Sixteen-year follow-up of the cemented spectron femoral stem for hip arthroplasty

Clinical and radiographic follow-up was performed on a consecutive series of 105 patients who underwent 120 total hip arthroplasties at the authors' institution from 1983 to 1988 with a straight, cobalt-chrome femoral stem implanted using a second-generation cementing technique. The mean age at the time of surgery was 68.5 years, and the mean follow-up was 16 years. At 16 years' follow-up, the prevalence of revision for aseptic loosening of the Spectron femoral component was only 4.2%; 5 stems were revised for aseptic loosening at a mean of 10.2 years after implantation. Sixteen-year survivorship of the component was 93.9% +/- 2.7% when revision for aseptic loosening was taken as the endpoint or 90.3% +/- 4.4% when either revision for aseptic loosening or radiographic evidence of loosening was taken as the endpoint.     

Results of cemented metal-backed acetabular components: A 10-year-average follow-up study

The clinical and radiographic results of 86 primary total hip arthroplasties performed in 74 patients from 1983 to 1987 with a cemented metal-backed acetabular component and a cemented collared straight femoral stem with a 32-mm head were reviewed at a mean follow-up of 10.1 years. Seven patients (9.2%) underwent acetabular component revision at a mean of 9.0 years after implantation; an additional 24 components (31.6%) demonstrated evidence of radiographic loosening, resulting in a total failure rate of 40.8%. Periacetabular radiolucencies were noted in Charnley zones at the following rates: 34.2% in zone I, 18.4% in zone II, and 27.6% in zone III. In addition, 18.4% and 38.2% of implants demonstrated evidence of migration and excessive polyethylene wear. Excessively vertical cup placement (>49° inclination) at the time of initial arthroplasty was statistically correlated with polyethylene wear, implant migration, and fixation failure. A trend of increasing implant failure was also noted with decreasing polyethylene liner thickness. Periacetabular cement mantle thickness was not statistically correlated with subsequent component loosening or failure. Results of Kaplan-Meier survivorship analysis using revision as an endpoint showed 93.6% survivorship at 10 years and 88.4% at 12 years. The mean modified Harris hip scores were 46.9 preoperatively and 81.8 at final follow-up. The significant overall rates of radiographic loosening, migration, polyethylene wear, and implant revision confirm the suspected trend of increasing failure rates of cemented metal-backed acetabular components over time.     

Cemented revision total hip arthroplasties in patients younger than 55 years old: A multicenter evaluation of second-generation cementing technique

The results of all cemented first-time revisions in Sweden performed in patients younger than 55 years of age, during the period 1984–1986, are reported. The revisions were performed by the average orthopaedic surgeon in 25 hospitals distributed throughout Sweden. Second-generation femoral cementing technique was used. One third of the acetabular revisions were performed with pressurized cement. The reason for revision was aseptic loosening. Seventy hips in 68 patients were reviewed at an average follow-up period of 7 years (range, 4–10 years). The average age of the patients at the time of revision surgery was 47 years. Forty-eight cups and 57 stems were revised using cement. Survival analysis, with rerevision for aseptic loosening as the endpoint, suggests an overall 76% survival rate after 8 years. The survival rate for the cup was 80%, and for the stem, 85%. The radiographic evaluation revealed that the cement mantle was inadequate in many revisions. Localized osteolysis was rare. Clinical data were reported for 55 (53 patients) non-rerevised hips. Thirty-five hips were without pain or slightly painful. Forty patients limped when walking. Forty-three patients were satisfied with the revised hip. These results using second-generation femoral cementing technique are better than those reported with first-generation technique, but the failure rate in this young patient population is too high. The search for a more durable fixation in revision total hip athroplasty for young patients with long life expectancy is ongoing. These results emphasize that there is a need for centralization to gain experience in extended clinical research and to further improve surgical and cementing techniques.     

