Seven-year results of a tapered, titanium, hydroxyapatite-coated cementless femoral stem in primary total hip arthroplasty

Nano-topography and functionalization with the synthetic peptoid GN2-Npm9 as a strategy for antibacterial and biocompatible titanium implants

In recent years, antimicrobial peptides (AMPs) have attracted great interest in scientific research, especially for biomedical applications such as drug delivery and orthopedic applications. Since they are readily degradable in the physiological environment, scientific research has recently been trying to make AMPs more stable. Peptoids are synthetic N-substituted glycine oligomers that mimic the structure of peptides. They have a structure that does not allow proteolytic degradation, which makes them more stable while maintaining microbial activity. This structure also brings many advantages to the molecule, such as greater diversity and specificity, making it more suitable for biological applications. For the first time, a synthesized peptoid (GN2-Npm9) was used to functionalize a nanometric chemically pre-treated (CT) titanium surface for bone-contact implant applications. A preliminary characterization of the functionalized surfaces was performed using the contact angle measurements and zeta potential titration curves. These preliminary analyses confirmed the presence of the peptoid and its adsorption on CT. The functionalized surface had a hydrophilic behaviour (contact angle = 30°) but the hydrophobic tryptophan-like residues were also exposed. An electrostatic interaction between the lysine residue of GN2-Npm9 and the surface allowed a chemisorption mechanism. The biological characterization of the CT_GN2-Nmp9 surfaces demonstrated the ability to prevent surface colonization and biofilm formation by the pathogens Escherichia coli and Staphylococcus epidermidis thus showing a broad-range activity. The cytocompatibility was confirmed by human mesenchymal stem cells. Finally, a bacteria-cells co-culture model was applied to demonstrate the selective bioactivity of the CT_GN2-Nmp9 surface that was able to preserve colonizing cells adhered to the device surface from bacterial infection.

Proximal radiolucent lines around fully hydroxyapatite-coated tapered femoral stems: should we be concerned?

INTRODUCTION

Radiolucent lines occasionally develop around the proximal aspect of fully hydroxyapatite (HA)-coated tapered femoral stems after total hip arthroplasty (THA). It was hypothesised that distal wedging of stems may predispose to proximal radiolucent line formation, which may negatively impact clinical outcome.

METHODS

All primary THA performed with a collarless fully HA-coated stem that had a minimum of 1 year of radiographic follow-up were identified in a surgical database (n = 244). Radiographic measures of proximal femoral morphology and femoral canal fill at the middle and distal thirds of the stem were analysed for association with the presence of proximal radiolucent lines. Linear regression was used to explore any association between radiolucent lines and patient reported outcome measures (PROMs), available in 61% of patients.

RESULTS

Proximal radiolucent lines developed in 31 cases (12.7%) at final follow-up. Dorr A femoral morphology and increased canal-fill at the distal ⅓ of the stem correlated with the development of radiolucent lines (p < 0.001). No correlation was observed between pain or PROMs and the presence of proximal radiolucent lines.

DISCUSSION

We observed an unexpectedly high incidence of proximal femoral radiolucent lines about collarless fully HA coated stems. Distal-only implant wedging in Dorr A bone may compromise proximal fixation. Although this finding did not correlate with short-term outcomes, the long-term clinical impact requires further study.

Comparison of canal fill and radiolucent line formation between two fully coated, hydroxyapatite tapered stems: a 2-year follow-up after total hip arthroplasty

INTRODUCTION

Comparison between fully hydroxyapatite (HA)-coated stems with differing geometry are lacking in the total hip arthroplasty (THA) literature. This study aimed to compare femoral canal fill, radiolucency formation, and 2-year implant survivorship between two commonly used, HA-coated stems.

METHODS

All primary THAs performed with two fully HA-coated stems (Polar stem, Smith&Nephew, Memphis, TN and Corail stem, DePuy-Synthes, Warsaw, IN) with a minimum 2-year radiographic follow-up were identified. Radiographic measures of proximal femoral morphology based on the Dorr classification and femoral canal fill were analyzed. Radiolucent lines were identified by Gruen zone. Perioperative characteristics and 2-year survivorship were compared between stem types.

