Cementless Total Hip Arthroplasty in Crowe III and IV Dysplasia: High Hip Center and Modular Necks

Clinical outcomes following direct anterior approach during total hip arthroplasty without hip extension: a retrospective comparative study

BACKGROUND

Traditional total hip arthroplasty (THA) using the direct anterior approach (DAA) requires a hip extension. This study aimed to compare the clinical outcomes of patients undergoing THA with DAA using either the no hip extension (NHE) or the traditional hip extension (THE) strategy.

METHODS

A retrospective analysis of demographics, clinical and radiological outcomes, and occurrence of complications was performed using data from 123 patients treated between January 2020 and November 2021. The patients were categorised into two groups: NHE (84 patients) and THE (39 patients).

RESULTS

The NHE group exhibited shorter operative time and had more male participants with higher ages. Comparable outcomes were observed in the visual analogue scale, Harris Hip, and Oxford Hip scores at the final follow-up. Furthermore, complications were observed in the NHE and THE groups, including two and one greater trochanteric fractures and three and one transfusions, respectively.

CONCLUSIONS

Compared to the THE, employing the NHE strategy during THA with DAA in elderly and young female patients resulted in comparable clinical outcomes with several advantages, such as favourable surgical time. The NHE method also exhibited good safety and effectiveness. Therefore, the NHE strategy may be a favourable option for elderly and young female patients.

Mid-term results of titanium-titanium modular neck femoral stem in primary total hip arthroplasty

BACKGROUND

Modular neck femoral stems are advantageous because they can accurately restore the ideal hip geometry using various options in terms of offset, length, and version. However, there are concerns regarding junctional problems. Despite several reports on such issues, there is a lack of study on mid- to long-term results of these stems. The current study evaluated the mid-term results of patients who underwent primary total hip arthroplasty using a titanium-titanium (Ti-Ti) modular neck femoral stem.

METHODS

In total, data on 47 hips (42 patients) that could be followed-up for ≥ 5 years after primary total hip arthroplasty using the Ti-Ti modular neck femoral stem from 2011 to 2015 were reviewed. There were 22 male and 20 female patients, and their mean age was 56.3 (range: 31-76) years. The mean follow-up period was 8 (range: 5-12) years. Functional and radiological outcomes, complications, and reoperations were investigated. In addition, we conducted a comparative analysis of the outcomes between those who underwent surgery using the Ti-Ti modular neck femoral stem and 41 hips (35 patients, 19 males and 16 females) that underwent primary total hip arthroplasty using nonmodular femoral stems as a control.

RESULTS

In all Ti-Ti cases, the mean Harris Hip Scores were 50.6 (range: 6-59) preoperatively and 92.7 (range: 78-99) at the last follow-up (P < 0.001). Regarding the neck component's modularity, straight neck components were used in all Ti-Ti cases, and an anteverted or a retroverted neck was not used in any case. Stem revision was performed in one hip due to aseptic loosening. One hip underwent open reduction and internal fixation due to periprosthetic fracture without stem loosening. There were no cases of osteolysis and periprosthetic joint infection and clinically detectable junctional problems. The stem survival rate, with any stem revision as the endpoint, at 12 years was 96.6%. No significant difference was observed in the functional and radiological outcomes beween the Ti-Ti and nonmodular groups.

CONCLUSIONS

The Ti-Ti modular neck femoral stem had comparable results with broadly used nonmodular femoral stems; hence, it can be a reliable option in primary total hip arthroplasty. However, in terms of the modularity itself of the modular neck femoral stem, whether the modular neck femoral stem is useful in uncomplicated primary total hip arthroplasty is unclear.

A novel intraoperative acetabular reaming center locating method in total hip arthroplasty for Crowe type IV developmental dysplasia of the hip: a retrospective cohort study

PURPOSE

Although the principles of hip reconstruction are consistent, due to lack of reliable anatomical landmarks, how to decide the acetabular cup reaming centre intraoperatively in Crowe IV patients with developmental dysplasia of the hip (DDH) remains unclear. This study aims to address this question.

METHODS

Fifty-eight Crowe IV patients were enrolled from 2017 to 2019. By examining our previous clinical data, we analyzed the anatomical morphology of Crowe IV acetabulum and proposed a method of locating intraoperative reaming centering for implantation of a standard-sized acetabular cup, which is the upper two thirds of the posterior border of the true acetabulum. All patients included in this study were reamed according to this method. The average postoperative follow-up was 4.1 years (3-5 years). The position of the centre of rotation (COR), cup coverage (CC), and optimal range of joint motion (ROM) were examined by 3D computer simulation measurement. Postoperative complications and hip Harris score were collected and analyzed.

RESULTS

The morphology of the type IV DDH true acetabulum was mostly triangular. The intraoperative reaming centre were centered on the upper two thirds of the posterior border of the true acetabulum. The postoperative 3D CC was 80.20% ± 7.63% (64.68-90.24%, 44-48-mm cup size). The patients' mean Harris score improved from 39.7 ± 20.4 preoperatively to 91.5 ± 8.12 at the last follow-up.

CONCLUSION

Our study demonstrated that satisfactory CC and clinical results could be achieved by implanting a standard-sized cup with the reaming centre on the upper two thirds of the posterior border of the true acetabulum.

Direct Anterior Approach in Total Hip Arthroplasty for Severe Crowe IV Dysplasia: Retrospective Clinical and Radiological Study

Background and Objectives: total hip arthroplasty (THA) for Crowe IV hip dysplasia poses challenges due to severe leg shortening, muscle retraction and bone stock issues, leading to an increased neurological complication, and revision rate. The direct anterior approach (DAA) is used for minimally invasive THA but its role in Crowe IV dysplasia is unclear. This retrospective study examines if DAA effectively restores hip biomechanics in Crowe IV dysplasia patients with <4 cm leg length discrepancy, managing soft tissue and yielding functional improvement, limb length correction, and limited complications. Materials and Methods: 19 patients with unilateral Crowe IV hip osteoarthritis and <4 cm leg length discrepancy undergoing DAA THA were reviewed. Surgery involved gradual soft tissue release, precise acetabular cup positioning, and stem placement without femoral osteotomy. Results: results were evaluated clinically and radiographically, with complications recorded. Follow-up revealed significant Harris Hip Score and limb length discrepancy improvements. Abductor muscle insufficiency was present in 21%. The acetabular component was accurately placed, centralizing the prosthetic joint's rotation. Complications occurred in 16% of cases, including fractures, nerve issues, and infection. DAA in THA showcased positive outcomes for hip function, limb length, and biomechanics in Crowe IV dysplasia. Conclusions: the technique enabled accurate cup positioning and rotation center adjustment. Complications were managed well without implant revisions. DAA is a viable option for Crowe IV dysplasia, restoring hip function, biomechanics, and reducing limb length discrepancy. Larger, longer studies are needed for validation.

Comparative Study of Highly Cross-Linked Polyethylene Liner Wear by Hip Center Location Using Elevated Hip Center Technique in Crowe I to III Hip Dysplasia: Outcomes for a Minimum of Eighteen Years of Follow-Up

BACKGROUND

The literature has reported that supero-lateralization of the femoral head increases the rates of aseptic loosening and prosthesis revision. However, there are few reports on the influence of different hip center positions on liner wear with more than a 15-year follow-up period.

METHODS

From April 2000 to August 2003, 91 patients underwent 108 total hip arthroplasties using a highly cross-linked polyethylene liner combined with zirconia femoral head and cup components. Pelvic radiographs were used to assess the vertical and horizontal distances to the center of the hip and the amount of liner wear. Mean patient age at the time of surgery was 54 years (range, 33 to 73), and mean follow-up duration was 19 years (range, 18 to 21).

RESULTS

Average liner wear was 0.221 mm, with average annual wear of 0.012 mm/year. Mean vertical and horizontal distances for the hip center were 24.9 and 31.8 mm, respectively. There was no difference in linear wear between patients who had different hip center heights (<20, 20 to 30, and >30 mm), and quadrant partitioning showed no differences across the 4 quadrant zones.

CONCLUSION

At a minimum of 18 years of follow-up in patients having developmental dysplasia of the hip who had different Crowe subtypes and different hip centers, elevated hip center and uncemented fixation techniques using a highly cross-linked polyethylene on ceramic components were associated with very low wear rates and excellent functional scores.

Improved surgical exposure and early clinical outcomes using a femoral-release-first technique in direct anterior approach during total hip arthroplasty

BACKGROUND

Total hip arthroplasty (THA) performed using the direct anterior approach (DAA) has demonstrated favourable early-, mid-, and long-term outcomes. However, the traditional femoral release technique remains technically demanding and is associated with challenges and a heightened risk of complications. This study aimed to compare the clinical outcomes of patients who underwent THA with DAA performed using either the femoral-release-first (FRF) or the traditional approach (TA) strategy.

METHODS

A retrospective analysis of demographics, clinical and radiological outcomes, and occurrence of complications was performed using data from 106 patients between 2018 and 2019. The patients were categorised into two groups: FRF (44 hips) and TA (69 hips).

RESULTS

The FRF group showed a reduced operative time, haemoglobin (Hb) drop, postoperative hospital stay, and more optimal acetabular cup anteversion angles. Furthermore, during the first 2 months postoperatively, the FRF group demonstrated superior visual analogue scale, Harris Hip, and Oxford Hip scores. In the TA group, two hips experienced greater trochanter fractures, and one experienced delayed incision healing.

CONCLUSIONS

Compared with the TA, employing the FRF strategy during THA with DAA resulted in improved outcomes within the first 2 months postoperatively and comparable functional recovery beyond this period. The FRF method exhibited advantages such as favourable acetabular exposure and alignment and a reduced risk of complications. Therefore, the FRF strategy may be a favourable option.

