The Harris-Galante porous-coated, hemispherical, polyethylene-lined acetabular component in patients under 50 years of age

Fixation vs Arthroplasty for Femoral Neck Fracture in Patients Aged 40-59 Years: A Propensity-Score-Matched Analysis

Background

Methods

Results

Conclusions

Average 22-Year Results of Total Hip Arthroplasty Using Harris-Galante Prosthesis in Patients under 50 Years

Background

The Harris-Galante (HG) prosthesis is a first-generation, cementless total hip arthroplasty (THA) prosthesis. Considering the recent increase in the demand for THA in young patients and their life expectancy, a study with a follow-up duration of longer than 20 years in a young population is needed. Therefore, we evaluated the long-term clinical and radiographic results after cementless THA using the HG prosthesis in patients younger than 50 years.

Methods

A total of 61 THAs performed using the HG with a minimum follow-up of 10 years were included. There were 38 men and 11 women with an average age of 46 years and the mean follow-up duration was 22 years. Clinical evaluation included modified Harris Hip Score (HHS) and radiographic analysis consisted of cup inclination, anteversion angle, component stability, osteolysis, liner wear rate, wear-through, liner dissociation, and heterotopic ossification. Complications included recurrent dislocation, periprosthetic femoral fracture, and periprosthetic joint infection. Survivorship analysis included cup and stem revision for aseptic loosening, as well as any revision.

Results

The HHS improved from 46.5 preoperatively to 81.8 postoperatively (p < 0.001). The average linear wear rate was 0.36 mm/yr. A total of 34 hips (56%) were revised: stem revision in 10 (16.4%), cup revision in 9 (14.8%), exchange limited to bearing surface in 8 (13.1%), and revision of all components in 7 (11.5%). Estimated survivorship at 34 years postoperatively was 90.9% for cup revision for aseptic loosening, 80.5% for stem revision for aseptic loosening, and 22.1% for any revision.

Conclusions

THA using the HG prosthesis showed satisfactory estimated survivorship of the acetabular and femoral components at 34 years postoperatively with good clinical outcomes. Bearing-related problems, such as osteolysis and liner dissociation, accounted for 56% of revision operations and were concerns in patients younger than 50 years.

Relationship between use of screws and acetabular cup stability in total hip arthroplasty: a meta-analysis

Objective

The relationship between the use of screws and acetabular cup stability in total hip arthroplasty (THA) remains controversial. We evaluated cup stability in THA with and without the use of screws.

Methods

We performed a systematic literature search to identify studies on cup stability relative to the use of screws in patients undergoing THA before October 2018. Methodological quality assessment and data collection were performed by two individual reviewers. Meta-analysis was performed using Review Manager version 5.3.5.

Results

We included seven trials involving 1402 patients (1469 THAs): 767 patients (809 THAs) with screws and 635 patients (660 THAs) without screws. The findings of meta-analysis indicated that uncemented acetabular component fixation with the use of additional screws was not correlated with migration of the cup, migration on roentgen stereophotogrammetry, or reoperation after THA. Moreover, operation time was not significantly different according to whether screws were used. There was no relationship between use of additional screws and osteoporosis or Harris Hip Score; however, THA with or without the use of screws might be related to bone sclerosis in the C1 region.

Conclusion

Currently, limited evidence shows that the use of screws during THA may not improve cup stability.

Long-term outcomes of total hip arthroplasty in patients younger than 55 years: a systematic review of the contemporary literature

Background

Total hip arthroplasty (THA) is increasingly performed in younger patients despite the lack of comprehensive assessment of long-term outcomes. We systematically reviewed the contemporary literature to assess the 1) indications, 2) implant selection and long-term survivorship, 3) complication and reoperation rates and 4) radiographic and functional outcomes of primary THA in patients younger than 55 years.

Methods

We searched the Embase and MEDLINE databases for English-language articles published between 2000 and 2018 that reported outcomes of primary THA in patients younger than 55 years with a minimum follow-up duration of 10 years.

Results

Thirty-two studies reporting on 3219 THA procedures performed in 2434 patients met our inclusion criteria. The most common preoperative diagnoses were avascular necrosis (1044 [32.4%]), osteoarthritis (870 [27.0%]) and developmental dysplasia of the hip (627 [19.5%]). Modular implants (3001 [93.2%]), cementless fixation (2214 [68.8%]) and metal-on-polyethylene bearings (1792 [55.7%]) were frequently used. The mean 5- and 10-year survival rates were 98.7% and 94.6%, respectively. Data on survival beyond 10 years were heterogeneous, with values of 27%–99.5% at 10–14 years, 59%–84% at 15–19 years, 70%–77% at 20–24 years and 60% at 25–30 years. Rates of dislocation, deep infection and reoperation for any reason were 2.4%, 1.2% and 16.3%, respectively. The mean Harris Hip Score improved from 43.6/100 to 91.0/100.

Conclusion

Total hip arthroplasty in patients younger than 55 years provides reliable outcomes at up to 10 years. Future studies should evaluate the outcomes of THA in this population at 15–20 years’ follow-up.

