Custom total hip arthroplasty

Custom total hip arthroplasty (THA) has been advocated as a primary operation to achieve optimal proximal fit and fill in THA. Because of the increased cost of the implant, it must be proved that survivorship of the custom component is improved compared with a well-cemented or cementless off-the-shelf femoral prosthesis. A series of 64 primary and revision femoral component custom titanium uncemented THAs were reviewed. In the primary custom group 90.9%, and in the revision group 80%, had good to excellent results using the Harris hip scoring system at a mean follow-up period of 6.5 years. The age range was 32 to 74 years (mean, 53 years). Thigh pain was present in 17% of the patients in this series. Significant osteolysis occurred in 4.7% of the cases. The average time to failure for the four primary custom THAs was 4.1 years, and for the four revision custom THAs, 2.4 years. Despite excellent proximal fit and fill, these short-term results have not resulted in improved success rates compared with a well-cemented or cementless off-the-shelf femoral component when performing THA.     

Computer-aided reconstruction of hip joint in revision arthroplasty

Geometric revision reconstruction of the hip joint of a female patient is presented. Because of extensive bone resorption and strong bone obstruction, we decided to employ a custom–made prosthesis not only in the pelvis but also in the femur. The custom prosthesis design and manufacturing processes were carried out with the aid of computed tomography (CT), a system of tomographic image processing, a computer–aided design (CAD) system and a computer–aided manufacturing (CAM) system. The process included tomographic measurements of the patient’s hip joint, conversion of the CT images, geometrical modelling of the femur and pelvis in the CAD system, prostheses design, virtual simulation of the reconstructed acetabulum, determination of prosthesis matching, and manufacturing on a CNC machine. The outcome of this engineering process was a total hip arthroplasty (THA) surgical operation.     

Proximal femoral osteotomy as an adjunct in cementless revision total hip arthroplasty

Cementless total hip replacement techniques are increasingly used in revision arthroplasty. A major challenge is to achieve implant stability in a femur distorted by a failed arthroplasty. Five patients with aseptic loosening of cemented primary or revision total hip replacements complicated by significant proximal femoral disease, four with marked angular deformity of the femur and one with a subtrochanteric nonunion, were treated successfully with cementless revision arthroplasty combined with proximal femoral osteotomy. At follow-up examination, all femoral and trochanteric osteotomies had healed and D'Aubigne and Postel scores for pain, function, and range of motion had improved. All porous prostheses demonstrated radiographic features consistent with bone ingrowth fixation. No progressive stress shielding has been observed. Concomitant femoral osteotomy to correct anatomic deformity, in association with cementless total hip arthroplasty, results in union of the osteotomy and restoration of hip function.     

Ten-year results of uncemented hip stems for failed intertrochanteric osteotomy

Introduction Inferior survival of cemented total hip arthroplasty has been reported after previous femoral osteotomy. The purpose of this study was to evaluate the long-term survival of uncemented stems after femoral osteotomy.Materials and methods Forty-eight hips in 45 patients had undergone conversion THA for a failed intertrochanteric osteotomy of the hip after a mean of 12 years (2–33 years). Mean time of follow-up was 11 years (5–15 years).Results At follow-up, two patients (three hips) had died, and one patient (one hip) was not located. Three patients (three hips) underwent femoral revision—one for infection and two for aseptic loosening of the stem. Survival of the stem was 94% at 10 years, and survival with femoral revision for aseptic loosening as an end point was 96%. The median Harris Hip Score at follow-up was 80 points. Radiolucent lines in Gruen zones 1 and 7 were present in 14 and 18% of hips, respectively. Radiolucencies in other zones were not detected. There was no radiographic evidence of femoral osteolysis, stress-shielding or loosening.Conclusion The results with this type of uncemented tapered titanium femoral component after proximal femoral osteotomy are encouraging and compare to those achieved in patients with regular femoral anatomy.     

Primary and revision total hip replacement without cement and with associated femoral osteotomy

Nine porous-coated total hip prostheses were implanted without cement in nine patients who had a major proximal femoral deformity. Six patients had revision and three, primary total hip replacement. In all nine patients, as well placed corrective osteotomy was needed to successfully perform the arthroplasty. The average time until union of the proximal femoral osteotomy was fifteen weeks for the patients who had a primary arthroplasty and twenty-seven weeks for the patients who had a revision arthroplasty. The average Harris hip-rating score was 94 points for the patients who had a primary arthroplasty and 84 points (range, 60 to 93 points) for those who had a revision arthroplasty. The length of follow-up averaged forty-seven months.     

