Clinical outcome in total hip arthroplasty using a cemented titanium femoral prosthesis

Between 1988 and 1993, 118 total hip arthroplasties were carried out using cemented titanium alloy stems with modular cobalt-chrome heads. At a mean follow-up of 66.2 months, the overall clinical failure rate as a result of aseptic loosening of the femoral stem was 11.5%. Most failures occurred with smaller stems, especially in heavier patients. Clinical and radiographic data suggest that failure of femoral component fixation was due to high stresses in the cement mantle associated with the increased flexibility of the smaller stems. Radiographs of successful arthroplasties in patients with larger stems showed proximal stress shielding in most. The findings in this study do not support the contention that titanium alloys provide an advantage over more rigid materials in the manufacture of cemented femoral components for total hip arthroplasty.     

Clinical experiences with a titanium alloy total hip prosthesis: a posterior approach

Using a titanium alloy femoral prosthesis (STH Zimmer) and an ultra high molecular weight polyethylene acetabular cup with a posterior surgical approach to the hip joint, 237 consecutive total hip arthroplasties in 215 patients were performed between December 1975 and May 1977. The preliminary results and early postoperative complications suggest that this system can be considered an alternative to total hip arthroplasty using other materials and surgical approaches.     

Revision total hip arthroplasty with titanium ingrowth prosthesis and bone grafting for failed cemented femoral component loosening

Fifty-seven hips (55 patients) had revision for failed cemented femoral component loosening using titanium ingrowth femoral components and cancellous bone grafting. The patients' average age was 59 years (range, 25-86 years), and the average follow-up period was 2.8 years (range, two to six years). The preoperative hip score averaged 45.5 (range, 10.0-80.7) and the postoperative hip score averaged 82.5 (range, 43.0-100.0). Complications included dislocation (4.0%), infection (4.0%, one recurrence from a previously infected hip and one acute hematogenous infection), and a 4.0% revision rate for loose femoral component. Another patient had a revision for a loose acetabular component. All parameters of hip function (i.e., pain, limp, activities of daily living, use of support, and distance walked) improved with time. Femoral component loosening is classified into four types based on the severity of loosening and instability. In Type I there is minimal endosteal or inner cortical bone loss, i.e., loosening from the cement-metal-bone interface or a broken stem (seven hips). In Type II there is proximal canal enlargement with cortical thinning of 50% or more and sometimes a lateral wall defect with an intact circumferential wall (23 hips). In Type III there is a posteromedial wall defect involving the lesser trochanter (23 hips). In Type IV there is total proximal circumferential bone loss in varying distances below the lesser trochanter (three hips). The Harris hip scores for the four groups were 93.0, 83.0, 80.0, and 78.0, respectively.     

Ten-year survivorship of cemented ceramic-ceramic total hip prosthesis.

In the first 187 consecutive alumina-alumina combination hip arthroplasties performed from 1977 to 1979, both components were cemented with conventional techniques. At ten-year follow-up evaluation, 87 patients were reviewed or interviewed by telephone, 37 were dead, 39 were lost to follow-up evaluation, and 24 failures were reoperated on before the end of ten years. The major cause of failure was aseptic loosening of the acetabular component (15 failures). Fracture of the socket and of the femoral head occurred in five patients in this series. However, these complications were not seen with components manufactured after 1979. At the end of ten years, survivorship analysis depicted a 82.59% survival rate when reoperation was considered as failure and a 88.57% rate when reoperation for aseptic loosening was considered as failure. The femoral component had a 99.16% survival rate and the acetabular component had an 88.57% survival rate when reoperation for aseptic loosening was considered as failure. Age, appearance of a two- or three-zone demarcation at the intermediate follow-up evaluation, and outer diameter of the acetabular component were the major parameters influencing the results. Better results observed in the population younger than 50 years of age may be related to the small amount of wear debris produced by the alumina-alumina combination. This combination in hip prosthesis is secure, but should be implanted in young and active patients; the outer diameter of the acetabular component must be at least 50 mm. The major problem that remains is the socket's fixation. It could be improved by a design modification, by choosing another mode of fixation, or both.     

Long-term outcome of cemented total hip arthroplasty with the Charnley-type femoral stem made of titanium alloy