RESULTS

A total of 233 patients were identified with 132 (56.7%) receiving the Polar stem (P) and 101 (43.3%) receiving the Corail stem (C). No differences were observed with respect to proximal femoral morphology. Femoral stem canal fill at the middle third of the stem was greater for P stem patients than for C stem patients (P stem; 0.80 ± 0.08 vs. C stem; 0.77 ± 0.08, p = 0.002), while femoral stem canal fill at the distal third of the stem and presence of subsidence were comparable between groups. A total of six and nine radiolucencies were observed in P stem and C stem patients, respectively. Revision rate at 2-year (P stem; 1.5% vs C stem; 0.0%, p = 0.51) and latest follow-up (P stem; 1.5% vs C stem; 1.0%, p = 0.72) did not differ between groups.

CONCLUSION

Greater canal fill at the middle third of the stem was observed for the P stem compared to the C stem, however, both stems demonstrated robust and comparable freedom from revision at 2-year and latest follow-up, with low incidences of radiolucent line formation. Mid-term clinical and radiographic outcomes for these commonly used, fully HA-coated stems remain equally promising in THA despite variations in canal fill.

7-year results of primary total hip arthroplasty with the uncemented Avenir stem

AIMS

The aim of the present study was to evaluate the 7-year functional outcome and radiographic results of primary total hip arthroplasties (THAs) performed with the uncemented Avenir stem.

PATIENTS AND METHODS

Between January 2006 and October 2008, 100 consecutive primary hips in 92 patients were enrolled at 2 centres. The mean age at operation was 58.5 years (27-87 years). Mini-incision (50%) and standard approaches (50%) were used to implant 22 standard and 78 lateralised stems.

RESULTS

The 7-year Kaplan-Meier survival rate was 98.9% (95% CI, 92.9-99.8) with stem revision for any reason as endpoint. No stem related complications occurred. 1 stem revision was due to deep infection at 51 months post-op. We had 4 acetabular revisions. The mean Harris Hip Score (HHS) at 7 years follow-up was 93.1 points (60-100). Radiographic analysis showed 2 patients had non-progressive radiolucent lines and no patient had any signs of stem subsidence or loosening.

CONCLUSION

The 7-year implant survival and the functional outcomes for THA performed with the study device are excellent and were in line with those documented for comparable contemporary uncemented fully HA-coated stems. Longer term follow-up of this consecutive series needs to be performed.

Control of calcium accessibility over hydroxyapatite by post-precipitation steps: influence on the catalytic reactivity toward alcohols

Hydroxyapatites exhibit Ca²⁺ and POH surface acid sites, which relative accessibilities can be varied by synthesis to tune the catalytic reactivity toward alcohols.

Evaluation of sorption capacity of antibiotics and antibacterial properties of a cyclodextrin-polymer functionalized hydroxyapatite-coated titanium hip prosthesis

Infection still present as one of common complications after total hip replacement (∼2.5%), which may cause serious outcomes. For preventing such risk, loading antibiotics onto implants for increasing local drug concentration at targeted sites could be a solution. This study aims at modifying the surface of hydroxyapatite (HA) coated titanium hip implant material (Ti-HA) with polymer of cyclodextrin (polyCD) for loading antibiotics, to achieve a sustained local drug delivery. Two widely applied antibiotics (tobramycin and rifampicin) in orthopedic surgery were loaded alone or in combination. The drug adsorption isotherm, drug release kinetics and drug's efficacy were thoroughly investigated. The results proved that polyCD coating significantly improved the affinity of both drugs to Ti-HA surface, while the mechanism of drug-polyCD interaction varies from the nature of drug, courtesy of the structural complex of polyCD. The advantage of dual-drug loading was highlighted by its strong efficacy against both Staphylococcus aureus and Enterobacter cloacae, which overcomes the limitation of mono-drug loading for an effective treatment against both bacterial strains. The prolonged antibacterial activity of antibiotic loaded Ti-HA-polyCD samples confirmed that polyCD could be a promising drug-delivery system, for sustained antibiotics release or other potential applications e.g., antimitotic agent release.

Hip resurfacing versus total hip arthroplasty: a systematic review comparing standardized outcomes

BACKGROUND

Metal-on-metal hip resurfacing was developed for younger, active patients as an alternative to THA, but it remains controversial. Study heterogeneity, inconsistent outcome definitions, and unstandardized outcome measures challenge our ability to compare arthroplasty outcomes studies.