Blood flow changes to the proximal femur during total hip arthroplasty.

OBJECTIVE: To determine the changes in perfusion to the proximal femur that occur during cemented and uncemented total hip arthroplasty (THA). DESIGN: Case series. SETTING: A single tertiary-care centre. PATIENTS: Twenty-two consecutive patients. Those who had undergone previous hip surgery or received systemic corticosteroid therapy were excluded. INTERVENTION: Cemented (11 procedures) or uncemented (12 procedures) THA. MAIN OUTCOME MEASURE: Changes in blood flow at the level of the proximal femur, measured with laser Doppler flowmetry at 4 different times during THA. RESULTS: In both the cemented and the uncemented procedure overall proximal femoral blood flow was reduced (p = 0.002, p = 0.008, respectively). A greater reduction in overall proximal femoral perfusion was seen in the cemented group compared with the uncemented group (p = 0.004). This greater reduction in perfusion was seen primarily in the proximal femoral diaphysis (p = 0.004). CONCLUSION: The extensive canal preparation involved with the cemented procedure or the introduction of bone cement under pressure into the femoral canal may contribute to the greater reduction in perfusion to the proximal femur.     

Total hip arthroplasty with shortening osteotomy in congenital major hip dislocation sequelae

We retrospectively evaluated the postoperative results of total hip arthroplasty (THA) in patients presenting with Crowe group IV dislocated hips. Overall, results were compared with regard to the type of osteotomy performed (Z or oblique) to define the correct indications for surgical technique and choice of prosthetic implant. Thirty-three subtrochanteric shortening and derotational osteotomies in primary THA were performed in 26 patients secondary to congenital hip dislocation. A Z osteotomy was performed in 14 cases and an oblique osteotomy in 19. The surgical approach was direct lateral, and surgery was aimed at restoring the anatomic hip center. Femoral and acetabular fixation was uncemented. The most used stem was the S-ROM (DePuy, Leeds, United Kingdom), and the couplings used were ceramic-ceramic (7 cases), ceramic-polyethylene (3 cases), metal-polyethylene (15 cases), and metal-metal (3 cases). Mean follow-up was 88±45 months. According to the Merle D'Aubigné score, the overall clinical results were good in 23 cases, satisfactory in 6, and fair in 4. Union of the osteotomy occurred in 97% of cases, and the mean time required for osteotomy union was 6±2 months without significant differences between Z and oblique osteotomies. At last follow-up, there was loosening of 1 cup and 1 stem, and revision was necessary. Twelve percent of patients experienced postoperative dislocation and 9% developed neuropraxia of the femoral nerve. The clinical and radiological results were similar in both groups, with a high rate of pain relief, an improvement in limb-length discrepancy, and reduced limping, leading to a smaller or no insole. Currently, the more complex Z osteotomy has been abandoned, because a modular stem prosthesis with metaphyseal sleeve allows the oblique osteotomy to be used with an easier and shorter surgical procedure.     

Total hip arthroplasty with step-cut subtrochanteric femoral shortening osteotomy in high riding hip dislocated patients with previous femoral osteotomy

Background

To evaluate the long-term clinical and radiological outcomes of cementless total hip arthroplasty (THA) in high riding hip dislocated patients with previous proximal femoral osteotomy.

Subtrochanteric transverse shortening osteotomy in cementless total hip arthroplasty achieved using a modular stem

It is challenging to reconstruct normal hip motion after a high hip dislocation. Although total hip arthroplasty (THA) with shortening osteotomy is a solution for high hip dislocation, osteotomy nonunion is a major complication. To improve the rate of osteotomy union, subtrochanteric transverse shortening osteotomy was performed using a modular-type stem, S-ROM, that can be fixed to both the proximal and distal parts of the femur individually with a stepped proximal sleeve and polished distal flutes with fins, respectively. The stem can facilitate union of the osteotomy by maintaining rigid rotational stability and generating compression pressure between bone parts of the femur even in simple transverse osteotomy. Moreover, transverse osteotomy is technically simple and minimizes the damage of the periosteum at the osteotomy. In our series, this procedure was performed on 6 hips in 6 patients with high hip dislocation. The mean follow-up period was 8.1 years. Osteotomy union was achieved in all patients for a mean of 8.8 weeks. This procedure is a good option for surgical treatment of high hip dislocation.     

