Clinical and radiographic results of the muller straight stem used as á press-fit

Prior to the introduction of porous coating, 21 patients had 24 ME Muller straight-stem femoral prostheses inserted as a press fit for the treatment of osteoarthrosis. Five hips have been revised for aseptic loosening; the remaining 19 prostheses are still in situ after a mean of 7.3 years (range, 6.2–8.3 years). A prospective clinical assessment has been undertaken using a modified Harris hip score, with scores increasing on average from a preoperative 43 to a postoperative 79. Eighteen of the 19 remaining hips are functioning well. Variable distances of subsidence are evident in 10 hips. Despite the use of a prosthesis that was not designed for cementless proximal wedge fitting, the results indicate an exceptionally low incidence of bone resorption and lysis. Unlike cemented and some porous-coated prostheses, stress shielding and osteopenia were not a feature in this series     

Gender‐dependent association of the GNAS1 T393C polymorphism with early aseptic loosening after total hip arthroplasty

The G‐protein Gαs is involved in the physiology and pathophysiology of bone. Especially, Gαs is a key regulator of interleukin‐6, which is a potent promoter of aseptic loosening. We hypothesized that the common single nucleotide polymorphism GNAS1 T393C could also affect time to aseptic loosening. Caucasian patients were genotyped for the GNAS1 T393C polymorphism. Time and median time to aseptic loosening were analyzed for dependency on GNAS1 genotypes. Time and median time were not significantly associated with genotypes. Additional analysis corrected for gender revealed, that the TT genotype was associated with significantly longer time (p = 0.048) as well as median time (p = 0.022) to aseptic loosening in female patients. In contrast to the findings in females, male TT genotype carriers had significantly shorter time (p = 0.018) and median time (p = 0.023) to aseptic loosening. Compared with TT genotype carriers heterozygous patients had a 6.25‐fold lower risk with a hazard ratio of 0.160 (p = 0.016) and male patients carrying the CC genotype had an 11‐fold lower risk with a hazard ratio of 0.088 (p = 0.006) in multivariate analysis. The present study suggests a significant gender‐dependent role of the T393C polymorphism in aseptic loosening. The apparently contradictory results in women and men and the finding that the GNAS1 T393C genotype is an independent factor for time to aseptic loosening in male patients assigned this polymorphism as an interesting target for further investigations in bone diseases. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res     

Long-Term Survival of the Cemented Exeter Universal Stem in Patients 50 Years and Younger: An Update on 130 Hips

BackgroundThere is variable evidence regarding survivorship beyond 20 years of total hip arthroplasties in young patients. We report the long-term results of the Exeter cemented hip system in patients ≤50 years at minimum of 20 years.MethodsClinical and radiological outcomes of 130 consecutive total hip arthroplasties in 107 patients aged 50 years or younger at primary operation were reviewed; 77% had a diagnosis other than osteoarthritis. All patients were followed at 5-year intervals, no patients were lost to follow-up, and the status of every implant is known.ResultsMean age at surgery was 41.8 (17-50) years. Mean follow-up was 22.0 (20.0-26.1) years. There were 79 hips surviving, 14 hips (11 patients) deceased, and 37 hips revised. Reasons for revision: 29 hips for aseptic cup loosening (26 stems revised using cement-in-cement, three left in-situ); three stems for femoral osteolysis, two related to acetabular polyethylene wear (14.1 and 17.0 years), one with Gaucher’s disease (21.1 years); one broken stem (12.9 years); one cup for instability (4.3 years–stem revised using cement-in-cement); and two hips with infection (8.5 and 23.8 years). There were no cases of aseptic loosening of the Exeter stem. There were no radiologically loose stems although eight patients had radiological evidence of loosening of the cemented cup. Survivorship at 22 years was 74.9% for revision for all causes and 96.3% for revision of the stem for aseptic loosening or lysis.ConclusionThe Exeter cemented stem has excellent survivorship at minimum 20 years in young patients. Acetabular component survivorship was less favorable, but the advent of highly cross-linked polyethylene may improve this in the long term.     

