Results of Charnley total hip arthroplasty at a minimum of thirty years. A concise follow-up of a previous report

The purpose of the current study was to update the results of a prospective, single-surgeon series of primary Charnley total hip arthroplasties performed with cement. This investigation is one of the first studies in which hips treated with total hip arthroplasty with cement were followed for a minimum of thirty years. Twenty-seven patients (thirty-four [10.3%] of the hips in the initial study group) were alive at a minimum of thirty years postoperatively. These patients served as the focus of the present study. Revision because of aseptic loosening of the acetabular component was performed in 7.3% (twenty-three) of the hips from the original study group (excluding those revised because of infection or dislocation) and 26% (eight) of the hips in the living cohort. Revision because of aseptic loosening of the femoral component was performed in 3.2% (ten) of the hips from the original study group (excluding those revised because of infection or dislocation) and 10% (three) of the hips in the living patients. Since the twenty-five-year review, three hips were revised (one because of acetabular loosening, one because of femoral loosening, and one because of instability). This end-result study demonstrated the remarkable durability of cemented Charnley total hip replacements over a span of three decades, with 88% of the original prostheses intact at the time of the final follow-up or at the patient's death.     

Uncemented acetabular components with bulk femoral head autograft for acetabular reconstruction in developmental dysplasia of the hip: results at five to twelve years.

BACKGROUND: Anterolateral acetabular bone deficiency is one of the technical problems associated with total hip arthroplasty in patients with developmental hip dysplasia. The purpose of this study was to evaluate the results of one method of acetabular reconstruction for hip dysplasia-placement of an uncemented socket in conjunction with a bulk femoral head autograft. METHODS: Forty-four hips in thirty-five patients (twenty-nine female and six male; average age, thirty-nine years) with developmental hip dysplasia were treated with primary total hip arthroplasty with use of an uncemented porous-coated titanium cup fixed with screws and an autogenous bulk femoral head graft. The patients were followed clinically in a prospective fashion for five to 12.3 years (mean, 7.5 years), and radiographs were analyzed retrospectively. RESULTS: Four acetabular components were revised: two, because of severe polyethylene wear and osteolysis; one, because of aseptic loosening; and one, because of fracture of the acetabular shell. The mean Harris hip score for the unrevised hips improved from 51 points preoperatively to 91 points postoperatively. No unrevised socket had definite radiographic evidence of loosening. Forty-three of the forty-four hips had no radiographic evidence of resorption of the graft or had radiographic evidence of resorption limited to the nonstressed area of the graft lateral to the edge of the cup. CONCLUSIONS: This method of reconstruction provided reliable acetabular fixation and appeared to restore acetabular bone stock in patients with developmental hip dysplasia. We use this technique for patients with moderate anterolateral acetabular bone deficiency requiring total hip arthroplasty.     

Results of porous-coated anatomic total hip arthroplasty without cement at fifteen years: a concise follow-up of a previous report

The purpose of this study was to update the results of a prospective series of primary cementless total hip arthroplasties after a minimum of fifteen years of follow-up. It is one of the first studies of cementless total hip arthroplasties followed for a minimum of fifteen years. One hundred consecutive Porous Coated Anatomic (PCA) total hip replacements were implanted between October 1983 and January 1986. Fifty-five patients (sixty-four hips) that were alive at a minimum of fifteen years postoperatively are the focus of the present study. At this time of follow-up, at an average of 15.6 years (range, fifteen to seventeen years) after the total hip arthroplasty, 17% (seventeen hips) of the entire cohort and 23% (fifteen hips) of the living cohort had undergone revision because of loosening of the acetabular component or osteolysis. Seven percent (seven hips) of the entire cohort and 6% (four hips) of the living cohort had undergone revision for loosening of the femoral component or osteolysis. Only four femoral stems had been revised for isolated loosening (without osteolysis). The PCA femoral component proved to be durable at a minimum of fifteen years postoperatively, while the acetabular component was less durable.     