Rheumatoid arthritis and hydroxyapatite-coated hip prostheses: Five-year results

Medium- and long-term results from cemented total hip arthroplasty (THA) in patients with rheumatoid arthritis (RA) show a higher incidence of infection and aseptic loosening when compared to other diagnoses. Early results using uncemented prostheses are variable. Hydroxyapatite (HA) coatings are thought to improve early osseointegration in uncemented THA. In a prospective, international, multicenter clinical study, 32 RA patients who received 33 uncemented HA-coated prostheses were followed up for a minimum of 5 years. Medium-term clinical results are excellent. No infection or aseptic loosening has been recorded. Excellent osseointegration was observed radiographically. Bone remodeling was consistent with mainly proximal to midstem stress transfer. We conclude that uncemented, proximally HA-coated prostheses are a promising alternative to cemented prostheses for RA patients.     

Cementless total hip arthroplasty in the treatment of severe hip dysplasia or dislocated hips

We present our experience over 6 years with the use of uncemented total hip arthroplasty (THA) for developmental dysplasia of the hip (DDH) with a mean follow-up of 3 years. In a 6-year period, 26 THAs were performed in 19 patients with Hartofilakidis grades 2 and 3 dislocation of the hips. Out of 19 patients, seven had bilateral dislocations. Uncemented acetabular and femoral components were used in all patients. Patients with a minimum follow-up of 1 year were included in the study. The average age at the time of surgery was 38 (range 20–69) years. Approaches used include trochanteric osteotomy in 14 (54%) patients and a lateral approach in 12 (46%) patients. In addition, subtrochanteric osteotomy was performed in four (15%) patients. A Mallory-head femoral stem was used in 15 (58%) patients; a DDH femoral stem was in nine (35%), and the S-ROM femoral prosthesis in two (8%). A Mallory head acetabular shell was used in all cases, a 22.2-mm chrome cobalt head was used in 18 (69%), and a 28-mm chrome cobalt head was used in eight (31%). The average follow-up was 3 (range 1–6) years. The Harris hip score (HHS) improved in the cohort from a mean preoperative score of 51 to a mean postoperative score of 86 (p<0.05). The mean preoperative SF36v2 score was 42 compared to postoperatively of 67(p<0.05). The complication rate was 11% with nonunion of a subtrochanteric osteotomy in one patient, dislocation in one, and trochanteric bursitis due to fracture of Dall-Miles cables in one. THA for DDH is a technically demanding procedure. This short-term follow-up of THA for DDH using uncemented implants is encouraging for arthrosis secondary to DDH. It provides better function compared to arthrodesis or excision arthroplasty, especially in young individuals. A long-term follow-up is required in order to establish the role of this management strategy.     

The relative cost of cemented and uncemented total hip arthroplasties

The use of uncemented femoral stems in primary total hip arthroplasty (THA) has been slow to develop in the UK because of the lack of encouraging published long-term follow-up data, the continued success of the cemented primary THA, and the perceived excessive relative cost of the uncemented THA. In this article, we argue that the total costs of 3 "proven" uncemented stems are comparable with commonly used cemented femoral components, when all necessary materials are taken into consideration. In addition, we will also discuss other potential benefits and drawbacks for considering the use of uncemented stems.     

A Reliable Femoral Osteotomy in Total Hip Arthroplasty for Hartofilakidis Type C Developmental Dysplasia of the Hip: Proximal Femoral Reconstruction

BackgroundProcedure of the femur is extremely challenging during total hip arthroplasty (THA) for Hartofilakidis type C developmental dysplasia of the hip. The main purpose of this study is to compare the clinical effectiveness of proximal femoral reconstruction (PFR) with subtrochanteric transverse osteotomy (STO).MethodsBetween 2006 and 2015, 33 primary THAs in 26 patients were performed with PFR and 16 hips in 13 patients underwent STO. The mean follow-up was 4.2 (range, 2.2-10.8) years in PFR group and 5.9 (range, 3.5-11.3) years in STO group. At the final follow-up, clinical scores and radiographic results were evaluated for 33 hips in PFR group and 15 hips in STO group.ResultsPostoperative Harris hip scores and implant position did not differ between the treatment groups. The mean length of the oblique osteotomy line at proximal femur was 6.9 cm (range, 5.8-7.6 cm) in PFR group. The amount of bone union occurred within 6 months after surgery was 24 (72.7%) hips in PFR group and 9 (60.0%) in STO group. Three major postoperative complications occurred in PFR group, and medial femoral calcar erosion was noted in 1 hip in STO group.ConclusionSimilar with STO, the clinical results of PFR technique are a reliable solution for femoral procedure during THA in patients with Hartofilakidis type C developmental dysplasia of the hip.     