Long-term results of use of a collared matte-finished femoral component fixed with second-generation cementing techniques. A fifteen-year-median follow-up study

BACKGROUND: So-called second-generation cementing techniques in total hip arthroplasty have been shown to provide better survival of the femoral component than first-generation methods do; however, surface finish and other features of the component design also influence the durability of the reconstruction. The purpose of this study was to determine the results of primary total hip replacement with use of a collared femoral component with a matte-finished surface fixed with second-generation cementing techniques and followed for ten to twenty years. METHODS: The study group consisted of 256 consecutive hips in 236 patients who had had a primary total hip arthroplasty with fixation of a Harris Design-2 femoral component with second-generation cementing techniques (use of an intramedullary plug and a cement gun). The mean age of the patients at the time of the operation was sixty-six years. One hundred and twelve patients were male, and 124 were female. Seven patients were lost to follow-up less than ten years after the operation. The median duration of follow-up of the living patients who had not had a revision was 15.4 years. RESULTS: At the time of the most recent follow-up, nineteen femoral components (7%) had been revised because of aseptic loosening, five (2%) had been removed because of deep infection, and one (0.4%) had been revised because of recurrent dislocation. The mean Harris hip score for the surviving patients who had not had a revision improved from 51 points preoperatively to 91 points at the most recent evaluation. At fifteen years, the estimated survival rate of the femoral components was 92.2% with revision due to aseptic loosening as the end point and 90.1% with mechanical failure (radiographic loosening or revision due to aseptic loosening) as the end point. Patients who were younger than fifty years old at the time of the operation had a lower fifteen-year rate of survival of the femoral implant, in terms of both revision due to aseptic loosening (72.3% compared with 95.7%, p = 0.0001) and mechanical failure (72.3% compared with 93.1%, p = 0.005), than did patients who were fifty years or older. CONCLUSIONS: Fixation of this collared matte-finished femoral component with use of second-generation cementing techniques for primary total hip replacement provided satisfactory results at ten to twenty years in older patients but less satisfactory results in younger patients.     

Outcome of revision for mechanical stem failure using the cemented Charnley's stem: A Study of 399 Cases

Three hundred ninety-nine cemented stem revision total hip arthroplasties performed in cases with mechanical stem failure without infection and having a minimum follow-up period of 3 years were prospectively studied. Two hundred eighty-three were revised for aseptic stem loosening and 116 were revised for fractured stem. Bone-grafting was not performed in any of the cases. The average follow-up period was 7 years 5 months. At the last follow-up evaluation, 70.4% of the patients were pain free and 20.6% had only mild or occasional discomfort. On radiographic evaluation, 31 stems (7.8%) were loose. Thirty-five hips (8.8%) required a rerevision, of which only 20 (5.0%) were for recurrence of mechanical stem failure. Clinical survivorship of the revised stem was 93.9% at 10 years, whereas radiographic survivorship was 91.5% at 10 years. On radiographic analysis, the mechanical failure rate at the last follow-up evaluation was greater after revision for fractured stem than after revision for aseptic stem loosening. Prerevision femoral cortical bone stock did not appear to adversely affect the outcome of the procedure. The clinical and radiologic results achieved with cemented stem revision arthroplasty for mechanical stem failure are excellent.     

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.     

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%).     

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

Background

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

Methods

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

Results

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

Conclusions

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

Charnley total hip arthroplasty with use of improved cementing techniques: a minimum twenty-year follow-up study.