Single-taper conical tapered stem in total hip arthroplasty for developmental dysplasia of the hip: A long-term evaluation

INTRODUCTION

Conical tapered stems may be useful implants to manage the reconstruction of complex dysplastic anatomies. The aims of this paper were to assess: 1) the preoperative CT features of the dysplastic femurs; 2) survival rates, complications and reasons for revision; 3) the clinical outcomes; 4) the radiographic outcomes of single-taper conical stems in dysplasia (defined as center edge angle < 20°) at a long-term follow-up.

HYPOTHESIS

Monoblock conical stem provides a 10-year survival rate of at least 95%, with excellent clinical outcomes and bony ingrowth.

MATERIALS AND METHODS

In total, 100 THAs in 85 patients (15 bilateral cases) were enrolled. The average age of the patients at surgery was 50.9±11.5 years. Assessment of the native femoral morphology was performed using CT-scan, coronal (neck-shaft angle, offset, center of rotation position) and axial parameters (anteversion, mediolateral and anteroposterior femoral diameters). Clinical (HHS score) and radiological (osseointegration, subsidence and offset reconstruction) outcomes were evaluated at the last available follow-up.

RESULTS

The mean follow-up was 9.34±5.61 years. Severely distorted anatomies from Crowe I to Crowe IV were included, with a mean canal flare of 4.3 and a mean femoral antetorsion of 34°. The survival rates were stable at long-term (98.9% at 10 and 15 years): no aseptic loosening occurred. The mean postoperative HHS was 89.8±6.8 points. Ninety-nine percent of the stems showed bone ingrowth, from 6 months to the last available follow-up. Subsidence occurred in 18% of the cases (mean value: 2.5mm, range: 1-6mm) in the first month, with subsequent stabilization. A mild proximal stress shielding occurred in 28% of the THAs. Radiolucent lines were detected in the 8% of the cases. There was a postoperative loss of offset in 12% of the cases.

DISCUSSION

Conical stems in dysplastic hips achieved bony ingrowth at long-term outcome, even in complex anatomies. Subsidence, proximal stress shielding and imperfect offset restoration may occur with this implant.

LEVEL OF PROOF

IV; retrospective study.

Titanium modular stems in total hip arthroplasty due to developmental dysplasia: a registry comparison with single-taper implants

INTRODUCTION

The routine use of proximal femoral modularity was discouraged in total hip arthroplasties (THAs). However, titanium dual-taper (DT) implants may provide some advantages over single-taper (ST) stems in cases of complex deformity. A registry study comparing ST and DT stems in dysplasia was designed, aiming to assess: (1) survival rates at long-term; (2) reasons for revision; (3) the profile of failed implants.

METHODS

The arthroplasty registry RIPO was investigated for cementless THAs performed for dysplasia since 2000. ST implants were compared to titanium-on-titanium DT stems. Demographics and implant features were collected. Survival rates and reasons for revision were compared. The profile of DT stem failures in dysplasia was defined.

RESULTS

6429 implants were included in the study, 3642 ST and 2787 DT. The demographic and implant features of the 2 cohorts were not comparable. The DT cohort achieved higher survival rates at long-term (93.9% vs. 91.6%, p = 0.018). DT implants showed a higher rate of implant breakage (0.6%, p = 0.011) and a lower rate of aseptic loosening (p = 0.005). There were no differences in terms of revisions for dislocation. No metallosis occurred. There were more revisions in DT implants in males <65 years, with a 28-mm head size or smaller.

CONCLUSIONS

Modularity did not result in lower survival rates in dysplastic patients and may even reduce the rate of aseptic loosening in comparison to ST stems. The rate of implant breakage is not negligible. Younger males are not good candidates for titanium DT stems.

Mid-term outcomes of revision hip arthroplasty due to titanium modular neck failure

INTRODUCTION

The current strategy for modular neck failures in total hip arthroplasty (THA) is calibrated on CrCo neck failures. Stem revision is usually required, but the procedure is challenging and achieves modest outcomes (up to 20% of re-revisions at short-term). No study reports revision strategies and outcomes after Ti neck failures. Aims of the study were to evaluate: (1) demographic and implant features of the cohort to be revised, (2) intra-operative findings and surgical revision strategies and (3) clinical and radiological post-revision outcomes.

MATERIALS AND METHODS

Hospital database was enquired about revisions due to Ti neck failures in primary THAs. Sixty-five revisions were enrolled (all with the same modular system). Neck exchange was attempted as the first-line treatment. Patients were clinically and radiographically evaluated after revision.

RESULTS

The revision cohort encompassed fatigue neck fractures occurred 4.4 ± 2.6 years after THA: patients < 65 years and/or > 80 kg (98.5%) were predominant. Fifty-three neck exchanges were performed (81.5%). Eleven failures required stem revisions (16.9%), generally due to demanding neck extraction. Six complications occurred after neck exchange (11.3%), among them 2 acute infections requiring surgery (3.8%). Among stem revisions, one aseptic loosening and one neck re-fracture (18.5%) required re-revisions. At a mean follow-up of 7.1 ± 4 years, the neck exchange cohort achieved a mean HHS of 89.1 ± 6.3 (stem revisions: 84.1 ± 10.9).

CONCLUSIONS

Revisions for Ti neck failures were predominantly performed due to fatigue fractures. In case of failures, neck exchange is a feasible procedure in most of the cases, with good outcomes at 7 years.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Current Surgical Techniques in the Treatment of Adult Developmental Dysplasia of the Hip

The surgical protocols currently used for the treatment of developmental dysplasia of the hip (DDH) are varied, with sufficient differences in clinical outcomes that warrant a review of the role of practicing orthopedic surgeons. This paper aims to summarize the current novel techniques within the realm of surgical treatment for adult DDH, thus serving as a guide to surgeons looking to quickly familiarize themselves with available techniques. We performed computer systematic literature searches of the Embase and PubMed databases from 2010 to 2 April 2022. Study parameters as well as their respective patient reported outcomes (PROMs) were described in detail and compiled into diagrams. Two novel techniques were identified for the treatment of borderline or low-grade DDH. Six techniques which included modifications to the Bernese periacetabular osteotomy (PAO) were identified for the treatment of symptomatic DDH. Three techniques which include combinations of arthroscopy and osteotomy were identified for the treatment of DDH with concomitant hip pathologies such as cam deformities. Finally, six techniques, all of which are modifications to total hip arthroplasty (THA), were identified for the treatment of high-grade DDH. The techniques detailed in this review therefore equip surgeons with the necessary knowledge to improve outcomes in patients with varying degrees of DDH.

Total Hip Arthroplasty in Patients with Crowe III/IV Developmental Dysplasia of the Hip: Acetabular Morphology and Reconstruction Techniques

The severe anatomic deformities render acetabular reconstruction as one of the greatest challenges in total hip arthroplasty (THA) for patients with Crowe III/IV developmental dysplasia of the hip (DDH). Thorough understanding of acetabular morphology and bone defect is the basis of acetabular reconstruction techniques. Researchers have proposed either true acetabulum position reconstruction or high hip center (HHC) position reconstruction. The former can obtain the optimal hip biomechanics, including bulk femoral head autograft, acetabular medial wall displacement osteotomy, and acetabular component medialization, while the latter is relatively easy for hip reduction, as it can avoid neurovascular lesions and obtain more bone coverage; however, it cannot achieve good hip biomechanics. Both techniques have their own advantages and disadvantages. Although there is no consensus on which approach is better, most researchers suggest the true acetabulum position reconstruction. Based on the various acetabular deformities in DDH patients, evaluation of acetabular morphology, bone defect, and bone stock using the 3D image and acetabular component simulation techniques, as well as the soft tissue tension around the hip joint, individualized acetabular reconstruction plans can be formulated and appropriate techniques can be selected to acquire desired clinical outcomes.

Acetabular Diameter Assessment and Three-Dimensional Simulation for Acetabular Reconstruction in Dysplastic Hips

BACKGROUND

This study aimed to investigate the relationship between acetabular width, three-dimensional (3D) simulation, and surgical results in total hip arthroplasty patients who have developmental dysplasia of the hip (DDH).

METHODS

This retrospective study included 216 DDH cases. Inner and outer acetabular width (OAW) was measured at the plane passing through the center of acetabular fossa. 3D simulation and 2D standard templating were performed. The actual cup size and the use of augments during surgery were recorded. Association among the indices and their distribution in different types of DDH were analyzed.

RESULTS

A difference of 13 to 14 millimeters (mm) was found between the inner acetabular width and actual cup size used in type II, III, and IV cases, while the difference was 0.2 to 3.6 mm for OAW. The accuracy of 2D templating and 3D simulation in predicting cup size was comparable in Crowe type I (86.5 versus 76%, P = .075), type II (72.7 versus 51.5%, P = .127), and type III (93.3 versus 66.7%, P = .169). The 3D simulation was significantly more accurate in Crowe type IV (89.1% versus 60.9%, P = .001). Augments and bone grafts were significantly more commonly used in type II (25%) than in the other types (0 to 6.5%).

CONCLUSION

OAW more accurately predicted actual cup size than inner acetabular width. The supero-lateral acetabular bone defects in type II cases require additional attention. Compared with 2D templating, 3D simulation is more accurate in predicting actual cup size in dysplastic hips with severe deformity and may be recommended in these selected cases, especially for Crowe IV patients.