Total hip arthroplasty using an Omniflex modular system: 5 to 12 years followup

We evaluated intermediate-term results of primary cementless Omniflex prostheses. Forty-nine patients (57 hips) with a mean age of 44 years were observed for an average of 8.6 years. The average Harris hip score was 46 points before surgery and 87 points at final followup. Revision was done in five hips (9%) in five patients. Two acetabular components (4%) were revised because of breakage of the polyethylene insert. Three femoral components (5%) were revised because of aseptic loosening. Six femoral components (10%) were radiographically loose. Overall, 11 hips (19%) were considered mechanical failures. Osteolysis was identified around three acetabular components (5%) and around 20 femoral components (35%). Nine hips (16%) had femoral osteolysis around the distal stem tip. The average annual polyethylene liner wear was 0.18 mm. These results were inferior to those using other recent cementless total hip systems.     

High placement of noncemented acetabular components in revision total hip arthroplasty. A concise follow-up, at a minimum of fifteen years, of a previous report

We previously reported the average ten-year results associated with the use of porous-coated noncemented acetabular shells that were placed at a high hip center at the time of revision total hip arthroplasty in thirty-four patients (thirty-six hips) with severe acetabular bone loss. We now report the average 16.8-year results for twenty-one patients (twenty-three hips). Of the original cohort of forty-four patients (forty-six hips), thirty-nine patients (forty-one hips; 89%) retained the shell. Two shells (4.3%) were revised because of aseptic loosening, and three (6.5%) were revised because of infection. Six femoral components were revised because of femoral osteolysis, and seven were revised because of aseptic loosening without osteolysis. On the basis of our results after an average duration of follow-up of 16.8 years, we believe that the placement of an uncemented acetabular component at a high hip center continues to be an excellent technique for revision total hip arthroplasty in selected patients with severe acetabular bone loss.     

Wagner resurfacing hip arthroplasty. The results of one hundred consecutive arthroplasties after eight to ten years

In a prospective study of 100 consecutive Wagner resurfacing hip arthroplasties in ninety-three patients, the outcomes for all hips were determined for an eight to ten-year follow-up period. By survivorship analysis, the rate of survival of the arthroplasty was calculated to be 70 per cent at five years, but only 40 per cent at eight years. The major cause of failure was aseptic loosening of the acetabular or femoral component, or both. Fracture of the neck of the femur occurred in three hips. Although the medium-term results (at fifty-six to eighty-three months) were better than those in most comparable studies of resurfacing arthroplasty, the poor long-term results (at ninety-one to 118 months) show that meaningful studies of new prosthetic designs must continue for at least eight years, and, if at all possible, must include 100 per cent follow-up. The survival curve for the resurfacing arthroplasties in this study can serve as the basis for comparison of the early, medium, and long-term results of future designs of resurfacing hip prostheses.     

Results of metal-on-metal hybrid hip resurfacing for Crowe type-I and II developmental dysplasia

BACKGROUND: Modern hip resurfacing implants may increase stability and preserve more bone than conventional total hip arthroplasty. The purpose of this retrospective study was to analyze the mid-term results in a consecutive series of middle-aged patients with developmental dysplasia of the hip treated with hybrid resurfacing joint arthroplasty. METHODS: Metal-on-metal hip resurfacing was performed in fifty-one patients (fifty-nine hips), forty-two of whom were female and nine of whom were male. The average age at the time of surgery was 43.7 years. Radiographic and clinical data were collected at six weeks, at three months, and at yearly follow-up visits. Seven hips had Crowe type-II developmental dysplasia of the hip and fifty-two had type-I. RESULTS: The follow-up period ranged from 4.2 to 9.5 years (average, 6.0 years). Initial stability was achieved in all but three hips. The clinical outcomes, as rated with the University of California at Los Angeles (UCLA) hip score, improved significantly compared with the preoperative ratings. On the average, the pain rating improved from 3.2 to 9.3 points; the score for walking, from 6.0 to 9.7 points; the score for function, from 5.7 to 9.6 points; and the score for activity, from 4.6 to 7.3 points (all p = 0.0001). The mean Short Form-12 (SF-12) mental score increased from 46.6 to 53.5 points, and the mean SF-12 physical score increased from 31.7 to 51.4 points (both p < 0.0001). The mean postoperative Harris hip score was 92.5 points. On the average, the range of flexion improved from 106 degrees to 129.6 degrees ; the abduction-adduction arc, from 41.9 degrees to 76.9 degrees ; and the rotation arc in extension, from 32.1 degrees to 84.8 degrees (all p = 0.0001). Four patients delivered a total of six healthy babies since the time of implantation of the prosthesis. Radiographic analysis showed a decrease in the mean body weight lever arm from 118.5 mm preoperatively to 103.9 mm postoperatively (p = 0.007). There were five femoral failures requiring conversion to a total hip arthroplasty. One hip showed a radiolucency around the metaphyseal femoral stem. There were no complete acetabular radiolucencies, and all sockets remained well fixed. CONCLUSIONS: The mid-term results of metal-on-metal resurfacing in patients with Crowe type-I or II developmental dysplasia of the hip were disappointing with respect to the durability of the femoral component. However, the fixation of the porous-coated acetabular components without adjuvant fixation was excellent despite incomplete lateral acetabular coverage of the socket. More rigorous patient selection and especially meticulous bone preparation are essential to minimize femoral neck fractures and loosening after this procedure.     

