Isolated revision of an acetabular component to a ceramic-on-ceramic bearing in patients under 50 years of age

Isolated acetabular cup revision in Metal-on-Metal total hip arthroplasty: a low-complication strategy feasible in only half of cases

PURPOSE

There is still a debate regarding the removal of the femoral stem due to the risk of trunnion. To answer this question, we conducted a study to compare long terms outcomes of isolated acetabular to total revision of MoM THA using an institutional arthroplasty registry.

METHODS

From 1996 to 2019, 150 patients (12.5%) of the 1202 revision THAs (rTHA) recorded in Geneva Arthroplasty Registry (GAR) underwent a revision of a MoM THA. After matching the two groups,126 patients were finally included: 63 in each group. The mean age was 64.4 (SD 11.6) years, 48.4% (61/126) were women with a mean BMI of 27.2 (SD 5.5) Kg/m2.

RESULTS

The overall survival rate was 88.1% [79.9-97.2%] at ten years. 10-year survival rate was 93.5% [86.2-100.0%] after isolated acetabular rTHA and 79.5% [61.7-100.0%] after total rTHA (p = 0.16). Regarding Hip Harris score and Merle d'Aubigne score, no difference at last follow-up was observed between the two groups (respectively: p = 0.39; p = 0.33). Regarding the chrome, cobalt, and nickel level reduction, no difference was observed between the two groups (respectively, p = 0.38, 0.81 and 0.97).

CONCLUSION

No difference was observed between isolated acetabular and total revision of MoM THAs regarding survival rate and ions levels at long term. It seems advisable to perform an isolated acetabular revision of a MoM THA when it is indicated.

LEVELS OF EVIDENCE

Level III, case control studies.

Periprocedural clinical outcomes of revision hip arthroplasty: a multi-centric comparison of current strategies based on the NSQIP

INTRODUCTION

Recent projections suggest a substantial rise in demand for revision total hip arthroplasties, emphasizing the need for optimized perioperative care. Various revision techniques, such as isolated acetabular or femoral component revisions and total replacements, have garnered attention. Further research is needed to establish the most effective strategies for improving clinical outcomes.

METHODS

This retrospective analysis utilized data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use File from 2016 to 2021. The study aimed to compare clinical characteristics and 30-day outcomes among patients undergoing combined acetabular and femoral (A + F) revision,  acetabulum-only (A) revision, and femoral side-only (F) revision surgeries.

RESULTS

The analysis of 18,888 patients revealed crucial differences in preoperative and postoperative outcomes among various revision strategies. Specifically, there were notable variations in patient demographics, comorbidities, and emergency procedures. Postoperative data showed distinct rates of mortality, complications, and readmissions across the groups. Notably, femoral component revisions were associated with increased risks of mortality, transfusion, and urinary tract infections, underscoring the need for careful evaluation and consideration when opting for this revision approach.

CONCLUSION

The study's significance lies in its extensive patient cohort and multifaceted evaluation of revision strategies. Although consensus is lacking on single-component revisions, targeting the acetabulum component appears relatively safer. Continued research and individualized evaluations are crucial for refining revision strategies and optimizing outcomes in THA revisions.

The impact of retaining the femoral stem in revision total hip arthroplasty: a systematic review, meta-analysis, and meta-regression

INTRODUCTION

The management of well-fixed femoral stems in revision total hip arthroplasty (rTHA) remains a subject of debate, with concerns over potential complications arising from stem retention. This study aimed to investigate the re-revision rates due to aseptic loosening of the stem, overall re-revision rates, dislocation rates, and factors influencing these outcomes in rTHA with a retained well-fixed femoral stem.

MATERIALS AND METHODS

A systematic search was conducted across several databases including PubMed, EMBASE, and CENTRAL to identify pertinent publications from their inception through 2023. We specifically focused on studies that reported outcomes of rTHA with retained well-fixed femoral stems. The study designs incorporated in our research encompassed both cohort studies and case series studies. Thirty-five studies involving isolated acetabular revision and retaining the stem were included, representing a total of 3497 patients. Data extraction was tailored to the study questions. Meta-analyses, meta-regression, and subgroup analyses were conducted to evaluate the outcomes and their relationship with various factors. Pooled results, meta-regression, and subgroup analyses were performed using random-effects models. To assess and reduce bias, we employed Egger's test and the trim and fill method.