Prosthetic femoral head erosion through an acetabular component treated with revision and implant preservation

We present a case report of the rare complication of a femoral head prosthesis eroding through the acetabular liner and shell resulting in a clinical presentation of pseudo-dislocation. The patient presented with a 1-month history of progressive anterior and peritrochanteric hip pain without antecedent trauma. Radiographs demonstrated presumed hip dislocation with superior-posterior superimposition of the femoral head over the acetabular component. The patient underwent revision total hip arthroplasty with intraoperative evidence of extensive metallosis, osteolysis, and femoral head erosion through the acetabular polyethylene liner, acetabular shell, and implantation into the ilium. The femoral stem and acetabular shell were well-fixed, allowing for filling of the defect with bone void filler and cementation of a new polyethylene liner into the acetabular shell.

An 18-year comparison of hybrid total hip replacement and Birmingham hip resurfacing in active young patients

AIM

To compare the long-term clinical and radiological results of metal-on-polyethylene hybrid total hip replacement (THA) with metal-on-metal Birmingham hip resurfacing (BHR) in young, active patients.

PATIENTS AND METHODS

From the 1st consecutive 63 hips in young, active patients who underwent BHR by the senior author, 54 (51 patients) were matched to patients who had undergone THA with regard to age, gender, body mass index and preoperative levels of activity. Radiologically, all hips were assessed for migration and osteolysis, THAs for polyethylene wear and BHRs for a pedestal sign. Patient-reported outcomes, mortality and revision rates were compared.

RESULTS

The mean follow-up of the patients with a hybrid THR was 19.9 years and for those with a BHR, 17.6 years. 13 patients with a hybrid THR and 5 with a BHR had died. 1 hybrid THR and 3 BHRs were lost to follow-up. The revision rate of the hybrid THRs was 14/54 and of the BHRs 6/54. Log rank comparison of Kaplan-Meier survival estimates demonstrated a significantly lower mortality in the BHR group (p = 0.039; hazard ratio [HR] = 0.37 [95% CI, 0.15-0.95]) but a non-significant difference in revision rates (p = 0.067; HR = 0.43 [95% CI, 0.18-1.06]). The BHRs recorded superior OHS (p = 0.03), UCLA (p = 0.0096), and EuroQol visual analogue scores (p = 0.03). Significantly more BHRs had run, played sport and undertaken heavy manual labour in the month preceding follow-up.

CONCLUSION

After 18 years, patients with BHRs remained more active with a lower mortality rate but demonstrated no significant difference in revision rates. Both groups demonstrated progressive radiological changes at long-term follow-up.

Clinical and Radiographic Outcomes of Total Hip Arthroplasty With a Specific Liner in Small Asian Patients: Influence of Patient-Related, Implant-Related, and Surgical Factors on Femoral Head Penetration

BACKGROUND

We evaluated the clinical and radiographic outcomes, including femoral head penetration, of total hip arthroplasty performed using a specific polyethylene (PE) liner in small Asian patients at 10 years after the index surgery. In addition, we investigated whether femoral head penetration was affected by patient-related, implant-related, and surgical factors.

METHODS

Between August 2002 and June 2005, for cementless primary total hip arthroplasty, we used acetabular PE liners that were manufactured from GUR 1050 resin, machined from isostatic compression-molded bar stock, and sterilized with a gamma ray irradiation in argon gas. We assessed 82 hips in 78 patients who received these liners.

RESULTS

The mean Harris hip score improved from 41.0 preoperatively to 84.5 at 10 years postoperatively. Periprosthetic osteolysis was observed in 7 hips (9.8%). No acetabular component migration was detected, and no revision surgery was performed 10 years postoperatively. The mean steady-state wear rate was 0.031 mm/y, which was lower than the wear rate for other conventional PE liners of the previous studies. Among the patient-related, implant-related, and surgical factors, sex was significantly associated with the mean steady-state wear rate, with a higher rate in male patients than in female patients.

CONCLUSION

PE acetabular liners used in small Asian patients show similar clinical outcomes and reduced wear compared with those of other liners. In addition, sex is significantly associated with the mean steady-state wear rate, and the steady-state wear rate is higher in male patients than in female patients.

The Morscher Press-Fit Acetabular Component: An Independent Long-Term Review at 18-22 Years

BACKGROUND

There are relatively few 20-year results of uncemented acetabular components, and most of these are modular designs. This study reports the 20-year results of a monoblock press-fit acetabular component.

METHODS

A total of 122 total hip arthroplasties (111 patients) using the Morscher cup were reviewed at a mean of 19.7 years. The average age at implantation was 57.3 years (range, 36-74 years), and 81 (66%) were men.

RESULTS

Twenty-two patients (25 hips) had died. Seven hips were revised, including 5 acetabular revisions. Six patients (6 hips) declined to participate but were known not to have been revised. The mean Oxford hip score was 41.1 (range, 22-48), and the mean reduced Western Ontario and McMaster Universities Osteoarthritis Index score was 5.7/48 (range, 0-24). Eccentric wear was seen in 13 (15.7%) and major osteolysis in 14 (17%) of 82 surviving hips with radiographs. The all-cause revision rate was 0.32 per 100 observed component years (95% confidence interval [CI], 0.13-0.66). The 20-year Kaplan-Meier survival was 93.4% (CI, 86.6-96.8) for all-cause revisions, 95.5% (CI, 89.4-98.1) for any acetabular revision, and 97.1% (CI, 91.2-99.1) for acetabular aseptic loosening, wear, or osteolysis.