Cup Overhanging in Anatomic Socket Position or High Hip Center of Rotation in Total Hip Arthroplasty for Crowe III and IV Dysplasia: A CT-Based Simulation

Cup overhanging in total hip arthroplasty is a predisposing factor to iliopsoas impingement. In dysplastic hips, cup implantation was simulated in an anatomic hip center of rotation (AHCR) and in high hip center (HHCR). We sought to assess: (1) the percentage of prominent cups; (2) quantify the cup protrusion at different sites on frontal, axial and sagittal views. In 40 Crowe III-IV hips, using a 3D CT-based planning software, cup planning in AHCR and HHCR (CR height ≥ 20 mm) was performed for every hip. Cup prominence was assessed on every plane. HHCR cups were less anteverted (p < 0.01), less medialized (p < 0.001) and less caudal (p = 0.01) than AHCR sockets. AHCR cups were more frequently prominent on at least one plane (92.5% vs. 77.5%), with minimal agreement between the two configurations (k = 0.31, p = 0.07). AHCR cups protruded more than HHCR sockets in the sagittal (p = 0.02) and axial planes (p < 0.001). Axially, at the center of the cup, prominence 6−11 mm occurred in nine (22.5%) AHCR and one (2.5%) HHCR socket. In conclusion, while a routine high hip center should not be recommended, cup placement at a center of rotation height < 20 mm is associated with higher rates and magnitudes of anterior cup protrusion in severe dysplasia.

Impaction Bone Grafting with Low Dose Irradiated Freeze-Dried Allograft Bone for Acetabular Reconstruction

OBJECTIVE

Reconstruction of acetabular defects has been extremely challenging in both primary and revision total hip arthroplasty (THA). Impaction bone grafting (IBG) can restore the acetabulum bone mass and anatomically reconstruct the acetabulum. Our study aimed to report the short and medium-term clinical and radiographic outcomes of IBG for acetabular reconstruction in the cemented THA in the Chinese population.

METHODS

This was a single-center retrospective review enrolling 57 patients between May 2013 and July 2019. The patients with acetabular defects were treated with IBG, using low dose irradiated freeze-dried allograft bone with or without autograft bone, in the cemented THA performed by one senior surgeon. Harris hip score (HHS), standard pelvis anterior-posterior radiograph and lateral hip radiograph were obtained before operation and at 1 week, 3 months, 12 months, and yearly. Graft osteointegration was evaluated by Oswestry's criteria, and complication was documented at the last follow-up. Independent sample ANOVA test and Pearson chi-square tests are used for statistical analysis.

RESULTS

There were 61 hips in 57 patients. The average follow-up time was 35.59 months (5-77 months). According to AAOS classification, a total of 18 hips were identified as segmental bone deficiency (type I), with 21 and 22 hips for cavitary bone deficiency (type II) and the combined bone deficiency (type III), respectively. The average HHS was improved from 44.49 (range: 32-58) preoperatively to 86.98 (range: 78-93) postoperatively. Graft osteointegration was satisfactory (Oswestry score ≥2) in all patients. No dislocation occurred in the 57 patients (61 hips) during follow-up. Although one cup migrated, no revision, re-revision, radiographic loosening, graft bone lysis, or postoperative complications were detected at the final follow-up.

CONCLUSIONS

IBG with low-dose irradiated freeze-dried allograft bone in acetabular bone defect reconstruction is a reliable technique for restoring acetabular bone defects in THA.

[Three-dimensional morphological study of the effect of false acetabulum on the femoral structure in Crowe type developmental dysplasia of the hip]

OBJECTIVE

To explore the effect of false acetabulum on the development and anatomical morphology of proximal femur in Crowe type Ⅳ developmental dysplasia of the hip (DDH), providing a theoretical basis for the development of femoral reconstruction strategy and prosthesis selection for total hip arthroplasty.

METHODS

The medical records of 47 patients (54 hips) with Crowe type Ⅳ DDH between February 2008 and March 2020 were retrospectively analyzed, of which 21 patients (26 hips) were Crowe type Ⅳa (type Ⅳa group) and 26 patients (28 hips) were Crowe type Ⅳb (type Ⅳb group). There was no significant difference in general data such as gender, age, height, weight, body mass index, and side between the two groups ( P>0.05), which were comparable. The height of femoral head dislocation, the height of pelvis, and the proportion of dislocation were measured based on preoperative anteroposterior pelvic X-ray film. Based on the preoperative femoral CT scan data, the anatomical parameters of the femur and femoral medullary cavity were measured after three-dimensional reconstruction using Mimics19.0 software to calculate the canal fare index; and the femoral medullary cavity parameters were matched with the modular S-ROM prosthesis parameters.

RESULTS

The results of X-ray film measurement showed that the height of femoral head dislocation and the proportion of dislocation in type Ⅳa group were significantly higher than those in type Ⅳb group ( P<0.05). There was no significant difference in the height of pelvis between the two groups ( P>0.05). The results of CT three-dimensional reconstruction measurements showed that compared with the type Ⅳb group, the type Ⅳa group had less isthmus height, smaller femoral head, shorter femoral neck, narrower neck-shaft angle, increased anteversion angle, and higher greater trochanter, and the differences were significant ( P<0.05). There was no significant difference in the height of femoral head, femoral offset, and height difference between greater trochanter and femoral head between the two groups ( P>0.05). There was no significant difference in the mediolateral width (ML), anteroposterior width (AP), and diameter of the isthmus (Ci level) and the AP of the medullary cavity in the plane 40 mm distal to the most prominent point on the medial side of the lesser trochanter (C _-40 level) ( P>0.05), and the size of medullary cavity was significantly smaller in type Ⅳa group than in type Ⅳb group at the other levels ( P<0.05). Compared with the type Ⅳb group, the difference between the outer diameter of the prosthetic sleeve and the diameter of the medullary cavity fitting circle in the plane where the center of femoral head rotation was located from the medial most prominent point of the lesser trochanter (C ₀ level) in type Ⅳa group was smaller, and the proportion of negative values was greater ( P<0.05). The difference between the longest diameter of the prosthetic sleeve triangle and the ML of the medullary cavity in the plane 10 mm proximal to the most prominent point on the medial side of the lesser trochanter (C ₊₁₀ level) in type Ⅳa group was smaller, and the proportion of negative values was greater ( P<0.05).

CONCLUSION

False acetabulum has a significant impact on the morphology of the proximal femur and medullary cavity in patients with Crowe type Ⅳ DDH, and the application of three-dimensional reconstruction technique can accurately evaluate the femoral morphology and guide the selection of femoral prosthesis.

Preliminary application of 3D-printed individualised guiding templates for total hip arthroplasty in Crowe type IV developmental dysplasia of the hip

OBJECTIVE

To evaluate the feasibility and accuracy of three-dimensional (3D)-printed individualised guiding templates in total hip arthroplasty (THA) for the treatment of developmental dysplasia of the hip (DDH).

METHODS

12 hips in 12 patients with Crowe type IV DDH were treated with THA. A 3D digital model of the pelvis and lower limbs was reconstructed using the computed tomography data of the patients. Preoperative surgical simulations were performed to determine the most suitable surgical planning, including femoral osteotomy and prosthesis placement. Based on the ideal surgical planning, individualised guiding templates were designed by software, manufactured using a 3D printer, and used in acetabulum reconstruction and femoral osteotomy during surgery.

RESULTS

12 patients were followed up for an average of 72.42 months (range 38-135 months). During surgery, the guiding template for each case was matched to the bony markers of the acetabulum and proximal femur. Preoperative and follow-up Harris Hip Scores were 34.2 ± 3.7 and 85.2 ± 4.2; leg-length discrepancy, 51.5 ± 6.5 mm and 10.2 ± 1.5 mm; and visual analogue scale scores, 6.2 ± 0.8 and 1.3 ± 0.3, respectively, with statistical difference. Shortened deformity and claudication of the affected limb were obviously improved after surgery. However, 1 patient had artificial hip dislocation 2 weeks after surgery, and another patient had sciatic nerve traction injury, both of whom recovered after physical treatment.

CONCLUSIONS

Preoperative surgical simulation and 3D-printed individualised guiding templates can fulfil surgeon-specific requirements for the treatment of Crowe type IV DDH. Accurate THA can be achieved using 3D-printed individualised templates, which provide a new personalised surgical plan for the precise positioning and orientation of acetabular reconstruction and femoral osteotomy.

Acetabular Revision Arthroplasty Based on 3-Dimensional Reconstruction Technology Using Jumbo Cups

Background: This study was aimed at evaluating the changes in cup coverage (CC) and hip center of rotation (HCOR) in acetabular defects of various severities treated with acetabular revision using jumbo cups.

Methods: A total of 86 hips were included. The American Academy of Orthopedic Surgeons (AAOS) classification of these patients was as follows: 16 patients, AAOS I; 16 patients, AAOS II; and 16 patients, AAOS III. A three-dimensional (3D) implant simulation technique was used to visualize the placement of jumbo cups during revision arthroplasty. The acetabular anteversion, inclination, CC, and the HCOR were measured.

Results: The inclination and anteversion of simulated acetabular cups in AAOS I–III groups were consistent with the normal acetabular anatomy. Compared with the controls, in AAOS I–III groups, the HCOR was significantly increased and CC was significantly decreased. The HCOR elevation was significantly higher in AAOS III patients than in AAOS I (p = 0.001) and AAOS II patients (p < 0.001). The use of the jumbo cup technology for acetabular revision would decrease the CC in AAOS I–III patients to 86.47, 84.78, and 74.51%, respectively.

Conclusion: Our study demonstrated that in patients with acetabular defects, acetabular revision arthroplasty using jumbo cups will lead to decreased CC and HCOR upshift. Upon classifying these patients according to the AAOS classification, CC decreased with the severity of acetabular defects, and the elevation of the HCOR in AAOS III patients exceeded 10 mm and was significantly higher than in other patients.