QUESTIONS/PURPOSES

We asked how early revisions or reoperations (within 5 years of surgery) and overall revisions, adverse events, and postoperative component malalignment compare among studies of metal-on-metal hip resurfacing with THA among patients with hip osteoarthritis. Secondarily, we compared the revision frequency identified in the systematic review with revisions reported in four major joint replacement registries.

METHODS

We conducted a systematic review of English language studies published after 1996. Adverse events of interest included rates of early failure, time to revision, revision, reoperation, dislocation, infection/sepsis, femoral neck fracture, mortality, and postoperative component alignment. Revision rates were compared with those from four national joint replacement registries. Results were reported as adverse event rates per 1000 person-years stratified by device market status (in use and discontinued). Comparisons between event rates of metal-on-metal hip resurfacing and THA are made using a quasilikelihood generalized linear model. We identified 7421 abstracts, screened and reviewed 384 full-text articles, and included 236. The most common study designs were prospective cohort studies (46.6%; n = 110) and retrospective studies (36%; n = 85). Few randomized controlled trials were included (7.2%; n = 17).

RESULTS

The average time to revision was 3.0 years for metal-on-metal hip resurfacing (95% CI, 2.95-3.1) versus 7.8 for THA (95% CI, 7.2-8.3). For all devices, revisions and reoperations were more frequent with metal-on-metal hip resurfacing than THA based on point estimates and CIs: 10.7 (95% CI, 10.1-11.3) versus 7.1 (95% CI, 6.7-7.6; p = 0.068), and 7.9 (95% CI, 5.4-11.3) versus 1.8 (95% CI, 1.3-2.2; p = 0.084) per 1000 person-years, respectively. This difference was consistent with three of four national joint replacement registries, but overall national joint replacement registries revision rates were lower than those reported in the literature. Dislocations were more frequent with THA than metal-on-metal hip resurfacing: 4.4 (95% CI, 4.2-4.6) versus 0.9 (95% CI, 0.6-1.2; p = 0.008) per 1000 person-years, respectively. Adverse event rates change when discontinued devices were included.

CONCLUSIONS

Revisions and reoperations are more frequent and occur earlier with metal-on-metal hip resurfacing, except when discontinued devices are removed from the analyses. Results from the literature may be misleading without consistent definitions, standardized outcome metrics, and accounting for device market status. This is important when clinicians are assessing and communicating patient risk and when selecting which device is most appropriate for individual patients.

Outcomes of long tapered hydroxyapatite-coated stems in revision total hip arthroplasty

The purpose of this study was to evaluate the outcome of femoral component revisions using a long tapered HA coated femoral revision stem. Between 2001 and 2008, 55 femoral component revisions were performed using this stem. Forty-one patients were available for follow up evaluation at average of 59 months. The clinical results were evaluated using the HHS and serial radiographs were evaluated for loosening. The mean HHS was 71 (range 22-100). Three hips required revision of KAR stem (1 aseptic loosening, 1 infection, 1 limb length discrepancy). Only one prosthesis demonstrated radiographic evidence of subsidence. Our study suggests that long tapered HA coated revision femoral components can provide stable fixation and in-growth in cases where there is good proximal femoral bone stock and favorable canal geometry.

In vivo testing of canine prosthetic femoral components with HA-Ti ladder-type coating on vacuum plasma-sprayed Ti substrate

