Total hip arthroplasty with cement and without acetabular bone graft for severe hip dysplasia. A concise follow-up, at a minimum of twenty years, of a previous report

We previously evaluated a cohort of fifty-three patients with severe hip dysplasia (Crowe Type-II, III, or IV subluxation) who underwent a total of sixty-six Charnley total hip arthroplasties. The acetabular component was placed at the anatomic hip center, the superolateral defect was filled with cement, and no bone-grafting was used to supplement the acetabular wall. All but one patient, who was lost to follow-up, were followed until death or for a minimum of twenty years. Radiographic and functional follow-up data were collected prospectively. This retrospective review included twenty-four patients (thirty-four hips) who were alive at a minimum of twenty years following the surgery. Fourteen (22%) of the sixty-five hips underwent revision of a component, with eleven of the revisions performed because of aseptic loosening. Eight of those eleven hips underwent revision because of acetabular loosening alone; two, because of femoral loosening alone; and one, because of loosening of both components. The combined prevalence of revision because of aseptic loosening of the acetabular component and radiographic evidence of failure of the acetabular component was 28% (eighteen hips). With the numbers available, the need for acetabular revision was not associated with the percentage of cement coverage (p = 0.362) or the Crowe classification (p = 0.159). At a minimum of twenty years postoperatively, the survivorship of the acetabular component was 86% +/- 8% with revision because of aseptic loosening as the end point and 82% +/- 10% with revision because of aseptic loosening or radiographic evidence of loosening as the end point. The results that we evaluated at a minimum of twenty years after use of this technique can be compared with the results of other techniques in studies with similar long-term follow-up periods.     

Cementless total hip arthroplasty using a threaded cup and a rectangular tapered stem. Follow-up for ten to 17 years

We carried out a clinical and radiological review of 103 cementless primary hip arthroplasties with a tapered rectangular grit-blasted titanium press-fit femoral component and a threaded conical titanium acetabular component at a mean follow-up of 14.4 years (10.2 to 17.1). The mean Harris hip score at the last follow-up was 89.2 (32 to 100). No early loosening and no fracture of the implant were found. One patient needed revision surgery because of a late deep infection. In 11 hips (10.7%), the reason for revision was progressive wear of the polyethylene liner. Exchange of the acetabular component because of aseptic loosening without detectable liner wear was carried out in three hips (2.9%). After 15 years the survivorship with aseptic loosening as the definition for failure was 95.6% for the acetabular component and 100% for the femoral component.     

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.     

Cementless total hip arthroplasty in patients 50 years or younger

This report examines the mean 9-year results of 100 second-generation cementless total hip arthroplasty in 91 patients 50 years or younger. The mean age at arthroplasty was 39 years (range, 14-50 years), and follow up averaged 9 years (range, 5-13 years). There were 13 revisions (7 related to polyethylene wear and/or osteolysis, 5 for instability, and 1 for infection). No femoral components were revised for loosening and none were radiographically loose. Two acetabular shells were revised for loosening secondary to extensive osteolysis. Ten-year survivorship using revision for any reason as the end point was 87.5%, using femoral component aseptic loosening as the end point was 100%, and using acetabular component aseptic loosening as the end point was 97.1%.     

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.     

Total hip arthroplasty with a cemented, polished, collared femoral stem and a cementless acetabular component. A follow-up study at a minimum of ten years

BACKGROUND: Recent studies have suggested that cemented femoral components with a polished surface may provide superior long-term fixation when compared with femoral components with a roughened surface. The purpose of this study was to evaluate the results of total hip arthroplasty with a cemented femoral component with a polished surface finish and compare them with the results of total hip arthroplasty performed with a similar design of cemented femoral component with a rougher surface finish. METHODS: We retrospectively reviewed a consecutive group of 132 patients (149 hips) in whom primary total hip arthroplasty had been performed by one surgeon using a cemented collared femoral component with a polished (0.1-microm Ra) surface finish and a cementless acetabular component. Ninety-eight patients (115 hips) were followed for a minimum of ten years. We compared the survivorship of this prosthesis with that of a femoral component of similar design but with rougher surfaces (matte or grit-blasted). RESULTS: No polished stems were revised because of aseptic loosening or demonstrated radiographic evidence of loosening; however, eight hips (5.4%) with a polished stem demonstrated osteolysis distal to the greater or lesser tro-chanter. In contrast, six stems (2.0%) with a matte surface finish of 0.8-microm Ra were revised because of aseptic loosening, and an additional five stems were seen to be loose radiographically. Eleven stems (9.2%) with a grit-blasted surface finish of 2.1-microm Ra were revised because of aseptic loosening, and an additional four stems were seen to be loose radiographically. The difference in the prevalence of revision due to aseptic loosening between the group with the 0.1-microm Ra surface and the group with the 2.1-microm Ra surface was significant (p = 0.001), as was the difference between the prevalence of revision due to aseptic loosening between the group with the 0.8-microm Ra surface and the group with the 2.1-microm Ra surface (p = 0.001). No cups were revised because of aseptic loosening, and one hip had radiographic signs of acetabular loosening. CONCLUSIONS: This study demonstrated excellent durability of a prosthesis consisting of a cemented, collared, polished femoral component and a cementless acetabular component. While no hips were revised because of aseptic loosening, distal femoral osteolysis was observed in eight hips (5.4%), a higher prevalence than has been reported by others after similar durations of follow-up of tapered, collarless, polished femoral components.     

