports the FE model as a valid predictor of the measured strain in the composite pelvis models, confirming its suitability for further computational investigations on acetabular prostheses.

Analysis of bone formation on porous and calcium phosphate-coated acetabular cups: a randomised clinical [18F]fluoride PET study

We present a study using Fluoride-Positron Emission Tomography (F-PET/CT) to analyse new bone formation in periacetabular bone adjacent to press fit cups following THA. In 16 THA (8 patients) with bilateral hip osteoarthritis simultaneous bilateral total hip arthroplasty (THA) was performed, employing electrochemically applied calcium phosphate coated (HA) cups or porous-coated (PC) cups allocated at random to compare the two sides. A reference group of 13 individuals with a normal healthy hip was used to determine 'normal' bone metabolism. [18F]fluoride -PET/CT was used to analyze bone formation adjacent to the cups 1 week, 4 months and 12 months after surgery. Clinical and radiographic evaluation was performed preoperatively, postoperatively and at 2 years. Bone forming activity had a mean of 5.71, 4.69 and 3.47 SUV around the HA- and 5.04, 4.80 and 3.50 SUV around the PC-cups at 1 week, 4 months and 12 months respectively. Normal bone metabolism was 3.68 SUV. After 1 year activity had declined to normal levels for both groups. The clinical results were good in all cases. HA coating resulted in higher uptake indicating higher bone forming activity after 1 week. F-PET/CT is a valuable tool to analyse bone formation and secondary stabilisation of an acetabular cup.

Experimental Validation of Finite Element Models of Intact and Implanted Composite Hemipelvises Using Digital Image Correlation

A detailed understanding of the changes in load transfer due to implantation is necessary to identify potential failure mechanisms of orthopedic implants. Computational finite element (FE) models provide full field data on intact and implanted bone structures, but their validity must be assessed for clinical relevance. The aim of this study was to test the validity of FE predicted strain distributions for the intact and implanted pelvis using the digital image correlation (DIC) strain measurement technique. FE models of an in vitro hemipelvis test setup were produced, both intact and implanted with an acetabular cup. Strain predictions were compared to DIC and strain rosette measurements. Regression analysis indicated a strong linear relationship between the measured and predicted strains, with a high correlation coefficient (R = 0.956 intact, 0.938 implanted) and a low standard error of the estimate (SE = 69.53 με, 75.09 με). Moreover, close agreement between the strain rosette and DIC measurements improved confidence in the validity of the DIC technique. The FE model therefore was supported as a valid predictor of the measured strain distribution in the intact and implanted composite pelvis models, confirming its suitability for further computational investigations.

Changes in bone mineral density of the acetabulum, femoral neck and femoral shaft, after hip resurfacing and total hip replacement

It is accepted that resurfacing hip replacement preserves the bone mineral density (BMD) of the femur better than total hip replacement (THR). However, no studies have investigated any possible difference on the acetabular side.

Between April 2007 and March 2009, 39 patients were randomised into two groups to receive either a resurfacing or a THR and were followed for two years. One patient’s resurfacing subsequently failed, leaving 19 patients in each group.

Resurfaced replacements maintained proximal femoral BMD and, compared with THR, had an increased bone mineral density in Gruen zones 2, 3, 6, and particularly zone 7, with a gain of 7.5% (95% confidence interval (CI) 2.6 to 12.5) compared with a loss of 14.6% (95% CI 7.6 to 21.6). Resurfacing replacements maintained the BMD of the medial femoral neck and increased that in the lateral zones between 12.8% (95% CI 4.3 to 21.4) and 25.9% (95% CI 7.1 to 44.6).