BackgroundTotal hip arthroplasty is a successful treatment for hip diseases including osteoarthritis, osteonecrosis of the femoral head, and rheumatoid arthritis. Various designs of cemented femoral stems made of stainless steel and titanium alloy have been used. Among them, Charnley-type femoral stems made of stainless steel have often been reported to have good long-term outcome. However, the long-term outcome of the Charnley-type femoral stem made of Ti alloy is yet to be reported. We conducted a retrospective study to assess the long-term outcome of cemented primary total hip arthroplasty with the Charnley-type femoral stem made of Ti alloy.MethodsBetween October 1988 and February 1997, 341 cemented primary total hip arthroplasties with the Charnley-type femoral stem made of Ti alloy were consecutively performed in our hospital. Among these, 164 patients (211 hips) who underwent this procedure were followed up for more than 12 years, and the surgical hips were analysed clinically and radiologically. The mean follow-up period was 20.6 years. Kaplan–Meier survival analyses were performed to assess femoral component survival. Factors affecting stem revision for aseptic loosening were also investigated using log-rank tests.ResultsIn the functional assessment, the preoperative Japanese Orthopaedic Association score significantly improved from 47.2 points preoperatively to 79.0 points at the final follow-up. Eventually, 33 femoral stems were revised, of which 12 were revised for aseptic loosening. In the Kaplan–Meier survival analysis, the 20-year survival rates with stem revision for aseptic loosening and radiological stem loosening at the end points were 95.9% and 97.1%, respectively. Original diagnosis (non-osteoarthritis) was the only significant factor for aseptic loosening of the femoral stem.ConclusionsCemented primary total hip arthroplasty with the Charnley-type femoral stem made of Ti alloy showed excellent outcomes for more than 20 years.     

Osteolysis in cemented versus cementless acetabular components

A prospective, randomized, double-blind, clinical trial comparing cemented with cementless total hip arthroplasty was performed to compare the prevalence and pattern of acetabular osteolysis. Both groups were similar before surgery. Acetabular components were metal-backed, titanium implants. Twenty-eight-millimeter modular femoral heads with titanium femoral stems were used. At a minimum 2-year and mean 4-year follow-up period (range, 2–6 years), 224 patients had clinical and radiographic data available. There was no significant difference in the prevalence of acetabular osteolysis between cemented (5%) and cementless (9%) fixation. With or without cement, the use of a titanium femoral head led to osteolysis within a relatively short period after surgery in almost all of the cases, although this was not significant. The pattern of acetabular osteolysis was different. Progressive osteolysis occurred predominantly in acetabular zone 1 in the cemented group and zone 2 in the cementless group. Cementless fixation of acetabular components has been advocated in an attempt to minimize osteolysis that may occur in cemented total hip arthroplasty. This study found no difference in the prevalence of acetabular osteolysis between the two groups.     

Osteolysis in third-generation alumina ceramic-on-ceramic hip bearings with severe impingement and titanium metallosis

The most common cause of long-term failure of total hip arthroplasty is osteolysis and aseptic loosening secondary to wear debris. Combinations of hard materials such as ceramic-on-ceramic generate smaller volumes of particulate wear debris than traditional combinations such as metal-on-polyethylene. We describe 2 cases where osteolysis arose in hips with third-generation alumina ceramic-on-ceramic couplings. Periarticular tissue in both cases contained titanium wear debris due to impingement of the neck of the titanium femoral component against the rim of the titanium shell and ceramic debris from edge loading wear (stripe wear) of the ceramic. It is not clear whether the titanium debris, the ceramic debris, or both caused the osteolysis. These cases illustrate that the risk of osteolysis persists, even with third-generation alumina ceramics.     

Revision arthroplasty in aseptic loosening of cemented sockets of hip prosthesis]

The aim of this paper was to assess early results of revision arthroplasty in aseptic loosening of cemented sockets. A group of 67 patients (53 females and 14 males) age ranging from 47 to 78 years (average: 72 years) who underwent revision arthroplasty because of aseptic loosening of cemented sockets. Early surgical treatment can spare the patient from a risky procedure and lead to better end results. In cases with massive bone destruction of the pelvis good results can be achieved by using bone grafts and anti-protrusion cages.     

The effect of femoral prosthesis design on cement strain in cemented total hip arthroplasty

Finite element studies show that the highest cement stresses are located at the most proximal and distal ends of the prosthesis. In vitro biomechanical and histologic analyses of autopsy-retrieved cemented femoral components show these areas to be associated with cement-prosthesis debonding. In this study, cement strains were measured in 2 geometrically different femoral stems in paired cadaver femora: A straight, collared, moderately tapered stem (Centralign) was compared with an anatomically curved, collarless, dramatically tapered stem (Scientific Hip Prosthesis [SHP]). Results showed that the maximum strain and the overall strain profile differed between the 2 stems. The Centralign had peak strains located at the most proximal gauge positions, whereas the peak strains of the SHP were located around the middle of the femoral stem. Minimization of cement strain, especially at the crucial proximal and distal areas of the stem, by altering component design may be able to reduce cement-prosthesis debonding and improve clinical results.     

Increased metal release from cemented femoral components made of titanium alloy: 19 hip prostheses followed with radiostereometry (RSA)

In 19 patients the concentrations of metal were measured in serum, urine and joint fluid 2 years after implantation of uncemented commercially pure titanium acetabular cups and cemented or uncemented femoral components made of titanium alloy. A ceramic against the polyethylene articulation was used. The fixation of the components was followed with radiostereometry (RSA). Samples from 12 patients scheduled for hip or knee prostheses and without any metallic implant were used as controls.