Postoperative Hip Center Position Associated With the Range of Internal Rotation and Extension During Gait in Hip Dysplasia Patients After Total Hip Arthroplasty

Background: Total hip arthroplasty (THA) for hip dysplasia patients is sometimes complex and compromises pathomorphological changes in these patients. However, it remains unclear whether it is preoperative deformities or postoperative structures or anatomic changes during THA that have the most remarkable correlation with the hip dynamic function during gait. The purpose of this study was to investigate this relationship and propose insights into the surgical reconstruction strategy in patients with developmental dysplasia of the hip.

Methods: A total of 21 unilateral hip dysplasia patients received computed tomography scans for the creation of 3D hip models before surgery and at the last follow-up. Acetabular and femoral orientations, hip center positions, and femoral length were measured before and after THA. Hip kinematics of the operated side during gait was quantified using a dual fluoroscopic imaging technique. Pearson correlation and multiple linear regression were performed to evaluate the relationship between hip maximum range of motion in six directions and demographics characters and above hip anatomic parameters before and after THA and their changes in surgery.

Results: Pearson correlation analysis found significant correlations with the gait range of motion mainly in postoperative structures, including postoperative hip center positions and acetabulum and combined anteversion. Further multiple linear regression indicated that a laterally placed hip center was significantly correlated with an increased internal rotation (R2 = 0.25, p = 0.021), which together with increased postoperative acetabulum anteversion explained 45% of external rotation decreasing (p = 0.004). A proximally placed hip center was correlated with more extension (R2 = 0.30, p = 0.010). No significant demographic characters or preoperative deformities or surgical changes were included into other multiple regression models.

Conclusion: Strong correlations between postoperative structures, especially hip center positions and gait range of motion in unilateral hip dysplasia patients after THA were found. It indicated that postoperative prosthesis structures, particularly hip center positions had significant impact on the hip gait motion range and should be treated with particular caution in surgery.

Does robotic-assisted computer navigation improve acetabular cup positioning in total hip arthroplasty for Crowe III/IV hip dysplasia? A propensity score case-match analysis

AIMS

Total hip arthroplasty (THA) in patients with hip-dislocation dysplasia remains challenging. This study aims to evaluate whether these patients may benefit from robotic-assisted techniques.

METHODS

We reviewed 135 THAs (108 conventional THAs and 27 robotic-assisted THAs) for Crowe type III or IV from January 2017 to August 2019 in our institution. Robotic-assisted THAs were matched with conventional THAs at a 1:1 ratio (27 hips each group) using propensity score matching. The accuracy of cup positioning and clinical outcomes were compared between groups.

RESULTS

The inclination of the cup for conventional THAs and robotic THAs was 42.1 ± 5.7 and 41.3 ± 4.6 (p = 0.574), respectively. The anteversion of the cup for conventional THAs was significantly greater than that of robotic THAs (29.5 ± 8.1 and 18.0 ± 4.6; p < 0.001), respectively. The ratio of the acetabular cup in the Lewinnek safe zone was 37% (10/27) in conventional THAs and 96.3% (26/27) in robotic THAs (p < 0.001). Robotic THAs did not achieve better leg length discrepancy than that of conventional THAs (- 0.4 ± 10.9 mm vs. 0.4 ± 8.8 mm, p = 0.774). There was no difference in Harris Hip Score and WOMAC Osteoarthritis index between groups at the 2-year follow-up. No dislocation occurred in all cases at the final follow-up.

CONCLUSION

Robotic-assisted THA for patients with high dislocation improves the accuracy of the implantation of the acetabular component with respect to safe zone.

Bone defect map of the true acetabulum in hip dysplasia (Crowe type II and III) based on three-dimensional image reconstruction analysis

The high hip center technique (HHC) is considered to be feasible for acetabular reconstruction in patients with DDH, but there is little in-depth study of its specific impact on Crowe type II and III DDH. The purpose of this study was to simultaneously analyze the effect of HHC on bone coverage of the cup (CC) in the acetabular reconstruction of type II and III DDH patients and to propose a map of acetabular bone defects from the perspective of the cup. Forty-nine hip CT data of 39 patients with DDH (Crowe type II and III) were collected to simulate acetabular reconstruction by cup models of different sizes (diameter 38mm–50 mm, 2 mm increment) with the HHC technique. The frequency distribution was plotted by overlapping the portions of the 44 mm cups that were not covered by the host bone. The mean CC of cups with sizes of 38 mm, 40 mm, 42 mm, 44 mm, 46 mm, 48 mm, and 50 mm at the true acetabula were 77.85%, 76.71%, 75.73%, 74.56%, 73.68%, 72.51%, and 71.75%, respectively, and the maximum CC increments were 21.24%, 21.58%, 20.86%, 20.04%, 18.62%, 17.18%, and 15.42% (P < 0.001), respectively, after the cups were elevated from the true acetabula. The bone defect map shows that 95% of type II and III DDH acetabula had posterosuperior bone defects, and approximately 60% were located outside the force line of the hip joint. Acetabular cups can meet a CC of more than 70% at the true acetabulum, and approximately 60% of Crowe type II and III DDH patients can obtain satisfactory CC at the true acetabulum by using a 44-mm cup without additional operations.

Modular neck stems in total hip arthroplasty: current concepts

Modular neck (MN) implants can restore the anatomy, especially in deformed hips such as sequelae of development dysplasia.

Early designs for MN implants had problems with neck fractures and adverse local tissue, so their use was restricted to limited indications.

Results of the latest generation of MN prostheses seem to demonstrate that these problems have been at least mitigated.

Given the results of the studies presented in this review, surgeons might consider MN total hip arthroplasty (THA) for a narrower patient selection when a complex reconstruction is required.

Long MN THA should be avoided in case of body mass index > 30, and should be used with extreme caution in association with high offset femoral necks with long or extra-long heads. Cr-Co necks should be abandoned, in favour of a titanium alloy connection.

Restoring the correct anatomic femoral offset remains a challenge in THA surgeries.

MN implants have been introduced to try to solve this problem. The MN design allows surgeons to choose the appropriate degree and length of the neck for desired stability and range of motion.

Cite this article: EFORT Open Rev 2021;6:751-758. DOI: 10.1302/2058-5241.6.200064

Jumbo cup in hip joint renovation may cause the center of rotation to increase

BACKGROUND

Utilizing the large jumbo cup in revision total hip arthroplasty is an effective approach to cure many lacunar and segmental peripheral bone defects. However, with the use of the jumbo cup, the center of the hip joint may become elevated relative to the primary acetabulum, and the diameter of the large cup is greater.

AIM

To study the height and the significance of the elevation of the hip joint center.

METHODS

Eighty-eight patients matched the criteria for this condition and were included in the study. The center height of the hip joint was measured relative to the opposite normal hip joint. The diameter of the jumbo cup was measured and checked according to operation notes, and the diameter of the jumbo cup was measured with a prosthesis label. Then, the horizontal and vertical centers of rotation were measured on the surgical side and opposite side. The average center height of the hip joint on the renovated side and the opposite side and the position of the hip cup relative to the teardrop were compared using a paired t-test.

RESULTS

Radiometric analysis showed that the average hip joint center was elevated by 7.6 mm. The rotational center height delta of the renovated hip was 7.6 ± 5.6 mm, and there was an obvious difference between the two groups (P = 0.00). The difference in horizontal distance was 0.5 ± 5.1 mm (-11.5 -14.0 mm), and there was no obvious difference between the two groups (P = 0.38). According to the foreign standard, the rotational center height delta of the renovated hip was 7.5 ± 6.2 mm, and there was a significant difference between the two groups (P = 0.00). There was no obvious difference between the domestic and foreign standards (P > 0.05) between the two groups.

CONCLUSION

The application of the jumbo cup elevates the rotational center of the hip joint, but it is feasible and effective to use the jumbo cup.

Survival rates and reasons for revision of different stem designs in total hip arthroplasty for developmental dysplasia: a regional registry study

INTRODUCTION

Total hip arthroplasty (THA) in dysplastic hips is challenging, and each specific implant used in this context has been associated with specific complications. A registry study was performed to query survival rates, hazard ratios, and reasons for revision of different stem designs in THAs after developmental dysplasia of the hip.

MATERIALS AND METHODS

A regional arthroplasty registry was inquired about cementless THAs performed for hip dysplasia from 2000 to 2017. Patients were stratified according to stem design in tapered (TAP; wedge and rectangular), anatomic (ANAT), and conical (CON), and divided on the basis of modularity (modular, M; nonmodular, NM). In total, 2039 TAP stems (548 M and 1491 NM), 1435 ANAT (1072 M and 363 NM), and 2287 CON (1020 M and 1267 NM) implants were included. Survival rates and reasons for revisions were compared.

RESULTS

The groups were homogeneous for demographics, but not fully comparable in terms of implant features. NM-CON stems showed the highest risk of failure (significant) and a high risk for cup aseptic loosening (2.5%). The adjusted risk ratio showed that NM-CON was more prone to failure (HR versus NM-ANAT: 3.30; 95%CI 1.64-7.87; p = 0.0003). Revision rates for dislocations and stem aseptic loosening did not differ between cohorts.

CONCLUSIONS

NM-CON stems showed the highest risk of failure, especially high rates of cup aseptic loosening. NM-CON implants were not more prone to dislocations and stem aseptic loosening. Clinical comparative studies are required to investigate the causes of NM-CON failures, which may be due to abnormal acetabular morphology or imperfect restoration of the proximal biomechanics.