Contemporary Total Hip and Total Knee Arthroplasty Results in Patients with Hemochromatosis

BackgroundHemochromatosis can result in metabolic bone pathology (due to excessive iron absorption) and degenerative joint disease, leading to total joint arthroplasties. The aim of this study is to analyze the survivorship, complications, radiographic results, and clinical outcomes of patients with hemochromatosis who received either a total hip arthroplasty (THA) or a total knee arthroplasty (TKA).MethodsWe identified 34 lower extremity arthroplasties in 29 patients with hemochromatosis performed between 2000 and 2016. There were 17 primary THAs in 15 patients and 17 primary TKAs in 14 patients. Mean age at arthroplasty was 63 years with 76% being male. The mean body mass index was 28 kg/m². Mean follow-up was 5 years.ResultsThe survivorship free from any revision for THAs was 94% at 10 years. One patient was revised for aseptic loosening of the femoral stem at 6 months. In THA patients, no infections, no other complications, and no radiographic evidence of aseptic loosening were identified. Harris Hip Scores improved from a mean of 55 preoperatively to 94 postoperatively (P < .001). The survivorship free from any revision for TKAs was 100% at 10 years. Two patients (12%) developed acquired idiopathic stiffness postoperatively; no infections were identified. There was no radiographic evidence of aseptic loosening in any TKA. Knee Society Scores improved from a mean of 61 preoperatively to 94 postoperatively (P < .001).ConclusionThis study found excellent survivorship, significant improvements in clinical outcomes, and a very low complication profile for both THA and TKA in patients with hemochromatosis.     

Minimum 25-Year Results of a Tapered Titanium Porous Plasma Spray Coated Femoral Component

BackgroundPrevious studies have reported excellent results with tapered, titanium, porous plasma-sprayed components in patients undergoing uncemented primary total hip arthroplasty (THA). The purpose of this study was to examine survival and clinical results at a minimum 25-year follow-up.MethodsWe reviewed all patients who underwent primary THA at our center through 1995 with a specific femoral component that was essentially unchanged since its 1984 introduction, except porous coating was continued circumferentially in 1987, a hydroxyapatite-coated option was offered in 1988, and an offset option was added in 1999. There were 332 patients (396 THA) who had a minimum 25-year follow-up (range, 25 to 37). Mean age at surgery was 48 years (range, 21 to 70 years). Mean follow-up in nonfailed patients was 29 years (range, 25 to 37 years).ResultsThere were 31 femoral revisions (7.8%): 9 infections, 3 failures of ingrowth, 5 aseptic loosening, 8 osteolysis well-fixed, 2 periprosthetic fractures, 2 polyethylene wear with trochanteric avulsion, 1 component breakage, and 1 malalignment well-fixed. Kaplan-Meier survival with the endpoint of all-cause stem revision was 94.8% (95% confidence interval: ±0.9%) at 37 years, and with the endpoint of aseptic loosening/failure of ingrowth was 98.7% (95% confidence interval: ±0.5) at 37 years. Harris hip scores improved significantly from 43 preoperatively to 76 most recently.ConclusionThis tapered, titanium, porous plasma spray-coated femoral component continues to demonstrate high long-term survival with a low rate of femoral component revision for any reason or aseptic loosening/failure of ingrowth.     

Selective screw fixation is associated with early failure of primary acetabular components for aseptic loosening

Selective supplementation of acetabular component fixation with a screw during primary total hip arthroplasty (THA) assumes that the surgeon can detect when an acetabular component needs additional stability. In contrast, nonselective screw users do not alter their practice based on their interpretation of stability and either use screws all or none of the time. We aimed to determine the effect of selective screw use on aseptic acetabular component loosening. We retrospectively reviewed aseptic failures of acetabular components after primaty THA. We compared the survivorship of selective and nonselective supplementation of acetabular fixation with respect to time to revision, obesity, and screw use. Selective screw use (n = 16) was associated with earlier acetabular component aseptic loosening (median: 1.9 years; interquartile range [IQR]: 1.1-5.0) compared to nonselective screw use (n = 22; median: 5.6 years; IQR: 2.0-15.3; P = .010). Selective screw use was independently associated with earlier revision after adjusting for patient obesity. Obesity was associated with selective screw use in 50% of the cases vs 14% of nonselective cases (odds ratio: 6.3; confidence interval: 1.2-25.2; P = .028), possibly reflecting the increased difficulty in achieving acetabular component stability in this and other settings with compromised bone. Surgeons should carefully assess component stability at time of primary THA. If the acetabulum is not stable, the addition of screws alone may not be sufficient for acetabular component stability.     