CONCLUSION

The Morscher acetabular component has continued to perform well at 20 years despite using conventional polyethylene with results that match or surpass other cementless acetabulae.

Screws are not needed when secure interference fit of uncemented acetabular components is adequate: a 5- to 15-year follow-up with clinical and radiological analysis

PURPOSE

Even with good surgical preparation, adequate primary stability of the acetabular component is not always achieved after primary total hip replacement (THR). We hypothesise that adequate bone preparation for appropriate cortical loading would allow us to avoid screw use.

METHODS

A total of 791 uncemented cups were analysed to compare the need for screws to obtain primary fixation in 5 different designs. Arthritic hips with inflammatory arthritis or severe congenital hip disease were excluded. A press-fit technique was first tried in all hips and screws were only used when strictly needed. Radiological acetabular shape and postoperative cup position were assessed in all hips. The mean follow-up was 9.6 (5-15) years.

RESULTS

Screws were required in 155 hips (19.6%). We could not detect any difference in the percentage of screw use between designs. We found that female patients (odds ratio [OR] 2.06; 95% confidence interval [CI], 1.41-3.02) and cups with a greater distance to the hip rotation centre on the postoperative radiograph (OR 1.69; 95% CI, 1.17-2.45) had a higher risk for screw use. A greater anteversion of the cup had a lower risk for screw use (OR 0.96; 95% CI, 0.94-0.99). At latest follow-up no hips had needed revision for aseptic loosening.

CONCLUSIONS

Good intraoperative technique is not enough to avoid screw use since more accurate cup position and reconstruction of the hip rotation centre are required for an adequate interference fit. A press-fit technique can provide similar mid-term results to screw use in hips without severe deformities.

A review of outcomes and modes of presentation following liner dissociation from Harris-Galante uncemented acetabular components

PURPOSE

Dissociation of the polyethylene liner is a known failure mechanism of the Harris Galante I and II uncemented acetabular components. The outcomes of revision surgery for this indication and the influence of time to diagnosis are not well described.

METHODS

We report a series of 29 cases revised due to this failure mechanism. The median time from primary to revision surgery was 13 years.

RESULTS

At a median of 4 years follow-up, the mean OHS was 34 (range 6-48) but results were poorer (mean 29; range 6-45) when the diagnosis and revision was delayed compared to when it was not (mean 39; range 20-48). A large proportion of our patients (n = 14) presented with sudden onset of symptoms with or without trauma. Osteolysis was common in this series but the cup was well fixed in 20/29 cases. There was macroscopic damage to the shell in all cases.

CONCLUSIONS

In our experience, prompt revision of liner dissociation optimises outcomes in this group of patients and radiology reporting alone is not sufficient to identify these cases.

ORIF or Arthroplasty for Displaced Femoral Neck Fractures in Patients Younger Than 65 Years Old: An Economic Decision Analysis

BACKGROUND

The decision between open reduction and internal fixation (ORIF) and arthroplasty for a displaced femoral neck fracture in a patient ≤65 years old can be challenging. Both options have potential drawbacks; if a fracture treated with ORIF fails to heal it may require a revision operation, whereas a relatively young patient who undergoes arthroplasty may need revision within his/her lifetime. The purpose of this study was to employ decision analysis modeling techniques to generate evidence-based treatment recommendations in this clinical scenario.

METHODS

A Markov decision analytic model was created to simulate outcomes after ORIF, total hip arthroplasty (THA), or hemiarthroplasty in patients who had sustained a displaced femoral neck fracture between the ages of 40 and 65 years. The variables in the model were populated with values from studies with high-level evidence and from national registry data reported in the literature. The model was used to estimate the threshold age above which THA would be the superior strategy. Results were tested using sensitivity analysis and probabilistic statistical analysis.

RESULTS

THA was found to be a cost-effective option for a displaced femoral neck fracture in an otherwise healthy patient who is >54 years old, a patient with mild comorbidity who is >47 years old, and a patient with multiple comorbidities who is >44 years old. The average clinical outcomes of THA and ORIF were similar for patients 40 to 65 years old, although ORIF had a wider variability in outcomes based on the success or failure of the initial fixation. For all ages and cases, hemiarthroplasty was associated with worse outcomes and higher costs.

CONCLUSIONS

Compared with ORIF, primary THA can be a cost-effective treatment for displaced femoral neck fractures in patients 45 to 65 years of age, with the age cutoff favoring THA decreasing as the medical comorbidity and risk of ORIF fixation failure increase. Hemiarthroplasty has worse outcomes at higher costs and is not recommended in this age group.

LEVEL OF EVIDENCE

Economic and decision analysis Level III. See Instructions for Authors for a complete description of levels of evidence.

The 21- to 27-year results of the Harris-Galante cementless total hip arthroplasty

BACKGROUND

The Harris-Galante total hip arthroplasty (THA) is a first-generation cementless THA with a porous coating for biological fixation of the implant. Many studies report excellent long-term results for the acetabular cup, but few long-term studies exist for the femoral stem because of relatively poor short-term and midterm results. Here we present the 21- to 27-year results of the cup and the stem of the Harris-Galante THA.

