Comparison of cemented and cementless total hip arthroplasty in patients with bilateral hip arthroplasties

Cemented versus Cementless Femoral Fixation for Elective Primary Total Hip Arthroplasty: A Nationwide Analysis of Short-Term Complication and Readmission Rates

Cementless fixation during total hip arthroplasty (THA) is the predominant mode of fixation utilized for both acetabular and femoral components during elective primary THAs performed in the United States. This study aims to compare early complication and readmission rates between primary THA patients receiving cemented versus cementless femoral fixation. The 2016-2017 National Readmissions Database was queried to identify patients undergoing elective primary THA. Postoperative complication and readmission rates at 30, 90, and 180 days were compared between cemented and cementless cohorts. Univariate analysis was conducted to compare differences between cohorts. Multivariate analysis was performed to account for confounding variables. Of 447,902 patients, 35,226 (7.9%) received cemented femoral fixation, while 412,676 (92.1%) did not. The cemented group was older (70.0 vs. 64.8, p < 0.001), more female (65.0% vs. 54.3%, p < 0.001), and more comorbid (CCI 3.65 vs. 3.22, p < 0.001) compared to the cementless group. On univariate analysis, the cemented cohort had decreased odds of periprosthetic fracture at 30 days postoperatively (OR: 0.556, 95%-CI 0.424-0.729, p < 0.0001), but higher odds of hip dislocation, periprosthetic joint infection, aseptic loosening, wound dehiscence, readmission, medical complications, and death at all timepoints. On multivariate analysis, the cemented fixation cohort demonstrated reduced odds of periprosthetic fracture at all postoperative timepoints: 30 (OR: 0.350, 95%-CI 0.233-0.506, p < 0.0001), 90 (OR: 0.544, 95%-CI 0.400-0.725, p < 0.0001), and 180 days (OR: 0.573, 95%-CI 0.396-0.803, p = 0.002). Cemented femoral fixation was associated with significantly fewer short-term periprosthetic fractures, but more unplanned readmissions, deaths, and postoperative complications compared to cementless femoral fixation in patients undergoing elective THA.

Primary stability of a proximally coated and tapered stem

AIMS

The aim of this prospective cohort study was to evaluate the early migration of the TriFit cementless proximally coated tapered femoral stem using radiostereometric analysis (RSA).

METHODS

A total of 21 patients (eight men and 13 women) undergoing primary total hip arthroplasty (THA) for osteoarthritis of the hip were recruited in this study and followed up for two years. Two patients were lost to follow-up. All patients received a TriFit stem and Trinity Cup with a vitamin E-infused highly cross-linked ultra-high molecular weight polyethylene liner. Radiographs for RSA were taken postoperatively and then at three, 12, and 24 months. Oxford Hip Score (OHS), EuroQol five-dimension questionnaire (EQ-5D), and adverse events were reported.

RESULTS

At two years, the mean subsidence of the head and tip for the TriFit stem was 0.38 mm (SD 0.32) and 0.52 mm (SD 0.36), respectively. The total migration of the head and tip was 0.55 mm (SD 0.32) and 0.71 mm (SD 0.38), respectively. There were no statistically significant differences between the three to 12 months' migration (p = 0.105) and 12 to 24 months' migration (p = 0.694). The OHS and EQ-5D showed significant improvements at two years.

CONCLUSION

The results of this study suggest that the TriFit femoral stem achieves initial stability and is likely to be stable in the mid and long term. A long-term outcome study is required to assess late mechanisms of failure and the effects of bone mineral density (BMD) related changes. Cite this article: Bone Joint J 2021;103-B(4):644-649.

Distal femoral cortical hypertrophy after hip arthroplasty using a cementless doubletapered femoral stem

PURPOSE

To review 437 hips in 404 patients who underwent total hip arthroplasty (THA) or hemiarthroplasty using the Accolade TMZF stem to determine the incidence and risk factors of distal femoral cortical hypertrophy (DFCH).

METHODS

Records of 437 hips in 169 men and 235 women aged 26 to 100 (mean, 65.7) years who underwent THA (n=293) or hemiarthroplasty (n=144) using the Accolade TMZF femoral stem by 2 senior surgeons and were followed up for a mean of 54.7 months were reviewed. Clinical outcome was assessed using the modified Harris Hip Score and visual analogue score for pain. Proximal femoral geometry and canal flare index were assessed on preoperative radiographs, and DFCH, stem position, subsidence, loosening, and stress shielding were assessed on postoperative radiographs according to the Gruen zone.