Does Cup Position at the High Hip Center or Anatomic Hip Center in THA for Developmental Dysplasia of the Hip Result in Better Harris Hip Scores and Revision Incidence? A Systematic Review

BACKGROUND

One goal of THA is to restore the anatomic hip center, which can be achieved in hips with developmental dysplasia by placing cups at the level of the native acetabulum. However, this might require adjuvant procedures such as femoral shortening osteotomy. Another option is to place the cup at the high hip center, potentially reducing surgical complexity. Currently, no clear consensus exists regarding which of these cup positions might offer better functional outcomes or long-term survival.

QUESTION/PURPOSE

We performed a systematic review to determine whether (1) functional outcomes as measured by the Harris hip score, (2) revision incidence, and (3) complications that do not result in revision differ based on the position of the acetabular cup (high hip center versus anatomic hip center) in patients undergoing THA for developmental dysplasia of the hip (DDH).

METHODS

We performed a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, including studies comparing the functional outcomes, revision incidence, and complications of primary THA in dysplastic hips with acetabular cups placed at the high hip center versus those placed at the anatomic hip center, over any time frame. The review protocol was registered with PROSPERO (registration number CRD42020168183) before commencement. Of 238 records, eight comparative, retrospective nonrandomized studies of interventions were eligible for our systematic review, reporting on 207 hips with cups placed at the high hip center and 268 hips with cups at the anatomic hip center. Risk of bias within eligible studies was assessed using the Risk Of Bias In Non-randomized Studies of Interventions tool. Due to low comparability between studies, data could not be pooled, so these studies were assessed without summary effects.

RESULTS

Six studies compared Harris hip scores, two of which favored high hip center cup placement and three of which favored anatomic hip center cup placement, although none of the differences between cohorts met the minimum clinically important difference. Five studies reliably compared revision incidence, which ranged from 2% to 9% for high hip center at 7 to 15 years and 0% to 5.9% for anatomic hip center at 6 to 16 years. Five studies reported intra- and postoperative complications, with the high hip center being associated with higher incidence of dislocation and lower incidence of neurological complications. No clear difference was observed in intraoperative complications between the high hip center and anatomic hip center.

CONCLUSION

No obvious differences could be observed in Harris hip score or revision incidence after THA for osteoarthritis secondary to DDH between cups placed at the anatomic hip center and those placed at the high hip center. Placement of the acetabular cup in the high hip center may lead to higher risk of dislocation but lower risk of neurologic complications, although no difference in intraoperative complications was observed. Surgeons should be able to achieve satisfactory functional scores and revision incidence using either technique, although they should be aware of how their choice influences hip biomechanics and the need for adjunct procedures and associated risks and operative time. These recommendations should be considered with respect to the several limitations in the studies reviewed, including the presence of serious confounding factors and selection biases, inconsistent definitions of the high hip center, variations in dysplasia severity, small sample sizes, and follow-up periods. These weaknesses should be addressed in well-designed future studies.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Cementless ceramic-on-ceramic total hip arthroplasty in post-traumatic osteoarthritis after acetabular fracture: long-term results

INTRODUCTION

Total hip arthroplasty (THA) is the standard procedure for post-traumatic osteoarthritis (OA) of the hip after acetabular fracture. However, it is not as simple as a primary THA, challenging the surgeon with anatomical deformity and intra and postoperative complications. In the current literature, there is a lack of studies reporting long-term results. May ceramic-on-ceramic (CoC) bearings provide good clinical and radiological outcomes at a long-term follow-up in patients undergoing THA following acetabular fracture?

MATERIALS AND METHODS

We retrospectively analyzed 68 patients (mean age 47 years [range 22-75)] who underwent cementless modular neck stem THA, all implants CoC bearings (50 previously operatively treated and 18 non-operatively treated) after a specific CT study protocol at our Institute since 2000-2008. Clinical outcomes, prosthetic components' osseointegration, survival rate, and reasons for revision were analyzed. Minimum clinical and radiological follow-up was 10 years.

RESULTS

HHS improved significantly after surgery from 37.6 ± 14.1 to 88.4 ± 11.6. 8 revision surgeries were performed, none for infection: we reported 2 stem aseptic loosening, 2 periprosthetic femoral fractures and 4 modular neck fractures. One implant noise (third-generation ceramic coupling) was described. Cup osseointegration was present (according to Moore the presence of at least 3 radiological criteria defines an effective osseointegration) in 67 patients (98.5%). After a 10 years follow-up, survival rate resulted 88.4%, sensibly higher than most of results reported in the current literature.

CONCLUSION

The high survival rate may be related to CoC: no osteolysis and no infections were reported. Also acetabular cup loosening incidence was sensibly lower (1.47%) among loosening rate described by other authors. Clinical and radiological outcomes were decent, probably due to modular prosthesis design. Modular necks are a solution which can help achieving a proper functional reconstruction of the hip (offset, center of rotation), but should be avoided in young and overweight patients because of the high risk of fracture. CoC bearings in THAs in post-traumatic OA after acetabular fracture showed good results despite the fact that specific ceramic-related issues have to be considered.

Functional and radiographical results of asymmetrically reconstructed total hip arthroplasty in patients with bilateral dysplastic arthritic hips with one hip Crowe II-III and the other Crowe IV: a retrospective cohort study

Background

The study aimed to evaluate the functional and radiographical results of asymmetrically reconstructed total hip arthroplasty in patients with bilateral dysplastic arthritic hips with one hip Crowe II–III and the other hip Crowe IV.

Materials and methods

From April 2006 to April 2019, we evaluated 23 patients who had a reconstruction of one Crowe II–III hip with high hip center (HHC) and the other Crowe IV hip at the anatomical position (H group). The radiographic and clinical outcomes were compared with those of a control group of 19 patients with bilateral dysplasia who had one Crowe IV hip and the contralateral hip both reconstructed in the anatomical position (A group). Medical records and radiographs were reviewed, and a complete follow-up was conducted for all patients.

Results

The mean vertical center of rotation (V-COR) and horizontal center of rotation (H-COR) in the H group were 30.6 ± 5.8 mm and 30.0 ± 5.5 mm, respectively. In the A group, the corresponding values were 14.0 ± 4.3 mm and 23.0 ± 2.3 mm, respectively. A significant difference was found in terms of V-COR and H-COR between the two groups, and no significant difference was shown regarding the cup inclination, abductor lever arm (ALA), ALA ratio, and leg length discrepancy (LLD). Three patients of the H group and four patients of the A group exhibited LLD > 10 mm. All seven patients who had LLD > 10 mm underwent the shortening subtrochanteric osteotomy (SSTO) of the Crowe IV hip. Subgroup analysis based on the presence and absence of SSTO showed that the LLD of the SSTO group was greater than that of the non-SSTO group in both groups, but the difference was only statistically significant in the A group. At the last follow-up, the mean Harris Hip Scores significantly improved in the two groups, and there was no revision during the follow-up period. In the H group, four patients presented with a slight limp and three patients with a moderate limp, while it was six patients and one patient in the A group, respectively.

Conclusions

Asymmetrical reconstruction in patients with bilateral dysplastic arthritic hips with one hip Crowe II–III and the other Crowe IV is acceptable and comparable when compared with bilateral anatomical reconstruction.

Level of evidence

III, retrospective observational study.

Trial registration Chinese Clinical Trail Registry. ChiCTR2000033848

lsolated acetabular revisions of articular surface replacement (ASR) XL implants with highly porous titanium cups and Delta bearings

INTRODUCTION

Articular surface replacement (ASR) XL implants exhibit higher-than-expected revision rates, blood ion concentrations and soft tissue lesions, making revisions troublesome and potentially unsatisfying. Appropriate techniques and outcomes in ASR XL revisions are rarely documented. The aims of this study were the assessments of pre-revision data, post-revision clinical and radiographic outcomes and ion levels in isolated acetabular ASR XL revisions performed using highly porous titanium cups and Delta ceramic articulations.

METHODS

18 isolated acetabular ASR XL revisions in 16 patients were performed using Ti-Por cups (Adler Ortho, Milan, Italy) and Delta bearings (CeramTec, Plochingen, Germany). Pre-revision demographic, clinical, radiological and implant-related features were assessed. Clinical and radiographic parameters (cup positioning, osseointegration) after revisions were evaluated at a minimum follow-up of 5 years. Ion concentrations in blood and urine were collected in pre-revision setting and 1 year after revision.

RESULTS

4 complications occurred in 3 different revisions (16.7%), 1 dislocation, 2 infections, 1 psoas impingement. No re-revision was performed at 5 years (1 scheduled arthroscopy). Good clinical outcomes were achieved (HHS score: 88.3 ± 9.2). All the cups showed reassuring signs of osseointegration (>3 parameters). Blood ion concentrations significantly decreased: patients with Co blood ion concentration over the threshold (7 μg/l) decreased from 76.5% to 0%. No pre-revision or intraoperative data influenced the revision outcomes.

CONCLUSIONS

Highly porous titanium cups and Delta ceramic articulations provided reliable mid-term clinical and radiographic outcomes in isolated acetabular ASR XL revisions. Ion concentrations significantly decreased. Multicentre prospective controlled studies are required to confirm these preliminary outcomes.