METHODS

From 1985 to 1991, 102 Harris-Galante THAs were inserted in 82 patients. At the time of the THA, the mean patient age was 54 years (range, 20-78 years). The primary diagnosis was secondary osteoarthritis due to developmental hip dysplasia (69 [68%] hips). The Japanese Orthopaedic Association (JOA) hip score and thigh pain were measures of clinical outcome. Radiographic review was performed retrospectively. Implant survival was evaluated by Kaplan-Meier analysis.

RESULTS

Of 102 hips, 35 hips were from 31 deceased patients, 5 patients (6 hips) were lost to follow-up, 12 hips were revised, and 49 hips were from patients living at the latest follow-up. Among the living patients, 36 hips had a clinical evaluation and 42 hips had a radiograph obtained more than 21 years. The JOA hip score improved from 42 points preoperatively to 83.5 points at the latest follow-up. Thigh pain was reported in 13 hips. One cup and four stems were loose at the latest radiographic review. Most cup revisions were related to acetabular osteolysis. Fifteen hips showed severe stress shielding. Kaplan-Meier analysis of survivorship with any revision, acetabular reoperation, stem revision, and stem loosening as the end point was 87.0%, 90.3%, 95.7% and 86.4%, respectively, at 24.6 years.

CONCLUSIONS

Long-term implant survival and clinical results of the Harris-Galante THA were good. Acetabular osteolysis-related cup loosening was a problem of the cup. Loosening, thigh pain, and stress shielding were problems of the stem.

Good outcome of total hip replacement in patients with cerebral palsy: A comparison of 389 patients and 425,813 controls from the National Joint Registry for England and Wales

BACKGROUND AND PURPOSE

People with cerebral palsy (CP) often have painful deformed hips, but they are seldom treated with hip replacement as the surgery is considered to be high risk. However, few data are available on the outcome of hip replacement in these patients.

PATIENTS AND METHODS

We linked Hospital Episode Statistics (HES) records to the National Joint Registry for England and Wales to identify 389 patients with CP who had undergone hip replacement. Their treatment and outcomes were compared with those of 425,813 patients who did not have CP. Kaplan-Meier estimates were calculated to describe implant survivorship and the curves were compared using log-rank tests, with further stratification for age and implant type. Reasons for revision were quantified as patient-time incidence rates (PTIRs). Nationally collected patient-reported outcomes (PROMS) before and 6 months after operation were compared if available. Cumulative mortality (Kaplan-Meier) was estimated at 90 days and at 1, 3, and 5 years.

RESULTS

The cumulative probability of revision at 5 years post-surgery was 6.4% (95% CI: 3.8-11) in the CP cohort as opposed to 2.9% (CI 2.9-3%) in the non-CP cohort (p < 0.001). Patient-reported outcomes showed that CP patients had worse pain and function preoperatively, but had equivalent postoperative improvement. The median improvement in Oxford hip score at 6 months was 23 (IQR: 14-28) in CP and it was 21 (14-28) in non-CP patients. 91% of CP patients reported good or excellent satisfaction with their outcome. The cumulative probability of mortality for CP up to 7 years was similar to that in the controls after stratification for age and sex.

INTERPRETATION

Hip replacement for cerebral palsy appears to be safe and effective, although implant revision rates are higher than those in patients without cerebral palsy.

Long-term results with the Atlas IIIp elastic cementless acetabular component in total hip replacement

PURPOSE

Modular cementless elastic acetabular systems have advantages over cemented and hard shell cementless acetabular systems. There are few reports on the medium-term and long-term follow up of this particular type of implant. This study describes our experience with the Atlas IIIp modular acetabular system, which is a thin shell cementless elastic acetabular implant for total hip replacement commercialized under this name in many countries.

METHODS

We prospectively followed 244 patients treated with Atlas IIIp acetabular system between 2001 and 2004. Minimum ten year follow up was available for 148 hips (139 patients) from the original cohort of 263 hips (244 patients). One hundred five patients had died from unrelated causes and were excluded from the results. Post-operative and follow up radiographs of patients were assessed; and Harris hip scores were used as clinical outcome. Revision for any reason was defined as the end point for survivorship analysis.

RESULTS

The mean pre-operative Harris hip score was 48 (S.D. 16) and the average post-operative score was 82 (S.D. 12). The mean follow up in our series was 11.5 years, ranging from ten to 13.5 years. Thirteen hips required further surgery in our cohort; of which ten cases required cup revision. The 13-years cumulative implant survival was 91.2 % and the risk of implant revision was 8.8 % at 13 years in 148 hips (139 patients). Kaplan-Meier analysis showed the implant survival rate of 95.2 % at ten years for revision for any reason and 99.4 % for aseptic loosening.

CONCLUSIONS

Our clinical experience with this acetabular cup suggests good long-term survival rates that are similar to other cups on the market. The clinical experience in this study shows long-term survival rates that are consistent, acceptable and good results achieved with a low revision rate.

LEVEL OF EVIDENCE

Therapeutic III; therapeutic study.