Extra-large uncemented hemispherical acetabular components for revision total hip arthroplasty

BACKGROUND: Extra-large uncemented components provide several advantages for acetabular revision, but limited information is available on the results of their use. The purpose of this study was to evaluate, at a minimum of five years, the results associated with the use of an extra-large uncemented porous-coated component for acetabular revision in the presence of bone loss. METHODS: Eighty-nine extra-large uncemented hemispherical acetabular components were used for revision after aseptic failure of a total hip arthroplasty in forty-six men and forty-three women (mean age at revision, fifty-nine years; range, thirty to eighty-three years). The revision implant (a Harris-Galante-I or II cup fixed with screws) had an outside diameter of > or = 66 mm in men and > or = 62 mm in women. Seventy-nine patients had a segmental or combined segmental and cavitary acetabular bone deficiency before the revision. Particulate bone graft was used in fifty-four hips and bulk bone graft, in nine. RESULTS: One patient died with the acetabular component intact and two patients were lost to follow-up within five years after the operation. At the time of the last follow--up, four acetabular components had been removed or revised again (two for aseptic loosening). All of the remaining patients were followed clinically for at least five years (mean, 7.2 years; range, 5.0 to 11.3 years). In the hips that were not revised again, only two sockets had definite radiographic evidence of loosening. All four of the sockets that loosened were in hips that had had combined cavitary and segmental bone loss preoperatively. In the hips that were not revised again, the mean modified Harris hip score increased from 56 points preoperatively to 83 points at the time of the most recent follow-up. The most frequent complication, dislocation of the hip, occurred in eleven patients. The probability of survival of the acetabular component at eight years was 93% (95% confidence interval, 85% to 100%) with removal for any reason as the end point, 98% (95% confidence interval, 92% to 100%) with revision for aseptic loosening as the end point, and 95% (95% confidence interval, 88% to 100%) with radiographic evidence of loosening or revision for aseptic loosening as the end point. CONCLUSIONS: This study demonstrates that extra-large uncemented components used for acetabular revision in the presence of bone loss perform very well and have a low rate of aseptic loosening at the time of intermediate-term follow-up.     

Acetabular reconstruction with impaction bone-grafting and a cemented cup in patients younger than fifty years old

BACKGROUND: Acetabular bone deficiency can present a challenge during total hip arthroplasty, especially in young patients. The purpose of the present study was to evaluate the long-term clinical and radiographic outcomes of primary and revision acetabular reconstruction with use of an impaction bone-grafting technique and a cemented polyethylene cup in young patients who had preexisting acetabular bone deficiency. METHODS: Forty-two consecutive acetabular reconstructions were performed in thirty-seven patients who were younger than fifty years old (average, 37.2 years old). The impaction bone-grafting technique was used for twenty-three primary and nineteen revision acetabular reconstructions. Twenty-eight patients (thirty-one hips) were available for review after a minimum duration of follow-up of fifteen years. Clinical and radiographic results were assessed, and survivorship analysis was performed with the Kaplan-Meier method. RESULTS: Eight hips were revised at a mean of twelve years (range, three to twenty-one years) after a primary reconstruction (four hips) or revision reconstruction (four hips). The revision was performed because of aseptic loosening of the acetabular component in four hips and because of culture-proven septic loosening in two. Two additional cups (both in hips that had had a revision reconstruction) were revised, during revision of the femoral stem, because of wear (one hip) or because of persistent intraoperative instability (one hip). Twenty-eight hips (in twenty-five patients) had retention of the acetabular component for a minimum of fifteen years. The mean Harris hip score for that group was 89 points. Twenty-six of these twenty-eight hips had no or slight pain. Kaplan-Meier analysis revealed a twenty-year survival rate of 80% (95% confidence interval, 67% to 94%) with acetabular revision for any reason as the end point and of 91% (95% confidence interval, 80% to 100%) with acetabular revision because of aseptic loosening as the end point. CONCLUSIONS: Acetabular reconstruction with use of impaction bone-grafting and a cemented polyethylene cup is a reliable and durable technique that is associated with good long-term results in young patients with acetabular bone-stock defects.     