High levels of titanium were found in cemented hips and when large acetabular cups had been inserted. Increased aluminum levels were also noted in the cemented hips. Vanadium was not detected in any of the samples. Micromotions were detected in most of the implants, but the magnitude of these movements could not be used to predict the release of metal into the synovial fluid.     

Osteolysis in patients with a metal-on-metal hip arthroplasty

Background: Despite design and manufacturing improvements in contemporary metal‐on‐metal hip replacements, the problem of wear particles persists. The local and systemic biological consequences of this ionic debris have been the subject of much investigation and it has become clear that cell‐mediated delayed‐type hypersensitivity reactions are a discrete mode of osteolysis in susceptible patients. Methods: We have carried out a consecutive series of 125 primary hip replacements using the Metasul (Zimmer, Warsaw, IN, USA) bearing couple. The radiographs, periprosthetic tissue and retrieved implants of patients undergoing revision for osteolysis were analysed. Results: Three patients underwent revision procedures during a follow‐up period of 3–9 years. Histological analysis showed a perivascular lymphocytic infiltrate of the pseudocapsule. Infection was excluded in each patient, there was no implant loosening and no evidence of impingement between trunion and acetabular component. Conclusion: We report a prevalence of 2.6% of patients displaying femoral osteolysis associated with characteristic clinical and histological findings.     

A prospective study of a titanium femoral component for cemented total hip arthroplasty

The authors studied the clinical and radiographic results of a modern titanium-alloy femoral stem with a cobalt-chrome-alloy head for use in cemented total hip arthroplasty. One hundred sixteen hips (102 patients) were operated on using modern cement techniques and prospectively followed using the Hospital for Special Surgery hip rating system and standard radiographic criteria. At a mean follow-up period of 4.8 years (range, 2–8 years), 69 hips were rated excellent, 38 good, 4 fair, and 5 poor. A total of 13 femoral components (11%) were radiographically loose according to the criteria of Harris. In 11 of these loose femoral components, debonding or separation at the cement-prosthesis interface, was the initial cause of failure, with bone-cement interface erosions occurring later in five hips. Revision of a loose femoral component has been performed in three hips and is pending in two other hips (4.3%). Significant calcar resorption was seen in only 17 hips (14.6%), and serial measurements of distal femoral cortical widths showed no distal cortical hypertrophy except in one femur. The incidence of loosening with this cemented titanium-alloy femoral component (with a cobalt-chrome-alloy head) is much higher than published reports of similar cobalt-chrome-alloy stems. The authors have abandoned the use of titaniumalloy femoral components for cemented total hip arthroplasty.     

全髋关节置换术假体周围骨溶解的临床分析

目的分析股骨假体周围骨溶解的发生情况、程度和方式,了解骨溶解与假体松动的关系。方法根据Ｇｒｕｅｎ’ｓ分区法,在标准正位Ｘ光片上对１９８０年１９９６年间进行连续Ｘ线随防的全髋关节置换术病人共１１２例进行分析,其中骨水泥固定８４例,非骨水泥固定２８例,平均随访时间为８３月。结果骨水泥固定和非骨水泥固定的假体周围骨溶解的总发生率分别为５８．３％和２５．０％,假体周围骨溶解进行性发展的发生率分别为８６％和     

Osteolysis associated with cemented total knee arthroplasty: A case report

Osteolysis induced by particulate debris occurs within 5 years after cementless total knee arthroplasty, but has not been reported to be a problem after cemented total knee arthroplasty. It has been suggested that the bone-cement interface may form a barrier to polyethylene-debris migration, thereby limiting bone loss. The authors have observed osteolysis in a 75-year-old woman 9 years after cemented total knee arthroplasty. An osteolytic area appeared to return to an area of normal bone architecture 3 years after the removal of synovium and particulate debris without implant revision.     

Metal wear and tissue response in failed titanium alloy total hip replacements

Thirteen total hip replacements with titanium alloy femoral components required revision for loosening at an average of two years after implantation. At revision the soft tissues around the implant were darkly stained and a proliferative membrane had invaded the cement-bone interface. The femoral components showed polishing of parts of their shot-blasted surfaces. Histology showed a fibroblastic reaction with abundant titanium lying free and within histiocytes, and a scanty foreign-body giant-cell reaction. Surface analysis of the removed femoral components and chemical analysis of the excised tissues is described. Tissue reaction in response to the metal-wear debris may have contributed to the early failure of these implants.     

Survival of a cemented porous-coated prosthesis

Porous-surfaced femoral components were approved by the United States Food and Drug Administration for implantation with polymethyl methacrylate cement in total hip arthroplasty. The ability of porous coating to prevent loosening of prostheses in vivo has not been reported in the literature previously. This study compared the radiographic and clinical success of two structurally similar prosthetic designs, one of which incorporates a porous coat. Kaplan-Meier survival analysis showed no significant difference between the components (P greater than .05) when failure is defined as revision alone, radiolucency alone, or the combination of revision and radiolucency.