BACKGROUND: In total hip arthroplasty, techniques for cementing the femoral component have changed over time. The purpose of the present study was to determine whether a cementing technique that includes use of a distal cement plug and retrograde filling of the femoral canal affects the fixation of the femoral component at a minimum of twenty years after the operation. METHODS: Between 1976 and 1978, the senior one of us (R.C.J.) performed 357 total hip arthroplasties with use of a Charnley flatback polished femoral stem and a contemporary cementing technique (insertion of a distal cement plug and retrograde filling of the femoral canal with cement) in 320 patients. The results after a minimum follow-up of twenty years were compared with those after 330 total hip arthroplasties performed, between 1970 and 1972, with the same femoral stem by the same surgeon with use of a hand-packing technique of cementing in 262 patients. The clinical and radiographic evaluation as well as the duration of follow-up were identical in the two groups. RESULTS: In the group managed with the contemporary cementing technique, six (1.8%) of the 336 hips that had not been lost to follow-up or revised because of infection or dislocation were revised because of aseptic loosening of the femoral component. Of the ninety-one hips in the eighty-two patients who were alive at a minimum of twenty years, five (5%) had a revision because of aseptic loosening of the femoral component. Only one hip was revised during the fifteen-to-twenty-year follow-up interval. (The revision was performed because of a fracture of the femoral component.) The rate of failure when radiographic signs of loosening were included was 4.8% (sixteen of 336 femoral components that had not been revised because of infection or dislocation) for the group managed with the contemporary cementing technique compared with 6.3% (twenty of 319 hips) in the group managed with the hand-packing technique; the difference was not significant (p = 0.40). Adequate filling of the femoral canal with cement was found to be associated with improved survival of the femoral component (p = 0.03). CONCLUSIONS: While no significant difference between the two cementing techniques could be identified, the ability to deliver adequate cement around the femoral component was more predictable with the contemporary cementing technique. In addition, the prevalence of loosening of the femoral component was low with use of either technique, a tribute to the Charnley flatback polished femoral component design.     

Modular Fluted Tapered Stems in Aseptic Oncologic Revision Total Hip Arthroplasty: A Game Changer?

BackgroundModular fluted tapered (MFT) stems are the most frequently used femoral component in revision total hip arthroplasties (THAs). Despite this, no data are available on how they perform in revision THA for oncologic salvage. This is a unique population, often with severe bone loss and prior radiation that extends the limits of uncemented femoral reconstruction. The aims of this study were to evaluate the implant survivorship, radiographic results, and clinical outcomes of MFT stems used for revision oncologic salvage.MethodsWe identified 17 patients treated initially with primary THA for an oncologic diagnosis (15 primary oncologic, 2 metastatic disease) who underwent subsequent femoral revision with an MFT stem. Mean age at revision was 66 years and 35% of patients were female. Mean follow-up was 4 years. Before revision, 5 of 17 had undergone local radiation.ResultsTen-year survivorship free from aseptic loosening was 100%. The survivorship free of any reoperation was 76%. There were no femoral component fractures. Three patients were revised for recurrent instability, and 1 patient underwent irrigation and debridement for an acute infection. At most recent follow-up, no patient had radiographic evidence of progressive femoral component subsidence or failure of osteointegration. The mean Harris Hip Score improved from 29 preoperatively to 76 postoperatively (P < .0001).ConclusionIn this series of patients with cancer, many of whom had severe bone loss and/or prior local radiation, being treated with revision THA, there were no revisions for femoral component loosening and no cases of implant fracture.Level of EvidenceIII.     

Cemented revision of failed uncemented femoral components of total hip arthroplasty

