Revision of cemented hip arthroplasties. 101 hips followed for 5 (4-9) years

Is a Total Hip Arthroplasty Stem in Varus a Risk Factor of Long-Term Mechanical Complication?

BACKGROUND

The impact of implanting cementless femoral stems in varus alignment on long-term mechanical complications remains poorly defined in the literature. The aim of our study was to compare survivorship and functional and radiographic outcomes of stems in varus alignment to those in neutral alignment with and average follow-up of 10 years.

METHODS

This single-center, multisurgeon, retrospective case-control study compared a group of 105 total hip arthroplasty (THA) patients who had varus stem alignment (Varus Stem) to a matching group of 105 THA patients who had neutral stem alignment, operated on between January 2007 and December 2012. The primary outcome measure was implant survival. Secondary outcomes included functional (Harris Hip Score, Postel Merle d'Aubigné Score, thigh pain, dislocation and hip range of motion) and radiographic outcomes (radiolucency, osseointegration, heterotopic ossification, subsidence, and stress shielding).

RESULTS

There was no significant difference in implant survival between the 2 groups with 95.7% (±2.46) in the Varus Stem group versus 97.7% (±1.64) in the Neutral Stem group (P = .41) after an average follow-up of 10 years. There was no significant difference in clinical and radiographic outcomes between groups.

CONCLUSION

Cementless femoral stems in varus alignment were not the cause of mechanical complications with an average follow-up of 10 years. The comparison between groups in terms of implant survival, functional, and radiographic outcomes does not show any significant differences. Positioning a femoral stem in varus alignment may be an alternative for surgeons wishing to restore preoperative offset and to ensure satisfactory hip stability.

Cement Mantle Quality and Stem Alignment in Cemented Collarless Polished Tapered Stems Implanted via the Direct Anterior and Direct Lateral Approaches: A Single Institution Experience

BACKGROUND

The aim of this study was to compare the stem alignment and the quality of cement mantle of collarless polished tapered cemented stems inserted through the direct anterior approach (DAA) and the direct lateral approach (DLA).

METHODS

A comparative retrospective study of 232 hybrid total hip arthroplasties using a cemented collarless polished tapered stem through either the DAA (n = 147) or DLA (n = 85) was performed. Radiographic evaluation included stem alignment, cement mantle quality, and cement mantle thickness.

RESULTS

On anteroposterior radiographs, stems implanted through the DLA were more likely to be in neutral alignment, than those implanted through the DAA (83.5%[n = 71] versus 71.4% [n = 105]; P = <.001). No difference between approaches was noted for stem alignment on lateral radiographs or cement mantle quality. Multivariate analysis revealed factors associated with suboptimal cement mantle and included Dorr type B or C femur as well as male gender. A mean cement mantle thickness ≥2mm was achieved in all Gruen zones for both approaches.

CONCLUSION

In our series, the DAA was associated with a higher incidence of coronal plane stem malalignment compared to the DLA when using cemented tapered polished femoral components for total hip arthroplasty. No difference in lateral stem alignment or cement mantle quality was found.

A Role for Modern Primary Cementless Femoral Stems in Revision Hip Arthroplasty

BACKGROUND

In revision total hip arthroplasty (THA) cases with preserved femoral metaphyseal bone, tapered proximally porous-coated "primary" femoral stems may be an option. The objective of this study was to compare outcomes of patients with Paprosky I or II femoral bone loss undergoing revision THA with either a primary metaphyseal-engaging cementless stem or a revision diaphyseal-engaging stem.

METHODS

This was a retrospective analysis of 70 patients with Paprosky I or II femoral bone loss who underwent femoral revision. 35 patients who were revised using a primary cementless femoral stem were compared with 35 patients who underwent femoral revision using a revision diaphyseal-engaging stem. The groups were similar regarding age, gender, body mass index, and American Society of Anesthesiologists. Clinical and radiographic outcomes and complications were compared over an average follow-up of 2.9 years (SD 1.4).

RESULTS

Revision THA was most commonly performed for periprosthetic joint infection (N = 27, 38.6%). The groups were similar with regards to Paprosky femoral classification (P = .56), length of stay (P = .68), discharge disposition (P = .461), operative time (P = .20), and complications (P = .164). There were no significant differences between primary and revision femoral stem subsidence (0.12 vs. 0.75 mm, P = .18), leg length discrepancy (2.3 vs. 4.05 mm, P = .37), and Hip Disability and Osteoarthritis Outcome Score Jr (73.1 [SD 21.1] vs. 62.8 [SD 21.7], P = .088). No patient underwent additional revision surgery involving the femoral component.