RESULTS

The meta-analysis included 3497 patients with a mean follow-up of 9.28 years. The 10-year risk of re-revision after retaining femoral stem using highly cross-linked polyethylene was 1.7% (95% CI 1.1%-2.3%; I2: 60%) for stem aseptic loosening and 8.8% (95% CI 6.2%-11.4%; I2: 78%) overall re-revision. Dislocation risk was 5.7% (95% CI 4.1-7.0%; I2: 61%). Ceramic heads showed lower stem failure risk than metal heads in long-term follow-ups (P < 0.001). The posterolateral approach in revision surgery resulted in better long-term outcomes compared to the direct lateral approach (P < 0.001). Follow-up duration, timeline of study, Harris Hip Score, type of stem fixation, femoral head material, BMI, age, stem age, and surgical approach were evaluated as influential factors on these outcomes.

CONCLUSION

The re-revision rate due to aseptic loosening of the retained stem during rTHA was found to be significantly low, supporting the idea of retaining well-fixed stems during rTHA. The overall re-revision and dislocation rates also presented comparable or better outcomes to prior studies. A range of factors, including the use of highly cross-linked polyethylene and ceramic femoral heads, was found to influence these outcomes.

LEVEL OF EVIDENCE

IV.

PROSPERO REGISTRATION NUMBER

CRD42022351157.

Survivorship of the retained femoral component after revision total hip arthroplasty: A systematic review and meta-analysis

Objective

This systematic review and meta-analysis aimed to estimate re-revision rates of retained femoral components after revision of total hip arthroplasty (THA).

Methods

Papers were searched in the PubMed, Embase, Web of Science, and Cochrane Library databases with predetermined keywords from January 2000 to January 2022. The studies reporting the re-revision rates of retained stems after revision THA were identified. Pooled rates of re-revision for any reason and aseptic loosening were calculated using a random-effects model or a fixed-effects model based on the results of heterogeneity assessment after the Freeman–Tukey double-arcsine transformation. A meta-regression was performed to explore potential sources of heterogeneity.

Results

There were 20 studies with 1,484 hips that received the isolated cup revision with the femoral component retained. The pooled re-revision rate of retained stems was 1.75% [95% confidence interval (CI) 0.43%–3.65%]. The re-revision rate of retained stems due to aseptic loosening was 0.62% (95% CI, 0.06%–1.55%). The meta-regression showed that the fixation type (cemented or cementless) was related to the re-revision rate for any reason and the re-revision rate for aseptic loosening.

Conclusion

Based on the existing evidence, the isolated cup revision with a stable stem in situ yields low re-revision rates. The cement status of retained stems may influence the survivorship of stems.

The outcome of subsequent revisions after primary total hip arthroplasty in 1,049 patients aged under 50 years : a single-centre cohort study with a follow-up of more than 30 years

AIMS

The aim of this study was to determine the outcome of all primary total hip arthroplasties (THAs) and their subsequent revision procedures in patients aged under 50 years performed at our institution.

METHODS

All 1,049 primary THAs which were undertaken in 860 patients aged under 50 years between 1988 and 2018 in our tertiary care institution were included. We used cemented implants in both primary and revision surgery. Impaction bone grafting was used in patients with acetabular or femoral bone defects. Kaplan-Meier analyses were used to determine the survival of primary and revision THA with the endpoint of revision for any reason, and of revision for aseptic loosening.

RESULTS

The mean age of the patients at the time of the initial THA was 38.6 years (SD 9.3). The mean follow-up of the THA was 8.7 years (2.0 to 31.5). The rate of survival for all primary THAs, acetabular components only, and femoral components only at 20 years' follow-up with the endpoint of revision for any reason, was 66.7% (95% confidence interval (CI) 60.5 to 72.2), 69.1% (95% CI 63.0 to 74.4), and 83.2% (95% CI 78.1 to 87.3), respectively. A total of 138 revisions were performed. The mean age at the time of revision was 48.2 years (23 to 72). Survival of all subsequent revision procedures, revised acetabular, and revised femoral components at 15 years' follow-up with the endpoint of revision for any reason was 70.3% (95% CI 56.1 to 80.7), 69.7% (95% CI 54.3 to 80.7), and 76.2% (95% CI 57.8 to 87.4), respectively. A Girdlestone excision arthroplasty was required in six of 860 patients (0.7%).