Revision total hip arthroplasty with cemented femoral component

We reviewed retrospectively the results of 28 hips (25 patients) after revision of the femoral component with use of a cemented stem, because of aseptic loosening. The mean duration of follow-up was 4.43 years (range 2–12 years). Over the course of the study period, repeat revision was done in 4 hips after an average of 4.45 years. Three hips had a repeat revision of the femoral component because of aseptic loosening and one for a deep infection. The rate of loosening of the femoral component was 32.4% (9 hips) at an average of 5.22 years. The 5-year survival rate was 76.9% with mechanical failure as end point; and 90% with re-revision of femoral component because of aseptic loosening as end point. The cement mantle was the principal factor, which was significantly associated with a better survival rate of femur fixation (P < 0.05). No correlation was noted between quality of bone loss at the time of revision, bone graft or the use of long stems, and the survival rate of femoral component. By improving the cementing technique and in selected patients, the use of cemented femoral stem could be a good alternative for aseptic loosening THA.     

Long-Term Results of Acetabular Reconstruction Using Ganz Acetabular Rings

Background

Our study examines the long-term results of acetabular reconstruction using the Ganz acetabular reinforcement ring (GRR) in total hip arthroplasty.

Correlation of Aspiration Results With Aseptic Loosening in Total Hip Arthroplasty

In the evaluation of patients with a persistently painful total hip arthroplasty establishing an accurate diagnosis is paramount in the selection of a successful treatment regimen. It is unknown whether synovial analysis might differentiate aseptic loosening from other causes of failure. A physiological basis exists to suggest that aseptic loosening might be a process of non-segmented leukocytes. The objective of this study was to determine if the synovial fluid differential cell count might aid in the diagnosis of aseptic loosening. A retrospective chart review of all patients who had undergone revision hip arthroplasty with pre-operative or intra-operative aspiration results was performed. Aseptic loosening was defined as gross intraoperative movement in the absence of infection. From these results Relative-Operating Characteristic (ROC) curves were created, and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. A diagnosis of aseptic loosening was established in 76 of the 253 hips. The ROC curves indicated that lymphocyte count does have utility in the diagnosis of aseptic loosening. If an aspirate has a combination of fewer than 2500 WBCs (sensitivity 93%, specificity 42%, NPV 94%, accuracy 57%) or more than 10% lymphocytes (sensitivity 86%, specificity 42%, NPV 87%, accuracy 55%) then the sensitivity for aseptic loosening is 96%, the specificity is 33%, the NPV is 95% and the accuracy is 52%. In patients with painful total hip arthroplasties in whom infection has been excluded, aspiration data can be a useful adjunct in the diagnosis of aseptic loosening. In aspirates with neither a WBC cell count of less than 2500 nor a lymphocyte cell count of greater than 10% aseptic loosening can be effectively “ruled out” as fewer than 5% of these patients will have aseptic loosening. While non-specific, aspirate differential can be useful to “rule-out” aseptic loosening with a sensitivity and negative predictive value well exceeding that of standard radiographs.     

Association of NLRP3 and CARD8 Inflammasome Polymorphisms With Aseptic Loosening After Primary Total Hip Arthroplasty