Abductor muscle strengthening in THA patients operated with minimally-invasive anterolateral approach for developmental hip dysplasia

OBJECTIVE

In developmental hip dysplasia (DDH) patients, the chronic dislocation of the femoral head with respect to the true acetabulum determines muscle contracture and atrophy, particularly of the abductor muscles, and leads to secondary osteoarthritis (OA) with severe motor dysfunction, pain and disability. The correct positioning when a total hip replacement (THR) is performed is fundamental to the recovery of gait function. Also, inadequate rehabilitation of the abductor muscles for pelvic stabilisation can be responsible for residual dysfunction. Consensus on a programme for abductor muscle strengthening in these patients is not currently available. The aim of this study was to evaluate the effectiveness of a specific program of exercises for strengthening the abductor muscles in these patients.

METHODS

A multicentre, prospective, randomised clinical trial was carried out in an outpatient rehabilitation setting on 103 patients given THR for DDH through a minimally-invasive anterolateral approach. Patients were randomly divided into a Study Group, including 46 patients, and a Control Group, including 57 patients. All patients underwent standard early postoperative rehabilitation. In addition, the Study Group were given an extra 2-week rehabilitation once full weight-bearing on the operated limb was allowed, aimed at strengthening the abductor muscles. All patients were evaluated preoperatively, and at about 3 and 6 months postoperatively. Clinical measures (lower limb-length differences, hip range of motion, abductor muscle strength), and functional measures (WOMAC, HHS, 10mt WT, SF-12) were taken.

RESULTS

Hip range of motion and functional outcome measures showed a progressive improvement at follow ups in both groups, significantly higher in the Study Group. In particular, abductor strength at 6 months post-op improved by 92.5% with respect to 35.7% in the Control Group.

CONCLUSION

In addition to standard rehabilitation, a rehabilitation programme for strengthening the gluteal muscles in DDH patients who underwent THR determined an increase in muscle strength that improved functional performance and patient satisfaction.

Surgical Technique and Case Series of Total Hip Arthroplasty with the Hueter Anterior Approach for Crowe Type-IV Dysplasia

BACKGROUND

Total hip arthroplasty (THA) is being increasingly performed via the Hueter anterior approach (HAA), which has proven benefits with nondysplastic hips; however, little has been published on its outcomes with dysplastic hips, where it can provide better acetabular exposure. We describe our technique for THA via the HAA in hips with Crowe type-IV developmental dysplasia and report the mid-term outcomes of cases that were performed over 5 consecutive years.

METHODS

We retrospectively evaluated a continuous series of 8 hips (6 patients) with Crowe type-IV dysplasia; the patient ages ranged from 44 ± 20 years (range, 17 to 65 years) at the index THA. All of the patients received uncemented implants via the HAA on a traction table to restore the hip center of rotation to the true acetabulum. Femoral head autografts (FHAs) were used to increase acetabular coverage in 6 hips, and subtrochanteric shortening osteotomies (SSOs) were performed in 5 hips. Patients were assessed clinically and radiographically at a minimum follow-up of 2 years.

RESULTS

There were no revisions, deaths, dislocations, or infections. Two hips (25%) had intraoperative complications, and 1 hip (13%) had a postoperative complication that required reoperation without implant removal. All of the hips were assessed clinically and radiographically at 4 ± 1 years (range, 2 to 6 years). The modified Harris hip score (mHHS) improved from 33 ± 7 to 90 ± 7, and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) improved from 53 ± 14 to 89 ± 6; the postoperative leg-length discrepancy was 3.2 mm (range, -10 to 20 mm). None of the hips had osteolysis or radiolucent lines of >2 mm.

CONCLUSIONS

THA via the HAA on a traction table for hips with Crowe type-IV dysplasia yielded satisfactory mid-term outcomes. Both FHA and SSO can be adequately performed via the HAA to help restore the hip center of rotation to the true acetabulum.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Metal on metal hip arthroplasty surveillance at a tertiary centre: design, patients' adherence, and cost analysis

PURPOSE

Metal-on-metal (MOM) bearings may carry higher than expected revision rates and serious complications: an appropriate surveillance may be advocated. Aims of this paper were to (1) present the biennial experience of MOM surveillance in a tertiary centre, (2) describe the patients' adherence to monitoring, and (3) analyze the costs of the surveillance METHODS: The design of MOM surveillance was developed according to the guidelines of the Italian Society of Orthopaedics and Traumatology. The adherence to every follow-up was expressed as raw numbers and percentages. A cost analysis (direct and indirect costs) was conducted and projected in a five year time span.

RESULTS

About 61.1% of patients adhered to the first step of the surveillance, and 13.5% answered to a specific questionnaire about MOM implant. About 36.2% of the patients participated for the annual follow-up, and 18.1% entered the six month follow-up program. Of the implants, 2.5% required a revision. A two year surveillance costs €45,520.30, €236,443.98 (57.7%) including revisions. Five-year projected costs will be €23.113,64 (5.6%). Hospital indirect costs, including personnel working days, were €150,392.30 (36.7%). The estimated economic burden for seven years will be €409,949.92 (direct € 259,557.62, indirect €150,392.30).

CONCLUSION

Patients' adherence to MOM surveillance is modest and the rate of dropouts seems not to stop over the time. Most of the expenses are due to revision surgeries, as well as indirect costs. Economy of scale may be suggested to reduce the costs, involving as much MOM population as possible.

Acetabular Bone Defect in Total Hip Arthroplasty for Crowe II or III Developmental Dysplasia of the Hip: A Finite Element Study

Background

The purpose of this study was to establish the finite element analysis (FEA) model of acetabular bone defect in Crowe type II or III developmental dysplasia of the hip (DDH), which could evaluate the stability of the acetabular cup with different types of bone defects, different diameters of femoral ceramic heads, and the use of screws and analyze the stress distribution of screws.

Methods

The FEA model was based on the CT scan of a female patient without any acetabular bone defect. The model of acetabular bone defect in total hip arthroplasty for Crowe II or III DDH was made by the increasing superolateral bone defect area of the acetabular cup. Point A was located in the most medial part of the acetabular bone defect. A 52 mm PINNACLE cup with POROCOAT Porous coating was implanted, and two screws (the lengths were 25 mm and 40 mm) were implanted to fix the acetabular cup. The stability of the acetabular cup and the von Mises stress of point A and screws were analyzed by a single-legged stance loading applied in 1948 N (normal working). The different diameters of the femoral ceramic head (28 mm, 32 mm, and 36 mm) were also analyzed.

Results

The von Mises stress of point A was gradually increased with the increasing uncoverage values. When the uncoverage values exceeded 24.5%, the von Mises stress of point A without screws increased significantly, leading to instability of the cup. Screws could effectively reduce the von Mises stress of point A with uncoverage values of more than 24.5%. However, the peak von Mises stress in the screws with the uncoverage values that exceeded 24.5% was considerably increased. The diameter of the femoral ceramic head had no significant effect on the von Mises stress and the stability of the acetabular cup.

Conclusions

We recommend that uncoverage values of less than 24.5% with or without screw is safe for patients with Crowe II or III DDH.

Comparison of Trochanteric Slide and Subtrochanteric Shortening Osteotomy in the Treatment of Severe Hip Dysplasia: Mid-Term Clinical Outcomes of Cementless Total Hip Arthroplasty

BACKGROUND

The aim of this study is to compare clinical results of Crowe type III-IV developmental dysplasia of the hip (DDH) patients who underwent total hip arthroplasty with either trochanteric slide osteotomy (TSO) or subtrochanteric shortening osteotomy (SSO).

METHODS

The patients who underwent cementless total hip arthroplasty with femoral shortening osteotomy due to Crowe type III/IV DDH between 2004 and 2014 and completed at least 5 years of follow-up were retrospectively analyzed. The patients were grouped according to the type of shortening osteotomy as either TSO or SSO. Preoperative and postoperative clinical evaluation included Harris Hip Score, Visual Analogue Scale pain, leg length discrepancy, and the presence of Trendelenburg sign. The clinical outcome measures and complication rates were compared in terms of osteotomy type.

RESULTS

The TSO group consisted of 34 patients (43 hips) and the SSO group consisted of 40 patients (51 hips). The SSO group (96.1%) had a slightly higher 5-year survival of the implant compared to TSO (93%) without statistical significance (P = .18). No significant difference was detected between the groups in terms of clinical outcomes. Complication rates did not significantly differ between the groups except for the lack of bony union which was significantly higher in TSO (P = .006) but this difference did not transform into clinical significance since 5 of 6 patients who did not have a bony union in the TSO group were symptom-free with a fibrous union.

CONCLUSION

TSO and SSO provide similar clinical outcomes at mid-term follow-up in the management of Crowe III-IV DDH by cementless total hip arthroplasty. Both techniques can be used safely depending on the surgeon's preference.

LEVEL OF EVIDENCE

Level III, Therapeutic, Case-control study.

Clinical and Radiological Results of Crowe Type 3 or 4 Dysplasia Patients Operated on With Total Hip Arthroplasty Using a Cementless Rectangular Femoral Component Without Fixating or Grafting the Transverse Osteotomy Site

BACKGROUND

Total hip arthroplasty (THA) involving shortening osteotomy for patients with Crowe type 3 or 4 dysplasia is a challenging surgical procedure. This study aims to demonstrate that rectangular femoral component use in anatomical reconstructions with THA and transverse shortening osteotomy yields successful results without the use of bone graft or any fixation material at the osteotomy site.

METHODS

Fifty hips from 41 patients were identified retrospectively as per study objectives. All patients were evaluated using the Harris Hip Score and Visual Analog Scale for pain. Complications were reported. Radiological evaluation criteria were then evaluated, including leg length discrepancy, degree of trochanter caudalization and stem subsidence, radiolucent and radiodense lines for both components and bone atrophy or hypertrophy around the stem according to Gruen zones, and the canal fill ratio of the stem.