RESULTS

Of 437 hips, 27 (6.2%) developed DFCH and 410 did not. Hips with DFCH had a higher incidence of thigh pain (18.5% vs. 2.2%, p<0.001) and earlier onset of thigh pain (12.3 vs. 20.8 months, p=0.015), compared with those without. Nonetheless, all femoral stems were well-fixed, and no osteolysis or loosening was detected. The 2 groups achieved comparable clinical outcome in terms of Harris Hip Score and pain. The mean canal flare index was higher in hips with than without DFCH (3.706 vs. 3.294, p=0.002). The mean vertical subsidence of the femoral stem was lower in hips with than without DFCH (1.5 vs. 3.4 mmp<0.001). Subsidence negatively correlated with the canal flare index (correlation coefficient= -0.110, p=0.022). The incidence of the DFCH increased with each unit of increment in canal flare index (odds ratio [OR]=1.828, p=0.043) and each year younger in age (OR=0.968, p=0.015).

CONCLUSION

The incidence of DFCH in hips withthe Accolade TMZF stem was 6.2%. Patients with a higher canal flare index and younger age had a higher incidence of DFCH. Nonetheless, DFCH did not affect clinical outcome or femoral stem stability.

Stable Fixation of a Cementless, Proximally Coated, Double Wedged, Double Tapered Femoral Stem in Total Hip Arthroplasty: A 5-Year Radiostereometric Analysis

BACKGROUND

The objective of this 5-year prospective study of 51 hips was to assess migration of a cementless tapered femoral stem using radiostereometric analysis (RSA), plain radiographs (radiolucencies), and patient-reported outcome measures (PROMs).

METHODS

Forty-seven patients (51 hips) agreed to participate in this prospective RSA study. All patients received a Taperloc stem. Tantalum beads were inserted into the femoral bone surrounding the stem to measure migration using RSA. RSA films, plain radiograph, and PROM follow-up were obtained immediately after surgery, 6 months, 1, 2, 3, and 5 years after surgery.

RESULTS

The median (interquartile range) subsidence was 0.03 mm (-0.23 to 0.06) at 5 years, with no significant differences over time. Four outlier stems had >1.5 mm of subsidence by 1 year. No stem showed radiolucencies in more than 3 zones during the 5 years. All PROMs remained favorable at 5 years, suggesting an excellent outcome. There were no stems revised for mechanical loosening; 1 stem was revised for an infection.

CONCLUSION

After initial settling, the cementless tapered femoral stems in our series were stable. The 4 outlier stems with >1.5 mm of subsidence by 1 year remain stable at 5 years. RSA was the most sensitive method of detection for stems at greater risk for potential future failure. This report adds contributions to the positive results associated with this type of fixation. The results at 5 years showed excellent midterm survivorship in this cohort with a cementless tapered femoral component.

Cemented versus uncemented fixation in total hip replacement: a systematic review and meta-analysis of randomized controlled trials

The optimal method of fixation for primary total hip replacements (THR), particularly fixation with or without the use of cement is still controversial. In a systematic review and metaanalysis of all randomized controlled trials comparing cemented versus uncemented THRS available in the published literature, we found that there is no significant difference between cemented and uncemented THRs in terms of implant survival as measured by the revision rate. Better short-term clinical outcome, particularly an improved pain score can be obtained with cemented fixation. However, the results are unclear for the long-term clinical and functional outcome between the two groups. No difference was evident in the mortality and the post operative complication rate. On the other hand, the radiographic findings were variable and do not seem to correlate with clinical findings as differences in the surgical technique and prosthesis design might be associated with the incidence of osteolysis. We concluded in our review that cemented THR is similar if not superior to uncemented THR, and provides better short term clinical outcomes. Further research, improved methodology and longer follow up are necessary to better define specific subgroups of patients in whom the relative benefits of cemented and uncemented implant fixation can be clearly demonstrated.

Total hip arthroplasty at the rothman institute

BACKGROUND

Total hip arthroplasty (THA) is one of the most successful surgical interventions devised in modern times. Attempts to change the current THA procedure with unproven innovations bring the risk of increased failure rates while trying to improve the benefit of the surgery.

QUESTIONS/PURPOSES

This manuscript examines the evolution of THA at the Rothman Institute illustrating the key elements that lead the success of this procedure at this institution. These key elements include femoral stem design, use of highly crossed-linked polyethylene and use of pain and rehabilitation protocols. We attempted to describe the long-term results regarding safety, effectiveness, and durability of specific THA implant designs used at this institution drawing on reported evidence in the literature.

METHODS

The authors performed a review of peer-reviewed articles related to the Rothman Institute's experience with THA.