CONCLUSION

Use of modern primary cementless femoral stems is a viable option for revision hip arthroplasty in the setting of preserved proximal femoral metaphyseal bone. Outcomes are not inferior to those of revision stems and offer potential benefits.

Cemented Femoral Fixation Using a Direct Anterior Approach: Background, Indications, and Surgical Technique

The use of the direct anterior approach (DAA) in total hip arthroplasty has increased dramatically over the past decade. Potential benefits of the DAA include earlier functional recovery and lower risk of periprosthetic dislocation, but issues with periprosthetic fracture and femoral loosening have been reported, particularly in elderly patients. Cemented femoral fixation may offer a means to decrease early femoral failure in elderly patients undergoing the DAA. Here, we will present a step-by-step technique for cementing the femoral implant through the DAA.

Influence of femoral broach shape on stem alignment using anterior approach for total hip arthroplasty: A radiologic comparative study of 3 different stems

Background

Malalignment of the femoral stem in total hip arthroplasty (THA) can detrimentally affect outcome. Poor preparation of the femur intraoperatively is an important cause of stem malalignment.

Purposes

The objective was to compare coronal alignment of three different stems using three different broaches.

Methods

Retrospective study of three groups of 60 patients following primary THA via direct anterior approach, by the same surgeon, between January 2015 and January 2016. Each group had a similar designed stem (Corail Depuy, Targos Lepine or Meije Tornier). Groups were matched for age, body mass index, gender, side, neck shaft angle and indications. The significant difference between groups was the broach shape. Broaches for the Corail and Meije stems had a prominent shoulder laterally, while the broach of the Targos stem had a rounded less prominent shape laterally. Coronal alignment was determined radiologically at 2 months.

Results

The mean varus was significantly lower for the Targos stems (1.1° +/-0.8) compared to the Corail (2.3° +/-1.5) and Meije stems (1.9° +/-1.2) (p<0.0001). There were significantly less Targos stems with varus greater than 3° (1.7%, n = 1) compared to the Corail (40%, n = 24) and Meije stems (20%, n = 12) (p<0.001).

Conclusion

A femoral broach with a prominent lateral shoulder when performing a THA via direct anterior approach will increase the risk of varus femoral stem alignment compared to a less laterally prominent broach.

Functional outcome after revision hip arthroplasty: a metaanalysis

The current study systematically reviews the literature describing patient outcomes after revision total hip arthroplasties using conventional global hip score ratings. Two thousand one hundred thirty-seven English-language articles published from 1966 through 2000 were identified through a computerized literature search and bibliography review. A three-step filter process was used to identify articles to be included in the metaanalysis. Forty-two articles with 2578 patients had data abstracted for the analysis. Metaanalysis of global hip scores was done using a fixed effects model with the assumption that the variances of each measurement were identical across studies. Thirty-nine articles reporting on 46 cohorts progressed through three filters and went to data extraction and analysis. Revision total hip arthroplasty is a reasonably safe and effective procedure for failed hip replacement Based on this exploratory analysis revision hip procedures seem to have comparable longevity, to primary hip replacement but appear to have slightly lower functional outcome (as measured by global hip scores), and slightly higher morbidity and mortality rates than primary procedures. Inconsistent reporting in the original studies limited exploration of other factors that may have affected outcomes.

Results of a tapered cementless femoral stem implanted in varus

Varus placement of the femoral component in total hip arthroplasty has been associated with poor outcomes. The purpose of this study was to examine results of total hip arthroplasty with varus alignment of a tapered titanium femoral prosthesis (Alloclassic; Sulzer, Zurich, Switzerland) at a minimum 5-year follow-up. Of a consecutive series of 585 patients, 23 met the inclusion criteria. Harris hip scores averaged 97, and all implants were clinically and radiographically stable at the most recent follow-up. In this series of patients, varus alignment of the prosthesis did not have an adverse effect on outcome. Although malalignment of the femoral prosthesis may compromise the results of some designs, the Alloclassic prosthesis has proved to be reliable and forgiving despite varus malalignment at 5 to 11 years' follow-up.