RESULTS

Postoperative Harris Hip Score was excellent for 68% of patients. No patient had poor results. Complication rate was 32%. One patient had nonunion (2%). The mean postoperative leg length discrepancy was 0.8(±0.6) cm. No patient had a subsidence of more than 5 mm. Radiolucent and radiodense lines were present in up to 34% of patients, and bone atrophy was present in the proximal femur in up to 96% of patients. No patient had osteolysis or loosening in neither component.

CONCLUSION

Successful clinical and radiological results can be obtained from Crowe type 3 and 4 dysplastic hips operated on with THA using a rectangular femoral component and transverse shortening osteotomy technique. The use of graft or any fixation material at the osteotomy site is not mandatory.

Comparison of two different on-shelf femoral stems for Crowe type IV developmental dysplasia of the hip

Objective

This study was performed to evaluate the proximal anatomical compatibility of stems for treatment of Crowe IV developmental dysplasia of the hip (DDH) using a previously developed three-dimensional comparison technique.

Methods

Patients with Crowe IV DDH who underwent computed tomography were retrospectively analyzed. The femoral medullary canals were three-dimensionally reconstructed, and models of cementless modular (S-ROM; DePuy Synthes) and conical (Wagner Cone; Zimmer Biomet) implants were used for virtual implantation. The negative point percentages (NPPs) were applied to verify fitting. The average distance (deviation) and the root mean square of the distance (RMSd) were used to quantify geometric compatibilities.

Results

Four (16.7%) and 12 (50.0%) femoral medullary canals could not be fitted properly with either the modular or conical implant. The NPPs in the distal comparison region were significantly greater in the conical than modular group. The deviation was significantly smaller in the modular than conical group. The RMSd was also significantly smaller in the modular than conical group.

Conclusions

Compared with conical implants, modular implants might be more effectively used in patients with Crowe type IV DDH. However, some Crowe IV DDH femurs with severe deformity cannot be fitted with either of these two on-shelf implants.

The Effect of the False Acetabulum on Femoral Proximal Medullary Canal in Unilateral Crowe Type IV Developmental Dislocation of the Hip

Purpose

To investigate the effect of the false acetabulum on femoral proximal medullary canal in unilateral Crowe type IV developmental dislocation of the hip (DDH) patients on anteroposterior radiographs.

Patients and Methods

We measured the following parameters of DDH and contralateral normal hip (CNH) of proximal morphology of femurs on 65 patients with unilateral Crowe type IV DDH (30 hips with no false acetabulum (type IVA) and 35 hips with a false acetabulum (type IVB)) in our hospital between September 2009 and July 2019 on anteroposterior radiographs: the widths of medullary canals at 20 mm above the center of lesser trochanter (CLT), 20 mm below the CLT and the isthmus. Canal flare index (CFI), metaphyseal canal flare index (MCFI), diaphyseal canal flare index (DCFI) were calculated.

Results

The values of CFI of DDH and CNH in unilateral type IVA patients were 2.8 and 4.4, respectively (p < 0.001), and those in type IVB patients were 3.9 and 4.6, respectively (p < 0.001). The MCFIs of DDH and CNH in type IVA group were 2.2 and 2.3, respectively (p = 0.032), and those in type IVB group were 2.4 and 2.4, respectively (p = 0.242). The DCFIs of DDH and CNH in type IVA group were 1.3 and 1.9, respectively (p < 0.001), and those in type IVB group were 1.7 and 1.9, respectively (p = 0.002).

Conclusion

The false acetabulum stimulated the development of the proximal femur in Crowe type IV DDH. The variation of the femoral proximal medullary canal in type IVA DDH mainly occurred at the metaphyseal and proximal diaphyseal levels, and that in type IVB DDH mainly occurred at the proximal diaphyseal level.

Cementless Total Hip Arthroplasty for Adult Patients With Sequelae From Childhood Hip Infection: A Medium-Term Follow-Up Study

BACKGROUND

The aim of this study is to evaluate midterm clinical and radiographic results of total hip arthroplasties (THAs) with cementless implants for adult patients with sequelae from childhood hip infection.

METHODS

Between 2002 and 2016, 165 patients (165 hips) who had a hip infection during childhood were treated with THAs with cementless implants. The average duration of follow-up was 93.5 months (range 26-206). Clinical results were evaluated via the Harris Hip Score and radiographic results were analyzed with postoperative serial X-rays.

RESULTS

The average Harris Hip Score increased from 27 (range 8-53) before surgery to 91 (range 45-100) at the latest follow-up examination (P < .001). At the latest follow-up evaluation, 9 cementless acetabular components demonstrated partial, nonprogressive radiolucencies. No subsidence of more than 2 mm or evidence of a radiolucent line was observed around the femoral components. Intraoperative periprosthetic fractures occurred in 11 hips, including 3 acetabular fractures, 2 fractures of greater trochanter, 1 femoral shaft fracture, and 5 fractures of femoral calcar. Postoperative complications included 3 cases of periprosthetic infection, 1 episode of dislocation, 1 case of a femoral periprosthetic fracture, 5 cases of sciatic nerve injury, 1 case of femoral nerve injury, and 1 case of squeaking from a ceramic bearing surface.

CONCLUSION

Cementless THA for adult patients with sequelae from childhood hip infection presents significant technical challenges and a relatively high complication rate. With meticulous surgical planning and anticipation for the key technical challenges frequently encountered, the medium-term clinical and radiographic results of THA in this setting were good with high implant survivorship and patient satisfaction.

Surgical Approach and Reaming Depth Influence the Direction and Magnitude of Acetabular Center of Rotation Changes During Total Hip Arthroplasty

Background

Changes in acetabular or hip center of rotation (HCOR) commonly occur during acetabular component preparation during total hip arthroplasty (THA). HCOR displacement in mediolateral or superoinferior directions is known to influence offset and leg length, but the incidence and range of HCOR change in the anteroposterior direction is less understood as the sagittal plane cannot be measured on standard anteroposterior radiographs. This study assessed the 3-dimensional displacement of HCOR after cup implantation and evaluated for potential factors associated with increased acetabular component translations.

Methods

A total of 894 THAs were performed using a posterior, lateral, or direct anterior approach. Only intraoperative data from the navigation device were included in the analysis. All THAs performed between September 2015 and October 2017 were included. Paired t-tests were used to compare native HCOR and new HCOR values.

Results

The mean HCOR displacement in 3 directions was 4.97mm medially (P < .001), 0.83mm superiorly (P < .001), and 0.64mm posteriorly (P < .001). Subgroup analysis revealed greater posterior HCOR displacement with the anterior approach than the lateral/posterior approach (2.32mm vs 0.44mm; P < .001). Increasing medial HCOR displacement also resulted in increased superior and posterior HCOR displacement across surgical cases (P < .001).

Conclusions

HCOR displacement is commonly observed in medial, superior, and posterior directions. HCOR changes are influenced by surgical approach, potentially secondary to patient positioning, with greater posterior HCOR displacement observed in anterior cases. Surgeons should be aware of these factors, particularly in cases with deficient or reduced posterior column bone stock.

The Direct Anterior Approach for Total Hip Arthroplasty for Severe Dysplasia (Crowe III and IV) Provides Satisfactory Medium to Long-Term Outcomes

BACKGROUND

The direct anterior approach (DAA) is increasingly used for total hip arthroplasty (THA). Although the DAA can reduce pain, recovery time, and dislocations in nondysplastic hips, few studies report its results in patients with severe dysplasia. We aimed to evaluate outcomes of primary THA through the DAA with cup placement at the true acetabulum in hips with severe dysplasia.

METHODS

We retrospectively evaluated 23 consecutive patients (29 hips) who underwent THA by DAA for osteoarthritis secondary to Crowe III-IV dysplasia. Surgical procedures were performed on a traction table, and the acetabular cup was placed in the true acetabulum. Patients were assessed clinically (complications, modified Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index, Oxford Hip Score) and radiographically (radiolucencies, subsidence, leg length discrepancies, cup inclination, and cup coverage) at a minimum of 2 years.

RESULTS

One patient (2 hips) died with original implants (at 13 and 14 years), 3 patients (3 hips) were revised due to wear-induced loosening (at 14, 16, and 18 years), and there were no dislocations or infections. The remaining 19 patients (24 hips) were assessed at 8.4 ± 4.7 years (range 2-20); 2 patients (2 hips) had complications that required reoperation without implant removal. The modified Harris Hip Score improved from 32 ± 9 to 94 ± 7, Western Ontario and McMaster Universities Osteoarthritis Index from 46 ± 18 to 90 ± 7, and Oxford Hip Score was 56 ± 4. Patients were very satisfied (90%) or satisfied (10%). Limb length discrepancy was 2.5 ± 9.0 mm.

CONCLUSION

THA through the DAA with cup placement at the true acetabulum provides satisfactory mid to long-term clinical and radiographic outcomes compared to other approaches for hips with severe dysplasia.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Mid-term outcomes of a partial 2-stage approach in late chronic periprosthetic hip infections

INTRODUCTION

Late chronic periprosthetic infections (LCPIs) are worrisome complications of primary hip arthroplasties. The gold standard procedure is the 2-stage revision. 1-stage exchange is gaining popularity in order to reduce the invasivity of the former technique. A partial 2-stage exchange technique, retaining fixed components, may overcome some of the drawbacks of the previous techniques, allowing a much easier reconstruction step.

METHODS

28 patients with a LCPI after a primary total hip arthroplasty underwent a first removal stage: the loosened component was removed (23 cups and 5 stems) and the fixed component, with no local signs of infection, was retained. An antibiotic hand molded spacer was positioned in 16 cases. After a mean time of 8 months and a tailored antimicrobial therapy, the spacer was removed and the implant was revised.