Intermediate-term results after hybrid total hip arthroplasty for the treatment of dysplastic hips

BACKGROUND: In recent studies, good intermediate-term results have been reported after primary hybrid total hip arthroplasty (a cementless acetabular component with a cemented femoral stem) for the treatment of primary osteoarthritis. However, few studies have described the results of this technique in patients with developmental dysplasia of the hip. METHODS: One hundred primary hybrid total hip replacements were performed in ninety patients to treat degenerative arthritis of the hip secondary to developmental dysplasia. Seventy-one patients (eighty-one hips) were available for clinical and radiographic evaluation. The average duration of follow-up was 10.6 years. There were ten men and sixty-one women. Seventy hips were classified as type 1 (dysplasia); seven, as type 2 (low dislocation); and four, as type 3 (high dislocation), according to the classification system of Hartofilakidis et al. RESULTS: At the time of the final follow-up, the average Harris hip score was 86 points. Structural autograft was used in fifteen hips to supplement acetabular coverage. Within five years postoperatively, the acetabular component in six of the fifteen hips had an average of 4.5 mm of vertical migration and an average increase in vertical rotation of 3 degrees, but the position appeared to stabilize thereafter. Revisions were performed in two hips because of recurrent dislocation. No acetabular or femoral component was revised because of aseptic loosening. Osteolysis was identified around two acetabular components and two femoral components. The average rate of polyethylene wear was 0.09 mm per year. CONCLUSIONS: Hybrid total hip arthroplasty for the treatment of symptomatic degenerative arthritis secondary to developmental dysplasia provides favorable results at intermediate-term follow-up. With lower grades of dysplasia, the majority of patients can be treated effectively without a structural bone graft by placement of the cementless acetabular component at a medial or high position.     

20-year experience with cemented primary and conversion total hip arthroplasty using so-called second-generation cementing techniques in patients aged 50 years or younger

We present the 20-year experience of 47 hips in 40 patients aged 50 years or younger with cemented primary total hip arthroplasty using second-generation femoral cementing techniques. Average follow-up duration in the 23 patients living at least 17 years was 18.2 years. Overall, 18 hips (38%) had components revised or removed for any reason, at an average duration of 12.6 years. Every revision or reoperation involved removing the acetabular component. Of these 18 acetabular components, 15 (32%) were revised for aseptic loosening. Eleven additional acetabular components were loose by radiographic criteria at final follow-up, yielding prevalence of aseptic acetabular loosening (55%). Four femoral components (8%) were revised for osteolysis without loosening, and 3 (6%) were revised for aseptic loosening. Femoral osteolysis, with or without component loosening, led to revision in 5 ( 11%) hips compared with 6% for aseptic loosening alone. Osteolysis was the primary problem leading to acetabular and femoral component revision in this series of people < or = 50 years old over the first 20 years after the index operation.     