The purpose of the present study was to observe the structure and functional change of the bone-coating-prosthesis interface in vivo and to evaluate the histocompatibility of self-made prosthetic femoral components in the body and the degree of their bonding with the surrounding bone tissues as well as their stability. Six mature beagle dogs underwent bilateral hip replacement with prosthetic femur components. Three groups were established in terms of different coating of prothesis (four joints in each group): atmosphere (A) plasma-sprayed pure titanium (Ti) prosthetic joint with hydroxyapatite (HA) coating (HA+Ti+A group); vacuum (V) plasma-sprayed pure Ti prosthetic joint with HA coating (HA+Ti+V group); vacuum plasma-sprayed pure Ti prosthetic joint with Ti-HA stepped coating (Ti+HAG+Ti+V group). The hip joints were functionally evaluated, and subjected to X-ray examination, biomechanics inspection, and histological examination. As a result, X-ray imaging revealed all prosthetic joints were in a good location and no dislocation of joint was found. Shear strength of interface was significantly higher in Ti+HAG+Ti+V group than in HA+Ti+V group (P<0.05) and HA+Ti+A group (P<0.05) at 28th week. Histological examination showed the amount of newborn bone in Ti+HAG+Ti+V group was more than in HA+Ti+V group and HA+Ti+A group after 28 weeks. It was suggested that vacuum plasma-sprayed pure Ti prosthetic joint with TI-HA stepped coating could improve the bonding capacity of bone-prosthesis, enhance the stability of prosthesis, and increase the fixion of prosthetic femoral components because of better bone growth. This new type of biological material in prosthetic femoral components holds promises for application in clinical practice.

Antibacterial and biological characteristics of silver containing and strontium doped plasma sprayed hydroxyapatite coatings

Infection in primary total joint prostheses is estimated to occur in up to 3% of all surgery. As a measure to improve the antimicrobial properties of implant materials silver (Ag) was incorporated into plasma sprayed hydroxyapatite (HA) coatings. To offset potential cytotoxic effects of Ag in the coatings strontium (Sr) was also added as a binary dopant. HA powder was doped with 2.0 wt.% Ag(2)O, 1.0 wt.% SrO and was then heat treated at 800 °C. Titanium substrates were coated using a 30 kW plasma spray system equipped with a supersonic nozzle. X-ray diffraction confirmed the phase purity and high crystallinity of the coatings. Samples were evaluated for mechanical stability by adhesive bond strength testing. The results show that the addition of dopants did not affect the overall bond strength of the coatings. The antibacterial efficacies of the coatings were tested against Pseudomonas aeruginosa. Samples that contained the Ag(2)O dopant were found to be highly effective against bacterial colonization. In vitro cell-material interactions using human fetal osteoblast cells were characterized by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay for cell viability, field emission scanning electron microscopy for cell morphology and confocal imaging for the important differentiation marker alkaline phosphatase (ALP). Our results showed evidence of cytotoxic effects of the Ag-HA coatings, characterized by poor cellular morphology and cell death and nearly complete loss of functional ALP activity. The addition of SrO to the Ag-HA coatings was able to effectively offset these negative effects and improve performance compared with pure HA-coated samples.

Failure behavior of plasma-sprayed HAp coating on commercially pure titanium substrate in simulated body fluid (SBF) under bending load

Four point bending tests with acoustic emission (AE) monitoring were conducted for evaluating failure behavior of the plasma-sprayed hydroxyapatite (HAp) top coat on commercially pure titanium (cp-Ti) plate with and without mixed HAp/Ti bond coat. Effect of immersion in simulated body fluid (SBF) on failure behavior of the coated specimen was also investigated by immersing the specimen in SBF. The AE patterns obtained from the bending test of the HAp coating specimens after a week immersion in SBF clearly showed the earlier stage of delamination and spallation of the coating layer compared to those without immersion in SBF. It was also found that the bond coating improved failure resistance of the HAp coating specimen compared to that without the bond coat. Four point bend fatigue tests under ambient and SBF environments were also conducted with AE monitoring during the entire fatigue test for investigating the influence of SBF environment on fatigue failure behavior of the HAp coating specimen with the mixed HAp/Ti bond coat. The specimens tested at a stress amplitude of 120 MPa under both ambient and SBF environments could survive up to 10⁷ cycles without spallation of HAp coating layer. The specimens tested under SBF environment and those tested under ambient environment after immersion in SBF showed shorter fatigue life compared to those tested under ambient environment without SBF immersion. Micro-cracks nucleated in the coating layer in the early stage of fatigue life and then propagated into the cp-Ti substrate in the intermediate stage, which unstably propagated to failure in the final stage. It was found from the XRD analysis that the dissolution of the co-existing phases and the precipitation of the HAp phase were taken place during immersion in SBF. During this process, the co-existing phases disappeared from the coating layer and the HAp phase fully occupied the coating layer. The degradation of bending strength and fatigue life of the HAp coating specimens tested under SBF environment would be induced by dissolution of the co-existing phases from the coating layer during immersion in SBF.