Total hip arthroplasty with a collarless, tapered, fiber metal proximally coated femoral stem: minimum 5-year follow-up

The purpose of this study was to evaluate the midterm results, osteointegration potential, and implant-related complications of a cementless, collarless, proximally coated, distally tapered femoral hip prosthesis. The clinical and radiographic results for 129 hips in 116 patients after total hip arthroplasty with a Fiber Metal Taper (Zimmer, Inc ,Warsaw, Ind) femoral stem are reported. One hundred twenty-two (95%) hips were available for the minimum of 5 years clinical and radiographic follow-up. The mean duration of follow-up was 81 months (range, 60-104 months). The mean Harris hip score improved from 44 to 92 at the most recent follow-up. All femoral components were clinically stable with radiographic evidence of bone ingrowth. There has been no evidence of subsidence greater than 2 mm, no significant thigh pain, and no femoral revisions for any reason. Total hip arthroplasty with the Fiber Metal Taper stem demonstrates good clinical and radiographic results at midterm follow-up.     

Collarless polished tapered stem: clinical and radiological results at a minimum of ten years' follow-up

We retrospectively reviewed 175 patients (191 hips) who had undergone primary cemented total hip replacement between November 1992 and November 1995 using a collarless polished double-tapered femoral component after a minimum of ten years (mean 11.08; 10 to 12.8). All stems were implanted using contemporary cementing techniques with a distal cement restrictor, pressurised lavage, retrograde cementing with a gun and proximal pressurisation. Clinical outcome was assessed using the Harris Hip score. Radiological analysis was performed on calibrated plain radiographs taken in two planes. Complete radiological data on 110 patients (120 hips) and clinical follow-up on all the surviving 111 patients (122 hips) was available. The fate of all the hips was known. At final follow-up, the mean Harris Hip score was 86 (47 to 100), and 87 of 116 patients (75%) had good or excellent scores. Survival with revision of the stem for aseptic loosening as the endpoint was 100%; and survival with revision of the stem for any reason was 95.9% (95% confidence interval 87.8 to 96.8) at ten years. All the stems subsided vertically at the stem-cement interface in a predictable pattern, at an overall mean rate of 0.18 mm per year (0.02 to 2.16), but with a mean rate of 0.80 mm (0.02 to 2.5) during the first year. The mean total subsidence was 1.95 mm (0.21 to 24). Only three stems loosened at the cement-bone interface. There was excellent preservation of proximal femoral bone stock. There was a high incidence of Brooker III and IV heterotopic ossification affecting 25 patients (22%). The collarless polished tapered stem has an excellent clinical and radiological outcome at a minimum of ten years' follow-up. The pattern and magnitude of subsidence of the stem within the cement mantle occurred in a predictable pattern, consistent with the design philosophy.     

Complex cemented revision using polished stem and morselized allograft

The aim of this study was to evaluate the results of complex hip revision using a cemented, collarless and polished femoral stem design (CPT, Zimmer, Warsaw, In.) within a tightly impacted morselized allograft. We have now been using the impaction grafting technique in combination with the CPT stem (Zimmer) for 10 years in complex cases of severe bone loss. In this study we have elected to report only those patients who have been revised at least once before revision using the impaction grafting technique. All the patients in the study group have a minimum follow-up of 5 years after the impaction grafting revision. In total, 43 consecutive hips in 40 patients, 22 men and 18 women, with a follow-up time of between 5 and 7 years are included in the study. The complications related to the revised hip consist of three early dislocations managed by closed reduction. Two patients suffered from periprosthetic fracture, both managed with plate osteosynthesis. Two cementless sockets were revised due to aseptic socket loosening. The Endoklinik rating of preoperative bone loss for the revised hips was 2 in 13 hips, 3 in 23 hips, and 4 in 7 hips. During the first year 29 stems subsided 2-4 mm within the cement mantle. In 8 cases, a subsidence of 5-9 mm was measured. The subsidence was nonprogressive, and no subsidence occurred after the 1st year. The Charnley, D'Aubigne, Postel scoring (maximum 6 points) for pain improved from 2.2 points preoperatively to 4.4 postoperatively, function from 2.3 to 4.3, and movement from 2.3 to 4.1. In conclusion, the concept of impaction grafting in THR revision in our study has so far proven to be successful with good clinical results at 5 years despite the relatively high early subsidence of the femoral component.     