Acetabular revision after failed total hip arthroplasty in patients with congenital hip dislocation and dysplasia. Results after a mean of 8.6 years

BACKGROUND: Revision of a total hip arthroplasty in a patient who has had congenital hip dysplasia or dislocation is often more difficult than a standard revision operation. The purpose of this study was to assess the efficacy and complications of use of a cementless hemispherical acetabular component for revision of an acetabular component of a failed total hip replacement in patients whose initial problem was arthritis secondary to congenital dislocation or dysplasia. The mean duration of follow-up was approximately eight years. METHODS: We reviewed a consecutive series of sixty-one hips in fifty-three patients who underwent a cementless acetabular revision with use of a hemispherical acetabular component, with or without concurrent femoral revision. Data were collected prospectively. The mean age of the patients at the time of the index operation was fifty-six years. A mean of 1.9 ipsilateral hip operations had been performed previously. Thirty-nine hips (64 percent) had a so-called high hip center prior to the index revision. With one exception, the uncemented acetabular component was fixed with screws. Fifty-one acetabular components were placed with so-called line-to-line fit, and ten were oversized by one to three millimeters. In thirty-eight hips, the femoral component was revised as well. Twenty-nine femora were reconstructed with use of a cemented device, and nine were revised with an uncemented patch-porous-coated femoral stem (a stem on which the porous coating appears in patches). RESULTS: Four patients (five hips) died prior to the five-year minimum follow-up interval. With the exception of one hip treated with resection arthroplasty because of deep infection, none of the hips in these deceased patients had been revised or had a loose component. One living patient (one hip) had a resection arthroplasty, and one additional patient (two hips) had both stable acetabular components rerevised at the time of femoral rerevision at another institution because of loosening and osteolysis. One patient refused to return for follow-up, but the components had not been revised. The remaining fifty-two hips in forty-six patients were followed for a mean of 8.6 years (range, 5.0 to 12.7 years). The mean Harris hip score was 80 points (range, 56 to 100 points) at the time of the latest follow-up. No acetabular component had been revised, although two had migrated. No other acetabular component was loose according to our radiographic criteria. Thus, the mechanical failure rate on the acetabular side was 3 percent (two of sixty-one) for the entire series and 4 percent (two of fifty-two) for the patients who had been followed for a mean of 8.6 years. On the femoral side, the mechanical failure rate was 3 percent (one of twenty-nine) for the cemented stems and six of nine for the uncemented patch-porous-coated stems. CONCLUSIONS: Of the approaches used in this difficult series of patients requiring revision, the hybrid arthroplasty (a cementless acetabular component and a cemented femoral component) yielded overall good results after an intermediate duration of follow-up.     

Use of constrained acetabular components for hip instability: an average 10-year follow-up study

The short-term efficacy of using constrained acetabular components for hip instability in the total hip arthroplasty construct has been documented. However, long-term concerns including late dislocation, loosening of components, and osteolysis have not been addressed. The authors evaluated, at an average 10.3-year follow-up, 101 tripolar constrained components (Stryker Howmedica Osteonics) used in the total hip arthroplasty construct. At final follow-up, 6 hips had dislocated or had failure of the constrained component, 5 of which were revised. In addition, 4 hips were revised for aseptic loosening of the acetabular component, 4 hips were revised for aseptic femoral loosening, and 1 hip was revised for acetabular osteolysis. Considering the complexity of the cases, this component has provided durable fixation and hip stability at this intermediate-term follow-up.     

Fractures of the femoral neck treated with a bipolar endoprosthesis

Seventy-five patients with 77 bipolar hip endoprostheses were reexamined and had roentgenograms taken at an average of 51 months postoperatively. The average age of the patients was 77 years. All prostheses had been inserted due to intracapsular fractures of the femoral neck. Three prostheses had been revised to a total hip arthroplasty at the time of follow-up examination. Radiologically, three cases of protrusion and ten cases with a radiolucent zone greater than 2 mm around the femoral stem were found. Functionally, the result was excellent or good in about 75% of the active ambulators. As acetabular erosion and protrusion appears to have been reduced to some extent, a bipolar hip prosthesis is found to be a good alternative to conventional hemiarthroplasty in elderly patients with a fracture of the femoral neck.     