RESULTS

The mean follow-up was 5 years. The HHS score was 82.7. 4 cases failed (2 patients presenting a septic relapse after revision and 2 patients undergoing Girdlestone arthroplasty), achieving a survival rate of 83.4% at 5 years. 2 patients were unwilling to perform a further procedure and did not proceed to the second stage. All the other patients had no clinical, radiological, laboratory signs of septic relapse.

CONCLUSIONS

The partial 2-stage approach seems a promising technique for LCPI in selected cases, with good infection control. It allows an easier revision by sparing the fixed components. Larger case series and longer follow-ups are needed to confirm the results and identify the limits of this approach.

Leg Length Balance in Total Hip Arthroplasty for Patients with Unilateral Crowe Type IV Developmental Dysplasia of the Hip

Objective

To explore the leg length balance in total hip arthroplasty (THA) with shortening subtrochanteric osteotomy (SSTO) or not for unilateral Crowe type IV developmental dysplasia of the hip (DDH) through the evaluation of postoperative full‐length anteroposterior radiographs.

Methods

The postoperative radiographs of 60 patients with unilateral Crowe type IV DDH from July 2012 to May 2019 were retrospectively reviewed. All patients underwent THA using the Pinnacle Acetabular Cup system, a ceramic liner and femoral head, and the S‐ROM stem with a proximal sleeve or cone. Patients with leg length discrepancy (LLD) < 10 mm were defined as the non‐LLD group. To identify differences associated with SSTO, the group was further divided into two groups based on whether the patient underwent SSTO. A total of 48 patients (26 for SSTO and 22 for non‐SSTO) were in the non‐LLD group. There were 3 male and 45 female patients. The mean age of the patients in the non‐LLD group was 39 years. These data, including leg length, femoral length, the height of center of rotation (COR) of the hip, the depth of the sleeve or cone in the femoral medullary canal and the height of the greater trochanter, were measured.

Results

In the non‐LLD group, the femoral lengths in both SSTO and non‐SSTO groups were significantly shorter on the operated side compared with the contralateral side, and the mean discrepancy in the SSTO group was approximately equal to the mean length of the SSTO. The mean height of the COR of the hip on the operated sides in both SSTO and non‐SSTO groups was 13.2 mm, and the contralateral sides were 15.2 and 15.5 mm, respectively. The depth of the sleeve or cone in the femoral medullary canal between SSTO and non‐SSTO groups was 21.7 and 30.6 mm, respectively. The depth of the sleeve or cone in the SSTO group was negatively correlated with the length of SSTO. The heights of the greater trochanter in the operated and contralateral sides were 5.3 and 16.6 mm in the SSTO group, and 13.2 and 17.2 mm in the non‐SSTO group, respectively.

Conclusions

Shortening subtrochanteric osteotomy led to femoral shortening on the operated side for patients with unilateral Crowe type IV DDH. The position of the sleeve or cone should be close to the apex of the greater trochanter to compensate the length of the SSTO. The position of the sleeve or cone without SSTO should be adjusted to make sure that the height of the greater trochanter on the operated side is close to that on the contralateral side.

Best bone of acetabulum for cup component placement in Crowe types I to III dysplastic hips: a computer simulation study

BACKGROUND

During cup implantation, vertical height of the cup center (V-HCC) should be precisely controlled to achieve sufficient bone-cup coverage (BCC). Our study aimed to investigate the acetabular bone stock and the quantitative relationship between V-HCC and BCC in Crowe types I to III hips.

METHODS

From November 2013 to March 2016, pelvic models of 51 patients (61 hips) with hip dysplasia were retrospectively reconstructed using a computer software. Acetabular height and doom thickness were measured on the mid-acetabular coronal cross section. V-HCC was defined as the vertical distance of cup rotational center to the interteardrop line (ITL). In the cup implantation simulation, the cup was placed at the initial preset position, with a V-HCC of 15 mm, and moved proximally by 3-mm increments. At each level, the BCC was automatically calculated by computer. Analysis of variance and Kruskal-Wallis test were used to compare the differences between groups.

RESULTS

There were no significant between-group differences in maximum thickness of the acetabular doom; however, peak bone stock values were obtained at heights of 41.63 ± 5.14 mm (Crowe type I), 47.58 ± 4.10 mm (Crowe type II), and 55.78 ± 3.64 mm (Crowe type III) above the ITL. At 15 mm of V-HCC, median BCC was 78% (75-83%) (Crowe type I), 74% (66-71%) (Crowe type II), and 61% (57-68%) (Crowe type III). To achieve 80% of the BCC, the median V-HCC was 16.27 (15.00-16.93) mm, 18.19 (15.01-21.53) mm, and 24.13 (21.02-28.70) mm for Crowe types I, II, and III hips, respectively.

CONCLUSION

During acetabular reconstruction, slightly superior placement with V-HCC <25 mm retained sufficient bone coverage in Crowe I to III hips.

Total Hip Arthroplasty for Crowe Type IV Hip Dysplasia: Surgical Techniques and Postoperative Complications

Total hip arthroplasty (THA) of Crowe type IV developmental dysplasia of the hip (DDH) is challenging. Although traditional (lateral, posterolateral, and posterior) THA approaches have been used with great anatomic success, they damage periarticular muscles, which are already quite weak in type IV DDH. The recently developed direct anterior approach (DAA) can provide an inter‐nerve and inter‐muscle approach for THA of type IV dysplasia hips. However, femur exposure with the DAA could be difficult during surgery and it is hard to apply femoral shortening osteotomy. THA techniques used for type IV DDH include anatomic hip center techniques (true acetabular reconstruction) and high hip center techniques, wherein an acetabulum is reconstructed above the original one. Although anatomic construction of the hip center is considered “the gold standard” treatment, it is impossible if the anatomical acetabular is too small and shallow. Procedures used to support type IV DDH reduction with anatomic hip center techniques include greater trochanter osteotomy, lesser trochanter osteotomy, and subtrochanteric osteotomy. However, these techniques have yet to be standardized, and it is unclear which is best for type IV DDH. One‐state and two‐state non‐osteotomy reduction techniques have also been introduced to treat type IV DDH. Potential complications of THA performed in patients with type IV DDH include leg length discrepancy (LLD), peri‐operative femur fracture, nonunion of the osteotomy site, and nerve injury. It is worth noting that nowadays an increasing number of Crowe type IV DDH patients are more sensitive to postoperative LLD.

Component positioning and ceramic damage in cementless ceramic-on-ceramic total hip arthroplasty

BACKGROUND

In ceramic-on-ceramic (CoC) total hip arthroplasty (THA), component positioning demonstrated to influence the bearing damage: however the connection between angles and clinical outcomes at long-term follow-ups is currently lacking. Aims of this study were: the computer tomography (CT) assessment of component positioning in CoC THAs; the correlation analysis between positioning and ceramic damage; the identification of safe zones.

METHODS

91 consecutive post-operative CT scans including two types of CoC implants, with a mean follow-up of 12 ± 4.4 years, were evaluated. III generation (74.2%) and IV generation (25.8%) CoC surfaces were included. The angle measurements (cup abduction, anteversion, cup tilt, stem antetorsion, sacral slope) were automated using a CT-based software. The combined anteversion was assessed as well as the cup-neck position at -15°, 0°, 45° and 90° of flexion. Ceramic damage was diagnosed using synovial fluid analyses and radiological criteria.

RESULTS

63.7% of THAs was inside the cup abduction target 30°-45° and 68.1% was inside the cup anteversion target 5°-25°. 19 patients (20.9%) showed signs of ceramic damage. High cup abduction and high cup-neck 45° minimum angle (which stood for high abduction and extreme combined version) significantly correlated with ceramic damage. No demographical features apart III generation ceramic bearings influenced the results. No safe zones could be detected.

CONCLUSIONS

In CoC THA, no safe zones can be described. However it is important to avoid cup inclination over 45° and a combination of steep cup and extreme combined version.

Highly Porous Titanium Cups versus Hydroxyapatite-Coated Sockets: Midterm Results in Metachronous Bilateral Total Hip Arthroplasty

OBJECTIVE

Highly porous titanium cups have been recently introduced, with contradictory outcomes. A retrospective consecutive case series involving bilateral metachronous total hip arthroplasties (THA) performed with 2 different cups, i.e., Fixa (F) and Fixa Ti-Por (T) (Adler Ortho, Milan, Italy), and the same stem, was evaluated. T sockets, manufactured using electron beam melting, were supposed to prove superior in terms of clinical results, survival rates, and radiographic parameters in comparison to hydroxyapatite-coated F cups with conventional porosity.

SUBJECTS AND METHODS

Twenty-four bilateral metachronous THAs with an F cup on one side and a T socket on the other side were evaluated. Preoperative and postoperative Harris hip scores (HHS) were collected for every patient. Radiographic signs of loosening were assessed. The radiographic signs of osseointegration (radiolucent lines, superolateral buttress, inferomedial buttress, radial trabeculae, and stress shielding) were evaluated.

RESULTS

No intraoperative complications occurred. The mean HHS score was excellent and comparable in both groups. At the mean follow-up of 134 months (F) and 79 months (T), no cup or liner revisions were performed. No radiographic signs of loosening were reported. All of the patients revealed 3 parameters of good bony ingrowth at least. Both groups showed similar radiographic parameters regarding osseointegration, which were stable over the time. Stress shielding was more evident in the T cohort (p =0.07).

CONCLUSION

Highly porous titanium cups produced using an additive manufacturing and electron beam melting technology achieved reliable midterm clinical and radiographic results not inferior to those of second-generation cups.