An oblong revision cup for large acetabular defects: design rationale and two- to seven-year follow-up

Loosening and migration of acetabular components often lead to extensive bony defects with an elongated, oval acetabular cavity. In these cases standard implants will not reestablish and maintain sufficient stability without leaving bone defects or using massive bone grafts or excess cement and additional metal rings or shells, disadvantages that are overcome by using an oblong revision cup without cement. The titanium shell is available in different sizes, is screwed to the autochthonous acetabular bone and houses an oblong polyethylene inlay, designed to reestablish the normal anatomic hip center. Of 109 consecutive revision cups, 102, implanted for American Academy of Orthopaedic Surgeons (AAOS) defects types I-IV, were followed up clinically and radiologically for 2 to 7 years (mean, 3.6 years). Primary stability was achieved in all cases. In 40% no bone grafting was necessary at all. The radiological follow-up revealed good remodeling of the surrounding bone and osseointegration of the implants. Zonal radiolucent lines, always smaller than 2 mm, were seen in 18 cases, only once completely and in only 5 cases partially progressing. Six cups migrated slightly (< or =2 mm), two moderately (3-5 mm), all without clinical symptoms, and two more than 5 mm. Migration and radiolucencies were mainly seen in patients with allografts and major defects, which indicates that bone ingrowth appears more unlikely in such cases. Few asymptomatic cases showed zonal sclerotic lines. There were two aseptic loosenings, one in a case with pelvic discontinuity, the other in a patient with severe rheumatoid arthritis following two previous revisions. Survivorship analysis based on implant removal because of aseptic loosening as the endpoint shows a cumulative success rate of 98.1% at 8 years.

Cemented revision total hip arthroplasties in patients younger than 55 years old. A multicenter evaluation of second-generation cementing technique

The results of all cemented first-time revisions in Sweden performed in patients younger than 55 years of age, during the period 1984-1986, are reported. The revisions were performed by the average orthopaedic surgeon in 25 hospitals distributed throughout Sweden. Second-generation femoral cementing technique was used. One third of the acetabular revisions were performed with pressurized cement. The reason for revision was aseptic loosening. Seventy hips in 68 patients were reviewed at an average follow-up period of 7 years (range, 4-10 years). The average age of the patients at the time of revision surgery was 47 years. Forty-eight cups and 57 stems were revised using cement. Survival analysis, with revision for aseptic loosening as the endpoint, suggests an overall 76% survival rate after 8 years. The survival rate for the cup was 80%, and for the stem, 85%. The radiographic evaluation revealed that the cement mantle was inadequate in many revisions. Localized osteolysis was rare. Clinical data were reported for 55 (53 patients) non-revised hips. Thirty-five hips were without pain or slightly painful. Forty patients limped when walking. Forty-three patients were satisfied with the revised hip. These results using second-generation femoral cementing technique are better than those reported with first-generation technique, but the failure rate in this young patient population is too high. The search for a more durable fixation in revision total hip athroplasty for young patients with long life expectancy is ongoing. These results emphasize that there is a need for centralization to gain experience in extended clinical research and to further improve surgical and cementing techniques.

Intraoperative complications of revision hip arthroplasty using a fully porous-coated straight cobalt-chrome femoral stem

The operative complications of a consecutive series of 135 cementless revision total hip arthroplasties using a fully porous-coated straight cobalt-chrome femoral stem were reviewed. Intraoperative complications occurred in 59 cases (44%), 22 of which (37%) involved more than one complication. Three categories of intraoperative complications were recorded: eccentric reaming, femoral perforation, and femoral fracture. Complications were noted to decrease throughout the period of the study. Surgical approach did not affect the complication rate. Stem length, stem diameter, and host-bone quality all affected the complication rate. Femoral perforations and fractures were more numerous with femoral stems longer than 200 mm. Larger-diameter femoral stems (> or = 18 mm) were associated with a higher complication rate (55%). Complications were also more numerous with poorer-quality host-bone. In cases of multiple complications, eccentric reaming often predisposed bone to perforation and subsequently to fracture. There was also greater blood loss in patients with intraoperative complications. Intraoperative complications may be avoided with the use of implants, as well as reaming no longer than absolutely necessary, and the use of intraoperative radiographs or flexible reamers early in femoral canal preparation.

Revision arthroplasty with an isoelastic uncemented femoral stem

We carried out 102 hip revision arthroplasties using an uncemented isoelastic femoral stem on 92 patients between 1985 and 1989. The proximal femoral bone stock had deteriorated in 45%. Eleven patients died during the mean follow up of 5.7 years. The femoral component has been revised again for loosening in 13, for infection in 5 and for dislocation in 3. Radiographs of 70 hips showed incipient migration at 3 months in 20, and at the time of review 27 hips had migrated 5 mm or more. Nine stems had migrated more than 8 mm and were judged to be loose. There were 11 fractures before operation and 15 during operation; they all healed. Slight cortical hypertrophy of not more than 2 mm was present in most cases. Three patients (4 hips) were excluded because of severe systemic illness. Of the remaining 66 hips, the clinical outcome was excellent in 18%, good in 50%, fair in 26% and poor in 6%. The isoelastic stem is associated with poor primary fixation which is indicated by early subsidence. The results, with a total failure rate of 33%, are unsatisfactory and the isoelastic femoral stem used in this series cannot be recommended for revision operations.