BACKGROUND: The long-term results of revision of failed primary cemented femoral components with use of cement have been reported, but there is little information about the results of revision of failed uncemented femoral components with use of cement. The purpose of the present study was to examine the minimum five-year results for patients in whom a failed uncemented primary femoral component was revised with use of modern cementing techniques. METHODS: Forty-eight consecutive hips (forty-seven patients) in which a failed primary uncemented femoral component was revised with use of cement at one institution from 1985 to 1992 were followed prospectively and reviewed retrospectively. The mean age of the patients at the time of revision was sixty-seven years. Only seven revisions were performed with a long-stem femoral component. The postoperative cement mantle was classified, according to the system of Mulroy and Harris, as grade A in four hips, grade B in twenty-five, grade C1 in seven, grade C2 in twelve, and grade D in none. RESULTS: Eleven femoral components were removed or revised because of aseptic loosening (ten) or deep infection (one). An additional four unrevised femoral components had evidence of probable or definite loosening at the time of the final radiographic follow-up. Thus, fourteen (29%) of the forty-eight femoral implants demonstrated aseptic loosening during the study period. Five of the twenty-nine hips in which the postoperative cement mantle was classified as grade A or B had mechanical failure at the time of the final follow-up, compared with nine of the nineteen hips in which the postoperative cement mantle was classified as grade C1 or C2 (p < 0.05). Among the hips with surviving prostheses, 79% had had moderate or severe pain preoperatively whereas 25% had moderate or severe pain at the time of the final follow-up. The six-year rate of survival of the femoral component was 72% with revision for aseptic loosening as the end point and 67% with mechanical failure (revision for aseptic loosening or radiographic loosening) as the end point. CONCLUSIONS: While revision of a failed uncemented femoral implant with use of cement provided pain relief and improved function for most patients, the rate of loosening at the time of intermediate-term follow-up was higher than that commonly reported after revision of failed cemented implants with use of cement and also was higher than that commonly reported after revision with use of uncemented extensively porous-coated implants. Bone removal at the time of the initial implantation of the stem and bone loss due to subsequent failure of the uncemented implant often left little intramedullary cancellous bone, which may explain the high rate of loosening observed in the first decade after revision in this series.     

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.     

Advantages in Using Cemented Polished Tapered Stems When Performing Total Hip Arthroplasty in Very Young Patients

Background

The risk of revision following primary total hip arthroplasty (THA) is increased in young patients who undergo THA for pathologies other than primary osteoarthritis. We report the results of primary THA performed with cemented polished stems in patients aged 40 years and younger for pathologies other than primary osteoarthritis.

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

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

The Harris-Galante cementless THA: a 19- to 25-year follow-up study

The goal of this study was to evaluate the long-term survivorship of primary cementless total hip arthroplasty (THA) using Harris-Galante porous I acetabular and Harris-Galante porous femoral components. From July 1985 to December 1991, we performed primary cementless THA on 76 hips (70 patients). Twenty-nine patients (31 hips) died due to causes unrelated to the THA, and 6 patients (7 hips) were lost to follow-up. Of 76 hips (70 patients) studied, 38 hips (35 patients) were available for follow-up at a mean 22.5 years (range, 19-25 years) postoperatively. Mean patient age at index procedure was 51.2 years (range, 42-65 years). Average Harris Hip Score was 40.5 points preoperatively and 85.8 points at final follow-up. No patient had an early or late postoperative deep infection. Radiographically, the acetabular component fixation was stable in all 38 hips. The femoral component was bone-ingrown in 26 hips, stable-fibrous in 10, and unstable in 2. One unstable hip required revision of the femoral component. Dissociation of the polyethylene liner occurred in 3 hips without fractures of the metal locking tines and required revision of the polyethylene liner and the articular head. A total of 4 hips had documented revision, and 1 femoral component failed radiographically. The survival rate with the endpoint defined as revision surgery and radiographic loosening was 86.8% at 22.5 years of follow-up. Mean polyethylene wear was 0.085 mm/year (range, 0.031-0.15 mm). This study found that the Harris-Galante porous I acetabular and Harris-Galante porous femoral components produce excellent long-term results.     

Revision total hip arthroplasty using third-generation cementing technique

A total of 83 consecutive first-revision total hip arthroplasties were performed in 83 patients using pressurized vacuum-mixed cement, a third-generation cementing technique. At a median follow-up of 3.6 years (range, 1.5-6.3 years), the overall failure rates (radiographic loosening, re-revision, or both) were 39% for the femoral components and 30% for the acetabular components. With definite radiographic loosening as an endpoint, the cement-bone interface achieved was the only significant factor to predict stem durability, with an adjusted odds ratio of 1.8 (95% confidence interval, 1.1-3.0). On the acetabular side, bone stock was the only significant factor, with an adjusted odds ratio of 5.3 (95% confidence interval, 4.0-27.7). In this retrospective cohort study, femoral cement pressurization per se did not appear to improve the results over those of other studies using second-generation techniques.     

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.