CONCLUSION

The long-term outcome of cemented primary and subsequent revision THA is promising in these young patients. We showed that our philosophy of using impaction bone grafting in patients with acetabular and femoral defects is a very suitable option when treating young patients. Surgeons should realize that knowledge of the outcome of subsequent revision surgery, which is inevitable in young patients, must be communicated to this group of patients prior to their initial THA. Cite this article: Bone Joint J 2022;104-B(3):368-375.

Long-Term Survival (up to 34 Years) of Retained Cementless Anatomic Femoral Stem in Patients <50 Years Old

BACKGROUND

There is a paucity of studies longer than 30 years to determine clinical and radiographic results of retained cementless anatomic stem. The purpose of this study is to determine the long-term (up to 34 years) survival rate of the retained cementless anatomic femoral stem in patients <50 years of age.

METHODS

Isolated cup revision was performed with retaining primary cementless anatomic femoral stem in 206 patients (149 men and 57 women). Clinical and radiographic results were monitored at each follow-up. At the latest follow-up, computed tomography scans were carried out in all hips to determine the prevalence of osteolysis. The mean follow-up of the retained femoral stem was 30.3 years (range 27-34). The mean follow-up of the revised cup was 25.5 years (range 22-29).

RESULTS

The mean Harris Hip Score was 91 ± 7.8 points (range 71-100) and the mean Western Ontario and McMaster Universities Osteoarthritis score was 16 ± 7 points (range 7-34) at the final follow-up. The mean University of California, Los Angeles activity score was 7 ± 4 points (range 5-10) at the final follow-up. The overall survival rate of retained cementless femoral stems was 98.9% (95% confidence interval 91-100) at 30.3 years. The survival rate of the revised cup was 93% (95% confidence interval 89-98) at 25.5 years.

CONCLUSION

The rate of aseptic loosening of already osseointegrated femoral stem remains low with ceramic-on-ceramic bearing in young active patients.

Delta-on-Delta Ceramic Bearing Surfaces in Revision Hip Arthroplasty

BACKGROUND

Fourth-generation ceramic-on-ceramic couplings were developed to improve ceramic toughness and strength. Encouraging outcomes in primary total hip arthroplasty were reported. This coupling was proposed as an attractive option even in the case of revision procedures, particularly in younger patients with a longer life expectancy. However, the pertinent literature is scarce. Thus, a registry study was conducted to investigate the midterm survival rates and reasons for re-revision of the fourth-generation ceramic-on-ceramic bearing surfaces in revision hip arthroplasties.

METHODS

A total of 327 revision implants (all the components were exchanged) with BIOLOX Delta couplings were investigated using the regional orthopedic registry RIPO. The demographics, the survival rates, and the reasons for re-revision were assessed. Revisions with bearings other than Delta were compared.

RESULTS

Delta bearings achieved a survival rate of 90.5% at 7 years, with stable results. Twenty-six (8%) re-revisions occurred at a mean follow-up of 4.1 years. And 2.8% of the re-revisions were due to recurrent dislocations; 1.5% of the cases were due to cup aseptic loosening. Septic loosening occurred in 1.6% of the cases. No ceramic fractures were reported. When compared to revisions with bearings other than Delta-on-Delta, Delta coupling cohort achieved similar performances at 5 and 7 years. Lower, nonsignificant rates of aseptic and septic loosening were reported in Delta cohort.

CONCLUSION

Delta-on-Delta couplings demonstrated to be reliable bearing surfaces in revision settings at a midterm follow-up. Clinical studies and longer follow-ups are required to investigate potential adverse effects, like squeaking and fractures, and confirm these preliminary findings.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Long-term results of isolated acetabular revisions with reinforcement rings: a 10- to 15-year follow-up

PURPOSE

The management of severe acetabular bone deficiency and a stable femoral stem can be a challenging problem in revision hip surgery. Replacement of both the acetabular and femoral component in elderly patients can increase perioperative risks without the certainty of a better functional outcome. We report the long-term outcome of reinforcement rings in isolated acetabular revision to determine whether this procedure allows hip function restoration and implant longevity.