On the acetabular side, BMD was similar in every zone at each point in time. The mean BMD of all acetabular regions in the resurfaced group was reduced to 96.2% (95% CI 93.7 to 98.6) and for the total hip replacement group to 97.6% (95% CI 93.7 to 101.5) (p = 0.4863). A mean total loss of 3.7% (95% CI 1.0 to 6.5) and 4.9% (95% CI 0.8 to 9.0) of BMD was found above the acetabular component in W1 and 10.2% (95% CI 0.9 to 19.4) and 9.1% (95% CI 3.8 to 14.4) medial to the implant in W2 for resurfaced replacements and THRs respectively. Resurfacing resulted in a mean loss of BMD of 6.7% (95% CI 0.7 to 12.7) in W3 but the BMD inferior to the acetabular component was maintained in both groups.

These results suggest that the ability of a resurfacing hip replacement to preserve BMD only applies to the femoral side.

Laser surface modification of titanium substrate for pulsed laser deposition of highly adherent hydroxyapatite

Biomedical implant devices made out of titanium and its alloys are benefited by a modified surface or a bioactive coating to enhance bone bonding ability and to function effectively in vivo for the intended period of time. In this respect hydroxyapatite coating developed through pulsed laser deposition is a promising approach. Since the success of the bioactive ceramic coated implant depends mainly on the substrate-coating strength; an attempt has been made to produce micro patterned surface structure on titanium substrate for adherent hydroxyapatite coating. A pulsed Nd-YAG laser beam (355 nm) with 10 Hz repetition rate was used for surface treatment of titanium as well as hydroxyapatite deposition. The unfocussed laser beam was used to modify the substrate surface with 500-18,000 laser pulses while keeping the polished substrate in water. Hydroxyapatite deposition was done in a vacuum deposition chamber at 400 °C with the focused laser beam under 1 × 10⁻³ mbar oxygen pressure. Deposits were analyzed to understand the physico-chemical, morphological and mechanical characteristics. The obtained substrate and coating surface morphology indicates that laser treatment method can provide controlled micro-topography. Scratch test analysis and microindentation hardness values of coating on laser treated substrate indicate higher mechanical adhesion with respect to coatings on untreated substrates.

Early periprosthetic bone remodelling around cemented and uncemented custom-made femoral components and their uncemented acetabular cups

INTRODUCTION

Periprosthetic bone remodelling after total hip replacement may contribute to aseptic loosening of the prosthesis. The selection between cemented and uncemented fixation of the stem is mainly determined by patient's age, general constitution and CT scan-estimated bone quality; intra-operative observation may ultimately influence the choice of the fixation method. The influence of cemented versus uncemented stem fixation on periprosthetic bone remodelling around the uncemented cup has, to our knowledge, never been studied until now.

METHODS

A total of 75 patients received intra-operatively manufactured stem prostheses and a standard hydroxy apatite-coated pinnacle cup. The pre-operative CT scans provides guidance for the bone quality and hence the type of stem fixation: cemented or uncemented. The influence of either type of stem fixation on periprosthetic bone remodelling around the cup and the stem was measured by bone mineral density at 6 weeks, and 3, 6 and 12 months after surgery.

RESULTS

Early changes in bone mineral density were noted. The type of stem fixation had an influence on the bone remodelling of the femur and also of the pelvis. The caudal part of the acetabulum was subject to a greater loss in BMD at 12 months in the group with cemented stem fixation. Changes at 12 months correlated with the changes measured at any time point.

CONCLUSIONS

The selection of the stem implant and its type of fixation in the femoral cavity (cemented or uncemented fixation) seems to have an impact on the bone mineral density of the acetabulum. Long-term clinical follow-up is required to draw conclusions regarding the influence on prosthesis survival.

Bone remodeling around porous metal cementless acetabular components

Bone remodeling around cementless acetabular components after total hip arthroplasty has not been well characterized. A randomized, prospective study of total hip arthroplasty was performed comparing 2 cementless acetabular implants: a solid titanium and a more elastic porous tantalum design. Seventeen hips (9 porous tantalum, 8 titanium) underwent quantitative computed tomography at mean of 7.7 years, and adjacent bone mineral density (BMD) was calculated. The absolute and relative decrease in BMD from preoperative level was less in zones 9 to 15 mm adjacent to the porous tantalum compared to the titanium component (P <or= .02) and predominated posterosuperiorly. The relative BMD increased in all regions adjacent to the porous tantalum component from 5% to 40% over the control. This data demonstrates stress-shielding likely occurs less around a highly porous metal implant of material with an elastic modulus similar to bone.