Long-term survivorship of cemented bipolar hemiarthroplasty for fracture of the femoral neck

Cemented bipolar hemiarthroplasty commonly is used to treat displaced fractures of the femoral neck in elderly patients. The purpose of the current study was to review the results and survivorship of 212 bipolar hemiarthroplasties done in 205 patients for acute femoral neck fracture between 1976 and 1985. The mean age of the patients at the time of surgery was 79 years (range, 61-100 years). The mean followup for the patients who were alive was 11.7 years (range, 5.3-16.8 years) and 5.8 years (range, 51 days-19.4 years) for the entire group. Ten hips (4.7%) were revised or removed: five for aseptic femoral component loosening, one for acetabular erosion, one for chronic dislocation, and three for infection. In living patients with surviving implants, 96.2% had no or slight pain. Ten-year survivorship free of reoperation for any reason was 93.6%, free of revision surgery for aseptic femoral loosening or acetabular cartilage wear was 95.9%, free of revision surgery for aseptic femoral loosening was 96.5%, and free of revision surgery for acetabular cartilage wear was 99.4%. Cemented bipolar hemiarthroplasty for acute femoral neck fracture is associated with excellent component survivorship in elderly patients. The rate of complications was low, and the arthroplasty provided satisfactory pain relief for the lifetime of the majority of elderly patients.     

Extensively porous-coated femoral revision for severe femoral bone loss

Of 275 femoral revisions done at our institution from 1982 to 1986, we identified 34 patients (35 hips) who represented the senior author's (C.A.E., Sr.) most difficult revision cases as a result of extensive femoral bone loss at least 10 cm below the lesser trochanter. The patients were revised with fully porous-coated femoral components ≥190 mm. We evaluated 25 of the patients (26 hips) who had a minimum 10-year follow-up (mean, 13.3 years). Survivorship was 89% at 10 years with femoral revision as the endpoint (Kaplan-Meier). The femoral aseptic loosening rate was 15% (4 of 26). Three stems were loose but did not warrant reoperation. One stem was revised for aseptic loosening, 1 was revised for septic loosening, and 1 was revised for a fractured femoral component. Bypassing weak or absent femoral bone with an extensively porous-coated stem is an effective reconstructive technique for patients with extensive femoral bone loss.     

Extensively porous-coated femoral revision for severe femoral bone loss: minimum 10-year follow-up

Of 275 femoral revisions done at our institution from 1982 to 1986, we identified 34 patients (35 hips) who represented the senior author's (C.A.E., Sr.) most difficult revision cases as a result of extensive femoral bone loss at least 10 cm below the lesser trochanter. The patients were revised with fully porous-coated femoral components >or=190 mm. We evaluated 25 of the patients (26 hips) who had a minimum 10-year follow-up (mean, 13.3 years). Survivorship was 89% at 10 years with femoral revision as the endpoint (Kaplan-Meier). The femoral aseptic loosening rate was 15% (4 of 26). Three stems were loose but did not warrant reoperation. One stem was revised for aseptic loosening, 1 was revised for septic loosening, and 1 was revised for a fractured femoral component. Bypassing weak or absent femoral bone with an extensively porous-coated stem is an effective reconstructive technique for patients with extensive femoral bone loss.     