Our aim was to investigate the association of inflammasome polymorphisms NLRP3 rs35829419 (p. Q705K) and CARD8 rs2043211 (p. C10X) with aseptic loosening of total hip endoprostheses. We asked whether patients with the loosening of total hip arthroplasty earlier than 15 years after primary implantation had a higher proportion of the polymorphisms Q705K and C10X in comparison to subjects without loosening. A retrospective case–control study compared 36 patients with total hip endoprosthesis loosening earlier than 15 years after primary implantation and 51 control subjects with unloosened total hip endoprostheses, matched for gender, age, and follow-up period. Buccal mucosa samples were used for genomic DNA analysis and genotyped for NLRP3 rs35829419 and CARD8 rs2043211 using a fluorescence-based competitive allele-specific real-time polymerase chain reaction. The proportion of subjects with both wild-type NLRP3 and CARD8 (i.e., without Q705K or C10X) was considerably higher in the control group when compared with patients with early total hip arthroplasty loosening (49% vs. 28%; p = 0.05). After adjustment for gender, age, and follow-up, patients with combined wild type of both NLRP3 and CARD8 had significantly smaller odds for early implant loosening (odds ratio 0.33, p = 0.02). Investigated polymorphisms may influence several inflammatory pathways and contribute to the loosening of artificial implants with potential clinical significance for the appropriate selection of patients and endoprostheses when planning elective total hip arthroplasty. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:417-421, 2020     

Fifteen-year Results of Precoated Femoral Stem in Primary Hybrid Total Hip Arthroplasty

Background

There has been controversy whether methylmethacrylate precoating of the cemented femoral stem is a solution for aseptic loosening or rather contributes to increased failure rates in cemented total hip arthroplasties.

Methods

On a retrospective basis, we analyzed 76 primary hybrid total hip arthroplasties from 63 patients with precoated, cemented femoral stems between October 1990 and December 1995. The mean age of the patients was 46.8 years (range, 22 to 77 years) with a minimum follow-up of 14 years (mean, 15.5 years; range, 14 to 19.5 years). Third generation cementing techniques were employed in all cases.

Results

Twenty-four out of 76 cases (31.6%) showed aseptic loosening of the femoral stems, of which 23 stems were revised at an average revision time of 8 years (range, 3 to 14.8 years). The main mode of loosening was cement-stem interface failure in 22 hips (91.7%). Twenty-one out of 24 failed hips (87.5%) demonstrated C2 cementing grades (p < 0.001). Kaplan-Meier survivorship analysis using radiographic aseptic loosening of the femoral stem as the endpoint for failure showed survival rates of 76.5% at 10 years (95% confidence interval [CI], 71.4 to 81.6) and 63.2% at 19 years (95% CI, 57.3 to 69.1).

Conclusions

An early failure of the precoated femoral stem in this study was mainly due to an insufficient cementing technique. Achievement of good cement mantle may improve the survival rates.     

Contemporary Porous Titanium Acetabular Components for Total Hip Arthroplasty After Pelvic Radiation

BackgroundPatients undergoing primary total hip arthroplasty (THA) following pelvic radiation have historically had poor survivorship free of aseptic acetabular component loosening. However, several series have reported improved results with tantalum acetabular components. The purpose of this study is to assess implant survivorship, radiographic results, and clinical outcomes of contemporary, porous titanium acetabular components in the setting of prior pelvic radiation.MethodsWe retrospectively reviewed 33 patients (38 hips) with prior pelvic radiation between 2006 and 2016 who underwent primary THA. The mean overall pelvic radiation dose was 6300 cGy with a mean latency period to THA of 5 years. The most common acetabular component was Pinnacle (DePuy Synthes) in 76%. Eight-seven percent of cups were fixed with screws. The mean age at primary THA was 74 years, 76% were male, and the mean body mass index was 30 kg/m². Mean follow-up was 5 years.ResultsThe 10-year survivorship free of revision for aseptic loosening, free of any revision, and free of any reoperation were 100%, 89%, and 89%, respectively, when accounting for death as a competing risk. There were 3 revisions; one each for taper corrosion, recurrent dislocation, and infection. Radiographically, all cups had evidence of osteointegration and none had radiographic evidence of loosening. The mean Harris Hip Score improved from 50 to 84 postoperatively (P < .0001).ConclusionContemporary porous titanium acetabular components with supplemental screws provided excellent implant fixation in patients with prior therapeutic pelvic radiation. At 10 years, 100% of these components were free of revision for aseptic loosening and 100% were radiographically well-fixed.Level of EvidenceLevel IV, Therapeutic.     