Empirical support for radiographic review: a follow-up study of total hip arthroplasty

Routine post surgery surveillance of total hip arthroplasty (THA) is widely recommended to identify asymptomatic failure but inclusion of an x-ray adds to service costs. Evidence is needed to support orthopaedic opinion in order to identify what should be included in surveillance. An investigation was conducted to establish whether an x-ray is needed in addition to patient reported outcome measures. One hundred and fifty-four THA had been assessed at 3 years and were reviewed again at 6 to 9 years (mid-term) when radiographic signs of deterioration commonly appear. Data were explored for associations between radiographic changes and changes in the participants' Oxford Hip Score, age, EuroQol 5-D score or comorbidities. Hierarchical multiple regression analysis showed that the number of radiographic changes could not be predicted by any of the other variables. This supports the inclusion of an x-ray in THA surveillance and suggests that the state of the THA cannot be determined by the use of patient reported outcome measures alone. This has implications for future arthroplasty surveillance.

10-year results of the uncemented Allofit press-fit cup in young patients

BACKGROUND AND PURPOSE

Uncemented acetabular components in primary total hip arthroplasty (THA) are commonly used today, but few studies have evaluated their survival into the second decade in young and active patients. We report on a minimum 10-year follow-up of an uncemented press-fit acetabular component that is still in clinical use.

METHODS

We examined the clinical and radiographic results of our first 121 consecutive cementless THAs using a cementless, grit-blasted, non-porous, titanium alloy press-fit cup (Allofit; Zimmer Inc., Warsaw, IN) without additional screw fixation in 116 patients. Mean age at surgery was 51 (21-60) years. Mean time of follow-up evaluation was 11 (10-12) years.

RESULTS

At final follow-up, 8 patients had died (8 hips), and 1 patient (1 hip) was lost to follow-up. 3 hips in 3 patients had undergone acetabular revision, 2 for deep infection and 1 for aseptic acetabular loosening. There were no impending revisions at the most recent follow-up. We did not detect periacetabular osteolysis or loosening on plain radiographs in those hips that were evaluated radiographically (n = 90; 83% of the hips available at a minimum of 10 years). Kaplan-Meier survival analysis using revision of the acetabular component for any reason (including isolated inlay revisions) as endpoint estimated the 11-year survival rate at 98% (95% CI: 92-99).

INTERPRETATION

Uncemented acetabular fixation using the Allofit press-fit cup without additional screws was excellent into early in the second decade in this young and active patient cohort. The rate of complications related to the liner and to osteolysis was low.

Uncemented porous tantalum acetabular components: early follow-up and failures in 613 primary total hip arthroplasties

Uncemented tantalum acetabular components were introduced in 1997. The purpose was to determine the 2- to 10-year results with this implant material in primary total hip arthroplasty. Our registry identified all primary total hip cases with porous tantalum cups implanted from 1997 to 2004. Clinical outcomes and radiographs were studied. 613 cases were identified. Seventeen percent of patients were lost to follow-up. Twenty-five reoperations were performed (4.4%). Acetabular cup removal occurred in 6 cases (1.2%). No cups were revised for aseptic loosening. Incomplete radiolucent lines were found on 9.3% of initial postoperative radiographs. At 2 years, 67% had resolved. Zero new radiolucent lines were detected. Two- to 10-year results of porous tantalum acetabular components for primary total hip arthroplasty demonstrate high rates of initial stability and apparent ingrowth.

Survivorship, patient reported outcome and satisfaction following resurfacing and total hip arthroplasty

Resurfacing (RA) and total hip arthroplasty (THA) are options in the treatment of debilitating hip pathology. 381 patients that had undergone arthroplasty with a BHR RA, ASR RA, metal-on-metal (MoM) THA or ceramic-on-ceramic (CoC) THA were reviewed for satisfaction, function, health and survivorship at a median follow up of 50 months. Significantly lower survivorship for revision and reoperation was observed in the ASR group. The BHR and CoC demonstrated better outcome scores than the ASR (OHS and SAPS) and the BHR better scores than the MoM (OHS and SF12 PCS). In the short to medium term, survivorship and outcomes for the best performing RA (BHR) and THA (CoC) were comparable. There was a non-significant trend towards poorer outcome scores in the MoM THA group.

High initial stability in porous titanium acetabular cups: a biomechanical study

Initial stability with limited micromotion in uncemented total hip arthroplasty acetabular components is essential for bony attachment and long-term biomechanical fixation. This study compared porous titanium fixation surfaces to clinically established, plasma-sprayed designs in terms of interface stability and required seating force. Porous plasma-sprayed modular and metal-on-metal (MOM) cups were compared to a modular, porous titanium designs. Cups were implanted into polyurethane blocks with1-mm interference fit and subsequently edge loaded to failure. Porous titanium cups exhibited 23% to 65% improvement in initial stability when compared to plasma-sprayed cup designs (P=.01): a clinically significant increase, based on experience and prior literature. The results of this study indicate increased interface stability in porous titanium-coated cups without significantly increasing the necessary force and energy required for full seating.

Cup press fit in uncemented THA depends on sex, acetabular shape, and surgical technique

BACKGROUND

Uncemented press-fit cups provide bone fixation in primary THA, but the use of screws is sometimes necessary to achieve primary stability of the socket. However, it is unclear whether and when screws should be used.

QUESTION/PURPOSES

We analyzed the factors related to screw use with a press-fit uncemented cup and assessed whether screw use is associated with the same rates of loosening and revision as a press-fit technique.