Massive early subsidence following femoral impaction grafting

The incidence of massive early subsidence (subsidence greater than 10 mm) following impaction grafting of the femur in revision surgery is reported. The first 79 consecutive revision total hip arthroplastics using morselized allograft, polymethyl methacrylate cement, and a double-tapered, polished, collarless stem were reviewed. Nine (11%) of the 79 revision femoral prostheses showed massive subsidence, with another nine hips subsiding to a lesser degree. Further elucidation of the critical factors contributing to the initial stability of the biologic composite is required.     

The effect of a collar and surface finish on cemented femoral stems: a prospective randomised trial of four stem designs

Purpose

The optimal design for a cemented femoral stem remains a matter of debate. Over time, the shape, surface finish and collar have all been modified in various ways. A clear consensus has not yet emerged regarding the relative merits of even the most basic design features of the stem. We undertook a prospective randomised trial comparing surface finish and the effect of a collar on cemented femoral component subsidence, survivorship and clinical function.

Methods

One hundred and sixty three primary total hip replacement patients were recruited prospectively and randomised to one of four groups to receive a cemented femoral stem with either a matt or polished finish, and with or without a collar.

Results

At two years, although there was a trend for increased subsidence in the matt collarless group, this was not statistically significant (p = 0.18). At a mean of 10.1 years follow-up, WOMAC scores for the surviving implants were good, (Range of means 89–93) without significant differences. Using revision or radiographic loosening as the endpoint, survivorship of the entire cohort was 93 % at 11 yrs, (CI 87–97 %). There were no significant differences in survivorship between the two groups with polished stems or the two groups with matt stems. A comparison of the two collarless stems demonstrated a statistically significant difference in survivorship between polished (100 %) and matt (88 %) finishes (p = 0.02).

Conclusions

In the presence of a collar, surface finish did not significantly affect survivorship or function. Between the two collarless groups a polished surface conferred an improved survivorship.     

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.     

Femoral component revision with use of impaction bone-grafting and a cemented polished stem

BACKGROUND: The purpose of this study was to evaluate the clinical and radiographic outcomes of revision of the femoral component of a hip arthroplasty with use of an impaction bone-grafting technique and a cemented polished stem. METHODS: Thirty-three consecutive femoral reconstructions that were performed between March 1991 and February 1996 with use of the X-change femoral revision system, fresh-frozen morselized allograft, and a cemented polished Exeter stem were followed prospectively. Femoral bone stock defects were classified according to the Endoklinik classification. The average age of the patients at the time of the femoral component revision was sixty-three years. No patient was lost to follow-up, which was performed at a minimum of eight years, but eight patients had died. None of the deaths was related to the surgery. RESULTS: No femoral reconstruction had been rerevised at a mean of 10.4 years postoperatively. There was one unrecognized intraoperative fracture, which healed following nonoperative treatment. There were three postoperative femoral fractures, all through cortical defects at the level of the tip of the prostheses. All fractures healed after plate fixation, and all femoral implants were left in situ. The average subsidence of the stem within the cement mantle was 3 mm; seven stems migrated > or =5 mm. The average Harris hip score improved from 49 points prior to surgery to 85 points (range, 68 to 100 points) at the time of this review. Subsidence did not affect the Harris hip score. Kaplan-Meier analysis, with an end point of femoral revision for any reason, showed a survival rate of 100% (one-sided 95% confidence interval, 100% to 91.3%). CONCLUSIONS: Femoral revision with use of an impaction bone-grafting technique and a cemented polished stem resulted in an excellent prosthetic survival rate at eight to thirteen years postoperatively. The major problem that occurred was a femoral fracture in four patients.     

The relationship between stem subsidence and improvement in the radiolucency in polished tapered stems

We studied the relationship between stem subsidence and improvement in the initial radiolucency at the bone-cement interface in polished- and rough-surface stems. Stem subsidence was seen in 34 of 42 hips (81.0%), and improvement in the initial radiolucency was seen in 15 hips (35.7%) in collarless polished tapered stems at 1 year after operation. In polished stems, stem subsidence in cases with improvement in the initial radiolucency was significantly greater than in those with no change (average 1.12 mm and 0.48 mm, P<0.005). In rough-surface stems partially coated with polymethylmethacrylate (VerSys Cemented Plus), no stem subsidence and no improvement in the initial radiolucency was seen. In polished stems, stem subsidence leads to cement creep and compressive force on the bone-cement interface and can improve the initial radiolucency.     