Increased risk of revision of acetabular cups coated with hydroxyapatite

BACKGROUND

Hydroxyapatite (HA) is the main inorganic component of bone, and HA coating is widely used on acetabular cups in hip arthroplasty. It has been suggested that this surface finish improves cup survival.

METHODS

All patients registered in the Swedish Hip Arthroplasty Register between 1992 and 2007 with an uncemented acetabular implant that was available either with or without HA coating were identified. 8,043 total hip arthroplasties (THAs) with the most common cup types (Harris-Galante, Romanus, and Trilogy) were investigated. A Cox regression model including type of coating, age, sex, primary diagnosis, cup type, and type of stem fixation was used to calculate adjusted risk ratios (RRs) for the risk of revision.

RESULTS

HA coating was a risk factor for cup revision due to aseptic loosening (adjusted RR 1.7; 95% CI: 1.3-2). Age at primary arthroplasty of < 50 years, a diagnosis of pediatric hip disease, the use of a cemented stem, and the Romanus and Harris-Galante cup types were also associated with statistically significantly increased risk of cup revision due to aseptic loosening.

INTERPRETATION

Our findings question the routine use of HA-coated cups in primary total hip arthroplasty. With some designs, this practice may even increase the risk of loosening-resulting in revision surgery.

Large head metal-on-metal cementless total hip arthroplasty versus 28 mm metal-on-polyethylene cementless total hip arthroplasty: design of a randomized controlled trial

Background

Osteoarthritis of the hip is successfully treated by total hip arthroplasty with metal-on-polyethylene articulation. Polyethylene wear debris can however lead to osteolysis, aseptic loosening and failure of the implant. Large head metal-on-metal total hip arthroplasty may overcome polyethylene wear induced prosthetic failure, but can increase systemic cobalt and chromium ion concentrations. The objective of this study is to compare two cementless total hip arthroplasties: a conventional 28 mm metal-on-polyethylene articulation and a large head metal-on-metal articulation. We hypothesize that the latter arthroplasties show less bone density loss and higher serum metal ion concentrations. We expect equal functional scores, greater range of motion, fewer dislocations, fewer periprosthetic radiolucencies and increased prosthetic survival with the metal-on-metal articulation.

Methods

A randomized controlled trial will be conducted. Patients to be included suffer from non-inflammatory degenerative joint disease of the hip, are aged between 18 and 80 and are admitted for primary cementless unilateral total hip arthroplasty. Patients in the metal-on-metal group will receive a cementless titanium alloy acetabular component with a cobalt-chromium liner and a cobalt-chromium femoral head varying from 38 to 60 mm. Patients in the metal-on-polyethylene group will receive a cementless titanium alloy acetabular component with a polyethylene liner and a 28 mm cobalt-chromium femoral head. We will assess acetabular bone mineral density by dual energy x-ray absorptiometry (DEXA), serum ion concentrations of cobalt, chromium and titanium, self reported functional status (Oxford hip score), physician reported functional status and range of motion (Harris hip score), number of dislocations and prosthetic survival. Measurements will take place preoperatively, perioperatively, and postoperatively (6 weeks, 1 year, 5 years and 10 years).

Discussion

Superior results of large head metal-on-metal total hip arthroplasty over conventional hip arthroplasty have been put forward by experts, case series and the industry, but to our knowledge there is no randomized controlled evidence.

Conclusion

This randomized controlled study has been designed to test whether large head metal-on-metal cementless total hip arthroplasty leads to less periprosthetic bone density loss and higher serum metal ion concentrations compared to 28 mm metal-on-polyethylene cementless total hip arthroplasty.

Trial registration

Netherlands Trial Registry NTR1399