Good survival of uncemented tapered stems for failed intertrochanteric osteotomy: a mean 16 year follow-up study in 45 patients

Introduction  Inferior survival of cemented total hip arthroplasty has been reported after previous femoral osteotomy. We previously presented 5–15 years results of uncemented femoral stems for this subgroup of patients. The purpose of the present study was to re-evaluate that same patient group at 10–20 years follow-up. Materials and methods  Forty-eight hips in 45 patients had undergone conversion THA for a failed intertrochanteric osteotomy of the hip after a mean of 12 years (2–33 years). Mean time of follow-up was 16 years (10–20 years). Results  At the latest follow-up five patients had died (five hips), and one patient (one hip) remained lost to follow-up. Compared to the previous evaluation, one more patient required femoral revision for aseptic loosening giving a total of four patients (four hips) with femoral revision––one for infection and three for aseptic loosening of the stem. Survival of the stem was 91% at 15 and 20 years respectively; survival with femoral revision for aseptic loosening as an end point was 93%. The median Harris-Hip-Score at final follow-up was 76 points (previously 80 points). Radiolucent lines in Gruen zones 1 and 7 were present in 20 and 17% of hips, respectively. Radiolucencies in other zones were not detected. There was no radiographic evidence of femoral osteolysis, stress-shielding or loosening. Conclusion  The long-term results with this type of uncemented tapered titanium femoral component after proximal femoral osteotomy remain encouraging and compare favorably to those achieved in patients with regular femoral anatomy. This paper has not been under consideration by any other journal. All authors equally contributed to this paper.     

Periprosthetic proximal bone loss after uncemented hip arthroplasty is related to stem size: DXA measurements in 138 patients followed for 2-7 years

Background Periprosthetic bone loss occurs around uncemented femoral stems and may be influenced by the stem size.

Patients and methods We studied 138 consecutive patients, 3 (2-7) years on average after a total hip arthroplasty operation (THA) for unilateral osteoarthritis with the Bi-Metric uncemented femoral stem. We analyzed Harris hip score and bone mineral density.

Results The mean Harris hip score was 97 at follow-up. Bone mineral density decreased proximally by 19% in both Gruen zones 1 and 7. Bone loss in zones 1, 2, 6, and 7 was significantly associated with stem size. Distally, a small gain in bone mass was found in zones 3 and 5 for medium femoral sizes.

Interpretation We found a marked proximal BMD loss, especially for the larger stems, which may be specific for this particular implant. Long-term studies should reveal whether this proximal bone loss will affect the longevity of the THA.     

Total hip reconstruction in the anatomically distorted hip

Recent reports in the literature strongly support the idea that cement is the optimum form of fixation of the femoral component in total hip replacement. For hybrid total hip arthroplasty, we used a cemented cup instead of an uncemented cup since this was inevitable in cases of poorly developed acetabulum. The uncemented cone femoral component is also beneficial in cases of extremely narrow and cylindrical configuration of the medullary cavity of untreated congenital dislocation of the hips (CDH) and tuberculosis or septic arthritis in childhood. We reviewed the clinical result of a consecutive series of patients with cemented total hip arthroplasty (THA) compared with recent studies on hybrid reconstruction using survivorship analysis. This subsequent study involved a hybrid uncemented Wagner cone femoral component and a cemented acetabular component with roof reinforcement by additional impacted cancellous allograft with hydroxyapatite (HA). We believe that early failure of the cemented components was due to an adverse effect of thin cement mantles around cemented femoral stems as well as the cemented cup in THA. In addition, 8 patients who received our modification of the Charnley CDH component had poor results even though we reduced the stem geometry and thickness. Furthermore, intraoperative fracture and splitting of the proximal femur was a major complication during implantation. Contrary to expectations, the results of these hybrid reconstructions were extremely encouraging (average follow-up period of 2–4.5 years). In addition to our experience of the cemented versus hybrid THA involving the uncemented Wagner femoral component, we have determined positive indications for the untreated and severely distorted anatomy of bilateral CDH for which surgical interventions for reconstruction were not recommended before.     