Impaction allograft with cement for the revision of the femoral component. A minimum 39-month follow-up study with the use of the Exeter stem in Asian hips

We report the results of impaction bone grafting of the femoral side in revision total hip arthroplasty in Asian hips (South Korean patients) in which the surgery was performed with the use of the Exeter stem. The minimum follow-up was 39 months (mean, 48.4; range, 39-66). There was subsidence of the cement-graft interface (<1 mm) in three hips (5%), of the stem-cement interface (<1 mm) in 12 hips (21%) and of the stem-cement interface (1-2 mm) in 14 hips (25%). Five hips (9%) developed intraoperative femoral fracture and two hips (4%) femoral perforation in revision. The complications of femoral fracture and subsidence did not have an adverse effect on the final clinical outcomes. The impaction of fresh-frozen allograft and use of a cemented, polished, tapered stem (Exeter stem) were also successful with good clinical and radiographic outcomes in our study of Asian hips (South Korean patients). However, we used smaller stems than the usual ones used for Western patients because of the smaller femur sizes.     

Clinical and radiological results of the collarless polished tapered stem at 15 years follow-up

We prospectively followed 191 consecutive collarless polished tapered (CPT) femoral stems, implanted in 175 patients who had a mean age at operation of 64.5 years (21 to 85). At a mean follow-up of 15.9 years (14 to 17.5), 86 patients (95 hips) were still alive. The fate of all original stems is known. The 16-year survivorship with re-operation for any reason was 80.7% (95% confidence interval 72 to 89.4). There was no loss to follow-up, with clinical data available on all 95 hips and radiological assessment performed on 90 hips (95%). At latest follow-up, the mean Harris hip score was 78 (28 to 100) and the mean Oxford hip score was 36 (15 to 48). Stems subsided within the cement mantle, with a mean subsidence of 2.1 mm (0.4 to 19.2). Among the original cohort, only one stem (0.5%) has been revised due to aseptic loosening. In total seven stems were revised for any cause, of which four revisions were required for infection following revision of the acetabular component. A total of 21?patients (11%) required some sort of revision procedure; all except three of these resulted from failure of the acetabular component. Cemented acetabular components had a significantly lower revision burden (three hips, 2.7%) than Harris Galante uncemented components (17 hips, 21.8%) (p < 0.001). The CPT stem continues to provide excellent radiological and clinical outcomes at 15?years following implantation. Its results are consistent with other polished tapered stem designs.     

初次混合式全髋关节置换术骨水泥柄的生存率分析

目的 探讨骨水泥柄全髋关节置换术后中期临床疗效.方法 接受骨水泥柄髋关节置换患者148例167髋,男95例106髋,女53例61髋;年龄28~87岁,平均62.8岁;体重45.2~87.4 kg,平均57.2 kg;身高146~184cm,平均161.5cm;平均体重指数21.4.临床疗效以Harris评分为标准,根据影像学资料评估股骨柄假体位置、骨水泥壳、假体周围骨重塑和骨溶解发生情况.以股骨假体无菌性松动和任何原因所致的假体翻修为终点,对假体生存率采用Kaplan-Meier分析.结果 106例114髋获得随访,随访时间6.5~9.5年,平均8.1年.术前Harris评分8~54分,平均42分;末次随访时76~100分,平均94分.无一例发生无菌性松动及假体翻修.6髋假体柄平均下沉1.83mm.16髋(14%)股骨侧出现<1mm的影像学透亮线,9髋(8%)Gruen Ⅰ区和Ⅶ区出现局灶性骨溶解所致斑点样影像学透亮区.106髋(93%)股骨侧有不同程度的皮质变薄或皮质松质骨化,均位于Ⅶ区.假体生存率为100%(95%可信区间.0.95-1.00).结论 采用第三代骨水泥技术固定股骨柄,可取得较好中期临床效果,但仍存在骨溶解、股骨近端皮质骨吸收重塑等潜在问题.     