Revision arthroplasty of the hip joint

Summary During the period 1974–1983, 768 total hip arthroplasties were performed at the Surgical Hospital, University Central Hospital in Helsinki. Brunswik prostheses were used until 1980, and after this the operations were routinely performed with Lubinus prostheses. Additionally, from 1977 to 1981 Wagner and Freeman resurfacing prostheses were used in 107 cases. Of all these patients, 44 (5.7%) needed revision arthroplasty. The average interval between the primary operation and revision arthroplasty was 3.7 years and the follow-up period after the second operation averaged 2.9 years. The patients who underwent revision arthroplasty were compared with a matched control group. In the revision group, radiographs revealed that the medial cement packing was complete in 28% of the hips, this being the case in 78% of the controls (P < 0.001). Also, the cement tip packing was more often incomplete in the revision hips than in the controls (P < 0.01). Regarding the lateral cement packing there was no statistical difference between the two groups. The revision rate of the resurfacing prostheses was 14.9%, compared with 7.8% of the Brunswik prostheses which were inserted at the same time. At the follow-up, the patients with revised hips had less pain than before the primary operation (P < 0.001) and their mobility was similarly improved. We conclude that adequate medial and tip cement packing must be emphasized in the primary arthroplasty. Resurfacing prostheses have a relatively high loosening tendency. Revision arthroplasty is the treatment of aseptic loosening after total hip replacement and it gives good clinical results.Aseptic loosening is the most common long-term complication after total hip replacement surgery. Clinical loosening rates are mostly judged by the number of patients who have been reoperated on, this probably leading to somewhat low figures. Reports on prosthesis loosening usually concern cemented prostheses, and both analyses based on radiographical evidence and revision rates have been published [1, 3, 4, 10, 12, 14]. It appears that most of the prostheses, at least as concerns femoral components, loosen during the first 5 years, and the numbers increase only slowly between 5 and 10 years postoperatively [16, 17].A certain proportion of prostheses will loosen even when the most progressive operative methods are used, and revision arthroplasties of the hip joint are part of the routine of orthopedic departments. We have analyzed our total hip revision arthroplasties, focusing on the factors leading to prosthesis loosening and on the outcome of hip revision operations.     

Omnifit cementless total hip arthroplasty. A 10-year average followup.

Seventy-six hips in 67 patients were evaluated an average of 119 months (range, 61-150 months) after total hip arthroplasty with porous coated Omnifit femoral and acetabular components. The patients were young (average age, 45 years), and most were male (67%). Two stems and one cup were revised for aseptic loosening, for aseptic revision rates of 2.6% on the femoral side and 1.3% on the acetabular side. Thigh pain was present in three cases, one of which was activity limiting. Twenty-five (35.7%) hips had evidence of osteolysis confined to proximal Gruen Zone 1 or 7 or to the acetabulum (22 proximal femoral, three both). There were no cases of intramedullary osteolysis in surviving stems. Thirteen (17.1%) hips have undergone reoperation for bone grafting of progressive proximal osteolysis without component revision, at an average 93 months after the total hip arthroplasty. At an average 40 months after reoperation, all stems remain well fixed, and there has been no recurrence of osteolysis of grafted femoral lesions. These results suggest that a circumferentially proximally porous coated femoral component in cementless total hip arthroplasty can provide stable fixation for as long as 12 years after implantation and caseal the canal from distal osteolysis. Serious concerns remain about the incidence of proximal femoral osteolysis.     

Precoated femoral component in total hip arthroplasty. Results of 5- to 9-year followup.

One hundred nineteen consecutive primary hybrid total hip arthroplasties with a precoated femoral component were performed by one surgeon in 100 patients and followed up prospectively. Ninety-eight hips in 82 patients (mean age, 67 years) were evaluated clinically and radiographically at a mean of 6.5 years (range, 5-9 years). The hips were evaluated clinically using the Harris hip score, and radiographs were evaluated for femoral cement grade, loosening, and osteolysis. Ninety-five hips remained in place at the most recent followup. Two femoral components were revised for definite loosening, and one well fixed femoral component was removed because of late hematogenous infection. Excluding the three hips that were revised, the clinical result was excellent or good in 79 hips (83%), fair in 12 hips (13%), and poor in four hips (4%). All other femoral components were well fixed. There were defects of the cement mantles (C1 and C2) in 90 hips. No femoral component had a stem and cement radiolucent line. Focal femoral osteolysis was seen in only two hips. One acetabular component was removed at 5 years because of late hematogenous infection. One acetabular component had asymptomatic migration. The remaining 96 acetabular components were well fixed. Focal acetabular osteolysis was present in four hips. The mean linear polyethylene wear rate was 0.06 (+/- 0.05) mm per year. In contrast to other reports of early failure and osteolysis, the use of a precoated femoral component in this study did not adversely affect the fixation of hybrid total hip arthroplasty, with definite failure of only 2% (two of 98) of the femoral components.     