RESULTS

Total hip arthroplasty is an efficient, safe, and durable procedure. It is a highly successful operation to restore function and improve pain. The survivorship of THA procedures at the Rothman Institute is higher than 99% at 10 years based on mechanical failure. The use of collarless, tapered wedge femoral stem, highly crossed-linked polyethylene, and improved pain rehabilitation protocols have contributed to this success.

CONCLUSIONS

There is a well-documented long-term survivorship after THA. Future innovation in THA should address new challenges with younger and more demanding patients, rather than change current methods that have a proven good survivorship. This innovation depends mainly upon improvements in the bearing surfaces and advances in pain control and rehabilitation.

Total hip arthroplasty: to cement or not to cement the acetabular socket? A critical review of the literature

The optimal method for acetabular socket fixation remains controversial. We present a critical analysis of the current evidence from a systemic literature review of comparative studies, long-term case series, prior literature reviews, meta-analysis, and national arthroplasty registry data for cemented and uncemented acetabular components to determine the respective survivorship rates, overall risk of re-operation, dislocation rates, and wear-related complications. Using contemporary techniques, both cemented and uncemented sockets can yield good long-term results, but our evaluation suggests that the overall/all cause re-operation risk is lower for cemented fixation. Until and unless crosslinked polyethylene (PE) liners or alternative bearings can prove to yield superior outcome in the future, the cemented PE cup remains the gold standard, in all age groups, by which every acetabular component should be compared.

Outcome of the cementless Taperloc stem: a comprehensive literature review including arthroplasty register data

BACKGROUND AND PURPOSE

The validity of various data sources for the assessment of the outcome quality of medical devices was investigated by comparative analysis of the published data sources available for a sample of implants. It was the aim of the study to determine the performance of this implant and to identify potential bias factors inherent to the various datasets.

METHODS

A comprehensive literature search was carried out from English-language, peer-reviewed journals and worldwide reports from national arthroplasty registers. Publications from Medline-listed journals were included. The main parameter was revision rate, calculated as "revisions per 100 observed component years" to allow adjusted direct comparison of different datasets.

RESULTS

Of 16 clinical studies that met the inclusion criteria, 9 originated from the implant developer's hospital. In the clinical studies category, publications from the developer's hospital suggested considerably lower revision rates than the other datasets. In fact, the values quoted were 5.5 times below the average of all other studies, and 9.51 times lower than in the Australian arthroplasty register. These differences are statistically significant.

INTERPRETATION

The cementless Taperloc stem is an implant that shows good performance regarding revision rates in registry data and in clinical studies. However, the excellent results published by the developer's clinic are generally not reproducible by other surgeons. In terms of reference data, registry data are able to make an important contribution to the assessment of clinical sample-based studies, particularly regarding evaluation of the extent to which published results are reproducible in daily routine.

Is there evidence for a superior method of socket fixation in hip arthroplasty? A systematic review

PURPOSE

Total hip arthroplasty has been a very succesful orthopaedic procedure. The optimal fixation method of the acetabular component however, has not yet been defined.

METHODS

We performed a systematic review using the Medline and Embase databases to find evidence for the superiority of cemented or cementless acetabular components on short- and long-term clinical and radiological parameters. Methodological quality for randomised trials was assessed using the van Tulder checklist, and for the non randomised studies we used the Newcastle-Ottawa quality assessment scale.

RESULTS

Our search strategy revealed 16 randomised controlled trials (RCT) and 19 non RCT studies in which cemented and cementless acetabular components are compared. A best evidence analysis for complications, wear, osteolysis, migration and clinical scores showed no superiority for either cemented or cementless socket in the RCTs. A best evidence analysis for non RCT studies revealed better osteolysis, migration properties and aseptic loosening survival for cementless sockets; however, wear and overall survival favoured the cemented sockets.

CONCLUSIONS

We recommend that an orthopaedic surgeon should choose an established cemented or cementless socket for hip replacement based on patient characteristics, knowledge, experience and preference.

Minimum 5-year results in 96 consecutive hips treated with a tapered titanium stem system

We performed total hip arthroplasty with single titanium stem in 96 consecutive, nonselected hips. All patients, regardless of bone type and shape, neck shaft angulation, or age, received the same implant. Patients were followed for a minimum of 5 years, and an independent radiographer evaluated the hips for ingrowth, subsidence, leg-length discrepancy, and remodeling. The average Harris Hip score was 96 points (range, 73-100 points) at final follow-up. Radiographically, all stems were ingrown. No stem had more than 3 mm of subsidence, and there were no leg-length discrepancies more than 5 mm. We concluded that this titanium stem is a versatile option for total hip arthroplasty in patients with a wide variety of demographic and femur characteristics.