METHODS

A retrospective study was conducted to evaluate the long-term results of isolated acetabular revision in thirty patients with a mean age of 70.6 years. 16 patients (16 hips) received an acetabular reinforcement ring, and 14 patients received a reconstruction cage. Acetabular defects were classified as Paprosky Type II in 16 cases and Type III in 14 cases. The mean follow-up was 11.3 years (range 10-15 years).

RESULTS

Radiographic signs of loosening were found in 9 cases (30%). 4 cases (13.3%) with severe osteolysis and implant migration underwent further revision surgery. All 30 unrevised femoral stems were considered stable. 1 (3%) early dislocation, was conservatively treated. Clinical assessment showed a significantly improved mean Harris Hip Score from 45.1 points preoperatively to 85.4 at the latest follow-up (p < 0.05). The 15-year survival rate was 86.7%.

CONCLUSIONS

Our long-term results showed that in selected patients, isolated acetabular revision with rings or antiprotrusio cages represents a reasonable surgical technique for the management of severe acetabular bone loss. However, concerns about the high radiographic loosening rates are possibly related to low bone ingrowth compared to new porous implants.

There Is No Significant Difference in Fretting and Corrosion at the Trunnion of Metal and Ceramic Heads

No study has compared the prevalence of fretting and corrosion at the trunnion of cobalt-chrome (Co-Cr) and zirconia ceramic heads in the same patients. The authors sought to compare the prevalence of fretting and corrosion at the trunnion after total hip arthroplasty with a 32-mm Co-Cr or a 32-mm zirconia ceramic head-on-polyethylene bearing. Isolated revision of the ace-tabular components was performed in 78 patients (156 hips) for polyethylene wear and osteolysis of the acetabulum. Seventy-eight Co-Cr head-titanium alloy stem pairs were compared with 78 zirconia ceramic head-titanium alloy stem pairs in the same patients. Using a visual scoring technique, the 156 head-stem pairs were analyzed for the prevalence of fretting and/or corrosion at the trunnion of the stem and the prevalence of metal transfer to the inner taper of the femoral head. Mean patient age was 48 years, and there were 65 men and 13 women. There was no trunnionosis in either group. Prevalence of fretting (81% vs 83%) and corrosion (4% vs 3%) at the trunnion was not significantly different (P=.518 vs .612, respectively) between the 2 groups. The median fretting scores (1.4±1.1 vs 1.2±1.4 points) and corrosion scores (1.2±0.8 vs 1.3±0.9 points) at the trunnion were not significantly different (P=.893 vs .781, respectively) between the 2 groups. Prevalence of metal transfer to the inner taper of the femoral head (8% vs 10%) and the median metal transfer scores (1.2±0.9 vs 1.4±1.1 points) were not significantly different (P=.213 vs .729, respectively) between the 2 groups. [Orthopedics. 2019; 42(1):e99-e103.].

Adapter Sleeves Are Not Needed to Reduce the Risk of Fracture of a New Ceramic Head Implanted on a Well-Fixed Stem

The purpose of this study was to assess (1) the prevalence of the fracture of ceramic heads implanted on used trunnions of well-fixed stems without using a titanium adapter sleeve; (2) the prevalence of trunnionosis secondary to fretting and/or corrosion at the trunnion of the well-fixed stem; and (3) clinical and radiographic results and the survival rate of the revised acetabular components. Eighty-eight patients (100 hips) underwent isolated revision of the acetabular components for polyethylene wear and osteolysis of the acetabulum. The study group consisted of 70 men and 18 women with a mean age of 52.8 years (range, 31-54 years) when the primary total hip arthroplasty was performed. Evidence of fretting and corrosion of the trunnion of all prostheses was examined macroscopically using a magnifying lens. Degree of fretting and corrosion of the trunnion was assessed using a 4-point scoring technique. A new 36-mm alumina delta ceramic head was implanted on the trunnion of a well-fixed stem without using a titanium adapter sleeve in all hips. The mean follow-up after revision of the acetabular component was 12.8 years (range, 10-14 years). Among the 100 new ceramic heads implanted on a well-fixed stem, no fracture of the ceramic head occurred at a mean follow-up of 12.8 years. The median fretting and corrosion scores for the trunnions were 1.5±1.1 and 1.3±0.9 points, respectively. The mean Harris hip score at the final follow-up was 89±15 points (range, 63-100 points). Survivorship of the revised acetabular components at 14 years was 95% (95% confidence interval, 87.6%-98.6%). [Orthopedics. 2018; 41(3):158-163.].