Revision Risk in a Cohort of US Patients Younger Than 55 Undergoing Primary Elective Total Hip Arthroplasty

BackgroundAs indications for elective total hip arthroplasty (THA) expand to younger patients, we sought to (1) compare revision risk following primary elective THA in patients <55 years at the time of their THA to patients aged ≥65 years and (2) identify specific risk factors for revision in patients <55 years.MethodsA Kaiser Permanente's total joint replacement registry was used to conduct a cohort study including primary elective THA patients aged ≥18 (2001-2018). In total, 11,671 patients <55 years and 53,106 patients ≥65 years were included. Multiple Cox regression was used to evaluate cause-specific revision risk, including septic revision, aseptic loosening, instability, and periprosthetic fracture. Stepwise Cox regression was used to identify patient and surgical factors associated with cause-specific revision in patients <55 years.ResultsPatients <55 years had a higher risk of septic revision (hazard ratio [HR] = 1.30, 95% confidence interval [CI] = 1.02-1.66), aseptic loosening (HR = 2.60, 95% CI = 1.99-3.40), and instability (HR = 1.35, 95% CI = 1.09-1.68), but a lower risk of revision for periprosthetic fracture (HR = 0.36, 95% CI = 0.22-0.59) compared to patients aged ≥65 years. In the <55 age group, risk factors for septic revision included higher body mass index, drug abuse, and liver disease. Hypertension, anterior approach, and ceramic-on-ceramic were associated with aseptic loosening. White race, American Society of Anesthesiologists classification ≥3, smoker, paralysis, posterior approach, ceramic-on-ceramic, and smaller head diameter were associated with instability.ConclusionIdentified risk factors varied depending on the cause for revision. Although septic revisions were related to patient characteristics, more modifiable factors, such as implant or surgical approach, were associated with revision due to aseptic loosening and instability.Level of EvidenceIII.     

Prevalence and Impact of Positive Intraoperative Cultures in Partial Hip or Knee Revision

BackgroundOur aim is to investigate the impact of unexpected positive cultures on the outcome of partial prosthetic revisions.MethodsData regarding patients who underwent a partial hip or knee revision from 2003 and 2012 with the preoperative diagnosis of aseptic loosening was retrospectively reviewed. The protocol of revision included at least 3 intraoperative cultures. Failure was defined as the need for re-revision due to aseptic or septic loosening at 5 years.ResultsA total of 99 hip and 46 knee partial revisions were included. All cases had at least 5 years of follow-up. Ninety-seven cases (66.9%) had all cultures negative, 35 (24.1%) a single positive culture and 13 (9.0%) ≥2 positive cultures for the same microorganism. The median time from primary arthroplasty to partial revision was significantly shorter for patients with ≥2 positive cultures (26 months) than in those with all cultures negative (48 months) or with a single positive culture (51 months). Partial revisions performed within the first 5 years of implantation had a higher 5-year re-revision rate. The presence of a single positive culture during the partial exchange was not associated with a higher re-revision rate (2 of 35, 5.7%) than in those with negative cultures (3 of 97, 3.1%). On the contrary, re-revision rate was significantly higher in cases with ≥2 positive cultures (3 of 13, 23.1%) than in those with negative cultures (P = .02).ConclusionPartial revisions performed within the first 5 years from implantation and ≥2 intraoperative positive cultures were associated with a higher re-revision risk at 5 years.     

Excellent Long-Term Survival Rate of Polished,Tapered, Cemented Stems in Patients Aged 35 Years or Younger With Avascular Necrosis or Inflammatory Arthritis of the Hip

BackgroundTotal hip arthroplasty (THA) for avascular necrosis (AVN) or inflammatory arthritis (IA) comes with a relatively high risk of aseptic stem loosening, especially in young patients. There are limited long-term data on the survivorship of polished, tapered, cemented stems in this population. We therefore performed a single-center retrospective study investigating the survival of this particular stem type in young patients with AVN or IA.MethodsAll patients aged ≤35 years who had received a THA for AVN or IA operated on by the senior author between 1990 and 2010 at the University Hospitals Leuven were identified. In total, 85 THAs in 62 patients were included. Primary endpoint was revision of the femoral component for aseptic loosening. Secondary endpoints were revision of the acetabular component for aseptic loosening, revision for other reasons, and the presence of radiolucencies around the components.ResultsThe mean follow-up for the entire cohort was 18.0 ± 5.3 years (range 8.0-28.9). Taking revision for aseptic loosening as endpoint, the survival of cemented stems was 100% after 15 years and 95.1% after 20 years. Survival of uncemented cups (91.3%) was significantly better than survival of cemented cups (50.3%) after 20 years of follow-up for aseptic loosening. Taking revision for any reason as endpoint, the survival of THAs with uncemented and cemented cups was 90% and 43.1% at 20 years respectively. Radiolucencies developed in the cement mantles around 11 of the 81 nonrevised stems, mainly in zones 1 and 7.ConclusionIn this cohort of young patients with high-risk profiles for aseptic stem loosening, polished, tapered, cemented stems showed excellent long-term survival rates and they therefore remain a viable alternative to uncemented stem designs.     