A proximally coated beaded stem minimum 5-year follow-up

This study reports the minimum 5-year clinical and radiographic outcome of a proximally beaded stem. A consecutive series of 159 primary uncemented total hip arthroplasties in 153 patients were evaluated clinically and radiographically by prospectively determined criteria. Radiographic results showed 97% of the femoral stems are bone ingrown and stable by Engh criteria. There have been 5 femoral revisions (2 for subsidence, 2 for loosening, and 1 broken trunion). At minimum 5-year follow-up, this femoral stem has demonstrated reliable clinical function, bone ingrowth, and proximal bone preservation.

Primary total hip arthroplasty with an uncemented femoral component: two- to seven-year results

This prospective study reports the midterm outcome of total hip arthroplasty performed in a consecutive series of patients using a tapered uncemented femoral component. The cohort consists of 631 patients (700 hips). The clinical records and the routine serial radiographs of these patients were monitored closely over a 5-year period. Follow-up averaged 4.35 years. There was a significant improvement in functional outcome of these patients as measured by Harris hip score and short-form 36.There were 4 revisions for aseptic loosening of the femoral component in this series, accounting for an overall survivorship of 99.4%. The study confirms that the midterm outcome of this stem is excellent, with a low revision rate.

21-year results of the uncemented fully textured lord hip prosthesis

We report the updated results for a previously evaluated patient cohort who had uncemented total hip arthroplasties using the Lord femoral component. The original cohort consisted of 114 total hip arthroplasties (110 patients) performed from 1979 to 1984. The patients were followed up for an average of 21 years postoperatively. We describe the radiographic findings of 57 hips. At the last followup 11 (9.6%) of the 114 femoral components were revised or removed. Excluding infection there was an 83% 21-year survival according to Kaplan-Meier analysis. No significant radiographic changes occurred since the last publication. The prostheses are very well-fixed with no signs of loosening. Our current findings show the durability of the uncemented Lord femoral component indicating this prosthesis provides good long-term results.

Cemented or uncemented femoral component in primary total hip replacement? A review from a clinical and radiological perspective

Controversy exists regarding the optimal method of fixation for primary total hip replacement, particularly the femoral component. We performed a systematic literature review to explore whether cemented total hip replacement can achieve better clinical and radiological outcomes. A total of 29 publications were selected using computer-aided and manual searches. A qualitative comparison of results in clinical and radiological changes was then conducted. Most of the literature showed that better short-term clinical and functional outcomes could be obtained from cemented femoral fixation than from uncemented femoral fixation. Results were less clear for the mid-term clinical outcome, though in general, cemented fixation still appeared to show a superior clinical outcome. Radiographic differences are variable and do not seem to correlate with clinical findings. For the short- and mid-term, cemented femoral component is recommended. However, a long-term randomised trial combined with a large cohort study or registry is needed.

Primary total hip arthroplasty with an uncemented femoral component: a long-term study of the Taperloc stem

The purpose of the current study was to evaluate the long-term result of a tapered, uncemented femoral component. We retrospectively reviewed the clinical and radiographic records of 121 patients (129 hips) who underwent primary total hip arthroplasty with the use of the Taperloc uncemented stem. Follow-up averaged 11 years (range, 6-15 years). The mean Harris Hip Score at the latest follow-up was 92.1. Thigh pain was reported in 5 patients (3.6%). One stem was revised at 6 years because of severe proximal femoral osteolysis. There was no evidence of radiographic subsidence or loosening around any stems. The overall medium- to long-term outcome of the Taperloc stem is excellent, with a low revision rate and high patient satisfaction.

Thigh pain after cementless total hip arthroplasty: evaluation and management

Data from short- and long-term follow-up studies indicate that thigh pain is a significant complication after apparently successful cementless total hip arthroplasty. In most cases, reported symptoms are mild to moderate, resolve spontaneously or do not progress, and require little or no therapeutic intervention. However, persistent thigh pain may be a source of dissatisfaction or may present as severe, disabling pain. Possible causes include bone-prosthesis micromotion, excessive stress transfer to the femur, periosteal irritation, or a mismatch in Young's modulus of elasticity that increases the structural rigidity of the prosthetic stem relative to the femur. Thorough diagnostic evaluation of thigh pain is essential to rule out prosthetic infection or loosening, stress fracture, or spinal pathology as the primary source. Treatment options in the aseptic, well-fixed femoral component include medical management, revision of the femoral component, or cortical strut grafting at the tip of the implant.