Isolated revision of the acetabular component using alumina-on-alumina bearings without a metal sleeve: A preliminary study

INTRODUCTION

There has been a debate on the use of ceramic-on-ceramic coupling with the retained femoral stem in isolated acetabular revision. The purpose of this study was to retrospectively review the results and complications of isolated revision of the acetabular component using alumina-on-alumina bearings.

METHODS

Between August 2010 and December 2013, 22 patients (23 hips) with a mean age of 60.74 years (40-73) underwent isolated revision of the acetabular component from metal-on-polyethylene to alumina-on-alumina bearings without using a metal sleeve on the undamaged trunnion. All patients completed clinical and radiographic evaluation.

RESULTS

At a mean follow-up of 3 years (2-5.5), all patients had a significant improvement in the clinical outcome, including Harris Hip Score (84.9 vs. 43, p < 0.001), West Ontario McMaster University Osteoarthritis Index Score (14.4 vs. 49.2, p < 0.001), and visual analogue pain score (1.42 vs. 6.63, p < 0.001). Complications included one aseptic loosening of the acetabular component and three noisy hips (click only). No fracture of the ceramic bearings, dislocation, infection, or squeaking noise were observed in any of the patients.

CONCLUSION

Isolated revision of the acetabular component to alumina-on-alumina bearings on the undamaged trunnion may be considered if there is no available titanium sleeves. Our study showed a satisfactory early outcome with minimal complications. However, a longer term follow-up study is necessary.

In-vivo postoperative motion analysis of metal and ceramic bipolar hip hemiarthroplasty

BACKGROUND

We hypothesized that ceramic bipolar shows less impingement between stem neck and outer head compared to metal bipolar, because of its low coefficient of friction with the acetabulum cartilage. In this paper, a three dimensional (3D) postoperative motion analysis has been used to assess the different motion characteristics of metal and ceramic bipolar hip hemiarthroplasty systems.

METHODS

This study was conducted on 40 patients divided in two matched cohorts: 20 patients with metal bipolar and 20 patients with the ceramic bipolar. We obtained motion pictures from standing position to maximum abduction in flexion by fluoroscopy then analyzed by 2D-3D image matching method. The motion range of the "Outer head angle", "Stem neck angle" and the "Stem neck and outer head angle" was compared between the metal bipolar group and the ceramic bipolar group.

RESULTS

The metal bipolar group's inner head's range of movement was greater than the ceramic bipolar group. Impingement between stem neck and outer head occurred in 30% of metal group patients. There were no impingement cases for the ceramic bipolar group.

CONCLUSIONS

The ceramic bipolar shows less impingement between stem neck and outer head compared to the metal bipolar. Ceramic bipolar may reduce the typical bipolar related complication and exert less effect on the acetabular cartilage due to less surface coefficient of friction.

Acetabular Reconstructions with Impaction Bone-Grafting and a Cemented Cup in Patients Younger Than 50 Years of Age: A Concise Follow-up, at 27 to 35 Years, of a Previous Report

We present an update of 19 acetabular reconstructions, performed with a cemented total hip arthroplasty and impaction bone-grafting, in situ at the time of our previous report. At a mean follow-up of 30 years (range, 27 to 35 years), no additional patients were lost to follow-up. Two patients (3 reconstructions) died for reasons unrelated to the hip surgery. Five reconstructions (5 patients) were revised, 4 for aseptic loosening and 1 for septic loosening, after a mean of 24 years (range, 22 to 27 years), leaving 11 surviving hips (11 patients) that were clinically and radiographically evaluated. Kaplan-Meier survival at 30 years was 0.40 (95% confidence interval [CI], 0.23 to 0.56) for revision for any reason, 0.56 (95% CI, 0.35 to 0.73) for aseptic loosening, and 0.53 (95% CI, 0.33 to 0.69) for radiographic loosening. Competing risk analysis showed that Kaplan-Meier analysis overestimates the revision risk by 18% for revision for any reason and 22% for aseptic loosening. Cemented impaction bone-grafting is a reasonable long-term solution for demanding primary and revision acetabular reconstructions in young patients with acetabular bone defects.

LEVEL OF EVIDENCE

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