The concentric all-polyethylene Exeter acetabular component in primary total hip replacement

We report the outcome of the flangeless, cemented all-polyethylene Exeter acetabular component at a mean of 14.6 years (10 to 17) after operation. Of the 263 hips in 243 patients, 122 prostheses are still in situ; 112 patients (119 hips) have died, 18 hips have been revised, and three patients (four hips) were lost to follow-up. Radiographs at the final review were available for 110 of the 122 surviving hips. There were acetabular radiolucent lines in 54 hips (49%). Two acetabular components had migrated but neither patient required revision. The Kaplan-Meier survivorship at 15 years with 61 hips at risk with revision for any cause as the endpoint was 89.9% (95% confidence interval (CI) 84.6 to 95.2) and for aseptic loosening of the acetabular component or lysis 91.7% (95% CI 86.6 to 96.8). In 210 hips with a diagnosis of primary osteoarthritis, survivorship with revision for any cause as the endpoint was 93.2% (95% CI 88.1 to 98.3), and for aseptic loosening of the acetabular component 95.0% (95% CI 90.3 to 99.7). The cemented all-polyethylene Exeter acetabular component has an excellent long-term survivorship.     

Primary total hip arthroplasty with a flanged, cemented all-polyethylene acetabular component: evaluation at a minimum of 20 years

One hundred twenty-three consecutive primary total hip arthroplasties in 107 patients were performed with the insertion of a cemented, all polyethylene, flanged acetabular component. At a minimum of 20 years, 66 patients had died (75 hips) and 8 patients (8 hips) were lost to follow-up evaluation, leaving 40 hips in 33 patients. At a mean of 21.1 years, 2 cups had been revised for aseptic loosening, one well-fixed cup was revised at the time of femoral component revision, and 4 additional cups had definite evidence of radiographic loosening. Survivorship analysis revealed a 77.3% survivorship for the component at 21 years, with revision or definite loosening as an endpoint (95% confidence interval, 67.8%-86.8%).     

Long-term survivorship of cemented all-polyethylene acetabular components in patients > 75 years of age

Between 1974 and 1982, 132 consecutive hips in 112 patients >75 years of age were treated with primary total hip arthroplasty for osteoarthritis using a cemented all-polyethylene T28 socket and cemented T28 or TR28 stem with a 28-mm head size. At the time of review, 94 patients (110 hips [83%]) had died and 18 patients (22 hips [17%]) were still living (mean age at follow-up, 93 years). Five hips (5 patients) were lost to follow-up. Clinical follow-up averaged 8.9 years for the entire group and 14.6 years for patients still living. Only 2 acetabular components have been revised (1 for recurrent dislocation, 1 for infection). No acetabular component has required revision for aseptic loosening. Survivorship free of acetabular revision for aseptic loosening at 10 years was 100%; free of symptomatic acetabular loosening, 97.4% (95% confidence interval, 91.8-100%); and free of acetabular loosening, 95.9% (95% confidence interval, 89.7-100%). The commonest complication was postoperative hip dislocation, which occurred in 11 hips (8.7%) and which required reoperation in 2 hips. Cemented acetabular components implanted in patients >75 years of age with a diagnosis of osteoarthritis showed a high rate of survivorship free of revision and free of symptomatic aseptic loosening.     

Press-fit metal-backed alumina sockets: a minimum 5-year followup study

Two hundred thirty-four consecutive alumina-on-alumina hip replacements using a press-fit metal-backed socket, performed on 214 patients (98 women, 116 men) have been reviewed. These included 201 primary procedures and 33 revision procedures. The median age of the patients at the time of surgery was 62 years (range, 21-83 years). Fourteen patients (16 hips) died from unrelated causes. Eleven patients (11 hips) underwent a total hip arthroplasty revision for recurrent dislocation (one hip), deep infection (two hips), fracture of alumina femoral head (one hip), persistent hip pain (one hip) and aseptic loosening (six hips). The survival rate after 9 years was 93.4% when revision of the prosthesis was considered the end point, and 97.4% if revision of the prosthesis for aseptic loosening was considered the end point. Results were assessed in the surviving patients with a minimal 5-year followup (170 patients, 184 hips). At the median followup of 7.8 years, the average Merle d'Aubigné and Postel score had improved from 11.9- to 17.7. Results were graded as excellent in 148 hips (80.5%), very good in 31 hips (17%), good in two hips (1%), and fair in three hips (1.5%). Radiologic data were documented for 134 patients (143 hips). Three sockets (2%) had a complete and nonprogressive radiolucent line less than 1-mm thick, one stem (0.7%) had lucencies involving five zones, and two stems (1.4%) had isolated femoral osteolysis. Neither component migration nor acetabular osteolysis were detected. A press-fit metal-backed socket may offer a good solution for alumina socket fixation when combined with a careful surgical technique of implantation.     