Midterm Outcomes of Revision Total Hip Arthroplasty With the Use of a Multihole Highly-Porous Titanium Shell

Background

We are reporting on the minimum 5-year outcomes of patients who underwent revision total hip arthroplasty (THA) using a specific highly-porous titanium shell. We assessed (1) aseptic and all-cause survivorship; (2) functional outcomes; (3) complications; and (4) radiographic outcomes.

Long-Term Outcomes After Metal-on-Metal Total Hip Arthroplasty With a 28-mm Head: A 17- to 23-Year Follow-Up Study of a Previous Report

Background

Second-generation, metal-on-metal total hip arthroplasty (MoM THA) using a 28-mm head has shown favorable results compared with large head MoM THA. The purpose of this study is to evaluate the long-term outcomes of cementless primary MoM THA with a 28-mm head and the incidence of osteolysis using computed tomography.

Etiology and Complications of Early Aseptic Revision Total Hip Arthroplasty Within 90 Days

BackgroundThe etiology, complications, and rerevision risks of early aseptic revision total hip arthroplasty (THA) within 90 days are insufficiently documented.MethodsA national insurance claims database (PearlDiver Technologies, Fort Wayne, IN) was queried for patients who underwent unilateral aseptic revision THA within 90 days of the index procedure using administrative codes. Patients who underwent revision for infection, without minimum 2-year follow-up, and younger than 18 years were excluded. This cohort was matched based on gender, age, and Charlson Comorbidity Index to a control group of patients who underwent primary THA without revision within 90 days. Two-year rerevision and 90-day complication rates were recorded. Chi-square and Fisher exact tests were used as appropriate for statistical comparison.ResultsFour hundred two patients met the inclusion criteria for early aseptic revision within 90 days of the index procedure and were matched to the control group. The overall 2-year rerevision rate was higher in the early revision group compared with control group (14.9% vs 2.5%, P < .001). Complications within 90 days occurred more frequently in the early revision group, including blood transfusion (10.2% vs 3.2%, P < .001), deep vein thrombosis (9.0% vs 3.2%, P = .001), and pulmonary embolism (2.74% vs 0.75%, P = .031). The most common reasons for early aseptic revision were dislocation (41.5%), fracture (38.1%), and loosening (17.4%).ConclusionEarly aseptic revision THA is associated with significantly higher 90-day complication rates and 2-year rerevision rates compared with a control group of primary THA without revision. The most common reasons for acute early revision were dislocation, fracture, and mechanical loosening.Level of EvidenceLevel III.     

Aseptic Loosening of Cemented Total Arthroplasties of the Hip in Relation to Positioning of the Prosthesis: New Utilization of the Tschuprow-Cramer Statistical Test

A statistical study of 1200 McKee-Farrar cemented total prostheses of the hip demonstrated the importance of a horizontal position of the cup and a valgus position of the prosthetic stem, in avoiding aseptic loosening of the prosthetic parts. A new test (the Cramer test) showed that a statistical bond exists between the position of the prosthesis and the occurrence of aseptic loosening.     

Obesity Is Independently Associated With Early Aseptic Loosening in Primary Total Hip Arthroplasty

Background

Obesity affects millions of patients in the United States and is associated with several complications after total hip arthroplasty (THA). The effect of obesity on the rate and mode of primary THA failure remains poorly understood, especially given other potentially confounding patient characteristics. We hypothesized that, among patients with a failed primary THA, obesity is independently associated with aseptic loosening and a higher rate of early revision.