Hybrid total hip arthroplasty using specifically-designed stems for patients with developmental dysplasia of the hip. A minimum five-year follow-up study

A 4-U hybrid total hip arthroplasty (THA) system was specifically designed for patients with developmental dysplasia of the hip (DDH). Straight stem with an appropriate offset and various size variations are advantages. We followed 128 hips in 124 patients, 13 men and 111 women, for a mean of 6.5 years (range, 5.0–7.5 years). Two acetabular and femoral components in two patients had been revised for infection, one acetabular component had been revised for recurrent dislocation, and one femoral component had been revised for periprosthetic femoral fracture. None of the acetabular or femoral components were revised for loosening or were found to be loose at follow-up. The Harris hip score increased from a preoperative average of 42 points to 88 points at the most recent follow-up. Primary THA using the 4-U system had a good mid-term result in patients with DDH. This system could be applied for all patients including those with the narrowest and deformed femurs.     

Primary hybrid total hip replacement, performed with insertion of the acetabular component without cement and a precoat femoral component with cement. An average ten-year follow-up study

One hundred and twenty-one primary hybrid total hip replacements were performed in 107 patients. A titanium, porous-coated, hemispherical acetabular component was fixed with screws, and a collared, chromium-cobalt femoral stem, with a roughened surface and a thin layer of methylmethacrylate on the proximal third, was inserted with contemporary cementing techniques (that is, use of a femoral medullary plug, a cement gun, and centrifugation and pressurization of the cement). Fifteen patients (fifteen hips) died before a minimum duration of follow-up of seven years, four patients (four hips) were too ill for a detailed follow-up examination at the time of the study, and two patients (two hips) refused to be evaluated at the time of the latest follow-up. None of these twenty-one hips had had a revision or a reoperation at the time of the latest follow-up. Eighty-six patients (100 hips) were available for clinical follow-up at an average of 120 months (range, eighty-four to 153 months) and for radiographic follow-up at an average of 118 months (range, eighty-four to 153 months). The average age of the patients at the time of the index arthroplasty was sixty-five years (range, forty-five to eighty-seven years). Three acetabular components were revised because of dissociation of the liner in association with a fracture of a locking tine. One well fixed acetabular component was revised because of pelvic osteolysis, and the femoral stem in the same patient was revised because of aseptic loosening. None of the ninety-six remaining acetabular components migrated, was classified as radiographically loose, or was revised because of aseptic loosening. Osteolytic lesions were identified adjacent to five acetabular components, and one of them was treated with bone-grafting around the well fixed acetabular shell. Two hips had a continuous radiolucent line at the interface between the acetabular implant and the bone. Three femoral stems had evidence of radiographic debonding (a radiolucent line that was one millimeter wide or less between the cement and the prosthesis), and they were classified as radiographically loose despite excellent clinical results. Seven hips had osteolytic areas located in the proximal aspect of the most proximal zones of Gruen et al., and five had small osteolytic regions in more distal areas. The Harris hip score for the eighty-two patients (ninety-six hips) who did not have a revision improved from 48 points (range, 22 to 70 points) preoperatively to 92 points (range, 53 to 100 points) at the most recent follow-up examination. Eighty-one patients had no, slight, or mild pain in the hip, and they were satisfied with the clinical result. In the present study, the hybrid total hip replacement with use of the Harris-Galante acetabular component and the Precoat femoral stem continued to provide an excellent result for most patients at an average of approximately ten years after the operation.