Total hip arthroplasty using two different cementless tapered stems

The authors report their 15-year experience with primary total hip arthroplasty using collarless, tapered, porous-coated femoral stems (Trilock and Taperloc) in patients with osteoarthritis, rheumatoid arthritis, and in octogenarians. Excellent clinical results were achieved in all groups at latest followup. For the patients with Trilock stems, Taperloc stems, and patients who were octogenarians and patients with rheumatoid arthritis, Charnley pain scores were 5.6, 5.5, 5.7, and 5.7; Charnley function scores were 5.2, 5.1, 4.2, and 5.3; Harris hip scores were 92, 92, 82, and 93 points, respectively. There was a 2% rate of thigh pain with the Trilock, 4% with Taperloc, 4% in octogenarians, and 2% in patients with rheumatoid arthritis. In 96% of the patients in the Trilock group, in 100% of the patients in the Taperloc group, in 100% of the patients who were octogenarians, and in 100% of the patients with rheumatoid arthritis, femoral components showed radiographic evidence of bone ingrowth. There were six (12%) femoral component revisions in the Trilock group (all secondary to nonmodularity of the component at the time of acetabular revision), one femoral component revision in the Taperloc group and no femoral component revisions in the patients who were octogenarians or who had rheumatoid arthritis. Design features (collarless tapered wedge fit, circumferentially porous-coated) virtually ensure bone ingrowth and are thought to be responsible for the excellent clinical results and longevity.

Matched-pair analysis of cemented and cementless acetabular reconstruction in primary total hip arthroplasty

In a matched-pair study of primary total hip arthroplasty, 45 all-polyethylene cemented acetabular components were compared with 45 cementless, hemispheric, titanium acetabular components. At 9 to 12 years, 1 of the cemented acetabular components was revised for aseptic loosening, and 14 (31%) were radiographically loose. Nine (20%) cemented acetabular components had pelvic osteolysis. In the cementless acetabular component group, 2 well-fixed components were revised. No components were radiographically loose, and 3 (7%) had pelvic osteolysis. Thirty-eight (97%) of the patients in each group were satisfied with the surgery. The clinical results of the cemented and cementless components were excellent. The cementless components had less loosening (P <.001) than the cemented components.

Cementless femoral fixation in the rheumatoid patient undergoing total hip arthroplasty: minimum 5-year results

Sixty-two total hip arthroplasties in 49 patients with a diagnosis of rheumatoid arthritis were performed between November 1986 and December 1992. All components were titanium alloy with a circumferential plasma-spray porous coating. Four patients (4 hips) died before 5-year follow-up, and 6 patients (8 hips) were lost to follow-up, leaving 39 patients (50 hips) for review at a minimum 5-year follow-up after surgery (mean, 8 years; range, 5-12 years). There were 12 men and 27 women, with a mean age at time of surgery of 55 years (range, 25-77 years) and a mean weight of 69 kg (range, 42-109 kg). Compared with the preoperative Charnley scores, there was significant improvement in the postoperative scores: pain, from 2.7 to 5.7, and function, from 3.2 to 5.3. Thigh pain was present in 1 patient (1 hip) (2.0%). No femoral fractures occurred intraoperatively with the insertion of the prosthesis. Spot welds consistent with bone ingrowth were identified in all of the femoral components. No femoral components showed evidence of radiographic loosening or required revision for aseptic loosening or incapacitating thigh pain, but 7 acetabular revisions were performed. Uncemented femoral fixation with this component design in rheumatoid patients appears to be a promising treatment.

Patients' perception of pain after total hip arthroplasty

A study was undertaken to determine the frequency with which patients had pain that they attributed to their hip after total hip arthroplasty. Pain drawings were used to allow patients to localize the area of their symptoms, and the degree of pain was quantified with visual analog scales. Complete clinical and radiographic data were collected on all patients so that the occurrence of pain could be correlated with a number of parameters previously reported to affect the incidence of pain, including age, sex, activity level, length of follow-up, stem size, bone type (Dorr index), and type of stem fixation (proximally coated, fully coated, or cemented). Results indicated that type of stem fixation was the only parameter statistically correlated with a higher incidence of thigh pain. Patients with proximally coated stems were more than twice as likely to complain of pain than patients with fully coated or cemented hips (P < .01). Although the incidence of thigh pain was significantly higher with proximally coated stems, the severity was not, averaging 3.0 to 3.5 out of 10 on visual analog scale in all 3 groups. The results indicate that patients perceived pain as originating in the hip in a high percentage of cases, particularly when proximally coated stems were used.