Preliminary results of an off-the-shelf press-fit stem. The anthropometric total hip femoral component using exact-fit principles

The use of custom-manufactured femoral prostheses as part of routine total hip arthroplasty (THA) has been suggested. However, there are several disadvantages, including possible inaccuracy of fit, inadequate instrumentation, and high cost. A series of 28 THAs (including 18% for revision of failed, cemented THA) using a press-fit prosthesis of contemporary design were investigated. The average follow-up period was 28 months (range, 12-49 months). Clinical results were overall very good, even in revision cases. Roentgenographic changes included rapid femoral remodeling, which may increase component stability. Given the clinical and roentgenographic results obtained in this complex-problem patient population, it is difficult to justify the use of custom femoral components in routine THA.     

Cementless total hip replacement after previous intertrochanteric valgus osteotomy for advanced osteoarthritis

We present a series of 30 uncemented total hip replacements performed between June 1985 and January 2002 with a mean follow-up of seven years (5 to 20) in 27 patients who had previously undergone a valgus intertrochanteric osteotomy. No further osteotomy was undertaken to enable hip replacement. We used a number of uncemented modular or monoblock femoral components, acetabular components and bearings. The patients were followed up clinically and radiologically. We report 100% survival of the femoral component. One acetabular component was revised at five years post-implantation for aseptic loosening. We noted cortical hypertrophy around the tip of the monoblock stems in six patients. We believe that modular femoral components should be used when undertaking total hip replacement in patients who have previously undergone valgus femoral osteotomy.     

大粗隆延长截骨结合记忆合金内固定在股骨柄翻修术中的应用

目的探讨大粗隆延长截骨结合记忆合金卡环或环抱器在股骨假体固定稳定型髋关节翻修手术中的应用及疗效。方法 对2004年1月至2010年3月,35例（35髋）接受髋关节股骨假体翻修手术中进行大粗隆延长截骨结合记忆合金卡环及环抱器固定的患者,平均年龄（68.2±9.6）岁,进行了平均（36.8±13.2）个月的随访,对手术时间、出血量、截骨长度、内固定方式、截骨愈合时间及术后髋关节功能进行评价。结果 手术时间平均为（95.4±23.6）min,术中出血量平均（852.5±228.3）ml,截骨长度平均为（13.5±3.5）cm,术中内固定采用记忆合金卡环2～3枚或记忆合金环抱器1枚。术后截骨愈合时间平均（4.8±1.2）个月,患者Harris评分由术前平均（39.5±13.6）分提高到术后平均（82.2±17.8）分。结论 大粗隆延长截骨在股骨柄固定牢固的髋关节翻修术中可以充分显露术野,有利于取出固定良好的骨水泥和非骨水泥股骨柄;结合记忆合金卡环或环抱器固定操作简便、固定牢靠,有利于截骨块的愈合,术后功能恢复良好。     

Crowe Ⅳ型髋关节发育不良的全髋关节置换术

目的 探讨全髋关节置换术治疗成人Crowe Ⅳ型髋关节发育不良(developmental dyspla-sia of the hip,DDH)的方法并评价其疗效.方法 1997年10月至2009年1月,应用全髋关节置换术治疗Crowe Ⅳ型DDH患者15例20髋,其中5例双侧、10例单侧.18髋采用Secur-Fit股骨假体,2髋采用Corail股骨假体.转子下斜行截骨6髋,髋臼底磨穿5髋,均行股骨头植骨.结果 15例中早期死亡1例(双髋),失访2例(2髋),余12例16髋获得平均44.2个月(5～92个月)随访.术后发生出血性休克1例,脂肪栓塞1例,术后脱位2例,股骨上端骨裂2例.转子下斜行截骨6髋中,1髋失随访,2髋分别于术后18和23个月随访时仍可见骨折线,下肢行走无异常,其余3髋骨愈合.髋臼底植骨5髋,除1髋失访外,其余均获得愈合.术后X线片显示髋臼假体均位于真臼内,完全骨性覆盖,无髋臼假体松动.术后双下肢长度差平均1.1 cm(0～2.2 cm).末次随访Harris评分由术前平均(24.7±5.7)分(15～32分)提高至末次随访(85.6±5.6)分(80～94分),差异有统计学意义.结论 对Crowe Ⅳ型DDH患者行全髋关节置换术时,良好的真臼暴露、加深髋臼、股骨短缩、斜行截骨及使用Secur-Fit假体能提高全髋关节置换术的治疗效果.