Femoral impaction bone allografting with an Exeter cemented collarless, polished, tapered stem in revision hip replacement: a mean follow-up of 10.5 years

Femoral impaction bone allografting has been developed as a means of restoring bone stock in revision total hip replacement. We report the results of 75 consecutive patients (75 hips) with a mean age of 68 years (35 to 87) who underwent impaction grafting using the Exeter collarless, polished, tapered femoral stem between 1992 and 1998. The mean follow-up period was 10.5 years (6.3 to 14.1). The median pre-operative bone defect score was 3 (interquartile range (IQR) 2 to 3) using the Endo-Klinik classification. The median subsidence at one year post-operatively was 2 mm (IQR 1 to 3). At the final review the median Harris hip score was 80.6 (IQR 67.6 to 88.9) and the median subsidence 2 mm (IQR 1 to 4). Incorporation of the allograft into trabecular bone and secondary remodelling were noted radiologically at the final follow-up in 87% (393 of 452 zones) and 40% (181 of 452 zones), respectively. Subsidence of the Exeter stem correlated with the pre-operative Endo-Klinik bone loss score (p = 0.037). The degree of subsidence at one year had a strong association with long-term subsidence (p < 0.001). There was a significant correlation between previous revision surgery and a poor Harris Hip score (p = 0.028), and those who had undergone previous revision surgery for infection had a higher risk of complications (p = 0.048). Survivorship at 10.5 years with any further femoral operation as the end-point was 92% (95% confidence interval 82 to 97).     

Polished stem displacement from a cement mantle--a case report]

Dislocation is a possible complication after primary and revision hip arthroplasty. Closed reduction is the first treatment option. Displacement of polished Exeter stem from a cement mantle during closed reduction of dislocated hip after revision hip arthroplasty is described. The patient was re-operated, new non-polished stem was cemented without any further complications. Placement of the cement mantle over superior and lateral part of the stem may prevent such complication.     

Primary total hip arthroplasty with an uncemented femoral component: a long-term study of the Taperloc stem

The purpose of the current study was to evaluate the long-term result of a tapered, uncemented femoral component. We retrospectively reviewed the clinical and radiographic records of 121 patients (129 hips) who underwent primary total hip arthroplasty with the use of the Taperloc uncemented stem. Follow-up averaged 11 years (range, 6-15 years). The mean Harris Hip Score at the latest follow-up was 92.1. Thigh pain was reported in 5 patients (3.6%). One stem was revised at 6 years because of severe proximal femoral osteolysis. There was no evidence of radiographic subsidence or loosening around any stems. The overall medium- to long-term outcome of the Taperloc stem is excellent, with a low revision rate and high patient satisfaction.     

Collarless polished tapered stem: clinical and radiological follow-up over 5 years

The clinical and radiologic outcome of a cemented, polished, tapered stem (CPT), implanted using contemporary cementing techniques in 108 consecutive operated hips in 100 patients (68 women and 32 men, aged 19 to 83 years at the time of surgery [mean, 65 years]) was assessed after >5 years. The Harris hip scores were good or excellent in 96% of the patients. Stem subsidence measured by the computer-assisted method described by Braud and Freeman was at a mean rate of 0.44 mm/y, 1.08 mm during the first year, and stabilizing to a mean total of 2.18 mm at >5 years. Subsidence was related inversely to the completeness of the cement mantle but did not correlate with the clinical or radiologic outcome. This study confirms that collarless, polished, tapered stems subside within the cement mantle but without loosening and that the CPT performs at least as well as the Exeter stem.     

应用锥形沟槽式股骨组配柄假体行全髋关节翻修术的中期疗效

目的 探讨应用锥形沟槽设计的股骨组配柄假体行全髋关节股骨侧假体翻修术的中期疗效.方法 2000年5月至2005年8月采用锥形沟槽式股骨组配柄假体行全髋关节翻修术19例,男6例,女13例;年龄47～86岁,平均67岁.单髋17例,双髋2例.术前诊断均为股骨柄和臼杯假体无菌性松动合并股骨侧骨缺损,按Paprosky标准诊断为Ⅱ型缺损4髋,Ⅲa型缺损14髋,Ⅲb型缺损3髋.股骨侧翻修均采用锥形沟槽式股骨组配柄假体(Lima-Lto,意大利),髋臼侧均采用SPH臼杯假体(LimaLto,意大利)行生物学固定.关节头臼界面采用陶瓷-陶瓷组合17髋,金属-聚乙烯组合4髋.结果 全部病例随访5～10年,平均7年.Harris髋关节评分由术前平均(46.2±15.2)分改善至翻修术后半年平均(90.3±5.3)分,末次随访平均(92.2±3.5)分.X线片显示翻修柄获广泛骨长入骨性固定者20髋(95%,20/21),纤维性稳定者1髋(5%,1/21).假体下沉0～10 mm,平均2.4 mm.随访期间无一例因假体松动或其他原因需行再次翻修.结论 采用锥形沟槽式股骨组配柄假体行伴有PaproskyⅡ型、Ⅲa和Ⅲb型骨缺损的股骨侧假体翻修术,可获得理想的初始稳定和永久生物学固定,中期随访疗效满意.