METHODS

We retrospectively reviewed 248 patients who underwent THA using the same prosthetic design. Eighty-eight hips had screws to achieve primary cup fixation (Group 1), and 189 did not (Group 2). Mean age was 50 years (range, 14-73 years). We analyzed factors related to the patient, acetabular type, and reconstruction of the rotation center of the hip. Minimum followup was 5 years (mean, 8.9 years; range, 5-12 years).

RESULTS

We found higher screw use in women, patients with less physical activity, Acetabular Types A or C, and a distance from the center of the prosthetic femoral head to the normal center of rotation of more than 3 mm. There were four revisions in Group 1 and five in Group 2. Eight hips had radiographic loosening in Group 1 and nine in Group 2. Cups with a postoperative abduction angle of more than 50° had a higher risk for loosening.

CONCLUSIONS

Press fit was achieved less frequently in women and patients with Acetabular Types A or C and less physical activity; a closer distance to the normal center of rotation decreased screw use. Screw use to augment fixation achieved survival similar to that of a press-fit cup.

LEVEL OF EVIDENCE

Level II, prognostic study. See Instructions for Authors for a complete description of levels of evidence.

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.

Cementless total hip arthroplasty with a metal-on-metal bearing in patients younger than 50 years

Total hip arthroplasty (THA) longevity is the primary concern in young patients. Metal-on-metal articulations were reintroduced to reduce polyethylene particle-induced osteolysis and improve survivorship; to date, based on issued reports, this strategy appears to have been successful. In this study, the authors investigated metal-on-metal articulation survivorship and osteolysis incidence in young patients (19-50 years old at index operations) and retrospectively reviewed cementless metal-on-metal THAs in 70 patients (78 hips) with a mean follow-up of 12.4 years. Metasul articulation was used with the Wagner acetabular component in all. Survivorship with revision for any cause was 98.7% (95% confidence interval, 98%-100%), and survivorship due to the development of osteolysis for any lesion was 97.5% (95% confidence interval, 95%-99%). Mean Harris hip score improved from 51 to 95 points at final follow-up. The findings of this study indicate that outcomes of cementless THA with a metal-on-metal bearing in young patients are satisfactory. However, longer-term studies in larger cohorts are required to determine whether metal-on-metal articulations are really a favorable option in young patients.

Midterm results of 506 solid trispiked reflection cementless acetabular components for primary total hip arthroplasty

The purpose of this prospective study was to evaluate the outcomes and survivorship of a trispiked, sintered bead-coated titanium shell with a polished inner surface, no screw holes, and an improved locking mechanism. A total of 506 total hip arthroplasties with a minimum 5-year follow-up were available for review at a mean of 7 years (range, 5-11 years). Three sockets (0.6%) were revised for reasons other than aseptic loosening, and 14 (2.8%) polyethylene liners were exchanged. There was no difference in revision rate between non-cross-linked and highly cross-linked liners (P = .4). There were no cases of radiographic loosening. Retroacetabular osteolysis was identified in 2%. The overall 5-year and 10-year Kaplan-Meier survivorship was 97.5% and 97.4%, respectively, whereas survivorship of the shell was 99.8%.

High survival in young patients using a second generation uncemented total hip replacement

Purpose

Whilst excellent long-term results with contemporary uncemented stems have been reported for total hip arthroplasty in young patients, the survival rates for the whole reconstruction are often compromised by high failure rates on the acetabular site due to peri-acetabular osteolysis and accelerated wear.

Methods

In patients 60 years old or younger, we retrospectively reviewed the results at a minimum of ten years of 89 consecutive uncemented total hip replacements in 88 patients using the press-fit Fitmore acetabular component in combination with the CLS Spotorno stem and a 28-mm Metasul metal-on-metal articulation or a 28-mm alumina ceramic on conventional polyethylene bearing. The mean age at the time of surgery was 49 years (range, 25–60). The mean clinical and radiological follow-up was 12 years (range, 10–15).

Results

Six patients (six hips) died and two patients (two hips) were lost to follow-up. Five hips were revised: one for deep infection, one for peri-prosthetic femoral fracture, and one for aseptic stem loosening. In two hips an isolated revision of the acetabular liner was performed (one for recurrent dislocation and one for unexplained pain). No revision was performed for accelerated wear, osteolysis or aseptic loosening of the acetabular shell. We could not detect peri-acetabular osteolysis visible on plain radiographs in those hips evaluated radiographically. The Kaplan-Meier survival with revision for any reason as the endpoint was 94% (95% confidence interval, 86–97) at 12 years.

Conclusions

The survival rates and the radiological outcomes with this implant combination in this young and active patient group are encouraging when compared to the results reported for other uncemented cups in this age group.

Silent soft tissue pathology is common with a modern metal-on-metal hip arthroplasty

BACKGROUND AND PURPOSE

Adverse reactions to metal debris have been reported to be a cause of pain in metal-on-metal hip arthroplasty. We assessed the incidence of both symptomatic and asymptomatic adverse reactions in a consecutive series of patients with a modern large-head metal-on-metal hip arthroplasty.

METHODS

We studied the early clinical results and results of routine metal artifact-reduction MRI screening in a series of 79 large-head metal-on-metal hip arthroplasties (ASR; DePuy, Leeds, UK) in 68 patients. 75 hips were MRI scanned at mean 31 (12-52) months after surgery.