Primary total hip arthroplasty with Asian-type AML total hip prosthesis: follow-up for more than 10 years

BACKGROUND: We retrospectively reviewed 137 consecutive total hip arthroplasties performed with AML-A stems and Tri-Lock cups to see whether design modifications made to these components would achieve durable biological fixation in the Japanese population in whom developmental dysplasia of the hip (DDH) is relatively common. Patients from our initial clinical series using these components are available for more than 10 years' follow-up. METHODS: Between April 1988 and June 1994, we performed 137 total hip arthroplasties using the AML-A prosthesis for the patients with osteoarthritis of the hip joint. We excluded 26 hips with less than 10 years' follow-up and five hips from patients who died before the 10-year follow-up. The mean follow-up for the 105 remaining THAs is 155.2 months (range 120-237 months). The average age of these patients at the time of surgery was 53.1 years (range 22-81 years). RESULTS: In total, 17 THAs required component revisions. In seven cases, the first revision was limited to a liner exchange for polyethylene wear or osteolysis. Another seven hips underwent revision surgery for recurrent dislocation. Three cups have been revised owing to aseptic loosening. Because of the high incidence of wear-related revisions, Kaplan-Meier survivorship at the 15-year follow-up, using acetabular component revision for any reason as an endpoint, was 75.0% (95% CI 69.4%-83.8%). In contrast, no revision of the femoral stem was performed. Severe stress shielding occurred in 12 hips. Thigh pain was mild, however, and all of the femoral stems remained stable. CONCLUSIONS: Despite revisions for wear-related complications, the fixation achieved with these porous-coated components remained durable throughout the 15-year follow-up. Acetabular osteolysis has been associated with cup reoperation, but femoral stress shielding has never resulted in stem loosening.     

Cementless Spotorno tapered titanium stems

We evaluated the clinical and radiographic results of the first consecutive 154 implantations of a cementless, double-tapered straight femoral stem (cementless Spotorno (CLS), Sulzer Orthopedics) in 141 patients under the age of 55 (mean 47 (13–55)) years. After a mean follow-up of 12 (10–15) years, 11 patients (11 hips) had died and 7 (7 hips) could not be located. 5 patients (5 hips) underwent femoral revision—1 for infection, 1 for periprosthetic fracture and 3 for aseptic loosening of the stem. The overall survival rate of the stem was 97% at 12 years (95% confidence limits, 93%–100%), and survival with femoral revision for aseptic loosening as an end point 98 (95–100)%. The survival rate of the acetabular components was 78 (71–85) % after 12 years. The median Harris hip score at follow-up was 84 points. None of the patients had thigh pain. Radiolucent lines in Gruen regions 1 and 7 were present in 21 hips (17%). 2 hips had radiolucent lines in regions 2–6 on anteroposterior (AP) radiographs. No femoral osteolysis was detected.

The mid- to long-term survival with this type of femoral component is excellent and compares favorably with cemented stems in this age group. However, the high rate of cup loosening and the low Harris hip scores are a concern in this subgroup of young patients.     

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.     

Cementless Spotorno tapered titanium stems: excellent 10-15-year survival in 141 young patients

We evaluated the clinical and radiographic results of the first consecutive 154 implantations of a cementless, double-tapered straight femoral stem (cementless Spotorno (CLS), Sulzer Orthopedics) in 141 patients under the age of 55 (mean 47 (13-55)) years. After a mean follow-up of 12 (10-15) years, 11 patients (11 hips) had died and 7 (7 hips) could not be located. 5 patients (5 hips) underwent femoral revision-1 for infection, 1 for periprosthetic fracture and 3 for aseptic loosening of the stem. The overall survival rate of the stem was 97% at 12 years (95% confidence limits, 93%-100%), and survival with femoral revision for aseptic loosening as an end point 98 (95-100)%. The survival rate of the acetabular components was 78 (71-85)% after 12 years. The median Harris hip score at follow-up was 84 points. None of the patients had thigh pain. Radiolucent lines in Gruen regions 1 and 7 were present in 21 hips (17%). 2 hips had radiolucent lines in regions 2-6 on anteroposterior (AP) radiographs. No femoral osteolysis was detected. The mid- to long-term survival with this type of femoral component is excellent and compares favorably with cemented stems in this age group. However, the high rate of cup loosening and the low Harris hip scores are a concern in this subgroup of young patients.