Abstract：

Objective To evaluate the midterm results of the revision total hip replacement with a fluted and tapered modular stem. Methods Nineteen patients (21 hips) underwent revision total hip arthroplasty from May 2000 to August 2005 were reviewed. There were 13 females and 6 males, with an average age of 67 years. Pre-revision diagnosis included aseptic loosening of the cups and stems associated with femoral defects (Paprosky classification) type Ⅱ 4 hips (19%), type Ⅲa 14 hips (67%), and type Ⅲb 3 hips (14%). The adopted acetabular component was SPH (Lima-Lto, Italy), and femoral component was a fluted and tapered modular stem (Lima-Lto, Italy). Clinical and radiographic evaluations were performed postoperatively. Results The mean follow-up was 7 years (range, 5-10). The Harris hip score improved from 46.2±15.2 preoperatively to 90.3±5.3 postoperatively, and maintain 92.2±3.5 at the latest follow-up. The X-ray films showed bone ingrowths fixation in 20 hips (95%) and fibrous stable fixation in 1 hip (5%). The average stem subsidence was 2.4 mm (range, 0-10 mm). There were no re-revisions of the femoral stem for any reason. Conclusion The midterm results of revision total hip replacement with a fluted and tapered modular stem in Paprosky type Ⅱ, Ⅲ a, Ⅲ b femoral defect associated aseptic loosening of the femoral stem was encouraging.     

A comparison of collared and collarless femoral components in primary cemented total hip arthroplasty: a randomized clinical trial

Between July 1986 and November 1989, 437 consecutive primary cemented total hip arthroplasties were performed using a straight-stemmed titanium alloy femoral component. Collared and collarless versions of this identical stem were randomly chosen by computer allowing a comparison between 213 collared stems (198 patients) and 224 collarless stems (209 patients). Diagnosis, sex, weight, and average age (72.8 years, collared; 72.0 years, collarless) were similar. Follow-up averaged 76 months (collared) and 72 months (collarless) with 49 patients followed for at least 10 years. Calcar-collar contact was noted in 205 hips (96%) on the initial postoperative radiograph. Early complications, including dislocations (5% each group), were similar. Late complications included 3 deep infections (2 collared, 1 collarless) and 2 postoperative femur fractures (1 each). Hip scores at the most recent follow-up averaged 91.2 and 90.1 in the collared and collarless groups. No or slight pain was noted in 93% of collared and 91.5% of collarless hips. Although no radiographic differences were noted in distal cortical hypertrophy, stem subsidence, and osteolysis, collarless hips lost significantly more medial femoral neck cortical bone (average 0.90 mm vs 0.63 mm). A higher incidence of radiolucent lines in femoral zone VI (20.7% vs 9.4%) was also noted in collarless hips.     

No increased stem subsidence after arthroplasty in young patients with femoral head osteonecrosis: 41 patients followed for 1-9 years

BACKGROUND: Poor bone stock in patients with osteonecrosis of the femoral head may be a reason for poor outcome after hip replacement. One way of studying bone quality is to measure implant migration. We thus investigated the clinical and radiographic results of cementless THR in younger patients with femoral head osteonecrosis. PATIENTS AND METHODS: We studied hips in 41 patients (mean age 48 (25-63) years) with a cementless hip arthroplasty after late stage osteonecrosis. Clinical evaluation was by the Harris hip score, the WOMAC score and the SF-36 score. Stem subsidence was measured with the Ein Bild Roentgen Analyse femoral component analysis (EBRA-FCA) at 3, 12, 24, 60, and 72 months after operation. The average duration of follow-up was 7(1-9) years, with less than 2 years for 2 patients. RESULTS: There was no revision of any hip. No radiographic or clinical stem loosening was seen. After 60 months, the cementless stems showed a median subsidence of -0.7 mm (95% CI: -0.9 to -0.2). No femoral osteolysis occurred. Femoral radiolucent lines, all < 1 mm, were seen in 10 hips. At the latest follow-up the Harris hip score was 83 (23-100) points. INTERPRETATION: Our findings for porous-coated stems in patients with femoral osteonecrosis indicate no greater risk of stem subsidence and rate of osteolysis after an average of 7 years follow-up. Thus, we continue to use uncemented stems in younger patients with femoral osteonecrosis. However, continued follow-up will be necessary to evaluate the long-term outcome.