RESULTS

27 of 75 hips had MRI-detected metal debris-related abnormalities, of which 5 were mild, 18 moderate, and 4 severe. 8 of these hips have been revised, 6 of which were revised for an adverse reaction to metal debris, diagnosed preoperatively with MRI and confirmed histologically. The mean Oxford hip score (OHS) for the whole cohort was 21. It was mean 23 for patients with no MRI-based evidence of adverse reactions and 19 for those with adverse reactions detected by MRI. 6 of 12 patients with a best possible OHS of 12 had MRI-based evidence of an adverse reaction.

INTERPRETATION

We have found a high early revision rate with a modern, large-head metal-on-metal hip arthroplasty. MRI-detected adverse rections to metal debris was common and often clinically "silent". We recommend that patients with this implant should be closely followed up and undergo routine metal artifact-reduction MRI screening.

A medium-term comparison of hybrid hip replacement and Birmingham hip resurfacing in active young patients

We compared the medium-term clinical and radiological results of hybrid total hip replacement (THR) with metal-on-metal Birmingham hip resurfacing (BHR) in two groups of 54 young patients matched for age, gender, body mass index and pre-operative levels of activity.

The clinical outcome was assessed by the University of California, Los Angeles (UCLA) activity score, the Oxford Hip Score (OHS) and the EuroQol scores. Radiologically, all hips were assessed for migration and osteolysis, the hybrid THRs for polyethylene wear and the BHRs for a pedestal sign. The mean follow-up of the patients with a hybrid THR was ten years and for those with a BHR, nine years. Four patients with a hybrid THR and one with a BHR had died. In each group five were lost to follow-up. The revision rate of the hybrid THRs was 16.7% (9 of 54) and of the BHRs 9.3% (5 of 54) (p = 0.195). Radiographs of a further eight hybrid THRs demonstrated wear and osteolysis, and they await revision (p = 0.008). Of the unrevised BHRs 90% had radiological changes, of which approximately 50% had progressed over the previous four years. All hybrid THRs demonstrated linear polyethylene wear with a mean of 1.24 mm (0.06 to 3.03). The BHRs recorded superior OHS (p = 0.013), UCLA (p = 0.008), and EuroQol visual analogue scores (p = 0.009).

After nine years, patients with BHRs remained more active and had a lower rate of revision than those with hybrid THRs. Both groups demonstrated progressive radiological changes at medium-term follow-up.

The Harris-Galante cementless THA: a 19- to 25-year follow-up study

The goal of this study was to evaluate the long-term survivorship of primary cementless total hip arthroplasty (THA) using Harris-Galante porous I acetabular and Harris-Galante porous femoral components. From July 1985 to December 1991, we performed primary cementless THA on 76 hips (70 patients). Twenty-nine patients (31 hips) died due to causes unrelated to the THA, and 6 patients (7 hips) were lost to follow-up. Of 76 hips (70 patients) studied, 38 hips (35 patients) were available for follow-up at a mean 22.5 years (range, 19-25 years) postoperatively. Mean patient age at index procedure was 51.2 years (range, 42-65 years). Average Harris Hip Score was 40.5 points preoperatively and 85.8 points at final follow-up. No patient had an early or late postoperative deep infection. Radiographically, the acetabular component fixation was stable in all 38 hips. The femoral component was bone-ingrown in 26 hips, stable-fibrous in 10, and unstable in 2. One unstable hip required revision of the femoral component. Dissociation of the polyethylene liner occurred in 3 hips without fractures of the metal locking tines and required revision of the polyethylene liner and the articular head. A total of 4 hips had documented revision, and 1 femoral component failed radiographically. The survival rate with the endpoint defined as revision surgery and radiographic loosening was 86.8% at 22.5 years of follow-up. Mean polyethylene wear was 0.085 mm/year (range, 0.031-0.15 mm). This study found that the Harris-Galante porous I acetabular and Harris-Galante porous femoral components produce excellent long-term results.

A cementless elastic monoblock socket in young patients: a ten to 18-year clinical and radiological follow-up

The survival of acetabular components depends on several factors: wear, osteolysis and septic or aseptic loosening. Osteolysis seems to be the main cause for concern in cementless arthroplasties. Acetabular osteolysis results from particle debris and segmental unloading of acetabular bone by rigid sockets. We investigated a cementless elastic monoblock socket with regard to acetabular osteolysis and aseptic loosening in a cohort of young patients. We evaluated 158 hip arthroplasties with a minimum follow-up of ten years (ten to 18) and a mean age of 42 years (18–50). The overall revision rate at 14 years was 80% with a 98% survival rate for aseptic loosening. The mean polyethylene wear rate was 0.11 mm/year. Progressive acetabular osteolysis was seen in 3% of patients evaluated. In conclusion, we found low pelvic osteolysis rates, acceptable overall wear rates, satisfactory overall survival and excellent survival rates for aseptic loosening of a cementless elastic monoblock socket in patients younger than 50 years. Ongoing tribology developments and knowledge about acetabular bone adaptations behind acetabular implants will further lower wear and osteolysis rates and optimise survival rates of cementless sockets.

Metal-backed acetabular components with conventional polyethylene: a review of 9113 primary components with a follow-up of 20 years

The Norwegian Arthroplasty Register has shown that several designs of uncemented femoral stems give good or excellent survivorship. The overall findings for uncemented total hip replacement however, have been disappointing because of poor results with the use of metal-backed acetabular components. In this study, we exclusively investigated the medium-to long-term performance of primary uncemented metal-backed acetabular components. A total of 9113 primary uncemented acetabular components were implanted in 7937 patients between 1987 and 2007. These were included in a prospective, population-based observational study. All the implants were modular and metal-backed with ultra-high-molecular-weight polyethylene liners. The femoral heads were made of stainless steel, cobalt-chrome (CoCr) alloy or alumina ceramic. In all, seven different designs of acetabular component were evaluated by the Kaplan-Meier survivorship method and Cox regression analysis. Most acetabular components performed well up to seven years. When the endpoint was revision of the acetabular component because of aseptic loosening, the survival ranged between 87% and 100% at ten years. However, when the endpoint was revision for any reason, the survival estimates were 81% to 92% for the same implants at ten years. Aseptic loosening, wear, osteolysis and dislocation were the main reasons for the relatively poor overall performance of the acetabular components. Prostheses with alumina heads performed slightly better than those with stainless steel or CoCr alloy in subgroups. Whereas most acetabular components performed well at seven years, the survivorship declined with longer follow-up. Fixation was generally good. None of the metal-backed uncemented acetabular components with ultra-high-molecular-weight polyethylene liners in our study had satisfactory long-term results because of high rates of wear, osteolysis, aseptic loosening and dislocation.

Acetabular options: notes from the other side

The socket remains the weakest link of primary total hip arthroplasty (THA). The revision rates of the socket are higher than those of the stem, with aseptic loosening and polyethylene wear being the most frequent indications for revision THA. Both cemented all-polyethylene cups and cementless sockets have benefited from stepwise improvements in surgical techniques and designs. In many countries, cementless sockets have replaced cemented cups during primary THA, with >90% of the acetabular components using a cementless fixation mode. The long-term prospective data of cementless sockets from high-volume centers show excellent and equivalent survivorship to cemented implants, but the insertion technique is easier and quicker. In addition, cementless sockets are more versatile than cemented all-polyethylene cups. With cementless sockets there is a move to increased porosity of the ingrowth surface, tri-bearing options, and enhanced locking mechanisms. There is a role for well-conducted randomized controlled trials to assess these new designs because data from various national registries show that the socket remains the weakest link of primary THA. Factors like sex, age, diagnosis, and bearing couples have a different and significant influence on the intermediate to long-term survivorship of contemporary cemented and cementless THA.

The Morscher Press Fit acetabular component: a nine- to 13-year review

We reviewed the results at nine to 13 years of 125 total hip replacements in 113 patients using the monoblock uncemented Morscher press-fit acetabular component. The mean age at the time of operation was 56.9 years (36 to 74). The mean clinical follow-up was 11 years (9.7 to 13.5) and the mean radiological follow-up was 9.4 years (7.7 to 13.1). Three hips were revised, one immediately for instability, one for excessive wear and one for deep infection. No revisions were required for aseptic loosening. A total of eight hips (7.0%) had osteolytic lesions greater than 1 cm, in four around the acetabular component (3.5%). One required bone grafting behind a well-fixed implant. The mean wear rate was 0.11 mm/year (0.06 to 0.78) and was significantly higher in components with a steeper abduction angle. Kaplan-Meier survival curves at 13 years showed survival of 96.8% (95% confidence interval 90.2 to 99.0) for revision for any cause and of 95.7% (95% confidence interval 88.6 to 98.4) for any acetabular re-operation.

Revision following cemented and uncemented primary total hip replacement: a seven-year analysis from the New Zealand Joint Registry

We have reviewed the rate of revision of fully cemented, hybrid and uncemented primary total hip replacements (THRs) registered in the New Zealand Joint Registry between 1999 and December 2006 to determine whether there was any statistically significant difference in the early survival and reason for revision in these different types of fixation. The percentage rate of revision was calculated per 100 component years and compared with the reason for revision, the type of fixation and the age of the patients. Of the 42 665 primary THRs registered, 920 (2.16%) underwent revision requiring change of at least one component. Fully-cemented THRs had a lower rate of revision when considering all causes for failure (p < 0.001), but below the age of 65 years uncemented THRs had a lower rate (p < 0.01). The rate of revision of the acetabular component for aseptic loosening was less in the uncemented and hybrid groups compared with that in the fully cemented group (p < 0.001), and the rate of revision of cemented and uncemented femoral components was similar, except in patients over 75 years of age in whom revision of cemented femoral components was significantly less frequent (p < 0.02). Revision for infection was more common in patients aged below 65 years and in cemented and hybrid THRs compared with cementless THRs (p < 0.001). Dislocation was the most common cause of revision for all types of fixation and was more frequent in both uncemented acetabular groups (p < 0.001). The experience of the surgeon did not affect the findings. Although cemented THR had the lowest rate of revision for all causes in the short term (90 days), uncemented THR had the lowest rate of aseptic loosening in patients under 65 years of age and had rates comparable with international rates of aseptic loosening in those over 65 years.